Clinical Pharmacokinetics

&
Pharmacotherapeutic Drug
Monitoring

Prepared By:
Dr SHIVARAJ D R
Sree Siddaganga College of Pharmacy
Tumakur

1
 INDEX
Sl.no. Topic Page no.

01 Introduction to clinical 03-07

pharmacokinetics

02 Design of Dosage Regimens 08-15

03 Pharmacokinetics of Drug 16-23

Interactions

04 Therapeutic Drug 24-51

Monitoring

05 Dosage adjustment in renal 52-71

and hepatic disease

06 Population pharmacokinetics 72-80

07 Pharmacogenetics 81-89

2
 Introduction to Clinical Pharmacokinetics

1. Give the importance of clinical pharmacokinetics?

• Pharmacokinetics is defined as the kinetics of drug absorption, distribution, metabolism

and excretion (KADME) and their relationship with the pharmacologic, therapeutic or
toxicological response in man and animals. The applications of pharmacokinetic
principles in the safe and effective management of individual patient are called as clinical
pharmacokinetics.
• Pharmacokinetics is also applied to therapeutic drug monitoring (TDM) for very potent
drugs such as those with a narrow therapeutic range, in order to optimize efficacy and to
prevent any adverse toxicity.

2. Define apparent volume of distribution and give the mathematical equation to

calculate this parameter?
It is defined as the hypothetical volume of body fluid into which a drug is dissolved or
distributed. It is called as apparent volume because all parts of the body equilibrated with
the drug do not have equal concentration.
𝐴𝑚𝑜𝑢𝑛𝑡 𝑜𝑓 𝑑𝑟𝑢𝑔 𝑖𝑛 𝑡ℎ𝑒 𝑏𝑜𝑑𝑦
Apparent volume of distribution =
𝑃𝑙𝑎𝑠𝑚𝑎 𝑑𝑟𝑢𝑔 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛
𝑋
Vd =
𝐶
The apparent volume of distribution bears no direct relationship with the real volume of
distribution.

3. Define non-linear pharmacokinetics?

✓ It is defined as the “Pharmacokinetic parameters change with the size of
administered dose.
✓ It is a dose-dependent and it follows combination of 1st order and zero order rate
process.

3
4. Describe the difference between first and zero order elimination and how each order
appears graphically?
First order kinetics Zero order kinetics

Constant fraction of drug is eliminated Constant amount of drug is eliminated per

per unit time unit time

Rate of elimination is proportional to Rate of elimination is independent to

plasma concentration plasma concentration

Clearance remains constant Clearance is more at low concentration and

less at high concentration

Half-life remains constant Half-life is less at low concentration and

more at high concentration

5. Define biological half-life and give its equation with units?

➢ It is defined as the time taken for the amount of drug in the body as well as
plasma concentration to decline by one-half or 50% its initial value.
➢ It is expressed in hours or minutes.
0.693
t1/2 = 𝐾𝐸

4
6. Give the relationship between biological half-life and elimination rate constant?
Biological half life also called as Elimination half life. It is defined as the time taken for
the amount of drug in the body as well as plasma concentration to decline by one-half or
50% its initial value.
Elimination rate constant (Ke) can be defined as the fraction of drug in an animal that
is eliminated per unit of time, e.g., fraction/h.
7. What is clearance? Give the relationship between clearance, drug dose and AUC?
Clearance is defined as the theoretical volume of body fluid containing from which the
drug is completely removed in a given period of time.
𝑅𝑎𝑡𝑒 𝑜𝑓 𝑒𝑙𝑖𝑚𝑖𝑛𝑎𝑡𝑖𝑜𝑛
Clearance =
𝑃𝑙𝑎𝑠𝑚𝑎 𝑑𝑟𝑢𝑔 𝑐𝑜𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛

Or

𝑑𝑥⁄
𝑑𝑡
Cl =
𝐶

Relationship b/w Cl, drug dose and AUC

F.X0 = AUC × Cl

Where; F = Fraction of drug absorbed

X0 = oral dose
AUC = Area under curve
Cl = clearance
8. Give the assumptions of compartment model?
✓ The body is considered as a single, kinetically homogenous unit that has no
barriers to the movement of drug.
✓ Drugs move dynamically in and out of this compartment.
✓ Elimination is a first order process with first order rate constant.
✓ Rate of input > rate of output
✓ Any change in plasma drug concentration reflects a proportional change in drug
concentration throughout the body.

5
9. Define pharmacokinetics. Name and define three pharmacokinetic parameters that
describe a typical plasma level time curve?

➢ Pharmacokinetics is defined as the kinetics of drug absorption, distribution, metabolism

and excretion (KADME) and their relationship with the pharmacologic, therapeutic or
toxicological response in man and animals.

➢ pharmacokinetic parameters:
1. Peak Plasma Concentration (Cmax):
• The point of maximum concentration of drug in plasma is called as the peak
and the concentration of drug at peak is known as peak plasma concentration.
It is also called as peak height concentration and maximum drug
concentration. It is expressed in mcg/mL
2. Time of Peak Concentration (tmax):
• The time for drug to reach peak concentration in plasma (after extra vascular
administration) is called as the time of peak concentration. It is expressed in
hours
3. Area under the Curve (AUC):
• It represents the total integrated area under the plasma level-time profile and
expresses the total amount of drug that comes into the systemic circulation
after its administration. AUC is expressed in mcg/mL X hours.

TYPICAL PLASMA LEVEL TIME CURVE

6
10. Define Loading dose and Maintenance dose. Give equations to calculate the same?
Loading dose: A drug does not show therapeutic activity unless it reaches the described
steady state. Plateau can be reached immediately by administering a dose that gives the
desired steady state. Such an initial dose intended to be therapeutic is called as loading
dose.
𝐶𝑠𝑠,𝑎𝑣 .𝑉𝑑
X0L =
𝐹
Maintenance dose: it is the maintenance rate [mg/h] of drug administered equal to the
rate of elimination at steady state.
𝐶𝑝 .𝐶𝑙
MD =
𝐹
11. Give any 4 applications of clinical pharmacokinetics?
 Design and development of new drugs with greatly improved therapeutic
effectiveness and no toxic effects.
 Design and development of an optimum formulation, for better use of the drug.
 Design and development of controlled /targeted-release formulation.
 Select the appropriate route for drug administration.
 Select the right drug for a particular illness.

7
 Design of Dosage regimens
1. Add a note on START and STOP criteria for drugs to be used in geriatric patients?
 Tools such as START/STOP to choose the most appropriate drug therapy in elderly
patients.
 Beers Criteria does not address some medications that should be avoided in the elderly,
drug interactions, duplications, and under prescribing
 STOP (Screening Tool of Older Persons potentially inappropriate Prescriptions)
 START (Screening Tool to Alert doctors to Right Treatment)
 Aims of STOPP/START to Provide explicit, evidence based rules of avoidance of
commonly encountered instances of potentially inappropriate prescribing and potential
prescribing omissions
• Improve medication appropriateness
• Prevent adverse drug events
• Reduce drug costs
2. Write different formulae for calculating child dose?
A. Dose calculation related to age
 Young’s rule

𝐴𝑔𝑒 (𝑦𝑟)
Child dose = × adult dose
𝐴𝑔𝑒 (𝑦𝑟)+ 12

 Dilling’s rule

𝐴𝑔𝑒 (𝑦𝑟)
Child dose = × adult dose
20

 Fried’s rule

𝐴𝑔𝑒 (𝑚𝑜𝑛𝑡ℎ𝑠)
Child dose = × adult dose
150

B. Dose calculation related to body weight

 Clarke’s rule
𝑏𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 (𝑝𝑜𝑢𝑛𝑑𝑠)
Child dose = × adult dose
150

8
3. Add a note on BEER’s criteria for drugs to be used in geriatric patients?

 The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults,
commonly called the Beers List, are guidelines for healthcare professionals to help
improve the safety of prescribing medications for older adults. They
emphasize deprescribing medications that are unnecessary, which helps to reduce the
problems of polypharmacy, drug interactions, and adverse drug reactions, thereby
improving the risk–benefit ratio of medication regimens in at-risk people.

 The criteria are used in geriatrics clinical care to monitor and improve the quality of care.

 These criteria include lists of medications in which the potential risks may be greater than
the potential benefits for people 65 and older. By considering this information,
practitioners may be able to reduce harmful side effects caused by such medications.

4. Write the importance of loading dose in finding drug dosing intervals.

• To attend quick plasma level
• Attain quick action
• The main importance of loading dose is average plasma concentration at steady
state as quickly as possible.
• In some cases loading dose helps to get therapeutic effect quickly.
5. Define Nomograms ad Tabulations.
Nomograms: A line chart in toxicology that relates time since toxic ingestion with blood
levels of the offending agent to estimate levels of toxicity and to guide therapy.
Advantage:
- Determine and administer dose.
- Random level 6-14hrs after beginning of infusion
- Determine interval based on level
- Less frequent dosing
Disadvantage:
Total dose is recognized as potential risk factor for toxicity.
Tabulations: It is a systematic & logical presentation of numeric data in rows and
columns, to facilitate comparison and statistical analysis.

9
6. Enumerate the methods for conversion of IV to oral dosing.
There are 3 methods
a. Sequential therapy
It refers to the act of replacing a parenteral version of a medication with its oral
counterpart.
b. Switch therapy
Used to describe a conversion from an IV to PO equivalent that may be within the same
class and have the level of potency, but is a different compound.
c. Step-down therapy
Refers to converting from an IV medication to oral agent in another class or to a different
medication within the same class where the frequency, dose, and the spectrum of activity
may not be exactly the same.
7. What are the factors affecting the drug absorption in geriatric patients.
✓ Roué of administration
✓ Co morbid conditions
✓ Increased GI pH
✓ Decreased gastric emptying
✓ Dysphagia
8. Mention the factors affecting the drug distribution in obese patients.
- Increased adipose tissue
- Increased organ mass, lean body mass, blood volume
- Volume of distribution

Therapeutic levels

Toxicity

10
 9. Explain the various factors considered in the design of dosage regimen for geriatric
and obese patients.
Because of reasonable homogeneity in humans, the dosage regimens are calculated on
population basis. However same dose of a drug may produce large differences in
pharmacological response in different individuals. This is called as intersubject
variability.
The 2 main sources of variability in drug response are:
 Pharmacokinetic variability
 Pharmacodynamic variability

The geriatric population is always defined as patients who are older than 65yrs. Elderly
population have been classified as:

• Young old (65-75yrs)

• Old (75-85yrs)
• Old old (>85yrs)
Factors which affect the dosage regimen in geriatrics are:

- Performance capacity and the loss of homeostatic resume

It decreases to a different degree in each organ & in each patient. Physiologic and cognitive
function tends to change with aging process and can affect compliance and therapeutic safety and
efficacy of a prescribed drug.

- Several vital physiological function such as:

✓ Renal plasma flow
✓ Glomerular filtration
✓ Cardiac output
✓ Breathing capacity can drop from 10-30%

Geriatrics when compared to adults, these physiologic changes due to aging marker a special
consideration for administering drugs in the elderly.

These will be an apparent increase in drug sensitivity in geriatrics due to pharmacokinetic or

pharmacodynamic changes or both.

11
Pharmacodynamic changes may be due to alteration in the quantity & quality of target drug
receptors. Quantitatively the number of drug receptor may decline with age whether qualitatively
a change in affinity for the drug may occur.

Pharmacokinetic changes may be in

• Absorption
• Distribution
• Elimination including renal excretion & hepatic clearance

 Drug absorption may include

▪ Deceased splanchnic blood flow
▪ Altered GI motility
▪ Increase in gastric pH
▪ Alteration in GI absorptive surface
 The incidence of achlorhydria in the elderly may have an effect and the dissolution of
certain drugs such as weak bases & certain dosage forms that require an acid environment
for disintegration and release.
 As in case of distribution, drug-protein binding in plasma may decrease as a result of
decrease in albumin concentration & the apparent volume of distribution may change due
to decrease in muscle mass & increase in body fat.
 Renal excretion may decline as a result of decrease in GFR and active tubular secretion.
 The activity of enzymes responsible for drug biotransformation may decrease with age,
results in decrease in hepatic clearance.

On a whole age related changes in the hepatic & renal function greatly alters the clearance of
drugs, because of progressive decrease in renal function, the dosage regimen of drugs that are
predominantly excreted unchanged in urine should be reduced in elderly patients.

Factors which affect the dosage regimen in obese are:

- Dosage regimen is usually calculated on the basis of body weight or it correlates with
volume of different fluids in the body, but their method is not reliable or accurate. In case
of obese patients, due to their poor distribution of drug into body fat. Prescribing heavy

12
 dose in obese patients according to their body weight may result in toxicity. Therefore in
obese patients the dosage regimen is designed by considering age & height.
The standard or ideal weight for men & women is calculated by following formula:

45𝑘𝑔 ±1𝑘𝑔
IBW (females) =
2.5𝑐𝑚 𝑎𝑏𝑜𝑣𝑒 𝑜𝑟 𝑏𝑒𝑙𝑜𝑤 150𝑐𝑚 ℎ𝑒𝑖𝑔ℎ𝑡

50𝑘𝑔 ±1𝑘𝑔
IBW (males) =
2.5𝑐𝑚 𝑎𝑏𝑜𝑣𝑒 𝑜𝑟 𝑏𝑒𝑙𝑜𝑤 150𝑐𝑚 ℎ𝑒𝑖𝑔ℎ𝑡

Patients with 25% more weight than ideal body weight (IBW) are said to be obese.

General consideration of dosage adjustment with respect to volume of distribution:-

➢ Polar drugs/water soluble drugs (gentamicine) should be prescribed in low dose as on the
basis of body weight as they distribute is excess in obese patients.
➢ Drugs that are poorly distributed in obese patients due to their body fat (digoxin) should
be calculated on the basis of IBW.
➢ Lipid soluble drugs (diazepam, phenytoin) distribute largely in adipose tissue resulting in
increased volume of distribution hence, in such case drug dose is calculated on the basis
of total body weight.
➢ Drugs that are equally distributed in lean tissue as well as adipose tissue should be
administered on the basis of total body weight.

10. Why dosage adjustment is necessary in obese patients. What are the
pharmacokinetic parameters to be considered in the dosage adjustment for obese
patients?
- Dosage regimen is usually calculated on the basis of body weight or it correlates with
volume of different fluids in the body, but their method is not reliable or accurate. In case
of obese patients, due to their poor distribution of drug into body fat. Prescribing heavy
dose in obese patients according to their body weight may result in toxicity. Therefore in
obese patients the dosage regimen is designed by considering age & height.
The standard or ideal weight for men & women is calculated by following formula:

45𝑘𝑔 ±1𝑘𝑔
IBW (females) =
2.5𝑐𝑚 𝑎𝑏𝑜𝑣𝑒 𝑜𝑟 𝑏𝑒𝑙𝑜𝑤 150𝑐𝑚 ℎ𝑒𝑖𝑔ℎ𝑡 13
 50𝑘𝑔 ±1𝑘𝑔
IBW (males) =
2.5𝑐𝑚 𝑎𝑏𝑜𝑣𝑒 𝑜𝑟 𝑏𝑒𝑙𝑜𝑤 150𝑐𝑚 ℎ𝑒𝑖𝑔ℎ𝑡

Patients with 25% more weight than ideal body weight (IBW) are said to be obese.

