Age and renal clearance of cimetidine

The role of transporters in drug interactions

Transport proteins play an important role in the adsorption, distribution and elimination of a wide variety of drugs. Therefore, it is not surprising that transporter-based drug interactions can occur in the clinic. These interactions can lead to changes in toxicity and/or efficacy of the affected drug. Here, we review such interactions and ask if these interactions could have been predicted from in vitro data. Conducting such in vitro-in vivo correlation is important for predicting future transporter-based drug interactions.

Pharmacokinetics in older persons

BACKGROUND

Physiologic changes and disease-related alterations in organ function occur with aging. These changes can affect drug pharmacokinetics in older persons.

OBJECTIVE

This article reviews age-related changes in pharmacokinetics and their clinical relevance.

METHODS

A PubMed search was conducted using the terms elderly and pharmacokinetics. Other reviews were also included for literature searching. The review includes literature in particular from 1990 through April 2004. Some articles from before 1990 were included to help illustrate principles of age-related pharmacokinetics.

RESULTS

There are minor changes in drug absorption with aging. The effect of aging on small-bowel transporter systems is not yet fully established. Bioavailability of highly extracted drugs often is increased with age. Transdermal absorption may be delayed, especially in the case of water-soluble compounds. Fat-soluble drugs may distribute more widely and water-soluble drugs less extensively in older persons. Hepatic drug metabolism shows wide interindividual variation, and in many cases, there is an age-related decline in elimination of metabolized drugs, particularly those eliminated by the cytochrome enzyme system. Any decrement in cytochrome enzyme metabolism appears nonselective. Synthetic conjugation metabolism is less affected by age. Pseudocapillarization of the sinusoidal endothelium in the liver, restricting oxygen diffusion, and the decline in liver size and liver blood flow may influence age-related changes in rate of hepatic metabolism. Frailty, physiological stress, and illness are important predictors of drug metabolism in older individuals. Inhibition of drug metabolism is not altered with aging, but induction is reduced in a minority of studies. Renal drug elimination typically declines with age, commensurate with the fall in creatinine clearance. Renal tubular organic acid transport may decline with age, while the function of the organic base transporter is preserved but may be less responsive to stimulation.

CONCLUSION

Changes in pharmacokinetics occur due to age-related physiologic perturbations. These changes contribute to altered dose requirements in older persons, particularly in the case of drugs eliminated by the kidney. Interindividual variation, disease, frailty, and stress may overshadow age-related changes.

Prescribing policy for antiulcer treatment in the elderly

In the short and long term treatment of peptic ulcer in the elderly some problems have yet to be resolved, mainly concerning the physiology and pathophysiology of the aging stomach, the pharmacokinetic and pharmacodynamic properties of antiulcer drugs, and the presence of different risk factors compared with young patients. The available data from controlled trials of peptic ulcer in the general population and from the limited experience in geriatrics, show that the clinical efficacy and tolerability of the anti-secretory drugs (e.g. cimetidine, ranitidine and famotidine) and of cytoprotective compounds are similar to that observed in younger patients. However, more data are necessary concerning the optimal dosage in relation to physiological age-related changes of liver and kidney function, the duration of prophylactic treatment, and importantly, the assurance of adequate patient compliance.

Procainamide-cimetidine drug interaction in elderly male patients

Thirty-six hospitalized male patients receiving oral sustained-release procainamide every six hours for the treatment of ventricular arrhythmias were studied at steady-state before and after oral cimetidine 300 mg every six hours for three days. Average age and weight were 73 +/- 12 (SD) years and 76 +/- 10 kg. Patients did not have a myocardial infarction within the last two years or congestive heart failure and had calculated creatinine clearances (CrCl) between 35 and 75 mL/min/70 kg. Ten patients had urine collections that permitted computation of the ratio between the renal clearance of procainamide and CrCl (PA/CrCl) and the renal clearance of n-acetyl-procainamide (NAPA) and CrCl (NAPA/CrCl). The average steady-state procainamide and NAPA concentrations increased 55% and 36%, respectively, during cimetidine treatment (P less than .01). Twelve patients experienced mild to severe symptoms of what may have been procainamide toxicity. Apparent procainamide oral clearance decreased 41% while patients received cimetidine (P less than .01). PA/CrCl and NAPA/CrCl ratios decreased by 33% and 21%, respectively, during cimetidine therapy (P less than .05). Cimetidine therapy given to older male patients taking procainamide can cause steady-state concentrations of procainamide to rise to toxic levels. Patients prescribed this combination should be monitored carefully for adverse side effects.

