Impact of Plasma Protein Binding in Drug Clearance Prediction: A Data Base Analysis of Published Studies and Implications for In Vitro-In Vivo Extrapolation.

Plasma protein-mediated uptake (PMU) and its effect on clearance (CL) prediction have been studied in various formats; however, a comprehensive analysis of the overall impact of PMU on CL parameters from hepatocyte assays (routinely used for IVIVE) has not previously been performed. The following work collated data reflecting the effect of PMU for 26 compounds with a wide variety of physicochemical, drug, and in vivo CL properties. PMU enhanced the unbound intrinsic clearance in vitro (CLint,u in vitro) beyond that conventionally calculated using fraction unbound and was correlated with the unbound fraction of drug in vitro and in plasma (fup) and absolute unbound intrinsic clearance in vivo (CLint,u in vivo) in both rat and human hepatocytes. PMU appeared to be more important for highly bound (fup < 0.1) and high CLint,u in vivo drugs. These trends were independent of species, assay conditions, ionization, and extended clearance classification system group, although the type of plasma protein used in in vitro assays may require further investigation. Such generalized trends (spanning fup 0.0008-0.99) may suggest a generic mechanism behind PMU; however, multiple drug-dependent mechanisms are also possible. Using the identified relationship between the impact of PMU on CLint,u in vitro and fup, PMU-enhanced predictions of CLint,u in vivo were calculated for both transporter substrates and metabolically cleared drugs. PMU was accurately predicted, and incorporation of predicted PMU improved the IVIVE of hepatic CL, with an average fold error of 1.17 and >50% of compounds predicted within a 2-fold error for both rat and human data sets (n ≥ 100). SIGNIFICANCE STATEMENT: Current strategies for prediction of hepatic clearance from in vitro data are recognized to be inaccurate, but they do not account for PMU. The impact of PMU on CLint,u in vitro is wide ranging and can be predicted based on fraction unbound in plasma and applied to CLint,u in vitro values obtained by standard procedures in the absence of plasma protein. Such PMU-enhanced predictions improved IVIVE, and future studies may easily incorporate this PMU relationship to provide more accurate IVIVE.

Use of Segregated Hepatocyte Scaling Factors and Cross-Species Relationships to Resolve Clearance Dependence in the Prediction of Human Hepatic Clearance.

Human and rat hepatocytes have a strong tendency to underpredict hepatic intrinsic clearance (CLint) and the extent of underprediction increases with increasing observed CLint In this study, application of the log average rat hepatocyte-rat in vivo empirical scaling factor (ESF) of 4.2 to human hepatocyte prediction successfully removed bias but did not improve precision. An analogous method using individual drug rat ESFs only achieved marginal improvement in accuracy but not precision. A novel approach to resolve clearance-dependent prediction, involving rat ESFs calculated for particular (order of magnitude) ranges of observed CLint (log average range, 0.12-2.1) improved human prediction precision but only modestly reduced bias. However, rat in vivo CLint was several-fold greater than human in vivo CLint and this was reflected in greater rat hepatocyte and microsome CLint, suggesting that rat metabolic enzymes are more efficient than their human counterparts, by several-fold. By applying the segregated rat ESFs followed by the human/rat CLint ratio, which was consistent regardless of CLint (log average 3.5), both accuracy and precision were improved, providing both a means of mitigating clearance dependence and reaffirming the potential role of rat hepatocytes for prediction of human metabolic CLint These cross-species observations indicate that underprediction from human in vitro systems may be predominantly consequential of an intrinsic property of the in vitro system rather than individual drug properties.

Clearance Prediction Methodology Needs Fundamental Improvement: Trends Common to Rat and Human Hepatocytes/Microsomes and Implications for Experimental Methodology.

Although prediction of clearance using hepatocytes and liver microsomes has long played a decisive role in drug discovery, it is widely acknowledged that reliably accurate prediction is not yet achievable despite the predominance of hepatically cleared drugs. Physiologically mechanistic methodology tends to underpredict clearance by several fold, and empirical correction of this bias is confounded by imprecision across drugs. Understanding the causes of prediction uncertainty has been slow, possibly reflecting poor resolution of variables associated with donor source and experimental methods, particularly for the human situation. It has been reported that among published human hepatocyte predictions there was a tendency for underprediction to increase with increasing in vivo intrinsic clearance, suggesting an inherent limitation using this particular system. This implied an artifactual rate limitation in vitro, although preparative effects on cell stability and performance were not yet resolved from assay design limitations. Here, to resolve these issues further, we present an up-to-date and comprehensive examination of predictions from published rat as well as human studies (where n = 128 and 101 hepatocytes and n = 71 and 83 microsomes, respectively) to assess system performance more independently. We report a clear trend of increasing underprediction with increasing in vivo intrinsic clearance, which is similar both between species and between in vitro systems. Hence, prior concerns arising specifically from human in vitro systems may be unfounded and the focus of investigation in the future should be to minimize the potential in vitro assay limitations common to whole cells and subcellular fractions.

