SERIOUS ADR - Norfolk State University

SERIOUS ADR - Norfolk State University

COMPARTMENTAL ANALYSIS OF DRUG DISTRIBUTION Arthur J. Atkinson, Jr., M.D. Senior Advisor in Clinical Pharmacology Clinical Center, NIH DRUG DISTRIBUTION THE POST-ABSORPTIVE TRANSFER

OF DRUG FROM ONE LOCATION IN THE BODY TO ANOTHER GOALS OF DRUG DISTRIBUTION LECTURE SIGNIFICANCE OF DRUG DISTRIBUTION VOLUMES

PHYSIOLOGIC BASIS OF MULTICOMPARTMENT PHARMACOKINETIC MODELS CLINICAL IMPLICATIONS OF DRUG DISTRIBUTION KINETICS

DIGOXIN DISTRIBUTION VOLUME DOSE 750 g/Lg Vd 536 L C0 1.4 g/Lg/L

BODY FLUID SPACES (CONVENTIONAL VIEW) cell membranes DRUGS WITH Vd CORRESPONDING TO PHYSIOLOGICAL FLUID SPACES INTRAVASCULAR SPACE: NONE EXTRACELLULAR FLUID SPACE:

INULIN PROTEINS & OTHER MACROMOLECULES NEUROMUSCULAR BLOCKING DRUGS (N+) AMINOGLYCOSIDE ANTIBIOTICS (initially) TOTAL BODY WATER: UREA CAFFEINE ETHYL ALCOHOL ANTIPYRINE (some protein binding)

DISTRIBUTION VOLUME OF REPRESENTATIVE MACROMOLECULES FACTORS AFFECTING Vd ESTIMATES OF MOST DRUGS BINDING TO PLASMA PROTEINS: THYROXINE THEOPHYLLINE TISSUE BINDING (PARTITIONING):

DIGOXIN (Na+ - K+ ATPase) LIPOPHILIC COMPOUNDS PHYSIOLOGICAL SPACES FOR DRUG DISTRIBUTION CELL MEMBRANES ECF

ELIMINATION ICF EFFECT OF BINDING CHANGES ON Vd OF THYROXINE & THEOPHYLLINE* fu is the free fraction, the fraction of drug in plasma that is not bound to plasma proteins. * Atkinson AJ Jr, et al. Trends Pharmacol Sci 1991;12:96-101.

IMPACT OF PROTEIN BINDING ON THYROXINE DISTRIBUTION VOLUME* fu = 0.03% Vd = VECF * From Larsen PR, Atkinson AJ Jr, et al. J Clin Invest 1970;49:126679. IMPACT OF PROTEIN BINDING ON

THEOPHYLLINE DISTRIBUTION VOLUME* fu = 60% Vd = VECF + fuVICF * From Atkinson AJ Jr, et al. Trends Pharmacol Sci 1991;12:96-101. BASIS FOR INCREASED THEOPHYLLINE Vd IN PREGNANCY

* From Frederiksen MC, et al. Clin Pharmacol Ther 1986;40;321-8. EFFECT OF BINDING CHANGES ON Vd OF MOST DRUGS* is the ratio of tissue/plasma drug concentration. * Atkinson AJ Jr, et al. Trends Pharmacol Sci 1991;12:96-101. LIPID SOLUBILITY & VD (L/kg)

fU OCTANOL/WATER PARTITION COEF. = 10 100* PHENYTOIN 0.64 0.08 12

DIAZEPAM 1.10 0.013 185 OCTANOL/WATER PARTITION COEF. = 100 - >1000* PROPRANOLOL 4.30 0.13 82 NORTRIPTYLINE 18.0

0.08 572 *measured at pH 7 APPARENT Vd OF DIGOXIN represents binding to Na+-K+ ATPase. mC/gm

TISSUE VS. PLASMA DIGOXIN LEVELS HOURS GOALS OF DRUG DISTRIBUTION LECTURE

SIGNIFICANCE OF DRUG DISTRIBUTION VOLUMES PHYSIOLOGIC BASIS OF MULTICOMPARTMENT PHARMACOKINETIC MODELS

CLINICAL IMPLICATIONS OF DRUG DISTRIBUTION KINETICS BASIC PHARMACOKINETIC MODELS* * From Atkinson AJ Jr, et al. Trends Pharmacol Sci 1991;12:96-101. MONES BERMAN MATHEMATICAL VS.

