Displacement of bilirubin from albumin by ibuprofen in vitro.

Ibuprofen binds to plasma albumin and could interfere with the binding of bilirubin in jaundiced newborn infants. Most clinical studies have not shown increased concentrations of unbound bilirubin (UB) in plasma from infants treated with ibuprofen for a patent ductus arteriosus. However, studies in vitro have not been equally conclusive. Plasma were obtained from routine samples from jaundiced newborn infants and pooled. Total and UB were measured with the peroxidase method after addition of ibuprofen or sulfisoxazole as a known bilirubin displacer. Final ibuprofen concentrations varied from 0.43 to 2.6 mM. Bilirubin concentrations were varied from 176 to 708 microM by adding bilirubin to plasma samples. Ibuprofen caused a linear increase in UB up to +54% at a concentration of 1.8 mM, compared with an increase of 87% by sulfisoxazole (1.32 mM). A double reciprocal plot of molar concentrations of bound versus UB at bilirubin concentrations ranging from 176 to 708 microM showed a competitive displacement of bilirubin by ibuprofen. The data indicate that ibuprofen is a competitive displacer of bilirubin in vitro. Ibuprofen should be used with caution in premature infants with a significant hyperbilirubinemia.

Effects of cefotaxime on the serum protein binding of sulfisoxazole.

The possible acylating effects of cefotaxime on sulfisoxazole binding to serum proteins were evaluated in vitro in samples of human sera incubated with 50-1000 micrograms ml-1 cefotaxime at 37 degrees for 1 h and then dialyzed against saline. This incubation resulted in concentration-related increases in the free fraction of sulfisoxazole (+25 per cent, +30 per cent, and +45 per cent, with 250, 500, and 1000 micrograms ml-1 cefotaxime, respectively). Sulfisoxazole binding was also studied in samples of sera from patients given prophylactic cefotaxime (3 g d-1, IV) following elective surgery. Sulfisoxazole free fraction increased from 7.6 +/- 0.7 per cent in samples obtained before starting treatment to 9.2 +/- 0.8 per cent 24 h thereafter, and to 10.4 +/- 1.0 per cent after 5 days of treatment, but this difference was not statistically significant. A Scatchard plot of pooled samples showed a reduction in overall affinity (from 2.38 X 10(-4) M to 1.77 X 10(-4) M) without changes in the number of binding sites. The effects of cefotaxime on sulfisoxazole binding and kinetics were also studied experimentally in the rabbit. Treatment with 30 mg kg-1 cefotaxime t.i.d. for 2 days increased the unbound fraction of sulfisoxazole in vivo, from 17.2 +/- 2.9 per cent to 27.3 +/- 3.6 per cent (p less than 0.02). Treatment with high doses of cefotaxime, and perhaps other 3-acetoxymethylcephalosporins, may result in changes in the serum protein binding of some acidic drugs.

[Differential effect of sodium bicarbonate on disposition of sulfadimethoxine and sulfisoxazole in rabbits].

The orally co-administered sodium bicarbonate significantly enhanced the blood concentration of sulfadimethoxine at the early stage after oral administration to rabbits, by increasing its intestinal absorption. On the other hand, the sodium bicarbonate significantly reduced the blood concentration of sulfisoxazole at the elimination phase after oral administration to rabbits, by increasing its urinary excretion. The fact that sodium bicarbonate exhibits different effects in the disposition of these two sulfonamides is an interesting example to gain a better understanding for the complexity of drug interaction.

Serum protein binding of sulfisoxazole and diazepam in patients with chronic obstructive pulmonary disease.

Binding of two acidic drugs, sulfisoxazole and diazepam, to serum proteins has been investigated in patients with chronic obstructive pulmonary disease and in a control group of healthy volunteers. Marked increases in the free fraction of both drugs in serum were detected in patients (14.5 +/- 0.8% versus 6.1 +/- 0.3% in the case of sulfisoxazole, and 5.8 +/- 0.5% versus 3.2 +/- 0.0% in the case of diazepam). Decreased serum albumin concentration appeared to play a role in the defective binding of sulfisoxazole, although when this factor was corrected, some correlation between serum binding of sulfisoxazole and PaO2 values was detected. Other factors have to be considered to explain the decreased binding of diazepam in the serum of patients with chronic obstructive pulmonary disease.