Methodological uncertainty in quantitative prediction of human hepatic clearance from in vitro experimental systems.

Mechanistic prediction of unbound drug clearance from human hepatic microsomes and hepatocytes correlates with in vivo clearance but is both systematically low (10 - 20 % of in vivo clearance) and highly variable, based on detailed assessments of published studies. Metabolic capacity (Vmax) of commercially available human hepatic microsomes and cryopreserved hepatocytes is log-normally distributed within wide (30 - 150-fold) ranges; Km is also log-normally distributed and effectively independent of Vmax, implying considerable variability in intrinsic clearance. Despite wide overlap, average capacity is 2 - 20-fold (dependent on P450 enzyme) greater in microsomes than hepatocytes, when both are normalised (scaled to whole liver). The in vitro ranges contrast with relatively narrow ranges of clearance among clinical studies. The high in vitro variation probably reflects unresolved phenotypical variability among liver donors and practicalities in processing of human liver into in vitro systems. A significant contribution from the latter is supported by evidence of low reproducibility (several fold) of activity in cryopreserved hepatocytes and microsomes prepared from the same cells, between separate occasions of thawing of cells from the same liver. The large uncertainty which exists in human hepatic in vitro systems appears to dominate the overall uncertainty of in vitro-in vivo extrapolation, including uncertainties within scaling, modelling and drug dependent effects. As such, any notion of quantitative prediction of clearance appears severely challenged.

Reliability of human cryopreserved hepatocytes and liver microsomes as in vitro systems to predict metabolic clearance.

A total of 110 drugs, selected to cover a range of physicochemical and pharmacokinetic properties, were used to explore standard approaches to the prediction of in vivo metabolic clearance using drug-depletion profiles from human liver microsomes (HLMs) and cyropreserved hepatocytes. A total of 41 drugs (37% of the compounds tested) showed measurable depletion rates using HLMs (depletion by 20% or more over the time course). The most reliable correlations in terms of bias (average fold error (AFE) = 2.32) and precision (root mean square error (RMSE) = 3501) were observed by comparing in vivo intrinsic clearance (CL(int)), calculated using the parallel-tube model and incorporating the fraction unbound in blood, with in vitro CL(int) adjusted for microsomal binding. For these reference drugs, 29% of predictions were within two-fold of the observed values and 66% were within five-fold. Compared with HLMs, clearance predictions with cryopreserved hepatocytes (57 drugs) were of similar precision (RMSE = 3608) but showed more bias (AFE = 5.21) with 18% of predictions within two-fold of the observed values and 46% within five-fold. However, with a broad complement of drug-metabolizing enzymes, hepatocytes catalysed measurable CL(int) values for a greater proportion (52%) of the reference compounds and were particularly proficient at defining metabolic rates for drugs with predominantly phase 2 metabolic routes.

Prediction of metabolic clearance using fresh human hepatocytes: comparison with cryopreserved hepatocytes and hepatic microsomes for five benzodiazepines.

1. Predictions of in vivo intrinsic clearance from cryopreserved human hepatocytes may be systematically low. In the current study, the metabolite kinetics of a series of CYP3A4 substrates (benzodiazepines) in fresh human hepatocytes from five donors, via a major UK supplier, were investigated and compared with those previously reported (by the authors' laboratory) for cryopreserved human hepatocytes and hepatic microsomes. 2. A high incidence of autoactivation (up to tenfold) and heteroactivation (by testosterone, up to 14-fold) among the major pathways was observed. CYP capacity (V(max)) was marginally lower and 'affinity' constants (K(M), S(50)) were marginally greater compared with cryopreserved hepatocytes. 3. Average intrinsic clearance (based on maximal clearance, CL(max)) was sevenfold lower than in cryopreserved hepatocytes (reflecting sensitivity of intrinsic clearance estimation in vitro to mechanistic parameter values, particularly those involving atypical kinetics), but scaled intrinsic clearances for fresh (and cryopreserved) hepatocytes were within the range previously determined in hepatic microsomes. 4. There was no evidence from this series of studies that fresh hepatocytes provide quantitatively improved estimates of intrinsic clearance over cryopreserved hepatocytes.

