Dose-dependent enzyme induction

Bad weed: synthetic cannabinoid–associated coagulopathy

Recent multistate outbreaks of coagulopathy caused by brodifacoum-tainted synthetic cannabinoids or “fake weed” highlight the public health impact of long-acting anticoagulant rodenticides (LAARs). Patients presenting with this syndrome have had recent exposure to synthetic cannabinoids, evidence of isolated vitamin K antagonism with or without bleeding, and detectable levels of brodifacoum and other LAARs in circulation. This article will provide information on synthetic cannabinoids, LAARs, and coagulopathic manifestations arising from use of adulterated synthetic cannabinoids and their management.

Substrate-dependent irreversible inactivation of cytochrome P-450: conversion of its haem moiety into modified porphyrins

2-Allyl-2-isopropylacetamide and other drugs containing either an allyl, a vinyl or an ethynyl unsaturated side chain are metabolized by liver cytochrome P-450 to reactive derivatives that irreversibly inhibit the haemoprotein by a suicidal type of inactivation. The main target is the haem moiety of cytochrome P-450 which is converted into abnormal porphyrins. These have been isolated from the liver of treated rats, extensively purified and compared with model porphyrins. The abnormal porphyrins incorporate metal ions in vitro much more readily than does their parent porphyrin, protoporphyrin. They are also much more basic than protoporphyrin, and on titration with a strong acid they readily give rise to a porphyrin monocation which then requires relatively large amounts of acid for conversion to the porphyrin dication. In all these respects and also in the intensity of their bathochromic shifts these abnormal porphyrins closely resemble N-alkylated porphyrins and they markedly differ from porphyrins that are substituted at one of their meso-carbon positions or which bear electron-withdrawing substituents at the beta-positions of the pyrrole rings. This suggests strongly that reactive derivatives of the unsaturated drugs act as electrophilic reagents and alkylate one of the pyrrole nitrogen atoms of cytochrome P-450. A model centred on the apoprotein of cytochrome P-450 is considered for the degradation of liver haem caused by unsaturated drugs. The apocytochrome may accept exchangeable pools of liver haem for degradation, leading to a state of haem depletion and to activation of delta-aminolaevulinate synthase.

Interindividual variability in inhibition and induction of cytochrome P450 enzymes

Drug interactions have always been a major concern in medicine for clinicians and patients. Inhibition and induction of cytochrome P450 (CYP) enzymes are probably the most common causes for documented drug interactions. Today, many pharmaceutical companies are predicting potential interactions of new drug candidates. Can in vivo drug interactions be predicted accurately from in vitro metabolic studies? Should the prediction be qualitative or quantitative? Although some scientists believe that quantitative prediction of drug interactions is possible, others are less optimistic and believe that quantitative prediction would be very difficult. There are many factors that contribute to our inability to quantitatively predict drug interactions. One of the major complicating factors is the large interindividual variability in response to enzyme inhibition and induction. This review examines the sources that are responsible for the interindividual variability in inhibition and induction of cytochrome P450 enzymes.

Time course of enzyme induction in humans: effect of pentobarbital on nortriptyline metabolism

To study the effect of induction we gave six male volunteers 10 mg nortriptyline three times a day for 4 weeks and 0.2 gm pentobarbital on days 8 to 21. Plasma and urinary levels of nortriptyline and metabolites were measured. The rate and extent of induction of the enzyme(s) were estimated by a model with use of nortriptyline concentrations. There was a marked decrease of nortriptyline levels after 2 days of pentobarbital treatment. Total clearance of nortriptyline increased more than twofold (range, 1.6-fold to 4.1-fold). Apparent metabolic clearance by 10-hydroxylation increased markedly. The decrease in nortriptyline levels was more rapid than the increase after pentobarbital cessation, fitting with the theory of the model. The induction of nortriptyline metabolism is probably mainly the result of an increase in a non-CYP 2D6 P450 isozyme, possibly CYP 3A4 or a CYP 2C form. More knowledge of induction characteristics of drugs should lead to better predictions of decreased effects and appearance of adverse effects. The kinetic model used for analysis of our data could then be useful.

Dose-dependent induction of the microsomal monooxygenase system by phenobarbital and 3-methylcholanthrene in the ad libitum and calorie-restricted female rat

1. We characterized the dose-dependent induction of the microsomal monooxygenase system by phenobarbital (PB) and 3-methylcholanthrene (MC) in the female Fischer 344 rat, which was either calorie restricted (CR) or fed ad libitum (AL). 2. Maximal induction of the major inducible isozymes (2B1/2B2 or 1A1) in rat was achieved at the lowest of the inducer doses employed (10 mg/kg body weight) in both feeding groups. 3. The patterns of dose-dependent PB induction and its magnitude differed between total P450 induction and induction of catalytic activities in AL and CR groups, whereas no differences between CR and AL rat were found in either spectrally detected P450 or EROD activity patterns of dose-dependent MC induction. 4. Calorie restriction increased the inducibility of some hepatic drug-metabolizing enzyme activities. 5. Monoclonal antibody-directed inhibition of MC-induced ethoxyresorufin O-deethylation (EROD) was 55-60% at all induction levels in AL rat and 65-70% in CR rat, while MAb inhibition of PB-induced pentoxyresorufin O-depenthylation (PROD) averaged about 55% in AL and 60% in CR rat.

