Brain and cerebrospinal fluid uptake of zidovudine (AZT) in rats after intravenous injection

Bile duct ligation enhances AZT CNS toxicity partly by impairing the expression and function of BCRP in rat brain

Breast cancer resistance protein (BCRP) is one of ATP-binding cassette (ABC) transporters in brain microvessel endothelial cells that transport their substrates from brain to blood, thus limiting substrates to crossing into brain through blood-brain barrier. Our previous works show that bile duct ligation (BDL) impairs expression and function of brain BCRP in rats. Since zidovudine (AZT) is BCRP substrate, we investigated whether impaired expression and function of BCRP increased brain distribution and toxicity of AZT in BDL-D7 rats. After administration of AZT (10 mg/kg, i.v.), BDL markedly increased brain AZT concentrations, compared with sham-operated (SO) rats. The ratio of AZT brain-to-plasma area under concentration curve (AUC) in BDL rats was increased to 1.6-folds of SO rats. After treatment with AZT (100 mg/kg every day, i.v.) for 7 days, BDL significantly impaired cognitive functions compared with SO rats, evidenced by the significantly decreased percentage of alternation in Y-maze test and prolonged escaped latency in two-way passive avoidance trial. Furthermore, AZT treatment caused significant decrease in copies of mitochondrial DNA and mitochondrial membrane potential in hippocampus of BDL rats. Moreover, AZT treatment caused a significant decrease of cortex microtubule-associated protein 2 and hippocampus synaptophysin levels in BDL rats. AZT-induced CNS adverse alterations in BDL rats were not observed in SO rats treated with AZT. In conclusion, BDL decreases the function and expression of brain BCRP in rats, leading to increased brain distribution of AZT, which in turn enhances AZT CNS toxicity, leading to mitochondrial dysfunction, neuronal damage, and ultimately cognitive dysfunction.

Pharmacokinetic, Pharmacogenetic, and Other Factors Influencing CNS Penetration of Antiretrovirals

Neurological complications associated with the human immunodeficiency virus (HIV) are a matter of great concern. While antiretroviral (ARV) drugs are the cornerstone of HIV treatment and typically produce neurological benefit, some ARV drugs have limited CNS penetration while others have been associated with neurotoxicity. CNS penetration is a function of several factors including sieving role of blood-brain and blood-CSF barriers and activity of innate drug transporters. Other factors are related to pharmacokinetics and pharmacogenetics of the specific ARV agent or mediated by drug interactions, local inflammation, and blood flow. In this review, we provide an overview of the various factors influencing CNS penetration of ARV drugs with an emphasis on those commonly used in sub-Saharan Africa. We also summarize some key associations between ARV drug penetration, CNS efficacy, and neurotoxicity.

Species Differences in the Metabolism and Disposition of Antiviral Nucleoside Analogues: 2. Zidovudine

Preclinical and clinical studies on the disposition of zidovudine, a thymidine analogue with potent activity against human immunodeficiency virus, identified significant species differences in the metabolism and elimination of the drug. Zidovudine was extensively metabolized to the 5′-O-glucuronide in man and other primates. Rabbits and dogs were intermediate in their extent of biotransformation to the glucuronide conjugate, whereas rats and mice excreted the drug largely unchanged. Decreased metabolism was compensated by increased renal elimination, such that plasma elimination phase half-lives for zidovudine were similar (0.6–1.1 h) in all species. Rapid and extensive absorption and considerable penetration into tissues were also observed for all species studied. Only in the brain and testes were drug levels less than in plasma, although effective antiviral concentrations of zidovudine were achieved in brain and CSF. This review summarizes the variety of studies of the absorption, distribution, metabolism, and elimination of zidovudine in several species, including humans.

