Diflunisal disposition and hypouricemic response in osteoarthritis

The problems and pitfalls of NSAID therapy in the elderly (Part II)

The elderly are most susceptible to pharmacokinetic drug interactions between various NSAIDs and anticoagulants, sulphonylurea hypoglycaemic agents, certain anticonvulsants, methotrexate, digoxin, aminoglycosides and lithium. Pharmacodynamic interactions between some NSAIDs and antihypertensive drugs, anticoagulants, sulphonylurea agents and other NSAIDs are also potentially significant in the elderly. Despite the finding that mean therapeutic responses of large groups of patients have been generally equivalent for the wide range of NSAIDs studied thus far, it is also apparent that marked variability exists in the response of individual patients to different NSAIDs. Subsequent dosage increments may predispose 'nonresponders' and some less sensitive 'responders' to toxicity from NSAIDs. This interindividual variability in response to NSAIDs may be contributed to by the differing physicochemical properties of NSAIDs, physician prescribing habits and patient expectations, variations in NSAID pharmacokinetics, and the differing effects of NSAIDs other than their common ability to inhibit prostaglandin synthesis. The principles for drug prescribing in the elderly are no different from those that should be applied to the prescribing of medication in any patient. The clinician should strive to make a diagnosis and should avoid treating symptoms in isolation. Critical assessment of the indication for prescribing NSAID therapy must include consideration of the available effective and safe alternatives. If an NSAID is commenced the lowest effective dose should be the desired goal, but after an appropriate trial it is acceptable clinical practice to employ an alternative NSAID. There is no justification for combination NSAID therapy. The progress of each patient must be carefully monitored, particularly during the first few months of treatment, while periodic review of the ongoing need for the NSAID is essential.

The effect of multiple dosage on the kinetics of glucuronidation and sulphation of diflunisal in man

1. The single (250 and 500 mg) and multiple dose (250 and 500 mg twice daily for 15 days) pharmacokinetics of diflunisal were compared in young volunteers. 2. The plasma clearance of diflunisal was lowered significantly after multiple dose administration (5.2 +/- 1.2 and 4.2 +/- 0.7 ml min-1 for the 250 and 500 mg twice daily regimens, respectively) as compared with single dose administration 11.4 +/- 3.1 and 9.9 +/- 2.0 ml min-1 for the 250 and 500 mg single doses, respectively). 3. The partial metabolic clearances of diflunisal by acyl and phenolic glucuronide formation were lowered significantly (greater than 50%) after multiple dose administration. 4. The urinary recovery of diflunisal sulphate increased as a function of dose: 6.1 +/- 2.8 and 9.1 +/- 3.5% following the 250 and 500 mg single dose, respectively, and 10.9 +/- 3.1 and 15.9 +/- 3.6% following the 250 and 500 mg twice daily regimens. The partial metabolic clearance of diflunisal by sulphate conjugation was unchanged following multiple dose administration. 5. The plasma protein binding of diflunisal was concentration-dependent. Analysis of unbound plasma clearances of diflunisal showed that its total plasma clearance following 500 mg twice daily was affected by both saturable glucuronidation and concentration-dependent plasma binding.

Elimination of diflunisal as its acyl glucuronide, phenolic glucuronide and sulfate conjugates in bile-exteriorized and intact rats

1. The disposition of diflunisal (DF) was investigated in both bile-exteriorized and intact rats given 10 and 100 mg/kg doses intravenously (i.v.). 2. In addition to the phenolic glucuronide (DPG) and acyl glucuronide (DAG) conjugates, the sulfate conjugate (DS) was found to be a major metabolite. The glucuronides were excreted preferentially in bile, whereas DS was excreted almost exclusively in urine. 3. In bile-exteriorized animals, recoveries of DPG, DAG and DS in bile were 12.2%, 23.8%, 0.4%, respectively, and in urine, 10.3%, 5.6% and 15.2%, respectively, at the 10 mg/kg dose; and in bile, 11.3%, 41.6% and 1.0% respectively, and urine 2.9%, 1.1% and 17.0%, respectively, at the 100 mg/kg dose. 4. Total plasma clearance of DF and formation clearance of DF to DPG were reduced at the higher dose, suggesting saturation of this glucuronidation pathway. Formation clearances of DF to DAG and DS were little affected by the dose change. 5. Considerable enterohepatic recirculation of DF was apparent from the prolongation of DF and its conjugates in plasma of rats with an intact bile flow into the gut. The net metabolic effect of such cycling was enhancement of overall DS formation, from 15.6% and 18.0% of the 10 and 100 mg/kg doses, respectively, in bile-exteriorized rats to 28.5% and 42.1% of the doses respectively, in the intact animals.