Effect of phenobarbital and other model inducers on cytochrome P450 isoenzymes in primary culture of dog hepatocytes

1. The effects of phenobarbital (PB), beta-naphthoflavone (beta-NF), omeprazole (Omep) and rifampicin (Rif) on drug-metabolizing activities in dog hepatocytes, cultured with William's medium E, were examined. 2. The drug metabolizing activities of the hepatocytes decreased during culture; 7-ethoxycoumarin O-deethylase (ECOD) activity was nearly 70% of initial value at 72 h, but 7-methoxycoumarin O-demethylase (MCOD), 7-propoxycoumarin O-depropylase (PCOD), progesterone 6 beta-hydroxylase (6 beta-OH-P), progesterone 16 alpha-hydroxylase (16 alpha-OH-P), progesterone 21-hydroxylase (21-OH-P), 7-ethoxyresorufin O-deethylase (EROD) activities and total cytochrome P450 content were approx. 50%. 3. When the hepatocytes were cultured with PB, the enzyme activities increased time- and dose-dependently. MCOD, ECOD and PCOD activities increased 5-8 fold with 2 mM PB in 96 h. Similar results were obtained for 6 beta-OH-P, 16 alpha-OH-P and 21-OH-P activities, and total cytochrome P450. The effect of PB was abolished when 2.5 microM cycloheximide or 0.1 microM actinomycin D was included in the culture. 4. Treatment of hepatocytes with 40 microM beta-NF for 72 h resulted in 25-fold elevation of EROD activity. beta-NF enhanced PCOD activity approx. six-fold, while ECOD increased only slightly, and 7-MCOD negligibly. 5. Omep (100 microM) increased EROD activity nearly 10-fold, and 25 microM Rif increased 6 beta-OH-P activity approx. 8-fold, but ECOD only slightly. 6. Western blot analysis of microsomes from cultured dog hepatocytes with anti-rat CYP 2B1 antibodies indicated that PB increased an immunochemically-reactive protein. The protein showed the same mobility as the major dog P450 isozyme (cytochrome P450 PBD-2 or CYP 2B11) purified from liver microsomes of PB-treated male beagle dog. In a similar manner, induction of cytochrome P450 PBD-1 (CYP 3A12) by PB was confirmed.

The effect of malaria infection on antipyrine metabolite formation in the rat

We have shown that malaria infection can impair selectively the formation of antipyrine metabolites in the rat. During malaria, a significant increased urinary levels of unchanged antipyrine was observed (control: 1.7 +/- 0.4 vs test: 8.1 +/- 1.1% of dose, P less than 0.001). This was associated with significantly decreased excretion of 3-hydroxymethylantipyrine (control: 24.5 +/- 1.2 vs test: 21.4 +/- 0.7%, P less than 0.001) and 4-hydroxyantipyrine (control: 20.1 +/- 0.9 vs test: 15.5 +/- 1.3%, P less than 0.001) but not norantipyrine compared to control. Following treatment of the malaria infection with halofantrine, only the formation of 3-hydroxymethylantipyrine (control: 25.2 +/- 0.9 vs test: 24.1 +/- 0.6%, P less than 0.05) is impaired. The implications of these findings in relation to metabolism of other antimalarial drugs during malaria remains to be elucidated. Further work is needed to determine the changes in the pharmacokinetics of AP and its metabolites before, during and after MI in the rat in order to give a better insight into the effect of MI on hepatic drug metabolism.

Species variation in the response of the cytochrome P-450-dependent monooxygenase system to inducers and inhibitors

1. In the safety evaluation of drugs and other chemicals it is important to evaluate their possible inducing and inhibitory effects on the enzymes of drug metabolism. 2. While many similarities exist between species in their response to inducers and inhibitors, there are also important differences. Possible mechanisms of such variation are considered, with particular reference to the cytochrome P-450 system. 3. Differences in inhibition may be due to differences in inhibitory site of the enzyme involved, which is not always the active site of the enzyme, in competing pathways or in the pharmacokinetics of the inhibitor. 4. Differences in induction could be due to differences in the nature of the induction mechanism, in the isoenzyme induced, in tissue- or age-dependent regulation, in competing pathways for the substrate or its products, or in the pharmacokinetics of the inducing agent. 5. Examples of each of these possible differences are considered, often from our own work on the P450 IA subfamily, and results in animals are compared with those in humans, where possible. 6. At present, the differences between species in their response to inducers and inhibitors make extrapolation to humans from the results of animal studies difficult, so that ultimately such effects should be studied in the species of interest, humans.