PHYSICAL MODELS* MATHEMATICAL MODEL: FUNCTIONS OR DIFFERENTIAL EQUATIONS ARE EMPLOYED WITHOUT REGARD TO ANY MECHANISTIC ASPECTS OF THE SYSTEM PHYSICAL MODEL: IMPLIES CERTAIN MECHANISMS OR ENTITIES THAT HAVE PHYSIOLOGICAL, BIOCHEMICAL OR PHYSICAL SIGNIFICANCE

* Berman M: The formulation and testing of models. Ann NY Acad Sci 1963;108:182-94 FIRST MULTICOMPARTMENTAL ANALYSIS OF DRUG DISTRIBUTION* * From Teorell T. Arch Intern Pharmacodyn 1937;57:205-25. IS CENTRAL COMPARTMENT INTRAVASCULAR SPACE?

USUALLY NOT IDENTIFIED AS SUCH UNLESS DRUG GIVEN RAPIDLY IV NEED TO CONSIDER: - IF DISTRIBUTION LIMITED TO ECF,

COMPARE VC WITH PLASMA VOLUME. - IF LARGER DISTRIBUTION VOLUME, COMPARE VC WITH BLOOD VOLUME ACCOUNTING FOR RBC/ PLASMA. IF VC IS BASED ON PLASMA CONCENTRATION MEASUREMENTS RBC/P = red cell/plasma partition ratio Hct = hematocrit

ANALYSIS OF PA & NAPA CENTRAL COMPARTMENT VOLUMES* DRUG VC (L) INTRAVASCULAR SPACE

RBC/P (L) PREDICTED OBSERVED PA 6.7 1.52

5.6 5.5 NAPA 7.5 1.62

5.6 6.0 * From Stec GP, Atkinson AJ Jr. J Pharmacokinet Biopharm 1981;9:167-80. ANALYSIS OF EXPERIMENTAL DATA HOW MANY COMPARTMENTS? DESPITE AVAILABILITY OF

COMPUTER PROGRAMS FOR PK ANALYSIS, STILL NEED TO MAKE INITIAL ESTIMATES. TECHNIQUE OF CURVE PEELING A

COMPARTMENTAL ANALYSIS DATA EQUATION: C = Ae -t + Be -t Dose Central k21

V1 k01 k12 Periph. V2 MODEL EQUATION:

dX1/dt = -(k0 + k12)X1 + k21X2 TWO-COMPARTMENT MODEL Dose Central V1 Periph.

CLI V2 CLE Vd(ss) = V1 + V2 3 DISTRIBUTION VOLUMES

Vd (extrap.) DOSE C 0 Vd (area) Vd (ss) t 1/2 CL E 0.693 V1 V2 ..... Vn TWO-COMPARTMENT MODEL

Dose Central CLI V1 CLE

Periph. V2 k01 CLE = k01V1 INTERCOMPARTMENTAL CLEARANCE* A VOLUME-INDEPENDENT PARAMETER

CHARACTERIZING THE RATE OF ANALYTE TRANSFER BETWEEN COMPARTMENTS OF A KINETIC MODEL * From Saperstein et al. Am J Physiol 1955;181:330-6. TWO-COMPARTMENT MODEL Dose k21 Central

V1 Periph. CLI V2 k12 CLE

CLI = k21 V1 = k12 V2 [PROCAINAMIDE] (g/Lg/mL) 3-COMPARTMENT MODEL OF PA PHARMACOKINETICS HOURS

CATENARY 3-COMPARTMENT MODEL cell membranes [INULIN] (mg/dL) ANALYSIS OF INULIN KINETICS WITH A 2-COMPARTMENT MODEL*

AFTER INFUSION AFTER BOLUS MINUTES * Gaudino M. Proc Soc Exper Biol Med 1949;70:672-4. 3-COMPARTMENT MODEL OF INULIN KINETICS

EXTRACELLULAR FLUID Dose CL F VF VC CL S

CLE VS CELL MEMBRANES BASIS FOR KINETIC HETEROGENETIY ENDOTHELIAL FENESTRAE IN

HEPATIC SINUSOIDS INTERENDOTHELIAL CELL JUNCTION IN CONTINUOUS CAPILLARY PK-PD STUDY OF INSULIN ENHANCEMENT OF SKELETAL MUSCLE GLUCOSE UPTAKE* * From Sherwin RS, et al. J Clin Invest 1974;53:1481-92.

