Pharmacokinetics

Arini Setiawati
Dept. of Pharmacology & Therapeutics
Medical Faculty, Univ. of Indonesia

Pharmacokinetics
= fate of drugs in the body
= effects of the body on drugs

4 processes : ADME
- Absorption (A)
- Distribution (D)
- Metabolism (M)
- Excretion (E)

Elimination
Absorption (1)
= the movement of drug from the site of
administration into the blood stream

- site of adm. : GI tract, skin, lung, muscle
- most important route of adm. : oral
major site of absorption : small intestine
surface area of abs. : 200 m
2

(280 cm long, 4 cm , villi, microvilli)
Absorption (2)










capillary
endothelial
cells
intestinal
epithelial
cells
Intestinal
lumen
capillary
bl. v.
mesenteric
bl. v.
portal
vein
Liver
Syst.
blood
absorption
process
inter-
stitium
Drug 100%

a%
not
absorbed

b%
metab. in
intest. wall

100-a-b 100-a-b 100-a-b


C%
metab.
in liver
100-a-b-c
= (100-a) -(b+c)
= F







Absorption (3)
Absorption = (100-a) %
(b + c) % = presystemic elimination/metabolism
= first-pass elimination/metabolism
Bioavailability = absorption-presyst. elim.
F = (100-a)% - (b + c)%
Sublingual route of adm.
only for drugs with very high lipid solubility,
bec. the surface area of abs. is small
the drug should dissolve & be absorbed
very rapidly
eg. nitroglycerin
blood from the mouth drains directly to
superior vena cava, does not pass portal
vein the drug does not undergo first-
pass metab. by the liver
Rectal route of adm.
unconscious / vomiting pts.
only 50 % of blood from rectum will pass
portal vein
first-pass elim. by the liver only 50%
rectal abs. often irregular & incomplete
many drugs cause irritation of the rectal
mucosa
Passive diffusion
absorption method for most drugs
absorption barrier : membrane of GI epithelial cells
lipid bilayer
drug mols should be lipid soluble,
but first should be water soluble
rate of diffusion is proportional to :
- lipid solubility of the drug molecule
- concentration gradient across the membrane
(the driving force)
- area of the absorbing membrane
Degree of ionization (1)
Most drugs are weak electrolytes : weak acids or
weak bases
In water ionized to ion form
Weak acids : HA H
+
+ A

[H
+
] [A

]
Ionization constant Ka =
[HA]
[HA]
pKa = pH + log
[A

]
[A

]
pH = pKa + log
[HA]
[A

] [Ion]
Degree of ionization = = = 10
pH-pKa

[HA] [Union]

Degree of ionization (2)

Weak bases : B + H
+
BH
+


[BH
+
] [Ion]
Degree of Ionization = = = 10
pKa-pH

[B] [Union]






Henderson-Hasselbalch equation
Passive diffusion (Ficks law) :
only for most unionized (UI) form usually lipid soluble,
not for the ionized (I) form no lipid solubility

UI UI


I I
membrane
(lipid)
barrier

The 2-compartments :
if different pH different degree of ionization
different total conc. or different distribution of drug
pH partition hypothesis
Passive diffusion for acidic / basic drugs (1)
Example : A weak acid with pKa = 4.4
Stomach Blood
pH = 1.4 pH 7.4

[1] UI UI [1]


[0.001] I I [1000]

[UI + I] = [1.001] [1001] = [UI + I]
GI epithelial
cell membrane
1001
C
blood
/ C
stomach
= = 1000
1.001
I
= 10
pH-pKa

