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PubMed1999

A novel approach to predicting P450 mediated drug metabolism. CYP2D6 catalyzed N-dealkylation reactions and qualitative metabolite predictions using a combined protein and pharmacophore model for CYP2D6.

A combined protein and pharmacophore model for cytochrome P450 2D6 (CYP2D6) has been extended with a second pharmacophore in order to explain CYP2D6 catalyzed N-dealkylation reactions. A group of 14 experimentally verified N-dealkylation reactions form the basis of this second pharmacophore. The combined model can now accommodate both the usual hydroxylation and O-demethylation reactions catalyzed by CYP2D6, as well as the less common N-dealkylation reactions. The combined model now contains 72 metabolic pathways catalyzed by CYP2D6 in 51 substrates. The model was then used to predict the involvement of CYP2D6 in the metabolism of a "test set" of seven compounds. Molecular orbital calculations were used to suggest energetically favorable sites of metabolism, which were then examined using modeling techniques. The combined model correctly predicted 6 of the 8 observed metabolites. For the well-established CYP2D6 metabolic routes, the predictive value of the current combined protein and pharmacophore model is good. Except for the highly unusual metabolism of procainamide and ritonavir, the known metabolites not included in the development of the model were all predicted by the current model. Two possible metabolites have been predicted by the current model, which have not been detected experimentally. In these cases, the model may be able to guide experiments. P450 models, like the one presented here, have wide applications in the drug design process which will contribute to the prediction and elimination of polymorphic metabolism and drug-drug interactions.

1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine↗

PubMed2000

Pharmacokinetic variability and therapeutic drug monitoring actions at steady state.

PURPOSE: To develop a mathematical model for therapeutic drug monitoring and to assess the kinetic relationships between the intensity of corrective action and the approach of drug concentrations to target values. METHODS: A mathematical model that succinctly accounts for the corrective actions and the variability inherent in the pharmacokinetics was used. RESULTS: The validity of the variability term was tested using experimental data for steady state concentrations of the drug procainamide. The approach of the monitored process to the target value followed exponential kinetics and an analytical expression for dependence the variance with time and various dosing parameters was derived. The variance of the drug concentration depends critically on a single non-dimensional parameter containing the rate constant for the therapeutic corrective actions and a coefficient describing the variance rate. When the rate constant for the therapeutic corrective actions was less than this critical value, the variance increased indefinitely. CONCLUSIONS: From a dosing standpoint, large variances in drug concentrations are undesirable because some patients will be overdosed or underdosed. Since deterministic models cannot provide analytical solutions for the moments of drug concentration distribution functions, stochastic models can be used to provide useful insights into the design of therapeutic regimens.

Algorithms↗

PubMed1991

The role of metabolites in bioequivalency assessment. I. Linear pharmacokinetics without first-pass effect.

The estimation of bioequivalency using metabolite data was investigated for immediate release formulations with drugs exhibiting linear pharmacokinetics and no first-pass effect. This was accomplished by generating parent drug and metabolite plasma level profiles assuming formation and excretion rate-limited pharmacokinetic models with absorption rate constants obtained from bivariate normal distributions and designated random errors. Simulation results indicated that bioequivalence determination using Cmax of parent drug and metabolite was independent of the metabolite models as evaluated by confidence interval approach. However, a clear difference with respect to the outcome of bioequivalence evaluation arises depending upon the utilization of Cmax values for the parent drug and metabolite. The major reason for this disparity was attributed to the minimal effect of the absorption process for the parent drug on the formation of the metabolite. This phenomenon results in an apparent lower intrasubject variability for Cmax of the metabolite and, in turn, a tighter confidence interval for Cmax of the metabolite in comparison with the parent drug. The simulated results have been found to be in agreement with the bioequivalency data for acetohexamide, allopurinol, procainamide, and sulindac. In all cases, the interval of the 90% confidence limit for Cmax of the metabolite is always smaller than that of the parent drug, regardless of the drug pharmacokinetics and the level of error contained in the data.

Acetohexamide↗

PubMed1994

Comparison of single and multiple dose pharmacokinetics using clinical bioequivalence data and Monte Carlo simulations.