Prescription monitoring of drug dosages in the county of Jämtland and Sweden as a whole in 1976, 1982 and 1985

Prescribed doses of drugs for which individualisation of dosage is deemed necessary were recorded from one national and one local Swedish prescription monitoring study for the years 1976, 1982 and 1985. Dose patterns were analysed in order to determine whether the practice of individualising drug doses had become more widely adopted by physicians. Amongst drugs eliminated primarily by metabolism, (propranolol and amitriptyline were prescribed in highly variable doses (30-fold or more). The three commonest doses of these agents accounted for about 60% of the prescriptions. In general, doses decreased with increasing patient age. Prescribing practices for piroxicam differed markedly from those of propranolol and amitriptyline, with one fixed dose of piroxicam accounting for about 90% of all prescriptions. For drugs eliminated mainly by renal excretion (digoxin, cimetidine and atenolol) there was an 8-10-fold variation in the prescribed doses. The most frequent dose of these drugs accounted for 40-60% of the prescriptions. Doses of cimetidine and atenolol were lowered only in the oldest patients. The doses of digoxin decreased more evenly with increasing age, and were reduced in elderly patients on long-term maintenance therapy. The difference in digoxin dose between young and old patients increased during the study period. Prescription monitoring as a method for following-up drug usage may be instrumental in evaluating the effect of drug educational efforts.

Amiloride disposition in geriatric patients: importance of renal function

1. The absorption and disposition of the potassium sparing diuretic amiloride were determined in nine elderly patients aged 71 to 87 years and in eight young (25 to 38 years) subjects following oral administration of 5 mg amiloride HCl daily to steady-state. 2. The maximum and steady-state plasma amiloride concentrations were significantly (P less than 0.05 and P less than 0.001) higher in the elderly patients. The renal clearance of amiloride was lower in the elderly than in young subjects (102 +/- 36 ml min -1 vs 300 +/- 64 ml min-1, P less than 0.001) as was the urinary excretion of amiloride (36 +/- 13 vs 62 +/- 18% of the dose, P less than 0.01). 3. The steady-state plasma amiloride concentration correlated significantly (r2 = 0.61, P less than 0.001) with amiloride renal clearance and with creatinine clearance (r2 = 0.59, P less than 0.001). There was a very strong positive correlation between renal amiloride clearance and creatinine clearance (r2 = 0.76, P less than 0.001). The slope of the regression line was 2.5 indicating substantial proximal tubular secretion of amiloride. 4. Sodium and potassium excretion, along with urine volume were significantly (P less than 0.05) lower in the elderly (by 39, 45 and 34% respectively). 5. The disposition of amiloride was highly dependent on renal function, with higher plasma amiloride concentrations in the elderly reflecting diminished renal function. The dose of amiloride should be titrated to individual response, and the lower potassium excretion in the elderly patients suggests that the dose of amiloride could be reduced in this group of patients.

Effect of aging on hepatic elimination of cimetidine and subsequent interaction of aging and cimetidine on aminopyrine metabolism

