Foye's Principles of Medicinal Chemistry (Lemke, Foye's Principles of Medicinal Chemistry)

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Color Section

Fig. 3.1. Visualization of a drug molecule N-(4-hydroxyphenyl)-acetamide (Tylenol or acetaminophen) computerized with different levels of graphic representations. (A) Molecular structure of the drug Tylenol. (B) Ball-stick model showing atomic positions and types. (C) Ball-stick model with van der Waals dot surfaces. (D) Space-filled model showing van der Walls radii of the oxygen, nitrogen, and carbon atoms. (E) Solvent accessible surface model (solid) (solvent radius, 1.4Å). (See black and white image.)

Fig. 3.3. Graphic visualization of molecular orbital surface

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HOMO/LUMO calculation for the drug molecule acetaminophen. (See black and white image.)

Fig. 3.7. Nuclear magnetic resonance NOE-constrained molecular dynamics/molecular mechanics structure calculation of (A) the polypeptides CB 2 I298-K319; (B) the amino acid backbone superimposition of 10 low-energy conformers; (C) the cylinder representation with a turn at the fifth residue, arginine; (d) and the ribbon display of the two helical segments, showing a curve side chain of Arg302 forming a salt bridge (green line) with Glu305. (See black and white image.)

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Fig. 3.8. A workflow of in silico virtual screening process: receptor-based and ligand-based approaches. (See black and white image.)

Fig. 3.9. Three-dimensional G protein–coupled CB 2 receptor structure (right) constructed by homology and multiple sequence alignment

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method (left), including the seven transmembrane helices (cylinders, I–VII) and loop regions (ribbons). (From Xie XQ, Chen JZ, Billings EM. 3D structural model of the G protein–coupled cannabinoid CB2 receptor. Proteins: Structure, Function, and Genetics 2003;53:307–319; with permission.) (See black and white image.)

Fig. 3.10. MOLCAD-predicted CB 2 -binding pocket surrounded by active amino acid residues, showing an amphipathic contour, hydrophilic center (blue), and hydrophobic cleft (brown). The site-directed mutagenesis–

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detected binding residues are color-coded in terms of their distance to the pocket (magenta > yellow > green > blue) as the interaction weakens. (See black and white image.)

Fig. 3.11. CoMFA contour maps for arylpyrazole antagonists of cannabinoid receptor subtypes CB 1 (A) and CB 2 (B). Sterically favored areas (contribution level, 80%) are shown in green. Sterically unfavored areas (contribution level, 20%) are shown in yellow, and positivepotential favored areas (contribution level, 80%) are shown in blue. Positive-potential unfavored areas (contribution level, 20%) are shown in red. Plots of the corresponding CoMFA-calculated and experimental values of binding affinity (given as pK i ) of arylpyrazole compounds at CB 1 (AA) and CB2 (BB) receptor, respectively are shown as well. (Adapted with permission from Chen J, Han X, Lan R, et al. 3D-QSAR studies of arylpyrazole antagonists of cannabinoid receptor subtypes CB1 and CB2. A combined NMR and CoMFA approach. J Med Chem 2006;49:625–636; with permission.) (See black and white image.)

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Fig. 17.4. Ribbon diagram of monomeric PDE4D2 (PDB 1PTW). 5′-AMP is shown as balls-and-sticks, whereas two divalent metal icons are shown as solid spheres. (From Manallack DT, Hughes RA, Thompson PE. The next generation of phosphodiesterase inhibitors: structural clues to ligand and substrate selectivity of phosphodiesterases. J Med Chem 2005;48:3449–6342; with permission.) (See black and white image.)

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Fig. 17.5. Surface representation showing 5′-AMP in the nucleotide binding pocket of PDE4D2 (PDB 1PTW). 5′-AMP is shown as ballsand-sticks, while two divalent zinc icons are shown as solid spheres. (From Manallack DT, Hughes RA, Thompson PE. The next generation of phosphodiesterase inhibitors: structural clues to ligand and substrate selectivity of phosphodiesterases. J Med Chem 2005;48:3449–6342; with permission.) (See black and white image.)

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Fig. 17.7. Ribbon diagram of the active site of PDE4D2. The AMP phosphate group binds two divalent zinc icons and forms hydrogen bonds with His-160, Asp-201, and Asp-318. The adenine group of AMP adopts an anticonformation and orients toward the hydrophobic pocket made up of residues Tyr-159 (not shown), Leu-319, Asn-321, Thr-333, Ile-336, Gln-369, and Phe-372. It forms three hydrogen bonds with Gln-369 and Asn-321 and buttresses against Phe-372. The ribose of AMP has a C3′-endo puckering configuration and makes van der Waals contacts with residues His-160, Met-273, Asp-318, Leu-319, Ile-336, Phe-340, and Phe-372. (From Manallack DT, Hughes RA, Thompson PE. The next generation of phosphodiesterase inhibitors: structural clues to ligand and substrate selectivity of phosphodiesterases. J Med Chem 2005;48:3449–6342; with permission.) (See black and white image.)

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Fig. 17.9. Overlay of sildenafil with 5′-GMP in the active site of PDE5. (From Matot I, Gozal Y. Pulmonary responses to selective phosphodiesterase-5 and phosphodiesterase-3 inhibitors. Chest 2004;125:644–651; with permission.) (See black and white image.)

Fig. 17.11. Overlay of (R,S)-rolipram with 5′-AMP in the active site of PDE4D. (From Maurice DH, Palmer D, Tilley DG, et al. Cyclic nucleotide phosphodiesterase activity, expression, and targeting in cells of the cardiovascular system. Mol Pharmacol 2003;64:533–546; with permission.) (See black and white image.)

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Historical Perspective of Medicinal Chemistry John L. Neumeyer “The unprecedented increase in human life expectancy, which has almost doubled in a hundred years, is mainly due to drugs and to those who discovered them.” (1)

History and Evolution of Medicinal Chemistry J u s t a s i n a l l f i e l d s o f s c ie n c e , t h e h i s t o r y o f m e d i c i n a l c h e m i s t r y i s c o m p r i s e d o f the ideas, knowledge, and available tools that have advanced contemporary knowledge. The spectacular advances in medicinal chemistry over the years are no exception. Burger (1) stated that “the great advances of medicinal chemistry have been achieved by two types of investigators: those with the genius of prophetic logic, who have opened a new field by interpreting correctly a few well-placed experiments, whether they pertained to the design or the mechanism of action of drugs; and those who have varied patiently the chemical structures of physiologically active compounds until a useful drug could be evolved as a tool in medicine.” To place the development of medicinal chemical research into its proper perspective, one needs to examine the evolution of the ideas and concepts that have led to our present knowledge.

Drugs of Antiquity The oldest records of the use of therapeutic plants and minerals are derived from the ancient civilizations of the Chinese, the Hindus, the Mayans of Central America, and the Mediterranean peoples of antiquity. The Emperor Shen Nung (2735 BC) compiled what may be called a pharmacopeia, including ch'ang shang, an antimalarial alkaloid, and ma huang, from which ephedrine was isolated. Chaulmoogra fruit was known to the indigenous American Indians, and the ipecacuanha root containing emetine was used in Brazil for the treatment of dysentery and diarrhea and is still used for the treatment of amebiasis. The early explorers found that the South American Indians also chewed cocoa leaves (containing cocaine) and used mushrooms (containing tryptamine) as hallucinogens. In ancient Greek apothecary shops could be found herbs such as opium, squill, hyoscyamus, and viper toxin and such metallic drugs as copper and zinc ores, iron sulfate, and cadmium oxide.

The Middle Ages The basic studies of chemistry and physics shifted from the Greco-Roman to the Arabian alchemists between the thirteenth and sixteenth centuries. Paracelsus (1493–1541) glorified antimony and its salts in elixirs as cure-alls in the belief that chemicals could cure disease.

The Nineteenth Century Age of Innovation and Chemistry The nineteenth century saw a great expansion in the knowledge of chemistry, which

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greatly extended the herbal pharmacopeia that had previously been established. Building on the work of Lavoisier, chemists throughout Europe refined and extended the techniques of chemical analysis. The synthesis of acetic acid by Kolbe in 1845 and of methane by Berthelot in 1856 set the stage for organic chemistry. Pharmacognosy, the science that deals with medicinal products of plant, animal, or mineral origin in their crude state, was replaced by physiological chemistry. The emphasis was shifted from finding new medicaments from the vast world of plants to finding the active ingredients that accounted for their pharmacologic properties. The isolation of morphine by Sertürner in 1803, of emetine from ipecacuanha by Pelletier in 1816, and his purification of caffeine, quinine, and colchicine in 1820 all contributed to the increased use of “pure” substances as therapeutic agents. The nineteenth century also contributed to the use of digitalis by William Withering, the English physician and botanist, for the treatment of dropsy. Niemann isolated cocaine in 1860 and the active ingredient, physostigmine, from the calabar bean in 1864. As a result of these discoveries and the progress made in organic chemistry, the pharmaceutical industry came into being at the end of the nineteenth century.

The Twentieth Century and the Pharmaceutical Industry Diseases of protozoal and spirochetal origin responded to synthetic chemotherapeutic agents. Interest in synthetic chemicals that could inhibit the rapid reproduction of pathogenic bacteria and enable the host organism to cope with invasive bacteria was dramatically increased when Domagk reported that the red dyestuff 2,4-diaminoazobenzene-4′-sulfonamide (Prontosil) dramatically cured d a n g e r o u s , s y s t e m i c G r a m - p o s i t i v e b a c t e r i a l i n f e c t i o n s i n m an a n d a n i m a l s . T h e observation by Woods and Fildes in 1940 that the bacteriostatic action of sulfonamide-like drugs was antagonized by p-aminobenzoic acid was one of the early examples in which a balance of stimulatory and inhibitory properties depends on the structural analogies of chemicals. Together with the discovery of penicillin by Fleming in 1929 and its subsequent examination by Florey and Chain in 1941, this led to a water soluble powder of much higher antibacterial potency and lower toxicity than P.2 those of previously known synthetic chemotherapeutic agents. With the discovery of a variety of highly potent anti-infective agents, a significant change was introduced into medical practice.

Developments Leading to Various Medicinal Classes Psychopharmacologic Agents and the Era of Brain Research Psychiatrists have been using agents that are active in the central nervous system for hundreds of years. Stimulants and depressants were used to modify the mood and mental states of psychiatric patients. Amphetamine, sedatives, and hypnotics were used to stimulate or depress the mental states of patients. The synthesis of chlorpromazine by Charpentier ultimately caused a revolution in the treatment of schizophrenia, but who really discovered chlorpromazine? Charpentier, who first synthesized the molecule in 1950 at Rhone-Poulenc's research laboratory; Simon Courvoisier, who reported distinctive effects on animal behavior; Henri Laborit, a French military surgeon who first noticed distinctive psychotropic effects in man; or Pierre Deniker and Jean Delay, French psychiatrists who clearly outlined what has


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now become its accepted use in psychiatry and without whose endorsement and prestige Rhone-Poulenc might never have developed it further as an antipsychotic. B e c a u s e o f t h e b i t t e r d i s p u t e s o v e r t h e d is c o v e r y o f c h l o r p r o m a z i n e , n o N o b e l P r i z e was ever awarded for what has been the single most important breakthrough in psychiatric treatment. The discovery of the antidepressant effects of the antitubercular drug iproniazid led to the first-generation tricyclic antidepressant imipramine in 1957 and the monoamine oxidase inhibitor phenelzine. These were followed by present-day selective serotonin reuptake inhibitors, such as fluoxetine (Prozac). The antianxiety agents in the benzodiazepine class are examples of the serendipitous discovery of new drugs based on random screening of chemicals synthesized in the laboratory. The discovery of these drugs also was based on observations made by pharmacologists who recognized significant animal signs during general biologic screening of random chemicals. In 1946, F.M. Berger and, in 1957, L.O. Randall, working at Hoffmann LaRoche Laboratories, independently observed unusual and characteristic paralysis and relaxation of voluntary muscles in laboratory animals f o r d i f f e r e n t s e r i e s o f c om p o u n d s . A t t h i s p o i n t , t h e t r e a t m e n t o f a m b u l a t o r y , anxious patients with meprobamate and of psychotic patients with one of the aminoalkyl-phenothiazine drugs was possible. There was a need for drugs of greater selectivity in the treatment of anxiety because of the side effects often encountered with phenothiazines. Leo Sternback, a chemist working in the research laboratory of Hoffman-LaRoche in New Jersey, decided to reinvestigate a relatively unexplored class of compounds that he had studied in the 1930s, when he was a postdoctoral fellow at the University of Cracow in Poland. He synthesized approximately 40 c o m p o u n d s i n t h i s s e r i e s , a l l o f w h i ch w er e d i s a p p o i n t i n g i n p h a r m a c o l o g i c t e s t s , after which the project was abandoned. In 1957, during a cleanup of the laboratory, one compound synthesized 2 years earlier had crystallized and was submitted for testing to L.O. Randall, a pharmacologist. Shortly thereafter, Randall reported that this compound was hypnotic and sedative and had antistrychnine effects similar to those of meprobamate. The compound was named chlordiazepoxide and marketed as Librium in 1960, just 3 years after the first pharmacologic observations by Randall. Structural modifications of benzodiazepine derivatives were undertaken, and a compound 5- to 10-fold more potent than chlordiazepoxide was synthesized in 1959 and marketed as diazepam (Valium) in 1963. The synthesis of many other experimental analogues soon followed, and by 1983, approximately 35 benzodiazepine drugs were available for therapy (see Chapter 22). Benzodiazepines are used in the pharmacotherapy of anxiety and related emotional disorders and in the treatment of sleep disorders, status epilepticus, and other convulsive states. They are used as centrally acting muscle relaxants, for premedication, and as inducing agents in anesthesiology.

Endocrine Therapy and Steroids The first pure hormone to be isolated from an endocrine gland was epinephrine, which led to further molecular modifications in the area of sympathomimetic amines. Subsequently, norepinephrine was identified from sympathetic nerves. The development of chromatographic techniques allowed the isolation and characterization of a multitude of hormones from a single gland. In 1914, biochemist Edward Kendall isolated thyroxine (T4) from the thyroid gland. He subsequently won the Nobel Prize in Physiology or Medicine in 1950 for his discovery of the activity of cortisone. Two of the hormones of the thyroid gland, T4 and liothyronine (T3,3,5,3′triiodo-thyronine) have similar effects in the body, regulating metabolism, whereas


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the two hormones from the posterior pituitary gland, vasopressin, which exerts pressor and antidiuretic activity, and oxytocin, which stimulates lactation and uterine motility, differ considerably both in their chemical structure and physiological activity (Fig. I.1). Less than 50 years after the discovery of oxytocin in 1904 by Sir Henry Dale, who found that an extract from the human pituitary gland contracted the uterus of a pregnant cat, the biochemist du Vigneud synthesized the cyclic peptide hormone. His work resulted in the Nobel Prize in Chemistry in 1955. A major achievement in drug discovery and development was the discovery of insulin in 1921 from animal sources. Frederick G. Bunting and Charles H. Best, working in the laboratory of John J.R. McLeod at the University of Toronto, isolated the polypeptide hormone and began testing it in dogs. By 1922, researchers, with the P.3 help of James B. Collip and the pharmaceutical industry, were able to purify and produce animal-based insulin in large quantities. Insulin soon became a major product for Eli Lilly & Co. and Novo Nordisk, a Danish pharmaceutical company. In 1923, McLeod and Bunting were awarded the Nobel Prize in Medicine or Physiology, and after much controversy, they shared the prize with Collip and Best. For the next 60 years, cattle and pigs were the major sources of insulin. With the development of genetic engineering in the 1970s, new opportunities arose for making synthetic insulin that is chemically identical to human insulin. In 1978, the biotech company Genentech and the City of Hope National Medical Center produced human insulin in the laboratory using recombinant DNA technology. By 1982, Lilly's Humulin became the first genetically engineered drug to be approved by the U.S. Food and Drug Administration (FDA). At about the same time, Novo Nordisk began selling the first semisynthetic human insulin made by enzymatically converting porcine insulin. Novo Nordisk also was using recombinant technology to produce insulin. Recombinant insulin was a significant milestone in the development of genetically engineered drugs, and it combined the technologies of the biotech companies with the knowhow and resources of the major pharmaceutical industries. Inhaled insulin was a p p r o v e d b y t h e F D A i n 2 0 0 6 . M a n y d r u gs a r e n o w a v a i l a b l e ( s e e C h a p t e r 3 2 ) t o treat the more common type 2 diabetes, in which natural insulin production in the human needs to be increased. Insulin had been the only treatment for type 1 diabetes until 2005, when the FDA approved Amylin Pharmaceuticals' Symlin to c o n t r o l b l o o d s u g a r l e v e l s i n c o m b i n a t i o n w i t h t h e p o l yp e p t i d e h o r m o n e . T h e isolation and purification of several polypeptide hormones of the anterior pituitary and hypothalamic-releasing hormones now makes it possible to produce synthetic peptide agonists and antagonists that have important diagnostic and therapeutic applications.


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Fig. I.1. Hormones from the endocrine glands.

Extensive and remarkable advances in the endocrine field have been made through an understanding, development, and utilization of steroid hormones. The isolation and characterization of minute amounts of the active principles of the sex glands and from the adrenal cortex eventually led to their total synthesis. The various male a n d f e m a l e s e x h o r m o n e s a r e u se d i n t h e t r e a t m e n t o f a v a r i e t y o f d i so r d e r s associated with sexual development and the sexual cycles of males and females as well as in the selective therapy of malignant tumors of the breast and prostate gland. Synthetic modifications of the structure of the male and female hormones have furnished improved hormonal compounds, such as the anabolic agents (see Chapter 45). Since early days, women have ingested every manner of substance as birth control agents. In the early 1930s, Russell Marker found that for hundreds of years, Mexican women had been eating wild yams of the Dioscorea genus for contraception, apparently successfully. Marker determined that diosgenin is abundant in yams and has a structure similar to that of progesterone. Marker was able to convert diosgenin into progesterone, a substance known to stop ovulation in rabbits. Progesterone, however, is destroyed by the digestive system when ingested. In 1950, Carl Djerassi, a chemist working at the Syntex Laboratories in Mexico City, synthesized norethindrone, the first orally active contraceptive steroid, by a subtle modification of the structure of progesterone. Gregory Pincus, a biologist working at the Worcester Foundation for Experimental Biology in Massachusetts studied Djerassi's new steroid together with its double-bond isomer norethynodrel (Fig. I.2). By 1956, clinical studies led by John Rock, a gynecologist, showed that progesterone, in combination with norethindrone, was an effective oral contraceptive. G.D. Searle was the first on the market with Enovid, a combination of mestranol and norethynodrel. In 2005. approximately 11 million American women, and approximately 100 million women worldwide, were using oral contraceptive pills. In 1993, the British weekly The Economist considered the pill to be one of the seven


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wonders of the P.4 modern world, bringing about major changes in the economic and social structure for women throughout the world.

Fig. I.2. Steroidal agents.

In the early 1930s, chemists recognized the similarity of a large number of natural products, including the cortical steroids, such as hydrocortisone. The medicinal value of Kendall's Compound F and Reichstein's Compound M was quickly recognized. The 1950 Nobel Prize in Physiology or Medicine was awarded to Philip S. Hench, Edward C. Kendall, and Tadeus Reichstein “for their discovery relating to the hormones of the adrenal cortex, their structure and biological effects” (2). An interesting development in the study of glucocorticoids led to the synthesis in 1980 of the “abortion pill,” RU-486, by Etienne-Emile Beaulieu, a consultant to the French pharmaceutical company Rousel-Uclaf. Researchers at that time were investigating glucocorticoid antagonists for the treatment of breast cancer, glaucoma, and Cushing's syndrome. In screening RU-486, researchers at RouselUclaf found that it had both antiglucocorticoid activity as well as high affinity for progesterone receptors, where it could be used for fertility control. Also known as mifepristone (Mifeprex), RU-486 entered the French market in 1988. but sales were suspended by Rousel-Uclaf when antiabortion groups threatened to boycott the company. In 1994, the company donated the U.S. rights to the New York City–based Population Council, a nonprofit reproductive and population control research institution. Mifepristone is now administered in doctors' offices as a tablet in c o m b i n a t i o n w i t h m i s o p r o s t o l , a p r o s t a g l a n d i n t h a t c a u s e s u t e r i n e co n t r a c t i o n s t o help expel the embryo. The combination of mifepristone and misoprostol is more than 90% effective. Plan B, also known as the “morning-after pill,” has been referred to as an emergency contraceptive. It contains norgestrel, the same


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progestin that is in the pill. It should be taken within 3 days of unprotected sex and can reduce the risk of pregnancy by 89%.

Anesthetics and Analgesics The first use of synthetic organic chemicals for the modulation of life processes occurred when nitrous oxide, ether, and chloroform were introduced in anesthesia during the 1840s. Horace Wells, a dentist in Hartford, Connecticut, administered nitrous oxide during a tooth extraction, and Crawford Long, a Georgia physician, employed ether as an anesthetic for excising a growth on a patient's neck. It was William Morton, a 27-year-old dentist, however, who gave the first successful public demonstration of surgical anesthesia on October 16, 1846, at the surgical a m p h i t h e a t e r t h a t i s n o w c a l l e d t h e E t h e r D o m e a t M a s s a c h u s e tt s G e n e r a l H o s p i t a l . Morton attempted to patent his discovery but was unsuccessful, and he died penniless in 1868. Chloroform also was used as an anesthetic at St. Bartholomew's Hospital in London. In Paris, Pierre Fluorens tested both chloroform and ethyl chloride as anesthetics in animals. T h e p o t e n t a n a l g e s i c a n d e u p h o r i c p r o p e r t i e s o f t h e e x t r a ct o f t h e o p i u m p o p p y have been known for thousands of years. In the sixteenth century, the Swiss physician and alchemist Paracelsus (1493–1541) popularized the use of opium in Europe. At that time, an alcoholic solution of opium, known as laudanum, was the method of administration. Morphine was first isolated in pure crystalline form from opium in 1805 by the German apothecary Friedrich W. Sertürner, who named the compound “morphium,” after Morpheus, the Greek god of dreams. It took another 120 years before the structure of morphine was elucidated by Sir Robert Robinson at the University of Oxford. The chemistry of morphine and the other opium alkaloids obtained from Papaver somniferum have fascinated and occupied chemists for more than 200 years, resulting in many synthetic analgesics that are available t o d a y ( s e e C h a p t e r 2 4 ) . ( - )- M o r p h i n e w a s f i r s t s y n t h e s i z e d b y M a r s h a l l G a t e s a t t h e University of Rochester in 1952. Although a number of highly effective, stereoselective synthetic pathways have been developed, it is unlikely that a commercial process can compete with its isolation from the poppy. D i a c e t y l m o r p h i n e , k n o w n a s h e r o i n , i s h i g hl y a d d i c t i v e a n d i n d u c e s t o l e r a n c e . T h e illicit worldwide production of opium now exceeds the pharmaceutical production by almost 10-fold. In the United States, some 800,000 people are chemically addicted to heroin, and a growing number are becoming addicted to oxycontin, a synthetic opiate also known as oxycodone. Another synthetic opiate, methadone, blocks the opiate receptors in the brain, curbing the craving for heroin or morphine. A series of studies in the 1960s at Rockefeller University by Vincent Dole and his wife, Marie Nyswander, found that methadone also could be a viable maintenance treatment to k e e p a d d i c t s f r o m h e r o i n . I t i s e s t i m a t ed t h a t a p p r o x i m a t e l y 2 5 0 , 0 0 0 a d d i c t s a r e taking methadone in the United States. Unfortunately, it has not been widely recognized in the United States that opiate addiction is a medical condition for which there is no known cure. More than 80% of U.S. heroin addicts lack access to methadone treatment facilities, primarily because of the strong stigma against drug users and the medical distribution of methadone. Only within the last 25 years have scientists begun to understand the effects of opioid analgesics at the molecular level. In 1954, Beckett and Casey at the University of London proposed that opiate effects were receptor mediated, but it was not until the early 1970s that the stereo-specific binding of opiates to specific receptors was demonstrated. The characterization and classification of three


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different types of opioid receptors (µ, κ, and δ) by W.R. Martin formed the basis of o u r c u r r e n t u n d e r s t a n d i n g o f o p i o i d p h a r m a c o l o g y . T h e d e m o n st r a t i o n o f s t e r e o specific binding of radiolabeled ligands to opioid receptors led to the development of radioreceptor-binding assays for each of the opioid receptor types, a technique that has been of major importance in the identification of selective opioids as well as many other P.5 receptors. In 1973, Avram Goldstein, Solomon Snyder, Ernst Simon, and Lars Terenius independently described saturable, stereospecific binding sites for opiate d r u g s i n t h e m a m m a l i a n n e r v o u s s y s t e m . S h o rt l y t h e r e a f t e r , J o h n H u g h e s a n d H a n s Kosterlitz, working at the University of Aberdeen in Scotland, described the isolation from pig brains of two pentapeptides that exhibited morphine-like actions on the guinea pig ileum. At about the same time, Goldstein reported the presence of peptide-like substances in the pituitary gland that showed opiate-like activity. Subsequent research revealed three distinct families of opiate peptides: the enkephalins, the endorphins, and the dynorphins.

Hypnotics and Anticonvulsants Since antiquity, alcoholic beverages and potions containing laudanum, an alcoholic extract of opium, and various other plant products have been used to induce sleep. Bromides were used in the middle of the nineteenth century as a sedative-hypnotic, as was chloral hydrate, paraldehyde, urethane, and sulfenal. Von Merring, on the assumption that a structure having a carbon atom carrying two ethyl groups would have hypnotic properties, investigated diethyl acetyl urea, which proved to be a potent hypnotic. Further investigations led to 5,5-diethylbarbituric acid, a compound synthesized 20 years earlier, in 1864, by Adolph von Beyer. Phenobarbital was synthesized by the Bayer Pharmaceutical Company and introduced to the market u n d e r t h e n a m e L u m i n o l ( F i g . I . 3 ) . T h e c o m p o u n d w a s e f f e c t i v e a s a h y p n o t i c, b u t i t also exhibited anticonvulsant properties. The success of phenobarbital led to the testing of more than 2,500 barbiturates, of which approximately 50 were used clinically, many of which are still in clinical use. Modification of the barbituric acid molecule also led to the development of the hydantoins. Phenytoin, also known as diphenylhydantoin or Dilantin, was first synthesized in 1908, but its anticonvulsant properties were not discovered until 1938. Because phenytoin was not a sedative at ordinary doses, it established that antiseizure drugs need not induce drowsiness and encouraged the search for drugs with selective antiseizure action (Fig. I.3).

Local Anesthetics The local anesthetics can be traced back to the naturally occurring alkaloid cocaine isolated from Erythroxylon coca. A Viennese ophthalmologist, Carl Koller, had experimented with several hypnotics and analgesics for use as a local anesthetic in the eye. His friend, Sigmund Freud, suggested that they attempt to establish how the South American Indians allayed fatigue by chewing leaves of the coca bush. Cocaine had been isolated from the plant by the chemist Albert Niemann at Gothenburg University, Sweden, in 1860. Koller found that cocaine numbed the tongue; thus, he discovered a local anesthetic. He quickly realized that cocaine was an effective, nonirritating anesthetic for the eye, leading to the widespread use of cocaine in both Europe and the United States. Richard Willstatter in Munich determined the structure of both cocaine and atropine in 1898 and succeeded in synthesizing cocaine 3 years later. Although today cocaine is of greater historic than medicinal importance and is widely abused, few developments in the chemistry


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of local anesthetics can disclaim a structural relationship to cocaine (Fig. I.4). Benzocaine, procaine, tetracaine, and lidocaine can all be considered structural analogues of cocaine, a classic example of how structural modification of a natural product can lead to useful therapeutic agents.

Fig. I.3. Examples of early an early hypnotic and anticonvulsant.

Fig. I.4. Synthetic local anesthetics development based on the structure of cocaine.

Drugs Affecting Renal and Cardiovascular Function Included in the category are the diuretics, vasopressin, rennin and angiotensin drugs used in the treatment of myocardial ischemia, pharmacotherapy of congestive heart failure, antiarrythmic drugs, and drugs used in therapy for hypercholesterolemia. Use of the cardiac drug digoxin dates back to the folk-remedy foxglove, attributed to William Withering, who in 1775 discovered that the foxglove plant, Digitalis purpurea, was beneficial to those suffering from abnormal fluid buildup. The active principles of digitalis were isolated in 1841 by E. Humolle and T.


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Quevenne in Paris. These active principles consisted mainly of digitoxin. The other glycosides of digitalis were subsequently isolated in 1869 by Nativelle and in 1875 by Schmiedberg. The correct structure of digitoxin was established more than 50 years later by Adolf Windaus at Gothenburg University. In 1929, Sydney Smith at Burroughs Welcome isolated and separated a new glycoside from Digitalis purpurea, known as digoxin. This is now the most widely used cardiac glycoside. P.6 Today, dried foxglove leaves are processed to yield digoxin, much like the p r o c e d u r e u s e d b y W i t h e r i n g . I t t a k e s a pp r o x i m a t e l y 1 , 0 0 0 k g o f d r i e d f o x g l o v e leaves to make 1 kg of pure digoxin. The group of drugs used in the therapy for hypercholesterolemia has received the greatest success and financial reward for the pharmaceutical industry during the last decade. Cholesterol-lowering drugs, known as statins, are one of the cornerstones in the prevention of both primary and secondary heart diseases. Drugs s u c h a s M e r ck ' s l o v a s t a t i n ( M e v a c o r ) a n d P f i z e r ' s L i p i t o r a r e a h u g e s u c c e s s . I n 2004, Lipitor was the world's top-selling drug, with sales of more than $10 billion. As a class, cholesterol- and triglyceride-lowering drugs were the world's top category, with sales exceeding $30 billion. The discovery of the statins can be credited to Akira Endo, a research scientist at Sankyo Pharmaceuticals in Japan (3). Endo's 1973 discovery of the first anticholesterol statin has almost been relegated to obscurity. The story of his research and the discovery of lovastatin are not typical but often escape attention. When Endo joined Sankyo after his university studies to investigate food ingredients, he searched for a fungus that produced an enzyme to make fruit juice less pulpy. The search was a success, and Endo's next assignment was to find an enzyme that would block the production of cholesterol, known as HMG-CoA reductase. With Endo's interest and background, he searched for fungi that would block this enzyme. After testing 6,000 fungal broths, he found such a fungus in 1973. A substance made by a mold, Penicillium citrinum, produced a potent inhibitor of the enzyme that helps the body to make cholesterol, and it was named compactin. The substance did not work in rats, but it did work in hens and dogs. Endo's bosses were unenthusiastic about his discovery and discouraged further research with this compound. With the collaboration of Akira Yamamoto, a physician treating patients with extremely high cholesterol because of a genetic defect, Endo prepared samples of his drug and had it administered to an 18-year-old woman by Yamamoto. Further testing in nine patients led to an average lowering of cholesterol of 27%. In 1978, using a different fungus, Merck discovered a substance that was nearly identical to Endo's; this one was named lovastatin. Merck held the U.S. rights and, in 1987, started marketing it in the United States as Mevacor, the first FDAapproved statin. Sankyo eventually gave up compactin and pursued another statin, which they licensed to Bristol-Myers Squibb, and it was sold as Pravachol. In 1985, Michael S. Brown and Joseph Goldstein won the Nobel Prize in Physiology or Medicine for their work in cholesterol metabolism. It was only in January of 2006 that Endo received the Japan Prize, considered by many to be equivalent to the Nobel Prize. There is no doubt that millions of people whose lives have been—and will be—extended through statin therapy owe their longevity to Akira Endo.

Anticancer Agents


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Sulfur mustard gas was used as an offensive weapon by the Germans during World War I, and the related nitrogen mustards were manufactured by both sides in World War II. Later, investigations showed that the toxic gasses had destroyed the blood's white cells, which subsequently led to the discovery of drugs used in leukemia therapy. These compounds, although effective antitumor agents, were very toxic. 6Mercaptopurine was really the first effective leukemia drug and was developed by George Hitchings and his technician, Gertrude Elion, who, working together at Burroughs Welcome Research Laboratories, shared the Nobel Prize in 1988 (Fig. I.5). By a process now termed “rational drug design,” Hitchings hypothesized that it m i g h t b e p o s s i b l e t o u s e a n t a g o n i s t s t o s t o p b a c t e r i a l o r t u m or c e l l g r o w t h b y interfering with nucleic acid biosynthesis in a way similar to how sulfonamides blocked cell growth. Unlike many cancer drugs available today, cisplatin is an inorganic molecule with a simple structure (Fig. I.5). Cisplatin interferes with the growth of cancer cells by binding to DNA and interfering with the cells' repair mechanism, eventually causing cell death. It is used to treat many types of cancer, but primarily testicular, ovarian, bladder, lung, and stomach cancers. Cisplatin is now the gold standard against which new medicines are compared. It was first synthesized in 1845, and its structure was elucidated by Alfred Werner in 1893. It was not until the early 1960s, however, when Barnett Rosenberg, a professor of biophysics and chemistry at Michigan State University, observed the compound's effect in cell division, which prompted him to test cisplatin against tumors in mice. The compound was found to be effective and entered clinical trials in 1971. There is an important lesson to be learned from Rosenberg's development of cisplatin. As a biophysicist and chemist, Rosenberg realized that when he was confronted with interesting results for which he could not find explanations, he needed to enlist the help and expertise of researchers in microbiology, inorganic chemistry, molecular P.7 biology, biochemistry, biophysics, physiology, and pharmacology. Such a multidisciplinary approach is the key to the discovery of modern medicines today. Although cisplatin is still an effective drug, researchers have found secondgeneration compounds, such as carboplatin, which has less toxicity and fewer side effects.


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Fig. I.5. Anticancer drugs.

The third compound in this class of anticancer agents is Taxol, which was discovered in 1963 by Monroe E. Wall and Masukh C. Wani at Research Triangle Park in North Carolina (Fig. I.5). Taxol was isolated from extracts of the bark of the P a c i f i c y e w t r e e , T a x u s b r e v i f o l i a . T h e e x t r a c t s s h o w e d p o t e n t a n t i c a n c e r a ct i v i t y . By 1967, Wall and his coworkers had isolated the active ingredients, and in 1971, they had established the structure of the compound. Susan Horwitz, working at the Albert Einstein College of Medicine in New York, studied the mechanism of how Taxol kills cancer cells. She discovered that Taxol works by stimulating the growth o f m i c r o t u b u l e s a n d b y s t a b i l i z i n g t h e c e l l s t r u ct u r e s s o t h a t t h e k i l l e r c e l l s a r e u n a b l e t o d i v i d e a n d m u l t i p l y . I t w a s n o t u nt i l 1 9 9 3 , h o w e v e r , t h a t T a x o l , g e n e r i c a l l y called paclitaxel, was brought to the market by Bristol-Myers Squibb, but it soon became an effective drug for treating ovarian, breast, and certain forms of lung cancers. The product became a huge commercial success, with annual sales of approximately $1.6 billion in 2000.

Old Drugs as Targets for New Drugs Cannabis is used throughout the world for diverse purposes and has a long history characterized by usefulness, euphoria or evil, depending on one's point of view. To the agriculturist cannabis is a fiber crop; to the physician of a century ago it was a valuable medicine; to the physician of today it is an enigma; to the user, a euphoriant; to the police, a menace; to the trafficker, a source of profitable danger; to the convict or parolee and his family, a source of sorrow (4). The plant Cannabis sativa, the source of marijuana, has a long history in folk medicine, where it has been used for such ills as menstrual pain and the muscle spasms that affect multiple sclerosis sufferers. As in so many other areas of drug research, progress was achieved through the understanding of the pharmacology and biogenesis of a naturally occurring drug only when the chemistry had been well established and researchers had at their disposal pure compounds of known composition and stereochemistry. Cannabis is no exception in this respect, with the last 50 years producing the necessary know-how in the chemistry of the cannabis constituents so that chemists could devise practical and novel synthetic schemes to provide the pharmacologists with pure substances. The isolation and determination of the structure of tetrahydrocannabinol (Δ9-THC), the principal active ingredient, was determined in 1964 by Rafael Mechoulam at Hebrew University in Israel. Although cannabis and some of its structural analogs have been—and are still— used in medicine, during the last few years research has focused on the endocannabinoids and their receptors as targets for drug development. It was shown that Δ9-THC exerts its effects by binding to receptors that are targets of naturally occurring molecules, termed endocannabinoids, that have been involved in controlling learning, memory, appetite, metabolism, blood pressure, emotions such as fear and anxiety, inflammation, bone growth, and cancer. It is no surprise then that drug researchers are focusing on developing compounds that either act as


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agonists or antagonists of the endocannabinoids. In 1990, Lisa Matsuda and Tom Bonner at the National Institutes of Health cloned a Δ9-THC receptor, now called CB1, from a rat brain. Shortly thereafter, Mechoulam's group identified the first of these endogenous cannabinoids, called anandamide, and a few years later identified 2-arachidonylgyclerol. In 1993, the second cannabinoid receptor, CB2, was cloned by Muna Abu-Shaar at the Medical Research Council in Cambridge, United Kingdom. The drug rimonabant, an endocannabinoid antagonist under development by the French pharmaceutical company Sanofi-Aventis, is the drug closest to clinical development. The drug binds to CB1, but not CB2, receptors and promotes weight loss. Efforts to develop other endocannabinoids as therapeutic agents are in full swing at many laboratories and include preclinical testing for epilepsy, pain, anxiety, and diarrhea. Thus, a new series of drugs may soon be on the market that are not centered on marijuana itself but, rather, are inspired by its active ingredient, Δ9-THC, mimicking the endogenous substances acting in the brain or the periphery.

Molecular Imaging C l i n i ci a n s n o w h a v e a t t h e i r d i s p o s a l a v a r i e t y o f d i a g n o s t i c t o o l s t o h e l p o b t a i n i n f o r m a t i o n a b o u t t h e p a t h o p h y s i o l o g i c a l s t a t u s o f i n t e r n a l o r g a n s. T h e m o s t w i d e l y used methods for noninvasive imaging are scintigraphy, radiography (x-ray and computed tomography), ultrasonography, positron-emission tomography (PET), single- photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI). Chemists continue to make important contributions to the preparation of radiopharmaceuticals and contrast agents. These optical, nuclear, and magnetic methods are increasingly empowered by new types of imaging agents. These modalities are now routinely being used to judge the effectiveness of new and old drugs to treat disease and to monitor the response to therapies. The expanded use of the cyclotron in the late 1930s and of the nuclear reactor in the early 1940s made available a variety of radionuclides for potential applications in medicine. The field of nuclear medicine was founded with reactor-produced radioiodine for the diagnosis of thyroid dysfunction. Soon, other radioactive tracers, such as 18F, 123I, 131I, 99mTc, and 11C, became available. Together with more sensitive radiation detection instruments and cameras, this made it possible to study many organs of the body, such as the liver, kidney, lung, and brain. The P.8 diagnostic value of these noninvasive techniques served to establish nuclear medicine and radiopharmaceutical chemistry as distinct specialties. A radiopharmaceutical is defined as any pharmaceutical that contains a radionuclide (5). Historically, radioiodine has a special place in nuclear medicine. In 1938, Hertz, Roberts, and Evans first demonstrated the uptake of 128I by the thyroid gland. With a longer half life (8 days), 131I later became available and is now widely used. Although iodine has 24 known isotopes, 123I, 131I, and 125I are the only ones currently used in medicine. At present, the most widely used PET r a d i o p h a r m a c e u t i c a l i s t h e g l u c o s e a n a l o g u e 1 8 F - F D G ( 2 - f l u o r o - 2 - d e o x y - D - g l u c o se ; half-life = 1.8 hours); it is routinely employed for functional studies of brain, heart, a n d t u m o r g r o w t h . T h e p r o c e s s i s d e r i v e d f ro m t h e e a r l i e r a n i m a l s t u d i e s q u a n t i f y i n g regional glucose metabolism with [14C]-2-dexoyglucose, which passes through the blood-brain barrier by the same carrier-facilitated transport system used for glucose. With the advancement in highly selective PET and SPECT ligands, the


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potential of the noninvasive imaging procedures will achieve wider application both in pharmacologic research and in the diagnosis of central nervous system disorders.

The Next Wave in Drug Discovery Genomics Gleevec (imatinib) was discovered through the combined use of high-throughput screening and medicinal chemistry that resulted in the successful treatment of chronic myeloid leukemia. By molecular modifications, improved activity against the platelet-derived growth factor receptor (PDGFR) and tyrosine kinase as well as the loss of serine/threonine kinase inhibition were obtained. As a result of the success of Gleevec, scientists are modifying their drug discovery and development strategies to consider the patient's genes, without abandoning the more traditional drugs. It has been known for many years that genetics plays an important role in an individual's well-being. Attention is now being paid to manipulating the proteins that are produced in response to malfunctioning genes by inhibiting the out-of-control tyrosine kinase enzymes in the body that play such an important role in cell signaling events in growth and cell division. Using the knowledge obtained from the Human Genome Project, scientists with a knowledge of the sequencing of DNA and genes of various species have shown that some cancers are caused by genetic errors that direct the biosynthesis of dysfunctional proteins. Because proteins carry o u t t h e i n s t r u c t i o n s f r o m t h e g e n e s l o c a t e d o n t h e D N A , d y sf u n c t i o n a l p r o t e i n s , s u c h as the kinases, deliver the wrong message to the cells, making them cancerous. The emphasis is now on inhibiting the proteins to slow the progression of the cancerous growth. An emphasis in the pharmaceutical industry as well as in academia is to develop drug formulations that guarantee therapies will reach specific targets in the body. Vaccines based on a proprietary plasmid DNA that will activate skeletal muscles to m a n u f a c t u r e d e s i r e d p r o t e i n s a n d a n t i g e n s a r e b e i n g d e v e l o p e d . P l a sm i d D N A vaccine technology represents a fundamentally new means of treatment that is of great importance for the future of drug targeting. Currently, the number of products coming out of biotechnology companies is increasing. Biotechnology drug discovery and drug development tools are used to create the more traditional small molecules. The promise of pharmacogenetics lies in the potential to identify sources of interindividual variability in drug responses that affect drug delivery and safety. Recent success stories in oncology demonstrate that the field of pharmacogenetics has progressed substantially. The knowledge created through pharmacogenetic trials can contribute to the development of patient-specific medicines as well as to improved decision making along the research and development value chain (6).

Combinatorial Chemistry and High-Throughput Screening No discussion of the history and evolution of medicinal chemistry would be complete without briefly mentioning combinatorial chemistry and high-throughput screening. Combinatorial chemistry is one of the new technologies developed by academics and researchers in the pharmaceutical and biotechnology industries to reduce the time and cost associated with producing effective, marketable, and competitive new drugs. Chemists use combinatorial chemistry to create large populations of molecules that can be screened efficiently, generally using high-throughput screening. Thus, instead of synthesizing a single compound, combinatorial


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chemistry exploits automation and miniaturization to synthesize large libraries of compounds. Combinatorial organic synthesis is not random but, rather, systematic a n d r e p e t i t i v e , u s i n g s e t s o f c h e m i c a l “ b u i l d i n g b l oc k s ” t o f o r m a d i v e r s e s e t o f molecular entities. Random screening has been a source of new drugs for several decades. Many of the drugs currently on the market were developed from leads identified through screening of natural products or compounds synthesized in the laboratory. In the late 1970s and 1980s, however, screening fell out of favor in the industry. Using traditional methods, the number of novel selective leads that were generated did not make this approach cost-effective. The last 25 years have seen an enormous advance in our understanding of critical cellular processes, leading to a more rationally designed approach in drug discovery. The availability of cloned genes for use in high-throughput screening to identify new molecules has led to a reexamination of the screening process. Targets now are often recombinant proteins (i.e., receptors) produced from cloned genes that are heterologously expressed in a number of ways. Combinatorial libraries complement the enormous numbers of synthetic libraries available from new and old synthetic programs. The development and P.9 use of robotics and automation have made it possible to screen large numbers of compounds in a short period of time. It also should be emphasized that computerized data systems and analysis of the data have facilitated the handling of the information being generated, leading to the identification of new leads.

Summary It is fair to say that more than 50% of the drugs in use today had their origin in a plant, animal, or mineral that had been used as cures for alleviating diseases occurring in humans. Examples of a number of discoveries of important drugs in use today are recounted as “case studies” in the drug discovery process and are described in more detail in the following chapters. The discoveries briefly described are, in large measure, a result of the increased sophistication brought to bear in the isolation, identification, structure determination, and synthesis of the active ingredients of the drugs used empirically hundreds of years ago. The emergence of the pharmaceutical industry took place in conjunction with the advances in organic/medicinal/pharmaceutical chemistry, pharmacology, bacteriology, biochemistry, and medicine as distinct fields of science in the late nineteenth century. Current research efforts are now focused not only on discovering new, biologically active compounds using ever increasingly sophisticated technology but also on gaining a better understanding of how and where drugs exert their effects at the molecular level. One should not underestimate, however, that the discoveries in the twentieth and twenty-first centuries, and before, represent an amazing amount of insight, determination, and luck by researchers in chemistry, pharmacology, biology, and medicine. We owe gratitude and admiration to those earlier scientists who had the imagination and inspiration to develop drugs to cure so many illnesses.

References 1. Burger A. The practice of medicinal chemistry. Burger A, eds. Medicinal


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Chemistry, New York. New York: Wiley, 1970: 4–9.

2. Daemmrich A, Bowden ME. A rising drug industry. Chem & Eng News. Am Chem Soc, 2005; 83(25): 28–42.

3. Landers P. Stalking cholesterol: How one scientist intrigued by molds found f i r s t s t a t i n ; f e a t o f J a p a n ' s D r . E n d o l ed t o h e a r t - c a r e r e v o l u t i o n b u t b r o u g h t him nothing; nature as a drug laboratory. The Wall Street Journal. (Eastern edition), Jan. 9, 2006: A.1.

4. Miloriya TH. Marijuana in medicine: past, present and future. California Medicine 1969;110(1):34–40.

5. Counsel RE, Weichert JP. Agents for organ imaging. In: Foye WO, Lemke TL, Williams DA, eds. Principles of Medicinal Chemistry. 4th ed. Baltimore: Williams & Wilkins, 1995; Chap 43:927–947.

6. Mullin R. The next wave of biopharmaceuticals. Chem & Eng News. Am Chem Soc, 2005;83(35):16–19.

Suggested Readings Djerassi C. The Politics of Contraception. New York: Norton, 1970.

Healy D. The Antidepressant Era. Cambridge, MA: Harvard University Press, 1998.

Marx J. Drugs Inspired by a Drug. Sci. 2006; 311:322–325.

Meyer P. Discovering new drugs: The legacy of the past, present approaches, and hopes for the future. In: Wermuth G, ed. The Practice of Medicinal Chemistry. London: Academic Press, 1996:11–24.

Podolsky ML. Cures Out of Chaos. Williston, VT: Harwood Academic, 1997.

Sheehan JC. The Enchanted Ring—The Untold Story of Penicillin. Cambridge, MA: MIT Press, 1982.


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Chapter 1 Drug Discovery from Natural Products A. Douglas Kinghorn

Introduction “Pharmacognosy” is one of the oldest established pharmaceutical sciences, and the term has been used for nearly two centuries. Initially, this term referred to the investigation of medicinal substances of plant, animal, or mineral origin in their crude or unprepared state, used in the form of teas, tinctures, poultices, and other types of formulation (1,2,3,4). By the middle of the twentieth century, however, the chemical components of such crude drugs began to be studied in more detail. Today, the subject of pharmacognosy is highly interdisciplinary, and it incorporates aspects of analytical chemistry, biochemistry, biosynthesis, biotechnology, ecology, ethnobotany, microbiology, molecular biology, organic chemistry, and taxonomy, among others (5). The term “pharmacognosy” is defined on the Web site of the American Society of Pharmacognosy (http://www.phcog.org) as “the study of the physical, chemical, biochemical, and biological properties of drugs, drug substances, or potential drugs or drug substances of natural origin, as well as the search for new drugs from natural sources.” There seems little doubt that humans have used natural drugs since before the advent of written history. In addition to their use as drugs, the constituents of plants have afforded poisons for darts and arrows used in hunting and euphoriants with psychoactive properties used in rituals. The actual documentation of drugs derived from natural products in the Western world appears to date back as far to the Sumerians and Akkadians in the third century BC as well as to the Egyptian Ebers Papyrus (approximately 1,600 BC). Other important contributions on the uses of drugs of natural origin were documented by Dioscorides (De Materia Medica) and Pliny the Elder in the first century AD and by Galen in the second century. Written records also exist from about the same time period regarding plants used in both Chinese traditional medicine and Ayurvedic medicine. Then, beginning approximately 500 years ago, information concerning medicinal plants began to be documented in herbals. In turn, the laboratory study of natural product drugs commenced approximately 200 years ago, with the purification of morphine from opium. This corresponds with the beginnings of organic chemistry as a scientific discipline. Additional drugs isolated from plant sources in the nineteenth century included atropine, caffeine, cocaine, nicotine, quinine, and strychnine, and in the twentieth century, digoxin, reserpine, paclitaxel, vincristine, and chemical precursors of the steroid hormones. Even as we enter the twenty-first century, approximately three-quarters of the world's population is reliant on primary health care from systems of traditional medicine, including the use of herbs. In recent years, a more profound understanding of the chemical and biological aspects of plants used in the traditional medicine of countries such as the People's Republic of China, India, Indonesia, and Japan, in addition to the medicinal plants used in Latin America and Africa. Many important scientific observations germane to natural product drug discovery have been made as a result (1,2,3,4). By the mid-twentieth century, therapeutically useful alkaloids had been purified and derivatized from the ergot fungus, as uterotonic and sympatholytic agents. Then, the penicillins were isolated, along with further major structural classes of effective and potent antibacterials from terrestrial microbes, and these and later antibiotics revolutionized the treatment of infectious diseases. Of the types of organisms producing natural products, terrestrial microorganisms have been found to afford the largest number of compounds currently used as drugs for a wide range of human diseases, and these include antifungal agents, the “statin” cholesterol-lowering agents, immunosuppressive agents, and several anticancer agents (1,2,3,4). At the beginning of the twenty-first century, there is much interest in the discovery and development of drugs from marine animals and plants. To date, however, marine organisms have had a relatively brief history as sources of drugs. Although the oceans occupy 70% of the surface of the earth, an intense effort to investigate the chemical structures and biological activities of marine fauna and flora has only been ongoing for approximately 30 years. Two established drugs based on marine-derived nucleoside model compounds are the antileukemic


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agent cytosine arabinoside and the antiviral agent, adenine arabinoside (6). The term “natural product” generally is taken to mean a compound that has no known primary biochemical role in the producing organism. Such small-molecular-weight organic molecules also may be referred to as “secondary metabolites,” and they tend to be biosynthesized by the producing organism in a biologically active chiral form to increase the chances of survival, such as by repelling predators or, in the case of terrestrial plants, serving as insect pollination attractants (1,2,3,4). There have been a number of studies to investigate the physicochemical parameters of natural products in recent years, and it has been concluded that “libraries,” or collections of these substances, tend to afford a higher degree of “drug-likeness” when compared to compounds in either synthetic or combinatorial “libraries” (7,8). This characteristic might well be expected, because natural products are P.13 p r o d u c e d b y l i v i n g s y s t e m s , w h e r e t h e y a r e s u b j e c t t o t r a n s p o rt a n d d i f f u s i o n a t t h e c e l l u l a r level. Small-molecule natural products are capable of modulating protein–protein interactions and, thus, can affect cellular processes that may be modified in disease states. When compared to synthetic compounds, natural products tend to have more protonated amine and free hydroxy functionalities and more single bonds, with a greater number of fused rings containing more chiral centers. Natural products also differ from synthetic products in the average number of halogen, nitrogen, oxygen, and sulfur atoms, in addition to their steric complexity (9). It is considered that natural products and synthetic compounds occupy different regions of “chemical space”; hence, they each tend to contribute to the overall chemical diversity required in a drug discovery program (7,8). Fewer than 20% of the ring systems produced among natural products are represented in currently used drugs (8). Naturally occurring substances may serve either as drugs in their native or unmodified form or as “lead” compounds (prototype bioactive molecules) for subsequent semisynthetic or totally synthetic modification—for example, to improve biological efficacy or to enhance solubility (7,8,9,10). In the present era of efficient drug design by chemical synthesis aided by computational and combinatorial techniques, and with other new drugs obtained increasingly through biotechnological processes, it might be expected that traditional natural products no longer have any significant role to play in this regard. Indeed, during the past decade, emphasis on the screening of natural products for new drugs by pharmaceutical companies has decreased, with greater reliance being placed on screening large “libraries” or collections of synthetic compounds (7,8,10). In a landmark review article, however, Newman et al. (11) from the U.S. National Cancer Institute pointed out that from 1982 to 2002, approximately 28% of the new chemical entities in Western medicine were either natural products per se or derived from natural products. Thus, of 1,031 new chemical entities over this 22-year period, 5% were unmodified natural products, and 23% were semisynthetic agents based on natural product lead compounds. An additional 14% of the synthetic compounds were designed based on knowledge of a natural product “pharmacophore” (the region of the molecule containing the essential organic functional groups that directly interact with the receptor active site and, therefore, confer the biologic activity of interest). Furthermore, in the thirteenth revision of the World Health Organization Model List of Essential Medicines, of approximately 300 drugs considered necessary for the practice of medicine, approximately 210 are small-molecular agents. Of these, more than 40 are unmodified natural products, 25 are semisynthetic drugs based on natural product prototypes, and more than 70 are either synthetic drugs based on natural product prototype molecules or synthetic mimics of natural products (12). The launch of new natural product drugs in the United States, Europe, and Japan has continued in the early years of the present decade of this new century, and such compounds introduced to the market recently have been reviewed by Butler (13). Thus, the secondary metabolites of organisms generally are recognized to afford a source of small-organic molecules of outstanding chemical diversity that are highly relevant to the contemporary drug discovery process. Potent and selective leads are obtained from increasingly exotic organisms as collection efforts venture into increasingly inhospitable locales throughout the world, such as deep caves in terrestrial areas and thermal vents on the ocean floor. On occasion, a natural lead compound may help to elucidate a new mechanism of interaction with a biological target for a disease state under investigation. Natural products may serve to provide molecular inspiration in certain therapeutic areas for which there are only a limited number of


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synthetic lead compounds. A widespread perception remains, however, that the resupply of the source organism of a secondary metabolite of interest may prove to be problematic and, consequently, will hinder the timely, more detailed biological evaluation of a compound that is available initially only in milligram quantities. In addition, natural product extracts have been regarded by some as being incompatible with the modern rapid screening techniques and the successful market development of a natural product–derived drug as being too time-consuming (7,8,13). A further consideration of the factors involved in the discovery of drugs from natural products will be presented in the next section. This will be followed by examples of natural products currently used in various therapeutic categories as well as a few selected representatives with future clinical potential.

Natural Products and Drug Discovery Collection of Source Organisms There are at least five recognized approaches to the choice of plants and other organisms for the laboratory investigation of their biological components: random screening; selection of specific taxonomic groups, such as families or genera; a chemotaxonomic approach in which restricted classes of secondary metabolites, such as alkaloids, are sought; an informationmanaged approach, which involves the target collection of species selected by database surveillance; and selection by an ethnomedical approach (e.g., by investigating remedies used in traditional medicine by “shamans” or medicine men or women) (14). In fact, if plant-derived natural products are taken specifically, it has been estimated that of 122 drugs of this type used worldwide from a total of 94 species, 72% can be traced to the original ethnobotanical uses that have been documented for their plant of origin (14). The need for increased research concerning natural product discovery involving ethnobotany should be regarded as urgent because to the accelerating loss in P.14 developing countries of indigenous cultures and languages, inclusive of knowledge of traditional medical practice (15). It is common, however, for a given medicinal plant to be used ethnomedically in more than one disease context, which sometimes may obscure its therapeutic utility for a specific disease condition. Another manner in which drugs have been developed from terrestrial plants and fungi is through following up on observations of the causes of livestock poisoning, leading to new drugs and molecular tools for biomedical investigation (16). When the origin of plants with demonstrated inhibitory effects in experimental tumor systems was considered at the U.S. National Cancer Institute, medicinal or poisonous plants with uses as either anthelmintics or arrow and homicidal poisons were three- to fourfold more likely to be active in this regard than species screened at random (17). Some shallow-water marine specimens may be collected simply by wading or snorkeling down to 20 feet below the water surface, but scuba diving permits the collection of organisms to depths of 120 feet. Deep-water collections of marine animals and plants have been made by dredging and trawling and through the use of manned and unmanned submersible vessels. Collection strategies for specimens from the ocean must take into account marine macroorganism– microorganism associations that may be involved in the biosynthesis of a particular secondary metabolite of interest (18). Thus, there seems to be a complex interplay between many marine host invertebrate animals and symbiotic microbes that inhabit them, and several bioactive compounds previously thought to be of animal origin may be produced by their associated microorganisms instead (19). The process of collecting or surveying a large set of flora (or fauna) for the purpose of biological evaluation and isolation of lead compounds is called “biodiversity prospecting” (20). Many natural product collection programs are focused on tropical rain forests to take advantage of the inherent biological diversity (or “biodiversity”) evident there, with the hope of harnessing as broad a profile of chemical classes as possible among the secondary metabolites produced by the species to be obtained. To exemplify this, there may be more tree species in a relatively small area of a tropical rainforest than in the whole of the temperate regions of North America. A generally accepted explanation for the high biodiversity of secondary metabolites in humid forests in the tropics is that these molecules are biosynthesized (a process of chemical synthesis by the host organism) for ecological roles in response to a continuous growing season


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under elevated temperatures, high humidity, and great competition resulting from the high species density present. Maximal biodiversity in the marine environment is found on the fringes of the ocean or sea bordering land, where intense competition for attachment space exists among sessile (nonmoving) organisms, such as algae, corals, sponges, and some other invertebrate animals space (21). Great concern should be expressed about the continuing erosion of tropical rain forest species, which is accelerating as the twenty-first century begins (22). Approximately 25 “hot spots” of especially high biodiversity have been proposed that represent 44% of all vascular plant species and 35% of all species of vertebrates in approximately 1.4% of the earth's surface (23). At present, many of the endemic (or native) species to these biodiversity “hot spot” areas have been reported to be undergoing massive habitat loss and are threatened with extinction, especially in tropical regions (22,23). Following the United Nations Convention on Biological Diversity, which was passed in Rio de Janeiro in 1992, biological or genetic materials are owned by the country of origin (20). A major present-day component of being able to gain access to the genetic resources of a given country for the purposes of drug discovery and other scientific study is the formulation of a Memorandum of Agreement, which itemizes access, previous informed consent (involving human subjects in cases where ethnomedical knowledge is divulged), intellectual property related to drug discovery, and equitable sharing of the financial benefits that may accrue from the project, such as patent royalties and licensing fees (20). When access to marine organisms is desired, the United National Convention on the Law of the Sea must be considered as well (24). Once a formal “benefit sharing” agreement is on hand, the organism collection process can begin. Usually, 0.3 to 1 kg of each dried plant sample and approximately 1 kg wet weight of a marine organism are initially collected for preliminary screening studies (25). In the case of a large plant (tree or shrub), it is typical to collect up to four different organs or plant parts, because the secondary metabolite composition may vary considerably between the leaves, where photosynthesis occurs, and the storage or translocation organs, such as the roots and bark. Increasing evidence suggests that considerable variation in the profile of secondary metabolites occurs in the same plant organ when collected from different habitats, depending on local environmental conditions; thus, it may be worth reinvestigating even well-studied species in drug discovery projects (26). Taxa that are endemic to a particular country or region generally are of higher priority than pandemic weeds. It is very important not to remove all quantities of a desired species at the site of collection to conserve the native germplasm encountered. Also, rare or endangered species should not be collected; a listing of the latter is maintained, for example, by the Red List of Threatened Species of the International Union for Conservation of Nature and Natural Resources (http://www.redlist.org), covering terrestrial, marine, and freshwater organisms. A crucial aspect of the organism collection process is to deposit voucher specimens representative of the species collected in a central repository, such as an herbarium or a museum, so that this material can be P.15 accessed by other scientists. It is advisable to deposit specimens in more than one repository, including regional and national institutions of the country in which the organisms were collected. Collaboration with general and specialist taxonomists is very important, because without an accurate identification of a source organism, the value of subsequent isolation, structure elucidation, and biological evaluation studies will be greatly reduced. Organisms for natural product drug discovery work may be classified into the Kingdoms Eubacteria (bacteria, cyanobacteria [or “blue-green algae”]), Archaea (halobacterians, methanogens), Protoctista (e.g., protozoa, diatoms, “algae” [including red algae, green algae]), Plantae (land plants [including mosses and liverworts, ferns, and seed plants]), Fungi (e.g., molds, yeasts, mushrooms), and Animalia (mesozoa [worm-like invertebrate marine parasites], s p o n g e s , j e l l y f i s h , c or a l s , f l a t w o r m s , r o u n d w o r m s , s e a u r c h i n s , m o l l u s k s [ s n a i l s , s q u i d ] , segmented worms, arthropods [crabs, spiders, insects], fish, amphibians, birds, mammals) (20). Of these, the largest numbers of organisms are found for arthropods, inclusive of insects (~950,000 species), with only a relatively small proportion (5%) of the estimated 1.5 million fungi in the world having been identified. At present, with 300,000 to 500,000 known species,


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plants are the second-largest group of classified organisms, representing approximately 15% of our biodiversity. Of the 28 major animal phyla, 26 are found in the sea, with eight of these exclusively so. More than 200,000 species of invertebrate animals and algal species have been found in the sea (5,18,20). During the last decade, a high proportion of the new natural product molecules was isolated from fungal sources (27). An area of investigation with great potential for expansion in the future will be microbes, particularly actinomycetes and cyanobacteria of marine origin, especially if techniques can be developed for their isolation and culturing in the laboratory (28). Along the same lines, endophytes (microorganisms that reside in the tissue of living plants) have been found to produce an array of biologically interesting new compounds and are worthy of more intensive investigation (29). Interestingly, in a survey regarding the origin of 30,000 structurally assigned lead compounds of natural origin, these compounds were derived from animals (13%), bacteria (33%), fungi (26%), and plants (27%) (9). A basic premise inherent in natural product drug discovery work is that the greater the degree of phylogenetic (taxonomic) diversity of the organisms sampled, the greater the resultant chemical diversity. Therefore, whereas natural product researchers tend to specialize in the types of organism on which they work, it is reasonable to envisage that the future investigation of all the major groups mentioned above will provide dividends in terms of affording new prototype biologically active compounds of use in drug discovery.

Preparation of Initial Extracts and Preliminary Biological Screening Different laboratories tend to adopt different procedures for initial extraction of the source organisms being investigated, but typically, terrestrial plants undergo extraction initially with a polar solvent, such as methanol or ethanol, then subject this extract to a defatting (lipidremoving) partition with a nonpolar solvent, such as hexane or petroleum ether, and partition the residue between a semipolar organic solvent, such as chloroform or dichloromethane, and a polar aqueous solvent (26). Marine and aquatic organisms are commonly extracted fresh into methanol or a mixture of methanol and dichloromethane (25). A peculiarity of working on plant extracts is the need to remove a class of compounds known as “vegetable tannins” or “plant polyphenols” before subsequent biological evaluation, because these compounds act as interfering substances in enzyme inhibition assays as a result of precipitating proteins in a nonspecific manner. Several methods to remove plant polyphenols have been proposed, such as passage over polyvinylpyrrolidone and polyamide, on which they are retained. Alternatively, partial removal of these interfering substances may be effected by washing the final semipolar organic layer with an aqueous sodium chloride solution (25). It should be noted, however, that active interest remains in pursuing purified and structurally characterized vegetable tannins for their potential medicinal value (30,31). Caution also needs to be expressed in regard to common saturated and unsaturated fatty acids that might be present in natural product extracts, because these may interfere with various enzyme-inhibition and receptor-binding assays (32). Fatty acids and other lipids may largely be removed from more polar natural product extracts using the defatting solvent partition stage mentioned above. Drug discovery from organisms is a “biology-driven” process, and as such, biological activity evaluation is at the heart of the drug discovery process from crude extracts prepared from organisms. So-called “high-throughput” screening (HTS) assays have become widely used for affording new leads. In this process, large numbers of crude extracts from organisms can be simultaneously evaluated in a cell- or noncell-based format, usually utilizing multiwell microtiter plates (33). Cell-based in vitro bioassays allow a considerable degree of biological relevance, and manipulation may take place so that a selected cell line may involve a genetically altered organism (34) or incorporate a reporter gene (20,33). In noncellular (cell-free) assays, natural product extracts and their purified constituents may be investigated for their effects on enzyme activity (30,32) or receptor-binding (35). Other homogenous and separation-based assays that are suitable for the screening of natural products have been reviewed (36). For maximum efficiency and speed, HTS may be automated through the use of robotics and may be rendered a more effective process through miniaturization. P.16

Methods for Compound Structure Elucidation and Identification


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Bioassay-directed fractionation is the process of isolating pure active constituents from some type of biomass (e.g., plants, microbes, marine invertebrates) using a decision tree that is dictated solely by bioactivity. A variety of chromatographic separation techniques are available for these purposes, including those based on adsorption on sorbents, such as silica gel, alumina, Sephadex, and more specialized solid phases, and methods involving partition chromatography inclusive of countercurrent chromatography. Recent improvements have been made in column technology, automation of high-performance liquid chromatography (HPLC; a technique often used for final compound purification), and compatibility with HTS methodology (13). Routine structure elucidation is performed using combinations of spectroscopic procedures, with particular emphasis on one- and two-dimensional 1H- and 13C-nuclear magnetic resonance (NMR) spectroscopy and mass spectrometry (MS). Considerable progress has been made in the development of cryogenic and microcoil NMR probe technology for the determination of structures in submilligram amounts of natural products (8). In addition, the automated processing of spectroscopic data for the structure elucidation of natural products is a practical proposition (37). Another significant advance is the use of “hyphenated” analytical techniques for rapid determination of the structure of natural products without the need for a separate isolation step, such as LC-NMR and LC-NMR-MS (8,13). The inclusion of an on-line solid-phase extraction cartridge is advantageous in the identification of natural product molecules in crude extracts using LC-NMR (38). “Dereplication” is a process of determining whether an observed biological effect of an extract or specimen is caused by a known substance. This is applied during natural product drug discovery programs in an attempt to avoid the reisolation of compounds of previously determined structure. A step like this is essential to prioritize the resources available to a research program so that the costly stage of bioassay-directed fractionation on a promising lead crude extract can be devoted to the discovery of biologically active agents representing new chemotypes (39). This has been particularly necessary for many years in studies on antiinfective agents from actinomycetes and bacteria, and it is applied routinely to extracts from higher plants and marine invertebrates. Methods for dereplication must be sensitive, rapid, and reproducible, and the chemical methods employed generally contain a mass spectrometric component (39). For example, the eluant (effluent) from an HPLC separation of crude natural product extracts may be split into two portions so that the major part is plated out into a microtiter plate, with the wells then evaluated in an in vitro bioassay of interest. The fractions from the minor portion of the column eluant are introduced to a mass spectrometer, and the molecular weights of compounds in active fractions can be determined. This information may then be introduced into an appropriate natural product database, and tentative identities of the active compounds in the active wells can be determined (26,39). “Metabolomics” is a recently developed approach in which the entire or “global” profile of secondary metabolites in a system (cell, tissue, or organism) is catalogued under a given set of conditions. Secondary metabolites may be investigated by a detection step, such as MS, after a separation step, such as gas chromatography, HPLC, or capillary electrophoresis (40). This type of technology has particular utility in systematic biology, genomics research, and biotechnology, and it should have value in future natural product drug discovery (40,41).

Compound Development A major challenge in the overall natural product drug discovery process is to obtain larger amounts of a biologically active compound of interest for additional laboratory investigation and potential preclinical development. One strategy that can be adopted when a plant-derived, active compound is of interest is to recollect the species of origin. To maximize the likelihood that the recollected sample will contain the bioactive compound of previous interest, the plant recollection should be carried out in the same location as the initial collection, on the same plant part, and during the same time of the year (26). Some success has been achieved with the production of terrestrial plant and marine cyanobacterial secondary metabolites via plant tissue culture and aqu- aculture, respectively. For microbes of terrestrial origin, compound scale up often can be carried out through cultivation and large-scale fermentation. Evaluation of crude extracts of organisms is not routinely carried out in animal models because of limitations of either test material or other project resources, but it is of great value to test in


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vitro–active natural products in a pertinent in vivo method to obtain a preliminary indication regarding the worthiness of a lead compound for preclinical development. A number of “secondary discriminator” bioassays also provide an assessment of whether a given in vitro– active compound is likely to be active in vivo, and these require quite small amounts of test material. For example, the in vivo hollow-fiber assay was developed at the U.S. National Cancer Institute for the preliminary evaluation of potential anticancer agents, and it uses confluent cells of a tumor model of interest deposited in polyvinylidene fluoride fibers that are implanted in nude mice (26,42). It also is important for pure bioactive compounds to be evaluated mechanistically for their effects on a particular biological target, such as on a given stage of the life cycle of a pathogenic organism or a cancer cell. Needless to say, a pure natural product of novel structure with in vitro and in vivo activity against a particular biological target relevant to human disease acting through a previously unknown P.17 mechanism of action is of great value in the drug discovery process. Once a bioactive natural product lead is obtained in gram quantities, it is treated in the same manner as a synthetic drug lead and, thus, subjected to pharmaceutical development leading to preclinical and clinical trials. This includes lead optimization via medicinal chemistry, combinatorial chemistry, computational chemistry, as well as formulation, pharmacokinetics, and drug metabolism studies, as described elsewhere in this volume. Often, a lead natural product is obtained from its organism of origin along with several naturally occurring structural analogues, permitting a preliminary study of the structure–activity relationship to be conducted. This information may be supplemented with data obtained by microbial biotransformation or the production of semisynthetic analogues to allow researchers to glean some initial information about the pharmacophoric site(s) of the naturally occurring molecule (7,8,10). “Combinatorial biosynthesis” is a contemporary approach with the ability not only to produce new natural product analogues but also to afford new drug candidates per se. This methodology involves the engineering of biosynthetic gene clusters in microorganisms. For example, the modification of bacterial polyketide synthases has led to production of some 200 new polyketides that do not occur naturally (43).

Selected Examples of Natural Product–Derived Drugs In this section, examples are provided of both naturally occurring substances and synthetically modified compounds based on natural products with drug use. Many of the examples shown reflect considerable structural complexity, and the compounds introduced to the market have been obtained from organisms of very wide diversity. More detailed treatises with many more examples of natural product drugs also may be found (1,2,3,4). Several recent reviews have summarized newly introduced natural product drugs introduced to the market in recent years as well as substances on which clinical trials are being conducted (6,13,44,45).

Drugs for Cardiovascular and Metabolic Diseases A very close relationship exists between natural product drugs and the treatment of cardiovascular and metabolic diseases. The powdered leaves of Digitalis purpurea have been used in Western medicine for more than 200 years, with the major active constituent being the cardiac (steroidal) glycoside digitoxin, which is still used for the treatment of congestive heart failure and atrial fibrillation. A more widely used drug today is digoxin, a constituent of Digitalis lanata, which has a rapid action and is more rapidly eliminated from the body than digitoxin. Deslanoside (deacetyllanatoside C) is a hydrolysis product of the D. lanata constituent lanatoside C and is used for rapid digitalization (1,2,3,4). The “statin” drugs used for lowering blood cholesterol levels are based on the lead compound mevastatin (formerly known as compactin), produced by cultures of Penicillium citrinum, and were discovered using a 3hydroxy-3-methylglutaryl–coenzyme A reductase assay. Because hypercholesterolemia is regarded as one of the major risk factors for coronary heart disease, several semisynthetic and synthetic compounds modeled on the mevastatin structure (inclusive of the dihydroxycarboxylic acid side chain), including atorvastatin, fluvastatin, pravastatin, and simvastatin, now have extremely wide therapeutic use. Lovastatin is a natural product drug of this type, isolated from Penicillium brevecompactin and other organisms (2). There also is a history of the successful


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production of cardiovascular agents from a terrestrial vertebrate—namely, the angiotensinconverting enzyme inhibitors, captopril and enalapril, which were derived from teprotide, a nonapeptide isolated from the pit viper, Bothrops jararaca (44).

Two more new drugs derived from a vertebrate and an invertebrate source, respectively, are bivalirudin and exenatide. Bivalirudin is a specific and reversible direct thrombin inhibitor that is administered by injection and is used to reduce the incidence of blood clotting in patients undergoing coronary angioplasty. This compound is a synthetic, 20-amino-acid peptide modeled on hirudin, a substance in the saliva of the leech, Haementeria officinalis (46,47). Exenatide is a synthetic version of a 39-amino-acid peptide (exenatide-4) produced in the salivary secretions of a lizard native to the southwestern United States and northern Mexico called the Gila monster, Heloderma suspectum, and it acts in the same manner as glucagon-like peptide-1 (GLP-1), a naturally occurring hormone. This drug also is administered by injection, and it enables improved glycemic control in patients with type 2 diabetes (44,48).

Central Nervous System Drugs A comprehensive review has appeared regarding natural products (mostly of experimental value) that affect the central nervous system, inclusive of analgesics, antipsychotics, anti-Alzheimer's disease agents, antitussives, anxiolytics, and muscle relaxants, among other categories (49). The authors point out in this review that apart from the extensive past literature concerning plants and their constituents as hallucinogenic agents, this area of research on natural products is not well developed but is likely to be very productive in future. P.18

Fig. 1.1. Analgesic drugs of natural origin or derived from naturally occurring


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analgesics.

The morphinan isoquinoline alkaloid, (-)-morphine, is the most abundant and important constituent of the dried latex (milky exudate) of Papaver somniferum (opium poppy), and the prototype of the opioid analgesics, being selective for µ opioid receptors (Fig. 1.1). This compound may be considered to be the paramount natural product lead compound, with many thousands of derivatives synthesized in an attempt to obtain derivatives with strong analgesic potency but without any addictive tendencies (1,2,3,4). One derivative now in late clinical trials as a pain treatment is morphine-6-glucuronide (M6G) (Fig. 1.1), the major active metabolite of morphine, with fewer side effects than the parent compound (44,50). The pyridine alkaloid epibatidine (Fig. 1.1), isolated from a dendrobatid frog, Epipedobates tricolor, found in Ecuador, activates nicotinic receptors and has an analgesic activity 200-fold more potent than that of morphine. The drug potential of epibatidine is limited by its concomitant toxicity, but it is an important lead compound for the development of future new analgesic agents with less addictive liability than the opiate analgesics (51). A nonopioid analgesic, ziconotide, which is prescribed for the amelioration of chronic pain, has been introduced to the market recently (Fig. 1.1). This drug is a synthetic version of the peptide ω-conotoxin MVIIA. The conotoxin class is produced by the cone snail, Conus magus, and these compounds are peptides with 24- to 27-amino-acid residues. Ziconotide selectively binds to N-type voltage-sensitive neuronal channels, causing a blockage of neurotransmission and a potent analgesic effect (44,52). This is one of the first examples of a new natural product drug from a marine source. (-)-Δ9-trans-Tetrahydrocannabinol (THC) is the major psychoactive (euphoriant) constituent of marijuana, Cannabis sativa. The synthetic form of THC (dronabinol) was approved approximately 20 years ago to treat nausea and vomiting associated with cancer chemotherapy, and it has been used for a lesser amount of time to treat appetite loss in patients with HIV/AIDS (44). More recently, an approximately 1:1 mixture of THC and the structurally related marijuana constituent cannabidiol has been approved in Canada for the alleviation of neuropathic pain and spasticity for patients with multiple sclerosis and is administered in low doses as a buccal spray (53). Considerable interest exists in using cannabinoid derivatives based on THC for medicinal purposes, but it is necessary to minimize the central nervous system effects of these compounds.

Another important natural product lead compound is the tropane alkaloid ester atropine [(±)hyoscyamine], from the plant Atropa belladonna (deadly nightshade) Atropine has served as a prototype molecule for several anticholinergic and antispasmodic drugs. One recently introduced example of an anticholinergic compound modeled on atropine is tiotropium bromide, which is used for the maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (54). P.19 In the category of anti-Alzheimer's disease agents, galanthamine hydrobromide is a selective


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acetylcholinesterase inhibitor that slows neurological degeneration by inhibiting this enzyme and by interacting with the nicotinic receptor (55). Galanthamine (also known as “galantamine”) is classified as an Amaryllidaceae alkaloid and has been obtained from several species in this family. Because commercial synthesis is not economic, it is obtained from the bulbs of Leucojum aestivum (snowflake) and Galanthus sp. (snowdrop) (1,2,3,4). some evidence indicates an ethnomedical basis for the current use of galanthamine (56).

Anti-infective Agents Since the introduction of penicillin G (benzylpenicillin) to chemotherapy as an antibacterial agent in the 1940s, natural products have been the most important subcategory of anti-infective agents. As well as the discovery of additional penicillins more resistant to acid hydrolysis and to the β-lactamase enzyme, other classes of antibacterials that have been developed from natural product sources are the aminoglycosides, cephalosporins, glycopeptides, macrolides, rifamycins, and tetracyclines. Antifungals, such as griseofulvin and the polyenes, and avermectins, such as the antiparasitic drug ivermectin, also are of microbial origin (1,2,3,4). Of the approximately 90 drugs in this category that were introduced in Western countries (inclusive of Japan) from 1981 to 2002, almost 80% can be related to a microbial origin (11). In spite of this, relatively few major pharmaceutical companies are currently working on the discovery of new anti-infective agents from natural sources, both because of possible bacterial resistance against new agents and because of concerns in regard to regulation (44). Higher plants also have afforded important anti-infective agents, perhaps most significantly the quinoline alkaloid quinine, obtained from the bark of several Cinchona sp. found in South America, including C. ledgeriana and C. succirubra. Quinine continues to be used for the treatment of multidrugresistant malaria and was the template molecule for the synthetic antimalarials chloroquine, primaquine, and mefloquine (1,2,3,4).


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Fig. 1.2. Natural occurring anti-infective agents.

The following examples, shown in Figure 1.2, have been chosen to represent an array of different structural types of antibacterial agents recently introduced into therapy (44). Biapenem is a carbapenem (a group of β-lactam antibiotics in which the sulfur atom in the thiazolidine ring is replaced by a carbon atop) and is based on thienamycin, isolated from Streptococcus cattleya. It is a broad-spectrum antibacterial and is more stable to hydrolysis by human renal dihydropeptidase-1 (DHP-1) than other antibiotics in its structural class (57). Tigecycline is a member of the glycylcycline class of tetracycline antibacterials and is the 9-tertbutylglycylamido derivative of minocycline, a semisynthetic derivative of chlortetracycline from Streptomyces aureofaciens. This is a broad-spectrum antibiotic, with activity against methicillinresistant Staphylococcus aureus (58,59). Daptomycin is the prototype member of the cyclic lipopeptide class of antibiotics, P.20 and although isolated initially from Streptomyces roseosporus, it is now produced by semisynthesis. This compound binds to bacterial cell membranes, disrupting the membrane potential, and blocks the synthesis of DNA, RNA, and proteins. Daptomycin is bactericidal against Gram-positive organisms (inclusive of vancomycin-resistant Enterococcus faecalis and E. faecium) and is approved for the treatment of complicated skin and dermal infections (60,61). Telithromycin is a semisynthetic derivative of the 14-membered macrolide erythromycin A, from Saccharopolyspora erythraea, and is a macrolide of the ketolide class that lacks a cladinose sugar but has an extended alkyl–aryl unit attached to a cyclic carbamate unit. It binds to domains II and V of the 23S rRNA unit of the bacterial 50S ribosomal unit, leading to inhibition of the ribosome assembly and protein synthesis. This macrolide antibiotic is used to treat bacteria that infect the lungs and sinuses, including community-acquired pneumonia caused by Streptomyces pneumoniae (62,63). Natural products have been a fruitful source of antifungal agents in the past, with the echinocandins being a recently introduced group of lipopeptides (44). Of these, two compounds are now approved drugs, including the acetate of caspofungin, which is a semisynthetic derivative of pneumocandin B0, a fermentation product of Glarea lozoyensis. Caspofungin inhibits the synthesis of the fungal cell wall β(1,3)-D-glucan by noncompetitive inhibition of the enzyme β(1,3)-D-glucan synthase, producing both a fungistatic and a fungicidal effect (64). The compound is administered by slow intravenous infusion and is useful for treating infections by Candida and Aspergillus sp. (65).

Malaria remains a parasitic scourge that is still extending in incidence. In 1972, the active principle from Artemisia annua, a plant used for centuries in Chinese traditional medicine to treat fevers and malaria, was established as a novel antimalarial chemotype. This compound, artemisinin (“qinghaosu” in Chinese), is a sesquiterpene lactone with an endoperoxide group that is essential for activity, and it reacts with the iron in heme in the malarial parasite, Plasmodium falciparum (Fig. 1.3). Because this compound is poorly soluble in water, a number


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of derivatives have been produced with improved formulation, including arteether and artemether. Animal experiments have suggested that artemisinin derivatives are neurotoxic, but this may not be the case in patients with malaria (1,2,3,4). Artemisinin-based combination treatments, such as coartemether (artemether and lumefantrine), are now widely used for treating drug-resistant falciparum malaria (66). Coartemether also is known as Artemisinin Combination Therapy and is registered in approximately 75 countries. A second ether derivative of artemisinin, arteether, also has been developed and is registered in the Netherlands (67).

Fig. 1.3. Artemisins used for the treatment of malaria.

Anticancer Agents For several decades, natural products have served as a very useful group of structurally diverse cancer chemotherapeutic agents, and many of our most important anticancer agents are of m i c r o b i a l o r p l a n t o r i g i n . T hu s , t h e a n t i t u m o r a n t i b i o t i c s i n c l u d e t h e a n t h r a c y c l i n e s (daunorubicin, doxorubicin, epirubicin, idarubucin, and valrubucin), bleomycin, dactinomycin (actinomycin D), mitomycin C, and mitoxantrone. Four main classes of plant-derived antitumor agents are used—namely, the vinca (Catharanthus sp.) bisindole alkaloids (vinblastine, vincristine, and vinorelbine), the semisynthetic epipodophyllotoxin derivatives (etoposide, teniposide, and etoposide phosphate), the taxanes (paclitaxel and docetaxel), and the camptothecin analogues (irinotecan and topotecan) (1,2,3,4). The parent compounds, paclitaxel (originally called “taxol”) and camptothecin, were both discovered in the laboratory of the late Monroe E. Wall and Mansukh Wani at Research Triangle Institute in North Carolina (Fig. 1.4). Like some other natural product drugs, several years elapsed between the initial discovery of these substances and their ultimate clinical approval in either a chemically unmodified or modified form (68). One of the factors that served to delay the introduction of paclitaxel to the market was the need for the large-scale acquisition of this compound from a source other than from the bark of its original plant of origin, the Pacific yew, Taxus brevifolia, because this would involve destroying the slow-growing tree. Presently, paclitaxel and its semisynthetic analogue docetaxel are produced by partial synthesis. To enable this, the diterpenoid “building block,” 10-deacetylbaccatin III, is used as a starting material. This material can be isolated from the needles of the ornamental yew, Taxus baccata, a renewable botanical resource that can be cultivated in greenhouses (68). P.21 P.22 The initial source plant of camptothecin, Camptotheca acuminata, is a rare species found in southern regions of the People's Republic of China. Today, camptothecin is produced commercially not only from cultivated C. acuminata trees in mainland China but also from the roots of Nothapodytes nimmoniana (formerly known as both N. foetida and Mappia foetida), which is found in the southern regions of the Indian subcontinent (69). Interestingly, these two antineoplastic agents are particularly important both because of the clinical effectiveness of their derivatives as cancer chemotherapeutic agents and because they are prominent lead


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compounds for synthetic optimization. Numerous taxanes and camptothecin derivatives are now i n c l i n i c a l t r i a l s ( 4 3 , 4 4 ) . E n d o p hy t i c f u n g i a l s o h a v e b e e n r e p o r t e d t o p r o d u c e p a c l i t a x e l ( 2 9 ) and camptothecin (70), so in the future, it may be possible to produce these important compounds by fermentation rather than by cultivation. Paclitaxel and camptothecin were each found to exhibit a unique mechanism of action for the inhibition of cancer cell growth: Paclitaxel promotes the polymerization of tubulin and the stabilization of microtubules, whereas camptothecin was the first inhibitor of the enzyme DNA topoisomerase I (68).

Fig. 1.4. Lead anticancer drugs paclitaxel and camptothecin and their respective derivatives.


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Fig. 1.5. Potential anticancer chemotherapeutic agents from marine, bacterial, plant, and fungal origin.

A large number of other new natural products of diverse origin have great potential for future therapeutic use as anticancer agents. Several other natural product molecules or their derivatives have been shown to have a action similar to that of paclitaxel against tubulin and are now either in clinical trials or preclinical development; these include dictyostatin-1, eleutherobin, laulimalide, and sarcodictyin, all of which are marine origin (6,43,44,71). Also included in this group are discodermolide, a polyketide lactone from the marine sponge, Discodermia dissoluta, which has now been synthesized (71,72), and several epothilones from the terrestrial myxobacterium Sorangium cellulosum, of which epothilone B and its semisynthetic derivative ixabepilone are representative (Fig. 1.5) (70,73). Two further examples of promising new anticancer agents are combretastatin A4 phosphate, a water-soluble prodrug of combretastatin A4 from the South African plant, Combretum caffrum, and ecteinascidin 743 (ET743; trabectedin), biosynthesized from the marine tunicate, Ecteinascidia turbinata, but now produced by partial synthesis from a microbial metabolite (Fig. 1.5). Combretastatin A4 phosphate binds to tubulin and also affects tumor blood flow, and it is being evaluated along with other cytotoxic agents and radiotherapy (70,74). It binds to the minor groove of DNA, blocks cells in the G2/M phase, and is being evaluated in patients with soft-tissue sarcoma (70,75). An example of a natural product derivative that has been recently introduced into cancer chemotherapy is gemtuzumab ozogamicin (Fig. 1.5). This is a conjugated molecule in which the highly active enediyne DNA-damaging agent component, calichaemicin γ1, produced by Micromonospora echinospora, is linked to a monoclonal antibody that binds specifically to the CD33 cell-surface antigen of acute myeloid leukemic cells, where the enediyne is released (8,76).


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Fig. 1.6. Natural occurring chemopreventive agents.

Cancer chemoprevention is regarded as the use of synthetic or natural agents to inhibit, delay, or reverse the process of carcinogenesis through intervention before the appearance of invasive disease. This new approach toward the management of cancer has involved gaining a better understanding of the mechanism of action by cancer chemopreventive agents (77). Among the natural products that have been studied for this purpose, there has been a renewed interest in the effects of the phytochemical components of the diet, and some of these compounds have been found to block cancer initiation (“blocking agents”) or to reverse tumor promotion and/or progression (“suppressing agents”) (77). Members of many different structural types of plant secondary metabolites have been linked to potential cancer chemopreventive activity (78). Recently, approximately 35 foods of plant origin have been found to produce cancer chemopreventive agents, such as curcumin from turmeric, epigallocatechin 3-O-gallate from green tea, trans-resveratrol from grapes and certain red wines, and d-sulforaphane from broccoli (Fig. 1.6) (79).

Immunomodulators T h e f u n g a l - d e r i v e d c y c l i c p e p t i d e c y c l o s p o r i n e ( c y c l o s p o r i n A ) w as f o u n d s o m e y e a r s a g o t o b e an immunosuppressive agent in organ and tissue transplant surgery. Another compound with this same type of use and that also acts by the inhibition of T-cell activation is the macrolide tacrolimus (FK-506), from Streptomyces tsukubaensis (2). Two further natural product–derived immunosuppressants have been introduced recently, mycophenolate sodium and everolimus (Fig. 1.7) (44). The active principle of both mycophenolate sodium and an earlier introduced form, mycophenolate mofetil (a morpholinoethyl derivative), is mycophenolic acid, obtained from several Penicillium sp. This compound is a reversible inhibitor of inosine monophosphate dehydrogenase, which is involved in guanosine nucleotide synthesis (80). P.23 Everolimus is an orally active, semisynthetic 40-O-(2-hydroxyethyl) derivative of rapamycin (also known as sirolimus) and was originally obtained from Streptomyces hygroscopicus. Everolimus is a proliferation inhibitor that blocks growth factor–mediated signal transduction and prevents organ rejection through a different mechanism than mycophenoliate mofetil (81).


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Fig. 1.7. Natural occurring immunosuppressants.

Botanical Dietary Supplements The use of phytomedicines (herbal remedies) as prescription products has been well established in Germany and several other countries of Western Europe for approximately 25 years. Approximately 80% of physicians in Germany prescribe phytomedicines through the orthodox health care system. During the last decade, there has been a large influx of botanical products into community pharmacy practice and health food stores in the United States as a result of the Dietary Supplement Health and Education Act in 1994. Such products are regulated by the U.S. Food and Drug Administration as foods rather than drugs, and they must adhere to requirements in regard to product labeling and acceptable health claims (82). Currently, among the most popular botanical products used in the United States are those containing black cohosh, cranberry, echinacea, evening primrose, garlic, ginkgo, ginger, ginseng, green tea, milk thistle, saw palmetto, soy, St. John's wort, and valerian. These are purchased as either the crude powdered form in compressed tablets or capsules or as galenical preparations, such as extracts or tinctures, and they frequently are ingested in the form of a tea (82). In addition to the United States, a parallel increased interest in herbal remedies has occurred in Europe, Canada, and Australia, in part because of a greater awareness of complementary and alternative medicine. Many clinical trials focusing on these products have been conducted in Europe, and some are occurring in the United States under the sponsorship of the National Institutes of Health. The recent widespread introduction of a large number of botanical dietary supplements has opened a new door in terms of research inquiry for natural product scientists in the United States. Not all of these products, however, have a well-documented efficacy (82). Three important needs in the scientific investigation of herbal remedies are the characterization of active principles (when these are not known), the development of rigorous and validated analytical methods for quality-control procedures, and the determination of potential toxicity and interactions with prescription medications (83). Unlike compounds approved as single-chemical drugs, it is accepted that combinations of plant secondary metabolites may be responsible for the physiological effects of herbal medicines. For example, both the terpene lactone (e.g., ginkgolide B) (Fig. 1.8) and flavonoid glycoside constituents of Ginkgo biloba leaves are regarded as being necessary for mediation of the symptoms of peripheral vascular disease, for which this phytomedicine is used in Europe (82). Moreover, an acetone-soluble extract of G. biloba containing standardized amounts of flavone glycosides (24%) and terpene lactones (6%) has been used in many clinical trials on this herb (82). If the “active principles” of an herbal remedy are known or can be discovered, these substances can act as reference standards, and their specified concentration levels can be quantified in chemical quality-control procedures, which are predominantly performed by HPLC. A number of official monographs for the standardization of botanical dietary supplements have been developed over the last decade in the United States (84). Other scientific challenges regarding herbal remedies are to establish more completely their dissolution, bioavailability, and shelf life. These products should be free of adulteration (the deliberate addition of nonauthentic plant material or of biologically active or


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inactive compounds); free of other additives, such as herbicides, pesticides, heavy metals, and solvent residues; and free of microbial and biological contaminants (82,83,84).

Fig. 1.8. Chemicals found in various phytomedicinal remedies.

Unfortunately, many herbal remedies may pose toxicity risks or be involved in harmful drug interactions. A drastic example of toxicity caused by a herbal product involves to the Chinese medicinal plant Aristolochia fangchi, which was P.24 substituted in error for another Chinese plant in a weight-reducing regimen taken by a number of women in Belgium approximately 15 years ago. Several years later, this product was linked to the generation of severe renal disease, characterized as interstitial fibrosis with atrophy of the tubules, as well as the development of tumors. These toxic symptoms, also known as “Chinese herb nephropathy,” were attributed to the presence of the phenanthrene derivatives, aristolochic acids I and II (Fig. 1.8), produced by A. fangchi, which have been found experimentally to intercalate with DNA (85). The presence of high levels of the phloroglucinol derivative hyperforin (Fig. 1.8) in St. John's wort, Hypericum perforatum, products has been found to induce cytochrome P450 enzymes (particularly CYP34A), leading to decreased plasma concentrations of prescription drugs that are coadministered, such as alprazolam, cyclosporine, digoxin, indinavir, irinotecan, simvastatin, and warfarin, as well as oral contraceptives (86).

Future Prospects The beginning years of the twenty-first century seem opportune for renewed efforts to be made in regard to the discovery of new secondary-metabolite, prototype biologically active compounds from animals, fungi, microorganisms, and plants of both terrestrial and marine origin. Although many pharmaceutical companies have reduced their investment in natural product research in favor of screening libraries of synthetic compounds and combinatorial chemistry, this has coincided with disappointing numbers of single-chemical entities being introduced as new drugs in recent years (8,11,13). Fortunately, many smaller “biotech” companies have actively taken up the challenge of contemporary natural product drug discovery from organisms (87). There continues to be a steady stream of new natural product–derived drugs introduced for the treatment of many common human diseases (e.g., cancer, cardiovascular diseases, neurological conditions) (13,43). There is ample potential, however, for much greater utilization of natural product–derived compounds in the treatment or prophylaxis of such major worldwide scourges as HIV/AIDS, tuberculosis, hepatitis C, and tropical diseases (inclusive of lymphatic filariasis, leishmaniasis, and schistosomiasis). The search for such agents should be enhanced by the availability of extensive libraries of taxonomically authenticated crude extracts of terrestrial and


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marine origin as well as pure secondary metabolites from microorganisms, plants, and animals. In addition, this will be facilitated by recently developed techniques, such as biocatalysis, combinatorial biosynthesis, combinatorial and computational chemistry, metabolic engineering, and tissue culture. The high “drug-like” quality of natural product molecules stands as a constant, and it only remains for natural product chemists and biologists to investigate these substances in the most technically ingenious and expedient ways. It should not be thought that, after approximately 200 years of investigation, the prospects of finding new drugs of natural origin are nearing exhaustion; much hope for success remains in this type of endeavor. For example, if one considers plants, less than 20% have been evaluated chemically or biologically. Moreover, of approximately 21,000 alkaloids, which are mainly of plant origin, approximately 75% have never been subjected to testing in a bioassay (87). The urgency of performing this type of work cannot be understated in view of the increasing erosion of natural resources that will accelerate as the twenty-first century progresses.

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Chapter 2 Drug Design and Relationship of Functional Groups to Pharmacologic Activity Medicinal chemistry is the discipline concerned with determining the influence of chemical structure on biological activity. As such, it is necessary for the medicinal chemist to understand not only the mechanism by which a drug exerts its effect but also the physicochemical properties of the molecule. The term “physicochemical properties” refers to the influence of the organic functional groups within a molecule on its acid-base properties, water solubility, partition coefficient, crystal structure, stereochemistry, and so on. All these properties influence the absorption, distribution, metabolism excretion, and toxicity of the molecule. To design better medicinal agents, the medicinal chemist needs to understand the relative contributions that each functional group makes to the overall physicochemical properties of the molecule. Studies of this type involve modification of the molecule in a systematic fashion and determination of how these changes affect biological activity. Such studies are referred to as studies of structure– activity relationships (SARs)—that is, what structural features of the molecule contributes to, or takes away from, the desired biological activity of the molecule of interest. Because of the fundamental nature of the subject matter, this chapter includes numerous case studies throughout (as boxes) as well as at the end. In addition, a list of study questions at the end of—and unique to—this chapter provides further self-study material regarding the subject of drug design.

Introduction Chemical compounds, usually derived from plants and other natural sources, have been used by humans for thousands of years to alleviate pain, diarrhea, infection, and various other maladies. Until the nineteenth century, these “remedies” were primarily crude preparations of plant material of unknown constitution. The revolution in synthetic organic chemistry during the nineteenth century produced a concerted effort toward identification of the structures of the active constituents of these naturally derived medicinals and synthesis of what were hoped to be more efficacious agents. By determining the molecular structures of the active components of these complex mixtures, it was thought that a better understanding of how these components worked could be elucidated.

Relationship Between Molecular Structure and Biological Activity Early studies of the relationship between chemical structure and biological activity were conducted by Crum-Brown and Fraser (1) in 1869. They showed that many compounds containing tertiary amine groups became muscle relaxants when converted to quaternary ammonium compounds. Compounds with widely differing pharmacologic properties, such as strychnine (a convulsant), morphine (an analgesic), nicotine (deterrent, insecticide), and atropine (anticholinergic), could be converted to muscle relaxants with properties similar to those of tubocurarine when methylated (Fig. 2.1). Crum-Brown and Fraser therefore concluded that muscle-relaxant activity required a quaternary ammonium group P.27 within the chemical structure. This initial hypothesis was later disproven by the discovery of the natural neurotransmitter and activator of muscle contraction, acetylcholine (Fig. 2.2). Even though Crum-Brown and Fraser's initial hypothesis concerning chemical structure and muscle relaxation was incorrect, it demonstrated the concept that molecular structure influences the biological activity of chemical compounds.


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Fig. 2.1. Effects of methylation on biological activity.

Fig. 2.2. Acetylcholine, a neurotransmitter and muscle relaxant.

With the discovery by Crum-Brown and Fraser that quaternary ammonium groups could produce compounds with muscle-relaxant properties, scientists began looking for other organic functional


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groups that would produce specific biological responses. The thinking during this time was that specific chemical groups, or nuclei (rings), were responsible for specific biological effects. This lead to the postulate, which took some time to disprove, that “one chemical group gives one biological action” (2). Even after the discovery of acetylcholine by Loewi and Navrati (3), which effectively dispensed with Crum-Brown and Fraser's concept of all quaternary ammonium compounds being muscle relaxants, this was still considered to be dogma and took a long time to replace.

Selectivity of Drug Action and Drug Receptors Although the structures of many drugs or xenobiotics, or at least the composition of functional groups, were known at the start of the twentieth century, how these compounds exerted their effects was still a mystery. Utilizing his observations regarding the staining behavior of microorganisms, Ehrlich (4) developed the concept of drug receptors. He postulated that certain “side chains” on the surfaces of cells were “complementary” to the dyes (or drug), thereby allowing the two substances to combine. In the case of antimicrobial compounds, this combining of the chemical to the “side chains” produced a toxic effect. This concept effectively was the first description of what later became known as the receptor hypothesis for explaining the biological action of chemical compounds. Ehrlich also discussed selectivity of drug action via the concept of a “magic bullet” for compounds that would eradicate disease states without producing undue harm to the organism being treated (i.e., the patient). This concept was later modified by Albert (5) and generally is referred to as “selective toxicity.” Utilizing this concept, Ehrlich developed organic arsenicals that were toxic to trypanosomes as a result of their irreversible reaction with mercapto groups (-SH) on vital proteins within the organism. The formation of As-S bonds resulted in death to the target organism. It was soon learned, however, that these compounds were toxic not only to the target organism but also to the host once certain blood levels of arsenic were achieved. The “paradox” that resulted after the discovery of acetylcholine—how one chemical group can produce two different biological effects (i.e., muscle relaxation and muscle contraction)—was explained by Ing (6) using the actions of acetylcholine and tubocurarine as his examples. Ing hypothesized that both acetylcholine and tubocurarine act at the same receptor, but that one molecule fits to the receptor in a more complementary manner and “activates” it, causing muscle contraction. (Ing did not elaborate just how this activation occurred.) The blocking effect of the larger molecule, tubocurarine, could be explained by its occupation of part of the receptor, thereby preventing acetylcholine, the smaller molecule, from interacting with the receptor. With both molecules, the quaternary ammonium functional group is a common structural feature and interacts with the same region of the receptor. If one closely examines the structures of other compounds with opposing effects on the same pharmacologic system, this appears to be a common theme: Molecules that block the effects of natural neurotransmitters (antagonists) generally are larger in size than the native compound. Both agonists and antagonists share common structural features, however, thus providing support to the concept that the structure of a molecule, its composition and arrangement of chemical functional groups, determines the type of pharmacologic effect that it possesses (i.e., SAR). Thus, compounds that are muscle r e l a x a n t s a c t i n g v i a t h e c h o li n e r g i c n e r v o u s s y s t e m w i l l p o s s e s s a q u a t e r n a r y a m m o n i u m o r protonated tertiary ammonium group and will be larger than acetylcholine. Structure–activity relationships are the underlying principle of medicinal chemistry. Similar molecules exert similar biological actions in a qualitative sense. A corollary to this is that structural elements (functional groups) within a molecule most often contribute in an additive manner to the physicochemical properties of a molecule and, therefore, to its biological action. One need only peruse the structures of drug molecules in a particular pharmacologic class to become convinced of this (e.g., histamine H1 antagonists, histamine H2 antagonists, and βadrenergic antagonists). The objective of medicinal chemists in their quest for better medicinal agents (drugs) is to discover what functional groups within a specific structure are important for its pharmacologic activity and how can these groups be modified to produce more potent, selective, and safer compounds. An example of how different functional groups can yield compounds with similar physicochemical properties is shown with sulfanilamide antibiotics. In Figure 2.3, the structures of sulfanilamide


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and p-aminobenzoic acid (PABA) are shown. In 1940, Woods (7) demonstrated that PABA was capable of reversing the antibacterial action of sulfanilamide (and other sulfonamides antibacterials) and that both PABA and sulfanilamide had similar steric and electronic properties. Both compounds contain acidic functional groups, with PABA containing an aromatic carboxylic acid and sulfanilamide an aromatic sulfonamide. When ionized at physiological pH, P.28 both compounds have a similar electronic configuration, and the distance between the ionized acid and the weakly basic amino group also is very similar. It should therefore be no surprise that sulfanilamide acts as an antagonist to PABA metabolism in bacteria.

Fig. 2.3. Ionized forms of p-aminobenzoic acid (PABA) and sulfanilamide, with comparison of the distance between amine and ionized acids of each compound. Note how closely sulfanilamide resembles PABA.

Physicochemical Properties of Drugs Acid-Base Properties The human body is 70 to 75% water, which amounts to approximately 51 to 55 L of water for a 160-lb (73-kg) individual. For an average drug molecule with a molecular weight of 200 g/mol and a dose of 20 mg, this leads to a solution concentration of approximately 2 × 10-6 M. When considering the solution behavior of a drug within the body, we therefore are dealing with a dilute solution, for which the Brönsted-Lowry (8) acid-base theory is most appropriate for explaining and predicting acid-base behavior. This is a very important concept in medicinal chemistry, because the acid-base properties of drug molecules directly affect absorption, excretion, and compatibility with other drugs in solution. According to the Brönsted-Lowry Theory, an “acid” is any substance capable of yielding a proton (H+), and a “base” is any substance capable of accepting a proton. When an acid gives up a proton to a base, it is converted to its “conjugate base.” Similarly, when a base accepts, a proton it is converted to its “conjugate acid” (Eqs. 2.1 and 2.2):

Note that when an acid loses its proton, it is left with an extra pair of electrons that are no longer neutralized by the proton. This is the “ionized” form of the acid and is now more water


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soluble because of the charge. Because the acid has lost its proton, it also often is referred to as having undergone “dissociation.” Many different organic functional groups behave as acids, and these are listed in Table 2.1. It is important that the student learn to recognize these f u n c t i o n a l g r o u p s a n d t h e i r r e l a t i v e a c i d s t r en g t h s . T h i s w i l l h e l p t h e s t u d e n t t o p r e d i c t absorption, distribution, excretion, and potential incompatibilities between drugs. When a base is converted to its conjugate acid, it too becomes ionized. In this instance, however, it becomes positively charged because of the presence of the extra proton. Most basic drugs usually are derived from primary, secondary, and tertiary amines or imino amines, such as guanidines and amidines. Other organic functional groups that act as bases are shown in Table 2.2. Again, the student should become familiar with these functional groups and be able to readily recognize them by name and relative strengths. Organic functional groups that cannot give up or accept a proton are considered to be “neutral” (or “nonelectrolytes”) with respect to their acid-base properties. Common functional groups of this type are shown in Table 2.3. In the case of quaternary ammonium compounds, the molecule is not electrically neutral, even though it is neither acidic nor basic. Additional reading on the acid-base behavior of the functional groups listed in Tables 2.1 through 2.3 can be found in Gennaro (9) and Lemke (10). Further review of organic functional groups and their acid-base properties can be found at http://www-home.cr.duq.edu/~harrold/. A molecule may contain multiple functional groups and, therefore, possess both acidic and basic properties. For example, ciprofloxacin (Fig. 2.4), a fluoroquinolone antibiotic, contains a secondary alkylamine, two tertiary arylamines (aniline-like amines), and a carboxylic acid. The two arylamines are weakly basic and, therefore, do not contribute significantly to the acid-base p r o p e r t i e s o f c i p r o f l o x a c i n . D e p e n d i n g o n t h e p H o f t h e s o l u t i o n ( or t i s s u e ) , t h i s m o l e c u l e w i l l either accept a proton (secondary alkylamine), yield a proton (carboxylic acid), or both. Thus, it is amphoteric (both acidic and basic) in its properties. Figure 2.5 shows the acid-base behavior of ciprofloxacin at two different locations of the gastrointestinal tract. Note that at a given pH (e.g., pH 1.0–3.5), only one of the functional groups (the alkylamine) is ionized. To be able to make this prediction, one has to understand the relative acid-base strength of acids and bases. Thus, one needs to know which acid or base within a molecule containing multiple functional groups is the strongest and which acid or base is the weakest. The concept of pKa not only indicates the relative acid-base strength of organic functional groups but also allows one to calculate, for a given pH, exactly how much of the molecule is in the ionized and un-ionized form, which therefore allows prediction of relative water solubility, absorption, and excretion for a given compound. P.29


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Table 2.1. Common Acidic Organic Functional Groups and Their lonized (Conjugate Base) Forms

Relative Acid Strength (pK a ) Strong acids and bases completely dissociate or accept a proton in aqueous solution to produce their respective conjugate bases and acids. For example, mineral acids, such as HCl, or bases, such as NaOH, undergo 100% dissociation in water, with the equilibrium shifted completely to the right side, as shown in Equations 2.3 and 2.4:

Acids and bases of intermediate or weak strength, however, incompletely dissociate or accept a proton, and the equilibrium lies somewhere in between. The equilibrium is such that all possible species may exist. Note that in Equations 2.3 and 2.4, water is acting as a base in one instance and as an acid in the other. Water is amphoteric—that is, it may act as an acid or a base, depending on the conditions. Because we are always dealing with a dilute aqueous solution, the strongest base that can be present is OH-, and the strongest acid is H3O+. This is known as the “leveling effect” of water. Thus, some organic functional groups that are considered to be acids or bases with respect to their chemical reactivity do not behave as such under physiological conditions in aqueous solution. For example, alkyl alcohols, such as ethyl alcohol, are not sufficiently acidic to undergo ionization to a significant extent in aqueous solution. Water is not sufficiently basic to remove the proton from the alcohol to form the ethoxide ion (Eq. 2.5). Therefore, under physiological conditions, alcohols may be considered to be neutral with respect to acid-base properties:

P.30


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Table 2.2. Common Basic Organic Functional Groups and Their lonized (Conjugate Acid) Forms

Predicting the Degree of Ionization of a Molecule From general principles, it is possible to predict if a molecule is going to be ionized or unionized at a given pH simply by knowing if the functional groups on the molecule are acidic or basic. To be able to quantitatively predict the degree of ionization of a molecule, however, one must know the pKa values of the acidic and basic functional groups that are present and the pH of the environment to which the compound will be exposed. The Henderson-Hassalbach equation (Eq. 2.6) can be used to calculate the percentage ionization of a compound at a given pH (this equation was used to calculate the major forms of ciprofloxacin in Fig. 2.5):

Table 2.3. Common Organic Functional Groups That Are Considered Neutral Under Physiologic Conditions

The key to understanding the use of the Henderson-Hassalbach equation for calculating percentage ionization is to realize that this equation relates a constant, pKa, to the ratio of acidic form to the basic form of the drug. Because pKa is a constant for any given molecule, the ratio of acid to base will determine the pH of the solution. Conversely, a given pH determines the ratio of acid to base. A sample calculation is shown in Figure 2.6 for the sedative hypnotic amobarbital.


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When dealing with a base, the student must recognize that the conjugate acid is the ionized form of the drug. Thus, as one should expect, a base behaves in a manner opposite to that of an acid. Figure 2.7 shows the calculated percentage ionization for the decongestant phenylpropanolamine. It is very important to recognize that for a base, the pKa refers to the conjugate acid or ionized P.31 form of the compound. To thoroughly comprehend this relationship, the student should calculate the percentage ionization of an acid and a base at different pH values.

Fig. 2.4. Chemical structure of ciprofloxacin showing the various organic functional groups.

Water Solubility of Drugs The solubility of a drug molecule in water greatly affects the routes of administration that are available as well as its absorption, distribution, and elimination. Two key concepts to keep in mind when considering the water (or fat) solubility of a molecule are the hydrogen bond–forming potential of the functional groups in the molecule and the ionization of functional groups.

Fig. 2.5. Predominate forms of ciprofloxacin at two different locations within the gastrointestinal tract.

Hydrogen Bonds Each functional group capable of donating or accepting a hydrogen bond will contribute to the overall water solubility of the compound and increase the hydrophilic (water-loving) nature of


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the molecule. Conversely, functional P.32 g r o u p s t h a t c a n n o t f o r m h y d r o g e n b o n d s w i l l n o t e n h a n c e h y d ro p h i l i c i t y a n d w i l l a c t u a l l y contribute to the hydrophobicity (water-hating) nature of the molecule. Hydrogen bonds are a special case of what generally are referred to as dipole–dipole bonds. Dipoles result from unequal sharing of electrons between atoms within a covalent bond. This unequal sharing of electrons results when two atoms involved in a covalent bond have significantly different electronegativities. As a result, partial ionic character develops between the two atoms, producing a permanent dipole—that is, one end of the covalent bond has higher electron density than the other. When two molecules containing dipoles approach one another, they align such that the negative end of one dipole is electrostatically attracted to the positive end of the other. When the positive end of the dipole is a hydrogen atom, P.33 this interaction is referred to as a “hydrogen bond” (or H-bond). Thus, for a hydrogen bond to occur, at least one dipole must contain an electropositive hydrogen. The hydrogen atom must be involved in a covalent bond with an electronegative atom, such as oxygen (O), nitrogen (N), sulfur (S) or selenium (Se). Of these four elements, only oxygen and nitrogen contribute significantly to the dipole, and we will therefore concern ourselves only with the hydrogenbonding capability of OH and NH groups. (This is only in reference to functional groups that “donate” hydrogen bonds.)

Absorption/Acid-Base Case

A long-distance truck driver comes into the pharmacy complaining of seasonal allergies. He asks you to recommend an agent that will act as an antihistamine but that will not cause drowsiness. He regularly takes TUMS for indigestion because of the bad food that he eats while on the road. 1. Identify the functional groups present in Zyrtec and Tavist, and evaluate the effect of each functional group on the ability of the drug to cross lipophilic membranes (e.g., blood-brain barrier). Based on your assessment of each agent's ability to cross the blood-brain barrier (and, therefore, potentially cause drowsiness), provide a rationale for whether the truck driver should be taking Zyrtec or Tavist. 2. Patanol is sold as an


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aqueous solution of the hydrochloride salt. Modify the structure above to show the appropriate salt form of this agent. This agent is applied to the eye to relieve itching associated with allergies. Describe why this agent is soluble in water and what properties make it able to be absorbed into the membranes that surround the eye. 3. Consider the structural features of Zyrtec and Tavist. In which compartment (stomach [pH 1] or intestine [pH 6–7]) will each of these two drugs be best absorbed? 4. TUMS neutralizes stomach acid to pH 3.5. Based on your answer to question 3, determine whether the truck driver will get the full antihistaminergic effect if he takes his antihistamine at the same time that he takes his TUMS. Provide a rationale for your answer.

Acid-Base Chemistry/Compatibility Cases

The IV technician in the hospital pharmacy gets an order for a patient that includes the two drugs drawn below. She is unsure if she can mix the two drugs together in the same IV bag and is not certain how water soluble the agents are.


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1. Penicillin V potassium is drawn in its salt form, whereas codeine phosphate is not. Modify the structure above to show the salt form of codeine phosphate. Determine the acidbase character of the functional groups in the two molecules drawn above as well as the salt form of codeine phosphate. 2. As originally drawn above, which of these two agents is more water soluble? Provide a rationale for your selection that includes appropriate structural properties. Is the salt form of codeine phosphate more or less water soluble than the free base form of the drug? Provide a rationale for your answer based on the structural properties of the salt form of codeine phosphate. 3. What is the chemical consequence of mixing aqueous solutions of each drug in the same IV bag? Provide a rationale that includes an acidbase assessment.


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Fig. 2.6. Calculation of percentage ionization of amobarbital. Calculation indicates that 80% of the molecules are in the acid (or protonated) form, leaving 20% in the conjugate base (ionized) form.

Fig. 2.7. Calculation of percentage ionization of phenylpropanolamine. Calculation indicates that 99% of the molecules are in the acid form, which is the same as the percentage ionization.


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Fig. 2.8. Examples of hydrogen-bonding between water and hypothetical drug molecules.

Even though the energy involved for each hydrogen bond is small (1–10 kcal/mol/bond), it is the additive nature of multiple hydrogen bonds that contributes to water solubility. We will see in Chapter 4 that this same bonding interaction also is important in drug–receptor interactions. Figure 2.8 shows several possible hydrogen bond types that may occur with different organic functional groups and water. As a general rule, the more hydrogen bonds that are possible, the greater the water solubility of the molecule. Table 2.4 lists several common organic functional groups and the number of potential hydrogen bonds for each. Note that this table does not take into account the possibility of intramolecular hydrogen bonds that could form. Each intramolecular hydrogen bond decreases water solubility (and increases lipid solubility), because one less interaction with solvent occurs.

Table 2.4. Common Organic Functional Groups and Their Hydrogen-Bonding Potential

Absorption/Binding Interactions Case A 24-y ear-ol d man c omes i nto th e pha rmacy a nd as ks you to re commend a tre atment for th e itch ing a nd bur ning h e has recen tly no ticed on bo th fe et. He indic ates that h e would prefer a cre am rath er tha n a s pray o r a po wder. Your r ecommen dation to t his patien t is t o use Lamisi l®, a very effect ive to pical antif ungal agent that is sol d ove rthe-co unter.


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1. I dentif y the struc tural charac terist ics an d the corre spondi ng pr operti es tha t make t erbina fine an age nt th at can be u tilize d topi cally. 2. Th e bio logica l targ et of drug action for t erbina fine is squ alene epoxi dase. C onside r each of t he str uctura l feat ures of thi s anti funga l agen t, an d desc ribe t he t ype o f inte ractio ns tha t the drug will h ave wi th the targe t for drug action . Which a mino a cids a re lik ely to be p resent in th e act ive si te of this e nzyme?

Ionization In addition to the hydrogen-bonding capability of a molecule, another type of bonding interaction plays an important role in determining water solubility: ion–dipole interaction. This type of interaction comes into play when one deals with organic salts. Ion–dipole interactions develop between either a cation or anion and a formal dipole, such as water. A cation, having a d e f i c i e n c y i n e l e c t r o n d e n s i t y , wi l l b e a t t r a c t e d t o r e g i o n s o f h i g h e l e c t r o n d e n s i t y . W h e n d e a l i n g with water, this would be the two lone pairs of electrons associated with the oxygen atom. An anion will associate with regions of low electron density or the positive end of the dipole. In the case of water as solvent, this would be the hydrogen atoms (Fig. 2.9).

Fig. 2.9. Examples of ion–dipole interactions.

P.34 Not all organic salts are necessarily very water soluble. To associate with enough water molecules to become soluble, the salt must be highly dissociable; in other words, the cation and anion must be able to separate and interact with water molecules. Highly dissociable salts are those formed from strong acids with strong bases (e.g., sodium chloride), weak acids with strong


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bases (e.g., sodium phenobarbital), or strong acids with weak bases (e.g., atropine sulfate). Examples of strong acids (strong acids are 100% ionized in water [i.e., no ionization constants or pKa values of 1 0 0 k c a l / m o l / Å ) . S o , b o t h c r o ss - t e r m s a n d t h e M o rs e p o t e n t i a l sh o u l d b e u s e d o n l y w i t h t h e r e a s o n a b l y o p t i m i z e d s t r u c t u re s .

Other force fields In addition to the classical force fields above, many other force fields have been developed for small drug molecules or m a c r o mo l e c u l e s . T h e M M 2 , M M 3 , a n d M M4 f o r c e f i e l d s w e r e d e v e l o p e d b y N o r m a n L . A l l i n g e r f o r a b r o a d r a n g e o f c h e m i c a l s , a n d C F F i s a f a m i l y o f f o r ce f i e l d s a d a p t e d t o a b r o a d v a r i e t y o f o r g a n i c c o mp o u n d s , p o l y m e r s , me t a l s , a n d s o o n . T h e M M F F f o r c e f i e l d w a s d e v e l o p e d a t M e r ck f o r a b r o a d r a n g e o f c h e m i c a l s . R e a x F F i s a r e a c t i v e f o r ce f i e l d , d e v e l o p e d b y W i l l i a m G o d d a r d a n d c o w o rk e r s, i s f a s t , t r a n s f e r a b l e , a n d t h e c o m p u t a t i o n a l m e t h o d o f c h o i c e f o r a t o m i s t i c -s c a l e d yn a mi c s s i m u l a t i o n s o f c h e mi c a l reactions. T h e s e p ro g ra m s a r e o rg a n i z e d q u i t e d i f f e re n t l y . T h e m o st p o p u l a r c o m me r c i a l p a ck a g e s o f f e r m a t u r e , s o p h i s t i c a t e d u s e r i n t e r f a c e s , w i t h e a s i e r p o i n t - a n d - c l i c k i n t e r f a c e s f o r m a n y f u n c t i o n s . T h e a c a d e m i c v e r si o n s t y p i c a l l y o f f e r m o r e a d va n c e d f e a t u r e s a n d m e t h o d s t h a t a r e s t i l l u n d e r d e ve l o p m e n t . T h e i r u s e r i n t e r f a c e s a r e i m p r o v i n g b u t l a c k r o b u s t p o i n t - a n d - c l i c k i n t e r f a c e s. E a c h o f f e rs a d va n t a g e s a n d d i s a d v a n t a g e s t h a t m u s t b e co n si d e r e d b e f o r e s e l e c t i n g o n e p r o g r a m a n d s p e n d i n g t h e t i me t o l e a r n i t . T h e a d v a n t a g e s o f e m p i r i ca l f o r c e f i e l d me t h o d s l i e i n t h e i r a b i l i t y t o t r e a t t h o u s a n d s o f a t o m s a n d t h e i r d i r e c t c o n n e c t i o n w i t h s t a t i s t i c a l t h e r m o d y n a m i c s . M a n y b i o l o g i c a l s y st e m s , s u c h a s e n z y m e s , p r o t e i n s , a n d D N A a n d t h e i r c o m p l e x e s , a r e w i t h i n t h e r a n g e o f m o l e c u l a r m e c h a n i c s . S c o r i n g f u n c t i o n s a n d s i mu l a t i o n s b a s e d o n e m p i r i ca l f o rc e f i e l d s h a v e s u c ce s s f u l l y a n a l y z e d b i n d i n g m o d e s , f o l d i n g m e c h a n i s m s , a n d a l l o s t e r i c e f f e c t s . T h e s i m u l a t i o n s ma y b e a n a l y ze d w i t h s t a t i s t i c a l t h e r m o d y n a m i c s m e t h o d s t o e s t i ma t e t h e f re e e n e rg y o f b i n d i n g o r f o l d i n g . T r a j e c t o r i e s o f a t o m s m a y b e u s e d t o d e r i v e d i f f u s i o n c o n s t a n t s o r t o c o m p a r e w i t h n u c l e a r m a g n e t i c r e s o n a n c e ( N M R ) e s t i m a t e s o f a t o m i c m o t i o n . T h e f l e x i b i l i t y o f e mp i ri c a l f o r c e f i e l d m e t h o d s m u s t b e b a l a n c e d w i t h t h e t i m e r e q u i r e d t o d e v e l o p p a r a me t e r s f o r a n e w s y s t e m. P ro t e i n s , n u c l e o t i d e s , a n d c a r b o h y d r a t e s p a r a m e t e r s e t s c o n t i n u e t o e v o l v e b u t h a v e b e e n u s e f u l f o r m o r e t h a n 1 0 y e a r s . N o v e l l e a d c o mp o u n d s o f t e n w i l l r e q u i r e p a r a m e t e r i z a t i o n t o a ch i e v e m e a n i n g f u l re s u l t s . P.62

Molecular Mechanics Energy Minimization M o l e c u l a r m e c h a n i cs i s a n a p p r o a c h o f e n e rg y m i n i m i z a t i o n t h a t f i n d s s t a b l e , l o w - e n e r g y c o n f o r m a t i o n s b y c h a n g i n g t h e g e o m e t r y o f a s t r u c t u r e o r i d e n t i f y i n g a p o i n t i n t h e c o n f i g u r a t i o n s p a c e a t w h i c h t h e n e t f o r c e o n e a c h a t o m va n i s h e s . I n o t h e r w o r d s , i t i s t o f i n d t h e co o rd i n a t e s w h e r e t h e f i r s t d e r i v a t i v e s o f t h e p o t e n t i a l e n e r g y f u n c t i o n e q u a l s z e r o . S u ch a c o n f o r m a t i o n r e p r e se n t s o n e o f m a n y d i f f e r e n t c o n f o r m a t i o n s t h a t a m o l e cu l e m i g h t a s su m e a t a t e m p e r a t u r e o f 0 ° K . T h e p o t e n t i a l e n e r g y f u n c t i o n ( o r f o r c e f i e l d ) is evaluated by a certain algorithm or minimizer (e.g., steepest descent or conjugate gradient) that moves the atoms in the m o l e c u l e t o a n e a r e s t l o c a l mi n i m u m (n o t n e c e ss a r i l y t h e g l o b a l m i n i m u m ), w h e r e a s t h e s e l e ct i o n o f d i f f e re n t m i n i m i z a t i o n algorithms is important for various molecule systems, as discussed below.

Steepest Descent S t e e p e s t d e s c e n t m e t h o d (3 2 ) i s a n o p t i m i z a t i o n a l g o ri t h m t h a t a p p r o a c h e s a l o c a l m i n i m u m o f a f u n c t i o n b y t a k i n g st e p s p ro p o r t i o n a l t o t h e n e g a t i v e o f t h e g r a d i e n t (o r t h e a p p r o x i m a t e g r a d i e n t ) o f t h e f u n c t i o n a t t h e c u r re n t p o i n t . S i m p l y p u t , s t e e p e s t d e s c e n t u s e s t h e g ra d i e n t t o d e t e rm i n e t h e d i r e c t i o n a n d m o ve d o w n i n o n e d i m e n s i o n p a r a l l e l t o t h e n e t f o rc e . S t e e p e st d e s c e n t w i l l l e a d d i r e c t l y t o t h e n e a r e st l o c a l m i n i mu m b y f o l l o w i n g a p a t h t h a t i s d e t e rm i n e d b y m o v i n g f r o m t h e p r e v i o u s v a l u e t o a n e w v a l u e ( a t s o me c o n s t a n t t i me s ) i n t h e d i r e c t i o n s i n w h i c h t h e e n e r g y i s d e c r e a s i n g (F i g . 3 . 6 ) . I f t h e n e w m o v e me n t d e c r e a s e s t he e n e r g y , t h e n e w s t r u c t u r e i s a c ce p t e d , a n d t h e p r o c e s s i s r e p e a t e d . I f , o n t h e o t h e r h a n d , t h e e n e r g y i n c r e a s e s , t h e p r e v i o u s s t r u c t u r e i s r e s t o r e d . T h i s a l g o r i t h m c o n v e r g e s f a s t i n a s t e e p p l a c e f o r c o rr e c t i n g “ b a d ” i n i t i a l g e o m e t r y , e s p e c i a l l y w h e n sy s t e m s a re f a r f r o m h a r mo n i c . I t h a s p o o r c o n v e r g e n c e p r o p e r t i e s , h o w e v e r , a n d o f t e n j i t t e r s a r o u n d t h e m i n i m u m a r e a , b e c a u s e t h e g ra d i e n t a p p r o a c h e s z e r o n e a r t h e m i n i m u m .


Página 9 de 36

Fig. 3.6. Steepest descent algorithm (thin line): The derivative vector from the initial point P0 (x0,y0) defines the line search direction. The derivative vector does not point directly toward the minimum (O). The negative gradient of the potential energy (the force) points into the direction (P0 → b, P1 → c) of the steepest descent of the energy hypersurface and is always oriented perpendicular to energy isosurfaces. Conjugate gradients algorithm (thick line): The search direction (a → P1 → O) is in one dimension for the minimum. The energy point P1 takes the direction P1 → O instead of the direction P1 → c. The direction P1 → c of gradient conjugates to the direction P0 → b.

Conjugate Gradient T h e c o n j u g a t e g r a d i e n t m e t h o d ( 3 2 , 4 3 ) i m p r o v e s t h e s t e p e f f i c i e n c y b y m i n i m i zi n g o n l y a l o n g d i r e ct i o n s t h a t a r e m u t u a l l y conjugate so that movement along one direction will not counteract progress made in earlier iterations. The conjugate gradient m e t h o d t a k e s t h e n e xt s e a r ch d i r e c t i o n t o b e a l i n e a r c o m b i n a t i o n o f t h e c u r r e n t g r a d i e n t a n d t h e p r e v i o u s o n e s ( F i g . 3 . 6 ) . C o n j u g a t e g r a d i e n t s r e q u i re f e w e r e n e r g y e v a l u a t i o n s a n d g r a d i e n t ca l c u l a t i o n s , a n d f u r t h e r c o n v e rg e n c e c h a r a c t e r i z a t i o n s a r e b e t t e r t h a n w i t h s t e e p e s t d e s c e n t . C o n j u g a t e g r a d i e n t i s t h e m e t h o d o f c h o i c e f o r l a r g e s y s t e m s i n w h i c h s t o ri n g a n d m a n i p u l a t i n g a l a r g e s e c o n d d e r i v a t i v e ma t r i x i s i m p a r t i a l , s u c h a s t h e N e w t o n - R a p h s o n m e t h o d .

Newton-Raphson Procedure T h e N e w t o n - R a p h so n p r o c e d u r e ( 3 2 ) i s a p o w e rf u l , c o n v e rg e n t mi n i m i z a t i o n p ro c e d u re , b u t i t r e q u i r e s t h e s e c o n d d e r i v a t i v e m a t r i x t o b e a v a i l a b l e . T h e N e w t o n -R a p h s o n p r o c e d u r e i s b a s e d o n t h e a ss u m p t i o n t h a t t h e e n e r g y i s q u a d r a t i c a l l y d e p e n d e n t — i n o t h e r w o r d s , t h a t i t b e h a v e s l i k e a c l a s si c a l s p r i n g . T h e n , t h e n e w c o o r d i n a t e s i n e a ch i t e ra t i o n c a n b e f o u n d b y t h e ca l c u l a t i o n o f t h e m a t ri x o f t h e se c o n d d e r i v a t i v e w i t h r e s p e ct t o t h e c o o r d i n a t e s a n d t h e f i r s t d e r i v a t i v e s . T h e a d va n t a g e o f t h e N e w t o n - R a p h s o n p ro c e d u re t h a t t h e mi n i m i z a t i o n c o u l d c o n v e rg e i n o n e o r t w o s t e p s . T h e m a j o r d r a w b a c k i s t h a t t h i s m e t h o d re q u i re s t h e c a l c u l a t i o n o f t h e s e co n d d e ri v a t i v e s . T h e m i n i m i z a t i o n ca n t h e n b e c o me u n s t a b l e w h e n a s t r u ct u r e i s f a r f r o m t h e m i n i m u m ( o r th e e n e r g y s u rf a c e i s a n h a r mo n i c ) .

Criteria for Evaluating Convergence in Minimization Processes G e o m e t r i c o p t i m i za t i o n i s a n i t e r a t i v e p ro c e d u r e o f c o m p u t i n g t h e e n e r g y o f a s t r u c t u r e a n d t h e n m a ki n g i n c r e me n t a l c h a n g e s t o r e d u ce t h e e n e rg y . M i n i mi z a t i o n o f a m o l e c u l e i n vo l ve s t w o st e p s . F i r st , a n e q u a t i o n d e s c ri b i n g t h e e n e r g y o f t h e s ys t e m a s a f u n c t i o n o f i t s c o o r d i n a t e s m u s t b e d e f i n e d a n d e v a l u a t e d f o r a g i v e n c o n f o r ma t i o n . S e c o n d , t h e c o n f o r m a t i o n i s a d j u s t e d t o l o w e r t h e va l u e o f t h e p o t e n t i a l f u n c t i o n . M i n i m i z a t i o n p r o v i d e s i n f o r m a t i o n co m p l e me n t a r y t o t h a t o b t a i n e d f ro m m o l e c u l a r d yn a mi c s . A m i n i m u m e n e rg y c o n f o r m a t i o n c a n b e f o u n d b u t m a y re q u i re t h o u s a n d s o f i t e r a t i o n s , d e p e n d i n g o n t h e n a t u r e o f t h e a l g o r i t h m , t h e form of the potential function, and the size of the molecule. P.63 T h e e f f i c i e n cy o f t h e m i n i m i z a t i o n i s j u d g e d b y b o t h t h e t i me t o e v a l u a t e t h e t a r g e t f u n c t i o n a n d t h e n u mb e r o f st ru c t u ra l a d j u s t m e n t s (i t e ra t i o n s ) n e e d e d t o co n ve r g e o n t h e m i n i mu m .

Zero Derivatives Mathematically, a minimum is reached by the point at which the derivatives of the function are zero, as in Equation 3.9:

S e v e r a l p o i n t s ma y e xi s t , h o w e v e r , w h e r e t h e n e t a t o m i c f o r c e s a r e z e r o . T h e p o i n t o f t h e l o w e s t e n e r g y , o r t h e g l o b a l m i n i m u m , w h i ch u s u a l l y i s t h e c o n f o r m a t i o n o f i n t e r e s t , s o m e t i m e s m a y n o t b e f o u n d f r o m a s i n g l e s t a r t i n g p o i n t o f e n e r g y m i n i m i za t i o n . T h e r e f o r e , t h o ro u g h c o n f o r ma t i o n s a mp l i n g ( e . g . , d y n a m i c s s i m u l a t i o n ) i s c r i t i c a l t o m i n i m i z a t i o n s t u d i e s . I n t h e o r y , c o n v e r g e nc e o cc u r s a t a m i n i m u m p o i n t w h e r e a l l d e r i v a t i v e s a r e z e r o a n d t h e s e co n d d e r i v a t i v e ma t r i x i s p o s i t i v e - d e f i n i t e . I n p r a c t i c e , h o w e v e r , i t c a n b e d i f f i c u l t t o j u d g e w h e t h e r i t i s c l o s e e n o u g h t o t h e t r u e g l o b a l m i n i mu m . T o s o l v e t h i s p r o b l e m , d i f f e r e n t a l g o r i t h m s a n d m e t h o d s a r e c h o s e n a n d c o m b i n e d t o s e a r c h f o r t h e g l o b a l m i n i m u m. S o m e m i n i m i z a t i o n a l g o ri t h m s a s s u me t h a t t h e e n e r g y s u r f a c e i s a p p r o x i m a t e l y h a r m o n i c o r , f o r n o n h a r m o n i c s u r f a c e s , t h a t t h e s h a p e o f t h e n o n h a r mo n i c s u rf a c e b e c o me s h a r m o n i c i n t h e l i m i t a s y o u c o n v e rg e o n t h e mi n i m u m . T h e d e r i v a t i v e s a r e p ro p o r t i o n a l t o t h e c o o r d i n a t e s f o r t h e m o l e cu l a r e n e r g y s u r f a c e s w h e re t h e f o r c e f i e l d i s h a r m o n i c. T h e d e ri v a t i v e s i n c l u d e t h e i n f o r m a t i o n r e g a r d i n g h o w f a r a w a y y o u a r e f r o m t h e m i n i mu m . T h e ma g n i t u d e o f t h e d e ri v a t i v e s a l s o i s t h e mo s t r i g o ro u s w a y t o c h a r a c t e r i z e t h e co n ve r g e n ce t o a m i n i m i z a t i o n . I n g e n e r a l , a m i n i m i z a t i o n i s c o n v e r g e d w h e n t h e d e r i va t i v e s a r e e q u a l (o r n e a r l y equal) to zero.

Evaluation of the Atomic Derivatives


Página 10 de 36

I n m o l e c u l a r m i n i m i z a t i o n , t h e r e su l t s o f m i n i m i z a t i o n i n t e r m s o f t h e a t o m i c d e r i va t i v e s m a y b e s u mm a r i z e d e i t h e r a s a n a v e r a g e , a r o o t m e a n s q u a re , o r t h e l a rg e st v a l u e o f d e r i v a t i v e s a s t h e f o l l o w i n g . An a v e r a g e d e r i va t i v e i s a n a v e r a g e o f t h e a b s o l u t e v a l u e o f t h e d e r i v a t i v e s, b e c a u s e t h e d i s t r i b u t i o n o f d e r i va t i v e s i s s ym m e t r i c a b o u t z e r o . A r o o t -m e a n - s q u a r e d e r i v a t i v e ( R MS ) w e i g h t s l a r g e r d e r i va t i v e s m o re ; t h e r e f o r e , i t i s l e s s l i k e l y t h a t a f e w l a rg e d e r i v a t i v e s e s c a p e f r o m t h e d e t e c t i o n , w h i c h c a n o c c u r w i t h s i m p l e a ve r a g e d e r i v a t i ve s . I n m o st s t u d i e s , t h e m a x i m u m d e r i v a t i v e i s u s e d t o e v a l u a t e t h e m i n i mi z a t i o n c o n v e r g e n c e . T h e re c a n n o t b e a mb i g u i t y a b o u t t h e q u a l i t y o f t h e m i n i m u m i f a l l d e r i v a t i ve s a re l e s s t h a n a g i v e n v a l u e . F o r i n s t a n c e , m i n i m i z i n g u n t i l m a x i m u m d e r i v a t i v e o f 1 . 0 k c a l / m o l / Å n o r m a l l y i s s u f f i c i e n t f o r r e l a x i n g o v e r l a p p e d a t o ms b e f o r e a d y n a m i c s ru n . T h e a c c e p t a b l e m a x i m u m d e r i v a t i v e , h o w e v e r , mu s t b e l e s s t h a n 0 . 0 0 1 kc a l / mo l i f a n o rm a l m o d e o f m i n i m i z a t i o n a n a l y s i s i s p e r f o r m e d .

Strategies for Selecting Minimization Algorithms N u m e r o u s a l g o r i t h m s a r e a va i l a b l e f o r g e o m e t r i c o p t i m i z a t i o n , s u c h a s s t e e p e s t d e sc e n t , c o n j u g a t e g r a d i e n t s , a n d N e w t o n R a p h s o n , a s d i s c u s se d a b o ve . T h e p r o p e r s e l e ct i o n o f a m i n i m i z a t i o n a l g o r i t h m m e a n s s e l e c t i n g t h e m o s t e f f i c i e n t o n e w i t h g o o d c o n v e r g e n c e . T h e c h o i c e o f t h e a l g o r i t h ms d e p e n d s o n t w o f a ct o r s , t h e s i z e o f t h e s y s t e m a n d t h e c u r re n t s t a t e o f o p t i m i z a t i o n . F o r e x a m p l e , w h e n t h e d e r i v a t i v e s a r e w e l l a b o v e 1 0 0 k ca l / m o l / Å , i t i s l i k e l y t h a t t h e s t r u c t u r e i s o u t s i d e t h e q u a d r a t i c r e g i o n o f t h e p o t e n t i a l e n e r g y s u r f a c e . S o , t h e a l g o r i t h m s ( c o n j u g a t e g ra d i e n t s a n d N e w t o n - R a p h so n ) t h a t a s s u m e t h e e n e r g y su r f a c e i s q u a d r a t i c c a n b e u n s t a b l e i n t h i s s i t u a t i o n . T yp i ca l l y , t w o m i n i m i za t i o n a l g o r i t h ms a r e co m b i n e d t o a c h i e v e t h e g o o d c o n v e r g e n c e e f f e ct i v e l y . A s a g e n e r a l r u l e f o r s e l e c t i n g m i n i mi z a t i o n a l g o r i t h m s , w h e n t h e d e r i v a t i ve i s l a r g e r t h a n 1 0 k c a l / m o l / Å , t h e s t e e p e s t d e s c e n t s a l g o r i t h m s h o u l d b e u s e d , a n d w h e n d e r i va t i v e i s l e s s t h a n 1 0 k c a l / mo l / Å , t h e c o n j u g a t e g r a d i e n t s a l g o ri t h m i s u s e d i f t h e m o l e c u l e i s l a r g e r t h a n 2 0 0 a t o m s a n d t h e N e w t o n - R a p h s o n a l g o r i t h m i f l e ss t h a n 2 0 0 a t o m s . T h e s t e e p e s t d e s c e n t a l g o r i t h m o f t e n i s t h e b e s t mi n i m i z e r t o u s e f o r t h e f i r s t 1 0 t o 1 0 0 s t e p s , a f t e r w h i c h t h e c o n j u g a t e g r a d i e n t s m i n i mi z e r c a n b e u se d t o c o m p l e t e t h e mi n i m i z a t i o n . T h e mo l e c u l a r s t r u c t u r e s b u i l t f r o m d e f a u l t b o n d a n d a n g l e g e o m e t r y n o r ma l l y a r e h e a v i l y d i s t o r t e d s t r u c t u r e s . I t i s re c o m m e n d e d t o u s e t h e s t e e p e s t d e s ce n t s w i t h n o M o rs e f u n c t i o n a n d n o c ro s s - t e r m o p t i o n s t o m i n i m i z e t h e s t r u c t u r e n e a r a m i n i m u m ( e . g . , ma x i m u m d e r i v a t i ve < 1 k c a l / m o l ) . T h e n , t h e c o n j u g a t e g r a d i e n t s a l g o r i t h m ca n b e u s e d w i t h o r w i t h o u t t h e Mo r s e p o t e n t i a l a n d c r o s s- t e r m a s n e e d e d t o d o mi n i m i z a t i o n . T h e N e w t o n -R a p h s o n m i n i m i z e r i s u s u a l l y r e s t r i c t e d t o s ma l l m o l e c u l e s , b e c a u s e i t r e q u i r e s a n a l yt i c a l l y c a l cu l a t i n g t h e s e c o n d d e r i va t i v e s . T h e a d v a n t a g e o f t h i s mi n i m i z e r i s i t s q u a d ra t i c c o n v e r g e n c e c l o s e t o t h e m i n i mu m . T h e N e w t o n - R a p h s o n m e t h o d ca n g i v e e x t r e me l y g o o d c o n v e rg e n c e t o a mu c h t i g h t e r c r i t e r i o n a f t e r ru n n i n g conjugate gradients to a near minimum. A s w e d e s c r i b e d a b o v e , m o l e c u l a r m e c h a n i cs i s a n a p p r o a c h o f m i n i m u m- e n e r g y co n f i g u r a t i o n c a l c u l a t i o n s b a se d o n t h e c e r t a i n f o r ce f i e l d a n d o n e o r m o r e m i n i m i z a t i o n a l g o r i t h m s o r mi n i m i z e r s. A c o m m o n l i m i t a t i o n o f cl a ss i c a l m o l e c u l a r m e c h a n i cs m i n i m i z a t i o n a l g o ri t h m s i s t h a t t h e m o l e c u l e s t e n d t o l o c a t e a t a l o c a l m i n i mu m c l o s e t o t h e s t a r t i n g c o n f i g u r a t i o n a n d n o t n e c e ss a r i l y a t t h e g l o b a l m i n i m u m , b e c a u s e t h e m i n i m i z e rs a r e s p e c i f i c a l l y d e s i g n e d t o i g n o re c o n f i g u r a t i o n s i f t h e e n e r g y i n c r e a s e s . S o , s u c h mi n i m a z a t i o n a l g o r i t h m s d o n o t p u s h a s ys t e m o v e r b a r r i e r s b u t , r a t h e r , d o w n i n t o t h e n e a re s t v a l l e y . T h i s p ro b l e m c a n b e s o l v e d u s i n g d y n a m i c s si m u l a t i o n s i n w h i c h k i n e t i c e n e r g y g e t s o ve r t h e l o c a l b a r r i e r , a s d e s c ri b e d i n t h e n e x t section. P.64

Molecular Dynamics Simulation Exploring Molecular Dynamics M o l e c u l a r d yn a mi c s h a s b e e n u s e d t o c o m p u t e t h e d y n a m i c s o f t h e m o l e c u l a r s y st e m , i n cl u d i n g t i m e - a ve r a g e d s t r u c t u r a l a n d e n e r g e t i c p r o p e rt i e s , s t r u c t u r a l f l u ct u a t i o n s , a n d c o n f o rm a t i o n a l t r a n s i t i o n s. T h e s u b s e q u e n t u s e o f m o l e c u l a r m e c h a n i c s e n e r g y m i n i m i z a t i o n s r e ve a l e d g r o u p s o f c o n f o r m a t i o n s. I n c o m p a r i so n , m o l e cu l a r m e c h a n i cs , o r e m p i r i c a l p o t e n t i a l e n e rg y f u n c t i o n s ( F i g . 3 . 4 ) , i g n o r e s t h e t i me e v o l u t i o n o f t h e s y st e m a n d , i n st e a d , f o cu s e s o n f i n d i n g p a r t i c u l a r g e o me t r i e s a n d t h e i r a s so c i a t e d e n e r g i e s o r o t h e r st a t i c p ro p e r t i e s ( 3 1 ) . The dynamics of a system may be simplified as the movements of each of its atoms. If the velocities and the forces acting on a t o m s c a n b e q u a n t i f i e d , t h e n t h e i r m o ve m e n t m a y b e s i mu l a t e d . D u r i n g t h e m o l e c u l a r d y n a m i c s p r o c e s s, t h e i n i t i a l c o n d i t i o n i s s p e c i f i e d b y t h e a n a l y t i c a l e x p r e s s i o n f o r t h e p o t e n t i a l e n e r g y o f a mo l e c u l a r s ys t e m t h a t i n c l u d e s c o o r d i n a t e s , e n e r g i e s, a n d a s e t of velocities for each atom. Then, a force is applied on each atom, which is described by Newton's equation of motion (Eq. 3.10): w h e re F i s t h e f o rc e o n a n a t o m , m i s t h e a t o m ' s m a s s , a n d a i s t h e a c c e l e r a t i o n . B e ca u se t h e n e g a t i v e o f t h e f i r st d e r i v a t i ve o f t h e p o t e n t i a l e n e r g y ( E ) w i t h r e s p e c t t o t h e c o o r d i n a t e s ( r ) g i v e s t h e f o r c e o n e a c h a t o m , N e w t o n ' s e q u a t i o n ( E q . 3 . 1 0 ) ca n b e u se d t o d e s c ri b e t h e m o t i o n o f a p a r t i c u l a r m o l e c u l e :

w h e re t i s t h e t i me a n d r r e p r e s e n t s t h e C a r t e s i a n c o o r d i n a t e s o f t h e a t o m. T h e f o r c e s a r e o b t a i n e d f r o m t h e e n e r g y e x p re s s i o n b y c a l c u l a t i o n o f t h e a n a l y t i c a l d e r i va t i v e s . T h e f o r ce s a r e a p p l i e d f o r a s m a l l t i m e s t e p ( ~ 1 0 - 1 5 s e c o n d s ) , a n d t h e a c c e l e r a t i o n i s c a l c u l a t e d f r o m N e w t o n ' s L a w ( E q . 3 . 1 1 ). T h e n , t h e v e l o c i t y a n d p o s i t i o n o f e a ch a t o m i s u p d a t e d t o a n e w v e l o c i t y a n d p o s i t i o n u si n g a n i n t e g r a t i o n a l g o r i t h m , a n d t h e f o rc e s a n d a c c e l e r a t i o n s a r e c a l c u l a t e d o n ce a g a i n a t t h e n e w a t o m i c p o si t i o n s . N e x t , t h i s p ro c e s s i s r e p e a t e d t o p r o d u c e a t r a j e c t o ry . T h e p o s i t i o n s o f e a c h a t o m i n t h e s ys t e m a re r e co r d e d i n t h e d y n a m i c s h i s t o r y f i l e . T h e s t ru c t u re s a re r e t r e a t e d a n d t h e n mi n i m i z e d w i t h mo l e c u l a r me c h a n i c s a n d a n a l y z e d l a t e r . A b o ve a l l , t h e s o l u t i o n o f E q . 3 . 1 1 u si n g a n e m p i r i ca l f i t t o t h e p o t e n t i a l e n e rg y s u rf a c e i s k n o w n a s m o l e c u l a r d y n a m i c s s i mu l a t i o n . I t i s t h e n p o s s i b l e t o a p p r o x i m a t e t h e m o v e m e n t o f a n a t o m a s h o r t t i m e i n t o t h e f u t u re , Δ t , u si n g a T a y l o r e x p a n s i o n :

This expression states that the position of an atom at some time in the future, (t + Δt), may be found from its initial position ( ), velocity ( ) and acceleration ( ). The new position is now in terms of known quantities, because molecular dynamics calculations keep track of atomic positions and velocities at each step. Keeping


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this in mind, two important factors need to be considered in using dynamics simulation, simulation temperature and sampling time steps, in order to make sure that all conformers are sampled during the simulation.

Temperature and Time Steps in Dynamics Simulation I t i s u n i q u e t h a t mo l e c u l a r d y n a m i cs c a n s i m u l a t e t h e m o l e cu l a r m o t i o n a t h i g h t e m p e r a t u r e . T h e s i m u l a t i o n o f m o l e c u l a r m o t i o n a t h i g h t e m p e r a t u r e i n c r e a s e s t h e p ro b a b i l i t y o f o v e rc o m i n g e n e r g y b a r r i e r s, g i v i n g t h e p o s s i b i l i t y o f s a m p l i n g a l l p o s s i b l e m i n i mu m c o n f o r ma t i o n s w i t h o u t b e i n g t ra p p e d i n a l o c a l e n e rg y m i n i mu m . h o w e v e r , t h e t e m p e r a t u re i s e x p r e s s e d i n t e r m s o f t h e a t o m i c v e l o ci t i e s , w h i c h a r e p r o p o r t i o n a l t o t h e ki n e t i c e n e rg y o f a s y st e m ( 3 1 , 4 2 ). T h e t e m p e r a t u r e s e t t i n g i s d i s c u ss e d i n t h e g i v e n m o l e c u l a r d yn a mi c s s i m u l a t i o n p r o t o c o l b e l o w . I n a d d i t i o n , t h e m o l e cu l a r d y n a m i c s s i m u l a t i o n r e q u i r e s u s i n g a va l u e o f t i me s t e p Δ t t h a t i s s m a l l e n o u g h t o co r r e c t l y s i m u l a t e t h e fastest atomic motions. Choosing the proper simulation time step is very important to make sure all conformers are sampled duri ng c a l c u l a t i o n . T h e C - H b o n d s v i b r a t e w i t h a p e r i o d o f a b o u t 1 0 - 1 4 s e c o n d s . T o s i m u l a t e t h e s e m o t i o n s, t h e t i m e s t e p m u s t b e r o u g h l y o n e - t e n t h o f t h a t , o r 1 0 t o 1 5 s e co n d s ( 1 f e mt o s e c o n d [ f s ] ) . S i mu l a t i o n s b e c o me u n s t a b l e w i t h v a l u e s m u ch l a r g e r t h a n t h i s 1 - f s t i m e s t e p . S i m u l a t i o n s a r e a l s o u n s t a b l e w h e n f o rc e s a re a p p l i e d f o r a l o n g e r t i m e i n t e r v a l ( Δ t ) t h a n t h a t f o r w h i c h t h e y a r e re a l l y v a l i d . F o r e x a m p l e , i f t h e a t t ra c t i ve f o r c e o f a c a rb o n a c t i n g o n a h y d r o g e n ( i n a C - H b o n d ) i s a p p l i e d f o r t o o l o n g a t i m e i n te r v a l o r f o r a l a rg e t i me s t e p , t h e h y d r o g e n w i l l h a v e b e e n r e p o s i t i o n e d t o o c l o s e t o t h e c a r b o n . D u r i n g t h e n e x t t i m e s t e p , a v e ry st ro n g r e p u l s i v e f o r c e w i l l l e a d t o t h e h y d ro g e n b e i n g r e p o si t i o n e d w e l l b e y o n d i t s t yp i c a l b o n d l e n g t h . T h i s o sc i l l a t o r y p ro c e s s w i l l c o n t i n u e u n t i l t h e e n e rg y o f t h e b o n d i s n o l o n g e r c o n s e r v e d a n d t h e m o l e c u l a r d yn a mi c s i n d i c a t e s a n e r r o r co n d i t i o n . A t y p i c a l m o l e c u l a r d yn a mi c s s i m u l a t i o n p r o t o c o l i s g i v e n b e l o w .

Molecular Dynamics Simulation Protocol A s d i s c u s s e d a b o v e , i n m o l e c u l a r d y n a m i c s , N e w t o n i a n e q u a t i o n s o f mo t i o n a re s o l v e d n u me r i c a l l y f o r a l l a t o m s a s a f u n ct i o n o f t i m e . A st a t i s t i c a l a v e r a g e w i t h t i m e i s o b t a i n e d b y a p p l y i n g i n i t i a l v e l o ci t i e s ( i . e . , k i n e t i c e n e r g y) , w h i c h a l l o w s t h e s y s t e m t o pa s s t h e e n e r g y b a r r i e rs a n d s a m p l e a l l t h e l o c a l m i n i m a . An e n e r g y c a l c u l a t i o n , h o w e v e r , h a s t o b e c a r r i e d o u t f o r e a c h o f a ve r y la r g e n u m b e r o f c o n f i g u r a t i o n s . O n l y m o l e c u l a r m e c h a n i cs c a n p r o v i d e t h e n e c e ss a r y c o m p u t a t i o n a l s p e e d . S o , mo l e c u l a r m e c h a n i c s a n d m o l e c u l a r d yn a mi c s o f t e n a r e u s e d t o g e t h e r t o a c h i e v e t h e t a rg e t c o n f o r me r s w i t h l o w e s t e n e r g y co n f i g u ra t i o n s . P.65 S e v e r a l m o l e cu l a r d y n a m i c s s i m u l a t i o n a p p r o a c h e s a r e a va i l a b l e , i n c l u d i n g r e g u l a r s i m u l a t i o n , c o n s t r a i n e d s i m u l a t i o n , a n d s i m u l a t e d a n n e a l i n g t e ch n i q u e s . I n a d d i t i o n , t h e s i mu l a t e d a n n e a l i n g d yn a mi c s s i m u l a t i o n a l s o w a s p o p u l a r i n c o m p u t a t i o n a l chemistry studies of proteins and drug molecules (34,44,45). A common experimental protocol has been widely used in molecular d yn a mi c s s i m u l a t i o n a s f o l l o w i n g ( 3 4 , 4 6 , 4 7 ) :

1.

B u i l d t h e t a rg e t p ro t e i n m o d e l . T h e i n i t i a l 3 D p ro t e i n s t r u ct u r e s ca n b e c o n s t r u c t e d f r o m a n N MR o r x -r a y c r ys t a l l o g r a p h i c s t r u c t u r e o r h o m o l o g y- p r e d i c t e d s t r u c t u r e . F o r e x a m p l e , o n e c a n i n co r p o r a t e t h e N MR e xp e ri m e n t a l d a t a i n t o t h e t a r g e t s t r u c t u r e b y a p p l yi n g t h e d i s t a n c e c o n s t r a i n t s a n d / o r d i h e d r a l c o n s t r a i n t s w i t h a s q u a r e - w e l l p o t e n t i a l a n d a f o r c e co n st a n t o f 5 0 k c a l / m o l / Å . I f i t i s t o s i m u l a t e t h e l i g a n d – p r o t e i n c o mp l e x , t h e l i g a n d sh o u l d b e p l a ce d i n t o t h e p u t a t i v e b i n d i n g s i t e .

2.

S e t u p t h e s i m u l a t i o n e n v i r o n m e n t . O n e c a n ch o o s e t h e s i m u l a t i o n e n vi r o n m e n t b y s e l e ct i n g t h e p ro p e r d i e l e c t r i c c o n s t a n t o r b y a d d i n g c o u n t e ri o n s a n d i mm e r s i n g t h e p ro t e i n i n t o a p e r i o d i c b o x o f w a t e r , e v e n i n l i p i d b i l a y e r s .

3.

P e r f o r m e n e rg y m i n i mi z a t i o n t o r e l a x t h e i n i t i a l m o l e c u l e . I t i s i m p o r t a n t t o r e m o ve a n y h i g h - e n e r g y a r t i f a c t s f r o m t h e construction process to avoid the fault simulation.

4.

Heat up the system, and equilibrate at the selected temperature (e.g., 1,000K). Typically, dynamics simulation will e q u i l i b r a t e a t t h e t e mp e ra t u r e f o r 1 t o 2 5 p i c o s e c o n d s ( p s ) t o a l l o w t h e t o t a l e n e r g y a n d c o re s t r u ct u r e s t o b e s t a b i l i z e d .

5.

B e g i n t h e m o l e c u l a r d yn a mi c s s i m u l a t i o n a t t h e d e s i r e d t e m p e r a t u r e . T y p i c a l l y , d y n a m i cs si m u l a t i o n i s p e r f o r m e d o v e r a p e r i o d o f t i me 2 0 0 p s , w i t h t h e s a m p l i n g t i m e s t e p o f 1 f s a n d t h e t r a j e c t o r i e s r e c o r d e d e ve r y 1 p s . T h e d yn a mi c s s a m p l i n g p e r i o d i s s e l e c t e d b a se d o n t h e t a r g e t p r o t e i n s i z e a n d t h e a v a i l a b l e c o m p u t e r c a p a c i t y ( 2 0 – 5 0 p s f o r l a r g e p r o t e i n s a n d 2 0 0 – 3 0 0 p s f o r s ma l l m o l e c u l e s ) . W i t h t h e t i m e s t e p o f 1 f s , a t o t a l o f 2 0 0 , 0 0 0 c o n f o r m a t i o n s o r f r a me s a re s a mp l e d d u r i n g t h e s i m u l a t i o n . T o re d u c e t h e v o l u m e o f t h e o u t p u t d a t a t o a m o r e m a n a g e a b l e l e v e l , co n f o r m e r s t r u c t u r e s w e r e r e c o r d e d a t 1 -p s i n t e r v a l s , t h u s r e d u c i n g t h e n u m b e r o f s t r u c t u r e s t o 2 0 0 f r a m e s .

6.

R e t r i e v e a n d e n e rg y - mi n i m i z e t h e sa m p l e d c o n f o r m e r s . T h e 2 0 0 c o n f o r me r s r e c o r d e d d u ri n g t h e d y n a mi c s r u n w e r e re t r i e v e d a n d e n e rg y - m i n i m i ze d w i t h a t w o - s t e p m i n i mi z a t i o n , u s i n g t h e s t e e p e s t d e s c e n t me t h o d f o r t h e f i r s t 1 0 0 i t e ra t i o n s a n d t h e n t h e c o n j u g a t e g r a d i e n t m e t h o d u n t i l t h e m a xi m u m d e ri v a t i v e w a s l e s s t h a n 0 . 0 0 1 k ca l / m o l .

F u r t h e r m o r e , t h e mo l e c u l a r d y n a m i cs s t u d y a l s o m a y b e p o s t p r o ce s s e d i n s e v e r a l w a y s . F i r s t , t h e s t u d y m a y a t t e m p t t o l o c a t e t h e l o w e s t - e n e r g y b i n d i n g m o d e s . I n t h i s ca s e , t h e t ra j e c t o r i e s o f t h e a t o ms ma y b e s a m p l e d a t 1 -p s i n t e r v a l s a n d t h e r e s u l t i n g structures then subjected to energy minimization. The resulting structures could be ranked according to their energy and used to e va l u a t e t h e e x p e c t e d b i n d i n g m o d e . A s e c o n d u s e w o u l d b e t o t r a c k t h e i n t e r a t o m i c d i s t a n c e s b e t w e e n r e s i d u e s o f i n t e r e s t . A t h i r d u s e i s t o d e r i v e q u a n t i t i e s , s u c h a s t h e f r e e e n e r g y o f b i n d i n g , co r r e l a t i o n f u n c t i o n s, d i f f u s i o n c o n s t a n t s , o r a p o t e n t i a l o f m e a n f o rc e . T h e f u l l p o w e r o f s t a t i s t i c a l t h e r m o d y n a m i cs ma y b e a p p l i e d t o a s i mu l a t i o n , b e ca u s e t h e t i me a v e r a g e d q u a n t i t i e s m a y b e u s e d t o a p p r o x i m a t e t h e f r e e e n e r g y. A n e x a mp l e o f s t r u c t u r e c a l c u l a t i o n o f a G -p r o t e i n - c o u p l e d r e c e p t o r ( G P C R ) j u x t a m e m b ra n e d o ma i n i s g i v e n h e r e t o i l l u s t r a t e t he m o l e c u l a r d yn a mi c s s i m u l a t i o n . T h e f o u r t h c yt o p l a s m i c d o m a i n , t h e s o - c a l l e d C - t e r m i n a l j u x t a m e m b r a n e s e g me n t , h a s b e e n i d e n t i f i e d i n n u me r o u s G p r o t e i n – c o u p l e d r e c e p t o rs a n d e x h i b i t s u n i q u e f u n c t i o n a l c h a r a c t e r i s t i c s . X i e a n d C h e n ( 4 8 ) a p p l i e d t h e m o l e c u l a r d yn a mi c s / m o l e c u l a r m e c h a n i cs s i m u l a t i o n w i t h N M R - d e f i n e d c o n s t r a i n t s t o s t u d y t h e 3 D s t r u c t u r a l c o n f o r m a t i o n s o f a synthetic peptide P.66


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C B 2 I 2 9 8 - K 3 1 9 f r a g m e n t o f G p ro t e i n – co u p l e d C B 2 r e c e p t o r ( F i g . 3 . 7 )

Fig. 3.7. NMR NOE-constrained MD/MM structure calculation of the polypeptides CB2I298-K319 (A), the backbone superimposition of 10 low energy conformers (B), the cylinder representation with a turn at the fifth residue arginine (C), and the ribbon display of the two helical segments (D), showing a curve side chain of Arg302 forming a salt bridge (green line) with Glu305. (See color plate.)

T h e i n i t i a l s t r u ct u r e w a s b u i l t b y u s i n g SY B Y L p r o g r a m a n d m i n i m i z e d t o r e l i e v e a n y o v e r l y s t r a i n e d c o o r d i n a t e s . M o l e c u l a r d yn a mi c s s i m u l a t i o n w a s c a r r i e d o u t u n d e r t h e K o l l m a n A l l A t o m f o r ce f i e l d a n d K o l l m a n c h a r g e s f o r 2 0 0 p s w i t h t i me s t e p s o f 1 f s a t 1 , 0 0 0 K . T h e N M R - d e t e r m i n e d N u c l e a r O v e r h a u s e r E f f e c t (N O E ) d i s t a n c e c o n s t r a i n t s , w i t h t h r e e b o u n d a r i e s o f 1 . 8 t o 2 . 8 Å ( s t r o n g ) , 1 . 8 t o 3 . 3 Å ( me d i u m ), o r 1 . 8 t o 5 . 0 Å (w e a k ) , w e r e a p p l i e d d u r i n g t h e d y n a m i c s s i m u l a t i o n w i t h a s q u a r e - w e l l p o t e n t i a l a n d a f o r c e c o n s t a n t o f 5 0 k c a l / m o l / Å . T h e d i s t a n c e r e s t r a i n t s w i l l b e l i n e a rl y r e l e a s e d i n 1 0 p s o f d y n a m i c s . A t o t a l o f 2 0 0 , 00 0 c o n f o r ma t i o n s o r f r a m e s w e r e s a m p l e d d u r i n g t h e si m u l a t i o n w i t h 1 - f s t i m e s t e p s , a n d t h e s a m p l e d c o n f o r m e r s t r u c t u r e s w e r e r e c o r d e d a t 1 - p s i n t e rv a l s . T h e 2 0 0 f r a me s r e c o r d e d d u r i n g t h e d y n a m i c s r u n w e r e r e t ri e v e d a n d mi n i m i z e d w i t h a t w o - st e p minimization, using the steepest descent method for the first 100 iterations and then the conjugate gradient method until the m a x i m u m d e r i v a t i v e w a s l e s s t h a n 0 . 0 0 1 kc a l / mo l . T h e s u p e r p o s i t i o n o f t h e b a c k b o n e s o f t h e 1 0 l o w - e n e r g y p e p t i d e c o n f o rm e r s o f t h e t a r g e t p e p t i d e i s i l l u s t r a t e d i n F i g . 3 . 7 B. T h e c a l c u l a t e d s t ru c t u re s s h o w t w o h e l i c a l p o r t i o n s, t h e s h o r t h e l i x s e g m e n t a nd a l o n g h e l i x d o m a i n , w h i c h a re a s s i g n e d t o t h e p a r t i a l s e g m e n t o f t r a n s me m b r a n e s e ve n ( T M 7 ) a n d t h e c yt o p l a s m i c d o m a i n ( H e l i x 8 ) , r e s p e c t i v e l y , a s d i s p l a y e d i n c y l i n d e r re p re s e n t a t i o n i n F i g . 3 . 7 C w i t h a t u r n a t t h e f i f t h r e s i d u e , a r g i n i n e . I n a d d i t i o n , t h e C B 2 I 2 9 8 K 3 1 9 p e p t i d e f r a g m e n t s h o w s a c u r v e s i d e c h a i n o f A r g 3 0 2 f o r m i n g a sa l t b r i d g e w i t h G l u 3 0 5 ( F i g . 3 . 7 D ) , w h i ch a t t r i b u t e s t o t h e s p e c i f i c i t y o f t h e s i g n a l t r a n s d u c t i o n a c t i v a t i o n b y t h e C -t e r m i n a l j u x t a m e m b r a n e re g i o n f o r t h e C B 2 re c e p t o r ( 4 8 ) .

Monte Carlo simulation U n l i k e t h e m o l e c u l a r d y n a m i c s t e c h n i q u e s t h a t e v a l u a t e f o rc e s t o d e t e r m i n e i n cr e m e n t a l a t o mi c m o t i o n s , Mo n t e C a rl o s i m u l a t i o n s i m p l y i m p o s e s r e l a t i ve l y l a r g e m o t i o n s o n t h e s y s t e m a n d d e t e r m i n e s w h e t h e r t h e a l t e r e d st ru c t u re i s e n e rg e t i c a l l y f e a s i b l e a t t h e t e m p e r a t u r e si m u l a t e d . B e c a u s e M o n t e C a r l o si m u l a t i o n s a m p l e s co n f o r m a t i o n sp a c e b y j u m p i n g a b ru p t l y f r o m c o n f o r ma t i o n t o c o n f o r ma t i o n r a t h e r t h a n e vo l vi n g s m o o t h l y t h r o u g h t i m e , i t c a n n o t p r o v i d e t i m e -d e p e n d e n t q u a n t i t i e s . I t ma y , h o w e ve r , b e mu c h b e t t e r t h a n m o l e c u l a r d y n a m i c s i n e s t i m a t i n g a v e r a g e t h e r m o d y n a m i cs p r o p e rt i e s f o r w h i c h t h e s a m p l i n g o f ma n y s ys t e m c o n f i g u r a t i o n s i s i m p o r t a n t . M o n t e C a r l o t e c h n i q u e s ( 4 9 , 5 0 ) a r e s t o ch a s t i c m e t h o d s i n w h i ch a s t a t i s t i c a l e n s e m b l e o f c o n f i g u r a t i o n s a r e g e n e r a t e d a n d t h e a v e r a g e s t r u ct u r a l f e a t u r e s a n d t h e r m o d y n a m i c s p r o p e r t i e s a r e o b t a i n e d b y w e i g h t e d a ve r a g e s. M o n t e C a r l o m a k e s u se o f B o l t z m a n n p ro b a b i l i t i e s, b u t n o t f o r ce s . T h e p r o b a b i l i t y P ( x ) o f a c o n f i g u ra t i o n i s ca l cu l a t e d as the Eq. 13:

w h e re t h e E i s t h e e n e r g y o f t h e c o n f i g u r a t i o n , k i s t h e Bo l t z ma n n c o n s t a n t , a n d T i s t h e t e m p e r a t u re . T h e f a c t o r e - E / k T i s t h e B o l t z m a n n f a ct o r . T h e e n e r g y i s c a l c u l a t e d f o r e a c h c o n f o r m e r o r c o n f i g u r a t i o n g e n e r a t e d , a n d a s t r u c t u r a l t h e r m o d y n a m i cs


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a ve r a g e i s o b t a i n e d a c c o rd i n g t o t h e B o l t z ma n n d i s t r i b u t i o n . U n l i k e e n e r g y m i n i m i z a t i o n s , Mo n t e C a r l o d o e s n o t f i n d a n e n e r g y m i n i m u m b u t , ra t h e r , sa m p l e s a n e n s e mb l e o f s t a t e s , j u s t a s t h e a c t u a l m o l e cu l a r s y s t e m d o e s , w i t h h i g h e r - e n e r g y s t a t e s b e i n g s a m p l e d a s t e m p e r a t u r e i n c r e a s e s . As o p p o s e d t o m o l e cu l a r d y n a m i c s t e c h n i q u e s , i n w h i c h t h e e q u a t i o n s o f m o t i o n a r e i n t e g r a t e d n u m e ri c a l l y a n d t h e s m a l l t i m e s t e p s a re n e c e s s a r y , i n Mo n t e C a rl o s i m u l a t i o n o n e ca n t a ke l a r g e r t i m e s t e p s , w h i c h a r e t h e n o p t i m i z e d i n d e p e n d e n t l y . M o n t e C a r l o c a l c u l a t i o n s h a v e b e e n a p p l i e d t o a w i d e v a r i e t y o f b i o l o g i c a l p r o b l e m s, e s p e c i a l l y t h e s t u d y o f s o l v e n t a r o u n d p e p t i d e s a n d p ro t e i n s ( 5 1 ) a n d p r o t e i n f o l d i n g (5 2 ).

Virtual Drug Screening Techniques and Applications T r a d i t i o n a l m o l e c u l a r m o d e l i n g m e t h o d s d i s c u s se d i n t h e p r e v i o u s s e c t i o n s d e a l w i t h a s i n g l e o r f e w e r n u m b e r o f m o l e c u l e s f o r s t r u c t u r a l p r o p e r t i e s a t h i g h r e s o l u t i o n . M o d e r n c o m p u t a t i o n a l c h e m i s t r y o r c h e m i n f o r m a t i c s t e n d s t o d e a l w i t h m a s s i v e a mo u n t o f m o l e c u l e s o r c o m p o u n d s f o r t h e i r b i o l o g i ca l b e h a v i o r s a t l o w e r r e s o l u t i o n . T h i s i s a c c o m p l i sh e d b y u si n g h i g h -t h r o u g h p u t v i r t u a l s c r e e n i n g t e c h n i q u e s , o r 3 D d a t a b a se s e a r c h me t h o d s . T h e t e ch n i q u e s a r e s i m i l a r , h o w e v e r , i n t h e i r a t t e m p t t o i m p ro v e t h e i r q u a l i t y a n d g e n e r a l i t y b y i n c l u d i n g a s m a n y o f t h e p r i n c i p l e s o f c o m p u t a t i o n a l c h e m i s t r y a s p o ss i b l e . F o r e x a mp l e , sc o r i n g f u n c t i o n s g e n e r a l l y a re b a s e d o n s i m p l i f i e d e m p i r i c a l f o rc e f i e l d s . P a r a me t e r s f o r t h e s c o r i n g f u n c t i o n s a r e i n cr e a s i n g l y d e ri v e d f r o m q u a n t u m m e c h a n i c a l c a l c u l a t i o n s f o r i m p ro v i n g t h e o v e r a l l a cc u r a c y . M o l e c u l a r d y n a m i c s o r M o n t e C a r l o s a mp l i n g s c h e m e s a re d e s i g n e d t o e x p l o r e a s m u c h o f t h e r e l e v a n t r e g i o n s o f c o n f o rm a t i o n s p a c e s a s p o s s i b l e . I n s h o rt , s c r e e n i n g t e c h n i q u e s a t t e mp t t o i n c o r p o r a t e a s m u c h o f t h e m o l e c u l a r mo d e l i n g me t h o d s d i s c u s s e d a b o v e a s p o ss i b l e a n d s t i l l g e t t h e st u d y c o m p l e t e d within an acceptable amount of time. Actually, the virtual screening and 3D database search techniques have been increasingly used in the pharmaceutical industry as l e a d g e n e r a t i o n , s e l e c t i o n , a n d o p t i m i z a t i o n a r e b e c o mi n g a k e y b o t t l e n e c k i n d r u g d i sc o v e r y . T h e r e a l - t i m e e x p e r i me n t a l h i g h t h r o u g h p u t d r u g s c r e e n i n g ( H T S ) i s t h e p ro c e s s t o a c c e l e r a t e d r u g d i sc o v e r y b y b i o l o g i c a l l y s c r e e n i n g l a rg e l i b r a r i e s o f compounds P.67 ( d r u g ca n d i d a t e s ) a g a i n s t t a r g e t s (r e c e p t o r o r e n z y m e s) u s i n g 9 6 - , 3 8 4 - , o r 1 , 5 3 6 - w e l l m i c r o p l a t e ( 2 5 0 µ L a t 1 – 1 0 µ M ) a t a r a t e o f t h o u s a n d s o f co m p o u n d s p e r w e e k . A t s c r e e n i n g r a t e s o f 5 0 0 , 0 0 0 co m p o u n d s p e r w e e k , h o w e v e r, a co s t o f $ 1 p e r w e l l i s s t i l l d i f f i c u l t f o r m a n y c o mp a n i e s o r a ca d e m i c i n s t i t u t e s t o a f f o r d o n a w e e k l y b a s i s ( 5 3 ) . T h e co s t s o f r o b o t i c e q u i p m e n t , c o m p o u n d p u r c h a s i n g , a ss a y d e v e l o p m e n t , a n d r a d i o a c t i v e ma t e r i a l d i sp o sa l s a l s o t h e m a i n i s s u e s c h a l l e n g i n g t h e H T S m e t h o d d e v e l o p m e n t and applications. Most importantly, the data show that only 1 in 100,000 HTS actives reaches the stage of becoming a drug c a n d i d a t e , w h i c h o f t e n a l s o f a i l s l a t e r b e c a u s e o f t h e l a c k o f g o o d p e rm e a b i l i t y , s o l u b i l i t y , o r A D M E p r o p e r t i e s . I n t h i s r e g a rd , c o m p u t a t i o n a l c h e m i s t r y a n d a k n o w l e d g e - b a s e d i n s i l i c o d e si g n a p p r o a c h c a n p l a y a n i mp o rt a n t r o l e i n d r u g s c re e n i n g . I t c a n b e c a r r i e d o u t a s a “ p r e s cr e e n ” o r “v i r t u a l s cr e e n ” b e f o r e co m m i t t i n g t o t h e c o st l y e x p e r i m e n t a l t e s t i n g o f l a r g e n u m b e r s o f c o m p o u n d s . T h e i n s i l i c o m e t h o d s w i l l n o t o n l y e x p e d i t e t h e d i sc o v e r y o f n e w l e a d s b u t a l s o g e n e r a t e a s t r u c t u r a l l y d i v e r s e s e t o f molecules or sublibraries of compounds that merit more detailed study. T h u s , t h e p r e s s u r e t o i d e n t i f y g o o d l e a d s a n d , t h e re f o r e , d r u g c a n d i d a t e s a t a n e v e r - i n cr e a s i n g p a c e h a s l e d t o t h e r a p i d a d v a n c e me n t o f m o l e c u l a r d a t a b a s e o r c h e m i n f o r m a t i c s t h a t m a n a g e s i n f o r m a t i o n a b o u t sm a l l m o l e cu l e s , i n c l u d i n g t h e s t o r a g e , d i s p l a y, a n d s e a r c h i n g o f c h e m i c a l st ru c t u re s a n d t h e i r p h y s i c a l a n d b i o l o g i c a l p r o p e rt i e s . I n g e n e r a l , f o u r c o m p u t e r v i rt u a l s c r e e n i n g t e c h n i q u e s a r e a v a i l a b l e , w h i c h a r e re l a t e d t o e a c h o t h e r i n t e rm s o f t h e a v a i l a b l e s t r u c t u r a l i n f o r m a t i o n f o r t h e c o m p o u n d s a n d t h e i r t a r g e t s : d o c k i n g r e c e p t o r – b a s e d d e s i g n , l i g a n d -b a se d d e s i g n , c o m b i n a t o r i a l c o m p u t a t i o n a l c h e m i st r y, a n d d e novo design techniques (2,3,4,5,6,7,8,9,10).

Table 3.2. Available Software Programs for Pharmacophore Identification and Ligand-Based Design Software

Pharmacophore Identification Programs and Resources

GALAHALD

Genetic Algorithm with Linear Assignment for Hypermolecular Alignment of Datasets (GALAHAD), Tripos, Inc. http://www.tripos.com/data/SYBYL/GALAHAD_9-7-05.pdf

DISCO and DISCOtech

DIStance COmparison for multiple pharmacophores generations, Based on clique detection. The conformational search is separated. Tripos, Inc. www.tripos.com/data/SYBYL/DISCOTech_072505.pdf

GASP

Genetic Algorithm Similarity Program. A flexible genetic algorithm. The pharmacophoric features are defined by the SYBYL package. Tripos, Inc. www.tripos.com/data/SYBYL/GASP_072505.pdf

Catalyst

An integrated environment for database management and querying tasks for drug discovery. Accelrys, Inc. http://www.accelrys.com/products/catalyst/

HipHop

HipHop matches the chemical features of compounds without considering activity. The resulting hypotheses can be used to iteratively search chemical databases Accelrys, Inc. http://www.accelrys.com/products/catalyst/catalystproducts/cathypo.htm

HypoGen

HYpothesis GENerator uses ligand activity values and incorporates them into the scoring function. The conformational search is separated. Accelrys, Inc. www.accelrys.com/products/catalyst/catalystproducts/cathypo.html

PHASE

PHASE applys a novel, tree-based partitioning algorithm to exhaustively identify spatial arrangements of functional groups that are common and essential to the


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biologic activity of a set of high affinity ligands. Schrodinger Inc. http://www.schrodinger.com/ MOE/pharmcophore modeling

Molecular Operating Environment (MOE). MOE's pharmacophore modeling module is to generate and use 3D geometric information to search for novel active compounds, particularly when no receptor geometry is available. Chemical Computing Group:http://www.chemcomp.com/software.htm

FlexS

Flexible Shape-Based Screening of Ligands http://www.biosolveit.de/FlexS/

MPHIL

Mapping Pharmacophores in Ligands. Relaxed MCS approach. A rigid alignment, based on clique detection and genetic algorithm. (141)

RAPID

Randomized Pharmacophore Identification. A rigid alignment based on mapping triangles of 3D atom coordinates. (142)

SCAMPI

Statistical classification of activities of molecules for pharmacophore identification. Handles large heterogeneous data sets. A random conformational search is combined. (144) Glaxo Wellcome, Inc. www.gsk.com/index.htm

(Adapted from Dror O, Shulman-peleg A, Nussinov R, Wolfson HJ: Predicting molecular interactions in silico: I. A guide to pharmacophore identification and its applications to drug design. Current Medicinal Chemistry 2004;11(1):71–90; with permission.)

In Silico Drug Design Programs and Resources V a r i o u s v i r t u a l s c r e e n i n g t e c h n i q u e s h a v e b e e n d e v e l o p e d a s a r e s u l t o f t h e t e m p t a t i o n t o p r e d i c t t h e g e o m e t ri e s o f P.68 b i o mo l e c u l a r c o m p l e x a n d t o d i s co v e r n o v e l l i g a n d s a s l e a d s f o r d ru g d e s i g n . C h o i c e s o f va r i o u s p r o g r a ms d e p e n d o n t h e t a r g e t g o a l s a n d p u r p o s e s o f t h e p e rf o r m e d c o m p u t a t i o n a l ch e mi s t r y , t h e c a p a c i t y o f c o m p u t e r f a c i l i t i e s , a n d t h e a v a i l a b i l i t y o f s o f t w a r e p ro g ra m s .

Table 3.3. Available Molecular Docking Software and Sources Program

Source Information

Surflex-Dock

Tripos, Inc. http://www.tripos.com/resources/fileroot/surflex_final2.pdf Scientific and Software Partner with UCSF Cancer Center & Biopharmics (Prof. Ajay N. Jain)

FlexX

BioSolveIT GmbH, Sankt Augustine, Germany www.biosolveit.de/FlexX/ (previous:http://catan.gmd.de/flexx)

LigandFit

Accelrys, Inc., www.accelrys.com/products/cerius2/cerius2products/c2ligandfit.html

GOLD

Cambridge Crytallographic Data Center, Cambridge, UK www.ccdc.cam.ac.uk/products/life_sciences/gold/

DOCK

University of California, San Francisco (Irwin Kuntz) dock.compbio.ucsf.edu/

AUTODOCK

The Scripps Research Institute (David Goodsell) www.scripps.edu/pub/olsonweb/doc/autodock

Glide

Schrödinger Inc. New York www.schrodinger.com/

Fred

OpenEye Scientific Software http://www.eyesopen.com/products/applications/fred.html

BiomedCAChe

CAChe Software http://www.cachesoftware.com/biomedcache\

MOE

Chemical Computing Group: http://www.chemcomp.com/software.htm


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eHITS

SimBioSys http://www.simbiosys.ca/

ICM

Molsoft LLC, http://www.molsoft.com/

Molegro Virtual Docker

Molegro ApS, http://www.molegro.com/products.php

WHAT IF

Centre for Molecular and Biomolecular informatics, Radboud University, NIJMEGEN, Netherlands http://swift.cmbi.kun.nl/whatif

(Adapted from Seifert MHJ, Wolf K, Vitt D. Virtual high-throughput in silico screening. Biosilico 2003;1:143–149; with permission.)

T h e s o f t w a r e p ro g ra m s u s e d f o r l i g a n d - b a s e d a p p r o a c h d e a l w i t h t h e p u r p o s e o f l i g a n d p h a rm a c o p h o r e i d e n t i f i c a t i o n s a n d 3 D d a t a b a s e s e a r ch p r o g r a m s . T h e a v a i l a b l e p h a r m a c o p h o re i d e n t i f i c a t i o n p r o g r a m s a r e s u m m a r i z e d i n T a b l e 3 . 2 . N e w p h a r ma c o p h o r e -g e n e r a t i o n p r o g r a m s , s u c h a s G A L A H A D ( G e n e t i c A l g o r i t h m w i t h L i n e a r A s si g n m e n t f o r H y p e r m o l e c u l a r A l i g n m e n t o f D a t a s e t s ) ( 5 4 ) , a r e e m e r g i n g w i t h i mp r o v e d co m p u t a t i o n a l a b i l i t y a n d c a p a ci t y . G AL A H A D a s su m e s s h a r e d p h a r ma c o p h o r e / s h a p e , e x p l o r e s “ a l l ” o f c o n f o r m a t i o n a l sp a ce , a n d g e n e r a t e s m u l t i p l e p a r t i a l - m a t c h c o n s t r a i n t s ( o r p h a r ma c o p h o r e ) f o r 3 D d a t a b a s e s e a r c h . G A L A H A D i s a n i m p r o v e me n t o ve r G A S P i n i t s m u l t i o b j e c t i ve s c o ri n g c a p a b i l i t y a n d a b i l i t y t o d e a l w i t h l a rg e n u m b e r s o f m o l e c u l e s , a n d i t i s a n i m p r o v e me n t o ve r D I S C O i n t h e s i m p l i c i t y o f i t s i n t e r f a c e a n d h i g h e rq u a l i t y m o l e cu l a r a l i g n m e n t s . O t h e r c o m m o n l y u s e d l i g a n d - b a s e d v i rt u a l s c r e e n i n g p r o g r a ms a r e U M O E ( 5 5 ) , F l e x S ( 5 6 ) a n d C a t a l y s t ( 5 7 , 5 8 ) , w h i c h a r e b a s e d o n a c t i v e l i g a n d p h a r m a c o p h o r e m o d e l s, a n d R O C S ( 5 9 ) , w h i c h i s b a s e d o n a c t i v e l i g a n d s h a p e . M o s t so f t w a re p r o g r a m s , h o w e ve r , i n v o l v e a l a r g e n u m b e r o f d o c k i n g t o o l s a n d s co r e f u n c t i o n s t h a t h a v e b e e n d e v e l o p e d f o r r e c e p t o r - b a s e d v i rt u a l sc r e e n i n g , a s su m m a r i ze d i n T a b l e 3 . 3 . T h e c o m m o n l y u s e d D O C K p ro g ra m ( 6 0 ) m o d e l s r e ce p t o r s p h e r e c e n t e r s t o l i g a n d a t o ms v i a e i t h e r r i g i d o r f l e x i b l e d o c ki n g t o b e sc o r e d b y e v a l u a t i o n o f e m p i r i c a l f o r c e f i e l d e n e r g y, u s i n g A M B E R ( 6 1 ) . S i mi l a r l y , A U T O D O C K ( 6 2 ) u s e s a si m u l a t e d a n n e a l i n g o r g e n e t i c a l g o r i t h m a n d A M B E R s co r i n g me t h o d . F l e x X (6 3 ), h o w e v e r , a p p l i e s t h e f r a g m e n t - b a s e d i n cr e m e n t a l b u i l d u p st ra t e g y a n d s c o re s t h e d o c k e d l i g a n d s b y a n e m p i r i c a l a l g o ri t h m b a s e d o n t h e B o h m f u n c t i o n ( 6 4 ) . T h i s s t r a t e g y b a s i c a l l y c o u n t s h y d ro g e n b o n d s , sa l t b ri d g e s , a r o m a t i c - r i n g i n t e r a c t i o n s , a n d h yd r o p h o b i c i n t e r a ct i o n s , a n d i t e f f e c t i ve l y re d u c e s t h e n u m b e r o f c o n f o r m a t i o n a l p o s s i b i l i t i e s (6 5 , 6 6 ) . G O L D ( 6 7 ) a p p l i e s a g e n e t i c a l g o r i t h m f o r g e n e ra t i n g l i g a n d -d o c k e d p o s e s , a n d t h e r e s u l t s a r e s co r e d b y a n e m p i r i c a l f u n ct i o n b a s e d o n i n t e r a ct i o n p o s s i b i l i t i e s d e r i v e d f r o m a t o m– a t o m c o n t a c t p r o b a b i l i t i e s i n t h e C a m b r i d g e S t r u c t u r a l D a t a b a s e ( C S D ) ( 6 8 ) . O t h e r p r o g r a m s , i n c l u d i n g G L I D E ( 6 9 ) , L i g a n d F i t (7 0 ), F F L D ( 7 1 ) , E u d o c k ( 7 2 ) , a n d I C M - D I S C O ( 7 3 ) , a l so a r e w i d e l y u s e d f o r i n s i l i co d r u g screening. I n r e v i e w i n g t h e s e d r u g a v a i l a b l e m o l e cu l a r d o c k i n g p r o g r a m s u s e d f o r i n s i l i c o s cr e e n i n g p l a t f o rm s ( T a b l e 3 . 3 ) , t h e i r a l g o r i t h ms a n d a d v a n t a g e s h a v e b e e n a d d r e ss e d i n t h e l i t e r a t u re ( 4 ). F o r e x a mp l e , D O C K ( 6 0 ) a n d F l e x i d o ck / U N I T Y ( 5 5 ) a l l o w u se r s t o d o c k t h e l i g a n d a s f l e x i b l e s t r u c t u r e s o n t o t h e t a r g e t e n z y me o r r e c e p t o r u s i n g t h e d i r e c t e d t w e a k a l g o r i t h m ( 5 5 ) . T h e s e m e t h o d s a r e v e r y t i m e - c o n s u m i n g , h o w e v e r , b e c a u s e s u c h “ o n - t h e -f l y ” c o n f o r m a t i o n a l P.69 s e a r c h e s m u s t b e r e p e a t e d f o r e a ch p h a r m a c o p h o r i c s e a r c h q u e r y . T h e t i m e w i l l i n c r e a s e s e v e r a l - f o l d w h e n v a n d e r W a a l s b u mp c h e c k i s i n cl u d e d ( 7 4 ) . F o r e x a mp l e , C h e m D B S - 3 D / C h e m i c a l D e si g n ( 7 5 ) , C a t a l y s t / M S I ( 5 7 , 7 6 ), a n d M e r c k F l e x i b a s e d a t a b a s e s ( 7 7 ) u se t h e m e t h o d t o g e n e ra t e a n u m b e r o f e n e r g e t i c a l l y r e a s o n a b l e r e p r e s e n t a t i v e c o n f o r ma t i o n s f o r e a c h st ru c t u r e a t t h e t i m e o f c o m p o u n d r e g i s t r a t i o n a n d s t o r e s t h e s e c o n f o r m e r s i n t h e d a t a b a s e . T h i s l a t t e r a p p r o a c h r e q u i r e s a s u f f i c i e n t co v e ra g e o f t h e a va i l a b l e co n f o r m a t i o n a l s p a c e s u c h t h a t a t l e a s t o n e c o n f o r m a t i o n o f e a c h a ct i v e c o m p o u n d i s s u f f i c i e n t l y c l o s e t o t h e a c t i v e c o n f o r ma t i o n t o b e c o n s i d e r e d a h i t b y a d a t a b a s e q u e r y . F O U N D A T I O N (7 8 ) a n d 3 D s e a r c h ( 7 9 ) h a ve d a t a b a s e q u e ri e s co n s i s t i n g o f p h a r ma c o p h o r e m o d e l s s u p p l e me n t e d b y s t e r i c c o n s t r a i n t s d e f i n e d f r o m p r o t e i n c r y s t a l l o g ra p h i c c o o r d i n a t e s . O n l y a s i n g l e c o n f o r ma t i o n o f a l i g a n d i s c o n s i d e re d , h o w e v e r, a n d F O U N D A T I O N o n l y e x a m i n e s a s i n g l e o r i e n t a t i o n o f a l i g a n d . T h e L U D I ( 8 0 ) s o f t w a r e p a c ka g e h a s b e e n a p p l i e d t o 3 D d a t a b a s e m i n i n g , b u t i s r e s t r i c t e d t o s i n g l e c o n f o r m a t i o n s o f s m a l l , r i g i d m o l e c u l e s . O t h e r p r o g r a ms , su c h a s C L I X ( 8 1 ) a n d F L O G ( 8 2 ) , e s s e n t i a l l y u s e t h e D O C K a p p r o a c h , a l t h o u g h i n F L O G , m u l t i p l e co n f o r m a t i o n s o f e a c h c o m p o u n d a r e e x p l i c i t l y st o r e d i n a d a t a b a se . S o , m a n y c h o i c e s f o r d o c k i n g p ro g ra m s a r e a va i l a b l e e i t h e r c o m m e r ci a l l y or free for academics (Table 3.3).

In Silico Design and Virtual Screening Techniques S e v e r a l c o m p u t a t i o n a l c h e m i s t r y a p p r o a c h e s a r e b a s e d o n t h e a va i l a b i l i t i e s o f t h e t a rg e t p r o t e i n s t r u c t u r e s a n d k n o w n a c t i v e ligands.

DOCK Receptor-Based Approach W h e n r e c e p t o r a n d l i g a n d s t r u c t u r e s a r e b o t h k n o w n , t h e d o c k i n g re c e p t o r -b a se d a p p ro a ch i s t h e m o s t i d e a l s i t u a t i o n ( 6 , 8 3 , 8 4 , 8 5 ) . T h e l i g a n d c a n b e d o c k e d i n t o t h e kn o w n r e c e p t o r s i t e a n d m o l e c u l a r me c h a n i c s u se d t o s i m u l a t e re c e p t o r – l i g a n d i n t e r a c t i o n s a n d d yn a mi c s . O n e ca n a d d re s s h i g h l y s p e c i f i c r e c e p t o r – l i g a n d i n t e r a c t i o n s u s i n g t h e s e t e c h n i q u e s, b u t e v e n h e r e , t h e re c a n b e surprises in the form of alternative modes of binding and conformational changes in the receptor structure. It is frequently n e c e ss a r y ( o r o f m o re i n t e r e s t ) t o st u d y t h e b i n d i n g o f t h o u s a n d s o f c o mp o u n d s a t l o w r e so l u t i o n r a t h e r t h a n f e w e r c o m p o u n d s a t high resolution. This often is the case when searching for lead compounds. The GRID approach (86) maps the binding site by s u p e ri m p o s i n g a g r i d a n d c a l c u l a t i n g t h e e l e c t r o s t a t i c s, h y d r o g e n - b o n d i n g s i t e s , o r l i p o p h i l i c i t y a t e a c h g r i d p o i n t . A m o n g t h e d o c k i n g -r e l a t e d p r o g r a m s d i s c u s se d a b o ve , c l a s s i ca l D O C K p ro g ra m u s e s a s i m i l a r a p p ro a ch ( 6 0 ) f o r s c o r i n g a n d a l s o p r o v i d e s o t h e r t o o l s f o r s co r i n g c o m p o u n d s , a t t e m p t i n g a l t e r n a t e o ri e n t a t i o n s , a n d p e r f o r mi n g g e o m e t ry o p t i m i z a t i o n t o i n c l u d e t h e f l e x i b i l i t y o f t h e l i g a n d . A g r i d - b a s e d a p p r o a c h d r a ma t i c a l l y r e d u c e s t h e a m o u n t o f c o m p u t e r t i m e r e q u i r e d . E a c h l i g a n d ' s i n t e r a c t i o n i s c o m p u t e d w i t h t h e l i m i t e d n u m b e r o f g r i d p o i n t s a n d n o t a l l o f t h e t a r g e t ' s a t o m s . S e v e r a l c o m mo n p r o g r a m s , i n c l u d i n g AU T O D O C K, G l i d e , L U D I , L i g a n d F i t , a n d F l e x X/ C S C o r e s, a l s o h a v e b e e n w i d e l y u s e d i n l i g a n d d o ck i n g a n d l e a d


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s c r e e n i n g s t u d i e s (6 ) ( T a b l e 3 . 3 ) .

Ligand-Based Approach W h e n t h e re c e p t o r s t r u c t u r e i s u n k n o w n b u t t h e l i g a n d s t r u c t u r e s a r e k n o w n , a l i g a n d - b a s e d a p p r o a c h i s u se d ( 7 , 8 7 , 8 8 , 8 9 , 9 0 ). T h i s s i t u a t i o n r e p r e se n t s t h e m o s t c o m m o n c a s e . A n e x t e n s i o n o f t h e Q S AR a p p r o a c h i s t a k e n t o s t u d y t h e a ct i v e l i g a n d s , a l so k n o w n a s p h a r ma c o p h o r e -b a se d d r u g d e s i g n . T h e p h a r m a c o p h o r e r e f e r s t o a n e n se m b l e o f s t e r i c a n d e l e c t r o n i c f e a t u r e s (o r 3 D a rr a n g e me n t o f t h e f u n c t i o n a l g r o u p s ) t h a t e n a b l e s a m o l e c u l e t o e x h i b i t a s p e c i f i c b i o l o g i c a l a c t i v i t y . T h e l i g a n d - b a s e d a p p r o a c h i s b a s i c a l l y a n i n d i r e ct m e t h o d o f p h a r m a c o p h o re i d e n t i f i c a t i o n s . I n g e n e r a l , p h a r ma c o p h o r e - b a s e d v i r t u a l s c r e e n i n g t e c h n i q u e s d e p e n d o n t h e a p p l i c a t i o n o f d e s c r i p t o r s o f m o l e c u l a r s t r u c t u re a n d p ro p e r t i e s ( 2 , 9 1 , 9 2 ), i n c l u d i n g s t r u c t u r e - o r d e sc r i p t o r - b a s e d q u e r i e s ( o r s i mi l a r i t y se a rc h i n t w o -d i me n si o n a l ( 2 D ) a n d 3 D su b st r u c t u r e s o r p h a rm a c o p h o r e mo d e l s ), f i n g e r p ri n t q u e r i e s ( o r b i n a r y b i t st ri n g - s e a r c h b a s e d o n T a n i m o t o c o e f f i c i e n t , 2 D / 3 D p h a r m a c o p h o r e f i n g e r p r i n t s ) , a n d c l u s t e ri n g a n d p a r t i t i o n i n g ( o r i n t e r m o l e c u l a r d i s t a n c e s i n c h e m i c a l r e f e re n ce s p a c e s a n d r e f e r e n c e f r a m e ). T h e d e t a i l s d e s c r i p t i o n s o f t h e s e t e c h n i q u e s h a v e b e e n re v i e w e d i n l i t e r a t u r e (2 , 7 , 8 7 ) a n d s u mm a r i z e d i n T a b l e 3 . 2 .

Combinatorial-Based Approach W h e n r e c e p t o r a n d l i g a n d s t r u c t u r e s a r e b o t h u n k n o w n , v i r t u a l c o m b i n a t o r i a l c h e m i s t r y a p p r o a c h e s a r e u se d . I n t h i s c a s e , c o m p u t a t i o n a l c h e m i s t r y i s u s e d b o t h t o g e n e ra t e s t r u c t u r e s a n d i n p a r a l l e l t o p e r f o r m c h e m i ca l s i m i l a ri t y a n d d i v e rs i t y s e a r c h a n a l y s i s b e f o r e a n d a f t e r co m b i n a t o r i a l ch e mi s t r y - b a s e d e x p e ri m e n t a l H T S . F o r e x a m p l e , t h e co m b i n a t o r i a l ch e mi s t r y s o f t w a r e p a c k a g e f r o m A c c e l r y s a n d T r i p o s co m p a n i e s p r o v i d e s t h e u n i q u e f e a t u r e s t o p r e a n a l y z e a n d s e l e c t d i v e r s e b u i l d i n g b l o c k s f o r t h e t a r g e t l i b r a r i e s t o h e l p d i s co v e r s m a l l m o l e c u l e d r u g t h e r a p i e s . T h i s p ro m i s e s a ma x i m u m r a n g e o f d r u g - l i ke c o m p o u n d s a n d i n c r e a s e s t h e p o t e n t i a l o f f i n d i n g a c t i v e l e a d s f o r t h e t a rg e t s . T h e d e v e l o p m e n t s o f c o m b i n a t o r i a l c h e m i s t r y l i b r a r y h a v e b e e n d e s c r i b e d i n t h e l i t e r a t u r e (9 3 , 9 4 , 9 5 ) .

De Novo Design-Based Approach W h e n r e c e p t o r s t r u c t u r e i s kn o w n a n d l i g a n d s t r u c t u re s a re u n k n o w n , d e n o v o d e s i g n - t e c h n i q u e s a r e u s e d ( 1 0 , 9 6 , 9 7 ) . I n t h i s s i t u a t i o n , t h e r e i s a v a i l a b l e i n f o r m a t i o n a b o u t t h e t a r g e t r e c e p t o r , o r a si m i l a r r e c e p t o r, b u t n o e x i s t i n g l e a d s t h a t c a n i n t e r a c t w i t h t h e a c t i v e r e c e p t o r si t e s . O n e ca n u s e r e c e n t l y d e v e l o p e d d e n o v o d e s i g n - t e ch n i q u e s t o p r o p o s e n e w l i g a n d s , w h i c h a r e complementary to the active site. These techniques use 3D searching of large databases to identify small molecule fragments that c a n i n t e r a c t w i t h s p e c i f i c s i t e s i n t h e r e c e p t o r , b r i d g i n g f ra g me n t s w i t h t h e c o r r e c t s i z e a n d g e o m e t ry , o r f ra m e w o r k s t r u c t u r e s t h a t c a n s u p p o r t f u n c t i o n a l g ro u p s a t f a v o r a b l e o r i e n t a t i o n s . F o r e x a mp l e , p r o g r a m s s u c h a s G R O W ( 9 8 ) o r L E G EN D ( 9 9 ) P.70 u se “ s e e d ” s t r u c t u r e s t h r o u g h d e n o v o d e s i g n o f a c o mp o u n d t o f i t t h e b i n d i n g s i t e a n d a d d f u n c t i o n a l g ro u p s t o o p t i m i z e t h e u s e o f p o s s i b l e b i n d i n g s i t e s. T h e s e t o o l s h a v e b e e n m o s t e f f e c t i v e w h e n u se d t o s u p p o r t r a t h e r t h a n t o a u t o m a t e d r u g d e s i g n e f f o rt s (10).

Fig. 3.8. A workflow of in silico virtual screening process: receptor-based and ligand-based approaches. (See color plate.)

Practical Aspects of Virtual Screening Applications G i v e n t h e r e c e n t a d v a n c e s i n s u p e r c o m p u t e r c l u s t e r s / C P U h o r se p o w e r f o r n e w c o m p u t e - i n t e n s i v e a l g o r i t h m s a s w e l l a s t h e a va i l a b i l i t y o f p u b l i c a n d p r o p r i e t a r y d a t a b a s e s, i n s i l i c o d r u g d e s i g n a n d v i r t u a l s c r e e n i n g m e t h o d s h a v e b e e n a d v a n c e d t o s e a r c h l a r g e c o m p o u n d d a t a b a s e s o r h y p o t h e t i ca l v i r t u a l l i b ra r i e s i n s i l i c o b y c o m p u t e r a n a l ys i s a n d s e l e c t i o n o f a l i m i t e d n u m b e r o f c a n d i d a t e m o l e c u l e s l i k e l y t o b e a c t i v e a g a i n s t a b i o l o g i c a l t a r g e t . T h e g e n e r a l m e t h o d s o f i n si l i c o d e s i g n o r v i r t u a l s c r e e n i n g ca n b e i l l u s t ra t e d p r a c t i c a l l y a s i n F i g . 3 . 8 : p ro t e i n s t r u c t u r e -b a se d c o m p o u n d s c r e e n i n g o r d o c k i n g r e c e p t o r - b a s e d d e s i g n ( 1 0 0 , 1 0 1 ) , a n d c h e m i c a l - s i m i l a r i t y s e a rc h i n g b a s e d o n s m a l l m o l e c u l e s o r l i g a n d - b a s e d d e s i g n ( 1 0 2 ). B a s i c a l l y , t h e v i r t u a l s c r e e n i n g e x p e r i me n t a l p ro t o c o l ( F i g . 3 . 8 ) c o u l d b e d e s cr i b e d a s f o l l o w s :

1.

B u i l d v i rt u a l co m p o u n d d a t a b a s e .


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2.

G e n e r a t e t h e d a t a b a s e se a rc h q u e r y , e i t h e r l i g a n d p h a r ma c o p h o r e h y p o t h e s e s o r r e c e p t o r - b i n d i n g p o c k e t s.

3.

Refine and modify the query through training databases.

4.

S e a r c h t h e t a r g e t c o mp o u n d d a t a b a s e s f o r n o v e l l e a d s w i t h n e w ch e mi c a l s c a f f o l d s a n d b e t t e r b i n d i n g a c t i v i t i e s

5.

Carry out the hit selection based on defined criteria.

6.

B i o - v a l i d a t e t h e h i t l e a d s v i a H T S e x p e r i me n t s a n d f u n c t i o n a l a s s a y s .

7.

C o n d u c t l e a d o p t i m i z a t i o n v i rt u a l l y a n d e x p e r i m e n t a l l y t o i m p ro v e t h e n o v e l l e a d b i o a c t i v i t y .

Build Virtual Compound Libraries T h e f i r s t s t e p o f v i r t u a l s c r e e n i n g i s t o b u i l d v i r t u a l c o m p o u n d c o l l e c t i o n s t h a t c a n b e u s e d f o r i n s i l i c o vi r t u a l s c re e n i n g . P h a r m a c e u t i c a l c o mp a n i e s t re a t t h e d a t a b a se s o f c o mp o u n d s t h e y h a v e sy n t h e s i ze d o r p u rc h a s e d a s a v a l u e d c o r p o r a t e a s s e t . T h e N a t i o n a l I n st i t u t e s o f H e a l t h ( N I H ) r e c e n t l y c o n s t r u c t e d a p u b l i c c o m p o u n d l i b r a r y , P u b C h e m , t h a t c o n s i s t s o f m o r e t h a n 1 1 m i l l i o n c o mp o u n d s ( h t t p : / / p u b c h e m . n c b i . n l m . n i h . g o v / ) . I n g e n e r a l , t w o ma j o r c o mp o u n d l i b r a ri e s a r e n e e d e d i n v i r t u a l s c r e e n i n g .

Construct known compound training databases A t r a i n i n g d a t a b a s e i s r e c o m me n d e d t o b e c o n s t r u c t e d f o r t h e p u r p o s e s o f o p t i m i z i n g t h e q u e r y h yp o t h e s e s t o i m p r o v e t h e h i t a cc u r a c y i n d a t a b a se s e a r c h . S u c h a t r a i n i n g d a t a b a se u s u a l l y c o n t a i n s a t h o u sa n d c o m p o u n d s t y p i c a l l y , co n si s t i n g o f 9 8 0 r a n d o m m o l e c u l e s a n d 2 0 k n o w n a c t i v e l i g a n d s . F o r e xa m p l e , u s e r s c a n e xa m i n e a n d re f i n e t h e h y p o t h e t i c p h a r m a c o p h o re ( o r q u e r y ) a g a i n s t t h e t e s t d a t a b a s e i n t e rm s o f h i t p r e c i s i o n r a t e , f a l s e - n e g a t i v e ra t e , a n d f a l s e - p o s i t i v e ra t e . T h e p r o c e s s i s v e r y P.71 i m p o r t a n t . i t a l s o h e l p s t o e v a l u a t e t h e q u a l i t i e s o f p h a r m a co p h o r e q u e r i e s a n d m o l e cu l a r a l i g n m e n t s g e n e ra t e d o r t h e b i n d i n g pocket defined in the target protein before searches in the large target database.

Construct target compound databases T h e 3 D t a rg e t v i r t u a l c o m p o u n d d a t a b a s e c a n b e c o n s t r u c t e d t h ro u g h s i n g l e m o l e c u l a r e n t r y o r s y st e m a t i c a l l y i m p o r t i n g f r o m o t h e r p u b l i c o r c o m m e r c i a l co m p o u n d c a t a l o g s o u r c e s ( i n e i t h e r S F D , M O L 2 , o r S m i l e s f o r m a t s ) ( T a b l e 3 . 4 ). F o r e x a mp l e , c o m p o u n d l i b ra r y c a t a l o g s c a n b e c o n v e r t e d f r o m t h e 2 D d a t a f o r ma t i n t o a 3 D s e a rc h a b l e c o m p o u n d d a t a b a s e b y t h e C O N C O R D p r o g r a m ( 1 0 3 ) o r D a y l i g h t R u b i c o n p r o g r a m ( 1 0 4 ) u s i n g a r t i f i c i a l i n t e l l i g e n c e a n d g e o m e t r y o p t i mi z a t i o n . I n a d d i t i o n , s t r u ct u r a l l y d i v er s e s u b l i b ra r y o r t a r g e t - s p e c i f i c l i b r a ri e s a l so c a n b e c o n s t r u c t e d f r o m t h e l a r g e v i rt u a l l i b r a ri e s o f m i l l i o n s o f co m p o u n d s . F o r e xa m p l e , t h e N I H P u b C h e m d a t a b a s e c o n s i s t s o f a p p ro x i m a t e l y 1 1 mi l l i o n c o m p o u n d s . I t w i l l b e re a so n a b l e t o c r e a t e o n e o r s e v e r a l s u b l i b ra r i e s f r o m t h e P u b C h e m d a t a b a s e a n d t h e n e v a l u a t e t h e m b y u s i n g s o f t w a r e p r o g r a m s , s u c h a s T r i p o s ' D i v e r se S o l u t i o n (1 0 5 ) , S e l e c t o rs (1 0 6 ) , o r t h e T i m T e c ' s D i v e r s i t y p r o g r a m ( 1 0 7 ) . T h e d i v e r se s u b l i b r a r i e s a r e c r e a t e d t o r e p r e s e n t t h e p a r e n t l i b r a ri e s w i t h t h e s a me d i v e r si t i e s b u t m u c h s m a l l e r d a t a s e t s ( u s u a l l y ~ 1 0 – 2 0 % c o m p o u n d s ) . T h e s u b l i b r a r i e s a r e c r e a t e d m a i n l y f o r t h e p u rp o se o f e n h a n c i n g t h e c o m p u t e r s cr e e n i n g . A l t h o u g h t h e v i r t u a l sc r e e n i n g i s m u c h f a s t e r t h a n t h e e x p e r i me n t a l H T S , e sp e ci a l l y w i t h t h e h i g h - h o r s e p o w e r c o m p u t a t i o n a l f a c i l i t i e s n o w a v a i l a b l e , i t w i l l s t i l l t a k e a m o n t h t o s e a r ch t h r o u g h a 3 D database with millions of compounds.

Table 3.4. Available Chemical and Drug Compound Databases Database Name MDL®ACD

No. of Compounds 435,000

Company/Web site MDL®- Available Chemicals Directory. MDL Information System, Inc.

www.mdli.com/products/experiment/available_chem_dir/index.jsp MDL®SCD

3.5 million

MDL® Screening Compounds Directory (formerly ACD-SC). MDL Information System, Inc.www.mdli.com/products/experiment/screening_compounds/index.jsp

MDL®PCD

1.5 million

MDL® Patent Chemistry Database. MDL Information System, Inc. www.mdli.com/products/knowledge/patent_db/index.jsp

MDL®MDDR

132,726

MDL®-Drug Data Report. MDL Information System, Inc. www.mdli.com/products/knowledge/drug_data_report/index.jsp

MDL®CMC

8,473

MDL® Comprehensive Medicinal Chemistry MDL Information System, Inc. www.mdl.com/products/knowledge/medicinal_chem/index.jsp

ZINC

2.67 million purchasable

Free database of commercially-available compounds. University of California @ San Francisco http://blaster.docking.org/zinc/, non-commercial database for virtual screening

NCID

213,628

National Cancer Institute Databases, NCI http://dtp.nci.nih.gov/docs/3d_database/Structural_information/structural_data. html distributed by MDL Information System, Inc.


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www.mdli.com/products/knowledge/cancer_db/index.jsp CNPD

57,000

Chinese nature product database. Neotrident Technology Ltd. And Shanghai Institute of Materia Medica. www.neotrident.com/newpage/

ACX

500,000

Available Chemicals Xchange. CambridgeSoft Corporation. http://chemfinder.cambridgesoft.com/

CLP

260,000

ComGenex Library Portfolio (ComGenex, Ltd) www.comgenex.com

Menai Organics

4,000

Ryan Scientific, Inc. www.ryansci.com/

Pubchem

5,404,047

NCBI http://pubchem.ncbi.nlm.nih.gov/

BioSpecs

240,000

SPECS, Inc. http://www.specs.net

Chembank

110,000

Harvard university http://chembank.broad.harvard.edu/

CSD

400,000

Cambridge Crystallographic Data Center http://www.ccdc.cam.ac.uk/

(Adapted from Shen J, Xu X, Cheng F, et al. Virtual screening on natural products for discovering active compounds and target information. Curr Med Chem 2003;10:2327–2342; with permission.)

I n a d d i t i o n , a q u a l i t y - c o n t r o l p r o c e d u r e i s r e q u i r e d t o e n su r e t h e 2 D t o 3 D s t r u c t u r e - c o n v e rt i n g a c c u r a c y a n d d a t a i n t e g r i t y a s w e l l a s f u r t h e r d a t a p o r t a b i l i t y . T h i s i n cl u d e s r a n d o m l y s e l e c t i n g t h e c o n v e r t e d c o mp o u n d s P.72 a n d e xa m i n i n g t h e m f o r t h e mo l e c u l a r st ru c t u r e ( b o n d t y p e s / l e n g t h s , b o n d a n g l e s, a t o m t y p e s / ch a rg e s, a n d c a r b o n c h i r a l i t y) , 3 D m o l e c u l a r g e o m e t r y ( q u i c k e n e r g y m i n i m i z a t i o n , i f n e e d e d ) , t h e co m p o u n d c a t a l o g n u m b e r s v e rs u s t h e i r o r i g i n a l n u m b e r s a n d t h e r e f e r e n c e s o u r ce , a n d t h e d a t a e x p o r t f e a t u r e s t o e n s u r e p o r t a b i l i t y o f t h e d a t a f o r s h a r i n g .

Build 3D Structure of the Target Protein K n o w l e d g e o f t h e 3 D s t r u c t u re o f a t a r g e t p ro t e i n i s o f t e n a p r e r e q u i s i t e f o r t h e re c e p t o r - b a s e d v i r t u a l s c r e e n i n g a n d b u i l d i n g a r e l i a b l e 3 D p r o t e i n s t r u c t u r e i s a f i r s t i mp o rt a n t s t e p f o r a s u c ce s s f u l r e ce p t o r - b a s e d d e si g n . I n g e n e r a l , p r o t e i n s t r u c t u r e s a r e m a i n l y d e r i ve d f r o m x - r a y, N M R , o r h o m o l o g y m o d e l s . T h e e x p e r i m e n t a l s o u r c e s o f 3 D s t r u c t u r e s a r e a v a i l a b l e f r o m C a m b r i d g e S t r u c t u r a l D a t a b a s e ( C S D ) ( ~ 2 5 0 , 0 0 0 x - ra y s t r u c t u r e s ) a n d t h e B r o o k h a v e n P r o t e i n D a t a B a n k (P D B ; ~ 1 7 , 0 0 0 s t r u c t u r e s o f p ro t e i n s d e f i n e d b y x - r a y , N M R , a n d c o m p u t a t i o n s ) . S e ve r a l r e vi e w s o f x - r a y c r y s t a l l o g ra p h y p r o v i d e e xc e l l e n t o v e r v i e w s o f l i g a n d f r e e a n d l i g a n d - b o u n d p r o t e i n c ry s t a l l o g r a p h i c d a t a f o r d r u g d e s i g n ( 1 0 8 ) . T h e x - r a y c r y s t a l l o g r a p h i c m e t h o d , h o w e v e r , i s l i m i t e d b y t h e a v a i l a b l e p u r e c r y s t a l s o f t h e t a rg e t p ro t e i n s , p a r t i c u l a r l y f o r l a rg e m e m b ra n e p r o t e i n s . T h e G P C R m e m b r a n e p ro t e i n s d o n o t g e n e r a l l y c r y s t a l l i z e i n a f o rm s u i t a b l e f o r x - ra y c r y st a l l o g r a p h y . I n a d d i t i o n , t h e c r y s t a l p r o t e i n c o n f o r m a t i o n s o m e t i m e s m a y b e d i s t o r t e d b y c r y st a l p a c k i n g f o rc e a n d m a y n o t b e e x a c t l y r e l e va n t t o i t s i n v i v o c o u n t e r p a r t . B e c a u s e o f t h e d i f f i c u l t i e s i n c r y st a l l i z i n g m e m b r a n e - b o u n d p r o t e i n f o r x -r a y c ry s t a l l o g r a p h y , t h e o n l y G PC R t h a t h a s b e e n c r y s t a l l i z e d w i t h h i g h re s o l u t i o n xray is rhodopsin (109).

Fig. 3.9. Three-dimensional G protein–coupled CB2 receptor structure (right) constructed by homology and multiple sequence alignment method (left), including the seven transmembrane helices (cylinders, I–VII) and loop regions (ribbons) (See color plate.) (From Xie XQ, Chen JZ, Billings EM. 3D structural model of the G protein–coupled


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cannabinoid CB2 receptor. Proteins: Structure, Function, and Genetics 2003;53:307–319; with permission.)

T h e N M R st ru c t u re s o f t a r g e t p r o t e i n s g e n e ra l l y a re d e t e r m i n e d i n a s o l u t i o n o r me m b r a n e - l i k e e n v i r o n m e n t , w h i c h i s s i m i l a r t o t h e p h y s i o l o g i c a l s t a t e o f m o s t sy s t e m s . O f t e n , h o w e v e r , t h e N M R -d e t e r m i n e d p r o t e i n s t ru c t u re s a re s t u d i e d a t l o w p H , w h e r e a s t h e r e s u l t i n g s t r u c t u re s s o m e t i me s c a n s h o w s i g n i f i c a n t p H - d e p e n d e n t v a ri a t i o n a n d t h e p r o t e i n b a c k b o n e ma y d i s p l a y c o n s i d e r a b l e motion and unfolding at different pH values (110). C o m p u t e r h o m o l o g y m o d e l i n g p r o v i d e s a n a l t e r n a t i v e w a y t o p r e d i ct 3 D p r o t e i n s t r u c t u r e . T h e h o m o l o g y - g e n e r a t e d m o d e l s u s u a l l y a re r e f i n e d f u r t h e r b y i n c o r p o r a t i n g e x p e ri m e n t a l c o n s t r a i n t s m e a s u re d b y x - r a y a n d N M R . A c t u a l l y , i f t h e s e q u e n c e i d e n t i t y b e t w e e n t h e t a r g e t p r o t e i n a n d t e m p l a t e i s s u f f i c i e n t l y h i g h ( > 5 0 % ), t h e i n si l i c o d e s i g n a n d v i r t u a l s c re e n i n g r e s u l t s u s i n g homology-predicted 3D models have been shown to be similar to those when x-ray structures are used (111). The homologyp re d i c t e d 3 D m o d e l s h a v e p r o v e n t o b e s u c ce s s f u l i n d o c ki n g r e c e p t o r- b a s e d st u d i e s o r re c e p t o r -b a se d v i r t u a l s c r e e n i n g . A n e xa m p l e i n F i g u r e 3 . 9 i s g i v e n h e r e t o i l l u s t r a t e t h a t t h e co m p u t e r h o m o l o g y a n d m u l t i p l e se q u e n c e a l i g n m e n t t e c h n i q u e s w e r e u se d t o b u i l d a 3 D r e c e p t o r s t r u ct u r e ( 3 4 , 4 8 ) . X i e e t . a l . c o n s t r u c t e d t h e 3 D s t r u c t u r a l m o d e l o f c a n n a b i n o i d r e c e p t o r C B 2 b y u s i n g m u l t i p l e s e q u e n c e a l i g n m e n t o f 1 0 h o mo l o g o u s G P C R s ( 3 4 ) . A l i g n m e n t s w e r e a n a l yz e d w i t h m u t a t i o n s c o r e s , p a i rw i se h yd r o p h o b i c i t y p r o f i l e s , a n d K y t e - D o o l i t t l e p l o t s. T h e 3 D mo d e l o f t h e t ra n s me m b r a n e s e g m e n t w a s g e n e r a t e d b y ma p p i n g t h e C B 2 s e q u e n c e o n t o t h e h o m o l o g o u s re s i d u e s o f t h e x -r a y c r ys t a l l o g r a p h i c d a t a o f rh o d o p s i n s t r u c t u re . T h e e x t ra - a n d i n t r a ce l l u l a r lo o p r e g i o n s o f t h e C B 2 w e re g e n e r a t e d b y s e a r c h i n g f o r h o m o l o g o u s C α b a c k b o n e P.73 s e q u e n c e s o f p u b l i s h e d s t r u c t u r e s i n t h e B r o o k h a v e n P r o t e i n D a t a b a n k ( P D B ). R e s i d u e s i d e c h a i n s w e r e p o s i t i o n e d t h r o u g h a c o m b i n a t i o n o f ro t a m e r l i b r a r y s e a r c h e s , s i mu l a t e d a n n e a l i n g a n d m i n i m i z a t i o n . O t h e r su c c e s s f u l h o mo l o g y m o d e l s h a v e b e e n u s e d i n d o ck i n g a p p l i c a t i o n s a n d h a v e s u cc e s s f u l l y r e s u l t e d i n t h e d i s c o v e r y o f n o v e l h i t s, i n c l u d e r e t i n o i c a c i d r e c e p t o r ( 1 1 2 ) , t h y ro i d h o r m o n e r e c e p t o r ( 1 1 3 ) , C K2 k i n a s e ( 1 1 4 ) , S A R S (s e v e r e a cu t e r e s p i r a t o ry s y n d r o m e ) p r o t e a s e ( 1 1 5 ) , C D K4 k i n a s e ( 1 1 6 ) , a n d S r C sH 2 ( 1 1 7 ) f o r t h e a p p l i c a t i o n o f d e n o v o d e s i g n m e t h o d s ( 1 1 7 ).

Predict the Binding Sites of the Target Proteins A f t e r d e t e r mi n a t i o n o f t h e 3 D t a r g e t p r o t e i n s t r u c t u r e , i d e n t i f i c a t i o n o f t h e t a r g e t b i n d i n g s i t e i s t h e n e x t i m p o r t a n t s t e p , w h i ch o f t e n d e p e n d s o n w h e t h e r t h e l i g a n d – r e c e p t o r c o mp l e x i s k n o w n . A c c o r d i n g l y , b i n d i n g s i t e s g e n e r a l l y a r e re f e r re d t o a s c a v i t i e s o r g ro o ve s ( i . e . , t h e d e p r e s s i o n i n t h e p ro t e i n s u r f a c e ). I f t h e l i g a n d – t a rg e t c o m p l e x s t r u c t u r e s a r e a v a i l a b l e t h r o u g h x - r a y o r N M R , i d e n t i f i c a t i o n o f t h e b i n d i n g s i t e i s s t r a i g h t f o r w a r d . T h e e x p e r i m e n t a l s i t e - d i r e c t e d mu t a g e n e s i s re s u l t s w i l l a l so b e ve r y i n f o r m a t i v e t o c h a r a c t e r i z e t h e r e s i d u e s i m p l i ca t e d i n l i g a n d b i n d i n g o r f u n ct i o n . O f t e n , h o w e v e r , l i m i t e d m u t a g e n e se s d a t a a r e a v a i l a b l e a b o u t t h e b i n d i n g s i t e s, a n d l i t t l e i s k n o w n a b o u t t h e p r o t e i n o r t h e p r o t e i n c o m p l e x , w h i c h r e q u i re s u si n g c o m p u t a t i o n a l t e ch n i q u e s t o d e t e c t t h e s e s u r f a c e f e a t u r e s t o p r e d i c t t h e p o t e n t i a l b i n d i n g s i t e s . S e v e r a l g e o m e t r y - b a s e d c o m p u t a t i o n a l me t h o d s a re a v a i l a b l e , i n c l u d i n g Si t e I D (1 1 8 ) , L I G S I T E ( 1 1 9 ) , AP R O P O S ( A u t o m a t i c P R O t e i n P o c k e t S e a r c h ) ( 1 2 0 ) , a n d P A S S (P u t a t i v e A c t i ve S i t e w i t h S p h e r e s ) (1 2 1 ) . O t h e r p ro g ra m s , s u c h a s G R I D ( 8 6 ) , va n d e r W a a l s – F F T ( 1 2 2 ) , a n d X SI T E ( 1 2 3 ) , w e r e u s e d t o s e a r c h f o r c o m p l e m e n t a r i t i e s b e t w e e n t h e l i g a n d f u n c t i o n a l g r o u p s a n d s i t e f u n c t i o n a l i t y a n d t o i d e n t i f y t h e p h y s i c o ch e mi c a l p ro p e r t i e s o f t h e d i f f e r e n t c a v i t i e s t o i d e n t i f y t h e s i t e o f i n t e re s t s . I n t h e 3 D p r o t e i n s t r u c t u r e co n st ru c t i o n a n d b i n d i n g s i t e p r e d i ct i o n a b o v e , d r u g b i n d i n g p o c k e t ( s) s h o u l d b e m a p p e d o u t f o r 3 D d a t a b a s e s e a r ch u s i n g t h e d o c k i n g p r o g r a m . A n e x a m p l e i s g i v e n h e re t o i l l u s t r a t e t h e c o m p u t e r p r e d i ct i o n o f t h e p r o t e i n b i n d i ng p o c k e t s. X i e e t a l . (3 4 ) a p p l i e d t h e M O L C A D s o l v e n t - a cc e s s i b l e c h a n n e l su r f a ce s c a l c u l a t i o n (1 2 4 ) t o p r e d i c t t h e b i n d i n g s i t e of t h e ca n n a b i n o i d C B 2 r e c e p t o r , a s sh o w n i n F i g u r e 3 . 1 0 . T h e re s u l t w a s c o n f i r m e d b y T r i p o s Si t e I D p r o g r a m ( 1 1 8 ) . T h e p re d i c t e d b i n d i n g s i t e a l so i s c o r r e l a t e d w e l l w i t h k n o w n s i t e m u t a g e n e s i s d a t a ( e x ce p t P h e 8 7 ) , a s s h o w n i n F i g . 3 . 1 0 . T h e d a t a a l s o s h o w e d a n a m p h i p a t h i c b i n d i n g c o n t o u r (F i g . 3 . 1 0 ) : T h e h y d r o p h i l i c c e n t e r ( b l u e ) i s f ra m e d b y p o l a r r e si d u e s , w h e re a s t h e h y d r o p h o b i c c l e f t (b r o w n ) i s s u r r o u n d e d b y a r o m a t i c re s i d u e s . T h e c o m p u t a t i o n a l c h e m i s t r y a p p r o a c h o f f e rs a n a l t e r n a t i v e a v e n u e f o r u n d e r s t a n d i n g t h e r e c e p t o r– l i g a n d i n t e r a c t i o n s i n t e r ms o f h y d r o g e n -b o n d i n g , h y d r o p h o b i c c e n t e r s , c h a r g e d c e n t e r s, a n d s t e r i c interactions that are defined in the pharmacophoric feature identification process and for assisting the in silico virtual screening.

Derive Active Pharmacophore Models F o r a l i g a n d - b a s e d d e s i g n a p p r o a c h , g e n e r a t i n g r e l i a b l e p h a r m a c o p h o re h y p o t h e s e s i s a p re r e q u i s i t e f o r t h e 3 D p h a r ma c o p h o r e d a t a b a s e s e a r ch . S e v e r a l a p p r o a c h e s a r e a v a i l a b l e f o r g e n e r a t i n g p h a r m a co p h o r e m o d e l s, i n c l u d i n g p r o g r a m s t o d e r i v e t h e a c t i v e p h a r ma c o p h o r e m o d e l s o r “v i r t u a l re c e p t o r ” ( e . g . , 3 D Q S A R / C o MF A (1 2 5 ) a n d A A A [ A c t i v e A n a l o g A p p r o a c h ] ( 1 2 6 ) ) a n d p r o g r a ms t o g e n e r a t e h y p o t h e t i c a l p h a r m a co p h o r e q u e r i e s ( e . g . , D I SC O ( 1 2 7 ) a n d G A L L A H AD ( 5 4 ) ) f o r d a t a b a s e se a rc h e s o f t h e n e w c h e m i c a l s c a f f o l d s t h a t m a t c h t h e t a r g e t p h a r m a c o p h o r e s . An e x a m p l e o f t h e p h a r m a c o p h o re g e n e ra t i o n s i s g i ve n b e l o w . T h e C o F M A (C o mp a ra t i v e M o l e c u l a r F i e l d A n a l ys i s ) i s s u p e r i o r t o c l a s si c a l Q S A R i n m a p p i n g o u t 3 D Q S AR m o d e l s . T h e C o M F A p ro g ra m ( 1 2 8 ) p r o vi d e s t o o l s t o p o s t u l a t e a b i o l o g i c a l a c t i v e co n f o r m a t i o n a n d t o e s t a b l i sh a s e t o f a l i g n me n t r u l e s ( 1 2 9 ) t o s u p e ri m p o s e t h e m o l e cu l e s u n d e r co n si d e r a t i o n . I t w i l l g e n e r a t e a g r i d o r l a t t i ce a s a b o x o f p o i n t s a r o u n d t h e m o l e c u l e s a n d c a l c u l a t e t h e e l e c t r o s t a t i c a n d st e r i c f i e l d s t h a t e a c h mo l e c u l e e x e r t s o n a p ro b e a t o m p o s i t i o n e d a t e a c h l a t t i c e p o i n t . T h e n , a s t a t i s t i c a l a n a l y s i s o f t h e d a t a u s i n g p a r t i a l l e a s t sq u a r e s s t a t i s t i cs i s m a d e t o d e r i v e a l i n e a r co r r e l a t i o n ( 3 D Q S A R ) b e t w e en t h e c a l c u l a t e d v a l u e s a n d t h e i n p u t b i o l o g i c a l d a t a . S u b s e q u e n t l y , i t va l i d a t e s t h e p r e d i c t a b i l i t y o f t h e d e r i v e d m o d e l b y u s i n g c r o s s v a l i d a t i o n ( r 2 ) . F i n a l l y, a c t i v e l i g a n d C o M F A m o d e l s a r e e s t a b l i sh e d t h a t c a n b e u s e d t o g u i d e n o v e l l i g a n d d e si g n a n d t o p r e d i c t t h e b i o l o g i c a l a c t i v i t i e s . C o M F A a n a l y s i s h a s b e e n u s e d t o s t u d y t h e p h a rm a c o p h o r i c r e q u i r e m e n t s o f c a n n a b i n o i d a n t a g o n i s t s ( 1 2 5 ) (F i g . 3 . 1 1 ) , t o s t u d y t h e e f f e ct o f s h a p e o n b i n d i n g o f s t e r o i d s t o c a r r i e r p r o t e i n s ( 1 3 0 ), t o d e d u c e a c t i v e si t e g e o m e t r i e s o f a n g i o t e n s i n - c o n v e r t i n g e n zy m e ( 1 3 1 ) , a n d t o a n a l y z e a s e t o f m u s c a ri n i c a g o n i s t s ( 1 3 2 ) . T h e D I S C O ( D I St a n c e C o mp a ri s o n ) p ro g ra m ( 1 3 3 ) o f t e n i s u s e d t o g e n e ra t e m u l t i p l e p h a r m a c o p h o r e m o d e l s b y i d e n t i f y i n g c o m m o n p h a r m a c o p h o ri c f e a t u r e s (e . g . , H - b o n d d o n o r a t o m s , H -b o n d a cc e p t o r a t o ms , c h a r g e d c e n t e r s , a n d c e n t e r s o f m a s s o f h yd r o p h o b i c r i n g s ) f o r a g i v e n se t o f a c t i ve c o mp o u n d s , p r o d u c i n g o p t i m a l l y a l i g n e d s t r u ct u r e s, a n d e x t r a c t i n g t h e k e y f e a t u r e s o f t h e p h a r m a co p h o r e s . T h e n , t h e s e p h a r m a c o p h o r e h y p o t h e s e s c a n b e co m p a r e d , r e f i n e d , a n d u s e d t o g u i d e l e a d g e n e r a t i o n a n d o p t i m i z a t i o n a n d i n p e r f o r mi n g 3 D se a rc h e s o f d a t a b a se s f o r n e w l e a d s . D I S C O h a s b e e n u s e d i n p h a r m a c o p h o r e g e n e r a t i o n d u r i n g s t u d i e s o f m u sc a r i n i c M 3 r e c e p t o r a n t a g o n i s t s (1 3 4 ) , m u s c a r i n i c a g o n i s t s (1 3 5 ) , a n d m e l a t o n i n a n a l o g u e s ( 1 3 6 ) .


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O t h e r p h a r m a co p h o r e i d e n t i f i c a t i o n a p p r o a c h e s ( 7 ) i n c l u d e G A L A H A D ( 5 4 ) , G A S P ( 1 3 7 ) , H i p H o p (1 3 8 ) , H y p o G e n ( 1 3 9 ) , P H A SE ( 1 4 0 ), M PH I L ( 1 4 1 ), R A P I D ( 1 4 2 ), M O E ( 1 4 3 ) , a n d S C A M P I ( 1 4 4 ), a s w e l l a s A A A ( 1 2 6 ) a n d e n s e m b l e d i s t a n ce g e o m e t ry ( 1 4 5 ) . P.74 T h e g e n e r a t e d v a r i o u s p h a rm a c o p h o r e mo d e l s w i l l b e u s e d a s h y p o t h e t i c q u e r i e s i n t h e d a t a b a s e s e a r c h f o r l e a d d i s c o v e ry T o a c h i e v e a s u c c e s s f u l d a t a b a se s e a r c h , o n e m u s t e n su r e t h e q u a l i t y o f t h e d e r i v e d p h a r m a co p h o r e m o d e l s b y c o n s i d e r i n g t h e f o l l o w i n g i s s u e s w h i l e c o mp o si n g a 3 D d a t a b a se q u e r y :

Fig. 3.10. MOLCAD-predicted CB2-binding pocket surrounded by active amino acid residues, showing an amphipathic contour, hydrophilic center (blue), and hydrophobic cleft (brown). The site-directed mutagenesis– detected binding residues are color-coded in terms of their distance to the pocket (magenta > yellow > green > blue) as the interaction weakens. (See color plate.)

1. 2.

Which functional groups or set of topological constraints should be chosen? W h a t a v e ra g e d i st a n c e s h o u l d s e p a r a t e t h e p h a rm a c o p h o r i c f e a t u re s , o r b y w h a t a v e ra g e a n g l e s h o u l d t h e f e a t u r e s b e a rr a n g e d ?

3.

W h i c h t y p e o f g e o m e t ri c r e l a t i o n s h i p s s h o u l d b e i m p o s e d , a n d w h a t a r e t h e i r t o l e r a n c e s (e . g . , i n t e r a t o mi c d i s t a n c e s , a n g u l a r relationships between two pendant substituents, and the angle of a lone pair to the plane of a phenyl ring)?

These factors often have influence on the false-positive or false-negative hits during the database search, as discussed later.

3D Database Search Protocol T h e b a s i c r a t i o n a l e s o f 3 D d a t a b a se s e a r c h me t h o d s a re t h e s a m e f o r e i t h e r l i g a n d -b a se d o r r e c e p t o r- b a s e d a p p r o a c h e s , a s r e v i e w e d i n l i t e r a t u re s ( 2 , 6 , 5 3 ), w h e r e a s t h e s e a r c h p r o t o c o l s m a y n e e d t o b e c h a n g e d a s d i f f e r e n t a p p r o a c h e s a r e u s e d . I n g e n e r a l , t h e d o c k i n g r e c e p t o r - b a s e d v i rt u a l sc r e e n i n g t e c h n i q u e s a r e b a s e d o n t h e a c t i v e d e f i n e d r e c e p t o r b i n d i n g p o ck e t s a s q u e r i e s , w h e re a s t h e l i g a n d p h a rm a c o p h o r e - b a s e d se a rc h i s b a s e d o n t h e a ct i v e l i g a n d p h a r m a c o p h o re m o d e l s o r s h a p e s a s database queries. Although 3D structures of target proteins are becoming increasingly available as search templates, small m o l e c u l e v i rt u a l sc r e e n i n g s t i l l d o mi n a t e s t h e f i e l d . T h i s i s p a r t i c u l a rl y t r u e f o r t h e re c e p t o r s l a c k i n g 3 D s t r u c t u r e s , e x c e p t f o r P.75 r h o d o p s i n . I n l i g h t o f p a g e l i m i t a t i o n s , w e w i l l i l l u s t r a t e t h e l i g a n d p h a r m a c o p h o r e d a t a b a s e s e a r c h a n d u s e t h e U N I T Y p ro g ra m a s an example.

Fig. 3.11. CoMFA contour maps for arylpyrazole antagonists of cannabinoid receptor subtypes CB1 (A) and CB2


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(B). Sterically favored areas (contribution level, 80%) are shown in green. Sterically unfavored areas (contribution level, 20%) are shown in yellow, and positive-potential favored areas (contribution level, 80%) are shown in blue. Positive-potential unfavored areas (contribution level, 20%) are shown in red. Plots of the corresponding CoMFAcalculated and experimental values of binding affinity (given as pKi) of arylpyrazole compounds at CB1 (AA) and CB2 (BB) receptor, respectively are shown as well. (See color plate.) (Adapted with permission from Chen J, Han X, Lan R, et al. 3D-QSAR studies of arylpyrazole antagonists of cannabinoid receptor subtypes CB1 and CB2. A combined NMR and CoMFA approach. J Med Chem 2006;49:625–636; with permission.)

F o r a l i g a n d - b a s e d s e a r c h , a t y p i c a l s e a r c h q u e r y c o n s i s t s o f t h e f o l l o w i n g t y p e s o f i n f o r m a t i o n : a 2 D p a t t e r n ( r e p r e se n t i n g i m p o r t a n t g ro u p s i n t h e m o l e c u l e ; e . g . , C C (C = O ) N d e f i n e s t h e b a c k b o n e o f a n a mi n o a c i d ) , 3 D g e o m e t ri c f e a t u r e s (e . g . , n a me = h b o n d ; a t o ms = 1 , 2 , 3 ; d i s t a n c e = 1 . 5 7 ; a n g l e = 1 2 0 . 0 ; d i h e d r a l = 1 8 0 . 0 ) , a n d 3 D c o n s t r a i n t s (d e f i n e t h e r e l a t i o n s h i p b e t w e e n g e o m e t r i c f e a t u r e s a n d e x c l u d e d vo l u m e s) . T h e c o mm o n d a t a b a s e s e a r c h p r o t o c o l i s g i ve n h e r e a s a n i l l u s t r a t i o n :

1.

A 2 D s i m i l a r i t y s e a r ch i s f i rs t ca r r i e d o u t t o f i n d s p e c i f i c f ra g me n t s i n t h e d a t a b a s e ( e . g . , C C ( C = = O )N f o r a n a m i n o a c i d ) . W i t h t h e d e f i n e d p h a r ma c o p h o r e p a t t e r n s , w e w i l l s e a r c h t h e d a t a b a s e u si n g s u b - / s u p e r s t r u c t u r e s e a r c h , s i mi l a r i t y se a rc h , T a n i m o t o c o e f f i c i e n t ( 1 4 6 ), T v e r s k y s e a r c h (1 4 7 ) , a n d s o o n . T h e s e a r c h re t u r n e d h i t l i s t w i l l b e g r o u p e d i n t o a m o l e c u l a r s p r e a d s h e e t f o r f u rt h e r s t u d i e s . T h e 2 D d a t a b a s e s e a r c h e s u s u a l l y a r e c a r r i e d o u t a s i n i t i a l sc r e e n i n g , f o l l o w e d b y 3 D searches.

2.

A 3 D g e o m e t r i c s e a r c h i s t h e n p e r f o r m e d t o l o o k f o r re l a t i o n s h i p s b e t w e e n f e a t u re s i n a m o l e cu l e . T h e i n i t i a l 2 D p a t t e r n s e a r c h t a k e s i n t o a c c o u n t o n l y t h e co m p o s i t i o n o f t h e m o l e c u l e , s u c h a s a t o m t y p e s a n d b o n d t y p e s. T h e 3 D p o r t i o n i s o n l y c o n c e r n e d w i t h t h e g e o me t r i c re l a t i o n s b e t w e e n t h e f e a t u re s ( e . g . , d i s t a n c e , a n g l e , e x cl u si v e va n d e r W a a l s v o l u m e , o ve r l a p p i n g v a n d e r W a a l s v o l u m e , a n d co n st ra i n t s ) . A 3 D s e a r ch m a k e s u s e o f t h e c o o r d i n a t e s s t o re d i n t h e d a t a b a s e f o r d e t e r m i n i n g w h e t h e r co n st r a i n t s a r e sa t i s f i e d .

3.

A f l e x i b l e 3 D s e a r c h i s s u b s e q u e n t l y co n d u c t e d b y a l t e ri n g t h e g e o m e t r y o f t h e m o l e c u l e t o d e t e r m i n e a n y p o s s i b l y s a t i s f i e d g e o m e t r i c c o n s t r a i n t s w i t h o u t h a v i n g t o s a v e e v e r y p o s s i b l e c o n f o r m a t i o n i n t h e d a t a b a s e . T h e co n f o r m a t i o n a l f l e x i b i l i t y c a n b e e x p l o r e d b y d e t e r m i n i n g t h e g e o m e t r i e s a t s e a r ch t i m e w i t h o u t h a v i n g t o s a v e e v e r y p o s s i b l e c o n f o r m a t i o n , w h i c h i s c o n s i d e re d t o b e a u n i q u e f e a t u re f o r t h e U N I T Y d a t a b a s e c o m p a r e d w i t h o t h e r 3 D d a t a b a s e s ( 1 3 4 , 1 4 8 ) .

4.

T h e n e xt s t e p i s d a t a b a s e se a rc h h i t e v a l u a t i o n a n d s e l e c t i o n . C o m p o u n d s t h a t h a v e a t l e a s t o n e c o n f o r m a t i o n sa t i s f y i n g t h e g e o m e t r i c r e q u i r e m e n t s a n d p o ss e s s f u n c t i o n a l g r o u p s r e s i d i n g w i t h i n t h e r e s p e c t i v e t o l e r a n c e sp h e r e s o f t h e p h a r ma c o p h o r i c f e a t u re s a r e c o n s i d e r e d t o b e “ h i t s” ( i . e . , p o t e n t i a l c a n d i d a t e s f o r b i o l o g i ca l t e s t i n g ) . A n u m b e r o f a d d i t i o n a l c r i t e r i a a re u s e d i n t h e s e l e c t i o n o f c o m p o u n d s f o r b i o l o g i c a l e v a l u a t i o n a n d e x p e r i m e n t a l v a l i d a t i o n s t o a c h i e v e m a x i m u m e f f i c i e n c y i n t h e d i s c o v e ry o f l e a d c o m p o u n d s . T h e h i t s e l e ct i o n s t r a t e g y i s i n i t i a l l y e s t a b l i s h e d o n t h e b a s i s o f L i p i n s k i ' s r u l e s ( 1 4 9 ). H i t s e l e c t i o n c ri t e r i a f o r a g o o d l e a d c o m p o u n d h a v e t h e f o l l o w i n g p r o p e rt i e s : s i m p l e c h e m i c a l s t r u c t u r e , e a s y sy n t h e s i s , c a l c u l a t e d l o g P ( C l o g P ) o f l e s s t h a n 5 (or measured logP 0.7) extraction ratio drugs. Table 9.8 lists the representative drugs with their hepatic or extraction ratios. The influence of blood flow and intrinsic clearance of an organ on the clearance of a drug is determined by the extraction ratio of the drug. The clearance of a drug (Cl) also may be viewed as a proportionality constant relating the elimination rate of a drug to its plasma concentrations at a given time and is expressed as

where –Cp is the average plasma concentration of a drug at a time that corresponds to the rate of elimination. It follows from an earlier equation (Eq. 9.54) that

where Q and ER have been previously defined and, because the drug elimination follows a first-order process, clearance is independent of the drug concentrations or the dose administered.

Table 9.8. Hepatic and Renal Extraction Ratios of Selected Drugs and Metabolites Low (< 0.3)

Intermediate (0.3–0.7)High (> 0.7)

Hepatic extractiona Carbamazepine

Aspirin

Alprenolol

Diazepam

Quinidine

Arabinosyl-cytosine

Digitoxin

Codeine

Desipramine

Indomethacin

Nortriptyline

Doxepin

Phenobarbital

Isoproterenol

Phenytoin

Lidocaine

Procainamide

Meperidine

Salicylic Acid

Morphine

Theophylline

Nitroglycerin

Tolbutamide

Pentazocine

Valproic Acid

Propoxyphene


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Warfarin

Propranolol

Atenolol

Cimetidine

(Many) Glucuronides

Cefazolin

Cephalothin

Hippurates

Chlorpropamide

Procainamide

(Some) Penicillins

Digoxin

(Some) Penicillins

(Many) Sulfates

Furosemide Gentamicin Lithium Phenobarbital Sulfisoxazole Tetracycline aAt least 30% of the drug is eliminated by this route.

P.236 The total body clearance of a drug the from blood is equal to the ratio of the overall elimination rate to drug concentration (Eq. 9.54), where the overall elimination rate is comprised of the sum of the elimination processes occurring in all organs and the removal of a drug in all its forms. Therefore, the overall clearance, (Cl)s, represents the renal clearance (i.e., unchanged form of a drug) and the metabolic clearance (i.e., removal of a drug as metabolic by kidney). It also is very useful to keep in mind that the clearance can be expressed as the product of the apparent volume of distribution (V) and the elimination rate constant (K) for drugs that exhibit characteristics of one compartment model. Thus,

Renal Clearance Drug elimination occurs by renal excretion and an extrarenal pathway, usually hepatic metabolism. Renal clearance is defined as the proportionality constant between the urinary excretion rate and the plasma concentration:

where (dXm/dt) is the average urinary excretion rate(mg/hr); (Cl)r is the renal clearance (mL/hr), and p– is the plasma drug concentration. Equation 9.57, however, presents practical difficulty in measuring renal clearance, because the plasma drug concentration changes:


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where Cpdt corresponds to the area under the plasma concentration–time curve (AUC). The urine collection interval (dt) is composed of many such very small increments of time, and the amount of drug excreted in a collection interval is the sum of the drug amount excreted in each small time interval line. Then,

where (Xu)∞ is the total amount excreted in the urine and (AUC)0∞ is the area under the plasma concentration–time curve from t = 0 to t = ∞. To account for all the administered drugs in the urine when the drug is administered intravenously often is not possible. This may be caused by the excretion of some of the drug via an extrarenal route, excretion of a metabolite via an extrarenal route, further biotransformation of primary metabolite into chemical forms that are not identified by the analytical method used, or formation of unknown and unidentified primary metabolites. If the total amount of metabolites can be identified in the urine, then one can determine the metabolite clearance using the following equation:

where (Xmu)∞ is the amount of matabolite in the urine at time infinity.

Hepatic Clearance Although metabolism can take place in many organs, the liver frequently has the greater metabolic capacity and, therefore, has been the most thoroughly studied. The most direct quantitative measure of the liver's ability to eliminate a drug is hepatic clearance, (Cl)H, which includes biliary excretion clearance and hepatic metabolic clearance: where QH is the sum of the hepatic portal and hepatic arterial blood flow rates, the values of which are 1,050 and 300 mL/min, respectively. Under conditions of normal body functions, the pharmacokinetic behavior of most drugs can be established within reasonable limits, and optimal dosage regimens can be designed using the observed values of the pharmacokinetic parameters of the drug. When, however, the renal function is compromised as a result of acute or chronic renal diseases or the patient's age, drugs that are eliminated predominantly through the kidneys are likely to be retained in the body for a longer duration and accumulate to the extent of providing toxic drug levels with repeated dosing. If the drug is converted to a metabolite, the accumulation of active metabolite also may lead to toxic effect, and although most metabolites are inactive, their accumulation with repeated dosing may produce toxic reactions by displacement of the parent drug from plasma protein and by inhibiting further drug metabolism. Renal failure can result from a variety of pathologic conditions. If renal impairment is rapid in onset and short in duration, then renal failure is described as acute. The primary cause of acute renal failure may be prerenal (i.e., acute congestive heart failure or shock), intrarenal (i.e., acute tubule necrosis) or postrenal (i.e., hypercalcemia). The condition generally is reversible; however, complete restoration of renal function may take 6 to 12 months. Chronic renal failure almost always is caused by intrinsic renal diseases and is characterized by slow, progressive development. Unlike the acute condition, chronic renal impairment generally is irreversible. The degree or loss of kidney functional capacity in the chronic condition is best described in terms of the intact “nephron” hypothesis, in which the diseased kidney is comprised of nephrons that are essentially nonfunctional because of pathologic conditions together with normal nephrons. Progressive renal impairment is the result of an increasing fraction of nonfunctional nephrons. The prolonged and progressive nature of chronic renal failure is of particular concern in older


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patients, who may require a variety of medications, both for their renal condition and for other unrelated conditions. The inability of P.237 these patients to excrete drugs and drug metabolites adequately and the influence of their uremic conditions on the functions of other physiological systems require careful adjustments of drug dosage to obtain accurate and adequate blood levels without increased toxicity.

Compounds (e.g., drugs) are cleared by kidneys because of passive filtration through the glomeruli or by active secretion in the kidney tubule. Once in the nephrons, compounds also may be reabsorbed into the circulation. The glomerular filtration rate can be measured using any compound that is filtered by glomeruli and not secreted and reabsorbed. Although exogenous compounds, such as urea and inulin, can be used for this purpose, the relative ease of using endogenous creatinine has made this the method of universal choice. In principle, the following equation determines the relationship between the creatine clearance, (Cl)cr, the serum creatinine concentration, ( S)cr, and creatinine excretion rate, (dXµ/dt) ·cr:

Serum creatinine concentration is constant unless there is a change in the rate of production of creatinine in the body or creatinine clearance. The creatinine clearance in normal kidneys is approximately 110 to 130 mL/min. This value declines with progressive renal impairment, and it drops to zero with severe renal impairment. Creatinine clearance values of 20 to 30 mL/min signify moderate renal impairment; values of less than 10 mL/min signify several renal impairment. Creatinine is poorly secreted and not subject to tubular reabsorption; therefore, its clearance is a useful measure of the glomerular filtration rate. Although creatinine clearance tells us about only one aspect of renal function (i.e., filtration), it is an excellent indicator for assessing the severity of renal impairment. The extent to which decreased renal function influences drug elimination is a function of the percentage of circulating drug being cleared by the kidneys. From the literature, the influence of renal impairment on the elimination half-life of a drug clearly will be a direct function of the percentage of the drug cleared through the kidneys. If the elimination half-life of a drug that is cleared essentially unchanged via the kidneys is plotted against the endogenous creatinine clearance (Fig. 9.27), the result will be a hyperbola.

Intravenous Bolus Administration (Two-Compartment Model) Following the administration of a drug intravenously, it usually takes a finite amount of time before the distribution equilibrium is attained in the body. During this distribution phase, the drug concentration in the plasma will decline more rapidly than during the postdistribution phase, as shown in Figure 9.28. There are three possible types of two-compartment models. They differ in whether the elimination of the drug occurs from the central compartment, the peripheral compartment, or both. These three types of two-compartment models are, mathematically, indistinguishable on the basis of available concentration data. The type of two-compartment model illustrated in Figure 9.22 most often is used to describe the pharmacokinetics of drugs. In this model, it is assumed that drug elimination from a two-compartment model occurs exclusively from the central compartment, because the site of biotransformation and excretion (i.e., liver and kidney) are well perfused with blood and presumably, therefore, rapidly accessible to P.238 drug in the systemic circulation. Whether this distribution phase is apparent will depend on the early collection of blood samples. A distribution phase may last for only a few minutes or for several hours.


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Fig. 9.27. Curvilinear relationship between the elimination half-life of 5-fluorocytosine and renal function (creatinine clearance). (from Gibaldi M. Biopharmaceutics and Clinical Pharmacokinetics, 4th Ed. Philadelphia: Lea and Febiger, 1991; with permission.)

Fig. 9.28. Semilogarithmic plot of drug concentration in the plasma against time following administration of a rapid intravenous injection when the body may be represented as a two compartment open model. The dashed line is obtained by “feathering” the curve.

A semilogarithmic plot of plasma drug concentration as a function of time (Fig. 9.28) after rapid intravenous injection of a drug often can be resolved into two linear components. This can be done graphically by employing the residual, or “feathering,” method, as shown in Figure 9.28, in which the slopes of rapid and slow disposition phases will permit the determination of α and β, respectively, in Eq. 9.63. The intercepts on the concentration axis are designated A and B. The entire plasma concentration–time curve may be described by the following equation:

where α and β are the first-order distribution and disposition rate constants, respectively. A biexponential decline in the plasma drug concentration justifies, mathematically, the representation of


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the body as a two-compartment model. The intercompartmental rate constants (K21 and K12) (Eqs. 9.64 and 9.66) and the elimination rate constant (K10) (Eq. 9.65) for a drug that exhibits the characteristics of a two-compartment model can be determined from the knowledge of α, β, A, and B (Fig. 9.28). This is achieved by employing the following equations:

where K21 is the rate constant associated with the transfer of a drug from compartment II to compartment I (i.e., from the peripheral to the central compartment):

where K10 is the elimination rate constant of the drug. where K12 is the rate constant associated with the transfer of the drug from compartment I to compartment II (i.e., from the central compartment to the peripheral compartment). Determination of these rate constants permits an assessment of the relative contribution of distribution and the elimination processes to the drug concentration versus time profile. The knowledge of the transfer rate constant (K12) also is required to calculate the amount of drug in the peripheral compartment (Xp) as a function of time after an intravenous administration:

where X0 is the administered dose.

Fig. 9.29. After oral administration, a drug must pass sequentially through the gut lumen, gut wall, and then through the liver before reaching the general circulation. Metabolism may occur in the lumen before absorption, in the gut wall during the absorption, or in the liver after absorption and before reaching the systemic circulation. (From Rowland M, Tozer T. Clinical Pharmacokinetics: Concepts and Application, 2nd Ed. Philadelphia: Lea and Febiger, 1989; with permission.)

Extravascular Route of Administration When a drug is administered by extravascular routes, absorption is a requisite for a drug to reach the general circulation. Absorption is defined here as a process of a drug proceeding from the site of administration to the site of measurement within the body, generally blood, plasma, or serum. Figure 9.29 represents the passage of a drug through the gastrointestinal tract into the general circulation. When a drug is administered orally, there are several possible sites for drug loss. One such site is the gastrointestinal lumen, where the decomposition of a drug may occur. If it is assumed that the drug survives destruction in P.239


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the gut lumen and is metabolized by enzymes as it passes through the membrane of the gastrointestinal tract, then even though the drug leaves the site of administration, it is considered not to be absorbed systemically. Indeed, loss at any site in the gastrointestinal tract before reaching the site of measurement may contribute to a decrease in the systemic absorption of the drug. The requirement for an orally administered drug to pass through the gastrointestinal tract makes the extent of absorption not always complete. The loss of a drug as it passes for the first time through gastrointestinal membrane and the lining, during absorption, is known as the first-pass effect. Figure 9.30 represents the time course of a drug and metabolite at each site in the body. The rate or the change in the amount of drug in the body (dX/dt) following administration of a drug by an extravascular route is a function of both the absorption rate (KaXa) and the elimination rate (KX):

where KaXa is the first-order absorption rate, KX is the first-order elimination rate, and Ka and K are the first-order absorption and elimination rate constants, respectively. When the absorption rate is greater than the elimination rate (i.e., KaXa > KX), the amount of drug in the body and the drug concentration in the plasma increase with time. Conversely, when the amount of drug remaining at the absorption site (Xa) is sufficiently small, the elimination rate exceeds the absorption rate (i.e., KX > KaXa); therefore, the amount of drug in the body and the drug concentration in the plasma decrease with time.

Fig. 9.30. Time course of a drug at each site following an extravascular administration.

The maximum, or peak, plasma concentration after drug administration occurs at the moment when the absorption rate equals the elimination rate (i.e., KaXa = KX). The faster the drug is absorbed, the higher the maximum plasma concentration and the shorter the time required following administration of a dose to observe the peak plasma concentration. Integration of Equation 9.68 from t = 0 to t = t* and converting the amount to the concentration results in the following equation:

where (Xa)0 is the administered dose and F is the fraction of the administered dose that is absorbed and available to reach the general circulation. Equation 9.69 often is used to determine plasma concentration after administration of a drug by an extravascular route when the administered drug manifests the characteristics of a one-compartment model. The absorption rate constant (Ka) of a drug frequently is larger than the elimination rate constant (K). Under such a condition, at some time after drug administration, the value of the term e-Kt in Equation 9.69 approaches zero, indicating that no more drug is available for absorption, and Equation 9.69 simplifies to


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When the absorption is complete, the term XaKa disappears from the Equation 9.68, and the equation is reduced to

During the postabsorption phase, the decline in the plasma concentration with time follows first-order kinetics. A typical plot of plasma concentration versus time is shown in Figure 9.31, where the intercept of the extrapolated line (I*) is a complex function of absorption and elimination rate constants (Ka and K, respectively) as well as the dose or amount absorbed, F(Xa)0, and the apparent volume of distribution (V). It is, however, incorrect to assume that the intercept approximates the ratio of dose over the apparent volume of distribution unless the drug is rapidly and completely absorbed, which rarely occurs.

Importance of Absorption Rate The influence of absorption on the drug concentration time profile is shown in Figure 9.32. Administration of an P.240 equal dose of a drug in three different dosage forms or by three different extravascular routes or three different formations results in threefold the drug in the plasma. The faster the drug is absorbed (i.e., Ka >>> K), the greater the peak plasma concentration and the shorter the time required to achieve peak plasma drug concentration.

Fig. 9.31. Typical semilogarithmic plot of drug concentration versus time profile in plasma following the administration of a drug by an extravascular route. The dashed line represents the “feathered line” used to obtain the absorption rate constant (Ka).

Many drugs do not exhibit demonstrable pharmacological effects or do not elicit a desired degree of pharmacological response unless a minimum concentration is reached at the site of an action and, therefore, a minimum therapeutic concentration in the plasma. Thus, the absorption rate of a drug m a y a f f e c t t h e c l i n i c a l r e s p o n s e i f i t f a i l s t o y i e ld t h e m i n i m u m e f f e c t i v e c o n c e n t r a t i o n . A s e v i d e n t i n Figure 9.32, the more rapid the absorption of a drug, the faster its onset of response (i.e., curve A). When the drug is absorbed rather slowly (curve C), the minimum effective concentration is just barely attained. The intensity of maximum pharmacological effects is a function of the drug concentration. The data presented in Figure 9.32 suggest that the administered dose of a drug in curve A may


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produce a more intense response than observed in curves B and C. The peak plasma drug concentration is always lower following administration of a drug by the extravascular route compared with its initial plasma concentration following administration of an identical dose by intravenous solution. In the former, at peak time, some drugs may still remain at the absorption site and some has been eliminated, whereas the entire dose is in the body immediately following the intravenous administration.

Fig. 9.32. A plasma concentration versus time profile illustrating the influence of absorption rate constant (Ka) on the rate of absorption as reflected in the peak time (tmax) and peak plasma concentration (Cp)max.

The delay between drug administration and a drug reaching the general circulation may be of particular importance when a rapid onset of effect is desired. This delay is termed “lag time,” and it can be anywhere between a few minutes to many hours. Lag time generally is attributed to the slow and poor absorption of the drug, either because of slow disintegration and dissolution of the drug from the dosage form or because of slow removal of the coating material from coated tablets.

Determination of Peak Time The determination of peak time (tmax) can be achieved by employing the following equation:

where Ka and K are the first-order absorption and elimination rate constants, respectively. Equation 9.74 shows that the peak time is a function only of the relative magnitude of the absorption and elimination rate constants. As the rate of absorption decreases (i.e., smaller Ka value), the peak time will be higher, as shown in Figure 9.32, progressing from curve C to curve A. The rate of drug absorption varies when the extravascular route is changed, when the formulation of a drug is changed, or when the dosage form is changed. These changes will be reflected in different peak times for the same dose of a drug. The peak time will be unaffected, however, by a mere change in the size of the administered dose. In many disease states, the impairment in the renal function may affect the elimination rate constant, thereby producing a change in the peak time. P.241

Determination of Peak Plasma Concentrations The peak (maximum) plasma drug concentration, (Cp)max, in the body occurs at time tmax, which is described by substituting tmax for time t in Equation 9.69:


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Equation 9.75 is further simplified into

where the intercept of the plasma drug concentration versus time is equal to KaF(Xa)0/V(Ka - K), as described earlier in Equations 9.70 through 9.72. A much simpler expression can be obtained as follows: At peak time,

Substituting for e-Ktmax in Equation 9.75 yields

which, on the cancellation of terms, is readily simplified into

where F is the fraction of the dose absorbed, (Xa)0 is the administered dose, V is the apparent volume of distribution, and K and tmax are elimination rate constants and peak time, respectively. Equation 9.79 suggests that the peak plasma concentration of a drug is a function of a dose entering the general circulation, the apparent volume of distribution, and the first-order rate constants for absorption and elimination. Again, like the absorption rate constant, the fraction of the administered dose reaching the general circulation will depend on the route of administration, the formulation, and the dosage form. These factors therefore will contribute to the peak plasma concentration of a drug.

Bioavailability The bioavailability of a drug is defined as the rate and extent to which the administered dose of a drug reaches the general circulation. Generally, rapid and complete absorption of a drug is desirable if it is used for pain, allergy response, insomnia, and other conditions for which a quick onset of action is desired. As indicated earlier (Fig. 9.32), the more rapid the absorption, the shorter the onset of action and the greater the intensity of a pharmacological response. Bioavailability determines the amount of administered dose that reaches the circulation, which also is related to rate of drug clearance (Fig. 9.25). The efficacy of a single dose is a function of both the rate and the extent of absorption. Thus, for two dosage forms or two extravascular routes to be comparable with regard to the bioavailability following the administration of a drug, the absorption rate of a drug and the extent to which a drug reaches the general circulation from each dosage form or extravascular route must be comparable. The useful estimate of relative absorption rates of a drug from different products, through different routes of administration or different conditions (i.e., with or without food or in the presence of other drugs, etc.) can be made by comparing the magnitude of time of occurrence of peak concentration, peak concentration, and area under the peak plasma concentration curve, (AUC)∞0. The peak time and peak plasma concentration can be determined by employing Equations 9.74 and 9.76 or 9.79, respectively, and the extent of absorption can be determined as described below.

Estimating the Extent of Absorption The extent of absorption can be estimated by determining the total area under the plasma drug concentration–time curve, (AUC)∞0, or the total amount of an unchanged drug excreted in urine, (Xu) ∞, after the administration of a drug. (AUC)∞0 can be estimated by several methods, such as a planimeter, which is an instrument for measuring the area of a plan figure, and the cut-and-weight method, which weighs the paper of plasma concentration–time curve. The weight is converted to weight per unit area. The most common methods, however, are the application of trapezoidal rule and equation, when possible. In a single-dose study, we cannot determine the area under the plasma concentration time curve by the use of trapezoidal rule alone. In this case, a widely used practice is to determine the area under the plasma concentration–time curve from t = 0 to t = t* (the last sampling time) by means of trapezoidal rule and estimate the remaining area by employing the following equation: where (AUC)t ∞ is the area under the plasma concentration–time curve from the last sampling time to * time ∞, Cp* is the last observed plasma concentration, and K is the first-order elimination rate constant. This area under the curve, (AUC)t ∞, will be added to the area under the curve obtained *


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from t = 0 to t = t* to calculate the total area under the plasma concentration–time curve:

When an intravenous administration of a drug exhibits the characteristics of a one-compartment model, the total area under the plasma concentration vs. time curve is estimated by the following equation:

where VK is the systemic clearance of a drug. P.242 Following the administration of a drug by an intravenous injection, if it is necessary to use a twocompartment model, the area under the plasma concentration–time curve from t = 0 to t = t* (the last sampling time) may be estimated by using trapezoidal rules, as mentioned earlier. Additionally, the area under plasma concentration–time curve from t = t* to t = ∞ may be computed using the following equation: where Cp* is the last observed plasma concentration and β is the first-order disposition rate constant. When a drug is administered by an extravascular route, one may use the following equation to determine (AUC)0∞:

If it is desired to assess the relative extent of drug absorption from a product, the total area under the plasma concentration from the product to that obtained for a reference drug standard is compared. The reference standard may be an intravenous injection, an orally administered aqueous or water-miscible solution, or another product accepted as a standard. When it is desired to assess the absolute bioavailability, the reference drug standard becomes an intravenous injection, and when it is desired to judge the bioequivalence, the reference standard is an innovator product. If the (AUC)0∞ values are identical following the administration of equal doses of a drug through a test product and the reference intravenous solution, we conclude that the drug from the test product is completely absorbed and not subject to presystemic metabolism. Frequently, however, the standard is an innovator product or another established product. If the (AUC)0∞ values are identical following the administration of equal doses of the test and reference products, we conclude that the test product is completely bioavailable relative to the standard. It is essential to use the term “relative to the standard,” because we do not know if the standard is completely absorbed or available. Additionally, when two products produce comparable peak plasma drug concentrations and tmax and the reference standard is an innovator product, then the products are judged to be bioequivalent. By using the ratio of area under the plasma concentration–time curve for extravascular to intravenous routes, one can determine the absolute bioavailability of a drug from a test product as follows:

where F is the absolute bioavailability of a drug or the fraction of the administered dose that reaches the general circulation following the administration of equal dose of a drug. If the administered doses of a drug are different then the AUC0∞, then estimates can be scaled approximately to permit

comparison under identical conditions or equivalent doses—assuming, of course, that (AUC)0∞ is directly proportioned to the administered dose. The relative bioavailability (Frel) of a drug from a test product may be determined by using the following expression:

Equation 9.86 assumes that the doses administered from each product are identical, and if not, the (AUC)0∞ values should be scaled for the dose differences. The determination of bioavailability from the urinary excretion of an unchanged drug following administration by intravenous solution can be assessed using the following equations:

where (Xu)∞ is the amount of drug excreted in unchanged form in the urine after administration of a


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dose and Ku and K are the first-order excretion and the elimination rate constants, respectively. On the other hand, for drugs administered by an extravascular route, the amount of an unchanged drug excreted in urine, (Xu)∞, is obtained by

where F is the fraction of the administered dose that reaches the general circulation. Therefore, the bioavailability of a drug following its extravascular administration can be expressed as

To determine the assessment of relative bioavailability (Frel), Equation 9.89 becomes

and Equations 9.89 and 9.90 are applicable under the condition that the administered doses are identical. The utility of these equations depends on how much of the drug is eliminated by urinary excretion, the sensitivity of the analytical procedure, and the variability in urinary output of the drug. Many drugs are extensively metabolized, with little, if any, drug appearing in an unchanged form in the urine. In such cases, the bioavailability is estimated from the plasma concentration time data. P.243

Presystemic or First-Pass Metabolism Following oral administration, a drug must pass sequentially from the gastrointestinal lumen, through the gut wall, and through the liver before reaching the general circulation (Fig. 9.29). Because the gut wall and liver are the sites of drug metabolism, a fraction of the amount of drug absorbed may be eliminated or metabolized before reaching the general circulation. Therefore, an oral dose of a drug may be completely absorbed yet incompletely available to reach the general circulation because of presystemic or first-pass effect (metabolism) in the gut wall or liver. If such is the case, it will be reflected in the values of (AUC)0∞ for the administered dose. Criteria have been developed to identify and quantify the extent of presystemic metabolism and to indicate when it is occurring. The determination of presystemic metabolism requires only that the systemic availability of a drug is less than the fraction of the dose absorbed. The fraction absorbed may be determined from the urinary excretion of a drug and metabolite after oral administration of a drug relative to that after intravenous administration. Many drugs undergoing presystemic metabolism in humans have been identified on the basis of this type of information. Differentiation between the gut wall and the liver as the site of presystemic metabolism in humans is more difficult, though relatively easy in animals. The liver is the most important site of presystemic elimination because of high levels of drugmetabolizing enzymes, its ability to rapidly metabolize different types of drugs, and its unique anatomical location. The following are selected examples of drugs that are subject to considerable hepatic first-pass metabolism: the β-blockers propranolol and metoprolol; the analgesics propoxyphene, meperidine, and pentazocine; the antidepressants imipramine and nortriptyline; and the antiarrhythmic lidocaine. Hepatic presystemic metabolism is most easily understood when liver is the sole organ of drug elimination. Under these conditions, the clearance of the drug, as determined following intravenous administration of the drug, is equal to

Hepatic clearance, however, also is equal to where (Cl)H is the hepatic clearance, QH is the hepatic blood flow rate, and EH is the dimensionless hepatic extraction ratio of the drug. Hepatic blood flow rate (QH) has a mean range from approximately 1.1 to 1.8 L/min, with an average of approximately 1.5 L/min. The hepatic extraction ratio (EH) of a drug may range from zero to one, depending on the liver's ability to metabolize the drug. The maximum hepatic clearance of a drug, excluding hepatic metabolism, is equal to hepatic blood flow; this occurs when EH = 1.0. The fraction of a drug eliminated from portal blood (Fig. 9.29) during the absorption phase is given by the hepatic extraction ratio (EH); the remainder of the drug (i.e., 1 – EH) escapes into the systemic circulation and then is cleared from the circulation by the


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liver according to Equation 9.56. If the fraction of the oral dose is absorbed and then subjected to hepatic presystemic metabolism, the AUC0∞ following oral administration of a drug is given by

Because QH·EH is equal to hepatic clearance (Eq. 9.92), which under these conditions is given by the ratio of an intravenous dose to an area under the concentration–time curve, (AUC)0∞ IV, Equation 9.93 can be rewritten as

The ratio of (AUC)0∞ after oral and intravenous administration of equal doses of drugs is the systemic availability (i.e., the fraction absorbed). If it is assumed that the drug is completely absorbed (i.e., F = 1), then Equation 9.94 reduces to

Equation 9.95 shows that the systemic availability of the drug depends on the hepatic extraction ratio of the drug, and those drugs with low hepatic extraction ratios, such as antipyrine, tolbutamide, and warfarin, undergo little presystemic metabolism. An estimate of hepatic extraction ratio (EH) may be made from determination of the clearance of a drug following intravenous administration and comparing this value to the mean value of liver blood flow according to Equation 9.92, when rearranged:

The intravenous clearance of propranolol is approximately 1.05 L/min. Assuming that the average liver blood flow is approximately 1.5 L/min, we can determine that the hepatic extraction for propranolol (EH) is 0.7 and that the fraction absorbed (F) is 0.3. This means that even though propranolol is well absorbed, only 30% of the oral dose is available for systemic circulation. This type of information, in conjunction with the value of the fraction absorbed (F), has been used to substantiate the predominantly hepatic presystemic elimination of several drugs, including propranolol, lidocaine, pentazocine, and so on. The plasma concentrations for pentazocine, following the oral administration of a 100-mg dose and an intravenous administration of a 30-mg dose, are shown in Figure 9.33. Figure 9.33 shows that P.244 even though the intravenous dose is smaller, this route of administration provides higher plasma concentration than an oral dose. The systemic availability (F) of pentazocine after oral administration was reported to be 11 to 32%, with a mean of 18%. This low systemic availability is consistent with its high hepatic clearance.

Fig. 9.33. Pentazocine concentration in plasma (ng/mL) after administration of 100 mg orally (○) or 30 mg intravenously (•). (From Ehrnebo M, Boreus L, Lonroth U.


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Bioavailability and first-pass metabolism of oral pentazocine in man. Clin Pharmacol Ther 1977;22:888–892; with permission.)

Intravenous Infusion If a drug is administered intravenously at a constant rate, its plasma concentration at any time will be provided by the following equation:

where Q is the constant infusion rate (dose/unit time) and VK is the systemic clearance of the drug. The plasma drug concentration will rise (Fig. 9.34) with time after the start of an infusion and will slowly approach a constant level, at which the rate of elimination of the drug from the body equals the rate of infusion. After the commencement of an infusion, it takes approximately 4.32 elimination half-lives of the drug for the plasma concentration of the drug to be within 5% of the constant plateau level and seven elimination half-lives for the concentration to be within 1% of the plateau level. The plateau, or true steady-state, plasma concentration, (Cp)ss, can be determined from Equation 9.97 by recognizing that the term (e-Kt) approaches zero with increased time. Therefore,

Equation 9.98 permits one to calculate the infusion rate necessary to attain and then maintain the desired steady-state plasma concentration of a drug if the systemic clearance of the drug is available. Equation 9.98 also provides a convenient way to determine the apparent volume of distribution of a drug by means of intravenous infusion experiment if the infusion rate (Q), the elimination rate constant (K), and the steady-state plasma concentration (Cp)SS are known.

Fig. 9.34. Typical plasma concentration versus time profile following administration of a drug by intravenous infusion.

The decline of plasma concentration after the infusion is stopped can be calculated using the following equation:

where (Cp)t′ is the plasma concentration at time t′ following the cessation of infusion, and (Cp)T is the plasma concentration at the time the infusion is stopped. Because the time required to reach the steady-state plasma drug concentration will be quite long for a drug with a long elimination half-life, the administration of an intravenous loading dose often is convenient to attain the desired drug concentration immediately and then maintain this concentration by the continuous infusion. The loading dose (DL) required to attain the desired drug concentration is calculated as follows:


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Using Equation 9.98 or 9.101, one can determine the infusion rate (Q) needed to maintain the plasma concentration obtained by the administration of the loading dose (DL).

Repetitive Drug Administration (Multiple Dosing) If a fixed intravenous dose of a drug is administered repeatedly at a constant time interval (τ), the plasma P.245 concentration of a drug at any time may be calculated using the following expression:

Fig. 9.35. A typical plasma concentration versus time profile for a drug administered intravenously as a fixed dose (X0) at a fixed dosing interval (τ).

where n is the number of doses that have been administered, t is the time between t = 0 and t = τ, τ is dosing interval, X0 is the dose administered, V is the apparent volume of distribution of the drug, and K is the elimination rate constant. At the plateau, Equation 9.102 reduces to

where (Cp)∞ is the steady-state plasma concentration. The maximum plasma concentration of a drug (Fig. 9.35) at the steady state, (Cp)∞ max, and its minimum plasma concentration at the steady state, (Cp)∞ min, can be determined by setting t = 0 and t = ∞, respectively. Equation 9.102 then becomes

and

When drugs are administered as repetitive doses (multiple doses), it often is of practical use to determine the “average” plasma concentration at the plateau or


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steady state, ( p)ss average. This is obtained by

where t is the dosing interval, X0 is the administered dose, and VK is its systemic clearance. Equation 9.106 clearly indicates that by knowing the apparent volume of distribution and the elimination rate constant, obtained from the administration of a single intravenous bolus dose, the average plasma concentration of a drug can be predicted for the intravenous bolus administration of a fixed dose (X0) at a constant dosing interval (t). Equation 9.106 clearly indicates that only the size of the dose (X0) and the dosing interval (t) may be adjusted to obtain the desired average steadystate plasma drug concentration.

It is important to recognize that the average steady-state plasma drug concentration, ( p)ss average, is neither the arithmatic nor geometric mean of (Cp)∞ max and (Cp) ∞ min but, rather, the ratio of the area under the plasma concentration–time curve during the dosing interval (t) at the plateau over the dosing interval (t). We know from Equation 9.82 that the ratio of a dose over systemic clearance (VK) equals the area under the plasma concentration–time curve, (AUC)0∞. Therefore, substituting dose/clearance from Equation 9.82 into Equation 9.106 provides the following:

where (AUC)0∞ represents the area under the plasma drug concentration–time curve following the administration of a single intravenous bolus dose. When the drug is administered by oral route (Fig. 9.36), the mathematical expressions are more complex than analogous equations for intravenous administration:

P.246 where (Xa)0 is the dose administered; F is the fraction absorbed; Ka and K are the first-order absorption and the elimination rate constants, respectively; V is the apparent volume of distribution; and t and t are time and dosing intervals, respectively. Following the administration of each successive dose in the postabsorption period, Equation 9.100 reduces to


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Fig. 9.36. A typical plasma concentration versus time profile for a drug administered orally as a fixed dose (Xa)0 at a fixed dosing interval (τ).

The average steady-state plasma concentration of a drug when administered by an extravascular route can be obtained using the following equation:

or, by substituting Eq. 9.84 into Eq. 9.110,

where F is the fraction absorbed or absolute bioavailability of a drug. Taking the ratio of Equations 9.110 over 9.106 following the attainment of the steady-state condition permits one to determine the bioavailability of a drug; of course, this assumes that the administered doses are identical. Repeated administration of a fixed dose at a constant dosing interval (t) produces a gradual increase of drug levels in the body until the steady-state condition is attained. This increase is the result of drug accumulation factor (R) because of the sequential dosing of the drug. Therefore, predicting the degree of accumulation of a drug under defined conditions becomes important. Multiplying each side of Equation 9.106 by the apparent volume of distribution and dividing by the administered dose, Equation 9.112 is obtained:

where Xss average/X0 = R = drug accumulation factor where Xss average is the “average” amount of drug in the body at the steady-state condition. The ratio of the average amount of a drug at its steady state and the administered dose is defined as drug accumulation (R). Equation 9.112 describes that the magnitude of drug accumulation is a function of the elimination half-life of a drug and the chosen dosing interval. For example, if a drug with an elimination half-life of 12 hours (i.e., K = 0.0577 hr-1) is administered every 6 hours (t), the ratio of Xss average over dose is 2.9. This means that repeated administration of a fixed dose of a drug in the body is approximately 2.9-fold the amount administered in a single dose. It also is clear from Equation 9.112 that the drug accumulation ratio (R) is directly proportional to the elimination half-life of the drug (t1/2) and inversely proportional to the dosing interval (t); however, R is independent of the size of the administered dose. Because considerable time may elapse before a steady-state condition is attained as a result of repeated drug administration, it often is desirable to administer a large dose initially (i.e., loading dose) to achieve the desired drug levels immediately. Equation 9.42, which describes the time course of drug concentration after a single intravenous bolus dose, may be written as


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where (Cp)1 min is the drug concentration immediately before administration of the second dose of the same size as the first one (i.e., the minimum concentration occurs at t = t following administration of the first dose). The minimum steady-state plasma concentration, (Cp)∞ min, is given by Equation 9.105. Thus, the ratio of (Cp)∞ min to (Cp)1 min (i.e., Eqs. 9.105 and 9.113) is another way to measure the drug accumulation (R). This ratio may be calculated by means of the following expression:

This ratio of minimum drug concentrations, numerically, is not equal to the ratio of the “average” dose of a drug at steady state and the dose administered (Eq. 9.112). P.247 If one wished to administer a loading dose (DL) that produces the minimum concentration equal to (Cp)∞ min:

Dividing the Equation 9.105 by Equation 9.115 will result in

Equation 9.116, on rearrangement, yields an expression to determine the loading dose (DL):

In Equations 9.116 and 9.117, DL is the loading dose and D is the maintenance dose. Equation 9.117 permits the calculation of loading dose for the chosen maintenance dose and dosing interval (t) and is applicable for the administration of a drug not only by an intravenous bolus but also by the extravascular route. When a drug is administered by the extravascular route, however, it is essential that each maintenance dose be administered following the complete absorption of a drug from the previous dose. Conversely, Equation 9.117 also permits the determination of the maintenance dose required to maintain the minimum drug level produced by the administration of the initial dose for any chosen dosing interval.

Plasma Protein Binding in Pharmacokinetics Drug binding to plasma proteins affects drug distribution and elimination as well as the pharmacological effect of a drug. The high molecular weight of plasma proteins restricts their passage across capillaries, and their low lipid solubility prevents them from crossing the cell membrane. Analogously, binding of drugs to plasma protein restricts their passage across cell membranes. Only that fraction of the drug concentration that is freely circulating or unbound can penetrate the cell membrane and be subject to glomerular filtration. Hepatic metabolism of most drugs is also limited by the availability of free fraction of drug in the blood. Because the interaction of drugs with plasma protein is a rapidly reversible process, one may view the plasma protein-binding phenomenon as being temporary storage of a drug, subject to instant recall. Drug binding to plasma protein may be attributed to ionic, Van der Waals, and hydrogen bonding. The most important contribution to drug binding in the plasma is made by albumin, which comprises approximately 50% of the total plasma protein. In healthy subjects, albumin concentration in the plasma is approximately 4 g/100 mL. During pregnancy and other diseases, however, low levels of plasma protein may be observed. Albumin binds a wide variety of drug molecules; however, it plays a particularly important role in the binding of weak acidic and neutral drugs. α1-Acid glycoprotein is another important binding protein with an affinity for basic drugs. α1-Acid glycoprotein is a low-molecular-weight protein. It is an acute-phase reactant, and its concentration in plasma rises in inflammation, malignant diseases, and stress. Conversely, its plasma concentration falls in hepatic diseases and nephrotic syndrome. The average concentration of α1-acid glycoprotein is approximately 40 to 100 mg/100 mL. The presence of other plasma proteins plays a limited role in drug binding. The drug proteins interactions can be described by applying the law of mass action:


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where DF and DB represent the free and bound drug, respectively, and K1 and K2 are the rate constant of association and dissociation, respectively. Thus,

where K is the equilibrium association constant, K1 and K2 are binding rate constants, n is the number of available binding sites per mole of protein, and [DF], [DB], and P are the molar concentration of free drug, bound drug, and protein, respectively. The binding rate constants K1 and K2 appear to be large, because the equilibrium is established almost immediately. The value of the equilibrium constant (K) varies from zero, at which essentially no drug is bound, to greater than 106, at which almost all drug is bound to the protein. The fraction of drug in the plasma that is free or unbound (fp) is then obtained as follows:

where [DT] is the total drug concentration in the plasma. In most cases, for a given amount of drug in the body, the greater the binding of drug to plasma protein and the larger is the total drug concentration of drug in the plasma. Changes in drug binding usually affect the blood level of total drug and play a role in pharmacokinetic variability. The free fraction of drug in the plasma (fp) depends on the magnitude of the equilibrium constant (K), the total drug concentration, [DT], and the protein concentration, [P]. In theory, there are limited numbers of P.248 binding sites on the protein. As the drug concentration in the plasma increases, the number of available free sites decreases; therefore, the fraction of available free drug increases. In reality, however, the fraction unbound drug in plasma for most drugs, when administered in therapeutic doses, is essentially constant over the entire drug concentration range. Concentration-dependent changes in the fraction of free drug in the plasma are most likely to occur with drugs exhibiting a high association constant (K = 105 to 106) administered in large doses. The relationship between bioavailability and area under the plasma concentration–time curve is nonlinear and absorption rate dependent when the plasma protein binding of a drug is concentration dependent. Two drug products from which a drug is equally well absorbed will produce different values for the area under the plasma concentration–time curve if a difference exists in the absorption rate. Generally, such a comparison will overestimate the extent of drug absorption of the more slowly absorbed product. The clearance of many drugs from blood is directly proportional to free fraction in the plasma (fp). The steady-state concentrations of these drugs is inversely proportional to the free fraction in the plasma. On the other hand, clearance of some drugs is largely independent of plasma protein binding. The direction and magnitude of the effect of plasma protein binding on the elimination halflife of a drug depends on the size of the drug's apparent volume of distribution (V) and whether the drug exhibits restrictive clearance (i.e., has an intrinsic clearance less than the liver blood flow). The half-life of a restrictively cleared drug with relatively small apparent volume of distribution (i.e., V < 0.25 L/kg) may show a small decrease in elimination half-life when there is decrease in plasma protein binding (i.e., an increase in the free fraction in plasma. Conversely, the half-life of a nonrestrictively cleared drug with a small apparent volume of distribution may show a small increase in half life when the free fraction is increased. Drugs with a large value for the apparent volume of distribution (i.e., V > 0.5 L/kg) either will be essentially independent of the changes in plasma protein binding (restrictive clearance) or will show an increase in half-life that is directly proportional to the increase in free fraction (nonrestrictive clearance). The classical methods of studying protein binding of drugs include equilibrium dialysis and ultrafiltration. The latter may provide quick measurements but is not necessarily as accurate as the equilibrium dialysis method. Detailed discussions on this may be found in textbooks listed in Suggested Readings.

Statistical Moment Analysis


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Statistical moment analysis is a noncompartmental method, based on statistical moment theory, for calculation of the absorption, distribution, and elimination parameters of a drug. This approach to estimating pharmacokinetic parameters has gained considerable attention in recent years.

Table 9.9. Drug Concentration and Drug Concentration–Time Data During and After a 1Hour, Constant-Rate Infusion Time (hours)Concentration (µg/mL)Concentration-Time (µg/mL/hr) 0.5

3.2

1.6

1.0

5.9

5.9

2.0

4.2

8.4

3.0

3.0

9.0

4.0

2.1

8.4

5.0

1.5

7.5

6.0

1.1

6.6

8.0

0.5

4.0

The zero moment in the drug plasma concentration–time curve is the total area under the plasma concentration–time curve from t = 0 to t = ∞, (AUC)0∞. Estimates of the area under this curve are useful in calculating bioavailability as well as drug clearance, which is the ratio of dose over area under the concentration–time curve for an intravenous dose. The first moment of the plasma concentration–time profile is the total area under the concentration– time curve resulting from plot of the product of plasma concentration and time (i.e., Cpt) versus time, as illustrated in Table 9.9 and Figure 9.37 (39). Column 2 of Table 9.9 shows the concentration vs. time data obtained following a 1-hour constantrate infusion, and column 3 also includes concentration-time values for the product of concentration × time. These values are plotted against time in Figure 9.34. The area P.249 under the curve for the concentration–time plot can be obtained by employing trapezoidal rule. The total area under the curve for the product of concentration × time is termed the “area under the firstmoment curve” (AUMC).


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Fig. 9.37. Plots of drug concentration (µg/mL; •) and drug concentration × time (µg/mL/hr; ○) versus time during and after 1 hour of a constant-rate infusion. The area under the concentration versus time plot to infinity is AUC; the area under the concentration × time versus time plot to infinity is AUMC. (From Gibaldi M. Biopharmaceutics and Clinical Pharmacokinetics, 4th Ed. Philadelphia: Lea and Febiger, 1991; with permission.)

The ratio of the AUMC over the area under the concentration–time curve for any drug, according to the theory, is the assessment of the mean residence time (MRT). The MRT provides a quantitative estimate of the persistence of a drug in the body, and like the half-life of a drug, MRT or persistence is a function of distribution and elimination of a drug. Comparison of MRTs following administration of a drug as an intravenous bolus or via any other extravascular route provides information regarding the mean absorption time (MAT). One of the most useful properties of statistical moment analysis is that it permits estimation of the apparent volume of distribution that is independent of drug elimination (i.e. regardless of the model chosen to describe the concentration time data).

Mean Residence Time (MRT) The MRT of a drug following administration of a single dose is provided by the following equation:

The MRT for a drug administered intravenously provides a useful estimate of the persistence time in the body. Therefore, in this sense, it is related to the half-life of a drug. When applied to a drug that distributes rapidly (i.e., one-compartment model), it has been shown that

where K is the elimination rate constant. Because the half-life of a drug is equal to 0.693/K, half-life is a measurement of the time required to eliminate 50% of the administered dose. The MRT, on the other hand, indicates the time required to eliminate 63.2% of the administered dose. When a drug is administered by an extravascular route, statistical moment analysis theory also can be employed for estimating the rate of absorption. This approach, however, requires the calculation of MRT for intravascular as well as extravascular routes, because the method is based on the differences in MRT for different modes of administration. In general, where (MRT)EV is the MRT following administration of a drug by an extravascular route and (MRT)IV is the MRT for the intravenous bolus dose. When the administered drug follows the first-order process,


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where Ka is the first-order absorption rate constant. Under these conditions,

and the absorption half-life is obtained by 0.693/MAT. The statistical moment theory offers an attractive alternative for the evaluation and estimation of the absorption data, and even in the absence of intravenous data, this method permits the ranking of several dosage forms, with respect to drug release and absorption, from the available MRT values.

Summary From this discussion, the efficacy of a drug is not determined by its pharmacodynamic characteristics alone, but efficacy also depends, to a large extent, on the pharmacokinetic parameters of the drug, because ADME processes control the rate and extent to which an administered dose of a drug reaches its site of action. In light of a high degree of structural variability of drugs, multiplicity of kinetics and metabolite kinetics, the task of establishing a clear correlation between the structured chemistry of substituents and their pharmacokinetic properties appears somewhat daunting. The pharmacokinetic fate of a drug molecule, however, appears to be a consequence of its physicochemical properties and, therefore, may, to some extent, be predicted from its chemical structure. Although the drug in the formulation has received considerable attention, many of the alterations in the formulation may be considered as chemical changes. Most of what has been reported applies primarily to the gastrointestinal absorption of drugs and may be viewed as attempts to:

1.

Maximize the rate of absorption by increasing the rate of dissolution (i.e., micronization, salt of acid or bases, amorphous form and metastable polymorph, etc.).

2.

Decrease the loss of a drug because of its degradation in the stomach (i.e., acid, insoluble esters or salt, and chemically stable derivatives of a drug).

3.

Extend the duration of action by reducing the rate of a drug's release from a dosage form (e.g., timed release, depot-forming injectable, macrocrystals, and slowly dissolving salts).

4.

Decrease the loss of a drug by reducing the complex formation.

These examples for enhancing gastrointestinal absorption represent the response to a particular problem with the parent compound and, therefore, may be viewed as P.250 “corrective” research. It is of considerable interest to see this aspect of research become “predictive and preventive,” in which the pharmacokinetic parameters of drugs are required in the early phases of drug design to optimize the effectiveness of drugs. An immediate problem facing those who would consider optimizing all factors of a drug is physically locating the receptor site and defining the ideal time course for the drug–receptor interaction, sustained effects, and so on. An ideal drug molecule should reach the site of action, arrive rapidly in sufficient quantity, remain at the site of action for sufficient time, be excluded from other sites, and be removed from the site, when appropriate. Such an ideal drug molecule rarely exists, however, and alternate approaches are chosen to optimize the effectiveness of a drug. Furthermore, if a correlation exists between a biological response and the blood levels of a drug in the biological fluid, then the pharmacokinetic parameters play an important role in influencing the biological response, because these parameters influence the magnitude of the blood level of a drug in the body. The task of examining the examples of drugs illustrating the connection between biological response and pharmacokinetics study is not an easy one, but the results do convey the important facts that:

1.

Pharmacokinetic parameters influence the biological responses, which are critical in drug design, and

2.

Pharmacokinetic parameters can be modified by subtle structural changes, which in turn may influence the desired blood level.


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The ultimate goal is to design a drug molecule that exhibits the desired pharmacological effect as a result of the proper balance of ADME processes. Figure 9.37 illustrates how modification of a parent structure can influence the availability of a drug to the receptor site (53). The following are some of the processes shown in Figure 9.38 that may be altered by changing a substituent group on the drug molecule:

Fig. 9.38. How some of the processes can be altered by changing a substituent group on a drug molecule.

I.

II.

III.

Supply and loss: A.

Rate of transfer from the dosage form.

B.

Binding of a drug in the depot and

C.

Stability of a drug in the depot.

Distribution in the body: A.

Binding of a drug in the central and peripheral compartments.

B.

Apparent volume of distribution and

C.

Transfer of a drug to the receptor sites.

Drug-receptor interaction.