The metabolism of the 5HT3 antagonists ondansetron, alosetron and GR87442 I: a comparison of in vitro and in vivo metabolism and in vitro enzyme kinetics in rat, dog and human hepatocytes, microsomes and recombinant human enzymes.

The metabolism of the structurally related 5HT3 antagonists ondansetron, alosetron and GR87442 in the rat, dog and human was determined in hepatocytes, liver microsomes and human recombinant microsomes. The profiles of phase I metabolites were similar in human hepatocytes and microsomes. The metabolites of all three compounds produced in rat, dog and human microsomes and hepatocytes were similar to those seen in vivo, with the major routes of metabolism being N-dealkylation and/or hydroxylation. There was more extensive metabolic processing in hepatocytes than in microsomes; however, sequential metabolism was less extensive in vitro compared with in vivo. The pharmacokinetics of the three 5HT3 antagonists investigated were dominated by CYP3A4 (and/or 2C9) compared with CYP1A2 in man, possibly determined by enzyme capacity rather than relative enzyme affinity. These data support the use of rat, dog and human hepatocytes for the prediction of in vivo metabolites of ondansetron, alosetron and GR87442.

The metabolism of the 5HT3 antagonists, ondansetron, alosetron and GR87442 II: investigation into the in vitro methods used to predict the in vivo hepatic clearance of ondansetron, alosetron and GR87442 in the rat, dog and human.

The in vitro clearances of the 5HT3 antagonists, ondansetron, alosetron and GR87442 were investigated. Intrinsic clearances using either metabolite formation or substrate depletion methods were equivalent (R2 = 0.95). Hepatocytes from preclinical species were superior to microsomes for the prediction of hepatic clearance (CL(H)), whereas the predictions from human microsomes and hepatocytes were similar. Using a non-restrictive model, seven of the nine CL(H) predictions using hepatocytes were within 2-fold of the in vivo CL(H) values. If the unbound fraction was included, the clearance of the compounds was generally under-predicted by both in vitro models. However, for the most metabolically stable compound, GR87442, the non-restrictive model over-predicted CLp. This and the possibility of extrahepatic metabolism indicate that the restrictive model is more appropriate for prediction of CL(H). The rank order of metabolic stability correlated with that in vivo. All three compounds were more metabolically stable in human than in the preclinical animal species examined.

Microsomal prediction of in vivo clearance and associated interindividual variability of six benzodiazepines in humans.

The intrinsic clearances (CLint) of midazolam, triazolam, diazepam, nordiazepam, flunitrazepam and alprazolam were determined from two liver banks (n=21) by formation kinetics of ten metabolites. A literature-collated database of in vivo CLint values (811 subjects) was used to assess predictions and variability. The in vivo clearance of six benzodiazepines was generally underpredicted by in vitro data and the degree of bias was in agreement with a database of structurally diverse compounds (n=37). The variability observed for in vitro clearances (11--19--fold for midazolam, diazepam and nordiazepam in liver bank 1; 101--269--fold for triazolam, flunitrazepam and alprazolam in liver bank 2) exceeded the in vivo variability for the same compounds (4--59 and 10--29, respectively). This mismatch may contribute to the bias in microsomal predictions and it highlights the need for careful selection of representative livers for human liver banks.

Impact of end-product inhibition on the determination of in vitro metabolic clearance.

End-product inhibition was explored as a mechanism for the lower clearance determination obtained from microsomes compared with hepatocytes. Triazolam, diazepam and phenytoin microsomal substrate depletion was reduced by 23, 34 and 39%, respectively, when incubated with their primary metabolites. Ki values of 28+/-6 and 11+/-1 microM were obtained when 4'-hydroxydiazepam and p-hydroxyphenytoin where incubated with diazepam and phenytoin, respectively. Alamethicin (a glucuronidation activator) was unsuccessful in alleviating these effects. IC50 values of 17, 32 and 18 microM for phenytoin and 83, 110 and 97 microM for diazepam were observed with salicylamide- (a glucuronidation inhibitor) treated hepatocytes, control hepatocytes and microsomes, respectively, when incubated with their primary metabolites. These differences suggest that metabolite concentrations in the vicinity of the enzyme are lower in hepatocytes compared with microsomes, reducing the likelihood of end-product inhibition in the former system. In conclusion, end-product inhibition may be more prominent in microsomes (in particular for substrate depletion assays where metabolism tends to be more extensive); results suggest that this phenomenon may contribute to the observed variations in metabolism characteristics and intrinsic clearance (CLint) between hepatocytes and microsomes.

