Drug combinations--concepts and terminology.

The terms "synergism" and "antagonism" are used inconsistently in pharmacology and toxicology designating different circumstances. This is a source of recurring scientific conflict. The present paper elucidates the existing discrepancies, and offers a consistent terminology incorporating also such terms as "additivity", "potentiation", and "simple similarity".

Dose-response analysis of combination preparations.

A parametric model for quantal response to combination preparations is defined and discussed. Tests for additivity of the combination preparation are specified and demonstrated by an example. Parallelism of the dose-response curves is not required.

Application of the isobologram technique for the analysis of combined effects with respect to additivity as well as independence.

Combined actions of two substances with similar effects are frequently expressed by pairs of doses that produce a fixed response, usually 50%, in so-called isobolograms (ED50 isobolograms). In addition to the dose scales in such graphs we propose the addition of effect scales, where possible, to indicate the effect at certain doses, e.g., the ED30. We further propose to construct isoboles for expected independent interaction, in addition to the additivity line, for which purpose a simple procedure is delineated. In practice, an independent isobole for 50% effect passes through the point formed by the ED30s of A and of B in ED50 isobolograms. Thus, the ED30s constitute the "zenith" of an independent isobole in ED50 isobolograms. It is shown that theoretical independent isoboles can either represent additive, overadditive, or underadditive interactions, depending on the steepness of the dose-response curves of the components. Hence, drugs with shallow dose-response curves exhibit overadditive independent effects, compounds with exponentially steep curves show additive independent interactions. Substances with very steep dose-response curves, producing lethal effects, exhibited marked underadditive effects which could be ascribed largely to an independent mechanism of action of the components. Hence, the inclusion of independent isoboles into conventional isobolograms provides new insights into the mechanisms of interactions and into the actions of the components. Interactions can thus be characterized better and more completely, and misinterpretations appear less likely than with conventional isoboles.

[Biochemical aspects of the evaluation of fixed drug combinations]. / Biometrische Aspekte zur Bewertung fixer Arzneimittelkombinationen.

Various disciplines have to contribute to the general problem of the evaluation of fixed dose combination drugs, as for instance (clinical) pharmacology, biometry, scientific drug regulations and public health officials. The EC guideline 75/318/EWG and its eludications as well as the German "Arzneimittelprüfrichtlinien" of Dec. 14, 1989 (as referred to in the "Arzneimittelgesetz" of 1986) required that such issues concerning fixed dosage combination drugs must be considered and taken into account. In this framework it is the responsibility of biometry to both to guarantee the use of a valid study design to assure interpretation of the results and to quantify the reliability of pharmacological and clinical considerations. The following paper is concerned with biometrical aspects of the combination drug problem. Basic considerations from a clinical or a pharmacological point of view with respect to the question of whether fixed combination drugs are reasonable or not are not discussed. To support the use of combinations of drugs, a central argument is the improvement of the benefit risk relation compared with that of an adequate monotherapy. Beyond this the fixed combination drugs require additional arguments regarding the enhencement of the safety or the simplicity of the therapy fixing the ratio. It follows that fixed combination drugs have to be supported twice, first with respect to the combination itself, and second with respect to the fixed mixing ratio of its components. The biometrical aspects of the assessment of the gains from (fixed) drug combinations are related to the kind of benefit/risk improvement that is expected. In the first section we discuss some possible types of benefit and risk.(ABSTRACT TRUNCATED AT 250 WORDS)