Morphometry of the nulliparous pelvic floor.

OBJECTIVES: To describe morphometry of the pelvic floor in a large population of nulliparous women, comparing those with and those without pelvic pain. We also aimed to assess its association with characteristics such as age and body mass index (BMI). METHODS: This was a prospective study performed between January 2013 and November 2015 in non-pregnant nulliparous women attending a general gynecology clinic. Following collection of demographic data, women were examined using translabial four-dimensional (4D) ultrasound. Dynamic volumes of pelvic floor muscle were obtained at rest, on maximal contraction and on Valsalva maneuver, and analyzed at a later date by an assessor blinded to demographic details. Standard measurements for each volume included levator hiatal area and anteroposterior and transverse diameters, and pubovisceral muscle length and width. Subanalysis was performed comparing women with and those without pelvic pain. Linear regression analysis was performed to assess the association between characteristics, including age and BMI, and levator hiatal area at rest. RESULTS: Three hundred and sixty eight nulliparous women were examined using translabial 4D ultrasound. Median levator hiatal area was 10.62 cm2 at rest, 11.95 cm2 on Valsalva maneuver and 8.18 cm2 on maximal contraction. There was no difference between women with and those without pelvic pain when comparing biometric measurements of the pelvic floor musculature, except for in pubovisceral muscle width during the contraction phase. Regression analysis demonstrated that higher age and BMI were associated with increased levator hiatal area measurement. CONCLUSIONS: Pelvic floor morphometry in nulliparous women is unchanged by pelvic pain, but levator hiatal area is increased in women with higher BMI and age. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Four-dimensional ultrasound guidance for pelvic floor Botulinum toxin-A injection in chronic pelvic pain: a novel technique.

OBJECTIVE: Botulinum toxin-A (BoNT-A) is used in the treatment of pelvic floor muscle overactivity associated with chronic pelvic pain (CPP) when conservative methods such as physiotherapy are not effective or appropriate. Traditional injection techniques require finger-guided palpation of pelvic floor muscles with concurrent insertion of the needle. The aim of this study was to describe a novel technique for the injection of BoNT-A into the pelvic floor musculature using four-dimensional ultrasound (4D-US) guidance. METHODS: Thirty-one BoNT-A injections were performed using the new technique between October 2013 and January 2016, on women scheduled to have BoNT-A injection for pelvic floor muscle overactivity and CPP. The pelvic floor was assessed by 4D-US. A test injection of saline was performed to confirm location of the needle, then BoNT-A was injected into the muscle under ultrasound guidance, using 4D-US to confirm that the fluid expanded and tracked along muscle fibers. RESULTS: The saline test confirmed correct location of the needle following a median of 1 (range, 1-3) attempt at needle placement. In all 31 instances, satisfactory injection of BoNT-A, with 4D-US confirmation of fluid expansion within the muscle body, was performed. CONCLUSIONS: Injection of BoNT-A under 4D-US guidance is feasible and allows accurate placement into the target muscle in women with pelvic floor muscle overactivity associated with CPP. This technique may provide a safer alternative to finger-guided methods, owing to a lower likelihood of operator needle-stick injury. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Probable glucometer interference caused by topical iodine solution test site preparation.

WHAT IS KNOWN AND OBJECTIVE: Use of disinfectants, such as alcohol prep pads, for test site preparation have demonstrated alterations in glucose readings. One case report details an overestimation of blood glucose (BG) readings when using Chemstrip bG and Visidex reagent test strips after cleaning test site with povidone-iodine swabs CASE SUMMARY: We present a case of a clinically relevant probable drug-device interaction between topical iodine and a point-of-care glucometer in a 28 year old pregnant woman of Chinese descent. In this case, the use of 10% povidone-iodine solution on the testing site before lancing likely resulted in variable and inaccurate BG readings, which was not reproduced when the patient used hand washing instead of iodine. WHAT IS NEW AND CONCLUSION: Our report expands on this prior knowledge by demonstrating that such an alteration associated with iodine can occur with modern electrochemical glucometers. In patients that have aberrant or variable BG readings, providers should investigate for improper testing technique.