General consideration of dosage adjustment with respect to volume of distribution:-

➢ Polar drugs/water soluble drugs (gentamicine) should be prescribed in low dose as on the
basis of body weight as they distribute is excess in obese patients.
➢ Drugs that are poorly distributed in obese patients due to their body fat (digoxin) should
be calculated on the basis of IBW.
➢ Lipid soluble drugs (diazepam, phenytoin) distribute largely in adipose tissue resulting in
increased volume of distribution hence, in such case drug dose is calculated on the basis
of total body weight.
➢ Drugs that are equally distributed in lean tissue as well as adipose tissue should be
administered on the basis of total body weight.

Following generalization can be made regarding drug distribution and dose adjustment in
obese patients.

• For drugs such as digoxin that don’t significantly distribute in the excess body space,
Vd doesn’t change and hence dose to be administered should be calculated on IBW
basis.
• For polar drugs such as antibiotics which distribute in excess body space of obese
patient to an extent less than that in lean tissues, the dose should be lesser on per kg
total body weight basis; hence, dose should be administered on total body weight
basis.
• For drugs such as phenytoin, diazepam which is lipid soluble and distributes more in
adipose tissue, the Vd is larger per kg body weight in obese patient & hence, they
required larger doses, more than that on total body weight basis.

Changes in dose based on alteration of Vd are also attributed to modification of clearance and
half-life of the drug.

14
11. The elimination half-life of an antibiotic is 3hrs with an apparent volume of
distribution equivalent to 20% of body weight. The usual therapeutic range of this
antibiotic is between 5-15 µg/ml. calculate the dose and dosing interval that will just
maintain the therapeutic concentration.
Determine the maximum dosage interval (τ)
15 1
= 0.693
5 −(
3 )τ
𝑒
Take the natural logarithm (ln) on both sides of equation
-0.2312 = -1.10
τ = 4.76hrs
𝐷
∞
Then, determine the dose required to produce 𝐶𝑚𝑎𝑥 , after substitution of 𝐶0𝑝 = 0⁄𝑉
𝑑
𝐷0
⁄𝑉
∞ 𝑑
𝐶𝑚𝑎𝑥 =
1 − 𝑒 −𝐾𝑇

Solve the dose Do, Vd = 200ml/kg (20% body weight)

𝐷0
⁄𝑉
𝑑
15 =
1 − 𝑒 −(0.231)(4.76)

D0 = 2mg/kg
∞ ∞
To check this dose for therapeutic effectiveness, calculate 𝐶𝑚𝑖𝑛 & 𝐶𝐴𝑉
∞ 𝐷𝑜 2000
𝐶𝑚𝑖𝑛 = =
𝑉𝑑𝐾𝑇 (200)(0.231)(4.76)

∞
𝐶𝐴𝑉 = 9.09µg/ml

Pharmacokinetics of Drug Interactions

15
1. Explain the various pharmacokinetic drug interactions with suitable interactions.
Pharmacokinetic drug interactions: these interactions are those in which the absorption,
distribution, metabolism and excretion of the object drug are altered by the precipitant
and hence such interactions are called as ADME interactions. The resultant effect is
altered plasma concentration of the object drug.
PK interactions can be classified as:
i. Absorption interaction: are those where the absorption of the object drug is altered.
The net effect of such an interaction is:
• Faster or slower drug absorption
• More or less complete drug absorption
Major mechanisms of absorption interactions are:
 Complexation and adsorption
 Alteration in gastric PH
 Alteration in gastric motility
 Inhibition of GI enzymes
 Alteration of GI microflora
 Malabsorption syndrome
Example: An alteration in Parenteral drug absorption is rare but can occur when an
adrenergic agent such as adrenaline is extravasularly injected concomitantly with
another drug. These agents alter the systemic absorption of the latter due to
vasoconstriction or vasodilatation.
ii. Distribution interactions: The major mechanism for distribution interaction is
alteration in protein drug binding.
Example: oral hypoglycemic such as sulphonylureas. These agents exert their
therapeutic effects by displacing insulin from protein binding sites in pancreas,
plasma and other regions resulting in its elevated levels.
iii. Metabolism interactions: Mechanism of metabolism interactions include
➢ Enzyme induction: increased rate of metabolism
➢ Enzyme inhibition: decreased rate of metabolism. It is the most significant
interaction in comparison to other interactions and can be fatal.

16
 Example: The metabolic pathway usually affected is phase-1 oxidation. Enzyme
inducers reduce the blood level and clinical efficacy of co-administered drugs but
may also enhance the toxicity of drugs having active metabolites.
iv. Excretion interactions: major mechanisms are:
➢ Alteration in renal blood flow: e.g. NSAIDs (reduces renal blood flow) with
lithium.
➢ Alteration of urine PH: e.g. antacids with amphetamine.
➢ Competition for active secretion: e.g. probenecid and penicillin.
➢ Forced dieresis.
Example: thiazide diuretics and lithium alters the GFR, renal blood flow, passive
tubular reabsorption, active tubular secretion and urine PH.

2. Discus drug interactions related to protein binding and metabolism.

(a) Interaction affecting distribution of drugs: Though several factors govern the
distribution of drugs to various tissues, clinically significant interactions result due to
competition between drugs for binding proteins/tissues and displacement of one drug by
the other. Competitive displacements, which result when two drugs are capable of
binding to the same site on the protein, cause the most significant interaction. Greater risk
of interaction exists when the displaced drug is highly protein bound (more than 95%),
has a small volume of distribution and has narrow therapeutic index (e.g. tolbutamide,
warfarin and phenytoin), and when the displacer drug has a higher degree of affinity than
the drug to be displaced. In such situation, displacements of even a small percent of drug
results in a tremendous increase in the free form of the drug, which precipitates increased
therapeutic or toxic-effects.
Drugs may also be displaced from binding site in tissues. An interesting example of this
is oral hypoglycemic such as the sulphonylureas (tolbutamide, glibenclamide, etc.). These
agents exert their therapeutic effects by displacing insulin from protein binding sites in
pancreas, plasma and other region resulting in its elevated levels.
(b) Interaction affecting metabolism of drugs: The most important and most common
cause of pharmacokinetic interaction is alteration in the rate of biotransformation of
drugs. Major problems arise when one drug either induces or inhibits the metabolism of

17
 anther drug. Even the environmental chemical can bring about such an effect. The
influence of enzyme inducers and inhibitors become more pronounced when drugs
susceptible to first-pass hepatic metabolism are giving concurrently. The metabolic
pathway usually affected is phase-1 oxidation. Enzyme inducers reduce the blood level
and clinical efficacy of co-administered drugs but may also enhance the toxicity of drugs
having active metabolites. In contrast to enzyme induction, which is usually not
hazardous, enzyme inhibition leads to accumulation of drug to toxic levels and serious
adverse effects may be precipitated.

3. Explain the influence of drug interaction on drug absorption with examples.

Interactions Affecting Absorption of Drugs: Altered absorption after oral
administration is very common. The interaction may result in a change in the rate of
absorption (an increase or a decrease), a change in the amount of drug absorbed (an
increase or a decrease) or both. Several mechanisms may be involved in the alteration of
drug absorption from the GIT. In general, drugs that are not absorbed completely/rapidly
are more susceptible to changes in GI absorption. A decrease in the rate of absorption is
clinically significant in acute conditions such as pain where the drug is administered in a
single dose but is of little importance for drugs used in chronic therapy.
An alteration in Parenteral drug absorption is rare but can occur when an adrenergic agent
such as adrenaline or a cholinergic drug such as methacholine is extravasularly injected
concomitantly with another drug. These agents alter the systemic absorption of the latter
due to vasoconstriction or vasodilatation.
Example:
1. Complexation and Adsorption

Tetracycline, Antacids, food and mineral Formation of poorly

Fluoroquinolones like supplements containing Al. soluble and unabsorbable
ciprofloxacin, penicillamine Mg. Fe, Zn, Bi and Ca ions complex with such heavy
metal ions
Cephalexin, Reduced absorption due
sulfamethoxazole, adsorption and binding
Cholestyramine
trimethoprim warfarin and
thyroxine

18
2. Alteration of GI PH

Sulphonamides, aspirin Antacids Enhanced dissolution and

absorption rate

Ferrous sulphate Sodium bicarbonate, Decreased dissolution and

calcium carbonate hence absorption

Ketoconazole, tetracycline, Antacids Decreased dissolution and

atenolol bioavailability
3. Alteration of Gut Motility
Aspirin, diazepam, levodopa, Metoclopramide Rapid gastric emptying;
lithium carbonate, increased rate of absorption
paracetamol, mexiletine

Levodopa, lithium Anticholinergic (atropine) Delayed gastric emptying;

carbonate, mexiletine decreased rate of
absorption

4. Explain the influence drug interaction on drug metabolism with respect to enzyme
induction and enzyme inhibition.
 Induction of drug metabolism can lead to unexpected drops in drug concentration
or the build-up of metabolites. The reverse can occur when there is inhibition of
drug metabolism.
 The major organ involved in metabolism is liver and the major enzyme system
involved in drug metabolism is CYP 450, the well-known family of oxidative
hemo-proteins. Induction CYP 450 enzymes at the liver is responsible for
induction of metabolism of many drugs.

Induction

 The phenomenon of increased drug metabolizing ability of the enzymes by

several drugs and chemicals is called as enzyme induction.
 A number of drugs can cause an increase in liver enzyme activity over time. This
in turn can increase the metabolic rate of the same or other drugs. Phenobarbitone
will induce the metabolism of itself, phenytoin, warfarin, etc.

19
Hormone induced CYP 450 expression:

• Hormones induce induction of certain drugs like tamoxifen, tacrine, acetaminophen and
xenobiotics like dietary phytochemicals and carcinogens like aromatic amines produced
in cooking and those found in cigarette smoke.

Molecular mechanism:

o In the case of CYP1 family, this type of induction is mediated by specific aryl
hydrocarbon (Ah) receptor. The best known example is induction of CYP 450 enzymes
of polycyclic aromatic hydrocarbons, which combine with specific receptor, resulting an
inducer-receptor complex.
o This complex is trans-located to the nucleus of the hepatocytes where induction-specific
mRNA is transcribed from the DNA. In the nucleus, the trans-located Ah receptor forms
a heterodimer (with a second nucleic protein), which will bind to a common response
element known as xenobiotic responsive element, that functions as a transcriptional
enhancer, resulting in stimulation of gene transcription.
o Large amounts of newly translated, specific CYP 450 are then incorporated into the
membrane of hepatic endoplasmic resulting in induction of drugs and xenobiotics.

Most Enzyme Inducers have following properties:

 They are lipophilic compounds.

 They are substrate for the induced enzyme system.

 They have long elimination half lives.

Mechanisms involved in enzyme induction are:

- Increase in both liver size and liver blood flow.

- Increase in both total and microsomal protein content.

- Increase in stability of enzymes.

- Increase in synthesis of cytochrome P-450.

- Proliferation of smooth endoplasmic reticulum.

20
Consequences of enzyme induction include:

• Decrease in pharmacological activity of drugs.

• Increase in activity where the metabolites are active.

• Altered physiological status due to enhanced metabolism of endogenous compounds such

as sex hormones.

Inhibition

 The phenomenon of decreased drug metabolizing ability of the enzymes by several drugs
and chemicals is called as enzyme inhibition.

The process of inhibition may be of two types:

[1] Direct Inhibition

[2] Indirect Inhibition

Direct Inhibition; - It may result from the interaction of enzyme site, the outcome being a change
in enzyme activity. Direct inhibition can occur by one of the three mechanisms:

 Competitive inhibition: This occurs when ‘normal’ substrate and the inhibitor substrate
share the structural similarities. Many enzymes have multiple drug substrates that can
compete with each other.

Eg: Methacholine inhibits metabolism of Ach by competing with it for cholinesterase.

 Non-competitive inhibition: It arises when structurally un-related agent reacts with the
enzyme and prevents the metabolism of drugs. Since the interaction is not structurally
specific, metals like Lead, Mercury, Arsenic and Organophosphorous insecticide inhibits
the enzymes non-competitively.
Eg: Isoniazid inhibits the metabolism of Phenytoin by the same enzymes.
 Product Inhibition: This occurs when metabolic product generated by the enzyme inhibits
the reaction on the substrate (feedback inhibition). This usually occurs when the product
has physical characteristics very similar to that of substrate.
Eg: Xanthine Oxidase inhibitors (Allopurinol) and MAO inhibitors (Phenelzine) also
inhibit the enzyme activity directly.

21
Indirect Inhibition;- It is brought about by one of the two mechanisms:

 Repression: is defined as the decrease in enzyme content. It may be due to fall in the rate
of enzyme synthesis as affected by ethionine, puromycin and actinomycin-D or because
of rise in the rate of enzyme degradation such as by Carbon tetrachloride, Carbon
disulphide, Disulphiram etc.
 Altered Physiology: due to nutritional deficiency or hormonal imbalance.
Enzyme inhibition is more important clinically than enzyme induction, especially for
drugs with narrow therapeutic index.
Eg: anticoagulants, antiepileptics, hypoglycemics, since it results in prolonged
pharmacological action with increased possibility of precipitation of toxic effects.

5. Explain the effect of inhibition of biliary excretion of drugs and list out the drug
interactions which influence the biliary excretion?
Inhibition of Biliary Excretion
Drug interactions in biliary excretion:
 Drugs or often conjugated and excreted in bile. Some drugs are excreted in bile
biotransformation.
Eg: In humans most water soluble drugs and metabolites of relatively high molecular
weight (more than 450) are excreted largely in the bile.
 This excretion is mainly via transporters and possibility exists for drug interaction with
concomitant administration.
 Conjugates such as glucoronides are often excreted in bile and deconjugated in the
intestinal tract and reabsorbed enterohepatic circulation.
 Drug interaction in the process of biliary excretion may affect the residence time and
AUC of unchanged drug plasma.

Hepatobiliary Drug Interaction:

Transporter Drug Inhibitor Result of interaction

P-gp Digoxin Quinidine Decreased in biliary excretion
MR1*2 SN-38 Probenecid Decreased in biliary excretion
Results in increased AUC

22
 • The co-administration of drugs which inhibits the co-transporter involved in biliary
excretion can reduce the biliary excretion of drug which is substrates of the transporter,
leading to elevated plasma drug concentration.

Eg: Biliary and urinary of digoxin, both mediated by p-gp are inhibited by Quinidine
which is an inhibitor of p-gp.

Effect on biliary excretion:

 Verapamil and cyclosporine are both inhibitors of p-gp, but through different
mechanism, verapamil is a substrate for p-gp and is a competitive inhibitor of this pump,
where as cyclosporine inhibit transport function by interfering with substrate recognition
and ATP hydrolysis.

