Towards a quantitative framework for the prediction of DDIs arising from cytochrome P450 induction.

Although CYP induction is not generally considered to be as clinically relevant as CYP inhibition, there are important examples where induction has caused both therapeutic failure, due to insufficient exposure to parent drug, and toxicity, mediated by increased formation of reactive metabolites. Furthermore, while there has been considerable progress in the extrapolation of in vitro data to predict the in vivo consequences of enzyme inhibition, less attention has been given to the quantitative impact of enzyme induction as a mechanism of drug-drug interaction (DDI) and as a component of compound selection and early drug development. We discuss current approaches in the context of a mechanistic framework for the prediction of the extent and time-course of enzyme induction in vivo based on in vitro experimentation. Factors influencing the extent of DDI due to CYP induction are summarised, and areas deficient in information that would allow more accurate prediction within target populations are highlighted.

Modified-release hydrocortisone for circadian therapy: a proof-of-principle study in dexamethasone-suppressed normal volunteers.

BACKGROUND: All existing long-term glucocorticoid replacement therapy is suboptimal as the normal nocturnal rise and waking morning peak of serum cortisol is not reproduced. AIM: To test whether it is possible to reproduce the normal overnight rise and morning peak in serum cortisol using an oral delayed and sustained release preparation of hydrocortisone (Cortisol(ds)). SUBJECTS AND METHODS: Six healthy normal male volunteers attended on two occasions, in a single-dose, open-label, nonrandomized study. Endogenous cortisol secretion was suppressed by administration of dexamethasone. Cortisol(ds) (formulation A or B) was administered at 2200 h on day 1. Blood samples for measurement of cortisol were taken from 2200 h every 30 min until 0700 h, then hourly until 2200 h on day 2. Fifteen body mass index (BMI)-matched control subjects had serum cortisol levels measured at 20-min intervals for 24 h. Serum cortisol profiles and pharmacokinetics after Cortisol(ds) were compared with those in controls. RESULTS: Formulations A and B were associated with delayed drug release (by 2 h and 4 h, respectively), with median peak cortisol concentrations at 4.5 h (0245 h) and 10 h (0800 h), respectively, thereby reproducing the normal early morning rise in serum cortisol. Total cortisol exposure was not different from controls. CONCLUSIONS: For the first time we have shown that it is possible to mimic the normal circadian rhythm of circulating cortisol with an oral modified-release formulation of hydrocortisone, providing the basis for development of physiological circadian replacement therapy in patients with adrenal insufficiency.

Development and applications of a physiologically-based model of paediatric oral drug absorption.

There is increasing interest in paediatric drug absorption and the development of biopharmaceutics tools to facilitate the development of oral formulations for neonates, infants and children. We describe the development and application of a physiologically-based model of paediatric drug absorption applicable from full term birth onwards. Paediatric age-specific parameters were included for salivary flow, gastric pH, gastric emptying (and associated food effects) and duodenal bile salt concentrations and the associated algorithms were integrated into a dissolution, absorption and metabolism model as part of a PBPK platform. For other parameters, there was either evidence for no age-related changes or a lack of data, so that adult values were applied. An initial assessment of the model was carried out by simulating the oral absorption of theophylline, paracetamol and ketoconazole over a range of paediatric ages. The absorption of the first two drugs, both BCS class 1 compounds, was predicted to be slower in early neonates compared to older age groups (median tmax values of 3 vs 2h, respectively), but with invariant fraction absorbed (fa). This is in agreement with clinical observations. The tmax of ketoconazole, a BCS class 2 compound, was predicted to be about 1h in both neonates and adults, but the fa value was higher in the former (0.87 vs 0.69). There is clearly a need to expand the components of the model as new information on the ontogeny of GI tract parameters becomes available, and to assess it against more in vivo data with evidence of specific age-related changes in oral drug absorption.

A critical evaluation of the experimental design of studies of mechanism based enzyme inhibition, with implications for in vitro-in vivo extrapolation.

