Comparison of patient questionnaires, medical records, and plasma assays in assessing exposure to benzodiazepines in elderly subjects.

OBJECTIVE: Exposure in pharmacoepidemiologic studies can rely on various sources such as medical records, patient questionnaires, or plasma samples, which do not always concur. This study endeavored to compare sources of information on current exposure to benzodiazepines in elderly subjects. METHODS: In a study in a hospital admissions department, 1136 elderly subjects included in a case-control study each completed a structured questionnaire. In addition, an inspection of the medical records of each subject was performed, as well as screening of a plasma sample (high-pressure liquid chromatography--diode array detector) for current exposure to benzodiazepines. RESULTS: Benzodiazepines were found in the plasma of 33% of 1013 patients, in the records of 31% of patients, and in the questionnaires of 36% of 797 respondents. With use of the plasma results as a standard, questionnaires had 11% false positives and 28% false negatives; medical records had 14% false positives and 23% false negatives. The kappa for concordance between questionnaires and records was 0.63. Most of the errors were related to the unexpected presence in plasma of clorazepate, commonly used as a hypnotic agent. CONCLUSIONS: Patient recall and medical records are not reliable measures of current exposure to benzodiazepines in elderly persons, although this unreliability may be more marked with certain drugs used as hypnotic agents.

Clinical pharmacokinetics of low-dose pulse methotrexate in rheumatoid arthritis.

Low-dose pulse methotrexate has emerged as one of the most frequently used slow-acting, symptom-modifying antirheumatic drugs in patients with rheumatoid arthritis (RA) because of its favourable risk-benefit profile. Methotrexate is a weak bicarboxylic acid structurally related to folic acid. The most widely used methods for the analysis of methotrexate are immunoassays, particularly fluorescence polarisation immunoassay. After oral administration, the drug is rapidly but incompletely absorbed. Since food does not significantly affect the bioavailability of oral methotrexate in adult patients, the drug may be taken regardless of meals. There is a marked interindividual variability in the extent of absorption of oral methotrexate. Conversely, the intraindividual variability is moderate even over a long time period. Intramuscular and subcutaneous injections of methotrexate result in comparable pharmacokinetics, suggesting that these routes of administration are interchangeable. A mean protein binding to serum albumin of 42 to 57% is usually reported. Again, the unbound fraction exhibits a large interindividual variability. The steady-state volume of distribution is approximately 1 L/kg. Methotrexate distributes to extravascular compartments, including synovial fluid, and to different tissues, especially kidney, liver and joint tissues. Finally, the drug is transported into cells, mainly by a carrier-mediated active transport process. Methotrexate is partly oxidised by hepatic aldehyde oxidase to 7-hydroxymethotrexate. This main, circulating metabolite is over 90% bound to serum albumin. Both methotrexate and 7-hydroxy-methotrexate may be converted to polyglutamyl derivatives which are selectively retained in cells. Methotrexate is mainly excreted by the kidney as intact drug regardless of the route of administration. The drug is filtered by the glomeruli, and then undergoes both secretion and reabsorption processes within the tubule. These processes are differentially saturable, resulting in possible nonlinear elimination pharmacokinetics. The usually reported mean values for the elimination half-life and the total body clearance of methotrexate are 5 to 8 hours and 4.8 to 7.8 L/h, respectively. A positive correlation between methotrexate clearance and creatinine clearance has been found by some authors. Finally, the pharmacokinetics of low-dose methotrexate appears to be highly variable and largely unpredictable even in patients with normal renal and hepatic function. Furthermore, studies in patients with juvenile rheumatoid arthritis provide evidence of age-dependent pharmacokinetics of the drug. These features must be considered when judging the individual clinical response to methotrexate therapy. Various drugs currently used in RA may interact with methotrexate. Aspirin might affect methotrexate disposition to a greater extent than other nonsteroidal anti-inflammatory drugs without causing greater toxicity. Corticosteroids do not interfere with the pharmacokinetics of methotrexate, whereas chloroquine may reduce the gastrointestinal absorption of the drug. Folates, especially folic acid, have been shown to reduce the adverse effects of methotrexate without compromising its efficacy in RA. Finally, both trimethoprim-sulfamethoxazole (cotrimoxazole) and probenecid lead to increased toxicity of methotrexate, and hence should be avoided in patients receiving these drugs. A relationship between oral dosage and efficacy has been found in the range 5 to 20mg methotrexate weekly. The plateau of efficacy is attained at approximately 10 mg/m2/week in most patients. No clear relationship between pharmacokinetic parameters and clinical response has been demonstrated. Overall, the dosage must be individualised because of interindividual variability in the dose-response curve. This variability is probably related, at least in part, to the wide interindividual variability in the disposition of the drug.