Warfarin is an effective modifier of multiple UDP-glucuronosyltransferase enzymes: evaluation of its potential to alter the pharmacokinetics of zidovudine

In this study, we aimed to determine the modulatory effects of warfarin (an extensively used anticoagulant drug) and its metabolites on UDP-glucuronosyltransferase (UGT) activity and to assess the potential of warfarin to alter the pharmacokinetics of zidovudine (AZT). The effects of warfarin and its metabolites on glucuronidation were determined using human and rat liver microsomes (HLM and RLM) as well as expressed UGTs. The mechanisms of warfarin-UGT interactions were explored through kinetic characterization and modeling. Pharmacokinetic studies with rats were performed to evaluate the potential of warfarin to alter the pharmacokinetics of AZT. We found that warfarin was an effective modifier of a panel of UGT enzymes. The effects of warfarin on glucuronidation were inhibitory for UGT1A1, 2B7, and 2B17, but activating for UGT1A3. Mixed effects were observed for UGT1A7 and 1A9. Consistent with its inhibitory effects on UGT2B7 activity, warfarin inhibited AZT glucuronidation in HLM (Ki = 74.9-96.3 μM) and RLM (Ki = 190-230 μM). Inhibition of AZT glucuronidation by UGT2B7, HLM, and RLM was also observed with several hydroxylated metabolites of warfarin. Moreover, the systemic exposure (AUC) of AZT in rats was increased by a 1.5- to 2.1-fold upon warfarin coadministration. The elevated AUC was associated with suppressed glucuronidation that was probably attained through a combined action of warfarin and its hydroxylated metabolites. In conclusion, the activities of multiple UGT enzymes can be modulated by warfarin and the nature of modulation was isoform dependent. Also, pharmacokinetic interactions of zidovudine with warfarin were highly possible through inhibition of UGT metabolism.

CSF penetration by antiretroviral drugs

Severe HIV-associated neurocognitive disorders (HAND), such as HIV-associated dementia, and opportunistic CNS infections are now rare complications of HIV infection due to comprehensive highly active antiretroviral therapy (HAART). By contrast, mild to moderate neurocognitive disorders remain prevalent, despite good viral control in peripheral compartments. HIV infection seems to provoke chronic CNS injury that may evade systemic HAART. Penetration of antiretroviral drugs across the blood-brain barrier might be crucial for the treatment of HAND. This review identifies and evaluates the available clinical evidence on CSF penetration properties of antiretroviral drugs, addressing methodological issues and discussing the clinical relevance of drug concentration assessment. Although a substantial number of studies examined CSF concentrations of antiretroviral drugs, there is a need for adequate, well designed trials to provide more valid drug distribution profiles. Neuropsychological benefits and neurotoxicity of potentially CNS-active drugs require further investigation before penetration characteristics will regularly influence therapeutic strategies and outcome.

Poly(ethylene oxide/propylene oxide) copolymer thermo-reversible gelling system for the enhancement of intranasal zidovudine delivery to the brain

The purpose of this study was to investigate the olfactory transfer of zidovudine (ZDV) after intranasal (IN) administration and to assess the effect of thermoreversible gelling system on its absorption and brain uptake. The nasal formulation was prepared by dissolving ZDV in pH 5.5 phosphate buffer solution comprising of 20% polyethylene oxide/propylene oxide (Poloxamer 407, PLX) as thermoreversible gelling agent and 0.1% n-tridecyl-β-D-maltoside (TDM) as permeation enhancer. This formulation exhibited a sufficient stability and an optimum gelation profile at 27-30 °C. The in vitro permeation studies across the freshly excised rabbit nasal mucosa showed a 53% increase in the permeability of ZDV from the formulation. For in vivo evaluation, the drug concentrations in the plasma, cerebrospinal fluid (CSF) and six different regions of the brain tissues, i.e. olfactory bulb (OB), olfactory tract (OT), anterior, middle and posterior segments of cerebrum (CB), and cerebellum (CL) were determined by LC/MS method following IV and IN administration in rabbits at a dose of 1mg/kg. The IN administration of Poloxamer 407 and TDM based formulation showed a systemic bioavailability of 29.4% while exhibiting a 4 times slower absorption process (t(max) = 20 min) than control solution (t(max) = 5 min). The CSF and brain ZDV levels achieved after IN administration of the gelling formulation were approximately 4.7-56 times greater than those attained after IV injection. The pharmacokinetic and brain distribution studies revealed that a polar antiviral compound, ZDV could preferentially transfer into the CSF and brain tissue via an alternative pathway, possibly olfactory route after intranasal administration.