Consider the following well-known example for the design of a urinary tract anti-effective. The site of infection is the urinary tract. The example selected is the pro-drug, methenamine. In acidic pH, methenamine is converted to formaldehyde, which acts as an antibacterial agent (Fig. 9.39). Tablets of methenamine often are enteric coated to prevent conversion to formaldehyde in the stomach. Methenamine is cleared intact from the kidney into the urine, where it is hydrolyzed to formaldehyde if the pH is less than 6.5. The rate of hydrolysis is controlled by the urinary pH. The influence of structural effects on pharmacokinetic parameters can be illustrated using the following examples: The steady-state levels of the antibiotic carbenicillin are twice those of ampicillin. These higher blood levels of carbenicillin following intravenous administration have been attributed to its efficacy in the treatment of relatively resistant infections, such as Pseudomonas sp. The reason for these differences in the higher steady-state plasma concentration is the larger apparent volume of distribution for ampicillin, because the elimination rate constants are similar. If all the factors were equal, one may argue that an increased value for the apparent volume of distribution is a clinical advantage, because bacteria germinate more frequently in the tissue than in the blood. The effectiveness of an antibiotic depends on its penetration into tissues, particularly inflamed tissue. Thus, if plasma protein binding is equal for both antibiotics, the antibiotic with a larger volume of distribution would appear to be reaching the site of action with better efficacy, but this is by no means unequivocal. Therefore, the spectrum of research activity in the area of antibiotics would imply that the following goals for molecular modifications are generally pursued:


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P.251

Fig. 9.39. Conversion of methenamine to formaldehyde in acidic pH.

1.

Increased tissue distribution.

2.

Longer half-life to maintain a higher blood level and decrease the frequency of dose administration.

3.

Decreased binding capacity to foods and plasma protein.

Acknowledgment The author would like to acknowledge Dr. Philip Breen, Associate Professor of Pharmaceutics, School of Pharmacy and the University of Arkansas for Medical Sciences, for helpful discussions and suggestions in preparing this chapter.

References 1. Ariens EJ. Intrinsic activity: partial agonists and partial antagonists. J Cardiovasc Pharmacol 1983;5:S8–S15.

2. Venter JC, Fraser CM. Mechanism of action and regulation. In: Kito S, Segawa T, Kuriyama K, eds. Neurotransmitter Receptors. New York: Plenum Press, 1984.

3. Lefkowitz RJ, Stadel JM, Caron MG. Adenylate cyclase–coupled β-adrenergic receptors: structure and mechanisms of activation and desensitization. Annu Rev Biochem 1983;52:159– 186.

4. Florence AT, Attwood D. Physiochemical Principles of Pharmacy; 2nd Ed. New York: Chapman and Hall, 1988.

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6. Wagner JG. Biopharmaceutics and Relevant Pharmacokinetics. Hamilton, IL: The Hamilton Press, 1971.

7. Shore PA, Brodie BB, Hogben CAM. The gastric secretion of drugs: a pH partition hypothesis. J Pharmacol Exp Ther 1957;119:361–369.


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8. Hogben CAM, Tocco DJ, Brodie BB, et al. On the mechanism of intestinal absorption of drugs. J Pharmacol Exp Ther 1959;125:275–282.

9. Schanker LS. On the mechanism of absorption of drugs from the gastrointestinal tract. J Med Pharm Chem 1960;2:343–359.

10. Schanker LS. Mechanism of drug absorption and distribution. Annu Rev Pharmacol 1961;1:29–44.

11. Schanker LS. Passage of drugs across the gastrointestinal epithelium in drugs and membrane. In: Hogben CAM, ed. Proceedings of the First International Pharmacology Meeting, vol 4. New York: The Macmillan Company, 1963.

12. Schanker LS. Physiological transport of drug. In: Harper NJ, Simons AB, eds. Advances in Drug Research. London: Academic Press, 1966:71–106.

13. Rowland M, Tozer T. Clinical Pharmacokinetics: Concepts and Application, 2nd Ed. Philadelphia: Lea and Febiger, 1989.

14. Schanker LS. Absorption of drugs from the rat small intestine. J Pharmacol Exp Ther 1958;128:81–87.

15. Zimmerman JJ, Feldman S. Physical–chemical properties and biologic activity. In: Foye WO, ed. Principles of Medicinal Chemistry, 3rd Ed. Philadelphia: Lea and Febiger, 1988:7–38.

16. Winne D. The influence of unstirred layers on intestinal absorption in intestinal permeation. In: Kramer M, Lauterbach F, eds. Workshop Conference Hoechest, vol 4. Amsterdam: Excerpta Medica, 1977:58–64.

17. Levy G, Leonard JR, Procknal JA. Development of in vitro dissolution tests which correlate quantitatively with dissolution rate limited absorption. J Pharm Sci 1965;54:1319–1325.

18. Kwan KC. Oral bioavailability and first-pass effects. Drug Metab Drug Dispos 1997;25:1329– 1336.

19. Burton P, Goodwin J, Vidamas T, et al. Predicting drug absorption: how nature made it a difficult problem. J Pharmacol Exp Ther 2002;303:889–895.

20. Lipinsky CA, Lombordo F, Dominy W, et al. Experimental and computational approaches to estimate solubility and permeability in drug discovery and development settings. Adv Drug Deliv Rev 1997;23:3–25.

21. Stewart B, Wang Y, Surendran N. Ex. In vivo approaches to predicting oral pharmacokinetics in humans. In: Ann Repts Med Chem. Trauma, 6 ed, Academic Press, 2000;35:299–307.

22. Ertl P, Rohde B, Selzer P. Fast calculation of molecular polar surface area as a sum of fragment-based contributions and its application to the prediction of drug transport properties. J Med Chem 2000;43:3714–3717.

23. Sinko PJ, Leesman GD, Amidon GL. Predicting fraction of dose absorbed in humans using a


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macroscopic mass-balance approach. Pharm Res 1991;8:979–988

24. Artusson P, Karlsson J. Correlation between oral drug absorption in humans and the apparent drug permeability coefficient in human intestinal epithelia (Caco-2) cells. Biochem Biophys Res Commun 1991;14:880–885.

25. Avdeef A. Absorption and Drug Development: Solubility, Permeability, and Charge State. New York: Wiley-Interscience, 2003.

26. Hilgers AR, Smith DP, Biermacher JJ, et al. Predicting oral absorption of drugs: a case study with novel class of antimicrobial agents. Pharm Res 2003;20:1149–1155.

27. Amidon GL, Sinko PJ, Fleisher D. Estimating human oral fraction dose absorbed: a correlation using rat intestinal permeability for passive and carrier-mediated compounds. Pharm Res 1988;5:651–654.

28. Dressman JB, Fleisher D. Mixing-tank model for predicting dissolution rate control oral absorption. J Pharm Sci 1986;75:109–116.

29. Johnson DA, Amidon GL. Determination of intrinsic transport parameters from perfused intestine experiments: a boundary layer approach to estimating the aqueous and unbiased membrane permeability. J Theor Biol 1988; 131:93–106.

30. Hidalgo I. Assessing the absorption of new pharmaceuticals. Curr Top Med Chem 2001;1:385–401.

31. Fleisher D, Cheng L, Zhou Y, et al. Drug, meal, and formulation interactions influencing drug absorption after oral administration: clinical implications. Clin Pharmacokinet 1999;36:233–254.

32. Amidon G, Lenncranas H, Shah V, et al. A theoretical basis for a biopharmaceutics drug classification: the correlation of in vitro drug product and in vivo bioavailability. Pharm Res 1995;12:413–420.

33. Kunta JR, Sinko PJ. Intestinal drug transporters: in vivo function and clinical importance. Curr Drug Metab 2004;5:109–124.

34. Matheney C, Lamb M, Brouwer K, et al. Pharmacokinetics and pharmacodynamic implications of P-glycoprotein modulation. Reviews of Therapeutics 2001;21:778–796.

35. Foltz EL. Clinical pharmacology of pivampicillin. Antimicrob Agents Chemother 1970;10:442– 454.

36. Surendran N, Covits KMY, Han HK, et al. Evidence for overlapping substrate specificity between large neutral amino acid (LNAA) and dipeptide (hPEPT1) transporters for PD 158473, an NMDT antagonist. Pharm Res 1999;16:391–395.

37. Lin J, Chiba M, Baillie T. Is the role of the small intestine in first-pass metabolism overemphasized? Pharmacol Rev 1999;51:135–157.

38. Noyes NA, Whitney WR. The rate of solution of solid substances in their own solution. J Am


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Chem Soc 1897;19:930–942.

39. Gibaldi M. Biopharmaceutics and Clinical Pharmacokinetics, 4th Ed. Philadelphia: Lea and Febiger, 1991.

40. Ogata H, Shibazoki T, Inoue T, et al. Studies on dissolution tests of solid dosage forms. IV. Relation of absorption sites of sulfonamides administered orally in solid dosage forms to their solubilities and dissolution rates. Chem Pharm Bull 1979;27:1281–1286.

41. Pottage A, Nimmo J, Prescott LF. The absorption of aspirin and paracetamol in patients with achlorhydria. J Pharm Pharmacol 1974;26:144–145.

42. Juncher H, Raaschou F. Solubility of oral preparation of penicillin V. Antibiotic Med 1957;4:497–507.

43. Anderson KW. Oral absorption of quinalbarbitone and its sodium salt. Arch Int Pharmacodyn Ther 1964;147:171–177.

44. Grant DJW. Theory and origin of polymorphism. In: Brittain HG, ed. Polymorphism in Pharmaceutical Solids. New York: Marcel Dekker, 1999:1–34.

45. Brittain HG, Grant DJW. Effect of polymorphism and solid-state solvation on solubility and dissolution rate. In: Brittain HG, ed. Polymorphism in Pharmaceutical Solids. New York: Marcel Dekker, 1999:34–66.

46. Johnson KC, Swindell AC. Guidance in the setting of drug particle size specifications to minimize variability in drug absorption. Pharm Res 1996;13:1795–1798.

47. Dressman JB, Amidon GL, Fleisher D. Absorption potential: estimating the fraction absorbed for orally administered compounds. J Pharm Sci 1985;74:588–589.

48. Lombardo F, Obach RS, Dicapua FM, et al. A hybrid mixture discriminant analysis–random forest computational model for the prediction of volume of distribution of drugs in human. J Med Chem. 2006;49:2262–2267.

49. Lombardo F, Obach RS, Shalaeva MY, et al. Prediction of volume of distribution values in humans for neutral and basic drugs using physicochemical measurements and plasma protein binding data. J Med Chem 2002;45:2867–2876.

50. Lombardo F, Obach RS, Shalaeva MY, et al. Prediction of human volume of distribution values for neutral and basic drugs. 2. Extended data set and leave-class-out statistics. J Med Chem 2004;47:1242–1250.

51. Nelson E. Comparative dissolution rates of weak acids and their sodium salts. J Am Pharm Assoc (Sci Ed) 1958;47:297–299.

52. Ehrnebo M, Boreus L, Lonroth U. Bioavailability and first-pass metabolism of oral pentazocine in man. Clin Pharmacol Ther 1977;22:888–892.

53. Notari R. Pharmacokinetics and molecular modification: implications in drug design and


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evaluation. J Pharm Sci 1973;62:865–881.

Suggested Readings Avdeef A. Absorption and Drug Development: Solubility, Permeability, and Charge State. New York: Wiley-Interscience, 2003.

Ganellin C, Roberts S. eds. Medicinal Chemistry: The Role of Organic Chemistry in Drug Research, 2nd Ed. New York: Academic Press, 1993.

Garrett E. Classical pharmacokinetics to frontiers. J Pharmacokinet Biopharm 1973;1:341–361. P.252 Gibaldi M. Biopharmaceutics and Clinical Pharmacokinetics, 4th Ed. Philadelphia: Lea and Febiger, 1991.

Gibaldi M, Perrier D. Pharmacokinetics, 2nd Ed., vol 15: Drugs and the Pharmaceutical Sciences. New York: Marcel Dekker, 1982.

Horter D, Dressman JB. Influence of physiochemical properties on dissolution of drugs in the gastrointestinal tract. Adv Drug Deliv Rev 2001;46:75–87.

Hug C. Pharmacokinetics of drugs administered intravenously. Anesth Analg 1978;57:704–723.

Rowland M, Tozer T. Clinical Pharmacokinetics: Concepts and Application, 3rd Ed. Philadelphia: Lea and Febiger, 1994.

Taylor J, Kennewell P. Modern Medicinal Chemistry: Ellis Horwood Series in Pharmaceutical Technology. New York: Ellis Horwood, 1993.

Wagner J. A Modern view of pharmacokinetics. J Pharmacokinet Biopharm 1973;1:363–401.

Wagner J. Do you need a pharmacokinetic model, and, if so, which one? J Pharmacokinet Biopharm 1975;3:457–478.

Welling P. Pharmacokinetics: Processes and Mathematics. Monograph 185. Washington. DC: American Chemical Society, 1986.

Wermuth C, Koga N, Konig H, et al. Medicinal Chemistry for the 21st Century. Boston: Blackwell Scientific Publications, 1992.


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Chapter 10 Drug Metabolism Dav id A. William s What is a poison? All substances are poisons; T here is none that is not a poison. T he right dose differentiates a poison from a drug. —Paracelsus (1493–1541)

Introduction Humans are exposed throughout their lifetime to a large variety of drugs and nonessential exogenous (foreign) compounds (collectively termed “ xenobiotics” ) that may pose health hazards. Drugs taken for therapeutic purposes as well as oc cupational or private exposure to the vapors of volatile chemicals or solvents pose p ossible health risks; smoking and drinking involve the absorption of large amounts of substances with potential adverse health effects. Furthermore, the ingestion of natural toxins in vegetables and fruits, pesticide residues in food, as well as carcinogenic pyrolysis produc ts from fats and protein formed during the charbroiling of meat have to be considered. Most of these xenobiotics undergo enzymatic biotransformations by xenobiotic-metabolizing enzymes in the liver and extrahepatic tissues and are eliminated by excretion as hydrophilic metabolites. In some cases, especially during oxidative metabolism, numerous c hemical procarcinogens form reactive metabolites capable of c ovalent binding to biopolymers, such as proteins or nucleic acids—critical components that can lead to mutagenicity, cytotoxicity, and carcinogenicity. T herefore, insight regarding the biotransformation and bioactivation of xenobiotics becomes an indisputable prerequisite for the assessment of drug safety and risk estimation of chemicals and drugs. Detoxication and toxic effects of drugs and other xenobiotics have been studied extensively in various mammalian species. Frequently, differences in sensitivity to these toxic effects were observed and can now be attributed to genetic differences between spec ies in the isoenzy me/isoforms of cytochrome P450 monooxy genases (CYP450). T he level of expres sion of the CYP450 enzymes is regulated by genetics and a variety of endogenous factors, such as hormones, gender, age, and disease, as well as the presence of environmental factors, such as inducing agents. Drugs were developed and prescribed under the old paradigm that “ one dose fits all,” which largely ignores the fact that humans (both adults and children) are genetically and metabolically different, resulting in a variable response to drugs. Drugs can no longer be regarded as chemically stable entities that elicit the des ired pharmacological response and then are excreted from the body. Drugs undergo a variety of chemic al changes in humans by enzymes of the liver, intestine, kidney, lung, and other tissues, with subsequent alterations in the nature of their pharmacological activ ity, duration of activity, and toxicity. T hus, the pharmacological and toxicological activity of a drug (or xenobiotic) is, in many ways, the consequence of its metabolism. Drug therapy is becoming oriented more toward controlling metabolic, genetic, and environmental illnesses (e.g., cardiovascular disease, mental illness, cancer, and diabetes) rather than short-term therapy. In most of these cases, drug therapy lasts for months or even years, and the problem of drug toxicity from long-term therapy has become increasingly important. T he practice of pres cribing sev eral drugs simultaneously is common. T hus , an awareness of pos sible drug–drug interactions is es sential to avoid catastrophic synergistic effects and chemical, enzy mic, and pharmacokinetic interac tions that may produce toxic side effects. T he study of xenobiotic metabolism has developed rapidly during the past few decades (1,2,3,4,5,6,7,8,9). T hese studies have been fundamental in the assessment of drug efficacy, safety, and the design of dosage regimens ; in the development of food additiv es and the assessment of potential hazards of contaminants; in the evaluation of toxic chemicals; and in the development of pesticides and herbicides and their metabolic fate in insects, other animals, and plants. T he metabolism of drugs and other xenobiotics is fundamental to many toxic processes, such as carcinogenesis, teratogenesis, and tis sue necrosis. Often, the same enzymes involved in drug metabolism also carry out the regulation and metabolism of endogenous subs tances. Consequently, the inhibition and induction of these enzymes by drugs and xenobiotics may have a profound effec t on the normal processes of intermediary metabolism, such as tissue growth and development, hematopoiesis, calcification, and lipid metabolism. Familiarity with the mechanisms of drug metabolism often can predict the consequences of drug–drug interactions, drug–food interactions, and herbal drug–drug interactions to explain a patient's adv erse responses to drug regimens. Incorporating pharmacogenomics into the selection of drug regimens will change the way in which drugs are chosen for patients. Selection based on the patient's indiv idual genetic makeup could eliminate the unpredictable res ponse of drug treatment because of genetic polymorphisms that effects metabolism, clearance, and tolerance. Pharmacogenomic testing to predict P.254 a patient's phenotype (i.e., poor metabolizer) and, thus, their ability to metabolize drugs will become common in the future. Armed with such k nowledge, improved selection of proper drug regimen and dose can be assured before therapy begins.

C lin ical Significan ce T he basic principles of drug metabolism may inform a wide variety of c linical decisions regarding pharmacotherapy. For example, a

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thorough understanding enables a careful assess ment for drug-drug interactions in particular patient cases. Drugs, as chemical entities, can be subs trates, inhibitors, or inducers of metabolic enzymes. T he interplay of these roles potentially influences serum drug concentrations in ways that may directly affect the desired outcome, i.e., decreases in levels that may prevent therapeutic efficacy or increases that may enhance ris ks of toxicity. T here are certainly many more theoretic al pharmacokinetic interactions that inv oke these mechanisms than are actually seen in clinical practice. T hrough c areful observation and analysis of unexpected and possibly concentration-dependent events, one could more readily identify and doc ument which interactions are of greater clinic al significance by v irtue of their actual oc currence in patients. T he clinician would then be poised to recommend appropriate dosage adjustments or medication changes based on the actual outcomes of these interactions. In addition, the biotransformation of drugs may produce reactive metabolites which, through basic chemical reactions, may interact with the components of cellular membranes and prote ins in a manner that dis rupts normal structure and function. A working knowledge of those functional groups within drug molecules that may be more susceptible to reactive metabolite formation could help explain toxic sequelae when they emerge during a medication trial. T his could be useful information whenever alternative therapeutic agents within a given chemical class are being cons idered. Ongoing discov eries from s tudies in the pharmacogenetics field are expanding the drug metabolism literature in directions that hint at the future prospect of truly indiv idualized drug re gimens. T he need to keep abreast of these new developments is both compelling and exciting, and their application builds upon the principles presented in this c hapter.

Mark D. Watanabe, PharmD, PhD, BCPP Assi stant Cl i ni cal Speci al i s t, Department of Pharmacy Practi ce, Northeastern Uni versi ty, Boston, M A

T he increased knowledge of drug metabolism, fed by the need for greater s afety evaluation of drugs and chemic als , has res ulted in a proliferation of publications (e.g., Drug M etabol i sm Revi ews, Drug M etabol i sm and Di sposi ti on, and Xenobi oti ca) and a series of monographs that present the current state of knowledge of foreign compound metabolism from biochemical and pharmacologic al viewpoints (3,4,5,6,7,8,9).

Pathways of Metabolism Drugs, plant toxins, food additives, environmental chemicals, ins ecticides , and other c hemicals foreign to the body undergo enzymic transformations that usually result in the loss of pharmacological activity. T he term “ detoxication” d escribes the result of such metabolic changes. Although drug metabolism usually leads to detoxication, the processes of oxidation, reduction, glucuronidation, sulfation, and other enzy me-catalyzed reactions may lead to the formation of a metabolite having therapeutic or toxic effects. T his proces s often is referred to as “ bioactivation.” One of the earlies t examples of bioactivation was the reduction of Prontosil to the antibac terial agent sulfanilamide. Other examples of drug metabolism le ading to therapeutically ac tive drugs include the h ydroxylation of ac etanilid to acetaminophen as well as the N-demethy lation of the antidepressant imipramine to desipramine and the a nxioly tic diazepam to desmethyldiazepam. T he insecticide parathion is desulfurized by both insects and mammals to paraoxon. Most drugs and other xenobiotics are metabolized by enzymes normally associated with the metabolis m of endogenous constituents (e.g., steroids and biogenic amines). T he liver is the major site of drug metabolism, although other xenobiotic-metabolizing enzymes are found in nervous tissue, kidney, lung, plasma, and the gastrointestinal tract (digestive secretions, bacterial flora, and the intestinal wall). Although hepatic metabolism continues to be the most important route of metabolism for xenobiotics and drugs, other biotransformation pathways play a significant role in the metabolism of these substances. Among the more ac tive extrahepatic tissues capable of metabolizing drugs are the intes tinal mucosa, kidney, and lung (see the discussion of extrahepatic metabolism). T he ability of the liver and extrahepatic tissues to metabolize substances to either pharmacologically inactive or bioactive metabo lites before reaching s ystemic blood levels is termed “ first-pas s metabolism” or the “ presystemic first-pass effect.” Other metabolism reac tions oc curring in the gastrointestinal tract are associated with the bacteria and other microflora of the tract. T he bacterial flora can affect metabolism through the 1) production of toxic metabolites, 2) formation of carc inogens from inactive precursors, 3) detoxication, 4) exhibition of species differences in drug metabolism, 5) exhibition of individual differenc es in drug metabolism, 6) production of pharmacologically active metabolites from inactive P.255 precursors, and 7) production of metabolites not fo rmed by animal tissues.

Phase 1 Reactions T he pathways of xenobiotic metabolism are divided into two major categories. Phase 1 reactions (biotransformations) include oxidation, hydroxylation, reduc tion, and hy droly sis. In these enzymatic reactions, a new functional group is introduced into the s ubstrate molecule, an existing functional group is modified, or a functional group or acceptor site for Phase 2 transfer reactions is exposed, thus making the xenobiotic more polar and, therefore, more readily excreted.

Phase 2 Reactions Phase 2 reactions (conjugation) are enzymatic sy ntheses whereby a functional group, such as alcohol, phenol, or amine, is mas ked by the addition of a new group, such as acetyl, s ulfate, glucuronic acid, or certain amino acids, which further increases the polarity of the drug or xenobiotic. Most substances undergo both Phas e 1 and Phas e 2 reactions sequentially. T hose xenobiotics that are resistant to metabolizing enzymes or are already hy drophilic are excreted largely unchanged. T his basic pattern of xenobiotic metabolism is common to all animal species, including humans, but species may differ in details of the reaction and enzyme control.

Factors Affecting Metabolism As indicated earlier, drug therapy is becoming oriented more toward controlling metabolic, genetic, and environmental illness es rather than short-term therapy associated with infectious diseases. In most cases, drug therapy lasts for months or even years, and the problems of drug–drug interactions and chronic toxicity from long-term drug therapy have become more serious. T herefore, a greater knowledge of

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drug metabolism is essential. Several factors influencing xenobiotic metabolism include: 1. Geneti c factors. Individual differences in drug effectiveness (drug sensitivity or drug resistance), drug interactions, and drug toxicity may depend on racial and ethnic characteristics with the population frequencies of the many polymorphic genes and the expression of the metabolizing enzymes. Pharmacogenetics focuses primarily on genetic polymorphisms (mutations) responsible for interindividual differences in drug metabolism and disposition (10). Genotype–phenotype correlation studies have v alidated that inherited mutations result in two or more distinct phenotypes causing very different responses following drug administration. T he genes encoding for CYP2A6, CYP2C9, CYP2C19, and CYP2D6 are functionally polymorphic; therefore, at leas t 30% of CYP450dependent metabolism is performed by polymorphic enzymes. For example, mutations in the CYP2D6 gene result in poor, intermediate, or ultrarapid metabolizers of more than 30 cardiovascular and central nervous system drugs . T hus, each of these phenotypic subgroups experience different responses to drugs extensively metabolized by the CYP2D6 pathway ranging from severe toxicity to complete lack of efficacy . For example, ethnic specificity has been observed with the sensitivity of the Japanese and Chinese to ethanol as compared to Caucasians, CYP2C19 polymorphism (affects ~ 20% Asians and ~ 3% Caucasians) and the variable metabolism of omeprazole (proton pump inhibitor) and antiseizure drugs, and the polymorphic paraoxonase–catalyzed hydrolysis of the neurotoxic organophosphates and lipid peroxides (atherosclerosis) (see the discussion of genetic polymorphism). Incorporating pharmacogenomic s, the study of heritable traits affecting patient response to drug treatment, into drug therapy will alter the way in which drug regimens are chosen for patients based on their individual genetic makeup (10), thus eliminating the unpredictable response of drug treatment because of genetic polymorphisms that effect metabolism, clearance, and tolerance. Understanding how individuals are genetically predisposed to differences in metabolism risk may result in new class es of drugs that are metabolized by nonpoly morphic CYP450 enzymes. 2. Physi ol ogi c factors. Age is a factor bec ause the very young and the old have impaired metabolism. Hormones (including those induced by stress), s ex differenc es, pregnancy, changes in the intestinal microflora, diseases (espec ially those involving the liver), and nutritional status also can influence drug and xenobiotic metabolism. Because the liver is the principal site for xenobiotic and drug metabolism, liver disease can modify the pharmacok inetics of drugs metabolized by the liver (11,12,13). Several factors identified as major determinants of the metabolism of a drug in the dis eased liver are the nature and extent of liver damage, hepatic blood flow, the drug involved, the dosage regimen, and the degree of participation of the liver in the pharmacokinetics of the drug. Liver diseas e affec ts the elimination half-life of some drugs but not of others, although all undergo hepatic biotransformation (T able 10.1). Some results have shown that the c apacity for drug metabolism is impaired in chronic liver disease, which could lead to drug overdosage. Consequently, becaus e of the unpredictability of drug effects in the presence of liver dis orders, drug therapy under these c ircumstances is complex, and more than the usual caution is needed (13). P.256

Table 10.1. The Effect of Liver Disease in Humans on the Elimination Half-Life of Various Drugsa Difference Reported

No Difference Reported

Acetaminophen

Chlorpromazine

Amylbarbital

Dicoumarol

Carbenicillin

Phenytoin

Chloramphenicol

Phenylbutazone

Clindamycin

Salicylic Acid

Diazepam

Tobutamide

Hexobarbital Isoniazid Lidocaine Meperidine Meprobamate

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Pentobarbital Phenobarbital Prednisone Rifamycin Tolbutamide Theophylline a

Clearance is disputable but may be increased.

Substances influencing drug and xenobiotic metabolism (other than enzyme induc ers) include lipids, proteins, vitamins, and metals. Dietary lipid and protein deficiencies diminish microsomal drug-metabolizing activity . Protein deficiency leads to a reduc tion in hepatic microsomal protein and lipid deficiency; oxidative metabolism is decreased because of an alteration in endoplasmic reticulum (ER) membrane permeability affecting electron transfer. In terms of toxicity, protein deficiency would increas e the toxicity of drugs and xenobiotics by reducing their oxidative microsomal metabolism and clearance from the body. 3. Pharmacodynami c factors . Dose, frequency, and route of administration, plus tissue dis tribution and protein binding of the drug, affect its metabolism. 4. Envi ronmental factors. Competition of inges ted environmental substances with other drugs and xenobiotic s for the metabolizing enzymes and poisoning of enzymes by toxic chemicals, such as carbon monoxide or pesticide synergists, alter metabolism. Induction of enzy me express ion (the number of enzyme molecules is increased, but the activity is constant) by other drugs and xenobiotics is another consideration. Such factors may change not only the kinetic s of an enzyme reaction but also the whole pattern of metabolis m, thereby altering the bioavailability, pharmacokinetics, pharmacological activity, or toxicity of a xenobiotic. Species differences in response to xenobiotics must be considered during the extrapolation of pharmacological and toxicological data from experiments in animals to humans. T he primary factors in these differences probably are the rate and pattern of drug and xenobiotic metabolism in the various species.

Drug Biotransform ation Pathway (Phase 1) Human Hepatic Cytochrome P450 Enzyme System Introduction Oxidation probably is the most common reaction in xenobiotic metabolism. T his reaction is catalyzed by a group of membrane-bound monooxygenases found in the smooth ER of the liver and other extrahepatic tissues, termed the “ cytochrome P450 monooxygenase enzyme system” (14) (hereafter, the abbrev iation CYP450 will be used for this enzyme sy stem). Additionally, CYP450 has been called a mixed-function oxidase or microsomal hy droxylase. T he tissue homogenate fraction containing the smooth ER is called the microsomal fraction. T he CYP450 functions as a multicomponent electron-transport system responsible for the oxidative metabolism of a variety of endogenous substrates (e.g., steroids, fatty ac ids , prostaglandins, and bile ac ids ) and exogenous substances (xenobiotics ), including drugs, carcinogens, insectic ides, plant toxins, environmental pollutants, and other foreign chemicals. Central to the functioning of this unique superfamily of heme proteins is a iron protoporphyrin. T he iron protoporphyrin is coordinated to the sulfur of c ysteine and has the ability to form a complex with carbon monoxide, the result of which is a complex that has its major absorption band at 450 nm (thus the title of these metabolizing CYP450 enzymes). T he CYP450 has an absolute requirement for NADPH (reduc ed form of nic otinamide adenine dinucleotide phosphate) and molecular oxygen (dioxygen). T he rate at which v arious compounds are metabolized by this system depends on the species, strain, nutritional status, tiss ue, age, and pretreatment of the animals. T he v ariety of reactions catalyzed by CYP450 include (T able 10.2) the oxidation of alkanes and aromatic compounds; the epoxidation of alkenes , polycy clic hydroc arbons, and halogenated benzenes; the dealkylation of secondary and tertiary amines and ethers; the deamination of amines ; the conversion of amines to N-oxides, hydroxylamine, and nitroso derivativ es; and the dehalogenation of halogenated hydrocarbons. It also catalyzes the oxidative cleavage of organic thiophosphate es ters, the sulfoxidation of some thioethers, the conversion of phosphothionates to the phos phate derivatives, and the reduction of azo and nitro compounds to primary aromatic amines. T he most important function of CYP450 is its ability to “ activate” molecular oxygen (dioxygen), permitting the incorporation of one atom of oxygen into an organic substrate molecule concomitant with the reduction of the other atom of oxygen to water. T he introduc tion of a hydroxyl group into the hydrophobic substrate molecule provides a site for subsequent conjugation with hydrophilic compounds (Phase 2), thereby increasing the aqueous solubility of the product for its transport and excretion from the organism. T his enzyme system not only catalyzes xenobiotic transformations in ways that usually lead to detoxication but also, in some cases, in ways that lead to products P.257 having greater cytotoxic, mutagenic, or carc inogenic properties. A nonheme, microsomal flavoprotein monooxygenase is responsible for

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the oxidation of certain nitrogen- and sulfur-c ontaining organic compounds.

Table 10.2. Hydroxylation Mechanisms Catalyzed by Cytochrome P450

Components of CYP450 T he CYP450 consists of at leas t two protein components: a heme protein called cytochrome P450, and a flavoprotein called NADPHCYP450 reductase, containing both flavin mononucleotide (FMN) and flavin dinucleotide (FAD). T he CYP450 is the substrate- and oxygenbinding site of the enzyme sy stem, whereas the reductase serves as an electron carrier, shuttling electrons from NADPH to CYP450. A third component essential for electron transport from NADPH to CYP450 is a phospholipid, phosphatidy lcholine, that facilitates the transfer of electrons from NADPH-CYP450 reductase to CYP450 (14). Although the phospholipid does not function in the system as an electron carrier, it has great influence on the CYP450 monooxy genase sys tem. T he phospholipid makes up approximately one-third of the hepatic ER and contributes to a negatively charged environment at neutral pH. Of the three components involved in micros omal oxidative xenobiotic metabolism, CYP450 is important be cause of its vital role in oxygen activation and substrate binding. T he CYP450 is an integral membrane protein deeply imbedded in the membrane matrix. T he environment surrounding the enzyme is negatively charged at neutral pH becaus e of the phospholipids. T he electron components of CYP450 are located on the cytoplas mic side of the ER and the hydrophobic active site toward the lumen of the ER (15). T he ac tive site of CYP450 consists of a hydrophobic substrate-binding domain in which is imbedded an iron protoporphyrin (heme) prosthetic group. T his group is exactly like that of hemoglobin, peroxidase, and the b-type cytoc hromes. T he iron in the iron protoporphyrin is coordinated with four nitrogens via a tetradentate to the porphyrin ring. X-ray studies reveal that in the ferric state, the two nonporphyrin ligands are water and cysteine (Fig. 10.1). T he cysteine thiolate ligand (proximal) is present in all states of the enzy me and is absolutely essential for the formation of the reactive oxenoid intermediate. T he sixth (distal) coordination position is occ upied by an easily exchangeable ligand, most likely water, which is labile and easily exchanged for stronger ligands, such as cyanide, amines, imid azoles, and pyridines. T he ferrous form loses the water ligand completely, leaving the s ixth position open for binding ligands such as oxygen and carbon monoxide.

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Fig. 10.1. Ferric heme thiolate catalytic center of CYP450. The porphyrin side chains are deleted for clarity.

T he vast array of xenobiotics presents a unique challenge to the human body to metabolize these lipophilic foreign compounds and makes it impractical to have one enzyme for each compound or each class of compounds. T herefore, whereas most cellular functions usually are very specific, xenobiotic oxidation requires CYP450s with diverse substrate spec ificities and regioselectiv ities (multiple sites of oxidation). Several types of CYP450 enzymes can be found in a single species of animal. For example, the rat has more than 40 different CYP450 genes, each coding for a different version of the enzyme (is oform) that can metabolize almost any lipophilic compound to which they are exposed.

Classification of the CYP450 Multigene Family Nebert et al. (16,17) classified the CYP450 supergene family on the basis of their structural (evolutionary) relationships T he CYP450 monooxygenases resulting from this supergene family have been subdivided into families with greater than 40% amino acid homology and subfamilies with greater than 55% homology (16,17). T he CYP450s are named using the root symbol CYP (CYtochrome P450), followed by an Arabic numeral designating the family member (e.g., CYP1, CYP2, or CYP3), a letter denoting the subfamily (e.g., CYP1A, CYP2C, CYP2D, or CYP2E), and another Arabic numeral repres enting the individual gene. Names of genes are written in italics . T he nomenclature system is based solely on sequence similarity P.258 among the CYP450s and does not indicate the properties or function of individual P450s. Of the more than 17 CYP450 isoforms that have been identified to date, the major isoforms responsible for drug metabolis m in the liver are presented in Figure 10.2 (18). It is quite evident that the CYP3A and CYP2C families are the isoforms most involved in the metabolism of clinic ally relevant drugs, and the CYP1A2 isoform is predominantly involved in the bioactivation of environmental substances.

Fig. 10.2. Total human CYP450 isoforms expressed in the liver that metabolize drugs.

T he CYP450s probably evolved initially for the regulation of endogenous substances, such as for metabolization of cholesterol to maintain membrane integrity and for steroid biosynthesis and metabolism, rather than for metabolizing foreign compounds. T he CYP450s are either involved in highly specific s teroid hydroxylations located in the inner mitochondrial membrane or bound to the ER of the cell having broad substrate specificity. In evolutionary terms , CYP450s evolved from a common ancestor, and only more recently (during the last 100 million years) have CYP450 genes taken on the role of producing enzymes for metabolizing a v ast array of lipophilic foreign compounds. T he emergence of the xenobiotic CYP450 genes probably evolved from the steroidogenic CYP450s for enhancing animal survival by synthesizing new CYP450s for metabolizing plant toxins in the food c hain. It is not surprising that animals and humans possess a large array of diverse CYP450 enzymes capable of handling a multitude of xenobiotic s. Interindividual variation in the express ion of xenobiotic CYP450 genes (genetic polymorphism) or their induc ibility may be associated with differences , such as in individual susceptibility to cigarette smoke carcinogenesis. Certain CYP450 isoforms that clearly exhibit genetic polymorphis m are known to metabolize and generally inactivate therapeutic agents. T he extent of CYP450 polymorphisms in humans is being investigated to determine the risk or protection against cancer. Food mutagens typically are carcino gens in tissue, but they are ac tivated by CYP1A2 in the liver and CYP3A. Specific forms of CYP450 in hepatic micros omes are regulated by hormones (e.g., CYP3A subfamily ) and are induced or inhibited by drugs, food toxins, and other environmental xenobiotics (see the section on induction and inhibition of CYP450 iso forms). Identification of a s pecific CYP450 isoform as the major form responsible for metabolism of a drug in humans permits reconciliation of its toxicity or other pharmacological effects.

Substrate Specificity No evidence exists that the active oxy genating species differ between CYP450s, s uggesting that the substrate specificities, substrate

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affinity, regioselectivity, and rates of reac tion probably are a c onsequence of topographic features of the active site of apoproteins (14,15,19,20). Because a primary function of these enzy mes is the metabolism of hydrophobic substrates, it is likely that hydrophobic forces are important in the binding of many s ubstrates to the apoproteins. Nonspecific binding is consistent with the multiple substrate orientations in the active s ite necessary for the broad regioselectivities observ ed. A s pecific binding requirement would decrease the diversity of substrates. Some CYP450 isoforms have constrained binding sites and, thus, metabolize small organic molecules (e.g., CYP2E1): CYP1A1/2 have planar binding sites and only metabolize aromatic planar compounds (i.e., polycyc lic aromatic hydrocarbons [PAHs]); CYP2D6 exhibits high affinities with specific apoprotein interactions (hydrogen bonds, ion-pair formation) for s pecific substrates, such as lipophilic amines; and CYP3A4 has broader affinity for a variety of lipophilic substrates (molecular weight, 200–1,200 daltons). If the CYP450 isoforms are tightly membrane bound, substrate access to the active site would be limited to compounds that c an diffuse through the membrane, whereas a different CYP450 isoform may be bound less tightly and will metabolize hydrophilic compounds. In the past, the CYP450s often were referred to as having broad and overlapping specificities, but it became apparent that the broad substrate specificity can be attributed to multiple isoenzy mic forms of CYP450. T he phenotype of an individual with respect to the forms and amounts of the individual CYP450s expressed in the liver can determine the rate and pathway of the metabolic clearanc e of a compound (see the disc ussion of genetic polymorphism). Significant differences exist between humans and animal species with respect to the catalytic activities and regulation of the expression of the hepatic drug-metabolizing CYP450s. T hese differences often make it difficult to extrapolate to humans the results of CYP450-mediated metabolis m studies performed experimentally in animal species. Caution is warranted in the extrapolation of rodent data to humans, because some isoforms are s imilar between species (e.g., CYP1A and CYP3A subfamilies) whereas others are different (e.g., CYP2A, CYP2B, CYP2C, and CYP2D). T he unique and diverse characteristics of the CYP450 ensure that predicting the metabolism of xenobiotics will be difficult. T o date, no crystal structure for a mammalian membrane-bound CYP450 isoform has been described. P.259

Other CYP450 Isoforms T he other CYP450 isoforms catalyzing the oxidation of steroids, bile acids, fat-soluble vitamins, and other endogenous substanc es include the following: CYP4, arachidonic acid or fatty acid metabolism; CYP5, thromboxane A 2 s ynthase converts arac hidonic acid into thromboxane A2 , which causes platelet aggregation; CYP7A, 7α-hydroxy las e cataly zes the rate-determining step in the biosynthesis of bile acids from cholesterol; CYP7B, brain-spec ific form of 7α-hydroxylase catalyzing the synthesis of the neurosteroids, 7α-hydroxy dehydroepiandros terone, and 7α-hydroxy pregnenolone ; CYP8A, prostacyclin synthase catalyzes the synthesis of prostaglandin I 2 and the regulation of hemostasis that opposes CYP5; CYP8B, 12α-hy droxylase in bile acid biosynthesis; CYP11A1, the first s tep in mitochondrial steroid biosynthesis that oxidatively cleaves the 17-side chain of cholesterol to pregnenolone, with d efects in this enzyme lead to a lack of glucocorticoids, feminization, and hypertension; CYP11B1, a mitochondrial 11β- hydroxylas e that hy droxylates 11-deoxyc ortisol to hydrocortisone or 11-deoxycorticosterone to corticosterone; CYP11B2, mitochondrial aldosterone synthase that hydroxylates corticosterone at the 18-pos ition to aldosterone; CYP17, 17α-hy droxylase and 17,20-lyas e (two enzymes in one) are required for production of testosterone and estrogen (lack of this enzyme affects sexual development at puberty); CYP19, aromatase, catalyzes the aromatization of ring A of testosterone to estrogen (lack of this enzyme caus es an estrogen deficiency and failure of females to develop at puberty); CYP21, C21 s teroid hy droxylase (lack of this enzyme prevents cortisol synthesis, div erting exc ess 17-hydroxy progesterone into overproduction of tes tos terone biosynthesis); CYP24, mitochondrial 25-hydroxy vitamin D 3 24-hydroxylase for the degradation/inactivation of vitamin D metabolites; CYP26A1, all-trans-retinoic acid hydroxylase, may be involved in terminating the retinoic acid signal and thus turning off a developmental s witc h.; CYP26B1, retinoic acid hydroxy las e may hydroxylate the ci s-retinoic acids not recognized by the CYP26A1; CYP26C, retinoic ac id hydroxylase, function is not known; CYP27A1, 27-hydroxylase, oxidizes cholesterol 17-s ide c hain as the first step in bile acid biosynthesis to the feedback inhibitors, cholic acid, and chenodeoxy cholic ac id, and 25-hydroxy-vitamin D 3 ; CYP27B1, mitochondrial vitamin D 3 1-α-hydroxylase activates vitamin D 3 ; CYP27C1, unknown function; CYP39, 7-hydroxylase of 24-hydroxy cholesterol with unknown function; CYP46 , cholesterol 24-hydroxylase with unknown function; CYP51, lanosterol 14α-demethylase, for converting lanosterol into cholesterol, inhibited by ketoconazole.

Cytochrome P450 Isoforms M etabolizing Drugs/Xenobiotics (18,19,20) Figure 10.3 shows the participation (%) of hepatic CYP450 isoforms in the metabolism of drugs and xenobiotics (21). Outstanding is the fact that more than one-third of all the drugs are metabolized by one isoform, CYP3A4, increasing the potential for drug–drug interactions. When two drugs are metabolized by the same isoform, only one drug can serve as a s ubstrate at one time, increasing the likelihood of a drug–drug interaction, es pecially if one drug has a lower therapeutic thres hold.

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Fig. 10.3. Percentage of clinically important drugs metabolized by human CYP450 isoforms.

Family 1 T he CYP1A subfamily plays an integral role in the metabolis m of two important classes of environmental carcinogens, PAHs, and arylamines (T ables 10.3 and 10.4) (22). T he PAHs commonly are pres ent in the env ironment as a result of industrial combustion processes and in tobacco products. Several potent carcinogenic arylamines result from the pyrolysis of amino acids in cooked meats and can cause colon cancer in rats. Environmental and genetic factors can alter the expression of this subfamily of thes e enzymes.

CYP1A1 T he CYP1A1 (also called aromatic hydrocarbon hydroxylase) is expressed primarily in extrahepatic tis sues, small intes tine, placenta, skin, and lung as well as in the liv er in response to the presence of CYP1A1 inducers, such as PAHs (i.e., in cigarette smoke and the carcinogen 3-methylcholanthrene), α-naphthoflavone (a noncarcinogenic inducer related to dietary flavo nes), and indole-3-carbinol (found in Brussel sprouts and related vegetables). T he CYP1A1 metabolizes a range of PAHs, including a large number of procarcinogens and promutagens. Diethylstilbestrol and 2- and 4-hydroxyestradiol (catecholes trogens) are oxidized by CYP1A1 to their quinone analogues, which normally are reduced to inactive metabolites (23). In the absence of a detoxifying reduction step, howev er, the quinones may accumulate and initiate carc inogenic processes or cell death by covalently damaging DNA or cellular proteins. Interindiv idual variation in the inducible express ion of CYP1A1 might be related to a genetic difference in aromatic hormone (Ah) receptor expression, which could explain differences in individual s usceptibility to cigarette smoke–induced lung cancer. T herefore, genetic fac tors appear to be important in the expression of the CYP1A1 gene in humans and its involvement in human carc inogenesis. Women who smoke are at greater risk than men of developing lung cancer (adenocarcinoma) and chronic obstructive P.260 pulmonary diseases . T he mechanis m for the induction of the CYP1A1 gene begins with binding of the inducing agents to a cytosolic receptor protein, the Ah receptor, which is translocated to the nucleus and binds to the DNA of the CYP1A1 gene, thus enhancing its rate of transcription. T he presence of the Ah receptor in hepatic and intes tinal tis sues may have implications beyond xenobiotic metabolism and may play a role in the induc tion of other genes for the control of cellular growth and differentiation. On the other hand, CYP1A1 may metabolize procarcinogens to hydroxylated inactive compounds that are not mutagenic. T he question of how the bowel protects itself from ingested compounds known to be activated by CYP1A1 (i.e., PAH) remains unanswered (22).

Table 10.3. Some Substrates and Reaction Type for Human Subfamily CYP1A2a Acetaminophen (imino quinone) Amitriptyline (N-demethylation) Caffeine (N 1 - and N 3 -demethylation) Chlordiazapoxide Cinacalcet Clomipramine (N-demethylation) Clopidogrel Clozapine Cyclobenzaprine Desipramine (N-demethylation) Diazepam Duloxetine Erlotinib Estradiol (2- and 4-hydroxylation) Flutamide Fluoroquinolones (3′-hydroxylation of piperazine ring) Fluvoxamine Haloperidol Imipramine (N-demethylation) Levobupivacaine Mexiletine Mirtazepine Naproxen Nortriptyline Olanzapine Ondansetron Propafenone Propranolol Ramelteon Riluzole Ropivacaine Roprinirole

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Tacrine Theophylline Tizanidine Verapamil R-warfarin Zileuton Zolmitriptan a

Drugs in bold italic have been reported to cause drug–drug interactions.

Table 10.4. Some Procarcinogens and Other Toxins Activated by Human Cytochrome P450s CYP1A1 Benzo[a]pyrene and other polycyclic aromatic hydrocarbons

CYP1A2 4-Aminobiphenyl 2-Naphthylamine 2-Aminofluorene 2-Acetylaminofluorene 2-Aminoanthracene Heteropolycyclic amines (2-aminoquinolines) Aflatoxin B1 Ipomeanol

CYP2E1 Benzene Styrene Acrylonitrile Vinyl bromide Trichloroethylene Carbon tetrachloride Chloroform Methylene chloride N-nitrosodimethylamine 1,2-Dichloropropane Ethyl carbamate

CYP3A4 Aflatoxin B1 Aflatoxin G1 Estradiol 6-Aminochrysene Polycyclic hydrocarbon dihydrodiols

CYP1A2 T he CYP1A2 (also known as phenacetin O-deethylase, caffeine demethylase, or antipyrine N-demethylase) catalyzes the oxidation (and, in some cases, bioactivation) of ary lamines, nitrosamines, and aromatic hydrocarbons and the bioactiv ation of promutagens and procarcinogens, caffeine, and other substances (T ables 10.3 and 10.4). It is express ed in the liver to the extent of 13% (range of up to 40%), intestine, and stomach and is induced by smoking, PAHs, and is osafrole (a noncarcinogenic dietary compound). CYP1A2 is primarily responsible for the activation of the c arcinogen aflatoxin B1 under ordinary conditions of human expos ure and the pneumotoxin ipomeanol. T he latter activation occurs in the liver and not in the lungs by CYP2F1 and CYP4B1 as previous ly thought. Evidence for polymorphism of this isoform has been reported, and it is likely that low CYP1A2 ac tivity will be associated with altered susceptibility to the bioactivation of procarcinogens, promutagens, and other xenobiotics known to be substrates for this enzyme. T he expression of the CYP1A2 gene in the stomach becomes an important issue for gastric carcinogenesis induc ed by smok ing and the metabolic activation of the procarcinogens, arylamines, to mutagens (22). P.261 Clinical studies have suggested that the N-demethylation of imipramine is greater in smokers than in n onsmokers.

Table 10.5. Some Substrates for Human Subfamily CYP2B6 Bupropion Cyclophosphamide Efavirenz Ifosfamide Methadone

Family 2 CYP2A6 T he CYP2A6 is the only member of this subfamily that is expressed primarily in the liver and also may be expressed in lung and nasal epithelium. It has a low level of hepatic expressio n and represents approximately 4% of the total hepatic CYP450 isoforms (Fig. 10.2). It catalyzes the 7-hydroxylation of coumarin (coumarin 7-hy droxylase), hydroxylation of aflatoxin B1, nicotine (C-oxidation to cotinine),

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naproxen, tacrine, clozapine, mexiletine, and cyc lobenzaprine as well as the bioactivation of nitrosamines and procarc inogens. T he CYP2A6 exhibits polymorphism with an incidence of 2% in the Caucasian population. T his population is characterized as poor metabolizers. Smokers with a defective CYP2A6 gene smoke fewer cigarettes, implicating a genetic factor in nicotine dependence.

Table 10.6. Some Substrates and Reaction Type for Human Subfamily CYP2Ca CYP2C8

CYP2C9

CYP2C19

Amiodarone

Amitriptyline

Piroxicam

Amitriptyline

Amodiaquine

Carvedilol

Ramelteon

Carisoprodol

Benzphetamine

Celecoxib

Rosiglitazone

Cilostazol

Carbamzepine

Chlorpheniramine

Sildenafil

Citalopram

Cerivastatin

Chloramphenicol

Sulfamethoxazole

Clomipramine

Docetaxel

Clomipramine

Sulfinpyrazone (aromatic hydroxylation)

Cyclophosphamide

Fluvastatin

Desogestrel

Isotretinoin

Diclofenac (4′-hydroxylation)

Suprofen

Diazepam (N-demethylation)

Paclitaxel

Diazepam

Tamoxifen

Escitalopram

Phenytoin

Dronabinol

Tienilic acid (thiophene ring hydroxylation)

Esomeprazole

Pioglitazone

Fluoxetine

Repaglinide

Flurbiprofen

Retinol

Fluvastatin

Rosiglitazone

Formoterol

Torsemide

Indomethacin

Tolbutamide

Glibenclamide

∆ 1 -THC (7-hydroxylation)

Lansoprazole

Torsemide

Glimepiride

Testosterone (16α-hydroxylation)

Loratidine (descarbethoxyation)

Verapamil

Glipizide

Valdecoxib

(S)-Mephenytoin (4′-hydroxylation)

Zopliclone

Glyburide

Vardenafil

(R)-Mephenytoin (N-demethylation)

Hexobarbital (3′-hydroxylation)

Valsartan

(R)-Mephobarbital

Desipramine

Formoterol Tolbutamide (p-methylhydroxylation)

Hexobarbital

Imipramine (N-demethylation)

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Ibuprofen (i-butylmethylhydroxylation)

Voriconazole

Moclobemide

S-Warfarin (7′-hydroxylation)

Nelfinavir

Imipramine

Zafirlukast

Nilutamide

Indomethacin

Zileuton

Omeprazole (hydroxylation)

Irbesartan

Pantoprazole

Irinotecan

Pentamidine

Lomoxicam

Phenobarbital

Losartan

Phenytoin (ring hydroxylation)

Mefenamic acid

Progesterone

Meloxicam

Proguanil (cyclization)

(R)-Mephenytoin

Propranolol (side chain hydroxylation)

Montelukast

Rabeprazole

Nateglinide

Teniposide

Omeprazole

Thioridazine

Phenytoin (4′-hydroxylation)

Tolbutamide

Phenylbutazone (4-hydroxylation)

Voriconazole

(R)-Warfarin *Drugs in bold italic have been reported to cause drug-drug interactions.

CYP2B6 Limited data are available regarding the CYP2B6 isoform, and it represents less than 1% of the total hepatic CYP450 isoforms. Its level of expression is low, and phenobarbital appears to induce its formation. T he role of CYP2B6 in human drug metabolism is questionable, although cyclophosphamide, ifos famide, bupropion, and nicotine are metabolized by this isoform (T able 10.5).

CYP2C T he human CYP2C subfamily is the most complex family consis ting of CYP2C8, CYP2C9, and CYP2C19, metabolizing approximately 25% of the clinically important drugs (Fig. 10.3), including S-warfarin, S-mephenytoin, and tolbutamide (T able 10.6). It represents P.262

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approximately 20% of the total CYP450 isoforms in the liver (Fig. 10.2). T he CYP2C8 is express ed primarily in extrahepatic tissues (kidney, adrenal, brain, uterus, breast, ovary, and intestine) and metabolizes the tricy clic antidepres sants, diazepam, and verapamil. Its level of expression is less than CYP2C9 and CYP2C19. Both CYP2C9 and CYP2C19 are found primarily in the liver and intestine. T he expression of CYP2C19 in the liver is less than that for CYP2C9. Both CYP2C9 and CYP2C19 exhibit polymorphism (difference in the DNA sequence for the CYP2C gene) that changes the enzyme's ability to metabolize its substrates (i.e., poor metabolizer phenoty pe). Because of this genetic differenc e in expressing CYP2C isoforms, it is important to be aware of a pers on's rac e when pres cribing drugs that are metabolized differently by different populations (see the section concerning genetic polymorphism). T he CYP2C9 is involved in tolbutamide methyl hydroxylation and is a factor in the 4′-hydroxylation of phenytoin, 6/7– hydroxylation of S-warfarin, and R-mephenytoin. T he CYP2C19 (S-mephenytoin hydroxylase) is the isoform associated with the 4′-hydroxylation of S-mephenytoin. T he CYP2C subfamily apparently is not inducible in humans.

CYP2D6 T he CYP2D6 polymorphism is, perhaps, the mos t studied CYP450 (see the section on genetic polymorphis m). T his enzyme is responsible for at least 30 different drug oxidations, represen ting approximately 21% of the clinically important drugs (Fig. 10.3). T he CYP2D6 is only 3% expressed in the liv er and minimally expressed in the intestine, and it does not appear to be inducible (Fig. 10.2). Because there may be no other way to clear drugs metabolized by CYP2D6 from the system, poor metabolizers of CYP2D6 substrates may be at s evere risk for adverse drug reactions or drug overdose. T he metabolism of debrisoquine by CYP2D6 is one of the most studied examples of metabolic polymorphism, with its molecular basis of defective metabolism being well understood (T able 10.7) (see the section on genetic polymorphism). T his isoform metabolizes a wide variety of lipophilic amines and is probably the only CYP450 for which a charged or ion-pair interaction is important for substrate binding. It also appears to preferentially catalyze the hydroxy lation of a single enantiomer (stereoselectivity) in the presence of enantiomeric mixtures. Quinidine is an inhibitor of CYP2D6, and concurrent adminis tration with CYP2D6 substrates results in increas ed blood levels and toxicity for these subs trates. If the pharmacological action of the CYP2D6 substrate depends on the formation of active metabolites, quinidine inhibition results in a lack of a therapeutic response. T he interaction of two subs trates for CYP2D6 can prompt a number of clinical respons es. For example, depending on which substrate has the greater affinity for CYP2D6, the first-pass hepatic metabolism of the substrate (drug) with weaker affinity will be inhibited by a second substrate having greater affinity. T he result of this will be a decrease and prolongation of elimination of the first substrate, leading to a higher plasma concentration and an increased potential for adverse toxic ity.

CYP2E1 Few drugs are metabolized by CYP2E1, but it plays a major role in the metabolism of numerous halogenated hydroc arbons (including volatile general anesthetics) and a range of low-molecular-weight organic compounds, including dimethyformamide, acetonitrile, acetone, ethanol, and benzene, as well as in the activation of acetaminophen to its reactiv e metabolite, N-acetyl-p-benzoquinoneimine (T able 10.8) (24,25). T he CYP2E1 is of most interest bec ause of the toxicity and carcinogenicity of its metabolites. T his isoform is expressed in the liver (7%), kidney, intestine, and lung, and it is inducible by ethanol, isoniazid, 4-methylpyrazole, and other chemicals (see T able 10.12). It also is known as microsomal ethanol-oxidizing system, benzene hy droxylase, or aniline hydroxylase. T he CYP2E1 is induced in alcoholics, and there is a polymorphism associated with this isoform that is more common in Chines e people. T his is oform also appears to be related to smoking-induced canc er (c.f., CYP1A2). Most of the same compounds that induce CYP2E1 also are subs trates for the enzyme. T he induction of this enzyme in humans can cause enhanced susceptibility to the toxicity and carcinogenesis of CYP2E1 substrates. Some evidence shows interindividual variation in the in vitro liver expression of this isoform. Diabetes and dietary alterations (i.e., fasting and obesity) result in the induction of CYP2E1. Ketogenic diets (increased serum k etone levels), including those deficient in carbohydrates or high in fat, are known to enhance the metabolism of halogenated hydrocarbons in rats (25). T he mechanism of induction appears to be a combination of an increase in CYP2E1 transcription, mRNA translation efficiency, and stabilization of CYP2E1 against proteolytic degradation. T he induction of CYP2E1 resulting from ketosis (i.e., starvation, a high-fat diet, uncontrolled diabetes, and obesity) or exposure to alcoholic beverages or other xenobiotics may be detrimental to individuals simultaneously exposed to halogenated hydrocarbons (increased hepatotoxicity from exposure to halothane, chloroform). Chronic alcohol intake is known to enhance the hepatotoxicity of halogenated hydrocarbons. T estosterone appears to regulate CYP2E1 levels in the kidney and pituitary growth hormone for regulating hepatic levels of CYP2E1. Kidney damage from halocarbons was greater for male rats but not for female rats. T his finding may have implications for s exual differenc es in the nephrotoxicity of CYP2E1 s ubstrates in humans .

Family 3 CYP3A4 T he CYP3A subfamily includes the most abundantly expressed CYP450s in the human liver and intestine (extrahepatic metabolism). Although CYP3A4 is responsible for approximately two-thirds of CYP3A-mediated drug metabolism, the other minor isoforms (CYP3A5, CYP3A7, and CYP3A43) also contribute. T he P.263 CYP3A5 is the best studied of the minor CYP3A isoforms. Approximately 20% of human livers express CYP3A5. T he expression of CYP3A5 shows interethnic differences, with the wild-type CYP3A5*1 allele being more common in Africans than in Caucasians and Asians. In individuals who express CYP3A5, 17 to 50% of the total hepatic CYP3A is this isoform. Additionally, CYP3A5 also is expressed in a range of extrahepatic tissues and is inducible via pregnane X rec eptor. Both CYP3A4 and CYP3A5 exhibit significant overlap in s ubstrate specificity but can differ in catalytic activity and regioselectivity. Results from a comparison of CYP3A4 and CYP3A5 enzyme kinetics indicate that CYP3A5 has different enzymic characteristics from CYP3A4 in some CYP3A-catalyzed reac tions . T he enzyme kinetics for CYP3A5 suggest a faster substrate turnover than with CYP3A4.

Table 10.7. Some Substrates and Reaction Type for Human CYP2D6 Isoforma

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Alprenolol (4-hydroxylation) Amitriptyline (10-hydroxylation) Amphetamine Aripiprazole Atomoxetine Bifuralol (1′-hydroxylation) Bisoprolol Captopril Carvedilol Cevimeline Chlorpheniramine (N-demethylation, ring hydroxylation, deamination) Chlorpromazine Chlorpropamide Cinacalcet Clemastine Clomipramine (hydroxylation) Clozapine (aromatic hydroxylation) Codeine (O-demethylation) Cyclobenzaprine Darifenacine Debrisoquine (4-hydroxylation) Desipramine Dexfenfluramine Dextromethorphan (O-demethylation) Diphenhydramine (N-demethylation, ring hydroxylation, cleavege ether bond) Dolasetron (hydroxylation of indole ring) Donepezil Doxepin Duloxetine Encainide (N-demethylation, O-demethylation) Fenfluramine Fluphenazine Fentanyl Flecainide (O-dealkylation) Fluoxetine(N-dealkylation) Fluvoxamine Formoterol Galantamine Guanoxan (6- and 7-hydroxylation) Haloperidol Hydrocodone Hydroxyzine (ring hydroxylation) Imipramine (2-hydroxylation) Indoramin (6-hydroxylation) Lidocaine (3-hydroxylation) Maprotiline Meperidine Methadone Methamphetamine Methoxyamphetamine (4-hydroxylation, N-demethylation) Metoclopramide Metoprolol (O-demethylation) Mexilletine (4-hydroxylation and methyl hydroxylation) Minaprine Mirtazepine Morphine Nebivolol Nortriptyline (10-hydroxylation) Olanzepine Ondansetron (hydroxylation of indole ring) Oxycodone Paroxetine Perhexiline (4′-hydroxylation) Perphenazine (aromatic hydroxylation) Phenacetin

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Phenformin (4-hydroxylation) Pindolol Promethazine (ring hydroxylation, S-oxidation, N-demethylation) Propafenone (4-hydroxylation) Propoxyphene Propranolol (4′-hydroxylation) Quetiapine Quinidine (hydroxylation) Ranolazine Risperidone Ritonavir Sertraline S-Metoprolol Sparteine (N-oxidation) Tamoxifen Thioridazine (aromatic hydroxylation) Timolol (O-dealkylation) Tolterodine (2-hydroxylation) Tramadol Trazodone Tripelennamine Tropisetron (hydroxylation of indole ring) Venlafaxine a


Approximately one-third of the total CYP450 in the liver and two-thirds in the intestine is CYP3A4. T his isoform is responsible for the metabolism of more than one-third of the clinically important drugs. T he CYP3A4 is expressed in the intestine, lung, placenta, kidney, uterus, and brain and is glucoc orticoid inducible. T he CYP3A7 is predominantly expressed in fetal liver (~ 50% of total fetal CYP450 enzymes) but also is found in s ome adult livers and extrahepatically. T he CYP3A7 has a specific role in hydroxylation of retinoic acid, 16α-hydroxylation of steroids, and hydroxylation of allylic and benzylic P.264 carbons and, therefore, is of relevance both to normal development and to carcinogenesis. T he most recently discovered CYP3A isoform is CYP3A3. In addition to a low level of expression in liver, it is expressed in prostate and testis. Its substrate specificity c urrently is unclear. Polymorphisms predic ting absence of active enzyme have been identified.

Table 10.8. Some Substrates and Reaction Type for Human CYP2E1 Isoforma Acetaminophen (p-benzoquinone imine) Styrene (epoxidation) Theophylline (C-8 oxidation) Disulfiram Halogenated Hydrocarbons Dehalogenation of chloroform, methylene chloride Volatile Anesthetics (fluorinated hydrocarbons) Enflurane, Halothane, Methoxyflurane, Sevoflurane, Desflurane Miscellaneous Organic Solvents Ethanol (to acetaldehyde) Glycerin Dimethylformamide (N-demethylation) Acetone Diethylether Benzene (hydroxylation) Aniline (hydroxylation) Acetonitrile (hydroxylation to cyanohydrin) Pyridine (hydroxylation) a

Drugs in bold italics have been reported to cause drug–drug interactions.

T he CYP3A4 subfamily metabolizes a wide range of clinically important drugs (T able 10.9) and is inhibited by a number of xenobiotics, including erythromycin (T able 10.10). It also appears to ac tivate aflatoxin B1 and, poss ibly, benzo[a]pyrene metabolism. T he

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interindividual differences reported for the metabolism of nifedipine, cy closporine, triazolam, and midazolam probably are related to changes in induction and not to polymorphism. Binding of CYP3A is predominantly lipophilic (14). Drugs known to be substrates for CYP3A4 have a low and variable oral bioavailability that may be explained by prehepatic metabolism by a combination of intestinal CYP3A4 and P-glycoprotein in the enterocytes of the intestinal wall (see the section on oral bioavailability). T herefore, it is the expression and function of CYP3A4 that gov erns the rate and extent of metabolism of the substrates for the CYP3A subfamily. T he induction of the CYP3A subfamily by phenobarbital in humans may ultimately be responsible for many of the well-documented interactions between barbiturates and other drugs (19,20). Clearly, no one animal model or combination of animal models reflects the metabolic capabilities of humans. By having a complete understanding of the factors (e.g., inducers, inhibitors , and effect of disease state) that alter the expression and activity of the enzyme responsible for the metabolism of a particular compound, and by a determination of responsible isoforms and patient phenotyping, it may be possible to predict drug interactions and metabolic c learance. An alphabetical listing of the clinically important drugs and their CYP450 isoforms catalyzing their oxidative metabolism is presented in T able 10.11.

Catalytic Cycle of Cytochrome P450: Steps of the Catalytic Cycle T he many variant CYP450 isoforms that have been isolated show a remarkable uniformity for the c ataly tic mechanism (21,26,27). T he current view illustrating the cyclic mechanism for the reduction and oxygenation of CYP450 as it interacts stepwise with substrate molecules, electron donors, and oxygen is shown in Figure 10.4 and can be s ummarized as follows (26,27): Step a. T he ferric CYP450 binds reversibly with a molecule of the substrate (RH), resulting in a complex analogous to an enzyme– substrate complex. T he binding of the substrate facilitates the first one-electron reduction step. Step b. T he substrate complex of ferric–CYP450 undergoes reduction to a ferrous–CYP450 substrate complex by a n electron originating from NADPH and transferred by the flavoprotein, NADPH-CYP450 reductase, from the FNMH2/FADH complex. Step c. T he reduced CYP450 complex readily binds dioxygen as the ferrous iron sixth ligand to form oxy–CYP450 complex. Step d. Oxy–CYP450 undergoes auto-oxidation to a superoxid e anion. Step e. T he ferric superoxide anion undergoes further reduction by accepting a second electron from the flavo protein (or possibly cytochrome b5) to form the equivalent of a two-electron-reduced complex, P.265 P.266 P.267 P.268 peroxy–CYP450. T he cycle c an be aborted (uncoupled) from subsequent substrate hydroxylation at this step by xenobiotics, which can cause the superoxide anion to disproportionate to hydrogen peroxide and dioxygen with regeneration of the starting point of the cycle, the ferric heme protein–substrate complex.

Fig. 10.4. Cyclic mechanism for CYP450. The substrate is RH, and the valence state of the heme iron in CYP450 is indicated.

Table 10.9. Substrates and Reaction Type for Human CYP3A4 Isoforma

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Alfentanyl Alfuzosin Almotriptan Alprazolam Amitriptyline Amiodarone (N-deethylation) Amlodipine Amprenavir Aprepitant Aripiprazole Astemizole Atazanavir Atorvastatin “Azole” antifungals Bepridil Bexarotene Bromocriptine Budesonide Buprenorphine Buspirone Cafergot Caffeine Cannabinoids Carbamzepine (epoxidation) Cerivastatin Cevimeline Chlorpheniramine Cilostazol Cinacalcet Citopram Clarithromycin Clindamycin Clomipramine Clonazepam Clopidogrel Clozapine Cocaine Codeine (N-demethylation) Colchicine Cyclophosphamide Cyclosporine (N-demethylation and methyl oxidation) Dapsone (N-oxide) Darifenacin Delavirdine Desogestrel Dextromethorphan (N-demethylation) Diazepam (C-7 hydroxylation) Dihydroergotamine Diisopyramide Diltiazem (N-deethylation) Docetaxel Dofetilide Dolasetron (N-oxide) Domperidone Donepezil Doxorubicin Dronabinol Duasteride Efavirenz Eplerenone Ergotamine Erlotinib Erythromycin (N-demethylation) Esomeprazole Eszopiclone

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Ethinylestradiol Ethosuximide Etonogestrel Etoposide Exemestane Felodipine Fentanyl Finasteride Fexofenadine Flutamide Fluticasone Galantamine Gleevec Haloperidol Hydrocodone Imatinib Imipramine (N-demethylation) Isradipine (aromatization) Indinavir Irinotecan Itraconazole Keotconazole Lansoprazole Letrozole Lercanidipine Lidocaine (N-deethylation) Loratidine Lopinavir Lovastatin (6-hydroxylation) Methadone Midazolam (methyl hydroxylation) Mifepristone Mirtazepine Modafinil Mometasone Montelukast Nateglinide Nelfinavir Nevirapine Nicardipine (aromatization) Nifedipine Nisoldipine Nitrendipine Norethindrone Odanestron Omeprazole Oral contraceptives/progestins Oxybutynin Paclitaxel Pantoprazole Pioglitazone Propranolol Quetiapine Quinidine (not 3A5) (C-3 hydroxylation) Quinine Rabeprazole Ramelteon Ranolazine Repaglinide Rifampin, rifabutin, and related compounds Ritonavir Salmeterol Saquinavir Sertraline

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Sibuttramine Sildenafil Simvastatin Sirolimus Solifenacin Sorafenib Sunitinib Steroids Testosterone (6β-hydroxylation) Progesterone (6β-hydroxylation) Estradiol (2- and 4-hydroxylation) 17α-ethinyl estradiol (2- and 4- hydroxylation) Norethisterone (2-hydroxylation) Hydrocortisone (6-hydroxylation) Methylprednisolone Prednisone (6β-hydroxylation) Prednisolone (6β-hydroxylation) Dexamethasone Tacrolimus Tadalafil Tamoxifen (N-demethylation) Telithromycin Temazepam ∆ 1 -THC (6β-hydroxylation) Theophylline (C-8 oxidation) Tiagabine Tinidazole Tipranavir Tolterodine (N-demethylation) Toremifene Tramadol Trazodone Triazolam Trimetrexate Valdecoxib Valproic acid (hydroxylation and dehydrogenation) Vardenafil Verapamil (N-demethylation) Vinblastine Vincristine Voriconazole R-Warfarin Zaleplon Zileuton Ziprasidone Zolpidem Zonisamide a


Table 10.10. Cytochrome P450 Inhibitorsa CYP1A2 Amiodarone Atazanavir Cimetidine Ciprofloxacin Citalopram Clarithromycin Diltiazem

CYP2B6 Thiotepa Ticlopidine

CYP2C8 Anastrozole Gemfibrozil Glitazones Montelukast Nicardipine Sulfinpyrazone Trimethoprim

CYP2C19 Cimetidine Citalopram Delavirdine Efavirenz Felbamate Fluconazole Fluoxetine Fluvastatin

CYP2C9 Amiodarone Atazanavir Cimetidine Clopidogrel Cotrimoxazole Delavirdine Disulfiram

CYP2D6 Amiodarone Bupropion Celecoxib Chloroquine Chlorpheniramine Chlorpromazine Cimetidine

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Enoxacin Erythromycin Ethinyl Estradiol Fluoroquinolones Fluvoxamine Interferon Isoniazid Ketoconazole Methoxsalen Mibefradil

Fluvoxamine Indomethacin Isoniazid Ketoconazole Lansoprazole Modafinil Omeprazole Oxcarbazepine Probenicid Ticlopidine Topiramate

Efavirenz Fenofibrate Fluconazole Fluorouracil Fluoxetine Fluvastatin Fluvoxamine Gemfibrozil Imatinib Isoniazid Itraconazole Ketoconazole Leflunomide Lovastatin Methoxsalen Metronidazole Mexiletine Modafinil Nalidixic acid Norethindrone Norfloxacin Omeprazole Oral Contraceptives Paroxetine Phenylbutazone Probenicid Sertraline Sulfamethoxazole Sulfaphenazole Sulfonamides Tacrine Teniposide Ticlopidine Tipranavir Troleandomycin Voriconazole Zafirlukast Zileuton

Cinacalcet Citalopram Clemastine Clomipramine Cocaine Darifenacin Desipramine Diphenhydramine Doxepin Doxorubicin Duloxetine Escitalopram Fluoxetine Fluphenazine Halofantrine Haloperidol Hydroxychloroquine Hydroxyzine Imatinib Levomepromazine Methadone Metoclopramide Mibefradil Midodrine Moclobemide Norfluoxetine Paroxetine Perphenazine Propafenone Propoxyphene Propranolol Quinacrine Quinidine Ranitidine Ranolazine Ritonavir Sertraline Terbinafine Thioridazine Ticlopidine Tipranavir Tripelennamine

a

CYP450 isoform inhibitors presented in bold italics have been associated with drug interactions of clinical relevan that may require dosage adjustment. (Data from Stockley's Drug Interactions: A Source Book of Interactions, Their Management. London and Chicago: Pharmaceutical Press, 2006.)

Table 10.11. Substrates for the CYP450 Isoforms Catalyzing Their Metabolism Acetaminophen

1A2, 2E1, 3A4

Albendazole

3A4, 1A2

Alfentanil

3A4

Alprazolam

3A4

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Amiodarone

3A4, 2C8

Amitriptyline

1A2, 2C9, 2D6, 3A4, 2C19

Amlodipine

3A4

Amphetamine

2D6

Anastrozole

3A4

Astemizole

3A4

Atomoxetine

2D6

Atorvastatin

3A4

Bepridil

3A4

Bisoprolol

2D6

Bupropion

2B6

Busulfan

3A4

Caffeine

1A2

Cannabinoids

3A4

Carbamazepine

2C8, 3A4

Carisoprodol

2C19

Carvedilol

2C9, 2D6

Celecoxib

2C9

Cerivastatin

3A4

Cevimeline

2D6

Chlordiazepoxide

1A2

Chloroquine

3A4

Chlorpromazine

2D6, 3A4

Chlorzoxazone

2E1

Cilostazol

2C19

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Cimetidine

3A4

Cisapride

3A4

Citalopram

2C19

Clarithromycin

3A4

Clindamycin

3A4

Clomipramine

1A2, 2C9, 2C19, 2D6, 3A4

Clopidogrel

1A2

Clonazepam

3A4

Clozapine

1A2, 2D6, 2A6

Cocaine

3A4

Codeine

2D6, 3A4

Cyclobenzaprine

1A2, 2A6, 2D6, 3A4

Cyclophosphamide

2B6, 2C19, 3A4

Cyclosporine

3A4

Dapsone

2C9, 3A4

Delavirdine

3A4

Desipramine

1A2, 2C19, 2D6

Desogestrel

2C9

Dexamethasone

3A4

Dexfenfluramine

2D6

Dextromethorphan

2D6, 3A4

Diazepam

1A2, 2C19, 2C9, 3A4

Diclofenac

2C8/9

Diltiazem

3A4

Disopyramide

3A4

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Divalproex sodium

2C19

Docetaxel

2C8, 3A4

Dolasetron

2D6, 3A4

Donepezil

2D6, 3A4

Doxepin

2D6

Doxorubicin

3A4

Dronabinol

2C9

Enalapril

3A4

Encainide

2D6

Enflurane

2E1

Ergot alkaloids

3A4

Erythromycin

3A4

Esomeprazole

2C19

Estradiol

1A2

Estrogens, oral

3A4

Ethanol

2E1

Ethinyl estradiol

3A4

Ethosuximide

3A4

Etoposide

3A4

Felodipine

3A4

Fenfluramine

2D6

Fentanyl

2D6, 3A4

Fexofenadine

3A4

Finasteride

3A4

Flecainide

2D6

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Fluconazole

3A4

Flurbiprofen

2C9

Fluoxetine

2C9, 2D6

Fluvastatin

2C8, 2C9

Fluphenazine

2D6

Flutamide

1A2, 3A4

Fluvoxamine

1A2, 2D6

Formoterol

2C9, 2C19, 2D6

Galantamine

2D6

Glimepiride

2C9

Glipizide

2C9

Glyburide

2C9, 3A4

Granisetron

3A4

Halofantrine

3A4

Haloperidol

1A2, 2D6

Halothane

2E1

Hexobarbital

2C19, 2C9

Hydrocodone

2D6, 3A4

Hydrocortisone

2D6, 3A4

Ibuprofen

2C9

Ifosfamide

2B6, 3A4

Imipramine

1A2, 2C19, 2C9, 2D6, 3A4

Indinavir

2D6, 3A4

Indomethacin

2C9, 2C19

Irbesartan

2C9

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Isoflurane

2E1

Isoniazid

2E1

Isotretinoin (retinoids)

1A2, 2C8, 3A4

Isradipine

3A4

Itraconazole

3A4

Ketoconazole

3A4

Labetalol

2D6

Lansoprazole

2C19, 3A4

Lidocaine

2D6, 3A4

Losartan

2C9, 3A4

Lovastatin

3A4

Maprotiline

2D6

Meclobemide

2C19

Mefenamic acid

2C9

Mefloquine

3A4

Meloxicam

2C9

Meperidine

2D6

Mephenytoin

2C19

Mephobarbital

2C9

Methadone

1A2, 2D6

Methamphetamine

2D6

Metoprolol

2D6

Mexiletine

1A6, 2D6, 2A6

Mibefradil

3A4

Miconazole

3A4

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Midazolam

3A4

Mirtazapine

1A2, 2D6, 3A4

Montelukast

2C9

Morphine

2D6

Naproxen

1A2, 2C18, 2C9, 2A6

Nateglinide

2C9

Navelbine

3A4

Nefazodone

3A4

Nelfinavir

3A4

Nevirapine

3A4

Nicardipine

3A4

Nicotine

2A6, 2B6

Nifedipine

3A4/5

Nilutamide

2C19

Nimodipine

3A4

Nisoldpine

3A4

Nitrendipine

3A4

Nortriptyline

1A2, 2D6

Olanzapine

2D6

Omeprazole

2C19, 2C9, 3A4

Ondansetron

1A2, 2D6, 2E1, 3A4

Oral contraceptives

3A4

Oxycodone

2D6

Paclitaxel

2C8, 3A4

Pantoprazole

2C19

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Paroxetine

2D6

Perphenazine

2D6

Phenacetin

1A2

Phenformin

2D6

Phenol

2E1

Phenytoin

2C19, 2C8, 2C9

Pimozide

3A4

Pindolol

2D6

Pioglitazone

2C8

Piroxicam

2C18, 2C9

Pravastatin

3A4

Praziqantel

2B6, 3A4

Prednisone

3A4

Progesterone

3A4, 2C19

Proguanil

2C18, 2C19

Propafenone

1A2, 2D6, 3A4

Propoxyphene

2D6

Propranolol

1A2, 2C18, 2C19, 2D6

Quetiapine

2D6

Quinidine

3A4

Quinine

3A4

Rabeprazole

2C19

Rapaglinide

2C8

Retinoic acid

2C8

Rifabutin

3A4

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Rifampin

3A4

Riluzole

1A2

Risperidone

2D6

Ritonavir

2A6, 2C19, 2C9, 2D6, 2E1, 3A4

Ropinirole

1A2

Ropivacaine

1A2, 2D6

Rosiglitazone

2C8, 2C9

Salmeterol

3A4

Saquinavir

3A4

Selegiline

2D6

Sertindole

2D6

Sertraline

2D6, 3A4

Sevoflurane

2E1

Sildenafil

2C9, 3A4

Simvastatin

3A4

Sufentanil

3A4

Sulfamethoxazole

2C9

Tacrine

1A2, 2A6

Tacrolimus

3A4

Tamoxifen

1A2, 2A6, 2B6, 2D6, 2E1, 3A4

Temazepam

3A4

Teniposide

3A4, 2C19

Terfenadine

3A4

Testosterone

3A4

Theophylline

1A2, 2E1, 3A4

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Thiabendazole

1A2

Thioridazine

2C19, 2D6

Tiagabine

3A4

Timolol

2D6

Tolbutamide

2C8,2C9, 2C19

Tolteridine

2D6

Torsemide

2C9

Tramadol

2D6

Trazodone

2D6

Tretinoin

2C8, 3A4

Triazolam

3A4

Troleandomycin

3A4

Tropisetron

2D6

Valsartan

2C9

Valproic acid

2C19

Valdecoxib

2C9

Vardenafil

3A4

Venlafaxine

2D6

Verapamil

1A2, 3A4,2C8

Vinblastine

3A4

Vinca alkaloids

3A4

Vincristine

3A4

Voriconazole

2C9

Warfarin

2C18, 2C9

R-warfarin

1A2

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S-warfarin

2C9, 2C18

Yohimbine

2D6

Zafirlukast

2C9

Zaleplon

3A4

Zileuton

1A2, 2C9, 3A4

Zolpidem

3A4

Zoplicone

2C8, 3A4

Step f. T he ferric peroxy–CYP450 complex undergoes heterolytic cleavage of peroxide anion to water and to a highly elec trophilic perferryl oxenoid intermediate (Fe

5+

= = O) or a perferryl oxygen–cysteine–porphyrin res onance-stabilized complex. T his perferryl

oxygen species repres ents the cataly tically active oxygenation species. Step g. Abstraction of a hydrogen from the subs trate by the perferryl oxygen species giv es rise to a carbon-centered radical– perferric hydroxide pair, radical addition to a π-b ond, or electron abstraction from a heteroatom to form a heteroatom-centered radical–c ation perferryl intermediate. Step h. Subsequent radic al recombination (oxygen rebound) or electron-transfer (deprotonation) yields the hydroxylated product and the regeneration of the ferric–CYP450 complex. P.269

Fig. 10.5. Proposed mechanisms for the hydroxylation and dehydrogenation of alkanes.

Oxygen Activation E leme ntal o xygen (dioxyg en) is a relatively unreac tive f orm of oxyge n that exis ts as an unpaired dirad ic al in the triplet f orm. A lte rnative ly, s inglet oxyg en is a f o rm of dioxyge n in whic h the diradic al elec trons are paired . I n this f orm, oxyg en is too re ac tive f o r biolog ic al s ys te ms . Free oxygen ato ms (oxe nes ), f o rmed b y s plitting dioxyg en, are highly reac tive but are not known to exis t in bioc hemic al proc es s es . The s olution to the problem of a re ac tive f o rm of oxyge n lies in the s ug ges tion that the reduc tion of d io xygen o c c urs to one of the reac tive oxygen s pe c ies (RO S), s uc h as s up eroxide radic al anion, pero xid e, hydroxyl radic al, o r o xygen ato m. A ny of thes e R OS c ould oxidize an organic s ubs trate with the net ins ertio n of an oxyge n ato m. I n eac h c as e, re duc tive reac tions are re quired f or ac tivatio n of dio xygen to one of the ROS f ro m elec trons s upplied by NADP H. The ge neration of a c arbon-

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c entered radic al and a hydroxyl radic al with triple t oxyge n atom has b een f ound to b e relevant to a number of enzymatic and c hemic al reac tions involving oxenoids (o xygen rebo und mec hanis m) (28). The f unc tion of C YP45 0 mo nooxyg enas e s us ually is the hydroxylation of a s ubs trate. A reac tive rad ic al-like iro n oxeno id intermediate is gene rate d that is reac tive enough to s plit aliphatic C -H bond s , ad d to bonds α to he te roatoms , o r remove s ing le e le c tro ns f rom he te roatoms . T he me c hanis ms of CYP 450 are not f ully und ers tood, and the reac tive o xygen intermediate has no t be en is olated or even s pec tros c o pic ally o bs erved .

Fig. 10.6. Proposed mechanisms for the oxidation of alkene and aromatic compounds.

Up to the final step, the oxidizable substrate has been an inactive spectator in the chemical events o f oxygen activ ation. None of the preceding oxygenated intermediates has been sufficiently reactiv e to abstract hydrogen from the subs trate. T he perferryl–iron oxenoid complex (Step g), however, is a competent hydrogen abstrac tor, even for relatively inert terminal methy l groups on hydrocarbon c hains. Evidence shows that the oxidant is selective in its choice of hydrogen atoms, balancing stability of the resulting carbon radical with stereochemical constraints. Because the inert aliphatic region of the substrate has been converted to a highly reactive radical, the process is described as substrate activation. Various studies have shown that the hydroxylation or alkene formation proceeds not by a direct one-step insertion of the oxygen atom but, rather, by a two-step, two-electron process involvin g radical or cationic substrate intermediates with subsequent radical recombination (oxygen rebound) to products (Fig. 10.5) (28). Despite considerable experimental ev idence, the proposed mechanism and intermediates of monooxygenation of unsaturated substrates (alkenes, alkynes, and aromatics) remains controv ersial (19,20,29,30,31). T he P.270 proposed mechanism for the oxidation of π-bonds in alkenes involves a stepwise sequenc e of one-electron transfer between the radical complex and the perferryl oxygen intermediate ([Fe

5+

= = O]) (alkene oxidation) (Fig. 10.6). Following the initial formation of an unsaturated

CYP450 π-complex, the one-electron transfer yields a radical σ-complex whic h c an either c ollaps e to arene or alkene epoxide (steps a or d, Fig. 10.6), undergo a 1,2-group migration to a carbonyl product (steps a and b, Fig. 10.6), or give a vinyl hydroxylated product (step c, Fig. 10.6), or a σ-complex whic h c an break down to a phenol (step e, Fig. 10.6). T he presence of an oxygen radic al in the porphy rin ring allows some substrate radicals to covalently bond through N-alk ylation of a pyrrole nitrogen rather than recombining with (Fe–OH)

3+

. T his

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deviation from the normal c ourse of reaction explains the suicide inhibition exhibited by some xenobiotics, such as the oral c ontraceptives, erythromycin, and paroxetine (32,33). In the case of aromatic oxidations (Fig. 10.6), following the initial formation of an arene CYP450 π-complex, one-electron transfer yields either a π-complex or a radical σ-complex. T he radical σ-complex c an collapse to the arene epoxide (Fig. 10.6, step d), or the π-complex can proceed to a σ-complex followed by a NIH shift (1,2-group migration) to a phenolic product (Fig. 10.6, step e). Arene oxides are highly unstable entities and rearrange (NIH shift) nonenzymatically to phenols or hydrolyzed enzymatically with epoxide hydrolase to 1,2-dihydrodiols (trans configuration) (Fig. 10.6, step f), which subs equently are dehydrogenated to 1,2-diphenols. T he oxidation of aromatic compounds can be highly specific to individual CYP450 isoforms, suggesting that substrate binding and orientation in the active site may dominate the mechanism of oxidative catalysis. Heteroatom-containing substrates usually undergo hydroxylation adjac ent (α) to the heteroatom, as c ompared to other positions. Reactions of this type include N-, O-, and S-dealkylation as well as dehydrohalogenations and oxidative deamination (dealkylation) reactions. T wo mechanisms have been suggested (Fig. 10.7). One is the P.271 abstraction of a hydrogen atom from the carbon adjacent to the heteroatom, and the resultant carbon radical is stabilized by the heteroatom. Alternatively, abstraction of an electron from the heteroatom to form a heteroatom radical subsequently transfers a hydrogen atom from the more labile α-carbon to generate a carbon radical. Collaps e of the carbon radical–perferric hy droxide radical pair hydroxylates the carbon adjacent to the heteroatom, generating an unstable geminal hydroxy heteroatom-substituted intermediate (e.g., carbinolamine, halohydrin, hemiacetal, hemiketal, or hemithioketal) that breaks down, releasing the he teroatom and forming a carbonyl compound (29,30,31).

Fig. 10.7. Proposed mechanism for heteroatom-compound oxidation, dealkylation, and dehalogenation.

Xenobiotics containing heteroatoms (N, S, P, and halogens) frequently are metabolized by heteroatom oxidation to its corresponding heteroatom oxide (tertiary amine to its N-oxide, sulfides to sulfoxides , or phos phines to phosphine oxides). Heteroatom oxidation also can be attributed to a microsomal flavin-containing monooxygenase. As is the c ase with heteroatom α-hydroxylation, one-electron oxidation of the heteroatom occurs as the firs t step to form the heteroatom cation perferric hydroxide radic al intermediate, which collapses to generate the heteroatom oxide. T his reaction is favored by the absence of α-hydrogens and stability of the heteroatom radical-cation (29,30,31). All the known oxidative reactions catalyzed by CYP4 50 monooxygenase can be desc ribed in the context of a mec hanistic scheme involving the ability of a high-valent iron oxenoid species to bring about the stepwise one-electron oxidation through the abstrac tion of hydrogen atoms, abstraction of electrons from heteroatoms, or addition to π-bonds. A series of radical recombination reactions completes the oxidation process.

Table 10.12. Drugs that Induce the Expression of CYP450 Isoformsa Amprenavir

3A4

4-Methylpyrazole

2E1

Aprepitant

2C9

Modafinil

3A4

Barbiturates

3A4, 2C9, 2C19, 2B6

Nevirapine

3A4

Norethindrone

2C19

Omeprazole

1A1/2, 3A4

Carbamazepine

1A2, 3A4, 2C8,

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2C9, 2D6 Oxcarbazepine

3A4

Charbroiled meats

1A1/2,

Phenobarbital

3A4, 2C, 2B6, 2D6, 1A2

Cigarette smoke

1A1/2

Phenytoin

3A4, 1A2, 2B6, 2C8, 2C19, 2D6

Clotrimazole

1A1/2, 3A4

Primidone

3A4, 2C9, 1A2, 2B6, 2D6

Ethanol

2D6, 2E1

Psoralen

1A1/2

Efavirenz

3A4

Ethosuximide

3A4

Erythromycin

3A4

Polycyclic aromatic hydrocarbons

1A1/2

Glucocorticoids

3A4, 2A6,

Rifampin

2C8, 2C9,2C19, 2D6, 3A4

Rifampicin

2C8

Rifabutin

2C8, 3A4

Rifapentine

3A4

(Dexamethasone, prednisone) 2C19

Griseofulvin

3A4

Ritonavir

2D6, 3A4

Isoniazid

2E1

St. Johns Wort

1A2, 2C9, 3A4

Lansoprazole

1A1/2, 3A4

Troglitazone

3A4

Mephenytoin

2B6

Topiramate

3A4

a

Drugs in bold italic have been reported to cause drug-drug interaction.

Induction and Inhibition of Cytochrome P450 Isoforms Induction Many drugs, environmental chemicals, and other xeno biotics enhance the metabolism of themselves or of other coingested/inhaled compounds, thereby altering their pharmacological and toxicological effects (34,35,36). Prolonged administration of a drug or xenobiotic can lead to enhanced metabolism of a wide variety of other compounds. Enzyme induction is a dos e-dependent phenomenon. Drugs and xenobiotics exert this effect by inducing transcription of CYP450 mRNA and synthesis of xenobiotic-metabolizing enzymes in the smooth ER of the liv er and other extrahepatic tissues (34,35). T his phenomenon is termed “ enzyme induction,” which has been used to describe the process by which the rate of synthesis of an enzyme is increas ed relative to the rate of synthesis in the uninduced organism. In many older studies of mammalian s ystems, the term “ induction” was inferred from the increase in enzyme activity, but the amount of enzyme protein had not been determined. Enzy me induction is important for interpreting the results of c hronic toxicities, mutagenicities, or carcinogenesis and explaining certain unexpected drug interactions in patients. Many drugs and xenobiotics s timulate the activity of the CYP450 isoforms, as shown in T able 10.12. T hese stimulators hav e nothing in

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common as far as their pharmacological activity or chemical structures are conc erned, but they are all metabolized by one or more of the CYP450 isoforms. Most are lipid soluble at physiologic pH. Polyc yclic aromatic hy drocarbons in cigarette P.272 smoke, xanthines and flavones in foods, halogenated hydrocarbons in ins ecticides, polychlorinated biph enyls, and food additives are but a few of the environmental chemicals that alter the ac tivity of CYP450 enzymes (37). Enzyme induction can alter the pharmacokinetics and pharmacodynamics of a drug, with clinical implications for the therapeutic actions of a drug and increased potential for drug interactions. As a result of induction, a drug may be metabolized more rapidly to metabolites that are more potent, more toxic, or less active than the parent drug. Induction also can enhance the activation of procarcinogens or promutagens. Not all inducing agents enhance their own metabolis m; for example, phenytoin induces CYP3A4 but is hydroxylated by CYP2C9, which is constitutive. Some of the more common enzy me inducers of CYP450 subfamilies , whic h also may be substrates for the same CYP450 isoform, include phenobarbital (CYP2B6, CYP2C, and CYP3A4), rifampicin (CYP3A4), and cigarette smoke (CYP1A1/2) (T able 10.12). T he broad range of drugs metabolized by these CYP450 s ubfamilies (T able 10.11) and that also are affected by these enzyme inducers raises the issue of clinically significant drug interactions and their clinical implications. Examples of a clinical CYP450–drug interaction and an herbal drug–drug interaction include rifampin and oral contraceptives as well as St. J ohn's wort and oral contraceptives. Both induce the expression of CYP3A4, thereby reducing the serum levels of the oral co ntraceptive because of increased oxidative metabolism of the oral contraceptives by CYP3A4 to less active metabolites, increasing the risk for pregnancy. Drugs poorly metabolized by CYP450 enzymes are less affected by enzyme induction. Inducers of CYP450 is oforms also stimulate the oxidative metabolism or synthesis of endogenous substances, such as the hydroxylation of androgens, estrogens, progestational steroids (synthetic oral contraceptives), glucocorticoids, vitamin D, and bilirubin, decreasing their biological activity. T hese enzyme inducers also might be implicated in deficiencies associated with these steroids. For example, the induction of C-2 hydroxylation of es tradiol and synthetic estrogens by phenobarbital, dexamethasone, or cigarette smoking in women res ults in the increased formation of the principal and less active metabolite of these estrogenic substances, reducing their effectiveness (38). T hus, cigarette smoking in premenopausal women could result in an estrogen deficiency, increasing the risk of osteoporosis and early menopause. Postmenopausal women who s moke and take estrogen replacement therapy may lose the effectiv eness of the estrogen. In addition to enhancing metabolism of other drugs, many c ompounds, when chronically administered, s timulate their own metabolism, thereby decreasing their therapeutic activity and producing a state of apparent tolerance. T his self-induction may explain some of the change in drug toxic ity observed in prolonged treatment. T he sedativ e action of phenobarbital, for example, becomes shorter with repeated doses and can be explained in part on the basis of increased metabolism. T he time course of induction varies with different inducing agents and different isoforms, except that CYP1A induction involves the Ah receptor. Increased trans cription of CYP450 mRNA has been detected as early as 1 hour after the administration of phenobarbital, with maximum induction after 48 to 72 hours. After the administration of PAH, such as 3-methylcholanthrene and benzo[a]pyrene, maximum induction of the CYP1A subfamily is reached within 24 hours. Less potent inducers of hepatic drug meta bolis m may take as long as 6 to 10 days to reach maximum induction (34,35). Exposure to a variety of xenobiotics may preferentially inc re ase the hepatic content of specific forms of CYP450 (34,35,36). T herefore, the process of enzyme induction inv olv es the adaptive increase in the content of specific enzymes in response to the enzyme-inducing agent. Other inducible metabolizing enzymes include uridine diphosphate (UDP)–glucuronosyl transferase and glutathione transferase.

Specific Inducers Phenobarbital and rifampin Phenobarbital and rifampin probably are the enzy me inducers that have been studied mos t extensively. T hese drugs could alter the pharmacokinetics and pharmacodynamics of many concurrently administered drugs listed in T ables 10.6 (CYP2C) and 10.9 (CYP3A4), raising the issue of clinically significant drug interactions.

Cigarette smoke Cigarette smoke has been shown to increase the hy drocarbon-induc ible isoforms CYP1A1 and CYP1A2 in the lungs, liver, small intestine, and plac enta of c igarette smokers. A decrease in the pharmacological action and stimulation of the metabolism of several drugs is the end result. Cigarette smoking has been reported to lower the blood levels of theophylline, imipramine, estradiol, pentazocine, and propoxyphene; to decrease the urinary excretion of nicotine; and to decrease drowsiness from chlorpromazine, diazepam, and chlordiazepoxide. T he plasma levels, half-life, or total clearanc e for diazepam, however, are unchange d.

Dietary substances A diet containing Brussel sprouts , cabbage, and cau liflower was found to s timulate CYP450 activity in rat intestine (39). It was subsequently determined that indole derivatives (indole-3-carbinol) were responsible for the enzyme induction. Other examples of chemicals found naturally in foods that enhance metabolis m in animals are flav ones, safrole, eucalyptol, xanthines, β-ionone, and organic peroxides. Volatile oils in soft woods (e.g., cedar) have been shown to be enzyme inducers.

Alcohol Sober alcoholics show an increas e in CYP2E1 enzyme activity, leading to more rapid clearance of drugs and xenobiotics that are substrates for this isoform from the body. As discussed previously, hepatic CYP2E1 P.273 oxidizes ethanol, and chronic ethanol intake increa ses the activity of CYP2E1 through enzyme induction (24). When intoxicated, alcoholics are more susceptible to the action of various drugs because of inhibition of drug metabolism as a result of an excessive quantity of alcohol in the liver and an additive or synergistic effect in the central nervous system. T he basis for this inhibition is unknown. Furthermore, moderate ethanol cons umption reduces the clearance of some drugs, presumably because of competition between ethanol and the other drugs for hepatic biotransformation. T he changes in drug metabolism in alcoholics also can be attributed to other factors, such as malnutrition, other drugs, and the trace chemic als that determine the flavor and odor of alcoholic beverages. Heavy drink ers metabolize

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phenobarbital, tolbutamide, and phenytoin more rapidly than nonalcoholics do, which may be clinically important because of problems in adjusting drug therapy in alcoholics.

Inhibition Another method of altering the in vivo effects of xenobiotics metabolized by CYP450s is through the use of inhibitors (T able 10.10). T he CYP450 inhibitors can be divided into three categories according to their mechanism of action: reversible inhibition, metabolite intermediate complexation of CYP450, or mechanism-based inactivation of CYP450 (36,40,41). T he polysubstrate nature of CYP450 is responsible for the large number of documented inte ractions associated with the inhibition of drug oxidation and drug biotransformation.

Reversible inhibition Reversible inhibition of CYP450 is the res ult of reversible interactions at the heme–iron active center of CYP450, the lipophilic sites on the apoprotein, or both. T he interaction occurs before the oxidation steps of the catalytic cycle, and their effects dissipate quickly when the inhibitor is discontinued. T he most effective reversible inhibitors are those that interact s trongly with both the apoprotein and the heme–iron. It is widely accepted that inhibition has an important impact on the oxidative metabolis m and pharmacokinetics of drugs with a metabolism that cosegregates with that of an inhibitor (T ables 10.3 and 10.6,10.7,10.8,10.9) (40,41). Drugs interacting revers ibly with CYP450 include the fluoroquinolone antimicrobials, cimetidine, the azole antifungals, quinidine (specific for CYP2D isoforms), and diltiazem. Cimetidine is the only H-2 antagonist that inhibits CYP450 by interacting directly with the CYP450 heme–iron through one of its imidazole ring nitrogen atoms. Cimetidine is not a universal inhibitor of CYP450 oxidative metabolism, but it does bind differentially to several CYP450 isoforms (T able 10.10). Cimetidine inhibits the oxidation of theophylline (CYP1A), chlordiazepoxide (CYP2C), diazepam (CYP2C), propranolol (CYP2C and CYP2D), warfarin (CYP2C), and antipyrine (CYP1A) but not that of ibuprofen (CYP2C), tolbutamide (CYP2C), mexiletine (CYP2D), 6-hydroxylation of steroids (CYP3A), and carbamazepine (CYP3A) (36). T he imidazole-based azole antifungals are potent inhibitors of CYP3A and of the CYP450-mediated biosynthesis of endogenous steroid hormones. T he azole antifungals exert their fungiostatic effects through inhibition of fungal CYP450, inhibiting the oxidativ e biosynthesis of lanosterol to ergosterol, thereby affecting the integrity and permeability of the fungal membranes.

Fig. 10.8. Sequence of oxidation of dialkylamine to nitroso metabolite intermediate.

CYP450 complexation inhibition Noninhibitory alkylamine drugs have the ability to undergo CYP450-mediated oxidation to nitrosoalkane metabolites (Fig. 10.9), which have a high affinity for forming a stable complex with the reduced (ferrous) heme intermediate for the CYP2B, CYP2C, and CYP3A subfamilies. T his process is termed “ metabolite intermediate complexation” (40,41). T hus, the CYP450 isoform is unavailable for further oxidation, and synthesis of the new enzyme is required to restore CYP450 activity. T he process relies on at least one cycle of the CYP450 catalytic cycle to generate the required heme intermediate. T he macrolide antibiotics, troleandomy cin, erythromycin, and clarithromycin, as well as their analogues are selec tive inhibitors of CYP3A4 that are c apable of inducing the expression of hepatic and extrahepatic CYP3A4 mRNA and induction of their own biotransformation into nitrosoalkane metabolites. T he clinical s ignificance of this inhibition with CYP3A4 is the long-lived impairment of the metabolism of a large number of coadministered substrates for this isoform and the potential for drug–drug interactions and time-dependent nonlinearities in their pharmacokinetics on long-term administration (T ables 10.9 and 10.10). For the macrolides to be s o metabolized, they mus t possess an unhindered dimethylamino s ugar, and the whole compound must be lipophilic. Other alkylamine-based drugs demonstrating this type of inhibition include orphenadrine (antiparkinson drug), the antiprogestin, mifepristone (CYP3A), and SKF525A (the original CYP450 inhibitor). Methylenedioxyphenyl compounds (i.e., the insecticide synergist piperonyl butoxide and the flavoring agent isosafro le) generate metabolite intermediates that form stable complexes with both the ferric and ferrous state of CYP450.

Mechanism-based inhibition Certain drugs that are noninhibitory of CYP450 contain functional groups that, when oxidized by CYP450, generate metabolites that P.274 bind irreversibly to the enzyme. T his proces s is termed “ mechanism-based inhibition” (“ s uic ide inhibition'') and requires at least one catalytic CYP450 cycle either during or s ubsequent to the oxygen-transfer step, when the drug is activated to the inhibitory species. Alkenes and alkynes were the first functionalities found to inactivate CYP450 by generation of a radical intermediate that alkylates the heme structure (see the section on alkene and alky ne hydroxylation) (32,33,40,41). Iron is lost from the heme and abnormal N-alkylated porphyrins are produced. Drugs that are mechanism-based inhibitors of CYP450 inc lude the 17α-acetylenic estrogen, 17α-ethiny l

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estradiol, the 17α-acetylenic progestin, norethindrone (norethisterone), and their radical intermediates that N-alkylate heme of CYP3A; chloramphenicol and its oxidativ e dechlorination to an acyl moiety that alkylates CYP450 apoprotein; cyclophosphamide (CYP3A) and its generation of acrolein and phosphoramide mus tard; spironolac tone and its 7-thio metabolite that alkylates heme; 8-methoxypsoralen (a furocoumarin) and its epoxide metabolite that alk ylates the CYP450 apoprotein of CYP2A6; 21-halosteroids; halocarbons; and secobarbital. T he s electivity of CYP450 isoform destruction by several of these inhibitors indicates the involvement of this isoform in its bioactivation of such drugs.

Oxidations Catalyzed by Cytochrome P450 Isoforms Aliphatic and alicyclic hydroxylations T he accepted mechanism for the hydroxy lation of alkane C-H bonds is shown in Figure 10.5 and has been reviewed in detail elsewhere (29,30,31). T he princ ipal metabolic pathway for the methyl group is oxidation to the hydroxymethyl derivative followed by its nonmicrosomal oxidation to the carboxylic acid (e.g., tolbutamide) (Fig. 10.9). On the other hand, s ome methyl groups are oxidized only to the hydroxymethyl derivative, without further oxidation to the acid. Where there are several equivalent methyl groups, usually only one is oxidized. For aromatic methyl groups, the para methyl is the most vulnerable. Alkyl side chains often are hydroxylated on the terminal or the penultimate carbon atom (e.g., pentobarbital) (Fig. 10.9). T he isopropyl group is an interesting side chain that undergoes hydroxylation at the tertiary carbon and at either of the equivalent methy l groups (e.g., ibuprofen) (Fig. 10.9). Hydroxylation of alkyl side chains attac hed to an aromatic ring does not follo w the general rules for alky l side chains, because the aromatic ring influences the position of hydroxylation. Generally, oxidation occurs preferentially on the benzylic methylene group and, to a lesser extent, at other positions on the side chain. T he methylene groups of an alicycle are readily hydroxylated, generally at the least hindered position, or at an activated position—for example, α to a carbonyl (cy clohexanone), α to a double bond (cyclohexene), or α to a phenyl ring (tetralin). T he produc ts of hydroxylation often show stereoisomerism. Nonaromatic heterocycles generally undergo oxidation at the carbon adjacent to the heteroatom (e.g., phenmetrazine) (Fig. 10.9).

Fig. 10.9. Examples of oxidative metabolism of aliphatic and alicyclic hydrocarbons catalyzed by CYP450.

In addition to hydroxylation reactions, CYP450s can catalyze the dehydrogenation of an alkane to an alkene(olefin). T he reac tion is thought to involve the formation of a carbon radical, electron transfer to the perferryl complex of CYP450 giving a carbocation, and deprotonation to a dehydrogenated product alkene (Fig. 10.5) (29,30,31). An example of the ability of CYP450 to function as both a dehydrogenase and a monooxygenase has been demonstrated with the antiseizure valproic acid. Whereas the major metabolic products in humans are β-oxidation and acyl glucuronidation, se veral alkenes are formed, including (E)2-ene isomer (Fig. 10.9) (42). Presumably, the

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CYP3A subfamily cataly zes these reactions. T he factors determining whether CYP450 catalyzes hydroxylation (oxygen rebound/recombination) or dehydrogenation (electron transfer) remain unknown, but hydroxylation generally is favored. In s ome instances, dehydrogenation may be the primary produc t (i.e., 6,7-dehydrogenation of testosterone). P.275

Alkene and alkyne hydroxylation T he oxidation of alkenes yields primarily epoxides and a series of products derived from 1,2-migration (see previous disc ussion) (Fig. 10.6). T he stereochemical configuration of the alkene is retained during epoxidation. T he epoxides can differ in reactivity. T hose that are highly reactive either undergo pH-catalyzed hydrolysis to excretable vicinal dihydrodiols or react covalently (alkylate) with macromolecules , suc h as proteins or nucleic ac ids , leading to tissue necrosis or carcinogenic ity. Moreover, the ubiquitous epoxide hydrolas e can catalyze the rapid hydrolysis of epoxides to nontoxic vicinal dihydrodiols . Several drugs (carbamazepine, cyproheptadine, and protriptyline), however, were found to form s table epoxides at the 10,11-position during biotransformation (Fig. 10.10). T he fact that these epoxides could be detected in the urine indicates that these oxides are not particularly reac tive and should not readily react covalently with macromolecules. T he epoxidation of terminal alkenes is accompanied by the mechanism-bas ed (“ s uic ide'') N-alkylation of the heme–porphyrin ring. If the π-complex attaches to the alkene at the internal c arbon, the terminal carbon of the double bond c an irrevers ibly N-alkylate the pyrrole nitrogen of the porphyrin ring (32,33). T he heme adduc t formation is mostly observed with monosubstitu ted, unconjugated alkenes (i.e., 17α-ethylenic steroids and 4-ene metabolite of valproic acid). In addition to the formation of epoxides, heme adducts, and hydroxylated products, carbonyl products also are created. T hese latter products result from the migration of atoms to adjac ent c arbons (i.e., 1,2-group migration). For example, during the CYP450-catalyzed oxidation of trichloroethylene, a 1,2-s hift of chloride occurred to yield chloral (Fig. 10.10).

Fig. 10.10. Examples of oxidative metabolism of alkenes and alkynes catalyzed by CYP450.

Fig. 10.11. Alkyne oxidation catalyzed by CYP450.

Like the alkenes , alkynes (acetylenes) are readily oxidized but us ually faster. Depending on which of the two alkyne carbons are attacked, different products are obtained (32,33). If attachment of CYP450 occurs on the terminal alkyne c arbon, a hydrogen atom migrates, forming

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a ketene intermediate that readily hydrolyzes with water to form an acid or that can alkylate nucleophilic protein side chains (i.e., lysinyl or cysteinyl) to form a protein adduct (Fig. 10.11). T he effect of attaching the perferryl oxygen at the internal alkenyl carbon is N-alkylation of a pyrrole nitrogen in the porphyrin ring by the terminal acetylene carbon, with the formation of a keto heme adduct (Fig. 10.11). T he latter mechanism has been proposed for the irreversible inactivation of CYP3A4 with 17α-alkenyl steroids (i.e., 17α-ethinyl estradiol).

Aromatic hydroxylation T he metabolic oxidation of aromatic carbon atoms by CYP450 depends on the isoform catalyzing the oxidation and the oxidation potential of the aromatic compound. T he products usually are phenolic products , and the position of hydroxylation can be influenc ed by the type of substituents on the ring according to the theories of aromatic electrophilic substitution (Fig. 10.6). For example, electron-donating substituents enhance p- and o-hydroxylation, whereas electron-withdrawing s ubstituents reduce or prevent m-hydroxylation. Moreover, steric factors also must be considered, because oxidation usually occurs at the least hindered position. For monosubstituted benzene compounds, parahydroxylation usually predominates, with some ortho product being formed (Fig. 10.12). When there is more than one phenyl ring, usually only one is hydroxylated (e.g., phenytoin). T raditionally, the hydroxylation of aromatic compounds by CYP450 has been cons idered to be mediated by an arene oxide (epoxide) intermediate followed by the “ NIH shift,'' as discus sed previously (29,30,31) (Fig. 10.6). T he formation of phenols and the isolation of urinary dihydrodiols, catechols, and glutathione conjugates (mercapturic acid derivatives) implicates arene oxides as intermediates in the metabolism of benzene and substituted benzenes in mammalian s ystems. T he arene oxides P.276 also are susceptible to conjugation with glutathione to form premercapturic acids (see the section on glutathione conjugation).

Fig. 10.12. Examples of oxidative metabolism of aryl compounds catalyzed by CYP450.

T he CYP1A2 and CYP3A subfamilies are important contributors to 2- and 4-hydroxylation of estradiol, and CYP3A4 is an important contributor for the 2-hydroxylation of the sy nthetic es trogens (e.g., 17α-ethinyl es tradiol) (38). T he principal metabolite (as much as 50%) for estradiol is 2-hydroxyestradiol, with 4-hydroxy and 16α-hydroxyestradiol as the minor metabolites (Fig. 10.12). T he 2-hydroxy metabolite of both estradiol and ethinyl estradiol have limited or no estrogenic activ ity, whereas the C-4 and C-16 α-hydroxy metabolites have a potency similar to es tradiol. In humans, 16α-hydroxyestradiol is the major estrogen metabolite in pregnancy and in breast cancer. T he metabolites 16α-hydroxyestrone and 4-hy droxyestrone may be carcinogenic in specific c ells, because they are capable of damaging cellular proteins and DNA after their further activation to quinone intermediates. Xenobiotic-metabolizing enzymes not only detoxify xenobiotics but also cause the formation of active intermediates (bioactiv ation), which in certain circumstances may elicit a diversity of toxicities, including mutagenesis, carcinogenesis, and hepatic necrosis (37). In addition to glutathione, some nucleophiles, such as other sulfhydryl compounds (most effective), alcohols, and phos phates, can react with arene oxides. Many of these nucleophiles are found in proteins and nucleic acids . T he covalent binding of th ese bioactive epoxides to intracellular macromolecules provides a molecular bas is for these toxic effects (see the disc ussion of toxicity from oxidative metabolism).

N-dealkylation, oxidative deamination, and N-oxidation N-dealkylation T he dealkylation of secondary and tertiary amines to yield primary and sec ondary amines, respectively, is one of the most important and frequently encountered reactions in drug metabolism. T he proposed mechanis m for oxidative N-dealkylation inv olv ing α-hydrogen abstraction or an electron abstraction from the nitrogen by the perferryl oxygen has been discussed previously (29,30,31) (Fig. 10.7). T ypical N-substituents removed by oxidative dealk ylation are methyl, ethyl, n-propyl, is opropyl, n-butyl, allyl, and benzyl. Usually,

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dealkylation initially occurs with the smaller alkyl group. Substituents that are more resistant to dealkylation inc lude the tert-butyl (no α-hydrogen) and the cyclopropylmethyl. In general, tertiary amines are dealkylated to secondary amines faster than sec ondary amines are dealkylated to primary amines. T his difference in rate has been correlated with lipid solubility . Appreciable amounts of sec ondary and primary amines therefore accumulate as metabolites that are more polar than the parent amine, thus s lowing their rates of diffusion across membranes and reducing their accessibility to receptors. Frequently , these amine metabolites contribute to the pharmacological activity of the parent substance (e.g., imipramine) (Fig. 10.13) or produce unwanted side effects, such as hypertension, resulting from the N-dealkylation of N-isopropylmethoxamine to methoxamine. T he design of an analogous drug without these unwanted drug metabolites can be achieved by proper choice of replacement substituents, such as substituting the N-isopropyl group in N-isopropy lmethoxamine with a tert-butyl (N-tert-butylmethoxamine or butoxamine). N-dealkylation of substituted amides and aromatic amines occ urs in a similar manner. N-substituted nonaromatic nitrogen heteroc ycles undergo oxidation on the α-carbon to a lactam (c otinine) as well as N-dealkylation (nicotine to nornicotine, c otinine, and norcotinine ) (Fig. 10.13).

Oxidative deamin ation T he mechanism of oxidative deamination follows a pathway similar to that of N-dealkylation. Initially, oxidation to the imminium ion occurs, followed by decomposition to the carbony l metabolite and ammonia. Oxidativ e deamination can occur with α-substituted amines, exemplified by amphetamine (Fig. 10.13). Disubstitution of the α-carbon inhibits deamination (e.g., phentermine). Some secondary and tertiary amines as well as amines s ubstituted with bulky groups can undergo deamination directly, without N-dealkylation (e.g., fenfluramine). Apparently , this behavior is associated with increased lipid solubility.

N-oxidation In general, N-oxygenation of amines form stable N-oxides with tertiary amines and amides, and hydroxylamines with primary and secondary amines, P.277 when no α-protons are available (e.g., mephentermine and arylamines) (Fig. 10.13). T ertiary amines having one or more hydrogens on the adjacent carbon dealkylate via the N-oxide. Rearrangement of the N-oxide to a carbinolamine, which subsequently collaps es, gives rise to the secondary amine. T he amine metabolites can be N-conjugated, increas ing their excretion.

Fig. 10.13. Examples of N-dealkylation, oxidative deamination, and N-oxidation reactions catalyzed by CYP450.

O- and S-dealkylation Oxidative O-dealkylation of ethers is a common metabolic reaction with a mechanism of dealkylation analogous to that of N-dealkylation; oxidation of the α-carbon, and subsequent decomposition of the unstable hemiacetal to an alcohol (or phenol) and a carbonyl product

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(29,30,31). T hioethers also are dealkylated by the same mechanism to hemithioacetals. T he majority of ether groups in drug molecules are aromatic ethers (e.g., codeine, prazoc in, and verapamil). For example, codeine is O-demethylated to mo rphine (Fig. 10.14). T he rate of O-dealkylation is a function of chain length (i.e., increasing chain length or branching reduces the rate of dealkylation). Steric factors and ring substituents influence the rate of dealkylation but are complicated by electronic effects. Some drug molecules contain more than one ether group, in which case usually only one ether is dealkylated. T he methy lenedioxy group undergoes variable rates of dealkylation to the 1, 2-diphenolic metabolite. Metabolism of such a group also is being capable of forming a stable complex with and inhibiting CYP450.

Fig. 10.14. Examples of O- and S-dealkylations catalyzed by CYP450.

Aliphatic and aromatic methyl thioethers undergo S-dealk ylation to thiols and carbony l compounds. For example, 6-methy lthiopurine is demethylated to give the active anticancer drug 6-mercaptopurine (Fig. 10.14). Other thioethers are oxidized to sulfoxides (see N- and S-oxidations).

Dehalogenation Many halogenated hydrocarbons, s uch as insecticides, pesticides, general anesthetics, plasticizers, flame retardants, and commercial solvents, undergo a variety of different dehalogenation biotransformations (24,25). Because of our potential exposure to these halogenated compounds as drugs and environmental pollutants in air, soil, water, or food, it is important to understand the interactions between metabolism and toxicity. Some halogenated hydrocarbons form glutathione or mercapturic acid conjugates, whereas others undergo dehydrohalogenation and reductive dehalogenation catalyzed by CYP2E1. In many cases, reactive intermediates, including radicals, anion, and cations, are produced that may react with a variety of tissue molec ules. Halogenated hydrocarbons differ in their chemical reactivity as a result of the electron-withdrawing p roperties of the halogens on adjacent carbon atoms, resulting in the α-carbon developing an electrophilic character. T he halogen atoms also have the ability to stabilize α-carbon cations, free radicals, carbanions, and carbenes. Oxidative dehydrohalogenation is a common metabolic pathway for many halogenated hydrocarbons (25,29,30,31). T he CYP450-catalyzed oxidation generates the transient gem-halohydrin (analogous to alk ane hydroxylation) that can eliminate the hydrohalic acid to form carbonyl derivatives (aldehy des, ketones, acyl halides, and carbony l halides) (Fig. 10.7). T his reaction P.278 requires the presence of at least one halogen and one α-hydrogen. gem-T rihalogenated hydrocarbons are more readily oxidized than are the gem-dihalogenated and monohalogenated c ompounds. T he acyl and carbonyl halides formed are reactive metabolites that can react either with water to form carboxylic acids or nonenzy matically with tissue molecules (with a potential for eliciting increased toxicity). Chloramphenicol (RNHCOCHCl 2 ) is biotransformed into an acyl halide (RNHCOCOCl) that selectively acylates the apoprotein of CYP450 (40,41).

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Fig. 10.15. CYP2E1-catalyzed metabolism of fluorinated volatile anesthetics to antigenic proteins.

An excellent example of oxidative dehydrohalogenation leading to significant hepatotoxicity and nephrotoxicity is seen with the fluorinated inhalation anesthetics (Fig. 10.15). T he toxicity of halothane and the fluranes is related to their metabolism to either an acid chloride (or fluoride) or a trifluoroacetate intermediate (see Fig. 18.7). T he CYP2E1 has been identified as the is oform catalyzing the biotransformation of the fluranes (25,43,44). T he hydroxylated intermediate decomposes spontaneous ly to reactive intermediates, an acid chloride (or fluoride) or trifluoroacetate, that c an either react with water to form halide anions and a fluorinate d c arboxylic acid or bind covalently to tissue proteins to produce an acylated protein. T he acylated protein becomes a “ hapten,'' stimulating an immune response and a hypersensitivity reaction. Halothane has received the most attention because of its ability to cause “ halothane-associated” hepatitis. T his immunologic reaction occurs after repeated exposure in surgical patients to trifluoroacetylate protein. T he patient is sensitized to future exposures of the volatile anesthetic. After subsequ ent exposure to a fluorinated anesthetic, the antig enic trifluoroacetylate protein stimulates an immune response, producing halothane-like hepatitis. Because of the common metabolic pathway inv olv ing CYP2E1 for enflurane, isoflurane, desflurane, and methoxyflurane, halothane-exposed patients who have halothane hepatitis can show crosssensitization to one of the other fluranes, triggering an idiosyncratic hepatic necrosis. T he formation of antigenic protein is related to the amount of CYP2E1-catalyzed metabolism for each agent: halothane (20–40%) > enflurane (2–8%) > isoflurane (0.2–1.0%) > desflurane (< 0.1%). Enough fluoride ion is generated from oxidative dehalogenation during flurane anesthesia to produce subclinical nephrotoxicity. Interestingly, female rats metabolize halothane more slowly than males do and are less susceptible to hepatotoxicity than males are. For patients with preexisting liver dys function, isoflurane or desflurane may be a better choice of anesthetic. In today's environment, most humans have been exposed to many CYP2E1-inducing agents (including rec reational, industrial, agricultural chemicals, and alcohol), having an unknown effect on hepatic toxic ity from volatile anesthetics. Enhanc ed activity for CYP2E1 has been observed in obesity, isoniazid therapy , ketogenic d iets, and alcoholism.

Azo and nitro reduction In addition to the oxidative sys tems, liver microsomes also contain enzyme systems that catalyze the reduction of azo and nitro compounds to primary amines. A number of azo compounds, such as Prontosil and sulfasalazine (Fig. 10.16), are c onverted to aromatic primary amines by azoreduc tas e, an NADPH-dependent enzyme system in the liver microsomes. Evidence exists for the participation of CYP450 in some reductions. Nitro compounds (e.g., chloramphenic ol and nitrobenzene) are reduced to aromatic primary amines by a nitroreductase, presumably through nitrosamine and hydroxylamine in termediates. T hese reductases are not solely responsible for the reduction of azo and nitro compounds ; reduction by the bacterial flora in the anaerobic environment of the intestine also may occ ur. P.279

Fig. 10.16. CYP450-catalyzed reduction of azo and nitro compounds.

N- and S-Oxidations Catalyzed by Flav in Monooxygenase T he major hepatic monooxygenase systems responsible for the oxidation of many drugs, carcinogens, pes ticides, aromatic polycy clic hydrocarbons, and other xenobiotics containing nitrogen, sulfur, or phosphorus are CYP450 monooxygenase and microsomal flav incontaining monooxygenase (FMO) (45). T he FMO exhibits broader substrate specificities than CYP450 monooxygenases and has a mechanism distinctly different from that of CYP450 monooxygenases. Because oxygen ac tivation occurs be fore s ubstrate addition, any compound binding to 4α-hydroperoxyflavin, the enzyme-bound monooxygenating FMO intermediate, is a pote ntial subs trate. T ypically, FMO catalyzes oxygenation of the N- and S-heteroatoms (“ soft nucleophiles'') (Fig. 10.17) but not heteroatom dealk ylation reac tions. T he products formed from FMO-catalyzed oxidation are consistent with a direct two-electron oxidation of the heteroatom. T hus, FMO constitutes an alternative biotransformation pathway for N- and S-containing lipophilic xenobiotic s. Normally, FMO is not inducible by phenobarbital, nor is it affected by CYP450 inhibitors. With few exceptions, however, xenobiotic substrates for FMO also are substrates for the isoforms of CYP450, producing similar oxidation products. Which monooxygenase is responsible for the oxidation can be readily determined, because FMO is thermally labile in the abs ence of NADPH whereas CYP450 is stable. Of the many nitrogen functional groups in xenobiotics, only secondary and tertiary acyclic, cyclic, and arylamines as well as hydroxylamines and hy drazines are oxidized by FMO and excreted in the urine (Fig. 10.17). T he tertiary amines form stable amine oxides, and secondary amines are sequentially oxidized to h ydroxylamines , nitrones, and a complex mixture of products. Secondary N-alkylarylamines can be N-oxygenated to reactive N-hydroxy lated metabolites, which are responsible for the toxic, mutagenic, and

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carcinogenic activity of these aromatic amines. For example, the chemically uns table hydroxylamine intermediates of aromatic amines degrade into bladder carcinogens (see the discussion for this type of toxic mechanism under glucuronic acid conjugation), and the hydroxamic acid intermediates of N-arylacetamides are bioactivated into liver carcinogens. Hepatic FMO, however, will not catalyze the oxidation of primary alkyl- or arylamines, except for the carc inogenic N-hydroxy lated derivatives of 2-aminofluorene, 2-aminoanthracene, and other amino PAHs.

Fig. 10.17. Examples of flavin monooxygenase (FMO) oxidations.

S-oxidation occurs almost exclusively by FMO (Fig. 10.17). Sulfides are oxidized to sulfoxides and sulfones , thiols to disulfides, and thiocarbamates, mercaptopyrimidines, and mercaptoimidazoles (i.e., the antithyroid drug methimazole) via sulfenates (RSOH) to sulfinates (RSO 2 H), all of whic h are eliminated in the urine. T he FMO does not catalyze epoxidation reactions or hydroxylation at unac tivated carbon atoms of xenobiotics. Primary aromatic amines and amides, aromatic heterocy clic amines and imines, and the aliphatic primary amine phentermine are N-oxidized by CYP450 to hydroxylamines. T he CYP450 oxidizes carbon disulfide to carbon dioxide and hydrogen sulfide and the antips ychotic phenothiazines to sulfoxides. T he major steps in the c ataly tic cycle for FMO are shown in Figure 10.18 (45,46). Like most of the other monooxygenases, FMO requires NADPH and oxygen as c osubstrates to catalyze the oxidation of the xenobiotic P.280 substrate. Unlike CYP450, however, the xenobiotic being oxidized does not need to be bound to the 4α-hydroperoxyflavin intermediate (FAD-OOH) for oxygen activation to occur. Apparently, FMO is present within the cell in its enzyme-bound ac tivated hy droperoxide (Enz-FAD-OOH) state ready to oxidize any suitable lipophilic substrate that binds to it. T he FMO us es a nonradical, nucleophilic displacement type of mechanism binding dioxygen with a reduced flavin. T he reactiv e oxygen intermediate is a reactive derivativ e of hydrogen peroxide, flavin-4α-hydroperoxide (Fig. 10.18, insert), which is reactive enough to succes sfully attack a lone electron pair on a heteroatom, such as nitrogen or sulfur, but not reac tive enough to attack a typical C-H bond. T hes e studies suggest the xenobiotic substrate interacts with the 4α-hydroperoxyflavin form of FMO and is oxidized by oxygen transfer from Enz-FAD-OOH to form the oxidized product. Neither the substrate nor the oxidized sub strate is essential for any other steps in the cycle. Steps 2 to 5 simply regenerate the oxygenating agent Enz-FAD-OOH from Enz-FAD-OH, NADPH, oxygen, and a proton. Any compound readily crossing cell membranes by passive diffusion and penetrating to the FMO-bound hydroperoxyflavin intermediate is a potential substrate, thus explaining the broad substrate specificity exhibited for FMO. T he fact that the xenobiotic substrate is not required for activation of the FMO-hydroperoxyflavin state distinguishes FMO from CYP450 monooxy genases , in which substrate binding initiates the CYP450 catalytic cy cle and activ ation of oxygen to the perferryl oxygenating agent. It is not unusual for FMO oxidation products to undergo reduction to the parent xenobiotic, which can enter into repeated redox reactions (termed “ metabolic cycling” ).

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Fig. 10.18. Flavin monooxygenase (FMO) catalytic cycle. Oxygenated substrate is formed by nucleophilic attack of a substrate (Sub.) by the terminal oxygen of the enzyme-bound hydroperoxyflavin (FAD-OOH), followed by heterolytic cleavage of the peroxide (1). The release of H 2 O (2) or of NADP + (3) is rate-limiting for reactions catalyzed by liver FMO. Reduction of flavin by NADPH (4) and addition of oxygen (5) complete the cycle by regeneration of the oxygenated FAD-OOH.

Results of substrate specificity studies suggest that the number of ionic groups on endogenous substrate is an important factor enabling FMO to distinguish between xenobiotic and endogenous substrates , preventing the indiscriminate oxidation of physiologically important amine and sulfur compounds (47). Without exception, FMO readily catalyzes the oxidation of uncharged a mines or sulfur c ompounds (in equilibrium with its respective monocation or monoanion; for sulfur compounds, the charge is on sulfur atom). T he FMO will not catalyze the oxidation of dianions (e.g., thiamine pyrophosp hate), dications (e.g., polyamines ), dipolar ions (e.g., amino acids and peptides ), or other polyionic compounds with one or more anionic groups (i.e., COO) distal to the heteroatom (e.g., coenzyme A). Unlike the CYP450 sy stem, only three isoforms of hepatic FMO have been characterized in the adult human liver (48,49): minor form I (or FMO 1A1), which is the major form in fetal tissue; major form II (FMO 1D1); and form III, of which little is currently known. T he substrate specificities for these isoforms have not been reported. T he availability of different forms of FMO may be of clinical importance in the pharmacological and toxicological properties of FMO-dependent drug oxidations.

Peroxidases and Other Monooxygenases Peroxidases are hemoproteins and, perhaps, the most c los ely related enzymes to CYP450 monooxygenase (50,51). T he normal course of peroxide (ROOH)-catalyzed oxidation involves the formation of the [FeO] + 3 intermediate, analogous to the perferryl complex in CYP450. It can perform heteroatom oxygenation and aromatization (oxidation) of 1,4-dihydropyridines (calcium channel blockers). P.281

Other monooxy genases catalyzing oxidation reac tions similar to CYP450 include dopamine β-monooxygenase, a mammalian coppercontaining enzyme catalyzing carbon hydroxylation, epoxidation, S-oxygenation, and N-dealkylation reactions, and nonheme iron–containing enzymes from bacteria and plants.

Nonmicrosomal Oxidations In addition to the microsomal monooxygenases, other oxidases and dehydrogenases that catalyze oxidation reactions are present in the mitochondrial and soluble frac tions of tissue homogenates.

Oxidation of alcohols Alcohol dehydrogenase is an NAD-specific enzyme located in the soluble frac tion of tissue homogenates. It exhibits a broad specificity for

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alcohols. Most primary alc ohols are readily oxidized to their corresponding aldehydes. Some secondary alcohols are oxidized to the ketones, whereas other secondary and tertiary alc ohols are excreted either unchanged or as their conju gate metabolite. Some s econdary alcohols also show mixed activity because of steric factors and a lack of substrate affinity for the enzy me.

Oxidation by alcohol dehydrogenase is the principal pathway for ethanol metabolism, but the microsomal is oform CYP2E1 also plays a significant role in ethanol metabolism and tolerance. Apparently, two-thirds of ingested ethanol is oxidized by alcohol dehy drogenase and the remainder by CYP2E1; during intoxication, however, ethanol induces the expression of CYP2E1. T he induc tion of CYP2E1 c ontributes to the activation of some xenobiotics, increasing the vulnerability of heavy drinkers to anesthetic drugs, over-the-counter analgesics, prescription drugs, and chemical carcinogens . In turn, the excessive amounts of acetaldehyde generated cause hepatotoxicity, lipid peroxidation of membranes, formation of protein add ucts, and other cellular changes. T he toxicity of methanol and ethylene glycol in humans has long been recognized, but frequent reports of such toxicity are not s urprising given the number of consumer products containing methanol and ethylene glycol (automotive antifreeze). Methanol (wood alcohol or methyl alcohol) is commonly used as a solvent in organic synthetic procedures, and is available to consumers in a variety of products, ranging from solid fuels (Sterno), paint removers, solvent for “ ditto'' c opying mac hines, motor fuels, antifreeze, to alcoholic beverages (unintentional ingredient). Oral methanol toxicity in humans is characterized by its rapid absorption from the gut, followed by a latent period of many hours before metabolic ac idosis (lowered blood pH and bicarbonate levels) and ocular toxicity are evident. T he metabolic acidosis and blindness result from the excessive accumulation of formic acid and the inability of the hepatic tetrahydrofolate pathway to oxidize formate to carbon dioxide. T he rate of elimination of methanol from the blood is relatively slow compared to that of ethanol, accounting for its long latency period. Its half-life ranges from 2 to 3 hours at low blood concentration to 27 hours at high blood concentration. Evidence supports the singular role of liver alcohol dehydrogenas e in the metabolism of methanol to formaldehyde, although it is oxidized slowly by alcohol dehydroge nase (approximately one-sixth the rate of ethanol). T he demonstration that methanol is a substrate for alcohol dehydrogenase provides a ra tional basis for the use of ethanol in the treatment of methanol toxicity. Ethanol depresses the rate of methanol oxidation by acting as a competitive substrate for alcohol dehydrogenase, reducing the formation of formaldehyde. On the other hand, formaldehyde is not usually detected in the blood because of its rapid metabolism by aldehyde dehydrogenase to formate. Although human exposure to methanol vapor is les s prevalent, methanol is rapidly absorbed through the skin or by inhalation, and depending on the severity of exposure, this can result in methanol poisoning. Ethylene glycol is oxidized to hydroxyacealdehyde and glyoxal and, subsequently, to oxalate by aldehyde dehy drogenase. When eliminated into the urine, oxalate forms calcium oxalate crys tals that can block the kidney tubules . 4-Methylpyrazole (Fomepizole) is an alcoho l dehydrogenase inhibitor that is used as an antidote for the treatment of methanol or ethylene glycol poisoning. 1,4-Butanediol is a solvent that has became popular as a date-rape drug and drug-of-abus e because of its metabolism to γ-hydroxy butyrate (s ee Chapter 15), which binds to the γ-hydroxybutyrate receptor, which in turn produces central nervous system sedation with amnes ia. Alcohol dehydrogenase also functions as a reductase when it catalyzes the reduction of an aldehyde or ketone to an alcohol. In addition, other NADP- or NAD-dependent dehydrogenases in the cytosol are capable of reduc ing a variety of ketones. Ketones are stable to further oxidation and, consequently, yield reduction products as major metabolites . Examples of reduction include the sedative-hypnotic chloral hydrate to trichloroethanol, the opioid antagonist naltrexone to 6-β-hydroxynaltrexol, the opioid analgesic methadone to α-methadol, the antipsychotic haloperidol to hydroxyhaloperidol, and the antiemetic dolasetron to dihydrodolasetron. T hese alcohol metabolites are all pharmacologically active. P.282

Aldehyde dehydrogenase A NAD-specific aldehyde dehydrogenase catalyzes the oxidation of endogenous aldehydes, such as those produc ed by the oxidation of primary alcohols or the deamination of biogenic amines , and of exogenous aldehydes to the corresponding c arboxylic acids. By inhibiting this enzyme, disulfuram (Antabuse) and metronidazole produce an unpleasant set of reactions (flus hing, abdominal cramping, and headache) when small amounts of alcohol are inges te d. Antabuse is used therapeutically in controlling alcohol abuse. Aldehyde dehydrogenase defic iency exhibits significant polymorphic expression in Chinese patients.

Molybdenum hydroxylases Molybdenum hydroxylases are additional non-CYP450 enzymes capable of catalyzing the oxidation of drugs. T he molybdenum hydroxylases, which include aldehyde oxidase, xanthine oxidase, and xanthine dehydrogenase, are more commonly found in the cytosol of mammalian liver and carry out the oxidation and detoxification of a number of structurally different azaheteroc ycles (52). T he efficient oxidation of endogenous purine nucleosides sugges ts that their metabolism and detoxification might be an important physiological role for the molybdenum hydroxylases. Among the azaheterocycles metabolized are derivatives of pyridine, quinoline, py rimidine, purine, quinazoline, and pteridines. T hese hydroxylases generally oxidize the α-carbon to the nitrogen of the azaheterocycle to oxo metabolites

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(also known as lactams). T he molybdenum hydroxylases contain a common electron-transfer sy stem in each subunit: one molybdenum atom, two Fe/S clusters, and one flavin adenine dinucleotide molecule. T he molybdenum hydroxylases catalyze their reactions differently than CYP450 and other hydroxylase enzymes, requiring water rather than molecular oxygen as the source of the oxygen atom incorporated into the metabolite, and with the concomitant reduction of molecular oxygen to superoxide (53,54). T he active sites possess a catalytically labile Mo V-OH (or, possibly, Mo VI-OH 2 ) group that is transferred to the s ubstrate during the course of the hydroxylation reaction.

Aldehyde oxidase In addition to metabolizing some aldehydes, aldehyd e oxidase also oxidizes a variety of azaheterocycles but not thia- or oxaheterocycles. Of the various purine nucleosides metabolized by aldehyde oxidase, the 2-hydroxy- and 2-amino derivatives are more efficiently metabolized, and for the N 9 -substituents, the typical order of preference is the acyclic nucleosides is as follows: 9-[(hydroxyalkyloxy)methyl]-purines ) > 2′-deoxyribofuranosyl > ribofuranosyl > arabinofuranosy l > H. T he kinetic rate constants for purine analogues revealed that the pyrimidine portion of the purine ring system is more important for substrate affinity than the imidazole portion. Aldehyde oxidase is inhibited by potassium cyanide and menadione (synthetic vitamin K). Aldehyde oxidase metabolizes an assortment of azaheterocycles including the short-acting sedative-hypnotic drug zaleplon (a pyrazolo[1,5α] pyrimidine derivative) to its 5-oxo metabolite; the anticancer drug thioguanine to 8-oxothioguanine; the α 2 -adrenergic agonist brimonidine (a pyrimidine derivative) to its 2-oxo-, 3-oxo-, and 2,3-dioxo- metabolites; quinine and quinidine to their 2-quinolone 6

metabolites ; the pro-antiviral drug famiclovir (a purine derivative) to its active 6-oxo metabolite (pencic lov ir); O -benzy lguanine to its 8-oxo metabolite (also formed primarily from CYP3A4); the metabolism of the anticancer drug DACA (an acridine-4-carboxamide derivative) to its 9-acridone metabolite; and the antiseizure drug zonisamide (a 1,2-benzis oxazole derivativ e) primarily by reduc tive cleavage of the 1,2-benzisoxazole ring to 2-sulfamoylacetylphenol. Although the azaheterocycles thiazole and oxazole are not metabolized by aldehyde oxidase, their carbocyclic analogues, benzothiazole, benzoxazole, and 1,2-benzisoxazole, are metabolized. On the other hand, the heterocycles, benzothiophene and benzofuran, whic h do not contain a nitrogen atom, are not metabolized by or inhibit aldehyde oxidase. T he hepatotoxic and neurotoxic 1-methyl-4-phenyl-1,2,3, 6-tetrahydropyridine (MPT P) is metabolized by aldehy de oxidase to its nontoxic MP-2-pyridone metabolite (MPT P lactam). Although S-cotinine is formed primarily from S-nicotine in human smokers by CYP2A6, in vitro studies suggest that aldehyde oxidase contributes to S-nicotine metabolism by oxidizing the intermediate metabolite (S-nicotine ∆-1′,5′ -imminium ion) to S-cotinine. T hese results s uggest that hepatic aldehyde oxidase is a key detoxification enzyme for MPT P and S-nicotine. Both aldehyde oxidase and xanthine oxidase contribute to the first-pass hepatic metabolism of orally administered methotrexate (a 2,4-diaminopteridine) to its 7-hydroxymethotrexate metabolite.

Xan thin e oxidase an d xanth ine deh ydrogenase Xanthine oxidase and xanthine dehydrogenase represent different forms of the s ame gene product. Xanthine dehy drogenase and xanthine oxidase are interconvertable; thus , these two enzyme forms and their reactions often are referred to as xanthine oxidoreductase. Xanthine oxidase is the rate-limiting enzyme in purine catabolism of hypoxanthine to uric acid via xanthine. Both xanthine oxidase and xanthine dehydrogenase play important roles in the P.283 metabolism of a number of purine anticanc er drugs to their active and inactive metabolites. Although xanthine oxidase is s trongly inhibited by the antigout drug allopurinol, aldehyde oxidas e oxidizes it to oxypurinol. Only xanthine dehydrogenase requires NAD

+

as an electron

acceptor for the oxidation of azaheterocy cles. 6-Mercaptopurine is metabolized by xanthine oxidase to 6-mercapturic acid.

Oxidativ e Deamination of Amines Monoamine oxidase (MAO) and diamine oxidase catalyze oxidativ e deamination of amines to the aldehydes in the presence of oxygen. T he aldehy de products can be metabolized further to the corres ponding alcohol or acid by aldehyde oxidase or dehydrogenase.

Monoamine oxidase Monoamine oxidase is a mitochondrial membrane flavin-containing enzyme that catalyzes the oxidative de amination of monoamines according to the following equation:

Substrates for this enzyme include several monoamines, secondary and tertiary amines in which the amine s ubstrates are methyl groups. T he amine must be attached to an unsubs tituted methylene group, and compounds having substitution at the α-carbon atom are poor substrates for MAO (e.g., aniline, amphetamine, and ephedrine) but are oxidized by the microsomal CYP4 50 enzymes rather than by MAO

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(Fig. 10.13). For secondary and tertiary amines, alk yl groups larger than a methyl and branched alkyl groups (i.e., is opropyl, t-butyl, or β-phenylisopropyl) inhibit MAO oxidation, but s uch substrates may function as rev ersible inhibitors of MAO. Nonselective irreversible inhibitors of MAO include hy drazides (phenelzine) and tranylcypromine and the MAO-B selective inhibitors pargyline and selegiline. Monoamine oxidase is important in regulating the metabolic degradation of catecholamines and serotonin in neural tis sues, and hepatic MAO has a crucial defens ive role in inactiv ating circulating monoamines or those that originated in the gastrointestinal tract and were absorbed into the s ystemic circ ulation (e.g., tyramine). T wo types of MAO are isolated: MAO-A, and MAO-B. T hey show dissimilar substrate preferences and different sensitivities to inhibitors. T he type MAO-A is found mainly in peripheral adrenergic nerve terminals and shows subs trate preference for 5-hy droxytryptamine, norepinephrine, and epinephrine. T he type MAO-B is found principally in platelets and shows s electivity for nonphenolic, lipophilic β-phenethylamines. Common substrates to both MAO-A and MAO-B are dopamine, tyramine, and other monophenolic phenylethylamines. A contaminant in the s ynthesis of rev ersed esters of meperidine, MPT P was discovered to be a highly selective neurotoxin for dopaminergic cells, producing parkinsonism (47). T he neurotoxicity of MPT P is associated with cellular destruction in the substantia nigra along with severe reductions in the concentration of dopamine, norepinephrine, and serotonin. T he remarkable neurotoxic action for MPT P involves a sequence of events beginning with the metabolic activ ation of MPT P to the toxic metabolite MPP ion) by MAO-B, specific uptake and acc umulation of MPP

+

+

(1-methyl-4-phenylpyridinium

in the nigros triatal dopaminergic neurons, and end ing with the inhibition of

oxidative phosphorylation (of NADH dehydrogenase in complex I). T his inhibition results in mitoc hondrial injury depriving the sens itive +

nigrostriatal cells of oxidative phosphorylation with their eventual cell death (neurotoxic actions of MPP ). T he MAO-B inhibitors (e.g., deprenyl) blocked this biotransformation.

Diamines, such as H 2 N-(CH 2 ) n -NH 2 , in which n is less than six, are not attack ed and show little affinity for MAO. If the intermolec ular distance between the amine groups is inc reased, the rate of oxidation by MAO increas es. Evidently, the sec ond amine group interferes with attachment of the amine to the enzyme.

Diamine oxidase Diamine oxidase attacks both diamines and histamine in muc h the s ame way that MAO attacks monoamines, forming aldehydes. T his enzyme is inhibited by carbonyl-blocking reagents and produces hydrogen peroxide, supporting the role of pyridoxal phosphate and the flavin prosthetic groups in the catalytic action of the enzyme. Diamine oxidase is recovered in the supernatant after centrifugation and removal of particulate matter. It is present in kidneys, intestines, liver, lung, and nervous tissue. It limits the biologic al effects of histamine and the polymethylene amines putrescine and cadaverine. It also attacks monoamines, but at a higher subs trate concentration.

Plasma amine oxidases are in blood plasma of mammals and include spermine oxidase, which deaminates s permine and other polyamines.

Miscellaneous Reductions Disulfides (e.g., disulfiram), sulfoxides (e.g., dimethyls ulfoxide), N-oxides , double bonds such as those in progestational steroids, and dehydroxylation of aromatic and aliphatic hydroxyl deriv atives are examples of reductions occ urring in microsomal or nonmicrosomal (usually cytosol enzymes) fractions . P.284

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Various studies regarding the biotransformation of xenobiotic ketones have established that k etone reduction is an important metabolic pathway in mammalian tiss ue. Because carbonyl compounds are lipophilic and may be retained in tissues, their reduction to the hydrophilic alcohols and subsequent conjugation are critical to their elimination. Although ketone red uctases may be closely related to the alcohol dehydrogenases, they have distinctly different properties and use NADPH as the cofactor. T he metabolism of xenobiotic ketones to free alcohols or conjugated alcohols has been demonstrated for aromatic, aliphatic, alicyclic, and unsaturated ketones (e.g., naltrexone, naloxone, hydromorphone, and daunorubicin). T he carbonyl reductas es are dis tinguished by the stereospecificity of their alcohol metabolites .

β-Oxidation Alkyl carboxylic acids, as their coenzyme A (CoA) thioesters, are metabolized by oxidation at the β–χαρβoν to the carboxylic carbon (β-oxidation). T his pathway involves the oxidative cleav age of two carbon units at a time (as acetate), beginning at the carboxyl terminus and continuing until no more acetate units c an be remov ed. T he reaction is terminated when a branch (e.g., valproic acid) or aromatic group is encountered. T he metabolism of even and odd phenylalkyl acids can serve as an example:

Hydrolysis In general, esters and amides are hydrolyzed by enzymes in the blood, liver microsomes, kidneys , and o ther tissues . Esters and certain amides are hydrolyzed rapidly by a group of enzymes termed “ carboxylesterases.” T he more lipophilic the amide, the more fav orable it is as a substrate for this enzyme. In mos t cas es, the hydrolysis of an es ter or amide bond in a toxic sub stance results in bioinac tivation to hydrophilic metabolites that are readily excreted. Some of these metabolites may yield conjugated metabolites (i.e., glucuronides ). Carboxylesterases include cholinesteras e (pseudocholines terase), arylcarboxyesterases, liv er microsoma l carboxylesterases, and other unclassified liv er carboxylesterases. Cholines terase hydrolyzes choline-like esters (s uccinylcholine) and procaine as well as acetylsalicylic acid. Genetic variant forms of cholinesterase have been identified in human serum (e.g., succinylcholine toxic ity when administered as ganglionic blocker for muscle relaxation). Meperidine is hydrolyzed only by liver microsomal carboxylesterases (Fig. 10.19). Diphenoxylate is hydrolyzed to its active metabolite, diphenoxylic acid, within 1 hour (Fig. 1 0.19). Presumably, the peripheral pharmacological action of diphenoxylate is attributed to zwitterionic diphenoxylic acid, which is readily eliminated in the urine.

Fig. 10.19. Examples of hydrolysis reactions.

A distinct type of esterase is the enzyme serum paraoxonase (PON1), which appears to act as an important guardian against the neurotoxicity of organophosphates and cellular damage from oxidized lipids in the LDL proteins (55). T he PON1 (A-esterase) is similar to arylesterase in that it catalyzes the hydrolys is of phenyl acetate and other aryl es ters . Without PON1, the organophos phate is free to react with, and irreversibly inhibit, acetylcholinesterse (see Chapter 12). Additionally, PON1 exhibits a substrate-dependent polymorphism. Individuals who are susceptible to the toxic effects of organophosphates such as paraoxon and chlorpyrifos (Dursban) are deficient in this isoenzyme.

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Esters that are sterically hindered are hydrolyzed more slowly and may appear unchanged in the urine. For example, approximately 50% of a dose of atropine appears unchanged in the urine of humans . T he remainder appears to consist of unhydrolyzed biotransformed products. As a rule, amides are more stable to esterase hydrolysis than are esters, and it is not surprising to find amides excreted largely unchanged. T his fact has been exploited in dev eloping the antiarrhythmic drug procainamide. Procaine is not useful because of its rapid esterase hydrolysis, P.285 but 60% of a dose of procainamide was recovered unchanged from the urine of humans , with the remainder being mostly N-acetylprocainamide. On the other hand, the deacylated metabolite of indomethacin (a tertiary amide) is one of the major metabolites detected in human urine. Amide hy droly sis of phthalylsulfathiazole and succ iny lsulfathiazole by bacterial enzymes in the colon releases the antibacterial agent sulfathiazole.

Summary In summary, Phase 1 metabolic transformations introduce new and polar functional groups into the molecule, which may produce one or more of the following changes: 1. Decreased pharmacologic al activity (deactivation) 2. Increased pharmacological activity (activation) 3. Increased toxic ity (carcinogenesis, mutagenesis , cytotoxicity) 4. Altered pharmacological activity Drugs exhibiting increas ed activ ity or activity different from the parent drug generally undergo furth er metabolism and conjugation, resulting in deactivation and excretion of the inactive conjugates.

Drug Conjugation Pathways (Phase 2) Conjugation reactions represent probably the most important xenobiotic biotransformation reaction (53,54). Xenobiotics usually are lipophilic, well absorbed in the blood, but slowly exc reted in the urine. Only after conjugation (Phase 2) reactions have added an ionic hydrophilic moiety, such as gluc uronic acid, sulfate, or glycine, to the xenobiotic is water solubility increased and lipid solubility decreased enough to make urinary elimination poss ible. T he major proportion of the administered drug dose is excreted as conjugates into the urine and bile. Conjugation reactions may be preceded by Phase 1 reactions. For xenobiotics with a functional group available for conjugation, conjugation alone may be its fate. T raditionally, the major conjugation reactions (glucuronidation and s ulfation) were thought to terminate pharmac ological ac tivity by transforming the parent drug or Phase 1 metabolites into readily excreted ionic polar products. Moreover, thes e terminal metabolites would have no significant pharmacological activity (i.e., poor cellular diffusion and affinity for the active drug's receptor). T his long-es tablished view changed, however, with the discoveries that morphine 6-glucuronide has more analgesic ac tivity th an morphine in humans and that minoxidil sulfate is the active metabolite for the antihypertensive minoxidil. For most xenobiotics, conjugation is a detoxification mechanism. Some compounds, however, form reactive intermediates that have been implicated in c arcinogenesis, allergic reaction, and tissue damage.

Fig. 10.20. Sequential conjugation pathways for p-aminosalicylic acid.

Sequential conjugation for the same subs tance gives rise to multiple conjugated products (see p-aminosalicy lic acid in Fig. 10.20). T he xenobiotic can be a s ubstrate for more than one metabolizing enzyme. For example, different conjugation pathways could compete for the same functional group. T he outcome is an array of metabolites excreted in the urine or feces. T he factors determining the outcome of this interplay include availability of cosubstrates, enzyme kinetics (V m ax ), substrate affinity (K m ) for the metabolizing enzyme, and tiss ues. When a cosubstrate is low or depleted, the competing reactions can take over. T he reactivity of the functional group determines all subsequent events. For example, major conjugation reactions are sulfation, ether glucuronidation, and methylation for the phenolic hydroxyl groups; acetylation, sulfation, and glucuronidation for amine groups; and amino acid conjugation and ester glucuronidation for carboxyl groups. Conjugation enzymes may show stereospec ificity toward enantiomers when a racemic drug is administered. T he metabolite pattern of the

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same drug when administered orally may be different when administered intravenously bec ause of presystemic intestinal conjugation. A current and in-depth rev iew of the different Phas e 2 c onjugations is available in Mulder (56).

Glucuronic Acid Conjugation Glucuronide formation probably is the major and most common route for xenobiotic Phase 2 metabolism to water-soluble metabolites, and it accounts for the major share of the conjugated metabolites found in the urine and bile (56). Its significance lies in the readily available supply of glucuronic acid in the liver and in the many functional groups forming glucuronide conjugates (e.g., phenols, alcohols, carboxylic acids, and amines).

Mechanism of Glucuronide Conjugation T he reaction involves the direc t condensation of the xenobiotic (or its Phas e 1 product) with the activated form of glucuronic acid, UDP–glucuronic acid (UDPGA). T he overall scheme of reactions is shown in Figure 10.21. T he reaction between UDPGA and the acceptor compound is catalyzed by UDP–glucuronosyl transferases (UGT ), a multigene family of isozymes located along the ER of liver, epithelial cells of the intestine, and other extrahepatic tissues. Its unique location in the ER along with the CYP450 isoforms has important physiologic effects in the neutralization of reactive P.286 metabolites generated by the CYP450 isoforms and in c ontrolling the levels of reactive metabolites present in these tissues.(Fig. 10.22). T his cartoon depicts the spatial orientation and the interrelationship of the ER membrane–bound enzy mes such as CYP450, UGT s, and membrane-bound transporters (57). T he transporters carry the UDPGA and xenobiotics (D) from the cytosol into the ER lumen and transport the glucuronide metabolite from the ER lumen into the cytosol. T he pres ence of the activ e site for UGT toward the ER lumen catalyzes the reaction between the substrate and UDPGA. T he resultant glucuronide has the β-c onfiguration about carbon 1 of glucuronic acid. With the attachment of the hy drophilic carbohydrate moiety containing an easily ionizable carboxy l group (pK a = 3–4), a lipid-soluble substance is converted into a conjugate that is poorly reabsorbed by the renal tubules from the urine and is excreted more readily into the urine or, in some cases, into the bile. Endogenous substances conjugated with glucuronic acid include steroids, bilirubin, and thyroxine. Not all glucuronides are excreted by the k idneys. Some are excreted into the intestinal trac t with bile (enterohepatic cycling), where 1

β-glucuronidase in the intestinal flora hydrolyzes the C -O-glucuronide back to the aglycone (xenobiotic or their metabolites) for reabsorption into the portal circ ulation.

Fig. 10.21. Glucuronidation pathway catalyzed by UDP-glucuronosyl transferases (UGTs).

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Fig. 10.22. Proposed topological model of UGT. A lipophilic drug (D) reaches the active site of CYP450 from the membrane or cytoplasm and is hydroxylated. The hydroxylated metabolite is transferred to UGT, where glucuronidation occurs, followed by release into the lumen and excretion from the cell. The UDPGA is synthesized in the cytoplasm and transported via translocase. (Adapted from Oesch F. Metabolic transformation of clinically used drugs to epoxides: new perspectives in drug–drug interactions. Biochem Pharmacol 1976;25 1935–1937; with permission.)

UGT Families T he UGT s have been class ified into families ac cording to similarities in amino acid sequences, analogous to the CYP450 family. T he human UGT family is divided into two subfamilies, UGT 1 and UGT 2 (58). Considerable overlap in substrate spec ificities exists between the two families. T he human UGT 1A1 isoform is primarily respons ible for the glucuronidation of bilirubin, estradiol, and other estrogenic steroids; UGT 1A3 and UGT 1A4 catalyze the glucuronidation of drugs with tertiary amines to form quaternary gluc uronides and hydroxylated xenobiotics; UGT 1A6 exhibits limited substrate specificity for planar phenolic substances; UGT 1A9 has a wide range of substrate specificity and can glucuronidate nonplanar phenols, plant subs tances (e.g., anthraquinones and flavones), steroids, and other phenolic drugs; and UGT 1A10 glucuronidates mycophenolic acid an inhibitor of inosine monophosphate dehydrogenase. Human family 2 isoform UGT 2B4 is homologous to UGT 2B7 and catalyzes the glucuronidation of the 6α-hydroxyl group of bile ac ids ; UGT 2B7 glucuronidates, the highest number of substrates, including the 3- and 6-glucuronidation of morphine and 6-glucuronidation of codeine; UGT 2B11 glucuronidates a wide range of planar phenols, bulky alcohols, and polyhy droxylated estradiol metabolites; and UGT 2B15 catalyzes the glucuronidation of the P.287 17α-hydroxyl group of dihydrotestosterone and other steroidal compounds as well as phenolphthalein. T he UGT 1A isoforms are inducible with 3-methylc holanthrene and cigarette smoking, and the UGT 2B family is inducible by barbiturates. Approximately 40% of the glucuronides are produced by UGT 2B7, 20% by UGT 1A4, and 15% by UGT 1A1.

UGT Distribution T he human liver has been established as the most important tissue for all routes of metabolism, inc luding gluc uronidation. Studies have shown that the rate of glucuronidation is not uniform in the different sections of the liver: T he UGT 1A6 content was greatest in the middle but also found in the bile duct epithelium and in the endothelium of the hepatic artery and portal vein; UGT 2B2 was uniformly dis tributed throughout the liver. T he UGT s expressed in the intestine include UGT 1A1 (bilirubin-glucuronidating isoform), UGT 1A3, UGT 1A4, UGT 1A6, UGT 1A8, UGT 1A9, and UGT 1A10. Substrate spec ificities of intestinal UGT isoforms are comparable to those in the liver. T he UGT isoforms in the intestine c an glucuronidate orally administered drugs , suc h as morphine, acetaminophen, α- and β-adrenergic agonists and other phenolic phenethanolamines, as well as other dietary xenobiotics, reducing their oral bioavailability (first-pass metabolism). Although UGT isoforms are found in kidney, brain, and lung, they are not uniformly distributed, with UGT 1A6 being the isoform that is ubiquitous in extrahepatic tissue.

O-, N-, and S-Glucuronides T he xenobiotics forming glucuronides with alcohols and phenols are ether glucuronides. Aromatic and some aliphatic carboxylic acids form ester (acyl) glucuronides. Aromatic amines form N-glucuronides, and sulfhydryl c ompounds form S-glucuronides, both of which are more labile to acid compared with the O-glucuronides (Fig. 10.21). Some tertiary amines (e.g., tripelennamine) have been reported to form quaternary ammonium N-glucuronides. Substanc es containing a 1,3-dicarbonyl structure (e.g., phenylbutazone) can undergo formation of C-gluc uronides by direct conjugation without previous metabolis m. T he acidity of the methylene carbon of the 1,3-dicarbonyl group determines the degree of C-glucuronide formation.

Acyl Glucuronides 1

Drug–acyl glucuronides are reac tive conjugates at p hysiologic pH. T he acyl group of the C -ac yl glucuronide can migrate via transesterification from the original C-1 position of the glucuronic acid to the C-2, C-3, or C-4 positions (Fig. 10.21). T he resulting positional isomers are not hydrolyzable by β-glucuronidase, giving the appearance of a new unk nown con jugate. Under physiologic or 1

weakly alkaline conditions , however, the C -acyl glucuronide can hydrolyze in the urine to the parent substance (aglycone) or undergo 1

acyl migration to an acceptor macromolecule. T he pH-catalyzed migration of the acyl group from the drug C -O-acyl glucuronide to a protein or other cellular constituent occ urs with the formation of a cov alent bond to the protein (59). T he acylated protein becomes a

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“ hapten'' and could stimulate an immune response against the drug, resulting in the expression of an hypersens itivity reaction or other forms of immunotoxicity. A high incidence of anaphylactic reactions have been reported for s everal nonsteroidal anti-inflammatory drugs (NSAIDs; benoxaprofen, zomepirac, indoprofen, alclofenac, ticry nafen, and ibufenac) that have been removed from the market. All of these NSAIDs are metabolized by humans to acyl glucuronides. Similar reactions have been reported for other NSAIDs, including tolmetin, sulindac, ibuprofen, ketoprofen, and acetylsalicylic acid. T he frequency of the immunotoxic response may be related to the stability of the acyl glucuronide, the chemical rate kinetics for th e migration of the acyl group, and the concentration and stability/half-life of the antigenic protein. When the acyl glucuronide is the primary metabolite, in patients with dec reased renal function (i.e., elderly individuals), or when probenecid is coadministered, renal cycling of the unconjugated (aglycone) parent drug or metabolite is likely to occur, resulting in the plasma accumulation of the aglycone. T he reduced elimination of the acyl glucuronide increas es its hydrolysis back to the aglycone or the 1

migration of the C -O-acyl group to an acceptor macromolecule.

Bioactiv ation and Toxic Glucuronides Generally, glucuronides are biologically and chemically less reactiv e than their parent molecules and are readily eliminated without interaction with intracellular substances. Some gluc uronide conjugates, however, are more active than the parent drug (60). Morphine, for example, forms the 3-O- and 6-O-glucuronides in the intestine and in the liver. T he 3-O-glucuronide is the primary glucuronide metabolite of morphine, with a blood concentration 20-fold that of morphine. Pharmacologically, it is an opiate a ntagonist. On the other hand, 6-O-glucuronide, with a blood concentration twice that of morphine, is a more potent µ-receptor agonist and, whether administered orally or parentally, is 650-fold more analgesic than morphine in humans. T hus, the analgesic effects of morphine are the result of a complex interaction of the drug and its two metabolites with the opiate receptor. Apparently, the 6-O-glucuron ide can pass into the brain v ia an anion-transport sys tem. Glucuronidation also is capable of promoting cellular injury (e.g., hepatotoxicity and carcinogenes is) by facilitating the formation of reactive electrophilic (electron-deficient) intermediates and their transport into target tissues (37). T he induction of bladder carcinogenesis by aromatic amines may result from the glucuronidation of N-hydroxylary lamine. T hese O-glucuronides become concentrated in the urine, where they are readily h ydrolyzed by the acid pH of the urine back to the P.288 N-hydroxylarylamines. Elimination of water under these conditions leads to the formation of electrophilic arylnitrenium species. T his reactive species can bind covalently with endogenous cellular constituents (e.g., nucleic acids and proteins), initiating carcinogenesis. Sulfation and glucuronidation occur side by side, o ften competing for the same substrate (most commonly phenols, i.e., acetaminophen). T he balance between sulfation and glucuronidation is influenced by such factors as species, dose, av ailability of cos ubstrates, and inhibition and induction of the respective transferases.

Sulfate Conjugation Sulfate conjugation is an important reac tion in the biotransformation of steroid hormones, catecholamine neurotransmitters, thyroxine, bile acids, phenolic drugs, and other xenobiotics (56). T he major physiologic consequence of sulfate conjugation of a drug or xenobiotic is its increased aqueous solubility and excretion, becaus e the pK a of the s ulfonate groups is approximately one to two. T he sulfate conjugates are almost totally ionized in physiologic solutions and possess a smaller volume of dis tribution than unconjugated steroids and drugs. In certain instances, however, sulfate conjugation can result in bioac tivation to reactive electrophiles or therapeutically active conjugates (e.g., minoxidil sulfate). T he cytosolic sulfotransferases generally associated with the conjugation of phenolic steroids, neurotransmitters, and xenobiotics. T he membrane-bound sulfotransferases are localized in the Golgi apparatus of mos t cells and are responsible for the sulfation of glycosaminoglyc ans, glycoproteins, and the tyrosinyl group of peptides and protein but generally are not associated with xenobiotic metabolis m.

Mechanism of Sulfate Conjugation A xenobiotic is sulfated by transfer of an active sulfate from 3′-phosphoadenosine-5′-phosphos ulfate (PAPS) to the acceptor molec ule, a cytosolic reaction catalyzed by a multigene s ulfotransferas es (Fig. 10.23); PAPS is formed enzymatically from adenosine triphosphate (AT P) and inorganic sulfate. Sulfate conjugation is a reac tion principally of phenols and, to a lesser extent, of alcohols to form highly ionic and polar sulfates (R-O-SO 2 H). T he availability of PAPS and its prec ursor inorganic sulfate determines the reaction rate. T he total pool of sulfate usually is limited and can be readily exhausted. With increasing doses of a drug, conjugation with sulfate becomes a less predominant pathway. At high doses with a competing substrate (i.e., acetaminophen), glucuronidation usually predominates over that of sulfation, which prevails at low doses. Other precu rs ors for sulfate include L-methionine and L-cysteine. When PAPS, inorganic s ulfate, or the sulfur amino acids are low or depleted, or when a substrate for sulfation is given in high doses, competing reactions with glucuronidation can take over. Additionally, O-methylation is a competing reaction for c atecholamine.

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Fig. 10.23. Sulfation pathways.

Sulfotransferase Family In humans, sulfotransferases are divided into two families , SULT 1 and SULT 2 (61). T he isoforms SULT 1A1, SULT 1A2, and SULT 1A3 catalyze the sulfation of many phenolic drugs, cate cholamine, hormones, aromatic amines, and other xenobiotics (62). T he SULT 1A1/2 (formerly known as phenol sulfotransferase thermally stable) preferentially s ulfates small planar phenols in the micromolar concentration range, estradiol and synthetic estrogens, phytoestrogens , acetaminophen, the N-oxide of minoxidil, and N-hy droxyaromatic and heterocylic amines; SULT 1A3 (formerly known as phenol sulfotransferase thermally labile) s electively sulfates the catecholamines dopamine, norepinephrine, and epinephrine as well as the N-oxide of minoxidil, thyroid hormones, but not es trogenic steroids and other hydroxy steroids; SULT 1B1 catalyzes the s ulfation of the thyroid hormones; SULT 1C1 is involved with the bioactivation of proc arcinogens via sulfation; SULT 1E1 (formerly known as estrogen sulfotransferase) preferentially sulfates estradiol in the nanomolar range; SULT 2A1 (formerly known as dehydroepiandrosterone [DHEA] sulfotransferase) conjugates DHEA, estradiol (micromolar range), the synthetic estrogens, and other estrogen metabolites; and SULT 2B1 (formerly known as hydroxysteroid sulfotransferase) sulfates DHEA and pregnenolone. P.289 Sulfate conjugation appears to be an important reaction in the transport and metabolism of s teroids . Sulfation decreases the biological activity of the steroid, becaus e the steroid sulfates are not capable of binding to their receptors. It provides for the transport of an inactive form of the steroid to its target tissue, where the active steroid is regenerated by sulfatases at the target tissue.

Sulfotransferase Distribution T he SULT 1A families are abundantly expressed in the liver, small intestine, brain, kidneys, and platelets (61). For example, phenol is sulfated by a sulfotransferase in the liver, kidneys , and intestines, whereas steroids are sulfated only in the liver. T he broad diversity of compounds sulfated in human tissues results, in part, from the multi-isoforms of the cytosolic sulfotransferases and their overlapping substrate specificities. Sulfate conjugates are almost totally ionized and, therefore, are excreted mostly in the urine, but biliary elimination is common for steroids. On hydrolysis of biliary sulfate conjugates in the intestine by s ulfatases, the parent drug (or xenobiotic) or its metabolites may be reabsorbed into the portal circulation for ev entual elimination in the urine as a sulfate conjugate (enterohepatic cycling). T he rate of sulfation appears to be age dependent, decreas ing with age. An important site of sulfation, especially after oral administration, is the intestine. T he res ult is a presystemic first-pass effect: dec reasing drug bioavailability of several drugs for which the primary route of conjugation is sulfation. Drugs such as isoproterenol, albuterol, steroid hormones, α-methyldopa, acetaminophen, and fenoldopam are affected. Competition for intestinal sulfation between coadminis tered substrates may influence their bioavailability with either an enhancement of or a decrease in therapeutic effects. An example would be coadministration of acetaminophen and the oral contraceptive ethiny l estradiol.

Bioactiv ation and Toxicity As with glucuronidation, sulfation is a detoxic ation reaction, although s ulfate conjugates have been reported to be pharmacologically active (e.g., minoxidil sulfate, dehydroepiandrosterone sulfate, and morphine 6-sulfate) or to be converted into unstable sulfate conjugates that form reactive intermediates implicated in carcinogenesis and tiss ue damage. Sulfation of an alcoh ol generates a good leaving group and can be an activation process for alcohols to produce a reactive electrophilic s pecies (37). Like the N-glucuronides, however, N-sulfates are capable of promoting cytotoxicity by facilitating the formation of reactive electrophilic intermediates. Sulfation of N-oxygenated aromatic amines is an activation process for some arylamines that c an eliminate the sulfate to an electrophilic species capable of reacting with proteins or DNA (e.g., 2-ac ety laminofluorene). T he N-sulfation of arylamines to arylsulfamic acids (R-NHSO 3 H) is a minor pathway.

Stereoselectiv ity T he SULT 1A3 displays stereoselec tivity in the sulfation of chiral phenolic phenethanolamines. T his isoform may be responsible, in part, for the enantiomer-s pecific metabolis m observed for the β-adrenergic agonists. For example, the (+ )-enantiomers of terbutaline and isoproterenol and the (–)-enantiomer of albuterol a re selectively sulfated.

Conjugation with Amino Acids Conjugation with amino acids is an important metabolic route in the metabolism of xenobiotic carboxylic ac ids before elimination (56). Glycine, the most common amino acid, forms water-soluble ionic conjugates with aromatic, arylaliphatic, and heterocy clic carboxy lic acids. T hese amino acid conjugates usually are less toxic than their precursor acids and are excreted readily into the urine and bile. T hese reactions involve the formation of an amide or peptide bond between the xenobiotic carboxylic acid and the amino group of an amino acid, usually glycine. T he xenobiotic must first be activated to its CoA thioester before reacting with the amino group (Fig. 10.24). T he formation of the xenobiotic acyl CoA thioester is of c ritical importance in intermediary metabolism of lipids as well as intermediate- and long-chain fatty acids. T he major metabolic biotransformations for xenobiotic carboxylic acids include conjugation with either glucuronic acid or glycine. T he metabolic fate of these carboxylic acids depends on the size and type of substituents adjacent to the carboxyl group. Most unbranched aliphatic acids are completely oxidized and do not usually form c onjugates, although branc hed aliphatic and arylaliphatic acids are resistant to β-oxidation and form glycine or glucuronide conjugates. Interestingly, substitution of the α-carbon P.290 favors glucuronidation rather than glycine conjugation. Benzoic and heteroc yclic aromatic ac ids are principally conjugated with glycine. Glycine conjugation is preferred for xenobiotic carboxy lic acids at low doses , and gluc uronidation is preferred at high dos es with broad substrate selectivity. In humans and some spec ies of monkeys, glutamine forms a conjugate with phenylacetic acids and related arylacetic

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acids. Bile acids form conjugates with glycine and taurine by the action of enzymes in the microsomal fraction rather than in the mitochondria.

Fig. 10.24. Amino acid conjugation pathways of carboxylic acids with glycine and acetylation pathways.

In contrast to the enhanced reactivity and toxicity of the various glucuronide, s ulfate, acetyl, and glutathione conjugates, amino acid conjugates have not proven to be toxic. It has been proposed that amino acid conjugation is a detoxication pathway for reactive acyl CoA thioesters.

Conjugation with CoA Several carboxylic acid–containing drugs (e.g., zomiperac and benzoxaprofen) have been implicated in rare but serious adverse reactions. T hese carboxylic acids were withdrawn in the late 1980s from the market because of unpredictable allergic reactions that may have been caused by carboxylic acid–protein adducts formed by reaction of their reactive acyl glucuronide or acyl CoA thioesters with endogenous proteins. T he carboxylic acids can be bioactivated via two distinct pathways: UGT -catalyzed conjugation with glucuronic acid to acyl glucuronides, or acy l CoA synthetase–catalyzed formation of acyl CoA thioesters. T he reac tive CoA thioester intermediates of carboxylic acids are electrophilic and, therefore, c an contribute to the acylation of target proteins. T he acyl CoA thioester serves as an obligatory intermediate in the formation of glycine and carnitine ester. T herefore, their appearance in metabolis m studies and urine is of s ignificance, because they serve as biomarkers for the formation acyl CoA thioesters, which may provide the link between protein-reactive acyl CoA thioesters and the rare and unpredictable idiosyncratic drug reactions in humans . A nontoxic reaction involving acyl CoA thioesters includes c hiral inversions of the 2-arylpropionic acids (“ profens''), a major group of NSAIDs that exist in two enantiomeric forms (59). T he anti-inflammatory activity (inhibition of cyclooxygenase) for the NSAIDs resides with the S-(+ )-enantiomer. T he intriguing aspect for the metabolism of the NSAID is their unidirectional c hiral inversion from the R-(–)- to the S-(+ )-enantiomer (Fig. 10.25). T he NSAID acyl CoA thioester is the c ritical intermediate for this chiral inversion of the 2-arylpropionic acids, and the formation of the thioester is s tereospecific for the pharmacologically inactive R-enantiomer (61). Rac emic ibuprofen and related anti-inflammatory 2-arylpropionic acids (e.g., benoxaprofen, carprofen, c icliprofen, clidanac, fenoprofen, indoprofen, ketoprofen, loxoprofen, and naproxen) undergo in vivo metabolic inversion to the more activ e S-enantiomer via the formation, epimerization, and hydrolysis of their res pective acyl CoA thioesters (63). T he unidirectional R- to S-inversion of ibuprofen is attributed to the stereoselective thioester formation of R-Ibuprofen CoA, not to the stereoselectivity of either the epimerization or hy droly sis steps (64). S-(+ )-Ibuprofen does not form its CoA thioester in vivo. Because the formation of 2-arylpropionyl CoA thioester is analogous to the activation and metabolism of medium and long-chain fatty acids, it seems possible that conditions either elevating (e.g., diabetes or fasting) or depleting CoA may alter CoA thioester formation of the 2-arylpropionic acids and their in v ivo metabolic inversion. Amino acid conjugation (i.e., CoA activation) is more sensitive to s teric hindrance than is glucuronidation (e.g., arylacetic acids).

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Fig. 10.25. Coenzyme A (CoA) conjugation pathway: Stereospecific inversion of R(–)- to S(+)-ibuprofen.

Acetylation Acetylation is principally a reaction of amino groups involving the transfer of acetyl CoA to primary aliphatic and aromatic amines, amino acids, hydrazines , or sulfonamide groups (56). T he liver is the primary site of acetylation, although extrahepatic sites have been identified. 1

4

Sulfonamides, being difunctional, c an form either N or N acetyl derivatives, and in some instances, the diacetylated derivative has been identified. Secondary amines are not acetylated. Acetylation may produce conjugates that retain the pharmacological activity of the parent drug (e.g., N-acetylprocainamide) (Fig. 10.24). T he existence of genetic polymorphism in the rate of acetylation has important consequenc es for drug therapy and tumorigenicity of xenobiotics. Acetylation polymorphism has been associated with differences in human drug toxicity between the two acetylator phenotypes, slow and fast acetylators. Slow acetylators are more prone to drug-induced toxicities and accumulate higher blood concentrations of the unacetylated drug (e.g., hydralazine and procainamide-induced lupus erythematous, isoniazid-induced peripheral nerve damage, and sulfasalazine-induced hematologic disorders ) than fast acetylators do. Fast acetylators eliminate the drug more rapidly by P.291 conversion to its relatively nontoxic N-acetyl metabolite. For s ome drug substances, however, fas t acetylators may pose a greater risk of liver toxicity than slow acetylators, because fast ac ety lators produce toxic metabolites more rapidly (e.g., isoniazid forms the hepatotoxic monoacetylhydrazine metabolite). T hus, differenc es in ac etylator phenotype can influence adverse drug reactions.

Fig. 10.26. Bioactivation of acetylated arylamines.

T he possibility arises that genetic differenc es in acetylating capacity may confer differences in susceptibility to chemical carcinogenicity from arylamines. T he tumorigenic activity of arylamines (1 in Fig. 10.26) may be the result of a complex series of sequential metabolic reactions commencing with N-acetylation (2 in Fig. 10.26), subsequent oxidation to arylhy droxamic acids (3 in Fig. 10.26), and metabolic transformation to acetoxyarylamines by N, O-acyltrans ferase (4 in Fig. 10.26). T he ac etoxyarylamine can eliminate the acetoxy group to form the reactive arylnitrenium ion (5 in Fig. 10.26), which is capable of covalently binding to nuc leic acids and proteins , thus increasing the risk for development of bladder and liver tumors (65). T he rapid acetylator phenotype is expected to form the acetoxy arylamine metabolite at a greater rate than the slow acetylator and, thereby, to present a greater risk for development of tumors c ompared with the slow acetylator.

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Fig. 10.27. Glutathione and mercapturic acid conjugation pathways.

Glutathione Conjugation and M ercapturic Acid Synthesis Mercapturic acids are S-derivatives of N-acetylcysteine synthesized from glutathione (GSH) (53,54). It is generally accepted that most compounds metabolized to mercapturic acids first undergo conjugation with glutathione, catalyzed by the enzyme glutathione S-transferase (GST ), a multigene isoenzyme family that is abundant in the soluble supernatant liver fractions. In humans , GST s are divided into two isoforms, GST M1 and GST T 1. T he princ ipal drug substrates for GST M1 are the nitrosourea and mustard-ty pe anticancer drugs. T he GST T 1 isoform metabolizes small organic molecules, s uch as solvents, halocarbons, and electrophilic compounds (e.g., αβ-unsaturated carbonyl compounds). T he reaction is depicted in Figure 10.27. P.292 T he enzyme GST apparently inc reases the ionization of the thiol group of GSH, increasing its nucleophilicity toward electrophiles and conjugating with thes e potentially harmful electrophiles, thereby protecting other vital nucleophilic centers in the cell, such as nucleic acids and proteins. Glutathione als o is capable of reacting nonenzymatically with nucleophilic sites o n neighboring macromolecules. Once conjugated with GSH, the electrophiles usually are excreted in the bile and urine. A range of functional groups y ields thioether conjugates of GSH as well as products other than thioethers (Fig. 10.27). T he nucleophilic attack by GSH occurs on elec trophilic carbons with leaving groups (e.g., halogen [alky l, alkenyl, aryl, or aralkyl halides], sulfate [alkylmethanesulfonates], and nitro [alkyl nitrates] groups), ring opening of small ring ethers (epoxides and β-lactones, e.g., β-propiolactone), and the Michael-type addition to the activated β-carbon of an α,β-unsaturated carbonyl compound (e.g., acrolein). Organic nitrate esters (e.g., the c oronary vasodilator nitrogly cerin) undergo a dismutation reaction that results in the oxidation of GSH to GSSG (through formation of the labile S-nitrate conjugation produc t) and reduction of the nitrate ester to an alc ohol and inorganic nitrite. T he lack of substrate specificity gives argument to the fact that glutathione transferase has undergone adaptive changes to accommodate the variety of xenobiotics to which it is exposed. Usually, the conjugation of an elec trophilic compound with GSH is a reaction of detoxication, but some c arcinogens hav e been activated through conjugation with GSH (29,30,31). T he enzymatic conjugation of GSH with epoxides provides a mechanism for protecting the liver from injury c aused by certain bioactivated intermediates (see the s ubsequent Metabolic Bioactivation section). Not all epoxides are substrates fo r this enzyme, but the more chemically reactive epoxides appear to be better substrates. Important among the epoxides that are subs trates for this enzyme are those produced from halobenzenes and PAHs through the action of CYP450 monooxy genase. Epoxide formation exemplifies bioactivation, because the epoxides are reactive and potentially toxic, whereas their GSH conjugates are inactive. Conjugation of GSH with the epoxides of aryl hydrocarbons eventually results in the formation of hydroxymercapturic acids (premerc apturic ac ids ), which undergo acid-catalyzed dehydration to the mercapturic acids. T he halobenzenes usually are conjugated in the para position. Monohalogenated, gem-dihalogenated, and vicinal dihalogenated alkanes undergo glutathione trans ferase–catalyzed conjugation reactions to produce S-substituted glutathione derivatives that are metabolically transformed into the more stable and less toxic mercapturic acids. T his common route of metabolism occurs through nucleophilic displac ement of a halide ion by the thiolate anion of glutathione (see the discuss ion on glutathione conjugation). T he mutagenicity of the 1,2-dihaloethanes (e.g., the pesticide and fumigant ethylene dibromide) has been attributed to GSH displacing bromide with the formation of the S-(2-haloethyl) glutathione, which s ubsequently rearranges to a reactive episulfonium ion electrophile that, in turn, alkylates DNA. Many of the halogenated hydrocarbons exhibiting nephrotoxicity undergo the formation of similar S-substituted cy steine derivatives . T he mercapturic acid pathway appears to have evolv ed as a protective mechanism against xenobiotic-induced hepatotoxicity or

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carcinogenicity, serving to detoxify a large number of noxious substances that we inhale or ingest or that are produced daily in the human body. A correlation exists between the hepatotoxicity of acetaminophen and levels of GSH in the liv er. T he probable mechanism of toxicity that has emerged from animal studies is that acetaminophen is CYP1A2- and CYP2E1-oxidized to the N-acetyl-p-benzoquinonimine intermediate that conjugates with and depletes hepa tic GSH levels (Fig. 10.28). T his action allows the benzoquinonimine to bind covalently to tissue macromolecules. T he mercapturic acid derivative of acetaminophen represents approximately 2% of the administered dose of ac etaminophen. T hus, the possibility exists that those toxic metabolites that us ually are detoxified by conjugating with GSH exhibit their hepatotoxicity (or, perhaps, c arcinogenicity) because the liver has been depleted of GSH and is incapable of inactivating them. Pretreatment of animals with phenobarbital often hastens the depletion of GSH by increasing the formation of epoxides or other reactive intermediates.

M ethylation Methylation is a common biochemical reaction but appears to be of greater significance in the metabolism of P.293 endogenous compounds than for drugs and other foreign compounds (56). Methylation differs from other conjugation proc esses in that the O-methyl metabolites formed may, in some cases , have as great or greater pharmac ologic al ac tivity and lipophilicity than the parent molecule (e.g., the convers ion of norepinephrine to epinephrine). Methionine is involved in the methylation of endogenous and exogenous substrates, because it transfers its methyl group via the activated intermediate S-adenosylmethionine to the substrate under the influence of methy l transferases (Fig. 10.29). Methylation results principally in the formation of O-methylated, N-methy lated, and S-methylated products.

O-Methylation T he process of O-methylation is catalyzed by the magnesium-dependent enzyme catechol-O-methy ltransferase (COMT ) transferring a methyl group to the meta- or, less frequently, the paraphenolic -OH (regioselectivity ) of catecholamines (e.g., norepinephrine) as well as by their deaminated metabolites. It does not methylate monohydric or other dihydric phenols. T he meta:para product ratio depends greatly on the type of substituent attached to the catechol ring. Substrates spec ific for COMT include the catecholamines norepinephrine, epinephrine, and dopamine; the catechol amino acids L-DOPA and α-methyl-DOPA; and 2- and 4-hy droxyestradiol metabolites of estradiol. T he enzyme is thought to function in the biologic al inactivation of the adrenergic neurotrans mitter no repinephrine as well as other endogenous and exogenous catechol-like substances . It is found in liver, kidneys, nervous tissue, and other tis sues.

Fig. 10.28. Proposed mechanism for the CYP450-catalyzed oxidation of acetaminophen to its N-acetylp-benzoquinoneimine intermediate, which can further react with either glutathione (GSH) or cellular macromolecules (NH 2 -protein).

Hy droxyindole-O-methyltransferase, which is O-methy lates N-acetylserotonin, serotonin, and other hydroxyindoles , is found in the pineal gland and is involved in the formation of melatonin. T his enzy me differs from COMT in that it does not methylate c atecholamines and has no requirement for magnesium iron.

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Fig. 10.29. Methylation pathways.

N-Methylation T he N-methylation of various amines is among severa l conjugate pathways for metabolizing amines. Specific N-methyltransferases catalyze the transfer of active methyl groups from S-adenosylmethionine to the ac ceptor substance. PhenylethanolamineN-methyltransferase methylates a number of endogenous and exogenous phenylethanolamines (e.g., normetanephrine, norepinephrine, and norephedrine) but does not methylate phenylethylamines. Histamine-N-methyl trans ferase specifically methylates histamine, producing 1

the inactive metabolite N -methylhistamine. Amine-N-methyltransferase will N-methylate a variety of primary and secondary amines from a number of sources, including endogenous biogenic amines (serotonin, try ptamine, tyramine, and dopamine) and drugs (desmethylimipramine, amphetamine, and normorphine). Amine-N-methyl transferases seem to have a role in recycling N-demethylated drugs.

Thiol Methylation T hiols generally are considered to be toxic, and the role of thiol S-methyl transferases is a nonoxidative detoxific ation pathway of these compounds (see the dis cussion of flavin-containing monooxy genases ). T he S-methylation of sulfhydryl co mpounds also involves a microsomal enzyme requiring S-adenosylmethionine. Although a wide range of exogenous s ulfhy dryl compounds are S-methylated by this microsomal enzyme, none of the endogenous sulfhydryl compounds (e.g., cysteine and GSH) can function as substrates. Clearly, S-methylation represents a detoxication step for thiols. Dialkyldithiocarbamates (e.g., disulfiram) and the P.294 antithyroid drugs (e.g., 6-propyl-2-thiouracil), mercaptans, and hydrogen sulfide (from thioglycosides as natural constituents of foods, mineral sulfides in water, fermented beverages, and bac terial digestion) are S-methy lated. Other drugs undergoing S-methylation include captopril, thiopurine, penicillamine, and 6-mercaptopurine.

Conjugation of Cyanide T he toxicity of hydrogen cyanide is the result of its ionization to cyanide ion in biological tissues. It is a powerful metabolic inhibitor that arrests cellular respiration by inactivating cytochrome enzymes that are fundamental to the respiratory process as well as combining with hemoglobin to form cyanomethemoglobin, which is inc apable of transporting oxygen to tissues. With the wide prevalence of cyanoglycosides in plant materials, the ability to detoxify cyanide is a vital function of the liv er, erythrocy tes, and other tissues. Rhodanase, a mitoc hondrial enzyme in liver and other tissues, c ataly zes the formation of thiocyanate from cyanide rapidly in the presence of thiosulfate and colloidal sulfur, but cysteine and GSH are poor sulfur donors. T he detoxification of cyanide depends on the availability of a physiologic pool of thiosulfate, the origin of which is not k nown. A poss ible sourc e for thiosulfate is the transamination of cysteine to β-mercaptopyruvate and transfer of the mercapto group by a sulfur transferase to sulfite-producing thios ulfate. Depletion of this pool increases c yanide toxicity. In the presence of exces s cy anide, howev er, minor pathways for cyanide metabolism may occur, including -

oxidation to cyanate (NCO ), reaction with c obalamin (vitamin B 12 ) to form cyanoc obalamin, and the formation of 2-iminothiazolidine4-carboxylic acid from the nonenzymatic reaction between cysteine and cyanide (66).

Elim ination Pathways Most xenobiotics are lipid-soluble and are altered chemically by the metabolizing enzymes, usually into less toxic and more water-soluble substances, before being excreted into the urine (or, in some cases, bile). T he formation of conjugates with sulfate, amino acids, and glucuronic acid is particularly effective in inc reasing the polarity of drug molecules. T he principal route of excretion of drugs and their metabolites is in the urine. If drugs and other compounds foreign to the body are not metabolized in this manner, substances with a high lipid–water partition coefficient could be reabsorbed readily from the urine through the renal tubular membranes and into the plasma. T herefore, such substances would continue to be recirculated, and their pharmacological or toxic effects would be prolonged. Very polar or highly ionized drug molec ules often are excreted in the urine unchanged.

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Urine T ubular reabsorption is greatly reduced by convers ion of a drug into a more polar substance with a lower partition coefficient. In general, the more resistance a drug is to the metabolizing e nzymes , the greater the therapeutic action and the smaller the dose needed to achieve a particular therapeutic goal. Urine is not the only route for excreting drugs and their metabolites from the animal body. Other routes include bile, saliva, lungs, sweat, and milk. T he bile has been recognized as a major route of excretion for many endogenous and exogenous compounds.

Enterohepatic Cycling of Drugs T he liver is the princ ipal organ for the metabolis m and eventual elimination of xenobiotics from the human body in either the urine or the bile. When eliminated in the bile, steroid hormones, bile acids, drugs, and their respective conjugated metabolites are available for reabsorption from the duodenal–intestinal tract into the portal circ ulation, undergoing the process of enterohepatic cy cling (EHC) (67). Nearly all drugs are excreted in the bile, but only a few are concentrated in the bile. For example, the bile salts are so efficiently concentrated in the bile and reabsorbed from the gastrointestinal tract that the entire body pool recycles sev eral times per day. T herefore, EHC is responsible for the c onservation of bile acids, steroid hormones, thyroid hormones, and other endogenous substances. In humans, compounds excreted into the bile usually have a molecular weight greater than 500Da, whereas with rats, the critical molecular weight is 325Da. Cons equently, biliary excretion is more common in rats than in humans. Compounds with a molecular weight between 300 and 500Da are excreted in both urine and bile. Some c ompounds would not be expected to be excreted in the bile because of a molecular weight of less than 300Da and a relatively nonpolar structure. Compounds exc reted into bile usually are strongly polar substances that may be charged (anionic; e.g., dyes) or uncharged (e.g., cardiac glycosides and steroid hormones). Biotransformation of this type of compound by means of Phase 1 and Phase 2 reactions would produce a conjugated metabolite, whic h usually is anionic, more polar, and has a molecular weight greater than that of the parent compound. T hey most often are present as their glucuronide conjugates, because glucuronidation adds 176Da to the molecular weight of the parent compound. Unchanged drug in the bile is exc reted with the feces, metabolized by the bacterial flora in the intestinal tract, or reabs orbed into the portal circulation. Not unexpectedly, the bacterial intestinal flora is directly involved in EHC and the recy cling of drugs through the portal circulation (see the discuss ion of extrahepatic metabolism). A conjugated drug and metabolites excreted via the bile may be hydroly zed by enzymes of the bacterial flora, releasing the parent drug or its Phase I metabolite for reabsorption into the portal P.295 circulation (68). Among the numerous compounds metabolized in the enterohepatic circulation are the estrogenic and progestational steroids, digitoxin, indomethacin, diazepam, pentaerythritol tetranitrate, mercurials, arsenicals, and morphine. T he oral ingestion of xenobiotics inhibiting the gut flora (i.e., nonabsorbable antibiotics) c an effect the pharmacok inetics of the initial drug. T he impact of EHC on the pharmac okinetics and pharmacodynamics of a drug depends on the importance of biliary excretion of the drug relative to renal clearance and on the efficiency of gastrointestinal abs orption. T he EHC becomes dominant when biliary excretion is the major clearance mechanism for the drug. Becaus e the majority of the bile is stored in the gallbladder and released on the ingestion of food, intermittent spik es in the plasma drug conc entration is observ ed following reentry of the drug from the bile via EHC. From a pharmacodynamic point of view, the net effect of EHC is to increase the duration of a drug in the body and to prolong its pharmacological action. Chronic treatment with the enzyme inducer phenobarbital enhances the biliary excretion of drug molecules and their metabolites by increasing liver size, bile flow, and more efficient transport into the bile. T his behavior is not shared by all inducers of the CYP450 monooxygenases. T he route of administration also may influence excretion pathways . Direct adminis tration into the portal circulation might be expected to result in more biliary excretion than could be expec ted via the sys temic route.

Drug Metabolism and Age Approximately 30% of the population is older than 65 years of age and is responsible for more than 50% of the national drug expenditures. People older than 65 years represent a significant portion of the population; they are the most medicated and account for more than one-third of all pres cription drugs dispensed. T he av erage elderly patient in a health care facility could receive as many as 10 medications daily, which results in the potential for a greater incidence of adverse drug reactions. T he widesprea d use of medications in the elderly will increase the potential for an increased inc ide nce of drug-related interactions. Not unexpectedly, these interactions will be related to changes in drug metabolism and clearance from the body (T able 10.13). T he interpretation of the age-related alteration in drug response must consider the contributions of absorption, distribution, metabolism, and excretion (69). Drug therapy in the elderly is expected to become one of the more significant problems for clinical medicine. It has been well documented that th e metabolism of many drugs and their elimination is impaired in the elderly.

M etabolism in the Elderly T he decline in drug metabolism bec ause of old age is associated with physiological changes that have pharmacokinetic implications affecting the steady-state plasma c oncentrations and renal clearanc e for the parent drug and its metabolites (70,71). T hose changes relevant to the bioavailability of drugs in the elderly are decreases in hepatic blood flow, glomerular filtration rate, hepatic microsomal enzy me activity, plasma protein binding, and body mass. Because the rate of a drug's elimination from the blood through hepatic metabolis m is determined by hepatic blood flow, protein binding, and intrinsic clearance, a reduction in hepatic blood flow can lead to an increase in drug bioav ailability and decreased clearance, with the symptoms of drug overdose and toxicity as the outcome. Drugs for which elimination is dependent on hepatic blood flow have a high extraction ratio and undergo extensive first-pass metabolism when administered orally. Available evidenc e s uggests that age is associated with a reduction in first-pass metabolism of some, but certainly not all, drugs. T hose orally administered drugs exhibiting a reduction in first-pass metabolism in the elderly include the dihy dropyridine calcium antagonists, c hlormethiazole, diazepam, lorazepam, chlordiazepoxide, alprazolam, propranolol, verapamil, labetalol, theophylline, morphine, amitriptyline, and nortriptyline. T he bioavailability of drugs with low extraction ratios de pends on the percentage of drug–protein binding and not on first-pass hepatic metabolism. Inasmuc h as drug binding to plasma proteins is an important factor in the rate of P.296

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drug metabolism, it appears not to be a significant factor in the elderly.

Table 10.13. Effect of Age on the Clearance of Some Drugs No Change

Decrease

Acetaminophen*

Alprazolam

Aspirin

Amitriptylene

Diclofenac

Carbenoxolone

Digitoxin

Chlordiazepoxide

Diphenhydramine

Chlormethiazole

Ethanol

Clobazam

Flunitrazepam

Desmethyldiazepam

Heparin

Diazepam

Lormetazepam

Labetalol

Midazolam

Lidocaine

Nitrazepam

Lorazepam

Oxazepam

Morphine

Phenytoin*

Meperidine

Prazosin

Nifedipine and other dihydropyridines

Propylthiouracil

Norepinephrine

Temazepam

Nortriptyline

Thiopental*

Phenytoin

Tolbutamide* Warfarin

Piroxicam Propranolol Quinidine Quinine Theophylline

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Verapamil *Drugs for which clearance is disputable but may be increased.

Age-related changes in drug metabolis m are a complicated interplay between the age-related physiological changes, genetics, environmental influences (diet and nutritional status, smoking, and enzyme induction), concomitant dis eases states, and drug intake. In most studies, the elderly appear just as responsive to drug-metabolizing enzyme activ ity (Phase I and Phase II) as young individuals. All the common pathways of drug conjugation, including glucuronidation, sulfation, and glycine conjugation, are variably affected by aging. Given the number of factors that determine the rate of drug metabolism, it is not surprising that the effects of aging on drug elimination by metabolism has yielded variable results even for the same drug. T herefore, the bioavailability of a drug in the elderly and the potential for drug toxicity is largely dependant on its extraction ratio and mode of administration. T he fact that drug elimination may be altered in old age suggests that initial doses of metabolized drugs should be reduced in older patients and then modified according to the clinical response (70,71). A decrease in hepatic drug metabolism coupled with age-related alterations in clearance, volume of distribution, and receptor sensitivity can lead to prolonged plasma half-life and increased drug toxicity (T able 10.13).

Drug Interactions Although drug–drug interactions constitute only a small proportion of adverse drug reactions in the elderly, they are important, because they often are predictable and, therefore, avoidable or manageable. T heir frequency is related to the age of the patient, the number of drugs prescribed, the number of physicians involved in the patient's care, and the presence of increasing frailty . T he most important mechanisms for drug–drug interactions are the inhibition or induction of drug metabolism. Interactions involving a loss of action of one of the drugs are at least as frequent as those involving an increas ed effect. Although only approximately 10% of potential interactions result in clinically significant adverse events, death or serious clinical consequences are rare, but low-grade, clinical morbidity in the elderly may be much more common. Nonspecific complaints (e.g. confusion, lethargy, weak ness, dizziness, incontinence, depression, and falling) should all prompt a closer look at the patient's drug list. A number of strategies can be adopted to decrease the risk of potential clinical problems. T he number of drugs prescribed for each individual should be limited to as few as necess ary. T he use of drugs should be reviewed regularly, and unneces sary agents withdrawn if possible, with subsequent monitoring. Patients should be encouraged to engage in a “ prescribing partnership” by alerting physicians, pharmacis ts, and other health care professionals to sy mptoms that occ ur when new drugs are introduced. Health care professionals should develop a strategy for monitoring their drug treatment looking for the drug–drug interactions that have been encountered. T hose CYP substrates reported to cause drug–drug interactions are shown in T ables 10.3 through 10.10 in bold italics.

Fetal M etabolism T he ability of the human fetus and placenta to metabolize xenobiotics is well established. A 1973 clinic al study reported that women ingest an average of 10 drugs during pregnancy, not including anesthetics, intravenous fluids, vitamins , iron, nicotine, cosmetic products, artificial sweeteners, or exposure to environmental contaminants. T he majority of these subs tances readily cross the placenta, thus exposing the fetus to a large number of xenobiotic agents. T he knowledge regarding the effects of prenatal exposure to drugs, environmental pollutants (e.g., smoking), and other xenobiotics (e.g., ethanol) on the fetus has led to a decreas e in the exposure to these substances during pregnancy. T he human fetus is at special risk from these subs tances because of the presence of the CYP450 monooxygenase system, which is capable of metabolizing xenobiotics during the first part of gestation. Placentas of tobacco smokers have shown a significant increas e in the rate of placental CYP450 monooxygenase activity (CYP1A subfamily). Concern for this type of enzyme activity is increasing, because this enzyme sys tem is known to catalyze the formation of reactive metabolites capable of cov alently binding to mac romolecules producing permanent effec ts (e.g., teratogenic, hepatotoxic, or carcinogenic) in the fetus and newborn. A more disturbing fact is that the other conjugation enzymes (i.e., glucuronosyl transferases, epoxide hydras e, glutathione transferas e, and sulfotransferase), which are important for the formation of Phase 2 conjugates of these reactive metab olites, are found in low to negligible levels, increasing the exposure of the fetus to these potentially toxic metabolites. Fetal drug metabolism functions either as a protectiv e mechanism against environmental xenobiotics to transform active molecules into inactive molecules or as a toxifying system when transforming innoc uous substances into reactive molecules. T he placenta is not a barrier protecting the fetus from xenobiotics; almost every drug present in the maternal circulation will cross the placenta and reach the fetus. For some drugs, however, the plac ental efflux transport protein, P-glycoprotein (P-gp; discussed later), functions as a maternofetal barrier, pumping drugs and P-gp substrates out of the fetal circulation back into the maternal circulation (72) and protecting the fetus from exposure to potentially harmful teratogenic xenobiotics /drugs and endogenous substances that have been absorbed through the placenta. T he P-gp inhibitors should be carefully ev aluated for their potential to increase fetal sus ceptibility to drug/c hemical-induced teratogenesis. On the other hand, selectiv e inhibition of P-gp could be used clinically to improve pharmacotherapy of the unborn child. Depending on the pharmacological activity of the parent substance or its metabolites , both fetal and adult maternal drug metabolism may be viewed as complimentary yet contradictory. Becaus e metabolites generally are more water P.297 soluble than the parent substance, drug metabolites, when formed in the fetus, may be trapped and accumulate on the fetal side of the placenta. Such accumulation can result in drug-induced toxicities or developmental defects. T he difference between fetal and adult metabolis m, however, can be used advantageously and constitutes the rational for trans placental therapy (e.g., the administration of betamethasone several days before delivery can increase the production of surfac tant in the fetal lung and prevent respiratory distress syndrome in the neonate). T he activity of CYP3A isoenzymes in the human fetal liver is similar to that seen in adult liver mic ro somes . T he fetal activity for CYP3A7 isoenzyme is unusual as most other fetal isoenzymes of CYP450 exhibit 5 to 40% of the adult isoenzymes . Fetal and neonatal drug-metabolizing enzyme activities may differ from those in the adult.

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Neonatal M etabolism From the day of birth, the neonate is exposed to drugs and other foreign compounds persis ting from pregnancy as well as those transferred via breast milk. Fortunately, many of the drug-metabolizing enzymes operative in the neonate developed during the fetal period. T he routine us e of therapeutic agents during labor and delivery, as well as during pregnanc y, is widespread, and consideration must be given to the fact that potentially harmful metabolites can be generated by the fetus and newborn. Consequently, the us e of drugs capable of forming reactive metabolic intermediates should be av oided during pregnancy, delivery , and the neonatal period. T he activity of Phase 1 and Phase 2 drug-metabolizing enzymes is high at birth but decreases to normal levels with increasing age. Evidence suggests increased activity of drug-metabolizing enzy mes in liver micros omes of neonates resulting from treatment of the mother during the pregnancy with enzyme inducers (e.g., phenobarbital).

Genetic Polym orphism T he reality of drug therapy is that many drugs do not work in all patients. By current estimates, the percentage of patients who will react favorably to a specific drug ranges from 20 to 80%. Drugs have been developed and dosage regimens prescribed under the old paradigm that “ one dose fits all,” which largely ignores the fact that humans are genetically different, resulting in interindividual differences in drug metabolism and dispos ition (10). It is widely accepted that genetic factors have an important impact on the oxidative metabolism and pharmacokinetics of drugs. Genotype–phenotype correlation studies (pharmacogenetics) have shown that inherited mutations in CYP450 genes (allelles) result in distinct phenotypic subg roups. For example, mutations in the CYP2D6 gene result in poor (PM), intermediate (or extens ive [EM]), and ultrarapid (UM) metabolizers of CYP2D6 substrates (73) (T able 10.7). Each of these phenoty pic subgroups experience different responses to drugs extensively metabolized by the CYP2D6 pathway, ranging from severe toxicity to complete lack of efficacy. Genetic studies confirm that “ one dos e does not fit all,” leaving the question of why we wou ld continue to develop and prescribe drugs under the old paradigm. As early as 1997, the U.S. Food and Drug Administration (FDA) recognized that identifying genetic polymorphisms might allow the safe dosing, marketing, and approv al of drugs that would otherwise not be approved and advised pharmaceutical companies to inc orporate the knowled ge of genetic polymorphisms into drug development (see sidebar below). Importantly, pharmacogenomic testing (the study of heritable traits affec ting patient response to drug treatment) can signific antly increas e the likelihood of developing drug regimens that benefit most patients without severe adverse events.

U.S. FDA Advisory on Genetic Polymorphism “ W he n a genetic polymorphis m af f e c ts an impo rtant metabolic route of elimination, large dos ing adjus tme nts may be nec es s ary to ac hieve the s af e and e f f e c tive us e of the drug … indeed in s ome c as es unde rs tanding how to adjus t the d os e to avoid toxic ity may allow the marketing of a drug that would have an unac c eptable level of toxic ity were its toxic ity unpre dic table and unpreventable.” —U.S . F DA Gu i d anc e of Indu s try , D rug Me ta bol i s m /D rug Interac ti on S tu di es i n the Drug D ev el op m e nt P roc es s : S tu di e s i n Vi tro, A pril 1997 .

Polymorphisms are expressed for a number of metabolizing enzymes, but the polymorphic CYP450 isoforms that are most important for drug metabolism include CYP2A6, CYP2C9, CYP2C19, and CYP2D6. T hese polymorphic isoforms give rise to p henotypic subgroups in the population differing in their ability to perform clinically significant biotransformation reactions with obv ious c linical ramific ations (74). Metabolic polymorphism may have several c onsequences; for example, when enzymes that metabolize drugs used either therapeutically or socially are deficient, adv erse or toxic drug reactions may occur in these individuals. T he discovery of genetic polymorphism resulted from the observation of increased frequency of adverse e ffects or no drug effects after normal doses of drugs to some patients (e.g., hyper– central nervous system response from the administration of the antihistamine doxylamine or no analgesic res ponse with codeine). A polymorphism is a difference in DNA sequence found at 1% or greater in a population and expressed as an amino acid substitution in the protein sequence of an enzyme resulting in changes in its rate of activ ity (V m ax ) or affinity (K m ). T hus, mutant DNA sequences can lead to interindividual differences in drug metabolism. Furthermore, the poly morphisms do not occur with equivalent frequency in all rac ial or ethnic groups. Because of these differences, it is important to be aware of a person's race and ethnicity P.298 when giving drugs that are metabolized differently by different populations (73,75). Because no other way exists to adequately clear these drugs from the body, PMs may be at greater risk for advers e drug reactions or toxic overdoses. T he signs and symptoms of these overdoses are primarily extensions of the drug's common adverse effects or pharmacological effects (T able 10.14) (75). T he level of adverse reactions or overdosage depends very much on the overall contribution of the mutant isoform to the drug's metabolism. Perhaps the most interesting explanation for the various mu tant isoforms is that they evolved as protec tive mechanisms against alkaloids and other common substances in the food chain for the different ethnicities. Although much effort has gone into finding polymorphisms of CYP3A4 and CYP1A2 genes , none has yet to be discovered.

Table 10.14. Impact of Human CYP450 Polymorphisms on Drug Treatment in Poor Metabolizers Polymorphic Enzyme CYP2C9

Adverse Effects Decreased Clearance (overdosage) S-Warfarin

Bleeding

Phenytoin

Ataxia

Reduced Activation of Prodrug Losartan

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Losartan

CYP2C19

CYP2D6

Tolbutamide

Hypoglycemia

NSAIDs

GI bleeding?

Omeprazole

Proguanil

Diazepam

Sedation

TC antidepressants

Cardiotoxicity

Tramadol

SSRIs

Serotonin syndrome

Codeine

Anti-arrythmic drugs

Arrythmias

Ethylmorphine

Perhexiline

Neuropathy

Haloperidol

Parkinsonism?

Perphenazine Zuclopenthixol S-Mianserin Tolterodine CYP2A6

Nicotine

Occasionally, one derives benefit from an unusual CYP phenotype. For example, cure rates for peptic ulcer treated with omeprazole are substantially greater in individuals with defec tive CYP2C19 because of the sustained high plasma levels achieved.

CYP2C9 and CYP2C19 T he CYP2C9 and CYP2C19 are the main isoforms for the metabolism of the antiseizure drug phenytoin and for the anticoagulant S-warfarin. Although CYP2C19 metabolizes fewer drugs than CYP2D6 does, the drugs CYP2C19 does metabolize are clinically important (T able 10.6). Deficit of CYP2C19 is found in the PM phenotype, which is only seen in 8 to 13% of Caucasians, 20 to 30% of the Asian population (11–23% of Japanese and 5–37% of Chinese), up to 20% of the black African-American population, 14 to 15% of Saudi Arabians and Ethiopians, and up to 70% of Pacific Islanders (73,75). T he more common mutant allele in these individuals is CYP2C19*2, which expresses an inactive enzyme. T he large interindiv idual variability observed in the therapeutic respons e to the antiseizure drug mephenytoin is attributed to CYP2C19 polymorphism, which catalyzes the p-hydroxylation of its S-stereoisomer (74). T he R-enantiomer is N-demethylated by CYP2C8 with no difference in its metabolism between PMs and EMs. T he CYP2C9 is the primary is oform for the metabolism of the antiseizure drug phenytoin, the anticoagulant S-warfarin, and the hypoglycemic drug tolbutamide. Other clinically important drugs are listed in T able 10.6. At least six different mutant CYP2C9 alleles have been identified; of these, the two alleles primarily responsible for CYP2C9 deficiency are CYP2C9*2 and CYP2C9*3 and code for enzymes with reduced affinity for substrates (73,75). A deficienc y of this isoform, however, is seen in 8 to 13% of Caucasians, 2 to 3% of African Americans, and 1% of the As ians. Individuals with the PM phenotype who possess this deficient is oform variant are ineffec tive in clearing S-warfarin (so much so that they may be fully anticoagulated on just 0.5 mg of warfarin per day) and in the clearance of phenytoin, which has a potentially very toxic narrow therapeutic range. On the other hand, the pro-drug losartan will be poorly activated and ineffective.

CYP2D6 T he CYP2D6 is of particular importance, because it metabolizes a wide range of commonly prescribed drugs, including antidepressants, antipsychotics, β-adrenergic blockers, and antiarrhythmics (T able 10.7). T he CYP2D6 deficiency is a c linically important genetic variation of drug metabolis m characterized by three phenotypes: UM, EM and PM. T he PM phenotype is inherited as an autos omal recessive trait,

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with 5 of 30 of the known CYP2D6 gene mutations leading to either zero expression or the P.299 expression of a nonfunctional enzyme (73). Approximately 12 to 20% of Caucasians expres s the CYP2D6*4 allele, and 5% express the other CYP2D6 alleles. Up to 34% of African Americans express the CYP2D6*17 allele, and 5% express the other CYP2D6 alleles. Up to 50% of Chinese express the CYP2D6*10 allele, and 5% express the other CYP2D6 alleles (these individuals are referred to as PM) (73,75). Conversely, the 20 to 30% of Saudi Arabian s and Ethiopians who express the CYP2D6*2XN allele are known as UMs of CYP2D6 substrates, because they express excess enzyme as a result of having multicopies of the gene (73). Inasmuch as CYP2D6 is not inducible, individuals of Ethiopian and Saudi Arabian descent have genetically developed a different strategy to cope with the (presumed) high load of alkaloids and other substances in their diet; thus, the high expression of CYP2D6 using multiple copies of the gene. T hose individuals who are deficient in CYP2D6 will be predispos ed to adverse effects or drug toxic ity from antidepres sants or neuroleptics caused by inadequate metabolism or long half-lives, but the metabolism of pro-drugs in these patients will be ineffective because of lack of activation (e.g., codeine, which must be metabolized by O-demethylation to morphine). T hose with the UM phenotype will require a dose that is much higher than normal to attain therapeutic drug plasma concentrations (e.g., one patient required a daily dose of ~ 300 mg of nortryptyline to achieve therapeutic plasma levels) or a lower dose for pro-drugs that require metabolic activation. In dividuals with the PM phenoty pe also are characterized by loss of CYP2D6 stereoselectivity in hydroxylation reactions. It can be antic ipated that large differences in steady-state concentration for CYP2D6 substrates will occur between individuals with the different phenotypes when they receive the same dose. Depending on the drug and reaction type, a 10- to 30-fold difference in blood concentrations may be observed in the PM-phenoty pe debrisoquine polymorphism (76).

CYP2A6 T he CYP2A6 is of particular importance, because it activates a number of procarcinogens to c arcinogens and is the major isoform metabolizing nicotine to cotinine. Approximately 15% of Asians express the CYP2A6*4del allele, and 2% of Caucasians express the other CYP2AD6*2 allele. Both these alleles express zero or a nonfunctional enzyme; these indiv iduals are referred to as hav ing the PM phenotype (73,75). A benefit from being a PM of CYP2A6 substrates might be the protection from some carcinogens and smoking because of the high plasma levels of nicotine achieved with fewer cigarettes.

Acetylation Acetylation, a nonmicrosomal form of metabolism, also exhibits polymorphisms and was first demonstrated in the acetylation of isoniazid (see the section on ac etylation). Several forms of acetyl transferase occur in humans. Some clinically used drugs undergoing polymorphic acetylation include isoniazid, procainamide, hydralazine, phenelzine, dapsone, caffeine, some benzodiazepines, and possibly, the carcinogenic secondary N-alk ylarylamines (2-aminofluorene, benzidine, and 4-aminobiphenyl). Intestinal acetyl transferas e appears not to be polymorphic (i.e., 5-aminosalicylic acid). T he proportion of the fast acetylation phenotype is approximately 30 to 45% in Caucausians, 89 to 90% in the Oriental population, and 100% in Canadian Esk imos. Drug-induced s ystemic lupus erythematosus from chronic procainamide therapy is more likely to appear with slow acetylators.

Other Polymorphic M etabolizing Enzymes T he polymorphism for CYP2E1 is expressed more in Chinese than in Caucasians. T hose with the CYP2E1 PM phenotype exhibit tolerance to alcohol and less toxicity from halohydrocarbon solvents. T he only FMO pathway exhibiting polymorphism is the genetic dis ease trimethylaminuria, in which individuals excrete diet-derived free trimethylamine in the urine. Usually, trimethylamine undergoes extensive FMO N-oxidation. In human populations, serum PON1 exhibits a substrate-dependent polymorphism to the neurotoxic effects of organophosphates in those susc eptible individuals that are deficient in PON1 (i.e., PM phenoty pe) (55). T he PON1 catalyzes the hydrolysis of paraoxon, chlorpyrifos (Dursban), and other organophosphates . Polymorphism has been assoc iated with serum cholinesterases (particularly succinyl cholinesterase, causing skeletal mus cle paralysis), alcohol dehydrogenases, aldehyde dehydrogenases, epoxide hydrolase, and xanthine oxidase (74). Approximately 50% of the Oriental population lack aldehyde dehydrogenase, resulting in high lev els of acetaldehyde following ethanol ingestion and causing nausea and flushing. People with genetic variants of cholinesterase respond abnormally to succ iny lcholine, procaine, and other related choline esters. T he clinical consequence of reduced enzymic activity of cholinesteras e is that succinylcholine and pro caine are not hydrolyzed in the blood, resulting in prolongation of their respective pharmacological activities. A suggestion has been made that those with EM phenotypes may be more prone than those with PM phenotyp es to develop cancers, because they are better able to activate procarcinogens. Suc h interindividual variations may have a major influence in determining the risk of cancer. T he activity of a particular CYP450 isoform may be a rationale for predicting the individual risk from exposure to carcinogenic compounds. Our increasing knowledge of genetic poly morphism has contributed a great deal to our understanding about interindividual variation in the metabolis m of drugs, including how to change dose regimens accordingly to minimize drug toxicity and improve therapeutic efficacy. In humans, drugs not subjec t to polymorphic metabolism also exhibit substantial interindividual variation in their disposition, which is attributed to a great extent to environmental factors (e.g., inducing agents, smoking, and alcohol ingestion). P.300

Oral Bioavailability Oral bioavailability (see Chapter 9) is the fraction of the total dos e of a drug that reaches the systemic circulation. T he low oral bioavailability for a drug may be the result of disintegration and dissolution properties of the drug formulation, solubility of the drug molecule in the gastrointestinal environment, membrane permeability, presystemic intestinal metabolism, hepatic first-pass metabolism, or susc eptibility to membrane transporters, s uch as P-gp efflux. Other routes of administration (e.g., subc utaneous, intravenous, inhalation, and nasal) for susceptible drugs have been inves tigated in an attempt to overc ome the pronounced presys temic metabolism. T he extent of first-pass metabolism depends on the drug delivery sys tem, because a formulation may increase or decrease the rate of dissolution, the

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residence time of a drug in the gastrointestinal tract, and the dose. T he more prolonged the residence time, the greater the efficiency of first-pass metabolism. T he drug form and delivery system s hould yield optimal bioavailability and pharmacokinetic profiles, resulting in a reproducible clinical response. Studies are being performed to determine the effect of presystemic and hepatic first-pass metabolism on the toxicity and carcinogenicity of xenobiotics. For a nontherapeutic toxic substance, the existence of a first-pass effect is desirable, because the liver c an bioinactivate it, preventing its distribution to other parts of the body. On the other hand, first-pass metabolism may increase its toxicity by biotransforming the toxicant to a more toxic metabolite, which can reenter the blood and exert its toxic effect.

Presystemic First Pass M etabolism Although hepatic metabolism continues to be the most important route of metabolism for xenobiotics, the ability of the liver and intestine to metabolize substances to either pharmacologically inac tive or bioactive metabolites before reac hing systemic blood levels is called prehepatic or presystemic first pass metabolism, which results in the low systemic availability for susceptible drugs. Sulfation and glucuronidation are major pathways of presy stemic intestinal firs t-pass metabolism in humans for acetaminophen, phenylephrine, terbutaline, albuterol, fenoterol, and isoproterenol. T he discovery that CYP3A4 is found in the mucosal enteroc ytes of the intestinal villi signifies its role as key determinant in the oral bioavailability of its numerous drug substrates (T able 10.9) (77). Drugs known to be substrates for CYP3A usually have a low and variable oral bioavailability that may be explained by presystemic first-pass metabolism by the s mall intestine CYP450 isoforms. T he concentration of functional intestinal CYP3A is influenced by gen etic dispos ition, induction, and inhibition, which to a great extent determines drug blood levels and therapeutic response. Xenobiotics when ingested orally can modify the activity of intestinal CYP3A enzymes by induction, inhibition, and stimulation. By modulation of the isoform pattern in the intestine, a xenobiotic could alter its own metabolism and that of others in a time- and dose-dependent manner. Its co ncentration in the intestine is comparable to that of the liver. T he oral administration of dexamethasone induces the formation of CYP3A and erythromycin inhibits it. T he glucocorticoid inducibility of CYP3A4 also may be a factor in differences of metabolism between males and females. Studies have suggested that intestinal CYP3A4 C-2 hydroxylation of estradiol contributed to the oxidative metabolism of endogenous es trogens circ ulating with the enteroh epatic recycling pool (38). Norethisterone has a low oral bioavailability of 42% because of oxidative first-pass metabolism (CYP3A), but levonorgestrel is c ompletely available in women with no conjugated metabolites. Several clinically relev ant drug interactions between orally coadminis tered drugs and CYP3A4 can be explained by a modification of drug metabolis m at the CYP450 level. If a drug has high presys temic elimination (low bioavailability) and is metabolized primarily by CYP3A4, then coadministration with a CYP3A4 inhibitor can be expected to alter the drug's pharmacokinetics by reduc ing its metabolism, thus increasing its plasma concentration. Drugs and some foods (e.g., grapefruit juice) that are known inhibitors, inducers, or s ubstrates for intestinal CYP3A4 can potentially interac t with the metabolism of a c oadministered drug, affecting its area under the curve and rate of clearance (T ables 10.10 and 10.12) (78). Induc ers c an reduce abs orption and oral bioavailability, whereas these same factors are increased by inhibitors. For example, erythromycin can enhance the oral absorption of another drug by inhibiting its metabolism in the small intestine by CYP3A4. By virtue of being competitive substrates for CYP3A4, prednisone, prednisolone, and methylprednisolone (but not dexamethasone) are competitive inhibitors of synthetic glucocorticoid metabolism. T his is because a major metabolic pathway for synthetic glucocorticoids involves CYP3A4. In addition to coadministered drugs, metabolic interactions with exogenous CYP3A4 substrates secreted in the bile are possible. T he poor oral bioavailability for cyclosporine is attributed to a combination of intestinal metabolism by CYP3A4 and efflux by P-gp (79). Because the intestinal mucosa is enriched with glucuronosyltransferases, sulfotransferases, and glutathione transferases , presy stemic first-pass metabolism for orally administered drugs susceptible to these c onjugation reactions results in their low oral bioavailability (65). Pres ystemic metabolism often exceeds liver metabolism for some drugs. For example, more than 80% of intravenously administered albuterol is excreted unchanged in urine, with the balance as glucuronide conjugates, whereas when albuterol is administered orally, less than 5% is sy stemically absorbed because of intestinal sulfation and glucuronidation. Pres ystemic metabolism is a major pathway in humans for most β-adrenergic agonists, P.301 such as glucuronides or sulfates for terbutaline, fenoterol, albuterol, and isoproterenol, morphine (3–O-gluc uronide), acetaminophen (O-sulfate), and estradiol (3–O-sulfate). T he bioavailability of orally administered estradiol or ethinyl es tradiol in females is approximately 50%. Mestranol (3-methoxyethinyl estradiol) has gre ater bioavailability, however, because it is not significantly conjugated. Levodopa has a low oral bioavailability because of its metabolis m by intestinal L-aromatic amino acid decarboxylase. T he activity of this enzyme depends on the percentage bound of its cofactor pyridoxine (vitamin B 6 ). T yramine, which oc curs in fermented foods such as cheeses and red wines, ripe bananas, and yeast extracts, is metabolized by both MAO-A and MAO-B in the gut wall. T he extensive presystemic first-pass sulfation of phenolic drugs, for example, can lead to inc reased bioavailability of other drugs by competing for the available sulfate pool, resulting in the possibility of drug toxicity (56). Concurrent oral administration of acetaminophen with ethinyl estradiol resulted in a 48% increase in ethinyl es tradiol blood levels. Ascorbic acid, which is sulfated, also increases the bioavailability of conc urrently administered ethinyl estradiol. Sulfation and glucuronidation oc cur s ide by s ide, often competing for the same substrate, and the balance between sulfation and glucuronidation is influenced by sev eral factors, such as species, doses, availability of cosubstrates, inhibition, and induction of the res pective transferases.

First-Pass M etabolism Several orally administered drugs are known to undergo liver first-pass metabolism during their transport to the systemic circulation from the gastrointestinal tract (e.g., metoprolol). T hus, the liver can remove substances from the blood after their absorption from the gastrointestinal tract, thereby preventing distribution to other parts of the body. T his effect can seriously impair the bioavailability of an orally administered drug, reduc ing the amount of the drug that reaches the systemic c irculation and, ultimately, its receptor to produce its pharmacological effect. Drugs subject to first-pass metabolism are included in T able 10.15.

Table 10.15. Examples of Drugs Exhibiting First-Pass Metabolism

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Acetaminophen

Isoproterenol

Oxprenolol

Albuterol

Lidocaine

Pentazocine

Alprenolol

Meperidine

Propoxyphene

Aspirin

Methyltestosterone

Propranolol

Cyclosporin

Metoprolol

Salicylamide

Desmethylimipramine

Dihydropyridines

Terbutaline

Fluorouracil

(Nifedipine)

Hydrocortisone

Nortriptyline

Imipramine

Organic nitrates

Verapamil

P-Glycoprotein Description of P-Glycoprotein P -glyc opro te in is a trans memb rane AT P-dep endent ac tive trans p ort p ro tein that is s trategic ally expres s ed in the luminal e ndothe lial c ells of o rgans as s oc iated with lip ophilic xe nobiotic abs o rp tion and dis trib ution. F or e xample, in the intes tinal muc o s a, P-gp f unc tions to move xenobiotic s into the intes tine to bloc k the ir abs orptio n into the p ortal c irc ulation; in the e ndothe lial c ells of the b rain, as a b lo od-brain barrier to move s ubs tanc e s out of the brain into s ys temic c irc ulation; and in the e ndothe lial c ells of the re nal p roximal tubules of the kidne y and in the c anic ular membranes of hepato c ytes , to inc re as e xenobiotic elimination into the urine and bile, res pec tively (81). Add itionally, P-gp is exp re s s ed in the end othelial c e lls of the adrenal c ortex and medulla, of the tes tis and ovaries , of the periphe ral ne rves (f unc tions as a blood -nerve barrier), and of the p anc reas ; in the epithelial c ells o f the p lac enta, where it s erves as the maternof etal barrier f or the f e tus ; and in the s te m c e lls of the b one marrow. The p artic ular loc alization of P-g p s ugges ts that this trans me mbrane trans porter protein prob ably evolved as a p rotec tive mec hanis m agains t the abs orp tion o f xe no biotic s to inc reas e their trans port out of thes e o rg ans and tis s ue s . I t appears that the s ub s trate s , inhibitors , or induc e rs are nons elec tive f or various P -g ps . P-glyc op rotein s hould exhibit s aturatio n/nonlinear kinetic s ; at o r ne ar s aturatio n c onc entrations , an inc reas e in drug abs o rptio n c an res ult in a two - to three f o ld inc re as e in plas ma drug c onc entratio n. A c tivity of P-gp is c o ntro lled b y a varie ty of endogenous and e nviro nme ntal s timuli that e voke s tres s res pons e s , inc lud ing c ytotoxic agents , heat s hoc k, irrad iation, genotoxic s tres s , inf lammation, inf lammatory med iators , c ytokine s , and growth f ac tors .

Another fac tor that must be considered in the oral bioavailability of many CYP3A4 substrates is intestinal P-gp (80). Originally discovered as a transmembrane transporter protein associated with the resistance (elimination) of anticanc er drugs, P-gp also can play a role in how a drug is absorbed, distributed, metabolized, and eliminated from the body (79,80). Considering its role as a transporter protein (efflux pump), it is logical that it should exhibit saturable (nonlinear) kinetics. P-glycoprotein exhibits a broad specificity for a large number of substrates, inhibitors, and inducers (T able 10.16). T he common link between P-gp s ubstrates is that most of the same compounds also are substrates for CYP3A4. T he close physical location of P-gp and CYP3A4 in the endothelial cells of the intestinal mucosa allows these proteins to work in concert with each other to decrease drug plasma c oncentrations of CYP3A4 subs trates, suggesting a complementary protective mechanism for these two proteins, forming a barrier to the absorption intestinal of CYP3A4 substrates. Hepatic and renal P-gp also appear to func tion in a complementary manner, promoting the elimination of substrates into the bile and urine, respectively. For example, if a drug is a substrate for intestinal P-gp, its oral abs orption will be P.302 incomplete, and this same drug will be actively transported by the renal tubules into the urine, enhan cing its elimination. On the other hand, inhibiting P-gp would be expected to improve the oral bioavailability of P-gp substrates, but if the inhibitor also is a s ubstrate for CYP3A4, increased metabolism (pres ystemic) would occur. Drugs with low oral bioav ailability or high first-pass metabolism may be particularly susceptible to alterations in the transport kinetics of P-gp. Because P-gp exhibits saturation (nonlinear) kinetics, drugs with low dosages can have their oral bioavailability enh anced by increasing its oral dosage, thus saturating the P-gp pump. As with CYP3A4, there is significant interindividual variation (4- to 10-fold) in the intestinal expression of P-gp, which could explain the variance observed in the pharmacokinetics for CYP3A4 substrates. T he interactive nature of CYP3A4 and P-gp will be of importance in controlling and improving the oral bioavailability of CYP3A4 s ubstrates and drug regimens. T he presence of inhibitors of P-gp in grapefruit juice (e.g., 6,7-dihydroxybergamottin and other furanocoumarins ) has c onfirmed that the inhibition of efflux transport of drugs and of drug metabolism by CYP3A4 could be an important caus e of drug–grapefruit juice interaction (82).

Table 10.16. Some Substrates, Inhibitors, and Inducers for P-Glycoprotein

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Substrate Acetolol Amiodarone* Atorvastatin* Celiprolol Cimetidine* Ciprofloxacin Colchicine Cyclosporin* Daunorubicin* Debrisoquine Dexamethasone* DHEA Digoxin* Diltiazem* Docetaxel* Domperidone* Doxorubicin* Enoxacin Erthromycin* Estradiol* Etoposide* Fexofenadine* Hydrocortisone* Idarubicin Indinavir* Ivermectin Lidocaine* Loperamide* Methotrexate Mibefradil Nadolol Nelfinavir* Nicardipine* Ondansetron* Paclitaxel* Pravastatin* Quinidine* Quinolones Ranitidine Rifampin* Ritonavir* Saquinaivr* Tacrolilmus* Taxol* Teniposide* Terfenadine* Timolol Verapamil* Vinblastine* Vincristine * Vindesine* Inhibitors Amiodarone* Amitriptyline* Astemizole* Atorastatin* Carvedilol Chlorpromazine* Clarithromycin* Cyclosporin* Desipramine Dexverapamil* Diltiazem* Dipyridamole Disulfiram

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Doxepin Erythromycin* Flupenthixol Felodipine* Fluphenazine Glibenclamide Haloperidol* Hydrocortisone* Imipramine* Itraconazole* Ivermectin Ketoconazole* Lidocaine* Lovastatin* Maprotiline Mefloquine* Mibefradil* Midazolam* Mifepristone* Nelfinavir* Nicardipine* Nifedipine* Nitrendipine* Ofloxacin Prochlorperzine Progesterone* Propanolol Propafenone* Quinidine* Quinine* Reserpine Rifampin* Ritonavir* Saquinavir* Tacrolimus* Testosterone* Tamoxifen* Trimipramine Verapamil* Foods Daidzein Genistein Grapefruit juice* Orange juice Isoflavones Inducers Dexamethasone* Prazosin Progesterone* Quercetin Rifampin St. John's Wort* *CYP3A4 substrate, inhibitor or inducer.

In summary, oral bioavailability for xenobiotics is dependent on a combination of factors, including physical properties of the drugs and formulation and biological factors such as metabolizing enzymes, membrane permeability, and the membrane efflux pump, P-gp.

Extrahepatic Metabolism Because the liv er is the primary tissue for xenobiotic metabolism, it is not surprising that our understanding of mammalian CYP450 monooxygenase is based chiefly on hepatic studies. Although the tissue content of CYP450s is highest in the liver, CYP450 enzymes are ubiquitous, and their role in extrahepatic tissues remains unclear. T he CYP450 pattern in these tissues differs considerably from that in the human liver (83). In addition to liver tiss ue, CYP450 enzymes are found in lung, nasal epithelium, intestinal tract, kidney and adrenal tissues, and brain. It is possible that the expression of the polymorphic genes and induc tion of the isoforms in the extrahepatic tissues may affect the activity of the CYP450 isoforms in the metabolism of drugs, endogenous steroids, and xenobiotics. T herefore, characterization

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of CYP450, UGT , SULT , and other polymorphic drug-metabolizing enzymes in extrahepatic tissues is important to our overall understanding about the biological importance of these isoform families to improved drug therapy, design of new drugs and dosages forms, toxicity, and c arcinogenicity. T he mucosal surfaces of the gas trointestinal tract, the nasal passages, and the lungs are major portals of entry for xenobiotics into the body and, as such, are continuously exposed to a variety of orally ingested or inhaled airborne xenobiotics, including drugs, plant toxins, environmental pollutants, and other chemical subs tances. As a consequence of this exposure, these tissues represent a major target for necrosis, tumorigenesis, and other chemically induced toxicities. Many of these toxins and chemical carcinogens are relatively inert substances that must be bioactivated to exert their cytotoxicity and tumorigenicity. T he epithelial cells of these tissues are capable of metabolizing a wide variety of exogenous and endogenous substanc es, and these cells provide the principal and initial source of P.303 biotransformation for these xenobiotics during the absorptiv e phase. T he consequences of such presystemic biotrans formation is either a decrease in the amount of xenobiotics available for systemic absorption by facilitating the elimination of polar metabolites or toxification by activation to carcinogens, which may be one determinant of tissue s usceptibility for the development o f intestinal cancer. T he risk of colon cancer may depend on dietary constituents that c ontain either proc arcinogens or compounds modulating the respons e to carcinogens.

Intestinal M etabolism Mounting evidence shows that many of the clinically relevant aspects of CYP450 may, in fact, occur at the level of the intestinal mucosa and could account for differenc es among patients in dos ing requirements. T he intestinal mucosa is enriched especially with CYP3A4 isoform, glucuronosyl transferases, s ulfotrans ferases, and GST s, making it particularly important for orally administered drugs susceptible to oxidation (77), glucuronidation or sulfation con jugation pathways (56), or glutathione conjugation pathways. T he highest concentrations of CYP450s occur in the duodenum, with gradual tapering into the ileum. In the human intestine, CYP2E, CYP3A, CYP2C8, CYP2C9, CYP2C19, and CYP2D6 have been identified. T herefore, intestinal CYP450 isoforms provide potential presystemic first-pas s metabolism of ingested xenobiotics affecting their oral bioav ailability (e.g., hydroxylation of naloxone) or bioactivation of carcinogens or mutagens. It is not surprising that dietary factors can affect the intestinal CYP450 isoforms. For example, a two-day dietary exposure to c ooked Brussel sprouts significantly decreased the 2α-hydroxylation of testos terone yet induced CYP1A2 activity for PAH. An 8-oz. glass of grapefruit juice inhibited the sulfoxidation metabolis m of omeprazole (CYP3A4) but not its hydroxylation (CYP2C19), thus increas ing its systemic blood concentration. T hese types of interactions between a drug and a dietary inhibitor could result in a clinically significant drug interaction. In the intestine, UGT isoforms can glucuronidate orally administered drugs, such as morphine, acetamin ophen, α- and β-adrenergic agonists and other phenolic phenethanolamines, and other dietary xenobiotics. T his is a result of reduction in their oral bioavailability (increasing first-pass metabolism), thus altering their pharmacok inetics and pharmacodynamic s. T he UGT s expressed in the intestine include UGT 1A1 (bilirubin-glucuronidating isoform), UGT 1A3, UGT 1A4, UGT 1A6, UGT 1A8, UGT 1A9, and UGT 1A10. Substrate specificities of intestinal UGT isoforms are comparable to those in the liver. Gluc uronidase hydrolysis of biliary glucuronide conjugates in the intestine can contribute to EHC of the parent drug. Likewise, the sulfotransferases in the small intestine can sulfate orally administered drugs and xenobiotics for which the primary route of conjugation is sulfation (e.g., isoproterenol, albuterol, steroid hormones, α-methyldopa, acetaminophen, and fenoldopam), decreasing their oral bioavailability and, thus, altering their pharmacokinetics and pharmacodynamics. Competition for intestinal sulfation between coadministered substrates may influenc e their bioavailability with either an enhancement or a decrease of therapeutic effects. Sulfatase hydrolysis of biliary sulfate conjugates in the intestine can contribute to EHC of the parent drug. T he occurrence of intestinal CYP450 enzymes and bacterial enzymes in the microflora allows the metabolism of relatively stable environmental pollutants and food-derived xenobiotics (i.e., plants contain a variety of protoxins, promutagens, and procarcinogens) into mutagens and carcinogens (68). For example, cruciferous vegetables (Brussel sprouts, cabbage, broccoli, cauliflower, and spinach) are all rich in indole c ompounds (e.g., indole 3-carbinol), which with regular and chronic ingestion are capable of inducing some intestinal CYP450s (CYP1A subfamily) and inhibiting others (CYP3A subfamily). It is likely that thes e vegetables also would alter the metabolism of food-derived mutagens (e.g., heterocyclic amines produced during charbroiling of meat are CYP450 N-hydroxylated and become carcinogenic in a manner similar to arylamines) and carcinogens. T he extent of a drug's metabolism in the s mall bowel and its role in clinically relevant drug interaction remain to be evaluated and must be taken into account during oral pharmacok inetics ana lys is of future drug interaction studies. Clinically significant interaction will not always occur when a drug is combined with other isoform subfamily substrates. Oral coadminis tration of a drug with drugs that interact with its metabolism need not be avoided. T he blood concentration of the drug must be monitored closely, however, and the dose should be adapted to avoid adverse drug reac tions .

Intestinal Microflora When drugs are orally ingested or there is considerable biliary excretion of a drug or its metabolites into the gastrointestinal tract, such as with a parentally administered drug (EHC or recirculation), the intestinal bacterial mic roflora can have a role in the metabolism of these drugs. T he microflora plays an important role in the enterohepatic recirculation of xenobiotics via their conjugated metabolites (e.g., digoxin, the oral contraceptives norethisterone and ethinyl estradiol, and chloramphenicol) and endogenous substances (steroid hormones, bile acids, folic acid, and cholesterol), which reenter the gut via the bile (68). Compounds eliminated in the bile are conjugated with glucuronic acid, glycine, sulfate, and glutathione, and once secreted into the small intestine, the bacterial β-glucuronidase, s ulfatase, nitroreductases, and various glycosidases catalyze the hydrolysis of the conjugates . T he activity of orally administered conjugated estrogens (e.g., Premarin) involves the hydrolysis of the sulfate conjugates by s ulfatases, releasing estrogens to be reabsorbed from the intestine into the portal circulation. T he clinical use of oral P.304 antibiotics (e.g., erythromycin, penicillin, clindamycin, and aminoglyc osides) has a profound effect on the gut microflora and the enzymes responsible for the hydrolysis of drug conjugates u ndergoing EHC. Bacterial reduction includes nitro reduction of nitroimidazole, azo reduction of azides (sulfasalazine to 5-aminosalicylic acid and sulfapyridine), and reduction of the sulfoxide to its sulfide. T he sulfoxide of sulindac is reduced by both gut microflora and hepatic CYP450s. Other ways in which bacterial flora can affect metabolism inc lude the

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following: 1) production of toxic metabolites, 2) formation of carcinogens from inactive precursors, 3) detoxication, 4) exhibition of species differences in drug metabolism, 5) exhibition of individual differences in drug metabolism, 6) production of pharmacologically active metabolites from inactive precursors, and 7) production of metabolites not formed by animal tissues . In contrast to the predominantly hepatic oxidative and conjugative metabolism of the liv er, gut microflora is largely degradative, hydrolytic , and reductiv e, with a potential for both metabolic activation and detoxication of xenobiotics.

Lung M etabolism Some of the hepatic xenobiotic biotransformation pathways also are operative in the lung (84,85). Because of the differences in organ sizes, the total content of the pulmonary xenobiotic-metabolizing enzyme systems generally is lower than in the liver, c reating the impression of a minor role for the lung in xenobiotic elimination. T he CYP2E1 is the CYP450 isoform that is expressed in the lung to the greatest extent. T he other CYP450s, FMO, epoxide hydrolase, and the Phase 2 conjugation pathways, howe ver, are comparable to those in the liver. T hus, the lungs may play a significan t role in the metabolic elimination or activation of small-molecular-weight inhaled xenobiotics. When drugs are injected intravenously, intramus cularly, or subcutaneously, or after skin absorption, the drug initially enters the pulmonary circulation, after which the lung becomes the organ of first-pass metabolism for the drug. T he blood levels and therapeutic response of the drug are influenced by genetic disposition, induction, and inhibition of the pulmonary metabolizing enzymes. By modulation of the CYP450 isoform pattern in the lung, a xenobiotic could alter its own metabolism and that of others in a time- and dose-dependent manner. Because of its position in the circulation, the lung provides a second-pass metabolism for xen obiotics and their metabolites exiting from the liver, but it also is susceptible to the cytotoxicity or carcinogenic ity of hepatic activated metabolites. Antihistamines, β-blockers , opioids, and tricyclic antidepressants are among the basic amines known to accumulate in the lungs as a result of their binding to surfactant phospholipids in lung tissue. T he significance of this relationship to potential pneumotoxicity remains to be seen.

Nasal M etabolism T he nasal mucosa is recognized as a first line of defense for the lung against airborne xenobiotics, b ecause it is constantly exposed to the external environment (86). Drug metabolism in the nas al mucosa is an important consideration not only in drug delivery but also for toxicological implications because of xenobiotic metabolis m of inhaled environmental pollutants or other volatile chemicals. T he CYP450 enzymes in the nasal epithelial cells can conv ert some of the airborne chemicals to reactive metabolites, increasing the risk of carcinogenesis in the nasopharynx and lung (e.g., nitrosamines in cigarette smoke). T he most striking feature of the nasal epithelium is that CYP450 catalytic activity is higher than in any other extrahepatic tissue, as well as the liver. Nasal decongestants, essences, anesthetics, alcohols, nicotine, and cocaine have been shown to be metabolized in vitro by CYP450 enzymes from the nasal epithelium. Because the CYP450s in the nasal mucosa are active, first-pass metabolism should be considered when delivering susceptible drugs to the nasal tissues. Flavin monooxygenases, carboxylesterases , aldehyde dehydrogenase, and other conjugation (Phase 2) enzymes also are active in the nasal epithelium.

M etabolism in Other Tissues T he isoforms of CYP450s and their regulation in the brain are of interest in defining the pos sible involvement of CYP450s in central nervous system toxicity and carcinogenicity. T he CYP450s in the kidney and adrenal tissues include iso forms primarily involved in the hydroxylation of steroids, arachidonic acid, and 25-hy droxycholcalciferol.

Stereochem ical Aspects of Drug Metabolism In addition to the physicochemical factors that affect xenobiotic metabolism, stereochemical factors p lay an important role in the biotransformation of drugs. T his involvement is not unexpected, bec ause the xenobiotic-metabolizing enzymes also are the same enzymes that metabolize certain endogenous substrates, which for the most part are c hiral molecules. Most of these enzymes show stereoselectivity but not stereospecificity; in other words, one stereoisomer enters into biotransformation pathways preferentially but not exclusively. Metabolic s tereochemical reactions can be categorized as follows: substrate stereoselectivity, in which two enantiomers of a chiral substrate are metabolized at different rates; product stereoselectivity, in which a new chiral c enter is created in a symmetric molecule and one enantiomer is metabolized preferentially; and substrate-produc t stereoelec tivity, in whic h a new chiral center of a chiral molec ule is metabolized preferentially to one of two poss ible diastereomers (87). An example of substrate stereoselectivity is the preferred decarboxylation of S-α-methyldopa to S-α-methyldopamine, with almost no reaction for R-α-methyldopa. T he reduction of ketones to stereoisomeric P.305 alcohols and the hydroxylation of enantiotropic pro tons or phenyl rings by monooxygenas es are examples of product stereoselectiv ity. For example, phenytoin undergoes aromatic p-hydroxylation of only one of its two phenyl rings to create a chiral center at C-5 of the hydantoin ring, methadone is reduced preferentially to its α-diastereometric alcohol, and naltrexone is reduced to its 6-β-alcohol. An example of substrate-product stereoselectivity is the reduction of the enantiomers of warfarin and the β-hy droxylation of S-α-methyldopamine to (1R,2S)-α-methylnorepinephrine, whereas R-α-methyldopamine is hydroxylated only to a negligible extent. In vivo studies of this type often can be confused by the further biotransformation of one stereoisomer, giving the false impress ion that only one s tereoisomer was formed preferentially. Moreover, some compounds show stereoselective absorption, distribution, and excretion, whic h proves the importance of also performing in vitro studies. Although studies regarding the stereoselec tive biotransformation of drug molecules are not yet extensive, those that have been done indicate that stereochemical factors play an important role in drug metabolism and, in some cases, could account for the differences in pharmacological activ ity and duration of action between enantiomers (s ee the discussion of chiral inversion of the NSAIDs).

Metabolic Bioactivation: Role in Hepatotoxicity, Idiosyncratic Reactions, and Chem ical Carcinogenesis Drug-Induced Hepatotoxicity Drug-induced hepatotoxicity is the leading cause of hepatic injury, ac counting for approximately half of all cases of acute liver failure in the U.S. (88,89). Recent studies have shown that drug-induced hepatotoxic ity represents a larger perce ntage of adverse drug reactions

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than reported previously and that the incidence and severity of drug-induced liver injury is underestimated among the general population. Acetaminophen overdose is the leading cause for calls to Poison Control Centers (> 100,000 calls/year) and accounts for more than 56,000 emergency room visits, 2,600 hos pitalizations, and an estimated 458 deaths from acute liver failure eac h year. Among the listed drugs in T able 10.17, acetaminophen is the most frequent hepatotoxic agent and can cause extensiv e hepatic necrosis with as little as 10 to 12 g (30–40 tablets). Chronic alcohol intake enhances ac etaminophen hepatotoxicity more than five times as compared to acute alcohol intake, yet acetaminophen is heav ily marketed for its safety as compared to nonsteroidal analgesics. U.S. drug manufacturers continue to market and promote Extra-strength acetaminophen products (500–750 mg/tablet) and a variety of Extra-strength ac etaminophen-drug combination products. Self-poisoning with acetaminophen (paracetamol) also is a common caus e of hepatotoxicity in the Western World. T o reduce the number of acetaminophen poisonings in the UK, OT C sales of acetaminophen are limited to 16 tablets per packet. Drug-induced hepatic damage is also the most frequent reason that new therapeutic agents are not approved by the U.S. FDA (e.g., ximelagatran in 2004) and the most common adverse drug reaction leading to withdrawal of a drug from the market (T able 10.17). Hepatotoxicity almost always involves metabolism with Phase I CYP450 enzymes rather than Phas e II enzymes. More than 600 drugs, chemicals, and herbal remedies can cause hepatotoxicity, of which more than 30 drugs have either been withdrawn from the U.S. market P.306 because of hepatotoxicity or have carried a black box warning for hepatotoxicity since 1990. T able 10.17 includes some of the more common drugs that have exhibited drug-induced hepatotoxicity ranging from severe, requiring the drug's regulatory withdrawal from the market (italics in T able 10.17); moderate to severe, requiring black box warning restrictions (bold in T able 10.17); or mild to moderate, requiring frequent liver function monitoring.

Table 10.17. Some Drugs Causing Hepatic Injurya Acarbose Acetaminophen Allopurinol Amiodarone Amprenavir Anagrelide Atomoxetine Atorvastatin Azathioprine Bicalutamide Bosentan Bromfenac (1998) Carbamazepine Celecoxib Dapsone Deferasirox Diclofenac Disulfiram Duloxetine Efavirenz Ethotoin Ethosuximide Felbamate Fenofibrate Fluconazole Flutamide Fluvastatin Gemfibrozil Gemtuzumab Griseofulvin Halothane Imatinib Indinavir Infliximab Interferon-β 1a Interferon-β 1b Isoflurane Isoniazid Isotretinoin Itraconazole Ketoconazole Ketorolac Lamivudine Leflunomide

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Lovastatin Meloxicam Methotrexate Methsuximide Methyldopa Nabumetone Naproxen Nefazodone (2005) Nevirapine Niacin (SR) Nitrofurantoin Olanzapine Oxaprozin Peg-interferon-α 2a Pemoline (2005) Pentamidine Pioglitazone Piroxicam Pravastatin Pyrazinamide Ribavirin Rifabutin Rifampin Riluzole Ritonavir Rosiglitazone Rosuvastatin Saquinavir Simvastatin Sulindac Tacrine Tamoxifen Tasosartan (1998) Terbinafine Testosterone Thioguanine Tizanidine Tolcapone Troglitizone (2000) Trovafloxacin Valproic acid Voriconazole Ximelagatran (2004) Zileuton Zifirlukast a

Drugs in italics have exhibited severe drug-induced hepatotoxicity were withdrawn either voluntarily or by a regulatory agency (year given). Drugs in bold have exhibited moderate–severe drug-induced hepatotoxicity requiring a black box warning restricting their use. The other drugs have exhibited mild to moderate drug-induced hepatotoxicity that may need frequent liver transaminase testing for those at risk (see Table 10.18).

However, Watkins (90) recently reported in the Journal of the American Medical Association that 1/3 of 106 patients taking a maximum daily acetaminophen dos e of 4 grams for 8 days, either alone or in combination with Hydrocodone, exhibited a 3-fold increas e in liver enzymes associated with acetaminophen-induced liver injury. T his 3-fold increase in transminase levels is a signal for potential liver safety concerns in thos e individuals who are at risk of acetaminophen-induced liver toxicity. Drug-induced injury is most common and includes hepatic necrosis and steatosis, which can affect significant portions of the liver (88). Drugs reported to cause hepatoc ellular necrosis include ac etaminophen, methyldopa, valproic acid, trazodone, nefazodone, venlafaxine, and lovastatin. Drug-induced liver damage occurs after a prolonged period of drug administration.

Some Drugs Exhibiting Drug-induced Hepatotoxicity Never Approved for Use in United States D rugs with reac tive metabolites that were us e d in o ther c ountries but neve r ap proved in the United S tates inc lude: alpidem, aminep tine , amodiaquine, c inc hophe n, d ihydralazine, dile valol, eb ro tidine , glaf enine, ibuf e nac , is oxic am, nipe ro tidine , p erhexiline, p irp ro f en, and tilbro quinol.

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T he most commonly used indicators of hepatotoxicity (i.e., liver injury) are increased levels of the liver transaminases, aspartate aminotransferase (AST ) and alanine aminotransferas e (ALT ) (88,89). Drug-induced hepatotoxicity c an develop rapidly, often before abnormal laboratory tests are notic ed, which are characterized by rapid elevations in ALT and AST of 8 to 500 times the upper normal limit, with variable elevations in bilirubin. Drugs causing acute liver injury (hepatocellular necrosis) exhibit elevations in hepatic transaminases ranging from 50 to 100 times higher than the normal level. On the other hand, the elevations of ALT and AST in alcoholic liver disease are two- to three times higher than normal. Some hepatotoxins , however, do not elevate transaminases, whereas nonhepatic toxins can elevate ALT . Most drug-induced hepatotoxicity is of an idiosy ncratic nature, occ urring in a small percentage of patients (1 in 5,000) who ingest the drug (88,89). T hese reactions tend to be of two distinct types: 1) hypersensitivity reactions that are immune mediated, occurring within the first 4 to 6 weeks, and are associated with fever, rash, eosinophilia, and a hepatitis-like picture (e.g., phenytoin, sulindac and allopurinol); and 2) metabolic idiosyncratic reactions that tend to occur at almost any time during the first year of treatment (e.g., troglitazone and isoniazid). T he incidence of overt idiosyncratic liver diseases varies with the drug, ranging from approximately 1 in 100 with isoniazid to 1 in 1,000 with phenytoin, to 1 in 10,000 or more with sulindac and troglitazone, and 1 in 100,000 with diclofenac. T o detect a single case of drug-induced hepatotoxicity with 95% confidence requires the number of patients studied to be threefold the incidence of the reaction. For one adverse drug reaction in 10,000 patients, at le ast 30,000 patients need to be evaluated. T hus, many drugs are approved before liver toxicity is observed. It is the res ponsibility of postmarketing surv eillance and monitoring of liver transaminases to identify potential cases of liver-adverse drug reactions. Risk factors (T able 10.18) for drug-induc ed liver injury, s uch as age, gender, genetic predis position, multiple drugs or dietary supplements, and degree of alcohol c onsumption, appear to increase the susceptibility to drug-induced hepatotoxicity (88,89). Patients with mild to moderate chronic liver disease do not appear to be at inc reased risk for idiosyncratic hepatic injury from drugs. However, the drugs in T able 10.17 should be used with caution in these patients, because such patients may have altered metabolism of thes e drugs and, therefore, may be at increased ris k for liver injury. T he coadministration of drugs in T able 10.17 with enzyme inducers, such as phenobarbital, phenytoin, ethanol, and/or cigarette s moke, can induc e hepatic enzymes, resulting in the enhanc ement of hepatotoxicity. Most hepatic adverse effects associated with drugs occur in adults rather than children. Drug-induced liver injury occurs at a higher rate in patients older than 50 years, and drug-associated jaundice also occurs more frequently in the geriatric population (88,89). T his age-risk may be the result of increased frequency of drug expos ure, multidrug therapy, and age-related changes in drug metabolism. For reasons that are unclear, drug-induced liver injury affects females more than males: Females accounted for approximately 79% of all reactions to acetaminophen and 73% of all idiosyncratic drug-induced reactions (88). Females exhibit increased risk of hepatic injury from drugs such as atorvastatin, nitrofurantoin, methyldopa, and diclofenac. Genetic factors as a result of enzyme polymorphism in affected individuals may decrease the ability to metabolize or eliminate drugs, thus increasing their duration of action and the drug expos ure and/or decreasing the ability to modulate the immune response to drugs or metabolites . Chronic ingestion of alcohol may also predispose many patients to increased hepatotoxic ity from drugs by lowering the store of glutathione (a detoxifying mechanis m), which prevents trapping of the toxic metabolites as mercapturate conjugates that are excreted in the urine. P.307

Table 10.18. Risk factors for drug-induced liver injury Race

Some drugs exhibit different toxicities based on race because of individual CYP450 polymorphism. For example, blacks and Hispanics may be more susceptible to isoniazid (INH) toxicity.

Age

Elderly persons are at increased risk of hepatic injury because of decreased clearance, drug-to-drug interactions, reduced hepatic blood flow, variation in drug binding, and lower hepatic volume. In addition, poor diet, infections, and multiple hospitalizations are important reasons for drug-induced hepatotoxicity. Hepatic drug reactions are rare in children (e.g., acetaminophen, halogenated general anesthetics).

Gender

Although the reasons are unknown, hepatic drug reactions are more common in females. Females are more susceptible to acetaminophen, halothane, nitrofurantoin, diclofenac, and sulindac.

Alcohol

Alcoholics are susceptible to drug toxicity, because alcohol induces liver injury and cirrhotic changes that alter drug metabolism. Alcohol causes depletion of glutathione (hepatoprotective) stores, making the person more susceptible to toxicity by drugs (e.g., acetaminophen, statins).

Liver disease

Patients with chronic liver disease are not uniformly at increased risk of hepatic injury. Although the total CYP450 level is reduced, some patients may be affected more than others. The modification of doses in persons

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with liver disease should be based on knowledge of the specific CYP450 isoform involved in the metabolism. Patients with HIV infection who are coinfected with hepatitis B or C virus are at increased risk for hepatotoxic effects. Similarly, patients with cirrhosis are at increased risk to hepatotoxic drugs (e.g., methotrexate, methyldopa, valproic acid). Genetic factors

Genetic (polymorphic) differences in the formation of CYP450 isoforms (2C family and 2D6) can result in abnormal reactions to drugs, including idiosyncratic reactions (see Table 10.18).

Other comorbidities

Patients with AIDS, renal disease, diabetes mellitus, persons who are malnourished, and persons who are fasting may be susceptible to drug reactions because of low glutathione stores.

Pharmacokinetics

Long-acting drugs may cause more injury than shorter-acting drugs, as well as sustained-release drug product formulation.

Drug adulterants

Contaminants are often found in noncertified herbal supplements (e.g., hepatitis C).

Other factors include the effect of drug formulation (sustained vs. rapid release; increased exposure) on pharmacokinetics, e.g., elimination half-life of the drug or adulterants (e.g., enzyme inducers) in dietary supplements. Drug-induced hepatotoxicity can be categorized as intrinsic (predictable) or idiosyncratic (unpredic ta ble) drug reactions (89). Most drugs involved in hepatotoxicity belong to the idiosyncratic group. Intrinsic heptotoxins produce liver injury in a dose-related manner when the toxic amount of drug is ingested without bioactivation, such as these toxins found in the Amani ta mus hroom. Fortunately, few drugs are intrinsic heptotoxins. Idiosync ratic hepatotoxicity is the result of the toxic effec ts of a drug's metabolites. T he common trigger for both mild and severe forms of hepatotoxicity is bioactivation of relatively inert functional groups to reactiv e electrophilic intermediates, which is considered to be an obligatory event in the etiology of many drug-induced idiosyncratic hepatotoxicity (91,92). A great deal of evidence now shows that reac tive metabolites are formed from drugs known to cause idiosyncratic hepatotoxicity, but how these toxic species initiate and propagate tissue damage remains poorly understood. However, the relationship between bioactivation and the occurrence of hepatic injury is not simple. For example, many drugs at therapeutic doses undergo bioactivation in the liver but are not hepatotoxic. T he tight coupling of bioactivation with bioinactivation pathway s may be one reason for the lack of hepatotoxic ity with these drugs . Examples of bioinactivation (detoxification) pathways inc lude glutath ione conjugation of quinones by glutathione S-transferas es (GST s) and hydration of arene oxides to dihydrodiols by epoxide hydrolases. When reactive metabolites are poor substrates for such detoxifying enzymes, they can es cape bioinactivation and, thereby, damage proteins and nucleic acids, prompting hepatotoxic ity. Most drugs, howev er, are not directly chemically reactive but, through the normal proces s of drug metabolism, may form electrophilic, chemically reactive metabolites (90,91,92). Formation of chemically reactive metabolites is mainly catalyzed by CYP450 enzymes (Phase I), but products of Phase II metabolism (e.g., acylglucuronides, acyl CoA thioesters, or N-sulfonates) also can lead to toxicity . However, if Phase I drug bioactivation is closely coupled with Phase II bioinactivation (e.g. glutathione c onjugation to mercapturates), then the net chemical process is one of detoxification if the final product is rapidly c leared. T oxicity may accrue when accumulation of a chemically reactive metabolite that, if not detoxified, can lead to covalent modification of biological macromolecules. T he identity of the target macromolecule and the functional consequence of its modification will dictate the resulting toxicologic al response. T he CYP450 enzymes are present in many organs, mainly the liv er but also the kidney and lung, and thus can bioactivate chemicals to cause organ-specific toxicity. Evidence for the formation of reactive metabolites was found for five of the six drugs that have been withdrawn from the marketplace since 1995 and for 8 of the 15 drugs that have blac k box warnings. Evidence for reac tive metabolite formation has been found for acetaminophen, bromfenac, dic lofenac, c lozapine, and troglitazone (91,92,93). Acetaminophen is the most studied hepatotoxin. T he current hypotheses of how reactive metabolites lead s to liver injury suggests that hepatic (target) proteins can be modified by reactive metabolites. Much more important may be the identification of the target proteins modified by these toxic metabolites and how this reactions alters the function of P.308 the target proteins. Additionally, it is important to note that the toxic ity of reactive metabolites also may be mediated by noncovalent binding mechanisms, which may have profound effects on normal liver physiology. T echnological developments in the wake of the genomic revolution now provide unprecedented power to chara cterize and quantify c ovalent modification of individual target proteins and their functional consequences (93). Such information should dramatically improve our understanding of drug-induced hepatotoxic reactions. Moreover, covalent binding per se does not necessarily lead to drug hepatotoxicity. T he regiois omer of acetaminophen, 3-hydroxyacetanilide, becomes c ovalently bound to hepatic proteins in rodents without inducing hepatotoxicity (94).

Hard/Soft Acids/Bases T he nonenzymatic reac tio n of an elec trophilic metab o lite with a nuc leo philic molec ule us ually oc c urs via a s ubs titution o r ad dition mec hanis m involving the do nation of an elec tron pair by the nuc leo phile to an ac c ep to r molec ule, an elec trop hile, with s ubs eq uent f ormation o f a c o valent bond and an adduc t p ro duc t (Coles B . E f f e c ts of mod if ying s truc ture on e le c trophilic re ac tio ns with biologic al nuc leop hiles . D rug Me tab Rev. 198 4–19 85;15:13 07–34 ). T he mo s t ac c epted c o nc e p t c las s if ies

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e le c tro philes and nuc le ophiles ac c o rding to Pears o n's “ hard-s of t ac id-bas e s ” (HSAB ) mod el. Thus , hard elec trophiles have a f o rmal pos itive c harge at the elec trop hilic c ente r, and the vale nc e elec trons are not eas ily deloc alized or polarized (e.g ., ac ylonium ions , c arb oc ations , nitre nium ions , Figs . 10 .3 0 and 10.3 3), whereas s o f t elec trop hile s have a partial p os itive c harge d ens ity and valenc e elec trons that are deloc alized (p olarize d), s uc h as ac tivated do uble bond s of α,β-uns aturated c arbonyl c omp ounds as s hown in Fig. 10 .3 2. Hard nuc leo phile s have high elec tronegativity (oxygen and nitroge n g roups ) and lo w p olarization o f vale nc e elec trons , whereas s o f t nuc leo philes have low e le c tro negativity and are more p olarizable. The s o f te s t b io lo gic al nuc leophilic s ite s are c ys teine thiol groups o n p roteins and glutathione (G SH). The p rimary and s e c ondary amino g roups of lys ine and his tidine or the hyd ro xyI groups of s e rine o r threo nine on proteins are hard nuc leophiles , whereas the hardes t nuc leo phile s are the oxyge n atoms o f purine s and pyrimidine s on DNA and R NA. B as ed o n the HSA B theory, the reac tion rates and s e lec tivities of elec trop hiles and nuc leo phile s are d epe ndent upo n c omp arable s tates of “ hardne s s .” Spec if ic ally a s of t e le c trophile s uc h as q uinoneimine will reac t pred o minantly with a s of t nuc leophile s uc h as the thio l group of c ys teine. A hard elec trop hile s uc h as the ac ylonium ion f orme d f ro m ac yl gluc uro nid e will re ac t with hard nuc leop hiles s uc h as the hydro xyl g ro up of s erine. This pref ere ntial non-e nzymatic reac tivity is d ue primarily to the hig h-energy trans ition s tate that ac ts as a barrier to the re ac tio n of a hard elec trophile with a s of t nuc leop hile s uc h as , the d eloc alized do uble bond s of p -benzoq uinoneimines , p -benzo quinone methide s , and other α,β-uns aturate d c arbonyl intermediates whic h reac t by Mic hael- T ype add ition of the nuc le o phile to the polarized (partial p os itive c harge) lo c ated on the β-c arbon. A dduc t f ormation is d ependent not only upon the p hys ioc he mic al nature of the elec trophilc but als o up o n the mic roe nviro nme nt o f the nuc leophilic c enter, whic h c an vary s ig nif ic antly eve n amo ng c enters of the s ame elemental type (e.g., s ulf ur or amino g roups ). Thus , nuc le ophilic re ac tivity among f ree s ulf hyd ryl gro ups on proteins c an be divers e and, c o ns eq uently, s of t e le c tro philic metabo lites will f o rm adduc ts with the more reac tive thiol groups o n a given protein or f ree thiols on glutathione. T his divers ity in nuc le ophilic reac tivity is a f unc tio n of both s teric and elec tronic f ac tors mediated primarily by the tertiary s truc ture of a p rotein. F or example, adjac ent ac idic and bas ic amino ac ids o n a protein s ignif ic antly inf luenc e the re ac tivity of the targ et nuc leophilic group. De pend ing upon the phys io c hemic al nature of the elec trophile, the re s ulting e le c trophilic metabo lite c an produc e to xic ity by reac ting with e ithe r a s o f t thiol nuc leophilic s ites on proteins and f re e thio ls s uc h as GS H or harder nuc leophilic c enters on D NA and RNA to produc e adduc ts . F or example, metab olic ep oxidation of an aromatic ring p ro duc es an epoxide , a relatively hard elec trop hilic me tabolite that will f o rm a ring-opened hydroxyl ad duc t primarily with hard nuc leop hilic c ente rs o n guanine and adenine o n DNA , and not with s of t thiol nuc leo phile s . O n the other hand, a s of t e lec tro phile s uc h as the N-ac etyl p -b enzoq uinone imine m etabo lite of ac etamino phen will f orm add uc ts with thio l groups o n proteins and f re e thio ls o n GSH, b ut not with hard nuc leophilic group s on lys ine o r s e rine on proteins or with thos e on g uanine and adenine on D NA . G lutathione of f ers little protec tion agains t c arc inogens , mos t of whic h are hard nuc leop hiles . Thes e examples s how that the bioac tivated metabolite c an exhibit dis tinc t e le c tro philic c harac teris tic s and dif f erent nuc leop hilic target mo le c ules . Thus , s o f t elec trop hiles are as s oc iated with org ans pec if ic to xic ities , e.g., heptatotoxic ity, re nal to xic ity, and hard e le c tro phile s with c arc inoge nic ity.

It therefore is necessary to identify targets for these reactive metabolites (i.e., covalently modified macromolecules ) that are critical to the toxicological process. Hard electrophiles generally reac t with hard nucleophiles, such as the basic groups in DNA and lysine ω-amino residues in proteins. Soft electrophiles react with soft nucleophiles , whic h include cysteine residues in proteins and in glutathione. Unfortunately, no simple rules predict the target mac romolecules for a partic ular chemically reactive metabolite or the biological consequences of a particular modification. Furthermore, noncovalent interactions also P.309 play a role, because covalent binding of hepatotoxins is not indiscriminate with respect to proteins. Even within a single protein, there can be selective modification of an amino acid side chain found repeatedly in the primary structure. T hus, the microenvironment (e.g., pK a and hydrophobicity) of the amino acid in the tertiary s tructure appears to be the crucial determinant of selectiv e binding and, therefore, the impact of covalent binding on protein func tion. In turn, the extent of binding and the bioc hemical role of the protein will determine the toxicological insult of drug bioactivation. T he resulting pathological consequences will be a balance between the rates of protein damage and the rates of protein replacement and cellular repair.

Drug-Induced Idiosyncratic Reactions Idiosyncratic drug reactions (IDR; type B adv erse drug reactions) occur in from 1 in 1,000 to 1 in 50,000 patients, are not predictable from the known pharmacology or toxicology of the drug, a re not produced experimentally in vitro and in vivo , and are dose independent. T he occurrence of IDRs during late clinical trials or after a drug has been released can lead to severe restriction of its use and even its withdrawal. T he IDRs usually do not result from the drug its elf, because most people can tolerate the drug, but, rather, from a unique set of patient characteristic s, including gender, age, genetic predisposition, and a lack of drug-metabolizing enzymes, that may increase the risk of these adverse drug reactions. Most IDRs are caus ed by hypersensitivity reactions and can result in hepatocellular injury. T he hepatic injury occurs within 1 week to 12 months after initiation of drug therapy and often is accompanied by systemic characteristics of allergic drug reactions, such as rash and fever. Signs of hepatic injury reappear with subsequent administration of the same drug with only one or two doses. Hypersensitivity reactions can be severe and associated with fatal reactions as a multiorgan clinical syndrome usually characterized by the following: 1) fever; 2) ras h; 3) gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea, or abdominal pain); 4) generalized malaise, fatigue, or achines s; and 5) res piratory symptoms (e.g., dyspnea, cough, or pharyngitis). Examples of drugs causing IDRs through a hypersensitivity mechanis m include penicillin, methy ldopa, chlorpromazine, erythromycin, azathioprine toxicity in thiopurine methyltransferase–deficient indiv iduals, sulfonamide and acetaminophen hepatotoxicity in alcoholics and in UGT 1A6 deficient cats, ivermectin neurotoxic ity in Collie dogs deficient in P-gp, perhexilene hepatotoxicity in CYP2D6-deficient individuals, pheny toin toxicity in CYP2C9-deficient individuals, and valproic acid hepatotoxicity. T he clinical features of some cases of drug-induced idiosyncratic hepatotoxicity strongly suggest an involvement of the immune sy stem (95). T hes e c linical characteristics include the following: 1) concurrence of rash, fever, and eosinophilia; 2) delay of the initial reaction (1–8 weeks) or requirement of repeated exposure to the culprit drug; 3) rapid recurrence of toxicity on reexposure to the drug; and 4) presence of antibodies specific for native or drug-modified hepatic proteins. Our current understanding of drug-induced adaptive immune responses is largely based on the hapten hy pothesis. Idiosyncratic drug reactions that are connected with hepatotoxicity involve the formation of reactive metabolites (91,92). Such reactions

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are not predictable, but current bioanalytical tec hnology have enabled the in vivo identification of the formation of reac tive metabolites, as evidenced by the detection of biomarkers (i.e., mercapturate or cysteine adduc ts) in urine, drug-specific antibodies, or antibodies to CYP isoforms (93). As a result, some drugs k nown to cause hepatic injury continue to be us ed, because the drug's benefit outweighs its risk and no alternative efficacious drug exists. For example, isoniazid, a drug commonly used to treat tuberculosis, is implicated in approximately 15 to 20% of the individuals who show increased serum transaminas es after receiving the drug as a single agent for tuberculosis prophylaxis . Of these individuals, an estimated 1 in 1,000 patients may develop sev ere hepatic necrosis. Additionally, NSAIDs, including cyclooxygenase-2 inhibitors , commonly are as sociated with idiosy ncratic liver injury. Most of the idiosyncratic toxins listed in T able 10.19 that have been s tudied to date produce reactive metabolites. Current hy potheses regarding IDRs suggest that meta bolic ac tivation of a drug to a reactive metabolite is a P.310 necessary yet insufficient step in the generation of an idiosyncratic reaction (91,92). Evidence for this hy pothesis comes from drugs that are associated with hepatotoxicity (T able 10.19) and the detection of a drug-metabolite spec ific antibodies in affected patients.

Table 10.19. Some Examples of Idiosyncratic Toxins Abacavir Acetaminophen Amiodarone Aromatic anticonvulsants Cefaclor Clozapine Diclofenac Felbamate Fibrates Halothane Indomethacin Isoniazid Levamisole Nefazodone Nevirapine Oral contraceptives Paroxetine Phenytoin Statins Sulfonamides Tamoxifen Tacrine Tienilic acid Ticlopidine Troglitazone Valproic acid Vesnarinone Penicillinaminea Hypersensitivity Hepatotoxicity Hepatotoxicity Hypersensitivity Hepatotoxicity Agranulocytosis Hepatotoxicity Aplastic anemia Hepatotoxicity Hepatotoxicity Hepatotoxicity Hepatotoxicity Hepatotoxicity Hepatotoxicity agranulocytosis Hepatotoxicity Hepatotoxicity Hepatotoxicity Hepatotoxicity Stevens-Johnson syndrome Hepatotoxicity Hepatotoxicity Hypersensitivity

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Agranulocytosis Hepatotoxicity Hepatotoxicity Agranulocytosis Hypersensitivity a

Does not produce reactive metabolites.

For the other drugs that hav e been assoc iated with idiosyncratic hepatotoxicity but that do not have black box warnings, either evidence for hepatotoxicity was not available or suitable studies had not been carried out. High dos es increase the ris k for an IDR (e.g., cloazapine at 300 mg/day vs. olanzapine 20 mg/day). Strong evidence also exists that T cells play an important role in immune-mediated IDR and can trigger cell death. In patients exhibiting IDR, pretreatment with immunosuppressants prevented the IDR (rash). T he incidence of IDRs also appears to be lower in patients with low T -c ell counts. T he hapten hypothesis proposes that the reactive metabolites of the drugs act as haptens and covalently bind to endogenous proteins to form immunogenic drug–protein adduc ts triggering either antibody or cytotoxic T -cell responses (92,96). T he hapten hypothesis is supported by the detection of antibodies that rec ognize drug-modified hepatic proteins in the sera of drug-induced liver injury (DILI) patients. For example, antibodies that recognize trifluoroacetate-altered hepatic proteins have been detected in the sera of patients with halothane-induced hepatitis. Such drug-specific antibodies or autoantibodies that recognize native liver proteins also have been found in patients with liver injury caused by other drugs, such as diclofenac. In patients who developed IDRs of the liver and other organs, drug-specific T cells have been detected, and in some cases, T -cell clones were generated. Most drugs are small molec ules and are unlikely to form haptens. Electrophilic acylators (hard electrophiles) can react with the lysine ω-amino residues (hard nuc leophiles) of the target protein or guanos ine res idues of DNA. How much chemical modification is required to trigger an IDR remains unknown. Halothane is the most studied molecule for supporting this hypothesis regarding IDRs (91). T herefore, it is not s urprising that irreversible chemical modification of a protein, which has a profound effec t on function, is a mechanis m of idiosy ncratic hepatotoxicity. However, it is important to note that a number of drugs (e.g., penicillins, aspirin, and omeprazole) rely on c ovalent binding to proteins for their efficac y; thus, prevention of their covalent binding through chemical modification of the compound also may, inadvertently, lead to loss of efficacy. Drug-induced stress and/or damage of hepatocytes may trigger activ ation and inflammatory responses of the immune s ystem within the liver (95,96). Evidence to support this idea has been obtained mainly from studies of liver injury induced by overdoses of acetaminophen, which is one of the few drugs that prov ide an experimental animal model of drug-induced liver injury. Evidenc e is growing that the initial benzoquinoneimine-induced hepatocyte damage may lead to activation of immune cells within the liver, thereby stimulating hepatic infiltration by inflammatory cells. Activated T cells of the immune system produce a range of inflammatory mediators, including cytokines, chemokines, and reac tive oxygen and nitrogen spec ies , that contribute to the progression of liver injury. On the other hand, the immune cells also represent a major source of hepatoprotective factors.

Reactive M etabolites Resulting from Bioactivation Electrophiles T he concept that small organic molecules c an undergo bioactivation to electrophiles and free radicals and elicit toxicity by chemical modification of cellular macromolecules has its basis in chemical c arcinogenicity and the pioneering work of the Millers (97) and Gillette et al. (98,99,100). A number of different types of reactive metabolites exist; however, they may be broadly classified as either electrophiles (Fig. 10.30) or free radic als (Fig. 10.31) (93,101). T hese reactive metabolites are short-lived, with half-lives of generally less than 1 minute, and usually are not detectable in plasma or urine except as phase 2 conjugates or other biomarkers. Electrophiles are reactive because they possess electron-deficient centers (po larization-activated double bonds or positiv e-charge acylators) (Figs. 10.30 and 10.32) and can form covalent bonds with electron-rich biological nucleophiles. T hey are either soft electrophiles that react directly with soft nucleophiles (:Nuc), such as the thiol groups in either glutathione or cy steine res idues within p roteins, or hard electrophiles that react with hard nucleophiles, such as basic groups in DNA and lysine ω-amino residues in proteins, or are mediated by bioinactivation enzymes, such as glutathione transferase or epoxide hydrase. Softness or hardness are associated with the polarizability of the electrophilic/nucleophilic s pecies (see Hard/Soft Acids/Bases). Activated double bonds are s oft electrophilic intermediates as shown in Fig. 10.32. Examples of activated double bond electrophiles include α, β-unsaturated carbonyl compounds, quinones, quinoneimines, quinonemethides and diiminoquinones as shown in Fig. 10.32B. T hese electrophilic intermediates are highly polarized and can react with nucleophiles in a 1,4-Michael-type addition at the more electrophilic or β-carbon of the activated double bond intermediate to the addition product (Fig. 10.32A). Specific examples of activ ated double bond electrophiles that hav e been propos ed for the anticancer drug leflunamide, the food antioxidant butylated hydroxytoluene, acetaminophen, the antiandrogen flutamide, the anticonvulsant felbamate and the cytotoxic cyclophosphamide as shown in Fig. 10.32C. T he bioinactivation pathways for these electrophilic intermediate can involve either direct addition, with or without transferases, depending u pon the degree of polarization and reactivity of the electrophilic intermediate (hard vs soft electrophiles). Other commonly found electrophilic intermediate for drug molecules in Fig. 10.30 include the formation of ketenes from the bioactivation of acetylenic groups (e.g., P.311 ethinylestradiol) (Fig. 10.30-2), isocyanates from thiazoldinediones (e.g., the “ glitazones ” ) (Fig. 10.30-4) (93), acylonium ions from halogenated hydrocarbons (e.g., halothane) (Fig. 10 .30-3) (93) and carboxylic acids, β-dicarbonyl from furans (e.g., furosemide) (Fig. 10.30-5) (93), activated thiophene-S-oxide from thiophenes, suc h as ticlopidine, tenoxicam which cause an IDR, agranulocytosis (Fig. 10.30-6) (93), and epoxides and arene oxides from olefins and aromatic compounds (Fig 10.30-7)(93). Drug possessing structural features

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prone to metabolic epoxidations are abundant. T herefore the incidence of epoxide metabolites in mediating adverse biologic effects has aroused concern about c linically used drugs known to be metabolized to epoxides. Metabolically produced epoxides have been reported for allobarbital, secpbarbital, protripty line, carbamazepine, cyproheptadine, and are implicated with 8-methoxypsoralen and other furanocoumarins (6,7-dihydroxybergamottin in grapefruit juice), phenytoin, phensuximide, phenobarbital, mephobarbital, lorazepam, and imipramine (81). T he alarming biologic effects of some epoxides, however, do not imply that all epoxides have similar effects. Epoxides vary greatly in molecular geometry, s tability, elec trophilic reactivity, and relative activity as substrates for epoxide-transforming enzymes (e.g., epoxide hydrolase, glutathione S-transferas e, and other).

Fig. 10.30. Some examples of electrophilic intermediates resulting from bioactivation. NUC = nucleophiles.

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Fig. 10.31. Drug bioactivation to free radicals.

Some carboxylic acid–containing drugs have been implicated in rare IDRs, which was the basis for the market withdrawal of the NSAIDs, zomiperac, and benzoxaprofen. T hese drugs (e.g., NSAIDs, fibrates , “ statins,” and valproic acid) c an be bioactivated to acyl glucuronides or acyl CoA thioesters (Fig. 10.30A). T hese products are electrophilic acylators that can acylate targ et proteins if they escape inactivation by S-glutathione–thioester formation. A c rucial factor is the c oncentration of acyl gluc uronides in hepatocytes because of their transport by conjugate export pumps, where acylglucuronides may selectively acylate c analicular membrane proteins. Acyl CoA esters may be either rapidly hydrolyzed or further metabolized in hepato cytes. Evidence is accumulating that acy l glucuronides can alter cellular function by haptenation of P.312 peptides, target protein acylation or gly cation, or direct stimulation of neutrophils and macrophages. T he role of acyl CoA reactive metabolites is less clear. It should be noted that some nonc arboxylic acid drugs can be biotransformed by oxidative metabolism in the liver to the respective carboxy lic acids.

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Fig. 10.32. Some examples of activated double bonds as electrophilic reactive intermediates.

Free Radicals 1

Cy tochrome P450 activates molecular dioxygen to generate reactive oxygen species (ROS), such as s inglet oxygen ( O 2 ) or superoxide (see Oxygen Activation p. 269). Reactive metabolites that possess unpaired electrons are free radicals (molecular species which contain an odd unpaired electron) which can react with mole cular oxygen (ground state triplet) to generate intracellular oxidativ e s tres s damage (93,98,99,100). Free radicals usually abstract a hy drogen atom from other molecules rather than becoming covalently bound. Free radical reactions can be self-propagating by abstracting a hydrogen atom from the double bond of a lipid that initiates a chain reaction leading to lipid peroxidation, oxidative stress or other types of modification of biologic al molecules. Some examples of free-radicals generated by the bioactivation of drug molecules are shown in Fig. 10.3 1. Isoniazid is acetylated to its major metabolite acetylisoniazid, which is hydrolyzed to acety lhy drazine and isonicotinic acid (Fig. 10.31-1). Acetylhydrazine is further metabolized by the CYP2E1 to an N-hydroxy intermediate that hydrates into an acetyl radic al, which can then initiate the process that leads to hepatic nec rosis. Other carbon-centered radicals are formed from hydrazines such as the antihypertensive hydralazine, and thio-radicals from the ACE inhibitor captopril (Fig. 10.31-2 and -3).

Bioinactivation Mechanisms Several enzyme sys tems exist as cellular defens e (d etoxification) pathways against the chemically reactive metabolites generated by CYP metabolism (91,92,102,103). T hese include GST , epoxide hydrolase, and quinone reductas e, as well as catalase, glutathione peroxidase, and superoxide dismutas e, which detoxify the peroxide and superoxide by-products of metabolism. T he efficiency of the bioinactivation process is dependent on the inherent chemical reactiv ity of the electrophilic intermediate, its affinity and selectivity of the reactive metabolite for the bioinactivation enzymes, the tissue expres sion of these enzymes, and the rapid upregulation of these enzymes and cofactors mediated by the cellular sensors of c hemical stress. T he reactive metabolites that can evade these defense sy stems may damage target proteins and nucleic acids by either oxidation or covalent modification. T he most abundant agents of cellular defense are thiols. Glutathione is a soft electrophile and, there fore, will only react noncatalytically with soft electrophiles, such as activated double bonds (Fig. 10.32). Glutathione c onjugation to mercapturates is one of the most important defenses against hepatoc ellular injury. Glutathione protects cellular enzymes and membranes from toxic metabolites, and its inadequate stores can compromise efficient detoxification of the reactive metabolites. T he subsequent inability to detoxify the reactive metabolites can result in hepatocellular injury. T he rate-limiting factor for glutathione synthes is is the intrac ellular concentration of cysteine. N-acetylcysteine is often used as an alternative to glutathione to trap the iminoquinone intermediate in the treatment of acute

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acetaminophen toxicity. Glutathione plays a protective role in the hepatic tissue injury produced by a cetaminophen but not by furosemide. T he relationship between bioactivation, bioinactiv ation, and DNA adduct formation has been well established for a number of hepatocarcinogens. Glutathione conjugation of hard electrophiles becomes more efficient when catalyzed by GST s, an important example being the detoxication of the hepatocarcingen aflatoxin. Aflatoxin, a hepatocarc inogen and a hepatotoxin found in mold growing P.313 on peanuts, is converted into aflatoxin B1 epoxide in rodents, which is more readily detoxified by GST enzy mes than by epoxide hydrolase. T he balance between these transferase reactions exp lains the greater DNA damage in humans compared with rodents, becaus e human forms of GST are less able to catalyze the conjugation of aflatoxin epoxide compared with the rodent forms. T ransgenic knockout mice have been used to establish the role of bioactivation by CYP450 and bioinactivation by GST s for a number of carcinogenic polyaromatic hydrocarbons.

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Fig. 10.33. Some examples of drug bioactivation to their hepatotoxic intermediates.

Substances that detoxify free radicals include the antioxidants vitamin C, vitamin E, and carotene, which scavenge free radic als , including reactive metabolites and reactive oxygen species ge nerated as a consequence of chemical s tres s.

Specific Examples Some examples of bioactivation to hepatotoxic or IDR electrophilic intermediates are shown in Fig. 10.33. Bioactiv ation may occur by both oxidation and conjugation reactions, s uch as those with diclofenac, which undergoes the formation of an acyl glucuronide and/or acyl CoA (acylator intermediates) or to produce iminoquinones via formation of a phenol intermediator (Fig. 10.33-1) (92). T he anticonvulsant carbamazepine is 2-hydroxylated and the elimination of the amide group yields the reactive quinoneimine intermediate (Fig. 10.33-2), and the antidepressant paroxetine and other xenobiotics with the common methylenedioxyphenyl nucleus undergo methylene oxidation to a

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p-quinoid intermediate (Fig. 10.33-3). T he COMT inhibitor us ed in the treatment of Parkinsonism, tolcapone, the nitro group is first reduced to an amine, then oxidized to a o-quinoneimine (Fig. 10.33-4). T he mitochondrial/hepatotoxoc ity of the anticonvulsant valproic acid results from the formation of an activated α,β-unsaturated CoA thioester via mitochrondrial β-oxidation, most commonly associated with the oxidation of fatty acids (Fig. 10.33-5). T he agranulocytosis resulting from the ingestion of the antipsychotic clozapine is bioactivated by its oxidation by hypochlorous acid in neutrophils to a nitrenium intermediate (Fig. 10.33-6) (93). T he effect of s truc ture modification for troglitazone that reduced its hepatotoxicity is shown in Fig. 10.34. T he p-dihydroxy elements of the chroman ring nucleus (outlined in bold bonds in Fig. 10.34) of troglitazone is bioactivated to an activated double bond (p-quinone) and has been replaced with a pyridine ring that is not bioactivated, although the thiazolidone ring can be bioac tivated to an isocyanate (Fig. 10.30) (92). T he oxidation of acetaminophen to the chemically re active N-acetyl-p-benzoquinoneimine (Fig. 10.32), is catalyzed by the isoforms CYP1A2 and CYP2E1, which can either reac t covalently with glutathione to form an inactive product or with cellular macromolec ules, initiating the processes leading to hepatic necrosis (Fig. 10.28) (93). T he usual route for acetaminophen metabolism is either glucuronidation. If insufficient UDP-glucuronic acid is present, then bioactiv ation will dominate. P.314

Fig. 10.34. The effect of structure modification on the drug-induced hepatotoxicity of troglitazone.

Furosemide, a frequently used diuretic drug, is rep ortedly a human hepatocarcinogen. T he hepatic toxic ity apparently results from metabolic activation of the furan ring to a β-dicarbonyl intermediate (Fig. 10.30-5) (93). T iclopidine and tenoxic am, reported to cause agranulocytosis, do so via metabolic activ ation of the thiophene ring to an S-oxide (Fig. 10.30-6) (93). T he agranulocytosis resulting from the ingestion of clozapine is via its bioactivation to a nitrenium ion intermediate (Fig. 10.33-6) (96 ,97,98,99,100,101).

Drug-Induced Chemical Carcinogenesis T he mechanism whereby xenobiotics are transformed into chemic al carcinogens is generally accepted as bioactivation to reactive metabolites , which are responsible for initiating c arcinogenicity (98,99,100). Many carc inogens elicit their cytotoxicity through a covalent linkage to DNA. T his process can lead to mutations and, potentially, to cancer. Mos t chemical carcinogens of concern are chemically inert but require activation by the xenobiotic-metabolizing enzymes before they can undergo reaction with DNA or proteins (cy totoxicity). T here are many ways to bioactivate procarcinogens, promutagens, plant toxins, drugs, and other xenobiotic s (37) (Fig. 10.35). Oxidative bioactivation reactions are by far the most studied and common. Conjugation reactions (Phase 2), however, are also capable of activating these xenobiotics to produce electrophiles, in which the conjugating derivativ e acts as a leaving group. T hese reactive metabolites are mostly electrophiles, such as epoxides, quinones, or free radicals formed by the CYP450 enzy mes or FMO. T he reactive metabolites tend to be oxygenated in sterically hindered positions, making them poor substrates for subsequent bioinactivation transferases, such as epoxide hydrolase and GST . T herefore, their princip al fate is formation of covalent link age to intracellular macromolecules, including enzyme proteins and DNA. Experimental studies indicate that the CYP1A subfamily can oxygenate aromatic hydrocarbons (e.g., PAHs) in sterically hindered positions to arene oxides. Activation by N-hydroxylation of polycyclic aromatic amines (e.g., aryl N-acetamides) appears to depend on either FMO or CYP450 isoforms . T he formation of chemically reactive metabolites is important, because they frequently caus e a number of different toxicities, including tumorigenesis, mutagenesis, tissue necrosis, and hypersensitivity reactions. Our understanding of these reactions was advanced by the studies of the Millers (97) and Gillette et al. (98,99,100). T hey proposed that the proportion of the dose that binds covalently to critical macromolecules could depend on the quantity of the reactive metabolite is formed. A scheme illustrating the complexities of drug-induced chemical carcinogenesis is shown in Fig. 10.35. Reactions that proceed via the open arrows eventually lead to neoplasia. Some carcinogens may form the “ ultimate carcinogen” directly through CYP450 isoform bioactivation; others, like the PAHs (e.g., benzo[a]pyrene), appear to involve a multistep reaction sequence forming an epoxide, reduction to a diol by axpoxide hydrase and perhaps, the formation of a second epoxide group on another part of the molecule. P.315 Other procarcinogens form the N-hydroxy intermediate that requires transferase-catalyzed conjugation (e.g., O-gluc uronide and O-sulfate) to form the “ ultimate carcinogen.” T he quantity of “ ultimate carcinogen” formed should relate directly to the proportion of the dose that binds or alkylates DNA.

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Fig. 10.35. The bioactivation of procarcinogens and a proposed mechanism of chemical carcinogenesis.

T he solid-arrow reaction sequenc es in Figure 10.35 are intended to show detoxification mechanisms, which involve several s teps. First, the original chemical may form les s active products (phenols, diols, mercapturic acids, and other conjugates). Sec ond, the “ ultimate carcinogen” may rearrange so as to be prevented from its reaction with DNA (or whatever the critical macromolecule is). T hird, the covalently bound DNA may be repaired. Fourth, immunologic removal of the tumor cells may occur. Several mechanisms within this scheme could regulate the quantity of covalently bound c arcinogen: 1) T he activity of the rate-limiting enzyme, such as epoxide hydrolase, CYP450 isoform, or one of the transferases , could be involved; 2) the availability of cosubstrates, su ch as glutathione, UDP-glucuronic acid, or PAPS, may be rate-limiting; 3) relativ e CYP450 activities for detoxification and activation must be considered; 4) availability of alternate reaction sites for the ultimate carcinoge n (e.g., RNA and protein may be involved); 5) and possible specific transport mechanisms that deliver either the proc arcinogen or its ultimate carcinogen to s elected molecular or subcellular sites. It is now well established that numerous organic compounds that are essentially nontoxic as long as their structure is preserved can be converted into cytotoxic, teratogenic, mutagenic, or carcinogenic c ompounds by normal biotransformatio n pathway s in both animals and humans (37). T he reac tive electrophilic intermediate (hard acids) involves its reaction with cellular constituents (hard bases) forming either detoxified products or binding covalently with essential macromolecules, initiating processes that eventually lead to the toxic effect. A better understanding of the mechanisms underlying these reactions may lead to more rational approach es to the development of nontoxic therapeutic drugs. For the pres ent, it seems that new advanc es in drug therapy cannot occur without some risk of causing structural tissue lesions. Special attention to risk factors is required for drugs that will be used for long periods in the same patient. Some toxic chemicals exert their toxic action by lethal injury or biological auto-oxidation (radical lipid peroxidation). Lethal injury involves the disruption of cellular energy metabolism by inhibition of oxidative phosphorylation or adenosine triphos phatase, resulting in disruption of subcellular organelles, cell death, and tissue necrosis. Because the early stages of lethal injury are rev ersible, complete recovery may occur. Auto-oxidation is the process whereby cellular components are irrev ersibly oxidized and damaged by free radic als or free radical– generating s ystems. T his results in the oxidation and depletion of glutathione, various thiol enzymes, or lipid peroxidation, which in turn leads to the disruption of cellular membranes and to cell death, tissue necrosis, and death of the organism. When cell death does not occur, nonlethal changes, such as mutations and malignant transformations, are likely.