Aging and cimetidine may each impair hepatic microsomal drug metabolism. To test if and by what mechanisms advanced age may increase sensitivity to the inhibitory effects of cimetidine, the interaction of these two factors with aminopyrine metabolism in the rat was studied using a correlative approach. Initial studies using the aminopyrine breath test indicated that a 40 mg/kg dose of cimetidine, i.p., impaired the 14CO2 exhaled by up to 76% more in aged (26-month) than in young (3- to 4-month-old) rats. Using an isolated liver perfusion to dissect out hepatic components of this phenomenon, it was found that various doses of cimetidine impaired aminopyrine clearance to a greater degree (P less than 0.05) in aged than in young livers. However, cimetidine metabolism in this system ranged from 36 to 78% less in aged versus young livers (P less than 0.05). Subsequent in vitro studies indicated that microsomes isolated from aged livers also averaged a 76% lower rate of cimetidine metabolism (P less than 0.05). A fixed cimetidine concentration, however, inhibited aminopyrine demethylation to the same degree in aged versus young rats (P less than 0.05). In vivo pharmacokinetics showed an age-related decrease in both aminopyrine and cimetidine systemic clearance. In the young rat the liver contributed about 30% to total systemic clearance of cimetidine. In the aged rat, all clearance was renal. Despite a decrease in glomerular filtration rate, net tubular cimetidine secretion was well-maintained. Despite this, absence of the hepatic component resulted in decreased overall systemic clearance of the drug in aged rats. It is concluded that (1) the aged rat liver exhibits impaired cimetidine metabolism, resulting in decreased overall systemic clearance of the drug despite normal net renal tubular secretion, (2) there is no age-related enhanced sensitivity to cimetidine of the hepatic microsomal oxidizing system using aminopyrine as the probe drug, and (3) the larger inhibition of aminopyrine metabolism in aged rats following various doses of cimetidine is due to decreased overall cimetidine clearance, resulting in higher concentrations of the inhibitor in the liver of aged rats.

Effects of age and chronic renal failure on the urinary excretion kinetics of famotidine in man

The plasma and urine concentrations of famotidine, a new, potent H2-receptor antagonist, have been measured in 16 healthy young adults, 8 healthy elderly people and 18 patients with varying degrees of renal dysfunction after intravenous administration. Both the plasma elimination and renal excretion of famotidine were decreased in the elderly volunteers and renal patients. The renal clearance of famotidine averaged 4.43 ml/min/kg (310 ml/min) in normal young volunteers, which exceeded the mean creatinine clearance 1.55 ml/min/kg (109 ml/min), suggesting net secretion is a significant mechanism for elimination of famotidine. The ratio of famotidine renal clearance to creatinine clearance decreased as creatinine clearance decreased; these results suggest that the deterioration in the secretion process was much faster than that in glomerular filtration and are incompatible with the "intact nephron hypothesis". Nevertheless, both total body clearance and renal clearance were significantly correlated with creatinine clearance. The apparent half-life was also significantly correlated with creatinine clearance. Since famotidine is essentially free of dose-related adverse effects, dose adjustment in patients with mild renal insufficiency and in elderly people is not required; however, either a prolonged dosing interval or a decrease in daily dose during long-term therapy may be adapted for the patients with severe renal insufficiency to avoid accumulation and the potential undesirable effects.

Pharmacokinetic studies of cimetidine in patients with liver disease

The tolerability and metabolism of cimetidine administered for over 7 days were studied in 30 patients with liver diseases and 19 control subjects who had peptic ulcers. Cimetidine was well tolerated by these patients without any side effects. The cimetidine in the serum and urine was determined by high-performance liquid chromatography. The serum cimetidine levels and pharmacokinetic parameters of the patient group did not significantly differ from those of the control group after oral administration. Following intravenous administration, the half-life of cimetidine increased and cimetidine clearance decreased in the liver disease group. These differences seem to be totally explicable by the impaired renal function associated with the liver disease. Furthermore, accumulation of cimetidine in serum did not occur following continuous treatment with cimetidine in these patients. It was concluded that a reduction of cimetidine dosage is not necessary in patients with liver disease as far as their renal function is not disturbed, since the metabolism of cimetidine was not affected by the liver dysfunction itself.

Nizatidine, and H2-receptor antagonist: disposition and safety in the elderly

Nizatidine is an orally active H2-receptor blocker. Its disposition and safety in eight young and 12 elderly volunteers were investigated. Single oral doses of nizatidine were administered: from 100 mg to 300 mg in the elderly, and from 100 mg to 350 mg in the young. The nizatidine AUC was directly proportional to dose for both groups. Calculated pharmacokinetic variables in the elderly vs. the young were t1/2 = 1.9 vs. 1.6 hr; CLp/f = 32 vs. 40 L/hr, and Vd beta/f = 1.2 vs. 1.3 L/kg. The impaired renal function of some elderly volunteers prolonged nizatidine elimination and lowered its clearance. Renal impairment rather than advanced age per se was the predominant factor in decreasing the nizatidine elimination rate. Because Clcr correlated directly with nizatidine renal clearance, Clcr values may be used to estimate nizatidine dosage reductions in renal insufficiency. During the trial, no serious adverse effects occurred.