The published literature on mechanism based inhibition (MBI) of CYPs was evaluated with respect to experimental design, methodology and data analysis. Significant variation was apparent in the dilution factor, ratio of preincubation to incubation times and probe substrate concentrations used, and there were some anomalies in the estimation of associated kinetic parameters (k(inact), K(I), r). The impact of the application of inaccurate values of k(inact) and K(I) when extrapolating to the extent of inhibition in vivo is likely to be greatest for those compounds of intermediate inhibitory potency, but this also depends on the fraction of the net clearance of substrate subject to MBI and the pre-systemic and systemic exposure to the inhibitor. For potent inhibitors, the experimental procedure is unlikely to have a material influence on the maximum inhibition. Nevertheless, the bias in the values of the kinetic parameters may influence the time for recovery of enzyme activity following re-synthesis of the enzyme. Careful attention to the design of in vitro experiments to obtain accurate kinetic parameters is necessary for a reliable prediction of different aspects of the in vivo consequences of MBI. The review calls for experimental studies to quantify the impact of study design in studies of MBI, with a view to better harmonisation of protocols.

Metformin and cimetidine: Physiologically based pharmacokinetic modelling to investigate transporter mediated drug-drug interactions.

Metformin is used as a probe for OCT2 mediated transport when investigating possible DDIs with new chemical entities. The aim of the current study was to investigate the ability of physiologically-based pharmacokinetic (PBPK) models to simulate the effects of OCT and MATE inhibition by cimetidine on metformin kinetics. PBPK models were developed, incorporating mechanistic kidney and liver sub-models for metformin (OCT and MATE substrate) and a mechanistic kidney sub-model for cimetidine. The models were used to simulate inhibition of the MATE1, MATE2-K, OCT1 and OCT2 mediated transport of metformin by cimetidine. Assuming competitive inhibition and using cimetidine Ki values determined in vitro, the predicted metformin AUC ratio was 1.0 compared to an observed value of 1.46. The observed AUC ratio could only be recovered with this model when the cimetidine Ki for OCT2 was decreased 1000-fold or the Ki's for both OCT1 and OCT2 were decreased 500-fold. An alternative description of metformin renal transport by OCT1 and OCT2, incorporating electrochemical modulation of the rate of metformin uptake together with 8-18-fold decreases in cimetidine Ki's for OCTs and MATEs, allowed recovery of the extent of the observed effect of cimetidine on metformin AUC. While the final PBPK model has limitations, it demonstrates the benefit of allowing for the complexities of passive permeability combined with active cellular uptake modulated by an electrochemical gradient and active efflux.

The use of tolbutamide-induced hypoglycemia to examine the intraislet role of insulin in mediating glucagon release in normal humans.

Disruption of intraislet mechanisms could account for the impaired glucagon response to hypoglycemia in type 1 diabetes. However, in contrast to animals, there is conflicting evidence that such mechanisms operate in humans. We have used i.v. tolbutamide (T) (1.7 g bolus + 130 mg/h infusion) to create high portal insulin concentrations and compared this with equivalent hypoglycemia using an i.v. insulin infusion (I) (30 mU/m2 x min). Ten normal subjects underwent two hypoglycemic clamps; mean glucose; I (53 +/- 1 mg/dL); and T (53 +/- 1 mg/dL) (2.9 +/- 0.04 mmol/L vs. 2.9 +/- 0.05 mmol/L), held for 30 min. During hypoglycemia, mean peripheral insulin levels were greater with I (59 +/- 4 mU/L) than T (18 +/- 3 mU/L), P < 0.001. Calculated peak portal insulin concentrations were greater during T (282 +/- 28 mU/L) than I (78 +/- 4 mU/L), P < 0.00005. The demonstration of a reduced glucagon response during T-induced hypoglycemia (111 +/- 8 ng/L vs. 135 +/- 12 ng/L, P < 0.05) with higher portal insulin concentrations suggests that intraislet mechanisms may contribute to the release of glucagon during hypoglycemia in man.

