Pharmac. Ther. Vol. 17, pp.

383 to 397, 1982

Printed in Great Britain All rights reserved

0163-7258/82/030383-15507.50/0
Copyright 1982 Pergamon Press Ltd

Specialist Subject Editors: M. ROWLAND and G. T. TUCKER

TIME-DEPENDENT

PHARMACOKINETICS
LEVY

RENI~ H.

Department of Pharmaceutics BG-20, University of I,Vashinyton, Seattle, Washinyton 98195, U.S.A.

1. INTRODUCTION The literature in pharmacokinetics indicates that for a number of years, the term nonlinearity has been associated almost exclusively with dose-dependent changes in pharmacokinetic parameters. The other type of nonlinearity, time dependency, has only been rarely alluded to and then, mostly in the context of chronobiology. No systematic treatment of time-dependent kinetics has appeared to date. Considering that any treatment of drug accumulation in the simplest pharmacokinetic model must assume that all pharmacokinetic parameters are time-invariant. However, it should not be concluded that the paucity of information on this subject reflects an awareness of the implications of the assumption of time-invariance. Rather, it is probably related to the fact that studies of time dependency necessarily involve longitudinal observations beyond those of typical single dose pharmacokinetic studies. This review represents an attempt to classify and analyze the various types of time dependencies based on the available literature. 2. CLASSIFICATION A major distinguishing feature between dose and time dependency is that the latter involves an actual physiological or biochemical change in the organ(s) of the body associated with the drug disposition parameters in question. For example, in time dependence of the auto or heteroinduction type, the increase in drug intrinsic clearance results from an increase in amount of enzyme (in protein synthesis). However, in a typical Michaelis-Menten dose dependency, drug clearance changes with concentration and such a system should not be considered time-dependent simply because the values of pharmacokinetic parameters also change with time. If that system was truly time-dependent, drug clearance should change with time while drug concentration is invariant (i.e., at steady state). However, the possibility exists, as will be shown later, that dose and time dependency can coexist simultaneously. There are at least two types of time dependencies. The first one is related to the fact that rhythms are a fundamental property of most physiologic functions. The word chronopharmacokinetics* has been used to describe these phenomena when these rhythms manifest-themselves in a corresponding change in the pharmacokinetic parameter of a drug. Typical examples include circadian rhythms in drug absorption, distribution and elimination. The second type of time dependency is best exemplified by the phenomena of auto or heteroinduction and could be classified as chemically-induced. It starts only after the introduction of an exogenous substance in the body and ultimately disappears after the causing agent is removed. However, the above distinguishing features are not absolute since certain rhythms are also dependent on environmental conditions and can therefore be manipulated exogenously. Also, it is conceivable that rhythmic changes in kinetic parameters could be chemically induced or altered. Time-dependent changes in pharmacokinetic parameters cannot always be classified within one of these two categories. A perusal of the literature shows the existence of a number of irregularities (such
*This term was formally introduced by F. Halberg at Capri, Italy, April 8, 1974 and by F. M. Sturtevant at Ravenna, Italy, October 18, 1974, at International chronobiological symposia. 383

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as 'bumps') in plasma drug concentration-time curves especially in single dose studies. In general, the mechanism of this type of time is unknown and has not been the subject of prospective studies. 3. PHYSIOLOGICALLY-INDUCED TIME DEPENDENCY: CHRONOPHARMACOKINETICS Chronopharmacokinetics as a subdiscipline arises as a result of the chronobiological concept of the human body proposed by Halberg and coworkers (Reinberg and Halberg, 1979). The chronobiological concept as opposed to the traditional homeostatic view of the human body takes into consideration the fact that basic cellular functions are cyclic and that there exists a number of cyclic humoral and neural controls which are in phase with environmental inputs. There are biologic clocks with a time scale distinct from calendar time. From the chronobiology concept emerges the notion of chronopharmacology which is the study of time dependent physiological responses to drugs. Several pharmacological classes of drugs have shown marked rhythms of effectiveness and toxicity. These include anesthetics (halothane, cyclopropane and barbiturates), analeptics (tremorine, amphetamine) corticosteroids, anabolic steroids, antihistamines and antihypertensive drugs (see review of Ede, 1973). Early findings of chronopharmacology led to the investigation of chronovariability in some of the factors responsible for drug action, in particular drug absorption, distribution and elimination. The majority of reported studies dealing with chronopharmacokinetics are descriptive rather than mechanistic. Few studies address specific fundamental parameters of drug disposition such as intrinsic clearance or blood flow to an eliminating organ. This is not surprising given that they were performed over the last fifteen years, during which time the discipline of pharmacokinetics has grown and evolved significantly. In this review an attempt has been made to separate the reported time dependencies into the following categories: (1) absorption--elimination parameters, (2) systemic clearance, (3) enzymatic metabolic activity, (4) plasma binding, (5) renal clearance, and (6) cerebrospinal fluid drug concentration.
3.1. TIME DEPENDENCY IN ABSORPTION--ELIMINATIONPARAMETERS

This category includes studies involving oral drug administration, generally given as a single dose at various fixed times. In most cases, the parameters measured represent hybrids of absorption and elimination such as peak time and peak concentration." In general, the differences observed between various periods in a diurnal cycle are relatively small. The apparent objective in most studies has been to determine whether any chronovariability is present. For a comprehensive list of drugs which exhibit some chronopharmacokinetic property, see Reinberg (1978 and Halberg et al. (1980). In an attempt to separate the contribution of environmental and genetic factors to the frequently observed intersubject variability in drug disposition, Vesell and coworkers investigated the kinetics of phenacetin, acetaminophen and antipyrine at various times of the day (Shively and Vessell, 1976; Vesell et al., 1977). Overall, only small differences were found in the elimination half-life between 06.00 and 14.00hr. In a group of 19 subjects, 12 showed a difference in antipyrine half-life between 12.00 and 24.00hr of greater than 10~o. However, of these 12 subjects, 5 had the shorter half-life at midnight while for the remainder this occurred at midday. When the studies were repeated, in 8 of the 12 subjects, each responded as before. When chlorazepate (50 mg capsule) was administered daily at 7.00 and 19.00 hr to five subjects, the time to reach the peak plasma drug concentration was longer after the evening than after the morning treatment (Aymard and Soulairac, 1979). Carosella et al. (1979) performed several studies with fl-methyldigoxin (BMD). A group of six normal volunteers received a 1 m dose of BMD elixir at six different times of the day. Using the cosinor method of analysis, the authors found a circadian rhythm in the