Dose-dependent pharmacokinetics of cimetidine in the rat

The pharmacokinetics of cimetidine were studied in the rat after intraperitoneal administration of 10, 40 and 100 mg/kg. The area under the plasma concentration-time curve increased more than proportionately with dose. The total plasma clearance of cimetidine decreased as the dose increased (4.11 to 2.21 l/h per kg) with a consequent increase in half-life (24.0 to 37.9 min) but no change in volume of distribution (mean 2.31 l/kg). The fraction of dose excreted unchanged increased slightly with dose (0.37 to 0.45), whereas the fraction excreted as the sulphoxide metabolite decreased significantly with increased dose (0.35 to 0.14). Both the renal clearance (1.52 to 0.99 l/h per kg) and the formation clearance of the sulphoxide metabolite (1.45 to 0.30 l/h per kg) decreased with increasing dose. Residual clearance, calculated as the difference between total clearance and the sum of renal and metabolic clearance, did not change with dose (mean 1.08 l/h per kg). The formation clearance of the sulphoxide metabolite became saturated at a lower cimetidine concentration than the renal clearance.

Pharmacokinetics of cimetidine in advanced cirrhosis

The effect of impaired liver function on the pharmacokinetics of cimetidine was studied in 8 patients with advanced cirrhosis given single doses of 100 mg i.v. and 400 mg p.o. on separate days. Compared to a control group of 10 healthy volunteers, the total renal and nonrenal clearance was significantly reduced in the cirrhotic patients; (total plasma clearance mean +/- SD) 356 +/- 181 vs 789 +/- 262 ml/min (p less than 0.01); renal clearance (Clr) 296 +/- 100 vs 588 +/- 181 ml/min (p less than 0.01) and nonrenal clearance ( Clnr ) 97 +/- 111 vs 205 +/- 89 ml/min (p less than 0.05). Compared to published results for age-matched ulcer patients, both total and nonrenal clearance were lower whereas renal clearance was within the reported normal range. A significant reduction in volume of distribution (Vd beta) was found, from 2.1 +/- 0.1 l/kg in controls to 1.0 +/- 0.4 l/kg, and in the patient group there was a significant correlation between Vd beta and total plasma clearance (r = 0.72, p less than 0.05). Volume of distribution in steady state (Vdss) did not differ from published results in age-matched controls. No significant change in half-life was found. Bioavailability, estimated by AUC-measurement, showed considerable patient variability (21-143%), with a mean of 70 +/- 39%. This was lower than in the controls. In contrast, measurement of urinary excretion showed higher bioavailability in the patients (66 +/- 23 vs 51 +/- 8%). No correlation was found between any of the kinetic parameters and the clinical and laboratory data.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting the response to inhibition of drug metabolism by cimetidine--dose response and sensitivity of elderly and induced subjects

The effect of cimetidine on oxidative drug metabolism was characterised using antipyrine clearance in a group of healthy volunteers. In six subjects cimetidine produced a dose dependent reduction of antipyrine clearance: 400 mg/day (16.8 +/- 2.2%, mean +/- s.e. mean), 800 mg/day (26.3 +/- 1.5%) and 1600 mg/day (33.5 +/- 2.4%). The effect of cimetidine (800 mg/day) was of similar magnitude (approximately 25%) in two groups of six young (21-26 years) and six elderly (65-78 years) subjects. The effect of pretreatment begun just 1 h before administration of antipyrine was similar to that of 24 h pretreatment and that reported for chronic cimetidine pretreatment. The percentage reduction in antipyrine clearance produced by cimetidine 800 mg/day was greater (44 +/- 5 vs 24 +/- 3%; P less than 0.05) in six subjects who had been pretreated with the hepatic enzyme inducer rifampicin (600 mg/day for 21 days) than in the control uninduced state. Although cimetidine was capable of rapidly reversing the effect of rifampicin on antipyrine clearance, following withdrawal of both rifampicin and cimetidine there was still evidence of enzyme induction. These results suggest that the effect of cimetidine on oxidative metabolism is dose dependent, is more marked in enzyme induced subjects, is independent of the duration of pretreatment and is of similar magnitude in young and elderly subjects.