Drug metabolizing capacity in vitro and in vivo--II. Correlations between hepatic microsomal monooxygenase markers in phenobarbital-induced rats

Pretreatment with various doses of phenobarbital (PB) has been used to create a pool of rats with a wide range of hepatic microsomal monooxygenase activity to systematically examine relationships between and within in vivo and in vitro markers. The in vivo clearance of tolbutamide (TOL), theophylline (TH), antipyrine (AP) and its metabolites were determined in the same rats used for hepatic microsome preparation and assessment of P450 content and activities (via 7-ethoxycoumarin O-deethylase (ECOD), 7 ethoxyresorufin O-deethylase, 7-methoxycoumarin O-demethylase (MCOD) and aldrin epoxidase determinations). A graded dose-response relationship was found between PB treatment and most but not all parameters. The need for careful selection of in vivo and as well as in vitro markers is apparent from these studies. The most responsive parameters--TOL and AP clearances, MCOD and ECOD activities--were also those producing the strongest in vivo-in vitro correlations. Despite the diffuse nature of the PB induced response in P450 complement, good predictive relationships were apparent between ECOD and TOL clearance (r2 = 0.88).

Enzyme induction and inhibition

The rate and extent of drug metabolism significantly influences drug effect. Enzyme induction by increasing the metabolism of drugs may result in important drug interactions. Other implications of enzyme induction include alterations in the metabolism of endogenous substrates, vitamins and activity of extrahepatic enzyme systems. Similarly a wide range of drugs may produce clinically significant drug interactions following enzyme inhibition. Assessment of enzyme induction and inhibition in man involves diverse methods including the use of model drugs.

Decreased plasma concentrations and clinical effects of alprenolol during combined treatment with pentobarbitone in hypertension

The antihypertensive effect of alprenolol has been studied before, during and after additional pentobarbitone treatment. The combined alprenolol-pentobarbitone treatment significantly decreased alprenolol levels by 59% and 4-hydroxyalprenolol by 24%. The effect was significant after three doses and declined over 4-5 days after pentobarbitone withdrawal. The decreased alprenolol plasma levels were associated with increased pulse rate (6%), and systolic (8%) and diastolic (9%) blood pressure. The inhibition of exercise tachycardia by alprenolol was reduced by 18% at the end of pentobarbitone treatment compared to initial monotherapy with alprenolol. The interaction is probably clinically important in those patients with hypertension and angina pectoris that are treated with barbiturates and alprenolol.

The effect of low-dose phenobarbitone on three indices of hepatic microsomal enzyme induction

The effects of low-dose phenobarbitone on three indices of hepatic enzyme induction were studied. Eight healthy volunteers took phenobarbitone 7.5 mg daily for 4 weeks followed by 15 mg daily for 4 weeks; five subjects took 30 mg daily for a further 2 weeks. Phenobarbitone 15 mg daily produced a significant rise in antipyrine clearance (P less than 0.05). Phenobarbitone 30 mg daily produced a further rise, but probably because of the reduced numbers of subjects, this did not achieve significance (P = 0.06). Urinary 6-beta-hydroxycortisol and D-glucaric acid levels did not change significantly and remained within the range seen in subjects not taking enzyme-inducing drugs. We conclude that phenobarbitone 7.5 mg daily produces little (if any) enzyme induction whereas 15 mg, or more, may have the potential to produce drug interactions through enzyme induction.

The influence of a graded dose schedule of aminoglutethimide on the disposition of the optical enantiomers of warfarin in patients with breast cancer

The pharmacokinetics of the optical enantiomers of warfarin (R-warfarin and S-warfarin) were investigated in patients treated for breast cancer with aminoglutethimide (AG). The patients received 125 mg AG b.i.d. (i.e., low-dosage regimen); 250 mg AG q.i.d. together with cortisone acetate (i.e. high-dosage regimen); or an escalating dose schedule was followed (i.e. low-dosage regimen followed by high-dosage regimen). The pharmacokinetics for R-warfarin and S-warfarin were determined before initiation of AG treatment and again after 2, 4, or 8 weeks of continuous AG treatment. The plasma clearance for both enantiomers showed a moderate increase (mean 41.2%) in patients receiving the low AG dose, whereas in patients treated according to the high-dosage regimen a marked increase (mean 90.8%) was observed. There was a corresponding reduction in warfarin half-life, and no alteration in distribution volume. These effects on the warfarin pharmacokinetics appeared after 14 days of AG treatment, and after this time point there was no further increase in warfarin clearance. Notably, the effect of AG on warfarin kinetics was the same for both enantiomeric forms of warfarin. These data show that there is a dose-response relationship between AG dose and induction of warfarin metabolism.

Characterization of antipyrine autoinduction in the rat utilizing a new microsampling technique for serial blood sample collections

A new microsampling technique is described and applied to the collection of a large number of blood samples from individual rats receiving a chronic intravenous antipyrine infusion. From these samples, a detailed description of the time-course of antipyrine autoinduction of clearance in the rat was provided. Antipyrine clearance was increased 4-5-fold over 8 d of antipyrine administration, with the increase in clearance following a monoexponential process in all animals. The assumption that the time-course of induction should reflect the degradation rate of induced enzymes was examined by comparing the half-life of antipyrine autoinduction with in vitro estimates for the half-life of induced cytochrome P-450 enzymes. The results of this comparison are discussed with respect to utilizing this kinetic model to quantitate the turnover of drug metabolism enzymes in vivo.