Decreased pituitary sensitivity to glucocorticoids in endurance-trained men.

OBJECTIVE: Muscular exercise induces hypothalamo-pituitary-adrenal (HPA) axis activation and when regularly repeated, as in endurance training, leads to HPA axis adaptation. To assess whether non-professional endurance-trained (ET) men with a substantial training load and no clinical or biological features of HPA axis overactivity can present subtle alterations of HPA axis sensitivity to glucocorticoid negative feedback, nine ET men were subjected to HPA axis testing using the dexamethasone-corticotrophin-releasing hormone (CRH) test. DESIGN: Nine endurance-trained men and eight healthy age-matched sedentary men were studied. Morning plasma cortisol and 24 h urinary free cortisol (UFC) were determined and a low dose dexamethasone suppression test (LDDST) was performed followed by CRH stimulation (dexamethasone-CRH test). RESULTS: After a day without physical exercise, at 0800 h, plasma ACTH and cortisol concentrations, and the 24 h UFC and UFC/urinary creatinine (UC) ratio were similar in ET and sedentary men. By contrast, clear differences between the groups were seen in cortisol and ACTH responses to the dexamethasone-CRH test. In eight ET subjects, after LDDST, basal ACTH and cortisol levels were similar to those of sedentary men, whereas one ET subject displayed a poor suppression of cortisol level (131 nmol/l). After injection of CRH, however, three of nine ET men's cortisol levels were not suppressed by dexamethasone but instead displayed significant CRH-induced increase (peak cortisol: 88, 125 and 362 nmol/l). No sedentary subject exhibited any increase in cortisol levels. CONCLUSION: Three of nine ET men with a mean maximum rate of O2 uptake (VO2, max) of 61 ml/kg per min, running 50-70 km per week, were resistant to glucocorticoid suppression during the combined dexamethasone-CRH test.

Determination of third-generation cephalosporins by high-performance liquid chromatography in connection with pharmacokinetic studies.

The third-generation cephalosporins are semisynthetic beta-lactam antibiotics, including several oral and parental agents with extended activity against Gram-negative pathogens. They are generally determined either by microbiological techniques or by high-performance liquid chromatography (HPLC). The major drawback or bioassays is the lack of specificity, especially when a biotransformation of the cephalosporin molecule leads to active metabolites, or when the antibacterial therapy is based on association with drugs. Thus, for many years, numerous reversed-phase HPLC procedures have been proposed to overcome these difficulties. This review presents different HPLC methods proposed for the quantification in biological fluids of fourteen third-generation cephalosporins, ranged between parenteral and oral compounds. The sensitivity and specificity of these chromatographic procedures are discussed with regard to the pharmacokinetic properties of the antibiotics studied.

Influence of lipophilicity on the diffusion of cephalosporins into the cerebrospinal fluid.

The aim of this quantitative structure-activity relationship (QSAR) study was to investigate the influence of lipophilicity on the diffusion of cephalosporins into the cerebrospinal fluid (CSF). The lipophilicity was expressed as the chromatographic capacity factor (log k'w) determined by high-performance liquid chromatography in a reversed-phase system. The penetration of eight cephalosporins into CSF was studied in male Wistar rats receiving the drugs intramuscularly (1.5 mg/kg). One hour after administration, CSF and blood samples were collected, and concentrations of free drug were measured in CSF (CCSF) and in plasma (CP). A significant parabolic relationship was sought between lipophilicity (log k'w) and the capacity of diffusion across the blood-brain barrier expressed as log (CCSF/CP). The cephalosporins exhibiting a moderate lipophilicity diffused well into CSF. A pharmacokinetic study was performed at 1, 2 and 4 h after administration of three cephalosporins: cefazolin, ceftriaxone and cefsulodin. These compounds were choosen according to their lipophilicities (low, moderate and high values, respectively). The AUC0-4h for both free plasma (AUCP) and cerebrospinal fluid (AUCCSF) concentrations were determined. The AUCCSF/AUCP ratio presented a maximum value for a strongly albumin bound cephalosporin, ceftriaxone. In our experimental conditions, the ideal lipophilicity (log k'w) range for diffusion of cephalosporins from plasma into CSF was between 1.6 and 1.8.