 Decrease clearance of drug through inhibition of p-gp translates clinically in to increase

AUC and increased in toxicity.

 Examples:

o Decreased in vincristine clearance in presence of verapamil. Decreased in

palcitaxel or etoposide clearance in presence of chromophore.

o Decrease in etoposide or doxorubicin clearance in presence of cyclosporine

23
 THERAPEUTIC DRUG MONIROING

➢ TDM is a practice applied to a small group of drugs which possess a direct relationship
between the plasma concentration and response as well as a narrow therapeutic window
and are effective and safe.
➢ TDM can also be defined as a process of assessing concentration of the drug in biological
fluids (i.e., blood or plasma or serum) such that it is maintained with the therapeutic
range.

NECESSITY OF TDM:

Which drugs required monitoring?

1. Pharmacokinetic variability e.g. Aspirin, Digoxin

2. Concentration related therapeutic and adverse effects e.g. Phenytoin
3. Narrow therapeutic index e.g. digoxin
4. Effect difficulty to monitor.
5. Inter individual variations in metabolism.
6. Saturation kinetics e.g. omeprazole
7. Difficult to recognize toxicity clinically e.g. cyclosporine
8. Hepatic and renal diseases e.g. aminoglycosides
9. Multiple drug therapy and drug interaction.
10. Doubtful patient’s compliance.

NOT NECESSITY OF TDM:

• Broad range of doses.

• Direct measurement of response.
• No correlation between plasma concentration and clinical response.
• Expensive procedure.

24
OBJECTIVES OF TDM:

TDM can be applied for;

1. Obtaining maximum beneficial outcome of drug therapy by approximate dosing of drugs.

2. Attaining the required therapeutic concentration of the drug within least time.
3. Maintain the concentration of the drug within the therapeutic range such that no toxic
effects are produced.
4. Regulation of the drug therapy by monitoring the concentration of drug in plasma and its
pharmacological response.
5. Providing medical advantage by reducing the chances of drug toxicity.
6. Providing economic convenience to patients by shortening their stay in the hospital.
7. Monitoring of factors like disease state, patients characteristics (i.e., age, sex,
physiology), drug interactions etc., in order to reduce variability between individuals.
8. Recognizing a substance or drug whose presence may lead to medical crisis.
9. Adjusting dose of drug in patients having pre-existing hepatic or renal impairment and
thus preventing the accumulation of drugs in the body which may lead to toxicity.
10. Empirical methods require longer time for adjustment of dose as they depend on the half-
life, of the drug. TDM provides a rapid means for dose titration and hence reduces the
time required for the adjustment of dose.
PROCESS OF TDM:

Decision to request drug level

Biological sample

The request

Laboratory measurement

Result communication by laboratory

Clinical interpretation

Therapeutic management

25
1. Decision to request drug level:
Decision will be based on proper reasons:
• Suspected toxicity
• Lack of response/compliance.
• To assess therapy following change in dosage.
• Change in clinical state of patient.
• Potential drug interactions due to concomitant medications.
2. The biological sample:
➢ After decision is made, biological sample is collected for to provide measurement.
➢ Serum or plasma samples are usually collected for TDM.
➢ Serum separator tubes should be avoided as lipophilic drugs can dissolve in gel
barrier.
➢ Blood sample should be collected once the drug concentration have attained
steady state (SS).
➢ Levels approximating SS may be reached earlier if a loading dose has been
administered.
• However, drugs with long half-lives should be monitored before SS is
achieved to ensure that individuals with impaired metabolism or renal
excretion are not in the risk of developing toxicity at the initial dosage
prescribed.
• If toxicity is suspected the concentration should be measured as soon as
possible.
• Blood samples should be collected in elimination phase rather than
absorption/distribution phase
• Usually blood samples are collected at the end of the dosage interval.
• For antibiotics given intravenously, peak concentrations are also
measured.
• Usually drug concentrations are monitored in venous blood, serum, or
plasma and it is important that the appropriate matrix is assayed.

26
3. The Request:
Following details must be effectively communicated to members of TDM team with a
drug assay request:
- Timing of sample.
- Dosage regimen
- Patient demographics (age, sex, ethnicity etc.)
- Co-medications, if any – Indication for monitoring.
- PK & therapeutic range of drug.

When a drug which is commonly measured for TDM is suspected of causing toxicity, it is
very important for requesting clinicians to clearly communicate the expectation of a high
concentration and need for a rapid feedback of results.

4. Laboratory measurement:
➢ A quality drug assay should be performed within a clinically useful time frame.
➢ The assay procedure should be validated one.
➢ Wherever possible assay procedure should be evaluated with an external quality
assurance program.
➢ Senior laboratory staff should verify the assay results in light of clinical request.
➢ Ideally the results of the assay should be available to the clinician before the next
dose is given.

The analytical methodology employed should ideally:

- Distinguish between compounds of similar structure- unchanged drug ad

metabolites.
- Detect small amounts.
- Be simple enough to use as a routine assay.
- Be unaffected by other drugs administered simultaneously.

Various analytical techniques available are

- Spectrophotometry and Fluorimetry,

- TLC
- HPLC & GLC
27
 - Radio Immunoassay
- Enzyme Immunoassay
- Fluorescence polarization Immunoassay (FPIA)
5. Result communication by Laboratory:
• The assay results should be c communicated as quickly as possible once it is
verified by the senior laboratory personnel.
• The drug concentrations measured are generally reported in mass or molar units.
• To relate concentration back to dose, mass units are preferable.
• The result should clearly state the therapeutic concentration range for the drug
assayed.
6. Clinical Interpretation:
✓ Clinical interpretation can ‘add value’ and convert ‘therapeutic measurement
service’ into ‘therapeutic drug monitoring service’.
✓ Just relating a drug concentration to a published therapeutic range is not an
adequate interpretation.
✓ Concentration must always be interpreted in the light of clinical response,
individual patient demographics and dosage regimen used.
✓ Therapeutic ranges are available but should only be used as a guide.
7. Therapeutic management:
▪ The clinician caring for a patient will modify a drug dosage regimen in light of all
available information.
▪ Physicians usually accept and implement recommendations of TDM team.
▪ Hence, remember of the TDM team with appropriate clinical expertise should be
available to conduct a successful TDM.

INDICATIONS OF TDM:

❖ Drugs for which relationship between dose and plasma concentration is unpredictable e.x
phenytoin.
❖ Drugs which narrow therapeutic window: - will allow dosage alterations to produce
optimal therapeutic effect or to avoid toxic effect ex., Lithium, phenytoin, and digoxin.
❖ Drugs with steep dose response curve ex., theophylline.

28
 ❖ Drugs for which there is difficulty in measuring or interpreting the clinical evidence of
therapeutic or toxic effects.
❖ Drugs with saturable metabolism ex. phenytoin.
❖ Drugs with poorly defined end point or difficult to clinically predict the response e.x.,
immunosuppressant drugs.
❖ Renal disease: alter the relationship between dose & the plasma concentration. Important
in case of digoxin, lithium, & aminoglycosides antibiotics.
❖ Drug interactions: When another drug alters the relationship between dose & plasma
concentration
❖ Drug with large individual variability at SS PDC in any given dose.
❖ For diagnosis of suspected toxicity & determining drug abuse.
❖ To evaluate compliance of patient.
❖ Guiding withdrawal of therapy: Ant epileptic’s, Cyclosporine.

ADVANTAGES OF TDM:

▪ Side effect monitoring

▪ Short hospital stay
▪ Better disease control
▪ Dose adjustment
▪ Doses guideline
▪ Individualized dose requirement

LIMITATIONS FOR TDM PROCESS

- Scientific accuracy of the drug assays

- Laboratory variability in reporting
- Limited accessibility and infrastructure
- Facilities in rural areas
- Validity of suggested target areas
- Cost involved

29
TDM PROCESS OF CARBAMAZEPINE:

Pharmacokinetic parameters and TDM information:

i. Elimination half-life (t1/2): clearance and plasma half-life of carbamazepine are changed
by co-administration with other anti-epileptic drugs.
25-40hr (single dose in normal)
15-25hr (chronic monotherapy)
6-14hr (chronic polytherapy)
2.5-15hr (children)
8-37hr (neonates)
ii. Total body clearance (TBC) (ml/kg/hr):
25± 5 (single dose in normal)
25± 16 (chronic monotherapy)
108±39 (chronic polytherapy)
iii. Volume of distribution: 1-2L/kg
iv. Plasma protein binding: 40-90%
v. Therapeutic range: 21-28day
vi. Time to steady state concentration: 21-28day
vii. Maintenance dose: at twice-a-day therapy
• 7-15mg/kg/day for adults
• 11-40mg/kg children <15yrs
viii. Percent removed by dialysis: <20%
ix. Available dosage forms:
Dosage form Tablets Tablets (chewable) Suspension

100,200mg 100mg 100mg/5ml

Bioavailability >75%

4-8hrs or more
Tmax IV dosage forms are not
1-3hrs available for human use

30
 x. Factors affecting plasma levels:
Factors Effect(s)

Food Decreased levels for suspension

Neogastric findings
Drug
Phenytoin Decreased levels for suspension
Phenobarbital Decreased plasma level
Primidone Decreased plasma level

TDM PROCESS OF CYCLOSPORIN:

Pharmacokinetic parameters and TDM information

i. Elimination Half-life’s 1/2’: 5.6 ± 2 hours

ii. Total Body Clearance ‘TBC’: 5.3 ± 1.5ml/min/hr
iii. Volume of Distribution ‘V’: 1.3L/kg (mean value)
iv. Erythrocyte Binding: 50-60%
v. Leucocyte Binding: 10-20%
vi. Plasma Protein Binding: 10-15%
vii. Unbound Fraction: 4.3-20%
viii. Dosing; 15mg/kg once daily dose. This dose is initiated 4 to 24 hours prior to
transplantation and is continued for 1-2 weeks, patients who don’t tolerate
cyclosporine orally or when it is important to rapidly attain therapeutic
concentrations.
ix. Sampling for TDM: cyclosporine pharmacokinetic exhibit diumal variation, therefore
blood samples should be obtained at approximately the same time of day.

After the drug has reached steady state, trough concentrations yield the most useful
information for routine TDM. Several blood samples between two or six hours after oral
dosing can be obtained to minimize inter and intra patient variability due to bioavailability.
Cyclosporine levels should be monitored two to three times a weeks during the first few

31
 weeks to months of therapy, and less often later in the post-transplant period. More frequent
monitoring is required if the patient has clinical problems that can change cyclosporine
pharmacokinetics (liver dysfunction, diarrhea, drugs etc).

x. Elimination: mainly through the bile to the faeces. Renal elimination ‹1%.
xi. Available Dosage Forms

Dosage form Soft gelatin Soft gelatin Oral emulsion Parenteral

capsules capsules It must be concentrate for
(liquid-filled) (liquid-filled, or diluted with IV injection
emulsion) plain or 50mg/ml
25, 50,100mg 25, 100mg chocolate milk,
orange juice 25,
100mg
Bioavailability 20-50% 20-30%
Greater than
capsules
Tmax 2-6 hours

xii. Factors Affecting Plasma Levels

Factor Effect(s)
Food • High fat meals may increase plasma levels while low fat meals
may decrease plasma concentrations.
• Grape fruit increases cyclosporine levels due to inhibition of
the pre systemic metabolism in the intestinal mucosa leading to
increased bioavailability after oral administration by 20-200%.

Age • Plasma levels in children below 10 years may be decreased

because they have a larger volume of distribution and faster
body clearance.

32
Drugs
1) Anticonvulsants Decrease cyclosporine level
Carbamazepine
Phenobarbital
Phenytoin
Nafcillin
Octerotide
Ticlopidine
Rifampin
Sulphonamides and trimethoprim

2) Physiologic Disorders Increased fraction of

Fever unbound drug
Diabetes mellitus

TDM PROCESS OF DIGOXIN

Elimination half life (hr): 36 hr(adults)

18 – 37 hr (children)

Total Body Clearance (ml/kg/hr): 2.7

Volume of Distribution: This value is for normal renal function. In CHF and renal failure it is
decreased ‘V’

6 – 7 L/kg (total body weight)

Plasma Protein Binding: 20-30%

Therapeutic Range: 0.9-2mg/ml for a-fib (0.5-1.2 for CHF)

Time to Steady State: Samples for TDM should be collected at least 6 hours and preferably 12
hours from the last dose concentration 6-10 days

33
Loading dose: The dose is reduced to half when creatinine clearance <20ml/min. Loading dose
for infants and children with CHF as the following [20mg/kg (premature infant), 30mg/kg (full
term neonate <2 months), 40-50 mg/kg (infant <2 years old) and 30-40mg/kg (children >2 years
old)]. Two 0.5mg oral tablet doses or two 0.375mg IV doses, separated by 6 hours (patients with
creatinine clearance >20ml/min) 0.2mg/day (creatinine clearance >20ml/min)

Maintenance Dose: May be started without a loading dose 0.125mg/day (creatinine clearance
>20ml/min or body weight <40kg)

Clinically Important Metabolite: Bis and mono-digitoxosides, as cardio active as digoxin

Digoxin Toxicity: Toxic doses of digoxin may result in hypokalemia which may lead to various
consequences like arrhythmias etc. Hence, digoxin in some cases is administered along with a
potassium sparing diuretic or in some cases the digoxin toxicity can be treated with an
Intravenous infusion of potassium chloride.

Available Dosage Form

Dosage form Tablets Capsules Elixir Parenteral

(Conventional) (Lanoxicaps) Injection
125, 250, 500 µg 50, 100, 200 µg 50 µg/ml 100, 250 µg/ml
Bioavailability 60-80% 90-100% 60-80% 100% after IV
administration
Tmax There is a significant distribution phase after administration, even after IV
administration. Therefore there is a time lag before maximum effect.

Factors Affecting Plasma Levels

Factor Effect(s)
Age TBC and V are small in new borns and increase with
age up to 5 years; then decrease gradually until puberty.
Obesity May affect plasma concentrations are the dose based on
the weight and the drug does not distribute to fat

34
Physical exercise ↓ Plasma level and drug concentration in skeletal
muscle
Administration with a high fiber meal ↓ Plasma level of tablets because it decreases their
bioavailability
Malabsorption ↓ Plasma level of drug because it decreases
bioavailability
Hypoalbuminemia ↑ Plasma level of free drug due to plasma protein
binding
Chronic renal failure ↑ Plasma level (it is a potential effect)
Drugs ↓ Plasma level due to decreased absorption
↓ Plasma level due to enhancing absorption (40%
Antacid increase in bioavailability) by decreasing the intestinal
Oral Antibiotics (only tetracycline and bacterial flora that metabolize digoxin
erythromycin have been tested) ↓ Plasma level due to decreased absorption by
Cholestyramine or Colestipol complexation (20-35% decrease in bioavailability)
Kaolin-pectin ↓ Plasma level due to decreased absorption (60%
decrease in bioavailability)
Neomycin ↓ Plasma level due to decreased absorption
Sulfasalazine ↓ Plasma level due to decreased absorption
Amiodarone ↑ Plasma level by 70% due to decreased renal and non
renal elimination
Propantheline ↑ Plasma level specially with tablets due to increased
GI absorption
Metoclopramide ↓ Plasma level specially slow-release tablets due to
decrease in drug transit time (40% decrease in
bioavailability)
Disease state Enhanced cardiac effects and toxicity (replace
Hypokalemia potassium)
Hypomagnesemia Enhanced toxicity, perhaps due to decreased
intracellular Potassium (replace potassium)

35
Coronary artery disease or old Enhanced toxicity (decreasing the dose may be helpful)
myocardial infarction
Atrial fibrillation Possible decreased sensitivity to digoxin
Cor pulmonale Possible enhanced toxicity
Hyperthyroidism Decreased sensitivity to digoxin (decreasing the dose is
not helpful and toxicity may be difficult to be avoided)
Hypothyroidism Increased sensitivity to digoxin (decreasing the dose is
helpful and also monitor toxicity)

TDM PROCESS OF PHENYTOIN

CLINICAL USE:

• Widely used alone and in combination with other Anticonvulsants

• All forms of epilepsy except absence seizures.
• Fosphenytoin, a Phenytoin, pro drug for IV use in status Epilepticus.
• Used to treat trigeminal neuralgia if carbamazepine is inappropriate.

