Drug Metabolism

Tuesday, July 30, 2002 9:00 a.m. 10:00 a.m. Robert G. Lamb, Ph.D. E-mail Address: rglamb@vcu.edu Post a question to the bulletin board

Lecture Outline:
Objectives | Required Reading | Characteristics of enzyme catalyzed reactions | | Cellular location of drug metabolizing enzymes | Overall scheme of drug biotransformation | | Types of drug metabolism reactions | Factors influencing drug metabolism | | Drugs to Remember |

OBJECTIVES After studying the material of this lecture, the student should be able to: 1. Discuss the role of phase I and phase II biotransformation reactions in regulating drug action. 2. Explain how the prior administration of one drug inhibits or stimulates the biotransformation of another drug. Explain the consequences of these alterations on drug metabolism. 3. Identify the factors (age, diet, glutathione, etc.) which influence drug metabolism and discuss their mechanism of action and the consequence of changes in these parameters. 4. Identify the primary cellular site of oxidative drug metabolism and tell what factors regulate this metabolic process 5. Outline and discuss the metabolic fate of aspirin and acetaminophen. Required Reading Katzungs Clinical Pharmacology, 8th Edition., pp. 51-63,1026-8,1030-1,1037.

Many drugs are difficult to eliminate since they are lipophilic. However, various tissues (lung, intestine, liver, kidney, brain, etc.) contain enzymes which alter the chemical structure of drugs. The liver is the major site of drug biotransformation and plays a very important role in terminating drug effects. In most cases, drug biotransformation produces drug metabolites which are pharmacologically inactive, more polar, less lipid soluble and more readily excreted by tissues such as the kidney and liver. However, drug

metabolites may also have more, less, or the same pharmacologic effect as the administered drug. In some cases, drug metabolites may also bind to membrane components (proteins and/or phospholipids) and produce membrane dysfunction (injury) or they may be mutagenic, teratogenic or carcinogenic.

I.

CHARACTERISTICS OF ENZYME CATALYZED REACTIONS A. Enzyme (E) + Substrate (S) ES Product [metabolite] B. C. D. Reaction rate proportional to level of E at saturating concentrations of S. Reaction rate proportional to level of S at low concentrations and independent at high concentrations with constant amounts of E. Maximum reaction rate when enzyme is saturated.

II.

CELLULAR LOCATION OF DRUG METABOLIZING ENZYMES A. B. C. D. Plasma (hydrolysis) Mitochondria (oxidation, reduction) Endoplasmic reticulum (oxidation, glucuronidation) Cytosol (conjugation, reduction and hydrolysis)

III.

OVERALL SCHEME OF DRUG BIOTRANSFORMATION (Metabolism) A. Phase I reactions (hydrolysis, oxidation, reduction) 1. B. Active and chemically reactive metabolites

Phase II reactions (conjugation with sulfate, acetate, etc.) 1. Inactive metabolites that are readily excreted

IV.

TYPES OF DRUG METABOLISM REACTIONS A. Phase I (nonsynthetic) reactions 1. Hydrolysis a. Esters

b.

Amides

2.

Reduction

3.

Oxidation (Microsomal Mixed Function Oxidase) a. b. Non-specific Components 1. Cytochrome P450 (multiple forms) a. b. Microsomal hemoprotein Inducible 1. 1A1 [12%] Cigarette Smoke & Charcoal Broiled Foods [3-methylcholanthrene & Benzo(a)pyrene]

2. 3. 4.

2B [20%] Phenobarbital & Rifampin (antimycobacterial) 2E1 [6%] Ethanol & Isoniazid (antimycobacterial) 3A [28%] Phenobarbital, Phenytoin (anticonvulsant), Rifampin, etc. Major CYP 450

2. 3. 4.

NADPH O2 Microsomal enzyme a. NADPH cytochrome P450 reductase

5.

Overall reaction NADPH + O2 + H+ + drug NADP+ + H2O + oxidized drug

6.

Reaction sequence

1. SUBSTRATE BINDING binding of drug to oxidized (Ferric) cytochrome P450. 2. SUBSTRATE REDUCTION - Ferric-R complex accepts electron from NADPH cytochrome P450 reductase to form Ferrous-R complex. 3. SUBSTRATE OXYGENATION Ferrous-R complex binds molecular oxygen to form oxycytochrome P450. Complex can also bind CO (in the absence of oxygen). Superoxide anion is formed. 4. SUBSTRATE REDUCTION oxycytochrome P450 accepts an additional electron (source of electron not clear) to form peroxycytochrome P450 . Hydrogen peroxide is formed. 5. SUBSTRATE REARRANGEMENT complex rearranges with the release of water.

