Pharmacokinetic studies of tolmetin in man.

The pharmacokinetics of the new anti-inflammatory agent tolmetin have been studied after its oral administration to normal subjects and to patients with rheumatoid arthritis. Plasma concentration-time data were fitted to a one-compartment open model. Following single oral doses, no basic differences in rates of drug absorption and elimination were found between normal subjects and arthritic patients. For the 12 subjects studied, the overall mean elimination rate constant was 0.839 hr-1, corresponding to a plasma half-life of 0.83 hr. The drug was rapidly absorbed and had a mean apparent volume of distribution of 0.098 l/kg. Plasma levels and pharmacokinetic parameters of tolmetin in arthritic patients after multiple dosing were smaller to those after a single dose.

Rate of motor response to oral levodopa and the clinical progression of Parkinson's disease.

We investigated the relationship between the rate of motor response after a standard levodopa oral dose and drug dynamic variables and disease-related factors in 66 patients with Parkinson's disease. Time to maximum finger tapping effect was positively correlated with matched duration of levodopa dose response and fell from a median 120 minutes in patients at Hoehn and Yahr stage I and II to 60 minutes in stage IV patients (p < 0.001). The accelerated response to levodopa dose with the advancement of disease was also apparent as an increased steepness of the tapping effect versus time curve, with a shift from a hyperbolic to a sigmoid profile. The rate of motor response to oral levodopa may reflect the rate of dopamine interaction with the postsynaptic receptors, providing an indirect objective index of presynaptic dopaminergic homeostasis.

Gastric emptying rate and the systemic availability of levodopa in the elderly parkinsonian patient.

The gastric emptying rate and systemic availability of levodopa, administered as a single oral dose, was studied in six elderly parkinsonian patients, five elderly nonparkinsonian subjects, and six young healthy volunteers. In both elderly groups, gastric emptying was slowed relative to the young healthy volunteers. The lack of significant differences in the plasma elimination half-life of levodopa among the three groups was accompanied by increased absorption of the drug in the elderly patient groups. These findings are discussed in relation to a possible age-related alteration in the activity of peripheral dopa decarboxylase in the elderly parkinsonian patients.

Clinical pharmacokinetics of the non-depolarising muscle relaxants.

Muscle relaxants are of great benefit to the anaesthetist as adjuncts to anaesthesia. These drugs are used to facilitate endotracheal intubation and to reduce muscle tone during surgery, and may also find application in assisting ventilator care in the intensive care situation. The pharmacological effect of the relaxants may be readily assessed by the anaesthetist by means of a variety of techniques to quantify muscular activity in response to electrical stimulation. A number of factors may modify the effects of the muscle relaxants including anaesthetic agents, hypothermia, patient age and disease status and a variety of drugs. The disposition kinetics of the muscle relaxants have been well characterised although information on protein binding and placental transfer is somewhat scanty. A common characteristic of their pharmacokinetics is multicompartmental behaviour. Clearance of the relaxants ranges from total elimination by the kidneys (gallamine) to substantial hepatic clearance (fazadinium), and thus their clearance may be adversely affected by renal or hepatic disease. Dosage regimens have been designed using knowledge of the disposition kinetics of the relaxants to provide for continuous adequate relaxation during prolonged surgical procedures. With the use of sophisticated pharmacokinetic and pharmacodynamic models good relationships have been demonstrated between plasma concentrations of the relaxants throughout the entire range of relaxant response.

Gastric emptying rate in the elderly: implications for drug therapy.

The effect of the aging process on gastric emptying was studied in 11 elderly subjects (mean age, 77) and in 7 young healthy volunteers (mean age, 26). Gastric emptying rates were assessed by a modified sequential scinti-scanning technique after administration of the nonabsorbable chelated radiopharmaceutical 99mTc-DTPA. The rate of emptying, expressed as half-time (T 1/2e) in minutes, was significantly longer (p less than 0.001) in the elderly subjects (mean apparent T 1/2e = 123.23 min) compared to the young healthy volunteers (mean apparent T 1/2e = 49.69 min). Clinical implications of these findings are discussed, particularly with respect to the rate and extent of drug absorption in elderly persons.

Relationship between gallamine plasma concentration and neuromuscular paralysis in surgical patients.