Evaluating the use of commercial drug-specific calibrators for determining PT and APTT reagent sensitivity to dabigatran and rivaroxaban.

Suitable laboratory methodologies for quantifying the non-vitamin K oral anticoagulants (NOAC) include liquid chromatography-tandem mass spectrometry (LC-MS/MS) or drug-calibrated assays such as the dilute thrombin time for dabigatran or anti-Xa measurements for rivaroxaban. In situations when these tests are unavailable, it has been suggested that using commercial drug calibrators on APTT and PT assays would theoretically provide reagent sensitivity to these drugs. The purpose of this study was to determine whether commercial drug calibrators deliver similar reagent sensitivity information as samples from patients receiving dabigatran or rivaroxaban as part of their routine care. Two laboratory sites tested commercial calibrator material for dabigatran and rivaroxaban (Hyphen Biomedical) using PT and APTT reagents and data was compared to samples collected from patients taking NOACs that were quantified by LC-MS/MS. Correlation statistics and calculating the amount of drug required to double the clotting time of normal plasma were performed. All drug calibrator material correlated more strongly (R²> 0.95) for any reagent/drug combination than patient samples (R² ranged from 0.29-0.86). Dabigatran calibrator results and patient data were equivalent for SynthASil and PTT-A APTT reagents. The dabigatran and rivaroxaban calibrator material over-estimated drug sensitivity for all PT reagents when compared to sensitivity data calculated based on drug levels obtained by LC-MS/MS from patient samples. In conclusion, drug-specific calibrators overestimated reagent sensitivity which may underestimate in vivo drug concentration in a given patient. Further studies are required to assess whether this method of determining relative sensitivity of NOAC on routine coagulation assays should be recommended.

Performance of coagulation tests in patients on therapeutic doses of dabigatran: a cross-sectional pharmacodynamic study based on peak and trough plasma levels.

BACKGROUND: Knowledge of anticoagulation status during dabigatran therapy may be desirable in certain clinical situations. OBJECTIVE: To determine the coagulation tests that are most useful for assessing dabigatran's anticoagulant effect. METHODS: Peak and trough blood samples from 35 patients taking dabigatran 150 mg twice daily, and one sample each from 30 non-anticoagulated individuals, were collected. Mass spectrometry and various coagulation assays were performed. 'Therapeutic range' was defined as the range of plasma dabigatran concentrations determined by mass spectrometry between the 2.5th and 97.5th percentiles of all values. RESULTS: The therapeutic range was 27-411 ng mL(-1) . The prothrombin time (PT) and activated partial thromboplastin time (APTT), determined with multiple reagents, and activated clotting time (ACT) were insensitive to therapeutic dabigatran: 29%, 18% and 40% of samples had a normal PT, APTT, and ACT, respectively. However, normal PT, ACT and APTT ruled out dabigatran levels above the 75th percentile. The thrombin clotting time (TCT) correlated well and linearly with dabigatran levels below the 50th percentile, but was unmeasurable above it. The dilute thrombin time, ecarin clotting time and ecarin chromogenic assay showed linear correlations with dabigatran levels over a broad range, and identified therapeutic and supratherapeutic levels. CONCLUSIONS: The prothrombin time, APTT and ACT are often normal in spite of therapeutic dabigatran plasma levels. The TCT is useful for detecting minimal dabigatran levels. The dilute thrombin time and chromogenic and clotting ecarin assays accurately identify therapeutic and supratherapeutic dabigatran levels. This trial is registered at www.clinicaltrials.gov (#NCT01588327).

Improvement in pelvic pain with botulinum toxin type A - Single vs. repeat injections.

