Metabolites decrease the plasma clearance of isosorbide dinitrate in rats

Pharmacokinetics of isosorbide dinitrate in healthy volunteers after 24-hour intravenous infusion

No studies have examined the pharmacokinetics of isosorbide dinitrate (ISDN) after infusion of long duration, even though such infusions are used in patients. We therefore measured ISDN and its active metabolites, isosorbide-5-mononitrate (IS5MN) and isosorbide-2-mononitrate (IS2MN), in plasma of 9 healthy volunteers who received a continuous intravenous infusion of ISDN for 24 hours at a dose rate that lowered diastolic blood pressure by 10% during the first 30 minutes of infusion. All subjects tolerated the infusion except one who experienced intolerable headache. Five subjects received 1 microgram.min-1.kg-1, one 2 micrograms.min-1.kg-1, and two 4 micrograms.min-1.kg-1 ISDN, whereas the full rate of 6 micrograms.min-1.kg-1 was used continuously in one subject. At all infusion rates the plasma concentrations of ISDN were higher at 24 hours than at earlier times, suggesting that a steady-state condition had not been reached at that time. The same was true for the mononitrate metabolites, which reached higher plasma concentrations and were cleared more slowly than the parent compound after the end of the infusion. Apparent elimination half-lives of ISDN, IS2MN, and IS5MN were 67 +/- 10 minutes, 115 +/- 13 minutes, and 272 +/- 38 minutes, respectively. Comparison of low-rate infusions (1 and 2 micrograms.min-1.kg-1) with high-rate infusions (4 and 6 micrograms.min-1.kg-1) showed that the plasma concentration ratios at 24 hours of mononitrate metabolites to parent drug and apparent plasma clearance of ISDN were almost halved at the higher infusion rates.

Tolerance to nitroglycerin in rabbit aorta. Investigating the involvement of the mu isozyme of glutathione S-transferases

We have proposed that glutathione S-transferases (GSTs), especially the mu isozyme, play a critical role in the metabolism of nitroglycerin (glyceryl trinitrate, GTN), leading to pharmacologic effects. Here we study this enzyme(s) during tolerance development in male New Zealand white rabbits. Each aorta was divided into two segments designated as GTN pretreated and buffer control. Tolerance was induced in rabbit aortic strips so assigned by incubation with GTN (0.22 mM). The activity of the mu isozyme and of total GSTs was determined in portions f each segment. In each rabbit aorta, the response to GTN (0.5 microM) was determined in GTN-pretreated and buffer-pretreated strips by measuring cyclic GMP levels (N = 7 pairs) and percent relaxation (N = 4 pairs). In GTN-pretreated strips, a significant decrease was observed in the activity of the mu isozyme of GST, while the total GST activity was unchanged as compared with control strips. The decrease in isozyme activity correlated very well with the decrease in response to GTN. Two rabbit aortae did not become tolerant, and the activity of the mu isozyme was also not affected. The levels of thiols were not affected by GTN pretreatment and aortae tolerant to GTN did not develop tolerance to S-nitroso acetylpenicillamine (SNAP), indicating that thiol depletion and guanylate cyclase desensitization probably play a minor role in tolerance development to GTN in our model. These studies suggest that tolerance to GTN in rabbit aorta in vitro is associated with a decrease in GST mu activity, which correlates well with the decrease in GTN response.

Nitroglycerin dinitrate metabolites do not affect the pharmacokinetics and pharmacodynamics of nitroglycerin in the dog: a preliminary report

Studies were carried out in conscious dogs to determine the effects of 1,2-glyceryl dinitrate (1,2-GDN) and 1,3-glyceryl dinitrate (1,3-GDN) on nitroglycerin (GTN) pharmacokinetics and pharmacodynamics. In the first set of experiments, steady state plasma levels (Css) of either 1,2-GDN or 1,3-GDN in three dogs were rapidly achieved by giving an iv bolus (77 micrograms/kg), followed immediately by an infusion (50 micrograms/min) of the same GDN. A single iv bolus dose of GTN (0.025 micrograms/kg) was given 50 min after beginning the GDN infusion and compared with plasma concentrations following a similar GTN dose in the absence of dosed GDNs. No significant differences in GTN AUC (p > 0.9) and CL(app) (p > 0.7) were found. In a second set of experiments, an infusion of nitroglycerin was begun in each of 4 dogs and continued for 160 min at an infusion rate of 100 micrograms/min. Steady state concentrations of GTN were achieved within 100 min, at which time the dog received, simultaneously, an iv bolus dose (5.14 mg) of one of the GDNs and an infusion dose (100 micrograms/min) of the same GDN. For both dinitrate metabolites no significant differences (p > 0.5) were found between control and interaction arterial and venous clearances, although venous GTN clearances tended to decrease in the presence of dosed GDNs. Steady state systolic blood pressure during GDN infusions could be further reduced when GTN doses were administered; however, the steady state systolic blood pressure decrease caused by GTN could not be further reduced by the GDN infusions. Results suggest that the GDNs do not inhibit nitroglycerin metabolism or hemodynamics at the dose levels studied here.