The effects of phenytoin dosage on the induction of alpha 1-acid glycoprotein and antipyrine clearance in the dog

Doses of phenytoin from 90 to 800 mg/d were used to study induction of hepatic cytochrome P-450 and plasma alpha 1-acid glycoprotein in dogs. The antipyrine clearance was increased by 80%, which is equivalent to an increase in cytochrome P-450 of 140%, and the plasma glycoprotein concentration rose 200% at the highest dose of phenytoin used. Plasma concentrations of phenytoin were measured at each dose level to provide a definitive value for the amount of inducer present. These data were used to assess the concentration-response relationship for phenytoin inducing either cytochrome P-450 or the glycoprotein. A simple relationship between concentration and effect was not observed, suggesting a complex mechanism of induction.

Induction of mixed function oxidase activity in man by rifapentine (MDL 473), a long-acting rifamycin derivative

The effects of rifapentine (MDL 473) administration on hepatic mixed function oxidase activity in man have been investigated in six healthy volunteers. Administration of rifapentine (600 mg 48 h-1) for 10 days resulted in a significant reduction in antipyrine half-life (from 13.2 +/- 1.0 h to 7.7 +/- 0.4 h) and a corresponding increase in its total body clearance (from 41.8 +/- 5.5 ml min-1 to 67.4 +/- 5.6 ml min-1). Twelve days after stopping rifapentine administration, these values had largely returned to base-line. 24-Hour excretion of 6 beta-hydroxycortisol was significantly increased, by approximately three-fold, following administration of rifapentine for 10 days. Again, 12 days after stopping drug administration, 6 beta-hydroxycortisol excretion had returned to pretreatment values. Clearance of antipyrine to its three oxidative metabolites was increased by rifapentine administration, although the increase for 3-hydroxymethylantipyrine was not significant. The greatest increase (+140%) was observed for norantipyrine. Twelve days after the last dose of rifapentine, all values had returned to control levels. It is concluded that, like rifampicin, rifapentine is a potent inducer of mixed function oxidase activity in man and that the possibility of clinically significant drug interactions should be anticipated in the therapeutic use of this compound.

Effects of phenobarbital steady state levels on antipyrine clearance and distribution in the rat

A group of 15 rats received two intravenous bolus doses of antipyrine (15 mg/kg) separated by a 57 hour infusion (with bolus dose) of phenobarbital. Phenobarbital bolus doses and infusion rates were based on a preliminary pharmacokinetic study (7 rats) and were varied to achieve a broad range of steady state levels. Antipyrine and phenobarbital blood levels were measured by high pressure liquid chromatography. Antipyrine kinetics obeyed first order monoexponential decay, and the parameters (clearance, volume, half-life) were determined. Antipyrine clearance increased in all animals during phenobarbital infusions with a per cent increase ranging between 54.6 and 269 per cent. However, no significant correlation was found between the per cent increase in antipyrine clearance and phenobarbital concentration (r = 0.19). The volume of distribution of antipyrine increased in 14 of 15 animals with increases ranging between 7.7 and 45.8 per cent.

A comparative study of the relative enzyme inducing properties of anticonvulsant drugs in epileptic patients

The antipyrine clearance and the urinary excretion of D-glucaric acid (D-GA) were determined in 122 patients receiving chronic anticonvulsant drug treatment and in 21 drug-free control subjects. Patients treated with carbamazepine (CBZ), phenytoin (DPH), primidone (PMD) and phenobarbitone (PB), either alone or in combination, showed higher values of antipyrine clearance and excreted larger amounts of D-GA as compared to controls. While antipyrine clearance values did not differ significantly from one drug group to another, D-GA excretion was significantly higher in patients treated with CBZ than in those treated with DPH. In patients treated with sodium valproate antipyrine clearance did not differ from control values. There was a trend for D-GA excretion to be higher in these patients but the difference was not statistically significant. Significant positive correlations were found between the dosage of CBZ, DPH, PMD and PB and both indices of enzyme induction. These data demonstrate a dose-dependent degree of enzyme induction in patients receiving therapeutic doses of these anticonvulsants. The relative potency at average dose levels for antipyrine clearance was PB (1), DPH (0.92), CBZ (0.84), PMD (0.82) and for log D-GA excretion was PB (1), CBZ (0.96), PMD (0.95), DPH (0.90).

Enzyme induction and beta-adrenergic receptor blocking drugs

All beta-adrenergic receptor blockers that require metabolism prior to elimination are potentially subject to drug interactions due to enzyme induction. However, data is only available in man for propranolol, metoprolol and alprenolol. Cross-sectional population studies suggest that environmental factors, such as smoking in the young, are able to influence the oral clearance of propranolol. Long-term studies comparing within-subject clearances of metoprolol, alprenolol and propranolol before and after rifampicin and pentobarbitone, indicate that oral clearance is increased by 50%-500%. Inducing agents can influence intrinsic clearance, liver blood flow, and protein binding in addition to drug metabolising ability, indicating that changes in pharmacokinetic disposition may be complex. Enzyme induction exhibits both dose and time dependency relationships. The maximal extent of enzyme induction is similar between subjects. The range of intersubject variation in drug metabolism is similar before and after induction. The reduction in steady-state beta-adrenergic receptor drug concentration following enzyme induction is sufficiently large that an altered pharmacodynamic response would be expected if no dosage modification is made.