UREA-15N2 KINETICS IN A NORMAL SUBJECT MULTICOMPARTMENTAL MODEL OF INULIN AND UREA KINETICS* * From Atkinson AJ Jr, et al. Trends Pharmacol Sci 1991;12:96-101. ROLE OF TRANSCAPILLARY EXCHANGE THE CENTRAL COMPARTMENT FOR

BOTH UREA AND INULIN IS INTRAVASCULAR SPACE. THEREFORE, TRANSCAPILLARY EXCHANGE IS THE RATE-LIMITING STEP IN THE DISTRIBUTION OF BOTH COMPOUNDS TO THE PERIPHERAL COMPARTMENTS OF THE MAMMILLARY 3-COMPARTMENT MODEL. RENKIN EQUATION*

Cl Q (1 e P/Q ) Q = capillary blood flow P = capillary permeability coefficient-surface area product (sometimes denoted PS).

* From Renkin EM. Am J Physiol 1953;183:125-36. 3-COMPARTMENT MODEL Dose = L F C

VC CLE 1 ( QF e

CL S = QS ( 1e ) VF )

VS PF/Q F PS /Q S SIMULTANEOUS ANALYSIS OF

INULIN AND UREA-15N2 KINETICS SUBJECT 1 INULIN UREA How does QF + QS compare with C.O.?

FOR EACH COMPARTMENT 3 UNKNOWNS: Q, PU , PI 3 EQUATIONS: PU Q ln Q Q - ClU P I Q ln Q Q - Cl I PU PI DU D I U = urea; I = inulin

D = free water diffusion coefficient CARDIAC OUTPUT AND COMPARTMENTAL BLOOD FLOWS* * From Odeh YK, et al. Clin Pharmacol Ther 1993;53;419-25. MECHANISMS OF TRANSCAPILLARY EXCHANGE

DIFFUSIVE TRANSFER: M.W. < 6,000 DALTONS CONVECTIVE TRANSFER: M.W. > 50,000 DALTONS CAPILLARY PERMEABILITY VS. M.W.* * From Dedrick RL, Flessner MF. Immunity to Cancer 1989;II:429-38. MECHANISMS OF

TRANSCAPILLARY EXCHANGE TRANSFER OF SMALL MOLECULES (M.W. < 6,000 Da): TRANSFER PROPORTIONAL TO D - POLAR, UNCHARGED (urea, inulin) TRANSFER RATE < PREDICTED FROM D - HIGHLY CHARGED (quaternary compounds) - INTERACT WITH PORES (procainamide) TRANSFER RATE > PREDICTED FROM D - LIPID SOLUBLE COMPOUNDS (anesthetic gases) - FACILITATED DIFFUSION (theophylline)

THEOPHYLLINE KINETICS REFERENCED TO INULIN AND UREA THEOPHYLLINE UREA INULIN THEOPHYLLINE I.C. CLEARANCE AND COMPARTMENTAL BLOOD FLOWS*

* From Belknap SM, et al. J Pharmacol Exp Ther 1987;243:963-9. UREA & THEOPHYLLINE DIFFUSION COEFFICIENTS* MOLECULAR WEIGHT (DALTONS)

CORRECTED STOKESEINSTEIN RADIUS () Dm @ 37 C (x 10-5 cm2/sec) UREA

60 2.2 1.836 THEOPHYLLINE 180

3.4 1.098 * From Belknap SM, et al. J Pharmacol Exp Ther 1987;243;963-9. PRESUMED CARRIER-MEDIATED TRANSCAPILLARY EXCHANGE

SIGNIFICANCE OF DRUG DISTRIBUTION RATE AFFECTS TOXICITY OF IV INJECTED DRUGS THEOPHYLLINE DELAYS ONSET OF DRUG ACTION DIGOXIN INSULIN TERMINATES ACTION AFTER BOLUS DOSE THIOPENTAL LIDOCAINE

EARLY BENEFITS & LATER RISKS OF INITIAL IV THEOPHYLLINE DOSES 1937 THEOPHYLLINE 1st USED SUCCESSFULLY TO TREAT STATUS ASTHMATICUS Herrman G, Aynesworth MB. J Lab Clin Med 1937;23:135-48. 1943 3 CASES OF ARRHYTHMIC DEATH AFTER SLOW IV INJECTION OF 200 mg THEOPHYLLINE Merrill GA. JAMA 1943;123:1115.

1948 3 CASES OF CONVULSIVE CARDIORESPIRATORY DEATH AFTER SLOW BUT UNMEASURED INJECTION OF 88 - 300 mg THEOPHYLLINE Bresnick E, et al. JAMA 1948;136:397-8. 1971 - IV INJECTION OF 250 750 mg THEOPHYLLINE OVER 3 - 5 min RESULTS IN 60% OF DRUG-RELATED CARDIAC ARRESTS IN LA COUNTY SHOCK WARD Camarata, et al. Circulation 1971;44:688-95.