Mechanisms of nitrate tolerance: a review

With the increased use of long-acting nitroglycerin preparations, there has been greater recognition of the problem of nitrate tolerance. In recent years extensive research has broadened our understanding of the mechanisms of nitroglycerin action and the mechanisms of drug attenuation. This paper reviews the current state of knowledge regarding nitroglycerin tolerance, with an emphasis on the concepts of cellular and neurohumoral mechanisms of drug attenuation. The discussion includes potential approaches to prevent nitrate tolerance, including the introduction of a nitrate-free interval, or concomitant administration of sulfhydryl donors or neurohumoral blocking agents.

Pharmacokinetics and pharmacodynamics of organic nitrates

The pharmacokinetic and pharmacodynamic aspects of organic nitrates are discussed, with particular emphasis on the 3 major organic nitrates currently in use, nitroglycerin (NTG), isosorbide dinitrate and isosorbide-5-mononitrate. After intravenous administration, both NTG and isosorbide dinitrate exhibit large systemic clearances and both nitrates appear to be extensively distributed in vascular and other peripheral tissues. Two pharmacokinetic features appear particularly notable for NTG: there is a significant arteriovenous extraction of the drug, and its systemic clearance is related to cardiac output. Both of these features, plus other evidence, suggest that organic nitrates may be substantially removed from the systemic circulation by the vasculature itself. During nitrate tolerance, plasma drug concentrations remain elevated, but vascular activity is diminished. This apparent paradox might be explainable by a unifying hypothesis of reduced nitrate metabolism during vascular tolerance; thus, in the tolerant state, reduced systemic clearance of the intact drug brought about elevated plasma concentrations, whereas reduced cellular metabolism at the smooth muscle brought about a decrease in vascular activity. The complex relations among plasma kinetics, vascular metabolism and pharmacologic action of organic nitrates are still poorly understood.

Tolerance to organic nitrates in ischemic heart disease

The development of tolerance to organic nitrates in patients with ischemic heart disease is reviewed, with particular interest in alterations to both the hemodynamic and antiischemic effects over time. The article primarily focuses on how tolerance is defined, what biochemical mechanisms are involved when this condition occurs, which agents have been associated with the development of tolerance, and what can be done to prevent or reverse the condition in patients taking nitrates for ischemic heart disease. From a historical perspective, tolerance to organic nitrates has been a recognized phenomenon since the last century. The role that blood-level determinations and nitroglycerin pharmacokinetics have in the development of tolerance is discussed, and an extensive overview of currently marketed organic nitrate preparations and a few others available only through approved investigational protocols is presented. The role of cross-tolerance is discussed as is the role that nitrate-free intervals play in partially or completely reversing the effects of tolerance during chronic nitrate therapy. Additionally, a discussion of which specific nitrate formulation are least likely to have tolerance associated with their use is included, such as short-acting nitrate formulations with the exception of the intravenous dosage form. Finally, buccal nitroglycerin is presented as another new formulation that appears to be associated with minimal tolerance in studies already completed.

Metabolite inhibition of nitroglycerin metabolism in sheep tissue homogenates

The metabolism of nitroglycerin in sheep tissue homogenates has been examined using tritiated nitroglycerin and a HPLC separation procedure. Nitroglycerin was metabolized by liver, lung, muscle, arterial and venous tissue to its dinitrometabolites and subsequently to mononitroglycerin. Addition of the dinitrometabolites substantially inhibited the degradation of nitroglycerin in all tissue homogenates.