Clinical evaluation of prolonged chemotherapy combined with induction of hepatic drug-metabolizing enzymes as an adjuvant for treating patients with gastric cancer

A clinical trial of a protracted adjuvant cancer chemotherapy was carried out on 207 patients with operable gastric cancer, from April, 1977, in the First Department of Surgery, Chiba University Hospital and two closely related hospitals. These patients were given intravenously 0.4 mg/kg and 0.2 mg/kg of mitomycin C on the day of operation and the next day, respectively, and then 16 mg/kg intravenously of Futraful (FT-207) daily from the 10th postoperative day until discharge, followed by oral administration of FT-207, 12 mg/kg, for 24 to 36 months after discharge. Two mg/kg of phenobarbital and 30 mg/kg of glutathione were administered randomly to half the number of patients (induction group) to induce hepatic drug-metabolizing enzymes. Significantly higher levels of serum 5-Fluorouracil (5-FU) released from FT-207 were found in the induction group than in the controls. Five-year overall survival rates in the induction and control groups revealed no difference. However, the survival rates in Stage III patients in the induction group were significantly superior in the 3-5 postoperative years, compared to those in the Stage III of the control group, while Stage I, II and IV patients apparently received no benefit from this induction treatment.

Induction of propranolol metabolism by rifampicin

The effect of rifampicin on the blood concentration-time curve of propranolol at steady-state following oral administration of 120 mg every 8 h was investigated in six normal, young, male subjects. After an initial 2 week dosing period, all individuals additionally received 600 mg rifampicin daily for 3 weeks followed by a 4 week period during which again only the propranolol was given. In four of the subjects the effects of 900 and 1200 mg rifampicin daily was also studied. Changes in disposition were assessed by estimation of propranolol's oral clearance and elimination half-life during the dosage interval. Rifampicin (600 mg/day) caused a large increase in propranolol's oral clearance (35.7 +/- 16.3 vs 96.1 +/- 26.9 ml min-1 kg-1, mean +/- s.d.), but neither the elimination half-life nor extent of plasma binding were affected. Increasing the daily dosage to 900 and 1200 mg did not cause any additional changes in oral clearance. Four weeks after discontinuing rifampicin, propranolol's oral clearance had essentially returned to its pre-induction level. The oral clearance of propranolol was significantly smaller (89.5 +/- 14.4%) during the dosage interval immediately after administration of the last rifampicin dose than the value measured 24 h later. The findings are consistent with rifampicin causing induction of the drug metabolizing enzymes responsible for propranolol's biotransformation. The marked reduction in the steady-state propranolol blood concentration that results from chronic rifampicin administration would be expected to result in a significant change in clinical effectiveness of the beta-adrenoceptor blocker when the two drugs are used concurrently.

Hepatic enzyme induction and leucocyte delta-aminolaevulinic acid synthase activity: studies with carbamazepine

Antipyrine metabolism, daily urinary 6-beta-hydroxycortisol excretion, carbamazepine (CBZ) half-lives and leucocyte delta-aminolaevulinic acid synthase (ALA.S) activities were measured following 2 weeks' treatment with CBZ 400 mg and 600 mg once daily in eight healthy male volunteers. Dose-dependent induction of antipyrine metabolism was demonstrated but cortisol hydroxylation appeared maximally induced by the 400 mg dose. CBZ half-lives fell significantly in both studies (P less than 0.01 in each case) but a greater fall was seen with the higher dose (P less than 0.01). Plasma CBZ concentrations were higher following the eighth doses (P less than 0.01) in both studies. Leucocyte ALA.S activity increased by a mean of 657% following 1 week's treatment with 400 mg CBZ and 1145% on the 600 mg dose. In both studies ALA.S activities fell towards baseline during the second week of treatment. CBZ possesses potent dose-dependent hetero- and auto-inducing properties. Leucocyte ALA.S activity may represent a novel in vivo index of extrahepatic enzyme induction in man.

Saliva carbamazepine levels in children before and during multiple dosing

1 Saliva carbamazepine (CBZ) pharmacokinetics were determined in six children aged 7-11 years at the start and after 5 weeks of CBZ therapy. 2 A single oral dose of CBZ, 14.7 +/- 2.3 mg kg -1, was administered and mixed saliva was collected at intervals during the next 36 h. CBZ therapy was then continued using the same total daily dose divided into two equal doses. After 5 weeks of therapy saliva samples were collected once more as on day 1. 3 The mean (+/- s.d.) saliva CBZ clearance increased over the study period from 142 +/- 28 to 402 +/- 79 ml h -1 kg -1 (P less than 0.001) and the mean half-life decreased from 23.6 +/- 5.3 to 8.0 +/- 2.3 h (P less than 0.005). The mean apparent volume of distribution after the first dose, 4.72 +/- 0.84 1 kg -1, was similar to that after 5 weeks treatment, 4.66 +/- 1.68 1 kg -1. 4 The mean saliva steady-state CBZ concentrations after 5 weeks therapy were less than 40% of those predicted from the single dose kinetic parameters.