UI
= 10
-3

I
= 10
pH-pKa

UI
= 10
3

Passive diffusion for acidic / basic drugs (2)
Union Ion
The UI form lipid soluble diffuses into blood (absorbed)
the equilibrium shift to the right
until the UI conc. in blood = UI conc. in stomach
the passive diffusion will stop
Weak acids : basic environm. ionization slow abs.
acidic environm. ionization rapid abs.
Weak bases: acidic environm. ionization slow abs.
basic environm ionization rapid abs.
Membrane Transporters (1)
Drug transport across membrane is also mediated by
membrane transporters :
1. P-glycoprotein (P-gp) transporters
* ATP-dependent efflux transporters for hydrophobic
drugs and conjugates out of the cells
* location : apical membrane of secretory cells :
- luminal membrane of small intestinal cells
- bile canalicular membrane of liver cells
- luminal membr. of renal prox. tubular cells
- luminal side of endoth. cells of blood-brain &
blood-testes barrier
* function : - abs. from & removal into the gut
- removal into bile & urine
- entry into brain & testes
Membrane Transporters (2)
2. Organic Anion Transporting Polypeptide (OATP)
transporters :
* uptake transporters for hydrophobic drugs and
conjugates into the cells
* location :
- luminal membrane of enterocytes
- basolateral (sinusoidal) membr. of hepatocytes
- basolateral membrane of renal epith. cells
- apical membrane of renal epith. cells (for reabs.)
* function :
- in the intestine : opposing P-gp action for absorp.
- in the liver & kidney : sequential action with P-gp
for secretion

Transport interactions (1)
Quinidine, verapamil : substrates & inhibitors of P-gp
digoxin : substrate of P-gp
interaction : plasma digoxin conc.
(inhibition of P-gp in the intestine & kidney)
Quinidine : substrate & inhibitor of P-gp
loperamide : substrate of P-gp
interaction : loperamide conc. in the brain
(inhibition of P-gp in the BBB)
respiratory depression


Transport interactions (2)
Grapefruit, orange, apple juice : inhibitors of OATP
fexofenadine : substrate of OATP
interaction : bioavailability of fexofenadine
(inhibition of OATP in the intestine)

IM & SC injection
Directly enter the interstitium of skeletal muscle or
subcutaneous tissue capillary bl. v. systemic
blood.
Capillary bl. v. wall :
1 layer of endoth. cells with intercellular gap
large enough for drugs (mostly : MW 100-1000)
Lipid-sol. drugs : passive diffusion across
capillary endoth. membrane
Water-sol. drugs : pass through the endoth.
intercellular gap (the rate is
inversely related to the MW)
Rate of abs rate of blood flow
Protein & other macromols : via lymphatic circ.




Distribution (1)
In the blood : drug + protein drug-protein
complex
Plasma proteins :
- Albumin : acidic drugs
Site I : warfarin, phenylbutazone, phenytoin,
valproic acid, tolbutamide, sulfonamide,
bilirubin
Site II : benzodiazepines,
carboxylic acids (most NSAIDs),
penicillin & derivatives
Fatty acids : have specific primary binding sites
on albumin
(warfarin
site)
(diazepam
site)
Distribution (2)
Plasma proteins :
- a
1
-acid glycoprotein : basic drugs
- lipoproteins : basic drugs
- CBG : corticosteroids
- SSBG : sex-steroid hormones
Drug-protein complex will circulate throughout
the body
Drug-protein complex can dissociate very rapidly
(t ~ 20 msec)
Unbound drugs diffuse into tissues :
- sites of drug action
- sites of drug binding (depot tissues)
- sites of elimination : liver, kidney
Distribution (3)
In tissues :
- water-soluble drugs : in interstitial fluid
- lipid-soluble drugs : intracellular (diffuse across
cellular membrane)
* intracellular (pH 7) : basic drugs >
* extracellular (pH 7.4) : acidic drugs >

Accumulation in the tissues :
- quinacrine : liver
- DDT : adipose tissue
- Pb : bone
- digoxin : heart muscle, skeletal muscle
- chlorpromazine : brain
Volume of distribution (1)
Not anatomical volume, only apparent vol.
which reflects the extent of distribution
Calculated based on plasma conc.
FD
Vd =
C
Large C the drug is concentrated in blood &
the Vd is small
Small C the drug is extensively distributed
in the body or accumulated in
tissues & the Vd is large.
(F = bioavailability; D = drug dose;
C = plasma conc.)
Volume of distribution (2)
Examples :
Vd of phenylbutazone = 0.1 l/kg = 5 l/50 kg
concentrated in blood
Vd of caffeine = 0.6 l/kg = 36 l/50 kg
distributed in total body water
Vd of digoxin = 7 l/kg = 350 l/50 kg
accumulated in tissues

