Metabolite identification by mass spectrometry: forty years of evolution.

When the Drug Metabolism Discussion Group was instigated in 1971, metabolite identification by mass spectrometry was a slow and laborious process undertaken by mass spectrometrists who seemed to continually disappoint their colleagues by failing to obtain the metabolite spectra. This was usually because not enough material was supplied or the material was impure. Today, accurate metabolite information can be obtained rapidly with little material by utilizing a range of mass spectrometers with complementary properties. This review will discuss how both technology and strategy have evolved over the past forty years to meet the changing demands of metabolism studies within the pharmaceutical industry.

Looking back through the MIST: a perspective of evolving strategies and key focus areas for metabolite safety analysis.

The publication of the US FDA MIST guidance document in 2008 reignited the debate around the most appropriate strategies to underwrite metabolite safety for novel compounds. Whilst some organizations have suggested that the guidelines necessitate a paradigm shift to more thorough metabolite analysis during early development, an evaluation of historical practices shows that the principles of the guidelines have always largely underpinned metabolism studies within the pharmaceutical industry. Therefore, it is argued that existing practices, when coupled to appropriate emerging analytical tools and a case-by-case consideration of the relevance of the generated metabolism data in terms of structure, physicochemisty, abundance and activity, represent a fit-for-purpose approach to metabolite-safety assessments.

A holistic strategy for characterizing the safety of metabolites through drug discovery and development.

The subject of metabolites in safety testing has had much debate in the recent past and has shown itself to be a complex issue with no simple solutions to providing absolute assurance of drug safety. Much of the attention has focused on the ability to identify metabolites and then demonstrate that their risk has been adequately characterized, either through their exposure in toxicology species or, failing this, by direct safety testing. In this review, we summarize our forward operational strategy that combines the principles summarized in the FDA Guidance, together with discussions at scientific meetings and literature opinions. It is a balance between the primary goal of assuring patient safety with one of reasonable investment. A key principle in striking this balance is to build stepwise information on metabolites through the drug discovery and development continuum. This allows assessments to be made from early nonclinical studies onward as to whether or not metabolite safety is underwritten by exposure in toxicology species. This strategy does not require absolute quantitation of the metabolites in early clinical trials but relies upon comparison of relative exposures between animals and humans using the capabilities of modern analytical techniques. Through this strategy, human disproportionate metabolites can be identified to allow a decision regarding the need for absolute quantitation and direct safety testing of the metabolite. Definitive radiolabeled studies would be initiated following proof of pharmacology or efficacy in humans, and nonclinical safety coverage would be adequately assessed prior to large-scale clinical trials. In cases where metabolite safety is not supported through the parent compound toxicology program, approaches for the direct safety testing of metabolites with regard to general and reproductive toxicology, safety pharmacology, and genetic safety have been defined.

Metabolite quantitation: detector technology and MIST implications.

HPLC detector technology has advanced dramatically over the past 20 years, with a range of highly sensitive and specific detectors becoming available. What is still missing from the bioanalyst's armoury, however, is a highly sensitive detector that gives an equimolar response independent of the compound. This would allow for quantification of compounds without the requirement for a synthetic standard or a radiolabeled analogue. In particular, such a detector applied to metabolism studies would establish the relative significance of the various metabolic routes. The recently issued US FDA guidelines on metabolites in safety testing (MIST) focus on the relative quantitation of human metabolites being obtained as soon as feasible in the drug-development process. In this article, current detector technology is reviewed with respect to its potential for quantitation without authentic standards or a radiolabel and put in the context of the MIST guidelines. The potential for future developments are explored.

A randomised controlled trial of the effects of a web-based PSA decision aid, Prosdex. Protocol.

BACKGROUND: Informed decision making is the theoretical basis in the UK for men's decisions about Prostate Specific Antigen (PSA) testing for prostate cancer testing. The aim of this study is to evaluate the effect of a web-based PSA decision-aid, Prosdex, on informed decision making in men. The objective is to assess the effect of Prosdex on six specific outcomes: (i) knowledge of PSA and prostate cancer-related issues - the principal outcome of the study; (ii) attitudes to testing; (iii) decision conflict; (iv) anxiety; (v) intention to undergo PSA testing; (vi) uptake of PSA testing. In addition, a mathematical simulation model of the effects of Prosdex will be developed. METHODS: A randomised controlled trial with four groups: two intervention groups, one viewing Prosdex and the other receiving a paper version of the site; two control groups, the second controlling for the potential Hawthorn effect of the questionnaire used with the first control group. Men between the ages of 50 and 75, who have not previously had a PSA test, will be recruited from General Practitioners (GPs) in Wales, UK. The principal outcome, knowledge, and four other outcome measures - attitudes to testing, decision conflict, anxiety and intention to undergo testing - will be measured with an online questionnaire, used by men in three of the study groups. Six months later, PSA test uptake will be ascertained from GP records; the online questionnaire will then be repeated. These outcomes, and particularly PSA test uptake, will be used to develop a mathematical simulation model, specifically to consider the impact on health service resources.

Complete reversal of adult-onset isolated hypogonadotropic hypogonadism with clomiphene citrate.

OBJECTIVE: Inhibition of pituitary gonadotropin secretion in men by T is principally mediated by aromatization to estrogen (E), which inhibits hypothalamic secretion of GnRH. We hypothesized that adult-onset isolated hypogonadotropic hypogonadism (IHH) might result from an altered central set-point for E-mediated negative feedback. DESIGN AND SETTING: Longitudinal clinical investigation unit-based evaluation of the clinical and biochemical response to E-receptor blockade. PATIENT(S): A 31-year-old man presenting with an 18-month history of sexual dysfunction resulting from severe adult-onset IHH (LH 1.7 U/L, FSH 2.0 U/L, T 3.5 nmol/L). INTERVENTION(S): Initial therapy with 50 mg of clomiphene citrate (CC) three times a day for 7 days, with overnight LH pulse profiling and 9 am T levels evaluated at baseline and on completion. A 2-month washout period, followed by low-dose maintenance therapy (25-50 mg/d) for 4 months. MAIN OUTCOME MEASURE(S): Baseline and stimulated T levels and LH pulsatility; effect on sexual function. RESULT(S): Clomiphene therapy resulted in complete normalization of pulsatile gonadotropin secretion, serum T level, and sexual function. CONCLUSION(S): Isolated hypogonadotropic hypogonadism may result from an acquired defect of enhanced hypothalamic sensitivity to E-mediated negative feedback. Whereas direct T replacement therapy can further suppress endogenous gonadotropin secretion, treating IHH men with gonadotropins can stimulate endogenous T secretion and enhance fertility potential. On theoretical grounds, reversal of gonadotropin deficiency with CC might be expected to have a similar biological effect.