Prophylaxis for venous thromboembolism in hip fracture surgery: total costs and cost effectiveness in The Netherlands.

Fracture of the hip is one of most significant risk factors for development of deep vein thrombosis (DVT) and its complications. A number of pharmacological prophylactic methods are currently available which can reduce the incidence of postoperative thromboembolism in patients undergoing surgery for fracture of the hip. A retrospective analysis of controlled clinical studies was performed to examine in this patient group the total cost of prevention and treatment, and the cost effectiveness in terms of lives saved, of 5 prophylactic regimens--oral anticoagulants, dextran, low dose heparin, low molecular weight (LMW)-heparin and danaparoid sodium--compared with clinical diagnosis and conventional treatment of DVT only. Our results show that the total cost, including the savings in treatment of the complications of DVT, of each prophylactic regimen is less than the total cost of no prophylaxis. Thus, prophylaxis may not only save lives but may also lead to lower costs of care (including prophylaxis costs). The total cost of the new antithrombotic danaparoid sodium is less than that of the other forms of prophylaxis considered and danaparoid sodium appears to be the most cost-effective modality. We conclude that general use of danaparoid sodium in surgery for hip fracture is the most efficient approach to decreasing the incidence of postoperative morbidity and mortality and reducing healthcare expenses for the complications of DVT.

Pharmacokinetics of steroidal muscle relaxants in isolated perfused rat liver.

Both in humans and animals hepatic elimination is an important factor determining the duration of action of non-depolarizing neuromuscular blocking drugs. To elucidate the hepato-biliary disposition of muscle relaxants the pharmacokinetics of several structurally related but physicochemically distinct steroidal neuromuscular blocking drugs were studied in isolated perfused rat livers. Pharmacokinetics analysis with the DIFFIT computer program enabled the simultaneous fitting of independently measured perfusate disappearance and biliary excretion rate curves using a numerical approach. The hepatic disposition of the steroidal muscle relaxants could be adequately described by a three compartment model with elimination from the peripheral compartment V2 (biliary excretion) and storage in a deep compartment (V3) connected to V2. In addition, for vecuronium only slow ester hydrolysis occurring in V2 and V3 was included in the model. The lipophilicity rather than the relative mobility of the muscle relaxants showed a positive relationship with biliary clearance (Cl20) and the initial hepatic uptake (Cl12), indicating that hepato-biliary transport of these organic cations is highly dependent on the hydrophobic character of the compounds. In addition, net hepatic uptake of the steroidal cations was influenced markedly by transport from the liver to perfusate (hepatic efflux). This hepatic efflux (k21) decreased with increasing lipophilicity. In contrast, the extent of intracellular sequestration into deep compartments, indicated by high k23/k32 ratios, seemed to be inversely related to the lipophilicity of the muscle relaxants and might explain the observed prolonged hepatic storage of some of these compounds. In combination with data from subfractionation studies the results indicate that the pharmacokinetic analysis of the hepatic disposition of steroidal muscle relaxants may be used to evaluate actual transport phenomena participating in the hepatic disposition of these drugs.

Investigations on the hepatic uptake systems for organic cations with a photoaffinity probe of procainamide ethobromide.

Azido procainamide methoiodide (APM), a photolabile derivative of the transport model compound procainamide ethobromide (PAEB), shows a close resemblance to PAEB from a physicochemical point of view. Like PAEB it is effectively taken up by the liver and excreted into bile. Kinetics of the uptake of APM in isolated hepatocytes revealed that in addition to a non-saturable process, two saturable uptake systems are involved (Km1 = 3 microM, Vmax1) = 80 pmol/min/10(6) cells, Km2 = 100 microM, Vmax2 = 130 pmol/min x 10(6) cells). The uptake rate of APM was inhibited markedly in the presence of other organic cations. Organic anions and uncharged compounds generally had no inhibitory effect on the APM uptake. These results support the theory that there is a separate hepatic uptake system for organic cations like APM. Photoaffinity labeling of intact hepatocytes as well as plasma membrane sub-fractions enriched with sinusoidal domains disclosed two major binding polypeptides with apparent M(r) of 48,000 and 72,000. Such labeling patterns were not observed in membranes from hepatoma cells that are deficient in organic solute uptake. Differential photoaffinity labeling with other cationic compounds such as tributylmethyl ammonium and d-tubocurarine reduced the incorporation of APM in these polypeptides. The 48- and 72-kDa proteins might be involved in carrier-mediated transport of type I organic cations at the hepatic uptake level.