Caffeine urinary metabolite ratios as markers of enzyme activity: a theoretical assessment.

At least six urinary metabolite ratios of caffeine have been proposed as probes for in vivo CYP1A2 activity and three for in vivo NAT2 activity. Claims for the frequency distribution of the activity of CYP1A2 based on these empirical ratios have varied from log-normal to trimodal. We have examined the validity of these nine ratios by developing computer simulations using values reported in the literature for the kinetic parameters of caffeine and its metabolites. The results show that the sensitivity of the ratios to confounding variables is, in some cases, greater than their sensitivity to the activity of the enzyme that they are intended to mark. The six CYP1A2 ratios did not exhibit the same pattern of dependency on confounding variables which, in turn, resulted in different shapes of population distributions for each ratio as enzyme activity was varied systematically. Although the dependency of the three NAT2 ratios on confounding variable was less marked, they also showed different patterns of dependency. The outcomes of the simulations were consistent with much of the experimental data on caffeine metabolite ratios. To support the findings from the simulations, simplified equations for each metabolite ratio were derived which emphasize the dominant determinants. With some of the CYP1A2 ratios urine flow was significant to the point where its variance and heterogeneity between populations could lead to spurious detection of polymorphism in CYP1A2 function. Also, if the variability of a dominant confounding factor was high and sensitivity of the ratio to intrinsic CYP1A2 activity was low, any polymorphism in the latter would be obscured. When a specific time interval was defined for urine collection, this time was shown to be a critical factor in the ability to discriminate bimodality in some of the ratios, when a marked polymorphism in enzyme activity was assumed. Those ratios which have shown no evidence for bimodality in CYP1A2 function in experimental studies are inherently more discriminant of such heterogeneity compared to those ratios which have been claimed to detect polymorphism of CYP1A2 from experimental data. While recommending a 'best buy' from amongst the caffeine urinary metabolite ratios, we favour plasma/saliva indices (caffeine half-life or paraxanthine/caffeine ratio in a spot sample).

In-vivo indices of enzyme activity: the effect of renal impairment on the assessment of CYP2D6 activity.

Urinary drug:metabolite ratios and urinary recoveries of metabolites, have been used to assess specific enzyme activity non-invasively in vivo. These indices are potentially confounded by the effect of renal function. A recent study of the effects of renal impairment has found discrepancies between different indices used to mark CYP2D6 activity based on sparteine and dextromethorphan urinary recoveries. We have re-examined these experimental data from a theoretical viewpoint. The results suggest that the dependence of fractional urinary recovery of metabolites on renal function varies with the importance of different elimination routes. Therefore, no consistent behaviour of this index is expected when markers with different pharmacokinetics are used. However, when collecting the urine until full recovery of drug and metabolite, drug:metabolite ratios show the same degree of dependence on renal function regardless of the marker. The application of the analysis to the experimental data indicates that CYP2D6 activity is compromised in parallel with deterioration of renal function.

Meta-analysis of studies of the CYP2D6 polymorphism in relation to lung cancer and Parkinson's disease.