Serum protein binding of model acidic drugs in smokers and non-smokers.

The serum protein binding of sulfisoxazole (sulfafurazole, INN) and diazepam, drugs that bind to the two main binding sites for acidic drugs on albumin, has been studied in young smokers and non-smokers. No differences between the two groups could be detected with regard to the serum protein binding of either drug. Thiocyanate, present in relatively large amounts in the serum of smokers, does not seem to affect the drug-binding properties of serum proteins.

Treatment of nonpulmonary infections due to Mycobacterium fortuitum and Mycobacterium chelonei on the basis of in vitro susceptibilities.

One hundred twenty-three patients with nonpulmonary infections due to Mycobacterium fortuitum or Mycobacterium chelonei were treated by wound debridement and with chemotherapy on the basis of in vitro susceptibilities of the organism. Of 76 patients with infections caused by M. fortuitum, 13 required no therapy or were adequately treated with surgery alone. Patients with active localized disease received single drug therapy (usually with a sulfonamide) for a mean period of 10.6 weeks for cellulitis and seven months for osteomyelitis. Patients with extensive disease received amikacin or amikacin plus cefoxitin (mean, four weeks) followed by a sulfonamide (mean, six months). The 47 patients with infections caused by M. chelonei received no therapy or were treated with surgery alone (6); with amikacin (10), erythromycin (6), doxycycline (3), or cefoxitin (1); or with amikacin plus cefoxitin followed by cefoxitin alone for a total of 10-12 weeks (20); or other multiple-drug regimens (1). Surgery was performed on 74 (60%) patients. Schlichter tests or serum drug levels were determined for 81 (66%) patients. Response to therapy was excellent; 68 (90%) infections with M. fortuitum and 34 (72%) with M. chelonei were successfully treated. Cultures became negative within six weeks of chemotherapy, except for sternal osteomyelitis, for which cultures were not negative until up to 14 weeks. Follow-up for a mean period of 12 months following therapy was possible in 80% of cases. Relapses were rare except in patients with disseminated disease, and drug resistance developed in only one patient. These studies demonstrate the value of routine susceptibility testing of these mycobacterial species and the benefit of chemotherapy on the basis of in vitro susceptibilities.

Binding and disposition of sulfisoxazole in alcoholic cirrhosis.

The disposition of sulfisoxazole was studied in six male patients hospitalized with biopsy-proven Laennec's alcoholic cirrhosis and six normal, healthy volunteers. Four of the patients were restudied at a time their liver disease had improved clinically. On the average, compared to the normal group, the metabolism of sulfisoxazole (clearance values with respect to unbound concentration values) appears to be unaltered for the cirrhotic patients. For patients with alcoholic cirrhosis having normal renal function for age and weight, the renal elimination of sulfisoxazole was normal. For those subjects with decreased renal function, the renal clearance of sulfisoxazole appeared to be disproportionately decreased, as evidenced by a lower-than-normal sulfisoxazole renal clearance-to-creatinine clearance values. The apparent steady-state volume of distribution of unbound sulfisoxazole was not altered in cirrhotic patients when compared to normal subjects, while the apparent volume of distribution of total drug increased by more than what could be expected from protein binding changes alone. The elimination rate constant did not differ from values found in normals. These data suggest that the total binding capacity of sulfisoxazole in cirrhotic patients is not different from that of normal subjects.

Abnormal serum protein binding of acidic drugs in diabetes mellitus.