Drug–Drug Interactions Drug–drug interactions represent a common clinical problem, which has been compounded by the introduction of many new drugs and the expanded the use of herbal medicines. Between 1999 and 2005, approximately 100 drug–drug interactions were reported, of which approximately 50% involved CYP450 inhibition. Drug– drug interactions occur when the efficacy or toxicity of a medic ation is changed by coadministration of another s ubstance, drug, food (i.e., grapefruit), or herbal product (103,104). Pharmacokinetic interactions often occur as a result of a change in drug metabolis m. For example, CYP3A4 oxidizes more than 60% of the clinically used drugs with a broad spectrum of s tructural features, and its location in the small intestine and liv er permits an effect on both presystemic and sy stemic drug disposition. Some interactions with CYP3A4 substrates/inhibitors also may involve inhibition of P-gp. Other clinically important drug interactions resulting from coadministration of CYP3A4 subs trates or inhibitors inc lude rhabdomyolysis with the coadministration of some 3-hydroxy-3-methylglutaryl–CoA reductase inhibitors (“ statins” ), symptomatic hypotension with some dihydropyridine calcium antagonists, excessive sedation from benzodiazepine or nonbenzodiazepine hypnosedatives, ataxia with carbamazepine, and ergotism with ergot alkaloids. T he clinical importance of any drug–drug interaction depends on factors that are drug-, patient-, and administration-related. Drugs with low oral bioavailability or high firs t-pass metabolism are particularly susceptible to drug–drug interactions as a result of c oadministration of inhibitors that alter absorption, distribution, and elimination. Generally, a doubling or more in the plasma drug concentration has the potential for enhanced adverse or beneficial drug response. Less pronounced pharmacokinetic interactions may still be clinically important for drugs with a steep conc entration–response relationship or narrow therapeutic index. In most c ases, the extent of drug interaction varies markedly among individuals; this is likely to be dependent on interindividual differences in CYP450 content (polymorphism), preexisting medical conditions , and possibly, age. Interactions may occur under single-dos e conditions or only at steady s tate. T he pharmacodynamic consequences may or may not closely follow pharmacokinetic changes. Drug–drug interactions may be most apparent when patients are stabilized on the affected drug a nd the CYP450 substrates or inhibitors are then added to the regimen (103). One reason for the increased inc idence of drug–drug interactions is the practic e of simultaneously prescribing several potent drugs as well as

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concurrently ingesting nonprescription products and herbal products. P.316 Although drug–drug interactions constitute only a small proportion of adverse drug reactions, they have become an important is sue in health care. Many of the drug–drug interactions can be explained by alterations in the metabolic enzymes in the liver and other extrahepatic tissues, and many of the major pharmacokinetic interactions between drugs are c aused by hepatic CYP450 isoenzymes being affected by coadministration of other drugs. Some drugs act as potent enzyme induc ers, whereas others are inhibitors. Drug–drug interactions involving enzyme inhibition, however, are much more c ommon. Understanding these mechanisms of enzyme inhibition or induction is extremely important to give appropriate multidrug therapies. In the future, individuals at greatest ris k for drug–drug interactions and adv erse events need to be identified. Cytochrome P450s play a dominant role in the metabolism and elimination of drugs from the body, and their substrates are shown in T ables 10.3 and 10.6 through 10.9. Drugs in bold italics have been ass ociated with drug interactions (103). Inhibitors of CYP450 are shown in T able 10.10. Pharmacok inetic interactions may arise when the biotransformation and elimination of a drug are impaired by coadministered drugs. T hus, drugs may compete for biotransformation by a common CYP450. Adverse drug reactions, including toxicity, can occur if elimination is dependent on a CYP450 that exhibits defective gene variants. T hus, the genetic makeup of the individual (see the section on genetic polymorphis m) has a major influence on the duration of drug action as well as on drug efficacy and safety. CYP450 pharmacogenetics affects the tendency for certain drug–drug interactions to occur. T hus, the future safe use of drug combinations in patients may require genotyping and phenotyping of individuals before the commenc ement of therapy. Identification of subjec ts who metabolize drugs in a different fashion from the general population should minimize the impact of pharmacogenetic variation on drug pharmacokinetics . Many drug–drug interac tions are a result of inhibition or induction of CYP450 enzymes. Metabolism-based enzy me inhibition us ually involves competition between two drugs for the enzyme-active site. Metabolic drug–drug interactions occ ur when drug A (or its metabolite) alters the pharmacokinetics of a coadministered drug B by inhibiting, activating, or inducing the activity of the enzy mes that metabolize drug B. Inhibitory drug–drug interactions could result in serious adverse effects, including fatalities in patients receiving multiple medications. T his process is usually competitive, begins with the first dose of the inhibitor, and the extent of inhibition correlates with their relative affinities for the enzymes and the metabolic half-lives of the drugs involved. On the other hand, mechanis m-based (irreversible) inhibition results from a metabolite that binds irreversibly with a covalent bond to the enzyme, rendering the enzyme inactive. Enzymespecific CYP450 inhibitors, including metabolism- and mechanism-based inhibitors, or are metabolized by specific CYP450 isoforms and are usually excluded from further consideration for new drug development. Not only is CYP3A4 the most abundant isoform in human liver, it also metabolizes more than 60% of the drugs in clinical use, which renders CYP3A4 highly susceptible to both metabolism- (rev ersible) and mechanism-based inhibition. T he CYP3A subfamily is involved in many clinically s ignificant drug–drug interactions , including those involving nons edating antihis tamines and cisapride, that may result in cardiac dysrhythmias . For example, inhibitors of CYP1A2 can increase the risk of toxicity from clozapine or theophylline. Inhibitors of CYP2C9 can increase the risk of toxicity from pheny toin, tolbutamide, and oral anticoagulants (e.g., warfarin). Inhibitors of CYP3A4 can increase the risk of toxicity from many drugs , including carbamazepine, cisapride, cyclosporine, ergot alkaloids, lovastatin, pimozide, protease inhibitors, rifabutin, simvastatin, tacrolimus, and vinca alkaloids. Inhibitors of CYP2D6 can increase risk of toxicity of many antidepres sants, opiate analgesics, and psychotherapeutic agents. An excellent example of a metabolism-based inhibition drug–drug interaction that resulted in a life-threatening ventric ular arrhythmia associated with QT prolongation (torsades de pointes) occurred when CYP3A4 substrates or inhibitors were coadministered with terfenadine, astemizole, cisapride, or pimozide. T his potentially lethal drug interaction led to the withdrawal of terfenadine and cisapride from clinical use and to the introduction of fexofenadine, the metabolite of terfenadine, which does not have this interaction. Examples of enzyme inducers include barbiturates, carbamazepine, glutethimide, griseofulv in, phenytoin, primidone, rifabutin, and rifampin. Some drugs, such as ritonavir, may act as either an enzyme inhibitor or an enzyme inducer, depending on the situation. Drugs metabolized by CYP3A4 or CYP2C9 are particularly susceptible to enzyme induction. Mechanism-based inhibition is characterized by NADP H-, time-, and c oncentration-dependent enzyme inactivation, occurring when some drugs are converted by CYP450s to reactive metabolites (103). Mechanism-based inactivation of CYP3A4 by drugs can be the result of chemical modification of the heme, the apoprotein, or both, as a result of covalent binding of the modified heme to the protein. T he clinical pharmacokinetic effect of a CYP3A4 inactivator is a function of its enzyme kinetics (i.e., K m and V m ax ) and the synthesis rate of new or replacement enzyme. Predicting drug–drug interactions involving CYP3A4 inactivation is possible when pharmacokinetic principles are followed. Such prediction may become difficult, howev er, bec ause the clinical outcomes of CYP3A4 inactivation depend on many factors associated with the enzyme, the drugs, and the patients. Some of the clinically important drugs that have be en identified to be mechanism-based CYP3A4 inhibitors include antibiotics (e.g., erythromycin), anticancer drugs (e.g., irinotecan), antidepressants (e.g., fluoxetine and paroxetine), anti-HIV agents (e.g., ritonavir and P.317 delavirdine), antihypertensives (e.g., dihydralazine and verapamil), steroids and their receptor modulators (e.g., ethinyl estradiol, gestodene, and raloxifene), dihydrotestosterone reduc tase inhibitors (e.g., finasteride), and some herbal constituents (e.g., bergamottin and glabridin). Compared to the more common metabolism-based (reversible) inhibition, mechanism-based inhibitors of CYP3A4 usually are the cause for unfav orable drug–drug interactions, because the inactivated CYP3A4 mus t be replaced by newly synthes ized CYP3A4 protein. Most CYP3A4 inactivators also are P-gp s ubstrates/inhibitors, confounding the in vitro–to–in vivo extrapolation. Clinicians should have good knowledge about these CYP3A4 inactivators and avoid their combination use. T he clinical significance of CYP3A inhibition for drug safety and efficacy warrants closer understanding of the mechanis ms for each inhibitor. Furthermore, such inactivation may be exploited for therapeutic gain in certain circumstances . By understanding the unique functions and characteristic s of these enzymes, health care prac titioners may better anticipate and manage drug interactions. T hey also may predict or explain an individual's response to a particular therapeutic regimen.

Beneficial Drug– Drug Interactions A benef ic ial drug interac tion, f or example, is the c o adminis tration of a CYP3A4 inhib itor with c yc los p orine, whic h allows re duc tion of the dos age and c o s t o f the immunos upp re s s ant. Certain HI V p roteas e inhibitors , s uc h as s aquinavir, have a lo w oral b io availability bec aus e of intes tinal C YP 3A4 metabo lis m. T he oral bioavailability of s aquinavir c an be prof oundly inc re as ed by the additio n of a low dos e o f a C YP3 A4 inhibito r, s uc h as ritonavir. This c o nc ept of altering drug pharmac o kinetic s by adding a low, s ubtherape utic d os e of a CYP3A 4 inhib itor (rito navir) to inc reas e the oral bioavailability of ano the r p ro teas e inhibitor,

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lop inavir (C YP3A 4 s ubs trate), led to the marketing of K aletra, a new drug c o mbination o f lopinavir and ritinavir.

Grapefruit Juice–Drug Interactions Historical Significance of Grapefruit Juice T he dis c overy that g rapef ruit juic e c an marked ly inc reas e the oral bioavailability of CYP3A 4 drugs was bas ed on an unexpec ted o bs ervation f rom an inte rac tio n s tudy betwe en the d ihydrop yrid ine c alc ium c hannel antagonis t f elodipine and ethanol in whic h g rapef ruit juic e was us ed to mas k the tas te of the ethano l. Subs equent inves tigatio ns c onf irme d that g rapef ruit juic e s ignif ic antly inc re as ed the oral bioavailab ility o f f elod ip ine by reduc ing p re s ys temic f e lod ip ine metab olis m through s ele c tive inhib ition of C YP 3A4 expres s ion in the intes tinal wall (10 6).

Grapefruit juice is a beverage often cons umed at break fast for its health benefits and to mask the taste of drugs or foods. Unlike other citrus fruit juices, however, grapefruit juic e c an significantly increase the oral bioavailability of drugs that are metabolized primarily by intestinal CYP3A4, causing an elevation in their se rum concentrations (T able 10.20). T hose drugs with high oral bioavailabilities (> 60%), however, are all likely safe to take with grapefruit juice, because their high oral bioavailability leaves little room for elevation by grapefruit juice. T he importance of the interaction appears to be influenc ed by indiv idual patient susc eptibility, type and amount of grapefruit juice, and administration-related factors. Grapefruit juice can alter oral drug pharmac okinetic s by different mechanisms. Irreversible inactivation of intestinal CYP3A4, which can persist up to 24 hours, is produced by grapefruit juice given as a single, normal, 200- to 300-mL drink or by whole fres h fruit segments (T able 10.20). As a result, presystemic metabolism is reduced, and oral drug bioavailability increased. Enhanced oral drug bioavailability can occur up to 24 h after juice consumption. Inhib ition of P-gp is a possible mechanism that increases oral drug bioavailability by reducing intestinal and/or hepatic efflux transport. Inhibition of organic anion–transporting polypeptides by grapefruit juice and apple juice has been observed; intestinal uptake transport appe ared to be decreased as oral drug bioavailability was reduc ed. Numerous medications used in the prevention or treatment of coronary artery disease and its complications have been observed or predicted to interact with grapefruit juice. Such interactions may increase the risk of rhabdomyolysis when dy slipidemia is treated with the HMG-CoA reductase inhibitors (“ statins” ). Such interactions also might caus e excessive vasodilatation when hypertension is managed with the dihydropyridines felodipine, nicardipine, nifedipine, nisoldipine, or nitrendipine. An alternative agent could be amlodipine. T he therapeutic effect of the angiotensin II type I receptor antagonist los artan may be reduced by grapefruit juice. Grapefruit juice interacting with the antidiabetic agent repaglinide may cause hypoglycemia, and interaction with the appetite suppressant sibutramine ma y c ause elevated blood pressure and heart rate. In angina pectoris, administration of grapefruit juice could result in atrioventricular conduction disorders with verapamil or attenuated antiplatelet activity with clopidrogel. Grapefruit juic e may enhance the drug toxicity for antiarrhythmic agents , suc h as amiodarone, quinidine, disopyramide, or propafenone, and for the conges tive heart failure drug carvediol. Some drugs for the treatment of peripheral or central vascular disease also have th e potential to interact with grapefruit juice. Interaction with sildenafil, tadalafil, or vardenafil for erectile dys function may cause serious s ystemic vasodilatation, especially when combined with a nitrate. In stroke, interaction with nimodipine may cause systemic hypotension. P.318

Table 10.20. Some CYP3A4 Substrates and Interactions with Grapefruit Juice (78) Drug

Interactiona

Calcium channel blocker

Drug

Interactiona

HMG-CoA reductase inhibitors

Amlodipine

Y

Atorvastatin

Y

Felodipine

Y

Cerivastatin

Y?

Nifedipine

Y

Fluvastatin

N?

Nimodipine

Y

Lovastatin

Y

Nisoldipine

Y

Pravastatin

N?

Nitrendipine

Y

Simvasta

Y

Pranidipine

Y

CNS Drugs

Antiarrhythmics Diltiazem

N

Buspirone

Y

Carbamazepine

Y

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Verapamil

N

Diazepam

Y

Quinidine

N

Midazolam

Y

Triazolam

Y

Antihistamines Ebastine

Y?

Loratidine

Y?

HIV protease inhibitors

Immunosuppressants Cyclosporine

Y

Tacrolimus

Y?

Indinavir

N?

Other

Nelfinavir

N?

Methadone

Y

Ritonavir

N?

Sildenafil

Y

Saquinavir

Y

Macrolides Clarithromycin

N

a Y (yes) and N (no) indicate published evidence of the presence or absence of an interaction with grapefruit juice. Y? and N? indicate expected findings based on available data. Those drugs with Y or Y? should not be consumed with grapefruit juice in an unsupervised manner.

If a drug has low inherent oral bioavailability from presystemic metabolism by CYP3A4 or efflux transport by P-gp and the potential to produce serious overdose toxicity, avoidance of grapefruit juice entirely during pharmacotherapy appears mandatory. Although altered drug response is variable among individuals, the outcome is difficult to predict, and avoiding the combination will guarantee that toxicity is prevented. T he elderly are at particular risk, because they often are presc ribed medications and frequently consume grapefruit juice. T he mechanism by which grapefruit juice produces its effect is through inhibition of the enzymatic activity and a decrease in the intestinal expression of CYP3A4. T he P-gp efflux pump also trans ports many CYP3A4 s ubstrates; thus, the pres ence of inhibitors of P-gp in grapefruit juice (e.g., 6′,7′-dihydroxybergamottin and other furanocoumarins) could be a related fac to r for drug–grapefruit juice interactions (82). Numerous studies have s hown that grapefruit juice acts on intestinal CYP3A4, not at the hepatic level. Does the quantity of juice matter? T he majority of the presy stemic CYP3A4 inhibition is obtained following inges tion of one glass of grapefruit juice; however, 24 hours after ingestion of a glass of grapefruit juice, 30% of its effect is still present (78). T he reduction in intestinal CYP3A4 concentration is rapid: a 47% decrease occurred in a healthy volunteer within 4 hours after consuming grapefruit juice. Daily ingestion of grapefruit juice results in a los s of CYP3A4 from the small intes tinal epithelium. Consumption of very large quantities of grapefruit juice (six to eight glasses/day) may lea d to inhibition of hepatic CYP3A4.

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T he active constituents found in grapefruit juice responsible for its effects on CYP3A4 include flavon oids (e.g., naringenin and naringin) and furanocoumarins (e.g., bergamottin and 6′,7′-dihydroxybergamottin) (82). Of particular interest are the effects of naringin and 6′,7′-dihydroxybergamottin on the activity of intestinal CYP3A4. T he majority of studies to date have used either freshly squeezed grapefruit juice, reconstituted frozen juice, commercial grapefruit juice, grapefruit s egments , or grapefruit extract; all are capable of causing drug–drug interactions with CYP3A4 substrates (blended grapefruit juices have not yet been investigated). T he active constituents in grapefruit juice are pres ent not just in the juice but also in the pulp, peel, and core of the fruit and are responsible for its flavor. Bergamottin and 6′,7′-dihydroxybergamottin are potent mechanism-bas ed inhibitors of CYP3A4, and naringenin isomers are competitive inhibitors of CYP3A4 (82). Higher concentrations of 6′,7′-dihy droxybergamottin P.319 and naringin are present in grapefruit segments. T hus, any therapeutic concern for a drug interaction with grapefruit juice should now be extended to include whole fruit and other products derived from the grapefruit peel. T he difference in the in vitro CYP3A4 inhibition between grapefruit juice and orange juice is that orange juice contained no measurable amounts of 6′,7′-dihydroxybergamottin. If a patient has been taking medication with grapefruit juice for some time without ill effects, is it safe to continue to do so? Much of this unpredictability results from the inconsistency of the juice concentrations and the sporadic manner in which grapefruit juice is consumed, suggesting that this approach may not be entirely safe (106). Given the unpredic tability of the effect of grapefruit juice on the oral bioavailability of the drugs in T able 10.20, patien ts should be advised to avoid this combination, thus preventing the onset of potential adverse effects. Each patient's situation should be considered, and advice should be based on consumption history and the specific medications involved. T he benefits of increased and controlled drug bioavailability by grapefruit juice may, in the future, be achieved through either standardizing the constituents or coadministration of the isolated active ingredients. T his would then lead to a safe, effective, and cost-saving means to enhanc e the absorption of many therapeutic agents.

P-glycoprotein–Drug Interactions From the earlier discuss ion regarding P-gp, it is obvious that P-gp–mediated transport plays an important role in pharmacokineticmediated drug–drug interactions (79). T hus , inhibition of P-gp–mediated transport could dramatically increase the systemic bioavailability of an otherwise poorly absorbed drug. Similar conse quences could be expected with a reduction in renal or biliary clearances (e.g., digoxin). Numerous investigations with drugs such as digoxin, etoposide, cy closporine, v inblastine, taxol, loperamide, domperidone, and ondansteron demonstrate that P-gp has an important role in determining the pharmacokinetics of substrate drugs (79). For example, if drug A is a substrate for both P-gp and onl y for CYP3A4, and if a second drug B is added that is an inhibitor for both P-gp and CYP3A4 (T able 10.16), then the plasma drug concentration for unmetabolized drug A will be elev ated, with increased potential for drug–drug interactions as adverse effects or for causing a drug overdose. If drug A is a subs trate for multiple CYP450 isoforms, however, then drug A will be metabolized by these other isoforms, with minimal effect on plasma drug c oncentrations. On the other hand, if the second drug B is only an inhibitor for P-gp, then drug A will be subject to CYP3A4 metabolism, thus decreasing the plasma concentration for drug A to subtherapeutic levels. T he effect of P-gp inhibition is to increase the oral bioavailability so that the later actions of CYP3A4 inhibition will be increased. One of the best examples is the interaction between digoxin and quinidine. Quinidine blocks P-gp in the intestinal muscosa and in the proximal renal tubule; thus, digoxin elimination into the intestine and urine is inhibited, increasing the plasma digoxin concentration to toxic levels. Another example is loperamide, which is an opiate antidiarrheal normally k ept out of the brain by the P-gp pump; however, inhibition of P-gp allows accumulation of loperamide in the brain, leading to respiratory depress ion. Increas ingly, the relevant clinical data for drug interactions can be found on the World Wide Web. T he components of grapefruit juice reportedly inhibit P-gp, and this may be one of the mechanisms for the increase in bioavailability of drugs that are substrates for P-gp (T able 10.16). Although fexofenadine is a P-gp substrate, rather than a dec rease in its plasma levels when it is coadminis tered with grapefruit juice, th e blood levels are increased as a result of fexofen adine being a subs trate of the anion transporter (OAT P) in the intes tine. Studies have shown that apple and other fruit juices are more potent inhibitors of OAT P than of P-gp.

Food–Drug Interactions Drug pharmacokinetics can be altered by the fat con tent of food through changes in drug solubility as well as the nutritional status of a patient (107). T he fact that grapefruit juice can increas e the bioavailability of certain drugs by the ir reduc ing presystemic intestinal metabolism has led to renewed interes t in the area of “ food–drug interactions,” with partic ular interest regarding the effects of grapefruit constituents. Specific naturally occurring chemicals in food have been associated with drug interactions. For example, severe hypertensive reactions have occurred when patients treated with antidepressant MAO inhibitors have ingested chees es and other foods rich in the biogenic amine tyramine (see Chapter 21).

Drug–Dietary Supplement Interactions

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T he increasing use of dietary s upplements presents a special challenge in health care; thus, there is an increasing need to predict and avoid these potential adv erse drug–dietary supplement interactions. T he present interest and widespread use of herbal remedies has created the possibility of interaction between them and over-the-counter or prescription drugs if they are used simultaneous ly. As herbal medicines become more popular, herbal hepatotoxicity is being increasingly recognized. Females appear to be predis posed to hepatotoxicity, and coadministered agents that induce CYP450 enzymes (e.g., St. Johns wort) also may increase indiv idual susceptibility to some dietary supplements. Currently, nearly one in five adults tak ing prescription medicines also are taking at least one dietary supplement. T he mechanisms for drug–dietary supplement interactions are similar to those for drug–drug interactions affecting the pharmacokinetics of the respective drug. Little is known regarding the pharmacokinetic properties of many of the substances in dietary supplements. T herefore, the P.320 potential for drug–dietary supplement interactions has greatly increased. Licoric e, when taken with steroids, can reduce their metabolism and elimination.

St. John's Wort A commonly reported drug–dietary supplement interaction is between St. J ohn's Wort and HIV protease inhibitors, leading to drug resistance and treatment failure. St. John's wort is a popular dietary supplement often us ed for depression. Of the two substanc es found in St. John's wort, hypericin and hyperforin, hyperforin appears to be the main constituent, with in vitro s elective serotonin reuptake inhibitor (SSRI) activity (see Chapter 21). Hyperforin also appears to be the more potent induc er of CYP3A enzymes based on in vitro and in vivo studies. T he U.S. FDA has issued a statement that “ concomitant use of St. John's wort with proteas e inhibitors or nonnucleoside reverse transcriptase inhibitors is not recommended.” St. John's wort appeared to hav e minimal effects on the CYP3A4 enzymes after acute administration; however, chronic administration (≥2 weeks ) of St. John's wort selectively induced CYP3A4, with a greater effect in the small intestine than in the liver. Administration of St. John's wort for 8 weeks decreased the plasma levels of norethindrone, a low-dose oral contraceptive, and reduced the half-life of ethinyl estradiol, consistent with increased CYP3A ac tivity, increase breakthrough bleeding, and reduce contraceptive efficacy. Based on the these in vivo and in vitro studies, the efficacy of drugs that are subs trates for the CYP3A family or P-gp may be reduced on coadministration of St. John's wort. St. John's wort should be listed along with other known CYP3A inducers (e.g., rifampin and rifabutin) as possibly decreasing plasma levels of CYP3A s ubstrates. T he drug products Kaletra (lopinavir and ritonavir), Mifeprex (mifepristone, RU-486), Nuvaring (etonogestrel/ethinyl estradiol), Gleevec (imatinib), Neoral (cyclosporine), Rapamune (s irolimus), and Prograf (tacrolimus) include information about drug interactions with St. John's wort in their labeling. T hus, patients ingesting St. John's wort products should be advised that St. J ohn's wort can have potentially dangerous interactions with some prescription drugs and to consult a physician before taking St. John's wort if currently taking anticoagulants, oral contraceptives, antidepressants, antiseizure medications, drugs to treat HIV or prevent transplant rejections, or any other prescription drug. St. John's Wort also decreases the absorption of digoxin and fexofenadine, apparently by inducing P-gp in the intestinal and renal endothelium, increasing their elimination in the in testine and urine, respectiv ely , and their plasma concentrations.

Echinacea In vitro or in vivo chronic administration studies of Echinacea, an herbal product used for the treatment of colds and viral infections, inhibited hepatic CYP1A2 and intestinal CYP3A activities and induced hepatic CYP3A. Based on these preliminary findings, the effect of Echinacea on various CYP3A substrates may vary depending on the relativ e contribution to a given drug's overall clearance by intestinal CYP3A versus hepatic CYP3A in the individual substrate's clearance pathway.

Ginkgo Biloba In vitro studies with Ginkgo biloba, often used for memory improvement, exhibited induction of CYP2C19. T he extent of induction appears to be CYP2C19 genotype dependent.

Kav a Reports of hepatotoxicity have been associated with the us e of kava, a popular drug in Europe and North America. Hepatotoxic ity was not observed when kava was prepared as a water infusion but was with solvent-extracted products available in stores and on the World Wide Web. T he three kava lactones (methysticin, desmethoxyyangonin, and yangonin; active principles ) are po tent inhibitors of CYP1A2, CYP2C9, CYCYP2C19, CYP2E1, and CYP3A4, with methysticin being the most potent enzyme inhibitor as well as the most cytotoxic. T he potent inhibition of CYP450 enzymes suggests a high potential for interactions with drugs and other herbs that are metabolized by the same CYP450 enzymes. Long-term use or use in individuals with liver disorders should be avoided, and liver function transaminases need to be chec ked frequently.

Other Dietary Supplements Exhibiting Drug-Induced Heptatotoxicity DHEA and androstenedione are testosterone precursors that have been associated with hepatic toxicity a nd should be avoided in those with hepatic disease or coingestion with other potentially hepatotoxic products or enzyme inducers tha t might increas e the risk of liver damage. Liver enzymes should be monitored once or twice a year. Boldo can cause hepatotoxicity and exacerbate existing liver disease. Because chaparral, comfrey, germander, skullcap, valerian root can cause ac ute and chronic liver injury, these produc ts should be considered unsafe. Pennyroyal oil can cause acute hepatotoxicity liver injury, which has been attributed to the bioactivation of the terpine, R (+ ) pulegone resulting in depletion of hepatic glutathione. In some cases, unknown adulterants found in these herbal produc ts may be responsible for the hepatotoxicity. Black cohos h, commonly used by women for menopausal symptoms, including hot flashes and sleep disorders, formed quinone metabolites in vitro, but no mercapturate conjugates were detected in urine samples from women who consumed multiple oral doses of up to 256 mg of a standardized black cohosh extract. At moderate doses of black cohosh, the risk of liver injury is minimal. Si l ybum mari anum (milk thistle) is used in the treatment of c hronic or acute liver disease as well as in protecting the liver against toxicity

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(109). Silybum is cited as one of the oldest known herbal medicines. T he active P.321 constituents of milk this tle are flavonolignans , whic h are known collectively as silymarin. T he mos t remarkable use of silymarin is in the treatment of Amani ta mus hroom poisoning. Amani ta mushrooms possess two extremely powerful hepatotoxins, amanitin and phalloidin (the median lethal dose of amanitin is 0.1 mg/kg body we ight). Sev ere liver damage (and death) is avoided if silymarin is administered within 24 hours following inges tion of Amani ta. It also is a hepatoprotective on chronic exposure to ethanol and acetaminophen toxicity.

M iscellaneous Drug Interactions T he ability of drugs and other foreign substances to stimulate (induction) metabolism of other drugs has already been discussed. Phenobarbital, for example, stimulates metabolism of a variety of drugs (e.g., phenytoin and coumarin antic oagulants). Stimulation of bishydroxycoumarin metabolism can create a problem in patients undergoing anticoagulant therapy. If phenobarbital administration is stopped, the rate of metabolism of the anticoagulant decreases, resulting in greater plasma concentrations of bishydroxycoumarin and enhanced anticoagulant activity, increasing the possibility of hemorrhage. Serious side effects have resulted from this type of interaction. T hese observations indicate that combined therapy of a potent drug (e.g., bishydroxycoumarin) and a in ducer of drug metabolism (e.g., phenobarbital) can create a hazardous s ituation if the enzyme induc er is withdrawn and therapy with the potent drug is continued without an appropriate decrease in dose. Some drugs are competitive inhibitors of nonmicros omal metabolic pathways. Serious reactions hav e been reported in patients treated with an MAO inhibitor, such as trancypromine or iproniazid, because they usually are sensitive to a subsequent dos e of a sympathomimetic amine (e.g., amphetamine) or a tric yclic antidepressant (e.g., amitriptyline), whic h is metabolized by MAO. Allopurinol, a xanthine oxidase inhibitor used for the treatment of gout, inhibits metabolism of 6-mercaptopurine and other drugs metabolized by this enzyme. A serious drug interaction results from the concurrent use of allopurinol for gout and 6-mercaptopurine to block the immune response from a tissue transplant or as antimetabolite in neoplastic diseases. In some cases, however, allopurinol is used in conjunction with 6-mercaptopurine to control the increase in uric acid elimination from 6-mercaptopurine metabolism. T he patient should be supervised closely, becaus e when given in large doses , allopurinol, an inhibitor of purine metabolism, may have serious effects on bone marrow.

Gender Differences in Drug Metabolism T he role of gender as a contributor to variability in xenobiotic metabolism and IDRs , whic h are more common in women than in men, is not clear, but increasing numbers of reports s how differences in metabolism between men and women, raising the intriguing possibility that endogenous sex hormones, hydrocortisone, or their synthetic equivalents may influence the activ ity of inducible CYP3A. For example, N-demethylation of erythromycin was significantly higher in females than males. Nevertheless, the N-demethylation was persistent throughout adulthood. In contrast, males exhibited unchanged N-demethylation values. Gender-dependent differences of metabolic rates have been detected for some drugs. Side-chain oxidation of propranolol was 50% faster in males than in females , but no differences between genders were noted in aromatic ring hydroxy lation. N-demethylation of meperidine was depressed during pregnancy and for women taking oral contraceptives . Other examples of drugs cleared by oxidative drug metabolism more rapidly in men than in women included chlordiazepoxide and lidocaine. Diazepam, prednisolone, caffeine, and acetaminophen are metabolized slightly faster by women than by men. No gender differences have been observed in the clea rance of phenytoin, nitrazepam, and trazodone, which interestingly are not s ubstrates for the CYP3A s ubfamily. Gender differences in the rate of glucuronidation have been noted. More investigation is warranted, and future pharmac okinetic studies examining the alteration in drug metabolism in one gender need to be reexamined with respect to the other gender. Even in postmenopausal women, CYP3A function may be altered and influenced by the lack of estrogen or the presence of androgens.

Major Pathways of Metabolism T able 10.10 contains an extensive list of commonly us ed drugs and the CYP450 isoforms that catalyze their metabolism. In addition, Phase 1 and Phase 2 metabolic pathways for some c ommon drugs are lis ted in T able 10.21. P.322 P.323 P.324

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Table 10.21. Metabolic Pathways of Common Drugs

Cast Study V ictor ia F. Ro che S . Willia m Zito W H-L is a 62 -year-old, Beijing-born s c ientis t attending an international s c ientif ic mee ting in your ho me to wn. W hile de livering his g roundb re aking pap er o n the neurop ro te c tive ac tio n of s ome unique bic yc lic mo le c ules he has s ynthes ize d, W H-L exp erienc ed a very rapid and irre gular heart rate, f o llowed by a tight, g ripp ing pain in his c hes t. R ec og nizing that he was having a myoc ardial inf arc tion (MI ), W H-L immediately took an as pirin tablet while his c olleagues c alled an ambulanc e to take him to a nearby hos pital. F ortunately, his q uic k ac tio n has averted a f atality, although the me dic al s taf f c annot get his heartbeat to s tabilize. His s ituation is c ons id ered dire, and the de c is io n is m ade to put him o n an antiarrhythmic age nt until he is well enoug h to re turn home to c o ns ult with his p ers onal phys ic ian. I t als o is d ec ided that β-ad re nergic bloc king therap y is in orde r. W H-L has e videnc e o f c oronary artery dis eas e and elevated blood pres s ure . He is taking ros uvas tatin c alc ium (C res tor' 20 mg q .d.) to kee p his s erum c holes terol levels in c hec k and f lurbiprof e n potas s ium (A ns aid, 50 mg q.i.d .) f or mild–mod erate arthritis pain. A s the pharmac is t-in-c harge on the d rug therapy de c is io n te am, you c o ns ult with W H-L and learn that he rec ently had an o ral abs c es s that res ulted in a tooth extrac tion and us e d c o deine s ulf ate to treat his s ig nif ic ant, but s ho rt-term, po s ts urgic al pain. A f e w years ago , he experienc e d a deep vein thro mbo s is that was tre ated f or 12 we eks with s tandard d os es of warf arin s o dium (C oumadin). A dec is ion is made to initiate warf arin therapy again pos t-MI . W H-L doe s not c ons ume alc ohol b ut loves grapef ruit juic e, whic h he always has f o r b re akf as t and of ten onc e or twic e again during the c o urs e of the day. He has as ked f or it ro utine ly while in the ho s pital. G ive n this medic al his tory, and kee ping the drug metabolis m p athways f irmly in mind, s elec t one antiarrhythmic agent and one β-bloc ker that would b es t s uit the need s o f this patient. As s ume that all d rug c hoic es would be the rapeutic ally ef f ec tive f o r the d is eas e they are intend ed to tre at. 1. I dentif y the therapeutic problem(s ) f or whic h the p harmac is t' s inte rvention may b enef it the patie nt. 2. I dentif y and prioritize the p atient-s p ec if ic f ac to rs that mus t be c ons id ered to ac hieve the des ired therap eutic o utc omes . 3. Conduc t a thorough metabo lic analys is of all therap eutic alternatives provide d in the c as e. 4. Evaluate the metabolic f indings agains t the p atient-s p ec if ic f ac to rs and des ired the rapeutic outc omes and make a therapeutic de c is io n. 5. Couns el your patient.

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54. Lang D, Kalgutkar AS. Non-P450 mediated oxidative metabolism of xenobiotics. In: Lee JS, Obach RS, Fisher MB, Drug Metabolizing Enzymes: Cytochrome P450 and Other Enzymes in Drug Discovery and Development. New York: F ontisMedia-Marcel Dekker, 2003, pp483–539.

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58. Burchell B, Mcgurk K, Brierly CH, et al. UDP-glucuronosyltrans ferases. In: Guengerich FP, ed. Comprehensive T oxicology, vol 3. New York: Pergamon–Elsevier Science, 1997, pp449–473.

59. Spahn-Langguth H, Benet LZ. Acy lglucuronides revisited: is the glucuronidation proces s a toxification as well as a detoxication mechanism. Drug Metab Rev 1992;24:5–48.

60. Mulder GJ. Pharmacological effects of drug conjugates: is morphine 6-glucuronide an exception. T rends Pharmacol Sci 1992;13:302–304.

61. Falani CN. Enzymology of human cytos olic sulfotransferases. FASEB J. 1997;11:206–216.

62. Raftigianis RB, Wood T C, Weinshilboum RM. Human phenolsulfotransferases SULT 1A2 and SULT 1A1. Bioch em Pharmacol 1999;58:605–616.

63. Caldwell J, Hutt AJ, Fournel-Gigleux S. T he metabolic chiral inversion and dispositional enantioselectivity of the 2-arylpropionic acids and their biological activity. Biochem Pharmacol 1988;37:105–115.

64. T racy T S, Wirthwein DP, Hall SD. Metabolic inversion of R-ibuprofen. Drug Metab Dispos 1993;21:114–119.

65. Nelson SD. Arylamines and arylamide: oxidation mechanisms. In: Anders M, ed. Bioactivation of foreign compounds. New York: Academic Press, 1985:349–375.

66. Ahmed AE. Nitriles. In: Anders M, ed. Bioactiv ation of foreign compounds. New York: Academic Press, 1985:485–489.

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67. Dobrinska MR. Enterohepatic circulation of drugs . J Clin Pharmacol 1989;29:577–580.

68. Ilett KF, T ee LBG, Reeves PT , et al. Metabolism of drugs and other xenobiotics in the gut lumen and wall. Pharmacol T her 1990;46:67–93.

69. Sc hmucker DL. Aging and drug disposition: an update. Pharmacol Rev 1985;37:133–145.

70. Durnas C, Loi CM, Cusack BJ. Hepatic drug metabolism and aging. Clin Pharmacokinet 1990;19:359–389.

71. Woodhouse K, Wynne HA. Age-related changes in hepatic function: implic ations for drug therapy. Drugs Aging 1992;2:243–246.

72. Smit JW, Huisman MT , van T ellingen O, et al. Absenc e or pharmacological blocking of placental P-glycoprotein profoundly increases fetal drug exposure. J Clin Inves t 1999;104:1441–1447.

73. Ingelmann-Sundberg M, Os carson M, McLellan RA. Polymorphic human cy tochrome P450 enzymes: an opportunity for individualized drug treatment. T rends Pharmacol Sci 1999;20:342–349.

74. Daly AK, Cholerton S, Gregory W, et al. Metabolic polymorphisms. Pharmacol T her 1993;57:129–160.

75. Gaedigk A. Interethic differences of drug-metabolizing enzymes. Int J Clin Pharmacol T her 2000;38:61–68.

76. Myer UA, Skoda RC, Zanger UM. T he genetic polymorphism of debrisoquine/sparteine metabolism—molecular mechanisms et al. Pharmacol T her 1990;46:297–308.

77. Kaminsky LS, Fas co MJ. Small intestinal c ytochromes P450. Crit Rev T oxicol 1991;21:407–422.

78. Kane GC, Lipsky JJ. Drug–grapefruit juice interactions. Mayo Clin Proc 2000;75:933–942.

79. Yu Dk. T he contribution of P-glycoprotein to the pharmacokinetic s of drug–drug interactions. J Clin Pharmacol 1999;39:1203–1211.

80. Silverman JA. Multidrug resistance transporters. Pharm Biotechnol 1999;12: 353–386.

81. Oesch F. Metabolic transformation of clinically used drugs to epoxides: new perspectives in drug–drug interactions. Biochem Pharmacol 1976;25:1935–1937.

82. Ohnishi A, Matsuo H, Yamada S, et al. Effec t of furanocoumarin derivatives in grapefruit juice on the uptake of vinblastine by Caco-2 cells and on the activity of cytochrome P450 3A4. Br J Pharmacol 2000;130:1369–1377. P.326 83. Watkins PB. Role of cytochrome P450 in drug metabolism and hepatotoxicity. Semin Liv er Dis 1990;10:235–250.

84. Roth RA, Vinegar A. Action by the lungs on circulating xenobiotic agents, with a case study of physiologically based pharmacokinetic modeling of benzo[a]pyrene disposition. Pharmacol T her 1990;48:143–155.

85. Reed CJ. Drug metabolism in the nasal cavity. Drug Metab Rev 1993;25:173–205.

86. Sarkar MA. Drug metabolism in the nasal mucosa. Pharmac ol Res 1992;9: 1–8.

87. T esta B, Jenner P, eds. Drug metabolism: chemical and biological aspects . New York: Marc el Dekker, 1976.

88. Lee WM. Drug-induced hepatotoxic ity. N Engl J Med 2003;349:474–485.

89. Navarro VJ, Senior JR. Drug-related hepatotoxicity. N Engl J Med. 2006:354:731–739.

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90. Watkins, PB, Kaplowitz, N, Slattery J T , et al. Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily. JAMA 2006;296:87–93.

91. Park BK, Kitteringham NR, Maggs JL, et al. T he role of metabolic activation in drug-induc ed hepatotoxicity. Annu Rev Pharmacol T oxicol 2005;45: 177–202.

92. Williams DP, Kitteringham NR, Naisbitt DJ, et al. Are chemically reactiv e metabolites responsible for adverse reactions to drugs? Curr Drug Metab 2002;3:351–366.

93. Kalgutkar AS, Gardner I, Obach RS, et al. A comprehensive listing of bioactivation pathways of organic functional groups. Curr Drug Metab 2005;6:161–225.

94. Myers T G, Dietz EC, Anderson N, et al. A comparative study of mouse liver proteins arylated by reactive metabolites of acetaminophen and its nonhepatotoxic regioisomer, 3′-hydroxyacetanilide. Chem Res T oxicol 1995;8:403–413.

95. Holt MP, Ju C. Mechanis ms of drug-induced liver injury . AAPS J 2006;3; 8:E48–E54.

96. Ju C, Uetrecht J P. Mechanis m of idiosy ncratic drug reactions: reactive metabolite formation, protein binding, and the regulation of the immune system. Curr Drug Metab 2002;3:367–377.

97. Miller EC, Miller JA. Mechanisms of chemical carcinogenesis. Cancer 1981;47:1055–1064.

98. Gillette JR. T he problem of chemically reactive metabolites. Drug Metabolism Reviews 1982;13:941–961.

99. Reed DJ. Cellular defense mechanisms against re activ e metabolites. In: Anders M, ed. Bioactivation of Foreign Compounds. New York: Ac ademic Pres s, 1985:71–108.

100. Nelson SD, et al. Role of metabolic activ ation in chemical-induced tissue injury. In: Jerina DM, ed. Drug Metabolism Concepts. ACS Symposium Series 44. Washington, DC: American Chemical Soc iety, 1977:155–185.

101. Uetrecht J. Bioactivation. In: Lee JS, Obach RS, Fisher M, eds . Drug-Metabolizing Enzy mes: Cytochrome P450 and Other Enzymes in Drug Dis covery and Development. Weimar, T X: Culinary and Hospitality Industry Publications Serv ices , 2003, pp87–145.

102. Boelsterli UA. Xenobiotic ac yl glucuronides and acyl CoA thioes ters as protein-reactive metabolites with the potential to cause idiosyncratic drug reactions. Curr Drug Metab 2002;3:439–450.

103. Zhou S, Yung Chan S, Cher Goh B, et al. Mechanism-based inhibition of cytochrome P450 3A4 by therapeutic drugs. Clin Pharmacokinet 2005;44: 279–304.

104. Dressor GK, Spence JD, Bailey DG. Pharmacokinetic–pharmacodynamic consequences and clinical relevance of cytochrome P450 3A4 inhibition. Clin Pharmacokinet 2000;38:41–57.

105. Michalets EL. Update: clinically significant cytochrome P450 interactions. Pharmacotherapy 1998;18:84–112.

106. Bailey DG, Dresser GK, Kreeft J H, et al. Grapefruit–felodipine interaction: effect of unprocessed fruit and probable active ingredients. Clin Pharmacol T her 2000;68:468–477.

107. Evans AM. Influence of dietary components on the gas trointestinal metabolism and transport of dru gs. T her Drug Monit 2000;22:131–136.

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109. Saller R, Meier R, Brignoli R. T he use of s ilymarin in the treatment of liver diseases. Drugs 200 1;61:2035–2063.

Suggested Readings

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Anders M, ed. Bioactivation of Foreign Compounds. New York: Academic Press, 1985.

Caldwell J, Jakoby W, eds. Biological Basis of Detoxication. New York: Academic Press, 1983.

Jak oby W, ed. Enzy matic Basis of Detoxication, vols I and II. New York : Academic Press , 1980.

Jak oby W, Bend JR, Caldwell J, eds. Metabolic Basis of Detoxication—Metabolism of Functional Groups. New York : Academic Press, 1982.

Lee JS, Obach RS, Fisher M, eds., Drug-Metabolizing Enzymes :Cytochrome P450 and Other Enzymes in Drug Discovery and Development. Weimer, T X: Culinary and Hospitality Industry Publications Serv ices, 2003.

Mulder GJ, ed. Conjugation Reactions in Drug Metabolism: An Integrated Approach. London: T ay lor and Francis, 1990.

Ortiz de Montellano PR, ed. Cytochrome P450: Structure Mechanis m and Biochemistry, 2nd Ed. New York: Plenum Press, 1995.

T esta B, Jenner P, eds. Concepts in Drug Metabolism. New York: Marcel Dekker, 1981.

T esta B, Jenner P, eds. Drug Metabolism: Chemical and Biochemical Aspects. New York: Marcel Dekker, 1976.

Williams RT , ed. Detoxication Mechanisms, 2nd Ed. New York: John Wiley and Sons, 1959.

Wolf T F, ed. Handbook of Drug Metabolism. New York: Marcel Dekker, 1999.

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Chapter 11 U.S. Drug Regulation: An Overview Douglas J. Pisano

Introduction Regulations and laws are central, social constructs that provide guidance for all societies around the globe. Governments create laws in a number of ways and with various intents for a myriad of purposes. In the United States, laws are created by the Congress, a body of officials elected by the citizenry and charged with the governance of the country by representing the common, public good. The Congress proposes and passes laws that are relatively general in nature and intended to address some particular issue in a fashion that can be consistently applied by all who are affected by them. Once passed, laws are remanded to the appropriate government or administrative agency, which then decides how these laws are to be applied. These applications of law are termed “regulations.” Regulations serve as the practical foundation from which citizens adhere to the law as it was originally intended. In the United States, all food, drugs, cosmetics and medical devices, for both humans and animals, are regulated under the authority of the U.S. Food and Drug Administration (FDA). The U.S. FDA and all its regulations were created by the federal government in response to the pressing need to address the safety of the public with respect to its foods and medicinals. The purpose of this chapter is to describe and explain the nature and extent of these regulations as they apply to drugs in the United States. A historical perspective is offered as a foundation for regulatory context. In addition, the chapter will discuss the U.S. FDA's regulatory o v e r s i g h t a n d t h a t o f o t h e r a g e n c i e s , t h e d r u g a p p r o v a l a n d d e v e l o p m e n t p r o c e s s, the mechanisms used to regulate manufacturing and marketing, as well as various violation and enforcement schema.

Brief History of Drug Laws and Regulations B e f o r e 1 9 0 2 , t h e U . S . g o v e r n m e n t t o o k a h a n d s- o f f a p p r o a c h t o t h e r e g u l a t i o n o f drugs. Many of the drugs available were so-called “patent medicines,” which were so named because each had a more or less descriptive or patent name that was protected by a trademark, the contents of which were incompletely disclosed. No laws, regulations, or standards existed to regulate drugs, their purity, and their strength to any noticeable extend, even though the U.S. Pharmacopeia (USP) became a reality in 1820 as the first official compendia of the United States. The USP set standards for drug strength and purity that could be used by physicians and p h a r m a c i s t s w h o n e e d e d c e n t r a l i z e d g u i d e l i n e s t o e x t r a c t , c o m p o u n d , a n d o t h e r w i se use drug components that existed at the time (1).

Biologics Control Act In 1848, however, the first U.S. drug law, the Drug Importation Act, was enacted when American troops serving in Mexico became seriously ill from the quinine that was administered to treat malaria. The quinine was subsequently discovered to be adulterated. This law required laboratory inspection, detention, and even


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destruction of drugs that did not meet acceptable standards. Later, in 1902, the Virus, Serum, and Toxins Act (Biologics Control Act) was passed in response to tetanus-infected diphtheria antitoxin serum that was manufactured by a small laboratory in St. Louis, Missouri. Ten schoolchildren died as a result of the infected serum. No national standards were as yet in place for establishing purity or potency of medicinal products.

Wiley Act T h e B i o l o g i c s C o n t r o l A c t a u t h o r i z e d t h e U . S . P u b l i c H e a l t h S e r v i ce t o l i c e n se a n d regulate the interstate sale of serum, vaccines, and related biological products used to prevent or treat disease. This Act also spurred Dr. Harvey W. Wiley, Chief Chemist for the Bureau of Chemistry, a branch of the U.S. Department of Agriculture and the forerunner for today's U.S. FDA, to investigate the country's foods and drugs. He established the Hygienic Table, a group of young men who volunteered to serve as human guinea pigs, which would allow Dr. Wiley to feed them a controlled diet laced with a variety of preservatives and artificial colors. More popularly known as the “Poison Squad,” they helped Dr. Wiley gather enough data to prove that many of America's foods and drugs were either “adulterated” and that the products' strength or purity were suspect or “misbranded” with inadequate or inaccurate labeling. Dr. Wiley's efforts, along with publication of Upton Sinclair's The Jungle (a book revealing the putrid conditions in America's meat industry), were rewarded when Congress passed America's first food and drug law in 1906, the Pure Food and Drug Act (USPFDA; also known as the Wiley Act). The Wiley Act prohibited interstate commerce of misbranded foods or drugs based on their labeling. This act did not affect unsafe drugs, however, in that its legal authority would only come to bear when a product's ingredients were falsely labeled. Even intentionally false therapeutic claims were not prohibited. P.328

Sherley Amendment Changes in the labeling of drugs began to occur in 1911 with the enactment of the Sherley Amendment, which was intended to prohibit the labeling of medications with false therapeutic claims that were meant to defraud the purchaser. The Sherley Amendment, however, required the government to find proof of intentional labeling fraud. Later, in 1937, a sentinel event occurred that changed the entire regulatory picture. Sulfa (e.g., sulfanilamide) became the miracle drug of the time and was u s e d t o t r e a t m a n y l i f e - t h r e a t e n i n g i n f e c t i o n s . I t t a s t e d b ad a n d w a s h a r d t o swallow, which led entrepreneurs to seek a palatable solution. S.E. Massingill Co. of Bristol, Tennessee, developed what they thought was a palatable, raspberryflavored liquid product. They used diethylene glycol to solubilize the sulfa, however, and six gallons of this dangerous mixture (“Elixir of Sulfanilamide”) killed approximately 107 people, mostly children.

Federal Food, Drug, and Cosmetic Act T h e r e s u l t o f t h e s e u n n e c e s s a r y d e a t h s f ro m i n g e s t i o n o f d i e t h y l e n e g l y c o l w a s t h e passage of one of the most comprehensive statutes in the history of U.S. health l a w , t h e F e d e r a l F o o d , D r u g , a n d C o s m e t i c A c t o f 1 9 3 8 ( F D C A ) . T h e e n a ct m e n t o f this act repealed the Sherley Amendment and required that all new drugs be tested by their manufacturers for human safety and that results then be submitted to the government for marketing approval via a New Drug Application. The FDCA also


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mandated that drugs be labeled with adequate directions if they were shown to have had harmful effects. In addition, the FDCA authorized the U.S. FDA to conduct unannounced inspections of drug manufacturing facilities. Though amended many times since 1938, the FDCA is still the broad foundation of the statutory authority for the U.S. FDA as it exists today. A new crisis loomed, however. Throughout the late 1950s, European and Canadian p h y s i c i a n s b e g a n t o e n c o u n t e r a n u m b e r o f i n f a n t s b o r n w i t h a c u r i o u s b i r t h d e f e ct called phocomeglia, which resulted in limbs that resembled “flippers” similar to those found on seals. These birth defects were traced back to mothers who had been prescribed the drug thalidomide in an effort to relieve morning sickness while pregnant. The manufacturer of this drug applied for U.S. marketing approval as a s l e e p a i d . B e c a u se o f t h e e f f o r t s o f D r . F r a n c e s O . K e l s e y , h o w e v e r , w h o w a s t h e U.S. FDA's chief medical officer at the time, the case was made that the drug was not safe for human consumption and, therefore, not effective for release in the U.S. marketplace.

Kefauver-Harris Act Dr. Kelsey's efforts and decisive work by the Congress resulted in yet another necessary amendment to the FDCA in 1962, the Kefauver-Harris Act. This Act essentially closed many of the loopholes regarding drug safety in U.S. law. These “Drug Efficacy Amendments” now required manufacturers to prove the safety and efficacy of their drug products registered with the U.S. FDA, to be inspected at least every 2 years, to have their prescription drug advertising approved by the U.S. FDA (this authority being transferred from the Federal Trade Commission), to provide and obtain documented “informed consent” from research subjects before human clinical trials, and to have increased controls over drug manufacturing and testing to determine drug effectiveness. To address these new provisions of the Act, the U.S. FDA contracted the National Academy of Sciences, along with the National Research Council, to examine some 3,400 drug products approved between 1938 and 1962 based on safety alone. Called the Drug Efficacy Study Implementation Review of 1966 (DESI), it charged these organizations with making a determination as to whether post-1938 drug products were “Effective,” “Probably Effective,” “Possibly Effective,” or “Ineffective” for the indications claimed in their labeling. Those products not deemed “Effective” were either removed from the marketplace, reformulated, or sold with a clear warning to prescribers that the product was deemed not to be effective.

Over-The-Counter Product Review L a t e r , i n 1 9 7 2 , t h e U . S . F D A b e g a n t o e x a m i n e o v e r - t h e - co u n t e r ( O T C ) d r u g products. Phase II of the Drug Efficacy Amendments required the U.S. FDA to d e t e r m i n e t h e e f f i c a c y o f O T C d r u g p r o d u c t s . T h i s p r o j e c t w a s m u c h l a r g e r i n s co p e than the analysis of prescription drugs. During the 1970s, American consumers could choose from more than 300,000 OTC drug products. The U.S. FDA soon r e a l i z e d t h a t i t d i d n o t h a v e t h e r e s o u r c e s t o e va l u a t e e a c h a n d e v e r y O T C d r u g p r o d u c t a n d , h e n c e , c r e a t e d a d v i s o r y p a n e l s o f s c i e n t i s t s , m e d i c a l p r o f e ss i o n a l s , and consumers who were charged with evaluating the active ingredients used in OTC products within 80 defined therapeutic categories. After examining both the scientific and medical literature of the day, the advisory panels made decisions regarding active ingredients and their labeling. The result was a “monograph” that described, in detail, acceptable active ingredients and labeling for products within a


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therapeutic class. Products that complied with monograph guidelines were deemed “Category I: Safe and Effective, Not Misbranded.” Products not in compliance with monograph guidelines, however, were deemed “Category II: Not Safe and Effective” or “Misbranded.” Category II products were removed from the marketplace or r e f o r m u l a t e d . P r o d u c t s f o r w h i c h d a t a w as i n s u f f i c i e n t f o r c l a s s i f i c a t i o n w e r e deemed “Category III” and allowed to continue on the market until substantive data could be established or until they were reformulated and in compliance with the monograph. The OTC Drug Review took approximately 20 years to complete.

Federal Controlled Substances Act Though numerous other federal laws and regulations were passed throughout the 1970s, many were based on P.329 regulating the professional practice of medical professionals or for the direct protection of consumers. For example, the Federal Controlled Substances Act, part of the Comprehensive Drug Abuse and Prevention Act of 1970, placed drugs with a relatively high potential for abuse into five federal schedules along with a “closed record keeping system” designed to track federally controlled substances via a definite paper trail as they were ordered, prescribed, dispensed, and used throughout the health care system.

Orphan Drug Act The 1980s also saw significant regulatory change. Biotechnology had begun on a grand scale, and the pharmaceutical industry was on its cutting edge. Many of the medicinal compounds being discovered were shown to be very expensive and to have limited use in the general U.S. population. These compounds could prove lifesaving, however, to demographically small patient populations (less than 200,000) who suffered from diseases and conditions considered to be rare. In an effort to encourage these biotech pharmaceutical companies to continue developing these and other products, Congress passed the Orphan Drug Act in 1983. The Act continues to allow manufacturers to gain incentives for research, development, and marketing of drug products used to treat rare diseases or conditions that otherwise w o u l d b e u n p r o f i t a b l e v i a a s y s t e m o f b re a k s a n d d e d u c t i o n s i n a m a n u f a c t u r e r ' s corporate taxes. Though the success of the Orphan Drug Act provided great medical benefit for a few, a scandal was looming in other parts of the pharmaceutical industry.

Price Competition and Patent Restoration Act (WaxmanHatch Act) The generic pharmaceutical industry experienced steady growth as many of the exclusive patents enjoyed by major pharmaceutical companies for brand-named products were beginning to expire. Generic versions of these now freely copied products were appearing much more frequently in the marketplace. These generic copies, however, were required to undergo the same rigorous testing that brand name, pioneer, or innovator products did. This led to a very public scandal in which a few unscrupulous generic pharmaceutical companies took shortcuts in reporting data, submitted fraudulent samples, and offered bribes to U.S. FDA officials to gain easy and rapid market approval of their products. As a result, Congress passed the Price Competition and Patent Restoration Act of 1984. This Act, also called the Waxman-Hatch Act after its sponsors, was designed to level the playing field in the


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prescription drug industry with regard to pioneer/innovator/brand name prescription drug products and their generic copies. The Act was composed of two distinct parts, or “Titles.” Title I was for the benefit of the generic pharmaceutical industry and e x t e n d e d t h e s c o p e o f t h e A b b r e v i a t e d N e w D r u g A p p l i ca t i o n t o c o v e r g e n e r i c versions of drug products approved after 1962. It required that generic versions of pioneer or innovator drugs have the same relevant properties regarding bioequivalence (rate and extent of absorption of the active drug in the human body) and pharmaceutical equivalence (same dosage form as the pioneer drug to which it is compared). Though somewhat simplified, the Waxman- Hatch Act permitted easier market access to generic copies of pioneer drugs provided they were not significantly different from the pioneer drug in its absorption, action, and dosage form. In addition, Title II was designed to aid and encourage research-based or innovator pharmaceutical companies in continuing their search for new and useful medicinal compounds by extending the patent life of pioneer drug products while in the U.S. FDA “review period.”

Prescription Drug User Fee Act The patent extension benefit has become somewhat moot, however, because of an overall reduction in U.S. FDA review time as a result of prescription drug user fees. In 1992, Congress passed the Prescription Drug User Fee Act (PDUFA). The Act was intended to help the U.S. FDA generate additional funds to upgrade and modernize its operations and to accelerate drug approval. It authorized the U.S. FDA to charge pharmaceutical manufacturers a “user fee” to accelerate drug review. As a result of the PDUFA legislation, the U.S. FDA has been able to reduce approval time of new pharmaceutical products from more than 30 months to approximately 13 to 15 months. The Act had a “sunset” provision, however, that limited the authority of the U.S. FDA to charge user fees until the year 1997.

U.S. FDA Modernization Act After reviewing the successes of the PDUFA legislation, Congress extended the user fee provisions during passage of the U.S. FDA Modernization Act (FDAMA) of 1997. The FDAMA reauthorized the fees until the year 2002 in an effort to further reduce prescription drug approval time. The Act, however, not only extended user fee provisions. It also gave the U.S. FDA the authority to conduct “fast-track” product reviews to further speed life-saving drug therapies to market, permitted an additional 6-month patent exclusivity for pediatric prescription drug products, and required the National Institutes of Health to build a publicly accessible database of clinical studies involving investigational drugs or life-threatening diseases.

Summary American drug law has come quite far since the early 1900s. Today, the U.S. FDA continues to work with Congress and the pharmaceutical industry to regulate and evaluate new and existing drug, biologic, and device products. The overriding regulatory challenge that the U.S. FDA will face will be to keep current, through regulation P.330 and policy, with future technological advances by the science and the industry.

Regulatory Oversight of Pharmaceuticals


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The primary responsibility for the regulation and oversight of pharmaceuticals and the pharmaceutical industry lies with U.S. FDA, created in 1931 and one of several branches within the U.S. Department of Health and Human Services. The U.S. FDA's counterparts within that department include agencies such as the Centers for Disease Control and Prevention, the National Institutes of Health, and the Health Care Financing Administration.

U.S. Food and Drug Administration The U.S. FDA is organized into a number of Offices and Centers headed by a Commissioner who is appointed by the President with consent of the Senate. It is a scientifically based law enforcement agency whose mission is to safeguard the public health and to ensure honesty and fairness between health regulated i n d u s t r i e s ( i . e . , p h a r m a c e u t i c a l , d e v i c e , b i o l o g i c, a n d t h e c o n s u m e r ) ( 2 ) . I t l i c e n s e s and inspects manufacturing facilities, tests products, evaluates claims and prescription drug advertising, monitors research, and creates regulations, guidelines, standards and policies. It does all this through its Office of Operations, which contains component Offices and Centers such as the Center for Drug Evaluation and Research (CDER), Center for Biologics Evaluation and Research, Center for Devices and Radiological Health (CDRH), Center for Food Safety and Applied Nutrition, Center for Veterinary Medicine, Office of Orphan Products D e v e l o p m e n t , O f f i c e o f B i o t e c h n o l o g y , O f f ic e o f R e g u l a t o r y A f f a i r s , a n d N a t i o n a l Center for Toxicological Research. Each of these entities has a defined role, but sometimes their authorities overlap. For example, if a pharmaceutical company submits a drug that is contained and delivered to a patient during therapy by a device not comparable to any other, the CDER and CDRH may need to coordinate t h a t p r o d u c t ' s a p p r o v a l . M o s t p r e s c r i p t io n d r u g s a r e e v a l u a t e d b y C D E R , b u t a n y other Center or Office may become involved with its review. One of the most significant resources to industry and consumers is the U.S. FDA's website (http://www.fda.gov) and its FDA approved drug products website (http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm). Easily accessible and navigable, each Center and Office has its own HTML page within the site.

Other Governmental Agencies T h e U . S . F D A i s n o t t h e o n l y a g e n c y w i t h i n t h e U . S . g o v e r n m e n t w i t h a st a ke i n pharmaceutical issues. The Federal Trade Commission has authority over general business practices in general, such as deceptive and anticompetitive practices (i.e., false advertising). In addition, the Federal Trade Commission regulates the advertising of OTC drugs, medical devices, and cosmetics. To a lesser degree, the Consumer Product Safety Commission regulates hazardous substances and the containers of poisons and other harmful agents, the U.S. Environmental Protection Agency regulates pesticides used in agriculture, the U.S. FDA regulates food products; the Occupational Safety and Health Administration regulates the working environment of employees who may use U.S. FDA–regulated commodities (i.e., syringes, chemotherapy, and chemical reagents); the Health Care Financing Administration regulates the federal Medicaid and Medicare programs, and the Drug Enforcement Administration enforces the Federal Controlled Substances Act and is charged with controlling and monitoring the flow of licit and illicit controlled substances. Additionally, various state and local drug control agencies establish their own regulations and procedures for manufacturing, research, and development of pharmaceuticals.


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New Drug Approval and Development Before any discussion of how pharmaceuticals make their way through the U.S. FDA for market approval, one needs to have an understanding of what constitutes a “drug.” A drug is a substance that exerts an action on the structure or function of t h e b o d y b y c h e m i c a l a c t i o n o r m e t a b o l i s m a n d i s i n t e n d e d f o r u se i n t h e d i a g n o s i s , cure, mitigation, treatment, or prevention of disease (3). The concept of “new drug” stems from the Kefauver-Harris Amendments to the FDCA. A new drug is defined as one that is not generally recognized as safe and effective for the indications proposed. This definition has much greater reach, however, than simply a “new” chemical entity. The term “new drug” also refers to a drug product already in existence but never approved by U.S. FDA for marketing in the United States, a new therapeutic indication, a new dosage form, a new route of administration, a new dosing schedule, or any other significant clinical differences than those previously approved (4). Therefore, any chemical substance intended for use in humans or animals for medicinal purposes, or any existing chemical substance that has some significant change associated with it, is considered not safe or effective and to be a new drug until proper testing is performed and U.S. FDA approval is granted. Approval by the U.S. FDA can be a fairly lengthy and expensive process. For a pharmaceutical manufacturer to place a product on the market for human use, a multiphase procedure must be followed. Remember that the mission of U.S. FDA is to protect the public, and they take that charge very seriously. Hence, all drug products must at least follow the stepwise process.

Preclinical Investigation The testing of new drugs in humans cannot begin until solid evidence exists that the drug product can be used with reasonable safety in humans. This phase is termed P.331 “preclinical investigation.” The basic goal of preclinical investigation is to assess the potential therapeutic effects of the substance on living organisms and to gather sufficient data to determine reasonable safety of the substance in humans through laboratory experimentation and animal investigation (5). The U.S. FDA requires no previous approval for investigators or pharmaceutical industry sponsors to begin a preclinical investigation on a potential drug substance. Investigators and sponsors are, however, required to follow Good Laboratory Practices (GLP) regulations (6). The GLPs govern laboratory facilities, personnel, equipment, and operations. Compliance with GLPs requires procedures and documentation of training, study schedules, processes, and status reports, which are submitted to facility management and are included in the final study report to the U.S. FDA. Preclinical investigation usually takes from 1 to 3 years to complete. If at that time enough data are gathered to reach the goal showing a potential therapeutic effect and reasonable safety, the product sponsor must formally notify the U.S. FDA of their wishes to test the potential new drug on humans.

Investigational New Drug Application Overview Unlike the preclinical investigation stage, the Investigational New Drug Application (INDA) phase has much more direct U.S. FDA activity throughout. Because a preclinical investigation is designed to gather significant evidence of reasonable


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safety and efficacy of the compound in live organisms, the INDA phase is the clinical phase in which all activity is used to gather significant evidence of reasonable safety and efficacy data about the potential drug compound in humans. C l i n i ca l t r i a l s i n h u m a n s a r e c a r e f u l l y s c r u t i n i z e d a n d r e g u l a t e d b y t h e U . S . F D A t o protect the health and safety of human test subjects and to ensure the integrity and usefulness of the clinical study data (7). Numerous meetings between both the agency and sponsor will occur during this time. As a result, the clinical investigation phase may take as many as 12 years to complete. Only one in five compounds tested may actually demonstrate clinical effectiveness and safety and reach the U.S. marketplace. The sponsor will submit the INDA to the U.S. FDA. The INDA must contain information regarding the compound itself and information about the study. All INDAs must have the same basic components: a detailed cover sheet, a table of c o n t e n t s , a n i n t r o d u c t o r y s t a t e m e n t a n d b a s i c i n ve s t i g a t i v e p l a n , a n i n v e s t i g a t o r s ' brochure, comprehensive investigation protocols, the compound's actual or proposed chemistry, manufacturing and controls, any pharmacology and toxicology information, any previous human experience with the compound, and any other pertinent information that the U.S. FDA deems necessary. After submission, the s p o n s o r c o m p a n y m u s t w a i t 3 0 d a y s t o c o m m e n c e c l i n i ca l t r i a l s . I f t h e U . S . F D A does not object within that period, the trials may begin.

Institutional Review Board Before the actual commencement of the clinical investigations, however, a few ground rules must be established. For example, a clinical study protocol must be developed, proposed by the sponsor, and reviewed by an Institutional Review Board (IRB). An IRB is required by regulation (8) and is a committee of medical and ethical experts designated by an institution, such as a University Medical Center, in which the clinical trial will take place. The charge of the IRB is to oversee the r e s e a r c h t o e n s u r e t h a t t h e r i g h t s o f h u m a n t e st s u b j e c t s a r e p r o t e c t e d a n d t h a t rigorous medical and scientific standards are maintained (9). The IRBs must approve the proposed clinical study and monitor the research as it progresses. It must develop written procedures of its own regarding its study review process and its reporting of any changes to the ongoing study as they occur. In addition, an IRB must review and approve documents for informed consent before commencement of the proposed clinical study. Regulations require that potential patients in a clinical study are informed adequately about the risks, benefits, and treatment alternatives before participating in experimental research (10). The membership of an IRB must b e s u f f i c i e n t l y d i v e r s e t o r e v i e w t h e s t u d y i n t e r m s o f t h e s p e c i f i c r e s e a r ch i s s u e , community and legal standards, and professional conduct and practice norms. All its activities must be well documented and open to U.S. FDA inspection at any time. Once the IRB is satisfied that the proposed trial is ethical and proper, the clinical trial phase will begin. The clinical trial phase has three steps or phases. Each phase has a purpose, requires numerous patients, and can take more than 1 year to complete.

Phase I A Phase I study is relatively small ( methylcarbamic acid esters > dimethylcarbamic acid esters (40).

Regeneration of active AChE by hydrolysis of the carbamylated enzyme is much slower than hydrolysis of the acetylated enzyme. T he rate for hydrolytic regeneration of the carbamylated AChE is measured in minutes (e.g., the half-life for methyl carbamylated enzyme is ~ 15 minutes); the rate of hydrolytic regeneration of acetylated AChE is measured in milliseconds (e.g., the half-life for acetylated enzyme is ~ 0.2 milliseconds). Despite the longer time required to regenerate the carbamylated enzyme, the active form of AChE eventually is regenerated. T herefore, these inhibitors are considered to be reversible.

Aryl carbamates are superior to alkyl carbamates as AChEIs, because they have better affinity for AChE and, therefore, carbamylate AChE more efficiently. Physostigmine and other aryl carbamates exhibit inhibition constants (K i ) on the order of 10 -9 to 10 -8 M and are three to four orders of magnitude more effective than alkyl carbamates, such as carbachol (K i ~ 10 -5 M). T his is to be expected, because phenoxide anions are more stable than and, hence, are better leaving groups than alkoxide anions. Phenoxide anions are stabilized through resonance with the aromatic ring. T hus, the therapeutically effective carbamate inhibitors of AChE are derived from phenols.

Specific Agents Reversible acetylcholinesterase inhibitors

Physostigmin e T he classic AChEI, physostigmine, is an alkaloid obtained from seeds of the Calabar bean (Physosti gma venenosum) (37). Its parasympathomimetic effects were recognized long before its structure was elucidated in 1923. In 1929, Stedman found that the mechanism of the parasympathomimetic effects of physostigmine was inhibition of AChE; it inhibits AChE by acting as a substrate and carbamylating the enzyme. Acetylcholinesterase is carbamylated at a slow rate, but physostigmine has exceptionally high affinity (K i ~ 10 -9 M) for the catalytic site of the enzyme. By comparison, the K s for acetylcholine is on the order of 10 -4 M. T hus, physostigmine is classified as a reversible AChEI that carbamylates the enzyme at a slow rate; the carbamylated AChE also is regenerated quite slowly. Because physostigmine is a tertiary amine with +

a pK a of 8.2 ( BH) rather than a quaternary ammonium salt, it is more lipophilic than many other AChEIs and can diffuse across the blood-brain

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barrier. T he tertiary amine also imparts pH dependence to its ability to inhibit AChE, because its affinity for AChE is greater when the amine is protonated. Physostigmine is metabolized in vivo by esterases to the phenol and has an elimination half-life of 1 to 2 hours. Its aqueous solutions are subject to hydrolytic decomposition to form eseroline, which undergoes light-catalyzed oxidation to form rubreserine, a red-colored compound (Fig. 12.15). Both degradation products are inactive as AChEIs. Physostigmine has been used for many years in ophthalmology for the treatment of glaucoma. More recent ly, the salicylate salt has been used in hospital emergency rooms to treat overdoses of compounds possessing significant anticholinergic CNS effects (for example, antidepressants), such as atropine and tricyclic antidepressants. Physostigmine's ability to cross the P.377 blood-brain barrier has led to renewed interest in this molecule, and it also is one of a number of centrally active AChEIs being investigated as indirect cholinomimetics for use in the treatment of Alzheimer's disease and other cognitive disorders.

Fig. 12.15. In vitro degradation of physostigmine.

Neostigmin e (Prostigmin ) T he discovery that physostigmine and other aryl carbamates inhibit AChE reversibly led to research to find other AChEIs possessing this activity. Most of this research involved incorporation of the required structural features of both physostigmine and acetylcholine into the new molecules. T his led to synthesis of neostigmine, a compound resembling physostigmine but having a much simpler structure. Neostigmine retains the substituted carbamate group, the benzene ring, and the nitrogen atom of the first heterocyclic ring of physostigmine. T he distance between the ester and the quaternary ammonium group is approximately the same as that found in acetylcholine and physostigmine. Because of its quaternary ammonium group, it lacks central activity. Neostigmine is metabolized to 3-hydroxyphenyltrimethylammonium, 3-hydroxyphenyldimethylamine, and its glucuronide conjugate, and it has an elimination half-life of 15 to 90 minutes. Neostigmine is indicated for prophylaxis of postoperative abdominal distension and urinary retention, myasthenia gravis, reversal of neuromuscular blockade.

Pyridostigmine (Mestinon ) Pyridostigmine, a closely related structure to neostigmine that incorporates the charged nitrogen into a pyridine ring, acts by the same mechanism as physostigmine, but it lacks CNS activity. It is orally effective and, compared to neostigmine, has a longer duration of action and a lower incidence of side effects. T hus, it is a better choice for oral therapy of myasthenia gravis. It is approved for U.S. military use as an adjunct for prophylaxis of soman nerve gas exposure. It is also administered parenterally to reverse the effects of nondepolarizing neuromuscular blocking agents. Its elimination half-life is 1 to 2 hours.

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Carbaryl Carbaryl is a reversible, carbamate-derived AChEI that has tremendous economic impact as an insecticide for use on houseplants and vegetables as well as for control of fleas and ticks on pets. Its structural relationship to physostigmine and neostigmine is readily apparent. A number of other carbamate AChEIs also are commercially available for this use.

Edroph on ium ch loride (Enlon, Reversol) Edrophonium is a quaternary ammonium-substituted phenol. Because it is a phenol derivative rather than a carbamate ester of a phenol, it does not carbamylate AChE. It does, however, inhibit AChE in a reversible manner, and it also exhibits a direct cholinomimetic effect at skeletal muscle. Edrophonium is used intravenously for the diagnosis of myasthenia gravis, where it acts rapidly to increase muscle strength. It also is administered intramuscularly to rapidly reverse the effects of nondepolarizing neuromuscular blocking agents like d-tubocurarine and gallamine. It is not effective, however, at reversing the effects of the depolarizing blockers such as succinylcholine and decamethonium. Its elimination half-life 1.3 to 2.4 hours.

Reversible acetylcholinesterase inhibitors for treatment of Alzheimer's disease Of all the age-related disorders in which dementia is a component, Alzheimer's disease (AD) is probably the best known. Much effort has been expended to discover the cause of AD. Autopsy examination of the brains of patients who had AD has revealed microscopic structural changes characteristic of the disease. In addition, neurotransmitter dysfunction involving reduction in acetylcholine, serotonin, norepinephrine, dopamine, and glutamate levels have been reported. For a revi ew of AD and the search for therapies, see Rzeszotarski (41). It is known that in AD patients, there is widespread atrophy in the primary motor and sensory cortices and cerebellum. T here is a disruption in cholinergic innervation in these areas of the brain, along with decreases in choline acetyltransferase, high-affinity nicotinic acetylcholine receptor binding, and choline transporter sites (42,43,44,45). Impairment of short-term memory is the first observable symptom of the disease, and progressive memory impairment, severe mood changes, and depression coupled with loss of judgment and reasoning ability follow. T he U.S. Food and Drug Administration has approved four AChEIs for the treatment of AD: tacrine, donepezil, rivastigmine, and galantamine. Although these four AChEIs are not without problems, they do provide some benefit in early to mild AD. T heir clinical effectiveness in advanced AD is yet to be shown. P.378

T acrine hydrochloride (Cogn ex) T acrine, an aminoacridine synthesized in the 1930s, is a nonclassic cholinesterase inhibitor that binds to both AChE or butyrylcholinesterase (46). It was approved in 1993 for the treatment of AD. Approximately 20% of tacrine-treated patients may show improvement, but its use has been limited because of hepatotoxicity. Use of tacrine has greatly decreased because of the recent development of safer AChEIs. T acrine is extensively metabolized by CYP450 to at least three metabolites. T he major metabolite, 1-hydroxy-tacrine, is active. Its elimination half-life is between 1.5 and 4 hours, with metabolites being are excreted via the urine.

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Don epezil (Aricept) Donepezil is another “ nonclassic,” centrally acting, reversible, noncompetitive AChEI that was approved in 1997 for treatment of mild-tomoderate AD and dementia. Its selectivity for AChE is 570- to 1,250-fold that for butyrylcholinesterase, and it also exhibits greater affinity for brain AChE than for AChE in the periphery (47). When compared to tacrine, donepezil exhibits greater CNS AChE selectivity, longer elimination half-life (70–104 hours in subjects older than 55 years) and little or no potential for hepatotoxicity. Donepezil is metabolized by CYP2D6 and CYP3A4 via demethylation, debenzylation, hydroxylation, oxidation to the ci s-N-oxide, and glucuronidation. T he 6-O-desmethyl metabolite accounts for 11% of a dose, and it exhibits AChE inhibitory activity comparable to that of the parent compound.

Rivastigmin e (Exelon ) Rivastigmine is a centrally selective, arylcarbamate AChEI that was approved in 2000 for oral administration in the treatment of AD. It has an elimination half-life of 1.4 to 1.7 hours but is able to inhibit AChE for up to 10 hours. Because of the slow dissociation of the carbamylated enzyme, it has been referred to as a pseudo-irreversible AChEI (47). Like donepezil, rivastigmine exhibits a low level of hepatotoxicity. It is rapidly and extensively hydrolyzed in the CNS by cholinesterase with minimal involvement of CYP450. T he phenolic metabolite is excreted primarily via the kidneys.

Galantamin e h ydrobromide (Razadyn e) Galantamine, which was introduced in 2001, is an alkaloid found in plants of the family Amaryllidaceae, which includes the daffodil (Narci ssus pseudonarci ssus) and snowflake (Leucojum aesti vum). It is a reversible inhibitor of AChE, but it does not appear to inhibit butyrylcholinesterase. Because it is a tertiary amine and can cross the blood-brain barrier, it is indicated for treatment of mild-to-moderate AD and dementia. It has been used outside the U.S. for more than 30 years as an anticurare agent in anesthesia. Galantamine differs from other cholinesterase inhibitors, because it allosterically binds to nicotinic receptors, giving it a dual cholinergic action. It is metabolized (75%) by CYP2D6 and CYP3A4 to afford the normethyl, O-desmethyl, and O-desmethylnormethyl metabolites, along with some other minor metabolites. Unlike tacrine, galantamine is not associated with hepatotoxicity. Its elimination half-life is 5.7 hours.

Irrev ersible Inhibitors of Acetylcholinesterase

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Mechanism of action T he chemical logic involved in the development of effective AChEIs was to synthesize compounds that would be substrates for AChE and result in an acylated enzyme more stable to hydrolysis than a carboxylate ester. Phosphate esters are very stable to hydrolysis, being even more stable than many amides. Application of this chemical property to the design of AChEI compounds led to derivatives of phosphoric, pyrophosphoric, and phosphonic acids that are effective inhibitors of AChE. T hese act as inhibitors by the same mechanism as the carbamate inhibitors, except that they leave the enzyme esterified as phosphate esters. T he rate of hydrolytic regeneration of the phosphorylated enzyme is much slower than that of the carbamylated enzyme, and its rate is measured in hours (e.g., the half-lives for diethyl phosphates are ~ 8 hours). Because the duration of action of these compounds is much longer than that of carbamate esters, they are referred to as irreversible inhibitors of AChE. An important difference between irreversible phosphoester-derived AChEIs and reversible AChEIs is that the phosphorylated AChE can undergo a process known as aging (Fig. 12.16). T he aging process plays an P.379 important role in the toxicity of these irreversible AChEIs. Aging is the result of cleavage of one or more of the phosphoester bonds while the AChE is phosphorylated. T his reaction affords an anionic phosphate that possesses a phosphorus atom that is much less electrophilic and, therefore, much less likely to undergo hydrolytic regeneration than the original phosphoester. T hus, the aged phosphorylated enzyme does not undergo nucleophilic attack and regeneration by antidotes (see next section) for phosphate ester AChEIs. T his aging process occurs over a period of time, which depends on the rate of the P-O bond cleavage reaction; during this time, the antidotes to phosphate ester poisoning may be effective.

Fig. 12.16. Aging of phosphorylated AChE.

Only those phosphorus-derived AChEIs that have at least one phosphoester group undergo the aging process. Knowledge of the chemical mechanisms associated with irreversible inhibition of AChE and the aging process led to the development of deadly phosphorus-derived chemical warfare agents, one of which is sarin (GB is the two letter NAT O designation for this nerve agent). When this compound phosphorylates AChE, only one aging reaction takes place, and then the enzyme becomes refractory to regeneration by the currently available antidotal agents.

Specific agents

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Ech oth iophate iodide (Ph osph olin e Iodide) Echothiophate iodide has found therapeutic application for the treatment of glaucoma and strabismus. Echothiophate is applied topically as a solution and is the only irreversible AChEI for the treatment of glaucoma. T he decrease in intraocular pressure observed can last up to 4 weeks. Phosphoester AChEIs exhibit cataractogenic properties; thus, their use should be reserved for patients who are refractory to other forms of treatment (i.e., short-acting miotics, β-blockers, epinephrine, and possibly, carbonic anhydrase inhibitors). Because of its toxicity, echothiophate is not used for its systemic action. Selectivity of echothiophate for the AChE catalytic site was enhanced by incorporation in the molecule of a quaternary ammonium salt functional group two carbons removed from the phosphoryl group.

Fig. 12.17. Irreversible acetylcholinesterase inhibitors used as insecticides.

In secticidal AChEIs A number of lipophilic derivatives of phosphoester AChEIs have been designed as insecticides; the structures of some of these are shown in Fig. 12.17. T his group of irreversible AChEI insecticides is beneficial to agricultural production throughout the world. In addition to being extremely lipophilic, another physicochemical property common to these compounds is a high vapor pressure. T his combination of physicochemical properties makes it imperative that these compounds be used with extreme caution in the presence of humans and other mammals to prevent inhalation of the vapors and their absorption through the skin. Both routes of exposure cause a number of poisoning accidents every year, some of which are fatal. Some of these irreversible AChEI insecticides have a sulfur atom bonded to the phosphorus atom with a coordinate-covalent bond. T hese compounds exhibit little AChEI activity, but they are rapidly bioactivated via desulfurization by microsomal oxidation in insects to afford the corresponding oxo derivatives (phosphate esters), which are quite potent. A good example of this bioactivation phenomenon is illustrated by the commercially available insecticide parathion and its bioactivation to a toxic metabolite paraoxon.

Malathion (Ovide) Malathion (Fig. 12.17) is a dithiophosphate ester that has found use both as an aerial insecticide and clinically as a mitocide for topical treatment of lice infestations of the hair and scalp. It will kill P.380 both hatched lice and their eggs (nits) within 3 seconds after application. Compared to other organophosphate AChEIs, malathion exhibits lower transdermal absorption. On intact skin, less than 10% of a topical dose is systemically absorbed. Similar to parathion, malathion is bioactivated in insects to its toxic phosphate ester metabolite. It is much less toxic in humans, mammals, and birds than in insects. Selective toxicity with malathion is achieved because plasma esterases hydrolyze the carboxylate esters to less toxic carboxylic acid metabolites that are rapidly eliminated in urine as carboxylate anions in humans but not in insects. Acute toxicity with malathion is rare and usually occurs only after oral ingestion. T he lethal dose in mammals is approximately 1 g/kg.

Antidotes for Irrev ersible AChEIs

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Background T he marked toxicity of the phosphate ester irreversible AChEIs, their widespread use as insecticides, and their proliferation as chemical warfare agents posed serious problems that stimulated research to develop antidotes for these agents. T his required rational use of reaction kinetics, organic reaction mechanisms, and synthetic organic chemistry. Water is a nucleophile capable of rapidly hydrolyzing acetylated AChE and regenerating the active enzyme. Phosphorylated AChE (irreversibly inhibited), however, was known to involve a phosphate ester of serine. It is well established from reaction kinetic studies that the rate of hydrolysis is much slower for organic phosphate esters than for carboxylate esters and that a significantly stronger nucleophile than water would be required for efficient hydrolysis of phosphate esters. T he problem required the design of reagents capable of efficiently catalyzing phosphate ester cleavage to regenerate active AChE while being safe enough for use as therapeutic agents. T he resolution of this problem is an elegant example of the application of chemical principles to the solution of a therapeutic problem (48,49,50). Hydroxylamine (NH 2 OH) is a strong nucleophilic compound that efficiently cleaves phosphate esters. It significantly increases the rate of hydrolysis of phosphorylated AChE, but only at toxic concentrations (51). T his prompted the development of a number of structurally related compounds in the hope of eliminating toxicity. T he toxicity inherent in hydroxylamine would most probably be present in any structurally related compound, but this toxicity might be minimized if sufficiently small doses could be used. It would be logical to design a compound that would have a high degree of selectivity and strong binding affinity for AChE and also carry a hydroxylamine-like nucleophile into close proximity to the phosphorylated serine residue. T his was achieved by synthesis of hydroxylamine derivatives of organic compounds possessing a functional group bearing a positive charge. Reaction of hydroxylamine with aldehydes or ketones affords oximes, which possess the desired nucleophilic oxygen atom. A pyridine ring was considered an attractive carrier for the oxime function, because such groups are common in a number of biochemical systems (e.g., NAD and NADP), indicating a possible low order of toxicity. Furthermore, three readily available positional isomers of pyridine aldehyde can be converted easily to oximes. Finally, the nitrogen atom of the pyridine ring can be converted to a quaternary ammonium salt by treatment with methyl iodide. T his cationic charge would be expected to increase affinity of the compound for the anionic-binding site of the phosphorylated AChE.

T he three isomeric pyridine aldoxime methiodides were synthesized and biologically evaluated. Of these, the most effective is the isomer derived from 2-pyridinylaldehyde. T his compound, known as pralidoxime chloride (2-PAM, or 2-pyridine aldoxime methyl chloride) currently is the only available agent proven to be clinically effective as an antidote for poisoning by phosphate ester AChEIs. T he proposed mechanism for regeneration of AChE by 2-PAM is illustrated in Fig. 12.18. T he initial step involves binding of the quaternary ammonium nitrogen of 2-PAM to the anionic-binding site of phosphorylated AChE. T his places the nucleophilic oxygen of 2-PAM in close proximity to the electrophilic phosphorus atom. Nucleophilic attack of the oxime oxygen results in breaking of the ester bond between the serine oxygen atom and the phosphorus atom. T he final products of the reaction are the regenerated active form of AChE and phosphorylated 2-PAM.

Pralidoxime is administered subcutaneously, intramuscularly, or intravenously, and it must be given wi thin a short P.381 period of time after enzyme phosphorylation, generally a few hours after exposure, for it to be effective because of the aging process of the phosphorylated enzyme. Little reactivation is likely if given 36 hours after exposure. If the phosphorylated AChE has aged, 2-PAM will not regenerate the enzyme. For this reason, as well as because new phosphate ester AChEIs capable of aging rapidly are being developed as insecticides and chemical warfare agents, there is a continuing effort to discover new and better substitutes for 2-PAM. T his research is focused on finding substitutes for 2-PAM that are better nucleophiles and, therefore, more effective generators of active AChE as well as compounds that cross the blood-brain barrier to regenerate phosphorylated AChE in the brain.

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Fig. 12.18. Reactivation of AChE with 2-PAM.

Acetylcholine Antagonists—M uscarinic Antagonists Muscarinic antagonists are compounds that have high binding affinity for muscarinic receptors but have no intrinsic activity. When the antagonist binds to the receptor, it is proposed that the receptor protein undergoes a conformational perturbation that is different from that produced by an agonist. T herefore, antagonist binding to the receptor produces no response. Muscarinic antagonists commonly are referred to as anticholinergics, antimuscarinics, cholinergic blockers, antispasmodics, or parasympatholytics. T he term “ anticholinergic” refers, in a pure sense, to medicinal agents that are antagonists at both muscarinic and nicotinic receptors. Common usage of the term, however, has become synonymous with muscarinic antagonist, and it is used as such in this section.

Therapeutic Application Muscarinic antagonists frequently are employed as both prescription drugs and over-the-counter medications. Because they act as competitive (reversible) antagonists of acetylcholine, these compounds have pharmacological effects that are opposite those of muscarinic agonists. Responses of muscarinic antagonists include decreased contractions of smooth muscle of the gastrointestinal and urinary tracts, dilation of the pupils, and reduced gastric, mucociliary, and salivary secretions. It follows that these compounds have therapeutic value in treating smooth muscle spasms associated with increased tone of the gastrointestinal tract or with overactive bladder, in ophthalmologic examinations, and in treatment of gastric ulcers. Compounds possessing muscarinic antagonist activity are common components of cold and flu remedies that act to reduce nasal and upper respiratory tract secretions. In addition to reducing gastric motility, anticholinergic agents decrease gastric acid secretion and were once widely used to manage peptic ulcers. Histamine H 2 antagonists and, more recently, the proton pump inhibitors have largely replaced them for this use. When used systemically, they tend to produce undesirable side effects, such as blurred vision, photophobia, dry mouth, and difficulty in urination. T hese side effects tend to reduce patient compliance. Anticholinergic agents exhibit a mydriatic action and, thus, must be used with caution because of their effect on intraocular pressure. Drainage of the canal of Schlemm is restricted by the iris when the pupil is dilated, and this can cause an increase in intraocular pressure. Hence, muscarinic antagonists are contraindicated in patients with glaucoma. T he aforementioned side effect of causing difficulty in urination has been used to advantage with the recent approval of several anticholinergic agents—darifenacin trospium, solifenacin, tolterodine, and oxybutynin—for the treatment of overactive bladder. Centrally acting belladonna alkaloids, such as scopolamine, have been used in transdermal delivery systems for the prevention of motion sickness. T hey are most effective when used prophylactically; they have less effect when used after nausea and vomiting have begun. Several of the synthetic muscarinic antagonists have been used to treat parkinsonism and to block the extrapyramidal effects of antipsychotic agents. T he anticholinergic alkaloid atropine is used for treatment of central and peripheral symptoms associated with poisoning by organophosphorus anticholinesterase agents.

Specific Agents—Solanaceous Alkaloids T he earliest known anticholinergic agents were alkaloids found in the family Solanaceae, a large famil y of plants that includes potatoes. Atropa bel l adonna (deadly nightshade), Hyoscyamus ni ger (black henbane), and Datura stramoni um (jimsonweed, thorn apple) are plants that have significant historical importance to our understanding of the parasympathetic nervous system. Pharmacological effects of extracts from these plants have been recognized since the Middle Ages, although these effects were not associated with the autonomic nervous system until the latter part of the 19th century. (–)-Hyoscyamine, isolated as atropine, and scopolamine are the two alkaloids that have found the widespread clinical applications.

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Atropine Atropine is the tropic acid ester of tropine and is marketed as the sulfate salt. T he naturally occurring alkaloid, (–)-hyoscyamine, undergoes base-catalyzed racemization during isolation from plants of the Solanaceae to give (±)-hyoscyamine or atropine. It was the first compound shown to block the effects of electrical P.382 stimulation and muscarine on the parasympathetic nervous system. Atropine sulfate has a number of clinical uses; two of the most common are treatment of bradycardia and as a preoperative agent to reduce secretions before surgery. Its use for management of parkinsonism has been supplanted by newer agents with fewer peripheral side effects. It has been used in ophthalmology as a cycloplegic agent to paralyze the iris and ciliary muscle in the treatment of iritis and uveitis and as a cycloplegic/mydriatic agent. Atropine is contraindicated in glaucoma because of its ability to increase intraocular pressure during mydriasis. Its prolonged duration of mydriasis makes other drugs more attractive for this purpose. In poisoning by organophosphate nerve agents and insecticides, atropine is used to decrease the muscarinic cholinergic actions (e.g., lacrimation, salivation, sweating, bradycardia, and breathing problems) associated with this poisoning. It only treats the symptoms and does not reverse the underlying AChE inhibition. Atropine undergoes nonenzymatic ester hydrolysis in vivo and has an elimination half-life of 4 hours in adults and 6.5 hours in children.

Scopolamine Scopolamine, another Solanaceous alkaloid, is chemically and pharmacologically similar to atropine. Scopolamine is the generic name given to (–)-hyoscine, the naturally occurring alkaloid. T he racemic compound, isolated during extraction of the alkaloid from plants, is atroscine. Scopolamine is marketed as the hydrobromide salt, because it is less deliquescent than some of its other salts. Scopolamine is a CNS depressant at usual therapeutic doses, whereas atropine and other antimuscarinic agents are CNS stimulants. It has been used for the treatment of uveitis, iritis, and parkinsonism, but its most widespread use is for the treatment of motion sickness. For this indication, scopolamine is used in a transdermal patch applied behind the ear. It is almost completely metabolized in the liver and is excreted via the kidneys. Its elimination half-life is approximately 8 hours.

Structure–activity relationship Atropine, the prototype anticholinergic agent, provided the structural model that guided the design of synthetic muscarinic antagonists for almost 70 years. T he circled portion of the atropine molecule depicts the segment resembling acetylcholine.

Although the amine functional group is separated from the ester oxygen by more than two carbons, the conformation assumed by the tropine ring orients these two atoms such that the intervening distance is similar to that in acetylcholine. One important structural difference between atropine and acetylcholine, both of which are esters of amino alcohols, is the size of the acyl portion of the molecules. Based on the assumption that size was a major factor in blocking action, many substituted acetic acid esters of amino alcohols were prepared and evaluated for biological activity. It became apparent that the most potent compounds were those that possessed two lipophilic ring substi tuents on the carbon α to the carbonyl of the ester moiety. T his is the first of the classic SARs for muscarinic antagonist activity, and this SAR became defined more precisely as research on these antagonists continued. T he SAR for muscarinic antagonists can be summarized as follows:

1. Substituents R 1 and R 2 should be carbocyclic or heterocyclic rings for maximal antagonist potency. T he rings may be identical, but the

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more potent compounds have different rings. Generally, one ring is aromatic and the other saturated or possessing only one olefinic bond. Substituents R 1 and R 2 , however, may be combined into a fused aromatic tricyclic ring system, such as that found in propantheline (T able 12.1). T he size of these substituents is limited. For example, substitution of naphthalene rings for R 1 and R 2 affords compounds that are inactive, apparently because of steric hindrance of the binding of these compounds to the muscarinic receptor. 2. T he R 3 substituent may be a hydrogen atom, a hydroxyl group, a hydroxymethyl group, or a carboxamide, or it may be a component of one of the R 1 and R 2 ring systems. When this substituent is either a hydroxyl group or a hydroxymethyl group, the antagonist usually is more potent than the same compound without this group. T he hydroxyl group presumably increases binding strength by participating in a hydrogen bond interaction at the receptor. 3. T he X substituent in the most potent anticholinergic agents is an ester, but an ester functional group is not an absolute necessity for muscarinic antagonist activity. T his substituent may be an ether oxygen, or it may be absent completely. 4. T he N substituent is a quaternary ammonium salt in the most potent anticholinergic agents. T his is not a requirement, however, because tertiary amines also possess antagonist activity, presumably by binding to the receptor in the cationic (conjugate acid) form. T he alkyl substituents usually are methyl, ethyl, propyl, or isopropyl. 5. T he distance between the ring-substituted carbon and the amine nitrogen apparently is not critical; the length of the alkyl chain connecting these may P.383 be from two to four carbons. T he most potent anticholinergic agents have two methylene units in this chain.

Fig. 12.19. Anticholinergic aminoalcohol esters.

Muscarinic antagonists must compete with agonists for a common receptor. T heir ability to do this effectively is because the large groups R 1 and R 2 enhance binding to the receptor. Because antagonists are larger than agonists, this suggests that groups R 1 and R 2 bind outside the binding site of acetylcholine. It has been suggested that the area surrounding the binding site of acetylcholine is hydrophobic in nature (52). T his accounts for the fact that in potent cholinergic antagonists, groups R 1 and R 2 must be hydrophobic (usually phenyl, cyclohexyl, or cyclopentyl). T his concept also is supported by the current models for muscarinic receptors. Figures 12.19 and 12.20 and T able 12.3 include structures and pharmacological properties of some of the anticholinergic agents that have found clinical application. T hese compounds reflect the SAR features that have been described. All these compounds are effective when administered orally or parenterally. Anticholinergic agents possessing a quaternary ammonium functional group generally are not well absorbed from the gastrointestinal tract because of their ionic character. T hese drugs are useful primarily in the treatment of ulcers or other conditions for which a reduction in gastric secretions and reduced motility of the gastrointestinal tract are desired. T hose antagonists having a tertiary nitrogen are much better absorbed and distributed following all routes of administration and are especially useful when systemic distribution is desired. T he tertiary amino-derived anticholinergic agents readily cross the blood-brain barrier. T hese have proven to be particularly beneficial in the treatment of Parkinson's disease and other diseases requiring a central anticholinergic effect.

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Fig. 12.20. Aminoalcohol, aminoether, and miscellaneous anticholinergic agents.

All these drugs display pronounced selectivity for muscarinic receptors; however, some of those possessing the quaternary ammonium functional group exhibit nicotinic antagonist activity at high doses. With the exception of the M 3 antagonists, solifenacin and darifenacin, these agents display no marked selectivity for muscarinic receptor subtypes.

Recent muscarinic antagonists More recently discovered muscarinic antagonists display a higher affinity for P.384 P.385 the receptors compared with the older agents, as exemplified by quinuclidinylbenzilate (QNB), which has structural features common to the classic anticholinergic agents. Radiolabeled QNB was instrumental in the development of muscarinic receptor labeling techniques as well as the discovery of subtypes of muscarinic receptors. T his latter research also depended on the M 1 -selective antagonist pirenzepine, a compound having a novel structure for muscarinic antagonist activity. A number of compounds structurally related to pirenzepine have demonstrated a similar M 1 selectivity; among these is telenzepine (53). Because of their selectivity for muscarinic M 1 receptors, pirenzepine and telenzepine have been evaluated in clinical trials for the treatment of duodenal ulcers. It is of interest to note that AFDX-116, structurally similar to pirenzepine, is a muscarinic antagonist exhibiting selectivity for cardiac M 2 receptors.

Table 12.3. Anticholinergic Agents

Name

Calculateda Log P Log D (pH 7) Half-life

Metabolism

Indications

Comments

Atropine

1.53–1.21

3.5 ± 1.5 hours

Hydrolysis; N-dealkylation; N-oxide

Bradycardia; parkinsonism; cycloplegic/mydriatic

Nonselective muscarinic antagonist; stimulates the CNS

Scopolamine

0.76 0.29

8 hours

Almost completely metabolized (liver)

Uveitis; iritis; parkinsonism; motion

Nonselective muscarinic

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sickness

antagonist; CNS depressant

Homatropine (Isopto Homatropine)

1.57 –1.17

—

—

Cycloplegic/mydriatic

Nonselective muscarinic antagonist; less potent an shorter duration than atropine

Ipratropium bromide (Atrovent)

—

2 hours

Hydrolysis

Bronchodilator (oral inhalation); seasonal rhinitis (nasal spray)

Nonselective muscarinic antagonist; slow onset after inhalation

Tiotropium bromide (Spiriva)

—

5–6 days

CYP2D6 and CYP3A4 Hydrolysis; N-dealkylation; glucuronide conjugation

Chronic obstructive pulmonary disease (oral inhalation)

Equal affinity for M1 , M2 and M3 receptors

Trospium Chloride (Sanctura)

—

20 hours

Hydrolysis; conjugation

Urinary and gastrointestinal antispasmodic

High affinity for M1 and M3 receptors, lesser affinity for M2 .

Oxybutynin

5.19

(Oral: Ditropan and Ditropan XL) Oxybutynin (transdermal: Oxytrol)

3.93

2–5 hours

CYP3A4 Hydrolysis; N-dealkylation

Overactive bladder

Nonselective muscarinic antagonist

Solifenacin (Vesicare)

3.70 1.70

55 hours

4 R-Hydroxy (active); N-glucuronide; N-oxide; 4R-hydroxyN-oxide

Overactive bladder

Selective M3 antagonist

Tolterodine (Detrol)

5.77 2.79

2–4 hours (extensive metabolizers) 9.6 (poor metabolizers)

Primary pathway: CYP2D6 (primary); 7% of Caucasians & 2% of African Americans lack CYP2D6; CYP3A4 is the primary pathway in the latter. Metabolites: 5-hydroxymethyl (active), 5-carboxylic acid, N-dealkylated5-carboxylic acid

Overactive bladder

Nonselective muscarinic antagonist

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Darifenacin

4.50 2.25

—

CYP2D6 (primary; see tolterodine above); hydroxylation of the dihydrobenzofuran; ring opening (dihydrobenzofurna); N-dealkylation

Overactive bladder

Selective M3 antagonist

a

Values calculated using ACD Lab Solarius, Chemical Abstracts Service, 2006, Columbus, OH (values for quaternary compounds are not listed).

Nicotinic Antagonists—Neurom uscular Blocking Agents Nicotinic antagonists are chemical compounds that bind to cholinergic nicotinic receptors but have no efficacy. All therapeutically useful nicotinic antagonists are competitive antagonists; in other words, the effects are reversible with acetylcholine. T here are two subclasses of nicotinic antagonists—skeletal neuromuscular blocking agents and ganglionic blocking agents—classified according to the two populations of nicotinic receptors. T his section emphasizes nicotinic antagonists used clinically as neuromuscular blocking agents. T hese medicinal agents should not be confused with those skeletal muscle relaxant compounds that produce their effects through the CNS.

History In terms of the historical perspective, tubocurarine, the first known neuromuscular blocking drug, was as important to the understanding of nicotinic antagonists as atropine was to that of muscarinic antagonists. T he neuromuscular blocking effects of extracts of curare were first reported as early as 1510, when explorers of the Amazon River region of South America found natives using these plant extracts as arrow poisons. Early research with these crude plant extracts indicated that the active components caused muscle paralysis by effects on either the nerve or the muscle (remember that the concept of neurochemical transmission was not introduced until the late 19th century). In 1856, however, Bernard (54) described the results of his experiments, which demonstrated unequivocally that curare extracts prevented skeletal muscle contractions by an effect at the neuromuscular junction, rather than the nerve innervating the muscle or the muscle itself.

Much of the early literature concerning the effects of curare is confusing and difficult to interpret. T his is not at all surprising considering that this research was performed using crude extracts, many of which came from different plants. It was not until the late 1800s that scientists recognized that curare extracts contained quaternary ammonium salts. T his knowledge prompted the use of other quaternary ammonium compounds to explore the neuromuscular junction. In the meantime, curare extracts continued to be used to block the effects of nicotine and acetylcholine at skeletal neuromuscular junctions and to explore the nicotinic receptors. In 1935, King (55) isolated a pure alkaloid, which he named d-tubocurarine, from a tube curare of unknown botanical origin. T he word “ tube” refers to the container in which the South American natives transported their plant extract. It was almost 10 years later that the botanical source for d-tubocurarine was clearly identified as Chondodendron tomentosum. T he structure that King assigned to tubocurarine possessed two nitrogen atoms, both of which were quaternary ammonium salts (e.g., a bi s-quaternary ammonium compound). It was not until 1970 that the

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correct structure was reported by Everett et al. (56). T he correct structure, shown here, has only one quaternary ammonium nitrogen; the other nitrogen is a tertiary amine salt. Nevertheless, the incorrect structure of tubocurarine served as the model for the synthesis of all the neuromuscular blocking agents in use today. T hese compounds have been of immense therapeutic value for surgical and orthopedic procedures and have been essential to research that led to the isolation and purification of nicotinic receptors. T he potential therapeutic benefits of the neuromuscular blocking effects of tubocurarine as well as the difficulty in obtaining pure samples of the alkaloid encouraged medicinal chemists to design structurally related compounds possessing nicotinic antagonist activity. Using the incorrectly assigned bi s-quaternary ammonium structure of tubocurarine (as reported by King) as P.386 a guide, a large number of compounds were synthesized and evaluated. It became apparent that a bi s-quaternary ammonium compound having two quaternary ammonium salts separated by 10 to 12 carbon atoms (similar to the distance between the nitrogen atoms in tubocurarine) was a requirement for neuromuscular blocking activity. T he rationale for this structural requirement was that in contrast to muscarinic receptors, nicotinic receptors possessed two anionic-binding sites, both of which had to be occupied for a neuromuscular blocking effect. It is important to observe that the current transmembrane model for the nicotinic receptor protein has two anionic sites in the extracellular domain. Some of the new bi s-quaternary ammonium agents produced depolarization of the postjunctional membrane at the neuromuscular junction before causing blockade; other compounds, such as tubocurarine, did not produce this depolarization. T hus, the structural features of the remainder of the molecule determined whether the nicotinic antagonist was a depolarizing or a nondepolarizing neuromuscular blocker.

Therapeutic Application Neuromuscular blocking agents are used primarily as an adjunct to general anesthesia. T hey produce skeletal muscle relaxation that facilitates operative procedures such as abdominal surgery. Furthermore, they reduce the depth requirement for general anesthetics; this decreases the overall risk of a surgical procedure and shortens the postanesthetic recovery time. Muscles producing rapid movements are the first to be affected by neuromuscular blocking agents. T hese include muscles of the face, eyes, and neck. Muscles of the limbs, chest, and abdomen are affected next, with the diaphragm (respiration) being affected last. Recovery generally is in the reverse order. Neuromuscular blocking agents also have been used i n the correction of dislocations and the realignment of fractures. Short-acting neuromuscular blocking agents, such as succinylcholine, are routinely used to assist in tracheal intubation. When choosing a neuromuscular blocking agent, four questions must be considered: 1. Will the compound produce the desired neuromuscular blockade? 2. What is its duration of action? 3. What are its adverse effects? 4. What is its relative cost?

Side Effects Adverse reactions to most, but not all, of the neuromuscular blocking agents may include hypotension, bronchospasm, and cardiac disturbances. T he depolarizing agents also cause an initial muscle fasciculation before relaxation. Many of these agents cause release of histamine and subsequent cutaneous (flushing, erythema, urticaria, and pruritus), pulmonary (bronchospasm and wheezing), and cardiovascular (hypotension) effects.

Specific Depolarizing Neuromuscular Blocking Agents

Decamethonium bromide Decamethonium was one of the first neuromuscular blocking agents to be synthesized. An SAR study on a series of bi s-quaternary ammonium compounds with varying numbers of methylene groups separating the nitrogen atoms demonstrated that maximal neuromuscular blockade occurred with 10 to 12 unsubstituted methylene groups. Activity diminished as the number of carbons was either decreased or increased. T he compound with six methylene groups, hexamethonium, is a nicotinic antagonist at autonomic ganglia (ganglionic blocking agent). All the compounds in this series that possessed neuromuscular blocking activity also caused depolarization of the postjunctional membrane.

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Succinylcholine chloride (Anectine) Succinylcholine is a depolarizing neuromuscular blocking agent that represents a dimer of acetylcholine bonded through their α carbons. T he molecule can exist in an extended conformation (antiperiplanar), as shown in the Newman projection. T his would account for the appropriate separation of the quaternary nitrogens. Succinylcholine is rapidly hydrolyzed and rendered inactive both in aqueous solution and by plasma esterases; this chemical instability must be considered when preparing solutions for parenteral administration. T his same chemical property, however, gives the compound a brief duration of action. As a result, succinylcholine is frequently used for the rapid induction of neuromuscular blockade and when blockade of short duration is desired (T able 12.4). As such, it is used primarily to produce muscle relaxation during endotracheal intubation or endoscopic procedures. T he depolarizing property is undesirable in neuromuscular blockers, so most research efforts have been directed toward the design of nondepolarizing agents.

Specific Nondepolarizing Neuromuscular Blocking Agents Compounds in this class have one or two quaternary ammonium groups. T hose with only one quaternary ammonium group, however, exist as bi s-cations in vivo because of the second positive charge being on a protonated tertiary amine. T he various structures of these compounds serve primarily as a “ scaffold” to position two P.387 positive charges in the correct three-dimensional orientation for interaction with the transmembrane nicotinic receptors.

Table 12.4. Properties of Clinically Useful Neuromuscular Blocking Agents

Agent

Time of Onset (min)

Duration of Action (min)

Half-life (min) Mode of Elimination

Succinylcholine

1–1.5

6–8

norepinephrine > isoproterenol. P.396 In contrast, β-adrenoceptors are stimulated in the following descending order of potency: isoproterenol > epinephrine > norepinephrine.

In the years since Ahlquist's original classification, additional small molecule agonists and antagonists have been used to allow further subclassification of α- and β-receptors into α 1 and α 2 subtypes of α-receptors and the β 1 , β 2 , and β 3 subtypes of β-adrenoceptors. T he powerful tools of molecular biology have been used to clone, sequence, and identify even more subtypes of alpha receptors for a total of six. Currently, three types of α 1 -adrenoceptor, called α 1A, α 1B , and α 1D , are known. (T here is no α 1C , because identification of a supposed α 1C was found to be incorrect.) Currently, three subtypes of α 2 , known as α 2A, α 2B , and α 2C , also are known (8). T he data derived from molecular biology provides a wealth of information on the structures and biochemical properties of both α- and β-receptors. Intensive research continues in this area, and the coming years may provide evidence of additional subtypes of both α- and β-receptors. At this time, however, only the α 1 -, α 2 -, β 1 -, and β 2 -receptor subtypes are sufficiently well differentiated by their small molecule binding characteristics to be clinically significant in pharmacotherapeutics, although therapeutic agents acting selectively on β 3 -adrenoceptors to induce fat catabolism may become available in the near future (9). T he adrenoceptors, both α and β, are members of a receptor superfamily of membrane-spanning proteins, including muscarinic, serotonin, and dopamine receptors, which are coupled to intracellular GT P-binding proteins (G proteins), which determine the cellular response to receptor activation (10). All these receptors exhibit a common motif of a single polypeptide chain that is looped back and forth through the cell membrane seven times with an extracellular N-terminus and intracellular C-terminus. T he human β 2 -adrenoceptor was one of the first to be cloned and thoroughly studied (Fig. 13.4) (11). T he seven transmembrane domains, T MD1 through P.397 T MD7, are composed primarily of lipophilic amino acids arranged in α-helices connected by regions of hydrophilic amino acids. T he hydrophilic regions form loops on

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the intracellular and extracellular faces of the membrane. In all the adrenoceptors, the agonist/antagonist recognition site is located within the membrane-bound portion of the receptor. T his binding site is within a pocket formed by the membrane-spanning regions of the peptide, as illustrated in Figure 13.5 for epinephrine bound to the human β 2 -receptor. All the adrenoceptors are coupled to their effector systems through a G protein, which is linked through reversible binding interactions with the third intracellular loop of the receptor protein.

Fig. 13.4. Human β 2 -adrenergic receptor: amino acid sequence of the human β 2 -receptor showing the seven transmembrane domains (I–VII), the connecting intracell ular and extracell ular l oops, extracel lular glycosylation sites at asparagines 6 and 15, and intrachain disulfide bonds between cysteines 106–184 and 190–191. Also indicated are the amino acids identified as participating in neurotransmitter binding—aspartate 113 in transmembrane domain III, which binds the positively charged amine of the neurotransmitter, and serines 204 and 207 of transmembrane domain V, which form hydrogen-bonds with the catechol hydroxyls. Phenylal anine 290 may participate in agonist binding as well . Amino acids 222–229 and 258–270 of the third intracellul ar l oop are critical for G protein–coupl ing, and palmitoylated cysteine 341 is critical for proper adenylyl cyclase activation. (From Ostrowski J, Kjelsberg MA, Caron MG, et al. Mutagenesis of the β 2 -adrenergic receptor: how structure elucidates function. Annu Rev Pharmacol Toxicol 1992;32:167–183; with permission.)

Fig. 13.5. Proposed arrangement for the transmembrane hel ices of the β 2 -adrenergic receptor depicting the binding site for epinephrine as viewed from the extracell ular side. (From Ostrowski J, Kjelsberg MA, Caron MG, et al . Mutagenesis of the β 2 -adrenergic receptor: how structure elucidates function. Annu Rev Pharmacol Toxicol 1992;32:167–183; with permission.)

Salient features of the extensively studied β 2 -adrenoreceptor are indicated in Figure 13.4. Binding studies with selectively mutated β 2 -receptors have provided strong evidence for binding interactions between agonist functional groups and specific residues in the transmembrane domains of adrenoceptors. Such studies indicate that Asp113 in transmembrane domain 3 (T MD3) of the β 2 -receptor is the acidic residue that forms a bond, presumably ionic or a salt bridge, with the positively charged amino group of catecholamine agonists. An aspartic acid residue also is found in a comparable position in all the other adrenoceptors as well as other known G protein– coupled receptors that bind substrates having positively charged nitrogens in their structures. Elegant studies with mutated receptors and analogues of isoproterenol demonstrated that Ser204 and Ser207 of T MD5 are the residues that form hydrogen bonds with the catechol hydroxyls of β 2 -agonists (12). Furthermore, the evidence indicates that Ser204 interacts with the meta hydroxyl group of the ligand, whereas Ser207 interacts specifically with the para hydroxyl group. Serine residues are found in corresponding positions in T MD5 of the other known adrenoceptors. Evidence indicates that the phenylalanine residue of T MD6 also is involved in ligandreceptor bonding with the catechol ring. Studies such as these and others that indicated the presence of specific disulfide bridges between cysteine residues of the β 2 -receptor led to the binding scheme shown in Figure 13.5. Structural differences exist among the various adrenoceptors with regard to their primary structure, including the actual peptide sequence and length. Each of the adrenoceptors is encoded on a distinct gene, and this information was crucial to the proof that each adrenoreceptor is, indeed, distinct although related. T he amino acids that make up the seven transmembrane regions are highly conserved among the various adrenoreceptors, but the hydrophilic portions are quite variable. T he largest differences occur in the third intracellular loop connecting T MD5 and T MD6, which is the site of linkage between the receptor and its associated G protein. Compare the diagram of the β 2 -receptor in Figure 13.4 with that of the α 2 -receptor in Figure 13.6 (13).

Effector Mechanisms of Adrenergic Receptors

Each adrenoceptor is coupled through a G protein to an effector mechanism. Effector mechanisms are proteins that are able to translate the conformational change caused by activation of the receptor into a biochemical event within the cell. All the β-adrenoceptors are coupled via specific G proteins (G s ) to the activation of adenylyl cyclase* (14). T hus, when the receptor is stimulated by an agonist, adenylyl cyclase is activated to catalyze the formation of cyclic AMP (cAMP) from AT P. Called a second P.398 messenger for the β-adrenoceptors, cAMP is known to function as a second messenger for a number of other receptor types. cAMP is considered to be a messenger, because it can diffuse through the cell for at least short distances to modulate biochemical events remote from the synaptic cleft. Modulation of biochemical events by cAMP includes a phosphorylation cascade of other proteins. Additionally, cAMP is rapidly deactivated by hydrolysis of the phosphodiester bond by the enzyme phosphodiesterase. T he α 2 -receptor may use more than one effector system depending on the location of the receptor. T o date, however, the best-understood effector

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system of the α 2 -receptor appears to be similar to that of the β-receptors, except that linkage via a G protein (G i ) leads to inhibition of adenylyl cyclase instead of activation.

Fig. 13.6. Human kidney α 2 -adrenergic receptor: amino acid sequence of the human kidney α 2 -receptor showing the seven transmembrane domains and the connecting intracellul ar and extracellul ar l oops. Note particularly the large third intracellular loop, which is the G protein– binding site. The arrows point to the sites of gl ycosylation. Amino acids in black circles are those identical to the amino acids in the human platelet α 2 -receptor. (From Regan JW, Kobil ka TS, Yang-Feng TL, et al . Cloning and expression of a human kidney cDNA for an α 2 -adrenergic receptor subtype. Proc Natl Acad Sci U S A 1988;85:6301–6305; with permission.)

T he α 1 -adrenoreceptor is linked through yet another G protein to a complex series of events involving hydrolysis of polyphosphatidylinositol (15). T he first event set in motion by activation of the α 1 -receptor is activation of the enzyme phospholipase C. Phospholipase C catalyzes the hydrolysis of phosphatidylinositol-4,5-biphosphate. T his hydrolysis yields two products, each of which has biological activity as second messengers of the α 1 -receptor (see Chapter 4). T hese two products are 1,2-diacylglycerol (DAG) and inositol-1,4,5-triphosphate (IP 3 ). T he latter, IP 3 , causes the release of calcium ions from intracellular storage sites in the endoplasmic reticulum, resulting in an increase in free intracellular calcium levels. Increased free intracellular calcium is correlated with smooth muscle contraction. T he other product, DAG, is thought to activate cytosolic protein kinase C, which may induce slowly developing contractions of vascular smooth muscle. T he end result of a complex series of protein interactions triggered by agonist binding to the α 1 -receptor includes increased intracellular free calcium, which leads to smooth muscle contraction. When the smooth muscle innervated by α 1 -receptors is in vascular walls, stimulation leads to vascular constriction.

Receptor Localization T he generalization made in the past about synaptic locations of adrenoreceptor subtypes was that all α 1 -, β 1 -, β 2 -, and β 3 -receptors are postsynaptic receptors that are linked to stimulation of biochemical processes in the postsynaptic cell. Presynaptic β-receptors, however, are P.399 known to occur, although their function is unclear. T raditionally, the α 2 -receptor has been viewed as a presynaptic receptor that resides on the outer membrane of the nerve terminus or presynaptic cell and reacts with released neurotransmitter. T he α 2 -receptor serves as a sensor and modulator of the quantity of neurotransmitter present in the synapse at any given moment. T hus, during periods of rapid nerve firing and neurotransmitter release, the α 2 -receptor is stimulated and causes an inhibition of further release of neurotransmitter. T his is a well-characterized mechanism for modulation of neurotransmission. Not all α 2 -receptors are presynaptic, but the physiologic significance of postsynaptic α 2 -receptors is less well understood (16).

T herapeutic Relevance of Adrenergic Receptor Subtypes T he clinical utility of receptor-selective drugs becomes obvious when one considers the adrenoreceptor subtypes and effector responses of only a few organs and tissues innervated by the sympathetic nervous system. T he major adrenoceptor subtypes are listed in T able 13.2. For example, the predominant response to adrenergic stimulation of smooth muscle of the peripheral vasculature is constriction causing a rise in blood pressure. Because this response is mediated through α 1 -receptors, an α 1 -antagonist would be expected to cause relaxation of the blood vessels and a drop in blood pressure with clear implications for treating hypertension. In addition, the presence of α 1 -adrenoceptors in the prostate gland leads to the use of α 1 -antagonists in treating benign prostatic hyperplasia. T he principal therapeutic uses of adrenergic agonists and antagonists are shown in T able 13.3. A smaller number of β 2 -receptors on vascular smooth muscle mediate arterial dilation, particularly to skeletal muscle, and a few antihypertensives act through stimulation of these β 2 -receptors. (Adrenergic antihypertensives are discussed more thoroughly in Chapter 29.) Adrenergic stimulation of the lungs causes smooth muscle relaxation and bronchodilation mediated through β 2 -receptors. Drugs acting as β 2 -agonists are useful for alleviating respiratory distress in persons with asthma or other obstructive pulmonary diseases (see Chapter 44). Activation of β 2 -receptors in the uterus also causes muscle relaxation, and so some β 2 -agonists are used to inhibit uterine contractions in premature labor. Adrenergic stimulation of the heart causes an increase in rate and force of contraction, which is mediated primarily by β 1 -receptors. Drugs with β 1 -blocking activity slow the heart rate and decrease the force of contraction. T hese drugs have utility in treating hypertension, angina, and certain cardiac arrhythmias (see Chapters 26 and 29).

Table 13.2. Selected Tissue Responses to Stimulation of Adrenoceptor Subtypes Organ or Tissue

Type Receptor M ajorResponse

Arteriol es, vascular bed to skeletal muscle

α 1, α 2 β2

Constriction Dil ation

Eye (radial muscle)

α1

Contraction (papillary dil ation)

Heart

β1

Increased rate and force

Lungs

β2

Relaxation (bronchodilation)

Liver

α 1, β 2

Increased gluconeogenesis and glycogenolysis

Fat cel ls

α 1, β 3

Lipol ysis

Uterus (pregnant)

α1 β2

Contraction Relaxation

Intestine

α 1, β 2

Decreased motil ity

From the preceding discussions of the biosynthesis, storage, release, and fate of norepinephrine, one can readily conceive of a number of possible sites of drug action for adrenergic drugs. As mentioned, there are drugs that act P.400

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directly on the receptors as agonists and antagonists, drugs that affect storage and release from vesicles, drugs that affect neurotransmitter biosynthesis, and drugs that affect uptake and catabolism of norepinephrine and epinephrine. T hese categories are discussed in turn. Most adrenergic drugs fit into well-defined classes with readily defined SARs, but a few adrenergic drugs do not permit such straightforward structural definition of their activity. We begin with a discussion of phenylethanolamine (or phenethanolamine) agonists, which do have reasonably clear SARs. Although many of these drugs directly stimulate adrenoceptors, others exhibit what is termed “ indirect activity.” Indirect agonists do not directly bind to and activate adrenergic receptors; rather, they are taken up into the presynaptic neuron, where they cause the release of norepinephrine, which can diffuse into the receptor causing the observed response. Mixed-acting drugs have both a direct and an indirect component to their action, and the relative amount of direct versus indirect activity for a given drug varies considerably with its chemical structure, the tissue preparation examined, and the experimental animal species.

Table 13.3. Principal Therapeutic Uses of Adrenergic Agonists and Antagonists AdrenoceptorDrug Action α1

Therapeutic Uses

Agonists

Shock, hypotension (to raise blood pressure) Hasal decongestants

Antagonists

Antihypertensives Benign prostatic hyperplasia (BPH)

α2

Agonists

Antihypertensives Gl aucoma Anal gesia Sedatives

β1

Antagonists

Antihypertensives Antiarrythmics

β2

Agonists

Bronchodilators (asthma and COPD) Gl aucoma

β3

Agonists

Weight l oss (investigational drugs)

Structure-Activity Relationships of Adrenergic Agonists Phenylethanolamine Agonists T he structures of many clinically useful phenylethanolamine-type adrenergic agonists are summarized in T able 13.4. Agents of this type have been extensively studied over the years since discovery of the naturally occurring prototypes, epinephrine and norepinephrine, and the structural requirements and tolerances for substitutions at each of the indicated positions have been established (2). In general, a primary or secondary aliphatic amine separated by two carbons from a substituted benzene ring is minimally required for high agonist activity in this class. Because of the basic amino groups (pK a range, ~8.5–10), all these agents are highly positively charged at physiologic pH. By definition, agents in this class have a hydroxyl group on C1 of the side chain, β to the amine, as in epinephrine and norepinephrine. T his hydroxyl-substituted carbon must be in the R absolute configuration for maximal direct activity as in the natural neurotransmitter, although most drugs currently are sold as mixtures of both (R) and (S) stereoisomers at this position (racemates). Given these features in common, the nature of the other substituents determines receptor selectivity and duration of action. In the following discussions, keep in mind that saying a drug is selective for a given receptor does not mean it has no activity at other receptors and that the clinically observed degree of selectivity is frequently dose-dependent.

R 1 , Substitution on the Amino Nitrogen We have already seen that as R 1 is increased in size from hydrogen in norepinephrine to methyl in epinephrine to isopropyl in isoproterenol, that activity at α-receptors decreases, and that activity at β-receptors increases. T hese P.401 compounds were used to define α- and β-activity long before receptor proteins could be isolated and characterized. T he activity at both α- and β-receptors is maximal 1

1

1

when R is methyl as in epinephrine, but α-agonist activity is dramatically decreased when R is larger than methyl and is negligible when R is isopropyl, as in isoproterenol, leaving only β-activity. In fact, the β-activity of isoproterenol actually is enhanced over norepinephrine and epinephrine. Presumably, the β-receptor has a large lipophilic binding pocket adjacent to the amine-binding aspartic acid residue, which is absent i n the α-receptor. As R 1 becomes larger than t-butyl into aryl-αmethylalkyl groups, affinity for α 1 -receptors, but not intrinsic activity, returns, which means large lipophilic groups can afford compounds with α 1 -blocking activity (e.g., labetalol, a mixed α/β-antagonist). In addition, the N-substituent also can provide selectivity for different β-receptors, with a t-butyl group affording selectivity for β 2 -receptors. For example, with all other features of the molecules being constant, colterol is a selective β 2 -agonist, whereas isoproterenol is a nonselective β-agonist. When considering use as a bronchodilator, a nonselective β-agonist, such as isoproterenol, has undesirable cardiac stimulatory properties because of its β 1 -activity, which is greatly diminished in a selective β 2 -agonist, such as albuterol. Also, an arylalkyl group (where the alkyl chain ranges from 2–11 carbon/oxygen atoms) can provide β-selectivity with increased lipophilicity and cell penetration for longer duration of action.

Table 13.4. Phenylethanolamine Adrenergic Agonists

Drug

R1

R2

R3

Receptor Activity

Norepinephrine

H

H

3′,4′-diOH

α + β

Epinephrine

CH 3

H

3′,4′-diOH

β ≥ α

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α-Methylnorepinephrine

H

CH 3

3′,4′-diOH

α + β

Ethyl norepinephrine

H

CH 2 CH 3

3′,4′-diOH

β > α

Isoproterenol

CH(CH 3 ) 2

H

3′,4′-diOH

General β

Isoetharine

CH(CH 3 ) 2

CH 2 CH 3

3′,4′-diOH

Selective β 2

Colterol

C(CH 3 ) 3

H

3′,4′-diOH

Selective β 2

Metaproterenol

CH(CH 3 ) 2

H

3′,5′-diOH

Selective β 2

Terbutaline

C(CH 3 ) 3

H

3′,5′-diOH

Selective β 2

Albuterol

C(CH 3 ) 3

H

3′-CH 2 OH, 4′-OH

Selective β 2

Phenylephrine

CH 3

H

3′-OH

α

Metaraminol

H

CH 3

3′-OH

α

Methoxamine

H

CH 3

2′,5′-diOCH 3

α

Ephedrine, pseudoephedrine

CH 3

CH 3

H

α + β

Phenylpropanolamine

H

CH 3

H

α + β

Salmeterol

-(CH 2 ) 6 -O-(CH 2 ) 4 -C 6 H 5

H

3′-CH 2 OH, 4′-OH

β2 > β1

Formoterol

-CH(CH 3 )CH 2 -C 6 H 4 -4-OCH 3

H

3′-NH-COH, 4′-OH

β2 > β1

R 2 , Substitution α to the Basic Nitrogen, Carbon-2 Small alkyl groups, methyl or ethyl, may be present on the carbon adjacent to the amino nitrogen, carbon-2 in T able 13.4. Such substitution slows metabolism by MAO but has little overall effect on duration of action in catecholamines, because they remain substrates for COMT . Resistance to MAO activity is more important in noncatechol, indirect-acting phenylethylamines. An ethyl group in this position diminishes α-activity far more than β-activity, affording compounds with β-selectivity, such as ethylnorepinephrine. Substitution on this carbon also introduces another asymmetric center into these molecules producing pairs of diastereomers, which can have significantly different biological and chemical properties. For example, maximal direct activity in the stereoisomers of α-methylnorepinephrine resides with the erythro stereoisomer with the 1R,2S absolute configuration (17). T he configuration of C2 has a great influence on receptor binding, because the 1R,2R diastereomer of α-methylnorepinephrine has primarily indirect activity, even though the absolute configuration of the hydroxyl-bearing C1 is the same as in norepinephrine. In addition, with respect to α-activity, this additional methyl group makes the direct-acting 1R,2S stereoisomer of α-methylnorepinephrine more selective for α 2 -adrenoceptors than for α 1 -adrenoceptors. T his has important consequences in the antihypertensive activity of α-methyldopa, which is discussed later and in Chapter 29. T he same stereochemical relationships hold for metaraminol and other phenyletha-nolamines, in which stereochemical properties have been investigated.

R 3 , Substitution on the Aromatic Ring T he natural 3′,4′-dihydroxy–substituted benzene ring in norepinephrine provides excellent receptor activity for both α- and β-sites. Such catechol-containing compounds have poor oral activity, however, because they are rapidly metabolized by COMT . Alternative substitutions have been found that retain good activity but are more resistant to COMT metabolism. In particular, 3′,5′-dihydroxy compounds are not good substrates for COMT and, in addition, provide selectivity for β 2 -receptors. T hus, because of its ring substitution pattern, metaproterenol is an orally active bronchodilator with little of the β 1 cardiac stimulatory properties possessed by isoproterenol. Other substitutions are possible that enhance oral activity and provide selective β 2 -activity, such as the 3′-hydroxymethyl and 4′-hydroxy substitution pattern of albuterol, the 3′-amino or 3′-formylamino, which also are resistant to COMT . At least one of the groups must be capable of forming hydrogen bonds, and if there is only one, it should be at the 4′ position to retain β-activity. For example, ritodrine has only a 4′-OH for R3 yet retains good β-activity, with the large substituent on the nitrogen making it β 2 selective. Ritodrine has been administered to pregnant women to prevent premature labor, consistent with β 2 -adrenoceptor stimulation relaxing the uterus.

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If R3 is only a 3′-OH or 3′-sulfonamide, however, activity is reduced at α sites but almost eliminated at β sites, thus affording selective α-agonists, such as phenylephrine and metaraminol. Further indication that α sites have a wider range of substituent tolerance for agonist activity is shown by the 2′,5′-dimethoxy substitution of methoxamine, which is a selective α-agonist that also has β-blocking activity at high concentrations. In keeping with the presence of α-adrenoceptors in the peripheral vasculature, all three of these agents cause vasoconstriction. P.402

When the phenyl ring has no phenolic substituents (i.e., R3 = H), these phenylethanolamines may have both direct and indirect activity. Direct activity (i.e., agonist) is the stimulation of an adrenoceptor by the drug itself; indirect activity is the result of displacement of norepinephrine from its storage granules or reuptake inhibition, resulting in nonselective stimulation of the adrenoceptors by the displaced norepinephrine. Because norepinephrine stimulates both α- and β-adrenoceptors, indirect activity cannot be selective. Stereochemistry of the various substituents also may play a role in determining the extent of direct/indirect activity. For example, ephedrine and pseudoephedrine have the same substitution pattern, but substitution of both carbons 1 and 2 means four stereoisomers are possible. Racemic (±)-ephedrine is a mixture of the erythro enantiomers 1R,2S and 1S,2R, whereas the threo pair of enantiomers, 1R,2R and 1S,2S, are known as racemic pseudoephedrine (±)-ephedrine). As discussed for α-methylnorepinephrine, (–)-ephedrine is the naturally occurring stereoisomer and has the 1R,2S absolute configuration with a mixed direct activity on both α- and β-receptors and some indirect activity. Its 1S,2R-(+)-enantiomer exhibits primarily indirect activity. 1S,2S-(+)-Pseudoephedrine has virtually no direct receptor activity and is mostly indirect acting.

Norepinephrine and Epinephrine Norepinephrine has limited clinical application because of the nonselective nature of its action, which causes both vasoconstriction and cardiac stimulation. In addition, it must be given intravenously, because it has no oral activity (poor oral bioavailability) as a result of its rapid metabolism by intestinal and liver COMT and MAO, 3′-O-glucuronidation/sulfation in the intestine, and low lipophilicity. Rapid metabolism by MAO and COMT limits its duration of action to only 1 or 2 minutes, even when given by infusion. T he drug is used to counteract various hypotensive crises, because its α-activity raises blood pressure and as an adjunct treatment in cardiac arrest, where its β-activity stimulates the heart. Epinephrine is far more widely used clinically than norepinephrine, although it also lacks oral activity for the same reasons as norepinephrine. Epinephrine, similar to norepinephrine, is used to treat hypotensive crises and, because of its greater β-activity, to stimulate the heart in cardiac arrest. T he β 2 -activity of epinephrine leads to its administration intravenously and in inhalers to relieve bronchoconstriction in asthma and to application in inhibiting uterine contractions. Because it has significant α-activity, epinephrine has been used in nasal decongestants. Constriction of dilated blood vessels in mucous membranes shrinks the membranes and reduces nasal congestion, although significant aftercongestion may limit its utility.

Selective α-Adrenergic Agonists α 1 -Agonist Phenylethanolamines: Metaraminol, Methoxamine, and Phenylephrine Metaraminol, methoxamine, and phenylephrine are selective for α 1 -receptors and have minimal cardiac stimulatory properties. Because they are not substrates for COMT , their duration of action is significantly longer than that of norepinephrine. T heir α 1 -agonist activity makes them strong vasoconstrictors, however, and their primary systemic use is limited to treating hypotension during surgery or severe hypotension accompanying shock. Methoxamine is bioactivated by O-demethylation to an active m-phenolic metabolite. T he β-blocking activity of methoxamine, which is seen at high concentrations, affords some use in treating tachycardia. Phenylephrine, which also is a selective α 1 -agonist, is used similarly to metaraminol and methoxamine for hypotension. It also has widespread use as a nonprescription nasal decongestant in both oral and topical preparations. Its oral bioavailability is less than 10% because of its hydrophilic properties and intestinal

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3′-O-glucuronidation/sulfation. Phenylephrine preparations applied topically to the eye constrict the dilated blood vessels of bloodshot eyes and, in higher concentrations, are used to dilate the pupil during eye surgery.

2-Arylimidazoline α 1 -Agonists In addition to phenylethanolamine derivatives, α-adrenoceptors accommodate a diverse assortment of structures. T he imidazoline derivatives in Figure 13.7 also are selective α 1 -agonists and, therefore, are called vasoconstrictors/vasopressors. T hey all contain a one-carbon bridge between C2 of the imidazoline ring (pK a range, 10–11) and a phenyl substituent; therefore, the general skeleton of a phenylethylamine is contained within the structures. Lipophilic substitution on the phenyl ring ortho to the methylene bridge appears to be required for agonist activity at α 1 - and α 2 -receptors (15). Presumably, the bulky lipophilic groups attached to the phenyl ring at the meta or para positions provide selectivity for the α 1 -receptor by P.403 diminishing affinity for α 2 -receptors. T hese highly ionic compounds are widely used only in topical preparations as nasal decongestants and eye drops (T able 13.5). Systemically, they are potent vasoconstrictors.

Fig. 13.7. Imidazoline α 1 -adrenergic agonists.

α 2 -Adrenergic Agonists: 2-Aminoimidazolines and Other α 2 -Agonists T hree subtypes of α 2 -adrenoceptors, α 2A, α 2B , and α 2C , are recognized. Each plays a role in the different clinical applications of α 2 -agonists, which include use as antihypertensives (see Chapter 29), antiglaucoma drugs, and analgesics. T he first of these drugs, clonidine, was introduced as an antihypertensive, an effect attributed to central α 2A-adrenoceptors in cardiovascular control areas of the brain (18).

Clonidine (Catapres) Closely related structurally to the imidazoline nasal decongestants is clonidine and other developed analogues (Fig. 13.8). Clonidine was originally synthesized as a vasoconstricting nasal decongestant but, in early clinical trials, was found to have dramatic hypotensive effects—in contrast to all expectations for a vasoconstrictor (19). Subsequent pharmacological investigations showed that clonidine not only has some α 1 -agonist (vasoconstrictive) properties in the periphery but also that it is a powerful α 2 -adrenergic agonist and exhibits specific binding to nonadrenergic imidazoline binding sites in the CNS (mainly in the medulla oblongata) causing inhibition of sympathetic output (sympathoinhibition) (see Chapter 29). Because of its peripheral activity on extraneuronal vascular postsynaptic α 2B -receptors (18), initial doses of clonidine may produce a transient vasoconstriction and an increase in blood pressure that is soon overcome by vasodilation as clonidine penetrates the blood-brain barrier and interacts with CNS α 2A-receptors.

Table 13.5 Imidazoline α 1 -Agonists in Over-the-Counter Vasoconstrictors Drug

Nasal Decongestant

Eye drops

Xylometazoline

Otrivin, Inspire

—

Oxymetazoline

Afrin, Duration, Neo-Synephrine, Vicks Sinex

Visine L.R. Ocu Clear

Tetrahydrozol ine

—

Murine, Visine, Soothe

Naphazoline

4-Way Fast Acting, Privine

Naphcon, Clear Eyes

Fig. 13.8. Imidazoline α 2 -adrenergic agonists.

Similar to the imidazoline α 1 -agonists, clonidine has lipophilic ortho-dichloro substituents on the phenyl ring, but the most readily apparent difference between clonidine and the α 1 -agonists in Figure 13.7 is the replacement of the CH 2 bridge on C1 of the imidazoline by an amine NH. T his makes the imidazoline ring part of a guanidino group, and the uncharged form of clonidine exists as a pair of tautomers as shown.

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Clonidine has a pK a of 8.3 and is approximately 80% ionized at physiologic pH. Its experimental log P is 1.6 (log D at pH 7.4 is 0.8). T he positive charge is shared through resonance by all three nitrogens of the guanidino group. Steric crowding by the bulky ortho-chlorine groups does not permit a coplanar conformation of the two rings, as illustrated in Figure 13.9. T he o,o′-dichloro-substituents in clonidine can be replaced by a methyl group without losing any potency or selectivity. A methyl group is approximately similar in size (volume) as a chlorine atom; thus, it will exhibit similar steric interactions to force the phenyl ring to assume proper conformation for binding to the α 2 -receptors similar to Figure 13.9. T hus, replacement of the o-dichlorines by bulky groups in clonidine will retain its agonist potency. T he aromatic methyl group, however, will be readily P.404 metabolized by the cytochrome P450 enzyme to the corresponding hydroxymethyl and then to the carboxylic acid group, both of which are inactive at the α 2 -receptors. T hus, the methyl analogue will have a shorter duration of action.

Fig. 13.9. Protonated clonidine.

In addition to its use as an antihypertensive, clonidine has been proven useful in a wide variety of conditions. Clonidine has sedative properties and has been used to treat attention-deficit hyperactivity disorder, nicotine and opiate withdrawal, and glaucoma among other uses. Epidural anesthesia has been found to be enhanced by α 2 -agonists (20), and clonidine is available in an injectable form for epidural administration.

Tizanidine T izanidine (Fig. 13.8) is a centrally active muscle relaxant analogue of clonidine that is approved for use in reducing spasticity associated with cerebral or spinal cord injury. Its mechanism of action for reducing spasticity suggests presynaptic inhibition of motor neurons at the α 2 -adrenergic receptor sites, reducing the release of excitatory amino acids and inhibiting facilitatory ceruleospinal pathways, thus resulting in a reduction in spasticity. T izanidine only has a small fraction of the antihypertensive action of clonidine, presumably because of action at a selective subgroup of α 2C -adrenoceptors, which appear to be responsible for the analgesic and antispasmodic activity of imidazoline α 2 -agonists(20).

Apraclonidine (Iopidine) and brimonidine (Alphagan) T he other imidazoline α 2 -agonists in Figure 13.8 that are clinically used for treatment of glaucoma are apraclonidine (pK a = 9.22, log P = 1.53) and brimonidine (pK a = 7.4, log P = 0.78). Stimulation of α 2 -receptors in the eye reduces production of aqueous humor and enhances outflow of aqueous humor, thus reducing intraocular pressure, and also has a neuroprotective effect apparently through α 2A-receptors located in the retina (21,22). Animal and human studies suggest that apraclonidine's primary mechanism of action may be related to a reduction of aqueous formation, whereas brimonidine lowers intraocular pressure by reducing aqueous humor production and increasing uveoscleral outflow. Brimonidine is approximately 1,000-fold more selective for α 2 -receptors than are clonidine or apraclonidine and is a first-line agent for treating glaucoma. It exhibited minimal effect on blood pressure and heart rate. Although both are applied topically to the eye, measurable quantities of these drugs are detectable in plasma, so caution must be employed when cardiovascular agents also are being coadministered to the patient. Plasma brimonidine levels peaked within 1 to 4 hours and declined with a systemic half-life of approximately 3 hours. Brimonidine has been reported to enter the brain and can potentially cause fatigue and/or drowsiness in some patients. Brimonidine is primarily metabolized by aldehyde oxi dase.

Guanfacine (Tenex) and guanabenz (Wytensin) Following the discovery of clonidine, extensive research into the SAR of central α 2 -agonists showed that the imidazoline ring was not necessary for activity in this class but that the phenyl ring required at least one ortho chlorine or methyl group. T wo clinically useful antihypertensive agents resulting from this effort are guanfacine and guanabenz (see Chapter 29). T hese are ring-opened analogues of clonidine, and their mechanism of action is the same as that of clonidine.

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Methyldopa (Aldomet) Although structurally unrelated to the aminoimidazolines or the guanidines, the pro-drug L-α-methyldopa (methyldopa) is an α 2 -agonist acting in the CNS via its active metabolite, α-methylnorepinephrine (Fig. 13.10). Methyldopa is transported across the blood-brain barrier, where it is decarboxylated by aromatic L-amino acid decarboxylase in the brain to α-methyldopamine, which is then stereospecifically hydroxylated to 1R,2S-α-methylnorepinephrine. T his stereoisomer is a selective α 2 -agonist and acts as an antihypertensive agent much like clonidine to inhibit sympathetic neural output from the CNS, thus lowering blood pressure. α-Methylnorepinephrine and α-methyldopamine do not cross the blood-brain barrier because of their hydrophilicity. Originally synthesized as a norepinephrine biosynthesis inhibitor, methyldopa was thought to act through a combination of inhibition of norepinephrine biosynthesis through dopa decarboxylase inhibition and metabolic decarboxylation to generate α-methylnorepinephrine. T he latter was thought to replace norepinephrine in the nerve terminal and, when released, to have less intrinsic activity than the natural neurotransmitter. T his latter mechanism is an example of the concept of a false neurotransmitter. (T he antihypertensive properties for methyldopa are further described in Chapter 29.)

β-Adrenergic Agonists β 2 -Agonist Phenylethanolamines Most of the β 2 -selective adrenergic agonists listed in T able 13.4 are used primarily as bronchodilators in P.405 asthma and other constrictive pulmonary conditions. T heir pharmacological and pharmacokinetic properties are described in T able 13.6. Isoproterenol is a nonselective β-agonist (β 2 /β 1 = 1), and the cardiac stimulation caused by its β 1 -activity and its lack of oral activity have led to its diminished use in favor of more selective β 2 -agonists.

Fig. 13.10. Methyldopa bioactivation.

Table 13.6. Pharmacologic Effects and Pharmacokinetic Properties of Sympathomimetic Bronchodilators

Sympathomimetic

Adrenergic Receptor Activity

Route of Administratio Onset Duration β 2 -potency (min) (hr)

Salmetero2 (Serevent)

β1 5,000 nM ) for h5-HT 1D receptors (34,35). T he major functional difference between rat 5-HT 1B rec eptors and human h5-HT 1B receptors has been attributed to both the presence of a threonine residue at position 355 (i.e., T hr 355) in T M 7 of the latter and the presence of an asparagine residue at the corresponding position in 5-HT 1B rec eptors; site-directed mutagenesis studies have demonstrated that c onversion of T hr 355 to an asparagine (i.e., a T 355N mutant) accounts for the binding differences of certain ligands (e.g., aryloxyalk ylamines such as propranolol). Combined ligand SAR, site-directed mutagenes is, and molecular modeling studies have led to the c onclusion that although most typical

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s erotonergic agonists bind in the central cavity formed by T M3, T M4, T M5, and T M6 (S ite 1) (Fig. 14.3), propranolol most likely occupies the region defined by T M1, T M 2, T M3, and T M7 (Site 2). T he higher affinity of propranolol for the T 355N mutant 5-HT 1B receptors relative to the wild-type receptors was specifically attributed to the formation of two hydrogen bonds between the receptor as paragine and the ether and hydroxyl oxygen atoms of propranolol ( 35).

5-HT 1D agonists and antagonists T here are few 5-HT 1D -selective agonists, but one agent commonly referred to as a prototypical 5-HT 1D agonist is sumatriptan (Imitrex). Sumatriptan, however, exhibits only 2- to 20-fold greater s electivity for the 5-HT 1D receptors than for certain other populations of 5-HT 1 receptors, binds at h5-HT 1D and h5-HT 1B receptors with nearly identical affinity, and also binds at 5-HT 1F r eceptors (36). Structure–activ ity relationships for 5- HT 1D agonists have been reported for many indolealkylamines or tryptamine derivatives, which bind with high affinity but with little selectivity. New agents displaying high affinity and reasonable s electivity for h5-HT 1D /h5-HT 1B receptors over other populations of 5-HT receptors (37) include, for example, zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), and alniditan. Of thes e, all are tryptamine derivatives or sumatriptan-related str uctures except for the benzopyran alniditan. Many of these are commercially available or c urrently undergoing clinical trials. Other investigational agonists are shown in Figure 14.8.

S everal 5-HT 1D receptor antagonists have been developed, including GR127935 (high affinity for h5-HT 1D /h5-HT 1B receptors but possibly a low-efficacy partial agonist) and GR55562. B oth of these agents antagonize many of the effects of sumatriptan.

5-HT 1D receptors: clinical significance T he c linical significance of 5-HT 1D receptors remains largely unk nown. T hese receptors are speculated to be involved in anxiety, depress ion, and other neuropsyc hiatric disorders, but this remains to be substantiated. Recent studies show, however, that 5-HT 1D receptors are the dominant species P.425 in human cerebral blood vessels. S umatriptan and several closely related agents are clinically effective in the treatment of migraine, and logical extr apolation implies a role for 5-HT 1D receptors in this disorder. Agents with 5-HT 1D agonist activity that have found application in the treatment of migraine are, as a group, termed “ triptans,” because the first agent introduced was sumatriptan. As efficacious as the triptans may be, however, it is unknown if their activity involves action only in the periphery or in the CNS as well (38). S umatriptan is a h5-HT 1B and h5-HT 1D agonist. It also is an agonist at 5-HT 1F receptors. Most triptans s hare a similar binding profile. T he vasoconstrictor properties of sumatriptan probably are mediated by its action on arterial s mooth muscle. T he triptans also are believed to inhibit the activation of peripheral nociceptors (38), and this might be related to the localization of 5-HT 1D receptors on peptide nociceptors. Relativ ely little sumatr iptan normally penetrates the blood-brain barrier. Although it has been s peculated that transient changes in blood-brain barrier permeability might occur during migraine attack s, agents with greater lipophilicity (and, hence, enhanced ability to penetrate the blood-brain barrier) have been introduced, including zolmitriptan and rizatriptan (T able 14.3), T heir greater lipophilicity, however, does not seem to correlate with significantly improved clinical efficacy over sumatriptan (38). Other triptans (Fig. 14.8) c urrently being examined include eletriptan, almotriptan, donatriptan, and frovatriptan (37). In general, the newer triptans (e.g. zolmitriptan, rizatriptan, and naratriptan) have a higher oral bioavailability and longer plasma half-life than sumatriptan (39,40) (T able 14.3). Additionally, most triptans bind at 5-HT 1F receptors, and 5-HT 1F rec eptor agonists have demonstrated efficacy in the treatment of migraine (41). At this time, it is not k nown whether 5-HT 1D (i.e., h5-HT 1B and h5-HT 1D ), 5-HT 1F , or a combination of 5-HT 1D /1F actions are most important for the treatment of migraine. T he 5-HT receptor binding characteristics of various triptans have been compared (37). T he s afety of the triptans has been established, with more than 8 million patients treating greater than 340 million attac ks with sumatriptan alone. All triptans narrow coronary arteries by 10 to 20% at clinical doses and should not be administered to patients with coronary or cerebrovascular disease. T riptans having the potential for significant drug–drug interactions include sumatriptan, naratriptan, rizatriptan, almotriptan, and MAO inhibitors; rizatriptan and propanolol; zolmitriptan and cimetidine; and zolmitriptan, naratriptan, and eletriptan and CYP 3A4-metabolized drugs and P -glycoprotein pump inhibitors. T he rational employment of triptans should be governed by the use of these medications for patients with disability associated with migraine. Patients with greater than 10 days of at least 50% disability during 3 months have benefited from treatment with triptans as their first-line treatment for ac ute attacks. When the decision has been made to treat with a triptan, the patient should be instructed to treat ear ly in the attack, when the pain is at a mild phase. T his approach increases the likelihood of achieving a pain-free response, with fewer adverse events and lower likelihood of the headache recurring.

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Fig. 14.8. 5-HT1D receptor agon ists.

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Table 14.3. Pharmacokinetics of the 5-HT 1 Agonists (the Triptans) Parameters

Sumatriptan

Zolmitriptan

Naratriptan Rizatriptan

Almotriptan

Frovatriptan

Eletriptan

Trade name

Imitrex

Zomig

Amerge

Maxalt

Axert

Frova

Relpax

Log P (calc)a

0.7 ± 0.6

1.6 ± 0.4

1.4 ± 0.6

0.9 ± 0.6

1.9 ± 0.6

0.9 ± 0.4

3.1 ± 0.6

Log D (p H 7) (calc)a

–1.7

–0.8

–1.2

–1.4

–0.5

–2.1

0.18

Oral

14–15b

40–50b

70c Female: 75 Male: 60

40–50b

70–80

20–30b Female: ~30 Male: ~20

50cd

Nasal

17

102

—

—

—

—

—

—

—

—

—

—

Bioavailab ility (%)

SQ (su bcutaneous)

97

Protein b ind in g (%)

14–20

25

28–30

14

35

15

85

Volume of distrib ution (L/kg)

50

PO: 7 Nasal: 4

170

110–140

180–200

3–4

2.0–2.5

Elimin ation half-life (h )

PO: 2.5 SC: 2.5

PO: 2–3 Nasal: 3–4

5–6

2- 3

PO: 3–4 SC: 3–4

25

4–5 Eld erly: 6

Major metabolites (%)

In doleacetic acid Glu curon id es Hep atic: 60%

N-d emethyl (act): 4 In doleacetate: 31

Hep atic: 50%

Ind olacetate N-demeth yl (act) 6-OH

Ind ol acetate GABA N-demeth yl Hep atic: 60%

N-d emethyl (act) N-Ac d emethyl

N-d emeth yl (act)

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Metab olizin g enzymes

MAO-A

CYP3A4

CYP3A4 MAO-A

MAO-A CYP3A4

CYP3A4/CYP2D6:12% MAO-A: 27%

CYP1A2

CYP3A4

Excretion (%)

PO: Urine metab : ~60

Urin e metab : 60

Urine metab: 30

Urine metab: 80

Urine metab: 75

Urin e metab : 10–30

Urine metab: ~ 90%

Feces metab : ~40

Feces metab: 30

Feces metab: ~15

Feces metab: 12

Feces metab : 10

Feces metab : 60

Un chan ged: enflurane = sevoflurane > isoflurane > desflurane = halothane.

Low-Level Chronic Exposure

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T ypically, patients are exposed to greater-than-MAC concentrations of the volatile anesthetics for limited periods of time, such as a number of hours during a surgical procedure and not for extended periods of time (e.g., days or weeks). Because surgical and dental personnel, however, may be exposed to low levels of the general anesthetics for prolonged periods over many years or even decades, the ability of such agents to produce chronic toxicity is of paramount concern. Although the occupational exposure to these agents has been minimized with improved waste gas–scavenging devices, some epidemiological studies have demonstrated increased levels of spontaneous abortions, congenital birth defects in offspring, and increased rates of certain cancers in chronically exposed medical personnel (34).

Nitrous Oxide Commonly called “ laughing gas,” nitrous oxide (dinitrogen monoxide, or N 2 O) is a gas at room temperature P.501 and is the least potent of the inhalation anesthetics used today (T able 18.5). With an MAC value in excess of 105%, this colorless, tasteless, and odorless to slightly sweet-smelling gas is not normally capable of producing surgical anesthesia when administered alone. T he MAC for nitrous oxide has been demonstrated to be between 105 and 140% and, thus, cannot achieve surgical anesthesia under conditions at standard barometric pressure. T o demonstrate that the MAC was greater than 100%, Bert in 1879 used a mixture of 85% nitrous oxide with oxygen at 1.2 atmospheres in a pressurized chamber. Only at this elevated pressure could an MAC adequate for surgical anesthesia be achieved. Decreasing the oxygen content of a nitrous oxide mixture to values less than 20% to allow an increase in the concentration of nitrous oxide to greater than 80% can be dangerous, because hypoxia would be expected to result. T hus, when administered alone, nitrous oxide finds utility as an anesthetic agent during certain procedures (e.g., dental) in which full surgical anesthesia is not required. Most commonly, however, nitrous oxide is used in combination with other general anesthetics, because it is capable of decreasing the concentration of the added anesthetic required to produce an adequate depth of anesthesia for surgical procedures. While no firm underlying mechanisms have been demonstrated, some authors have suggested that irreversible oxidation of the cobalt atom in vitamin B 12 by nitrous oxide can lead to inactivation of enzymes dependent on this vitamin, with resultant metabolic aberrations. Such examples have included methionine synthetase and thymidylate synthetase, which are essential in the synthetic pathways leading to the production of myelin and thymidine, respectively. Should these enzymes be impaired during the sensitive periods of in utero development, the potential for malformations may unfortunately be realized. T o date, no studies have been able to demonstrate conclusively that low-level exposure to nitrous oxide is associated with a meaningful disruption of crucial metabolic functions to produce the above-described toxicity; however, measures including improved waste gas–scavenging systems should be taken to minimize exposure of personnel.

Clinically Useful Intravenous Agents Propofol

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T he most commonly used parenteral anesthetic used in the United States is propofol. Used intravenously, propofol is not chemically related to the barbiturates or other intravenous anesthetics. Propofol appears to act via enhancing GABAergic neurotransmission within the central nervous system. T his occurs most likely at the GABA receptor complex, but at a site distinct from where the benzodiazepines bind. Because of its poor water solubility, propofol is formulated as a 1 or 2% emulsion with soybean oil, egg lecithin, and glycerol. Sodium metabisulfite or ethylenediaminetetra-acetic acid also is included in the parenteral dosage form. Because of the likelihood of bacterial contamination of open containers, propofol should be either administered or discarded shortly after sterility seals are broken. Following intravenous administration of a dose of 2.0 to 2.5 mg/kg, a state of hypnosis is achieved within 1 minute, which lasts for approximately 5 minutes. A longer anesthetic state can be achieved by additional propofol dosing or, as typically is the case, maintenance with a volatile anesthetic agent. Blood pressure and heart rate usually are decreased following propofol administration. Metabolism of propofol proceeds rapidly via hepatic conversion to its glucuronide and sulfate conjugates, with less than 0.3% excreted unchanged. Because this agent produces a rapid induction and recovery and is infrequently associated with episodes of vomiting, propofol has found utility as an anesthetic agent in outpatient surgical environments.

Ketamine

Ketamine hydrochloride is an injectable, very potent, rapidly acting anesthetic agent. As with propofol above, its duration of anesthetic activity also is relatively short (10–25 minutes). Ketamine does not relax skeletal muscles and, therefore, can only be used alone in procedures of

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short duration that do not require muscle relaxation. Recovery from anesthesia may be accompanied by “ emergence delirium,” which is characterized by visual, auditory, and confusional illusions. Disturbing dreams and hallucinations can occur up to 24 hours after the administration of ketamine. Its elimination half-life is 2 to 3 hours, and its volume of distribution is 2 to 3 L/kg. Ketamine has an oral bioavailability of less than 16%. T ermination of the acute action of ketamine is largely a result of its redistribution from the brain into other tissue; however, the formation of the glucuronide conjugate and metabolism in the liver to a number of metabolites does occur. One of these metabolites of interest, norketamine, is formed via the action of CYP2B6. T his N-demethylated derivative retains significant activity at the NMDA receptor and may account for some of the longer-lasting effects of this anesthetic agent. Eventual conversion of norketamine P.502 to hydroxylated metabolites and subsequent conjugation leads to metabolites that can be renally eliminated. Less than 4% of a dose is excreted unchanged in the urine. Ketamine is capable of producing a “ dissociative” anesthesia, which is characterized by EEG changes indicating a dissociation between the thalamocortical and limbic systems (35). T hese neuronal systems, which normally are associated with one another, help to maintain the neuronal connections required for consciousness. When disassociated, the subject will appear to be cataleptic, with the eyes open in a slow, nystagmic gaze (1). A potent analgesic and amnesic effect is produced, as is an increase in muscle tone in some areas. Although patients may appear to be awake, they are incapable of communicating and do not remember the event or the people around them. Blood pressure and heart rate usually are increased following ketamine administration. Ketamine appears to act similarly to phencyclidine (PCP; also known as Angel Dust), which acts as an antagonist within the cationic channel of the NMDA receptor complex (36). By preventing the flow of cations through this channel, ketamine prevents neuronal activation, which normally is required for the conscious state. T he analgesic activity of ketamine, however, is more likely the result of an interaction with an opioid receptor or the less-well-understood σ-receptor. Other studies have suggested a possible involvement of serotonin receptors and muscarinic receptors (37). Ketamine, like PCP, has a significant potential for abuse.

Etomidate

Etomidate is the ester of a carboxylated imidazole, with a log P of 3 and a weak base pK a of 4.5, that is available as the D-isomer solubilized in 35% propylene glycol for intravenous injection in addition to being available for rectal administration. It is a potent, short-acting hypnotic agent (< 3 min) without analgesic activity and with a rapid onset of action. T his agent is useful for the induction of anesthesia in hemodynamically unstable patients prone to hypotension because of hypovolemia, coronary artery disease, or cardiomyopathies. Recovery is similarly rapid following

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discontinuance of the drug. Etomidate is hydrolyzed by hepatic esterases to the corresponding inactive carboxylic acid, with subsequent renal and biliary excretion terminating its action. Its apparent elimination half-life is approximately 5 to 6 hours, with a volume of distribution of 5 to 7 L/kg. Changes in hepatic blood flow or hepatic metabolism will have only moderate effects on etomidate disposition. Concerns regarding the ability of etomidate to precipitate myoclonic jerks and inhibit adrenal steroid synthesis have been reported.

Ultrashort-Acting Barbiturates

T he ultrashort-acting barbiturates (e.g., thiopental) are used intravenously to produce a rapid unconsciousness for surgical and basal anesthesia. T hese agents may be used initially to induce anesthesia, which then can be maintained during the surgical procedure with a general anesthetic agent. T he induction typically is very rapid and pleasant. (T hese ultrashort-acting barbiturates are discussed in Chapter 19.)

Case Study Victor ia F . Ro che S. Willia m Zito J A is a bro ught to the eme rge nc y departme nt where yo u work. He is a 58-year-old s treet pers on. His c lothes are dis heve led, he needs a bath and a s have, and he s mells of alc o hol. J A is in extre me p ain and grumpily c omplains that he was pus hed down hard by a c ouple of young “ punks ” who were af ter his s hop ping c art, whic h c ontained all of his world ly pos s e s io ns . The pain is radiating f rom his right hip, and radiographs reveal that he has an inte rtroc hanteric hip f rac ture jus t below the f e mo ral nec k of his rig ht le g. This type of f rac ture is treated by repairing the f rac ture with a metal plate and s c rews . Tes ts re veal that J A has s lightly low b loo d p res s ure (10 5/7 0 mm Hg), and his live r enzymes and c re atinine c learanc e are ind ic ative of dec reas e d live r and kid ney f unc tion, mos t likely bec aus e o f alc ohol and the hard lif e on the s treets . Evaluate s truc tures 1 to 4 f or us e as the ge neral anes thetic f or J A 's s urgery.

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1. I d entif y the the rap eutic problem(s ) in whic h the pharmac is t's intervention may benef it the patient. 2. I d entif y and prioritize the patient-s p ec if ic f ac tors that mus t b e c ons idered to ac hieve the de s ired therapeutic outc omes . 3. Conduc t a thoro ugh and mec hanis tic ally oriented s truc ture– ac tivity analys is of all the rap eutic alternatives provided in the c as e. 4. Evaluate the s truc ture–ac tivity relations hip f indings agains t the p atient-s p ec if ic f ac tors and des ire d therap eutic outc omes , and make a the rapeutic dec is io n. 5. Couns el your patient.

P.503

References 1. Stoelting RK. Pharmacology and Physiology of Anesthetic Practice, 3rd Ed. Philadelphia: Lippincott Williams & Wilkins, 1999.

2. Stevens WC, Kingston HGG. Inhalation anesthesia. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical Anesthesia, 2nd Ed. Philadelphia: JB Lippincott, 1992, pp. 439–465.

3. Harrison NL, Flood P. Molecular mechanisms of general anesthetic action. Sci Med 1998;(May:June):50:18–27.

4. Meyer HH. T he theory of narcosis. JAMA 1906;26:1499–1502.

5. Overton E. Studien ueber die narkose, zugleich ein beitrag zur allgemeinem pharmakologie. Jena: Gustav Fischer, 1901.

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6. Hemming HC, Akabas MH, Goldstein PA, et al. Emerging molecular mechanisms of general anesthetic action. T rends Pharmacol Sci 2005:26:503–510.

7. Lysco GS, Robinson JL, Casto R, et al. T he stereospecific effects of isoflurane isomers in vivo. Eur J Pharmacol 1994;263:25–29.

8. Graf BM, Boban M, Stowe DF, et al. Lack of stereospecific effects of isoflurane and desflurane isomers in isolated guinea pig hearts. Anesthesiology 1994;81:129–136.

9. Sidebotham DA, Schug SA. Stereochemistry in anesthesia. Clin Exp Pharmacol Physiol 1997;24:126–130.

10. Cheng S-C, Brunner EA. Effects of anesthetic agents on synaptosomal GABA disposal. Anesthesiology 1981;55:34–40.

11. Olsen RW. T he molecular mechanism of action of general anesthetics: structural aspects of interactions with GABAA receptors. T oxicol Lett 1998;100–101:193–201.

12. Moody EJ, Harris BD, Skolnick P. Stereospecific actions of the inhalation anesthetic isoflurane at the GABAA receptor complex. Brain Res 1993;615:101–106.

13. T omlin SL. Stereoselective effects of etomidate optical isomers on γ-aminobutyric acid type A receptors and animals. Anesthesiology 1998:88:708–717.

14. Krasowski MD, Harrison NL. General anesthetic actions at ligand-gated ion channels. Cell Mol Life Sci 1999:55:1278–1303.

15. Koltchine VV. Agonist gating and isoflurane potentiation in the human GABAA receptor determined by the volume of a T M2 residue. Mol. Pharmacol 1999:56:1087–1093.

16. Belelli D, Pistis M, Peters JA, et al. General anesthetic action at transmitter-gated inhibitory amino acid receptors. T rends Pharmacol Sci 1999;20:496–502.

17. Bai D. Distinct functional and pharmacological properties of tonic and quantal inhibitory postsynaptic currents mediated by γ-aminobutyric acid A receptors in hippocampal neurons. Mol Pharmacol 2001:59:814–824.

18. Bai D. T he general anesthetic propofol slows deactivation and desensitization of GABAA receptors. J Neurosci 1999:19:10635–10646.

19. Flohr H, Glade U, Motzko D. T he role of the NMDA synapse in general anesthesia. T oxicol Lett 1998;100–101:23–29.

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20. Perouansky M, Kirson ED, Yaari Y. Mechanism of action of volatile anesthetics: effects of halothane on glutamate receptors in vitro. T oxicol Lett 1998;100–101:65–69.

21. Larsen M, Langmoen IA. T he effect of volatile anesthetics on synaptic release and uptake of glutamate. T oxicol Lett 1998; 100–101:59–64.

22. Hudspith MJ. Glutamate: a role in normal brain function, anesthesia, analgesia and CNS injury. Br J Anaesth 1997;78:731–747.

23. Narahashi T , Aistrup GL, Lindstrom JM, et al. Ion modulation as the basis for general anesthetics. T oxicol Lett 1998;100–101:185–191.

24. Shiraishi M, Harris RA. Effects of alcohol and anesthetics on recombinant voltage-gated NA + channels. J Pharmacol Exp T her 2004:309:987–994.

25. Franks NP, Lieb WR. Stereospecific effects of inhalational general anesthetic optical isomers on nerve ion channels. Science 1991;25:427–430.

26. Heurteaux C. T REK-1, a K+ channel involved in neuroprotection and general anesthesia. EMBO J 2004:23:2684–2695.

27. Doze VA, Chen BX, T icklenberg JA, et al. Pertussis toxin and 4-aminopyridine differentially affect the hypnotic-anesthetic action of dexmedetomidine and pentobarbital. Anesthesiology 1990;73:304–307.

28. Perry LB, Gould AB, Leonord PE. Case history number 82: “ nonflammable” fires in the operating room. Anesth Analg 1975;54:152–154.

29. Eger EI II. Anesthetic Uptake and Action. Baltimore: Williams & Wilkins, 1974.

30. Christ DD, Kenna JG, Kammerer W, et al. Enflurane metabolism produces covalently bound liver adducts recognized by antibodies from patients with halothane hepatitis. Anesthesiology 1988;69:833–888.

31. Koblin DD. Characteristics and implications of desflurane metabolism and toxicity. Anesth Analg 1992;75:S10–S16.

32. Dodds C. General anesthesia: practical recommendations and recent advances. Drugs 1999;58:453–467.

33. Mazze RI, Calverely RK, Smith NT . Inorganic fluoride nephrotoxicity: prolonged enflurane and halothane anesthesia in volunteers. Anesthesiology 1977;46:265–271.

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34. Lane GA Nahrwold ML, T ait AR. Anesthetics as teratogens: nitrous oxide is fetotoxic, xenon is not. Science 1980;210:899–901.

35. Reich DL, Silvay G. Ketamine: an update on the first twenty-five years of clinical experience. Can J Anaesth 1989;36:186–197.

36. Yamamura T , Harada K, Okamura A, et al. Is the site of action of ketamine anesthesia the N-methyl-D-aspartate receptor? Anesthesiology 1990;72:704–710.

37. T oro-Matos A, Redon-Platas AM, Avila-Valdez E, et al. Physostigmine antagonizes ketamine. Anesth Analg 1980;59:764–767.

Suggested Readings Cooper JR, Bloom FE, Roth RH. T he Biochemical Basis of Neuropharmacology, 7th Ed. New York: Oxford University Press, 1996.

Ezekiel MR. Handbook of Anesthesiology. 2004–2005 Edition. Laguna Hills, CA: CCS Publishing, 2004.

Hardman JG, Limbird LE, Molinoff PB, et al. T he Pharmacological Basis of T herapeutics, 9th Ed. New York: McGraw Hill, 1996.

Mashour GA, Forman GA, Campagna SA, et al. Mechanisms of general anesthesia: from molecules to mind. Best Pract Res Clin Anesthesiol 2005;19:349–364.

Stoelting RK. Pharmacology and Physiology of Anesthetic Practice, 3rd Ed. Philadelphia: Lippincott Williams &Wilkins, 1999.

T ung A. New anesthesia techniques. T horacic Surg Clin 2005;15:27–38.

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Chapter 19 Sedative-Hypnotics William Soine

Drugs cov ered in this chapter: Be nz o dia z e p in e s e d a tiv e -h y p n o tic s E stazo lam F luraze p am Quaze p am T e maze p am T riazo lam No nb e n z od ia z e p ine s e d a tiv e -h y p n otic s Z o lp id e m Z ale p lo n E szo p ic lo ne Ba r bitu r a te A mo b arb ital A p ro b arb ital B utab arb ital P e nto b arb ital P he no b arb ital S e c o b arb ital M e la to n in r e c e p to r a g o n is t R ame lte o n Ch lo r a l h y d r a te An tih is ta min e s D ip he nhyd ramine D o xylamine

Introduction Hypnotics often are referred to as sleeping pills, sedative medications, soporifics, and sedative-hypnotics and are used to treat insomnia. T his class of drugs causes drowsiness and facilitates the initiation and maintenance of sleep. T he observed pharmacological effects of most drugs in this class usually are dose related. Small doses cause sedation, larger doses cause hypnosis (sleep), and still larger doses may bring about surgical anesthesia. Drugs used as hypnotics often are sedative and anxiolytic (depending on the dose), but not all anxiolytic drugs cause sedation. See Chapter 22 for more information concerning sedative/anxiolytic use of the benzodiazepines. T his chapter will emphasize the concepts important in sleep and wakefulness, then present current drugs used to initiate and maintain sleep. Clinical situations commonly are encountered that require the use of hypnotics. Insomnia can be classified as primary (pathogenesis unknown) or secondary (from other causes). Secondary insomnia is more common and can be the result of situational stress, lifestyle habits, drugs, and psychiatric or medical disorders (1). T here are effective nonpharmacological treatments for insomnia; however, a need remains to use hypnotics on both a

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short-term and a long-term basis to facilitate sleep (2). T he drugs currently used as hypnotics are effective, but there is ample need for newer and safer hypnotics. T he introduction of supposedly a newer yet safer and more effective hypnotic drug has always been greeted with optimism, such as the piperidinedione thalidomide (3). T halidomide was proposed to be a substitute for the barbiturates in the 1950s. Similar to most other drugs used as hypnotics or sedatives, however, only after its introduction and extensive clinical use did its limitations become better understood. T he ideal hypnotic should 1) cause a transient decrease in the level of consciousness for the purpose of sleep without lingering effects (sleep induction and sleep maintenance), 2) have no potential for decreasing or arresting respirations (even at relatively high doses), and 3) produce no abuse, addiction, tolerance or dependence (4). A search for newer and better hypnotics continues.

Physiology of Sleep Sleep Cycle At the start of the 20th century, sleep was considered to be a passive process. During the late 1920s and 1930s, it was possible to monitor human electrical brain activity using the electroencephalogram (EEG). Using the EEG, it was established that there occurred a passive nature of sleep that alternated with wakeful activity (5). T his was followed by the discovery by Moruzzi and Magoun of the ascending reticular activating system and its relationship to the EEG (6). T his discovery provided the basis for the modern theories of sleep and was validated by finding that sleeping animals could be awakened through stimulation of electrodes implanted in the midbrain reticular formation. Sleep is studied using related techniques that permit electronic monitoring of the head and neck muscles (electromyogram) and eye movements (electro-oculogram). From these and related studies, three states have been defined: 1) wakefulness, 2) slow-wave sleep (nonrapid eye movement [NREM] sleep), and 3) paradoxic sleep (PS; rapid eye movement [REM] sleep). Wakefulness is characterized by low-voltage fast activity of the EEG, high muscle activity, and numerous REMs, indicating intensive interaction with the environment. T he two states of sleep, NREM and REM, have been characterized primarily using EEG. T he NREM sleep has been subdivided by Dement and Kleitman into four stages, which are precisely defined (although somewhat arbitrarily) using the EEG (5). Stages 1 through 4 follow a sleep continuum, with the ability to arouse an individual P.505 being lowest in stage 1 and highest in stage 4 sleep. When sleep overtakes wakefulness, the transition is gradual; indeed, not one single measure is reliable all of the time.

C lin ic a l S ig nific a n c e T he pharmacotherapy of insomnia has improved dramatically, and the recent development of novel agents has continued to grow thanks to the drug discovery process. Older medications, such as the barbiturates, are used as sedative-hypnotics, but toxicity limits their widespread use. For example, they can cause significant central nervous system (CNS) depression, physical dependence, and tolerance. Additionally, they are potent inducers of liver enzymes, which can lead to clinically significant drug interactions when these medications are administered with other drugs extensively metabolized by the liver. T he benzodiazepines are much safer for the treatment of insomnia and are commonly used for this purpose. Within the benzodiazepine class, drug discovery has resulted in medications with improved pharmacokinetic profiles for the treatment of insomnia. For example, the newer triazolobenzodiazepines posses a much shorter elimination half-life, and this feature can be used clinically to improve sleep while at the same time inducing less daytime sedation. T he nonbenzodiazepine agents also are effective and, thus far, appear to be even safer than the benzodiazepines. T he three medications belonging to this class are known as the “ Z” drugs and are zolpidem, zopiclone (i.e., eszopiclone), and zaleplon. With these drugs, the basic sciences have provided clinicians with medications that are both safe and effective. T he most recent addition to the armamentarium is the melatonin receptor agonist ramelteon. Molecular modifications to melatonin resulted in this potent and selective melatonin receptor agonist. T his medication is very unique in that it does not appear to posses any abuse liability and is not a controlled substance like

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most other sedative-hypnotics. Also, it does not appear to interfere with cognitive function or memory. T he drug discovery process and an understanding of structure–activity relationships has taken us from very toxic medications that were dangerous at high doses and caused physical dependence (i.e., barbiturates) to medications that are safe and apparently free from any abuse liability (i.e., ramelteon). T hese newer medications, brought to us by basic science techniques, will improve the quality of life for many who suffer from insomnia. Christian T eter Pharm.D. Assi stant Professor, Northeastern Uni versi ty, Department of Pharmacy Practi ce, Bouvé Col l ege of Heal th Sci ences

T he simplest pattern of sleep is that associated with a normal young adult. T he normal adult enters sleep through NREM sleep. After approximately 90 minutes of NREM sleep, the first REM sleep occurs, with a mean duration of approximately 20 minutes. T hereafter, NREM and REM sleep alternate cyclically through the night, with the average length of the NREM-REM sleep cycle being approximately 90 to 120 minutes. REM sleep tends to be greatest during the last third of the night. T herefore, a normal young adult displays a sleep pattern of 75 to 80% NREM and 20 to 25% REM sleep. T he length of nocturnal sleep is dependent on a number of factors, of which voluntary control is the most significant. Other important factors are genetic determinants and processes associated with circadian rhythms. As sleep is extended, the amount of REM sleep is increased. A number of factors modify sleep stage distribution: age, previous sleep history, drug ingestion, circadian rhythms, temperature, and pathology. Only the first four factors will be discussed in this chapter.

Age Age related differences are seen in infants. T he cyclic alteration of NREM-REM sleep at birth has a period of 50 to 60 minutes versus 90 minutes in adults. Infants gradually develop normal nocturnal slow-wave sleep after 2 to 6 months of life. Slow-wave sleep becomes maximal in young children and decreases markedly with age. Slow-wave sleep may no longer be present by 60 years of age, but this is more common in men than in women. T he interindividual variability in the elderly is greatly increased, and the generalizations made for young adults concerning “ normal” sleep are no longer applicable.

Previous Sleep History and Drug Ingestion Previous sleep history and the effects of drug ingestion on sleep history are important when comparing hypnotics. An individual experiencing sleep loss on one or more nights will show a sleep pattern of increased slow-wave sleep during the first recovery night, with REM sleep showing a rebound on the second or subsequent nights. When an individual becomes deprived of REM sleep by being awakened every time the electro-oculogram and EEG indicated that dreaming has begun, the individual becomes selectively deprived of REM sleep, and a pressure for REM sleep builds. A preferential rebound of REM sleep will occur. T he cyclic patterns of sleep states and sleep stages can be affected by many common drugs, including the hypnotics. T he ability of drugs to differentially affect one sleep stage over another can, on withdrawal, produce rebound effects leading to exacerbation of the sleep disorder, comparable to deprivation of REM sleep. P.506

Circadian Rhythms T he importance of the circadian phase at which sleep occurs and its effect on the distribution of sleep stages has become of interest because of the current popularity of melatonin. It has been shown that with individuals sleeping in situations free of all time cues, circadian phase can influence the timing of sleep onset and length of sleep. If sleep onset is delayed until the peak REM phase of circadian rhythm (early morning), REM sleep can predominate and even may occur at the onset of sleep. T his abnormal sleep-onset pattern or phase shift can occur because of a work-shift change or a change resulting from jet travel across a number of time zones. As a brief summary, the normal adult human enters sleep through NREM sleep. After approximately 80 minutes or longer, the individual starts REM sleep after which NREM-REM sleep alternates through the remainder of the sleep period. Any situation that causes an alteration of this normal sleep cycle leads to compensation of REM or NREM sleep in subsequent nights.

Sleep Factors

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T he involvement of many autonomic, physiologic, and biochemical changes are associated with wakefulness, NREM sleep, and REM sleep. T he relationship of cause and effect in relation to these systems is still somewhat controversial and a rapidly changing area of research. Several brain regions that regulate sleep have now been identified; however, the specific contribution on any one region to sleep is still controversial (7). T he roles of the major systems are important to be familiar with in relation to sleep. T his not only helps one to understand the mechanism by which hypnotics work but also provides some understanding of why unrelated drugs, such as neuroleptics, antihistamines, antidepressants, and antimanic drugs, occasionally are used as hypnotics to facilitate sleep.

Neurotransmitter/Neuromodulator Every neurotransmitter has, at one time or another, been implicated in sleep or wakefulness. T he assumption is that if a neurotransmitter is involved in wakefulness, it may be involved in initiation or maintenance of REM sleep. In contrast, an antagonist of the neurotransmitter would be anticipated to initiate or maintain NREM sleep. Studies of this type rarely are unambiguous because of the integration of the neural pathways. Some of the evidence for the involvement of these neurotransmitters in sleep or wakefulness is presented; however, the reader should consult Kales (7) for details.

Catecholamines It would be anticipated that catecholamines (originating from the locus ceruleus) would be involved in wakefulness and REM sleep (8). Initial experiments with reserpine suggested that a decrease in catecholamines involved in neurotransmission caused a decrease in REM sleep. Contradictory and inconsistent findings with other compounds that modulate catecholamine synthesis, however, gave ambiguous results concerning the relationship between monoamine levels and stages of sleep. T he only consistent finding is that an intact catecholamine transmission system is needed for the REM component of sleep. T he catecholaminergic effects on sleep and wakefulness can be broken down in the following manner: a. Drugs interfering with catecholaminergic transmission via the depletion or inhibition of the synthesis of the catecholamines. b. α 1 -and α 2 -agonists and antagonists and β-adrenergic agonists and antagonists. c. Dopamine 1 and 2 agonists and antagonists. Studies support the hypothesis that norepinephrine neurons aid in regulating wakefulness and REM sleep. For example, an α 1 -agonist (e.g., methoxamine) decreased REM sleep, whereas an α 1 -antagonist increased REM sleep. Clonidine, primarily an α 2 -agonist is associated with a sleep induction but inhibits deep NREM (stages 3 and 4) sleep. Involvement of the β-adrenergic receptors for regulation of sleep is ambiguous. Propranolol in humans often is associated with the side effect of insomnia that can be reversed by β-agonists and has been interpreted as suggesting these receptors are involved in regulation of REM sleep. It has been proposed that dopamine has a facilitative and active role in the sleep-wakefulness cycle. Waking appears to be a state maintained by D2 activation, whereas decreased D2 activity appears to promote sleep. T he D1 receptor may be important in the regulation of REM sleep, but it is not important in initiation or timing of REM sleep.

Serotonin Initially, serotonin was thought to be a sleep-promoting neurotransmitter or an “ antiwaking” agent (9). T he recognition of the numerous 5-HT receptor subtypes, often with unique anatomical distribution, has required that a more complex role for serotonin be developed. Current studies indicate that conditions for sleep are now met when the serotoninergic system becomes inactive. T he serotonin agonists for the 5-HT 1 (via the 5-HT 1A and 5-HT 1B types at the hypothalamic level), 5-HT 2 , and 5-HT 3 receptors cause wakefulness and inhibit sleep. Blockade of the 5-HT 2 receptors (e.g., the 5-HT 2 antagonist ritanserin) results in increased NREM sleep and inhibition of REM sleep. It has been proposed that the 5-HT 1A and 5- HT 2 may be involved in sleep by regulation of sleep-promoting substances in the hypothalamus. With the development of newer and more selective ligands for use in studying the numerous serotonin receptor subtypes (see also Chapter 14), a better understanding of the role of serotonin in sleep will evolve.

Histamine It is proposed that histamine may have an involvement in wakefulness and REM sleep (10). Histamine-related

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functions in the CNS are regulated at postsynaptic sites by both the H 1 and H 2 receptors, whereas P.507 the H 3 receptors appear to be a presynaptic autoreceptor regulating the synthesis and release of histamine. T hese three receptors differ in molecular structure, distribution in the CNS, and physiologic responses. T he H 1 receptor agonists and the H 3 receptor antagonists increase wakefulness, whereas the H 1 receptor antagonists (e.g., diphenhydramine) and H 3 receptor agonists have the opposite effect. T he H 2 receptor agonists and antagonists have not been shown to have any effect on wakefulness or sleep parameters. T he H 1 receptor agonists do not modify sleep induction or maintenance, although it does increase stage 4 NREM sleep and sleep latency. In controlled sleep laboratory studies, the H 1 receptor antagonists (e.g., diphenhydramine), when given before bedtime to normal subjects, have little effect on wakefulness. In equal doses given during the day, however, they increase drowsiness, with an increased tendency to sleep and impair performance.

Acetylcholine T he cholinergic system was the first neurotransmitter system shown to have a role in wakefulness and initiation of REM sleep (11). Because of the poor penetration of the cholinergic drugs into the CNS, the role of this system in sleep has relied on animal studies using microinjection into the brain, primarily in the area of the dorsal pontine tegmentum. Acetylcholine, cholinergic agonists (e.g., arecoline or bethanechol), and cholinesterase inhibitors are effective in the initiation of REM sleep from NREM sleep after microinjection. Conversely, administration of anticholinergic drugs (e.g., atropine or scopolamine) hinders the transition to REM sleep. Increase in the rate of discharge of these cholinergic cells (that activate the thalamus, cerebral cortex, and hippocampus) during REM sleep parallel the same pattern seen with arousal and alertness.

Adenosine Adenosine acts as neurotransmitter in the mammalian nervous system (12). Because of the highly polar nature of adenosine, it also has to be injected into the brain (intracerebroventricular and preoptic). T he stimulation of the adenosine A1 receptors with adenosine causes a hypnotic effect. It has been proposed that the hypnotic effect occurs via suppressing calcium efflux into presynaptic nerve terminals and decreasing the amount of neurotransmitters released into the synapse in brain regions critical for sleep. T his apparent induction and maintenance of sleep is associated with increases in both NREM and REM sleep. Consistent with the above proposal is that blocking of the central adenosine receptors with methylxanthines (e.g., caffeine or theophylline) is associated with wakefulness and a reduction in total sleep time. Studies also suggest that some of the actions of the benzodiazepines may be related to their ability to inhibit adenosine uptake, leading to downregulation of central adenosine receptors.

g-Aminobutyric acid γ-Aminobutyric acid (GABA) probably represents the most important inhibitory transmitter of the mammalian CNS (also see Chapter 15) (13). Both types of GABAergic inhibition (pre- and postsynaptic) use the same GABAA receptor subtype, which acts by regulation of the chloride channel of the neuronal membrane. A second GABA receptor type, GABAB , that is a G protein–coupled receptor is not considered to be important in understanding the mechanism of hypnotics. Activation of a GABAA receptor by an agonist increases the inhibitory synaptic response of central neurons to GABA through hyperpolarization. Because many, if not all, central neurons receive some GABAergic input, this leads to a mechanism by which CNS activity can be depressed. For example, if the GABAergic interneurons are activated by an agonist that inhibits the monoaminergic structures of the brainstem, hypnotic activity will be observed. T he specific neuronal structures in different brain regions affected by GABAA agonist continues to be better defined.

Neurohumoral Modulators Sleep and circadian rhythmicity, both of which are controlled by the CNS, can exhibit significant effects on hormonal release. Many of the hypophyseal hormones follow a circadian rhythm; however, both growth hormone (GH) and prolactin (PRL) appear to be the most closely linked with sleep. T his suggests that these hormones may affect sleep and contribute to the maintenance and quality of sleep.

Growth hormone and prolactin In normal adult subjects, the plasma level of GH remains very stable at a low level; however, a secretory pulse of GH occurs in association with the first phase of NREM sleep (14). Most of the GH pulse secretions occur during NREM sleep, and a good correlation has been observed between the amount of GH secreted and the

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duration of NREM sleep. Studies in healthy elderly men (age, 67–84 years) have observed that a decreased secretion of GH in the elderly parallels the decrease in NREM sleep and may be related to the decrease in sleep observed in the elderly. Regardless of the time of day, sleep onset has a stimulatory effect on PRL release (14). Maximal effect is observed, however, when sleep and circadian effects are superimposed. Because of pulse-like secretions of PRL, there seems to be a relationship between the low PRL levels and initiation of REM sleep or nocturnal awakenings, especially in the elderly.

Melatonin

Melatonin, at times referred to as the “ hormone of darkness,” normally is secreted during the night (15,16,17). It is synthesized in the pineal gland, and its secretion is controlled by the suprachiasmatic nucleus, following an endogenous circadian rhythm. Studies indicate that melatonin may P.508 have effects on circadian rhythm and sleep processes. T he presence of a pharmacologically specific receptor for melatonin in which the molecular structure is known are referred to as MT 1 , MT 2 , and MT 3 receptors. T he MT 1 and MT 2 receptors are high-affinity G protein–coupled receptors, whereas MT 3 is a form of quinone reductase. T he MT 1 receptor appears to be primarily involved in initiating sleep, whereas the MT 2 receptor appears to mediate melatonins effect in the eye, circadian rhythm, and vascular effects (18). T he importance of MT 3 , although widely distributed in different tissues, is currently unknown. T he normal physiological concentration of melatonin observed at night is approximately 100 to 200 pg/mL, and oral doses of 0.1 to 0.3 mg of melatonin are adequate to obtain these concentrations even though melatonin frequently is given at doses of 1 to 10 mg to obtain “ supraphysiological” levels. T hese higher doses may be the reason for some of the side effects not currently associated with the melatonin receptors. Melatonin is most effective in young individuals and appears to be less effective in elderly individuals (possibly because of a decreased number of receptors). Melatonin causes a phase shift of approximately 1 hour per day. T his means that the use of melatonin in the morning can delay the onset of evening sleepiness, whereas melatonin taken in the evening has been associated with faster onset of sleep and increased total sleep time. Melatonin is sold as a food supplement in the United States, but it has become popular for use as a hypnotic and for alleviating jet lag (a flight across five or more time zones) and helping to resynchronize individuals who have difficulty adapting to night-shift work.

CNS peptides Several CNS peptides have been associated with regulation of sleep and wakefulness. Currently, the hypocretins (orexins) are of greatest interest (19,20). T hey consist of two neuropeptides, Hcrt-1 and Hcrt-2, that are synthesized by neurons in the posterolateral hypothalamus. Initially, these peptides were shown to be involved in the regulation of arousal, motor tone, locomotion, regulation of appetite, and neuroendocrine and autonomic functions. Recent research has indicated that these peptides also are involved in the regulation of sleep and wakefulness, especially in relation to narcolepsy. It has been observed that approximately 80% of patients with narcolepsy had low or undetectable levels of Hcrt-1, suggesting that a deficiency or abnormality in hypocretin neurotransmission may play a pivotal role in this disease. T he Hcrt-1 is a 33-amino-acid, carboxyamidated peptide with an N-terminal pyroglutamyl residue and two intrachain disulfide bonds, whereas the Hcrt-2 is a C-terminally amidated, linear peptide of 28 amino acids. T he hypocretins bind at two G protein– coupled receptors with high affinity and have excitatory effects on the neurons. It has been proposed that

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hypocretin receptor antagonists may be useful in the treatment of insomnia, although no drug is currently in clinical studies based on this concept.

T esting and Developm ent of New Hypnotics As presented in the earlier section, a number of potential receptors can be identified that are associated with causing sleep and have the potential to be developed into a hypnotic. Initially, animal tests have been used for identifying new hypnotic drugs. In vitro receptor binding studies can then be used for screening of drugs that bind with improved specificity. T he animal assays basically measure varying levels of CNS depression instead of sleep. T he assumption is that CNS depression will relate to clinical hypnosis, although exceptions commonly occur. Common assays in mice or rats include an increase in sleeping time, a loss of righting reflex, rotorod impairment, decreased activity in an activity cage, or potentiation of other CNS depressants. T he observed pharmacological effects of many drugs in this class usually are dose related such that small doses cause sedation, larger doses cause hypnosis, and still larger doses may bring about surgical anesthesia. Larger animals, including rats, cats, and monkeys, are studied in a sleep laboratory. In these studies, electrophysiologic and electroencephalographic measurements are obtained and often are helpful in gaining information about the site of action of CNS depressants as well as about induced sleep patterns. Drug discrimination studies also have been useful in differentiating sites of action of CNS depressants. Guidelines for the clinical evaluation of hypnotic drugs have been developed by the U.S. Food and Drug Administration for specific evaluation of this class of drugs. Human sleep laboratory studies have become increasingly valuable in determining a range of efficacy and defining an optimal dose. Because sleep laboratory studies are under closely controlled conditions, they are capable of continuous electrophysiologic measurement throughout the night. T his is then followed by objective measurement of pre- and postsleep results to assess effectiveness and withdrawal effects of new hypnotics. T he sleep laboratory studies coupled with clinical studies based on patients' subjective estimates of efficacy provide a thorough and clinically relevant approach for developing a new hypnotic (21).

Classification of Hypnotics Introduction to Classes of Hypnotics T he hypnotic drugs are not characterized by common structural features. Instead, a wide variety of chemical compounds have been used in clinical therapy. An arbitrary classification is as follows: GABAA receptor agonists Benzodiazepines Imidazopyridines and cyclopyrrolones Pyrazolopyrimidines Barbiturates P.509 Chloral Melatonin receptor agonists Antihistamines Antidepressants Herbal preparations

Benzodiazepines Benzodiazepines are used as daytime anxiolytics, sleep inducers, anesthetics, anticonvulsants (also known as antiseizure agents), and muscle relaxants; they will be discussed in depth in Chapters 20 and 22. Examination of the basic pharmacodynamic properties of the benzodiazepines (defined as receptor-specific binding activity) show that the clinically useful benzodiazepines exhibit comparable sedative activity at therapeutically comparable doses (Fig. 19.1) (13). T he use of a specific benzodiazepine as a hypnotic is based primarily on

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pharmacokinetic properties and marketing considerations. Hypnotics are unusual in that they normally are given as a single dose. T he following variables will determine how well a benzodiazepine will work as a hypnotic: 1) Is acute tolerance developed to the benzodiazepine that will diminish CNS effects before the drug is eliminated from the CNS, 2) is redistribution of the benzodiazepine from the CNS to other tissues very rapid, and 3) is there a rapid drug elimination by biotransformation and the metabolite active? T he benzodiazepines that are specifically promoted as sleep inducers are listed in T able 19.1 (22); however, it is important to keep in mind that depending on the dose, any benzodiazepine may be used for its hypnotic effect.

Fig. 19.1. Hypnotic benzodiazepines and their metabolites.

Mechanism of Action T he initial studies suggesting a possible involvement of the benzodiazepines with GABA provided a basis for understanding the pharmacological effects of this class of P.510 drugs. T he identification of specific, high-affinity binding sites for the benzodiazepines on the GABAA receptors was an important advance (23,24). T he majority of GABAA receptors are made up of a mixture to subunit types (α 1–6 , β 1–3 , γ1–3 , θ, ε, δ, and π) with the majority of receptors composed of α, β, and γ subunits in the ratio of 1:2:1 (13). T he major combinations of subunits are α 1 β 2 γ2 (~ 60%) and α 2 β 3 γ2 (~ 15–20%) of the GABAA receptors. Studies suggest that drugs interacting with the α 1 subunit receptor are involved in the modulation of

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sedative, amnesic, and seizure protection, whereas drugs binding with the α 2 subunits receptors provide anxiolytic and myorelaxant properties. T he current generation of benzodiazepines bind with comparable affinity at both GABAA receptor subtypes. It has been proposed that compounds specific for the α 2 subunit would be “ nonsedative,” whereas compounds specific for α 1 would primarily be sedative-hypnotic (13). All of the benzodiazepines affect the normal sleep stages. T hey increase total sleep and EEG fast activity, and they decrease nocturnal wakefulness, body movements, number of awakenings, sleep latency (the time required to fall asleep), and stages 3 and 4 sleep (NREM). On withdrawal of the drug, a gradual return to baseline values of NREM sleep returns. T hey also cause a mild suppression of REM sleep, especially during the first third of the night, with rapid return to baseline on withdrawal.

Table 19.1. Some Properties and Pharmacokinetics of the Benzodiazepine Sedative-Hypn Parameters

Estazolam

Flurazepam

Trade name

Prosom

Dalmane

Doral

Ristoril

Log P (calc)a

3.3 ± 0.9

4.0 ± 0.7

4.1 ± 0.8

2.2 ± 0.6

Log D (pH 7)a

3.3

1.4

4.1

2.2

Oral bioavailability (%)

Rapid

Rapid

Rapid

>80

Protein binding (%)

93

97

95

>96

5.0–8.6

0.8–1.4

Volume of distribution (L/kg)

Quazepam

Temazepam

Elimination half-life (hours)

10–24

2.4

39 (25 41)

8–15

Major metabolites (half-life hours)

4-OH (inactive) N-1-OH-ethyl (2 4)

N-desethyl (47 100)

2-oxo (39)

O-glucuronide

T max (hours)

0.5–6.0

0.5–1.0

fluvoxamine> sertraline> desmethylsertraline> norfluoxetine> nefazodone> fluoxetine and only weakly inhibited by venlafaxine, ODV, citalopram, and desmethylcitalopram. T he inhibition of bupropion hydroxylation in vitro by SSRIs suggests the potential for clinical drug interactions. T herefore, coadministration of drugs that inhibit CYP2D6 warrants careful monitoring. Because of its selective inhibition of DA reuptake, pharmacodynamic interactions with dopamine agonists (e.g., levodopa) and antagonists should be anticipated. Coadministration of bupropion with drugs that lower the seizure threshold should be avoided because of the risk of serious seizures. Drugs that affect metabolism by CYP2B6 (e.g., orphenadrine and cyclophosphamide) also have the potential to interact with bupropion.

Therapeutic Uses Besides being used to treat depression, bupropion is a nonnicotine aid in the cessation of smoking. T he efficacy of bupropion in smoking cessation is comparable to that of nicotine replacement therapy and should be considered as a second-line treatment in smoking cessation (72,73). It possesses a broad spectrum of infrequent P.586 adverse effects, however, with potential drug metabolism interactions with T CAs, β-adrenergic blocking drugs, and class Ic antiarrhythmics.

Miscellaneous Norepinephrine and Dopamine Reuptake Inhibitors Nomif ensine is a s ubstituted phenylpiperidine (an aminophenyltetrahydroisoquinoline) structurally related to sertraline that was marketed as a stimulatory antidepressant in the mid-1970s but later withdrawn because of a high inc idence of hemolytic anemia. Nomif ensine inhibits the NE and dopamine reuptake transporters . I t displays high af f inity f or NET (human pK i = 7.8), moderate af f inity f or dopamine transporter (pK i = 6.6), and a low af f inity f or SERT (5-HT:NE ratio, 65).

Mazindol (Sanorex®) is a phenyl-substituted imidazobenzoisoindole that inhibits both NE and dopamine reuptake transporters . I t exhibits high af f inity f or the NET (rat pK i = 9.3), good af f inity f or dopamine trans porter (rat pK i = 7.8), and a 5-HT:NE ratio of 224. Dopamine reuptake inhibitors suppress appetite; thus, mazindol is approved to be marketed as an appetite suppressant.

Serotonin Receptor Modulators

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Serotonin Antagonist/Reuptake Inhibitors Gen eral mech an ism of action Serotonin receptor modulators are a class of antidepressants, the function of which is to modulate the concentration of 5-HT in the brain. A neuromodulator functions as a “ volume control in the brain and nervous system,” regulating the other neurotransmitters through its receptors in the brain in response to external stimuli. As previously described, the serotonergic system modulates a large number of physiological events, such as temperature regulation, sleep, learning and memory, behavior, sexual function, hormonal secretions, and immune activity, and is implicated in stress, anxiety, aggressiveness, and depression disorders. Of the various types of 5-HT receptors (see Chapter 14) mediating serotonergic activity, the 5-HT 1B receptors play an important role in modulating the serotonergic system. T he 5-HT 1B receptors are autoreceptors localized on serotonergic neuron terminals, where they inhibit the release of 5-HT and its biosynthesis; they also are heteroreceptors located on nonserotonergic terminals, where they inhibit the release of other neurotransmitters, such as acetylcholine, γ-aminobutyric acid (GABA), and NE. Excessive amounts of 5-HT in the brain may cause relaxation, sedation, and a decrease in sexual drive; inadequate amounts of 5-HT can lead to psychiatric disorders. T herefore, the 5-HT receptor modulator antidepressants exert their antidepressant effects by mechanisms that enhance noradrenergic or serotonergic transmission by acting as mixed 5-HT 2 antagonists/5-HT reuptake inhibitors (SARI; trazodone), and α 2 adrenergic antagonists/5-HT 2 and 5-HT 3 antagonists (NaSSA; mirtazapine). Chronic antidepressant treatment with SARIs and NaSSAs modulate 5-HT receptor expression and, in turn, 5-HT function.

T razodon e T razodone is a phenylpiperazine–triazolopyridine antidepressant that is structurally unrelated to most of the other antidepressant classes (Fig. 21.22).

Mech an ism of action T razodone acts as an antagonist at 5-HT 2A receptors and is a weak inhibitor of 5-HT reuptake at the presynaptic neuronal membrane, potentiating the synaptic effects of 5-HT . Its mechanism of action is complicated by the presence of its metabolite, m-chlorophenylpiperazine (Fig. 21.23), which is a 5-HT 2C agonist. At therapeutic dosages, trazodone does not appear to influence the reuptake of dopamine or NE within the CNS. It has little anticholinergic activity and is relatively devoid of toxic cardiovascular effects. T he increase in serotonergic activity with long-term administration of trazodone decreases the number of postsynaptic serotonergic (i.e., 5-HT 2 ) and β-adrenergic binding sites in the brains of animals, decreasing the sensitivity of adenylate (or adenylyl) cyclase to stimulation by β-adrenergic agonists. It has been suggested that postsynaptic serotonergic receptor modification is mainly responsible for the antidepressant action observed during long-term administration of trazodone. T razodone does not inhibit MAO and, unlike amphetamine-like drugs, does not stimulate the CNS.

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Fig. 21.22. Serotonin receptor modulators.

T razodone is rapidly and almost completely absorbed from the GI tract following oral administration, with an oral bioavailability of approximately 65% (T able 21.11). Peak plasma concentrations of trazodone occur approximately 1 hour after oral administration when taken on an empty stomach or 2 hours when taken with food. At steady state, its plasma concentrations exhibit wide interpatient variation. T razodone is extensively metabolized in the liver by N-dealkylation to its primary active metabolite, m-chlorophenylpiperazine (m-CPP), which subsequently undergoes aromatic hydroxylation to p-hydroxy-m-CPP (Fig. 21.23) (75). In vitro studies indicate that CYP3A4 is the major isoform involved in the production of m-CPP from trazodone (and CYP2D6 to a lesser extent). T he p-hydroxy-m-CPP and oxotriazolopyridine-propionic acid (the major metabolite excreted in urine) are conjugated with glucuronic acid. Less than 1% of a dose is excreted unmetabolized. T razodone therapy has been associated with several cases of idiosyncratic hepatotoxicity (see Chapter 10). Although the mechanism of hepatotoxicity remains unknown, the generation of an iminoquinone, an epoxide reactive metabolite or both may play a role in the initiation of trazodone-mediated hepatotoxicity (Fig. 21.23)(75). Studies have shown that the bioactivation of trazodone involves, first, aromatic hydroxylation of the 3-chlorophenyl ring, followed by its oxidation to a reactive iminoquinone intermediate, which then reacts with glutathione or, oxidation of the triazolopyridinone ring to an electrophilic epoxide and ring opening by either a Nucleophile (:Nu) or to generate the corresponding hydrated trazodone–Nucleophile conjugate or the stable P.587 diol metabolite, respectively. T he pathway involving trazodone bioactivation to the iminoquinone also has been observed with many para-hydroxyanilines (e.g., acetaminophen) (see Chapter 10). including the structurally related antidepressant nefazodone. T he reactive intermediates consume the available glutathione, allowing the reactive intermediate to react with hepatic tissue leading to liver damage.

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Fig. 21.23. Metabolism of trazodone.

Unlike the T CAs, trazodone does not block the fast sodium channels and, thus, does not have significant arrhythmic activity. Compared with the SSRIs, it has a lesser tendency to cause drug-induced male sexual dysfunction as a side effect. Although trazodone displays α 1 -adrenergic blocking activity, hypotension is relatively uncommon. Signs of overdose toxicity include nausea, vomiting, and decreased level of consciousness. T razodone produces a significant amount of sedation in normal and mentally depressed patients (principally from its central α 1 -adrenergic blocking activity and antihistaminic action).

Dru g in teraction s T razodone possesses serotonergic activity; therefore, the possibility of developing 5-HT syndrome should be considered in patients who are receiving trazodone and other SSRIs or serotonergic drugs concurrently. When trazodone is used concurrently with drugs metabolized by CYP3A4, caution should be used to avoid excessive sedation. T razodone can cause hypotension, including orthostatic hypotension and syncope; concomitant administration of antihypertensive therapy may require a reduction in dosage of the antihypertensive agent. T he possibility of drug–drug interactions with trazodone and other substrates, inducers, and/or inhibitors of CYP3A4 exists (75).

T h erapeu tic u ses T razodone is used primarily in the treatment of insomnia, mental depression, or depression/anxiety disorders. T he drug also has shown some efficacy in the treatment of benzodiazepine or alcohol dependence, diabetic neuropathy, and panic disorders.

Noradrenergic Specific Serotonergic Antidepressants Mirtazapine Mirtazapine is a piperazinodibenzoazepine antidepressant that is an isostere of the antidepressant mianserin (Fig. 21.22). A seemingly simple isosteric replacement of an aromatic methine group (CH) in mianserin with a nitrogen to give a pyridine ring (mirtazapine) has profound effects on the physicochemical properties, pharmacokinetics, mechanisms of action, and antidepressant activities (T able 21.12) (31). Profound differences between receptor affinity and transporter affinity, pharmacokinetics, regioselectivity in the

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formation of metabolites, and toxicity are observed for mianserin and mirtazapine and their antidepressant mechanisms of action. T he pyridine ring increases the polarity of the molecule and decreases the measured partition coefficient and the basicity. Mianserin is a potent inhibitor of NET , whereas mirtazapine has negligible effects on the inhibition of NET (pK i = 7.1 vs. 5.8 respectively). Mianserin is currently marketed in Europe as an antidepressant. Mianserin has not been approved for use in the United States because of its serious adverse effects of P.588 agranulocytosis and leukopenia. Mirtazapine has not exhibited this adverse effect

Nef azodone is a phenylpiperazine antidepressant structurally related to trazodone, but it dif f ers pharmacologic ally f rom trazodone, the SSRI s, the MAOI s, and the TCAs (Fig. 21.22). W hen compared with trazodone, nef azodone displays approximately twice the af f inity potency f or SERT. Nef azodone therapy, however, was associated with lif e-threatening cas es of idiosync ratic hepatotoxicity, and as a result, nef azodone was withdrawn f rom both the North American and European markets in 2003. The mechanism of hepatotoxicity remains unknown, but nef azodone, being structurally similar to trazodone (Fig. 21.23), is metabolized to p-hydroxynef azodone, m-CPP, and phenoxyethyltriazoledione. I n turn, p-hydroxynef azodone is thought to be oxidized to an iminoquinone and/or an epoxide reactive metabolite, which may play a role in the initiation of nef azodone-mediated hepatotoxic ity (76).

Mech an ism of action Animal studies indicate that the efficacy of mirtazapine as an antidepressant results from enhancing central noradrenergic and serotonergic activity, possibly through blocking central presynaptic α 2 -adrenergic receptors. Blocking these receptors inhibits the negative feedback loop, which increases the release of NE into the synapse. Mirtazapine also is a potent antagonist at 5-HT 2 and 5-HT 3 receptors, and it shows no significant affinity for 5-HT 1A or 5-HT 1B receptors. Additionally, it displays some anticholinergic properties, and it produces sedative effects (because of potent histamine H 1 receptor antagonism) and orthostatic hypotension (because of moderate antagonism at peripheral α 1 -adrenergic receptors). Its antidepressant effect is comparable to the T CAs and may be better than some SSRIs, especially in patients with depression of the melancholic type, but at higher doses, it may cause drowsiness and weight gain. T he drug generally is well tolerated, producing no more adverse events (including anticholinergic events) than the SSRIs and fewer adverse events than the T CAs. T he pharmacokinetics for mirtazepine are shown in T able 21.11. Mirtazapine absorption is rapid and complete, with a bioavailability of approximately 50% as a result of first-pass metabolism. T he rate and extent of mirtazapine absorption are minimally affected by food. Dose and plasma levels are linearly related over a dose range of 15 to 80 mg. T he elimination half-life of the (–)-enantiomer is approximately twice that of the (+ )-enantiomer. In females of all ages, the elimination half-life is significantly longer than in males (mean half-life, 37 versus 26 hours).

Table 21.12. Physicochemical and Properties of M irtazapine and M ianserin Properties

M irtazapine

M ianserin

pKa

7.1

7.4

Lipophilicitya

3.3

4.0

Polarity

2.63 debye

0.82 debye

NERT affinity (pK i )

5.8

7.1

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5-HT release a

Yes

No

Partition coefficient (log P) experimental determination.

Following oral administration, mirtazapine undergoes first-pass metabolism by N-demethylation and ring hydroxylation to its 8-hydroxy metabolite, followed by O-glucuronide conjugation (77). In vitro studies indicate that CYP2D6 and CYP1A2 are involved in the formation of the 8-hydroxy metabolite and that CYP3A4 is responsible for the formation of the N-desmethyl and N-oxide metabolites (Fig. 21.24). T he 8-hydroxy and N-desmethyl metabolites possess weak pharmacological activity, but their plasma levels are very low and, thus, are unlikely to contribute to the antidepressant action of mirtazapine. Clearance for mirtazapine may decrease in patients with hepatic or renal impairment, increasing its plasma concentrations. T herefore, it should be used with caution in these patients. In vitro studies have shown mirtazapine to be a weak inhibitor of CYP1A2, CYP2D6, and CYP3A4.

M onoamine Oxidase Inhibitors T he discovery of MAOIs resulted from a search for derivatives of isoniazid (isonicotinic acid hydrazide) (Fig. 21.25) with antitubercular activity. During clinical trials with this hydrazine derivative, a rather consistent beneficial effect of mood elevation was noted in depressed patients with tuberculosis. Although no longer used clinically, iproniazid (Fig. 21.25), the first derivative to be synthesized, was found to be hepatotoxic at dosage levels required for antitubercular and antidepressant activity. T he antidepressant activity of iproniazid, however, prompted a search for other MAOIs, which resulted in P.589 the synthesis of hydrazine and nonhydrazine MAOIs that were relatively less toxic than iproniazid.

Fig. 21.24. Metabolism of mirtazepine.

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Fig. 21.25. MAOI antidepressants.

T he MAOIs can be classified as hydrazines (e.g., phenelzine) and nonhydrazines (e.g., tranylcypromine), which can block the oxidative deamination of naturally occurring monoamines. MAOIs can also be classified according to their ability to selectively or nonselectively inhibit MAO. T he currently available MAOI antidepressants (phenelzine and tranylcypromine) (Fig. 21.25) are considered to be irreversible nonselective inhibitors of MAO. T he mechanism of antidepressant action of the MAOIs suggests that an increase in free 5-HT and NE and/or alterations in other amine concentrations within the CNS is mainly responsible for their antidepressant effect.

Mechanisms of Action Common to MAOIs An enzyme found mainly in nerve tissue and in the liver and lungs, MAO catalyzes the oxidative deamination of various amines, including epinephrine, NE, dopamine, and 5-HT . At least two isoforms of MAO exist, MAO-A and MAO-B, with differences in substrate preference, inhibitor specificity, and tissue distribution. T he MAO-A substrates include 5-HT , and the MAO-B substrates include phenylethylamine. T yramine, epinephrine, NE, and dopamine are substrates for both MAO-A and MAO-B. T he cloning of MAO-A and MAO-B has demonstrated unequivocally that these enzymes consist of different amino acid sequences and also has provided insight regarding their structure, regulation, and function (51). Both MAO-A and -B knockout mice exhibit distinct differences in neurotransmitter metabolism and behavior (51). T he MAO-A knockout mice have elevated brain levels of 5-HT , NE, and dopamine, and they manifest aggressive behavior similar to human males with a deletion of MAO-A. In contrast, MAO-B knockout mice do not exhibit aggression, and only levels of phenylethylamine are increased. Both MAO-A and -B knockout mice show increased reactivity to stress. T hese knockout mice are valuable models for investigating the role of monoamines in psychoses and in neurodegenerative and stress-related disorders. T he pharmacological effects of MAOIs are cumulative. A latent period of a few days to several months may occur before the onset of the antidepressant action, and effects may persist for up to 3 weeks following discontinuance of therapy.

Adverse Effects Common to MAOIs Common side effects for the nonselective MAOIs include difficulty getting to sleep and broken sleep, daytime insomnia, agitation, dizziness on standing that results in fainting (orthostatic hypotension), dry mouth, tremor (slight shake of muscles of arms and hands), syncope, palpitations, tachycardia, dizziness, headache, confusion, weakness, overstimulation including increased anxiety, constipation, GI disturbances, edema, dry

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mouth, weight gain, and sexual disturbances.

Drug Interactions Common to MAOIs T he most significant drug interaction limiting the efficacy of the nonselective MAOIs is with certain foods that have the potential to cause hypertensive crisis because of the release and potentiation of catecholamines. T he severity and consequences of such interactions vary among individuals from only minor increases in blood pressure to substantial and rapid increases in blood pressure within 20 minutes. T hese patients may experience symptoms associated with brain hemorrhage or cardiac failure. Hypertensive crises with MAOIs have occurred in some patients following ingestion of foods containing large amounts of tyramine or tryptophan. In general, patients taking MAOIs should avoid protein foods that have undergone protein breakdown by aging, fermentation, pickling, smoking, or bacterial contamination. Some of the common foods to avoid are shown in T able 21.13. Patients should be warned against eating foods P.590 with a high tyramine content, because hypertensive crisis may result. Excessive amounts of caffeine also reportedly may precipitate hypertensive crisis.

Table 21.13. Foods To be Avoided Due to Potential M onoamine Oxidase Inhibitor–Food Interactions Cheeses Cheddar Camembert Stilton Processed cheese Sour cream Spirits Chianti Champagne Alcohol free/reduced wines Fish Pickled herring Anchovies Caviar M iscellaneous Shrimp paste Chocolate Meat tenderizers (papaya) M eats Chicken livers Genoa salami Hard salami Pepperoni Lebanon bologna Fruit Figs (overripe/canned) Raisins Overripe bananas Dairy product Yogurt Vegetable products

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Yeast extract Pods-broad beans Bean curd Soy sauce Avocado

Table 21.14. Common Information for Patients taking M onoamine Oxidase Inhibitors (M AOIs) Patient Information

Recommendation

Discontinuance of therapy or dose adjustment

Consult physician

Adding medication (prescription/overthe-counter)

Consult physician

Tyramine containing foods and over- the-counter products

Avoid

Drowsiness, blurred vision

Avoid driving or performing tasks requiring alertness or coordination

Dizziness, weakness, fainting

Arise from sitting position slowly

Alcohol use

Avoid alcohol

Onset of action

Effects may be delayed for a few weeks

Severe headache, palpitation,

Consult physician tachycardia, sense of constriction in throat or chest, sweating, stiff neck, nausea, or vomiting

New physician or dentist

Inform practitioner of MAOI use

T he MAOIs interfere with the hepatic metabolism of many prescription and nonprescription (over-the-counter) drugs and may potentiate the actions of their pharmacological effects (i.e., cold decongestants, sympathomimetic amines, general anesthetics, barbiturates, and morphine).

Therapeutic Uses Common to MAOIs T he MAOIs are indicated in patients with atypical (exogenous) depression and in some patients who are unresponsive to other antidepressive therapy. T hey rarely are a drug of first choice. Unlabeled uses have included bulimia (having characteristics of atypical depression), treatment of cocaine addiction (phenelzine),

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night terrors, posttraumatic stress disorder; some migraines resistant to other therapies, seasonal affective disorder (30 mg/day), and treatment of some panic disorders. A list of information that should be transmitted to the patient concerning use of MAOIs is shown in T able 21.14.

Nonselectiv e MAOI antidepressants Phenelzine Phenelzine is a hydrazine MAOI (Fig. 21.25). Its mechanism of action is the prolonged, nonselective, irreversible inhibition of MAO. Phenelzine has been used with some success in the management of bulimia nervosa. T he MAOIs, however, are potentially dangerous in patients with binge eating and purging behaviors, and the American Psychiatric Association states that MAOIs should be used with caution in the management of bulimia nervosa.

Table 21.15. Pharmacokinetics of the M onoamine Oxidase Inhibitors (M AOIs)

Parameters

Phenelzine (Nardil)

Tranylcypromine (Parnate)

M eclobemide

Oral bioavailability (%)

NA

~50

50–90

Protein binding (%)

NA

NA

50

Volume of distribution (L/kg)

NA

1.1–5.7

1.2

Elimination half-life (hours)

NA

2.5 (1.5–3.2)

1.5

Peak plasma concentration (hours)

2–3

1.5 (0.7–3.5)

0.82

Excretion route

Urine

Urine

Renal

Feces

Feces

NA, not available.

Limited information is available regarding MAOI pharmacokinetics of phenelzine (T able 21.15). Phenelzine appears to be well absorbed following oral administration; however, maximal inhibition of MAO occurs within 5 to 10 days. Acetylation of phenelzine to its inactive acetylated metabolite appears to be a minor metabolic pathway (78). Phenelzine is a substrate as well as an inhibitor of MAO, and major identified metabolites of phenelzine include phenylacetic acid and p-hydroxyphenylacetic acid. Phenelzine also elevates brain GABA levels, probably via its β-phenylethylamine metabolite. T he clinical effects of phenelzine may continue for up to 2 weeks after discontinuation of therapy. Phenelzine is excreted in the urine mostly as its N-acetyl metabolite. Interindividual variability in plasma concentrations have been observed among patients who are either slow or fast acetylators. Slow acetylators of hydrazine MAOIs may yield exaggerated adverse effects after standard dosing. If adverse neurological reactions occur during phenelzine therapy, phenelzine-induced pyridoxine deficiency should be considered. Pyridoxine supplementation can correct the deficiency while

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allowing continuance of phenelzine therapy.

Tranylcypromine T ranylcypromine is a nonhydrazine, irreversible MAO inhibitor antidepressant agent that was designed as the cyclopropyl analogue of amphetamine (Fig. 21.25). Instead of exhibiting amphetamine-like stimulation, its mechanism of action is nonselective, irreversible inhibition of MAO. Its onset of antidepressant action is more rapid than for phenelzine. T ranylcypromine is well absorbed following oral administration (T able 21.15). Metabolism occurs via aromatic ring hydroxylation and N-acetylation (78). It is a competitive inhibitor of CYP2C19 and CYP2D6 and a noncompetitive inhibitor of CYP 2C9. Most metabolism studies suggest that tranylcypromine is not metabolized to amphetamine contrary to debate. Maximal MAO inhibition, however, occurs within 5 to 10 days. T he GI absorption of the tranylcypromine shows interindividual P.591 variation and may be biphasic in some individuals, achieving an initial peak within approximately 1 hour and a secondary peak within 2 to 3 hours. It has been suggested that this apparent biphasic absorption in some individuals may represent different absorption rates. Following discontinuance of tranylcypromine, the drug is excreted within 24 hours. On withdrawal of tranylcypromine, MAO activity is recovered in 3 to 5 days (possibly in up to 10 days). Concentrations of urinary tryptamine, an indicator of MAO-A inhibition return to normal, however, within 72 to 120 hours.

Reversible MAO-A Inhibitor Antidepressants T he major goal for developing new reversible MAO-A inhibitors (RIMAs) is to avoid the severe, life-threatening hypertensive reactions that can occur with irreversible inhibitors. Irreversible inhibition of intestinal and hepatic MAO-A can lead to inhibition of tyramine degradation, thus allowing excessive amounts of naturally occurring tyramine to be absorbed from the food. Because these reversible compounds form unstable complexes with the MAO-A subtype, they can be easily displaced from MAO-A by tyramine. T hus, it becomes possible for ingested tyramine to be metabolized, diminishing the need for the dietary restrictions that plague the use of older irreversible nonselective MAOIs. T his new class of selective and reversible inhibitors of MAO-A includes moclobemide (Fig. 21.25).

Moclobemide Moclobemide is a benzamide derivative containing a morpholine ring with a pK a of 6.2 and a partition coefficient of 40 in a octanol/pH 7.4 buffer solution. Moclobemide is not currently available commercially in the United States, but is available in the United Kingdom and Australia.

Mech an ism of action Moclobemide is an RIMA that preferentially inhibits MAO-A (~ 80%) and, to a lesser extent, MAO-B (20–30% inhibition), thereby increasing the concentration of 5-HT , NE, and other catecholamines in the synaptic cleft and in storage sites. During chronic therapy with the MAOIs, adaptive changes at the noradrenergic and serotonergic receptors occur (“ downregulation” ) as a result of neurotransmitter hypersensitivity because of prolonged concentrations of NE and 5-HT at the postsynaptic receptor (see the discussion of the receptor sensitivity hypothesis for details). T his mechanism is likely the basis for its antidepressant activity. Inhibition of MAO-A by moclobemide is short-acting (maximum, 24 hours) and reversible. T his is in contrast to phenelzine, which is nonselective, long-acting, and irreversible in its binding to MAO-A and MAO-B. T he pharmacokinetics (T able 21.15) for moclobemide are linear only up to 200 mg; at higher doses, nonlinear pharmacokinetics are observed (79). Although well absorbed from the GI tract, the presence of food reduces the rate but not the extent of absorption of moclobemide. Small quantities of moclobemide are distributed into human breast milk. Moclobemide undergoes a complex metabolism, initially involving morpholine carbon and nitrogen oxidation, deamination, and aromatic hydroxylation. T he N-oxide and ring-opened metabolites retain some in vitro MAO-A inhibition. Moclobemide is a weak inhibitor of CYP2D6 in vitro. It is extensively metabolized in the liver by oxidation and is eliminated primarily into the urine as conjugates. Less than 1% of an administered dose of moclobemide is eliminated unmetabolized. Because moclobemide is partially metabolized by the polymorphic isozymes CYP2C19 and CYP2D6, plasma concentrations of moclobenmide may be affected in patients who are poor metabolizers. In patients who are slow metabolizers, the AUC for moclobemide was 1.5 times greater than the AUC in patients who are

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extensive metabolizers and receiving the same dose. T his increase is within the normal range of variation (up to twofold) typically seen in patients. Drug interactions for the RIMAs include interaction with SSRI antidepressants, which can cause the 5-HT syndrome (see the discussion of SSRIs). T he effect of stimulant drugs, such as methylphenidate and dextroamphetamine (used to treat ADHD), may be increased. Some over-the-counter cold and hay fever decongestants (i.e., sympathomimetic amines) can have increased stimulant effects. Selegiline, a selective MAO-B used for Parkinson's disease, should not be used concurrently with the RIMAs. Unlike the irreversible MAOIs, no significant interactions with foods occur, because the selective inhibition of MAO-A does not stop the metabolism of tyramine. T he RIMAs must not be taken concurrently with a nonreversible MAOI.

M ood Stabilizers Manic-depression, or bipolar affective disorder, is a prevalent mental disorder with a global impact. Mood stabilizers have acute and long-term effects and, at a minimum, are prophylactic for manic or depressive disorders. Lithium is the classic mood stabilizer and exhibits significant effects on mania and depression but may be augmented or substituted by some antiepileptic drugs. T he biochemical basis for mood stabilizer therapies or the molecular origins of bipolar disorder is unknown. Lithium ion directly inhibits two signal transduction pathways. It suppresses inositol trisphosphate signaling through depletion of intracellular inositol and inhibits glycogen synthase kinase-3 (GSK-3), a multifunctional protein kinase. A number of GSK-3 substrates are involved in neuronal function and organization and, therefore, present plausible targets for manic-depression. Despite these intriguing observations, it remains unclear how changes in inositol trisphosphate signaling underlie the origins of bipolar disorder (80,81). P.592

Inositol (myo-inositol), a naturally occurring isomer of glucose, is a key intermediate of the phosphatidylinositol signaling pathway, a second messenger system used by noradrenergic, serotonergic, and cholinergic receptors. T he suggestion that lithium might treat mania via its reduction of inositol levels led to experiments showing that oral doses of inositol reverse the behavioral effects of lithium in animals and the side effects of lithium in humans. Cerebrospinal fluid levels of inositol are low in depressed individuals (82). T he effectiveness of inositol in treating manic-depression was shown in a double-blind trial that large doses of inositol (12 g) increased inositol concentrations in human cerebrospinal fluid by 70% and led to improvement in depressed patients compared to placebo (82). Valproic acid and carbamazepine are antiepileptic drugs with mood-stabilizing properties that also inhibit inositol trisphosphate signaling through the inositol-depletion mechanism. Inositol significantly reduced the number of panic attacks per week in patients as compared to fluvoxamine and without the nausea and tiredness that are common with fluvoxamine. Inositol has few known side effects, thus making it attractive for administration to patients with manic-depression who are ambivalent about taking other antidepressant drugs (82).

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Lithium Lithium (from the Greek word l i thos, meaning “ stone” ) is a monovalent cation that competes with sodium, potassium, calcium, and magnesium ions at intracellular binding sites; at sugar phosphatases; at protein surfaces; at carrier binding sites; and at transport sites. Lithium readily passes through sodium channels, and high concentrations can block potassium channels. In the 1870s, claims for the healthful effects of lithium fueled the markets for products such as Lithia Beer and Lithia Springs Mineral Water (in 1887, analysis of Lithia Springs Mineral Water proved the water to be rich not only in lithium but also in potassium, calcium, magnesium, fluoride, and other essential trace minerals). In 1890, the Lithia Springs Sanitorium (Georgia) was established using natural lithium water to treat alcoholism, opium addiction, and compulsive behavior, even though manic depression had not been identified as a form of mental illness until the early 1900s. Lithium's mood-stabilizing properties were revitalized in the 1940s when an Australian physician, John Cade, hypothesized that a toxin in the blood was responsible for bipolar illness. Believing that uric acid would protect individuals from this toxin, he began studying the effects of a mixture of uric acid and lithium in rats. Lithium carbonate was used to dissolve the uric acid. He observed a calming effect of this combination on the rats and subsequently determined that the lithium, rather than the uric acid, was responsible for this calming effect. He then speculated that lithium might be useful in humans as a mood attenuator, subsequently administered lithium to a sample of patients with bipolar disorder, and discovered that lithium not only decreased the symptoms of mania but also prevented the recurrence of both depression and mania when taken regularly by these patients. After a decade of clinical trials, the U.S. FDA approved lithium for treatment of mania in 1970. Lithium carbonate (Eskalith) is the most commonly used salt of lithium to treat manic depression. Lithium carbonate dosage forms are labeled in mg and mEq/dosage unit, and lithium citrate (Lithobid) is labeled as mg equivalent to lithium carbonate and mEq/dosage unit. Lithium is effectively used to control and prevent manic episodes in 70 to 80% of those with bipolar disorder as well as to treat other forms of depression. T hose who respond to lithium for depression often are those who have not responded to T CAs after several weeks of treatment. When giving lithium in addition to their antidepressants, some of these people have shown significant improvement.

Mechanism of action Lithium therapy for disorders is believed to be effective because of its ability to reduce signal transduction through the phosphatidylinositol signaling pathway (Fig. 21.26) (83,84). In this pathway, the second messengers diacylglycerol and inositol 1,4,5-trisphosphate are produced from the enzymatic hydrolysis of phosphatidylinositol-4,5-bisphosphate (a membrane phospholipid) by the receptor-mediated activation of the membrane-bound, phosphatidylinositol-specific phospholipase C. T he second messenger activity for inositol 1,4,5-trisphosphate is terminated by its hydrolysis in three steps by inositol monophosphatases to inactive inositol, thus completing the signaling pathway. T o recharge the signaling pathway, inositol must be recycled back to phosphatidylinositol bisphosphate by inositol phospholipid–synthesizing enzymes in the CNS, because inositol is unable to cross the blood-brain barrier into the CNS in sufficient concentrations to maintain the signaling pathway. By uncompetitive inhibition of inositol phosphatases in the signaling pathway, the therapeutic plasma concentrations of lithium ion deplete the pool of inositol available for the resynthesis of phosphatidylinositol-4,5- bisphosphate, ultimately decreasing its cellular levels and, thereby, P.593 reducing the enzymatic formation of the second messengers. T hus, lithium ion restores the balance among aberrant signaling pathways in critical regions of the brain.

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Fig. 21.26. Intracell ular phosphatidylinositol signaling pathway and site of action for lithium. Phospholipase (PLC) is a membrane-bound enzyme. IP, inositol monophosphate; DAG, diacylglyceride; IMP, inositol monophosphatase.

T he effects of lithium ion on disorders are surprisingly specific because of the inability of inositol to cross the blood-brain barrier and replenish depleted inositol levels. Lithium ion exerts its greatest influence on this signaling pathway when the lithium ion concentration is at saturation conditions. T he clinical efficacy of lithium in the prophylaxis of recurrent affective episodes in bipolar disorder is characterized by a lag in onset and remains for weeks to months after discontinuation. T hus, the long-term therapeutic effect of lithium likely requires reprogramming of gene expression. Protein kinase C and GSK-3 signal transduction pathways are perturbed by chronic lithium at therapeutically relevant concentrations and have been implicated in modulating synaptic function in nerve terminals (84).

Pharmacokinetics T he absorption of lithium is rapid and complete within 6 to 8 hours. T he absorption rate of slow-release capsules is slower and the total amount of lithium absorbed lower than with other dosage forms. Lithium is not protein bound. T he elimination half-life for elderly patients (39 hours) is longer than that for adult patients (24 hours), which in turn is longer than that for adolescent patients (18 hours). T he time to peak serum concentration for lithium carbonate is dependent on the dosage form (tablets, 1–3 hours; extended tab, 4 hours; slow release, 3 hours). Steady-state serum concentrations are reached in 4 days, with the desirable dose targeted to give a maintenance lithium ion plasma concentration range of 0.6 to 1.2 mEq/L, with a level

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of 0.5 mEq/L for elderly patients. T he risk of bipolar recurrence was approximately threefold greater for patients with lithium dosages that gave plasma concentrations of 0.4 to 0.6 mEq/L. Adverse reactions are frequent at therapeutic doses, and adherence is a big problem. T oxic reactions are rare at serum lithium ion levels of less than 1.5 mEq/L. Mild to moderate toxic reactions may occur at levels from 1.5 to 2.5 mEq/L, and severe reactions may be seen at levels from 2.0 to 2.5 mEq/L, depending on individual response. T he onset of therapeutic action for clinical improvement is 1 to 3 weeks. Renal elimination of lithium ion is 95%, with 80% actively reabsorbed in the proximal tubule. T he rate of lithium ion urinary excretion decreases with age. Fecal elimination is less than 1%.

Drug interactions Lithium pharmacokinetics may be influenced by a number of factors, including age. Elderly patients require lower doses of lithium to achieve serum concentrations similar to those observed in younger adults as a result of reduced volume of distribution and P.594 reduced renal clearance. Lithium ion clearance decreases as the glomerular filtration rate decreases with increasing age. Reduced lithium ion clearance is expected in patients with hypertension, congestive heart failure, or renal dysfunction. Larger lithium ion maintenance doses are required in obese compared with nonobese patients. T he most clinically significant pharmacokinetic drug interactions associated with lithium involve drugs that are commonly used in the elderly and that can increase serum Li + concentrations. People who are taking lithium should consult their physician before taking the following drugs: acetazolamide, antihypertensives, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, calcium channel blockers, carbamazepine, thiazide diuretics, hydroxyzine, muscle relaxants, neuroleptics, table salt, baking powder, tetracycline, T CAs, MAOIs, and caffeine. T he tolerability of lithium is lower in elderly patients. Lithium toxicity can occur in the elderly at concentrations considered to be “ therapeutic” in the general adult populations. Serum concentrations of lithium ion need to be markedly reduced in the elderly population—and particularly so in the very old and frail.

Adverse effects Common side effects of lithium include nausea, loss of appetite, and mild diarrhea, which usually taper off within first few weeks. Dizziness and hand tremors also have been reported. Increased production of urine and excessive thirst are two common side effects that usually are not serious problems, but patients with kidney disease should not be given lithium. T aking the day's dosage of lithium at bedtime also seems to help with the problem of increased urination. Other side effects of lithium include weight gain, hypothyroidism, increased white blood cell count, skin rashes, and birth defects. While on lithium, a patient's blood level must be closely monitored. If the blood level of lithium ion is too low, the patient's symptoms will not be relieved. If the blood level of lithium ion is too high, there is a danger of a toxic reaction.

Therapeutic uses For many years, lithium has been the treatment of choice for bipolar disorder, because it can be effective in smoothing out the mood swings common to this condition. Its use must be carefully monitored, however, because the range between an effective and a toxic dose is small.

N-M ethyl-D-Aspartate Antagonists In spite of intensive research, the problem of treating antidepressant-resistant patients has not yet been solved. T he past decade has seen a steady accumulation of evidence supporting a role for the excitatory amino acid neurotransmitter, glutamate, and its mGluR1 and mGluR5 receptors in depression and antidepressant activity (85,86). Glutamate plays an essential role as a neurotransmitter in many physiological functions, and an increase in glutamate release can result in activation of NMDA receptors, an underlying cause for depression and anxiety. T he NMDA receptor is a ligand-gated ion channel that mediates excitatory synaptic transmission in the CNS. T his channel opening and receptor activation are triggered by synaptically released glutamate and require the binding of glycine, which is a coagonist. Studies with NMDA receptor antagonists of mGluR1 and mGluR5 receptors, as well as positive modulators of α-amino-3-hydroxy-5-methyl4-isoxazolepropionic acid (AMPA) receptors, have antidepressant-like activity in a variety of preclinical models. Furthermore, evidence implicates disturbances in glutamate metabolism, NMDA, and mGluR1/5

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receptors in depression and suicidality. Moreover, antidepressant-like activity can be produced not only by drugs modulating the glutamatergic synapse but also by agents that affect subcellular signaling systems linked to excitatory amino acid neurotransmitter receptors (e.g., nitric oxide synthase). T hese studies suggest that an intimate relationship exists between regulation of monoaminergic and excitatory amino acid neurotransmission and antidepressant effects. T he concept of NMDA antagonists as antidepressants has generated considerable interest in the NMDA receptor as a target for new antidepressant therapies (85,86,87). Recent data indicate that ci s-1-phenyl2-[1-aminopropyl]-N,N-diethylcarboxamide, a NMDA receptor antagonist and homologue of milnacipran, produces sustained relief from depressive symptoms. Several studies have shown that chronic antidepressant treatment can modulate NMDA receptor expression and function. Preclinical studies with this and other NMDA receptor antagonists have demonstrated their potential antidepressant properties. T he combination of traditional antidepressant drugs (e.g., imipramine) and uncompetitive NMDA receptor antagonists (e.g., memantine) may produce enhanced antidepressive effects as a result of synergism. T his observation may be of particular importance for the treatment of antidepressant-resistant patients. Most interesting was the observation that fluoxetine, which was inactive in the forced swimming test in rats when given alone, showed a positive effect when combined with memantine (2.5 and 5 mg/kg).

Neuropeptides T he pharmacological treatment of depressive illness has been dominated by drugs that directly target P.595 monoamine neurotransmitter systems. Monoamine transport inhibitors are first-line treatments for depression. Current antidepressants exhibit a delayed onset of therapeutic action, and a significant number of patients are nonresponsive to this treatment regimen (54). Moreover, many patients discontinue treatment because of adverse side effects, including nausea, sexual dysfunction, anorexia, mouth dryness, and cardiotoxicity. A complementary strategy is to identify other treatments that target other neurotransmitter and neuromodulators in the brain. Neuropeptides have been shown to be attractive targets for depression (88,89). Neuropeptides are short-chain amino acid neurotransmitters and neuromodulators often localized in brain regions that mediate emotional behaviors and the response to stress (88,89). T he neuropeptides that have been identified in stress include the tachykinins (substance P and neurokinin A), corticotropin-releasing factor, vasopressin, galanin, brain-derived neurotrophic factor (BDNF) and melanocyte- inhibiting factor. T hus, drugs that are antagonists at these neuropeptide receptors might exhibit a lower incidence of adverse effects, because such antagonists would not be expected to bind to the NE and 5-HT neurotransmitter receptors. T he expression of BDNF in individuals with MDD is decreased suggesting that BDNF plays a role in the pathophysiology of depression as a regulator of neuronal signaling pathways. Antidepressant drugs increase the BDNF brain levels, and therefore, enhance the mechanism of action of the antidepressant drugs. Drugs that boost the levels of BDNF may lead to the development of novel therapeutic agents for the treatment of MDD and bipolar disorders.

Corticotropin-Releasing Factor

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Increasing evidence suggests that the neuroendocrine changes seen in patients suffering from affective disorders may be causally related to the course of depression. T he most robustly confirmed neuroendocrine finding among patients with affective disorders is hyperactivity of the hypothalamic-pituitary-adrenocortical (HPA) system, resulting from hyperactive hypothalamic corticotropin-releasing factor (CRF) neurons. Abnormal HPA activity has been implicated in conditions related to stress, including HPA overactivation in depression, eating and substance abuse disorders, irritable bowel syndrome, inflammation, and cardiovascular dysfunction. Preclinical and clinical evidence suggests that both genetic and environmental factors contribute to the development of these HPA system abnormalities. Corticotropin-releasing factor is a 41-amino-acid neuropeptide that initiates and regulates the HPA-axis response to stress, and it has been intensively studied in the pathophysiology and treatment of depression (90). In humans, the CRF system consists of CRF and two G protein–coupled CRF receptors (CRF 1 and CRF 2 ). T he CRF 1 receptors play an important role in mediating the HPA response to stress. Additionally, CRF is capable of reproducing the hormonal changes that are characteristically seen in depressed patients. Postmortem and endocrine studies suggest that both hypothalamic and extrahypothalamic concentrations of CRF are elevated in proportion to antidepressant treatment. High CRF concentrations tend to reestablish the HPA imbalance. T he careful manipulation of CRF concentrations with high-affinity CRF 1 antagonists, such as R121919, may hold therapeutic promise for sufferers of depression.

Substance P Substance P is an 11-amino-acid neuropeptide belonging to the tachykinin family, mediating its biological actions through activation of G protein–coupled tachykinin (neurokinin-1 [NK 1 ]) receptors. Its proposed physiological roles include inflammation, pain, GI and respiratory function, stress responses, and emesis. Substance P is uniquely associated with the monoamine neurotransmitters, 5-HT and NE. T he 5-HT neurons coexpress substance P, and the firing of NE neurons is modulated by substance P. Preclinical studies have supported a role of the substance P–NK 1 receptor system in stress-related disorders, which has guided the antidepressant development of centrally active NK 1 receptor antagonists, such as aprepitant (91). T he NK 1 antagonists are generally well tolerated and exhibit less nausea and sexual dysfunction than some currently used antidepressants.

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Vasopressin T he nonapeptide vasopressin is well known for its role on fluid metabolism (see Chapter 7), but it also is a key regulator of the HPA axis. Stress stimulates the release of vasopressin in the pituitary gland, where it strongly potentiates the effects of CRF on adrenocorticotropic P.596 hormone release. T hese findings suggest that HPA axis dysregulation in depression might be associated with the development of centrally acting vasopressin receptor antagonists for the treatment of depression.

Galanin Since its discovery in 1983, the neuropeptide galanin has been found to be involved in a wide range of functions, including pain sensation, sexual activity, feeding, and learning and memory (92). Galanin is widely distributed in the central and peripheral nervous systems and in the endocrine system, and it acts as a inhibitory neuromodulator of NE and 5-HT in the brain. T he 29- to 30-amino-acid sequence of galanin is conserved (almost 90% among species), indicating the importance of the molecule among species. Galanin is colocalized with acetylcholine, 5-HT , and NE in neurons or in brain regions implicated in cognitive and affective behavior, suggesting a possible role in the regulation of 5-HT and NA neurotransmission in depressive states and during the course of antidepressant therapy. T hree galanin receptor subtypes have been cloned and studied, but little is known about their specific contributions to behavioral processes. In the CNS, galanin inhibits acetylcholine release, suggesting a possible role for galanin in cholinergic dysfunction; inhibits neurotransmitter release and neuronal firing rate; and inhibits signal transduction by inhibition of phosphatidyl inositol hydrolysis, leading to symptoms of depression. T hus, blocking the inhibitory effects of galanin on monoamine neurotransmitters with galanin receptor antagonists would be predicted to mimic or augment the action of the other monoamine classes of antidepressants.

Melanocyte-Inhibiting Factor Nemifitide is a peptide analogue of melanocyte-stimulating hormone release–inhibiting factor currently in clinical development for the potential treatment of moderate to severely depressed patients (93). It is rapidly absorbed, with a peak plasma concentration of 10 min and an elimination half-life of 15 to 30 minutes in most subjects. T he pharmacokinetic results indicate that the dose is proportional in the dose range investigated. No evidence indicated systemic accumulation of drug following five daily doses. No serious adverse events or clinically significant systemic adverse events occurred at any of the doses investigated in the more than 100 subjects dosed in these studies. Drug-related adverse events were limited to local and transient skin reactions (pain and/or erythema) at the injection site, especially at the high doses administered. Melanocytestimulating hormone release–inhibiting factor-1 (MIF-1) has been shown to have antidepressant activity when administered subcutaneously (10 mg for 5 consecutive days) in a double-blind study to 20 depressed patients

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who all met the DSM-IIIR criteria for major depression. After the 5-day treatment with MIF-1, these patients all exhibited substantial improvement in their symptoms of depression (94). Moreover, the potential clinical efficacy of combining MIF-1 (0.01 mg/kg IP) with small doses of the T CAs amitriptyline (5 mg/kg IP) or desipramine (1.25 mg/kg IP) may be of benefit in the therapy of depressed patients.

Herbal Therapy In the past few years, much interest has been generated regarding the use of herbs in the treatment of both depression and anxiety (95). Recent studies, however, have revealed potentially fatal interactions between herbal remedies and traditional drugs. St. John's wort (Hyperi cum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has aroused interest in the United States. A bushy, low-growing plant covered with yellow flowers in summer, St. John's wort has been used for centuries in many folk and herbal remedies. In Germany, hypericum is used in the treatment of depression more than any other antidepressant. T he scientific studies that have been conducted regarding its use have been short-term, however, and have used several different doses. St. John's Wort works like the SSRIs, in that it not only increases the availability of 5-HT in synaptic clefts by blocking its reuptake but also increases the availability of NE, which increases energy and alertness, and dopamine, which increases the feeling of well-being. Ingestion of St John's wort increases the expression (i.e., upregulation) of intestinal P-glycoprotein and of CYP3A4 in the liver and intestine, which impairs the absorption and stimulates the metabolism of other CYP3A4 substrates (e.g., the protease inhibitors indinavir and nevirapine, oral contraceptives, and T CAs [e.g., amitriptyline]), resulting in their subtherapeutic plasma levels. Hyperforin, the principal component in St. John's wort (2–4% in the fresh herb) contributes to the induction of CYP3A4. Furthermore, it not only inhibits the neuronal reuptake of 5-HT , NE, and dopamine, like many other antidepressants, but also inhibits GABA and L-glutamate uptake. T his broad-spectrum effect is obtained by an elevation of the intracellular sodium ion concentration, probably resulting from activation of sodium conductive pathways not yet P.597 finally identified but most likely to be ionic channels. T his makes hyperforin the first member of a new class of compounds with a preclinical antidepressant profile because of a completely novel mechanism of action (95,96). Hypericin, the other component in St. John's wort, also may exhibit inhibitor action on key neuroreceptors and may be responsible for the phototoxicity/photosensitivity of St. John's wort. T he National Institutes of Health conducted a double-blind, 3-year study in patients with major depression of moderate severity using St. John's wort and sertraline. T his study did not support the use of St. John's wort in the treatment of major depression, but a possible role for St. John's wort in the treatment of milder forms of depression was suggested. Health care providers should alert their patients about potential drug interactions with St. John's Wort. Some other frequently used herbal supplements that have not been evaluated in large-scale clinical trials are ephedra, gingko biloba, echinacea, and ginseng. Any herbal supplement should be taken only after consultation with the physician or other health care provider.

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Electroconvulsive T herapy Electroconvulsive therapy (ECT ) has been in use since the late 1930s to treat a variety of severe mental illnesses, most notably major depression. Use of ECT is beneficial particularly for individuals whose depression is severe or life threatening or who cannot take antidepressant medication. Often, ECT is effective in cases where antidepressant drugs do not provide sufficient relief of symptoms. Electroconvulsive therapy remains the “ gold standard” for the treatment of major depression and a variety of other psychiatric and neurologic disorders (97). Because of the effectiveness and resurgence of ECT , more patients are considered to be good candidates for this treatment option. Overall, these patients are medication refractory and elderly and, thus, are more sensitive to polypharmacy. Additionally, these patients tend to have more coexisting medical problems. In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. T he stimulation causes a brief (~ 30 seconds) seizure within the brain. T he person receiving ECT does not consciously experience the electrical stimulus. For full therapeutic benefit, at least several sessions of ECT , typically given at the rate of three per week, are required. Electroconvulsive therapy appears to increase the sensitivity of postsynaptic 5-HT receptors and upregulation of 5-HT 1A postsynaptic receptors. Side effects may result from the anesthesia, the ECT treatment, or both. Common side effects include temporary short-term memory loss, nausea, muscle aches, and headache. Some people may have longerlasting problems with memory after ECT . Sometimes, a person's blood pressure or heart rhythm changes. If these changes occur, they are carefully watched during the ECT treatments and are immediately treated.

Case Study Victor ia F. Roche S. William Zito NL is an 84-year-old f emale who had to move to a retirement c ommunity af ter losing her husband to a prolonged battle with cancer. She desperately misses her home and the lif e they shared there, and the move was made all the more devastating because of the need to f ind good homes f or their beloved cats. NL has experienced symptoms of depres sion regularly during her adult lif e but never sought medical as sistance until her husband f ell ill. She has been taking escitalopram (Lexapro, 10 mg q.d.) f or 3 years, although it has not totally controlled the despair and anxiety that she experiences, especially at night. Af ter being of f cigarettes f or 20 years, she has started smoking again, which is adding to her distress. She is embarrassed by her need f or antidepressant medication and f inds it hard to talk with her physician about her f eelings. Rec ently, she has become restles s and agitated, both at bedtime and during the day, and is cons idering self -medicating with St. John's wort, which has been highly recommended by a member of the bridge club she has joined. She is in your pharmacy now, carrying a bottle of Kaopectate and trying to select a St. John' s wort produc t. NL has osteoporosis that is being managed with sodium alendronate (Fosamax), and f ortunately, the

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recent f alls she experienced af ter losing her balance on standing did not result in any broken bones. I n addition to thyroid hormone replacement therapy, her other current medications include metoprolol f or high blood pressure and clonazepam f or restless leg syndrome. Turn your attention to the antidepressant choices shown below, and prepare to make a recommendation to NL and her physician. 1. I dentif y the therapeutic problem(s) in whic h the pharmac ist' s intervention may benef it the patient. 2. I dentif y and prioritize the patient-specif ic f actors that must be cons idered to achieve the desired therapeutic outcomes . 3. Conduct a thorough and mec hanis tically oriented structure–activity analysis of all therapeutic alternatives provided in the cas e. 4. Evaluate the structure–activity relationship f indings agains t the patient specif ic f actors and desired therapeutic outcomes and make a therapeutic decision. 5. Counsel your patient.

P.598

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Chapter 22 Psychotherapeutic Drugs: Antipsychotic and Anxiolytic Agents Ray m ond G. Booth

Drugs cov ered in this chapter: Phe no thiazine c las s T hio xanthine s c las s Be nzamid e c las s Be nzaze p ines Clo zap ine L oxap ine Olanzapine Que tiapine Be nzis o xazo le and be nzis othiazo le s Ris p e rid one Zip ras id o ne Mis c e llane o us antip s yc ho tic ag ents Arip ip razole Mo lind one Se rtind o le Be nzod iaze p ines Chlo rdiazep o xid e Diazep am Fluraze p am Oxaze p am Mis c e llane o us anxiolytic age nts Es zop ic lo ne Zalp id e m Zo lpid em

Overview of Mental Illnesses Mental illnesses that can be treated with psychotropic drugs are broadly categorized as psychoses, neuroses, and mood (depression, bipolar) disorders. Different classes of psychotropic agents differ in their ability to modify symptoms of these mental illnesses; thus, an appropriate diagnosis is critical to selecting an efficacious psychotropic drug. T his chapter is focused on the medicinal chemistry of drugs that are used to treat psychosis and anxiety disorders. T he definitive diagnostic criteria for psychiatric disorders in the United States are well described in the Di agnosti c and Stati sti cal M anual of M ental Di sorders of the Ameri can Psychi atri c Associ ati on (DSM-IV-T R) (1). T he psychoses (e.g., schizophrenia) are among the most severe mental illnesses and commonly include symptoms of delusions and sensory hallucinations. In anxiety disorders (neuroses), the ability to comprehend reality is retained, but mood changes (anxiety, panic, dysphoria) and thought (obsessions, irrational fears) and behavioral (rituals, compulsions, avoidance) dysfunction can be disabling. Mood and panic disorders usually include dysfunction of the autonomic nervous system (e.g., altered patterns of sleep and appetite) in addition to psychic abnormalities. Depression can lead to self-harm and suicide. In general, antipsychotic agents, which can have severe neurological side effects, should be used to treat only the most severe mental illnesses (i.e., psychoses such as schizophrenia).

Schizophrenia

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Definition An historical definition of schizophrenia may begin approximately 100 years ago, with the German psychiatrist Emil Kraepelin's description of a type of dementia that was characterized as a severe, chronic mental disorder without known external causation wherein functional deterioration progresses with the symptoms of hallucinations, delusions, thought disorder, incoherence, blunted affect, negativism, stereotyped behavior, and lack of insight (2). T he deterioration progresses to catatonia and hebephrenia (illogical, incoherent, and senseless thought processes and actions, delusions, and hallucinations). Meanwhile, the Swiss psychiatrist Eugen Bleuler coined the term “ schizophrenia” to take into account the perceived “ schism” or splitting in mental functioning (3). A modern definition of schizophrenia comes from DMS-IV (1). T he diagnostic criteria for schizophrenia require two or more of the following characteristic symptoms to be present for a significant proportion of time during a 1-month period: delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. T here is, however, flexibility in the diagnostic criteria that leaves room for professional psychiatric judgment. For example, it is enough if hallucinations consist of a voice maintaining a running commentary on the patient's behavior or there are two or more voices that converse with each other. Also, for a significant proportion of time, one or more areas of social functioning, such as work, interpersonal relationships, or self-care, are markedly below the level achieved before the onset of symptoms. Continuous symptoms must persist for 6 months. Finally, before a diagnosis of schizophrenia is made, affective disorders as well as, drug/alcohol abuse or other medical conditions must be ruled out.

Etiology of Schizophrenia A neurobiological basis for schizophrenia and related psychotic syndromes remains elusive. Compelling evidence linking genetic factors to the etiology of schizophrenia is not apparent despite enormous progress in P.602 the field of molecular genetics and numerous investigations of hereditary factors associated with psychotic illnesses. Current epidemiological evidence suggests that individual variation in susceptibility to schizophrenia involves alleles of moderate to small effect in multiple genes. Investigations of environmental causative factors have focused on prenatal and perinatal risk factors for brain damage. For example, studies have examined the incidence of schizophrenics who were born under conditions of obstetrical complications, influenza epidemics, food shortages, and Rh factor incompatibility. Neuroanatomical hypotheses include increased ventricular volume; however, neuropathological changes associated with schizophrenic brains are not obvious as in, for example, Parkinson's disease. In contrast, neurochemical abnormalities are well documented. Alterations of brain dopaminergic neurotransmission in psychoses have been studied for more than 30 years, and this field of psychobiological research generally revolves around the “ dopamine hypothesis” of schizophrenia.

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Clinic al Significa nc e T here is probably no greater contribution to morbidity in life than those disorders that affect the mind. T he burden of depression, psychosis, anxiety, and other related disorders take a significant toll on individuals and society as a whole. T he ability to effectively address these maladies in clinical practice relies on an understanding of neuropharmacology and the chemical characteristics of psychotropic agents used to treat patients. Although certain agents may be effective, they also may convey significant adverse effects. Case in point, 25 years ago we had effective agents to treat psychosis. T heir effectiveness came at a high price, however, because in many patients, these agents produced severe extrapyramidal symptoms. As the understanding of neuropharmacology and structure–activity relationship evolved, the introduction of atypical antipsychotics to the treatment armamentarium came about. T he ability of these agents to influence serotonergic and dopaminergic activity is thought by many to convey additional effectiveness while limiting extrapyramidal symptoms. Consequently, these agents have revolutionized the treatment of psychosis and related disorders. As a class, the atypical antipsychotics are fairly heterogeneous, and clinicians may choose certain agents based on their activities at various receptors. As you read this chapter, pay particular attention to the receptor affinity of all the psychotropic agents and how it is thought to translate into effectiveness and/or toxicity. T his will help you in your practice to make rational treatment decisions based on inherent characteristics of these agents, their performance in clinical trials, and your clinical understanding of the patient. David Hayes Pharm.D. Clinical Assistant Professor, Department of Clinical Sciences & Administration, University of Houston College of Pharmacy

T he connection between dopaminergic neurotransmission and schizophrenia is an example of a “ pharmacocentric” approach to characterizing the etiology and neuropathology of mental illnesses (4,5,6). T he dopamine hypothesis of schizophrenia arose from observations that the first relatively safe and effective antipsychotic drugs, the phenothiazines, such as chlorpromazine, used in the early 1950s affected brain dopamine metabolism (7). Simply put, the dopamine hypothesis of schizophrenia suggests that schizophrenia results from increased dopaminergic neurotransmission and that approaches which decrease dopaminergic neurotransmission will alleviate psychotic symptoms (8). Most antipsychotic agents have activity to limit dopaminergic neurotransmission, providing some indirect evidence to support the dopamine hypothesis of schizophrenia. In a seminal study by Seeman et al. (9), the average daily dose of antipsychotic was found to correlate well with affinity for dopamine D 2 -type receptors. Moreover, extrapyramidal side effects of antipsychotic drugs certainly correlates with their dopamine D 2 antagonism effect. It should be noted, however, that functional interaction of antipsychotic drugs with the D 2 receptor is complex, involving antagonism, inverse agonism, and partial agonism. For example, recent studies show that essentially all clinically used antipsychotic drugs are D 2 inverse agonists (10), suggesting that biochemical as well as clinical effects may not be explained by simple blockade of agonist (dopamine) access to the D 2 receptor. T he dopamine hypothesis of schizophrenia and pharmacotherapy involving antagonism of dopamine receptors (especially the D 2 -type) has dominated research directions, but it should be noted that the entire argument is somewhat circular. Consideration of potential new drugs as antipsychotic agents usually is limited to compounds that have demonstrated behavioral or biochemical evidence of antidopaminergic actions. Of course, this somewhat conservative and exclusive approach is practical considering the lack of proven alternative neuropharmacological explanations of antipsychotic drug activity. Nevertheless, in light of the nearly 50 years of research focusing on brain dopaminergic systems, uncontested evidence linking the etiology of psychotic illnesses to the neurobiology of dopaminergic systems has remained elusive. Alternative explanations, especially those involving adrenergic and serotonergic receptor systems, probably will gain popularity as more P.603 atypical antipsychotic drugs (e.g., clozapine) are introduced and also found to have actions at these receptor systems, perpetuating and expanding the pharmacocentric approach to antipsychotic drug design and development.

Role of Dopamine Receptors in Schizophrenia Modern molecular biological methods involving recombinant DNA techniques have led to cloning and characterization of five different dopamine receptors: D 1 (446 amino acids), D 2 s hort (414 amino acids) and D 2 long (443 amino acids), D 3 (400 amino acids), D 4 (387 amino acids), and D 5 (477 amino acids) [for a review, see Hartman and Civelli (11)]. T he amino acid sequence, as deduced from their established nucleotide sequence,

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shows that dopamine receptors are a member of the G protein–coupled receptor (GPCR) superfamily that is structurally characterized by a 7-transmembrane-spanning region. Currently, no medicinal chemical probes with high selectivity to distinguish between the five subtypes are available; thus, dopamine receptors often are classified as two major types, according to the functional effect on adenylyl cyclase (12): T he D 1 -types that stimulate adenylyl cyclase are D 1 and D 5 ; the D 2 -types that inhibit adenylyl cyclase are D 2 s hor t , D 2 long , D 3 , and D 4 . Several chemical probes are available that can distinguish between the general D 1 -type and D 2 -type receptor families (Fig. 22.1). T he R-(+ )-isomer of the benzazepine derivative, SKF 38393, is used for research as a selective D 1 -type partial agonist. Meanwhile, the structurally related benzazepine derivative, R-(+ )-SCH 23390, is used as a selective D 1 -type receptor antagonist. Although not very selective for D 1 -type over D 2 -type receptors, the rigid benzophenanthridine derivative (–)-dihydrexidine is a useful research tool, because it is a D 1 -type full efficacy agonist (produces stimulation of adenylyl cyclase equivalent to dopamine itself) (13,14). Selective D 2 -type full agonists, such as the pyrazole derivative (–)-quinpirole, and D 2 -type antagonists, such as (–)-sulpiride, also are available to researchers. Currently, the dopamine D 3 receptor subtype is of particular neuropharmacological interest because of its preferential distribution in certain limbic regions of mammalian brain, notably in the nucleus accumbens of the basal forebrain. It is proposed that highly D 3 -selective drugs might be developed as antipsychotic agents with preferential limbic antidopaminergic actions while sparing the extrapyramidal basal ganglia, presumably decreasing the neurological movement disorder side effects associated with antipsychotic drug therapy (vide infra). T he tetrahydronaphthalene, (+ )-7-hydroxy-N,N-di-n-propyl-2-aminotetralin (7-OH-DPAT ), and some of its congeners are particularly promising D 3 -selective lead agents. T he benzazepine clozapine, which is proposed to have a superior antipsychotic clinical profile with a low incidence of extrapyramidal side effects, shows relatively greater affinity for the D 4 dopamine receptor subtype in addition to its relatively high affinity for serotonin 5-HT 2 , adrenergic a 1 and α 2 , muscarinic M 1 , and histamine H 1 receptors (15).

Fig. 22.1. Structures of compounds useful for characterizing dopamine receptors.

Dopamine Receptors and Functional Selectivity It is now realized that the same GPCR can couple to different Ga proteins to result in “ multifunctional” signaling (16). Molecular mechanisms to account for GPCR multifunctional signaling involve the concept of “ GPCR permissiveness,” which assumes a high degree of flexibility in the interactions between a ligand, receptor, and G protein (17). T hese interactions occur mainly between the G proteins and the second and third intracellular loops

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and carboxy-terminal tail of the receptor. Some factors that influence this interaction include receptor:G protein ratios and amounts, alternative GPCR splicing, and conformational changes in the G protein and/or receptor. A critical assumption of GPCR multifunctional signaling theory is that a heterogeneity of active receptor conformations exists and that agonist ligands differ in their ability to induce, stabilize, or select among receptor conformations, as described in the “ stimulus trafficking” hypothesis (18). Of particular relevance to the medicinal chemist, it follows that on binding, agonist ligand chemical structural parameters are among the most important determinants of GPCR conformation that influences type of Ga protein and signaling pathway activated. T hus, ligand stereochemistry or other more subtle structural parameters may influence GPCR conformation to affect the type of G protein and intracellular signaling pathway activated, resulting in ligand-specific functional outcomes (19,20). Ligands that show such “ functional selectivity” (21,22,23) can be exploited for drug design purposes. A P.604 clinically relevant example is the antipsychotic drug aripiprazole, which interacts with the dopamine D 2 receptor to produce antagonist, inverse agonist, or agonist functional effects, depending on the D 2 receptor cellular milieu (e.g., G-protein complement and concentration) and particular location (e.g., presynaptic vs. postsynaptic and extrapyramidal vs. limbic brain regions).

Fig. 22.2. Some dopamine pathways in mammalian brain.

T he dopamine D 1 -type and D 2 -type receptor families are differentially distributed in mammalian forebrain dopaminergic pathways. T he extrapyramidal nigrostriatal pathway, which plays a key role in locomotor coordination, consists of neurons with cell bodies in the A9 pars compacta of the substantia nigra in the midbrain. T hese neurons project to the basal ganglia structures caudate nucleus and putamen (collectively referred to as striatum) in the forebrain (Fig. 22.2). Degeneration of neurons in the nigrostriatal pathway is the hallmark pathological feature of Parkinson's disease, clinically manifested as bradykinesia, muscular rigidity, resting tremor, and impairment of postural balance. Blockade of dopamine receptors on cholinergic neurons in striatum is associated with the sometimes severe extrapyramidal, parkinsonian-like side effects (muscular rigidity, bradykinesia, akathisia) that frequently occur with antipsychotic drug treatment.

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Fig. 22.3. Tyrosine is hydroxylated in a rate-limiting step by tyrosine hydroxylase (TOH) to form dihydroxylphenylalanine (DOPA), which is decarboxylated by L-aromatic amino acid decarboxylase (AAD) to form dopamine (DA). Newly synthesized DA is stored in vesicles, from which release occurs into the synaptic cleft by depolarization of the presynaptc neuron in the presence of Ca 2+ . The DA released into the synaptic cleft may go on to stimulate postsynaptic D 1 - and D 2 -type autoreceptors that negatively modulate DA synthesis (via inhibition of TOH) and release. The action of synaptic DA is inactivated largely via reaccumulation into the presynaptic neuron by high-affinity DA neurotransport proteins located on the nerve terminal membrane. Free cytoplasmic DA negatively modulates DA synthesis via end-product (feedback) inhibition of TOH by competition with biopterin cofactor. Cytoplasmic pools of DA may undergo metabolic deamination by monoamine oxidase (MAO), an enzyme bound to the outer membrane of mitochondria, to form dihydroxyphenylacetaldehyde, which oxides to didydroxyphenylacetate (DOPAC). The DA or DOPAC may undergo methylation by catechol-O-methyltransferase (COMT), ultimately forming homovanillic acid (HVA), a metabolite excreted in urine.

T he mesolimbic and mesocortical pathway, involved in integration of emotions, behaviors, and higher thought processes, consists of neurons with cell bodies in the A10 ventral tegmentum. T hese neurons project to limbic forebrain structures, including the nucleus accumbens and amygdala, and to higher levels of cerebral function, such as the frontal cortex (Fig. 22.2). According to the dopamine hypothesis, increased dopaminergic neurotransmission in limbic pathways contributes to the “ positive” symptoms (e.g., hallucinations and excited delusional behavior that can be reduced with typical antipsychotic drugs) but not necessarily to the “ negative” symptoms (e.g., catatonia) observed in the clinical manifestation of schizophrenia. T ypical antipsychotic drugs act in both extrapyramidal and limbic brain regions at D 2 -type dopamine receptors that can be located postsynaptically (on cell bodies, dendrites, and nerve terminals of other neurons) as well as presynaptically on dopamine neurons. Dopamine receptors located presynaptically on dopamine cell bodies and nerve terminals are called autoreceptors and act to negatively modulate neuronal firing and dopamine synthesis and release (Fig. 22.3) (24). Low concentrations of certain P.605 dopamine agonists can stereospecifically activate dopamine D 2 -type autoreceptors to decrease dopamine synthesis (25,26) and release (27), thus reducing dopaminergic neurotransmission. T herefore, consistent with the dopamine hypothesis of schizophrenia, selective dopamine autoreceptor agonists could, theoretically, be pharmacotherapeutic agents in schizophrenia and related mental illnesses. In fact, activation of dopamine autoreceptors may form an integral part of the therapeutic action of the most recently developed antipsychotic drugs, such as the D 2 receptor partial agonist aripiprazole (28). In addition to postsynaptic dopamine receptors and presynaptic dopamine D 2 -type autoreceptors, heteroreceptors,

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such as adenosine (A2 ) (29), histamine (H 1 ) (30,31), and serotonin (5-HT 1A ) (32), located on or near presynaptic dopaminergic nerve terminals in the striatum (extrapyramidal) or nucleus accumbens (limbic) regions of brain can modulate dopamine synthesis (and release) by altering the activity of tyrosine hydroxylase, the rate-limiting step in catecholamine biosynthesis. Similarly, activation of adrenergic (α 2 ) autoreceptors in the limbic structure hippocampus negatively modulates the release of the neurotransmitter norepinephrine (33). It is proposed that atypical antipsychotic drugs, such as clozapine, may interact with these other neurotransmitter receptor systems (i.e., histamine, serotonin, and adrenergic) instead of (or in addition to) dopamine receptor systems. Preceding the introduction of the first clinically successful phenothiazine-type neuroleptic, chlorpromazine, the first phenothiazine to be used to treat psychiatric patients in the 1940s (unsuccessfully) was promethazine, an “ antihistamine” H 1 antagonist.

Treatment of Schizophrenia and Related Psychoses T he most widely used class of drugs in the treatment of psychotic disorders are the so-called neuroleptics. T his term suggests that such medicines “ take hold” (l epsi s) of the central nervous system (CNS) to suppress movement as well as behavior. Although the connotation has been stretched to include biochemical and clinical antagonism of dopamine D 2 receptors, debilitating extrapyramidal movement side effects are implicit in the clinical definition of neuroleptic antipsychotic drugs. Indeed, the term “ neuroleptic” is so synonymous with neurologic side effects that newer antipsychotic drugs, without substantial risk of extrapyramidal effects, are referred to as atypical neuroleptic drugs. Also implied in the term “ atypical” is a mechanism of antipsychotic action other than (or in addition to) postsynaptic D 2 receptor blockade. In general, neuroleptic therapy benefits patients with schizophrenia or other psychiatric illnesses marked by agitation, aggressive and impulsive behavior, and impaired reasoning. Positive symptoms respond to treatment with typical neuroleptics, whereas negative symptoms are not appreciably affected. In general, neuroleptics provide calming, mood-stabilizing, and antihallucinatory effects, and their beneficial impact on psychiatric medicine is unquestioned in spite of their sometimes severe extrapyramidal side effects. Chemical classes of neuroleptics include the phenothiazines, thioxanthenes, and butyrophenones. T he dibenzodiazepines and benzisoxazoles are examples of atypical neuroleptics that have less potential for extrapyramidal side effects and have activity at brain serotonin 5-HT 2 , adrenergic α 1 /α 2 , and/or histamine H 1 receptors, in addition to dopamine receptors.

Mechanism of Action of Antipsychotic Drugs Given that the pathogenesis of schizophrenia and related psychiatric disorders is unknown, it is perhaps naïve to suggest how drugs act at the molecular level to relieve the symptoms of these disorders. Nevertheless, it generally is agreed that the antipsychotic mechanism of action of neuroleptics involves modulation of dopamine neurotransmission in the mesolimbic–mesocortical pathways. T his may be achieved via direct interaction with D 2 -type receptors and include the functional spectrum of antagonism, inverse agonism, and/or partial agonism. Antipsychotic drug clinical efficacy, however, is not solely accounted for by D 2 -type receptor interactions; other CNS receptor systems (acetylcholine, histamine, norepinephrine, and serotonin) appear to be involved, especially for the atypical drugs described below.

Side Effects of Neuroleptics Many of the side effects associated with antipsychotic agents can be attributed to their antagonist activity at a variety of CNS receptors, which include histamine H 1 , adrenergic α 1 /α 2 , cholinergic M 1 receptors, serotonin 5-HT 2 , and dopamine D 2 receptors in the brain. For example, antipsychotic drug side effects such as sedation,

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hypotension, sexual dysfunction, and other autonomic effects reflect blockade of adrenergic and histamine receptors. Meanwhile, the anticholinergic actions of neuroleptics in cardiac, ophthalmic, gastrointestinal, bladder, and genital tissue result from antagonism of muscarinic acetylcholine receptors. Such anticholinergic actions also are characteristic of atypical antipsychotics such as clozapine, and it has been proposed that anticholinergic activity may be beneficial in controlling negative symptoms in schizophrenics. T he parkinsonian-like movement side effects of neuroleptics clearly result from antagonism of dopamine D 2 receptors in the nigrostriatal pathway, and the severity of these extrapyramidal side effects increases with the ratio of their antidopaminergic to anticholinergic potency. Extrapyramidal side effects occur in 30 to 50% of patients receiving standard doses of typical neuroleptics and tend to occur during the first to eighth week of therapy. Extrapyramidal side effects include acute dystonias (e.g., facial grimacing, torticollis, P.606 and oculogyric crisis), akathisia (motor restlessness), and parkinsonian-type symptoms, such as bradykinesia, cogwheel rigidity, tremor, masked face, and shuffling gait. T he higher the D 2 potency of the neuroleptic, the worse the side effects, some of which can be reversed using anticholinergic drugs. T ardive dyskinesia occurs in 15 to 25% of patients after prolonged treatment with typical neuroleptics and is characterized by stereotyped, involuntary, repetitive, choreiform movements of the face, eyelids, mouth (grimaces), tongue, extremities, and trunk. T here also are metabolic and endocrine side effects of neuroleptics, such as weight gain, hyperprolactinemia, and gynecomastia. Relatively common dermatologic reactions (e.g., urticaria and photosensitivity) also are observed especially with the phenothiazines. Interestingly, anticholinergic and dopaminergic agents worsen tardive dyskinesia, whereas antidopaminergic agents tend to suppress the symptoms. T he pathophysiology of tardive dyskinesia is not known, and the disorder essentially is irreversible. Meanwhile, antagonism of dopamine D 2 -type receptors in the chemoreceptor trigger zone in the brainstem is responsible for beneficial antiemetic effects produced by neuroleptics. Several phenothiazines (e.g., promethazine and prochlorperazine) are marketed to exploit this pharmacological effect.

Development of Phenothiazine and Related Neuroleptics

Although the phenothiazine nucleus was synthesized in 1883, and although it was used as an anthelmintic for many years, it has no antipsychotic activity. T he basic structural type from which the phenothiazine antipsychotic drugs trace their origins is the antihistamines of the benzodioxane type I (Fig. 22.4). In 1937, Bovet (34) hypothesized that specific substances antagonizing histamine ought to exist, tried various compounds known to act on the autonomic nervous system, and was the first to recognize antihistaminic activity. With the benzodioxanes as a starting point, many molecular modifications were carried out in various laboratories in a search for other types of antihistamines. T he benzodioxanes led to ethers of ethanolamine of type II, which after further modifications led to the benzhydryl ethers (type III), which are characterized by the clinically useful antihistamine diphenhydramine, or to ethylenediamine (type IV), which led to antihistamine drugs, such as tripelennamine (type V). Further modification of the ethylenediamine type of antihistamine resulted in the incorporation of one of the nitrogen atoms into a phenothiazine ring system, which produced phenothiazine (type VI), a compound that was found to have antihistaminic properties and, similar to many other antihistaminic drugs, a strong sedative effect. Diethazine (type VI) is more useful in the treatment of Parkinson's disease (because of its potent antimuscarinic action) than in allergies, whereas promethazine (type VII) is clinically used as an antihistaminic. After the ability of promethazine to prolong barbiturate-induced sleep in rodents was discovered, the drug was introduced into clinical anesthesia as a potentiating agent.

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Fig. 22.4. Development of phenothiazine-type antipsychotic drugs.

T o enhance the sedative effects of such phenothiazines, Charpentier and Courvoisier synthesized and evaluated many modifications of promethazine. T his research effort eventually led to the synthesis of chlorpromazine (type VIII) in 1950 at the Rhône-Poulenc Laboratories (35). Soon thereafter, the French surgeon Laborit and his coworkers described the ability of this compound to potentiate anesthetics and produce artificial hibernation (36). T hey noted that chlorpromazine, by itself, did not cause a loss of consciousness but did produce only a tendency to sleep and a marked disinterest in the surroundings. T he first attempts to treat mental illness with chlorpromazine alone were made in Paris in 1951 and early 1952 by Paraire and Sigwald. In 1952, Delay and Deniker began their important work with chlorpromazine (37). T hey were convinced that chlorpromazine achieved more than symptomatic relief of agitation or anxiety and that this drug had an ameliorative effect on psychosis. T hus, what initially involved minor molecular modifications of an antihistamine that produced P.607 sedative side effects resulted in the development of a major class of drugs that initiated a new era in the drug therapy for the mentally ill. More than anything else in the history of psychiatry, the phenothiazines and related drugs have positively influenced the lives of schizophrenic patients, enabling them to assume a greatly improved role in society.

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Table 22.1. Phenothiazine and the Thioxanthene Derivatives Used as Neuroleptics*

More than 24 phenothiazine and the related thioxanthene derivatives are used in medicine, most of them for psychiatric conditions. T he structures, generic and trade names, dose, and side effects of phenothiazines and thioxanthenes currently used as neuroleptics are listed in T able 22.1.

Structure–activity relationships of phenothiazine and thioxanthene neuroleptics It is presumed that phenothiazine and thioxanthene neuroleptics mediate their pharmacological effects mainly through interactions at D 2 -type dopamine receptors. Examination of the x-ray structures of dopamine (in the preferred trans a-rotamer conformation) and chlorpromazine shows that these two structures can be partly superimposed (Fig. 22.5) (38). In the preferred conformation of chlorpromazine, its side chain tilts away from the midline toward the chlorine-substituted ring. T he electronegative chlorine atom on ring “ a” is responsible for imparting asymmetry to this molecule, and the attraction of the amine side chain (protonated at physiologic pH) toward the ring containing the chlorine atom indicates an important structural feature of such molecules. Phenothiazine and related compounds lacking a chlorine atom in this position are, in most cases, inactive as neuroleptic drugs. In addition to the ring “ a” substituent, another major requirement for therapeutic efficacy of phenothiazines is that the side-chain amine contain three carbons separating the two nitrogen atoms (Fig. 22.5). Phenothiazines with two carbon atoms separating the two nitrogen atoms lack antipsychotic efficacy. Compounds such as promethazine (Fig. 22.4, VII) are primarily antihistaminic and are less likely to assume the preferred conformation. When thioxanthene derivatives that contain an olefinic double bond between the tricyclic ring and the side chain P.608 are examined, it can be seen that such structures can exist in either the ci s or trans isomeric configuration. T he ci s isomer of the neuroleptic thiothixene is several-fold more active than both the trans isomer and the compound obtained from saturation of the double bond. Structure D in Figure 22.5 shows that the active structure of dopamine does not superimpose with a trans-like conformer of chlorpromazine that would be predicted to be inactive.

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Fig. 22.5. Conformations of chlorpromazine (A), dopamine (B), and their superposition (C) as determined by x-ray crystallographic analysis. The a, b, and c in (A) designate rings. Also shown (D) is another conformation in which the alkyl side chain of chlorpromazine is in the trans conformation (ring a and amino side chain), which is not superimposable on to dopamine. (Adapted from Horn AS, Snyder SH. Chlorpromazine and dopamine: Conformational similarities that correlate with the antischizophrenic activity of phenothiazine drugs. Proc Natl Acad Sci U S A 1971;68:2325–2328; with permission.)

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Table 22.2. Long-acting Neuroleptics for IM Depot Injection

Long-acting neuroleptics T he duration of action of many of the neuroleptics with a free hydroxyl (OH) moiety can be considerably prolonged by the preparation of long-chain fatty acid esters (T able 22.2). T hus, fluphenazine decanoate and fluphenazine enanthate were the first of these esters to appear in clinical use and are longer acting, with fewer side effects, than the unesterified precursor. T he ability to treat patients with a single intramuscular injection every 1 to 2 weeks with the enanthate or every 2 to 3 weeks with the decanoate ester means that problems associated with patient compliance to the drug regimens and with drug P.609 malabsorption can be reduced. T able 22.2 lists long-acting forms of phenothiazine and thioxanthene, which are derivatives available in the United States and other countries.

Metabolism of phenothiazines and thioxanthenes Increasing evidence suggests that the metabolism of neuroleptic drugs is of major significance in the effects of these drugs. Although considerable information about the metabolism of the extensively studied chlorpromazine is available, information about many of the other drugs administered for prolonged periods is scant. Generally, however, the liver microsomal cytochrome P450–catalyzed metabolic pathways for neuroleptics are similar to those for many other drugs. Some metabolic pathways for chlorpromazine are shown in Figure 22.6. It should be kept in mind that during metabolism, several processes can and do occur for the same molecule. For example, chlorpromazine can be demethylated, sulfoxidized, hydroxylated, and glucuronidated to yield 7-O-glu-nor-CPZ-SO. T he combination of such processes leads to more than 100 identified metabolites. Evidence indicates that the 7-hydroxylated derivatives and, possibly, other hydroxylated derivatives as well as the mono- and didesmethylated products (nor 1 -CPZ, nor 2 -CPZ) are active in vivo and at dopamine D 2 receptors, whereas the sulfoxide (CPZ-SO) is inactive. Although the thioxanthenes are closely related to the phenothiazines in their pharmacological effects, there seems to be at least one major difference in metabolism: Most of the thioxanthenes do not form ring-hydroxylated derivatives. Metabolic pathways for phenothiazines and thioxanthenes are significantly altered, both quantitatively and qualitatively, by a number of factors, including species, age, gender, interaction with other drugs, and route of administration.

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Fig. 22.6. Metabolism of chlorpromazine. CPZ, chlorpromazine; NO, N-oxide; SO, sulfoxide; SO 2 , sulfone; O-Glu, O-glucuronide; Ph, phenothiazine; Pr-acid, propionic acid; O-SO 3 H, sulfate.

Development of Butyrophenone Neuroleptics In the late 1950s, Janssen and coworkers synthesized the propiophenone and butyrophenone analogues of meperidine in an effort to increase its analgesic potency (39). T he propiophenone analogue had 200-fold the P.610 analgesic potency of meperidine, but the butyrophenone analogue also displayed activity resembling that of chlorpromazine. Janssen and coworkers found that it was possible to eliminate the morphine type of analgesic activity and, simultaneously, to accentuate the chlorpromazine type of neuroleptic activity in the butyrophenone series, provided that certain structural changes are made.

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Structure–activity relationships Haloperidol binds with equally high affinity to dopamine D 2 , and serotonin 5-HT 2 receptors in mammalian brain tissue, and both of these receptor systems may be involved in mediating the antipsychotic activity of the butyrophenones. In most respects, the pharmacological effects of haloperidol and other butyrophenones differ in degree, but not in kind, from those of the piperazine phenothiazines. Haloperidol produces a high incidence of extrapyramidal reactions, but its sedative effect in moderate doses is less than that observed with chlorpromazine. Haloperidol has less prominent autonomic effects than the other antipsychotic drugs do, and only mild hypotension occurs with the use of haloperidol, even in high doses. All butyrophenone derivatives displaying high neuroleptic potency have the following general structure:

T he attachment of a tertiary amino group to the fourth carbon of the butyrophenone skeleton is essential for neuroleptic activity; lengthening, shortening, or branching of the three-carbon propyl chain decreases neuroleptic potency. Replacement of the keto moiety (e.g., with the thioketone group as in the butyrothienones, with olefinic or phenoxy groups, or reduction of the carbonyl group) decreases neuroleptic potency. In addition, most potent butyrophenone compounds have a fluorine substituent in the para position of the benzene ring. Variations are possible in the tertiary amino group without loss of neuroleptic potency; for example, the basic nitrogen usually is incorporated into a 6-membered ring (piperidine, tetrahydropyridine, or piperazine) that is substituted in the para position.

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Fig. 22.7. Haloperidol and it analogues.

Haloperidol was introduced for the treatment of psychoses in Europe in 1958 and in the United States in 1967 (Fig. 22.7). It is an effective alternative to more familiar antipsychotic phenothiazine drugs and also is used for the manic phase of bipolar (manic-depressive) disorder. Haloperidol decanoate has been introduced as depot maintenance therapy. When injected every 4 to 6 weeks, the drug appears to be as effective as daily orally administered haloperidol. Other currently available (mostly in Europe) butyrophenones include the very potent spiperone (spiroperidol) as well as trifluperidol and droperidol. Droperidol, a short-acting, sedating butyrophenone, is used in anesthesia for its sedating and antiemetic effects and, sometimes, in psychiatric emergencies as a sedativeneuroleptic. Droperidol often is administered in combination with the potent narcotic analgesic fentanyl for preanesthetic sedation and anesthesia. Modification of the haloperidol butyrophenone side chain by replacement of the keto function with a di-4-flurophenylmethane moiety results in diphenylbutyl piperidine neuroleptics, such as pimozide, penfluridol, and fluspirilene. T he diphenylbutyl piperidines neuroleptics have a longer duration of action than the butyrophenone analogues. All are effective in the control of P.611 schizophrenia, and pimozide in particular has been shown to be useful in treating acute exacerbation of schizophrenia and in reducing the rate of relapse in chronic schizophrenic patients (40). Pimozide also is used for treatment of T ourette's syndrome, a movement disorder that is characterized by facial tics, grimaces, strange and uncontrollable sounds, and sometimes, involuntary shouting of obscenities. T his disorder may be misdiagnosed by clinicians as schizophrenia. T ypically, the onset of T ourette's syndrome occurs at age 10, and standard treatment for T ourette's syndrome in the past has been the neuroleptics, such as haloperidol. Chronic treatment of T ourette's syndrome with haloperidol as well as with pimozide carries the risk of producing potentially irreversible tardive dyskinesia. Penfluridol and fluspiriline, although not currently available in the United States, are other examples of

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long-acting neuroleptics in this structure class.

Metabolism Haloperidol is readily absorbed from the gastrointestinal tract. Peak plasma levels occur 2 to 6 hours after ingestion. T he drug is concentrated in the liver and CNS. Approximately 15% of a given dose is excreted in the bile, and approximately 40% is eliminated through the kidney. Figure 22.8 shows the typical oxidative metabolic pathway of butyrophenones as exemplified by haloperidol (41).

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Fig. 22.8. Metabolism of haloperidol.

Additional Classes of Antipsychotic Agents Benzamide derivatives Certain benzamide derivatives have both local anesthetic and antiemetic properties (47). T he benzamide metoclopramide has limited local anesthetic activity but is an efficacious antiemetic drug that modifies gastric motility. Similar to the phenothiazine antiemetics (e.g., promethazine), metoclopramide was found to antagonize dopamine D 2 -type receptors in the chemoreceptor trigger zone of the brainstem and, subsequently, was shown to be neuroleptic (48). Metoclopramide has relatively low affinity and selectivity for several receptors in addition to D 2 /D 3 antagonism. It blocks muscarinic M 3 and serotonin 5-HT 1A GPCRs as well as the 5-HT 3 ligand-operated ion channel. Moreover, numerous studies have documented its anticholinesterase activity. T he weak affinity and lack of selectivity of metoclopramide likely is explained by the large number of permissible conformers arising from the flexible 2-(diethylamino)ethyl moiety. P.612

Toxicology As d e s c rib e d in the text (s e e the d is c us s ion re g arding s ide e f f ec ts o f neuro lep tic s ), e xtrap yramid al s id e e f f e c ts o c c ur in 3 0 to 5 0% o f patie nts re c e iving s tand ard do s e s o f typic al ne urole ptic s . Extrap yramidal s ide e f f e c ts inc lud e ac ute d ys to nias , akathis ia, and p arkins o nian-typ e s ymp to ms , s uc h as b radykine s ia, c o gwhee l rig id ity, tremo r, mas ke d f ac e , and s huf f ling g ait. T ard ive d ys kines ia is a s e ve re e xtrapyramid al s ide e f f e c t that o c c urs in 1 5 to 2 5 % o f patie nts af ter p ro lo ng ed tre atme nt with typ ic al ne uro le p tic s . Tard ive d ys kines ia is c harac terize d b y s tere o typ e d, invo luntary, re p etitive, c ho re if o rm mo veme nts o f the f ac e , e ye lid s , mo uth, tong ue , e xtremitie s , and trunk. The p atho p hys io lo g y o f tard ive d ys kines ia is no t kno wn, and the d is ord er e s s e ntially is irre ve rs ib le.

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Halop e rid ol (Fig . 2 2.7) is a p o te nt ne uro le p tic as s o c iate d with a hig h inc id enc e o f tard ive d ys kines ia. Mic ro s o mal-c atalyze d d ehyd ratio n of halo pe rido l yie ld s the c o rres po nd ing 1 ,2 ,3 ,6 -te trahyd rop yrid ine d erivative, HPTP, whic h is a c lo s e analog ue o f the p arkins o nian-ind uc ing ne uro to xin 1-methyl-4-p he nyl1 ,2 ,3,6-te trahydro p yrid ine (MPTP). L ong -te rm (5 8 -we e k) ad minis tratio n o f HPT P to no nhuman p rimate s alters bo th p re s ynaptic and po s ts ynap tic d op aminerg ic ne uro nal f unc tio n, whic h may c o ntrib ute to the ne urotoxic o lo gic e f f e c ts of halo p erido l (42 ). I n b ab o ons treated c hro nic ally with HPTP, animals de velo pe d o ro f ac ial dys kine s ia, and his to p atho lo g ic al s tud ie s re ve aled vo lume lo s s in the bas al f o reb rain and hypo thalamus , alo ng with o the r neuro nal c e ll los s that may b e rele vant to the p atho p hys io lo g y o f tard ive d ys kines ia (4 3). I n humans and b ab o ons , HPTP is o xid ized in vivo to the c o rre s p o nding p yridinium s p ec ie s , HPP + , s imilar to the o xidatio n o f MPTP to its ultimate ne uroto xic s pe c ie s MPP + . HPP + is ne urotoxic to do p amine rg ic and, e s pe c ially, s e roto ne rg ic neuro ns in vivo in rats (44 ), and HPP 1 has b ee n id e ntif ie d in the urine o f humans tre ate d with halo pe rid o l (4 5 ). Furthe rmore , in a re c e nt s tud y invo lving p s yc hiatric p atients who we re tre ate d c hro nic ally with halo p erido l, the s e verity of tard ive d ys kines ia and p arkins o nis m was as s o c iated with an inc re as e d s e rum c onc entratio n ratio o f HPP 1 to halo p erido l (46 ), p ro vid ing c omp e lling c linic al e vid e nc e f o r the ne uro to xic ity o f HPP + . I nve s tigatio ns c ontinue to d e te rmine if ne urole ptic -induc ed p atho log y o f the extrap yramidal mo tor s ys te m, s uc h as that as s o c iate d with tardive d ys kines ia, may b e re late d to pro d uc tion of MPP + /HPP + -type s p e c ie s in humans . Se e C hap te r 25 f o r a re late d d is c us s ion of Parkins o n' s d is eas e c aus e d by MPTP.

Several analogues of metaclopramide in which the side chain is incorporated into a pyrrolidine ring include S-(–)-sulpiride and S-(–)-remoxipride. Both drugs display neuroleptic properties. Sulpiride produces a relatively low incidence of extrapyramidal side effects, putatively because of a preferential effect on limbic versus extrapyramidal (striatum) tissue. T he hydrophilic properties of sulpiride may account for its poor oral absorption, limited penetration into the CNS, and resulting low potency. T he racemic para-amino congener of sulpride, amisulpride, is used as an antipsychotic agent outside the United States. Remoxipride was a promising neuroleptic that is comparable to haloperidol in potency and efficacy and has less incidence of extrapyramidal and autonomic side effects. Life-threatening aplastic anemia, however, was reported with remoxipride use, which prompted its withdrawal from the market.

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Benzazepine derivatives Clozapine, olanzapine, loxapine, and quetiapine are benzazepine-type derivatives with antipsychotic activity and atypically low risk of extrapyramidal side effects (Fig. 22.9).

Mech an ism of action Currently, it generally is agreed that the mechanism of benzazepine-type and other recently introduced atypical antipsychotic drugs (e.g., risperidone, ziprasidone, and aripiprazole) involves occupancy of both D 2 and 5-HT 2A receptors. Meanwhile, activity at other dopamine and serotonin receptor subtypes as well as at adrenergic, histamine, and muscarinic receptors may contribute to psychotherapeutic effects, such as modulation of negative symptoms, and certainly may cause autonomic (cardiovascular, sedative, sexual) and other peripheral antimuscarinic side effects P.613 (gastrointestinal, urinary, ophthalmic). Short-term weight gain for both typical and atypical antipsychotic drugs likely correlates to high H 1 receptor affinity (49). T he high 5-HT 2A receptor affinity of atypical antipsychotic agents (e.g., clozapine and olanzapine) led to the proposal that 5-HT 2A antagonism accounts for the lower propensity of these drugs to cause extrapyramidal side effects, but reduced affinity for D 2 receptors also likely plays a role. Nevertheless, antagonism of presynaptic 5-HT 2A receptors that inhibit dopamine release from striatal dopaminergic nerve terminals could increase dopaminergic neurotransmission in the striatum to modulate postsynaptic D 2 blockade and reduce extrapyramidal symptoms.

Fig. 22.9. Benzazepine derivatives.

Specific dru gs Clozapin e T he dibenzazepine clozapine is representative of the new generation of antipsychotic drugs that have greatly reduced or minimal extrapyramidal side effects and do not produce tardive dyskinesia with long-term use. Clozapine also appears to effectively alleviate the negative symptoms of schizophrenia and has proven to be beneficial in treating patients who do not respond adequately to classical neuroleptic agents, such as the phenothiazines or butyrophenones. A serious drawback to the use of clozapine, however, is the potentially fatal agranulocytosis that is reported to occur in 1 to 2% of unmonitored patients (50), necessitating weekly white blood cell counts for at least the first 6 months of pharmacotherapy. Clozapine is orally active and metabolized mainly by CYP3A4 to inactive desmethyl, hydroxyl, and N-oxide derivatives, with a half-life of approximately 12 hours. Clozapine has

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relatively low affinity for brain dopamine D 1 and D 2 receptors (moderate affinity for D 4 ) in comparison to its affinity at adrenergic α 1 and α 2 , histamine H 1 , muscarinic M 1 and serotonin 5-HT 2A receptors (15,51).

Olan zapin e T he thienobenzodiazepine olanzapine is an effective atypical antipsychotic agent that is close in structure to clozapine but has a somewhat different neuropharmacological profile, in that it is a more potent antagonist at dopamine D 2 and, especially, serotonin 5-HT 2A receptors (15). Olanzapine is well absorbed after oral administration and is metabolized mainly by CYP1A2 to inactive metabolites, with a variable half-life of approximately 20 to 50 hours.

Loxampin e T he dibenzo-oxazepine loxapine is another antipsychotic in this structural class that has a more typical neuroleptic biochemical profile with mainly antidopaminergic activity at D 2 -type receptors. Loxapine undergoes Phase I aromatic hydroxylation to yield several phenolic metabolites that have higher affinity for D 2 receptors than the parent. Loxapine also undergoes N-demethylation to form amoxapine, which is used clinically as an antidepressant. Amoxapine binds to D 2 receptors and inhibits the norepinephrine neurotransporter to block neuronal norepinephrine reuptake, a correlate of antidepressant activity.

Qu etiapin e Quetiapine is a dibenzothiazepine with a brain receptor–binding profile similar to that of clozapine. Quetiapine binds most effectively to histaminergic H 1 , adrenergic a 1 and a 2 , and serotonergic 5-HT 2A receptors in the brain and has even lower affinity than clozapine for dopaminergic D 2 receptors. Unlike clozapine, however, quetiapine also has very low affinity for muscarinic receptors. Quetiapine is 100% bioavailable, but first-pass metabolism yields at least 20 metabolites via CYP3A4, with a half-life of approximately 6 hours. Quetiapine is about as effective as haloperidol in treating the positive symptoms of schizophrenia, but it also manages negative symptoms and induces a lower incidence of extrapyramidal side effects.

Benzisoxazole and benzisothiazole derivatives Neuroanatomical and neurophysiologic interactions between dopaminergic and serotonergic systems, together with evidence that several benzazepine-type antipsychotic agents (e.g., clozapine and olanzapine) have high affinity for 5-HT 2A receptors, led to the proposal that combination D 2 /5-HT 2A antagonists may produce atypical antipsychotic effects (52,53). Combining the chemical features present in the potent benzamide D 2 antagonists (e.g., remoxipride) with those of the benzothiazolyl piperazine 5-HT 2A antagonists (e.g., tiospirone) led to the development of the 3-(4-piperidinyl)-1,2-benzisoxazole nucleus present in the 5-HT 2A/D 2 antagonist risperidone and ziprasidone, which also have relatively high affinity at histamine H 1 and adrenergic α 1 /α 2 receptors (Fig. 22.10). P.614

Fig. 22.10. Benzisoxazole and benzisothiazole antipsychotic agents.