Studies of associations between the CYP2D6 polymorphism and susceptibility to specific diseases, particularly lung cancer and Parkinsonism, have produced conflicting results with respect to an under or overrepresentation of poor metabolizers. Accordingly, we have re-evaluated this primary research (18 studies on lung cancer and 18 on Parkinsonism) using meta-analysis. For lung cancer, the median odds ratio (OR) was 0.69 (95% confidence interval (CI) 0.52-0.90), which differed significantly from unity (P < 0.007). A trail comprising 3000 patient and an equal number of control individuals would be required to demonstrate that this observation had arisen purely by chance (i.e. OR = 1). For Parkinson's disease, the analysis gave an OR of 1.32 (95% CI 0.98-1.78), which was of borderline statistical significance (P < 0.074). If the only individual study that was statistically significant was excluded, the P-value increased greatly to 0.489. A study of at least 500 patients and an equal number of control individuals giving the same value as the current mean OR of 1.32 would be required to make the overall analysis statistically significant. In summary, poor metabolizers with respect to CYP2D6 show a small decrease in susceptibility to lung cancer compared with extensive metabolizers and its is hard to justify further studies. The relationship between the CYP2D6 polymorphism and lung cancer, as a determinant of individual susceptibility, is not appreciable (OR = 0.69) compared with that between smoking and lung cancer (OR > 11). Nevertheless, the epidemiological impact on the number of poor metabolizers who are protected from lung cancer may be considerable. With regard to Parkinson's disease, additional well designed studies may allow a definitive conclusion, although any risk for poor metabolizers is likely to be small and therefore of questionable clinical significance. An important lesson from the current review of studies is that much time, effort, expense and patient inconvenience might have been avoid if more attention had been paid to appropriate study design particularly in the selection of control groups.

Debrisoquine and metoprolol oxidation in Zambians: a population study.

The 0-8 h urinary distributions of the metabolic ratios of debrisoquine (10 mg) and metoprolol (100 mg) were measured in 102 healthy, unrelated, black Zambian medical students. There was a statistically significant correlation (rs = 0.60, p < 0.001; n = 88) between the debrisoquine/4-hydroxydebrisoquine (D/HD) and metoprolol/alpha-hydroxymetoprolol (M/HM) ratios. Bimodality in the distribution of the log10D/HD ratio was not evident from visual inspection and following kernel density analysis of the data, although two subjects (ratios 20, 22) would be classified as phenotypic poor metabolizers (PMs) based on the antimode used for Caucasian populations. The distribution of the log10M/HM ratio was skewed and on the basis of kernel density analysis, bimodal. It was clear from visual inspection of the data that the very high M/HM value (> or = 302) of one individual had a profound influence on the population M/HM ratio distribution. No HM was detected in the urine of this subject but he was not one of the two PMs of debrisoquine (D/HD ratio 1.54). H117/04, the major metabolite of metoprolol was also not detected in this sample. Since H117/04 was shown to be present in all samples from previous population studies, the possibility that this subject did not comply with the protocol could not be excluded. All other subjects had M/HM ratios < or = 12.5. These findings suggest that there is a dissociation in the control of debrisoquine and metoprolol oxidation in Zambians as has been observed previously in Nigerians. Furthermore, clear evidence that the metabolism of these drugs exhibits genetic polymorphism in Zambians was not obtained.

Beeturia and the biological fate of beetroot pigments.

Beeturia, the passage of pink or red urine after the ingestion of beetroot, is said to occur in 10-14% of the population, and is more common in iron deficiency and malabsorption. A specific HPLC assay for betacyanins, the red beetroot pigments, in biological fluids was developed to study the prevalence of this apparent polymorphism in humans, and to investigate its basis in rats. Two major peaks were observed in chromatograms of extracts of unpickled beetroot. They had identical UV absorption spectra (lambda max = 535 nm) by diode array analysis, and mass spectrometry indicated that one (betacyanin 1) was betanin or its epimer and the other (betacyanin 2) a disaccharide of betacyanin 1. In a population of 100 normal subjects the 0-8 h urinary recoveries after an oral dose of 60 mg beetroot extract were 0.06-0.54% for betacyanin 1 and 0.01-0.6% for betacyanin 2. The distributions of these data were skewed but not clearly bimodal by visual inspection or by kernel density analysis. Four subjects produced visibly red urine and had betacyanin recoveries at the upper end of the population range. Studies using in situ isolated perfused rat jejunum and liver preparations indicated a negligible absorption of the pigments after 1 h and no detectable metabolism or biliary secretion. Intact anaesthetized rats given i.v. bolus doses of beetroot extract cleared both betacyanins from plasma at the rate of 3.3 +/- 0.9 (SD) ml min-1 (n = 5). The total urinary recovery of both pigments amounted to 80% of the dose, and their renal clearances approached their plasma clearances. These data suggest that beeturia does not arise from deficiencies in hepatic metabolism or renal excretion of betacyanins. After oral administration of beetroot extract to rats the betacyanin content of the stomach decreased rapidly with time but neither the intestines nor the bile duct were stained visibly red. These findings together with those showing instability of the betacyanins in acid conditions suggest that variability in the biological fate of beetroot pigments may be determined largely by gastric pH and emptying rate.

