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Pharmacokinetics
Pharmacokinetics* what the body does to a drug Pharmacodynamics what the drug does to the body There are three stages in the physiological handling of a drug 1. absorption into blood stream 2. distribution around body 3. elimination *technically the quantification of absorption, distribution and elimination
Inhaled drugs include anti-asthma drugs salbutamol and ipratropium bromide (atrovent) plus inhaled anaesthetics such as nitrous oxide and sevoflurane.
Oral absorption
There are several physiological factors that can affect oral absorption, such as digestive enzymes - can denature drugs such as insulin stomach acid - can denature drugs GI motility - can reduce or increase the rate of absorption presence of food - can reduce or alter the rate of absorption
Liver
GIT
Kidney Renal artery First pass metabolism through liver via hepatic portal vein
Interactions
When particular P450 isozymes are induced and their activity increases, this means that other drugs that are substrates for those isozymes are metabolised more quickly, generally decreasing their bioavailability*. When particular P450 isozymes are inhibited and their activity decreases, this means that other drugs that are substrates for those isozymes are metabolised more slowly, generally increasing their bioavailability. *Bioavailability is the proportion of a drug that appears in the systemic circulation after passing through the gastric mucosa and P450 enzymes in the liver. The term is unquantifiable because absorption varies between individuals and individual circumstances
Interactions
Certain foods can affect hepatic metabolism Grapefruit juice contains flavonoids and psoralen derivatives that inhibit CYP3A4 enzymes and so reduces the rate of first pass metabolism. The plasma concentration of drugs such as calcium channel blockers (verapamil etc.), simvastatin, ciclosporin etc. is increased See BNF, Appendix 01 for full details.
Interactions
Drugs that inhibit drug metabolising enzymes Cimetidine Corticosteroids Drugs affected by inhibition (concentration increased) Amiodarone, phenytoin, pethidine, warfarin Tricyclic anti-depressants
Ciprofloxacin
MOA inhibitors e.g. phenelzine
Theophylline
Pethidine
Interactions
Drugs that induce drug metabolising enzymes Phenobarbital Drugs affected by induction (concentration decreased)
Rifampicin
Griseofulvin
Phenytoin
Ethanol Carbamazepine St Johns wort
(Hypericum perforatum)
Generally, strong basic drugs e.g. the muscle relaxant suxamethonium are poorly absorbed so need to be given intravenously.
Absorption kinetics
For some drugs poor absorption is beneficial because their target is further along the digestive tract. The anti-bacterial vancomycin is poorly absorbed so is useful to treat the gut bacterium Clostridium difficile. Other drugs can be packed in capsules that resist absorption until the capsules degrade in the colon. Colpermin used to treat irritable bowel syndrome is an example.
Elimination
Elimination - involves two key processes metabolism and excretion
Most drugs are broken down by liver enzymes and the metabolites usually excreted by kidneys, although all body fluids can eliminate drugs. Some drugs are excreted via the bile duct into the gut
Processes sometimes referred to as Phase II reactions may be involved in the elimination of drugs. Generally increases a drugs solubility so enhances excretion These reactions take place predominantly in the liver and chemically change the drug to enhance its excretion.
Drug interactions
Drugs can affect the action of other drugs by inducing or inhibiting the activity of P450 hepatic enzymes, as has been described above. Herbal remedies such as St Johns Wort and even grapefruit juice can also affect drug metabolism via the P450 enzymes. Some drugs can occupy the receptor targets of other drugs. For example, the b-blockers such as propranolol that target b1 receptors on the heart also bind antagonistically to b2 receptors in the bronchioles. b2 receptors are prime targets for b2 agonist bronchodilators such as salbutamol.
Blocking the b2 receptors prevents salbutamol producing its bronchodilatory action. Not surprisingly, b-blockers are contraindicated for asthmatics.
Drug interactions
Diuretics may lower plasma K+ levels which can enhance the action of cardiac glycosides such as digoxin. Antibiotics that reduce bacterial production of vitamin K in the intestines can enhance the action of warfarin because vitamin K competes with warfarin for the enzyme vitamin K reductase. Anticoagulation activity is enhanced. Aspirin and warfarin can both cause bleeding in the stomach and their concurrent use increases the risk.
Drug interactions
NSAIDs such as indometacin and ibuprofen can produce unpredictable effects in patients being treated for hypertension. This is believed to be by their effect on prostaglandins in the kidney
Bile acid sequestrants such as colestyramine bind to drugs such as warfarin and prevent their absorption.
Distribution: Lean mass to fat ratio can change with age resulting in higher concentrations of water-soluble drugs and lower concentrations of fat soluble drugs Serum albumin decreases so in a patient with malnutrition, this may enhance drug effects because serum concentrations of unbound drug are increased.
Presystemic (first-pass) metabolism of some drugs given orally (eg, labetalol, propranolol, verapamil) is decreased, increasing their serum concentration and bioavailability.
Many drugs produce active metabolites in clinically relevant concentrations. Examples are some benzodiazepines, amitriptyline and opioid analgesics such as morphine. The accumulation of active metabolites can cause toxicity in the elderly due to age-related decreases in renal clearance. Toxicity is likely to be severe in those with renal disease.
100
Drug A
Drug B
20
0 0 1 2 3 4 5 Time (hours) 6 7 8 9 10
End of Presentation