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Specific dru gs Risperidon e Risperidone has antiserotonergic effects similar to the benzazepine-type antipsychotic drugs. It is proposed that the 5-HT 2A antagonist activity of risperidone uninhibits dopaminergic neurotransmission in the striatum and cortex, reducing the severity of D 2 antagonist-induced extrapyramidal side effects and alleviating negative symptoms of schizophrenia while maintaining a blockade of limbic system D 2 receptors (54). Risperidone is well absorbed orally and undergoes hepatic CYP2D6-catalyzed 9-hydroxylation (active metabolite) and N-dealkylation (Fig. 21.10). T he half-life of risperidone (as well as of hydroxyrisperidone) is approximately 22 hours.

Ziprasidon e Ziprasidone is chemically similar to risperidone but with a substitution of piperzinyl and benzisothiazole for piperidinyl and benzisoxazole and with minor aromatic modification. Like risperidone, ziprasidone is a high-affinity antagonist at 5-HT 2A/C and D 2 receptors as well as at adrenergic α 1 /α 2 and histamine H 1 receptors. Moreover, ziprasidone can activate 5-HT 1A receptors (55) that regulate dopaminergic neurotransmission in brain regions involved in critical cognitive functions. T hus, in addition to D 2 partial agonism (see below), 5-HT 1A agonism is now thought to be an important pharmacological property for atypical antipsychotic drug efficacy (56). Ziprasidone (half-life, 6 hours) has an oral bioavailability of approximately 60%, which can be enhanced in the presence of fatty foods. It is extensively metabolized (< 5% excreted unchanged) by aldehyde oxidase, which results in reductive cleavage of the S–N bond, and then by S-methylation. Ziprasidone also can undergo CYP3A4-catalyzed N-dealkylation and S-oxidation (Fig. 22.11) (57).

Miscellan eou s derivatives Aripiprazole

Aripiprazole is an arylpiperazine quinolinone derivative that has complex functional activity at several aminergic receptors currently thought to be important in the pathophysiology and pharmacotherapy of schizophrenia, including dopamine D 2 and serotonin 5-HT 1A and 5-HT 2A/C receptors. T he affinity of aripiprazole for D 2 receptors is relatively high; however, it has a low propensity to cause untoward extrapyramidal symptoms and hyperprolactinemia (58). T his may be explained by the ability of aripiprazole to show partial agonist activity at some D 2 receptors, depending on the cell type expression—that is, it is a functionally selective drug (59). Aripiprazole also is a high-affinity partial agonist at 5-HT 2A receptors and a low-affinity agonist at 5-HT 2C receptors, and it has moderate affinity for α 1 -adrenergic and histamine H 1 receptors. As with other atypical antipsychotic drugs, such as the benzazepines, molecular mechanisms related to efficacy are presumed to include a balanced P.615 occupancy of 5-HT 2A receptors and D 2 receptors. Interestingly, the incidence of clinically significant weight gain is relatively low for aripiprazole as well as for risperidone (58), likely because of the relatively moderate histamine H 1 receptor affinity of these agents. In addition, the agonist properties of aripiprazole at 5-HT 2C receptors may reduce its potential for weight gain, because 5-HT 2C activity is associated with satiety (60). Aripiprazole (half-life, 75 hours) is orally bioavailable (90%) and undergoes hepatic CYP3A4- and CYP2D6-catalyzed N-dealkylation and hydroxylation as well as dehydrogenation to dehydroaripiprazole (half-life, 90 hours), which is an active metabolite (Fig. 22.12) (61).

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Fig. 22.11. Metabolism of ziprasidone.

Fig. 22.12. Metabolism of aripiprazole.

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Molin don e Molindone hydrochloride, a tetrahydro-indolone derivative, is a neuroleptic agent that is structurally unrelated to any of the other marketed neuroleptics. Molindone is less potent than haloperidol at blocking D 2 receptors; however, it nonetheless can produce extrapyramidal side effects. Metabolism studies in humans show molindone to be rapidly absorbed and metabolized when given orally. T here are 36 recognized metabolites, with less than 2 to 3% unmetabolized molindone being excreted in urine and feces. Clinical studies show that the antipsychotic effects of molindone last more than 24 hours, suggesting that one or more metabolites may contribute to its activity in vivo (62).

Sertin dole Sertindole is an indole-containing compound that behaves as a high-affinity serotonin 5-HT 2 receptor antagonist, with weak affinity for adrenergic α 1 receptors and almost no affinity for dopaminergic D 2 receptors. It is about as effective as haloperidol in the treatment of acute and chronic schizophrenia, but with much lower incidence of extrapyramidal side effects. Sertindole is relatively nonsedating, and its effects are long lasting (several days) (63).

Anxiety and Anxiety Disorders Definitions Anxiety can be defined as a sense of apprehensive expectation. In reasonable amounts and at appropriate times, anxiety is helpful (e.g., anxiety before an examination may cause a student to initiate an appropriate study plan). T oo much anxiety, however, can be deleterious. Anxiety can be considered pathological when it is either completely inappropriate to the situation or is in excess of what the situation normally should call for. An example of the former is nocturnal panic attacks—episodes of extreme anxiety that arise out of one of the most physiologically quiet times of the day, stage III/IV sleep (64). An example of the latter is specific phobias—for example, an irrational fear to venture outside of one's home. P.616 According to the DMS-IV (1), abnormal anxiety is that level of anxiety that interferes with normal social or

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occupational functioning. T his definition is helpful to distinguish between normal and pathologic levels of anxiety. T o meet general DSM-IV criteria, anxiety symptoms must not be caused by an exogenous factor (e.g., caffeine) or a medical condition (e.g., hyperthyroidism). Examples of anxiety disorders include specific phobias, generalized anxiety disorder (chronic abnormally high level of worry), social phobia (e.g., fear of public speaking), obsessivecompulsive disorder, panic disorder with or without agoraphobia (avoidance of situations believed by the patient to precipitate panic attacks), and posttraumatic stress disorder.

Etiology of Anxiety Disorders Studies of patients with anxiety disorders have not revealed a general gross neuroanatomical lesion. In vivo functional imaging studies, however, show altered blood flow or utilization of glucose in certain brain areas in patients with anxiety conditions, including obsessive-compulsive disorder (65,66), panic disorder (67,68), specific phobia (69), generalized anxiety disorder (70), and posttraumatic stress disorder (71), mostly implicating the prefrontal cortex and hippocampus (and other limbic areas) as being involved in the anatomy of pathologic anxiety. It is important to note that there is significant comorbidity for anxiety and major depressive disorders, and it is not clear if one illness has primacy or is part of the other (72). Likewise, although there may be genetic predisposition to general distress that can lead to anxiety and/or depression, no clear genetic evidence suggests specific symptoms of either disorder. A variety of neurotransmitters, neuromodulators (e.g., adenosine), and neuropeptides (e.g., cholecystokinin, corticotropin-releasing factor, and neuropeptide Y) are suggested to be involved in the pathophysiology of anxiety. Currently, abundant evidence exists to document the involvement of the neurotransmitters γ-aminobutyric acid (GABA), norepinephrine, and serotonin in anxiety, and research increasingly is revealing that these neurotransmitter systems have complex anatomical and functional interrelationships. For example, stimulation of the locus ceruleus, which contains the highest concentration of norepinephrine cell bodies in the CNS, generates a state of agitation and fear behaviors in laboratory animals (73). Meanwhile, data suggest that benzodiazepines influence norepinephrine release by stimulating inhibitory GABA receptors located on noradrenergic neurons (74).

GABA Receptors T he major inhibitory neurotransmitter in the mammalian CNS, GABA is widespread, with approximately one-third of all synapses in the CNS utilizing this neurochemical for intercellular communication (75). T he two major classes of GABA receptors are inotropic GABAA and metabotropic GABAB receptors. T here also exist GABAC inotropic receptors that activate chloride channels, similar to GABAA. T he GABAC receptors may play a role in cognitive and memory functions (76); however, there currently are no drugs that target these receptors.

GABAA Receptor T he GABAA receptor is a member of the gene superfamily of ligand-gated ion channels that is known as the “ cys-loop” family because of the presence of a cysteine loop in their N-terminal domain (77,78,79). T hese receptors exist as heteropentameric subunits arranged around a central ion channel (Fig. 22.13). T he five polypeptide subunits are composed of an extracellular region, four membrane-spanning α-helical cylinders, and a large intracellular cytoplasmic loop. T he GABAA ion channel conducts chloride and is defined by the second of the P.617 four membrane-spanning α-helical cylinders. T he first GABAA polypeptide subunit was sequenced in 1987 (80), and so far, 19 different subunits have been isolated. T hese polypeptides are denoted as α 1–6 , β 1–3 , γ1–3 , δ, ε, π, θ, and θ 1–3 . T he subunits can combine in varied proportions (81) and alternatively spliced variants are common. T hus, many possible receptor subtypes may exist. T he major (60%) GABAA receptor isoform in the adult mammalian (rat) brain consists of α 1 , β 2 , and γ2 subunits (GABAA1a ) (82).

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Fig. 22.13. Schematic representation of the γ-aminobutyric acid A (GABAA ) receptor. The GABAA receptors have a pentameric structure composed predominantly of α, β, and γ subunits arranged, in various proportions, around a central ion channel that conducts chloride. Each subunit has four membrane-spanning regions and a cysteine loop in the extracellular N-terminal domain (dashed line). The type and proportion of α and γ subunit composition affects affinity, pharmacological activity, and efficacy of ligands. (Chou J. Strichartz GR, Lo EA. Pharmacology of Excitatory and Inhibitory Neurotransmission. In: Golan DE, ed. Principles of Pharmacology. Philadelphia: Lippincott Williams & Wilkins, 2005:142; with permission.)

T he GABAA extracellular N-terminal region contains a number of distinct binding sites for neuroactive drugs (e.g., barbiturates, benzodiazepines, β-carolines, and neurosteroids). T he benzodiazepines, among the most commonly prescribed anxiolytic agents, bind to the benzodiazepine receptor (BZR), which is defined mostly by the α and γ subunits. T he α and γ subunit composition can dramatically affect affinity and efficacy of BZR ligands (83,84). Early research on the BZR gave rise to the pharmacological concept of inverse agonism in addition to the better known concepts of agonism and antagonism. Inverse agonist compounds bind to the BZR on the GABAA receptor complex and negatively modulate GABA binding and neurophysiological activity (i.e., agonists decrease chloride conductance), producing physiological effects opposite that of GABA (e.g., anxiogenesis and pro-convulsant action). T he BZR agonist ligands potentiate GABA binding and activity to increase chloride conductance, enhancing physiological effects of GABA (e.g., sedation and anticonvulsant activity). T he BZR antagonists occupy the receptor but have no intrinsic activity to modulate GABA binding and function. A clinical example of a BZR antagonist is the compound flumazenil, which is used to reverse benzodiazepine-induced sedation in overdose. T here also have been developed agents that are partial agonists and inverse partial agonists at the BZR/GABAA receptor complex. T he

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existence of a GABAA receptor complex that recognizes benzodiazepines has implications for our understanding of both normal and pathologic anxiety states and suggests the existence of endogenous GABAA receptor ligands. T hus, anxiety could conceivably be either a lack of an endogenous GABAA receptor agonist or a relative excess of a GABAA receptor antagonist or inverse agonist.

Fig. 22.14. Schematic representation of the γ-aminobutyric acid B (GABAB ) receptor.

GABAB Receptors T he GABAB receptors are GPCRs that exist as two major subtypes, GABAB(1) and GABAB(2) . T he GABAB(1) subtype can be expressed as GABAB(1a) and GABAB(1b) isoforms that differ in their extracellular NH 2 -terminal domains but are derived from the same gene (85). Interestingly, it was discovered early on that compared to native GABAB receptors, recombinant GABAB(1a) and GABAB (1b) receptors expressed in heterologous cells display 100- to 150-fold lower affinity for agonist ligands. Likewise, recombinant GABAB(1a) and GABAB(1b) receptors were shown to couple inefficiently to their effector systems (predominantly via Gα i and Gα o ). T hese surprising pharmacological findings were explained by the discovery that recombinant GABAB( 1a) and GABAB(1b) receptors expressed in heterologous cells are retained in the endoplasmic reticulum (84). In fact, it turned out that GABAB( 1) receptors do not traffic to the cell membrane surface in the absence of GABAB( 2) receptors. T his remarkable discovery that the GABAB(2) receptor coexpresses on the cell surface with the GABAB (1a) or GABAB( 1b) receptor to form a functional heterodimeric GPCR was reported simultaneously by three industry research groups in 1998 (85,86,87,88). T he GABAB receptors were the first GPCR shown to function not as a single protein but, rather, as two distinct subunits, neither of which is functional by itself (Fig. 22.14). Homo- and/or heterodimerization (and oligomerization) now is documented for many GPCRs and may account for the diverse signaling functionality for this protein family. P.618

The s truc ture of f unc tio nal he te ro d ime ric GABA B(1) /GABA B(2) GPC Rs (F ig . 2 2 .1 4) is as s ume d to b e ve ry d if f ere nt and c ons id e rably mo re c omp le x in c o mp aris on to other amine rg ic GPC Rs that are ab le to f unc tio n as mo no me rs . F unc tional GABA B re c e p tors are p ro po s e d to c o ntain a b inding p oc ke t that c o ns is ts o f two g lo b ular lo be s s ep arate d b y a hing e reg io n. Ac c o rding to the Ve nus f lytrap mo de l, the two lob e s c lo s e on lig and b ind ing ; ho weve r, it is tho ught that ligands bind in o nly o ne o f the lo b es (8 9 ,9 0 ,91 ). T he ind ividual GABA B(1) and G ABA B( 2) s ub units c an af f e c t a numbe r o f o the r me mbrane and c yto p las mic p rote ins to res ult in c omp le x s ig naling and a d ive rs e array o f pharmac o lo g ic al and phys iolo g ic al e f f e c ts . Fo r e xamp le , GABA B rec ep to rs mod ulate ac tivity o f c alc ium c hanne ls , po tas s ium c hanne ls , ade nylyl c yc las e , and p hos pho lip as e C via Gα i , G α o , and G β γ p ro te ins . Me anwhile , p re c linic al data s ug g es ts that drug s whic h af f ec t GABA B rec e p to r f unc tion may p rod uc e , f o r e xamp le , anxiolytic , antic o nvuls ant, and antid ep re s s ant e f f e c ts as we ll as mus c le relaxant and analg e s ic ef f e c ts (9 0,91 ).

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The o nly d rug c urrently in c linic al us e that s e le c tive ly inte rac ts with the GABA B re c e p to r is b ac lo f e n (β-p -c hlo ro phenyl-GABA). Bac lo f e n was f irs t s ynthe s ize d in 1 96 2 and was s hown to have p o te nt mus c le relaxant and analg e s ic ac tivity. I n 1 97 2 , the rac e mate was markete d to tre at s p as tic ity dis o rde rs (9 2). I n 1 98 0 , the R -(– )-enantio me r o f b ac lof e n was s ho wn to s te reo s e le c tively inte rac t (as an ag o nis t) with what is no w kno wn as the GABA B re c ep to r (9 3). T he ro le of GABA B re c e ptors in anxiety, howe ve r, is no t c le ar, and b ac lo f e n (rac emate ) is ap p ro ved o nly f o r us e as a s pas mo lytic ag e nt (s e e Chapter 2 5 ).

Drugs Used in the Treatment of Anxiety Benzodiazepines T he benzodiazepines are the prototypic antianxiety agents. T hey target the GABAA receptor, and although other molecular targets (e.g., serotonin neuroreceptors) now are exploited for anxiolytic pharmacotherapy, none of the alternative approaches has been shown to match either the efficacy or the rapid onset of the benzodiazepines (84). Chlordiazepoxide was the first benzodiazepine to be marketed for clinical use in 1960. Its effectiveness and wide margin of safety were major advances over compounds, such as barbiturates, used previously. A variety of new benzodiazepines followed, each with some minor differences from the competition. T he major factors considered when selecting an agent include rate and extent of absorption, presence or absence of active metabolites, and degree of lipophilicity. T hese factors help to determine how a benzodiazepine is marketed and used; for example, an agent that is rapidly absorbed, highly lipid soluble, and without active metabolites would be useful as a hypnotic but less useful for treatment of a chronic anxiety state. On the other hand, a compound with slower absorption, active metabolites, and low lipophilicity would be a more effective antianxiety agent but less helpful as a soporific. Despite their efficacy in a variety of pathologic anxiety syndromes, the benzodiazepines are not perfect anxiolytics. Such a hypothetical agent would selectively ameliorate anxiety without inducing other behavioral effects. Future efforts to enhance the efficacy of benzodiazepine anxiolytics may depend on a greater understanding of the heterogeneity of the GABAA receptor—for example, which specific clinical actions (anxiolytic, muscle relaxation, sleep facilitation) reside with which specific subunit composition.

Development of benzodiazepine anxiolytics In the 1950s, the medicinal chemist Sternbach noted that “ basic groups frequently impart biological activity,” and in accordance with this observation, he synthesized a series of compounds by treating various chloromethylquinazoline N-oxides with amines to produce what he hoped would be products with “ tranquilizer” activity at the New Jersey laboratories of Hoffman LaRoche (94,95). Sternbach's studies included the reaction of 6-chloro-2-chloromethyl-4-phenylquinazoline-3-oxide with methylamine, which yielded the unexpected rearrangement product 7-chloro-2-(N-methylamino)-5-phenyl-3H-1,4,-benzodiazepin-4-oxide (Fig. 22.15). T his product was given the code name RO 50690 and screened for pharmacological activity in 1957. Subsequently, Randall et al. (96,97) reported that RO 50690 was hypnotic and sedative and had antistrychnine properties similar to the propanediol meprobamate, a sedative that has tranquilizer (anxiolytic) properties only at intoxicating doses. Renamed chlordiazepoxide, RO 50690 was marketed in 1960 as Librium, a safe and effective anxiolytic agent. Chlordiazepoxide turned out to have rather remarkable pharmacological properties and tremendous potential as a pharmacotherapeutic product, but it possessed a number of unacceptable physical chemical properties. In an effort to enhance its “ pharmaceutical elegance,” structural modifications of chlordiazepoxide were undertaken that eventually led to the synthesis of diazepam in 1959. In contrast to the maxim that basic groups impart biological

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activity, diazepam contains no basic nitrogen moiety. Diazepam, however, was found to be 3- to 10-fold more potent than chlordiazepoxide and was marketed in 1963 as the still enormously popular anxiolytic drug Valium. Subsequently, thousands of benzodiazepine derivatives were synthesized, and more than two dozen benzodiazepines are in clinical use in the United States (Fig. 22.16). P.619

Fig. 22.15. Synthesis of chlordiazepoxide.

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Fig. 22.16. Structures of some commercially available benzodiazepines.

P.620

Endogenous BZR Ligands An e nd og e no us lig and with af f inity f or the CNS b enzo d iaze pine rec e p to r (BZ R) o f the GABA A re c e p tor c o mp lex has no t b ee n c onc lus ive ly id entif ied . Se veral c o mpo und s o f e ndo g e no us o rig in, ho weve r, that inhib it the b inding o f rad iolab e le d b enzo diazep ines to the BZR have be e n re po rte d. I n 1 98 0 , Brae s trup et al. (98 ) re po rte d the pre s e nc e in no rmal human urine o f β-c arb oline-3 -c arbo xylic ac id e thyl es te r (βCC E), whic h has ve ry hig h af f inity f or the BZ R c o mp le x. I t was s ub s e q ue ntly s ho wn, howe ver, that βCC E f orme d as an artif ac t f ro m Braes trup' s e xtrac tio n p ro c ed ure , d uring whic h the urine e xtrac t was he ate d with e thano l at p H 1 , a c ondition f avo ring f o rmatio n o f the ethyl e s te r f ro m β-c arb o line -3-c arb o xylic ac id , a tryptop han metabo lite .

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Although βC CE ac tually was s ho wn not to be o f e nd og e no us o rig in, its d is c o very as a hig h-af f inity BZR lig and s timulate d re s earc h that le d to the s ynthe s is o f a s e rie s o f β-c arb o line de rivative s with a variety o f intrins ic ac tivitie s , p re s umably me d iated thro ug h the BZ R that is as s o c iate d with the GABA A re c e ptor c o mp lex. F or e xamp le, although βC CE is c o ns id ere d to b e a partial inve rs e ag onis t at this s ite , 6 ,7 -d ime tho xy-4 -e thyl-β-c arbo line -3 -c arb o xylic ac id me thyl e s te r (DMC M) ap pe ars to b e a f ull invers e ag onis t (9 9 ). I n f ac t, βC CE b loc ks the c onvuls io ns pro d uc e d b y the very po te nt c onvuls ant DMC M (10 0 ). The s e e f f e c ts are e ven mo re c o mp lex and inte res ting in lig ht o f the ap p roximate ly 1 0 -f o ld hig he r af f inity that βC CE s hows f o r the BZR lab ele d b y [ 3 H]d iaze p am when c omp ared to D MCM (10 1 ). The β-c arbo line s c urrently are imp ortant res earc h to ols to p rob e the ag o nis t, c o mpe titive antago nis t, invers e ag o nis t, and p artial ag o nis t/inve rs e ago nis t p harmac o p hore s o f the BZR /GABA rec e p to r c o mp lex

A major advance in the BZR field was made in 1981 with the first report that the imidazobenzodiazepinone derivative, flumazenil, binds with high affinity to the BZR and blocks the pharmacological effects of the classical 3

benzodiazepines in vitro and in vivo (102). Unlike agonists, binding of [ H]flumazenil to the BZR is not affected by modulators such as GABA and several ions that induce changes in receptors (103). T he insensitivity of flumazenil to changes in BZR conformation suggests that the ligand does not induce a conformational change in the receptor to trigger a biological response and is a pure antagonist (104). Such benzodiazepine antagonists are being used to characterize the pharmacological nature of the BZR, and several of these agents, including flumazenil, are used to treat benzodiazepine overdose. Other imidazobenzodiazepinone derivatives are not true BZR antagonists but, rather, have inverse agonist activity. For example, RO 15-4513, is reported to be a partial inverse agonist that produces anxiogenic-like effects in rats (105), a pharmacological activity quite different from a true BZR competitive antagonist, such as flumazenil.

Mechanism of action of anxiolytic benzodiazepines T he BZR ligands, regardless of intrinsic activity, do not directly alter transmembrane chloride conduction to produce their observed characteristic physiologic anxiolytic or anxiogenic effects. T he BZR is an allosteric modulator of GABA binding to the GABAA receptor complex that, in turn, modulates the transmembrane conductance of chloride. In the presence of BZR agonists or partial agonists, affinity and functional potency of GABA at GABAA receptors is enhanced maximally or submaximally, respectively, and conductance of chloride is increased. Inverse agonists and partial inverse agonists reduce the effect of GABA and GABAA receptor–mediated conductance of chloride is accordingly decreased. T he GABAA receptor–chloride channels thus become either more or less sensitive to GABA in the presence of BZR agonists or inverse agonists, respectively. BZR competitive antagonists block access of agonists to the BZR but have no intrinsic activity to affect GABA-modulated conductance of chloride. A representation of the relationship between ligand interaction with the BZR and intrinsic activity to modulate GABAA receptor function is shown in Figure 22.17. T he interaction of agonists, competitive antagonists, and inverse agonists with the BZR, as shown in the figure, is a simplistic rendering of the proposed three-state model of the BZR and GABAA receptor interrelationship (106,107). T his model is based on the hypothesis that the BZR and GABAA receptor exist in three spontaneously oscillating conformational states, functionally described as “ active” or agonist, “ neutral” or “ resting,” and “ inactive” or inverse agonist. T he BZR agonists and partial agonists bind to and stabilize the “ active” state, inducing a conformational change in the GABAA receptor complex that results in chloride channel opening, which may lead to an anticonvulsant or anxiolytic effect. T he BZR inverse agonists and partial

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inverse agonists bind to and stabilize the “ inactive” state, resulting in the chloride channel remaining closed, that may lead to a convulsant or anxiogenic effect. T he BZR competitive antagonists P.621 presumably bind equally well to both states (hence, they bind to a “ neutral” state) and affect no change in GABAA receptor function or chloride conductance, but access of agonists to the BZR is blocked.

Fig. 22.17. Ligand interaction with the γ-aminobutyric acid A (GABAA )/benzodiazepine receptor complex.

T he classical BZR is located on the GABAA receptor complex mainly at the interface of the α and γ subunits that can be rendered benzodiazepine-insensitive by a point mutation in the α subunit, replacing a critical histidine residue for arginine (108). Different α and γ subunit compositions give rise to subtypes of the BZR receptor that are pharmacologically distinct with regard to ligand affinity and intrinsic activity (109,110,111), providing a mechanistic basis for development of ligands that are anxioselective (i.e., anxiolysis in the absence of sedation, muscle relaxation, amnesia, and ataxia). T hus, current drug discovery approaches target specific α and γ molecular subunits of the GABAA receptor complex in the quest for benzodiazepine and nonbenzodiazepine (see below) drugs that demonstrate anxioselectivity. As a group, currently used benzodiazepines are not α subtype-selective. Interestingly, in recent studies using nonhuman primates, it has been suggested that GABAA α 2 , α 3 , and α 5 subunits mediate anxiolytic and muscle relaxant effects of benzodiazepines, whereas α 1 receptors mediate the sedative effects (112). Several putative anxioselective compounds have reached the clinic; however, they have not exhibited the degree of anxioselectivity predicted from preclinical testing and, usually, have lower efficacy than standard benzodiazepines (84). Of possible clinical importance, “ uncoupling” of the BZR/GABAA receptor complex has been observed in response to chronic benzodiazepine exposure both in vitro (113) and in vivo (114). In the absence of exogenous influences, however, coupling efficiency appears to be determined by the composition and stoichiometry of the α subunits (109), whereas benzodiazepine affinity, intrinsic activity, and efficacy is determined by the nature of both the a and g subunits (84,110,111).

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Structure–activity relationships T he structure–activity relationship for classical 5-phenyl-1,4-benzodiazepine-2-one anxiolytic agents has been described by Sternbach and other investigators (94,104,106,115). T housands of benzodiazepine derivatives with a variety of substituents have been synthesized that interact with the BZR; however, classical quantitative structure– activity relationship and molecular modeling techniques have been used to reduce this myriad of structures to the minimal common molecular features necessary for binding (116,117,118). T he pharmacological activity continuum (agonist, antagonist, inverse agonist) displayed by BZR ligands would seem to suggest that such diverse functional activity be mediated by ligand interaction with different sites on the GABAA receptor-chloride channel complex. T his continuum of activity, however, is displayed by ligands within the same chemical class, and small modifications in the chemical structure of a ligand can shift the intrinsic activity from agonist to antagonist to inverse agonist. Moreover, each functional class of BZR ligands can competitively inhibit the binding of the other two classes as well as functionally antagonize each other. T hese observations suggest that the binding sites of functionally diverse BZR receptor ligands, at least, P.622 overlap. Nevertheless, most BZR pharmacophore models that describe ligand functional activity are based initially on the BZR pharmacophore for ligand binding activity at a single binding domain, and this approach is used here to summarize the structure–activity relationship for benzodiazepine derivatives at the BZR receptor.

Rin g A In general, the minimum requirements for binding of 5-phenyl-1,4-benzodiazepin-2-one derivatives to the BZR includes an aromatic or heteroaromatic ring (ring A), which is believed to participate in π-π stacking with aromatic amino acid residues of the receptor. Substituents on ring A have varied effects on binding of benzodiazepines to the BZR, but such effects are not predictable on the basis of electronic or (within reasonable limits) steric properties. It is generally true, however, that an electronegative group (e.g., halogen or nitro) substituted at the 7-position markedly increases functional anxiolytic activity, albeit effects on binding affinity in vitro are not as dramatic. On the other hand, substituents at positions 6, 8, or 9 generally decrease anxiolytic activity. Other 1,4-diazepine derivatives in which ring A is replaced by a heterocycle generally show weak binding affinity in vitro and even less pharmacological activity in vivo when compared to phenyl-substituted analogues.

Rin g B A proton-accepting group is believed to be a structural requirement of both benzodiazepine and nonbenzodiazepine ligand binding to the GABAA receptor, putatively for interactions with a histidine residue that serves as a proton source in the GABAA α 1 subunit (119). For the benzodiazepines, optimal affinity occurs when the proton-accepting group in the 2-position of ring B (i.e., the carbonyl moiety) is in a coplanar spatial orientation with the aromatic ring A. Substitution of sulfur for oxygen at the 2-position (as in quazepam) may affect selectivity for binding to GABA BZR subpopulations, but anxiolytic activity is maintained. Substitution of the methylene 3-position or the imine nitrogen is sterically unfavorable for antagonist activity but has no effect on agonist (i.e., anxiolytic) activity (e.g., clobazam). Derivatives substituted with a 3-hydroxy moiety have comparable potency to nonhydroxylated analogues and are excreted faster. Esterification of a 3-hydroxy moiety also is possible without loss of potency. Neither the 1-position amide nitrogen nor its substituent is required for in vitro binding to the BZR, and many clinically used analogues are not N-alkylated (Fig. 22.16). Although even relatively long N-alkyl side chains do not dramatically decrease BZR affinity, sterically bulky substituents like tert-butyl drastically reduce receptor affinity and in vivo activity. Neither the 4,5-double bond, nor the 4-position nitrogen (the 4,5-[methyleneimino] group) in ring B is

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required for in vivo anxiolytic activity, albeit in vitro BZR affinity is decreased if the C= N bond is reduced to C–N. It is proposed that in vivo activity of such derivatives results from oxidation back to C= N (69). It follows that the 4-oxide moiety of chlordiazepoxide can be removed without loss of anxiolytic activity.

Rin g C T he 5-phenyl ring C is not required for binding to the BZR in vitro. T his accessory aromatic ring may contribute favorable hydrophobic or steric interactions to receptor binding, however, and its relationship to ring A planarity may be important. Substitution at the 4′-(para)-position of an appended 5-phenyl ring is unfavorable for agonist activity, but 2′-(ortho)-substituents are not detrimental to agonist activity, suggesting that limitations at the para position are steric, rather than electronic, in nature.

Annelating the 1,2-bond of ring B with an additional “ electron-rich” (i.e., proton acceptor) ring, such as s-triazole or imidazole, also results in pharmacologically active benzodiazepine derivatives with high affinity for the BZR (Fig. 22.17). For example, the s-triazolo-benzodiazepines triazolam, alprazolam, and estazolam and the imidazobenzodiazepine midazolam are popularly prescribed, clinically effective anxiolytic agents (Fig. 22.16).

Stereochemistry Most clinically useful benzodiazepines do not have a chiral center; however, the 7-membered ring B may adopt one of two possible boat conformations, a and b, that are “ enantiomeric” (mirror images) to each other. Nuclear magnetic resonance studies indicate that the two conformations can easily interconvert at room temperature, making it impossible to predict which conformation is active at the BZR, a priori. Evidence for stereospecificity for binding to the BZR was provided by introducing a 3-substituent into the benzodiazepine nucleus to provide a chiral center and enantiomeric pairs of derivatives (104). In vitro BZR binding affinity and in vivo anxiolytic activity of several 3-methylated enantiomers was found to reside in the S-isomer. Moreover, the S-enantiomer of 3-methyldiazepam was shown to stabilize conformation a for ring B, whereas the R-enantiomer stabilizes conformation b. Also, the 3-S configuration and a conformation for ring B is present in both the crystalline state (120) and in solution (121) for 3-methyldiazepam. In spite of the enantioselectivity P.623 demonstrated for benzodiazepines, the commonly used 3-hydroxylated derivatives (e.g., lorazepam and oxazepam)

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are commercially available only as racemic mixtures.

Physiochemical and pharmacokinetics T he physiochemical and pharmacokinetic properties of the various benzodiazepines vary widely, and these properties have clinical implications. For example, depending on the nature of substituents, particularly with regard to electronegative substituents, the lipophilicity of the benzodiazepines may vary by more than three orders of magnitude, affecting absorption, distribution, and metabolism of individual agents. In general, most benzodiazepines have relatively high lipid:water partition coefficients (log P values) and are completely absorbed after oral administration and rapidly distributed to the brain and other highly perfused organs. A notable exception is clorazepate, which is rapidly decarboxylated at the 3-position to N-desmethyldiazepam and, subsequently, quickly absorbed. Also, most benzodiazepines and their metabolites bind to plasma proteins. T he degree of protein binding is dependent on lipophilicity of the compound and varies from approximately 70% for more polar benzodiazepines, such as alprazolam, to 99% for very lipophilic derivatives, such as diazepam. Hepatic microsomal oxidation, including N-dealkylation and aliphatic hydroxylation, accounts for the major metabolic disposition of most benzodiazepines. Subsequent conjugation of microsomal metabolites by glucuronyl transferases yields polar glucuronides that are excreted in urine. In general, the rate and product of benzodiazepine metabolism varies, depending on route of administration and the individual drug.

Fig. 22.18. Metabolism of chlordiazepoxide and related benzodiazepines.

Ch lordiazepoxide Chlordiazepoxide is well absorbed after oral administration, and peak blood concentration usually is reached in approximately 4 hours. Intramuscular absorption of chlordiazepoxide, however, is slower and erratic. T he half-life of chlordiazepoxide is variable but usually quite long (6–30 hours). T he initial N-demethylation product, N-desmethylchloridiazepoxide, undergoes deamination to form the demoxepam (Fig. 22.18), which is extensively metabolized, and less than 1% of a dose of chlordiazepoxide is excreted as demoxepam. Demoxepam can undergo four different metabolic fates. Removal of the N-oxide moiety yields the active metabolite, N-desmethyldiazepam (desoxydemoxepam). T his product is a metabolite of both chlordiazepoxide and diazepam and can be hydroxylated to yield oxazepam, another active metabolite that is rapidly glucuronidated P.624 and excreted in the urine. Another possibility for metabolism of demoxepam is hydrolysis to the “ opened lactam,” which is inactive. T he two other metabolites of demoxepam are the products of ring A hydroxylation (9-hydroxydemoxepam) or ring C hydroxylation (4′-hydroxydemoxepam), both of which are inactive. T he majority of a

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dose of chlordiazepoxide is excreted as glucuronide conjugates of oxazepam and other phenolic (9- or 4′-hydroxylated) metabolites. As with diazepam (vide infra), repeated administration of chlordiazepoxide can result in accumulation of parent drug and its active metabolites, which may have important clinical implications, including excessive sedation (4,5).

Diazepam Diazepam is rapidly and completely absorbed after oral administration. Maximum peak blood concentration occurs in 2 hours, and elimination is slow, with a half-life of approximately 20 to 50 hours. As with chlordiazepoxide, the major metabolic product of diazepam is N-desmethyldiazepam, which is pharmacologically active and undergoes even slower metabolism than its parent compound. Repeated administration of diazepam or chlordiazepoxide leads to accumulation of N-desmethyldiazepam, which can be detected in the blood for more than 1 week after discontinuation of the drug. Hydroxylation of N-desmethyldiazepam at the 3-position gives the active metabolite oxazepam (Fig. 22.18).

Oxazepam Oxazepam is an active metabolite of both chlordiazepoxide and diazepam and is marketed separately, as a shortacting anxiolytic agent. Oxazepam is rapidly inactivated to glucuronidated metabolites that are excreted in the urine (Fig. 22.18). T he half-life of oxazepam is approximately 4 to 8 hours, and cumulative effects with chronic therapy are much less than with long-acting benzodiazepines, such as chlordiazepoxide and diazepam. Lorazepam is the 2′-chloro derivative of oxazepam and has a similarly short half-life (2–6 hours) and pharmacological activity.

Flu razepam Flurazepam is administered orally as the dihydrochloride salt. It is rapidly 1 N-dealkylated to give the 2′-fluoro derivative of N-desmethyldiazepam, and it subsequently follows the same metabolic pathways as chlordiazepoxide and diazepam (Fig. 22.18). T he half-life of flurazepam is fairly long (~ 7 hours); consequently, it has the same potential as chlordiazepoxide and diazepam to produce cumulative clinical effects and side effects (e.g., excessive sedation) and residual pharmacological activity, even after discontinuation. Chlorazepate is yet another benzodiazepine that is rapidly metabolized (3-decarboxylation) to N-desmethyldiazepam and so shares similar clinical and pharmacokinetic properties to chlordiazepoxide and diazepam.

Detailed ph armacokin etic an alysis Detailed pharmacokinetic analysis for most benzodiazepines is complex. T wo-compartment models may be adequate to describe the disposition of most derivatives, but three-compartment models are necessary for highly lipophilic agents, such as diazepam. T he distribution of such lipophilic drugs is further complicated by enterohepatic circulation. T hus, the usually stated elimination half-life of benzodiazepines may not adequately account for the pharmacodynamics of the distributive phase of the drug, which can be clinically important. For example, the distributive (α) half-life of diazepam is approximately 1 hour, whereas the elimination (β) half-life is approximately 1.5 days, acutely, and even longer after chronic dosing that results in accumulation of drug (4,5). Furthermore, plasma concentration and clinical effectiveness of benzodiazepines is difficult to correlate, and only a two-fold increase in clinically effective levels produces sedative side effects. Consequently, in spite of the long half-life of many benzodiazepines, they are not safe or effective when given in one daily dose and usually are divided into two to four doses per day for treatment of daytime anxiety (4,5). Both therapeutic and toxic effects may persist several days after discontinuation of chronically administered, long-acting benzodiazepines, such as chlordiazepoxide and diazepam. T hus, short-acting benzodiazepines, such as oxazepam, that are rapidly metabolized to inactive products should be considered in elderly or hepatocompromised patients.

Nonbenzodiazepine Agonists at the Benzodiazepine Receptor Relatively few structural classes of nonbenzodiazepine compounds have clinically relevant affinity for the BZR and show pharmacological activity in vivo. Examples of these classes include the β-carbolines, triazolopyridazines, cyclopyrrolones, pyrazolopyrimidines, and imidazopyridines. Representative drugs of these classes in current clinical use are the pyrazolopyrimidine zaleplon, the cyclopyrrolone eszopiclone, and the imidazopyridazine zolpidem. T hese nonbenzodiazepine BZR ligands show greater selectivity for GABAA receptors containing the α 1 subunit; however, it should be noted that the α 2 , α 3 , α 5 , and γ subunits may be important in mediating anxiolytic effects of BRZ agonists (84).

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β-Carboline Several β-carbolines have approximately 10-fold higher affinity for the BZR when compared to diazepam. T he ethyl ester of β-carboline-3-carboxylic acid (βCCE), identified in human urine extracts as an artifact of the extraction procedure, has very high affinity for the BZR. Although βCCE and other β-carbolines are not endogenous BZR ligands (vide supra) and are not currently approved for clinical use, they are used to characterize different GABAA/BZR subtypes (based on a and g subunit composition) and function (e.g., the partial agonist abecarnil) toward the discovery of anxioselective drugs. In this regard, the β-carboline ring system is planar in comparison P.625 to the boat conformation of the 1,4-benzodiazepines (see the discussion of stereochemistry); thus, β-carbolines have been useful to extend structure–activity relationship information for the agonist, antagonist, and inverse agonist pharmacophores of the various GABAA /BZR subtypes.

CL 218,872 T he triazolopyridazine CL 218,872 is another research tool used to probe BZR heterogeneity, because it is known to have selective high affinity at BZR subtypes containing the a1 subunit, hypothesized to mediate anxioselective actions (84,122). CL 218,872 has lower efficacy than benzodiazepines in potentiating GABA-gated chloride currents, but it produces anxiolytic effects in animal models at substantially lower doses than those required to produce untoward side effects (e.g., sedation, ataxia, and muscle relaxation) (78,122).

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Eszopiclone T he cyclopyrrole zopiclone is described as a “ superagonist” at BZRs with the subunit composition α 1 β 2 γ2 and α 1 β 2 γ3 , because it potentiates the GABA-gated current more than the benzodiazepine (flunitrazepam) reference agonist (123). Racemic zopiclone has been available in Europe since 199,2 and the higher affinity S-enantiomer (eszopiclone) was marketed in the United States in 2005, primarily to treat insomnia, because of its rapid onset and moderate duration (half-life, ~6 hours) of hypnotic-sedative effect (124). Less than 10% of orally administered eszopiclone is excreted unchanged, because it undergoes extensive CYP3A4- and CYP2E1-catalyzed oxidation and demethylation to metabolites excreted primarily in urine.

Pyrazolopyrimidines T he pyrazolopyrimidines zaleplon, indiplon, and ocinaplon have selective high affinity for α 1 -containing BZRs but also produce effects at other BZR/GABAA subtypes. Animal studies show that both zaleplon and indiplon are effective sedative-hypnotics (125). In patients with insomnia, zaleplon is effective to decrease sleep latency and does not appear to induce withdrawal symptoms or rebound insomnia on discontinuation. Indiplon is similar and currently under review by the U.S. FDA. Zaleplon is absorbed rapidly and reaches peak plasma concentrations in approximately 1 hour, with a half-life approximately 1 hour as well. Less than 1% of a dose of zaleplon is excreted unchanged, because most is oxidized by aldehyde dehydrogenase and CYP3A4 to inactive metabolites, which are converted to glucuronides and eliminated in urine. Ocinaplon, on the other hand, is being studied for its putative anxioselective activity rather than for its sedative effects. In rats, ocinaplon produces muscle relaxation, ataxia, and sedation only at doses 25-fold higher than the effective anxiolytic dose (122). Likewise, in patients with generalized anxiety disorder, ocinaplon produces anxiolytic effects at doses that do not cause greater incidence of sedation or dizziness than placebo. As a group, the pyrazolopyrimidines may be useful compounds to study discrepancies observed using molecular (GABAA subunit-selective) approaches versus transgenic animals and other in vivo models in the quest for anxioselective drugs. For example, for some compounds, partial agonism at a particular α subunit may be sufficient to produce a

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full anxiolytic activity in vivo, whereas other compounds must be full agonists for clinically relevant anxiolysis. Currently, it appears that high relative potency and high relative efficacy at multiple receptor subtypes can account for anxioselective properties of certain compounds, including for ocinaplon (122), which currently is under U.S. FDA review.

Imidazopyridines T he imidazopyridines, zolpidem and alpidem, represent another example of α 1 subunit-selective BZR/GABAA ligands that have clinical profiles different from those of typical benzodiazepines. For example, although the agonist effects of zolpidem on GABAA receptors qualitatively resemble those of benzodiazepines, clinically it shows a weaker anticonvulsant effect and a stronger sedative effect, which may mask anxiolytic effects. Zolpidem was marketed as a sedative-hypnotic in the United States in 1993, and it appears to be effective in shortening sleep latency and prolonging total sleep time, without affecting sleep stages, in patients P.626 with insomnia (126). Zolpidem is readily absorbed from the gastrointestinal tract and is extensively metabolized by the liver to inactive oxidized products, with a half-life of approximately 2 hours. Alpidem is similar to zolpidem in that it apparently induces no significant changes in sleep parameters (127) and has no effect on memory or muscle tone (128). Alpidem was found to be of at least equal efficacy to lorazepam in the treatment of patients with generalized anxiety disorder (129); however, it recently was withdrawn because of hepatotoxicity (130).

GABAA Partial Allosteric Modulators Partial agonists of the GABAA receptor complex offer some theoretical and practical advantages over full agonists. For example, compared to the benzodiazepine-type full agonists, partial agonists seem to have lesser side effects, such as sedation, ataxia, and potentiation of alcohol. Also, there may be less abuse potential associated with partial agonists. T hree partial agonists of GABAA receptors currently are being investigated: imidazenil, bretazenil, and abecarnil (Fig. 22.19). Abecarnil is reported by some investigators to have preferential affinity for BZR/GABAA α 1 subunits, whereas imidazenil and bretazenil are not subtype selective. In any event, abecarnil as well as bretazenil exhibit anxioselectivity in animal models, but data from clinical trials do not support the anxioselective profile predicted from preclinical results (84). Imidazenil is an imidazobenzodiazepine carboxamide that has higher BZR affinity than diazepam but is only about half as efficacious at modulating GABA effects on chloride currents. Consistent with the general pharmacological principle that partial agonists may show antagonist functional effects in competition with a more efficacious agonist, imidazenil blocks the sedative and ataxic effects of diazepam (131). Interestingly, however, imidazenil does not block the anticonvulsant effects of diazepam; accordingly, it has been proposed as an alternative to flumazenil in the alleviation of benzodiazepine-induced withdrawal symptoms (131). Bretazenil has qualitatively similar binding and clinical characteristics as imidazenil (132). Its anxiolytic activity comes with significant sedation, however, and this led to discontinuation of its development. Abecarnil is a β-carboline with anxiolytic properties. T ypical of other partial allosteric modulators, abecarnil demonstrates antianxiety and anticonvulsant activities, with little or no development of tolerance to these effects (133). Like bretazenil, however, doses of abecarnil required to produce anxiolysis also produce sedation, and it is unlikely that this drug lead will be developed (84).

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Fig. 22.19. Structures of γ-aminobutyric acid A (GABAA ) receptor partial agonists.

Miscellaneous Anxiolytic Agents Serotonin receptor–active agents In the development of anxiolytic agents that do not act via the GABAA receptor complex, serotonin receptors have been the focus of intensive research in recent years, because preclinical and clinical evidence supports the involvement of serotonin in anxiety (134,135). For example, serotonin 5-HT 1A receptors are found in relatively high density in the septohippocampal region of the brain, which is involved in the modulation of anxiety (136). In the structures of the limbic system, 5-HT 1A receptors are predominantly postsynaptic, whereas presynaptic 5-HT 1A are found in the dorsal and median raphe nuclei. Presynaptic 5-HT 1A receptors function as autoreceptors to inhibit serotonergic neurotransmission, and postsynaptic receptor activation also results in decreased neuronal activity. T he pyrimidinylbutylpiperazines (azapirones), buspirone, ipsaperone, and gepirone (Fig. 22.20) partial agonists at brain 5-HT 1A receptors and have anxiolytic activity in humans (135,137). T heir anxiolytic effects appear only after several days of treatment, and although it is well P.627 established that agonistic activity is required, the optimal level of intrinsic activity is still a matter of debate. T hus, it is unclear whether their mechanism of action is to acutely increase serotonergic activity or chronically decrease serotonergic activity (138). Buspirone is the only one of these agents currently marketed in the United States. It also has antidopaminergic activity that complicates interpretation of its interaction with 5-HT 1A receptors regarding anxiolytic effects. In any event, busiprone is shown to be effective in the treatment of generalized anxiety disorders that are mild to moderate in severity, but it is not useful for severe anxiety (e.g., with panic attacks).

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Fig. 22.20. Structures of 5-HT1A partial agonists.

Fig. 22.21. Structures of the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, fluvoxamine, paroxetine, sertraline, and escitalopram.

Serotonin reuptake inhibitors Several selective serotonin reuptake inhibitors (SSRIs), including escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline (Fig. 22.21), are effective as first-line treatment of some anxiety disorders, with the purported advantage that they lack the addictive properties of benzodiazepines (135). Specifically, the SSRIs have been shown to be effective in obsessive-compulsive disorder (139), panic disorder (140), and social phobia (141). T he mechanism of action of these agents in anxiety may differ with their role in the treatment of depression; however,

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current understanding centers on functional imaging studies that show SSRI treatment can dampen brain excitability (135).

Acknowledgm ent T he author wishes to express his gratitude to Drs. John L. Neumeyer and Ross J. Baldessarini for the training and guidance involved in preparing this chapter.

Case Study Vic to r ia F. Ro ch e S. Willia m Zito RP is a 45 -ye ar-old Cauc as ian male who s e inc re as ing ly impuls ive , agitate d , and antis o c ial be haviors have c ulminate d in a d iagno s is o f s c hizo p hrenia. This is a p artic ularly d if f ic ult s ituatio n g ive n that f o r the p as t s e ve ral ye ars , he has b ee n e xhib iting s ymptoms o f p re mature Parkins o n' s d is e as e , with g ait and b alanc e b eing his mos t ad ve rs e ly af f e c ted ab ilitie s . RP' s Parkins o n' s d is e as e is c urre ntly b e ing tre ate d with le vod o p a/c arb id o pa (Sine me t 25 /1 0 0 t.i.d.), althoug h he is s till exp erienc ing p e rio ds of rigid ity and uns te ad ines s in his mo veme nts . He is o f the p o or 2 D6 me tab olize r p henotyp e but the c o mpo und s in Sineme t (the o nly d rug he is taking ) are kno wn to b e me tab o lized b y CYP2 D 6. RP is s ing le and, s inc e the ons et o f the Parkins o n's dis e as e , has live d with his b ro the r's f amily, whic h inc lud e s his wif e and 6 -ye ar-o ld twin b oys . He has a hig h s c ho o l e d uc atio n and c o ntributes to the ho us e ho ld inc o me thro ug h his job as a ho s t at a ne arb y p anc ake res taurant. I n the s mall Midwe s te rn c o mmunity in whic h he live s , he has re c e ived e motio nal s up p ort f ro m his f riend s and ne ig hb ors (inc luding tho s e who f re q ue nt the re s taurant), but the re is c onc ern ab o ut the imp ac t o f this ne w d iag no s is o n his ab ility to re tain his job , p artic ularly b ec aus e he has re c e ntly had his f irs t aud itory halluc inatio n. I n ad d itio n, RP' s s is te r-in-law is be c o ming c o nc e rne d abo ut the imp ac t o f his b ehavio r o n her two young s ons . Co ns id er the s truc ture s o f the antips yc ho tic ag e nts d rawn b e lo w, and p re pare to make a re c o mme nd atio n to RP' s p s yc hiatris t. 1. I d e ntif y the the rap e utic pro b le m(s ) in whic h the pharmac is t' s inte rve ntio n may b enef it the p atie nt. 2. I d e ntif y and p rio ritize the patie nt-s p e c if ic f ac to rs that mus t b e c ons id e re d to ac hie ve the d e s ire d therap e utic o utc o mes . 3. C o nduc t a thoro ug h and me c hanis tic ally oriente d s truc ture -ac tivity analys is o f all the rap eutic alte rnative s p ro vide d in the c as e . 4. Evaluate the s truc ture – ac tivity relatio ns hip f ind ing s ag ains t the patie nt-s p e c if ic f ac to rs and d e s ire d therap e utic o utc o mes , and make a therap e utic d ec is io n. 5. C o uns e l yo ur p atie nt.

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P.628

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Chapter 23 Hallucinogens, Stimulants, and Related Drugs of Abuse Richard A. Gle nnon

Psychotom im etic/Hallucinogenic Agents Introduction Why study psychotomimetic agents? In the past, it was argued that investigations of such agents might shed light on mental illness and its treatment. Although studies with psychotomimetic agents have certainly contributed to our understanding of these disorders, it is now recognized that there are many kinds of mental illnesses and that the actions—and putative mechanisms of action—of psychotomimetic agents are only tangentially related to their etiology or treatment. It also has been argued that investigations of psychotomimetic agents might contribute to a greater general understanding of basic neurochemical mechanisms and neurotransmitter function. T his research approach has been more rewarding. Studies with psychotomimetic agents have contributed significantly to what is currently known about G protein–coupled receptors (e.g., cannabinoid receptors and serotonin receptors) and ion channel receptors (e.g., phencyclidine [PCP] receptors and excitatory amino acid receptors). Subsequent work with these receptors has identified new receptor subtypes that are being targeted for the development of novel therapeutic agents. Indeed, the past 10 years have witnessed an explosion of interest in the investigation of psychoactive substances because of their relevance to neurochemical mechanisms. Perhaps the most important reason to study psychotomimetic agents, however, is because these agents represent a large group of abused substances, and pharmacists generally serve as one of the first lines of defense for the dissemination of drug abuse prevention and treatment information. In addition, the past one or two decades have seen the popularization of controlled substance analogues (i.e., designer drugs), and the future will likely witness the introduction of yet more designer drugs. So, a second reason to study these agents is to prepare for the future: An understanding of the presently available agents and their structure–activity relationships (SARs) will be instructive, because many designer drugs result from the clandestine application of these same structure–activity principles at the street level. Lastly, some agents currently in clinical use possess an abuse liability that should be recognized. An understanding of how these drugs of abuse work can lead to new treatment modalities.

Definitions and Classification “ Psychotomimetic” and “ hallucinogenic” are commonly used terms, and they frequently are used interchangeably. Little agreement, however, exists regarding what constitutes such agents or exactly what they do. Because the actions of these agents are largely subjective, the best information should come from those who are experiencing the agents, yet by experiencing their effect, one may not be in a position to accurately describe the effects they produce (1). In contrast, an outside observer can never fully and accurately describe the effects of the agents. T his has led to problems of definition. Perhaps the best and most widely accepted definition of a psychotomimetic substance is that provided by Hollister (2): Psychotomimetic/hallucinogenic agents are those that on administration of a single effective dose consistently produce changes in thought, mood, and perception with little memory impairment; produce little stupor, narcosis, or excessive stimulation; produce minimal autonomic side effects; and are nonaddicting. Although certain opioid analgesics occasionally produce psychotomimetic effects, they are effectively eliminated from this category of agents, because they do not meet the necessary criteria (e.g., they can be addicting). Likewise, chronic administration of high doses of stimulants, such as amphetamine and cocaine, sometimes produce hallucinogenic episodes (i.e., amphetamine psychosis and cocaine psychosis). T hese agents are not considered to be hallucinogens, however, because multiple doses typically are required to produce this effect. T he Hollister criteria have served a very useful function in narrowing the list of agents that belong to this category of drugs. Nevertheless, Hollister was still able to identify several classes of psychotomimetic agents: lysergic acid derivatives (e.g., lysergic acid diethylamide [LSD]), phenylethylamines (e.g., mescaline), indolealkylamines (e.g., N,N-dimethyltryptamine), other indolic derivatives (e.g., ibogaine and the harmala derivatives), piperidyl benzilate esters (e.g., JB-329), phenylcyclohexyl compounds (e.g., PCP), and miscellaneous agents (e.g., kawain, dimethylacetamide, and cannabinoids) (2). Over time, it has been demonstrated that psychotomimetic agents represent a behaviorally heterogeneous class of psychoactive agents. For example, human subjects can differentiate between the actions produced by certain compounds in this category, and cross-tolerance develops among some of these agents but not between others. Likewise, it is possible to differentiate between certain of these agents using various animal procedures. Subcategorization was necessary. T oday, it is recognized that some hallucinogens act primarily via a serotonergic

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mechanism, that the cannabinoids probably produce their behavioral effects via cannabinoid receptors, and that PCP likely produces its effects via PCP receptors. T his is not to imply that a full understanding of how these agents work now exists, but it does support P.632 the concept that the agents do not belong to a homogeneous mechanistic class.

Human Versus Animal Studies: Applicability of Animal Models Human subjects should be best suited to provide the most reliable assessment of the actions and potency of psychotomimetic agents, and considerable human data are available for some agents. Much less information, however, is available for most. Often, what information is available comes from studies that were not well controlled, that included limited subject populations, or that investigated only a few drug doses. Some of what is known even comes from anecdotal reports. Very few clinical studies with psychotomimetic agents were sanctioned following the early 1960s. Although some limited human evaluation has been allowed since in the early 1990s, for a period of approximately 30 years information concerning psychotomimetic substances relied—and continues to rely—heavily on the use of animal studies. T his raises several questions: Do animal models exist that can accurately reflect human hallucinogenic activity? Indeed, do animals hallucinate? Many attempts have been made to develop animal models of psychotomimetic or hallucinogenic activity, but to date, no single animal model accounts for the actions of these agents as a class (3).

drug discrimination paradigm One animal technique that has seen widespread application for the investigation of psychoactive agents is the drug discrimination paradigm (4). It must be emphasized at the outset that this method does not represent a model of psychotomimetic activity. Indeed, the technique has general applicability and has been employed to study a wide variety of centrally acting agents, including stimulants, barbiturates, anxiolytics, opiates, and many other drug classes. T he technique may be viewed as a “ drug detection” procedure. Specifically, animals (typically rats, pigeons, or monkeys) are trained to recognize or discriminate the stimulus effects of a training drug from vehicle; humans also have been used as subjects in some drug discrimination studies. Many centrally acting agents produce an interoceptive cue or stimulus that that subjects recognize. When animals are used, they are taught to make a particular response (e.g., to respond on one lever of a two-lever operant apparatus or Skinner box) when administered a training drug and to make a different response (e.g., to respond on the second of the two levers) when administered saline vehicle. After a period of time, the animals learn the stimulus cue and associate it with one of the two levers; that is, the animals make more than 80% of their responses on the training-drug lever (i.e., > 80% drug-appropriate responding) when administered the training dose of the training drug and less than 20% of their responses on the same lever when administered vehicle. Doses of training drug less than those of the training dose result in a decrease in percentage drug-appropriate responding. T he effect is dose related, and a dose–response curve can be constructed. A median effective dose (ED50) also can be calculated as a measure of potency. Once trained, these animals can be used in what are referred to as tests of substitution or stimulus transfer or, more commonly, as tests of stimulus generalization. In such tests, other agents (i.e., challenge drugs) are administered to the animals to determine if they produce stimulus effects similar to those of the training drug. Stimulus generalization is said to have occurred when animals make more than 80% of their responses on the training drug–appropriate lever following administration of some dose of challenge drug. Stimulus generalization or substitution implies that the challenge drug and the training drug are producing similar stimulus effects in the animals. It should be noted that no claim has ever been made that the agents—the training drug and a challenge drug—are producing identical effects; rather, there is an implication that the agents are capable of producing a common stimulus effect or a behavioral cue common to the two agents (e.g., a drug that produces effects A and B may be recognized by animals trained to a drug that produces effects B and C; although this may not be a common occurrence, it should be recognized that it is possible). T hus, not only is it possible to determine if two agents are producing similar stimulus effects, it also is possible to compare their relative potencies by calculating an ED50 for the challenge drug. Other studies that can be conducted are tests of stimulus antagonism. T hat is, a specific training drug can be administered together with another agent; if the combination results in less than 20% training drug–appropriate responding, stimulus antagonism is said to have occurred. Although this technique can be employed in the development of novel antagonists for a series of agents for which an antagonist is unknown, it is more common to use a receptor-selective antagonist to investigate mechanisms of action. Drug discrimination, then, is a very powerful tool for investigating the actions and mechanisms of action of many different kinds of centrally acting agents. Specific examples of stimulus generalization and stimulus antagonists will be described later. T he drug discrimination procedure has seen broad application in the investigation of centrally acting agents, and a wide variety of different training drugs has been employed. When a psychotomimetic agent is used as the training drug, it should be possible to identify other agents that produce similar stimulus effects (5). In this manner, it has

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been demonstrated that the psychotomimetics represent a behaviorally heterogeneous group of agents, much in the same way that humans have been able to differentiate the effects of these agents. Animals trained to discriminate LSD, for example, do not recognize PCP, and animals trained to discriminate PCP do not recognize LSD. Neither LSDP.633 nor PCP-trained animals recognize tetrahydrocannabinol (T HC). However, LSD-trained animals recognize mescaline, 1-(2,5-dimethoxy-4-methylphenyl)-2-aminopropane (DOM), and certain other hallucinogens. Using this technique, then, it has been possible to identify what are termed the “ classical hallucinogens” (6). T he classical hallucinogens are LSD-like agents that share common stimulus properties and that may act via a common mechanism of action. T he remaining psychotomimetic agents will be referred to here as nonclassical agents; these groups of agents act by different mechanisms and produce distinct effects common to members within each group.

Psychoactive Drugs of Abuse: Nonclassical Hallucinogens T he term “ nonclassical hallucinogen” is used here to differentiate these psychoactive agents from the classical hallucinogens that will be discussed later in this chapter. Several categories of agents are described, but there is no implication that these classes produce similar effects or act via similar mechanisms.

Cannabinoids T he marijuana or cannabis plant represents one of the oldest and most widely used psychoactive substances in the world. Botanically, there are three major species of the plant—Cannabi s sati va, Cannabi s i ndi ca, and Cannabi s ruderal i s—and cannabis has been cultivated since approximately 6,000 BC. Reference is made to three preparations, listed here in order of increasing potency: bhang, ganja, and hashish. Bhang typically refers to the leaves and stems of the plant, ganja is prepared from the flowering tops of the plant, and hashish is the pure resin. Although marijuana is active orally, inhalation by smoking is a more frequently used route of administration. One of 9 the major active constituents of the plant is ∆ -T HC (often referred to simply as T HC). T HC is rapidly and efficiently

absorbed by inhalation; it is absorbed into body tissue and slowly released back into circulation. Deuterium-labeled T HC has been detected in human plasma up to nearly 2 weeks postadministration. A major metabolite of T HC is 11-hydroxy-∆ 9 -T HC. Evidence suggests that tolerance develops to T HC and that T HC does not generally lead to physical dependence. Marijuana can produce impairment of performance, memory, and learning; controversy exists over whether it produces an amotivational syndrome. T here are many claims for the medicinal use of marijuana and T HC.

Over the years, many cannabinoids and related structures, such as CP-55,940, were synthesized and evaluated. Noncannabinoids, such as WIN-55,212-2, also were shown to possess T HC-like actions. Few compounds displayed cannabinoid antagonist properties, and an extensive search was conducted to find possible candidates that would be

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useful for better defining the actions of T HC. A number of compounds were explored, and the pyrazole analogue SR141716A (rimonabant) has been found to be one of the most effective. SR141716A attenuates the effects of WIN-55,212-2 and T HC (7) as well as the stimulus effects of T HC. T hus, in addition to cannabinoids and cannabinoid-related structures such as CP-55,940, there are other structural classes of cannabinoid ligands, including indolic derivatives such as WIN-55,212–2, pyrazoles such as SR141716A, and fatty acid derivatives such as anandamide (discussed below).

P.634

Mechanism of action For many years, it was thought that cannabinoids were acting in a nonspecific manner, but in the early 1990s, two populations of cannabinoid receptors were identified: CB-1, and CB-2 (8,9). Human forms of these receptors have been cloned. Both types are G protein–coupled, seven-helix transmembrane-spanning receptors. T hese receptors are differentially expressed: CB-1 receptors, which may mediate the psychoactive effects of T HC-related agents, are found primarily in the brain, whereas CB-2 receptors, which possibly are involved in immunomodulatory actions, are found almost exclusively in the periphery. T he identification of such receptors suggested the possible existence of endogenous ligands, and claims for several have been published. T he best investigated of these is the eicosanoid derivative arachidonylethanolamide or anandamide, which initially was isolated from porcine brain. Anandamide (K i = 52 nM) binds at CB-1 receptors with an affinity similar to that of T HC (46 nM) (10). Related structures also have been detected in brain, including docosatetraenylethanolamide (K i = 34.4 nM) and homo-γ-linolenyllathanolamide (K i = 53.4 nM) (10). A related compound, palmitoylethanolamide, may show selectivity for CB-2 receptors. Anandamide seems to be a T HC-like agent. Although the actions of anandamide may not be identical to those of T HC, particularly regarding in vivo studies, differences may be related to the metabolic instability of anandamide. For example, in drug discrimination studies, a T HC stimulus failed to consistently or reliably generalize to anandamide; however, the more metabolically stable methanandamide, a chain-methylated analogue of anandamide, produced T HC-like effects. Furthermore, methanandamide has been used as a training drug, and the methanandamide stimulus generalizes to T HC (11).

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Structure–activity relationships Structure–activity relationships both for T HC-like actions and for CB receptor binding have been formulated (7). Structure–activity studies can be discussed on the basis of several different types of behavioral assays in rodents, and it has been shown for 60 cannabinoids that behavioral potencies are highly correlated with receptor binding affinities (12). T HC-like discriminative effects probably offer a more specific method of detecting and measuring cannabimimetic effects and are particularly useful for formulating SARs (4). Using this approach, it has been demonstrated that SARs for T HC-like stimulus effects are not necessarily identical to those for the analgesic, antiemetic, or anticonvulsant actions of cannabinoids. An early study showed that animals trained to discriminate intraperitoneal dosing of T HC recognized hashish smoke and that animals trained to discriminate hashish smoke recognized T HC, supporting the concept that T HC likely accounts for the stimulus actions of hashish. A number of cannabinoids now have been evaluated. Cannabidiol, for example, does not produce T HC-like stimulus effects. 9

9

Relative to ∆ -T HC (ED50 = 0.43 mg/kg IP), some 11-hydroxy metabolites are quite potent, such as 11-OH ∆ -T HC 8

8

(ED50 = 0.10 mg/kg) and 11-OH ∆ -T HC (ED50 = 0.38 mg/kg). One of the more potent cannabinoids is ∆ -T HC-DMH (ED50 = 0.05 mg/kg), in which the 4-pentyl moiety of T HC has been replaced with a 1,1-dimethylheptyl (i.e., DMH) 8

group; its 11-hydroxyl analogue, 11-OH ∆ -T HC-DMH (ED50 = 0.002 mg/kg), is even more potent (4). One of the most extensively studied cannabinoid ligands is WIN-55,212-2 (13). Molecular modeling and site-directed mutagenesis studies suggest that cannabinoids, CP-55,940, and anandamide bind in a similar fashion but in a manner that differs from the binding of WIN-55,212-2. T wo distinct pharmacophores have been proposed (13,14). Attempts also are being made to identify CB-1 versus CB-2 pharmacophoric features (14). T he discovery of CB receptors, and novel chemical tools with which to investigate these receptors (7,15), has generated renewed interest in the cannabinoids; in fact, during the past 18 months as of this writing, more than 600 scientific papers have been published regarding cannabinoid research. In particular, the discovery of cannabinoid antagonists, endogenous cannabinoids, subpopulations of CB receptors, and agents showing selectivity for the two subpopulations finally promise that the mechanism of action of T HC will be unraveled and that novel therapeutic agents lacking T HC's psychoactive effects will be developed. For example, cannabinoid receptor agents might be of value in the treatment of glaucoma, spasticity associated with multiple sclerosis, T ourette's syndrome, neuropathic pain, Parkinson's disease, epilepsy, drug abuse, immune disorders, and several types of neuropsychiatric disorders (16). Because T HC has been shown to result in decreased appetite, cannabinoids also have been examined for the control of appetite. Currently, SR141716A (rimonabant) is in late-phase clinical trials for the treatment of obesity (17).

PCP-Related Agents

P.635 Phencyclidine, or 1-(1-phenylcyclohexyl)piperidine (PCP), was introduced as a dissociative anesthetic during the late 1950s. Shortly after its introduction, clinical studies were terminated because of the occurrence of schizophrenic-like psychotomimetic effects, particularly during emergence from anesthesia. T his might have been the end of the story except that 1) additional attempts were made to exploit the anesthetic effects of PCP, leading to the development of novel agents, such as ketamine; 2) it was theorized that PCP-like states might provide a good model for investigating schizophrenia, leading to studies of PCP's mechanism of action; and 3) PCP (e.g., “ Angel Dust” ), administered by inhalation, injection, or smoking (as with PCP-laced parsley, tobacco, or marijuana), and ketamine (e.g., “ Special K” ) emerged as drugs of abuse, leading to investigations of their abuse liability. Shortly thereafter, it was discovered that PCP behaves as an N-methyl-D-aspartate (NMDA) antagonist. Because NMDA receptors had been implicated in seizures and trauma, PCP and related arylcycloalkylamines were explored as potential antiepileptics and

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neuroprotective agents.

Actions In humans, PCP can produce disorientation, confusion, incoordination, delirium, impaired memory, and euphoria (18). Additionally, PCP has a history of producing aggression and violent behavior. Because PCP often is consumed together with other substances, however, it sometimes has been difficult to establish exactly which effects are produced by PCP and which may be related to possible drug interactions. PCP has seen extensive investigation in animals, and it appears to produce effects similar to those of amphetamine-like stimulants and central depressants. PCP is self-administered by animals, and tolerance develops to the behavioral effects of PCP on repeated exposure to the drug (18). PCP has both direct and indirect effects on dopaminergic systems; this may account, at least in part, for some of the amphetamine-like effects of PCP and may contribute to the production of its schizophrenic-like actions. T he PCP model of schizophrenia was particularly attractive, because PCP seemed to produce both the positive and negative symptoms associated with this disorder. PCP also has been widely investigated as a training drug in animals during drug discrimination studies.

Mechanism of action N-Allylnormetazocine (NANM; SKF-10047) produces some effects reminiscent of those produced by PCP. At one time, NANM was considered a prototypic σ opiate receptor ligand. It is now recognized that the σ receptors likely are not a class of opioid receptors and that the low-affinity NANM is only one of very few opiates that bind at these receptors. Subsequent structure–activity studies showed that NANM simply possesses certain minimal pharmacophoric features that are required for σ receptor binding (19). Nevertheless, the behavioral similarities between NANM and PCP led to early investigations regarding the binding of PCP at σ receptors. and because of its affinity (albeit low) for these receptors, the σ receptors were renamed NANM-PCP receptors, or σ/PCP receptors. T his confusion continued for several years, until it was demonstrated that agents with much higher affinity and selectivity than PCP for σ receptors failed to produce PCP-like actions in animals (18). Later, it was shown that PCP 3

antagonizes the effects of the excitatory amino acid NMDA. [ H]PCP has been used to label putative PCP binding sites, and PCP binding and NMDA binding has displayed similar regional distribution in brain. It is established that PCP is a noncompetitive NMDA receptor antagonist.

Fig. 23.1. NMDA ion channel receptor showing binding sites for glycine, NMDA, and PCP.

T he NMDA receptor (Fig. 23.1) is a ligand-gated ion channel receptor that regulates the flow of cations (Na + , Ca 2+ ) into certain neurons. T he receptor complex possesses multiple binding sites, similar to the benzodiazepine/γaminobutyric acid (GABA) receptor complex, that allows the binding of glutamate, glycine, polyamines, and other ligands that can modulate the actions of NMDA. Like the NMDA antagonist dizocilpine (MK-801), PCP binds at a site (i.e., the PCP site) that is believed to be located within the ion channel. Drug discrimination studies have shown that PCP-trained animals recognize NMDA antagonists that bind at PCP receptors; for example, MK-801 is nearly 10-fold more potent than PCP. Furthermore, animals trained to discriminate MK-801 recognize PCP and other PCP-related agents. Consistent with early findings that PCP produces a psychotic state in humans, PCP has been shown to produce a pattern of metabolic, neurochemical, and behavioral changes in animals that reproduce almost exactly those seen in patients with schizophrenia. Consequently, this provides new insight regarding the mechanisms

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underlying such disorders, and it offers an animal model for the evaluation of novel antipsychotic agents (20).

Structure–activity relationships Structure–activity relationships for PCP-like actions have not been particularly well defined, and what little is known stems primarily from drug discrimination studies. T he PCP stimulus does not generalize to opioids, sympathomimetic stimulants, anticholinergic agents, or classical hallucinogens and only partially generalizes to depressants, such as barbiturates; in P.636 general, the stimulus properties of PCP are not shared by members of other drug classes (21). T he PCP stimulus generalizes to ketamine and other structurally related derivatives of PCP, such as T CP, an analogue of PCP in which the phenyl ring has been replaced by the isosteric 2-thienyl group.

PCP does not possess a chiral center. Several 1,3-dioxolanes possessing an asymmetric center produce PCP-like effects and have proven to be useful for investigating PCP-like actions. Dioxadrol, or 2-(2,2-diphenyl1,3-dioxolan-4-yl) piperidine, and etoxadrol (i.e., dioxadrol in which one of the phenyl groups has been replaced by an ethyl group) are examples of such dioxolanes. T he (+ )-isomer of dioxadrol, dexoxodrol, but not the (–)-isomer levoxadrol, binds at PCP receptors and is recognized by PCP-trained animals (21).

Psychoactive Drugs of Abuse: Classical Hallucinogens Classical hallucinogens are agents that meet the Hollister definition (2) and, in addition, bind at 5-HT 2 serotonin receptors and are recognized by DOM-trained animals in tests of stimulus generalization (5). T he classical hallucinogens all possess the general structure Ar-C-C-N, where Ar is a substituted phenyl, 3-indolyl, or substituted 3-indolyl moiety; C-C is an ethyl or branched ethyl chain; and N is a primary, secondary, or tertiary amine. T his will be further discussed. (See Chapter 14 for additional information on serotonin receptors.)

Classification T here are two major structural categories of classical or arylalkylamine hallucinogens: the indolealkylamines, and the phenylalkylamines. T he indolealkylamines are further divided into the simple N-substituted tryptamines, the α-alkyltryptamines, the ergolines (or lysergamides), and tentatively, the β-carbolines. T he phenylalkylamines consist of the phenylethylamines and the phenylisopropylamines. In humans, examples from the different categories seem to produce similar effects. It should be noted, however, that relatively few agents have been examined in comprehensive and carefully controlled clinical situations. Furthermore, no claim is made that these agents produce identical effects in humans. Each category—and, indeed, even certain examples from within a given category—may produce effects that make them somewhat different from the others. As if to underscore the behavioral similarity among these agents, however, examples from each of the above categories produce common DOM-like stimulus effects in animals (T able 23.1).

Table 23.1. Results of Stimulus Generalization Studies with Examples from the Various Categories of Classical Hallucinogens Using Animals Trained to Discriminate DOM from Vehicle

Category

Examplea

ED50 Value for DOM -Stimulus Generalization (mg/kg)b

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N-Alkyltryptamines

DMT

5.8

α-Alkyltryptamines

α-MeT

3.1

Lysergamides

(+)LSD

0.05

β-Carbolines

Harmaline

6.2

Phenylethylamines

Mescalin e

14.6

Phenylisopropylamines

DOB

0.2

a

See text for explanation of abbreviations.

b

Data from Glennon et al. (4) and from Glennon (5).

Indolealkylamines N-Alkyl tryptamin es One of the best-investigated hallucinogens is N,N-dimethyltryptamine (DMT ) (T able 23.2), which is considered to be the prototype of this subclass of agents. Although readily synthesized in the laboratory, DMT also is a naturally occurring substance. Its actions are characterized by a rapid onset (typically < 5 minutes) and short duration of action (~ 30 minutes). Like some other members of this family, DMT is not active via oral administration; it generally is administered by inhalation or by smoking. Although less common, DMT also can be injected. Some indolealkylamines are sensitive to the acidic conditions of the stomach. T he corresponding secondary amine, N-monomethyltryptamine, and primary amine, tryptamine, are inactive as psychoactive substances, both because they are not sufficiently lipophilic to readily penetrate the blood-brain barrier and because what little does get into the brain is rapidly metabolized by monoamine oxidase (MAO). Other tertiary amine derivatives, such as the N-ethyl-N-methyltryptamine, N,N-diethyltryptamine (DET ), N,N-di-n-propyltryptamine (DPT ), and some secondary amines, also are hallucinogenic in humans. If the N-alkyl or N,N-dialkyl substituents are bulky and lipophilic enough, these tryptamines can be orally active (T able 23.2). T he effect of substitution in the pyrrole portion of DMT has not been extensively investigated in humans. In contrast, substitution in the benzenoid ring can enhance or diminish potency depending on the specific nature and location of the substituents. T able 23.2 shows some of the more frequently encountered derivatives of DMT , their common names, and their approximate human potency. Serotonin is not hallucinogenic and does not readily penetrate the blood-brain barrier P.637 when administered systemically. N,N-Dimethylserotonin (bufotenine [5-OH DMT ]) has been reported to be a weak hallucinogen, but the results of human studies are controversial. It, too, likely does not readily penetrate the blood-brain barrier and produces considerable peripheral effects (e.g., facial flushing and cardiovascular actions) that prevent evaluation of an extended dose range. O-Methylation of bufotenine results in 5-OMe DMT , one of the more potent N-alkyltryptamines. A naturally occurring substance, 5-OMe DMT is a constituent of a number of plants used in various concoctions prepared by South American Indians for ceremonial and visionary purposes. Bufotenine and 5-OMe DMT also are found in the skin of certain frogs and may have given rise to the phenomenon of “ toad licking.” Psilocin is 4-hydroxy DMT . Like bufotenine, with a polar hydroxyl group, psilocin might not have been expected to enter the brain, yet it is hallucinogenic. Although this phenomenon has never been adequately explained, it has been speculated that the 4-hydroxyl group forms a hydrogen bond with the terminal amine and that this reduces polarity just enough that psilocin penetrates the blood-brain barrier. Psilocin and its phosphate ester, psilocybin, are widely found in certain species of mushrooms and have given rise to the terms “ shrooms” and “ shrooming.” T here are no reports that 6-methoxy DMT or 7-methoxy DMT are hallucinogenic. It is quite difficult to make strict potency comparisons within this series because the different routes of administration that have been used (T able 23.2).

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Table 23.2. Psychoactive Indolealkylamine and Related Agents

In tests of stimulus generalization, the DOM stimulus has been shown to generalize to DMT , DET , DPT , 4-OMe DMT , 5-OMe DMT , and a number of other DMT analogues, but not to 5-OH DMT , 6-OMe DMT , or 7-OMe DMT . T he metabolism of these agents has not been well investigated. T he indolealkylamine 5-HT is a substrate for oxidative deamination by MAO. What evidence exists suggests that other indolealkylamines also are substrates for this enzyme system.

α-Alkyltryptamin es T ryptamine is not psychoactive. Introduction of an α-methyl group seemingly enhances lipophilicity and sufficiently protects against metabolism such that α-methyltryptamine (α-MeT ) (T able 23.2) is approximately twice as potent as DMT . As a general rule of thumb, α-methyltryptamines, when such agents have been investigated, typically are twice as potent as their corresponding DMT counterpart. Otherwise, their SAR is essentially the same as that of the DMT analogues. For example, 5-methoxy-α-methyltryptamine (5-OMe α-MeT ) is approximately twice as potent as 5-OMe DMT . Introduction of the α-methyl group results in the creation of an asymmetric center and the S-(+ )-isomers of α-methyltryptamines are more potent than their R-(–)-enantiomers. Homologation of the α-methyl group to an P.638 α-ethyl group affords α-ethyltryptamines. α-Ethyltryptamine (α-EtT ) has been reported to be hallucinogenic, with effects somewhat distinguishable by human subjects from those of LSD and mescaline (23). Interestingly, α-EtT was clinically available during the early 1960s as an antidepressant because of its actions as an MAO inhibitor; however, it was removed from the market about a year after its introduction. It may be the MAO inhibitory effect that allowed the actions of α-EtT to be distinguished from those of LSD and mescaline (see also the section below on designer drugs). During the mid-1990s, α-ET made an appearance on the clandestine market as a designer drug (i.e., “ ET ” ). (±)-α-Methyltryptamine, (±)-5-methoxy-α-methyltryptamine and both of its optical isomers, and (±)-α-ethyltryptamine are recognized by DOM-trained animals in tests of stimulus generalization.

Ergoli nes or l ysergamides (+ )-LSD is perhaps the best known—and, certainly, one of the most potent—of the classical hallucinogens. Although LSD itself is not naturally occurring, many related ergolines are found in nature. In terms of potency, LSD is at least 3,000-fold more potent than mescaline, with doses of 100 µg showing activity. Certain structurally modified analogues of LSD retain hallucinogenic activity; although many derivatives are possible, relatively few have been investigated in humans. Structural changes often can reduce the activity of a pharmacologically active substance.

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Here is an instance in which a structural change resulting in even a 1,000-fold decrease in potency can afford a very active agent. Some work has been reported on the SARs of LSD (24,25).

In humans, LSD has been thoroughly investigated (24); no other hallucinogen has been as extensively studied as this agent. Its actions in humans can be divided into three major categories: perceptual (altered shapes and colors, heightened sense of hearing), psychic (alterations in mood, depersonalization, visual hallucinations, altered sense of time), and somatic (nausea, blurred vision, dizziness). In terms of principal effects, there seems to be little difference between LSD, psilocybin, and mescaline. Although LSD has been sold on the clandestine market in tablet form, it is not uncommon to find this material available on “ blotter paper” because of its high potency. A sheet of porous paper is impregnated with a solution of LSD, and the sheet can later be cut to afford the appropriate dose.

β-Carbolines T he β-carbolines represent a very interesting class of agents generally referred to as the harmala alkaloids. Several are naturally occurring. In South America, β-carbolines are found in certain vines and lianas (e.g., Bani steri opsi s caapi ), and in the Old World, β-carbolines are constituents of Syrian Rue (Pegnum harmal a). South American Indians prepare a variety of concoctions and snuffs, the most notable of which is Ayahuasca, that are used for their hallucinogenic and visionary healing properties. In fact, the first written account of the use of these substances was made by a member of the Columbus expedition in 1493. T here is little question that the concoctions are psychoactive; however, these plant preparations usually consist of admixtures in which certain tryptamines, such as DMT or 5-OMe DMT , sometimes have been identified. Some β-carbolines possess activity as MAO inhibitors; thus, the MAO inhibitory effect of the β-carbolines might be simply potentiating the effect of any tryptaminergic hallucinogens possibly present in an admixture by interfering with their metabolism. Studies with individual β-carbolines, especially under carefully controlled clinical settings, have been very limited. T he three most commonly occurring β-carbolines are harmine, harmaline, and tetrahydroharmine, and evidence suggests that harmine and harmaline are hallucinogenic in humans (with potencies not greater than that of DMT ) (27). Harmaline has seen some limited experimental application as an adjunct to psychotherapy (28). Like other classical hallucinogens, certain β-carbolines bind at 5-HT 2A receptors, and in animal studies, DOM stimulus generalization occurs to harmaline (28). Using harmaline-trained animals, harmaline stimulus generalization occurs to DOM. T o date, however, very few β-carbolines have been investigated, so they are only tentatively categorized as classical hallucinogens.

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Although the scientific community has been aware of the psychoactive effects of the β-carbolines or β-carboline– containing natural substances for more than 100 years, only in the past decade or so have they become popular “ on the street.” T he use of β-carboline–containing plants has moved out of the jungle and given rise to a variety of religious movements in some South American cities. Recent books and movies also are helping to popularize the use of these preparations, and they are now being encountered in North America.

Phenylalkylamines Phenylalkylamines, the phenylethylamines and the phenylisopropylamines, represent the largest group of classical hallucinogens (29,30). T he phenylethylamines are the α-desmethyl counterparts of the phenylisopropylamines; as with the indolealkylamines, the presence of the α-methyl group increases P.639 the agent's lipophilicity and reduces its susceptibility to metabolism by MAO. As a consequence, the phenylethylamines typically produce effects that are qualitatively similar to those of their corresponding phenylisopropylamines but typically less potent. Phenylethylamine counterparts of weak phenylisopropylamines might be inactive. Literally hundreds of analogues have been examined in human and in animal studies (29).

Ph en yleth ylamines Phenylethylamines are usually less-potent analogues of the phenylisopropylamines. Some hallucinogenic phenylisopropylamines are claimed to possess some stimulant character that may be minimized or altogether absent in the corresponding phenylethylamines. T he phenylisopropylamines also possess a chiral center that is absent in the phenylethylamines. Otherwise, the SARs of the two groups of agents are relatively similar; consequently, the phenylethylamines will not be discussed in detail here. T he most common—and, indeed, one of the oldest known— phenylethylamine hallucinogens is mescaline. A constituent of peyote (and other) cactus, mescaline is a relatively weak hallucinogenic agent (total human dose ~ 350 mg). Like many of the hallucinogens, mescaline is listed as a Schedule I substance; however, the use of peyote in certain native American Indian religious practices is sanctioned.

Ph en ylisopropyl amin es Structural modification of mescaline and related substances by introduction of an α-methyl group and by deletion or rearrangement of the position of its methoxy groups results in a series of agents known as the

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phenylisopropylamines. As might have been expected, introduction of an α-methyl group, to afford 3,4,5-T MA or α-methylmescaline, doubles the potency of mescaline. Although different nomenclatures exist for the dimethoxy- and trimethoxyphenylisopropylamines, the one used herein is a commonly used nomenclature: T he position of methoxy groups is given by indicating its position, and the number of methoxy groups is indicated by a prefix. For example, α-methylmescaline is 3,4,5-T MA, indicating that it is a trimethoxy analogue and that the methoxy groups are situated at the 3-, 4-, and 5-positions. Dimethoxy analogues are referred to as DMAs. T here are three possible monomethoxyphenylisopropylamines: the ortho-methoxy analogue OMA, the meta-methoxy analogue MMA, and the para-methoxy analogue PMA (T able 23.3). Although PMA is specifically listed as a Schedule I substance, none of these three analogues is hallucinogenic. PMA possesses weak central stimulant actions and is an abused substance; several deaths have been attributed to PMA overdose within the past few years. T here are six isomeric DMA analogues. T hese have not been thoroughly investigated in humans, and few produce DOM-like stimulus effects in animals (T able 23.3). None is more potent than DOM. T he most potent agent, and one that has been evaluated in humans, is 1-(2,5-dimethoxyphenyl)-2-aminopropane, or 2,5-DMA. T here also are six different T MA analogues (T able 23.3). Here, most show some activity, but the 2,4,5-timethoxy analogue 2,4,5-T MA (sometimes referred to simply as T MA) is the most potent of the series. Most of the trimethoxy analogues are recognized by DOM-trained animals, but none is more potent than DOM itself (5). T he presence of the 2,5-methoxy substitution pattern in 2,5-DMA and 2,4,5-T MA might be noted. T he DMAs and T MAs are methoxy-substituted derivatives of the parent phenylisopropylamine known as amphetamine (Fig. 23.2). Amphetamine undergoes several different routes of metabolism; one of these is para-hydroxylation (a route that seems more important in rodents than in humans). Initially, it was thought that the greater potency of 2,4,5-T MA over that of 2,5-DMA might be related to the 4-position of the former being blocked to metabolism by para-hydroxylation. Keeping the 2,5-dimethoxy substitution intact, different 4-position substituents were examined. T his led to a series of agents, such as DOM and DOB (T able 23.3). T hese 4-substituted 2,5-dimethoxy analogues represent some of the most potent members of the series. 1-(2,5-Dimethoxy-4-methylphenyl)-2-aminopropane (DOM) represents the prototype member of this family of agents. Increasing the length of this 4-methyl group to an ethyl or n-propyl group (i.e., DOET and DOPR, respectively) results in enhanced potency on a molar basis. Further extension of the alkyl chain results in a decrease in potency or loss of action. Substitution at the 4-position by electron-withdrawing groups, particularly those with hydrophobic character, also results in active agents, such as DOB (T able 23.3), which is quite a potent agent and has been misrepresented on the clandestine market as LSD both in tablet and “ blotter” form. When optical isomers have been examined, activity resides primarily with the R-(–)-isomer; the S-(+ )-isomers typically are less active, inactive, or have received little study. For example, although not well investigated, it appears that R-(–)-DOM and R-(–)-DOB show activity at total human doses of less than 4 and less than 1 mg, respectively. N-monomethylation reduces potency or abolishes activity; for example, the N-monomethyl analogues of DOM and DOB are approximately 10% as potent as their primary amine counterparts. T he SARs for the DOM-like actions of phenylisopropylamines are summarized in T able 23.3 and Figure 23.2. T able 23.3 also provides a comparison of the approximate human doses of various phenylisopropylamines when administered via the oral route. T hese agents represent a mere sampling of the agents that have been P.640 P.641 examined; it can be imagined, using only those functional groups shown in the table, how many different analogues are possible on the basis of structural rearrangement. T here is no reason to suspect that each of these agents produces identical effects. In fact, the actions of some of these agents have been reported to be quite unique, ranging from hallucinations and closed-eye imagery to intellectual and sensory enhancement to erotic arousal (29).

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Table 23.3. Psychoactive Phenylisopropylamines and Related Agents

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Fig. 23.2. Comparative SAR for the amphetamine-like stimulant actions and the DOM-like action of the phenylisopropylamines (30).

Classical Hallucinogens: Mechanism of Action Given that the arylalkylamines may not be producing identical effects, a common mechanism of action may not be expected. LSD was one of the first hallucinogens to be investigated mechanistically; another agent to see extensive investigation is mescaline. Interestingly, from a potency perspective, these two agents seem to represent opposite extremes. LSD has been proposed to produce its effects via numerous mechanisms, including those involving serotonergic, dopaminergic, histaminergic, adrenergic, and other receptors. LSD binds with high affinity at many different receptor populations and acts as an agonist at some, an antagonist at others, and a partial agonist at yet others. For many years, it was supposed that mescaline might be acting via a dopaminergic or adrenergic mechanism because of its structural similarity to dopamine and norepinephrine. As early as the late 1950s, it was speculated, because of its structural similarity to 5-HT , that LSD might be working through a serotonergic mechanism. Significant experimental evidence supported this claim. Controversy exists, however, regarding whether LSD was a serotonergic agonist or antagonist. Furthermore, later studies revealed the existence of at least 14 populations of 5-HT receptors (see Chapter 14). With the subsequent availability of 5-HT 2 selective antagonists, it was demonstrated that several of these antagonists (e.g., ketanserin and pirenperone) were particularly effective in blocking the stimulus effects of DOM, and of DOM stimulus generalization to other hallucinogens, such as LSD, in tests of stimulus antagonism. It was later shown that the classical hallucinogens bind at 5-HT 2 serotonin receptors and that their receptor affinities were significantly correlated with both their DOM stimulus generalization potencies and their human hallucinogenic potencies (30). T he classical hallucinogens are now thought to produce their effect by acting as agonists at 5-HT 2 receptors in the brain (i.e., the 5-HT 2 hypothesis of hallucinogen action). Radiolabeled analogues of DOB and DOI (e.g., [ 3 H]DOB and [ 125 I]DOI, respectively) are now available for the investigation of 5-HT 2 pharmacology. More recently, it has been demonstrated that 5-HT 2 receptors actually represent a family of 5-HT receptors that consist of 5-HT 2A, 5-HT 2B , and 5-HT 2C receptor subpopulations. Fewer than three dozen arylalkylamines have been compared, but it appears that they show little selectivity for one subpopulation versus another. Various pharmacological studies with selective antagonists or employing antagonist correlation analysis, however, suggest that it may be the 5-HT 2A subtype that plays a predominant role in the behavioral actions of these agents (30,31). Although the 5-HT 2A receptors might be responsible for those actions that the classical hallucinogens have in common, other neurochemical mechanisms may account for their differences. For example, LSD is a very promiscuous agent that binds with high affinity at many receptor populations for which most other classical hallucinogens show little to no affinity. Many of the indolealkylamines bind with high affinity at multiple populations of 5-HT receptors, and some display comparable or higher P.642

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affinity at these receptors (e.g., 5-HT 1A, h5-HT 1D , and 5-HT 6 ) than they do at 5-HT 2A receptors. T he phenylalkylamines are quite selective for 5-HT 2 receptors but, as mentioned above, display little selectivity for the three 5-HT 2 subpopulations. Some β-carbolines, although they bind at 5-HT 2 receptors, also possess activity as MAO inhibitors. T hus, these differences might account for their somewhat different actions. T he one feature that all the classical hallucinogens have in common (i.e., the common component hypothesis) is that they bind at 5-HT 2A receptors (5).

Central Stim ulants Introduction, Classification, and Definitions Stimulants can be divided into several categories. T he term “ stimulant,” or “ behavioral stimulant,” typically refers to agents with a central stimulatory effect for which the actions are manifested mostly in motor activity, whereas the term “ analeptics” refers to agents that have a stimulant effect primarily on autonomic centers, such as those involved in the regulation of respiration and circulation. Nicotine and related nicotinic agents also possess stimulant properties but are best discussed with other cholinergic agents. Analeptics include agents such as pentylenetetrazol, nikethamide, and strychnine. T he boundary between analeptics and behavioral stimulants is not sharply defined. Caffeine, for example, has been classified as an analeptic, but high doses produce a stimulant effects. Caffeine is probably the best known of a series of xanthines; in fact, caffeine, which is found in coffee, tea, chocolate, and other naturally occurring substances, is probably the most widely used psychoactive substance in the world. Although most analeptics do not represent significant abuse problems, evidence does exist for caffeine abuse (32). However, because caffeine, particularly in the form of its naturally occurring products, is not subject to legal constraints, it will not be discussed here. T he term “ stimulant” typically conjures up substances such as the phenylisopropylamine amphetamine and the tropane analogue cocaine. T he following discussion will focus primarily on such substances.

Phenylisopropylam ine Stimulants: Amphetam ine-Related Agents T he simplest unsubstituted phenylisopropylamine is 1-phenyl-2-aminopropane, or amphetamine. Amphetamine possesses central stimulant, anorectic, and sympathomimetic actions, and it is the prototype member of this class (33). It is common to refer to amphetaminergic structures and amphetaminergic activity, but amphetamine may be more of an exception than a rule. Most substituted derivatives of amphetamine (i.e., phenylisopropylamine) lack central stimulant activity; in fact, pharmacologically, there are a greater number of “ non-amphetamine-like” derivatives of amphetamine than there are “ amphetamine-like” derivatives of amphetamine. Relatively few derivatives of amphetamine retain the activity of amphetamine; still fewer retain the potency of amphetamine. T he present section will focus almost exclusively on the central stimulant actions of amphetamine, and it should be recognized that these SARs are not necessarily identical to those for anorectic or sympathomimetic actions.

Structure–Activity Relationships for Amphetamine-like Stimulant Action In general, the SARs for amphetamine-like actions of the phenylisopropylamines are quite distinct from those for the DOM-like actions of the phenylisopropylamines, even though both share a common structural skeleton. T he SARs for the two actions are summarized in Figure 23.2. T he stimulus effects of amphetamine analogues have been reviewed elsewhere (34).

Aryl-substituted derivatives In general, incorporation of substituents into the aromatic ring of amphetamine reduces or abolishes amphetamine-like stimulant activity. T he sympathomimetic agent 4-hydroxyamphetamine lacks central stimulant action and is unlikely to penetrate the blood-brain barrier because of the presence of the polar aromatic hydroxyl group. Masking of the hydroxyl group in the form of its methyl ether affords the Schedule I substance PMA (paramethoxyamphetamine, also known as 4-methoxyamphetamine). PMA is a weak central stimulant with approximately 10% of the potency of amphetamine. 4-Methylamphetamine (1-(para-tolyl)-2-aminopropane [pT AP]) also has been found on the clandestine market and is, at best, a weak central stimulant. Incorporation of electron-withdrawing substituents results in agents that generally lack central stimulant properties. For example, PCA, or para-chloroamphetamine, is a 5-HT –releasing agent that saw evaluation as a potential antidepressant. Another related analogue is the 5-HT –releasing agent fenfluramine, which was used for some time as an appetite suppressant. Both of these latter agents are still widely employed as pharmacological tools in basic neuroscience research.

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Amine substitution In general, the primary amines are more potent than the secondary amines, and the secondary amines are more potent than the tertiary amines, as central stimulants. With regard to secondary amines, as the length of the amine substituent increases, activity decreases; the N-monoethyl and N-mono-n-propyl amines retain stimulant character but are somewhat less potent than amphetamine itself. Larger substituents typically P.643 result in agents with little to no stimulant character. T he one exception is the N-monomethyl derivative methamphetamine. Methamphetamine (e.g., “ crystal,” “ ice,” or “ meth” ) is at least as potent as amphetamine as a central stimulant; in most studies, it may be two- to threefold more potent than amphetamine. Methamphetamine is the most widely abused synthetic substance in the world. N-Hydroxylation of amphetamine has little effect on stimulant action. N,N-Dimethylamphetamine has been seized from clandestine laboratories, but it has never been certain whether this agent was being prepared for its possible stimulant actions or as a by-product of methamphetamine synthesis.

α-Substituents Amphetamine possesses an α-methyl group. As already mentioned at the beginning of this chapter, α-demethylation (to afford phenylethylamine or 2-phenyl-1-aminoethane in the case of amphetamine) results in agents with decreased lipophilicity and increased susceptibility to metabolism. Phenylethylamine lacks central stimulant activity. Homologation of the α-methyl group to, for example, an α-ethyl or α-n-propyl group results in a decrease or loss of central stimulant activity. T he presence of the α-methyl group in amphetamine creates a chiral center; hence, amphetamine exists as a pair of optical isomers. With respect to central stimulant actions, the S-(+ )-isomer (i.e., dextroamphetamine) is several-fold more potent than its R-(–)- enantiomer (i.e., levamphetamine); this is not necessarily the case with other actions produced by amphetamine, particularly those produced in the periphery, such as its cardiovascular actions.

β-Substituents T he β-position has not been particularly well investigated. Perhaps the best-studied derivatives are ephedrine and norephedrine—and even these agents have not been especially well investigated. Ephedrine and norephedrine are phenylpropanolamines that may be viewed as the β-hydroxy analogues of methamphetamine and amphetamine, respectively. Actually, β-hydroxylation of amphetamine or methamphetamine results in the creation of a new chiral center; hence, a total of four optical isomers result from hydroxylation in each case. T hese eight structures are shown in Figure 23.3. Relatively little comparative information is available regarding the central stimulant actions of these phenylpropanolamine isomers. During the 1970s, there was a problem with what were termed “ look-alike drugs.” Look-alikes available on the clandestine market were made to resemble amphetamine and methamphetamine, both in action and physical appearance, to circumvent the control of amphetamine. T he major constituents of these agents were various combinations of ephedrine, norephedrine, and caffeine. Although the look-alikes are no longer a major problem, the 1990s witnessed the introduction of “ herbal dietary supplements.” T hese supplements were—and still are—legally available in some health food and herbal shops; several dozen such preparations have appeared on the market. T he major ingredients of many of these preparations are various combinations of ephedrine and caffeine (or of ephedrine-containing natural products [e.g., ma huang or ephedra] or caffeine-containing natural products [e.g., guarana or kola nut]). Interestingly, although ephedrine and caffeine possess stimulant character of their own, evidence suggests that these agents may potentiate one another's actions (35). T he exact mechanism by which they

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do so, however, is unknown.

Fig. 23.3. Structures of β-oxidized analogues of methamphetamine (ephedrine and pseudoephedrin e) and amphetamine (norephedrine and norpseudoephedrine). Note that norpseudoephedrine also is known as cathine.

Although β-hydroxylation of amphetamine results in decreased central stimulant actions, this may be the result of the decreased ability of norephedrine to penetrate the blood-brain barrier, or it may be a clue that the presence of a β-oxygen substituent is inherently detrimental to activity. Support for the former possibility is derived from the shrub Catha edul i s. Commonly known as khat or kat, C. edul i s is a plant indigenous to certain regions of the Middle East and eastern portion of Africa. T he fresh shrub is sold openly in local markets and is used for its central stimulant character, much in the same way as the West uses coffee. Khat is used to prepare an infusion, or the fresh leaves are simply chewed. For more than 50 years, it was thought that the active constituent was the phenylpropanolamine cathine or (+ )-norpseudoephedrine (Fig. 23.3). In the late 1970s, however, a more potent compound was isolated from fresh leaves and shown to be what is now called cathinone. Cathinone, which is simply β-ketoamphetamine or an oxidized analogue of norephedrine, is at least as potent as amphetamine as a central stimulant. Certain anorectic agents, such as diethylpropion, also possess a benzylic keto group. T he anorectic agent phenmetrazine or 3-methyl2-phenylmorpholine and aminorex possess a benzylic oxygen atom in the form of an ether. All three of these agents possess stimulant character. A related stimulant is pemoline (available as a magnesium salt). Hence, P.644 it is specifically the hydroxyl analogues that seem to possess weak stimulant actions, and this is likely a result of their reduced lipophilicity and not because they simply possess an oxygen atom at the β or benzylic position.

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Metabolism of Amphetamine In humans, (+ )-amphetamine has a half-life of approximately 7 hours. Some of the metabolic products of amphetamine metabolism are shown in Figure 23.4. Although a significant portion of amphetamine is excreted unchanged, it also undergoes both Phase I (functionalization to more polar derivatives) and Phase II (conjugation) metabolism (36). T he Phase I metabolism of amphetamine analogues is catalyzed by two enzyme systems: cytochrome P450, and flavin monooxygenase. T he latter system oxidizes secondary and tertiary amine analogues of amphetamine. Amphetamine undergoes hydroxylation on the α-carbon, the β-carbon, the terminal amine, and on the aromatic ring. T hese metabolites are subsequently oxidized, where possible, or conjugated. Amphetamine is oxidized to phenylacetone via a presumed carbinolamine intermediate. T he phenylacetone is further oxidized directly to benzoic acid or, first, to a hydroxy keto analogue that is subsequently converted to benzoic acid. Amphetamine also can undergo aromatic hydroxylation to parahydroxyamphetamine. Initial work with rats indicated that para-hydroxylation is a major route of metabolism; however, subsequent studies showed that benzoic acid is the major metabolite in humans. Subsequent oxidation at the benzylic position by dopamine β-hydroxylase affords parahydroxynorephedrine. Alternatively, direct oxidation of amphetamine by dopamine β-hydroxylase can afford norephedrine. Amphetamine and related derivatives also undergo N-hydroxyalation, and the N-hydroxy derivatives can be further oxidized to nitroso, nitro, and oximino compounds. Some evidence suggests that the oximino derivative is hydrolyzed to phenylacetone. Additional metabolites are possible as well. In Phase II reactions, ring-hydroxylated metabolites are conjugated to their corresponding glucuronides. Sulfation of the enol form of phenylacetone has been reported. Approximately 23% of methamphetamine is excreted unchanged, 18% as parahydroxymethamphetamine, and 14% as the demethylated product (36).

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Fig. 23.4. Some products of amphetamine metabolism.

Mechanism of Action of Amphetamine Amphetamine is an indirect-acting dopaminergic and noradrenergic agonist; that is, amphetamine causes an increase in the synaptic concentrations of these neurotransmitters. T he central stimulant actions of amphetamine primarily involve the dopamine system; amphetamine enhances the release of dopamine and, to a lesser extent, prevents the reuptake of dopamine into presynaptic terminals (Fig. 23.5). T he stimulant actions of amphetamine can be attenuated by the administration of dopamine antagonists, such as the antipsychotic phenothiazine chlorpromazine and the butyrophenone haloperidol. Chronic administration of high doses of amphetamine may result in “ amphetamine psychosis,” which exhibits symptoms similar to those of acute paranoid psychosis. T his is consistent with a role for dopamine in the central actions of amphetamine and, P.645 further, with the dopamine antagonist mechanisms proposed for certain antipsychotic agents. Similar psychotic episodes have been associated with khat (“ khat psychosis” or “ cathinone psychosis” ) and cocaine (“ cocaine psychosis” ).

Fig. 23.5. Schematic of a dopaminergic nerve terminal. Amphetamine increases synaptic concentration of dopamine primarily by causing its release from presynaptic terminals, whereas cocaine increases syn aptic con centration by preventing its reuptake (α).

Clinical Applications Although phenylisopropylamines generally are known for their abuse liability, several have gained clinical acceptance. Indeed, certain of these agents display reduced stimulant character and/or are infrequently abused. Ephedrine (and, later, phenylpropanolamine) and amphetamine were two of the first agents used to treat obesity. Caffeine also has been used to treat obesity, and when given in combination with ephedrine, the combination has a supra-additive effect (37,38). Alternatives to the synthetic products include herbal preparations that contain ephedrine (e.g., ma huang) or caffeine (e.g., guarana). Recent studies indicate that ephedrine–caffeine combinations are associated with an increased risk of psychiatric, autonomic, cardiovascular, and other side effects (38). T he central stimulant actions of the phenylispropylamines led to their structural modification and the subsequent introduction of anorectic agents, such as diethylpropion, phenmetrazine, and phentermine. Despite a lack of widespread abuse, many of these agents retain central stimulant properties. (±)-Fenfluramine was developed in the

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®

1960s and marketed as Pondimin . Although structurally related to amphetamine, fenfluramine is devoid of stimulant character. Unlike amphetamine-related agents that act primarily via noradrenergic and dopaminergic mechanisms, fenfluramine is primarily a serotonin-releasing agent. T he more potent isomer in reducing food intake, (+ )-fenfluramine (i.e., dexfenfluramine), was introduced clinically during the 1980s. Fenfluramine also was available in combination with phentermine (i.e., phen-fen). Unfortunately, some patients treated with this combination displayed symptoms of valvular heart disease, resulting in the voluntary withdrawal from the market in 1997 of fenfluramine-containing anorectic agents. (±)-Fenfluramine is metabolized to its primary amine norfenfluramine, and evidence suggests that valvulopathy might be the result of the agonist action of norfenfluramine on cardiac 5-HT 2B receptors (39,40). T oday, it is not unusual for new drug candidates to be examined for 5-HT 2B agonist action during the early stages of their development. Other serotonergic agents have been evaluated for their antiobesity actions including selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine) (37) (see Chapter 21). Sibutramine, an agent with an amphetamine-like structural skeleton that was initially developed as an antidepressant, is an inhibitor of serotonin and norepinephrine reuptake. Animal studies indicate that sibutramine reduces food intake by decreasing meal duration rather than feeding frequency, suggesting an effect on satiation mechanisms (37). Sibutramine stimulates thermogenesis and effectively reduces amounts of visceral fat (41). Side effects of sibutramine include increased heart rate and blood pressure that have been attributed to its adrenergic action. T hese and other approaches and strategies to the treatment of obesity have been recently reviewed elsewhere (37,41).

Causes of excessive daytime sleepiness are numerous and include intrinsic sleep disorders, such as obstructive sleep apnea/hypopnea syndrome and narcolepsy; circadian rhythm sleep disorders, such as jet lag; and sleep disorders associated with neuropsychiatric conditions, such as anxiety and depression (42). In many instances, excessive daytime sleepiness is treated by addressing the underlying cause; however, the specific etiology of narcolepsy is unknown. Narcolepsy also can be characterized by brief periods of muscle paralysis (cataplexy). Hence, a need exists for agents that can effectively treat narcolepsy and cataplexy. Because of the increased behavioral activation (i.e., arousal, alertness, and motor activity) caused by psychostimulants, their use has been the mainstay for the treatment of narcolepsy. Agents such as methylphenidate and amphetamine frequently are used, and methamphetamine and caffeine are used less commonly. Pemoline (Cyclert) also has seen some application but has been reported to produce liver toxicity (42,43,44). Adderall, a combination of amphetamine salts (equal amounts of (+ )-amphetamine saccharate, (+ )-amphetamine sulfate, amphetamine aspartate, and amphetamine sulfate), was introduced in 1996; although used primarily for the treatment of attention-deficit hyperactivity disorder (ADHD), it + also is used in the treatment of narcolepsy. Newer agents include sodium oxybate (HO-CH 2 CH 2 CH 2 COO Na ; presumed to act through a gabaminergic mechanism) and modafanil. Modafinil (Provigil) is a new agent that seems to promote wakefulness without producing the arousing effects associated with many other stimulants; it also has been approved for the treatment of obstructive sleep apnea/hypopnea syndrome (45). T he exact mechanism of action of modafinil is unknown but has been shown by various investigators to involve dopamine, norepinephrine, histamine,

serotonin, and/or GABA receptors; modafinil also binds at hypocretin (orexin receptors) (46,47). Modafinil showed reduced stimulant character relative to methylphenidate, and its potential for abuse in patients with narcolepsy has been demonstrated to be low (42). Hepatic metabolism responsible for the clearance of modafinil include amide hydrolysis to modafinil acid, its primary inactive metabolite. S-oxidation and aromatic ring hydroxylation occurred via CYP2C9. Less than 10% is excreted as unchanged drug. Motor suppression seen in patients with cataplexy is similar to the motor suppression seen in healthy individuals during REM sleep. Consequently, agents previously found to decrease REM sleep have been evaluated for the P.646 treatment of cataplexy (44,46). Agents that suppress REM sleep include those that increase noradrenergic,

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serotonergic, and dopaminergic signaling. T ricyclic antidepressants, certain SSRIs, selective norepinephrine– serotonin reuptake inhibitors (e.g., venlafaxine) and MAO inhibitors have found application in the treatment of cataplexy, as has sodium oxybate (46,47). Psychostimulants also might be of some anticataplexic benefit, but modafinil generally produces little improvement (46).

Cocaine-Related Agents T here are eight possible stereoisomeric forms of methyl 3-(benzoyloxy)-8-methyl-azabicyclo[3.2.1]octan2-carboxylate, of which one, R-cocaine, is simply referred to as “ cocaine.” Chemically, cocaine is known as 2R-carbomethoxy-3S-benzyloxy-1R-tropane. Cocaine is naturally occurring in a variety of plants belonging to the Erythroxyl on coca species, which is indigenous to some countries in South America. In addition to its stimulant actions, cocaine possesses vasoconstrictor actions and is a local anesthetic; it has served as a template for the development of other therapeutically useful agents, including local anesthetics and 5-HT 3 serotonin antagonists. Cocaine has a very interesting history. T he coca plant was used by South American Indians for religious and mystical purposes and as a stimulant both to increase endurance and to alleviate hunger. It was introduced into Europe during the 1800s, and at the end of the 19th century, cocaine use was popular and socially acceptable. Various cocaine-containing preparations were available, and it also was used to “ fortify” wines (e.g., Vin Coca). For a period of approximately 20 years, until just after the turn of the century, it was a constituent of the soft drink Coca-Cola. Additionally, cocaine was used for therapeutic reasons but was later supplanted by amphetamine. Cocaine is active via nearly every possible route of administration; however, insufflation of “ snow” or “ coke” represents one of the most popular routes. Administered in this manner, peak effects and plasma levels are achieved within 30 minutes (48). Smoking the freebase form of cocaine (“ crack” ) results in an even more rapid effect. T he freebase form rather than the hydrochloride salt is used for smoking, because the temperatures required for vaporization of the salt result in considerable decomposition (48). Intravenously administered cocaine can achieve peak blood levels within a few minutes. Cocaine is metabolized to benzoylecgonine, the methyl ester of ecgonine, and to a lesser extent, to ecgonine, norcocaine, and hydroxylated derivatives.

Mechanism of Action of Cocaine Cocaine has been shown to block the reuptake of norepinephrine, serotonin, and dopamine; however, the reinforcing and stimulant nature of cocaine seems to be related primarily to blockade of dopamine reuptake, leading to the “ dopamine hypothesis” of cocaine's actions (49). [ 3 H]Cocaine was used in an attempt to identify the “ cocaine receptor,” and this was later shown to be similar to the dopamine transporter. Currently, it is thought that cocaine produces it reinforcing effects by interfering with dopamine reuptake (Fig. 23.5) by blocking the dopamine transporter (50). Although the human dopamine transporter has been cloned, it is unknown if the dopamine and cocaine binding domains are identical or how much they overlap (49).

Cocaine-like structure–activity relationships and cocaine-like agents Because cocaine binds at the dopamine transporter, this provides a convenient method for the investigation and formulation of SARs; these have been recently reviewed elsewhere (48,49). Important features for the binding of cocaine analogues include configuration, substituent at C 2 , stereochemistry at C 2 , substituent at N 8 , and substituents at C 3 . With respect to cocaine analogues, inversion of configuration can decrease activity. T he C 2 -position is quite important: Epimerization from β to α reduces activity by 30- to 200-fold, and hydrolysis of the

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ester to the acid (i.e., benzoylecgonine) reduces activity by more than 1,500-fold. Although an ester function seems to be important, the methyl group can be replaced by other substituents (e.g., phenyl or benzyl) with relatively little effect. A basic nitrogen atom appears to be optimal. Replacement of the N 8 -methyl group by other substituents, such as small alkyl or benzyl, has only a small negative influence on activity, whereas quaternization or acylation (of norcocaine) reduces activity by 33- and 111-fold, respectively (49). Other dopamine transport blockers are known, and their SARs have been investigated (50). One of the oldest and 3

most widely investigated is WIN 35,428, and [ H]WIN 35,428 is available as a radioligand. Others include benztropine, GBR 12909, mazindol, and methylphenidate (50,51). T hese latter compounds produce varying degrees of cocaine-like actions and, thus, are being examined as structural leads for the development of therapies for the treatment of cocaine abuse (50). Because there are currently more than 1.7 million cocaine users in the United States, various novel pharmacotherapies are being pursued, including gabaminergic agents, dopaminergic agents, adrenoceptor antagonists, vasodilators, and cocaine vaccines (52). P.647

Designer Drugs Introduction Designer drugs, or controlled substance analogues, are the end result of the application of SARs at the clandestine level. T hat is, knowledge of the established SARs of a particular class of abused substances can be applied at the clandestine level for the development of novel agents of abuse. What is particularly frightening about this concept is that the novel agents are not necessarily—or even commonly—examined for action or toxicity before they are put on the illicit market. T he term “ designer drug” was first introduced in reference to novel opiate-related analogues that appeared on the clandestine market approximately three decades ago; today, the term is applied more generically to any class of abusable substance. Furthermore, the term is now commonly applied to nearly any substance, novel or not, that is new to the street scene. Designer drugs have appeared that are structurally related to the hallucinogens and stimulants discussed above; the present discussion will focus on some of these agents.

Specific Examples Because some designer drugs result from the clandestine application of SARs, it should be possible to legitimately forecast the actions and, perhaps, even the approximate potencies of novel street drugs on the basis of the same SAR data. In fact, this sometimes is the case. For example, “ Nexus” made an appearance on the east coast of the United States in the early 1990s. Nexus is α-desmethyl DOB, or 2-(4-bromo-2,5-dimethoxyphenyl)-1-aminoethane. Knowing that DOB is a potent phenylisopropylamine hallucinogen and that α-demethylation typically reduces the potency of phenylisopropylamines, it might be suspected that Nexus would be a DOB-like agent with reduced potency. T his has been supported by the results of drug discrimination studies in animals. Furthermore, this material, also known as 2C-B, has been shown to be active in humans at 12 to 24 mg relative to approximately 2 mg for DOB (29). In the last year or two, a number of related agents have been found on the clandestine market and, like 2C-B, are phenylethylamine analogues of their phenylisopropylamine counterparts; for example, 2C-C, 2C-I, 2C-N, 2C-E, and 2C-P are the phenylethylamine analogues of DOC, DOI, DON, DOET , and DOPR, respectively (T able 23.3) (Fig.

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23.6). Another agent attracting recent attention is 2C-T -7 (e.g., “ Blue Mystic” or “ T ripstasy” ) (53), which has been recently controlled as a Schedule I substance. Recently controlled indolealkylamine analogues include α-MeT (AMT ), α-EtT (“ ET ” ), and 5-methoxy-N,N-diisopropyltryptamine (“ Foxy Methoxy” ) (Fig. 23.6); these agents had been previously shown to produce DOM-like stimulus effects in animals (54).

Stimulant designer drugs also have appeared. For example, CAT , or methcathinone, has been found on the illicit American market. Interestingly, it seems that methcathinone was a popular drug of abuse in the former Soviet Union (where it was known under a variety of names including ephedrone), but reports of this agent were never published in either the scientific or lay literature of that time. Methcathinone is the N-monomethyl analogue of cathinone. Indeed, structurally, methcathinone is to cathinone what methamphetamine is to amphetamine. Methcathinone, which may be viewed as an oxidation product of ephedrine (hence the name ephedrone) is a potent central stimulant that is at least as potent as methamphetamine. Another example of a stimulant designer drug is 4-methylaminorex (U4Euh), which has been misrepresented on the illicit market as cocaine or methamphetamine. 4-Methylaminorex, an alkylated version of the anorectic/stimulant aminorex, P.648 contains two chiral centers and, hence, exists as four optical isomers. T ypically, it is a mixture of the two ci s isomers that has been confiscated by law enforcement officials, and ci s 4-methylaminorex is now classified as a Schedule I substance. Interestingly, all four isomers behave as amphetamine-like agents, with the trans-(4S,5S) isomer being the most active, having a potency slightly greater than that of (+ )-amphetamine itself. Yet other examples include the piperazines. Several piperazine analogues have been reported to produce amphetamine-like effects in humans, and one in particular, N-benzylpiperazine (known either alone or in combination with other piperazines as “ Rapture” ), has been recently classified as a Schedule I substance (Fig. 23.6).

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Fig. 23.6. Designer drugs.

Not all designer drugs result in actions that are entirely predictable. One of the most popular of such agents is MDMA, or N-methyl-1-(3,4-methylenedioxyphenyl)-2-aminopropane (e.g., “ Ecstasy,” “ XT C,” or “ Adam” ) (Fig. 23.6). MDMA is the N-monomethyl analogue of MDA, or 1-(3,4-methylenedioxyphenyl)-2-aminopropane. MDA was popular during the 1960s, when it was known on the street as the “ Love Drug.” It was reported to produce effects in humans akin to a combination of cocaine and LSD. It has since been shown that MDA produces both amphetamine-like and DOM-like stimulus effects in animals and, furthermore, that animals trained to discriminate MDA recognize central stimulants, such as amphetamine and cocaine, as well as classical hallucinogens, such as LSD, mescaline, and DOM. Interestingly, the stimulant actions of MDA appear to be associated with the S-(+ )-isomer, whereas the DOM-like actions are associated with the R-(–)-isomer. Knowing that N-monomethylation of phenylisopropylamine stimulants enhances their potency, whereas the corresponding change is detrimental to DOM-like actions, it would have been predicted that MDMA would probably behave as an amphetamine-like stimulant. Consistent with this prediction, amphetamine-trained (but not DOM-trained) animals recognized MDMA in tests of stimulus generalization. Furthermore, animals trained to discriminate MDMA recognized amphetamine but not DOM. However, MDMA was claimed to produce empathogenic effects in humans (i.e., increased empathy and sociability and enhanced feelings of well being) and was used for several years as an adjunct to psychotherapy before emergency scheduling under the Controlled Substances Act as a Schedule I substance. It was argued that MDMA produced a unique, nonamphetamine-like effect (55). Although both optical isomers are active, the S-(+ )-isomer is the more active of the two. A closely related agent is its N-ethyl homologue MDE (“ Eve” ). T he general consensus today is that MDMA is probably an empathogen with amphetamine-like stimulant side effects. Homologation of the α-methyl group of phenylisopropylamine stimulants and hallucinogens typically diminishes their potency or abolishes their activity; however, the α-ethyl analogue of MDMA (MBDB, or N-methyl-1-(3,4-methylenedioxyphenyl)-2-aminobutane) retains MDMA-like actions (56) (Fig. 23.6). Another agent, sold as a substitute for MDMA, is 4-MT A (e.g., “ Flatliners” or “ Golden Eagles” ) (Fig. 23.6); this agent produces MDMA-like stimulus effects in animals but did not produce either DOM-like or cocaine-like effects (53). A closely related agent is PMMA, or N-methyl-1-(4-methoxyphenyl)-2-aminopropane. PMMA is a hybrid structure of two phenylisopropylamine stimulants: PMA, and methamphetamine (Fig. 23.6) Surprisingly, PMMA lacks significant central stimulant actions, and unlike PMA and methamphetamine, PMMA is not recognized by (+ )-amphetamine– trained animals. Because PMMA is structurally related to metabolites of MDMA, it was examined in MDMA-trained animals and found to be several-fold more potent than MDMA. Animals have been trained to discriminate PMMA from vehicle, and PMMA stimulus generalization occurred to (±)-MDMA and S-(+ )-MDMA, but not to DOM, (+ )-amphetamine, R-(–)-MDMA, or R-(–)-PMMA. Another psychoactive agent that has not been well investigated is 3,4-DMA (T able 23.3). 3,4-DMA may be viewed as an O-methyl ring-opened analogue of MDA (Fig. 23.6). Although 3,4-DMA was not recognized by either DOM- or (+ )-amphetamine–trained animals, it was recognized by MDA- and PMMA-trained animals. T hese results, coupled with the above discussion of MDMA, suggest that phenylisopropylamines may not be best described as merely central stimulants or hallucinogens; a third action needs to be accounted for. Although MDMA is widely abused, a contributing factor may be related to its amphetaminergic actions. It is not yet known if agents that fall into this third pharmacological category possess abuse potential; consequently, they have been referred to simply as “ other” agents. It has been proposed that the behavioral actions of the phenylisopropylamines can be described by the Venn diagram shown as Figure 23.7. As depicted in that figure, the three types of actions are classical hallucinogen (H), stimulant (S), and PMMA-like (P) (57). Because MDMA P.649 possesses both PMMA-like and (+ )-amphetamine–like activity, it is perhaps best represented by Intersect 2. As mentioned above, R-(–)-MDA is hallucinogenic, and S-(+ )-MDA is a stimulant. Both isomers possess PMMA-like activity. T hus, R-(–)-MDA is best represented by Intersect 3, whereas S-(+ )-MDA is best represented by Intersect 2. T he common intersect (shaded area) describes the actions of (±)-MDA. Using this classification system, it should be possible to classify the various phenylisopropylamines as falling into one or more categories. Furthermore, there is no reason to suspect that this classification system will be limited to the phenylisopropylamines; that is, there is evidence that the indolealkylamines might be classified in a similar manner. For example, S-(+ )-α-EtT produces both DOM- and PMMA-like effects, but not (+ )-amphetamine–like effects, whereas R-(–)-α-EtT produces (+ )-amphetamine– and PMMA-like effects, but not DOM-like effects (58). T he classification scheme suggests that there will be three different SARs and three different mechanisms of action. Certain agents, because they fall into more than one category, may represent mechanistic and structure–activity composites. T he same may be said of arylalkylamine designer drugs; indeed, it may be the particular “ mix” of actions that makes certain designer drugs so attractive as drugs of abuse.

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Fig. 23.7. The behavioral effects of arylalkylamines may be described as falling into one or more of three different stimulus categories: classical hallucinogen (H), central stimulant (S) or PMMA-like (O). See text for fu rther discussion.

Perhaps the most worrisome things about designer drugs are that almost none has been investigated under controlled clinical settings, that relatively little is known about their toxicity or long-term effects, and that medical professionals generally are unfamiliar with them (or with the treatment of their overdose) in emergency room settings. T he situation is further exacerbated by the broad availability of Web sites describing such agents to potential users (59).

Neuronal Plasticity and Drugs of Abuse Release of neurotransmitter from presynaptic terminals results in the activation of postsynaptic neurotransmitter receptors that can be coupled to complex effector mechanisms. T hrough modulation of postsynaptic pathways, the state of the neuron can be altered such that neurons become more or less responsive to the neurotransmitter (60). T his process is referred to as functional plasticity. One of the most exciting recent findings with implications for the treatment of drug abuse (as well as other neuropsychiatric disorders) involves the regulation of DARPP-32, an integrator of intracellular signaling. Interaction of dopamine at D 1 -like receptors (D 1 /D 5 ) activates adenylate cyclase, which increases cyclic adenosine monophosphate (cAMP) levels; this, in turn, can regulate phosphorylation of DARPP-32 (dopamine- and cAMP-regulated phosphoprotein of 32 kDa) by protein kinase A P.650 (PKA). Interaction of dopamine at D 2 -like receptors (D 2 /D 3 /D 4 , which are negatively coupled to cAMP) has an effect that is essentially opposite that of activation of D 1 receptors. Phosphorylation of a specific amino acid residue (threonine 34 [T hr 34 ]), induced by D 1 agonists, converts DARPP-32 to an inhibitor of protein phosphatase-1 (PP-1); thus, when phosphorylated at T hr 34 , DARPP-32 behaves as an amplifier of PKA-mediated signaling through its ability to inhibit PP-1. T he actions of DARPP-32 also can be modulated by phosphorylation (or dephosphorylation) of T hr 75 (Fig. 23.8). Activation of D 1 receptors decreases the phosphorylation state of DARPP-32 at T hr 75 by a process that involves PKA-dependent activation of protein phosphatase-2A (PP-2A); this disinhibits phosphorylation of T hr 34 by PKA (i.e., results in enhanced phosphorylation of T hr 34 ). T he result is potentiation of dopaminergic signaling. T ogether, PKA and PP-1 regulate the phosphorylation state of downstream neuronal effector proteins. Additionally, DARPP-32 can be phosphorylated at serine 137 (Ser 137 ), and this phosphorylation decreases the rate of dephosphorylation of T hr 34 .

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Fig. 23.8. A simplistic schematic showing the proposed involvement of DARPP-32 in neurotransmission. Agonists (e.g., DA and 5-HT) can interact with certain postsynaptic G protein–coupled receptors to activate second messenger systems. Agonist action at D 1 receptors increases cAMP levels and causes PKA to phosphorylate DARPP-32 at Thr 34 ; activation of D 1 receptors also decreases the phosphorylation state of DARPP-32 at Thr 75 by what appears to involve PKA-dependent activation of a protein phosphatase (PP-2A). Likewise, the action of 5-HT at 5-HT 4 and 5-HT 6 receptors increases p hosphorylation of Thr 34 and decreases phosphorylation of Thr 75 . Interaction of 5-HT at 5-HT 2 receptors activates phospholipase C (PLC) and promotes phosphorylation of DARPP-32 at Ser 137 . Phosphorylation at Thr 34 inhibits protein phosphatase-1 (PP-1). Inhibition of PP-1 enhances signaling. Phosphorylation of Thr 75 has an inhibitory effect on Thr 34 phosphorylation (conversely, decreased Thr 75 phosphorylation disinhibits PKA to increase Thr 34 phosphorylation), whereas phosphorylation of Ser 137 preven ts dephosphorylation of Thr 34 . Other receptors can impinge on this mechanism (60,61,62,63,64,65).

Serotonin causes an increase in phosphorylation of T hr positively coupled to cAMP) and Ser

137

34

(via activation of 5-HT 4 and 5-HT 6 receptors, which are

(via activation of 5-HT 2 receptors–receptors coupled to phospholipase C),

and a decrease in the phosphorylation of T hr 75 (via activation of 5-HT 4 and 5-HT 6 receptors). Hence, serotonin inhibits PP-1 through what might be considered a synergistic mechanism (61). Other receptors that might modulate DARPP-32 include glutamate, GABA, adenosine, nitrous oxide, and opioid receptors. Hence, it has been speculated that various drugs of abuse, including amphetamine, methamphetamine, cocaine, caffeine, opioids (e.g., morphine),

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nicotine, and ethanol involve a DARPP-32 mechanism; furthermore, agents such as antidepressants, antipsychotics, and antiparkinsonian drugs have been shown to influence phosphorylation of DARPP-32. Classical hallucinogens, as described above, are thought to act by activation of 5-HT 2A receptors. It has been shown that LSD increases phosphorylation of Ser

137

(62). In theory, DARPP-32 should be modulated by various designer drugs that act via a

dopaminergic or serotonergic mechanism. Only selected aspects of intracellular integration have been mentioned here, and others already have been implicated. T he state of the art has been recently described (61,62,63,64,65). Nevertheless, the actions of many drugs of abuse might involve such postsynaptic events and certainly require further attention.

Acknowledgem ent Work from the author's laboratory was supported by PHS grant DA 01642.

Case Study Victor ia F. Roche S. Willia m Zito EW , a 2 5-year-old wild hair who has always b een “ jus t this s id e” of the law, is on a so lo motorc yc le trip thro ugh the des e rt Southwes t with an ultimate de stination of Me nd oc ino, Calif ornia. He is traveling light, but he d id take care to p ac k e nough gras s to last the trip —o r s o he tho ug ht. Some where around Gallup, New Mexico , he met up with s ome other “ born to be wild” f olks he ading s o uth to Mexic o, and they p ooled their s tashe s and p artie d tog ether until everything was go ne . As he c ro ss e d into Arizona and entered the Navajo Nation a f e w hours late r (s till half -s toned), he was wo ndering how in the hec k he was g oing to make it to Calif o rnia without the aid o f illic it pharmace utic als . W he n he rod e by a Native-Americ an c hurc h building , he exercis ed s ome very po or judg ment in turning around, breaking in, and s tealing a small quantity o f bo tanic al inte nd ed to be us ed in a sac re d manner to f ac ilitate s piritual co mmunion with the Cre ator. Af raid o f be ing c aught with his s tolen prope rty, EW dec ided to c ons ume what he had taken and, a f e w hours late r, be gan to have vis ual hallucinations that d is torted his image o f the road ahead. The me sas appe are d to be on f ire and , f ee ling dizzy and abrup tly “ se eing ” the oc ean right in f ront of him, he turne d s harply, ran of f the road at 75 mph, and was thrown f rom his bike into a was h. The trib al po lic e no w have him in c us tod y, and he was take n to the health c are f acility in Chinle f o r treatment of his injuries . As the I HS pharmac is t in c harge , you and your ro tation s tud ent are no w abo ut to se e him as you make your morning ro und s . Yo u as k yo ur s tudent to take the lead on the co nsultation, be ginning b y id entif ying the halluc inoge nic sub stanc e f rom the s truc tural choic es provided below. 1. I d entif y the therapeutic prob lem(s ) where the pharmac ist' s interventio n may benef it the p atient. 2. I d entif y and prio ritize the p atient-sp ec if ic f ac tors that mus t be co nsidered to achieve the des ired therap eutic outc ome s. 3. Conduc t a tho ro ug h and mec hanis tically o riented SAR analys is o f all struc tures provided in the c ase . 4. Couns el your p atient

P.651

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Chapter 24 Opioid Analgesics Dav id S. Frie s

Introduction Agents that decrease pain are referred to as analgesics, or analgetics. Although analgetic is grammatically correct, common use has made analgesic preferable to analgetic for the description of the pain-killing drugs. Pain relieving agents also are called antinociceptives. A number of classes of drugs are used to relieve pain. T he nonsteroidal anti-inflammatory agents have primarily a peripheral site of action, are useful for mild to moderate pain, and often have an anti-inflammatory effect associated with their pain-killing action. Local anesthetics inhibit pain transmission by inhibition of voltage-regulated sodium channels. T hese agents often are highly toxic when used in concentrations sufficient to relieve chronic or acute pain in ambulatory patients. Dissociative anesthetics (ketamine), and other compounds that act as inhibitors of N-methylD-aspartate (NMDA)–activated glutamate receptors in the brain, are effective antinociceptive agents when used alone or in combination with opioids. Compounds, such as the antiseizure drug pregabulin, which inhibits voltage regulated Ca 2+ ion channels, are useful in treating neuropathic pain. Most central nervous system (CNS) depressants (e.g., ethanol, barbiturates, and antipsychotics) will cause a decrease in pain perception. Inhibitors of serotonin and norepinephrine reuptake (i.e., antidepressant drugs) are useful either alone and in combination with opioids in treating certain cases of chronic pain. Current research into the antinociceptive effects of centrally acting α-adrenergic-, cannabinoid-, and nicotinic-receptor agonists may yield clinically useful analgesics working by nonopioid mechanisms. Research in one or more of the above areas may lead to new drugs, but at present, severe acute or chronic pain generally is treated most effectively with opioid agents. Historically, opioid analgesics have been called narcotic analgesics. Narcotic analgesic literally means that the agents cause sleep or loss of consciousness (narcosis) in conjunction with their analgesic effect. T he term “ narcotic” has become associated with the addictive properties of opioids and other CNS depressants. Because the great therapeutic value of the opioids is their ability to induce analgesia without causing narcosis, and because not all opioids are addicting, the term “ narcotic analgesic” is misleading and will not be used further in this chapter.

History T he juice (opi um in Greek) or latex from the unripe seed pods of the poppy Papaver somni ferum is among the oldest recorded medications used by humans. T he writings of T heophrastus around 200 BC describe the use of opium in medicine; however, evidence suggests that opium was used in the Sumerian culture as early as 3500 BC. T he initial use of opium was as a tonic, or it was smoked. T he pharmacist Surtürner first isolated an alkaloid from opium in 1803. He named the alkaloid morphine, after Morpheus, the Greek god of dreams. Codeine, thebaine, and papaverine are other medically important alkaloids that were later isolated from the latex of opium poppies. Morphine was among the first compounds to undergo structure modification. Ethylmorphine (the 3-ethyl ether of morphine) was introduced as a medicine in 1898. Diacetylmorphine (heroin), which may be considered to be the first synthetic pro-drug, was synthesized in 1874 and marketed as a nonaddicting analgesic, antidiarrheal, and antitussive agent in 1898. P.653

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Clinical Significan ce Opioid agonists and partial agonist/antagonists generally act on δ, µ, and κ receptors. All of these receptors have subtypes that provide varying degrees of analgesia, euphoria or dysphoria, central nervous system depression, and perhaps, the potential for tolerance. By modifying their structures, properties can be changed to develop agents that require more or less hepatic metabolism and, thus, affect the duration of action and the bioavailability. Other changes in the chemical structures can yield agents with much higher affinity for analgesic receptors, which corresponds to more potency on a milligram-to-milligram basis. Other alterations of the chemical structures can lead to improved profiles regarding respiratory depression, emesis, tolerance, and allergenicity. By altering the affinities for some receptors more than others, the addictive properties also may be manipulated. T hrough an understanding of the relationship of chemical structures to biological activity, the clinician can improve the selection of drug to the specific patient. Jill T. Johnson, Pharm .D., BCPS Associ ate Professor Department of Pharmacy Practi ce Col l ege of Pharmacy Uni versi ty of Arkansas for M edi cal Sci ences

Opiate/Opioid T he use of the terms “ opiate” and “ opioid” requires clarification. Until the 1980s, the term “ opiate” was used extensively to describe any natural or synthetic agent that was derived from morphine. One could say an opiate was any compound that was structurally related to morphine. In the mid-1970s, the discovery of peptides in the brain with pharmacological actions similar to morphine prompted a change in nomenclature. T he peptides were not easily related to morphine structurally, yet their actions were like those produced by morphine. At this time, the term “ opioid,” meaning opium- or morphine-like in terms of pharmacological action, was introduced. T he broad group of opium alkaloids, synthetic derivatives related to the opium alkaloids, and the many naturally occurring and synthetic peptides with morphine-like pharmacological effects are called opioids. In addition to having pharmacological effects similar to morphine, a compound must be antagonized by an opioid antagonist, such as naloxone, to be classed as an opioid. T he neuronal-located proteins to which opioid agents bind and initiate biological responses are called opioid receptors.

Endogenous Opioid Peptides and T heir Physiological Functions Scientists had postulated for some time, based on structure–activity relationships (SARs), that opioids bind to specific receptor sites to cause their actions. It also was reasoned that morphine and the synthetic opioid derivatives are not the natural ligands for the opioid receptors and that some analgesic substance must exist within the brain. T echniques to prove these two points were not developed until the mid-1970s. Hughes et al. (1) used the electrically stimulated contractions of guinea pig ileum and the mouse vas deferens, which are very sensitive to inhibition by opioids, as bioassays to follow the purification of compounds with morphine-like activity from mammalian brain tissue. T hese researchers were able to isolate and determine the structures of two pentapeptides, T yr-Gly-Gly-Phe-Met (Met-enkephalin) and T yr-Gly-Gly-Phe-Leu (Leu-enkephalin), that caused the opioid activity. T he compounds were named enkephalins after the Greek word Kaphal e, which

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translates as “ from the head.” At about the same time as Hughes and coworkers were making their discoveries, three other laboratories, using a different assay technique, were able to identify endogenous opioids and opioid receptors in the brain (2,3,4). T hese scientists used radiolabeled opioid compounds (radioligands), with high specific activity, to bind to opioid receptors in brain homogenates (5). T hey demonstrated saturable binding (i.e., the tissue contains a finite number of binding sites that can all be occupied) of the radioligands and that the bound radioligands could be displaced stereoselectively by nonradiolabeled opioids. Discovery of the enkephalins was soon followed by the identification of other endogenous opioid peptides, including β-endorphin (6), the dynorphins (7), and the endomorphins (8). T he opioid peptides isolated from mammalian tissue are known collectively as endorphins, a word that is derived from a combination of endogenous and morphine. T he opioid alkaloids and all of the synthetic opioid derivatives are exogenous opioids. Interestingly, the isolation of morphine and codeine in small amounts has been reported from mammalian brain (9). T he functional significance of endogenous morphine remains unknown.

Opioid Peptides T he endogenous opioid peptides are synthesized as part of the structures of large precursor proteins (10). T here is a different precursor protein for each of the major types of opioid peptides (Fig. 24.1). Proopiomelanocortin is the precursor for β-endorphin. Proenkephalin A is the precursor for Met- and Leu-enkephalin. Proenkephalin B (prodynorphin) is the precursor for dynorphin and P.654 α-neoendorphin. T he pronociceptin protein has been identified and contains only one copy of the active peptide, whereas the precursor protein for the endomorphins remains to be identified. All of the pro-opioid proteins are synthesized in the cell nucleus and transported to the terminals of the nerve cells from which they are released. T he active peptides are hydrolyzed from the large proteins by processing proteases that recognize double basic amino acid sequences positioned just before and after the opioid peptide sequences.

Fig. 24.1. Precursor proteins to the endogenous opioid peptides.

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Peptides with opioid activity have been isolated from sources other than mammalian brain. T he heptapeptide β-casomorphin (T yr-Pro-Phe-Pro-Gly-Pro-Ile), found in cow's milk, is a µ opioid agonist (11). Dermorphin (T yr-D-Ala-Phe-Gly-T yr-Pro-Ser-NH2), a µ-selective peptide isolated from the skin of South American frogs, is approximately 100-fold more potent than morphine in in vitro tests (12). T he endogenous opioids exert their analgesic action at spinal and supraspinal sites (Fig. 24.2). T hey also produce analgesia by a peripheral mechanism of action associated with the inflammatory process. In the CNS, the opioids exert an inhibitory neurotransmitter or neuromodulator action on afferent pain-signaling neurons in the dorsal horn of the spinal cord and on interconnecting neuronal pathways for pain signals within the brain. In the brain, the arcuate nucleus, periaqueductal gray, and the thalamic areas are especially rich in opioid receptors and are sites at which opioids exert an analgesic action. In the spinal cord, concentrations of endogenous opioids are high in laminae 1, laminae 2, and trigeminal nucleus areas. All of the endogenous opioid peptides and the three major classes of opioid receptors appear to be at least partially involved in the modulation of pain. T he actions of opioids at the synaptic level are described in Figure 24.3. Analgesia that results from acupuncture or is self-induced by a placebo or biofeedback mechanisms is caused by release of endogenous endorphins. Analgesia produced by these procedures can be prevented by the previous dosage of a patient with an opioid antagonist. Electrical stimulation from electrodes properly placed in the brain causes endorphin release and analgesia. T his procedure is used for the “ self-stimulated” release of endorphins in patients with chronic pain who do not respond to any other medical treatment. As with exogenously administered opioid drugs, tolerance develops to all procedures that work by release of endogenous opioids.

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Fig. 24.2. Location of endogenous opioid nerve tracts in the central nervous system. Endorphins and opioid receptors in the dorsal horn of the spinal cord, thalamus, and periaqueductal gray (PAG) areas are associated with the transmission of pain signals.

Opioid Receptors T here are the three major types of opioid receptors: µ, κ (13), and δ (14). All three of the receptor types have been well characterized and cloned (15). A nomenclature adopted by the International Union of Pharmacology (IU PHAR) in 1996 classifies the three opioid receptors by the order in which they were cloned (16). By this classification, δ opioid receptors are OP 1 receptors, κ opioid receptors are OP 2 receptors, and µ opioid receptors are OP 3 receptors. T he IUPHAR approved a new nomenclature in 2000, naming the receptors as MOP-µ, DOP-δ, and KOP-κ. In current literature, however, the opioid receptors often are referred to as DOR (δ), KOR (κ), and MOR (µ). T here is evidence for subtypes of each of these receptors; however, the failure of researchers to find genomal evidence for P.655 additional receptors indicates that the receptor subtypes are posttranslational modifications (splice

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variants) of known receptor types (17). Receptor subtypes also may be known receptor types that are coupled to different signal transduction systems. T able 24.1 lists the opioid receptor types and subtypes, their known physiological functions, and selective agonists and antagonists for each of the receptors. All three of the opioid receptor types are located in human brain or spinal cord tissues, and each has a role in the mediation of pain. At this time, only µ and κ agonists are in clinical use as opioid analgesic drugs.

Fig. 24.3. Schematic representation of a δ enkephalinergic nerve terminal. (1) Pro-opioid proteins (proenkephalin A) are synthesized in the cell nucleus. (2) Pro-opioid proteins undergo microtubular transport to the nerve terminal. (3) Active endogenous opioids (E) are cleaved from the pro-opioid proteins by the action of “processing” proteases. (4) The active peptides (E) are taken up and stored in presynaptic vesicles. (5) The peptides are released when the presynaptic neuron fires. (6) The endogenous opioid peptides bind to postsynaptic receptors and activate second messenger systems. (7) For all opioid receptors, the second messenger effect is primarily mediated by a G-inhibitory (G i/ o ) protein complex, which promotes the inactivation of adenylate cyclase (AC), a decrease in intracellular cyclic-adenosine-3′,5′-monophosphate (cAMP), and finally, an efflux of potassium ions (K + ) from the cell. The net effect is the hyperpolarization of the postsynaptic neuron and inhibition of cell firing. (8). Exogenous opioids (Op), such as morphine, combine with opioid receptors and mimic the actions of E. (9) Opioid antagonists, such as naloxone (Nx), combine with opioid receptors and competitively inhibit the actions of E or Op. (10) The action of E is terminated by a membrane-bound endopeptidase [EC3.4.24.11] (enkephalinase), which hydrolyze the Gly3-Phe4 peptide bond of enkephalin. Other endopeptidases may be employed in the metabolism of different endogenous opioid peptides.

Orphan Opioid Receptor A fourth receptor has been identified and cloned (OP 4 ) based on homology with cDNA sequence of the known (µ, δ, and κ) opioid receptors (18). Despite the homology in cDNA sequence with known opioid receptors, this new receptor did not bind the classical opioid peptide or nonpeptide agonists

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or antagonists with high affinity. T hus, the receptor was called the orphan opioid receptor (NOP). In subsequent studies, two research groups found a heptadecapeptide (Phe-Gly-Gly-T hr-Gly-AlaArg-Lys-Ser-Ala-Lys-Ala-Asn-Gln) to be the endogenous peptide for the orphan opioid receptor. One of the research groups (19) named the heptadecapeptide nociceptin, because they determined that it caused hyperalgesia (nociception) after intracerebral ventricular injection into mice. T he other research group (20) named the heptapeptide orphanin FQ, after its affinity for the orphan opioid receptor and the first and last amino acids in the peptides sequence (i.e., F = Phe and Q = Gln) Nociceptin/orphanin FQ resembles dynorphin-A in structure, with the most notable difference being the replacement of T yr at the N-terminus with Phe. Conflicting results have now been published regarding the ability of nociceptin/orphanin FQ to produce hyperalgesia versus analgesia in rodent pain assay models. One study has established this compound to be a potent initiator of pain signals in the periphery, where it acts by releasing substance P from nerve terminals (21). Injection of a nociceptin/orphanin antagonist into the brains of laboratory animals results in an analgesic effect, raising hope for the use of these agents in the management of pain (22).

Identification and Activation of Opioid Receptors Identification of multiple opioid receptors has depended on the discovery of selective agonists and antagonists, the identification of sensitive assay techniques (23), and ultimately, the cloning of the receptor proteins (15). T he techniques that have been especially useful are the radioligand binding assays on brain tissues and the electrically stimulated peripheral muscle preparations. Rodent brain tissue contains all three opioid receptor types, and special evaluation procedures (computerassisted line fitting) or selective blocking (with reversible or irreversible binding P.656 agents) of some of the receptor types must be used to sort out the receptor selectivity of test compounds. T he myenteric plexus–containing longitudinal strips of guinea pig ileum contain µ and κ opioid receptors. T he contraction of these muscle strips is initiated by electrical stimulation and is inhibited by opioids. T he vas deferens from mouse contains µ, δ, and κ receptors and reacts similarly to the guinea pig ileum to electrical stimulation and to opioids. Homogenous populations of opioid receptors are found in rat (µ), hamster (δ), and rabbit (κ) vas deferentia.

Table 24.1. Opioid Receptor Types and Subtypes Receptor Type (Natural Ligand) Selective Agonists µ, mu, MOP, OP 3 (endomorphin 1) (endomorphin 2) (β-endorphin)

Agonist Properties

Selective Antagonists

Morphine

Analgesia (morphine-like)

Naloxone

Sufentanil

Euphoria

Naltrexone

DAMGO (Tyr-DAla-MePheNH-(CH 2 ) 2 OH

Increased gastrointestinal transit time

CTOP Cyprodime

PLO17 (Tyr-ProMePhe-D-Pro-NH 2 BIT (affinity label)

Immune suppression Respiratory depression

β-FNA (affinity label)

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(volume) µ 1 (high affinity)

Meptazinol Etonitazene

µ 2 (low affinity)

TRIMU-5 (Tyr-D-Ala-Gly-NH-(CH 2 ) 2 -CH-(CH 3 ) 2

κ, kappa, KOP, OP 2 (dynorphins) (β-endorphin)

Ethylketocyclazocine (EKC) Bremazocine Mr2034 dyn (1–17) Trifluadom

κ 1 (high affinity)

U-50,488 Spiradoline (U-62,066) U-69,593 PD 117302

κ2

dyn 1–17

κ3

NalBzOH

δ, delta, DOP, OP 1 (enkephalins) (β-endorphin)

DADLE (D-Ala 2 D-Leu 5 - enkephalin) DSLET (Tyr-DSer-GlyPhe-Leu-Thr) DPDPE (D-Pen 2 -

Emetic effects Tolerance Physical dependence

Analgesia Sedation Miosis Diuresis Dysphoria

Naloxonazine

TENA nor-BNI

UPHIT

Analgesia Immune stimulation Respiratory depression (rate)

ICI 174864 FIT (affinity label) SUPERFIT (affinity label)

D-Pen 5 -Convulsions (?) Enkephalin) δ2

DADLE

Naltrindole (NTI) BNTX

δ2

D-Ala 2 -deltorphin II

Naltriben (NTB) Naltrindol

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isothiocyanate (NTII)

T he signal transduction mechanism for µ, δ, and κ receptors is through G i/o proteins. Activation of opioid receptors is linked through the G protein to an inhibition of adenylate cyclase* activity. T he resultant decrease in cAMP production, efflux of potassium ions and closure of voltage-gated Ca 2+ channels causes hyperpolarization of the nerve cell (24,25), and a strong inhibition of nerve firing.

µ Opioid Receptors Endomorphin-1 (T yr-Pro-T rp-Phe-NH 2 ) and endomorphin-2 (T ry-Pro-Phe-Phe-NH 2 ) are endogenous opioid peptides with a high degree of selectivity for µ (MOP) receptors (8). A number of therapeutically useful compounds have been found that are selective for µ opioid receptors (Fig. 24.4). All of the opioid alkaloids and most of their synthetic derivatives are µ-selective agonists. Morphine, normorphine, and dihydromorphinone have 10- to 20-fold µ receptor selectivity and were particularly important in early studies to differentiate the opioid receptors. Sufentanil and the peptides DAMGO (26) and dermorphin (27), all with 100-fold selectivity for µ over other opioid receptors, frequently are used in the laboratory studies to demonstrate µ receptor-selectivity in cross-tolerance, receptor binding, and isolated smooth muscle assays. Studies with µ receptor knockout mice have confirmed that all the major pharmacological actions observed on injection of morphine (e.g., analgesia, respiratory depression, tolerance, withdrawal symptoms, decreased gastric motility, and emesis) occur by interactions with µ receptors (28). P.657

Fig. 24.4. Structures of compounds selective for µ (OP 3 ) opioid

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receptors.

Naloxone and naltrexone are antagonists that have weak (5 to 10 times) selectivity for µ receptors. Cyprodime is a selective nonpeptide µ antagonist (~ 30-fold selective for µ over κ and 100-fold selective for µ over δ) available for laboratory use (29). CT OP, a cyclic peptide analogue of somatostatin, is a selective µ antagonist (30). T here is evidence that µ 1 receptors are high-affinity binding sites that mediate pain neurotransmission, whereas µ 2 receptors control respiratory depression. Naloxoneazine is a selective inhibitor of µ 1 opioid receptors (31).

κ Opioid Receptors Ethylketazocine and bremazocine are 6,7-benzomorphan derivatives with κ opioid receptor selectivity (Fig. 24.5). T hese two compounds were used in early studies to investigate κ (KOP) receptors. T hey are not highly selective, however, and their use in research has diminished. A number of arylacetamides derivatives, having a high selectivity for κ over µ or δ receptors, have been discovered. T he first of these compounds, (±)-U50488, has a 50-fold selectivity for κ over µ receptors and has been extremely important in the characterization of κ opioid activity (32). Other important agents in this class are (±) PD-117302 (33) and (-) CI-977 (34). Each of these agents has 1,000-fold selectivity for κ over µ or δ receptors. Evidence suggests that the arylacetamides bind to a subtype of κ receptors. In general, κ agonists produce analgesia in animals, including humans. Other prominent effects are diuresis, sedation, and dysphoria. Compared to µ agonists, κ agonists lack respiratory depressant, constipating, and strong addictive (euphoria and physical dependence) properties. It was hoped that κ agonists would become useful strong analgesics that lacked addictive properties; however, clinical trials with several highly selective and potent κ agonists were aborted because of the occurrence of unacceptable sedative and dysphoric side effects. κ-Selective opioids with only a peripheral action have been shown to be effective in relieving inflammation and the pain associated with it (35). T he scientific evidence suggesting κ 1 , κ 2 , and κ 3 subtypes of κ receptors; however, the physiological effects initiated by the κ receptor subtypes are not well defined (36). T he peptides related to dynorphin are the natural agonists for κ receptors. T heir selectivity for κ over µ receptors is not very high. Synthetic peptide analogues have been reported that are more potent and more selective than dynorphin for κ receptors (37,38). T he major antagonist with good selectivity for κ receptors is nor-binaltorphimine (39). T his compound has approximately 100-fold selectivity for κ over δ receptors and an even greater selectivity for κ over µ receptors when tested during competitive binding studies in monkey brain homogenate. No medical use for a κ antagonist has been found.

δ Opioid Receptors Enkephalins, the natural ligands at δ (DOP) receptors, are only slightly selective for δ over µ receptors. Changes P.658 in the amino acid composition of the enkephalins can give compounds with high potency and selectivity for δ receptors. T he peptides most often used as selective δ receptor ligands (Fig. 24.6) 2

5

2

5

are [D-Ala , D-Leu ] enkephalin (DADLE) (40), [D-Ser , Leu ] enkephalin-T hr (DSLET ) (41), and 2

5

the cyclic peptide [D-Pen , D-Pen ] enkephalin (DPDPE) (42). T hese and other δ receptor selective peptides have been useful for in vitro studies, but their metabolic instability and poor distribution properties (i.e., penetration of the blood-brain barrier is limited by their hydrophilicity) has limited their usefulness for in vivo studies. Nonpeptide agonists that are selective for δ receptors have been reported. Derivatives of morphindoles were the first nonpeptide molecules to

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show δ selectivity in in vitro assays (43). SNC-80 is a newer and more selective δ opioid receptor agonist (44). T his compound produces analgesia after oral dose in several rodent models and side effects appear minimal. Clinical trials with SCN-80 and other nonpeptide δ receptor agonists were attempted and aborted, primarily because of the convulsant action of δ receptor agonists. Radioligand binding studies in rodent brain tissue and in electrically stimulated vas deferentia have provided evidence of δ 1 and δ 2 receptors (45). T he functional significance of this differentiation has not been determined.

Fig. 24.5. Structures of compounds selective for κ (OP 2 ) opioid receptors. (–)-Stereoisomers are the most active compounds.

Naltrindol and naltriben are highly selective nonpeptide antagonist for δ receptors (46,47). Naltrindol penetrates the CNS and displays antagonist activity that is selective for δ receptors in in vitro and in vivo systems. Peptidyl antagonists T IPP and T IPP-ψ are selective for δ receptors

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(48,49); however, their usefulness for in vivo studies and as clinical agents is limited by their poor pharmacokinetic properties. T he δ opioid receptor antagonists have shown clinical potential as immunosuppressants and in treatment of cocaine abuse.

Receptor Affinity Labeling Agents A number of opioid receptor selective affinity labeling agents (i.e., compounds that form an irreversible covalent bond with the receptor protein) have been developed (Fig. 24.7). T hese compounds have been important P.659 in the characterization and isolation of the opioid receptor types. Each of the affinity-labeling agents contains a pharmacophore that allows initial reversible binding to the receptor. Once reversibly bound to the receptor, an affinity labeling agent must have an electrophilic group positioned so that it can react with a nucleophilic group on the receptor protein. T he receptor selectivity of these agents is dependent on 1) the receptor type selectivity of the pharmacophore, 2) the location of the electrophile within the pharmacophore structure so that when bound to the receptor it is positioned near a nucleophile, and 3) the relative reactivities of the electrophilic and nucleophilic groups.

Fig. 24.6. Structures of compounds selective for δ (OP 1 ) opioid receptors.

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Fig. 24.7. A representation of the concept of affinity labeling of receptors and affinity labeling agents for opioid receptors.

Examples of important affinity labeling agents are β-CNA, which because of its highly reactive 2-chloroethylamine electrophilic group irreversibility binds to all three opioid receptor types (50). T he structurally related compound β-FNA has a less reactive fumaramide electrophilic group and reacts irreversibly with only µ receptors (51). Derivatives of the fentanyl series, FIT and

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SUPERFIT , bind µ and δ receptors, but only the δ receptor is bound irreversibly (52,53). Apparently, when these agents are bound to µ receptors, the electrophilic isothiocyanate group is not oriented in proper juxtaposition to a receptor nucleophile for covalent bond formation to occur. Incorporation of the electrophilic isothiocyanate into the structure of the highly κ receptor–selective arylacetamides has provided affinity labeling agents (UPHIT and DIPPA) for κ receptors (54,55).

Neurobiology of Drug Abuse and Addiction T he factors that drive some individuals to abuse drugs, with resultant tolerance and psychological and physical dependence, remains unknown. It has been proposed that a deficiency exists in the opioid-mediated self-reward system of individuals who have a predisposition to abuse addictive drugs (56). In the United States, the use of highly addictive drugs, such as heroin and cocaine, is treated as a crime rather than as a medical problem. New insights regarding the neurobiology of drug addiction is now providing an understanding of why individuals abuse drugs and how drug abuse and addiction can be avoided and treated.

Self-Reward Response It is now evident that all forms of drug addiction are driven by the stimulation of the brain's self-reward system (57), which originates in the ventral tegmental nucleus (VT N) and extends to the nucleus accumbens (NAC) area of the midbrain (Fig. 24.8). Self-reward is initiated by the release of dopamine (DA) from the mesocorticolimbic DA neurons originating in the VT N and stimulating D 1 and D 2 receptors in the NAC. Cocaine acts by inhibiting the reuptake of DA at nerve terminals, thus increasing the intensity and duration of the reward response. Amphetamine, methamphetamine, and similar indirect acting adrenergic stimulants cause inhibition of DA reuptake, DA release, and inhibition of monoamine oxidase–mediated mediated of DA at this site. T he µ opioid agonists work upstream in the reward neuronal system by exerting an inhibitory action on GABAergic neurons, thus removing the inhibitory GABAergic tonus on DA neurons and initiating the self-reward response. T he κ opioid agonists work at a site more downstream in the system and cause the opposite effect of the µ agonists. T he κ neurons synapse directly onto the DA nerve terminal in the NAC and exert an inhibitory effect (negative tonus) on DA release. T hus, a µ agonist will cause a self-reward and euphoric stimulus, and a κ agonist will cause an aversive and dysphoric stimulus. Alcohol (ethanol) also causes a stimulation of the self-reward system, partially by acting on the µ opioid neurons to facilitate the release of endogenous opioids P.660 (58). Nicotine, acting through nicotinic cholinergic receptors, also has been shown to stimulate the DA self-reward system (59).

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Fig. 24.8. The neurochemical basis of drug abuse and addiction. The diagram is a representation of the brain's self-reward system. According to this theory, any agent that promotes stimulation of type-1 dopamine (D 1 ) receptors in the nucleus accumbens (NCA) potentiates self-reward and has the potential to be abused. Major drugs of abuse exert their actions at various sites within the self-reward system to increase dopamine (DA) in the NCA and stimulate D 1 receptors. Site 1: Cocaine blocks DA reuptake by the DA transporter (DAT) and greatly enhances DA action at D 1 . Site 2: Amphetamine, methamphetamine, and related drugs cause DA release with the resultant stimulation of D 1 . Site 3: Opioid κ agonists exert an inhibitory effect on DA neuronal firing, resulting in a decrease in DA release and aversion in animals. Site 4: Opioid µ agonists, such as morphine and heroin, exert an inhibitory action on γ-aminobutyric acid (GABA) interneurons in the VAT, thus removing the GABAergic inhibition on DA neuronal firing. Site 5: GABA agonists, such as gabapentin, enhance DA neuronal firing and DA release, and these agents may be useful in treating or preventing drug abuse and addiction. Other abused agents, such as nicotine and cannabis, also cause an increase in DA release in the NAC, but their exact neuronal connections to the self-reward system is not yet understood.

T hus, the common driving pathway in drug addiction is the euphoria experienced when a drug is taken and the self-reward system is activated by DA release. T he self-reward response tends to be self-limiting, because feedback (adaptive) mechanisms in the nerve cells attenuate the reward delivered after prolonged or repeated activation of the system. Agents that slowly distribute to the brain have minor abuse potential, because the adaptive mechanisms in the self-reward neuronal system are able to respond quickly enough to attenuate the euphoric response. Highly abused substances tend to have high potency, full efficacy, and a fast onset of action so that the reward signal is initiated and fully activated before the adaptive process can take effect. Factors that contribute to fast onset of action are high lipophilicity of the drug and a dosing method that allows rapid distribution to the brain. Most abused drugs are highly lipophilic so that they rapidly cross the blood-brain barrier. T he dosage routes preferred by drug addicts (smoking and intravenous injection) meet the criteria for fast distribution to the brain. Of course, agents that are rapidly distributed to and absorbed by the brain also are rapidly redistributed from the brain to other body tissues. Because of the redistribution phenomenon, the intense euphoric rush experienced by the addict is short-lived and must be frequently reinduced. Repeated exposure of the reward system to the drugs activates the adaptive mechanisms, which results in desensitization (tolerance) of the system to the abused substance. T he addict must take a larger dose of the drug to get the euphoric high that she or he seeks, which results in increased tolerance and propagation of the addiction cycle.

Opioid Tolerance and Withdrawal T olerance to and withdrawal from the opioids is explained by the cellular adaptation that occurs on repeated activation of µ opioid receptors (60). When an agonist binds to the µ receptor, G i/o second messenger proteins are activated, and inhibition of adenylate cyclase occurs. Continual activation of the receptors results in an upregulation of adenylate cyclase to compensate for the decrease in cellular concentrations of cAMP. In addition, cellular mechanisms are activated that result in a decrease in the synthesis of G i/o protein subunits and an internalization of the µ

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receptor protein. T ogether, these adaptations cause a decrease in the magnitude of the opioid response to a given dose of agonist and explain the development of tolerance in the system and the need for ever-higher doses to get the same degree of euphoric response. When the nerve cells are pushed into a highly tolerant state, they have a great capacity to make cAMP because of the upregulation in adenylate cyclase; however, the capacity is held in check by inhibitory effect of the opioids on P.661 adenylate cyclase. On cessation of dosing the opioid (~ 4–6 hours with heroin), the inhibitory effect on the upregulated adenylate cyclase system is removed, and the cells overproduce cAMP. T he increase in cellular cAMP induces a number of abnormal and unpleasant effects that are recognized collectively as opioid withdrawal symptoms. T he acute phase of withdrawal lasts for days (i.e., the time required for cAMP levels and receptor mechanisms to return to a normal state). T he long-term effect of drug addiction is a learned drug-craving behavior, which can last for a lifetime and is thought to be responsible for the high incidence of stress-induced relapses into drug abuse. Interestingly, not all µ opioid agonists have the same capacity to initiate receptor internalization and downregulation, which are typical occurrences in the development of tolerance. Morphine has a high capacity to induce tolerance, whereas methadone has a much lower tolerance capacity. Clinical studies are in progress to see if coadministration of morphine and methadone will result in lower tolerance development (61).

Rehabilitation of Opioid Addiction T herapeutic programs that employ drugs in the rehabilitation of drug addicts have been in use for some time. T he best-known treatment is the use of methadone maintenance in the rehabilitation of the opioid addict. In a well-run program, daily treatment with oral methadone maintains the addicted (tolerant) state while allowing minimal euphoric/aversive mood swings, attenuates drug craving, decreases the spread of HIV (by decreasing needle sharing), and minimizes the social destructive behavior (e.g., prostitution and theft) of the addicted patient (62). Other agents, such as the µ agonist L-α-acetylmethadol (levomethadyl) and the partial µ agonist buprenorphine, can be substituted for methadone and offer the advantage of dosing every third day (63,64). T he biggest problem with addiction treatment programs is their failure to alleviate the drug-craving behavior of the recovering addict, and she or he resumes the habit of drug abuse. Evidence suggests that treatment of a detoxified opioid addict (i.e., an individual who has been weaned from opioid dependence through a methadone or other treatment program) with a long-acting opioid antagonist, such as naltrexone, can not only pharmacologically block readdiction but also curb the addict's drug-craving urge (65). Interestingly, naltrexone treatment has been shown to inhibit alcohol craving in recovering alcoholics (66). Naltrexone and buprenorphine have shown promise in treatment of cocaine abuse (67,68). A number of possible neurobiological mechanisms have been identified by which drug intervention might prevent drug abuse or aid in the recovery of the addict (Fig. 24.8). T he use of µ opioid agonists, partial agonists, and antagonists has been described in the preceding paragraph. Additional opioid-related mechanisms may be effective in the prevention of drug abuse and addiction. When a δ opioid agonist is given in combination with a µ opioid agonist, analgesia is enhanced, and there is minimal induction of tolerance and physical dependence (69). It also has been shown that administration of a µ agonist along with a δ antagonist to rodents resulted in analgesia without inducing tolerance and physical dependence (70). α-Adrenergic agonists are known to interact with many of the same neuronal systems as the opioids. T he centrally acting µ-agonist clonidine works through the same G i/o second messenger system as the opioids, and it is used clinically to inhibit withdrawal symptoms in patients addicted to opioids. T esting of the long-acting indirect GABAergic agent vigabatrin (a suicide inhibitor of GABA aminotransferase) has been proposed for the treatment of drug addiction (71). One additional area of promise is the proposal that a high-affinity, slow-onset inhibitor of the DA transporter will be effective for the

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treatment of cocaine abuse (72).

Structure–Activity Relationships of µ Receptor Agonists M orphine Morphine is the prototype opioid (T able 24.2). It is selective for µ opioid receptors. T he structure of morphine is composed of five fused rings, and the molecule has five chiral centers with absolute stereochemistry 5(R), 6(S), 9(R), 13(S) and 14(R). T he naturally occurring isomer of morphine is levo-[(–)] rotatory. (+ )-Morphine has been synthesized, and it is devoid of analgesic and other opioid activities (73). It is important to remember that a minor change in the structure of morphine (or any other opioid) will likely cause a different change in the affinity and intrinsic activity of the new compound at each of the opioid receptor types. T hus, the opioid receptor selectivity profile of the new compound may be different than the structure from which it was made or modeled (i.e., a selective µ agonist may shift to become a selective κ agonist, etc.). In addition, the new compound will have different physicochemical properties than its parent. T he different physicochemical properties (e.g., solubility, partition P.662 coefficient, and pK a ) will result in different pharmacokinetic characteristics for the new drug and can affect its in vivo activity profile. For example, a new drug (Drug A) that is more lipophilic than its parent may distribute better to the brain and appear to be more active, whereas in actuality, it may have lower affinity or intrinsic activity for the receptor. T he greater concentration of Drug A reaching the brain is able to overcome its decreased agonist effect at the receptor. T he SARs discussed in the following paragraphs describe the relative therapeutic potencies of the compounds and are a combination of pharmacokinetic and receptor binding properties of the drugs.

Table 24.2 Structure, Numbering and Selected SAR for (-)-M orphine)

T he A ring and the basic nitrogen, which exists predominantly in the protonated (ionized) form at physiological pH, are the two most common structural features found in compounds displaying opioid analgesic activity. T he aromatic A ring and the cationic nitrogen may be connected either by an ethyl linkage (9,10-positions of the B ring) or a propyl linkage (either edge of the piperidine ring that forms the D ring). T he A ring and the basic nitrogen are necessary components in every potent µ agonist known. T hese two structural features alone are not sufficient for µ opioid activity, however, and additional pharmacophoric groups are required. In compounds having rigid structures (i.e., fused A, B, and D rings), the 3-hydroxy group and a tertiary nitrogen either greatly enhance or

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are essential for activity. A summary of other important SAR features for morphine is given in T able 24.2.

Nitrogen Atom T he substituent on the nitrogen of morphine and morphine-like structures is critical to the degree and type of activity displayed by an agent. A tertiary amine usually is necessary for good opioid activity. T he size of the N-substituent can dictate the compound's potency and its agonist versus antagonist properties. Generally, N-methyl substitution results in a compound with good agonist properties. Increasing the size of the N-substituent to three to five carbons (especially where unsaturation or small carbocyclic rings are included) results in compounds that are antagonists at some or all opioid receptor types. Larger substituents on nitrogen return agonist properties to the opioid. An N-phenylethyl–substituted opioid usually is on the order of 10-fold more potent as a µ agonist than the corresponding N-methyl analogue.

Ideal Opioid T housands of derivatives of morphine and other µ agonists have been prepared and tested (74,75). T he objective of most of the synthetic efforts has been to find an analgesic with improved pharmacological properties over known µ agonists. Specifically, one would like to have an orally active drug that retains the strong analgesic properties of morphine yet lacks its ability to cause tolerance, physical dependence, respiratory depression, emesis, and constipation. T he success of this search has been limited. Many compounds that are more potent than morphine have been discovered. Also, compounds with pharmacodynamic properties different from those of morphine have been discovered, and some of these compounds are preferred to morphine for selected medical uses. T he ideal analgesic drug, however, is yet to be discovered. Research to find new centrally acting analgesics has turned away from classic µ agonists and now is focused on agents that act through other types or subtypes of opioid receptors or through nonopioid neurotransmitter systems.

3-Phenolic Hydroxy Group T he SARs of compounds structurally related to morphine are outlined in T able 24.2. A number of the structural variations on morphine have yielded compounds that are available as drugs in the United States. T he most important of these agents, in terms of prescription volume, is the alkaloid codeine. Codeine, the 3-methoxy derivative of morphine, is a relatively weak µ agonist, but it undergoes slow metabolic O-demethylation to morphine, which accounts for much of its action. Codeine also is a potent antitussive agent and is used extensively for this purpose.

Heroin T he 3,6-diacetyl derivative of morphine is commonly known as heroin. It was synthesized from morphine in 1874 and was introduced to the market in 1898 by the Friedrich Bayer Co. in Germany. T he 1906 Squibb's M ateri a M edi ca listed 10-mg tablets of heroin at $1.20 per 1,000. At the time of its introduction, heroin was described as “ preferable to morphine because it does not disturb digestion or produce habit readily.” Heroin itself has relatively low affinity for µ opioid receptors; however, its high lipophilicity compared to morphine results in enhanced penetration of the blood-brain barrier. Once in the body (including the brain), serum and tissue esterases hydrolyze the 3-acetyl group to produce 6-acetylmorphine. T his latter compound has µ agonist activity in excess of morphine. T he combination of rapid penetration by heroin into the brain after intravenous dose and rapid conversion to a potent µ agonist provides a “ euphoric rush” that makes this compound a popular drug of abuse. Repeated use of heroin results in the development of tolerance, physical dependence, and acquisition of a drug habit that often is destructive to the user and society. In addition, the use of unclean or shared hypodermic needles for self-administering heroin often results in the transmission of the HIV, hepatitis, and other infectious diseases.

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C Ring Changes in the C-ring chemistry of morphine or codeine can lead to compounds with increased activity. Hydromorphone is the 7,8-dihydro-6-keto derivative of morphine, P.663 and it is 8 to 10 times more potent than morphine on a weight basis. Hydrocodone, the 3-methoxy derivative of hydromorphone, is considerably more active than codeine.

Fig. 24.9. Diverse structural families that yield potent opioid agonists.

14α-Hydroxy-6-Keto Derivatives T he opium alkaloid thebaine can be synthetically converted to 14α-hydroxy-6-keto derivatives of

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morphine. T he 14α-hydroxy group generally enhances µ agonist properties and decreases antitussive activity, but activity varies with the overall substitution on the structure. Oxycodone, the 3-methoxy-N-methyl derivative, is about as potent as morphine when given parenterally, but its oral to parenteral dose ratio is better than that for morphine. Oxymorphone is the 3-hydroxy-N-methyl derivative, and it is 10 times as potent as morphine on a weight basis. Substitution of an N-cyclobutylmethyl for N-methyl and reduction of the 6-keto group to 6α-OH of oxymorphone gives nalbuphine, which acts through κ receptors and has approximately half the analgesic potency of morphine. Nalbuphine is an antagonist at µ receptors. Interestingly, N-allyl- (naloxone) and N-cyclopropylmethyl- (naltrexone) noroxymorphone are “ pure” opioid antagonists. Naloxone and naltrexone are slightly µ receptor selective and are antagonists at all opioid receptor types. Figure 24.9 contains some of the diverse chemical structures that produce µ agonist activity. T he structures shown in the figure illustrate that the morphine structure may be built up or broken down to yield compounds that produce potent agonist activity. Reaction of thebaine with dienophiles (i.e., Diels-Alder reactions) results in 6, 14-endo-ethenotetrahydrothebaine derivatives, which are commonly called oripavines (76). Some of the oripavine derivatives are extremely potent µ agonists. Etorphine and buprenorphine are the best known of these derivatives. Etorphine is approximately 1,000 times more potent than morphine as a µ agonist. Etorphine has a low therapeutic index in humans, and its respiratory depressant action is difficult to reverse with naloxone or naltrexone. T hus, the compound is not useful in medical practice. Etorphine (M-99) is available for use in veterinary medicine for the immobilization of large animals. T he oripavine structure–based antagonist diprenorphine is used to reverse the tranquilizing effect of etorphine. Buprenorphine, a marketed oripavine derivative, is a P.664 partial agonist at µ receptors, with a potency of 20 to 30 times that of morphine. T he compound's uses and properties are described in the section on clinically available agents.

3,4-Epoxide Bridge and the M orphinans Removal of 3,4-epoxide bridge in the morphine structure results in compounds that are referred to as morphinans. One cannot remove the epoxide ring from the morphine structure by simple synthetic means. Rather, the morphinans are prepared by total synthesis using a procedure described by Grewe (77). T he synthetic procedure yields compounds as racemic mixtures and only the levo-(–)-isomers possess opioid activity. T he dextro isomers have useful antitussive activity. T he two morphinan derivatives that are marketed in the United States are levorphanol and butorphanol. Levorphanol is approximately eight times more potent than morphine as an analgesic in humans. Levorphanol's increased activity results from an increase in affinity for µ opioid receptors and its greater lipophilicity, which allows higher peak concentrations to reach the brain. Butorphanol is a µ antagonist and a κ agonist. T he mechanism of action of the mixed agonist/antagonists is described in more detail later in this chapter.

Benzomorphans Synthetic compounds that lack both the epoxide ring and the C ring of morphine retain opioid activity. Compounds having only the A, B, and D rings are named chemically as derivatives of 6,7-benzomorphan (Fig. 24.9) or, using a different nomenclature system, of 2,6-methano3-benzazocine. T hey are commonly referred to simply as benzomorphans. T he only agent from this structural class that is marketed in the United States is pentazocine, which has an agonist action on κ opioid receptors—an effect that produces analgesia. Pentazocine is a weak antagonist at µ receptors. T he dysphoric side effects that are produced by higher doses of pentazocine result from actions at κ opioid receptors and also at σ (PCP) receptors. T he benzomorphan-derivative phenazocine (N-phenylethyl) is approximately 10 times as potent as morphine as a µ agonist and is marketed in Europe. Aminotetralins represent A- and B-ring analogues of morphine. A number of active compounds in

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this class have been described, but only dezocine, a mixed agonist/antagonist, has been marketed.

4-Phenylpiperidines Analgesic compounds in the 4-phenylpiperidine class may be viewed as A- and D-ring analogues of morphine (Fig. 24.9). T he opioid activity of these agents was discovered serendipitously. T he first of these agents, meperidine, was synthesized in 1937 by Eislab (78), who was attempting to prepare antispasmodic agents. T he compound produced an S-shaped tail (Straub tail) in cats, an effect that had been recognized as a response caused by morphine and its derivatives. Meperidine proved to be a typical µ agonist, with approximately one-fourth the potency of morphine on a weight basis. It is particularly useful in certain medical procedures because of its short duration of action because of esterases hydrolysis to a zwitterionic metabolite. Reversed esters of meperidine have greater potency, and several of these derivatives have been marketed. T he 3-methyl reversed ester derivatives of meperidine, α- and β-prodine, were available in the United States but have been removed from the market because of their low prescription volume and their potential to undergo elimination reactions to compounds that resemble the neurotoxic agent MPT P (see Chapter 25). T rimeperidine or µ-promedol, the 1,2,5-trimethyl reserved ester of meperidine, is used in Russia as an analgesic.

Anilidopiperidines Structural modification of the 4-phenylpiperidines has led to discovery of the 4-anilidopiperidine, or the fentanyl, group of analgesics (Fig. 24.9). Fentanyl and its derivatives are µ agonists, and they produce typical morphine-like analgesia and side effects. Structural variations of fentanyl that have yielded active compounds are substitution of an isosteric ring for the phenyl group, addition of a small oxygen containing group at the 4-position of the piperidine ring, and introduction of a methyl group onto the 3-position of the piperidine ring. Newer drugs that illustrate some of these structural changes are alfentanil and sufentanil. Both of these drugs have higher safety margins than other µ agonists. For unknown reasons, the compounds produce analgesia at much lower doses than is necessary to cause respiratory depression.

Diphenylheptanone In the period just before or during the Second World War, German scientists synthesized another series of open-chain compounds as potential antispasmodics. In a manner analogous to that of meperidine, animal testing showed some of the compounds to possess analgesic activity. Methadone was the major drug to come from this series of compounds (Fig. 24.9). Methadone is especially useful for its oral activity and its long duration of action. T hese properties make methadone useful in maintenance therapy for opioid addicts and for pain suppression in the terminally ill (i.e., hospice programs). Methadone is marketed in the United States as a racemic mixture, but the (–)-isomer possesses almost all of the analgesic activity. Many variations on the methadone structure have been made, but little success in finding more useful drugs in class has been achieved. Reduction of the keto and acetylation of the resulting hydroxyl group gives the acetylmethadols (see below). Variations of the methadone structure have led to the discovery of the useful antidiarrheal opioids diphenoxylate and loperamide. P.665 Propoxyphene is an open-chain compound that was discovered by structural variation of methadone. Propoxyphene is a weak µ opioid agonist having only one-fifteenth the activity of morphine. T he (+ )-isomer produces all of the opioid activity.

µ Antagonists T he SAR for µ antagonists is relatively simple if one focuses just on marketed compounds. All of the marketed, rigid-structured opioid analogues that have the 3-phenolic group and an N-allyl,

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N-cyclopropylmethyl (N-CPM), or N-cyclobutylmethyl (N-CBM) substituent replacing the N-methyl are µ antagonists (Fig. 24.5). Compounds behaving as µ antagonists may retain agonist activity at other opioid receptor types. T he only exception to this rule is buprenorphine, which has an N-CPM substituent and is a potent partial agonist (or partial antagonist) at µ receptors. Only two compounds are pure antagonists (i.e., act as antagonists at all opioid receptors). T hese compounds are the N-allyl (naloxone) and N-CPM (naltrexone) derivatives of noroxymorphone. T he 14α-hydroxyl group is believed to be important for the pure antagonistic properties of these compounds. It is not understood how the simple change of an N-methyl to an N-allyl group can change an opioid from a potent agonist into a potent antagonist. T he answer may lie in the ability of opioid receptor protein to effectively couple with signal transduction proteins (G proteins) when bound by an agonist but not to couple with the G proteins when bound by an antagonist. T his explanation infers that an opioid having an N-substituent of three to four carbons in size induces a conformational change in the receptor or blocks essential receptor areas that prevent the interaction of the receptor and the signal transduction proteins. T hose interested in an in-depth understanding of the SAR for µ receptor antagonists should be aware that properly substituted N-methyl-4-phenylpiperidines, N-methyl-6,7-benzomorphans, and even nonphenolic opioid derivatives that have good antagonist activity are known.

Structure–Activity Relationships of κ Receptor Agonists T he SAR for marketed κ agonists is somewhat related to that of µ antagonists (Fig. 24.5). All of the marketed κ agonists have structures related to the rigid opioids and N-allyl, N-CPM or N-CBM substitutions. T he compounds are all µ receptor antagonists and κ receptor agonists. T he κ agonist activity is enhanced if there is an oxygen group placed at the 8-position (e.g., ethylketazocine) or into the N-substituent (e.g., bremazocine). T he oxygen group in a N-furanylmethyl substituent also enhances κ activity. Potent and selective κ agonists that lack antagonistic properties at any of the opioid receptors are found in a number of trans-1-arylacetamido-2-aminocyclohexane derivatives. T here are not enough compounds reported in this class to develop strong trends in SARs. T he relative mode of receptor binding for the morphine-related verses the arylacetamide κ agonists is not known. Evidence exists for the selective binding of the arylacetamides to κ 1 and of the benzomorphan compounds (e.g., bremazocine) to κ 2 and κ 3 opioid receptor subtypes.

Structure–Activity Relationships of δ Receptor Agonists Structure–activity relationships for δ receptor agonists are the least developed among the opioid compounds. Peptides with high selectivity for δ receptors are known. T he SARs for some of these peptides are discussed in the following paragraphs. Nonpeptide δ selective agonists (Fig. 24.6) have been discovered, and SARs are being developed (79). Several selective δ agonists entered clinical trials but were withdrawn because of the potential convulsive (80) action of the agents.

Structure–Activity Relationships of Opioid Peptides T housands of derivatives related to the endogenous opioid peptides have been prepared since the discovery of the enkephalins in 1975 (81) (Fig. 24.1). A thorough discussion of the SAR of these peptides would be a major task; however, some major trends have emerged and easily can be discussed. Some selected general SAR points for peptide opioids are: 1. All of the endogenous opioid peptides, except for the endomorphans, have Leu- or Met-enkephalin as their first five amino acid residues. 2. T he tyrosine at the first amino acid residue position of all the endogenous opioid peptides is essential for activity. Removal of the phenolic hydroxyl group or the basic nitrogen (amino

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terminus group) will abolish activity. T he T yr 1 free amino group may be alkylated (methyl or allyl groups to give agonists and antagonists), but it must retain its basic character. T he 1

structural resemblance between morphine and the T yr group of opioid peptides is especially obvious. 1

3. In addition to the phenol and amine groups of T yr , the next most important moiety in the enkephalin structure is the phenyl group of Phe 4 . Removal of this group or changing its distance from T yr 1 results in full or substantial loss in activity. 4. T he enkephalins have several low-energy conformations, and different conformations likely are bound at different opioid receptor types and subtypes. 5. T he replacement of the natural L-amino acids with unnatural D-amino acids can make the peptides resistant to the actions of several peptidases that generally rapidly degrade the natural endorphins. T he use of a D-Ala in place of Gly 2 has been P.666 especially useful for protecting the peptides from the action of nonselective aminopeptidases. T he placement of bulky groups into the structure (e.g., the addition of N-Me to Phe 4 ) also will slow the action of peptidases. When evaluating new peptides for opioid activity, it often is difficult to tell if changes are caused by metabolic stability or receptor affinity. 6. Conversion of the terminal carboxyl group into an alcohol or an amide will protect the compound from carboxy peptidases. 7. Any introduction of unnatural D- or L-amino acids or bulky groups into the enkephalin structure will affect its conformational stability. T he resultant peptides will have an increase or decrease in affinity for each of the opioid receptor types. T he right combination of increases and/or decreases in receptor affinity will result in selectivity for a receptor type. 8. Structural changes that highly restrict the conformational mobility of the peptides (e.g., substitution of proline for Gly 2 or cyclization of the peptide) have been especially useful for the discovery of receptor-selective opioid peptides. For examples of the above SARs, see the structures of the peptides given in Figures 24.4, 24.5, and 24.6.

Enkephalin Peptides T he effect of lengthening the amino acid chain of the enkephalin peptides deserves special consideration. As previously noted, the endogenous opioids found in mammals most often have Leu- or Met-enkephalin at their amino terminus end. Lengthening the carboxyl terminus can give the peptide greater affinity or selectivity for an opioid receptor type. T his effect can be illustrated by the dynorphins, for which incorporation of the basic amino acids (especially Arg 7 ) into the C-terminus chain results in a marked increase in affinity for κ receptors. T he message-address analogy has been used to describe this effect. T he first four amino acids [T yr-Gly-Gly-Phe] are essential for peptide ligands to bind to and to activate all opioid receptor types. T he N-terminus amino acids can then be referred to as carrying the “ message” to the receptors. Adding additional amino acids to the C-terminus can “ address” the message to a specific receptor type. T he additional peptide chain may be affecting the address (selectivity) by providing new and favorable binding interactions to one of the receptor types. Alternatively, the additional peptide could be inducing a conformational change in the message portion of the peptide that favors interaction with one of the receptor types.

Metabolism of T he Opioids

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Knowledge of the metabolism of the opioid drugs is essential to the understanding of the uses of these agents. T he poor oral versus parenteral dose ratio (~ 6:1) of morphine is caused by extensive first-pass metabolic conjugation of morphine at the phenolic (3-OH) position (Fig. 24.10). T he metabolism occurs predominantly in the liver and requires the action of sulfotransferase or glucuronyltransferase enzymes. T he conjugates have low activity and poor distribution properties. T he 3-glucuronide does undergo enterohepatic cycling, which explains the need for high initial oral doses of morphine, followed by lower maintenance doses. Glucuronidation of morphine at the 6-OH position results in the formation of an active metabolite. Morphine is also N-demethylated to give normorphine, a compound that has decreased opioid activity and decreased bioavailability to the CNS. Normorphine undergoes N- and O-conjugations and excretion. Geriatric patients metabolize morphine at a slower rate than normal adult patients; thus, they are likely to show greater sensitivity to the drug and require lower doses.

Fig. 24.10. Metabolism of morphine and codeine.

In human subjects, approximately 10% of an oral dose of codeine is O-demethylated by CYP2D6 to

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produce morphine. T he morphine produced as a metabolite of codeine is essential for the analgesic effect. A significant portion of the American population (8–10%) lacks CYP2D6, and these individuals do not experience analgesia P.667 when dosed with codeine (82). T he antitussive activity of codeine is produced by the unmetabolized drug at nonopioid receptors and is not affected by the lack of CYP2D6. T he bioactivation of codeine (versus the bioinactivation of morphine) results in an oral:parenteral dose ratio for codeine of 1.5:1; however, codeine is seldom given parenterally because of its strong effect to release histamine from mast cells.

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Fig. 24.11. Metabolism of methadone and levomethadyl (LAAM).

Other rigid-structured opioid analogues undergo routes of metabolism similar to that of morphine. T he amount of first-pass 3-O-conjugation varies from compound to compound; thus, the relative oral:parenteral dosages of the agents will vary. In general, compounds that are more potent and lipophilic than morphine (e.g., levorphanol) tend to have better oral activity. Compounds with N-alkyl groups larger than methyl get N-dealkylated as a major route of inactivation. T he short duration of action of meperidine is the result of rapid metabolism. Plasma esterases cleave the ester bond to leave the inactive zwitterionic 4-carboxylate derivative. Meperidine also undergoes N-demethylation to give normeperidine. Normeperidine has little analgesic activity, but it contributes significantly to the toxicity of meperidine. T he metabolism of methadone, as outlined in Figure 24.11, is important to its action. T he major route of inactivation results from N-demethylation and cyclization of the secondary amine into an inactive pyrrole derivative. If the keto group is reduced by alcohol dehydrogenase to give methadol, the demethylation product can no longer cyclize to the pyrrole derivatives. Methadol is less active than methadone as an analgesic, but the N-demethylation products of methadol, normethadol and dinormethadol, are active analgesics with increased half-lives compared to that of methadone. T he buildup of these metabolites is responsible for the long duration of action and the mild, prolonged withdrawal symptoms associated with methadone. Levo-α-acetylmethadol (LAAM, levomethadyl acetate) is longer acting than methadone. Its slow onset of action P.668 after oral dose (and the isolation of at least three active metabolites) suggests that LAAM itself is a pro-drug. T he relative contributions of LAAM and its active metabolites to the analgesic and addition maintenance properties in humans have not been determined. It is clear that a 75- to 100-mg oral dose of this agent will suppress withdrawal symptoms in opioid addicts for 3 to 4 days.

µ Opioid Receptor Models A number of models have been proposed to represent the bonding interactions of agonists at µ opioid receptors. T hese models are “ reflections” of complementary bonding interactions of µ agonists to the receptor as revealed from SAR studies. Beckett and Casy (83) published the first such receptor drawing in 1954. T hey studied the configurations and conformations of the µ agonists known at that time and proposed that all opioids could bind to the template (receptor model) shown in Figure 24.12. T he model presumed that nonrigid opioids (e.g., meperidine and methadone) took a shape like that of morphine when binding to the receptor. It soon became apparent that the most stable conformations of meperidine and methadone were not able to be superimposed on the structure of morphine. New compounds that could not assume the shape of morphine also were being discovered, and it became apparent that the Beckett and Casy model could not explain the activity of all µ agonists. In the mid-1960s, Portoghese (84) attempted to correlate the structures and analgesic activities of rigid and nonrigid opioids that contained the same series of N-substituents. He argued that if all opioids bound the receptor in the same conformation, then a substituent at a like position on any of the compounds should fall on the same surface area of the receptor. One would expect the same structural modification on any opioid structure to give the same type and degree of bonding interaction and, thus, the same contribution to analgesic activity. Portoghese found that parallel changes of the N-substituent on rigid (morphine, morphinan, or benzomorphan) analgesic parent structures gave parallel changes in activity. T his finding supported the notion that rigid-structured opioid compounds bound to the receptor for analgesia in the same manner. When the same test

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was applied to nonrigid (meperidine-like) opioid structures, however, varying the N-substituent did not produce an activity change that paralleled that seen for the rigid-structured series. Apparently, the N-substituents in the rigid and nonrigid opioid series were falling on different surfaces of a receptor and, thus, making different contributions to analgesic activity. Portoghese concluded that the rigid and nonrigid series of compounds either were binding to different receptors or were interacting with the same receptor by different binding modes. He introduced the bimodal receptor binding model (Fig. 24.13) as one possible explanation of the results. Later, it was discovered that the activity of the rigid opioid compounds (Series 1) was enhanced by a 3-OH substituent on the aromatic ring, whereas a like substituent in some nonrigid opioids (Series 2) caused a loss of activity. Again, like substituents produced nonparallel changes in activity, indicating that the aromatic rings in the two series were not binding to the same receptor site. T o provide an explanation for these results, the bimodal binding model was modified to incorporate the structure of the enkephalin (Fig. 24.14) (85). T he rigid-structured opioids that benefit from the inclusion of a phenolic P.669 hydroxyl group were proposed to bind the µ receptor in a manner equivalent to the tyrosine (T yr 1 or T -subsite) of enkephalin. T he nonrigid-structure opioids, which lose activity on introduction of a phenolic hydroxyl group into their structure, were proposed to interact with the receptor in a manner equivalent to the phenylalanine (Phe 4 or P-subsite) of enkephalin. T he free amino group of T yr 1 occupies the anionic binding site of the receptor that is the common binding point of both opioid series. T his model closely resembles original bimodal binding proposal.

Fig. 24.12. A representation of the original model for the opioid receptor as proposed by Beckett and Casy (83). The morphine structure would have to rotate 180º about a vertical axis before it could bind to the receptor site. The model is only good for µ-selective agents.

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Fig. 24.13. A representation of the bimodal binding model of the µ opioid receptor as proposed by Portoghese (84). Different opioid series bind to different surface areas of the same receptor protein.

Fig. 24.14. A representation of the enkephalin binding site of µ opioid receptors (85). (A) An enkephalin bound to the receptor. (B) Morphine binding the receptor by utilizing the T-subsite (i.e., the tyrosine-binding site). (C) A meperidine-type opioid binding the receptor by utilizing the P-subsite (i.e., the phenylalanine-binding site).

+

Models that attempt to explain the ability of Na to decrease the binding affinity of agonists, but not antagonists, for the opioid receptor have been made (86). Sodium ions also protect the receptor

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from alkylation by nonselective alkylating agents. T he Beckett and Casy model was extended to explain the increased potency of the oripavine analogues, such as etorphine (Fig. 24.15) (76). T he affinity of the oripavines for the µ opioid receptor can be much greater than that seen for morphine. It is likely that the increased receptor affinity comes from auxiliary drug–receptor bonding interactions similar to those depicted in the receptor model. Martin (87) has proposed a receptor model for κ opioid receptors. Martin's model considers just the binding of rigid morphine-related opioid structures. T he relationship of how rigid morphine-related agents interact with the κ receptor compared to the arylacetamide κ agonist derivatives has not been well studied. Models for the δ opioid receptors have not been proposed.

Specific Drugs µ Agonists Structures of specific drugs and compounds are given in T able 24.3.

(–)-Morphine Sulfate Morphine sulfate is the analgesic used most often for severe, acute, and chronic pain. Morphine is a µ agonist and is a Schedule II drug. It is available in intramuscular, subcutaneous, oral, rectal, epidural, and intrathecal dosage forms. T he epidural and intrathecal preparations are formulated without a preservative. Morphine is three- to six times more potent when given intramuscularly than when given orally. T he difference in activity results from extensive first-pass 3-O-glucuronidation of morphine—an inactive metabolite. T he half-life of intramuscularly dosed (10 mg) morphine is approximately 3 hours. T he dose of morphine, by any dosage route, must be reduced in patients with renal failure and in geriatric and pediatric patients. T he enhanced effects of morphine in renal failure is believed to be caused by a buildup of the active 6-glucuronide metabolite, which depends on renal function for elimination. T he analgesic effect of orally dosed morphine can equal that obtained by parenteral administration, if proper doses are given. When given orally, the initial P.670 dose of morphine is usually 60 mg, followed by maintenance doses of 20 to 30 mg every 4 hours. Addiction to clinically used morphine by the oral route generally is not a problem.

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Fig. 24.15. A representation of the binding of an oripavine-type analgesic to the µ opioid receptor (76). The hydroxyl and phenyl groups in the side chain are believed to form additional bonding interactions with the receptor compared to the Beckett and Casy receptor model.

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Table 24.3. M arketed Drugs that are Derivatives of M orphine

Overdoses of morphine, as well as all µ agonists in this section, can be effectively reversed with naloxone.

(–)-Codeine Phosphate Codeine is used extensively to treat moderate to mild pain. Codeine is a weak µ agonist, but approximately 10% of an oral dose (30–60 mg) is metabolized to morphine (see the section on metabolism in this chapter), which contributes significantly to its analgesic effect. T he plasma half-life of codeine after oral dose is 3.5 hours. T he dose of codeine needed to produce analgesia after parenteral dose causes releases of histamine sufficient to produce hypotension, pruritus, and other allergic responses. T hus, administration of codeine by parenteral route is not recommended.

(–)-Hydromorphone Hydrochloride (Dilaudid) Hydromorphone is a potent µ agonist (eight times greater than morphine) that is used to treat severe pain. It is available in intramuscular, intravenous, subcutaneous, oral, and rectal dosage forms. Like all strong µ agonists, hydromorphone is addicting and is a Schedule II drug. Hydromorphone has an oral:parenteral potency ratio of 5:1. T he plasma half-lives after parenteral and oral dosage are 2.5 and 4 hours, respectively.

(–)-Oxymorphone Hydrochloride (Numorphan) Oxymorphone is a potent µ agonist (10 times greater than morphine) that is used to treat severe pain. It is used by intramuscular, subcutaneous, intravenous, and rectal routes of administration. T he intramuscular dose of oxymorphone (1 mg) has a half-life of 3 to 4 hours. It is a Schedule II drug. Oxymorphone, because of its 14-hydroxy group, has low antitussive activity.

(–)-Lev orphanol Bitartrate (Lev o-Dromoran) Levorphanol is a potent µ agonist (approximately sixfold greater than morphine), and its uses, side effects, and physical dependence liability are like those of oxymorphone or hydromorphone. Levorphanol is available in oral, subcutaneous, and intravenous dosage forms. T he oral dose of levorphanol is approximately twice the parenteral dose. T his drug is unique among the µ agonists in that its analgesic duration of action is 4 to 6 hours, whereas its clearance half-life is 11.4 hours. T hus, effective analgesic doses of this agent can lead to a buildup of the drug in the body and result in excessive sedation.

(–)-Hydrocodone Bitartrate (Lortab, Vicodin in Combinations with Acetaminophen) Hydrocodone is a Schedule III drug that is used to treat moderate pain. It is used mostly by the oral route (5-mg tablets and solutions) in combination with acetaminophen. T he compound has good oral bioavailability and is metabolized in a manner similar to codeine.

(–)-Oxycodone Hydrochloride (Roxicodone, Oxycontin Sustained Release; and Percocet, Percodan, Tylox; in Combinations) Oxycodone is about equipotent with morphine, but because of the 3-OCH group, it has a much lower oral:parenteral dose ratio. T hus, oxycodone is used orally to treat severe to moderate pain. It is a Schedule II drug as a single agent and when combined in strong analgesic mixtures. Oxycodone has a plasma half-life of approximately 4 hours and requires dosing every 4 to 6 hours.

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Metabolism of this agent is comparable to that of codeine.

Meperidine Hydrochloride (Demerol)

Meperidine is a µ agonist with approximately one-tenth the potency of morphine after intramuscular dose. Meperidine produces the analgesia, respiratory depression, and euphoria caused by other µ opioid agonists, but it causes less constipation and does not inhibit cough. When given orally, meperidine has 40 to 60% bioavailability because of significant first-pass metabolism. Because of the limited bioavailability, it is one-third as potent after an oral dose compared to a parenteral dose. Meperidine has received extensive use in obstetrics because of its rapid onset and short duration of action. When it is given intravenously in small (25-mg) doses during delivery, the respiratory depression in the newborn child is minimized. Meperidine is used as an analgesic P.671 in a variety of nonobstetric anesthetic procedures. Meperidine is extensively metabolized in the liver, with only 5% of the drug being excreted unchanged. Prolonged dosage of meperidine may cause an accumulation of the metabolite normeperidine (see the section on metabolism in this chapter). Normeperidine has only weak analgesic activity, but it causes CNS excitation and can initiate grand mal seizures. It is recommended that meperidine be discontinued in any patient who exhibits signs of CNS excitation. Meperidine has a strong adverse reaction when given to patients receiving a monoamine oxidase inhibitor. T his drug interaction has been seen recently in patients with Parkinson's disease taking the monoamine oxidase–selective inhibitor selegiline (Eldepryl). T he elimination half-life of meperidine is 3 to 4 hours, and it can double in patients with liver disease. Acidification of the urine will cause enhanced clearance of meperidine, but there is a lesser effect on the clearance of the toxic metabolite normeperidine.

(±)Tramadol HCl (Ultram)

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T he analgesic activity of tramadol is attributed to a synergistic effect caused by the opioid activity of the (+ )-isomer and the neurotransmitter reuptake blocking effect of the (–)-isomer. T he (+ )-isomer possesses weak µ opioid agonist activity equivalent to approximately 1/3,800 that of morphine. T he O-desmethyl metabolite (CYP2D6) of (±)-tramadol has improved µ opioid activity equivalent to 1/35 that of morphine. Affinity for both δ and κ receptors is improved. Despite its higher opioid potency, the contribution of O-desmethlytramedol to the overall analgesic effect has been questioned but not well studied. Individuals who lack CYP2D6 or are taking a CYP2D6 inhibitor have a reduced effect to tramadol (88). T he fact that naloxone causes a decrease in the analgesic potency of tramadol argues strongly for an opioid component to the analgesic activity. (–)-T ramadol possesses only 1/20 the opioid activity of its (+ )-isomer, but it has good activities for inhibition of norepinephrine (K i = 0.78 µM) and serotonin (K i = 0.99 µM) reuptake. T ramadol's neurotransmitter reuptake activity is approximately 1/20 that of imipramine, a tricyclic antidepressant agent that is used widely in pain management. Although none of the individual pharmacological activities of tramadol is impressive, they interact to give a synergistic analgesic effect that is clinically useful. T ramadol has been used in Europe since the 1980s and was introduced to the U.S. market in 1995. T he drug is nonaddicting and, thus, is not a scheduled agent. In addition, tramadol does not cause respiratory depression or constipation.

(±)-Methadone Hydrochloride (Dolophine Hydrochloride)

Methadone is a synthetic agent with about the same µ opioid potency as morphine. T he drug is used as a racemic mixture in the United States, but nearly all of the activity is caused by the

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R-(–)-isomer. Methadone's usefulness is a result of its greater oral potency and longer duration compared to most other µ agonists. When given orally, a 20-mg dose given every 8 to 12 hours can provide effective analgesia. Methadone is an excellent analgesic for use in patients with cancer, and it often is used in hospice programs. Oral doses of 40 mg are commonly used for 24-hour suppression of withdrawal symptoms (addiction maintenance) in opioid addicts. When given parenterally in doses of 2.5 to 10 mg, methadone (Schedule II drug) has all the effects of morphine and other µ agonists. T he metabolism of methadone is extremely important in determining its long duration of action (see the section on metabolism in this chapter). T he elimination of methadone is dependent on liver function and urinary pH. T he typical half-life is 19 hours. When urinary pH is raised from normal values of 5.2 to 7.8, the half-life becomes 42 hours. At the higher pH, a lower percentage of methadone exists in the ionized form, and there is more renal reabsorption of the drug. T he metabolism of methadone by liver enzymes is extensive, and there are at least two active metabolites. CYP3A4 is the major enzyme catalyzing methadone metabolism. Enzyme inducers (e.g., phenytoin and rifampin) can lead to the initiation of opioid withdrawal symptoms in patients using methadone for maintenance of addiction. T oxic concentrations of methadone can accumulate in patients with liver disease, in geriatric patients with a decreased oxidative metabolism capacity, or in patients taking an inhibitor of CYP3A4 (e.g., nifedipine, diazepam, and fluvoxamine). Methadone is a good drug for maintenance of addiction, but it is not ideal. Methadone requires once-a-day dosing, usually at a clinic, to suppress withdrawal symptoms. Once-a-day dosing is expensive and, sometimes, logistically difficult to achieve. Levomethadyl acetate is available and is used in some treatment programs to overcome the problems of methadone. Levomethadyl acetate is more potent than methadone, and it has a longer duration of action. A single oral dose of this agent can suppress abstinence withdrawal for up to 3 days. Both P.672 methadone and levomethadyl are associated with rare induction of cardiac arrhythmias through increases in the QT interval.

Propoxyphene Hydrochloride or Napsylate (Darv on, Dolene, Darv on-N & Generics)

Propoxyphene is a weak µ agonist that is used as a single agent and in mixtures with nonsteroidal anti-inflammatory agents to treat mild or moderate pain. T he active (+ )-isomer has (2S,3R) absolute configuration. Propoxyphene is only available in oral dosage forms. Propoxyphene has approximately one-twelfth the potency of morphine, and most studies show it to be equally or less effective than aspirin as an analgesic. Doses of propoxyphene that approach the analgesic efficacy of morphine are toxic. Propoxyphene's popularity results from the fact that physicians prescribe it

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for its lower abuse potential (Schedule IV) compared to that of codeine.

Fentanyl Citrate (Sublimaze; Also in Combination with Droperidol) T he structure of fentanyl and related compounds are given in T able 24.4. Fentanyl is a µ agonist with approximately 80 times greater potency than morphine. Fentanyl has been used in combination with nitrous oxide for “ balanced” anesthesia and in combination with droperidol for “ neurolepalgesia.” T he advantages of fentanyl over morphine for anesthetic procedures are its shorter duration of action (1–2 hours) and the fact that it does not cause histamine release on intravenous injection.

Table 24.4. Analogues Related to Fentanyl [4-(phenylpropionamido) piperidines]

A fentanyl patch is available for the treatment of severe chronic pain. T his dosage form delivers fentanyl transdermally and provides effective analgesia for periods of up to 72 hours. In 1999, fentanyl also became available in a lollipop dose form for absorption from the oral cavity. Fentanyl's short duration of action after parenteral dose is caused by redistribution rather than by metabolism or excretion. Repeated doses of fentanyl can result in accumulation and toxicities. Elderly patients usually are more sensitive to fentanyl and require lower doses. Opioids have a wide spectrum of P-glycoprotein (P-gp) activity, acting as both substrates and inhibitors, which might contribute to their varying CNS-related effects. Although fentanyl, sufentanil, and alfentanil did not behave as P-gp substrates, they inhibited the in vitro P-gp–mediated efflux of drugs known to be P-gp transported, such as digoxin, increasing their blood levels and the potential for important drug interactions by inhibition of P-gp efflux transporter.

Sufentanil Citrate (Sufenta) Addition of the 4-methoxymethyl group and bioisosteric replacement of the phenyl with a

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2-thiophenyl on the fentanyl structure results in a 10-fold increase in µ opioid activity (T able 24.4). T he resultant compound, sufentanil, is 600 to 800 times more potent than morphine. Despite its greater sedative and analgesic potency, sufentanil produces less respiratory depression at effective anesthetic doses. Sufentanil is available in an intravenous dosage form, and it is used for anesthetic procedures. It has a faster onset and shorter duration of action than fentanyl. T he short duration is caused by redistribution from brain tissues after intravenous dosage.

Alftentanil Hydrochloride (Alfenta) Substitution of tetrazol-5-one for the thiophene ring in sufentanil results in a decrease in potency (~ 25 times that of morphine) and a decrease in the pK a of the resultant compound, alfentanil (T able 24.4). T he lower pK a of alfentanil results in a lower percentage of the drug existing in the ionized form at physiological pH. Being more un-ionized, alfentanil penetrates the blood-brain barrier faster than other fentanyl derivatives and has a faster onset and shorter duration of action. Alfentanil is 99% metabolized in the liver and has a half-life of only 1.3 hours. Alfentanil is available as an intravenous dosage form for use in ultrashort anesthetic procedures.

Remifentanil HCl (Ultiv a) Remifentanil is much like alfentanil in its pharmacodynamic effects. It is a selective µ opioid agonist with 15 to 20 times greater potency than alfentanil (T able 24.4). Remifentanil has an onset of action of 1 to 3 minutes when given intravenously. Its unique property is its rapid P.673 offset of action, which is independent of the duration of administration of the compound. T hus, it is very useful for titration of antinociceptive effect, followed by a rapid and predictable recovery time of 3 to 5 minutes. T he short duration of action is a result of the ester group, which has been rationally designed into the substituent on the piperidine nitrogen. T his ester group is rapidly hydrolyzed to the inactive carboxylic acid by serum and tissue esterases, making the drug's duration of action essentially independent of the liver or renal function of the patient. Remifentanil is used extensively for analgesia associated with general anesthesia procedures. It often is used in combination with injectable general anesthetic agents, such as midazolam or propofol.

M ixed Agonist/Antagonists (–)-Buprenorphine Hydrochloride (Buprenex)

Buprenorphine is 20 to 50 times more potent than morphine in producing an ED50 analgesic effect in animal studies; however, it cannot produce an ED100 (compared to morphine) in these tests. T hus, buprenorphine is a potent partial agonist at µ opioid receptors. It also is a partial agonist at κ

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receptors but more of an antagonist at δ receptors. Buprenorphine, at 0.4 mg intramuscular dose, will produce the same degree of analgesia as 10 mg of morphine. Because of its partial agonist properties, it has a lower ceiling on its analgesic action but also produces less severe respiratory depression. It is incapable of producing tolerance and addiction comparable to full µ agonists. In fact, buprenorphine's partial agonist action, very high affinity for opioid receptors, and high lipophilicity combine to give buprenorphine a tolerance, addiction, and withdrawal profile that is unique among the opioids. When given by itself to opioid-naive patients, little tolerance or addictive potential (Schedule 5) is observed. A mild withdrawal can occur some 2 weeks after the last dose of buprenorphine. Buprenorphine will precipitate withdrawal symptoms in highly addicted individuals, but it will suppress symptoms in individuals who are undergoing withdrawal from opioids. It effectively blocks the effect of high doses of heroin. Because of these properties, buprenorphine has been approved for office-based use in treating opioid dependence (64). It also has been reported to suppress cocaine use and addiction. Buprenorphine undergoes extensive first-pass 3-O-glucuronidation, which negates its usefulness after oral dose. It is available in parenteral and sublingual dosage forms. T he typical dose is 0.3 to 0.6 mg three times per day by intramuscular injection for analgesia or 8 mg/day as a sublingual tablet for opioid-dependence maintenance. T he duration of analgesic effect is 4 to 6 hours. After parenteral dose, approximately 70% of the drug is excreted in the feces, and the remainder appears as N-dealkylated and conjugated metabolites in the urine. Naloxone is not an effective antagonist to buprenorphine because of the latter's high binding affinity to opioid receptors.

(–)-Butorphanol Tartrate (Stadol)

Butorphanol is a strong agonist at κ opioid receptors, and through this interaction, it is five times more potent than morphine as an analgesic. T he κ agonists have a lower ceiling analgesic effect than full µ agonists; thus, they are not as effective in treating severe pain. Butorphanol is an antagonist at µ opioid receptors with approximately one-sixth the potency of naloxone. If given to a person addicted to a µ agonist, butorphanol will induce an immediate onset of abstinence syndrome. Butorphanol has a different spectrum of side effects than µ opioid analgesics. Respiratory depression occurs. T here is a lower ceiling on this effect, however, and it is not generally lethal, as is the case with high doses of µ agonists. Major side effects after normal analgesic doses are sedation, nausea, and sweating, as well as dysphoric (hallucinogenic) effects at higher doses. Butorphanol causes an increase in pulmonary arterial pressure and pulmonary vascular resistance. T here is an overall increased workload on the heart, and it should not be used in patients with congestive heart failure or to treat pain from acute myocardial infarction. Butorphanol has low

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abuse potential and is not a scheduled drug. Because of first-pass metabolism, butorphanol is not used in an oral dose form. Given parenterally, it has a plasma half-life and duration of analgesic effectiveness of 3 to 4 hours. T he outpatient use of butorphanol has been greatly increased by the introduction of a metered inhalant dosage form of the drug. T he major metabolite of butorphanol is the inactive trans-3-hydroxycyclobutyl product, which is excreted primarily in the urine.

Nalbuphine Hydrochloride (Nubain) Nalbuphine (T able 24.3) is an antagonist at µ receptors and an agonist at κ receptors. As an antagonist, it has approximately one-fourth the potency of naloxone, and it produces withdrawal when given to addicts. On a weight basis, the analgesic potency of nalbuphine P.674 approaches that of morphine. An intramuscular injection of 10 mg will give about the same degree and duration of analgesia as an equivalent dose of morphine. Side effects of nalbuphine are like those of other κ. Dysphoria is not as common as with pentazocine. Sedation is the most common side effect. Nalbuphine does not have the adverse cardiovascular properties found with pentazocine and butorphanol. Nalbuphine has low abuse potential and is not listed under the Controlled Substances Act. Nalbuphine is only available for parenteral dosage. Its elimination half-life is 2 to 3 hours. Metabolism of nalbuphine is by conjugation of the 3-OH group, and greater than 90% of the drug is excreted as conjugates in the feces.

(–)-Pentazocine Hydrochloride and Lactate (Talwin Nx and Talwin)

Pentazocine is a weak antagonist (one-thirtieth the potency of naloxone) at µ receptors and an agonist at κ receptors. Pentazocine is one-sixth as potent as an analgesic compared to morphine after parenteral doses. Pentazocine also is dosed orally and has an oral:parenteral dose ratio of approximately 2:1. It is used to treat moderate pain. T he µ antagonist properties of pentazocine are sufficient to produce abstinence signs in opioid addicts. T he side effects of pentazocine are like other κ agonists. It has a greater tendency to produce dysphoric episodes, and it causes an increase in blood pressure and heart rate similar to butorphanol. Pentazocine is a Schedule IV drug. T he major abuse of pentazocine has been its injection along with the antihistaminic drug tripelennamine (the “ T 's and blues” ). Inclusion of the antihistaminic drug reportedly causes an increase in the euphoric, while decreasing the dysphoric, effects of the pentazocine. T he manufacturers of pentazocine have attempted to thwart this use by

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including naloxone in the oral dose formulation of pentazocine. When taken orally, as intended, the naloxone has no bioavailability, and the pentazocine is able to act as normal. When the tablet is dissolved and injected, the naloxone will effectively block the opioid actions of the pentazocine. T he elimination half-life of pentazocine is approximately 4 hours after parenteral dosage and 3 hours after oral dosage. Bioavailability after oral dose is only 20 to 50% because of first-pass metabolism. Pentazocine is metabolized extensively in the liver and is excreted via the urinary tract. T he major metabolites are 3-O-conjugates and hydroxylation of the terminal methyl groups of the N-substituent. All metabolites are inactive.

Dezocine (Dulgan)

Dezocine is classified as a mixed agonist/antagonist. T he SAR of dezocine is unique among the opioids. It is a primary amine, whereas all other nonpeptide opioids are tertiary amines. Its exact receptor selectivity profile has not been reported; however, its pharmacology is most similar to that of buprenorphine. It seems to be a partial agonist at µ receptors, to have little effect at κ receptors, and to exert some agonist effect at δ receptors. On a weight basis, it is about equipotent with morphine, and like morphine, it is useful for the treatment of moderate to severe pain. It is available for intramuscular and intravenous dose. T he drug is indicated for postoperative and cancerinduced pain. Dezocine has a half-life of 2.6 to 2.8 hours in healthy patients and 4.2 hours in patients with liver cirrhosis. T he onset of action of dezocine is faster (30 minutes) than equivalent analgesic doses of morphine, and its duration of action is longer (4–6 hours). Dezocine is extensively metabolized by glucuronidation of the phenolic hydroxyl group and by N-oxidation. Metabolites are inactive and excreted mostly via the renal tract. Dezocine causes respiratory depression, but like buprenorphine, there is a ceiling to this effect. Presumably, there also is a ceiling to the analgesic effect of dezocine, but this point is not well documented. Dezocine has lower affinity for µ receptors than buprenorphine, allowing its respiratory depressant effect to be readily reversed by naloxone. T he major side effects of dezocine are dizziness, vomiting, euphoria, dysphoria, nervousness, headache, pruritus, and sweating. Normal volunteers and recovered addicts report the subjective effects of single doses of dezocine to be like morphine. Because of the partial agonist mechanism of dezocine, one would not expect it to have a high abuse potential.

Opioids Used as Antidiarrheal Agents Structure modification of 4-phenylpiperidines has led to the discovery of opioid analogues that are

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used extensively as antidiarrheal agents. Opioid agonists that act on µ and δ receptors have a strong inhibitory action on the peristaltic reflex on the intestine. T his action occurs because endogenous opioid tracts innervate the intestinal wall, where they synapse onto cholinergic neurons. When opioids are released onto cholinergic neurons, they inhibit the release of acetylcholine and, thus, inhibit peristalsis. Any µ agonist used in medicine causes constipation as a side effect. Most µ agonists are not used as P.675 antidiarrheal agents because of their potential for abuse and addiction. Opium tincture and camphorated opium tincture (Paregoric) have long been used as effective antidiarrheal agents. T he bad taste of these liquid preparations and their abuse potential (Schedule II and III, respectively) serve to limit their use and to favor newer agents. Codeine sulfate or phosphate salt, as a single agent, is sometimes used for the short-term treatment of mild diarrhea. Synthetic agents that are structural combinations of meperidine and methadone are used extensively as antidiarrheal agents. Structures and uses of these agents are given below.

Diphenoxylate HCl with Atropine Sulfate (Lomotil)

Diphenoxylate HCl (2.5 mg) and atropine (0.025 mg) are combined in tablets or 5 mL liquid and are used effectively as symptomatic treatment for diarrhea. T he typical dose is two tablets or 10 mL every 3 to 4 hours. T he combination with atropine enhances the block of acetylcholine-stimulated peristalsis, and the adverse effects of atropine helps to limit the abuse of the opioid. T he combination is Schedule V under the Controlled Substances Act. Diphenoxylate itself has low µ opioid agonist activity. It is metabolized rapidly by ester hydrolysis to the zwitterionic free carboxylate (difenoxin), which is five times more potent after oral dosing. T he zwitterionic properties of difenoxin probably limits its penetration into the CNS and explains the low abuse potential of this agent. High doses of diphenoxylate (40–60 mg) will cause euphoria and addiction.

Difenoxin HCl with Atropine Sulfate (Motofen) Difenoxin, the active metabolite of diphenoxylate (as described above), also is used as an antidiarrheal agent. T ablets contain 1 mg of difenoxin and 0.025 mg of atropine sulfate. Dosage, uses, and effectiveness are similar to those of diphenoxylate.

Loperamide HCL (Imodium)

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Loperamide is a safe and effective opioid-derived antidiarrheal agent, and it is not listed under the Controlled Substances Act. T his medication is now available as a nonprescription item in the United States. It is used extensively for traveler's diarrhea. It exerts its antidiarrheal effects through interaction with µ-opiate receptors in the intestine to reduce peristalsis. Loperamide is marketed as capsules (2 mg) and liquid (1 mg/5 mL) preparations. T he recommended dose is 4 mg initially and an additional 2 mg following each diarrheal stool. T he dose should not exceed 16 mg/day. It is too lipophilic to dissolve in water for an intravenous dosage form, a property that limits its abuse potential. T he compound is highly lipophilic and undergoes slow dissolution, thus limiting the bioavailability of the agent to approximately 40% of the dose. Its low oral bioavailability also can be attributed to first-pass metabolism by both CYP2C8 and CYP3A4 to its primary N-demethyl metabolite. Peak plasma levels are reached in approximately 5 hours, with an elimination half-life of approximately 11 hours. Approximately 1% of the dose is excreted into the urine unchanged. Loperamide also is a potent inhibitor of intestinal CYP3A4, increasing the intestinal absorption of other CYP3A4 substrates. T he clinically significant drug interactions of loperamide with coadministered CYP3A4 and CYP2C8 substrates or inhibitors would be limited, however, because of its two metabolic pathways. T he efflux transporter P-gp is a major determinant of the pharmacokinetics and pharmacodynamics of loperamide, a potent opiate. T he main reason that loperamide does not produce opioid CNS effects at usual doses in patients is a combination of slow dissolution, first-pass metabolism, and P-gp–mediated efflux, which prevents brain absorption, perhaps contributing to its low addiction potential. Loperamide produced no respiratory depression when administered alone, but when administered with a P-gp inhibitor, respiratory depression occurred, which could not be explained by increased plasma loperamide concentrations. T his effect demonstrates the potential for important drug interactions by inhibition of P-gp efflux transporter. T he lack of respiratory depression produced by loperamide, which allows it to be safely used therapeutically, can be reversed by a drug causing P-gp inhibition, resulting in serious toxic and abuse potential.

Enkephalinase Inhibitors as Antidiarrheal Agents Although not available in the United States, inhibitors of enkephalinase, the major enzyme for the inactivation of endogenous opioid peptides, are available in Europe and much of the world for the treatment of diarrhea. Acetorphan (racecadotril), a pro-drug of thiorphan, is a good example of a clinically useful enkephalinase inhibitor used to treat diarrhea. T he free thio group of thiorphan binds tightly to the zinc ion in the active site of the enzyme and inhibits its proteolytic action. Orally dosed acetorphan causes its antidiarrheal effect by inhibition of intestinal secretions and has a complementary effect when used in combination with loperamide, which exerts its effects by decreasing gastrointestinal transit time. P.676

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Opioid Agents Used as Cough Suppressants (Antitussives) Many of the rigid-structured opioids have cough suppressant activity. T his action is not a true opioid effect in that it is not always antagonized by opioid antagonists, the (+ )-isomers are equally effective with the analgesic (–)-isomers as cough suppressants, and the SARs for opioid analgesia and cough suppression do not parallel each other. T he 3-methoxy derivatives of morphine (codeine and hydrocodone) are nearly as effective antitussive agents as free phenolic agents. T he better oral activity and decreased abuse potential of the methoxy derivatives make them preferred as antitussive agents. Incorporation of the 14α-hydroxyl into the structure (oxycodone) greatly decreases antitussive activity. If no cough suppression is desired in a patient being treated for pain, meperidine is the preferred agent. Codeine is used extensively as a cough suppressant. It is available as a single agent or as mixtures in a variety of tablet and liquid cough suppressant formulations. As a simple agent, codeine is Schedule II, and in mixtures, it is Schedule V under the Controlled Substances Act. When used properly as a cough suppressant, codeine has little abuse potential; however, cough formulas of codeine often are abused. Hydrocodone bitartrate is approximately threefold more effective on a weight basis as an oral antitussive medication compared to codeine. Hydrocodone also has greater analgesic activity and abuse potential than codeine. Hydrocodone is only available as a Schedule III prescription agent in combination formulations for cough suppression. Dextromethorphan HBr is the (+ )-isomer of the 3-methoxy form of the synthetic opioid levorphanol. It lacks the analgesic, respiratory depressant, and abuse potential of µ opioid agonists but retains the centrally acting antitussive action. Dextromethorphan is not an opioid and is not listed in the Controlled Substances Act. Its effectiveness as an antitussive is less than that of codeine. Dextromethorphan is available in a number of nonprescription cough formulations.

Case Study Victor ia F. Roche S. William Zito SJ is a 75-year-old native Hawaiian woman with debilitating degenerative arthritis of the s pine. She has been s tabilized on 50 µg/hour trans d ermal patc hes of f e ntanyl f or 2 years , and thes e patc hes have allowed her to res ume normal ac tivities of daily living, inc luding playing bridge with f riends , vis iting grandc hildren, walking, and gardening. Her quality of lif e was good until las t month, when she began having s ignif ic ant bouts of breakthrough pain that c ompromis ed both her abilities and her s p irit. She s ought help f rom her phys ic ian

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to achieve better pain c ontrol, and he pres c ribed c ompound 1, adminis tered intranas ally. SJ has jus t pres ented the pres c ription at your pharmac y. On chec king SJ 's patient prof ile, you f ind that s he is a poor CYP 2C9 metabolizer who is on low-dos e, delayed-releas e s odium valproate f or the treatment of c omplex partial s eizure dis order. Her s eizures are being well-c ontrolled on this medic ation. You evaluate the physic ian's therapeutic rec ommendation against the other analges ic s you have available in your pharmac y and prepare to make a therapeutic decis ion on SJ 's behalf . 1. I dentif y the therapeutic problem(s ) in whic h the pharmacis t's intervention may benef it the patient. 2. I dentif y and prioritize the patient-s pec if ic f ac tors that mus t be c ons idered to ac hieve the des ired therapeutic outc omes . 3. Conduc t a thorough and mec hanistic ally oriented struc ture–ac tivity analys is of all therapeutic alternatives provided in the c ase. 4. Evaluate the SA R f indings agains t the patient-s pec if ic f actors and des ired therapeutic outc omes , and make a therapeutic dec is ion. 5. Couns el your patient.

P.677

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Evans CJ. Secrets of the opium poppy revealed. Neuropharmacology 2004;47:293–299.

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Chapter 25 Drugs Used to Treat Neuromuscular Disorders: Antiparkinsonian and Spasmolytic Agents Ray m ond G. Booth

Overview of Neurom uscular Disorders Neuromuscular disorders covered in this chapter include the neurodegenerative movement disorder, Parkinson's disease, and various spasticity disorders. Parkinson's disease is characterized by debilitating tremor, rigidity, and bradykinesia. T he neuropathology (but not the etiology) of Parkinson's disease, with resulting dopamine neurotransmitter deficit, has been well defined for decades; however, pharmacotherapy of the disorder remains far from satisfactory. T he development of prophylactic and, perhaps, curative pharmacotherapy of Parkinson's disease requires advances in our understanding of the causes and pathogenesis of the disease, and this chapter reviews some current research in these areas in addition to available drugs. Spasticity disorders covered here generally are characterized by an increase in tonic stretch reflexes and flexor muscle spasms together with muscle weakness. Muscle spasticity may accompany a number of different disorders but mostly is associated with cerebral palsy, multiple sclerosis, spinal cord injury, and stroke. T hese disorders do not share a similar pathophysiology with neurodegenerative diseases, such as parkinsonism. Accordingly, drugs used to treat spastic neuromuscular disorders have mechanisms of action that differ from those used to treat Parkinson's disease. Nevertheless, most drugs described in this chapter to treat neurodegenerative or spastic neuromuscular disorders have in common the ability to reduce muscle tone by virtue of their action on the central nervous system (CNS).

Parkinson's Disease Clinical Features and Neuropathology Parkinson's disease, first described by James Parkinson in 1817, affects approximately 0.3% of the general population and 1 to 2% of individuals who are 65 years or older. T he average onset age is approximately 60 years, and the disorder presents clinically as a classic triad of signs: resting tremor, rigidity, and bradykinesia. Dementia also is a common feature of Parkinson's disease and occurs 6.6-fold more frequently in elderly patients with the disease than in elderly patients without the disease. Along with this morbidity, mortality is two- to five-fold higher among patients with Parkinson's disease than in age-matched controls, greatly reducing life expectancy among affected individuals (1). Neuropathologically, Parkinson's disease is a slowly progressive, neurodegenerative disorder of the extrapyramidal dopaminergic nigrostriatal pathway (Fig. 25.1). T he disease is characterized by the destruction of dopaminergic cells in the pars compacta region of the substantia nigra in the midbrain, leading to a deficiency of dopamine in the nerve terminals of the striatum in the forebrain (2). Degenerative changes in the pigmented nuclei of the noradrenergic locus ceruleus region also are typical, as is the appearance of intraneuronal inclusions called Lewy bodies. Neurochemically, the striatal dopamine deficiency accounts for the major motor symptoms of the disease, but loss of noradrenergic nerve terminals with concomitant reductions in norepinephrine may account for several of the nonmotor features seen in Parkinson's disease, including fatigue and abnormalities of blood pressure regulation. T he mainstay of pharmacological treatment (3),

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developed in the mid-1960s, continues to be replacement therapy with the α-amino acid L-dihydroxyphenylalanine (L-dopa), the biochemical precursor to the catecholamine neurotransmitters dopamine and norepinephrine (Fig. 25.2).

Pathophysiology Parkinson's disease primarily affects the part of the brain known as the basal ganglia, which consists of five interconnected, subcortical nuclei that span the telencephalon P.680 (forebrain), diencephalon, and mesencephalon (midbrain). T hese nuclei include the striatum (caudate and putamen), globus pallidus, subthalamic nucleus, substantia nigra pars compacta, and substantia nigra pars reticulata. T he neuroanatomical connections of the basal ganglia, cerebral cortex, and motor neurons of the spinal cord are complex, and current understanding is incomplete. However, recent models of basal ganglia function (Fig. 25.3) have helped to understand pharmacological management of Parkinson's disease (4).

Clinic a l Signific a nc e T he identification and description of Parkinson's disease in the early 1800s started us down a road to understanding and discovery that would be revolutionized almost 140 years later. T his revolution centered on elucidating the nigrostriatal pathway and its important role in facilitating motor function and movement. T hrough better characterization of the structure and function of this anatomy and an understanding of the interrelationship of GABAergic, glutamatergic, dopaminergic, and cholinergic pathways, progress has been—and continues to be—made in relation to pharmacotherapy. In addition, understanding the contributions of genetics and environment to the development of diseases affecting motor function may ultimately lead to preventative therapies and, perhaps, cures. While reading this chapter, pay particular attention to the chemistry of agents that are used to treat movement disorders and how they affect the neuropharmacology of critical pathways. Applying this same knowledge to other agents with opposing pharmacology will help to reveal their potential to cause movement disorders. Ultimately, better clinical application will occur through a thorough comprehension of neuropharmacology as it relates to motor function and movement as well as the chemical nature and pharmacology of agents that affect it. Dav id Hay e s, Pharm .D. Cl i ni cal Assi stant Professor Department of Cl i ni cal Sci ences and Admi ni strati on Uni versi ty of Houston Col l ege of Pharmacy

In normal striatum, dopamine, which is released from nerve terminals of dopaminergic cells originating in the substantia nigra, modulates the activity of inhibitory γ-aminobutyric acid (GABA) neurons. In turn, striatal GABAergic neurons, through a series of complex “ direct” and “ indirect” neuronal pathways, modulate neuronal outflow to the thalamus, which provides excitatory (glutamatergic) input to the motor cortex. In the direct pathway are two sequential inhibitory GABAergic links that provide input directly to the thalamus. T he first set of striatal GABAergic neurons in the direct pathway contains a predominance of excitatory dopamine D 1 -type receptors. T hus, the net effect of dopamine D 1 -mediated stimulation of striatal GABA neurons in the direct pathway is increased excitatory outflow from the thalamus to the motor cortex (Fig. 25.3). T he indirect pathway uses two sequential GABAergic links, like the direct pathway, that are followed

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by an excitatory glutamatergic link and another inhibitory GABAergic input to the thalamus. T he first set of striatal GABAergic neurons in the indirect pathway contains a predominance of inhibitory D 2 -type receptors; thus, the net effect of dopamine D 2 -mediated modulation of striatal GABAergic neurons in the indirect pathway is to reduce excitatory outflow from the thalamus to the motor cortex (Fig. 25.3). In the normal condition, the direct pathway is dominant, but in Parkinson's disease, the reduced levels of striatal dopamine negates this preference, and the indirect pathway becomes more apparent, with a net effect of decreased excitatory input to the motor cortex (Fig. 25.3).

Fig. 25.1. Some dopaminergic pathways in the brain. The nigrostriated pathway (A9 cell bodies in substantia nigra; nerve terminals in striatum) is degenerated in Parkinson's disease.

Etiology Although the neuropathology is well defined, the cause of Parkinson's disease is unknown. T he development of effective pharmacotherapeutic and prophylactic therapy will require advances in our understanding of the etiology of the disease. Currently, there are several, sometimes convergent theories regarding the cause of P.681 Parkinson's disease: “ proteolytic stress,” which recently has been characterized in connection with rare Parkinson's disease genetic mutations as well as environmental and/or endogenous neurotoxicants, mitochondrial dysfunction, and oxidative metabolism—any and all of which may lead to “ oxidative stress.” T his section describes these and some alternative proposals regarding the etiology of Parkinson's disease.

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Fig. 25.2. Important pathways in the biosynthesis and metabolism of levodopa. Major pathways are shown by heavy arrows. COMT, catecholO-methyltransferase; MAO, monoamine oxidase, PNMT, phenylethanolamine N-methyltransferase.

Several neurodegenerative disorders (including the movement disorder Huntington's disease) are genetically determined; thus, researchers have investigated a possible genetic influence in Parkinson's disease. Epidemiological studies have found that apart from age, a family history of Parkinson's disease is the strongest predictor of an increased risk of the disorder (5,6); however, the role of shared environmental exposure in families must be considered. One familial form of the disease is characterized by mutations in the α-synuclein gene, originally reported in a single large Italian family, three smaller Greek families, and a German family (7,8). α-Synuclein is a highly conserved, abundant, 140-amino-acid protein that is expressed mainly in presynaptic nerve terminals in the brain; however, its function is unclear (9). Aggregation of α-synuclein protein leads to pathological inclusions (synucleinopathy) P.682 that characterize many neurodegenerative disorders, including Parkinson's disease (10).

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Fig. 25.3. Striatal dopaminergic stimulation of the direct and indirect pathways modulates the thalamus excitatory outflow to the motor cortex.

Mutations in four other genes, parkin, DJ-1, PINK1, and LRRK2 codes for dardarin protein, are unequivocally associated with the development of familial Parkinson's disease (11), and a number of other mutations also are implicated. It is proposed that such mutations may lead to excessive production of damaged proteins and/or dysfunction of protein clearance mechanisms in the brain (12). In normal physiological conditions, damaged proteins usually are degraded and cleared by the ubiquitin–proteasome system (UPS). Increased production of damaged proteins and/or decreased UPS-mediated degradation and clearance of proteins may lead to protein aggregation and proteolytic stress. Proteolytic stress affects a variety of cellular structures and processes, and it can lead to cell death (13,14). In cases of familial Parkinson's disease associated with LRRK2/dardarin mutations, protein accumulation and Lewy body formation have been documented in postmortem analysis (15), but such data currently are unavailable for the parkin (a UPS enzyme), DJ-1, and PINK-1 mutations. Meanwhile, several studies have failed to detect mutations in the α-synuclein gene in a large sampling of families (16,17), and studies using both identical and heterozygous twins, which provide a rigorous genetic analysis, have failed to reveal a genetic component of Parkinson's disease (18). T hus, although compelling evidence exists for apparently rare cases of genetically linked Parkinson's disease, primarily involving early onset of the disorder, the majority of cases are not associated with known genetic mutations and are considered to be sporadic (19). It should be noted, however, that synucleinopathy has been detected in sporadic cases of Parkinson's disease (20), suggesting that hypotheses involving protein aggregation may be relevant to the etiology of the more common forms of the disease. Moreover, although Parkinson's disease associated with genetic mutation is rare (< 10% of cases), the study of these cases has facilitated understanding of the molecular pathways that lead to neurodegeneration, especially involving dopaminergic neurons. In contrast to Parkinson's disease forms that are associated with genetic mutations, little evidence suggests that the disorder is autoimmune-related (21). Likewise, although a form of parkinsonism associated with influenza virus–induced encephalitis did occur in a 1918 epidemic, recent studies indicate no evidence for a communicable infectious etiology (22). Strong evidence, however, suggests that some cases of Parkinson's disease may be caused by environmental toxicants. For instance, manganese miners in South America have a high risk of developing the

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disease (23), and in the major agricultural region of the Quebec province of Canada, a remarkably high correlation between the incidence of Parkinson's disease and the sale of pesticides is documented (24). An interesting link to the environment and/or endogenous milieu is that the incidence of Parkinson's disease is lower in cigarette smokers than in nonsmokers (25). It has been proposed that something in cigarette smoke may protect against a toxicant (environmental or endogenous) relevant to parkinsonian neuropathology. For example, the carbon monoxide in cigarette smoke may detoxify free radicals from environmental or endogenous sources. It also has been suggested that compounds in cigarette smoke, or the metabolites of these compounds, may inhibit monoamine oxidase (MAO)-B activity (26), the main enzyme responsible for metabolism of monoamine neurotransmitters, such as dopamine. In fact, dopamine itself has been implicated in the disease process through production of chemically reactive oxidation products, suggesting that endogenously formed substances may be etiologic factors in Parkinson's disease (27). For example, the MAO-catalyzed oxidation of the monoamine neurotransmitters (dopamine, norepinephrine, and serotonin) generates hydrogen peroxide (see Equation 1 in Fig. 25.4), which can undergo a redox reaction with superoxide in the Haber-Weiss reaction (28) to form the extremely cytotoxic hydroxy radical (see Equation 2 in Fig. 25.4). Moreover, the auto-oxidation of dopamine to the corresponding electrophilic semiquinone and quinone (Fig. 25.4) species has received attention, because these oxidation P.683 products also are cytotoxic (29). Manganese ion can catalyze oxidation of dopamine, and the resulting semiquinone and quinone species have been implicated in manganese neurotoxicity (30). T he auto-oxidation of dopamine also leads to the formation of the polymeric black pigment neuromelanin (29). T he physiologic role of neuromelanin is poorly understood. T he pigment is increasingly deposited in catecholaminergic neurons with advancing age, however, and it has been suggested that its accumulation in nigral neuronal cells eventually causes cell death (2).

Fig. 25.4. Formation of cytotoxic chemical species.

It has been postulated that Parkinson's disease might be the consequence of normal aging superimposed on a lesion in the substantia nigra that occurred earlier in life (31). Dopamine neurons degenerate with advancing age, and in normal adults, dopamine levels in striatum decline by approximately 13% per decade (32). Parkinsonian symptoms usually become apparent when striatal dopamine levels decline by approximately 80% (33). Conceivably, the symptoms of

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parkinsonism could be produced by two processes, a specific disease-related insult combined with pathological changes resulting from normal aging. T his two-pronged pathophysiology may explain why Parkinson's disease is a progressive disorder of late onset. T he discovery of the potent and selective dopaminergic neurotoxicant N-methyl-4-phenyl-1, 2,3,6-tetrahydropyridine (MPT P) has greatly aided scientists conducting studies to determine the etiology of Parkinson's disease.

Parkinsonism Caused by M PTP T he cyclic tertiary amine MPT P (Fig. 25.5) induces a form of parkinsonism in humans and monkeys similar in neuropathology and motor abnormalities to idiopathic Parkinson's disease (34,35,36). T he role of MPT P in parkinsonian disorders was revealed by a serendipitous series of events. In 1977, a 23-year-old college student suddenly developed parkinsonian symptoms, with severe rigidity, bradykinesia, and mutism. T he abrupt and early onset of symptoms was so atypical that the patient initially was thought to have catatonic schizophrenia. T he subsequent diagnosis of parkinsonism was substantiated by a therapeutic response to L-dopa, whereupon the patient was referred to the National Institute of Mental Health in Bethesda, Maryland. T he patient admitted having synthesized and used several illicit drugs, after which the psychiatrist who had elicited the patient's history visited his home and collected glassware that had been used for chemical syntheses. Chemical analysis revealed several pyridines, including MPT P, formed as by-products in synthesizing the reverse ester of the narcotic analgesic meperidine known as N-methyl-4-propionoxy-4-phenylpiperidine (MPPP), “ designer heroin,” or “ synthetic heroin.” T his substance also is an analogue of another narcotic analgesic, α-prodine (Fig. 25.6). It was initially unclear, however, whether MPT P or other constituents of the injected mixture accounted for the neurotoxicity.

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Fig. 25.5. Chemical conversion of MPPP and probable mechanism of MPTP neurotoxicity.

After the patient returned home, he continued to abuse drugs and died of an overdose; autopsy revealed degeneration of the substantia nigra—the hallmark P.684 neuropathological feature of Parkinson's disease. Subsequently, other patients were identified with virtually identical parkinsonian symptoms who had also been receiving intravenous injections of MPPP preparations containing varying amounts of MPT P. In several patients, MPT P was the principal or sole constituent injected, providing the first definitive evidence that MPT P is a parkinsonism-producing neurotoxicant. Both the clinical and neuropathological features of MPT P-induced parkinsonism resemble idiopathic Parkinson's disease more closely than any previous animal or human disorder elicited by toxins, metals, viruses, or other means. Accordingly, understanding the molecular pathophysiology of MPT P neurotoxicity has shed light on the neurodegenerative mechanisms in idiopathic parkinsonism.

Fig. 25.6. Phenylpiperidine synthetic analgesics.

Mechanisms of Neuronal Cell Death in MPTP-Induced Parkisonism Consideration of the chemical structure of MPT P would suggest that the compound is relatively chemically inert, because no highly reactive functional group is present. Almost immediately, it was recognized that MPT P might undergo some type of metabolic activation to a more reactive metabolite. Researchers soon discovered that brain MAO-B catalyzes the two-electron oxidation of MPT P at the allylic α-carbon to give the unstable intermediate product 1-methyl-4-phenyl+

2,3-dihydropyridinium (MPDP ), which subsequently undergoes a further two-electron oxidation +

to the stable 1-methyl-4-phenylpyridinium species (MPP ) via auto-oxidation, disproportionation, and enzyme-catalyzed mechanisms (Fig. 25.5) (37,38,39). Inhibitors of MAO-B subsequently were shown to prevent MPT P-induced parkinsonism in primates (40), and it currently is accepted that MPP is the major metabolite of MPT P responsible for the destruction of dopamine neurons, although a role for the unstable dihydropyridinium species MPDP + has not been ruled out.

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T he relationship of MAO and MPT P has neurobiological relevance beyond MPT P neurotoxicity. Monoamine oxidase catalyzes the α-carbon oxidation of the monoamine neurotransmitters (e.g., dopamine, norepinephrine, and serotonin) (Fig. 25.2). Oxidation of a heterocyclic tertiary amine (i.e., MPT P) by MAO is unprecedented and suggests a novel physiologic role for this enzyme. For example, MAO could be important in regulating the oxidation state of pyridine systems, such as those involving nucleic acids and NADH (41), which may be involved in the neurotoxicity of MPT P (vide infra). Interestingly, biochemical and epidemiologic evidence suggests that cigarette smokers have depressed MAO-B activity (42) and a lower incidence of Parkinson's disease (43). Nicotine is not a particularly potent inhibitor of MAO, and in fact, nicotine increases the neurotoxicity of MPT P (44). Other components of cigarette smoke, however, do inhibit MAO, and cigarette smoke protects against MPT P-induced depletion of striatal dopamine in mice (45). Although extensive metabolic, biochemical, and toxicological investigations have established that the nigrostriatal neurodegenerative properties of MPT P are mediated by the MAO-B derived +

metabolite, MPP , this bioactivation reaction must proceed outside of the target nigrostriatal dopamine neurons, because they apparently do not contain MAO-B (46). It is thought that MPT P is oxidized to MPDP in MAO-B–rich glial cells near striatal nerve terminals and nigral cell bodies; the conjugate base MPDP presumably diffuses out of glial cells and is subsequently oxidized to the MPP + metabolite. T he MPP + is sequestered into striatal dopaminergic nerve terminals via the dopamine neurotransporter, which accepts MPP + as a substrate (Fig. 25.5) (47). Intraneuronally, MPP + is concentrated into mitochondria, where it selectively inhibits complex I of the electrontransport chain, inhibiting NADH oxidation and, eventually, depleting the nigrostriatal neuronal cell of adenosine triphosphate (48,49). T hus, the current hypothesis regarding the mechanism of nigrostriatal cell death induced by MPT P (via MPP + ) is energy failure at the level of the mitochondrial respiratory chain (50,51). Several sequential factors may account for the selective damage of nigrostriatal dopamine neurons by MPT P (Fig. 25.5). First, MPT P binds selectively to MAO-B, which is highly concentrated in glial cells in human substantia nigra and corpus striatum. T hen, the MPP + produced from MPT P is selectively accumulated by dopamine neurotransporters into nigral +

dopamine cells and striatal dopamine nerve terminals. Finally, within nigral cell bodies, MPP binds to neuromelanin and may be gradually released in a depot-like fashion, maintaining a toxic intracellular concentration of MPP + that inhibits mitochondrial respiration. T he serendipitous discovery and subsequent scientific investigation of the mechanism of parkinsonism produced by MPT P refocused study of the etiology and pathogenesis of idiopathic Parkinson's disease. For example, evidence suggests that a defect of mitochondrial respiratory chain function may occur in idiopathic Parkinson's disease (52,53). Specifically, it has been documented that there is a 30 to 40% reduction in mitochondrial complex I activity in the substantia nigra of patients with Parkinson's disease (52,53). In general, mitochondrial dysfunction and disorders of oxidative metabolism (oxidative stress), which can include a genetic component (11), now are considered to be critical components of most theories of nigral cell degeneration in Parkinson's disease. Discovery of the selective ability of MPT P to induce nigral cell death has stimulated broad interest in identifying potential environmental or endogenous compounds that may be causative agents in Parkinson's disease.

Pharmacotherapy of Parkinson's Disease So far, clinical studies to evaluate the effectiveness of coadministration of an MAO-B inhibitor plus the antioxidant P.685 vitamin E to slow the progression of neurodegeneration in Parkinson's disease have not yielded encouraging results (54,55,56). T hus, currently available pharmacotherapy continues to be

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symptomatic, involving replacement of the dopamine deficiency in striatum by one or more of the following means: 1) augmentation of the synthesis of brain dopamine, 2) stimulation of dopamine release from presynaptic sites, 3) direct stimulation of dopamine receptors, 4) decreasing reuptake of dopamine at presynaptic sites, or 5) decreasing dopamine catabolism.

Levodopa Therapy About 40 years after its introduction, levodopa remains the most effective pharmacotherapy in Parkinson's disease (57). Despite controversy regarding long-term efficacy, side effects, and even potential neurotoxicity, most patients derive a substantial benefit from levodopa over the entire course of their illness. Moreover, levodopa increases life expectancy among patients with Parkinson's disease, and survival is significantly reduced if the initiation of levodopa therapy is delayed (58). T he seminal report by Cotzias et al. (59) in 1967, describing dramatic symptomatic improvement of parkinsonian patients given high oral doses of racemic dopa, was followed by more clinical trials that confirmed the efficacy and safety of the levo isomer. T he effectiveness of levodopa requires penetration of the drug into the CNS and its subsequent enzymatic decarboxylation to dopamine. Dopamine does not cross the blood-brain barrier, because it exists primarily in its protonated form under physiologic conditions (pK a = 10.6 [NH 2 ]) (60). T he precursor amino acid levodopa, however, is less basic (pK a = 8.72 [NH 2 ]) and, thus, can penetrate the CNS.

Biosynthesis and metabolism Levodopa is an intermediary metabolite in the biosynthesis of catecholamines, formed from L-tyrosine in a rate-limiting hydroxylation step by tyrosine hydroxylase (Fig. 25.2). Levodopa subsequently is decarboxylated by the cytoplasmic enzyme L-aromatic amino acid decarboxylase (dopa decarboxylase) to form dopamine. T he effects observed following systemic administration of levodopa have been attributed to its catabolites, dopamine, norepinephrine, and epinephrine, acting at various sites in the periphery and in the brain. T he principal metabolic pathways for levodopa are shown in Figure 25.2. A small amount is methylated to 3-O-methyldopa, which accumulates in the CNS because of its long half-life. Most levodopa, however, is decarboxylated to dopamine, small amounts of which are metabolized to norepinephrine and epinephrine. T he activity of dopa decarboxylase, however, is greater in the liver, heart, lungs, and kidneys than in the brain (61). T herefore, ingested levodopa is converted to dopamine in the periphery in preference to the brain. It is thought that in humans, levodopa thus enters the brain only when administered in doses high enough to overcome losses caused by peripheral metabolism (3–6 g daily). Inhibition of peripheral decarboxylase activity, by coadministration of a peripheral decarboxylase inhibitor such as carbidopa, can markedly increase the proportion of levodopa that crosses the blood-brain barrier (Fig. 25.7).

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T he greater amount of dopamine that is formed in the brain after orally administered levodopa/carbidopa presumably provides symptomatic relief of parkinsonian symptoms, such as rigidity and bradykinesia. Parkinsonian patients not previously treated with levodopa usually are started on a combination therapy with Sinemet, which is available in a fixed ratio of 1 part carbidopa and 10 parts levodopa. Once formed from levodopa, metabolism of dopamine then proceeds relatively rapidly to the principal excretion products 3,4-dihydroxyphenylacetic acid and 3-methoxy-4-hydroxyphenylacetic acid (homovanillic acid) (Fig. 25.2). Pyridoxine (a coenzyme for dopa decarboxylase) can reverse the therapeutic effects of levodopa by increasing decarboxylase activity, which results in more levodopa being converted to dopamine in the periphery and, consequently, less being available for penetration into the CNS. When peripheral dopa decarboxylation is blocked with carbidopa, however, the pyridoxine effect on peripheral levodopa metabolism is negligible (Fig. 25.7).

Side effects One of the most common side effects of levodopa therapy is gastric upset with nausea and vomiting. T his appears to be the result of direct gastrointestinal irritation as well as stimulation by dopamine of the chemoreceptor trigger zone in the area postrema of the brainstem that activates the emetic center of the medulla. T he blood-brain barrier is poorly developed in the area postrema, and the chemoreceptor trigger zone is accessible to emetic substances in the circulation. One of the advantages of combining levodopa with a peripheral decarboxylase inhibitor, such as carbidopa, is that a 75 to 80% reduction of the dosage of levodopa is permitted; thus, some side effects may be avoided or lessened in severity. Administration of carbidopa with levodopa results in a significant decrease in the incidence and severity of nausea and vomiting associated with levodopa alone. Other side effects of levodopa involve activation of peripheral adrenergic and dopaminergic receptors by dopamine (Fig. 25.7). For example, dopamine stimulation of peripheral α-adrenergic receptors causes vasoconstriction, and stimulation of β-adrenergic receptors enhances heart rate. Either of these may lead to increased blood pressure, and stimulation of peripheral dopamine receptors causes renal and mesenteric vasodilation. T hese cardiovascular side effects of levodopa (via dopamine) also can be diminished by coadministration of carbidopa to allow a lower dose of levodopa. P.686

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Fig. 25.7. Diagrammatic representation of the peripheral decarboxylation of levodopa to form dopamine (DA) and the mode of action of extracerebral decarboxylase on levodopa metabolism and distribution in vivo. The concurrent administration of levodopa and a decarboxylase inhibitor decreases the amount of levodopa required to elicit a therapeutic response in parkinsonism. HVA, homovanillic acid.

After approximately 5 years of levodopa therapy, 50% of patients develop motor fluctuations; the proportion of patients affected increases to 70% after 15 years of therapy (62). Motor complications include “ off” periods of immobility or greater severity of other parkinsonian symptoms and various abnormal involuntary movements. T his phenomenon may be caused by progression of the disease, with resulting striatal nerve terminal degeneration and decreased synthesis and storage of dopamine generated from endogenous or exogenous levodopa. In addition to these presynaptic changes, changes in postsynpatic D 1 -type and D 2 -type receptor systems in the striatum also may occur. Psychiatric disturbances, such as visual hallucinations, mania, hypersexuality, and paranoid psychosis, also are complications of levodopa therapy. It generally is believed that these psychiatric disturbances result from dopamine (produced from levodopa) stimulation of dopamine receptors outside the motor striatum (i.e., in the mesolimbic dopaminergic system).

MAO-B Inhibitors

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Selegiline and rasagiline Selegiline and rasagiline are propargylamine-type selective inhibitors of MAO-B, which inactivates dopamine in the brain. T he MAO-B inhibitors extend the duration of response to levodopa by reducing metabolism of dopamine; thus, the dose of levodopa can be reduced without loss of therapeutic benefit (3). It has been proposed that MAO-B inhibitors may prevent formation of neurotoxic oxidation products of dopamine and slow neurodegeneration in Parkinson's disease; however, data from recent clinical studies do not support this attractive “ neuroprotective” hypothesis (54,55). Nevertheless, MAO-B inhibitors have a beneficial effect on motor fluctuations because of their levodopa-sparing effect (56). Selegiline and rasagiline undergo extensive hepatic metabolism. Selegiline is N-dealkylated via CYP2B6 and CYP2C19 to (–)-methamphetamine and, subsequently, to (–)-amphetamine, which has vasoactive activity similar to (+ )-amphetamine (63). T he amphetamine metabolites of selegiline may contribute to its other pharmacological property of dopamine and norepinephrine reuptake inhibition, thus potentiating the pharmacological effects of levodopa (50). T he amphetamine metabolites of selegiline have been associated with cardiovascular (orthostatic hypotension) and psychiatric (hallucinations) side effects. Rasagiline is N-dealkylated primarily by CYP1A2 to (R)-1-aminoindan, which does not have vasoactive activity (63). P.687

Catechol-O-Methyltransferase Inhibitors

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Tolcapone and entacopone T olcapone and entacopone are reversible inhibitors of catechol-O-methyltransferase (COMT ), which normally transfers a methyl group from the metabolic intermediate S-adenosyl-L-methionine to the 3-phenolic moiety of dopamine, resulting in inactivation of the neurotransmitter (Fig. 25.2). T herefore, because tolcapone and entacopone block the activity of COMT , they prolong the activity of dopamine. Because COMT also inactivates levodopa, COMT inhibitors prolong the action of levodopa. (Fig. 25.2). Examination of the chemical structures of tolcapone and entacapone reveal obvious similarities, and the molecular mechanisms by which these drugs interact with human COMT are proposed to be similar (64). Although the mechanisms of action and pharmacotherapeutic effects are similar for tolcapone and entacapone, they differ with respect to pharmacokinetic properties and adverse effects. T olcapone has a relatively longer duration of action (8–12 hours) and acts both in the brain and periphery, whereas entacapone has a shorter duration of action (2 hours) and acts mostly in the periphery to inhibit COMT . Some common adverse effects of these agents are predictable and attributable to increased brain dopamine (e.g., nausea, vivid dreams, confusion, and hallucinations). A potentially fatal adverse effect, however, occurs only with tolcapone—after marketing, three fatal cases of fulminant hepatic failure were observed, leading to its restriction to only those patients who have not responded to other therapies and who have appropriate monitoring for hepatic toxicity. T he unforeseen hepatotoxicity associated with tolcapone has left entacapone as the only COMT inhibitor in wide clinical use (65). T he mechanism by which liver damage is induced exclusively by tolcapone is believed to involve uncoupling of mitochondria oxidative phosphorylation, significantly reducing cellular generation of adenosine triphosphate (66,67). Additionally, it recently was shown that tolcapone (but not entacapone) induces cytotoxic pro-oxidant radical formation in hepatocytes (68). Finally, both COMT inhibitors may cause severe diarrhea and produce increased dyskinesias that may require a reduction in the dose of levodopa (69).

Dopamine Release and Dopamine Reuptake Inhibitor agents

Amantadine and memantine Amantadine demonstrates clinically significant antiparkinsonian effects during the initial stages of the disease. Relief of symptoms generally is attributed to its activity to promote dopamine release from intraneuronal storage sites and to prevent dopamine reuptake (70). Both amantadine and its dimethyl derivative memantine (approved for Alzheimer's disease) are glutamic acid (N-methylD-aspartate [NMDA]) receptor antagonists that may be neuroprotective by preventing excessive

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influx of calcium into neuronal cells that may lead to excitotoxicity (70). Amantadine is a primary amine, with a pK a of 10.8, and most of the drug is in the protonated form at physiologic pH. Nevertheless, the drug may enter the brain because of its cage-like structure that not only increases its lipophilicity but also precludes its catabolism by oxidative enzymes; metabolism studies have shown that amantadine is excreted in the urine unchanged.

Dopamine Receptor Agonists Mechanism of action T he nigrostriatal neurodegeneration that proceeds over the course of Parkinson's disease limits the number of striatal nerve terminals that are available to decarboxylate levodopa to dopamine. Drugs that act directly to stimulate dopamine receptors, however, do not require functioning dopaminergic nerve terminals and can be useful in the management of late-stage disease problems during levodopa therapy. Dopamine receptor agonists currently available are nonselective and without balanced activity at D 1 -type and D 2- type receptors–clinically used agents are full or partial agonists primarily at D 2 -type receptors. Use of dopamine agonist monotherapy (i.e., without levodopa) has been suggested as initial therapy for Parkinson's disease based on the hypothesis that oxidative metabolites of dopamine (formed from exogenous and endogenous levodopa) may be neurotoxic. At present, however, no substantial evidence supports an indirect neuroprotective effect of dopamine receptor agonists. Meanwhile, dopamine receptor agonists have a longer duration of action (8–24 hours) compared to levodopa (6–8 hours) and may be less likely than levodopa to induce on/off effects and dyskinesias. In fact, the dopamine receptor agonists pramipexole and ropinirole (Fig. 25.8) do produce reduced motor fluctuations compared to levodopa; however, they also produce increased incidence of other adverse effects (71,72), such as nausea and vomiting (presumably from activation of the chemoreceptor trigger zone), sedation, and hallucinations and other psychiatric disturbances that are particularly troublesome for elderly patients. T hus, the dopamine agonists usually are given in combination with a reduced dose of levodopa/carbidopa, but monotherapy may be used for younger patients better able to tolerate side effects (3).

Bromocriptine Bromocriptine (Fig. 25.8) is an ergot peptide derivative that is a partial agonist at D 1 -type and a full agonist at D 2 -type postsynaptic dopamine receptors P.688 (73), usually given in combination with levodopa therapy. It was the first direct dopamine receptor agonist used in treatment of Parkinson's disease after its development as an inhibitor of prolactin release (via activation of anterior pituitary D 2 receptors). At low doses (typically 1–5 mg/day), bromocriptine is an effective prolactin inhibitor, and at higher doses (typically 10–20 mg/day), the antiparkinsonism and mood-elevating effects of bromocriptine become apparent. Bromocriptine is absorbed after oral administration, but approximately 90% of a dose undergoes extensive first-pass hepatic metabolism, with the remainder hydrolyzed in the liver to inactive metabolites that are eliminated mostly in the bile. T he half-life is relatively short (~ 3 hours).

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Fig. 25.8. Structures of the dopamine agonists bromocriptine, pergolide, ropinirole, and pramipexole.

Pergolide Pergolide (Fig. 25.8) is a nonpeptide ergot derivative with higher potency and efficacy as a D 1 agonist and equivalent D 2 agonist activity when compared to bromocriptine (73). For Parkinson's disease, as well as for inhibition of lactation, pergolide is more potent than bromocriptine and may be effective in patients who have become tolerant to bromocriptine. After oral administration, pergolide undergoes hepatic metabolism to 10 metabolites, some of which are pharmacologically active. Elimination of the drug is primarily renal, with a half-life is approximately 27 hours.

Ropinirole and pramipexole Ropinirole and pramipexole (Fig. 25.8) are nonergot compounds that are full agonists selective for dopamine D 2 and D 3 receptors, in contrast to ergot derivatives that also have activity at D 1 -type and other nondopaminergic neurotransmitter receptors. Both ropinirole and pramipexole are indicated for treatment of early Parkinson's disease, either as monotherapy and as combination therapy with levodopa. A slower decline of dopaminergic neuronal function is noted for pramipexole monotherapy compared to initial treatment with levodopa (74). Ropinirole also is approved to treat restless leg syndrome, and although the mechanism is not clear, neuropharmacological studies suggest that dopaminergic neurotransmission is involved. Ropinrole is orally active and metabolized principally via CYP1A2 to form hydroxylated and N-dealkylated inactive products, with an elimination half-life of approximately 6 hours. Pramipexole is orally absorbed and primarily eliminated via the kidneys unchanged, with an elimination half-life of approximately 8–12 hours.

Structure–activity relationships of dopamine receptor agonists As described in Chapter 22, molecular cloning technology has been used to identify five genes

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that code for dopamine receptor proteins: two D 1 -type receptors (D 1 and D 5 ), and three D 2 -type receptors (D 2 , D 3 , and D 4 ). Whereas antipsychotic drug design (see Chapter 22) is directed toward discovery of molecules that act as antagonists at, especially, dopamine D 2 -type receptors (albeit, an important role for the D 1 family has not been ruled out), the dopamine deficiency that characterizes Parkinson's disease naturally directs research toward discovery of ligands that act as agonists at dopamine receptors. Currently, however, no validated three-dimensional orientation of the amino acid residues at the ligand binding site has been reported for D 1 -type or D 2 -type receptors. T hus, development of selective agonists and antagonists for dopamine receptors still is guided by quantitative structure–activity relationships based on probe molecules. T he side chain of dopamine possesses unlimited flexibility and unrestricted rotation about the β-carbon–phenyl bond; thus, little information can be obtained concerning the conformational requirements for activation of dopamine receptors using the endogenous ligand. Accordingly, various compounds in which the catechol ring and the amino-ethyl moiety of dopamine are held in rigid conformation have been synthesized to probe the molecular determinants for binding and activation of dopamine receptors. One such compound is the aporphine alkaloid apomorphine (Fig. 25.9), which is obtained by the acid-catalyzed rearrangement of morphine. Apomorphine directly stimulates central dopamine receptors to produce effects similar to those of dopamine, including emetic and antiparkinson actions, which provide its pharmacotherapeutic usefulness.

Although the pK a of apomorphine is approximately nine (mostly protonated at physiologic pH), the molecule P.689 apparently is lipophilic enough to pass across the blood-brain barrier, whereas dopamine (pK a = 10.6) cannot. In the brain, (R)-(–)-apomorphine is a potent D 1 and D 2 agonist and produces an antiparkinsonian effect equivalent to that of levodopa. Interestingly, S-(+ )-apomorphine is a postsynaptic D 2 -type antagonist and a presynaptic D 2 -type autoreceptor agonist that decreases dopamine synthesis (theoretically, such neurobiochemical activity would be desirable in an antipsychotic drug) (75). Unfortunately, apomorphine is difficult to administer because of first-pass enterohepatic metabolism and potent emetic effects. Apomorphine can be administered by subcutaneous injection and is approved to treat late-stage Parkinson's disease (76).

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Fig. 25.9. Model of apomorphine molecule as determined by the x-ray crystal data of Giesecke (77) showing the structural relationship to dopamine in the trans α-rotameric conformation.

T o help characterize the structure and function of dopamine receptors at the molecular level, the x-ray crystal structure of apomorphi ne (77) was compared to a structural model of dopami ne (Fig. 25.9). It i s obvi ous that apomorphi ne contai ns mol ecul ar features i n common wi th the structure of dopami ne i n the trans α-rotamer conformati on (Figs. 25.9 and 25.10). Isoapomorphi ne, whi ch embeds the structure of dopami ne i n the trans β-rotameri c conformati on (Fig. 25.10), i s l ess acti ve than apomorphi ne as a dopami ne agoni st. The 1,2-di hydroxyaporphi ne anal ogue, whi ch mi mi cs the ci s α-rotamer conformati on of dopami ne, i s i nacti ve (78). In other studi es, the semi ri gi d ami notetral i n 2-ami no-6,7-di hydroxy-1,2,3,4tetrahydronaphthal ene (A-6,7-DTN), whi ch has a trans β-rotamer conformati on between the benzene ri ng and the ami no si de chai n (Fig. 25.10), was found to be a more potent dopami ne agoni st than 2-ami no-5,6-di hydroxy-1,2,3,4-tetrahydronaphthal ene (A-5,6-DTN), whi ch has a trans α-rotamer conformati on (Fig. 20.10) (79). Thus, resul ts of experi ments usi ng these ri gi d dopami ne-mi meti c compounds suggest that the preferred conformati on of dopami ne i s the extended trans conformati on (α- or β-rotamer). Resul ts from other experi mental and mol ecul ar model i ng/computati onal chemi stry studi es i ndi cate that l i gand acti vi ty at D 1 vs. D 2 receptors i s cri ti cal l y dependent on the posi ti on of a l i gand protonated ni trogen moi ety that can form a hi gh-affi ni ty i oni c bond wi th an ani oni c asparti c aci d resi due i n the thi rd transmembrane α-hel i x of the receptor (80).

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Adjunct Therapy—Anticholinergic and Antihistamine Drugs Cholinergic interneurons in the striatum exert mainly excitatory effects on GABAergic output from the striatum. Historically, it had been observed that drugs which increase cholinergic neurotransmission (e.g., the cholinesterase inhibitor physostigmine and the cholinergic agonist carbachol) aggravate parkinsonism in humans. Accordingly, before the discovery of levodopa, drug therapy for parkinsonism depended primarily on the limited efficacy of the natural belladonna alkaloids (e.g., atropine), which are cholinergic muscarinic receptor antagonists. With newer synthetic alkaloids (T able 25.1), attempts were made to increase central anticholinergic effects as well as to reduce undesirable peripheral effects, such as dry mouth, blurred vision, constipation, urinary retention, and tachycardia. Unfortunately, the CNS side effects of these agents also are very troublesome and include delusions, hallucinations, somnolence, ataxia, and dysarthria. In general, anticholinergic drugs rarely produce more than 20% improvement, and despite continued use, the symptoms of the disease continue to progress. T he most important present usage of the anticholinergic agents is as adjunct therapy with L-dopa. T he antihistamines, particularly those with central anticholinergic effects, generally are better tolerated in the elderly and may produce slightly greater relief from tremor, but this therapy is rarely used today.

Spasticity Disorders Clinical Evaluation Spasticity is characterized by skeletal muscle spasms and an increase in tonic stretch reflexes, sometimes with accompanying muscle weakness. Spasticity often is associated with cerebral palsy, multiple sclerosis, spinal cord injury, or stroke. T he mechanisms that underlie clinical spasticity appear to involve damage to descending pathways in the spinal cord that results in hyperexcitability of α motor neurons. In addition to lack of accurate experimental models, a limiting factor in characterizing the pathophysiology of spasticity and effectiveness of antispasmodic drugs continues to be lack of quantitative methodology for assessment of the spasmodic condition P.690 (87,88). Simple tests of muscle tone or reflex latency have not been fruitful; however, global clinical assessments, such as the number of painful spasms per day, have been more useful. Even the combined subjective impressions of improvement by the patient, family, and physician, however, may not establish that a particular drug is efficacious. Furthermore, spasm frequently coexists with pain and spasmolytic drug efficacy may be related to both skeletal muscle relaxation and analgesia. A straightforward strategy to establish whether a spasmolytic drug produces any benefit is gradual withdrawal of the drug (89). T he diversity of neurological disorders that culminate in spasticity and the subjectivity of many of the measurements make it difficult to establish efficacy of any one of the spasmolytic drugs (90). In summary, clinical evidence for efficacy of oral antispasmodic agents is scarce and weak.

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Fig. 25.10. Conformations of dopamine in the trans α-rotameric, trans β-rotameric, and cis α-rotameric forms and structural relationships to the rigid dopamine analogues apomorphine, isoapomorphine, and 1,2-dihydroxyaporphine. Also shown are the corresponding semirigid analogue s of dopamine, the dihydroxytetralins, A-5,6-DTN and A-6,7-DTN.

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Spasmolytic Drugs Skeletal Muscle Relaxants Background T he drugs used for spasmolytic conditions are diverse in their chemical structures and their sites and mechanisms of action. T he first drug recognized to exhibit spasmolytic activity was antodyne or 3-phenoxy-1,2-propanediol. In guinea pigs and rabbits, P.691 antodyne produced prolonged paralysis without impairing consciousness. Antodyne was introduced into clinical medicine in 1910 as an analgesic and antipyretic. T he duration of its skeletal muscle relaxant effect, however, was too short-lived to be clinically useful. In 1943, structure–activity relationship studies of a series of simple glyceryl ethers related to antodyne led to the development and introduction of mephenesin (T able 25.2) in 1946 (91). Pharmacological studies revealed that mephenesin selectivity depressed polysynaptic, while sparing monosynaptic, spinal cord reflexes. T he relative safety and selective action of mephenesin on the spinal cord led to its use as the first widely prescribed centrally acting skeletal muscle relaxant. Accordingly, mephenesin is the prototype of the interneuronal blocking type of muscle relaxant, albeit mephenesin itself no longer is used. In general, the pharmacology of the mephenesin-like muscle relaxants is remarkably similar to that of sedative-hypnotics. Indeed, the only apparent difference is that the spasmolytics have greater selectivity for modulating effects mediated by the spinal cord, thus producing less sedation than general sedative-hypnotics. Both classes produce a reversible, nonspecific depression of the CNS, and sedation, dizziness, and muscle weakness are common side effects.

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Table 25.1. Drugs Used for Parkinsonism

T able 25.2 shows several compounds with mephenesin-like pharmacological profiles that have been developed and marketed as antispasmodic muscle relaxants. Chlorphenesin carbamate and methocarbamol are carbamate analogues of mephenesin that are designed to be longer lasting. T heir duration of action, however, has not been reported. T he alcohol carbon of methocarbamol is chiral, and the R-(+ )-enantiomer was found to have greater muscle relaxant activity in mice (92). T he drug, however, is prescribed as the racemate. Meprobamate is the principal metabolite of carisoprodol; thus, the pharmacology of the two overlap. In clinical studies, carisoprodol has modest efficacy for treatment of low-back pain associated with sprain or strain. Carisoprodol and meprobamate have sedative and anxiolytic effects similar to benzodiazepines, such as diazepam, and carry a similar liability for abuse and dependency (88). Metaxalone, on the other hand, is not associated with abuse, and although no data from high-quality clinical trials are available, it generally is reported to achieve muscle P.692 relaxation without excessive sedation. Chloroxazone is another agent marketed as a skeletal muscle relaxant, but with unclear efficacy in spasmodic conditions. A considerable drawback to empirical use of chloroxazone is that idiosyncratic hepatotoxicity and several sensitivity reactions

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(urticaria, erythema, and pruritus) have been reported (88). Orphenadrine is an ethanolamine ether that is related both chemically and pharmacologically to diphenhydramine-type histamine H 1 antagonists. Although its efficacy is not clearly established, any muscle relaxant effects of orphenadrine may be caused by CNS anticholinergic activity, because this drug shows significant muscarinic receptor antagonism. Orphenadrine also is an NMDA receptor antagonist; however, it is unclear if this activity may lead to antispasmodic effects. T he antimuscarinic activity of orphenadrine certainly leads to unpleasant peripheral side effects, such as dry mouth, blurred vision, and urinary retention. Cyclobenzaprine is another agent with prominent antimuscarinic activity that is used as a skeletal muscle relaxant, although its efficacy is modest. It is proposed that the muscle relaxant effects of cyclobenzaprine may result from antagonism of serotonin 5-HT 2 receptors in descending neurons of the spinal cord (93), but anticholinergic mechanisms cannot be ruled out. Although the presence of a double bond in the cycloheptyl ring of cyclobenzaprine is the only structural difference from the tricyclic antidepressant amitriptyline, cyclobenzaprine is not an efficacious antidepressant. Cyclobenzaprine has a long plasma half-life (1–3 days) and accumulation on multiple dosing contributes to its high incidence of sedation.

Clinical Applications: Radiopharmaceuticals in Diagnosis of Parkinson's Disease Eve n f o r an e xp e rie nc e d ne uro lo g ist, a diag no s is o f Parkins o n' s d is e ase c an b e dif f ic ult to co nf irm, e s p e cially during the e arly s tag e s o f this d is e ase . Dis e as e p ro gres s ion is highly variab le. The d eg re e o f d is ab ility c an f luctuate d ramatically, and no two p e o p le have e xac tly the s ame s ymp toms . I n ad d itio n, a numb e r o f co nd itio ns mimic Parkins o n's d ise as e , b ut the s e co nd itio ns c anno t b e tre ate d e f f e c tive ly with antip arkins o nis m d rug s. I maging tec hniq ue s are inc re asing ly ap p lied to ne uro p harmaco lo g ic al s tud ie s o f brain f unctio n. Po s itro n-e miss io n to mog rap hy (PE T) and sing le -p ho to n e mis s ion c o mp ute d to mog rap hy (SP ECT) are se ns itive me tho d s that can b e us e d in suc h s tud ie s . Altho ug h s p atial re s o lutio n re mains so me what g re ater with PET, s eve ral ad vantag e s are o f f e re d b y SP ECT te c hno log y. Po sitro n-emitting nuc lid e s have s uc h s hort half -live s ( 11 C, 2 0 min; 18

F, 1 09 min) that the y us ually re q uire an o n-site cyc lo tro n f o r the ir prod uc tio n, where as

SP ECT nuc lide s have lo ng e r half -live s ( 123 I , 1 3 hr) s o that they c an b e s up p lie d c o mme rc ially. Quantitative as s e ss me nt o f nig ro s triatal p re s ynap tic d o pamine rg ic ne rve te rminal f unc tio n als o has b e e n a us e f ul d iag no stic to o l f o r the e arly diag no s is o f Parkins o n' s d is e ase (8 1 ). Pre vio usly, 6 -[ 18 F]f luo ro -L -d o p a ([ 18 F]-DOPA) has b e e n us ed in P ET to as s es s d op amine nerve te rminal f unc tio n in human b rain. Me anwhile , it has b e e n known f o r s o me time that c o c aine and its rad io lab e le d d e rivative s b ind to the d o p amine ne uro trans po rte r lo cate d on p re s ynap tic do p amine rg ic ne rve te rminals . R es e arche rs have inve s tig ate d whe the r it might b e po s s ib le to d e p ict the se d o p amine ne uro transp o rte r p ro teins us ing rad io labe le d analog ue s o f c o c aine (8 2 ). Altho ug h rad io lab e le d c oc aine analo g ue s have b e e n sho wn to b ind to the ne uro trans p orte r, rap id hyd ro lys is o f its b e nzo yl e s te r f unc tio n limits its us e in SPEC T imag ing . By re mo val o f the e s te r g ro up and d ire ctly linking the phe nyl ring to the he te ro c yc lic ring s yste m, mo re s tab le tro pane mo le cule s are o b tained that c an b e rad io labe le d f o r imaging purp o s e s.

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The f irs t rad io p harmac eutical to e me rg e f rom this re s earc h, [ 123 I ]2 -β-c arbo me tho xy3 β-(4 -iod o p he nyl)trop ane , is kno wn as [ 123 I ]β-CI T o r RTI -5 5 (8 3 ,8 4). The rad io active io d ine ato m in the p ara p os itio n o f the p henyl ring p ro vide s f o r the imag ing p ro p e rtie s o f [ 123 I ]β-CI T. A limiting f ac to r with [ 123 I ]β-C I T, ho we ve r, is that it must b e adminis te re d 8 ho urs b e f o re imag ing to ac hie ve p e ak up take to d o p amine ne rve te rminal re gio ns. I n an e f f o rt to imp ro ve the p harmac o kinetic pro f ile of [ 123 I ]β-C I T, Neume ye r e t al. (8 5 ) d e ve lo p e d the N-3 -f luo ro p ro p yl analo g ue o f β-CI T, kno wn as [ 123 I ]FP-C I T. This d o p amine ne rve te rminal imaging ag e nt rap id ly re ache s its targ e t site s (d o p amine re up take pro te ins ) s o that patie nts c an b e image d 1 to 2 ho urs af te r inje ctio n o f [ 123 I ]FP-C I T. Mo re o ve r, re s earc he rs d e ve lo p e d a rad io ligand suitab le f o r PET imag ing b y re p lac e me nt o f the f luorine ato m with [ 18 F] and re plac eme nt o f the [ 123 I ] ato m with iod ine in [ 123 I ]FP -CI T (8 6 ). I n Euro p e , [ 123 I ]FP -CI T is ap p ro ve d f o r clinic al us e , and b o th [ 123 I ]β-CI T and [ 123 I ]FP -CI T are us e d as re se arc h to o ls to ass e s s d o p amine ne rve te rminal f unc tio n in neuro d e g e ne rative and ne uro p s yc hiatric d is orde rs .

Diazepam T he second group of antispastic drugs to be developed were the benzodiazepines, typified by diazepam. Diazepam exerts its skeletal muscle relaxant effect by binding as an agonist at the benzodiazepine P.693

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receptor of the GABAA receptor complex, which enhances GABA potency to increase chloride conductance (see Chapter 22). T he muscle relaxant properties of classical benzodiazepines, such as diazepam, appear to be mediated mainly by the GABAA α 2 and α 3 subunits (94,95). T he result is neuronal hyperpolarization, probably at both supraspinal and spinal sites for spasmolytic activity. Its actions are sufficient to relieve spasticity in patients with lesions affecting the spinal cord and in some patients with cerebral palsy (96). Few high-quality clinical trials have evaluated diazepam as a muscle relaxant, but these few suggest that diazepam is no more efficacious than, for example, carisoprodol, cyclobenzaprine, or tizanidine (i.e., efficacy is marginal) (87,88). Moreover, diazepam produces drowsiness and fatigue in most patients at doses required to significantly reduce muscle tone.

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Table 25.2. Skeletal M uscle Relaxants

Baclofen Baclofen (β-p-chlorophenyl-GABA) is a GABAB receptor agonist and is one of the most commonly used antispastic agents.

P.694 T he (R)-(–)-enantiomer is the active isomer at GABAB receptors, but the racemate (Lioresal) is approved for use as a spasmolytic agent. T he molecular mechanisms of GABAB receptors in muscle spasticity are not understood any better than other putative receptor-based mechanisms discussed above. It is proposed that baclofen inhibits spinal cord monosynaptic and polysynaptic reflexes via GABAB receptor-mediated opening of neuronal potassium channels that leads to hyperpolarization of primary afferent fiber terminals. Baclofen also may reduce the release of excitatory neurotransmitters and substance P in the brain and/or spinal cord via GABAB -mediated neuronal hyperpolarization (90,96). Adverse effects of oral baclofen include sedation, excessive weakness, vertigo, and psychological disturbances. It is used for the treatment of spasticity in paraplegia and quadriplegia, patients with multiple sclerosis, and traumatic lesion to the spinal cord (96). Baclofen is completely absorbed after oral administration, undergoes minimal hepatic metabolism, and is excreted mainly as the parent compound in urine and feces, with a half-life of approximately 3 to 4 hours. Intrathecal administration via an implanted infusion pump is used to control severe spasticity and pain that is not responsive to medication given by oral or other parenteral routes.

Dantrolene Dantrolene is a hydantoin derivative that acts peripherally to reduce spasticity and is indicated for use in spinal cord injury, stroke, cerebral palsy, and multiple sclerosis (97).

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T he site of action of dantrolene is believed to be at the sarcoplasmic reticulum in skeletal muscle cells. Dantrolene binds to a calcium channel protein (ryanodine receptor) on the sarcoplasmic reticulum to close the channel and inhibit the release of calcium; the alkaloid ryanodine activates the same receptor to open the channel. Dantrolene is believed to act directly on the contractile mechanism of skeletal muscle to decrease the force of contraction in the absence of any demonstrated effects on neural pathways, on the neuromuscular junction, or on the excitable properties of the muscle fiber membranes (97). Cardiac muscle and smooth muscle are minimally affected by dantrolene, likely because calcium release from sarcoplasmic reticulum of these muscle cell types occurs via a mechanism that differs from skeletal muscle. T he muscle relaxant effect of dantrolene on skeletal muscle, however, is not specific, and generalized muscle weakness occurs as a major adverse side effect. Like other hydantoins, dantrolene is a weak base (pK a = 7.5) that can cross the blood-brain barrier; thus, CNS depressant side effects (e.g., sedation) are common. Dantrolene sodium salt is slowly absorbed from the gastrointestinal tract. T he mean half-life of the drug in adults is approximately 9 hours after a 100-mg dose. It is slowly metabolized by the liver to give the 5-hydroxy and acetamido (nitro reduction and acetylation) metabolites, as well as unchanged drug, excreted in the urine. Interestingly, dantrolene also is valuable in alleviating the signs of malignant hyperthermia. T his rare, genetically determined condition, which can be triggered by a variety of stimuli, including inhalation anesthetics and neuromuscular blocking drugs, involves an impaired ability of the sarcoplasmic reticulum to sequester calcium. For treating malignant hyperthermia, dantrolene is administered intravenously.

Tizanidine T izanidine is a centrally acting adrenergic α 2 receptor agonist used to treat chronic muscle spasticity conditions, such as multiple sclerosis.

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Postulated mechanisms include α 2 receptor-mediated decreased release of norepinephrine and serotonin from spinal interneurons (98). T izanidine is structurally related to the α 2 agonist clonidine that is used to treat hypertension; however, the blood pressure–lowering potency of tizanidine is approximately 10 to 20% that of clonidine. Nevertheless, patients may experience hypotension with tizanidine, together with muscle weakness, that may result in dizziness and falls in mobile patients. T izanidine is rapidly and almost completely absorbed from the gastrointestinal tract; however, the estimated bioavailability is only 10 to 15% because of extensive first-pass metabolism, mainly by CYP1A2 (99), which results in oxidative degradation of the imidazoline ring and hydroxylation of the aromatic system (100). Elevated liver enzyme values are not frequent with tizanidine use. Hepatic injury and death because of liver failure have been reported, however, and this complication should be considered in view of its marginal antispasmodic efficacy (87,88). Other frequently reported side effects of tizanidine are drowsiness and dry mouth. Clonidine also has been used to treat spasticity; however, even less high-quality clinical study data are available for this agent.

Acknowledgem ents T he author wishes to express his gratitude to Drs. John L. Neumeyer and Ross J. Baldessarini for guidance in preparing this chapter. P.695

Case Study Vic tor ia F. Roc he S. Willia m Zito ST is a 6 8 -ye ar-o ld f emale who trade d in he r s tre s s f ul jo b as an acad e mic adminis trator at a majo r ac ad e mic he alth c e nter f o r the relaxe d lif e o f No rthe rn C alif o rnia. He ad ing to “ wine co untry” with he r c ats , re tire me nt f und s, and a f e w f amily he irlo o ms, s he p urp o se f ully so ug ht a new lif e , making ne w f rie nd s and d o ing the thing s s he lo ve s mos t. She ' s b e e n ve ry p o litic ally and c ulturally ac tive in he r c ommunity, and s he tho ro ughly e njo ys he r jo b as the s oc ial e vents p lanne r at a s mall, f amily-o wne d wine ry that is jus t no w b e ginning to g ain re g io nal no to rie ty. Atte nd ance at he r nig htly “ wine and che e s e” g athe ring s has incre as ed d ramatic ally o ve r the pas t ye ar, giving ST a chanc e to ne two rk with clie nts and to s ho wc as e the high q uality o f her e mp loye r' s “ vino .” L if e se e me d p e rf e c t until a d iag nos is o f Parkins o n' s d is e ase was es tab lis he d thre e mo nths ag o . ST' s s ymp to ms are characte ris tic o f this d o p amine de f ic ie nc y d iso rd e r and includ e rig id ity, d if f iculty s p e aking , and s lowed mo ve me nts . She is s till ab le to f unctio n at

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wo rk b ut is o b vio us ly wo rried ab o ut what the f uture ho ld s . She b e g an le vo d o p a the rapy imme d iate ly (4 0 0 mg b .i.d .) b ut is s trug g ling to co p e with d rug -ind uce d naus e a and vo miting s e ve re e no ug h to limit he r us ually p as s ionate invo lveme nt with a lo c al Parkins o n' s re se arc h ad vo c acy g ro up . I n ad d itio n, althoug h previo us ly no rmo te nsive , s he has e xpe rie nce d an incre as e in b lo o d p re ss ure that is now be ing tre ate d with a thiazid e d iure tic . Yo u me e t up with ST at a wine -tas ting e ve nt at the vine yard , and in a p rivate mo me nt, s he as ks f o r yo ur pro f e s s io nal ad vic e and co unse l. Co nsid e r the s truc ture of the co mp o und s d rawn be lo w, and d e cid e whic h mig ht b e ne f it this p atie nt. 1. I d e ntif y the therap e utic p ro b le m(s ) in whic h the p harmacis t's inte rve ntio n may b e nef it the p atie nt. 2. I d e ntif y and p rio ritize the p atie nt-s p ec if ic f ac tors that mus t b e co ns id e re d to ac hie ve the d e s ire d the rape utic o utco me s. 3. C ond uct a tho ro ug h and me c hanistic ally o rie nte d s truc ture – ac tivity re latio ns hip analysis of all s tructure s p ro vid e d in the cas e . 4. Evaluate the struc ture – ac tivity re lations hip f ind ing s ag ains t the p atie nt-s p e c if ic f ac to rs and d e s ire d therap e utic o utc o mes , and make a the rape utic d e c is io n. 5. C ouns el your p atie nt

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http://thepointeedition.lww.com/pt/re/9780781768795/bookContentPan...

Chapter 26 Cardiac Agents: Cardiac Glycosides, Antianginal, and Antiarrhythmic Drugs Ahm e d S. Me hanna T hose drugs with BP (British Pharmacopeia) designation are available only in Canada and countries other than the United States. Heart diseases are grouped into three major disorders: cardiac failure or contractile dysfunction, ischemic heart disease (with angina as its primary symptom), and cardiac arrhythmia.

Drugs for the T reatm ent of Heart Failure Congestive Heart Failure Cardiac failure can be described as inability of the heart to pump blood effectively at a rate that meets the needs of metabolizing tissues. T his is the direct result of a reduced contractility of the cardiac muscles, especially those of the ventricles, which causes a decrease in cardiac output, increasing the blood volume of the heart (hence the term “ congested” ). As a result, the systemic blood pressure and the renal blood flow are both reduced, which often lead to the development of edema in the lower extremities and the lung (pulmonary edema) as well as renal failure. A group of drugs known as the cardiac glycosides were found to reverse most of these symptoms and complications.

Drugs for the Treatment of Congestive Heart Failure Cardiac glycosides: positive ionotropic drugs T he cardiac glycosides are an important class of naturally occurring drugs, the actions of which include both beneficial and toxic effects on the heart. T heir desirable cardiotonic action is of particular benefit in the treatment of congestive heart failure (CHF) and associated edema, and their preparations have been used as medicinal agents as well as poisons since 1500 BC. T his dual application serves to highlight the toxic potential for this class of life-saving drugs. Despite the extended use and obvious therapeutic benefits of the cardiac glycosides, it was not until the famous monograph by William Withering in 1785, “ An Account of the Foxglove and Some of its Medical Uses,” that cardiac glycoside therapy started to become more standardized and rational (1,2,3). T he therapeutic use of purified cardiac glycoside preparations has occurred only over the last century. T oday, the cardiac glycosides represent one of the most important drug classes available to the physician for the treatment of treat CHF. P.699

Clinical Significance Cardiovascular disease is by far the leading cause of death in industrialized nations. Although improved treatments have lowered this death rate, an additional result is a growing number of patients who are surviving with diseased hearts and who require intensive drug therapy regimens. T he cardiac glycosides and, most recently, digoxin have been used for centuries, but only within the last decade has their role been clarified by modern clinical trials. Still, many questions remain, including the precise mechanism(s) of action beyond the positive inotropic effect, the ideal dose and serum concentration, and the best methods to avoid toxicity and drug interactions. In particular, understanding how the structure of digoxin affects its pharmacokinetics allows the clinician to anticipate problems when it is used with potentially interacting drugs or in patients with organ dysfunction.

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In many clinical situations, antiarrhythmic drugs have given way to implantable defibrillators for potentially life-threatening arrhythmias, but they are still commonly used both as adjunct therapy and in other arrhythmias, such as atrial fibrillation. T he sheer number of antiarrhythmic agents with diverse mechanisms of action and the possibility of serious or even lethal adverse effects makes understanding how the structure of these drugs contributes to their efficacy and toxicity a high priority for pharmacists. Je ffre y T. She re r, Pharm .D., MPH, BCPS, CGP Cl i ni cal Assi stant Professor Uni versi ty of Houston Col l ege of Pharmacy

Ch emistry of th e cardiac glycosides Cardiac glycosides and other similar glycosides are composed of two portions: the sugar moiety, and the nonsugar (the aglycone) moiety.

Aglycon es T he aglycone portion of the cardiac glycosides is a steroid nucleus with a unique set of fused rings, which makes these agents easily distinguished from the other steroids. Rings A-B and C-D are ci s fused, whereas rings B-C have a trans configuration. Such ring fusion gives the aglycone nucleus of cardiac glycosides the characteristic “ U-shape,” as shown in Figure 26.1. T he steroid nucleus also carries, in most cases, two angular methyl groups at C-10 and C-13. Hydroxyl groups are located at C-3, the site of the sugar attachment, and at C-14. T he C-14 hydroxyl is normally unsubstituted; however, additional hydroxyl groups may be found at C-12 and C-16, the presence or absence of which distinguishes the important genins: digitoxigenin, digoxigenin, and gitoxigenin (Fig. 26.2). T hese additional hydroxyl groups have significant impact on the partitioning and pharmacokinetics for each glycoside, as discussed later. T he lactone ring at C-17 is another major structural feature of the cardiac aglycones. T he size and degree of unsaturation of the lactone ring varies with the source of the glycoside. In most cases, the cardiac glycosides of plant origin, the cardenolides, possess a 5-membered, α,β-unsaturated lactone ring, whereas those derived from animal origin, the bufadienolides, possess a 6-membered lactone ring with two conjugated double bonds (generally referred to as α-pyrone) (Fig. 26.1).

Fig. 26.1. Cardenolide and bufadienolide aglycones.

Su gars T he hydroxyl group at C-3 of the aglycone portion usually is conjugated to a monosaccharide or a

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polysaccharide with β-1,4-glucosidic linkages. T he number and identity of sugars vary from one glycoside to another, as P.700 detailed subsequently. T he most commonly found sugars in the cardiac glycosides are D-glucose, D-digitoxose, L-rhamnose, and D-cymarose (Fig. 26.3). T hese sugars predominately exist in the cardiac glycosides in the β-conformation. In some cases, the sugars exist in the acetylated form. T he presence of an O-acetyl group on a sugar greatly affects the lipophilic character and pharmacokinetics of the entire glycoside, as discussed subsequently.

Fig. 26.2. Major cardenolide aglycones.

Fig. 26.3. Selected sugars found in naturally occurring cardiac glycosides.

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Sou rces an d common n ames of cardiac glycosides T he cardiac glycosides occur mainly in plants and, in rare cases, in animals, such as poisonous toads. Di gi tal i s purpurea or the foxglove plant, Di gi tal i s l anata, Strophanthus gratus, and Strophanthus kombe are the major plant sources of the cardiac glycosides. Based on the nature and number of sugar molecules and the number of hydroxyl groups on the aglycone moiety, each combination of sugars and aglycones assumes different generic names. T he site of the glycosides concentration in the plant, the types of glycosides, and the names of the structural components of these glycosides are summarized in T able 26.1.

Digitalis lan ata Lanatoside A is composed of the aglycone digitoxigenin (genin indicates no sugar) connected to three digitoxose sugar molecules, the third of which carries a 3-acetyl group, and a terminal glucose molecule. In other words, the structure sequence is glucose 4 -3-acetyldigitoxose 3 -digitoxose 2 digitoxose 1 -digitoxigenin.

Lanatoside B has the identical sugar portion to lanatoside A, except that the aglycone has extra hydroxyl group at C-16 and is given the name gitoxigenin. T he structural sequence is glucose 4 -3acetyldigitoxose 3 -digitoxose 2 -digitoxose 1 -gitoxigenin. Lanatoside C also has the same sugars found in both lanatosides A and B; however, the aglycone has the nucleus of lanatoside A plus an additional hydroxyl group at C-12. T his cardenolide is named digoxigenin. T he structural sequence is glucose 4 -3-acetyldigitoxose 3 -digitoxose 2 -digitoxose 1 digoxigenin. Partial hydrolysis of the glucose molecule and the acetate group from lanatoside A and C produces, respectively, two new and most important cardiac glycosides, digitoxin and digoxin, with the following sequences: digitoxin, (digitoxose) 3 -digitoxigenin; and digoxin, (digitoxose) 3 -digoxigenin.

Digitalis pu rpu rea Purpurea glycosides A and B have structures identical to those of lanatosides A and B, but with no acetyl group on the third digitoxose. T herefore, the purpurea glycosides A and B sometimes are called desacetyl digilanides A and B. T heir sequences are as follows: purpurea glycoside A, glucose-(digitoxose) 3 -digitoxigenin; and purpurea glycoside B, glucose-(digitoxose) 3 -gitoxigenin. T here is no purpurea glycoside C.

Table 26.1. Selected Natural Cardiac Glycosides and Their Sources Source Digitalis lanata (leaf)

Glycoside Lanatoside A (digilanide A)

Aglycone Digitoxigenin Gitoxigenin

Sugara Glucose3-acetyldigitoxose-

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Lanatoside B (digilanide B) Lanatoside C (digilanide C)

Digoxigenin

digitoxosedigitoxose

Digitalis purpurea (leaf)

Purpurea glycoside A (desacetyl digilanide A) Purpurea glycoside B (desacetyl digilanide B)

Digitoxigenin Gitoxigenin

Glucosedigitoxosedigitoxosedigitoxose

Strophanthus gratus (seed)

G-Strophanthin

Oubagenin

Rhamnose

Strophanthus kombe (seed)

k-Strophanthoside

Strophanthidin

Glucose-glucosecymarose

a

Conjugated with the C-3 hydroxyl of the aglycone via the sugar to the far right. All sugars are conjugated via β-1,4–glucosidic bond.

