Plasma drug protein binding

Update: 01:/07/2006 binding- 1

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 Biological relevance of drug binding

The binding of drug to plasma (and

tissue) proteins is a major determinant of
drug disposition (distribution)
Binding has a very important effect on
drug dynamics since only the free
(unbound) drug interacts with receptors

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Relevance of plasma and tissue
protein binding

From a biological point of view YES

From a clinical point of view NO
problem of drug interaction and displacement
has been overestimated

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 Influence of drug binding on
pharmacokinetic parameters

Distribution
fu
VD VPlasma VTissue
f uT

Elimination
Q organ f u Cl int
Cl organ
Q organ f u Cl int
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Clinical relevance of drug binding

The importance of plasma protein

binding displacement interaction has
been overestimated and overstated

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 Case for which we need to know
in vivo free concentration
For extrapolation
from in vitro to in vivo
in vitro, Kd (binding) and EC50 (functional response)
are free concentrations but EC50 (for PK/PD) is total
concentration
CMI (free) vs effective plasma concentration (Ctot)
between species
comparison of EC50 between animals requires to take
into account free fraction
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The problem of drug interaction
and displacement has been
overestimated

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 The classical example:
Phenylbutazone/warfarin interaction

Interaction actually exists

Displacement actually exists
but the plasma binding displacement
is not the underlying mechanism of
interaction
PBZ stereoselectivity inhibits the
metabolism of s-warfarin
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 Why plasma binding seldom
has clinical relevance

Because few drugs (so-called displacer)

are therapeutically used

Because when displacement exists, it has

no consequence on the receptor exposure
to the free concentration of the displaced
drug which generally remains unaffected
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 Is there often displacement of
drug from the binding site?

No
For a substantial displacement to take
place, the displacer must occupy most of
the available binding site thereby lowering
the binding site available to the primary
drug

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 Is there often displacement of
drug from the binding site?
No
To take place, the molar concentration of the
drug in plasma must exceed the molar
concentration of albumin (150 g/mL for a a
drug with a MW of 250)
e.g.: PBZ, phenytoin, valproic acid
This is not true for 1-glycoprotein acid
(basic drug)
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Why plasma protein displacement
seldom has clinical relevance
Generally only the free (unbound) drug is
metabolized and can access to the
receptor
AND
the free drug concentration is controlled
by the free drug clearance which is
independent of the plasma binding

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Plasma drug protein binding
Physiological aspects

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 Plasma binding proteins

Proteins MW Concentration
g/L M
Albumin 67 000 35-50 500-700
-glycoprotein 42 000 0.4-1.0 9-23
acid
Lipoproteins 200 000 variable
to 2.4 106
Transcortin 53 000 0.03-0.07 0.6-1.4
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 Drug binding protein concentration and
percentage of free drug in serum of healthy
dogs and dogs with inflammation

Healthy Inflammation level of significance

Total protein (g/L) 71.6 72.3 NS
Albumin (g/L) 31.3 27.6 xxx
-acid glycoprotein (mg/L) 374 1632 xxx

Percentage free
Lidocaine 43.5 11.7 xx
Propanolol 27.8 9.3 xx
Phenytoin 18.1 17.6 NS
Digitoxin 15.5 18.9 xx
Diazepam 1.57 2.78 x

Baggot The physiological basis of vet clin pharmacol p.103 binding- 17

 The free fraction
&
the free concentration

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 Drug plasma protein binding

Expressed in % or by fu (free fraction)

>90% = highly bound

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 The free fraction : fu

Definition:

free concentration Cfree

fu = total concentration =
Ctot

fu and Cfree are not synonymous terms

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 The free, the Bound
&
the total concentration

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 The bound concentration
Cbound
The bound concentration
Bmax
B max Cfree
Cbound
K D Cfree Bmax/2

Bmax : maximal concentration of KD Cfree

binding sites
proportionnal to plasma protein concentration

KD : free drug concentration corresponding to half maximal binding

inversely proportional to drug affinity for the protein binding- 33
 Ctot is a function of Cfree

Ctot = Cfree + Cbind

Bmax x Cfree
Ctot = Cfree +
Kd + Cfree

Dependent variable Parameters Independent variable

controlled by Clfree

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Relationship between fu, the Free
and the bound concentrations

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 The free fraction fu
Physiological factors controlling fu

fu =
Cfree
= Cfree
ctot
cfre

Ctot Cfree + Cbind

Cfree
fu
B max Cfree
Cfree
Kd Cfree

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 The unbound fraction : fu

Cfree K D Cfree
fu fu
Cfree Cbound B max K D Cfree

Linear binding : Cfree << KD

KD
fu
B max K D
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 Total concentration:
a convenient but illicit rearrangement
which can be misleading when
discussing drug interaction

Cfree = fu x Ctotal

indirectly known from in measured by

estimated vitro assay analytical technique

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 Total concentration

Ctot = Cfree
fu

!! When conceptualizing dependency and

functionality, this equation should not be
rearranged

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 Total concentration:
Why the free displaced drug concentration
is not controlled by plasma binding

The fundamental relationship independent variable

free concentration
Total concentration =
fu
(free fraction)

dependent variable parameters

Where fu is altered, Ctot is modified, not Cfree

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 Total concentration:
a convenient but illicit rearrangement
which can be misleading when
discussing drug interaction
What is the consequence of fu

Cfree
Ctot = or Cfree = fu x Ctotal
fu
YES NO

Displacement (fu) modifies Ctot, not Cfree

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Drug interaction and
protein binding

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 Cfree Cfree
fu
Ctot
AND Ctot
Ctot
fu
fu
Cfree

Bmax
Kd
Definition
Physiological relationship

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 Drug interaction and protein binding