The pharmacodynamics of the neuromuscular blocking drug gallamine were investigated in 10 surgical patients using a constant-rate infusion regimen, and results are compared to those for d-tubocurarine (dTc). Gallamine effect (paralysis)-time data gathered during and following the infusion were fitted to a pharmacodynamic effect model, while paralysis-plasma concentration data gathered during (onset) and following (offset) the infusion were fitted separately to a nonlinear form of the Hill equation. The effect model was most appropriate in characterizing the combined (on and off infusion) effect data. While there was also an excellent characterization of onset and offset data with the Hill equation, the two effect-concentration curves were not superimposable. The mean (+/- S.D.) plasma concentration of gallamine at 50 per cent paralysis during onset of action (Cp50(onset) 8.0 +/- 1.8 micrograms/ml) or that predicted to exist at steady state using the effect model (Cp50(ss) 5.4 +/- 1.4 micrograms/ml). Cp50(offset) and Cp50(ss) did not differ significantly, and there was no significant difference in the power factor (lambda) estimates for the various model fits. Comparison of the pharmacodynamic parameters for gallamine and dTc using the effect model revealed no significant differences in keo, t1/2(keo), and lambda estimates. However, Cp50(ss) for gallamine (5.4 +/- 1.4 micrograms/ml) was nine times higher than that for dTc (0.61 +/- 0.15 micrograms/ml) in absolute terms and seven times higher when compared on a molar basis.

Use of methotrexate in older patients. A risk-benefit assessment.

Methotrexate is eliminated almost entirely by the kidneys. The risk of methotrexate toxicity is therefore increased in patients with poor renal function, most likely as a result of drug accumulation. Declining renal function with age may thus be an important predictor of toxicity to methotrexate. Up to 60% of all patients who receive methotrexate for rheumatoid arthritis (RA) discontinue taking it because of adverse effects, most of which occur during the first year of therapy. Gastrointestinal complications are the most common adverse effects of methotrexate, but hepatotoxicity, haematological toxicity, pulmonary toxicity, lymphoproliferative disorders and exacerbation of rheumatic nodules have all been reported. Decreased renal function as a result of disease and/or aging appears to be an important determinant of hepatic, lymphoproli ferative and haematological toxicity. Concomitant use of low doses of folic acid has been recommended as an approach to limiting toxicity. Interactions between methotrexate and several nonsteroidal anti-inflammatory drugs have been reported, but they may not be clinically significant. However, caution is advised in the use of such combinations in patients with reduced renal function. More serious toxicities (e.g. pancytopenia) may result when other inhibitors of folate utilisation [e.g. cotrimoxazole (trimethoprim-sulfamethoxazole)] or inhibitors of renal tubular secretion (e.g. probenecid) are combined with methotrexate. Before starting low dose methotrexate therapy in patients with RA, a full blood count, liver function tests, renal function tests and chest radiography should be performed. Blood counts and liver function tests should be repeated at regular intervals. Therapeutic drug monitoring of methotrexate has also been suggested as a means of limiting toxicity. Patients with RA usually respond very favourably to low dose methotrexate therapy, and the probability of patients continuing their treatment beyond 5 years is greater than for other slow-acting antirheumatic drugs. Thus, given its sustained clinical utility and relatively predictable toxicity profile, low dose methotrexate is a useful addition to the therapy of RA.

Apple II program to simulate the response-time profile of non-depolarising muscle relaxants.

We have developed a BASIC program for the Apple II microcomputer which can simulate the effect (degree of paralysis) time curve obtained following bolus intravenous administrations of pancuronium. The program is based on a combined pharmacokinetic/pharmacodynamic model and has practical application to the anaesthetist under operating room conditions. Knowing the disease state of the patient and the doses and times of administration of pancuronium the microcomputer can predict the degree of paralysis which exists at any time and so assists in the timing of the next dose of relaxant and in deciding when to effect reversal.

Oral administration of erythromycin stearate: effect of dosage form on plasma levels.

The clinical effectiveness of three different oral dose forms of erythromycin stearate was assessed by following plasma levels during continued dosage. The assessment was carried out in 12 volunteers who took 250 mg of the drug every six hours in a cross-over design with intravenous administration of erythromycin lactobionate as a reference. While in some patients levels which were obtained after the initial dose were low, plasma levels sufficient to inhibit the majority of bacterial pathogens which cause acute respiratory tract infections were obtained and maintained after the second dose.

Disposition of ceftriaxone in rat: application of a pharmacokinetic-protein binding model and comparison with cefotaxime.