Effect of rifampicin on metoprolol and antipyrine kinetics

1 Effects of rifampicin on the pharmacokinetics of single oral doses of metoprolol and antipyrine are reported. 2 Rifampicin, administered daily for 15 days, reduced the area under the plasma concentration-time curve (AUC) of metoprolol but the rate constant for elimination (beta) of metoprolol from plasma did not alter significantly. 3 Administration of rifampicin for 13 days reduced AUC and increased beta of antipyrine. Thirteen days after discontinuing rifampicin. AUC and beta of antipyrine remained significantly different from the initial values. 4 Some loss of beta-adrenoceptor blockade should be anticipated if rifampicin is administered to patients who are receiving metoprolol.

Induction of microsomal enzyme activity by flupenthixol in chronic schizophrenics

The effect of long-term treatment with flupenthixol on hepatic microsomal enzyme activity was studied in 12 chronic schizophrenic outpatients who had been receiving two weekly maintenance doses for at least 6 months. Antipyrine half-life was measured in the 12 patients while they continued to receive the drug. Flupenthixol was then discontinued for 6 weeks and antipyrine half-life was repeated in 7 of the 12 patients. In the 12 patients the plasma antipyrine elimination half-life was 4-24 h (mean 9.73 +/- 1.61 h) when receiving flupenthixol and there was a significant negative correlation between antipyrine half-life and the dose of flupenthixol (r = 0.582, P less than 0.05). In the seven patients to whom antipyrine was given on two occasions, antipyrine half-life was 7.33 +/- 1.07 h and 12.04 +/- 1.87 h on and off flupenthixol treatment respectively. The clearance significantly decreased when flupenthixol was discontinued, but there was no change in the apparent volume of distribution.

Effect of pentobarbital on the formation of diastereomeric oxazepam glucuronides in man: analysis by high performance liquid chromatography

Barbiturate treatment can enhance drug oxidation in man, but its effects on glucuronidation of clinically used drugs are unknown. We have studied the effect of 10 days treatment with pentobarbital on oxazepam glucuronidation in six volunteers. The diastereomeric (+ and -) glucuronides in urine were analyzed separately by high performance liquid chromatography and oxazepam in plasma by gas liquid chromatography. The area under the plasma concentration time curve for oxazepam (15 mg sod) decreased after pentobarbital treatment in all subjects, mean 10.4 before and 6.9 h X mumol/l after treatment (P less than 0.05) and oxazepam's plasma clearance increased by about 50 per cent. The glucuronides appeared more rapidly in the initial urinary fractions. The ratio between the glucuronides (+/-) appearing in urine decreased on pentobarbital treatment. Our data indicate that pentobarbital treatment increases the clearance of oxazepam by increased glucuronide conjugation, probably reflecting barbiturate induced changes of UDP glucuronyltransferase.

Clinical implications of enzyme induction and enzyme inhibition

The pharmacological effect of a drug is partly dependent upon its concentration at its site of action, which in turn is partly dependent upon its rate of elimination. The rate of elimination of many lipophilic drugs is governed by the activity of the hepatic microsomal mixed-function oxidases. Consequently any alteration in the activity of these enzymes may result in a modification of drug action. A wide range of chemically unrelated substances may stimulate the activity of the mixed-function oxidases by enzyme induction. The drugs most frequently encountered as enzyme-inducing agents in man are barbiturates, rifampicin and phenytoin. Enhancement of drug metabolism by ethanol, tobacco smoking and diet may also involve enzyme induction. Enzyme induction is normally associated with a reduction in the drug efficacy but may also alter the toxicity of certain substances. Enzyme induction has been assessed in man by measuring changes in the pharmacokinetics of a marker drug, or changes in the disposition of endogenous compounds such as gamma-glutamyltranspeptidase, D-glucaric acid and 6beta-hydroxycortisol. The therapeutic problems associated with enzyme inhibition have received much less attention than those associated with enzyme induction. The effect on the rate of elimination of a particular drug will depend upon the fraction of the dose that is normally metabolised by the inhibited enzyme and on the affinity of the enzyme for the drug and the inhibitor. An alteration in the dosage schedule is usually only necessary for drugs with a small therapeutic ratio.

Differential induction of antipyrine metabolism by rifampicin

Antipyrine is oxidised to three main metabolites in man. There is evidence that the different metabolites are products of different forms of cytochrome P-450. The effect of rifampicin administration for two weeks on the rates of formation of these metabolites was investigated in healthy volunteers. Rifampicin increased antipyrine clearance and shortened its half-life. Two weeks after stopping rifampicin the induction had largely been reversed. Clearance to all three metabolites was increased by rifampicin. Clearance to 3-hydroxymethylantipyrine was increased from 7.8 +/- 0.9 ml/min to 13.3 +/- 1.3 ml/min, to norphenazone from 5.8 +/- 0.6 ml/min to 19.3 +/- 2.1 ml/min and to 4-hydroxyantipyrine from 14.3 +/- 2.2 ml/min to 21.9 +/- 3.9 ml/min. Thus clearance to norphenazone was increased to a much greater extent than to either of the other two metabolites. It is concluded that this provides evidence for the involvement of at least two different forms of cytochrome P-450 in antipyrine metabolism in man.