6. PRODUCT DISSOCIATION - product is released with the generation of ferric cytochrome P450. Oxidation of drugs is regulated by the level of enzymes [cytochrome P450 and NADPH cytochrome P450 reductase and substrates [Drug, NADPH and Oxygen]. Enzyme levels are increased [induced] by various agents [drugs, chronic alcohol intake, smoking, foods, etc.] and under these conditions various drugs are metabolized more rapidly. This means that patients with increased (induced) liver drug metabolism must be given higher doses of drugs to obtain the appropriate therapeutic effect. Infants and elderly individuals have a lower rate of hepatic drug oxidation. As a result, infants and the elderly should be given lower doses of drugs that are primarily metabolized by the P450-dependent oxidation of drugs in the liver. 2. Some examples of drugs that are oxidized by CytP450.

Oxidative dealkylation NDealkylation ODealkylation SDealkylation N-Oxidation Primary amines

Morphine, ethylmorph benzphetam aminopyrin caffeine, theophylline

Codeine, pnitroanisole

6Methylthiop methitural.

Aniline chlorphente

Secondary amines

2-Acetylam fluorene, acetaminop

Tertiary amines

Nicotine, methaqualo

S-Oxidation

Thioridazin cimetidine, chlorproma

Deamination

Amphetami diazepam.

Desulfuration 3. 2. Phase I reactions precede phase II reactions because they generate drug metabolites which possess an appropriate group for undergoing addition (conjugation) reactions. However, if the drug already has appropriate reactive sites then the drug can undergo phase II reactions immediately.

Thiopental.

B.

Phase II (synthetic or conjugation) reactions 1. Glucuronide synthesis (Glucose) - Major route a. UDP - glucuronic acid (UDPG) (UDPG) + RZH R-Z-glucuronide
E

b.

Enzyme is glucuronosyltransferase (E) 1. 2. 3. 4. Induced Microsomal Low in neonates Various forms of enzyme

2.

Amide formation a. Acetylation Acyltransferase N-AT = N

b.

Glycine conjugation

3.

Methylation a. O-, N- and S-methyltransferases

b.

S-Adenosylmethionine (SAM) is the substrate for methylation.

4.

Mercapturic Acid Formation (Acetaminophen Hepatotoxicity) a. b. c. d. Glucuronide and sulfate metabolites are non-toxic. Glutathione conjugation of oxidative metabolite (safe). Glutathione depletion results in metabolite-induced injury. N-Acetylcysteine (Mucomyst) reduces liver damage by increasing the biosynthesis of glutathione.

II.

FACTORS INFLUENCING DRUG METABOLISM A. Enzyme Induction (slow increase in the rate of drug metabolism) 1. 2. 3. 4. Agent or condition increases drug metabolism [hyperthyroidism] Accelerates drug clearance (increased drug metabolism) Reduces duration of drug action Examples of inducers (many drugs) a. Phenobarbital [anticonvulsant], 3-Methylcholanthrene [in cigarette smoke, Benzo(a)pyrene, [cigarettes and charcoal], Rifampin [antibiotic], Ethanol (chronic), Testosterone, etc.

B.

Enzyme Inhibition (rapid decrease in the rate of drug metabolism) 1. 2. 3. 4. Agent or condition reduces drug metabolism [pregnancy] Decreases drug clearance Prolongs duration of drug action Examples of inhibitors (many drugs) a. Chloramphenicol [antibiotic], Cimetidine [anti- ulcer], Disulfiram [drinking deterrant], Ethanol (acute), Grapefruit juice, etc.

C.

Age 1. 2. Drug metabolism is depressed in infants Drug metabolism [primarily oxidation] is depressed in the elderly

D.

Nutrition 1. Acute alcohol intake inhibits whereas chronic intake induces metabolism.

2. E. F.

Charcoal broiled food induces drug metabolism.

Liver disease decreases drug metabolism Genetic Variation 1. Isoniazid (INH) [prophylaxis of tuberculosis] produces liver injury in slow acetylators. Succinylcholine produces prolonged respiratory depression in patients with abnormal plasma cholinesterase [pseudocholinesterase]

2.

DRUGS TO REMEMBER Aspirin [antipyretic, analgesic, anti-inflammatory, anti-thrombotic], Procaine [local anesthetic], Procainamide [antiarrhythmic agent], Lidocaine [local anesthetic], Chloral Hydrate [sedative], Rifampin [antibiotic], 3-Methylcholanthrene and Benzo(a)pyrene [ DM inducers in cigaretette smoke], Phenobarbital [anticonvulsant, DM inducer], Ethanol [sedative, DM inducer (chronic intake) and inhibitor (acute intake)], Isoniazid [prophylaxis of tuberculosis], Epinephrine [vasoconstrictor], Norepinephrine [vasoconstrictor], Acetaminophen [antipyretic, analgesic], N-Acetylcysteine [mucomyst, reduces liver damage], Chloramphenicol [antibiotic, DM inhibitor], Disulfiram [drinking deterrent, DM inhibitor], Cimetidine [treatment of ulcers, DM inhibitor] and Testosterone [steroid, DM inducer].