Multifunctional peptide-PEG intercalating conjugates: programmatic of gene delivery to the blood-brain barrier

PURPOSE

To enhance transfection efficacy of pDNA through the application of multifunctional peptide-PEG-tris-acridine conjugates (pPAC) and the formation of biodegradable core-shell polyplexes for gene delivery to the blood-brain barrier (BBB).

METHODS

pPAC-mediated transfection was compositionally optimized in mouse BBB cells (bEnd.3). Cellular uptake and trafficking, and brain accumulation of pDNA was evaluated by fluorescent imaging and histochemistry. We constructed anti-MRP4 siRNA-producing vectors and evaluated the efficacy of MRP4 down-regulation of MRP4 by Western blot and qPCR, and its effect on the uptake of (3)H-AZT, an MRP4 substrate.

RESULTS

A core-shell gene delivery system (GDS) was assembled from pDNA and pPAC, carrying multifunctional peptides with NLS, TAT, and brain-specific BH, or ApoE sequences, and biodegradable pLPEI polyamine. This GDS demonstrated better cellular and nuclear accumulation, and a 25-fold higher transfection efficacy in slow-dividing bEnd.3 cells compared to ExGen500. Inclusion of brain-targeting pPAC enhanced in vivo accumulation of functional pDNA in brain capillaries. Treatment by encapsulated anti-MRP4 siRNA-producing pDNA caused transient down-regulation of MRP4, and, after intravenous injection in Balb/c mice, enhanced AZT uptake in the brain by 230-270%.

CONCLUSIONS

The pPAC represent novel efficient components of GDS that could find various gene therapy applications, including genetic modulation of the BBB.

Central nervous system distribution kinetics of indinavir in rats

The central nervous system (CNS) distribution kinetics of indinavir were extensively evaluated using a combinational in-vivo model comprising the integration plot method (a single-passage approach) and neuropharmacokinetic method (a multiple-passage approach). A 5 mg kg−1 dose of indinavir was administered intravenously to rats. Blood and cerebrospinal fluid (CSF) samples and whole brain were collected from the animals at specified time points and the drug concentration in each sample was determined using a high-performance liquid chromatography method. For the neuropharmacokinetic study, the simultaneous plasma, CSF and brain concentrations were fitted to an integrated model, which resulted in the estimation of the influx (Kin) and efflux (Kout) rate constants of the drug to/from CSF and brain parenchyma. The integration plot method involved plotting the brainplasma or CSF-plasma concentration ratios (Kp,app) against AUC0r̊t/Cp(t), and estimating the uptake clearance of the drug by brain/CSF from the slope of the initial linear portion of the plot. The Kin and Kout values of the drug to/from CSF were estimated to be 2.42 times 10−2 and 13.26 times 10−2min−1, respectively, and the corresponding values for brain parenchyma were 1.02 times 10−2 and 1.32 times 10−2 min−1, respectively. The uptake clearances of indinavir by CSF and brain parenchyma were 8.89 and 8.38 μLmin−1 g−1, respectively. The permeability surface area products of the drug for the blood-brain barrier and blood-CSF barrier were estimated as 1.05 times 10−2 and 2.45 times 10−2 mL min−1 g−1, respectively. The estimated kinetic parameters indicated limited CNS entry of the drug because of the limited blood-brain barrier permeability and the efficient drug efflux from CNS, particularly from CSF.