USUAL DOSE AND DOSE INTERVAL:

• One hundred fifty to 300 milligrams per day initially, adjust according to response and
plasma concentration, usual dose 200-300 mg daily.
• Child initially 5mg/kg in 2 divided dose to a maximum of 8 mg/kg.
• Fosphenytoin is equivalent to phenytoin in a weight ratio of 3.2. doses are stated in
phenytoin equivalents (PE).(eg,1.5 mg Fosphenytoin=1.0mg PE)
• Fosphenytoin (status Epilepticus) 20 mg (PE)/Kg initially, then 50-100mg(PE)/minute:
maintenance 4-5mg(PE)/Kg daily in 1 or 2 divided doses with trough plasma
concentration monitoring. Consult local guidelines for children.

36
FACTORS AFFECTING CONCENTRATION:

• Metabolized by CYP2C9 [90%] and 2C19 [10%] limited capacity.

• Saturation kinetics (non linear or zero order kinetics)-i.e. small changes in dose may
lead to disproportionate changes in plasma phenytoin concentrations.
• Individuals vary as to when their kinetics become non linear
• Valproate displaces protein-bound phenytoin
• Variable and slow absorption rate
• Unbound (i.e. free phenytoin concentrations) affected by some drugs or changes in
availability of albumin for binding.
• Pregnancy increases clearance.
• Induces metabolism of some other ant epileptic’s and many other drugs.
• CYPC28

TOXIC EFFECTS

• Poor side effects profile limit use

• Neurotoxicity(nystagmus, dysarthria, diploplia, ataxia)
• Chronic side effects may cause disabling or disfiguring (eg. ataxia or gingival
hyperplasia, acne and hisutism
• Rare severe reactions(eg.megaloblastic anemia)
• Paradoxical seizures if dose too high.

MONITORING THERAPY

• Essential to monitor therapy to enable informed and safe dosage changes

• There is no dose effect relationship
• Saliva concentrations reflect plasma concentrations
• Free plasma concentrations best reflect effect
• Dose changes should be made judiciously
• Be aware of drug interactions

37
KEY PHARMACOKINETIC PARMETERS

Optimum sampling time In steady state this is not too important as the effective half-life
is long, a trough sample if on short term fosphenytoin.
Time to peak 3-2h(formulation dependent)

Route of elimination Hepatic metabolism(>95%)

Apparent elimination half-life 6-24 hr(up to 60h if metabolism saturated)

Time to steady state 2-6 days of chronic dosing

Protein binding ~92%

Target range Total phenytoin:5-20mg/L (20-80µmol/L)

Free phenytoin:0.5-2.0mg/L(2-8µmol/L)
VMAX :100-1000mg/d
KM : 1-15mg/L(4-60µmol/L))

TDM PROCESS OF LITHIUM

Therapeutic range: 0.6-1.2 mmol/L NB at plateau (pre-dose) and avoid Li-heparin tubes.

Toxicity: signs as a guide - TR: fine tremor especially at dosing peak.

- Moderate intoxication (1.5-3): coarse tremor, ataxia and

diarrhea.
- Severe intoxication (›3): confusion and fits.

PK problems: complete absorption- SR formulations to reduce peak levels.

›95% excreted by the kidney- initial t1/212h

But terminal t1/2much longer 70-80% reabsorbed in PCT with no distal

Reabsorption (unlike Na)

38
 PCT retention (hence toxicity risk) is increased by

1. Reduced exchangeable Na from any cause

2. Loop or thiazide diuretics
3. NSAIDs or ACEIs

Special problems: Pregnancy- dose requirements increase due to increased renal clearance. Li is
also teratogenic and excreted in breast milk.

Severe intoxication: usually requires dialysis but because of slow clearance

from some compartments rebound raises in Li levels may necessitate repeated HD.

EFFECT OF ELIMINATION HALF-LIFE ON DURATION OF ACTIVITY

Because elimination of drugs is due to the processes of excretion and metabolism, an alteration
of any of these elimination processes will affect the t1/2 of the drug. In certain disease states,
pathophysiologic changes in hepatic or renal function will decrease the elimination of a drug, as
observed by a prolonged t1/2. This prolonged t1/2 will lead to retention of the drug in the body,
thereby increasing the duration of activity of the drug (teff) as well as increasing the possibility
of drug toxicity.

To improve antibiotic therapy with the penicillin and cephalosporin antibiotics, clinicians have
intentionally prolonged the elimination of these drugs by giving a second drug, probenecid,
which competitively inhibits renal excretion of the antibiotic. Similarly, Augmentin is a
combination of amoxicillin and clavulanic acid; the latter is an inhibitor of b-lactamase. This b-
lactamase is a bacterial enzyme that degrades penicillin-like drugs. For all doses, a 100%
increase in the t1/2 will result in a 100% increase in the teff. For example, for a drug whose t1/2 is

0.75 hour and that is given at a dose of 2 mg/kg, the teff is 3.24 hours. If the t1/2 is increased to

1.5 hours, the teff is increased to 6.48 hours, an increase of 100%.

39
However, the effect of doubling the dose from 2 to 4 mg/kg (no change in elimination processes)
will only increase the teff to 3.98 hours, an increase of 22.8%. The effect of prolonging the elimi-
nation half-life has an extremely important effect on the treatment of infections, particularly in
patients with high metabolism, or clearance, of the antibiotic. Therefore, antibiotics must be
dosed with full consideration of the effect of alteration of the t1/2 on the teff. Consequently, a
simple proportional increase in dose will leave the patient’s blood concentration below the
effective antibiotic level most of the time during drug therapy. The effect of a prolonged teff is
shown in lines a and c and the disproportionate increase in teff as the dose is increased tenfold is
shown in lines a and b.

40
Emax model:

Receptor occupancy theory forms the basis of pharmacodynamic response evaluation and is
routinely employed to describe concentration–effect/exposure-response relationship in drug
discovery and development. The origins of the fundamental PD models can be derived using the
receptor occupancy theory. The theory and derivation are described in detail as follows.
In general, as the drug is administered, one or more drug molecules may interact with a receptor
to form a complex that in turn elicits a pharmacodynamic response.

R+C↔RC

The rate of change of the drug–receptor (RC) complex is given by the following equation:

𝑑[𝑅𝐶]
=kon .(RT-RC) . C-koff . RC
𝐷𝑇

Where RT is the maximum receptor density, C is the concentration of the drug at the site of
action, kon is the second-order association rate constant, and koff is the first-order dissociation
rate constant. The term (RT - RC) represents the free receptors, R, available as the total number of
receptors, or the maximum receptor density can be written as RT = R + RC. Under equilibrium
𝑑[𝑅𝐶]
conditions, that is, when =0, the above equation becomes:
𝑑𝑡

kon . (RT-RC) . C=koff . RC

Upon further rearrangement we get

kon . RT . C= RC . (kon . C+ koff)
𝑘𝑜𝑛 . 𝑅𝑇 .𝐶
RC=
𝑘𝑜𝑓𝑓 +𝑘𝑜𝑛 .𝐶

𝑇𝑅 .𝐶
RC= 𝑘𝑜𝑓𝑓
+𝐶
𝑘𝑜𝑛

𝑅𝑇 .𝐶
RC=
𝐾𝐷 +𝐶

41
 𝑘𝑜𝑓𝑓
Where KD is the equilibrium dissociation constant ( ). Under the assumption that the
𝑘𝑜𝑛

magnitude of effect, E, is proportional to the [RC] complex, the fraction of maximum possible
𝐸
effect, Emax, is equal to the fractional occupancy, fb= , of the receptor, which can be
𝐸𝑚𝑎𝑥

described as

𝐸 [𝑅𝐶]
𝑓𝑏 = =
𝐸𝑚𝑎𝑥 𝑅𝑇

Hence,
𝑅𝑇 .𝐶
𝐾𝐷 +𝐶
E=Emax.
𝑅𝑇

𝐸𝑚𝑎𝑥 .𝐶
E=
𝑘𝐷 +𝐶

Here, KD has the units of concentration and represents the concentration at which 50% of Emax is
achieved. On substituting KD= EC50 yields the classical Emax concentration–effect relationship as
below:

𝐸𝑚𝑎𝑥 .𝐶
E=
𝐸𝐶50 +𝐶

Emax refers to the maximum possible effect that can be produced by a drug and EC50 is the
sensitivity parameter or the potency parameter representing the drug concentration producing
50% of Emax. As the fundamental PK parameters of a drug are clearance (Cl) and volume of
distribution (VD), Emax and EC50 are the fundamental PD parameters for a drug, and hence they
define the pharmacodynamic properties of the drug. From the above equation, it can be inferred
that the typical effect–concentration relationship is curvilinear with parameters as Emax= 100 and
EC50=50µg/ml.

42
HILL EQUATION or SIGMOIDAL Emax MODEL:

The Hill equation or the sigmoidal Emax model contains an additional parameter, typically
represented as ᵞ and called as the Hill coefficient. The sigmoidal Emax model is shown in
equation below:

𝐸𝑚𝑎𝑥. 𝐶 𝛾
𝐸= 𝛾
𝐸𝐶50 + 𝐶 𝛾

The Hill coefficient, ᵞ (or the slope term), describes the steepness of the effect–concentration
relationship.

Some researchers also describe ᵞ as the number of drug molecules binding to a receptor. When
more drug molecules bind (typically ᵞ > 5), the effect–concentration relationship is very steep.
The graph shows the sigmoidal Emax model for different Hill coefficient values. As seen from
the graph, values of ᵞ less than or equal to unity have broader slopes, and as ᵞ increases, the
steepness of the relationship increases with values of ᵞ > 4 signifying an all-or-none response.
The utility of the Hill coefficient in model building is usually considered as an empirical device
to provide improved model fit for the data. However, the value of Hill coefficient potentially is
from its real application in terms of treatment adherence. For example, if a drug has a steep
concentration–effect relationship, then missing a dose can have greater impact on the response
for a subject as compared to a drug for which the Hill coefficient is around unity.

43
Relationship between dose and pharmacological effect of a drug

The onset, intensity and duration of the pharmacological effect depend on dose and the
pharmacokinetics of the drug as the dose increases the drug concentration at the receptor site
increases and the pharmacological response (effect) increases up to a maximum effect.

A plot of the pharmacological effect to a dose on a linear scale generally results in a hyperbolic
curve with the maximum effect at the plateau.

The same data may be compressed and plotted on a log linear scale and will result in a sigmoid
curve

44
For a drug that follows one-compartment pharmacokinetics, the volume of distribution is
constant; therefore, the pharmacological response is also proportional to the log plasma drug
concentration within a therapeutic range.

Mathematically, the relationship in graph may be expressed by the following equation, where m
is the slope, e is an extrapolated intercept, and E is the drug effect at drug concentration C:

E = m log C + e ….(1)
Solving for log C yields

Log C = E –e / m ….(2)
However, after an intravenous dose, the concentration of a drug in the body in a one-
compartment open model is described as follows:

Log C = log Co – kt /2.3 ….. (3)

45
By substituting Equation 2 into Equation 3, we get Equation 4, where Eo = effect at
concentration Co:

E-e/m = Eo-e/m – kt/2.3 ….(4)

E = Eo – kmt/2.3
The theoretical pharmacologic response at any time after an intravenous dose of a drug may be
calculated using Equation 4. Equation 4 predicts that the pharmacologic effect will decline
linearly with time for a drug that follows a one-compartment model, with a linear log dose–
pharmacologic response. From this equation, the pharmacologic effect declines with a slope of
km/2.3. The decrease in pharmacologic effect is affected by both the elimination constant k and
the slope m. For a drug with a large m, the pharmacologic response declines rapidly and multiple
doses must be given at short intervals to maintain the pharmacologic effect.

Protocol for the TDM of a drug

o Title of the study/project

o Investigators: 1. Chief Investigator

2. Joint Investigators

3. Co- Investigators (a) clinical

(b) Research fellow

o Phase of study
o Patient recruitment place
o Need for TDM study
o Objectives for study
o Criteria for selection of patients
o Patient History
o Withdrawal of blood sample and storage
o Instrument for (a) Measurement of Drug levels
(b) Measurement of clinical parameters like EEG, ECG, Respiration etc...
o Report preparation
o Clinical Interpretation

46
RELATIONSHIP BETWEEN DOSE AND DURATION OF ACTIVITY (teff), SINGLE
IV BOLUS INJECTION

The relationship between the duration of the pharmacologic effect and the dose can be
inferred from Equation 21.3. After an intravenous dose, assuming a one-compartment model,
the time needed for any drug to decline to a concentration C is given by the following
equation, assuming the drug takes effect immediately:
2.3(𝑙𝑜𝑔𝐶0−𝑙𝑜𝑔𝐶)
t= 𝑘

Using Ceff to represent the minimum effective drug concentration, the duration of drug
action can be obtained as follows:

Some practical applications are suggested by this equation. For example, a doubling of the
dose will not result in a doubling of the effective duration of pharmacologic action. On the
other hand, a doubling of t1/2 or a corresponding decrease in k will result in a proportional
increase in duration of action. A clinical situation is often encountered in the treatment of
infections in which Ceff is the bactericidal concentration of the drug, and, in order to double
the duration of the antibiotic, a considerably greater increase than simply doubling the dose is
necessary.
ROLE OF PHARMACIST IN TDM
• Evaluating and adjusting dosage for patients on hemodialysis.
• Managing acute drug intoxication.
• Involving in research activities like determining possible drug interaction, estimation of
cost benefit ratio.
• Depending upon the TDM results and patient’s response, revision and adjustment of
dosage regimen should be done.
• Assessing various other possible reasons for unexpected results like patients non-
compliance medication or laboratory errors, drug interactions, pharmacogenetic
variations etc.