Passage of S-(+)- and R-(-)-ketoprofen across the human isolated perfused placenta.

Ketoprofen is a chiral non-steroidal anti-inflammatory drug (NSAID) available as a racemic (rac) mixture of S-(+)- and R-(-)-isomers. Its inhibitory effect on prostaglandin biosynthesis resides virtually in the S-form. Interestingly, R-ketoprofen does not undergo substantial metabolic inversion in humans. Though contraindicated during the last trimester of pregnancy, NSAIDs, including ketoprofen, are used as tocolytic agents in some cases. The S/R plasma concentration ratio was reported to average 2.3 in premature neonates whose mothers were given rac-ketoprofen and to be close to 1 in the maternal plasma. Thus, we investigated the placental transfer of rac-ketoprofen in vitro using Schneider's perfused human cotyledon model. Glucosed Earle solutions with and without human serum albumin (HSA) were used. Several maternal perfusates were tested with different rac-ketoprofen concentrations together with 20 mg L-1 of antipyrine as a reference substance. Ketoprofen enantiomers were assayed by a specific HPLC method with derivatization procedure. HSA concentrations in maternal perfusate influenced the placental transfer of ketoprofen enantiomers. In the absence of HSA in the maternal perfusate, the S-(+)/R-(-) concentration ratio was close to 1 in the fetal perfusate. By contrast, this ratio averaged 1.44 after addition of HSA 10 g L-1 on the maternal side. Similar results were found for dialysis experiments using an inert Spectrapor 2 membrane suggesting that the S-(+)-free concentration is superior to the R-(-)-free concentration in the presence of HSA. Direct measurements of the free concentrations by centrifugal ultrafiltration confirmed this hypothesis. Accordingly, the data observed in vivo may result, at least in part, from the stereoselective protein binding of ketoprofen.

Rapid high-performance liquid chromatographic measurement of amisulpride in human plasma: application to manage acute intoxication.

Amisulpride, a substituted benzamide derivative, is a second-generation (atypical) antipsychotic and is effective as maintenance therapy in patients with schizophrenia. For toxicological purpose, a rapid RP-HPLC assay was developed for the determination of amisulpride in human plasma. A linear response was observed over the concentration range 100-1000 ng/ml. A good accuracy (< or =5%) was achieved for all quality controls, with intra- and inter-day variation coefficients equal or inferior to 4.9%. The lower limit of quantification was 20 ng/ml, without interferences of endogenous components. This rapid method (run time <5 min) was used to monitor eight intoxications involving amisulpride.

Determination of mirtazapine and its demethyl metabolite in plasma by high-performance liquid chromatography with ultraviolet detection. Application to management of acute intoxication.

Mirtazapine is a new centrally acting noradrenergic and specific serotonin antidepressant, with an active demethyl metabolite. For toxicological purposes, a specific and accurate RP-HPLC assay was developed for the simultaneous plasma determination of these compounds. A linear response was observed over the concentration range 50-500 ng/ml. A good accuracy (bias <10%) was achieved for all quality controls, with intra-day and inter-day variation coefficients less than 8.3%. The lower limit of quantification was 20 ng/ml, without interferences with endogenous or exogenous components. This rapid method (run time <12 min) was used to manage three intoxications involving mirtazapine.

Simultaneous determination of four antipsychotic drugs in plasma by high-performance liquid chromatography. Application to management of acute intoxications.