Factors affecting delivery of antiviral drugs to the brain

Although the CNS is in part protected from peripheral insults by the blood-brain barrier and the blood-cerebrospinal fluid barrier, a number of human viruses gain access to the brain, replicate within this organ, or sustain latent infection. The efficacy of antiviral drugs towards the cerebral viral load is often limited as both blood-brain interfaces impede their cerebral distribution. For polar compounds, the major factor restricting their entry lies in the tight junctions that occlude the paracellular pathway across these barriers. For compounds with more favourable lipid solubility properties, CNS penetration will be function of a number of physicochemical factors that include the degree of lipophilicity, size and ability to bind to protein or red blood cells, as well as other factors inherent to the vascular and choroidal systems, such as the local cerebral blood flow and the surface area available for exchange. In addition, influx and efflux transport systems, or metabolic processes active in both capillary endothelial cells and choroid plexus epithelial cells, can greatly change the bioavailability of a drug in one or several compartments of the CNS. The relative importance of these various factors with respect to the CNS delivery of the different classes of antiviral drugs is illustrated and discussed.

Choroid plexus controls brain availability of anti-HIV nucleoside analogs via pharmacologically inhibitable organic anion transporters

OBJECTIVE

In AIDS, early suppression of the viral load in the central nervous system is critical for the efficacy of antiretroviral therapy, in order to prevent the emergence of a reservoir of resistant strains of virus, and brain impairment in late stages of the infection. The blood-cerebrospinal fluid (CSF) interface (i.e. the choroidal epithelium) constitutes the most direct route to reach the ventricular meningeal and perivascular infected macrophages, and may modulate the cerebral biodisposition of antiretroviral drugs through various transport systems. Our aim was to address nucleoside drug transfer specifically across the blood-CSF interface, and identify the possible mechanisms involved in their transport.

METHODS

Drug influx and efflux were measured using an in vitro cellular model that reproduces the barrier and transport properties of the blood-CSF interface in vivo. Transport mechanisms were investigated by competition studies.

RESULTS

The CSF influx rate of zidovudine was the highest, although moderate, followed by that of stavudine. The permeability coefficients of the other drugs tested were low. Zidovudine influx into the CSF is independent of thymidine transport systems, and more importantly is limited by an efflux mechanism. This efflux involves an apical (CSF-facing) carrier belonging to the solute carrier (Slc) 22 family of organic anion transporters, and can be inhibited by a therapeutic concentration of benzbromarone.

CONCLUSIONS

The demonstration and characterization of this efflux mechanism is the basis for the development of specific inhibitory agents in view to increase the delivery of antiretroviral nucleoside analogs to the brain.

AZT distribution in the fetal and postnatal rat central nervous system

The distribution of 3'-azido-3'-deoxythymidine (AZT, zidovudine), an antiviral drug used in the treatment of human immunodeficiency virus, was investigated in gestation day-20 (G-20) fetuses and in postnatal day-20 (PND-20) rats. At both ages, a single dose of 150 mg/kg (1.78 mmol/kg) AZT was administered orally along with tracer amounts of 14C-AZT, and rats were randomly killed at 15, 30, 60, 120, or 240 min after dosing. The fetuses, brains, and spinal cords were processed for autoradiography. The peak concentrations of AZT in plasma of G-20 and PND-20 rats were 92.2 microg/mL (0.345 micromol/mL) and 56.6 microg/mL (0.21 micromol/mL) at 15 and 30 min after intubation, respectively. The peak concentration of fetal tissue occurred in the colon at 60 min and was 205.8 microg/g tissue. In the G-20 rats, the brain showed higher levels of AZT than spinal cord only at the 30-min sample time, whereas in the PND-20 rats, greater radioactivity was found in the spinal cord up to the 240-min sample time. This pattern of AZT distribution in the central nervous system may hypothetically be attributed to the postnatal development of an organic anion carrier system believed to be responsible for transporting AZT from the brain to the blood, resulting in relatively greater overall exposure of the spinal cord to AZT than observed in the brain.