47
SHORT ANSWERS:

1. Enlist various types of samples used for analysis in TDM?

➢ Plasma or serum is commonly used for drug assays.
➢ Whole blood: - for cyclosporine, tacrolimus, sirolimus, as there are large shifts of
drug between red cells and plasma with storage and temperature change.
➢ Saliva, which gives a measure of the unbound drug concentration, may be a
useful alternative when blood samples are difficult to collect.
Ex: Phenytoin, Lithium, Amitryptyline

2. What do you understand by drug tolerance and physical dependency?

Drug tolerance is a pharmacological concept describing subjects' reduced reaction to a
drug following its repeated use. Increasing its dosage may re-amplify the drug's effects;
however this may accelerate tolerance, further reducing the drug's effects. Drug tolerance
is indicative of drug use but is not necessarily associated with drug
dependence or addiction
Physical dependence is a physical condition caused by chronic use of
a tolerance forming drug, in which abrupt or gradual drug withdrawal causes unpleasant
physical symptoms. Physical dependence can develop from low-dose therapeutic use of
certain medications such as benzodiazepines, opioids, and antidepressants, as well as
the recreational misuse of drugs such as alcohol, opioids, and benzodiazepines

3. Define narrow therapeutic index with suitable example?

Narrow therapeutic index drugs are drugs where small differences in dose or blood
concentration may lead to serious therapeutic failures and/or adverse drug reactions that
are life-threatening or result in persistent or significant disability or incapacity
Ex: carbamazepine, phenytoin, digoxin, cyclosporine etc.

4. Define TDM. Name any 4 drugs that require TDM?

✓ TDM is a practice applied to a small group of drugs which possess a direct
relationship between the plasma concentration and response as well as a narrow
therapeutic window and are effective and safe.

48
 ✓ TDM can also be defined as a process of assessing concentration of the drug in
biological fluids (i.e., blood or plasma or serum) such that it is maintained with
the therapeutic range.
✓ immunosuppressant’s : cyclosporine
✓ cardiac drug :digoxin
✓ psychiatric drugs: lithium
✓ Antiepileptic drugs: carbamazepine
✓ Antibiotic drugs : gentamicine
5. Write the protocol for the TDM of a drug?
o Title of the study/project
o Investigators: 1. Chief Investigator

2. Joint Investigators

3. Co- Investigators (a) clinical

(b) Research fellow

o Phase of study
o Patient recruitment place
o Need for TDM study
o Objectives for study
o Criteria for selection of patients
o Patient History
o Withdrawal of blood sample and storage
o Instrument for (a) Measurement of Drug levels
(b) Measurement of clinical parameters like EEG, ECG, Respiration etc..
o Report preparation
o Clinical Interpretation

49
6. Give any four indications for TDM?
❖ Drugs for which relationship between dose and plasma concentration is unpredictable
ex. phenytoin.
❖ Drugs which narrow therapeutic window: - will allow dosage alterations to produce
optimal therapeutic effect or to avoid toxic effect ex., Lithium, phenytoin, and
digoxin.
❖ Drugs with steep dose response curve ex., theophylline.
❖ Drugs for which there is difficulty in measuring or interpreting the clinical evidence
of therapeutic or toxic effects.
❖ Drugs with saturable metabolism ex. phenytoin.
7. Why is TDM necessary for Digitoxin?
✓ Narrow therapeutic range with severe toxicity or ADR.
✓ To distinguish toxicity from inadequate therapy.
✓ Impaired renal function to adjust the dose rate.
✓ Due to its incomplete absorption and substantial elimination by the kidney.
8. Why is TDM necessary for Methotrexate?
• Narrow therapeutic range.
• Variable pharmacokinetics.
• Complication of ineffective therapy and ADR
9. Explain the necessity of monitoring Cyclosporine?
➢ Cyclosporine has a narrow therapeutic index.
➢ It exhibits the desirable pharmacological effect only within narrow ranges of
concentration in the blood too much drug lead to nephrotoxicity and too little to graft
rejection.
➢ The dose response relationship is poor as cyclosporine absorption is highly variable
both between and within patients.
10. Give the necessity for TDM of Lithium?
• Can be measured in blood, saliva, RBC and tears.
• In general only serum or plasma concentrations are measured.
• Narrow therapeutic window.

50
11. Why is TDM necessary for Methotrexate?
➢ TDM is necessary a guide to dosage adjustment.
➢ Also necessary as the drug exhibits non linear kinetics.
➢ Necessary as phenytoin has a low therapeutic index.
➢ The relative rate of elimination is slower at higher concentrations than of lower
concentration of the drug.

12. Explain the reasons for monitoring drug levels?

• Drugs with a narrow therapeutic window.
• Drugs with steep dose response curve. Example: theophylline.
• Drug with poorly defined end point or difficult to clinically predict the response.
Example: immunosuppressant’s.
• Drug with saturable metabolism

51
 DOSAGE ADJUSTMENT IN RENAL AND HEPATIC
DISEASE
1. Enumerate various causes for renal impairment. Discuss in detail the
pharmacokinetic considerations in the renal failure patients

Causes of Renal impairment

Pyelonephritis Inflammation and deterioration of the pyelonephrons due to infection,
antigens, or other idiopathic causes.
Hypertension Chronic overloading of the kidney with fluid and electrolytes may lead to
kidney insufficiency.
Diabetes mellitus The disturbance of sugar metabolism and acid-base balance may lead to or
predispose a patient to degenerative renal disease
Nephrotoxic Certain drugs taken chronically may cause irreversible kidney damage—e.g.,
drugs/metals the aminoglycosides, phenacetin, and heavy metals, such as mercury and
lead.
Hypovolemia Any condition that causes a reduction in renal blood flow will eventually
lead to renal ischemia and damage.
Neophroallergens Certain compounds may produce an immune type of sensitivity reaction with
nephritic syndrome—e.g., quartan malaria Nephrotoxic serum.
Pharmacokinetic considerations:

• Uremic patients may exhibit pharmacokinetic changes in Bioavailability, Volume of

distribution, and Clearance.
• The oral bioavailability of a drug in severe uremia may be decreased as a result of
disease – related changes in gastrointestinal motility and PH caused by nausea,
vomiting and diarrhea.
• Mesenteric blood flow also altered.
• However, the oral bioavailability of a drug such as propranolol (which has a high
first-pass effect) may be increased in patients with renal impairment as a result of the
decrease in first-pass hepatic metabolism.

52
 • The apparent volume of distribution (VD) depends largely on drug protein binding in
plasma or tissues and total body water.
• Renal impairment may alter the distribution of the drug as a result of changes in fluid
balance, drug protein binding or other factors that may cause changes in the apparent
volume of distribution.
• The plasma protein binding of weak acidic drugs in uremic patients is decreased,
whereas the protein binding of weak basic drugs is less affected.
• The decrease in drug protein binding results in a larger fraction of free drug and an
increase in the volume of distribution.
• However, the net elimination half-life is generally increased as a result of the
dominant effect of reduced glomerular filtration.
• Protein binding of the drug may be further compromised due to the accumulation of
metabolites of the drug and accumulation of various biochemical metabolites, such as
free fatty acids and urea, which may compete for the protein binding sites for the
active drug.
• Total body clearance of drugs in uremic patients is also reduced by either a decrease
in glomerular filtration rate and possibly active tubular secretion or reduced hepatic
clearance resulting from a decrease in intrinsic hepatic clearance.

2. Explain in detail the general approaches for dosage adjustment in renal diseases?
Most of the approaches for estimating the appropriate dosage regimen in renal
impairment assume that the required therapeutic plasma drug concentration in uremic
patients is similar to that required in patients with normal renal function.
The design of dosage regimens for uremic patients is based on the
pharmacokinetic changes that have occurred as a result of the uremic condition. Drugs
administered in patients with uremia or renal impairment exhibit prolonged elimination
half-lives and a change in the apparent volume of distribution.
Dose adjustment based on Drug Clearance: These methods are based on drug
clearance and try to maintain the desired average concentration after multiple oral doses
or multiple i.v bolus injections as the total drug clearance changes. In cases of uremia or

53
renal impairment, the total body clearance is changed. Hence, to maintain the same
desired average concentration, the dose must be changed to a uremic dose.
Dose adjustment based on changes in the elimination rate constant: In uremia, the
overall elimination rate constant for most of the drugs is reduced. A dosage regimen may
be designed for the uremic patients either by reducing the normal dose of the drug and
keeping the frequency of dosing constant, or by decreasing the frequency of dosing and
keeping the dose constant. For drugs with narrow therapeutic range, the dose of drug is to
be reduced particularly if the drug has accumulated in the patient prior to determination
of kidney function.
Dose adjustment for uremic patients: In uremic or renal impaired patients, the
adjustment of dose should be made with respect to the changes in the pharmacodynamics
and pharmacokinetics of the drug. The active metabolites of the drug formed may also to
be considered for additional pharmacologic effects when adjusting dose.
The loading dose of the drug is based on the apparent volume of distribution of
the patient. It is generally assumed that the apparent volume of distribution is not altered
significantly and therefore that the loading dose of the drug is same in uremic patients as
in subjects with normal renal function.
The maintenance dose of the drug is based on the clearance of the drug in the
patient. In uremia, the renal drug excretion rate is decreased hence the total body
clearance is decreased. Most of methods for dose adjustment assume nonrenal drug
clearance to be unchanged. The fraction of normal renal function remaining in the uremic
patient is estimated from creatinine clearance.
After estimating the remaining total body clearance, the dosage regimen for
uremic patient may be developed by
▪ Decreasing the maintenance dose
▪ Increasing the dosage internal, or
▪ Changing both maintenance dose and dosage interval.

54
 3. Explain in detail the different methods of extracorporeal removal of drugs?

i. Peritoneal Dialysis

• Peritoneal dialysis uses the peritoneal membrane in the abdomen as the filter. The peritoneum
consists of visceral and parietal components. The peritoneum membrane provides a large
natural surface area for diffusion of approximately 1–2 m2 in adults; it is permeable to solutes
of molecular weights ≤30,000 Da. However, only a small portion of the total splanchnic blood
flow (70 mL/min out of 1200 mL/min at rest) comes into contact with the peritoneum and gets
dialyzed.
• Placement of a peritoneal catheter is surgically simpler than hemodialysis and does not require
vascular surgery and heparinization. The dialysis fluid is pumped into the peritoneal cavity,
where waste metabolites in the body fluid are discharged rapidly. The dialysate is drained and
fresh dialysate is reinstalled and then drained periodically.
• Peritoneal dialysis is also more amenable to self-treatment. However, slower drug clearance
rates are obtained with peritoneal dialysis compared to hemodialysis, and thus longer dialysis
time is required.
• Continuous ambulatory peritoneal dialysis (CAPD) is the most common form of peritoneal
dialysis. Many diabetic patients become uremic as a result of lack of control of their disease.
About 2 L of dialysis fluid is instilled into the peritoneal cavity of the patient through a
surgically placed resident catheter.
• The objective is to remove accumulated urea and other metabolic waste in the body. The
catheter is sealed and the patient is able to continue in an ambulatory mode. Every 4–6 hours,
the fluid is emptied from the peritoneal cavity and replaced with fresh dialysis fluid.
• The technique uses about 2 L of dialysis fluid; it does not require a dialysis machine and can be
performed at home.

ii. Hemodialysis

• Hemodialysis uses a dialysis machine and filters blood through an artificial membrane.
• Hemodialysis requires access to the blood vessels to allow the blood to flow to the dialysis
machine and back to the body.
• For temporary access, a shunt is created in the arm, with one tube inserted into an artery and
another tube inserted into a vein. The tubes are joined above the skin.
55
 • For permanent access to the blood vessels, an arteriovenous fistula or graft is created by a
surgical procedure to allow access to the artery and vein.
• Patients who are on chronic hemodialysis treatment need to be aware of the need for infection
control of the surgical site of the fistula.
• At the start of the hemodialysis procedure, an arterial needle allows the blood to flow to the
dialysis machine, and blood is returned to the patient to the venous side. Heparin is used to
prevent blood clotting during the dialysis period.
• During hemodialysis, the blood flows through the dialysis machine, where the waste material is
removed from the blood by diffusion through an artificial membrane before the blood is
returned to the body.
• Hemodialysis is a much more effective method of drug removal and is preferred in situations
when rapid removal of the drug from the body is important, as in overdose or poisoning.
• In practice, hemodialysis is most often used for patients with end-stage renal failure. Early
dialysis is appropriate for patients with acute renal failure in whom resumption of renal
function can be expected and in patients who are to be renally transplanted. Other patients may
be placed on dialysis according to clinical judgment concerning the patient’s quality of life and
risk/ benefit ratio

iii. Hemoperfusion

• Hemoperfusion is the process of removing drug by passing the blood from the patient through
an adsorbent material and back to the patient.
• Hemoperfusion is a useful procedure for rapid drug removal in accidental poisoning and drug
overdose. Because the drug molecules in the blood are in direct contact with the adsorbent
material, any molecule that has great affinity for the adsorbent material will be removed.
• The two main adsorbents used in Hemoperfusion include
o activated charcoal, which adsorbs both polar and non-polar drug,
o Amberlite resins. Amberlite resins, such as Amberlite XAD-2 and Amberlite
XAD-4, are available as insoluble polymeric beads, with each bead containing
an agglomerate of cross-linked polystyrene microspheres.
• The Amberlite resins have a greater affinity for nonpolar organic molecules than activated
charcoal.

56
 • The important factors for drug removal by Hemoperfusion include affinity of the drug for the
adsorbent, surface area of the adsorbent, absorptive capacity of the adsorbent, rate of blood
flow through the adsorbent, and the equilibration rate of the drug from the peripheral tissue
into the blood.

iv. Hemofiltration

• An alternative to hemodialysis and Hemoperfusion is hemofiltration. Hemofiltration is a

process by which fluids, electrolytes, and small-molecular-weight substances are removed
from the blood by means of low-pressure flow through hollow artificial fibers or flat-plate
membranes. Because fluid is also filtered out of the plasma during hemofiltration, replacement
fluid is administered to the patient for volume replacement.
• Hemofiltration is a slow, continuous filtration process that removes non protein-bound small
molecules (<10,000 Da) from the blood by convective mass transport.
• The clearance of the drug depends on the sieving coefficient and ultra filtration rate.
Hemofiltration provides a creatinine clearance of approximately 10 mL/min and may have
limited use for drugs that are widely distributed in the body, such as aminoglycosides,
cephalosporin’s, and acyclovir.
• A major problem with this method is the formation of blood clots within the hollow filter
fibers.

4. Discuss various markers used in the measurement of glomerular filtration rate along with
their advantages and disadvantages. Enumerate the various formulae used for the
measurement of creatinine clearance.

Several drugs and endogenous substances have been used as markers to measure GFR. These
markers are carried to the kidney by the blood via the renal artery and are filtered at the
glomerulus. Several criteria are necessary to use a drug as a marker to measure GFR:
1. The drug must be freely filtered at the glomerulus.
2. The drug must neither be reabsorbed nor actively secreted by the renal tubules.
3. The drug should not be metabolized.
4. The drug should not bind significantly to plasma proteins.

