Roadblocks to effective pain treatment.

Managed care "backlash" rhetoric to the contrary, roadblocks to effective pain treatment occur both intrinsic and extrinsic to the healthcare system. Pain medicine, an emerging, formally recognized specialty, and the special population of patients which it serves, experience additional discreet barriers. Chief among these is a lack of clear identity and recognition of the specialty and the disenfranchisement of many of the patients it serves in the American healthcare system. Special problems within various healthcare financing environments is discussed.

Enterohepatic recirculation of the new antihypertensive drug UP 269-6 in humans. A possible model to account for multiple plasma peaks.

Following a single dose of a new antihypertensive drug, UP 269-6 (5-methyl-7-propyl-8-[(2'-(1H-tetrazol-5-yl) biphenyl-4-yl)methyl]-1,2,4-triazolo[1,5-c]pyrimidin-2(3H)-one, CAS 148504-51-2), to 12 healthy volunteers, the plasma levels showed at least two secondary peaks. To explain this observation, the data were fitted to a new compartmental model of enterohepatic recirculation, without using a numerical method. Most subjects exhibited two cycles of recirculation. The amount of drug involved in each recirculation was calculated and the AUCs compared. The drug showed high biliary excretion and reabsorption.

Influence of dose range on degree of nonlinearity detected in dose-proportionality studies for drugs with saturable elimination: single-dose and steady-state studies.

Deviation from proportionality occurs when the ratio of area under the curve (AUC) values is not equal to the ratio of administered doses. The degree of nonlinearity (fNL) can be quantitated as the ratio of AUCs divided by the ratio of doses. We explore positive deviation from proportionality (fNL > 1) using the classical Michaelis-Menten model of nonlinear elimination after a single dose (n = 1) or at steady state (ss). The degree of nonlinearity is related to the ratio of the highest dose to the lowest dose (Rd = DH/DL): fn = 1NL = (2 + Rd.epsilon)/(2 + epsilon), fssNL = (Rd.omega - 1)/(Rd.omega - Rd), where epsilon is the ratio of the initial concentration after the lowest dose to the Km (epsilon = DL/Km.V) and omega is the ratio of the Vmax to the average rate of input for the highest dose (omega = Vmax tau/F.DH). From these relationships, we find that (1) for single-dose studies, Km is the important Michaelis-Menten parameter, while Vmax is important at steady state; (2) the degree of nonlinearity cannot exceed the ratio of doses in single-dose studies, and when doses in extreme excess of Km.V are chosen, the degree of nonlinearity is equal to the dose range; and (3) at steady state, the degree of nonlinearity can exceed the ratio of doses and approaches infinity as the average input rate approaches Vmax. Literature data (phenytoin and ethanol) support these findings. We conclude that the degree of nonlinearity is not a useful measure of nonlinearity in and of itself and propose percentage saturation as being more informative.

Simultaneous determination of phenolphthalein and phenolphthalein glucuronide from dog serum, urine and bile by high-performance liquid chromatography.

A procedure is described to simultaneously quantitate phenolphthalein and its glucuronide metabolite from dog serum, urine and bile using high-performance liquid chromatography. The major advantages of this over pre-existing methods include direct analysis of the parent compound and glucuronide metabolite without enzymatic hydrolysis, increased sensitivity and the potential for automation of a large number of samples. Analytes were extracted from serum and urine using a combination of liquid- and solid-phase extraction methodology. Bile samples were analyzed directly after a twenty-fold dilution with mobile phase. The components plus internal standard were separated by reversed-phase high-performance liquid chromatography using step gradient elution and quantitated by the absorbance of ultraviolet light at 230 nm. Limits of detection from 1 ml of serum, 0.1 ml of urine and 0.05 ml of bile were 0.1, 0.5 and 10 microgram/ml for phenolphthalein and 0.1, 10 and 50 microgram/ml for phenolphthalein glucuronide, respectively.

The disposition of 2-cyano-1-methyl 3-(4-(4-methyl-6-oxo-1,4,5,6-tetrahydro-pyridazin-3-yl)phenyl)guanidine in animals.