Use of cultured cerebral capillary endothelial cells in modeling the central nervous system availability of 2',3'-dideoxyinosine

The biochemical and physiological mechanisms responsible for the limited central nervous system (CNS) uptake of dideoxynucleoside reverse transcriptase inhibitors currently used to treat HIV-1 infection in humans are poorly understood. In vitro models of the blood-brain barrier (BBB) offer an attractive alternative to in vivo or in situ animal studies for understanding the role of the blood-brain barrier in regulating brain tissue concentrations of these agents. In the present study, the kinetics of 2', 3'-dideoxyinosine (ddI) uptake and purine nucleoside phosphorylase (PNP) mediated catabolism in primary cultures of bovine brain microvessel endothelial cells (BBMECs) were determined in order to ascertain the importance of both transport and metabolism governing the CNS availability of this purine dideoxynucleoside. Initial rates of ddI uptake as a function of ddI donor concentration suggest the involvement of both passive diffusion and carrier-mediated processes. These studies confirm earlier in vivo findings that transporters may play a role in regulating the CNS concentration of ddI. Analysis of ddI uptake and metabolite accumulation in BBMECs over longer time intervals (beyond the intial rate region) provide substantial in vitro evidence for an enzymatic BBB for ddI. Simulations of the CNS availability of ddI derived from in vitro estimates of parameters for passive diffusion, carrier-mediation, and metabolism indicate that the fraction of ddI entering the BBB cells which actually reaches the brain parenchyma may be quite low (< 2%) due to metabolism by PNP localized within the BBB, consistent with the low CNS delivery of ddI observed in vivo. Transporters and metabolic enzymes within the BBB may function in coordinated fashion to reduce the CNS concentrations of both rapidly metabolized and poorly metabolized dideoxynucleosides.

Investigation of distribution, transport and uptake of anti-HIV drugs to the central nervous system

The distribution of currently available anti-HIV drugs into the CNS is reviewed with a focus on transport mechanisms. Among these drugs, nucleoside analogs are most well studied for their CNS distribution. The average reported values of the CSF/plasma steady-state concentration or corresponding AUC ratios are 0.23 (AZT), 0.06 (ddI), 0.04 (ddC), 0.49 (d4T), and 0.08 (3TC). Active efflux transport out of the CNS appears to be a predominant mechanism limiting nucleoside access to the CNS, although poor penetration may contribute to some extent for some polar nucleosides. The nature of the efflux pump for these drugs is speculated to be MRP-like transporter(s) in blood-brain and blood-CSF barriers. For non-nucleoside and protease inhibitors, much research remains to be done on the extent, time course, and mechanisms of their CNS distribution. The CNS penetration of some protease inhibitors is restricted by P-glycoprotein. A better understanding of transport mechanisms of anti-HIV drugs in the CNS is essential to develop approaches to enhance CNS delivery of available drugs and to identify new drugs less subject to active efflux transporter(s) in the CNS.

Transport, metabolism and elimination mechanisms of anti-HIV agents

Currently available anti-HIV drugs can be classified into three categories: nucleoside analogue reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors. Knowledge of these anti-HIV drugs in various physiological or pharmacokinetic compartments is essential for design and development of drug delivery systems for the treatment of HIV infection. The input and output of anti-HIV drugs in the biological systems are described by their transport and metabolism/elimination in this review. Transport mechanisms of anti-HIV agents across various biological barriers, i.e., gastrointestinal wall, skin, mucosa, blood cerebrospinal barrier, blood-brain barrier, placenta, and cellular membranes, are discussed. Their fates during and after systemic absorption and their metabolism-related drug interactions are reviewed. Many anti-HIV drugs presently marketed in the US bear some significant drawbacks such as relatively short half-life, low bioavailability, poor penetration into the central nervous system, and undesirable side effects. Efforts have been made to design drug delivery systems for the anti-HIV agents to: (1) reduce the dosing frequency; (2) increase the bioavailability and decrease the degradation/metabolism in the gastrointestinal tract; (3) improve the CNS penetration and inhibit the CNS efflux; and (4) deliver them to target cells selectively with minimal side effects. We hope to stimulate further interests in the area of controlled delivery of anti-HIV agents by providing current status of transport and metabolism/elimination of these agents.