The purpose of this study was to evaluate the relative performance and usefulness of single dose (SD) and multiple dose (MD) regimens for bioequivalence (BE) determination. Drugs such as indomethacin, procainamide, erythromycin, quinidine, nifedipine were tested for BE under SD and MD dose regimens. Drugs characterized by low accumulation indices (AI) showed virtually no change in the 90% confidence interval (CI) of AUC and CMAX upon multiple dosing. On the other hand, drugs with higher AI appeared to have smaller CI at steady-state. For example, the CI range of AUC and CMAX of quinidine (AI of 1.54) decreased from 26 to 12 and from 22 to 12, respectively, upon multiple dosing. A Monte Carlo simulation study of SD and MD bioequivalence trials was performed. The probability of failing the bioequivalence test was evaluated for several situations defined by different levels of variability and correlation in ka constants, presence or absence of inter- and/or intra-individual variability in clearance (CL) and volume of distribution (V), and different degrees of accumulation. All the possible combinations of these factors were tested with SD and MD study designs. All simulations used 1000 data sets with 30 subjects in each data set for a total of 144 unique designs (total of 144,000 simulations of bioequivalence trials). Upon multiple dosing, narrowing of CI ranges was observed for drugs simulated to have high AI high variability and a large difference in absorption constants (ka) between test and reference formulations.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1980

Kinetics of N-acetylprocainamide deacetylation.

The kinetics of N-acetylprocainamide (NAPA) deacetylation to procainamide (PA) were determined in a normal subject using NAPA-13C, labeled in the acetyl group. The deacetylation clearance of NAPA (ClD) was found to be 6.5 ml/min whereas total NAPA elimination clearance was 231 ml/min, so that 2.8% of the administered NAPA-13C was metabolized by deacetylation. This estimated of ClD was shown to be representative of the rate of NAPA deacetylation in four patients on long-term NAPA therapy. Steady-state [PA]/[NAPA] ratios averaged 0.024, but would be expected to rise to 0.057 if functionally anephric patients were treated with NAPA. Despite reports that patients with the PA-induced systemic lupus erythematosus-like reaction have had symptomatic and immunologic remission when switched to NAPA, the demonstration that NAPA is deacetylated to PA indicates that the apparently greater immunologic safety of NAPA may be relative rather than absolute.

Acecainide↗

PubMed1982

N-Acetylprocainamide kinetics after single and repeated oral doses.

The kinetic behavior of N-acetylprocainamide (NAPA) was studied after single and repeated oral doses in six healthy subjects and five patients with cardiomyopathy. Renal clearance (CLR) of NAPA was lower in patients than in normal subjects after an initial 1-gm dose (1.3 +/- 0.4 [x +1- SD] and 2.7 +/- 0.4 ml . min-1 . kg-1, P less than or equal to 0.001) and a final 2 gm dose (1.6 +/- 0.4 and 2.6 +/- 0.5 ml . min-1 . kg-1, P less than or equal to 0.01) even though there was no difference between measured creatinine clearance (ClCR) 80.8 +/- 23.6 and 93.2 +/- 19.3 ml . min-1 [1.73 M2]-1). The decrease in the ratio of NAPA ClR to ClCR (R) could not be accounted for by age alone. A published regression formula overestimated the R ratio for patients (1.65 +/- 0.09 and 1.25 +/- 0.17, P less then 0.025), but accurately predicted the R ratio for healthy subjects (2.10 +/- 0.04 and 1.99 +/- 0.54). Mean steady-state concentration (normalized for daily dose per unit of body mass) after 2 gm every 8 hr for at least 3 days was higher for patients (P less than or equal to 0.05). Comparing the parameters for all subjects after the initial 1-gm dose to those after the last 2-gm dose with paired data, oral clearance was somewhat lower after the last dose (3.7 +/- 1.0 and 3.1 +/- 1.0 ml . min-1 . kg-1, P less than or equal to 0.01). In spite of this, before and 2 hr after dose steady-state NAPA serum concentration were generally proportional to dose over the concentration range studied. Net deacetylation of NAPA to procainamide in both groups was minimal.

Acecainide↗

PubMed1989

Pharmacokinetics of N-acetylprocainamide in patients profiled with a stable isotope method.