57
5. The drug should neither have an effect on the filtration rate nor alter renal function.
6. The drug should be nontoxic.
7. The drug may be infused in a sufficient dose to permit simple and accurate quantization
in plasma and in urine.
Therefore, the rate at which these drug markers are filtered from the blood into the urine per unit
of time reflects the GFR of the kidney. Changes in GFR reflect changes in kidney function that
may be diminished in uremic conditions.
Inulin, a fructose polysaccharide, fulfills most of the criteria listed above and is therefore used as
a standard reference for the measurement of GFR. In practice, however, the use of inulin
involves a time-consuming procedure in which inulin is given by intravenous infusion until a
constant steady-state plasma level is obtained. Clearance of inulin may then be measured by the
rate of infusion divided by the steady-state plasma inulin concentration. Although this procedure
gives an accurate value for GFR, inulin clearance is not used frequently in clinical practice.
Method Advantage Disadvantage
Urine inulin clearance • Gold-standard for
GFR determination o Inulin unavailable for
practitioners.
o Assay not readily
available.
o Expensive.
Plasma inulin clearance • Compares to urine
inulin clearance o Lack of drug
availability and assay.
o Expensive.
C- inulin clearance • No urine collection
needed. o Lack of drug
• Compares to urine availability
inulin clearance o Specialized equipment
for measuring radio
labeled compound.

The clearance of creatinine is used most extensively as a measurement of GFR. Creatinine is

an endogenous substance formed from creatinine phosphate during muscle metabolism.
Creatinine production varies with age, weight, and gender of the individual. In humans,
creatinine is filtered mainly at the glomerulus, with no tubular Reabsorption. However, a small
amount of creatinine may be actively secreted by the renal tubules, and the values of GFR
obtained by the creatinine clearance tend to be higher than GFR measured by inulin clearance.
Creatinine clearance tends to decrease in the elderly patient. The physiologic changes due to
aging may necessitate special considerations in administering drugs in the elderly.

58
Advantages:
• More accurate the serum creatinine.
• Combine with other tests e.g. protein
Disadvantages:
➢ Small amounts of creatinine secreted by renal tubules can increase even further in
advanced renal failure.
➢ Collection of urine is often incomplete.
➢ Creatinine levels are affected by-
• Meat and muscle mass
• Certain drugs like cimetidine, trimethoprim
Measurement of Blood Urea Nitrogen (BUN) is a commonly used clinical diagnostic laboratory test
for renal disease. Urea is the end product of protein catabolism and is excreted through the kidney.
Normal BUN levels range from 10 to 20 mg/dl. Higher BUN levels generally indicate the presence of
renal disease. However, other factors, such as excessive protein intake, reduced renal blood flow,
hemorrhagic shock, or gastric bleeding, may affect increased BUN levels. The renal clearance of urea
is by glomerular filtration and partial Reabsorption in the renal tubules. Therefore, the renal clearance
of urea is less than creatinine or inulin clearance and does not give a quantitative measure of kidney
function.
Disadvantages:
• Less sensitive
• Completely filtered by glomeruli and 30-40% is reabsorbed.
• Considerable destruction of renal parenchyma – blood urea elevation.
- Protein diet
- Upper GI hemorrhage
- Liver function
Various formulae used for the measurement of creatinine clearance.
Creatinine clearance may be defined as the volume of plasma cleared of creatinine per unit time.
Creatinine clearance can be calculated directly by dividing the rate of urinary excretion of creatinine
by the patient’s serum creatinine concentration.
➢ The below equation is used to calculate creatinine clearance in mL/min when the
serum creatinine concentration is known:

59
 𝑅𝑎𝑡𝑒 𝑜𝑓 𝑈𝑟𝑖𝑛𝑎𝑟𝑦 𝑒𝑥𝑐𝑟𝑒𝑡𝑖𝑜𝑛 𝑜𝑓 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒
ClCr =
𝑆𝑒𝑟𝑢𝑚 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒
𝐶𝑢𝑉 × 100
ClCr =
𝐶𝑐𝑟 ×1440
Where Ccr = creatinine concentration (mg/dL) of the serum
V = volume of urine excreted (mL) in 24 hours
Cu = concentration of creatinine in urine (mg/mL), and
Clcr = creatinine clearance in mL/min.
➢ Jellife’s equation for the measurement of creatinine clearance?
For males:
98−0.8×(𝑝𝑎𝑡𝑖𝑒𝑛𝑡 ′ 𝑠𝑎𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠−20
CrCl =
𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝑙

For females:
CrCl = 0.9× CrCl determined using formula for males
➢ Cockraft and Gault’s equation for the measurement of creatinine clearance
For males:
(140−𝑝𝑎𝑡𝑖𝑒𝑛𝑡 ′ 𝑠 𝑎𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠)×𝐵𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔
CrCl =
72×𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝑙

For females:
CrCl = 0.85× CrCl determined using formula for males
➢ calculation of creatinine clearance in children
0.55𝑏𝑜𝑑𝑦 𝑙𝑒𝑛𝑔𝑡ℎ(𝑐𝑚)
CrCl =
𝐶𝑐𝑟
Where, CrCl = Creatinine Clearance in ml/min
Ccr = Creatinine Concentration in mg/dl
➢ MDRD equation for the measurement of creatinine clearance
MDRD = Modification of Diet in Renal Disease
eGFR (ml/min/1.73m2) = 175× (Ccr)-1.154×(age)-0.203×(0.742 if female)×(1.212 if
African & American)

60
 5. The maintenance dose of gentamicin is 80 mg every 6 hours for a patient with
normal renal function. Calculate the maintenance dose for a uremic patient with
creatinine clearance of 20 mL/min. Assume a normal creatinine clearance of 100
mL/min.

Solution
fe = 1
Clucr = 20ml/min = creatinine clearance
ClN
cr = 100ml/min = normal creatinine clearance

DN = 80mg = normal dose

G = Giusti-Hayton factor =???
Tu = dosage interval for the dose in uremic patients =????
TN = dosage interval for the dose in patients with normal renal function
From the literature, gentamicin is reported to be 100% excreted by the kidney (i.e., fe = 1). Use
Giusti-Hayton Equation
kU Clu
cr
= 1 - fe (1 - )=G
kN ClN
cr

kU 20
= 1 - 1(1 - ) = 0.2
kN 100

Because
DU kU
=
DN kN

Or

kU
D u = DN ×
kN

Where Du = uremic dose and DN = normal dose,

Du = 80 mg× 0.2 = 16 mg

61
The maintenance dose is 16 mg every 6 hours. Alternatively, the dosing interval can be adjusted
without changing the dose:
𝑇𝑢 kN
=
𝑇𝑁 ku

Or

kN
Tu = TN ×
ku

1
Tu = 6hr × = 30hr
0.2

Therefore, TU and TN are dosing intervals for uremic and normal patients, respectively. The
patient may be given 80 mg every 30 hours.

6. What is the creatinine clearance for a 25-year-old male patient with a Scr of 1
mg/dL? The patient is 5 ft, 4 in height and weighs 103 kg.

Solution
Where;
Age = 25yrs
Weight = 103kg
Scr = 1mg/dl
Height = 5 ft 4 inches
The patient is obese and the Clcr calculation should be based on ideal body weight.
LBW (males) = 50 kg + 2.3 kg for each inch over 5 ft
LBW (males) = 50 kg + [2.3 × 4] = 59.2 kg

Using the Cockcroft–Gault method the Clcr can be calculated.

(140−𝑝𝑎𝑡𝑖𝑒𝑛𝑡 ′ 𝑠 𝑎𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠)×𝐵𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔
CrCl =
72×𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝑙
(140−25)×59.2
CrCl =
72×1
CrCl = 94.6 ml/min

62
SHORT ANSWERS:

1. Enumerate the factors influencing dialyzability of drugs?

Physicochemical and Pharmacokinetic Properties of the Drug

Water solubility Insoluble or fat-soluble drugs are not
dialyzed—e.g., glutethimide, which is very
water insoluble.
Protein binding Tightly bound drugs are not dialyzed
because dialysis is a passive process of
diffusion— e.g., propranolol is 94%
bound.
Molecular weight Only molecules with molecular weights of
less than 500 are easily dialyzed—eg,
vancomycin is poorly dialyzed and has a
molecular weight of 1800.
Drugs with large volumes of distribution Drugs widely distributed are dialyzed
more slowly because the rate-limiting
factor is the volume of blood entering the
machine—e.g., for digoxin, VD = 250–300
L. Drugs concentrated in the tissues are
usually difficult to remove by dialysis.
Characteristics of the Dialysis Machine
Blood flow rate Higher blood flows give higher clearance
rates.
Dialysate Composition of the dialysate and flow
rate.
Dialysis membrane Permeability characteristics and surface
area.
Transmembrane pressure Ultra filtration increases with increase in
transmembrane pressure.
Duration and frequency of dialysis

63
2. Enumerate the causes for renal failure?

Pyelonephritis Inflammation and deterioration of the

pyelonephrons due to infection, antigens, or
other idiopathic causes.

Hypertension Chronic overloading of the kidney with fluid

and electrolytes may lead to kidney
insufficiency.

Diabetes mellitus The disturbance of sugar metabolism and

acid-base balance may lead to or predispose
a patient to degenerative renal disease.

Nephrotoxic drugs/metals Certain drugs taken chronically may cause

irreversible kidney damage—e.g., the
aminoglycosides, phenacetin, and heavy
metals, such as mercury and lead.

Hypovolemia Any condition that causes a reduction in

renal blood flow will eventually lead to renal
ischemia and damage.

Neophroallergens Certain compounds may produce an immune

type of sensitivity reaction with nephritic
syndrome—e.g., quartan malaria
Nephrotoxic serum.

3. Give any four pharmacokinetic parameter changes observed in the renal failure
patients?
• The oral bioavailability of a drug in severe uremia may be decreased as a result of disease –
related changes in gastrointestinal motility and PH caused by nausea, vomiting and diarrhea.
• The apparent volume of distribution (VD) depends largely on drug protein binding in plasma
or tissues and total body water.

64
• The net elimination half-life is generally increased as a result of the dominant effect of
reduced glomerular filtration.
• Total body clearance of drugs in uremic patients is also reduced by either a decrease in
glomerular filtration rate and possibly active tubular secretion or reduced hepatic clearance
resulting from a decrease in intrinsic hepatic clearance.

4. List the markers used in the measurement of GFR?

✓ Inulin
✓ Creatinine clearance
✓ Blood urea nitrogen
✓ Beta 2 microglobulin
✓ Microglobulin
✓ Cystatin c
✓ Radioisotopes

5. Give any four ideal characteristics of the marker drugs to be used for GFR
measurement?
➢ The drug must be freely filtered at the glomerulus.
➢ The drug must neither be reabsorbed nor actively secreted by the renal tubules.
➢ The drug should not be metabolized.
➢ The drug should not bind significantly to plasma proteins.
➢ The drug should neither have an effect on the filtration rate nor alter renal function.
6. Give two advantages and disadvantages of inulin as a marker for GFR measurement?
Method Advantage Disadvantage

Urine inulin clearance • Gold-standard for o Inulin unavailable for

GFR determination practitioners.
o Assay not readily
available.
o Expensive.
Plasma inulin clearance • Compares to urine o Lack of drug
inulin clearance availability and assay.
o Expensive.

65
 C- inulin clearance • No urine collection o Lack of drug
needed. availability
• Compares to urine o Specialized equipment
inulin clearance for measuring
radiolabeled
compound.
o Expensive.

7. Give the Jellife’s equation for the measurement of creatinine clearance?

For males:
98−0.8×(𝑝𝑎𝑡𝑖𝑒𝑛𝑡 ′ 𝑠𝑎𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠−20
CrCl =
𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝑙

For females:
CrCl = 0.9× CrCl determined using formula for males
8. Give the Cockraft and Gault’s equation for the measurement of creatinine clearance?
For males:
(140−𝑝𝑎𝑡𝑖𝑒𝑛𝑡 ′ 𝑠𝑎𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠)×𝐵𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔
CrCl =
72×𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝑙
For females:
CrCl = 0.85× CrCl determined using formula for males
9. Give the formula for the calculation of creatinine clearance in children?
0.55𝑏𝑜𝑑𝑦 𝑙𝑒𝑛𝑔𝑡ℎ(𝑐𝑚)
CrCl =
𝐶𝑐𝑟
Where, CrCl = Creatinine Clearance in ml/min
Ccr = Creatinine Concentration in mg/dl
10. Give the MDRD equation for the measurement of creatinine clearance?
MDRD = Modification of Diet in Renal Disease
eGFR (ml/min/1.73m2) = 175×(Ccr)-1.154×(age)-0.203×(0.742 if female)×(1.212 if
African & American)

66
11. Name the methods for the extracorporeal removal of drugs?
• Haemodialysis
• Haemofiltration
• Haemoperfusion
• Peritoneal dialysis
12. Give any two advantages and disadvantages of peritoneal dialysis?
Advantages:
✓ Simple to setup and perform
✓ Easy to use in infants
✓ Hemodynamic ability
✓ No anticoagulation
✓ Treat severe hypothermia or hyperthermia
Disadvantages:
➢ Unreliable untrafiltration
➢ Slow fluid & soft removal
➢ Drainage failure & leakage
➢ Not good for hyperammonemia or intoxication with dialyzable poisons
13. Give any two advantages and disadvantages of Hemodialysis?
Advantages:
✓ Maximum solute clearance
✓ Ready availability
✓ Limited anticoagulation time
✓ Bedside vascular access
Disadvantages:
➢ Hemodynamic instability
➢ Hypoxemia
➢ Rapid fluid + solute shifts
➢ Difficult in small infants

67
14. Define intrinsic clearance of drugs with its clinical significance?