Carrier-mediated transport in the hepatic distribution and elimination of drugs, with special reference to the category of organic cations.

Carrier-mediated transport of drugs occurs in various tissues in the body and may largely affect the rate of distribution and elimination. Saturable translocation mechanisms allowing competitive interactions have been identified in the kidneys (tubular secretion), mucosal cells in the gut (intestinal absorption and secretion), choroid plexus (removal of drug from the cerebrospinal fluid), and liver (hepatobiliary excretion). Drugs with quaternary and tertiary amine groups represent the large category of organic cations that can be transported via such mechanisms. The hepatic and to a lesser extent the intestinal cation carrier systems preferentially recognize relatively large molecular weight amphipathic compounds. In the case of multivalent cationic drugs, efficient transport only occurs if large hydrophobic ring structures provide a sufficient lipophilicity-hydrophilicity balance within the drug molecule. At least two separate carrier systems for hepatic uptake of organic cations have been identified through kinetic and photoaffinity labeling studies. In addition absorptive endocytosis may play a role that along with proton-antiport systems and membrane potential driven transport may lead to intracellular sequestration in lysosomes and mitochondria. Concentration gradients of inorganic ions may represent the driving forces for hepatic uptake and biliary excretion of drugs. Recent studies that aim to the identification of potential membrane carrier proteins indicate multiple carriers for organic anions, cations, and uncharged compounds with molecular weights around 50,000 Da. They may represent a family of closely related proteins exhibiting overlapping substrate specificity or, alternatively, an aspecific transport system that mediates translocation of various forms of drugs coupled with inorganic ions. Consequently, extensive pharmacokinetic interactions can be anticipated at the level of uptake and secretion of drugs regardless of their charge.

Hepatic transport mechanisms for bivalent organic cations. Subcellular distribution and hepato-biliary concentration gradients of some steroidal muscle relaxants.

In order to characterize the hepato-biliary transport of bivalent cations in more detail, the subcellular distribution of three steroidal muscle relaxants, that differ physicochemically and kinetically, was studied by differential centrifugation of liver homogenates. Binding of the muscle relaxants to macromolecular compounds was measured in Krebs-albumin solution, in cytosolic fraction of liver homogenate and in bile, to estimate the unbound concentrations in the particular fluids. Cytosol/plasma concentration ratios increased in the order pancuronium less than Org 6368 less than vecuronium, but for all of the compounds did not exceed the value that would be attained by passive equilibration according to the membrane potential. The subcellular distribution patterns of the three substances indicated that the mitochondrial fraction is a major storage compartment in the liver. Yet Org 6368 was bound to the particulate fraction of liver homogenate to a larger extent than pancuronium and vecuronium. The high bile/cytosol concentration ratios indicate that for all of these cations an active transport system is involved in the biliary excretion process. For Org 6368 and vecuronium the bile/cytosol concentration ratios are in the same range (about 30) and substantially higher than for pancuronium (about 6). This suggests that for Org 6368 and vecuronium the transport across the canalicular membrane is more efficient than for pancuronium. The combined data indicate that the extensive binding of Org 6368 to particles within the cell is a major factor in the relative efficient hepatic uptake and the modest biliary excretion of this agent. The limited hepato-biliary transport of pancuronium appears to be due to a relatively small net transport, both at the sinusoidal land at the canalicular membrane.

Uptake and excretion of vecuronium bromide and pancuronium bromide in the isolated perfused rat liver.