The aim of this prospective study was to report the outcomes of pain and vaginal pressures of successive botulinum toxin type A injections for women with objective pelvic floor muscle overactivity and a two-year history of pelvic pain. Between 2005 and 2008, 37 women underwent injection of 100 IU of botulinum toxin type A into the puborectalis and pubococcygeous muscles with dysmenorrhoea, dyspareunia, dyschesia, and non-menstrual pelvic pain assessed using a visual analogue scale (VAS), and vaginal pressure measured by vaginal manometry, at 0, 4, 12 and 26 weeks from each injection. 26 women (70%) had one injection of botulinum toxin type A and 11 (30%) had 2 or more injections. The second injection was performed at the earliest at 26 weeks after the first, with subsequent injections having a median time to re-injection of 33.4 weeks (range 9.4-122.7 weeks). Single and repeated injections both demonstrated a statistically significant reduction in dyspareunia by VAS scores from 54 to 30 in the single injection group and from 51 to 23 in the multiple injection group (p = .001), non-menstrual pelvic pain VAS from 37 to 25 (p = .04), as well as vaginal pressures; 40 versus 34 cm H(2)O (p = .02). No statistically significant difference in dysmenorrhoea or dyschesia was observed for either group from their baseline scores. Multiple injections of botulinum toxin type A in women with pelvic floor muscle overactivity provide significant relief from dyspareunia and non-menstrual pelvic pain. The upper limit between re-injection is not yet determined, nor is the maximum number of treatments. Clinical outcomes for single and subsequent injection of botulinum toxin type A for recurrent pelvic pain are equivalent. Women who have had benefit from a single injection of botulinum toxin type A can be reassured that if symptoms reoccur, repeated injections can be expected to be equally efficacious.

Formation of the quaternary ammonium-linked glucuronide of nicotine in human liver microsomes: identification and stereoselectivity in the kinetics.

The formation of the N1-glucuronide metabolite of each nicotine enantiomer was studied in pooled human liver microsomes (n = 6). The metabolite formed from natural S(-)-nicotine was identified by comparison of the high-pressure liquid chromatography (HPLC) retention time and positive ion electrospray ionization-mass spectral characteristics with a synthetic reference standard. A radiometric HPLC method was used to quantify the metabolite. The specificity of the assay method was demonstrated by experiments in which beta-glucuronidase treatment of incubated assay samples resulted in elimination of the peak due to the N1-glucuronide metabolite. The glucuronides of S(-)- and R(+)-nicotine were formed by one-enzyme kinetics, with K(m) values of 0.11 and 0.23 mM and V(max) values of 132 and 70 pmol/min/mg of protein, respectively. There is marked stereoselectivity in the apparent intrinsic clearance values (V(max)/K(m)) in that the value for S(-)-nicotine is 4 times greater than for the R(+)-isomer (1.2 versus 0.31 microl/min/mg of protein).

Quaternary ammonium-linked glucuronidation of 1-substituted imidazoles: studies of human UDP-glucuronosyltransferases involved and substrate specificities.

A series of eight 1-substituted imidazoles was investigated as model substrates for glucuronidation at an aromatic tertiary amine of polyaza heterocyclic ring systems. The human UDP-glucuronosyltransferases (UGTs) involved and substrate specificities were investigated. Nine expressed enzymes (UGT1A1, UGT1A3, UGT1A4, UGT1A6, UGT1A7, UGT1A9, UGT1A10, UGT2B7, and UGT2B15) were examined, but only UGT1A4 catalyzed the formation of a quaternary ammonium-linked glucuronide metabolite for six of the substrates. UGT1A3 also catalyzed the glucuronidation of the previously investigated 1-phenylimidazole but none of the newly investigated compounds. No glucuronidation was observed with 1-(4-nitrophenyl)imidazole, the compound with the 4-phenyl substituent with the largest electron withdrawing effect. The incubation conditions for the determination of the kinetic constants for UGT1A4 catalysis of six substrates were optimized and included incubation at pH 7.4 with alamethicin at 10 microg/mg of protein. Latency disrupting agents, including alamethicin and sonication, enhanced glucuronidation 1.25-fold at most. There were 17.5- and 2.2-fold variations in the apparent K(m) (range, 0.18-3.15 mM) and V(max) values (range, 0.16-0.35 nmol/min/mg of protein). Linear correlation analyses between UGT1A4 kinetics and substrate physicochemical parameters showed significant correlation between V(max) and both the partition coefficient (log P, n-octanol/water) and pK(a) and between K(m) and pK(a), thereby indicating that the lipophilicity and the ease of availability of the tertiary amine lone pair of electrons of the substrate are important with respect to enzyme catalysis.