Comparative study of the metabolism of drug substrates by human cytochrome P450 3A4 expressed in bacterial, yeast and human lymphoblastoid cells.

1. The aim was to compare the metabolic activity of human CYP3A4 expressed in bacteria (E. coli), yeast (S. cerevisiae) and human lymphoblastoid cells (hBl), with the native CYP3A4 activity observed in a panel of human livers. 2. Three CYP3A4 substrates were selected for study: dextromethorphan (DEM), midazolam (MDZ) and diazepam (DZ). The substrate metabolism in each of the four systems was characterized by deriving the kinetic parameters K(m) or S(50), V(max) and intrinsic clearance (CL(int)) or maximum clearance (CL(max)) from the kinetic profiles; the latter differing by 100-fold across the three substrates. 3. The K(m) or S(50) for the formation of metabolites 3-methoxymorphinan (MEM), 1'-hydroxymidazolam (1'-OH MDZ) and 3-hydroxydiazepam (3HDZ) compared well in all systems. For CYP3A4-mediated metabolism of DEM, MDZ and DZ, the V(max) for hBl microsomes were generally 2-9-fold higher than the respective yeast and human liver microsomes and E. coli membrane preparations, resulting in greater CL(int) or CL(max). In the case of 3HDZ formation, non-linear kinetics were observed for E. coli, hBl microsomes and human liver microsomes, whereas the kinetics observed for S. cerevisiae were linear. 4. The use of native human liver microsomes for drug metabolic studies will always be preferable. However, owing to the limited availability of human tissues, we find it is reasonable to use any of the recombinant systems described herein, since all three recombinant systems gave good predictions of the native human liver enzyme activities.

Multisite kinetic models for CYP3A4: simultaneous activation and inhibition of diazepam and testosterone metabolism.

Some substrates of cytochrome P450 (CYP) 3A4, the most abundant CYP in the human liver responsible for the metabolism of many structurally diverse therapeutic agents, do not obey classical Michaelis-Menten kinetics and demonstrate homotropic and/or heterotropic cooperativity. The unusual kinetics and differential effects observed between substrates of this enzyme confound the prediction of drug clearance and drug-drug interactions from in vitro data. We have investigated the hypothesis that CYP3A4 may bind multiple molecules simultaneously using diazepam (DZ) and testosterone (TS). Both substrates showed sigmoidal kinetics in B-lymphoblastoid microsomes containing a recombinant human CYP3A4 and reductase. When analyzed in combination, TS activated the formation of 3-hydroxydiazepam (3HDZ) and N-desmethyldiazepam (NDZ) (maximal activation 374 and 205%, respectively). For 3HDZ, V(max) values remained constant with increasing TS, whereas the S(50) and Hill values decreased, tending to make the data less sigmoidal. Similar trends were observed for the NDZ pathway. DZ inhibited the formation 6beta-hydroxytestosterone (maximal inhibition, 45% of control), causing a decrease in V(max) but no significant change to the S(50) and Hill values, suggesting that DZ may inhibit via a separate effector site. Multisite rate equation models have been derived to explore the analysis of such complex kinetic data and to allow accurate determination of the kinetic parameters for activation and inhibition. The data and models presented are consistent with proposals that CYP3A4 can bind and metabolize multiple substrate molecules simultaneously; they also provide a generic solution for the interpretation of the complex kinetic data derived from CYP3A4 substrates.

Extraperitoneal placement of renal allografts in children weighing less than 15 kg.