Volume of distribution (3)
edema / ascites : Vd of water-soluble drugs
elderly : muscle mass Vd of digoxin
elderly : total body water Vd of theoph.
Blood-Brain and Blood-CSF Barriers
Capillary endothelial cells in the brain form
tight-junction (no intercellular gap)
Long processes of astrocytes form sheaths
around the capillaries
Only lipid-soluble drugs can diffuse across
the barriers and enter brain tissue.
Membrane transporter P-gp at the BBB will
expel lipid-soluble drugs that are its
substrates, to protect the brain from harmful
drugs. E.g. loperamid is lipid soluble, but also
a P-gp substrate not enter the brain
Placental Barrier
1 layer of epithelial cells of the villi and
1 layer of endothelial cells of fetal capillaries
similar to gastrointestinal barrier

Membrane transporter P-gp at the placental
barrier, as at the BBB, also performs barrier
function to protect the fetus from harmful
drugs
Protein binding displacement
interactions (1)
Plasma protein binding :
- strong for lipophilic drugs
- weak for hydrophilic drugs
Limited amounts of plasma proteins
displacement :
- among acidic drugs for albumin site I
- among acidic drugs for albuin site II
- among basic drugs for a
1
-acid glycoproteins
Protein binding displacement
interactions (2)
These interactions are clinically important if :
the displaced drugs fulfill 3 criteria :
- high plasma protein binding : > 85%
- small Vd : < 0.15 l/kg (acidic drugs)
- narrow margin of safety
a prerequisite for a displacer drug :
- its conc. is high enough to begin saturating
its own binding sites, eg.
phenylbutazone, salicylic acid, valproic acid
and sulfonamides for albumin binding


Protein binding displacement
interactions (3)
Example :
Phenylbutazone : a displacer for albumin site I
Warfarin : binding with albumin site I 99%,
Vd 0.14 l/kg
Tolbutamide : binding with albumin site I 96%,
Vd 0.12 l/kg
Phenylbutazone will displace warfarin from
albumin free warfarin hemorrhage
Phenylbutazone will displace tolbutamide from
albumin free tolbutamide hypoglycemia
Metabolism = Biotrasformation (1)
Main site of drug metabolism : the liver
Other tissues : intestine, kidneys, lung, blood,
brain, skin
To convert lipid soluble drugs to more polar
compounds can be excreted via kidneys or bile
Phase I reactions : oxidation, reduction, hydrolysis
- drugs become inactive, less / more active, or toxic
- drugs obtain polar groups (-OH, -NH
2
, -COOH, -SH)
can react with endog. substrates in phase II
reactions
Metabolism = Biotrasformation (2)
Phase II reactions :
conjugation with endog. substrates
(glucuronic acid, sulfate, acetyl, glutathion)
- drugs almost always become inactive

Phase I reaction only, phase II only, or phase I
followed by phase II
Metabolic reactions (1)
Most important : oxidation by cytochrome P450 (CYP)
in liver microsomes
50 CYP isoenzymes are functionally active in human
Major CYPs for drug metabolism :
- CYP3A4/5 - metabolised > 50% drugs for human
the most important metabolic enz.
- also expressed in intestinal epith. and kidney
- CYP2D6 - the first known
= debrisoquine hydroxylase
- CYP2C9, CYP2C19
- CYP1A2 - previously known as cytochrome P448
- CYP2E1
Metabolic reactions (2)
Most important Ph. II reactions :
glucuronidation by UDP-glucuronyltransferase (UGT)
(also in liver microsomes)