Characterization of rat liver microsomal metabolites of clivorine, an hepatotoxic otonecine-type pyrrolizidine alkaloid.

The metabolism of the hepatotoxic otonecine-type pyrrolizidine alkaloid (PA), clivorine, was investigated using rat liver microsomes. The metabolites dehydroretronecine (DHR), 7-glutathionyldehydroretronecine (7-GSH-DHR), 7, 9-diglutathionyldehydroretronecine (7,9-diGSH-DHR), and clivoric acid were identified using chromatographic and mass spectrometric analyses. NMR characterizations were also performed on the isolated clivoric acid and the synthetic 7-GSH-DHR and 7,9-diGSH-DHR. The results indicated that the two glutathione (GSH) conjugates were formed by reaction of the unstable toxic pyrrolic ester with GSH added in the microsomal incubation system, whereas DHR was generated from hydrolysis of the unstable pyrrolic ester, and that clivoric acid was produced from all these further conversions of the unstable pyrrolic ester. Furthermore, tissue-bound pyrroles were also determined to be present after microsomal incubation of clivorine. Clivoric acid has not been previously identified, and DHR and 7, 9-diGSH-DHR were found, for the first time, as metabolites of an otonecine-type PA, while 7-GSH-DHR was previously reported by us to be a microsomal metabolite of clivorine. The in vitro metabolic pathway of clivorine was delineated to be the initial formation of the unstable pyrrolic ester, which then may undergo hydrolysis, GSH conjugations, or covalent binding with hepatic tissues that may lead to hepatotoxicity. The present definitive identification of four pyrrolic ester-related metabolites of clivorine and indirect determination of bound pyrroles provide the strongest evidence to date to support the hypothesis that the formation of an unstable pyrrolic ester plays a key role in otonecine-type PA-induced hepatotoxicity.

Synthesis and identification of the quaternary ammonium-linked glucuronide of 1-phenylimidazole in human liver microsomes and investigation of the human UDP-glucuronosyltransferases involved.

1-Phenylimidazole was investigated as a potential model substrate with respect to formation of a quaternary ammonium-linked glucuronide (N(+)-glucuronide) at an aromatic type tertiary amine. A reference sample of the potential N(+)-glucuronide metabolite of 1-phenylimidazole was obtained by organic synthesis. The structural identity of the metabolite formed by incubation of 1-phenylimidazole with human liver microsomes was proven to be the N(+)-glucuronide by exhibiting the same HPLC retention time and electrospray ionization mass spectrum as the reference sample. The screening of 1-phenylimidazole against a panel of nine expressed human UDP-glucuronosyltransferases indicated the involvement of UGT1A3 and UGT1A4 in the formation of the N(+)-glucuronide metabolite.

Characterization of two structural forms of otonecine-type pyrrolizidine alkaloids from Ligularia hodgsonii by NMR spectroscopy.

Clivorine (1) and ligularine (2), two hepatotoxic otonecine-type pyrrolizidine alkaloids isolated from Ligularia hodgsonii, an antitussive traditional Chinese medicine, were investigated in CDCl(3) and D(2)O by various NMR techniques to delineate why this type of alkaloid displays uncharacteristic solubility properties by dissolving in both nonpolar organic and aqueous solutions. The results demonstrated that both alkaloids exist in a non-ionized form in CDCl(3), but in an ionized form in D(2)O, suggesting that this unique dual solubility may play a role in the intoxication resultant from consumption of water extracts of herbs, including herbal teas, containing otonecine-type pyrrolizidine alkaloids.

Stability and enzymatic hydrolysis of quaternary ammonium-linked glucuronide metabolites of drugs with an aliphatic tertiary amine-implications for analysis.