P.701

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Stroph an th u s gratu s an d Stroph an th u s kombe T he glycosides extracted from the plants Strophanthus gratus and Strophanthus kombe are called g-strophanthin (or ouabain) and k-strophanthoside, respectively. T he corresponding aglycone for ouabain is ouabagenin, and that for k-strophanthoside is strophanthidin. Ouabagenin has a polyhydroxylated steroidal nucleus, and strophanthidin has an additional hydroxyl group at C-5 with an angular aldehyde group at C-10, replacing the traditional methyl group at that position (Fig. 26.2). Ouabagenin is conjugated only to a single molecule of L-rhamnose, whereas strophanthidin is conjugated to a molecule of cymarose, which is further linked to two molecules of glucose.

T he medicinally used preparations are mainly obtained from Di gi tal i s purpurea and Di gi tal i s l anata plants. T hese glycosides generally are referred to as digitalis glycosides, cardiac glycosides, or simply, cardenolides. Strophanthus glycosides (e.g., ouabain) are no longer used therapeutically but were previously administered only intravenously because of poor oral absorption. Cardiac glycosides from animal sources (generally referred to as bufadienolides) are rare and of far less medicinal importance because of their high toxicity. Pharmaceutical preparations of whole plants and partially hydrolyzed glycosides of Di gi tal i s l anata and Di gi tal i s purpurea have been widely used clinically. Advancements in isolation and purification techniques, however, have made it possible to obtain highly purified digoxin preparations.

Ph armacology Cardiac glycosides affect the heart in a dual fashion, both directly (on the cardiac muscle and the specialized conduction system of sinoatrial [SA] node, atrioventricular [AV] node, and His-Purkinje system) and indirectly (on the cardiovascular system mediated by the autonomic nervous reflexes). T he combined direct and indirect effects of the cardiac glycosides lead to changes in the electrophysiological properties of the heart, including alteration of the contractility; heart rate; excitability; conductivity; refractory period; and automaticity of the atrium, ventricle, Purkinje fibers, AV node, and SA node. T he heart response to the cardiac glycosides is a dose-dependent process and varies considerably between the normal hear and the heart with CHF. T he effects observed after the administration of low doses (therapeutic doses) differ considerably from those observed at high doses (cardiotoxic doses). T he pharmacological effects discussed consequently relate mainly to therapeutic doses administered to patients with CHF. T he effects of cardiac glycosides on the properties of the heart muscle and different sites of the conduction system are summarized in T able 26.2. T he increased force and rate of myocardial contraction (positive inotropic effect) and the prolongation of the refractory period of the AV node are the effects most relevant to the CHF problem. Both of these effects result from the direct action of the cardiac glycosides on the heart. T he indirect effects are manifested as increased vagal nerve activity, which probably results from the glycoside-induced sensitization of the baroreceptors of the carotid sinus to changes in the arterial pressure; in other words, any given increase in the arterial blood pressure results in an increase in the vagal activity (parasympathetic) coupled with a greater decrease in the sympathetic activity. T he vagal effect with uncompensated sympathetic response results in decreased heart rate and decreased peripheral vascular resistance (afterload). T herefore, cardiac glycosides reverse most of the symptoms associated with CHF as a result of increased sympathetic system activity, including increased heart rate, vascular resistance, and afterload. T he administration of cardiac

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glycosides to a patient with CHF increases cardiac muscle contraction, reduces heart rate, and decreases both edema and the heart size.

Table 26.2. Effects of Cardiac Glycosides on the Heart Purkinje Atrium Ventricle

AV Fiber

SA Node

Node

Contractility

↑

↑

—

—

—

Excitability

0

Variable

↑

—

—

Conductivity

↑

↑

↓

↓

—

Refractory period

↓

↓

↑

↑

—

Automaticity

—

—

↑

—

↓

AV, atrioventricular; SA, sinoatrial; ↑ increased action; ↓ decreased action; 0, no action; —, no data available.

P.702

Bioch emical mech an ism of action T he mechanism whereby cardiac glycosides cause a positive inotropic effect and electrophysiological changes is still not completely known despite years of active investigation. Several mechanisms have been proposed, but the most widely accepted mechanism involves the +

+

ability of cardiac glycosides to inhibit the membrane-bound Na /K –adenosine triphosphatase +

+

(Na /K -AT Pase) pump responsible for sodium/potassium exchange. T o understand better the correlation between the pump and the mechanism of action of cardiac glycosides on the heart muscle contraction, one has to consider the sequence of events associated with cardiac action potential that ultimately leads to muscular contraction. T he process of membrane depolarization/repolarization is controlled mainly by the movement of the three ions, Na + , K + , Ca 2+ , in and out of the cell. At the resting state (no contraction), the concentration of sodium is high outside the cell. On membrane depolarization, Na

+

fluxes in, leading to an immediate elevation of the action potential.

Elevated intracellular sodium triggers the influx of Ca 2+ , which occurs slowly and is represented by the plateau region of the cardiac action potential. T he influx of calcium results in efflux of potassium out of the myocardium. T he Na 1 /K + exchange occurs at a later stage of the action potential to restore the membrane potential to its normal level (for further detail, see the discussion of 1

antiarrhythmic agents and their classification at the end of this chapter). T he Na /K +

+

exchange

+

requires energy and is catalyzed by the enzyme Na /K -AT Pase. Cardiac glycosides are proposed to inhibit this enzyme, with a net result of reduced sodium exchange with potassium (i.e., increased intracellular sodium), which in turn results in increased intracellular calcium. Elevated intracellular calcium concentration triggers a series of intracellular biochemical events that ultimately result in an increase in the force of the myocardial contraction, or a positive inotropic effect. (T he events that lead to muscle contraction are covered in further detail in the discussion of the mechanism of action of the calcium channel blockers later in this chapter.) T his mechanism of the cardiac glycosides via inhibiting the Na + /K + -AT Pase pump is in agreement with the fact that the action of the cardiac glycosides is enhanced by low extracellular potassium and inhibited by high extracellular potassium. T he cardiac glycosides–induced changes in the

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electrophysiology of the heart also can be explained based on the inhibition of Na + /K + -AT Pase. It has been suggested that the intracellular loss of potassium because of inhibition of the pump causes a decrease in the cellular transmembrane potential approaching zero. T his decrease in the membrane potential is sufficient to explain the increased excitability and other electrophysiological effects observed following cardiac glycosides administration.

Stru ctu ral requ iremen ts for in trin sic activity Many hypotheses have been put forth to explain the cardiac glycoside structure–activity relationships (SARs). Some of the difficulty in arriving at a universally acceptable SAR model has been attributed to the early method of testing cardiac glycoside preparations and the lack of a well-characterized cardiac glycoside “ receptors.” Until the early 1970s, nearly all the cardiac glycosides were evaluated based on their cardiac toxicity rather than on the more therapeutically relevant criteria. T his was partly because of the belief that the cardiac toxicity was, in fact, an extension of the desired cardiotonic action. T hus, comparisons of cardiac glycoside preparations were based on the amount of drug required to cause cardiac arrest in test animals, usually anesthetized cats. More recently, most SAR studies have relied, at least initially, on results obtained with isolated cardiac tissue or whole-heart preparations. In these models, inotropic activity, contractility, and so forth can be directly assessed. In addition, the recognition of cardiac Na + /K + -AT Pase as the probable receptor for the cardiac glycosides has made the inhibition of this enzyme system an important criterion for the cardiac glycosides activity. Much of the interest in the effects of structural modification on cardiotonic activity results from the desire to develop agents with less toxic potential. Early studies based primarily on cardiac toxicity testing data suggested the importance of the steroid “ backbone” shape, the 14-β-hydroxyl and the 17-unsaturated lactone for activity. More recent studies have been directed toward characterizing +

+

the interaction of the cardiac glycosides with Na /K -AT Pase, the putative cardiac glycoside receptor. Using this enzyme model with enzyme inhibition as the biological end point, a number of hypotheses for cardiac glycoside receptor–binding interactions have been put forth. Many of these suggested that the 17-lactone plays an important role in receptor binding. Using synthetic analogues, it was found that unsaturation in the lactone ring was important, with the saturated lactone analogue showing diminished activity (4,5). Further investigations of synthetic compounds in which the lactone was replaced with open-chain structures of varying electronic and steric resemblance to the lactone showed that, in fact, the α,β-unsaturated lactone ring at C-17 was not an absolute requirement and that several α,β-unsaturated open-chain groups could be replaced with little or no loss in activity (4,5). For example, analogs possessing an α,β-unsaturated nitrile at the 17-β position had high activity. In light of this, most current theories point toward a key interaction of the carbonyl oxygen (or nitrile nitrogen) with the cardiac glycoside binding site on Na + /K + -AT Pase (6,7). Some controversy, however, exists regarding this point. T he importance of the “ rest” of the cardiac glycoside molecule must not be ignored. Despite the apparently dominant role of the 17-lactone, it is the steroid (A-B-C-D) ring system that provides the lead structure for cardiac glycoside activity. Lactones alone, when not attached to the steroid ring system, show no 1

+

Na /K -AT Pase inhibitory activity. Some important steroid structural features have become apparent. P.703 T he C-D ci s ring juncture appears to be critical for activity in compounds possessing the unsaturated butyrolactone in the normal 17-β position. T his apparent requirement may be a reflection of changes in the spatial orientation of the 17-substituent (7). Moreover, the 14-β-OH is now believed to be dispensable, and the contribution to activity previously attributed to this group is thought to be related to the need to retain the sp 3 and ci s character of the C-D ring juncture. T he earlier interpretation arose from the fact that 14-deoxy analogues often had unsaturation in the D ring in place of the 14-β-OH. T his double bond markedly influenced the position of the C-17 substituent, thereby complicating interpretation of 14-β-OH group importance. Finally, the A-B ci s ring juncture also appears not to be mandatory for cardiac glycosides activity. T his feature, however, is characteristic of all clinically useful cardiac glycosides, and conversion to an A-B trans ring system generally leads to a marked drop in activity unless compensating modifications are made elsewhere in the molecule.

Ph armaceu tical preparation s T he cardiac glycoside preparations that have been used range from powdered digitalis leaf to

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purified individual glycosides, including gitalin, lanatoside C, its partially hydrolyzed product deslanatoside C (desacetyl lanatoside C), digoxin, and ouabain (T able 26.3). Currently, digoxin is the only cardiac glycoside commercially available for therapeutic use in the United States. T o arrive at an effective plasma concentration, a large initial dose (i.e., digitalizing or loading dose) often is given. T he purpose of this large initial dose is to achieve a therapeutic blood and tissue level in the shortest possible time. Depending on the condition of the patient and the desired therapeutic goal, the loading dose may be much less than, or almost equal to, the dose that is likely to cause toxicity. Once the desired effect is obtained, the amount of drug lost from the body per day is replaced with a maintenance dose.

Absorption , metabolism, an d excretion T he therapeutic effects of all cardiac glycosides on the heart are qualitatively similar; however, the glycosides largely differ in their pharmacokinetic properties. T he latter are greatly influenced by the lipophilic character of each glycoside. In general, cardiac glycosides with more lipophilic character are absorbed faster and exhibit longer duration of action as a result of a slower urinary excretion rate. T he lipophilicity of a cardiac glycoside is measured by its partitioning between chloroform and water mixed with methanol: T he higher the concentration of the cardiac glycoside in the chloroform phase, the higher its partition coefficient, and the more lipophilic it is. T he partition coefficients for five cardiac glycosides are listed in T able 26.4. It is evident from a comparison of the coefficients that their lipophilicity is markedly influenced by the number of sugar molecules and the number of hydroxyl groups on the aglycone part of a given glycoside. Lanatoside C, with a partition coefficient of 16.2, is far less lipophilic than that of acetyldigoxin (partition coefficient, 98), which structurally differs only in lacking the terminal glucose molecule. Likewise, a comparison of digitoxin and digoxin structures reveals that they only differ by an extra hydroxyl in digoxin at C-12. T his seemingly minor difference in their partition coefficients from 96.5 to 81.5 for digitoxin and digoxin, respectively, results in significant differences in their pharmacokinetic behavior (T able 26.5). T able 26.4 also illustrates that the P.704 presence of the 3-O-acetyl group on acetyldigoxin enhances its lipophilic character more than that of desacetyl analogue, digoxin (partition coefficients of 98 and 81.5, respectively). T he glycoside G-strophanthin (ouabain) possesses a very low lipophilic character because of the presence of five free hydroxyl groups on the steroid nucleus of the aglycone ouabagenin.

Table 26.3. Cardiac Glycosides and Their Dosage Forms Namea

Dosage Forms

Digoxin USP and BP

Tablets, elixir, pediatric

Digitalis powder (Leaf) BP

Tablets, capsules

Digitoxin BP

Tablets, injection

Lanatoside C BP

Tablets

Ouabain BP

Injection (G-Strophanthin)

Deslanatoside C BP

Injection (desacetyllanatoside C)

a

Those cardiac glycosides with only the BP (British Pharmacopeia) designation are available only in Canada and other countries except the United States.

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Table 26.4. Effect of Glycoside Structure on Partition Coefficient Partition Coefficient (CHCl 3 /16% aq.M eOH)

Glycoside Lanatoside C (glucose3-acetyldigitoxose–digitoxose 2 – digoxigenin)

16.2

Digoxin (digitoxose 3 -digoxigenin)

81.5

Digitoxin (digitoxose 3 -digitoxigenin)

96.5

Acetyldigoxin (3-acetyldigitoxosedigitoxose 2 -digoxigenin)

98.0

G-Strophanthin (rhamnose-ouabagenin)

very low

Table 26.5. Comparison of the Pharmacokinetic Properties for Digoxin and Digitoxin Digoxin

Digitoxin

Gastrointestinal absorption

70–85%

95–100%

Average half life

1–2 days

5–7 days

Protein binding

25–30%

90–95%

Enterohepatic cycling

5%

25%

Excretion

Kidneys; largely unchanged

Liver metabolism

Therapeutic plasma level

0.5–2.5 ng/ml

20–35 ng/ml

Digitalizing

Oral: 0.75–1.5

Oral: 0.8–1.2

IV: 0.5–1.0

IV: 0.8–1.2

0.125–0.5

0.05–0.2

dose (mg) Maintenance dose (oral mg)

Digoxin is the most frequently used cardiac glycoside. T he absorption of digoxin from the

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gastrointestinal tract is a passive process that depends on its lipid solubility, dissolution, and membrane permeability of the drug. T he oral bioavailability of digoxin following oral administration exhibits interindividual variability, ranging from 70 to 85% of an administered dose. T his interindividual variability has been attributed to intestinal P-gp efflux and P-gp–dependent renal elimination. Although digoxin is not extensively metabolized, it is transported from intestinal enterocytes along its epithelium into the intestinal lumen (effluxed) by P-glycoprotein (P-gp), which is also expressed in the kidney and liver. Alterations in P-gp transport may be the basis for several digoxin–drug interactions. For this reason, it is important to establish carefully the effective dose of digoxin for each patient to avoid digitalis toxicity. Once the cardiac glycosides are absorbed, they bind to plasma proteins; digoxin has only 30% binding. T he half-life of digoxin in patients with normal renal function is 1.5 to 2.0 days. Biliary excretion of digoxin is minimal. Digoxin is eliminated primarily unchanged by renal tubule excretion. Contributing to the discontinuance of digitoxin as a therapeutic agent was a half-life range between 5 and 7 days because of its enterohepatic circulation. Approximately 25% of an absorbed dose of digitoxin is excreted in the bile unchanged, to be reabsorbed via enterohepatic circulation. Digitoxin, however, is extensively metabolized by the liver to a variety of metabolites, including (digitoxose) 2 digitoxigenin, (digitoxose) 1 -digitoxigenin, and (digitoxose) 1 -digitoxigenin. T race amounts of digoxin have been discovered in the urine. T he pharmacokinetic data for digoxin and digitoxin is summarized in T able 26.5.

Dru g in teraction s Digoxin–drug interactions are common causes of digitalis toxicity. Recently, the clinical significance of the P-gp–dependent renal tubular secretion of digoxin associated with the well-documented digoxin–quinidine interaction has been reported (8). T he discovery that digoxin is actively secreted into the urine by the renal tubular cell via the P-gp efflux pump has led to the conclusion that the digoxin–quinidine interaction can be attributed to inhibition of renal tubular secretion of digoxin by quinidine (a P-gp substrate). Quinidine competitively binds to P-gp in the renal tubule reducing the renal secretion of digoxin by as much as 60%, raising digoxin's plasma concentration to toxic levels. Other drugs that are substrates for renal P-gp also are likely to be associated with digoxin–drug interactions. Another documented digoxin–drug interaction associated with increased digoxin blood levels and toxicity is with verapamil. Unlike quinidine, verapamil inhibits intestinal P-gp efflux of digoxin, thereby blocking the intestinal secretion of digoxin into the lumen of the intestine and raising digoxin blood levels to toxic levels. On the other hand, the rifampin–digoxin interaction involves the rifampin induction of intestinal P-gp expression, thereby increasing the P-gp–mediated secretion of digoxin. T his results in the lowering of digoxin blood levels to subtherapeutic concentrations. T he P-gp transporters and their substrates, inhibitors, or inducers (see T able 10.16 for list) appear to play an important role in controlling the digoxin area under the curve (AUC) values through the renal tubular and intestinal secretion of digoxin and, subsequently, to digoxin–drug interactions and digitalis toxicity. Concurrent use of the cardiac glycosides with antiarrhythmics, sympathomimetics, β-adrenergic blockers, and calcium channel blockers that are substrates for P-gp may alter control of arrhythmias. T he absorption of digoxin after oral administration also can be significantly altered by other drugs concurrently present in the gastrointestinal tract. For example, laxatives may interfere with the absorption of digoxin because of increased intestinal motility. T he presence of the drug cholestyramine, an agent used to treat hyperlipoproteinemia, decreases the absorption of digoxin by binding to and retaining digoxin in the gastrointestinal tract. Antacids, especially magnesium trisilicate, and antidiarrheal adsorbent suspensions also may inhibit the absorption of the digoxin. Potassium-depleting diuretics, such as thiazides, may increase the possibility of digitalis toxicity because of the additive hypokalemia. Several other drugs that are known to bind to plasma proteins, such as thyroid hormones, have the potential to displace digoxin from its plasma-binding sites, thereby increasing its free drug concentration to a toxic level.

T h erapeu tic u ses Although the primary clinical use for digoxin is in the treatment of CHF, this agent also is used in cases of atrial flutter or fibrillation and paroxysmal atrial tachycardia.

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T oxicity All cardiac glycosides preparations have the potential to cause toxicity. Because the minimal toxic dose of the glycosides is only two- to threefold the therapeutic dose, intoxication is quite common. In mild to moderate toxicity, the common symptoms are anorexia, nausea and vomiting, muscular weakness, bradycardia, and ventricular premature contractions. T he nausea is a result of excitation of the chemoreceptor trigger zone in the medulla. In severe toxicity, the common symptoms are blurred vision, disorientation, diarrhea, ventricular tachycardia, and AV block, which may progress into ventricular fibrillation. It generally is accepted that the toxicity of the cardiac glycosides results +

+

from inhibition of the Na /K -AT Pase pump, which results in increased intracellular levels of Ca Hypokalemia (decreased potassium), which can be induced by coadministration of

2+

. P.705

thiazide diuretics, of glucocorticoids, or by other means, can be an important factor in initiating a toxic response. It has been shown that low levels of extracellular K + partially inhibit the Na + /K + -AT Pase pump. In a patient stabilized on a cardiac glycoside, the Na + /K + -AT Pase pump already is partially inhibited, and the hypokalemia only further inhibits the pump, causing an intracellular buildup of sodium, which leads to an increase in intracellular calcium levels. T he high levels of calcium are responsible for the observed cardiac arrhythmias characteristic of the cardiac glycosides toxicity. A common procedure used in treating cardiac glycoside toxicity is to administer potassium salts to +

+

increase extracellular potassium level, which stimulates the Na /K -AT Pase pump, resulting in decreased intracellular sodium levels and, thus, decreased intracellular calcium. In treating any cardiac glycoside–induced toxicity, it is important to discontinue administration of the drug in addition to administering a potassium salt. Other drugs that may be useful in treating the tachyarrhythmias present during toxicity are lidocaine, phenytoin, and propranolol. Specific antibodies directed toward digoxin (Dig-Bind) have been used experimentally and proven to be very effective.

Nonglycosidic Positiv e Inotropic Agents Nonglycosidic positive inotropic drugs can be divided into two main classes: those that act via stimulating the synthesis of cyclic adenosine monophosphate (cAMP), such as adrenergic and dopaminergic agonists; and those that inhibit the hydrolysis of cAMP, such as phosphodiesterase 3 (PDE3) inhibitors.

Phosphodiesterase 3 Inhibitors T he mechanism of cardiac contraction involves a G-protein signal transduction pathway, which regulates intracellular calcium concentrations. Activation of the G s -protein involves the formation of intracellular cAMP, which thereby increases intracellular calcium, stimulating cardiac muscle contraction (see Chapter 4). Relaxation occurs when the released cAMP is hydrolyzed by cytosolic cAMP-dependent PDE3, one of the phosphodiesterase isofoms. T herefore, inhibition of PDE3 increases intracellular cAMP, promoting cardiac muscle contraction but vasodilation of vascular smooth muscle. (See Chapter 17 for more information about phosphodiesterases.) T he overall cardiostimulatory and vasodilatory actions of PDE3 inhibitors make them suitable for the treatment of heart failure, because vascular smooth muscle relaxation reduces ventricular wall stress and the oxygen demands placed on the failing heart. T he cardiostimulatory effects of the PDE3 inhibitors increases inotropy, which further enhances stroke volume and ejection fraction. Clinical trials have shown that long-term therapy with PDE3 inhibitors increases mortality in heart failure patients. T herefore, these PDE3 inhibitors are not used for the long-term, chronic therapy of CHF. T hey are very useful, however, in treating acute, decompensated heart failure or temporary bouts of decompensated chronic failure. T hey are not used as a monotherapy. Instead, they are used in conjunction with other treatment modalities, such as diuretics, angiotensin-converting enzyme inhibitors, β-blockers, or cardiac glycosides. T he PDE3 inhibitors contract cardiac muscle and are used for treating heart failure, whereas the phosphodiesterase 5 (PDE5) inhibitors are vasodilators and are used for treating male erectile dysfunction. Note that the generic names for PDE3 inhibitors end in “ one,” and those for the PDE5 inhibitors end in “ fil.”

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Side effects an d con train dication s T he most common and severe side effect of PDE3 inhibitors is ventricular arrhythmias, some of which may be life-threatening. Other side effects included headaches and hypotension, which are not uncommon for drugs that increase cAMP in cardiac and vascular tissues, with other examples being β-agonists.

Milrin on e (Primacor®) an d imamrin on e (In ocor®) Although the digitalis glycosides may be the principal therapeutic agents for the treatment of CHF, they are not the only positive inotropic agents available. Among the “ nonglycoside” inotropic agents are the bipyridines, inamrinone and milrinone, which are selective PDE3 inhibitors (Fig. 26.4). Inamrinone and milrinone are positive inotrope and vasodilators indicated for the short-term intravenous management of CHF in patients who have not responded adequately to digitalis, diuretics, and/or vasodilators (9,10). Milrinone is the drug of choice from among the currently available PDE3 inhibitors because of its greater selectivity for PDE3, shorter half-life (30–60 min), and fewer side effects. Imamrinone is associated with thrombocytopenia in 10% of patients. Inamrinone was introduced in 1978, and it produces both positive inotropic and concentrationdependent vasodilatory effects. Despite similar positive inotropic action to the cardiac glycosides, the inotropic action involves inhibition of PDE3, as previously described. Inamrinone was approved for the short-term intravenous administration in patients with severe heart failure refractory to other measures. Although inamrinone is orally active, several adverse side effects have dampened enthusiasm for long-term oral inamrinone therapy. T hese effects include gastrointestinal disturbances, thrombocytopenia, and impairment of the liver function. For intravenous infusion, inamrinone lactate and milrinone lactate injection solutions may be P.706 diluted in sodium chloride injection. Inamrinone lactate for injection is preserved with sodium metabisulfite and needs protection from light. It should not be diluted with solutions containing dextrose because a chemical reaction occurs in 24 hours. For milrinone, an immediate chemical interaction with furosemide with the formation of a precipitate is observed when furosemide is injected into an infusion of milrinone. Patients sensitive to bisulfites may also be sensitive to inamrinone lactate injection, which contains sodium metabisulfite.

Fig. 26.4. Miscellaneous inotropic agents.

T he pharmacokinetics for inamrinone shows a half-life in healthy volunteers of approximately 3 to 4 hours, whereas in patients with CHF, the plasma half-life increases approximately 50% (5–8 hours). For infants younger than 4 weeks, the half-life life is 12.7 to 22.2 hours, and infants older than 4 weeks, the half-life is 3.8 to 6.8 hours. T ime to peak effect is less than 10 minutes, with its duration of action ranging from 30 minutes to 2 hours depending on the dosage. Approximately 63% of imamrinone is eliminated via the urine as unchanged drug, and 18% is eliminated in the feces. Elderly patients are more likely to have age-related impairment of renal function, which may require adjustment of dosage in patients receiving inamrinone.

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T he limited success of inamrinone led to the development of structurally related newer agents, such as milrinone, with a mechanism of action similar to inamrinone. Milrinone, however, is an order of magnitude more potent than inamrinone. Furthermore, preliminary reports show it to be better tolerated, with no apparent thrombocytopenia or gastrointestinal disturbances. Milrinone is excreted largely unchanged in the urine, and accordingly, patients with impaired renal function require reduced dosages. T he pharmacokinetics for milrinone following intravenous injections to patients with CHF showed an elimination half-life of 2 to 3 hours. Its primary route of excretion is via the urine as unchanged milrinone (83%) and its O-glucuronide metabolite (12%). In patients with renal function impairment, elimination of unchanged milrinone is reduced, suggesting that a dosage adjustment may be necessary.

β-Adrenergic Receptor Agonists Another promising area for the development of new positive inotropic agents is that of β-adrenergic receptor agonists (11) (see Chapter 13). T he myocardium has mostly β 1 -adrenergic receptors, and stimulation of these receptors by a variety of β-adrenergic agonists produces a potent positive inotropic response involving the G-protein signal transduction process increasing intracellular cAMP levels that lead to a cascade of events that ultimately produce an increase in intracellular Ca 2+ , thereby increasing myocardial contractility (discussed in Chapters 4 and 13). Although many drugs possess β-adrenergic agonist activity, most have side effects that make them inappropriate for the treatment of CHF. For example, the well-known catecholamines, norepinephrine and epinephrine, are potent nonselective adrenergic receptor agonists. Because the actions of these agents are not limited to the myocardial β 1 -receptors, however, they produce undesirable positive chronotropic effects, exacerbate arrhythmias, and result in vasoconstriction. T hese effects limit their utility in the treatment of CHF.

Dobu tamin e (Dobu trex) Among the most promising β 1 adrenergic agonists are those derived from dopamine, the endogenous precursor to norepinephrine. Dopamine itself is a potent stimulator of the β 1 -receptors, but it results in many of the undesirable side effects described in Chapter 13. T he new analogs of dopamine that have been developed retain the potent inotropic effect but possess fewer effects on heart rate, vascular tone, and arrhythmias. Dobutamine is a prime representative of this group of agents. Dobutamine is a potent β 1 -adrenergic agonist on the myocardium (as well as α 1 -agonist and -antagonist activities; see Chapter 13 for details concerning its mechanism of action) with beneficial effects, the composite of a variety of actions on the heart and the peripheral vasculature. Dobutamine is active only by the intravenous route because of its rapid first-pass metabolism via COMT (catechal-O-methyl transferase). T herefore, its use is limited to critical care situations. Nonetheless, its parenteral success has led to the search and development of orally active drugs. One of the major limitations associated with β 1 -agonists is the phenomenon of myocardial β-receptor desensitization. T his lowered responsiveness (desensitization) of the receptors appears to be due to a decrease in the number of β 1 -receptors and partial uncoupling of the receptors from adenylate cyclase.

Drugs for T he T reatm ent of Angina Angina Pectoris Angina pectoris is the chronic disease affecting the coronary arteries, which supply oxygenated blood from the left ventricle to all heart tissues, including the ventricles themselves. When the lumen of the coronary artery becomes restricted, it becomes less efficient in supplying blood and oxygen to the heart, and the heart is said to be “ ischemic” (oxygen deficient). Angina is the primary symptom of ischemic heart disease and is characterized by a sudden, severe pain originating in the chest, often radiating to the left shoulder and down the left arm. Angina is further subclassified into typical or variant angina based on the precipitating factors and the electrophysiological changes observed during the attack. T ypical angina usually is the result of an advanced state of atherosclerosis and is provoked by food, exercise, and emotional factors. It is characterized by low ST segment of the electrocardiogram. Variant or acute angina results from sudden spasm in the coronary artery unrelated to atherosclerotic narrowing of the coronary circulation and can occur at rest. It is

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characterized by an increase in the ST segment of the electrocardiogram.

Antianginal Drugs T herapy of angina is directed mainly toward alleviating and preventing anginal attacks by altering the oxygen P.707 supply/oxygen demand ratio to the cardiac muscle or dilating the coronary vessels. T hree classes of drugs are found to be very efficient in this regard, although via different mechanisms. T hese include organic nitrates, calcium channel blockers, and β-adrenergic blockers.

Organic Nitrates Organic nitrates have dominated the treatment of acute angina over the last 100 years. Although the recent introduction of the calcium channel blockers and the β-blockers as antianginal agents has expanded the physician therapeutic arsenal, organic nitrates are still the class of choice in the treatment of acute anginal episodes.

Overview Organic nitrates are esters of simple organic alcohols or polyols with nitric acid. T his class was developed after the antianginal effect of amyl nitrite (ester of isoamyl alcohol with nitrous acid) was first observed in 1857. Five members of this class are in clinical use today: amyl nitrite (amyl nitrite inhalant USP), nitroglycerin, isosorbide dinitrate, erythrityl tetranitrate, and pentaerythritol tetranitrate (Fig. 26.5). T wo additional organic nitrates, tenitramine and propatylnitrate, are currently available in Europe (Fig. 26.5). T his class usually is referred to as organic nitrates, because all of these agents, except amyl nitrite, are nitrate esters. It should be noted that the generic names do not always precisely describe the chemical nature of the drug but, rather, are used for simplicity. For example, the drug nitroglycerin is not really a nitro compound, because a nitro compound means a nitro group attached to a carbon atom (i.e., NO 2 -C); the correct chemical name of nitroglycerin is glyceryltrinitrate. Another example is amyl nitrite, the structure of which indicates that it is an ester of isoamyl alcohol with nitrous acid; the correct chemical name of this drug is isoamyl nitrite. T he chemical nature of these molecules as esters constitutes some problems in formulating these agents for clinical use. T he small lipophilic ester character makes them volatile. Volatility is an important concern in drug formulation because of the potential loss of the active principle from the dosage form. In addition, moisture should be avoided during storage to minimize the hydrolysis of the ester bond, which can lead to a decrease in the therapeutic effectiveness. Lastly, because these agents are nitrate esters, they possess explosive properties, especially in the pure concentrated form. Dilution in a variety of vehicles and excipients eliminates this potential hazard. T he lipophilic nature of these esters, however, makes these agents very efficient in emergency treatment of anginal episodes as a result of their rapid absorption through biomembranes.

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Fig. 26.5. Organic nitrates and nitrites.

Pharmacological actions T he oxygen requirements of the myocardial tissues are related to the workload (oxygen demand) of the heart, which is, in part, a function of the heart rate, the systolic pressure, and the peripheral resistance of the blood flow (oxygen supply). Myocardial ischemia occurs when the oxygen supply is insufficient to meet the myocardial oxygen demand. T his can occur, as explained previously, because of atherosclerotic narrowing of the coronary circulation (typical) or vasospasm of the coronary artery (variant). T he nitrates have been shown to be effective in treating angina resulting from either cause. T he vasodilating effect of organic nitrates on the veins leads to pooling of the blood in the veins and decreased venous return to the heart (decreased preload), whereas vasodilation of the coronary arterioles decreases the resistance of the peripheral tissues (decreased afterload). T he decrease in both preload and afterload results in a generalized decrease in the myocardial workload, which translates into a reduced oxygen demand by the myocardium. Organic nitrates restore the balance between oxygen supply by venous dilation and oxygen demand by decreasing the myocardial workload.

Biochemical mechanism of action T he organic nitrates (Fig. 26.5) are pharmacological sources of nitric oxide (NO) for the body. In the cardiovascular system, NO is naturally produced by vascular endothelial cells. T his endothelialderived NO has several important functions, including relaxation of vascular smooth muscle, inhibiting platelet aggregation (antithrombotic), and inhibiting leukocyte-endothelial interactions (anti-inflammatory). T hese actions involve NO-stimulated formation of cyclic guanosine monophosphate (cGMP) (see Chapter 29). Nitrodilators are drugs that mimic the actions of endogenous NO by releasing NO or forming NO within tissues. Free tissue sulfhydryl groups play a key role in the venodilation effect of nitroglycerin, which is supported by experimental evidence showing that prior administration of N-acetylcysteine, which should increase the availability of free sulfhydryl groups, resulted in an increase in the venodilating effect of organic nitrates. Similarly, pretreatment with reagents that react with free sulfhydryl groups, such as ethacrynic acid, blocked glyceryl trinitrate venodilation in vitro (13). A more complex mechanism for nitrate venodilation, however, was proposed P.708 by Ignarro et al. (14). T hey suggested that the nitrates act indirectly, by stimulating the enzyme guanylate (also known as guanylyl) cyclase and, thereby, producing elevated levels of cGMP, which in turn leads to venodilation. T he initial stimulation of soluble guanylate cyclase is believed to be

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mediated by a nitrate-derived nitrosothiol metabolite produced intracellularly. In support of this mechanism is the observation that a variety of synthetic nitrosothiols were found to increase markedly soluble guanylate cyclase activity and to produce venodilation in vitro (15,16,17,18,19). Such a mechanism is consistent with the requirement for free sulfhydryl groups described previously. A unifying mechanism suggests that the organic nitrates through the formation of NO via a nitrosothiol-intermediate activate soluble guanylate cyclase, increasing intracellular cGMP concentrations, which in turn blocks the Ca 2+ -catalyzed vascular contractions (Fig. 29-3) (20,21,22,23). Depletion of sulfhydryl groups during this metabolic process may be a major factor in the development of nitrate tolerance, along with compensatory physiologic mechanisms. Data also exist suggesting that organic nitrates increase intraplatelet cGMP concentrations, thereby inhibiting platelet aggregation. T hese pharmacological actions of organic nitrates appear to preferentially occur within portions of blood vessels containing damaged endothelium, thus making them extremely useful in the pharmacotherapy of acute ischemic events.

Pharmaceutical preparations and dosage forms Organic nitrates are administered by inhalation; by infusion; as sublingual, chewable, and sustainedrelease tablets; as capsules; as transdermal disks; and as ointments.

Absorption, metabolism, and therapeutic effects Organic nitrates are used for both treatment and prevention of painful anginal attacks. T he therapeutic approaches to achieve these two goals, however, are distinctly different. For the treatment of acute anginal attacks (i.e., attacks that have already begun), a rapid-acting preparation is required. In contrast, preventative therapy requires a long-acting preparation with more emphasis on duration and less emphasis on onset. T he onset of organic nitrate action is influenced not only by the specific agent chosen but also by the route of administration. Sublingual administration is used predominantly for a rapid onset of action. T he duration of nitrate action is strongly influenced by rate of metabolism. All of the organic nitrates are subject to rapid first-pass metabolism not only by the action of glutathione-nitrate reductase in the liver, but also in extrahepatic tissues, such as the blood vessel walls themselves (24,25). In addition, rapid uptake into the vessel walls plays a significant role in the rapid disappearance of organic nitrates from the bloodstream. Sublingual, transdermal, and buccal administration routes have been used in an attempt to avoid at least some of the hepatic metabolism. Acute angina most frequently is treated with sublingual glyceryl trinitrate. T his sublingual preparation is rapidly absorbed from the sublingual, lingual, and buccal mucosa and usually provides relief within 2 minutes. T he duration of action also is short (~ 30 minutes). Other treatments include amyl nitrite by inhalation and sublingual isosorbide dinitrate. Amyl nitrite is by far the fastest-acting preparation, with an onset of action in approximately 15 to 30 seconds, but the duration of action is only approximately 1 minute. Isosorbide dinitrate, although usually used as a long-acting agent, may be used to treat acute angina. Sublingually administered isosorbide dinitrate has a somewhat slower onset than glyceryl trinitrate (~ 3 minutes), but its action may last for 4 to 6 hours. Although the onset appears to be almost as rapid as that of glyceryl trinitrate, waiting an additional minute for relief may be deemed unacceptable by some patients. T o prevent recurring angina, long-acting organic nitrate preparations are used. Several agents fall into this category, such as orally administered isosorbide dinitrate, pentaerythritol tetranitrate, and erythrityl tetranitrate. In addition, a number of long-acting glyceryl trinitrate preparations are available. T hese include oral sustained-release forms, glyceryl trinitrate ointment, transdermal patches, and buccal tablets. Of these therapeutic options, isosorbide dinitrate and glyceryl trinitrate preparations are by far the most frequently used. At first, the whole concept of prophylactic nitrate use was met with skepticism by many physicians, both because early studies indicated that oral nitrates were almost completely broken down by first-pass metabolism (24,25) and because blood levels of the parent drug appeared to be virtually nil. T hese findings, in conjunction with several clinical studies showing equivocal efficacy, led Needleman et al. (25) to conclude, “ T here is no rational basis for the use of ‘long-acting' nitrates (administered orally) in the prophylactic therapy of angina pectoris.” More recent studies, however, suggest that oral prophylactic nitrates may be effective if appropriate doses are used (26). Moreover, some metabolites of long-acting nitrates are active as venodilators, albeit less potent than the parent drug. An example of this is isosorbide dinitrate, which is metabolized primarily in the liver by glutathione-nitrate reductase, which also

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participates in the metabolism of other organic nitrates, catalyzing the denitration of the parent drug to yield two metabolites, 2- and 5-isosorbide mononitrate (27). Of these, the 5-isomer is still a potent vasodilator, and its plasma half-life of approximately 4.5 hours is much longer than that of isosorbide dinitrate itself. T he extended half-life, because of the metabolite's resistance to further metabolism, indicates that it may be contributing to the prolonged duration of action associated with use of isosorbide dinitrate (27).

Adverse effects Most patients tolerate the nitrates fairly well. Headache and postural hypotension are the most common side effects of organic nitrates. Dizziness, nausea, vomiting, rapid pulse, and restlessness are among the additional side effects reported. T hese symptoms may be controlled by administering low doses initially P.709 and then gradually increasing the dose. Fortunately, tolerance to nitrate-induced headache develops after a few days of therapy. Because postural hypotension may occur in some individuals, advise the patient to sit down when taking a rapid-acting nitrate preparation for the first time. An effective dose of nitrate usually produces a fall in upright systolic pressure of 10 mm Hg and a reflex rise in heart rate of 10 beats per minute. Another concern associated with prophylactic nitrate use is the development of tolerance (26,28). T olerance, usually in the form of shortened duration of action, is commonly observed with chronic nitrate use. T he clinical importance of this tolerance is, however, a matter of controversy. Because tolerance to nitrates has not been reported to lead to a total loss of activity, some physicians feel that it is not clinically relevant. In addition, an adjustment in dosage can compensate for the reduced response (26). It also has been reported that intermittent use of long-acting and sustained-release preparations may limit the extent of tolerance development.

Drug interactions T he most significant interactions of organic nitrates are with those agents that cause hypotension, such as other vasodilators, alcohol, and tricyclic antidepressants, in which the potential for orthostatic hypotension may arise. On the other hand, concurrent administration with sympathomimetic amines, such as ephedrine and norepinephrine, may lead to a decrease in the antianginal efficacy of the organic nitrates.

Nitric oxide donor Molsidomine (Corvaton) is an oral NO donor known as a sydnone imine, a mesionic compound that is soluble in both water and organic solvents. Molsidomine is enzymatically metabolized by liver esterases to its active metabolite, linsodimine, which is spontaneously converted in the blood into its nitroso metabolite SIN-1A (Fig. 26.6). Molecular oxygen is required to release NO from SIN-1A. T he beneficial effects of molsidomine in treatment of angina were recognized before the role of endogenous NO for causing vasodilation was identified. A possible explanation may revolve around activation of K + channels. Molsidomine has a slower onset and longer duration of action than conventional nitrates because of the relatively slow rate of conversion to linsodimine, which has a rapid onset and short duration of action. Nitric oxide acts as a cellular messenger, leading to activation of soluble guanylate cyclase to release cGMP (see Chapter 29) and vasodilation. Because the metabolites of molsidomine generate NO without the need for enzymes or cofactors, other than the presence of oxygen, tolerance to prolonged exposure does not occur. T his mechanism differs from organic nitrates in which cysteine or thiol donors are required for conversion into NO. It is believed that cysteine depletion is the major factor in the development of nitrate tolerance.

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Fig. 26.6. Molsidomine metabolism to nitric oxide.

Molsidomine and lindosimine are therapeutic alternatives to traditional organic nitrates in treatment of stable angina, coronary vasospasm, and heart failure. Unlike organic nitrates, however, molsidomine and lindosimine have significant antiplatelet activity at therapeutic doses. T he cogeneration of superoxide during the release of NO is a major concern limiting its therapeutic potential in the treatment of angina. Its short duration of action necessitates an increased dose frequency, which might be inconvenient in a clinical setting. T he light sensitivity of molsidomine necessitates careful protection of infusion bags and tubing during administration.

Calcium Channel Blockers T he second major therapeutic approach to the treatment of angina is the use of calcium channel blockers (29.30) (see also the corresponding subsection in Chapter 28). In the 1906s, it was recognized that inhibition of calcium ion (Ca 2+ ) influx into myocardial cells may be advantageous in preventing angina. Currently, three classes of calcium channel blockers are approved for use in the prophylactic treatment of angina: the dihydropyridines nifedipine, nicardipine, and amlodipine; the benzothiazepine derivative diltiazem; as well as the aralkyl amine derivative verapamil and the diaminopropanol ether bepridil (Fig. 26.7). T he last-mentioned are reserved for treatment failures in that serious arrhythmias may occur.

Chemistry T he structural dissimilarity of these agents is apparent and serves to emphasize the fact that each is distinctly different from the others in its profile of effects. Although nifedipine and similar drugs belong to the dihydropyridine family, diltiazem belongs to the benzo[b-1,5]thiazepine family. Verapamil is structurally characterized by a central basic nitrogen to which alkyl and aralkyl groups are attached. It is noteworthy that diltiazem and verapamil are both chiral, possessing asymmetric centers. In each case, the dextro-rotatory (i.e., the (+ )-enantiomer) is approximately one order of magnitude more potent as a calcium channel blocker than the levo-rotatory (i.e., (–)-enantiomer).

Pharmacological Effects Calcium ions are known to play a critical role in many physiologic functions. Physiologic calcium is found in a P.710 variety of locations, both intracellular and extracellular. Because calcium plays such a ubiquitous role in normal physiology, the overall therapeutic effect of the calcium channel blockers often is the composite of numerous pharmacological actions in a variety of tissues. T he most important of these tissues associated with angina are the myocardium and the arterial vascular bed. Because of the dependency of myocardial contraction on calcium, these drugs have a negative inotropic effect on the heart. Vascular smooth muscle also depends on calcium influx for contraction. Although the

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underlying mechanism is somewhat different, inhibition of calcium channel influx into the vascular smooth muscles by the calcium channel blockers leads to arteriolar vasodilation. T he venous beds appear to be less affected by the calcium channel blockers. T he negative inotropic effect and arterial vasodilation result in decreased heart workload and afterload, respectively. T he preload is not affected because of a lesser sensitivity of the venous bed to the calcium channel blockers.

Fig. 26.7. Calcium channel blockers.

Mechanism of Action T he depolarization and contraction of the myocardial cells are mediated, in part, by calcium influx. As previously explained, the overall process consists of two distinct, inward ion currents: First, sodium ions flow rapidly into the cell through the “ fast channels,” and subsequently, calcium enters more slowly through the “ slow channels.” T he calcium ions trigger contraction indirectly by binding and inhibiting troponin, a natural suppressor of the contractile process. Once the inhibitory effect of troponin is removed, actin and myosin can interact to produce the contractile response. T he calcium channel blockers produce a negative inotropic effect by interrupting the contractile response. In vascular smooth muscles, calcium causes constriction by binding to a specific intracellular protein calmodulin to form a complex that initiates the process of vascular constriction. T he calcium channel blockers inhibit vascular smooth muscle contraction by depriving the cell from the calcium ions. T he effects of the three classes of calcium channel blockers on the myocardium and the arteries vary from one class to the other. Although verapamil and diltiazem affect both the heart and the arteriolar bed, the dihydropyridines have much less effect on the cardiac tissues and higher specificity for the arteriolar vascular bed. T herefore, both verapamil and diltiazem are used clinically in the management of angina, hypertension, and cardiac arrhythmia, whereas the dihydropyridines are used more frequently as antianginal and antihypertensive agents. Because nicardipine has a less negative inotropic effect than nifedipine, it may be preferred over nifedipine for patients with angina pectoris or hypertension who also have CHF dysfunction.

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T he recognition of the pivotal role of calcium flux on biological functions led to the reexamination of several therapeutic agents already in clinical use to see if their effects also were mediated through calcium-dependent mechanisms. Interestingly, many drugs were found to influence calcium movement and availability. In many cases, however, this effect was not found to contribute significantly to the desirable pharmacological activity, with other mechanisms playing more dominant roles.

Pharmaceutical Preparations Calcium channel blockers are administered as oral tablets and capsules as regular or sustainedrelease forms. Verapamil and diltiazem also are administered by injection.

Absorption, Metabolism, and Excretion T he calcium channel blockers are rapidly and completely absorbed after oral administration (see T able 28.11 for summary of pharmacokinetic parameters). Prehepatic first-pass metabolism by CYP3A4 enzymes occurs with some orally administered calcium channel blockers, especially verapamil, with its low bioavailability of 20 to 35%. T he bioavailability of diltiazem is 40 to 67%, of nicardipine 35%, of nifedipine 45 to 70%, and of amlodipine 64 to 90%. Verapamil is metabolized by CYP3A4 N-demethylation to its principal metabolite, norverapamil, which retains approximately 20% of the activity of verapamil, and by O-demethylation (CYP2D6) into inactive metabolites. Diltiazem is metabolized by enzyme hydrolysis to its primary metabolite, desacetyl derivative, which retains approximately 25 to 50% of the activity of diltiazem. T he oral bioavailability of diltiazem and verapamil may be increased with chronic use and increasing dose (i.e., bioavailability is nonlinear). Diltiazem undergoes P.711 N-demethylation by CYP3A4 and O-demethylation by CYP2D6. T he N-demethylated metabolism pathway results in mechanism-based inhibition of CYP3A4. T he major metabolite, detected following oral and continuous intravenous administration but not following rapid intravenous administration, is desacetyl diltiazem, which has one-quarter to one-half the arteriolar vasodilation activity of the parent compound. Its elimination half-life ranges from 5 to 8 hours, depending on the dosage. Its onset of action following oral administration is 30 to 60 minutes; 2 to 4% is excreted unchanged. For extended-release capsules, the onset of action is 2 to 3 hours. CYP3A4 inhibition by diltiazem and substrate for CYP2D6 provide a rational basis for pharmacokinetically significant interactions when they are coadministered with drugs that are cleared primarily by CYP3A4 or CYP2D6 mediated pathways. Considerable variability for verapamil may be observed in the elimination half-life of 1.5 to 7 hours. In addition, the plasma half-life may not always accurately predict the duration of action because of the presence of active metabolites. Less than 5% of an orally administered dose of verapamil is excreted unchanged into the urine. Its protein binding is approximately 90%. A well-documented drug interaction between digoxin and verapamil that increases the AUCs for digoxin has been attributed to verapamil blocking the intestinal P-gp efflux of digoxin (previously described under digoxin–drug interactions). T he fact that verapamil is a substrate for P-gp transport of drugs may be a potential source of other drug interactions. T he oral coadministration of verapamil with CYP3A4 inhibitors (see T able 10.10 for a list of inhibitors) has resulted in at least a 100 to 200 times increase in the blood AUCs for verapamil and, thereby, a toxic dose. T he dihydropyridines are metabolized largely to a variety of inactive metabolites. T heir binding to plasma proteins is high, ranging from 70 to 98% depending on the individual agent: For verapamil, protein binding is 90%; for diltiazem, 70 to 80%; for nifedipine, 92–98%; for nicardipine, greater than 90%; and for amlodipine, greater than 90%. Less than 4% of the dihydropyridine dose is excreted unchanged into the urine. T he duration of action of the calcium channel blockers ranges from 4 to 8 hours (verapamil, 4 hours; diltiazem, 6–8 hours; nifedipine, 4–8 hours; and nicardipine, 6–8 hours). Amlodipine has a 24-hour duration of action. T hus, it is the only calcium channel blocker that can be given once daily as a nonsustained-release product.

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Adverse Effects T he most common side effects of the calcium channel blockers include dizziness, hypotension, headache, and peripheral and pulmonary edema. T hese symptoms are related mainly to the excessive vasodilation, especially with the dihydropyridines. Verapamil was reported to cause constipation to some patients.

Drug Interactions Clinically significant drug interactions between calcium channel blockers and coadministration of CYP3A4 inhibitors, such as 6 to 8 oz. of grapefruit juice, HIV protease inhibitors, and erythromycin, have resulted in a 100- to 200-fold increase in the AUC for some calcium channel blockers (31). On the other hand, the coadministration of CYP3A4 inducers, such as rifampin or phenobarbital, result in an approximately 50% decrease in the AUC of calcium channel blockers. With other vasodilators, antihypertensive drugs, and alcohol, excessive hypotension may arise because of an additive effect. T he high-protein-binding nature of these drugs precipitates a potential for mutual plasma displacement with other drugs known to possess the same property, such as oral anticoagulants, digitalis glycosides, oral hypoglycemic agents, sulfa drugs, and salicylates. Dose adjustment may be necessary in some cases.

Therapeutic Uses Calcium channel blockers are clinically used as antianginal, antiarrhythmic, and antihypertensive agents (see corresponding subsection in Chapter 28).

β-Adrenergic Blocking Agents T he use of β-adrenergic blockers as antianginal agents is limited to the treatment of exertioninduced angina. Propranolol is the prototype drug in this class, but several newer agents have been approved for clinical use in the United States (see Chapter 13). Although these agents may be used alone, they often are used in combination therapy with nitrates, calcium channel blockers, or both. In several instances, combination therapy was found to provide more improvement than with either agent alone. T his, however, is not always the case.

M odulators of M yocardial M etabolism

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Ranolazine (Ranexa) is a novel metabolic modulator approved for the treatment of chronic angina in combination with amlodipine, β-adrenoceptor antagonists, or P.712 nitrates in patients who have not achieved an adequate response with other antianginals. Although the exact mechanism of its antianginal and anti-ischemic effect is unknown, its antianginal and anti-ischemic action is not dependent on heart rate or blood pressure reduction, and it does not increase myocardial workload. Numerous studies suggest that ranolazine modulates myocardial metabolism by shifting myocardial energy metabolism from free fatty acids to glucose by inhibition of fatty acid oxidation, increasing glucose oxidation and, thus, generating more adenosine triphosphate (AT P) per molecule of oxygen consumed. Ranolazine mainly affects the late sodium current across the membrane with the potential to reduce the cardiac ischemic burden without significantly changing blood pressure and heart rate. T he oral bioavailability of ranolazine from extended-release tablets is 76%, and plasma concentration is not effected by food. Metabolism is mainly by CYP3A4 and, to a lesser degree, by CYP2D6, with less than 5% being excreted unchanged in the urine and feces. After a single oral dose of ranolazine solution, approximately 75% of the dose is excreted in the urine and approximately 25% in feces. Its elimination half-life for extended-release tablets is 7 to 9 hours. Ranolazine is an inhibitor of P-gp transporter. Ranolazine plasma concentrations are increased by CYP3A4 inhibitors. T he CYP2D6 inhibition has a negligible effect on ranolazine exposure.

M iscellaneous Coronary Vasodilators Another approach to the treatment of myocardial insufficiency is the use of the coronary vasodilators dipyridamole and papaverine. Dipyridamole, a PDE3 inhibitor, (Fig. 26.8) causes a long-acting and selective coronary vasodilation by increasing coronary blood flow via selective dilation of the coronary arteries. T he state of the coronary arteries may determine the effect of dipyridamole on coronary blood flow and metabolic responses. Blood flow increased by 80% in unobstructed coronary vessels, whereas in stenotic coronary arteries, flow increased by approximately 40%. In patients with single-vessel coronary artery disease, intravenous dipyridamole increases flow to the ischemic area, probably by increasing collateral blood flow. Dipyridamole increases intracellular concentrations of the coronary vasodilator adenosine and cAMP and inhibits adenosine metabolism and uptake by vascular endothelial cells. T he increased concentration of adenosine in vascular smooth muscle stimulates adenylate cyclase activity, leading to increased cAMP synthesis and, consequently, to relaxation of vascular smooth muscle (vasodilation). T he effect of dipyridamole may not result only from its effect on adensoine but also from its ability to increase prostacyclin (vasodilator and platelet inhibitor) production by increasing cAMP concentration. Dipyridamole also increases intracellular cAMP by inhibiting PDE3, decreasing cAMP breakdown. Adenosine is a natural vasodilatory substance released by the myocardium during hypoxic episodes. Some structural similarity of adenosine to dipyridamole is apparent and substantiates this mechanism. Dipyridamole generally is used prophylactically, but its efficacy in reducing the incidence and severity of anginal attacks is not universally accepted.

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Fig. 26.8. Miscellaneous coronary vasodilators.

Papaverine (Fig. 26.8) is a benzoisoquinoline vasodilator that produces generalized, nonspecific arteriolar dilatation and smooth muscle relaxation. Its oral bioavailability ranges from 30 to 50%, suggesting first-pass metabolism. Increased levels of intracellular cAMP secondary to inhibition of phosphodiesterase may contribute to its vasodilatation and relaxation effects without involving nerve supply. Large doses of papaverine can cause hypotension and tachycardia. Other studies suggest that it also depresses cardiac conduction and prolongs the refractory period. T he natriuretic polypeptide nesiritide (Natrecor) is manufactured in the United States using recombinant DNA technology for intravenous use to treat cases of angina and CHF. Nesiritide has the same amino acid sequence of the natural, 32-amino-acid natriuretic peptide that normally is released during cardiac ischemia and acts as vasodilator. Nesitride acts as a coronary vasodilator by binding to the soluble guanylate cyclase receptors in vascular smooth muscles, leading to increased intracellular concentrations of the vasodilator cGMP. Nicorandil (Dancor, Ikorel) is a nicotinamide-nitrate ester (Fig. 26.8) used for the treatment of angina pectoris and CHF and has a dual mechanism of action. Structurally, it is a hybrid between organic nitrates and potassium channel activators. Although nicorandil contains a nitrate moiety, its pharmacological properties differ from organic nitrates. T he nicotinamide moiety is responsible for the effect on K + -AT P channels, which produces vascular smooth muscle relaxation by increasing potassium flux through AT P-sensitive sarcolemmal potassium channels. T his leads to hyperpolarization of the cell membrane and subsequent decreases in levels of cytoplasmic calcium (calcium channel blockade) and dilation of arterial resistance vessels. Other agents in this class are minoxidil and diazoxide. T he nitrate group explains its NO-like vasodilation on large coronary arteries, whereas its potassium channel–opening action is responsible for the dilatation of coronary resistance vessels, P.713 enabling it to decrease both preload and afterload and to increase coronary blood flow. Nicorandil induces nitrate-like activation of soluble guanylate cyclase, increasing intracellular levels of cGMP with resultant dilation of venous capacitance vessels. Increases in cGMP are less than those observed with conventional nitrates, although the degree of vasodilation produced appears to be similar. Its oral bioavailability ranges from 75 to 80%. Food reduces the rate, but not the extent, of absorption. Nicorandil is extensively metabolized via denitration to inactive N-(2-hydroxyethyl)-nicotinamide, which undergoes further side-chain degradation to nicotinuric acid and, subsequently, nicotinamide and nicotinamide metabolites (e.g., nicotinic acid and Nmethylnicotinamide). T he nicotinamide derived from nicorandil merges into the endogenous pool of nicotinamide adenine dinucleoside coenzymes. Its elimination half-life is approximately 1 hour. Approximately 30% of nicorandil is excreted into the urine as metabolites, with less than 1% excreted unchanged.

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Drugs for the T reatm ent of Cardiac Arrhythm ia Arrhythmia Arrhythmia is an alteration in the normal sequence of electrical impulse rhythm that leads to contraction of the myocardium. It is manifested as an abnormality in the rate, the site from which the impulses originate, or in the conduction through the myocardium. T he rhythm of the heart normally is determined by a pacemaker site called the SA node, which consists of specialized cells that undergo spontaneous generation of action potentials at a rate of 100 to 110 action potentials (“ beats” ) per minute. T his intrinsic rhythm is strongly influenced by the vagus nerve, overcoming the sympathetic system at rest. T his “ vagal tone” brings the resting heart rate down to a normal sinus rhythm of 60 to 100 beats per minute. Sinus rates below this range are termed “ sinus bradycardia,” and sinus rates above this range are termed “ sinus tachycardia.” T he sinus rhythm normally controls both atrial and ventricular rhythm. Action potentials generated by the SA node spread throughout the atria, depolarizing this tissue and causing atrial contraction. T he impulse then travels into the ventricles via the AV node. Specialized conduction pathways within the ventricle rapidly conduct the wave of depolarization throughout the ventricles to elicit ventricular contraction. T herefore, normal cardiac rhythm is controlled by the pacemaker activity of the SA node. Abnormal or irregular cardiac rhythms (heartbeats) may occur when the SA node fails to function normally, when other pacemaker sites (e.g., ectopic pacemakers) trigger depolarization, or when a dysfunction occurs along the normal conduction pathways.

Causes of Arrhythmias Many factors influence the normal rhythm of electrical activity in the heart. Arrhythmias may occur either because pacemaker cells fail to function properly or because of a blockage in transmission through the AV node. Underlying diseases, such as atherosclerosis, hyperthyroidism, or lung disease, also may be initiating factors. Some of the more common arrhythmias are those termed “ ectopic,” which occur when electrical signals spontaneously arise in regions other than the pacemaker and then compete with the normal impulses. Myocardial ischemia, excessive myocardial catecholamine release, stretching of the myocardium, and cardiac glycoside toxicity have all been shown to stimulate ectopic foci. A second mechanism for the generation of arrhythmias is from a phenomenon called reentry. T his occurs when the electrical impulse does not die out after firing but, rather, continues to circulate and reexcite resting heart cells into depolarizing. T he result of this reexcitation may be a single, premature beat or runs of ventricular tachycardia. Reentrant rhythms are common in the presence of coronary atherosclerosis.

Drugs for the Treatment of Antiarrhythmias and Their Classification It is widely accepted that most currently available antiarrhythmic drugs may be classified into four categories, which are grouped on the basis of their effects on the cardiac action potential and, consequently, on the electrophysiological properties of the heart. T o understand the basis of classification and the pharmacology of these agents, an understanding of normal cardiac electrophysiology is necessary.

Normal Physiologic Action Normal cardiac contractions largely are a function of the action of a single atrial pacemaker, a fast and generally uniform conduction in predictable pathways, and a normal duration of the action potential and refractory period. Figure 26.9 depicts a normal cardiac action potential from a Purkinje fiber. T he resting cell has a membrane potential of approximately -90 mV, with the P.714 inside of the cell being electronegative relative to the outside of the cell. T his is termed the “ transmembrane resting potential.” On excitation, the transmembrane potential reverses, and the inside of the membrane rapidly becomes positive with respect to the outside. On recovery from excitation, the resting potential is restored. T hese changes have been divided into five phases: Phase 0 represents depolarization and reversal of the transmembrane potential, phases 1–3 represent different stages of repolarization, and phase 4 represents the resting potential. During phase 0, which also is referred to as rapid depolarization, the permeability of the membrane for

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sodium ions increases, and sodium rapidly enters the cell, causing it to become depolarized. Phase 1 results from the ionic shift, which creates an electrochemical and concentration gradient that reduces the rate of sodium influx but favors the influx of chloride and efflux of potassium. Phase 2, the plateau phase, results from the slow inward movement of calcium, which is triggered by the rapid inward movement of sodium in phase 0. During this time, there also is an efflux of potassium that balances the influx of calcium, thus resulting in little or no change in membrane potential. Phase 3 is initiated by a slowing of the calcium influx coupled with a continued efflux of potassium. T his continued efflux of potassium from the cell restores the membrane potential to normal resting potential levels. During phase 4, the Na + , K + -AT Pase pump restores the ions to their proper local concentrations. T he action potential is a coordinated sequence of ion movements in which sodium initially enters the cell, followed by a calcium influx, and finally, a potassium efflux returns the cell to its resting state. Several antiarrhythmic agents exert their effects by altering these ion fluxes.

Fig. 26.9. Cardiac action potential recorded from a Purkinje fiber.

Classification of Antiarrhythmic Drugs Class IA antiarrhythmic drugs Class IA drugs generally are local anesthetics acting on nerve and myocardial membranes to slow conduction by blocking fast Na + channels, inhibiting phase 0 of the action potential (Fig. 26.9). Myocardial membranes show the greatest sensitivity. Class IA drugs decrease the maximal rate of depolarization without changing the resting potential. T hey also increase the threshold of excitability, increase the effective refractory period, decrease conduction velocity, and decrease spontaneous diastolic depolarization in pacemaker cells. T he decrease in diastolic depolarization tends to suppress ectopic foci activity. Prolongation of the refractory period tends to abolish reentry arrhythmias. T able 26.6 summarizes these effects. Quinidine is considered to be the prototype drug for class IA.

Qu in idin e Quinidine (Fig. 26.10) is widely used for acute and chronic treatment of ventricular and supraventricular arrhythmias, especially supraventricular tachycardia. It is a member of a family of alkaloids found in Cinchona bark (Ci nchona offi ci nal i s L.) and is the diastereomer of quinine. Despite their structural similarity, quinidine and quinine differ markedly in their effects on the cardiac muscles, with the effects of quinidine being much more pronounced. Structurally, quinidine is composed of a quinoline ring and the bicyclic quinuclidine ring system, with a hydroxymethylene bridge connecting these two components. Examination of quinidine reveals two basic nitrogens, with

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the quinuclidine nitrogen (pK a = 11) being the stronger of the two. Because of the basic character of quinidine, it is always used as water-soluble salt forms. T hese salts include quinidine sulfate, gluconate, and polygalacturonate. Good absorption (~ 95%) is observed with each of these forms after oral administration. In special situations, quinidine may be administered intravenously as the gluconate salt. T he use of intravenous quinidine, however, is rare. T he gluconate salt is particularly suited for parenteral use because of its high water solubility and lower irritant potential. Quinidine's bioavailability appears to depend on a combination of metabolism and P-gp efflux. T he bioavailabilities of quinidine sulfate and gluconate are 80 to 85% and 70 to 75%, respectively. Once absorbed, quinidine is subject to hepatic first-pass metabolism and is approximately 85% plasma protein bound, with an elimination half-life of approximately 6 hours. Quinidine is metabolized mainly in the liver, and renal excretion of unchanged drug also is significant (~ 10–50%). T he metabolites are hydroxylated derivatives at either the quinoline ring through first-pass O-demethylation or at the quinuclidine ring through oxidation of the vinyl group. T hese metabolites possess only about one-third the activity of quinidine. T heir contribution to overall therapeutic effect of quinidine is unclear. Recently, the clinical significance of the well-documented digoxin–quinidine interaction was described previously under digoxin–drug interactions. Apparently, quinidine (a P-gp substrate) inhibits the renal tubular secretion of digoxin via the P-gp efflux pump, resulting in increased plasma concentration for digoxin.

In addition, a common contaminant in quinidine preparations, dihydroquinidine, which is derived from reduction of the quinuclidine vinyl group at C-3 to an ethyl group, also may contribute to its activity (32). Although similar to quinidine in pharmacodynamic and pharmacokinetic behavior, this contaminant is both more potent as an antiarrhythmic and more toxic. T hus, levels of this contaminant may contribute to variability between commercial preparations. T he most frequent adverse effects associated with quinidine therapy are gastrointestinal P.715 disturbances, such as nausea, diarrhea, and vomiting.

Table 26.6. Summary of the Cardiac Physiological Effects of the Antiarrhythmic Drugs

ClassificationM echanism of Action Class IA

Primary Sites of Action

Drug Examples

-Na + channel blockade -intermediate rate of dissociation from sodium channels

Quinidine Procainamide

-slows phase 0 depolarization -prolongs action

Disopyramide

Atrial and ventricular tissue

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potential duration -slows conduction Class IB

-Na + channel blockade -rapid rate of dissociation from sodium channels

Lidocaine Mexiletine

-shorten phase 3 repolarization -shortens action potential duration

Ventricular tissue

Phenytoin Tocainide

Class 1C

- Na + channel blockade -slow rate of dissociation from sodium channels -markedly slows phase 0 depolarization -slows conduction

Ventricular tissue

Flecainide Encainide Propafenone Moricizine

Class II

- blocks sympathetic stimulation of β I adrenergic receptors -slow phase 4 depolarization -slows firing of SA node and conduction through AV node prolonging repolarization

SA node AV node

Propranolol Sotalol β I blockers

Class III

- K + channel blockade (block delayed rectifier current) -prolong phase 3 repolarization -prolongs duration of action potential which prolongs refractory period

Atrial and ventricular tissue

Amiodarone Sotalol Bretylium Ibutilide

Class IV

-Ca +2 channel blockade

SA node

Verapamil

-slow phase 4

AV node

Diltiazim

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depolarization -slows firing of SA node and conduction through AV node prolonging repolarization of AV node

Procain amide Procainamide (Fig. 26.10) is effective in the treatment of several types of cardiac arrhythmias. Its actions are similar to those of quinidine, yet procainamide may be effective in patients who are unresponsive to quinidine. T he initial development of procainamide was stimulated by the observation that the local anesthetic procaine (the ester bio-isostere of procainamide), when administered intravenously, produced significant though short-lived antiarrhythmic effects. Unfortunately, considerable central nervous system toxicity, in addition to the short duration, limited the usefulness of this agent. Moreover, procaine is not active orally because of its short duration of action caused by both chemical and plasma esterase hydrolysis. A logical modification of this molecule was the isosteric replacement of the ester with an amide group. T his produced orally active procainamide, which is more resistant to both enzymatic and chemical hydrolysis. Peak plasma levels of procainamide are observed within 45 to 90 minutes after oral administration, and approximately 70 to 80% of the dose is bioavailable. Approximately half of this dose is excreted unchanged, and the remaining half undergoes acetylation metabolism in the liver. Metabolites of procainamide include p-aminobenzoic acid and N-acetylprocainamide. Interestingly, the acetylated metabolite is also active as an antiarrhythmic. Its formation accounts for up to one-third of the administered dose and is catalyzed by the liver enzyme N-acetyl transferase. Because acetylation is strongly influenced by an individual's genetic background, marked variability in the amounts of this active metabolite may be observed from patient to patient. Renal excretion dominates, with approximately 90% of a dose excreted as unchanged drug and metabolites. T he elimination half-life is approximately 3.5 hours. A substantial percentage (60–70%) of patients on procainamide show elevated levels of antinuclear antibodies after a few months. Of these patients, between 20 and 30% develop a drug-induced lupus syndrome if therapy is continued. T hese adverse effects, which are attributed to P.716 the aromatic amino group, are observed more frequently and more rapidly in “ slow acetylators.” Usually, the symptoms associated with procainamide-induced lupus syndrome subside fairly rapidly after the drug is discontinued. T hese problems, however, have discouraged long-term procainamide therapy.

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Fig. 26.10. Class IA antiarrhythmics.

Disopyramide Disopyramide phosphate is used orally for the treatment of certain ventricular and atrial arrhythmias. Despite its structural dissimilarity to procainamide (Fig. 26.10), its cardiac effects are very similar. Disopyramide is rapidly and completely absorbed from the gastrointestinal tract. Peak plasma level is usually reached within 1 to 3 hours, and a plasma half-life of 5 to 7 hours is common. Approximately half of an oral dose is excreted unchanged in the urine. T he remaining drug undergoes hepatic metabolism, principally to the corresponding N-dealkylated form. T his metabolite retains approximately half the antiarrhythmic activity of disopyramide and also is subject to renal excretion. Adverse effects of disopyramide frequently are observed. T hese effects are primarily anticholinergic in nature and include dry mouth, blurred vision, constipation, and urinary retention.

Class IB antiarrhythmic drugs Lidocain e Lidocaine, similar to procaine, is an effective, clinically used local anesthetic (Fig. 26.11) (see Chapter 16). Its cardiac effects, however, are distinctly different from those of procainamide or quinidine. Lidocaine normally is reserved for the treatment of ventricular arrhythmias and, in fact, usually is the drug of choice for emergency treatment of ventricular arrhythmias. Its utility in these situations results from the rapid onset of antiarrhythmic effects on intravenous infusion. In addition, these effects cease soon after the infusion is terminated. T hus, lidocaine therapy may be rapidly modified in response to changes in the patient's status. Lidocaine is effective as an antiarrhythmic only when given parenterally, and the intravenous route is the most common. Antiarrhythmic activity is not observed after oral administration because of the rapid and efficient first-pass metabolism by the liver. Parenterally administered lidocaine is approximately 60 to 70% plasma protein bound. Hepatic metabolism is rapid (plasma half-life, ~ 15–30 minutes) and primarily involves N-deethylation to yield monoethylglycinexylide, followed by amidase-catalyzed hydrolysis into N-ethylglycine and 2,6-dimethylaniline (2,6-xylidine) (Fig. 26.12).

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Fig. 26.11. Class IB antiarrhythmics.

Fig. 26.12. Metabolism of lidocaine.

Monoethylglycinexylide has good antiarrhythmic activity. It is not clinically useful, however, because it undergoes rapid enzymatic hydrolysis. T he adverse effects of lidocaine include emetic and convulsant properties that predominantly involve the central nervous system and heart. T he central nervous system effects may begin with dizziness and paresthesia and, in severe cases, ultimately lead to epileptic seizures.

T ocain ide T ocainide (T onocard) (Fig. 26.11) is an α-methyl analogue structurally related to monoethylglycinexylide, the active metabolite of lidocaine, which possesses very similar electrophysiologic effects to lidocaine. In contrast to lidocaine, tocainide is orally active, and its oral absorption is excellent. Like lidocaine, it usually is reserved for the treatment of ventricular arrhythmias. T he α-methyl group is believed to slow the rate of metabolism and, thereby, to contribute to oral activity. T he plasma half-life of tocainide is approximately 12 hours, and nearly 50% of the drug may be excreted unchanged in the urine. Adverse effects associated with tocainide are like those observed with lidocaine—specifically, gastrointestinal disturbances and central nervous system effects.

Mexiletin e Mexiletine (Mexitil)(Fig. 26.11) is similar to both lidocaine and tocainide in its effects and therapeutic

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application. It is used principally to treat and prevent ventricular arrhythmias. Like tocainide, mexilitine has very good oral activity and absorption properties. Clearance depends on metabolism and renal excretion. A relatively long plasma half-life of approximately 12 to 16 hours is common. Adverse effects are similar to those experienced with tocainide and lidocaine.

Ph en ytoin For 50 years, phenytoin (Fig. 26.11) has seen clinical use in the treatment of epileptic seizures (see Chapter 20). During this time, it was noticed that phenytoin also produced supposedly adverse cardiac effects. On closer examination, these adverse effects actually P.717 were found to be beneficial in the treatment of certain arrhythmias. Currently, phenytoin is used in the treatment of atrial and ventricular arrhythmias resulting from digitalis toxicity. It is not, however, officially approved for this use. Phenytoin may be administered either orally or intravenously and is absorbed slowly after oral administration, with peak plasma levels achieved after 3 to 12 hours. It is extensively plasma protein bound (~ 90%), and the elimination half-life is between 15 and 30 hours. T hese large ranges reflect the considerable variability observed from patient to patient. Parenteral administration of phenytoin is usually limited to the intravenous route. Phenytoin for injection is dissolved in a highly alkaline vehicle (pH 12). T his alkaline vehicle is required because phenytoin is weakly acidic and has very poor solubility in its un-ionized form. Reportedly, however, its phosphate ester fosphenytoin has water solubility advantages over phenytoin for injection. Intramuscular phenytoin generally is avoided, because it results in tissue necrosis at the site of injection and erratic absorption because of high alkalinity. In addition, intermittent intravenous infusion is required to reduce the incidence of severe phlebitis. Phenytoin metabolism is relatively slow and predominantly involves aromatic hydroxylation to p-hydroxylated inactive metabolites (see Chapter 20). Phenytoin also induces its own metabolism and is subject to large interindividual variability. T he major metabolite, 5-p-hydroxyphenyl5-phenylhydantoin, accounts for approximately 75% of a dose. T his metabolite is excreted through the kidney as the β-glucuronide conjugate. Phenytoin clearance is strongly influenced by its metabolism; therefore, agents that affect phenytoin metabolism may cause intoxication. In addition, because phenytoin is highly plasma protein bound, agents that displace phenytoin also may cause toxicity.

Class IC antiarrhythmic drugs Flecain ide Flecainide (T amborcor) exhibits properties distinctly different from those of Class IA or IB antiarrhythmic drugs. Flecainide is a fluorinated benzamide derivative (Fig. 26.13), available as the acetate salt. Flecainide has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of ventricular arrhythmias. Clinical studies suggest that this agent may be more effective than either quinidine or disopyramide in suppressing premature ventricular contractions. Oral flecainide is well absorbed, and the plasma half-life is approximately 14 hours. About half of an oral dose is metabolized in the liver, and one-third is excreted unchanged in the urine. As with other antiarrhythmics, flecainide may produce adverse effects. T he most severe is flecainide's occasional tendency to aggravate existing arrhythmias or to induce new ones. Although fewer than 10% of patients experience this effect, it may be life-threatening. Accordingly, it may be desirable to start therapy in the hospital. Other less serious side effects include blurred vision, headache, nausea, and abdominal pain.

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Fig. 26.13. Class IC antiarrhythmics.

En cain ide Encainide (Enkaid) (Fig. 26.13) represents another benzamide derivative, with similar pharmacological properties to flecainide but with less negative inotropic effect.

Propafen on e Propafenone (Rythmol) (Fig. 26.13) is a Class I, local anesthetic–type antiarrhythmic agent. Propafenone is structurally related to other Class IC antiarrhythmic drugs and also to β-adrenergic receptor blockers. It is used primarily for ventricular and supraventricular arrhythmias. T he drug is administered orally and intravenously; however, the parenteral dosage forms are not commercially available in the United States. After oral administration, the drug is rapidly and almost completely absorbed from the gastrointestinal tract. Propafenone metabolism involves hepatic CYP2D6 enzymes. Its rate of metabolism is genetically determined by an individual's ability to metabolize the so-called phenotype compounds (fast or slow metabolizers) (see Chapter 10).

Moricizin e Moricizine (Ethmozine) (Fig. 26.13) is a phenothiazine analogue that processes the same electrophysiological effects on the heart as those of Class IC antiarrhythmics. Despite its short half-life after oral administration, its antiarrhythmic effects can persist for many hours, suggesting that some of its metabolites may be active.

Class II antiarrhythmic drugs Class II antiarrhythmic drugs (Fig. 26.14) are β-adrenergic receptor blocking agents, which block the role of the sympathetic nervous system in the genesis of certain cardiac arrhythmias. T heir dominant electrophysiological effect is to depress adrenergically enhanced calcium influx through β-receptor blockade. Drugs in this class decrease neurologically induced automaticity at normal therapeutic doses. At higher doses, these drugs also may exhibit anesthetic properties, which cause decreased excitability, decreased conduction velocity, and a prolonged effective refractory period. In normal therapeutic situations, the β-blocking effects are more important than any local anesthetic effects that these P.718 drugs may have. Propranolol is the prototype β-adrenergic blocker drug for class II (see Chapter 13).

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Fig. 26.14. Class III inhibitors of depolarization.

Propran olol (+ )-Propranolol, a nonselective β-adrenergic blocker, is the prototype for Class II antiarrhythmics. Its pharmacology and pharmacokinetics are discussed in detail in Chapters 13 and 29. Its use as an antiarrhythmic usually is for the treatment of supraventricular arrhythmias, including atrial flutter, paroxysmal supraventricular tachycardia, and atrial fibrillation. Propranolol also is reported to be effective in the treatment of digitalis-induced ventricular arrhythmias. Moreover, beneficial results may be obtained when propranolol is used in combination with other agents. For example, in certain cases, quinidine and propranolol together have proved to be more successful in alleviating atrial fibrillation than either agent has alone. Few serious adverse effects are associated with propranolol therapy.

Sotalol (±)-Sotalol (Betapace, Sotacor), a nonselective β-adrenergic blocker, is a methanesulfonanilide antiarrhythmic agent. As an antiarrhythmic, it is dually classified as Class II and Class III because of the similarity of its cardiac effects to both classes. Sotalol is used orally to suppress and prevent the recurrence of life-threatening ventricular arrhythmia.

Class III inhibitors of repolarization Class III drugs cause a homogeneous prolongation of the duration of the action potential. T his results in a prolongation of the effective refractory period. It is believed that most of Class III antiarrhythmic agents act through Phase 3 of the action potential by blocking potassium channels. Figure 26.15 illustrates the chemical structures of members of Class III. Bretylium is the prototype drug for this class.

Bretyliu m tosylate Bretylium tosylate is a quaternary ammonium salt derivative (Fig. 26.15) originally developed for use as an antihypertensive. Its antiarrhythmic use is limited to emergency, life-threatening situations in which other agents, such as lidocaine and procainamide, have failed. Generally, bretylium is used only in intensive care units and may be administered either intravenously or intramuscularly. T he plasma elimination half-life usually is approximately 10 hours, and it is eliminated largely unchanged in the urine. T he major adverse effect associated with bretylium tosylate is hypotension, including orthostatic hypotension, which may be very severe.

Amiodaron e Initially developed as an antianginal (coronary vasodilator), amiodarone (Fig. 26.15) has antiarrhythmic effects that are somewhat similar to those of bretylium. It is approved by the U.S. FDA for the treatment of life-threatening ventricular arrhythmias that are refractory to other drugs. Its

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cardiac effects are not well characterized, but clinical studies indicate that it is primarily a Class III agent but also acts as a Class I, II, and IV antiarrythmic. It has a unique mechanism of action that involves alteration of the lipid membrane in which ion channels and receptors are located. Its severe toxicity, however, makes it the drug of last choice. As with bretylium tosylate, use of this agent should be initiated in a hospital setting.

Fig. 26.15. Class III antiarrhythmic agents.

Ibu tilide Ibutilide (Corvert) is another methanesulfonanilide derivative (Fig. 26.15), but unlike sotalol, it lacks any β-adrenergic blocking activity. Like sotalol, it exhibits electrophysiologic effects characteristic of Class III. Ibutilide is used only by intravenous infusion as its fumarate salt.

Dofetilide Dofetilide (T ikosyn) is a bis-methanesulfonanilide derivative that is essentially the non-β-blocking moiety of the sotalol molecule (Fig. 26.15). It exhibits only Class III electrophysiological effects, but like ibutilide, it lacks any β-adrenergic blocking activity. Dofetlide is used orally to suppress atrial fibrillation and flutter. It is more potent and selective than other Class III methanesulfonanilides, including sotalol. Dofetilide is well absorbed from the gastrointestinal tract, with a bioavailability of 96 to 100%. T he bioavailability of oral dofetilide is not affected by food or antacids. Protein binding is 60 to 70%. Dofetilide is metabolized by the hepatic CYP3A4 enzyme system via N-dealkylation and N-oxidation to inactive or minimally active metabolites. Of the approximately 80% of a dose excreted in urine, approximately 80% is excreted unchanged, with the other 20% as metabolites. P.719

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Fig. 26.16. Antiarrhythmic drugs in Phase III clinical trials.

Azimilide Azimilde is another Class III antiarrhythmic agent structurally unrelated to any of the above agents (Fig. 26.15). Azimilide is not available in the United States; it is only available in Europe. Following oral administration, the drug is completely absorbed, with no effect of food. Protein binding is 94%. It is metabolized in the liver to an active carboxylate metabolite, but its concentration in plasma is less than 5% of the parent compound. T hus, it is considered to be therapeutically inactive. Renal excretion is approximately 10%. Its elimination half-life is 3 to 4 days.

Class IV calcium channel blockers Class IV calcium channel antiarrhythmic drugs (Fig. 26.7) comprise a group of agents that selectively block the slow inward current carried by calcium (i.e., calcium channel blockers). T he slow inward current in cardiac cells has been shown to be of importance for the normal action potential in SA node cells. It also has been suggested that this inward current is involved in the genesis of certain types of cardiac arrhythmias. Administration of a Class IV drug causes a prolongation of the refractory period in the AV node and the atria, a decrease in AV conduction, and a decrease in spontaneous diastolic depolarization. T hese effects block conduction of premature impulses at the AV node and, thus, are very effective in treating supraventricular arrhythmias. Verapamil and diltazem are prototype drugs for this class (Fig. 26.7), but dihydropyridine drugs are less effective in cardiac tissues. Refer to the section on calcium channel blocker under antianginal drugs for pharmacokinetic information.

Antiarrhythm ic Drugs in Phase III Clinical T rials Antiarrhythmic drugs in Phase III clinical trials are shown in Figure 26.16. Nifekalant is a pyrimidinone Class III agent. Sematilide is a Class III agent that is a benzamide derivative of ibutilide, and SSR-149744c and dronedarone are noniodinated analogues of amiodarone, reportedly with fewer adverse effects than amiodarone.

Case Study

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Victor ia F. Roche S. William Zito BZ s hows up at the hos pital where you work. He is a 30-year-old computer joc k who works f or one of the high-tec h I nternet c ompanies. He has no history of any health-related problems , but today, he reports that he has been coming in f rom playing basketball on the c ompany grounds f eeling dizzy and thinking he is go ing to f aint. At f irst, he thought it was the res ult of too muc h exertion in the heat of the summer; however, thes e symptoms have c ontinued even when he is not strenuously exercising. I n the emergency department, BZ is s till experienc ing these s ymptoms , and on questioning, he says he c an f eel his heart beating, is anxious , and is vis ibly out of breath when speaking. A physical examination reveals a puls e of 220 beats per minute, with normal temperature and lung sounds. An elec troc ardiogram reveals a regular narrow QRS comp lex at 200 to 220 beats per minutes. He is diagnos ed with paroxys mal s upraventricular tachyc ardia (PSVT) and treated with intravenous adenos ine af ter vagal maneuvers f ail (b lowing on his thumb, “ bearing down” as if he were f orc ing a bowel movement, or splashing his f ace with ice water) to restore him to normal s inus rhythm. BZ is admitted to the hospital f or observation. Overnight and into the next day, BZ c ontinues to have mild PSVTs; theref ore, the cardiologist decides that prophylac tic therapy is neces s ary. Evaluate structures 1 to 4 f or possible use in this case. 1. I dentif y the therapeutic problem(s) in which the pharmacist's intervention may benef it the patient. 2. I dentif y and prioritize the patient-specif ic f actors that must be considered to achieve the des ired therapeutic outc omes. 3. Conduc t a thorough and mec hanistically oriented structure–activity analysis of all therapeutic alternatives provided in the case. 4. Evaluate the SAR f indings against the patient-s pecif ic f actors and desired therapeutic outc omes , and make a therapeutic decision. 5. Couns el your patient.

P.720

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Suggested Readings Fozzard HA, Sheets MF. Cellular mechanism of action of cardiac glycosides. J Am Coll Cardiol 1985;5:10A–15A.

Hansten PD, ed. Drug Interactions: Clinical Significance of Drug–Drug Interactions, 5th Ed. Philadelphia: Lea and Febiger, 1985.

Kaplan HR. Advances in antiarrhythmic drug therapy: changing concepts.' Federation Proc 1986;45:2184–2213.

Katz AM. Effects of digitalis on cell biochemistry: sodium pump inhibition. J Am Coll Cardiol 1985;5:16A–21A.

Kowey PR. Pharmacological effects of antiarrhythmic drugs. Arch Intern Med 1998;158:325–332.

Mangini RJ, ed. Drug Interaction Facts. St. Louis: JB. Lippincott, 1983.

Michel T . Drugs used for the treatment of myocardial ischemia. In: Goodman and Gilman's T he Pharmacological Basis of T herapeutics, 11th Ed. New York: McGraw-Hill, New York, 2006, pp 823–844.

Rocco T , Fong JG, T reatment of congestive heart failure. In: Goodman & Gilman's T he Pharmacological Basis of T herapeutics, Brunton L, Lazo T , Barker K, 11th ed. New York: McGraw-Hill, 2006, pp 869–898.

T homas RE. Cardiac drugs. In: Wolff ME, ed. Burger's Medicinal Chemistry and Drug Discovery, 5th Ed., Part IIA, vol 2. New York: John Wiley and Sons, 1996. pp 153–261.

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Chapter 27 Diuretics Gary O. Rankin

Introduction Diuretics are chemicals that increase the rate of urine formation (1). By increasing the urine flow rate, diuretic usage leads to increased excretion of electrolytes (especially sodium and chloride ions) and water from the body without affecting protein, vitamin, glucose, or amino acid reabsorption. T hese pharmacological properties have led to the use of diuretics in the treatment of edematous conditions resulting from a variety of causes (e.g., congestive heart failure, nephrotic syndrome, and chronic liver disease) and in the management of hypertension. Diuretic drugs also are useful as the sole agent or as adjunct therapy in the treatment of a wide range of clinical conditions, including hypercalcemia, diabetes insipidus, acute mountain sickness, primary hyperaldosteronism, and glaucoma. T he primary target organ for diuretics is the kidney, where these drugs interfere with the reabsorption of sodium and other ions from the lumina of the nephrons, which are the functional units of the kidney. T he amount of ions and accompanying water that are excreted as urine following administration of a diuretic, however, is determined by many factors, including the chemical structure of the diuretic, the site or sites of action of the agent, the salt intake of the patient, and the amount of extracellular fluid present. In addition to the direct effect of diuretics to impair solute and water reabsorption from the nephron, diuretics also can trigger compensatory physiological events that have an impact on either the magnitude or the duration of the diuretic response. T hus, it is important to be aware of the normal mechanisms of urine formation and renal control mechanisms to understand clearly the ability of chemicals to induce a diuresis.

Norm al Physiology of Urine Form ation T wo important functions of the kidney are 1) to maintain a homeostatic balance of electrolytes and water and 2) to excrete water-soluble end products of metabolism. T he kidney accomplishes these functions through the formation of urine by the nephrons (Fig. 27.1). Each kidney contains approximately 1 million nephrons and is capable of forming urine independently. T he nephrons are composed of a specialized capillary bed called the glomerulus and a long tubule divided anatomically and functionally into the proximal tubule, loop of Henle, and distal tubule. Each component of the nephron contributes to the normal functions of the kidney in a unique manner; thus, all are targets for different classes of diuretic agents. Urine formation begins with the filtration of blood at the glomerulus. Approximately 1,200 mL of blood per minute flows through both kidneys and reaches the nephron by way of afferent arterioles. Approximately 20% of the blood entering the glomerulus is filtered into Bowman's capsule to form the glomerular filtrate. T he glomerular filtrate is composed of blood components with a molecular weight less than that of albumin (~ 69,000 daltons) and not bound to plasma proteins. T he glomerular filtration rate (GFR) averages 125 mL/min in humans but can vary widely even in normal functional states. T he glomerular filtrate leaves the Bowman's capsule and enters the proximal convoluted tubule (S1, S2 segments, Fig 27.1), where the majority (50–60%) of filtered sodium is reabsorbed osmotically. Sodium reabsorption is coupled electrogenetically with the reabsorption of P.723 glucose, phosphate, and amino acids and nonelectrogenetically with bicarbonate reabsorption. Glucose and amino acids are completely reabsorbed in this portion of the nephron, whereas phosphate reabsorption is between 80 and 90% complete. T he early proximal convoluted tubule also is the primary site of bicarbonate reabsorption (80–90%), a process that is mainly sodium dependent and coupled to hydrogen ion secretion. T he reabsorption of sodium and bicarbonate is facilitated by the enzyme carbonic anhydrase, which is present in proximal tubular cells and catalyzes the formation of carbonic acid from water and carbon dioxide. T he carbonic acid provides the hydrogen ion, which drives the reabsorption of sodium bicarbonate. Chloride ions are reabsorbed passively in the proximal tubule, where they follow actively transported sodium ions into tubular cells.

Clin ic a l Sign ific a nc e It is important for the clinician to understand the medicinal chemistry of the diuretics to appropriately use them in individual patients. T his diverse group of medications is classified in many ways: mechanism of action, site of action, chemical class, and effect on urine contents. Knowledge of structure–activity relationships helps to predict indications, possible off-label uses, magnitude of diuresis, potency, and side effect profile. Consequently, diuretics have a variety of uses. T hiazide diuretics may be used either alone or in combination with other pharmacotherapy for the treatment of hypertension. Loop diuretics can provide immediate diuresis and are used for heart failure and in lieu of thiazides in patients with compromised renal function. In addition to more traditional uses, certain potassium-sparing diuretics provide added benefit to other pharmacotherapy in patients with primary hyperaldosteronism, heart failure, or post–acute myocardial infarction. Carbonic anhydrase inhibitors have limited use for diuresis; however, they may be used to reduce intraocular pressure and treat acute mountain sickness. A thorough understanding of the medicinal chemistry, mechanisms of action, and pharmacokinetics helps the clinician to use available diuretics appropriately. As new medications are developed, the clinician will rely on these basic concepts to continue tailoring therapy to the individual patient with the goals to maximize outcomes, improve quality of life, and minimize adverse events. Kimberly Birtcher Pharm.D. Clinical Assistant Professor, Department of Clinical Sciences and Administration, University of Houston College of Pharmacy

Fig. 27.1. The nephron. BC, Bowman's capsule; G, glomerulus; PCT, proximal convoluted tubule; PST, proximal straight tubule; DLH, descending limb of the Loop of Henle; TALH, thick ascending limb of the loop of Henle; DCT, distal convoluted tubule; CD, collecting duct.

T he reabsorption of electrolytes and water also occurs isosmotically in the proximal straight tubule or pars recta (S3 segment, Fig. 27.1). By the end of the straight segment, between 65 and 70% of water and sodium, chloride, and calcium ions; 80 to 90% of bicarbonate and phosphate; and essentially 100% of glucose, amino acids, vitamins, and protein have been reabsorbed from the glomerular filtrate. T he proximal tubule also is the site for active secretion of weakly acidic and weakly basic organic compounds. T hus, many of the diuretics can enter luminal fluid not only by filtration at the glomerulus but also by active secretion.

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T he descending limb of the loop of Henle is impermeable to ions, but water can freely move from the luminal fluid into the surrounding medullary interstitium, where the higher osmolality draws water into the interstitial space and concentrates luminal fluid. Luminal fluid continues to concentrate as it descends to the deepest portion of the loop of Henle, where the fluid becomes the most concentrated. T he hypertonic luminal fluid next enters the water-impermeable, thick ascending limb of the loop of Henle. In this segment of the nephron, approximately 20 to 25% of the filtered sodium and chloride ions are reabsorbed via a cotransport system (Na + /K + /2Cl - ) on the luminal membrane. Reabsorption of sodium and chloride in the medullary portion of the thick ascending limb is important for maintaining the medullary interstitial concentration gradient. Reabsorption of sodium chloride in the cortical component of the thick ascending limb of the loop of Henle and the early distal convoluted tubule contributes to urinary dilution, and as a result, these two nephron sections sometimes are called the cortical diluting segment of the nephron. P.724 Luminal fluid leaving the early distal tubule next passes through the late distal tubule and cortical collecting tubule (collecting duct), where sodium is reabsorbed in exchange for hydrogen and potassium ions. T his process is partially controlled by mineralocorticoids (e.g., aldosterone) and accounts for the reabsorption of between 2 and 3% of filtered sodium ions. Although the reabsorption of sodium ions from these segments of the nephron is not large, this sodium/potassium/hydrogen ion exchange system determines the final acidity and potassium content of urine. Several factors, however, can influence the activity of this exchange system, including the amount of sodium ions delivered to these segments, the status of the acid-base balance in the body, and the levels of circulating aldosterone. T he urine formed during this process represents only approximately 1 to 2% of the original glomerular filtrate, with more than 98% of electrolytes and water filtered at the glomerulus being reabsorbed during passage through the nephron. T hus, a change in urine output of only 1 to 2% could double urine volume. Urine leaves the kidney through the ureters and travels to the bladder, where it is stored until urination removes the it from the body.

Norm al Regulation of Urine Form ation T he body contains several control mechanisms that regulate the volume and contents of urine. T hese systems are activated by changes in solute or water content of the body, by changes in systemic or renal blood pressure, and by a variety of other stimuli. Activation of one or more of these systems by diuretic drugs can modify the effectiveness of these drugs to produce their therapeutic response and may require additional therapeutic measures to ensure a maximal response. T he kidney has the ability to respond to changes in the GFR through the action of specialized distal tubular epithelial cells called the macula densa. T hese cells are in close contact with the glomerular apparatus of the same nephron and detect changes in the rate of urine flow and luminal sodium chloride concentration. An increase in the urine flow rate at this site (as can occur with the use of some diuretics) activates the macula densa cells to communicate with the granular cells and vascular segments of the juxtaglomerular apparatus. Stimulation of the juxtaglomerular apparatus causes renin to be released, which leads to the formation of angiotensin II and subsequent renal vasoconstriction. Renal vasoconstriction leads to a decrease in GFR and, possibly, a decrease in the effectiveness of the diuretic. Renin release also can be stimulated by factors other than diuretics, including decreased renal perfusion pressure, increased sympathetic tone, and decreased blood volume. Another important regulatory mechanism for urine formation is antidiuretic hormone (ADH), also known as vasopressin, which is released from the posterior pituitary in response to reduced blood pressure and elevated plasma osmolality. In the kidney, ADH acts on the collecting tubule to increase water permeability and reabsorption. As a result, the urine becomes more concentrated, and water is conserved in the presence of ADH.

Disease States T he diuretic drugs are used primarily to treat two medically important conditions, edema and hypertension. Both conditions are common, although some patients exhibit refractory disease states that require additional modification of the drug regimen to include alternative diuretics or addition of nondiuretic drugs. Edema (excessive extracellular fluid) normally results from disease to the heart, kidney, or liver. Decreased cardiac function (e.g., congestive heart disease) can result in decreased perfusion of all organs (e.g., kidney) and limbs and an accumulation of edema fluid in the extremities, particularly around the ankles and in the hands. Left-sided heart failure can lead to the development of acute pulmonary edema, which is a medical emergency. Right-sided heart failure shifts extracellular fluid volume from the arterial circulation to the venous circulation, which leads to general edema formation. Kidney dysfunction can lead to edema formation as a result of decreased formation of urine and the subsequent imbalance of water and electrolyte (e.g., sodium ion) homeostasis. Retention of salt and water results in an expansion of the extracellular fluid volume and, thus, edema formation. T hus, when salt intake exceeds salt excretion, edema can form. Edema formation also is associated with deceased protein levels in blood, as seen in nephrotic syndrome and liver disease. Cirrhosis of the liver leads to increased lymph in the space of Disse. Eventually, the increased lymph volume results in movement of fluid into the peritoneal cavity and ascites develops. Hypertension develops from many causes and will be discussed in more detail elsewhere (see Chapter 29). In general, hypertension occurs when blood pressure is sustained at greater than 140/90 mm Hg. At this blood pressure level, patients are at increased risk for developing cardiovascular disease. One key element in controlling blood pressure is sodium ion, and early antihypertensive effects of diuretics are related to increased salt and water excretion. Additionally, however, diuretics have long-term effects resulting in decreased vascular resistance that contribute to blood pressure control. Although effects on vascular calcium-activated potassium channels have been proposed as contributing to the chronic antihypertensive effects of thiazide diuretics, the exact mechanisms of long term effects remain to be determined. Diuretics also are useful in treating a number of other conditions including increased cranial (trauma or surgery) or intraocular (glaucoma) pressure (i.e., osmotic diuretics), diabetes insipidus (i.e., thiazides), hypercalcemia (i.e., loop diuretics), acute mountain sickness (i.e., P.725 carbonic anhydrase inhibitors), primary hyperaldosteronism (i.e., aldosterone antagonists), and osteoporosis (i.e., thiazides).

General T herapeutic Approaches Diuretic drugs may be administered acutely or chronically to treat edematous states. When immediate action to reduce edema (e.g., acute pulmonary edema) is needed, intravenous administration of a loop diuretic often is the approach of choice. T hiazide or loop diuretics normally are administered orally to treat nonemergency edematous states. T he magnitude of the diuretic response is directly proportional to the amount of edema fluid that is present. As the volume of edema decreases, so does the magnitude of the diuretic response with each dose. If concern exists about diuretic-induced hypokalemia developing, then a potassium supplement or potassium-sparing diuretic may be added to the drug regimen. T he development of hypokalemia is particularly important for patients with congestive heart failure who also are taking cardiac glycosides, such as digitalis. Digitalis has a narrow therapeutic index, and developing hypokalemia can potentiate digitalis-induced cardiac effects with potentially fatal results. Diuretic drugs (thiazide and loop diuretics) are administered orally to help control blood pressure in the treatment of hypertension. Diuretics often are the first drugs used to treat hypertension, and they also may be added to other drug therapies used to control blood pressure with beneficial effects.

Diuretic Drug Classes History Compounds that increase the urine flow rate have been known for centuries. One of the earliest substances known to induce diuresis is water, an inhibitor of ADH release. Calomel (mercurous chloride) was used as early as the 16th century as a diuretic, but because of poor absorption from the gastrointestinal tract and toxicity, calomel was replaced clinically by the organomercurials (e.g., chlormerodrin). T he organomercurials represented the first group of highly efficacious diuretics available for clinical use. T he need to administer these drugs parenterally, the possibility of tolerance, and their potential toxicity, however, soon led to the search for newer, less toxic diuretics. T oday, the organomercurials are no longer used as diuretics, but their discovery began the search for many of the diuretics used today. Other compounds previously used as diuretics include the acid-forming salts (ammonium chloride) and methylxanthines (theophylline).

Structure Classification T he diuretics currently in use today (T able 27.1) are classified by their chemical class (thiazides), mechanism of action (carbonic anhydrase inhibitors and osmotics), site of action (loop diuretics), or effects on urine contents (potassium-sparing diuretics). T hese drugs vary widely in their efficacy (i.e., their ability to increase the rate of urine formation) and their site of action within the nephron. Efficacy often is measured as the ability of the diuretic to increase the excretion of sodium ions filtered at the glomerulus (i.e., the filtered load of sodium) and should not be confused with potency, which is the amount of the diuretic required to produce a specific diuretic response. Efficacy is determined, in part, by the site of action of the diuretic. Drugs (e.g., carbonic anhydrase inhibitors) that act primarily on the proximal convoluted tubule to induce diuresis are weak diuretics because of the ability of the nephron to reabsorb a significant portion of the luminal contents in latter portions of the nephron. Likewise, drugs (potassium-sparing diuretics) that act at the more distal segments of the nephron are weak diuretics, P.726 because most of the glomerular filtrate has already been reabsorbed in the proximal tubule and ascending limb of the loop of Henle before reaching the distal tubule. T hus, the most efficacious diuretics discovered so far, the high-ceiling or loop diuretics, interfere with sodium chloride reabsorption at the ascending limb of the loop of Henle, which is situated after the proximal tubule but before the distal portions of the nephron and collecting tubule.

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Table 27.1. Diuretics: Sites and M echanisms of Action Class of Diuretic

Site of Action

Osmotics

Mechanism of Action

Proximal tubule

Osmotic effects decrease sodium and water reabsorption

Loop of Henle

Increases medullary blood flow to decrease medullary hypertonicity and reduce sodium and water reabsorption

Collecting tubule

Sodium and water reabsorption decreases because of reduced medullary hypertonicity and elevated urinary flow rate

Carbonic anhydrase inhibitors

Proximal convoluted tubule

Inhibition of renal carbonic anhydrase decreases sodium bicarbonate reabsorption

Thiazides and thiazide-like

Cortical portion of the thick ascending limb of loop of Henle and distal tubule

Inhibition of Na + /Cl - symporter

Loop or high-ceiling

Thick ascending limb of the loop of Henle

Inhibition of the luminal Na + /K + /2Cl - transport system

Potassiumsparing

Distal tubule and collecting duct

Inhibition of sodium and water reabsorption by: Competitive inhibition of aldosterone (spironolactone) Blockade of sodium channel at the luminal membrane (triamterene and amiloride)

Osmotic Diuretics Mechanism of Action Osmotic diuretics are low-molecular-weight compounds that are freely filtered through the Bowman's capsule into the renal tubules, are nonreabsorbable solutes, and are not extensively metabolized except for glycerin and urea (see T able 27.2) for their pharmacokinetic properties). Once in the renal tubule, osmotic diuretics have a limited reabsorption because of their high water solubility. When administered as a hypertonic (hyperosmolar) solution, these agents increase intraluminal osmotic pressure, causing water to pass from the body into the tubule. Since the osmotic agent and associated water are not reabsorbed from the nephron, a diuretic effect is observed. Osmotic diuretics increase the volume of urine and the excretion of water and almost all of the electrolytes. Polyols, such as mannitol, sorbitol, and isosorbide, provide this effect. Sugars, such as glucose and sucrose, also can have a diuretic effect by this mechanism. Although not a polyol, urea has a similar osmotic effect and has been used in the past as an osmotic diuretic.

Therapeutic Applications Osmotic diuretics are not frequently used in medicine today except in the prophylaxis of acute renal failure, in which these drugs inhibit water reabsorption and maintain P.727 urine flow. T hey also may be helpful in maintaining urine flow in cases where urinary output is diminished because of severe bleeding or traumatic surgical experiences. T he osmotic diuretics also have been used to acutely reduce increased intracranial or intraocular pressure. T hey are not considered to be primary diuretic agents in treating ordinary edemas, because osmotic diuretics can expand extracellular fluid volume.

Table 27.2. Pharmacokinetic Properties of the Nonthiazide Diuretics

Drug

Relative Trade Name Potency

Oral Absorption (%)

Peak Plasma

Duration of Effect Half-life

Route of Elimination

Osmotic diuretics Glycerin

>80

1–1.5 h

4–6 h

0.5–0.75 h

>90% metabolism

Isosorbide

>80

NA

NA

5–9.5 h

Urine unchanged

Mannitol

90

2h

6–8 h

0.5–1 h

30–50% urine unchanged 30% mercapturate

Torsemide

Demadex

3

80–100%

NA

NA

0.8–4 h

30% urine 70% metabolized

>90

1–3 h

NA

70

2–4 h

>24 h

2–3 h

Metabolized to active metabolites

Aldosterone antagonists; potassium-sparing diuretics (mineralocorticoid receptor antagonists) Spironolactone

Aldactone

Canrenone

>90c NA

1–2 h

2–3 d

1–3 h

Active metabolite

13–24 h

3–4 h

Urine

(7α-thiospironolactone) active metabolite a

Food affects bioavailability.

b

In patients with renal insufficiency.

c

Formulation affects bioavailability. Data from McEvoy GK, ed. AHFS 2000 Drug Information. Bethesda, MD: American Society of Health-System Pharmacists, 2000. NA, no data available.

Adv erse Effects Osmotic diuretics induce few adverse effects, but expansion of the extracellular fluid volume can occur, as noted above. Alteration of blood sodium levels can be seen, and these drugs should not be used in anuric or unresponsive patients. If cranial bleeding is present, mannitol or urea should not be used.

Specific Drugs Mannitol Mannitol is the agent most commonly used as an osmotic diuretic. Sorbitol also can be used for similar reasons. T hese compounds can be prepared by the electrolytic reduction of glucose or sucrose. Mannitol is administered intravenously in solutions of 5 to 50% at a rate of administration that is adjusted to maintain the urinary output at 30 to 50 ml/hour. Mannitol is filtered at the glomerulus and is poorly reabsorbed by the kidney tubule. T he osmotic effect of mannitol in the tubule inhibits the reabsorption of water, and the rate of urine flow can be maintained. It also is used to reduce intracranial pressure by reducing cerebral intravascular volume.

Isosorbide Isosorbide is basically a bicyclic form of sorbitol that is used orally to cause a reduction in intraocular pressure in glaucoma cases. Although a diuretic effect is noted, its ophthalmologic properties are its primary value.

Carbonic Anhydrase Inhibitors Mechanism of Action In 1937, it was proposed that the normal acidification of urine was caused by secretion of hydrogen ions by the tubular cells of the kidney. T hese ions were provided by the action of the enzyme carbonic anhydrase, which catalyzes the formation of carbonic acid (H 2 CO 3 ) from carbon dioxide and water.

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It also was observed that sulfanilamide rendered the urine of dogs alkaline because of the inhibition of carbonic anhydrase. T his inhibition of carbonic anhydrase resulted in a lesser exchange of hydrogen ions for sodium ions in the kidney tubule. Sodium ions, along with bicarbonate ions, and associated water molecules were then excreted, and a diuretic effect was noted. T he large doses required and the side effects of sulfanilamide prompted a search for more effective carbonic anhydrase inhibitors as diuretic drugs. It was soon learned that the sulfonamide portion of an active diuretic molecule could not be monosubstituted or disubstituted. It was reasoned that a more acidic sulfonamide would bind more tightly to the carbonic anhydrase enzyme. Synthesis of more acidic sulfonamides produced compounds more than 2,500-fold more active than sulfanilamide. Acetazolamide was introduced in 1953 as an orally effective diuretic drug. Before that time, the organic mercurials, which commonly required intramuscular injection, were the principal diuretics available. Carbonic anhydrase inhibitors induce diuresis by inhibiting the formation of carbonic acid within proximal (proximal convoluted tubule; S2) and distal tubular cells to limit the number of hydrogen ions available to promote sodium reabsorption. For a diuretic response to be observed, more than 99% of the carbonic anhydrase must be inhibited. Although carbonic anhydrase activity in the proximal tubule regulates the reabsorption of approximately 20 to 25% of the filtered load of sodium, the carbonic anhydrase inhibitors are not highly efficacious diuretics. An increased excretion of only 2 to 5% of the filtered load of sodium is seen with carbonic anhydrase inhibitors because of increased reabsorption of sodium ions by the ascending limb of the loop of Henle and more distal nephron segments.

Therapeutic Applications With prolonged use of the carbonic anhydrase inhibitor diuretics, the urine becomes more alkaline, and the blood becomes more acidic. When acidosis occurs, the carbonic anhydrase inhibitors lose their effectiveness as diuretics. T hey remain ineffective until normal acid-base balance in the body has been regained. For this reason, this class of compounds is limited in its diuretic use. T oday, they are most commonly used in the treatment of glaucoma, in which they reduce the rate of aqueous humor formation and, subsequently, reduce the intraocular pressure. T hese compounds also have found some limited use in the treatment of absence seizures, to alkalinize the urine, to treat familial periodic paralysis, to reduce metabolic alkalosis, and prophylactically, to reduce acute mountain sickness.

Specific Drugs Acetazolamide Acetazolamide was the first of the carbonic anhydrase inhibitors to be introduced as an orally effective diuretic, with a diuretic effect that lasts approximately 8 to 12 hours (see T able 27.2 for its pharmacokinetic properties). As mentioned earlier, its diuretic action is limited because of the systemic acidosis it produces. Acetazolamide reduces the rate of aqueous humor formation and is used primarily for reducing intraocular pressure in the treatment of glaucoma. T he dose is 250 mg to 1 g per day. P.728

Glaucoma T he following carbonic anhydrase inhibitors are used orally in the treatment of glaucoma.

Methazolamide Methazolamide is a derivative of acetazolamide in which one of the active hydrogens has been replaced by a methyl group. T his decreases the polarity and permits a greater penetration into the ocular fluid, where it acts as a carbonic anhydrase inhibitor, reducing intraocular pressure. Its dose for glaucoma is 50 to 100 mg two to three times a day.

Ethoxzolamide and dichlorphenamide Ethoxzolamide is another carbonic anhydrase inhibitor with properties and uses resembling those of acetazolamide. Dichlorphenamide is a disulfonamide derivative that shares the same pharmacological properties and clinical uses as the previously discussed compounds. T he dose of dichlorphenamide is 25 to 100 mg one to three times a day.

Benzothiadiazine or Thiazide Diuretics Further study of the benzene disulfonamide derivatives was undertaken to find more efficacious carbonic anhydrase inhibitors. T hese studies provided some compounds with a high degree of diuretic activity. Chloro and amino substitution gave compounds with increased activity, but these compounds were weak carbonic anhydrase inhibitors. When the amino group was acylated, an unexpected ring closure took place. T hese compounds possessed a diuretic activity independent of the carbonic anhydrase inhibitory activity, and a new series of diuretics called the benzothiadiazines was discovered.

Mechanism of Action T he mechanism of action of the benzothiadiazine diuretics is primarily related to their ability to inhibit the Na + /Cl - symporter located in the distal convoluted tubule. T hese diuretics are actively secreted in the proximal tubule and are carried to the loop of Henle and to the distal tubule. T he major site of action of these compounds is in the +

-

distal tubule, where these drugs compete for the chloride binding site of the Na /Cl symporter and inhibit the reabsorption of sodium and chloride ions. For this reason, they are referred to as saluretics. T hey also inhibit the reabsorption of potassium and bicarbonate ions, but to a lesser degree.

Structure–Activ ity Relationship

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T he thiazide diuretics are weakly acidic (see Appendix A for their pKa values), with a benzothiadiazine 1,1-dioxide nucleus. T he structure for the thiazide diuretics, relative activities, and pharmacokinetic properties for the thiazides are shown in T able 27.3. Chlorothiazide is the simplest member of this series, having a pK a of 6.7 and 9.5. T he hydrogen atom at the 2-N is the most acidic because of the electron-withdrawing effects of the neighboring sulfone group. T he sulfonamide group that is substituted at C-7 provides an additional point of acidity in the molecule but is less acidic than the 2-N proton. T hese acidic protons make possible the formation of a water-soluble sodium salt that can be used for intravenous administration of the diuretics.

An electron-withdrawing group is necessary at position 6 for diuretic activity. Little diuretic activity is seen with a hydrogen atom at position 6, whereas compounds with a chloro or trifluoromethyl substitution are highly active. T he trifluoromethyl-substituted diuretics are more lipid-soluble and have a longer duration of action than their chloro-substituted analogues. When electron-releasing groups, such as methyl or methoxyl, are placed at position 6, the diuretic activity is markedly reduced. Replacement or removal of the sulfonamide group at position 7 yields compounds with little or no diuretic activity. Saturation of the double bond to give a 3,4-dihydro derivative produces a diuretic that is 10-fold more active than the unsaturated derivative. Substitution with a lipophilic group at position 3 gives a marked increase in the diuretic potency. Haloalkyl, aralkyl, or thioether substitution increases the lipid solubility of the molecule and yields compounds with a longer duration of action. Alkyl substitution on the 2-N position also decreases the polarity and increases the duration of diuretic action. Although these compounds do have carbonic anhydrase activity, there is no correlation of this activity with their saluretic activity (excretion of sodium and chloride ions).

Therapeutic Applications T he thiazide diuretics are administered once a day or in divided daily doses. Some have a duration of action that permits administration of a dose every other day. Some of these compounds are rapidly absorbed orally and can show their diuretic effect in an hour (T able 27.3). T hese compounds are not extensively metabolized and are primarily P.729 P.730 excreted unchanged in the urine. T hiazide diuretics are used to treat edemas caused by cardiac decompensation as well as in hepatic or renal disease. T hey also commonly are used in the treatment of hypertension. T heir effect may be attributed to a reduction in blood volume and a direct relaxation of vascular smooth muscle.

Table 27.3. Pharmacological and Pharmacokinetic Properties for the Thiazide Diuretics

Generic Name Chlorothiazide

Trade Name Diuril

Benzthiazide

Exna

Hydrochlorothiazide

HydroDiuril Esidrix Oretic

Structure Structure I: R1 = H

Carbonic Peak Relative Anhydrase Plasma Half-life PotencyaInhibitionbBioavailability (hours) (hours) 0.8

2×

Duration Route of (hours) Elimination

80%

4

6–15

6–12

U

Diurese Metahydrin Naqua

Structure II: R 1 = CHCl 2 R 2 = Cl; R 3 = H

1.7

Var

6

NA

24

U

Methyclothiazide

Enduron Aquatensen

Structure II: R 1 = CH 2 Cl R 2 = Cl; R 3 = CH 3

1.8

—

Var.

6

NA

>24

U

Polythiazide

Renese

Structure II: R 1 = –CH 2 -S-CH 2 -CF 3 R 2 = Cl; R 3 = CH 3

2.0

5×

var

6

NA

24–48

U 30% M

Structure II: R 1 = H R 2 = CF 3 ; R3 = H

1.3

Inc

3–4

17 active metab.

18–24

U active metab.

Trichloromethiazide

Hydroflumethiazide

Saluron Diucardin

10-5

6× 10-5

10-7

2× 10-4

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Bendroflumethiazide

Naturetin

Structure II: R 1 = benzyl R 2 = CF 3 ; R3 = H

1.8

3×

>90%

4

8.5

6–12

U

10-4

a

The numerical values refer to potency ratios (in humans) with the natriuretic response to that of a standard dose of meralluride, which is given a value of one.

b

50% inhibition of carbonic anhydrase in vitro. Data from AHFS 2000 Drug Information. Bethesda, MD: American Society of Health-System Pharmacists, 2000; and USPDI Vol. I Drug Information for the Health Care Professional, 20th Ed. Rockville, MD: U.S. Pharmacopeial Convention. 2000. U, urine unchanged; M, metabolized; NA, data not available; Var, variables absorption; Inc, incomplete absorption.

Adv erse Effects T hiazide diuretics may induce a number of adverse effects, including hypersensitivity reactions, gastric irritation, nausea, and electrolyte imbalances, such as hyponatremia, hypokalemia, hypomagnesemia, hypochloremic alkalosis, hypercalcemia, and hyperuricemia. Individuals who exhibit hypersensitivity reactions to one thiazide are likely to have a hypersensitivity reaction to other thiazides and sulfamoyl-containing diuretics (e.g., thiazide-like and some high-ceiling diuretics). Potassium and magnesium supplements may be administered to treat hypokalemia or hypomagnesemia, but their use is not always indicated. T hese supplements usually are administered as potassium chloride, potassium gluconate, potassium citrate, magnesium oxide, or magnesium lactate. T he salts are administered as solutions, tablets, or timed-release tablets. Generally, approximately 20 mEq of potassium is given daily. In cases of hypokalemia, 40 to 100 mEq/day may be administered. Potassium-sparing diuretics (e.g., triamterene or amiloride) also may be used to prevent hypokalemia. Combination preparation of hydrochlorothiazide or a potassium-sparing diuretic are available (e.g., Diazide and Moduretic). Long-term use of thiazide diuretics also may result in decreased glucose tolerance and increased blood lipid (low-density lipoprotein cholesterol, total cholesterol, and total triglyceride) content.

Quinazolinone Derivatives—Quinethazone and M etolazone

Ov erview T he quinazolin-4-one molecule has been structurally modified in a manner similar to the modification of the thiazide diuretics. Quinethazone and metolazone (pK a = 9.7) are examples of this class (T able 27.4). T he structural difference between the quinazolinone diuretics is the replacement of the 4-sulfone group (–SO 2 –), with a 4-keto group (–CO–). Because of their similar structures, it is not surprising that the quinazolinones have a diuretic effect similar to that of the thiazides.

Mechanism of Action and Therapeutic Applications T he pharmacokinetic properties for the quinazolinone diuretics are listed in T able 27.4. T hey have a long duration of action, usually as a result of protein binding. Although chlorothiazide has a duration of action of 6 to 12 P.731 hours, quinethazone a duration of 18 to 24 hours, and metolazone a duration of 12 to 24 hours. Metolazone has a bioavailability of 65% (Zaroxolyn) and a prolonged onset to reach peak plasma concentrations of action ranging from 8 to 12 hours. When reformulated as for Mykrox™, however, metolazone is almost completely absorbed, with peak plasma concentrations reached in 2 to 4 hours. T hus, other versions of metolazone cannot be interchanged with Mykrox. Approximately 50 to 70% of metolazone is bound to carbonic anhydrase in the erythrocytes. Metolazone also has an increased potency, and the mode of action for both compounds is similar to that of the thiazide derivatives. In contrast to thiazide diuretics, metolazone may be effective as a diuretic when the GFR falls below 40 mL/min. T he dose of quinethazone is 50 to 100 mg daily and that of metolazone 2.5 to 20 mg given as a single oral dose. Side effects are similar to adverse effects induced by the thiazide diuretics.

Table 27.4. Pharmacokinetic Properties for the Thiazide-Like Diuretics

Phthalimidine Derivatives—Chlorthalidone

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Ov erview Chlorthalidone (pK a = 9.4) is an example of a diuretic in this class of compounds that bears a structural analogy to the quinazolinones (T able 27.4). T his compound may be named as a 1-oxo-isoindoline or a phthalimidine. Although the molecule exists primarily in the phthalimidine form, the ring may be opened to form a benzophenone derivative. T he benzophenone form illustrates the relationship to the quinazolinone series of diuretics. It may be regarded as an open ring variation.

Therapeutic Application Chlorthalidone has a long duration of action (48–72 hours) (see T able 27.3 for its other pharmacokinetic properties). Although quinethazone and metolazone are administered daily, chlorthalidone may be administered in doses of 25 to 100 mg three times a week. When chlorthalidone is formulated with the excipient povidone, the product, T halitone, has greater bioavailability (> 90%) and reaches peak plasma concentrations in a shorter time compared with its other products. Similar to the quinazolinones, it also is extensively bound to carbonic anhydrase in the erythrocytes. Chlorthalidone-induced effects on urine content and side effects are similar to those induced by thiazide diuretics.

Indolines—Indapamide Mechanism of Action T he prototypic indoline diuretic is indapamide, which was reported as a diuretic in 1984. Indapamide contains a polar chlorobenzamide moiety and a nonpolar lipophilic methylindoline group. In contrast to the thiazides, indapamide does not contain a thiazide ring, and only one sulfonamide group is present within the molecular structure (pK a = 8.8). It is rapidly and completely absorbed from the gastrointestinal tract and reaches its peak plasma level in 2 to 3 hours, with a duration of action of up to 8 weeks. T his prolonged duration of action is associated with its extensive binding to carbonic anhydrase in the erythrocytes. It exhibits biphasic kinetics, with a half-life of 14 to 18 hours and an elimination half-life of 24 hours. Indapamide is extensively metabolized, with 60 to 70% of the oral dose being eliminated in the urine as glucuronide and sulfate metabolites and less than 10% being excreted unchanged. T he remaining 20 to 30% is eliminated via extrahepatic cycling.

Therapeutic Application Uses of indapamide include the treatment of essential hypertension and edema resulting from congestive heart failure. Like metolazone, indapamide is an effective diuretic drug when GFR falls below 40 mL/min. T he duration of action is approximately 24 hours, with the normal oral adult dosage starting at 2.5 mg given each morning. T he dose may be increased to 5.0 mg/day, but doses beyond this level do not appear to provide additional results. Effects on urine content and side effects are similar to effects induced by thiazide diuretics.

High-Ceiling or Loop Diuretics Mechanism of Action T his class of drugs is characterized more by its pharmacological similarities than by its chemical similarities. T hese diuretics produce a peak diuresis much greater than that observed with the other commonly used diuretics, hence the name high-ceiling diuretics. T heir main site of action is believed to be on the thick ascending limb of the +

+

-

loop of Henle, where they inhibit the luminal Na /K /2Cl symporter. T hese diuretics are commonly referred to as loop diuretics. Additional effects on the proximal and distal tubules also are possible. High-ceiling diuretics are characterized by a quick onset and short duration of activity. T heir diuretic effect appears in approximately 30 minutes and lasts for approximately 6 hours. T he pharmacokinetic properties for the loop diuretics are listed in T able 27.2.

Specific Drugs Furosemide

Structure–Activity Relation sh ips Furosemide is an example of a high-ceiling diuretic and may be regarded as a derivative of anthranilic acid or o-aminobenzoic acid. P.732 Research on 5-sulfamoylanthranilic acids at the Hoechst Laboratories in Germany showed them to be effective diuretics. T he most active of a series of variously substituted derivatives was furosemide. T he chlorine and sulfonamide substitutions are features also seen in previously discussed diuretics. Because the molecule possesses a free carboxyl group, furosemide is a stronger acid than the thiazide diuretics (pK a = 3.9). T his drug is excreted primarily unchanged. A small amount of metabolism, however, can take place on the furan ring, which is substituted on the aromatic amino group (see T able 27.2 for its other pharmacokinetic properties).

T h erapeu tic Application s Furosemide has a saluretic effect 8- to 10-fold that of the thiazide diuretics; however, it has a shorter duration of action (~ 6–8 hours). Furosemide causes a marked excretion of sodium, chloride, potassium, calcium, magnesium, and bicarbonate ions, with as much as 25% of the filtered load of sodium excreted in response to initial treatment. It is effective for the treatment of edemas connected with cardiac, hepatic, and renal sites. Because it lowers the blood pressure similar to the thiazide derivatives, one of its uses is in the treatment of hypertension. Furosemide is orally effective but may be used parenterally when a more prompt diuretic effect is desired, such as in the treatment of acute pulmonary edema. T he

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dosage of furosemide, 20–80 mg/day, may be given in divided doses because of the short duration of action of the drug and carefully increased up to a maximum of 600 mg/day.

Adverse Effects Clinical toxicity of furosemide and other loop diuretics primarily involves abnormalities of fluid and electrolyte balance. As with the thiazide diuretics, hypokalemia is an important adverse effect that can be prevented or treated with potassium supplements or coadministration of potassium-sparing diuretics. Increased calcium ion excretion can be a problem for postmenopausal osteopenic women, and furosemide generally should not be used in these individuals. Hyperuricemia, glucose intolerance, increased serum lipid levels, ototoxicity, and gastrointestinal side effects might be observed as well. Hypersensitivity reactions also are possible with furosemide (a sulfonamide-based drug), and cross-reactivity with other sulfonamide containing drugs is possible.

Bumetanide

T h erapeu tic Application s A diuretic structurally related to furosemide is bumetanide. T his compound also functions as a high-ceiling diuretic in the ascending limb of the loop of Henle. It has a duration of action of approximately 4 hours. T he uses of this compound are similar to those described for furosemide. T he dose of bumetanide is 0.5 to 2 mg/day given as a single dose. Adverse effects are similar to those induced by furosemide.

Structure–Activity Relation sh ips For bumetanide, a phenoxy group has replaced the customary chloro or trifluoromethyl substitutions seen in other diuretic molecules. T he phenoxy group is an electronwithdrawing group similar to the chloro or trifluoromethyl substitutions. T he amine group customarily seen at position 6 has been moved to position 5. T hese minor variations from furosemide produced a compound with a mode of action similar to that of furosemide, but with a marked increase in diuretic potency. T he short duration of activity is similar, but the compound is approximately 50-fold more potent. Replacement of the phenoxy group at position 4 with a C 6 H 5 NH- or C 6 H 5 S- group also gives compounds with a favorable activity. When the butyl group on the C-5 amine is replaced with a furanylmethyl group, such as in furosemide; however, the results are not favorable.

Torsemide

Further modification of furosemide-like structures has led to the development of torsemide. Instead of the sulfonamide group found in furosemide and bumetanide, torsemide contains a sulfonylurea moiety. Similar to other high-ceiling diuretics, torsemide inhibits the luminal Na 1 /K 1 /2Cl - symporter in the ascending limb of the loop of Henle to promote the excretion of sodium, potassium, chloride, calcium, and magnesium ions and water. An additional effect on the peritubular side at chloride channels may enhance the luminal effects of torsemide. In contrast to furosemide and bumetanide, however, torsemide does not act at the proximal tubule and, therefore, does not increase phosphate or bicarbonate excretion. Peak diuresis is observed 1 to 2 hours following oral or intravenous administration, with a duration of action of approximately 6 hours. T orsemide is indicated for the treatment of edema resulting from congestive heart failure and for the treatment of hypertension. In patients with cirrhosis and ascites, T orsemide should be used with caution. Adverse effects are similar to those induced by furosemide. P.733

Ethacrynic acid

Mech an ism of Action Another major class of high-ceiling diuretics is the phenoxyacetic acid derivatives, of which ethacrynic acid is the prototypical agent. T hese compounds were developed at about the same time as furosemide but were designed to act mechanistically similar to the organomercurials (i.e., via inhibition of sulfhydryl-containing enzymes involved in solute reabsorption). T he mechanism of action of ethacrynic acid appears to be more complex than the simple addition of sulfhydryl groups of the enzyme to the drug molecule. When the double bond of ethacrynic acid is reduced, the resultant compound is still active, although the diuretic activity is diminished. T he sulfhydryl groups of the enzyme would not be expected to add to the drug molecule in the absence of the α,β-unsaturated ketone. T he pharmacokinetic properties for ethacrynic acid are listed in T able 27.2. In 1984, a new series of diuretics was reported (2,3). T he following substance is representative of this series:

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T hese compounds are potent high-ceiling diuretics that resemble ethacrynic acid in their mechanism of action. T he ethyl ester group represents a pro-drug that can be easily hydrolyzed to the free carboxyl group. As in ethacrynic acid, a 2,3-dichloro substitution is necessary. In addition, a para-hydroxyl group and an unsubstituted aminomethyl group on the benzene ring are highly beneficial. T he carbonyl group can be replaced with an ether or sulfide group. T hese compounds have no ability to add the sulfhydryl groups of the kidney enzymes. T he complete mechanism of action of these compounds remains in doubt. Similar to the other high-ceiling diuretics, ethacrynic acid inhibits the Na 1 /K 1 /2Cl - symporter in the ascending limb of the loop of Henle to promote a marked diuresis. Sodium, chloride, potassium, and calcium excretion are increased following oral or intravenous administration of ethacrynic acid. Oral administration of ethacrynic acid results in diuresis within 1 hour and a duration of action of 6 to 8 hours. T oxicity induced by ethacrynic acid is similar to that induced by furosemide and bumetanide. Ethacrynic acid is not widely used, however, because it induces a greater incidence of ototoxicity and more serious gastrointestinal effects than those of furosemide or bumetanide.

Structure–Activity Relation sh ip Optimal diuretic activity was obtained when an oxyacetic acid group was positioned para to an α,β-unsaturated carbonyl (or other sulfhydryl-reactive group) and chloro or methyl groups were placed at the 2- or 3-position of the phenyl ring. In addition, hydrogen atoms on the terminal alkene carbon also provided maximum reactivity. T hus, a molecule with a weakly acidic group to direct the drug to the kidney and an alkylating moiety to react with sulfhydryl groups and lipophilic groups seemed to provide the best combination for a diuretic in this class. T hese features led to the development of ethacrynic acid as the prototypic agent in this class.

New drugs

Four additional high-ceiling diuretics are azosemide, muzolimine, piretanide, and tripamide. Azosemide has low oral bioavailability (~10–15%) because of high first-pass metabolism in the liver, whereas piretanide has comparable pharmacokinetics to bumetanide. As can be seen by these varied structures, the high-ceiling diuretics are characterized more by their pharmacological similarities than by their chemical similarities.

Potassium-Sparing Diuretics (M ineralocorticoid Receptor Antagonists) —Antihormone Diuretics Mechanism of Action T he adrenal cortex secretes a potent mineralocorticoid called aldosterone, which promotes salt and water retention and potassium and hydrogen ion excretion.

Other mineralocorticoids have an effect on the electrolytic balance of the body, but aldosterone is the most potent. Its ability to cause increased reabsorption of sodium and chloride ion and increased potassium ion excretion is approximately 3,000-fold that of hydrocortisone. A substance that antagonizes the effects of aldosterone could conceivably be a good diuretic drug. Spironolactone is such an antagonist. P.734

Specific Drugs Spironolactone Spironolactone is a competitive antagonist to the mineralocorticoids, such as aldosterone. T he mineralocorticoid receptor is an intracellular protein that can bind aldosterone. Spironolactone binds to the receptor and competitively inhibits aldosterone binding to the receptor. T he inability of aldosterone to bind to its receptor prevents reabsorption of sodium and chloride ions and the associated water. T he most important site of these receptors is in the late distal convoluted tubule and collecting system (collecting duct).

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Metabolism On oral administration, approximately 90% of the dose of spironolactone is absorbed and is significantly metabolized during its first passage through the liver to its major active metabolite, canrenone (see T able 27.2 for their pharmacokinetic properties), which is interconvertible with its canrenoate anion. Canrenone is an antagonist to aldosterone.

T he canrenoate anion is not active per se but acts as an aldosterone antagonist because of its conversion to canrenone, which exists in the lactone form. Canrenone has been suggested to be the active form of spironolactone as an aldosterone antagonist. T he formation of canrenone, however, cannot fully account for the total activity of spironolactone. Both canrenone and potassium canrenoate are used as diuretics in other countries, but they are not yet available in the United States.

T h erapeu tic Application s Spironolactone is useful in treating edema resulting from primary hyperaldosteronism and refractory edema associated with secondary hyperaldosteronism. Spironolactone is considered to be the drug of choice for treating edema resulting from cirrhosis of the liver. T he dose of spironolactone is 100 mg/day given in single or divided doses. Another use of spironolactone is coadministration with a potassium-depleting diuretic (e.g., a thiazide or loop diuretic) to prevent or treat diuretic-induced hypokalemia. Spironolactone can be administered in a fixed-dose combination with hydrochlorothiazide for this purpose, but optimal individualization of the dose of each drug is recommended.

Adverse Effects T he primary concern with the use of spironolactone is the development of hyperkalemia, which can be fatal. Spironolactone may cause hypersensitivity reactions, gastrointestinal disturbances, peptic ulcer, gynecomastia, decreased libido, and impotence. It also has been implicated in tumor production during chronic toxicity studies in rats, but human risk has not been documented.

Eplerenone

A newer drug, eplerenone, has a structure similar to that of spironolactone and a similar mechanism of action. It was initially approved for use in the treatment of hypertension but it can now be used in the treatment of patients with left ventricular systolic dysfunction and congestive heart failure after myocardial infarction. It has a half-life of approximately 5 hours and undergoes hepatic metabolism to inactive metabolites as its main route of elimination. Clinical experience with eplerenone is currently limited.

Pteridines—Triamterene Pteridines have a marked potential for influencing biological processes. Early screening of pteridine derivatives revealed that 2,4-diamino-6,7-dimethylpteridine was a fairly potent diuretic. Further structural modification led to the development of triamterene.

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Mechanism of action T riamterene interferes with the process of cationic exchange by blocking luminal sodium channels in the late distal convoluted tubule and collecting duct. Sodium channel inhibitors block the reabsorption of sodium ion and inhibit the secretion of potassium ion. Aldosterone is not antagonized by triamterene. T he net result is increased sodium and chloride ion excretion P.735 in the urine and almost no potassium excretion. T riamterene is more than 70% absorbed on oral administration (see T able 27.2 for its other pharmacokinetic properties). T he diuretic effect occurs rapidly (~ 30 minutes) and reaches a peak plasma concentration in 2 to 4 hours, with a duration of action of more than 24 hours. T riamterene is extensively metabolized, and some of the metabolites are active as diuretics. Both the drug and its metabolites are excreted in the urine.

Structure–activity relationships Modifications of the triamterene structure are not usually beneficial in terms of diuretic activity. Activity is retained if an amine group is replaced with a lower alkylamine group. Introduction of a para-methyl group on the phenyl ring decreases the activity by approximately half. Introduction of a para-hydroxyl group on the phenyl ring yields a compound that is essentially inactive as a diuretic.

Therapeutic applications T riamterene is useful in combination with a thiazide or loop diuretic in the treatment of edema or hypertension. Liddle's syndrome also may be treated with a sodium channel blocking drug, such as triamterene. T riamterene is administered initially in doses of 100 mg twice a day. A maintenance dose for each patient should be individually determined. T his dose may vary from 100 mg a day to as low as 100 mg every other day.

Adverse effects T he most serious side effect associated with the use of triamterene is hyperkalemia. For this reason, potassium supplements are contraindicated, and serum potassium levels should be checked regularly. T riamterene also is used in combination with hydrochlorothiazide. Here, the hypokalemic effect of the hydrochlorothiazide counters the hyperkalemic effect of the triamterene. Other side effects that are seen with the use of triamterene are nausea, vomiting, and headache.

Aminopyrazines—Amiloride

Amiloride, another potassium-sparing diuretic, is an aminopyrazine structurally related to triamterene as an open-chain analogue. Similar to triamterene, it interferes with the process of cationic exchange in the distal convoluted tubule by blocking luminal sodium channels. It blocks the reabsorption of sodium ion and the secretion of potassium ion. It has no effect on the action of aldosterone. Oral amiloride is approximately 50% absorbed (see T able 27.2 for its other pharmacokinetic properties), with a duration of action of 10 to 12 hours, which is slightly longer than that for triamterene. Although triamterene is extensively metabolized, approximately 50% of amiloride is excreted unchanged. Renal impairment can increase its elimination half-life. Like triamterene, amiloride combined with a thiazide or loop diuretic is used to treat edema or hypertension. Aerosolized amiloride has shown some benefit in improving mucociliary clearance in patients with cystic fibrosis. As with triamterene, the most serious side effect associated with amiloride is hyperkalemia, and it also has the other side effects associated with triamterene. T he dose of amiloride is 5 to 10 mg per day. Amiloride also is combined with hydrochlorothiazide in a fixed-dose combination. P.736

Therapeutic Application of Diuretics BD is a 6 7 -ye ar-o ld man who was adm itte d with a co m plaint o f s ho rtne ss of b re ath that has increase d o ve r the las t f e w mo nths. He als o indicate d that he has re ce ntly g aine d mo re than 1 2 p o und s without chang ing his e ating o r exe rcise hab its and that he o f te n has tro ub le b re athing when clim bing s tairs at ho me . Physical e xaminatio n re veals signs and symp to ms co ns is te nt with b oth rig ht-s id e d (s yste mic e d e ma, he pato me g aly, ne ck ve in d iste nsion) and le f t-s id e d (we akne s s, f atig ue , rale s, c yano sis) he art f ailure. A d iag no s is o f co ng e s tive he art f ailure (CHF) is e stab lis he d , and a d e cis io n is m ad e to limit s o d ium intake (low s o dium die t) and to initiate o ral the rap y with d ig italis to imp ro ve he art f unctio n. A d iure tic also will b e add e d to he lp re mo ve e de m a f luid and d e cre as e the wo rklo ad o n the he art. W hat d iuretics wo uld b e ap p ro p riate to use in this p atie nt?

ANSW ER: Se le c tio n o f a diur e tic wou ld be ba s e d o n the dr ug's a bility to mob ilize e de ma fluid a nd to h elp r e du c e the wor klo a d on th e h e ar t. T h ia z ide a nd loop (hig h-ce ilin g) d iur etic s ar e e ffec tiv e in mobiliz ing e de ma flu id a nd co uld b e us e d in this pa tie nt. Os motic d iur etic s ar e not e ffe ctiv e a t mo bilizin g e de ma flu id a nd will e x pa nd e x tr a c e llula r fluid , whic h wou ld wor s e n the wor k loa d on th e h e ar t. C a r bo nic a nhy d r a s e inhib itor s a r e we ak diur e tic s a nd wou ld no t p r ov id e a d e qua te d iur e s is to e ffe ctiv e ly r e duc e the wor k lo ad on the he a r t. Pota ss iu m-s pa r in g diu r e tic s a ls o a r e le s s effe c tive tha n thia zid e s o r lo op d iur e tic s in mo biliz in g e de ma flu id a nd wo uld n ot b e a diur e tic of fir st c hoic e in this pa tie nt. Cho os ing b e twe e n a th ia zide or a loop diur e tic de p en ds on ma n y fa c to r s , inc lud ing the a moun t of e de ma pr e s e nt, s ev e r ity of s ymp toms , a nd the pa tie nt' s r e na l func tion. L oop diur e tic s (e .g ., fur os e mide a nd tor s emide ) a r e mor e e ffic a c ious tha n thia zid e s a n d c a n r e mov e e de ma flu id fa s ter tha n thia z ide s c an , th us pr ov iding quic k e r r e lie f. Lo op d iur etic s als o ha v e dir e c t effe c ts o n the pulmo na r y v e nou s s ys te m to he lp imp r o ve pulmon a r y s y mp toms r ela te d to th e fa iling h e ar t. Ad ditio na lly , howe v e r , loo p d iur e tics c a n c a us e mor e dr a ma tic imba la nc e s in e x tr a c ellu la r vo lume a nd e le c tr oly te le v e ls th an th iaz ide s c a n, a nd lo op d iur etic s c an a lte r the s e le ve ls s oo ne r tha n with th ia zide u se . T hu s , loop diur e tic s sh ou ld be e mploy e d wh en mo de r a te to s e v e r e CHF is p r e s e nt, but th iaz ide s ma y b e pr e fe r r e d wh e n mild CHF is p r e s e nt. B e c au s e this pa tie nt h a s mo de r a te to s e v e r e s y mpto ms , fur os e mid e is c h os e n a s th e d iur etic to u s e in th is pa tie nt. I f BD had b e e n s e en whe n his C HF was mild b ut his re nal f unctio n was alre ad y imp aire d (g lo me rular f iltratio n rate [GF R], 2 5 mL /min), ho w wo uld the s e circumstanc es af f e ct yo ur se le ctio n o f a d iure tic?

ANSW ER: Altho ugh a thia z ide diur e tic no r ma lly wo uld b e the d iur e tic of c h oic e in tr e a ting mild CHF, a thia zide g e ne r a lly is le ss e ffe c tiv e in p a tie nts with

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r e na l ins u fficie n cy . T h iaz ide s c a n r e a c h the ir s ite of a c tion (the lu min a l so dium io n– c hlor ide ion tr a n s por te r o f the dis tal c o nv olu te d tubu le ) follo wing filtr ation at th e glome r u lus . T he a mo unt of dr u g filte r e d at th e glome r u lus de pe n ds on the e x te n t of pla s ma p r o te in b indin g fo r tha t d r ug . In a ddition , be c a us e thia z ide s a r e we ak ly a c idic dr ugs (pK a , 7 .0 –9 .0 ), the y a r e s u bs tr ate s fo r a c tiv e s e cr e tio n by the or ga nic a nion tr a ns por t sy s te m o f the pr ox ima l tubu la r c e lls . With the e x ce p tion of me tola zo ne a nd in da pa mide , ho wev e r , mo st th ia zide s a r e in effe c tive a s diu r e tic s whe n the GFR is 3 0 to 40 mL/min (no r ma l GF R, 12 5 mL/min). Loo p diu r e tic s r ea c h the ir site of ac tion (lumina l s od ium ion– p ota s s ium ion – 2 ch lor ide ion tr a n sp or te r o f the a sc e n ding limb of the loo p of He nle ) pr ima r ily v ia a c tiv e s e cr e tio n by the or ga nic a nion tr a ns por t s y s te m of pr ox imal tub ula r c e lls . As s tro nge r or g an ic a cid s tha n thia z ide diu r e tic s (e .g., p K a o f fur o s emid e 5 4 .7 ), lo op d iur etic s ar e goo d s ub s tr a te s for s ec r e tion . Exte ns iv e pla s ma p r ote in bin ding by th e s e d r u gs limits th eir ac c e s s to the lu min a of n e phr ons v ia filtr a tion. T hu s , a ma r ke d r e du ction in GFR do es n ot limit ac c e s s of loop diur e tic s to tub ula r lu min a or ma r k ed ly alte r the th e r a pe utic e ffic a c y of th es e dr ug s. As a r e s ult, a loop diur e tic wou ld s till b e a p r e fe r r e d c ho ic e for tr e ating BD if his CHF h ad be e n mild bu t h is r e na l fu nc tio n r e d uc e d. Fo llo wing 6 we e ks o n his lo w-s alt d ie t and d rug the rap y, BD's co nd itio n s e e ms to b e g re atly im pro ve d. His se rum p o tassium le ve ls , ho weve r, have d e cre ase d f rom 4 .2 to 3 .1 mEq /L (normal value , 3 .8 – 5 .6 m Eq /L ). W hat c aus e d his se rum p o tas sium leve ls to d e crease o ve r time ? W hy is this chang e a c o nce rn? W hat can b e d o ne to re me d y this p ro b le m?

Answer On e of the ma jor s id e e ffe c ts o f us in g a loo p diu r e tic is e x c e ss iv e e x c r e tio n of e le ctr o lyte s , inc lud ing p ota s s ium ion s . Los s of pota s s ium ca n ev e n tua lly le a d to hy po k a lemia (lo w bloo d po ta s s ium), a nd hy po k ale mia a lone c a n le a d to the de v e lopme nt of c ar dia c a r r hy th mia s . Pota ss iu m los s , howe v e r , a ls o p ote n tia te s the a ction s o f d igita lis (ca r dia c s odiu m– p ota s s ium– a de no s ine tr ipho s pha ta se in hibition) a nd c a n le a d to d igita lis indu ce d c ar dia c a r r hy th mia s a s well. Hy po k a lemia c a n be tr e a te d /pr e v e nte d by the us e of pota s siu m su pple me nts or the us e of a pota s siu msp a r ing diur e tic (e.g ., tr iamte r e ne a nd amilo r ide ). Be c au s e pota ss iu m-s pa r in g diu r e tic s a r e we a k ly ba s ic d r u gs , th ey d o no t a lte r th e a c tiv e se c r etion of lo op d iur etic s .

Case Study Vic tor ia F . Roc he S. Willia m Zito Yo u o f ten e at lunc h with yo ur f avo rite g rand ma, who is 8 5 ye ars o ld and g e ne rally in go o d he alth exc e pt f o r inf re q ue nt b o uts o f g o ut. D uring the las t f e w ye ars whe n yo u me e t with he r, yo u have no tice d that she has b ee n g aining we ig ht aro und he r mid d le and that he r leg s and ankle s e em to be p uf f y. D uring yo ur mo st re ce nt lunch date , g rand ma s hare s with yo u a p ro ble m she has b e en having at night. I t d o e sn't hap p en e very nig ht, b ut e ve ry now and the n she wake s gasp ing f o r air, whic h re quire s he r to ge t o ut of b e d and o p e n the wind o w to g e t relie f . She has take n to p ro pp ing he rse lf up using two o r thre e p illo ws to g et b ack to slee p . The ne xt d ay, yo u ac co mp any g rand ma to the f am ily d oc to r, who b as e d on p hysical e xam inatio n and a che s t rad io g rap h make s a d iagno sis o f m ild (Ne w Yo rk He art Asso c iatio n [NYHA] Functio nal Clas sif icatio n o f C lass I I ) co ng e s tive he art f ailure (CHF). A re co m me nd atio n is made to limit so d ium intake , ins titute a re g ime n o f exe rcise and initiate diure tic the rapy to re mo ve p ulmo nary and p e d al ed e ma f luid , and d e cre ase the wo rklo ad o n g randm a' s he art. The do c to r kno ws yo u are a p harm acy s tud e nt who like s m ed icinal che mis try and as ks yo u to make an ap p rop riate cho ice f ro m struc ture s 1 to 4 . 1. I d e ntif y the the rap e utic p ro b le m(s ) in which the p harmacis t's interve ntion may b e ne f it the patie nt. 2. I d e ntif y and p rio ritize the patie nt-sp e c if ic f ac to rs that must b e co nsid e re d to achie ve the d es ire d the rap eutic o utco me s . 3. C o nd uc t a tho roug h and me chanistically orie nted s tructure – activity analysis o f all the rap e utic alte rnative s p ro vid e d in the case . 4. Evaluate the structure – ac tivity re latio nship f ind ing s against the p atie nt-sp e cif ic f acto rs and d es ire d the rape utic outco me s , and make a the rap e utic d e cisio n. 5. C o uns e l yo ur p atie nt.

P.737

References 1. Jackson EK. Diuretics. In: Brunton L, Lazo JS, Parker KL, eds. Goodman and Gilman's T he Pharmacological Basis of T herapeutics, 11th Ed. New York, McGraw-Hill, 2006, pp 757–769.

2. Lee CM, Plattner JJ, Ours CW, et. al. [(Aminomethyl)aryloxy]acetic acid esters. A new class of high-ceiling diuretics. 1. Effects of nitrogen and aromatic nuclear substitution. J Med Chem 1984;27:1579–1587.

3. Plattner JJ, Fung AK, Smital JR, et al. [(Aminomethyl)aryloxy]acetic acid esters. A new class of high-ceiling diuretics. 2. Modifications of the oxyacetic side chain. J Med Chem 1984;27:1587–1596.

Suggested Readings Acara MA. Renal pharmacology—diuretics. In: Smith CM, Reynard AM, eds. T extbook of Pharmacology. Philadelphia, WB Saunders, 1992, pp 554–588.

Friedman PA, Berndt, WO. Diuretic drugs. In: Craig CR, Stizel RE, eds. Modern Pharmacology with Clinical Applications, 6th Ed. Philadelphia: Lippincott Williams & Wilkins, 2004; pp 239–255.

Brenner BM, Rector FC Jr, eds. T he Kidney, 4th Ed. Philadelphia, WB Saunders, 1991.

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Breyer J, Jacobson HR. Molecular mechanisms of diuretic agents. Annu Rev Med 1990;41:265–275.

Kalantarinia K, Okusa MD. Diuretics: Drugs that increase the excretion of water and electrolytes. In: Minneman KP, Wecker L, eds. Brody's Human Pharmacology; Molecular to Clinical, 4th Ed. Philadelphia: Elsevier Mosby, 2005; pp 163–182.

Jackson EK. Diuretics. In: Brunton L, Lazo JS, Parker KL, eds. Goodman and Gilman's T he Pharmacological Basis of T herapeutics, 11th Ed. New York: McGraw-Hill, 2006; pp 737–769.

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Chapter 28 Angiotensin-Converting Enzyme Inhibitors, Antagonists and Calcium Blockers Marc Harrold

T he Renin-Angiotensin Pathway T he renin-angiotensin system is a complex, highly regulated pathway that is integral in the regulation of blood volume, electrolyte balance, and arterial blood pressure. It consists of two main enzymes, renin and angiotensin-converting enzyme (ACE), the primary purpose of which is to release angiotensin II from its endogenous precursor, angiotensinogen (Fig. 28.1). Angiotensin II is a potent vasoconstrictor that affects peripheral resistance, renal function, and cardiovascular structure (1).

History and Overview of Pathway Historically, the renin-angiotensin system dates back to 1898, when T iegerstedt and Bergman demonstrated the existence of a pressor substance in crude kidney extracts. A little over 40 years later, two independent research groups discovered that this pressor substance, which had previously been named renin, actually was an enzyme and that the true pressor substance was a peptide formed by the catalytic action of renin. T his peptide pressor substance initially was assigned two different names, angiotonin and hypertensin; however, these names eventually were combined to produce the current designation, angiotensin. In the 1950s, it was discovered that angiotensin exists as both an inactive decapeptide, angiotensin I, and an active octapeptide, angiotensin II, and that the conversion of angiotensin I to angiotensin II is catalyzed by an enzyme distinct from renin (3). Angiotensinogen is an α 2 -globulin with a molecular weight of 58,000 to 61,000 daltons. It contains 452 amino acids, is abundant in the plasma, and is continually synthesized and secreted by the liver. A number of hormones, including glucocorticoids, thyroid hormone, and angiotensin II, stimulate its synthesis. T he most important portion of this compound is the N-terminus, specifically P.739 the Leu 10 -Val 11 bond. T his bond is cleaved by renin and produces the decapeptide angiotensin I. T he Phe 8 -His 9 peptide bond of angiotensin I is then cleaved by ACE to produce the octapeptide angiotensin II. Aminopeptidase can further convert angiotensin II to the active heptapeptide angiotensin III by removing the N-terminal arginine residue. Further actions of carboxypeptidases, aminopeptidases, and endopeptidases result in the formation of inactive peptide fragments. An additional compound can be formed by the action of a prolylendopeptidase on angiotensin I. Cleavage of the Pro 7 -Phe 8 bond of angiotensin I produces a heptapeptide known as angiotensin 1-7. T he actions of all of these compounds are discussed below.

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Fig. 28.1. Schematic representation of the renin-angiotensin pathway. The labile peptide bonds of angiotensinogen and angiotensin I are highlighted.

Clin ica l Sign ifican ce T he treatment of hypertension and congestive heart failure (CHF) has improved significantly with the introduction of angiotensinconverting enzyme (ACE) inhibitors, angiotensin receptor blockers, and calcium channel blockers. T he SARs and structural modifications of these agents have produced major therapeutic advances. T hese drugs have become cornerstones of therapy today. For example, more than 25 years ago, captopril was the first ACE inhibitor to be developed. Subsequent molecular modifications led to the development of newer agents, such as lisinopril. Although lisinopril exerts comparable ACE inhibition, it possesses a superior pharmacokinetic profile. Instead of having to administer captopril three times daily, lisinopril can be administered once daily. Medication compliance is notoriously poor in cardiovascular patients. Administering an ACE inhibitor such as lisinopril once daily results in greatly enhanced medication compliance. T he therapeutic outcomes of patients with hypertension and CHF have improved

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immensely as a result. Similar molecular enhancements have been made with angiotensin receptor blockers and calcium channel blockers. T he application of basic science in modifying the chemical structure of these agents has ultimately resulted in patients living longer and suffering fewer cardiovascular events, such as myocardial infarction or worsening CHF. Importantly, their day-to-day quality of life is preserved as well. Thom as L. Rihn, Pharm .D. Seni or Vi ce Presi dent and Chi ef Cl i ni cal Offi cer Uni versi ty Pharmacotherapy Associ ates Associ ate Professor of Cl i ni cal Pharmacy Duquesne Uni versi ty School of Pharmacy

Actions and Properties of Renin-Angiotensin Pathway Components Renin is an aspartyl protease that determines the rate of angiotensin II production. It is a much more specific enzyme than ACE. Its primary function is to cleave the leucine-valine bond at residues 10 and 11 of angiotensinogen. T he stimulation of renin release is controlled very closely by hemodynamic, neurogenic, and humoral signals (Fig. 28.2). Hemodynamic signals involve the renal juxtaglomerular cells. T hese cells are sensitive to the hemodynamic stretch of the afferent glomerular arteriole. An increase in the stretch implies a raised blood pressure and results in a reduced release of renin, whereas a decrease in the stretch increases renin secretion. Additionally, these cells also are sensitive to NaCl flux across the adjacent macula densa. Increases in NaCl flux across the macula densa inhibit renin release, but decreases in the flux stimulate release. Further, neurogenic enhancement of renin release occurs via activation of β 1 receptors. Finally, a variety of hormonal signals influence the release of renin. Somatostatin, atrial natriuretic factor, and angiotensin II inhibit renin release, whereas vasoactive intestinal peptide, parathyroid hormone, and glucagon stimulate renin release (4). In contrast, ACE, also known as kininase II, is a zinc protease that is under minimal physiological control. It is not a rate-limiting step in the generation of angiotensin II and is a relatively nonspecific dipeptidyl carboxypeptidase that requires only a tripeptide sequence as a P.740 substrate. T he only structural feature required by ACE is that the penultimate amino acid in the peptide substrate cannot be proline. For this reason, angiotensin II, which contains a proline in the penultimate position, is not further metabolized by ACE. T he lack of specificity and control exhibited by ACE results in its involvement in the bradykinin pathway (Fig. 28.3). Bradykinin is a nonapeptide that acts locally to produce pain, cause vasodilation, increase vascular permeability, stimulate prostaglandin synthesis, and cause bronchoconstriction. Similar to angiotensin II, bradykinin is produced by proteolytic cleavage of a precursor peptide. Cleavage of kininogens by the protease kallikrein produces a decapeptide known as either kallidin or lysyl-bradykinin. Subsequent cleavage of the N-terminal lysine by aminopeptidase produces bradykinin. T he degradation of bradykinin to inactive peptides occurs through the actions of ACE. T hus, ACE not only produces a potent vasoconstrictor but also inactivates a potent vasodilator (1,4,5).

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Fig. 28.2. Summary of the factors involved in renin release and the effects medicated by angiotensin II.

Fig. 28.3. Schematic representation of the bradykinin pathway and its relationship to ACE and the renin-angiotensin pathway.

Angiotensin II is the dominant peptide produced by the renin-angiotensin pathway (Fig. 28.2). It is a potent vasoconstrictor that increases total peripheral resistance through a variety of mechanisms: direct vasoconstriction, enhancement of both catecholamine release and neurotransmission within the peripheral nervous system, and increased sympathetic discharge. T he result of all these actions is a rapid pressor response. Additionally, angiotensin II causes a slow pressor response, resulting in a long term stabilization of arterial blood pressure. T his long-term effect is accomplished by the regulation of renal function. Angiotensin II directly increases sodium reabsorption in the proximal tubule. It also alters renal hemodynamics and causes the release of aldosterone from the adrenal cortex. Finally, angiotensin II causes the hypertrophy and remodeling of both vascular and cardiac cells through a variety of hemodynamic and nonhemodynamic effects (1). Although secondary peptides, angiotensin III and angiotensin 1-7, also are thought to contribute to the overall effects of the reninangiotensin pathway, angiotensin III is equipotent with angiotensin II in stimulating aldosterone secretion; however, it is only 10 to 25% as potent in increasing blood pressure. In contrast, angiotensin 1-7 does not cause either aldosterone secretion or vasoconstriction, but it does have potent effects that are distinct from those of angiotensin II. Similar to angiotensin II, angiotensin 1-7 causes neuronal excitation and vasopressin release. Additionally, it enhances the production of prostaglandins via a receptor-mediated process that does not involve an increase in intracellular calcium levels. It has been proposed to be important in the modulation of cell-to-cell interactions in cardiovascular and neural tissues (6).

Role of T he Renin-Angiotensin Pathway in Cardiovascular Disorders Because the renin-angiotensin pathway is central to the maintenance of blood volume, arterial blood pressure, and electrolyte balance, abnormalities in this pathway (e.g., excessive release of renin and overproduction of angiotensin II) can contribute to a variety of cardiovascular disorders. Specifically, overactivity of this pathway can result in hypertension or heart failure via the mechanisms previously described. Abnormally high levels of angiotensin II can contribute to hypertension through both rapid and slow pressor responses. Additionally, high levels of angiotensin II can cause cellular hypertrophy and increase both afterload and wall tension. All of these events can cause or exacerbate heart failure. High blood pressure is a relatively common disorder, affecting more than 50 million Americans. It is more prevalent in males than in females and in blacks than in Caucasians. Onset usually begins during the third, fourth, and fifth decades of life, and the incidence of the disorder increases with age. Hypertension is classified as either primary or secondary. Primary hypertension, also known as essential hypertension, is the most prevalent form of the disorder and is defined as high blood pressure of an unknown etiology. Most cases of primary hypertension are thought to result from a variety of underlying pathophysiological mechanisms and not from a single, specific cause. Additionally, genetic factors appear to be important in the development of primary hypertension. Secondary hypertension is associated with a specific disorder (e.g., chronic renal disease, pheochromocytoma, and Cushing's syndrome), is present in approximately 5% of individuals with high blood pressure and, in some instances, is potentially curable. Secondary hypertension is much more common in children than in adults (7). Heart failure (previously designated as congestive heart failure) affects approximately 5 million Americans and is the most common hospital discharge diagnosis in patients older than 65 years. T he overall 5-year survival rate is approximately 50% for all patients, with women having an overall lower mortality rate than men. T he disease results from conditions in which the heart is unable P.741 to supply blood at a rate sufficient to meet the demands of the body. Similar to hypertension, this pathophysiological state can occur via a variety of mechanisms. Any pathophysiological event that causes either systolic or diastolic dysfunction will result in heart failure. Systolic dysfunction, or decreased contractility, can be caused by dilated cardiomyopathies, ventricular hypertrophy, or a reduction in muscle mass. Diastolic dysfunction, or restriction in ventricular filling, can be caused by increased ventricular stiffness, mitral or tricuspid valve stenosis, or pericardial disease. Both ventricular hypertrophy and myocardial ischemia can contribute to increased ventricular stiffness. Angiotensin II causes and/or exacerbates heart failure by increasing systemic vascular resistance, promoting sodium retention,

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stimulating aldosterone release, and stimulating ventricular hypertrophy and remodeling (8).

Overview of Drug T herapy Affecting T he Renin-Angiotensin Pathway Because angiotensin II produces the majority of the effects attributed to the renin-angiotensin pathway, compounds that can block either the synthesis of angiotensin II or the binding of angiotensin II to its receptor should attenuate the actions of this pathway. Indeed, enzyme inhibitors of both renin and ACE, as well as receptor antagonists of angiotensin II, have all been shown to produce beneficial effects in decreasing the actions of angiotensin II. Inhibitors of ACE were the P.742 first class of compounds to be marketed. T his occurred in 1981 with the approval by the U.S. Food and Drug Administration of captopril. Fourteen years later, losartan was approved as the first angiotensin II receptor blocker (previous referred to as an angiotensin II receptor antagonist). T he development, structure–activity relationship (SAR), physicochemical properties, interactions, and indications of these classes of drugs are discussed below.

Dev elopment of Orally Activ e Renin Inhibitors Re nin is a very s pec if ic e nzyme. The oc tape ptide , His-Pro-Phe-His-Le u-L eu-Val-Tyr, is the smalles t sub strate re co gnize d by the enzyme and is similar to the eight-amino-ac id se que nce , His 6 -Pro 7 -Phe 8 -His 9 -Le u 10 -Val 11 -I le 12 -His 13 , whic h is f ound in ang iotensino gen. Using this oc tape ptide , Bo ger (9 ) re plac ed the lab ile L eu-Leu bond with the stable d ip ep tid e mimic statine and rep laced the two C-terminal res id ue s (Val–Tyr) with similar hyd rop hob ic amino acids (L eu-Phe ).

The res ulting co mpound, N-isovaleryl-His-Pro -Phe-His-Sta-Leu-Phe-NH2 (SCRI P), s howed ef f e ctive, altho ug h sho rt-lived, inhibition of renin when g iven intravenous ly (IV). I nf us ion e xpe rime nts with SCRI P were the f irst to de mons trate that a small molec ule renin inhibito r c ould maintain a lo we red b lo od pres sure f or an e xtende d pe rio d o f time. Susc ep tib ility to p roteo lytic cleavag e, ho wever, limited the therap eutic utility of SCRI P and othe r analo go us p eptide s. Structure– ac tivity s tudies with SCRI P reve aled that the N-terminal His-Pro -Phe se que nc e co uld be rep laced with an acylated phe nylalanine o r tyros ine without any sig nif ic ant los s in inhib ito r activity. Additional change s to SCRI P resulte d in the clinical drug candidate enalkiren, als o known as A-64 66 2 (Fig . 2 8.4). T he histidine re sidue (His 6 ), whic h is pre sent in ang io tens inog en and all previo us inhibitors, was thoug ht to be ess ential f o r enzyme rec ognitio n and was lef t unchange d. The ac ylated tyros ine pro te cts the co mp ound f ro m aminope ptidase e nzyme s and also contrib utes to enzyme ac tive-site re co gnition. T he remaind er of the mole cule is a stab le dipe ptide is os te re. T he cyclohexylme thylene and iso-b utyl side chains are lip op hilic and app roximate the lipo philic sid e chains p rese nt in Le u 10 and Val 11 o f ang io tens inog en. Add itionally, the use o f a C-te rminal alco hol inste ad o f a C-te rminal carboxylate p rotec ts enalkiren f ro m c arbo xyp eptid ase enzymes (1 0,11 ).

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Fig. 28.4. Structures of enalkiren and zankiren.

Enalkiren has b ee n exte nsive ly stud ied in p reclinical and c linical trials and has be en s hown to b e ef f icacious if given I V. I t lacks signif ic ant bio availab ility, howeve r, mainly bec aus e of a lack o f lipid solub ility. A more lipo philic analog ue, zankiren (A-7 251 7) (Fig. 2 8.4), has de mons trated increased oral b io availability and e f f icac y. Pre clinical and clinical trials with orally administe red zankiren s howed goo d b io availability and s ignif icant reduction in bloo d pre ssure (11 ,12). Z ankire n has sinc e be en withdrawn f rom clinical trials f o r und is clos ed re aso ns; howeve r, the FDA rece ntly ap proved Aliskiren (Tektournan), the f irs t, non-p ep tid ic orally active re nin inhib ito r. I t is appro ved f or the tre atment o f hyp ertension and will b e available f o r use in 200 7. See Drug upd ate: http ://thep oint./www.c om/f oyebe .

Attempts to develop orally active, bioavailable renin inhibitors actually predate the development of ACE inhibitors. Research in this area continues today; however, one of the main attractions of renin inhibitors, specificity, has proven to be a significant hurdle to the clinical development (9) of these agents.

Angiotensin-Converting Enzym e Inhibitors Currently, there are 11 ACE inhibitors approved for therapeutic use in the United States. T hese compounds can be subclassified into three groups based on their chemical composition: sulfhydryl-containing inhibitors (exemplified by captopril), dicarboxylate-containing inhibitors (exemplified by enalapril), and phosphonate-containing inhibitors (exemplified by fosinopril). Captopril and fosinopril are the lone representatives of their respective chemical subclassifications, whereas the majority of the inhibitors contain the dicarboxylate functionality. All of these compounds effectively block the conversion of angiotensin I to angiotensin II and have similar therapeutic and physiological effects. T he compounds differ primarily in their potency and pharmacokinetic profiles (1). Additionally, the sulfhydryl group in captopril is responsible for certain effects not seen with the other agents. Detailed descriptions of the rationale for the development of captopril, enalapril, and fosinopril are provided below.

Sulfhydryl-Containing Inhibitors: Development of Captopril In 1965, Ferreira et al. (13) reported that the venom of the South American pit viper (Bothrops jararaca) contained factors that potentiated the action of bradykinin. T hese factors, originally designated as bradykinin-potentiating factors (BPFs), were isolated and found to be a family of peptides containing 5 to 13 amino acid residues. T heir actions in potentiating bradykinin were subsequently linked to their ability to inhibit the enzymatic degradation of bradykinin. Soon thereafter, Bakhle et al. (14) reported that these same peptides also inhibited the enzymatic conversion of angiotensin I to angiotensin II. T his latter enzyme, ACE, is now known to be identical with the former bradykininase enzyme (kininase II). Even at the time of these initial discoveries, however, BPFs were seen as lead compounds for the development of new antihypertensive agents, because they possessed dual activities—inhibition of the degradation of bradykinin, a potent vasodilator, and inhibition of the biosynthesis of angiotensin II, a potent vasoconstrictor (15).

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Fig. 28.5. A model of substrate binding to carboxypeptidase A (A) and ACE (B).

A nonapeptide, SQ 20,881 (teprotide), isolated from the original BPFs had the greatest in vivo potency in inhibiting ACE and was shown to consistently lower blood pressure in patients with essential hypertension. It also exerted beneficial effects in patients with heart failure; however, because of its peptide nature and lack of oral activity, teprotide had limited activity in the therapeutic treatment of these diseases (15,16).

Cushman, Ondetti, and coworkers (17,18,19) used SQ 20,881 and other peptide analogues to provide an enhanced understanding of the enzymatic properties of ACE. Using knowledge of substrate-binding specificities and the fact that ACE has properties similar to those of pancreatic carboxypeptidases, these researchers developed a hypothetical model of the enzyme active site. Carboxypeptidase A, like ACE, is a zinc-containing exopeptidase. T he binding of a substrate to carboxypeptidase A involves three major interactions (Fig. 28.5A). P.743 First, the negatively charged carboxylate terminus of the amino acid substrate binds to the positively charged Arg-145 on the enzyme. Second, a hydrophobic pocket in the enzyme provides specificity for a C-terminal aromatic or nonpolar residue. T hird, the zinc atom is located close to the labile peptide bond and serves to stabilize the negatively charged tetrahedral intermediate, which results when a molecule of water attacks the carbonyl bond between the C-terminal and penultimate amino acid residues (20). Similarly, the binding of substrates to ACE was proposed to involve three or four major interactions (Fig. 28.5B). First, the negatively charged carboxylate terminus of angiotensin I and other substrates was assumed to occur via an ionic bond with a positively charged amine on ACE. Second, the role of the zinc atom in the mechanism of ACE hydrolysis was assumed to be similar to that of carboxypeptidase A. Because ACE cleaves dipeptides instead of single amino acids, the position of the zinc atom was assumed to be located two amino acids away from the cationic center for it to be adjacent to the labile peptide bond. T hird, the side-chains R 1 and R 2 could contribute to the overall binding affinity; however, ACE, unlike carboxypeptidase A, does not show specificity for C-terminal hydrophobic amino acids and was not expected to have a hydrophobic binding pocket. Finally, the terminal peptide bond is nonlabile and was assumed to provide hydrogen bonding between the substrate and ACE. T he development of captopril and other orally active ACE inhibitors began with the observation that D-2-benzylsuccinic acid was an extremely potent inhibitor of carboxypeptidase A (17,18,19). T he binding of this compound to carboxypeptidase A (Fig. 28.6A) is very similar to that seen for substrates with the exception that the zinc ion binds to a carboxylate group instead of the labile peptide bond. Byers and Wolfenden (21) proposed that this compound is a by-product analogue that contains structural features of both products of peptide hydrolysis. Most of the structural features of the compound are identical to the terminal amino acid of the substrate (Fig. 28.5A), whereas the additional carboxylate group is able to mimic the carboxylate group that would be produced during peptide hydrolysis (21). Applying this concept to the hypothetical model of ACE described above resulted in the synthesis and evaluation of a series of succinic acid derivatives (Fig. 28.6B). Because proline was present as the C-terminal amino acid in SQ 20,881 as well as in other potent, inhibitory snake venom peptides, it was included in the structure of newly designed inhibitors. T he first inhibitor to be synthesized and tested was succinyl-L-proline (Fig. 28.7). T his compound proved to be somewhat disappointing. Although it provided reasonable specificity for ACE, it was only approximately 1/500 as potent as SQ 20,881.

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Fig. 28.6. Inhibitor binding models of (A) D-2-benzylsuccinic acid to carboxypeptidase A and (B) succinic acid derivatives to ACE.

Fig. 28.7. Compounds prepared in the development of captopril.

Substitution of other amino acids in place of proline produced compounds that were even less potent; hence, all subsequent SAR studies were conducted using analogues of L-proline (Fig. 28.7). T he addition of a methyl group to the 2 position of succinyl-L-proline to mimic the amino acid side chain, R 2 , of the substrate enhanced activity but only marginally. D-2-Methylsuccinyl-L-proline had effects similar to SQ 20,881 but was still only 1/300 as potent. T he D-isomer, rather than the L-isomer normally seen for amino acids, was necessary because of the isosteric replacement of an NH 2 with a CH 2 present in succinyl-L-proline. A comparison of the R 2 group of the substrate (Fig. 28.5B) with the methyl group of D-2-methylsuccinyl-L-proline, illustrates that this methyl group occupies the same binding site as the side chain of an L-amino group. One of the most important alterations to succinyl-L-proline was the replacement of the succinyl carboxylate with other groups having enhanced affinity for the zinc atom bound to ACE. Replacement of this carboxylate with a sulfhydryl group produced 3-mercaptopropanoylL-proline. T his compound has an IC 50 value of 200 nM and is greater than 1000-fold more potent than succinyl-L-proline (Fig. 28.7). Additionally, it is 10- to 20-fold more potent than SQ 20,881 in inhibiting contractile and vasopressor responses to angiotensin I. Addition of a 2-D-methyl group further enhanced activity. T he resulting compound, captopril (Fig. 28.7), is a competitive inhibitor of ACE with a K i value of 1.7 nM and was the first ACE inhibitor to be marketed. P.744

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Fig. 28.8. A comparison of enalaprilat and the transition state of angiotensin I hydrolysis by ACE.

T he sulfhydryl group of captopril proved to be responsible not only for the excellent inhibitory activity of the compound but also for the two most common side effects, skin rashes and taste disturbances (e.g., metallic taste and loss of taste). T hese side effects usually subsided on dosage reduction or discontinuation of captopril. T hey were attributed to the presence of the sulfhydryl group, because similar effects had been observed with penicillamine, a sulfhydryl containing agent used to treat Wilson's disease and rheumatoid arthritis (22,23).

Dicarboxylate-Containing Inhibitors Dev elopment of Enalapril Researchers at Merck (24) sought to develop compounds that lacked the sulfhydryl group of captopril yet maintained some ability to chelate zinc. Compounds having the general structure shown below were designed to meet this objective.

T hese compounds are tripeptide substrate analogues in which the C-terminal (A) and penultimate (B) amino acids are retained but the third amino acid is isosterically replaced by a substituted N-carboxymethyl group (C). Similar to the results seen in the development of captopril, C-terminal proline analogues provided optimum activity. T he use of a methyl group at R 3 (i.e., B = Ala) and a phenylethyl group at R 4 resulted in enalaprilat (Fig. 28.8). In comparing the activity of captopril and enalaprilat, it was found that enalaprilat, with a K i of 0.2 nM, was approximately 10-fold more potent than captopril. Studies investigating the binding of enalaprilat revealed that its ability to chelate the enzyme-bound zinc atom was significantly less than that of captopril. T he enhanced binding was proposed to be caused by the ability to mimic the transition state of angiotensin I hydrolysis. As shown in Figure 28.8, enalaprilat possess a tetrahedral carbon in place of the labile peptide bond. T he secondary amine, the carboxylic acid, and phenylethyl groups all contribute to the overall binding of the compound to ACE. T he secondary amine is located at the same position as the labile amide nitrogen, the ionized carboxylic acid can form an ionic bond with the zinc atom, and the phenylethyl group mimics the hydrophobic side chain of the Phe amino acid, which is present in angiotensin I. Despite excellent IV activity, enalaprilat has very poor oral bioavailability. Esterification of enalaprilat produced enalapril (Fig. 28.9), a compound with superior oral bioavailability. T he combination of structural features in enalaprilat, especially the two carboxylate groups and the secondary amine, are responsible for its overall low lipophilicity and poor oral bioavailability. Zwitterion formation also has been suggested to contribute to the low oral activity (25), and a comparison of the pK a values for the secondary amine of enalaprilat and enalapril supports this explanation. Ionization of the adjacent carboxylate in enalaprilat greatly enhances the basicity of the secondary amine such that the pK a of the amine in this compound is 8.02, whereas in enalapril, it is only 5.49. T hus, in the small intestine, the amine in enalaprilat will be primarily ionized and form a zwitterion with the adjacent carboxylate, but the amine in enalapril will be primarily un-ionized (26). Intravenous administration of either enalapril or enalaprilat produced similar effects on angiotensin II production P.745 despite the fact that enalapril showed a 1,000-fold decrease in in vitro activity. Subsequent studies showed that enalapril undergoes

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bioactivation and, thus, is a pro-drug of enalaprilat. Because human plasma was reported to lack enalapril esterolytic activity, bioactivation by hepatic esterases (Fig. 28.9) has been suggested as the most probable mechanism for enalaprilat formation (27,28).

Fig. 28.9. Bioactivation of enalapril.

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Table 28.1. Additional Dicarboxylate-containing Angiotensin Converting Enzyme Inhibitors

Additional Dicarboxylate Inhibitors Eight other dicarboxylate inhibitors (T able 28.1) have been approved for various therapeutic indications; however, spirapril has never been marketed. Lisinopril is chemically unique in two respects. First, it contains the basic amino acid lysine (R 1 = CH 2 CH 2 CH 2 CH 2 NH 2 ) instead of the standard nonpolar alanine (R = CH 3 ) P.746 residue. Second, it does not require bioactivation, because neither of the carboxylic acid groups are esterified (i.e., R 2 = H). Lisinopril was developed at the same time as enalapril. Despite the addition of another ionizable group, the oral absorption of lisinopril was found to be superior to that of enalaprilat but less than that of enalapril. In vitro studies of enalaprilat and lisinopril showed lisinopril to be slightly more potent than enalaprilat (27,28). Lisinopril, along with captopril, currently are the only two ACE inhibitors that are not pro-drugs.

Fig. 28.10. A modified model of ACE inhibitor binding.

T he major structural difference among the remaining ACE inhibitors is in the ring of the C-terminal amino acid. Lisinopril, like enalapril and captopril, contains the pyrrolidine ring of proline, whereas all the other compounds contain larger bicyclic or spiro ring systems. Studies of indoline analogues of captopril indicated that a hydrophobic pocket similar to that seen in carboxypeptidase A also was present in ACE. T his led to a modification (Fig. 28.10) of Ondetti and Cushman's original model and the development of inhibitors that contained larger hydrophobic ring systems (29). Although this modified model was proposed for captopril analogues, it is readily adaptable to include enalaprilat analogues. In general, the varied ring systems seen in benazepril, moexipril, perindopril, quinapril, ramipril, spirapril, and trandolapril provide enhanced binding and potency. T hey also lead to differences in absorption, plasma protein binding, elimination, onset of action, duration of action, and dosing among the drugs. T hese differences are discussed in more detail in Pharmacoki neti c Properti es below.

Phosphonate-containing Inhibitors: the Development of Fosinopril T he search for ACE inhibitors that lacked the sulfhydryl group also lead to the investigation of phosphorous-containing compounds (30). T he phosphinic acid shown in Figure 28.11 is capable of binding to ACE in a manner similar to enalapril. T he interaction of the zinc atom with the phosphinic acid is similar to that seen with sulfhydryl and carboxylate groups. Additionally, this compound is capable of forming the ionic, hydrogen, and hydrophobic bonds similar to those seen with enalapril and other dicarboxylate analogues. A feature unique to this compound is the ability of the phosphinic acid to more truly mimic the ionized, tetrahedral intermediate of peptide hydrolysis. Unlike enalapril and other dicarboxylate analogues, however, the spacing of this tetrahedral species is shorter, being only two atoms removed from the proline nitrogen. Additionally, the spacing between the proline nitrogen and the hydrophobic phenyl ring is one atom longer than that seen in the dicarboxylates.

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Fig. 28.11. The binding of phosphinate analogues to ACE.

Structural modification to investigate more hydrophobic, C-terminal ring systems, similar to that described above for the dicarboxylate compounds, lead to a 4-cyclohexylproline analogue of the original phosphinic acid. T his compound, fosinoprilat (Fig. 28.12), was more potent than captopril but less potent than enalaprilat. T he above-mentioned differences in the spacing of the phosphinic acid and phenyl groups may be responsible for this latter difference in potency. Similar to the dicarboxylates, fosinoprilat was too hydrophilic and exhibited poor oral activity. T he pro-drug fosinopril contains an (acyloxy)alkyl group that allows better lipid solubility and improved bioavailability (30). Bioactivation via esterase activity in the intestinal wall and liver produces fosinopril (Fig. 28.12).

M echanism of Action T he ACE inhibitors attenuate the effects of the renin-angiotensin system by inhibiting the conversion of angiotensin I to angiotensin II (Fig. 28.1). T hey also inhibit the conversion of [des-Asp 1 ]angiotensin I to angiotensin III; however, this action has only a minor role in the overall cardiovascular effects of these drugs. T hey are selective in that they do not directly interfere with any other components of the renin-angiotensin system; however, they do cause other effects that are unrelated to the decrease in angiotensin II concentration. Inhibitors of ACE increase bradykinin levels that, in turn, stimulate prostaglandin biosynthesis (Fig. 28.3). Both of these compounds have been proposed to contribute to the overall action of ACE inhibitors. Additionally, decreased angiotensin II levels increase the release of renin and the production of angiotensin I. Because ACE is inhibited, P.747 angiotensin I is shunted toward the production of angiotensin 1-7 and other peptides. T he contribution of these peptides to the overall effect of ACE inhibitors is unknown (1).

Fig. 28.12. Bioactivation of fosinopril.

Structure–Activity Relationships T he structural characteristics for ACE inhibitory activity are given in T able 28.2. Angiotensin-converting enzyme is a stereoselective drug target. Because currently approved ACE inhibitors act as either di- or tripeptide substrate analogues, they must contain a stereochemistry that is consistent with the L-amino acids present in the natural substrates. T his was established very early in the development of ACE inhibitors when compounds with carboxyl-terminal D-amino acids were discovered to be very poor inhibitors (31). Later work by Patchett et al. (24) reinforced this idea. T hey reported a 100- to 1,000-fold loss in inhibitor activity whenever the configuration of either the carboxylate or the R 1 substituent (T able 28.1) was altered. T he S,S,S-configuration seen in enalapril and other dicarboxylate inhibitors meets the above-stated criteria and provides for optimum enzyme inhibition.

Physicochemical Properties Captopril and fosinopril are acidic drugs, but all other ACE inhibitors are amphoteric. T he carboxylic acid attached to the N-ring is a common structural feature in all ACE inhibitors. It has a pK a in the range of 2.5 to 3.5 and will be ionized primarily at physiological pH. As discussed above P.748 with enalapril, the pK a and ionization of the secondary amine in the dicarboxylate series depends on whether the adjacent functional group is in the pro-drug or active form. In the pro-drug form, the amine is adjacent to an ester, is less basic, and is primarily un-ionized at

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physiological pH. Following bioactivation, the amine is adjacent to an ionized carboxylic acid that enhances both the basicity and ionization of the amine. Similarly, the basic nitrogen enhances the acidity of the adjacent carboxylic acid such that it usually has a lower pK a than the carboxylic acid attached to the N-ring. As an example, the pK a values of enalapril are 3.39 and 2.30. T hese values correspond to the carboxylic acid on the N-ring and the carboxylic acid adjacent to the amine, respectively. T he analogous values for these functional groups in lisinopril are 3.3 and 1.7 (26).

Table 28.2. Structure activity relationship of ACE inhibitors.

Table 28.3. Pharmacokinetic Parameters of ACE Inhibitors

Drug

Oral Effect of Calculated Bioavailability Food on Log P (%) Absorption

Active Metabolite

Protein Onset of Binding Action (%) (hours)

Duration of Action Major Route( (hours) of Eliminatio

Benazepril

5.504

37

Slows absorption

Benazeprilat

>95

1

24

Renal (primary) Biliary (secondary)

Captopril

0.272

60–75

Reduced

NA

25–30

0.25–0.50

6–12

Renal

Enalapril

2.426

60

None

Enalaprilat

50–60

1

24

Renal/Fecal

Enalaprilat

1.545

NA

NA

NA

—

0.25

6

Renal

Fosinopril

6.092

36

Slows absorption

Fosinoprilat

95

1

24

Renal (50%) Hepatic (50%)

Lisinopril

1.188

25–30

None

NA

25

1

24

Renal

Moexipril

4.055

13

Reduced

Moexiprilat

50

1

24

Fecal (primary) Renal (secondary)

Perindopril

3.363

65–95

Reduced

Perindoprilat

60–80

1

24

Renal

Quinapril

4.318

60

Reduced

Quinaprilat

97

1

24

Renal

Ramipril

3.409

50–60

Slows absorption

Ramiprilat

73

1–2

24

Renal (60%)

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Fecal (40%) Spirapril

3.162

50

—

Spiraprilat

—

1

24

Renal (50%) Hepatic (50%)

Trandolapril

3.973

70

Slows absorption

Trandolaprilat

80

0.5–1.0

24

Fecal (primary) Renal (secondary)

NA, not applicable, —, data not available.

T he calculated log P values (26) along with other pharmacokinetic parameters for the ACE inhibitors are shown in T able 28.3. With three notable exceptions, captopril, enalaprilat, and lisinopril, all of the compounds possess good lipid solubility. Compounds that contain hydrophobic bicyclic ring systems are more lipid soluble than those that contain proline. A comparison of the log P values of benazepril, fosinopril, moexipril, perindopril, quinapril, ramipril, spiropril, and trandolapril to those for captopril and enalapril illustrates this fact. As previously discussed, enalaprilat is much more hydrophilic than its ester pro-drug and is currently the only ACE inhibitor marked for IV administration. In terms of solubility, lisinopril probably is the most interesting compound in that it is the most hydrophilic inhibitor, yet unlike enalaprilat, it is orally active. One possible explanation for this phenomenon is that in the duodenum, lisinopril will exist as a di-zwitterion in which the ionized groups can internally bind to one another. In this manner, lisinopril may be able to pass through the lipid bilayer with an overall net neutral charge.

M etabolism Lisinopril and enalaprilat are excreted unchanged, whereas all other ACE inhibitors undergo some degree of metabolic transformation (1,32,33,34). As previously discussed and illustrated (Figs. 28.9 and 28.12), all dicarboxylate and phosphonate pro-drugs must undergo bioactivation via hepatic esterases. Additionally, based on their structural features, specific compounds can undergo metabolic inactivation via various pathways (Fig. 28.13). Because of its sulfhydryl group, captopril is subject to oxidative dimerization or conjugation. Approximately 40 to 50% of a dose of captopril is excreted unchanged, whereas the remainder is excreted as either a disulfide dimer or a captopril-cysteine disulfide. Glucuronide conjugation has been reported for benazepril, fosinopril, quinapril, and ramipril. T his conjugation can occur either with the parent pro-drug or with the activated drug. Benazepril, with the N-substituted glycine, is especially susceptible to this reaction because of a difference in steric hindrance. For all ACE inhibitors, except P.749 benazepril, the carbon atom directly adjacent to the carboxylic acid is part of a ring system and provides some steric hindrance to conjugation. T he unsubstituted methylene group (i.e., –CH 2 –) of benazepril provides less steric hindrance and, thus, facilitates conjugation. Moexipril, perindopril, and ramipril can undergo cyclization to produce diketopiperazines. T his cyclization can occur with either the parent or active forms of the drugs.

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Fig. 28.13. Metabolic routes of ACE inhibitors.

A comparative study of the metabolism and biliary excretion of lisinopril, enalapril, perindopril, and ramipril revealed that whereas neither lisinopril nor enalapril underwent any appreciable metabolism beyond bioactivation of enalapril to enalaprilat, both perindopril and ramipril were extensively metabolized beyond the initial bioactivation. It was proposed that these differences in hepatic metabolism could be explained, in part, by the larger, more hydrophobic rings present on perindopril and ramipril (35).

Pharmacokinetic Parameters T he pharmacokinetic parameters and dosing information for ACE inhibitors are summarized in T ables 28.3 and 28.4, respectively (1,32,33,34). T he oral bioavailability of this class of drugs ranges from 13 to 95%. Differences in both lipid solubility and first-pass metabolism are most likely responsible for this wide variation. Both parameters should be considered when comparing any two or more compounds. With the exceptions of enalapril and lisinopril, the concurrent administration of food adversely affects the oral absorption of ACE inhibitors. Product literature specifically instructs that captopril should be taken 1 hour before meals and that moexipril should be taken in the fasting state. Although not specifically stated, similar instructions also should benefit patients taking an ACE inhibitor whose absorption is affected by food. T he extent of protein binding also exhibits wide variability among the different compounds. T he data suggests that this variation has some correlation with the calculated log P values for the compounds (T able 28.3). T hree of the more lipophilic compounds—fosinopril, quinapril, and benazepril—exhibit protein binding of greater than 90%, whereas three of the least lipophilic compounds—lisinopril, enalapril, and captopril— P.750 exhibit much lower protein binding. T he lack of a protein binding value for spirapril prevents a more definitive statement on this correlation. Renal elimination is the primary route of elimination for most ACE inhibitors. With the exceptions of fosinopril and spirapril, altered renal function significantly diminishes the plasma clearance of ACE inhibitors, including those that are eliminated primarily by the feces. T herefore, the dosage of most ACE inhibitors should be reduced in patients with renal impairment (1). Studies of fosinopril in patients with heart failure demonstrated that it is eliminated by both renal and hepatic pathways and does not require a dosage reduction in

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patients with renal dysfunction (36). Spirapril also exhibits similar properties; however, it is not currently available for use. It should be noted that the literature data for routes of elimination are not always consistent. T he designation of renal elimination is quite clear, but it is difficult to correlate what some sources call renal/hepatic elimination with what others call renal/fecal elimination. Additionally, it is uncertain whether the designation of fecal elimination also includes unabsorbed drug. As a result, there is some variability for major routes of elimination listed in T able 28.3. With one exception, all ACE inhibitors have a similar onset of action, duration of action, and dosing interval. Captopril has a more rapid onset of action; however, it also has a shorter duration and requires a more frequent dosing interval than any of the other compounds. When oral dosing is inappropriate, enalaprilat can be used IV. T he normal dose administered to hypertensive patients is 0.625 to 1.25 mg every 6 hours. T he dose usually is administered over 5 minutes and may be titrated up to 5 mg IV every 6 hours.

Chemical/Pharmacological Classes Used to Treat Hypertension Diuretics (se e Chapter 2 7), ACE inhibitors , angio te ns in I I b lockers, calcium channe l blockers (s ee Chapter 2 8), ce ntral α 2 -agonists, pe riphe ral α 1 -antago nists , β-bloc kers , g anglionic b locke rs, and vasod ilators (se e Chap ter 29 ).

Therapeutic Applications T he ACE inhibitors have been approved for the treatment of hypertension, heart failure, left ventricular dysfunction (either post–myocardial infarction [MI] or asymptomatic), improved survival post-MI, diabetic nephropathy, and reduction of the risk of MI, stroke, and death from cardiovascular causes. Although all ACE inhibitors possess the same physiological actions and, thus, should produce similar therapeutic effects, the approved indications differ among the currently available agents (T able 28.4). P.751 Inhibitors of ACE have been designated as first-line agents for the treatment of hypertension (37) and are effective for a variety of cardiovascular disorders. T hey can be used either individually or with other classes of compounds. T hey are especially useful in treating patients with hypertension who also suffer from heart failure, left ventricular dysfunction, or diabetes. Arterial and venous dilation seen with ACE inhibitors not only lowers blood pressure but also has favorable effects on both preload and afterload in patients with heart failure. Additionally, the ability of ACE inhibitors to cause regression of left ventricular hypertrophy has been demonstrated to reduce the incidence of further heart disease in patients with hypertension. T he use of ACE inhibitors in patients with MI is similarly based on the ability of ACE inhibitors to decrease mortality by preventing postinfarction left ventricular hypertrophy and heart failure. Current recommendations to give ACE inhibitors to all patients with impaired left ventricular P.752 systolic impairment regardless of the presence of observable symptoms also are based on the ability of these inhibitors to block the vascular and cardiac hypertrophy and remodeling caused by angiotensin II. Inhibitors of ACE also have been reported to slow the progression of diabetic nephropathy and, thus, are preferred agents in the treatment of hypertension in a patients with diabetes. It also has been suggested that ACE inhibitors be used in patients with diabetic nephropathy regardless of the presence or absence or hypertension (1,7,8,33).

Table 28.4. Dosing Information for Orally Available ACE Inhibitors

Trade Generic Name Name(s)

Approved Indications

Dose Dosing Range Maximum Reduction (Treatment of Daily with Renal Hypertension) Dose Dysfunction

Available Tablet Strengths (mg)

Benazepril

Lotensin

Hypertension

10–40 mg q.d. or b.i.d.

80 mg

Yes

5, 10, 20, 40

Captopril

Capoten

Hypertension, heart failure, left ventricular dysfunction (post-MI), diabetic nephropathy

25–150 mg b.i.d. or t.i.d.

450 mg

Yes

12.5, 25, 50, 100

Enalapril

Vasotec

Hypertension, heart failure, left ventricular dysfunction (asymptomatic)

2.5–40 mg q.d. or b.i.d.

40 mg

Yes

2.5, 5, 10, 20

Fosinopril

Monopril

Hypertension, heart failure

10–40 mg q.d.

80 mg

No

10, 20, 40

Lisinopril

Prinivil,

Hypertension,

10–40 mg

40 mg

Yes

2.5, 5,

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Zestril

heart failure, Improve survival post-MI

q.d.

10, 20, 30, 40

Moexipril

Univasc

Hypertension

7.5–30 mg q.d. or b.i.d.

30 mg

Yes

7.5, 15

Perindopril

Aceon

Hypertension

4–8 mg q.d. or b.i.d.

16 mg

Yes

2, 4, 8

Quinapril

Accupril


10–80 mg q.d. or b.i.d.

80 mg

Yes

5, 10, 20, 40

Ramipril

Altace

Hypertension, heart failure, reduce risk of MI, stroke, and death from cardiovascular causes

2.5–20 mg q.d. or b.i.d.

20 mg

Yes

1.25, 2.5, 5, 10

Trandolapril

Mavik

Hypertension, heart failure, left ventricular dysfunction (post-MI)

1–4 mg q.d.

8 mg

Yes

1, 2, 4

MI, myocardial infarction.

Combination Products That Include an ACE Inhibitor ACE In hi bi to r/Di u reti c: be nazepril/hyd roc hlorothiazide , c ap to pril/hyd rochlorothiazide , e nalapril/hydro chlo rothiazide, f osinopril/hyd roc hloro thiazide , lisinopril/hydroc hloro thiazide , mo exip ril/hydro chloro thiazid e, and quinapril/hyd roc hloro thiazide ACE In hi bi to r/Ca l ci um Chan ne l Bl oc ker: b enazep ril/amlo dipine , enalapril/f elod ip ine, trando lapril/verapamil

Unlabeled Uses Hyperte nsive crise s, reno vas cular hype rtens io n, ne onatal and childhood hyp ertension, s troke prevention, mig raine p rop hylaxis , nondiab etic ne phropathy, chronic kid ney dise ase , d iagnosis o f scle rode rma renal crisis, and Bartter's syndro me (32 ,33)

Peptide Mimetics: Design of Agonists/Antagonists Pe ptide mimetics have be en d ef ine d as mo lecule s that mimic the action o f pe ptides , have no p ep tid e bo nd s (i.e., no amid e bo nds b etwee n amino acids ), and a mo lecular we ig ht of le ss than 70 0 Daltons . In comp ariso n with p eptid e drugs, p eptide mime tic s have numerous pharmace utical advantage s. Fo remo st among thes e are incre ase d bio availab ility and inc reas ed duratio n o f action. T he majo rity of kno wn pep tide mimetics have bee n dis covered by rando m s cree ning technique s; ho we ver, this pro ce ss is co stly, labo r intens ive, and unpred ictab le . A more logic al and rational appro ach is de novo pe ptide mimetic d esig n (40 ), and an example o f this app roach is illustrate d in Figure 28 .14 . I n this example, the ove rall p roc ess is divide d into three s te ps (A–C). I nitially, the amino acid s that c omprise the pharmaco pho re of the pe ptide must be id entif ied . Thus, a knowle dg e of the SARs f or the pep tide unde r conside ration is ess ential. I n F igure 28 .1 4A, the sid e chains p rese nt on amino ac id res id ue s 1, 3, and 5 o f a hypothetical he ptap ep tid e are ass umed to co mp rise the pharmaco pho re, and the re maind er of the pep tide is assume d to p rovid e the p rop er struc tural suppo rt f or the se key gro up s. I n the s eco nd step o f this de novo de sign proc ess , the pro pe r spatial arrang ement o f the p harmac op horic gro ups must be e lucid ated . Nuc le ar mag netic re sonanc e sp ectro sco py, x-ray dif f rac tio n studies , and mo le cular mo deling pro grams that allow e ne rgy-minimization proc edures and mo le cular d ynamic s simulatio n can be used to co nstruc t a mode l of the biolo gically active co nf o rmatio n. Returning to the example, the s ide c hains repre se nting the pharmaco pho re are ass umed to be locate d o n the inside o f the p eptid e, whereas the re maining resid ues are as sume d to b e located o n the o utsid e of the pe ptide (Fig. 2 8.14 B). I n the f inal ste p of the pro ces s, the p harmac op horic g roup s mus t b e mounted on a nonp ep tid e temp late in such a manner that the y retain the p ro pe r spatial arrang ement fo und in the o riginal p eptid e. This is sho wn in Figure 28 .14C, where s ide

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chains 1, 3 , and 5 of the original p ep tid e are connec ted to a rigid temp late (rep rese nted by the po lygo n). A varie ty of aro matic ring systems (e .g., be nze ne, b ip henyl, phe nanthrene, and be nzo diaze pine ) can be used to pro vide the rigid te mp late, and app rop riately placed alkyl gro ups can be used to enhance sp ac ing and incre ase f lexibility. Ad ditionally, is oste res o f the orig inal pharmaco pho ric gro ups may be use d to circ umvent s pe cif ic synthetic p roble ms (41 ).

Fig. 28.14. A general process for the rational design of peptide mimetics: (A) identification of crucial pharmacophoric groups, (B) determination of the spatial arrangement of these groups, and (C) use of a template to mount the key functional groups in their proper conformation. Groups highlighted with an asterisk comprise the pharmacophore of the heptapeptide. (From Harrold MW. Preparing students for future therapies: the development of novel agents to control the reninangiotensin system. Am J Pharm Educ 1997;61:173–178; with permission.)

Adverse Effects and Drug Interactions T he most prevalent or significant side effects of ACE inhibitors are listed below while drug interactions for ACE inhibitors are listed in T able 28.5 (1,32,33). Some adverse effects can be attributed to specific functional groups within individual agents, whereas others can be directly related to the mechanism of action of this class of compounds. T he higher incidence of maculopapular rashes and taste disturbances observed for captopril have been linked to the presence of the sulfhydryl group in this compound. All ACE inhibitors can cause hypotension, hyperkalemia, and a dry cough. Hypotension results from an extension of the desired physiological effect, whereas hyperkalemia results from a decrease in aldosterone secretion secondary to a decrease in angiotensin II production. Cough is by far the most prevalent and bothersome side effect seen with the use of ACE inhibitors. It is seen in 5 to 20% of patients, usually is not dose related, and apparently results from the lack of selectivity of this class of drugs. As previously discussed, ACE inhibitors also prevent the breakdown of bradykinin (Fig. 28.3), and because bradykinin stimulates prostaglandin synthesis, prostaglandin levels also increase. T he increased levels of both bradykinin and prostaglandin have been proposed to be responsible for the cough (38). T he use of ACE inhibitors during pregnancy is contraindicated. T his class of compounds is not teratogenic during the first trimester, but administration during the second and third trimester is associated with an increased incidence of fetal morbidity and mortality. Inhibitors of ACE can be used in women of childbearing age; however, they should be discontinued as soon as pregnancy is confirmed.

Adv erse Effects of ACE Inhibitors Hypote nsio n, hyp erkale mia, cough, ras h, taste disturb anc es, head ache, dizziness , f atigue , nausea, vomiting, diarrhea, acute renal f ailure, ne utrop enia, p roteinuria, and ang ioed ema

Table 28.5. Drug Interactions for ACE Inhibitors

Drug

ACE Inhibitor

Result of Interaction

Allopurinol

Captopril

Increased risk of hypersensitivity

Antacids

All

Decreased bioavailability of ACE inhibitor (more likely with captopril and fosinopril)

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Capsaicin

All

Exacerbation of cough

Digoxin

All

Either increased or decreased plasma digoxin levels

Diuretics

All

Potential excessive reduction in blood pressure; the effects of loop diuretics may be reduced.

Iron Salts

Captopril

Reduction of captopril levels unless administration is separated by at least 2 hours

K + preparations or

All

Elevated serum potassium levels

Lithium

All

Increased serum lithium levels

NSAIDs

All

Decreased hypotensive effects

Phenothiazides

All

Increased pharmacological effects of ACE inhibitor

Probenecid

Captopril

Decreased clearance and increased blood levels of captopril

Rifampin

Enalapril

Decreased pharmacological effects of enalapril

Tetracycline

Quinapril

Decreased absorption of tetracycline (may result from high magnesium content of quinapril tablets)

+

K -sparing diuretics

NSAIDs, nonsteroidal anti-inflammatory agents.

Angiotensin II Receptor Blockers From an historical perspective, the angiotensin II receptor was the initial target for developing compounds that could inhibit the reninangiotensin pathway. Efforts to develop angiotensin II receptor antagonists began in the early 1970s and focused on peptide-based analogues of the natural agonist. T he prototypical compound that resulted from these studies was saralasin, an octapeptide in which the Asp 1 and Phe 8 residues of angiotensin II were replaced with Sar (sarcosine, N-methylglycine) and Ile, respectively. Saralasin as well as other peptide analogues demonstrated the ability to reduce blood pressure; however, these compounds lacked oral bioavailability and expressed unwanted partial agonist activity. More recent efforts have used peptide mimetics to circumvent these inherent problems with peptide-based antagonists. T he culmination of these efforts was the 1995 approval of losartan, a nonpeptide angiotensin II receptor blocker (ARB) (1,39).

Development of Losartan T he development of losartan can be traced back to two 1982 patent publications (42), which described the antihypertensive effects of a series of imidazole-5-acetic acid analogues. T hese compounds are exemplified by S-8308 P.753 (Fig. 28.15) and were later found to block the angiotensin II receptor specifically. Although these compounds were relatively weak antagonists, they did not possess the unwanted agonist activity previously seen in peptide analogues. A computerized molecular modeling overlap of angiotensin II with the structure of S-8308 revealed three common structural features: T he ionized carboxylate of S-8308 correlated with the C-terminal carboxylate of angiotensin II, the imidazole ring of S-8308 correlated with the imidazole side chain of the His 6 residue, and the n-butyl group of S-8308 correlated with the hydrocarbon side chain of the Ile 5 residue (Fig. 28.15). T he benzyl group of S-8308 was proposed to lie in the direction of the N-terminus of angiotensin II; however, it was not believed to have any significant receptor interactions.

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Fig. 28.15. Structural comparison of S-8308, an imidazole-5-acetic acid analogue, with angiotensin II. (Adapted from Timmermans PB, Wong PC, Chiu AT, et al. Angiotensin II receptors and angiotensin II receptor antagonists. Pharmacol Rev 1993;45:205–213; with permission.)

From S-8308, a number of molecular modifications were carried out in an attempt to improve receptor binding and lipid solubility, with the latter being important to assure adequate oral absorption. T hese changes resulted in the preparation of losartan, a compound with high receptor affinity (IC 50 , 0.019 M) and oral activity (Fig. 28.16).

Fig. 28.16. The development of losartan from S-8308.

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Fig. 28.17. Structures of losartan analogues. The highlighted portions of candesartan cilexitil and olmesartan medoxomil are hydrolyzed via esterases to produce their respective active, carboxylate metabolites.

Additional Angiotensin II Receptor Blockers Valsartan, irbesartan, telmisartan, candesartan, and olmesartan are biphenyl analogues of losartan (Fig. 28.17). T hese compounds possess structural features that are similar to those seen in losartan. Valsartan, named for the valine portion of the compound, is the first nonimidazole-containing ARB and is slightly more potent (IC 50 , 0.0089 µM) than losartan. T he amide carbonyl of valsartan is isosteric with the imidazole nitrogen of losartan and can serve as a hydrogen bond acceptor similar to the imidazole nitrogen. Irbesartan is a spirocompound that lacks the primary alcohol of losartan but that has a 10-fold greater binding affinity (IC 50 , 0.0013 µM) for the angiotensin II receptor. Hydrogen bonding, or ion–dipole binding, of the carbonyl group can mimic the interaction of the primary alcohol of losartan, whereas the spirocyclopentane can provide enhanced hydrophobic binding. Both candesartan cilexitil and telmisartan contain benzimidazole rings that provide some enhanced hydrophobic binding, similar to that seen with the spirocyclopentane ring of irbesartan. Both candesartan cilexitil and olmesartan medoxomil are pro-drugs that are rapidly and completely hydrolyzed during absorption from the gastrointestinal tract to their active carboxylic acid metabolites, candesartan and olmesartan, respectively. T hese carboxylic acids lie in exactly the same locations as the hydroxyl group of losartan, the carboxylic acid of valsartan, and the ketone of irbesartan and can participate in both ionic and dipole interactions. P.754

Fig. 28.18. The development of eprosartan from S-8308. The Phe 8 residue of angiotensin II contains the C-terminal carboxylic acid.

Eprosartan was developed using a different hypothesis than that for losartan (Fig. 28.18). Similar to the rationale for losartan, the carboxylic acid of S-8308 was thought to mimic the Phe 8 (i.e., C-termi nal ) carboxyl ate of angi otensi n II. The benzyl group of S-8308 was

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proposed to be an i mportant structural feature that mi mi cked the aromati c si de chai n of Tyr 4 present i n the agoni st. Thus, the major structural change was not an extensi on of the N-benzyl group but, rather, an enhancement of the compound's abi l i ty to mi mi c the C-termi nal end of angi otensi n II. Thi s was accompl i shed by substi tuti ng the 5-aceti c aci d group wi th an α-thi enyl acryl i c aci d. In addi ti on, a para-carboxyl ate (a functi onal group i nvesti gated duri ng the devel opment of l osartan) al so was added. The thi enyl ri ng i sosteri cal l y mi mi cs the Phe 8 phenyl ri ng of angi otensi n II and, al ong wi th the para-carboxyl ate, i s responsi bl e for the excel l ent potency (IC 50 = 0.0015 µM ) of thi s compound (39).

M echanism of Action T he angiotensin II receptor exists in at least two subtypes, type 1 (AT 1 ) and type 2 (AT 2 ). T he AT 1 receptors are located in brain, neuronal, vascular, renal, hepatic, adrenal, and myocardial tissues and mediate the cardiovascular, renal, and central nervous system (CNS) effects of angiotensin II. All currently available ARBs are 10,000-fold more selective for the AT 1 receptor subtype and act as competitive antagonists at this site. In terms of relative affinity for the AT 1 receptor, candesartan and olmesartan have the greatest affinity; irbesartan and eprosartan have a somewhat lower affinity; and telmisartan, valsartan, and losartan have the lowest affinity. All ARBs prevent and reverse all of the known effects of angiotensin II, including rapid and slow pressor responses, stimulatory effects on the peripheral sympathetic nervous system, CNS effects, release of catecholamines, secretion of aldosterone, direct and indirect renal effects, and all growth-promoting effects. T he function of the AT 2 receptors is not as well characterized; however, they have been proposed to mediate a variety of growth, development, and differentiation processes. Some concern has arisen that unopposed stimulation of the AT 2 receptor in conjunction with AT 1 receptor antagonism may cause long-term adverse effects. As a result, compounds that exhibit balanced antagonism at both receptor subtypes are currently being sought (1,43).

Structure–Activity Relationships All commercially available ARBs are analogues of the following general structure:

1. T he “ acidic group” is thought to mimic either the T yr 4 phenol or the Asp 1 carboxylate of angiotensin II. Groups capable of such a role include the carboxylic acid (A), a phenyl tetrazole (B), or a phenyl carboxylate (C). 2. In the biphenyl series, the tetrazole and carboxylate groups must be in the ortho position for optimal activity (the tetrazole group is superior in terms of metabolic stability, lipophilicity, and oral bioavailability). 3. T he n-butyl group of the model compound provides hydrophobic binding and, most likely, mimics the side chain of Ile 5 of angiotensin II. As seen with candesartan, telmisartan, and olmesartan, this n-butyl group can be replaced with either an ethyl ether or an n-propyl group. 4. T he imidazole ring or an isosteric equivalent is required to mimic the His 6 side chain of angiotensin II. 5. Substitution can vary at the “ R” position. A variety of R groups, including a carboxylic acid, a hydroxymethyl group, a ketone, or a benzimidazole ring, are present in currently available ARBs and are thought to interact with the AT 1 receptor through either ionic, ion–dipole, or dipole–dipole bonds.

Physicochemical Properties All ARBs are acidic drugs. T he tetrazole ring found in losartan, valsartan, irbesartan, candesartan, and olmesartan has a pK a of approximately 6 and will be at least 90% ionized at physiological pH. T he carboxylic acids found on valsartan, candesartan, olmesartan, telmisartan, and eprosartan have pK a values in the range 3–4 and also will be primarily ionized. Currently, available agents have adequate, but not excellent, lipid solubility. As previously mentioned, the tetrazole group is more lipophilic than a carboxylic. Additionally, the four nitrogen atoms present in the tetrazole ring can create a greater charge distribution than that available for a carboxylic acid. T hese properties have been proposed to be responsible for the enhanced binding and bioavailability of the tetrazole-containing compounds (44). Similar to ACE inhibitors, P.755 the stereochemistry of valsartan is consistent with the L-amino acids in the natural agonist.

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Fig. 28.19. The metabolic conversion of losartan to EXP-3174 by cytochrome P450 isozymes.

M etabolism Approximately 14% of a dose of losartan is oxidized by the isozymes CYP2C9 and CYP3A4 to produce EXP-3174, a noncompetitive AT 1 receptor antagonist that is 10- to 40-fold more potent than losartan (Fig. 28.19). T he overall cardiovascular effects seen with losartan result from the combined actions of the parent drug and the active metabolite; thus, losartan should not be considered to be a pro-drug (1). As previously mentioned, candesartan cilexetil and olmesartan medoxomil are rapidly and completely hydrolyzed to candesartan and olmesartan, respectively, in the intestinal wall. None of the other compounds are converted to active metabolites. All of these compounds are primarily (80%) excreted unchanged. Approximately 20% of valsartan is metabolized to inactive compounds via mechanisms that do not appear to involve the CYP450 system. T he primary circulating metabolites for irbesartan, telmisartan and eprosartan, are inactive glucuronide conjugates. A small amount of irbesartan is oxidized by CYP2CP; however, irbesartan does not substantially induce or inhibit the CYP450 enzymes normally involved in drug metabolism (1,32,33,34).

Pharmacokinetic Parameters T he pharmacokinetic parameters and dosing information for angiotensin receptor antagonists are summarized in T ables 28.6 and 28.7, respectively (32,33,34). With the exception of irbesartan (60–80%) and, possibly, telmisartan (42–58%), all of the compounds have low, but adequate, oral bioavailability (15–33%). Given the fact that most of the compounds are excreted unchanged, the most probable reasons for the low bioavailability are poor lipid solubility and incomplete absorption. Effects of food on the absorption of losartan, eprosartan, valsartan, and eprosartan is to reduce absorption; however, these effects have been deemed to be clinically insignificant; thus, the compounds can be taken either with or without food. All of the compounds have similar onsets, are highly protein bound, have elimination half-lives that allow once- or twice-daily dosing, and with the exception of olmesartan, are primarily eliminated via the fecal route. Candesartan and telmisartan appear to require a slightly longer time to reach peak plasma concentrations. As with ACE inhibitors, literature designation of fecal elimination is unclear regarding whether it includes unabsorbed drug. Candesartan cilexetil, losartan, and olmesartan differ from the other compounds in several respects. T hey are the only compounds with active metabolites, and they have the highest renal elimination of all of the agents. Product labeling indicates that renal impairment does not require a dosage reduction for losartan, but area under the curve values are increased by 50% in patients with P.756 a creatinine clearance of less than 30 mL/min and are doubled in hemodialysis patients. T hese increases are not seen for the other agents. Losartan and telmisartan are the only two agents that require initial dose reductions in patients with hepatic impairment. Because of significantly increased plasma concentration, patients with impaired hepatic function or biliary obstructive disorders should avoid the use of telmisartan.

Table 28.6. Pharmacokinetic Parameters of Angiotensin II Receptor Blockers

Drug

Oral Bioavailability Active (%) Metabolite

Protein Binding (%)

Time to Peak Plasma Elimination Concentration Half-Life (hours) (hours)

Major Route(s) of Elimination

Candesartan Cilexetil

15

Candesartan

99

3–4

9

Fecal (67%) Renal (33%)

Eprosartan

15

None

98

1–2

5–9

Fecal (90%) Renal

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(10%) Irbesartan

60–80

None

90

1.5–2.0

11–15


Losartan

33

EXP-3174

98.7 (losartan) 99.8 (EXP-3174)

1 (losartan) 3–4 (EXP-3174)

1.5–2.0 (losartan) 6–9 (EXP-3174)


Olmesartan Medoxomil

26

Olmesartan

99

1.5–3.0

10–15

Fecal (35–50%) Renal (50–65%)

Telmisartan

42–58

None

100

5

24

Fecal (97%)

Valsartan

25

None

95

2–4

6


Table 28.7. Dosing Information for Angiotensin II Receptor Blockers

Generic Name

Trade Name(s)

Approved Indications

Initial Dose Reduction Dose Dosing Range Maximum with Reduction (Treatment of Daily Hepatic with Renal Hypertension) Dose Dysfunction Dysfunction

Available Tablet Strengths (mg)

Candesartan Cilexetil

Atacand


8–32 mg q.d.

32 mg

No

Only with severe impairment

4, 8, 16, 32

Eprosartan

Teveten

Hypertension

400–800 mg q.d. or b.i.d.

900 mg

No

Decrease maximum daily dose to 600 mg

400, 600

Irbesartan

Avapro

Hypertension, nephropathy in type II diabetics

150–300 mg q.d.

300 mg

No

No

75, 150, 300

Losartan

Cozaar

Hypertension, nephropathy in type II diabetics, hypertension with left ventricular hypertrophy

25–100 mg q.d. or b.i.d.

100 mg

Yes

Adults, no Children, yes

25, 50, 100

Olmesartan

Benicar

Hypertension

20–40 mg

40

No

No

5, 20,

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Medoxomil

q.d.

mg

40

Telmisartan

Micardis

Hypertension

40–80 mg q.d.

80 mg

Yes (avoid)

No

20, 40, 80

Valsartan

Diovan

Hypertension heart failure

80–320 q.d.

320 mg

No

No

40, 80, 160, 320

Therapeutic Applications All ARBs are currently approved for the treatment of hypertension and, along with ACE inhibitors, diuretics, β-blockers, and calcium channel blockers, have been designated as first-line agents either alone or in combination with other antihypertensive agents (37). All ARBs are available as single agents and as combination products with hydrochlorthiazide. Additionally, irbesartan and losartan have been approved for the treatment of nephropathy in type II diabetes, losartan for the treatment of hypertension with left ventricular hypertrophy, and candesartan and valsartan for the treatment of heart failure. Based on their ability to attenuate the renin-angiotensin system, one should expect a gradual increase in the number of uses and approved indications for this class of agents.

Adverse Effects T he most prevalent side effects of ARBs are listed above and discussed below. (1,32,33,34). Overall, this class of agents is well tolerated, with CNS effects being the most commonly reported complaint. Similar to ACE inhibitors, some of the adverse effects are directly related to attenuation of the renin-angiotensin pathway. Notably absent are the dry cough and angioedema seen with ACE inhibitors. Because ARBs are specific in their actions, this class of drugs does not affect the levels of bradykinin or prostaglandins and, thus, does not cause these bothersome side effects. Like ACE inhibitors, the use of ARBs during pregnancy is contraindicated, especially during the second and third trimesters. T he use of ARBs should be discontinued as soon as pregnancy is confirmed unless the benefits outweigh the potential risks.

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Chapter 29 Central and Peripheral Sympatholytics and Vasodilators Dav id A. William s

Cardiovascular Hypertension Hypertension is the most common cardiovascular disease and is the major risk factor for coronary artery disease, heart failure, stroke, and renal failure. Approximately 50 million Americans have a systolic or diastolic blood pressure above 140/90 mm Hg. T he onset of hypertension is defined as having a blood pressure of 140/90 mm Hg or greater and most commonly appears during the fourth, fifth, and sixth decades of life (1). T he importance of controlling blood pressure is well documented (1), although the rates of awareness, treatment, and control of hypertension have not risen as expected in the National Health and Nutrition Examination Survey (2). T his survey showed that 68% of Americans are aware that they have high blood pressure but that only 53% are receiving treatment and only 27% have their blood pressure under control. Since 1976, there had been a significant improvement in the rates of awareness, treatment, and control of hypertension, but since 1990, whatever progress had been achieved has now reached a plateau (2). Although the age-adjusted death rates from stroke and coronary heart disease during this period have fallen by 59 and 53%, respectively, these rates of decline also appear to have reached a plateau (2). T hese troubling trends should awaken clinicians to be more aggressive in the treatment of patients with hypertension. When the decision to initiate hypertensive therapy is made, physicians often are presented with the dilemma of which of more than 80 antihypertensive products, representing more than 8 different drug classes, to use for their patients (T able 29.1) (1,3). T hose factors that can affect the outcomes from the treatment of hypertension include potential adverse effects, clinically significant drug–drug interactions (especially when so many different drug classes are involved), patient compliance, affordability (especially for the elderly and those on fixed incomes), risk/benefit ratios, and dosing frequency must be considered (3). Having considered these factors, the health care provider (clinician or pharmacist) arrives at an appropriate choice of antihypertensive drug (3). Once the patient is stabilized on a antihypertensive medication, some of these issues need to be reevaluated. Patients should be continually asked about side effects, because many of the antihypertensive drugs possess side effects that the patient may not tolerate (1). T his problem and the cost of drug therapy can affect compliance to drug therapy especially for the elderly and those on fixed incomes (4). Drug therapy in the management of hypertension must be individualized and adjusted based on coexisting risk factors, including the degree of blood pressure elevation, severity of the disease (e.g., presence of target organ damage), presence of underlying cardiovascular or other risk factors, response to therapy (single or multiple P.770 drugs), and tolerance to drug-induced adverse effects (1,3). Antihypertensive therapy generally is reserved for patients who fail to respond to nondrug therapies along with lifestyle modifications, such as diet including sodium restriction and adequate potassium intake, regular aerobic physical activity, moderation of alcohol consumption, and weight reduction (3).

Clinic al Significa nc e Understanding the pathophysiology of hypertension and the medicinal chemistry of the treatment options allows the clinician to tailor pharmacotherapy to each individual patient. T he patient with hypertension may start on a single oral agent but, eventually, will need a combination of medications from different drug classes, especially if the patient has diabetes, heart failure, or renal disease. A through understanding of the basic chemical properties of the drugs and their respective mechanism of action will be invaluable to making appropriate clinical decisions. T he therapy for patients with hypertension must be “ fine-tuned” as the clinical presentation of the hypertension changes or the patient's ability to metabolize and eliminate the medications changes. T he therapeutic benefits can be maximized, and the side effects or other toxicities can be minimized. T he ultimate goal for these patients would be to maximize the quality of life by controlling blood pressure and preventing long-term complications. T he astute clinician understands the differences between the medications in the individual medication classes. All β-blockers are not considered to be equally safe and effective in treating patients with peripheral arterial disease, reactive airway disease, heart failure, or a cocaine overdose. Not all calcium channel blockers and β-blockers may be safely combined for angina treatment, and only certain antihypertensive agents may be used safely during

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pregnancy. T he study of medicinal chemistry gives us hope for future treatment options for hypertension. Knowledge of structure–activity relationships and mechanisms of action foster the development of new medications and administration techniques. Clinicians will have to stay up to date with the new developments in the etiology of the disease state, the molecular bases of the drugs' actions, and the pharmacokinetic properties of the drugs to provide the best therapeutic outcomes for patients. Kim be rly Birtche r, Pharm .D. Cl i ni cal Assi stant Professor Uni versi ty of Houston Col l ege of Pharmacy

It is not surprising that compliance with antihypertensive therapy may be as low as 40% when one considers that the patient, if he or she has other chronic diseases, may be taking as many as 10 different drugs and up to 40 tablets or capsules per day (4). T o achieve better compliance requires educating the patient and simplification of the drug regimen by reducing the number of drugs being taken.

Table 29.1. Classification of Antihypertensive Activity According to Mechanism of Action I. Diuretics (Chapter 24) II. II. Sympatholytic drugs 1. Centrally acting drugs (methyldopa, clonidine, guan abenz, guanfacine) (Chapter 29) 2. Ganglionic blocker drugs (Chapter 29) 3. Adrenergic neuron blocking drugs (Chapter 29) 4. β-Adrenergic blocking drugs (Chapters 12 and 29) 5. α-Adrenergic blocking drugs (Chapters 12 and 29) 6. Mixed α/β-adrenergic blocking drugs (Chapters 12 and 29) III. Vasodilator (Chapter 29) Arterial (hydralazine, minoxidil, diazoxide) Arterial and venous (sodium nitroprusside) IV. Calcium channel blockers (Chapter 27) V. Angiotensin-converting enzyme inhibitors (Chapter 23) VI. Angiotensin receptor antagonists (Chapter 27)

Hypertension in pregnancy presents a formidable therapeutic challenge and requires comprehensive management with close monitoring for both maternal and fetal welfare (5). Mechanisms involved with pregnancy-related hypertension include an hyperadrenergic state, plasma volume reduction, reduction in uteroplacental perfusion, hormonal control of vascular reactivity, and prostacyclin deficiency may result from or activate the mechanisms that elevate blood pressure. Effective blood pressure control for pregnancy-related hypertension often can be achieved with methyldopa (recommended), β-blockers, or mixed α/β-blockers (combinations of β-blockers with α-blockers). T he vasodilating agent hydralazine is used to treat hypertensive emergencies associated with eclampsia (1,6). T he presence or development of proteinuria (preeclampsia) in a hypertensive pregnant woman implies a major increase in risk to the fetus and warrants immediate admission to a hospital for specialist management (5).

Combination Antihypertensive Therapy It is well-documented that monotherapy adequately controls hypertension only in approximately 50% of patients (7,8). T herefore, a large percentage of patients will require at least two drugs to control their blood pressure and symptoms of hypertension. By combining different antihypertensive drug classes in low doses, their different mechanisms of action result in synergistic blood pressure lowering as well as in minimizing the adverse effects and improving compliance issues (1,8). For example, the addition of a low-dose thiazide diuretic dramatically increases the response rates to methyldopa, angiotensin-converting P.771 enzyme (ACE) inhibitors, and β-blockers without producing the undesirable side effects. In the latest guidelines for treatment of hypertension, the Joint National Committee for Prevention, Detection, Evaluation, and T reatment of High Blood Pressure (JNC VI), clinicians are encouraged to use either diuretics or mixed α/β blockers or β 1 -blockers for initial monotherapy in patients with uncomplicated hypertension, because both of these drug classes have been shown

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to decrease morbidity and mortality in long-term clinical trials (2). In the presence of other cardiovascular diseases, however, the other antihypertensive classes that could be used as first-line agents include ACE inhibitors, calciumchannel blockers, α 1 -blockers, or mixed α/β-blockers. In patients with risk factors for heart disease or with clinical manifestations of cardiovascular disease (T able 29.2), treatment should be more aggressive, with the goal of reducing blood pressure to less than 140/90 mm Hg (1). T hese recommendations reflect the current awareness of the importance of addressing other cardiovascular conditions aside from just lowering the blood pressure.

Table 29.2. Risk Factors for Cardiovascular Disease Correctable

Noncorrectable

Cigarette smoking

Age > 60 years

Hypertension

Sex (men and postmenopausal women)

Elevated cholesterol

Family history of cardiovascular disease or stroke (women 90

3–4c

Propranolol (Inderal)

β1 β2

11

0

High

90

30

3–5

9–18

8–11

Propranolol, LA Timolol (Blocadren)

β1 β2

0

0

Low to moderate

90

75

4

Labetalold (Normodyne)

β1 β2 α1

0

0

Moderate

100

30–40

5.5–8.0

Carvedilol (Coreg)

β1 β2 α1

0

0

Moderate to high

>90

25–35

7–10

a

Inhibits β 2 -receptors (bronchial and vascular) at higher doses.

b

Detectable only at doses much greater than required for β-blockade.

c

In elderly hypertensive patients with normal renal function; half-life variable, 7–15 hours.

d

Not labetalol monograph.

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Adapted from Drug Facts and Comparison 2000; with permission. NA, not applicable (available as intravenous only); 0, none; +, low; 11, moderate; 111, high.

P.775

Mechan ism of Action T he VSM are lined with β 2 -adrenoceptors that normally are activated by norepinephrine released from sympathetic adrenergic nerves or by circulating epinephrine. T hese receptors, like those in the heart, are coupled to a G s protein, which stimulates the formation of cAMP. Although increased cAMP enhances cardiac contraction, with VSM an increase in cAMP leads to smooth muscle relaxation (Fig. 29.2). T herefore, increases in intracellular cAMP caused by β 2 -agonists inhibits MLCK, thereby producing less contractile force (i.e., promoting relaxation). Inhibition of cardiac β 1 and β 2 -adrenoceptors reduce the contractility of the myocardium (negative inotropic), decreasing heart rate (negative chronotropic), blocking sympathetic outflow from the central nervous system (CNS), and suppressing renin release (9). T he antianginal and antiarrhythmic effects of the β-blockers are discussed in Chapter 26.

Th erapeutic Applications (1,6,10) β-Blockers decrease arterial blood pressure by reducing cardiac output. Many forms of hypertension are associated with an increase in blood volume and cardiac output. T herefore, reducing cardiac output by β-blockade can be an effective treatment for hypertension, especially when used in conjunction with a diuretic. Hypertension in some patients is caused by emotional stress, which causes enhanced sympathetic activity. β-Blockers are very effective in these patients and are especially useful in treating hypertension caused by a pheochromocytoma, which results in elevated circulating catecholamines. β-Blockers have an additional benefit as a treatment for hypertension in that they inhibit the release of renin by the kidneys (the release of which is partly regulated by a β 1 -adrenoceptors in the kidney). Decreasing circulating plasma renin leads to a decrease in angiotensin II and aldosterone, which enhances renal loss of sodium and water and further diminishes arterial pressure. Acute treatment with a β-blocker is not very effective in reducing arterial pressure because of a compensatory increase in systemic vascular resistance. T his may occur because of baroreceptor reflexes working in conjunction with the removal of β 2 vasodilatory influences that normally offset, to a small degree, α-adrenergic–mediated vascular tone. Chronic treatment with β-blockers lowers arterial pressure more than acute treatment, possibly because of reduced renin release and effects of β-blockade on central and peripheral nervous systems. T he selection of oral β-blockers as monotherapy for uncomplicated hypertension is based on several factors, including their cardioselectivity and preexisting conditions, ISA, lipophilicity, metabolism, and adverse effects (exception is esmolol) (T able 29.3). Esmolol is a very short-acting cardioselective β 1 -blocker administered by infusion because of its rapid hydrolysis by plasma esterases to a rapidly excreted zwitterionic metabolite (plasma half-life, 9 minutes). Following the discontinuation of esmolol infusion, blood pressure returns to preexisting conditions in approximately 30 minutes. Oral β-blockers are recommended as initial therapy for uncomplicated hypertension or in the stepped-care approach to antihypertensive drug therapy (as step 1). T he elderly hypertensive patient (age, > 65 years) may not tolerate or respond to these drugs because of their mechanism of lowering cardiac output and increasing systemic vascular resistance (11).

Adverse Effects Common adverse effects for the β-blockers include decreased exercise tolerance, cold extremities, depression, sleep disturbance, and impotence, although these side effects may be less severe with the β 1 -selective blockers, such as metoprolol, atenolol, or bisoprolol (12). T he use of lipid-soluble β-blockers, such as propranolol (T able 29.3), has been associated with more CNS side effects, such as dizziness, confusion, or depression (1,6). T hese side effects can be avoided, however, with the use of hydrophilic drugs, such as nadolol or atenolol. T he use of β 1 -selective drugs also helps to minimize adverse effects associated with β 2 -blockade, including suppression of insulin release and increasing the chances for bronchospasms (asthma) (1,6). It is important to emphasize that none of the β-blockers, including the cardioselective ones, is cardiospecific. At high doses, these cardioselective agents can still adversely affect asthma, peripheral vascular disease, and diabetes (1,6). Nonselective β-blockers are contraindicated in patients with bronchospastic disease (asthma), and β 1 -selective blockers should be used with caution in these patients. β-Blockers with ISA, such as acebutolol, pindolol, carteolol, or penbutolol (T able 29.3), partially stimulate the β-receptor while also blocking it (13). T he proposed advantages of β-blockers with ISA over those without ISA include less cardiodepression and resting bradycardia as well as neutral effects on lipid and glucose metabolism. Neither cardioselectivity nor ISA, however, influences the efficacy of β-blockers in lowering blood pressure (6).

α 1 -Adrenergic blockers

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T he structures for the available α 1 -receptor blockers are shown in Figure 29.5. T hese include prazosin, doxazosin, and temazosin, the structure–activity relationships of which were previously discussed in Chapter 13, along with their pharmacokinetics and metabolism.

Fig. 29.5. α 1 -Selective adrenergic blockers.

P.776

Mechan ism of Action T hese drugs block the effect of sympathetic nerves on blood vessels by selectively binding to α 1 -adrenoceptors located on the VSM (Fig. 29.1), stimulating G q protein, and activates smooth muscle contraction through the IP 3 signal transduction pathway. Most of these drugs act as competitive antagonists by competing with the binding of norepinephrine to α 1 -adrenergic receptors on VSM. Some α-blockers are noncompetitive (e.g., phenoxybenzamine) (see Chapter 12), which greatly prolongs their action. Prejunctional α 2 -adrenoceptors located on the sympathetic nerve terminals serve as a negative feedback mechanism for norepinephrine release. α-Blockers dilate both arteries and veins, because both vessel types are innervated by sympathetic adrenergic nerves. T he vasodilator effect is more pronounced, however, in the arterial resistance vessels. Because most blood vessels have some degree of sympathetic tone under basal conditions, these drugs are effective dilators. T hey are even more effective under conditions of elevated sympathetic activity (e.g., during stress) or during pathologic increases in circulating catecholamines caused by an adrenal gland tumor (pheochromocytoma) (9). α 2 -Adrenoceptors also are abundant in the smooth muscle of the bladder neck and prostate and, when inhibited, cause relaxation of the bladder muscle increasing urinary flow rates and the relief.

Th erapeutic Applications (6,14) α 1 -Blockers are effective agents for the initial management of hypertension and are especially advantageous for older men who also suffer from symptomatic benign prostatic hyperplasia. In the stepped-care approach to antihypertensive drug therapy, α 1 -blockers are suggested as a step 1 drug. T hey have been shown to be as effective as other major classes of antihypertensives in lowering blood pressure in equivalent doses. α 1 -Blockers possess a characteristic “ first-dose” effect, which means that orthostatic hypotension frequently occurs with the first few doses of the drug. T his side effect can be minimized by slowly increasing the dose and by administering the first few doses at bedtime.

Side Effects an d Contraindication s T he most common side effects are related directly to α 1 -adrenoceptor blockade. T hese side effects include dizziness, orthostatic hypotension (because of loss of reflex vasoconstriction on standing), nasal congestion (because of dilation of nasal mucosal arterioles), headache, and reflex tachycardia (especially with nonselective α-blockers). Fluid retention also is a problem that can be rectified by use of a diuretic in conjunction with the α 1 -blocker. α-Blockers have not been shown to be beneficial in heart failure or angina and should not be used in these conditions.

Mixed α/β-blockers T he two available mixed α/β-receptor blockers are carvedilol (15) and labetalol (16) (pK a = 9.3) (Fig. 29.6), and their

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structure–activity relationships were previously discussed in Chapter 13 along with their pharmacokinetics and metabolism (T able 29.3). T he α-methyl substituent attached to the N-arylalkyl group appears to be responsible for the α-adrenergic blocking effect. Carvedilol is administered as its racemate. Its S-(–)-enantiomer is both an α- and nonselective β-blocker, whereas its R-(+ )-enantiomer is an α 1 -blocker. Labetalol possesses two chiral centers and, therefore, is administered as a mixture of four stereoisomers, of which R(CH 3 ),R(OH) is the active β-blocker diastereomer with minimal α 1 -blocking activity and the S(CH 3 ),R(OH) diastereomer is predominantly an α 1 -blocker. T he R,R diastereomer is also known as dilevalol. T he S(CH 3 ),S(OH) and R(CH 3 ),S(OH) diastereomers are both inactive. T he comparative potency for labetalol reflects the fact that 25% of the diastereomeric mixture is the active R,R-diastereomer.

Fig. 29.6. Mixed α/β-selective adrenergic blockers.

Mechan ism of Action T he mixed α/β-receptor blocking properties in the same molecule confer some advantages in the lowering of blood pressure. Vasodilation via α 1 -blockade lowers peripheral vascular resistance to maintain cardiac output, thus preventing bradycardia more effectively when compared to β-blockers (17). β-Blockade helps to avoid the reflex tachycardia sometimes observed with the other vasodilators listed below.

Th erapeutic Applications Monotherapy with these mixed-acting antihypertensive drugs reduces blood pressure as effectively as other major antihypertensives and their combinations (15,16,17). In the stepped-care approach to antihypertensive drug therapy, mixed α/β-blockers are recommended for initial management of mild to moderate hypertension (step 1). Both drugs effectively lower blood pressure in essential and renal hypertension. Carvedilol also is effective in ischemic heart disease.

Adverse Effects Any adverse effects usually are related to β 1 - or α 1 -blockade. T he β-effects usually are less bothersome, because the α 1 -blockade reduces the effects of β-blockade.

Centrally Acting Sympatholytics T he sympathetic adrenergic nervous system plays a major role in the regulation of arterial pressure. Activation of these nerves to the heart increases the heart rate (positive chronotropy), contractility (positive inotropy), and velocity of electrical impulse conduction (positive dromotropy). Within the medulla are located preganglionic sympathetic excitatory neurons, which travel from the spinal cord to the ganglia. T hey have significant basal activity, which generates a level of sympathetic tone to the heart and vasculature even under basal conditions. T he sympathetic P.777 neurons within the medulla receive input from other neurons within the medulla and together, these neuronal systems regulate sympathetic (and parasympathetic) outflow to the heart and vasculature. Sympatholytic drugs can block this sympathetic adrenergic system are three different levels. First, peripheral sympatholytic drugs, such as α-adrenoceptor and β-adrenoceptor antagonists, block the influence of norepinephrine at the effector organ (heart or blood vessel). Second, there are ganglionic blockers that block impulse transmission at the sympathetic ganglia. T hird, there are drugs that block sympathetic activity within the brain, centrally acting sympatholytic drugs. Centrally acting

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sympatholytics block sympathetic activity by binding to and activating α 2 -adrenoceptors, which reduces sympathetic outflow to the heart, thereby decreasing cardiac output by decreasing heart rate and contractility. Reduced sympathetic output to the vasculature decreases sympathetic vascular tone, which causes vasodilation and reduced systemic vascular resistance, which in turn decreases arterial pressure.

Specific drug Meth yldopa an d Methyldopate Ester Hydroch loride

Physicochemical Properties Methyldopa is structurally and chemically related to L-DOPA and the catecholamines. T o increase its water solubility for parenteral administration, the zwitterion methyldopa is esterified and converted to its hydrochloride salt, methyldopate ethyl ester hydrochloride (referred to as methyldopate). Methyldopate ester hydrochloride is used to prepare parenteral solutions of methyldopa, having a pH in the range of 3.5 to 6.0. Methyldopa is unstable in the presence of oxidizing agents (i.e., air), alkaline pH, and light. Being related to the catecholamines, which are subject to air oxidation, metabisulfite/sulfite may be added to dosage formulations to prevent oxidation. Some patients, especially those with asthma, may exhibit sulfite-related hypersensitivity reactions. Methyldopate hydrochloride injection has been reported to be physically incompatible with drugs that are poorly soluble in an acidic medium (e.g., sodium salts of barbiturates and sulfonamides) and with drugs that are acid labile. Incompatibility depends on several factors (e.g., concentrations of the drugs, specific diluents used, resulting pH, and temperature).

Mechanism of Action As discussed in Chapter 12, the central mechanism for the antihypertensive activity of the pro-drug methyldopa is not caused by its inhibition of norepinephrine biosynthesis but, rather, by its metabolism in the CNS to α-methylnorepinephrine, an α 2 -adrenergic agonist (9). Other more powerful inhibitors of aromatic L-amino acid decarboxylase (e.g., carbidopa) have proven to be clinically useful, but not as antihypertensives. Rather, these agents are used to inhibit the metabolism of exogenous L-DOPA administered in the treatment of Parkinson's disease (see Chapter 24).

T he mechanism of the central hypotensive action for methyldopa is attributed to its transport into the CNS via an aromatic amino acid transport mechanism, where it is decarboxylated and hydroxylated into α-methylnorepinephrine

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(9). T his active metabolite of methyldopa decreases total peripheral resistance, with little change in cardiac output and heart rate, through its stimulation of central inhibitory α 2 -adrenoceptors. A reduction of plasma renin activity also may contribute to the hypotensive action of methyldopa. Postural hypotension and sodium and water retention also are effects related to a reduction in blood pressure. If a diuretic is not administered concurrently with methyldopa, tolerance to the antihypertensive effect of the methyldopa during prolonged therapy can result.

Pharmacokinetics (18) T he oral bioavailability of methyldopa ranges from 20 to 50% and varies among individuals. Optimum blood pressure response occurs in 12 to 24 hours in most patients. After withdrawal of the drug, blood pressure returns to pretreatment levels within 24 to 48 hours. Methyldopa and its metabolites are weakly bound to plasma proteins. Although 95% of a dose of methyldopa is eliminated in hypertensive patients with normal renal function, with a plasma half-life of approximately 2 hours, in patients with impaired renal function the half-life is doubled to approximately 3 to 4 hours, with about 50% of it excreted. Orally administered methyldopa undergoes presystemic first-pass metabolism in the gastrointestinal (GI) tract to its 3-O-monosulfate metabolite. Sulfate conjugation occurs to a greater extent when the drug is given orally than when it is given intravenously (IV). Its rate of sulfate conjugation is decreased in patients with renal insufficiency. Methyldopa is excreted in urine as its mono-O-sulfate conjugate. Any peripherally decarboxylated α-methylnorepinephrine is metabolized by catecho-o-methyltransferase (COMT ) and monoamine oxidase (MAO). Methyldopate is slowly hydrolyzed in the body to form methyldopa. T he hypotensive effect of IV methyldopate begins in 4 to 6 hours and lasts 10 to 16 hours.

Therapeutic Applications (1,6) Methyldopa is used in the management of moderate to severe hypertension and is considered to be a step 2 drug reserved for patients who fail to respond to therapy with step 1 drugs. Methyldopa P.778 also is coadministered with diuretics and other classes of antihypertensive drugs, permitting a reduction in the dosage of each drug and minimizing adverse effects while maintaining blood pressure control. Methyldopa has been used in the management of hypertension during pregnancy without apparent substantial adverse effects on the fetus and also for the management of pregnancy-induced hypertension (i.e., preeclampsia) (5). Intravenous methyldopate may be used for the management of hypertension when parenteral hypotensive therapy is necessary. Because of its slow onset of action, however, other agents, such as sodium nitroprusside, are preferred when a parenteral hypotensive agent is employed for hypertensive emergencies.

Adverse Effects (6) T he most common adverse effect for methyldopa is drowsiness, which occurs within the first 48 to 72 hours of therapy and may disappear with continued administration of the drug. Sedation commonly recurs when its dosage is increased. A decrease in mental acuity, including impaired ability to concentrate, lapses of memory, and difficulty in performing simple calculations, may occur and usually necessitates withdrawal of the drug. Patients should be warned that methyldopa may impair their ability to perform activities requiring mental alertness or physical coordination (e.g., operating machinery or driving a motor vehicle). Nightmares, mental depression, orthostatic hypotension, and symptoms of cerebrovascular insufficiency may occur during methyldopa therapy and is an indication for dosage reduction. Orthostatic hypotension may be less pronounced with methyldopa than with guanethidine but may be more severe than with reserpine, clonidine, hydralazine, propranolol, or thiazide diuretics. Nasal congestion commonly occurs in patients receiving methyldopa. Positive direct antiglobulin (Coombs') test results have been reported in approximately 10 to 20% of patients receiving methyldopa, usually after 6 to 12 months of therapy. T his phenomenon is dose related. Methyldopa should be used with caution in patients with a history of previous liver disease or dysfunction, and it should be stopped if unexplained drug-induced fever and jaundice occurs. T hese effects commonly occur within 3 weeks after initiation of treatment. Dosage forms of methyldopa and methyldopate may contain sulfites, which can cause allergic-type reactions, including anaphylaxis and life-threatening or less severe asthmatic episodes. T hese allergic reactions are observed more frequently in asthmatic than in nonasthmatic individuals. Methyldopa is contraindicated in patients receiving MAO inhibitors.

α 2 -Adrenergic agonists T he mechanism of action, therapeutic applications, and adverse effects common to the α 2 -adrenergic agonists clonidine, guanabenz, and guanfacine (Fig. 29.7) will be discussed together, but any significant differences between these specific agents will be included in the discussions of the individual drugs.

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Fig. 29.7. Centrally acting sympatholytics.

Mechan ism of Action T he overall mechanism of action for the centrally active sympatholytics, clonidine, guanabenz, and guanfacine, appears to be stimulation of α 2 -adrenoceptors and specific binding to nonadrenergic imidazoline binding sites (I1 -IBS) in the CNS (mainly in the medulla oblongata), causing inhibition of sympathetic output (sympathoinhibition) (19,20). T his effect results in reduced peripheral and renovascular resistance and leads to a decrease in systolic and diastolic blood pressure. T hrough the use of imidazoline and α 2 -adrenergic antagonists, specific I 1 -IBS have recently been characterized in CNS control of blood pressure (21). Specific I1 -IBS are G protein-coupled receptors, with agmatine being the endogenous ligand for IBS. Specific I1 -IBS are pharmacologically distinct from α 2 -receptors, because they are not activated by catecholamines but characterized by their high affinity for 2-iminoimidazolines (or 2-aminoimidazolines) and low affinity for guanidines (21). T hus, the central hypotensive action for clonidine, other 2-aminoimidazolines, and structurally related compounds need both the I1 -IBS and α 2 -adrenoceptors to produce their central sympatholytic response (20). As a result of this discovery, a new generation of centrally acting antihypertensive agents selective for the I1 -IBS receptor has been developed, moxonidine (a pyrimidinyl aminoimidazoline) and rilmenidine (an alkylaminooxazoline) (Fig. 29.7). Rilmenidine and moxonidine are both highly selective for the I1 -IBS while having low affinity for α 2 -adrenoceptors, and both control blood pressure effectively without the adverse effects associated with binding to α 2 -receptors (e.g., sedation, bradycardia, and mental depression) (20). Clonidine appears to be more selective for α 2 -adrenoceptors than for I1 -IBS. Another antihypertensive is efaroxan which exhibits good affinity for I1 -IBS but is an antagonist at α 2 -receptors.

Ph armacokin etics T he effective oral dose range for rilmenidine is 1 to 3 mg, with a dose-dependent duration of action of 10 to 20 hours. Moxonidine is administered once a day at a dose range of 0.2 to 0.4 mg. T he oral bioavailability of P.779 moxonidine in humans is greater than 90%, with approximately 40 to 50% of the oral dose excreted unmetabolized in the urine (22,23). T he principal route of metabolism for moxonidine is oxidation of the 2-methyl group in the pyrimidine ring to 2-hydroxymethyl and 2-carboxylic acid derivative as well as the formation of corresponding glucuronides. Following an oral dose of monoxidine, peak hypotensive effects occur within 2 hours, with an elimination half-life of greater than 8 hours (23,24). Rilmenidine is readily absorbed from the GI tract, with an oral bioavailability greater than 95%. It is poorly metabolized and is excreted unchanged in the urine, with an elimination half-life of 8 hours (25,26). Following IV or oral administration of these drugs in normotensive patients, an initial hypertensive response to the drug occurs that is caused by activation of the peripheral α 2 -adrenoceptors and the resulting vasoconstriction. T his response is not observed, however, in patients with hypertension.

Th erapeutic Applications (1,6)

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T he selection of these drugs for monotherapy or in the stepped-care approach is based on several factors, including their similar mechanism of action, preexisting conditions, pharmacokinetics, distribution, and metabolism. T he α 2 -adrenergic antagonists show a similarity in adverse effects. Clonidine, guanabenz, and guanfacine are used in the management of mild to moderate hypertension (1,6). T hey have been used as monotherapy or to achieve lower dosages in combination with other classes of antihypertensive agents. In the stepped-care approach to antihypertensive drug therapy, centrally acting sympatholytics generally are step 2 drugs and reserved for patients who fail to respond to therapy with a step 1 drug (e.g., diuretics, β-adrenergic blocking agents, ACE inhibitors, and α 1 -blockers). Clonidine, guanabenz, and guanfacine have been used in conjunction with diuretics and other hypotensive agents, permitting a reduction in the dosage of each drug, minimizing adverse effects while maintaining blood pressure control. Geriatric patients, however, may not tolerate the adverse cognitive effects of these sympatholytics. All three drugs reduce blood pressure to essentially the same extent in both supine and standing patients; thus, orthostatic effects are mild and infrequently encountered. Exercise does not appear to affect the blood pressure response to guanabenz and guanfacine in patients with hypertension. Plasma renin activity may be unchanged or reduced during long-term therapy with these drugs.

Adverse Effects (6) Overall, the frequency of adverse effects produced by clonidine, guanabenz, and guanfacine are similar and appear to be dose related. Drowsiness, tiredness, dizziness, weakness, bradycardia, headache, and dry mouth are common adverse effects for patients receiving clonidine, guanabenz, and guanfacine. T he sedative effect for these centrally acting sympatholytics may result from their central α 2 -agonist activity. T he dry mouth induced by these drugs may result from a combination of central and peripheral α 2 -adrenoceptor mechanisms, and the decreased salivation may involve inhibition of cholinergic transmission via stimulation of peripheral α 2 -adrenoceptors. Orthostatic hypotension does not appear to be a significant problem with these drugs, because there appears to be little difference between supine and standing systolic and diastolic blood pressures in most patients. Other adverse effects include urinary frequency and sexual dysfunction (e.g., decreased libido and impotence), nasal congestion, tinnitus, blurred vision, and dry eyes. T hese symptoms most often occur within the first few weeks of therapy and tend to diminish with continued therapy, or they may be relieved by a reduction in dosage. Although adverse effects of the drug generally are not severe, discontinuance of therapy has been necessary in some patients because of intolerable sedation or dry mouth. Sodium and fluid retention may be avoided or relieved by administration of a diuretic.

Dru g Interaction s (6) T he hypotensive actions for clonidine, guanabenz, and guanfacine may be additive with, or may potentiate the action of, other CNS depressants, such as opiates or other analgesics, barbiturates or other sedatives, anesthetics, or alcohol. Coadministration of opiate analgesics with clonidine also may potentiate the hypotensive effects of clonidine. T ricyclic antidepressants (i.e., imipramine and desipramine) have reportedly inhibited the hypotensive effect of clonidine, guanabenz, and guanfacine, and the increase in blood pressure usually occurs during the second week of tricyclic antidepressant therapy. Dosage should be increased to adequately control hypertension if necessary. Sudden withdrawal of clonidine, guanabenz, and guanfacine may result in an excess of circulating catecholamines; therefore, caution should be exercised in concomitant use of drugs that affect the metabolism or tissue uptake of these amines (MAO inhibitors or tricyclic antidepressants, respectively). Because clonidine, guanabenz, and guanfacine may produce bradycardia, the possibility of additive effects should be considered if these drugs are given concomitantly with other drugs, such as hypotensive drugs or cardiac glycosides.

Specific Dru gs Clonidine Clonidine is an aryl-2-aminoimidazoline that is more selective for α 2 -adrenoceptors than for I1 -IBS (Fig. 29.7) in producing its hypotensive effect. It is available as oral tablets, injection, or a transdermal system.

Mechanism of Action In addition to its central stimulation of I1 -IBS and α 2 -adrenoceptors (20,21), clonidine (as well as other α 2 -adrenergic agonists), when administered epidurally, produces analgesia by stimulation of spinal α 2 -adrenoceptors, inhibiting sympathetically mediated pain pathways that are activated by nociceptive stimuli, thus preventing transmission of pain signals to the brain (9). Activation of α 2 -adrenoceptors also apparently stimulates acetylcholine release and inhibits the release of substance P.780 P, an inflammatory neuropeptide. Analgesia resulting from clonidine therapy is not antagonized by opiate antagonists.

Pharmacokinetics

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Clonidine has an oral bioavailability of more than 90%, with a pK a of 8.3 and a log P(exp) of 1.56 (6). It also is absorbed when applied topically to the eye. Clonidine is well absorbed percutaneously following topical application of a transdermal system to the arm or chest (27,28,29). Following application of a clonidine transdermal patch, therapeutic plasma concentrations are attained within 2 to 3 days. Studies have indicated that release of clonidine from the patch averages from 50 to 70% after 7 days of wear. Plasma clonidine concentrations attained with the transdermal systems generally are similar to twice-daily oral dosing regimens of the drug. Percutaneous absorption of the drug from the upper arm or chest is similar, but less drug is absorbed from the thigh (29). Replacement of the transdermal system at a different site at weekly intervals continuously maintains therapeutic plasma clonidine concentrations. Following discontinuance of transdermal therapy, therapeutic plasma drug concentrations persist for approximately 8 hours and then decline slowly over several days; over this time period, blood pressure returns gradually to pretreatment levels. Blood pressure begins to decrease within 30 to 60 minutes after an oral dose of clonidine, with the maximum decrease in approximately 2 to 4 hours (6). T he hypotensive effect lasts up to 8 hours. Following epidural administration of a single bolus dose of clonidine, it is rapidly absorbed into the systemic circulation and into cerebrospinal fluid (CSF), with maximal analgesia within 30 to 60 minutes. Although the CSF is not the presumed site of action of clonidinemediated analgesia, the drug appears to diffuse rapidly from the CSF to the dorsal horn. After oral administration, clonidine appears to be well distributed throughout the body, with the lowest concentration in the brain. Clonidine is approximately 20 to 40% bound to plasma proteins, and it crosses the placenta. T he plasma half-life of clonidine is 6 to 20 hours in patients with normal renal function and 18 to 41 hours in patients with impaired renal function. Clonidine is metabolized in the liver to its inactive major metabolite, 4-hydroxyclonidine, and its glucuronide and sulfate conjugates (10–20%) (Fig. 29.8). In humans, 40 to 60% of an oral or IV dose of clonidine is excreted in urine as unchanged drug within 24 hours. Approximately 85% of a single dose is excreted within 72 hours, with 20% of the dose excreted in feces, probably via enterohepatic circulation.

T herapeutic Applications (6) Clonidine is administered twice a day for the management of mild to moderate hypertension (6). T ransdermal clonidine also has been successfully substituted for oral clonidine in some patients with mild to moderate hypertension whose compliance with a daily dosing regimen may be a problem (28).

Fig. 29.8. Metabolites formed from clonidine, guanabenz, and guanfacine.

When administered by epidural infusion, clonidine is used as adjunct therapy in combination with opiates for the management of severe cancer pain not relieved by opiate analgesics alone. Other nonhypertensive uses for clonidine include the prophylaxis of migraine headaches, the treatment of severe dysmenorrhea, menopausal flushing, rapid detoxification in the management of opiate withdrawal in opiate-dependent individuals, in conjunction with benzodiazepines for the management of alcohol withdrawal, and for the treatment of tremors associated with the adverse effects of methylphenidate in patients with attention-deficit disorder. Clonidine has been used to reduce intraocular pressure in the treatment of open-angle and secondary glaucoma.

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Adv erse Effects (6) Adverse effects occurring with transdermal clonidine generally appear to be similar to those occurring with oral therapy (28,29). T hey have been mild and have tended to diminish with continued treatment. Hypotension has occurred in patients receiving clonidine by epidural infusion as adjunct therapy with epidural morphine for the treatment of cancer pain. With the transdermal system, localized skin reactions, such as erythema and pruritus, have occurred in some patients. Within 2 to 3 hours following the abrupt withdrawal of oral clonidine therapy, a rapid increase in systolic and diastolic blood pressures occurs, and blood pressures may exceed pretreatment levels. Associated with the clonidine withdrawal syndrome, the symptoms observed include nervousness, agitation, restlessness, anxiety, insomnia, headache, sweating, palpitation, increased heart rate, tremor, and increased salivation. T he exact mechanism of the withdrawal syndrome following discontinuance of α 2 -adrenergic agonists has not been determined but may involve increased concentrations of circulating catecholamines, increased sensitivity of adrenoceptors, enhanced renin-angiotensin system activity, decreased P.781 vagal function, failure of autoregulation of cerebral blood flow, and failure of central α 2 -adrenoceptor mechanisms to regulate sympathetic outflow from the CNS (6). T he clonidine withdrawal syndrome is more pronounced after abrupt cessation of long-term therapy and with administration of high oral dosages (> 1.2 mg daily). Withdrawal symptoms have been reported following discontinuance of transdermal therapy or when absorption of the drug is impaired because of dermatologic changes (e.g., contact dermatitis) under the transdermal system. Epidural clonidine may prolong the duration of the pharmacologic effects, including both sensory and motor blockade, of epidural local anesthetics.

Guanabenz Acetate Guanabenz, a centrally active hypotensive agent, is pharmacologically related to clonidine but differs structurally from clonidine by the presence of an aminoguanidine side chain rather than an aminoimidazoline ring (Fig. 29.7). At pH 7.4, guanabenz (pK a = 8.1) is predominately (80%) in the nonionized, lipid-soluble base form. Guanabenz can be given as a single daily dose administered at bedtime to minimize adverse effects.

Pharmacokinetics (30) T he oral bioavailability of guanabenz is 70 to 80%. Following an oral dose, the hypotensive effect of guanabenz begins within 1 hour, peaks within 2 to 7 hours, and is diminished within 6 to 8 hours. It has an elimination half-life averaging 4 to 14 hours. T he blood pressure response can persist for at least 12 hours. Following IV dosing, guanabenz is distributed into the CNS, with brain concentrations 3 to 70 times higher than concurrent plasma concentrations. Guanabenz is approximately 90% bound to plasma proteins. In patients with hepatic or renal impairment, its elimination half-life may be prolonged. Guanabenz is metabolized principally by hydroxylation to its inactive metabolite, 4-hydroxyguanabenz, which is eliminated in the urine as its glucuronide (major) and sulfate conjugates (Fig. 29.8). Guanabenz and its inactive metabolites are excreted principally in urine, with approximately 70 to 80% of its oral dose excreted in urine within 24 hours and approximately 10–30% in feces via enterohepatic cycling. Approximately 40% of an oral dose of guanabenz is excreted in urine as 4-hydroxyguanabenz and its glucuronide, and less than 5% is excreted unchanged. T he remainder is excreted as unidentified metabolites and their conjugates.

T herapeutic Applications (6,30) Overall, the therapeutic applications for guanabenz are similar to those of clonidine and other α 2 -adrenergic agonists. One advantage for guanabenz is its once-a-day dosing schedule. Guanabenz has been used in diabetic patients with hypertension without adverse effect on the control of or therapy for diabetes, and it has been effective in hypertensive patients with chronic obstructive pulmonary disease, including asthma, chronic bronchitis, or emphysema. Guanabenz has been used alone or in combination with naltrexone in the management of opiate withdrawal in patients physically dependent on opiates and undergoing detoxification. Guanabenz also has been used as an analgesic in a limited number of patients with chronic pain.

Adv erse Effects (6,30) Overall, the frequency of adverse effects produced by guanabenz is similar to that produced by clonidine and the other α 2 -adrenergic agonists, but the incidence is lower. As with the other centrally active sympatholytics (e.g., clonidine), abrupt withdrawal of guanabenz may result in rebound hypertension, but the withdrawal syndrome symptoms appear to be less severe.

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Guanfacine Hydrochloride Guanfacine, a phenylacetyl guanidine derivative (pK a = 7) (Fig. 29.7), is a centrally acting sympatholytic that is more selective for α 2 -adrenoceptors than is clonidine. Its mechanism of action is similar to clonidine and is an effective alternative to that of the other centrally acting antihypertensive drugs. Although guanfacine is 5- to 20-fold less potent than clonidine on a weight basis, comparable blood pressure–lowering effects have been achieved when the two drugs were given in equipotent dosages. Its relatively long elimination half-life permits a once-a-day dosing schedule. Guanfacine activates peripheral α 2 -adrenoceptors, because a transient increase in blood pressure is observed in normotensive, but not in hypertensive, patients.

Pharmacokinetics (31,32,33) T he pharmacokinetic properties for guanfacine differ from those of clonidine, guanabenz, and α-methyldopa. At pH 7.4, guanfacine is predominately (67%) in the nonionized, lipid-soluble base form, which accounts for its high oral bioavailability (>80%). Following an oral dose, peak plasma concentrations occur in 1 to 4 hours, with a relatively long elimination half-life of 14 to 23 hours. T he maximum blood pressure response occurs in 8 to 12 hours after oral administration and is maintained up to 36 hours following its discontinuation. Following IV dosing, guanfacine achieves the highest concentrations in liver and kidney, with low concentrations in the brain. Guanfacine is 64% bound to plasma proteins. In patients with hepatic or renal impairment, its elimination half-life may be prolonged. Guanfacine is metabolized principally by hepatic hydroxylation to its inactive metabolite, 3-hydroxyguanfacine (20%), which is eliminated in the urine as its glucuronide (30%), sulfate (8%), or mercapturic acid conjugate (10%), and 24 to 37% is excreted as unchanged guanfacine (Fig. 29.8). Its nearly complete bioavailability suggests no evidence of any first-pass effect. Guanfacine and its inactive metabolites are excreted principally in urine, with approximately 80% of its oral dose excreted in urine within 48 hours. P.782

T herapeutic Applications (6,32) Overall, the therapeutic applications for guanfacine are similar to those of the other centrally acting α 2 -adrenergic agonists and methyldopa. It has been effective as monotherapy in the treatment of patients with mild to moderate hypertension. One advantage for guanfacine is its once-a-day dosing schedule. T he use of diuretics to prevent accumulation of fluid may allow a reduction in the dosage for guanfacine.

Adv erse Effects (6,32) Overall, although the frequency of troublesome adverse effects produced by guanfacine is similar to that produced by clonidine and the other centrally acting sympatholytics, their incidence and severity are lower with guanfacine. Unlike clonidine, abrupt discontinuation of guanfacine rarely results in rebound hypertension. When a withdrawal syndrome has occurred, its onset was slower and its symptoms less severe than the syndrome observed with clonidine.

Metyrosine

Hypothetically, inhibitors of any of the three enzymes involved in the conversion of L-tyrosine to norepinephrine (see Fig. 13.1) could be used as drugs to moderate adrenergic transmission. Inhibitors of the rate-limiting enzyme tyrosine hydroxylase would be the most logical choice. One inhibitor of tyrosine hydroxylase, metyrosine or α-methyl-L-tyrosine, a competitive inhibitor of tyrosine hydroxylase, is in limited clinical use to help control hypertensive episodes caused by excess catecholamine biosynthesis. T he drug also can control other symptoms of catecholamine overproduction in patients with the rare adrenal tumor pheochromocytoma. Although metyrosine is useful in treating hypertension

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associated with pheochromocytoma, it is not useful for treating essential hypertension. T he drug metyrosine is the S-enantiomer of α-methyltyrosine. T he R-enantiomer, R-α-methyltyrosine, does not bind to the active site of tyrosine hydroxylase and, thus, has no useful pharmacologic activity.

Adrenergic Neuron Blocking Agents Bretylium, guanethidine, and guanadrel are three drugs with similar mechanisms of action involving norepinephrine storage granules. T hese drugs are transported into the adrenergic neurons by uptake-1, where they bind to the storage vesicles and prevent release of neurotransmitter in response to a neuronal impulse. Reserpine, guanethidine, and guanadrel are orally active antihypertensives that actually replace norepinephrine in the storage vesicles, resulting in a slow release in the amount of norepinephrine that is present. At usual doses, guanethidine and guanadrel act as “ false neurotransmitters” in that they are released into the synapse but do not effectively stimulate the receptors. At higher acute doses, their principal mechanism is a poorly understood inhibition of neurotransmitter release. Bretylium is a quaternary ammonium salt and must be given IV, because it has poor oral absorption. Initially, it can cause a release of norepinephrine and a transient rise in blood pressure, but its clinical utility is limited to cardiac arrhythmias and so will not be discussed in this chapter (see Chapter 26).

Reserpine

An old and historically important drug that affects the storage and release of norepinephrine is reserpine. Reserpine is one of several indole alkaloids isolated from the roots of Rauwol fi a serpenti na; these roots were used in India for centuries both as a remedy for snake bites and as a sedative. T he antihypertensive effects of the root extracts were first reported in India in 1918 and in the West in 1949. Shortly thereafter, reserpine was isolated and identified as the principal active agent. Reserpine was the first effective antihypertensive drug introduced into Western medicine, but it has largely been replaced in clinical use by agents with fewer side effects.

Mechan ism of Action (9) Reserpine acts to replace and deplete the adrenergic neurons of their stores of norepinephrine by inhibiting the active transport Mg-AT Pase responsible for sequestering norepinephrine and dopamine within the storage vesicles. T he norepinephrine and dopamine that are not sequestered in vesicles are destroyed by MAO. As a result, the storage vesicles contain little neurotransmitter, adrenergic transmission is dramatically inhibited, and sympathetic tone is decreased, leading to vasodilation. Reserpine has the same effect on epinephrine storage in the adrenal medulla. Reserpine readily enters the CNS, where it also depletes the stores of norepinephrine and serotonin. T he CNS neurotransmitter depletion led to the use of reserpine in treating certain mental illnesses.

Ph armacokin etics (6,9) Limited information is available regarding the pharmacokinetics of reserpine. Peak blood concentrations for reserpine occur within 2 hours following oral administration, and the full effects for reserpine usually are delayed for at least 2 to 3 weeks. Both CNS and cardiovascular effects may persist for several P.783 days to several weeks after chronic oral therapy is discontinued. Reserpine appears to be widely distributed in body tissues, especially adipose tissue; crosses the blood-brain barrier and the placenta; and is distributed into milk. T he elimination of reserpine appears to be biphasic, with a plasma half-life averaging 4.5 hours during the first phase and approximately 11.3 days during the second phase. Reserpine is metabolized to unidentified inactive compounds. Unchanged reserpine and its metabolites are excreted slowly in urine and feces, with an average of 60% reserpine recovered in feces within 96 hours after oral administration of 0.25 mg of radiolabeled reserpine.

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Th erapeutic Application (6) Reserpine has been used in the management of mild to moderate hypertension, but because of very significant CNS adverse effects and its cumulative action in the adrenergic neurons, reserpine is rarely used. Reserpine and related Rauwol fi a alkaloids have been used in the symptomatic treatment of agitated psychotic states, such as schizophrenic disorders, although other antipsychotic agents generally have replaced reserpine and the alkaloids.

Adverse Effects (6) T he common adverse CNS effects for reserpine include drowsiness, fatigue, or lethargy. Mental depression is one of the most serious potential adverse effects for reserpine, which may be severe enough to require hospitalization or result in suicide attempts. Reserpine-induced depression may persist for several months after the drug is discontinued.

Guanethidine monosulfate Guanethidine contains two basic nitrogen atoms with pK a values of 9.0 and 12.0 and, therefore, can form guanethidine monosulfate (C 10 H 22 N 4 · H 2 SO 4 ) or guanethidine sulfate [(C 10 H 22 N 4 ) 2 · H 2 SO 4 ] salts. Caution should be exercised when interchanging between these sulfate forms, because the potency of guanethidine may be expressed in terms of guanethidine sulfate or guanethidine monosulfate, a significant difference in molecular weight.

Mechan ism of Action Guanethidine is an adrenergic neuronal blocking agent that produces a selective block of peripheral sympathetic pathways by replacing and depleting norepinephrine stores from adrenergic nerve endings, but not from the adrenal medulla (6,9). It prevents the release of norepinephrine from adrenergic nerve endings in response to sympathetic nerve stimulation. T he chronic administration of guanethidine results in an increased sensitivity of these effector cells to catecholamines. Following the oral administration of usual doses of guanethidine, depletion of the catecholamine stores from adrenergic nerve endings occurs at a very slow rate, producing a more gradual and prolonged fall in systolic blood pressure than in diastolic pressure. Associated with the decrease in blood pressure is an increase in sodium and water retention and expansion of plasma volume (edema). If a diuretic is not administered concurrently with guanethidine, tolerance to the antihypertensive effect of the guanethidine during prolonged therapy can result.

Ph armacokin etics (6) Guanethidine is incompletely absorbed from the GI tract and is metabolized in the liver to several metabolites, including guanethidine N-oxide (from flavin mononucleotide). T hese metabolites of guanethidine are excreted in the urine and have less than 10% of its hypotensive activity. T he amount of drug that reaches the systemic circulation after oral administration is highly variable from patient to patient and may range from 3 to 50% of a dose. Guanethidine accumulates in the neurons with an elimination half-life of 5 days.

Th erapeutic Applications (6) Guanethidine is used in the management of moderate to severe hypertension and in the management of renal hypertension. In the stepped-care approach to antihypertensive drug therapy, guanethidine has been suggested as a step 2 or step 3 drug and generally is reserved for patients who fail to respond adequately to an antihypertensive regimen that includes a diuretic and other step 1 drugs, such as β-blockers, ACE inhibitors, or calcium-channel blocking agents. Its coadministration with other hypotensive agents permits a reduction in the dosage of each drug and a minimization of adverse effects while maintaining blood pressure control. It has been administered as ophthalmic drops in the treatment of chronic open-angle glaucoma and for endocrine ophthalmopathy, ophthalmoplegia, lid lag,

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and lid retraction.

Adverse Effects (6) Adverse effects of guanethidine frequently are dose related, including dizziness, weakness, lassitude, and syncope resulting from postural or postexercise hypotension. A hot environment (i.e., a hot bath) may aggravate postural hypotension. Patients should be warned about possible orthostatic hypotension and about the effect of rapid postural changes on blood pressure (e.g., arising in the morning) that may cause fainting, especially during the initial period of dosage adjustment. Sodium retention (edema) usually is controlled by the coadministration of a diuretic.

Dru g Interaction s (6) Diuretics and other hypotensive drugs can potentiate the hypotensive effects of guanethidine. Reportedly, MAO inhibitors antagonize the hypotensive effect of guanethidine. Oral sympathomimetic, nasal decongestants, and other vasopressor agents should be used cautiously in patients receiving guanethidine, because guanethidine may potentiate their pressor effects. T he mydriatic response to ophthalmic administration of phenylephrine is markedly increased in patients receiving guanethidine either ophthalmically or orally. P.784 T ricyclic antidepressants and some phenothiazines block the uptake of guanethidine into adrenergic neurons and, thus, prevent the hypotensive activity of guanethidine. Orthostatic hypotension may be increased by concomitant administration of alcohol with guanethidine, and patients receiving guanethidine should be cautioned to limit alcohol intake.

Guanadrel sulfate Guanadrel sulfate is a adrenergic neuronal blocking agent that is structurally and pharmacologically related to guanethidine: Both are guanidine derivatives. Guanadrel differs structurally from guanethidine by the presence of a dioxaspirodecyl ring system linked to guanidine by a methyl group rather than a hexahydroazocinyl ring linked by an ethyl group.

Mechan ism of Action Guanadrel, like guanethidine, produces a selective block of efferent, peripheral sympathetic pathways by replacing and depleting norepinephrine stores from adrenergic nerve endings, thus preventing the release of norepinephrine from adrenergic nerve endings in response to sympathetic nerve stimulation (9,34). Unlike guanethidine, it does not release norepinephrine from the adrenal medulla and reportedly depletes norepinephrine stores in the GI tract to a lesser extent than guanethidine does. Guanadrel decreases systolic blood pressure more than diastolic blood pressure.

Ph armacokin etics (34) Guanadrel, unlike guanethidine, is rapidly and almost completely absorbed following oral administration. Following oral administration, its peak plasma concentrations usually are achieved in approximately 2 hours, and its hypotensive effect usually has an onset of 0.5 to 2.0 hours, with peak activity at 4 to 6 hours and a duration of action of 4 to 14 hours. Approximately 20% of guanadrel is bound to plasma proteins, and little, if any, of the drug crosses the blood-brain barrier or distributes into the eye. Guanadrel has a plasma half-life of approximately 2 hours and an elimination half-life of approximately 10 to 12 hours in patients with normal renal function. Approximately 40 to 50% of guanadrel is metabolized in the liver to 2,3-dihydroxypropylguanidine and several unidentified metabolites, which are excreted principally in the urine (Fig. 29.9). Unlike guanethidine, approximately 85% of an oral dose of the drug is excreted in the urine within 24 hours, with 40 to 50% of the dose excreted in the urine unchanged. In patients with

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impaired renal function, the half-life of guanadrel is prolonged, and apparent total body clearance and renal clearances are decreased.

Fig. 29.9. Metabolism of guanadrel.

Th erapeutic Application (6,34) Guanadrel is used in the management of hypertension, and its efficacy is similar to that of guanethidine. Guanadrel generally is considered to be a step 2 drug and is reserved for patients who fail to respond to therapy with a step 1 drug or for cases requiring more prompt or aggressive therapy. Postural and postexercise hypotension is common in patients receiving guanadrel, and it also is likely that heat-induced vasodilation will augment its hypotensive effect. T here is a possibility that geriatric patients may not tolerate the postural hypotensive effects of guanadrel. Being a peripheral adrenergic neuron blocking drug, guanadrel shares the toxic potentials of guanethidine, and the usual precautions of this drug should be observed.

Adverse Effects (6) Overall, the frequency of adverse effects produced by guanadrel is similar or less than those produced by guanethidine and by methyldopa. In patients with impaired renal function, the elimination half-life of unmetabolized guanadrel is prolonged and its clearance decreased, thus increasing the incidence of adverse effects if the usual dosage is maintained in these patients.

Dru g Interaction s Being a peripheral adrenergic neuron blocking drug, guanadrel shares the same potential for drug interactions as guanethidine, and the usual precautions of this drug should be observed.

Vasodilators Vasodilator drugs relax the smooth muscle in blood vessels, which causes the vessels to dilate. Dilation of arterial vessels leads to a reduction in systemic vascular resistance, which leads to a fall in arterial blood pressure. Dilation of venous vessels decreases venous blood pressure. Arterial dilator drugs commonly are used to treat systemic and pulmonary hypertension, heart failure, and angina. T hey reduce arterial pressure by decreasing systemic vascular resistance, thereby reducing the afterload on the left ventricle and enhancing stroke volume and cardiac output. T hey also decrease the oxygen demand of the heart and, thereby, improve the oxygen supply/demand ratio. T he primary functions of venous dilators in treating cardiovascular hypertension include reduction in venous pressure, thus reducing preload on the heart and decreasing cardiac output and capillary fluid filtration and edema formation (a decrease in capillary hydrostatic pressure). T herefore, venous dilators sometimes are used in the treatment of heart failure along with other drugs, because they help to reduce pulmonary and/or systemic edema that results from heart failure. P.785 T here are three potential drawbacks in the use of vasodilators: First, vasodilators can lead to a baroreceptor-mediated reflex stimulation of the heart (increased heart rate and inotropy) from systemic vasodilation and arterial pressure reduction. Second, they can impair the normal baroreceptor-mediated reflex vasoconstriction when a person stands up, which can lead to orthostatic hypotension and syncope on standing. T hird, they can lead to renal retention of sodium

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and water, increasing blood volume and cardiac output. Vasodilator drugs are classified either based on their site of action (arterial vs. venous) or, more commonly, by their primary mechanism of action.

Direct-acting vasodilators Hydralazine Hydroch loride

Mechanism of Action T he only drug in this group, hydralazine, does not fit neatly into the other mechanistic classes, in part because its mechanism of action is not entirely clear. It appears to have multiple, direct effects on the VSM. Hydralazine, a phthalazine-substituted hydrazine antihypertensive drug with a pK a of 7.3, is highly specific for arterial vessels, producing its vasodilation by a couple of different mechanisms. First, it causes smooth muscle hyperpolarization, quite likely through the opening of K

+

channels. Activation therefore increases the efflux of potassium ions from the cells,

causing hyperpolarization of VSM cells and, thus, prolonging the opening of the potassium channel and sustaining a greater vasodilation on arterioles than on veins (9). It also may inhibit the second messenger, IP 3 -induced release of calcium from the smooth muscle sarcoplasmic reticulum (the PIP 2 signal transduction pathway) (Fig. 29.2). Finally, hydralazine stimulates the formation of NO by the vascular endothelium, leading to cGMP-mediated vasodilation (Fig. 29.1). T he arterial vasodilator action of hydralazine reduces systemic vascular resistance and arterial pressure. Diastolic blood pressure usually is decreased more than systolic pressure is. T he hydralazine-induced decrease in blood pressure and peripheral resistance causes a reflex response, which is accompanied by increased heart rate, cardiac output, stroke volume, and an increase in plasma renin activity. It has no direct effect on the heart (6). T his reflex response could offset the hypotensive effect of arteriolar dilation, limiting its antihypertensive effectiveness. Hydralazine also causes sodium and water retention and expansion of plasma volume, which could develop tolerance to its antihypertensive effect during prolonged therapy. T hus, coadministration of a diuretic improves the therapeutic outcome.

Fig. 29.10. Metabolism of hydralazine.

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Pharmacokinetics (6,9) Hydralazine is well absorbed from the GI tract and is metabolized in the GI mucosa (prehepatic systemic metabolism) and in the liver by acetylation, hydroxylation, and conjugation with glucuronic acid (Fig. 29.10; see T able 8.17). Little of the hydralazine dose is excreted unchanged in urine but mainly as metabolites, which are without significant therapeutic activity. A small amount of hydralazine is reportedly converted to a hydrazone, most likely with vitamin B 6 (pyridoxine), which may be responsible for some its neurotoxic effects. Following the oral administration of hydralazine, its antihypertensive effect begins in 20 to 30 minutes and lasts 2 to 4 hours. T he plasma half-life of hydralazine generally is 2 to 4 hours but, in some patients, may be up to 8 hours (i.e., slow acetylators). In slow acetylator patients or those with impaired renal function, the plasma concentrations for hydralazine are increased and, possibly, prolonged. Approximately 85% of hydralazine in the blood is bound to plasma proteins following administration of usual doses. First-pass acetylation in the GI mucosa and liver is related to genetic acetylator phenotype (8). Acetylation phenotype is an important determinant of the plasma concentrations of hydralazine when the same dose of hydralazine is administered orally. Slow acetylators have an autosomal recessive trait that results in a relative deficiency of the hepatic enzyme N-acetyl transferase, thus prolonging the elimination half-life of hydralazine (see Chapter 10). T his population of hypertensive patients will require an adjustment in dose to reduce the increased overactive response. Approximately 50% of African Americans and Caucasians, and the majority of American Indians, Eskimos, and Orientals are rapid acetylators of hydralazine. T his population of patients will have subtherapeutic plasma concentrations of hydralazine because of its rapid metabolism to inactive metabolites and shorter elimination times. Patients with hydralazine-induced systemic lupus erythematosus frequently are slow acetylators.

Therapeutic Applications (6) Hydralazine is used in the management of moderate to severe hypertension. In the stepped-care approach to antihypertensive drug therapy, hydralazine has been suggested as a step 2 or step 3 drug P.786 and generally is reserved for patients who fail to respond adequately to an antihypertensive regimen that includes a diuretic and other hypotensive drugs, such as β-blockers, ACE inhibitors, or calcium-channel blockers. Hydralazine is recommended for use in conjunction with a diuretic and another hypotensive drugs, such as β-adrenergic blockers, and has been effectively used in conjunction with cardiac glycosides, diuretics, and other vasodilators for the short-term treatment of severe congestive heart failure. Patients who engage in potentially hazardous activities, such as operating machinery or driving motor vehicles, should be warned about possible faintness, dizziness, or weakness. Hydralazine should be used with caution in patients with cerebrovascular accidents or with severe renal damage. Parenteral hydralazine may be used for the management of severe hypertension when the drug cannot be given orally or when blood pressure must be lowered immediately. Other agents (e.g., sodium nitroprusside) are preferred for the management of severe hypertension or hypersensitive emergencies when a parenteral hypotensive agent is employed.

Drug interactions T he coadministration of diuretics and other hypotensive drugs may have a synergistic effect, resulting in a marked decrease in blood pressure.

Potassium channel openers Specific dru gs Minoxidil Although several potassium channel openers have been used in research for many years, only one, minoxidil, is approved for use in humans for treating hypertension. Minoxidil is the N-oxide of a piperidinopyrimidine hypotensive agent, with a pK a of 4.6, and is not an active hypotensive drug until it is metabolized by hepatic sulfotransferase to minoxidil N-O-sulfate (9).

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Mechanism of Action Potassium channel openers are drugs that activate (i.e., open) AT P-sensitive K

+

channels in the VSM (Fig. 29.1). By

opening these potassium channels, there is increased efflux of potassium ions from the cells, causing hyperpolarization of VSM, which closes the voltage-gated calcium channels and, thereby, decreases intracellular calcium. With less calcium available to combine with calmodulin, there is less activation of MLCK and phosphorylation of myosin light chains. T his leads to relaxation and vasodilation. Because small arteries and arterioles normally have a high degree of smooth muscle tone, these drugs are particularly effective in dilating these resistance vessels, decreasing systemic vascular resistance, and lowering arterial pressure. T he fall in arterial pressure leads to reflex cardiac stimulation (baroreceptor-mediated tachycardia). Minoxidil, as its active metabolite minoxidil O-sulfate, prolongs the opening of the potassium channel, sustaining greater vasodilation on arterioles than on veins. T he drug decreases blood pressure in both the supine and standing positions, and there is no orthostatic hypotension. Associated with the decrease in peripheral resistance and blood pressure is a reflex response that is accompanied by increased heart rate, cardiac output, and stroke volume, which can be attenuated by the coadministration of a β-blocker (6). Along with this decrease in peripheral resistance is increased plasma renin activity and sodium and water retention, which can result in expansion of fluid volume, edema, and congestive heart failure. T he sodium- and water-retaining effects of minoxidil can be reversed by coadministration of a diuretic. When minoxidil is used in conjunction with a β-adrenergic blocker, pulmonary artery pressure remains essentially unchanged.

Pharmacokinetics (35) Minoxidil is absorbed from the GI tract and is metabolized to its active sulfate metabolite. Plasma concentrations for minoxidil sulfate peak within 1 hour and then decline rapidly. Following an oral dose of minoxidil, its hypotensive effect begins in 30 minutes, is maximal in 2 to 8 hours, and persists for approximately 2 to 5 days. T he delayed onset of the hypotensive effect for minoxidil is attributed to its metabolism to its active metabolite. T he drug is not bound to plasma proteins. T he major metabolite for minoxidil is its N-O-glucuronide, which unlike the sulfate metabolite is inactive as a hypotensive agent. Approximately 10 to 20% of an oral dose of minoxidil is metabolized to its active metabolite, minoxidil O-sulfate, and approximately 20% of minoxidil is excreted unchanged.

T herapeutic Applications Hypert ension (6,35) Being effective arterial dilators, potassium-channel openers are used in the treatment of hypertension. T hese drugs are not first-line therapy for hypertension because of their side effects; therefore, they are relegated to treating refractory, severe hypertension. T hey generally are used in conjunction with a β-blocker and a diuretic to attenuate the reflex tachycardia and retention of sodium and fluid, respectively. Minoxidil is used in the management of severe hypertension and is considered to be a step 3 drug. It generally is reserved for resistant cases of hypertension that have not been managed with maximal therapeutic dosages of a diuretic and two other hypotensive drugs or for patients who have failed to respond adequately to step 3 therapy that includes hydralazine. T o minimize sodium retention and increased plasma volume, minoxidil must be used in conjunction with a diuretic. A β-adrenergic blocker (e.g., propranolol) must be given before minoxidil therapy is begun and should be continued during minoxidil therapy P.787 to minimize minoxidil-induced tachycardia and increased myocardial workload.

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Androgenetic alopecia (6,36) Minoxidil is used topically to stimulate regrowth of hair in patients with androgenic alopecia (male pattern alopecia, hereditary alopecia, or common male baldness) or alopecia areata. Commercially available topical minoxidil preparations should be used rather than the extemporaneous topical formulations from tablets to reduce the potential of minoxidil being absorbed systemically.

Drug Interactions When minoxidil is administered with diuretics or other hypotensive drugs, the hypotensive effect of minoxidil increases, and concurrent use may cause profound orthostatic hypotensive effects.

Diazoxide

Diazoxide is a nondiuretic hypotensive and hyperglycemic agent that is structurally related to the thiazide diuretics. Being a sulfonamide with a pK a of 8.5, it can be solubilized in alkaline solutions (pH of injection is 11.6). Solutions or oral suspension of diazoxide are unstable to light and will darken when exposed to light. Such dosage forms should be protected from light, heat, and freezing. Darkened solutions may be subpotent and should not be used.

Mechanism of Action Diazoxide reduces peripheral vascular resistance and blood pressure by a direct vasodilating effect on the VSM with a mechanism similar to that described for minoxidil by activating (opening) the AT P-modulated potassium channel (36). T hus, diazoxide prolongs the opening of the potassium channel, sustaining greater vasodilation on arterioles than on veins (9). T he greatest hypotensive effect is observed in patients with malignant hypertension. Although oral or slow IV administration of diazoxide can produce a sustained fall in blood pressure, rapid IV administration is required for maximum hypotensive effects, especially in patients with malignant hypertension (6). Diazoxide-induced decreases in blood pressure and peripheral vascular resistance are accompanied by a reflex response, resulting in an increased heart rate, cardiac output, and left ventricular ejection rate. In contrast to the thiazide diuretics, diazoxide causes sodium and water retention and decreased urinary output, which can result in expansion of plasma and extracellular fluid volume, edema, and congestive heart failure, especially during prolonged administration. Diazoxide increases blood glucose concentration (diazoxide-induced hyperglycemia) by several different mechanisms: by inhibiting pancreatic insulin secretion, by stimulating release of catecholamines, or by increasing hepatic release of glucose (6,9). T he precise mechanism of inhibition of insulin release has not been elucidated but, possibly, may result from an effect of diazoxide on cell-membrane potassium channels and calcium flux.

Pharmacokinetics (6) Following rapid IV administration, diazoxide produces a prompt reduction in blood pressure, with maximum hypotensive effects occurring within 5 minutes. T he duration of its hypotensive effect varies from 3 to 12 hours, but ranges from 30 minutes to 72 hours have been observed. T he elimination half-life of diazoxide following a single oral or IV dose has been reported to range from 21 to 45 hours in adults with normal renal function. In patients with renal impairment, the half-life is prolonged. Approximately 90% of the diazoxide in the blood is bound to plasma proteins. Approximately 20 to 50% of diazoxide is eliminated unchanged in the urine, along with its major metabolites, resulting from the oxidation of the 3-methyl group to its 3-hydroxymethyl- and 3-carboxyl-metabolites.

T herapeutic Applications

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Severe hypertension (6) Intravenous diazoxide has been used in hypertensive crises for emergency lowering of blood pressure when a prompt and urgent decrease in diastolic pressure is required in adults with severe nonmalignant and malignant hypertension and in children with acute severe hypertension. Generally, however, other IV hypotensive agents are preferred for the management of hypertensive crises. Diazoxide is intended for short-term use in hospitalized patients only. Although diazoxide also has been administered orally for the management of hypertension, its hyperglycemic and sodiumretaining effects make it unsuitable for chronic therapy.

Hypoglycemia (6) Diazoxide is administered orally in the management of hypoglycemia caused by hyperinsulinism associated with inoperable islet cell adenoma or carcinoma or extrapancreatic malignancy in adults.

Phosphodiesterase inhibitors Mechan ism of Action of cAMP-Depen dent Ph osph odiesterase In h ibitors (PDE3) T he PDE3 is one of the isoforms of phosphodiesterase found in the heart and VSM. T he mechanism by which cAMP and cGMP relaxes VSM has been described previously in the section on VSM contraction and relaxation (Fig. 29.1) (see also Chapter 17). T he cAMP released is broken down by a cAMP-dependent phosphodiesterase (PDE3). T herefore, inhibition of PDE3 increases intracellular cAMP, which further inhibits MLCK, thereby producing less contractile force (i.e., promoting relaxation). T he overall cardiac and vascular effects of cAMP-dependent phosphodiesterase inhibitors cause cardiac stimulation, increasing cardiac output and reducing systemic vascular resistance, thereby lowering arterial pressure. Because cardiac output increases and systemic vascular resistance decreases, the change in arterial pressure depends on the relative effects of the phosphodiesterase inhibitor on the heart versus the VSM. At normal therapeutic doses, PDE3 inhibitors, such as milrinone, have a greater effect on VSM P.788 than cardiac muscle so that arterial pressure is lowered in the presence of augmented cardiac output. Because of the dual cardiac and vascular effects of these compounds, they sometimes are referred to as inodilators.

Mechan ism of Action of cGMP-Dependen t Ph osphodiesterase In hibitors (PDE5) A second isoenzyme form of phosphodiesterase found in VSM is PDE5, a cGMP-dependent phosphodiesterase, which also is found in the corpus cavernosum of the penis (erectile dysfunction). T his enzyme is responsible for breaking down cGMP that forms in response to increased NO (Fig. 29.1). Increased cGMP leads to smooth muscle relaxation primarily by reducing calcium entry into the cell. Inhibitors of cGMP-dependent phosphodiesterase increases intracellular cGMP, thereby enhancing VSM relaxation and vasodilation.

Th erapeutic Indications T he cardiostimulatory and vasodilatory actions of PDE3 inhibitors make them suitable for the treatment of heart failure, because VSM relaxation reduces ventricular wall stress and the oxygen demands placed on the failing heart. T he cardiostimulatory effects of the PDE3 increase inotropy, which further enhances stroke volume and ejection fraction. A baroreceptor reflex, which occurs in response to hypotension, may contribute to the tachycardia. Clinical trials have shown that long-term therapy with PDE3 inhibitors increases mortality in patients with heart failure; therefore, these drugs are not used for long-term, chronic therapy. T hey are very useful, however, in treating acute, decompensated heart failure or temporary bouts of decompensated chronic failure. T hey are not used as a monotherapy. Instead, they are used in conjunction with other treatment modalities, such as diuretics, ACE inhibitors, β-blockers, or digitalis. T he somewhat selective vasodilatory actions of PDE5 inhibitors have made these compounds very useful in the treatment of male erectile dysfunction and as a combination therapy for pulmonary hypertension. T he PDE3 inhibitors are used for treating heart failure, whereas the PDE5 inhibitors are used for treating male erectile dysfunction. Note that the generic names for PDE3 inhibitors end in “ one” and those for the PDE5 inhibitors end in “ fil” .

Specific Dru gs

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Milrinone (Primacor as Lactate Salt) and Inamrinone (Inocor as Lactate Salt) Inamrinone and milrinone are positive inotropes and vasodilators indicated for the short-term IV management of congestive heart failure in patients who have not responded adequately to digitalis, diuretics, and/or vasodilators. For IV infusion, inamrinone lactate and milrinone lactate injection solutions may be diluted in sodium chloride solution for injection. Inamrinone lactate for injection is preserved with sodium metabisulfite and needs protection from light. It should not be diluted with solutions containing dextrose, because a chemical interaction occurs over 24 hours. For milrinone, an immediate chemical interaction with furosemide with the formation of a precipitate is observed when furosemide is injected into an infusion of milrinone. Patients who are sensitive to bisulfites also may be sensitive to inamrinone lactate injection, which contains sodium metabisulfite. T he pharmacokinetics for inamrinone shows protein binding from 10 to 49%. Its half-life in healthy volunteers is approximately 3.6 hours, whereas in patients with congestive heart failure, the plasma half-life increases to approximately 5.0 to 8.3 hours. For infants younger than 4 weeks, the half-life is 12.7 to 22.2 hours, and for infants older than 4 weeks, the half-life is 3.8 to 6.8 hours. T ime to peak effect is less than 10 minute. Its duration of action is dose related, ranging from 30 minutes at low dose to 2 hours at the higher dosages. Approximately 63% of the administered dose is eliminated via the urine as unchanged drug, and 18% is eliminated in the feces. Elderly patients are more likely to have age-related renal function impairment, which may require adjustment of dosage in patients receiving inamrinone. T he pharmacokinetics for milrinone following IV injections to patients with congestive heart failure showed a volume of distribution of 0.38 to 0.45 L/kg, a mean terminal elimination half-life of 2.3 hours, and a clearance of 0.13 L/kg/hour. T hese pharmacokinetic parameters were not dose-dependent, and the area under the plasma concentration versus time curve following injections was significantly dose-dependent. Milrinone is approximately 70% bound to human plasma protein. T he primary route of excretion for orally administered milrinone is via the urine, with unchanged milrinone (83%) and its O-glucuronide metabolite (12%) being present. Elimination in normal subjects via the urine is rapid, with approximately 60% recovered within the first 2 hours following dosing and approximately 90% within the first 8 hours following dosing. In patients with renal function impairment, elimination of unchanged milrinone is reduced, suggesting that a dosage adjustment may be necessary. T he selective PDE5 inhibitor most commonly used is sildenafil (Viagra). Studies in vitro have shown that sildenafil is selective for PDE5. Its effect is more potent on PDE5 than on other known phosphodiesterases (10 times P.789 for PDE6, > 80 times for PDE1, and > 700 times for PDE2, PDE3, PDE4, PDE7, PDE8, PDE9, PDE10, and PDE11). T he approximately 4,000 times selectivity for PDE5 versus PDE3 is important, because PDE3 is involved in control of cardiac contractility. Sildenafil is only approximately 10 times as potent for PDE5 compared to PDE6, an enzyme found in the retina that is involved in the phototransduction pathway of the retina. T his lower selectivity is thought to be the basis for abnormalities related to color vision observed with higher doses or plasma levels. (For a complete discussion of the pharmacokinetics including drug metabolism, see Chapter 45.)

Side Effects and Contraindications

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T he most common and severe side effect for PDE3 inhibitors is ventricular arrhythmias, some of which may be life-threatening. Other side effects include headaches and hypotension, which are not uncommon for drugs that increase cAMP in cardiac and vascular tissues (e.g., β-agonists). In addition to human corpus cavernosum smooth muscle, PDE5 also is found in lower concentrations in other tissues, including platelets, vascular and visceral smooth muscle, and skeletal muscle. T he inhibition of PDE5 in these tissues by sildenafil may be the basis for the enhanced platelet antiaggregatory activity of NO observed in vitro, an inhibition of platelet thrombus formation in vivo, and peripheral arterial-venous dilatation in vivo. T he most common side effects for PDE5 inhibitors include headache and cutaneous flushing, both of which are related to vascular dilation caused by increased vascular cGMP. Clinical evidence suggests that nitrodilators may interact adversely with PDE5 inhibitors. T he reason for this adverse reaction is that nitrodilators stimulate cGMP production, whereas PDE5 inhibitors inhibit cGMP degradation. When combined, these two drug classes greatly potentiate cGMP levels, which can lead to hypotension and impaired coronary perfusion.