Other phase II reactions : in liver cytosol


Note : If the metabolic enzyme is saturated at
therapeutic dose range nonlinear pharmaco-
kinetics
eg. - phenytoin for epilepsy
- acetylsalicylic acid as NSAID
Metabolic enzymes in liver cytosol :
Sulfotransferase (ST)
N-acetyltransferase (NAT) : NAT1, NAT2
Glutathion S-transferase (GST)
Thiopurine methyltransferase (TPMT)

In general : conjugates more water soluble
except : acetyl conjugates less water soluble
crystalluria when urinary flow <

CYP3A4 : substrates
lidocaine erythromycin lovastatin
quinidine clarithromycin simvastatin
amiodarone cortisol atorvastatin
diltiazem dexamethasone ritonavir
verapamil estradiol indinavir
felodipine tamoxifen
carbamazepine cyclosporin
alprazolam terfenadine
midazolam astemizole
triazolam cisapride


CYP3A4 : inhibitors & inducers
Inhibitors Inducers
ketoconazole ritonavir phenobarbital
itraconazole indinavir phenytoin
erythromycin grapefruit carbamazepine
clarithromycin rifampicin
nefazodone dexamethasone
fluvoxamine St. Johns wort
fluoxetine
diltiazem
verapamil

CYP2D6
Substrates Inhibitors
amitriptyline codeine quinidine
imipramine dextromethorphan paroxetine
clomipramine tramadol fluoxetine
fluoxetine metoprolol moclobemide
paroxetine propranolol haloperidol
fluvoxamine timolol perphenazine
haloperidol thioridazone
perphenazine
thioridazine Inducers
--
(relatively resistant to induction)
CYP2C9
Substrates Inhibitors Inducers
S-warfarin fluvoxamine rifampicin
phenytoin fluoxetine barbiturates
tolbutamide sulfaphenazole carbamazepine
glipizide phenylbutazone
losartan fluvastatin
irbesartan fluconazole
diclofenac
ibuprofen
piroxicam
fluvastatin
CYP2C19
Substrates Inhibitors Inducers
S-mephenytoin fluvoxamine rifampicin
omeprazole fluoxetine carbamazepine
lansoprazole omeprazole
pantoprazole lansoprazole
proguanil ketoconazole
phenobarbital
moclobemide

CYP1A2
Substrates Inhibitors Inducers
theophylline fluvoxamine polycyclic aromatic
caffeine ciprofloxacine hydrocarbons in
paracetamol cigarette smoke,
clozapine charcoal-broiled meat
haloperidol rifampicin
tacrine carbamazepine
R-warfarin cabbage, broccoli
ciprofloxacin

CYP2E1
Substrates Inhibitors Inducers
paracetamol disulfiram ethanol (chronic)
ethanol INH
halothane
enflurane

NAT2
Substrates
INH, dapsone
procainamide
sulfapyridine
CYP3A4, P-gp and OATP
co-localize in the same organs for drug
disposition : - intestinal wall
- liver & biliary tract
- kidney (tubulus)
many drugs are substrates/inhibitors of
these 3 proteins.
E.g. - diltiazem, verapamil
- cyclosporin, cortisol
- ritonavir, nelfinavir
net effect depends on which one is
predominant (varied among individuals)
Interactions in drug metabolism (1)
Induction of metabolic enzymes : enz. synthesis
- rate of metab. of drug substrates phkin. tolerance
- requires 3 days to 1 wk before max. effect is achieved

Inhibition of metab. enzymes : occur directly
directly conc. of drug substrates
dose of drug substrates or
should not be adm. concomitantly (C.I.)
if the conseq. is dangerous

Inhibition of metabolic enz. : - reversible
- irrevers., eg. grapefruit


Interactions in drug metabolism (2)
Example :
Terfenadine, astemizole, cisapride (substrates of CYP3A4)
contraindicated with
ketoconazole, itraconazole, erythromycin, clarithromycin
(potent inhibitors of CYP3A4)

conc. of terfenadine, astemizole, cisapride

QTc interval (on ECG)

ventricular arrhythmias (torsades de pointes) death

Terfenadine : withdrawn in UK & USA (1998)
Astemizole : withdrawn worldwide (June 1999)
Cisapride : withdrawn worldwide (July 2000)