Evidence for a dissociation in the control of sparteine, debrisoquine and metoprolol metabolism in Nigerians.

The 0-8 hour urinary distributions of the metabolic ratios of sparteine (100 mg), debrisoquine (10 mg) and metoprolol (100 mg) were measured in 165 healthy, unrelated, black Nigerian medical students. There was a weak correlation (rs = 0.51, p < 0.001; n = 82) between the metoprolol/alpha-hydroxymetoprolol (M/HM) and the sparteine/total (2- + 5-) dehydrosparteine (S/DHS) ratios. No significant correlations were found between the debrisoquine/4-hydroxydebrisoquine (D/HD) and M/HM ratios (rs = 0.16, n = 33) and between the D/HD and S/DHS ratios (rs = 0.31, n = 38). Both visual inspection and kernel density analysis of the data suggested the presence of two phenotypic groups for sparteine oxidation, with 4% of the population studied being putative poor metabolizers. In contrast biomodality was not apparent in the distribution of the log10M/HM and log10D/HD ratios. These findings provide evidence for a dissociation in the control of metoprolol, sparteine and debrisoquine oxidation in Nigerians and highlight the difficulties in the interpretation of data from pharmacogenetic studies in different ethnic groups.

Polymorphic debrisoquine 4-hydroxylase activity in the rat is due to differences in CYP2D2 expression.

The female Dark Agouti rat is widely used as an animal model for the CYP2D6 poor metabolizer phenotype, males of other strains such as Sprague Dawley or Wistar serving as models for the extensive metabolizer phenotype. To determine the relative level of expression of CYP2D enzymes in the liver of female and male Dark Agouti, Sprague Dawley and Wistar rats, anti-peptide antibodies were raised in rabbits against short synthetic peptides representing the C-termini of the rat P450 enzymes CYP2D1, CYP2D2, CYP2D3, CYP2D4 and CYP2D5. In immunoblotting studies, it was found that the hepatic expression of CYP2D1 was greater in Dark Agouti rats than Sprague Dawley or Wistar rats. In contrast, hepatic CYP2D2 was 30-40-fold less abundant in female Dark Agouti than female Sprague Dawley or Wistar rats and six- to eightfold less abundant in male Dark Agouti than male Sprague Dawley or Wistar rats. No hepatic CYP2D3 could be detected in either sex of any of the three strains. Hepatic CYP2D4 expression was generally greater in male than female rats, and higher in Dark Agouti compared with Sprague Dawley or Wistar strains. CYP2D5 was expressed in the livers of female and male Dark Agouti rats but not in female Sprague Dawley or Wistar rats. This form was variably expressed in livers of male Sprague Dawley and Wistar rats. Hepatic debrisoquine 4-hydroxylase activity was markedly reduced in female and male Dark Agouti rats as compared to Sprague Dawley or Wistar rats and correlated (r = 0.88; P < 0.001) with the hepatic CYP2D2 content. Recombinant CYP2D2 was 18-fold more active at catalysing the 4-hydroxylation of debrisoquine than CYP2D1. Furthermore, quinine markedly inhibited CYP2D2-mediated debrisoquine and metoprolol oxidation, while quinidine, its diastereoisomer, inhibited the reactions to a lesser extent. In conclusion, these results show that impaired debrisoquine 4-hydroxylase activity in the female Dark Agouti rat is due to low levels of CYP2D2.

In-vitro analysis of the contribution of CYP2D6.35 to ultra-rapid metabolism.