Rapid high-performance liquid chromatographic methods for the determination of overdose concentrations of some non-steroidal anti-inflammatory drugs in plasma or serum

Separate methods are described for the determination of the non-steroidal anti-inflammatory drugs diflunisal, indomethacin, fenoprofen, ibuprofen, ketoprofen, naproxen, mefenamic acid and piroxicam at overdose concentrations in human plasma or serum, using high-performance liquid chromatography and ultraviolet detection. A common extraction, involving protein precipitation with acetonitrile, is employed for all methods. A 25 cm Hypersil ODS (5 mu particle size) analytical column is used for all chromatographic separations, with a mobile phase of acetonitrile-acetate buffer (pH 4.2 or 4.8). The methods are all reproducible and can also determine concentrations that fall within the normal therapeutic range for each drug.

High-performance liquid chromatographic method for the simultaneous quantitation of diflunisal and its glucuronide and sulfate conjugates in human urine

A direct high-performance liquid chromatographic (HPLC) assay was developed to simultaneously quantitate diflunisal and its three known metabolites (i.e., the phenolic and acyl glucuronides and the sulfate conjugate) in human urine. Chromatographically pure standards of the diflunisal conjugates were isolated from urine of volunteers following ingestion of multiple doses of diflunisal (500 mg twice daily). Diflunisal, its three conjugates, and an internal standard (naproxen) were separated on a reversed-phase column using gradient elution. The column eluate was monitored fluorometrically (excitation: 258 nm; emission: 428 nm). Urine samples were diluted with phosphate buffer (pH 5.75) and injected onto the column. The limit of detection was approximately 1 microgram/mL for each conjugate and 0.1 microgram/mL for diflunisal. Due to the presence in most urine samples of significant concentrations of rearrangement products of the biosynthetic 1-O-acyl glucuronide of diflunisal, the acyl glucuronide could not be reliably quantitated by direct injection of diluted urine samples. Instead, diflunisal acyl glucuronide was quantitated indirectly following alkaline hydrolysis of the urine samples. The method has been successfully used to investigate the dose-dependent glucuronidation and sulfation of diflunisal in humans.

Effect of dose on the glucuronidation and sulphation kinetics of diflunisal in man: single dose studies

1. The effect of dose (100 mg, 250 mg, 500 mg, 750 mg and 1000 mg) on the glucuronidation and sulphation of diflunisal was studied in six healthy volunteers. 2. Total urinary recovery ranged from 78.9 +/- 11.9% to 91.5 +/- 18.7% of the administered dose. Urinary recovery (normalized for total urinary recovery) of diflunisal sulphate (DS) significantly increased with dose from 9.3 +/- 3.7% to 18.1 +/- 4.8%. 3. Normalized urinary recovery for diflunisal phenolic glucuronide (DPG) was unaffected by dose (range: 30.6 +/- 3.8% to 40.6 +/- 6.6%). Normalized urinary recovery for the acyl glucuronide (DAG) significantly decreased from 52.3 +/- 4.6% to 40.2 +/- 3.4% as the dose increased. 4. Total plasma clearance of diflunisal significantly decreased from 14.4 +/- 1.4 ml min-1 to 8.7 +/- 1.4 ml min-1 as the dose increased from 100 mg to 750 mg. A further increase in dose to 1000 mg resulted in an unexplained increase in total plasma clearance to 10.3 +/- 1.8 ml min-1. 5. Dose-dependent plasma clearance of diflunisal was caused mainly by saturation of the formation of DAG, whereas the formation of DS and DPG were relatively unaffected by dose.

Assay methodology for quantification of the ester and ether glucuronide conjugates of diflunisal in human urine

Diflunisal is a salicylate derivative with analgesic and anti-inflammatory properties. It is excreted in the urine as an ether glucuronide, a 1-O-acyl glucuronide and as unchanged drug. The 1-O-acyl glucuronide rearranges to isomeric esters of glucuronic acid under neutral to alkaline pH conditions. The development of a urine assay for the conjugates enables the elucidation of diflunisal non-linear pharmacokinetics. The assay quantitates the ether and ester glucuronides and free diflunisal in urine at 0.5-1.0 micrograms/ml. Analysis of the glucuronides does not require authentic standards.