N-Acetylprocainamide (NAPA) absorption and disposition were profiled in five patients with ventricular arrhythmias by the simultaneous intravenous administration of NAPA-13C and oral administration of a 500 mg NAPA hydrochloride tablet. NAPA distribution was modeled with a three compartment mammillary system. The central compartment volume of 14.1 +/- 2.6 L (mean +/- SD) was similar to expected intravascular space, corrected for NAPA partitioning between erythrocytes and plasma. Other compartment volumes, intercompartmental and nonrenal clearances, and the steady-state distribution volume of 1.45 +/- 0.09 L/kg were similar to normal subject values. The least-squares estimate of 1.67 for the NAPA renal clearance/creatinine clearance ratio was similar to the value of 1.68 previously reported for functionally anephric patients and showed the expected age-associated decrease. The oral NAPA dose was 78.0% +/- 11.7% absorbed and interindividual variation in NAPA absorption was correlated with fast intercompartmental clearance (r = 0.89, p = 0.045). Because fast intercompartmental clearance partly reflects splanchnic blood flow, hemodynamic changes may affect NAPA bioavailability, as has been found for procainamide.

Absorption↗

PubMed2000

Wide QRS tachycardia refractory to pharmacologic interventions and cardioversion.

The case of a 43-year-old man with an idiopathic wide QRS tachycardia resistant to adenosine, lidocaine, procainamide, and multiple electric shocks is described. The tachycardia eventually stopped after a pacing wire was introduced in the right ventricle, inducing a run of rapid ventricular tachycardia. The possible causes of resistance to medications and cardioversion, and alternative treatment modalities are reviewed.

Adenosine↗

PubMed1988

Clinical characteristics of patients with ventricular fibrillation during antiarrhythmic drug therapy.

We retrospectively studied 28 patients with 38 episodes of newly occurring ventricular fibrillation during antiarrhythmic drug therapy. Twenty-six of these patients, who had ventricular fibrillation during single-drug therapy with quinidine, procainamide, or disopyramide, were compared with a control group of 62 patients who had been treated similarly for ventricular arrhythmias but did not have ventricular fibrillation during treatment. The median duration of therapy before ventricular fibrillation was three days. The left ventricular ejection fraction of the study group was lower than that of the control group (0.29 vs. 0.43; P less than 0.0001), and concomitant treatment with digitalis and diuretic agents was more common in the study group. The base-line QT interval (corrected for heart rate) was slightly longer in the study group than in the controls (0.47 vs. 0.44; P less than 0.005), although both groups had similar degrees of QT prolongation during drug therapy. Four of 13 patients (31 percent) who underwent multiple trials of antiarrhythmic drugs had recurrent episodes of ventricular fibrillation. Six patients died suddenly after a mean follow-up of 18 months--four who were receiving antiarrhythmic therapy and two who were not. We conclude that drug-associated ventricular fibrillation is an early event, that there may be an increased risk of its recurrence with subsequent trials of antiarrhythmic drugs, and that left ventricular dysfunction and concomitant therapy with digitalis and diuretic agents may predispose patients to this complication.

Anti-Arrhythmia Agents↗

PubMed1981

Renal manifestations of drug-induced systemic lupus erythematosus.

Renal failure secondary to crescentic glomerulonephritis developed in a patient who had typical serologic features of drug-induced systemic lupus erythematosus after two years of therapy with procainamide. Renal function and proteinuria improved after the drug was discontinued and steroid therapy begun. A review of previously reported cases of glomerulonephritis in association with drug-induced systemic lupus erythematosus revealed a high incidence of renal failure. Crescentic glomerulonephritis has not to our knowledge been previously documented in drug-induced systemic lupus erythematosus.

Biopsy↗

PubMed1984

A sheep preparation for studying interactions between blood flow and drug disposition. II: Experimental applications.