Intrinsic clearance (CLint): It is the inherent ability of the liver to metabolize drugs in the
absence of limitations, ideal situations, & reflects total enzyme activity.
15. Calculate creatinine clearance for a 30 year old female patient with a serum creatinine
value of 0.8mg/dl. The patient is 5ft 1inch tall and weighs 69kgs?
Calculate creatinine clearance by using Cockraft and Gault’s equation
(140−𝑝𝑎𝑡𝑖𝑒𝑛𝑡 ′ 𝑠𝑎𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠)×𝐵𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔
CrCl =
72×𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝑙

Where, Age = 30yrs

Scr = 0.8 mg/dl
Weight = 69kgs
Height = 5ft 1inch
(140−30𝑦𝑟)×69 𝑘𝑔
CrCl = = 131.7 ml/min
72×0.8 𝑚𝑔/𝑑𝑙
For female:
CrCl = 0.85× CrCl determined using formula for males
CrCl = 0.85× 131.7 = 111.94 ml/min
16. Name the metabolic markers used in liver function test with their normal values?
➢ Aminotransferase Normal ALT: male, 10–55 U/L; female, 7–30 U/L;
Normal AST: male, 10–40 U/L; female, 9–25 U/L)
➢ Alkaline phosphatase (normal: male, 45–115 U/L; female, 30–100 U/L)
➢ Bilirubin (normal total = 0–1.0 mg/dL: direct = 0–0.4 mg/dL)
➢ Prothrombin time (PT; normal, 11.2–13.2 s)
17. Define Hepatic clearance?
Hepatic clearance may be defined as the volume of blood that perfuses the liver and is
cleared of drug per unit of time.
ClH = ClT - ClR
Where,
ClH = Hepatic clearance
ClT = Total clearance
ClR = Renal clearance

68
18. Give the importance of extra corporeal removal of drugs?
➢ Extracorporeal therapy is a medical procedure which is performed outside the body. For
patients with end-stage renal disease and drug overdose to remove accumulated drug and
its metabolites
➢ Objective: To remove rapidly the undesirable drugs and metabolites from the body
without disturbing the fluid and electrolyte balance in the body.
19. Calculate creatinine clearance for a 23 year old male patient with a serum creatinine
value of 1.2 mg/dl. The patient is 5 ft 5 inch tall and weighs 98 kgs.
Calculate creatinine clearance by using Cockraft and Gault’s equation
(140−𝑝𝑎𝑡𝑖𝑒𝑛𝑡 ′ 𝑠𝑎𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠)×𝐵𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔
CrCl =
72×𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝑙
Where, Age = 23yrs
Scr = 1.2 mg/dl
Weight = 98kgs
Height = 5ft 5inch
(140−23𝑦𝑟)×98 𝑘𝑔
CrCl = = 132.70 ml/min
72×1.2 𝑚𝑔/𝑑𝑙

20. Using the method of Cockroft and Gault, Calculate creatinine clearance for a 36 year
old female patient with a serum creatinine value of 1.8 mg/dl. The patient is 5 ft 5 inch
tall and weighs 58 kgs.
Calculate creatinine clearance by using Cockraft and Gault’s equation
(140−𝑝𝑎𝑡𝑖𝑒𝑛𝑡 ′ 𝑠𝑎𝑔𝑒 𝑖𝑛 𝑦𝑒𝑎𝑟𝑠)×𝐵𝑜𝑑𝑦 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔
CrCl =
72×𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝑙
Where, Age = 36yrs
Scr = 1.8 mg/dl
Weight = 58kgs
Height = 5ft 5inch
(140−36𝑦𝑟)×58 𝑘𝑔
CrCl = = 46.54 ml/min
72×1.8 𝑚𝑔/𝑑𝑙
For female:
CrCl = 0.85× CrCl determined using formula for males
CrCl = 0.85× 46.54 = 39.55 ml/min

69
Dose adjustment for uremic patients:

➢ The loading dose is based on the apparent Vd of the patient.

➢ It is generally assumed that the apparent Vd is not altered significantly, therefore the
loading dose of the drug is some in uremic patients as in subjects with normal renal
function.
➢ The maintenance dose is based on clearance of the drug in the patient.
➢ In the uremic patients, the rate of renal drug excretion has decreased, leading to a
decrease in total body clearance.
➢ Most methods for dose adjustment assume nonrenal drug clearance to be unchanged.
➢ After the remaining Tcl in the uremic patient is estimated a dosage regimen may be
developed by
- Decreasing the maintenance dose
- Increasing the dosage interval
- Changing both maintenance dosage intervals.
➢ Tcl is a more accurate index of drug dosing,
➢ The elimination half life of the drug is more commonly used for dosage adjustment
➢ Clearance allows for the prediction of steady state drug concentration, while elimination
half life yields information on the time it takes to reach steady state concentration.

The Wagner method:

✓ In renal dose adjustment, assume that the Vd & the fraction of drug excreted by nonrenal
routes are unchanged. These assumptions are convenient & hold true for many days.
✓ In the absence of reliable information assuring the validity of these assumptions, the
equations should be demonstrated as statistically reliable.
✓ A statistical approach was used by Wagner, who established a linear relationship between
creatinine concentration & the first order elimination constant of the drug in patients.
✓ This method takes advantage of the fact that the elimination constant for a patient can be
obtained from the creatinine clearance as follows.
K% = a + b Clcr
The values of a & b are determined statistically for each drug from pooled data
(combination of time series & cross sectional data) on uremic patient.

70
✓ The method is simple to use & should provide accurate determination of elimination
constant for patients when a good linear relationship exists between elimination constant
& creatinine concentration.
The theoretical derivation of this approach is as follows:
K% = Total elimination rate constant

Knr = Non renal elimination rate constant (%)

KR = Renal excretion rate constant
Cl = Total body clearance of drug
𝐶𝑙
R=
𝐶𝑙𝑐𝑟
Cl = R. Clcr
𝑅
K = Knr + Clcr
𝑉𝑑
100𝑅
100K = 100 Knr + Clcr
𝑉𝑑

K% = a + b Clcr
✓ This equation can also be used with drugs that follow the two compartment models.

The Giusti-Hayton method:

Assumes that the effect of reduced kidney function on the renal portion of the elimination
constant can be estimated from the ratio of the uremic creatinine Clarence to the normal
creatinine clearance.

𝐾𝑈
𝐾𝑁
= (1-fe) + fe [ ] 𝑈
𝐶𝑙𝑐𝑟
𝑁
𝐶𝑙𝑐𝑟

𝐾𝑈
Du = DN ×
𝐾𝑁
𝐾𝑁
Tu = TN ×
𝐾𝑢

71
 POPULATION PHARMACOKINETICS

1. Describe Bayesian theory?

✓ It was originally developed to improve forecast accuracy by combining subjective
prediction with improvement from newly collected data.
✓ In the diagnosis of disease, the physician may make a preliminary diagnosis based
on both sets of information. Bayesian theory provides a method to weigh the prior
information (ex. physical diagnosis) and new information (ex. Results from
laboratory tests) to estimate a new b probability for predicting the disease.
✓ In developing drug dosage regimen was assess the patient’s medication history
and the use average or population pharmacokinetic parameters appropriate for the
patient’s condition to calculate the initial dose.
✓ After initial dose, plasma or serum drug concentrations are obtained from the
patient that provides new information to assess the adequacy of the dosage.
✓ The dosing approach of combining old information with new involves a
“feedback” process and to some degree inherent in many dosing methods
involving some parameter readjustment when new serum drug concentration
become known.
✓ Because of inter and intrasubject variability the pharmacokinetic parameters of
an individual patient must be estimated from limited data in the presence of
Random error (assays etc...) known covariates variables such as clearance,
weight, and disease factor etc.
✓ Bayesian methods often employ a special weighted least squares (WLS) approach
and allow improved estimation of patient pharmacokinetic parameters when there
is a lot of variation in data.
𝐷
𝐻 𝑃 ( )𝑃 (𝐻)
𝐻
P( )=
𝐷 𝑃 (𝐷)

Where, H = hypothesis
D = data
Prob (H) = the probability of the patient’s parameter within the assumed
population distribution

72
 Prob (D/H) = the probability of measured concentration within the
population
P (D) = marginal probability of D
P (H/D) = posterior probability

ADVANTAGES:

Bayesian approach is the improvement in estimating the patients pharmacokinetic

parameters based on Bayesian probability versus an ordinary least square based program.

DISADVANTAGE:

Bayesian method is the subjective selection of prior probability. Therefore, it is not

considered to be unbiased by many staticians for drug approval purpose.

2. Explain dosing with feedback?

✓ In dosing drugs with narrow therapeutic ratios, an initial dose is calculated based
on mean population pharmacokinetic parameters. After dosing, plasma drug
concentrations are obtained from the patient. As more blood samples are drawn
from the patient, the calculated individualized patient pharmacokinetic parameters
become increasingly more reliable. This type of approach is referred as adaptive
method with feedback.
✓ When a specialized least-squares algorithm is used. Many ordinary least square
computer software packages are available to clinical practice for parameter and
dosage calculation.
✓ Many software packages record medical history and provide adjustments weight,
age, and in some cases disease factors.
✓ A common approach is to estimate the Cl and Vd from intermittent infusion.
✓ An adoptive algorithm is used to estimate pharmacokinetic parameters. The
average population Cl and Vd of drugs are used for initial estimates and the

program computes patient specific Cl and Vd as serum drug concentrations are

entered. This is estimated from Scr concentration using Cockroft-Gault equation.

73
 ✓ Many least-squares (LS) and weighted-least-squares (WLS) algorithms are
available for estimating patient pharmacokinetic parameters.
✓ Common objective involves estimating the parameters with minimum bias and
good prediction.
✓ The advantage of this method is the ability to input known information into the
program, so that the search for the real pharmacokinetic parameter is more
efficient and more precise.
3. Discuss population pharmacokinetics using NONMEM method?
Or
Describe the two- stage approach in population pharmacokinetics data?
➢ NONMEM = Nonlinear mixed effect model
➢ It refers to fitting a pharmacokinetic model to the data of each individual
➢ This model uses both fixed and random factors to describe data.
➢ Fixed factors such as patient weight, age, gender, and creatinine concentration are
assumed to have no error, whereas random factors include inter and intra-
individual differences.
➢ NONMEM is a statistical program that allows Bayesian pharmacokinetic
parameters to be estimated using an efficient algorithm called first order (FO)
method.
➢ NONMEM fits plasma drug concentration data for all subjects in the groups
simultaneously and estimates the population parameter and its variance. The
parameter may be Cl or Vd.
➢ The model describes the observed plasma drug concentration (Ci) in terms of a
model with:
a) Pk = fixed effect parameters, which include pharmacokinetic parameters or patient
effect parameters.
b) Random effect parameters, including
 The variance of the structural parameter Pk or intrasubject variability within the
population
 The residual intrasubject variance or variance due to measurement errors
➢ There are 2 reliable and practical approaches to population pharmacokinetics.

74
 i. Standard two stages (STS) method: it is useful because unknown factors that affect
the response in one patient will not carryover and bias parameter estimates of the
others. The method works well when sufficient drug concentration & time data are
available.
ii. First order (FO) method procedure is based on minimization of an extended least-
squares criterion.
➢ It is not applicable when the individual data are too sparse for individual model fits
4. Discuss analysis of population pharmacokinetic data?
Explain Bayesian theory and dosing with feedback
5. Give the applications of population pharmacokinetics?
 It allows using both sparsely and intensively sampled data.
 It helps to carry out the pharmacokinetic investigations in special populations
such as neonates, elderly, patients with AIDS and cancer etc..
 Individualizing the dose to get optimum benefit
 Designing dosing guidelines for drug labeling
 Communicating important aspects of drug clinical pharmacology to regulatory
bodies.
 Understanding the effect of competing dosing regimens on outcomes of clinical
trials.
 Helps the quantitative assessment of typical pharmacokinetic parameters, and
between individual and residual variability in drug absorption, distribution,
metabolism and excretion.
6. Give the reasons for conducting population pharmacokinetics?
➢ It seeks to obtain relevant pharmacokinetic information in patients who are
representative of the target of the target population to be treated with the drug.
➢ It recognizes sources of variability, such as inter subject, intra-subject and inter-
occasion as important features that should be identified and qualified during drug
development or evaluation.
➢ It seeks to explain variability by identifying factors of demographic,
pathophysiologic, environmental or drug related origin that may influence the
pharmacokinetic behavior of drug.

75
 ➢ It seeks to quantitatively estimate the magnitude of the unexplained part of the
variability in the patient population.
7. Explain the differences between traditional pharmacokinetics and population
pharmacokinetics?
Traditional Population

Population Healthy volunteers Target patient population

Highly selected patients (pediatrics, elderly, AIDS)

Study size Small Large or integrated

(observational or
experimental)

Sampling data Dense (typically 1 to 6 time Sparse, few samples for many
points) following drug patients
administration
Inter-individual variability Minimized through restrictive Demographics,
criteria Pathophysiological,
concomitant medications

Relationships of concentration limited Extensive, make predictions

about future events- steady
state concentration and
efficacy. Guide dosage
adjustments. Determine
therapeutic window, guide
dosage for safety.

8. Define adaptive method in population pharmacokinetics study?

In dosing drugs with narrow therapeutic ratios, an initial dose is calculated based on
mean population pharmacokinetic parameters. After dosing, plasma drug concentrations
are obtained from the patient. As more blood samples are drawn from the patient, the
calculated individualized patient pharmacokinetic parameters become increasingly more
reliable. This type of approach is referred as adaptive method with feedback.

76
9. Define population pharmacokinetics?
“The study of the source and correlates of variability in drug concentration among
individuals who represent the target population that ultimately receive relevant doses of a
drug of interest.”

10. Define inter-individual variation?

The inter-individual variability in the response to any drug can be defined as “an effect of
varying intensity occurring in different individuals at a specified dose of a drug”, or as
“a requirement of a range of doses in order to produce an effect of specified intensity in
all of the patients”.
Example: gender, age, ethnic background, anxiety levels or attachment style
.
11. Define within subject variation?

12. What is random error?

➢ A random error, as the name suggests, is random in nature and very difficult to predict. It
occurs because there are a very large number of parameters beyond the control of the
experimenter that may interfere with the results of the experiment.
Or
“It is a deviation that can vary in direction and magnitude during the treatment”
➢ Random error is also called as statistical error because it can be gotten rid of in a
measurement by statistical means because it is random in nature.

13. What do you understand by typical value?

• The term typical value refers to the “middle” value or perhaps a central tendency
of the data and is measured using the mean, median and mode.

77
 • Each of these measures is calculated differently, and the one that is best to use
depends upon the situation.
Mean The average
Median The number or average of the numbers in the middle
Mode The number that occurs most
• Typical value is nothing but some sort of average.
14. List various software’s used for conducting population pharmacokinetics study?
➢ NONMEM (NON-linear Mixed Effects Modeling)
➢ MK MODEL
➢ NPEM 2 (Non Parametric Expectation Maximization)
➢ USCPACK PC Programs

15. What are the advantages of population pharmacokinetics study over traditional
pharmacokinetics study?
Traditional Population

Population Healthy volunteers Target patient population

Highly selected patients (pediatrics, elderly, AIDS)

Study size Small Large or integrated

(observational or
experimental)

Sampling data Dense (typically 1 to 6 time Sparse, few samples for many
points) following drug patients
administration
Inter-individual variability Minimized through restrictive Demographics,
criteria Pathophysiological,
concomitant medications

Relationships of concentration limited Extensive, make predictions

about future events- steady
state concentration and
efficacy. Guide dosage
adjustments. Determine
therapeutic window, guide
dosage for safety.

78
16. Give Bayesian equation?
𝐷
𝐻 𝑃 ( )𝑃 (𝐻)
𝐻
P( )=
𝐷 𝑃 (𝐷)

Where, H = hypothesis

D = data

Prob (H) = the probability of the patient’s parameter within the assumed
population distribution

Prob (D/H) = the probability of measured concentration within the population

P (D) = marginal probability of D

P (H/D) = posterior probability

17. What do you understand by goodness of fit plot?

The goodness of fit test is used to test if sample data fits a distribution from a certain
population (i.e. a population with a normal distribution). In other words, it tells you if
your sample data represents the data you would expect to find in the actual population.

18. Define FO & FOCE?

FO: The first-order method (FO) used in NONMEM also results in biased estimates of
parameters, especially when the distribution of interindividual variability is specified
incorrectly.
FOCE: The first-order conditional estimation (FOCE) method is more complex than
the first-order (FO) approximation method because it estimates the empirical
Bayes estimate (EBE) for each repetition. By contrast, it is a further approximation of the
Laplacian (LAPL) method, which uses second- order expansion terms.