A specific reversed phase-high pressure liquid chromatography (RP-HPLC) method has been developed for the simultaneous determination of clozapine (CZP), loxapine (LXP), zuclopenthixol (ZPT) and flupenthixol (FPT) in plasma. These four antipsychotic drugs are frequently used for the treatment of schizophrenia and other neuropsychiatric diseases. Carpipramine, a dihydrodibenzazepine, was used as an internal standard (I.S.). A liquid-liquid procedure was used to extract the drugs from human plasma. The analysis was performed on a XTerra MS C18 column with UV detection. Calibration curves were linear in the range 50-1000 microg/l. The limit of quantification (LOQ) was 15 microg/l for clozapine and loxapine and 20 microg/l for zuclopenthixol and flupenthixol. The coefficient of variation (CV) for intra- and inter-day precision was 7.2% or less with accuracies within 10% for the three concentrations.This isocratic and rapid method (run time<10 min) is useful for the management of acute intoxication.

High-performance liquid chromatographic method with diode array detection to identify and quantify atypical antipsychotics and haloperidol in plasma after overdose.

For toxicological purposes, an HPLC assay was developed for the simultaneous determination of haloperidol and atypical antipsychotics (risperidone, 9-hydroxyrisperidone, olanzapine, clozapine) in human plasma. After a double-step liquid-liquid extraction, compounds were separated on a C(8) column eluted with a gradient of acetonitrile and phosphate buffer 50 mM pH 3.8. A sequential ultraviolet detection was used (260, 280 and 240 nm). Calibration curves were linear in the range 10-1000 ng/ml. The limits of quantification were 5 ng/ml for all drugs. Average accuracy at four concentrations ranged from 93 to 109%. Both inter- and intra-day variation coefficients were lower than 11% for all drugs. This simple and rapid method (run time<15 min) is currently used for poison management.

Piroxicam concentrations in plasma and synovial fluid after a single dose of piroxicam-beta-cyclodextrin.

AIMS: The efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in rheumatic diseases depends on their concentrations within the joint. We determined piroxicam concentrations in plasma and synovial fluid (SF) after a single oral dose of 20 mg in the form of one tablet of piroxicam-beta-cyclodextrin. METHODS: 45 patients, aged 21 to 84 years, presenting with an effusion of the knee, related to degenerative or inflammatory joint disease, were included in this study after having given their written consent. One blood and one SF sample were drawn concomitantly in each patient from 0.5 to 48 h after NSAID administration. Piroxicam assays were performed by high performance liquid chromatography. Pharmacokinetic parameters were obtained from the mean plasma and synovial concentrations measured at various sampling times. RESULTS: The peak concentration was higher in plasma (2.51+/-0.25 microg/ml) than in SF (1.31+/-0.76 microg/ml), but the elimination half-life was much longer in SF (90.7 h) than in plasma (32.5 h). The SF/plasma area under the concentration-time curve ratio (evaluating the quantity of NSAID transferred from the blood to the joint) was equal to 0.39. CONCLUSIONS: Piroxicam contained in piroxicam-beta-cyclodextrin diffused well into the SF where its pharmacokinetic profile corresponded to that of a long half-life NSAID.

Determination of buprenorphine in plasma by liquid chromatography: application to heroin-dependent subjects.

A rapid, sensitive, precise and accurate HPLC assay with UV detection was developed for the determination of buprenorphine (BN) in human plasma. This method involved a two-step extraction in the presence of clothiapine as internal standard. The compounds were chromatographied on a reversed-phase Spherisorb C8 column with a mobile phase consisting of 0.06 M KH2PO4/Na2HPO4 pH 6.4-acetonitrile-triethylamine-Pic B5 (520:480:0.5:15, v/v) and detected at 214 nm. The recovery of BN was greater than 94% with an intra-day relative standard deviation < or = 4.8% and an inter-day relative standard deviation < or = 14.6% at any studied level. Studies of drug stability during sample storage at -20 degrees C and at +4 degrees C did not show any significative degradation of BN. This method was successfully applied to explore the overdose state of heroin-dependent subjects treated by high-dose BN.

In vitro distribution of ketoprofen enantiomers in articular tissues of osteoarthritic patients.