Time-dependent pharmacokinetics

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total area under the plasma drug concentration-time curve and in peak plasma drug concentration (mesor 8.38 mg/ml; amplitude 1.28 mg/ml; acrophase 03.50 hr). The curves obtained in four of the six treatment times showed a second peak. A circadian rhythm in this second peak was also found (acrophase 10.07 hr). In a number of cases, the presence of this second peak precluded treatment of elimination as a first-order process. This second peak was also found after intravenous administration of the drug to another group of five subjects. Although a significant fraction of the dose is excreted unchanged, no significant differences in cumulative urinary excretion were found. The time dependence of the pharmacokinetics of indomethacin was investigated in a group of healthy volunteers who each received the drug at five different fixed times of the diurnal cycle (Clench et al., 1977). Cosinor analysis showed a circadian rhythm in peak height, peak time but no circadian variation in area. Administration of the drug at 19.00 hr was associated with the smallest peak height and longest peak time. In the rat, Labrecque et al. (1979) found no diurnal variation in indomethacin plasma concentrations after administration at 8.00, 14.00 and 20.00 hr. Although, in the same study, time-dependent variations in the effect of the drug were observed. Preliminary results of a study of circadian rhythm in the bioavailability profile of theophylline in man showed that time to peak was shorter for the 01.00 hr dose, and the peak drug concentration was highest after the 07.00 hr dose (Kyle et al., 1979). Valli et al. (1980) reported on the pharmacokinetics of carbamazepine administered orally to rats at four fixed times: 04.00, 10.00, 16.00 and 22.00hr. Compared to the 16.00 hr administration, the other three treatments showed significant differences in the ratio of peak plasma drug concentration to time to peak. The apparent half-lives of the 22.00 and 04.00 hr treatments were significantly shorter than the other two times. However, it should be pointed out that half-lives of 10-15 hr, found in this study, are several fold longer than those reported previously and can be explained by prolonged absorption. This explanation is also compatible with the finding that there was no significant differences in area under the curve. Variability in the fraction of carbamazepine plasma unbound as well as the plasma albumin and total protein concentrations was also observed throughout the diurnal cycle. In a recent study, Cenraud et al. (1981) monitored the plasma concentration of valproic acid continuously for 24 hr in two groups of patients receiving the drug two or three times daily. When the dosing interval was 12 hr, the concentration profile during two consecutive periods were not the same. Time to reach peak drug concentration was much longer at night than the day time. The difference could be explained by a previous finding that food intake delays drastically the absorption of valproic acid from enteric coated tablets (Levy et al., 1980). The pharmacokinetics of ethanol in both man and rodents has been studied for several decades (Sturtevant, 1976), mostly without regard for chronovariability. Recently, Reinberg et al. (1974, 1975a) administered a single oral dose of ethanol to six normal males at 07.00, 11.00, 19.00 and 23.40 hr and monitored the plasma ethanol concentration. Cosinor analysis showed a circadian rhythm in the pharmacokinetics (based on 6 samples over 4 hr). Peak concentration was highest after the morning dose (acrophase 10.40 hr; amplitude 12.7~o of mean). Peak time was longest after evening dosing (acrophase at 23.55 hr; amplitude 23.2Yo of mean) and area was largest after midday dosing (acrophase 14.39 hr; amplitude 14.4y/oof mean). Recently Sturtevant et al. (1978) used multiple doses to maintain plasma ethanol concentrations within a constant range in a group of five healthy males. In each dosing interval a zero order equation was fitted to the concentration data during the post absorption phase. An analysis of covarience yielded a rejection of the hypothesis that the slopes were from the same population (four out of five subjects). The slowest rates of decline were generally between 12.00 and 20.00 hr. The authors pointed out that although a cosine function could be adequately fitted to the mean data, such a treatment is not proper since it would obscure individual variation. The findings of this study, as well as those of previous workers (Wilson, 1956; Jones, 1974; Swoyer, 1975; Reinberg, 1976)are

386

RENEH. LEvY

compatible with the suggestion that ethanol is metabolized more slowly during the second half of the awake phase of the diurnal cycle. In a recent study, Madsen and Rossi (1980) investigated the effects of sleep on the ethanol Michaelis-Menten parameters describing the elimination of ethanol. There was no significant differences in either Vmax or K,, between the recumbent awake and sleep phases. Preliminary communications (Pinkston e t al., 1979; Sturtevant and Garber, 1979) report that ethanol kinetics follow a light-dark cycle is present, that they exhibit phase shifting and are significantly altered by feeding habits. 3.2. TIME DEPENDENCY IN SYSTEMICCLEARANCE The studies to be described here represent a homogeneous group and are different from the previous ones in that drug was administered intravenously at a constant rate, that observations were made at steady state, thus reflecting directly variations in systemic clearance and that one animal species, namely the rhesus monkey, was used. Patel e t al. (1977) gave infusions of ethosuximide in over 4 months to three rhesus monkeys under strictly controlled environmental conditions (light 06.00-18.00 hr, dark

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Time-dependent pharmacokinetics

387

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FIG. 2. Plasma clonazepam concentrations during Study I in Monkeys 1, 3, 6 and 7. The durations of clonazepam and carbamazepine administration are illustrated at the top of individual plots. The continuous lines were simulated with parameters obtained from curve fitting of experimental data (from Lai and Levy, 1979; with permission of the Journal of Pharmaceutical Sciences). 0 indicates latency.