Quaternary ammonium-linked glucuronide (N+-glucuronide) metabolites formed at aliphatic tertiary amine functional groups of xenobiotics have not been previously systematically studied with respect to their stability over a wide pH range and the ease of enzymatic hydrolysis by beta-glucuronidase from various sources. Three and four N+-glucuronide metabolites were respectively studied regarding their non-enzymatic and enzymatic stabilities where the metabolites were quantified by HPLC procedures. The N+-glucuronide metabolites of clozapine, cyclizine, and doxepin were stored at 18-22 degrees C in buffers at each nominal pH value over the 1-11 pH range. All three metabolites were stable for 3 months over the 4-10 pH range, while two metabolites slowly degraded (k in the range 0.002-0.01 days(-1)) at each of the other extreme pH values. In the initial enzymatic study the N+-glucuronide metabolites of chlorpromazine, clozapine, cyclizine, and doxepin were each treated in pH 5.0 and 7.4 buffers at 37 degrees C with beta-glucuronidase from three different sources, namely commercial brands from bovine liver, mollusks (Helix pomatia), and bacteria (Escherichia coli). Clozapine N+-glucuronide and the standard phenolphthalein O-glucuronide were susceptible to hydrolysis by the enzyme from all three sources. In contrast, the other three N+-glucuronide metabolites were resistant to hydrolysis, except for the E. coli source of beta-glucuronidase at pH 7.4. Also when examined at 50-fold increase in concentration of the enzyme sources from bovine liver and H. pomatia cyclizine N+-glucuronide was still resistant to hydrolysis by the former enzyme preparation. The optimum pH for the hydrolysis of each of the four N+-glucuronide metabolites from the E. coli enzyme source was investigated and was found to be in the pH range 6.5-7.4. These data have important implications with respect to the analysis of N+-glucuronide metabolites formed at an aliphatic tertiary amine: in general, their non-enzymatic stability will not be an important factor in the development of an analytical procedure, and when developing an indirect approach to the analysis of N+-glucuronide metabolites that involves beta-glucuronidase hydrolysis to the aglycone preliminary work should involve determining the appropriate enzyme source, buffer pH, and length of time of incubation.

Dose staggering as a strategy to reduce drug--drug interactions due to reversible enzyme inhibition between orally administered drugs with high first pass effect: a computer simulation study.

A physiological computer model was designed to simulate the metabolic drug-drug interactions between two orally co-administered drugs due to reversible enzyme inhibition using drug concentrations in the portal vein. The extent of interactions was compared at steady-state for the effects of a delay in time between the administration of the substrate and the inhibitor. It was demonstrated that the extent of the interactions can be strongly affected by a time interval between the two drug administrations. By delaying the administration of the inhibitor until after the absorption phase of the substrate, one can significantly reduce the extent of the drug--drug interactions. This is because drug concentrations in the portal vein and the liver are much higher than that in the systemic circulation during the absorption phase. The model also showed that interactions involving substrates with a high extraction ratio (E(H)), i.e., drugs with higher first-pass effect, can be more strongly affected by dose staggering. Substrates with a low absorption rate constant (k(a)) require a longer interval with the inhibitor in order to reduce the extent of the interactions. This observation suggests dose staggering as a simple and cost-effective way to reduce the extent of unwanted drug--drug interactions in clinical practice.

Characterization of the human hepatic cytochromes P450 involved in the in vitro oxidation of clozapine.