The distribution of ketoprofen enantiomers in joint tissues was studied as a function of their relative tissular affinities using the multi-chamber distribution dialysis system described by Bickel et al. Selected off-cuts of synovial membrane, joint capsule, cartilage and ligament were obtained from ten patients suffering from osteoarthritis of the knee (n=3) or hip (n=7). Sörensen solution (4 ml) spiked with racemic ketoprofen (2 microg ml(-1)) was dialysed against 1 ml of the four solutions of tissue homogenates (0.4 g ml(-1)). Ketoprofen enantiomers were quantified in buffer and tissue solutions by high-performance liquid chromatography. The distribution of ketoprofen enantiomers in the Bickel's multi-compartment model indicated that there was a non-stereoselective affinity of ketoprofen enantiomers for their potential target tissues. Despite the interindividual variability in articular tissues, the concentrations (+/-S.D.) of R- and S-ketoprofen were significantly higher in synovial membrane (8.69 (4.76) microg g(-1) for S, 9.14 (5.57) microg g(-1) for R), joint capsule (5.71 (2.49) microg g(-1) for S, 5.49 (2.62) microg g(-1) for R) and ligament (6.28 (3.61) microg g(-1) for S, 6.40 (3.64) microg g(-1) for R) than in articular cartilage (3.67 (1.75) microg g(-1) for S, 3.70 (1.67) microg g(-1) for R). There were no significant differences in the distribution of R- and S-ketoprofen between the solutions of joint capsule, synovium and ligament tissues. These data may be related to differences in ketoprofen affinity for the different constituents of joints. This in vitro distribution profile is similar to that reported in vivo for other non-steroidal anti-inflammatory drugs.

Relationship between lipophilicity and binding to human serum albumin of arylpropionic acid non-steroidal anti-inflammatory drugs.

A possible relationship between lipophilicity and binding to human serum albumin was investigated for 11 arylpropionate non-steroidal anti-inflammatory drugs. The lipophilic parameter was determined by a reversed-phase high-performance liquid chromatographic procedure as the capacity factor (k'). The binding of arylpropionic acids to human serum albumin was studied in vitro by equilibrium dialysis. For each compound, a Scatchard analysis was performed considering two classes of binding sites characterized by high- and low-affinity constants, K1 and K2, respectively. A linear relationship was found between lipophilicity and binding parameters, n1K1 (r = 0.88, P < 0.0005) and n2K2 (r = 0.96, P < 0.0002). These results suggest the role of hydrophobic interactions in the binding of arylpropionic acids to human serum albumin.

Influence of a polymeric formulation of ketoprofen on its diffusion into cerebrospinal fluid in rats.

Poly(D,L)lactide nanocapsules (NCs) have been proposed as an alternative carrier for many drugs. We investigated the influence of this formulation on the pharmacokinetics of ketoprofen in the plasma and cerebrospinal fluid (CSF). Male Wistar rats were given intraperitoneal dose of ketoprofen (5 mg/kg) in a suspension of NCs or in a carboxymethylcellulose (CMC) solution (reference preparation). Blood and CSF samples were collected at different times up to 24 h after dosing. The unbound fraction of ketoprofen in plasma (f(u)) was determined using ultrafiltration. The total (C(T)) and free (C(F)) concentrations of ketoprofen in plasma and the simultaneous CSF concentrations (C(CSF)) were measured by a HPLC method and the areas under the curve (AUC(T), AUC(F), AUC(CSF)) were calculated. AUC(T) of ketoprofen-loaded NCs in plasma was similar to that of the reference solution, while AUC(F) of the former (5.41 mg/l x h) was higher than that produced by the latter (4.03 mg/l x h). Accordingly, the unbound fraction (f(u)) was higher after administration of NCs than that of the solution (2.5 and 1.8%, respectively). Finally, AUC(CSF) were identical for both formulations. These findings suggest that the binding of ketoprofen to plasma proteins is not the major factor that governs its blood-to-CSF exchanges.

[Pharmacokinetics of cimetidine in ascitic cirrhotics]. / Pharmacocinétique de la cimétidine chez le cirrhotique ascitique.

Eleven patients with ascitic cirrhosis and eleven patients without liver disease received 200 mg of cimetidine orally and intravenously. Plasma concentrations of cimetidine were analysed by high pressure liquid chromatography. No differences were observed in cimetidine half-life (2.53 +/- 0.63 and 2.33 +/- 0.40 h) between the two groups. Cimetidine clearance was diminished by about 30 p 100 in cirrhotic patients (0.426 +/- 0.138 vs. 0.649 +/- 0.163 l/h/kg). The apparent volume of distribution was also significantly diminished (1.50 +/- 0.44 vs. 2.14 +/- 0.55 l/kg) in patients with cirrhosis and ascites.