18.00-4)6.00 hr, EEG verification of sleep). Plasma drug samples were collected at 2 hr intervals over a 26 hr period once a week for 5 weeks. Analysis of plasma drug concentration data showed a decline from 08.00 to 14.00-16.00hr, a plateau or small rise between 16.00 and 20.00 hr and a decline until 20.00-24.00 hr, followed by a steady rise until 08.00-10.00 hr the following day. The minimum, occurring during the night period, reflected the largest percent change in plasma drug concentrations (4-8~o, using the 08.00 hr value as reference). This time course of plasma concentrations was reproducible on successive weeks. Cross-correlation analysis yielded periods very close to 24 hr. Using a similar experimental design, Levy et al. (1977a) investigated the diurnal variability in the steady state concentration of valproic acid in rhesus monkey. Between 10.00 and 18.00hr, the plasma concentrations remained stable or decreased; between 18.00 and 06.00 hr (second day), they increased and reached a maximum (maxima were 40-140% higher than minima); and between 06.00 and 12.00hr they decreased to reach values which were within 10% of those of the previous day. Cross-correlation analysis yielded amplitudes between 20 and 30~ and periods between 23 and 31 hr. These observations above prompted a study in a group of 12 epileptic monkeys of both these drugs (Levy et al., 1977b). Ethosuximide was infused to maintain two consecutive stepwise steady-state concentrations (50/~g/ml for 3 weeks and 100#g/ml for 2 weeks). Valproic acid was maintained at three consecutive stepwise steady-state concentrations (50pg/ml for 3 weeks; 100#g/ml for 2 weeks; 150/~g/ml, for 2 weeks). Plasma samples were collected from all animals every two hours over a 24 hr period at each step animal. The results are shown in Figs 1 and 2. Interanimal variability was relatively small and individual curves could be averaged. The pattern of oscillations was similar to that observed in the previous studies. The mean ratios of maximum to minimum concentration were 1.25 and

388

RENEH. LEVY

1.19 for the two steps (increasing) of ethosuximide and 1.46, 1.32 and 1.31 for the three steps of valproic acid. Since the two previous studies showed that plasma levels tended to increase during the dark period, another study was designed to test that correlation by phase-reversing the light-dark cycle (Lockard et al., 1977). The experimental design comprised 4 months of synchronous 12 hr light-dark cycle, with blood sampling at 2 hr intervals for 48 hr, then reversal of the light-dark cycle to 12 hr out of phase for 2 months and repetition of the 48 hr blood sampling period. It was found that the diurnal pattern (low levels during day, high levels at night) was reproducible on two consecutive days. The extent of oscillation was consistent with previous observations. After reversal, valproate levels declined between 18.00 and 02.00 hr (in opposition to increases observed during this period prior to reversal). Also the occurrence of the time of maximum and minimum was out of phase with the prereversal data. Although the reversal was probably not complete (monkeys slept less during dark phase after reversal), the results indicate that the diurnal variations in steady state concentration of valproic acid are related to the circadian sleep cycle in the rhesus monkey. In a recent study (Loiseau et al., unpublished) steady-state valproic acid concentration levels were achieved in five patients by a combination of an intravenous bolus and a constant rate infusion. Small but significant oscillations in the concentration were observed ranging from 22 to 34yo of the mean value. However no circadian rhythm in systemic clearance was apparent. Using similar designs, the same authors found diurnal oscillations in steady state levels of carbamazepine (Lockard et al., 1979a) and clonazepam (Lockard et al., 1979b). For these four drugs (ethosuximide, valproic acid, carbamazepine and clonazepam), it was consistently found that systemic clearance decreases at night and increases during daytime. This is noteworthy since these drugs are eliminated mostly by metabolism, through a variety of metabolic pathways involving not only oxidation but also reduction (as in the case of clonazepam). For drugs with low extraction ratios, diurnal fluctuation in systemic clearance can be explained by fluctuations in intrinsic metabolic clearance, in plasma protein binding or both. These two aspects are examined in the next two sections. 3.3. TIME DEPENDENCY IN ENZYMATIC METABOLIC ACTIVITY Two classic studies performed in rodents have illustrated daily variations in drug metabolizing enzymatic activity. Radzialowski and Bousquet (1968) followed the microsomal metabolism of aminopyrine, p-nitroanisole, hexobarbital and 4-dimethylamino azobenzene (4-DAB) in male rats. They found a circadian rhythm with maximum activity at 02.00 hr and minimum at 14.00 hr. Plasma corticosterone levels also followed a circadian rhythm, but 12 hr out of phase with the rhythm of enzymatic activity. Adrenalectomy abolished the rhythm of the oxidative metabolism of aminopyrine, p-nitroanisole and hexobarbital but had no effect on the reduction of 4-DAB. Maintenance of elevated plasma corticosterone levels resulted also in the disappearance of the rhythm in oxidative metabolism. These findings suggest that the circadian rhythm in enzymatic activity is related to a similar rhythm in plasma corticosterone levels. Jori et al. (1971) examined the metabolic activity of rat microsomal preparations with respect to four substrates. When the light phase was between 06.30 and 18.30hr, the minimum activity was between 10.00 and 14.00 hr. After a 12 hr phase reversal, the minimum activity was also reversed (i.e. during the light phase). The cycle in plasma corticosterone levels was also reversed. 3.4. TIME DEPENDENCY IN PLASMA BINDING A small number of studies have reported diurnal variations in plasma binding of drugs. In the previously mentioned study of carbamazepine in rat (Valli et al., 1980), it was

Time-dependent pharmacokinetics

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found that albumin, total protein, and carbamazepine-free fraction varied significantly during a 24hr period. Carbamazepine free fraction decreased by 50% from 10.00 to 04.00 hr. In a recent study (Patel et al., unpublished) phenytoin and valproate free fractions were determined in plasma samples collected every 2 hr for 25 hr in six subjects. The values for valproic acid exhibited marked fluctuations with a ratio of maximum to minimum ranging from 1.30 to 1.68 (maxima around 02.00 or 08.00hr, minima between 16.00 and 20.00 hr). In contrast, phenytoin did not show important fluctuations. Valproate free fraction was significantly correlated to free fatty acid (FFA), albumin and total protein concentrations. Supporting these observations Naranjo et al. (1980) have shown that in normal subjects diazepam free fractions decreased significantly concomitantly with FFA two hours after a standard breakfast. Since FFA levels vary during the diurnal period and they have been shown to alter the extent of binding of many drugs, this source of chronovariability in pharmacokinetic parameters should be taken into consideration.