In vitro models of the blood-brain barrier to polar permeants: comparison of transmonolayer flux measurements and cell uptake kinetics using cultured cerebral capillary endothelial cells

Given that the cerebral microvasculature within the brain constitutes the rate-limiting barrier to drug entry, primary cultures of cerebral capillary endothelial cells would appear to offer a potentially useful model system for predicting drug delivery to the central nervous system. In the present study, the predictive capabilities of two potential models of the in vivo blood-brain barrier (BBB) to the passive diffusion of polar permeants were assessed. A comparison of the logarithms of the in vitro transmonolayer permeability coefficients (Pmonolayer) for several polar permeants varying in lipophilicity (from this study and literature data) with the well-established relationship between the logarithms of the in vivo BBB permeability coefficients (log PBBB) and permeant lipophilicity as measured by the logarithm of the octanol/water partition coefficient (log PCoctanol/water) demonstrated that in vitro permeation across these monolayers is largely insensitive to polar permeant lipophilicity as a result of the predominance of the paracellular component in the transmonolayer flux. Conversely, kinetic studies of uptake of the same compounds into monolayers yielded transfer rate constants (kp) reflecting membrane permeability coefficients ranging over several orders of magnitude, similar to the variation in permeant lipophilicity. Furthermore, a linear relationship could be demonstrated between the logarithms of kp and in vivo BBB log P (slope = 1.42 +/- 0.35; r = 0. 92). In conclusion, this preliminary investigation suggests that monitoring the kinetics of cell uptake into cerebral capillary endothelial cell monolayers may be superior to transmonolayer flux measurements for predicting the passive diffusion of polar permeants across the BBB in vivo.

Zidovudine transport within the rabbit brain during intracerebroventricular administration and the effect of probenecid

The elimination of zidovudine (AZT) from cerebrospinal fluid (CSF), its distribution from CSF to brain tissue, and its transport from brain extracellular fluid (ECF) to plasma were studied during intracerebroventricular (i.c.v.) infusion in unanesthetized rabbits. The effect of probenecid (PBD) on these transport processes was also studied. The concentration of AZT in brain ECF was measured by microdialysis with retrodialysis calibration for in vivo recovery. Plasma and CSF were sampled and analyzed for AZT and PBD using HPLC. The elimination of AZT from CSF showed nonlinear characteristics as the i.c.v. infusion rate was increased to 1 mg/h kg. The estimated maximum transport capacity and dissociation constant were 3.5 micrograms/min kg and 127 micrograms/mL, respectively. The total linear elimination clearance from CSF was 0.0073 mL/min kg. The spatial distribution of AZT in brain during i.c.v. infusion was simulated using a mathematical model which describes diffusive solute transport in brain ECF and efflux across the blood-brain barrier. This analysis yielded a brain to plasma efflux rate constant of 0.040/min. This parameter and the elimination clearance from CSF decreased significantly by the end of an 8-hour period during which PBD was infused intravenously at a rate of 15 mg/h kg.

Zidovudine transport in the rabbit brain during intravenous and intracerebroventricular infusion

The distribution of zidovudine (AZT) between plasma, brain extracellular fluid (ECF), and cerebrospinal fluid (CSF) was investigated in a crossover design study (n = 5) in unanesthetized rabbits. Drug was administered by intravenous (iv) and intracerebroventricular (icv) infusions at the same infusion rate (1.5 mg/h.kg). The concentrations of AZT in ECF and CSF were measured by HPLC with microdialysis sampling. Plasma concentrations of AZT were quantitated by HPLC. Following iv infusion, the ECF- and CSF-to-plasma concentration ratios at steady state (SS), were 0.19 +/- 0.05 and 0.29 +/- 0.06, respectively. These values were less than unity, indicating the existence of active transport processes for the transport of AZT from brain to plasma across the blood-brain barrier (BBB) or blood-CSF barrier (BCB). The transport processes were modeled by compartmental model analysis, and the results suggest that the transport efficiency of AZT across the BBB is asymmetric; that is, the efflux clearance was five times greater than the influx clearance. Similarly, the efflux clearance from CSF is three times larger than the influx clearance into CSF. The SS concentrations of AZT in brain ECF in the same animals that received an icv infusion of AZT in the crossover design study were approximately two orders of magnitude greater than those in animals following iv infusion at the same dosing rate. Nevertheless, the SS plasma concentrations of AZT were similar for both routes of administration (1.2 +/- 0.19 and 1.2 +/- 0.13 micrograms/mL for iv and icv routes, respectively), confirming that the brain is not an organ that exhibits first-pass metabolism under the present experimental conditions.