Benzodiazepines and hip fractures in elderly people: case-control study.

OBJECTIVE: To determine whether benzodiazepines are associated with an increased risk of hip fracture. DESIGN: Case-control study. PARTICIPANTS: All incident cases of hip fracture not related to traffic accidents or cancer in patients over 65 years of age. 245 cases were matched to 817 controls. SETTING: Emergency department of a university hospital. MAIN OUTCOME MEASURES: Exposure to benzodiazepines and other potential risk or protective factors or lifestyle items. RESULTS: The use of benzodiazepines as determined from questionnaires, medical records, or plasma samples at admission to hospital was not associated with an increased risk of hip fracture (odds ratio 0.9, 95% confidence interval 0.5 to 1.5). Hip fracture was, however, associated with the use of two or more benzodiazepines, as determined from questionnaires or medical records but not from plasma samples. Of the individual drugs, only lorazepam was significantly associated with an increased risk of hip fracture (1.8, 1.1 to 3.1). CONCLUSION: Except for lorazepam, the presence of benzodiazepines in plasma was not associated with an increased risk of hip fracture. The method used to ascertain exposure could influence the results of case-control studies.

[Pharmacokinetics of methotrexate in rheumatoid arthritis: therapeutic implications]. / Pharmacocinétique du méthotrexate dans la polyarthrite rhumatoide: implications thérapeutiques.

The fraction of oral methotrexate (MTX) absorbed averages 70 per cent at low doses (< or = 10 mg/m2), both fasting and after food. The mean binding of MTX to serum albumin is 42-57 per cent. Less than 10 per cent of MTX is oxidised to 7-OH-MTX. Furthermore, MTX is partly converted to polyglutamate derivatives which accumulate in some cells resulting in sustained efficacy of the drug in spite of its relatively short plasma elimination half-life. MTX is mainly excreted by the kidney as intact drug. Accordingly careful monitoring of renal function is justified. MTX undergoes bidirectional transport within the renal tubules leading to drug interactions. Oral, intramuscular and subcutaneous routes of administration were reported to result in comparable bioavailability. There is a marked interindividual variability in MTX disposition. Conversely, the intraindividual variability is moderate even over a long time period. Finally, no clear relationship between pharmacokinetic parameters and clinical response or toxicity has been found in patients with rheumatoid arthritis.

[Plasmatic dosage of antiretroviral drugs by high performance liquid chromathography ]. / Dosage plasmatique des antirétroviraux par chromatographie liquide haute performance.

A high-performance liquid chromatographic method has been developed for the determination of eight antiretroviral drugs (amprenavir, indinavir, lopinavir, nelfinavir, ritonavir, saquinavir, efavirenz and nevirapine) in a single run. After a liquid-liquid extraction with diethylether, the antiretroviral drugs are separated on a Stability RP18 column eluted with a gradient of acetonitrile and phosphate buffer (50 mM pH 5.65). A sequential ultraviolet detection allowed for simultaneous quantitation of antiretroviral drugs (240, 215, 260 nm). Calibration curves were linear in the range 100-10,000 ng/ml. The limit of quantitation was 50 ng/ml for all drugs except for nevirapine (100 ng/ml). The accuracies ranged from 88.2% to 110.9% and both inter- and intra-day coefficients of variation were lower than 11%. The extraction recoveries were higher than 62%. This method is simple and shows good specificity with respect to commonly coprescribed drugs.

[Pharmacokinetics in the elderly]. / Pharmacocinétique chez le sujet âgé

Physiological changes that occur in the aging process may directly affect drug pharmacokinetics. In the absence of disease or other pathologic conditions, age-related changes in pharmacokinetics principally affect drug absorption, distribution, metabolism or elimination. One factor that does change consistently with age is renal clearance, consequently a common pharmacokinetic change is reduced drug clearance, especially for drugs excreted largely unchanged by the kidneys. Alteration of the pharmacokinetics of drugs in the elderly may necessitate adjustment of dosages to prevent toxicity or inadequate therapy. As a broad generalization, dosage should be reduced in elderly patients, reflecting the general decline in body function with age.