From 10 to 30% of CYP2D6 ultra-rapid metabolizers of Caucasian origin harbor alleles with duplicated or amplified functional CYP2D6 genes. Recently, the CYP2D6*35 allele has been reported to be more frequent in ultra-rapid metabolizing subjects than in extensive metabolizers, suggesting a possible role of this variant in CYP2D6 duplication-negative ultra-rapid metabolizing subjects. In this study, we examined the functional consequences of the Val11Met, Arg296Cys and Ser486Thr amino acid substitutions associated with the CYP2D6*35 on the expression and catalytic activity of the variant enzyme, heterologously expressed in yeast. Our results indicate that the functional activity and level of expression of recombinant CYP2D6.35 are comparable with those of the wild-type enzyme, thus precluding the hypothesis that the high level of enzyme activity in CYP2D6 duplication-negative ultra-rapid metabolizing subjects is a consequence of the expression of a more catalytically effective CYP2D6.35 enzyme.

Systemic availability of orally administered meperidine.

A comparison of the areas under the plasma concentration-time curves after intravenous and oral administration of meperidine in 4 normal subjects indicated that 48% to 56% of the oral dose avoided "first-pass" metabolism and was systemically available. Similar estimates were obtained by applying the Loo-Riegelman method for calculating drug absorption viz, 47% to 60%. Oral availability predicted from a knowledge of drug clearance (blood) after intravenouration-time curves after oral administration exhibited irregularities and double peaks possibly indicative of the action of meperidine on the gut or a recycling process.

Altered plasma drug binding in cancer: role of alpha 1-acid glycoprotein and albumin.

Altered concentrations of serum proteins often accompany malignant disease. The effect of these changes on drug binding was studied with lidocaine, a basic drug, and tolbutamide, an acidic drug. Patients with cancer had increased serum concentrations of the acute-phase protein alpha 1-acid glycoprotein (AAG) and lowered serum concentration of albumin. In association with these changes lidocaine binding was increased at all concentrations studied (predialysis concentrations 2, 6, and 10 microgram . ml-1) and that of tolbutamide was decreased at the highest concentration (200 microgram . ml-1). Not all of the increase in lidocaine binding was explicable on the basis of increased serum AAG concentration. Estimation of binding parameters with a model with two independent sites showed increased affinity at the high affinity site in cancer patients with no change in the calculated number of binding sites. Therefore, in cancer there is increased lidocaine binding in association with increased AAG concentrations. We also record the novel observation of a change in the intrinsic properties of the high affinity binding site.

Metoprolol and debrisoquin metabolism in Nigerians: lack of evidence for polymorphic oxidation.

The role of genetic polymorphism in the oxidative metabolism of metoprolol and debrisoquin was investigated in a population of 138 unrelated Nigerians. The debrisoquin/4-hydroxydebrisoquin 0-8 hour urinary ratio (D/HD) correlated significantly with the metoprolol/alpha-hydroxymetoprolol 0-8 hour urinary ratio (M/HM) (rs = 0.54; P less than 0.001), the metoprolol/H117-04 [4-(2-hydroxy-3-isopropylaminopropoxy)-phenylacetic acid] 0-8 hour urinary ratio (M/H117-04) (rs = 0.42; P less than 0.001), and the plasma metoprolol concentration at 3 hours (rs = 0.48; P less than 0.01). Both the median D/HD and M/HM ratios were significantly higher in this population than in a previously studied population of white British subjects. According to criteria established in studies of white populations, only one subject, later identified as an Indian, would be classified unequivocally as a poor metabolizer of both metoprolol and debrisoquin. All the other subjects were black Africans. Bimodality in the frequency distribution of both the log10 M/HM and D/HD ratios was not apparent. The poor hydroxylation trait may, therefore, be present at a lower frequency than in whites, absent altogether, or obscured by other factors. In ethnic studies of drug metabolism each racial group should be examined separately for evidence of polymorphic metabolism and antimodes should not be extrapolated from one population to another.