Pharmacokinetics and pharmacodynamics of isosorbide dinitrate

It has long been believed that organic nitrates, including isosorbide dinitrate (ISDN), are completely metabolized during their first passage through the liver and that oral therapy with this class of compounds is thus irrational. In the past few years, convincing data have been obtained in patients showing that intact ISDN is significantly bioavailable to the systemic circulation after oral administration; the oral bioavailability is about 20% relative to an intravenous dose and about 45% relative to a sublingual dose, with the balance metabolized to isosorbide mononitrates. These pharmacologically active metabolites have longer biologic half-lives than ISDN and are thus believed to contribute to the sustained duration of action of this drug. After acute dosing, changes in the pharmacologic effects of ISDN mirror those in plasma concentration. However, after long-term therapy, partial nitrate tolerance develops despite elevated plasma ISDN concentrations. Available evidence suggests that during sustained dosing, nitrate metabolism is generally reduced throughout the body; thus reduced hepatic and peripheral tissue metabolism raises plasma ISDN concentrations while reduced vascular tissue metabolism decreases the metabolic activation (perhaps to nitrosothiols?) necessary for vascular relaxation.

Dose dependent pharmacokinetics of nitroglycerin after multiple intravenous infusions in healthy volunteers

Evaluation of the pharmacokinetics of nitroglycerin has been hindered in the past by the lack of specific and sensitive analytical procedures, and the unavailability of parenteral nitroglycerin and infusion sets which did not adsorb nitroglycerin. The purpose for this present study was to determine the pharmacokinetic parameters of nitroglycerin and the dinitrate metabolites after multiple intravenous infusions of nitroglycerin in healthy volunteers. Six volunteers received variable infusion rates of nitroglycerin. Generally, at 0, 40, 80, and 120 min, the infusion rates were adjusted to 10, 20, 40, and 10 micrograms/min, respectively. Plasma samples were drawn and analyzed for nitroglycerin and its 1,2- and 1,3-dinitrate metabolites using capillary GC. Steady-state nitroglycerin plasma concentrations attained at 10, 20, 40, and 10 micrograms/min were 0.44 +/- 0.31, 1.32 +/- 0.71, 4.23 +/- 1.50 and 1.04 +/- 0.43 ng/ml, respectively. As the infusion rate was increased, the steady-state concentrations increased disproportionately. When the dose was decreased from 40 to 10 micrograms/min, the steady-state nitroglycerin concentrations were always higher than those at the initial low infusion rate. Thus, in the majority of subjects, a hysteretic type of response was present. The hysteresis observed in the dose versus steady-state concentration curve may be explained by either end-product inhibition or saturable binding of nitroglycerin to blood vessels. The clearance values (5.5 to 711/min) were very high and far exceed the maximum possible hepatic clearance suggesting that nitroglycerin is metabolized by organs other than liver. Clearance was not directly related to plasma concentrations but was found to decrease to a constant value (approximately 11 +/- 6 l/min) as nitroglycerin concentrations initially increased.

Transdermal isosorbide dinitrate in angina pectoris: effect of acute and sustained therapy

Twelve patients with chronic, stable angina pectoris underwent hemodynamic investigations and treadmill exercise testing before and during a 24-hour period after the application of 100 mg of transdermal isosorbide dinitrate (ISDN) and matching placebo. Compared with placebo, there were no changes in systolic blood pressure or heart rate at rest or during exercise; but treadmill walking time to the onset of angina and to the development of moderate angina was significantly prolonged at 2, 4 and 8 hours, but not at 24 hours, after drug application. Patients subsequently received these same treatment regimens for 7 to 10 days and underwent repeat exercise testing. During this sustained phase of the investigation, treadmill walking time to the onset of angina and to the development of moderate angina was similar 4, 8 and 24 hours after application of ISDN and placebo. Thus, transdermal ISDN in a dose of 100 mg is effective for 8 hours during acute therapy, but during sustained therapy tolerance developed and no antianginal effects of ISDN persisted.

Pharmacokinetic determinants of nitrate action

An update on some of the recent studies relating to organic nitrate pharmacokinetics and pharmacodynamics is presented. The systemic clearance of nitroglycerin was found to be unaffected by portacaval shunting in animals. Thus, the liver only plays a minor role in the metabolism of systemic nitroglycerin. Organic nitrates are extensively taken up by blood vessels in which metabolic activation can occur to produce vascular activity. During sustained therapy, nitrate metabolites may decrease the systemic and hepatic clearance of the parent drug, thus increasing its plasma concentration. Metabolites could also decrease the extent of metabolism in vascular tissues, thus contributing to vascular nitrate tolerance. Therefore, during long-term angina therapy when metabolites are present, the same plasma nitrate concentration may produce less effects compared with that obtained after acute dosing. Nitrate action was shown to be possibly dependent on the rate of drug input. An alternate dosing mode is proposed that speculatively may provide an improvement in producing and maintaining nitrate action in long-term angina therapy.