3.5. TIME DEPENDENCY IN RENAL CLEARANCE

Most of the studies describing time dependence in urinary excretion were performed some fifteen years ago, at the time when the discipline of pharmacokinetics was emerging. The principle involved centers around the fact that the diurnal rhythm in urinary pH influences the urinary excretion of weak acids and bases with pKas in the sensitive range. The classic study of Beckett and Rowland (1964) showed that the wide variations in excretion rate of amphetamine in man were not random. The excretion rate was rhythmic over a 48 hr period and paralleled the changes in urinary pH. Amphetamine is a weak base with a high pKa and pH-sensitive excretion. Another classic investigation of the consequences of diurnal changes of urinary pH was the study of Dettli and Spring (1966) with two sulfonamides. The authors based their study on the hypothesis that acidification of the urine during sleep should decrease the urinary excretion of sulfasymazine (pKa = 5.5) but have little or no effect on the excretion of sulfanilamide (pK~ = 10.5). As predicted, the mean half-life of sulfasymazine was three times longer at night (35 hr) than during the day (13.5 hr). The half-life of sulfanilamide was not different during the two diurnal phases. Reinberg et al. (1967) examined the urinary excretion of salicylate in a group of six healthy subjects who received four single oral doses at 07.00, 11.00, 19.00 and 23.00 hr. There was a difference in duration of salicylate excretion between the 07.00 hr administration (22 + _ 1.36 hr) and the 19.00 hr administration (17.3 _ 1.33 hr). A cosinor analysis _ performed on tile excretion during the first 4 hr period showed a significant circadian rhythm, corresponding to a higher excretion after drug administration at 19.00 hr. The results of this study were later reanalyzed by the same authors (Reinberg et al., 1975b).

3.6. TIME DEPENDENCY IN CEREBRO-SPINAL FLUID (CSF) DRUG CONCENTRATION

Are oscillations in plasma drug concentrations accompanied by oscillations of drug in other body fluids? This question was addressed for valproate levels in CSF in a study from our laboratory (Vishwanathan et al., unpublished). Plasma and CSF concentrations of valproic acid were monitored simultaneously in a group of six Rhesus monkeys during constant rate intravenous infusion of the drug. The time course of CSF concentration showed the existence of a diurnal cycle: they paralleled plasma concentration with maxima during the dark period (02.00-05.00 hr) and minima during the light period (14.00--17.00 hr). The ratio of maximum to minimum concentration ranged from 1.31 to 1.42 for plasma and 1.35 to 1.81 for CSF.

390

RENI~H. LEVY 4. C H E M I C A L L Y I N D U C E D T I M E D E P E N D E N C Y 4.1. AUTO AND HETERO-INDUCTION

Auto and hetero-induction represent typical examples of this type of time dependency. Whereas in biochemical pharmacology, induction is often considered as a state (i.e. induced or not induced), the aspect of the phenomenon of induction which is of interest in the present context is its time course. From a whole-body drug disposition point of view, this time course often manifests itself in terms of characteristic decreases (or increases) in plasma levels. The literature on this subject is not extensive. For clarity, it has been divided into several categories. The criterion used has been whether or not the data were fitted to a mathematical model. It appears that in most of the early literature, no attempt was made to describe the time course of induction in quantitative terms but that, in the last five years some mathematical descriptions have been proposed.
4.1.1. Time Course o f Induction with N o Mathematical Model

Breckenridge and Orme (1971) described several cases of decreases in the steady state plasma concentration of warfarin in patients after addition of hypnotic agents (inducers), followed by increases in concentration after removal of those inducing agents. These studies were undertaken because of incidence of severe haemorrhage with oral anticoagulants several days after withdrawal of hypnotic drugs. The basic experimental design included three consecutive phases of approximately one month each, a control period, an interaction period, and a third phase to describe the behavior of warfarin concentrations after discontinuation of the hypnotic agent. These studies also included also an assessment of anticoagulant control by the Thrombotest. The effect of dichloralphenazone (molecular complex of chloral hydrate and phenazone or antipyrine) (dose 1300 mg/day) was examined in five patients. In the last 14 days of dichloralphenazone administration, warfarin concentration represented 20-69~o of the values in the control phase. In one subject for whom the time course was shown, most of the decrease in warfarin levels occurred in the first 12 days of dichloralphenazone treatment. The induced steady state was maintained for 8-10 days as long as dichloralphenazone was administered. When dosage of the latter was stopped, warfarin concentrations began to rise slowly, eventually reaching a postinduction steady state close to the control level. The percent Thrombotest values tended to follow the warfarin levels. In a follow up study, where chloral hydrate and antipyrine were administered separately, the authors showed that this effect was due to antipyrine. The latter was shown to decrease warfarin levels in 15-20 days. Amylobarbital (200mg/day) administered to three patients (200mg/day) decreased mean warfarin concentration from 1.76_+0.32 to 0.90 _+ 0.19 /~g/ml. Secobarbital (100 mg/day) was also able to reduce warfarin levels in three patients. The time courses of induction produced by amy]obarbital and secobarbital were found to be reproducible in two consecutive experiments (in one subject each). In a later study, Breckenridge et al. (1973) followed the change in warfarin concentration associated with quinalbarbitone treatment in six patients and following recovery. Plasma warfarin concentration decreased within 8 days of barbiturate treatment and reached an induced steady state by 20-26 days. Following the end of the barbiturate administration, warfarin concentration increased back to control values within 20 days. In an attempt to correlate antipyrine kinetics with urinary excretion of D-glucaric acid, Davis et al. (1974) followed plasma antipyrine concentration during the administration of 600 mg of the drug twice daily for 2 weeks. By the 7th day~ plasma antipyrine concentration started to decrease and reached a lower steady state by the 15th day. In a recent study, Bertilsson et al. (1980) followed the time course of autoinduction of carbamazepine in three epileptic children. They used an elegant experimental design

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which consisted of administration of deuterated carbamazepine four times during approximately 5 months of treatment. This approach enabled the determination of the pharmacokinetic parameters of carbamazepine from the deuterated species, while the patients received their regular treatment. Drug clearances were measured during each of those administrations (day 1, day 6, days 21-36, days 146-162). Clearance started to increase on day 6, continued to increase at days 21-36, but showed no further increase at the fourth study period (days 146-162).