Genetic polymorphism
CYP2D6
CYP2C9
CYP2C19
NAT2 -- rapid vs slow acetylators (RA vs SA)
In South-east Asians :
- frequency of PM CYP2D6 : 1 - 2 %
- frequency of PM CYP2C19 : 15 - 25 %
- frequency of SA NAT2 : 5 - 10 %
Potent inhibitors : EM genotype PM phenotype
extensive vs poor metabolizers
(EM vs PM)
Drug metabolism
in - liver cirrhosis
- fatty liver
- liver cancer
- liver blood flow : - heart failure
- shock
- drug
Severe cirrhosis metabolism 30-50 %

bioavailability 2-4 x
(in those undergoing first-pass
metabolism)
Metabolic enzymes
Mature at the age of 6 months
Except UGT for bilirubin (UGT1A1) :
- very deficient in premature babies/neonates
(50-70 % of adult value)

hyperbilirubinemia
+ sulfa + chloramphenicol
kernicterus gray syndrome
- mature at the second decade of life
Excretion
Most important organ : kidneys
Excretion : unchanged form & metabolites
Excretion of unchanged & active forms :
renal elimination
3 processes :
- glomerular filtration
- active secretion in proximal renal tubule
- reabsorption along the renal tubules
Renal function :
- mature at the age of 2 years
- after the age of 40 : 1% / year
Glomerular filtration
ultrafiltrate (plasma minus protein)
all free drugs !
Active secretion
From bloodstream to the lumen of proximal renal
tubule
Membrane transporters :
- P-gp : for organic cations & neutral compounds
- MRP : for organic anions & conjugated
metabolites
Competition among organic acids, and
among organic bases
Example : penicillin + probenecid for gonorrhea
Reabsorption
mostly occurs by nonionic passive diffusion
along the renal tubules
the degree of ionisation depends on the pH of
the luminal fluid
- acidic drugs : pKa 3.0 7.5
- basic drugs : pKa 6.0 12.0
E.g. in cases of phenobarbital or salicylate
toxicity : alkalinize the tubular urine with
NaHCO
3
ionisation excretion
membrane transporters at distal renal tubule :
for active reabs. from the tubular lumen
back into the systemic circulation, of
compounds required

can be affected
by urinary pH
Renal excretion
in renal dysfunction

drug doses or interval of drug adm.
(Calculation based on creatinine clearance)

Biliary Excretion
Into intestinal lumen excreted with feces
Transport systems :
in canalicular membrane of hepatocytes
active secretion of drugs & metabolites into
bile
Membrane transporters :
- P-gp : for organic cations & neutral compounds
- MRP : for organic anions & conjugated
metabolites, also for endogeneous
compounds
Enterohepatic cycle
lipid soluble drugs & metabolites :
can be reabsorbed back from the
intestinal lumen
conjugated metabolites like glucuronides :
may require enzymatic hydrolysis by the
intestinal microflora, but may be
absorbed directly via OATP
prolong the drug effects, eg.
estrogen in oral contraceptives

Excretion by Other Routes (1)
Pulmonary excretion :
mainly for the elimination of anesthetic gases
and vapors
Excretion in breast milk, saliva, sweat, and tears :
- quantitatively unimportant
- depend mainly on passive diffusion of the
nonionized, lipid-sol. form through the epith.
cells of the glands, and is pH-dep.
Excretion by Other Routes (2)
Excretion in breast milk :
- small amts, but important because may
cause unwanted effects in the nursing infant
- milk is more acidic than plasma
more basic compounds and less acidic comp.
than in plasma
Excretion in saliva :
drug conc. in saliva is the same as the unbound
conc. in plasma saliva may be used to
determine drug conc. when obtaining blood is
difficult or inconvenient.
Excretion into hair & skin :
may have forensic significance