Using the isolated perfused rat liver preparation, the disappearance from the perfusate and the excretion in the bile of vecuronium bromide and pancuronium bromide and their metabolites were followed for 2 h after the addition of 1 mg of either drug to the perfusate. In addition, the rate of change of the hepatic content of these two compounds was calculated by serially subtracting the amount of the compound and the metabolites in the bile and in the perfusate from the dose of drug added to the perfusate. It was found that, whereas the concentration of pancuronium in the perfusate declined slowly and monoexponentially, vercuronium concentration in the perfusate declined rapidly in a biexponential manner. No metabolites of either drug were detected in the perfusate. Approximately 40% of the injected dose of vecuronium was excreted in the bile as unchanged vecuronium and another 30% as the 3-hydroxy metabolite. No other metabolites of vecuronium were found in the bile. In total only about 7% of pancuronium (unchanged) was collected in the bile by the end of the experiment. It is concluded that, in comparison to pancuronium, the rat liver takes up large amounts of vecuronium rapidly, half of which is eliminated as unchanged vecuronium and half as the 3-hydroxy derivative. A small amount of vecuronium or its 3-hydroxy metabolite is returned to the perfusate from the liver. Some possible mechanisms underlying these differences are discussed.

Mechanisms for the hepatic uptake of organic cations. Studies with the muscle relaxant vecuronium in isolated rat hepatocytes.

In hepatobiliary transport of organic cations some remarkable differences have been reported between the monovalent compounds (prototype procainamidethobromide) and the potentially bivalent cations, containing a second quaternary ammonium group or a protonated tertiary amine function (prototype d-tubocurarine). In order to characterize the hepatic uptake mechanism for such bivalent cations in more detail, we studied the uptake of the steroidal muscle relaxant vecuronium in isolated rat hepatocytes. Uptake occurred by both a saturable (Vmax = 181 pmol/min x 10(6) cells, Km = 15 microM) and a nonsaturable process (rate constant = 1.10 pmol/min/10(6) cells/microM). The uptake of vecuronium was reduced by various metabolic inhibitors and by sulfhydryl-blocking agents. The transport system showed temperature dependency with an activation energy of 85 kJ/mol. Sodium replacement by lithium or choline in the extracellular medium had no effect on the uptake of vecuronium. Replacement of sodium chloride by sucrose led to a decrease of the uptake, whereas chloride replacement by bicarbonate or iodide stimulated the vecuronium uptake. These data point to a significant anion-dependency of the uptake system and indicate electroneutral uptake of vecuronium. The uptake of vecuronium was inhibited by a variety of hepatic transport model compounds, including bile acids, uncharged compounds and high molecular weight organic cations. Low molecular weight monovalent cations had no effect on the uptake of vecuronium.(ABSTRACT TRUNCATED AT 250 WORDS)

Paracellular transport of inorganic and organic ions across the rat ileum.

The properties of the absorption route via the tight junctions and the intercellular spaces (the paracellular pathway) in rat ileum were investigated with inorganic and organic ions. Isolated ileal epithelial sheets were used, mounted between two chambers. Biionic and diffusion potentials of the ions were measured with Ag/AgCl electrodes. From the Goldman-Hodgkin-Katz equation relative permeabilities were calculated and selectivity isotherms constructed. The paracellular pathway behaved as an aqueous pore with cation selectivity. The permeability order is K+ congruent to NH+4 greater than Na+ greater than Cl congruent to Li+ greater than tetramethylammonium+ greater than tetraethylammonium+ congruent to choline+ greater than carbachol+. TAP+ (2,4,6-triaminopyrimidinium) appeared, in contrast to the situation in other tissues, not to be an inhibitor of this pathway. The permeability for organic cations is high: compounds with a mol. wt of about 150 have a permeability relative to sodium of 0.45. Together with the results of previous studies, in which the transcellular aspects of organic cation transport were investigated, a model for organic cation absorption is developed.