4.1.2. Time Course of Induction with a Mathematical Model 4.1.2.1. Empirical fitting Pitlick et al. (1976) followed the time course of carbamazepine autoinduction in six subjects receiving a 6 mg/kg daily dose for 22 days. Average steady state concentrations were determined during dosing intervals at days 8, 15 and 22. By the end of the third week, average concentrations were 50~ of those predicted from single dose studies. The complete time course of blood levels was fitted to a one-compartment model with firstorder absorption and an exponentially increasing elimination rate constant. The increase in the elimination rate constant was governed by a first-order induction rate constant. This was an empirical model based on the observation that the minimum concentrations appeared to decrease exponentially. The fit of experimental data to these model predictions was adequate and yielded induction half-lives ranging from 2.2 to 6.4 days with a mean of 4.0 _ 1.6 days (Levy et al., 1976). In a subsequent study (Pitlick and Levy, 1977), the time course of carbamazepine autoinduction in rhesus monkey was followed during constant rate intravenous infusion of the drug. Plasma concentration reached an initial (preinduction) steady state (8-12 hr) then decreased over a period of 36-48 hr to a lower (induced) steady state. The latter was maintained for an additional five days. The fall in carbamazepine steady state concentration appeared to be exponential and the data were adequately fitted by a monoexponential function from which an induction rate constant was obtained. Induction half-lives of 5.8, 11.6 and 7.6 hr were obtained. Guelen and Van der Kleijn (1978)described the time course of increase in clearance of valproic acid in one dog following phenobarbital treatment. Valproate clearance started to increase between the fourth and sixth day, reached a maximum by day 18 and remained at that level until day 28. The clearance increased over three-fold. The data appeared to have been fitted to an exponential function. 4.1.2.2. Acute autoinduction model Reilly et al. (1978) reexamined the apparent dose-dependency of amobarbital kinetics in dogs reported by previous workers and found that this behavior could be better explained by single dose autoinduction. They showed that the rate constant of the terminal phase was larger after a high dose than after a low dose, and proposed a model involving drug-induced transformation of inactive into active enzyme. A differential equation was proposed, but no explicit solutions were derived. 4.1.2.3. Biochemical and pharmacokinetic model of auto- and hetero-induction (1) Theoretical basis. This theory relates changes in enzyme levels following induction to changes in intrinsic drug clearance (Levy et al., 1979a). After induction, the following sequence of events is proposed: (i) rapid increase in enzyme synthesis rate (and/or decrease in degradation rate);

(ii) time-dependent increase in enzyme level governed by the degradation rate constant
of the enzyme (kt);
J.P.T. 17/3--8

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REN~H. LEVY

(iii) time-dependent increase in maximum velocity of enzymatic metabolic reaction (Vmax) also governed by k; (iv) increase in intrinsic clearance C L i , t (where C L i , ~ = V m , x / K m ; K m = Michaelis constant); (v) concomitant decrease in steady-state drug plasma level (Cs~). For a unienzyme system, the increase in intrinsic drug clearance is monoexponential:
CLan, = CL'i,, - (CL'i,, CL~,,) e - k ' t

(1)

where CLimand CL'i~ t refer to the preinduced and induced states, r e s p e c t i v e l y . Thus the model proposes that the time course of drug clearance is also controlled by the enzyme degradation rate constant. For drugs with low hepatic extraction ratios, equations have been derived to describe the time course of drug concentration after single or multiple dose situations (Levy et al., 1979b). Under single doses, this model predicts t h a t the slope, of the semilogarithmic plot of drug amount (or concentration) vs time, increases with time (drug elimination is faster as time increases). The case of autoinduction during constant rate drug administration (intravenous or oral) required a knowledge of the relationship between drug half-life and the latency of induction. If the latter is longer than 5 hall'-lives, drug levels will reach a steady state and then decreases after the beginning of induction. If not, induction will start before steady state is achieved. In the latter case, drug concentrations increase, reach a maximum, and decrease towards the induced steady state without achieving a preinduction steady state. Levy and Dumain (1979) showed that these equations are consistent with the corresponding equations of the one-compartment model with constant clearance. Both sets of equations can be written in an identical fashion using the area subtended by the CL vs t curve. When the clearance is constant, that area is simply equal to the product of C L and t. (2) A p p l i c a t i a n s . A series of studies were performed to test the applicability of this theory. (a) A n i m a l studies. In preliminary studies, the time courses of induction of valproic acid and ethosuximide by carbamazepine (inducer) were examined in rhesus monkeys. The experimental design involved intravenous infusion of the inducer and induced species to maintain steady states of both species. Computer regression of model predictions to experimental data gave correlation coefficients ranging from 0.886 to 0.996. The carbamazepine-clonazepam interaction in rhesus monkey (Lai and Levy, 1979) represents the most comprehensive validation study because it included an examination of the time course of induction after addition (Study I) and removal (Study II) of the inducer. In Study I, clonazepam was infused in 4 monkeys at a constant rate for 8-9 days. After 2 days, when a preinduction steady state was achieved, carbamazepine was added to the infusion. In Study II, carbamazepine was infused in 4 monkeys during days l through 6 and clonazepam during days 4-12. Figure 2 shows the results of Study I. Conazepam levels increased to a preinduction steady state, then decreased after a variable latency time to reach an induced steady state, and decayed with an induced elimination half-life. The half-lives of induction were 6.9, 27.2, 66.4 and I 1.4 hr. Figure 3 shows the data of Study II. Following removal of the inducer, there was a latency period after which clonazepam levels increased to a postinduction (control) steady state. The disappearance half-lives were significantly longer than those measured during approach to steady state. The half-lives of induction were shorter than in Study I: 18.2, 5.7, 19.3 and 2.7 hr. The fits between experimental data and model predictions gave correlations between 0.924 to 0.993 for Study I, and between 0.905 to 0.964 for Study II. (b) H u m a n studies. The time course of induction of clonazepam by carbamazepine was studied in seven healthy volunteers by Lai et al. (1978). Each subject received 1 mg of clonazepam daily for 29 days and carbamazepine 200 mg daily during days 8 through 29. An example of the time course of clonazepam levels and corresponding model predictions is shown in Fig. 4. Prior to carbamazepine addition, clonazepam levels reached a

Time-dependent pharmacokinetics

393

MOrlKEY ~

~ - " . _

MONKEY 3

F"k

TIME [HOURS]

TIME [HOURS]

~m

C *~-~J .L .O.N .A. . .ZE. P A M . . ...