The interaction of phenobarbital and other anticonvulsants with oral contraceptive steroid therapy

In a group of 5 women on long-term anticonvulsant and oral contraceptive therapy, the plasma ethynylestradiol (EE) concentration on 50 microgram EE daily was 11.1 +/- 4.5 pg/ml. These values were at the lower end of the range found in normal women in this laboratory taking 30 microgram EE daily (6-190 pg/ml). Four women have been studied prospectively for 3 months, over 1 cycle before and 2 cycles during phenobarbital 30 mg b.i.d. therapy. Significant falls in the plasma EE concentration were seen in two women (from 104.8 +/- 13.4 to 37.7 +/- 2.0 pg/ml and from 125.6 +/- 23.8 to 34.8 +/- 6.7 pg/ml p less than 0.01) and breakthrough bleeding was seen in both women. No changes in plasma concentrations of follicle stimulating hormone, progesterone, norethindrone or norgestrel were seen. There was a significant increase in the sex hormone binding globulin capacity from 100.7 +/- 5.8 to 133.3 +/- 1.2 nmoles/1 (p less than 0.05). These changes are consistent with the known microsomal enzyme inducing effect of phenobarbital.

Induction of drug metabolism in the rat by taglutimide, a sedative-hypnotic glutarimide derivative

Pretreatment with taglutimide significantly decreased the plasma dicoumarol level and shortened the duration of hexobarbital-induced narcosis in rats. Furthermore, taglutimide pretreatment accelerated the in vitro metabolism of dicoumarol, hexobarbital, o-nitrophenyl acetate and procaine, but not of 3,4-benzypyrene, as assayed in the 10,000xg supernatant fraction of rat liver homogenate. No definite increase was observed in liver wet weight, nor in the amount of microsomal and total liver protein in comparison with the control values. No marked differences were found between the effects of short- (4-day) and long-term (17-day) pretreatment on any of the studied parameters. The changes in drug metabolism and liver protein observed after taglutimide pretreatment differed from those observed after pretreatment with either phenobarbital or 3,4-benzypyrene. Taglutimide, like other inducing agents, is lipophilic, but differs from them in not being a substrate of monooxygenases.

Intensified cancer themotherapy by induction of hepatic drug-metabolizing enzymes as a trial for the treatment for stomach cancer

Studies of an intensified chemotherapy of FT-207, combined with MMC, have been under way since April 1977 in the First Department of Surgery of Chiba University Hospital and five closely related hospitals. These studies were performed on 114 patients with curative stomach cancer. The 114 patients received intravenously 0.4 mg/kg and 0.2 mg/kg of MMC on the operation day and the next day, respectively, and then intravenously 800 mg of FT-207 daily from the 10th postoperative day until discharge, followed by oral administration of FT-207, 600 mg, for more than 1 year after discharge. The 114 patients were divided into two groups. Half of the patients received 100 mg of phenobarbital and 30 mg/kg of glutathione for the purpose of induction of hepatic drug-metabolizing enzymes (induction group). Significantly higher levels of serum 5-FU released from FT-207 were observed in the patients of the induction group when compared to those of the control group. However, there was no statistically significant difference in survivals at both 12 and 24 months after operation between both groups.

A multi-dose study on the human metabolism of amylobarbitone

1. The metabolism of amylobarbitone has been investigated in two healthy male volunteers, and the urinary excretion of unchanged drug, and the products of omega and omega-1 oxidation, quantitatively determined for four days after each of three doses to each volunteer. 2. In contrast to observations with butobarbitone, amylobarbitone was shown to have little effect on the rate of its own metabolism. 3. The t 1/2 for urinary excretion of the parent drug was 16.3 h while that for the two metabolites was 22.2 h.

Enzyme induction and renal function in man

1. In a previous study in rats, an increased PAH clearance was found following chronic phenobarbitone administration. These results formed the basis for the present study in which fifteen healthy male volunteers were investigated and the parameters of liver microsomal enzyme activity and renal function were measured. 2. As parameters of liver microsomal enzyme activity, the antipyrine elimination in the plasma, the gamma-glutamyl-transpeptidase and the D-glucaric excretion in the urine were measured. Endogenous creatinine clearance, 51Cr-EDTA and 125I-Hippuran clearance were determined as measurements of renal function. 3. No correlation was found between any of the parameters of microsomal enzyme activity and renal function. 4. Of the fifteen volunteers, seven having a mean antipyrine half-life of 13.3 h were given antipyrine (500 mg) daily for 3 weeks. Afterwards all measurements of liver microsomal enzyme activity and renal function were repeated. The antipyrine half-life decreased to 8.5 h, while the antipyrine clearance was increased by about 56%. gamma-glutamyl-transpeptidase and D-glucaric acid were also significantly increased, while renal function remained unchanged. 5. Therefore, an increased PAH-clearance, as found in the rat, is not obtained in man following induction of liver microsomal enzyme activity.

Interactions of CNS drugs--hypnotics and sedatives

The physicochemical properties of the barbiturates and a brief review of microsomal enzyme induction introduces this literature review of the interactions of sedative and hypnotic drugs. Food has been shown to delay absorption of barbiturates; barbiturates, in turn, may interfere with the absorption of griseofulvin, dicumarol, and folic acid. Barbiturate-produced enzyme induction may result in interactions with the oral anticoagulants, the anticonvulsants, vitamin D, bilirubin, digitoxin, doxycycline, and perhaps other drugs. The problem of additive central nervous system depression and the relative lack of documented evidence is considered. Finally, the interactions of nonbarbiturate hypnotics, such as glutethimide, chloral hydrate, and others are reviewed.