SAFETY LINKED TO RATE OF THEOPHYLLINE ADMINISTRATION THE TOTAL DOSE ..DOES NOT SEEM TO BE IMPORTANT, WITHIN THERAPEUTIC LIMITS, THE FATAL DOSE HAVING VARIED FROM 0.1 Gm TO 0.36 Gm. IT IS QUITE POSSIBLE THAT THE SPEED OF INJECTION IS MORE IMPORTANT. Bresnick E, et al. JAMA 1948;136:397-8. CURRENT RECOMMENDATION: IV THEOPHYLLINE LOADING DOSE SHOULD BE

5 mg/kg INFUSED OVER 20 40 min. PK MODEL OF THEOPHYLLINE DISTRIBUTION IV Dose CNS QF

= CL F SPLANCHNIC IVS HEART CLE CL

S = QS SOMATIC CO = QF + QS SIGNIFICANCE OF DRUG DISTRIBUTION RATE AFFECTS TOXICITY OF IV INJECTED DRUGS THEOPHYLLINE

DELAYS ONSET OF DRUG ACTION DIGOXIN INSULIN TERMINATES ACTION AFTER BOLUS DOSE THIOPENTAL LIDOCAINE DIGOXIN IS NOT THE 1ST DRUG GIVEN TO PATIENTS WITH ACUTE PULMONARY EDEMA

VASOCONSTRICTIVE EFFECTS MYOCARDIAL EFFECTS PLASMA VS. MYOCARDIAL DIGOXIN LEVELS EFFECTS ON CNS VOMITING CENTER SIGNIFICANCE OF DRUG DISTRIBUTION RATE AFFECTS TOXICITY OF IV INJECTED DRUGS THEOPHYLLINE

DELAYS ONSET OF DRUG ACTION DIGOXIN INSULIN TERMINATES ACTION AFTER BOLUS DOSE THIOPENTAL LIDOCAINE DISTRIBUTION TERMINATES EFFECT OF BOLUS LIDOCAINE DOSE*

THERAPEUTIC RANGE * From Atkinson AJ Jr. In: Melmon KL, ed. Drug Therapeutics: Concepts for Physicians, 1981:17-33. ANALYSIS OF LIDOCAINE DISTRIBUTION KINETICS* * From Benowitz N, et al. Clin Pharmacol Ther 1974;16:87-98. CONSEQUENCES OF VERY

SLOW DRUG DISTRIBUTION FLIP-FLOP KINETICS EFFECTIVE HALF-LIFE PSEUDO DOSE DEPENDENCY GENTAMICIN ELIMINATION PHASE PRECEEDS ITS DISTRIBUTION PHASE* * From Schentag JJ, et al. JAMA 1977;238:327-9.

GENTAMICIN ELIMINATION IN A NEPHROTOXIC VS. NON-TOXIC PATIENT* NEPHROTOXIC NON-TOXIC * From Coburn WA, et al. J Pharmacokinet Biopharm 1978;6:179-86.

CONSEQUENCES OF VERY SLOW DRUG DISTRIBUTION FLIP-FLOP KINETICS EFFECTIVE HALF-LIFE PSEUDO DOSE DEPENDENCY TOLRESTAT CUMULATION WITH REPEATED DOSING*

*From Boxenbaum H, Battle M: J Clin Pharmacol 1995;35:763-6. CUMULATION FACTOR TOLRESTAT CUMULATION OBSERVED C. F. ( = 12 hr): 1.29

PREDICTED (T = 31.6 hr): 4.32 EFFECTIVE HALF- LIFE* * From Boxenbaum H, Battle M. J Clin Pharmacol 1995;35:763-66. EFFECTIVE HALF-LIFE OF TOLRESTAT*

* From Boxenbaum H, Battle M. J Clin Pharmacol 1995;35:763-66. PSEUDO DOSE DEPENDENCY DISTRIBUTION VOLUME OF REPRESENTATIVE MACROMOLECULES COMPARTMENTAL ANALYSIS OF DRUG DISTRIBUTION

PARAMETERS OF COMPARTMENTAL MODELS THREE DIFFERENT DISTRIBUTION VOLUMES TECHNIQUE OF CURVE PEELING TWO-COMPARTMENT MODEL Dose

k21 Central V1 CLE CLI k12 k01

Periph. V2 3 DISTRIBUTION VOLUMES Vd (extrap.) DOSE C 0 Vd (area) Vd (ss)

t 1/2 CL E 0.693 V1 V2 ..... Vn TECHNIQUE OF CURVE PEELING A

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