-

jl~

' bC , z ' Zig

~

c~o.,ZE,,. ~

--

MONKEY 6

e,

MONKEY 7

o_ E t

o_
CD

L, e"

TIME [HOURS]

TIME [HOURS]

FIG. 3. Plasma clonazepam concentrations during Study II in Monkeys 4, 3, 6 and 7. The carbamazepinc (CBZ) and c]onazepam administrations arc illustrated at the top of individual plots. Zero time is defined as the time when clonazepam infusion was started. Three to four days prior to zero time, animals were started on the carbamazcpine infusion (indicated by an arrow starting prior to zero time in the carbamazcpine bar). The continuous lines were simulated with parameters obtained from curve fitting of experimental data. (From Lai and Levy, 1979, with permission of the Journa/of Pharmaceutical Sciences.) 0 indicates latency.

C L 0 N A Z [ P A M

t4

lllllilIll1111ttllll~ll~liil
SUBJECT G

~to

00

l0

15

20

25

30

35

FIG. 4. Plasma clonazepam concentrations in subject G. Clonazepam (1 mg once daily) was administered for 29 days and carbamazepine (200 mg once daily) on days 8 to 29. (From Levy and Lai, 1980; In: Anti-Epileptic Therapy: Advances in Drug Monitoring, with permission of Raven Press.)

394

REN~H. LEVY

preinduced steady state (4~7 #g/ml) and during carbamazepine treatment, clonazepam decreased over a period of a week to an induced steady state (2.5-4/~g/ml). The mean correlation coefficient for fits of model predictions to experimental data was 0.935 __ 0.095. Half-lives of induction ranged between 1 and 6 days. The time course of decrease in valproic acid levels following induction by carbamazepine was examined in normal volunteers using a design similar to the previous study (Bowdle et al., 1979). Valproic acid was given for 22 days and carbamazepine was added from day 5 to 22. Valproate clearance was determined on days 4, I l, 18 and 22. Except in one subject, valproate clearance did not increase between days 4 and I l and therefore it was not possible to obtain an induction half-life. Recently, Warren et al. (unpublished) studied the time course of induction of ethosuximide clearance by carbamazepine in normal subjects. Ethosuximide clearance was determined prior to (day 10) and following carbamazepine treatment (days 17, 21 and 28). Those values were fitted to Eqn l and the following induction half-lives were obtained: 136, 806 and 85 hr. These studies have shown that this induction model, with a realistic biochemical basis, was applicable to a variety of induction situations in both monkey a.nd man. It introduces a new pharmacokinetic parameter, the induction half-life to describe the time dependency of clearance. The determination of this parameter provides a means of quantifying the intersubject variability in time dependency. Subjects can be separated into slow and fast inducers. Several questions remain unanswered, in particular the fact that multiple enzymes may be induced. Simulated data have shown that it is possible to distinguish between mono and biexponential increases in clearance. If more than two enzymes are involved, the time course measured from clearance determinations becomes a hybrid which then reflects those enzymes with the slowest turnover half-lives. Other questions presently under investigation include the application of this model to drugs with medium to high extraction ratios and the relationship between drug half-life and induction half-life. 4.2. OTHER TYPES OF CHEMICALLY-INDUCEDTIME DEPENDENCY The fact that enzymatic induction has been classified as a type of time dependency raises the issue of enzyme inhibition. The latter does not constitute time dependency because the decrease in clearance is generally proportional to the concentration of the inhibitor and is not accompanied by a permanent physiological or biochemical change in organism. One exception would be the type of irreversible inactivation of P4~0 enzymes caused by ethynyl or so-called 'suicide' substrates (Ortiz de Montellano and Kunze, 1980). However, the pharmacokinetic correlate of this biochemical phenomenon has not yet been defined. Another possible type of chemically-induced time dependency which has not been investigated would be a time dependent change in volume of distribution resulting perhaps from changes in tissue binding. Progress in this area will probably be dependent on progress in experimental approaches to the determination of binding of drugs in tissues. 5. C O N C L U D I N G C O M M E N T S In addition to difference in their etiology, the two types of time dependencies described in this review present differences in other characteristics, in particular in their significance in therapeutics and in research into drug disposition. F r o m a point of view of clinical significance, it appears that, at the present time, the chemically-induced type of time dependency has more impact. Although this may be a broad generalization, it is based on the observation that, quantitatively, the changes in drug clearances which accompany enzyme induction are larger than those seen in chronopharmacokinetics. For example, dosage modifications after addition or removal of an inducer have become a

Time-dependent pharmacokinetics

395

clinical reality. Dosage adjustments to compensate for a chronopharmacokinetic* property or phenomenon have not yet entered pharmacology and therapeutics textbooks. However, from a research point of view, chronopharmacokinetic phenomena should be taken into consideration, especially in experimental designs. For example, whenever blood samples are taken over several days, attempts should be made to make comparisons based on observations made in the same portion of the diurnal cycle. Also, a number of additional experimental variables which affect chronopharmacokinetic phenomena should be controlled. In particular, the level of physical activity, posture and durations of light and dark phases, etc. It should also be noted that the physiologicallyinduced time dependency cannot be simply eliminated by controlling exogenous variables (such as removing inducers). The best that can be done is to make the phenomenon reproducible by controlling as many variables as possible. A significant portion of the literature examined in this review represents fairly recent work. The area of time dependency has grown significantly in the last five years and this development is expected to continue.
Acknowledgements--The author acknowledges the assistance of Ms. Raina H. Ballard in the preparation of this manuscript.