It was aimed to identify the cytochrome(s) P450 (CYPs) involved in the N-demethylation and N-oxidation of clozapine (CLZ) by various approaches using human liver microsomes or microsomes from human B-lymphoblastoid cell lines. The maximum rates of formation were measured in the microsomal fraction of human livers and the Michaelis-Menten kinetics one enzyme model was found to best fit the data with mean K(M) for CLZ N-oxide and N-desmethyl-CLZ of 336 and 120 microM, respectively. Significant correlations were observed between the maximum rates of formation (Vmax) for CLZ N-oxide and N-desmethyl-CLZ with the microsomal immunoreactive contents of CYP1A2 (r = 0.92, P < 0.009 and r = 0.77, P < 0.077; respectively) and CYP3A (r = 0.89, P < 0.02 and r = 0.82, P < 0.05; respectively). Antibodies directed against CYP1A2 and CYP3A inhibited formation of CLZ N-oxide in human liver microsomes by 10.7+/-6.1%) and 37.2+/-6.9% of control, respectively, whereas CLZ N-demethylation was inhibited by 32.2+/-15.4% and 33.6+/-7.4%, respectively. Troleandomycin (CYP3A inhibitor) and furafylline (CYP1A2 inhibitor) inhibited CLZ N-oxidation in human liver microsomes by 23.2+/-12.1% and 7.8+4.3%, respectively, whereas CLZ N-demethylation was inhibited by 17.5+/-13.9% and 25.6+/-16.5%, respectively. While ketoconazole did not inhibit N-oxidation of CLZ, the N-demethylation pathway was inhibited by 34.1+/-10.0%. Formation in stable expressed enzymes indicated involvement of CYP3A and CYP1A2 in CLZ N-oxide formation and CYP2D6, CYP1A2 and CYP3A4 in CLZ N-demethylation. This apparent involvement of CYP2D6 in the N-demethylation of CLZ did not corroborate with the findings of other experiments. In conclusion, these data indicate that while both CYP isoforms readily catalyze both metabolic routes in vitro, CYP1A2 and CYP3A4 are more important in N-demethylation and N-oxidation, respectively.

N+-glucuronidation, a common pathway in human metabolism of drugs with a tertiary amine group.

Glucuronidation of either an aliphatic or aromatic tertiary amine group in a molecule results in a quaternary ammonium-linked glucuronide metabolite (i.e. N+-glucuronide). The development of sound information on N+-glucuronide metabolites, including their characterization, has been slow. In part, this is because the presence of both the carboxylic acid group and cationic center in their structure imparts physiochemical properties such that procedures used in their analysis, including extraction, require judicious selection. The techniques used in the identification of N+-glucuronide metabolites and those metabolites identified in human urine are the focus of this review. Especially useful in their identification are the availability of an authentic synthetic sample and the use of mass spectrometry and nuclear magnetic resonance (NMR) techniques that, in the first instance, involve atmospheric pressure ionization or fast atom bombardment modes of ionization and high-resolution 1H NMR. More than 30 N+-glucuronide metabolites of xenobiotics have been identified in human urine. In particular, N+-glucuronidation is a common phenomenon in the metabolism of H1 antihistamine and antidepressant drugs with an aliphatic tertiary amine group. Those marketed drugs in which the reported N+-glucuronide mean urinary excretion of the orally administered dose exceeds 10% include cyclizine, cyclobenzaprine, cyproheptadine, dothiepin, doxepin, ketotifen, lamotrigine, mianserin, and tioconazole. The pharmacological importance of N+-glucuronidation has not been clarified.

Microsomal formation of a pyrrolic alcohol glutathione conjugate of clivorine. Firm evidence for the formation of a pyrrolic metabolite of an otonecine-type pyrrolizidine alkaloid.

The formation of the pyrrolic alcohol glutathione (GSH) conjugates of two different types of pyrrolizidine alkaloids (PAs), i.e. clivorine (an otonecine-type PA) and retrorsine (a retronecine-type PA), was investigated with rat microsomes in the presence of GSH. Two GSH conjugates identified as metabolites of retrorsine were the pyrrolic alcohol conjugated with one [7-GSH-dehydroretronecine (DHP)] or two (7,9-diGSH-DHP) molecules of GSH. diGSH-DHP, the less abundant of the two conjugates, had not been previously identified as a metabolite of PAs. In the case of clivorine, 7-GSH-DHP was identified. This is the first unequivocal identification of a pyrrolic metabolite of an otonecine-type PA. Consequently, this study provides the strongest evidence obtained to date to support the hypothesis, suggested >25 years ago, that the mechanism of hepatotoxicity induced by otonecine-type PAs involves key metabolic steps similar to those for retronecine-type PAs.