Nonenzymatic glycosylation of proteins is common in diabetes mellitus and glycosylation of serum albumin in this condition has been described. To evaluate whether glycosylation of albumin affects acidic drug binding, sulfisoxazole and diazepam binding was examined in samples of normal serum incubated with glucose and in samples of serum from 42 patients with diabetes mellitus. Incubation of normal serum with 20mM glucose for several days resulted in progressive glycosylation of proteins, with decreased binding of sulfisoxazole (100 micrograms/ml) but not of diazepam (3 micrograms/ml). Free fractions of sulfisoxazole and diazepam were higher in serum from patients with diabetes. The percentage of free sulfisoxazole in serum from 10 normal subjects was 5.1% +/- 0.2%, whereas it was 16.0% +/- 1.3% in serum from 42 patients with diabetes with varying degrees of carbohydrate control. The percentage of free diazepam in plasma was 2.6% +/- 0.1% in the normal group and 3.6% +/- 0.4% in patients with diabetes. Decreased serum albumin levels, increased levels of free fatty acids, and glycosylation of plasma proteins seem to play a role in the defective acidic drug binding in diabetes. Elevated free fatty acid levels explain the abnormal binding of diazepam and the increased free fraction of sulfisoxazole is directly related to glycosylation of plasma proteins.

Pharmacokinetics of sulfisoxazole in young and elderly subjects.

The pharmacokinetics of sulfisoxazole was studied in 6 elderly (age 63-75 years) and 7 young (age 22-37 years) healthy nonsmoking volunteers following the oral administration of 2 g of Gantrisin. The plasma levels of sulfisoxazole obtained in the postabsorption phase were higher in the elderly subjects. There was no significant variation between the two groups of volunteers in the absorption rate constant, Cmax, bioavailability, the fraction of the dose of sulfisoxazole excreted unchanged, the area under the plasma curve of the N4-acetyl conjugate formed, and in the apparent volume of distribution of the drug. The tmax value and plasma half-life of sulfisoxazole were significantly longer, and the total body and renal clearances of the drug decreased in the elderly subjects. Diminished renal function as estimated by the creatinine clearance and urinary flow may explain the slower elimination of sulfisoxazole in the elderly subjects. Therefore, advancing age should be considered as a factor in the adjustment of sulfisoxazole dosage.

Differential effects of hepatic cirrhosis on the plasma protein binding of drugs.

The binding of sulfisoxazole (sulfafurazole-INN) (100 micrograms/ml), diazepam (3 micrograms/ml) and digitoxin (0.025 micrograms/ml) has been studied in plasma from normal volunteers and from patients with hepatic cirrhosis. The free fraction of sulfisoxazole and diazepam in plasma was increased in these patients (22.9 +/- 3.0% and 6.5 +/- 0.7%) vs 6.6 +/- 0.6% and 3.1 +/- 0.2% in normal subjects, respectively), but binding of digitoxin did not greatly change (13.7 +/- 3.95% vs 13.9 +/- 2.27% in the control group). The increase in the free fraction of sulfisoxazole and diazepam correlated well with decreased serum albumin levels; but a change in albumin affinity, perhaps due to increased bilirubin levels, should also to be taken in consideration to explain this decreased drug binding in hepatic cirrhosis.

Bilirubin-displacing effect of furosemide and sulfisoxazole. An in vitro and in vivo study in neonatal serum.

Sulfisoxazole and furosemide, 0.1-1.0 mM, both decreased reserve albumin concentration for bilirubin binding in pooled cord serum as estimated by rate of dialysis of 14C-monoacetyl-diamino-diphenylsulfone (MADDS) in undiluted serum at 37 degrees C. Peroxidase oxidation at a bilirubin:albumin ratio of 0.5 also showed that both drugs were capable of displacing bilirubin in vitro when added in molar excess of the albumin present. However, when aliquots of the same treated sera which had been used undiluted in the MADDS assay were diluted 40-fold and titrated with bilirubin and peroxidase, no drug-related increase in free bilirubin or decrease in reserve albumin could be shown. In vivo administration of 1 mg/kg furosemide showed no change in total bilirubin or reserve albumin by the MADDS technique in 8 infants. Estimation of the peak plasma level theoretically achievable with 1 mg/kg of furosemide suggests that peak plasma levels achieved with that dose are probably not high enough to produce significant reduction of reserve albumin, in agreement with the in vivo findings. In testing neonatal serum for bilirubin displacement by drugs, the choice of method, drug concentration, and dilution of the sample may influence the interpretation of results.