PURPOSE: Extraperitoneal renal transplantation is not routine in small recipients, in whom transperitoneal engraftment is the norm. The outcome of extraperitoneal placement of renal allografts in children weighing less than 15 kg. was evaluated at 2 institutions. MATERIALS AND METHODS: We retrospectively reviewed all pediatric renal transplantations at 2 institutions from 1988 to 2000 and identified 29 children 14 to 72 months old (mean age 29.2) weighing less than 15 kg. (range 8 to 14.8, mean 11.2). All children underwent allograft placement extraperitoneally via a modified Gibson and low midline retroperitoneal incision in 27 and 2, respectively. A concurrent procedure was done via the same incision during 2 ipsilateral and 2 bilateral nephrectomies. RESULTS: Of the 29 patients 25 have a functioning renal allograft. In 2 cases the initial allograft was lost due to early postoperative thrombosis and acute rejection in 1 each. Two patients with a functioning allografts died of medical complications greater than 2 years after transplantation. One child required reexploration secondary to fascial dehiscence and an additional recipient required pyeloureterostomy due to ureteral necrosis after living related donor transplantation. CONCLUSIONS: Extraperitoneal renal transplantation is technically feasible in children who weigh less than 15 kg. This approach preserves the peritoneal cavity, limits potential gastrointestinal complications and allows the confinement of potential surgical complications, such as bleeding and urinary leakage. In addition, this approach provides complete access to the retroperitoneum to enable concurrent retroperitoneal surgery, such as nephrectomy, to be performed safely. We recommend that extraperitoneal renal engraftment should become routine in children weighing less than 15 kg. rather than using the more common transperitoneal approach for allograft placement.

A transgenic insertion causing cryptorchidism in mice.

A distinctive feature of gonadal maturation in mammals is the movement to an extraabdominal location. Testicular descent is a complex, multistage process whereby the embryonic gonads migrate from their initial abdominal position to the scrotum. Failure in this process results in cryptorchidism, a frequent congenital birth defect in humans. We report here a new mouse transgenic insertional mutation, cryptorchidism with white spotting (crsp). Males homozygous for crsp exhibit a high intraabdominal position of the testes, associated with complete sterility. Heterozygous males have a wild-type phenotype, and homozygous females are fertile. Surgically descended testes in crsp/crsp males show normal spermatogenesis. Using FISH and genetic analyses, the transgenic insert causing the crsp mutation has been mapped to the distal part of mouse chromosome 5. Transgene integration resulted in a 550-kb deletion located upstream of the Brca2 gene. A candidate gene encoding a novel G protein-coupled receptor (Great) with an expression pattern suggesting involvement in testicular descent has been identified.

In vitro human tissue models in risk assessment: report of a consensus-building workshop.

Advances in the technology of human cell and tissue culture and the increasing availability of human tissue for laboratory studies have led to the increased use of in vitro human tissue models in toxicology and pharmacodynamics studies and in quantitative modeling of metabolism, pharmacokinetic behavior, and transport. In recognition of the potential importance of such models in toxicological risk assessment, the Society of Toxicology sponsored a workshop to evaluate the current status of human cell and tissue models and to develop consensus recommendations on the use of such models to improve the scientific basis of risk assessment. This report summarizes the evaluation by invited experts and workshop attendees of the current status of such models for prediction of human metabolism and identification of drug-drug interactions, prediction of human toxicities, and quantitative modeling of pharmacokinetic and pharmaco-toxicodynamic behavior. Consensus recommendations for the application and improvement of current models are presented.

In vitro-in vivo scaling of CYP kinetic data not consistent with the classical Michaelis-Menten model.

Strategies for the prediction of in vivo drug clearance from in vitro drug metabolite kinetic data are well established for the rat. In this animal species, metabolism rate-substrate concentration relationships can commonly be described by the classic hyperbola consistent with the Michaelis-Menten model and simple scaling of the parameter intrinsic clearance (CL(int) - the ratio of V(max) to K(m)) is particularly valuable. The in vitro scaling of kinetic data from human tissue is more complex, particularly as many substrates for cytochrome P450 (CYP) 3A4, the dominant human CYP, show nonhyperbolic metabolism rate-substrate concentration curves. This review critically examines these types of data, which require the adoption of an enzyme model with multiple sites showing cooperative binding for the drug substrate, and considers the constraints this kinetic behavior places on the prediction of in vivo pharmacokinetic characteristics, such as metabolic stability and inhibitory drug interaction potential. The cases of autoactivation and autoinhibition are discussed; the former results in an initial lag in the rate-substrate concentration profile to generate a sigmoidal curve whereas the latter is characterized by a convex curve as V(max) is not maintained at high substrate concentrations. When positive cooperativity occurs, we suggest the use of CL(max), the maximal clearance resulting from autoactivation, as a substitute for CL(int). The impact of heteroactivation on this approach is also of importance. In the case of negative cooperativity, care in using the V(max)/K(m) approach to CL(int) determination must be taken. Examples of substrates displaying each type of kinetic behavior are discussed for various recombinant CYP enzymes, and possible artifactual sources of atypical rate-concentration curves are outlined. Finally, the consequences of ignoring atypical Michaelis-Menten kinetic relationships are examined, and the inconsistencies reported for both different substrates and sources of recombinant CYP3A noted.