Nitrodilators Mechan ism of Action Nitric oxide, a molecule produced by many cells in the body, has several important actions. NO is a highly reactive gas that participates in many chemical reactions. It is one of the nitrogen oxides (“ NOx” ) in automobile exhaust and plays a major role in the formation of photochemical smog, but NO also has many physiological functions. It is synthesized within cells by an enzyme NO synthase (NOS). T here are three isoenzymes, neuronal NOS (nNOS or NOS-1), inducible NOS (iNOS or NOS-2) found in macrophages, and endothelial NOS (eNOS or NOS-3) found in the endothelial cells that line the lumen of blood vessels. Whereas the levels of nNOS and eNOS are relatively steady, expression of iNOS genes awaits an appropriate stimulus. All types of NOS produce NO from arginine with the aid of molecular oxygen and NADPH. Because NO diffuses freely across cell membranes, there are many other molecules with which it can interact, and NO is quickly consumed close to where it is synthesized. T hus, NO affects only cells adjacent to its point of synthesis. NO relaxes the smooth muscle in the walls of the arterioles. At each systole, the endothelial cells that line the blood vessels release a puff of NO, which diffuses into the underlying smooth muscle cells, causing them to relax and, thus, to permit the surge of blood to pass through easily. T he signaling functions of NO begin with its binding to protein receptors on or in the cell, triggering the formation of cGMP from soluble guanylyl cyclase (Fig. 29.1). Mice in which the genes for the NOS found in endothelial cells (eNOS) has been “ knocked out” suffer from hypertension. Nitroglycerin, which often is prescribed to reduce the pain of angina, does so by generating NO, which relaxes venous walls and arterioles improving the oxygen supply/decreased ratio (see Chapter 24). Nitric oxide also inhibits the aggregation of platelets and, thus, keeps inappropriate clotting from interfering with blood flow. Other actions on smooth muscle include penile erection and peristalsis aided by the relaxing effect of NO on the smooth muscle in intestinal walls; NO also inhibits the contractility of the smooth muscle wall of the uterus, but at birth, the production of NO decreases, allowing contractions to occur. Nitroglycerin has helped some women who were at risk of giving birth prematurely to carry their baby to full term. T he NO from iNOS inhibits inflammation in blood vessels by blocking the release of mediators of inflammation from the endothelial cells, macrophages, and T lymphocytes. T he NO from iNOS has been shown to S-nitrosylate COX-2, increasing its activity, and drugs that prevent this interaction could work synergistically with the nonsteroidal anti-inflammatory drugs inhibiting COX-2. Nitric oxide affects hormonal secretion from several endocrine glands. Hemoglobin transports NO at the same time that it carries oxygen, and when it unloads oxygen in the tissues, it also unloads NO. Fireflies use NO to turn on their flashers. Since the dawn of recorded human history, nitrates have been used to preserve meat from bacterial spoilage. Harmless bacteria in our throat convert nitrates in our food into nitrites. When the nitrites reach the stomach, the acidic gastric juice (pH ~ 1.4) generates NO from these nitrites, killing almost all the bacteria that have been swallowed in our food. In the cardiovascular system, NO is produced primarily by vascular endothelial cells. T his endothelial-derived NO has several important functions, including relaxing VSM (vasodilation), inhibiting platelet aggregation (antithrombotic), and inhibiting leukocyte–endothelial interactions (anti-inflammatory). T hese actions involve NO-stimulated formation of cGMP (Fig. 29.1). Nitrodilators are drugs that mimic the actions of endogenous NO by releasing NO or forming NO within tissues. T hese drugs act directly on the VSM to cause relaxation and, therefore, serve as endothelialindependent vasodilators. P.790

Sodiu m Nitropru sside (Sodiu m Nitroferricyan ide; Nitropress; Nipride)

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T here are two basic types of nitrodilators: those that release NO spontaneously (e.g., sodium nitroprusside), and those that require an enzyme activation to form NO (organic nitrates). Sodium nitroprusside is a direct-acting vasodilator on VSM, producing its vasodilation by the release of NO. Since 1929, it has been known as a rapidly acting hypotensive agent when administered as an infusion. It is chemically and structurally unrelated to other available hypotensive agents. As a reminder in preparing extemporaneous infusions, the potency of sodium nitroprusside is expressed in terms of the dihydrated drug. When reconstituted with 5% dextrose injection, sodium nitroprusside solutions are reddish-brown in color, with a pH of 3.5 to 6.0. Its crystals and solutions are sensitive and unstable to light and should be protected from extremes of light and heat. T he exposure of sodium nitroprusside solutions to light causes deterioration, which may be evidenced by a change from a reddish-brown to a green to a blue color, indicating a rearrangement of the nitroso to the inactive isonitro form. Sodium nitroprusside solutions in glass bottles undergo approximately 20% degradation within 4 hours when exposed to fluorescent light and even more rapid degradation in plastic bags. Sodium nitroprusside solutions should be protected from light by wrapping the container with aluminum foil or other opaque material. When adequately protected from light, reconstituted solutions are stable for 24 hours. T race metals, such as iron and copper, can catalyze the degradation of nitroprusside solutions, releasing cyanide. Any change in color for the nitroprusside solutions is an indication of degradation, and the solution should be discarded. No other drug or preservative should be added to stabilize sodium nitroprusside infusions.

Mechanism of Action Sodium nitroprusside is not an active hypotensive drug until metabolized to its active metabolite, NO, the mechanism of action of which has been previously described (Fig. 29.1). Studies with sodium nitroprusside suggest that it releases NO by its interaction with glutathione or with sulfhydryl groups in the erythrocytes and tissues to form a S-nitrosothiol intermediate, which spontaneously produces NO, which in turn freely diffuses into the VSM, thereby increasing intracellular cGMP concentration (6,9). NO also activates K

+

channels, which leads to hyperpolarization and relaxation.

T he hypotensive effect of sodium nitroprusside is augmented by concomitant use of other hypotensive agents and is not blocked by adrenergic blocking agents. It has no direct effect on the myocardium, but it may exert a direct coronary vasodilator effect on VSM. When sodium nitroprusside is administered to hypertensive patients, a slight increase in heart rate commonly occurs, and cardiac output usually is decreased slightly. Moderate doses of sodium nitroprusside in patients with hypertension produce renal vasodilation without an appreciable increase in renal blood flow or decrease in glomerular filtration (6). Intravenous infusion of sodium nitroprusside produces an almost immediate reduction in blood pressure. Blood pressure begins to rise immediately when the infusion is slowed or stopped and returns to pretreatment levels within 1 to 10 minutes.

Pharmacokinetics Sodium nitroprusside undergoes a redox reaction that releases cyanide (6,9). T he cyanide that is produced is rapidly converted into thiocyanate in the liver by the enzyme thiosulfate sulfotransferase (rhodanase) and is excreted in the urine (6,9). T he rate-limiting step in the conversion of cyanide to thiocyanate is the availability of sulfur donors, especially thiosulfate. T oxic symptoms of thiocyanate begin to appear at plasma thiocyanate concentrations of 50 to 100 mg/mL. T he elimination half-life of thiocyanate is 2.7 to 7.0 days when renal function is normal but longer in patients with impaired renal function.

Therapeutic Applications (6) Intravenous sodium nitroprusside is used as an infusion for hypertensive crises and emergencies. T he drug is consistently effective in the management of hypertensive emergencies, irrespective of etiology, and may be useful

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even when other drugs have failed. It may be used in the management of acute congestive heart failure.

Adverse Effects (6) T he most clinically important adverse effects of sodium nitroprusside are profound hypotension and the accumulation of cyanide and thiocyanate. T hiocyanate may accumulate in the blood of patients receiving sodium nitroprusside therapy, especially in those with impaired renal function. T hiocyanate is mildly neurotoxic at serum concentrations of 60 µg/mL and may be life-threatening at concentrations of 200 µg/mL. Other adverse effects of thiocyanate includes inhibition of both the uptake and binding of iodine producing symptoms of hypothyroidism. Sodium nitroprusside can bind to vitamin B 12 interfering with its distribution and metabolism, and it should be used with caution in patients having low plasma vitamin B 12 concentrations. Excess cyanide also can bind to hemoglobin, producing methemoglobinemia.

Ganglionic blockers Mechan ism of Action Ganglionic blockers block impulse transmission at the sympathetic ganglia. Neurotransmission within the sympathetic and parasympathetic ganglia P.791 involves the release of acetylcholine from preganglionic efferent nerves, which binds to nicotinic receptors on the postganglionic efferent nerves. Ganglionic blockers inhibit autonomic activity by interfering with neurotransmission within autonomic ganglia. T his reduces sympathetic outflow to the heart, thereby decreasing cardiac output by decreasing heart rate and contractility. Reduced sympathetic output to the vasculature decreases sympathetic vascular tone, which causes vasodilation and reduced systemic vascular resistance, which decreases arterial pressure. Parasympathetic outflow also is reduced by ganglionic blockers.

Th erapeutic Indications Ganglionic blockers are not commonly used in the treatment of chronic hypertension largely because of their side effects and because numerous more effective and safer antihypertensive drugs can be used. T hey are, however, occasionally used for hypertensive emergencies. T he ganglionic blockers available for clinical use include trimethaphan camsylate and mecamylamine.

T hey are competitive antagonists at nicotinic acetylcholine receptors. T rimethaphan is a quaternary sulfonium ion and cannot cross lipid cell membranes, whereas mecamylamine is a secondary amine. T herefore, trimethaphan is a shortacting peripheral direct vasodilator that must be given as an IV infusion, whereas mecamylamine can be given orally. Mecamylamine rapidly disappears from the blood with a plasma half-life of 1 hour, and crosses the blood-brain barrier into the CNS. T rimethaphan is rapidly excreted in unchanged form by the kidney. Mecamylamine is excreted by the kidney much more slowly. T rimethaphan is the drug of choice for managing acute aortic dissection and for hypertensive emergencies. Both drugs are of limited use, because of the availability of more specific acting vasodilators. Mecamylamine has been used for labeling CNS nicotinic receptors and crosses into the CNS, where it can block neuronal nicotinic acetylcholine receptors. Mecamylamine has been studied for use with nicotine for smoking cessation.

Side Effects an d Contraindication s Side effects of trimethaphan include prolonged neuromuscular blockade and potentiation of neuromuscular blocking

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agents. It can produce excessive hypotension and impotence (because of its sympatholytic effect) as well as constipation, urinary retention, and dry mouth (because of its parasympatholytic effect).

Pulm onary Arterial Hypertension Pulmonary hypertension, which was once a rare life-threatening disease, reportedly affects about 160,000 people today. Pulmonary arterial hypertension (PAH) is defined as a group of diseases characterized by a progressive increase of pulmonary vascular resistance, leading to right ventricular failure. It includes a variety of pulmonary hypertensive diseases with different etiologies but similar clinical presentation (36). Primary pulmonary hypertension can occur, without any apparent cause (idiopathic), or can be inherited. Pulmonary arterial hypertension is a disease of the small pulmonary arteries, characterized by progressive narrowing of the pulmonary vascular bed. Vasoconstriction and scarring (or fibrosis) cause the pulmonary wall to become stiffer and thicker, contributing to an increased pulmonary vascular resistance. T his extra stress causes the heart to enlarge and become less flexible. Less blood flows from the heart, through the lungs, and into the body, resulting in additional symptoms. One direct effect of these abnormally elevated pressures is blood leakage from the pulmonary vessels. A blood-producing cough often is an indicator of leakage from the pulmonary vessels. T he pulmonary arterial walls produce a substance called endothelin, which causes these blood vessels to constrict. T he reasons for this overproduction are unknown. In some cases, the cause is genetically programmed or the person is predisposed genetically to primary pulmonary hypertension after being exposed to a certain drug (e.g. the diet drugs Fen-Phen [fenfluramine/phentermine], Redux [dexfenfluramine], or Pondimin [fenfluramine]). Often, primary pulmonary hypertension is not diagnosed in a timely manner, because its early symptoms can be confused with those of many other conditions (T able 29.4). T o establish a diagnosis of pulmonary hypertension, a series of tests are performed that show how well a person's heart and lungs are working. T hese tests may include assessment of daily living tasks, such as a 6-minute walk test, a computed tomography scan to rule out a pulmonary embolism or lung disease, a pulmonary function test to rule out obstructive lung disease, a formal sleep study to rule out sleep apnea, and laboratory tests to rule out hepatitis, collagen disease, HIV, or other conditions.

Rationale for Pharmacologic Treatment If PAH has an identifiable cause, then measures can be taken to correct the underlying problem. If the diagnosis P.792 is primary PAH, then pharmacologic intervention is required to reduce the pressure. T his is done using vasodilator drugs to decrease pulmonary vascular resistance and, thereby, to lower the pressure. Adjunct therapy may include diuretics to reduce blood volume, which will reduce central venous pressure and right ventricular stroke volume, as well as to reduce some of the signs and symptoms of edema and shortness of breath associated with PAH. Anticoagulants are administered to prevent the formation of pulmonary thrombi. Patients with cardiovascular hypertension generally are treated with antihypertensive drugs that reduce blood volume (which reduces central venous pressure and cardiac output), reduce systemic vascular resistance, or reduce cardiac output by depressing heart rate and stroke volume.

Table 29.4. Symptoms of Primary Pulmonary Hypertension Breathlessness or shortness of breath Feeling tired all the time Dizziness, especially when climbing stairs or stand ing up Fainting (often the symptom that brings people to their doctors) Swollen ankles and legs Chest pain, especially during physical activity

Drugs Used to Treat Pulmonary Hypertension Classes of drugs used in the treatment of PAH include thiazide diuretics, loop diuretics, vasodilators, calcium channel blockers, prostaglandins, endothelin receptor antagonists, NO, and PDE5 inhibitors (38). During the last decade, substantial improvements in the therapeutic options for PAH have emerged that target the mechanisms involved in the pathogenesis of this devastating disease. Intravenous epoprostenol was the first drug to improve symptoms and

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survival of patients with PAH (40). Novel prostanoids, including subcutaneous treprostinil and inhaled iloprost, have beneficial effects in many patients, although their long-term efficacy is less well known. Among the newer treatments for PAH, endothelin receptor antagonists and PDE5 inhibitors have reshaped clinical practice. T he endothelin receptor antagonist bosentan has been approved, and most guidelines recommend this drug as first-line treatment for patients with PAH and New York Heart Association (NYHA) functional class III heart failure (i.e., patients with marked limitation of activity; they are comfortable only at rest). Novel endothelin receptor antagonists, such as sitaxsentan sodium and ambrisentan, are currently being investigated. T he combination of the PDE5 inhibitor sildenafil and iloprost, prostacyclin analogue, are being intensively studied in patients with pulmonary hypertension. T argeting a single pathway cannot be expected to be uniformly successful, because PAH is a complex disorder. T hus, combining substances with different modes of action is expected to improve symptoms, hemodynamics, and survival in PAH patients, although combination therapy has yet to undergo the scrutiny of large randomized clinical trials.

Specific Drugs Phosphodiesterase Inhibitors Sildenafil (Revatio) Sildenafil has recently been approved for treatment of PAH through its inhibition of cGMP and smooth muscle relaxation of the pulmonary vasculature. T he reader is referred to the previous discussion of phosphodiesterase inhibitors under the topic of vasodilators.

Endothelin Receptor Antagonists Mechanism of action Endothelin-1 (ET -1) is a 21-amino-acid peptide that is produced by the vascular endothelium. It is a very potent vasoconstrictor that binds to VSM endothelin receptors ET A and ET B (Fig. 29.1). T he ET -1 receptors are linked to the G q protein and IP 3 signal transduction pathway (Fig. 29.11). T herefore, ET -1 causes sarcoplasmic reticulum release of calcium, increasing the VSM contractility. Vascular endothelial cells secrete the majority of ET -1. T he endothelins bind to two receptor subtypes: ET A, and ET B . In vascular tissue, ET A is located predominantly on smooth muscle cells, whereas ET B is found on both endothelial and smooth muscle cells. Activation of ET A by ET -1 leads to potent vasoconstriction from an increase in cytosolic calcium levels via influx of extracellular calcium and release from intracellular stores (Fig. 29.1). T he actions of ET B are more complicated. Like ET A, ET -1 activation of ET B on VSM cells leads to vasoconstriction. Furthermore, some studies suggest that in the pulmonary hypertensive state, blockade of both ET A and ET B is necessary to achieve maximal vasodilation. Activation of ET -B by P.793 ET -1 stimulates cyclooxygenase (COX) which catalyzes the formation of prostacyclin from arachidonic acid. Prostacyclin then binds to and activates the isoprostanoid receptor (IP) on VSM. ET -1 also activates ET -B which stimulates endothelial nitric oxide synthease (eNOS) to produce NO from L-arginine. Both prostacyclin and NO are potent vasodilators of VSM (relaxation). Additionally, ET -1 binds to the ET B receptors on the endothelium of pulmonary smooth muscle and stimulate the formation of NO, which produces vasodilation in the absence of smooth muscle ET A and ET B receptor activation. T his receptor distribution helps to explain the phenomenon that ET -1 administration causes transient vasodilation (initial endothelial ET B activation) and hypotension, followed by prolonged vasoconstriction (smooth muscle ET A and ET B activation) and hypertension.

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Fig. 29.11. The effects of endothelin-1, prostacyclin and nitric oxide on the contraction and relaxation (vasodilation) of vascular smooth muscle cells. (From Yeh DC, Michel T. Pharmacology of Vascular Tone. In: Golan DE, Tashjian AH, Armstrong E, et al., Principles of Pharmacology: The Pathophysiologic Basis of Drug Therapy. Baltimore: Lippincott Williams & Wilkins, 2004; with permission)

Therapeutic indications Because of its powerful vasoconstrictor properties and its effects on intracellular calcium, ET -1 has been implicated in the pathogenesis of hypertension, coronary vasospasm, and heart failure. A number of studies suggest a role for ET -1 in pulmonary hypertension as well as in systemic hypertension. Additionally, ET -1 has been shown to be released by the failing myocardium, where it can contribute to cardiac calcium overload and hypertrophy. Endothelin receptor antagonists, by blocking the vasoconstrictor and cardiotonic effects of ET -1, produce vasodilation and cardiac inhibition. Endothelin receptor antagonists have been shown to decrease mortality and to improve hemodynamics in experimental models of heart failure. At present, the only approved indication for endothelin antagonists is pulmonary hypertension.

Specific drugs Bosentan (T racleer)

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Bosentan is an orally administered, nonselective ET -1 receptor antagonist blocking ET A and ET B receptors and is approved for the treatment of patients with PAH. Following oral administration, bosentan attains peak plasma concentrations in approximately 3 hours, with an absolute bioavailability of approximately 50%. Food has no clinically relevant effect on its absorption recommended doses. Bosentan is approximately 98% bound to albumin, with a volume of distribution of 30 L. Its terminal half-life after oral administration is 5.4 hours and is unchanged at steady state. Steady-state concentrations are achieved within 3 to 5 days after multiple-dose administration. Bosentan is mainly eliminated from the body by hepatic metabolism and subsequent biliary excretion of the metabolites. T hree metabolites have been identified, formed by CYP2C9 and CYP3A4 (Fig. 29.12). T he pharmacokinetics of bosentan are dose-proportional up to 500 mg/day (multiple doses). T he pharmacokinetics of bosentan in pediatric patients with PAH are comparable to those in healthy subjects, whereas adult patients with PAH show a twofold increase in clearance. Severe renal impairment and mild hepatic impairment do not have a clinically relevant influence on its pharmacokinetics. Bosentan generally should be avoided in patients with moderate or severe hepatic impairment and/or elevated liver aminotransferases. Inhibitors of CYP3A4 increase the plasma concentration of bosentan as well as cause an increase in the clearance of drugs metabolized by CYP3A4 and CYP2C9 because of induction of these metabolizing enzymes. T he possibility of reduced efficacy of CYP2C9 and CYP3A4 substrates coadministered with bosentan is increased. No clinically relevant interaction was detected for P-glycoprotein. Bosentan can increase plasma levels of ET -1. Adverse effects include hypotension, headache, flushing, increased liver aminotransferases, leg edema, and anemia. Bosentan may cause birth defects and, therefore, is contraindicated in pregnancy. It also can cause liver injury.

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Fig. 29.12. Metabolism of bosentan.

Prostanoids (39) Epoprostenol (Flolan) Prostacyclin and its analogs (prostanoids) (Fig. 29.13) are potent vasodilators and possess antithrombotic and antiproliferative properties. Prostacyclin is derived from the endothelium of VSM, and its synthesis is reduced in patients with PAH. Its physiological antagonist, thromboxane A2 , is increased, however, causing vasoconstriction. Prostacyclin produces its P.794 vasodilation via activation of the PIP 2 signal transduction pathway, increasing concentrations of cAMP (Fig. 29.11). Epoprostenol is the sodium salt of prostacyclin and is administered as an implanted, continuous IV infusion because of its very short duration of action (2–3 minutes). It must be reconstituted with a special glycine buffer diluent, giving a reconstituted solution with pH 10 to 11 that is stable for 15 minutes at 4°C and for less than 10 minutes at 37°C. Its injection solution is unstable at a lower pH because of acid-catalyzed hydrolysis of the vinylether structure to 6-oxo-PGF 1α (Fig. 29.13). It is short acting because of rapid metabolism at the 15-hydroxy group to the inactive 15-oxo metabolite.

Treprostinil (Remodulin) T reprostinil (Fig. 29.13) is a synthetic, stable form of prostacyclin for the treatment for advanced pulmonary hypertension with NYHA class III or IV symptoms as well as for late-stage peripheral vascular disease (PVD). Its sodium salt injectable form is administered either as a continuous subcutaneous infusion directly into the skin or, if the subcutaneous infusion is not tolerated, as a continuous IV infusion without an implanted catheter. T reprostinil is rapidly absorbed from the subcutaneous site of infusion, with an almost 100% bioavailability and a mean half-life of 85 minutes (34 minutes for the IV infusion). T he IV solution must be diluted with normal saline or sterile water before starting the infusion. Unlike epoprostenol, treprostinil is stable at room temperature for up to 5 years, with vasodilation action lasting from 4 to 6 hours, compared with the short, 2- to 3-minute action for epoprostenol. Because of its long life in the body, it can be administered under the skin with a microinfusion subcutaneous infusion pump rather than into the bloodstream and, thus, without hospitalization, as contrasted with the central IV infusion of epoprostenol. Side effects include jaw pain, headaches, nausea, diarrhea, flushing, and localized pain at the delivery site under the skin. T his pain has been reported as slight to severe irritation. Patients using the drug seem to ex-perience improvement in their condition, including decreased fatigue, decreased shortness of breath, and decreased pulmonary artery pressures, as well as overall improvement in quality of life.

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Beraprost Beraprost is an oral formulation of a prostacyclin analog for the treatment of early stage pulmonary hypertension as well as early stage PVD. Beraprost is a chemically stable, oral form of prostacyclin that is readily absorbed from GI tract. Like natural prostacyclin, beraprost dilates blood vessels, prevents platelet aggregation, and prevents proliferation of smooth muscle cells surrounding blood vessels. It may be an important treatment for early stage PVD and for early stage pulmonary hypertension. Intermittent oral doses of beraprost, however, do not seem to provide the consistent blood levels P.795 necessary to treat the advanced stages of pulmonary hypertension. Beraprost has proven to be safe and effective for the treatment of PVD in the clinical studies conducted, and it has been approved for the treatment of PVD in Japan since 1994. It may soon be available for use in patients with pulmonary hypertension in the United States. Adverse effects include headache, flushing, jaw pain, and diarrhea.

Fig. 29.13. Prostacyclin analogs.

Iloprost (Ventavis) Iloprost is administered as an inhalation solution of a prostacyclin analog for the treatment of NYHA class III and class IV PAH. T he drug also can be administered as an IV infusion. It is stable at room temperature and to light, with a body half-life of 30 minutes. Iloprost has approximately 10 times greater potency than prostacyclin as a vasodilator of the pulmonary blood vessels; this greater potency of inhaled iloprost results from coating of the drug on the alveoli of the lungs. It relieves pulmonary vascular resistance. Patients inhale six to eight puffs every 2 to 3 hours. Each puff lasts approximately 15 minutes. T his therapy is used mainly in Europe and is not available in United States. Studies have reported minor side effects, such as coughing, headaches, and jaw pain.

Case Study Vic tor ia F . Roch e S. Willia m Zito

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KG is a 73 -ye ar-o ld, sing le , re tire d b ank exe cutive living in Paris who is in the early stag es o f Alzhe ime r's d ise ase . Fo ur mo nths ag o , she be g an the rap y with tacrine HCl (Co gne x c urre ntly 20 mg q .i.d .), which se ems to b e halting the ad vanc e o f d e me ntia. She e xp e rienced so me d ys pe p sia f ro m the tacrine which is be ing tre ate d with o me p razole (Prilo sec), as we ll as mild bradycard ia which is no t curre ntly inte rf e ring with her f unctio n. Altho ug h s he no long e r s moke s cig arettes , KG do e s have mild e mp hyse ma f ro m her years as a p ack-a-d ay smoke r. Mos t re cently, she has e xp erienced urinary inco ntine nce . “Accide nts” have b e en f e w, but she no w wears p ro te ctive und e rgarments. He r only o the r me dic atio n is calcium ato rvastatin (L ip itor, 10 mg q .d .) f or e levate d p lasma lo w-de nsity lip o protein and total cho le ste ro l. KG inve ste d wise ly as a young woman, o wns a chalet on the o utskirts o f the city, and is ab le to af f o rd q uality in-ho me as sistance . An atte ntive niece who stud ie s art at the So rb onne lives with her. KG has b e en b ord e rline hyp e rte nsive f or se veral ye ars and e le cte d to ke ep things und e r c ontro l with diet and a walking re g ime n. She d id well re stricting her f at and o ve rall calorie co nsump tion, b ut she f ound it ve ry d if f icult to e f f ec tive ly mo nitor he r so dium intake . Her b lo od p re ssure is no w e levated to the po int that antihyp erte nsive the rap y is no lo ng er o ptio nal. Conside r the symp atholytic choices shown be lo w, and p re pare to make a the rap eutic re comme ndatio n (en Francais). 1. I de ntif y the the rap eutic p ro ble m(s ) in which the p harmacist's inte rve ntio n may b e ne f it the p atient. 2. I de ntif y and p rio ritize the p atie nt-spe cif ic f acto rs that must b e co nsid e red to achie ve the de sire d the rap e utic o utco mes . 3. Conduc t a tho ro ug h and me chanistically o rie nted structure– activity analysis o f all the rap e utic alte rnative s p ro vide d in the case. 4. Evaluate the s tructure– activity relatio nship f ind ing s ag ainst the p atie nt-spe cif ic f acto rs and de sire d the rap e utic o utco mes , and make a the rap e utic d e cisio n. 5. Counse l yo ur patie nt

P.796

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24. Chrisp P, Faulds D. Moxonidine: a review of its pharmacology, and therapeutic use in essential hypertension. Drugs 1992;44:993–1012.

25. Genissel P, Bromet N, Fourtillan JB, et al. Pharmacokinetics of rilmenidine in healthy subjects. Am J Cardiol 1988;61:47D–53D.

26. Genissel P, Bromet N. Pharmacokinetics of rilmenidine. Am J Med 1989;87:8S–23S.

27. Langley MS, Heel RC. T ransdermal clonidine. A preliminary review of its pharmacodynamic properties and therapeutic efficacy. Drugs 1988;35:123–142.

28. Fujimura A, Ebihara A, Ohashi K-I, et al. Comparison of the pharmacokinetics, pharmacodynamics, and safety of oral (Catapres) and transdermal (M-5041T ) clonidine in healthy subjects. J Clin Pharmacol 1994;34:260–265.

29. Ebihara A, Fujimura A, Ohashi K-I, et al. Influence of application site of a new transdermal clonidine, M-5041T , on its pharmacokinetics and pharmacodynamics in healthy subjects. J Clin Pharmacol 1993;33:1188–1191.

30. Holmes B, Brogden RN, Heel RC, et al. Guanabenz. A review of its pharmacodynamic properties and therapeutic efficacy in hypertension. Drugs 1983;26:212–229.

31. Sorkin EM, Heel RC. Guanfacine: a review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy in the treatment of hypertension. Drugs 1986;31:301–336.

32. Cornish LA. Guanfacine hydrochloride. A centrally acting antihypertensive agent. Clinical Pharmacy 1988;7:187–197.

33. Carchman SH, Crowe JT Jr, Wright GJ. T he bioavailability and pharmacokinetics of guanfacine after oral and intravenous administration to healthy volunteers. J Clin Pharmacol 1987;27:762–767.

34. Finnerty FA Jr, Brogden RN. Guanadrel. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic use in hypertension. Drugs 1985;30:22–31.

35. Campese VM. Minoxidil: a review of its pharmacological properties and therapeutic use. Drugs 1981;22:257–278.

36. Clissold SP, Heel RC. T opical minoxidil: a preliminary review of its pharmacodynamic properties and

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therapeutic efficacy in alopecia areata and alopecia androgenetica. Drugs 1987;33:107–122.

37. Duty S, Weston AH. Potassium channel openers. Pharmacological effects and future uses. Drugs 1990;40:785–791.

38. Golpon HA, Welte T , Hoeper MM. Pulmonary arterial hypertension: pathobiology, diagnosis, and treatment. Minerva Med 2005;96:303–314.

39. Hoeper MM. Drug treatment of pulmonary arterial hypertension: current and future agents. Drugs 2005;65:1337–1354.

40. Olschewski H, Rose F, Schermuly R, et al. Prostacyclin and its analogues in the treatment of pulmonary hypertension. Pharmacol T her 2004;102:139–153.

41. Velliquette R-A, Kossover R, Previs S-F, et al. Lipid-lowering actions of imidazoline antihypertensive agents in metabolic syndrome X. Naunyn Schmiedebergs Arch Pharmacol 2006;372:300–312.

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Chapter 30 Antihyperlipoproteinemics and Inhibitors of Cholesterol Biosynthesis Marc Harrold

T he Chem istry and Biochem istry of Plasm a Lipids T he major lipids found in the bloodstream are cholesterol, cholesterol esters, triglycerides, and phospholipids. An excess plasma concentration of one or more of these compounds is known as hyperlipidemia. Because all lipids require the presence of soluble lipoproteins to be transported in the blood, hyperlipidemia ultimately results in an increased concent ration of these transport molecules, a condition known as hyperlipoproteinemia. Hyperlipoproteinemia has been strongly associated with atherosclerotic lesions and coronary heart disease (CHD) (1,2). Before discussing lipoproteins, their role in cardiovascular disease, and agents to decrease their concentrations, it is essential to examine the biochemistry of cholesterol, triglycerides, and phospholipids.

Synthesis and Degradation of Cholesterol Cholesterol is a C 27 steroid that serves as an important component of all cell membranes and as the precursor for androgens, estrogens, progesterone, and adrenocorticoids (Fig. 30.1). It is synthesized from acetyl coenzyme A (CoA), as shown in Figure 30.2 (4). T he first stage of the biosynthesis is the formation of isopentenyl pyrophosphate from three acetyl CoA molecules. T he conversion of 3-hydroxy-3-methylglutaryl (HMG)–CoA to mevalonic acid is especially important, because it is a primary control site for cholesterol biosynthesis. T his reaction is catalyzed by HMG-CoA reductase and reduces the thioester of HMG-CoA to a primary hydroxyl group. T he second stage involves the coupling of six isopentenyl pyrophosphate molecules to form squalene. Initially, three isopentenyl pyrophosphate molecules are condensed to form farnesyl pyrophosphate, a C 15 intermediate. T wo farnesyl pyrophosphate molecules are then combined using a similar type of reaction. T he next stage involves the cyclization of squalene to lanosterol. T his process involves an initial epoxidation of squalene, followed by a subsequent cyclization requiring a concerted flow of four pairs of electrons and the migration of two methyl groups. T he final stage P.798 involves the conversion of lanosterol to cholesterol. T his process removes three methyl groups from lanosterol, reduces the side-chain double bond, moves the other double bond within the ring structure, and requires approximately 20 steps.

Squalene Synthase: A Potential Drug Target I nhibitors o f s q uale ne s ynthas e , the e nzyme re s po nsib le f o r c atalyzing the two -s te p c o nve rs ion o f two mo le cule s o f f arne s yl p yro pho sp hate to s q uale ne , are curre ntly b e ing inves tig ated as antihyp erlipid e mic ag e nts. Sq uale ne synthas e c atalyze s the f irst c o mmitted s te p in s te ro l bio s ynthes is and o f f e rs so me p o te ntial advantag es o ve r 3 -hyd ro xy-3 -methylglutaryl– c o enzyme A (HMG-Co A) re d uc tase as a d rug targ et. T he latter group o f co mpo und s inhib its cho les te ro l synthe s is at an early stag e of the p athway and , thus , lacks s p e cif ic ity. Me valo nic acid , the imme d iate p ro d uc t o f HMG -Co A re duc tas e , is a c o mmo n interme diate in the bio s ynthes is of othe r is op re no ids , s uc h as ub iq uino ne (an e le ctron c arrie r in o xidative pho sp horylatio n), do lic ho l (a c o mp ound invo lve d in o lig os acc harid e s ynthes is ), and f arnes ylate d p ro teins (the f arne s yl p o rtio n targ e ts the p ro te in to c e ll membrane as o p po s e d to the cyto so l). I nhib ito rs o f s q uale ne s ynthase targ et an e nzyme involve d in a later stag e of c hole s te rol b io s ynthes is and co uld po te ntially ac c omp lis h the s ame d es ire d outc o me s as curre ntly availab le ag e nts without inte rf e ring with the b io s ynthe sis o f o the r e s se ntial, no nste ro id al co mp o und s. One c lass o f c ompo und s c urrently und er inve s tig atio n are the s quales tatins . T he se c ompo und s we re originally is o late d as f e rmentatio n p ro d uc ts p ro duc ed b y a s p ec ie s o f Ph o m a . Sq uale s tatin 1 is a p o te nt inhibito r o f s q uale ne s ynthe tas e and has b ee n s ho wn to prod uce a marked d e cre as e in s e rum c ho le ste ro l. Ad d itional analog ue s as well as o the r s tructural c las s es c ontinue to b e inve stig ate d and, ultimate ly, may p ro d uc e alternative s to curre ntly availab le the rapy (5 ,6 ).

Clin ic al Sig nific an c e T he development and availability of cholesterol and triglyceride-lowering agents has evolved significantly over the past 10 to 15

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years. T he structure–activity relationships and structural modifications of bile acid sequestrants, fibrates, and 3-hydroxy3-methylglutaryl–coenzyme A reductase inhibitors form the basis for this evolution and the therapeutic advances that have resulted. T he most widely used cholesterol-lowering agents in cardiovascular medicine today are the “ statins” (vastatins). Lovastatin was the first statin to be used clinically on a large scale. Structural modifications of the early statin molecules have produced superior agents in terms of their pharmacokinetic profile, potency, drug interactions, and perhaps, selective adverse effects. T his has resulted in the widespread clinical use of superior agents, such as atorvastatin. Such agents have been demonstrated in randomized clinical trials to exert a potent effect in lowering low-density lipoprotein (LDL) cholesterol as well as an important anti-inflammatory action. T he net effect of applying basic science in modifying the chemical structure of cholesterol-lowering drugs is that patient outcomes such as death, myocardial infarction, and other cardiovascular events have been vastly improved. T his is clearly a situation in which the application of basic science has produced a profound effect on tens of millions of patients. T homas L. Rihn Pharm.D. Seni or Vi ce Presi dent and Chi ef Cl i ni cal Offi cer, Uni versi ty Pharmacotherapy Associ ates, Associ ate Professor of Cl i ni cal Pharmacy, Duquesne Uni versi ty, School of Pharmacy

Cholesterol is enzymatically transformed by two different pathways. As illustrated in Figure 30.1, cholesterol can be oxidatively cleaved by the enzyme desmolase (side chain–cleaving enzyme). T he resulting compound, pregnenolone, serves as the common intermediate in the biosynthesis of all other endogenous steroids. As illustrated in Figure 30.3, cholesterol also can be converted to bile acids and bile salts. T his pathway represents the most important mechanism for cholesterol catabolism. T he enzyme 7α-hydroxylase catalyzes the initial, rate-limiting step in this metabolic pathway and, thus, is the key control enzyme for this pathway. Cholic acid and its derivatives are primarily (99%) conjugated with either glycine (75%) or taurine (24%). Bile salts, such as glycocholate, are surface-active agents that act as anionic detergents. T he bile salts are synthesized in the liver, stored in the gallbladder, and released into the small intestine, where they emulsify dietary lipids and fat-soluble vitamins. T his solubilization promotes the absorption of these dietary compounds through the intestinal mucosa. Bile salts are predominantly reabsorbed through the enterohepatic circulation and returned to the liver, where they exert a negative feedback control on 7α-hydroxylase and, thus, regulate any subsequent conversion of cholesterol (4,7). T he terms “ bile acid” and “ bile salt” refer to the un-ionized and ionized forms, respectively, of these compounds. For illustrative purposes only, Figure 30.3 shows cholic acid as a un-ionized bile acid and glycocholate as an ionized bile salt (as the sodium salt). At physiologic and intestinal pH values, both compounds would exist almost exclusively in their ionized forms.

Overview of Triglycerides and Phospholipids T riglycerides (or, more appropriately, triacylglycerols) are highly concentrated stores of metabolic energy. T hey are formed from glycerol 3-phosphate and acylated CoA (Fig. 30.4) and accumulate primarily in the cytosol of adipose cells. When required for energy production, triglycerides are hydrolyzed by lipase enzymes to liberate free fatty acids that are then subjected to β-oxidation, the citric acid cycle, and oxidative phosphorylation. Phospholipids, or phosphoglycerides, are amphipathic compounds that are used to make cell membranes, generate second messengers, and store fatty acids for use in the generation of prostaglandins. T hey can be synthesized from phosphatidate, an intermediate in triglyceride synthesis. T wo common phospholipids, phosphatidyl choline and phosphatidyl inositol, are shown below (4).

Lipoproteins and Transport of Cholesterol and Triglycerides Cholesterol, triglycerides, and phospholipids are freely soluble in organic solvents, such as isopropanol, chloroform, and diethyl ether, but are relatively insoluble in P.799 P.800 aqueous, physiologic fluids. T o be transported within the blood, these lipids are solubilized through association with macromolecular aggregates known as lipoproteins. Each lipoprotein is associated with additional proteins, known as apolipoproteins, on their outer surface. T hese apolipoproteins provide structural support and stability, bind to cellular receptors, and act as cofactors for enzymes involved in lipoprotein metabolism. T he compositions and primary functions of the six major lipoproteins are listed in T able 30.1 (7,8).

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Fig. 30.1. Cholesterol's role as a key intermediate in the biosynthesis of endogenous steroids.

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Fig. 30.2. The biosynthesis of cholesterol.

Fig. 30.3. The conversion of cholesterol to bile acids and bile salts.

Fig. 30.4. The biosynthesis and metabolism of triglycerides.

Lipoprotein nomenclature is based on mode of separation. When preparative ultracentrifugation is used, lipoproteins are separated according to their density and identified as very-low-density lipoproteins (VLDLs), intermediate-density lipoproteins (IDLs), low-density lipoproteins (LDLs), and high-density lipoproteins (HDLs). When electrophoresis is employed in the separation, lipoproteins are designated as pre-β, β, and α. T he IDLs are mainly found in the pre-β fraction as a second electrophoretic band and are currently

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believed to be an intermediate lipoprotein in the catabolism of VLDL to LDL. Chylomicron remnants and IDLs may show similar electrophoretic and ultracentrifugation separation characteristics. In general, VLDL, LDL, and HDL correspond to pre-β, β, and α lipoprotein, respectively. T he interrelationship among the lipoproteins is shown in Figure 30.5 (7,8). As illustrated, the pathway can be divided into both exogenous (dietary intake) and endogenous (synthetic) components. T he exogenous pathway begins following the ingestion of a fat-containing meal or snack. Dietary lipids are absorbed in the form of cholesterol and fatty acids. T he fatty acids are then reesterified within the intestinal mucosal cells and, along with the cholesterol, are incorporated into chylomicrons, the largest lipoprotein. During circulation, chylomicrons are degraded into remnants by the action of lipoprotein lipase, a plasma membrane enzyme located on capillary endothelial cells in adipose and muscle tissue. T he interaction of chylomicrons with lipoprotein lipase requires apolipoprotein (apo) C-II, and the absence of either the enzyme or the apolipoprotein can lead to hypertriglyceridemia and pancreatitis. T he liberated free acids are then available for either storage or energy generation by these tissues. T he remnants are predominantly cleared from the plasma by liver parenchymal cells via recognition of the apoE portion of the carrier. P.801

Table 30.1. Classification and Characteristics of Major Plasma Lipoproteins

Classification

Composition

M ajor Apolipoproteins

Primary Function(s)

Chylomicrons

Triglycerides 80–95%, free cholesterol 1–3%, cholesterol esters 2–4%, phospholipids 3–9%, apoproteins 1–2%

apoA-I, apoA-IV, apoB-48, apoC-I, apoC-II, apoC-III

Transport dietary triglycerides to adipose tissue and muscle for hydrolysis by lipoprotein lipase.

Chylomicron remnants

Primarily composed of dietary cholesterol esters.

apoB-48, apoE

Transport dietary cholesterol to liver for receptor-mediated endocytosis.

VLDL


apoB-100, apoE, apoC-I, apoC-II, apoC-III

Transport endogenous triglycerides to adipose tissue and muscle for hydrolysis by lipoprotein lipase.

IDL

Intermediate between VLDL and LDL

apoB-100, apoE, apoC-II, apoC-III

Transport endogenous cholesterol for either conversion to LDL or receptor-mediated endocytosis by the liver.

LDL


apoB-100

Transport endogenous cholesterol for receptormediated endocytosis by either the liver or extrahepatic tissues.

HDL


apoA-I, apoA-II, apoE, apoC-I, apoC-II, apoC-III

Removal of cholesterol from extrahepatic tissues via transfer of cholesterol esters to IDL and LDL

apo, apolipoprotein; VLDL, very-low-density lipoprotein; IDL, intermediate-density lipoprotein; LDL, low-density lipoprotein; HDL, high-density lipoprotein.

T he endogenous pathway begins in the liver with the formation of VLDL. Similar to chylomicrons, triglycerides are present in a higher concentration than either cholesterol or cholesterol esters; however, the concentration difference between these lipids is much less than that seen in chylomicrons. T he metabolism of VLDL also is similar to chylomicrons in that lipoprotein lipase reduces the triglyceride content of VLDL and increases the availability of free fatty acids to the muscle and adipose tissue. T he resulting lipoprotein, IDL, either can be further metabolized to LDL or can be transported to the liver for receptor-mediated endocytosis. T his latter effect involves an

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interaction of the LDL receptor with the apolipoproteins, apoB-100 and apoE, on IDL. T he amount of IDL delivered to the liver is approximately the same as that converted to LDL. T he half-life of IDL is relatively short as compared to that of LDL and, thus, accounts for only a small portion of total plasma cholesterol. In contrast, LDL accounts for approximately two-thirds of total plasma cholesterol and serves as the primary source of cholesterol for both hepatic and extrahepatic cells. As with IDL, the uptake of LDL by these cells is mediated by a receptor interaction with the apoB-100 on LDL. T he number of LDL receptors on the cell surface mediates regulation of cellular LDL uptake. Cells requiring increased amounts of cholesterol will increase the biosynthesis of LDL receptors. Conversely, it has been demonstrated that increased hepatic concentrations of cholesterol will inhibit both HMG-CoA reductase as well as the production of LDL receptors. As previously discussed, hepatic cholesterol can be converted to bile acids and bile salts and reenter the endogenous pathway through the bile and enterohepatic circulation.

Fig. 30.5. Endogenous and exogenous pathways for lipid transport and metabolism. FFA, free fatty acids; LDLR, low-density lipoprotein receptor; FC, free unesterified cholesterol; LCAT, lecithincholesterol acyltransferase.

Synthesized in the liver and intestine, HDL initially exists as a dense, phospholipid disk composed primarily of apoA-I. T he primary function of HDL is to act as a scavenger to remove cholesterol from extrahepatic cells and to facilitate its transport back to the liver. Nascent HDL accepts free, unesterified cholesterol. A plasma enzyme, lecithin-cholesterol acyltransferase, then esterifies the cholesterol. T his process allows the resulting cholesterol esters to move from the surface to the core and results in the production of spherical HDL 3 particles. As cholesterol content is added, HDL 3 is converted P.802 to HDL 2 , which is larger and less dense than HDL 3 . T he ultimate return of cholesterol from HDL 2 to the liver is known as reverse cholesterol transport and is accomplished via an intermediate transfer of cholesterol esters from HDL 2 to either VLDL or IDL. T his process regenerates spherical HDL 3 molecules that can recirculate and acquire excess cholesterol from other tissues. In this manner, HDL serves to prevent the accumulation of cholesterol in arterial cell walls and other tissue and may serve as the basis for its cardioprotective properties (7,8).

Classification of Hyperlipoproteinemias Hyperlipoproteinemia can be divided into primary and secondary disorders. Primary disorders are the result of genetic deficiencies or mutations, whereas secondary disorders are the result of other conditions or diseases. Secondary hyperlipoproteinemia has been associated with diabetes mellitus, hypothyroidism, renal disease, liver disease, alcoholism, and certain drugs (1,7,8). In 1967, Fredrickson et al. (9) classified primary hyperlipoproteinemias into six phenotypes (I, IIa, IIb, III, IV, and V) based on which lipoproteins and lipids were elevated. Current literature and practice, however, appear to favor the more descriptive classifications and subclassifications listed in T able 30.2 Primary disorders are currently classified as those that primarily cause hypercholesterolemia, those that primarily cause hypertriglyceridemia, and those that cause a mixed elevation of both cholesterol and triglycerides. Subclassifications are based on the specific biochemical defect responsible for the disorder. Classifications developed by Fredrickson have been included in T able 30.2 under the heading Previ ous Cl assi fi cati on for comparative and reference purposes. As shown in T able 30.2, some disorders are well characterized, whereas others are not (1,7,8). Familial hypercholesterolemia is caused

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by a deficiency of LDL receptors. T his results in a decreased uptake of IDL and LDL by hepatic and extrahepatic tissues and an elevation in plasma LDL levels. T he homozygous form of this disorder is rare but results in extremely high LDL levels and early morbidity and mortality because of the total lack of LDL receptors. A related disorder, familial defective apoB-100, also results in elevated LDL levels but is caused by a genetic mutation rather than a deficiency. Alteration of apoB-100 decreases the affinity of LDL for the LDL receptor and thus hinders normal uptake and metabolism. Elevations in chylomicron levels can result from a deficiency of either lipoprotein lipase or apoC-II. T hese deficiencies cause decreased or impaired triglyceride hydrolysis and result in a massive accumulation of chylomicrons in the plasma. Dysbetalipoproteinemia results from the presence of an altered form of apoE and is the only mixed hyperlipoproteinemia with a known cause. Proper catabolism of chylomicron and VLDL remnants requires apoE. T he presence of a binding-defective form of apoE, known as apoE 2 , results in elevated levels of VLDL and IDL triglyceride and cholesterol levels.

Diseases and Disorders Caused by Hyperlipidem ias Coronary heart disease, which includes acute myocardial infarction, ischemic heart disease, and angina pectoris, is the leading cause of mortality in the United States. In 2002, more than 494,382 deaths were caused by CHD. Additionally, mortality from CHD often occurs rapidly, either in an emergency room or before hospitalization. T he highest mortality is seen in patients older than 65 years; however, the vast majority of deaths in patients younger than 65 years occur during an initial attack. Risk factors associated with CHD include hypertension, cigarette smoking, elevated plasma cholesterol levels, physical inactivity, diabetes, and obesity (10). Atherosclerosis, which is named from the Greek terms for “ gruel” (athere) and “ hardening” (scl erosi s), is the underlying cause of CHD. It is a gradual process in which P.803 an initial accumulation of lipids in the arterial intima leads to thickening of the arterial wall, plaque formation, thrombosis, and occlusion (11,12,13). T he involvement of LDL cholesterol in this process is shown in Figure 30.6. Within the extracellular space of the intima, LDL is more susceptible to oxidative metabolism, because it is no longer protected by plasma antioxidants. T his metabolism alters the properties of LDL such that it is readily scavenged by macrophages. Unlike normal LDL, the uptake of oxidized LDL is not regulated; thus, macrophage cells can readily become engorged with oxidized LDL. Subsequent metabolism produces free cholesterol, which either can be released into the plasma or reesterified by the enzyme acyl CoA–cholesterol acyltransferase (ACAT ). Cholesterol released into plasma can be scavenged by HDL 3 and returned to the liver, thus preventing any accumulation or damage. In this manner, HDL acts as a cardioprotective agent, because high concentrations of reesterified cholesterol can morphologically change macrophages into foam cells. Accumulation of lipid-engorged foam cells in the arterial intima results in the formation of fatty streaks, the initial lesion of atherosclerosis. Later, the deposition of lipoproteins, cholesterol, and phospholipids causes the formation of softer, larger plaques. Associated with this lipid deposition is the proliferation of arterial smooth muscle cells into the intima and the laying down of collagen, elastin, and glycosaminoglycans, leading to fibrous plaques. Ultimately, the surface of the plaque deteriorates, and an atheromatous ulcer is formed with a fibrous matrix, accumulation of necrotic tissue, and appearance of cholesterol and cholesterol ester crystals. A complicated lesion also shows calcification and hemorrhage with the formation of organized mural thrombi. T hrombosis results from changes in the arterial walls and in the blood-clotting mechanism.

Table 30.2. Characteristics of the M ajor Primary Hyperlipoproteinemias

Current Classification

Biochemical Defect

Elevated Lipoproteins

Previous Classification

Hypercholesterolemias Familial hypercholesterolemia

Deficiency of LDL receptors

LDL

IIa

Mutant apoB-100

LDL

IIa

Unknown

LDL

IIa

Familial hypertriglyceridemia

Unknown

VLDL

IV

Familial lipoprotein lipase deficiency

Deficiency of lipoprotein lipase

Chylomicrons, VLDL

I (chylomicron elevation only), V

Deficiency of apoC-II

Chylomicrons, VLDL

I (chylomicron elevation only), V

Familial defective apoB-100 Polygenic hypercholesterolemia Hypertriglyceridemias

Familial apoC-II deficiency

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Mixed hypercholesterolemia and hypertriglyceridemia Familial combined hyperlipidemia Dysbetalipoproteinemia

Unknown

VLDL, LDL

IIb

Presence of apoE 2 isoforms

VLDL, IDL

III

LDL, low-density lipoprotein; apo, apolipoprotein; VLDL, very-low-density lipoprotein; IDL, intermediate-density lipoprotein.

Fig. 30.6. The role of LDL cholesterol in the development of atherosclerotic plaques. The mechanism by which HDL provides a cardioprotective action also is shown.

Obviously, individuals with higher cholesterol and LDL levels are more susceptible to these detrimental effects than those with normal cholesterol and LDL levels. T otal plasma cholesterol levels less than 200 mg/dL are considered desirable. Levels above 240 mg/dL are considered high, and levels between 200 and 239 mg/dL are considered borderline. For LDL, plasma levels of less than 100 mg/dL are considered optimal, plasma levels equal to or greater than 160 are considered high, plasma levels between 130 and 159 mg/dL are considered borderline, and plasma levels between 100 and 129 are considered above optimal. Current guidelines (8,13) also recommend an LDL level below 70 mg/dL as a goal for very high-risk patients (i.e., those with multiple risk factors and known cardiovascular disease). Elevated plasma triglyceride levels can contribute to atherosclerosis and CHD in mixed hyperlipoproteinemias, whereas pure hypertriglyceridemias are primarily associated with pancreatitis and show little to no relationship to CHD (7,8).

ACAT: A Potential Drug Target I nhibitors o f acyl Co A– cho les te ro l acyltrans f e rase (ACAT ) are c urre ntly b eing inve stig ate d as cho le ste ro l-lo we ring o r antiathe ro sc le ro tic ag e nts . I n add itio n to its ro le in f o am ce ll f o rmatio n, ACAT als o is re quire d f o r e ste rif ic ation o f c hole s terol in intes tinal muc o sal c ells and f o r s ynthe sis o f c ho le s terol e s te rs in he patic VLD L f ormation. T hus , ACAT inhib ito rs have the p o te ntial o f p ro vid ing thre e b ene f ic ial e f f e c ts in p atients with hyp ercho les te ro lemia: de c re as e d c ho le s te ro l ab s o rption, d e creas ed he patic VL DL s ynthe sis , and d e creas ed f o am c e ll f o rmatio n. I nitial s uc ce s se s at inhib iting ACAT we re d ampe ne d b y the d is co ve ry o f acc o mp anying adrenal to xic ity. Sub se q uent s tructural mo d if ic atio ns have le ad to the de velo p me nt o f

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p o te nt, o rally ac tive ACAT inhibito rs (e .g ., CI 1 0 1 1), whic h lac k this to xic ity and have g iven new ho p e that inhib ito rs of this e nzyme may p ro vide an alte rnative tre atme nt of athe ro sc le ro tic d is orde rs (1 2 ,1 4).

P.804

Overview of Drug T herapy Affecting Lipoprotein Metabolism Bile acid sequestrants, HMG-CoA reductase inhibitors (HMGRIs), ezetimibe, fibrates, and niacin are all used in the treatment of hyperlipoproteinemia. In general, successful use of these compounds depends on proper identification and classification of the hyperlipoproteinemia affecting the patient. With the possible exceptions of niacin, atorvastatin, and rosuvastatin, currently available compounds do not have equal efficacy in reducing both hypercholesterolemia and hypertriglyceridemia and, thus, are used primarily for their ability to decrease either cholesterol or triglyceride levels. Bile acid sequestrants, inhibitors of HMG-CoA reductase, and ezetimibe are effective in decreasing plasma cholesterol and LDL levels. T he fibrates also have some actions on plasma cholesterol; however, their main effect is to stimulate lipoprotein lipase and to increase the clearance of triglycerides. Niacin, through its ability to decrease VLDL formation, has been shown to decrease the plasma levels of both triglycerides and cholesterol. All of these compounds are discussed below. References for these sections have been limited to current reviews and texts, selected papers, and product literature, both traditional and electronic. Readers requiring additional references for any of these compounds should consult either the previous edition of this text or the references contained within the cited reviews and texts.

Bile Acid Sequestrants Historical Overview Cholestyramine was originally developed in the 1960s to treat pruritus secondary to elevated plasma concentrations of bile acids in patients with cholestasis. Its ability to bind (i.e., to hold or to sequester) bile acids and to increase their fecal elimination was subsequently shown to produce beneficial effects in lowering serum cholesterol levels. In 1973, cholestyramine was approved for the treatment of hypercholesterolemia in patients who do not respond to dietary modifications. Colestipol and colesevelam, which retain the key structural features required to bind bile acids, were approved in 1977 and 2000, respectively (7,15). Cholestyramine, colestipol, and colesevelam are chemically classified as anion-exchange resins. T his term arises from their ability to selectively bind and exchange negatively charged atoms or molecules with one another. T he selectivity comes from the fact that these positively charged resins do not bind equally to all anions. For example, the chloride ion of cholestyramine can be displaced by, or exchanged with, other anions (e.g., bile acids) that have a greater affinity for the positively charged functional groups on the resin.

M echanism of Action Cholestyramine, colestipol, and colesevelam lower plasma LDL levels by indirectly increasing the rate at which LDL is cleared from the bloodstream. Under normal circumstances, approximately 97% of bile acids are reabsorbed into the enterohepatic circulation. As previously discussed, these compounds are returned to the liver where they regulate their own production. Bile acid sequestrants are not orally absorbed but, rather, act locally within the gastrointestinal tract to interrupt this process. T hey bind the two major bile acids, glycocholic acid and taurocholic acid, and greatly increase their fecal excretion. As a result, decreased concentrations of these compounds are returned to the liver. T his removes the feedback inhibition of 7α-hydroxylase and increases the hepatic conversion of cholesterol to bile acids (Fig. 30.3). T he decrease in hepatic cholesterol concentrations leads to several compensatory effects: increased expression of LDL receptors, increased hepatic uptake of plasma LDL, induction of HMG-CoA reductase, and increased biosynthesis of cholesterol. T he latter two effects are insufficient to counteract the increases in cholesterol clearance and catabolism; however, concurrent use of an HMGRI can provide an additive effect in lowering LDL cholesterol. Bile acid sequestrants do not alter the removal of plasma LDL by nonreceptor-mediated mechanisms and, thus, are ineffective in treating homozygous familial hypercholesterolemia (7,15,16,17). T he decreased return of bile acids to the liver also will produce an increase in triglyceride synthesis and a transient rise in VLDL levels. Subsequent compensatory mechanisms will increase VLDL removal, most likely through the increased LDL receptors, and return VLDL levels to predrug levels. For those patients with preexisting hypertriglyceridemia, the compensatory mechanisms are inadequate, and a persistent rise in VLDL levels occurs (7).

Structure–Activity Relationships Cholestyramine (Fig. 30.7) is a copolymer consisting primarily of polystyrene, with a small amount of divinylbenzene as the cross-linking

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agent. In addition, it contains approximately 4 mEq of fixed quaternary ammonium groups per gram of dry resin. T hese positively charged groups function as binding sites for anions. Virtually all of these sites are accessible to bile acids. Increasing the amount of divinylbenzene from 2 to 4 to 8% increases the cross-linkage and reduces the porosity of the resin. T his prevents binding of bile acids to interior sites and decreases the efficacy of the compound. Colestipol (Fig. 30.7) is a copolymer of tetraethylenepentamine and epichlorhydrin and is commercially marked as its hydrochloride salt. T he key functional groups on colestipol are the basic secondary and tertiary amines. Although the total nitrogen content of colestipol is greater than that of cholestyramine, the functional anion-exchange capacity of the resin depends on intestinal pH and may be less than cholestyramine. Recent in vitro studies indicate that cholestyramine has a higher adsorption capacity than colestipol for bile salts (18). Quaternization of colestipol with methyl iodide increases the capacity in vitro for glycocholate (19). P.805

Fig. 30.7. Structures of cholestyramine, colestipol, and precursors for these polymeric resins. Also included are the basic and quaternary functional groups found on colesevelam. Note that cholestyramine will contain a fraction of unsubsituted aromatic rings (i.e., those that are neither cross-linked nor contain a quaternary ammonium group).

Colesevelam is a more diverse polymer; however, its initial formation is similar to colestipol. In the case of colesevelam, poly(allyamine) is initially cross-linked with epichlorhydrin and then alkylated with 1-bromodecane and (6-bromohexyl)-trimethylammonium bromide. T he resulting polymer contains four basic and/or quaternary functional groups, as shown in Figure 30.7. Fragment A is a primary amine, fragment B is a pair of secondary amines, fragment C is an alkylated amine attached to a quaternary ammonium group, and fragment D is a decylated amine. T he overall polymer is a hydrophilic gel and is insoluble in water (7).

Physicochemical Properties All bile acid sequestrants are large, hygroscopic, water-insoluble resins. T he molecular weight of cholestyramine is reported to be greater than 1,000,000 daltons; however, no specific molecular weight has been assigned to either colestipol or colesevelam. Cholestyramine contains a large number of quaternary ammonium groups and, thus, has multiple permanent positive charges. Colestipol contains a large number of secondary and tertiary amines, whereas colesevelam contains quaternary ammonium groups as well as primary and secondary amines. Normal pK a values for the amines range from 9.0 to 10.5; thus, all of these groups should be primarily ionized at intestinal pH.

Pharmacokinetic Parameters, M etabolism, and Dosing Cholestyramine, colestipol, and colesevelam are not orally absorbed and are not metabolized by gastrointestinal enzymes. T hey are excreted in the feces as an insoluble complex with bile acids. T heir onset of action occurs within 24 to 48 hours; however, it may take up to 1 month to achieve peak response (7,15,20). Cholestyramine is available as a powder that is mixed with water, juice, or other noncarbonated beverages to create a slurry to drink. Patients should experiment with various liquids to find the most palatable combination; however, patient acceptance and compliance with this dosage formulation can limit its use. Each packet or scoop of cholestyramine is equivalent to 4 g of cholestyramine. T he recommended daily dose for the treatment of hypercholesterolemia is 8 to 16 grams (two to four packets or scoops) per day divided into two doses and taken with meals. T he maximum daily dose for hypercholesterolemia is 24 g. Colestipol is available as either granules or

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1-g tablets. T he granules should be taken in a manner similar to that described for the cholestyramine powder. T he starting dose for the granules is 5g once or twice daily. T his dose can be increased in 5g increments every 1 to 2 months until therapeutic goals or a maximum of 30 g/day have been reached. T he starting dose for the tablets is 2g once or twice daily. T his dose can then be increased in 2g segments up to a maximum daily dose of 16 g. Patients must be advised that colestipol tablets should not to be chewed, crushed, or cut and should be taken with plenty of water (15,21). Colesevelam is available as 625-mg tablets and should be taken with a meal. T he starting dose is three tablets (1.875 g) twice a day or six tablets (3.75 g) once a day. T he dose may be increased to a maximum of seven tablets per (4.375 g) per day. P.806

Unlabeled Uses Diarrhe a, dig italis to xicity, and p s eud ome mb rano us c o litis

Therapeutic Applications Bile acid sequestrants are indicated for the treatment of hypercholesterolemia in patients who do not adequately respond to dietary modifications. T hey may be used either alone or in combination with HMGRIs or niacin. T hese combinations often can achieve a 50% reduction in plasma LDL levels. Cholestyramine, but neither colestipol nor colesevelam, also is approved for the relief of pruritus associated with partial biliary obstruction. Bile acid sequestrants should not be used to treat hypertriglyceridemias or mixed hyperlipoproteinemias in which hypertriglyceridemia is the primary concern. T hese compounds also are contraindicated in patients with cholelithiasis or complete biliary obstruction because of the impaired secretion of bile acids caused by these conditions. Finally, cholestyramine and colestipol are contraindicated in patients with primary biliary cirrhosis, because this can further raise serum cholesterol (7,15,21).

Adverse Effects Because bile acid sequestrants are not orally absorbed, they produce minimal systemic side effects and, thus, are one of the safest drugs to use for hypercholesterolemia. Constipation is by far the most frequent patient complaint. Increasing dietary fiber or using bulk-producing laxatives, such as psyllium, often can minimize this adverse effect. Other gastrointestinal symptoms, such as bloating and abdominal discomfort, usually disappear with continued use; however, the possibility of fecal impaction requires that extreme caution be used in patients with preexisting constipation. All three of these compounds release chloride ions as part of their exchange mechanism and can cause hyperchloremic acidosis. T his is not a common occurrence, but it may limit the use of bile acid sequestrants in patients with renal disease. Hypoprothrombinemia and bleeding are caused by the ability of bile acid sequestrants to bind with and impair the absorption of dietary vitamin K. T hese effects also are rare, but they may limit the use of these agents in patients with preexisting clotting disorder and in those being concurrently treated with anticoagulants (2,7,15,21).

Drug Interactions Because of their mechanism of action, bile acid sequestrants can potentially bind with and decrease the oral absorption of almost any other drug. Because these anion-exchange resins contain numerous positive charges, they are much more likely to bind to acidic compounds than to basic compounds or nonelectrolytes. T his is not an absolute, however, because cholestyramine and colestipol have been reported to decrease the oral absorption of propranolol (a base) and the lipid-soluble vitamins, A, D, E, and K (nonelectrolytes). As a result, the current recommendation is that all other oral medication should be administered at least 1 hour before or 4 hours after cholestyramine and colestipol. Interestingly, this drug interaction has been used in a beneficial manner to treat digitalis overdose and toxicity.

Adv erse Effects of Bile Acid Sequestrants Blo ating , ab do minal dis c omf o rt, c o ns tip atio n, b owe l o b struc tio n, s te atorrhe a, ano re xia, c hole lithias is , pancreatitis , hyp e rc hlo re mic acid o s is , hyp o p ro thrombine mia, and b lee d ing.

Colesevelam appears to be less likely to interfere with the absorption of concurrently administered drugs. No significant decreases in absorption were seen when colesevelam was coadministered with either digoxin, lovastatin, warfarin, metoprolol, quinidine, or valproic acid. Because of potential interactions, especially for drugs with a low therapeutic index, the administration of drugs that have not been directly studied in combination with colesevelam should be spaced accordingly, as described above for cholestryamine and colestipol (7,15).

HMG-CoA Reductase Inhibitors Currently, six HMGRIs are approved for therapeutic use in the United States. Chemically, they can be divided into two groups, natural products and synthetic agents. All of these compounds effectively block the conversion of HMG-CoA to mevalonic acid and have similar effects on plasma cholesterol levels. T he compounds differ somewhat in their indications, potencies, and pharmacokinetic profiles. T hey often are referred to as statins or, more recently, vastatins. Because of the potential confusion of the terms “ statin” and “ statine” (i.e., a stable dipeptide mimic [see Chapter 28]), it is suggested here that classifying an HMGRI as a vastatin is preferable to classifying it as a statin.

Historical Overview and Development T he development and use of HMGRIs began in 1976 with the discovery of mevastatin. Originally named compactin, this fungal metabolite was isolated from two different species of Peni ci l l i um and demonstrated potent, competitive inhibition of HMG-CoA reductase. Its affinity for the enzyme was shown to be 10,000-fold greater than that of the substrate HMG-CoA (22). Several years later, a structurally similar compound was isolated from M onascus ruber and Aspergi l l us terreus. T his compound was originally known as

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mevinolin, was later renamed lovastatin, and was more than twofold more potent than mevastatin (Fig. 30.8). Structurally, it differed from mevastatin only by the presence of a methyl group at P.807 the 6′ position of the bicyclic ring. As illustrated in Figure 30.8, mevastatin and lovastatin can bind very tightly with HMG-CoA reductase, because their hydrolyzed lactones mimic the tetrahedral intermediate produced by the reductase enzyme (7). Studies published in 1985 confirmed this theory and also established that the bicyclic portions of these compounds bind to the CoA site of the enzyme (23). Clinical trials of mevastatin were halted after reports of altered intestinal morphology in dogs (24); however, lovastatin received approval by the U.S. Food and Drug Administration (FDA) in 1987, representing the first HMGRI to be available in the U.S. for therapeutic use.

Fig. 30.8. Mechanism of action of mevastatin and lovastatin. Hydrolysis of these pro-drugs produces a 3,5-dihydroxy acid that mimics the tetrahedral intermediate produced by HMG-CoA reductase.

Structure–Activity Relationship Mevastatin and lovastatin served as lead compounds in the development of additional HMGRIs. Initial research published by Merck Pharmaceuticals examined alterations of the lactone and bicyclic rings as well as the ethylene bridge between them. T he results demonstrated that the activity of HMGRIs is sensitive to the stereochemistry of the lactone ring, the ability of the lactone ring to be hydrolyzed, and the length of bridge connecting the two ring systems. Additionally, it was found that the bicyclic ring could be replaced with other lipophilic rings and that the size and shape of these other ring systems were important to the overall activity of the compounds (25). Minor modifications of the bicyclic ring and side-chain ester of lovastatin produced simvastatin and pravastatin (Fig. 30.9). Pravastatin, a ring-opened dihydroxy acid with a 6α-hydroxyl group, is much more hydrophilic than either lovastatin or simvastatin. Proposed advantages of this enhanced hydrophilicity are minimal penetration into the lipophilic membranes of peripheral cells, better selectivity for hepatic tissues, and a reduction in the incidence of side effects seen with lovastatin and simvastatin. (26,27).

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Fig. 30.9. Commercially available HMG-CoA reductase inhibitors.

T he replacement of the bicyclic ring with various substituted, aromatic ring systems led to the development of fluvastatin, atorvastatin, and rosuvastatin (Fig. 30.9). T he initial rationale centered on a desire to simplify the structures of mevastatin and lovastatin. T he 2,4-dichlorophenyl analogue (compound A) was one of the first compounds to demonstrate that this type of substitution was possible; however, compound A was considerably less potent than mevastatin. Subsequent research investigated a variety of aromatic substitutions and heterocyclic ring systems to optimize HMGRI activity. T he substituted pyrrole (compound B) retained 30% of the activity of mevastatin (28) and was a key intermediate in the development of atorvastatin. T he 4-fluorophenyl and isopropyl substitutions found in compound B also are seen in the indole and pyrimidine ring systems of fluvastatin and rosuvastatin, respectively, and most likely represent the optimum substitutions at their respective positions. T he design of all three of these compounds included the ring-opened dihydroxyacid functionality first seen in pravastatin.

P.808

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Table 30.3. Structure-activity Relationship of HIM G CoA Reductase Inhibitors

All HMGRIs can be chemically classified as 7-substituted-3,5-dihydroxyheptanoic acids, the general structure of which is shown in T able 30.3. Additionally, these compounds can be subclassified based on their lower ring. Compounds structurally related to the natural products mevastatin and lovastatin have structural features common to ring A, whereas those that are completely synthetic have structural features common to ring B (25,27,28,29,30,31,32,33,34,35).

M echanism of Action Inhibitors of HMG-CoA reductase lower plasma cholesterol levels by three related mechanisms: inhibition of cholesterol biosynthesis, enhancement of receptor-mediated LDL uptake, and reduction of VLDL precursors (15,21). As previously discussed, HMG-CoA reductase is the rate-limiting step in cholesterol biosynthesis. Inhibition of this enzyme causes an initial decrease in hepatic cholesterol. Compensatory mechanisms result in an enhanced expression of both HMG-CoA reductase and LDL receptors. T he net result of all these effects is a slight to modest decrease in cholesterol synthesis, a significant increase in receptor-mediated LDL uptake, and an overall lowering of plasma LDL levels. Evidence to support the theory that enhanced LDL receptor expression is the primary mechanism for lowering LDL levels comes from the fact that most statins do not lower LDL levels in patients who are unable to produce LDL receptors (i.e., homozygous familial hypercholesterolemia). T he increased number of LDL receptors also may increase the direct removal of VLDL and IDL. Because these lipoproteins are precursors to LDL, this action may contribute to the overall lowering of plasma LDL cholesterol. Finally, all HMGRIs can produce a modest (8–12%) increase in HDL (15). Atorvastatin, rosuvastatin, and simvastatin appear to have some effects beyond those seen with the other HMGRIs. T hese compounds have been shown to decrease plasma LDL levels in patients with homozygous familial hypercholesterolemia, an effect that is proposed to result from their ability to produce a more significant decrease in the hepatic production of LDL cholesterol. Additionally, atorvastatin and rosuvastatin can produce a significant lowering in plasma triglycerides. In the case of atorvastatin, this effect has been attributed to its ability to produce an enhanced removal of triglyceride-rich VLDL (15,36,37).

Physicochemical Properties In their active forms, all HMGRIs contain a carboxylic acid. T his functional group is required for inhibitory activity, has a pK a in the range of 2.5 to 3.5, and will be primarily ionized at physiologic pH. Lovastatin and simvastatin are neutral, lactone pro-drugs and should be classified as nonelectrolytes. Pravastatin, fluvastatin, and atorvastatin can be classified as acidic drugs. T he nitrogen atoms in the indole and pyrrole rings of fluvastatin and atorvastatin, respectively, are aromatic nitrogens that are not ionizable. T his is because the lone pair electrons of these atoms are involved in maintaining the aromaticity of their respective rings and are not available to bind protons. Rosuvastatin is technically an amphoteric compound; however, its pyrimidine ring is weakly basic and most likely will not be ionized at physiologic pH. T he calculated log P values for the HMGRIs are shown in T able 30.4. Although some variation exists among the values for lovastatin, pravastatin, and simvastatin, the general trends are the same regardless of what program was used to calculate the values. Atorvastatin, fluvastatin, and the pro-drugs lovastatin and simvastatin have a much higher lipid solubility than either pravastatin and rosuvastatin. Hydrolysis of the lactone ring for the two pro-drugs P.809 produces a 3,5-dihydroxycarboxylate with significantly improves water solubility.

Table 30.4. Pharmacokinetic Parameters of HM G-CoA Reductase Inhibitors

Drug

Time to Oral Protein Peak Calculated Bioavailability Binding Conc. Log Pa (%) Active M etabolite(s) (%)

Elimination M ajor Half-Life Route(s) of (hours) Elimination

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(hours) Atorvastatin

4.13

12–14

ortho- and para-hydroxylated

98

1–2

14–19

Biliary/fecal (>90%) Renal (95

2

3–4


Pravastatin

1.44 (0.5)b

17

None

43–55

1.0–1.5

2–3


Rosuvastatin

0.42

20

N-desmethyl

88

3–5

19–20


Simvastatin

4.42 (4.2)b

5

3,5-Dihydroxy acid

95

4

3


a

A commercial program was used for calculated values (45).

b

Calculated using the CLOG program (38).

T he HMG-CoA reductase enzyme is stereoselective. T he 3R,5R stereochemistry seen in the active forms of mevastatin and lovastatin (Fig. 30.8) is required for inhibitory activity and is present in all other HMGRIs. Stereochemistry of the substituents on the bicyclic rings of lovastatin, simvastatin, and pravastatin is less crucial to activity, as indicated in the summary of the structure–activity relationships (SARs).

M etabolism As previously mentioned, lovastatin and simvastatin are inactive pro-drugs that must undergo in vivo hydrolysis to produce their effects (Fig. 30.8). T he active forms of these two compounds as well as most HMGRIs undergo extensive first-pass metabolism (15,20,36,37). T he CYP3A4 isozyme is responsible for the oxidative metabolism of atorvastatin, lovastatin, and simvastatin. In the case of atorvastatin, the ortho- and para-hydroxylated metabolites are equiactive with the parent compound and contribute significantly to the overall activity of the drug (T able 30.4). Rosuvastatin is metabolized to a limited extent by CYP2C9 to form an N-desmethyl metabolite that can contribute to activity, but is sevenfold less potent. In contrast, the activity of lovastatin and simvastatin resides primarily in the initial hydrolysis product (i.e., further oxidation decreases activity). Fluvastatin is metabolized by the CYP2C9 and CYP3A4 isozymes to active hydroxylated metabolites; however, these metabolites do not circulate systemically and do not contribute to the overall activity. Pravastatin also undergoes oxidative metabolism, but the resulting compounds retain only minimal activity and are not significant. Neither pravastatin nor rosuvastatin is metabolized by CYP3A4; therefore, these drugs are potentially advantageous for patients who must take concurrent medication that alters the activity of this isozyme.

Pharmacokinetic Parameters T he pharmacokinetic parameters and dosing information for HMGRIs are summarized in T ables 30.4 and 30.5 respectively (2,7,15,20,21,36,38,39). With a few exceptions, all of these compounds have similar onsets of action, durations of action, dosing intervals, and plasma protein binding. Despite the ability to attain a peak P.810 plasma concentration in 1 to 4 hours, HMGRIs require approximately 2 weeks to demonstrate an initial lowering of plasma cholesterol. Peak reductions of plasma cholesterol occur after 4 to 6 weeks of therapy for most compounds. Studies with atorvastatin, however, indicate that it may only need 2 weeks to produce its peak reduction. Atorvastatin and rosuvastatin also are unique in that they have much longer durations of action than the other compounds. With the exception of pravastatin, which is one of the more hydrophilic

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compounds in this class, most HMGRIs bind extensively to plasma proteins.

Table 30.5. Dosing Information for HM G-CoA Reductase Inhibitors

Generic Name

Brand Name(s)

Dosing Range

M aximum Daily Dose

Tablet Dose Reduction with Strengths Renal Dysfunction (mg)

Atorvastatin

Lipitor

10–80 mg q.d.

80 mg

No

10, 20, 40,80

Fluvastatin

Lescol Lescol XR

20–80 mg q.d. or b.i.d.

80 mg

Caution in severe impairment

20, 40, 80 (XR)

Lovastatin

Mevacor Altoprev (XR)

20–80 mg q.d. or b.i.d.

80 mg (60 mg if XR) (20 mg with fibrate)

Yes

10, 20, 40, 60 (XR)

Pravastatin

Pravachol

10–40 mg q.d.

80 mg

Yes

10, 20, 40, 80

Resuvastatin

Crestor

5–40 mg q.d.

40 mg (10 mg with fibrate)


5, 10, 20, 40

Simvastatin

Zocor

5–40 mg q.d.

80 mg (10 mg with fibrate)


5, 10, 20, 40, 80

Because of first-pass metabolism, the oral bioavailability of this class of drugs generally is low and does not reflect the actual absorption of the individual drugs. For example, 60 to 80% of a dose of simvastatin is orally absorbed, but only 5% is actually available to produce an effect. T he same is true with fluvastatin, pravastatin, and lovastatin, which have oral absorptions of 90%, 34%, and 35%, respectively, but much lower bioavailabilities (T able 30.4). With the exception of lovastatin, the concurrent administration of food does not affect the overall therapeutic effects of HMGRIs. Lovastatin should always be administered with food to maximize oral bioavailability. Failure to do this results in a 33% decrease in plasma concentrations. In general, HMGRIs should be administered in the evening or at bedtime to counteract the peak cholesterol synthesis, which occurs in the early morning hours. Exceptions to this are atorvastatin and rosuvastatin, which because of their long half-lives are equally effective regardless of when they are administered. T he primary route of elimination of these compounds is through the feces. Because of extensive hepatic transformation and the ability to elevate hepatic enzymes, HMGRIs are contraindicated in patients with active hepatic disease or unexplained persistent elevations in serum aminotransferase concentrations. Dosage reductions in patients with renal dysfunction depend on the individual agent. Atorvastatin, which has minimal renal excretion, requires no dosage reduction and may be the best agent for patients with renal disorders. Fluvastatin, rosuvastatin, and simvastatin require dosage reductions only in cases of severe renal impairment and are better choices than lovastatin and pravastatin, which require dosage reductions in mild or moderate impairment.

Therapeutic Applications All HMGRIs are approved for the treatment of primary hypercholesterolemia and familial combined hyperlipidemia (Fredrickson's type IIa and IIb) (T able 30.2) in patients who have not responded to diet, exercise, and other nonpharmacological methods (T able 30.6) (15,21). T hey may be used either alone or in combination with bile acid sequestrants, ezetimibe, or niacin. As previously mentioned, they should be administered at least 1 hour before or 4 to 6 hours after bile acid sequestrants when this combination is desired. Fluvastatin, lovastatin, pravastatin, and simvastatin have been specifically indicated to reduce the mortality of CHD and stroke. By reducing plasma LDL levels, these compounds slow the progression of atherosclerosis and reduce the risk of myocardial infarction and other ramifications of vascular occlusion. Atorvastatin, rosuvastatin, and simvastatin have been shown to be effective in homozygous familial hyperlipidemia and are indicated for this use. Additionally, atorvastatin, pravastatin, and simvastatin are indicated for primary dysbetalipoproteinemia (Fredrickson's type III) (T able 30.2). Finally, atorvastatin, pravastatin, rosuvastatin, and simvastatin are indicated for the treatment of hypertriglyceridemia.

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Table 30.6. Approved Therapeutics Conditions for HMG CoA Reductase Inhibitors

Inhibitors of HMG-CoA reductase are contraindicated in pregnancy. Fetal development requires cholesterol as a precursor for the synthesis of steroids and cell membranes; thus, inhibition of its synthesis may cause fetal harm. Additionally, HMGRIs are excreted in breast milk and should not be used by nursing mothers.

Adverse Effects T he most prevalent or significant side effects of HMGRIs are listed below (7,15,21). In general, this class of drugs is well tolerated. Gastrointestinal disturbances are the most common complaint; however, these and other adverse reactions tend to be mild and transient. Elevations in hepatic transaminase levels can occur with all HMGRIs. T hese increases usually occur shortly after the initiation of therapy and resolve after the discontinuation of medication. P.811 In a small percentage of patients, these levels can increase to more than threefold the upper limit of normal. T herefore, liver function tests should be done at the initiation of therapy, at 6 and 12 weeks after the initiation of therapy, and at periodic intervals (e.g., every 6 months) thereafter. Similar testing should be done with dosage increases. Approximately 5 to 10% of patients will experience mild increases in creatine phosphokinase levels; however, less than 1% will develop symptoms of myalgia and myopathy (e.g., fever, muscle aches or cramps, and unusual tiredness or weakness). T ests for creatine phosphokinase levels should be performed in patients reporting muscle complaints. Rhabdomyolysis (i.e., massive muscle necrosis with secondary acute renal failure) has occurred, but this is rare. T he risk of this very serious adverse effect increases when an HMGRI is taken with certain other medications, such as cyclosporine, erythromycin, niacin, or fibrates (T able 30.7). Specific dosage reductions have been suggested for the combination use of fibrates with lovastatin, rosuvastatin, or simvastatin. Despite reports that some HMGRIs present more of a risk of rhabdomyolysis than others, a U.S. FDA advisory statement in 2005 suggests that the risk is similar for all members of this drug class (15).

Combination Products That Include an HMGRI HMGR I and antithro mb o tic Pravastatin/asp irin (Pravig ard PAC) HMGR I and c alc ium channe l b loc ke r Atro vas tatin/amlo d ipine (Cadue t) HMGR I and add itio nal antihype rc hole s te ro lemic ag ent L ovas tatin/niac in (Ad vico r) Simvas tatin/e zetimib e (Vyto rin)

Potential Nonlipid-Lowering Uses of HMGRIs Ce llular me tab o lite s d e rived f rom me valo nic acid are re quire d f o r c ell p ro lif e ratio n. C ho le ste ro l is an e s se ntial c o mp o ne nt o f c e ll me mb rane s , f arnes yl p yro pho s phate is re q uired to c o valently bind to intrac e llular p ro te ins and mod if y their f unc tion, ub iquinone is re quire d f o r mito c ho ndrial e le ctron transp o rt, and d o licho l p ho s phate s are re q uire d f o r g lyco p ro tein s ynthes is . F arnes yl pyro p ho s phate (F ig. 3 0 .2 ) is an inte rme d iate in the b io synthe s is o f c ho les te ro l, ub iq uino ne, and do lic ho l p hos p hate s. Bas ed o n the ir s ite o f ac tio n, HMGRI s will d e cre ase the availab ility of all f o ur o f the se c omp ounds and , thus, d e c re as e ce ll p ro lif e ration. Po te ntial ap plic ations o f this antipro lif e rative e f f e c t includ e the p re ve ntion o f re s te no s is f ollo wing angio p lasty, p re ventio n o f g lo me rular injury in renal dis e as e , tre atme nt of malignant d is eas e , and p reve ntio n o f o rg an transp lantatio n re je c tion (4 0 ).

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Adv erse Effects of HMGRIs Co nstip atio n, f latule nc e , d ys p ep s ia, ab d ominal p ain, d iarrhea, naus ea, vo miting , he ad ache , rhinitis , s inus itis, ele vate d hep atic e nzyme s, arthralg ia, myalg ia, myo p athy, musc le c ram ps , rhabd o myo lys is, and che st p ain

Drug Interactions Drug interac tio ns f o r HMGRI s are lis te d in T ab le 3 0 .7

Ezetim ibe, a Cholesterol Absorption Inhibitor Historical Overview T he discovery of ezetimibe and its mechanism of action began with a desire to develop novel ACAT inhibitors, a potential target for hypercholesterolemia described earlier in this chapter (41). Compound C was one of the initial azetidinones tested for the ability to inhibit ACAT and to lower plasma cholesterol. Interestingly, this compound's ability to decrease plasma cholesterol exceeded its ability to inhibit ACAT . Further SAR studies resulted in the development of compound D and confirmed that the cholesterol-lowering activity of this class of compounds was independent of its ability to inhibit ACAT . Using compound D as a lead, as well as in vivo data suggesting that metabolic transformations produced the active compound ultimately responsible for the cholesterol lowering effect, structural modifications were made that, eventually, led to the development of ezetimibe. T he most important changes involved the introduction of hydroxyl groups to help localize the compound in the intestine and the introduction of p-fluoro groups to block undesirable metabolism.

M echanism of Action Ezetimibe lowers plasma cholesterol levels by inhibiting the absorption of cholesterol at the brush border of the small intestine (15). Specifically, it has been proposed to bind to a specific transport protein located in the wall of the small intestine, resulting in a reduction of cholesterol transport and absorption (42). Ezetimibe appears to be selective in its actions in that it does not interfere with the absorption of triglycerides, lipid-soluble vitamins or other nutrients. T he decreased absorption of cholesterol P.812 eventually leads to enhanced receptor-mediated LDL uptake similar to that seen with bile acid sequestrants and HMGRIs. When used as monotherapy, the decreased absorption of cholesterol causes a compensatory increase in cholesterol biosynthesis. T his is similar to that described for bile acid sequestrants and is insufficient to override the overall LDL lowering effects of ezetimibe.

Table 30.7. Drug Interactions for HM G-CoA Reductase Inhibitors (HM GRIs)

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Drug

HM GRIs


Amiodarone

Lovastatin, Simvastatin

Increased risk of myopathy

Antacids

Atorvastatin, Rosuvastatin

Decreased levels of atorvastatin rosuvastatin; no change in plasma LDL reduction; administer rosuvastatin at least 2 hours after antacid

Azole antifungal agents

All

Increased risk of severe myopathy or rhabdomyolysis; increased plasma levels of atorvastatin, lovastatin, and simvastatin because of inhibition of CYP3A4; additive decreases in concentrations or activity of endogenous steroid hormones

Bile acid sequestrants

All

Decreased bioavailability of HMGRI if administration is not adequately spaced

Cimetidine

Fluvastatin

Increase in plasma fluvastatin levels

Cyclosporine

All

Increased risk of severe myopathy or rhabdomyolysis

Danazol

Lavastatin


Digoxin

Atorvastatin, Fluvastatin, Simvastatin

Slight elevation in plasma concentrations of digoxin

Diltiazem

Atorvastatin, Lovastatin, Simvastatin

Increased risk of severe myopathy

Erythromcyin Clarithromycin

All

Increased risk of severe myopathy or rhabdomyolysis; increased plasma levels of atorvastatin, lovastatin, and simvastatin because of inhibition of CYP3A4

Ethanol

Fluvastatin, Lovastatin

Increased risk of hepatotoxicity

Fibrates

All


Grapefruit juice (>1 quart/day)


Elevated plasma levels of the HMGRIs and increased risk of myopathy

HIV protease inhibitors


Elevated plasma levels of the HMGRIs and increased risk of myopathy

Isradipine

Lovastatin

Increased clearance of lovastatin and its metabolites

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Niacin

All


Omeprazole

Fluvastatin


Oral contraceptives

Atorvastatin, Rosuvastatin

Increased plasma concentrations of norethindrone and ethinyl estradiol

Phenytoin

Fluvastatin

Increased plasma concentrations of both compounds because of CYP2C9 interaction

Ranitidine

Fluvastatin


Rifampin

Fluvastatin

Increased plasma clearance of fluvastatin

Ritonavir, Squinavir

Pravastatin

Decreased plasma levels of pravastatin

Spironolactone

All

Additive decreases in concentrations or activity of endogenous steroid hormones

St. John's wort

Lovastatin, Simvastatin

Decreased HMGRI plasma levels

Warfarin

Fluvastatin, Lovastatin, Rosuvastatin, Simvastatin

Anticoagulant effect of warfarin may be increased

Physicochemical Properties Ezetimbie is a crystalline powder that is practically insoluble in water but is freely soluble in ethanol and other organic solvents. Its calculated log P value is 3.50 (38). T he phenol present in ezetimibe allows this compound to be classified as an acidic compound; however, the phenol has a pK a of 9.72 and is predominantly un-ionized at physiologic pH.

M etabolism Following oral administration, ezetimibe is rapidly and extensively metabolized in the intestinal wall and the liver to its active metabolite, a corresponding phenol glucuronide. T his glucuronide is reexcreted in the bile back to its active site. A small amount (< 5%) of ezetimibe undergoes oxidation to covert the benzylic hydroxyl group to a ketone; however, ezetimibe does not appear to exert any significant effect on the activity of CYP450 enzymes (15,20,42).

Pharmacokinetic Parameters Ezetimibe is administered orally; however, its absolute bioavailability cannot be determined because of its aqueous insolubility and the lack of an injectable formulation. Based on area under the curve values, the oral absorption ranges from 35 to 60%. Mean peak concentrations of the active glucuronidated metabolite are reached within 1 to 2 hours. Both ezetimibe and its glucuronide conjugate are extensively bound (> 90%) to plasma proteins. T he relative plasma concentrations of ezetimibe and its glucuronide conjugate range from 10 to 20% and from 80 to 90%, respectively. Both compounds have a long half-life of approximately 22 hours. T he coadministration of food with ezetimibe has no effect on the extent of absorption. P.813

Table 30.8. Drug Interactions for Ezetimibe Drug Antacid

Result of Interaction Aluminum and magnesium-containing antacids decrease the C max of ezetimibe

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Bile Acid Sequestrants

Decreased bioavailability of ezetimibe if administration is not adequately spaced

Cyclosporine

Increased ezetimibe concentration.

Fibrates

Increased ezetimibe concentration and possible increased risk of cholelithiasis. Concomitant use is not recommended.

T he normal dose of ezetimibe is 10 mg once daily. Dosage reduction for patients with renal impairment, intermittent hemodialysis, or mild hepatic impairment is not necessary. Because of insufficient data, the use of ezetimibe is not recommended in patients with moderate to severe hepatic impairment (15,20,21).

Therapeutic Applications Ezetimibe is indicated as monotherapy or in combination with an HMGRI for the reduction of elevated total cholesterol, LDL cholesterol, and apoB in patients with primary (heterozygous familial and nonfamilial) hypercholesterolemia. When used as monotherapy, ezetimibe reduces LDL cholesterol by approximately 18%. When used in combination therapy with an HMGRI, LDL levels are reduced by 25 to 65% depending on the dose of the HMGRI inhibitor. Ezetimibe also is indicated for homozygous familial hypercholesterolemia in combination with either atorvastatin or simvastatin and for homozygous familial sitosterolemia. All indications are for patients who have not responded to diet, exercise, and other nonpharmacological methods.

Adv erse Effects of Ez etimibe Ab d o minal p ain, d iarrhea, arthralgia, b ack p ain, c oug h, pharyng itis, s inus itis , f atigue , and viral inf e c tion

Adverse Effects Ezetimibe generally is well tolerated. T he most common adverse effects are listed above. Whenever ezetimibe is used in combination with an HMGRI, the incidence of myopathy or rhabdomyolysis does not increase above that seen with HMGRI monotherapy (15,21). Drug interactions for ezetimibe are listed in T able 30.8.

Fibrates Historical Overview and Development T he use of this class of drugs to treat hyperlipoproteinemias can be traced back to 1962 and, thus, predates the use of bile acid sequestrants and HMGRIs. A random screening test on a series of aryloxyisobutyric acids demonstrated that these compounds could lower both plasma cholesterol and total lipid levels (43). T he compound that produced the best balance between activity and toxicity was ethyl p-chlorophenoxyisobutyrate (Fig. 30.10). Later renamed clofibrate, this compound was subsequently shown to be a pro-drug for p-chlorophenoxyisobutyric acid (clofibric acid). It was approved for therapeutic use in 1967, and for a time, it was a very popular and widely prescribed drug. Results from a 1978 World Health Organization trial changed the acceptance of clofibrate and dramatically decreased its use. T hese trials indicated that despite a 9% lowering of cholesterol, patients taking clofibrate showed no reduction of P.814 cardiovascular events and actually had an increase in overall mortality (7). Although clofibrate is no longer available in the United States, it has served as the prototype for the design of safer and more effective fibrates. Structural modifications, focused primarily on ring substitutions and the addition of spacer groups, have produced a number of active compounds (Fig. 30.10). Gemfibrozil and fenofibrate became available for therapy in 1981 and 1998, respectively. Fenofibrate was actually approved in 1993; however, its marketing was voluntarily delayed until a more bioavailable, micronized formulation of the drug was available (44). Both of these compounds are safer and more effective than clofibrate in lowering plasma triglyceride levels and increasing plasma HDL levels. Additional compounds, such as ciprofibrate and bezafibrate, are not currently available in the United States but have been used in other countries.

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Fig. 30.10. Bioactivation of clofibrate and chemical structures of other fibrates.

M echanism of Action Overall, fibrates decrease plasma triglyceride levels much more dramatically than they decrease plasma cholesterol levels. T hey significantly decrease VLDL levels, cause a moderate increase in HDL levels, and have variable effects on LDL concentrations. As an example of this latter point, gemfibrozil will raise LDL levels in patients with hypertriglyceridemia but lower LDL levels in patients with normal triglyceride levels. T he exact mechanisms for these actions have not been fully elucidated; however, studies have shown that this class of compounds can produce a variety of beneficial effects on lipoprotein metabolism. Many of these effects have been proposed to be mediated through the activation of peroxisome proliferator-activated receptors (PPARs) and an alteration of gene expression. Specifically, fibrates bind to PPARα (7,15,27,44). Decreases in plasma VLDL primarily result from the ability of these compounds to stimulate the activity of lipoprotein lipase, the enzyme responsible for removing triglycerides from plasma VLDL (Fig. 30.5). Additionally, fibrates can lower VLDL levels through PPARαmediated stimulation of fatty acid oxidation, inhibition of triglyceride synthesis, and reduced expression of apoC-III. T his latter effect enhances the action of lipoprotein lipase, because apoC-III normally serves as an inhibitor of this enzyme. Favorable effects on HDL levels appear to be related to increased transcription of apoA-I and apoA-II as well as a decreased activity of cholesteryl ester transfer protein. All fibrates accelerate the turnover and removal of cholesterol from the liver. T his increases the biliary secretion of cholesterol, enhances its fecal excretion, and may cause cholelithiasis (i.e., gallstone formation).

Structure–Activity Relationships Fibrates can be chemically classified as analogues of phenoxyisobutyric acid. Literature references to the SARs for this class of drugs are sparse; however, all compounds are analogues of the following general structure.

T he isobutyric acid group is essential for activity. Fenofibrate, which contains an ester, is a pro-drug and requires in vivo hydrolysis. Substitution at the para position of the aromatic ring with a chloro group or a chlorine containing isopropyl ring produces compounds with significantly longer half-lives. Although most compounds contain a phenoxyisobutyric acid, the addition of an n-propyl spacer, as seen in gemfibrozil, results in an active drug.

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Physicochemical Properties Similar to HMGRIs, the active forms of all fibrates contain a carboxylic acid. T he pK a of this functional group on clofibric acid is reported to be 3.5 (45) and, thus, will be primarily ionized at physiologic pH. Although not reported, the pK a and ionization values of gemfibrozil and fenofibric acid can reasonably be assumed to be similar. Both clofibrate and fenofibrate are neutral, ester pro-drugs and should be classified as nonelectrolytes. Gemfibrozil can be classified as an acidic drug. T he calculated log P values for fenofibrate and gemfibrozil are shown in T able 30.9 (45). Both compounds are highly lipid soluble despite the fact that gemfibrozil contains a water-soluble carboxylic acid. T his can be partially explained by examining the π values for the substituents on fenofibrate and gemfibrozil (46). T he 2,5-dimethyl ring in gemfibrozil is predicted to be much more hydrophobic than the 4-chloro ring of fenofibrate. Additionally, the propyl bridge seen in gemfibrozil, but not in fenofibrate, significantly adds to its hydrophobicity. T he isopropyl ester as well as the additional aromatic ring account for the enhanced lipid solubility of fenofibrate. All currently available fibrates are achiral molecules and not subject to stereochemical concerns.

Table 30.9. Pharmacokinetic Parameters of Fibrates

Drug

Oral Calculated Bioavailability Active Log P (%) M etabolite

Time to Protein Peak Elimination M ajor Binding Conc Half-Life Route(s) of (%) (hrs) (hrs) Elimination

Fenofibrate

5.24

60-90

Fenofibric acid

99

4-8

20-22

Renal (60-90%) Fecal (5-25%)

Gemfibrozil

3.9

> 90

none

99

1-2

1.5

Renal (70%) Fecal (6%)

P.815

Table 30.10. Dosage Information for Fibrates Brand Generic Name Name

Dosing Range

M aximum Daily Dose

Dose Reduction with Renal Dysfunction

Tablet/Capsule Strengths (mg)

Fenofibrate

TriCor

48-145 mg q.d. 54-160 mg q.d. 67-200 mg q.d.

145mg 160 mg 200 mg


48, 145 54, 160 (generic) 67, 134, 200 (generic)

Gemfibrozil

Lopid

600 mg b.i.d.

1200 mg

Yes

600

M etabolism T he pro-drug fenofibrate undergoes rapid hydrolysis to produce fenofibric acid. T his active metabolite can then be further metabolized by oxidative or conjugative pathways. Gemfibrozil is slightly different in that it does not require initial bioactivation; however, similar to fenofibric acid, it can be oxidized or conjugated. Oxidation of the aromatic methyl groups produces inactive hydroxymethyl and carboxylic acid analogues. As a drug class, fibrates and their oxidized analogues are primarily excreted as glucuronide conjugates in the urine. Oxidization requires the CYP3A4 isozyme; however, because of the ability of these compounds to be conjugated and eliminated either with or without oxidation, drug interactions with other compounds affecting the CYP3A4 system are less important here than with other drug classes.

Pharmacokinetic Parameters T he pharmacokinetic parameters and dosing information for the fibrates are summarized in T ables 30.9 and 30.10, respectively (7,15,20,21,45). T he pro-drug, fenofibrate, requires a longer time to reach peak concentrations compared with gemfibrozil. Because of differences in aromatic substitution, fenofibrate also has a much longer half-life than gemfibrozil. As previously mentioned, the 2,5-dimethyl substitution in gemfibrozil is much more susceptible to oxidative metabolism than the para-chloro group present in fenofibrate. Similar to HMGRIs, changes in lipid levels are not seen immediately, and up to 2 months may be required to reach maximal clinical effects and to determine the overall clinical efficacy.

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Fibrates have excellent bioavailability and are extensively bound to plasma proteins. Because food can significantly enhance their oral absorption, these compounds should be taken either with or just before meals. Fenofibrate was available in Europe and elsewhere as standard tablet and capsule formulations for many years before its approval and marketing in the United States, where it was introduced only after the development of a micronized formulation that allowed better oral absorption, a lower daily dose, and once-daily administration. A 67-mg dose of micronized fenofibrate is bioequivalent to a 100-mg dose of nonmicronized drug. Since that time, two additional tablet formulations have been developed. Abbott Laboratories currently markets T riCor as 48- and 145-mg tablets. T he 48-mg formulation is equivalent to previous 54- and 67-mg formulations, and the 145-mg tablet is equivalent to previous 160- and 200-mg formulations. As noted in T able 30.10, fenofibrate is currently available in all of these strengths. Renal elimination is the primary route through which these compounds are excreted from the body. Patients with mild renal dysfunction often can be managed with minor dosage adjustments, whereas those with severe impairment or renal failure may have to discontinue its use.

Therapeutic Applications Fibrates are approved to treat hypertriglyceridemia and familial combined hyperlipidemia (Fredrickson's type IIa, IIb, IV, and V) (T able 30.2) in patients who are at risk of pancreatitis and have not responded to dietary adjustments or in patients who are at risk of CHD and have not responded to weight loss, dietary adjustments, and other pharmacological treatment. T hey can be used either alone or in combination with niacin, bile acid sequestrants, or HMGRIs. If used with bile acid sequestrants, fibrates must be taken either 1 hour before or 4 to 6 hours after the sequestrant. As discussed previously and reemphasized below, caution should be used if fibrates are combined with HMGRIs. Fibrates are not effective in the treatment of hypertriglyceridemia associated solely to elevated chylomicron levels (Fredrickson's type I).

Adverse Effects T he most prevalent or significant side effects caused by the fibrates are listed below (7,15,21). Despite the potential to cause serious side effects, fibrates usually are well tolerated. Gastrointestinal complaints are the most common but do not usually cause discontinuation of therapy. In general, gemfibrozil and fenofibrate appear to be less problematic than the original compound, clofibrate. In fact, many of the concerns regarding fibrate therapy are based on the effects of clofibrate and the results of a 1978 clinical trial in which patients taking clofibrate had a significantly higher morbidity and mortality from causes other than CHD. T hese causes included malignancy, gallbladder disease, pancreatitis, and postcholecystectomy P.816 complications. Studies with gemfibrozil and fenofibrate have not shown similar increases; however, because all fibrates have similar pharmacological actions, cautions and contraindications generally are applied to the entire drug class. As an example, even though gemfibrozil and fenofibrate have not demonstrated a significant increase in gallbladder disease, as seen with clofibrate, all three of these compounds are contraindicated in patients with preexisting gallbladder disease or cholelithiasis. Similar to HMGRIs, fibrates can cause myopathy, myositis, and rhabdomyolysis. Although rare, the risk of these serious effects increases when these two classes of agents are used together. Fibrates also cause increases in plasma aspartate transaminase (AST ), alanine transaminase (ALT ), and creatine phosphokinase levels.

Unlabeled Uses Po lyme tab o lic s ynd ro me X (f eno f ib rate)

Adv erse Effects Ab d o minal p ain, d ysp e ps ia, nause a, vomiting , d iarrhea, c o ns tip atio n, cho le stas is, jaund ic e, cho lelithiasis , p anc re atitis , he ad ache , d izzine s s, d ro ws ine s s, blurre d vis io n, me ntal d e pres s ion, imp o te nc e , d ec re ase d lib ido , myo p athy, myo s itis , rhab do myo lys is, ane mia, leukop e nia, e o sino philia, p ruritus , and ras h

Drug interactions for fibrates are listed in T able 30.11.

Nicotinic Acid Historical Overview T he history of nicotinic acid (niacin) began in 1867, when it was first synthesized by oxidation of nicotine. T he name niacin was derived later from the words ni cotinic acid and vitami n in an effort to avoid confusing nicotinic acid and nicotinamide with nicotine. Although the terms “ niacin” and “ nicotinic acid” are today used interchangeably, only the more chemically descriptive term, “ nicotinic acid,” will be used in the following discussions.

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Discovery of the biochemical and pharmacological actions of nicotinic acid began in the early 1900s, when brewer's yeast was demonstrated to prevent pellagra in humans. T he subsequent isolation of nicotinic acid from brewer's yeast established its role as an essential dietary requirement. In the 1930s, its amide metabolite, nicotinamide, was isolated from liver extracts and found to be a +

required structural feature of nicotinamide adenine dinucleotide phosphate (NADP ), a cofactor involved in electron transport and intermediary metabolism (47). In 1955, Altschul et al. (48) observed that high doses of nicotinic acid lowered cholesterol levels in humans, an activity unrelated to its properties as a vitamin. Subsequent studies have shown that nicotinic acid also lowers serum triglyceride levels and is effective against a variety of hyperlipoproteinemias. None of these antihyperlipidemic effects are seen with nicotinamide.

M echanism of Action Nicotinic acid exerts a variety of effects on lipoprotein metabolism (7,16,49). One of its most important actions is the inhibition of lipolysis in adipose tissue. T his initial inhibition, like those of previously discussed antihyperlipidemic agents, produces a sequence of events that ultimately result in the lowering of plasma triglycerides and cholesterol. Impaired lipolysis decreases the mobilization of free fatty acids, thus reducing their plasma levels and their delivery to the liver. In turn, this decreases hepatic triglyceride synthesis and results in a decreased production of VLDL. Enhanced clearance of VLDL through stimulation of lipoprotein lipase also has been proposed to contribute to the reduction of plasma VLDL levels. Because LDL is derived from VLDL (Fig. 30.5), the decreased production of VLDL ultimately leads to a decrease in LDL levels. T he sequential nature of this process has been clinically demonstrated. T he reduction in triglyceride levels occurs within several hours after P.817 initiation of nicotinic acid therapy, whereas the reduction in cholesterol does not occur until after several days of therapy. Nicotinic acid also increases HDL levels because of a reduction in the clearance of apoA-I, an essential component of HDL. Unlike bile acid sequestrants and HMGRIs, nicotinic acid does not have any effects on cholesterol catabolism or biosynthesis.

Table 30.11. Drug Interactions for Fibrates Drug

Fibrate


Antidiabetic agents

All

Increased hypoglycemic effect through increased sensitivity and decreased glucagon secretion

Bexarotene

Gemfibrozil

Increased bexarotene plasma concentrations


All

Decreased bioavailability of fibrate if administration is not adequately spaced

Cyclosporine

Fenofibrate

Increased potential for neph rotoxicity

Ezetimibe

All

Increased ezetimibe concentration and possible increased risk of cholelithiasis; concomitant use is not recommended


All


Oral anticoagulants

All

Increased hypoprothrombinemic effect

Repaglinide

Gemfibrozil

Increased repaglinide plasma concentrations

Ursodiol

All

Increased hepatic cholesterol secretion which may increase the possibility of gallstone formation and counteract the effectiveness of ursodiol

Physicochemical Properties Nicotinic acid (niacin) is a stable, nonhygroscopic, white, crystalline powder. Its carboxylic acid has a pK a of 4.76 and, thus, is predominantly ionized at physiologic pH. T he pyridine nitrogen is a very weak base (pK a = 2.0) and, therefore, primarily exists in the un-ionized form. Nicotinic acid is freely soluble in alkaline solutions and has a measured log P of -0.20 at pH 6.0 (45).

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M etabolism +

+

Nicotinic acid is a B-complex vitamin that is converted to nicotinamide, NAD , and NADP . T he latter two compounds are coenzymes and are required for oxidation/reduction reactions in a variety of biochemical pathways. Additionally, nicotinic acid is metabolized to a number of inactive compounds, including nicotinuric acid and N-methylated derivatives. Normal biochemical regulation and feedback prevent large doses of nicotinic acid from producing excess quantities of NAD

+

+

and NADP . T hus, small doses of nicotinic acid, such as

those used for dietary supplementation, will be primarily excreted as metabolites, whereas large doses, such as those used for the treatment of hyperlipoproteinemia, will be primarily excreted unchanged by the kidney (15).

Pharmacokinetic Parameters Nicotinic acid is readily absorbed. Peripheral vasodilation is seen within 20 minutes, and peak plasma concentrations occur within 45 minutes. T he half-life of the compound is approximately one hour, thus necessitating frequent dosing or an extended-release formulation. Extended release tablets produce peripheral vasodilation within 1 hour, reach peak plasma concentrations within 4 to 5 hours, and have a duration of 8 to 10 hours. Dosing of nicotinic acid should be titrated to minimize adverse effects. An initial dose of 50 to 100 mg t.i.d. often is used with immediaterelease tablets. T he dose then is gradually increased by 50 to 100 mg every 3 to 14 days, up to a maximum of 6 g/day, as tolerated. T herapeutic monitoring to assess efficacy and prevent toxicity is essential until a stable and effective dose is reached. Similar dosing escalations are available for extended-release products, with doses normally starting at 500 mg once daily at bedtime. (7,15,21).

Therapeutic Applications Nicotinic acid is approved for the treatment of hyper-cholesterolemia, hypertriglyceridemia, and familial combined hyperlipidemia (Fredrickson's type IIa, IIb, IV, and V) (T able 30.2) in patients who have not responded to diet, exercise, and other nonpharmacological methods. It also is approved for nutritional supplementation, the prevention of pellagra, and as adjunct therapy for peripheral vascular disease and circulatory disorders. It is contraindicated in patients with hepatic disease and peptic ulcer disease. Additionally, because of its ability to elevate glucose and uric acid levels, especially when taken in large doses, nicotinic acid should be used with caution in patients who have or are predisposed to diabetes mellitus and gout (15,20,21).

Table 30.12. Drug Interactions for Nicotinic Acid Drug


Adrenergic blocking agents

Enhanced vasodilation and postural hypotension


Decreased bioavailability of nicotinic acid if administration is not adequately spaced

Ethanol

Potential enhanced hepatotoxicity and excessive peripheral or cutaneous vasodilation


Increased risk of myopathy and rhabdomyolysis

Vasodilating agents (calcium channel blockers, epoprostenol, nitrates)

Enhanced cutaneous vasodilation

Adverse Effects T he most common (and, often, dose-limiting) side effects of nicotinic acid treatment are cutaneous vasodilation (flushing and pruritus) and gastrointestinal intolerance, which may occur in 20 to 50% of treated patients. Flushing and pruritus are prostaglandin-mediated effects and may be prevented by taking aspirin or indomethacin before nicotinic acid. Gastrointestinal side effects, such as flatulence, nausea, vomiting, and diarrhea, can be minimized if nicotinic acid is taken either with or immediately after meals. As previously mentioned, all of these effects can be minimized by slowly titrating the dose of nicotinic acid. Hepatic dysfunction is one of the more serious complications of high dose nicotinic acid. Plasma AST , ALT , lactate dehydrogenase, and alkaline phosphatase levels often are elevated but usually return to normal when therapy is either adjusted or discontinued (7,15,21). Drug interactions for nicotinic acid are listed in T able 30.12.

Adv erse Effects of Niacin F lushing, pruritus , he ad ac he, naus e a, vo miting , diarrhe a, f latule nce , he patic dys f unc tio n, jaund ic e, hype rg lyce mia, hyp e ruric emia, b lurre d vis io n, and tac hyc ardia

P.818

Case Study

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Vic to r ia F . Ro c h e S. Willia m Zito MK is a 3 8-ye ar-o ld f emale with a his to ry of co nge nital card iomyo p athy that re s ulted in ao rtic value re p lac e me nt s urg ery 3 ye ars ag o. MK op te d f o r a me c hanic al valve and is now o n c hro nic co umadin antic o ag ulant the rap y and d oing we ll. She is a f ib ro myalgia p atie nt and manag e s he r p ain with o xyc od o ne , 5 mg as ne e d ed (no t to e xc e ed e ve ry 4 ho urs ). She manag es the c o ns tip atio n that has ac co mp anie d her re gular use o f o p ioid s with Se nna (two tab lets at b e dtime and two in the mo rning ). F e e ling s ome what help le ss ab out he r he alth situation, s he has b e g un tai-chi and yog a and to me d itate reg ularly, and s he has jo ined he r hus b and in his ve g etarian lif e style (he ' s the s o us -c hef at the wo rld -f amo us “ Meatle ss in Se attle ” res taurant). W hile d if f ic ult at f irs t, she now relig io us ly res tric ts he r intake o f f ats and c ho le ste ro l-ric h f o o ds . She has be e n taking St. J o hn's wo rt (p urc has ed at the loc al Health & Nutrition o utlet) f o r a mild , se lf -diag no s ed d e p re ss io n that she hop e s is te mp o rary. Af te r trying unsuc ce s sf ully f o r s eve ral ye ars to c o nc e ive a child , MK and he r hus b and are ac tive ly exp loring ado p tio n. At he r annual med ic al c hec kup , it was no te d that MK's to tal se rum c hole s te ro l and LD L le vels we re mild ly e le vate d , altho ugh he r trig lyc e rid es and HDL le ve ls we re ho vering aro und no rmal. G ive n he r c ardio vas c ular histo ry, the physic ian wis he s to imple me nt therap y to b ring her blo o d lipid s do wn to National Cho le stero l Ed ucatio n Prog ram (NCEP)-re c omme nd e d leve ls. 1. I d e ntif y the therap e utic p ro ble m(s) in whic h the p harmac ist's interve ntion may be ne f it the p atie nt. 2. I d e ntif y and p rio ritize the p atient-s p ec if ic f acto rs that must b e c ons ide re d to ac hieve the d e s ired the rape utic o utc omes . 3. Co nduc t a tho ro ugh and me c hanistic ally o rie nted s tructure – ac tivity analysis o f all the rap e utic alternative s p ro vid e d in this c as e . 4. Evaluate the SAR f ind ing s ag ains t the patie nt-sp e c if ic f ac to rs and d es ire d the rap eutic o utc o me s, and make a therap e utic d e cis io n. 5. Co uns e l yo ur p atie nt

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26. Sliskovic DR, Blankley CJ, Krause BR, et al. Inhibitors of cholesterol biosynthesis. 6. trans-5-[2-(-N-heteroaryl3,5-disubstituted-pyrazol-4-yl)ethyl/ethenyl]tetrahydro-4-hydroxy-2H-pyran-2-ones. J Med Chem 1992;35:2095–2103.

27. Bone EA, Davidson AH, Lewis CN, et al. Synthesis and biological evaluation of dihydroeptastatin, a novel inhibitor of 3-hydroxy3-methylglutaryl–coenzyme A reductase. J Med Chem 1992;35:3388–3393.

28. Roth BD, Ortwine DF, Hoefle ML, et al. Inhibitors of cholesterol biosynthesis. 1. trans-6-(2-Pyrrol-1-ylethyl)-4-hydroxypyran2-ones, a novel series of HMG-CoA reductase inhibitors. 1. Effects of structural modifications at the 2-and 5-positions of the pyrrole nucleus. J Med Chem 1990;33:21–31.

29. Hoffman WF, Alberts AW, Cragoe EJ Jr, et al. 3-Hydroxy-3-methylglutaryl–coenzyme A reductase inhibitors. 2. Structural modification of 7-(substituted aryl)-3,5-dihydroxy-6-heptenoic acids and their lactone derivatives. J Med Chem 1986;29:159–169.

30. Stokker GE, Alberts AW, Anderson PS, et al. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors. 3. 7-(3,5Disubstituted [1,1′-biphenyl]-2-yl)-3,5-dihydroxy-6-heptenoic acids and their lactone derivatives. J Med Chem 1986;29:170–181.

31. Heathcock CH, Davis BR, Hadley CR. Synthesis and biological evaluation of a monocyclic, fully functional analogue of compactin. J Med Chem 1989;32:197–202.

32. Lee T J, Holtz WJ, Smith RL, et al. 3-Hydroxy-3-methylglutaryl–coenzyme A reductase inhibitors. 8. Side chain ether analogues of lovastatin. J Med Chem 1991;34:2474–2477.

33. Hoffman WF, Alberts AW, Anderson PS, et al. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors. 4. Side chain ester derivatives of mevinolin. J Med Chem 1986;29:849–852.

34. Stokker GE, Alberts AW, Gilfillan JL, et al. 3-Hydroxy-3-methylglutaryl–coenzyme A reductase inhibitors. 5. 6-(Fluoren-9-yl)and 6-(fluoren-9-ylidenyl)-3,5-dihydroxyhexanoic acids and their lactone derivatives. J Med Chem 1986;29:852–855.

35. Procopiou PA, Draper CD, Hutson JL, et al. Inhibitors of cholesterol biosynthesis. 2. 3,5-Dihydroxy-7-(N-pyrrolyl)-6heptenoates, a novel series of HMG-CoA reductase inhibitors. J Med Chem 1993;36:3658–3662.

36. Atorvastatin—a new lipid-lowering drug. T he Medical Letter 1997;39:29–31.

37. Rosuvastatin—a new lipid-lowering drug. T he Medical Letter 2003;45:81–83.

38. Craig PN. Drug compendium. In: Hansch C, Sammes PG, T aylor JB, eds. Comprehensive Medicinal Chemistry, vol 6. Oxford: Permagon Press, 1990: 237–991.

39. Zocor (simvastatin) product literature. Merck, 1999.

40. Wheeler DC. Are there potential nonlipid-lowering uses of statins? Drugs 1998;56:517–522.

41. Clader JW. T he discovery of ezetimibe: a view from outside the receptor. J Med Chem 2004;47:1–9.

42. Kosoglou T , Statkevich P, Johnson-Levonas AO, et al. Ezetimibe: a review of its metabolism, pharmacokinetics, and drug interactions. Clin Pharmacokinet 2005;44:467–494.

43. T horp JM, Waring WS. Modification and distribution of lipids by ethyl chlorophenoxyisobutyrate. Nature 1962;194:948–949.

44. Hussar DA. New drugs of 1998. J Am Pharm Assoc 1999;39:170–172.

45. Values calculated by author using ACD/ChemSketch, Version 8.17, 2005. Obtained from Advanced Chemistry Development, Inc.

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Available at: http://www.acdlabs.com.

46. Hansch C, Leo A. Substituent constants for correlation analysis in chemistry and biology. New York: Wiley, 1979:49–54.

47. Garrett RH, Grisham CM. Biochemistry. Fort Worth, T X: Saunders College Publishing, 1995:468–473.

48. Altschul R, Hoffer A, Stephen JD. Influence of nicotinic acid on serum cholesterol in man. Arch Biochem 1955;54:558–559.

49. Drood JM, Zimetbaum PJ, Frishman WH. Nicotinic acid for the treatment of hyperlipoproteinemia. J Clin Pharmacol 1991;31:641–650.

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Chapter 31 Antithrombotics, Thrombolytics, Coagulants, and Plasma Extenders Matthias C. Lu Thom as L. Le m ke

Introduction Venous thromboembolism (VT E) is a complicating condition responsible for high morbidity and mortality in North America and Europe. T his disease commonly is linked to advanced age but has both hereditary and acquired risk factors, such as surgery, any form of trauma, and childbirth, associated with it. It encompasses the conditions of deep vein thrombosis (DVT ) and pulmonary embolism. In excess of 60,000 deaths annually are attributed to pulmonary embolism. Preventative therapy consists of the use of two different classes of antithrombotic agents, namely anticoagulants and antiplatelet drugs (1,2). Heparin was discovered serendipitously in 1916 by a young coal miner turned medical student, Jay McLean, while working in the research laboratory of Professor W.H. Howell (3). Its beneficial effects were not realized until the early 1970s, when Kakkar et al. (4) established in a prospective, double-blind trial that low doses of heparin can prevent DVT after major surgery. In 1933, Dr. K.P. Link discovered that hydroxycoumarins are contained in sweet clover after finding cattle hemorrhaging to death (3). T his discovery lead to the development of orally active anticoagulants for prophylaxis in VT E and other thrombotic disorders. Optimal therapy with warfarin and other coumarin derivatives are not easy, however, because of their narrow therapeutic indexes. T he need to carefully assess the benefit and risks for anticoagulation with frequent drug monitoring and dose adjustment also is troublesome (5). T hus, further development of novel antithrombotic agents with greater specificity on the coagulation cascade, with more predictable pharmacodynamic and pharmacokinetic profiles, and with fewer or no laboratory monitoring requirements is still needed for optimal treatment of thrombotic disorders (6,7). T hrombolytics, on the other hand, are drugs needed to dissolve the newly formed thrombi in conditions such as DVT , acute pulmonary embolism, or myocardial infarction. Because of their lack of specificity, however, these agents actually may cause internal bleeding and, thus, are contraindicated with the use of many other therapeutic agents. A variety of pathological and toxicological conditions can result in excessive bleeding from inadequate coagulation. Depending on the etiology and severity of the hemorrhagic episode, select coagulants that induce blood coagulation are therapeutically used to prevent excessive bleeding in these conditions. Plasma extenders and blood substitutes are used to maintain blood volume and blood circulation for resuscitation of severely anemic patients in emergency conditions. Although notable progress has been made in the development of oxygen-carrying blood substitutes that will someday bring effective replacements for whole blood into clinical practice, most still concentrate only on reproducing the function of hemoglobin, the molecule that carries oxygen through the body, and do not attempt to replicate the blood's other functions.

Disease States Requiring Antithrom botic T herapy A number of serious medical conditions are thrombotic in nature. In fact, in Western society, thrombotic conditions are the major cause of morbidity and mortality, and P.821 it is speculated that these disorders will be the leading cause of death worldwide within 20 years (1,8). As would be expected from the gravity of thrombotic disorders, many of the conditions involve the major vasculature, heart, brain and lungs.

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Clinical Significance T hrombotic disorders are among the most common causes of morbidity and mortality in the United States. More than 2 million people die each year from arterial or venous thrombosis or the consequences thereof. Antithrombotic and thrombolytic agents are the most commonly used pharmacological therapies to prevent and treat the whole spectrum of thrombotic disorders. T he management of patients with thrombotic disorders involves multidisciplinary specialties, such as medicine, pharmacy, and nursing. Approaching clinical thrombosis in a multidisciplinary manner has the ultimate goal of rendering the best possible care to our patients. Regardless of the discipline involved, mastering the basic chemical and pharmacological principles of the major drug classes used in the prevention and treatment of thrombotic disorders is the first and most critical step to implementing a successful treatment approach. Understanding the intricacies and the determinants of the coagulation cascade, along with the primary and secondary hemostatic and fibrinolytic pathways, allows us to clinically select and apply the best pharmacological agents targeted at these pathways. Furthermore, mastering the chemical and pharmacological properties of the various antithrombotic therapies is a necessary tool for clinicians involved in caring for patients with thrombosis. Often, selection of the safest and most effective therapeutic agent in certain specific patient circumstances will depend on our ability to differentiate among the characteristics of various options available. For example, in a patient with an allergic reaction to heparin (because of a suspected pork allergy), a good alternate anticoagulant for treatment of an acute thrombotic event is a synthetic agent, such as fondaparinux. In a patient with a deficiency of antithrombin (formerly known as antithrombin III), none of the heparin products or indirect factor Xa inhibitor products would work, because all of these have a mechanism of action dependent on Antithrombin. Alternate agents, such as direct inhibitors of thrombin, would need to be considered. In patients taking chronic warfarin therapy, dosing adjustments are made in increments of 5 to 20% of the patient's total weekly dose, because warfarin does not follow linear kinetics. Are there situations when using a combination of various antithrombotic agents would be appropriate? In certain indications, such as acute coronary syndromes, a combination of aspirin and clopidogrel is used, because these two agents have a complementary mechanism of action. T he examples given above show just a few scenarios of how some of the basic concepts presented in this chapter are applied in clinical practice and how they eventually will aid clinicians to apply this knowledge toward providing specific and tailored treatment plans for their patients. Edith A. Nute scu, Pharm .D. Cl i ni cal Associ ate Professor Di rector, Anti thrombosi s Center Col l ege of Pharmacy Uni versi ty of Il l i noi s at Chi cago

In the heart, a thrombotic condition may be involved in the disease state of acute myocardial infarction, valvular heart disease, unstable angina, and atrial fibrillation as well as surgical procedures, such as percutaneous transluminal coronary angioplasty and prosthetic heart valve replacement. T hrombotic conditions involving the vasculature include VT E, primary and secondary prevention of arterial thromboembolism, and peripheral vascular disease. T he most significant such condition involving the lungs is pulmonary embolism and, in the brain, cerebrovascular accidents. Anticoagulation therapy is indicated for all of these conditions.

Venous Thromboembolism and Pulmonary Embolism Venous thromboembolism occurs when red bloods cells, fibrin, and to a lesser extent, platelets and leukocytes coagulate to form a thrombus within an intact cardiovascular system (9). A patient undergoing orthopaedic surgery incurs the greatest risk for VT E (10). Pulmonary embolism occurs when a segment of a thrombus within the deep venous system detaches itself from the blood vessel, travels to the lungs, and lodges within the pulmonary arteries. Both of these conditions, if not

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properly detected and treated, can have serious consequences, such as sudden death or recurrent VT E and postthrombotic syndrome characterized by persistent pain, swelling, and skin discoloration or necrosis and ulceration of the affected limb (6,7).

Atrial Fibrillation Atrial fibrillation is the most common cardiac arrhythmia, being found in more than 2 million Americans. It is characterized as a storm of electrical energy that travels in spinning wavelets throughout the atria, causing the upper chambers to quiver or fibrillate. It also is one of the leading risk factors for ischemic stroke for those individuals older than 50 years (11,12,13). Atrial fibrillation is more prevalent in men than in women, and the median age of patients with atrial fibrillation is approximately 72 years. Anticoagulation with warfarin and lifestyle modification are the most effective treatment modalities for patients with atrial fibrillation. P.822

Pathophysiology of Throm bogenesis Arterial thrombosis usually is initiated by the exposure of the thrombogenic material as a result of spontaneous or mechanical rupture of an atherosclerotic plaque (6,14). Arterial thrombi usually form in medium-sized vessels as a result of surface lesions on endothelial cells roughened by atherosclerosis. In most cases, circulating platelets adhere to the areas of abnormal vascular endothelium. More platelets then aggregate with those stuck to the vascular wall, forming a clot known as an occlusive thrombus (14). T he formation of the occlusive thrombus at the site of the lesion is the major cause of complications of stroke and myocardial infarction. Venous thrombosis results from either an excessive activation of the coagulation cascade (hypercoagulability) or from some disease process or venous pooling (stasis) of the blood. Venous thrombus is initiated in the same fashion as the arterial thrombus formation, except that the bulk of the clot is formed of long fibrin tails that enmesh red blood cells. Venous thrombosis also can occur from vascular trauma caused by damage to the vessel wall, especially after major orthopedic surgery (9). Hypercoagulability, venous stasis, and vascular injury are known as Virchow's triad. As a general rule, arterial thrombi cause serious conditions through localized occlusive ischemia, whereas venous thrombi fragment give rise to pleural embolic complications.

Biochemical Mechanism of Blood Coagulation: The Coagulation Cascade T he formation of a blood clot is the result of an intricate and elegant cascade of biochemical events (Fig. 31.1).

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Fig. 31.1. The coagulation cascade. Circled factors are those inhibited by warfarin-like drugs; boxed factors are those affected by heparin. The star indicates the site of action of thrombolytic drugs, such as streptokinase and urokinase.

P.823

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Fig. 31.2. Structure of prothrombin. Thrombin is liberated through the cleavage of the Arg 274–Thr 275 and Arg 323–lle 324 peptide bonds (indicated by the stars). The γ-carboxyglutamate residues are in the released N-terminal portion of prothrombin and are not part of thrombin. The A and B chains of thrombin are joined by a disulfide bond.

T he coagulation in arteries or veins is triggered by tissue factor (T F), a small-molecular-weight glycoprotein that initiates the extrinsic clotting cascade. T he T F glycoprotein is expressed on the surface of macrophages, and T F is a major initiating factor of arterial thrombogenesis. T issue factor binds and activates factor VII to form T F/VIIa complex, which in turn activates factor IX and factor X from either the intrinsic or extrinsic pathways shown in Figure 31.1. Initiation of the intrinsic pathway involves the sequential activation of factors XII, XI, and IX. (T he activated form of a coagulation factor is indicated by a lowercase “ a.” ) In the presence of calcium, factor IXa binds to an activated factor VIII on the surface of activated platelets to form an intrinsic Xase complex, which initiates the activation of factor X to Xa. In addition, initiation of the extrinsic pathway involves activation of factor VII by T F to form T F/VIIa, which, like factor IXa, also catalyzes the conversion of factor X to Xa. T he underlying purpose of the intrinsic pathway is maintenance of homeostasis, whereas the extrinsic pathway is activated by trauma. T he intrinsic and extrinsic pathways come together with the conversion of factor X to its activated form, factor Xa. T he coagulation cascade is unique in that the product of a given reaction (i.e., activated form of a specific factor) catalyzes the activation of the next factor in the cascade. T he final steps in the coagulation cascade involve the conversion of prothrombin (factor II) to thrombin (factor IIa) by prothrombinase complex, consisting of factor Xa and activated factor V (Fig. 31.2). In turn, thrombin catalyzes the conversion of fibrinogen to soluble fibrin, which then becomes insoluble fibrin through the action of factor XIIIa. In its activated state, factor XIIIa actually is a transamidase enzyme. T his enzyme catalyzes the formation of isopeptide bonds between lysine and glutamine side chains of distinct fibrin molecules, resulting in cross-linked (insoluble) fibrin aggregates (Fig. 31.3) (15).

Strategies for Regulating Coagulation Coagulation can be regulated at several levels (6). T hese include T F pathway inhibitor (T FPI), antithrombin, and the protein C pathways. Because the design of many new anticoagulant drugs are aimed at enhancing endogenous anticoagulant or fibrinolytic mechanisms, a brief review of these pathways is warranted here. T issue factor pathway inhibitor is now recognized as a major physiological inhibitor of T F-initiated coagulation (16). Its main role is to modulate factor VIIa/T F catalytic activity by a two-step process. First, T FPI binds and inactivates factor Xa by forming a T FPI/factor Xa complex. T hen, the inactivated factor Xa/T FPI complex binds factor VIIa within the T F/VIIa complex to modulate its catalytic activity. Additionally, T FPI potentiates the effect of heparins (i.e., T FPI is released from the vascular endothelium after injection of either unfractionated heparin or low-molecular-weight heparins [LMWHs]), which may then provide high concentrations of T FPI at sites of tissue damage

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and ongoing thrombosis (17). T he propagation of coagulation occurs when T FPI concentrations are low (6). Antithrombin is a potent inhibitor of thrombin, factors IXa and Xa. It also has inhibitory actions on other activated clotting factors, including the T F/VIIa complex. In the absence of heparin, however, the action of antithrombin is slow. T he action of antithrombin is enhanced 1,000-fold in the presence of heparin. It should be pointed out that even though heparin is not normally found in the blood, the vascular endothelium is rich in heparin sulfate, which contains the antithrombin-binding pentasaccharide sequence of the heparin. Drugs such as fondaparinux and idraparinux block the propagation of coagulation by inactivating factor Xa and, thereby, inhibiting the thrombin formation (6). Direct P.824 thrombin inhibitors, such as hirudin and argatroban, work by inhibiting both the clot-bound and free thrombin and, thus, preventing fibrin formation, the final step in the coagulation cascade (6).

Fig. 31.3. Cross-linking of soluble fibrin monomers (factor la) through the activity of factor Xllla, a transamidase enzyme.

In the protein C pathway, thrombin also is inhibited by binding to thrombomodulin, a thrombin receptor found in the endothelium. On binding to thrombomodulin, thrombin changes conformation, converting it from a procoagulant into a potent activator of protein C, a vitamin K–dependent protein, which degrades and inactivates factors Va and VIIa, thereby attenuating thrombogenesis (18).

General Approaches to Anticoagulant T herapy Overview Because current clinically available antithrombotic drugs target only a few specific areas within the coagulation cascade, the selection of an appropriate anticoagulant for a given patient should be based on the patient's medical and drug history, age and location of the clot, underlying diagnosis of the disease state, and ultimate goal of the therapeutic intervention. If dissolving of an existing clot is needed, activation of plasminogen with the thrombolytic agents, which degrades insoluble fibrin, is the typical approach. If the therapeutic goal is prevention of thrombus formation or extension, however, inhibition of factor activation higher in the cascade with heparin and other oral anticoagulants is the most appropriate. An ideal anticoagulant should have reproducible pharmacodynamic and pharmacokinetic properties such that no coagulation monitoring is necessary. It also should have a wide therapeutic window, a rapid onset and offset of action, and minimal adverse effects, particularly with minimal interactions with food and other drugs.

Laboratory Assessment and M onitoring Anticoagulant drug dosing represents a fine balance between reducing the morbidity and mortality

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associated with the thrombotic condition and minimizing the risk of serious hemorrhage from excessive therapeutic anticoagulation. Because of the potentially life-threatening consequences of either inadequate or excessive anticoagulation, patients receiving antithrombotic medications, such as warfarin and unfractionated heparin, often are closely monitored with specific clinical laboratory assays. A baseline assessment of the patient's coagulation features is performed before the initiation of anticoagulant therapy. T his allows detection of congenital coagulation factor deficiencies, thrombocytopenia, hepatorenal insufficiency, and vascular abnormalities, which could prove to be catastrophic if anticoagulant therapy was instituted empirically. For monitoring oral anticoagulant therapy (i.e., vitamin K antagonists), the prothrombin time (PT ) is measured (19,20). T his test is used to assess the activity of the vitamin K–dependent clotting factors (II, VII, IX and X). T he PT is particularly sensitive to factor VII, which is not of great clinical significance in itself but serves as a rough estimate for the ability of the liver to synthesize proteins or the extent of vitamin K depletion from warfarin therapy. T he PT assay measures the time that it takes for a clot to form in citrated plasma after the addition of tissue thromboplastin and calcium. In normal (i.e., warfarin-free) plasma, this clot formation takes 10 to 13 seconds (19,20). Because of variances in commercially available thromboplastins, most clinical laboratories now report PT results in terms of international normalized ratios (INRs). Patients on warfarin therapy are optimally maintained with an INR of 2.0 to 3.0. In cases of patients who have had mechanical prosthetic heart valves placed, an INR of 2.5 to 3.5 often is recommended. At the initiation of warfarin therapy, daily PT 's are performed. As the drug dosage is adjusted appropriately based on these results, the length of time between PT assessments can be extended to weekly. Finally, after warfarin therapy has been optimized and the patient's PT results have stabilized within an acceptable range, monthly or bimonthly PT checks are reasonable. Heparin directly deactivates clotting factors II and X. T herapy with this drug is monitored based on the activated partial thromboplastin time (aPT T ) assay (19,20). T his assay monitors factors II and X as well as several others. Deficiencies of clotting factors that affect the aPT T result can be of little clinical significance (e.g., prekallikrein and factor XII), of potential clinical significance (e.g., factor XI), or of great clinical significance (e.g., factors VIII and IX and the hemophilic factors). In the aPT T assay, a surface activator, such as elegiac acid, kaolin, or silica, is used to activate the intrinsic pathway. When this activator comes in contact with citrated plasma in the presence of calcium and phospholipid, clot formation begins. As with the PT , the time taken for this clot to form is measured. In normal (nonheparinized) plasma, the average aPT T result is 25 to 45 seconds. A therapeutic aPT T in a patient receiving heparin typically is 70 to 140 seconds. In vivo, the platelet membrane rather than the phospholipid is the source of several clotting factors and the site of many of the coagulation reactions in the intrinsic pathway. T he phospholipid used in the aPT T assay does not completely substitute for the in vivo actions of the platelets. Although this phospholipid does potentiate the intrinsic pathway, it does so without activating factor VII. T his “ partial activation” of the intrinsic pathway is the genesis of the name of the assay (aPT T ). Several other laboratory assays are used to assess function at various points within the clotting cascade. Quantitative levels of fibrinogen and fibrin degradation products are used to assess the extent of the effects of conditions, such as acute inflammation, disseminated intravascular coagulation (DIC), and severe liver disease. T he specific clotting factors in which a given patient may be deficient also can be determined using various mixing studies (19,20). T hese assessments are far more specialized and performed much less frequently than the PT and aPT T .

Oral Anticoagulants T here are two different chemical classes of orally active anticoagulants, namely coumarin derivatives and 1,3-indandiones. P.825 It has been known since 1921 that cattle eating spoiled sweet clover hay often would die from uncontrollable bleeding after suffering a very minor injury. T his discovery and other subsequent findings eventually led to the isolation of bishydroxycoumarin (i.e., dicoumarol) in 1934 by Link and Campbell and its use in humans in 1954 as the first orally active anticoagulant drug (21).

Coumarin Derivatives Warfarin and other vitamin K antagonists have been the mainstay of oral anticoagulant therapy for

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more than 50 years. Although their effectiveness in the prophylaxis of thrombotic disorders has been established through many well-designed clinical trials, their usages in clinical practice are challenging because of their narrow therapeutic index, potential for drug–drug/food interactions, and patient variability that requires close assessment and drug monitoring (20).

Mechanism of Action Vitamin K antagonists, such as warfarin, produce their effect on blood coagulation by interfering with the cyclic interconversion of vitamin K and vitamin K 2,3-epoxide (Fig. 31.4) (22). Vitamin K is an essential cofactor necessary for the posttranslational carboxylation of the glutamic acid residues on the N-terminal portions of the specific clotting factors (II, VII, IX, and X) and anticoagulant proteins, such as protein C (22). T his γ-glutamyl carboxylation results in a new amino acid, γ-carboxyglutamate, which through chelation of calcium ions causes the proteins to undergo a conformational change. T his change in tertiary structure allows the four vitamin K–dependent clotting factors to become activated and bind to the negatively charged phospholipid membranes during clotting cascade activation. T he specific enzyme that carboxylates vitamin K–dependent coagulation factors requires a reduced form of vitamin K (vitamin K hydroquinone [KH 2 ]), molecular oxygen, and carbon dioxide as cofactors. In the process of this reaction, KH 2 is oxidized to vitamin K 2,3-epoxide. T he return of the epoxide to the active KH 2 form is the result of a two-step reduction. First, the epoxide is reduced to vitamin K quinone by vitamin K 2,3-epoxide reductase in the presence of NADH. T his quinone intermediate is then further reduced back to KH 2 by vitamin K quinone reductase. T he warfarin-like anticoagulants (i.e., vitamin K antagonists) exert their anticoagulant activity through the inhibition of vitamin K 2,3-epoxide reductase and, possibly, through inhibition of vitamin K quinone reductase, which in turn inhibits activation of the four affected coagulation factors. Unlike heparin, and as a direct result of their mechanism of action, the vitamin K antagonists only inhibit blood coagulation in vivo.

Structure–Activ ity Relationship of Coumarin Deriv ativ es All of the coumarin derivatives (Fig. 31.5) are water-insoluble lactones. Structure–activity relationship requirements typically are based on substitution of the lactone ring, specifically in positions 3 and 4. Although coumarin is a neutral compound, the clinically available derivatives are weakly acidic because of the presence of a 4-hydroxy substitution. T he acidity of the proton on the 4-hydroxy group allows formation of water-soluble sodium salts for commercial preparations. Furthermore, warfarin (and, possibly, P.826 acenocoumarol) also can exist in solution as two diastereomeric cyclic hemiketal conformers in addition to its open-chain conformer (Fig. 31.6). Because it has been suggested that vitamin K forms an active hemiketal in vivo, the cyclic hemiacetals of the vitamin K antagonists, such as warfarin, also may be the active conformers in vivo (23).

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Fig. 31.4. Redox cycling of vitamin K in the activation of blood clotting, which involves conversion of glutamate residues to γ-carboxyglutamates.

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Fig. 31.5. Chemical structures of coumarin and coumarin-derived drugs.

Fig. 31.6. Formation of a cyclic hemiketal of warfarin.

Pharmacokinetics T he substituents at position 3 greatly affect the pharmacokinetic and toxicological properties of warfarin and its derivatives (T able 31.1) (24). Dicoumarol is not completely absorbed in the gastrointestinal tract, often is associated with gastrointestinal discomfort, and is very rarely used clinically. T oday, the only coumarin used in the United States is warfarin, but phenprocoumon and acenocomumarol are used in Europe.

Warfarin Warfarin sodium is rapidly and completely absorbed (~ 100% bioavailability) following oral, intramuscular, intravenous, or rectal administration. Peak plasma concentrations occur at approximately 3 hours. Its anticoagulant effect is not immediately present, however, following initiation of therapy. Instead, a delay in onset of anticoagulation occurs while the clotting factors with normal activity are cleared and those that have not been carboxylated because of the actions of warfarin reach physiologically significant levels. On average, this delay is approximately 5 hours for

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factor V turnover and 2 to 3 days for factor II (thrombin). Consequently, because of the rapid decline in protein C levels, the anticoagulated state frequently is preceded by a period of hypercoagulability (25). Warfarin also is highly protein bound (95–99%) and, as a result, has numerous interactions with other drugs. T he free drug (i.e., that not bound to plasma proteins) is the active constituent. T herefore, any other substance that displaces bound drug from protein binding sites increases the levels of free drug and, as a result, can cause warfarin toxicity, which usually is manifested by hemorrhage. T he volume of distribution(V d ) is quite small (0.1–0.2 L/kg), and the plasma half-life is quite long, both of which presumably result from the high degree of plasma protein binding (20,26).

“Superwarfarin” Rodenticides Brodif ac oum is a member of the s ec ond-generation antic oagulant rodenticides known as “ s uperwarf arins ” (27). This c ompound and others like it (e.g., bromadiolone and dif enac oum) were developed to c ombat rodent resistance to warf arin (27).

Human inges tion of brodif ac oum typic ally is ac cidental in children but usually is intentional in adults (i.e., to c ommit s uic ide) (28). I n cases when large quantities are ingested, s evere and potentially f atal hemorrhaging c an res ult. Brodif ac oum is readily available over-the-counter in hardware s tores and s upermarkets , and it is marketed under numerous trade names in North Americ a, Europe, Aus tralia, and New Zealand. Brodif acoum, like warf arin, is thought to exhibit its antic oagulant ef f ec ts through inhibition of vitamin K epoxide reduc tas e. Despite the s imilarity in mec hanis m of ac tion between brodif acoum and warf arin, brodif acoum is at leas t f ivef old more potent as an antic oagulant rodenticide (27,29). The half -lif e of brodif ac oum in humans is approximately 24.2 days , which is roughly ninef old longer than that of warf arin (27,30,31). Brodif ac oum also has a volume of distribution roughly six times that of warf arin (30). For thes e reas ons, vitamin K therapy may be needed f or weeks to months af ter inges tion of a s uperwarf arin rodenticide (32).

Table 31.1. Pharmacokinetic Properties of the Coumarins and Anisindione

Drug

Onset Trade Name (hours)

Duration Half-life (days) (days)

Time to Peak Plasma Concentration (hours)

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Warfarin

Coumadin

Dicoumerol

1.5–3.0

2–5

0.62–2.5

4

1–5

2–10

1–4

1–9

Phenprocoumon

Marcumara

7–14

5–6

Acenocoumarol

Sinthroma

2

0.3–1.0

1–3

Anisindione

Miradon

1–3

3–5

2–3

a

~6

Not available in the United States but available in Europe.

P.827 T he clinically used preparation of warfarin is racemic, but the enantiomers are not equipotent. In fact, (S)-warfarin is at least fourfold more potent as an anticoagulant than the (R)-warfarin. T he difference in the activities and metabolism of the enantiomers is the key to understanding several stereoselective drug interactions. Similar stereochemical properties are noted for the other asymmetric coumarins (Fig. 31.5). In the case of acenocoumarol, the (R)-isomer is responsible for the majority of its activity. Warfarin and other coumarin derivatives undergo extensive hepatic oxidative metabolism catalyzed by CYP2C9 isozyme to give 6- and 7-hydroxywarfarins as the major inactive metabolites. Warfarin also undergoes, to a lesser extent, reductive metabolism of the ketone on the C-3 side chain to a pair of pharmacologically active, diastereomeric 2-hydroxywarfarins (Fig. 31.7). Almost no unchanged drug is excreted in the urine. As expected, those individuals with compromised hepatic function are at greater risk for warfarin toxicity secondary to diminished clearance. Many of the drug–drug interactions are associated with enhanced or inhibited metabolism of warfarin via CYP2C9 induction or inhibition. Many additional drugs and conditions have profound effects on warfarin therapy. A partial list of these factors is shown in T able 31.2 (24).

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Fig. 31.7. Metabolism of warfarin.

Table 31.2. Factors Affecting Warfarin Therapy

Potentiate Anticoagulation Drugs: Acetaminophen Alcohol/ethanol (acute intoxication) Allopurinol Amiodarone Anabolic & androgenic steroids Aspirin Bromelains Cephalosporins Chenodiol Chloral hydrate Cimetidine Clofibrate Clofibrate Clorpropamide Cotrimoxazole Dextran Diazoxide Diflunisal Disulfiram Erythromycin Ethacrynic acid Fenoprofen Fluconazole Glucagon Heparin Ibuprofen Indomethacin Inhalation anesthetics Isoniazid Ketoconazole Lovastatin Mefenamic acid Metronidazole

Antagonize Anticoagulation Miconazole Nalidixic acid Naproxen Omeprazole Oral hypoglycemics Pentoxiphylline Phenylbutazone Phenytoin Piroxicam Propafenone Propranolol Quinidine, quinine Sulfamethoxazole– trimethoprim Sulfonylureas Sulfinpyrazone Sulindac Tamoxifen Thyroxine Ticlopidine Tolmetin Tricyclic antidepressants

Other Factors: Fever Stress Congestive heart failure Radioactive compounds Diarrhea Cancer X-rays Hyperthyroidism Hepatic dysfunction

Drugs: Alcohol (chronic abuse) Aminoglycosides Antacid Antihistamines Barbiturates Carbamazepine Chlordiazepoxide Cholestyramine Colestipol Corticosteroids Dextrothyroxine Griseofluvin Haloperidol Meprobamate Nafcillin Oral contraceptives Penicillins (large doses) Phenytoin Primadone Rifampin Sucralfate Trazodone Vitamin K (large doses)

Drug Enhanced by Oral Anticoagulation Phenytoin

Other Factors: High–Vitamin K diet: spinach, cheddar cheese cabbage Edema Hypothyroidism Nephrotic syndrome

P.828

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Fig. 31.8. Chemical structures of 1,3-indandione and 1,3-indandione– derived drugs.

Indandiones Indane-1,3-dione derivatives (Fig. 31.8), such as phenindione and anisindione, are orally active anticoagulants having a similar mechanism of action to the coumarins but are rarely used clinically today because of their significant renal and hepatic toxicities. Furthermore, because of the structural similarity, patients who are allergic to warfarin will experience cross-sensitivity with anisindione and other indandione anticoagulants (33). Although anisindione reportedly has fewer significant side effects, most clinicians still prefer warfarin for oral anticoagulation. T he pharmacokinetic properties also are similar to those of the coumarins (T able 31.1). Most of the newer indandione drugs, such as chlorophacinone, are marketed as potent rodenticides.

Heparin-Based Anticoagulants Chemistry T he heparin anticoagulants are represented by a variety of structures, including the natural heparan sulfate that lines the vascular endothelium, unfractionated heparin, LWMHs, and most recently, the synthetic pentasaccharide fondaparinux. Heparin is composed of a heterogeneous mixture of straight-chain, sulfated, and negatively charged mucopolysaccharides of a molecular weight range of 5 to 30 kDa, isolated from bovine lung or porcine intestinal mucosa. Heparin, also known as heparinic acid, is an acidic molecule similar to chondroitin and hyaluronic acid. T he polysaccharide polymer chains are composed of two alternating sugar units, N-acetyl-D-glucosamine and uronic acid (either D-glucuronic or L-iduronic), linked by α, 1 → 4 bonds (Fig. 31.9) (34). T hese chains are called glycosaminoglycans and typically are composed of 200 to 300 monosaccharide units. In mast cells, approximately 10 to 15 of these chains are bound to a core protein to yield a proteoglycan (i.e., a protein/sugar conglomerate molecule) with a molecular weight of 750 to 1,000 kDa. Before the molecule is capable of binding to antithrombin, the proteoglycan must undergo a series of structural modifications (34). T hese modifications include O-sulfation and N-sulfation of the D-glucosamine residues at carbons 6 and 2, respectively; O-sulfation of the D-glucuronic acid at carbon 2; epimerization of the D-glucuronic acid at carbon 5 to form L-iduronic acid; O-sulfation at carbon 2 of the L-iduronic acid; and N-deacetylation of the glucosamine and O-sulfation of the glucosamine at position 3. None of these reactions goes to completion, so the resulting polysaccharide chains are structurally quite diverse (35,36). T he heparin proteoglycan then undergoes degradation by an endo-β-glucuronidase in mast cell granules to release the active 5- to 30-kDa polysaccharide chains. Under physiological pH conditions, heparin exists primarily as polysulfate anions and, therefore,

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usually is administered as a salt. In clinical use, standard heparin most often is the sodium salt, but calcium heparin also is effective. Lithium heparin is used in blood sample collection tubes to prevent clotting of the blood samples both in vitro but not in vivo. T he use of heparin salts also is important to maintain aqueous solubility, which is necessary for injection. Heparin can be administered intravenously or subcutaneously but not orally, because the polysaccharide P.829 chains are broken down by gastric acid. Intramuscular injection of heparin is associated with a high risk of hematoma formation and is not recommended.

Fig. 31.9. Chemical structure of heparin polymer.

M echanism of Action Heparin (unfractionated heparin) was the first parenteral anticoagulant to show efficacy in the treatment of VT E and has been in use since 1937. Heparin acts at multiple sites in the coagulation cascade (34). Anticoagulation occurs when heparin binds, via a distinct pentasaccharide sequence in its molecule, to the circulating antithrombin III (a serine protease inhibitor) and potentates the antithrombin III–mediated inhibition of thrombin (factor IIa) and factor Xa, two of the key proteases in the blood coagulation cascade (Fig. 31.10) (37). T he binding between heparin and antithrombin III consists of ionic bonding between sulfate and carboxylate anions in the pentasaccharide chain of heparin and arginine and lysine cations in the antithrombin III (38). Antithrombin III works by forming a stable 1:1 complex with both thrombin and factor Xa. Although the rates of these reactions (with IIa and Xa) are slow in the absence of heparin, binding is accelerated 1,000-fold when heparin is added (39). T he reason for this enhancement is that when heparin binds to the antithrombin III, it induces a conformational change, resulting in increased accessibility of its active site and more rapid interaction with its protease substrates (i.e., thrombin and factor Xa). It should be noted that the ability of heparin to expose the active sites of antithrombin III is related to the large molecular size of heparin. With smaller molecules, such as LMWH and fondaparinux, the binding of antithrombin to thrombin is diminished, and the drugs become more selective (see discussions of LMWH and fondaparinux). Interestingly, the role of heparin in this process is only catalytic in nature (i.e., it is not consumed, inactivated, or degraded P.830 by the reaction). In fact, once the complex of antithrombin and protease is formed, the heparin is released, with no loss of activity, to catalyze formation of more antithrombin/protease complexes (Fig. 31.10) (37). Additional effects of heparin on the coagulation of blood are a result of heparin's effects on plasminogen activator inhibitor, protein C inhibitor, and T FPI (17,18).

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Fig. 31.10. Schematic representation of catalytic role of the heparin drugs in promoting (A) antithrombin–factor Xa and antithrombin–thrombin complexes and (B) antithrombin–fondaparinux complex.

Pharmacokinetics T he pharmacokinetic profiles of heparin and LMWHs are quite different. Whereas heparin is only 30% absorbed following subcutaneous injection, 90% of LMWH is systemically absorbed (40). T he binding affinity of heparin to various protein receptors, such as those on plasma proteins, endothelial cells, platelets, platelet factor 4 (PF4), and macrophages, is very high and is related to the high negative-charged density of heparin. T his high nonspecific binding decreases bioavailability and patient variability. Additionally, heparin's nonspecific binding may account for heparin's narrow therapeutic window and heparin-induced thrombocytopenia (HIT ), a major limitation of heparin. T hese same affinities are quite low, however, in the case of LMWHs. T hese parameters explain several of the benefits of the LMWH's. T he favorable absorption kinetics and low protein binding affinity of the LMWHs results in a greater bioavailability compared with heparin. T he lowered affinity of LMWHs for PF4 seems to correlate with a reduced incidence of HIT . Heparin is subject to fast zero-order metabolism in the liver, followed by slower first-order clearance from the kidneys (41,42). T he LMWHs are renally cleared and follow first-order kinetics. T his makes the clearance of LMWHs more predictable as well as resulting in a prolonged half-life. Finally, the incidence of heparin-mediated osteoporosis is significantly diminished with use of LMWHs as

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opposed to heparin.

M etabolism Independent of molecular weight, the metabolic fate of the heparins is essentially the same. T he distribution of the compounds is limited primarily to the circulation, but heparins also are taken up by the reticuloendothelial system (26). Once this uptake occurs, rapid depolymerization of the polysaccharide chains ensues, resulting in products that are inactive as anticoagulants. Desulfation also occurs in mononuclear phagocytes, which also produces inactive metabolites. T hese metabolites, as well as some of the parent compound, are then excreted in the urine (26). Because of the depolymerization of heparin in the liver and ultimate renal elimination of both metabolites and parent drug, half-life is prolonged in patients with hepatic or renal dysfunction. Another heparin-like medication is danaparoid sodium (43). T he drug is composed of 84% heparan sulfate, 12% dermatan sulfate, and 4% chondroitin sulfate. T he average molecular weight is 5.5 kDa, and like the LMWHs, danaparoid is dosed in terms of antifactor Xa activity. Danaparoid is completely bioavailable intravenously or subcutaneously and attains maximal antifactor Xa activity 2 to 5 hours after administration. T he elimination half-life is approximately 24 hours, and clearance is through the kidneys. Coagulation assays (e.g., PT and aPT T ) are not routinely monitored in patients receiving danaparoid therapy, because the drug has a very limited effect on factor II (thrombin) activity.

Specific Heparin Drugs High-Molecular-Weight Heparin (Unfractionated Heparin) Standard heparin is unfractionated and contains mucopolysaccharides ranging in molecular weight from 5 to 30 kDa (mean, ~ 15 kDa) and is referred to as high-molecular-weight heparin (T able 31.2). T his group of compounds has a very high affinity for antithrombin III and causes significant in vivo anticoagulant effects. Because heparin is a heterogeneous mixture of polysaccharides with different affinities for the target receptor, dosing based on milligrams of drug is inappropriate (i.e., there frequently is a limited correlation between the concentration of heparin given and the anticoagulant effect produced). T herefore, heparin is dosed in terms of standardized activity units that must be established by bioassay. One USP unit for heparin is the quantity of heparin required to prevent 1.0 mL of citrated sheep blood from clotting for 1 hour after the addition of 0.2 mL of 1% calcium chloride (19). Commercially available heparin sodium USP must contain at least 120 USP units per milligram. Heparin therapy typically is monitored by the aPT T . A therapeutic aPT T is represented by a clotting time in the assay that is 1.5- to 2.5-fold the normal mean aPT T (19). Monitoring therapy with laboratory testing is critical.

Low-Molecular-Weight Heparins In the past two decades, an increased interest has surfaced in a group of compounds known as LMWHs (41). T he LMWHs typically are in the 4- to 6-kDa molecular weight range and are isolated as fractions from heparin using gel filtration chromatography or differential precipitation with ethanol (39). T he LMWHs have more favorable pharmacokinetic and pharmacodynamic profiles relative to standard heparins (T able 31.3) (44). T he mechanism of action of LMWHs is similar to conventional heparin, but the binding of LMWHs is more selective (i.e., LMWHs have more targeted activity against activated factor Xa and less against activated factor IIa [thrombin]) (Fig. 31.10). T he reason for this difference is that even though LMWHs still possess the exact same specific pentasaccharide sequence as that of heparin needed for binding and potentiating the antithrombin III–mediated inhibition of activated factor Xa, most of the LMWH/antithrombin III complex is of insufficient length to bind and inhibit factor Xa and thrombin at the same time (44). T hus, although all LMWHs inactivate factor Xa, only 25 to 50% of these molecules also inactivate thrombin (41). T his factor selectivity typically is defined as a higher factor Xa:thrombin (anti-Xa:anti-IIa) activity ratio. In fact, although standard (unfractionated) heparin has an anti-Xa:anti-IIa ratio of 1:1, the same ratio in the LMWHs varies from 2:1 to 4:1 (T able 31.3) (41). P.831

Table 31.3. Properties of Heparin Derivatives

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Drug

Trade Name

Dosing

M olecular Weight Binding (daltons) Ratio

Unfractionated heparin Heparin

Calciparine, Calcilean

b.i.d., t.i.d.

5–30

1:1

Low-molecular-weight heparins Dalteparin

Fragmin

q.d.

3–8

2.2:1

Enoxaparin

Lovenox

q.d., b.i.d.

3.5–5.5

2.7–3.9:1

Tinzaparin

Innohep

q.d.

5.5–7.5

2.8:1

Arixtra

q.d.

1.728

Xa only

Pentasaccharide fondaparinux

T hree LWMHs are commercially available in the United States. T he LWMHs are shown in T able 31.3. T he three drugs differ slightly in their medical indications for use as well as in their molecular weight ranges. All three compounds are indicated for perioperative thromboembolism prevention for specific abdominal and orthopaedic surgeries. Enoxaparin and dalteparin are approved for use, in combination with aspirin, for the prophylaxis of ischemic complications of unstable angina and non-Q-wave myocardial infarction (45). Enoxaparin also is used in therapy for DVT with or without concomitant pulmonary embolism (45). Because of the increased homogeneity of enoxaparin compared to heparin, dosing of this drug is based on drug weight rather than on USP unitage. A typical dosing scheme for enoxaparin is the administration of 1 mg/kg once or twice daily. In the cases of dalteparin and ardeparin, dosage is based on antifactor Xa units (a-Xa U). Dalteparin is given as a once-daily subcutaneous injection at a dose of 2,500 to 5,000 a-Xa U. T ypical dosing for tinzaparin is 175 a–Xa U/kg once daily. T he LMWHs have a limited anticoagulant effect on in vitro clotting assays, such as the aPT T . In contrast to the heparin, coagulation parameters, such as aPT T , usually are not monitored in patients receiving LMWHs, nor is monitoring these assays really necessary, because the LMWHs have a highly predictable dose–response relationship (41,44).

Newer Heparin Developments Many recent studies involving heparin have been directed toward either increasing oral bioavailability or decreasing unwanted side effects (35,46). T he poor bioavailability of heparin results from its high molecular weight and high anionic charge density. T hese properties combined with the instability of the polysaccharides to gastric acid make penetration of biological membranes, such as the gut wall, extremely difficult for heparin. Various approaches to increase heparin absorption following oral administration have been investigated (47). Formulations of heparin including the use of amine salts in enteric-coated tablets (48), salts from organic bases such as lipophilic amines (49), oil-water emulsions (50,51), liposomes (52), and microsphere encapsulation (53,54) have been examined. Combinations of heparin with assorted calcium binding substances and non-α-amino acids (N-acylated aminoalkanoic acids) for simultaneous oral administration also have been studied (47). None of these formulations has yet been approved for clinical use. Attempts to use structural modifications to heparin to attenuate undesirable side effects also have been investigated (46). Heparin-induced thrombocytopenia is caused by the interaction of heparin with

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PF4. T he PF4 binding domain appears to be distinct from the thrombin binding domain. T herefore, it should be possible to use shorter oligosaccharides that bind specifically to the thrombin inhibitory sites without binding to PF4 (46). T hese observations were used to develop and synthetically produce a series of oligosaccharides with good thrombin binding profiles that have limited interaction with PF4. T his preliminary work is quite promising, but these compounds are not yet clinically available.

Fondaparinux

Fondaparinux is a prototype of a novel class of anticoagulants with significant advantages compared to their structurally related heparin (55). Based on the active site of the heparins, fondaparinux is a synthetic, highly sulfonated pentasaccharide. T he immediate advantage of fondaparinux is that as a synthetic drug, its composition will not change, which results in improved pharmacokinetics and a more selective anticoagulant action.

Mechanism of action T he development of fondaparinux, a synthetically derived pentasaccharide that binds specifically to and activates antithrombin III, is a further refinement on the mechanism of action of heparin (56). Fondaparinus and a related analogue, idraparinux, are specific, indirect inhibitors of activated factor Xa via their activation of antithrombin (Fig. 31.10). Fondaparinux has strategically located sulfonates that bind to antithrombin. Fondaparinux is structurally related to the antithrombotic binding site of heparin (57,58). Unlike heparin or LMWHs, however, these inhibitors have no effect on thrombin, because they lack the longer saccharide chains required for binding to thrombin. T he highly sulfated heparins exhibit nonselective binding to a number of additional proteins, resulting in decreased bioavailability and significant variation in activity.

Therapeutic application Fondaparinux is the first selective factor Xa inhibitor that is approved for the prophylaxis of DVT , which may occur in patients undergoing hip fracture surgery or hip or knee replacement surgery P.832 (59). T he most common side effect is major and minor bleeding, and the patient must be carefully monitored. T he drug is not to be used when spinal anesthesia or spinal puncture is employed because of the potential for developing a blood clot in the spine. Fondaparinux has not been reported to cause thrombocytopenia, a condition seen with heparin (56,59,60). It is 100% bioavailable, with little or no protein binding.

I draparinux is a polymethylated derivative of f ondaparinux that may soon be marketed. Like f ondaparinux, this drug is an indirec t inhibitor of f actor Xa, whic h binds to antithrombin with high af f inity (62). The drug has a plas ma half -lif e of 80 hours and can be administered onc e a week. I draparinux is adminis tered s ubcutaneous ly, is 100% bioavailable, and does not bind to other plas ma proteins .

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Pharmacokinetics Fondaparinux is administered via subcutaneous injection with a single daily dose and shows complete absorption. T he drug is highly bound to antithrombin III (~ 94%), with no significant binding to other plasma proteins. Because of the predictable anticoagulant effect, the drug does not require routine coagulation monitoring (61). T he drug is not metabolized and is excreted in the urine unchanged within 72 hours in patients with normal renal function. Fondaparinux has an elimination half-life of 17 hours. Presently, no clinically significant drug interactions have been reported.

Direct T hrom bin Inhibitors In the last 10 years, with a better understanding of the molecular mechanisms of blood coagulation, the availability of molecular modeling and recombinant technologies, and the structure-based drug design strategies, many new anticoagulants that target almost every step in the coagulation pathway have been developed (6,63). Among these, five direct thrombin inhibitors (DT Is; hirudin, bibalirudin, lepirudin, argatroban, and ximelagatran) have been approved for clinical use in recent years (T able 31.4). Many other anticoagulants that act on the endogenous anticoagulation mechanisms, such as activated protein C pathway, T FPI, as well as additional orally active DT Is, currently are undergoing clinical trials (63,64).

Discovery and Design of Direct Thrombin Inhibitors Hirudin, the lead compound for the design of DT Is, is a small protein (65 amino acids) that was originally isolated from the salivary glands of the medicinal leech, Hi rudo medi ci nal i s (65). T his protein has potent and specific inhibitory effects on thrombin through the formation of a 1:1 complex with the clotting factor. T he anticoagulant activity of hirudin seems to be contained within its highly anionic C-terminus. Several clinical studies have compared hirudin and a small peptidomimetic analogue, hirulog, with heparin in the treatment of several thrombotic disorders. In many cases, hirudin seems to be more efficacious and the responses to it more predictable. Furthermore, some of the studies also indicate a lower incidence of bleeding complications with hirudin compared with heparin. Hirudin is now produced by recombinant technology, and many hirulogs continue to be screened (66,67). Significant progress in the design and development of direct thrombin inhibition has been achieved. T he recent emergence of orally active DT Is may simplify the prevention and treatment of various thrombotic disorders (68,69,70).

M echanism of Action T he DT Is bind and inactivate both free thrombin and thrombin bound to fibrin. Unlike heparin, DT Is, such as lepirudin, bivalirudin, argatroban, and ximelagatran, bind directly and reversibly to the active site of thrombin. Unlike the heparins, these inhibitors do not require an activated antithrombin III as a cofactor for their anticoagulant activity. Furthermore, contrary to the heparins, P.833 these agents inhibit only the activity of thrombin, whereas heparin indirectly inhibits factors IIa (thrombin), IXa, Xa, XIa, and XIIa (64). T here are three different domains where DT Is bind to and

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block the action of thrombin: the active site (or catalytic site, CS) as well as two additional exosites. Exosite-1 acts as a dock for substrates such as fibrin and, thereby, orients the appropriate peptide bonds in the active site for its biotransformation. Exosite-2 is the heparin binding domain. Bivalent DT Is, such as lepirudin and bivalirudin, block thrombin at the active site and exosite-1, whereas argatroban, melagatran, and dabigatran are univalent DT Is and, thus, bind only to the active site of the thrombin.

Table 31.4. Direct Thrombin Inhibitors (DTIs)

Drug

Route of Site of Trade Name Administration Binding

Hirudin

Half-life Reversibility (minutes)

IV

CS, exosite-1

Irreversible

Lepirudin

Refludan

IV

CS, exosite-1

Irreversible

80

Desiruden

Iprivask

SC

CS, exosite-1

Irreversible

120–180

Bivalirudin

Angiomax

IV

CS, exosite-1

Reversible

25

Argatroban

Novastan

IV

CS

Reversible

39–51

SC, IV

CS

Reversible

150

PO

CS

Reversible

180–228

Melagatran Ximelagatran

Exantaa

CS, catalytic site; IV, intravenous, PO, oral; SC, subcutaneous. a

AstraZeneca announced the withdrawal of Exanta from the market on February. 14, 200

Specific Drugs Recombinant Hirudin Derivatives: Lepirudin and Desirudin Lepirudin and desirudin have been approved for the treatment of HIT and of HIT with thrombotic syndrome (71). Both lepirudin and desirudin are recombinant hirudin derivatives that consists of a 65-amino-acid protein (72,73). Lepirudin is related to the recombinant product desirudin differing in the two N-terminal amino acids. T he N-terminal amino acids in lepirudin are leucine-1 and threonine-2, whereas in desirudin, the N-terminal amino acids are valine-1 and valine-2. Additionally, desirudin lacks a sulfated tyrosine at amino acid 63. T he antithrombin activity of the two drugs is slightly different. Lepirudin and desirudin are both bivalent DT I that bind to both the active site and the exosite-1 of thrombin. T he result of this binding is that they create a nearly irreversible inhibition of thrombin. Lepirudin and desirudin inhibit both free thrombin and thrombin bound to fibrin (74). Lepirudin is administered via intravenous bolus injection, followed by continuous infusion, whereas desirudin is administered subcutaneously twice daily (T able 31.4) (73,75). T he drugs are cleared via the kidneys. Lepirudin is nearly totally degraded before excretion (~ 90%), whereas desirudin is

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excreted 50% unchanged. Lepirudin has immunogenic properties, and a significant number of patients develop antihirudin antibodies. In addition, hemorrhages may occur in patients treated with lepirudin. T he drug half-life is approximately 1.3 hours (76).

Biv alirudin Bivalirudin, a 20-amino-acid peptide, has been approved for use in patients with unstable angina undergoing percutaneous coronary intervention (Fig. 31.11) (77). Bivalirudin is a rapid-onset, short-acting DT I that binds to both the active site and the exosite-1 of thrombin. Unlike lepirudin, bivalirudin is a reversible inhibitor of both free thrombin and thrombin bound to fibrin. T his reversibility is possible because the bound bivalirudin undergoes cleavage at the second N-terminal proline to release the portion of the drug bound to the active site. T he carboxyl-terminal portion of bivalirudin dissociates from thrombin to regenerate thrombin (Fig. 31.11) (76). Bivalirudin does not bind to plasma protein. Bivalirudin is administered via intravenous bolus injection, followed by continuous infusion (T able 31.4). T he drug exhibits a rapid onset and a short duration of action. Bivalirudin is eliminated by renal excretion. It has been suggested that dosage adjustments be made in patients with severe renal impairment and in patients undergoing dialysis. Approximately 30% is eliminated unchanged along with proteolytic cleavage products. Because of the reversible nature of bivalirudin the drug exhibits less risk of bleeding than other antithrombotics, and there have been no reported cases of antibody formation to bivalirudin (78).

Fig. 31.11. Chemical structure of bivlirudin, binding sites to thrombin, and release from thrombin.

P.834

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Fig. 31.12. Schematic representation of mechanism of action of argatroban.

Argatroban

Argatroban has been approved for the prophylaxis and treatment of thrombosis in patients with HIT (79). Argatroban is a peptidomimetic that binds selectively to the catalytic site of thrombin as a univalent competitive DT I (Fig. 31.12). Argatroban is available as a mixture of 21-R and 21-S diastereomers (64:36), with the S-isomer approximately twice as potent as the R-isomer (80). T he drug is a reversible inhibitor of both free thrombin as well as clot-bound thrombin.

Pharmacokinetics (Table 31.4) Argatroban is administered subcutaneously because of the low lipophilicity of the drug. T he drug is bound to plasma protein and is metabolized via CYP3A4/5 to the aromatized metabolite and the two hydroxylated metabolites (Fig. 31.13). T he M-1 metabolite retains 20 to 30% of the antithrombotic activity. Coadministration of argatroban with inhibitors of CYP3A4 does not appear to produce clinically significant effects. Argatroban is eliminated via biliary secretion into the feces (81).

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Fig. 31.13. Metabolism of argatroban.

Ximelagatran was the f irs t orally ac tive DTI , approved in 2004 f or the prevention of venous thromboembolis m f or patients undergoing total knee replac ement s urgery and in patients with atrial f ibrillation (82,83). Ximelagatran is a pro-drug that, f ollowing metabolism, gives ris e to the DTI melagatran. Melagatran inhibits both f ree thrombin and thrombin bound to f ibrin by revers ibly binding to a s ingle site in thrombin; thus , it is ref erred to as a univalent DTI . This is in c ontras t to lepirudin and bivalirudin, which bind nearly irreversibly to two sites in thrombin. Melagatran also inhibits platelet activation and cleavage of proteas e-ac tivated rec eptor-1 in a dos e-dependent manner (84,85).

Ximelagatran was reported to be well tolerated, with a low incidence of adverse ef f ec ts. I t had been reported, however, that the drug caused liver toxicity, although s tudies have indic ated that this is a rare event (86). On February 14, 2006, As traZenec a announced that the company had decided to withdraw melagatran/ximelagatran f rom the market and terminate its development because of a potential ris k of s evere liver injury when the drug was used beyond the approved 11 days.

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Previous studies had reported elevated liver transaminases in 7.9% of the patients and s ugges ted monitoring with long-term use of the drug. This ef f ect appeared af ter 1.5 to 4.0 months .

Antiplatelet Drugs Another site for regulating blood coagulation and subsequent thrombus formation is at the level of the platelets (87). Antiplatelet drugs work by inhibiting platelet activation via a number of different mechanisms (87,88). T he major role of antiplatelet drugs is in the prevention of ischemic complications in patients with coronary diseases (89). T hese drugs also are effective in combination with moderate-intensity anticoagulants for patients with atrial fibrillation.

Pathophysiology of Arterial Thrombosis T he pivotal role of platelets in thrombus formation and potential sites for drug interventions is illustrated in Figure 31.14 (89). Normal endothelial cells in the vascular wall synthesize and release prostacyclin (PGI 2 ), which P.835 stimulates the conversion of adenosine triphosphate (AT P) to cyclic adenosine monophosphate (cAMP), thus preventing platelet aggregation and degranulation. In the case of an injury to the vascular wall, glycoprotein (GP) receptors (i.e., GPI a and GPI b ) bind substances such as von Willebrand factor (vWf) and collagen from the exposed subendothelial surface, thereby activating the platelets. T he GPIIb /IIIa receptors (also known as the fibrinogen receptor or integrin αIIbβ3 receptor) then mediate the final step of platelet aggregation by binding to fibrinogen or vWf, thus cross-linking platelets to form aggregates (Fig. 31.14).

Fig. 31.14. Scheme describing platelet activation as it relates to blood clot formation. The thrombus is formed at the site of a damaged wall in the vasculature. Normal endothelial cells in vascular wall provide prostacyclin, which stimulates the conversion of adenosine triphosphate (ATP) to cyclic adenosine monophosphate (cAMP), preventing platelet

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aggregation. In injury, glycoprotein (GP) receptors bind substances such as von Willebrand factor and collagen, activating the platelet. The GPIIb/IIIa receptors cross-link platelets via fibrinogen binding. As the platelet degranulates, additional aggregating substances including thromboxane A2 (TXA2 ), serotonin (5-HT), and adenine diphosphate (ADP) are released. The substances bind to other platelets, activating them and resulting in a cascade effect. Also shown are the sites of inhibition of platelet aggregation.

T he adherent platelets degranulate and release additional aggregating substances, such as thromboxane A2 (T XA2 ), serotonin (5-HT ), and adenosine diphosphate (ADP). T hese substances serve as secondary chemical messengers to recruit more platelets to the site of vascular injury and, thereby, amplify platelet aggregation. For example, thrombin production releases ADP, which is a potent inducer of platelet aggregation and stimulates prostaglandin synthesis from arachidonic acid in the platelet. T he prostaglandins synthesized, PGI 2 and T XA2 , have opposite effects on thrombogenesis. T he PGI2 is synthesized in the walls of the vasculature and inhibits thrombus formation. Conversely, T XA2 , which is synthesized in the platelets, induces vasoconstriction and thrombogenesis. Serotonin, which also is released from the platelets, has similar and additive effects to those of T XA2 . T his rapid platelet aggregation and thrombus formation at the site of vascular injury is the main mechanism of hemostasis (stoppage of bleeding, a normal process of wound healing). When platelets are activated on the ruptured atherosclerotic plaques or in regions of restricted blood flow, however, it can lead to thromboembolic P.836 complications that contribute to common diseases, such as myocardial infarction or ischemic stroke.

M echanism of Action of Antiplatelet Drugs Most of the current available antiplatelet drugs, such as aspirin, dipyridamole, ticlopidine, and sulfinpyrazone, exert their actions by affecting only the secondary platelet aggregation pathways (87). For example, aspirin and sulfinpyrazone work by inhibiting the biosynthesis of T XA2 in the platelets (see Fig. 36.4). Aspirin works by irreversibly and permanently inactivating cyclooxygenase (COX) through covalent acetylation of a serine residue in close proximity to the active site of the enzyme. A cumulative inactivation effect occurs on platelets with long-term therapy, because platelets do not synthesize new COX (i.e., platelets are unable to synthesize, via de novo pathway, COX-1, because they are anucleated cells). T herefore, the effects of aspirin last for the lifetime of the platelet (7–10 days). Sulfinpyrazone also is a potent but reversible COX inhibitor that does not affect PGI2 synthesis in endothelial cells. Like nonsteroidal anti-inflammatory agents (NSAIDs), such as aspirin, this action inhibits the aggregation of platelets into thrombi. Dipyridamole interrupts platelet function through its effect of increasing cellular concentration of cAMP by inhibiting phosphodiesterase, an enzyme needed for degradation of cAMP. Dipyridamole also may stimulate PGI 2 release and inhibits T XA2 formation. T iclopidine and clopidogrel selectively inhibit ADP-induced platelet aggregation with no direct action on prostaglandin production. New and more selective antiplatelet drugs, such as integrin αIIbβ3 receptor antagonists (GPIIa/IIIb blockers), thromboxane synthase inhibitor, and T XA2 receptor antagonists, are currently being developed (88).

COX-1 Inhibitors Because T XA2 is a potent vasoconstrictor as well as a labile platelet aggregation inducer, inhibition of production of T XA2 effectively blocks platelet aggregation. Aspirin and related analogues (Fig. 31.15) exhibit their effectiveness through such a blocking mechanism.

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Fig. 31.15. Cyclooxygenase (COX)-1 inhibitors.

Aspirin Aspirin is a well-established antiplatelet drug in the treatment of atherothrombotic vascular disease (87,88,89). As stated earlier, aspirin works by its ability to acetylate and irreversibly deactivate platelet COX (COX-1), and its antithrombotic effect remains for the life span of the platelet (7–10 days). Aspirin also has been shown to have other antithrombotic effects that are unrelated to its action on COX-1 (87). T hese effects include the dose-dependent inhibition of platelet function, the enhancement of fibrinolysis, and the suppression of blood coagulation. Aspirin is rapidly absorbed in the stomach and quickly degraded by plasma cholinesterases (half-life, 15–20 min). A once-daily dose of 160 mg of aspirin, which is much lower than dosages needed for its anti-inflammatory/analgesic actions, is sufficient to completely inactivate platelet COX-1 irreversibly (90). Higher doses of aspirin only contribute to its side effects, especially internal bleeding and upper gastrointestinal irritations. In recent years, the term “ aspirin resistance” has been used to denote those situations in which the use of aspirin is unable to protect a patient from thrombotic complications, to cause a prolongation of the bleeding time, or to produce an anticipated effect on one or more in vitro tests of platelet function (87,90,91). One possible explanation for aspirin-resistant T XA2 biosynthesis is the transient expression of COX-2 in newly formed platelets (92). Many other clinical, pharmacodynamic, biological, and genetic factors, however, such as tobacco use, drug interaction, alternate pathways for platelet activation, and genetic polymorphism or mutations of the COX-1 gene, may be involved (93). Currently, many questions regarding the biochemical mechanism, diagnosis, prevalence, clinical relevance, and optimal therapeutic intervention for aspirin resistance remain unanswered (93).

Triflusal T riflusal (2-acetoxy-4-trifluoromethyl benzoic acid) is an antiplatelet drug that despite its structural similarity to aspirin (Fig. 31.15) exhibits quite different pharmacological and pharmacokinetic properties (94). Unlike aspirin, 2-hydroxy-4-trifluoromethylbenzoic acid (HT B), the deacetylated metabolite of triflusal, retains significant antiplatelet activity. T riflusal is rapidly absorbed and metabolized. T he area under the concentration–time curve for triflusal is 20.26 mg/L/hour after a 900-mg dose, whereas that for HT B is 42.27 mg/L/hour. Much of the pharmacokinetic data for triflusal activity is associated with HT B. T he inhibition of COX, as measured by reduced production of thromboxane B 2 , is 25% after 2 hours and 85% after 7 days with triflusal, whereas the effects of aspirin on thromboxane B 2 is more than 90% reduction after 2 hours and is maintained at this level after 7 days (95). It would appear that the presence of a 4-trifluoromethyl group also greatly

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enhances triflusal's ability to inhibit the activation of nuclear factor κB, which in turn regulates the expression of the mRNA of vascular P.837 cell adhesion molecule-1 (96) needed for platelet aggregation. In addition, triflusal increases nitric oxide synthesis in neutrophils, which results in an increased vasodilatory potential (97). Finally, an additional site of action for triflusal/HT B is the inhibition of cAMP phosphodiesterase, leading to increased levels of cAMP. Elevated cAMP levels decrease platelet aggregation through decreased mobilization of calcium. Aspirin and salicylic acid do not significantly increase cAMP levels. Although recent trials comparing triflusal and aspirin for the prevention of vascular events in patients following a stroke revealed no significant differences between these two antiplatelet drugs, triflusal's use was associated with a significantly lower rate of hemorrhagic complications (94).

Sulfinpyrazone (Anturane) Sulfinpyrazone is a structural derivative of the anti-inflammatory drug phenylbutazone. Unlike phenylbutazone, however, sulfinpyrazone does not have significant anti-inflammatory activity. It does have potent uricosuric effects and frequently is used in the treatment of gout. At least four metabolites of sulfinpyrazone have been identified, including the sulfide, sulfone, p-hydroxysulfide, and p-hydroxysulfinpyrazone derivatives (Fig. 31.16) (24). Only the parent sulfinpyrazone and its reduced sulfide metabolite, however, are active as COX inhibitors (98). Because these compounds are reversible inhibitors, the antithrombotic activity lasts only as long as blood levels of the drug and metabolite persist (half-life, 4–6 hours for parent sulfinpyrazone, 11–14 hours for the sulfide metabolite). Sulfinpyrazone is not yet approved in the United States for use in acute myocardial infarction or for transient ischemic attack prophylaxis.

Fig. 31.16. Metabolism of sulfinpyrazone.

Indobufen Many NSAIDs also inhibit T XA2 -dependent platelet function through a competitive, reversible

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inhibition of COX-1 (see Chapter 36 for their structures). At a conventional analgesic dosage, these drugs only inhibit COX-1 activity by 70 to 90%, which is inadequate for controlling platelet aggregation. T hus, unlike aspirin, most of the clinically available NSAIDs are not used clinically for their antithrombotic properties. In contrast, indobufen (Fig. 31.15), a reversible but very potent inhibitor of platelet COX-1 activity, was shown to have comparable clinical efficacy to that of aspirin in prevention of DVT after myocardial infarction and in blocking exercise-induced increase in platelet aggregation (99). In the secondary prevention of thromboembolic events, 100 or 200 mg of indobufen twice daily is as effective as warfarin or aspirin in patients with or without atrial fibrillation (100). Currently, indobufen is only available for routine clinical use in Europe.

Phosphodiesterase Inhibitors Phosphodiesterase-3 (PDE3) is an enzyme responsible for degradation of cAMP to AMP in platelets and blood vessels. Selective cAMP PDE3 inhibitors, such as dipyridamole and cilostazol (Fig. 31.17), inhibit the degradation of cAMP, thereby increasing cellular concentration of cAMP and leading to inhibition of platelet aggregation and vasodilation (see Chapter 17 for additional information) (101).

Dipyridamole (Aggrenox) Dipyridamole is a pyrimidopyrimidine derivative with vasodilatory and antiplatelet properties (Fig. 31.17). Dipyridamole exerts its antiplatelet function by increasing cellular concentrations of cAMP via its inhibition of the degradating enzyme, cyclic nucleotide PDE3. It also blocks adenosine uptake, which acts at A2 adenosine receptors to stimulate platelet adenyl cyclase. Less common uses for this drug include inhibition of embolization from prosthetic heart valves when used in combination with warfarin (the only currently recommended use) and reduction of thrombosis in patients with thrombotic disease when used in combination with aspirin. Alone, dipyridamole has little, if any, benefit in the treatment of thrombotic conditions (102).

Fig. 31.17. Chemical structures of phosphodiesterase inhibitors.

P.838

Cilostazol (Pletal) Cilostazol, a quinolinone derivative, is a potent orally active antiplatelet drug approved for the treatment of intermittent claudication (a peripheral artery disease resulting from blockage of blood vessels in the limbs). Cilostazol exhibits greater selectivity than dipyridamole as an inhibitor of PDE3A (Fig. 31.18) (102). T he drug does not affect the other PDEs (PDEs 1, 2, or 4). Cilostazol reversibly inhibit platelet aggregation induced by a number of stimuli, such as thrombin, ADP, collagen, or stress from exercise (103,104). Additionally, cilostazol inhibits adenosine uptake, leading to increased activity of adenosine at A1 and A2 receptors. Adenosine's action on A2 receptors in platelets increase cAMP levels, which, as previously indicated, leads to decreased

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platelet aggregation (105). Cilostazol is rapidly absorbed after oral administration, particularly with a high-fat meal, which greatly increases its bioavailability to approximately 90%. It is extensively metabolized in the liver by various cytochromes. by CYP2C19, with an metabolites produced 3,4-dehydrocilostazol

T he most important cytochromes appear to be CYP3A4 and, to lesser extent, elimination half-life of approximately 11 to 13 hours. Among the various (11 metabolites are known), the two major metabolites are and 4′-trans-hydroxycliostazol (Fig. 31.19). T hese two metabolites are

pharmacologically active. Studies indicate that the concomitant administration of cilostazol with CYP3A inhibitors can greatly increase cilostazol blood concentrations, and a dose reduction may be required (106). Similar results are seen when CYP2C19 is inhibited, leading to decreased formation of 4-trans-hydroxycliostazol and significant increases in cilostazol and 3,4-dehydrocilostazol (107).

Fig. 31.18. Sites of action of cilostazol, blocking phosphodiesterase 3A (PDE) and adenosine uptake, leading to increased levels of cyclic adenosine monophosphate (cAMP) directly by inhibition of cAMP breakdown and indirectly through adenosine binding to adenosine 2 receptors (A2 -receptor), which through G-protein coupling stimulates adenyl cyclase.

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Fig. 31.19. Metabolism of cilostazol.

Platelet P2Y Purinergic Receptor T he crucial role that ADP plays in platelet activation and aggregation has been extensively investigated (108). T he molecular targets of ADP in the platelet are G protein–coupled P2Y purinergic receptors. T here are three nucleotide receptors: P2X1 , a cation channel receptor activated by AT P, and purinergic receptors P2Y 1 and P2Y 12 , both of which are activated by ADP. Initial binding of ADP to the P2Y 1 purinergic receptor (373-amino-acid protein) induces platelet shape changes, causes intracellular calcium mobilization, and initiates aggregation. Subsequent binding of ADP to the P2Y 12 purinergic receptors (342 amino acids) leads to sustained platelet aggregation by inhibiting adenylate cyclase and, thereby, decreasing cellular cAMP levels (109). T he P2Y 12 receptor is coupled to the Gα i2 G protein. T he antithrombotic drugs ticlopidine and clopidogrel are irreversible antagonists of this P2Y 12 purinergic receptor (108). T he clinical relevance of this P2Y 12 receptor as a new target for antiplatelet drug development of novel reversible antagonists has been extensively reviewed (109,110,111).

Ticlopidine (Ticlid) and Clopidogrel (Plav ix)

P.839 T iclopidine and clopidogrel are thienopyridines, which through inhibition of platelet aggregation prolong bleeding time and delay clot retraction. T he thienopyridines are prescribed for reduction of myocardial infarction and stroke, for treatment of peripheral arterial disease, and in combination with aspirin for acute coronary syndromes. T his latter utility appears to result from the fact that both aspirin and the thienopyridines block major amplification pathways, leading to platelet aggregation

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and, thus, producing enhanced effectiveness. T riclopidine has major safety concerns in that in a small population (1–2%), neutropenia occurs that is potentially fatal, may cause thrombotic thrombocytopenic purpura, and is largely replaced with clopidogrel. T hese same side effects are rare with clopidogrel. Additional side effects include diarrhea, nausea, vomiting, and skin rash (112). T he thienopyridine class exhibit selective inhibition of ADP-induced platelet aggregation. T he action of ticlopidine and clopidogrel appear to be irreversible in that there is still antiplatelet activity for 7 to 10 days after discontinuation of the medications (despite the fact that the elimination half-life of ticlopidine is only 24–36 hours after a single dose) (24). Support of the theory of irreversible inhibition of P2Y 12 is provided by the observation that ticlopidine is not effective in blocking platelet aggregation in vitro when compared to the effect of the drug on the platelets of people taking ticlopidine. T he thienopyridines both function as pro-drugs requiring cytochrome P450 activation. T he thienopyridines are rapidly absorbed and extensively metabolized in the liver. T he most significant metabolites of clopidogrel are shown in Figure 31.20. An inactive carboxylic acid represents the major circulating metabolite, which through oxidation by CYP3A4 gives rise to the 2-oxo derivative, which in turn is hydrolyzed to the thiol. T he thiol is thought to bind irreversibly to P2Y 12 by forming a disulfide bridge to a cysteine in P2Y 12 (113,114,115). Specially, clopidogrel is thought to bind to Cys17 or Cys270 and, thus, block the binding of the agonist. In the case of ticlopidine, additional metabolites have been identified, dihydrothienopyridinium (M5) and thienodihydropyridinium metabolites (M6). T hese short-lived metabolites may be responsible for the toxic adverse reactions (116).

I n light of various limitations pos ed by clopidogrel, such as patient variability, res istance, and bleeding events , newer c ompounds continue to be developed. One s uch agent is pars ugrel, whic h pres ently is in Phas e I I /I I I c linical studies . Prasugrel and its active metabolite R-99224 exhibit a more rapid onset, a higher potency, and a low rate of bleeding (117).

Glycoprotein II b /III a Receptor Antagonists One of the newest groups of antithrombotic agents is the platelet receptor GPIIb /IIIa antagonists (87). T his novel class of compounds has been shown to provide more comprehensive inhibition of platelet aggregation than the usual combination of aspirin and heparin. T he final common pathway in platelet aggregation is the expression of functional GPIIb /IIIa (integrin αIIbβ3) receptors. T hese protein receptors are expressed regardless P.840 of the origin of the stimulus initiating the clotting cascade. T he normal substrate for the GPII b /III a receptor is fibrinogen. One fibrinogen molecule acts to cross-link two platelets via binding to the GPIIb /III a receptors on the platelet surfaces (Fig. 31.14). If the platelet surface receptors are occupied by another substrate that prevents fibrinogen binding and cross-linking, platelet aggregation will not occur. T o this end, a number of novel compounds representing diverse structural groups have been prepared as GPIIb /IIIa receptor antagonists (Fig. 31.21) (118). Included

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in this list of antagonists are monoclonal antibodies against the natural GPIIb /IIIa receptor, naturally occurring peptides isolated from snake venom that contain the Arg-Gly-Asp (RGD) sequence, synthetic peptides containing either the RGD or Lys-Gly-Asp (KGD) sequences, and peptidomimetic and nonpeptide RGD mimetics that compete with fibrinogen and other ligands for occupancy of the receptor (87). T he natural binding ligands, such as vWf and fibronectin, contain the natural RGD sequence.

Fig. 31.20. Metabolism of clopidogrel and ticlopidine.

T he GPIIb /IIIa receptor antagonists are indicated in therapy for unstable angina, non-Q-wave myocardial infarction, and percutaneous coronary procedures. Like other antithrombotic agents, the main concern associated with GPIIb /IIIa receptor antagonists is bleeding. Additionally, these drugs have been suggested to possibly increase the risk of thrombocytopenia (87). Although a number of orally active GPIIb /IIIa receptor antagonists have been prepared and evaluated, their clinical efficacy in acute treatment of patients with unstable angina and in those undergoing angioplasty has not been fully established (118).

Abciximab T he initial antibodies against the GPII b /III a receptor were murine in origin. Because of concerns about the antigenicity of a pure murine antibody, a chimeric human–mouse 7E3 Fab was developed (119). T his chimera, marketed as abciximab, is the clinically available form of the antibody (120). For an adult patient, the usual dosing scheme is 0.25 mg/kg as an intravenous bolus given 10 to 60 minutes before percutaneous coronary intervention, followed by the continuous infusion of 0.125 µg/kg/minute for 12 hours to a maximum of 10 µg/kg. Elimination of abciximab is biphasic. T he initial phase has a half-life of 10 minutes, whereas the half-life of the second phase is approximately 30 minutes and results from platelet binding. Platelet function returns to normal within 48 hours after infusion, even though abciximab is bound to circulating platelets for approximately 2 weeks (T able 31.5) (42).

Eptifibatide Eptifibatide is a cyclic heptapeptide composed of six amino acids and one mercaptopropionyl residue. T he cyclization is completed via a disulfide linkage between the cysteine and the mercaptopropionyl moieties. T he lysine-glycine-aspartate component of eptifibatide is highly specific for the GPIIb /IIIa receptor, with low P.841 binding affinity, as indicated by the rapid dissociation constant (T able 31.5). Because of this, eptifibatide is a reversible, parenterally administered antagonist of platelet aggregation.

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Fig. 31.21. Structures of selected glycoprotein (GP) ll b /lll a receptor antagonists.

Table 31.5. Pharmacokinetic Properties of the Glycoprotein IIb/IIIa Receptor Antagonists

Drug

M olecular Dissociation Plasma Protein Weight Constant Half-Life Binding Trade Name (daltons) (nmol/L) (hours) (%)

Abciximab

ReoPro

47,615

5

72

Eptifibatide

Integrelin

800

120

4

25

Tirofibin

Aggrastat

495

15

3–4

65

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T he drug is eliminated primarily via renal mechanisms as eptifibatide and deaminated eptifibatide. T he clinical importance of eptifibatide and its benefits in comparison with other therapeutic agents used in the treatment of acute coronary syndromes and percutaneous coronary intervention have recently been reviewed by Curran and Keating (121).

Tirofiban T irofiban is a member of a new class of antithrombotic agents known as the “ fibans” (Fig. 31.21). T hese compounds have a structural similarity to disintegrin, which was originally isolated from snake venoms. T he location of the –COO - and NH 3 + in the fibans is identical to the distance between the same functional groups of the RGD loop of disintegrin, and as a result, the fibans are able to effectively block the binding of fibrinogen to the GPIIb/IIIa receptor in an reversible manor. T irofiban, like eptifibatide, has a rapid dissociation constant (T able 31.5). T irofiban is a peptidomimetic (nonpeptide) that is parenterally administered and exhibits a reduced risk of bleeding because of its shorter biological half-life than abciximab. Additionally, it is less costly than other GPIIb/IIIa receptor antagonists. T he remaining fibans shown in Figure 31.21 are in various stages of development. Lamifiban is administered parenterally, whereas roxifiban and lefradafiban are used orally.

New Developments in Antiplatelet Drugs Several newer approaches to antiplatelet drug development have been recently discovered (122). T hese include inhibitions of the vWf/GPIb interaction, the platelet/collagen interaction, and the thrombin-induced platelet activation. Other approaches to platelet inhibition include the use of serotonin antagonists (because serotonin induces platelet aggregation), nitric oxide–donating antiplatelet agents, phosphodiesterase inhibitors, and inducers of adenyl cyclase. Specific inhibitors of thromboxane synthase have been tested for their ability to block this enzyme without inhibiting the entrie acachidonic acid cascade (123). T his allows an accumulation of prostaglandin G (PGG 2 ) and Prostaglandin H 2 (PGH 2 ) which can then be channeled into an increased production of prostacyclin (PGI2 ) which also has antithrombotic activity.

T hrom bolytic Drugs Early application of reperfusion therapy with thrombolytic agents has significantly improved the outcomes of acute myocardial infarction and other conditions, such as pulmonary embolism, DVT , arterial thrombosis, acute thrombosis of retinal vessel, extensive coronary emboli, and peripheral vascular thromboembolism (124). Although, the beneficial effect of the thrombolytic drugs, such as streptokinase and urokinase, for dissolving P.842

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newly formed thrombus in patients with acute myocardial infarction were first reported in 1958, their full acceptance into clinical practice was not realized until the early 1980s as a result of several prospective, randomized, controlled trials. T oday, with the approval of many second- and thirdgeneration thrombolytic drugs, thrombolytic therapy has become a standard treatment for patients presenting with acute myocardial infarction or stroke (124,125).

Snake Venom–Induced Coagulopathy The venom of s nakes of the Crotalinae f amily, which includes rattlesnakes, produces a state of impaired c oagulation. This c an lead to both local and systemic hemorrhagic events. Venom c ons is ts of many c omponents , including phospholipases and hemolysins, which c aus e c ell lys is by dis rupting platelet and red blo od c ell membranes. The venoms also c ontain proc oagulant c omponents that induce the f ormation of intravascular c lots as well as hemorrhagins that des troy vas c ular integrity. Typic ally, both PT and aPTT are elevated with total f ibrin levels being lowered and f ibrin degrad ation products being increas ed. All of the f indings are c ons is tent with a c ons umptive c oagulop athy. Because of the multiple mec hanisms af f ec ting c oagulation, c oagulopathies caused by snake venom are best managed us ing antivenin.

M echanism of Action Normally, newly formed blood clots (fibrin) are dissolved by the actions of the fibrinolytic system. the purpose of which is the removal of unwanted clots without damaging the integrity of the vascular system. T his system works via a relatively nonspecific protease enzyme called plasmin, the function of which is to digest fibrin (the very last step of the coagulation cascade) (Fig. 31.1). T he lack of substrate specificity of plasmin is illustrated by the fact that it degrades fibrin clots as well as some plasma proteins and coagulation factors. T he fibrinolytically active plasmin is produced from the circulating inactive “ proenzyme” plasminogen following the cleavage of a single peptide bond by a group of trypsin-like serine proteases known as the plasminogen activators. T he principal activator, tissue-type plasminogen activator (tPA), is released from the vascular endothelium. T hrombolytic drugs, such as streptokinase and urokinase, act like a plasminogen activator that converts this proenzyme to the active plasmin. Endogenously, plasmin activity is regulated by two specific inactivators known as tPA inhibitors 1 and 2.

First-Generation Throm bolytic Agents Streptokinase (Streptase) Streptokinase is a drug of choice for thrombolytic therapy based on its cost-effectiveness consideration, and it is the only thrombolytic drug approved by the U.S. Food and Drug Administration (FDA) for peripheral vascular disease (126). T he drug is approved for treatment of myocardial infarction but rarely is used for this condition today, having been replaced with the fibrinspecific agents discussed below (127).

Mechanism of action Streptokinase is a protein purified from culture broths of group C β-hemolytic streptococci bacteria. Streptokinase contains a single polypeptide chain of 414-amino-acid residues with a molecular weight of 47 kDa (126). Streptokinase by itself has no intrinsic enzymatic activity. T o be active, it must bind with plasminogen to form an activator complex (1:1 complex). T his complex then acts to convert uncomplexed plasminogen to the active fibrinolytic enzyme, plasmin. T he streptokinase/plasminogen complex not only degrades fibrin clots but also catalyzes the breakdown of fibrinogen and factors V and VII (124,126). As a result, streptokinase is considered to be a fibrinnonspecific drug.

Pharmacokinetics Unfortunately, the half-life of the activator complex is less than 30 minutes, which frequently is too short to completely lyse a thrombus. Anistreplase (APSAC; Eminase) is a 1:1 streptokinase/lysineplasminogen complex that has been acylated with an anisoyl group at the active-site serine within

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the lysine-plasminogen. Anistreplase is inactive as such, but following complexation with fibrin, the anisoyl group is slowly cleaved, exposing the active site and, thus, leading to degradation of fibrin. T he pro-drug nature of anistreplase exhibits an improved pharmacokinetic profile, with anistreplase acting as a semiselective lysis agent at the clot site. T he inactivity of the circulating anistreplase also allows this drug to be given as a very rapid intravenous infusion (typically, 30 U over 3–5 minutes). T issue reperfusion following anistreplase therapy compares favorably to streptokinase because of the extended half-life (90 minutes).

Side effects Because it is a foreign protein, streptokinase is associated with significant hypersensitivity reactions. Most people have, at some point in their lives, had a streptococcal infection and, therefore, have developed circulating antistreptococcal antibodies. T hese antibodies frequently are active against streptokinase as well. T he response of the streptokinase to these antibodies can vary widely, from inactivation of the fibrinolytic properties of the protein to rash, fever, and rarely, anaphylaxis. Significant allergic reactions to streptokinase occur in approximately 3% of patients.

Urokinase (Abbokinase) Urokinase is an enzyme with the ability to directly degrade fibrin and fibrinogen. It is now isolated from cultures of human fetal kidney cells and is composed of two polypeptide chains with molecular weights of 32 and 54 kDa. T his method of isolation is much more efficient than the original isolation of urokinase from human urine (128). Because of its source, the human body does not see urokinase as a foreign protein. T herefore, it lacks the antigenicity associated with streptokinase and frequently is used for patients with a known hypersensitivity to streptokinase (129). Plasmin cannot be used directly because of the presence of naturally occurring plasmin antagonists in plasma. No such inhibitors of urokinase exist in the plasma, however, allowing this enzyme to have clinical utility. Even so, urokinase is much more expensive (threefold the price of streptokinase) and has an even shorter half-life (15 minutes). Urokinase also has other fibrin-nonspecific actions similar to streptokinase. Currently, urokinase is only approved for treatment of pulmonary embolism.

Second-Generation Thrombolytic Agents Alteplase (Activ ase) Alteplase (tPA) is a serine protease with a low affinity for free plasminogen but a very high affinity for the P.843 plasminogen bound to fibrin in a thrombus (fibrin-specific agent) (Fig. 31.22). Both streptokinase and urokinase lack this specificity (i.e., are nonspecific) and act on free plasminogen, inducing a generalized thrombolytic state. Alteplase also has a greater specificity for older clots compared with newer clots relative to streptokinase and urokinase. Alteplase was originally isolated from cultures of human melanoma cells but is now produced commercially using recombinant DNA technology. Alteplase is unmodified human tPA, whereas reteplase (see below) is human tPA that has had several specific amino acid sequences removed (130). At low doses, alteplase is quite selective for degrading fibrin without concomitant lysis of other proteins, such as fibrinogen. At the higher doses currently used therapeutically, however, alteplase activates free plasminogen to some extent and, therefore, can cause hemorrhage. Many of the therapeutic indications for the other thrombolytic agents also are indications for alteplase (i.e., myocardial infarction, massive pulmonary embolism, and acute ischemic stroke). T he half-life of alteplase is very short (~ 5 minutes), necessitating its administration as a 15-mg intravenous bolus, followed by a 85-mg intravenous infusion over 90 minutes, or as 60 mg infused over the first hour, with the remaining 40 mg given at a rate of 20 mg/hour.

Prourokinase (scuPA, r-ProUK) Prourokinase is a single-chain, urokinase-like plasminogen activator of 411 amino acids that displays clot-lysis activity yet does not interfere with hemostasis (131). It is nonimmunogenic and has a more favorable dose-related safety and efficacy profile than both urokinase and

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streptokinase. T hus, it is a potentially useful thrombolytic drug in the treatment of peripheral vascular occlusion (132).

Third-Generation Thrombolytic Agents Many third-generation thrombolytic agents currently are under clinical trials. T hese agents are derived from P.844 structural modifications of the basic plasminogen activators (tPA or other tPA of animal origins) using technologies such as mutations, conjugation with monoclonal antibodies, or hybridization with another thrombolytic agent. Some of these agents are amediplase (hybrid of tPA and prourokinase), lanoteplase (mutant tPA), staphylokinase (from bacterial tPA) (125).

Fig. 31.22. Schematic diagram of alteplase, reteplase (removal of amino acids 1–172), and tenecteplase in which threonine (T) at position 103 is replaced with asparagines, asparagine (N) at position 117 is replaced with glutamine, and lysine (K)-histadine-arginine-asparagine at positions 296 to 299 are replaced with four alanines. (Adapted from Nordt TK. Bode C. Thrombolysis: Newer thrombolytic agents and their role in clinical medicine. Heart 2003;89: 1358–1362; with permission.)

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Reteplase (Retav ase) Reteplase is a recombinant deletion mutant of tPA lacking the finger, epidermal growth factor, kringle 1 domain, and carbohydrate side chain (Fig. 31.22) (133). As a highly fibrin-specific thrombolytic agent, reteplase is missing the first 172 amino acids that are present in alteplase and has 355 amino acids with a molecular weight of 39 kDa. Because of the removal of the finger kringle 1 domain, reteplase binding to fibrin is reduced from that of alteplase, and reteplase has reduced fibrin selectivity. In addition, the structural modification reduces hepatic elimination, leading to a longer half-life (reteplase, 14–18 minutes; alteplase, 3–4 minutes). Administered as a double bolus of 10 U every 30 minutes, reteplase is approved for use in acute myocardial infarction.

Tenecteplase (TNKase) T enecteplase is composed of 527 amino acids with 17 disulfide bridges. It differs structurally from anteplase by three point mutations (Fig. 31.22). T he mutations were bioengineered to occur at amino acid 103, where threonine (T ) is replaced by asparagine; at amino acid 117, where asparagine (N) is replaced by glutamine; and at amino acids 296 to 299, where lysine (K)-histidinearginine-arginine are replaced with four alanines. T hus, the name T NK is derived from the mutations. T he replacement of these amino acids along with their attached carbohydrate side chains results in a prolonged half-life (~ 17 minutes) and allows a single bolus application (133). T hese point-mutation changes also change the binding of tenecteplase to plasminogen activator inhibitor-1 (PAI-1) by 80-fold, thus improving activity. A physiological enzyme, PAI-1 inhibits fibrinolysis. Finally, tenecteplase shows a 15-fold higher fibrin specificity. T he drug is still eliminated via hepatic mechanisms.

T oxicity of Antithrom botics and T hrom bolytics Antithrombotic Toxicity Recall that warfarin exhibits its anticoagulation effects by preventing γ-carboxylation of specific glutamate residues necessary for vitamin K–dependent coagulation (Fig. 31.4). However, γ-carboxyglutamate proteins are not unique to coagulation factors. T hese types of proteins are synthesized in bone as well. As would be expected, warfarin also interferes with the carboxylation of these proteins, resulting in an inhibition of the effects of vitamin K on osteoblast development. It has been suggested that this is the mechanism responsible for bone abnormalities in neonates born to mothers who were treated with warfarin while pregnant (134). No evidence suggests that bone metabolism or development is affected by warfarin when the drug is administered to children or adults. Because of the mechanism of action of the warfarin-like drugs, the management of their toxicity is based largely on vitamin K therapy (see Coagulants below). Unlike warfarin, heparin is safe for anticoagulant therapy during pregnancy (134). Although warfarin is known to cause serious fetal malformations when used in pregnancy, heparin does not cross the placental barrier and has shown no tendency to induce fetal damage. Furthermore, heparin does not increase fetal mortality or prematurity. T o minimize the risk of postpartum hemorrhage, it is recommended that heparin therapy be withdrawn 24 hours before delivery. Despite its safety in pregnancy, several potential problems are associated with heparin therapy. Because heparins (high-molecular-weight heparins and LMWHs) are isolated from animal sources, the chance of antigenic hypersensitivity exists but is rarely observed. Heparin competitively binds many other plasma proteins (i.e., vitronectin and PF4) in addition to the antithrombin, resulting in inactivation of the heparin as an anticoagulant (36). T his may be the reason for heparin resistance and for a serious condition known as HIT . T ypically, this condition occurs 7 to 14 days after initiation of heparin therapy, but it may occur earlier in some patients who have had previous exposures to heparin. In these cases, heparin-induced platelet aggregation occurs and may result in the production of antiplatelet antibodies. Development of this condition necessitates termination of heparin therapy and institution of antiplatelet drugs or oral anticoagulants. On withdrawal of heparin, the thrombocytopenia usually is reversible. Mild increases in liver function tests frequently are associated with heparin therapy. Long-term use of full therapeutic doses of heparin (> 20,000 U/day for 3–6 months) has been associated with osteoporosis, and spontaneous vertebral fractures

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have been infrequently reported (36). Hemorrhagic complications of heparin therapy are managed, in part, with the specific antagonist protamine sulfate (36). T his agent is discussed in greater detail in the Coagul ants section of this chapter. T he structural and mechanistic diversity of the antiplatelet drugs disallows a cohesive description of their toxicities. Hemorrhage is certainly a concern, but other, more drug-specific toxicities may be of greater immediate concern. It is suggested that toxicity information for antiplatelet medications be obtained from P.845 appropriate references for the specific agent in question and from the most recent reviews of antiplatelet agents (87).

Thrombolytic Toxicities As discussed earlier, plasmin, because of its lack of specificity, not only digests fibrin but also degrades many other plasma proteins, including several coagulation factors and the anticoagulating factor, activated protein C. T hus, as expected, most thrombolytic drugs not only attack pathological clots but also exert their actions on any other site of compromised vascular integrity. T he dissolution of necessary clots results in the principal side effect of thrombolytic therapy, hemorrhage. Its action on the activated protein C also may be responsible for their neurovascular toxicities (135). Multiple studies have examined the incidence of life-threatening hemorrhage (i.e., intracranial hemorrhage) with the various thrombolytic medications. T hese studies indicate that the rate of significant hemorrhagic complication is essentially the same (0.1–0.7%) regardless of the specific therapeutic agent used. Supportive care is indicated in cases of thrombolytic toxicity. No specific antagonist exists to manage thrombolytic medication-induced hemorrhage, but antifibrinolytic drugs, such as aminocaproic acid and tranexamic acid, often are used. T hese compounds are described in detail in the Coagul ants section of this chapter.

Coagulants A variety of pathological and toxicological conditions can result in excessive bleeding from inadequate coagulation. Depending on the etiology and severity of the hemorrhagic episode, several possible blood coagulation inducers can be therapeutically employed.

Vitamin K Because the orally active anticoagulants, such as warfarin and the indandiones, act through interruption of the normal actions of vitamin K, it stands to reason that vitamin K should be effective

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in the treatment of bleeding induced by these agents (122). Vitamin K 1 (phytonadione, Mephyton) is the form of vitamin K most often used therapeutically. Vitamin K 1 is safe for use in infants, pregnant women, and patients with glucose-6-phosphate deficiency. Furthermore, phytonadione, being more lipid soluble, has a faster onset than other vitamin K preparations and requires smaller doses than vitamin K 3 (menadione) or vitamin K 4 (menadiol sodium diphosphate). Both vitamins K 3 and K 4 may produce hyperbilirubinemia and kernicterus in neonates as well as hemolysis in neonates and glucose-6-phosphate–deficient patients. In fact, the only advantage of vitamins K 3 and K 4 over vitamin K 1 is that whereas absorption of vitamin K 1 requires the presence of bile, absorption of vitamins K 3 and K 4 does not, because they are absorbed via a passive process directly from the intestine (122). T his may be a slight advantage for patients with cholestasis or severe pancreatic dysfunction. Only vitamin K 1 , however, is appropriate therapy for bleeding associated with warfarin and superwarfarin anticoagulation. Vitamin K 2 is not used therapeutically. Vitamin K 1 is effective at inducing coagulation when administered orally, subcutaneously, intramuscularly, or intravenously. Although the oral route is preferred, it is not always practical in a patient who is critically hemorrhaging. T he other routes of administration, though used clinically, all have significant potential drawbacks. Larger doses (e.g., volume > 5 mL) are not appropriate for subcutaneous administration, and intramuscular injection generally is avoided in patients who are at risk for significant hematoma formation (e.g., hemophiliacs). Intravenous dosing of vitamin K has been associated with severe anaphylactoid reactions (including death) presumably secondary to colloidal formulation. T he half-life of vitamin K 1 is quite short—only 1.7 hours via the intravenous route and 3–5 hours via the oral route. When given orally, vitamin K 1 is absorbed directly from the proximal small intestine in an energy-dependent and saturable process that requires the presence of bile salts. T hese kinetic features argue for administration in divided doses rather than larger, single daily doses. T he typical starting point for adults with drug-induced hypoprothrombinemia is 2.5 to 10 mg of vitamin K 1 orally, repeating in 12 to 48 hours if needed. In cases of ingestion of long-acting superwarfarin rodenticides (e.g., brodifacoum), therapy may be 125 mg/day for weeks or months. Practically speaking, because vitamin K 1 is dispensed as 5-mg tablets, superwarfarin-poisoned patients may require 10 to 30 tablets every 6 hours. Because of the short half-life of vitamin K 1 , dosing must be repeated two to four times per day for the duration of treatment. Furthermore, regardless of the route of administration, coagulant effects are not evident for up to 24 hours. Because of this delay in onset, severe P.846 acute hemorrhage is better managed initially with intravenous infusion of fresh-frozen plasma, followed by vitamin K therapy.

Protam ine Mechanism of Action Protamine sulfate has been approved in the United States as a specific antagonist to heparin since 1968 (134). Protamines are an arginine-rich, highly basic group of simple proteins derived from salmon sperm. T he highly acidic heparin polysaccharides exhibit their anticoagulant activity through binding to antithrombin III. Because of the basicity of protamine, heparin has an increased affinity for protamine relative to antithrombin III. In fact, its binding affinity for protamine is so much greater than that of antithrombin III that protamine actually will induce dissociation of the heparin/antithrombin III complex. If protamine is administered in the absence of heparin, it can have marked effects on coagulation. Protamine is not completely selective for heparin and, in vivo, also interacts with fibrinogen, platelets, and other plasma proteins causing anticoagulation. For this reason, use of the minimal amount of protamine necessary to antagonize heparin-associated bleeding should be employed (usually 1 mg of protamine intravenously for every 100 U of heparin remaining in the patient).

Side Effects Anaphylaxis also has been associated with the use of protamine. Although development of protamine anaphylaxis is not limited to diabetics, those patients with diabetes that have used protaminecontaining insulin (NPH or protamine zinc) do have a slightly increased risk of anaphylaxis. Some

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less common reactions to protamine include pulmonary vasoconstriction, hypotension, and thrombus formation.

Antifibrinolytic Agents Mechanism of Action Control of a variety of fibrinolytic states can be achieved using a number of synthetic antifibrinolytic agents, such as tranexamic acid (Cyklokapron) and ε-aminocaproic acid (Amicar), that completely inhibit plasminogen activation. Plasmin binds to fibrin through a lysine binding site to activate the final stages of fibrinolysis (Fig. 31.1). Aminocaproic acid, a lysine analogue, and tranexamic acid are antifibrinolytic agents with high affinity for the five lysine binding sites of plasminogen, thus effectively competing and preventing the binding of plasmin to fibrin.

Pharmacokinetics Both ε-aminocaproic acid and tranexamic acid are readily absorbed when administered orally. T hey also can be given intravenously, although significant hypotension can result if the infusion is given too quickly. Elimination of the drugs is primarily renal, with little metabolism taking place. T he half-lives of ε-aminocaproic acid and tranexamic acid are each approximately 2 hours.

Therapeutic Use T hese drugs find clinical utility in settings such as prevention of rebleeding in intracranial hemorrhages, as adjunctive therapy in hemophilia, and of course, in treatment of bleeding associated with fibrinolytic therapy. In most bleeding conditions, however, ε-aminocaproic acid therapy has not been shown to be of definitive benefit. In recent trials, tranexamic acid was found to reduce red cell transfusion better than ε-aminocaproic acid or placebo in patients undergoing liver transplantation (136).

Side Effects T he major risk associated with ε-aminocaproic or tranexamic acid therapy is intravascular thrombosis as a direct result of the inhibition of plasminogen activator. T hrombi that form during therapy are not easily lysed and, therefore, can have additional ischemic consequences. Additional possible complications include hypotension, abdominal discomfort, and rarely, myopathy and muscle necrosis.

Aprotinin (Traysylol) Operative procedures, such as heart valve replacement, frequently have effects on platelet function and endogenous coagulation factors (137). T hese effects may result in significant peri- or postoperative bleeding. Aprotinin is a serine protease inhibitor that blocks kallikrein and plasmin and provides some protection to platelets from mechanical injury. T he inhibition of fibrinolysis results in profound antihemorrhagic effects (137). Side effects of aprotinin therapy usually are minor, but anaphylaxis has possibly been implicated in a small population (< 0.5%). For this reason,

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it is suggested that a small test dose be given before initiation of the therapeutic infusion.

Plasma Fractions Spontaneous bleeding can result from dysfunction or deficiencies of specific coagulation factors. A list of coagulation factors and deficiency states is given in T able 31.6. Spontaneous bleeding usually occurs when the activity of coagulation factors falls below 5% of normal. T ypically, these deficiencies are the result of a chronic disease state, such as von Willebrand's disease or hemophilia. Management of an acute hemorrhagic event in a coagulation factor–deficient patient includes administration of the appropriate factors in concentrated form. T he most P.847 common inherited clotting factor deficiencies involve factor VIII (classic hemophilia A) and factor IX (hemophilia B, or Christmas disease).

Table 31.6. Clotting Factors

Factor Common Name

Deficiency State

Source

Half-Life of Infused Factor Target for (days) Action of

I

Fibrinogen

Afibrinogenemia, defibrination syndrome

Liver

4

II

Prothrombin

Prothrombin deficiency

Liver (requires vitamin K)

3

III

Tissue thromboplastin, thrombokinase, tissue factor

IV

Calcium (Ca 2+ )

V

Proaccelerin, labile factor

VI

Deleted factor

VII

VIII

Heparin (IIa), warfarin (synthesis)

Liver (may require vitamin K)

Factor V deficiency

Liver

1

Proconvertin, stable factor

Factor VII deficiency


0.25

Antihemophilic A factor (AHF), antihemophilic globulin (AHG)

Hemophilia A (classic) Von Willebrand's

Liver

0.5 Unknown

Heparin (VIIa); warfarin (synthesis)

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disease IX

Antihemophilic B factor, plasma thromboplastin component (PTC), Christmas factor

Hemophilia B (Christmas disease)


1

Heparin (IXa); warfarin (synthesis)

X

Stuart or Stuart-Prower factor

Stuart-Prower defect


1.5

Heparin (IXa); warfarin (synthesis)

XI

Plasma thromboplastin antecedent (PTA)

PTA deficiency

Unknown

3

XII

Hageman factor, contact factor

Hageman defect

Unknown

Unknown

XIII

Fibrinstabilizing factor, fibrinase Fletcher factor, prekallikrein factor Fitzgerald factor, high-molecularweight kininogen

Fibrin-stabilizing factor deficiency

Unknown Liver Liver

6

Antithrombin III Proteins C & S Plasminogen

Antithrombin III deficiency

3 Warfarin (synthesis) Thrombolytic enzymes, aminocaproic acid

T wo forms of factor VIII concentrate are clinically available, cryoprecipitate and lyophilized factor VIII concentrate. Cryoprecipitate is a factor VIII–rich plasma protein fraction (PPF) prepared from whole blood that also contains approximately 300 mg of fibrinogen per unit. Immediately before

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infusion, the required number of cryoprecipitate units are thawed in a sterile saline/citrate solution and pooled. T he lyophilized factor VIII concentrates are prepared from large plasma pools and also are rich in fibrinogen. Lyophilized factor VIII concentrates are not useful in therapy for von Willebrand's disease, because during the extraction and lyophilization process, the polymeric structure of factor VIII in the von Willebrand protein that supports platelet adhesion is destroyed, rendering the preparation inactive. Because of the pooling of blood from multiple donors in the preparation of lyophilized factor VIII concentrates, it generally is held that cryoprecipitate, which is isolated from a single donor, is safer. T he major concern associated with the use of concentrated clotting factors is the risk of viral transmission (primarily HIV and hepatitis B). T his fear has somewhat attenuated the use of concentrated plasma fractions, even in diseases such as hemophilia. Ultrapure factor VIII concentrates produced using recombinant DNA technology have been approved for use. Frequently, however, the expense of these recombinant agents is the reason why the more traditional plasma isolates are used—despite the possibility of viral transmission. P.848 Lyophilized preparations of prothrombin, factor IX, and factor X also are available. T he manufacturing process involves plasma extraction with solvents and detergents that renders the preparations virally inactive but still able to activate clotting factors. T o prevent excessive thrombus formation in these situations, heparin often is added to the therapeutic regimen. At times, a hemorrhagic event is possible but the patient does not require immediate coagulation therapy. For example, if a patient with mild hemophilia A needs to have a dental extraction performed, the potential for hemorrhage exists. In these cases, it is possible to increase the activity of the endogenous factor VIII through pretreatment with desmopressin acetate. T his preoperative measure may alleviate the need for clotting factor replacement.

Plasm a Extenders and Blood Substitutes Maintenance of circulation is secondary only to airway and breathing in the American Heart Association chain of survival (138). Circulation is governed by the three components of the Fick Principle: 1) on-loading of oxygen onto the erythrocytes (red blood cells), 2) delivery of oxygen-laden erythrocytes to the various cells and tissues, and 3) off-loading of the oxygen from the erythrocytes to the tissue cells (139). Interruption of any of these three components results in physiologic compromise. Inadequate blood volume (i.e., a loss of red blood cells) will disallow the transport of oxygen to tissues. Severe anemia, such as that secondary to major hemorrhage, is a complicated condition to manage. Simply replacing lost blood with new blood may not always be practical—or even beneficial to the patient. Numerous approaches and theories exist that attempt to define the best method of emergently managing severe blood loss. T wo basic types of fluid infusion are used for the resuscitation of severely anemic patients. T hese are sanguinous (blood-containing) infusions, in which fluids (e.g., whole blood and fractionated blood products) are used, and asanguinous (i.e., nonblood-containing) infusions, in which various crystalloids, colloids, blood substitutes, and plasma expanders are employed.

Sanguinous Resuscitation It seems intuitive that resuscitation following severe blood loss would be best accomplished by replacing lost blood with fresh blood (i.e., sanguinous resuscitation); however, this is not always in the best interest of the resuscitation. Nonetheless, infusion of blood and blood products is recommended in certain hypovolemic circumstances. Generally, if hemodynamic instability exists in a hypovolemic adult following the infusion of 2 L of crystalloid (three successive 20 mL/kg body weight infusions in a child), addition of blood to the resuscitative regimen is recommended (140). T he most significant advantage of sanguinous resuscitation is that infusion of red blood cells can replace both volume and oxygen-carrying capacity. Significant disadvantages of sanguinous resuscitation include limited supply, risk of transfusion reaction, expense, and possible transmission of bloodborne diseases. At one time, a significant controversy existed regarding whether survivability was increased with the use of whole-blood transfusion or infusion of packed red blood cells (known as component therapy).

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T raditionally, this decision was based on cost and the fact that few hospitals actually stored whole blood. Fortunately, however, scientists reached the same decision as the fiscal experts (140). T he three major conclusions drawn from the scientific community were as follows: 1. “ Whole blood out” does not require “ whole blood in.” Banked whole blood stored at 4°C lacks functional platelets and also suffers a progressive deterioration in the activities of various clotting factors. T here is little difference in these parameters between banked whole blood and packed red blood cells. Because trauma patients require red blood cells, clotting factors, and platelets to varying degrees, it makes more sense to use functional components to replace what is specifically needed at that time. 2. Whole blood is not infused more rapidly than packed red blood cells. In fact, infusion technology exists that allows replacement of packed red blood cells suspended in normal saline as fast as 1,600 mL/min. 3. T he overall risk of antigenic hypersensitivity reactions is greatly increased when using whole blood as opposed to specific components. T he standard of care at this time is judicious use of the individual components with crystalloid infusion to maintain volume while the defect resulting in the blood loss is repaired.

Asanguinous Resuscitation Crystalloids are aqueous electrolyte-containing solutions without proteins or large molecules. Examples of crystalloids are normal saline (0.9% NaCl) and lactated Ringer's solution. Colloids are aqueous solutions that contain various proteins or other larger molecules as well as electrolytes. Protein-containing colloids include albumin and PPF. Nonproteinaceous colloids include the dextrans and hetastarch. A list detailing the compositions of several common crystalloids and colloids is given in T able 31.7.

Crystalloids Crystalloids have several advantages, including being inexpensive and free of risk of transferring bloodborne pathogens or inducing anaphylaxis. Furthermore, they largely are compatible with drugs and undergo rapid P.849 renal clearance. T he crystalloids, however, have a very short resident time in the intravascular space—only 30% remains in the vasculature within a few minutes following infusion. T hese fluids rapidly leak out of the vasculature into the interstitial space and can result in significant extravascular fluid accumulations (“ third spacing” ). Furthermore, crystalloids do not have any oxygen-carrying capacity.

Table 31.7. Composition of Common Intravenous Fluids

Solution

Ionic Common/Trade Concentration Concentration Name Solute g/dL mEq/L

Indications

Crystalloids 0.9% Saline

Normal Saline

NaCl

0.90

Na + 154 Cl - 154

Hypovolemia Heat-related emergencies Freshwater drowning Diabetic ketoacidosis

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0.45% Saline

Half-Normal Saline

NaCl

0.45

Compromised cardiac function

3% Saline

Hypertonic Saline

NaCl

5% Dextrose in water

D5W

Glucose

5.0

Lactated Ringer's

Hartman's

NaCl

0.86

Na + 130

Hypovolemic shock

Solution

KCl CaCl 2 Na Lactate

0.03 0.02 0.31

K+ 4

Obstetric emergencies

Albumin

4.4

Na + 130–160

Fraction

Globulin

0.6

Cl - 130–160

Albumin

Albumin

5 25

Na + 130–160

Na + 77 Cl - 77

3.0

Hypovolemia, hyponatremia TCA OD

Na + 513 Cl - 513

Intravenous drug route Dilution of concentrated drugs for intravenous infusion

Ca 2+ :3, Cl - :109 Lactate 28

Colloids Plasma protein

Plasmanate

Hypovolemic shock

Hypovolemic shock

Cl 130–160 Hetastarch

Hespan

Hydroxyethyl Starch

6 (in saline)

Na + 154 Cl - 154

Hypovolemic shock

*TCA OD, Tricyclic antidepressant overdose

Attempts at lengthening intravascular resident time of the solution and limit third spacing have resulted in the development of “ hypertonic” crystalloid solutions. An example of a hypertonic solution is 3% NaCl (“ hypertonic saline” ). It has been suggested that the increased electrolyte

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concentration will result in an osmotic gradient pulling fluid from the interstitial and intracellular spaces into the vasculature. T hese fluid shifts therefore would require less total volume to be infused. As expected, the possibility of severe hypernatremia and hyperchloremia, among other electrolyte disturbances, exists.

Protein Colloids Protein colloids contain larger molecules and have a longer intravascular residence time than crystalloids, but eventual fluid loss to the extravascular space does occur. Protein colloids, such as albumin and PPF, are prepared from pooled human blood and, therefore, carry with them a risk of transmission of viral infection or induction of anaphylaxis. T he PPF is a 5% mixture (5 g of protein in 100 ml of 0.9% NaCl solution) of proteins that is osmotically equivalent to human plasma. T he composition of the protein mixture is 83 to 90% albumin. Albumin typically is administered as either a 5 or 25% solution. By definition, albumin preparations must be composed of a protein mixture that is more than 90% albumin. Generally, PPF is favored over albumin for fluid resuscitation, because albumin appears to cause more interstitial edema.

Nonproteinaceous Colloids Dextrans Nonproteinaceous colloids also are used in fluid resuscitation. T hese compounds generally are complex mixtures of sugar polymers. Dextrans are glucose polymers produced by bacteria linked in an α-1,6 chain and having an α-1,3 or α-1,4 branch about every fifth residue. T he specific positioning of the branching varies by the bacterium producing it. T he molecular weights of these chains generally are 40 or 70 kDa (dextran-40 and dextran-70, respectively), and the compounds work via an osmotic gradient similar to the colloids and hypertonic crystalloid solutions. Dextran-70 is a 4% solution, whereas dextran-40 is a 10% preparation. Dextrans have a longer intravascular residence time P.850 than albumin, which limits interstitial edema. As with the crystalloids and other colloids, the dextrans have no oxygen-carrying capacity. Furthermore, because they are bacterial products, the dextrans have the potential to be potent antigens and induce anaphylaxis. T he incidence of serious antigenic response seems to increase if the dextran used has a significant fraction of components with a molecular weight of greater than 100 kDa. In these cases, administration of dextran-1 (molecular weight, 1 kDa) before the higher-molecular-weight dextrans minimizes formulation of the very large immunogenic complexes. T his approach has been shown to decrease sensitivity responses to high-molecular-weight dextrans by as much as 15- to 20-fold. T his is particularly important in a number of European countries, where dextran-150 (molecular weight, ~ 150 kDa) is routinely used.

Hetastarch Hetastarch, another nonproteinaceous colloid, is a complex mixture of ethoxylated amylopectins

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ranging in molecular weight from 10 to 1,000 kDa (average molecular weight, ~ 450 kDa). When infused as a 6% solution, hetastarch approximates the activity of human albumin. T he larger molecular weights, however, increase its intravascular residence time as well as its plasma expansion effects relative to albumin. Hetastarch is synthetically produced, so it is degraded more slowly and is less antigenic than other colloids. Despite these advantages, hetastarch is quite expensive and also has no oxygen-carrying capacity. Plasma substitutes, such as dextrans and hetastarch, have some additional unusual disadvantages specific to the various classes. High-molecular-weight (70-kDa) dextran coats erythrocytes, making subsequent blood typing and cross-matching difficult. On the other hand, low-molecular-weight (40-kDa) dextran coats platelets, which can induce a bleeding disorder. Hetastarch has a dilutional effect on factor VIII and, therefore, should not be used to treat patients with factor VIII deficiency (e.g., hemophilia)–related hemorrhage. Combination use of hypertonic crystalloids with nonproteinaceous colloids has been investigated. For example, 7.5% NaCl in 6% dextran-70 (hypertonic saline–dextrose) has been studied in a variety of animal models and in human trauma patients with some success. Particularly promising are animal studies of closed head injury, which suggest not only a hemodynamic benefit but also a sustained decrease in intracranial pressure. Studies in this system as well as in burn and trauma patients are ongoing.

Red-Cell Substitutes (“Synthetic Blood”) Concerns about the safety and adequacy of the blood supply and the increasing need to rigorously screened human blood because of HIV and hepatitis B and C virus have stimulated extensive search for “ blood substitutes” (or, more accurately “ red-cell substitutes” ) for resuscitation of trauma patients (140,141). T hree different classes of materials have been evaluated clinically as potential blood substitutes (140). T hey are perfluorocarbon (PFC)-based emulsion, hemoglobin-based oxygen carriers (HBOCs), and liposome-enclosed hemoglobin. T hus far, only the PFCs and HBOCs have reached various phases of their clinical trials, whereas liposome-enclosed hemoglobin is still in the preclinical stage of development. Several excellent reviews have been published in recent years summarizing the clinical progress, efficacy, and toxicity of these agents (142,143,144,145,146).

Perfluorocarbon-Based Oxygen Carriers Some of the common ingredients of the synthetic blood substitutes are shown in Fig. 31.23. T he most significant benefit of PFCs is their ability to transport oxygen to the body tissues via the circulatory system and their in vivo metabolic stability (145). T his ability results from the high solubility of gases, such as oxygen and carbon dioxide, in the PFC preparations. Red blood cells with fully functional hemoglobin have an oxygen solubility of 17 to 20 mL/dL. Red blood cells without hemoglobin can only dissolve approximately 0.3 mL/dL of oxygen. T he oxygen solubility of PFC preparations is approximately 7 mL/dL.

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Fig. 31.23. Chemical structures of perfluorocarbon-based blood substitutes.

P.851 T he PFCs are formulated as stable aqueous emulsions with dextrose, egg yolk phospholipids, and physiologic electrolytes. T hese emulsions are somewhat less viscous than whole blood at 37°C. T he PFCs have a dose-dependent half-live of 8 to 24 hours. Normal doses are 10 mL/kg, but short-term doses of up to 30 mL/kg have been reported. T he PFCs are not metabolized and are eliminated unchanged in expired respiratory gases. Because they are highly lipophilic, multiple doses can cause PFC accumulation in the liver and spleen. T herefore, it is recommended that these compounds not be administered more than once in a 6-month period. During the early 1980s, PFC emulsions, such as Fluosol (a 20% emulsion of perfluorodecalin and perfluoro-tri-n-propylamine), were used as an oxygen carrier in the preoperative treatment of severely anemic patients, but often with significant toxicities, high incidence of hypertension, and potential to cause anaphylaxis reactions (143,147). Another use for PFC emulsions is decreasing or preventing myocardial ischemia during percutaneous transluminal coronary angioplasty in high-risk patients. T he emulsion is preoxygenated and injected transluminally through the coronary angioplasty balloon to deliver the oxygenated emulsion to areas distal to the point of balloon inflation. Less common but also investigated uses of PFC emulsions include therapy for carbon monoxide intoxication, oxygenation in cases of cerebral hypoxia, autoimmune hemolytic anemia, and nonavailability of compatible blood products. Newer PFCs, such as perflubron, that are less toxic have been used with some success in limited clinical trials during orthopaedic surgery (148).

Genetically Engineered and Chimeric Hemoglobin-Based Oxygen Carriers Stroma-free hemoglobin appears to hold significant promise as a potential acellular oxygen transporter. T hese preparations have no effect on colloid osmotic pressure and are not effective as plasma expanders. A number of potential advantages exist with this technology. For example, stroma-free hemoglobin can be prepared from bovine or outdated human erythrocytes, no cross-match is necessary, it is lyophilized for convenient and space-efficient storage, and it is reconstituted in normal saline (149). T wo major problems that are currently being addressed are large-scale production of the material and the fact that stroma-free hemoglobin does not readily release oxygen to the tissues at normal oxygen tensions. Recombinant DNA technology has allowed the production of large amounts of hemoglobin through synthetic gene expression in Escheri chi a col i and Saccharomyces cerevi si ae. New developments in hemoglobin polymerization also show promise (142,149). Another approach to stroma-free hemoglobin technology is the development of chimeric hemoglobins. Human hemoglobin stripped from red blood cells is not functional. Diphosphoglycerate (DPG) is required for oxygen release from hemoglobin, and insufficient DPG is available outside the red cell to induce oxygen release (i.e., oxygen affinity for hemoglobin is too high in the absence of DPG). T etrameric human hemoglobin decomposes into dimers when infused into the bloodstream. T hese dimers precipitate in the kidneys, potentially causing severe renal damage. In native red cell–bound hemoglobin, this decomposition is prevented by the high concentration of proteins inside the red blood cells. Interestingly, not all species require AT P and DPG to diminish oxygen affinity for hemoglobin. T he crocodile is one such animal in which red blood cells do not contain DPG, and this phosphate has no effect on oxygen affinity to their hemoglobin. Crocodile hemoglobin cannot be used directly in humans, because certain features of human hemoglobin are necessary for recognition and signaling. Genetic engineering technology has allowed the creation of a chimeric hemoglobin that is part human and part crocodile and that is useful in humans (149). It has the advantage of providing hemoglobin oxygen-carrying capacity without transmitting human bloodborne diseases. One major disadvantage is that the chimeric hemoglobins are not endogenous proteins and, therefore, may be potent antigens. A great deal of investigation is still necessary before chimeric hemoglobins will see any clinical usage.

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T he most successful HBOCs clinically are polymerized hemoglobin solution (142). Among these, Hemolink, Hemopure, and PolyHeme are undergoing U.S. FDA–approved phase III clinical trials. Hemolink is a product consisting of human hemoglobin polymerized using an oxidized trisaccharide, O-raffinose, followed by a reduction. Hemopure and PolyHeme, on the other hand, are produced by using glutaraldehyde as the polymerizing agent and with either bovine hemoglobin (Hemopure) or human hemoglobin (PolyHeme) as the source of hemoglobins. Newer HBOCs without the nitric oxide–scavenging properties of the first-generation HBOCs have been prepared and are being investigated as red-cell substitutes (150,151,152,153).

Liposome-Encapsulated Hemoglobin T he successful use of liposomes as drug-delivery vehicles has prompted the preparations of liposome-encapsulated hemoglobins as artificial red-cell substitutes (154). T his represents a promising approach for the design of longer storage half-life red-cell substitutes, because it has no blood group antigens on its surface and, thus, could be stored for long period of times (154). T he circulatory half-life of liposome-encapsulated hemoglobin is further improved with the design of cellular-based red-cell substitutes with an actin matrix underlying the lipid bilayer as a structure support (155). P.852

Case Study Victor ia F. Roche S. William Zito DF is a 24-year-old His panic man who appeared in the emergency department with a chief c omplaint of right leg s welling and pain. He reports that he received a severe trauma to his right c alf 5 days ago f rom the c rus h of people at a protes t rally in support of equal rights f or immigrant f arm workers . A review of DF's patient history reveals him to be a healthy male exc ept f or a previous HI T that res ulted f rom low-dose heparin prophylaxis associated with a laparos c opic repair of an inguinal hernia several years ago. On examination, the phys ician obs erves the c las s ic s igns of DVT, including pain when as ked to pull his f oot up toward himself agains t res is tanc e, tendernes s , swelling, and warmth. The presence of DVT was c onf irmed by Doppler ultras onography, and the physician wants to begin antic oagulation treatment and as ks your opinion of the f ollowing choices 1. I dentif y the therapeutic problem(s) where the pharmac ist' s intervention may benef it the patient. 2. I dentif y and prioritize the patient-spec if ic f actors that must be considered to achieve the des ired therapeutic outc omes. 3. Conduc t a thorough and mec hanistically oriented struc ture–activity analysis of all therapeutic alternatives provided in the case. 4. Evaluate the s truc ture–ac tivity relationship f indings against the patient-s pecif ic f actors and des ired therapeutic outc omes, and make a therapeutic decision. 5. Couns el your patient.

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Chapter 32 Insulin and Drugs Used for the Treatment of Diabetes Robin M. Zav od John L. Krste nansky Bruce L. Currie

Introduction History and Epidemiology T he term “ diabetes mellitus” is derived from the Greek word for siphon (diabetes) and the Latin word for sweet (mellitus). T he Greek physician Arateus, in the first century AD, described diabetes as “ the melting down of flesh and limbs into urine” (1). T he term “ mellitus” was added 1,000 years later in medieval times when physicians noticed the sweet taste of urine from some of their patients. Diabetes is not a single disease but, rather, is a group of metabolic diseases characterized by hyperglycemia caused by inadequate insulin secretion with or without a simultaneous decrease in hormone action at its receptor (2). T he World Health Organization estimates that 177 million people worldwide have diabetes. It is predicted that by 2010, there will be a 50% increase in this number, with the most significant increases in Africa, Asia, and South America (3). In the United States, it is estimated that 18.2 million people have diabetes. During the last 40 years, the prevalence of this disease has increased sixfold (4). Currently, diabetes is the fifth deadliest disease, killing 400,000 annually. In 1869, Paul Langerhans determined that the pancreas is comprised of two cell types: acinar cells, which secrete digestive enzymes, and cells clustered in islets with a different biological function (5). T wenty years later, in Strasbourg, France, Mehring and Minkowski induced diabetes in a dog by removing its pancreas. In doing this type of experiment, they determined that the pancreas is the origin of diabetes mellitus (6). By 1909, the German scientist Georg Zuelzer had created the first pancreatic extract; unfortunately, the side effects were too extreme for the extract to be of therapeutic benefit. In 1921, in a laboratory provided by John J. R. MacLeod, Frederick G. Banting (orthopaedic surgeon), and Charles H. Best (medical student) isolated insulin from the pancreas and initially tested it in dogs (7). On January 11, 1922, their pancreatic extract was administered to a 14-year-old diabetic boy, Leonard T hompson, who was near death, and he quickly recovered. On May 31, 1922, a bovine pancreatic extract was developed by William Sansum, M.D., and chief chemist Norman Blatterwick and was injected into 51-year-old Charles Cowan, who recovered and lived to age 90 (8). In 1922, insulin could be readily isolated and purified in large quantities from both cattle and pigs in Great Britain, so the British Medical Research Council introduced insulin as a therapeutic agent. In 1923, Eli Lilly made insulin available in the United States and Canada, and the Nobel Prize for Medicine or Physiology was given to Banting and MacLeod, who shared it with Collip and Best (7). By 1924, large companies in both the United States and Britain were producing insulin and marketing it worldwide. In 1960, the primary amino acid sequence of insulin was identified, and by 1963, the complete synthesis of insulin was possible. Hodgkin and coworkers determined the three-dimensional structure of insulin in 1972 (5).

Type 1 Diabetes T ype 1 diabetes, which represents the diagnosis for 5 to 10% of the diabetic population, is caused by an absolute deficiency in insulin secretion. T his overt absence of insulin production results from immune system–mediated destruction of the insulin-producing pancreatic β cells. Without insulin, the body's primary source of energy and the brain's only source of energy, glucose, is unable to P.856 enter cells. T his ultimately leads to the cells being energy starved as well as to elevated plasma blood glucose levels (hyperglycemia). Administration of exogenous insulin currently is the only method to effectively resolve this hormone deficiency.

C lin ic a l Sig nific a n c e Diabetes is a condition wherein the body no longer produces insulin (β-cell dysfunction) or uses insulin efficiently (insulin resistance). Insulin is a hormone that is needed to convert carbohydrates and other food into energy needed for life. T he cause of diabetes remains unknown, although genetics and environmental factors, such as obesity and a sedentary lifestyle, appear to play important roles. More than 20.8 million Americans, or 7% of the population, have diabetes. Unfortunately, an estimated 6.2 million people remain unaware that they have the disease. Diabetes is the leading cause of new-onset blindness, kidney failure, and nontraumatic amputations and has a major role in the development of heart disease, hypertension, sexual dysfunction, and dental disease.

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Many oral diabetes medications are available with different mechanisms of action. Combination therapy, using medications from the different classes to address the deficiencies causing diabetes, is standard in diabetes care. Secretagogues, such as the sulfonylureas and the meglitinides, increase pancreatic insulin secretion and usually are used early in the disease process, when pancreatic β cells still produce insulin. Sulfonylureas typically can reduce a patient's hemoglobin A1c by 2%, whereas meglitinides can cause a reduction of approximately 1%. Metformin blocks hepatic output of glucose, is used throughout the disease spectrum, and can reduce hemoglobin A1c by 2%. Metformin is particularly advantageous in its ability to delay the onset of diabetes and to promote weight loss in patients. T hiazolidinediones (T ZDs) enhance insulin sensitivity and may have a role early in preserving β-cell function in diabetes. T he initial concern about the hepatotoxicity of T ZDs has been relaxed, with few cases being reported with available agents. T he efficacy typically seen with T ZDs is an approximately 1.0 to 1.5% decrease in hemoglobin A1c . When the β cells of the pancreas cease to make insulin suddenly (type 1) or over time (type 2), exogenous insulin must be administered. T he overall goal of insulin is to mimic physiological insulin secretion. T his is achieved by using a combination of basal and bolus insulin. T ypes of basal insulin include neutral protamine Hagedorn, glargine, and detemir. T heir role as basal insulin is to provide a constant, relatively peakless supply of insulin throughout the day, regardless of meals. T ypes of bolus insulin include aspart, glulisine, lispro, and regular. T he role of bolus insulins is to provide insulin coverage for meals. With the introduction of incretin mimetics, the first new class of diabetes agents in nearly 20 years is now available. Incretins improve glucose control but also have the potential to improve insulin resistance and to restore β-cell function. One important aspect of treating a patient with diabetes is not to focus on blood sugar alone. T he leading cause of death for patients with diabetes is heart disease; therefore, health care providers need to assess cholesterol, blood pressure, and other risk factors for heart disease. Nathan A. Painter Pharm.D. Assi stant Professor of Pharmacy Practi ce, School of Pharmacy, Loma Li nda Uni versi ty

Type 2 Diabetes T ype 2 diabetes, for which 800,000 new cases are diagnosed per year, is a more complex disease. If one parent has type 2 diabetes, the risk of developing it is 38%, whereas if both parents are affected then, the risk of developing diabetes before age 60 is 60% (3). T ype 2 diabetes is characterized by end-organ insulin resistance and/or a relative deficiency in insulin secretion (9). Unlike the abrupt loss of β-cell function characteristic of type 1 diabetes, the pancreatic β cells in type 2 diabetes undergo progressive deterioration over a fairly long time. In many patients, insulin resistance causes an initial increase in plasma insulin levels as a result of a compensatory increase in insulin secretion. At this point, blood glucose levels likely appear normal and the patient is asymptomatic. As β-cell function falters and insulin resistance worsens, hyperglycemia results (2). For most patients with type 2 diabetes, resolution of their metabolic disease may occur with appropriate lifestyle changes, including a well balanced diet and regular exercise. For those type 2 patients who are unable to achieve normal blood glucose levels nonpharmacologically, several classes of oral agents are available that target various biochemical processes associated with insulin secretion and/or insulin receptor sensitivity.

Gestational Diabetes Gestational diabetes (GDM) complicates approximately 4% of all pregnancies in the United States (135,000 cases annually) (9). It is classified as any degree of glucose intolerance that first occurs during pregnancy, typically during the third trimester. T he risk factors associated with developing GDM include previous history of GDM, obesity, glycosuria, or a family history that includes diabetes (10). It is found more frequently in the following populations: African American, Hispanic American, Pacific Islander, and Native American (10). If GDM develops during pregnancy, then the woman has a 50% risk of developing type 2 diabetes in the future and a 50% risk of experiencing GDM in a subsequent pregnancy (10). Babies born to women with preexisting diabetes that is poorly controlled are two- to fourfold more likely P.857 to have a serious birth defect (e.g., eye defects, respiratory tract defects, cleft palate, anal atresia/stenosis, urinary tract defects, and positional defects of the foot) (10). Whether the mother has preexisting diabetes or develops GDM, she is at risk for delivering a large baby (≥10 pounds). It therefore is recommended that those women with preexisting diabetes maintain tight blood glucose control for 3 to 6 months before conception and that insulin therapy replace all oral hypoglycemic medications during the pregnancy.

Table 32.1. M aturity-Onset Diabetes of the Young: Classifications and Genetic Loci (9,11) TypeGenetic Loci 1

HNF-4α

Biochemical Effect Regulation of gene transcription in pancreatic β cells is abnormal. Defect in metabolic signaling of

Treatment Oral agent or

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insulin secretion results.

insulin

2

Glucokinase

Defective enzyme produced. Enzyme is required in conversion of glucose to glucose-6-phosphate (the rate limiting step in glucose metabolism). Defect in β-cell sensitivity to glucose and hepatic storage of glucose as glycogen results.

Diet and exercise

3

HNF-1α

Regulation of gene transcription in pancreatic β cells is abnormal. Defect in metabolic signaling of insulin secretion results.

Oral agent or insulin

4

IPF-1

Transcriptional regulation of β-cell development/function is abnormal.

Oral agent or insulin

5

HNF-1β

Regulation of gene transcription in pancreatic β-cells is abnormal. Defect in metabolic signaling of insulin secretion results.

Insulin

6

NeuroD1

Transcriptional regulation of β-cell development/function is abnormal.

Insulin

M aturity-Onset Diabetes of the Young Maturity-onset diabetes of the young may account for 1 to 5% of all cases of diabetes in the United States. It is not a single disease but, rather, represents several types of genetic disorders. T o date, there have been abnormalities detected at six genetic loci (T able 32.1). It generally is characterized by impaired insulin secretion with minimal or no defects in insulin action. In this scenario, the onset of hyperglycemia is early (< 25 years) (9,11).

M etabolic Syndrome Metabolic syndrome, also known as Syndrome X or the insulin resistance syndrome, was defined by the World Health Organization in 1999 as the presence of diabetes, impaired fasting glycemia, impaired glucose tolerance or insulin resistance, and two or more of the following: obesity, dyslipidemia, hypertension, or microalbuminuria (T able 32.2) (12). Somewhat similar definitions are used by other organizations. T he prevalence of this syndrome is highly age dependent (7% in ages 20–29, 44% in ages 60–69, and 42% in ages ≥70). Individuals with this syndrome are predicted to develop cardiovascular disease and diabetes.

Drug-Induced Diabetes A number of drugs impair insulin secretion or insulin action at its receptor (T able 32.3) and, potentially, cause drug-induced diabetes. Generally speaking, impairment in insulin secretion may not be sufficient to cause a patient to develop diabetes; however, it may be enough for those who are already predisposed to develop the disease or already experiencing insulin resistance (9). In a limited number of cases, patients develop diabetes and their blood glucose levels remain uncontrolled despite treatment with insulin, oral agents, and diet modification (13). T he greatest likelihood of developing drug-induced diabetes is associated with the glucocorticoids.

Prediabetes: Impaired Fasting Glucose and Impaired Glucose Tolerance Impaired fasting glucose (IFG; fasting blood glucose, ≥100 mg/dL and < 126 mg/dL) and impaired glucose tolerance (IGT ; 2-hour values for oral glucose tolerance, ≥140 mg/dL and < 200 mg/dL) are two additional metabolic states that must be mentioned. In addition to those diagnosed with diabetes, 16 million Americans experience IGT (4). Patients with either IFG or IGT could be classified as prediabetic, because the disease has not yet progressed far enough to cause hyperglycemia yet the blood glucose levels are too high to be considered normal (9). Approximately 7% of those patients who present with IFG or IGT progress to overt diabetes annually (3).

Table 32.2. Clinical M easures Associated with M etabolic Syndrome (12)

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Condition

M easurement

Gender Differences

Obesity

BMI >30

Waist to hip ratio: Males: >0.9 Females: >0.85

Dyslipidemia

Triglycerides ≥1.7 mmol/L

HDL cholesterol Males: 20 µg/min

BMI, body mass index; BP, blood pressure; HDL, high-density lipoprotein.

P.858

Table 32.3. Drugs that Impair Insulin Secretion or Insulin Action Thyroid hormone

β-Adrenergic agonists

Nicotinic acid

Thiazides

Glucocorticoids

Dilantin

Atypical antipsychotic agents

α-Interferon

Biochem istry and Pathogenesis of Diabetes Glucose M etabolism After consuming a meal, complex carbohydrates are broken down into simpler sugars in the gastrointestinal (GI) tract. Glucose can then be absorbed and serve as the primary source of energy for the body as well as the only source of energy for the brain. If too much glucose is absorbed, then hyperglycemia can result. Normally, the liver is able to prevent hyperglycemia by storing up to two-thirds of the glucose absorbed from the intestines and releasing it when the body requires additional energy (2). In addition to glucose being taken up and converted by glucokinase (hexokinase IV) to glucose-6-phosphate (G6P) and then, ultimately, to glycogen in the liver, it can be taken up or used by several other types of cells. In the presence of insulin, glucose is taken up into muscle (heart, skeletal, and smooth) cells and serves as a source of energy for those cells. Glucose can be taken up by pancreatic β cells via the glucose transporter 2 (GLUT 2) and is then, in the rate-limiting step, phosphorylated by glucokinase to G6P (3). In this reaction, glucokinase effectively serves as a glucose sensor for the pancreatic β cells, because it controls the rate of entry of glucose into the glycolytic pathway and the subsequent metabolism of G6P to adenosine triphosphate (AT P) (11). T hen, depending on the resulting ratio of adenosine diphosphate to AT P in the pancreatic islet cell, activation of the sulfonylurea receptor 1 (SUR1) protein occurs, followed by a cascade of biochemical events (3). T hese events include initial closure of potassium channels, which alters the membrane potential of the cell. Calcium channels then open, allowing calcium to flow into the pancreatic islet cell. T his increase in intracellular calcium concentration triggers the movement and ultimate release of preformed insulin granules from the islet cells (3).

Role of Insulin and Insulin Receptors Insulin plays a vital role in a number of biochemical processes, including more than 100 examples of gene regulation. In the liver and muscle tissues, insulin promotes the storage of excess glucose as glycogen. Insulin suppresses hepatic glucose production and the breakdown of fats into fatty acids and glycerol (2). Insulin facilitates absorption of amino acids into cells and their conversion into proteins. Insulin converts excess carbohydrates, which cannot be used as glycogen, into fats and then promotes the storage of fat in adipose tissue (2). When bound to cell surface receptors, insulin initiates a cascade of

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events that are integral to the transport of glucose into cells. T he insulin receptor is a large, transmembrane glycoprotein composed of two α subunits and two β subunits linked by disulfide bonds (5). T he α subunits, which possess the insulin binding domain, are located extracellularly. T he β subunits are transmembrane proteins that also possess enzymatic activity. When insulin binds to and activates this receptor, intramolecular autophosphorylation of several β-subunit tyrosine residues occurs (2). T his enhances the receptor's tyrosine kinase activity, which is responsible for phosphorylating insulin receptor substrates (IRS-1 to IRS-4). T hese phosphorylated proteins serve as intracellular signals for processes essential to cell survival and proliferation. T his includes translocation of the glucose transporters to the cell surface and synthesis of glycogen, protein, mRNAs, and nuclear DNA (3).

Role of Glucose Transporters Glucose transport into cells is regulated, in part, by glucose transporters. T hese integral membrane glycoproteins (~ 50,000 daltons) are comprised of 12 membrane- spanning α-helical domains (5). Several members of this family (GLUT 1 to GLUT 5) use a sodium-independent mechanism to facilitate glucose entry into the cell. When insulin binds to and activates its cell surface receptors, the intracellular vesicles, in which the GLUT 1 and GLUT 4 transporters normally reside, migrate toward the plasma membrane (5). T his is an energy-dependent process. T hese vesicles fuse with the membrane, and the transporters orient themselves such that they become channels through which glucose can enter the cell. T his process is reversible in that once insulin dissociates from the receptor, the intracellular vesicles re-form (via endocytosis), thereby moving the glucose transporters back into the intracellular pool. T he rate-limiting step in glucose transport into muscle and adipose tissue is the initial translocation of intracellular vesicles toward the plasma membrane. Alteration of one or more steps in this sequence can lead to an insulin-resistant state. For example, a decrease in GLUT 4 expression limits glucose entry into the cell (14).

Insulin Resistance Insulin resistance often is a component of type 2 diabetes, IGT , and metabolic syndrome. It can be caused by obesity, physical inactivity, and aging, or it can be secondary to other disease states (e.g., Cushing's syndrome and pheochromocytoma) or medication usage (e.g., β-adrenergic blocking agents, glucocorticoids, oral contraceptives, and thiazide diuretics) (15). Clinically, insulin resistance presents itself as hyperglycemia because of a decrease in insulinstimulated glucose transport into adipose tissue and skeletal muscle. T here are many potential reasons for the development of resistance, including downregulation of GLUT 4 expression (14), downregulation of GLUT 4 translocation P.859 to the cell membrane, a decrease in the number of available insulin receptors, and/or a decrease in the affinity of insulin for its receptor (15). It also is possible that downstream insulin signaling may be blocked. T his may be caused by dephosphorylation of the β-subunit tyrosine side chains by cellular protein–tyrosine phosphatases; phosphorylation of IRS-1, which reduces its ability to act as a substrate for the β-subunit tyrosine kinase; and/or degradation of the IRS proteins (3).

Hemoglobin A1c and Glucose Control Hemoglobin normally undergoes glycosylation of its amino terminal valine residue. T he product of this glycosylation, hemoglobin A1c (HbA 1c ), is a valuable endogenous marker for glycemic control over the previous 4 to 12 weeks (16). T his endogenous substance has a half-life equivalent to that of an erythrocyte. Measurement of an individual's HbA1c is an assessment of the concentration of plasma glucose and the length of time that hemoglobin was exposed to those glucose concentrations. Clinical trials (e.g., Diabetes Control and Complications T rial [DCCT ] and UK Prospective Diabetes Study) have clearly demonstrated that if a patient's HbA1c is maintained below 7%, the development and progression of neuropathy, nephropathy, and retinopathy in type 1 or 2 patients can be significantly decreased (17).

Diabetic Complications Uncontrolled or poorly controlled plasma glucose levels will result in the development and progression of microvascular and macrovascular diabetic complications that involve the eyes (retinopathy), kidneys (nephropathy), nerves (neuropathy), heart, and blood vessels (9). Diabetes is the leading cause of new blindness in adults (10,000 cases in diabetic patients per year) and represents 15% of all blindness (2,4). T ypically asymptomatic in its earliest, most treatable stages, diabetic eye disease (e.g., retinopathy, glaucoma, and cataracts) represents the most common microvascular diabetic complication. Diabetic retinopathy begins to develop as early as 7 years before the diagnosis of type 2 diabetes. It is caused by the accumulation of polyols, the formation of advanced glycation end products, oxidative stress, and the activation of protein kinase C. T hese products or processes have adverse effects on cellular metabolism, cell signaling, and growth factors (18). Diabetes is the leading cause of end-stage renal disease and represents 35% of all end-stage renal disease (2,4). T his complication is experienced by approximately 40% of all patients with diabetes and is correlated with increased cardiovascular mortality. Diabetic nephropathy, which is caused by both tubular and interstitial changes in kidney structure, is characterized by stage. Microalbuminuria or incipient nephropathy is defined as increased urinary albumin excretion (> 30 mg/24 hours and ≤299 mg/24 hours), whereas macroalbuminuria or overt neuropathy is defined as urinary albumin excretion

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of more than 300 mg/24 hours (19). It is more prevalent in the African-American, Asian, and Native-American populations than in the Caucasian population. Even acute episodes of hyperglycemia can cause an increase in glomerular filtration rate or vascular damage resulting in glomerular dysfunction (12). When plasma glucose levels remain high for an extended period of time, peripheral nerves are injured. Nerve damage, which can affect virtually every nerve fiber in the body, occurs in 60 to 70% of all diabetic patients (2). Peripheral neuropathy can lead to foot ulcerations, amputations, and Charcot joints (9). Cardiovascular autonomic neuropathy, a key cause of morbidity and mortality in the diabetic population, causes symptoms of orthostatic hypotension and decreased heart rate variability, contributes to exercise intolerance, and contributes to left ventricular dysfunction. Gastrointestinal autonomic neuropathy can result in gastroparesis, gastroesophageal reflux disease, delayed gastric emptying, and colon abnormalities. Genitourinary autonomic neuropathy can have adverse effects on both male and female sexual function and urinary continence. What most people associate with diabetic neuropathy actually is termed “ sensorimotor neuropathy,” which is characterized by pain, abnormal sensations and sensory loss (20). T he pathology of diabetic neuropathy is similar to that described for retinopathy. A staggering statistic is that diabetic neuropathy can be linked to between 50 and 75% of all nontraumatic amputations (4). T here are macrovascular complications to consider as well, including ischemic heart disease, cerebrovascular disease, and peripheral vascular disease. T hese complications are the primary cause of morbidity in type 2 patients. Diabetic patients have a two- to fourfold greater risk than the nondiabetic population of dying from a myocardial infarction or stroke (17). Insulin resistance has been shown to stifle the action of nitric oxide and increase the levels of prothrombotic factors (e.g., fibrinogen). Without nitric oxide an increase in vascular smooth muscle cell proliferation, an increase in platelet adhesiveness (as well as vasoconstriction) is likely. Insulin resistance also can interfere with the fibrinolytic process via an increase in the synthesis of plasminogen activator inhibitor-1 (PAI-1) (15). Abnormalities in lipid metabolism also contribute to the macrovascular complications. When the body is unable to use glucose as its source of energy, it relies on the metabolism of fats and proteins for energy. Lipolysis results in the release of fatty acids and glycerol from adipose tissue into circulation. T he liver converts excess fatty acids into cholesterol and phospholipids. Along with triglycerides, these substances are organized by the liver into lipoproteins and released into the circulation. T his results in the development of hypercholesterolemia and atherosclerosis. When the body increases fat utilization, there is a corresponding increase in the formation and release of keto acids into the circulation, which can result in metabolic ketoacidosis (diabetic ketoacidosis) (2). P.860

Diagnosis of Diabetes Some, but not all, diabetic patients display the classic signs and symptoms of hyperglycemia before diagnosis. T his includes polydipsia (excessive thirst), polyuria (excessive urination), as well as weight loss and a lack of energy despite the consumption of large amounts of food. T he diagnosis of any of the previously discussed metabolic disorders, including type 1 and 2 diabetes, requires the measurement of fasting plasma glucose levels and/or plasma glucose levels after an oral glucose challenge. T he clinical criteria for the diagnosis of diabetes mellitus are found in T able 32.4. Different clinical criteria exists for the clinical values associated with the diagnosis of IFG and IGT , as previously presented (9). T his also is true for GDM in pregnant women when the fasting plasma glucose is greater than 126 mg/dL or the casual plasma glucose is greater than 200 mg/dL. If a patient's plasma level exceeds these thresholds, then a glucose challenge test typically is ordered on a subsequent day. T his test, which does not require that the patient be fasting, involves consumption of a 50-g oral glucose load by the patient, followed by evaluation of their plasma glucose after 1 hour. A value of greater than 140 mg/dL indicates that the patient should undergo a subsequent 3-hour, 100-g oral glucose load on another day (10). A 3-hour postload plasma glucose level of 140 mg/dL or greater indicates that a provisional diagnosis of GDM should be made (9).

Role of Hormones Other than Insulin In addition to insulin, the pancreas produces glucagon from α cells, somatostatin from δ cells, and amylin from β cells. Each of these hormones has an influence on blood glucose concentrations.

Glucagon Glucagon stimulates glycogenolysis and gluconeogenesis through a receptor-mediated action in the liver. Hyperglycemia in patients with diabetes can be associated with elevated levels of glucagon in the blood. T hus, there is interest in developing glucagon antagonists as an approach to glycemic control (21).

Table 32.4. Diagnosis Criteria for Diabetes M ellitus (9) Clinical Values Non-fasting plasma glucose level ≥200

Symptoms Polydipsia, polyuria, unexplained weight

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mg/dL

loss

OR Fasting plasma glucose level ≥126 mg/dl OR 2-hour postload glucose ≥200 mg/dL after consumption of a 75-g oral glucose load

Somatostatin Originally isolated from hypothalamic tissue, somatostatin is characterized as an inhibitor of growth hormone (GH) release. T he structure was determined in 1971. Subsequent investigations led to the recognition that somatostatin also was released from the pancreas and has a role of inhibiting the secretion of both insulin and glucagon. A total of five somatostatin receptor subtypes have been characterized and cloned (sst1 to sst5). Subtype sst4 is associated with the inhibition of insulin release, and an sst4-selective inhibitor has been reported (22). T he somatostatin analogue SOM230 has exhibited selectivity for sst1, sst2, sst3, and sst5 in rats and effectively decreased plasma GH and insulin-like growth factor-1 (IGF-1) levels by 75% without significant effects on insulin or glucagon (23). Another analogue, PT R3173, with selectivity for recombinant human somatostatin receptor (hsst2, hsst4, hsst5) was substantially more effective in inhibiting GH secretion compared to glucagon and insulin release in rats (24). Nocturnal GH release and subsequent elevation of IGF-1 is thought to contribute to insulin resistance. Somatostatin analogues that can selectively control GH or glucagon release could be developed and aid in glycemic control (25). Recent investigations of somatostatin receptors in the retina have led to the proposed use of somatostatin or analogues for the treatment of diabetic retinopathy (26).

Amylin Amylin normally is cosecreted with insulin from secretory granules in pancreatic β cells in response to meals and works with insulin to provide postprandial glucose control. Native amylin is a single-chain peptide of 37 amino acids. Observed deficiencies of amylin in both type 1 and type 2 patients treated with insulin have led to research and drug development related to amylin (27).

Glucagon-like Peptide-1 Glucagon-like peptide-1 (GLP-1) is an incretin, a natural peptide hormone secreted in response to food intake. Incretins have multiple physiological effects to lower blood sugar, including the stimulation of insulin release and the inhibition of glucagon release following meals (28).

Adiponectin Adiponectin is a cytokine produced by adipocytes and is termed an “ adipokine.” Adiponectin functions as an insulin sensitizer. Downregulation of adiponectin receptors and low levels of adiponectin have been associated with obesity-linked insulin resistance (29). Exercise and dietary changes have been shown to raise low levels of adiponectin in obese adolescents (30). Additionally, sarpogrelate hydrochloride, a 5-HT 2A antagonist, elevates low adiponectin levels and normalizes other factors associated with vascular changes seen in type 2 diabetes (31). P.861

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Fig. 32.1. Primary structure of proinsulin, showing cleavage sites to produce insulin.

Insulin Biosynthesis of Insulin Insulin has a place in the biochemistry “ hall of fame” in that it was the first protein for which the chemical structure and molecular weight were determined and was the first genetically engineered drug approved by the U.S. Food and Drug Administration (7). T he active insulin hormone is composed of a 21-amino-acid A chain and a 30-amino-acid B chain that are linked by two disulfide bonds. Separately, each chain is biologically inactive. Insulin is initially synthesized as a 110-amino-acid preprohormone in the pancreatic β cells. T he preprohormone then undergoes translocation through the membrane of the rough endoplasmic reticulum. During this process, the cleavage of 24-amino-acids from the N-terminus of the B chain occurs to produce proinsulin. Inside the rough endoplasmic reticulum, the protein folds, and the three critical disulfide bonds form. In the Golgi complex, proinsulin undergoes additional modification that is catalyzed by calciumdependent endopeptidases (PC2 and PC3). In this process, four basic amino acids as well as the connecting C-peptide are removed via proteolysis (Fig. 32.1). T he resulting insulin protein represents the active form of the hormone found in the plasma. In solution, insulin can exist as a monomer, dimer, or hexamer. In the pancreas, insulin is stored in its hexameric form. In this form, two zinc ions are coordinated per insulin hexamer. T he half-life of insulin is 5 to 6 minutes, whereas the half life of proinsulin is approximately 17 minutes (5).

Secretion of Insulin Secretion of insulin from the pancreas is very tightly regulated. When glucose enters the β cell (GLUT -2–facilitated transport), it is phosphorylated by glucokinase to G6P. T he G6P is used to generate AT P, thereby changing the ratio of AT P to adenosine diphosphate (ADP) and prevents an AT P-sensitive potassium channel from functioning, which in turn leads to depolarization of the β cells. T his prompts activation of a voltage-gated calcium channel and calcium flows into the β cells. T he elevated intracellular calcium concentrations causes activation of phospholipases A 2 and C, and levels of inositol triphosphate rise (5). Inositol triphosphate, an intracellular second messenger, facilitates additional release of calcium into the cytosol. T he intracellular concentrations of calcium are now sufficiently high to promote insulin secretion from the β cells. Several classes of pharmacological agents alter the regulation of insulin release. A list of these agents and their respective effect on insulin secretion can be found in T able 32.5. Insulin interacts with its cell surface receptor via key amino acid residues located along the N- and C-termini of the A chain of insulin and along the carboxy terminus of the B chain of insulin (T able 32.6). T he binding of insulin occurs to amino acid residues located within the N- and C-terminal regions of the α subunit of the receptor, which includes a cysteine-rich region (5). Binding and activation of the insulin receptor results in a cascade of biochemical events previously described.

Table 32.5. Agents that Alter Insulin Secretion (5)

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Pharmacological Class

Effect on Insulin Secretion

α 2 -Adrenergic receptor agonist

Inhibits insulin secretion

α 2 -Adrenergic receptor antagonist

Promotes insulin secretion

β 2 -Adrenergic receptors agonists

Promotes insulin secretion

β 2 -Adrenergic receptors antagonists

Inhibits insulin secretion

P.862

Table 32.6 Amino Acid Interactions with Insulin Receptor ChainN-terminus

C-terminus

A

Gly A1, Glu A4, Gln A5

Tyr A19, Asn A21

B

Val B12

Tyr B16, Gly B23, Phe B24, Phe B25, Tyr B26

M etabolism of Insulin Insulin degradation occurs primarily in the liver and kidney. Of that which is secreted from the pancreatic islet cells, 50% reaches the liver via the portal vein and undergoes disulfide bond cleavage catalyzed by glutathione insulin transhydrogenase (insulinase). T his is followed by proteolytic degradation before entry into the general circulation. Insulin is filtered by the renal glomeruli and can then be reabsorbed or degraded by the tubules (5). At the tissue level, insulin degradation occurs to a limited extent at the cell surface.

Sources of Insulin Four types of cells are found within the islet of Langerhans, and each cell type secretes its own polypeptide hormone (T able 32.7). T he β cells produce a basal level of endogenous insulin at the rate of 0.25 to 1.5 IU/hour. Consumption of a meal causes a biphasic bolus secretion of insulin. T here is an immediate release of insulin, followed by an additional release 30 to 45 minutes after eating. Within 2 to 4 hours of a meal, insulin secretion returns to basal levels (8). Under fasting conditions (e.g., overnight), the pancreas produces 40 µg (1 IU)/hour. In the treatment of all patients with type 1 or some type 2 diabetes, exogenous insulin must be administered to achieve a euglycemic state. Initially, patients only had the option of administering either bovine- or porcine-based insulins. Insulins derived from these animals were considered to be viable alternatives to human insulin, because the amino acid sequence homology between species was superb (T able 32.8). As early as the 1950s, it became obvious that there were limitations to these sources of insulin, because 100% of these patients developed both high- and low-affinity insulin antibodies. As a result, immunologic insulin resistance (a syndrome in and of itself) was reported in those patients with elevated levels of insulin antibodies that bound tightly to insulin (32).

Table 32.7. Polypeptides Secreted by Cells in the Islet of Langerhans Type of Cell α

Hormone Secreted Glucagon

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β

Insulin and amylin

δ

Somatostatin

PP or F cell

Pancreatic polypeptide

Table 32.8. Insulin Sequence Homology Between Species

Source

Insulin Amino Acid Substitutions A Chain B Chain Position 8 Position 10 Position 30

Beef

Alanine

Valine

Alanine

Pork

Threonine

Isoleucine

Alanine

Human

Threonine

Isoleucine

Threonine

Once the complete synthesis of human insulin was accomplished (1963), human insulin could be synthesized via two possible routes. One method involved the synthesis of each chain separately, followed by linkage of the chains to produce the active hormone (7). T he other, more favored route involved the use of fermentation to synthesize the peptide hormone, followed by isolation of the pure substance. In 1978, Genentech and City of Hope National Medical Center were able to produce human insulin by recombinant DNA methods (7). T his involved the insertion of synthesized genes for each of the two chains into Escheri chi a col i and then the use of fermentation methods developed by Eli Lilly to generate commercial quantities of human insulin. Clinical trials started in 1980, and by 1982, Humulin (regular insulin) became the first genetically engineered drug approved by the U.S. Food and Drug Administration (7). Once this recombinant technology was established, it was rapidly applied to the production of a variety of insulin analogues.

Solution Structure of Insulin T he secondary and tertiary structure is substantially the same for all insulins despite differences in the primary structure from various species. T he A chain has two α-helices and the B-chain an α-helix and a β-turn, with the B21 to B30 region as a β-strand. T his conformation buries a number of hydrophobic A-chain residues in the interior of the peptide, which improves water solubility and stability. T he presence of phenol and cresol that often are used as preservatives in insulin formulations results in substantial changes in the insulin conformation. Phenol, in the presence of zinc ions, causes the formation of a B1-B8 helix, which involves movement of more than 25 Å in the B1 residue (33). Only the insulin monomer is able to interact with insulin receptors, and native insulin exists as a monomer at low, physiological concentrations (< 0.1 µM). Insulin dimerizes at the higher concentrations (0.6 mM) found in pharmaceutical preparations, and at neutral pH in the presence of zinc ions, hexamers form (34). T hese zinc-associated hexamers also are the storage form of insulin in β cells. At concentrations greater than 0.2 mM, hexamers form even in the absence of zinc ions. Changes in the insulin concentration can profoundly change absorption after subcutaneous administration P.863 (35). Insulin given at a concentration of 40 IU/mL (previously used commercially) is absorbed quite rapidly, but insulin at 100 IU/mL (now used commercially) is absorbed significantly more slowly. T his apparently reflects the decrease in monomer concentration, the only absorbable form, as the concentration of insulin increases.

Stability of Insulin T he importance of zinc ions for stabilizing insulin preparations has been known since the first reported crystallization of insulin in the presence of zinc ions in 1934 (36). Suspensions of zinc insulin were used at that time. Presently, all pharmaceutical preparations are either solutions of zinc insulin or suspensions of insoluble forms of zinc insulin. A longeracting and more stable form of insulin is protamine zinc insulin, which is prepared by precipitating insulin in the presence of zinc ions and protamine, a basic protein. T his precipitate is known to contain two zinc ions per insulin hexamer. A somewhat shorter-acting and more useful preparation is neutral protamine Hagedorn (NPH) insulin, which includes m-cresol

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as a preservative. T his also is known as isophane insulin. Six m-cresol molecules occupy cavities in the hexamer involving the B1-B8 helix formed as a result of the presence of the m-cresol. Later, it was reported that when small additional amounts of zinc ions were added to hexameric two-zinc insulin in neutral acetate buffer, insulin could be made to crystallize in several forms with varying rates of dissolution in water. T hus, the rapidly soluble amorphous semilente insulin is a two-zinc insulin, and the crystalline, more slowly soluble ultralente insulin is a four-zinc form (37,38). An additional form of insulin, partially unfolded insulin, can form a viscous or insoluble precipitates known as fibrils. Shielding of hydrophobic domains is the principal driving force for the aggregation. Further studies revealed that when the exposed hydrophobic domain (A2, A3, B11, and B15) interacts with the normally buried aliphatic residues (A13, B6, B14, and B18) in the hexameric structure, fibrils form (Fig. 32.1) (39). Fibrils also have been studied by electron microscopy, and packing considerations in the crystal lattice explain why fibril formation is accelerated when insulin is in the monomeric state (40). Insulin fibrils do not resuspend on shaking; thus, they are pharmaceutically inactive. Insulin fibril formation is particularly important with the advent of infusion pumps to deliver insulin. In these devices, insulin is exposed to elevated temperatures, the presence of hydrophobic surfaces, and shear forces, all factors that increase insulin's tendency to aggregate. T hese problems can be overcome if the insulin is prepared with phosphate buffer or other additives. Another physical stability problem associated with insulin is adsorption to tubing and other surfaces. T his normally occurs if the insulin concentration is less than 5 IU/mL (0.03 mM), and it can be prevented by adding albumin to the dosage form if a dilute insulin solution must be used (34). T here also are chemical instability issues associated with insulin. For 40 years, the only rapid-acting form of insulin was a solution of zinc insulin, with pH 2 to 3. If this insulin is stored at 4°C, deamidation of the asparagine at A21 occurs at a rate of 1 to 2% per month. T he C-terminal Asn, under acidic conditions, undergoes cyclization to the anhydride, which in turn can react with water, leading to deamidation. T he anhydride also can react with the N-terminal Phe of another chain to yield a cross-linked molecule. If stored at 25°C, the inactive deamidated derivative constitutes 90% of the total protein after 6 months (Fig. 32.2) (34). If insulin is stored at neutral pH, a different reactions may occur. Deamidation occurs on the Asn at B3, and the products, the aspartate and isoaspartate-containing insulins, are equiactive with native insulin (Fig. 32.2). Deamidation is virtually undetectable in suspensions of bovine insulin zinc (37). More problematic transformations are possible, including chain cleavage between A8 T hr and A9 Ser and covalent cross-linking, either with a second insulin chain or with protamine, if present. T hese processes are relatively slow compared to the deamidations, but they have the potential of leading to products that may cause allergic reactions. Specific antibodies against insulin dimers have been found in 30% of diabetic patients receiving insulin (41).

Use of Insulin for Treatment of Diabetes According to the DCCT and the UK Prospective Diabetes study, insulin and/or insulin analogues are the standard treatment for type 1, gestational, and some type 2 diabetes. P.864 T hese drugs represented $9 billion in sales in 2006, with an anticipated $20 billion in sales by 2012. Although prescribing habits are different between and within countries, the most common factors that influence insulin selection generally include awareness and availability of insulin preparations as well as differences in eating habits and lifestyles (6). As with most medications that treat chronic conditions, the dosage and type of insulin and/or insulin analogue should be individualized and take into consideration the degree to which the patient adheres to recommended diet and exercise regimens. In the evaluation of which types of insulin to prescribe, a number of factors should be considered that affect the onset, degree, and duration of insulin activity. A list of these factors can be found in T able 32.9. T hese factors relate to the solubility and stability of insulin discussed above.

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Fig. 32.2. Chemical degradation of insulin.

Table 32.9. Factors that Affect the Onset, Degree, and Duration of Insulin Activity (13) Primary structure

Additions, deletions, insertions, modifications, and rearrangement of amino acid residues at the N- and/or C-terminus of the B chain

Insulin crystal type

soluble, amorphous, crystalline, microcrystalline

Concentration of zinc Presence of modifying protein

protamine

Site of injection

abdomen, upper arms, thighs, buttocks

Insulin Overdose and Diabetic Coma T he most common and serious reaction to insulin therapy is hypoglycemia. It is important that patients with diabetes, especially those receiving insulin therapy, be able to recognize the signs and symptoms of hypoglycemia. Symptoms of hypoglycemia may be evident with a plasma glucose level at 60 to 80 mg/dL. Severe hypoglycemia can lead to convulsions and coma. Patients that vigorously attempt to achieve euglycemia to avoid various vascular complications risk increased frequency of hypoglycemic episodes (42). In the DCCT , the incidence of severe hypoglycemic reactions was threefold

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higher in the intensive insulin therapy group than in the conventional therapy group (43). It is now known that hypoglycemia kills neurons actively rather than by starvation from within. T hus, significant damage to regions of the brain can result from severe hypoglycemia (44). Because of these dangers, patients receiving insulin therapy should carry packets of sugar or candy to be used at the onset of the symptoms of hypoglycemia.

Insulin Analogues Structure–activity relationship studies have been conducted over several years. T hese studies revealed that variations or removal of amino acid residues from the C-terminus of the insulin B chain did not drastically change the biological activity but could influence the rate of dimer formation or separation. If dimer formation can be inhibited, rapid-acting insulins may be obtained. T hus, the various insulin analogues that have been developed have substitutions in or additions to the C-terminus starting at residue B28. T he resulting analogues have either a faster onset or a longer duration of action relative to native insulin. T hese analogues are all produced by recombinant DNA technology using a modified DNA template. Various analogues are summarized in T able 32.10.

Table 32.10. Insulin Analogues Generic NameTrade Name Change in A ChainChange in B Chain Lispro

Humalog

None

B28 Pro → Lys; B29 Lys → Pro

Aspart

NovoLog

None

B28 Pro → Asp

Glulisine

Apidra

None

B3 Val → Lys; B29 Lys → Glu

Glargine

Lantus

A21 Asn → Gly

Add: B31 Arg and B32 Arg

Detemir

Levemir

None

Remove: B30 Thr Add: C14 fatty acid to B29 Lys

Faster-Acting Analogues As indicated in T able 32.10, both insulin lispro and insulin aspart B28 Pro is replaced with a linear amino acid. T his change also results in a conformational change at the C-terminus and, therefore, the ability of the insulin to dimerize. Both of these analogues dissociate into monomers faster, and this produces a faster onset of action. Both insulin lispro and insulin aspart can be injected immediately before meals providing for more convenient timing and more accurate calculation of appropriate dosing. T hese analogues also can be used in combination with regular or NPH insulin (45).

Longer-Acting Analogues T he first long-acting analogue to be introduced to the market was insulin glargine. T his analogue results from the replacement of A21 Asn by Gly and the addition of two Arg amino acids to the C-terminus of the B chain, as indicated in T able 32.10. T he resulting analogue has an isoelectric point close to seven, which results in precipitation on subcutaneous injection. T he analogue is slowly released from the resulting depot. Insulin glargine produces minimal peak effects and has a duration of action of 22 ± 4 hours. It has been demonstrated to be comparable or slightly better than NPH insulin at maintaining or reducing HbA1c levels without nocturnal hypoglycemia (45). Insulin detemir is a long-acting analogue that was recently introduced to the market. T his analogue results P.865 from N-acylation of the B29 Lys with 14-carbon myristic acid (T able 32.10). T he fatty acid side chain binds to plasma albumin to produce a depot and longer action. It is not as long-lasting as insulin glargine, and is injected twice daily by patients with type 1 and type 2 diabetes (45,46).

Drug Developm ent Related to Other Horm ones Significant efforts are underway, in addition to those discussed earlier, to develop therapeutic approaches for the treatment of diabetes that are based on hormones other than insulin.

Glucagon Antagonists Several nonpeptide glucagon antagonist are being investigated as potential agents for the treatment of diabetes (Fig. 32.3).

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Presently, several of these drugs are in early clinical trials, whereas other antagonists of potential interest have not yet entered the clinic (47,48). BAY-27-9955 is an especially interesting antiglucagonemic agents. T he drug is being investigated in patients with poorly controlled type 2 diabetes.

Amylin Agonists Native amylin is a single-chain peptide of 37 amino acids. As previously discussed, amylin is cosecreted with insulin from the β cells in response to meals. Amylin has various actions, including a slowing of gastric emptying and a lowering of blood glucose levels by decreasing glucagon release. It has been reported that amylin levels are abnormally low in patients with type 1 diabetes and are insufficient at mealtime in insulin-using patients with type 2 diabetes. Amylin appears to produce these effects by binding to specific receptors in the central nervous system. T he administration of amylin in patients with type 1 diabetes is unsuitable because of a physicochemical property of amylin, which is that the peptide is insoluble and aggregates in solution. Recently, an analogue of amylin has been approved for use in type 1 and type 2 diabetes.

Fig. 32.3. Glucagon receptor antagonists.

Pramlintide Pramlintide is an analogue of amylin in which proline has replaced the normal amino acids at positions 25, 28, and 29, as indicated above. T he result of these substitutions is an increase in water solubility and a reduced tendency for self-aggregation.

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Pharmacokinetics Pramlintide is administered via subcutaneous injection immediately before meals, reaches maximum circulating concentrations within 20 minutes, and has a half-life of 29 minutes. T he drug is eliminated from the body primarily through the kidney. T he plasma concentrations are similar to those seen with postprandial amylin. Because the drug is formulated at pH 4.0, it is potentially incompatible with insulin (pH 7.8) if administered within the same syringe, although one study of pramlintide combined with Novolin or Humulin did not show changes in the pharmacokinetics of either drugs (49,50).

Mechanism of action Amylin receptors have been identified in distinct areas of the brain, including the nucleus accumbens and the dorsal vagal complex. Stimulation of these receptors reduces food intake and depresses GI motility. It is assumed that pranlintide stimulates these receptors, leading to the reported benefits of the drug in patients with diabetes, although the exact mechanism is still poorly understood. Pranlintide causes a moderate reduction in HbA1c and postprandial glucose levels when used in combination with insulin, which has benefits in normalizing fluctuations of circulating glucose levels.

Side effects T he major side effects reported for pramlintide consist of mild to moderate nausea, with severe nausea appearing in patients using large doses of the drug. T he nausea may decrease on continued use of the drug. T he rate of hypoglycemia appears to be quite low. P.866

Glucagon-like Peptide-1 Agonists Glucagon-like peptide-1 (GLP-1), a mammalian incretin hormone, consists of two peptides secreted by the endocrine L cells located in the small intestine. T he two forms of GLP-1 differ by one amino acid, with 80% of the GLP-1 possessing 30 amino acids (the minor peptide contains 31 amino acids). T he role of GLP-1 appears to be to prepare the body for a glucose surge following a sudden rise in plasma glucose. T he early insulin response (first-phase insulin secretion) appears to be lost in patients with type 2 diabetes. T he GLP-1 stimulates the first-phase release of insulin from the pancreatic β cells and, additionally, inhibits the release of glucagon, thus controlling the release of glucose from the liver. In addition, GLP-1 slows stomach empting, causing a feeling of fullness that reduces additional food intake; it does this by binding to GLP-1–specific receptors in the β cells of the pancreas. T he release of GLP-1 is only associated with elevated glucose levels; thus, its release drops when glucose serum levels drop. T he GLP-1 itself would appear to have drug potential if not for the fact that GLP-1 has a half-life of 90 seconds. T he enzyme dipeptidyl peptidase IV (DPP-IV) metabolizes GLP-1 by removal of two amino acids from the N-terminus of GLP-1. T he resulting peptide has a half-life of less than 2 minutes. T he enzyme DPP-IV is found in intestinal capillaries and in the liver. Diabetic patients in which GLP-1 was continuously administered exhibited a significant drop in HbA 1c (1.3%), a steady weight loss, and an improvement in pancreatic β-cells function. Although continuous administration GLP-1 is not practical, this work did suggest two potential drug avenues: the development of GLP-1 mimics, and the other DPP-IV inhibitors (51,52,53).

Exenatide

During the 1990s, it was discovered that saliva of Gila monsters contained a 39-amino-acid peptide, which had glucoregulatory activity. T his peptide, exendin-4, has the ability to bind to the GLP-1 receptor and mimics the action of GLP-1. T he synthetic version of exendin-4 is named exenatide. Exenatide shares 53% of the amino acid sequence with GLP-1 and also is a substrate for peptidase hydrolysis. Unlike GLP-1, however, exenatide has a half-life of 2 to 4 hours following subcutaneous injection. Exenatide is thought to exhibit its action via stimulation of GLP-1 receptors, resulting in the positive effects of improved insulin secretion, reduced glucagon release, reduced stomach emptying, as well as a reportedly slowing the loss of β cells and stimulating the differentiation and production of new β cells. T he latter effect

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appearing to be different from that experienced by GLP-1 release. Exenatide is approved for use in certain patients with type 2 diabetes that is not adequately controlled on metformin and/or a sulfonylurea. T he drug is administered via subcutaneous administration in combination with metformin or a sulfonylurea. It has not been approved for use in patients with type 1 diabetes. Some patients have experienced desired weight loss with long-term exenatide use (54). T he most commonly reported adverse effects include nausea, vomiting, diarrhea, jittery feelings, headaches, and dizziness. T he drug should not be administered prior to marks, but after meals.

Additional Experimental Agents Affecting GLP-1 Liraglutide Liraglutide is a GLP-1 derivative in which a 16-carbon fatty acid has been attached to 26-amino-acid lysine. T he fatty acid side chain promotes binding to albumin and limits degradation by DPP-IV, resulting in a prolonged duration of action (55). T he drug requires once-daily injection and leads to prolonged release of the GLP-1 derivative. T he released drug has been shown in animal models to reduce food intake and body weight and, like exenatide, to increase insulin secretion, decrease gastric empting, and reduce blood glucose levels. In addition, glucagon secretion is inhibited. In humans, the half-life of liraglutide has been shown to be extended to 10 hours, with a bioavailability of 55%.

Dipetidyl peptidase iv inhibitors A serine protease, DPP-IV is the primary protease responsible for degrading GLP-1. T his enzyme is found in both intestinal capillaries and the liver. T he enzyme removes two amino acids from GLP-1, thus inactivating GLP-1. Unfortunately, DPP-IV is not selective for GLP-1 and its derivatives, but it has protease activity on a variety of substrates, including neuropeptides and enzymes involved in the immune system. A number of pharmaceutical companies have DPP-IV inhibitors in various stages of clinical investigation. T wo such agents are saxagliptin (56) and vildagliptin (57). A new drug application has been submitted for vildagliptin with approval expected in 2007.

Oral Hypoglycem ic Agents First- and Second-Generation Sulfonylureas History In the 1940s, 2-(p-aminobenzenesulfonamide)-5-isopropylthiadiazole was used to treat typhoid fever but caused a number of deaths through prolonged hypoglycemia. About this same time, it was found that carbutamide was significantly more active and safer as a hypoglycemic agent. It became the first sulfonylurea hypoglycemic agent to be marketed but, because of effects on bone marrow, ultimately was withdrawn from the market. P.867 After the discovery of carbutamide, many sulfonylureas were examined, and a number are still marketed today. Until 1994 they were the only oral hypoglycemic agents available (58).

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Structure–Activ ity Relationships T he typical sulfonylurea is a mono substituted (usually para) aromatic sulfonylurea that has a bulky aliphatic substituent on the nonsulfonyl-attached nitrogen of the urea. Small alkyl groups, such as methyl or ethyl, are not active. In first-generation analogues, the aromatic substituent is a relatively simple atom or group of atoms (e.g., methyl, amino, acetyl, chloro, bromo, methylthio, or trifluoromethyl); however, the second-generation analogues have a larger p-(β-arylcarboxyamidoethyl) group that leads to significantly higher potency (T ables 32.11 and 32.12). Glimepiride typically is classified as a secondgeneration sulfonylurea, and it has a similar extended binding group like glyburide and glipizide; however, differences in its pharmacological profile may justify a separate classification. Sulfonylureas are weak acids, with pK a values of approximately 5.0 with proton dissociation from the sulfonyl-attached nitrogen of the urea. Serum protein binding is high (T able 32.12), so care must be taken when administering with other highly protein bound drugs.

Mechanism of Action T he principal action of the sulfonylureas is to stimulate the release of insulin from β cells. T hey act by affecting the AT P-sensitive potassium channel. T his channel is a hetero-octameric complex of two subunits: a sulfonylurea receptor (SUR1), and an inwardly rectifying potassium channel (Kir6.2). On binding to SUR1, potassium efflux is blocked, leading to depolarization of the membrane. T his depolarization opens voltage-dependent calcium channels, resulting in an influx of calcium. At higher intracellular calcium concentrations, calcium-sensitive proteins act to promote the release of stored insulin from the cells. T here are two phases to the release of insulin: T he first phase involves the insulin granules at the plasma membrane, and a second phase involves newly formed insulin granules that migrate to the membrane (59). T hese drugs are effective in patients with type 2 diabetes whose insulin-secreting capacity is intact but whose ability to produce adequate insulin in the presence of elevated glucose has been lost. Sulfonylureas can cause hypoglycemia, because these drugs can stimulate insulin secretion even when glucose levels are low. All sulfonylureas exhibit both insulin-secreting and extrapancreatic activities. Glimepiride relies on extrapancreatic effects for a greater proportion of its P.868 hypoglycemic effect, and it is possibly because of this that it is considered less likely to produce unwanted hypoglycemia. Glimepiride binds well to not only SUR1 in β cells but also to SUR2A (as found in cardiac smooth muscle) and SUR2B (brain and smooth muscle). In contrast, tolbutamide is more selective for SUR1 (60).

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Table 32.11. First and Second Generation Sulfonylureas

Table 32.12. Pharmacokinetic Properties of the Sulfonylureas Drug (Sulfonylureas)

Equivalent Dose (mg)

Serum Protein Binding (%)

Duration t ½ (hour) (hour)

Renal Excretion (%)

Tolbutamide

1000

95–97

4.5–6.5

6–12

100

Chlorpropamide

250

88–96

36

up to 60

80–90

Tolazamide

250

94

7

12–14

85

Acetohexamide

500

65–88

6–8

12–18

60

Glyburide

5

99

1.5–3.0

up to 24

50

Glipizide

5

92–97

4

up to 24

68

Glimepiride

2

99

2–3

up to 24

40

Pharmacokinetics and Metabolism Sulfonylureas are highly protein bound, primarily to albumin, which leads to a large volume of distribution (~ 0.2 L/kg) (T able 32.12). Food can delay the absorption of these drugs but does not typically affect bioavailability. Metabolism takes

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place in the liver, and the metabolites are renally excreted. Chlorpropamide has a considerably longer half life than the other sulfonylureas, and as a result has a greater tendency for adverse effects. One explanation for the long half-life is that its metabolism (ω and ω-1 hydroxylation of the propyl group) is slow. A significant amount of the drug (~ 20%) is secreted unchanged. In contrast, tolbutamide and tolazamide undergo a more rapid benzylic oxidation, leading to an inactive benzoic acid derivative (Fig. 32.4). An alternative hydroxylation of the aliphatic ring of tolazamide to an active metabolite results in a prolonged duration of action relative to tolbutamide. T he major metabolite of acetohexamide is reduction of the keto group, forming an alcohol. T he hydroxy metabolite exhibits 2.5-fold the hypoglycemic activity of the parent molecule. An additional reported metabolite results from hydroxylation of the cyclohexyl group at the 4′-position, leading to inactivity.