19. What do you understand by nested models?

“Nested” means that one model is a subset of another. For example, take a model for
pregnancy outcomes that includes four categorical independent variables:

79
• Age,
• Weight,
• Pre-existing conditions,
• Hereditary factors.
Several smaller models can be derived from this main one, and each is “nested” inside the main
model.

For example:

1. Age and weight,

2. Weight and pre-existing conditions,
3. Age and hereditary factors.
Basically, if you can get one model by constraining parameters of another, those models are
nested. For example, the set of normal distribution models contains an infinite number of nested
models, including normal distributions with means of 0, 1, or 99.

20. What is Naïve pooled data?

 It was proposed by Sheiner and Beal.
 Method involves pooling all the data from all individuals as if they were from a
single individual to obtain population parameter estimates.
 Generally, the naïve pooled approach performs well in estimating population
pharmacokinetic parameters from balanced pharmacokinetic data with small
between subject variations.

21. What is interoccasion variation?

Inter occasion variability (IOV) is of importance to consider in the development of a
design where individual pharmacokinetic or pharmacodynamic parameters are of interest.

80
 PHARMACOGENETICS
1. Define pharmacogenetics.
Pharmacogenetics is the study of influences of a gene on therapeutic and adverse effects
of drugs.
Or
Pharmacogenetics is also defined as the study of inherited variation in drug-
metabolizing enzymes and drug responses.
Pharmakon - Drug

Pharmacogenetics

Genetikos -Generative
(Origin)

E.g. Primaquine induced hemolysis in patients with G-6PD (Glucose-6-Phosphate

Dehydrogenase) deficiency, was the first pharmacogenetic discovery.
2. Describe genetic polymorphism in CYP2D6 isozymes.

➢ CYP2D6 is a large isozyme family that affects metabolism of many drugs. CYP2D6 is
highly polymorphic. More than 70 variant alleles of the CYP2D6 locus have been
reported. The metabolism of the tricyclic antidepressants amitriptyline, tetracyclic
compounds is influenced by the CYP2D6 polymorphism to various degrees. Genetic
polymorphism of CYP2D6 was first investigated with debrisoquine. Poor metabolizers
often carry two nonfunctional alleles of this gene, resulting in reduced drug clearance.
➢ Pharmacogenomic studies have revealed that some fast metabolizers of CYP2D6 are the
result of gene duplication among different racial groups.
3. Describe genetic polymorphism in CYP2C9 isozymes.

 CYP2C9 is a phase I drug-metabolizing cytochrome P450 (CYP450) enzyme plays a

major role in the oxidation of both xenobiotic and endogenous compounds.
 Another example of a clinically important drug metabolism polymorphism is the
association of variant alleles of CYP2C9 with the requirement for lower warfarin dose.

81
4. How to efflux transporters affect the bioavailability of the drugs.
▪ Efflux transporters, expressed in the intestine and/or in the liver, play important
roles in drug clearance and oral bioavailability
▪ Efflux transporters not only enhance enzymatic competition in relation to first-
order processes, but also change the predominance of some elimination routes.

5. Give any 2 examples for clinically important genetic polymorphism of drug

transporters.
Enzyme Drug Drug effect/Side effect
Warfarin Hemorrhage
CYP2C9 Tolbutamide Hypoglycemia
Losartan Decreased antihypertensive effect
Diazepam Prolonged Sedation
CYP2C19 Clopidogrel Inefficacy in poor metabolizers

6. Give any 2 examples for clinically important genetic polymorphism of drug targets.
• Beta-1 receptors are located in the heart and kidney, where they are involved in
the regulation of heart rate, cardiac contractility, and blood pressure. Two
common nonsynonymous SNPs in the β1- receptor gene are located at codons 49
and 389.
• The influence of the β1-receptor gene on blood pressure response to β1-receptor
blockade with metoprolol.

7. Describe the role of genetic polymorphism in drug targets.

Genetic polymorphisms occur commonly for drug target proteins, including receptors,
enzymes, ion channels, and intracellular signaling proteins. Drug target genes may work
in concert with genes that affect pharmacokinetic properties to contribute to
overall drug response.

82
8. With suitable examples, enumerate drug dosing in genetic dependent fast
acetylators.
Acetylator status
 In fast acetylators → INH (Isoniazid) → Acetyl hydrazine → Hepatotoxicity
 In slow acetylators → INH → peripheral neuritis
 In slow acetylator’s → Dapsone → hemolysis.

9. Role of genetic polymorphism in drug targets and is clinical significance.

 Genetic polymorphisms occur commonly for drug target proteins, including
receptors, enzymes, ion channels, and intracellular signaling proteins.
 Drug target genes may work in concert with genes that affect pharmacokinetic
properties to contribute to overall drug response.
❖ Receptor genotypes and drug response:
✓ β1 - Receptors are located in the heart and kidney, where they are involved in the
regulation of heart rate, cardiac contractility, and blood pressure. Two common
nonsynonymous SNPs in the β1- receptor gene are located at codons 49 & 389
✓ The influence of the β1-receptor gene on blood pressure response to β1-receptor blockade
with metoprolol.
✓ Hypertensive patients who were homozygous for both the Ser49 and Arg389 alleles had
greater reductions in diastolic blood pressure with metoprolol monotherapy compared
with carriers of the Gly49 and/or Gly389 alleles.
✓ β2 - Receptors are located on bronchial smooth muscle cells, where they mediate
bronchodilation upon exposure to the β2-receptor agonists.
✓ Inhaled β2-agonists are the most effective agents for acute reversal of bronchospasm;
however, the magnitude of their effects varies substantially among asthmatic patients.
✓ More than 11 SNPs have been identified in the β2-receptor gene, three of which occur
frequently and result in amino acid changes.
✓ Two common nonsynonymous SNPs are found in the gene’s coding block region, at
codons 16 and 27, and a third occurs upstream from the coding block in the gene’s
promoter region.

83
❖ Enzyme Genes And Drug Response:
➢ Vitamin K epoxide reductase (VKOR) is an example of an enzyme with genetic
contributions to drug response.
➢ Warfarin exerts its anticoagulant effects by inhibiting VKOR, thus preventing
carboxylation of clotting factors II, VII, IX, and X.
➢ The vitamin K epoxide reductase complex subunit-1 gene (VKORC1) encodes for
VKOR.
➢ Mutations in the VKORC1 coding region cause rare cases of warfarin resistance.
➢ Carriers of these mutations either require exceptionally high warfarin doses (>100
mg/wk) to achieve effective anticoagulation or fail to respond to any dose of warfarin.
❖ Genes For Intracellular Signaling Proteins, Ion Channels, And Drug Response:
Cellular responses to many drugs are mediated through GTP binding proteins, also called
G proteins.

✓ Disturbances in G-protein–mediated signal transduction have been implicated in the

response to antidepressant drugs.
✓ A common SNP (C825T) occurs in the gene for the inhibitory G (Gi) protein β3-
subunit and has been associated with enhanced intracellular signal transduction.
✓ The TT genotype has been correlated with greater improvement in depression symptoms
among patients treated with either a tricyclic antidepressant or serotonin reuptake
inhibitor, implying that the Gi protein β3-subunit gene may have a role in therapeutic
decisions for depression management.

84
✓ The epithelial sodium channel (ENaC) is an example of an ion channel with genetic
contributions to drug response.
✓ The ENaC is located in the distal renal tubule and collecting duct of the nephron, where
it serves as the final site for sodium reabsorption.
✓ The channel is composed of α-, β-, and γ-subunits. Mutations in the β- or γ- subunit cause
excessive sodium reabsorption and an inherited form of hypertension called Liddle
syndrome.
✓ The more common variant Thr594Met occurs exclusively in blacks and is associated
with high blood pressure in this population.

10. Role of genetic polymorphism in drug transports and is clinical significance.

▪ MDR1 (P-Glycoprotein)
The MDR1 or ABCB1 gene codes for the efflux protein P-glycoprotein (P-gp) that is
frequently associated with drug resistance to antineoplastic agents including vincristine
and doxorubicin. In cancers that express PGP, the drug is transported out of the cells,
keeping the drug concentrations inside the target cell low. In addition to this resistance
function, expression of PGP also contributes to the efflux of some drugs from various
tissues that affect the pharmacokinetics of these compounds. There are many PGP
substrates and inhibitors as outlined in Chapter 11. At least 66 SNPs in the ABCB1 gene
have been reported, and the three most studied SNPs include two synonymous and one
non-synonymous variant. The synonymous SNPs are reported to result in decreased
expression of PGP due to decreased mRNA expression, unstable mRNA, or alterations in
protein folding (Sissung et al, 2012). The effects of these SNPs on drug serum levels
have been examined in multiple studies with substrates including digoxin and docetaxel.
The reported results on the pharmacokinetic profile of these two drugs have been
inconsistent with studies showing increased blood levels or no change compared to the
wild-type gene (Sissung et al, 2012). These results highlight the dependency on the indi-
vidual substrate, the complexity, and the effect of specific tissue transporter expression,
which contributes to the pharmacokinetic profile of each drug. Additionally, there are
also known inhibitors to PGP that complicate the prediction of the pharmacokinetic
profile in patients that are administered multiple drugs.

85
▪ ABC Transporters
The multidrug resistance-associated proteins (MRPs) are members of the ATP-binding
cassette (ABC) super family with six members currently, of which MRP1 (ABCC1),
MRP2 (ABCC2), and MRP3 (ABCC3) are commonly known to effect drug disposition.
Like MDR, these transporters can also be expressed in cancer cells, which confer
resistance to the chemotherapeutic agent tamoxifen. It appears that polymorphisms in this
family are rare and occur at different frequencies among different populations. Despite
numerous studies, the functional importance of these polymorphisms remains unclear
Future studies with specific substrates and polymorphisms may ultimately provide
additional information on the variable responses or adverse effects of drugs.

▪ Solute Carrier Transporters

Another important class of drug transporters is the solute carriers (SLCs) such as the
organic anion transporter protein (OATP) and organic cation transporter (OCT). These
transporters are located throughout the body and have various roles in the transport of
many different drugs. OATP1B1 (coded by the SLCO1B1 gene) is a hepatic influx trans-
porter with at least 40 non-synonymous SNPs identified that result in either an altered
expression or activity of OATP1B1. While the clinical consequences of all of these SNPs
are unknown, one SNP has been associated with an increased risk of simvastatin-induced
myopathy. This non-synonymous SNP is associated with a lower plasma clearance of
simvastatin and is found in the SLCLO1B1*5, *15, and *17 alleles. These alleles are
present in most populations with a frequency between 5% and 20% and warrant the
avoidance of high-dose simvastatin (>40 mg) or treatment with another statin to decrease
the risk of simvastatin-induced myopathies.

86
11. Describe the genetic polymorphism in CYP2D6 and 2C9 isozymes.
Or
Discuss the importance of genetic polymorphism of cytochrome p-450 isozymes on
drug metabolism with suitable examples.
➢ CYP2C9 :
CYP2C9 has at least 30 different allelic variants with the two most common being
CYP2C9*2 and *3. Both of these variants result in reduced CYP2C9 activity and are
carried by about 35% of the Caucasian population. CYP2C9 is a major contributor to the
metabolism of the narrow therapeutic index blood thinner warfarin. When a patient has
one of these two polymorphisms, the dose of warfarin needed for clinically relevant
anticoagulation is generally much less since drug clearance is reduced. If the dose of
warfarin is not appropriately lowered, then there is an increased risk of bleeding. There
are several other drugs affected by the polymorphisms of CYP2C9, including many
nonsteroidal anti-inflammatory drugs, sulphonylureas, angiotensin II receptor antago-
nists, and phenytoin. For each of these, the CYP2C9*2 and *3 polymorphisms result in
higher plasma concentrations but, because of their high therapeutic indices (except
phenytoin), do not usually result in adverse effects. In the case of phenytoin, the
polymorphisms result in drug accumulation and require dose reduction to prevent
toxicity.

➢ CYP2D6:
• CYP2D6 isoenzyme metabolizes 25-30% of all clinically used medications, including
• Dextromethorphan,
• ß-blockers(e.g., metoprolol),
• Antiarrhythmics,
• Anti-depressants (e.g., fluvoxamine, fluoxetine, imipramine, nortriptyline),
• Antipsychotics (e.g., haloperidol, risperidone),
• Morphine derivatives, and many other drugs

87
Pharmacogenetics:

o Drug metabolism via CYP450 enzymes exhibit genetic variability (polymorphism) that
influences a patient’s response to a particular drug.

o For ex 1 out of 15 whites or blacks may have exaggerated response to standard doses of
beta- blockers or no response to analgesic-tramadol

o The gene encoding CYP2D6 isoenzyme has the most variations of all genes for CYP
isoenzymes, with more than 75 allelic variants identified to date, resulting from point
mutations, single base-pair deletions or additions, gene rearrangements, and deletion of
the entire gene.

o These mutations result in either a reduction or complete loss of activity

o A specific gene encodes each cyp450 enzyme

o Every person inherits one genetic allele from each parent

o Alleles are referred to as “wild-type” or “variant” with wild type occuring most
commonly in the general population.

o An “Extensive” (i.e. normal) metabolizers receives 2 copies of wild- type alleles (i.e.)
EMs carry an autosomal dominant wild type gene and may be homozygous or
heterozygous for this allele.

o Polymorphism occurs when a variant allele replaces 1 or both wild- type alleles.

o Persons with 2 copies of variant alleles are “Poor metabolizers” and those with 1 wild-
type and 1 variant allele have reduced enzyme activity.

o Genotype-phenotype studies have revealed that poor metabolizers possess nonfunctional

alleles and that the phenotype is an autosomal recessive trait.

o Some persons inherit multiple copies of wild-type alleles, which result in excess enzyme
activity. This phenotype is termed as “Ultra-rapid “metabolizers.

88
o An ultra-rapid metabolizer phenotype has been identified and found to result from
gene duplication (upto 13 copies of CYP2D6).

o Poor metabolizers are more likely to have adverse effects from drugs that are substrates
of the isoenzyme and decreased efficacy from drugs requiring CYP2D6-mediated
activation

o (e.g., codeine is converted into morphine by CYP2D6), while extensive and ultra-rapid
metabolizers may have therapeutic failure with drugs activated by CYP2D6

o The frequency of the phenotype of poor metabolizers differs among ethnic groups. Less
than 1% of Asians, 2-5% of African-Americans, and 6- 10% of Caucasians are poor
metabolizers of CYP2D6.[4] The most common variant alleles in Caucasians are
CYP2D6*3, *4, *5, and *6, which account for about 98% of poor metabolizers.

o Genotyping CYP2D6 has been shown to successfully predict the clearance of fluoxetine,
fluvoxamine, desipramine, and mexiletine.

o In some instances, the genotype for CYP2D6 has been useful in predicting adverse
effects associated with antidepressants and neuroleptics.

89
90