Drug interactions and clinical pharmacokinetics

Some drugs influence the gastro-intestinal absorption, distribution , metabolism or renal excretion of other drugs, i.e., processes involved in pharmacokinetic interactions. The clinical consequences of pharmacokinetic drug-drug interactions will be either an increase or a decrease in known therapeutic or toxic effects of the interacting drug. In order to evaluate the importance of drug interaction affecting gastro-intestinal absorption, it is necessary to distinguish between interactions which alter the rate of absorption of another drug and those which alter the amount of drug absorbed. Many drugs displace other drugs from their protein binding sites in vitro. This may cause an increase in the pharmacological effect of the displaced drug. However, much discrepancy exists between in vitro findings. In some cases, the enhanced effect only seems to be a temporary phenomenon. The degree of protein binding and the size of apparent volume of distribution (Vd) must also be taken into consideration. Perhaps the importance of interaction involving protein binding has been overemphasized. Barbiturates, glutethimide, rifampicin and phenytoin increase the rate of drug metabolism in man. The most important interactions reported are between oral anti-coagulants and barbiturates. After withdrawal of these hepatic microsomal enzyme inducing drugs, it takes 2 to 3 weeks before the rate of drug metabolism reaches the pretreatment level. In this period, risk of haemorrhage exists. Induction seems to be dose-dependent, but not all persons are inducible. Many drugs compete for the drug metabolising enzyme system in the liver and consequently some drugs inhibit the biotransformation of other drugs. The time course of these interactions depends on the pharmacokinetic properties of the drug involved, and these interactions also seem to be dose-dependent. The most important of such interactions, clinically involved the oral sulphonylurea hypoglycaemic drugs and the antiepilepic drug phenytoin. Drugs are eliminated by urinary excretion through three mechanisms: glomerular filtration, tubular reabsorption, and active tubular secretion. The most important interactions seem to be those involving competition for tubular secretion.

Effect of phenobarbitone on hepatic drug-metabolizing enzymes and urinary D-glucaric acid excretion in man

1 The activities of some hepatic drug-metabolizing enzymes representative of the four major pathways for the biotransformation of drugs were estimated in diagnostic wedge biopsy specimens obtained from 22 patients with Hodgkin's disease. Twelve patients (nine males and three females) were not on prolonged pre-operative treatment with any known inducing drugs. In this group, hexobarbitone oxidase activity, cytochrome P450 and microsomal protein contents were in the same range as those reported by other workers. 2 Ten patients (five males and five females) were pre-operatively treated with phenobarbitone (90 mg daily) for at least seven days. This resulted in a significant increase of hexobarbitone oxidase activity, cytochrome P450 and microsomal protein contents when the phenobarbitone untreated and treated groups were compared as a whole and provides direct evidence of induction of hepatic mixed function oxidase system. In respect of p-nitroreductase, 1-leucyl-beta-naphthylamide splitting enzyme and UDP glucuronyl transferase, there was no difference between the treated and untreated groups. 3 When untreated and treated patients were compared, the induction of the hepatic mixed function oxidase system, was associated with a significant increase in urinary D-glucaric acid excretion. In treated patients, however, there was no correlation between any of the indices studied and post-phenobarbitone D-glucaric acid content or the rise in D-glucaric acid excretion. However, the correlation between cytochrome P450 content and post-phenobarbitone D-glucaric acid or the rise in D-glucaric acid excretion was only just below statistical significance (r = 0.696 and 0.690 respectively, 0.10 greater than P greater than 0.05) whereas in the untreated group there was no correlation (r = 0.231, P greater than 0.60). 4 In two patients, whose phenobarbitone was discontinued for at least six days prior to surgery, all indices studied had returned to untreated values, except for microsomal protein content which remained significantly elevated.

Interaction between doxycycline and some antiepileptic drugs

The mean half life of doxycycline given to seven patients on long-term diphenylhydantoin treatment was 7.2 +/- 0.4 hours. In five patients on long-term carbamazepine treatment the half life was 8.4 +/- 1.4 hours. In four patients on combined diphenylhydantoin and carbamazepine treatment the half life was 7.4 +/- 0.7 hours. All these were significantly shorter than a mean half life of 15.1 +/- 1.0 hours when doxycycline was given to nine control patients. Therefore doxycycline in normal doses given to patients taking diphenylhydantoin or carbamazepine may fail to maintain the minimum inhibitory concentration necessary for proper bacteriostasis. When doxycycline is given in association with agents known to induce drug metabolism the serum concentration of the antibiotic should be watched to see that bacteriostatic levels are maintained.

Interaction between doxycycline and barbiturates

In a cross-over study of five hospitalized patients the half life of doxycycline was significantly shortened after 10 days' treatment with phenobarbitone. In five patients on continuous barbiturate therapy the half life of doxycycline was even shorter. Barbiturates or other agents inducing drug metabolism should be used cautiously in combination with doxycycline, since this might result in therapeutically inadequate serum concentrations of the antibiotic.