Fig. 32.4. Metabolism of tolbutamide and tolazamide.

Glipizide and glyburide are extensively metabolized (Fig. 32.5) to less active or inactive metabolites. Glipizide metabolites are excreted primarily in the urine, whereas glyburide's metabolites are excreted equally in the urine and bile. Glimepiride is metabolized in the liver, primarily by CYP2C9, to the active metabolite M-1 (Fig. 32.6). It is then further metabolized to the inactive metabolite M-2.

Therapeutic Applications Until the introduction of metformin and more recent antidiabetic treatments, sulfonylureas were the first line of pharmacological treatment. Both the first- and second-generation sulfonylureas appear to have the same clinical effectiveness, despite the large differences in potency. All produce a reliable glucose level reduction in patients with type 2 diabetes. T hese agents work best in patients whose type 2 diabetes is relatively mild (fasting serum glucose of < 200 mg/dL or who can be controlled on ≤20 U of insulin daily). Frequency of administration varies among the compounds but is typically only once or twice daily.

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Fig. 32.5. Metabolism of glyburide and glipizide.

P.869

M eglitinides Repaglinide

Repaglinide is a nonsulfonylurea insulin secretagogue that was introduced in the United States in 1998 for type 2 diabetes. Like glimepiride described above, it binds well to SUR1, SUR2A, and SUR2B to block AT P-sensitive K

+

channels, resulting

in insulin secretion from β cells in addition to having extrapancreatic effects (60). In an interesting conformational study, it was shown that repaglinide, several other active nonsulfonylurea hypoglycemics, as well as the sulfonylureas glyburide and glimepiride displayed a comparable “ U” -shaped conformation, as indicated in molecular modeling studies. In this conformation, hydrophobic cycle groups were placed at the end of each branch, and a peptidic bond was at the bottom of the “ U.” Several inactive analogues of repaglinide and the poorly active drug meglitinide displayed a different conformation, with a greater distance between the hydrophobic cycle groups (61). Repaglinide has a rapid onset and short duration of action compared to other hypoglycemic drugs. It is not associated with the prolonged hyperinsulinemia seen with the sulfonylureas, and possibly for this reason, it produces fewer side effects, including weight gain and potentially dangerous hypoglycemia. Repaglinide is at least fivefold more potent than glyburide on intravenous administration and nearly 10-fold more active on oral administration.

Nateglinide

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Approved in the United States in late 2000, nateglinide is a rapidly absorbed insulin secretagogue that has a mechanism of action similar to that of repaglinide, with effects appearing within 20 minutes following oral dosing. Bioavailability is 73%, and it is 98% protein bound, primarily to albumin. Nateglinide is tissue selective, with low affinity for cardiac and skeletal muscle. It is metabolized in the liver, with 16% excreted in the urine unchanged. T he major metabolites are hydroxyl derivatives (CYP2C9, 70%; CYP3A4, 30%) that are further conjugated to the glucuronide derivatives (Fig. 32.7). T he drug has an elimination half-life of 1.5 hours.

Fig. 32.6. Metabolism of glimepiride.

Like repaglinide, the insulin secretion produced by nateglinide is not as prolonged as that of the sulfonylureas and may result in less instances of hypoglycemia than other insulin-secreting agents. T his also may be a result of the glucosedependence of the insulin secretion caused by the drug. Low glucose levels lead to a diminished release of insulin.

Biguanides Historically, goat's rue (Gal ega offi ci nal i s) had been used in Europe as a traditional remedy for diabetes (62). It was discovered that the active principle in this herb, galegine (isoamyleneguanidine), apparently also was the toxic principle in the plant, which caused the deaths of grazing animals. In 1918, guanidine itself was found to lower blood glucose levels in animals; however, it was too toxic for therapeutic use. In the 1950s, phenformin was found P.870 to have antidiabetic properties and was used in the United States until 1977, when it was removed from the market because of patient deaths associated with lactic acidosis. Metformin was introduced in 1995 in the United States after a track record of safe and effective use for decades overseas, and it is currently in wide use.

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Fig. 32.7. Urinary metabolites of nateglinide.

Mechanism of Action Metformin and the other biguanides are described as insulin sensitizers. T heir complete mechanism of action has not been fully elucidated. T he biguanides act in the liver by decreasing excessive glucose production, most likely via reduced gluconeogenesis resulting from an increased sensitivity to insulin. T hey also improve glucose utilization by restoring tissue sensitivity to insulin (63). T hey appear to have their main action in the liver mitochondria via activation of adenosine 5′-monophosphate–activated protein kinase (AMPK) (64). Additional favorable effects resulting from metformin therapy, such as an improved lipid profile, have been reported. Metformin can lower free fatty acid concentrations by 10 to 30%. T his antilipolytic effect may help to explain the reduction in gluconeogenesis through reduced levels of available substrate (65). When given as a monotherapy, metformin treatment does not lead to hypoglycemia, so it is better described as an antihyperglycemic agent rather than a hypoglycemic agent. T he therapeutic effect of metformin requires the presence of insulin, and metformin does not stimulate the release of insulin or other factors, such as glucagon. In fact, the secretion of adiponectin, an insulin-sensitizing hormone, appears to be suppressed by metformin (66).

Pharmacokinetics and Metabolism Metformin is quickly absorbed from the small intestine. Bioavailability is from 50 to 60%, and the drug is not protein bound. Peak plasma concentrations occur at approximately 2 hours. T he drug is widely distributed in the body and accumulates in

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the wall of the small intestine. T his depot of drug serves to maintain plasma concentrations. Metformin is excreted in the urine, via tubular excretion, as unmetabolized drug with a half-life of approximately 2 to 5 hours; therefore, renal impairment as well as hepatic disease are contraindications for the drug (63,65). One key drug–drug interaction of note is the competitive inhibition of renal excretion of metformin by cimetidine, which can lead to increased metformin blood levels (67).

Therapeutic Applications Metformin is widely used as a monotherapy or in combination with a sulfonylurea in type 2 diabetes. For overweight and obese patients, it is the agent of choice. It is effective in patients of normal weight as well. Other benefits of metformin therapy are the potential for weight reduction and a 15 to 20% lowering of plasma triglycerides. Additional benefits of metformin therapy, particularly for patients with metabolic syndrome, are increased fibrinolysis and decreased plasminogen activator inhibitor-1 (PAI-1), an antithrombolytic protein (63). One study with overweight patients given metformin versus conventional treatment reported a statistically significant, 39% reduced risk of myocardial infarction (68). Contraindications for metformin include renal insufficiency, liver disease, alcohol abuse, cardiac insufficiency, metabolic acidosis or any hypoxia-related condition. An additional consideration is that chronic metformin therapy can decrease oral absorption and subsequent serum concentrations of cyanocobalamin (vitamin B 12 ); nevertheless, this effect, which is seen in approximately one in four patients, does not appear to result in anemia.

Thiazolidinediones (“Glitazones”) T he thiazolidinediones (Fig. 32.8), also known as “ glitazones,” sometimes are referred to as insulin enhancers. T hey are exemplified by ciglitazone, the first of the glitazones. Ciglitazone's antihyperglycemic effects were discovered serendipitously. T he first drug in this class to be marketed was the drug troglitazone, which was introduced in the United States in 1997. Although clinical studies did indicate hepatic and cardiac toxicity, the toxicities were not considered to be severe, and it was felt that the drug could be used if liver function was closely monitored. In a 96-week study of patients with type 2 diabetes, little or no cardiac toxicity was noted (69). Unfortunately, rare cases of liver failure, liver transplants, and deaths were reported during postmarketing use, and the drug was voluntarily withdrawn in 2000 (70). More recently, two new glitazones have been approved and marketed. T hese include rosiglitazone and pioglitazone, both of which were introduced in 1999. Both drugs have been approved for monotherapy and combination therapy with metformin, sulfonylureas, or insulin. T he P.871 glitazones lower blood glucose concentrations by improving sensitivity to insulin in target tissue, which includes adipose tissue, skeletal muscle, and liver. T hese agents are dependent on insulin for their activity.

Fig. 32.8. Thiazolidinedione hypoglycemic agents (“glitazones”).

Mechanism of Action Like biguanides, thiazolidinediones are insulin sensitizers; however, they have a different mechanism of action from that of the biguanides. T he thiazolidinediones stimulate peroxisome proliferator-activated receptor (PPAR)-γ stimulation. T he PPARγ expression is highest in adipose tissue. In association with the retinoid X receptor, PPARγ binds to nuclear response elements, leading to the transcription of insulin-sensitive genes and, subsequently, a wide variety of actions including increases in: glucose uptake (adipose, muscle, liver), lipogenesis (adipose, liver), fatty acid uptake and preadipocyte differentiation (adipose), and glycolysis and glucose oxidation (muscle); in addition to decreases in gluconeogenesis, and glycogenolysis (liver).

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Pharmacokinetics and Metabolism T he thiazolidinediones differ by the nature of the groups attached to the 2,4-thiazolidinedione nucleus (Fig. 32.8). T hese agents are extensively metabolized, with all metabolic changes occurring on or adjacent to the second aryl group. Considerable interest in the metabolism of troglitazone exists, because hepatic toxicity may be associated with a metabolite of troglitazone. Metabolic studies in rats, mice, dogs, monkeys, and humans report the presence of the four metabolites shown in Figure 32.9, with sulfate conjugation (M-1) being the primary metabolite in humans (71,72). T he more interesting metabolite is the quinone product M-3, which is thought to arise through the action of CYP2C8 and CYP3A4. Quinone-type metabolites are considered to be reactive intermediates that may induce hepatic toxicity.

Fig. 32.9. Metabolic pathway of troglitazone.

T he metabolism of pioglitazone has been studied in rats and dogs and has led to the discovery of up to eight metabolic products. T hese products result from oxidation at either carbon adjacent to the pyridine ring and are found as various conjugates in the urine and bile (Fig. 32.10) (73,74). Metabolites M-1, M-2, and M-3 appear to contribute to the biological activity of pioglitazone. T he metabolism of rosiglitazone has been reported in humans, and in excess of 14 metabolites have been identified (75). T he primary metabolites consist of sulfate and glucuronic acid conjugates of hydroxylation and N-demethylation products (Fig. 32.11). It is unlikely that these metabolites contribute to the biological activity of rosiglitazone.

Therapeutic Applications T he thiazolidinediones are beneficial in type 2 diabetes through a unique set of pharmacological effects. In a 6-month study of type 2 diabetes, a 600-mg daily dose of troglitazone lowered fasting serum glucose by 60 mg/dL, HbA 1c by 1.1%, insulin by 2.4 µU/mL, and triglycerides by 72 mg/dL versus placebo (76). T he drugs appear to enhance insulin action, especially in liver, muscle, and fat tissue, where insulin-dependent glucose transport is essential.

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Fig. 32.10. Metabolic pathway of pioglitazone.

P.872

Fig. 32.11. Metabolic pathway of rosiglitazone.

Dual PPARα and PPARγ Coactivators Because of the adipocyte differentiation effect of PPARγ activators (e.g., thiazolidinediones), weight gain can occur as an

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undesirable effect. In theory, a drug that activated both PPARα and PPARγ may be less prone to this side effect because of promotion of fatty acid oxidation. Activation of PPARα also is reported to reduce plasma triglyceride levels and to increase high-density lipoprotein levels; these are very desirable actions for the populations prone to type 2 diabetes. T wo such agents that act on both of these targets are muraglitazar and tesaglitazar (Fig. 32.12). Others are in the clinic as well. Clinical trials demonstrated the expected benefits for muraglitazar, and it is intended as a monotherapy or in combination with metformin. Some concerns from the trials, however, are an increase, compared to placebo, in serious cardiovascular events, including death, myocardial infarction, transient ischemic attack, and congestive heart failure (77).

α-Glucosidase Inhibitors Mechanism of Action T o be absorbed from the GI tract into the bloodstream, the complex carbohydrates that we ingest (i.e., starch) as part of our diet must first be hydrolyzed to monosaccharides (Fig. 32.13). T he rationale for the α-glucosidase inhibitor class of drugs is that by preventing the hydrolysis of carbohydrates, their rate of absorption could be reduced. Starch normally is digested by salivary and pancreatic α-amylases to yield disaccharides (maltose), trisaccharides (maltotriose), and oligosaccharides (dextrin). T he oligosaccharidases responsible for final hydrolysis of these materials are all located in the brush border of the small intestine and consist of two classes. T he β-galactosidases hydrolyze β-disaccharides, such as lactose, whereas the α-glucosidases act on α-disaccharides, such as maltose, isomaltose, and sucrose (78).

Fig. 32.12. Dual PPARα and PPARγ activators.

Fig. 32.13. Metabolism of complex carbohydrates.

Structure Activ ity Relationships An extensive search for α-glucosidase inhibitors from microbial cultures led to the isolation of acarbose from an actinomycete (Fig. 32.14) (79). Extensive structure–activity investigations revealed that active α-glucosidase inhibitors have a common pharmacophore, comprising a substituted cyclohexane ring and a 4,6-dideoxy-4-amino-D-glucose unit

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known as carvosine. It appears that the P.873 secondary amino group of this core structure prevents an essential carboxyl group of the α-glucosidase from protonating the glycosidic oxygen bonds of the substrate (80).

Fig. 32.14. α-Glucosidase inhibitors.

More recently, screening programs of small molecules have yielded several other α-glucosidase inhibitors resembling simple amino sugars, such as miglitol and voglibose (Fig. 32.14).

Therapeutic Applications Clinical studies on α-glucosidase inhibitors reveal that disaccharide hydrolysis is not blocked but, rather, is delayed. Because acarbose impacts end-stage hydrolysis of both starch and sucrose, however, it affects all primary dietary sources of glucose. Patients with type 2 diabetes have an insulin response that is slow as well as inadequate; therefore, slowing the rate of absorption of glucose following a meal should be helpful in preventing the large postprandial increases in serum glucose, which are associated with degenerative complications of diabetes. T reatment with acarbose in insulin-requiring patients with type 2 diabetes was associated with significantly decreased levels of HbA 1c (0.4%) and total daily insulin dose (8.3%) (81). Additionally, significant decreases in fasting glucose and in area under glucose–time curves following a meal. Overall, 45% of patients in the study showed a good clinical response to acarbose therapy. Acarbose is only minimally absorbed (0.5–1.7%) into the bloodstream; therefore, it is not associated with any significant systemic toxicity at normal doses. In the small intestine, amylases and bacteria degrade acarbose. Some of the by-products are systemically absorbed and eliminated in the urine. Because doses in excess of 100 mg three times daily are associated with increased serum transaminase levels indicative of liver damage, doses in excess of 100 mg are not recommended. Acarbose also is not recommended in patients with significant renal dysfunction or who suffer from inflammatory bowel disease, colonic ulceration, or partial intestinal obstruction. T he drug does cause annoying flatulence and bloating in approximately 60% of the patients who use it, and it is suggested that this may be overcome by starting with a low dose of the drug and then titrating the dose upward. Acarbose (50–100 mg) is taken with the first bite of each meal. T he small molecule α-glucosidase inhibitor voglibose was marketed in Japan in 1994. It also slows the release of monosaccharides from polymeric materials and, thereby, lowers postprandial glucose levels. Additionally, the drug maintains low levels of glucose, triglycerides, and insulin in genetically obese rats, indicating possible effectiveness in conditions other than diabetes, such as obesity. Miglitol, introduced in 1998, seems to produce therapeutic results similar to those of acarbose. It causes significant lowering of HbA1c and of postprandial and fasting serum glucose. Unlike acarbose, however, miglitol is rapidly and completely absorbed into the bloodstream following oral administration. It is distributed primarily to the extracellular space, and it is rapidly cleared through the kidney without evidence of hepatic metabolism. It is not transferred into the central nervous system (82,83).

Rimonabant

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Obesity is a major factor leading to type 2 diabetes. As such, effective treatment of obesity may prevent or slow the onset of diabetes. Researchers at Sanofi-Aventis hypothesized that if cannabinoids stimulate appetite in a receptor-specific fashion (e.g., “ the munchies” ), then blocking central cannabinoid receptors might lead to decreased appetite. Rimonabant was discovered as part of a screening effort directed at the CB1 endocannabinoid receptor. It was found to be a selective and potent antagonist of the receptor. Both preclinical studies with animals and human trials with obese patients indicated that administration of rimonabant led to the decreased consumption of fats and sugar, resulting in weight loss. Additionally, a Phase III trial (the RIO-Diabetes trial) in patients with type 2 diabetes using oral antidiabetic medications demonstrated significant improvement in HbA1c , high-density lipoprotein cholesterol, triglycerides, and systolic blood pressure, along with a reduction in waist circumference (84).

Approaches in Discovery and Development Phases Considering the medical and economic importance of type 2 diabetes and the need for improvement over existing treatments, new agents for existing targets and the development of new therapeutic targets are being actively pursued in the laboratory and the clinic. Many promising targets are only in the early stages of preclinical development (e.g., small molecule insulin mimetics or glucagon antagonists, glucokinase activators, and β-cell potassium channel openers). Listed below are some selected new classes of therapeutics, some of which are in clinical trials or earlier in research.

Retinoid X Receptor Modulators T he retinoid X receptor (RXR) forms a functional heterodimer with PPARγ as well as other nuclear hormone receptors. T he RXR modulators can activate the RXR-PPARγ complex, improving glucose tolerance in animal models; however, selectivity for this particular heterodimer is required to avoid undesirable side effects. Analogues acting by this mechanism are in earlier stages of development. P.874

Protein Tyrosine Phosphatase 1B Inhibitors It has been observed that mice lacking the protein tyrosine phosphatase 1B (PT P1B) gene generally are normal but have greater insulin sensitivity and gain less weight when given a high-fat diet. T he enzyme dephosphorylates both the insulin receptor and the insulin receptor substrate-1, leading to decreased insulin sensitivity. Hence, PT P1B has been an active target for type 2 diabetes drug research. Creating a bioavailable inhibitor has proved to be challenging, however, and research is still ongoing. As an alternative approach, ISIS 113715, which is in Phase II clinical trials, is an antisense oligonucleotide designed to block transcription of PT P1B. T he low doses from this trial reduced HbA1c and plasma glucose without causing hypoglycemia.

Case Study Vic to r ia F . Roc he S. Willia m Zito BA is an Af ric an A me ric an m ale and a f o rme r p ro f e s sio nal f o o tb all p laye r who at 6 8 ye ars o f ag e is o b e s e , with a b o d y we ig ht 4 0 % g re ate r than his id e al we ig ht. Alo ng with his o b e s ity, BA has hyp e rte nsio n, hyp e rlip id e m ia, and typ e 2 d iab e te s . His hyp e rte ns io n is und e r c o ntro l with e nalap ril (1 0 mg q .d .), and his hyp e rlip id e m ia is c o ntro lle d with ato rvas tatin (2 0 m g q .d .). His b lo o d g luco s e , ho we ve r, was unc o ntro llab le b y d ie t and g lip izid e (2 0 mg q .d .) o r b y vario us re g ime ns o f ins ulin (c urre ntly re g ular insulin and NPH ins ulin ad minis te re d s ub c utane o usly in the mo rning and at b e d time , re s p e c tive ly). L as t we e k, BA had lab o rato ry te s ts, and his re s ults s ho we d that he had d e ve lo p e d mild d iab e tic ne p hro p athy (c re atinine c le aranc e , 7 5 mL /min; urine alb umin, 5 9 0 g /2 4 ho urs ). His b lo o d te s ts sho we d c o ntinue d unc o ntro llab le f as ting p las ma g luc o s e (2 0 2 m g /d L ; HbA 1c , 1 1 %), and no w his p hys ic ian wants to ad d an o ral antid iab e tic d rug to his ins ulin the rap y. Evaluate s truc ture s 1 tho ug ht 4 f o r us e in this c as e .

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1. I d e ntif y the the rap e utic p ro b le m(s ) in whic h the p harmac is t' s inte rve ntio n m ay b e ne f it the p atie nt. 2. The p hys ic ian s e e ks yo ur ad vic e in s e le c ting an o ral antid iab e tic ag e nt (o the r than g lip izid e ) to ad d to BA's ins ulin tre atme nt. I d e ntif y and p rio ritize the p atie nt-s p e c if ic f ac to rs that m us t b e co nsid e re d to ac hie ve the d e s ire d the rap e utic o utc o me s . 3. Co nd uc t a tho ro ug h and me c hanistic ally o rie nte d struc ture – ac tivity analys is o f all the rap e utic alte rnative s p ro vid e d in the c as e . 4. Evaluate the s truc ture– ac tivity re latio ns hip f ind ing s ag ainst the p atie nt-s p e c if ic f ac to rs and d e s ire d the rap e utic o utc o me s , and make a the rap e utic d e c is io n. 5. Co uns e l yo ur p atie nt.

P.875

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Chapter 33 Adrenocorticoids Duane D. Mille r Robe rt W. Brue gge m e ie r Jam e s T. Dalton

Introduction T he adrenal glands are flattened, cap-like structures located above the kidneys. T he inner core (medulla) of the gland secretes catecholamines, whereas the shell (cortex) of the gland synthesizes steroid hormones known as the adrenocorticoids. T he adrenocorticoid steroids include the glucocorticoids, which regulate carbohydrate, lipid, and protein metabolism, and the mineralocorticoids, which influence salt balance and water retention. A third class of steroids produced by the adrenal glands is called the adrenal androgens, which have weak androgenic activity in men and women and can serve as precursors to the sex hormones, estrogens and androgens. T he adrenocorticoids (this chapter) and sex hormones (see Chapters 45 and 46) have much in common. All are steroids; consequently, the rules that define their structures, chemistry, and nomenclature are the same. T he rings of these biochemically dynamic and physiologically active compounds have a similar stereochemical relationship. Changes in the geometry of the ring junctures generally result in inactive compounds regardless of the biological category of the steroid. Similar chemical groups are used to render some of these agents water soluble or active when taken orally or to modify their absorption. In addition, the adrenocorticoids and the sex hormones, which include the estrogens, progestins, and androgens, are biosynthesized mainly from cholesterol (see Chapter 30), which in turn is synthesized from acetyl–coenzyme A. Cholesterol and steroid hormone catabolism take place primarily in the liver. Although the products found in the urine and feces depend on the hormone undergoing catabolism, many of the metabolic reactions are similar for these compounds. For example, reduction of double bonds at positions 4 and 5 or 5 and 6, epimerization of 3α-hydroxyl groups, reduction of 3-keto groups to the 3α-hydroxyl function, and oxidative removal of side chains are transformations common to these agents. Despite the similarities in chemical structures and stereochemistry, each class of steroids demonstrates unique and distinctively different biological activities. Minor structural modifications to the steroid nucleus, such as changes in or insertion of functional groups at different positions, cause marked changes in physiologic activity. T he first part of this chapter focuses on the similarities among the steroids and reviews steroid nomenclature, stereochemistry, and general mechanism of action. T he second portion of the chapter focuses on the adrenocorticoids and discusses the biosynthesis, metabolism, medicinal chemistry, pharmacology, and pharmacokinetics of endogenous steroid hormones, synthetic agonists, and synthetic antagonists.

Steroid Nom enclature and Structure Steroids consist of four fused rings (A, B, C, and D) (Fig. 33.1). Chemically, these hydrocarbons are cyclopentanoperhydrophenanthrenes; they contain a five-membered cyclopentane (D) ring plus the three rings of phenanthrene. A perhydrophenanthrene (rings A, B, and C) is the completely saturated derivative of phenanthrene. T he polycyclic hydrocarbon known as 5α-cholestane will be used to illustrate the numbering system for a steroid (Fig. 33.1). T he term “ cholestane” refers to a steroid with 27 carbons that includes a side chain of eight carbons at position 17. Numbering begins P.878 in ring A at C1 and proceeds around rings A and B to C10, then into ring C beginning with C11, and snakes around rings C and D to C17. T he angular methyl groups are numbered 18 (attached to C13) and 19 (attached to C10). T he 17 side chain begins with C20, and the numbering finishes in sequential order. Using the planar representation for drawing the steroid structure (Fig. 33.2), the basic steroid structure becomes a plane with two surfaces: A top or β surface is pointing out toward the reader, and the bottom or α surface is pointing away from the reader. Hydrogens or functional groups on the β side of the molecule are denoted by solid lines; those on the α side are designated by dotted lines. T he 5α notation is used to denote the configuration of the hydrogen atom at C5, which is opposite from the C19 angular methyl group, making the A/B ring juncture trans.

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T he C19 angular methyl group is assigned the β side of the molecule. Similarly, the configuration of the 8β and 9α hydrogens, and the 14α hydrogen and C18 angular methyl group, denote trans fusion for rings B/C and C/D. T he side chains at position 17 are always β unless indicated by dotted lines or in the nomenclature of the steroid (e.g., 17β or 17α).

C lin ic a l S ig n ific a n c e Few groups of drugs can rival the adrenocorticoids, which are used for the widest variety of conditions. From asthma to rheumatologic diseases to dermatological disorders, the adrenocorticoids are commonly prescribed for their beneficial action, but unfortunately, they also exhibit toxicity. Only by understanding their complicated mechanisms of action can pharmacists help in maximizing the therapeutic benefits while minimizing the numerous adverse effects of these agents. Pharmacists must be familiar with the numerous steroid products and dosage forms that are available as well as with the structure–activity relationships that determine their effects at different receptors. By understanding these factors, the likelihood that patients will derive significant benefits without untoward toxicities is significantly increased. Finally, an appreciation concerning the role of endogenous mineralocorticoids in the pathophysiology of other diseases, such as heart failure and hypertension, is growing. An understanding of how the structure of endogenous and exogenous mineralocorticoids affects their physiologic properties provides insight regarding how drugs that antagonize this system may provide therapeutic benefits for these and other conditions. Jeffrey T . Scherer Pharm.D., MPH, BCPS, CGP Cl i ni cal Assi stant Professor, Uni versi ty of Houston Col l ege of Pharmacy

Fig. 33.1. Basic steroid structure and numbering system.

Just as cyclohexane can be drawn in a chair conformation, the three-dimensional representation for 5α-cholestane is shown by the following conformational formula. Although cyclohexane may undergo a flip in conformation, steroids are rigid structures, because they generally have at least one trans fused ring system and these rings must be diequatorial to each other.

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Fig. 33.2. Planar and conformational structures of 5α-cholestane.

P.879

Fig. 33.3. Planar and conformational structures of 5β-cholestane.

If one is aware that the angular methyl groups at positions 18 and 19 are β and have an axial orientation (i.e., perpendicular to the plane of the rings), the conformational orientation of the remaining bonds of a steroid can be easily assigned. For example, in 5α-cholestane, the C19 methyl group attached at position 10 is always β-axial; the two bonds at position 3 must be β-equatorial and α-axial, as indicated. T he orientation of the remaining bonds on a steroid may be determined if one recalls that groups on a cyclohexane ring that are positioned on adjacent carbon atoms (vicinal, -C 1 H-C 2 H-) of the ring (i.e., 1,2 to each other) are trans if their relationship is 1,2-diaxial or 1,2-diequatorial and are ci s if their relationship is 1,2-equatorial-axial. Steroid chemists often refer to the series of carbon–carbon bonds shown with heavy lines as the backbone of the steroid (Fig. 33.1). T he ci s or trans relationship of the four rings may be expressed in terms of the backbone. T he compound 5α-cholestane (Fig. 33.2) is said to have a trans-anti -trans-anti -trans backbone. In this structure, all the fused rings have trans (diequatorial) stereochemistry; in other words, the A/B fused ring, the B/C fused ring, and the C/D fused ring are trans. T he term anti is used in backbone notation to define the orientation of rings that are connected to each other and have a trans-type relationship. For example, the bond equatorial to ring B, at position 9, which forms part of ring C, is anti to the bond equatorial to ring B, at position 10, which forms part of ring A. 5β-Cholestane (Fig. 33.3) has a ci s-anti -trans-anti -trans backbone in which the A/B rings are fused ci s. T he term syn is used in a similar fashion as anti to define a ci s-type relationship. No

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natural steroids exist with a syn-type geometry, although such compounds can be chemically synthesized. T hus, the conventional drawing of the steroid nucleus is the natural configuration and does not show the hydrogens at 8β, 9α, or 14β positions. If the carbon at position 5 is saturated, the hydrogen is always drawn as either 5α or 5β. Also, the conventional drawing of a steroid molecule has the C18 and C19 methyl groups shown only as solid lines (no CH 3 drawn). T he stereochemistry of the rings markedly affects the biological activity of a given class of steroids. Nearly all biologically active steroids have the cholestane-type backbone. In most of the important steroids discussed in this chapter, a double bond is present between positions 4 and 5 or 5 and 6; consequently, there is no ci s or trans relationship between rings A and B. T he symbol ∆ often is used to designate a carbon–carbon double bond (C= = C) in a steroid. If the C= = C is between positions 4 and 5, the compound is referred to as a 4

∆ -steroid. If the C= = C is between positions 5 and 10, the compound is designated a ∆ 5

5(10)

-steroid.

5

Cholesterol (cholest-5-en-3α-ol) is a ∆ -steroid or, more specifically, a ∆ -sterol, because it is an unsaturated alcohol. Biologically active compounds include members of the 5α-pregnane, 5α-androstane, and 5α-estrane steroid classes (Fig. 33.4). Pregnanes are steroids with 21 carbon atoms, androstanes 19 carbon atoms, and estranes 18 carbon atoms, with the C19 angular methyl group at C10 replaced by hydrogen. Numbering is the same as in 5α-cholestane. T he adrenocorticoids (adrenal cortex hormones) are pregnanes and are exemplified by cortisone, which is a 17α,21-dihydroxypregn-4-ene-3,11,20-trione. T he acetate ester is named 17α,21-dihydroxypregn-4-ene3,11,20-trione 21-acetate (cortisone acetate) (Fig. 33.4). Progesterone (pregn-4-ene-3,20-dione), a female sex hormone synthesized by the corpus luteum, also is a pregnane analogue. T he male sex hormones (androgens) are based on the structure of 5α-androstane. T estosterone, an important and naturally occurring androgen, is named 17β-hydroxyandrost-4-en-3-one. Dehydroepiandrosterone (DHEA) is the major adrenal androgen and is named 3β-hydroxyandrost-5-en-17-one (Fig. 33.4). T he estrogens, which are female sex hormones synthesized by the graafian follicle of the ovaries, are estrane analogues containing an aromatic A ring. Although the A ring does not contain isolated C= = C groups, these analogues are named as if the bonds were in the positions shown in 17β-estradiol. Hence, 17β-estradiol, a typical member of this class of P.880 drugs, is named estra-1,3,5,(10)-triene-3,17β-diol. Other examples of steroid nomenclature are found throughout this chapter.

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Fig. 33.4. Steroid classes and corresponding natural hormones.

Aliphatic side chains at position 17 are always assumed to be β when cholestane or pregnane nomenclature is employed. Hence, the notation 17β need not be used when naming these compounds. If a pregnane has a 17α chain, however, this should be indicated in the nomenclature. Finally, the final “ e” in the name for the parent steroid hydrocarbon is always dropped when it precedes a vowel, regardless of whether a number appears between the two parts of the word (e.g., note the nomenclature for cholesterol and testosterone versus that for cortisone). For a more extensive discussion of steroid nomenclature, consult the literature (1).

Mechanism of Steroid Horm one Action In addition to their structural similarities, adrenocorticoids, estrogens, progestins, and androgens share a common mode of action. T hey are present in the body only in extremely low concentrations (e.g., 0.1–1.0 nM), they exert potent physiologic effects on sensitive tissues, and they bind with high affinity to intracellular receptors. Extensive research activities directed at elucidation of the general mechanism of steroid hormone action have been performed for several decades, and many reviews have appeared (2,3,4,5,6,7). T he steroid hormones act on target cells to regulate gene expression and protein biosynthesis via the formation of steroid–receptor complexes, as outlined in Figure 33.5. T he lipophilic steroid hormones are carried in the bloodstream, with the majority of the hormones reversibly bound to serum carrier proteins. T he free steroids

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can diffuse through the cell membrane and enter cells. T hose cells sensitive to the particular steroid hormone (referred to as target cells) contain steroid receptors capable of high-affinity binding with the steroid. T hese receptors are soluble intracellular proteins that can both bind steroid ligands with high affinity and act as transcriptional factors via interaction with specific DNA sites. Early studies suggested that the unoccupied steroid receptors were located solely in the cytosol of target cells (8). Recent investigations on estrogen, progestin, and androgen action, however, indicate that active, unoccupied receptors also are present in the nucleus of the cell (2,7,9). Before the binding of the P.881 steroid, the steroid receptor is complexed with heat shock proteins. In the current model, the steroid enters the cell and binds to the steroid receptor in the cytoplasm or nucleus. T his binding initiates a conformational change and dissociation of the heat shock protein, allowing steroid receptor dimerization and translocation to the nucleus. T he receptor dimer interacts with particular regions of the cellular DNA, referred to as hormoneresponsive elements (HRE), and with various coactivators and nuclear transcriptional factors. Binding of the nuclear steroid–receptor complex to DNA initiates transcription of the DNA sequence to produce mRNA. Finally, the elevated levels of mRNA lead to an increase in protein synthesis in the endoplasmic reticulum. T hese proteins include enzymes, receptors, and secreted factors that subsequently result in the steroid hormonal response regulating cell function, growth, and differentiation and playing central roles in normal physiological processes as well as in many important diseases.

Fig. 33.5. Mechanism of steroid hormone action.

T he primary amino acid sequences of the various steroid hormone receptors have been deduced from cloned cDNA (3,5). T he steroid receptor proteins are part of a larger family of nuclear receptor proteins that also include receptors for vitamin D, thyroid hormones, and retinoids. T he overall structures of the receptors have strong similarities (Fig. 33.6). A high degree of homology (sequence similarities) in the steroid receptors is found in the DNA binding region that interacts with the HRE. T he DNA binding region has critically placed cysteine amino acids that chelate zinc ions, forming finger-like projections, called zinc fingers, that bind to the DNA. Structure–function studies of cloned receptor proteins also identify regions of the molecules that are important for interactions with nuclear transcriptional factors, coactivator or corepressor proteins, activation of

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gene transcription, and protein-to-protein interactions. Recent evidence suggests that the protein–protein interactions with AP-1 and/or NFκB (other known transcriptional proteins) work to titrate out the effects of the steroid receptors on DNA. T his may be critical for cross-talk between signaling pathways within the cell and may play an important role in feedback systems. Additional evidence suggests that steroid receptors may activate transcription in the absence of hormone, an effect that appears to depend on the phosphorylation of the receptor via cross-talk with membrane-bound adrenergic and/or growth factor receptors (10). T he interactions necessary for formation of the steroid–receptor complexes and subsequent activation of gene transcription are complicated, involve multistage processes, and leave many unanswered questions. T he basic mechanism of steroid hormone action on target cells is similar for the various classes of agents. Differences in the actions of adrenocorticoids, estrogens, progestins, and androgens arise from the specificity of P.882 the particular receptor proteins, the particular genetic processes initiated, and the specific cellular proteins produced.

Fig. 33.6. Structural features of steroid hormone receptors and hormoneresponsive elements (HREs). Schematic comparison of the amino acid sequences of steroid receptors (GR, glucocorticoid; MR, mineralocorticoid; PR, progesterone; ER, estrogen; AR, androgen) with high homology in the DNA binding region. The HRE sequences also are compared (GRE, glucocorticoid; MRE, mineralocorticoid; PRE, progesterone; ERE, estrogen; ARE, androgen).

History and Disease States T he importance of the adrenal glands was recognized long ago. Addison's disease, Cushing's disease, and Conn's syndrome are pathological conditions related to the adrenal cortex and the hormones produced by the gland. Addison's disease was named after T homas Addison. In 1855, Addison described a syndrome in which the physiologic significance of the adrenal cortex was emphasized (11). T his disease is characterized by extreme

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weakness, anorexia, anemia, nausea and vomiting, low blood pressure, hyperpigmentation of the skin, and mental depression resulting from decreased secretion of steroid hormones by the adrenal cortex. Addison's disease is a rare affliction that affects roughly 1 in 100,000 people and is seen equally in both sexes and in all age groups. Conditions of this type, generally referred to as hypoadrenalism, may result from several causes, including destruction of the cortex by tuberculosis or atrophy or decreased secretion of adrenocorticotropin (adenocorticotropic hormone [ACT H]) because of diseases of the anterior pituitary (adenohypophysis). Cushing's disease, or hyperadrenalism, on the other hand, may result from adrenal cortex tumors or increased production of ACT H caused by pituitary carcinoma. Cushing's syndrome also is rare, occurring in only two to five people for every 1 million people each year. Approximately 10 percent of newly diagnosed cases are observed in children and teenagers. Conn's syndrome is apparently caused by an inability of the adrenal cortex to carry out 17α-hydroxylation during the biosynthesis of the hormones from cholesterol. Consequently, the disease is characterized by a high secretory level of aldosterone, which lacks a 17α-hydroxyl functional group. In addition, hypernatremia, polyuria, alkalosis, and hypertension are observed (12). T he importance of the adrenocorticoids is most dramatically observed in adrenalectomized animals. T here is an increase of urea in the blood, muscle weakness (asthenia), decreased liver glycogen, decreased resistance to insulin, lowered resistance to trauma (e.g., cold and mechanical or chemical shock), and electrolyte disturbances. Potassium ions are retained, and excretion of Na + , Cl - , and water is increased. Adrenalectomy in small animals causes death in a few days. After Addison's observations in 1855, physiologists, pharmacologists, and chemists from many countries contributed to our understanding of adrenocorticoids. It was not until 1927, however, that Rogoff and Stewart found that extracts of adrenal glands, administered by intravenous (IV) injection, kept adrenalectomized dogs alive. P.883 Since that discovery, similar experiments have been repeated many times. Originally, the biological activity of the extract was thought to result from a single compound. Later, 47 compounds were isolated from such extracts, and some were highly active. Among the biologically active corticoids isolated, hydrocortisone, corticosterone, aldosterone, cortisone, 11-desoxycorticosterone (17α-hydroxyprogesterone), 11-dehydrocorticosterone (11-desoxycortisol), and 17α-hydroxy-11-desoxycorticosterone were found to be most potent (13). T he biosynthesis of these steroids is described below.

Biosynthesis

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Pregnenolone Form ation In the adrenal glands, cholesterol is converted by enzymatic cleavage of its side chain to pregnenolone (3β-hydroxypregn-5-en-20-one), which serves as the biosynthetic precursor of the adrenocorticoids (Fig. 33.7).T his biotransformation is performed by a mitochondrial cytochrome P450 enzyme complex. T his enzyme complex found in the mitochondrial membrane consists of three proteins: cytochrome P450 11A1 (CYP11A1; also known as P450 SCC ), adrenodoxin, and adrenodoxin reductase (14). Defects in CYP11A1 lead to a lack of glucocorticoids, feminization, and hypertension. T hree oxidation steps are involved in the conversion, and three moles of NADPH and molecular oxygen are consumed for each mole of cholesterol converted to pregnenolone. T he first oxidation results in the formation of cholest-5-ene-3β,22R-diol (step a), followed by the second oxidation yielding cholest-5-ene-3β,20R,22R-triol (step b). T he third oxidation step catalyzes the cleavage of the C20-C22 bond to release pregnenolone and isocaproic aldehyde (step c). Pregnenolone serves as the common precursor in the formation of the adrenocorticoids and other steroid hormones. T his C21 steroid is converted via enzymatic oxidations and isomerization of the double bond to a number of physiologically active C21 steroids, including the female sex hormone progesterone and the adrenocorticoids hydrocortisone (cortisol), corticosterone, and aldosterone. Oxidative cleavage of the two-carbon side chain of pregnenolone and subsequent enzymatic oxidations and isomerization lead to C19 steroids, including the androgens testosterone and dihydrotestosterone. T he final group of steroids, the C18 female sex hormones, are derived from oxidative aromatization of the A ring of androgens to produce estrogens. More detailed information regarding these biosynthetic pathways are described in this and the following chapters under the particular class of steroid hormones.

Fig. 33.7. Biosynthesis of pregnenolone from cholesterol.

Pregnenolone to Glucocorticoids and M ineralocorticoids T he biosynthesis of the glucocorticoids and mineralocorticoids are regulated by independent mechanisms. T he glucocorticoids, such as cortisol, are biosynthesized and released under the influence of peptide hormones secreted by the hypothalamus and anterior pituitary (adenohypophysis) to activate the adrenal cortex (the

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hypothalamic-pituitary-adrenal [HPA] axis). Removal of the pituitary results in atrophy of the adrenal cortex and a marked decrease in the rate of glucocorticoid formation and secretion. On the other hand, the secretion of the mineralocorticoids, corticosterone and aldosterone, are under the influence of the octapeptide, angiotensin II. Angiotensin II is the active metabolite resulting from the renin-catalyzed proteolytic hydrolysis of plasma angiotensinogen to angiotensin I in the blood. In hypophysectomized animals, the rate of secretion of aldosterone is only slightly decreased or remains P.884 unchanged. Consequently, the electrolyte balance remains nearly normal. T he peptide hormone in the anterior pituitary that influences glucocorticoid biosynthesis is ACT H (corticotropin), whereas the peptide hormone in the hypothalamus is corticotropin-releasing factor (CRF). T he production of both ACT H and CRF is regulated by the central nervous system and by a negative corticoid feedback mechanism. T he CRF is released by the hypothalamus and is transported to the anterior pituitary, where it stimulates the release of ACT H into the bloodstream. T hen, ACT H is transported to the adrenal glands, where it stimulates the biosynthesis and secretion of the glucocorticoids. T he circulating levels of glucocorticoids act on the hypothalamus and anterior pituitary to regulate the release of both CRF and ACT H. As the levels of glucocorticoids rise, smaller amounts of CRF and ACT H are secreted, and a negative feedback is observed (HPA suppression). Stimuli, such as pain, noise, and emotional reactions, increase the secretion of CRF, ACT H, and consequently, the glucocorticoids. Once the stimulus is alleviated or removed, the negative feedback mechanism inhibits further production and helps to return the body to a normal hormonal balance (15,16). Adrenocorticotropic hormone acts at the adrenal gland by binding to a receptor protein on the surface of the adrenal cortex cell to stimulate the biosynthesis and secretion of glucocorticoids. T he only steroid stored in the adrenal gland is cholesterol, found in the form of cholesterol esters stored in lipid droplets. Adrenocorticotropic hormone stimulates the conversion of cholesterol esters to glucorticoids by initiating a series of biochemical events through its surface receptor. T he ACT H receptor protein is coupled to a G protein and to adenylate cyclase. Binding of ACT H to its receptor leads to activation of adenylate cyclase via the G protein. T he result is an increase in intracellular cyclic adenosine monophosphate (cAMP) levels. One of the processes influenced by elevated cAMP levels is the activation of cholesterol esterase, which cleaves cholesterol esters and liberates free cholesterol. Free cholesterol is then converted within mitochondria to pregnenolone via the side-chain cleavage reaction described earlier (Fig. 33.7). Pregnenolone is converted to adrenocorticoids by a series of enzymatic oxidations and isomerization of the double bond (Fig. 33.8). T he next several enzymatic steps in the biosynthesis of glucocorticoids occur in the endoplasmic reticulum of the adrenal cortex cell. Hydroxylation of pregnenolone at position 17 by the enzyme 17α-hydroxylase (CYP17) produces 17α-hydroxypregnenolone (step b). T he 17α-hydroxyl group is important for adrenocorticoid hormone action. In one step, 17α-hydroxypregnenolone is oxidized to a 3-keto intermediate by the action of the enzyme 5-ene-3β-hydroxysteroid dehydrogenase (3β-HSD) and isomerized to 17α-hydroxyprogesterone by the enzyme 3-oxosteroid-4,5-isomerase (steps c and d). Another hydroxylation occurs by the action of 21-hydroxylase (CYP21) to give rise to 11-deoxycortisol, which contains the physiologically important ketol (-COCH 2 OH) side chain at the 17β position (step e). A lack of CYP21 prevents cortisol biosynthesis, diverting excess 17α-hydroxypregnenolone and 17α-hydroxyprogesterone into overproduction of C19 androgens. T he final step in the biosynthesis of hydrocortisone is catalyzed by the enzyme 11β-hydroxylase, a mitochondrial cytochrome P450 enzyme complex (CYP11B2). T his last enzymatic step (step f) results in the formation of hydrocortisone (cortisol), the most potent endogenous glucocorticoid secreted by the adrenal cortex. Approximately 15 to 20 mg of hydrocortisone are biosynthesized daily. Several reviews (14,15,17,18,19) provide more detailed discussions about the enzymology and regulation of adrenal steroidogenesis. T he pathway for the formation of the potent mineralocorticoid molecule, aldosterone, is similar to that for hydrocortisone and uses several of the same enzymes (Fig. 33.8). T he preferred pathway involves the conversion of pregnenolone to progesterone by 5-ene-3β-hydroxysteroid dehydrogenase and 3-oxosteroid-4, 5-isomerase (steps c and d). Hydroxylation at position 21 of progesterone by 21-hydroxylase results in 21-hydroxyprogesterone (11-deoxycorticosterone) (step e). Again, these first conversions occur in the endoplasmic reticulum of the cell, whereas the next enzymatic steps occur in the mitochondria. 11β-Hydroxylase (CYP11B2) catalyzes the conversion of 21-hydroxyprogesterone to corticosterone (step f), which exhibits mineralocorticoid activity. T he final two oxidations involve hydroxylations at the C18 methyl group and are catalyzed by 18-hydroxylase (step g). T hese reactions produce first 18-hydroxycorticosterone (not shown) and then aldosterone, the most powerful endogenous mineralocorticoid secretion of the adrenal cortex. T he aldehyde at C18 of aldosterone exists in equilibrium with its hemiacetal form.

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Metabolism Hydrocortisone (hormonally active) and cortisone (the inactive metabolite of hydrocortisone) are biochemically interconvertible by the enzyme 11β-hydroxysteroid dehydrogenase (Fig. 33.9). T wo isozymes of 11β-hydroxysteroid dehydrogenase are present, type 1 11β-hydroxysteroid dehydrogenase (11β-HSD1), referred to as the “ liver” isozyme, and type 2 11β-hydroxysteroid dehydrogenase (11β-HSD2), referred to as the “ kidney” isozyme (20,21,22). T he 11β-HSD1 isozyme is a bidirectional enzyme, readily interconverts hydrocortisone and cortisone, and is found in many tissues in the body. T his isozyme plays an important role in the regulation of hepatic gluconeogenesis in the liver and in fat production in adipose tissues. By contrast, the 11β-HSD2 isozyme is only unidirectional, catalyzing the 11β-dehydrogenation of hydrocortisone to give cortisone. T he 11β-HSD2 is present in placenta and in kidney, specifically the distal convoluted tubules and cortical collecting ducts in the kidney. T he 11β-HSD2 isozyme plays an important role in the rapid metabolism P.885 of hydrocortisone, thus preventing hydrocortisone from binding to the mineralocorticoid receptors present in the same kidney tissues. A deficiency of 11β-HSD2 is associated with the inherited genetic disease, apparent mineralocorticoid excess, which is characterized by hypertension, excessive salt retention, and hypokalemia caused by the elevated hydrocortisone levels in the kidney.

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Fig. 33.8. Biosynthesis of the adrenocorticoids from cholesterol.

Hydrocortisone is metabolized by the liver following administration by any route, with a half-life of approximately l.0 to 1.5 hours (23). Hydrocortisone is mainly excreted in the urine as inactive O-glucuronide conjugates and minor O-sulfate conjugates of urocortisol, 5β-dihydrocortisol, and urocortisone (Fig. 33.9). T he

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tetrahydro metabolite urocortisol is the major metabolite formed and has the 5β-pregnane geometry and 3α-hydroxyl function. T he 5β configuration is similar to the ring geometry for the nonhormonal bile acids. Several compounds of this type have been isolated (24,25). All of the biologically active adrenocorticoids contain a ketone at the 3-position and a double bond in the 4,5-position. T he formation of 5β-metabolites from hydrocortisone is characterized by reduction of the 4,5-double bond to a 5β geometry for rings A and B (a ci s configuration) by 5β-reductase or reduction of the 3-ketone by 3α-hydroxysteroid dehydrogenase (3α-hydroxyl configuration) or 3β-hydroxysteroid dehydrogenase (3β-hydroxyl configuration). T hese P.886 reactions represent the major pathways of metabolism for the glucocorticoids and their endogenous counterparts. Urocortisol and urocortisone are named after cortisol (hydrocortisone) and cortisone. Reversible oxidation of the 11β-hydroxyl group of many glucocorticoids (e.g., hydrocortisone, prednisolone, and methylprednisolone, but not dexamethasone and other 9α-fluorinated glucocorticoids) by 11β-hydroxysteroid dehydrogenase inactivates these drugs and limits their mineralocorticoid activity in the kidneys. Other routes of metabolism include 6β-hydroxylation (CYP3A4) and reduction of the 20-ketone (e.g., prednisolone) to form 20-hydroxyl analogues as well as oxidation of the 17-ketol side chain to 17β-carboxylic acids and loss of the 17-ketol side chain, resulting in 11β-hydroxy-17-keto-C19 steroids with the geometry of either 5α-androstane or 5β-androstane (15,17,18,19). In addition, some ring A aromatic adrenocorticoid metabolites that resemble the estrogens have been isolated (26). Biliary and fecal excretion contribute little to the elimination of the adrenocorticoids. T he rate of formation of 6β-hydroxyhydrocortisone is a biomarker for determining the level of HPA suppression and adrenal insufficiency.

Fig. 33.9. Major routes of metabolism for hydrocortisone.

Developm ent of Adrenocorticoid Drugs Systemic Corticosteroids Overview T he route of administration depends on the disease being treated and the physicochemical, pharmacologic, and pharmacokinetic properties of the drug (T able 33.1). T he clinically available adrenocorticoids may be administered by IV injection, oral tablets or solutions, topical formulations, intra-articular administration, and oral or nasal inhalation (T able 33.2). Only a handful of P.887 P.888

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corticosteroids are used clinically by the oral route, including hydrocortisone, prednisone, prednisolone, methylprednisolone, and dexamethasone (Fig. 33.10). T hese corticosteroids often are described as shortacting, intermediate-acting, or long-acting according to their biological half-life and duration of action (T able 33.2). T hey are well-absorbed, undergo little first-pass metabolism in the liver, and demonstrate oral bioavailabilities of 70 to 80%, except for triamcinolone (T able 33.3). T he larger volume of distribution for methylprednisolone compared to prednisolone is thought to result from a combination of increased lipophilicity, decrease in metabolism, and better tissue penetration. Glucocorticoids vary in the extent to which they are bound to the plasma proteins, albumin, and corticosteroid-binding globulin (transcortin) (T able 33.3) (27).

Table 33.1. Pharmacological and Pharmacokinetic Properties for Some Adrenocorticoids

Adrenocorticoid

Potency Relative to Hydrocortisone Half-life (hours) Oral Gluco- Gluco- Mineralo- Protein Duratio corticoid corticoid corticoid Binding Biologic of Actio Dosea (mg) Activityb Activityc (%)d Plasma (tissue) (days)

Short-acting Hydrocortisone

20

1

2+

>90

1.5–2.0

8–12

Cortisone

25

0.8

2+

>90

0.5

8–12

Prednisone

5

3.5

1+

>90

3.4–3.8

18–36

Prednisolone

5

4

1+

>90

2.1–3.5

18–36

Methylprednisolone

5

5

0e

>3.5

18–36

Triamcinolone

5

5

0e

>90

2–5

18–36

Dexamethasone

0.75

20–30

0e

>90

3.0–4.5

36–54

Betamethasone

0.6

20–30

0e

>90

3–5

36–54

Fludrocortisone

Not employed

10

10

9 mg/100 mL) and serves to oppose the hormonal effects of parathyroid hormone. In response to a hypercalcemic state (Fig. 35.1, B loops), increased calcitonin secretion drives serum calcium concentrations down via stimulation of urinary excretion of both calcium and phosphate (loop 3B), prevention of calcium resorption from the bone via inhibition of osteoclast activity (loop 1B), and inhibition of intestinal absorption of calcium (loop 2B). When serum calcium concentrations are low (hypocalcemia), the release of calcitonin is slowed, thereby activating loops 1A, 2A, and 3A.

Parathyroid Hormone

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Parathyroid hormone (PT H) is biosynthesized as a 115-amino-acid preprohormone in the rough endoplasmic reticulum of the parathyroid gland and is cleaved to the prohormone (84 amino acids) in the cisternal space of the reticulum. T he active hormone is finally produced (34 amino acids; molecular weight, 9,500 dalton) in the Golgi complex and is stored in secretory granules in the parathyroid gland. T his gland is exquisitely sensitive to serum calcium concentrations and is able to monitor these levels via calcium-sensing receptors (CaSR). T hese cell surface receptors help cells to react to micromolar changes in the concentration of ionized calcium in the serum (8). Binding of calcium to these receptors facilitates activation of phospholipase C and, ultimately, inhibition of PT H secretion. T he relatively short-acting PT H is secreted from the parathyroid gland chief cells in response to a hypocalcemic state and serves to oppose the hormonal effects of calcitonin (1). Unlike calcitonin, the biological activity of PT H resides solely in residues 1 to 34 in the amino terminus. Parathyroid hormone decreases renal excretion of calcium (Fig. 35.1, loop 3A), indirectly stimulates intestinal absorption of calcium (Fig. 35.1, loop 2A), and in combination with active vitamin D, promotes bone resorption (Fig. 35.1, loop 1A) by a complex, unknown mechanism, thereby elevating serum calcium concentrations. In addition, the secretion of PT H stimulates the biosynthesis and release of the third hormone associated with calcium homeostasis, vitamin D. When serum calcium concentrations are high, the release of PT H is inhibited.

Vitam in D Derived from cholesterol, vitamin D is biosynthesized from its prohormone cholecalciferol (D 3 ), the product of solar ultraviolet irradiation of 7-dehydrocholesterol in the skin (2). In 1966, it was first recognized that vitamin D must undergo activation vi a two oxidative metabolic steps (Fig. 35.2). T he first oxidation to 25-hydroxycholecalciferol (25(OH)D 3 : calcifediol; Calderol) occurs in the endoplasmic reticulum of the liver and is catalyzed by vitamin D 25-hydroxylase. T his activation step is not P.938 regulated by plasma calcium concentrations. T he major circulating form (10–80 µg/mL) is 25(OH)D 3 , which also is the primary storage form of vitamin D (2). In response to a hypocalcemic state and the secretion of PT H, a second oxidation step is activated in the mitochondria of the kidney, catalyzed by vitamin D 1α-hydroxylase (2,9). T he product of this reaction, 1,25-dihydroxycholecalciferol (1,25(OH) 2 D 3 : 1,25-calcitriol; Rocaltrol, Calcijex) is the active form of vitamin D. Its concentration in the blood is 1/500 that of its monohydroxylated precursor. T he biosynthesis of vitamin D is tightly regulated based on the serum concentrations of calcium, phosphate, PT H, and active vitamin D (2).

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Fig. 35.2. Bioactivation of vitamin D.

Sterol-specific cytoplasmic receptor proteins (vitamin D receptor) mediate the biological action of vitamin D (9). T he active hormone is transported from the cytoplasm to the nucleus via the vitamin D receptor, and as a result of the interaction of the hormone with target genes, a variety of proteins are produced that stimulate the transport of calcium in each of the target tissues. Active vitamin D works in concert with PT H to enhance active intestinal absorption of calcium, to stimulate bone resorption, and to prohibit renal excretion of calcium (2,9). If serum calcium or 1,25-calcitriol concentrations are elevated, then vitamin D 24-hydroxylase (in renal mitochondria) is activated to oxidize 25(OH)D 3 to inactive 24,25-dihydroxy-cholecalciferol and to further oxidize active vitamin D to the inactive 1,24,25-trihydroxylated derivative. Both the 1,24,25-trihydroxylated and the 24,25-dihydroxylated products have been found to suppress PT H secretion as well. Several factors have been identified in the regulation of the biosynthesis of vitamin D, including low phosphate concentrations (stimulatory) as well as pregnancy and lactation (stimulatory).

Norm al Physiology During growth periods in childhood and early adulthood, bone formation characteristically exceeds bone loss. In young adulthood, bone formation and bone resorption are nearly equal. After the age of 40 years, however, bone resorption is slightly greater than bone formation, and this results in a gradual decline in skeletal mass. Osteoblasts, osteoclasts, and osteocytes are the three types of cells that make up the bone remodeling unit (3) or bone metabolizing unit (4) and, therefore, are largely responsible for the bone remodeling process. Osteoblasts, which are of mesenchymal origin and are formed in the bone marrow, stimulate bone formation (6). In the maturation process, osteoblasts undergo multiple cell divisions and, in so doing, express the gene products that are needed to form the bone matrix or osteoid (3) as well as those products responsible for mineralization of that tissue (6). Multiple endogenous substances are involved in osteoblast maturation, including many cytokines (interleukins and granulocyte-macrophage colony-stimulating-factor) (3) as well as hormones and growth factors (6). It is in the rough endoplasmic reticulum that the biosynthesis of the bone matrix protein occurs (4). Osteoclasts are the large multinucleated cells of hemopoietic origin (6) that are responsible for carrying out the

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bone resorption or destroying process. Cytokines, PT H, and the active form of vitamin D activate these cells. Bone lining flat cells, derived from “ retired” osteoclasts and osteoblasts, are located on the bone surface (3). T he function of these flat cells is thought to serve to identify areas of the bone that have become weakened or misshapen and to send a signal to the bone remodeling unit to prepare the bone. Lining cells then digest the outer layer of the bone matrix in preparation for bone remodeling. T he osteoclast membrane then comes into contact with the bone surface and forms an impermeable “ sealing zone” of approximately 500 to 1,000 µm in size (2,6). T he H + AT Pase-rich osteoclast membrane that is in contact with the bone surface forms a ruffled border, the sealing zone becomes acidified, and ultimately, the bone minerals dissolve (6). Several types of lysosomal enzymes have been proposed to then digest the collagen matrix (3), thereby pitting the bone surface to a depth of 50 µm (4,5,6). Only calcitonin acts directly on the osteoclast to prevent bone resorption. Yet another type of cell is found deep within the bone matrix, the osteocyte. T he role of this type of cell has yet to be elucidated, but it has been proposed that it may be responsible for maintaining bone integrity (3) and for providing nutrition to the bone. Parathyroid hormone stimulates bone resorption by several mechanisms: 1) T ransformation of osteoprogenitor cells into osteoclasts is stimulated in the presence of PT H, 2) PT H promotes the deep osteocytes to mobilize calcium from perilacunar bone, and 3) surface osteocytes are stimulated by PT H to increase the flow of calcium out of the bone. Quantification of bone mineral density (BMD) can be measured by noninvasive radiographic tests, such as single-photon (3) or dual-photon absorptiometry (spine, hip, and total body) (10), dual-energy x-ray absorptiometry (3,10,11) (spine, hip, total and body), peripheral dual-energy x-ray absorptiometry (wrist, heel, and finger), single energy x-ray absorptiometry (wrist or heel) (12), quantitative computed tomography (spine) and peripheral quantitative computed tomography (wrist) (10), and quantitative ultrasound (heel, shin bone, and knee cap) (12). Dual-energy x-ray absorptiometry is considered to be the gold standard for measuring bone density and has an accuracy that exceeds 95% (4). T hese techniques measure the attenuation of x-rays or gamma rays as they cross the spine, hip, or radius before they reach the detector (6). Other methods under development that measure BMD include ultrasound, traditional x-rays, and blood/urine tests (6). T raditional x-rays can identify the site of fracture, but they cannot measure BMD (3). Blood/urine tests can identify if the patient is suffering from a medical condition (3) that is contributing to the loss of BMD and can identify important biochemical markers that can assess the rate of P.939 bone resorption and bone turnover. T he measurement of serum calcium, phosphorous, and vitamin D levels also may provide insight regarding the cause of decreased BMD (3). Often, patients suffer from multiple vertebral compression fractures (3) without seeking treatment other than an over-the-counter analgesic, and the diagnosis of osteoporosis occurs only after the patient has already lost significant (as much as 30%) bone mass.

Table 35.1. Classification of Osteoporosis (14)

Etiology

Type I (postmenopausal) Increased Osteoclast Activity and Bone Resorption

Type II (senile) Decreased Osteoblast Activity Type III and Bone Formation; (secondary) Drug Decreased GI Ca Therapies; Absorption Disease States

Typical age at diagnosis

50–75

>70

any age

Gender ratio

6:1 women/men

2:1 women/men

1:1 women/men

Typical fracture site

vertebrae, distal radius

femoral, neck, hip

vertebrae, hip, extremities

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Bone morphology

decreased trabecular

decreased trabecular and normal cortical bone

decreased cortical bone

Rate of bone loss

2–3% per year

0.3–0.5% per year

variable

Disease States Associated With Abnorm al Calcium Hom eostasis Osteoporosis Osteoporosis is a skeletal disease that is characterized by loss of bone mass as well as microarchitectural deterioration of the bone tissue. T his disease is associated with increased bone fragility and susceptibility to fracture. It is a condition that is characterized not by inadequate bone formation but, rather, by a deficiency in the production of well-mineralized bone mass. Whereas no medical cause typically is evident in primary osteoporosis (3), secondary osteoporosis classically stems from medical illness or medication use. T here are two types of primary adult osteoporosis, type I, or postmenopausal, and type II, or senile (T able 35.1). In type I osteoporosis, there is an accelerated rate of bone loss via enhanced resorption at the onset of menopause. In this form of the disease, the loss of trabecular bone is threefold greater than the loss of cortical bone. T his disproportionate loss of bone mass is the primary cause of the vertebral crush fractures and the wrist and ankle fractures experienced by postmenopausal women. In type II osteoporosis, which is associated with aging, the degree of bone loss is similar in both trabecular and cortical bone (5) and is caused by decreased bone formation by the osteoblasts. Drug- or disease-induced, or type III, osteoporosis (T able 35.2) accounts for up to 30% of the cases of vertebral fractures reported annually. It can be caused by a variety of factors, including long-term suppression of osteoblast function, an inhibition of calcium absorption from the gut, or excessive loss of calcium in the urine, as a result of estrogen deficiency, hyperparathyroidism (6,11), hyperthyroidism (6,11), hypogonadism (11,13), renal disease (6), depression, and treatment with glucocorticoids (13), thyroid hormone, anticonvulsants, methotrexate (13), cyclosporine (13), warfarin, lithium, or immunosuppressive therapy (6). Warfarin impairs the vitamin K–dependent biosynthesis of osteocalcin (13), it prevents the recycling of oxidized vitamin K to its active reduced form via inhibition of vitamin K epoxide reductase and vitamin K reductase. Long-term therapy with glucocorticoids has been shown to directly suppress osteoblast function and reduce calcium absorption from the gut (13). Vitamin D deficiency, as the cause of pseudohyperparathyroidism, is a common cause of osteoporosis in elder persons who are institutionalized and lack adequate sunlight exposure (2). Osteoporosis is the cause of nearly 1.5 million fractures annually in the United States (3), including 250,000 hip fractures and 550,000 vertebral fractures. As it relates to the percentage of women older than 50 years who are at risk for developing osteoporosis because of low bone mass, the statistics are sobering: 52% of Caucasian and Asian women, 35% of African-American women, and 49% of Hispanic women. It has been predicted that one in every three women who live to the age of 90 years will experience a hip fracture (3,15). It has been estimated that 15 to 35% of hip fracture patients will require long-term nursing home care. A surprising 60% of hip fracture patients do not regain full function, and within 3 to 4 P.940 months of hip fracture, as many as 25% die as a result of secondary complications (e.g., pneumonia or infection). Mortality also is increased 17% after both femoral and vertebral fractures. T he risk factors associated with osteoporosis are presented in T able 35.3. Given these statistics, osteoporosis should be considered a significant health problem that only stands to worsen unless appropriate interventions are pursued.

Table 35.2. Causes of Secondary (Type III) Osteoporosis (13,15)

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Alcohol

Hypopituitarism

Algodystrophy

Mastocytosis

Anorexia nervosa

Mylenoma

Celiac disease

Organ transplant

Crohn's disease

Osteogenesis imperfecta

Diabetes mellitus

Primary biliary cirrhosis

Drug-induced

Pregnancy

(corticosteroids, heparin, warfarin)

Rheumatic diseases Thyrotoxicosis/thyroid replacement

Exercise induced amenorrhea Gastrectomy

Turner's syndrome

Hyperparathyroidism

Ulcerative colitis

Hypogonadism

Table 35.3. Risk Factors for Osteoporosis (3) Lifestyle Factors

Genetic Factors M edical Disorders

Drugs

Smoking

White or Asian

Cushing's syndrome

Glucocorticoids

Sedentary lifestyle

Female

Hyperthyroidism

Thyroid hormone

Calcium intake

Family history

Congenital hypogonadism

Phenytoin

Milk intolerance

Small frame

Primary biliary cirrhosis

Carbamazepine

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Excessive caffeine

Early menopause

Malabsorption syndromes

Heparin

Excessive alcohol

Gastrointestinal resection

Aluminum antacids

Nulliparity

Primary hyperparathyroidism

GnRH agonists

High protein intake

Anorexia nervosa Multiple myeloma Depression

Furosemide

GnRH, gonadotropin-releasing hormone.

Osteopetrosis Osteopetrosis, also known as marble bone disease, describes a group of heritable disorders that are centered on a defect in osteoclast-mediated bone resorption. T here are four autosomal recessive and one autosomal dominant forms of osteopetrosis (T able 35.4) (16). It generally is characterized by abnormally dense, brittle bone and increased skeletal mass. Unlike osteoporosis, this disorder results from decreased osteoclast activity, which has an effect on both the shape and structure of the bone. In very extreme cases, the medullary cavity, which houses bone marrow, fills with new bone, and production of hematopoietic cells is hampered. Like osteoporosis, this disease can be detected radiographically and appears as though there is a “ bone within a bone.” T here is limited evidence that bisphosphonates can induce osteopetrosis via their inhibition of osteoclast activity (17).

Hypocalcem ia Hypocalcemia can be caused by PT H deficiency, vitamin D deficiency, various pharmacological agents, and miscellaneous disorders (T able 35.5) (18). A state of hypocalcemia will inhibit calcitonin release. T his results in an elevation of PT H biosynthesis and release and indirectly causes an increase in the production of vitamin D. T he left wing of Arnaud's butterfly model (Fig. 35.1) would be activated to increase serum calcium concentrations. In the absence of calcitonin, osteoclast activity is unregulated; therefore, bone resorption is accelerated. In acute cases of hypocalcemia, specifically in the case of hypocalcemic tetany, PT H is administered to correct the hormonal imbalance.

Hypercalcemia A state of hypercalcemia (T able 35.6) will promote calcitonin biosynthesis and release. As a result, PT H biosynthesis and its secretion are inhibited, as is the production of vitamin D. T he right wings of Arnaud's butterfly model (Fig. 35.1, B loops) would be activated to decrease serum calcium concentrations. In the presence of calcitonin, P.941 osteoclast activity is inhibited, so bone resorption is slowed. In acute cases of hypercalcemia, calcitonin is administered to reestablish calcium homeostasis. Hypercalcemia also can be treated with sulfate salts, ethylenediaminetetraacetic acid, furosemide, ethacrynic acid, glucocorticoids, and plicamycin.

Table 35.4. Human Osteopetrosis Genotypes Gene Involved

Function of Gene

Clinical Symptoms

% Patients Affected

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Autosomal Recessive Disorders CAII

Carbonic acid and proton production

Less severe: may improve with age, short stature, no hematologic failure

30 mL/min). Ibandronate should not be prescribed for patients with severe renal impairment (creatinine clearance, < 30 mL/min). Osteonecrosis of the jaw has been reported in patients receiving IV bisphosphonate therapy. T he majority of the patients who developed osteonecrosis of the jaw were undergoing chemotherapy, taking corticosteroids, and had undergone a dental procedure (e.g., tooth extraction). T he U.S. FDA recommends that patients receive a thorough dental examination before initiation of IV bisphosphonate therapy and that they avoid invasive dental work during treatment. T he remaining two bisphosphonates, pamidronate and zoledronic acid, are approved for treatment of hypercalcemia of malignancy as well as other cancer conditions and will be discussed later in the chapter.

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Calcitonin (Calcimar [IV, SC]; Miacalcin and Fertical [nasal spray]) Calcitonin (see earlier discussion in this chapter) has been approved for the treatment of postmenopausal osteoporosis, hypercalcemia of malignancy, and Paget's disease of the bone. Several sources are available (e.g., eel, human, salmon, and porcine). T he calcitonin isolated from salmon is the preferred source, because it has greater receptor affinity and a longer half-life than the human hormone (3,7). Calcitonin is commercially available as synthetic calcitonin-salmon, which contains the same linear sequence of 32 amino acids, as occurs in natural calcitonin-salmon. Calcitonin-salmon differs structurally from human calcitonin at 16 of 32 amino acids (see Fig. 7.16 for primary structure differences between human and salmon calcitonin). T he pharmacological activity of these calcitonins is the same, but calcitonin-salmon is approximately 50-fold more potent on a weight basis than human calcitonin with a longer duration of action. T he duration of action for calcitonin salmon is 8 to 24 hours following intramuscular (IM) or subcutaneous (SC) administration and 0.5 to 12.0 hours following IV administration. T he parenteral dose required for the treatment of osteoporosis is 100 IU/day (33). Initially only available by IM or SC injection, the peptide hormone calcitonin-salmon is available as a nasal spray (Miacalcin) and as a rectal suppository (6). A recombinant DNA form of calcitonin salmon was approved by the U.S. FDA in 2005 and is available as a nasal spray. T he bioavailability of calcitonin-salmon nasal spray shows great variability (range, 0.3–30.6% of an IM dose). It is absorbed rapidly from the nasal mucosa, with peak plasma concentrations appearing 30 to 40 minutes after nasal administration, compared with 16 to 25 minutes following parental dosing. Calcitonin-salmon is readily metabolized in the kidney, with an elimination half-life calculated at 43 minutes. As a result, the intranasal dose required is 200 IU/day (3). Once the Miacalcin nasal pump has been activated, the bottle may be kept at room temperature until the medication is finished (2 weeks).

Therapeutic application Calcitonin therapy requires the concomitant oral administration of elemental calcium (500 mg/day). Clinical studies have shown that the combination of intranasal calcitonin salmon (200 IU/day), oral calcium supplementation (> 1,000 mg/day of elemental calcium), and vitamin D (400 IU/day) has decreased the rate of new fractures by more than 75% and has improved vertebral BMD by as much as 3% annually (3). Calcitonin prevents the abnormal bone turnover characteristic of Paget's disease of the bone and has antiresorptive activity. In the presence of calcitonin, the osteoclast brush borders disappear, and the osteoclasts move away from the bone surface undergoing remodeling (36). Side effects are significantly more pronounced when calcitonin-salmon is administered by injection and can include nausea, vomiting, anorexia, and flushing. Because calcitonin-salmon is protein in nature, the possibility of a systemic allergic reaction should be considered, P.948 and appropriate measures for treatment of hypersensitivity reaction should be readily available. Although calcitonin-salmon does not cross the placenta, it may pass into breast milk. Calcitonin-salmon is a possible alternative to ERT ; however, only limited evidence suggests that it has efficacy in women who already have fractures. Resistance to calcitonin-salmon can result from the development of neutralizing antibodies (37). In addition to its antiresorptive action via suppression of osteoclast activity, calcitonin-salmon exhibits a potent analgesic effect and has provided considerable relief to those patients suffering from the pain associated with Paget's disease and osteoporosis. T his analgesic effect is a result of calcitonin-stimulated endogenous opioid release. T he potency of this analgesic effect has been demonstrated to be 30- to 50-fold that of morphine in selected patients. Calcitonin is preferred over estrogen and the bisphosphonates when treatment of both osteoporosis and related bone pain is warranted.

Bone-Form ing Agents Teriparatide (Forteo) In 2002, the U.S. FDA approved teriparatide for the treatment of postmenopausal osteoporosis in patients who have a high risk of fracture as well as to increase bone mass in men with primary or hypogonadal osteoporosis who have a high risk of fracture (38). T eriparatide is recombinant human PT H 1-34 (see p. 937), the biologically active portion of the endogenously produced preprohormone. Unlike the bisphosphonates, which are classified as bone restorative agents, teriparatide is the first approved bone-forming agent. Bone formation is possible because of the ability of this agent to increase the number of osteoblasts. Although teriparatide enhances the function of both osteoclasts and osteoblasts, the exposure incidence dictates its effect on the skeleton. If administered once daily or intermittently, teriparatide preferentially enhances osteoblastic function,

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and bone formation occurs. Continuous exposure to endogenous PT H may result in poor skeletal composition because of enhanced osteoclast-mediated bone resorption (36). After 18 months of treatment, lumbar BMD increased up to 12% in postmenopausal women. After 10 months of treatment, 53% of men had an increase of 5% or greater in spine BMD. T he risk for developing new vertebral fractures was reduced by 65% after 21 months of treatment, and the number of nonvertebral fragility fractures was reduced by 53% (23).

An New Drug Applic atio n (NDA) f or a f ull-length rec ombinant human parathyro id hormone (Pre os) is curre ntly under revie w b y the U.S. FDA.

Administered as a once-daily, 20-µg SC injection in the thigh or abdominal wall, teriparatide is a clear, colorless liquid that is available as a 750 µg/3 mL, prefilled, disposable pen that requires refrigeration. Concurrent calcium (1,000 mg) and vitamin D (400 IU) supplementation is recommended. T reatment for longer than 2 years is not recommended. T eriparatide is rapidly absorbed, demonstrates 95% bioavailability, and is quickly eliminated via both hepatic and extrahepatic routes. T he half life is 1 hour when administered SC. Metabolic studies have not been performed on teriparatide; however, the entire PT H preprohormone has been shown to undergo enzyme-mediated transformations in the liver. Dizziness and leg cramps are the most commonly reported adverse side effects. T emporary increases in serum calcium levels occur following administration of teriparatide. As a result, this agent is contraindicated in patients who are predisposed to hypercalcemia. Some evidence suggests that these elevations in serum calcium levels may cause a patient who is taking digitalis to experience digitalis toxicity (39). T eriparatide should not be prescribed to patients with Paget's disease, children, young adults, women who are pregnant or nursing, and those patients who have received skeletal radiation therapy (36). Because of an increased incidence of osteosarcoma (malignant bone tumors) observed in rats, teriparatide also carries a black box warning.

Inorganic Salts Calcium salts Appropriate intake of calcium during childhood, adolescence, and early adulthood increases peak BMD and may reduce the overall risk of developing osteoporosis. For those who are at low risk of developing osteoporosis and have adequate BMD, consumption of the recommended amounts of calcium (1,200–1,500 mg of elemental calcium per day for teenagers, 1,000 mg/day for premenopausal women and men, up to 1,500 mg/day for postmenopausal women not taking ERT , and 1,000 mg/day for postmenopausal women taking ERT ) typically is sufficient to prevent bone loss (15). T his often can be accomplished by eating a well-balanced diet. For those patients with established osteoporosis or areas of poorly mineralized bone, calcium supplementation alone is not sufficient to reverse the bone loss or to significantly improve mineralization of the bone (11). T he actual amount of elemental calcium that is present in the available calcium salts varies considerably; however, no one particular salt has been identified as an exceptional source of elemental calcium (T able 35.8). Absorption of calcium from the gastrointestinal tract (25–40%) improves under acidic conditions; therefore, those medications that change the acidic environment of the stomach (e.g., H 2 antagonists and proton-pump inhibitors) have an adverse effect on calcium absorption (3). T otal daily doses of elemental calcium that exceed 500 mg should be spaced out over the day to improve absorption (5,15). T he more water soluble and, therefore, more easily absorbed salts (e.g., citrate, lactate, and P.949 gluconate) are less dependent on the acidic environment for appropriate absorption and would be appropriate alternatives for patients who produce low levels of acid. Calcium carbonate is a poorly soluble form of calcium, but it is inexpensive and only requires the patient to take a few tablets per day with acidic food or beverages like citrus juice (15).

Table 35.8. Percent of Elemental Calcium Content in Various Salts (3) Salt Calcium carbonate

Calcium (%) Elemental Calcium (mg/tablet) 40

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Tums (500 mg chewable)

200 mg

Titrilac (1 g/5 mL suspension)

400 mg/5 mL

Alka-Mints (850 mg chewable)

340 mg

Os-Cal 500 (1,250 mg table)

500 mg

Viactive (1,250 mg chewable)

500 mg

Tricalcium phosphate

39

Calcium chloride

27

Tribasic calcium phosphate

23

Posture (1,565.2 mg tablets) Calcium citrate

600 mg 21

Citrical (950 mg tablets)

200 mg

Citrical Liquitab (2,376 mg effervescent tabs) Calcium lactate

500 mg

13

Generics (325 mg tablets)

42 mg

Generics (650 mg tablets)

84 mg

Calcium gluconate Neo-Calglucon (1.8 g/5 mL syrup)

9 115 mg/5 mL

Sodium fluoride Sodium fluoride (NaF) promotes the proliferation and activity of osteoblasts and is classified as a nonhormonal bone-forming agent. Because treatment with NaF induces bone formation, it is essential that this therapy be coupled with oral calcium supplementation (1,000 mg/day). Additionally, NaF exhibits moderate antiresorptive activity, because it inhibits osteoclastic activity when it is absorbed into the bone matrix. In the treatment of osteoporosis, the therapeutic window for this agent is fairly narrow: Doses less than 45 mg/day are subtherapeutic, and doses in excess of 75 mg/day impair bone mineralization. In addition, the bone that is formed in the presence of NaF is neither as well mineralized nor as strong as normal bone tissue. In fact, some

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studies have demonstrated that patients taking sodium fluoride have increased bone fragility despite the increase in bone mass and, as a result, have an increased nonvertebral fracture rate as compared to the placebo group (5,21,33). As a result, its use in the treatment of osteoporosis has not been approved and is considered to be somewhat controversial. Several studies have examined the benefits of continuous versus cyclic dosing of NaF in the treatment of osteoporosis. Intermittent dosing (25 mg b.i.d. for 12 months, followed by 2 months of calcium supplementation alone) of a slow-release formulation of sodium fluoride (SR-NaF; Neosten) with 400 mg of calcium citrate was shown to effectively improve bone mass (vertebra, 5% per year; femoral neck, 2% per year) as well as to decrease the number of vertebral fractures (40,41).

M iscellaneous Therapies Various classes of drugs, such as thiazide diuretics, proton-pump inhibitors, androgens, PT H, statins, and human monoclonal antibody, have been shown to have beneficial effects in treatment of diseases associated with abnormal calcium homeostasis through various mechanisms. T he thiazide diuretics, which reduce urinary calcium excretion, also may reduce the rate of bone loss (33). T his protective effect has been shown to vanish within 4 to 5 months after discontinuation of the thiazide. Elevated concentrations of proton-pump inhibitors, such as omeprazole, have been shown to inhibit bone +

+

resorption via inhibition of H ,K -AT Pase, a potential energy pump located in the osteoclast ruffled border (30). Androgens such as stanozolol (11), nandrolone (11), methandrostenolone, and the testosterone patch have been shown to increase bone mass by 5 to 10% and may be appropriate for men with a deficiency in testosterone. An increase in trabecular bone mass by as much as 50% has been demonstrated in patients treated with low doses of PT H, but it comes at the expense of the cortical bone (1,11,25). T reatment with high doses of PT H is correlated with stimulation of bone resorption (20). Cyclical therapy with PT H and calcitonin has been shown to improve BMD in the spine without adverse effects in the cortical bone (11). When given in combination with estrogen, PT H promoted the formation of well-mineralized trabecular bone. Strontium ranelate is an orally active agent that can be classified as both an antiresorptive agent and a bone-forming agent (42,43). It is able not only to stimulate replication of preosteoblastic cells to promote bone formation but also is able to decrease osteoclastic activity to prevent bone resorption. Biochemical markers for bone formation (e.g., bone-specific alkaline phosphatase), which normally decrease in the presence of antiresorptive therapy, are elevated in the presence of strontium ranelate (44). Lumbar spine BMD increased 11.4% in patients treated with this new agent. T he hydroxymethylglutaryl–coenzyme A (HMG-CoA) reductase inhibitors, otherwise known as the statins, have been found to increase bone formation via enhanced activity of the bone morphogenic protein 2 (BM P-2) gene. T his gene increases osteoblast differentiation. In addition, by inhibiting HMG-CoA reductase, the statins not only prevent the biosynthesis of cholesterol but also prevent the formation of compounds associated with osteoclast activation (45). Unfortunately, clinical data P.950 from several large studies conflict, and further study is warranted before the statins can be considered as a viable treatment for osteoporosis (46). AMG-162 (Amgen) is a fully human monoclonal antibody to the receptor activator of nuclear factor κB ligand (RANKL). Its receptor is located on the surface of osteoclasts and osteoclast precursors. When bound to its receptor, RANKL promotes the formation and activation of osteoclasts. T o balance the effects of RANKL, the body produces osteopotegerin, which binds to RANKL and prevents it from binding to and activating its receptor, modulating the production and activation of osteoclasts (47). When an individual develops osteoporosis, this balance is “ disrupted,” and RANKL overwhelms osteopotegerin activity, causing significant bone loss. AMG-162 was designed to mimic the biochemical effects of osteopotegerin. Studies show that AMG-162 is more effective in improving BMD (4–7%) than weekly administration of alendronate (5%) (47). It is anticipated that this agent will be administered SC biannually. T he most commonly reported adverse effect is dyspepsia. T here are a number of agents in the pipeline (T able 35.9), some with very novel mechanisms of action, including inhibitors of cathepsin B and protein tyrosine kinase Src, as well as antagonists at α ν β 3 integrin receptors (48).

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Drug T herapies Used to T reat Hyperparathyroidism Increased levels of PT H leads to moderately to severely elevated serum calcium concentrations (2) and alterations in phosphorous metabolism. T o modulate the levels of PT H released from the parathyroid gland chief cells, regulation of CaSR sensitivity is required. An agonist at this receptor, a calcimimetic, serves to activate the receptor, whereas an antagonist at this receptor is classified as a calcilytic. T here are two types of calcimimetic agents: those that activate the CaSR directly (type I), and those that require the presence of a cation, such as calcium or magnesium (type II) for activation (49). T ype I calcimimetics are polycations (e.g., magnesium and neomycin). T he first- and second-generation of type II calcimimetics are phenylalkylamine based. T hey have an indirect/allosteric action on CaSR mediated by a conformational alteration of these receptors.

Cinacalcet Hydrochloride (Sensipar) Cinacalcet is the first type II calcimimetic agent approved that improves CaSR sensitivity to calcium (19,50). When calcium is bound to the CaSR, phospholipase C is activated, and the secretion of PT H is inhibited. In the presence of cinacalcet, not only is a drop in P.951 PT H levels observed but also a decrease in serum calcium and phosphorous levels. T his represents a significant therapeutic advantage over vitamin D–based treatments for secondary hyperparathyroidism (19). Cinacalcet hydrochloride is a second-generation calcimimetic approved for the treatment of secondary hyperparathyroidism in patients with chronic kidney disease on dialysis and for the treatment of hypercalcemia in patients with parathyroid cancer. It can be used alone, with vitamin D, and/or with a phosphate binder (51).

Table 35.9. Experimental Agents for Treatment of Abnormal Calcium Homeostatis

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Drug T herapies Used to T reat Hypercalcem ia of Malignancy Zoledronic Acid (Zom eta) Zoledronic acid, a bisphosphonate, was approved by the U.S. FDA in 2001 for the treatment of hypercalcemia of malignancy, a metabolic complication that can be life-threatening (Fig. 35.7). Hypercalcemia of malignancy can occur in up to 50% of patients diagnosed with advanced breast cancer, multiple myeloma, and nonsmall cell lung cancer. T his condition arises when chemical moieties produced by the tumor cause overstimulation of osteoclasts. When there is an increase in bone degradation, there is a concomitant release of calcium into the plasma. When serum concentrations of calcium rapidly elevate, the kidneys are unable to handle the overload, and hypercalcemia results. T his can lead to dehydration, nausea, vomiting, fatigue, and confusion. Zoledronic acid effectively decreases plasma calcium concentrations via inhibition of bone resorption (inhibition of osteoclastic activity and induction of osteoclast apoptosis). It also prevents the increase in osteoclastic activity caused by tumor-based stimulatory factors. Additionally zoledronic acid has been approved by the U.S. FDA for the treatment of multiple myeloma and bone metastases associated with solid tumor–based cancers (e.g., prostrate and lung). T his agent is currently in late-stage clinical trials for the treatment and prevention of osteoporosis and, if approved, will be formulated as a 5-mg, once-yearly IV infusion. T he maximum recommended dose for the treatment of hypercalcemia of malignancy is 4 mg. A clinically significant deterioration in renal function occurs when single doses of this agent exceed 4 mg and the infusion duration is less than 15 minutes (52). It is recommended that patients be well hydrated before infusion. If serum calcium levels do not fall to normal levels, retreatment is appropriate, but retreatment is not recommended until 7 days have elapsed from the initial treatment. For the treatment of multiple myeloma and metastatic bone lesions, a 4-mg initial dose is recommended, followed by additional doses every 3 to 4 weeks for 9 to 15 months (prostate cancer, 15 months; breast cancer, 12 months; other solid tumors, 9 months). Zoledronic acid is a white, crystalline powder that is available in vials for reconstitution for IV infusion over at least 15 minutes. It does not undergo metabolic transformation and does not inhibit CYP450 enzymes. Clearance of this agent is dependent on the patient's creatinine clearance, not on dose. Serum creatinine levels should be evaluated before every treatment. Zolendronic acid is contraindicated in patients with severe renal impairment. Zolendronic acid should not be mixed with infusion solutions that contain calcium (e.g., lactated Ringer's) and should be administered via IV infusion in its own line. Because of the possibility of a serious deterioration in renal function, the manufacturer requires strict adherence to the infusion duration being no less than 15 minutes.

Pamidronate Disodium (Aredia) Pamidronate, a second-generation bisphosphonate, is 100-fold more potent than etidronate (Fig. 35.7) (6). It has been approved for the treatment of hypercalcemia of malignancy, for Paget's disease, and for osteolytic bone metastases of breast cancer and osteolytic lesions of multiple myeloma. When used to treat bone metastases, pamidronate decreases osteoclast recruitment, decreases osteoclast activity and increases osteoclast apoptosis (53). Erosive esophagitis has been reported with the use of pamidronate sodium.

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Gallium Nitrate (Ganite) Gallium nitrate (Ganite) has been approved for the treatment of hypercalcemia of malignancy (33) in patients that do not respond to hydration. Its effectiveness stems from its ability to inhibit bone resorption despite the presence of tumor-derived factors that promote calcium loss from the bone. Administered by infusion over 24 hours, the typical dose is 200 mg/m2 /day for five consecutive days. A lower dose is recommended if the 2

symptoms of hypercalcemia are mild (100 mg/m /day for 5 days). Steady state is achieved in 24 to 48 hours. Maintenance of patient hydration is essential during treatment. Gallium nitrate is not significantly metabolized and is largely excreted through the kidneys. It is contraindicated in patients with severe renal impairment. Renal function should be closely monitored in all patients receiving this agent. P.952

Case Study Vic tor ia F. Roche S. William Zito PA is a 62-year-o ld Cauc as ian f emale who pre sents to the eme rg enc y room with a comp laint of pers iste nt lower back p ain f or the past 2 we eks . She s ays that s he “ jus t wo ke up one morning with the back pain.” W hile having her histo ry taken, PA reve als that s he was diagnos ed with rhe umatoid arthritis 6 years ago, whic h was 3 mo nths af ter her se co nd mas tec tomy f o r b re as t c ance r. PA went through meno paus e 1 0 years ago, has not und ergone hyste re cto my, and has be en o n Synthroid (25 µg/daily) sinc e s he was surg ic ally tre ate d f or hyp erthyroidis m at the age o f 25. PA claims that her thyroid f unctio n was normal at her las t visit to her endoc rino log is t. Currently, PA is being tre ated with the f o llo wing drug s f or her RA:

Sulfasalazine

(500-mg tablets, three tablets b.i.d.)

Oxycodone

(5-mg tablets; as needed for pain)

Methotrexate

(2.5-mg tablets, eight tablets weekly)

Prednisone

(10-mg tablets, one tablet daily for flare-ups)

Hydrochlorthiazide

(12.5-mg tablets; one tablet daily for ankle edema)

On f urther ques tio ning, PA repo rts that f lare-up s req uiring her to g o on pred nisone have oc curre d at least twic e a year sinc e s he was f irs t diagnos ed with rheumatoid arthritis . The emerge nc y room phys ic ian o rd ered a dual-energy x-ray ab so rp tiometry s can o f the s pine and req ues ted a late ral s pine imag e to b e do ne at the s ame time. A diag nos is of os teo poros is was mad e bas ed on the pres enc e of vertebral f racture and a T value f or bone mas s de ns ity (BMD) of 2.0 standard deviatio ns below the young adult mean. I n addition to c alcium c arbo nate (500 mg t.i.d .) and vitamin D (400 U q.d.), the phys ic ian wants to p re sc ribe calc ium antires orptive therapy f or PA, and you have the f ollowing drugs available f ro m the hos pital f o rmulary. Make a rec ommendation. 1. I dentif y the the rape utic prob lem(s ) in whic h the pharmacist' s interventio n may benef it the patient. 2. I dentif y and p rioritize the p atient-s pe cif ic f ac tors that mus t be co ns ide re d to ac hie ve the de sire d the rape utic o utc omes . 3. Co nd uc t a thorough and me chanis tic ally orie nte d s tructure–ac tivity analys is o f all the rape utic alternative s pro vided in the c ase . 4. Evaluate the SAR f indings ag ains t the patient-spe cif ic f acto rs and d es ired therapeutic outco mes , and make a therapeutic de cis io n.

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5. Co uns el your patient.

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2. Bouillon R, Carmeliet G, Boonen S. Aging and calcium metabolism. Bailliere's Clin Endocrinol Metab 1997;11:341–365.

3. Haines ST , Caceres B, Yancey L. Alternatives to estrogen replacement therapy for preventing osteoporosis. J Am Pharm Assoc 1996;36(12):707–715.

4. Christenson RH. Biochemical markers of bone metabolism: an overview. Clin Biochem 1997;30:573–593.

5. Miller DR, Hanel HJ. Prevention and treatment of osteoporosis. US Pharmacist 1999;24:81–90.

6. Rodan GA. Emerging therapies in osteoporosis. Ann Rpts Med Chem 1994;29:275–285.

7. Arnaud CD. Calcium homeostasis: regulatory elements and their integration. Fed Proc 1978;37:2557–2560.

8. Iqbal J, Zaidi M, Schneider AE. Cinacalcet hydrochloride. IDrugs 2003;6: 587–592.

9. DeLuca HF, Zierold C. Mechanisms and functions of vitamin D. Nutr Rev 1998;56:S4–S10.

10. Schaefer B, Cone S. Increasing awareness of osteoporosis: a community pharmacy's experience. US

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Pharmacist 1998;23:72–85.

11. Francis RM. Management of established osteoporosis. Br J Clin Pharmacol 1998;45:95–99.

12. Saljoughian M. Postmenopausal osteoporosis. US Pharmacy 2003;28(9):18–35.

13. Reid DM, Harvie J. Secondary osteoporosis. Bailliere's Clin Endocrinol Metab 1997;11:83–99.

14. Hansen LB, Follin Vondracek S. Prevention and treatment of nonpostmenopausal osteoporosis. Am J Health-Syst Pharm 2004;61:2637–2656.

15. American Pharmaceutical Association. Special Report. T herapeutic Options for Osteoporosis. Washington, DC, 1993.

16. T olar J, T eitelbaum SL, Orchard PJ. Osteopetrosis. N Engl J Med 2004;351: 2839–2849.

17. Whyte MP, Wenkert D, Clements KL, et al. Bisphosphonate-induced osteoporosis. N Engl J Med 2003;349:457–463.

18. Pegoraro AA, Rutecki GM. Hypocalcemia. Available at: http://www.emedicine.com/med/topic1118.htm. Accessed June 13, 2005.

19. Block GA, Martin, KJ, De Franciso Al. Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis. N Engl J Med 2004;350:1516–1525.

20. Reginster J-YL, LeCart M-P. Efficacy and safety of drugs for Paget's disease of bone. Bone 1995;17:485S–488S.

21. De Silva Jardine P, T hompson D. Antiosteoporosis agents. Ann Rpts Med Chem 1996;31:211–220.

22. Hisel T M, Phillips BB. Update on the treatment of osteoporosis. Formulary 2003;38:223–243.

23. Greenblatt D. T reatment of postmenopausal osteoporosis. Pharmacotherapy 2005;25:574–584.

24. Francis RM. Bisphosphonates in the treatment of osteoporosis in 1997: a review. Curr T her Res 1997;58:656–678.

25. Yates AJ, Rodan GA. Alendronate and osteoporosis. Drug Discovery T oday 1998;3:69–78.

26. Speroff L, Clarkson T B. Is tibolone a viable alternative to HT ? Cont OB/GYN 2003;48(8):54–68.

27. Kemp DC, Fan PW, Stevens JC. Characterization of raloxifene glucuronidation in vitro: contribution of intestinal metabolism to presystemic clearance. Drug Metab Dispos 2002;30:694–700.

28. Jeong EJ, Lin H, Hu M. Disposition mechanisms of raloxifene in the human intestinal Caco-2 model. J Pharmacol Exp T her 2004;310:376–386.

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29. Jeong EJ, Liu Y, Lin H, et al. Species- and disposition model-dependent metabolism of raloxifene in gut and liver: role of UGT 1A10. Drug Metab Dispos 2005;33:785–794.

30. Gennari L. Ospemifene. Curr Opin Investig Drugs 2004;5:448-455.

31. Gruber C, Gruber D. Bazedoxifene. Curr Opin Investig Drugs 2004;5: 1086–1093.

32. Diener KM. Bisphosphonates for controlling pain from metastatic bone disease. Am J Health-Syst Pharm 1996;53:1917–1927.

33. Caggiano T J, Zask A, Bex F. Recent advances in bone metabolism and osteoporosis research. Ann Rpts Med Chem 1991;26. P.953 34. Ashworth L. Focus on alendronate. Formulary 1996;31:23–30.

35. Riley T N, DeRuitter J. US Pharmacist 2003:95–104.

36. Reginster J. Calcitonin for prevention and treatment of osteoporosis. Am J Med 1993;95(Suppl 5A):44S–47S.

37. Gennari C, Agnusdei D, Camporeale A. Long-term treatment with calcitonin in osteoporosis. Horm Metab Res 1993;25:484–485.

38. Freeman T R. T eriparatide: a novel agent that builds new bone. J Am Pharm Assoc 2003;43:535–537.

39. LoBuono C. New osteoporosis drug is first to form bone. Drug T opics 2003:24.

40. American Pharmaceutical Association. New Product Bulletin. Miacalcin Nasal Spray. Washington, DC, 1996.

41. Pak CYC, Sakhaee K, Rubin C, et al. Update of fluoride in the treatment of osteoporosis. T he Endocrinologist 1998;8:15–20.

42. Meunier PJ, et al. T he effects of strontium ranelate on the risk of vertebral fracture in women with postmenopausal osteoporosis. N Engl J Med 2004;350:459–468.

43. Reginster J-Y, Lecart M-P, Deroisy R, et al. Strontium ranelate—a new paradigm in the treatment of osteoporosis. Expert Opin Investig Drugs 2004; 13:857–864.

44. Marie PJ. Strontium ranelate: a novel mode of action optimizing bone formation and resorption. Osteoporosis Int 2005;16(Suppl 1):S7–S10.

45. Gonyeau M. Statins and osteoporosis: a clinical review. Pharmacotherapy 2005;25:229–243.

46. Richard AA, Harrison T M. Efficacy of HMG-CoA reductase inhibitors in treating osteoporosis. Am J

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Health-Syst Pharm 2002;59:372–377.

47. Bekker PJ, et al. A single-dose placebo-controlled study of AMG 162, a fully human monoclonal antibody to RANKL in postmenopausal women. J Bone Miner Res 2004;19:1059–1066.

48. Biskobing DM. Novel therapies for osteoporosis. Expert Opin Investig Drugs 2003;12:611–621.

49. Joy MS, Kshirsagar A, Franceschini N. Calcimimetics and the treatment of primary and secondary hyperparathyroidism. Ann Pharmacother 2004;38:171–180.

50. Franceschini N, Joy MS, Kshirsagar A. Cinacalcet HCl: a calcimimetic agent for the treatment of primary and secondary hypoparathyroidism. Expert Opin Investig Drugs 2003;12:1413–1421.

51. Hussar DA. New drugs of 2004. J Am Pharm Assoc 2005;45:185–218.

52. Zometa prescribing information.

53. Van Poznak CH. T he use of bisphosphonates in patients with breast cancer. Cancer Control 2002;9:480–489.

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Chapter 36 Nonsteroidal Anti-Inflammatory Drugs Ronald Borne Mark Le v i Norm an Wilson

Drugs cov ered in this chapter: Antipy re tic a na lge sics Ace taminophen Anti-infla matory analgesic s Asp irin and o the r s alic ylate s Dif lunis al I nd omethac in Diclof e nac Etodolac Nab ume tone Sulindac Tolmetin I buprof e n Fenop rof en Flurbip rof en Ketoprof en Ketoraloc Nap roxen Oxapro zin Sup rof en Mef enamic ac id Mec lof enamic acid Piroxic am Melo xic am COX-2 inhibitor s Celec oxib Rof ec oxib Valdec oxib Etorico xib L umirac oxib Drugs for ar thr itis Gold salts Hydroxyc hloroquine Methotre xate L ef lunomide Etanerc ept I nf liximab

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Adalimumab Rituximab Anakinra Abatac ep t Drugs for the tr ea tment of gout Colc hicine Prob enec id Sulf inp yrazo ne Allo purino l

Introduction T he classification of drugs covered in this chapter as nonsteroidal anti-inflammatory drugs (NSAIDs) is somewhat misleading, because many of these entities possess antipyretic and analgetic properties in addition to anti-inflammatory properties, which are useful in the treatment of a number of rheumatic disorders. On the other hand, there are drugs that possess analgetic/antipyretic properties but are essentially devoid of anti-inflammatory activity. Additionally, drugs that possess uricosuric properties useful in the treatment of gout will be covered here. T he prototype agent of this class is acetylsalicylic acid, aspirin, which has therapeutically useful analgetic, antipyretic, and anti-inflammatory actions; other drugs to be covered may possess only one or two of these properties. Steroids that are useful anti-inflammatory drugs are covered separately in Chapter 33. Nonsteroidal anti-inflammatory drugs continue to be one of the more widely used groups of therapeutic drugs. T he medicinal drugs covered in this chapter represent a major market in both prescription and nonprescription drugs. Other than caffeine or ethyl alcohol, aspirin may be the most widely used drug in the world (1). An estimated 70 to 100 million prescriptions are written annually for NSAIDs, with over-the-counter (OT C) use accounting for an additional use that may be up to sevenfold higher. Rheumatic diseases, which have been classified by the Arthritis Foundation (T able 36.1) (2), are inflammatory disorders affecting more individuals than any chronic illness. T he Centers for Disease Control and Prevention estimates that more than 40 million Americans have some form of arthritis or chronic joint disorder. Approximately 7 million Americans suffer from arthritis in its most debilitating forms (3,4). Osteoarthritis is the most common form of arthritis in the United States, affecting about 12% of Americans between the ages of 25 and 74. Rheumatoid arthritis is thought to affect well over 2 million Americans (two to three times more females more than males), whereas juvenile arthritis affects 71,000 children under 16 years of age, 61,000 of whom are females. In addition, nonrheumatoid osteoporosis affects 24 million females (half of all women older than 45 years and 90% of all women older than 75 years) (3,4) and 16 million males. Because more than 80% of the U.S. population older than 55 years have joint abnormalities that are detectable radiographically (5), the use of NSAIDs will increase as Americans experience a greater life expectancy. It is not surprising, therefore, that the development of new NSAIDs continues at a steady pace—a pace slowed down by the recent controversies surrounding selective cyclooxygenase (COX)-2 inhibitors. T he diseases mentioned are considered to be host defense mechanisms. Inflammation is a normal and essential response to any noxious stimulus that threatens the host and may vary from a localized response to a generalized response (6). T he resulting inflammation can be summarized as follows: 1) Initial injury causing release P.955 of inflammatory mediators (e.g., histamine, serotonin, leukokinins, SRS-A, lysosomal enzymes, lymphokinins, and prostaglandins); 2) vasodilation; 3) increased vascular permeability and exudation; 4) leukocyte migration, chemotaxis, and phagocytosis; and 5) proliferation of connective tissue cells. T he most common sources of chemical mediators include neutrophils, basophils, mast cells, platelets, macrophages, and lymphocytes (6). T he etiology of inflammatory and arthritic diseases has received a great deal of recent attention but remains, for the most part, unresolved, hindering the development of new agents that are curative in nature. Currently available drugs relieve the symptoms of the disease but are not curative.

Clinical Significanc e T he arachidonic acid pathway leading to the production of inflammatory mediators provides several targets for intervention on inflammation. T he most widely used nonsteroidal anti-inflammatory drugs (NSAIDs) in practice

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today are drugs like aspirin, naproxen, ibuprofen, diclofenac, and others that inhibit the cyclooxygenase (COX) enzymes. Although specific NSAIDs have found their niches in particular disease states, the NSAIDs generally work by the same mechanism with little exception. Aspirin, a salicylate, is somewhat different from the other agents in that its property of irreversibly inhibiting platelet homeostasis works to its advantage and broadens its use in coronary artery disease prophylaxis, in which it has been shown to reduce mortality whereas the others have not. Other salicylate varieties lack the ability to irreversibly inhibit platelet function and, therefore, are not clinically useful this way. Variations on the molecular structures have provided improved side effect profiles of agents used. For example, although phenacetin and acetaminophen are not anti-inflammatory agents, they are included in this chapter, because they are analgesics and antipyretics and illustrate the point that improvement in molecular structure from phenacetin to acetaminophen helped to reduce the hepatotoxicity and risk for drug-induced hemolytic anemia with which phenacetin was associated when it was on the market in the past. Changes to the currently available NSAIDs are constantly being produced, hence the abundance of “ me-too” drugs. With gastrointestinal (GI) bleeding and complications being the most feared consequence of taking these drugs, an emphasis on minimizing these risks has been one of the motivations to develop less offensive agents. Gastrointestinal side effects are believed to be related to indirect toxic effects (inhibiting COX enzymes) and direct toxic effects (local irritation to the GI mucosa). Molecular changes have been made to the various NSAIDs to produce more potent compounds, to reduce the direct irritant effects, and to create pro-drugs that lack the direct irritant effect altogether. Other changes have resulted in compounds with no more potency but with lower incidence of GI side effects, which still represents a therapeutic advantage. As can be seen, a thorough understanding and appreciation of the chemical nature of the NSAIDs is directly linked to clinically significant end points and positive therapeutic outcomes. Jill T . Johnson Pharm.D., BCPS Associ ate Professor, Department of Pharmacy Practi ce, Col l ege of Pharmacy, Uni versi ty of Arkansas for M edi cal Sci ences

Anti-inflammatory drugs may act by interfering with any one of several mechanisms, including immunological mechanisms such as antibody production or antigen–antibody complexation, activation of complement, cellular activities such as phagocytosis, interference with the formation and release of the chemical mediators of inflammation, or stabilization of lysosomal membranes. T he role of complement in inflammation is of considerable interest (7,8,9). T he complement system is one component of the host defense system that aids in the elimination of various microorganisms and antigens from blood and tissues. Although complement normally plays a functional role in the development of disease states, excessive complement activation, by promoting inflammation locally, is detrimental. Individuals with a deficiency of individual complement proteins, however, either acquired or hereditary, are more susceptible to infections caused by pyrogenic bacteria and diseases resulting from the generation of autoantibodies and immune complexes. Complement proteins are numbered C1 to C9, and their cleavage products are indicated by the suffixes a, b, and so on. T he complement system consists of two activating pathways (an antibody-mediated classical pathway and a nonimmunologically activated alternate pathway), a single termination pathway, regulatory proteins, and complement receptors and involves approximately 30 membrane and plasma proteins (8). A major function of complement is to mark antigens and microorganisms with C3 fragments that direct them to cells containing C3 receptors, such as phagocytic cells (8). Complement has been implicated in numerous diseases, including allergic, hematologic, dermatologic, infectious, renal, hepatic inflammatory (rheumatoid arthritis and systemic lupus erythematosus), pulmonary, and others (e.g., multiple sclerosis and myasthenia gravis). Complement activation can induce the synthesis or release of inflammatory mediators, such as interleukin-1 (a potent proinflammatory cytokine) and prostaglandins (e.g., PGE 2 ). Leukotri enes (e.g., LTB 4 ) and thromboxanes al so are rel eased. Compl ement P.956 al so ai ds the i mmi grati on of phagocytes associ ated wi th i nfl ammati on. Thus, i nhi bi ti on of the compl ement system by control l i ng i ts acti vati on or i nhi bi ti ng those acti ve fragments that are produced shoul d be benefi ci al i n reduci ng or el i mi nati ng ti ssue damage associ ated wi th i nfl ammatory di seases.

Table 36.1. Classification of Rheumatic Diseases A. Acute and chronic polyarthritis and other synovial diseases Rheumatoid arthritis B. Infection-related rheumatic diseases

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Septic arthritis Osteomyelitis Lyme disease Rheumatic fever C. Spondyloarthropathies Ankylosing spondylitis Reactive arthritis Psoriatic arthritis Enteropathic spondyloarthropathy (arthritis of inflammatory bowel disease) D. Osteoarthritis and related degenerative related diseases E. Crystal-induced arthropathies Gout (monosodium urate) Calcium pyrophosphate dehydrate, apatite, and other calcium crystals deposited in the joint G. Metabolic bone disease Osteoporosis H. Connective tissue disease Systemic lupus erythematosus Scleroderma/polymyositis Mixed connective tissue disease I. Musculoskeletal diseases (regional pain syndromes) Neck, lower back and lumbar spine stenosis, shoulder, elbow, wrist and hand, hip, and knee J. Inflammatory muscle (nonarticular) diseases Fibromyalgia Bursitis Tendinitis K. Vasculitis Polymyalgia rheumatica L. Sjogren's syndrome M. Neoplasms N. Drug-induced rheumatologic syndromes Systemic lupus erythematosus Glucocorticoid-induced arthritis Scleroderma (acrosclerosis) Vasculitis Statin-induced myositis

From Klippel JH, Wayand CM, Wortmann R, et al., eds. Primer on the Rheumatic Diseases. 12th Ed. Atlanta: Arthritis Foundation, 2001; with permission.

Connective tissue diseases include the following states: rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, polyarteritis nodosa, gout, rheumatic fever, and osteoarthritis, with the most common forms of which are rheumatoid arthritis, osteoporosis, and gout. Rheumatoid arthritis is a chronic, nonsuppurative inflammatory disease of unknown cause affecting primarily peripheral synovial joints. T he onset is usually insidious, with immunological reactions playing a major role. T he pathogenesis of rheumatoid arthritis has been summarized as follows (10): 1) An unknown initiation factor in the synovial joint causes the production of antigenic immunoglobulin (Ig) G, which stimulates the synthesis of the rheumatoid factors IgM and IgG, forming immune complexes; 2) IgG aggregates activate the complement system, leading to the generation of chemotactic factors (cytokines) that attract polymorphonuclear leukocytes into the articular cavity; 3) the polymorphonuclear leukocytes ingest immune complexes to become rheumatoid arthritis cells, which discharge hydrolases from lysosomal granules that, in turn, degrade extracellular tissue components, polysaccharides, and collagens in cartilage, thus provoking an inflammatory response in rheumatoid joints; and 4) all of which induce expression of cyclooxygenase. Clinical symptoms characteristically include symmetric swelling of at least three joints, accompanied by soft tissue swelling

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with tenderness, erythema, morning stiffness lasting at least an hour, and pain. T he joints primarily involved are those of the extremities, and the patient often suffers a low-grade fever accompanied by malaise, anorexia, and fatigue. Serum protein irregularities and abnormal amounts of rheumatoid factors are common. It often is difficult to distinguish rheumatoid arthritis from other connective tissues disorders because of lack of definitive diagnostic features. Because bone erosions, uniform joint-space narrowing, and osteopenia (decreased bone density) develop within 6 months in about 40% of those with early rheumatoid arthritis, it is more effective to treat early rheumatoid arthritis with disease modifying drug therapy (DMARDs) before structural damage develops than attempting to correct the damage. Corticosteroids are used for controlling the symptoms, not disease modifying. Osteoarthritis is a degenerative joint disease, and is the most common form of arthritis. It is characterized by degeneration of cartilage and hypertrophy of bone at the articular margin. Secondary inflammation of synovial tissue is common. T he most common symptoms involve joint pain associated with movement, joints lose range-of-motion, minimal swelling of the involved joint, and, sometimes, bone enlargement. Weight-bearing joints and joints of the hands and fingers generally are involved. T reatment usually involves exercise and pain medication. Aspirin is considered first-choice therapy, with acetaminophen and NSAIDs being employed in patients who do not tolerate salicylates. Nutritional supplements such as glucosamine and hyaluronic acid have been shown to possibly slow progression of osteoarthritis. Gout is a metabolic disease characterized by recurrent episodes of acute arthritis, usually monoarticular, and is associated with abnormal levels of uric acid in the body, particularly the presence of monosodium urate crystals in synovial fluid. Primary gout is a hereditary disease in which hyperuricemia is caused by an error in uric acid metabolism—either overproduction or an inability to excrete uric acid. Secondary gout refers to those cases in which hyperuricemia is caused by an acquired disease or disorder, such as chronic renal disease, lead poisoning, or myeloproliferative disorders. Gout generally occurs in P.957 mid-life and affects males significantly more than females (9:1). T reatment usually involves the use of uricosuric drugs, colchicine, NSAIDs, or corticosteroids. T he search for new and effective treatment modalities requires the availability of adequate screening tests. Although no model adequately reflects the events that occur in human arthritic conditions, several in vivo and in vitro assays are used. T he most common in vivo animal assays measure the ability of anti-inflammatory drugs to inhibit edema induced in the rat paw by carrageenan (a mucopolysaccharide derived from a sea moss of the Chondrus species), to inhibit adjuvant arthritis in rats induced by M ycobacteri um butyri cum or M . tubercul osi s, to inhibit granuloma formation usually induced by the implantation of a cotton pellet beneath the abdominal skin of rats, or to inhibit erythema of guinea pig skin as a result of exposure to ultraviolet radiation. In vitro techniques include the ability of NSAIDs to stabilize erythrocyte membranes or, more commonly, to inhibit the biosynthesis of prostaglandins, particularly in cultured human synoviocytes and chondrocytes, and monocyte culture fluid stimulated bovine synoviocytes and chondrocytes.

Role of Chem ical Mediators in Inflam m ation As indicated previously, a number of chemical mediators have been postulated to play important roles in the inflammatory process. Before 1971, the proposal by Shen (11,12) that the NSAIDs exert their effects by interacting with a hypothetical anti-inflammatory receptor was widely accepted. T he topography of the proposed receptor was based on known structure–activity relationships primarily within the series of indole acetic acid derivatives, of which indomethacin was the prototype. Most NSAIDs, whether they be salicylates, arylalkanoic acids, oxicams, or anthranilic acid derivatives, possess the common structural features of an acidic center, an aromatic or heteroaromatic ring, and an additional center of lipophilicity in the form of either an alkyl chain or an additional aromatic ring. T he proposed receptor to which indomethacin was postulated to bind consisted of a cationic site to which the carboxylate anion would bind, a flat area to which the indole ring would bind through van der Waals forces, and an out-of-the-plane trough to which the benzene ring of the p-chlorobenzoyl group would bind through hydrophobic or charge-transfer interactions. Additional binding sites for the methoxy and carbonyl groups also were suggested. In 1971, Vane (13) published a classic paper in which he reported that indomethacin, aspirin, and salicylate, in this descending order of potency, inhibited the biosynthesis of prostaglandins from arachidonic acid using cell-free preparations of guinea pig lung, and he further suggested that the clinical actions of these drugs resulted from this inhibition. T his theory has become the most widely accepted mechanism of action of NSAIDs. Gund and Shen (14) subsequently modified this hypothesis and proposed that the earlier anti-inflammatory receptor model actually described the active site of the key enzyme in prostaglandin biosynthesis (i.e., prostaglandin cyclooxygenase) (Fig. 36.1).

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Fig. 36.1. Shen's proposed model of the fatty acid substrate binding site of prostaglandin synthetase. (Modified from Gund P, Shen TY. A model for the prostaglandin synthetase cyclooxygenation site and its inhibition by anti-inflammatory arylacetic acids. J Med Chem 1977;20:1146–1152; with permission.)

Prostaglandins, Thromboxanes, Prostacyclin, and Leukotrienes Prostaglandins are naturally occurring, 20-carbon, cyclopentano–fatty acid derivatives produced in mammalian tissue from polyunsaturated fatty acids. T hey belong to the class of eicosanoids, a member of the group of autocoids derived from membrane phospholipids. T he eicosanoids are derived from unsaturated fatty acids and include the following groups of compounds: prostaglandins, thromboxanes, prostacyclin, and leukotrienes. T hey have been found in essentially every compartment of the body. In 1931, Kurzrok and Lieb (15) reported that human seminal fluid possessed potent contractile and relaxant effects on uterine smooth muscle. Shortly thereafter, Goldblatt (16) in England and von Euler (17) in Sweden independently reported vasodepressor and smooth muscle–contracting properties in seminal fluid; von Euler identified the active constituent as a lipophilic acidic substance, which P.958 he termed “ prostaglandin.” T hese observations attracted little attention during World War II, but shortly thereafter, primarily through the efforts of Bergstrom and Samuelsson (18), it was realized that von Euler's prostaglandin was actually a mixture of a number of structurally related fatty acids. T he first report of the structure of the prostaglandins in 1962 stimulated several studies relating to the chemical and biological properties of these potent substances.

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Fig. 36.2. General structure of the prostaglandins.

T he general structure of the prostaglandins is shown in Figure 36.2. All naturally occurring prostaglandins possess this substitution pattern, a 15α-hydroxy group and a trans double bond at C-13. Unless a double bond occurs at the C-8, C-12 positions, the two side chains (the carboxyl-bearing chain termed the α-chain and the hydroxyl-bearing chain termed the β-chain) are of the trans stereochemistry depicted. T he prostaglandins are classified by the capital letters A, B, C. D, E, F, G, H, and I (e.g., PGA, PGB, and so on) depending on the nature and stereochemistry of oxygen substituents at the 9- and 11-positions. For example, members of the PGE series possess a keto function at C-9 and an α-hydroxyl group at C-11, whereas members of the PGF series possess α-hydroxyl groups at both of these positions. Members of the PGG and PGH series are cycloendoperoxide intermediates in the biosynthesis of prostaglandins, as depicted in Figure 36.3. T he number of double bonds in the side chains connected to the cyclopentane ring is designated by subscripts 1, 2, or 3, indicative of the nature of the fatty acid precursor. T he subscript 2 indicates an additional ci s double bond at the C-5, C-6 positions, and the subscript 3 indicates a third double bond of ci s stereo-chemistry at the C-17, C-18 positions. Prostaglandins are derived biosynthetically from unsaturated fatty acid precursors. T he number of double bonds contained in the naturally occurring prostaglandins reflects the nature of the biosynthetic precursors. T hose containing one double bond are derived from 8,11,14-eicosatrienoic acid, those with two double bonds from arachidonic acid (5,8,11,14-eicosatetraenoic acid), and those with three double bonds from 5,8,11,14,17eicosapentenoic acid. T he most common of these fatty acids in humans is arachidonic acid; hence, prostaglandins of the 2 series play an important biological role. Arachidonic acid is derived from dietary linoleic acid or is ingested from the diet (19) and esterified to phospholipids (primarily phosphatidylethanolamine or phosphatidylcholine) in cell membranes. Various initiating factors interact with membrane receptors coupled to G proteins (guanine nucleotide– binding regulatory proteins) activating phospholipase A2 , which in turn hydrolyzes membrane phospholipids resulting in the release of arachidonic acid. Other phospholipases (e.g., phospholipase C) also are involved. Phospholipase C differs from phospholipase A 2 by inducing the formation of 1,2-diglycerides from phospholipids with the subsequent release of arachidonic acid by the actions of mono- and diglyceride lipases on the diglyceride (17). A polypeptide produced by leukocytes, interleukin-1, which mediates inflammation, increases phospholipase activity and, thus, prostaglandin biosynthesis. T he steroidal anti-inflammatory drugs (corticosteroids) appear to act, in part, by inhibiting these phospholipases, particularly phospholipase A 2 . T he liberated arachidonic acid may then be acted on by two major enzyme systems: by arachidonic acid cyclooxygenase (prostaglandin endoperoxide synthetase, COX) to produce prostaglandins, thromboxanes, and prostacyclin, or by lipoxygenases to produce leukotrienes.

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Fig. 36.3. Biosynthesis of prostaglandins from arachidonic acid.

Interaction of arachidonic acid with cyclooxygenase (COX) in the presence of oxygen and heme produces, first, the cyclic endoperoxide, PGG 2 , and then, through its peroxidase activity, PGH 2 , both of which are chemically unstable and decompose rapidly (half-life, 5 minutes). T he PGE 2 is formed by the action of PGE isomerase and PGD 2 by the actions of isomerases or glutathione-S-transferase on PGH 2 , whereas PGF 2α is formed from PGH 2 via an endoperoxide reductase system (Fig. 36.3). It is the cyclooxygenase step at which the NSAIDs inhibit prostaglandin biosynthesis, preventing inflammation. Because PGG 2 and PGH 2 themselves may possess the ability to mediate the pain responses and produce vasoconstriction, and because PGG 2 may mediate the P.959 inflammatory response, cyclooxygenase inhibition would have a profound effect on the reduction of inflammation. T hree isoforms of COX have been identified: COX-1, COX-2, and COX-3. COX was first purified in 1976 and first cloned in 1988. Among the more significant advances of the past decade was the isolation of a second isoform of the COX enzyme, COX-2, the expression of which is inducible by cytokines and growth factors (20,21,22,23,24). A third distinct COX isoform, COX-3, has recently been reported in addition to two smaller COX-1–derived proteins (partial COX-1, or PCOX-1, proteins, termed PCOX-1α and PCOX-1β). It has been long known that acetaminophen possesses analgetic and antipyretic activity but little, if any, anti-inflammatory activity. T hus, the identification of this third isoform of the COX enzyme may be of importance, because COX-3 is selectively inhibited by analgetic/antipyretic drugs and is potently inhibited by some NSAIDs. Inhibition of COX-3 may represent a primary central mechanism by which acetaminophen decreases pain and fever (discussed later). Both COX-1 and COX-2 are very similar in structure and almost identical in length, varying from 599 (human) to 602 (mice) amino acids for COX-1 and from 603 (mice) to 604 (human) for COX-2. Both isoforms possess molecular masses of 70 to 74 kDa and contain just over 600 amino acids, with an approximately 60% homology within the same species (25,26). Cyclooxygenase-2 contains an 18-amino-acid insert near the C-terminal end of the enzyme that is not present in COX-1, but all other residues that have been previously identified as being essential to the catalytic activity of COX-1 are present in COX-2. Both isoforms have been cloned from various species, including human, and are heme-containing membrane proteins that exist as dimers (25). T he three-dimensional radiographic crystal structure of COX-2 derived from human or murine sources can be superimposed on that of COX-1. Residues that form

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the substrate binding channel, the catalytic sites, and those residues immediately adjacent are essentially identical with the exception of two minor differences. T he isoleucine at positions 434 and 523 in COX-1 is exchanged for valine in COX-2. T he smaller size of Val-523 in COX-2 allows inhibitor access to a side pocket off the main substrate channel, whereas the longer side chain of Ile in COX-1 sterically blocks inhibitor access. A major difference between COX-1 and COX-2 is that compared to COX-1, COX-2 lacks a sequence of 17 amino acids from the N-terminus but contains a sequence of 18 amino acids at the C-terminus. T his causes a difference in the numbering systems of the two isoforms such that the serine residue acetylated by aspirin in COX-1 is numbered Ser-530, whereas in COX-2, the serine residue acetylated is Ser-516. Yet, the amino acid residues that are thought to be responsible for providing the catalytic role are the same, with both isoforms displaying similar ability to convert arachidonic acid to PGH 2 . Cyclooxygenase-1 appears to be more specific than COX-2 for fatty acid substrates, because COX-2 accepts a wider range of fatty acid substrates than COX-1. Cyclooxygenase-1 primarily metabolizes arachidonic acid, and COX-2 metabolizes C-18 and C-20 fatty acid substrates. Selective inhibitors of COX-2 do not bind to Arg-120, which is used by the —COOH of arachidonic acid and the carboxylic acid selective or nonselective COX-1 inhibitors. From a therapeutic viewpoint, the major difference between COX-1 and COX-2 lies in physiological function rather than in structure. Little COX-2 is present in resting cells, but its expression can be induced by cytokines in vascular smooth muscle, fibroblasts, and epithelial cells, leading to the suggestion that COX-1 functions to produce prostaglandins that are involved in normal cellular activity (protection of gastric mucosa, maintenance of kidney function) and COX-2 to produce prostglandins at inflammatory sites (27). Inducible COX-2 linked to inflammatory cell types and tissues is believed to be the target enzyme in the treatment of inflammatory disorders by NSAIDs. Until recently, most NSAIDs inhibited both COX-1 and COX-2, but with varying degrees of selectivity. Selective COX-2 inhibitors may eliminate side effects associated with NSAIDs because of COX-1 inhibition, such as gastric and renal effects. Prostaglandins are rapidly metabolized and inactivated by various oxidative and reductive pathways. T he initial step involves rapid oxidation of the 15α-OH to the corresponding ketone by the prostaglandin-specific enzyme, prostaglandin 15-OH dehydrogenase. T his is followed by reduction of the C-13, C-14 double bond by prostaglandin ∆ 13 -reductase to the corresponding dihydro ketone, which for PGE 2 represents the major metabolite in plasma. Subsequently, enzymes normally involved in β- and ω-oxidation of fatty acids more slowly cleave the α-chain and oxidize the C-20 terminal methyl group to the carboxylic acid derivative, respectively. Hence, dicarboxylic acid derivatives containing only 16 carbon atoms are the major excreted metabolites of PGE 1 and PGE 2 .

T he pharmacological actions of the various prostaglandins are quite diverse. When administered intravaginally, PGE 2 will stimulate the endometrium of the gravid uterus to contract in a manner similar to uterine contractions observed during labor. T hus, PGE 2 is therapeutically available as dinoprostone (Prostin E2) P.960 for use as an abortifacient at 12 to 20 weeks of gestation and for evacuation of uterine content in missed abortion or intrauterine fetal death up to 28 weeks of gestation. Additionally, PGE 2 is a potent stimulator of smooth muscle of the gastrointestinal (GI) tract and can elevate body temperature in addition to possessing potent vasodilating properties in most vascular tissue while possessing constrictor effects at certain sites. T he PGEs in general cause pain when administered via the intradermal route. Many of these properties are shared by PGF 2α that also is therapeutically available as an abortifacient at 16 to 20 weeks of gestation and is available as dinoprost tromethamine (Prostin F2α). T he synthetic 15-methyl derivative of PGF 2α , carboprost, also is available as the tromethamine salt (Prostin 15/M) as an abortifacient at 13 to 20 of weeks gestation. However, PGF 2α differs from PGE 2 in that it does not significantly

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alter blood pressure in humans. T he PGD 2 causes both vasodilation and vasoconstriction. T he PGEs produce a relaxation of bronchial and tracheal smooth muscle, but the PGFs and PGD 2 cause contraction. T he PGE 1 is available as alprostadil (Prostin VR Pediatric) to maintain patency of the ductus arteriosus in neonates until surgery can be performed to correct congenital heart defects. T he effects of prostaglandins on the GI tract deserve special mention. T he PGEs and PGI2 inhibit gastric secretion that may be induced by gastrin or histamine. Prostaglandins appear to play a major cytoprotective role in maintaining the integrity of gastric mucosa. T he PGE 1 exerts a protective effect on gastroduodenal mucosa by stimulating secretion of an alkaline mucus and bicarbonate ion and by maintaining or increasing mucosal blood flow. T hus, inhibition of prostaglandin formation in joints produces favorable results, as indicated by a reduction in fever, pain, and swelling. Inhibition of prostaglandin biosynthesis in the GI tract is unfavorable, however, because it may cause disruption of mucosal integrity, resulting in peptic ulcer disease that, as will be discussed later, is commonly associated with the use of NSAIDs and aspirin. Alternatively, nonprostanoids also can be formed from PGH 2 , as illustrated in Figure 36.4. T hromboxane synthetase acts on PGH 2 to produce thromboxane A 2 (T XA2 ), whereas prostacyclin synthetase converts PGH 2 to prostacyclin (PGI 2 ), both of which possess short biological half-lives. A potent vasoconstrictor and inducer of platelet aggregation, T XA2 has a biological half-life of approximately 30 seconds, being rapidly nonenzymatically converted to the more stable, but inactive, T XB 2 . Prostacyclin, a potent hypotensive and inhibitor of platelet aggregation, has a half-life of approximately 3 minutes and is nonenzymatically converted to 6-keto-PGF 1α . Platelets contain primarily thromboxane synthetase, whereas endothelial cells contain primarily prostacyclin synthetase. Considerable research efforts are being expended in the development of stable prostacyclin analogues and thromboxane antagonists as cardiovascular drugs. T he pharmacological effects of some prostaglandins, T XA 2 , and prostacyclin are summarized in T able 36.2.

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Fig. 36.4. Biosynthesis of thromboxanes, prostacyclin and leukotrienes.

T he existence of distinct prostaglandin receptors may explain the broad spectrum of action displayed by the prostaglandins. T he nomenclature of these receptors is based on the affinity displayed by natural prostaglandins, prostacyclin, or thromboxanes at each receptor type. T hus, EP receptors are those receptors for which the PGEs have high affinity, FP receptors are those for PGFs, DP receptors are those for PGDs, IP receptors are those for PGI2 , and T P receptors are those for T XA 2 . T hese receptors are coupled through G proteins to effector mechanisms that include stimulation of adenylate cyclase and, hence, increased cyclic adenosine monophosphate levels and phospholipase C that results in increased levels of inositol 1,4,5-triphosphate. T hree distinct receptors for leukotrienes have been identified as well. Lipoxygenases are a group of enzymes that oxidize polyunsaturated fatty acids possessing two ci s double bonds separated by a methylene group to produce lipid hydroperoxides (19). Arachidonic acid is thus metabolized to a number of hydroperoxy-eicosatetraenoic acid P.961 derivatives (HPET Es). T hese enzymes differ in the position at which they peroxidize arachidonic acid and in their tissue specificity. For example, platelets possess only a 12-lipoxygenase, whereas leukocytes possess both a 12-lipoxygenase and a 5-lipoxygenase (28). T he HPET E derivatives are not stable, being rapidly converted to a number of metabolites. Leukotrienes are products of the 5-lipoxygenase pathway and are divided into two major classes: hydroxylated eicosatetraenoic acids (LT s), represented by LT B 4 , and peptidoleukotrienes (pLT s), such as LT C 4 , LT D 4 , and LT E 4 . 5-Lipoxygenase will produce leukotrienes from 5-HPET E, as shown in Figure 36.5. LT A synthetase converts 5-HPET E to an unstable epoxide called LT A4 that may be converted by LT A hydrolase to the leukotriene LT B 4 or by glutathione-S-transferase to LT C 4 . Other cysteinyl leukotrienes (e.g., LT D 4 , LT E 4 , and LT F 4 ) can then be formed from LT C 4 by the removal of glutamic acid and glycine and then reconjugation with glutamic acid, respectively. Cysteinyl leukotrienes activate at least two receptors, designated as CysLT 1 and CysLT 2. A long-recognized mediator of inflammation, SRS-A (slow-reacting substance of anaphylaxis), is primarily a mixture of two leukotrienes, LT C 4 and LT D 4 . T he physiological roles of the various leukotrienes are becoming better understood. LT B 4 is a potent chemotactic agent for polymorphonuclear leukocytes, causes the accumulation of leukocytes at inflammation sites, and leads to the development of symptoms characteristic of inflammatory disorders. Both LT C 4 and LT D 4 are potent hypotensives and bronchoconstrictors. Because of the role played by LT s and pLT s in inflammatory conditions and asthma, it is not surprising that intensive research is being conducted in this area. T he first cysteinyl leukotriene receptor antagonist, zafirlukast (Accolate) (Fig. 36.6), was approved in 1996 for the prophylaxis and chronic treatment of asthma and has been labeled “ lukasts.” It is a selective and competitive receptor antagonist of the cysteinyl leukotriene, LT D 4 and LT E 4 . T he cysteinyl leukotrienes, originally described as slow-reacting substances of anaphylaxis, produce airway edema, smooth muscle constriction, and altered cellular activity associated with the inflammatory process, all of which are associated with the pathophysiology of asthma. In humans, pretreatment with single oral doses of zafirlukast inhibited bronchoconstriction caused by sulfur dioxide and cold air and reduced the both early and late-phase reaction in patients with asthma caused by inhalation of various P.962 antigens, such as grass, cat dander, and ragweed. Zafirlukast reduced the increase in bronchial hyperresponsiveness to inhaled histamine that followed inhaled allergen challenge. It is rapidly absorbed and food reduces bioavailability to approximately 40%. It is extensively metabolized via hydroxylation reactions mediated primarily by CYP2C9, and to a minor extent CYP3A4, to essentially inactive metabolites. Excretion is 90% fecal and 10% via urine. Its elimination half-life is approximately 10 hours. A second leukotriene antagonist, montelukast (Singulair) (Fig. 36.6), was approved shortly thereafter for prophylaxis and chronic treatment of asthma as an antagonist of LT D 4 at the CysLT 1 receptor. Its oral bioavailability ranges from 60 to 75% depending on the dosage form used. On oral administration, the time to peak concentration ranges from 2 to 4 h. Food can reduce its bioavailability, prolonging time to maximum plasma concentration. Protein binding is more than 99%. Montelukast is also extensively metabolized via hydroxylation reactions mediated by CYP2C9 and CYP3A4 to essentially inactive metabolites. Montelukast is excreted primarily in feces (86%), with an elimination half-life of 3 to 6 hours. T he first inhibitor of leukotriene biosynthesis, zileuton (Zyflo), was approved shortly after zafirlukast for prophylaxis and chronic treatment of asthma. Zileuton is a specific inhibitor of 5-lipoxygenase and, thus, inhibits the formation of LT B 4 , LT C 4 , LT D 4 , and LT E 4 . T he R- (+ )- and S-(–)- enantiomers equally inhibit 5-lipoxygenase, and the drug is marketed as the racemic mixture. Zileuton is metabolized primarily to two diasteromeric glucuronide conjugates and the N-dehydroxylated metabolite.

Table 36.2. Pharmacological Properties of Prostaglandins, Thromboxane, and Prostacyclin

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PGE 2

PGF 2α

Uterus

Oxytocic

Oxytocic

Bronchi

dilation

constriction

Platelets Blood vessels

Dilation

Constriction

PGI 2

TxA 2

Inhibits aggregation

Aggregation

Dilation

Constriction

Fig. 36.5. Biosynthesis of leukotrienes.

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Fig. 36.6. Leukotriene antagonists.

T herapeutic Approach to Arthritic Disorders T he goal of drug treatment in early rheumatoid arthritis is to induce remission or at least eliminate evidence of disease activity. Rheumatoid arthritis was traditionally treated with a stepwise approach starting with NSAIDs and progressing through more potent drugs such as glucocorticoids, DMARDs, and biologic response modifiers. T he DMARDs were avoided early in the disease because of their potentially serious side effects and were usually reserved for people who showed signs of joint damage. Over time, however, this strategy was recognized as being faulty, because people treated early with DMARDs have better long-term outcomes, with greater preservation of function and less work disability.

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Fig. 36.7. NSAID-induced production of gastric damage by a dual-insult mechanism.

T he current approach, therefore, is to treat rheumatoid arthritis aggressively with DMARDs and biologic response modifiers soon after diagnosis. T reating rheumatoid arthritis early with DMARDs, within 3–6 months after symptoms begin, controls inflammation better and is the best way to stop or slow progression of the disease and bring about remission and long term prevention of joint disease. Methotrexate is the cornerstone of DMARD therapy. Long-term treatment with methotrexate and biologic response modifiers may offer the best control of rheumatoid arthritis for the majority of people, which may eliminate the need for other NSAID medications. A large number of NSAIDs are therapeutically available for the treatment of pain and inflammation associated with arthritic disorders, differing in efficacy but, perhaps more importantly, differing also in overall toxicity. As a group, NSAIDs can cause GI toxicity, such as dyspepsia, abdominal pain, heartburn, gastric erosion leading to wall perforation, peptic ulcer formation, bleeding, diarrhea, renal disorders (e.g., acute renal failure, tubular necrosis, and analgesic nephropathy), and other effects (e.g., tinnitus and headache). Gastric damage produced by NSAIDs generally involves a dual insult mechanism (Fig. 36.7). Most NSAIDs are acidic substances that produce a primary insult because of direct acid damage, an indirect contact effect, and a back diffusion of hydrogen ions. T he secondary insult results from inhibition of prostaglandin biosynthesis in the GI tract, where prostaglandins exert a cytoprotective effect. T he dual insult leads to gastric damage. A report from the Arthritis, Rheumatism, and Aging Medical Information System Post-Marketing Surveillance Program, before the introduction of COX-2–selective drugs, ranked the overall toxicity of NSAIDs in the following decreasing order: indomethacin > tolmetic > meclofenamate > ketoprofen > fenoprofen > salsalate > aspirin. P.963

T herapeutic Classifications Antipyretic Analgetics

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Mechanism of Action Drugs included in this class possess analgetic and antipyretic actions but lack anti-inflammatory effects. Antipyretics interfere with those processes by which pyrogenic factors produce fever, but they do not appear to lower body temperature in afebrile subjects. It had been historically accepted that the antipyretics exert their actions within the central nervous system (CNS), primarily at the hypothalamic thermoregulatory center, but more recent evidence suggests that peripheral actions also may contribute. Endogenous leukocytic pyrogens may be released from cells that have been activated by various stimuli, and antipyretics may act by inhibiting the activation of these cells by an exogenous pyrogen or by inhibiting the release of endogenous leukocytic pyrogens from the cells once they have been activated by the exogenous pyrogen. Substantial evidence exists suggesting a central antipyretic mechanism, an antagonism that may result from either a direct competition of a pyrogen and the antipyretic agent at CNS receptors, or an inhibition of prostaglandins in the CNS (29). Despite the extensive use of acetaminophen, the mechanism of action has not been fully elucidated. Acetaminophen may inhibit pain impulses by exerting a depressant effect on peripheral receptors; an antagonistic effect on the actions of bradykinin may play a role. T he antipyretic effects may not result from inhibition of release of endogenous pyrogen from leukocytes but, rather, from inhibiting the action of released endogenous pyrogen on hypothalamic thermoregulatory centers. T he fact that acetaminophen is an effective antipyretic/analgetic but an ineffective anti-inflammatory agent may result from its greater inhibition of prostaglandin biosynthesis via inhibition of the COX-3 isoform in the CNS compared with that in the periphery.

Table 36.3. Binding Constants (IC 50 mM ) of Selected NSAIDs for the COX enzymes Drug

COX-1

COX-2

COX-3

Acetaminophen

>1,000

>1,000

460

Phenacetin

>1,000

>1,000

102

Aspirin

10

>1,000

3.1

Diclofenac

0.035

0.041

0.008

Ibuprofen

2.4

5.7

0.24

Indomethacin

0.010

0.66

0.016

Recent research in dogs has revealed a slice variant of COX-1 that was sensitive to inhibition by acetaminophen. T his novel variant of the cyclooxygenase system was named COX-3, and it was hypothesized that inhibition of COX-3 could represent a primary CNS mechanism by which acetaminophen and phenacetin exerted their analgesic and antipyretic effects (30). T he ability of selected analgesic/antipyretic drugs to inhibit COX-1, COX-2, and COX-3 is

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shown in T able 36.3 (30). Further studies revealed that similar cyclooxygenase variants were present in rodents and humans, but these did not appear to be inhibited by acetaminophen (31,32). T hese cyclooxygenase variants are proposed to be COX-active, however, and to have a role in the biochemistry of these species (33,34). T here is substantial nonhomology between the human, canine, and rodent COX-3 proteins. T he mode of action of acetaminophen therefore is still in question. Certainly, the analgetic and antipyretic properties parallel the decrease in PGE 2 levels in the CNS caused by acetaminophen. T he COX-1–deleted, but not the COX-2– deleted, mice showed a decrease in these actions (35). T hose authors suggest that in this species, it is COX-1, or a variant of it, that is affected by acetaminophen. Unlike other NSAIDs, such as ibuprofen or aspirin, acetaminophen does not have significant anti-inflammatory, antiplatelet, or gastric ulcerogenic activity. Other authors claim that the mechanism of action of acetaminophen is thought to involve inhibition of COX-2, and this fits with the therapeutic profile of the recently discovered, powerful, and selective COX-2 inhibitors (36). Acetaminophen is only effective, however, when COX-2 activity is at a low level. T his view partially explains the lack of anti-inflammatory action, because COX-2 activity will be high in this situation (37). Graham and Scott (37) also have put forward the interesting hypothesis that acetaminophen acts by depletion of the stores of glutathione, which is a known cofactor for PGE synthase. T his would explain the decrease in PGE production and the concomitant analgetic effect. T he depletion of glutathione is the main cause of acetaminophen toxicity. T he highly reactive benzoquinone-imine, formed by CYP2E1 isoform, must be conjugated with glutathione before it can react with other crucial cell components. In overdose, failure of this molecular mechanism results in serious liver damage. T he depletion of P.964 the body's supply of glutathione also should affect the biosynthesis of the inflammatory mediator leukotriene C4. At therapeutic acetaminophen levels, however, this does not seem to be significant. A review paper discussing the dichotomies of the acetaminophen mechanism and COX-3 is available (38).

Historical Background Acetanilide was introduced into therapy in 1886 under the name antifebrin as an antipyretic/analgetic agent but was subsequently found to be too toxic (methemoglobinemia and jaundice), particularly at high doses, to be useful. Phenacetin was introduced the following year and remained in use until the 1960s because of reports of nephrotoxicity. Phenacetin is longer acting than acetaminophen despite the fact that it is metabolized to acetaminophen but is a weaker antipyretic. Shortly thereafter, acetaminophen (paracetamol) was introduced in 1893 but remained unpopular for more than 50 years, until it was observed that it is a metabolite of both acetanilide and phenacetin. It remains the only useful agent of this group and is widely used as a nonprescription antipyretic/analgetic under a variety of trade names (T ylenol, Patrol, and T empera). T he analgetic activity of acetaminophen is comparable to that of aspirin, but acetaminophen lacks useful anti-inflammatory activity. Its advantages over aspirin as an analgetic, however, are that individuals who are hypersensitive to salicylates generally respond well to acetaminophen.

Structure–Activity Relationships T he structure–activity relationships of p-aminophenol derivatives have been widely studied. Based on the comparative toxicity of acetanilide and acetaminophen, aminophenols are less toxic than the corresponding aniline derivatives, although p-aminophenol itself is too toxic for therapeutic purposes. Etherification of the phenolic function with methyl or propyl groups produces derivatives with greater side effects than with ethyl groups. Substituents on the nitrogen atom that reduce basicity reduce activity unless that substituent is metabolically labile (e.g., acetyl). Amides derived from aromatic acids (e.g., N-phenylbenzamide) are less active or inactive.

Acetaminophen USP Acetaminophen is weakly acidic (pK a = 9.51) and synthesized by the acetylation of p-aminophenol. It is weakly bound to plasma proteins (18–25%). Acetaminophen is indicated for use as an antipyretic/analgetic, particularly in those individuals displaying an allergy or sensitivity to aspirin. It does not possess anti-inflammatory activity, but it will produce analgesia in a wide variety of arthritic and musculoskeletal disorders. It is available in various formulations, including suppositories, tablets, capsules, granules, and solutions. T he usual adult dose is 325 to 650 mg every 4 to 6 hours. Doses of greater than 2.6 g/day are not recommended for long-term therapy because of potential hepatotoxicity issues. Acetaminophen, unlike aspirin, is stable in aqueous solution, making liquid formulations readily available, a particular advantage in pediatric cases.

Metabolism an d T oxicity

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T he metabolism of acetanilide, acetaminophen, and phenacetin is illustrated in Figure 36.8 (39). As indicated earlier, both acetanilide and phenacetin are metabolized to acetaminophen. Additionally, both undergo hydrolysis to yield aniline derivatives that produce directly, or through their conversion to hydroxylamine derivatives, significant methemoglobinemia and hemolytic anemia, which resulted in their removal from the U.S. market. On the other hand, acetaminophen is undergoes rapid first-pass metabolism in the GI tract primarily by conjugation reactions, with the O-sulfate conjugate being the primary metabolite in children and the O-glucuronide being the primary metabolite in adults. A minor, but significant, product of both acetaminophen and phenacetin is the N-hydroxyamide produced by a CYP2E1 and CYP3A4. T he CYP2E1 is the rate-limiting enzyme that initiates the cascade of events leading to acetaminophen hepatotoxicity; in the absence of this cytochrome P450 enzyme, toxicity will only be apparent at high concentrations. T he N-hydroxyamide is then converted to a reactive toxic metabolite, an acetimidoquinone, which has been suggested (40) to produce the nephrotoxicity and hepatotoxicity associated with acetaminophen and phenacetin. Normally, this iminoquinone is detoxified by conjugation with hepatic glutathione. In cases of ingestion of large doses or overdoses of acetaminophen, however, hepatic stores of glutathione may be depleted by more than 70%, allowing the reactive quinone to interact with soft nucleophilic functional groups, primarily —SH groups, on hepatic proteins, resulting in the formation of covalent adducts that produce hepatic necrosis. Overdoses of acetaminophen can produce potentially fatal hepatic necrosis, renal tubular necrosis, and hypoglycemic coma. Various sulfhydryl-containing compounds were found to be useful as antidotes to acetaminophen overdoses. T he most useful of these, N-acetylcysteine (Mucomyst, Acetadote), serves as a substitute for the depleted glutathione by enhancing hepatic glutathione stores and/or by enhancing disposition by nontoxic sulfate conjugation (41). N-Acetylcysteine also may inhibit the formation of the toxic iminoquinone metabolite (42). In cases of acetaminophen overdoses, N-acetylcysteine is administered as a 5% solution in water, soda, or juice or intravenously (IV) at 140 mg/kg followed by 17 maintenance doses of 70 mg/kg every 5 hours.

Drug Interaction s Hepatic necrosis develops at much lower doses of acetaminophen in some heavy drinkers than would be expected (39), perhaps because of the induction of the CYP2E1 system, depletion of glutathione stores, or aberrations in the primary sulfate and glucuronide conjugation pathways. At 4 g per day, acetaminophen has been reported to potentiate the response to oral anticoagulants, increasing prothrombin time (INR values) two to three times. Interactions with warfarin P.965 (Coumadin), dicumarol, anisindione, and diphenadione have been suggested. T he mechanism of these interactions has not been fully elucidated but may be associated with competition for plasma protein binding sites, because acetaminophen is a weak acid and is weakly bound, but may also interfere with the enzymes involved in vitamin K-dependent coagulation factor synthesis. T he absorption of acetaminophen is enhanced by polysorbate and sorbitol and is reduced by anticholinergics and narcotic analgetics. Chemical incompatibilities also have been reported based on hydrolysis by strong acids or bases or by phenolic oxidation in the presence of oxidizing agents. Acetaminophen forms “ sticky” mixtures with diphenhydramine HCl and discolors under humid conditions in the presence of caffeine or codeine phosphate.

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Fig. 36.8. Metabolism of acetaminophen.

Anti-Inflammatory Drugs Salicylates T he use of salicylates dates back to the nineteenth century. Salicylic acid itself was first obtained in 1838 from salicin, a glycoside present in most willow and poplar bark. Interestingly, Hippocrates prescribed chewing willow bark for pain relief in the fifth century AD. In 1860, Kolbe synthesized salicylic acid from sodium phenoxide and carbon dioxide, a method that inexpensively produced large quantities. Derivatives of salicylic acid began to receive medical attention shortly thereafter. Sodium salicylate was employed as an antipyretic/antirheumatic agent in 1875, and the phenyl ester was used in 1886. Acetylsalicylic acid was prepared in 1853 but was not used medicinally until 1899. T he term “ aspirin” was given to acetylsalicylic acid by Dreser, the director of pharmacology at Frederich Bayer and Company in Germany, as a contraction of the letter “ a” from acetyl and “ spirin,” an older name given to salicylic acid (spiric acid) that was derived from a natural source in spirea plants. Since then, numerous derivatives of salicylic acid have been synthesized and evaluated pharmacologically, yet only a relatively few derivatives have achieved

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therapeutic utility. In addition to possessing antipyretic, analgetic, and anti-inflammatory properties, salicylates possess other P.966 actions that have been proven to be therapeutically beneficial. Because salicylates promote the excretion of uric acid, they are useful in the treatment of gouty arthritis. More recent attention has been given to the ability of salicylates to inhibit platelet aggregation, which may contribute to heart attacks and stroke. Aspirin appears to inhibit prostaglandin cyclooxygenase in platelet membranes, thus blocking formation of the potent platelet-aggregating factor T XA 2 in a manner that is irreversible. T he Physicians Health Study concluded that in a group of 22,071 participants, there was a 44% reduction in the risk of myocardial infarction in the group taking a single 325-mg aspirin tablet taken every other day versus the placebo group (43). T he role of aspirin in reducing cardiac mortality has been reviewed (44). Also, aspirin and other NSAIDs might be protective against colon cancer (45). T hus, the therapeutic utility of aspirin continues to increase. Unfortunately, a number of side effects are associated with the use of salicylates, most notably GI disturbances such as dyspepsia, gastroduodenal bleeding, gastric ulcerations, and gastritis.

Mechanism of action A number of possible mechanisms of action have been proposed for salicylates over the years. Among those that have been suggested are inhibition of the biosynthesis of histamine, antagonism of the actions of various kinins, inhibition of mucopolysaccharide biosynthesis, inhibition of lysosomal enzyme release, and inhibition of leukocyte accumulation. T he most widely accepted mechanism of action currently is the ability of these drugs to inhibit the biosynthesis of prostaglandins at the cyclooxygenase stage discussed earlier. Aspirin is the only NSAID that covalently modifies cyclooxygenase by acetylating Ser-530 of COX-1 and Ser-516 of COX-2. Aspirin, however, is 10 to 100 times more potent against COX-1 than against COX-2 (46). Aspirin's actions on COX-1 prevent both endoperoxide and 15-peroxidation of arachidonic acid, but its action on COX-2 does not prevent formation of 15-OOH arachidonic acid (25).

Structure–activity relationships Despite the vast effort that has been expended in the search to find a “ better” aspirin—that is, one possessing fewer GI side effects but a greater potency and a longer duration of action yet is inexpensive and an antipyretic, analgetic, and anti-inflammatory agent that is overall superior to aspirin—none has yet to be discovered. T he following structure–activity relationships have been established:

T he active moiety appears to the salicylate anion. T he side effects of aspirin, particularly the GI effects, appear to be associated with the carboxylic acid function. Reducing the acidity of this group (e.g., converting to an amide, salicylamide) maintains the analgetic actions of salicylic acid derivatives but eliminates the anti-inflammatory properties. Substitution on either the carboxyl or phenolic hydroxyl groups may affect potency and toxicity. Benzoic acid itself has only weak anti-inflammatory activity. Placing the phenolic hydroxyl group meta or para to the carboxyl group abolishes this activity. Substitution of halogen atoms on the aromatic ring enhances potency and toxicity. Substitution of aromatic rings at the 5-position of salicylic acid increases anti-inflammatory activity (e.g., diflunisal).

Absorption and metabolism Most salicylates are rapidly and effectively absorbed on oral administration with the rate of absorption and bioavailability being dependent on a number of factors, including the dosage formulation, gastric pH, food contents in the stomach, gastric emptying time, the presence of buffering agents or antacids, and particle size. Because

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salicylates are weak acids (acetylsalicylic acid pK a = 3.5), absorption generally takes place primarily from the small intestine and, to a lesser extent, from the stomach by the process of passive diffusion of un-ionized molecules across the epithelial membranes of the GI tract. T hus, gastric pH is an important factor in the rate of absorption of salicylates. Any factor that increases gastric pH (e.g., buffering agents) will slow its rate of absorption, because more of the salicylate will be in the ionized form. T he differences in the rates of absorption of aspirin, salicylate salts, and the numerous buffered preparations of salicylates actually are quite small, with absorption half-times in humans ranging from approximately 20 minutes for buffered preparations to 30 minutes for aspirin itself. T he presence of food in the stomach also slows the rate of absorption. Formulation factors may contribute to the differences in absorption rates of the various brands of plain and buffered salicylate preparations. T ablet formulations consisting of small particles are absorbed faster than those of larger particle size. T he bioavailability of salicylate from enteric-coated preparations may be inconsistent. Absorption of salicylate from rectal suppositories is slower and incomplete and is not recommended when high salicylate levels are required. T opical preparations of salicylic acid ester, e.g., methyl salicylate, are effective in that the rate of salicylate absorption from the skin is rapid. However, 3–5% solutions of salicylic acid are also applied topically as a keratolytic agent. Salicylates are highly bound to plasma protein albumin, with binding being concentration dependent. At low therapeutic concentrations of 100 µg/mL, approximately 90% of aspirin is plasma protein bound, whereas at higher concentrations of approximately 400 µg/mL, only 76% binding is observed. Plasma protein binding is a major factor in the drug interactions observed for salicylates. P.967

Fig. 36.9. Metabolism of salicylic acid derivatives. Glu, glucuronide conjugate; Gly, glycine conjugate.

T he major metabolic routes of esters and salts of salicylic acid are illustrated in Figure 36.9. T he initial route of metabolism of these derivatives is their conversion to salicylic acid, which may be excreted in the urine as the free acid (10%) or undergo conjugation with either glycine, to produce the major metabolite salicyluric acid (75%), or with glucuronic acid, to form the glucuronide ether and ester (15%). In addition, small amounts of metabolites resulting from microsomal aromatic hydroxylation are found. T he major hydroxylation metabolite, gentisic acid, was once thought to be responsible for the anti-inflammatory actions of the salicylates, but its presence in trace quantities would rule out a major role for gentisic acid, or the other hydroxylation metabolites, in the pharmacological action of salicylates. T he metabolism of pharmacokinetic properties of salicylates has been extensively reviewed (47).

Side effects T he most commonly observed side effects associated with the use of salicylates relate to disturbances of the GI

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tract. Nausea, vomiting, epigastric discomfort, intensification of symptoms of peptic ulcer disease (e.g., dyspepsia and heartburn), gastric ulcerations, erosive gastritis, and GI hemorrhage occur in individuals on high doses of aspirin. T he incidence of these side effects is more rare at low doses, but a single dose of aspirin can cause GI distress in 5% of individuals. Gastric bleeding induced by salicylates generally is painless but can lead to fecal blood loss and may cause a persistent iron deficiency anemia. At dosages that generally are useful in anti-inflammatory therapy, aspirin may lead to a loss of 3 to 8 mL/day of blood. T he mechanism by which salicylates cause gastric mucosal cell damage may be caused by a number of factors, including gastric acidity, ability of salicylates to damage the normal mucosal barrier that protects against the back diffusion of hydrogen ions, ability of salicylates to inhibit the formation of prostaglandins (particularly those of the PGE series, which normally inhibit gastric acid secretion), and inhibition of platelet aggregation (leading to an increased tendency toward bleeding). T hus, salicylate use before surgery or tooth extraction is contraindicated. Reye's syndrome is an acute condition that may follow influenza and chickenpox infections in children from infancy to their late teens, with the majority of cases occurring between the ages of 4 and 12 years. It is characterized by symptoms including sudden vomiting, violent headaches, and unusual behavior in children who appear to be recovering from an often mild viral illness. Although a rare condition (60–120 cases per year, or an incidence of 0.15 per 100,000 population of those ≤18 years), it can be fatal, with a death rate of between 20 and 30%. Fortunately, the number of cases is declining, partly because of the observations that more than 90% of children with Reye's syndrome were on salicylate therapy during a recent viral illness. Based on these observations, the U.S. Food and Drug Administration (FDA) has proposed that aspirin and other salicylates be labeled with a warning against their use in children younger than 16 years with influenza, chickenpox, or other flu-like illness. Acetaminophen would appear to be the drug of choice in children with these conditions. Salicylates account for approximately 25% of all accidental poisonings in the United States.

Drug interactions Because of the widespread use of salicylates, it is not surprising that interactions with many other drugs used in therapeutic combinations have been observed. Several of these interactions are clinically significant. More data are available for aspirin than for any other specific salicylate product. As mentioned previously, acetylsalicylic acid is a weak acid that is highly bound to plasma proteins (50–80%), and it will compete for these plasma protein binding sites with other drugs that are highly bound to these sites. T he interaction that results from the combination of salicylates with oral anticoagulants represents one of the most widely documented clinically significant drug interactions reported to date. T he plasma concentration of free anticoagulant increases in the presence of salicylates, necessitating a possible decrease in the dosage of anticoagulant required to produce a beneficial therapeutic effect. T he ability of salicylates to produce GI ulcerations and bleeding, coupled with the inhibition of the clotting mechanism, results in a clinically significant drug interaction. In addition, salicylates may inhibit the synthesis of prothrombin by antagonizing the actions of vitamin K. Additionally, NSAIDs can produce these interactions. T he competition for plasma protein binding sites also can lead to an increase in free methotrexate levels (thus enhancing the toxicity of methotrexate), enhanced toxicity of long-acting sulfonamides, and a hypoglycemic effect (resulting from displacement of oral hypoglycemic drugs). In large P.968 doses, salicylates given concomitantly with uricosuric drugs, such as probenecid and sulfinpyrazone, may lead to a retention of uric acid and, thus, antagonize the uricosuric effect, despite the fact that salicylates when used alone increases urinary excretion of uric acid. T he diuretic activity of aldosterone antagonists, such as spironolactone, may be antagonized by salicylates. Corticosteroids may decrease blood levels of salicylates because of their ability to increase the glomerular filtration rate. T he incidence and severity of GI ulcerations may be increased if corticosteroids, salicylates, and NSAIDs are administered together. T he GI bleeding induced by salicylates may be enhanced by the ingestion of ethanol. Numerous other interactions have been reported, but their clinical significance has not been fully established. Salicylate hypersensitivity, particularly to aspirin, is relatively uncommon but must be recognized, because severe and potentially fatal reactions may occur. Signs of aspirin hypersensitivity appear soon after administration and include skin rashes, watery secretions, urticaria, vasomotor rhinitis, edema, bronchoconstriction, and anaphylaxis. Less than 1% of the U.S. population may experience aspirin hypersensitivity; this group consists primarily of middle-aged individuals. Females are more likely to experience aspirin intolerance or hypersensitivity. Aspirinsensitive patients with asthma are especially at high risk. Mild salicylism may occur after repeated administration of large doses. Symptoms include dizziness, tinnitus, nausea, vomiting, diarrhea, and mental confusion. Doses of 10 to 30 g have been known to cause death in adults, but some individuals have ingested up to 130 g without fatality. More than 10,000 cases of serious salicylate toxicity occur in the United States each year.

Available preparations

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T he structures of the marketed preparations of salicylic acid are presented in Figure 36.10.

Fig. 36.10. Structures of marketed derivatives of salicylic acid.

Aspirin USP Acetylsalicylic acid, or aspirin, is a white powder that is stable in a dry environment but that is hydrolyzed to salicylic acid and acetic acid under humid or moist conditions. Hydrolysis also can occur when aspirin is combined with alkaline salts or with salts containing water of hydration. Stable aqueous solutions of aspirin are thus unobtainable despite the addition of modifying drugs that tend to decrease hydrolysis. Aspirin is rapidly absorbed largely intact from the stomach and upper small intestine on oral administration but is rapidly hydrolyzed by plasma esterases. Peak plasma levels usually are achieved within 2 hours after administration. Increasing the pH of the stomach by the addition of buffering agents may affect absorption, because the degree of ionization will be increased. Aspirin is indicated for the relief of minor aches and mild to moderate pain (325–650 mg every 4 hours), for arthritis and related arthritic conditions (3.2–6.0 g/day), to reduce the risk of transient ischemic attacks (1.3 g/day), for myocardial infarction prophylaxis (300–325 mg/day), and as a platelet aggregation inhibitor (80–325 mg per day). It is available in a large number of dosage forms and strengths as tablets, suppositories, capsules, enteric-coated tablets, and buffered tablets.

Salicylamide Salicylamide is less acidic (pK a 8.2) than other salicylic acid derivatives. Although poorly soluble in water, stable solutions can be formed at pH 9 through ionization of the phenolic group. It is absorbed from the GI tract on oral administration and is rapidly metabolized to inactive metabolites by intestinal mucosa, but not by hydrolysis. Activity appears to reside in the intact molecule. Salicylamide is approximately 40 to 55% plasma protein bound, and it competes with other salicylates and acetaminophen for glucuronide conjugation, decreasing the extent of conjugation of these other drugs. Excretion occurs rapidly, primarily in the urine. T he major advantages of salicylamide are its general lack of gastric irritation relative to aspirin, and its use in individuals who are hypersensitive to aspirin. Salicylamide enters the CNS more rapidly than other salicylates and will cause sedation and drowsiness when administered in large doses. Whereas salicylamide is reported to be as effective as aspirin as an analgetic/antipyretic and is effective in relieving pain associated with arthritic conditions, it does not appear to possess useful anti-inflammatory activity (48). T hus, indications for the treatment of arthritic disease states are unwarranted, and its use is restricted to the relief of minor aches and pain at a dosage of 325 to 650 mg three or four times per day. Its effects in humans are not reliable, however, and its use is not widely recommended.

Salicylate Salts Several salts of salicylic acid, sodium salicylate USP, choline salicylate USP, and magnesium salicylate USP, and

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one salt of thiosalicylic acid, sodium thiosalicylate USP, are available. T hese salts are used primarily to decrease GI disturbances or because they form stable aqueous solutions. Sodium salicylate is half as potent, on a weight basis, as aspirin as an analgetic/ P.969 antipyretic, but it produces less GI irritation and equivalent blood levels and is useful in patients exhibiting hypersensitivity to aspirin. It generates salicylic acid in the GI tract, accounting for some GI irritation, and sodium bicarbonate sometimes is given concomitantly to reduce acidity. Sodium salicylate, unlike aspirin, does not affect platelet function, although prothrombin times are increased. It is available as tablets, enteric-coated tablets, and as a solution for injection. Choline salicylate has a lower incidence of GI side effects compared with aspirin, and it has been shown to be particularly useful in treating juvenile rheumatoid arthritis, in which aspirin was ineffective. It is absorbed more rapidly than aspirin and produces higher salicylate plasma levels. It is available as a mint-flavored liquid. Magnesium salicylate has a low incidence of GI side effects. Both sodium salicylate and magnesium salicylate should be used cautiously in individuals in whom excessive amounts of these electrolytes might be detrimental. T he possibility of magnesium toxicity in individuals with renal insufficiency exists. It is available as tablets, but its safety in children under 12 years of age has not been fully determined. Sodium thiosalicylate (Solate) is administered intramuscularly (IM) for the treatment of rheumatic fever, muscular pain, and acute gout.

Salsalate (Disalcid) Salsalate, or salicylsalicylic acid, (pK a 3.5 [COOH], 9.8 [AR-OH]) is a dimer of salicylic acid. It is insoluble in gastric juice but is soluble in the small intestine, where it is partially hydrolyzed to two molecules of salicylic acid and absorbed. On a molar basis, it produces 15% less salicylic acid than aspirin. It does not cause GI blood loss and can be given to aspirin-sensitive patients. Salsalate is available as capsules and tablets.

Difl un isal (Dolobid) Diflunisal (pK a 3.3) was introduced in the United States in 1982 and has gained considerable acceptance as an analgetic and as a treatment of rheumatoid arthritis and osteoarthritis. Diflunisal is metabolized primarily to ether and ester glucuronide conjugates. No metabolism involving changes in ring substituents has been reported. It is more potent than aspirin but produces fewer side effects and has a biological half-life three to four times greater than that of aspirin. It is rapidly and completely absorbed on oral administration, with peak plasma levels being achieved within 2 to 3 hours of administration. It is highly bound (99%) to plasma proteins after absorption. Its elimination half-life is 8 to 12 hours, and it is excreted into urine primarily as glucuronide conjugates. T he most frequently reported side effects include disturbances of the GI system (e.g., nausea, dyspepsia, and diarrhea), dermatological reactions, and CNS effects (e.g., dizziness and headache). Diflunisal is a moderately potent inhibitor of prostaglandin biosynthesis, but it differs from the manner in which aspirin inhibits the cyclooxygenase system in that the inhibition is competitive and reversible in nature. Diflunisal does not have an appreciable effect on platelet aggregation, however, and does not significantly produce gastric or intestinal bleeding.

Arylalkanoic Acids

T he largest group of NSAIDs is represented by the class of arylalkanoic acids as typified by the general chemical

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structure, and several factors have caused this to be one of the most active areas of drug development in recent years. T he impact that the introduction of phenylbutazone in the 1950s had on arthritis therapy was more than matched by the interest generated by the introduction of indomethacin in the mid-1960s. As a result of a study designed to investigate the anti-inflammatory activity of 350 indole acetic acid derivatives related structurally to serotonin and metabolites of serotonin, the Merck group led by Shen (49) reported the synthesis and antipyretic and anti-inflammatory activity of the most potent compound in the series, indomethacin. T he observation that indomethacin possessed 1,085-fold the anti-inflammatory activity and 20-fold the antipyretic activity of phenylbutazone (and 10-fold the antipyretic activity of aminopyrine) generated considerable interest in the development of other aryl and heteroaryl acetic acid and propionic acid derivatives. T he marketplace was ripe for new anti-inflammatory drugs and most pharmaceutical companies joined in the search for new arylalkanoic acids. T he introduction of ibuprofen in the 1970s by Upjohn was quickly followed by the appearance of fenoprofen calcium, naproxen, and tolmetin. Sulindac, an analogue of indomethacin, was introduced in the late 1970s. T he 1980s produced zomepirac, benoxaprofen, ketoprofen, flurbiprofen, suprofen, and diclofenac sodium. T he 1990s produced ketorolac, etodolac, nabumetone, and most significantly, the development of selective COX-2 inhibitors, celecoxib, rofecoxib, and valicoxib, which reached the market during the period from 1997 to 2000. T his rapid development has been accompanied by some setbacks, however. Zomepirac, introduced in 1980 as an analgetic, was withdrawn in 1983 because of severe anaphylactoid reactions, particularly in patients sensitive to aspirin. Benoxaprofen was withdrawn within 6 months of its introduction in 1982 because of several deaths caused by cholestatic jaundice in Europe and the United States. In addition, benoxaprofen produced photosensitivity reactions in patients when they were exposed to sunlight and onycholysis (loosening of the fingernails) in some patients. Suprofen, introduced as an analgetic in 1985, was removed from the market two years later because of flank pain and transient renal failure. In 1989, however, it was reintroduced for ophthalmic use. Numerous other arylalkanoic acids currently are being evaluated in various stages of clinical trials. P.970

As discussed earlier, most NSAIDs possess a number of biochemical and pharmacological actions. As was the case for the salicylates, the arylalkanoic acids share, to various extents, the property of inhibition of prostaglandin biosynthesis by inhibiting COX-1 and COX-2 with varying degrees of selectivity (T able 36.3).

General structure–activity relationships Drugs of this class share a number of common structural features. T hese general structure–activity relationships will be discussed here as they pertain to the proposed mechanism of action. Specific structure–activity relationships for each drug or drug class will be presented separately, where appropriate. All nonselective COX inhibitors possess a center of acidity, which can be represented by a carboxylic acid function, an enolic function, a hydroxamic acid function, a sulfonamide, or a tetrazole ring. T he relationship of this acid center to the carboxylic acid function of arachidonic acid is obvious. T he activity of ester and amide derivatives of carboxylic acids generally is attributed to the metabolic hydrolysis products. One nonacidic drug, nabumetone, has been recently introduced in the United States, but as will be discussed later, its activity is attributed to its bioactivation to an active acid metabolite. T he center of acidity generally is located one carbon atom adjacent to a flat surface represented by an aromatic or heteroaromatic ring. T he distance between these centers is crucial, because increasing this distance to two or three carbons generally diminishes activity. Derivatives of aryl or heteroaryl acetic or propionic acids are most common. T his aromatic system appears to correlate with the double bonds at the 5- and 8-positions of arachidonic acid. Substitution of a methyl group on the carbon atom separating the acid center from the aromatic ring tends to increase anti-inflammatory activity. T he resulting α-methyl acetic acid, or 2-substituted propionic acid, analogues have been given the class name “ profens” by the U.S. Adopted Name

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Council. Groups larger than methyl decrease activity, but incorporation of this methyl group as part of an alicyclic ring system does not drastically affect activity. Introduction of a methyl group creates a center of chirality. Anti-inflammatory activity in those cases in which the enantiomers have been separated and evaluated, whether determined in vivo or in vitro by cyclooxygenase assays, is associated with the S-(+ )-enantiomer. Interestingly, in those cases in which the propionic acid is administered as a racemic mixture, in vivo conversion of the R-enantiomer to the biologically active S-enantiomer is observed to varying degrees. A second area of lipophilicity that is noncoplanar with the aromatic or heteroaromatic ring generally enhances activity. T his second lipophilic area may correspond to the area of the double bond in the 11-position of arachidonic acid. T his lipophilic function may consist of an additional aromatic ring or alkyl groups either attached to or fused with the aromatic center.

General metabolism Essentially all the arylalkanoic acid derivatives that are therapeutically available are extensively metabolized. Metabolism occurs primarily through hepatic microsomal enzyme systems and may lead to deactivation or bioactivation of the parent molecules. Metabolism of each drug will be treated separately.

Drug interactions All the arylalkanoic acids are highly bound to plasma proteins and, thus, may displace other drugs from protein binding sites, resulting in an enhanced activity and toxicity of the displaced drugs. Interestingly, despite the high degree of plasma protein binding, indomethacin does not display this characteristic drug interaction. T he most commonly observed interaction is that between the arylalkanoic acid and oral anticoagulants, particularly warfarin (Coumadin). Coadministration may prolong prothrombin time. Potential interactions with other acidic drugs, such as hydantoins, sulfonamides, and sulfonylureas, should be monitored. Concomitant administration of aspirin decreases plasma levels of arylalkanoic acids by as much as 20%. Probenecid, on the other hand, tends to increase these plasma levels. Interactions with drugs that may induce hepatic microsomal enzyme systems, such as phenobarbital, may enhance or diminish anti-inflammatory activity depending on whether the arylalkanoic acid is metabolically bioactivated or inactivated by this enzyme system. Certain diuretics, such as furosemide, inhibit the metabolism of prostaglandins by 15-hydroxy-prostaglandin dehydrogenase, and the resulting increase in PGE 2 levels induce plasma renin activity. Because the arylalkanoic acids block the biosynthesis of prostaglandins, the effects of furosemide can be antagonized, in part, offering a potentially significant drug interaction.

Aryl- and heteroarylacetic acids T he structures of the aryl- and heteroarylacetic acid derivatives and the aryl- and heteroarylpropionic acids (“ profens” ) available are presented in Figure 36.11.

In dometh acin Aqueous solutions of indomethacin are not stable because of the ease of hydrolysis of the p-chlorobenzoyl group. T he original synthesis of indomethacin by Shen et al. (49) involved the formation of 2-methyl-5-methoxyindole acetic acid and subsequent P.971 acylation after protection of the carboxyl group as the t-butyl ester. It was introduced in the United States in 1965. It is still one of the most potent NSAIDs in use. It also is a more potent antipyretic than either aspirin or acetaminophen, and it possesses approximately 10 times the analgetic potency of aspirin. T he analgetic effect,

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however, is widely overshadowed by concern over the frequency of side effects.

Fig. 36.11. Structures of aryl- and heteroarylacetic acid derivatives.

Stru ctu re–Activity Relation sh ips Replacement of the carboxyl group with other acidic functionalities decreases activity. Anti-inflammatory activity generally increases as the acidity of the carboxyl group increases and decreases as the acidity is decreased. Amide analogues are inactive. Acylation of the indole nitrogen with aliphatic carboxylic acids or aralkylcarboxylic acids results in amide derivatives that are less active than those derived from benzoic acid. N-Benzoyl derivatives substituted in the para-position with fluoro, chloro, trifluoromethyl, or thiomethyl groups are the most active. T he 5-position of the indole ring is most flexible with regard to the nature of substituents that enhance activity. Substituents such as methoxy, fluoro, dimethylamino, methyl, allyloxy, and acetyl are more active than the unsubstituted indole ring. T he presence of an indole ring nitrogen is not essential for activity, because the corresponding 1-benzylidenylindene analogues (e.g., sulindac) are active. Alkyl groups, especially methyl, at the α-position are more active than aryl substituents. Substitution of a methyl group at the α-position of the acetic acid side chain (to give the corresponding propionic acid derivative) leads to equiactive analogues. T he resulting chirality introduced in the molecules is important. Anti-inflammatory activity is displayed only by the S-(+ )-enantiomer. T he conformation of indomethacin appears to play a crucial role in its anti-inflammatory actions. T he acetic acid side chain is flexible and can assume a large number of different conformations. T he preferred and lower-energy conformation of the N-p-chlorobenzoyl group is one in which the chlorophenyl ring is oriented away from the 2-methyl group (or ci s to the methoxyphenyl ring of the indole nucleus) and is noncoplanar with the indole ring because of steric hindrance produced by the 2-methyl group and the hydrogen atom at the 7-position. T hese conformations are represented as follows:

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Absorption an d Metabol ism Absorption of indomethacin occurs rapidly on oral administration, and peak plasma levels are obtained within 2 to 3 hours. Being an acidic substance (pK a = 4.5), it is highly bound to plasma proteins (97%). Indomethacin is converted to inactive metabolites, approximately 50% of a single dose is 5-O-demethylated by CYP2C9 and 10% conjugated with glucuronic acid. Nonhepatic enzyme systems hydrolyze indomethacin to N-deacylated metabolites. T he metabolism of indomethacin is illustrated in Figure 36.12. T he ability of indomethacin to potently inhibit prostaglandin biosynthesis may account for its anti-inflammatory, antipyretic, and analgetic actions. Pronounced side effects are frequently observed at antirheumatic doses. A large number of individuals taking indomethacin, especially those over the age of 70, experience undesirable effects of the GI tract (e.g., nausea, dyspepsia, diarrhea, and erosion of the stomach walls), the CNS (e.g., headache, dizziness, and vertigo), and the ears (tinnitus), and many patients must discontinue its use. As with other arylalkanoic acids, administration of indomethacin with food or milk decreases GI side effects. Indomethacin is available for the short-term treatment of acute gouty arthritis, acute pain of ankylosing spondylitis, and osteoarthritis. An injectable form to be reconstituted also is available as the sodium trihydrate salt for IV use in premature infants with patent ductus arteriosus. Because of its ability to suppress uterine activity by inhibiting prostaglandin biosynthesis, indomethacin also has an unlabeled use to prevent premature labor. P.972

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Fig. 36.12. Metabolism of indomethacin. Glu, glucuronide.

Sulin dac Sulindac was introduced in the United States in 1978 by Merck as a result of chemical studies designed to produce an analogue without the side effects commonly associated with the use of indomethacin, particularly GI irritation. It achieved wide popularity, and it remains one of the more widely used NSAIDs. Its synthesis also was reported by Shen et al. (50). Sulindac is a pro-drug and is converted to a metabolite that appears to inhibit the cyclooxygenase system approximately eight-fold as effectively as aspirin. In anti-inflammatory and antipyretic assays, it is only about half as potent as indomethacin but is equipotent in analgetic assays.

Stru ctu re–Activity Relation sh ips T he use of classical bio-isosteric changes in medicinal chemistry drug design was invoked in the design of sulindac. T he isosteric replacement of the indole ring with the indene ring system resulted in a derivative with therapeutically useful anti-inflammatory activity and fewer CNS and GI side effects but with other undesirable effects, particularly poor water solubility and resultant crystalluria. T he replacement of the N-p-chlorobenzoyl substituent with a benzylidiene function resulted in active derivatives. However, when the 5-methoxy group of the indene isostere was replaced with a fluorine atom, enhanced analgetic effects were observed. T he decreased water solubility of the indene isostere was alleviated by replacing the chlorine atom of the phenyl substituent with a sulfinyl group. T he importance of stereochemical features in the action of sulindac, introduced by the benzylidene double bond, is evidenced by the observation that the (Z)-isomer is a much more potent anti-inflammatory agent than the corresponding (E)-isomer (Fig. 36.10). T his ci s-relationship of the phenyl substituent to the aromatic ring bearing the fluoro substituent is similar to the proposed conformation of indomethacin, suggesting that both indomethacin and sulindac assume similar conformations at the active site of arachidonic acid cyclooxygenase.

Absorption an d Metabol ism

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Sulindac is well absorbed on oral administration (90%), reaches peak plasma levels within 2 to 4 hours, and being acidic (pK a = 4.5), is highly bound to serum proteins (93%). T he metabolism of sulindac plays a major role in its actions, because all of the pharmacological activity is associated with its major metabolite. Sulindac is, in fact, a pro-drug, the sulfoxide function being reduced to the active sulfide metabolite. Sulindac is absorbed as the sulfoxide, which is not an inhibitor of prostaglandin biosynthesis in the GI tract. As discussed earlier, prostaglandins exert a protective effect in the GI tract, and inhibition of their synthesis here leads to many of the GI side effects noted for most NSAIDs. Once sulindac enters the circulatory system, it is reduced to the sulfide, which is an inhibitor of prostaglandin biosynthesis in the joints. T hus, sulindac produces less GI side effects, such as bleeding, ulcerations, and so on, than indomethacin and many other NSAIDs. In addition, the active metabolite has a plasma half-life approximately twice that of the parent compound (~ 16 hours versus 8 hours), which favorably affects the dosing schedule. In addition to the sulfide metabolite, sulindac is oxidized to the corresponding sulfone, which is inactive. A minor product results from hydroxylation of the benzylidene function and the methyl group at the 2-position. Glucuronides of several metabolites also are found. Sulindac as well as the sulfide and the sulfone metabolites are all highly protein-bound. Despite the fact that the sulfide metabolite is a major activation product and is found in high concentration in human plasma, it is not found in human urine, perhaps because of its high degree of protein binding. T he major excretion product is the sulfone metabolite and its glucuronide conjugate. T he complete metabolism of sulindac is illustrated in Figure 36.13. Whereas the toxicity of sulindac is lower than that observed for indomethacin and other NSAIDs, the spectrum of adverse reactions is very similar. T he most frequent side effects reported are associated with irritation of the GI tract (e.g., nausea, dyspepsia, and diarrhea), although these effects generally are mild. Effects on the CNS (e.g., dizziness and headache) are less common. Dermatological effects are less frequently encountered. Sulindac is indicated for long-term use in the treatment of rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and acute gouty arthritis. T he usual maximum dosage is 400 mg/day, with starting doses recommended at 150 mg twice a day. It is recommended that sulindac be administered with food. P.973

Fig. 36.13. Metabolism of sulindac. Glu, glucuronide.

T olmeti n Sodiu m T olmetin is synthesized straightforwardly from 1-methylpyrrole (51). It was introduced in the United States in 1976,

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and like other NSAIDs, inhibits prostaglandin biosynthesis. T olmetin, however, also inhibits polymorph migration and decreases capillary permeability. Its anti-inflammatory activity, as measured in the carrageenan-induced rat paw edema and cotton pellet granuloma assays, is intermediate between those of phenylbutazone and indomethacin.

Stru ctu re–Activity Relation sh ips T he relationship of tolmetin to indomethacin is clear, with each containing a noncoplanar p-chlorobenzoyl group and an acetic acid function. T olmetin possesses a pyrrole ring instead of the indole ring in indomethacin. Replacement of the 5-p-toluoyl group with a p-chlorobenzoyl moiety produced little effect on activity, whereas introduction of a methyl group in the 4-position of the pyrrole ring produced interesting results. T he 4-methyl-5-p-chlorobenzoyl analogue is approximately four times as potent as tolmetin. Substitution of the p-methyl group of tolmetin with a p-chloro group blocked oxidative metabolism, increasing duration of action to approximately 24 hours. McNeil marketed this compound in 1980 as zomepirac, an analgetic that was removed from the market in 1983 because of severe anaphylactic reactions, particularly in patients sensitive to aspirin. Unlike the previous structure–activity relationships discussed for arylalkanoic acids, the propionic acid analogue is slightly less potent than tolmetin.

Absorption an d Metabol ism T olmetin sodium is rapidly and almost completely absorbed on oral administration, with peak plasma levels being attained within the first hour of administration. It has a relatively short plasma half-life of approximately 1 hour because of extensive first-pass metabolism, involving hydroxylation of the p-methyl group to the primary alcohol, which is subsequently oxidized to the dicarboxylic acid shown below. T his metabolite is inactive in standard in vivo anti-inflammatory assays. T he free acid (pK a = 3.5) is highly bound to plasma proteins (99%), and excretion of tolmetin and its metabolites occurs primarily in the urine.

Approximately 15 to 20% of an administered dose is excreted unchanged and 10% as the glucuronide conjugate of the parent drug. Conjugates of the dicarboxylic acid metabolite account for the majority of the remaining administered drug. T he most frequently adverse reactions are those involving the GI tract (e.g., abdominal pain, discomfort, and nausea) but appear to be less than those observed with aspirin. T he CNS effects (e.g., dizziness and drowsiness) also are observed. Few cases of overdosage have been reported, but in such cases, recommended treatment includes elimination of the drug from the GI tract by emesis or gastric lavage and elimination of the acidic drug from the circulatory system by enhancing alkalinization of the urine with sodium bicarbonate. T olmetin sodium is indicated for the treatment of rheumatoid arthritis, juvenile rheumatoid arthritis, and osteoarthritis.

Diclofen ac Sodium Diclofenac is synthesized from N-phenyl-2,6-dichloroaniline (52). It is available in 120 different countries and, perhaps, is the most widely used NSAID in the world. It was introduced in the United States in 1989 but was first marketed in Japan in 1974. It ranks among the top prescription drugs in the United States. Diclofenac possesses structural characteristics of both arylalkanoic acid and the anthranilic acid classes of anti-inflammatory drugs, and it displays anti-inflammatory, analgetic, and antipyretic properties. In the carrageenan-induced rat paw edema assay, it is twice as potent as indomethacin and 450 times as potent as aspirin. As an analgetic, it is six times more potent than indomethacin and 40 times as potent as aspirin in the phenyl benzoquinone–induced writhing assay in mice. As an antipyretic, it is twice as potent as indomethacin and more than 350 times as potent as aspirin in the yeast-

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induced fever assay in rats. Diclofenac is unique among the NSAIDs in that it possesses three possible mechanisms of action: 1) inhibition of the arachidonic acid cyclooxygenase system (3 to 1,000 times more potent than other NSAIDs on a molar basis), resulting in a decreased production of prostaglandins and thromboxanes; 2) P.974 inhibition of the lipoxygenase pathway, resulting in decreased production of leukotrienes, particularly the pro-inflammatory LKB 4 ; and 3) inhibition of arachidonic acid release and stimulation of its reuptake, resulting in a reduction of arachidonic acid availability.

Stru ctu re–Activity Relation sh ips Structure–activity relationships in this series have not been extensively studied. It does appear that the function of the two o-chloro groups is to force the anilino-phenyl ring out of the plane of the phenylacetic acid portion, this twisting effect being important in the binding of NSAIDs to the active site of the COX, as previously discussed.

Absorption an d Metabol ism Diclofenac is rapidly and completely (~ 100%) absorbed on oral administration, with peak plasma levels being reached within 1.5 to 2.5 hours. T he free acid (pK a = 4.0) is highly bound to serum proteins (99.5%), primarily albumin. Only 50 to 60% of an oral dose is bioavailable because of extensive hepatic metabolism. Four major metabolites resulting from aromatic hydroxylation have been identified. T he major metabolite via CYP3A4 is the 4′-hydroxy derivative and accounts for 20 to 30% of the dose excreted, whereas the 5-hydroxy, 3′-hydroxy, and 4′,5-dihydroxy metabolites via CYP2C9 account for 10 to 20% of the excreted dose. T he remaining drug is excreted in the form of sulfate conjugates. Although the major metabolite is much less active than the parent compound, it may exhibit significant biological activity, because it accounts for 30 to 40% of all of the metabolic products. T he metabolism of diclofenac is illustrated in Figure 36.14.

Fig. 36.14. Metabolism of diclofenac.

Diclofenac sodium is indicated for the treatment of rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis.

Etodolac

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Etodolac is promoted as the first of a new chemical class of anti-inflammatory drugs, the pyranocarboxylic acids. Although not strictly an arylacetic acid derivative (because there is a two-carbon atom separation between the carboxylic acid function and the hetero-aromatic ring) (Fig. 36.10), it still possesses structural characteristics similar to those of the heteroarylacetic acids and is classified here. It was introduced in the United States in 1991 for acute and long-term use in the management of osteoarthritis and as an analgetic. It also possesses antipyretic activity. Etodolac is marketed as a racemic mixture, although only the S-(+ )-enantiomer possesses anti-inflammatory activity in animal models. Etodolac also displays a high degree of enantioselectivity in its inhibitory effects on the arachidonic acid cyclooxygenase system. With regard to its anti-inflammatory actions, etodolac was approximately 50 times more active than aspirin, three times more potent than sulindac, and one-third as active as indomethacin. T he ratio of the anti-inflammatory activity to the median effective dose (ED50) for gastric ulceration or erosion was more favorable for etodolac (median inhibitory dose [ID50]/ED50 = 10) than for aspirin, naproxen, sulindac, or indomethacin (ID50/ED50 = 4). At 2.5 to 3.5 times the effective anti-inflammatory dose, etodolac was reported to produce less GI bleeding than indomethacin, ibuprofen, or naproxen. T he primary mechanism of action appears to be inhibition of the biosynthesis of prostaglandins at the cyclooxygenase step, with no inhibition of the lipoxygenase system. Etodolac, however, possesses a more favorable ratio of inhibition of prostaglandin biosynthesis in human rheumatoid synoviocytes and chondrocytes than by cultured human gastric mucosal cells compared to ibuprofen, indomethacin, naproxen, diclofenac, and piroxicam. T hus, although etodolac is no more potent an NSAID than many others, the lower incidence of GI side effects represents a potential therapeutic advantage.

Stru ctu re–Activity Relation sh ips During a search for newer, more effective antiarthritic drugs in the 1970s, the Ayerst group led by Humber investigated a series of pyranocarboxylic acids of the general structure shown below (53,54).

Structure–activity relationship studies indicated that alkyl groups at R 1 and an acetic acid function at R 2 enhanced anti-inflammatory activity. Lengthening the acid chain, or ester or amide derivatives, gave inactive compounds. T he corresponding α-methylacetic acid derivatives also were inactive. Increasing the chain length of the R 1 substituent P.975 to ethyl or n-propyl gave derivatives that were 20 times more potent than methyl. A number of aromatic substituents in the aromatic ring were evaluated, and substituents at the 8-position were most beneficial. Among the most active were the 8-ethyl, 8-n-propyl, and 7-fluoro-8-methyl derivatives. Etodolac was found to possess the most favorable anti-inflammatory to gastric distress properties among these analogues.

Absorption an d Metabol ism Etodolac is rapidly absorbed following oral administration, with maximum serum levels being achieved within 1 to 2 hours, and it is highly bound to plasma proteins (99%) with pK a 4.7. T he penetration of etodolac into synovial fluid is greater than or equal to that of tolmetin, piroxicam, or ibuprofen. Only diclofenac appears to provide greater penetration. Etodolac is metabolized to three hydroxylated metabolites and to glucuronide conjugates, none of which possesses important pharmacological activity. Metabolism appears to be the same in the elderly as in the general population, so no dosage adjustment appears necessary. Etodolac is indicated for the management of the signs and symptoms of osteoarthritis and for the management of pain.

Nabu meton e Nabumetone is unique among the NSAIDs in that it represents a new class of nonacidic pro-drugs, being rapidly

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metabolized after absorption to form a major active metabolite, 6-methoxynaphthaleneacetic acid. It was introduced in the United States in 1992 and is synthesized from 2-acetyl-6-methoxynaphthalene (55). Nabumetone, being nonacidic, does not produce a significant primary insult and is an ineffectual inhibitor of prostaglandin cyclooxygenase in gastric mucosa, thus producing minimum secondary insult. T he result is that gastric side effects of nabumetone appear to be minimized. Once the parent drug enters the circulatory system, however, it is metabolized to an active metabolite, 6-methoxynaphthalene-2-acetic acid (6MNA), which is an effective inhibitor of cyclooxygenase in joints. Nabumetone thus represents a classic example of the prodrug approach in drug design.

Fig. 36.15. Metabolism of nabumetone.

In the carrageenan-induced rat paw assay, nabumetone is approximately 13 times more potent than aspirin, one-third as active as indomethacin, and half as active as diclofenac. It is only half as active as aspirin as an analgetic, as measured by the phenylquinone-induced writhing assay in mice. Despite its lower potency, the advantages of nabumetone may reside in its favorable gastric irritancy profile. T he ratio of gastric irritancy dose in rats to anti-inflammatory activity in rats (ED50) for nabumetone is 21.25, whereas this ratio is 0.41 for aspirin, 0.55 for indomethacin, 0.72 for diclofenac, 3.00 for tolmetin, and 7.85 for zomepirac.

Stru ctu re–Activity Relation sh ips Introduction of methyl or ethyl groups on the butanone side chain greatly reduced anti-inflammatory activity. T he ketone function can be converted to a dioxolane with retention of activity, whereas converting the ketone to an oxime reduced activity. Removal of the methoxy group at the 6-position reduced activity, but replacement of the methoxy with a methyl or chloro group gave active compounds. Replacement of the methoxy with hydroxyl, acetoxy, or N-methylcarbamoyl groups, or positional isomers of the methoxy group at the 2- or 4-positions, greatly reduced activity. T he active metabolite, 6-MNA, is closely related structurally to naproxen, differing only by the lack of an α-methyl group. T he ketone precursor, [4-(6-methoxy-2-naphthyl)pentan-2-one], that would be expected to produce naproxen as a metabolite was inactive in chronic models of inflammation.

Absorption an d Metabol ism Nabumetone is absorbed primarily from the duodenum. Milk and food increase the rate of absorption and the bioavailability of the active metabolite. Plasma concentrations of unchanged drug are too low to be detected in most subjects after oral administration, so most pharmacokinetic studies have involved the disposition of the active metabolite. Pharmacokinetic properties are altered in elderly patients, with higher plasma levels of the active metabolite being noted. Nabumetone undergoes rapid and extensive metabolism in the liver, with a mean absolute bioavailability of the active metabolite of 38%. T he metabolism of nabumetone is illustrated in Figure 36.15. T he major, P.976 most active metabolite is 6MNA, but the initial alcohol metabolite, a minor product, and its esters also possess significant anti-inflammatory properties.

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Fig. 36.16. Structures of aryl- and heteroarylpropionic acid derivatives.

Nabumetone is indicated for the acute and chronic treatment of the signs and symptoms of osteoarthritis and rheumatoid arthritis. T he recommended starting dosage is 1,000 mg as a single dose with or without food. More symptomatic relief of severe or persistent symp-toms may be obtained at doses of 1,500 or 2,000 mg/day.

Aryl- and heteroarylpropionic acids Structures of aryl- and heteroarylpropionic acid derivatives are shown in Figure 36.16.

±-Ibu profen T he synthesis of ibuprofen was originally reported in 1964 from p-isobutylacetophenone (56), but the drug was not marketed in the United States until 1974, despite the fact that it had been available for several years in Europe. It was the first NSAID approved since indomethacin, and was immediately accepted into therapy. Its success precipitated the introduction of many new drugs in the 1970s. T his chemical class currently comprises the largest group of NSAIDs. Ibuprofen became the first prescription NSAID to become available as an OT C analgetic in almost 30 years and is available under a number of brand names. It is marketed as the racemic mixture, although biological activity resides almost exclusively in the S-(+ )-isomer. Ibuprofen is more potent than aspirin but less potent than indomethacin in anti-inflammatory and prostaglandin biosynthesis inhibition assays, and it produces moderate degrees of gastric irritation.

Stru ctu re–Activity Relation sh ips T he substitution of an α-methyl group on the alkanoic acid portion of acetic acid derivatives enhances anti-inflammatory actions and reduces many side effects. For example, the acetic acid analogue of ibuprofen, ibufenac (p-isobutylphenylacetic acid), is less potent and more hepatotoxic than ibuprofen. T he stereochemistry associated with the chiral center in the arylpropionic acids, but lacking in the acetic acid derivatives, plays an important role in both the in vivo and in vitro activities of these drugs. As indicated earlier, although marketed as a racemic mixture, the (+ )-enantiomer of ibuprofen possess greater activity in vitro than the (–)-isomer. T he eudismic (S/R) ratio for the inhibition of bovine prostaglandin synthesis is approximately 160, but in vivo, the two enantiomers are equiactive (see next section on absorption and metabolism). T he (+ )-enantiomer of ibuprofen—and of most of the arylpropionic acids under investigation—has been shown to possess the (S)-absolute configuration.

Absorption an d Metabol ism Ibuprofen is rapidly absorbed on oral administration, with peak plasma levels being generally attained within 2 hours and a duration of action of less than 6 hours. As with most of these acidic NSAIDs, ibuprofen (pK a = 4.4) is extensively bound to plasma proteins (99%) and will interact with other acidic drugs that are protein bound. Metabolism occurs rapidly, and the drug is nearly completely excreted in the urine as unchanged drug and oxidative metabolites within 24 hours following administration (Fig. 36.17). Metabolism by CYP2C9 (90%) and CYP2C19 (10%) involves primarily ω-, and ω 1 -, and ω 2 -oxidation of the p-isobutyl side chain, followed by alcohol oxidation of the

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primary alcohol resulting from ω–oxidation to the corresponding carboxylic acid. All metabolites are inactive. When P.977 ibuprofen is administered as the individual enantiomers, the major metabolite isolated is the S-(+ )-enantiomer whatever the configuration of the starting enantiomer. Interestingly, the R-(–)-enantiomer is inverted to the S-(+ )-enantiomer in vivo via an acetyl–coenzyme A intermediate, accounting for the observation that the two enantiomers are bioequivalent in vivo. T his is a metabolic phenomenon that also has been observed for other arylpropionic acids, such as ketoprofen, benoxaprofen, fenoprofen, and naproxen (57).

Fig. 36.17. Metabolism of ibuprofen.

Ibuprofen is indicated for the relief of the signs and symptoms of rheumatoid arthritis and osteoarthritis, the relief of mild to moderate pain, the reduction of fever, and the treatment of dysmenorrhea.

±-Fenoprofen Calcium T he calcium and sodium salts of fenoprofen possess similar bioavailability, distribution, and elimination characteristics. It is the calcium salt that is marketed, however, because it has the advantage of being less hygroscopic. Its original synthesis was reported in 1970 (58), and it was marketed in the United States in 1976. Fenoprofen is less potent in anti-inflammatory assays than ibuprofen, indomethacin, ketoprofen, or naproxen. As an inhibitor of prostaglandin biosynthesis, it is much less potent than indomethacin, more potent than aspirin, and about equipotent with ibuprofen. It also possesses analgetic and antipyretic activity. It possesses other pharmacological properties, such as inhibition of phagocytic and complement functions and stabilization of lysosomal membranes. Fenoprofen is marketed as a racemic mixture, because no differences have been observed in the in vivo anti-inflammatory or analgetic properties of the individual enantiomers. T he ability of R-(–)-arylpropionic acids to undergo inversion to the S-(+ )-enantiomers, however, may be involved. Like other NSAIDs, in vitro prostaglandin

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synthesis assays indicate that the S-(+ )-enantiomer is more potent than the R-(–)-isomer.

Stru ctu re–Activity Relation sh ips Placing the phenoxy group in the ortho- or para-position of the arylpropionic acid ring markedly decreases activity. Replacement of the oxygen bridge between the two aromatic rings with a carbonyl group yields an analogue (ketoprofen) that also is marketed.

Absorption an d Metabol ism Fenoprofen is readily absorbed (85%) on oral administration and is highly bound (99%) to plasma proteins. Peak plasma levels are attained within 2 hours of administration. T he free acid has a pK a of 4.5, which is within the range of the other arylalkanoic acids. Fenoprofen is rather extensively metabolized, primarily through glucuronide conjugation with the parent drug and the CYP2C9 4′-hydroxy metabolite. Fenoprofen calcium is indicated for treatment of rheumatoid arthritis and osteoarthritis and for the relief of mild to moderate pain.

±-Ketoprofen Ketoprofen (Fig. 36.10) was introduced in 1986 and was synthesized from 2-(p-amino- phenyl)propionic acid via a thiaxanthone intermediate (59). Ketoprofen, unlike many NSAIDs, inhibits the synthesis of leukotrienes and leukocyte migration into inflamed joints in addition to inhibiting the biosynthesis of prostaglandins. It stabilizes the lysosomal membrane during inflammation, resulting in decreased tissue destruction. Antibradykinin activity also has been observed. Bradykinin is released during inflammation and can activate peripheral pain receptors. In addition to anti-inflammatory activity, ketoprofen also possesses antipyretic and analgetic properties. Although it is less potent than indomethacin as an anti-inflammatory agent and an analgetic, its ability to produce gastric lesions is about the same (60).

Absorption an d Metabol ism Ketoprofen is rapidly and nearly completely absorbed on oral administration, reaching peak plasma levels within 0.5 to 2 hours. It is highly plasma protein bound (99%) despite a lower acidity (pK a = 5.9) than some other NSAIDs. Wide variation in plasma half-lives has been reported. It is metabolized by glucuronidation of the carboxylic acid, CYP3A4 and CYP2C9 hydroxylation of the benzoyl ring, and reduction of the keto function. Ketoprofen is indicated for the long-term management of rheumatoid arthritis and osteoarthritis, for mild to moderate pain, and for primary dysmenorrhea.

Naproxen Naproxen is synthesized from 2-methoxynaphthalene and the (+ )-isomer obtained by resolution with cinchonidine (61). It was introduced in the United States in 1976 and, as a generic drug, has consistently been among the more popular NSAIDs. It is marketed as the S-(+ )-enantiomer, but interestingly, the sodium salt of the (–)-isomer also is on the market as Anaprox. As an inhibitor of prostaglandin biosynthesis, it is 12 times more potent than aspirin, 10 times more potent than phenylbutazone, three to four times more potent than ibuprofen, and four times times more potent than fenoprofen, but it is approximately 300 times less potent than indomethacin. In vivo anti-inflammatory assays are consistent with this relative order of potency. In the carrageenan-induced rat paw edema assay, it is 11 times more potent than phenylbutazone and 55 times as potent as aspirin, but only 0.7 times as potent as indomethacin. In the phenylquinone writhing assay for analgesia, it is nine times as potent as phenylbutazone and seven times as potent as aspirin, but only 10% as potent as indomethacin. In the yeast-induced pyrexia assay for antipyretic activity, it is seven times as potent as phenylbutazone, 22 times as potent as aspirin, and 1.2 times as potent as indomethacin. T he order of gastric ulcerogenic activity is sulindac < naproxen < aspirin, indomethacin, ketoprofen, and tolmetin.

Stru ctu re–Activity Relation sh ips In a series of substituted 2-naphthylacetic acids, substitution in the 6-position led P.978 to maximum anti-inflammatory activity. Small lipophilic groups, such as Cl, CH 3 S, and CHF 2 O, were active analogues, with CH 3 O being the most potent. Larger groups were found to be less active. Derivatives of 2-naphthylpropionic acids are more potent than the corresponding acetic acid analogues. Replacing the carboxyl group with functional groups capable of being metabolized to the carboxyl function (e.g., —CO 2 CH 3 , —CHO, or —CH 2 OH) led to a retention of activity. T he S-(+ )-isomer is the more potent enantiomer. Naproxen is the only arylalkanoic acid NSAID currently marketed as optically active isomers.

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Absorption an d Metabol ism Naproxen is almost completely absorbed following oral administration. Peak plasma levels are achieved within 2 to 4 hours following administration. Like most of the acidic NSAIDs (pK a = 4.2), it is highly bound (99.6%) to plasma proteins. Approximately 70% of an administered dose is eliminated as either unchanged drug (60%) or as conjugates of unchanged drug (10%). T he remainder is converted to the 6-O-desmethyl metabolite by both CYP3A4 and CYP1A2 and, further, to the glucuronide conjugate of the demethylated metabolite. T he 6-O-desmethyl metabolite lacks anti-inflammatory activity. Like most of the arylalkanoic acids, the most common side effect associated with the use of naproxen is irritation to the GI tract. T he most common other adverse reactions are associated with CNS disturbances (e.g., nausea and dizziness). Naproxen is indicated for the treatment of rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendinitis, bursitis, acute gout, and primary dysmenorrhea and for the relief of mild to moderate pain.

±-Suprofen Suprofen is a white, microcrystalline powder that is slightly soluble in water. It was originally synthesized from thiophene in 1974 (62) and was introduced in the United States in 1985 for the treatment of dysmenorrhea and as an analgetic for mild to moderate pain. Reports of severe flank pain and transient renal failure appeared, however, with the syndrome being noted abruptly within several hours after one or two doses of the drug; therefore, suprofen was removed from the U.S. market in 1987. Obviously, clinical trials are not always sufficient to determine a drug's safety, and postmarketing surveillance becomes most important. Suprofen was reintroduced in the United States in 1990 as a 1% ophthalmic solution for the prevention of surgically induced miosis during cataract extraction. Miosis complicates the removal of lens material and implantation of a posterior chamber intraocular lens that thus increases the risk of ocular trauma. T he mechanism of action also involves inhibition of prostaglandin synthesis, because prostaglandins constrict the iris sphincter independent of a cholinergic mechanism. Additionally, prostaglandins also break down the blood-aqueous barrier, allowing the influx of plasma proteins into aqueous humor, resulting in an increase in intraocular pressure.

±-Flu rbiprofen Flurbiprofen (Fig. 36.10) synthesis was originally reported in 1974 (63). During a study of the pharmacological properties of a large number of substituted phenylalkanoic acids, including ibuprofen and ibufenac, the most potent were found to be substituted 2-(4-biphenyl)propionic acids. Further toxicological and pharmacological studies indicated that flurbiprofen possessed the most favorable therapeutic profile, so it was selected for further clinical development. It was not marketed until 1987, when it was introduced as the sodium salt as Ocufen, the first topical NSAID indicated for ophthalmic use in the United States. T he indication for Ocufen is the same as that for Profenal—that is, to inhibit intraoperative miosis induced by prostaglandins in cataract surgery. T hus, flurbiprofen is an inhibitor of prostaglandin synthesis. T he oral form was introduced in 1988 as Ansaid (another non-steroidal anti-inflammatory drug) and gained immediate acceptance. In acute inflammation assays in adrenalectomized rats, flurbiprofen was found to be 536-fold more potent than aspirin and 100-fold more potent than phenylbutazone. Orally, it was half as potent as methylprednisolone. As an antipyretic, it was 403 times as potent as aspirin in the yeastinduced fever assay in rats and was 26 times more potent than ibuprofen as an antinociceptive.

Absorption an d Metabol ism Flurbiprofen is well absorbed after oral administration, with peak plasma levels being attained within 1.5 hours. Food alters the rate of absorption but not the extent of its bioavailability. It is extensively bound to plasma proteins (99%)

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and has a plasma half-life of 2 to 4 hours. Metabolism is extensive, with 60 to 70% of flurbiprofen and its metabolites being excreted as sulfate and glucuronide conjugates. Flurbiprofen shows some interesting metabolic patterns, with 40 to 47% as the 4′-hydroxy metabolite, 5% as the 3′,4′-dihydroxy metabolite, 20 to 30% as the 3′-hydroxy4′-methoxy metabolite, and the remaining 20 to 25% of the drug being excreted unchanged. None of these metabolites demonstrates significant anti-inflammatory activity. T he metabolism of flurbiprofen is presented in Figure 36.18. Flurbiprofen is indicated as an oral formulation for the acute or long-term treatment of rheumatoid arthritis and osteoarthritis and as an ophthalmic solution for the inhibition of intraoperative miosis.

Ketorolac T romethami ne Ketorolac (Fig. 36.10) represents a cyclized, heteroarylpropionic acid derivative, with the α-methyl group being fused to the pyrrole ring. It was introduced in 1990 and is indicated as a peripheral analgetic for P.979 short-term use and for the relief of ocular itching caused by seasonal allergic conjunctivitis, although it exhibits anti-inflammatory and antipyretic activity as well. It was initially introduced only in an injectable form, but recently, an oral formulation has been made available. Its analgetic activity resembles that of the centrally acting analgetics, with 15 to 30 mg of ketorolac producing analgesia equivalent to a 12-mg dose of morphine, and it has become a widely accepted alternative to narcotic analgesia. Ketorolac inhibits prostaglandin synthesis. Although the analgetic effect is achieved within 10 minutes of injection, peak analgesia lags behind peak plasma levels by 45 to 90 minutes. T he free acid has a pK a of 3.5, and it is not surprising that it is highly plasma protein bound (> 99%). Ketorolac is metabolized by CYP2C9 to its p-hydroxy derivative and to conjugates that are excreted primarily in the urine.

Fig. 36.18. Metabolism of flurbiprofen.

Oxaprozin Oxaprozin (Fig. 36.10) was marketed in 1993 for acute and long-term use in the management of signs and symptoms of osteoarthritis and rheumatoid arthritis. Oxaprozin is synthesized by condensing benzoin with succinic anhydride and cyclizing the resulting benzoin hemisuccinate with ammonium acetate. Although not formally a propionic acid of the α-methylacetic acid type, it appears to be similar to the other propionic acid derivatives considered here. Oxaprozin is well absorbed (100%) following oral administration, but maximum plasma concentrations are not reached until 3 to 5 hours following ingestion. Oxaprozin is an anti-inflammatory agent possessing a rapid onset of action and a prolonged duration of action. In both the carrageenan raw paw edema assay and analgetic tests, it was equipotent with aspirin. Oxaprozin has been associated with the appearance of rash and/or mild photosensitivity. Some patients experience an increased incidence of rash on sun-exposed skin during clinical testing. Oxaprozin, aspirin, ibuprofen, indomethacin, naproxen, and sulindac have comparable efficacy in the treatment of rheumatoid arthritis, whereas oxaprozin, aspirin, naproxen, and piroxicam have comparable efficacy in osteoarthritis. It is highly bound to plasma proteins (99%), is highly lipophilic, and undergoes little first-pass metabolism. Metabolism is via hepatic microsomal

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oxidation and glucuronidation. Active phenolic metabolites are produced (< 5%) but do not appear to contribute significantly to the overall pharmacological activity of oxaprozin. Oxaprozin possesses a relatively long elimination half-life of 59 hours (range, 26–92 hours), enabling once-daily dosing. Administration with food appears to delay absorption but not bioavailability. Several properties of the NSAIDs are summarized in T able 36.4.

N-Arylanthranilic Acids (Fenamic Acids) T he anthranilic acid class of NSAIDs is the result of the application of classical medicinal chemistry bio-isosteric drug design concepts, because these derivatives are nitrogen isosteres of salicylic acid. In the early 1960s, the Parke-Davis research group reported the development of a series of N-substituted anthranilic acids that have since been given the chemical class name of fenamic acids. T he fact that this class of compounds possesses little advantage over the salicylates with respect to their anti-inflammatory and analgetic properties has diminished interest in their large-scale development relative to the arylalkanoic acids. Mefenamic acid was introduced in the United States in 1967 as an analgetic, and this remains the primary indication despite the fact that it possesses modest anti-inflammatory activity. Flufenamic acid has been available in Europe as an antirheumatic agent, but there are no apparent plans to introduce this drug in the United States. With regard to anti-inflammatory activity, mefenamic acid is approximately 1.5 times as potent as phenylbutazone and half as potent as flufenamic acid. Meclofenamic acid was introduced in the United States as its sodium salt in 1980, primarily as an antirheumatic agent and analgetic. T he structures of these fenamic acids are shown in Figure 36.19. T he fenamic acids share a number of pharmacological properties with the other NSAIDs. Because these drugs are potent inhibitors of prostaglandin biosynthesis, it is tempting to speculate that this represents their primary mechanism of action. Scherrer, like Shen, had proposed a hypothetical receptor for NSAIDs and later modified (64) the receptor to represent the active site of arachidonic acid cyclooxygenase. Structurally, the fenamic acids fit the proposed active site of arachidonic acid cyclooxygenase proposed by Shen (12) (Fig. 36.1), because they possess an acidic function connected to an aromatic ring along with an additional lipophilic binding site—in this case, the N-aryl substituent. T he greater anti-inflammatory activity of meclofenamic acid compared to that of mefenamic acid correlates well with its ability to inhibit prostaglandin synthesis. Scherrer (65) compared the in vivo anti-inflammatory activities, clinical P.980 anti-inflammatory doses in humans, and the in vitro inhibition of prostaglandin synthesis activities of mefenamic acid, meclofenamic acid, phenylbutazone, indomethacin, and aspirin and suggested an important role of prostaglandin synthesis inhibition in the production of therapeutic effects of the fenamic acids.

Table 36.4. Some Properties of the NSAIDs

Drug

Onset Peak Protein Year Anti-inflammatory (Duration) Plasma binding Biotransformation Introduced Dose (mg) of Action Levels (h) (%)

Aspirin

1899

3200–6000

ND

2

90

Plasma hydrolysis and hepatic

Diclofenac (Voltaren)

1989

100–200

30 min (~8 h)

1.5–2.5

99

Hepatic; first-pass metabolism: 3A4

Diflunisal (Dolobid)

1982

500–1000

1h (8–12 h)

2–3

99

Hepatic

Etodolac (Lodine)

1991

800–1200

30 min (4–6 h)

1–2

99

Hepatic : 2C9

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Fenoprofen Ca (Nalfon)

1976

1200–2400

NR

2

99

Hepatic :2C9

Flurbiprofen (Ansaid)

1988

200–300

NR

1.5

99

Hepatic : 2C9

Ibuprofen (Motrin, Advil)

1974

1200–3200

30 min (4–6h)

2

99

Hepatic; first-pass

Indomethacin (Indocin)

1965

75–150

2–4 h (2–3 d)

2–3

97

Hepatic : 2C9

Ketoprofen (Orudis)

1986

150–300

NR

0.5–2

99

Hepatic :2c9, 3A4

Meclofenamate Na (Meclomen)

1980

200–400

1h (4–6h)

4.0

99

Hepatic :2C9

Mefenamic acid (Ponstel)

1967

1000

NR

2–4

79

Hepatic: 2C9

Meloxicam (Mobic)

2000

7.5–15

NR

4–5

99

Hepatic 2C9

Nabumetone* (Relafen)

1992

1500–2000

NR

2.5 (1–8) 6-MNA

99**

Hepatic; first-pass metabolism to 6-MNA

Naproxen (Naprosyn, Anaprox)

1976

500–1000

NR

2–4

99

Hepatic: 3A4, 1A2

Oxaprozin (Daypro)

1993

1200

NR

3–5

99

Hepatic: 2C9

Piroxicam (Feldene)

1982

20

2–4 h (24 h)

2

99

Hepatic: 2C9

Sulindac* (Clinoril)

1978

400

NR

2–4

93

Hepatic; sulfide metabolite active

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Tolmetin (Tolectin)

1976

1200

NR

2′ ≫ 4′ for monosubstitution, with the 3′-CF 3 derivative (flufenamic acid) being particularly potent.

T he opposite order of activity was observed, however, in the rat paw edema assay, with the 2′-Cl derivative being P.981 more potent than the 3′-Cl analogue. In disubstituted derivatives, in which the nature of the two substituents is the same, 2′,3′-disubstitution appears to be the most effective. A plausible explanation may be found in an examination of the proposed topography of the active sites of arachidonic acid cyclooxygenase using either the Shen or Sherrer models. Proposed binding sites include a hydrophobic trough to which a lipophilic group, noncoplanar with the ring bearing the carboxylic acid function, binds. Substituents on the N-aryl ring that force this ring to be noncoplanar with the anthranilic acid ring should enhance binding at this site and, thus, activity. T his may account for the enhanced

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anti-inflammatory activity of meclofenamic acid, which has two ortho-substituents forcing this ring out of the plane of the anthranilic acid ring, over flufenamic acid (no ortho-substituents) and mefenamic acid (one ortho-substituent). Meclofenamic acid possesses 25 times greater anti-inflammatory activity than mefenamic acid. T he NH-moiety of anthranilic acid appears to be essential for activity, because replacement of the NH function with O, CH 2 , S, SO 2 , N-CH 3 , or N-COCH 3 functionalities significantly reduces activity. Finally, the position, rather than the nature, of the acidic function is critical for activity. Anthranilic acid derivatives are active, whereas the m- and p-aminobenzoic acid analogues are not. Replacement of the carboxylic acid function with the isosteric tetrazole moiety has little effect on activity.

Drug interactions T he pK a values of the N-arylanthranilic acids (4.0–4.2) resemble those of the arylalkanoic acids; thus, it is not surprising that they are strongly bound to plasma proteins and that interactions with other highly protein bound drugs are very probable. T he most common interactions reported are those of mefenamic acid and meclofenamic acid with oral anticoagulants. Concurrent administration of aspirin results in a reduction of plasma levels of meclofenamic acid.

Specific drugs Mefen amic Acid Mefenamic acid is synthesized from o-chlorobenzoic acid and 2,3-dimethylaniline under catalytic conditions (66). Mefenamic acid is the only fenamic acid derivative that produces analgesia centrally and peripherally. Mefenamic acid is indicated for the short-term relief of moderate pain and for primary dysmenorrhea. Mefenamic acid is absorbed rapidly following oral administration, with peak plasma levels being attained within 2 to 4 hours. It is highly bound to plasma proteins (78.5%) and has a plasma half-life of 2 to 4 hours. Metabolism occurs through regioselective oxidation of the 3′-methyl group and glucuronidation of mefenamic acid and its metabolites. Urinary excretion accounts for approximately 50 to 55% of an administered dose, with unchanged drug accounting for 6%, the 3′-hydroxymethyl metabolite (primarily as the glucuronide) accounting for 25%, and the remaining 20% as the dicarboxylic acid (of which 30% is the glucuronide conjugate) (Fig. 36.20). T hese metabolites are essentially inactive.

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Fig. 36.20. Metabolism of mefenamic acid.

Meclofenamate Sodium Meclofenamate sodium is rapidly and almost completely absorbed following oral administration, reaching peak plasma levels within 2 hours. It is highly bound to plasma proteins (99%) and has a plasma half-life of 2 to 4 hours. Metabolism involves oxidation of the methyl group, aromatic hydroxylation, monodehalogenation, and conjugation. Urinary excretion accounts for approximately 75% of the administered dose. T he major metabolite is the product of 3′-methyl oxidation and has been shown to possess anti-inflammatory activity (Fig. 36.21). Meclofenamate sodium is indicated for the relief of mild to moderate pain, the acute and chronic treatment of rheumatoid arthritis and osteoarthritis, the treatment of primary dysmenorrhea, and the treatment of idiopathic, heavy menstrual blood loss.

Oxicams T he enolic acid class of NSAIDs has been termed “ oxicams” by the U.S. Adopted Name Council to describe the P.982 series of 4-hydroxy-1,2-benzothiazine carboxamides that possess anti-inflammatory and analgetic properties. T hese structurally distinct substances resulted from extensive studies by the Pfizer group in an effort to produce noncarboxylic acid, potent, and well-tolerated anti-inflammatory drugs. Several series were prepared, including 2-aryl-1,3-indanediones, 2-arylbenzothiophen-3-(2H)-one 1,1-dioxides, dioxoquinoline-4-carboxamides, and 3-oxa2H-1,2-benzothiazine-4-carboxamide 1,1-dioxides, and evaluated. T hese results, combined with the previously known activity of 1,3-dicarbonyl derivatives, such as phenylbutazone, led to the development of the oxicams. T he first member of this class, piroxicam, was introduced in the United States in 1982 as Feldene and gained immediate acceptance.

Fig. 36.21. Metabolism of meclofenamic acid.

Piroxicam is potent in standard in vivo assays, being 200 times more potent than aspirin and at least 10 times as potent as any other standard agent in the ultraviolet erythema assay, as potent as indomethacin and more potent than phenylbutazone or naproxen in the carrageenan-induced rat paw edema assay, and equipotent with indomethacin and 15 times more potent than phenylbutazone in the rat adjuvant arthritis assay. It is less potent than indomethacin, equipotent with aspirin, and more potent than fenoprofen, ibuprofen, naproxen, and phenylbutazone as an analgetic in the phenylquinone writhing assay. Piroxicam inhibits the migration of polymorphonuclear cells into inflammatory sites and inhibits the release of lysosomal enzymes from these cells. It also inhibits collagen-induced platelet aggregation. It is an effective inhibitor of arachidonic acid cyclooxygenase, being almost equipotent with indomethacin and more potent than ibuprofen, tolmetin, naproxen, fenoprofen, phenylbutazone, and aspirin in the inhibition of prostaglandin biosynthesis by methylcholanthrene-transformed mouse fibroblasts (MC-5) assay. A template for designing anti-inflammatory compounds based on CPK space-filling models of the peroxy radical precursor of PGG and inhibitors of cyclooxygenase was proposed (67), and the ability of oxicams, particularly piroxicam, to inhibit this enzyme was subsequently rationalized on the ability of oxicams to assume a conformation resembling that of the peroxy radical precursor (68).

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Approximately 20% of individuals on piroxicam report adverse reactions. Not unexpectedly, the greatest incidence of side effects result from GI disturbances. T he reported incidence of peptic ulcers, however, is less than 1%. As will be discussed later, a new oxicam derivative, meloxicam, has been approved as a selective COX-2 inhibitor for the treatment of osteoarthritis.

General structure–activity relationships Within the series of 4-hydroxy-1,2-benzothiazine carboxamides represented by the general structure shown below, optimum activity was observed when R 1 was a methyl substituent. T he carboxamide substituent, R, generally is an aryl or heteroaryl substituent, because alkyl substituents are less active. Oxicams are acidic compounds, with pK a values in the range of four to six. N-heterocyclic carboxamides generally are more acidic than the corresponding N-aryl carboxamides, and this enhanced acidity was attributed (69) to stabilization of the enolate anion by the pyridine nitrogen atom, as illustrated in tautomer A and additional stabilization by tautomer B:

T his explains the observation that primary carboxamides are more potent than the corresponding secondary derivatives, because no N-H bond would be available to enhance the stabilization of the enolate anion. When the aryl group is o-substituted, variable results were obtained, whereas m-substituted derivatives generally are more potent than the corresponding p-isomers. In the aryl series, maximum activity is observed with a m-Cl substituent. No direct correlations were observed between acidity and activity, partition coefficient, and electronic or spatial properties in this series. T wo major differences, however, are observed when R = heteroaryl rather than aryl: T he pK a values generally are two to four units lower, and anti-inflammatory activity increased as much as sevenfold. T he greatest activity is associated with the 2-pyridyl (as in piroxicam), 2-thiazolyl, or 3-(5-methyl) isoxazolyl ring systems, with the latter derivative (isoxicam) having been withdrawn from the European market in 1985 following several reports of severe skin reactions. In addition to possessing activity equal to or greater than indomethacin in the carrageenaninduced rat paw edema assay, the heteroaryl carboxamides also possess longer plasma half-lives, providing an improvement in dosing scheduling regimens.

General metabolism Although the metabolism of piroxicam varies quantitatively from species to species, qualitative similarities are found in the metabolic pathways of humans, rats, dogs, and rhesus monkeys. It is extensively metabolized in humans, with

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less than 5% of an administered dose being excreted unchanged. T he major metabolites in humans result from CYP2C9 hydroxylation of the pyridine ring and subsequent glucuronidation; other metabolites are of lesser importance P.983 (Fig. 36.22). Aromatic hydroxylation at several positions of the aromatic benzothiazine ring also occurs; two hydroxylated metabolites have been extracted from rat urine. On the basis of NMR deuterium-exchange studies, hydroxylation at the 8-position was ruled out, indicating that hydroxylation occurs at two of the remaining positions. Other novel metabolic reactions occur. Cyclodehydration gave a tetracyclic metabolite (the major metabolite in dogs), whereas ring contraction following amide hydrolysis and decarboxylation eventually yields saccharin. All the known metabolites of piroxicam lack anti-inflammatory activity. For example, the major human metabolite is 1,000-fold less effective as an inhibitor of prostaglandin biosynthesis than piroxicam itself. Related oxicams undergo different routes of metabolism. For example, sudoxicam (the N-2-thiazolyl analogue) undergoes primarily hydroxylation of the thiazole ring, followed by ring-opening, whereas isoxicam undergoes primarily cleavage reactions of the benzothiazine ring.

Fig. 36.22. Metabolism of piroxicam.

Drug interactions Few reports of therapeutically significant interactions of oxicams with other drugs have appeared. Concurrent administration of aspirin has been shown to reduce piroxicam plasma levels by approximately 20%, whereas the anticoagulant effect of acenocoumarin is potentiated, presumably as a result of plasma protein displacement.

Speci fic Drugs Piroxicam Prixoicam is synthesized by ring-expansion reactions of saccharin derivatives (70). Piroxicam is readily absorbed on oral administration, reaching peak plasma levels in approximately 2 hours. Peak plasma levels appear to be lower when given with food at low doses (30 mg), with no differences appearing with a 60-mg dose, but in general, food does not markedly affect bioavailability. Being acidic (pK a = 6.3), it is highly bound to plasma proteins (99%). Piroxicam possesses an extended plasma half-life (38 hours), making single daily dosing possible. Piroxicam is indicated for long-term use in rheumatoid arthritis and osteoarthritis.

Meloxicam In April 2000, the U.S. FDA approved meloxicam for the treatment of osteoarthritis. When meloxicam was initially

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introduced in the United Kingdom, it was promoted as a selective COX-2 inhibitor. Meloxicam, however, is less selective than celecoxib and much less selective than rofecoxib in in vitro studies (see Selective COX-2 Inhibitors). Meloxicam is readily absorbed when administered orally and is highly bound to plasma proteins. Meloxicam is extensively metabolized in the liver, primarily by CYP2C9 and, to a lesser extent, by CYP3A4. T he advantages of meloxicam over celecoxib and rofecoxib in the treatment of osteoarthritis (or rheumatoid arthritis) are not readily apparent.

Gastroenteropathy Induced By Nonselective COX NSAIDs T he effectiveness and popularity of the NSAIDs in the United States and Europe make this class one of the most commonly used classes of therapeutic entities. More than 75 million prescriptions are written annually for the NSAIDs, including aspirin. Unfortunately, until the introduction of the selective COX-2 inhibitors, almost all of the current drugs, which are nonselective COX-1 and COX-2 inhibitors, share the undesirable property of producing damaging effects to gastric and intestinal mucosa, resulting in erosion, ulcers, and GI bleeding, and these represent the major adverse reactions to the use of NSAIDs. As many as 20,000 deaths and 100,000 hospitalizations per year have been associated with GI complications resulting from the use of NSAIDs. Approximately 30 to 40% of patients taking NSAIDs report some type of gastric injury, and approximately 10% discontinue therapy because of these effects. T hese acute and chronic injuries to gastric mucosa result in a variety of lesions referred to as NSAID gastropathy, which differs from peptic ulcer disease by their localization more frequently in the stomach rather than in the duodenum. Additionally, NSAID-induced lesions occur more frequently in the elderly than typical peptic ulcers do. Normally, the stomach protects itself from the harmful effects of hydrochloric acid and pepsin by a number of protective mechanisms referred to as the gastric mucosal barrier, which consists of epithelial cells, the P.984 mucous and bicarbonate layer, and mucosal blood flow. Gastric mucosa actually is a gel consisting of polymers of glycoprotein, which limit the diffusion of hydrogen ions. T hese polymers reduce the rate at which hydrogen ions (produced in the lumen) and bicarbonate ion (secreted by the mucosa) mix; thus, a pH gradient is created across the mucus layer. Normally, gastric mucosal cells are rapidly repaired when they are damaged by factors such as food, ethanol, or acute ingestion of NSAIDs. Among the cytoprotective mechanisms is the ability of prostaglandins of the PGE series, particularly PGE 1 , to increase the secretion of bicarbonate ion and mucus and to maintain mucosal blood flow. T he prostaglandins also decrease acid secretion, permitting the gastric mucosal barrier to remain intact. As mentioned earlier, Figure 36.7 illustrates the ability of aspirin and NSAIDs to induce gastric damage by a dual-insult mechanism. Aspirin and the NSAIDs are acidic substances that can damage the GI tract, even in the absence of hydrochloric acid, by changing the permeability of cell membranes, allowing a back diffusion of hydrogen ions. T hese weak acids remain un-ionized in the stomach, but the resulting lipophilic nature of these substances allows accumulation or concentration in gastric mucosal cells. Once inside these cells, however, the higher pH of the intracellular environment causes the acids to dissociate and become “ trapped” within the cells. T he permeability of the mucosal cell membrane is thus altered, and the accumulation of hydrogen ions causes mucosal cell damage. T his gastric damage is a result, therefore, of the primary insult of acidic substances. As detailed earlier in this chapter, the primary mechanism of action of the NSAIDs is to inhibit the biosynthesis of prostaglandins at the cyclooxygenase step. T he resulting nonselective inhibition of prostaglandin biosynthesis in the GI tract prevents the prostaglandins from exerting their protective mechanism on gastric mucosa; thus, the NSAIDs induce gastric damage through this secondary insult mechanism. T he use of PGE 1 to reduce NSAID-induced gastric damage is limited by the fact that it is ineffective orally and degrades rapidly on parenteral administration, primarily by oxidation of the 15-hydroxy group. T o overcome these limitations, misoprostol was synthesized as a prostaglandin pro-drug analogue in which oral activity was achieved by

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administering the drug as the methyl ester, allowing the bioactive acid to be liberated after absorption. Oxidation of the 15-hydroxy group was overcome by moving the hydroxy group to the 16-position, thus “ fooling” the enzyme prostaglandin 15-OH dehydrogenase. Oxidation was further limited by the introduction of a methyl group at the 16-position, producing a tertiary alcohol that is more difficult to oxidize than the secondary alcohol group of the prostaglandins. Misoprostol was introduced in 1989 as a mixture of stereoisomers at the 16-position as Cytotec for the prevention of NSAID-induced gastric ulcers (but not duodenal ulcers) in patients at high risk of complications from a gastric ulcer, particularly the elderly and patients with concomitant debilitating disease and in individuals with a history of gastric ulcers.

Selectiv e COX-2 Inhibitors As previously discussed, the most notable achievement in the development of NSAIDs has been in the area of selective COX-2 inhibitors (coxibs). Classical NSAIDs share similar side effect profiles, particularly on the GI tract, many of which have been attributed to the inhibition of cyclooxygenase, the rate-limiting step in prostaglandin biosynthesis. With the discovery of two isoforms of cyclooxygenase, COX-1 and COX-2, and the realization that COX-1 is beneficial in maintaining normal processes in the GI tract by producing cytoprotective prostaglandins, stimulating bicarbonate secretion and mucus and producing an overall reduction in acid secretion, the search for drugs that selectively inhibit the COX-2 isoform has received much attention. T he traditional NSAIDs inhibit COX-1, COX-2, and thromboxane synthetase to varying degrees of selectivity. Decreased gastric mucosal protection (resulting in an enhanced risk of ulceration) and stress-induced decreased renal perfusion result from nonselective inhibition of COX, whereas inhibition of thromboxane synthesis results in increased prostaglandin synthesis and a reduction in platelet aggregation and, thus, an increased bleeding tendency. T hose NSAIDs with a greater selectivity for COX-1 generally cause greater GI bleeding and renal toxicity than those with greater selectivity for COX-2.

T hese early studies led to extensive efforts by many laboratories to develop selective inhibitors of the COX-2 isoform with the goal of developing an “ ideal” NSAID—that is, one that selectively inhibits COX-2, thus reducing the inflammatory response but not interfering with the GI-protective functions of COX-1. T wo early lead compounds were developed, NS-398 and DuP 697, which have served as the basis of the development of two widely explored chemical classes. NS-398 and nimesulide are the prototypes of compounds known as “ sulides,” P.985 whereas DuP 697 is the prototype of a class of COX-2 inhibitors termed “ coxibs.” T hese efforts led to the introduction of three selective COX-2 inhibitors in the U.S. market (celecoxib, rofecoxib, and valdecoxib), whereas

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other selective inhibitors under investigation may have been halted (Fig. 36.23). An excellent review of the various chemical classes of selective COX-2 inhibitors has been published (71). Selective COX-2 inhibitors were designed to take advantage of the much larger NSAID binding site on COX-2 compared to the NSAID binding site on COX-1, resulting from the substitution of the smaller amino acid valine in COX-2 for isoleucine at position 523 in COX-2 (see earlier discussion). In COX-1, the larger isoleucine residue near the active site restricts access by larger, relatively rigid side-chain substituents, such as sulfamoyl or sulfonyl side chains usually seen in the selective COX-2 inhibitors.

Fig. 36.23. Structures of selective COX-2 inhibitors.

A comparison of the selectivity of several NSAIDs and selective COX-2 inhibitors was recently presented (Fig. 36.24) (72). In another study regarding the pharmacological and biochemical profile of a new investigational selective COX-2 inhibitor, etoricoxib, the following comparison of COX-1/COX-2 selectivity for several selective and nonselective inhibitors in human whole blood assays was reported (T able 36.5) (73). T he U.S. FDA classifies only celecoxib, rofecoxib, and valdecoxib as selective COX-2 inhibitors. It classifies all other NSAIDs as nonselective. Perhaps as interesting as the role that COX-2 selective inhibitors play in reducing the incidence of GI side effects among NSAIDs are the reports of other potential therapeutic uses for this new class of drugs, including potential use in the treatment of Alzheimer's disease and carcinomas of various types. T he COX-2 appears to be induced in inflammatory plaques that are evident in the CNS in Alzheimer's disease. Several reports have appeared indicating that patients taking NSAIDs have a lower incidence and a decreased rate of progression of Alzheimer's disease. Epidemiological studies suggest a significant reduction in the risk for colon cancer in patients regularly taking aspirin. Additionally, NSAIDs have been reported to reduce the growth rate of polyps in the colon in humans as well as the incidence of tumors of the colon in animals. T he expression of COX-2 appears to be significantly up-regulated in carcinoma of the colon. T he effectiveness of NSAIDs in the prevention and treatment of other cancers, such as prostate cancer and mammary carcinoma, has been reported as well. P.986 T his effectiveness is more noticeable among COX-2 selective drugs.

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Fig. 36.24. Selectivity of COX-2 inhibitors and NSAIDs given as log inhibitory concentration (IC80) ratio. The “0” line indicates equipotency. (Adapted from Warner TD, Giuliano F, Vojnovic I, et al. Nonsteroid drug selectivities for cyclooxygenase-1 rather than cyclooxygenase-2 are associated with human gastrointestinal toxic-ity: a full in vitro analysis. Proc Natl Acad Sci U S A 1999;96:7563–7568; with permission.)

Table 36.5. A Comparison of IC50 (µM ) Binding Constants for Selective Versus Nonselective COX Inhibitors Drug

COX-1 COX-2 COX-1/COX-2 Ratio

Etoricoxib

116

1.1

106

Rofecoxib

18.8

0.53

35

Valdecoxib

26.1

0.87

30

Celecoxib

6.7

0.87

7.6

Nimesulide

4.1

0.56

7.3

Diclofenac

0.15

0.05

3.0

Etodolac

9.0

3.7

2.4

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Meloxicam

1.4

0.70

2.0

Indomethacin

0.19

0.44

0.4

Ibuprofen

4.8

24.3

0.2

6MNA

28.9

154

0.2

Piroxicam

0.76

9.0

0.08

6MNA, 6-methoxynaphthalene-2-acetic acid.

Despite the promise of therapeutic effectiveness of the selective COX-2 inhibitors, the potential for severe cardiovascular effects prompted a critical review of these drugs. T his concern was initiated through the revelation of long-term clinical trials of rofecoxib that indicated an increased risk of heart attack. One study completed in 2000, named VIGOR (74), showed an increased risk of myocardial infarction. A later retrospective analysis (75) of 1.4 million patients showed that daily rofecoxib doses of greater than 25 mg increased the risk of heart problems by 3.6-fold as compared with older NSAIDs. T he coxibs were found (76) to suppress the formation of PGI2 , which may result in elevated blood pressure and accelerated atherogenesis as well as predisposing patients on coxib therapy to a heightened thrombotic response on the rupture of an atherosclerotic plaque (77). T hese effects may be related to the different consequences of inhibition of COX-1 and COX-2. Whereas COX-1 mediates the production of prostaglandins and the platelet aggregate stimulator T XA2 , COX-2 may mediate the production of the platelet aggregate inhibitor, prostacyclin. In an excellent review of the adverse cardiovascular effects of selective COX-2 inhibitors, it was suggested that the apparent consequence of selective inhibition of COX-2 is a significant reduction in the production of prostacyclins, whereas the production of T XA2 by COX-1 is unaffected (78). Of practical interest is a report that resveratrol, an m-hydroxyquinone present in red wine that has been suggested to be one agent responsible for the cardioprotective effects observed with the consumption of red wine (i.e., the “ French Paradox” ), inhibits COX-1 with no apparent effect on COX-2 (79). T hus, the design of highly selective inhibitors of COX-2 would not be as desirable therapeutically as drugs that preferentially inhibit COX-2 but also inhibit COX-1 to a lesser extent. In one of the most publicized drug withdrawals, Merck voluntarily withdrew rofecoxib from the U.S. market in September 2004, followed by Pfizer's withdrawal of valdecoxib in April 2005. T hus, the future of selective COX-2 inhibitors in the treatment of inflammatory disorders is very clouded.

Specific drugs Celecoxib (Celebrex) Celecoxib is synthesized by condensing 4-methyl-acetophenone and ethyltrifluoroacetate with sodium methoxide and the resulting butanedione derivative cyclized with 4-hydrazinophenylsulfonamide (80). It was the first NSAID to be marketed as a selective COX-2 inhibitor. Celecoxib is well absorbed from the GI tract, with peak plasma concentrations generally being attained within 3 hours of administration. Peak plasma levels in geriatric patients may be increased, but dosage adjustments in elderly patients generally are not required unless the patient weighs less than 50 kg. Celecoxib is excreted in the urine and feces primarily as inactive metabolites, with less than 3% of an administered dose being excreted as unchanged drug. Metabolism occurs primarily in the liver by CYP2C9 and involves hydroxylation of the 4-methyl group to the primary alcohol, which is subsequently oxidized P.987 to its corresponding carboxylic acid, the major metabolite (73% of the administered dose) (Fig. 36.25). T he carboxylic acid is conjugated, to a slight extent, with glucuronic acid to form the corresponding glucuronide. None of the isolated metabolites have been shown to exhibit pharmacological activity as inhibitors of either COX-1 or COX-2. Celecoxib also inhibits CYP2D6; thus, the potential of celecoxib to alter the pharmacokinetic profiles of other drugs inhibited by this isoenzyme exists. Celecoxib, however, does not appear to inhibit other CYP isoforms, such as CYP2C19 or CYP3A4. Other drug interactions related to the metabolic profile of celecoxib have been noted, particularly with other drugs that inhibit CYP2C. For example, coadministration of celecoxib with fluconazole can

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significantly increase plasma concentration of celecoxib, because fluconazole inhibits CYP2C9.

Cele co xib may c ause an inc re as ed risk o f s erious c ardiovasc ular thrombo tic events , myoc ard ial inf arc tion, and s troke, whic h c an b e f atal. All NSAI Ds may have a s imilar ris k. This risk may increas e with d uration of us e . Patients with c ardiovas cular dis eas e or risk f ac to rs f o r c ardiovas c ular dise as e may b e at g reater ris k. The NSAI Ds , inc luding ce lec oxib, c aus e an inc reas ed ris k of s erious GI advers e e vents , includ ing bleed ing, ulc eratio n, and pe rf oration of the s tomac h o r inte stine s, whic h c an b e f atal. Thes e eve nts c an o cc ur at any time d uring us e and witho ut warning s ymptoms . Elde rly patients are at gre ate r ris k f o r s erious GI eve nts .

Fig. 36.25. Metabolism of celecoxib.

Celecoxib is currently indicated for the relief of signs and symptoms of osteoarthritis and rheumatoid arthritis and to reduce the number of adenomatous colorectal polyps in familial adenomatous polyposis as an adjunct to usual care. Celecoxib is at least as effective as naproxen in the symptomatic management of osteoarthritis and at least as effective as naproxen and diclofenac in the symptomatic treatment of rheumatoid arthritis, and it is less likely to cause adverse GI effects. Celecoxib appears to be effective in the management of pain associated with both of these arthritic conditions, but effectiveness in acute or chronic pain has not been fully demonstrated. Unlike aspirin, celecoxib does not exhibit antiplatelet activity. Concomitant administration of aspirin and celecoxib may increase the incidence of GI side effects. Another notable potential drug interaction with celecoxib is its ability, like other NSAIDs, to reduce the blood pressure response to angiotensin-converting enzyme inhibitors. A more detailed discussion of the chemical, pharmacological, pharmacokinetic, and clinical aspects of celecoxib is available (81).

Rofecoxib (Vioxx) Rofecoxib has been synthesized by a number of synthetic routes that have been summarized elsewhere (82). It was the second selective COX-2 inhibitor to be marketed. Rofecoxib is well absorbed from the GI tract on oral administration, with peak plasma levels generally being attained within 2 to 3 hours of dosing. Bioavailability averages 93% following administration of a single dose. T he area under the plasma concentration–time curve is increased in patients older than 65 years compared to younger adults and is increased slightly in black and Hispanic patients compared with white patients, but the difference is not considered to be clinically significant.

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Fig. 36.26. Metabolism of refecoxib.

Rofecoxib is excreted primarily in the urine (72%) as metabolites. Less than 1% is excreted in the urine as unchanged drug, whereas approximately 14% is excreted in the feces as unchanged drug. Although the metabolism of rofecoxib has not been fully determined, the microsomal cytochrome P450 system appears to play only a minor role—a major difference in the metabolic routes of rofecoxib and celecoxib. T he major metabolic route appears to form reduction of the dihydrofuranone ring system by cystolic enzymes to the to ci s- and trans- dihydro derivatives. Also isolated is the glucuronide of a hydroxy derivative that results from CYP2C9 oxidative metabolism. None of the isolated metabolites of rofecoxib possess pharmacological activity as COX-1 or COX-2 inhibitors. T he metabolism of rofecoxib is presented in Figure 36.26.

Rof ec oxib (Vioxx) was voluntarily withdrawn f ro m the United States and the worldwide market o n September 30, 2 004, b ec aus e of s af ety c onc erns re garding an inc rease d ris k f or c ardiovas cular events , inc luding heart attac k and stroke , in patients taking ro f ec oxib.

Rofecoxib was indicated for the relief of the signs and symptoms of osteoarthritis, for the management of acute pain in adults, and for the treatment of primary P.988 dysmenorrhea. Rofecoxib, diclofenac, and ibuprofen possess comparable efficacy in the treatment of osteoarthritis, but serious adverse effects on the GI tract are not observed with rofecoxib. In the treatment of pain, a single 50-mg dose of rofecoxib, a single 550-mg dose of naproxen sodium, and a single 400-mg dose of ibuprofen possess similar onsets of action. Rofecoxib, naproxen sodium, and ibuprofen displayed similar effectiveness in the treatment of postoperative dental pain. A 50-mg dose of rofecoxib was as effective as a 550-mg dose of naproxen sodium in the relief of primary dysmenorrhea in adults. Like celecoxib, rofecoxib does not affect platelet aggregation or bleeding and should not be used as a substitute for aspirin in the prevention of cardiovascular events. A more detailed discussion of the chemical, pharmacological, pharmacokinetic, and clinical aspects of rofecoxib is available (83). Rofecoxib is approved for the relief of the signs and symptoms of osteoarthritis and the treatment of primary dysmenorrheal.

Valdecoxib (Bextra) Valdecoxib is freely soluble in alkaline aqueous solutions. At recommended doses, the mean oral bioavailability for valdecoxib is 83%, and the time to peak concentration is approximately 3 hours. T ime to peak plasma concentration was delayed by 1 to 2 hours when administered with a high-fat meal. Protein binding is very high at 98%. Valdecoxib exhibits linear pharmacokinetics over the usual clinical dose range. Valdecoxib is extensively metabolized in humans. T he primary metabolite for valdecoxib involved CYP2C9 hydroxylation of the 5-Me group, which was further metabolized to the inactive carboxylate, and N-hydroxylation at the sulfonamide moiety. Oxidative breakdown of the N-hydroxy sulfonamide function group led to the formation of the corresponding sulfinic acid and sulfonic acid metabolites. T he O-and N-glucuronides were the major urinary metabolites. Only 3% of the administered dose was recovered in urine as unchanged valdecoxib. Its elimination half-life is 8 to 11 hours. Approximately 70% of a valdecoxib dose is eliminated in the urine as metabolites, and less than 5% is excreted in the feces and urine

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unchanged.

Vald ec oxib (Bextra) was voluntarily withd rawn f rom the U.S. market on April 7, 200 5, bec ause of s af e ty co nce rns reg arding increas ed ris k of cardio vas c ular e vents and reports of s erio us and pote ntially lif e-threatening s kin reac tions , inc luding d eaths , in patie nts taking valdec oxib.

Valdecoxib is approved for the relief of the signs and symptoms of osteoarthritis and adult rheumatoid arthritis and for the treatment of primary dysmenorrhea. Valdecoxib is contraindicated for the treatment of postoperative pain immediately following coronary artery bypass graft surgery. Precautions to consider for valdecoxib are that it may cause bronchoconstriction or anaphylaxis in aspirin-sensitive patients with asthma, who have experienced severe bronchospasm after taking aspirin or other NSAIDs.

Parecoxib (Parecoxib Sodium, Dyn stat) As shown in Figure 36.23, parecoxib is a pro-drug of valdecoxib administered IM or IV for perioperative analgesic and anti-inflammatory use. As a pro-drug, it undergoes rapid in vivo hydrolysis to valdecoxib. It is the only parenterally administered coxib. Parecoxib at greater than 20 mg has analgesic activity superior to that of placebo and similar to that of parenteral 30 or 60 mg of ketorolac in patients with postoperative dental pain. A significant adverse effect is drug hypersensitivity. Parecoxib is currently marketed worldwide but has not been approved for use in the United States.

Etori coxib (Arcoxia) Etoricoxib (Fig. 36.23) is a selective COX-2 inhibitor being developed for postsurgical treatment of dental pain (120 mg) and osteoarthritis. It has a methylsulfonyl group common to the other coxib inhibitors. Etoricoxib is rapidly absorbed, with an oral bioavailability of 80 to 100%, and reaches maximum plasma concentrations in 1 to 2 hours after dosing. Food decreases the rate of absorption but has no effect on the extent of absorption. It exhibits a long elimination half-life of approximately 22 hours, demonstrating linear plasma pharmacokinetics with no accumulation during multiple dosing. Etoricoxib is metabolized involving oxidation of its 6′-methyl group primarily by CYP3A4 but is not an inhibitor of CYP3A4. Other metabolites include 1′-N-oxide and glucuronides. Etoricoxib is primarily excreted as metabolites into the urine.

Lu miracoxib (Prexige) Lumiracoxib (Fig. 36.23) is a selective COX-2 inhibitor developed for the treatment of osteoarthritis, rheumatoid arthritis, and acute pain. It structurally differs from the other selective COX-2 inhibitors in being a phenylacetic acid with a carboxylic acid group (pK a = 4.7). Lumiracoxib is rapidly absorbed, with an oral bioavailability of 74%, and reaches a maximum plasma concentration 2 hour after dosing. It is highly plasma protein bound and has a short elimination half-life of approximately 4 hours, demonstrating linear plasma pharmacokinetics with no accumulation during multiple dosing. Lumiracoxib is extensively metabolized involving oxidation of its 5-Me group and 4′-hydroxylation of the dihalogenated aromatic ring. T he major in vitro oxidative pathways is catalyzed primarily by CYP2C9. Lumiracoxib and its metabolites are excreted via renal and fecal routes in approximately equal amounts. T he COX-2 selectivity was confirmed by a lack of inhibition of arachidonic acid and collagen-induced platelet aggregation. As with other selective coxibs, lumiracoxib exhibits a reduced incidence of gastroduodenal erosions compared with that of naproxen. It was approved for use in the United Kingdom and the United States in 2007. P.989

Disease-M odifying Antirheumatic Drugs T he drugs previously discussed as NSAIDs, both the nonselective COX and selective COX-2 inhibitors, have proven to be beneficial in the symptomatic treatment of arthritic disorders and to be a popular therapeutic regimen. Despite their effectiveness and popularity, however, it should be remembered that none of these drugs are effective in preventing or inhibiting the underlying pathogenic, chronic inflammatory processes. Recent interest has been generated by drugs that are effective in the treatment of arthritic disorders yet fail to demonstrate significant activity in the standard screening assays for antiarthritic drugs. Disease-modifying antirheumatic drugs (DMARDs) differ from the previously discussed drugs in that they are drugs that retard or halt the underlying progression, limiting the amount of joint damage that occurs in rheumatoid arthritis while lacking the anti-inflammatory and analgetic effects observed with NSAIDs. Although both NSAIDs and DMARDs improve symptoms of active rheumatoid arthritis, only DMARDs have been shown to alter the disease course and to improve radiographic outcomes. T he DMARDs have an effect on rheumatoid arthritis that is different and more delayed in onset than either NSAIDs or corticosteroids. Once persistent disease activity (chronic synovitis) is established, a DMARD should be considered. T he development of

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erosions or joint space narrowing on radiographs of the involved joints is a clear indication for DMARD therapy; however, one should not wait for radio-graphic changes to occur. T hey are much slower acting, taking as long as 3 months for measurable clinical benefits to be observed. Although these drugs also possess potentially dangerous adverse side effects, which in many cases limit their long-term use, DMARDs are effective in reducing joint destruction and the progression of early rheumatoid arthritis. A 2004 study reported that taking DMARDs at early stages in the development of rheumatoid arthritis is especially important to slow the disease and to save the joints and other tissues from permanent damage. T ypically, DMARDs are used with an NSAID or a cortico-steroid. T he NSAID or corticosteroid handles your immediate symptoms and limits inflammation, and the DMARD goes to work on the disease itself. T he DMARDS can be divided into two general categories: synthetic DMARDS, which can be taken orally, and biological DMARDS, which are given by IV infusion or subcutaneously, that target and inactivate cell proteins (cytokines) and T lymphocytes (T cells) from causing joint inflammation. T he DMARD methotrexate, in combination with the biological DMARDs, may offer the best control of rheumatoid arthritis for the majority of people, eliminating the need for NSAID medications.

Synthetic Disease-Modifying Antirheumatic Drugs T he synthetic DMARDs include gold salts, hydroxychloroquine, and sulfasalazine. Less common synthetic DMARDs are penicillamine and minocycline. Synthetic immunosuppressants used for the treatment of inflammatory diseases include the antimetabolites methotrexate, leflunomide, and azathioprine.

Gold compounds Historical Backgrou n d At the end of the 19th century, the chemotherapeutic applications of heavy metal derivatives were receiving considerable interest. Among those metals gaining the greatest attention were gold compounds (or gold salts). T he first of these, gold cyanide, was effective in vitro against M ycobacteri um tubercul osi s. T his discovery prompted others to extend the use of gold compounds in other disease states that are thought to be tubercular in origin. Early clinical observations had suggested similarities in the symptoms of tuberculosis and rheumatoid arthritis, and some thought rheumatoid arthritis to be an atypical form of tuberculosis. In 1927, aurothioglucose was found to relieve joint pain when used to treat bacterial endocarditis. T he area of chrysotherapy had begun. Subsequent investigations led to an extensive study of gold compounds in Great Britain by the Empire Rheumatism Council, which reported in 1961 that sodium aurothiomalate was effective in slowing the development of progressive joint diseases. Both aurothioglucose and sodium aurothiomalate are orally ineffective and are administered by IM injection. In 1985, the first orally effective gold compound for arthritis, auranofin, was introduced in the United States. Several other gold compounds have been evaluated clinically but do not appear to offer advantages in terms of efficacy or toxicity.

Mechanism of Action T he biochemical and pharmacological properties shared by gold compounds are quite diverse. T he mechanism by which they produce their antirheumatic actions has not been totally determined. T he earlier observations that gold compounds were effective in preventing arthritis induced by hemolytic streptococci and by pleuropneumonia-like organisms led to the postulation that they acted through an antimicrobial mechanism. T he inability of gold compounds to consistently inhibit mycoplasmal growth in vitro while inhibiting the arthritic process independent of microbial origins, however, suggested that they did not directly produce their effects by this mechanism. T he involvement of immunological processes in the pathogenesis of arthritis suggested that a direct suppression of the immunologic response by gold compounds was involved. Available evidence, however, suggests that whereas enzymatic mediators released as a result of the immune response may be inhibited, no direct effect on either immediate or delayed cellular responses is evident to suggest any immunosuppressive mechanism. Suggestions have been made that protein denaturation and macroglobulin formation cause the proteins to become antigenic, thus initiating the immune response and producing biochemical changes in connective tissue, which ultimately leads to rheumatoid arthritis. T he possibility that gold compounds inhibit the P.990 aggregation of macroglobulins and, in turn, inhibit the formation of immune complexes may account for their ability to slow connective tissue degradation. Interaction with collagen fibrils and, thus, reduction of collagen reactivity that alters the course of the arthritic process also have been postulated. Perhaps the most widely accepted mechanism of action is related to the ability of gold compounds to inhibit lysosomal enzymes, the release of which promotes the inflammatory response. T he lysosomal enzymes glucuronidase, acid phosphatase, collagenase, and acid hydrolases are inhibited, presumably through a reversible interaction of gold with sulfhydryl groups on the enzymes. Gold thiomalate inhibits glucosamine-6-phosphate synthetase, a rate-limiting step in mucopolysaccharide biosynthesis and

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a property shared, to a lesser extent, by several NSAIDs. Gold sodium thiosulfate is a potent uncoupler of oxidative phosphorylation. Gold sodium thiomalate also is a fairly effective inhibitor of prostaglandin biosynthesis in vitro, but the relationship of this effect to the antiarthritic actions of gold compounds has not been clarified.

Side Effects T oxic side effects have been associated with the use of gold compounds, with the incidence of reported adverse reactions in patients on chrysotherapy being as high as 55%. Serious toxicity occurs in 5 to 10% of reported cases. T he most common adverse reactions include dermatitis (e.g., erythema, papular, vesicular, and exfoliative dermatitis), mouth lesions (e.g., stomatitis preceded by a metallic taste and gingivitis), pulmonary disorders (e.g., interstitial pneumonitis), nephritis (e.g., albuminuria and glomerulitis), and hematologic disorders (e.g., thrombocytopenic purpura, hypoplastic and/or aplastic anemia, and eosinophilia; blood dyscrasias are rare in incidence but can be severe). Less commonly reported reactions are GI disturbances (e.g., nausea, anorexia, and diarrhea), ocular toxicity (e.g., keratitis with inflammation and ulceration of the cornea and subepithelial deposition of gold in the cornea), and hepatitis. In those cases in which severe toxicity occurs, excretion of gold can be markedly enhanced by the administration of chelating agents, the two most common of which are dimercaprol (British Anti-Lewisite [BAL]) and penicillamine. Corticoids also suppress the symptoms of gold toxicity and the concomitant administration of dimercaprol, and corticosteroids have been recommended in cases of severe gold intoxication.

General Stru cture–Activity Relation shi ps Structure–activity relationships of gold compounds have not received a great amount of attention. T wo important relationships, however, have been established: 1) Monovalent gold (aurous ion [Au + ]) is more effective than trivalent gold (auric ion [Au 3+ ]) or colloidal gold, and 2) only those compounds in which aurous ion is attached to a sulfurcontaining ligand are active (Fig. 36.27). T he nature of the ligands affects tissue distribution and excretion properties and, usually, are highly polar, water-soluble functions. Aurous ion has only a brief existence in solution and is rapidly converted to metallic gold or auric ion. Aqueous solutions decompose on standing at room temperature, posing a stability problem for the two injectable gold compounds therapeutically available (aurothioglucose and gold sodium thiomalate). Complexation of Au + with phosphine ligands stabilizes the reduced valence state and results in both nonionic complexes that are soluble in organic solvents and an enhancement of oral bioavailability. Other changes also occur. In the phosphine-Au-S compounds, gold has a coordination number of 2, and the molecules are nonconducting monomers in solution. T he injectable gold compounds are monocoordinated. Whereas nongold phosphine compounds are ineffective in arthritic assays, the nature of the phosphine ligand in the gold coordination complexes appears to play a greater role in antiarthritic activity than the other groups bound to gold. Within a homologous series, the triethylphosphine gold derivatives provide greatest activity.

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Fig. 36.27. Structures of disease-modifying antirheumatic drugs (DMARDs).

T he structures of the three therapeutically available gold compounds in the United States are shown in Figure 36.27.

Absorption an d Metabol ism Gold compounds generally are rapidly absorbed following IM injection, and the gold is widely distributed in body tissues, with the highest concentrations found in the reticuloendothelial system and in adrenal and renal cortices. Binding of gold from orally administered gold to red blood cells is higher than that of injectable gold. Gold accumulates in inflamed joints, where high levels persist for at least 20 days following injection. Although gold is excreted primarily in the urine, the bulk of injected gold is retained. Gold can be found in the urine months later.

Drug Interaction s T he only significant drug interactions reported are the concurrent administration of drugs that P.991 also produce blood dyscrasias (most notably phenylbutazone and the antimalarial and immunosuppressive drugs).

Speci fic Drugs Gold Sodi um T hiomalate Gold sodium thiomalate (actually a mixture of mono- and disodium salts of gold thiomalic acid) is very water soluble. It is available as a light-sensitive, aqueous solution of pH 5.8 to 6.5. T he gold content is approximately 50%. It is administered IM, because it is not absorbed on oral administration and is highly bound (95%) to plasma proteins. Gold sodium thiomalate is indicated in the treatment of active adult and juvenile rheumatoid arthritis as one part of a complete therapy program. It is recommended that injections be given to patients only when they are in a supine position. T hey must remain so for 10 minutes following injection.

Auroth ioglucose Aurothioglucose is highly water soluble, and its aqueous solutions decompose on long standing. It therefore is available as a suspension in sesame oil. Gold content is approximately 50%. Following IM injection, it is highly protein bound (95%), and peak plasma levels are achieved within 2 to 6 hours. Following a single 50-mg dose, the biological half-life ranges from 3 to 27 days, but following successive weekly doses, the half-life increases to 14 to 40 days after the third dose. T he therapeutic effect does not correlate with serum plasma gold levels but appears to depend on total accumulated gold. Aurothioglucose is indicated for the adjunctive treatment of adult and juvenile rheumatoid arthritis.

Auranofin Auranofin contains approximately 29% gold. T he carbohydrate portion assumes a chair conformation, with all substituents occupying the equatorial position. It is the first orally effective gold compound used to treat rheumatoid arthritis. On a mg gold/kg basis, it is reported to be as effective in the rat adjuvant arthritis assay as the parenterally effective drugs. Daily oral doses produce a rapid increase in kidney and blood gold levels for the first 3 days of treatment, with a more gradual increase on subsequent administration. Plasma gold levels are lower than those attained with parenteral gold compounds. T he major route of excretion is via the urine. Auranofin may produce fewer adverse reactions than parenteral gold compounds, but its therapeutic efficacy also may be less. Auranofin is indicated in adults with active rheumatoid arthritis who have not responded sufficiently to one or more NSAIDs.

Aminoquinolines Background T he 4-aminoquinoline class of antimalarial drugs has been known to possess pharmacological actions that are beneficial in the treatment of rheumatoid arthritis. T wo of these drugs, chloroquine and hydroxychloroquine (Fig. 36.27), have been used as antirheumatics since the early 1950s. T he corneal and renal toxicity of chloroquine, however, has resulted in its discontinuance for this purpose, although it is still indicated as an antimalarial agent and an amebicide. Whereas hydroxychloroquine is less toxic, it also is less effective than chloroquine as an antirheumatic. T he mechanism of action of these drugs as an antirheumatic remains unresolved. Interestingly, most

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of the data available relates to chloroquine rather than hydroxychloroquine but is assumed to be applicable to the latter. T he spectrum of action of the 4-aminoquinolines differs from the NSAIDs in that chloroquine appears to be an antagonist of certain preformed prostaglandins. T his effect, however, would indicate an acute, rather than a chronic, antirheumatic effect, whereas chloroquine has been shown to be similar to gold compounds in that it possesses a slow onset of action. Beneficial effects are noted only after 1 to 2 months of administration. Chloroquine inhibits chemotaxis of polymorphonuclear leukocytes in vitro but not in vivo. Its effects on collagen metabolism in connective tissue also are unclear. T he most widely accepted mechanism of action of chloroquine and, presumably, of hydroxychloroquine is related to its ability to accumulate in lysosomes. Although evidence indicating stabilization of lysosomal membranes is not convincing, it may inhibit the activity of certain lysosomal enzymes, such as cartilage chondromucoprotease and cartilage cathepsin B. T here does not appear to be a correlation of the antirheumatic effects of the 4-aminoquinolines with their antimalarial activity.

Hydroxychloroquine sulfate Hydroxychloroquine sulfate is highly water soluble and exists in two different forms of different melting points. It is readily absorbed on oral administration, reaching peak plasma levels within 1 to 3 hours. It concentrates in organs such as the liver, spleen, kidneys, heart, lung, and brain, thereby prolonging elimination. Hydroxychloroquine is metabolized by N-dealkylation of the tertiary amines, followed by oxidative deamination of the resulting primary amine to the carboxylic acid derivative. In addition to possessing corneal and renal toxicity, hydroxychloroquine also may cause CNS, neuromuscular, GI, and hematological side effects. Hydroxychloroquine sulfate is indicated for the treatment of rheumatoid arthritis, lupus erythematosus, and malaria.

Immunosuppressants T he discovery of drugs that modify the immune response, whether as immunoregulatory, immunostimulatory, or immunosuppressive agents, has been the focus of much recent research activity. Several substances that suppress the immune system have been explored as antirheumatic drugs, because the etiology of rheumatoid arthritis may involve a destructive immune response (3,4). T hus, unlike drugs previously discussed, immunosuppressive drugs may act at the steps involved in the pathogenesis of the inflammatory disorders. As a group, however, these drugs are cytotoxic, as evidenced P.992 by the initial development of these drugs as anticancer agents. Among the more widely employed immunosuppressants are azathioprine, methotrexate, leflunomide, and cyclophosphamide. All of these drugs are quite toxic and, generally, are indicated for rheumatoid arthritis only in those patients with severe, active disease who have not responded to full-dose NSAID therapy and at least one DMARD and a corticosteroid. Interestingly, although aspirin and NSAIDs are effective in only one-third of children with juvenile arthritis, methotrexate, when given only once a week at low doses (< 20 mg) to minimize side effects, is effective. Cyclosporine (Sandimmune) has been investigated in rheumatoid arthritis and appears to offer short-term benefits, although its toxic effects also limit its long-term use. Cyclosporine appears to inhibit the proliferation of T -helper/inducer lymphocytes, blocking the signaling pathway involved in the etiology of rheumatoid arthritis. T he immunosupressants can have potentially serious side effects, such as increased susceptibility to infection.

Speci fic Drugs Leflu nomide Leflunomide is a DMARD with anti-inflammatory and immunosuppressive activity used for the management of rheumatoid arthritis. It retards structural damage associated with arthritis in adults who have moderate to severe active rheumatoid arthritis. Leflunomide also is being investigated for use in patients with solid tumors and organ transplant recipients. Leflunomide is a pro-drug that is rapidly and almost completely metabolized (half-life, < 60 minutes) following oral administration to teriflunomide, the pharmacologically active α-cyanoenol metabolite (Fig. 36.28). T he C 3 -H of the isoxazole ring is essential for the ring opening to its active metabolite. T he reaction is similar to CYP1A2-catalyzed dehydration of aldoximes. T he exact mechanism of action of leflunomide in the management of rheumatoid arthritis has not been fully elucidated but appears to principally involve inhibition of B-lymphocyte (B-cell) proliferation, reducing antibody formation. Activated lymphocytes must proliferate and synthesize large quantities of cytokines, requiring increased de novo synthesis of uridine monophosphate (UMP) and other pyrimidine nucleotides for its cell life cycle. T herefore, any substance that reduces the intracellular concentration of pyrimidine nucleotides will affect the growth of these activated cells.

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Fig. 36.28. Metabolism of leflunomide.

Fig. 36.29. Dihydroorotate dehydrogenase (DHOH) pathway with cofactor, coenzyme Q.

Leflunomide is inactive, but teriflunomide inhibits pyrimidine de novo synthesis at low therapeutic doses by inhibiting dihydroorotate dehydrogenase (the rate-determining enzyme for the synthesis of UMP), decreasing DNA and RNA synthesis, and arresting the cell proliferation cycle and production of antibodies. T he reduction of dihydroorotate to orotate occurs concurrently with the reduction of its cofactor, ubiquinone (coenzyme Q) (Fig. 36.29). T he inhibition of dihydroorotate dehydrogenase by teriflunomide demonstrates noncompetitive and uncompetitive kinetics. Administration of leflunomide in patients with rheumatoid arthritis results in progressive removal of B cells and down-regulation of the immune process. T eriflunomide not only inhibits B-cell proliferation but also T -cell proliferation, blocking the synthesis of immunosuppressive cytokines. At high therapeutic doses, leflunomide inhibits protein tyrosine kinases. Leflunomide is administered orally as a single daily dose without regard to meals. T herapy may be initiated with a loading dosage given for 3 days, followed by the usual maintenance dose. It undergoes primarily enterohepatic circulation, extending its duration of action. Cholestyramine can be used to enhance its elimination in cases of toxicity.

Methotrexate Methotrexate (Fig. 36.27) is an antifolate drug approved for the treatment of severe active rheumatoid arthritis in

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adults who are intolerant to or have had an insufficient response to first-line therapy. Although the mechanism of action of methotrexate in rheumatoid arthritis is unknown, recent studies have shown that methotrexate reversibly inhibits dihydrofolate reductase, blocking the proliferation of B cells by interfering with DNA synthesis, repair, and replication. Oral absorption is dose-dependent, being well-absorbed at doses of 7.5–25 mg once a week. At this dose, oral bioavailability is approximately 60%, and food can delay absorption and reduce peak concentration. T he volume of distribution is 0.4 to 0.8 L/kg. Protein binding is approximately 50%. It is metabolized to active metabolites, methotrexate P.993 polyglutamates and 7-hydroxymethotrexate. Some metabolism occurs by intestinal flora after oral administration. Methotrexate is actively transported into the urine (80–90% unchanged in the urine within 24 hours) via the folate transporter, an organic anion transporter. Its elimination half-life is 3 to 10 hours. Life-threatening drug interactions are known to occur between methotrexate and NSAIDs, probenecid, and penicillin G. T he NSAIDs (salicylate, ibuprofen, ketoprofen, piroxicam, and indomethacin), probenecid, and penicillin G dose dependently inhibited methotrexate elimination into urine by human organic anion transporters (hOAT 1, hOAT 3, and hOAT 4). T he inhibitory effects of these drugs on hOAT 3 were comparable, with therapeutically relevant plasma concentrations of unbound drugs. T hus, patients with rheumatoid arthritis should not take NSAIDs while taking methotrexate. Methotrexate therapy requires monitoring of liver enzymes and is contraindicated in those with hepatic disease and in women considering pregnancy.

Sulfasalazin e (Azu lfidin e) Sulfasalazine is a pro-drug that is not active in its ingested form. It is broken down by colonic bacteria into 5-aminosalicylic acid (5-ASA; mesalamine) and sulfapyridine. Some controversy exists regarding which of these two products are responsible for the activity of azulfidine. 5-Aminosalicylic acid, however, is known to have a therapeutic benefit, although it is not clear whether sulfapyridine adds any further benefit. In the colon, the products created by the breakdown of sulfasalazine work as anti-inflammatory agents for treating colon inflammation. T he beneficial effect of sulfasalazine is believed to result from a local effect on the bowel, although there also may be a beneficial systemic immune-suppressant effect. Sulfasalazine was approved in 1950.

Following oral administration, sulfasalazine is poorly absorbed, with approximately 20% of the ingested sulfasalazine reaching the systemic circulation. T he remainder of the ingested dose is metabolized by colonic bacteria into its components, sulfapyridine and mesalamine (5-ASA). Most of the sulfapyridine metabolized from sulfasalazine (60–80%) is absorbed in the colon following oral administration, and approximately 25% of the 5-ASA metabolized from sulfasalazine is absorbed in the colon. T he apparent volume of distribution of sulfasalazine in eight healthy volunteers was 64 L/kg, and that of sulfapyridine was 0.4 to 1.2 L/kg. Protein binding is approximately 99% for sulfasalazine, approximately 50% for sulfapyridine, and approximately 43% for 5-ASA. T he absorbed sulfapyridine is acetylated and hydroxylated in the liver, followed by conjugation with glucuronic acid and, for 5-ASA, acetylation in the intestinal mucosal wall and the liver. T he elimination half-life is 5 to 10 hours for sulfasalazine and 6 to 14 hours for sulfapyridine, depending on acetylator status of the patient, and 0.6 to 1.4 hours for 5-ASA. T ime to peak serum concentration is 1.5 to 6 hours for oral sulfasalazine and 9 to 24 hours for oral sulfapyridine; for enteric-coated tablets, time to peak serum concentration is 3 to 12 hours for sulfasalazine and 12 to 24 hours for sulfapyridine. Approximately 5% of sulfapyridine and approximately 67% of mesalamine are eliminated in the feces, and 75 to 91% of sulfasalazine and sulfapyridine metabolites are excreted in urine within 3 days, depending on the dosage form

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used. 5-Aminosalicyclic acid is excreted in urine mostly in acetylated form. Sulfasalazine is used for the treatment of mild to moderate ulcerative colitis; as adjunct therapy in the treatment of severe ulcerative colitis, for the treatment of Crohn's disease, and for the treatment of rheumatoid arthritis or ankylosing spondylitis. Contraindications include hypersensitivity to sulfa drugs, salicylates, intestinal or urinary obstruction, and porphyria.

Biological Disease-Modifying Antirheumatic Drugs Cytokine inhibitors T umor Necrosis Factor Blockers T lymphocytes (T cells), a type of white blood cell, are important cells of the immune system. Patients with rheumatoid arthritis have increased numbers of T cells within the inflamed joints. T hese T cells are “ activated” —that is, they multiply and release chemicals (cytokines) that promote the destruction of tissues surrounding the joints and cause the signs and symptoms of rheumatoid arthritis (84). As discussed earlier in this chapter (see also Chapter 6 for a detailed discussion of cytokines), there is considerable expression of the cytokines, interleukin (IL)-1, IL-6, and tumor necrosis factor (T NF) α by the rheumatoid synovium. T NFα is a proinflammatory cytokine (cell protein) that plays a major role in the pathological inflammatory process of rheumatoid arthritis. T NF is an important mediator of local inflammation, and the release of T NFα from T -cells produces increased vascular permeability, release of nitric oxide with vasodilation, local activation of vascular endothelium, increased expression of adhesion molecules on endothelial blood vessels, and increased platelet activation and adhesion. As T NFα builds up in the joints, it leads to joint inflammation, which ultimately results in joint destruction. Because of its role in the progression of rheumatoid arthritis, methods for rendering T NFα inactive has P.994 become a key focus of therapies for rheumatoid arthritis (84). Patients with rheumatoid arthritis display elevated levels of the cytokines, T NFα, IL-1, and IL-6 in synovial fluid and tissue, and there appears to be a correlation between the amount of these products present and the severity of the disease. A significant advance in the treatment of arthritic diseases was the observation that therapy directed toward diminishing the effects of T NFα appeared to also improve the symptoms of ankylosing spondylitis and psoriatic arthritis. T wo different approaches have been developed to decrease T NF activity that has resulted in marketable drugs: administration of soluble T NF receptors (T NFRs; etanercept), and treatment with anti-T NFα antibodies (e.g., infliximab, adsalimumab). T hese compounds are designed to target and neutralize the effects of T NF, helping to reduce pain, morning stiffness, and tender or swollen joints, usually within 1 or 2 weeks after treatment begins. Evidence suggests that T NF blockers also may halt the progression of the disease. T hese medications work synergistically with methotrexate and therefore are often taken with methotrexate. T he T NF blockers approved for treatment of rheumatoid arthritis are etanercept, infliximab, adalimumab, and rituximab. Potential side effects include injection site irritation (adalimumab and etanercept), worsening congestive heart failure (infliximab), blood disorders, lymphoma, demyelinating diseases, and increased risk of infection. T hese drugs should not be taken if an active infection is present. Effectiveness is lost if the drugs are discontinued. Because T NF also is important for host defense against infections, the effects of long-term use on toxicity require further study. Substantial improvements in the course of the disease have been noted with both therapeutic approaches.

Etanercept (Enbrel) Etanercept (Fig. 36.30) is produced by recombinant DNA technology in a Chinese hamster ovary mammalian cell line and is the first biotechnology-derived drug to be introduced for the reduction of the signs and symptoms of moderately to severely active rheumatoid arthritis in patients who have not adequately responded to one or more of the synthetic DMARDs. It is a dimeric soluble form of the p75 T NFR capable of binding to two T NF molecules in the circulation. It consists of the extracellular ligand binding portion of the 75-kDa human T NFR fused to the Fc portion of human IgG1 (Fig. 36.30). T he Fc component of etanercept contains the C H2 domain, the C H 3 domain, and the hinge region, but not the C H1 domain of IgG1. It consists of 934 amino acids and has an apparent molecular weight of approximately 150 kDa. T wo T NFRs have been identified, a 75-kDa protein and a 55-kDa protein, that occur as monomeric molecules on cell surfaces and soluble forms in the blood. T he biological activity of T NF requires its binding to either of the two cell surface T NFRs. Etanercept can bind specifically to two molecules of T NFα in the circulation, preventing its interaction with cell surface T NFRs. It can be used as monotherapy or in combination with methotrexate. Some concern exists because of reports that etanercept may, in some cases, cause serious infections and may have contributed to the deaths of several patients using the drug. An excellent review of the properties and

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use of etanercept has recently appeared (6,85). Etanercept also binds T NFβ.

Fig. 36.30. Anti–tumor necrosis factor (TNF) agents. Etanercept is the extracellular portion of the human TNFR fused to the Fc domain of human immunoglobulin Ig G1. Infliximab is a partially humanized monoclonal antibody against TNFα. The Fv domains are derived from mouse antihuman sequences, whereas the Fc domain is composed of human IgG1 sequences. Adalimumab is fully humanized antibody to human TNFα (Fv and Fc derived from human sequences). Rituxan is a partially humanized monoclonal antibody against CD40. The Fv domains are derived from mouse antihuman sequences, and the Fc domain is composed of human IgG1 sequences.

Etanercept is available as a powder for injection in single-use vials containing 25 mg of the drug. T he reconstituted solution that is administered as a twice weekly subcutaneous injection should be clear and colorless. Etanercept has been approved for reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active rheumatoid arthritis; for reducing signs and symptoms in patients with active arthritis in patients with psoriatic arthritis; and for reducing signs and symptoms in patients with active ankylosing spondylitis.

In fliximab (Remicade) Infliximab is a chimeric (“ humanized” ) IgG1κ monoclonal antibody to human T NFα (see Chapter 6 for detailed discussions for monoclonal antibodies). By combining the Fv domain of the P.995 mouse antibody responsible for recognizing T NFα with parts of the human Fc domain of IgG1 (IgG1κ), the fused protein looks more like normal human IgG1 molecule (“ humanized” ), so there is a better chance the fused protein will not be destroyed by the patient's own immune system. Infliximab has an approximate molecular weight of 149,100 daltons and binds specifically, with high affinity, to both the transmembrane and soluble forms of T NFα in the blood, thus neutralizing its biological activity (Fig. 36.30). It does not bind to T NFβ (lymphotoxin A), a related cytokine that uses the same receptors as T NFα. Infliximab is produced by a recombinant cell line cultured by continuous perfusion and is purified by a series of steps that includes measures to inactivate and remove viruses. Cells expressing transmembrane T NFα bound by infliximab can be lysed. T he T NFα antibodies decrease synovitis and joint erosions

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in a murine model of collagen-induced arthritis and, when administered after disease onset, allows eroded joints to heal. After treatment with infliximab, patients with rheumatoid arthritis or Crohn's disease exhibited reduced infiltration of inflammatory cells and T NFα production in inflamed tissues and decreased levels of serum IL-6 and C-reactive protein compared to baseline. In psoriatic arthritis, treatment with infliximab resulted in a reduction in the number of T cells and blood vessels in the synovium and psoriatic skin as well as a reduction of macrophages in the synovium. Single IV infusions showed a linear relationship between the dose administered and the maximum serum concentration. T he volume of distribution at steady state was independent of dose and indicated that infliximab was distributed primarily within the vascular compartment. T he terminal half-life of infliximab is 8.0 to 9.5 days. No systemic accumulation of infliximab occurred on continued repeated treatment at 4- or 8-week intervals. Infliximab is supplied as a sterile, white, lyophilized powder formulated for IV infusion. Following reconstitution with Sterile Water for Injection, the solution should be used immediately after reconstitution, because the vials do not contain antibacterial preservatives. T he reconstituted solution should be colorless to light yellow and opalescent. Infliximab is indicated for the treatment of rheumatoid arthritis in combination with methotrexate and for Crohn's disease. Long-term use may be associated with the development of anti-infliximab antibodies, an effect that does not appear when it is used with methotrexate. Warnings associated with the use of infliximab include risks of autoimmunity, infections, and hypersensitivity reactions. An excellent review of the properties and use of infliximab has recently appeared (84). Infliximab is more specific than etanercept, because etanercept binds to both T NFα and T NFβ whereas infliximab is an antibody that binds only to T NFα. Infliximab possesses a longer half-life giving a dosing schedule of approximately every 6 to 8 weeks. Infliximab, in combination with methotrexate, is indicated for reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active rheumatoid arthritis; for reducing signs and symptoms and maintaining clinical remission in patients with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy; for reducing signs and symptoms in patients with active arthritis and in patients with psoriatic arthritis; and for reducing signs and symptoms in patients with active ankylosing spondylitis.

Adalimu mab (Hu mira) Adalimumab is a recombinant human IgG1 monoclonal antibody targeted for human T NFα. Adalimumab is produced by recombinant DNA technology in a mammalian cell expression system using a protein-engineering strategy for creating a T NFα antibody with human-derived, heavy- and light-chain variable regions (Fab) and human IgG1κ constant regions. It consists of 1,330 amino acids and has a molecular weight of approximately 148 kDa (Fig. 36.30). Adalimumab, as an antibody, works by targeting and binding T NFα, thus neutralizing the effect of T NFα and, thereby, reducing the symptoms of rheumatoid arthritis and slowing the progression of structural joint damage caused by the disease. Adalimumab does not bind or inactivate T NFβ. Adalimumab is supplied in single-use, prefilled, glass syringes as a sterile, preservative-free, colorless solution for subcutaneous administration. T he pharmacokinetics of adalimumab were linear over the dose range of 0.5 to 10.0 mg/kg following a single IV dose. T he mean elimination half-life was approximately 2 weeks.

Ritu ximab (Ritu xan ) Rituximab is a genetically engineered, fused mouse/human anti-CD40 monoclonal antibody that targets B lymphocytes by binding specifically to CD20 antigen, a protein found on the surface of B cells at certain stages in their life cycle. Rituximab is composed of two heavy chains of 451 amino acids and two light chains of 213 amino acids with an approximate molecular weight of 145 kDa (Fig. 36.30). Its binding affinity for the CD20 antigen is approximately 8.0 nM. T he mouse light- and heavy-chain Fab domains of rituximab, which binds to the CD20 antigen on B cells, is linked to the human Fc domains of IgG1κ. Once the rituximab molecule attaches to the B cells, it initiates B-cell lysis, inducing rapid and profound depletion of peripheral B cells, with patients showing near complete B-cell depletion within 2 weeks after receiving the first dose of rituximab. Because rituximab does not target B cells at the earliest stages of their development, however, these B-cell depletions usually are temporary. In clinical trials, the majority of patients showed peripheral B-cell depletion for at least 6 months, followed by subsequent gradual recovery. A small proportion of patients (4%) had prolonged peripheral B-cell depletion lasting more than 3 years after a single course of treatment. P.996 Rituximab is a sterile, clear, colorless, preservative-free, liquid concentrate formulated for IV administration. It has changed the treatment of rheumatoid arthritis by showing that targeted B-cell therapy in combination with methotrexate can reduce signs and symptoms of rheumatoid arthritis in adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more T NF antagonist therapies. Although

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B cells once were considered to be one of the main contributing factors in the pathogenesis of rheumatoid arthritis, recent evidence has shown that T cells, dendritic cells, and macrophages also were involved. Rituximab has rekindled interest in B cells, highlighting their important role in perpetuating the inflammatory process and showing how they may interact with other cell types and contribute to joint inflammation. For rheumatoid arthritis, rituximab is given as two 1,000-mg IV infusions separated by 2 weeks. Glucocorticoids also are recommended to reduce the incidence and severity of infusion reactions. Rituximab is given in combination with methotrexate. Its administration has been associated with hypersensitivity reactions (non-IgE-mediated reactions), which may respond to adjustments in the infusion rate and in medical management. People who have not found relief using T NF blockers might consider using rituximab. Side effects include flu-like signs and symptoms such as fever, chills, and nausea. Some people experience an “ infusion-reaction complex,” such as difficulty breathing and heart problems, that has resulted in fatalities. Although originally approved for use in people with non-Hodgkin's lymphoma, rituximab was approved for rheumatoid arthritis in 2006.

In terleu kin -1 Receptor An tagonist An akinra (Kineret) Anakinra is a recombinant, nonglycosylated form of the human IL-1 receptor antagonist (IL-1Rα) that neutralizes the inflammatory activity of IL-1 by competing with IL-1 for binding to its IL-1 type 1 receptor (IL-1R1). Interleukin-1 is a cytokine for which production is induced in response to inflammatory stimuli and which mediates various physiologic responses, including inflammatory and immunological responses that promotes inflammation. When IL-1 binds to IL-1R1, a signal is produced that increases the formation of nitric oxide, prostaglandin E 2 and collagenase in synovial cells, resulting in cartilage degradation as well as stimulation of bone resorption. T hus, IL-1Rα plays an important role for regulating synovial proinflammatory IL-1 activity by preventing IL-1 from binding to IL-1R1. Analysis of synovial fluid suggests that the rheumatoid synovium is characterized by an overexpression of IL-1. T he resulting imbalance between IL-1 and IL-1Rα has been implicated in perpetuating the pro-inflammatory response and destructive tide of events in rheumatoid arthritis. If IL-1 is prevented from binding to IL-1R1, the inflammatory response decreases. T he levels of the naturally occurring IL-lRα in synovium and synovial fluid from rheumatoid arthritis patients are insufficient to compete with the elevated amount of locally produced IL-1. T herefore, anakinra neutralizes the proinflammatory activity of IL-1 by competitively inhibiting the binding of IL-1 to IL-1RI, similar to the endogenous antagonist, IL-1Rα. In vitro studies have shown that anakinra inhibits the induction of the inflammatory mediators, nitric oxide and prostaglandin E 2 , and collagenase. Anakinra differs from native human IL-1Rα in that it has the addition of a single methionine residue at its amino terminus. Anakinra consists of 153 amino acids and has a molecular weight of 17.3 kDa. It is produced by recombinant DNA technology using an Escheri chi a col i bacterial expression system. Anakinra is the first IL-1Rα to be approved for use in adults with moderate to severe active rheumatoid arthritis who have not responded adequately to conventional DMARD therapy. It may be used either alone or in combination with methotrexate. Anakinra is supplied in single-use, prefilled, glass syringes as sterile, clear, preservative-free solution that is administered daily as a self-administered subcutaneous injection under the skin. Some potential side effects include injection site reactions, decreased white blood cell counts, headache, and an increase in upper respiratory infections. T here may be a slightly higher rate of respiratory infections in people who have asthma or chronic obstructive pulmonary disease. Persons with an active infection are advised not to use anakinra. Its elimination half-life after sc administration is 4 to 6 hours.

Costimulation Modul ators T wo signals are required to activate a T -cell response to an antigen, called costimulation. Regulation of costimulatory molecules may be a mechanism whereby the immune system limits the extent of an immune response. If an unactivated antigen-presenting cell (APC; a cell that “ presents” an antigen complex that is recognized by the T -cell receptor) presents an antigen to a T cell in the absence of an appropriate costimulatory signal, the T cell does not respond and becomes unreactive and nonresponsive to any further antigenic stimuli (Fig. 36.31). T he T -cell costimulatory activation pathway is initiated, however, when an activated APC presents both an antigen and a costimulatory ligand, such as B7 (CD86) that interacts with CD28 on the surface of the T cell to form B7-CD28 complex, initiating T -cell proliferation and differentiation in response to the antigenic stimulus. T his stimulus releases cytokines that bind to the T cell, further enhancing its activation. A counterbalance to CD28 is cytotoxic T -lymphocyte antigen-4 (CT LA-4), both of which are expressed on the surface of T cells. T he CT LA-4, which is homologous with CD28, becomes expressed on T -cell activation, where it then competes with CD28 for binding to B7 ligands on the surface of APCs. T he B7 ligands bind with much greater affinity to CT LA-4 than to CD28, preventing delivery of the costimulatory signal. T his built-in limit prevents T -cell activation P.997 from spiraling out of control. T he CT LA-4 is not expressed constitutively, and its expression is up-regulated on T -cell

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activation. Eventually, however, CD28 is down-regulated.

Fig. 36.31. Costimulation in the T-cell activation pathway.

Because the formation of a B7-CD28 complex between the APC and the T cell results in T -cell proliferation and the release of inflammatory cytokines, whereas the B7–CT LA-4 interaction inhibits the T -cell responses, the design of a pharmacological agent that prevents costimulation would preferentially inhibit only reactive T cells and be effective in treatment of rheumatoid arthritis. T hus, the discovery of abatacept.

Abatacept (Orenci a) Abatacept, the first in a new class of immunosuppressant agents, known as costimulation modulators, acts by down-regulating T -cell activation for the treatment of rheumatoid arthritis (86). Abatacept is a novel chimeric CT LA-4–IgG1 fused protein created from the fusion of the extracellular domain of the mouse CT LA-4 with the modified heavy-chain constant region of human IgG1. Abatacept, therefore, acts like an antibody that binds with great affinity to B7 ligands, preventing these ligands from interacting with CD28 on activated T cells. In patients with rheumatoid arthritis, blocking this response by abatacept prevents the generation of positive costimulation signals and stimulation of T -cell activation, suppressing the proliferation of reactive T -cells and the release of more cytokines that destroy tissue, causing the symptoms and signs of arthritis. T he extracellular CT LA-4 portion of abatacept is responsible for the affinity of B7. T hus, abatacept slows the damage to bones and cartilage and relieves the symptoms and signs of arthritis. People with moderate to severe active rheumatoid arthritis who have not been helped by T NF blockers might consider abatacept, which is administered IV monthly. Side effects may include headache, nausea, and mild infections, such as upper respiratory tract infections. Serious infections, such as pneumonia, can occur. T here is some concern that blocking of the suppressive signal from B7 to CT LA-4 may have a negative effect on regulatory T cells and, thus, eventually, promote autoimmunity.

Herbs At least a dozen different herbs are used to ease the symptoms of rheumatoid arthritis; most are considered to be anti-inflammatories. Herbs that have been tried include powdered ginger, borage seed oil, or devil's claw to reduce pain and swelling. Stinging nettles or turmeric also may lessen pain, stiffness, and inflammation. Because these herbs can interact with each other or with prescription comedications, lack of careful studies means that little is known about long-term effects and drug interactions. Ayurvedic medicine also uses herbal compounds both internally and externally for symptom relief. T opical curcumin may relieve the inflammation of rheumatoid arthritis. When taken in capsule form, it can reduce morning stiffness and boost endurance. A combination of Wi thani a somni fera, Boswel l i a serrata, and Cucurma l onga also caused a significant drop in pain and disability for study participants with osteoarthritis.

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T wo herbs that have been used for centuries to treat headaches, fever, sore muscles, and rheumatism are white willow bark and meadowsweet, commonly described as “ Nature's aspirin.” White willow bark (Sal i x al ba) contains salicin, a glycoside of salicylic acid. Once in the stomach, the salicin hydrolyzes into salicylic acid, which is the active principle for reducing pain and fever. White willow bark has been mentioned in ancient Egyptian, Assyrian, Greek, and Chinese manuscripts, and it was used to treat pain and fever by the ancient physicians Galen, Hippocrates, and Dioscorides. Native Americans used it for headaches, fever, sore muscles, rheumatism, and chills. In the mid-1700s, it was used to treat malaria. Salicin was isolated and identified in the early 1830s, but it was not conclusively shown to reduce the aches and soreness of rheumatism until 1874. White willow bark is recommended for headaches, backache, nerve pain, toothache, and injuries. P.998 Meadowsweet (Fi l i pendul a ul mari a) is a common wild plant in Britain, Europe, and North America that also contains salicin, but it is not as potent as willow bark which has a higher salicin content. Its primary medicinal actions are antirheumatic, anti-inflammatory, carminative, antacid, antiemetic, astringent, and diuretic. T he flower buds of meadowsweet are the source for salicin and methyl salicylate. Ingestion of the flower buds in a tea results in the breakdown of salicin to salicylic acid. Nicholas Culpeper, a seventeenth-century English pharmacist, mentioned the use of meadowsweet flower buds to help break fevers and promote sweating during a cold or flu.

Drugs Used to T reat Gout Pathophysiology Gout is an inflammatory disease characterized by elevated levels of uric acid (as urate ion) in the plasma and urine and may take two forms, acute and chronic. Acute gouty arthritis results from the accumulation of needle-like crystals of monosodium urate monohydrate within the joints, synovial fluid, and periarticular tissue and usually appears without warning. Initiating factors may be minor trauma, fatigue, emotional stress, infection, overindulgence in alcohol or food, or drugs, such as penicillin or insulin. Chronic gout symptoms develop as permanent erosive joint deformity appears. T he increase in extracellular urate may result from increased uric acid biosynthesis, decreased urinary excretion of uric acid, or perhaps, a combination of both. T he formation of uric acid from adenine and guanine is illustrated in Figure 36.32. Uric acid is formed by the oxidation of xanthine by the enzyme xanthine oxidase. Xanthine is a metabolic product of adenine (via hypoxanthine) and guanine formed by the enzymes adenine deaminase and guanine deaminase, respectively. T hus, uric acid is the excretory product of purine metabolism in humans as well as the scavenging of potential harmful oxygen free radicals in the body. In other mammals, uric acid is hydrolyzed to allantoin by the enzyme uricase, which is then subsequently hydrolyzed by allantoinase to allantoic acid. Hydrolysis of allantoic acid by allantoicase yields the final products, urea and glyoxylic acid.

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Fig. 36.32. Formation of uric acid, urea, and glyoxylic acid from purines.

Normal pool levels of uric acid are approximately 1,000 to 1,200 mg in males and half that in females. In patients suffering from gout, these levels may be as high as two- or three times the normal levels. Uric acid is a weak acid with two pK a values 5.7 and 10.3, with very low water solubility (~ 6 mg/100 mL). At physiological pH, it exists primarily as the monosodium salt, which is approximately 50 times more soluble in aqueous media than the free acid. Blood levels of urate are maintained by a careful balance between its formation and excretion. T he kidney plays a dominant role in urate elimination, excreting about 70% of the daily urate production. T he excretion of urate has been implicated in the development of hyperuricemia that leads to gout. In humans, the excretion of urate requires the urate anion transporter (URAT 1) located in renal proximal tubule cells, which plays a central role in urate homeostasis. T he URAT 1 is targeted by uricosuric and antiuricosuric agents that affect urate excretion. When levels of uric acid in the body increase, either as a result of decreased excretion or increased formation, the solubility limits of sodium urate are exceeded, and precipitation of the salt from the resulting supersaturated solution causes deposits of urate crystals to form. It is the formation of these urate crystals in joints and connective tissue that initiate attacks of gouty arthritis. T he control of gout has been approached from the following therapeutic strategies: 1) control of acute attacks by drugs that reduce inflammation caused by the deposition of urate crystals (these drugs may possess only an anti-inflammatory component, such as colchicine, or both anti-inflammatory and analgetic actions, such as indomethacin, phenylbutazone and naproxen), 2) increasing the rate of uric acid excretion (by definition, these drugs are termed “ uricosuric drugs” and include probenecid and sulfinpyrazone), and 3) inhibiting the biosynthesis of uric acid by inhibiting the enzyme xanthine oxidase by drugs such as allopurinol.

Treatment of Acute Gout T he management of gout has been approached with the following therapeutic strategies: 1) control of acute attacks with drugs that reduce inflammation caused by the deposition of urate crystals, and 2) control of chronic gout by increasing the rate of uric acid excretion (“ uricosuric drugs” ) and inhibiting the biosynthesis of uric acid by inhibiting the enzyme xanthine oxidase. T reatment of acute gout includes NSAIDs, such as indomethacin, colchicines, and glucocorticoids. T he choice of an NSAID generally is based on the side effect profile.