A sheep preparation has been developed which allows systematic direct studies into the sites and rates of distribution, formation and elimination of both endogenous and exogenous substances and their metabolites. Examples of some experimental applications are presented which provide information not usually available using traditional methods. Substantial metabolism at sites not usually regarded as important (e.g. limbs, lungs) was shown both for exogenous substances (procainamide and chlormethiazole) and for an endogenous substance (choline). Studies on drug clearance by kidney (cefoxitin), liver (chlormethiazole, pethidine and the optical isomers of mepivacaine) and lung (chlormethiazole) demonstrate that simple first-order elimination should not routinely be assumed to occur, as multiple sites and pathways may be involved, and kinetics may be non-linear as a result of characteristics of both organ flow and organ function. It was also shown that large changes (up to three-fold) in arterial blood drug concentrations may occur because of exogenous (anaesthesia) and endogenous (gastric recycling) perturbations, and that simple compartmental kinetics should not be assumed for either the whole body or individual organs. This preparation may be used in conjunction with traditional pharmacokinetic methods to resolve complex problems relating to interactions between drugs and the body, to establish a data base for physiological models of drug disposition, and to gain practical insights for drug treatment in patients.

Anesthesia, General↗

PubMed1981

N-acetylprocainamide induced changes in refractoriness and monophasic action potentials of the dog heart in situ.

The major metabolite of procainamide (PA) is N-acetylprocainamide (NAPA). The effect of this drug on the electrophysiology of the right ventricle was studied in the dog heart in situ by means of programmed electrical stimulation and monophasic action potential (MAP) recordings. A decrease in the beat interval caused a progressive decrease in refractoriness and MAP duration. Intravenous injection of NAPA 50 mg.kg-1 body weight increased refractoriness to a greater extent than MAP duration at shorter, while the opposite was observed at longer beat intervals. These observations are compatible with delayed recovery of excitability. On the basis of these findings, it is concluded that NAPA belongs to antiarrhythmic drugs of type I according to Vaughan Williams' classification, and NAPA may be an alternative drug for treatment of cardiac arrhythmias.

Acecainide↗

PubMed1989

Toxic delirium in a patient taking amantadine and trimethoprim-sulfamethoxazole.

Acute mental confusion occurred in a patient on a stable dose of amantadine after he was started on trimethoprim-sulfamethoxazole. Discontinuation of the drugs led to rapid improvement. Studies in a rat model of organic cation secretion demonstrate that both amantadine and trimethoprim, but not sulfamethoxazole, inhibit the renal secretion of the organic cation procainamide. This case may represent an amantadine-trimethoprim interaction.

Aged↗

PubMed2001

Intravenous antiarrhythmic agents.

Intravenous antiarrhythmic drugs can be used as diagnostic tools; for example, adenosine can be used to reveal the underlying rhythm in narrow QRS tachycardia. Newer class III antiarrhythmic agents, like ibutilide and dofetilide, are effective at the conversion of acute atrial fibrillation; however, electrical cardioversion is still the most effective method for restoration of sinus rhythm in persistent atrial fibrillation. Lidocaine and bretylium in the treatment and prevention of ventricular tachyarrhythmia are de-emphasized because of inefficacy, safety concerns (lidocaine), or shortage of drug (bretylium). Procainamide is effective for stable ventricular tachycardia, and amiodarone is effective in the treatment of shock-refractory ventricular fibrillation. Adrenergic blockade is likely important in the management of tachyarrhythmias, particularly in electrical storm, but more data will be necessary to establish its role.

Amiodarone↗

PubMedDate not supplied

Effective plasma concentrations of antiarrhythmic drugs against sustained halothane-adrenaline arrhythmia in dogs.

We determined the minimum effective plasma concentrations of several antiarrhythmic agents against canine halothane-adrenaline arrhythmia. Sustained ventricular tachycardia was produced by continuous adrenaline infusion at rates of 1.5 to 4 micrograms/kg/min under 1.5% halothane anesthesia. Procainamide, 20 mg/kg, produced ventricular fibrillation in three of nine dogs. Disopyramide, 3 mg/kg, suppressed the arrhythmia in nine of 11 dogs at a minimum effective plasma concentration of 4.2 micrograms/ml, but produced ventricular fibrillation in the remaining two dogs. Phenytoin, 5 mg/kg, was effective at a minimum concentration of 12 micrograms/ml. Lidocaine, 10 mg/kg, suppressed the arrhythmia at a minimum concentration of 15 micrograms/ml, which is much higher than the human toxic plasma level. These drugs may have suppressed the adrenaline arrhythmia by inhibiting the sodium channel, because their effective concentrations were very close to membrane-stabilizing concentrations in vitro. Small doses of 30 micrograms/kg propranolol and 0.1 mg/kg N-696, two beta-blockers, and 0.1 mg/kg verapamil, a calcium channel blocker, yielding a concentration of 0.03 micrograms/ml, suppressed the arrhythmia, probably by indirectly or directly blocking the calcium channel.