Comparative brain exposure to (-)-carbovir after (-)-carbovir or (-)-6-aminocarbovir intravenous infusion in rats

PURPOSE

Evaluate the ability of (-)-6-aminocarbovir ((-)-6AC) to improve the CNS exposure to (-)-carbovir ((-)-CBV).

METHODS

Activation of (-)-6AC in vitro was assessed by incubations of rat brain tissue homogenates. The in vivo brain exposure to (-)-CBV was then examined in rats after iv infusions of either (-)-CBV (n = 4) or (-)-6AC (n = 5). The drugs were infused to steady-state via the jugular vein. At the end of the infusion, a bolus of [3H]inulin was injected via the femoral vein in order to obtain an estimate of the brain vascular space.

RESULTS

(-)-6AC was converted to (-)-CBV by incubations of rat brain tissue homogenates. After iv infusion of (-)-CBV, the brain/blood concentration ratio of (-)-CBV was 0.032 +/- 0.009. The brain/blood concentration ratio of (-)-CBV after iv infusion of (-)-6AC was 0.080 +/- 0.020.

CONCLUSIONS

(-)-6AC improved the brain delivery of (-)-CBV, although the absolute exposure of the brain tissue to (-)-CBV was still quite low.

Partially successful treatment of Rasmussen's encephalitis with zidovudine: symptomatic improvement followed by involvement of the contralateral hemisphere

An 18-year-old woman with a 4-year history of Rasmussen's encephalitis (RE) manifested by progressive aphasia, right hemiparesis, and nearly continuous intractable simple partial seizures that frequently secondarily generalized was treated with zidovudine (AZT). Seizures had not responded to any of the major antiepileptic drugs (AEDs) administered to high and toxic levels, or to ACTH. AZT was given for 62 days and discontinued because of granulocytopenia. Within 6 weeks of AZT initiation, seizure stopped and neurologic deterioration was arrested for approximately 21 months. Subsequently, partial somatomotor seizures developed, affecting the previously uninvolved left hemibody. A 2-week repeat course of AZT was attempted, but unremitting fever and gastrointestinal (GI) side effects precluded continuation of AZT treatment. Spontaneous, sustained remission of seizures has not been reported in untreated RE. Seizure control and arrest of neurologic deterioration in this case outlasted use of AZT by 19 months. Because of the apparent response of this patient to AZT, clinical studies designed to assess long-term palliative/curative properties of antiviral agents, particularly in patients with involvement of the hemisphere dominant for language, appear warranted.

In vitro and in vivo transport of zidovudine (AZT) across the blood-brain barrier and the effect of transport inhibitors

The transport of the antiviral nucleoside analogue zidovudine (3'-azido-3'-deoxythymidine; AZT) into the central nervous system (CNS) was characterized in vitro and in vivo. The in vitro model consisted of primary cultures of isolated bovine capillary endothelial cells. The transport rate of AZT across the monolayer, expressed as endothelial permeability P, was determined following luminal and abluminal administration. P did not differ between the two administration sites (luminal, 1.65 +/- 0.44 cm/min/10(3); abluminal, 1.63 +/- 0.28 cm/min/10(3)). The transport of AZT across the endothelial cell monolayer was found to be concentration independent in the range between 0.4 and 50 micrograms/mL. AZT transport was not affected by pretreatment of the cells with either metabolic inhibitors (DODG and DODG/NaN3) or probenecid. This suggests that AZT passes the monolayer mainly by passive diffusion. The in vivo transport of AZT across the blood-brain barrier and the blood-CSF barrier was studied in male Wistar rats after coadministration of potential inhibitors of active transport of AZT: probenecid (organic anion transport) and thymidine (nucleoside transport). Intracerebroventricular and intravenous coadministration of probenecid caused a significant (P < 0.001) increase in the CSF/plasma concentration ratio compared to the control phase, indicating that the organic anion carrier is involved in AZT transport from CSF to blood. Since there was no effect of probenecid on the transport of AZT in vitro, it is suggested that this carrier is located at the choroid plexus. Coadministration of thymidine did not affect the CSF/plasma concentration ratio, suggesting that a nucleoside carrier system is not involved in AZT transport into or out of the CNS.