1. The pharmacokinetic profile and protein binding parameters of ceftriaxone were determined in rat, and compared with those of cefotaxime. 2. Plasma concentration-time curves of ceftriaxone and cefotaxime (single i.v. bolus; 100 mg/kg each) were described by a two-compartment, protein-binding model. 3. The corrected VTss (ml/kg) of ceftriaxone was lower than that of cefotaxime. The AUCs of both drugs were similar. The t1/2 beta of the two drugs differed significantly, being 29 min for ceftriaxone and 17 min for cefotaxime. 4. In vivo protein binding constants of both drugs were similar, but the concentrations of protein binding sites differed significantly. The average free fractions in plasma (Fp) of ceftriaxone and cefotaxime were 0.22 and 0.48 respectively. 5. Saturation of the binding site for cefotaxime was estimated to occur at about 30 micrograms/ml in plasma, whereas saturation for ceftriaxone was seen at lower concentrations.

High-performance liquid chromatographic assay of cefotaxime, desacetylcefotaxime and ceftriaxone in rat plasma.

A simple and selective high-performance liquid chromatographic method is described for the analysis of the cephalosporins cefotaxime (CXM), desacetylcefotaxime (DACXM) and ceftriaxone (CFX) in rat plasma. Plasma was deproteinized with methanol, and the supernatant was directly injected into the chromatograph and monitored at 254 nm. For determination of the unbound drugs, a centrifugal ultrafiltration method was employed. The calibration curves were linear (r = 0.999) from 2.5 to 500 micrograms/ml; the detection limits were 100 ng/ml for DACXM and 250 ng/ml for CXM and CFX. The method was not interfered with by other plasma components, nor by barbital sodium or caffeine, and has been applied to study the pharmacokinetics of the cephalosporins in rats.

High-performance liquid chromatographic method for the quantitation of bupivacaine, 2,6-pipecoloxylidide and 4'-hydroxybupivacaine in plasma and urine.

A high-performance liquid chromatographic method with ultraviolet detection at 210 nm for quantitation of bupivacaine and two of its metabolites from plasma and urine is described. The compounds are extracted into n-hexane-isopropanol (5:1), evaporated and the reconstituted residue injected onto a reversed phase C18 column. Standard curves for all compounds were linear (r2 greater than 0.999) in the range 20-2000 ng/ml, with a limit of detection of 10 ng/ml. The inter-day coefficients of variation ranged between 2.7 and 12.2%. The method was applied to analyse bupivacaine and metabolite concentrations in patients on long-term epidural bupivacaine-fentanyl infusions.

Clinical pharmacokinetics of pancuronium bromide.

Plasma concentrations of pancuronium bromide have been studied in seven surgical patients following a 6 mg intravenous bolus injection of the drug for neuromuscular blockade. Concurrently, evoked muscle twitch response was monitored for each patient as a measure of the pharmacodynamic effect of the drug. The plasma decay curve for pancuronium was found to be biphasic and after rigorous statistical analysis the data were interpreted according to a 2-compartment open model. The half-life of the beta-phase varied between 89.5 and 161.5 min. The apparent volume of distribution of the central compartment ranged from 62.9 to145.5 ml/kg and the plasma clearance from 57.6 to 187.3 ml/min. At the first sign of recovery from neuro-muscular blockade the mean pancuronium plasma level was found to be 0.218 mcg/ml. The mean duration of action as measured from time of onset of paralysis to 20% recovery was 83.4 min with the plasma level at 20% being 0.169 mcg/ml corresponding to 45.4% of dose remaining to be eliminated from the body.

Plasma concentrations of pancuronium during predetermined intensities of neuromuscular blockade.

The plasma concentrations of pancuronium were monitored during i.v. infusions of the relaxant in dogs. Pancuronium was administered at rates which maintained the degree of neuromuscular blockade at three predetermined levels. The concentrations of the drug in the blood were consistent for any one animal but showed considerable overlap for the three levels of paralysis between animals. Concentrations obtained during infusion and which maintained the twitch response at 20% and 80% of control were compared, in the same dogs, with concentrations obtained during recovery from a bolus injection of pancuronium. When the infusion maintained the twitch response at 20% of the control value, the mean plasma concentration of pancuronium was 0.152 microgram ml-1. That measured after the bolus injection was 0.156 microgram ml-1. The concentrations at 80% of control were 0.094 microgram ml-1 and 0.083 microgram ml-1 respectively. The agreement between these results suggests a relationship between the plasma concentration of the relaxant and its effect during the termination of the action after a large bolus injection of the drug. As this occurs chiefly during the postdistribution equilibrium, the relatively slow decrease in plasma concentration would appear to become the rate-limiting factor in recovery from paralysis.