N-oxygenation of clozapine by flavin-containing monooxygenase.

The involvement of FMO in the N-oxygenation of CLZ was investigated by use of purified FMOs and human liver microsomes that contained the mean amount of immunoreactive FMO3 relative to other human liver microsomal preparations in a liver bank. In the microsomal preparation the involvement of FMO was indicated through enzyme inhibition by methimazole, heat inactivation, and protection against heat inactivation by NADPH. Also the Michaelis-Menten kinetic constant; KM determined for CLZ N-oxidation catalyzed by purified human FMO3 (324 microM) was very similar to the mean value obtained in these laboratories for the microsomal preparations of seven human livers.

Identification of lactams as in vitro metabolites of piperidine-type phenothiazine antipsychotic drugs.

The metabolism of the piperidine-type phenothiazine antipsychotic agents thioridazine, mesoridazine and sulforidazine was studied in vitro with 10,000 g liver supernatants obtained from rats and dogs. After incubations at 37 degrees C for different time intervals, the incubates were extracted with dichloromethane and the isolated compounds analyzed by HPLC, direct probe MS and on-line HPLC-MS. Five lactam metabolites of these three drugs were unequivocally identified in the rat in vitro system, but none was found in dog preparations; at least one lactam metabolite was identified for each drug in the rat. The lactams of thioridazine and thioridazine ring sulfoxide were characterized as metabolites of thioridazine for the first time in any system. The other three lactam metabolites, namely the lactams of mesoridazine, sulforidazine and mesoridazine ring sulfoxide, were found in vitro for the first time, although they have been previously reported as in vivo metabolites of these drugs. The results indicate that rat would be a more suitable animal model than dog for further studies on the formation of lactam metabolites of these drugs.

Quinidine inhibits the 7-hydroxylation of chlorpromazine in extensive metabolisers of debrisoquine.

Quindine is a potent inhibitor of CYP2D6 (debrisoquine 4-hydroxylase). Its effect on the disposition of chlorpromazine was investigated in ten healthy volunteers using a randomised crossover design with two phases. A single oral dose of chlorpromazine hydrochloride (100 mg) was given with and without prior administration of quinidine bisulphate (250 mg). Chlorpromazine and seven of its metabolites were quantified in the 0- to 12-h urine while plasma concentrations of chlorpromazine and 7-hydroxychlorpromazine were measured over 48 h. All volunteers were phenotyped as extensive metabolisers with respect to CYP2D6 using the methoxyphenamine/O-desmethyl-methoxyphenamine metabolic ratio. Quinidine significantly decreased the urinary excretion of 7-hydroxylchlorpromazine 2.2-fold. Moreover the urinary excretion of this metabolite correlated inversely (rs = -0.80) with the metabolic ratio. The urinary recoveries of chlorpromazine, chlorpromazine N-oxide, 7-hydroxy-N-desmethylchlorpromazine, N-desmethyl-chlorpromazine sulphoxide and the total of all eight analytes were unaltered by quinidine. However, quinidine administration caused significant increases in the urinary excretions of chlorpromazine sulphoxide, N-desmethylchlorpromazine and N, N-didesmethylchlorpromazine sulphoxide, which indicated that compensatory increase in these metabolic routes of chlorpromazine might have been responsible for the lack of change observed in the urinary recovery of the parent drug. Quinidine administration produced modest decreases (1.2- to 1.3-fold) in the mean peak plasma concentrations and mean areas under the plasma concentration-time curves of 7-hydroxychlorpromazine and increases (1.3- to 1.4-fold) in these parameters for the parent drug chlorpromazine, but none of these changes reached statistical significance. Based on ANOVA the sample sizes required to detect these differences as significant (alpha = 0.5) with a probability of 0.8 were determined to vary between 15 and 42. These data suggest that CYP2D6 is involved in the metabolism of chlorpromazine to 7-hydroxychlorpromazine. However, genetic polymorphism in this metabolic process did not play a dominant role in accounting for the extremely large interindividual variations in plasma concentrations encountered with this drug.