Pharmacokinetics, oral bioavailability, and metabolic disposition in rats of (-)-cis-5-fluoro-1-[2-(hydroxymethyl)-1,3-oxathiolan-5-yl] cytosine, a nucleoside analog active against human immunodeficiency virus and hepatitis B virus

The pharmacokinetics and metabolism of the potent anti-human immunodeficiency virus and anti-hepatitis B virus compound, (-)-cis-5-fluoro-1-[2-(hydroxymethyl)-1,3-oxathiolan-5-yl] cytosine (FTC), were investigated in male CD rats. Plasma clearance of 10 mg of FTC per kg of body weight was biexponential in rats, with a half-life at alpha phase of 4.7 +/- 1.1 min (mean +/- standard deviation) and a half-life at beta phase of 44 +/- 8.8 min (n = 5). The total body clearance of FTC was 1.8 +/- 0.1 liters/h/kg, and the oral bioavailability was 90% +/- 8%. The volume of distribution at steady state (Vss) was 1.5 +/- 0.1 liters/kg. Increasing the dose to 100 mg/kg slowed clearance to 1.5 +/- 0.2 liters/kg/h, lowered the Vss to 1.2 +/- 0.2 liters/kg, and reduced the oral bioavailability to 65% +/- 15%. FTC in the brains of rats was initially less than 2% of the plasma concentration but increased to 6% by 2 h postdose. Probenecid elevated levels of FTC in plasma as well as in brains but did not alter the brain-to-plasma ratio. The urinary and fecal recoveries of unchanged FTC after a 10-mg/kg intravenous dose were 87% +/- 3% and 5% +/- 1.6%, respectively. After a 10-mg/kg oral dose, respective urinary and fecal recoveries were 70% +/- 2.5% and 25% +/- 1.6%. Two sulfoxides of FTC were observed in the urine, accounting for 0.4% +/- 0.03% and 2.7% +/- 0.2% of the intravenous dose and 0.4% +/- 0.06% and 2.5% +/- 0.3% of the oral dose. Also observed were 5-fluorocytosine, representing 0.4% +/- 0.06% of the intravenous dose and 0.4% +/- 0.07% of the oral dose, and FTC glucuronide, representing 0.7% +/- 0.2% of the oral dose and 0.4% +/- 0.2% of the intravenous dose. Neither deaminated FTC nor 5-fluorouracil was observed in the urine (less than 0.2% of dose). The high oral availability and minimal metabolism of FTC encourage its further preclinical development.

Penetration of zidovudine and 3'-fluoro-3'-deoxythymidine into the brain, muscle tissue, and veins in cynomolgus monkeys: relation to antiviral action

Cynomolgus monkeys had microdialysis probes implanted under ketamine anesthesia into peripheral veins, thigh muscles, and the brain in order to sample the extracellular fluid for the concentrations of unbound nucleoside analogs. A dose of 25 mg of zidovudine or 3'-fluoro-3'-deoxythymidine (FLT) per kg was administered subcutaneously to each of three animals. Relatively high antiviral concentrations of FLT and zidovudine were present in peripheral tissues and in the brain. It was found that the concentration of zidovudine in the brain was approximately one-third of that in muscle and veins; the same relation was observed for FLT. The in vivo unbound concentrations of both drugs in the brain, muscle, and venous blood exceeded those reported to inhibit human immunodeficiency virus replication in vitro. In addition, in a correlative study we found that the appearance of p24 antigen in sera of monkeys infected with simian immunodeficiency virus was significantly delayed by both compounds (15 mg/kg three times daily for 9 days after infection). Thus, we have shown that the extracellular concentrations of unbound FLT and zidovudine in the brain and peripheral tissues attained with in vivo antiviral doses exceed in vitro antiviral concentrations.