Animals↗

PubMedDate not supplied

Effects of pharmacologic agents on induced atrial flutter in dogs with right atrial enlargement.

The effects of selected drugs on the sustained atrial flutter induced in conscious dogs with surgically produced right atrial enlargement (TI dogs) were evaluated. This was done to better understand the electrophysiologic mechanism of the tachyarrhythmias. Agents known to cause a slowing of atrioventricular (AV) nodal conduction--verapamil, methacholine, and phenylephrine--did not significantly decrease the rate of the induced flutter, whereas beta-adrenergic stimulation with an infusion of isoproterenol increased the rate of the flutter in all trials. Propranolol and atropine had little effect on the atrial flutter rate. Agents known to increase atrial refractoriness, such as procainamide, n-acetylprocainamide, bretylium, and clofilium, all increased the cycle length of the induced flutter and, in some cases, terminated the arrhythmia. These results suggest then that the perpetuation of the sustained atrial flutter in the conscious TI dog is not due to a delayed afterdepolarization mechanism but is more likely due to reentrant excitation. Furthermore, it is unlikely that the flutter is due to reentry over a pathway involving the AV node; rather, the arrhythmia seems to be caused by reentrant excitation of the leading circle type.

Acecainide↗

PubMed1989

Alterations of phosphatidylethanolamine N-methylation in rat heart by quinidine.

To elucidate the molecular mechanism underlying the adverse depression of myocardial contractility observed during antiarrhythmic therapy of quinidine, we investigated its action on the phosphatidylethanolamine N-methyltransferase (EC 2.1.1.17) activities of cardiac subcellular membranes. Rat heart sarcolemma, mitochondria, and microsomes (sarcoplasmic reticular fragments) were isolated, and the three catalytic sites for N-methylation activities were examined with 0.055 (site I), 10 (site II), and 150 (site III) microM concentrations of S-adenosyl-L-[methyl-3H]methionine as a methyl donor. Total methyl group incorporation into sarcolemmal phosphatidylethanolamine was depressed by 10(-6)-10(-3) M quinidine at sites II and III. The activity of site I was stimulated at low (10(-9) M) concentrations and inhibited at high concentrations of the drug. A similar behaviour was observed with procainamide, although the inhibitory effect was less pronounced and was not additive with quinidine. Quinidine-induced inhibition was associated with a depression of Vmax, while the apparent affinity for S-adenosyl-L-methionine was unaltered. Analysis of individual methylated phospholipids confirmed inhibition by quinidine at sites II and III in sarcolemma. Microsomal phosphatidylethanolamine N-methylation was affected by 10(-6) M quinidine only at site II, whereas no changes were noted in mitochondria. Quinidine also inhibited both the positive inotropic response and concomitant increase in tissue N-methylated phospholipids observed upon L-methionine perfusion of rat heart. These results suggest that quinidine alters the intramembranal level of N-methylated phospholipids, and this may serve as a biochemical mechanism contributing to its negative inotropic effect.

Animals↗

PubMed1980

Impact of active metabolites on monitoring plasma concentrations of therapeutic drugs.

Monitoring plasma concentrations of therapeutic drugs presents special problems when these drugs are metabolized to compounds that have pharmacologic activity. This presentation reviews several methods for evaluating the pharmacologic activity of drug metabolites and describes the impact of active drug metabolites on the pharmacokinetic design of dose regimens and on the formulation of guidelines for plasma level interpretation. Lidocaine and monoethylglycinexylidide illustrate the considerations that pertain when both a drug and its active metabolite have similar therapeutic and toxic actions. Procainamide and N-acetylprocainamide exemplify the much more complex situation that arises when a drug and its active metabolite have different pharmacologic activity.

Animals↗