Clinical pharmacokinetics of cimetidine

Cimetidine is the first histamine H2-receptor antagonist with wide clinical application. It is a weak base and a highly water-soluble compound which can be measured in biological fluids by a number of high-pressure liquid chromatographic methods. Following intravenous administration, the plasma concentration profile follows multicompartmental characteristics. The total systemic clearance is high (500 to 600 ml/min) and is mainly determined by renal clearance. The volume of distribution (Vd beta or Vdss) is of the order of 1 L/kg and this about equals bodyweight. Elimination half-life is approximately 2 hours. Following oral administration of cimetidine, 2 plasma concentration peaks are frequently observed, probably due to discontinuous absorption in the intestine. The absolute bioavailability in healthy subjects is about 60%. In patients with peptic ulcer disease, bioavailability is around 70%, but the variation is much greater than in healthy subjects. Absorption and clearance of cimetidine are linear after 200 and 800mg doses. Mean steady-state plasma concentrations on a standard 1000mg daily dose are 1.0 microgram/ml (range 0.64-1.64 micrograms/ml) and are reproducible after treatment periods of up to 2 years. When taken with food, the extent of absorption is unaltered, but a delay occurs and only 1 peak in the plasma concentration curve is apparent. Partial gastrectomy (Billroth I, II) causes an increase in systemic availability of cimetidine by an unclear mechanism. Distribution of cimetidine leads to extensive uptake into kidney, lung and muscle tissues. It distributes into the cerebrospinal fluid (CSF) at a ratio of 0.1 to 0.2 compared with plasma. The mean saliva to plasma ratio is 0.2 (range 0.1-0.55). Plasma protein binding is 20%, and there is no relevant effect of changes in binding on the pharmacokinetics of cimetidine. Uptake of cimetidine into red blood cells leads to concentrations equal to those in plasma. Between 50 and 80% of the dose administered intravenously is recovered in urine as unchanged cimetidine. This fraction is less after oral doses, but is independent of the amount of the dose. In ulcer patients, 40% is recovered unchanged in urine after oral administration. Biliary excretion of cimetidine accounts for only 2% of the dose.(ABSTRACT TRUNCATED AT 400 WORDS)

Cimetidine kinetics and dynamics in patients with severe liver disease

Following cimetidine administration, 60% of the dose is excreted as unchanged drug in the urine, and 40% is eliminated by metabolism. We evaluated the effect of liver disease on cimetidine disposition by comparing its kinetics in 7 healthy subjects and 8 patients with alcoholic cirrhosis. Cirrhotic patients had severe liver disease as evidenced by the presence of ascites, hepatic encephalopathy, jaundice, muscle wasting, and low serum albumin, but serum creatinine and creatinine clearance did not differ significantly between controls and cirrhotics. Following intravenous administration, cimetidine systemic clearance was decreased by 56% in cirrhotics. This reduction was due in major part to an impairment of the renal clearance of unchanged drug. The ratio of cimetidine to creatinine clearance was 3.71 +/- 0.63 in controls, indicating active tubular secretion, and was decreased in cirrhotics (1.22 +/- 0.09, p less than 0.05). The volume of distribution of cimetidine was also decreased by 39% in cirrhotics. To verify whether these findings observed after a single dose could be extended to patients receiving chronic cimetidine treatment, cimetidine trough (predose) plasma levels were measured in an additional group of 56 subjects receiving continuous cimetidine therapy (15 controls and 41 cirrhotics). Trough plasma levels did not differ significantly in controls and patients with compensated liver disease, but were elevated in patients with moderate and severe hepatic dysfunction. It is concluded that cimetidine clearance is decreased in patients with severe liver disease, mostly due to an impairment of the tubular secretion of unchanged drug, and that a reduction of cimetidine dosage is warranted in these patients, even in the presence of a normal creatinine clearance.