Bmax x Cfree
Ctot = Cfree + possible interaction
Kd + Cfree

Interaction will modify Ctot but not Cfree

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 Conditions in which the plasma
concentration of the 2 major plasma
proteins to which drug binds are altered

Conditions Change in concentration

Albumin hepatic cirrhosis
burns
nephritic syndrome
pregnancy

-glycoprotein myocardial infarcts

surgery
trauma
rheumatoid arthritis
Rowland p.152 binding- 52
 Competitive interaction

Bmax x Cfree
Ctot = Cfree +
Kd (1 + A/Ki) + Cfree
Displacement

Ctot is decreased

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 Competitive interaction
Case of restrictively eliminated drug
Clfree = Clint = constant Cltot = fu x Clint
perfusion rate: K0

Ctot

Cltot
Cfree
redistribution Clfree = cst

Administration of the 2nd ligand, displacement fu

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 Competitive interaction for
restrictively eliminated drugs

when interaction occurs,

Ctot is altered not Cfree

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in vitro vs. in vivo situation

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 In vitro - closed system In vivo - open system
Drug with low extraction ratio

Css, tot = constant Css, free perfusion rate

= = constant
Css, free = f u Css,tot Clint
Css, tot = 1 C
fu ss, free

if fu then Cfree if fu then Ctot

Effect
1.0 Ctot 1.0

fu = 0.4
0.5 fu = 0.2 0.5 fu = 0.2 Ctot
Cfree
fu = 0.4
0.2 0.2 Cfree
Time Time

Competitive interaction Competitive interaction

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fu vs Cfree: in vitro situation
4 4
1 2 1 2

5 5
3 3
6 6

fu = 0.5 displacer fu = 0.83

displacee
Cfree = 3/V Cfree = 5/V
V= volume of
Ctot = 6/V the baker Ctot = 6/V

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 fu vs Cfree
in vivo situation: initial steady state
Plasma Extracellular fluid Intracellular fluid

4 1
2
Infusion=A 5
K12 Cfree

A=MT-1 6
3
K21 Cfree

Elimination = K10 x Cfree (3) = A equated by infusion

TOTAL CONCENTRATION = 6/V

FREE CONCENTRATION = 3/V binding- 70
 fu vs Cfree: in vivo situation:
just after administration of displacer
displacer
Plasma Extracellular fluid Intracellular fluid

4 1 K12xCfree: increase
2 transitively
Infusion=A
5

A=MT-1 6
3

K21 x Cfree
Just
displaced TOTAL CONCENTRATION = 6/V
Increase transitorily FREE CONCENTRATION = 5/V
free drug
K10 x Cfree (5) > A
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 fu vs Cfree:
in vivo situation: final steady state
displacer
Plasma Extracellular fluid Intracellular fluid

1 K12 x Cfree
2
Infusion=A

A=MT-1 6
3

K21 x Cfree

TOTAL CONCENTRATION = 4/V

Elimination = K10 x Cfree (3) = A FREE CONCENTRATION = 3/V
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 The three main exceptions to the
general rule for which drug interaction
has no clinical meaning

1. Rapid bolus IV injection

2. Parenteral administration of displaced drug
with a high extraction ratio
3. Therapeutic drug monitoring and drug
displacement from the plasma binding site
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Case for which drug interaction
at the binding site is relevant
1. Rapid IV injection
If the displacing agent is given rapidly (IV
bolus), the Cfree could increase dramatically
due to rapid displacement of the displaced
drug before the compensatory mechanism
(redistribution) takes place
Sulfamide and bilirubin kernicterus

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Case for which drug interaction at
the plasma binding site is relevant

3. Therapeutic drug monitoring and drug

displacement from plasma binding
Therapeutic drug monitoring is performed for
drugs with a narrow concentration range
between therapeutic and toxic effect
Monitoring is carried out on total plasma
concentrations

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Case for which drug interaction at
the plasma binding site is relevant

3. Therapeutic drug monitoring and drug

displacement from plasma binding
An example:
Phenytoin alone: Ctot = 20 g/mL
Phenytoin + Valproic acid: Ctot = 15 g/mL
no dosage adjustment is necessary because
Ctot decreased but not Cfree due to fu increase

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 Algorithm
Algorithm for
for determining
determining clinical
clinical significance
significance
of
of potential
potential binding
binding displacement
displacement interaction
interaction
Roslan 1994, B.J.Clin Pharmacol. 37, 125
Is drug of interest >90%
protein bound? no
Yes Clinically significant
no interaction not likely
Does the drug have a
narrow therapeutic index ? no
Yes low Would a transient increase
What is the hepatic extraction in free drug concentration
ratio of the drug ? be clinically relevant ?
High Yes
Is the drug given IV? no

Yes Clinically significant interaction likely.

Perform a clinical study to quantify effects
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 Protein Binding Interactions
the overall clinical importance of plasma protein
binding displacement interactions continues to be
overstated
Despite the theoretical and experimental data to the
contrary, the concept that plasma protein binding
displacement is a common cause of clinically significant
interactions may still be widely taught in some medical
schools, often appears in textbooks and is accepted by
many in the medical community and by drug
regulators.
Sansom LN & Evans AM. Drug Safety 1995;12:227-233.
Rolan PE. Br J Clin Pharmacol 1994;37:125-128.
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 Protein Binding Interactions
Drugs for which pure plasma protein binding
displacement interactions will lead to sustained changes
in Cssu
Extensively bound to plasma proteins
Nonrestrictively cleared
Administered by non-oral route
alfentanil, buprenorphine, lidocaine, verapamil
Very few orally administered drugs exhibiting properties
of extensive plasma protein binding, high hepatic first-
pass extraction and narrow therapeutic index

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