Comparison of the disposition of total and unbound sulfisoxazole after single and multiple dosing.

Plasma concentrations of total and unbound sulfisoxazole were followed after single intravenous and oral doses of 1 g sulfisoxazole and during a 500-mg, four-time-a-day dosing regimen in six healthy males, using a specific high pressure liquid chromatographic assay method. Saturable plasma protein binding was observed at total concentrations above 80-100 mg/liter. The clearance of sulfisoxazole was 18.7 +/- 3.9 ml/min for total drug and 232 +/- 64 ml/min for unbound drug. Renal elimination, on the average, accounted for 49% of the clearance of sulfisoxazole. The apparent volume of distribution for total drug was 10.9 +/- 2.0 liters and 136 +/- 36 liters for unbound drug, indicating that sulfisoxazole is primarily distributed extracellularly. Accumulation of N4-acetyl-sulfisoxazole during multiple dosing did not affect the disposition of sulfisoxazole. Adjusting for variable renal clearances between oral and intravenous administration and using the unbound plasma concentrations, the bioavailability for an oral dose of sulfisoxazole was found to be 0.95 +/- 0.04.

Pharmacokinetics of sulfisoxazole compared in humans and two monogastric animal species.

The pharmacokinetic profile of sulfisoxazole was studied and compared in dogs, swine, and humans. The trial was conducted over a 72-hr period after intravenous administration and a 96-hr period after oral administration in dogs and swine. In humans, the trial was conducted over an 8-hr period after oral administration. A two-compartment model system was used to define the pharmacokinetic profile. The mean half-lives for the distribution phase were 4.08, 1.30, and 0.56 hr in dogs, swine, and humans, respectively. For the elimination phase, the mean half-lives were 33.74, 46.39, and 7.40 hr in dogs, swine, and humans, respectively. The mean volume of the central compartment was approximately the same in dogs and swine, 10.6 and 10.5 liters, respectively. Humans had a smaller volume of distribution, 7.7 liters. The steady-state volumes of distribution were 17.2, 30.3, and 16.2 liters in dogs, swine, and humans, respectively. Dogs and swine excreted 42.2 and 30.7%, respectively, of the intravenous dose and 29.4 and 18.3%, respectively, of the oral dose. The bioavailability was 69.8% in dogs and 100.0% in swine. The fraction of drug bound ranged from 30 to 50% in dogs, 40 to 60% in swine, and 25 to 40% in humans.

A clinically applicable high-pressure liquid chromatographic method for measurement of serum theophylline, with detailed evaluation of interferences.

A high-pressure liquid chromatographic method for the routine measurement of serum theophylline that is accurate, specific, and sensitive is presented. It is technically simple, requires only 50 microliter serum, and takes relatively little technician time. Values for theophylline in sera obtained by this method correlate well with those obtained by use of a gas-liquid chromatographic method (r = 0.980) and with values obtained by the commonly used spectrophotometric method (r = 0.939) when the latter is free of interference. The assay has been employed for two years in a routine clinical chemistry laboratory, with interassay coefficients of variation of 2.4-3.2%. Interferences have been identified at an incidence rate of 3.8% of all specimens, and interfering substances include cephazolin, chloramphenicol, sulfamethoxazole, and sulfisoxazole. A calculation technic that allows a reliable and clinically useful estimation of a range of concentrations of theophylline in the serum when these interferences are present is described. In contrast, the incidence of interferences with the spectrophotometric method is 4.9%, and in this method the interferences prevent the analysis of theophylline. Of 33 samples having interferences by use of the spectrophotometric method, the high-pressure liquid chromatographic technic yielded precise values for theophylline in 21 and reliable estimates of ranges of concentrations of theophylline in the remaining 12.

"High-pressure" liquid chromatography of sulfisoxazole and N4-acetylsulfisoxazole in body fluids.