Cimetidine disposition in patients with Laennec's cirrhosis during multiple dosing therapy

The disposition of cimetidine after oral and intravenous administration during multiple dosing was studied in 11 patients with Laennec's cirrhosis. The average metabolic clearance of cimetidine in these patients was 15 l/h, similar to values reported for normal subjects. However, in 4 subjects with plasma prothrombin times above normal, the metabolic clearance was significantly decreased and ranged between 4.3 and 13.0 l/h. The renal clearance of cimetidine was proportional to the creatinine clearance in all subjects, regardless of the severity of the liver disease. The clearance of cimetidine in patients with Laennec's cirrhosis, therefore, appears to be predictable from creatinine clearance and prothrombin time.

Carcinogenesis and aging

Figure 2 illustrates a suggested mechanism of carcinogenesis. This scheme takes into account the effect of carcinogens at different integration levels: subcellular, tissue, and organism. Any of these levels may be age dependent. Age-associated changes in the activity of enzymes responsible for activation and inactivation of carcinogens, and variations in concentrations of lipids and proteins contributing to the transport of carcinogenic agents into cells, may play an important role in the modifying effect of age on carcinogenesis. The effects of age-associated changes in DNA repair need clarification. However, they are thought to exert a permissive influence on the age-associated rise in tumor incidence. It seems that proliferative activity of target tissues is the important modifying factor of carcinogenesis. Age-related changes of regulation at tissue and organism levels are also powerful factors in carcinogenesis modification. Age-dependent changes in the neuroendocrine system provide conditions for metabolic immunodepression and promotion of carcinogenesis. On the other hand, carcinogens per se (especially chemical and radiological) may intensify aging processes in the organism. Normalization, by drugs, of age-associated shifts requiring synthetic and energetic changes of a transformed tumor cells, and of immunological shifts, may exert both antitumor and geroprotective effects.

Cimetidine-procainamide pharmacokinetic interaction in man: evidence of competition for tubular secretion of basic drugs

The hypothesis that basic drugs can compete for active tubular secretion by the kidney was tested in six healthy volunteers by comparing the single dose pharmacokinetics of oral procainamide before and during a daily dose of cimetidine. The area under the procainamide plasma concentration-time curve was increased by cimetidine by an average of 35% from 27.0 +/- 0.3 micrograms/ml X h to 36.5 +/- 3.4 micrograms/ml X h. The elimination half-life increased from an harmonic mean of 2.92 to 3.68 h. The renal clearance of procainamide was reduced by cimetidine from 347 +/- 46 ml/min to 196 +/- 11 ml/min. All these results were statistically significant (p less than 0.016). The area under the plasma concentration-time curve for n-acetylprocainamide was increased by a mean of 25% by cimetidine due to a significant (p less than 0.016) reduction in renal clearance from 258 +/- 60 ml/min to 197 +/- 59 ml/min. The data suggests that cimetidine inhibits the tubular secretion of both procainamide and n-acetylprocainamide, and, if so, represents the first documented evidence for this type of drug interaction in man. The clinical implications from this study necessitate dosage adjustments of procainamide in patients being concomitantly treated with cimetidine. The interaction is pertinent not only for basic drugs that are cleared by the kidney, but also for metabolites of basic drugs and endogenous substances which require active transport into the lumen of the proximal tubule of the kidney for their elimination.

Cimetidine dosage regimen for patients with renal failure and for geriatric patients

Using a recently developed computer program based on a correlation between methods to predict the elimination half-life and apparent volume of distribution of cimetidine and actual data from patients, ideal dosage regimens were generated for patients with renal impairment and for geriatric patients, together with the corresponding maximum and minimum steady state concentrations. Using the ideal dosage regimens, practical regimens with feasible dosing intervals of 6, 8 and 12 h were computed, which should result in therapeutic concentrations of 0.4 to 1.3 micrograms/ml. For uraemic patients and geriatric patients above the age of 75 years it would be desirable to have an additional oral 100 mg dosage form.