Meperidine kinetics in man. Intravenous injection in surgical patients and volunteers.

The plasma concentration-time profiles of meperidine following intravenous injection in surgical patients and volunteers were investigated by reference to a classical two-compartment open model. Physiologic characteristics of the subject and variables associated with the surgery and anesthesia were screened as determinants of the kinetic patterns observed. When meperidine administration preceded induction of anesthesia, induction was consistently followed by an increase in venous plasma concentrations that prevented classical kinetic analysis. To facilitate calculations in subsequent studies in patients, meperidine injections were made following induction of anesthesia. Type of anesthesia or premedication, patients' sex, or cigarette smoking did not appear to be important factors in this evaluation. Increasing alcohol consumption was associated with increasing volumes of distribution. Increasing age was associated with increasing fraction of drug unbound in plasma. These factors may relate directly to clinical observations that heavy alcohol consumers tend to be more refractory to central nervous system (CNS) depressants and that elderly patients are more susceptible to respiratory depression from narcotics.

Differential stereoselective metabolism of metoprolol in extensive and poor debrisoquin metabolizers.

The hypothesis that variability in metoprolol metabolism stereoselectivity is related to debrisoquin oxidation phenotype was tested in six extensive (EM) and six poor (PM) debrisoquin metabolizers. In EM, plasma AUCs for (S)-metoprolol were 35% higher than for (R)-metoprolol, whereas in PM, AUCs for (S)-metoprolol were lower than for (R)-metoprolol. AUCs for total metoprolol correlated with the ratio of (S)- to (R)-metoprolol AUC. The renal clearance of metoprolol was also stereoselective but to the same extent in both EM and PM. Findings suggest that the enzyme system responsible for polymorphic oxidation of the debrisoquin-type is stereoselective. The relation between log total metoprolol plasma concentration and response (beta-blockade) was shifted to the right in PM relative to EM, which is compatible with a difference in pharmacologic activity of metoprolol enantiomers. Kinetic predictions based on total drug measurements will tend to overestimate dynamic differences between EM and PM, but the magnitude of the error is relatively small, and, in absolute terms, there is a large difference in pharmacologic activity between the phenotypes (beta-blockade at 24 hr: EM = 5.3 +/- 5.6%; PM = 18.9 +/- 3.8%).

Clinical pharmacokinetics of local anaesthetics.

The introduction of the new long acting local anaesthetics, bupivacaine and etidocaine, has stimulated an expansion of interest in regional anaesthesia, particularly for obstetrical applications and pain therapy. System toxicity following injection of local anesthetics occurs albeit infrequently, and tentative correlations have been made between the onset of CNS and cardiovascular effects and circulating drug concentrations in both adults and neonates. Amongst other factors, interpretation of these relationships depends upon blood distribution and plasma binding of the agents, sampling sites and acid-base balance. The disposition kinetics and placental transfer of the amide type agents have been well characterised. In adults their clearance is almost entirely hepatic but in neonates an increase in the renal component is, in part, a reflection of the immaturity of some of the enzymes responsible for their metabolism. Ester type agents are rapidly hydrolysed by plasma pseudocholinesterase and this has led to a preference for chloroprocaine in some obstetric procedures. Major determinants of the systemic absorption of the agents after perineural administration include their physicochemical and vasoactive properties, perfusion and tissue binding at the site of injection and whether or not adrenaline has been added. In respect of blood drug concentrations achieved after various regional anaesthetic procedures, the margin of systemic safety appears to favour bupivacaine and etidocaine compared to shorter acting analogues such as lignocaine and mepivacaine. The time course of local anaesthetic remaining at the site of injection has been calculated following intravenous regional anaesthesia and peridural block. This has allowed prediction of the local and systemic accumulation of the drugs following contined dosage. Blood concentrations of local anaesthetics after perineural injection are not closely related to age, weight or pregnancy but may be influenced by diseases associated with haemodynamic changes and by other drugs given at or around the time of regional blockade.