REFERENCES
AYMARD, N. and SOULAIRAC,A. (1979) Chronbiological changes in pharmacokinetics of dipotassic clorazepate, a benzodiazepine. In: Advances in the Biosciences, 19, pp. 111-116, REINBERG,A. and HALBERG,F. (eds). 7th int. Congr. Pharmac., Symposium on Chronopharmacology, Paris-Velizy, July, 1978. Pergamon Press, Oxford. BECKETT, A. H. and ROWLAND, M. (1964) Rhythmic urinary excretion of amphetamine in man. Nature 204: 1203-1204. BERTILSSON, L., H6JER, B., TYBR1NG, G., OSTER1OH, J. and RANE, A. (1980) Autoinduction of carbamazepine metabolism in children examined by a stable isotope technique. Clin. Pharmac. Ther. 27: 83-88. BOWDLE, T. A., LEVY, R. H. and CUTLER, R. E. (1979) Effects of carbamazepine on valproic acid kinetics in normal subjects. Clin. Pharmac. Ther. 26: 629-634. BRECKENRIDGE, A. and ORME, M. (1971) Clinical implications of enzyme induction. In: Drug Metabolism in Man, pp. 421--431, VESELL, E. S. (ed). Ann. N.Y. Acad. Sei. 179, N.Y. Academy of Sciences, New York. BRECKENRIDGE, A., ORME, L. E., DAVIES, L., THORGEIRSSON, S. S. and DAVIES, D. S. (1973) Dose-dependent enzyme induction. Clin. Pharmac. Ther. 14: 514-520. CAROSELLA, L., DINARDO, P., BERNABEI,R., COCCHI, A. and CARBONIN, P. (1979) Chronopharmacokinetics of digitalis circadian variations of beta-methyl-digoxin serum levels after oral administration. In: Advances in the Biosciences, 19, pp. 125-134, REINBERG, A. and HALBERG, F. (eds). 7th int. Congr. Pharmac., Symposium on Chronopharmacology, Paris-Velizy, July, 1978. Pergamon Press, Oxford. CENRAUD, B., GUYOT, M., LEVY, R. H., BRACHET-LIERMAIN,A., MORSELLI, P. L. and LOISEAU, P. (1981) Effect of dose regimen on valproic acid plasma levels. Proc. 12th Epilepsy int. Symp., Copenhagen, Sept. 6-10, 1980, DAM, M., GRAM, L. and PENRY, J. K. (eds). Raven Press, New York (In press). CLENCH, J., REINBERG, A, DZlEWANOSKA, J., GHATA, J. and DUPONT, J. (1977) Chronopharmacokinetics of Indomethacin in 9 healthy young human adults. Chronobiolooia 4. DAWS, M., SIMMONS, C., DORDONt, B. and WILLIAMS, R. (1974) Urinary o-glucaric acid excretion and plasma antipyrine kinetics during enzyme induction. Br. J. clin. Pharmac. 1 : 253-257. DETTLI, L. and SPRING, P. (1966) Diurnal variations in the elimination rate of a sulfonamide in man. Heir. reed. Acta 4: 291-306. EDE, M. C. M. (1973) Circadian rhythms of drug effectiveness and toxicity. Clin. Pharmac. Ther. 14(6): 925--935. GUELEN, P. J. M. and VAN DER KLEUN, E. (1978) Rational Anti-Epileptic Drug Therapy, p. 108. Elsevier, Amsterdam. HALBERG, F., KABAT, H. F. and KLEIN, P. (1980) Chronopharmacology: a therapeutic frontier. Am. J. Hosp. Pharm. 37: 101-106. JONES, B. M. (1974) Circadian variation in the effects of alcohol on cognative performance. Q. J. Stud. Alcohol 35: 1212. JORI, A., DISALLE, E. and SANTINI, V. (1971) Daily rhythmic variation and liver drug metabolism in rats. Biochem. Pharmac. 20: 2965-2969. KYLE, G. M., SMOLENSKY, M. H. and McGOVERN, J. P. (1979) Circadian variation in the susceptibility of rodents to the toxic effects of theophylline. In: Advances in the Biosciences, 19, pp. 219-244, REINBERG, A. and HALBERG, F. (eds). 7th int. Congr. Pharmac., Symposium on Chronopharmacology, Paris-Velizy, July 1978. Pergamon Press, Oxford. LABRECQUE,G., DORE, F., LAPERRIERE, A., PERUSSE, F. and BELANGER,P. M. (1979) Chronopharmacology ll--variations in the carrageenin-induced edema, in the action and the plasma levels of indomethacin. In: *This term does not include chronovariability in'receptor response.