2-Cyano-1-methyl 3-(4-(4-methyl-6-oxo-1,4,5,6-tetrahydro-pyridazin-3-yl)phenyl)guan idine (SK&F 94836), a new positive inotrope/vasodilator, is being evaluated for the treatment of congestive heart failure. The absorption, metabolism, and disposition of the compound have been investigated in the rat, mouse, and dog. SK&F 94836 was rapidly absorbed, widely distributed, and rapidly and completely excreted primarily via the urine. There was no evidence of metabolism of the compound in any of the species studied. The compound showed minimal interaction with cytochrome P-450. The compound contains a chiral center. The enantiomers have been shown not to interconvert in either rat or dog. The serum protein binding was low in all species, including humans, and exhibited no stereoselectivity. Studies conducted in rat and dog using constant rate co-infusion of racemic SK&F 94836 and radiolabeled inulin have demonstrated that SK&F 94836 is eliminated by active tubular secretion.

Mean residence time for drugs subject to enterohepatic cycling.

A physiologically realistic model of enterohepatic cycling (EHC) which includes separate liver and gallbladder compartments, discontinuous gallbladder emptying and first-order absorption from both an oral formulation and secreted bile (kapo and kab, respectively) has been developed. The effect of EHC on area under the first-moment curve (AUMC) of drug concentration in plasma and on parameters derived from the AUMC was investigated. Unlike AUC, AUMC is dependent on the time and time-course of gallbladder emptying, increasing as the interval between gallbladder emptying increases. Consequently, mean residence time (MRT) is also a time-dependent parameter. Analytical solutions for MRTiv and MRTpo were derived. Mean absorption time (MAT = MRTpo - MRTiv) is also time-dependent, contrary to findings previously published for a model of EHC with a continuous time lag. MAT is also dependent on kapo, kba and the hepatic extraction ratio. The difference between MRTpos for two formulations with unequal kapo values may deviate from the difference in the inverse of their absorption rate constants. Implications for design and interpretation of pharmacokinetic studies include (i) MAT values may be dominated by the time-course of recycling rather than the time-course of the initial absorption, depending on the extent of EHC and (ii) the unpredictable nature of the time of gallbladder emptying will contribute to intrasubject variability in derived parameters during crossover studies. Knowledge of the extent of EHC is invaluable in deciding whether modification of the in vitro release characteristics of an oral formulation will have any effect on the overall time-course of absorption in vivo. Techniques to monitor or control gallbladder emptying may be helpful for reducing variability in pharmacokinetic studies for compounds which are extensively cycled in bile.

An equation for the systemic availability of drugs undergoing simultaneous enterohepatic cycling, first-pass metabolism, and intestinal elimination.

A relationship between systemic availability and its determinants has been derived for a physiologically realistic model of drug disposition that includes enterohepatic cycling (EHC), gallbladder emptying (with an arbitrary time course), first-pass metabolism to noncycling metabolites, and fecal excretion. Systemic availability (F) has been shown to be determined by the fraction of the dose initially absorbed (f*a), the fraction of the drug excreted into the GI tract that is reabsorbed with each cycle (fa), the hepatic extraction ratio (E), and the fraction of extracted drug that is transported to the gallbladder for EHC (fg) according to the relationship F = f*a(1 - E)/(1 - fafgE) The implications of the above relationship are that (1) systemic availability is dependent on EHC, (2) values of F calculated to be greater than unity cannot be explained simply by the presence of EHC, (3) calculations of E based on the usual expression F = f*a(1 - E) are erroneous for drugs subject to EHC, and (4) a compound that has a high systemic availability and is subject to EHC is not necessarily inefficiently metabolized. The quantitative interrelationship of systemic availability and its determinants is illustrated using a contour plot. Slices through the surface are used to demonstrate that the presence of EHC changes the sensitivity of F to changes in E.

Digoxin and metabolites in urine and feces: a fluorescence derivatization--high-performance liquid chromatographic technique.