We describe a simple, rapid chromatographic method for separating and quantitatively determining sulfisoxazole and its N4-acetyl metabolite in plasma and urine. A 100-micro L sample of plasma or urine is combined with 200 micro L of a solution containing 12 mg/L of the internal standard, N4-acetylsulfamethoxazole, in absolute methanol and centrifuged to obtain a clear supernatant solution. This solution is then eluted through a 10-micron microparticulate column with a mobile phase of 32/68 (by vol) methanol/sodium acetate buffer (0.01 mol/L, pH 4.7), at a flow rate of 1.2 mL/min. The eluted sompounds are detected by their absorption at 254 nm. We calculated concentration from the peak-height ratios of sulfisoxazole or N4-acetylsulfisoxazole to N4-acetylsulfamethoxazole. The peak-height ratio was linear with concentration in the range 0.05--200 mg/L for both drug and metabolite in plasma and urine. Because this assay can be completed within 30 min of obtaining a blood or urine sample, it should be a valuable tool in clinical drug monitoring and pharmacokinetic studies.

The effect of semisynthetic penicillins on the binding of bilirubin by neonatal serum.

1. The effect of ampicillin, cloxacillin, flucloxacillin and sulphafurazole on bilirubin on bilirubin binding by pooled human umbilical cord serum and bovine serum albumin was studied in vitro using Sephadex gel filtration. 2. Sulphafurazole displaced bilirubin from binding; both cloxacillins displaced bilirubin from pooled cord serum but not bovine serum albumin. 4. No displacement of bilirubin by the cloxacillins from pooled cord serum could be detected at therapeutic plasma concentrations of these drugs. 5. Scatchard analysis of the interactions showed that displacement of bilirubin by these drugs occurred principally at the primary, high affinity, low capacity binding site.

Simultaneous automated determination of free and total sulfisoxazole and sulfamethoxazole in plasma and urine.

A fully automated method for the determination of sulfisoxazole, N4-acetylsulfisoxazole, sulfamethoxazole, and N4-acetylsulfamethoxazole in human plasma and urine was developed. Untreated plasma is analyzed by automation of dialysis, hydrolysis, color development, and quantitation. The method has a sensitivyt limit of 2 microgram/ml of plasma and has been used successfully to determine sulfonamide levels following administration of sulfoxazole and a combination drug product containing sulfamethoxazole and trimethoprim in humans. Samples are processed at the rate of 40 per hour, with a minimum of sample handling, data reduction, and materials.

The effects of some sweetening agents and osmotic pressure on the intestinal absorption of sulfafurazole in the rat.

The effects of some sugars and osmotic pressure have been examined on the absorption of sulfafurazole in the rat. Statistically significant correlations were found among the hypertonic solutions between the reciprocal of osmotic pressure and AUC0--infinity or Cmax. In addition, negative correlation existed between plasma concentrations at 15 min and osmotic pressure. No significant correlations were noted among the hypotonic solutions. More attention should be paid to the osmotic pressure of formulations. The osmotic pressure of hypertonic solutions, especially, might affect absorption of drug from its dosage form.

Effect of serum protein binding on sulfisoxazole distribution, metabolism, and excretion in rats.

This investigation determined the effect of serum protein binding on the kinetics of sulfisoxazole distribution, metabolism, and excretion. Adult rats, whose serum free fraction of sulfisoxazole (at a total concentration of 81 +/- 6 micrograms/ml) was 0.05-0.24, received a rapid intravenous injection of 20 mg/kg. Sulfisoxazole concentrations in plasma declined biexponentially with time. There were pronounced and reproducible interindividual differences in the total, metabolic, and renal sulfisoxazole clearances, each positively correlated with the serum free fraction of sulfisoxazole. The renal sulfisoxazole clearance had a component unaffected by serum protein binding. The apparent central compartment volume increased with an increasing serum free sulfisoxazole fraction, but the latter had not apparent effect on the first exponential term of the biexponential equation describing sulfisoxazole elimination kinetics in rats. Serum protein binding was a major determinant of intersubject differences in sulfisoxazole excretion and biotransformation kinetics.