396

RENI~ H. LEVY

Advances in the Bioseiences, 19, pp. 231-238, REINBERG,A. and HALBERG,F. (eds). 7th int. Congr. Pharmac. Symposium on Chronopharmacology, Paris-Velizy, July 1978. LAI, A. A., LEVY, R. H. and CUTLER, R. H. 0978) Time-course of interaction between carbamezepine and clonazepam in normal man. Clin. Pharmac. Ther. 24: 316-323. LAI, A. A. and LEVY, R. H. (1979) Pharmacokinetic description of drug interactions by enzyme induction: carbamezepine-clonazepam in monkeys. J. pharm. Sei. 68, 416-421. LEVY, R. H., PITLICK, W. H., TROUPIN, A. S. and GREEN, J. R. (1976) Pharmacokinetic implications of chronic drug treatment in epilepsy: carbamezepine. In: The effects of disease states on drug pharmacokinetics, pp. 87-95, BENET, L. (ed). Academy of Pharmaceutical Sciences, American Pharmaceutical Association. LEVY, R. H., LOCKARD, J. S. and PATEL, I. H. (1977a) Time-dependent kinetics III: Diurnal fluctuations in steady state plasma levels of valproic acid in Rhesus monkeys. J. pharm. Sci. 66: 1145-1156. LEVY, R. H., LOCKARD,J. S., PATEL, 1. H. and LAI, A. A. (1977b) Efficacy testing of valproic acid compared to ethosuximide in monkey model I: Dosage regimen design in the presence of diurnal oscillations. Epilepsia 18(2): 191-203. LEVY, R. H. and DUMAIN,M. S. (1979) Time-dependent kinetics VI: direct relationship between equations from drug levels during induction and those involving constant clearance. J. pharm. Sci. 68: 934~936. LEVY, R. H., LA1, A. A. and DUAMIN, M. S. (1979a) Time-dependent kinetics IV: Pharmacokinetic theory of enzyme induction. J. pharm. Sci. 68:398 399. LEVY, R. H., DUMAIN, M. S. and COOK, J. L. (1979b) Time-dependent kinetics. V: Time course of drug levels during enzyme induction (one-compartment model). J. Pharmacokin. Biopha, m. 7: 557-578. LEVY, R. H., CENRAUD, B., LOISEAU, P., AKBARALY,R., BRACHET-LIERMAIN,A., GUYOT, M., GOMENI, R. and MORSELLI, P. L. (1980) Meal-dependent absorption of enteric-coated sodium valproate. Epilepsi 21: 273-280. LOCKARD, J. S., LEVY, R. H., DUCHARMS,L. L., CONGDON, W. C. and PATEL, I. H. (1977) Diurnal variation of valproic acid plasma levels and day-night reversal in monkey. Epilepsia 18(2): 183. LOCKARD, J. S., LEVY, R. H., DUCHARME, L. L., CONGDON, W. C. and PATEL, I. H. (1979a) Carbamazepine revisited in a monkey model (short communication). Epilepsia 20: 169-173. LOCKARD,J. S., LEVY,R. H., CONGDON, W. C., DUCHARME,L. L. and SALONEN,L. D. (1979b) Clonazepam in a focal-motor monkey model: efficacy, tolerance, toxicity, withdrawal and management. Epilepsia 20: 683-695. MADSEN, B. W. and Rossl, L. (1980) Sleep and Michaelis-Menten elimination of ethanol. Clin. Pharmac. Ther. 27(1): 114-119. NARANJO, C. A., SELLERS,E. M. and KHOUW, V. (1980) Fatty acids modulation of meal-induced variations in diazepam free fraction. Br. J. clin. Pharmac. 10: 308-310. ORTIZ DE MONTELLANO,P. R. and KUNZE, K. L. (1980) Self-catalyzed inactivation of hepatic cytochrome P-450 by ethynyl substrates. J. biol. Chem. 255: 5578-5585. PATEL, I. H., LEVY, R. H. and LOCKARD,J. S. (1977)Time-dependent kinetics II: diurnal oscillations in steady state plasma levels of ethosuximide in Rhesus monkeys. J. pharm. Sci. 66: 650-653. PINKSTON, J. N., SOLIMAN,K: F. A. and WALKER,C. A. (1979) Circadian variation of ethanol metabolism in the rat. In : Advances in the Biosciences, 19, pp. 337, REINBERG, A. and HALBERG, A. and HALBERG, F. (eds). 7th int. Congr. Pharmac., Symposium on Chronopharmacology, Paris-Velizy, July 1978. Pergamon Press, Oxford. PITLICK, W. H., LEVY, R. H., TROUPIN, A. S. and GREEN, J. R. (1976) Pharmacokinetic model to describe self-induced decreases in steady state concentrations of carbamazepine. J. pharm. Sci. 65: 462-463. PITLICK, W. H. and LEVY, R. H. (1977) Time-dependent kinetics I: Exponential anto-induction of carbamezepine in monkeys. J. pharm. Sci. 66:647 649. RADZIALOWSKI,F. M. and BOUSQUET,W. F. 0968) Daily rhythmic variation in hepatic drug metabolism in the rat and mouse. J. Pharmac. exp. Ther. 163: 229-238. REILLY, P. A. J., TADANOBU,I., KADAR,D. and ENDRENYI,L. (1978) Enzyme induction following a single dose of amobarbital in dogs. J. Pharmacokin. Bipharm. 6: 305-313. REINBERG, A., ZAGULA-MALLY,Z. W., GHATA, J. and HALBERG, F. (1967) Circadian rhythm in duration of salicylate excretion referrred to phase of excretory rhythms and routine. Proc. Soc. exp. Biol. Med. 124: 826-832. REINBERG, A., CLENCH, J., AYMARD,N., GALLIOT, M., BOURDON, R., GERVAIS, P., ABULKER,C. and DUPONT, J. (1974) Rythmes circadiens des parametres de l'ethanolemie provoquee chez six hommes adultes, jeunes et sains. C.r. Acad. Sci. Paris. 278. REINBERG, A., CLENCH, J., AYMARD,N., GALLIOT, M., BOURDON, R., GERVAIS, P., ABULKER,C. and DUPONT, J. (1975a) Variations circadiennes des effets de l'ethanol et de l'ethanolemie chez l'homme adult sain. Etude chronopharmacologique. J. Physiol. 70: 435-456. REINBERG, A., CLENCH, J., GHATA, J., HALBERG, F., ABULKER,C., DUPONT, J. and XAGULA-MALLY,Z. (1975b) Rythmes circadiens des parametres de l'excretion urinaire du salicylate (chronopharmacocinetique) chez l'homme adulte sain. C.r. Acad. Sci. Paris. 280: 1697-1699. REINBURG,A. (1976) Advances in human chronopharmacology. Chronobiologia 3: 151. REINBERG, A. (1978) Clinical chronopharmacology, an experimental basis for chronotherapy. Drug Res. 28(11): 10a. REINBERG, A. and HALBERG, F., eds (1979) Advances in the Biosciences, 19, 7th int. Congr. Pharmac., Symposium on Chronopharmacology, Paris-Velizy, July, 1978. Pergamon Press, Oxford. SHIVELY,C. A. and VESELL,E. S. (1976) Temporal variations in acetaminophen and phenacetin half-life in man. Clin. Pharmac. Ther. 18:413-424. STURTEVANT,F. M. (1976) Chronopharmacokinetics of ethanol. I. Review of the literature and theoretical considerations. Chronobiologia 3:237 262. STURTEVANT, R. P. and GARNER, S. L. (1979) Changes in ethanol clearance rhythm in rats as affected by light-dark phase shifts and restricted feeding. Chronobioloqia 6: 160.

Time-dependent pharmacokinetics

397

STURTEVANT, R. P., STURTEVANT,F. M., PAULY, J. E. and SCEVING, L. E. (1978) Chronopharmacokinetics of ethanol. III: Variation in rate of ethanolemia decay in human subjects. Int. J. clin. Pharmac. 1602): 594-599. SWOYER, J., LAKATUA, D. J., HAUS, E., WARNER, T. and SACKETT, L. 0975) Circadian rhythm in ethanol disappearance rate from human plasma. Chronobiologia (suppl.) 1:7 I. VALLI, M., BRUGEROLLE, B., BOUYARD, L., JADOT, G. and BOUVARD, P. (1980) Rythmes circadiens des parametres pharmacocinetiques de la carbamazepine chez le rat. J. Pharmac. (Paris) (in press). VESELL E. S., SHIVELY, C. A. and PASSANANTI,G. T. (1977) Temporal variations of antipyrine half-life in man. Clin. Pharmac. Ther. 22(6): 843-852. WILSON, R. H. L., NEWMAN, E. J. and NEWMAN, H. W. (1956) Diurnal variation in rate of alcohol metabolism. J. appl. Physiol. 8: 556.