A high-performance liquid chromatography method is described for the determination of digoxin and its metabolites digoxigenin, digoxigenin monodigitoxoside, digoxigenin bis-digitoxoside and dihydrodigoxin (20S and 20R) excreted in urine and feces. The urine sample or fecal supernatant is extracted with methylene chloride in the presence of digitoxigenin or digitoxin as internal standard. Pre-column derivatization is achieved using 1-naphthoyl chloride with subsequent separation of the derivatized compounds on either a normal- or reversed-phase system with fluorescence detection. Recoveries for digoxin and all metabolites from fecal samples were in the range 60-74%, which is comparable to that previously determined for urine samples. Standard curve data revealed linearity over a wide range of concentrations. Coefficients of variation for the analysis were less than 10% for all compounds over a range of 5-125 ng per ml urine and 10-250 ng per 200 mg feces. Peaks for digoxin and metabolites in urine and feces were obtained when human excreta were analyzed.

Estimation of area under the curve for drugs subject to enterohepatic cycling.

A physiologically realistic model is used to provide insight into the design of sampling protocols for accurate determination of AUC(0-infinity) for drugs subject to enterohepatic cycling. Through simulation of plasma concentration-time curves for such drugs it is found that more than one peak is predicted after oral and intravenous administration of a single dose of drug, the relative magnitude of peaks is dependent on the hepatic extraction ratio for both oral and intravenous drug administration, the percent of the AUC(0-infinity) in later time intervals is also a function of the hepatic extraction ratio, and present methods for the design of sampling protocols may not provide accurate estimates of AUC(0-infinity) (especially for highly extracted drugs), because peaks are only evident at later times after intravenous administration when plasma sampling is less frequent, much of the area occurs at later times, and the amount of drug in the sampling compartment after oral administration is much lower than that after intravenous administration of drug and could be incorrectly interpreted as low bioavailability if sampling is not carried out for a long period of time. The types of oral and intravenous profiles predicted for highly extracted drugs are exemplified by data for naltrexone in the monkey.

Accumulation and time to steady state for drugs subject to enterohepatic cycling: a stimulation study.

A physiologically realistic model was used to investigate through simulation the multiple-dose behavior of drugs subject to enterohepatic cycling. The model included separate liver and gallbladder compartments and instantaneous emptying of the gallbladder at regular intervals of length phi. Two half-lives are described, only one of which is predictive of time to steady state and accumulation. This predictive half-life would be obtained if plasma samples were taken at regular intervals equal to phi, and has been termed the effective half-life. Incorporation of gallbladder emptying at irregular intervals into the model did not materially alter our conclusions regarding the existence and predictive nature of the effective half-life.

Formation of [20R]-dihydrodigoxin from digoxin in humans.

The objective of this research was to determine the stereochemical identity of dihydrodigoxin (DHD3), a metabolite of digoxin excreted in urine after digoxin administration in man. Separation of the individual epimers in reference DHD3 was effected by a chemical derivatization-HPLC procedure. Comparison of individual derivatized epimers of DHD3 with the known 20R and 20S epimers of derivatized dihydrodigoxigenin using chromatographic data and NMR spectroscopy permitted identification of the 20R and 20S epimers in reference DHD3. Material corresponding chromatographically to R-DHD3 was isolated from urine of a volunteer taking oral digoxin daily. The NMR spectrum of the chromatographically pure, derivatized urinary isolate was identical to the NMR spectrum of derivatized R-DHD3. Urine samples from 20 patients on chronic digoxin therapy and from two volunteers were surveyed for chromatographic evidence of R- or S-DHD3 using HPLC of a fluorescent derivative as well as HPLC of a UV-absorbing derivative. The more sensitive fluorescence procedure yielded evidence for R-DHD3 in eight patients and both volunteers. There was a sufficient concentration in four patients and both volunteers for independent evidence of R-DHD3 using the UV-absorbing derivative. Chromatographic evidence (fluorescent derivative) for S-DHD3 was found in urine from three patients. However, this evidence for S-DHD3 was demonstrated to be an artifact by the absence of the peak expected for S-DHD3 in the chromatogram of the UV-absorbing derivative as well as by the inability of fecal incubates to convert digoxin to S-DHD3. The results of the investigation indicate that the DHD3 metabolite formed in humans is the 20R epimer.