Colchicine Colchicine is a pale-yellow powder that is obtained from various species of Col chi cum, primarily Col chi cum autumnal e P.999 L. Its total chemical synthesis has been achieved, but the primary source of colchicine currently remains alcohol extraction of the alkaloid from the corm and seed of C. autumnal e L. It darkens on exposure to light and possesses

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moderate water solubility. Colchicine has a pK a of 12.4. Its use in the treatment of gout dates back to the sixth century AD. Unlike those drugs that will be discussed next, colchicine does not alter serum levels of uric acid. It does, however, appear to retard the inflammation process initiated by the deposition of urate crystals. Acting on polymorphonuclear leukocytes and diminishing phagocytosis, it inhibits the production of lactic acid, causing an increase in the pH of synovial tissue and, thus, a decrease in urate deposition, because uric acid is more soluble at the higher pH. Additionally, colchicine inhibits the release of lysosomal enzymes during phagocytosis that also contributes to the reduction of inflammation. Because colchicine does not lower serum urate levels, it has been found to be beneficial to combine colchicine with a uricosuric agent, particularly probenecid. It is a potent drug, being effective at doses of approximately 1 mg, but doses as small as 7 mg have caused fatalities.

Absorption and metabolism Colchicine is absorbed on oral administration, with peak plasma levels being attained within 0.5 to 2 hours after dosing. Plasma protein binding is only 31%. It concentrates primarily in the intestinal tract, liver, kidney, and spleen and is excreted primarily in the feces, with only 20% of an oral dose being excreted in the urine. It is retained in the body for considerable periods of time, being detected in the urine and leukocytes for 9 to 10 days following a single dose. Metabolism occurs primarily in the liver, with the major metabolite being the amine resulting from amide hydrolysis.

Side effects Colchicine may produce bone marrow depression, with long-term therapy resulting in thrombocytopenia or aplastic anemia. At maximum dose levels, GI disturbances (e.g., nausea, diarrhea, and abdominal pain) may occur. Acute toxicity is characterized by GI distress, including severe diarrhea resulting in excessive fluid loss, respiratory depression, and kidney damage. T reatment normally involves measures that prevent shock as well as morphine and atropine to diminish abdominal pain. A number of drug interactions have been reported. In general, the actions of colchicine are potentiated by alkalinizing substances and are inhibited by acidifying drugs, consistent with its mechanism of action of increasing the pH of synovial fluid. Responses to CNS depressants and to sympathomimetic drugs appear to be enhanced. Clinical tests may be affected; most notably, elevated alkaline phosphatase and SGOT (serum glutamate oxaloacetate transaminase) values and decreased thrombocyte values may be obtained.

Dosing Colchicine is indicated for the treatment of acute attacks of gout and is very effective. T he usual dose is 1.0 to 1.2 mg, followed by 0.5 to 1.2 mg every 1 to 2 hours until either pain relief is observed or symptoms of GI distress are observed. When a rapid response is required, or if GI reactions warrant discontinuance of oral administration, IV administration (usually 2 mg initially) may be indicated. It is available as 0.5- or 0.6-mg tablets and as an injectable solution of 1 mg in 2-mL ampoules. It often is given in combination with probenecid, and combination products of the two are available in tablets containing 500 mg of probenecid and 0.5 mg of colchicine.

Treatment of Chronic Gout Drugs That Increase Uric Acid Secretion Probenecid Probenecid is insoluble in water and acidic solutions but is soluble in alkaline solutions buffered to pH 7.4. Probenecid initially was synthesized as a result of studies in the 1940s on sulfonamides that indicated the sulfonamides decreased the renal clearance of penicillin, extending the half-life of penicillin as supplies diminished. Probenecid thus was initially used—and is still indicated—for that purpose. Probenecid promotes the excretion of uric acid by inhibiting the urate anion exchange transporter (URAT 1), decreasing the reabsorption of uric acid in the proximal tubules. T he overall effect is to decrease plasma uric acid concentrations, thereby decreasing the rate and extent of urate crystal deposition in joints and synovial fluids. Within the series of N-dialkylsulfamyl benzoates from which probenecid is derived, renal clearance of these compounds is decreased as the length of the N-alkyl substituents is increased. Uricosuric activity increases with increasing size of the alkyl group in the series methyl, ethyl, and propyl. Probenecid is essentially completely absorbed from the GI tract on oral administration, with peak plasma levels observed within 2 to 4 hours. Like most acidic compounds, probenecid (pK a = 3.4) is extensively plasma protein bound (93–99%). T he primary route of elimination of probenecid and its metabolites is the urine. It is extensively metabolized in humans, with only 5 to 10% being excreted as unchanged drug. T he major metabolites detected result from glucuronide conjugation of the carboxylic acid, ω-oxidation of the n-propyl side chain and subsequent oxidation of the resulting alcohol to the carboxylic acid derivative, ω 1 -oxidation of the n-propyl group, and N-dealkylation.

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T hose metabolites possessing a free carboxylic acid function generally possess some uricosuric activity. Probenecid appears to be generally well tolerated, with few adverse reactions. T he major side effect is GI distress (e.g., nausea, vomiting, and anorexia), but these occur in only 2% of patients at low doses. Other effects include headache, dizziness, urinary frequency, hypersensitivity reactions, sore gums, and anemia. Overdosages do not appear to present major difficulties; a case of a 49-year-old man who recovered from the ingestion of 47 g in a suicide attempt has been reported. Should overdosage occur, treatment consists of emesis or gastric lavage, short-acting barbiturates (if CNS excitation occurs), and epinephrine (for anaphylactic reactions). A number of drug interactions have been reported. Despite P.1000 the high degree of plasma protein binding, displacement interactions with other drugs bound to plasma proteins does not appear to occur to any significant extent. Salicylates counteract the uricosuric effects of probenecid. Because probenecid inhibits their renal excretion, increased plasma levels of the following drugs may be observed: aminosalicylic acid, methotrexate, sulfonamides, dapsone, sulfonylureas, naproxen, indomethacin, rifampin, and sulfinpyrazone. (T he effects on penicillin plasma levels were discussed previously.)

Fig. 36.33. Structures of agents used to control gout.

Probenecid is indicated for the treatment of hyperuricemia associated with gout and gouty arthritis and for the elevation and prolongation of plasma levels of penicillins and cephalosporins. In gout, treatment should not begin until an acute attack has subsided. It is not recommended in individuals with known uric acid kidney stones or blood dyscrasias or for children under 2 years of age.

Sulfinpyrazone Sulfinpyrazone (Fig. 36.33) is soluble in alkaline solutions. Its synthesis is similar to that of phenylbutazone (87) (Fig. 36.33). It produces its uricosuric effect in a manner similar to that of probenecid. A dose of 35 mg produces a uricosuric effect equivalent to that produced by 100 mg of probenecid, whereas 400 mg/day of sulfinpyrazone produces an effect comparable to that obtained with doses of 1.5 to 2 g of probenecid. It also possesses, not surprisingly, some of the properties of phenylbutazone. It is an inhibitor of human platelet prostaglandin synthesis at the cyclooxygenase step, resulting in a decrease in platelet release and a reduction in platelet aggregation. T his antiplatelet effect suggests a role for sulfinpyrazone in reducing the incidence of sudden death, which can occur in the first year following a myocardial infarction; however, it lacks the analgetic and anti-inflammatory effects of phenylbutazone. Sulfinpyrazone is a strong acid (enolic OH pK a = 2.8), a factor that is important in the production of the uricosuric effect, because within a series of pyrazolidinedione derivatives, the stronger the acid, the more potent the uricosuric effect. Polar substitution on the side chain also influences uricosuric activity, as discussed previously with regard to the pyrazolidinediones. Oral administration results in rapid and essentially complete absorption, with peak plasma levels being attained

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within 1 to 2 hours of administration. It is highly bound (98–99%) to plasma proteins, and it is excreted in the urine primarily (50%) as unchanged drug.

T he metabolites produced result from sulfoxide reduction, sulfur and aromatic oxidation, and C-glucuronidation of the heterocyclic ring in a manner similar to that for phenylbutazone. T he metabolite resulting from p-hydroxylation of the aromatic ring possesses uricosuric effects in humans. T he sulfide metabolite, a major metabolic product, may contribute to the antiplatelet effects of sulfinpyrazone but not to the uricosuric effects. T he most frequent adverse reactions are GI disturbances; however, the incidence is relatively low. It has been suggested that sulfinpyrazone is a much weaker inhibitor of prostaglandin synthesis in bovine stomach microsomes than either aspirin or indomethacin, a factor that may account for its gastric tolerance. Much rarer have been reports of blood dyscrasias and rash. Overdosage produces symptoms that are primarily GI in nature (e.g., nausea, diarrhea, and vomiting) but also may involve impaired respiration and convulsions. T reatment consists of emesis or gastric lavage and supportive care. Like probenecid, its uricosuric effects are antagonized by salicylates, and probenecid markedly inhibits the renal tubular secretion of sulfinpyrazone. It potentiates the actions of other drugs that are highly plasma protein bound, such as coumarin-type oral anticoagulants, antibacterial sulfonamides, and hypoglycemic sulfonylureas. Sulfinpyrazone is indicated for the treatment of chronic and intermittent gouty arthritis.

Drugs That Decrease Uric Acid Formation Allopurinol Mechanism of Action T he biosynthesis of uric acid from the immediate purine precursor xanthine that results from adenine, via the intermediate hypoxanthine, or from guanine is illustrated in Figure 36.32. T he enzyme xanthine oxidase (a molybdenum hydroxylase enzyme) is involved in two steps, the conversion of hypoxanthine to xanthine, and the final step, the conversion of xanthine to uric acid. Allopurinol originally was designed P.1001 as an antineoplastic antimetabolite to antagonize the actions of key purines inasmuch as it differs from normal purines only by the inversion of the nitrogen and carbon atoms at the 7- and 8-positions of the purine ring system but was found to have little or no effect on experimental tissues. It was subsequently found that allopurinol serves as a substrate for xanthine oxidase (15 to 20 times the affinity of xanthine) and reversibly inhibits that enzyme. Normally, uric acid is a major metabolic end product in humans. When allopurinol is administered, however, xanthine and hypoxanthine are elevated in the urine, and uric acid levels decrease. When the synthesis of uric acid is inhibited, plasma urate levels decrease, supersaturated solutions of urate are no longer present, and urate crystal deposits dissolve, eliminating the primary cause of gout. T he increased plasma levels of hypoxanthine and xanthine pose no real problem, because they are more soluble than uric acid and are readily excreted.

Absorption an d Metabol ism Allopurinol was synthesized in 1956 as part of a study of purine antagonists (88). It is well absorbed on oral administration, with peak plasma concentrations appearing within 1 hour. Decreases of uric acid can be observed within 24 to 48 hours. Excretion of allopurinol and its metabolite occurs primarily in the urine, with approximately 20% of a dose being excreted in the feces. Allopurinol is rapidly metabolized via oxidation and the formation of numerous

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ribonucleoside derivatives. T he major oxidation metabolite, alloxanthine or oxypurinol, has a much longer half-life (18–30 hours versus 2–3 hours) than the parent drug and is an effective, although less potent, inhibitor of xanthine oxidase. T he longer plasma half-life of alloxanthine results in an accumulation in the body during chronic administration, thus contributing significantly to the overall therapeutic effects of allopurinol. T he major adverse effects are primarily dermatological in nature (e.g., skin rash and exfoliative lesions). Other effects, such as GI distress (e.g., nausea, vomiting, and diarrhea), hematopoietic effects (e.g., aplastic anemia, bone marrow depression, and transient leukopenia), neurological disorders (e.g., headache, neuritis, and dizziness), and ophthalmological effects (e.g., cataracts) are less commonly encountered. Allopurinol also may initiate attacks of acute gouty arthritis during the early stages of therapy and may require the concomitant administration of colchicine. Drug interactions include those drugs that normally also are metabolized by xanthine oxidase. For example, the oxidation of 6-mercaptopurine, a useful antineoplastic agent, is inhibiting, permitting a reduction in the therapeutic dose. Allopurinol also has an inhibitory effect on liver microsomal enzymes, thus prolonging the half-lives of drugs, such as oral anticoagulants, that normally are metabolized and inactivated by these enzymes, although this effect is quite variable. T he incidence of ampicillin-related skin rashes increases with the concurrent administration of allopurinol.

Allopurinol is indicated for the treatment of primary and secondary gout, for malignancies such as leukemia and lymphoma, and for the treatment of patients with recurrent calcium oxalate calculi.

Case Study Victoria F. Roche S. Willia m Zito PR is a 15-year-old f emale g ymnas t who has just b een name d to the U.S. Olympic Team af te r months of grue ling and highly co mpetitive trials . Her s pe cialty eve nts are the uneve n p aralle l bars and the “ hors e ,” b ut she has perf o rmed well enough on all events to earn this c ovete d s pot on the team. She is e cs tatic but und ers tand ab ly nervous , bec aus e s he is, by nature , a private p erso n and the med ia sp otlight has bee n intens e s ince the announce ment. PR has c ons ulted the team p hys ician about dysme no rrhe a that has bec o me inc reas ingly wo rs e over the p as t 6 months . The c ramp ing is now almos t incapac itating f or 2 to 3 d ays out of eac h p eriod, and it has b een interf ering with he r training. She knows just whe n the “ b ig p ain” will s tart, bec ause PMS s ymptoms routinely beg in 36 hours be f o re the o ns et of bleed ing. She has looked ahead, and if her cycles re main reg ular, s he is due to have her period during the week of the s ummer Olympic game s. From her me dic ation his tory, the MD can s ee that PR takes OTC c hlorpheniramine maleate (Chlortrime ton) f airly f requently f or s easo nal and pet-re lated allergies . Des pite her young ag e, s he has co mplaine d of a “ nervous s tomach,” which has prompted he r to try Prilos ec OTC (o meprazole ), es p ec ially bef ore co mpetitions when her e motio ns and GI dis tres s are heig hte ne d. PR s peaks of he r ve ry jam-pac ked s c hedule of s c hool and training, and she as ks f o r onc e-daily therapy to treat he r me ns truatio n-re lated p ain if po ss ible . As the p harmacist f or the te am, co nsider the f ollowing NSAI D therape utic c hoice s, and prepare to make a re co mmendatio n. 1. I dentif y the therape utic p ro ble m(s ) in whic h the p harmac is t' s inte rve ntion may benef it the patie nt. 2. I dentif y and prioritize the patient-sp ec if ic f ac tors that mus t be c ons id ere d to ac hieve the d es ire d therap eutic outco mes . 3. Cond uc t a tho rough and mec hanis tically oriented structure –ac tivity analys is of all therap eutic alte rnatives provided in the cas e. 4. Evaluate the SAR f inding s agains t the patient-sp ec if ic f ac to rs and des ired therapeutic outc omes , and

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make a therap eutic dec is ion. 5. Couns el yo ur patie nt.

P.1002

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Chapter 37 Antihistamines and Related Antiallergic and Antiulcer Agents We nde l L. Ne lson

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Drugs cov ered in this chapter: Antihis ta mine s Ac rivas tine Aze las tine C are b astine C etirizine C romo lyn D es lo ratad ine Eb as tine Eme d astine Ep inas tine Fe xof enad ine Ke to tif en L e vo c e tirizine L e vo c o b as tine L o d o xamid e L o ratad ine Mizo las tine Ne d o c ro mil Olo p atad ine Pe miro las t Te rf e nad ine Antiulc e r a ge nts C ime tid ine Es o me prazo le Famotid ine L ans o p razo le Me to c lo promid e Mis o p ro sto l Nizatid ine Ome p razo le Panto prazo le R ab e p razo le R anitid ine Suc ralf ate

Introduction Histamine [2-(imidazol-4-yl)ethylamine] was synthesized and its effects in model biological systems were studied before it was found physiologically. Its synthesis occurs in many tissues, including mast cells, parietal cells of the gastric mucosa, and neurons of the central nervous system (CNS) and the periphery. Early hypotheses about its physiological function were based on the observed, dramatic effects of histamine in guinea pigs. T hese effects

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include massive bronchial spasm and effects on smooth muscle and the vasculature that resemble anaphylactic shock. Marked species differences in the observed effects occur, however, and these dramatic effects are not observed in humans. Histamine is located in many tissues, and on release, its effects are principally local ones, because it functions as an autocoid or paracrine (1). Its physiological function is complex and not completely understood. Histamine is one of the many mediators involved in allergic inflammatory responses, and it has an important role in regulating the secretion of gastric acid. T hese observations have led to development of many important drugs that antagonize its effects and are useful in treatment of allergic inflammatory disorders (H 1 antihistamines) and in the treatment of gastric hypersecretory disorders (H 2 antihistamines). Besides its role in allergic inflammatory processes and gastric acid secretion, a physiological role at axons in several regions of the CNS has established its role in the regulation of sleeping and waking, in energy and endocrine homeostasis, and in cognition and memory. Histamine modulates the release of neurotransmitters via H 3 auto- and heteroreceptors located at histaminergic and nonhistaminergic neurons both centrally and peripherally. A novel H 4 receptor also been described where histamine facilitates the synthesis and release of other proinflammatory mediators and modulates the chemotactic responses, principally at mast cells and eosinophils.

Chem istry Histamine has pK a values of 5.80 (imidazole) and 9.40 (aliphatic primary amine) (2). At physiological pH, it exists as an equilibrium mixture of tautomeric cations, with the monocation making up more than 96% of the total and the dication approximately 3%, with only a very small amount of the nonprotonated species. At lower pH values (e.g. the pH of acidic lipids), a much larger proportion of the dication exists. T he two protonated species (mono- and dication) often are considered to be the biologically active forms. Penetration of membranes by histamine would be expected to occur via the nonprotonated species, and the unprotonated imidazole group would be expected to participate readily in proton-transfer processes physiologically. Several aromatic ring congeners of histamine with weakly and very weakly basic heteroaromatic rings (e.g., 4-chloroimidazole, 1,2,4-triazole, thiazole, and pyridine) exhibit histamine agonist activity (T able 37.1) (3), although they are less potent than histamine. T hese data suggest that the monocation (protonated aliphatic amine) is sufficient for agonist activity and that protonation of the heterocyclic ring is not an absolute requirement. In aqueous solutions, the tautomeric equilibrium of the imidazole ring apparently favors the τ

τ

N -H tautomer by approximately 4:1. T he free base also prefers the N -H tautomer. In the crystalline form of the monohydrochloride salt of histamine, however, where intermolecular crystal P.1005 packing forces are important, the N π -H tautomer is preferred. Changes in tautomeric composition of analogues occur with changes in the 4-substituent (e.g., Me versus Cl), where τ

the proportion of N -H tautomer is decreased in the chlorine-substituted congener to 12%, compared with 70% for 4-methylhistamine, and decreased agonist potency is observed. An interpretation of these results is that tautomeric composition might be important in the agonist–receptor interaction (2).

Clinic a l Signific a nc e T he antihistamines and other agents presented in this chapter represent the extremes of many spectrums. T raditional antihistamines, like promethazine, have been marketed for more than 50 years; proton pump inhibitors have had new dosage forms approved as

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recently as 2005. Some of the agents are inexpensive, whereas others cost several dollars per dose. Indications for these medications range from minor allergic eye irritations to serious conditions, such as Zollinger-Ellison syndrome. T he most important comparison to make between the drug classes and specific agents within each class is the chemical structure of the product. T he differences and similarities of each structure define the function, potency, and side effect profile of the medication. T herefore, an understanding of the effect of chemical structure modifications is imperative to distinguish between the advantages and disadvantages of a treatment regimen. T his effort is well rewarded, because these products are commonly prescribed for medical treatments and many of these agents are available without a prescription. T he accessibility of these drugs presents a significant opportunity for pharmacists to assist patients with proper product selections. T o provide appropriate and pertinent therapeutic recommendations, the clinician must possess a thorough comprehension of the unique attributes for each medication, which can be determined by studying the chemical structure. Heidi H. Bragg R.Ph. Cl i ni cal Assi stant Professor, Department of Cl i ni cal Sci ences and Admi ni strati on, Uni versi ty of Houston, Col l ege of Pharmacy

Results of conformational studies performed on histamine and its congeners indicate both trans and gauche conformations exist in solution (Fig. 37.1) (2). T he trans conformation of 4-methylhistamine, however, which is a selective H 2 agonist, cannot readily adopt the fully extended trans conformation because of interaction of the 4-methyl group with the aliphatic two-carbon chain. Because α- and β-methylhistamine exist predominantly as gauche conformers and both are very weak H 1 and H 2 agonists, it has been suggested that the trans conformation of histamine is preferred at both H 1 and H 2 receptors. A gauche conformation has been suggested for histamine at the H 3 receptor, because α-methylhistamine and some other more conformationally restricted analogues are potent H 3 agonists. Addition of other alkyl substituents onto the histamine molecule generally produces compounds with decreased potency at H 1 and H 2 receptors. 2-Methylhistamine is a selective H 1 agonist (versus 4-methylhistamine, a selective H 2 agonist), but imidazole N-substitution 1

3

(N or N ) with methyl groups results in nearly inactive agents. Similarly, aliphatic amine +

nitrogen substitution results in decreasing activity (NH 2 > NHMe > NMe 2 > N Me 3 [quaternary ammonium salt]) at both H 1 and H 2 receptors (2).

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Physiological Characteristics of Histam ine Synthesis and M etabolism of Histamine Histamine is synthesized in the Golgi apparatus of mast cells and basophils by enzymatic decarboxylation of histidine. P.1006 T his conversion is catalyzed by L-histidine decarboxylase, with pyridoxal phosphate serving as a cofactor for this process. T he reaction mechanism for this decarboxylation probably involves the formation of an imine intermediate, followed by the loss of carbon dioxide, a mechanism demonstrated to occur for decarboxylation of many α-amino acids (Fig. 37.2). Pyridoxal phosphate provides an important catalytic function, and in the final step, the product is released by hydrolysis of the enzyme-bound Schiff base of histamine. Mechanism-based inhibitors of this process, such as α-fluoromethylhistidine, decrease the rate of synthesis of histamine and, thus, deplete cells of histamine. As such, α-fluoromethylhistidine is an important pharmacological tool (4). T his approach, however, has not been successfully developed into agents for the treatment allergic inflammatory disorders, peptic ulcer, or motion sickness.

Fig. 37.1. Conformers of histamine.

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Table 37.1. Histamine-Related Agonists a

Once released, histamine is rapidly metabolized in vivo (based on products from radiolabeled histamine administered intradermally) to nearly inactive metabolites by two major pathways: N-methylation, and oxidation (Fig. 37.3). Methylation (S-adenosylmethionine), which is catalyzed by the intracellular enzyme N-methyltransferase, yields an inactive metabolite. A portion of the N-methylated metabolite is oxidized sequentially via monoamine oxidase and then via aldehyde oxidase to the corresponding N-methylimidazole acetic acid. Histamine also is oxidized to imidazole acetic acid by diamine oxidase (histaminase). A small amount of this acid intermediate is converted to the corresponding ribotide, an unusual metabolite (5).

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Fig. 37.2. Formation of histamine by decarboxylation of histidine.

Storage and Release of Histamine In mast cells, histamine is stored in secretory granules as a complex with acidic residues of the proteoglycan heparin and in basophils in the blood as a complex with chondroitin sulfate (6,7). Mast cells are distributed in areas of skin and mucous membranes of the respiratory, gastrointestinal, and genitourinary tracts and in tissue adjacent to blood and lymph vessels. Although histamine is secreted at low levels from these mast cells and basophils, the primary mechanism of release is associated with cell activation by immunoglobulin (IgE)–mediated hypersensitivity processes (Fig. 37.4). Immediate hypersensitivity is initiated when allergen molecules cross-link to Fab components of adjacent IgE antibody molecules bound to high-affinity FcεRI receptors on the surface of these cells (FcεRI1 cells). Dimerization of occupied IgE-Fc receptors results in several membrane and cytosolic events. T hese include release of preformed mediators P.1007 from secretory granules by exocytosis, synthesis and release of chemotactic mediators and

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neutral proteases (e.g., tryptase), synthesis and release of other lipid mediators (e.g., leukotrienes and prostaglandins), and stimulation of synthesis of cytokines and their subsequent release. Other cell activation stimuli for the release of histamine include concanavalin A, substance P, polyamines, opiates, and several lymphokines and cytokines. Different subpopulations of cells respond differently to these stimuli. With the exocytotic response, histamine rapidly dissociates from the partially solubilized granule matrix. In basophils, the release process may be slightly different, occurring without degranulation. Other cell types, including lymphocytes, platelets, neutrophils, monocytes, and some macrophages, secrete histamine-releasing factors. T hese cells also have distinct low-affinity receptors for IgE, which when occupied result in secretion of mediators that selectively recruit and activate secondary effector cells in the inflammatory process.

Fig. 37.3. Major metabolic pathways of histamine, from intradermal histamine as measured in the urine in 12 hours in human males (5). HMT, histamine N-methyltransferase; MAO-B, monoamine oxidase type B; DAO, diamineoxidase; ALDH, aldehyde dehydrogenase; ADO, aldehyde oxidase; XO, xanthine oxidase; PRT, phosphoribosyl transferase.

Mast cells play an important role in the early response to allergens, and they provide mediators that lead to initial and late stages of the process and, subsequently, to chronic inflammatory reactions (8,9,10). Early stages appear to be related to degranulation and the release of many mediators, including histamine, prostaglandin D 2 (PGD 2 ) and leukotriene C 4 , platelet-activating factor, adenosine triphosphate (AT P), kinins, and some enzymes (e.g., tryptase and chymase). T hus, additional important mediators other than histamine have very

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significant roles. T hese mediators include platelet-activation factor, substance P, neurokinin A, and others. Besides processes of vasodilation and edema, activation of secondary inflammatory cells occurs, as do adherence of neutrophils and migration of eosinophils and T cells to postcapillary venule endothelial cells. T his latter process is mediated by specific cell adhesion molecules. A further array of mediators and cellular responses follows. A series of interleukins are generated and secreted by subtypes of T cells. Stimulation of many NFκB-mediated gene transcription pathways occurs via H 1 receptor activation. Important cytokines are produced and liberated, including tumor necrosis factor α (T NF-α), interleukin-4 (IL-4), IL-5, IL-1, and IL-6, which are involved in chemokine secretion and regulation of cell maturation and proliferation processes, changes that occur in late-stage inflammatory processes. T hus, the inflammatory cascade is a complex and intricate one, and the effects of histamine are only a small part of the process. Inhibition of the production of many of the proinflammatory cytokines occurs in the presence of many of the H 1 antihistamines. As a result of occupation of H 1 receptors by histamine, constriction of bronchial and gastrointestinal smooth muscle occurs. Spasm of the bronchi to inhaled histamine at one time was a test for airway reactivity. Intradermal injection of histamine produces vasodilation of arterioles as the first step in the “ triple response” mediated via H 1 and H 2 receptors. A flare response follows this stimulation, resulting in release of substance P and other neuropeptides. Edema from exudation of plasma fluids follows because of contraction of endothelial cells of the postcapillary venules. T he wheal and flare responses are mostly H 1 receptor mediated.

Histamine Receptors—M olecular and M echanistic Aspects Histamine receptors are found in various tissues. Among these are the H 1 receptors in smooth muscle of the bronchi, gut, and uterus. Contraction of the bronchi leads to restriction of air flow in the lungs. Histamine increases the permeability of capillary walls. Plasma constituents flow into extracellular spaces because of contraction of endothelial cells; this process leads to edema. At the level of the CNS, histamine secretion appears to be associated with wakefulness, because H 1 receptor antagonism centrally is associated with drowsiness. In the stomach, parietal cell stimulation increases production and secretion of acid, mediated through H 2 receptors. T he H 2 receptors play a minor role in allergic inflammatory processes. T he H 3 receptor is principally an autoreceptor in the CNS at histaminergic neurons, and it is a heteroreceptor on neurons that release other neurotransmitters, also in the brain. T he H 4 receptor is expressed primarily on eosinophils and mast cells, where it is associated with chemotactic responses. P.1008

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Fig. 37.4. Sequence of events in immediate hypersensitivity. Initial contact with an antigen leads to specific IgE synthesis by B cells. Secreted IgE binds to mast cells or basophils through high-affinity Fce receptors (FceRI). On subsequent exposure to the antigen, an immediate hypersensitivity reaction is triggered by cross-linking the IgE molecules.

All the histamine receptors appear to have constitutive receptor G-protein signaling activity independent of the presence of histamine (11). Most of the antihistamines studied are not antagonists, but some are inverse agonists. T hey reduce constitutive G-protein signaling activity. Occasionally, some antihistamines are neutral antagonists, i.e., they do not reduce the constitutive G protein–coupled activity of the receptor. A two-state model of inactive and active conformations of the receptor is consistent with this observation.

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T he human H 1 receptor gene encodes for a 487-amino-acid protein with the signature structural features of G protein–coupled receptors (seven transmembrane domains, N-terminal glycosylation sites, phosphorylation sites for protein kinases A and C, and a large intracellular loop with several serine and threonine residues) (11,12). It is coupled (via G q/11 proteins) to phosphatidyl inositol turnover as the second-messenger system. T he H 1 receptor shows 40% homology with the muscarinic M 1 receptor and the M 2 receptor. An aspartic acid in the third transmembrane domain is highly conserved in several species, and it is suggested to be a recognition site for the protonated aliphatic amine function of histamine at both H 1 and H 2 receptors. Based on mutation studies and homologous positions to α-adrenergic receptors, suggestions for sites of binding of the imidazole portion of histamine to amino acids threonine and/or asparagine in the fifth transmembrane have been made. Signal transduction processes begin with G q/11 -coupled hydrolysis of phosphatidylinositide to inositol-1,4,5-triphosphate and 1,2-diacylglycerol, which occurs via activation of phospholipase C. Elevation of intracellular calcium ion from intracellular stores occurs. Voltage-gated calcium channels may be opened by activation of ion channels permeable to 1

1

Na and K ions. Calcium channel antagonists block some effects of histamine on intestinal smooth muscle. In addition, the H 1 receptor can activate other signaling pathways, including phospholipase D and P.1009 phospholipase A2 , and stimulate NFκB-mediated gene transcription. T he H 2 receptor is a 359-amino-acid protein in humans. It has some features similar to the H 1 protein (e.g., N-terminal glycosylation sites) and phosphorylation sites in the C-terminal. An aspartic acid residue in the third transmembrane loop appears to be critical to agonist and antagonist binding, and threonine/aspartate and tyrosine/aspartate couples in the fifth transmembrane domain appear to be important for interaction of the imidazole part of the histamine molecule. It is positively coupled via G α s to activate adenylyl cyclase for synthesis of cyclic adenosine monophosphate (cAMP) as a second messenger. In some systems, it is coupled through G q proteins to stimulate phospholipase C. It appears in some cells that other processes, such as breakdown of phosphoinositides, control of intracellular calcium ion levels, and phospholipase A2 activity, can be regulated by other cAMP-independent pathways. T he highest density of H 3 receptors occurs in the brain, principally in the striatum, substantia nigra, and the cortex and to a much lesser extent at peripheral nerve terminals. It is a presynaptic auto- and heteroreceptor where activation leads to a decrease in neurotransmitter release. T he most widely studied H 3 receptor is 445 amino acids, but many splice variants have been observed (13). It is activated via G α i/o proteins (coupled negatively to adenylyl cyclase) to the activation of protein kinase A to modulate gene transcription. T he H 3 receptors, via G α i/o proteins, may activate phospholipase A2 , mitogen-activated protein kinase, and phosphatidyl inositol-3-kinase. T he H 3 receptors have low sequence homology with H 1 and H 2 receptors (~ 20% each). Activation of histaminergic neurons centrally, which promotes arousal and attention and improves learning in animals, is a potential target for H 3 receptor antihistamines. Like the H 1 and H 2 antihistamines, the H 3 antihistamines function primarily as inverse agonists. T he H 4 receptors appear to be limited to cells of the hematopoietic system, with expression occurring primarily on eosinophils, basophils, dendritic cells, and T cells. Histamine stimulation results in a chemotactic response, cell migration. T he presence of H 4 receptors on these cells suggests that this receptor plays a role in the inflammatory response. Evidence suggests that it may be regulated via inflammatory stimulation of T NF-α and IL-6. T he H 4 receptor has 390 amino acids and is coupled to inhibition of adenylyl cyclase via G α i/o . It has highest homology with the H 3 receptor (~ 35–40%), with greater homology (58%) of the transmembrane segments. T hus, antihistamines could be useful agents to antagonize the inflammatory response. Agents studied to date also appear to be inverse agonists.

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Inhibitors of Histam ine Release M echanism of Action T he bronchodilatory activity of khellin, a chromone obtained from a plant source (Ammi vi snaga) used by ancient Egyptians for spasmolytic activity, stimulated the search for related compounds with similar pharmacological properties (14). From a study of many bischromones, cromolyn sodium was developed and marketed (Fig. 37.5). Although it prevents bronchospasm, it does not reverse antigen-induced bronchiolar constriction. T hus, it and other agents like it that followed prevent the release of histamine and do not block the effects of histamine at its receptors. T he mechanism by which cromolyn and nedocromil inhibit degranulation of mast cells has been investigated (15). Both agents stimulate phosphorylation of moesin, a 78-kDa protein that is phosphorylated by isozymes of protein kinase C. It is suggested that phosphorylation results in conformational changes that exposes domains that promote association with actin and other proteins of the secretory granules. T his association results in immobilization of the granules and inhibition of exocytosis. Cromolyn and nedocromil (vide infra) apparently inhibit function of cells other than mast cells; these effects may occur during later stages of inflammatory responses. Cromolyn does not have intrinsic antihistaminic or anti-inflammatory activity. Mast cell stabilizers used in the treatment of asthma are additionally discussed in Chapter 44.

Therapeutic Applications of Specific Drugs Cromolyn (Intal, Nasalcrom, Gastrocrom) Cromolyn generally is used prophylactically for bronchial asthma (as an inhaled powder), for prevention of exercise-induced bronchospasm, and for seasonal and perennial allergic rhinitis (nasal solution). T opically, it also is used as eye drops for allergic conjunctivitis and keratitis. In P.1010 the management of asthmatic conditions, it is administered using a power-operated nebulizer. T he bioavailability is very low with oral administration because of poor absorption. By inhalation, the powder is irritating to some patients. After inhalation, much less than 10% of the dose reaches the systemic circulation. An oral dosage form is used for mastocytosis.

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Fig. 37.5. Mast cell degranulation inhibitors.

Nedocromil (Alocril, Tilade) Nedocromil is a chromone analogue also used by inhalation as an aerosol, primarily in the prophylaxis of asthma and reversible obstructive airway disease. It inhibits release of allergic mediators, and it is effective in a broad range of patients. An ophthalmic solution is available for the treatment of seasonal and perennial allergic conjunctivitis. Other structurally related compounds are not currently available in the United States but are available in other markets.

Lodoxamide (Alomide) Lodoxamide, which shows some structural similarities to cromolyn and nedocromil, also is a mast cell stabilizer that inhibits the immediate hypersensitivity reaction, preventing increases in vascular permeability associated with antigen-IgE–mediated responses. Its precise mechanism of action is not completely understood. It is used topically in the eye, principally for conjunctivitis and keratitis associated with vernal allergens.

Pemirolast (Alamast) Pemirolast, with an acidic tetrazole isosteric replacement for a carboxylic acid functionality, is used topically in the eye to prevent itching associated with allergic conjunctivitis. It is an inhibitor of the release of histamine and other inflammatory mediators, including leukotrienes. Significant use as a systemic agent has been reported, and it has been shown to be of value in preventing restenosis after percutaneous coronary angiopathy.

Inhibitors of Released Histam ine

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Historical Background T he first antihistamine was discovered by Forneau and Bovet (16), who observed that piperoxan protected guinea pigs against histamine-induced bronchospasm. T he sensitivity of the guinea pig was initially thought to make it a good model for anaphylaxis. Piperoxan also has important effects related to antagonism of norepinephrine at α-adrenergic receptors.

Antihistamines, specifically H 1 antihistamines (17,18), are useful in the treatment of allergy and inflammatory disorders, in which many but not all effects are mediated via histamine. Compounds that had antagonistic effects in these assays did not antagonize the effects of histamine on the stomach (acid secretion) and heart (positive chronotropic and inotropic effects). T hese differences led to suggestion of the presence of H 1 and H 2 receptors and, ultimately, to the development of selective H 2 antihistamines to diminish the secretion of gastric acid. A third class of histamine receptors, H 3 receptors, appears primarily to consist of autoreceptors that control the synthesis and release of histamine presynaptically and of heteroreceptors that control the release of other transmitters, primarily in the CNS. T he most recent class of histamine receptors, H 4 receptors, are expressed principally on eosinophils and mast cells, where they may play a role in the inflammatory response, especially during the late stages. Classical H 1 antihistamines do not bind to this histamine receptor, and H 4 receptors do not modulate degranulation of mast cells. T he first-generation H 1 antihistamines are useful and effective in the treatment of allergic responses (e.g., hay fever, rhinitis, urticaria, and food allergy). T hese agents also have effects at cholinergic, adrenergic, dopaminergic, and serotonergic receptors. Adverse central effects include sedation, drowsiness, decreased cognitive ability, and somnolence. Peripheral side effects associated with cholinergic blockade include blurred vision, dry mouth, urinary retention, and constipation. Other observed effects have included appetite stimulation, muscle spasm, anxiety, confusion, and occasionally, irritability, tremor, and tachycardia. Of all the side effects, CNS depression is the most common, and it can be so pronounced that some of these agents with short durations of action are used as over-the-counter (OT C) sleep aids. T he separation of CNS depressant and anticholinergic effects from peripheral antihistaminic effects in later agents led to the second-generation antihistamines (vide infra). Structural classes of H 1 antihistamines can be represented by a general structure of two aromatic groups linked through a short chain to a tertiary aliphatic amine (Fig. 37.6). T he aromatic groups (Ar 1 , Ar 2 ) usually are phenyl or substituted phenyl, thienyl, or pyridyl. T hese substituents are attached to the X group, which is a nitrogen atom in the ethylenediamines, a carbon attached to P.1011 an ether oxygen atom in the ethanolamine ether series, or only a carbon atom in the alkyl amines. T he spacer usually is two or three carbons in length, and it may be in a ring, may be branched, and may be saturated or unsaturated. T he R groups attached to the aliphatic amine

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usually are simple alkyl groups, generally methyl or, occasionally, aralkyl groups. One of the early thiophene-containing analogues was carcinogenic in rats. After thiophene versus benzene replacement in other series of compounds demonstrated some toxic effects, thiophene was relegated to one of the low-priority choices for isosteric replacement of a phenyl group.

Fig. 37.6. General structure of first-generation antihistamines.

Most H 1 antihistamines are inverse agonists rather than neutral antagonists. Like other histamine receptors, H 1 receptors have constitutive G protein–coupled activity in the absence of the agonist histamine that results in activation of second-messenger signaling pathways, such as phospholipase C activity and NFκB-mediated gene transcription (19). A model of active and inactive conformations of histamine receptors has been advanced to accommodate these biochemical findings. Inverse agonists bind to the inactive conformation of the receptor, shifting the equilibrium toward the inactive state. Neutral antagonists interact with both conformations of the receptor.

First-Generation H 1 Antihistamines Ethylenediamines T he earliest series of H 1 antihistamines is the ethylenediamines. T wo 2-carbon spacers may appear between the two nitrogen atoms in the piperazine series (vide infra). Examples of agents in the ethylenediamine class, of which phenbenzamine was the first of these agents, appear in T able 37.2. Compounds with several different but closely related aromatic rings are useful, such as phenyl, 2-pyridyl, halogen- and methoxy-substituted phenyl, or pyrimidyl. T hiazole-, furanyl-, and thiophene-ring congeners also were available in the past. T he small alkyl substituents on basic nitrogen usually are methyl groups. A number of these agents are still used. With the exception of antazoline, all have the ethylenediamine spacer. In antazoline, the alkyl tertiary amine in phenbenzamine is replaced with an imidazoline group. Central nervous system effects, usually sedation, are very common among agents in this class. Information regarding pharmacokinetic and metabolic disposition is limited, because this early group of compounds was not studied in depth. Only later, with second-generation H 1 antihistamines, and/or when issues of potential toxicity have arisen concerning some of the early compounds, has the metabolic disposition been examined more completely. T hus, the available information concerning the metabolism on these early antihistamines is sparse. From some of the ethylenediamines, expected products of N-demethylation and subsequent deamination have been reported. In addition, some produce quaternary N-glucuronides as

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urinary metabolites, a process that occurs, to some extent, in many relatively unhindered tertiary aliphatic amines among the antihistamines and also in other lipophilic aliphatic tertiary amine drug classes.

Table 37.2. Examples of Ethylenediamine Anthistamines

Ethanolamine Ethers Structure activity relationships T he prototype of the aminoalkyl ethers is diphenhydramine, a benzhydryl ether which more than a half-century after its introduction remains still widely used for allergic conditions. Structural analogues with various ring substituents (Me, OMe, Cl, and Br) in one of the aromatic rings also have been developed, as have compounds with a 2-pyridyl group replacing one of the phenyl groups (T able 37.3). Significant anticholinergic side effects are observed among members of the group (e.g., dry mouth, blurred vision, tachycardia, urinary retention, and constipation). It should be noted that diphenydramine is used in the treatment of parkinsonism because of its central anticholinergic properties. Other anticholinergic agents that are structurally related to the benzydryl ether antihistamines also are used in the treatment of parkinsonism (see Chapter 25). Sedative properties are very common as well. Sedation, accompanied by a short half-life and a wide margin of safety, allows some of these compounds to be used as OT C sleep aids. T he 8-chlorotheophyllinate salt of diphenhydramine is marketed as dimenhydrinate for use in the treatment of motion sickness. T he compound with the aryl groups p-Cl-Ph and 2-pyridyl is carbinoxamine, a potent antihistamine. Substitution of a methyl group at the carbon α to the ether function affords the related compound doxylamine, in which the aryl groups are phenyl and 2-pyridyl. Clemastine, a P.1012

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homologue with an additional carbon atom between the oxygen and the basic nitrogen, which is incorporated into a ring, is a recent addition to the group, with less sedative properties. Other analogues are used elsewhere. For example, setastine, a compound with the alkyl amine substituent being incorporated into a 7-membered hexahydroazepine ring, is available in Europe.

Table 37.3. Ethanolamine Ether Antihistamines

Antihistaminic versus anticholinergic activity Besides the structural analogues in T able 37.3 that possess increased selectivity for histamine H 1 receptors over muscarinic receptors, introduction of alkyl substituents at C-2' or C-4' of one aromatic ring results in significant changes in selectivity in tissue-based assays for antihistaminic versus anticholinergic activity. With increasing alkyl group size (Me, Et, iPr, and tBu) at C-2', large decreases in antihistaminic activity and increases in anticholinergic activity are observed (20). With larger alkyl groups, the possible spatial orientations of the two aromatic rings with regard to each other are limited because of increasing rotameric restrictions. Introduction of these alkyl substituents at C-4' decreases anticholinergic activity and yields small increases in antihistaminic activity. A chiral center is introduced with these changes, and differences in pharmacological properties of the enantiomers of each compound are observed. T wo examples are shown in T able 37.4.

Stereochemical and structural effects T he observed differences in potency of enantiomers in tissue-based assays suggest significant stereoselective interactions of antagonists at the receptor level. Differences in

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affinity of 60- to 200-fold are noted between enantiomers in several analogues where the chiral center results because of differences in the two aromatic rings, such as Ph and 2-pyridyl, or Ph and p-Br-Ph (21). Enantiomers with the S-absolute configuration usually are more potent. Clemastine, a more complex homologue, is marketed as the R,R-enantiomer, which is the more potent of the R,R- and S,S-enantiomeric pair and more potent than either the R,S- and S,R-enantiomers of the other diastereomer (22). Consistent with results from related compounds, the chiral center at the benzhydryl carbon has a significant influence on potency, whereas the one in the pyrrolidine ring is of lesser importance (T able 37.5).

Table 37.4. Antihistamine and Anticholinergic Activity of Enantiomers of Ring Substituted Ethanolamine Ethers (20)

Very small changes in the arrangement of aromatic groups in the members of the ethanolamine ether series significantly alter the scope of their pharmacological properties. Previous work has shown that the two aromatic rings in diphenhydramine can be located slightly differently with respect to each other, as in phenyltoloxamine, a potent antihistamine. A retro arrangement of carbon and oxygen atoms, however, prepared in an P.1013 attempt to investigate structural requirements for antihistamines, afforded significantly different pharmacological properties and, ultimately, led to a series of very important selective serotonin reuptake inhibitors, such as fluoxetine (Fig. 37.7). Unlike the bio-isosteric oxygen to nitrogen atom replacement, conversion of the oxygen atom to a sulfur atom in the diphenhydramine series results in a compound with greatly decreased antihistaminic activity (23).

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Table 37.5. Antihistamine Activity of Stereoisomers of Clemastine (22)

Fig. 37.7. Structural similarities among diphenhydramine-related structures.

Metabolism Only limited information regarding the metabolic disposition of this group of compounds is available. As expected, N-demethylation (formation of the corresponding secondary amine) and subsequent deamination (formation of the carboxylic acid metabolite) is a major pathway for diphenydramine (Fig. 37.8) and some of its analogues. Although the early experiments are relatively incomplete, it appears that the N-demethylation products have shorter half-lives than the corresponding parent drugs, and they probably contribute very little to the observed antihistaminic properties. Minor metabolites that are conjugates of the carboxylic acid products of deamination or of ether cleavage products have been found in some animal species. Compounds with shorter half lives, like diphenhydramine, when used as antihistamines require repeated administration, but a very short half life is an advantage

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when the same drugs are used as sleep aids (17,18).

Fig. 37.8. Metabolism of diphenhydramine.

Alkyl Amines A third class of analogues is one in which a carbon atom replaces the heteroatom spacer in the general structure. Examples are pheniramine, chlorpheniramine, brompheniramine, and the E-isomers of olefinic homologues (Fig. 37.9). T he ring halogen–substituted compounds are widely used OT C antihistamines for mild seasonal allergies. T hese agents are characterized by a long duration of antihistaminic action and by a decreased incidence of central sedative side effects compared to the ethylenediamines and ethanolamine ether series. T his structural change introduces a chiral carbon when the two aromatic rings are different (e.g., Ph and 2-pyridyl). T hese were the most extensively used antihistamines until the more selective second-generation antihistamines appeared.

Structural and stereochemical effects E- and Z-isomers of the alkenes in this series show very large differences in potency in tissue-based assays. For example, E-pyrrobutamine is more potent than its Z-isomer by 165-fold, and E-triprolidine (Fig. 37.9) is more potent than its Z-isomer by approximately 1,000-fold (2). Dimethidene has many of the structural features of both of these two agents in a more complex, cyclized structure. T he observed difference in potency between the E- and Z-isomers shows that the two aromatic rings probably have quite different binding environments at the receptor (24). T hese observations provide evidence suggesting that a 5to 6-Å distance between the tertiary aliphatic amine and one of the aromatic rings is required at the site of receptor binding (Fig. 37.10) (25). Differences in potency between the enantiomers of the conformationally mobile amino-alkanes also have been P.1014 observed. T he S-enantiomers have greater affinity for H 1 histamine receptors, occasionally by very large amounts, such as 200- to 1,000-fold in radioligand displacement assays and in tissue-based assays for S-(+ )- versus R-(–)-chlorpheniramine, with the (+ )-enantiomer being more potent (Ar= R-Ph, 2-pyridyl) (Fig. 37.9). Greater selectivity for H 1 receptors versus muscarinic and adrenergic receptors is observed as well. For members of the series, the chiral center of the more potent enantiomer correlates stereochemically with the more active enantiomer of the oxygen congener carbinoxamine (T able 37.3) (2,26). Single enantiomers of these agents are available (e.g., dexchlorpheniramine and dexbrompheniramine).

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Fig. 37.9. Examples of alkane and alkene antihistamines.

Fig. 37.10. Potential binding sites based on E/Z-configurations.

Half-life and metabolism T he alkyl amines have significantly less CNS-depressant effects than benzhydryl ethers of ethanolamines. Additionally, these compounds have long half-lives and extended durations of action. T hese agents have decreased antiemetic effects and decreased anticholinergic properties compared to ethanolamine ethers. Many are available in OT C preparations for hay

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fever and other mild allergic conditions, sometimes in combination with adrenergic decongestants. Most are suitable for once-a-day dosing because of their long half-lives (up to 24 hours), although they are routinely administered more frequently. Information concerning the metabolic disposition of some these agents has been reported. As expected, N-dealkylation is a major pathway, with the corresponding secondary and primary amines, as well as the parent drug, being found in the plasma.

Piperazines Members of the piperazine class of agents are structurally related to both the ethylenediamines and the benzhydryl ethers of ethanolamines. T heir structures include the 2-carbon separation between nitrogen atoms, which is incorporated into the piperazine ring (T able 37.6). Diarylmethylene groups (benzhydryl substituents, as in diphenhydramine) are attached to one of the nitrogen atoms, and an alkyl or aralkyl substituent is attached to the other nitrogen. Early compounds, such as cyclizine, chlorcyclizine, meclizine, buclizine, and hydroxyzine, have been widely used as antihistamines and as agents for treatment of motion sickness, because they have useful central antiemetic effects. T hese agents also have significant anticholinergic and antihistaminic properties. Anticholinergic side effects and drowsiness are common. T he primary use of these compounds remains treatment of motion sickness and vertigo and suppression of nausea and vomiting. Although teratogenic effects of cyclizine and meclizine have been observed in rodents, large studies have not demonstrated adverse fetal effects in humans; however, these agents are used cautiously in pregnant women and children. Oxatomide is used in Europe principally in allergic rhinitis, urticaria, and in combination with albuterol in asthma. Drowsiness and sedation are noted. Hydroxyzine is used in treatment of pruritis, and at higher dosages, it is used in the management of anxiety and emotional stress. Its acid metabolite, cetirizine, which is formed from oxidation of the terminal primary alcohol to the corresponding carboxylic acid, usually is classified with the second-generation, nonsedating antihistamines. T he amphoteric nature of cetirizine, having both the tertiary aliphatic amine and carboxylic acid functional groups, appears to be associated with decreased, but not absent, sedative side effects.

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Table 37.6. Examples of Tricyclic Antihistamines

Tricyclic H 1 Antihistamines T he two aromatic groups noted in several of the classes of antihistamines can be connected to each other through additional atoms (e.g., heteroatoms like sulfur or oxygen) or through a short, 1- or 2-carbon chain. T hey have a general structure shown in Figure 37.11. T he earliest potent tricyclic antihistamines (T able 37.7) were phenothiazines (Y= S, X= N). T he phenothiazine antihistamines contain a 2- or 3-carbon, branched alkyl chain between the nonbasic phenothiazine nitrogen and the aliphatic amine. T hey differ from the antipsychotic phenothiazine derivatives in which the chain usually is three P.1015 carbons long, unbranched, and usually, without substituents in the aromatic ring. Besides useful antihistaminic effects, most have pronounced sedative effects and long durations of action. Other uses include the treatment of nausea and vomiting associated with anesthesia and for the treatment of motion sickness.

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Fig. 37.11. General structure of tricyclic antihistamines.

Conformational and stereochemical effects In the active agents, the steric restrictions and decreased degrees of conformational freedom resulting from the connection of the two aromatic rings together suggests that certain spatial relationships between these two rings are acceptable in the drug–receptor interaction of H 1 antihistamines. T hese ring systems are not flat but, rather, are somewhat puckered, with the two aromatic rings not in the same plane. Usually, however, the conformations undergo rapid intraconversion. In some closely related systems, in which this intraconversion is very slow, conformational enantiomers (atropisomers) have been obtained and studied, including cyproheptadine, doxepine, and hydroxylated metabolites of loratadine (27,28). T he enantiomers of 3-methoxycyproheptadine have significantly different pharmacological potency as antihistamines, antiserotonin, and anticholinergic agents (Fig. 37.12) (29). T he (–)-isomer retained antihistaminic, antiserotonin, and appetite-stimulating effects similar to cyproheptadine, whereas the (+)-enantiomer had greater anticholinerigic potency. Differences of 9- to 60-fold have been observed in the reported assays.

Table 37.7. Examples of Tricyclic Antihistamines.

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Promethazine, an early agent in the series, has many useful pharmacological affects other than being an antihistamine. It has significant antiemetic and anticholinergic properties. It also has sedative-hypnotic properties and has been used to potentiate the effects of analgesic drugs. Subsequent analogues, such as trimeprazine and methdilazine, are used as antipruritic agents in the treatment of urticaria. Compounds in which the sulfur atom is replaced with another bridge (e.g., two methylene groups) also are available. Some have a pyridine ring replacing one of the benzenoid systems. Cyproheptadine, with a 2-carbon spacer between the aromatic rings, also has anticholinergic, antiserotonergic, and appetite-stimulating properties, which are useful in treatment of anorexic nervosa and in cachexia. T he pyridine analogue apparently lacks most of these qualities. Doxepine, an oxygen-containing congener of cyproheptadine, also has significant affinity for other receptors, and it has CNS-depressant qualities. It exists as a mixture of Z- and E-isomers (15:85) in its olefinic, nonpiperidine side chain. In tissue-based assays, the Z-isomer is more potent than the E-isomer by more than threefold (27). T he most widely used among the group is loratadine, which is considered to be in the category of nonsedating, second-generation antihistamines (vide infra).

Metabolism Information regarding the metabolic disposition and pharmacokinetic properties of agents in this group is limited, including incomplete identification of primary metabolic pathways, results of liver microsomal metabolic experiments, and only occasionally, pharmacokinetic information. In humans, products from the P.1016 phenothiazines include products of N-demethylation, aromatic hydroxylation, and occasionally, sulfoxidation. From tricyclic analogues, metabolites resulting from N-demethylation, aromatic hydroxylation, and formation of N-quaternary glucuronides have been reported (30).

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Fig. 37.12. Enantiomers (antropisomers) of 3-methoxycyproheptadine.

Second-Generation Nonsedating H 1 Antihistamines Background T he second-generation antihistamines marketed over the last 20 to 25 years have improved H 1 selectivity, have little or no sedative qualities, and they may have antiallergic effects apart from antihistaminic activity (31). T hey vary widely in structure (T able 37.8) but less so in pharmacological properties, having effects principally in the periphery. Structural resemblance to the first-generation H 1 antagonists is not always obvious. because some of these agents were discovered while investigating new molecular structures for other pharmacological targets. T hese agents possess selective peripheral H 1 antihistaminic effects, and they usually have less anticholinergic activity. Furthermore, they also have decreased affinity for adrenergic and/or serotonergic receptors and limited CNS effects. T he active agents apparently do not penetrate the blood-brain barrier significantly, perhaps because of their amphoteric nature (most are zwitterionic at physiological pH) and partitioning characteristics and/or because they are substrates for the drug efflux P-glycoprotein transporter or organic anion transporter proteins. A slow rate of dissociation from H 1 receptors also is reported for some of the agents. Several have antiallergic properties that are separate from their antihistaminic properties, which are not thoroughly understood. In most cases, the parent drug or its important metabolites have half-lives that are sufficiently long to account for the extended duration of action (32). Most are administered once daily.

Table 37.8. Second Generation Non-sedating Antihistamines

Specific Drugs Fexofenadine (Allegra) and terfenadine

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Pharmacological Effects T his group of nonsedating antihistamines usually is thought to include fexofenadine and its parent terfenadine, astemizole, cetirizine, and loratadine and its metabolite desloratadine. T erfenadine was synthesized as an analogue of azacyclanol in a search for antipsychotic agents. T he initial reports of its antihistaminic properties included the observation of similar effects of it acid metabolite fexofenadine (33). Whereas terfenadine is no longer available, it was once a very widely used nonsedating antihistamine. Extensive clinical experience resulted in the reports of dangerous cardiac arrhythmias occurring occasionally when certain other drugs were taken concomitantly. T hese cardiac arrhythmias included prolongation of the QT interval and torsades de pointes, a life-threatening ventricular arrhythmia. T hese cardiac effects are now known to be associated with blockade of the hERG (human ether-a-go-go) gene product, the α-subunit of an inward rectifying cardiac K + channel (34,35). T hese effects are associated only with the parent molecule. T he side effects occur primarily at high concentrations of this lipophilic amine and, usually, in the presence of other CYP3A4 substrates, such as ketoconazole or macrolide antibiotics (e.g., triacetyloleandomycin). In the presence of competing CYP3A4 substrates and inhibitors, P.1017 high plasma concentrations of the parent agent have resulted.

Metabolism Fexofenadine, the carboxylic acid metabolite of terfenadine, is widely available (Fig. 37.13). It accounts for the antihistaminic properties of terfenadine, which is very rapidly metabolized via CYP3A4-catalyzed processes. Members of the organic anion transporter protein family and the drug efflux transporter P-glycoprotein are involved in the disposition of fexofenadine. Fexofenadine does not have the antiarrhythmic side effects of terfenadine. T erfenadine and other lipophilic amines (e.g. astemizole, another second-generation antihistamine that is no longer marketed, grepafloxacin, thioridazine, sertrindole, and cisapride) are all aliphatic amines containing one or more aromatic groups (34). Each has been associated with life-threatening cardiac arrhythmias associated with binding to the hERG K 1 ion channel. T he disposition of each depends significantly on CYP3A4 for its oxidative metabolism so that in the presence of inhibitors or competitive substrates, significantly elevated plasma levels are observed. Screening of potential drug candidates for interaction with this ion channel in radioligand displacement assays is done routinely to attempt to develop safe new drugs. Similarly, proof of safety of agents that are primarily CYP3A4 substrates is required. Studies regarding the effect of high-dose ketoconazole on the plasma levels of the drug in vivo usually are required.

Loratadine (Claritin) and desloratadine (Clarinex) Pharmacological Effects Loratadine (T able 37.8) is related to the first-generation tricyclic antihistamines and to antidepressants. It is nonsedating, and neither it nor its major metabolite, desloratadine (descarboethoxyloratadine), is associated with the potentially cardiotoxic effects reported for terfenadine and astemizole. On chronic dosing, the AUC (plasma concentration–time curve) for the metabolite is greater than that for the parent drug, and its half-life is longer. Desloratadine is a more potent H 1 antagonist and more potent inhibitor of histamine release. T his metabolite, which probably accounts for the effects of loratadine, has been marketed. T he hydroxylated metabolite of desloratadine, the 3′-hydroxylated product, may contribute to the pharmacological properties of desloratadine (36).

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Fig. 37.13. Metabolism of terfenadine leading to fexofenadine.

Fig. 37.14. Metabolism of loratidine.

Metabolism T he metabolic conversion of loratadine to descarboethoxyloratadine occurs via an oxidative process and not via direct hydrolysis (Fig. 37.14). Both CYP2D6 and CYP3A4 appear to be the CYP450 isozymes catalyzing this oxidative metabolic process (37). Apparently, the metabolite does not reach the CNS in significant concentrations. Among the nonsedating second-generation antihistamines, this metabolite appears to be the only nonzwitterionic species. T he failure of zwitterionic molecules to reach CNS sites in significant concentrations can be rationalized readily, but a similar explanation is not apparent for loratadine or its metabolite. Competitive substrates for CYP3A4 do not produce a significant drug–drug 1

interaction, because the parent molecule lacks effects on hERG K channel in cardiac tissue.

Cetirizine (Zyrtec) and levocetirizine (Xysal, Xusal)

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Cetirizine, the acid metabolite from oxidation of the primary alcohol of the antihistamine hydroxyzine (Fig. 37.15 and T able 37.6), is a widely used antihistamine (38). It has a long duration of action and is highly selective for H 1 receptors. No cardiotoxicity has been reported, but some drowsiness occurs. T he R-enantiomer of cetirizine, levocetirizine, is marketed in Europe. Levocetirizine has higher affinity than its S-enantiomer for the H 1 receptor (> 30-fold) and is more slowly dissociated by more than 20-fold from the receptor (39). T hus, the antihistaminic P.1018 properties of cetirizine probably are accounted for by the R-enantiomer. Similar large differences in ratios of dissociation rates and K i values for closely related enantiomers also are reported.

Fig. 37.15. Metabolism of hydroxyzine to cetirizine.

Acrivastine (Semprex) Acrivastine, an acidic congener of triprolidine in which a carboxylic acid–substituted chain has been attached, also is a second-generation, nonsedating antihistamine. Penetration of the blood-brain barrier is limited, and it is less sedating than triprolidine. It is used principally in a combination with a decongestant.

Ebastine (Kestine) and carebastine Benzhydryl ethers of piperidinols also are useful antihistamines. T hose with large N-substituents, like those in terfenadine and other nonsedating antihistamines, are most successful. Ebastine (T able 37.8), which is similar structurally to terfenadine, is a potent selective H 1 antihistamine as measured in radioligand displacement assays. In these assays, its acid metabolite has significantly higher affinity than the parent molecule. It is nonsedating and, apparently, free of anticholinergic effects (40). Like some other second-generation antihistamines, ebastine blocks release of PGD 2 and leukotriene C 4 /D 4 in cellular assays. Pharmacokinetic data indicate that its acid metabolite carebastine is responsible for its antihistaminic properties, because the parent drug has a very short half-life and the active metabolite a much longer one (Fig. 37.16). In an animal model of torsades de pointes, ebastine, at a high dose, produced significant cardiac conduction abnormalities (e.g., prolongation of the QT interval), whereas the metabolite did not. At lower doses, these effects occurred only in the presence of competitive CYP3A4 substrates. Some in vitro data, however, suggest CYP450 isozymes other than CYP3A4 may be important in the initial hydroxylation. T he pharmacologically active acid metabolite carebastine is metabolically analogous to fexofenadine (oxidation of a t-butyl group), the acid metabolite of terfenadine.

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Ebastine is marketed in several countries but not in the United States.

Mizolastine (Mizollen) Misolastine (T able 37.8) is a second-generation, nonsedating antihistamine that structurally resembles astemizole (41). It has an extended half-life of 7.3 to 17.1 hours and is highly bound to plasma protein (~ 95%). Metabolism occurs primarily through glucuronidation, and only small amounts of the compound are metabolized oxidatively. T he AUC increases approximately twofold in the presence of ketoconazole, a CYP3A4 substrate and inhibitor. 1

Only weak interaction with the hERG K channel is reported, along with weak interactions with muscarinic receptors. Presently, it is only available in Europe.

Fig. 37.16. Metabolism of ebastine to carebastine.

Topical H 1 Antihistamines Therapeutic Applications T opical application of H 1 antihistamines to the eye is made to relieve itching, congestion of the conjunctiva, and erythema (15,42). T he density of mast cells in the conjunctiva is high, and the histamine concentrations in tear film are significant in the ocular allergic response. From eye drops, only small amounts of the antihistamine (1–5%) penetrate the cornea. More of the compound is absorbed via the conjunctiva and nasal mucosa, and still more ends up swallowed from tear duct and nasal drainage. Until recently, topical ocular antihistamines were limited to two classical agents: antazoline (T able 37.2), from the ethylenediamine series, and pheniramine (Fig. 37.9), from the alkylamine series. Both are used in combination with sympathomimetic vasoconstrictors. A slow rate of receptor dissociation of H 1 antagonists is associated with long duration of action systemically, which occurs with the more recently available ocular antihistamines. Based on correlations of pK a values and lipophilicity data, it appears that compounds with a log D (the sum of the partition coefficients of both the ionized and unionized species) near 1.0 60.5 at pH 7.4 are most efficacious, and their water-soluble salts also show a low incidence of ocular irritation. Relationships between partitioning characteristics of these and other antihistamines indicate (at least moderate) receptor affinity and that a particular range of optimal lipophilicity for topical ocular antihistamines with minimal ocular irritation (43). Some of these compounds are currently available (T able 37.9) or are being evaluated as nasal sprays, and some also are occasionally used as systemic antihistamines.

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Specific Drugs Olopatadine (Patanol) Olopatadine (T able 37.9) is structurally related to the tricyclic antihistamines. It has a long duration of action when applied topically, and it also appears to inhibit the release of inflammatory mediators (e.g., histamine, tryptase, and PGD 2 ) from mast cells. Its selectivity for H 1 receptors in tissue assays (over H 2 and H 3 receptors) is very high, and its selectivity for H 1 receptor blockade over α-adrenergic, dopaminergic, serotonergic, and muscarinic receptors also is very high. Olopatadine is reported to have a rapid onset of action and a long duration of action, consistent with high P.1019 histamine receptor affinity and a slow rate of receptor dissociation. T he presence of the carboxylic acid side chain apparently is responsible for the observed lack of muscarinic receptor affinity. T his feature also may be responsible for limited penetration. Olapatadine also a mast cell stabilizer as well. T he mechanism for this activity has not been delineated, but it has been shown to stabilize model cell membranes by interaction with phospholipid monolayers.

Table 37.9. Topical Antihistamines

Levocobastine (Livostin) Levocobastine is a potent, selective H 1 receptor antagonist used topically in eye drops for

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seasonal allergic conjunctivitis. A small amount of systemic absorption of the compound is reported. T he agent also prevents release of transmitters from mast cells. A nasal spray used for allergic rhinitis is available outside the United States.

Emedastine (Emadine) Emedastine also is a newer antihistamine used topically in the eye for conjunctivitis. It has very high H 1 receptor selectivity characteristics, and it is structurally related to the benzimidazoles, such as astemizole. Inhibition of mast cell release of inflammatory mediators has been noted.

Azelastine (Astelin) Azelastine, although not a close structural analogue to the benzimidazoles, has some structural similarities to them. It is used as a nasal spray for allergic rhinitis and as eye drops for allergic conjunctivitis. Like olopatadine, azelastine also stabilizes mast cells, preventing degranulation and subsequent release of histamine, leukotrienes, and PGD 2 . It is available in Europe for systemic use in the treatment of asthma and seasonal allergies. Besides antihistaminic effects, it also may block release of histamine and other inflammatory mediators from mast cells. When administered orally, the N-dealkylated metabolite appears to contribute significantly to its pharmacological effects.

Ketotifen (Zaditor) Ketotifen is a potent, selective H 1 antihistamine that also prevents release of transmitters from mast cells. It is approved in the United States for topical use to prevent itching of the eye because of allergic conjunctivitis, It is used as a systemic antiallergy agent in several countries outside the United States for the treatment of seasonal allergic rhinitis, hay fever, and asthma. Being structurally analogous to the cyproheptadine-like antihistamines, differences in activity of the two enantiomers (atropisomers) has been noted, being approximately six- to seven-fold in ligand displacement and rodent-based assays (44). Ketotifen has been shown to stabilize mast cells and to inhibit degranulation of eosinophils. Like olopatadine, it has been shown to interact with model membranes, stabilizing them by interaction with phospholipids monolayers.

Epinastine (Elestat) Epinastine is a potent, long-acting H 1 antihistamine and an inhibitor of the release of histamine and other transmitters from mast cells. It has some affinity for H 2 receptors as well. It is used as an eye drop for allergic conjunctivitis. It does not penetrate into the CNS and is classified as a nonsedating antihistamine.

Antiulcer Agents Background T he secretion of gastric acid occurs at the level of parietal cells of the oxyntic gland in the gastric mucosa (Fig. 37.17), producing 2 to 3 L of gastric juice per day, pH 1 in hydrochloric +

1

acid. Ultimately, this secretory process occurs via an H ,K -AT Pase that exchanges +

hydronium ion (H 3 O ) with uptake of a potassium ion. Several mediators regulate this secretion by way of receptor systems on the basolateral membrane. T he H 2 histaminergic pathway is cAMP dependent. Gastrin and muscarinic receptors also regulate the secretion of gastric acid through calcium ion dependent pathways. In parietal cells, E-series prostaglandins work in opposition to the histaminergic pathway, inhibiting histaminestimulated adenylyl cyclase activity. Other epithelial cells in the mucosal lining under the influence of prostaglandin-mediated pathways secrete bicarbonate and mucus, both of which are important in protecting the gastric lining from the effects of acid secretion. In many cases,

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hypersecretion of gastric acid appears to be associated with Hel i cobacter pyl ori infection, which may contribute to defects in mucosal protective defenses. Evidence suggests that some H 2 antihistamines, particularly cimetidine and ranitidine, have regulatory effects on T -cell lymphocyte proliferation by augmenting cytokine production and Ig P.1020 production. T hese effects may not be associated with histamine receptors and may not be shared by nizatidine and famotidine.

Fig. 37.17. Secretion of gastric acid and peptic ulcer disease. Histamine is secreted from and endochromaffin-like (ECL) cell, which is innervated by muscarinic receptors (M) via the enteric nervous system and by gastrin receptors (G). Agonist occupation of histamine H 2 receptors in parietal cells lead to gastric acid secretion. Other input at parietal cells includes the prostaglandins (PGs), gastrin, and muscarinic receptors. (Adapted from Hoogerwerf WA, Pasricha PJ. Pharmacotherapy of gastric acidity, peptic ulcers, and gastroesophageal reflux disease. In: Hardman JG, Limbird LE, Mollinoff PB, et al., eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 11th Ed. New York: McGraw-Hill, 2005:968; with permission.)

Therapeutic Applications of H 2 Antihistamines T he H 2 antihistamines are used in the treatment of duodenal ulcers, gastric ulcers, gastroesophageal reflux disease (GERD), pathological hypersensitivity disorders, and upper gastrointestinal bleeding in critically ill patients and are sold OT C for acid indigestion (45).

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T hey also are included in multidrug treatment protocols for eradication of H. pyl ori in treatment of peptic ulcers and before surgery to prevent aspiration pneumonitis. Like H 1 antihistamines, H 2 antihistamines are inverse agonists that block the basal level of activity at this receptor. Combinations of H 1 and H 2 antihistamines are useful in idiopathic urticaria not responding to H 1 antihistamines alone and in itching and flushing of anaphylaxis, pruritis, and contact dermatitis.

Structural requirements T he H 2 antihistamines specifically designed to decrease the secretion of gastric acid are based on an extensive investigative approach to drug design that began from the structures of partial agonist molecules very closely related to histamine (46). Ultimately, this work resulted in the development of cimetidine (T able 37.10), in which the imidazole ring like that of histamine is maintained. T he imidazole ring is substituted with a C-4 methyl group, which in histamine agonists affords H 2 selectivity; a four-atom side chain, which includes one sulfur atom (the sulfur atom increases potency compared to carbon and oxygen congeners); and a terminal polar nonbasic unit, in this case an N-cyanoguanidine substituent. Guanidines substituted with electron-withdrawing groups have significantly decreased basicity compared to guanidine, and they are neutral (nonprotonated) at physiological pH. T hus, these are logical substituents to replace the terminal thiourea feature in unsuccessful earlier homologous candidates, metiamide and burimamide. T he former agent was not marketed because of untoward effects, including agranulocytosis, and the latter agent lacked significant oral bioavailability. Subsequently, the nitromethylene unit was a replacement of the N-cyanoimino group in the substituted guanidine analogues, affording compounds of increased potency. Replacement for the imidazole ring with other heteroaromatic rings resulted in other useful analogues. P.1021

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Table 37.10. H 2 Receptor Antihistamines

Metabolism Cimetidine, ranitidine, and famotidine are subject to first-pass metabolism, and each has oral bioavailability of approximately 50%. T he oral bioavailability of nizatidine is approximately 90%. All have half-lives of 1.5 to 4.0 hours, with that of nizatidine being the shortest. Significant amounts of each of these H 2 antihistamines are excreted unchanged, with small amounts of urinary products of sulfoxidation being a common metabolic feature. As expected, hydroxylation of the imidazole C-4 methyl group of cimetidine occurs. Ranitidine is excreted largely unchanged, but minor metabolic pathways include N-demethylation as well as N- and S-oxidation. T he metabolites are not thought to contribute to the therapeutic properties of the parent drugs, with the exception of nizatidine, from which the N-desmethyl metabolite retains H 2 antihistamine activity (47).

Side effects and drug interactions Cimetidine, the earliest of these agents, shows the greatest number of drug interactions (48). Among them are somnolence and confusion in elderly patients with decreased renal function. Gynecomastia, presumably related to increased prolactin secretion, has been reported. Cimetidine inhibits CYP450-dependent metabolic processes, affording increased concentration of several agents, the most important being those having narrow therapeutic concentration windows (e.g., phenytoin, theophylline, some benzodiazepines, warfarin, and

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quinidine). Inhibition of several CYP450 oxidative processes is associated with the presence of imidazole ring of cimetidine, which apparently replaces the histidine that serves as a ligand to the porphyrin iron in CYP450 enzymes. Other agents in this group contain heterocyclic rings other than imidazole and do not show this effect. Cimetidine is an inhibitor of renal tubular secretion of some drugs (e.g., procainamide). T hese tubular secretion effects also are less prevalent or even absent with other agents in this class. T he other agents in the group are more potent than cimetidine, and significant differences are noted among them. Of these, ranitidine is the most widely used. T he agents have OT C status and are widely available for gastric hyperacidity.

Proton Pump Inhibitors Proton pump inhibitors are widely used in the treatment of duodenal and gastric ulcer, erosive esophagitis, GERD, GERD-related laryngitis, and hypersecretory conditions (e.g., ZollingerEllison syndrome) (49,50). T he final step in acid secretion in parietal cells of the gastric +

+

mucosa is a process mediated by H ,K -AT Pase, the gastric proton pump, an enzyme with +

+

+

+

significant homology to Na ,K -AT Pase. T his H ,K -AT Pase has some similarities to the +

+

H ,K -AT Pase in osteoclasts, which is involved in bone resorption. Gastric acid secretion can be inhibited in many ways. T hese include by antagonists at muscarinic, gastrin, or histamine H 2 receptors; by agonists at inhibitory receptors for prostaglandins and somatostatin; by proton pump inhibitors; or by carbonic anhydrase inhibitors.

Mechanism of action Omeprazole, lansoprazole, and related analogues (T able 37.11), produce inhibition of stimulated gastric acid secretion irrespective of the receptor stimulation process. Nearly all the compounds are close structural relatives, being weakly basic 2-pyridylmethylsulfinylbenzimidazoles. An analogue, tenatoprazole, which is an imidazopyridine isostere, is currently in clinical trials.

Table 37.11. H + /K + -ATPase Proton Pump Inhibitors

P.1022 Only a few successful changes of the heterocyclic rings are possible (51). T hese agents have irreversible effects on the secretion of gastric acid, because the molecule rearranges in the strongly acidic environment of the parietal cell. Covalent binding of the rearranged inhibitor to

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+

+

the H ,K -AT Pase results in inactivation of the catalytic function of the proton pump. Evidence indicates that two molecules of the intermediate from omeprazole are bound to the active site; one of these sites has been identified as cysteine-813 (and, probably, +

+

cysteine-892 and/or -822) of the cysteine-rich H ,K -AT Pase (52). T hese cysteines are in different environments (e.g., exposed to the lumen or in the membrane), and different proton pump inhibitors bind differentially to them and other sulfhydryl groups. In the covalent binding, disulfide bonds are formed with the receptor. Analogous, but slightly different, results are reported for lansoprazole, pantoprazole, and rabeprazole (53). A chemical mechanism for the process is shown in Figure 37.18. Because the initial rearrangement only occurs at a strongly acidic pH, acid-stable oral dosage forms are used that allow dissolution, release, and absorption of drug in the duodenum (e.g., enteric-coated granules in capsules or enteric-coated tablets). More recently, granular preparations of lansoprazole (enteric-coated granules) and omeprazole (with sodium bicarbonate) have become available. Intravenous dosage forms of lansoprazole, pantoprazole and esomeprazole are also available. T he acid-catalyzed rearrangement of absorbed drug then occurs selectively in the acidic environment of the canaliculus, as it is secreted into the gastric lumen from the parietal cells. Some differences may occur in the sites of binding of the agents, and differences have been noted in recovery times, with rabeprazole have a shorter duration of action (54). T enatoprazole has the longest plasma half-life and, in testing, appears to offer better control of nocturnal hyperacidity (55).

Fig. 37.18. Acid-catalyzed activation of omeprazole to reactive sulfonamide. At the parietal cell, H + /K + -ATPase, a cysteine residue, reacts to form disulfide-attached enzyme inhibitor.

CYP450 metabolism Metabolism of omeprazole and other proton pump inhibitors occurs primarily in the liver (Fig. 37.19). T he sulfone, hydroxylated, and O-demethylated metabolites have been reported as products. Omeprazole is a substrate primarily for CYP2C19 and may elevate concentrations of other substrates for this enzyme (e.g., diazepam) when given concurrently. T he CYP3A4 contributes to a lesser extent. Further oxidation of the sulfone affords additional metabolites,

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which are excreted in the feces. Lansoprazole is metabolized by analogous routes (56). Fewer drug interactions with lansoprazole have been reported, although it also is a substrate for CYP2C19. T hese sulfoxides have a chiral sulfur atom, and recent publications have been reported on the effects of stereochemistry on pharmacological and dispositional characteristics. T he oxidative metabolism of omeprazole is catalyzed principally by CYP2C19 (primarily 5'-hydroxylation and, to a lesser extent, benzimidazole O-demethylation) (57). In human liver microsomes, the R-(+ )-enantiomer is cleared more rapidly, and it is almost exclusively metabolized by CYP2C19. T he clearance of the S-(–)-enantiomer is more dependent on oxidation by CYP2C19 than on CYP3A4-mediated metabolism, primarily sulfone formation. T he marketed single enantiomer, esomeprazole, provides greater bioavailability in those who are CYP2C19 extensive metabolizers and less interindividual variation in those who are CYP2C19 poor metabolizers (~3% of Caucasians and up to 15–20% of Asians). T hus, the impact of variant alleles of CYP2C19 is less on the S-(–)-enantiomer than on the parent racemate. Higher blood levels and greater AUCs are observed, and increases in the time at a gastric pH greater than 4.0 are observed, which are correlated with healing rates. Different proton pump inhibitors depend differently on CYP2C19 for oxidative metabolism, and the enantiomers show variation in dependence on CYP2C19 and other pathways (principally CYP3A4). Pantoprazole and lansoprazole show greater metabolism via CYP2C19, with the enantiomers being affected differently, than rabeprazole, which is metabolized only to a small extent by oxidative CYP450 enzymes. P.1023

Fig. 37.19. Oxidation sites and CYP450 isozymes in the metabolism of omeprazole.

Combination therapy in Helicobacter pylori infections T he majority of peptic ulcers are related to H. pyl ori infections and nonsteroidal anti-inflammatory drug (NSAID) therapy. Hel i cobacter pyl ori apparently penetrates the layer of gastric mucus by producing ammonia and carbon dioxide (urease-catalyzed hydrolysis of urea) to withstand the acidic environment of the stomach. More than 90% of patients with duodenal ulcer, excluding those with gastrinoma or taking NSAIDs, show the presence of H. pyl ori . Determination of H. pyl ori infection is routinely performed by measuring production of 13

14

carbon dioxide (breath) or bicarbonate (blood) after oral administration of C- or C-labeled urea. Endoscopic examination and antigen-based serological tests may be used as confirmation (58). Eradication of H. pyl ori markedly decreases the incidence of ulcer recurrence. Several regimens of antibiotic therapy, widely used with proton pump inhibitors or

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less commonly with H 2 -antagonists, are effective. Double- and triple-drug combinations, such as proton pump inhibitors with amoxicillin and clarithromycin or metronidazole, are used.

Competitiv e K + Inhibitors Newer agents that block gastric acid secretion at the H + ,K + -AT Pase by binding as competitive inhibitors at the K + binding site are under development (Fig. 37.20) (45,49). An initial compound, SCH 28080, was hepatotoxic. Newer agents have included soraprazan and +

revaprazan. Each of them binds ionically to the proton pump at or near the K binding site. Revaprazan has reached clinical trials. Studies to determine whether these or other related compounds can become useful drugs are ongoing.

Prokinetic Agents Prokinetic drugs like metoclopramide, cisapride, and levosulpiride increase esophageal sphincter pressure and enhance peristalsis and gastric emptying, thus counteracting factors that lead to esophagitis (Fig. 37.21) (59). T hese agents appear to be 5-HT 4 partial agonists in the enteric nervous system, leading to release of acetylcholine. In addition, metoclopramide and levosulpiride are dopamine D 2 antagonists. Metoclopromide is used in GERD, in diabetic gastroparesis, and in nausea and vomiting of emetogenic cancer chemotherapy. Cisapride was removed from the U.S. prescription market because of metabolism-based interactions. In the presence of competing CYP3A4 substrates, high concentrations of the parent molecule lead to life-threatening cardiac arrhythmias via interaction with the hERG K + channel, similar to H 1 antihistamines terfenadine and astemizole. It is available only through an investigational limited-access program. Levosulpiride is available in Europe. T egaserod (Zelnorm), also a selective 5-HT 4 partial agonist used in irritable bowel syndrome in women, has been used successfully in critically ill patients with gastroparesis.

Fig. 37.20. Examples of proton pump competitive K + inhibitors.

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Fig. 37.21. Examples of prokinetic agents.

Prostaglandins Prostaglandins have antisecretory effects on gastric acid (Fig. 37.17). Besides inhibiting adenylyl cyclase activity in parietal cells, which results in secretion of gastric acid, prostaglandins stimulate secretion of mucus and bicarbonate in adjacent superficial cells. Cytoprotective effects of endogenous E-series prostaglandins and of other, more stable synthetic congeners are observed. T he only available oral prostaglandin in the United States is misoprostol. T he orally administered carboxylic acid ester is hydrolyzed to the pharmacologically active carboxylic acid. It is a synthetic analogue of prostaglandin E 1 , in which structural changes at C-13,14,15,16 are made to prevent rapid metabolic conversion to inactive products. T he presence of the tertiary alcohol 1-carbon removed to C-16 obviates the 13,14

usual conversion of the allylic secondary alcohol (∆ -15-alcohol) of prostaglandins to the corresponding saturated ketones. A mixture of diastereomers of misoprostol is used; most of the activity arises from the 11R,16S-isomer (60). Misoprostol reduces basal levels of gastric acid secretion, but it has considerable smooth muscle contraction effects.

P.1024

Therapeutic applications and side effects In the United States, misoprostol is administered with some current NSAIDs to reduce the risk

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of complications of gastric ulceration and bleeding. A primary mechanism of action by NSAIDs is derived from their inhibition of formation of prostaglandins from arachidonic acid. A prostaglandin may be added for the duration of NSAID therapy. A combination product of diclofenac (an NSAID) and misoprostol is available. Unlabelled uses of misoprostol include treatment of duodenal ulcers, for which it appears to be effective, and in the treatment of duodenal ulcers unresponsive to H 2 antagonists. In other countries, it has been used in the treatment of duodenal ulcers. Significant side effects are those associated with its abortifacient properties and other smooth muscle contraction effects, e.g., diarrhea and abdominal pain. Misoprostol also is an effective cervical ripening agent (by vaginal application) for the induction of labor. Other unlabeled uses include the treatment of postpartum hemorrhage and, with mifepristone, termination of pregnancy.

Sucralfate and Insoluble Bismuth Preparations

Sucralfate is a complex of the sulfuric acid ester of sucrose and aluminum hydroxide. Secondary polymerization with aluminum hydroxide forms intermolecular bridges between molecules of sulfate esters with aluminum (61). Limited dissociation of the complex occurs in gastric acid, but these anionic sulfate esters form insoluble adherent complexes with the proteinaceous exudate at the abraded surface of a crater of the ulcerated area in the stomach. T his physical complex protects the ulcer from the erosive action of pepsin and bile salts. Sucralfate also stimulates synthesis and release of prostaglandins, bicarbonate, and epidermal and fibroblast growth factors. Significant ulcer healing effects are noted in placebo-controlled trials. Only small amounts of sucralfate are absorbed systemically. In renal impairment, there is a risk of accumulation of absorbed aluminum from the drug. Sucralfate reduces absorption of other drugs, including H 2 antihistamines, quinolone antibiotics, phenytoin, and perhaps, warfarin (62). Bismuth-containing preparations (e.g., those containing colloidal bismuth subcitrate) have effects similar to those of sucralfate, apparently because of their similar physical properties and coating effects. A combination of ranitidine–bismuth citrate is used with clarithromycin for eradication of H. pyl ori in the treatment and prevention of recurrence of duodenal ulcers. Combinations of bismuth subcitrate with other antibiotics and with H 2 antihistamines also are used. Bismuth subsalicylate is used in this way as well.

H3 Receptor Agonists and Antagonists Physiological Role of H 3 Receptors T he H 3 receptor was identified as an autoreceptor that regulates the release of histamine. Histaminergic neurons are located primarily in the hippocampus, projecting to all major areas

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of the brain. T hese neurons are involved with the regulation of sleep and wakefulness and in feeding and memory (13). T he H 3 receptor also is a heteroreceptor in the CNS, where it is involved in the regulation of synthesis and release of other neurotransmitters. In addition, H 3 heteroreceptors have been identified in peripheral tissues, including the airway and gastrointestinal tract.

H 3 Agonists and Antagonists Several H 3 agonists and antagonists have been studied (T able 37.12). R-α-methylhistamine is a more potent agonist than histamine. T he addition of methyl groups to the side chain or to the aliphatic amine nitrogen of histamine usually results in potent H 3 agonists, such as α,α-dimethylhistamine, R-α,S-β-dimethylhistamine, and N-methyl- and N-ethylhistamine, unlike the deleterious effect of these P.1025 changes on H 1 and H 2 agonist activity. Other selective agonists are the isothiourea imetit, immepip and its N-methyl analogue (methimepip), both substituted piperidines, immethridine, a pyridine congener of immepip, and SCH 50971. All retain the imidazole ring of histamine.

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Table 37.12. Examples of H 3 Agonists and Antagonists

Early H 3 antagonists, like thioperamide and clobenpropit analogues of immepip and imetit, respectively, are primarily pharmacological tools. Like the H 3 agonists, these agents retain the imidazole group but possess widely varying N-substituents. Some of the imidazolecontaining agonist and antagonist analogues have affinity for other receptors (e.g., some α-adrenergic receptor subtypes), and they have the potential to interact with CYP450 enzymes as an iron–porphyrin ligand. T hus, nonimidazole-containing ligands have been sought. Allergic rhinitis is one condition in which H 3 antihistamines may be useful. T hioperamide and clobenpropit are effective in animal models alone and in combination with H 1 antihistamines. Dual H 1 /H 3 antihistamines are being studied, including a chlorpheniramine analogue that incorporates the imidazole alkylamine group of many H 3 antagonists (T able 37.12). Centrally acting H 3 antagonists are under study by several drug companies. Agents are sought for a variety of disorders. T hese include treatment of depression, mild cognitive impairment, Alzheimer's disease, schizophrenia, narcolepsy, obesity, and attention-deficient hyperactivity disorder. T wo examples are JNJ 5207852 (63), a compound that increases

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wakefulness, and ABT -239, a compound that is being evaluated for treatment of cognition related disorders (64).

H 4 Receptor Agonists and Antagonists Physiological Role of H 4 Receptors T he H 4 receptor is expressed in mast cells, eosinophils, and other cells of hematopoietic lineage, including basophils and T cells. It is a relatively recent discovery; thus, much is not yet understood about its physiological role. It is thought to play a role in inflammatory responses, especially in the mediation of chemotactic responses. Its sequence homology is greatest with the H 3 receptor (35–40%) and is very low versus H 1 and H 2 receptors (65).

Fig. 37.22. Other ligands at the H 4 receptor.

H 4 Agonists and Antagonists Classical leukocyte chemoattractant effects that occur are blocked by thioperamide, an H 3 /H 4 antihistamine. Other H 3 receptor ligands, such as R-α-methylhistamine and imetit, also are agonists at H 4 receptors, but they have lower affinity than at H 3 receptors (T able 37.12). Clobenpropit is a partial agonist at H 4 receptors, but it is an H 3 antihistamine (inverse agonist). T hioperamide is an inverse agonist at H 4 and H 3 receptors. 4-Methylhistamine (Fig. 37.22) has greater affinity (> 100-fold) for H 4 receptors than other histamine receptor subtypes (66). A selective H 4 antihistamine has recently been reported, JNJ 7777120 (Fig. 37.22). It blocks many mediated functions, including histamine-induced chemotaxis in mast cells and eosinophils (67). Conditions in which H 4 antagonists might be useful include autoimmune inflammatory and allergic disorders, including rheumatoid arthritis, asthma, and allergic rhinitis. Nasal stuffiness and blockage in allergic rhinitis, conditions that are poorly treated with H 1 and H 2 antihistamines, suggest the possible use of H 4 antihistamines in these conditions as well. P.1026

Case Study Vic tor ia F. Roc he S. Willia m Zito BL is a 7 1 -ye ar-o ld f inanc ial adviso r o n vac atio n at the Gulf Co as t with his wif e of 4 7

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ye ars . I t has be e n a the rape utic g e taway, e sp e c ially f o r Mrs . BL , who lo s t he r c e ntral vis io n to e xud ative mac ular d eg e ne ratio n 18 mo nths ag o . W hile the y hate to s e e the ir we e k of s urf , sun, and re laxatio n c o me to an e nd , the y are re ally lo o king f o rward to the d rive to Alb uque rq ue the y will b e g in to mo rro w f o r the we d d ing o f the ir o nly g rand d aug hte r. On the ir las t Gulf Sho re nig ht, they mad e re se rvatio ns f o r a g ala e vening ab o ard the cruise s hip Ch i c h i b ab i n , c omp le te with danc ing to the are a' s b e s t D ixie land jazz band and a s umptuo us b uf f e t o f C ajun f o o d s . The y had a b all, b ut unf ortunate ly, BL e xp erie nce d a se ve re allerg ic re ac tion to the c rayf ish he c o nsume d (he ate two d o ze n) and had to be take n o f f the s hip to the e me rg e ncy ro o m, whe re he re c e ive d an inje c tio n of hydroc o rtiso ne . Altho ugh he can no w b re athe e asie r, he s till has a re d , itc hy, and uns ightly ras h o n the up pe r half o f his b o d y, inc luding his arms , hand s , and f ace . I n ad d itio n to b e ing unco mf o rtab le , he is wo rrie d ab out how he will lo o k f o r his g rand d aug hte r's b ig d ay. Be f o re he ad ing o ut on the ir d rive to Albuq ue rq ue , BL and his wif e sto p at a lo cal p harmac y f o r s ome c alamine lo tio n and an antihis tamine to ke e p BL c omf o rtab le o n the trip . He will b e be hind the whe e l the who le way, be c aus e his wif e can no lo ng e r s e e we ll e no ug h to d rive . As the p harmacis t o n d uty that d ay, c ons ide r the antihistaminic s tructure s b e lo w, and p ro vid e this c o up le with s o me muc h-ne e d e d p harmac eutical care .

1. I d e ntif y the therap e utic p ro b le m(s ) in whic h the p harmacis t's inte rve ntio n may b e nef it the p atie nt. 2. I d e ntif y and p rio ritize the p atie nt-s p ec if ic f ac tors that mus t b e co ns id e re d to ac hie ve the d e s ire d the rape utic o utco me s. 3. C ond uct a tho ro ug h and me c hanistic ally o rie nte d s truc ture – ac tivity analys is o f all the rap e utic alte rnative s p ro vid e d in the c ase . 4. Evaluate the struc ture – ac tivity re lations hip f ind ing s ag ains t the p atie nt-s p e c if ic f ac to rs and d e s ire d therap e utic o utc o mes , and make a the rape utic d e c is io n. 5. C ouns el your p atie nt.

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Chapter 38 Antibiotics and Antimicrobial Agents Le ste r A. Mitsche r Thom as L. Le m ke Elm e r J. Ge ntry

Drugs cov ered in this chapter: Antibacter ials Me thenamine Phos phomycin Quinolone c lass Sulf onamide c lass Trimetho prim Antibiotics Penic illin c lass Ampicillin Amoxacillin Bacampicillin Be nzylpe nicillin Carbenicillin and ind anyl c arb enicillin Clavulanic ac id Methicillin Mezlocillin and pip eracillin Naf c illin Oxac illin, cloxac illin, and d ic lo xacillin Phenoxyme thyl p enicillin Pipe rac illin and tazobac tam Sulbac tam Tic arc illin Cephalosp orin clas s Cef ac lo r Cef adroxil Cef amand ole naf ate Cef azolin Cef dinir Cef ditoren pivo xil Cef epime Cef ixime Cef metazole Cef onic id Cef operazone Cef otaxime

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Cef ote tan Cef oxitin Cef podo xime pro xe til Cef prozil Cef tazidime Cef tibuten Cef tizoxime Cef triaxone Cef uro xime Cep hale xin Cep hapirin Cep hradine Loracarbef Carb apenems Ertapenem I mipenem Meropenem Mo nob actams Aztreonam Aminog lyco sides Amikac in Gentamicin Kanamycin Ne omycin Sp ectinomyc in Tobramycin Macrolide s and keto lide s Azithromycin Clarithro mycin Erythromycin estolate Erythromycin ethyls uc cinate Erythromycin stearate Telithro mycin Linco samid es Clindamyc in L incomyc in Tetrac yc line s and glycylcyclines Deme clocycline Doxyc ycline Oxyte tracycline Minocyc line Te tracycline Tigec ycline Bacitrac in Chlo ramphenicol

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Dapto myc in Linezolid Mup irocin Po lymyxin B Quinupris tin/dalf o pristin Vanc omycin

Introduction Antibiotics are microbial metabolites or synthetic analogues inspired by them that, in small doses, inhibit the growth and survival of microorganisms without serious toxicity to the host. Selective toxicity is the key concept. Antibiotics are among the most frequently prescribed medications today, although microbial resistance resulting from evolutionary pressures and misuse threatens their continued efficacy. In many cases, the clinical utility of natural antibiotics has been enhanced through medicinal chemical manipulation of the original structure, leading to broader antimicrobial spectrum, greater potency, lesser toxicity, more convenient administration, and additional pharmacokinetic advantages. T hrough customary usage, the many synthetic substances that are unrelated to natural products but still inhibit or kill microorganisms are referred to as antimicrobial agents instead. Because of a significant decrease in the pace of novel anti-infective discovery, increased regulatory constraints, and greater profits to be made by the use of medications for chronic conditions, there is presently a decreased research emphasis on antimicrobial agents. T his coincides with a dramatic increase in microbial resistance to chemotherapy, that portends a bleak future in which humankind may once again face infectious diseases with few available countermeasures. Our environment, body surfaces, and cavities support a rich and characteristic microbial flora. T hese cause us no significant illness or inconvenience as long as our neighbors or we do not indulge in behavior that exposes us to exceptional quantities or unusual strains of microbes or introduces bacteria into parts of the body where they are not normally resident. Protection against this happening is obtained primarily through public P.1029 health measures, healthful habits, intact skin and mucosal barriers, and a properly functioning immune system. All parts of our bodies that are in contact with the environment support microbial life. It is estimated that 1 g of feces contains approximately 10

13

microorganisms! All our internal fluids, organs, and body

structures, however, are sterile under normal circumstances, and the presence of bacteria, fungi, viruses, or other organisms in these places is diagnostic evidence of infection. When mild microbial disease occurs, the otherwise healthy patient often will recover without requiring treatment. Here, an intact, functioning immune system is called on to kill invasive microorganisms. When this is insufficient to protect us, appropriate therapeutic intervention is indicated.

Clinic al Signific ance T he treatment of bacterial infections is one of the few disease states that all clinicians are guaranteed to be challenged with at some time in their career. Because bacteria are constantly changing, the selection of appropriate antimicrobial therapy is crucial in providing efficacious treatment of infections. It is of the utmost importance that clinicians understand the medicinal chemistry of antimicrobial agents to choose the most effective therapy for their patients. Antimicrobial resistance trends are constantly changing and vary from institution to institution, so a complete understanding of the structural relationship differences between antibiotics, even in the same class, is helpful in selecting the most appropriate therapy for an individual patient. In addition, side chains and subtle structural differences within antimicrobial classes can change the side-effect profiles of these agents. T he informed clinician therefore can optimize their treatment choices from patient to patient while avoiding severe adverse effects. T he development of newer and more effective antimicrobial agents is essential in the fight against

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infectious diseases. Understanding the medicinal chemistry of the older and newer antimicrobial agents helps the clinician to comprehend their differences in antimicrobial spectrum and side-effect profile. Newer antibiotics are continuously being developed; however, many of them are from antimicrobial classes already established, with only small changes on the functional groups and/or side chains leading to dramatic differences in their antimicrobial spectrum. As stated previously, bacteria are constantly changing, as are antimicrobial susceptibility patterns. T o optimize patient care, a clinician needs to stay informed about the effects of the medicinal chemistry differences as newer drugs come to market and antimicrobial resistance trends change. Elizabeth Coyle Pharm.D. Cl i ni cal Assi stant Professor, Department of Cl i ni cal Sci ences & Admi ni strati on, Uni versi ty of Houston Col l ege of Pharmacy

T he chronicle of civilization before the discovery of bacteria and their role in infectious disease and, subsequently, the discovery of antibiotics and antimicrobial agents is punctuated by the outbreak of recurrent, devastating pandemics. An example is the successive waves of bubonic plague that dramatically decreased the population of Europe during the Middle Ages. Humankind was mystified as to the cause of infectious disease and what one might constructively do for prevention and cure. In warfare, infections often disabled or killed more individuals than the action of generals did. Our own family histories record the premature loss of loved ones, particularly small children, to one infection or another, and in the T hird World, this pattern remains all too common today. T his depressing picture was altered dramatically in the 20

th

century by the discovery and application of the powerful therapeutic agents described in this chapter. Fortunately, it no longer is common for persons to live short lives, and it now is rare for parents to bury their children. Public health measures, such as purification of water supplies, proper sewage disposal, routine preventive vaccination, pasteurization of milk, improved personal hygiene, and avoidance of unhealthy behavior (e.g., spitting in public places) also have greatly diminished our exposure to infection. Considering that the first truly effective antimicrobial agents date from the mid-1930s (the sulfonamides) and the first antibiotics came into use in the 1940s (the penicillins), it is amazing that we have already grown complacent. Diseases that very recently seemed to be on their way to extinction, such as tuberculosis and gonorrhea, are once again becoming serious public health problems because of societal changes, persistent poverty, lack of education, ease of international travel, and the emergence of resistance by pathogens. It is disturbing to consider that previously unknown infectious diseases, such as acquired immunodeficiency syndrome (AIDS), Ebola virus infections, and Legionnaires' disease, are an increasing feature of modern life. Unfortunately, we can no longer confidently depend on the discovery of increasing numbers of novel antibiotics and antimicrobial agents to keep infectious diseases under control, but we must increasingly pay attention to neglected public health measures and concentrate on using antibiotics only when those measures fail.

History Humankind has been subject to infection by microorganisms since before the dawn of recorded history. One presumes that humankind has been searching for suitable P.1030 therapy for nearly as long. T his was a desperately difficult enterprise given the acute nature of most infections and the nearly total lack of understanding about their origins that was prevalent until the last century. One can find indications in old medical writings of folkloric use of plant and animal preparations, soybean curd, moldy bread and cheese, counterinfection with other microbes, the slow development of public health measures, and an understanding of the desirability of personal cleanliness, but these factors were erratically and inefficiently applied and, when they were applied, often failed. Until the discovery of bacteria 300 years ago and the subsequent understanding of their role in infection about 150 years ago, there was no hope for rational therapy. In Germany during the 19th century, Robert Koch showed that specific microorganisms could always be isolated from the excreta and tissues of people with particular infectious diseases and that these same microorganisms usually were absent in healthy individuals. T hey could then be grown on culture media and be administered to healthy individuals to reproduce in those healthy individuals all the classic symptoms of the same disease. Finally, the identical microorganism could then be isolated from this deliberately infected

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person. Following these rules, at long last, a chain of evidence connecting cause and effect was forged between certain microorganisms and specific infectious diseases. T his work laid the foundation for rational prevention of and therapy for infectious diseases. In 1877, Louis Pasteur reported that when what he termed “ common bacteria” were introduced into a pure culture of anthrax bacilli, the bacilli died, and that an injection of deadly anthrax bacilli into a laboratory animal was harmless if “ common bacteria” were injected along with it. T his did not always work, but it did lead to the appreciation of antibiosis, wherein two or more microorganisms competed with one another for survival. Not until more than a half century later, however, did the underlying mechanisms begin to be appreciated and applied to achieve successful therapy. T he modern anti-infective era opened with the discovery of the sulfonamides in France and Germany in 1936 as an offshoot of Paul Ehrlich's earlier achievements in treating infections with organometallics and his theories of vital staining. T he discovery of the utility of sulfanilamide was acknowledged by the awarding of a Nobel Prize in 1938. T he well-known observation of a clear zone of inhibition (lysis) in a bacterial colony surrounding a colony of contaminating airborne Peni ci l l i um mold by Alexander Fleming in England in 1929, and the subsequent purification of penicillin from it in the late 1930s and early 1940s by Florey, Chain, Abraham, and Heatley, provided important additional impetus. With the first successful clinical trial of crude penicillin on February 12, 1941, and the requirements of wartime, an explosion of successful activity ensued that continues some 65 years later. In rapid succession, deliberate searches of the metabolic products of a wide variety of soil microbes led to the discovery of tyrothricin (1939), streptomycin (1943), chloramphenicol (1947), chlortetracycline (1948), neomycin (1949), and erythromycin (1952). T hese discoveries ushered in the age of the so-called “ miracle drugs.” Microbes of soil origin remain to this day the most fruitful sources of antibiotics, although the specific means employed for their discovery are infinitely more sophisticated today than those employed 50 years ago. Initially, extracts of fermentations were screened simply for their ability to kill pathogenic microorganisms in vitro. T hose that did were pushed along through ever more complex pharmacological and toxicological tests in attempts to discover clinically useful agents. T oday, many thousands of such extracts of increasingly exotic microbes are tested each week, and the tests now include sophisticated assays for agents operating through particular biochemical mechanisms or possessing particular desirable properties. T oday, combinatorial chemical synthesis coupled with high-throughput screening make it possible to screen, in a short time, hundreds of thousands of compounds for antimicrobial activity. T his is coupled with dramatic advances in all the relevant sciences. One would logically suppose that this would lead to the emergence of a large number of new antimicrobial agents. T hat this is yet to happen, however, is a measure of the complexity of the task. T he impact of genomics and proteomics is predicted to have a favorable impact on this effort. T he genome of Haemophi l us i nfl uenzae was determined in 1995, and a decade later, more than 200 microbial genomes have been deciphered and are publicly available (http://www.ncbi.nlm.nih.gov /genomes/Complete.html). Of the 1,709 genes of H. i nfl uenzae, it is thought that 256 are potentially essential and, thus, are targets for antimicrobial drug development. T hese exciting new possibilities have yet to yield practical results, however, because of to the inherent complexity of the task. In the year 2005, annual worldwide commerce in antibiotics was measured in multiple tons and was valued in excess of $10 billion. About half of this was associated with β-lactam antibiotics alone. Approximately 20% of the most frequently prescribed outpatient medications in the United States are anti-infective agents. Approximately 100 antibiotics have seen substantial clinical use, representing the most attractive of more than 20,000 known natural antibiotics and an order of magnitude more semisynthetic and totally synthetic antimicrobial agents. T hese agents have had a major impact on the practice of medicine and pharmacy and on the lives of persons still living, who remember well the perils and uncertainties of life before antibiotics became available. T his salubrious picture has an increasing dark side, however, because of the growing impact of bacterial resistance. Intrinsic resistance to antimicrobial agents (resistance present before exposure to antibiotics) was recognized from the beginning. Some bacteria are immune to treatment from the outset, because they do not take up the antibiotic or lack a susceptible target. Starting in the 1940s, however, and encountered with P.1031 increasing frequency to this day, bacteria that previously were expected to respond were found to be resistant. Alarmingly, many became resistant during the course of chemotherapy, and others were simultaneously resistant to several different antibiotics. T he latter were found to be capable of passing on

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this trait to other bacteria—even to those belonging to different genera. Similar findings are now encountered with fungi, viruses, and even tumors, indicating that this is a general biological phenomenon. T he spread of this phenomenon is abetted by their short generation time (measured in fractions of an hour) and genetic versatility as well as by poor antibiotic prescription and utilization practices. Some authorities predict an impending return to the defenseless days of the preantibiotic era. For example, in the United Kingdom, resistance of the important Gram-positive pathogen Staphyl ococcus aureus has risen from approximately 2% in the 1990s to nearly 42% by the year 2000. Resistance to vancomycin in the United States among patients infected with Enterococcus faeci um amounts to approximately 20 to 30%; such resistance was almost unknown a decade ago. Many other microbes and medicaments could be cited as well. An understanding of these phenomena and the devising of appropriate practical response measures are important contemporary priorities.

General T herapeutic Approach Drug Nomenclature T he names given to antimicrobials and antibiotics are as varied as their inventor's taste; however, some helpful unifying conventions are followed. For example, the penicillins are derived from fungi and have names ending in the suffix -cillin, as in ampicillin. T he cephalosporins likewise are fungal products, although their names mostly begin with the prefix cef- (or, sometimes, following the English practice, ceph-). T he synthetic fluoroquinolones mostly end in the suffix -floxacin. Although helpful in many respects, this nomenclature does result in many related substances possessing quite similar names. T his can make remembering them a burden. Most of the remaining antibiotics are produced by fermentation of soil microorganisms belonging to various Streptomyces species. By convention, these have names ending in the suffix -mycin, as in streptomycin. Some prominent antibiotics are produced by fermentation of various soil microbes known as M i cromonospora sp.; these antibiotics have names ending in -micin, as in gentamicin. T he student has to take considerable care to avoid confusing them. In earlier times, the terms “ broad spectrum” and “ narrow spectrum” had specific clinical meaning. T he widespread emergence of microbes resistant to single agents and to multiple agents, however, has made these terms much less meaningful. Nonetheless, it still is valuable to remember that some antimicrobial families have the potential of inhibiting a wide range of bacterial genera belonging to both Gram-positive and Gram-negative cultures and so are called broad spectrum (e.g., the tetracyclines). Others inhibit only a few bacterial genera and are called narrow spectrum (e.g., the glycopeptides, typified by vancomycin, which are used almost exclusively for a few Gram-positive and anaerobic microorganisms).

The Importance of Pathogen Identification Empiric-Based Therapy Fundamental to appropriate antimicrobial therapy is an appreciation that individual species of bacteria are associated with particular infective diseases and that specific antibiotics are more likely to be useful than others for killing them. Sometimes, this can be used as the basis for successful empiric therapy. For example, first-course, community-acquired urinary tract infections in otherwise healthy individuals are most commonly caused by Gram-negative Escheri chi a col i of fecal origin. Even just knowing this much can give the physician several convenient choices for useful therapy. Likewise, skin infections, such as boils, are commonly the result of infection with Gram-positive Staphyl ococcus aureus. In most other cases, however, the cause of the disease is less obvious, and so, likewise, is the agent that might be useful against it. It is important to determine the specific disease that one is dealing with in these cases and what susceptibility patterns are exhibited by the causative microorganism. Knowing these factors P.1032 enables the clinician to narrow the range of therapeutic choices. T he only certainty, however, is that inability of a given antibiotic to kill or inhibit a given pathogen in vitro is a virtual guarantee that the drug will fail in vivo. Unfortunately, activity in vitro all too often also results in failure to cure in vivo, but here, at least, there is a significant possibility of success. Before the emergence of widespread bacterial resistance, identification of the causative microorganism often was sufficient for selecting a useful antibiotic. T oday, however, this is only a useful first step, and much more detailed laboratory studies are needed to make a successful choice.

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Gram Stain Hans C.J. Gram, a Danish mic robiologist, develope d the Gram method f o r s taining bac te ria s o that they we re more re adily visible under the mic ros co pe. The term has proven to b e p artic ularly use f ul in des cribing antib iotics as well, bec ause antibiotic s are co nveniently classif ied by the ir ac tivity against microorg anis ms depe nding on their reactio n to this method. Gram-pos itive micro organisms are stained blue by contact with a methyl vio le t–iodine proce ss . T his is largely a conse quence of their lack of an outer membrane and the nature of the thick cell wall s urrounding them. Gram-ne gative micro organisms do not re tain the methyl violet–iodine s tain whe n washed with alc ohol but, rather, are colore d p ink when s ubs equently tre ated with the re d d ye saf ranin. The lipopo lysacc harides on their outer memb rane app arently are res pons ible f or the s taining b ehavior of Gram-ne gative cells. Bec ause the Gram s tain is dep ende nt on the outer layers of bacterial cells and this also strongly inf luenc es the ability of antimicrobial agents to reac h their c ellular targets, knowing the Gram-staining be havior of inf e ctious bac te ria helps one to decide which antimic rob ial might b e e f f ec tive in therapy. Not all bac teria c an be stained b y the Gram p roce dure, ho we ve r, and thes e of ten req uire spe cial s taining proc ess es f o r visualization. Amo ng the more prominent o f the se f or our p urp ose s are the myc obacte ria (the c ausative agents of tuberculos is, f or example). These very waxy c ells are called acid-f as t and are s tained by c arb ol f uchsin instead .

Experimentally Based Therapy T he modern clinical application of Koch's discoveries to the selection of an appropriate antibiotic involves sampling infectious material from a patient before instituting anti-infective chemotherapy, culturing the microorganism on suitable growth media, and identifying its genus and species. T he bacterium in question is then grown in the presence of a variety of antibiotics to see which of them will inhibit its growth or survival and what concentrations will be needed to achieve this result. T his is expressed in units of minimum inhibitory concentration (MIC). T his term refers to that concentration that will inhibit 99% or more of the microbe in question, and it represents the minimum quantity that must reach the site of the infection to be useful. T hese concepts are illustrated in Figure 38.1.

Fig. 38.1. In the top tubes (viewed from the top), a serially decreasing amount of antimicrobial agent is added to a suitable growth medium inoculated with a

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microorganism. Following incubation, microbial growth is detected by turbidity. The last concentration which produces no visible growth is scored as the minimum inhibitory concentration (MIC) (1/8). Next, a loopful is taken from each tube and placed in fresh medium not containing antibiotic (bottom row). In tubes where the organisms were killed by the drugs, there is no resumption of growth. Where the organisms were inhibited but not killed, removal of drug allows resumption growth. The last concentration that produces no visible growth under these conditions is scored as the minimum bactericidal concentration (MBC) (1⁄2).

T o “ cure” the infection, it usually is desirable to have several multiples of the MIC at the site of infection. T his requires not only an understanding of the MIC but also an understanding of pharmacokinetic and pharmacodynamic considerations as well as the results of accumulated clinical experience. T he choice of anti-infective agent is made from among those that are active. One of the most convenient experimental procedures is that of Kirby and Bauer. With their technique, sterile disks of filter paper impregnated with fixed doses of commercially available antibiotics are placed on the seeded Petri dish. T he dish is then incubated at 37°C for 12 to 24 hours. If the antibiotic is active against the particular strain of bacterium isolated from the particular patient, a clear zone of inhibition will be seen around the disk. If a given antimicrobial agent is ineffective, the bacterium may even grow right up to the edge of the disk. T he diameter of the inhibition zone is directly proportional to the degree of sensitivity of the bacterial strain and the concentration of the antibiotic in question. Currently, a given zone size in millimeters is dictated above which the bacterium is sensitive and below which it is resistant. When the zone size obtained is near this breakpoint (the breakpoint represents the maximum clinically achievable concentration of an anti-infective agent), the drug is regarded as being intermediate in sensitivity, and clinical failure can occur. T his powerful methodology gives the clinician a choice of possible antibiotics to use in the particular patient and is illustrated in Figure 38.2. T he widespread occurrence of resistance of individual strains of bacteria to given antibiotics reinforces the need to perform Kirby-Bauer susceptibility disk testing, but other laboratory methods can be employed for similar purposes. Of particular note are the E test strips, which utilize the P.1033 same idea but employ a gradient of drug concentrations on a filter-paper strip.

Fig. 38.2. Looking down on a Petri dish containing solidified nutrient agar to which had been added a suspension of a bacterial species. Next, six filter-paper disks containing six different antimicrobials was added followed by overnight incubation. The antimicrobials in disks 1, 4, and 5 were inactive. Of

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the active agents in disks 2, 3, and 6, antibiotic 2 was much more active, because the microorganism was not able to grow as near this impregnated disk.

T his high level of scientific medicine requires significant expertise and equipment, so it is practiced mainly in urban medical centers. In office practice, the choice of medicinal agents is more commonly made empirically.

Bactericidal Versus Bacteriostatic Almost all antibiotics have the capacity to be bactericidal in vitro; that is, they will kill bacteria if the concentration or dose is sufficiently high. In the laboratory, it is almost always possible to use such doses. Subsequent inoculation of fresh, antibiotic-free media with a culture that has been so treated will not produce growth of the culture, because the cells are dead. When such doses are achievable in live patients, such drugs are clinically bactericidal. At somewhat lower concentrations, bacterial multiplication is prevented even though the microorganism remains viable (bacteriostatic action). T he smallest concentration that will kill a bacterial colony is the minimum bactericidal concentration. T he difference between a minimum bactericidal dose and a bacteriostatic dose is characteristic of given families of antibiotics. With gentamicin, for example, doubling or quadrupling the dose changes the effect on bacteria from bacteriostatic to bactericidal. Such bactericidal doses usually are achievable in the clinic. T he difference between bactericidal and bacteriostatic doses with tetracycline is approximately 40-fold. It is not possible to achieve such doses safely in patients, so tetracycline is referred to as clinically bacteriostatic. If a bacteriostatic antibiotic is withdrawn prematurely from a patient, the microorganism can resume growth and the infection reestablish itself, because the culture is still alive. In this case, subsequent inoculation of fresh laboratory media not containing the antibiotic will result in colony development. Obviously, in immunocompromised patients who are unable to contribute natural body defenses to fight their own disease, having the drug kill the bacteria is essential for recovery. On the other hand, when a patient is immunocompetent or the infection is not severe, a bacteriostatic concentration will break the fulminating stage of the infection (when bacterial cell numbers are increasing at a logarithmic rate). With Escheri chi a col i , for example, the number of cells doubles every 2 hours. A bacteriostatic agent will interrupt this rapid growth and give the immune system a chance to deal with the disease. Cure usually follows if the numbers of live bacteria are not excessive at this time. T hus, whereas it is preferred that an antibiotic be bactericidal, bacteriostatic antibiotics are widely used and usually satisfactory. Obviously, however, patients should not skip doses or prematurely stop treatment.

M icrobial Susceptibility Resistance Resistance is the failure of microorganisms to be killed or inhibited by antimicrobial treatment. Resistance can either be intrinsic (exist before exposure to drug) or acquired (develop subsequent to exposure to a drug). Resistance of bacteria to the toxic effects of antimicrobial agents and to antibiotics develops fairly easily both in the laboratory and in the clinic and is an ever-increasing public health hazard. Challenging a culture in the laboratory with sublethal quantities of an antibiotic kills the most intrinsically sensitive percentage of the strains in the colony. T hose not killed or seriously inhibited continue to grow and have access to the remainder of the nutrients. A mutation to lower sensitivity also enables individual bacteria to survive against the selecting pressure of the antimicrobial agent. If the culture is treated several times in succession with sublethal doses in this manner, the concentration of antibiotic required to prevent growth becomes ever higher. When the origin of this form of resistance is explored, it almost always is found to result from an alteration in the biochemistry of the colony so that the molecular target of the antibiotic becomes less sensitive, or it can result from decreased uptake of antibiotic into the cells. T his is genomically preserved and passes to the next generation by reproductive fission. T he altered progeny may be weaker than the wild strain so that they die out if the antibiotic is not present to give them a competitive advantage. In some cases, additional compensatory mutations can occur that restore the vigor of the resistant organisms. Resistance of this type usually is expressed toward other antibiotics with the same mode of action and, therefore, is a familial characteristic—most tetracyclines, for example, show extensive

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cross-resistance with other agents in the tetracycline family. T his is very enlightening with respect to discovery of the molecular mode of action, but it is not very relevant to the clinical situation. In the clinic, resistance more commonly takes place by Resistance (R) factor mechanisms. In the more lurid examples, enzymes are elaborated that attack the antibiotic and inactivate it. Mutations leading to resistance occur by many mechanisms. T hey can result from point mutations, insertions, deletions, inversions, duplications, and transpositions of segments of genes or by acquisition of foreign DNA from plasmids, bacteriophages, and transposable genetic elements. T he genetic material coding for this form of resistance very often is carried on extrachromosomic elements consisting of small, circular DNA molecules known as plasmids. A bacterial cell may have many plasmids or none. T he plasmid may carry DNA for several different enzymes capable of destroying structurally dissimilar antibiotics. Such plasmid DNA may migrate within the cell from plasmid to plasmid or from plasmid to chromosome by a process known as transposition. Such plasmids may migrate from cell to cell by conjugation (passage through a sexual pilus), transduction (carriage by a virus vector), or transformation (excretion of DNA from cell A and its subsequent uptake by cell B). T hese mechanisms can convert an antibiotic-sensitive cell to an antibiotic-resistant cell. T his can take place many times in a bacterium's already short generation time. T he positive selecting pressure of inadequate levels P.1034 of an antibiotic favors explosive spread of R-factor resistance. T his provides a rationale for conservative but aggressive application of appropriate antimicrobial chemotherapy. Bacterial resistance generally is mediated through one of three mechanisms: 1) failure of the drug to penetrate into or stay in the cell, 2) destruction of the drug by defensive enzymes, or 3) alterations in the cellular target of the enzymes. It rarely is an all-ornothing effect. In many cases, a resistant microorganism can still be controlled by achievable, though higher, doses than are required to control sensitive populations.

Persistence Sensitive bacteria may not all be killed. Survivors are thought to have been resting (not metabolizing) during the drug treatment time and, therefore, to remain viable when tested subsequently. T hese bacteria are still sensitive to the drug even though they survived an otherwise toxic dose. Some bacteria also can aggregate in films. A poorly penetrating antibiotic may not reach the cells lying deep within such a film. Such cells, although intrinsically sensitive, may survive antibiotic treatment. Bacteria living in host cells or in cysts also are harder to reach by drugs and so are more difficult to control.

Postantibiotic Effect Some antibiotics exert a significant toxicity to certain microorganisms that persists for a time after the drug is withdrawn and the concentration of drug in the blood falls below the MIC. A constant multiple of the MIC of a drug may not be essential for therapeutic success when a postantibiotic effect (PAE) is operating, because the microbe is still affected for a time after the drug is withdrawn. T he PAE is defined by the time required for a 10-fold increase in viable bacterial colonies to occur after exposure to a single dose of the antimicrobial agent. T he pharmacological basis for this effect is not clear. It is speculated that adherence to the intercellular target prevents some significant quantity of the antimicrobial agent from being washed away for a time. Others believe that there are other drug-related effects that injure the bacterium and that it is only slowly able to repair. Some as-yet-undiscovered cause might be at play. Under some conditions, a PAE can be detected for days in the chemotherapy of mycobacterial infections. T he PAE has been observed for a variety of antibiotics, and its duration varies with the drug, the organism, the concentration of drug, and the duration of treatment. T his phenomenon can be used to assist in patient compliance by decreasing the frequency and the length of chemotherapy; however, it also may lead to drug resistance and should be employed conservatively.

Biphasic (“Eagle”) Effect T he biphasic effect is associated primarily with β-lactam antibiotics. It is a curious phenomenon in which low doses in vitro against certain bacteria (staphylococci and streptococci) produce lysis, whereas higher doses do not. T his is believed to result from the differential sensitivity of the penicillin binding proteins (see below for an explanation of this term) in that higher doses of β-lactams inhibit the autolysins (this term also will be defined later). T hese are enzymes that also contribute to bacterial lysis.

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Inoculum Effect In a number of cases, microbial resistance is mediated by the production of bacterial enzymes that attack the antibiotic molecule, changing its structure to an inactive form. T his can lead to a so-called inoculum effect, in which a susceptible antibiotic is apparently less potent when larger numbers of bacteria are present in the medium than when fewer cells are employed. T he more bacteria that are present, the more antibioticdestroying enzyme that is present, and the more antibiotic that is required to overcome this to achieve the desired response. An antibiotic that is not enzyme modified is comparatively free of inoculum effects.

Antimicrobial Dosing Combination Therapy T he student may suppose that use of combinations of antibiotics would be superior to the use of individual antibiotics, because this would broaden the antimicrobial spectrum and make the accurate identification of the pathogen less critical. It has been found, however, by experiment that all too often, such combinations are antagonistic. A useful generalization, but one that is not always correct, is that one often may successfully combine two bactericidal antibiotics, particularly if their molecular mode of action is different. A common example is the use of a β-lactam antibiotic and an aminoglycoside for first-day empiric therapy of overwhelming sepsis of unknown etiology. T herapy must be instituted as soon after a specimen is obtained, or the patient may die. T his often does not allow the microbiological laboratory sufficient time to identify the offending microorganism or to determine its antibiotic susceptibility. An emergency resort therefore is made to what is termed “ shotgun therapy.” Both of the antibiotic families applied in this example are bactericidal in readily achievable parenteral doses. As will be detailed later in this chapter, the β-lactams inhibit bacterial cell wall formation, and the aminoglycosides interfere with protein biosynthesis and membrane function. T heir modes of action are supplementary. Because of toxicity considerations and the potential for untoward side effects, this empiric therapy is replaced by suitable specific monotherapy at the first opportunity after the sensitivity of the offending bacterium is experimentally established. One also often may successfully combine two bacteriostatic antibiotics for special purposes, such as a macrolide and a sulfonamide. Occasionally, these are used in combination for the treatment of an upper respiratory tract infection caused by Haemophi l us i nfl uenzae, because the combination of a protein biosynthesis inhibitor and an P.1035 inhibitor of DNA biosynthesis gives fewer relapses than the use of either agent alone. T he use of a bacteriostatic agent, such as tetracycline, in combination with a bactericidal agent, such as a β-lactam, usually is discouraged. T he β-lactam antibiotics are much more effective when used against growing cultures, and a bacteriostatic agent interferes with bacterial growth, often giving an indifferent or antagonistic response when such agents are combined. Additional possible disadvantages of combination chemotherapy are higher cost, greater likelihood of side effects, and difficulties in demonstrating synergism in humans. T he rising tide of antibiotic resistance is overcoming these reservations, however, and combination therapy is becoming more common.

Serum Protein Binding T he influence of serum protein binding on antibiotic effectiveness is fairly straightforward. It is considered in most instances that the percentage of antibiotic that is protein bound is not available at that moment for the treatment of infections and, therefore, must be subtracted from the total blood level to get the effective blood level. T he tightness of the binding also is a consideration. T hus, a heavily and firmly serum protein-bound antibiotic would not generally be a good choice for the treatment of septicemias or infections in deep tissue, even though the microorganism involved is susceptible during in vitro tests. If the antibiotic is rapidly released from protein bondage, however, this factor decreases in importance, and the binding becomes a depot source. Distinguishing between these two types of protein binding is accomplished by comparing the percentages of binding to the excretion half-life. A highly bound but readily released antibiotic will have a comparatively short half-life and work well for systemic infections. Normally, an antibiotic that is not significantly protein bound will be rapidly excreted and have a short half-life. T hus, some protein binding of poorly water-soluble agents generally is regarded as being helpful. T he student will recall that under most circumstances, the urine is a protein-free filtrate, so the proportion of an antibiotic that is firmly bound to

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serum proteins will be retained in the blood. T hus, a highly and firmly protein-bound antibiotic could be satisfactory for mild urinary tract infections.

Preferred Means of Dosing Under ideal circumstances, it is desirable for an antibiotic to be available in both parenteral and oral forms. Whereas there is no question that the convenience of oral medication makes this ideal for outpatient and community use, very ill patients often require parenteral therapy. It would be consistent with today's practice of discharging patients “ quicker and sicker” to send them home from the hospital with an efficacious oral version of the same antibiotic that led to the possibility of discharge in the first place. In that way, the patient would not have to come back to the hospital at intervals for drug administration, nor would one have to risk treatment failure by starting therapy with a new drug. For drugs with significant toxicities, the physician will prefer the injection form; the physician using this method is certain that the whole dose has been taken at the appropriate time. If the local pharmacist is adept at administration of parenteral medication, these considerations become less important. Employing directly observed therapy also avoids many aspects of noncompliance. For patients with highly contagious and dangerous infections, such as tuberculosis and HIV, directly observed therapy is increasingly the treatment mode of choice.

Initiation of Therapy Because bacteria multiply rapidly—populations often double in 0.5 to 3.0 hours—it is important to institute antibiotic therapy as soon as possible. T hus, it often is desirable to initiate therapy with a double (loading) dose and then to follow this with smaller (maintenance) doses. T o prevent relapse, the patient must be instructed not to skip doses and to take all of the medication provided, even though the presenting symptoms (e.g., diarrhea or fever) may resolve before the entire drug is taken. All too often, treatment failure and the emergence of resistance probably is caused by poor compliance or premature cessation of therapy by the patient.

Prophylactic Use of Antibiotics Antibiotics often are used prophylactically, such as in preoperative bowel sanitization and orally for treatment of viral sore throats. T hese are not sound practices, because the patient is exposed to the possibility both of drug-associated side effects and a suprainfection by drug-resistant microorganisms. Moreover, the therapeutic gain from such practices often is marginal. As frustrating as this may be to the infectious diseases specialist, however, these are common medical practices and, hence, are difficult to stop.

Agricultural Use of Antibiotics It is estimated that half of the antibiotics of commerce are used for agricultural purposes. T heir use for treatment of infections of plants and animals is not to be discouraged so long as the drug residues from the treatment do not contaminate foods. In contamination, problems P.1036 such as penicillin allergy or subsequent infection higher up the food chain by drug-resistant microbes can occur. Several instances of death in humans have been recorded in the 1990s from such incidents. Animals grow demonstrably more rapidly to marketable size when antibiotics are added to their feed, even though the animals have no apparent infection. T his is believed to result, in large part, from suppression of subclinical infections that, consequently, would divert protein biosynthesis from muscle and tissue growth into proteins needed to combat the infection. Under appropriate conditions, antibiotic feed supplementation is responsible, in part, for the comparative wholesomeness and cheapness of our food supplies. T his practice has the potential, however, to contaminate the food that we consume or to provide reservoirs of drug-resistant enteric microorganisms. Occasionally, infections are traced to this cause, and resistance genes can originate in this manner and pass from strain to strain—and even to other species.

Cost Antibiotics o f te n are expensive, but s o are morbidity and mortality. None the le ss, f or many patients, c ost is a signif ic ant consideration. The pharmac is t is in an ideal pos ition to guid e b oth the phys ic ian and the patie nt on the que stio n o f p oss ib le alternative, eq uivale nt treatments that might be mo re af f o rdab le . The mos t f req uent comparis ons are bas ed on the cos t of the usual do se of a give n

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agent f or a sing le co urs e of the rap y (us ually the wholes ale cos t to the pharmacist f o r 1 0 d ays wo rth o f d rug).

T herapeutic Classes Synthetic Antim icrobial Agents Synthetic antimicrobial agents have not been modeled after any natural product, so they may not properly be termed “ antibiotics.” Some synthetics are extremely effective for treatment of infections and are widely used. Very few antibiotics are known to work in precisely the same way as these agents in killing bacteria. Also curious is the fact that those agents, for which the molecular mode of action is known, are at present nearly all effective against key enzymes needed for the biosynthesis or functioning of nucleic acids. Because they interrupt the biosynthesis or functions of nucleic acids rather than attack the finished products or substitute for them in nucleic acids, they are not genotoxic but are comparatively safe to use.

Sulfonamides Introduction T he antibacterial properties of the sulfonamides were discovered in the mid-1930s following an incorrect hypothesis but after observing the results carefully and drawing correct conclusions. Prontosil rubrum, a red dye, was one of a series of dyes examined by Gerhard Domagk of Bayer of Germany in the belief that it might be taken up selectively by certain pathogenic bacteria and not by human cells, in a manner analogous to the way in which the Gram stain works, and, therefore, serve as a selective poison to kill these cells. T he dye, indeed, proved to be active in vivo against streptococcal infections in mice. Curiously, it was not active in vitro. T refouel and Bovet in France soon showed that the urine of prontosil rubrum–treated animals was bioactive in vitro. Fractionation led to identification of the active substance as p-aminobenzenesulfonic acid amide (sulfanilamide), a colorless cleavage product formed by reductive liver metabolism of the administered dye. T oday, we would call prontosil rubrum a pro-drug. T he discovery of the in vivo antibacterial properties of sulfanilamide ushered in the modern anti-infective era, and these investigators shared a Nobel Prize for medicine in 1938. For the first time in the long and weary chronicle of human struggle against infectious disease, physicians now had a comparatively safe and responsive oral drug to use. Considered along with the use of penicillin only 5 years later, the era of the so-called “ wonder drugs” had dawned.

Once mainstays of antimicrobial chemotherapy, the sulfonamides have decreased enormously in popularity and now are comparatively minor drugs. T he relative cheapness of the sulfonamides is one of their most attractive features and accounts for much of their persistence in the market.

Mechanism of action T he sulfonamides are bacteriostatic when administered to humans in achievable doses. T hey inhibit the enzyme dihydropteroate synthase, an important enzyme needed for the biosynthesis of folic acid derivatives and, ultimately, the thymidine required for DNA. T hey do this by competing at the active site with

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p-aminobenzoic acid (PABA), a normal structural component of folic acid derivatives. PABA is otherwise incorporated into the developing tetrahydrofolic acid molecule by enzyme-catalyzed condensation with 6-hydroxymethyl-7,8-dihydropterin-pyrophosphate to form 7,8-dihydropteroate and pyrophosphate. T hus, sulfonamides also may be classified as antimetabolites (Fig. 38.3). Indeed, the antimicrobial efficacy of sulfonamides can be reversed by adding significant quantities of PABA into the diet (in some multivitamin preparations and as metabolites of certain local anesthetics) or into the culture medium. Most susceptible bacteria are unable to take up preformed folic acid from their environment and convert it to a tetrahydrofolic acid but, instead, synthesize their own folates de novo. Folates are essential intermediates for the biosynthesis of thymidine, without which bacteria cannot multiply. T his inhibition is strongly bacteriostatic and, ultimately, bactericidal. Humans are unable to synthesize folates from component parts, because we lack the necessary enzymes, including dihydropteroate synthase, and folic acid is supplied to us in our diet. Consequently, sulfonamides have no similarly lethal effect on human cell growth. T he basis for the selective toxicity of sulfonamides thus is clear. In a few strains of bacteria, however, the picture is somewhat more complex. Here, sulfonamides are attached to the dihydropteroate diphosphate in the place of the normal PABA. T he resulting unnatural product, however, is not capable of undergoing the next necessary reaction (condensation with glutamic acid). T his false metabolite P.1037 also is an enzyme inhibitor, and the net result is inability of the bacteria to multiply as soon as the preformed folic acid in their cells is used up and further nucleic acid biosynthesis becomes impossible. For these strains the result is the same, but the molecular basis of the effect is somewhat different (Fig. 38.3). Bacteria that are able to take up preformed folic acid into their cells are intrinsically resistant to sulfonamides.

Fig. 38.3. Microbial biosynthetic pathway leading to tetrahydrofolic acid synthesis and major site of action (⇒) of sulfonamides as well as site of action seen in some bacteria (←) resulting in incorporation of sulfonamide as a false metabolite.

Structure–activity relationships

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T he basis of the structural resemblance of sulfonamides to PABA that is so devastating to these bacteria is clear. T he functional group that differs in the two molecules is the carboxyl of PABA and the sulfonamide moiety of sulfanilamide. T he strongly electron-withdrawing character of the aromatic SO 2 group makes the nitrogen atom to which it is directly attached partially electropositive. T his, in turn, increases the acidity of the hydrogen atoms attached to the nitrogen so that this functional group is slightly acidic (pK a = 10.4). T he pK a of the carboxyl group of PABA is approximately 6.5. It was soon found, following a crash synthetic program, that replacement of one of the NH 2 hydrogens by an electron-withdrawing heteroaromatic ring was not only consistent with antimicrobial activity but also greatly acidified the remaining hydrogen and dramatically enhanced potency. With suitable groups in place, the pK a is reduced to the same range as that of PABA itself. Not only did this markedly increase the antibacterial potency of the product, it also dramatically increased the water solubility under physiologic conditions. T he pK a of sulfisoxazole, one of the most popular of the sulfonamides in present use, is approximately 5.0. T he poor water solubility of the earliest sulfonamides led to occasional crystallization in the urine (crystalluria) and resulted in kidney damage, because the molecules were un-ionized at urinary pH values. It is still recommended to drink increased quantities of water to avoid crystalluria when taking certain sulfonamides. T his form of toxicity is now comparatively uncommon with the more important agents used today, however, because these agents form sodium salts that are at least partly ionized and, hence, reasonably water soluble at urinary pH values. T hey are poorly tolerated on injection, however, because these salts are corrosive to tissues. Structural variation among the clinically useful sulfonamides is restricted primarily to installation of various heterocyclic aromatic substituents on the sulfonamide nitrogen.

Pharmacokinetics T he orally administered sulfonamides are well absorbed from the gastrointestinal (GI) tract, distributed fairly widely, and excreted by the kidney. T he drugs are bound to plasma protein (sulfisoxazole, 30–70%, sulfamethoxazole, 70%) and, as such, may displace other protein-bound drugs as well as bilirubin. T he latter phenomenon disqualifies them for use in late term pregnancy as they can cause neonatal jaundice. Sulfonamides are partly deactivated by acetylation at N-4 and glucuronidation of the anilino nitrogen in the liver. P.1038 Plasmid-mediated resistance development is common, particularly among Gram-negative microorganisms and usually takes the form of decreased sensitivity of dihydropteroate synthase or increased production of PABA.

Therapeutic Applications Of the thousands of sulfonamides that have been evaluated, sulfisoxazole acetyl in combination with erythromycin ethylsuccinate is currently the most popular. Sulfisoxazole acetyl is tasteless, which accounts for its use in pediatric preparations and is a pro-drug. T he acetyl moiety is removed in the GI tract, giving rise to the active sulfisoxazole. Along with the surviving sulfonamides (T able 38.1), it has a comparatively broad antimicrobial spectrum in vitro, especially against Gram-negative organisms, but its clinical use generally is restricted because of the development of bacterial resistance. Susceptible organisms may include Enterobacteriaceae (Escheri chi a col i , Kl ebsi el l a sp., and Proteus sp.) and Streptococcus pyogenes,

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Streptococcus pneumoni ae, and Haemophi l us sp. Sul famethoxazol e, i n combi nati on wi th tri methopri m, i s used for treatment of pri mary uncompl i cated uri nary tract i nfecti ons and, occasi onal l y, as a backup to other, normal l y more preferred agents i n speci al si tuati ons. T he remaining sulfonamides are not used systemically. Sulfadiazine in the form of its silver salt is used topically for treatment of burns and is effective against a range of bacteria and fungus. Sulfacetamide is used ophthalmically for treatment of eye infections caused by susceptible organisms, and sulfasalazine is a pro-drug used in the treatment of ulcerative colitis and Crohn's disease.

Table 38.1. Clinically Relevent Sulfonamides

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Fig. 38.4. Activation of sulfasalazine to 5-aminosalicylic acid.

Adverse effects Allergic reactions are the most common adverse effect and take the form of rash, photosensitivity, and drug fever. Less common problems are kidney and liver damage, hemolytic anemia, and other blood problems. T he most serious adverse effect is the Stevens-Johnson syndrome characterized by sometimes-fatal erythema multiforme and ulceration of mucous membranes of the eye, mouth, and urethra. Fortunately, these effects are comparatively rare.

Sulfasalazine Sulfasalazine stands out from the typical sulfonamide by the fact that although administered orally, the drug is not absorbed in the gut, so the majority of the dose is delivered to the distal bowel. In addition, the drug is a pro-drug, which undergoes reductive metabolism by gut bacteria, converting the drug into sulfapyridine and 5-aminosalicyclic acid the active component (Fig. 38.4). T he liberation of 5-aminosalicylic acid (mesalamine), an anti-inflammatory agent, is the purpose for administering this drug. T his agent is used to treat ulcerative colitis and Crohn's disease. Direct administration of salicylates is otherwise irritating to the gastric mucosa.

Trimethoprim

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Mechanism of action A further step in the pathway leading from the pteroates to folic acid and on to DNA bases requires the enzyme dihydrofolate reductase. Exogenous folic acid must be reduced stepwise to dihydrofolic acid and then to tetrahydrofolic acid, an important cofactor essential for supplying a 1-carbon unit in thymidine biosynthesis and, ultimately, for DNA synthesis (Fig. 38.5). T he same enzyme also must reduce endogenously produced dihydrofolate. Inhibition of this key P.1039 enzyme had been widely studied in attempts to find anticancer agents by starving rapidly dividing cancer cells of needed DNA precursors. T he student will recall that methotrexate and its analogues came from such studies. Methotrexate is, however, much too toxic to be used as an antibiotic. Subsequently, however, trimethoprim was developed in 1969 by George Hitchings and Gertrude Elion (who shared a Nobel Prize for this and other contributions to chemotherapy in the 1980s). T his inhibitor prevents tetrahydrofolic acid biosynthesis and results in bacteriostasis. T rimethoprim selectivity between bacterial and mammalian dihydrofolate reductases results from the subtle but significant architectural differences between these enzyme systems. Whereas the bacterial enzyme and the mammalian enzyme both efficiently catalyze the conversion of dihydrofolic acid to tetrahydrofolic acid, the bacterial enzyme is sensitive to inhibition by trimethoprim by up to 40,000-fold lower concentrations than the mouse enzyme is. T his difference explains the useful selective toxicity of trimethoprim.

Fig. 38.5. Site of action of trimethoprim.

Therapeutic application T rimethoprim frequently is used as a single agent clinically for the oral treatment of uncomplicated urinary tract infections caused by susceptible bacteria (predominantly community acquired Escheri chi a col i and other Gram-negative rods). It is, however, most commonly used in a 1:5 fixed concentration ratio with the sulfonamide sulfamethoxazole (Bactrim, Septra). T his combination is not only synergistic in vitro but also is less likely to induce bacterial resistance than either agent alone. It is rationalized that microorganisms not

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completely inhibited by sulfamethoxazole at the pteroate condensation step will not likely be able to push the lessened amount of substrates that leak past a subsequent blockade of dihydrofolate reductase. T hus, these agents block sequentially at two different steps in the same essential pathway, and this combination is extremely difficult for a naive microorganism to survive. It also is comparatively uncommon that a microorganism will successfully mutate to resistance at both enzymes during the course of therapy. Of course, if the organism is already resistant to either drug at the outset of therapy, which happens more and more often, much of the advantage of the combination is lost. Pairing these two particular antibacterial agents was based on pharmacokinetic factors and convenient availability. For such a combination to be useful in vivo, the two agents must arrive at the necessary tissue compartment where the infection is at the correct time and in the correct ratio. In this context, the optimum ratio of these two agents in vitro is 1:20. Of all the combinations tried, sulfamethoxazole came closest to being optimal for trimethoprim. Administration of a 1:5 combination of the two drugs orally produces the desired 1:20 ratio in the body once steady state is reached. Conveniently, sulfamethoxazole was already on the market, so it did not have to be approved specially by the U.S. Food and Drug Administration (FDA) for this purpose. It is easier to demonstrate synergy in vitro than in vivo, and concerns about the toxic contribution of the sulfonamide (and, doubtless, commercial considerations as well) have led to a recent vogue for the use of trimethoprim alone. T rimethoprim has a broad spectrum in vitro, so it is potentially useful against many microorganisms. Combined with sulfamethoxazole, it is used for oral treatment of urinary tract infections, shigellosis, otitis media, traveler's diarrhea, methicillin-resistant Staphyl ococcus aureus (MRSA), Legi onel l a infection, and bronchitis. Among the opportunistic pathogens that afflict patients with AIDS is the pneumonia-causing fungus Pneumocysti s ji roveci (previously classified as Pneumocysti s cari ni i ). Immunocompetent individuals rarely become infected with P. ji roveci , but it is a frequent pathogen in patients with AIDS and is nearly 100% fatal in such immunocompromised individuals. T he combination of sulfamethoxazole–trimethoprim has proven to be useful and comparatively nontoxic for these patients. A form for injection is available for use in severe infections and is particularly useful in patients with AIDS. T his treatment form leads to more frequent toxic reactions, however. T he most frequent side effects of trimethoprim–sulfamethoxazole are rash, nausea, and vomiting. Blood dyscrasias are less common, as is pseudomembranous colitis (caused by nonantibioticsensitive opportunistic gut anaerobes, often Cl ostri di um di ffi ci l e). Many broad-spectrum antimicrobials can lead to such severe drug related diarrhea, and this side effect must be monitored carefully. Severe, nonresolving diarrhea can be fatal; therefore, it is a justification for withdrawing existing therapy in favor of antianaerobic antibiotic. Despite a significant effort, no structurally related analogue has emerged to compete with trimethoprim. P.1040

Resistance Bacterial resistance to trimethoprim is increasingly common. In pneumococcal infections, it can result from a single amino acid mutation (Ile-100 to Leu) in the dihydrofolate reductase enzyme. Overexpression of dihydrofolate reductase by Staphyl ococcus aureus has been reported in resistant strains as well.

Quinolones Introduction

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T he quinolone antimicrobials comprise a group of synthetic substances possessing in common an N-1-alkylated 3-carboxypyrid-4-one ring fused to another aromatic ring, which itself carries other substituents. T he first quinolone to be marketed (in 1965) was nalidixic acid. Nalidixic acid and cinoxacin are classified as first-generation quinolones based on their spectrum of activity and pharmacokinetic properties. While still available, they are considered to be minor urinary tract disinfectants that are effective primarily against certain susceptible Gram-negative bacteria. T hus, the quinolones were of little clinical significance until the discovery that the addition of a fluoro group to the 6-position of the basic nucleus greatly increased the biological activity. Brought to the market in 1986, norfloxacin, the first of the second-generation quinolones, has a broad spectrum and equivalent in potency to many of the fermentation derived antibiotics. Following its introduction, intense competition ensued, more than a thousand second-, third-, and fourthgeneration analogues have now been made. Alatrofloxacin, ciprofloxacin, enoxacin, gatifloxacin, gemifloxacin, lomefloxacin, norfloxacin, ofloxacin, levofloxacin, moxifloxacin, sparfloxacin, and trovafloxacin are currently marketed in the United States (Fig. 38.6). Ciprofloxacin and levofloxacin dominate the worldwide fluoroquinolone market, accounting between them for over $3 billion in 2002.

Fig. 38.6. Second-, third-, and fourth-generation quinolones.

It should be noted that the more recent quinolones also are referred to as the fluoroquinolones and that these agents are now an important class of antimicrobial agents.

Mechanism of action T he quinolones are rapidly bactericidal, largely as a consequence of inhibition of DNA gyrase and topoisomerase IV, key bacterial enzymes that dictate the conformation of DNA. T he Escheri chi a col i chromosome is a single, circular molecule of approximately 1 mm in length, whereas the cell is only 1 to 3 µm long. T hus, the DNA molecule must be dramatically compacted in a conformationally stable way so that it

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can fit. Using the energy generated by adenosine triphosphate (AT P) hydrolysis, the molecule is progressively wound about itself in a positive super coil. In the absence P.1041 of AT P, the process is reversed, relaxing the molecule. It also must be partially unwound so that the cell has access to the genetic information that it contains. T his requires reversible conformational changes so that it can be stored properly, unwound, replicated, repaired, and transcribed on demand. T hese enzymes alter the conformation of DNA by catalyzing transient double-strand cuts staggered by four base pairs, passing the uncut portion of the molecule through the gap, and resealing the molecule back together. In this way, DNA gyrase alters the degree of DNA twisting by introducing negative DNA super coils, releasing tensional stress in the molecule. On the other hand, DNA topoisomerase IV decatenates (unties) enchained daughter DNA molecules produced through replication of circular DNA. Inhibition of DNA gyrase and topoisomerase IV makes a cell's DNA inaccessible and leads to cell death, particularly if the cell must deal with other toxic effects at the same time. T hese processes are shown schematically in Fig. 38.7. Different quinolones inhibit these essential enzymes to different extents. T opoisomerase IV seems to be more important to some Gram-positive organisms and DNA gyrase to some Gram-negative organisms. T he coumermycins, of which novobiocin (now archaic) was the most clinically relevant, bind to a different site in these topoisomerases (i.e., where the AT P binds). Resistance to the coumermycins develops rather easily, and they find little use today.

Fig. 38.7. Schematic depicting supercoiling of circular DNA catalyzed by DNA gyrase.

Humans shape their DNA with a topoisomerase II, an analogous enzyme that does not bind quinolones at

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normally achievable doses, so the quinolones of commerce do not kill host cells.

Fig. 38.8. Major structure–activity relationship features.

Structure–activity relationship T he structural features of the quinolones strongly influence the antimicrobial and pharmacokinetic properties of this class of drugs. T he essential pharmacophore for activity is the carboxy-4-pyridone nucleus (Fig. 38.8). Apparently, the carboxylic acid and the ketone are involved in binding to the DNA/DNA-gyrase enzyme system. Reduction of the 2,3-double bond or the 4-keto group inactivates the molecule, and substitution at C-2 interferes with enzyme–substrate complexation. Fluoro substitution at the C-6 position greatly improves antimicrobial activity by increasing the lipophilicity of the molecule, which in turn improves the drugs penetration through the bacterial cell wall. Additionally, C-6 fluoro increases the DNA gyrase inhibitory action. An additional fluoro group at C-8 further improves drug absorption and half-life but also may increase drug-induced photosensitivity. Heterocyclic substitution at C-7 improves the spectrum of activity especially against Gram-negative organisms. T he piperazinyl (as in ciprofloxacin) and pyrrolidinyl (as in moxifloxacin) represent the most significant antimicrobial improvement. Unfortunately, the piperazinyl group at C-7 also increases binding to central nervous system (CNS) γ-aminobutyric acid (GABA) receptors, which accounts for CNS side effects. Alkyl substitution on the piperazine (lomefloxacin and ofloxacin) is reported to decrease binding to GABA, as does the addition of bulky groups at the N-1 position (sparfloxacin). T he cyclopropyl substitution at N-1 appears to broaden activity of the quinolones to include activity against atypical bacteria, including M ycopl asma, Chl amydi a, and Legi onel l a species. T he introduction of a third ring to the nucleus of the quinolones gives rise to ofloxacin. Additionally, ofloxaxin has an asymmetric carbon at the C-3' position. T he S-(–)-isomer (levofloxacin) is twice as active as ofloxacin and 8- to 128-fold more potent than the R-(+ )-isomer resulting from increased binding to the DNA-gyrase. Several of the quinolones produce mild to severe photosensitivity. A C-8 halogen appears to produce the highest incidence of photosensitivity via singlet oxygen and radical induction. Lomefloxacin has been reported to have the highest potential for producing phototoxicity. Substitution of a methoxy group at C-8 has been reported to reduce the photosensitivity (gatifloxacin). P.1042 Finally, a chemical incompatibility common to all the quinolones involves the ability of these drugs to chelate polyvalent metal ions (Ca

2+

, Mg 2+ , Zn 2+ , Fe 2+ , and Al 3+ ), resulting in decreased solubility and reduced drug

absorption. Chelation occurs between the metal and the 3-carboxylic acid and 4-keto groups. Agents containing polyvalent metals should be administered at least 4 hours before or 2 hours after the quinolones.

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Pharmacokinetics T he fluoroquinolones are well absorbed following oral administration, with excellent bioavailability. T he maximum plasma concentration usually is reached within a few hours, and the drugs are moderately bound to plasma protein, leading to comparatively long half-lives (T able 38.2). Earlier quinolones were rapidly excreted into the urine, which limited their therapeutic application to urinary tract infections, whereas the newer drugs are distributed to alveolar macrophages, bronchial mucosa, epithelial lining fluid, and saliva, improving the use in various systemic infections. Several studies have suggested that the ratio of mean peak plasma concentration to MIC and the 24-hour area under the curve to MIC may correlate with therapeutic outcomes. If this proves to be true, it could greatly help the clinician in choosing the appropriate drug and dosing schedule.

Therapeutic applications T he quinolones therapeutically fall into one of four classifications (T able 38.3). T he specific drugs within each classification include nalidixic acid and cinoxin as first-generation agents, with utility limited to uncomplicated urinary tract infections. T he second-generation quinolones include norfloxacin, lomefloxacin, enoxacin, ofloxacin, and ciprofloxacin. Whereas norfloxacin is used mainly for urinary tract infections (Enterobacter sp., Enterococcus sp., or Pseudomonas aerugi nosa), ciprofloxacin also is used for prostatitis, upper respiratory tract infections, bone infections, septicemia, staphylococcal and pseudomonal endocarditis, meningitis, sexually transmitted diseases (gonorrhea and chlamydia), chronic ear infections, and purulent osteoarthritis. T he third-generation quinolones, which include levofloxacin, sparfloxacin, gatifloxacin, and gemifloxacin, are used to treat infections caused by Legi onel l a sp., Chl amydi a sp., and M ycopl asma sp., as well as Streptococcus pneumoni ae. T hese agents may find use in the treatment of acute bacterial exacerbation of chronic bronchitis and community-acquired pneumonia. Gemifloxacin has been approved for use against multidrug-resistant S. pneumoni ae. Additional indications may include skin and skin structure infections and acute sinusitis caused by S. pneumoni ae, Haemophi l us i nfl uenzae, and M oraxel l a catarrhal i s. T he fourth-generation quinolines include trovafloxacin and moxifloxacin, which have a spectrum of activity that includes anaerobes, such as Bacteroi des fragi l i s.

Table 38.2. Pharmacokinetic Properties for Selective Quinolones Drug

Bioavailability (%)Protein Binding (%)Half-life (hours)

Ciprofloxacin

70

30

3.5

Enoxacin

90

40

3–6

Gatifloxacin

96

20

8.0

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Gemifloxacin

71

60–70

8.0

Levofloxacin

99

31

6.9

Lomefloxacin

95

10

8

Moxifloxacin

86

47

12.1

Norfloxacin

30–40

10–15

3–4

Ofloxacin

98

32

9

Sparfloxacin

90

56

18.7

Trovafloxacin

88

73

11.0

Table 38.3. Therapeutic Classification of Quinolones Generation

Characteristics

First generation

Poor serum and tissue concentration Not valuable for systemic infections Lack activity against Pseudomonas aeruginosa, Gram-positive organisms, and anaerobes

Second generation

Adequate serum and tissue concentration Good for systemic infections Active against Gram-negative organisms, including P. aeruginosa; weak activity against Streptococcus pneumoniae; no activity against anaerobes

Third generation

Once-daily dosing Active against S. pneumoniae and atypical bacteria; less active against P. aeruginosa

Fourth generation

Active against anaerobes and aerobic Gram-positive and Gram-negative organisms

Resistance Resistance to the quinolones is becoming more frequent and is associated with spontaneous mutations in two genes (gyrA and gyrB) that encode for the quinolone target protein, DNA gyrase. A single step mutation can lead to low-level resistance, whereas mutations in both genes lead to high-level resistance. T his mechanism of resistance would be expected to produce cross-resistance within the class of quinolones. In

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addition, there are suggestions that resistance may be associated with an increase in drug efflux or a decrease in outer membrane permeability affecting drug influx. Such a mechanism of resistance would be expected to be more common in Gram-negative organisms with a more complex cell wall than in Gram-positive organisms with its cell envelope.

Adverse effects T he quinolone class is associated with more side effects than the β-lactam and macrolide classes but, nonetheless, see very widespread medicinal use. P.1043 Among the side effects associated with quinolones is a proconvulsant action, especially in epileptics, but this is mainly associated with the first-generation agents. Other CNS problems include hallucinations, insomnia, and visual disturbances. Some patients also experience diarrhea, vomiting, abdominal pain, and anorexia. T hese effects are most common with trovafloxacin. T he quinolones are associated with erosion of the load-bearing joints of young animals. As a precaution, these drugs are not used casually in children younger than 18 years or in sexually active females of childbearing age. Ciprofloxacin is the fluoroquinolone of choice for children when use of a quinolone is required, because it has been extensively studied for this purpose. T hey also are potentially damaging in the first trimester of pregnancy because of a risk of severe metabolic acidosis and of hemolytic anemia. Coadministration with theophylline potentiates the action of the latter and should be monitored closely. Although it takes much higher concentrations of fluoroquinolones to inhibit human topoisomerase II than concentrations of either DNA gyrase or bacterial topoisomerase IV, some agents have a narrower margin of safety. With gemifloxacin, a mild to severe rash may develop.

Severe toxicities Certain members of the fluoroquinolone family were marketed for a time but were subsequently severely limited in use or withdrawn because of the unacceptable toxicities experienced by some patients. T hese agents had been introduced with great hopes because of their breadth of spectrum and potency against resistant microorganisms. T emafloxacin, for example, was removed from the market because of hemolysis, renal failure, and thrombocytopenia (the hemolytic uremic syndrome). T hese effects only became apparent when large numbers of patients received the drug. Severe liver toxicity led to the removal from the market in Europe and restrictions on the use of trovafloxacin in the United States only for severe infections involving institutional care, where the patient can be closely monitored. Grepafloxacin was introduced to the market in late 1997 as a broad-spectrum fluoroqinolone and was withdrawn from the market in 1999 based on cardiovascular toxicity. Gatifloxacin, gemifloxacin, and moxifloxacin carry warnings about QT -interval prolongation but are still in use. Sparfloxacin also has been reported to produce cardio- and phototoxicity and should be used with great care. T he drugs were reported to cause a prolonged QT c interval. Analogues with a C-8 chloro substituent, such as clinafloxacin and sitafloxacin, also were very potent but have largely fallen from favor because of excessive phototoxicity. All these drugs were well on the way to great popularity when these untoward events were detected. T hese phenomena were not apparently revealed during extensive previous animal and clinical studies. No consistent structural pattern is associated with these problems, with the exception that one would not use an N-1 2,4-difluorophenyl moiety except with great care.

Miscellaneous Agents Nitroheteroaromatic compounds

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Nitrofurantoin, a widely used oral antibacterial nitrofuran, has been available since World War II. It is used for prophylaxis or treatment of acute urinary tract infections when kidney function is not impaired, and it inhibits kidney stone growth. Nausea and vomiting are common side effects. T his is avoided, in part, by slowing the rate of absorption of the drug through use of wax-coated, large particles (Macrodantin). Nitrofurantoin inhibits DNA and RNA functions through mechanisms that are not well understood, although bioreductive activation is suspected to be an important component of this. Resistance is not commonly encountered. Rather severe side effects can be experienced when using this drug (e.g., acute pulmonary reactions, peripheral neuropathy, hemolytic anemia, liver toxicity, and fertility impairment), so caution is in order. Metronidazole was initially introduced for the treatment of vaginal infections caused by amoeba. T his nitroimidazole also is useful orally, however, for the treatment of trichomoniasis, giardiasis, and Gardnerel l a vagi nal i s infections. It has found increasing use of late in the parenteral treatment of anaerobic infections and in the treatment of pseudomembranous enterocolitis resulting from Cl ostri di um di ffi ci l e, an opportunistic pathogen that occasionally flourishes as a consequence of broad-spectrum antibiotic therapy. Infections with C. di ffi ci l e can be life-threatening. T he drug is believed to be metabolically activated by reduction of its nitro group to produce reactive oxygen species. Metronidazole also is a component of a multidrug cocktail used to treat Hel i cobacter pyl ori infections associated with gastric ulcers. Both drugs can cause disulfuram-like adverse reactions when alcohol is consumed. For many years, it had little competition from other therapies for its indications. Recently, tinidazole, another nitroimidazole, has been introduced in the United States as just such a competitor. It is too early to judge how competitive this agent will be, but it has a longer duration of action. Metronidazole use is associated with allergic rashes and CNS disturbances, including convulsions in some patients. It is carcinogenic in rodents. T hus, some caution is associated with its use.

Methenamine

P.1044 A venerable drug used for the disinfection of acidic urine, methenamine is a low-molecular-weight polymer of ammonia and formaldehyde that reverts to its components under mildly acidic conditions. Formaldehyde is the active antimicrobial component. Methenamine is used for recurrent urinary tract infections. T he drug is available in various dosage forms as well as various salts, including the hippurate and mandelate.

Phosphomycin

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Phosphomycin, introduced in 1972, inhibits enolpyruvial transferase, an enzyme catalyzing an early step in bacterial cell wall biosynthesis. Inhibition results in reduced synthesis of peptidoglycan, an important component in the bacterial cell wall. Phosphomycin is bactericidal against Escheri chi a col i and Enterobacter faecal i s infections.

Antibiotics: Inhibitors of Bacterial Cell Wall Biosynthesis Bacterial cell wall Bacterial cells are enclosed within a complex and largely rigid cell wall. T his differs dramatically from mammalian cells, which are surrounded by a flexible membrane, the chemical composition of which is dramatically different. T his provides a number of potentially attractive targets for selective chemotherapy of bacterial infections. For one thing, enzymes that have no direct counterpart in mammalian cells construct the bacterial cell wall. T hree of the main functions of the bacterial cell wall are 1) to provide a semipermeable barrier interfacing with the environment through which only desirable substances may pass, 2) to provide a sufficiently strong barrier so that the bacterial cell is protected from changes in the osmotic pressure of its environment, and 3) to prevent digestion by host enzymes. T he initial units of the cell wall are constructed within the cell, but soon, the growing and increasingly complex structure must be extruded; final assembly takes place outside of the inner membrane. T his circumstance makes the enzymes involved in the late steps more vulnerable to inhibition, because they are at or near the cell surface. Whereas individual bacterial species differ in specific details, the following generalized picture of the process is sufficiently accurate to illustrate the process.

Gram-Positive Bacteria T he cell wall of Gram-positive bacteria, although complex enough, is simpler than that of Gram-negative organisms. A schematic representation is shown in Figure 38.9. On the very outside of the cell is a set of characteristic carbohydrates and proteins that, together, make up the antigenic determinants that differ from species to species and that also cause adherence to particular target cells. T here also may be a lipid-rich capsule surrounding the cell (not shown in Fig. 38.9). T he next barrier that the wall presents is the peptidoglycan layer. T his is a spongy, gel-forming layer consisting of a series of alternating sugars (N-acetylglucosamine and N-acetylmuramic acid) linked (1,4)-β in a long chain (Fig. 38.10). T o the lactic acid carboxyl moieties of the N-acetylmuramic acid units is attached, through an amide linkage, a series of amino acids, of which L-alanyl-D-glutamyl-L-lysyl-D-alanine is P.1045 typical of Staphyl ococcus aureus. One notes the D-stereochemistry of the glutamate and the terminal alanine. T his feature is presumably important in protecting the peptidoglycan from hydrolysis by host peptidases, particularly in the GI tract. T his unusual structural feature facilitates successful parasitism.

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Fig. 38.9. Schematic of some features of the Gram-positive bacterial cell wall.

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Fig. 38.10. Schematic of cell wall cross-linking. Pentaglycyl group replaces terminal D-alanine.

Table 38.4. Pencillins Binding Proteins (PBP) of E. coli PBP

Function

Lethality?

1A

Cell elongation (peripheral wall extension)

Yes

1B

Cell elongation (peripheral wall extension)

Yes

2

Maintenance of rod shape

Yes

3

Septum formation

No

4

Limit the amount of cross linking of the peptidoglycan

No

5


No

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6


No

V. Lorian, Ed., Antibiotics in Laboratory Medicine, Williams & Wilkins, Baltimore (1986).

T he early steps in the biosynthesis of the peptidoglycan unit result in formation of a complex polymeric sheet. T his is then cross-linked to form a thickened wall. T his bonds the terminal D-alanyl unit to the lysyl unit of an adjacent tetrapeptide strand through a pentaglycyl unit. T his last step is an enzyme-catalyzed transamidation by which the terminal amino moiety on the last glycine unit of the A strand displaces the terminal D-Ala unit on the nearby B strand. T he cell wall transamidase (one of the penicillin binding proteins [PBPs]) forms a transient, covalent bond during the synthesis phase with a particular serine hydroxyl on the enzyme. Completion of the catalytic cycle involves displacement of the enzyme by a glycine residue, which regenerates the enzyme. T his process gives the wall additional rigidity, much as would be achieved by gluing the pages of a book together. T his strong barrier protects against osmotic stress and accounts for the retention of characteristic morphological shape of Gram-positive bacteria (e.g., globes and rods). T his step is highly sensitive to inhibition of β-lactam antibiotics. It also is the target of the glycopeptide antibiotics (e.g., vancomycin), as will be discussed later. T he peptidoglycan layer is traversed by complex glycophospholipids called teichoic and teichuronic acids. T hese are largely responsible for the acid mantle of Gram-positive bacteria. Beneath the peptidoglycan layer is the lipoidal cytoplasmic cell membrane in which a number of important protein molecules float in a lipid bilayer. Among these proteins are the β-lactam targets, known as the PBPs. T hese enzymes are important in cell wall formation and remodeling. In Gram-positive bacteria, the outer layers are relatively ineffective in keeping out antibiotics. It is the inner membrane and its protein components that provide the principal barrier to uptake of antibiotics. T here are at least seven types of PBPs. T hose of Escheri chi a col i are classified in T able 38.4. T he functions of all of these are not entirely understood, but they are important in construction and repair of the cell wall. β-Lactam antibiotics bind to these proteins and kill bacteria by preventing the biosynthesis of a functional cell wall. Various β-lactam antibiotics display different patterns of binding to these proteins. T he action of these proteins must alternate in a controlled and systematic way between their active and inert states so that bacterial cells can grow and multiply in an orderly manner. Selective interference by β-lactam antibiotics with the functioning of these proteins prevents normal growth and repair and creates serious problems for bacteria, particularly young cells needing to grow and mature cells needing to repair damage or to divide. T he rapid bactericidal effect of penicillins on such cells can readily be imagined.

Gram-Negative Bacteria With the Gram-negative bacteria, the cell wall is more complex and more lipoidal (Fig. 38.11). T hese cells usually contain an additional, outer lipid membrane that differs considerably from the inner membrane. T he outer layer contains complex lipopolysaccharides that encode antigenic responses, cause septic shock, provide the serotype, and influence morphology. T his exterior layer also contains a number of enzymes and exclusionary proteins. Important among these are the porins. T hese are transmembranal supermolecules made P.1046 up of two or three monomeric proteins. T he center of this array is a transmembranal pore of various dimensions. Some allow many kinds of small molecules to pass, and others contain specific receptors that allow only certain molecules to come in. T he size, shape, and lipophilicity of drugs are important considerations controlling porin passage. Antibiotics have greater difficulty in penetrating into Gram-negative bacterial cells as a consequence. Next comes a periplasmic space containing a somewhat less impressive and thinner, as compared to the Gram-positive organisms, layer of peptidoglycan. Also present is a phospholipid-rich cytoplasmic membrane in which floats a series of characteristic proteins with various functions. T he β-lactam targets (i.e., the PBPs) are found here.

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Fig. 38.11. Schematic of some features of the Gram-negative bacterial cell wall.

Other inner membrane proteins are involved in transport, energy, and biosynthesis. In many such cells are proteins that actively pump out antibiotics and other substances at the expense of energy and that may require the simultaneous entrance of oppositely charged materials to maintain an electrostatic balance.

β-Lactam antibiotics

T he name “ lactam” is given to cyclic amides and is analogous to the name “ lactone,” which is given to cyclic esters. In an older nomenclature, the second carbon in an aliphatic carboxylic acid was designated α, the third β, and so on. T hus, a β-lactam is a cyclic amide with four atoms in its ring. T he contemporary name for this ring system is azetidinone. T his structural feature was very rare when it was found to be a feature of the structure of the penicillins, so the name “ β-lactam” came to be a generic descriptor for the whole family. It is fortunate that this ring ultimately proved to be the main component of the pharmacophore, so the term

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possesses medicinal as well as chemical significance. T he penicillin subclass of β-lactam antibiotics is characterized by the presence of a substituted 5-membered thiazoldine ring fused to the β-lactam ring. T his fusion and the chirality of the β-lactam ring results in the molecule roughly possessing a “ V” -shape. T his drastically interferes with the planarity of the lactam bond and inhibits resonance of the lactam nitrogen with its carbonyl group. Consequently, the β-lactam ring is much more reactive and, therefore, more sensitive to nucleophilic attack when compared with normal planar amides.

History T he story of the discovery of the penicillins are widely known. In 1929, Alexander Fleming, a physician and a clinical microbiologist, was preserving a culture of a pathogen, and the plate became contaminated with an airborne fungus, Peni ci l l i um notatum (now named Peni ci l l i um chrysogenum), which not only grew on the plate but also produced a clear zone of inhibition around its colony. On returning from a vacation and finding this, he recognized the potential significance of this antibiotic effect, so he preserved the fungus and tried to identify its active constituent. T he state of development of the art as well as his background and training were insufficient for the task at that time. It was not until a decade later that a group of English chemists, including Abraham, Chain, Florey, and Heatley, succeeded in purifying the unstable antibiotic. Finally, on February 12, 1941, following heroic efforts necessitated by wartime conditions, enough material was available for clinical examination and the demonstration that penicillin actually worked in humans. Much new technology had to be developed before large-scale use of penicillin could take place. T he efforts of an international team solved, for example, the problems of large-scale sterile aerobic submerged fermentation, directed fermentation, strain improvement, and many other vexing problems. By 1943, penicillin was being produced in very large quantities for use by the armed forces. When peace came in 1945, production was in tons, and the drug was available very cheaply. T he earliest penicillins were produced by fungi from media constituents. T he bicyclic heterocyclic nucleus of 6-aminopenicillanic acid (6-APA) was constructed by an involved process catalyzed by enzymes. T he side chain was added essentially intact from media constituents. It was discovered that certain arylacetic acids, when added to the medium, were used to form the side chain amide moiety and that this was very important for stability and breadth of spectrum. It was later discovered that exclusion of such materials from the medium allowed the production of 6-APA without a side chain. Chemists could then add a much wider variety of side chains without being limited by the specific requirements of the enzymes. With this breakthrough, the penicillin field expanded to include orally active, broad-spectrum, and enzymatically stable penicillins. T he cephalosporins were discovered as secondary metabolites of a different fungal species. Because it was stable to many activity-destroying β-lactamases, its core nucleus, 7-aminocephalosporanic acid, was substituted with a wide variety of unnatural side chains, and three generations of clinically useful analogues resulted. Later work produced the monobactams, carbapenems, and β-lactamase inhibitors. In the year 2005, about half of the money spent worldwide on antibiotics was for β-lactams. More than 100,000 of these compounds have been prepared by partial or total chemical synthesis, and a significant number of these remain on the market more than 60 years after their discovery.

Pen icillin s T he medicinal classifications, chemical structures, and generic names of the penicillins currently available are presented in T able 38.5.

Preparation of Pen icillin s T he original fermentation derived penicillins were produced by growth of the fungus P.1047 Peni ci l l i um chrysogenum on complex solid media, with the result that they were mixtures differing from one another in the identity of the side-chain moiety. When a sufficient supply of phenylacetic acid is present in liquid media, this is preferentially incorporated into the molecule to produce mainly benzylpenicillin (penicillin G in the old nomenclature). Use of phenoxyacetic acid instead leads to phenoxymethyl penicillin (penicillin V). More than two dozen different penicillins have been made in this way, but these two are the only ones that remain in clinical use. T he bicyclic penicillin nucleus itself is prepared biosynthetically via a complex process from an acylated cysteinyl valyl peptide. T he complete exclusion of side chain precursor acids from the medium produces the fundamental penicillin nucleus, 6-APA, but in poor yield. By itself, 6-APA has only very weak antibiotic activity, but when substituted on its primary amino group with a suitable

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amide side chain, its potency and antibacterial spectrum are profoundly enhanced. With this key precursor isolated, limitations caused by enzyme specificities in biosynthesis could be overcome by use of partial chemical synthesis. A more practical modern process for making 6-APA employs naturally occurring fungal enzymes that selectively hydrolyze away the side chain of natural penicillins without cleaving the β-lactam bond. T hese enzymes are found in certain Gram-negative bacteria but P.1048 appear to be of negligible importance with respect to bacterial resistance to β-lactam antibiotics. More recently, ingeniously selective chemical processes have been devised for accomplishing removal of less interesting side chains from biosynthetic penicillins. T he operational chemical freedom resulting from the convenient availability of 6-APA has led to partial synthesis of many thousands of analogues.

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Table 38.5. Commercially Significant Pencillins and Related M olecules

T he sodium and potassium salts of penicillins are crystalline, hydroscopic, and water-soluble. T hey can be employed either orally or parentally. When dry, they are stable for long periods but hydrolyze rapidly when in solution. T heir best stability is noted at pH values between 5.5 and 8.0 (especially at pH 6.0–7.2). T he

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procaine and benzathine salts of benzylpenicillin, on the other hand, are water insoluble. Because they dissolve slowly, they are used for repository purposes following injection when long-term blood levels are required.

Nomen cl atu re T he nomenclature of the penicillins, as with most antibiotics, is complex. T he Chemical Abstracts system is definitive and unambiguous, but it is too complex for ordinary use (Fig. 38.12). For example, the chemical name for benzylpenicillin sodium is monosodium (2S,5R,6R)-3,3-dimethyl-7-oxo-6-(2-phenylacetamido)-4thia-1-azabicyclo[3.2.0]heptane-2-carboxylate. Confusingly, the U.S. Pharmacopeia uses a different system that results in the atoms being numbered differently. T he simplest system has stood the test of time and involves taking the repeating radical, carbonyl-6-APA, and using the chemical trivial name for the radical that completes the structure. T hus, use of the names benzylpenicillin and phenoxymethylpenicillin makes practical sense. T here are three asymmetric centers in the benzylpenicillin molecule, as indicated by the asterisk in T able 38.5. T his absolute stereochemistry must be preserved for useful antibiotic activity.

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Fig. 38.12. Ring and numbering systems of clinically available β-lactam antibiotic types.

Clin ical ly Relevan t Ch emical In stabilities T he most unstable bond in the penicillin molecule is the highly strained and reactive β-lactam amide bond. T his bond cleaves moderately slowly in water unless heated, but it breaks down much more rapidly in alkaline solutions to produce penicilloic acid, which readily decarboxylates to produce penilloic acid (Fig. 38.13). Penicilloic acid has a negligible tendency to re-close to the corresponding penicillin, so this reaction is essentially irreversible under physiologic conditions. Because the β-lactam ring is an essential portion of the pharmacophore, its hydrolysis deactivates the antibiotic. A fairly significant degree of hydrolysis also takes place in the liver. T he bacterial enzyme, β-lactamase, catalyzes this reaction as well and is a principal cause of bacterial resistance in the clinic. Alcohols and amines bring about the same cleavage reaction, but the products are the corresponding esters and amides. T hese products are inactive. A reaction with a specific primary amino group of aminoglycoside antibiotics is of clinical relevance, because it inactivates penicillins and cephalosporins (discussed later). When proteins serve as the nucleophiles in this reaction, the antigenic conjugates that cause many penicillin allergies are produced. Small molecules that are not inherently antigenic but that react with proteins to produce antigens in this manner are called haptens. Commercially P.1049 available penicillin salts may be contaminated with small amounts of these antigenic penicilloyl proteins derived from reaction with proteins encountered in their fermentative production or by high-molecular-weight, self-condensation–derived polymers resulting when penicillins are concentrated and react with themselves. Both of these classes of impurities are antigenic and may sensitize some patients.

Fig. 38.13. Instability of β-lactams to nucleophiles.

Solutions of penicillins for parenteral use should be refrigerated, used promptly, and not stored. In acidic

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solutions, the hydrolysis of penicillins is complex. Hydrolysis of the β-lactam bond can be shown through kinetic analysis to involve participation of the side-chain amide oxygen, because the rate of this reaction differs widely depending on the nature of the R group. T he main end products of the acidic degradation are penicillamine, penilloic acid, and penilloaldehyde (Fig. 38.14). T he intermediate penicillenic acid is highly unstable and undergoes subsequent hydrolysis to the corresponding penicilloic acid. An alternate pathway involves sulfur ejection to a product that, in turn, fragments to liberate penicilloic acid as well. Penicilloic acid readily decarboxylates to penilloic acid. T he latter hydrolyzes to produce penilloaldehyde and penicillamine (itself used clinically as a chelating agent). Several related fragmentations to a variety of other products take place. None of these products has antibacterial activity. At gastric pH (~ 2.0) and temperature of 37°C, benzylpenicillin has a half-life measured in minutes. T he less water-soluble amine salts are more stable.

Stru ctu re–Activity Relation sh ip T he chemical substituents attached to the penicillin nucleus can greatly influence the stability of the penicillins as well as the spectrum of activity. It is important to recognize whether the structural changes affect drug stability on the shelf or in the GI tract (in vivo), improve stability toward bacterial metabolism, or enlarge the spectrum of activity.

Fig. 38.14. Instability of penicillins in acid. Hydrolysis involves the C-6 side chain.

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Table 38.6. Improved Acid Stability and Absorption of Substituted Penicillins

T he substitution of a side-chain R group on the primary amine with an electron-withdrawing group decreases the electron density on the side-chain carbonyl and protects these penicillins, in part, from acid degradation. T his property has clinical implications, because these compounds survive passage through the stomach better and many can be given orally for systemic purposes. T he survival of passage and degree of absorption under fasting conditions is shown in T able 38.6. In addition, in vitro degradation reactions of penicillins can be retarded by keeping the pH of solutions between 6.0 and 6.8 and by refrigerating them. Metal ions, such as mercury, zinc, and copper, catalyze the degradation of penicillins, so they should be kept from contact with penicillin solutions. T he lids of containers used today are routinely made of inert plastics, in part, to minimize such problems. T he more lipophilic the side chain of a penicillin, the more serum protein bound is the antibiotic (T able 38.7). P.1050 T his has some advantages in terms of protection from degradation, but it does reduce measurably the effective bactericidal concentration of the drug in whole blood. Contrary to popular assumption, the degree of serum protein binding of the penicillins has comparatively little influence on their half-lives. T he penicillins are actively excreted into the urine via an active transport system for negatively charged ions, and the rate of release from their bound form is sufficiently rapid that the controlling rate is the kidney secretion rate. T he serum half-life of penicillin G is approximately 0.4 to 0.9 hours and that of phenoxymethyl penicillin approximately 0.5 hours. Both are excreted into the urine by tubular excretion. Probenicid, when present, competes effectively for excretion and, as a consequence, prolongs the half-life.

Table 38.7. Protein Binding of Penicillins Penicillin Benzyl penicillin

% Protein binding 45 – 68%

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Phenoxymethyl penicillin

75 – 89%

Methicillin

35 – 80%

Ampicillin

25 – 30%

Amoxicillin

25 – 30%

Carbenicillin

~50%

Oxacillin

>90% >90%

Cloxacillin

Fig. 38.15. β-Lactamase resistant/sensitive structural features.

Stability of the penicillins toward β-lactamase is influenced by the bulk in the acyl group attached to the primary amine. β-Lactamases are much less tolerant to the presence of steric hindrance near the side-chain amide bond than are the penicillin binding proteins. When the aromatic ring is attached directly to the side-chain carbonyl and both ortho positions are substituted by methoxy groups, β-lactamase stability results (Fig. 38.15). Movement of one of the methoxy groups to the para position, or replacing one of them by a hydrogen, resulted in an analogue sensitive to β-lactamases. Putting in a methylene between the aromatic ring and 6-APA likewise produced a β-lactamase–sensitive agent (see Fig. 38.15). T hese findings provide strong support for the hypothesis that its resistance to enzyme degradation is based on differential steric hindrance. Prime examples of this effect are seen in the drugs methicillin, nafcillin, oxacillin, cloxicillin, and dicloxicillin (T able 38.5).

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Fig. 38.16. Cell wall cross-linking and mechanism of action of β-lactams.

Mech an ism of Action T he molecular mode of action of the β-lactam antibiotics is a selective and irreversible inhibition of the enzymes processing the developing peptidoglycan layer (Fig. 38.16). Just before cross-linking occurs, the peptide pendant from the lactate carboxyl of a muramic acid unit terminates in a D-alanyl-D-alanine unit. T he terminal D-alanine unit is exchanged for a glycine unit on an adjacent strand in a reaction catalyzed by a cell wall transamidase. T his enzyme is one of the penicillin biding proteins (carboxypeptidases, endopeptidases, and transpeptidases) that normally reside in the bacterial inner membrane and perform construction, repair, and housekeeping functions, maintaining cell wall integrity and playing a vital role in cell growth and division. T hey differ significantly from bacterium to bacterium, and this is used to rationalize different potency and morphologic outcomes following β-lactam attack on the different bacteria. T he cell wall transamidase uses a serine hydroxyl group to attack the penultimate D-alanyl P.1051 unit, forming a covalent ester bond, and the terminal D-alanine, which is released by this action, diffuses away. T he enzyme–peptidoglycan ester bond is attacked by the free amino end of a pentaglycyl unit of an adjacent strand, regenerating the active site of transpeptidase for further catalytic action and producing a new amide bond, which connects two adjacent strands together. T he three-dimensional geometry of the active site of the enzyme perfectly accommodates to the shape and separation of the amino acids of its substrate. Because the substrate has unnatural stereochemistry at the critical residues, this enzyme is not expected to attack host peptides or even other bacterial peptides composed of natural amino acids. T he penicillins and the other β-lactam antibiotics have a structure that closely resembles that of acylated D-alanyl-D-alanine. T he enzyme mistakenly accepts the penicillin as though it were its normal substrate. T he highly strained β-lactam ring is much more reactive than a normal amide moiety, particularly when fused into the appropriate bicyclic system. T he intermediate acyl–enzyme complex, however, is rather different structurally from the normal intermediate in that the hydrolysis does not break penicillin into two pieces, as it

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does with its normal substrate. In the penicillins, a heterocyclic residue is still covalently bonded and cannot diffuse away as the natural terminal D-alanine unit does. T his presents a steric barrier to approach by the nearby pentaglycyl unit and, therefore, keeps the enzyme's active site from being regenerated and the cell wall precursors from being cross-linked. T he resulting cell wall is structurally weak and is subject to osmotic stress. Cell lysis can result, and the cell rapidly dies, assisted by another class of bacterial enzymes, the autolysins. T he result is a defective cell wall and an inactivated enzyme. T he relief of strain that is obtained on enzymatic β-lactam bond cleavage is so pronounced that there is virtually no tendency for the reaction to reverse. Water also is an insufficiently effective nucleophile and cannot hydrolyze the complex either. T hus, the cell wall transamidase is stoichiometrically inactivated. T he gaps in the cell wall produced by this covalent interruption are not filled in, because the enzyme is now inactivated. (More details of the putative drug–enzyme interaction will be discussed with the other classes of β-lactams.) Binding of β-lactam antibiotics to PBP-1A and PBP-1B (transpeptidase) of Escheri chi a col i leads to cell lysis; to PBP-2 (transpeptidase) leads to oval cells deficient in rigidity and to inhibition of cell division; to PBP-3 (transpeptidase) leads to abnormally long, filamentous shapes by failure to produce a septum; and to PBP-4 through PBP-6 (carboxypeptidases) leads to no lethal effects. Approximately 8% of a dose of benzylpenicillin binds to PCP-1, 0.7% to PCP-2, 2% to PBP-3, 4% to PBP-4, 65% to PBP-5, and 21% to PBP-6. T hus, the majority of the penicillin dose bonds to PBPs for which the function remains obscure. Binding to PBP-1 is lethal. Other β-lactam antibiotics display different binding patterns. Amoxicillin and the cephalosporins bind more avidly to PBP-1, methicillin and cefotaxime to PBP-2, and mezlocillin and cefuroxime to PBP-3. All these drugs are lethal to susceptible bacteria.

Resistan ce T he first literature reports of a penicillinase were published in 1940 and 1944. T his phenomenon was rare at the time and caused no particular alarm. T oday, unfortunately, resistance to β-lactam antibiotics is increasingly common and is rather alarming. It can be intrinsic and involve decreased cellular uptake of drug, or it can involve lower binding affinity to the PBPs. T his is particularly the case with MRSA, the PBP-2 of which has been mutated so that it no longer efficiently binds methicillin. Much more common, however, is the elaboration of a β-lactamase. β-Lactamases are enzymes (serine proteases) elaborated by microorganisms that catalyze hydrolysis of the β-lactam bond and inactivate β-lactam antibiotics to penicilloic acids before they can reach the PCPs (Fig. 38.17). In this, they somewhat resemble the cell wall transamidase from which they may have arisen. Hydrolytic regeneration of the active site is dramatically more facile with β-lactamases than is the case with cell wall transamidase so that the enzyme can turn over many times and a comparatively small amount of enzyme can destroy a large amount of drug. With Gram-positive bacteria, such as staphylococci, the β-lactamases usually are shed continuously into the medium and meet the drug outside the cell wall (Fig. 38.9). T hus, they are biosynthesized in significant quantities. With Gram-negative bacteria, a more conservative course is followed. Here, the β-lactamases are secreted into the periplasmic space between the inner and outer membrane, so although still distal to the PBPs, they do not readily escape into the medium and need not be resynthesized as often (Fig. 38.11). Numerous β-lactamases with various antibiotic substrate specificities are now known. Various classification systems are used for them, as illustrated in T ables 38.8 and 38.9. Elaboration of β-lactamases often is R factor–mediated and, in some cases, is even induced by the presence of β-lactam antibiotics. One now generally assumes that a Staphyl ococcus aureus strain will produce a P.1052 β-lactamase and that this will be less prevalent, but not uncommon, among Haemophi l us i nfl uenzae, M oraxel l a catarrhal i s, Escheri chi a col i , and Kl ebsi el l a, Enterobacter, Serrati a, Pseudomonas, and Bacteroi des sp. strains.

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Fig. 38.17. β-Lactamase catalyzed hydrolysis of penicillins.

Table 38.8. β-lactamase Classifications According to Sykes and M atthew

Type

Substrate preferences

Gene location

Inducibility

Gram +/-

Penicillins mainly

r-Plasmid

Mostly

I

Cephalosponins mainly

Chromosome

Mainly

II

Penicillins mainly

Chromosome

Constituitive

III

Broad spectrum

r-Plasmid

Constituitive

IV

Broad spectrum

Chromosome

Constituitive

V

Methicillin, oxacillin, cloxacillin

r-Plasmid

Constituitive

Sykes RB, Matthew M. The beta-lactamases of gram-negative bacteria and their role in resistance to beta-lactam

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antibiotics. J Antimicrob Chemother 1976; 2: 115–117.

Allergen icity Approximately 6 to 8% of the U.S. population is allergic to β-lactam antibiotics. Most commonly, this is expressed as a mild drug rash or itching and is of delayed onset. Occasionally, the reaction is immediate and profound. It may include cardiovascular collapse and shock and can even result in death. Sometimes, penicillin allergy can be anticipated by taking a medication history, and often, the patients who are likely to be allergic are those with a history of hypersensitivity to a wide variety of allergens (e.g., foods and pollens). A previous history of allergy to penicillins is a contraindicating factor to their use. T opical whealand-flare tests are available when there is doubt. When an allergic reaction develops, the drug must be discontinued, and, because cross-sensitivity is common, other β-lactam drugs should generally be avoided. Considering all therapeutic categories, penicillins, especially the ones most commonly employed (benzylpenicillin and ampicillin/amoxicillin), are probably the drugs most associated with allergy. Erythromycin and clindamycin are useful alternate choices for therapy in many cases of penicillin allergy.

Table 38.9. β-Lactamase Classification According to Amblera and Bush-Jacoby-M edeirosb Classa

Characteristics

A

Penicillinases and TEM-type, broad-spectrum enzymes

B

Increased activity against cephalosporins

C

Chromosomal cephalosporinases of Gram-negative bacteria

D

Oxacillin-hydrolyzing enzymes

Groupb

Characteristics

1

Cephalosporinases that are not inhibited by clavulanic acid

2

β-Lactamases inhibited by β-lactamase inhibitors

3

Metallo-β-lactamases that are poorly inhibited by all classical β-lactamase inhibitors

4

Penicillinases that are not inhibited by clavulanic acid

a

Ambler RP. The structure of beta-lactamases. Phil Trans Royal Soc London B 1980;289:321–331.

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b

Bush K, Jacoby GA, Medeiros AA. A functional classification scheme for beta-lactamase and its correlation with molecular structure. Antimicrob Agents Chemother 1995;39:1211–1233.

In some cases, the patient may have become sensitized without knowing it because of previous passive exposure through contaminated foodstuffs or cross-contaminated medications. Penicillins are manufactured in facilities separate from those used to prepare other drugs to prevent cross-contamination and possible sensitization. Animals treated with penicillins are required to be drug-free for a significant time before products prepared from them can be consumed. T he number of pharmacists who unknowingly override these protective measures by failing to cleanse their pill counters properly between prescriptions is unknown. Because the origin of the allergy is a haptenic reaction with host proteins and the responsible bond in the drug is the β-lactam moiety, this side effect is caused by the pharmacophore of the drug and is unlikely to be overcome by molecular manipulation.

In dividu al Pen icil lin s T he penicillins usually are discussed under various groups based on spectrum of activity and sensitivity or resistance toward β-lactamase. One of the earliest and still most commonly used penicillin is benzylpenicillin.

Benzylpenicillin Group Benzylpenicillin (Penicillin G, T able 38.5). With the exception of Nei sseri a gonorrhoeae and Haemophi l us i nfl uenza and a few bacteria encountered less frequently, the useful antimicrobial spectrum of benzylpenicillin is primarily against Gram-positive cocci. Because of its cheapness, efficacy, and lack of toxicity (except for acutely allergic patients), benzylpenicillin remains a remarkably useful agent for the treatment of diseases caused by susceptible microorganisms. As with most antibiotics, susceptibility tests must be performed, because many formerly highly sensitive microorganisms are now comparatively resistant. Infections of the upper and lower respiratory tract and of the genitourinary tract are the particular province of benzylpenicillin. Infections P.1053 caused by group A β-hemolytic streptococci (pharyngitis, scarlet fever, cellulitis, pelvic infections, and septicemia) are commonly responsive. Group B hemolytic streptococci infections; especially of neonates (acute respiratory distress, pneumonia, meningitis, septic shock, and septicemia) usually respond. Pneumococcal pneumonia, Haemophi l us i nfl uenza pneumonia of children, Streptococcus pneumoni ae– and Streptococcus pyogenes–caused otitis media and sinusitis, meningococcal meningitis and brain abscess, meningococcal and pneumococcal septicemia, streptococcal endocarditis (often by Streptococcus vi ri dans), pelvic inflammatory disease (often by Nei sseri a gonorrhoeae and S. pyogenes), uncomplicated gonorrhea (N. gonorrhoeae), meningitis (Nei sseri a meni ngi ti di s), syphilis (Treponema pal l i dum), Lyme disease (Borrel i a burgdorferi ), gas gangrene (Cl ostri di um perfri ngens), and tetanus (Cl ostri di um tetani ) are among the diseases that commonly respond to benzylpenicillin therapy, either alone or sometimes with other drugs used in combination. Nonpenicillinase-producing Staphyl ococcus aureus and Staphyl ococcus epi dermi di s are quite sensitive but are all too rare today. Other, less common bacterial diseases also respond, such as those caused by Baci l l us anthraci s (anthrax) and Corynebacteri um di phtheri ae (diptheria). Because of its cheapness, mild infections with susceptible microorganisms can be treated with comparatively large oral doses, although the most effective route of administration is parenteral, because fivefold the blood level can be regularly achieved in this manner. As previously indicated (see Clinically relevant chemical instabilities above), penicillin G is unstable under the acidic conditions of the stomach. Very water-insoluble penicillin salts form with procaine and with N, N′-benzathine. T hese find therapeutic application for deep intramuscular (IM) injections. T his produces lower but prolonged levels of penicillin as the drug slowly diffuses from the injection site. T he need to improve defects in benzylpenicillin stimulated an intense research effort that persists to this

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day. Overcoming such negative features as comparative instability (particularly to acid), comparatively poor oral absorption, allergenicity, sensitivity to β-lactamases, and relatively narrow antimicrobial spectrum have been objectives of this work. Only antigenicity has failed to respond significantly to this effort. Phenoxymethyl penicillin (Penicillin V, T able 38.5). Penicillin V is produced by fermentation in which the medium is enriched in phenoxyacetic acid. It also can be prepared by semisynthesis, and it is considerably more acid stable than benzylpenicillin, as indicated by oral absorption (T able 38.6). T his is rationalized as being caused by the electronegative oxygen atom in the C-7 amide side chain inhibiting participation in β-lactam bond hydrolysis. In any case, penicillin V was the first of the so-called oral penicillins, giving higher and more prolonged blood levels than penicillin G itself. Its antimicrobial and clinical spectrum is roughly the same as that of benzylpenicillin, although it is somewhat less potent and is not, as a rule, used for acutely serious infections. Penicillin V has approximately the same sensitivity to β-lactamases and allergenicity as penicillin G.

Penicillinase-Resistant Parenteral Penicillins Methicillin (T able 38.5). Although archaic today, methicillin was the first of the penicillinase-resistant agents to reach the clinic. It is unstable to gastric acid, having a half-life of 5 minutes at pH 2, so it must be administered via injection. As shown in Figure 38.15, increased bulk resulting from the addition of the dimethoxybenzoyl group to 6-APA leads to methicillin and a β-lactamase–resistant drug. Methicillin has a significantly narrower antimicrobial spectrum and less potency, so it was restricted to clinical use primarily for parenteral use in infections caused by β-lactamase–producing Staphyl ococcus aureus and a few other infections. Lately, an increasing number of infections have been found that are caused by MRSA. T he mode of resistance in these cultures appears to be a reduced uptake and alteration in the PBPs. In particular, an altered PBP-2 is formed that has a very low affinity for β-lactams, including methicillin. Furthermore, methicillin is an efficient inducer of penicillinases, further counting against it. Consequently, this drug fell out of favor, and methicillin has now been supplanted by a number of agents. Nafcillin (T able 38.3). Nafcillin has a fused benzene ring on one flank and an ethoxy moiety on the other of the side-chain amide linkage. Although slightly more acid stable than methicillin, it is virtually identical to it clinically. Oxacillin, cloxacillin, and dicloxacillin. Using an isoxazolyl ring as a bio-isosteric replacement for the benzene ring and a methyl on one flank and a substituted benzene ring on the other in place of the methoxyls of methicillin produces the isoxazolyl penicillins. T hese are oxacillin, cloxacillin, and dicloxacillin (T able 38.5). Chemically, they differ from one another in the number of chlorine substituents on the benzene ring. Like methicillin, these generally are less potent than benzylpenicillin against Gram-positive microorganisms (generally staphylococci and streptococci) that do not produce a β-lactamase but retain their potency against those that do. An added bonus exists in that they are somewhat more acid stable. T hus, they may be taken orally, and they are more potent as well. Because they are highly serum protein bound (T able 38.7), they are not good choices for treatment of septicemia. Microorganisms resistant against methicillin generally also are resistant to the isoxazolyl group of penicillins. Like nafcillin, the isoxazoyl group of penicillins is primarily used against Staphyl ococcus aureus in osteomyelitis, septicemia, endocarditis, and CNS infections. Vancomycin (discussed later) is the current favorite for treatment of infections by MRSA with cotrimoxazole and rifampin often of value as well. P.1054

Penicillinase-Sensitive, Broad-Spectrum, Oral Penicillins Ampicillin. T he important first member of this group, ampicillin, is a benzylpenicillin analogue in which one of the hydrogen atoms of the side-chain methylene has been replaced with a primary amino group to produce an R-phenylglycine moiety (T able 38.5). In addition to significant acid stability, enhancing its successful oral use, the antimicrobial spectrum is shifted so that many common Gram-negative pathogens are sensitive to ampicillin. T his is believed to result from greater penetration of ampicillin into Gram-negative bacteria. T he acid stability generally is believed to be caused by the electron withdrawing character of the protonated primary amine group, reducing participation in hydrolysis of the β-lactam bond as well as to the comparative + difficulty of bringing another positively charged species (H 3 O ) into the vicinity of the protonated amino

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group. T he oral activity of ampicillin is abetted, in part, by active uptake assisted by the small intestine peptide carrier. Ampicillin has an apparent half-life of approximately 15 to 20 hours at pH 2.0 and 35°C. It unfortunately lacks stability toward β-lactamases, and resistance is an ever-increasing phenomenon. T o assist in dealing with this, several additives for coadministration have been developed that inhibit the action of the β-lactamases (β-lactamase inhibitors). In addition to the usual mode of penicillin allergenicity, concentrated preparations of ampicillin can self-condense to form high-molecular-weight aggregates through reaction of its primary amino group with the β-lactam bond of another molecule. T hese aggregates are thought to be antigenic and to be responsible for ampicillin allergenicity—a form of hypersensitivity that differs in some details from the usual penicillin allergenicity, which ampicillin also possesses. Ampicillin and amoxicillin are the penicillins most commonly associated with drug-induced rash. Avoiding use of old preparations is a somewhat effective means of dealing with this potential problem. Ampicillin is essentially equivalent to benzylpenicillin for pneumococcal, streptococcal, and meningococcal infections, and many strains of Gram-negative Sal monel l a, Shi gel l a, Proteus mi rabi l i s, and Escheri chi a col i , as well as many strains of Haemophi l us i nfl uenzae and Nei sseri a gonorrhoeae, respond well to oral treatment with ampicillin. Bacampicillin

Although comparatively well absorbed (30–55%), the oral efficacy of ampicillin for systemic infections can be enhanced significantly through the preparation of pro-drugs. In contrast to ampicillin itself, which is amphoteric, bacampicillin is a weak base and is very well absorbed in the duodenum (80–98%). Enzymatic ester hydrolysis in the gut wall liberates carbon dioxide and ethanol, followed by spontaneous loss of acetaldehyde and production of ampicillin. T he acetaldehyde is metabolized oxidatively by alcohol dehydrogenase to produce acetic acid, which joins the normal metabolic pool. Amoxacillin (T able 38.5). Amoxicillin is a close analogue of ampicillin, in which a para-phenolic hydroxyl group has been introduced into the side-chain phenyl moiety. T his adjusts the isoelectric point of the drug to a more acidic value, and this is believed to be partially responsible, along with the intestine peptide transporter, for the enhanced blood levels obtained with amoxicillin as compared to ampicillin itself (T able 38.6). Better oral absorption (74–92%) leads to less disturbance of the normal GI flora and, therefore, less drug-induced diarrhea. T he antimicrobial spectrum and clinical uses of amoxicillin are approximately the same as those of ampicillin itself, and it is presently one of the most popular drugs in North America. T he addition of clavulanic acid (below) to amoxicillin (Augmentin) gives a combination in which the clavulanic acid serves to protect amoxicillin to a considerable extent against β-lactamases. T his is now an extremely popular antimicrobial combination for outpatient use. Clavulanic acid

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Clavulanic acid is a mold product with only weak intrinsic antibacterial activity, but it is an excellent irreversible inhibitor of most β-lactamases. It is believed to acylate the active site serine by mimicking the normal substrate. Hydrolysis occurs with some β-lactamases, but in many cases, subsequent reactions occur that inhibit the enzyme irreversibly. T his leads to its classification as a mechanism-based inhibitor (or so-called suicide substrate). T he precise chemistry is not well understood (Fig. 38.18), but when clavulanic acid is added to ampicillin and amoxicillin preparations, the potency against β-lactamase–producing strains is markedly enhanced. Sulbactam

Another β-lactamase–disabling agent is sulbactam. Sulbactam is prepared by partial chemical synthesis from penicillins. T he oxidation of the sulfur atom to a sulfone greatly enhances the potency of sulbactam. T he combination of sulbactam and ampicillin (Unasyn) is now clinically popular. P.1055

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Fig. 38.18. Speculative mechanism for irreversible inactivation of β-lactamase by clavulanic acid and sulbactam.

If instead of a β-lactamase, ampicillin resistance is caused by a penetration barrier, clavulanic acid and sulbactam are not able to overcome this, because the underlying mechanism is different. Not all β-lactamases, however, are sensitive to the presence of clavulanic acid or to sulbactam.

Penicillinase-Sensitive, Broad-Spectrum, Parenteral Penicillins Mezlocillin and piperacillin. Mezlocillin and piperacillin are ampicillin derivatives in which the D–side chain amino group has been converted by chemical processes to a variety of substituted urea analogues (T able 38.5). T hey are known as acylureidopenicillins. T hey preserve the useful anti-Gram-positive activity of ampicillin but have higher anti-Gram-negative potency. Even some strains of Pseudomonas aerugi nosa are sensitive to these agents. It is speculated that the added side-chain moiety mimics a longer segment of the peptidoglycan chain than ampicillin does. It is recalled that this cell wall fragment usually is a tetrapeptide, so there certainly is room for an extension in this direction. T his would give more possible attachment points to the penicillin biding proteins, and perhaps these features are responsible for their enhanced antibacterial properties. T hese agents are used parenterally with particular emphasis on Gram-negative bacteria, especially Kl ebsi el l a pneumoni ae and the anaerobe Bacteroi des fragi l i s. Resistance caused by β-lactamases is a prominent feature of their use, so disk testing and incorporation of additional agents (e.g., an aminoglycoside) for the treatment of severe infections is advisable. Piperacillin and tazobactam combination (Zosyn)

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T azobactam often is coadministered with piperacillin because of tazobactam's ability to inhibit β-lactamases. T azobactam, like other β-lactamase inhibitors, has little or no antibacterial activity. T his effect is analogous to that of clavulanic acid and sulbactam (discussed above). Carbenicillin and indanyl carbenicillin. Carbenicillin is a benzylpenicillin analogue in which one of the methylene hydrogens of the side chain has been substituted with a carboxylic acid moiety (T able 38.5). T he specific stereochemistry of this change is not very important, because both diastereoisomers are configurationally unstable and mutarotate with time to produce the same mixture of epimers. T he introduction of the side-chain carboxyl produces enhanced anti-Gram-negative activity. In fact, carbenicillin is intrinsically one of the broadest spectrum penicillins. Carbenicillin is an order of magnitude less potent than the acylureidopenicillins. T he drug is susceptible to β-lactamases and is acid unstable, so it must be given by injection. Because it is a malonic acid hemiamide with a carbonyl (amide) moiety β to the carboxyl group, carbenicillin can decarboxylate readily to produce benzylpenicillin (Fig. 38.19). Although still an antibiotic, this degradation product has no activity against the organisms for which carbenicillin would be indicated, so this is still considered to be a degradation. In addition, the large doses of carbenicillin sodium that had to be employed (multigrams per day) resulted in ingestion of a significant amount of sodium ion, which could be a consideration with heart patients. Many of these problems were avoided by switching to the oral prodrug ester indanyl carbenicillin. T his pro-drug is primarily used for oral treatment of urinary tract infections. T icarcillin. T icarcillin is a sulfur-based bio-isostere of carbenicillin that cannot decarboxylate as the carboxyl group of carbenicillin does (T able 38.5). T his agent is somewhat more potent against pseudomonads compared with indanyl carbenicillin. When potassium clavulanate is added to ticarcillin (T imentin), the combination has enhanced antipse– domonad activity because of its enhanced stability to lactamases.

Su mmary Statemen t T he penicillins ushered in the era of powerful antibiotics, and their use transformed the practice of antimicrobial chemotherapy. A significant percentage of the population alive today owe their P.1056 longevity and relative freedom from morbidity to the use of these agents. T he pace of discovery, however, has fallen off dramatically, and no new penicillin has been introduced into the market place for many years. T he penicillins retain their important place in contemporary medicine, but research has turned elsewhere for novel agents.

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Fig. 38.19. Decarboxylation of carbenicillin to benzylpenicillin.

Ceph alosporin s History In contrast to the discovery of the penicillins, in which the first agent had such outstanding biological antibiotic properties that it entered clinical use with comparatively little modification, the cephalosporins are remarkable for the level of persistence that was required before their initial discovery yielded economic returns. T he original cephalosporin-producing fungus, Cephal ospori um acremoni um, was discovered in a sewage outfall off the Sardinian coast by Brotsu. In England, Abraham and Newton pursued it, because one of the constituents had the useful property of activity against penicillin-resistant cultures as a result of its stability to β-lactamases. Cephalosporin C, the component of special interest, is not potent enough to be a useful antibiotic, but removal, through chemical means, of the natural side chain produced 7-aminocephalosporanic acid (7-ACA), which, analogous to 6-APA, could be fitted with unnatural side chains (Fig. 38.20). Many of the compounds produced in this way are remarkably useful antibiotics. T hey differ from one another in antimicrobial spectrum, β-lactamase stability, absorption from the GI tract, metabolism, stability, and side effects (detailed below). Exploitation of sulfenic acid chemistry by Robert Morin, then at Eli Lilly and Company, resulted in the conversion of penicillins to cephalosporins, including 3-desacetoxy-7-ACA (7-ADCA). T his process is practical because the penicillin fermentation is much more efficient than cephalosporin fermentation, making the transformation financially rewarding. Unfortunately, the chemistry involved is too complex to be covered in the space available here. Intensive investigation of the chemistry of 7-ACA and 7-ADCA has resulted in the subsequent preparation of many thousands of analogues from these two starting materials.

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Fig. 38.20. Chemical preparation of 7-ACA and 7-ADCA.

Ch emical Properties T he cephalosporins have their β-lactam ring annealed to a 6-membered dihydrothiazine ring in contrast to the penicillins, wherein the β-lactam ring is fused to a 5-membered thiazolidine ring. As a consequence of the bigger ring, the cephalosporins should be less strained and less reactive/potent. Much of the reactivity loss, however, is made up by possession of an olefinic linkage at C-2,3 and a methyleneacetoxy group at C-3. When the β-lactam ring is opened by hydrolysis, the acetoxy group can be ejected, carrying away the developing negative charge. T his greatly reduces the energy required for the process. T hus, the facility with which the β-lactam bond of the cephalosporins is broken is modulated both by the nature of the C-7 substituent (analogous to the penicillins) as well as by the nature of the C-3 substituent and its ability to serve as a leaving group. Considerable support for this hypothesis comes from the finding that isomerization of the olefinic linkage to C-3,4 leads to great losses in antibiotic activity. In practice, most cephalosporins are comparatively unstable in aqueous solutions, and the pharmacist often is directed to keep injectable preparations frozen before use. Being carboxylic acids, they form water-soluble sodium salts, whereas the free acids are comparatively water insoluble. In many cases, when the free acids are supplied, the injectable forms contain sodium bicarbonate to facilitate solution.

Clin ical ly Relevan t Ch emical In stabilities T he principal chemical instability of the cephalosporins is associated with β-lactam bond hydrolysis. T he role of the C-7 and C-3 side chains in these reactions was discussed previously. Ejection of the C-3 substituent following β-lactam bond cleavage usually is drawn for convenience as though this is an unbroken (concerted) process. Evidence on this point being equivocal, ejection of the side chain may, at certain times and with specific cephalosporins, involve a discrete intermediate with the β-lactam bond broken, but with the C-3 substituent not yet eliminated, whereas other cephalosporins have nonejectable C-3 substituents. T he methylthiotetrazole (MT T ) group, found in a number of cephalosporins, is capable of elimination. When this happens, this moiety is believed to be responsible, in part, for clotting difficulties and acute alcohol intolerance in certain patients. T he role of the C-7 side chain in all of these processes is clearly important, but active participation of the amide moiety in a manner analogous to the penicillins rarely is specifically invoked. T he same considerations that modulate the chemical stability of cephalosporins also are involved in dictating β-lactamase sensitivity, potency, and allergenicity as well.

Metabolism T hose cephalosporins that have an acetyl group in the side chain are subject to enzymatic hydrolysis P.1057 in the body. T he result is molecules with a hydroxymethyl moiety at C-3. A hydroxy moiety is a poor leaving group, so this change is considerably deactivating with respect to breakage of the β-lactam bond. In

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addition, the particular geometry of this part of the molecule leads to facile lactonization with the carboxyl group attached to C-2 (Fig. 38.21). In principle, this should result in formation of a different but reasonable leaving group; instead, the result is inactivation of the drugs involved. T he penicillin biding proteins have an absolute requirement for a free carboxyl group to mimic that of the terminal carboxyl of the D-alanylD-alanine moiety in their normal substrate. Lactonization masks this docking functional group and, as a result, blocks affinity of the inhibitor for the enzyme.

Fig. 38.21. Metabolism of C-3-acetyl–substituted cephalosporins.

Stru ctu re-Activity Relation sh ip

As with the penicillins, various molecular changes in the cephalosporin can improve in vitro stability, antibacterial activity, and stability toward β-lactamases. T he addition of an amino and a hydrogen to the α and α′ position, respectively, results in a basic compound that is protonated under the acidic conditions of the stomach. T he ammonium ion improves the stability of the β-lactam of the cephalosporin, leading to orally active drugs. T he 7β amino group is essential for antimicrobial activity (X = H), whereas replacement of the hydrogen at C-7 (X = H) with an alkoxy (X = OR) results in improvement of the antibacterial activity of the cephalosporin. Within specific cephalosporin derivatives, the addition of a 7α methoxy also improves the drugs stability toward β-lactamase. T he derivatives where Y = S exhibit greater antibacterial activity than if Y = O, but the reverse is true when stability toward β-lactamase is considered. T he 6α hydrogen is essential for biological activity. Finally, antibacterial activity is improved when Z is a 5-membered heterocycle versus a 6-membered heterocycle. In a study examining the stability of cephalosporins toward β-lactamase, it was noted that the following

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changes improved β-lactamase resistance: 1) T he L-isomer of an α amino α′ hydrogen derivative of a cephalosporin was 30- to 40-fold more stable than the D-isomer, 2) the addition of a methoxyoxime to the α and α′ positions increased stability nearly 100-fold, and 3) the Z-oxime was as much as 20,000-fold more stable than the E-oxime (Fig. 38.22). T hese changes have been incorporated into a number of marketed and experimental cephalosporins (Cefuroxime, Ceftizoxime, Ceftazidime, and Cefixime).

Mech an ism of Action T he cephalosporins are believed to act in a manner analogous to that of the penicillins by binding to the penicillin biding proteins, followed by cell lysis (Fig. 38.16). T he full details of the manner in which bacterial cells are killed are still obscure. Cephalosporins are bactericidal in clinical terms.

Resistan ce Analogous to the penicillins, susceptible cephalosporins can be hydrolyzed by β-lactamases before they reach the penicillin biding proteins. Many β-lactamases are known. Some are more efficient at hydrolysis of penicillins, some at hydrolysis of cephalosporins and some are indiscriminate. Certain β-lactamases are constitutive (chromosomally encoded) in certain strains of Gram-negative bacteria (Ci trobacter, Enterobacter, Pseudomonas, and Serrati a sp.) and normally are repressed. T hese are induced (or derepressed) by certain β-lactam antibiotics (e.g., imipenem, cefotetam, and cefoxitin). As with the penicillins, specific examples will be seen below wherein resistance to β-lactamase hydrolysis is conveyed by strategic steric bulk near the side-chain amide linkage. Recently, an increasing number of metalloβ-lactamases have been discovered. T he mechanism of these enzymes is dependent on divalent metal ions, commonly zinc. T hese are both chromosomally and plasmid derived and are as yet confined to the Gram-negative rods. Commonly, these enzymes attack some penicillins, cephalosporins, and carbapenems. Penetration barriers to the cephalosporins also are well known.

Allergen icity Allergenicity is less commonly experienced and is less severe with cephalosporins than with penicillins. Cephalosporins frequently are administered to patients who have had a mild or delayed penicillin reaction. Cross-allergenicity is comparatively common, however, and cephalosporins should be administered with caution for patients who have a history of allergies. Patients who have had a rapid and severe reaction to penicillins should not be treated with cephalosporins.

Fig. 38.22. Z- and E-oxime configuration.

P.1058

Nomen cl atu re an d Classification Most cephalosporins have generic names beginning with cef- or ceph-. T his is convenient for classification, but it makes discriminating between individual members a true memory test. T he cephalosporins are

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classified by a trivial nomenclature system loosely derived from the chronology of their introduction but more closely related to their antimicrobial spectrum. T he first-generation cephalosporins primarily are active in vitro against Gram-positive cocci (penicillinase-positive and -negative Staphyl ococcus aureus and S. epi dermi s), group A β-hemolytic streptococci (Streptococcus pyogenes), group B streptococci (Streptococcus agal acti ae), and Streptococcus pneumoni ae. T hey are not effective against MRSA. T hey are not significantly active against Gram-negative bacteria, although some strains of Escheri chi a col i , Kl ebsi el l a pneumoni ae, Proteus mi rabi l i s, and Shi gel l a sp. may be sensitive. T he second-generation cephalosporins generally retain the anti-Gram-positive activity of the first-generation agents but include Haemophi l us i nfl uenzae as well and add to this better anti-Gram-negative activity so that some strains of Aci netobacter, Ci trobacter, Enterobacter, Escheri chi a col i , Kl ebsi el l a, Nei sseri a, Proteus, Provi denci a, and Serrati a also are sensitive. Cefotetan, cefmetazole, and cefoxitin have some antianaerobic activity as well. T he thirdgeneration cephalosporins are less active against staphylococci than the first-generation agents but are much more active against Gram-negative bacteria than either the first- or the second-generation drugs. T hey frequently are particularly useful against nosocomial multidrug-resistant hospital-acquired strains. One also adds M organel l a sp. and Pseudomonas aerugi nosa to the list of species that often are sensitive. Unfortunately, the third-generation agents tend to be more expensive. T he fourth-generation cephalosporins have an antibacterial spectrum like the third-generation drugs but add some enterobacteria that are resistant to the third-generation cephalosporins. T hey also are more active against some Gram-positive organisms.

Table 38.10. First Generation Cephalosporins

T h erapeu tic Appl ication T he incidence of cephalosporin resistance is such that it usually is preferable to do sensitivity disk testing before instituting therapy. Infections of the upper and lower respiratory tract, skin and related soft tissue, urinary tract, bones, and joints, as well as septicemias, endocarditis, intra-abdominal, and bile tract infections caused by susceptible Gram-positive organisms usually are responsive to cephalosporins. When a Gram-positive bacteria is involved, a first-generation agent is preferable. When the pathogen is Gram-negative and the infection is serious, parenteral use of a third-generation agent is recommended. For pelvic inflammatory disease, the number-one cause of sterility in sexually active young women, a

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combination with doxycycline is preferred. T his infection often is mixed and frequently includes Chl amydi a trachomi ti s, anaerobes, and penicillinase-producing Nei sseri a gonorrhoeae.

Adverse Effects Aside from mild or severe allergic reaction, the most commonly experienced cephalosporin toxicities are mild and temporary nausea, vomiting, and diarrhea associated with disturbance of the normal flora. Rarely, a life-threatening pseudomembranous colitis diarrhea associated with the opportunistic and toxin-producing anaerobic pathogen, Cl ostri di um di ffi ci l e, can be experienced. Rare blood dyscrasias, which can even include aplastic anemia, also are seen. Certain structural types (details below) are associated with prolonged bleeding times and an antabuse-like acute alcohol intolerance.

First-gen eration Ceph alosporin s (Table 38.10) Cephapirin Cephapirin has a pyridylthiomethylene containing side chain at C-7. It is comparatively resistant to P.1059 staphylococcal β-lactamase, although it is sensitive to many other β-lactamases. Cephapirin also is sensitive to host deacetylation in the liver, kidneys, and plasma, which reduces potency by about half. Nonetheless, it finds significant use in the parenteral treatment of infections because of susceptible bacteria. It is a substitute for the nafcillin subgroup of penicillins. It is not orally active. It is comparatively painful on IM injection, and its doses must be reduced in the presence of renal impairment. Following injection, it is excreted primarily in the urine, partly by glomerular filtration and partly by tubular secretion.

Cefazolin Cefazolin has the natural acetyl side chain at C-3 replaced by a thio-linked thiadiazole ring. Although this group is an activating leaving group, the moiety is not subject to the inactivating host hydrolysis reaction that characterizes cephapirin. At C-7, it possesses a tetrazoylmethylene unit. Cefazolin is less irritating on injection than its cohort in this generation of drugs and has a longer half-life than cephapirin. Its dosing should be reduced in the presence of renal impairment. It is comparatively unstable and should be protected from heat and light.

Cephalexin Use of the ampicillin-type side chain conveys oral activity to cephalexin. Whereas it no longer has an activating side chain at C-3 and, as a consequence, is somewhat less potent, it does not undergo metabolic deactivation and, thus, maintains potency. It is rapidly and completely absorbed from the GI tract and has become quite popular. Somewhat puzzling is the fact that the use of the ampicillin side chain in the cephalosporins does not result in a comparable shift in antimicrobial spectrum. Cephalexin, like the other first-generation cephalosporins is active against many Gram-positive aerobic cocci but is limited against Gram-negative bacteria. It is a widely used drug, particularly against Gram-negative bacteria causing urinary tract infections, Gram-positive infections (Staphyl ococcus aureus, Streptococcus pneumoni ae and Streptococcus pyogenes) of soft tissues, pharyngitis, and minor wounds.

Cefadroxil Cefadroxil has an amoxicillin-like side chain at C-7 and is orally active. T here are some indications that cefadroxil has some immunostimulant properties mediated through T -cell activation and that this is of material assistance to patients in fighting infections. T he prolonged biological half-life of cefadroxil allows once-a-day dosage.

Cephradine In cephradine, an interesting drug design device has been used. T he aromatic ring in the ampicillin side chain has been partially hydrogenated by a Birch reduction such that the resulting molecule is still planar and π-electron excessive but has no conjugated olefinic linkages. It is comparatively acid stable and, therefore, is rapidly and nearly completely absorbed from the GI tract. Cephradine has the useful

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characteristic that it can be used both orally and IM so that parenteral therapy can be started in an institutional setting and then the patient can be sent home with the oral form, thus avoiding the risk of having to establish a different antibiotic. T his is consistent with the present economics requiring sending patients home earlier than some physicians prefer. Unfortunately, however, for other reasons the IM and intravenous (IV) versions of cephradine are no longer available in the United States.

Secon d-Gen eration Ceph alospori n s (Table 38.11) Cefamandole nafate Cefamandole nafate has a formylated D-mandelic amide moiety at C-7. T he formate ester is cleaved rapidly in the host to release the more active cefamandole. T he esterification also apparently overcomes the instability of cefamandole when it is stored in dry form. T his agent has increased activity against Haemophi l us i nfl uenzae and some Gram-negative bacilli as compared with the first-generation cephalosporins. Loss of the 5-thio-l-methyl-l-H-tetrazole moiety (referred to sometimes by the acronym MT T ) from C-3 is associated with prothrombin deficiency and bleeding problems as well as with an Antabuse-like acute alcohol intolerance. On the other hand, this grouping enhances potency and prevents metabolism by deacetylation. Like the other second-generation cephalosporins, cefamandole is more active against Gram-negative bacteria. T he principle clinical use is for lower respiratory tract, skin and skin structures, and bone and joint infections as well as septicemia and urinary tract infections when the organisms are sensitive.

Cefonicid Cefonicid has an unesterified D-mandelic acid moiety at C-7 and a methylsulfothiotetrazole group at C-3. T he latter is related to the MT T moiety mentioned above under cefamandole nafate; however, the clotting problems and Antabuse-like side effects associated with MT T have not been reported with cefonicid. T he extra acid group in the C-3 side chain leads to this molecule being sold as an injectable disodium salt. Pain and discomfort at IM sites is experienced by some patients, as is a burning sensation and phlebitis. Cefonicid has a longer half-life than the other members of its group but achieves this at the price of somewhat lower potency against Gram-positive bacteria and aerobes. T he drug is somewhat unstable, needs to be protected from light and heat, and may yellow or darken. If modest, however, this does not necessarily mean that the potency has decreased significantly, but overt precipitation does. Kirby-Bauer disk testing may overestimate the sensitivity of β-lactamase–producing bacteria to this agent, so some extra caution in interpretation of laboratory results is required.

Cefuroxime Cefuroxime has a Z-oriented methoxyimino moiety as part of its C-7 side chain (Fig. 38.22). T his conveys P.1060 considerable resistance to attack by many β-lactamases, but not by all. T his is believed to result from the steric demands of this group. T his hypothesis is supported by the finding that the E-analogue is attacked by β-lactamases. Resistance by Pseudomonas aerugi nosa, on the other hand, is attributed to lack of penetration of the drug rather than to enzymatic hydrolysis. T he carbamoyl moiety at C-3 is intermediate in

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metabolic stability between the classic acetyl moieties and the thiotetrazoles. Cefuroxime penetrates comparatively well into cerebral spinal fluid and is used in cases of Haemophi l us i nfl uenzae meningitis.

Table 38.11. Second Generation Cephalosporins

In the form of its axetil ester (1-[acetyloxy]ethyl ester) pro-drug, cefuroxime axetil, a more lipophilic drug is produced that gives satisfactory blood levels on oral administration. T he ester bond is cleaved metabolically, and the resulting intermediate form loses acetaldehyde spontaneously to produce cefuroxime itself. Conveniently for the patient, cefuroxime axetil is stable for approximately 24 hours when it is dissolved in apple juice. T he axetil is the only antibiotic officially labeled for treatment of Lyme disease (although doxycycline often is the first choice even without a label indication for that purpose).

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Cefoxitin Cefoxitin contains the same C-7 side chain as cephalothin and the same C-3 side chain as cefuroxime. T he most novel chemical feature of cefoxitin is the possession of an α-oriented methoxyl group in place of the normal H-atom at C-7. T his increased steric bulk conveys very significant stability against β-lactamases. T he inspiration for these functional groups was provided by the discovery of the naturally occurring antibiotic cephamycin C P.1061 derived from fermentation of Streptomyces l actamdurans. Cephamycin C itself has not seen clinical use but, rather, has provided the structural clue that led to useful agents such as cefoxitin. Agents that contain this 7α methoxy group are commonly referred to as cephamycins. Ingenious chemical transformations now enable synthetic introduction of such a methoxy group into cephalosporins lacking this feature.

Cefoxitin has useful activity against gonorrhea and some anaerobic infections as compared with its secondgeneration relatives. On the negative side, cefoxitin has the capacity to induce certain broad-spectrum β-lactamases.

Cefotetan Clearly, cefotetan also is inspired by cephamycin C but has a rather unusual sulfur-containing C-7 side-chain amide. Possession of two carboxyl groups leads to marketing it as a disodium salt. T he C-3 MT T side chain suggests caution in monitoring prothrombin levels and bleeding times as well as in ingesting alcohol when using this agent. Like cefoxitin, cefotetan has better activity than the rest of this group against anaerobes. Cefotetan is comparatively stable, lasting for approximately 24 hours at room temperature when reconstituted. Slight yellowing and slight darkening produce materials that are still acceptable for therapy. Cefotetan is chemically incompatible with tetracycline, aminoglycosides, and with heparin, often forming precipitates with them. With respect to its molecular mode of action, it has a special affinity for PBP-3 of Gram-negative bacteria, consequently producing filamentous forms. It also binds well with PBP-1A and -1B,

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therefore leading to cell lysis and death. Whereas it is stable to a wide range of β-lactamases, it also is a potent inducer in some bacteria.

Cefaclor Cefaclor differs from cephalexin primarily in the bio-isosteric replacement of methyl by chlorine at C-3 and is quite acid stable, allowing oral administration. It also is quite stable to metabolism. It is less active against Gram-negative bacteria compared with the other second-generation cephalosporins but is more active against Gram-negative bacteria compared with the first-generation drugs.

Loracarbef Loracarbef is a synthetic C-5 “ carba” analogue of cefaclor. T he smaller methylene moiety (as compared to sulfur) would be expected to make loracarbef more reactive/potent, and this seems to be the case. It is more stable chemically, however, and this adds to its virtues. Diarrhea is the most common adverse effect with loracarbef and, along with certain other adverse effects, is seen more frequently with children, so this lessens enthusiasm for the drug in patients younger than 12 years.

Cefprozil Cefprozil has an amoxicillin-like side chain at C-7, but at C-3, there is now a l-propenyl group conjugated with the double bond in the 6-membered ring. T he double bond is present in its two geometric isomeric forms, both of which are antibacterially active. Fortunately, the predominant trans form (T able 38.11) is much more active against Gram-negative organisms. Cefprozil most closely resembles cefaclor in its properties but is a little more potent. It is approximately 90% bioavailable following oral administration, and peak levels are not significantly smaller when taken with food. T he oral suspension of cefprozil is sweetened with aspartame, so phenylketonuric patients should be wary of this formulation.

Cefmetazole Cefmetazole is a cephamycin with a nonaromatic side chain at C-7. In addition to a fairly characteristic second-generation cephalosporin antimicrobial spectrum, it possess fairly significant anti-antiaerobic activity. T he ejection of its C-3 side chain leads to alcohol intolerance of the disulfuram type and prolonged clotting times.

T h ird-Gen eration Ceph al osporin s (Table 38.12) Cefotaxime Cefotaxime, like cefuroxime, has a Z-methoxyimino moiety at C-7 that conveys significant β-lactamase resistance. Microorganisms that produce chromosomally mediated β-lactamases usually are resistant following mutation to derepression of these enzymes. Cefoxitin, cefotetan, and imipenems are quite effective inducers of these enzymes. T he enzymes that result either hydrolyze the drug in the usual way or bind tightly to them, preventing them from attaching to the PBPs. T he clinical importance of this phenomenon is unclear. T he oxime moiety of cefotaxime is connected to an aminothiazole ring. Like other third-generation cephalosporins, it has excellent anti-Gram-negative activity and is useful institutionally. It has a metabolically vulnerable acetoxy group attached to C-3 and loses approximately 90% of its activity when this is hydrolyzed. T his metabolic feature also complicates the pharmacokinetic data, because both active forms are present and have different properties. Cefotaxime should be protected from heat and light and may color slightly without significant loss of potency. Like other third-generation cephalosporins, cefotaxime has less activity against staphylococci but has greater activity against Gram-negative organisms.

Ceftizoxime In ceftizoxime, the whole C-3 side chain has been omitted to prevent deactivation by hydrolysis. It rather resembles cefotaxime in its properties; however, not being subject to metabolism, its pharmacokinetic properties are much less complex.

Ceftriaxone

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Ceftriaxone has the same C-7 side-chain moiety as cefotaxime and ceftizoxime, but the C-3 side chain consists of a metabolically stable and activating thiotriazinedione in place of the normal acetyl group. T he C-3 side chain is sufficiently acidic that at normal pH, it forms an enolic sodium salt; thus, the commercial P.1062 product is a disodium salt. It is useful for many severe infections and, notably, in the treatment of some meningitis infections caused by Gram-negative bacteria. It is quite stable to many β-lactamases but is sensitive to some inducible chromosomal β-lactamases.

Table 38.12. Third Generation Cephalosporins

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Ceftazidime In ceftazidime the oxime moiety is more complex, containing two methyl groups and a carboxylic acid. T his assemblage conveys even more pronounced β-lactamase stability, greater anti–Pseudomonas aerugi nosa, and increased activity against Gram-positive organisms. T he C-3 side chain has been replaced by a charged pyridinium moiety. T he latter considerably enhances water solubility and also highly activates the β-lactam bond toward cleavage. T he drug must be protected against heat and light and may darken without significant loss of potency. It is not stable under some conditions. such as the presence of aminoglycosides and vancomycin. It also is attacked readily in sodium bicarbonate solutions. Resistance is mediated by chromosomally mediated β-lactamases and by lack of penetration into target bacteria. Otherwise, it has a very broad antibacterial spectrum. P.1063

Cefoperazone Cefoperazone has a C-7 side chain reminiscent of piperacillin's and also possesses the C-3 side chain (MT T ) that often is associated with the bleeding and alcohol intolerance problems among patients taking cephalosporins. Its useful activity against pseudomonads partly compensates for this, although it is not potent enough to be used as a single agent against this difficult pathogen. T he C-7 side chain does not convey sufficient resistance to many β-lactamases, although the addition of clavulanic acid or sulbactam would presumably help. T here are comparatively few orally active third-generation agents. T his group currently is represented by ceftibuten, cefixime, cefdinir, and cefpodoxime proxetil.

Cefixime In cefixime, in addition to the β-lactamase–stabilizing Z-oximino acidic ether at C-7, the C-3 side chain is a vinyl group analogous to the propenyl group of cefprozil. T his is believed to contribute strongly to the oral activity of the drug. Cefixime has anti-Gram-negative activity that is intermediate between that of the second-and third-generation agents described previously. It is poorly active against staphylococci, because it does not bind satisfactorily to PBP-2.

Ceftibuten Ceftibuten has a Z-ethylidinecarboxyl group at C-7 instead of the Z-oximino ether linkages seen previously. T his conveys enhanced β-lactamase stability and may contribute to oral activity as well. Ceftibuten has no C-3 side chain, so it is not measurably metabolized. It is highly (75–90%) absorbed on oral administration, but this is decreased significantly by food. Being lipophilic and acidic, it is significantly (65%) serum protein bound. Some isomerization of the geometry of the olefinic linkage appears to take place in vivo before excretion. It is mainly used for respiratory tract infections, otitis media, and pharyngitis as well as for urinary tract infections by susceptible microorganisms.

Cefpodoxime proxetil Cefpodoxime proxetil is a pro-drug. It is cleaved enzymically to 2-propanol, carbon dioxide, acetaldehyde, and cefpodoxime in the gut wall. It has better anti–Staphyl ococcus aureus activity than cefixime and is used to treat pharyngitis, urinary tract infections, upper and lower respiratory tract infections, otitis media, skin and soft tissue infections, and gonorrhea.

Cefdinir Cefdinir has an unsubstituted Z-oxime in its C-7 side chain, the consequence of which is attributed to its somewhat enhanced anti-Gram-positive activity—its main distinguishing feature. It has a vinyl moiety attached to C-3 that is associated with its oral activity. It has reasonable but not spectacular resistance to β-lactamases and is 20 to 25% absorbed on oral administration unless taken with fatty foods, which significantly diminishes blood levels.

Cefditoren Pivoxil

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Cefditoren pivoxil is a new orally active pro-drug. Similar to cefpodoxime proxetil, the pivoxil ester is hydrolyzed following intestinal absorption to release the active drug, cefditoren, along with formaldehyde and pivalic acid. Cefditoren pivoxil should not be administered with drugs that reduce stomach acidity, because this may result in decreased absorption. T he bioavailability of cefditoren pivoxil is increased if taken with food. Cefditoren pivoxil is indicated for mild to moderate infections in adults and adolescents with chronic bronchitis, pharyngitis/tonsillitis, and uncomplicated skin infections associated with Gram-negative bacteria. Effectiveness is reported against Haemophi l us i nfl uenzae and M oraxel l a catarrhal i s and includes β-lactamase–producing strains.

Fou rth -Gen eration Ceph alosporin s Cefepime

Cefepime is a semisynthetic agent containing a Z-methoxyimine moiety and an aminothiazolyl group at C-7, broadening its spectrum and increasing its β-lactamase stability as well as increasing its antistaphylococcal activity. T he quaternary N-methylpyrrolidine group at C-3 seems to help penetration into Gram-negative bacteria. T he fourth-generation cephalosporins are characterized by enhanced antistaphylococcal activity and broader anti-Gram-negative activity than the third-generation group. Cefepime is used IM and IV against urinary tract infections, skin and skin structure infections, pneumonia, and intra-abdominal infections.

Su mmary Statemen t With their broader spectrum, including many very dangerous bacteria, the cephalosporins have come to dominate β-lactam chemotherapy despite often lacking oral activity. Because the cephalosporin field is still being very actively pursued, the student can expect continual introduction of new agents into the foreseeable future.

Carbapen ems T hienamycin, the first of the carbapenems, was isolated from Streptomyces cattl eya. Because of its extremely intense and broad-spectrum antimicrobial activity as well as its ability to inactivate β-lactamases, it combines in one molecule the functional features of the best of the β-lactam antibiotics as well as the β-lactamase inhibitors. It differs structurally in several important respects from the penicillins and cephalosporins. T he sulfur atom is not part of the 5-membered ring but, rather, has been replaced by a methylene moiety at that position. Carbon is roughly half the molecular size of sulfur. Consequently, the carbapenem ring system is highly strained and very susceptible to reactions cleaving the β-lactam bond. T he sulfur atom is now attached to C-3 as part of a functionalized side chain. P.1064

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T he endocyclic olefinic linkage also enhances the reactivity of the β-lactam ring. Both make thienamycin unstable, which caused great difficulties in the original isolation studies. T he terminal amino group in the side chain attached to C-3 is nucleophilic and attacks the β-lactam bond of a nearby molecule through an intermolecular reaction destroying activity (Fig. 38.23). Ultimately, this problem was overcome by changing the amino group to a less nucleophilic N-formiminoyl moiety by a semisynthetic process to produce imipenem. At C-6, there is a 2-hydroxyethyl group attached with α-stereochemistry. T hus, the absolute stereochemistry of the molecule is 5R,6S,8S. With these striking differences from the penicillins and cephalosporins, it is not surprising that thienamycin analogues bind differently to the penicillin biding proteins (especially strongly to PBP-2), but it is gratifying that the result is very potent broad-spectrum activity.

Imipen em Imipenem, as well as thienamycin, penetrates very well through porins and is very stable, even inhibitory, to many β-lactamases. Imipenem is not, however, orally active. When used to treat urinary tract infections, renal dehydropeptidase-1 hydrolyzes imipenem through hydrolysis of the β-lactam and deactivates it. An inhibitor for this enzyme, cilastatin, is coadministered with imipenem to protect it. Inhibition of human dehydropeptidase does not seem to have deleterious consequences to the patient, making this combination highly efficacious against urinary tract infections. T he combination of imipenem and cilastatin (Primaxin) is approximately 25% serum protein bound. On injection, it penetrates well into most tissues, but not cerebrospinal fluid, and is subsequently excreted in the urine. It is broader in its spectrum than any other antibiotic presently available in the United States. T his very potent combination is especially useful for treatment of serious infections by aerobic Gram-negative bacilli, anaerobes, and Staphyl ococcus aureus. It is used clinically for severe infections of the gut in adults as well as of the genitourinary tract, bone, skin, and endocardia, with allergic reactions as its main risk factor; imipenem also has the unfortunate property of being a good β-lactamase inducer. Because of these features, imipenem–cilastatin is rarely a drug of first choice but, rather, is reserved for use in special circumstances.

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Fig. 38.23. Intermolecular instability reaction of thienamycin.

Meropen em

Meropenem is a synthetic carbapenem possessing a complex side chain at C-3. It also has a chiral methyl group at C-4. T his methyl group conveys intrinsic resistance to hydrolysis by dehydropeptidase-1. As a consequence, it can be administered as a single agent for the treatment of severe bacterial infections.

Ertapen em

Ertapenem is another synthetic carbapenem with a rather complex side chain at C-3. It is used once daily parenterally, with special application against anaerobes. As with meropenem, the 4-β-methyl group confers stability toward dehydropeptidase-1 It is not active against pseudomonads or acinetobacteria and, therefore, should not be substituted for imipenem or meropenem. It is relatively strongly bound to serum proteins, so it has a prolonged half-life, making it more convenient to use than the other carbapenems when its spectrum warrants this. Its reported indications include complicated intra-abdominal and complicated skin/skin structure infections caused by sensitive organisms (for intra-abdominal: Escheri chi a col i , Cl ostri di um cl ostri doforme, Bacteroi des fragi l i s, and Peptostreptococcus sp; for skin/skin structures: Staphyl ococcus aureus (methicillin-susceptible strains), Streptococcus pyogenes, E. col i , or Peptostreptococcus sp.). It can be administered once daily.

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T his class of antimicrobial agents is under intensive investigation, and several analogues were in various phases of preclinical investigation as of 2005. P.1065

Mon obactams Aztreon am

Fermentation of unusual microorganisms led to the discovery of a class of monocyclic β-lactam antibiotics, named monobactams. None of these natural molecules have proven to be important, but the group served as the inspiration for the synthesis of aztreonam. Aztreonam is a totally synthetic parenteral antibiotic, the antimicrobial spectrum of which is devoted almost exclusively to Gram-negative microorganisms, and it is capable of inactivating some β-lactamases. Its molecular mode of action is closely similar to that of the penicillins, cephalosporins, and carbapenems, the action being characterized by strong affinity for PBP-3, producing filamentous cells as a consequence. Whereas the principal side chain closely resembles that of ceftazidime, the sulfamic acid moiety attached to the β-lactam ring was unprecedented. Remembering the comparatively large size of sulfur atoms, this assembly may sufficiently spatially resemble the corresponding C-2 carboxyl group of the precedent β-lactam antibiotics to confuse the penicillin binding protons. T he strongly electron-withdrawing character of the sulfamic acid group probably also makes the β-lactam bond more vulnerable to hydrolysis. In any case, the monobactams demonstrate that a fused ring is not essential for antibiotic activity. T he α-oriented methyl group at C-2 is associated with the stability of aztreonam towards β-lactamases. T he protein binding is moderate (~ 50%), and the drug is nearly unchanged by metabolism. Aztreonam is given by injection and is primarily excreted in the urine. T he primary clinical use of aztreonam is against severe infections caused by Gram-negative microorganisms, especially those acquired in the hospital. T hese are mainly urinary tract, upper respiratory tract, bone, cartilage, abdominal, obstetric and gynecologic infections, and septicemias. T he drug is well tolerated, and adverse effects are infrequent. Interestingly, allergy would not be unexpected, but cross-allergenicity with penicillins and cephalosporins has not often been reported.

Antibiotics: Inhibitors of Protein Biosynthesis Basis for selectivity Once the bacterial cell wall is traversed, complex cellular machinery deeper within the cell becomes available to antibiotics. Some of the most successful antibiotic families exert their lethal effects on bacteria by inhibiting ribosomally mediated protein biosynthesis. At first glimpse, this may seem to be anomalous, because eukaryotic organisms also construct their essential proteins on ribosomal organelles and the sequence of biochemical steps is closely analogous to that in prokaryotic microorganisms. At a molecular level, however, the apparent anomaly resolves itself, because the detailed architecture of prokaryotic ribosomes is rather different. In Escheri chi a col i , for example, the 70S ribosomal particle is composed not only of three RNA molecules but also of 55 different structural and functional proteins arranged in a nonsymmetrical manner. T he small (30S) subunit has a 16S rRNA molecule and approximately 20 different proteins. T he large subunit has a 23S and a 5S rRNA and more than 30 proteins. Quite recently, the x-ray

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crystal structure of the components of the bacterial ribosome has been determined. T his is a landmark achievement given the size and complexity of this organelle. T he available picture is still fuzzy but allows one to unravel the molecular details not only of how proteins are biosynthesized but also where important antibiotics bind when they interrupt this process. T he functioning parts of the ribosome are the RNA molecules, and the proteins organize the whole and catalyze some portions of the biosynthetic cycle. T he tRNA molecules bind roughly at the interface where the 50S and 30S subparticles come together. T he codon–anticodon interaction with mRNA takes place in the 30S subunit, and the incoming amino acid and the growing peptide chain being made lies in the 50S subunit. Upsetting the view held for decades that the antibiotics bound to ribosomal proteins, it is now known that they bind to the rRNA instead. Aside from this important fact, most of the other key beliefs are still valid. Of key importance, the vital repeated movement of the tRNA bases mostly take place near interfaces between individual rRNA molecules, where this would be easiest. In agreement, it has been found that this region is comparatively disordered consistent with that movement (Fig. 38.24). At normal doses, antibiotics do not bind to or interfere with the function of eukaryotic 80S ribosomal particles. T he basis for the selective toxicity of these antibiotics is then apparent. Interference with bacterial protein biosynthesis prevents repair, cellular growth, and reproduction and can be clinically bacteriostatic or bactericidal.

Aminoglycosides and aminocyclitols In trodu ction T he aminoglycoside/aminocyclitol class of antibiotics contains a pharmacophoric 1,3-diaminoinositol moiety consisting of either streptamine, 2-deoxystreptamine, or spectinamine (Fig. 38.25). Several of the alcoholic functions of the 1,3-diaminoinositol are substituted through glycosidic bonds with characteristic amino sugars to form pseudo-oligosaccharides. T he chemistry, spectrum, potency, toxicity, and pharmacokinetics of these agents are a function of the specific identity of the diaminoinositol unit and the arrangement and identity of the attachments. T he various aminoglycoside antibiotics P.1066 are freely water soluble at all achievable pH values, are basic and form acid addition salts, are not absorbed in significant amounts from the GI tract, and are excreted in active form in fairly high concentrations in the urine following injection. When the kidneys are not functioning efficiently, the concentrations injected must be reduced to prevent accumulation to toxic levels. When given orally, their action is primarily confined to the GI tract. T hey are more commonly given IM or by perfusion. Recently, tobramycin has been sprayed into the lungs to successfully treat Pseudomonas aerugi nosa infections in patients with cystic fibrosis. T his route of administration results in significantly reduced toxicity to the patient. T hese agents have intrinsically broad antimicrobial spectra, but their toxicity potential limits their clinical use to severe infections by Gram-negative bacteria. T he aminoglycoside antibiotics are widely distributed (mainly in extracellular fluids) and have low levels of protein binding.

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Fig. 38.24. General mechanism of action of drugs that block protein synthesis by binding to ribosomal units.

Mech an ism of Action T he aminoglycosides are bactericidal because of a combination of toxic effects. At less than toxic doses, they bind to the 16S rRNA portion of the 30S ribosomal subparticle, impairing the proofreading function of the ribosome. A conformational change occurs in the peptidyl A site of the ribosome on aminoglycoside binding. T his leads to mistranslation of RNA templates and the consequent selection of wrong amino acids and formation of so-called nonsense proteins (Fig. 38.24). T he most relevant of these unnatural proteins are involved in upsetting bacterial membrane function. T heir presence destroys the semipermeability of the membrane, and this damage cannot be repaired without de novo programmed protein biosynthesis. Among the substances that are admitted by the damaged membrane are large additional quantities of aminoglycoside. At these increased concentrations, protein biosynthesis ceases altogether. T hese combined effects are devastating to the target bacterial cells. Given their highly polar properties, the student may wonder how these agents can enter bacterial cells at all. Aminoglycosides apparently bind initially to external lipopolysaccharides and diffuse into the cells in small amounts. T he uptake process is inhibited by Ca

2+

and Mg

2+

ions. T hese ions are, then, partially incompatible therapeutically. Passage through the

cytoplasmic membrane is dependent on electron transport and energy generation. At high concentrations, eukaryotic protein biosynthesis also can be inhibited by aminoglycoside/aminocyclitol antibiotics.

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Fig. 38.25. 1,3-Diaminoinositol moieties in aminoglycosides.

Bacterial Resistan ce Bacterial resistance to aminoglycoside antibiotics in the clinic is most commonly the result of bacterial elaboration of R factor–mediated enzymes that N-acetylate (aminoglycoside acetylase [AAC]), O-phosphorylate (aminoglycoside phosphorylase [APH]), and O-adenylate (aminoglycoside nucleotide transferase [ANT ]) specific functional groups, preventing subsequent ribosomal binding (Fig. 38.26). In some P.1067 cases, chemical deletion of the functional groups transformed by these enzymes leaves a molecule that is still antibiotic but is no longer a substrate; thus, agents with an intrinsically broader spectrum can be made semisynthetically in this way. In some other cases, novel functional groups can be attached to remote functionality that converts these antibiotics to poorer substrates for these R factor–mediated enzymes, and this expands their spectra (discussed later). Resistance also can involve point mutations of the ribosomal A site. T hese involve single-nucleotide residues at specific positions. T he substituent at position 6′ of the aminoglycoside, the number of protonated amino groups, and the linkage between the sugar rings and the central deoxystreptamine moiety are particularly important in the interactions with the rRNA. Resistance caused by decreased aminoglycoside/aminocyclitol uptake into bacterial cells also is encountered.

T h erapeu tic Appl ication Intrinsically, aminoglycosides have broad antibiotic spectra against aerobic Gram-positive and Gram-negative bacteria but are reserved for use in serious infections caused by Gram-negative organisms because of serious toxicities that often are delayed in onset. T hey are active against Gram-negative aerobes, such as Aci netobacter sp., Ci trobacter sp., Enterobacter sp., Escheri chi a col i , Kl ebsi el l a sp., Proteus vul gari s, Provi denci a sp., Pseudomonas aerugi nosa, Sal monel l a sp., Serrati a marscesans, Shi gel l a sp., and Gram-positive aerobes (e.g., Staphyl ococcus epi dermi di s).

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Fig. 38.26. Commercially important 2-desylstreptamine–containing aminoglycosides. Some points of inactivating attack by specific R factor– medicated enzymes are indicated by the following symbols. Ad ⇒ adenylation; Ac ⇒ acetylation; Phos ⇒ phosphorylation. APH(3′)-1, for example, is an acronym for an enzyme that phosphorylates aminoglycosides at the 3′-OH position.

Streptomycin and spectinomycin differ from the others in their useful antimicrobial spectra. Streptomycin is most commonly used for the treatment of tuberculosis and spectinomycin for treatment of gonorrhea. T he other antibiotics of this class are inferior for these purposes. T hese antibiotics have similar clinical spectra to those of the quinolones and are decreasing in popularity as quinolone use increases. Some aminoglycoside antibiotics in present clinical use are illustrated in Figure 38.26 along with some of their sites of enzymatic inactivation. T here has not been a new aminoglycoside antibiotic introduced since the 1970s.

Adverse Effects T he toxicities associated with the aminoglycosides involve ototoxicity to functions mediated by the eighth cranial nerve, such as hearing loss and vertigo. T heir use also can lead to kidney tubular necrosis, producing decreases in glomerular function. T hese toxic effects are related to blood levels and, apparently, are mediated by the special affinity of these aminoglycosides to kidney cells and to the sensory cells of the inner ear. T he effects may have a delayed onset, making them all the more treacherous, because the patient can be injured significantly before symptoms appear. Less common is a curare-like neuromuscular blockade believed to be caused by competitive inhibition of calcium ion–dependent acetylcholine release at the neuromuscular junction. T his effect can exaggerate the muscle weakness of patients with myasthenia gravis or Parkinson's disease. In current practice, all these toxic phenomena are well known; therefore, creatinine clearance should be determined and the dose adjusted downward accordingly so that these adverse effects are less common and less severe.

Specific Agen ts Kan amycin (Kan trex) Kanamycin is a mixture of at least three components (A, B, and C, with A predominating) isolated from Streptomyces kanamyceti cus. In addition to typical aminoglycoside antibiotic properties, kanamycin, along with gentamicin, neomycin, and paromomycin, is among the most chemically stable of the common antibiotics. Kanamycin can be heated without loss of activity for astonishing periods in acid or alkaline solutions and can even withstand autoclaving temperatures. Kanamycin, however, is unstable to R-factor enzymes, being O-phosphorylated on the C-3′hydroxyl by enzymes APH(3′)-I and APH(3′)-II and also is N-acetylated on the C-6′amino group, among others (Fig. 38.26). T hese transformation products are antibiotically inactive. Kanamycin is used parenterally against some Gram-negative bacteria, but Pseudomonas aerugi nosa and anaerobes usually are resistant. Although it also can be used in combination with other agents against certain mycobacteria (M ycobacteri um kansasi i , M ycobacteri um mari num, and M ycobacteri um i ntracel l ul are), its popularity for this use is fading. Injections of kanamycin are painful enough to require use of a local P.1068 anesthetic. Kanamycin occasionally is used in antitubercular admixtures.

Amikacin (Amikin ) Amikacin is made semisynthetically from kanamycin A. Interestingly, the L-hydroxyaminobutyryl amide (HABA) moiety attached to N-3 inhibits adenylation and phosphorylation in the distant amino sugar ring (at C-2′ and C-3′), even though the HABA substituent is not where the enzymatic reaction takes place. T his effect is attributed to decreased binding to the R factor–mediated enzymes. With this change, both potency and spectrum are strongly enhanced, and amikacin is used for the treatment of sensitive strains of M ycobacteri um tubercul osi s, Yersi ni a tul arensi s, and severe Pseudomonas aerugi nosa infections resistant to other agents.

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T obramycin (Nebcin ) T obramycin is one component (factor 6) of a mixture produced by fermentation of Streptomyces tenebrari us. Lacking the C-3′ hydroxyl group, it is not a substrate for APH(3′)-1 and APH(3′)-II and so has an intrinsically broader spectrum than kanamycin. It is a substrate, however, for adenylation at C-2′ by ANT (2′) and acetylation at C-3 by AAC(3)-I and AAC(3)-II and at C-2′ by AAC(2′) (Fig. 38.26). It is widely used parenterally for difficult infections, especially those by gentamicin-resistant Pseudomonas aerugi nosa. It is believed by some clinicians to be less toxic than gentamicin.

Gen tamicin (Garamycin ) Gentamicin is a mixture of several antibiotic components produced by fermentation of M i cromonospora purpurea and other related soil microorganisms (hence its name is spelled with an “ i” instead of a “ y” ). Gentamicins C-1, C-2, and C-1a are most prominent. Gentamicin is the most important of the aminoglycoside antibiotics still in use. Gentamicin was, for example, one of the first antibiotics to have significant activity against Pseudomonas aerugi nosa infections. T his water-loving, opportunistic pathogen frequently is encountered in burns, pneumonias, and urinary tract infections. It is highly virulent. As noted above, some of the functional groups that serve as targets for R factor–mediated enzymes are missing in the structure of gentamicins, so their antibacterial spectrum is enhanced. T hey are, however, inactivated through C-2′ adenylation by the enzyme ANT (2′) and acetylation at C-6′ by AAC(6′), at C-1 by AAC(1)-I and AAC(1)-II, and at C-2′ by AAC(2′). It often is combined with other anti-infective agents, and an interesting incompatibility has been uncovered. With certain β-lactam antibiotics, the two drugs react with each other so that N-acylation on C-1 of gentamicin by the β-lactam antibiotic takes place, thus inactivating both antibiotics (Fig. 38.27). T he two agents should not, therefore, be mixed in the same solution and should be administered into different tissue compartments (usually one in each arm) to prevent this. T his incompatibility is likely to be associated with other aminoglycoside antibiotics as well.

Fig. 38.27. A chemical drug–drug incompatibility between gentamicin C-2a and β-lactams.

Gentamicin is used for urinary tract infections, burns, some pneumonias, and bone and joint infections caused by susceptible Gram-negative bacteria. It often is used to prevent fouling of soft contact lenses. It also is used in polymer matrices in orthopaedic surgery to prevent sealed-in sepsis. It is given topically, sometimes in special dressings, to burn patients.

Spectin omycin (T robicin )

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An unusual aminoglycoside antibiotic, spectinomycin is produced by fermentation of Streptomyces spectabi l i s and differs substantially in its clinical properties from the others. T he diaminoinositol unit (spectinamine) contains two mono-N-methyl groups, and the hydroxyl between them has a stereochemistry opposite to that in streptomycin. T he glycosidically attached sugar also is unusual in that it contains three consecutive carbonyl groups, either overt or masked, and is fused by two adjacent linkages to spectinamine to produce an unusual, fused, three-ring structure. Spectinomycin is bacteriostatic as normally employed. It is used almost exclusively in a single bolus injection IM against Nei sseri a gonorrhea, especially penicillinase-producing strains, in cases of urogenital or oral gonorrhea and does not apparently produce any serious oto- or nephrotoxicity when used in this way. It is particularly useful for the treatment of patients allergic to penicillin and patients not likely to comply well with a medication scheme. It would likely be more widely used except that syphilis and chlamydia do not respond to it. It causes significant mistranslation following ribosomal binding but does not cause much inhibition of overall programmed protein biosynthesis. Resistance to spectinomycin by a kinase phosphorylating a hydroxyl group has been reported. P.1069

Streptomycin

Streptomycin is prod uce d b y f ermentatio n of Strep tom y ce s g ri s eus and se veral relate d s oil mic roorganis ms . I t was introduced in 1943 primarily f or the tre atment o f tube rculosis (s ee Chapter 4 1). Control o f this ancient sco urg e was gree ted with such enthus iasm that Selmon W aksman, the d is covere r o f s treptomycin, re ceived a No bel Prize in 19 52. Strepto mycin dif f ers f rom the typical aminog lyco sides with a mod if ied pharmac ophore in that the d iaminoino sitol unit is streptamine. Streptomycin als o has an axial hydro xyl group at C-2 and two highly basic guanido group s at C-l and C-3 in p lace of the primary amine moie ties of 2-deoxystreptamine . I t is p oss ible that the unus ual p harmac ophore of strep tomyc in acc ounts in large measure f or its unus ual antibacterial s pec trum. Another molec ular f eature, the α-hyd roxyaldehyde mo iety, is a ce nter of instability such that s tre pto mycin canno t be s te rilized by auto claving, s o s tre pto myc in s ulf ate so lutions that ne ed

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s terilization are made by ultraf iltration. Strep tomyc in is rarely us ed tod ay as a s ingle age nt. Res is tanc e to s treptomycin take s the f amiliar c ourse of N-ac etylatio n, O-pho sphorylation, and O-ad enylatio n o f s pec if ic f unc tional g roups.

Oral ly Used Amin oglycosides Kanamycin and another archaic member of the aminoglycoside antibiotic group, paromomycin (Humatin) finds some oral use for the suppression of gut flora. Paromomycin is also used for the oral treatment of amoebic dysentery. Amoebas are persistent pathogens causing chronic diarrhea and are acquired most frequently by travelers who consume food supplies contaminated with human waste.

Neomycin

Neomycin is a mixture of three compounds produced by fermentation of Streptomyces fradi ae, with neomycin B predominating. It is most commonly used in preoperative bowel sanitation and the treatment of enteropathogenic Escheri chi a col i infections. It also is found in nonprescription ointments and is used topically for treatment of bacterial skin infections. When applied to intact skin, the drug is not absorbed, but when applied to large, denuded areas, systemic absorption occurs with the potential for toxic side effects. It also has seen some use in lowering serum cholesterol.

Macrolide antibiotics In trodu ction T he term “ macrolide” is derived from the characteristic large lactone (cyclic ester) ring found in these antibiotics. T he clinically important members of this antibiotic family (Fig. 38.28) have two or more characteristic sugars (usually cladinose and desosamine) attached to the 14-membered ring. One of these sugars usually carries a substituted amino group, so their overall chemical character is weakly basic (pK a ~ 8). T hey are not very water-soluble as free bases. Salt formation with certain acids (glucoheptonic and lactobiononic acids in Fig. 38.28), however, increases water solubility, whereas other salts decrease solubility (laurylsulfate and stearic). Macrolide antibiotics with 16-membered rings are popular outside the United States, but one example, tylosin, finds extensive agricultural use in the United States. T he 14-membered ring macrolides are biosynthesized from propionic acid units so that every second carbon of erythromycin, for example, bears a methyl group and the rest of the ring carbons, with one exception, are oxygen bearing. T wo carbons bear so-called “ extra” oxygen atoms introduced later in the biosynthesis (not present in a propionic acid unit), and two hydroxyls are glycosylated (Fig. 38.29).

Ch emical Properties T he early macrolides of the erythromycin class are chemically unstable because of rapid acid-catalyzed internal cyclic ketal formation, leading to inactivity (Fig. 38.30). T his reaction that occurs in the GI tract is clinically important. Most acid-susceptible macrolides are administered in coated tablets to minimize this

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effect. Semisynthetic analogues have been prepared that are structurally incapable of undergoing this reaction (clarithromycin, dirithromycin, and azithromycin) (Fig. 38.28) and have become very popular of late in the clinic. Many macrolides have an unpleasant taste, which is partially overcome with water-insoluble dosage forms that also reduce acid instability and gut cramps. Enteric coatings are beneficial in reducing these adverse effects as well.

Mech an ism of Action T he macrolides inhibit bacteria by interfering with programmed ribosomal protein biosynthesis by binding to the 23S rRNA in the polypeptide exit tunnel adjacent to the peptidyl transferase center in the 50S subparticle (Fig. 38.24). Binding appears to occur at two specific regions within the rRNA, which are referred to as domain V at adenine 2058 and 2059 and domain II P.1070 at adenine 752. T hese sites are similar to those sites occupied by clindamycin, lincomycin, chloramphenicol, and streptogramin B antibiotics, leading to extensive cross-resistance. T he ratio of binding is 1:1 between 23S and the macrolide. Binding of the macrolide to 23S rRNA prevents the growing peptide from becoming longer than a few residues, resulting in the dissociation of peptidyl tRNA molecules. T he amino sugar moiety of the macrolides appears to be particularly important in the inhibition. Removal of the 3-L-cladinose results in reduced binding to domain V and an 100-fold decrease in biological activity. It also has been suggested that the L-cladinose is associated with GI distress resulting from the release of motilin

Fig. 38.28. Clinically important macrolide antibiotics.

Resistan ce Developed bacterial resistance is primarily caused by bacteria possessing R-factor enzymes that methylate a specific guanine residue on their own rRNA, making them somewhat less efficient protein biosynthesizers but comparatively poor binders of macrolides. T he erythromycin-producing soil organism utilizes the same ribosomal methylation technique to protect itself against the toxic effects of its own metabolite. T his leads to the speculation that the origin of some antibiotic resistance genes may lie in the producing organism itself and that this genetic material is acquired by bacteria from this source.

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Fig. 38.29. Biosynthetic pathway to erythromycins from propionic acid units. [X] ⇒ refers to modifications to the basic ring skeleton.

A second mechanism of resistance is associated with the mutation of adenine to guanine that occurs in domain V at adenine 2058. T his change results in a 10,000-fold reduction of binding capacity of erythromycin and clarithromycin to the 23S rRNA. T his mutation is much less likely to occur with the ketolide derivatives (telithromycin). Some bacterial strains, however, appear to be resistant to macrolides because of the operation of an active efflux process in which the drug is expelled from the cell at the cost of energy. Intrinsic resistance of Gram-negative bacteria is primarily caused by lack of penetration, because the isolated ribosomes from these organisms often are susceptible.

Fig. 38.30. Acid-catalyzed intramolecular ketal formation with erythromycin.

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Dru g In teraction s Drug–drug interactions with macrolides are comparatively common and usually involve competition for oxidative liver metabolism by a member (CYP3A4) of the cytochrome P450 oxidase family. Such drugs as ergotamine, theophylline, carbamazepine, bromocryptine, warfarin, digoxin, oral contraceptives, carbamazepine, cyclosporine, astemizole, terfenadine, midazolam, triazolam, and methylprednisone can be involved. T hese interactions can have severely negative consequences for the patient. T he result of this interaction is a longer half-life and enhanced potential toxicity by increasing the effective dose over time. T he interaction with astemizole and terfenadine can lead to very serious cardiovascular effects. T he main product of liver metabolism of erythromycin is the N-demethylated analogue.

T h erapeu tic Appl ication T he macrolides are among the safest of the antibiotics in common use and often are used for the treatment of upper and lower respiratory tract and soft-tissue infections primarily caused by Gram-positive microorganisms like Streptococcus pyogenes and Streptococcus pneumoni ae, Legionnaire's disease, prophylaxis of bacterial endocarditis by Streptococcus vi ri dans, upper and lower respiratory tract infections and otitis media caused by Haemophi l us i nfl uenzae (with a sulfonamide added), mycoplasmal pneumonia, and in combination with rifabutin in M ycobacteri um avi um complex infections in patients with AIDS, and it also finds some use for certain sexually transmitted diseases, such as gonorrhea and pelvic inflammatory disease, caused by mixed infections involving cell wall–free organisms, such as Chl amydi a trachomi ti s. Clarithromycin also is used to treat gastric ulcers because of Hel i cobacter pyl ori infection as a component of multidrug cocktails. T hus, the macrolides have a comparatively narrow antimicrobial spectrum, reminiscent of the medium-spectrum penicillins, but the organisms involved include many of the more commonly encountered community-acquired diseases and the macrolides are remarkably free of serious toxicity to the host and, of course, do not cause β-lactam allergy. T he utility of the macrolides against upper respiratory tract infections is aided by their particular affinity for these tissues. T issue levels in the upper respiratory tract often are several multiples of that seen in the blood. T he macrolides are primarily used orally for mild systemic infections of the respiratory tract, liver, kidneys, prostate, and milk gland even though absorption is somewhat irregular, especially when taken with food. Some derivatives are propropulsive through stimulation of gastrin production. T he resulting hyperperistalsis causes uncomfortable GI cramps in some patients. T hey are bacteriostatic in the clinic in achievable concentrations.

Specific Agen ts Eryth romycin Esters an d Salts Estolate One of the two most popular erythromycin pro-drugs, erythromycin estolate, is a C-2′-propionyl ester, N-laurylsulfate salt (Fig. 38.28). Administration of erythromycin estolate produces higher blood levels following metabolic regeneration of erythromycin. In a small number of cases, a severe, dose-related, cholestatic jaundice occurs in which the bile becomes granular in the bile duct, impeding flow so that the bile salts back up into the circulation. T his seems to be partly allergic and partly dose related. If the drug causes hepatocyte damage, perhaps this releases antigenic proteins that promote further damage. When cholestatic jaundice occurs, the drug must be replaced by another, nonmacrolide antibiotic, such as one of the penicillins, one of the cephalosporins, or clindamycin. It is postulated that the propionyl ester group is transferred to a tissue component that is antigenic, although the evidence for this is not compelling.

Ethylsuccinate (EryPed, EES) Erythromycin ethyl succinate is a mixed double ester pro-drug in which one carboxyl of succinic acid esterifies the C-2′ hydroxyl of erythromycin and the other ethanol (Fig. 38.28). T his pro-drug frequently is used in an oral suspension for pediatric use largely to mask the bitter taste of the drug. Film-coated tablets also are used to deal with this. Some cholestatic jaundice is associated with the use of EES.

Stearate Erythromycin stearate is a very insoluble salt form of erythromycin. T he water insolubility helps to mask the taste of the drug and enhances its stability in the stomach.

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Lactobionate Erythromycin lactobionate is a salt with enhanced water solubility that is used for injections.

Clarith romycin (Biaxin ) Clarithromycin differs from erythromycin in that the C-6 hydroxy group has been converted semisynthetically to a methyl ether. T he C-6 hydroxy group is involved in the process, initiated by protons, leading to internal cyclic ketal formation in erythromycin that results in drug inactivation (Fig. 38.30). T his ketal, or one of the products of its subsequent degradation, also is associated with GI cramping. Conversion of the molecule to its more lipophilic methyl ether prevents internal ketal formation, which not only gives better blood levels through chemical stabilization but also results in less gastric upset. An extensive saturable first-pass liver metabolism of clarithromycin leads to formation of its C-14 hydroxy analogue, which has even greater antimicrobial potency, especially against Haemophi l us i nfl uenzae. T he enhanced lipophilicity of clarithromycin also allows lower and less frequent dosage for mild infections.

Azith romycin (Zith romax, Zmax) Azithromycin, called an “ azalide,” has been formed by semisynthetic conversion of erythromycin to a ring-expanded analogue in which an N-methyl group has been inserted between carbons 9 and 10, and the carbonyl moiety thus is absent (Fig. 38.28). Azithromycin has a 15-membered lactone ring. P.1072 T his new functionality does not form a cyclic internal ketal. Not only is azithromycin more stable to acid degradation than erythromycin, it also has a considerably longer half-life, attributed to greater and longer tissue penetration, allowing once-a-day dosage. A popular treatment schedule with azithromycin is to take two tablets on the first day and then one tablet a day for the following 5 days and then to discontinue treatment. T his is convenient for patients who comply poorly. T he drug should be taken on an empty stomach. It does, however, give a metallic taste. Azithromycin tends to be broader spectrum than either erythromycin or clarithromycin. Both of these newer macrolides are quite similar in usage to erythromycin itself and are cross-resistant with it. Azithromycin has a significant postantibiotic effect against a number of pathogens. Azithromycin is commonly the first choice for treatment of infections that require a macrolide.

Ketolides Research activity in the macrolide antibiotic class has been intense recently in attempts to reduce side effects and to broaden their antimicrobial spectra. T he ketolides are a group of agents that are characterized by oxidation of the 3-position from an alcohol to a ketone. T hey are active against a significant number of erythromycin-resistant microorganisms. Recent investigation has been intense and a new agent has been introduced.

T el ith romycin (Ketek) T elithromycin (Fig. 38.28) is orally effective in the treatment of community-acquired pneumonia, acute bacterial exacerbations of chronic bronchitis, and acute sinusitis. Its principal advantage appears to be activity against drug-resistant infections. T elithromycin possesses several structural modifications from the traditional erythromycin nucleus, including removal of the L-cladinose sugar at C-3. T he L-cladinose is thought to be associated with the release of motilin and the resulting GI discomfort. Removal of L-cladinose and oxidation of the free hydroxy to a nonpolar ketone reduces biological activity through reduced binding to domain V, but this is offset by the addition of the chain at C-11/12, which greatly improves binding to domain II. Strong binding to domain V and II reduces bacterial resistance. T he C-6 methoxy improves acid stability. T elithromycin was approved by the U.S. FDA following a mammoth (24,000 patient) clinical trial. T he cost of this will no doubt inhibit further trials of replacement agents.

Lincosamides

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In trodu ction T he lincosamides contain an unusual 8-carbon sugar, a thiomethyl amino-octoside (O-thio-lincosamide), linked by an amide bond to an n-propyl–substituted N-methylpyrrolidylcarboxylic acid (N-methyl- n-propyltrans-hygric acid). Lincosamides are weakly basic and form clinically useful hydrochloric acid salts. T hey are chemically distinct from the macrolide antibiotics but possess many pharmacological similarities to them. T he lincosamides bind to 50S ribosomal subparticles at a site partly overlapping with the macrolide site, are mutually cross-resistant with macrolides, and work through essentially the same molecular mechanism of action (Fig. 38.24). T he lincoamides undergo extensive liver metabolism, resulting primarily in N-demethylation. T he N-desmethyl analogue retains biological activity.

Specific Agen ts Lin comycin (Lin cocin ) Lincomycin is a natural product isolated from fermentations of Streptomyces l i ncol nensi s var. l i ncol nensi s. It is active against Gram-positive organisms, including some anaerobes. It is indicated for the treatment of serious infections caused by sensitive strains of streptococci, pneumococci, and staphylococci. It generally is reserved for patients who are allergic to penicillin because of the increased risk of pseudomembranous colitis (described below). It also serves as the starting material for the synthesis of clindamycin (by a S N-2 reaction that inverts the R stereochemistry of the C-7 hydroxyl to a C-7 S-chloride).

Clin damycin (Cl eocin ) T he substitution of the chloride for the hydroxy group consequently make clindamycin more bioactive and lipophilic than lincomycin and, thus, is better absorbed following oral administration. It is significantly less painful than erythromycin when injected IM as a C-2 phosphate ester pro-drug and is approximately 90% absorbed when taken orally. It also is available as a palmitate ester hydrochloride salt that, interestingly, when reconstituted as instructed for use as an oral solution, has a pH between 2.5 to 5.0 Clindamycin has a clinical spectrum rather like the macrolides, although it distributes better into bones. Clindamycin works well for Gram-positive coccal infections, especially in patients who are allergic to β-lactams, and also has generally better activity against anaerobes. As with lincomycin, however, it is associated with GI complaints (nausea, vomiting, cramps, and drug-related diarrheas). T he most severe of these is pseudomembranous colitis caused by release of two toxins by Cl ostri di um di ffi ci l e, an opportunistic anaerobe. Its overgrowth results from suppression of the normal flora, the presence of which otherwise preserves a healthier ecological balance. T he popularity of clindamycin in the clinic has decreased even though pseudomembranous colitis is a comparatively rare side effect and also now is associated with several other broad-spectrum antibiotics. A less common side effect is exudative erythema multiform P.1073 (Stevens-Johnson syndrome). Clindamycin has excellent activity against Propi onobacteri um acnes when applied topically to comedones, and because it is white, it can be cosmetically tinted to match flesh tones better than the yellow tetracyclines. A very water-insoluble palmitate hydrochloride pro-drug of clindamycin also is available (lacks bitter taste).

Tetracyclines and glycylcyclines

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In trodu ction T he tetracycline family is widely, but not intensively, used in office practice. Of the agents in this family, minocycline and doxycycline are still frequently prescribed in the United States. T his family of antibiotics is characterized by a highly functionalized, partially reduced naphthacene (four linearly fused, 6-membered rings) ring system, from which both the family name and the numbering system are derived. T hey possess a number of adverse effects, although most of them are annoying rather than dangerous. Because their antimicrobial spectrum is broad enough to include many of the pathogens encountered in a community setting, they were once very widely used. T he advent of other choices and the high incidence of resistance that has developed has greatly decreased their medicinal prominence in recent years. Presently, they are recommended primarily for use against rickettsia, chlamydia, mycoplasma, anthrax, plague, and helicobacter organisms. A significant number of semisynthetic molecules derived from the antibacterial tetracyclines have shown potential activity in other therapeutic areas, such as antimetastasis, antitumor, anti-inflammatory, antiarthritic, antifungal, antineurotoxic, and antiperiodontal diseases, but discussion of these potential uses is beyond the scope of this chapter.

Table 38.13. Commercially Available Tetracyclines

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Ch emical Properties T he tetracyclines are amphoteric substances with three pK a values revealed by titration (2.8–3.4, 7.2–7.8, and 9.1–9.7) and have an isoelectric point at approximately pH 5. T he basic function is the C-4-αdimethylamino moiety. Commercially available tetracyclines (T able 38.13) generally are administered as comparatively water-soluble hydrochloride salts. T he conjugated phenolic enone system extending from C-10 to C-12 is associated with the pK a at approximately 7.5, whereas the conjugated trione system extending from C-1 to C-3 in ring A is nearly as acidic as acetic acid (pK a ~ 3). T hese resonating systems can be drawn in a number of essentially equivalent ways with the double bonds in alternate positions. T he formulae normally given are those settled on by popular convention.

Ch el ation Chelation is an important feature of the chemical and clinical properties of the tetracyclines. T he acidic functions of the tetracyclines are capable of forming salts through chelation with metal ions. T he salts of polyvalent metal ions, such as Fe 2+ , Ca 2+ , Mg 2+ , and Al 3+ , are all quite insoluble at neutral pHs (Fig. 38.31). T his insolubility not only is inconvenient for the preparation of solutions but also interferes with blood levels on oral administration. Consequently, the tetracyclines are incompatible with coadministered, multivalent ion–rich antacids and with hematinics, and concomitant consumption of daily products rich in calcium ion also is contraindicated. Further, the bones, of which the teeth are the most visible, are calcium-rich structures at nearly neutral pHs and so accumulate tetracyclines in proportion to the amount and duration P.1074 of therapy when bones and teeth are being formed. Because the tetracyclines are yellow, this leads to a progressive and, essentially, permanent discoloration in which, in advanced cases, the teeth are even brown. T he intensification of discoloration with time is said to be a photochemical process. T his is cosmetically unattractive but does not seem to be deleterious except in extreme cases, when so much antibiotic is taken up that the structure of bone is mechanically weakened. T o avoid this, tetracyclines are not normally given to children once they are forming their permanent set of teeth (age, 6–12 years). In severe cases, the teeth can be treated with dilute HCl solution to dissolve away the colored antibiotic. T his also significantly erodes the mineral matrix of the teeth, however, and must be repaired by plastic impregnation. People naturally prefer to avoid this heroic and expensive process. When concomitant oral therapy with tetracyclines and incompatible metal ions must be done, the ions should be given 1 hour before or 2 hours after the tetracyclines. Additionally, tetracyclines are painful on IM injection. T his has been attributed, in part, to formation of insoluble calcium complexes. T o deal with this, the injectable formulations contain ethylenediaminetetra-acetic acid and are buffered at comparatively acidic pH levels where chelation is less pronounced and water solubility is higher.

Fig. 38.31. Metal chelation with the tetracyclines.

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Epimerization T he α-stereo orientation of the C-4 dimethylamino moiety of the tetracyclines is essential for their bioactivity. T he presence of the tricarbonyl system of ring A allows enolization involving loss of the C-4 hydrogen (Fig. 38.32). Reprotonation can take place from either the top or bottom of the molecule. Reprotonation from the top of the enol regenerates tetracycline. Reprotonation from the bottom, however, produces inactive 4-epitetracycline. At equilibrium, the mixture consists of nearly equal amounts of the two diasteromers. T hus, old tetracycline preparations can lose approximately half their potency in this way. T he epimerization process is most rapid at approximately pH 4 and is relatively slower in the solid-state.

Fig. 38.32. Epimerization of tetracyclines.

Deh ydration Most of the natural tetracyclines have a tertiary benzylic hydroxyl group at C-6. T his function has the ideal geometry for acid-catalyzed dehydration involving the C-5a α-oriented hydrogen (antiperiplanar trans). T he resulting product is a naphthalene derivative, so there are energetic reasons for the reaction proceeding in that direction (Fig. 38.33). C-5a,6-anhydrotetracycline is much deeper in color than tetracycline and is biologically inactive. Discolored old tetracyclines are suspect and should be discarded. Not only can inactive 4-epitetracyclines dehydrate to produce 4-epianhydrotetracyclines, anhydrotetracycline also can epimerize to produce the same product. T his degradation product is toxic to the kidneys and produces a Fanconi-like syndrome that, in extreme cases, has been fatal. Commercial samples of tetracyclines are closely monitored for the presence of 4-epidehydrotetracycline, and injuries from this cause are now, fortunately, rare. T hose tetracyclines, such as minocycline and doxycycline, which have no C-6-hydroxyl groups, cannot undergo dehydration and, therefore, are completely free of this toxicity.

Cleavage in Base Another untoward degradation reaction involving a C-6-hydroxyl group is cleavage of the C-ring in alkaline solutions at or above pH 8.5 (Fig. 38.34). T he lactonic product, an isotetracycline, is inactive. T he clinical impact of this degradation under normal conditions is uncertain.

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Fig. 38.33. Acid-catalyzed instability of tetracyclines.

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Fig. 38.34. Base-catalyzed instability of tetracyclines.

Ph ototoxicity Certain tetracyclines, most notably those with a C-7-chlorine, absorb light in the visible region, leading to free radical generation and, potentially, cause severe erythema to sensitive patients on exposure to strong sunlight. Patients should be advised to be cautious about such exposure for at least their first few doses to avoid potentially severe sunburn. T his effect is comparatively rare with most currently popular tetracyclines.

Mech an ism of Action T he tetracyclines of clinical importance interfere with protein biosynthesis at the ribosomal level, leading to bacteriostasis. T etracyclines bind to rRNA in the 30S subparticle with the possible cooperation of a 50S site by a process that remains imprecisely understood despite intensive study (Fig. 38.24). T here is more than

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one binding site, but only one is believed to be critical for its action. T he points of contact with the rRNA are those associated with antibiosis with the puzzling exception of the dimethylamino function. Studies have suggested that the tetracyclines bind to the 16S rRNA via the functional groups located at the 1- and 10- to 12a-positions (referred to as the southern face of the tetracycline) and at the 2- and 3-positions (referred to as the eastern face of the tetracycline) (Fig. 38.35). T he dimethylamino function is known to be essential for activity but does not appear to bind in the x-ray pictures that are presently available. Once the tetracycline binds, it inhibits subsequent binding of aminoacyltransfer-RNA to the ribosomes, resulting in termination of peptide chain growth. Newer analogues of the tetracyclines suggest that substitution on the western and northern faces of the tetracycline are allowed as indicated by the newest glycylcyclines (see T igecycline below).

Fig. 38.35. Schematic representation of the primary binding site for a tetracycline and the sugar phosphate groups of 16S rRNA, which also involves a magnesium ion and the critical functional groups on the “southern” and “eastern” face of the tetracycline. (Adapted from Brodersen et al. The structural basis for the action of the antibiotics tetracycline, pactamycin, and hygromycin B on the 30S ribosomal subunit. Cell 2000;103:1143–1154, with permission from Elsevier.)

T he more lipophilic tetracyclines, typified by minocycline, also are capable of disrupting cytoplasmic membrane function, causing leakage of nucleotides and other essential cellular components from the cell, and have bactericidal properties. T he more lipophilic tetracyclines enter bacterial cells partly by passive diffusion and the more water-soluble members partly through water-lined protein porin routes, perhaps assisted by the formation of highly lipophilic calcium and magnesium ion chelates. Deeper passage, however, through the inner cytoplasmic membrane is an energy-requiring active process, suggesting that the tetracyclines are mistaken by bacteria as food.

Resistan ce Resistance to tetracyclines results in part from an unusual ribosomal protection process involving elaboration of bacterial proteins. T hese proteins associate with the ribosome, thus allowing protein P.1076 biosynthesis to proceed even in the presence of bound tetracycline, although exactly how this works is not well understood. Another important resistance mechanism involves R factor–mediated, energy-requiring,

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active efflux of tetracyclines from the bacterial cells. Some of the efflux proteins have activity that is limited to older tetracyclines, whereas others confer resistance to the entire family with the exception of glycylcyclines. Efflux resistance to glycylcylines, however, has been demonstrated in the laboratory, which suggests that it may occur clinically with extended use. Certain other microbes, such as M ycopl asma and Nei sseri a sp., seem to have modified membranes that either accumulate fewer tetracyclines or have porins through which tetracyclines have difficulty in passing. Because resistance is now widespread, these once extremely popular antibiotics are falling into comparative disuse.

T h erapeu tic Appl ication T he tetracyclines possess very wide bacteriostatic antibacterial activity. Because of the resistance phenomenon and the comparative frequency of troublesome side effects, they are rarely the drugs of first choice today. Nonetheless, they are still popular for office use against susceptible microbes. T he differences between the antimicrobial spectra of various tetracyclines are not large, although greater resistance to older agents may limit their use. T hey are used for low-dose oral and topical therapy for acne, first-course community-acquired urinary tract infections (largely caused by Escheri chi a col i ), brucellosis, borreliosis, sexually transmitted diseases (especially chlamydia), rickettsial infections, mycoplasmal pneumonia, prophylaxis of malaria, prevention of traveler's diarrhea, cholera, Enterobacter infections, as part of Hel i cobacter cocktails, Lyme disease, Rocky Mountain spotted fever, anthrax, and for many other less common problems. T he tetracyclines also are widely used for agricultural purposes.

Adverse Effects In addition to the adverse effects mentioned earlier (tooth staining, phototoxicity, and potential kidney damage with outdated drug), the tetracyclines are associated with nausea, vomiting, diarrhea, and some CNS effects (dizziness and vertigo). Rapid administration or prolonged IV use can lead to thrombophlebitis. T herefore, tetracyclines generally are administered orally, because they are well absorbed. T hey also distinguish imperfectly between the bacterial 70S ribosomes and the mammalian 80S ribosomes, so in high doses or special situations (i.e., IV use during pregnancy), these drugs demonstrate a significant antianabolic effect. T his may lead to severe liver and kidney damage; therefore, tetracyclines generally are not recommended in these situations. In cases of significant renal impairment, higher serum levels of tetracyclines can lead to azotemia. Additionally, inducers of cytochrome P450 metabolism (i.e., rifampin, barbiturates, and carbamazepine) increase metabolism of tetracyclines (especially doxycycline), so the dose of the tetracycline may require adjustment.

Specific Agen ts (Table 38.11) T etracyclin e T etracycline is produced by fermentation of Streptomyces aureofaci ens and related species or by catalytic reduction of chlortetracycline. T he blood levels achieved on oral administration often are irregular. Food and milk lower absorption by approximately 50%.

Demeclocyclin e Demeclocycline lacks the C-6-methyl of tetracycline and is produced by a genetically altered strain of Streptomyces aureofaci ens. Because it is a secondary alcohol, it is more chemically stable than tetracycline against dehydration. Food and milk co-consumption decrease absorption by half, although it is 60 to 80% absorbed by fasting adults. It is the tetracycline most highly associated with phototoxicity and has been shown to produce dose-dependent, reversible diabetes insipidus with extended use.

Oxytetracyclin e It also is one of the classic tetracyclines. It is produced by fermentation of Streptomyces ri mosi s and other soil microorganisms. T he most hydrophilic tetracycline on the market, it has largely now been replaced by its semisynthetic descendants. It is primarily used today for IM injections.

Min ocyclin e An important antibiotic produced by semisynthesis from demeclocycline is minocycline. It is much more lipophilic than its precursors, gives excellent blood levels following oral administration (90–100% available),

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and can be given once a day. Its absorption is lowered by approximately 20% when taken with food or milk. It is less dependent on active uptake mechanisms and has a somewhat broader antimicrobial spectrum. It also, apparently, is less painful on IM or IV injection, but it has vestibular toxicities (e.g., vertigo, ataxia, and nausea) not generally shared by other tetracyclines.

Doxycyclin e It is produced by semisynthesis from other tetracycline molecules and is the most widely used of the tetracycline family. Doxycycline is well absorbed on oral administration (90–100% when fasting; reduced by 20% by co-consumption with food or milk), has a half-life permitting once-a-day dosing for mild infections, and is excreted partly in the feces and partly in the urine. Once very widely used, tetracyclines have faded considerably in popularity because of widespread resistance and the introduction of newer broad-spectrum agents, such as amoxicillin with clavulanate. Research, however, continues, and novel analogues can be expected as indicated by the recent U.S. FDA approval of tigecycline, the first of a new class of tetracyclines referred to as the glycylcyclines. P.1077

T igecyclin e

T he increased incidence of resistance to the tetracyclines led to a renewed research effort to find novel agents within this class. T his effort led to the discovery of a new class of antibiotics, the glycylcyclines, that are closely related structurally to the tetracyclines but lack many of the clinical resistance issues. T hey are characterized by having an additional glycylamido substitution at the 9-position. As indicated earlier, substitution on the western face does not appear to interfere with binding of the drug to the rRNA. T igecycline is the first of these agents to be marketed. Although it has limited indications (treatment of complicated skin/skin structure and complicated intra-abdominal infections), this agent is a broad-spectrum antibiotic based on the in vitro data. It is administered IV and, like the tetracyclines, can cause injection site pain and thrombophlebitis. It is expected to have other adverse effects similar to the tetracyclines.

Special purpose antibiotics T his group of antibiotics consists of a miscellaneous collection of structural types for which the toxicities or narrow ranges of applicability give them a more specialized place in antimicrobial chemotherapy than those covered to this point. T hey generally are reserved for special purposes.

Ch loramph en icol (Ch loromycetin )

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In trodu ction Chloramphenicol was originally produced by fermentation of Streptomyces venezuel ae, but its comparatively simple chemical structure soon resulted in several efficient total chemical syntheses. With two asymmetric centers, it is one of four diastereomers, only one of which (1R,2R) is significantly active. Because total synthesis produces a mixture of all four, the unwanted isomers must be removed before use. Chloramphenicol is a neutral substance that is only moderately soluble in water, because both nitrogen atoms are nonbasic under physiologic conditions (one is an amide and the other a nitro moiety). It was the first broad-spectrum oral antibiotic used in the United States (1947) and was once very popular. Severe potential blood dyscrasia has greatly decreased its use in North America. Although its cheapness and efficiency makes it still very popular in much of the rest of the world where it can often be purchased over-the-counter without a prescription.

Mech an ism of action Chloramphenicol is bacteriostatic by virtue of inhibition of protein biosynthesis in both bacterial and, to a lesser extent, host ribosomes. Chloramphenicol binds to the 50S subparticle in a region near where the macrolides and lincosamides bind (Fig. 38.24). Resistance is mediated by several R-factor enzymes that catalyze acetylation of the secondary and, to some extent, the primary hydroxyl groups in the aliphatic side chain. T hese products no longer bind to the ribosomes and so are inactivated. Escheri chi a col i frequently is resistant because of chloramphenicol's lack of intercellular accumulation.

Metabolism When given orally, it is rapidly and completely absorbed but has a fairly short half-life. It is mainly excreted in the urine in the form of its metabolites, which are a C-3 glucuronide, and, to a lesser extent, its deamidation product and the product of dehalogenation and reduction. T hese metabolites are all inactive. T he aromatic nitro group also is reduced metabolically, and this product can undergo amide hydrolysis. T he reduction of the nitro group, however, does not take place efficiently in humans but, rather, primarily occurs in the gut by the action of the normal flora. Chloramphenicol potentiates the activity of some other drugs by inducing liver metabolism. Such agents include anticoagulant coumarins, sulfonamides, oral hypoglycemics, and phenytoin.

Pro-Dru g Forms T wo pro-drug forms of chloramphenicol are available (only the injectable form is available in the United States). T he drug is intensively bitter, but this can be masked for use as a pediatric oral suspension by the C-3 palmitate, which is cleaved in the duodenum to liberate the drug. Chloramphenicol's poor water solubility is largely overcome by conversion to the C-3 hemisuccinoyl ester, which forms a water-soluble sodium salt. T his is cleaved in the body by lung, liver, kidney, and blood esterases to produce active chloramphenicol. Because cleavage in muscles is slow, this pro-drug is used IV rather than IM.

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T h erapeu tic Appl ication s Despite potentially serious limitations, chloramphenicol is an effective drug when used carefully. Its special value is in typhoid fever, Haemophi l us infections (especially epiglottitis and meningitis, when given along with ampicillin), rickettsial infections, and in cases in which susceptible organisms have proven to be P.1078 resistant to other therapies. Safer antibiotics should be used whenever possible. It is approximately 60% serum protein bound and diffuses well into tissues, especially into inflamed cerebrospinal fluid and, therefore, is of value for meningitis. It also penetrates well into lymph and mesenteric ganglions, rationalizing its particular value in typhoid fever.

Adverse Effects T oxicities prevent chloramphenicol from being more widely used. Blood dyscrasias are seen in patients predisposed to them. T he more serious form is a pancytopenia of the blood that is fatal in approximately 70% of cases and is believed to be caused by one of the reduction products of the aromatic nitro group. T his side effect is known as aplastic anemia, and it has even occurred following use of the drug as an ophthalmic ointment. T here seems to be a genetic predisposition toward this in a very small percentage of the population. T his devastating side effect is estimated to occur once in every 25,000 to 40,000 courses of therapy. Less severe, but much more common, is a reversible inhibition of hematopoiesis seen in older patients or in those with renal insufficiency. If cell counts are taken, this can be controlled, because it is dose-related and marrow function will recover if the drug is withdrawn. T he so-called “ gray” or “ gray baby” syndrome, a form of cardiovascular collapse, is encountered when chloramphenicol is given to young infants (especially premature infants) if liver glucuronidation is underdeveloped, and successive doses will lead to rapid accumulation of the drug because of impaired excretion. A dose-related, profound anemia accompanied by an ashen-gray pallor is seen, as are vomiting, loss of appetite, and cyanosis. Deaths have resulted, often involving cardiovascular collapse.

Cyclic Peptides In trodu ction T he usual physiologically significant peptides are linear. Several bacterial species, however, produce antibiotic mixtures of cyclic peptides, some with uncommon amino acids and some with common amino acids but with the D absolute stereochemistry. T hese cyclic substances often have a pendant fatty acid chain as well. One of the consequences of this unusual architecture is that these glycopeptide agents are not readily metabolized. T hese drugs usually are water soluble and are highly lethal to susceptible bacteria, because they attach themselves to the bacterial membranes and interfere with their semipermeability so that essential metabolites leak out and undesirable substances pass in. Unfortunately, they also are highly toxic in humans, so their use is reserved for serious situations in which there are few alternatives or to topical uses. Bacteria rarely are able to develop significant resistance to this group of antibiotics. T hey generally are unstable, so solutions should be protected from heat, light, and extremes of pH.

Van comycin (Van cocin , Van coled)

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Vancomycin is produced by fermentation of Amycol atopsi s ori ental i s (formerly Nocardi a ori ental i s). It has been available for approximately 40 years, but its popularity has increased significantly with the emergence of MRSA in the early 1980s. Chemically, vancomycin has a glycosy lated hexapeptide chain that is rich in unusual amino acids, many of which contain aromatic rings cross-linked by aryl ether bonds into a rigid molecular framework.

Mechanism of Action Vancomycin is a bacterial cell wall biosynthesis inhibitor. Evidence suggests that the active species is a homodimer of two vancomycin units. T he binding site for its target is a peptide-lined cleft having high affinity for acetyl-D-alanyl-D-alanine and related peptides through five hydrogen bonds. It inhibits both transglycosylases (inhibiting the linking between muramic acid and acetyl glucosamine units) and transpeptidase (inhibiting peptide cross-linking) activities in cell wall biosynthesis (Fig. 38.10). T hus, vancomycin functions like a peptide receptor and interrupts bacterial cell wall biosynthesis at the same step as the β-lactams do, but by a different mechanism. By covering the substrate for cell wall transamidase, it prevents cross-linking resulting in osmotically defective cell walls.

Resistance Only very recently, despite decades of intensive use, have some vancomycin-resistant bacteria emerged (vancomycin-resistant enterococcus [VRE] and vancomycin-resistant Staphyl ococcus aureus) [VRSA]. It is alleged that these resistant strains emerged as a consequence of the agricultural use of avoparcin, a structurally related antibiotic that has not found use for human infections in the United States but was used in Europe before its recent ban. T he mechanism of resistance appears to be alteration of the target D-alanyl-D-alanine units on the peptidoglycan cell wall precursors to D-alanyl-D-lactate. T his results in lowered affinity for vancomycin due to lack of a key hydrogen bonding interaction. It is greatly feared that this form of resistance will become common in the bacteria for which vancomycin is presently the last sure hope for successful chemotherapy. If so, such infection P.1079 would become untreatable. T hese resistant strains are not yet common in clinically relevant strains, but most authorities believe that this is only a question of time. Vancomycin-intermediate S. aureus, also called glycoprotein-intermediate S. aureus (VISA), also has been reported. It appears to be resistant because of a thickened peptidoglycan layer.

Therapeutic Applications Although a number of adverse effects can result from IV infusion (see below), vancomycin has negligible oral activity. It can be used orally for action in the GI tract, especially in cases of Cl ostri di um di ffi ci l e

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overgrowth. T he useful spectrum is restricted to Gram-positive pathogens, with particular utility against multiply-resistant, coagulase-negative staphylococci and MRSA, which causes septicemias, endocarditis, skin and soft-tissue infections, and infections associated with venous catheters.

Adverse Effects Vancomycin is highly associated with adverse infusion-related events. T hese are especially prevalent with higher doses and a rapid infusion rate. A rapid infusion rate has been shown to cause anaphylactoid reactions, including hypotension, wheezing, dyspnea, urticaria, and pruritus. A significant drug rash (the so-called red man syndrome) also can occur. T hese events are much less frequent with a slower infusion rate. In addition to the danger of infusion-related events, higher doses of vancomycin can cause nephrotoxicity and auditory nerve damage. T he risk of these effects is increased with elevated, prolonged concentrations, so vancomycin use should be monitored, especially in patients with decreased renal function. T he ototoxicity may be transient or permanent and more commonly occurs in patients receiving high doses, patients with underlying hearing loss, and patients being treated concomitantly with other ototoxic agents (i.e., aminoglycosides).

Oth er Glycopepti des

T eicoplanin is a mixture of five related fermentation products related to vancomycin. It is more lipid soluble and, therefore, distributes better into tissues and bacteria. It also is highly protein bound, so it can be used IM or IV once daily. It is markedly less irritating than vancomycin on injection; therefore, it appears to be better tolerated by patients and on IV administration. It is not presently available in the United States but is available in a number of other countries. T he glycopeptide field is under intense investigation, and a number of agents are at various stages of preclinical evaluation.

Daptomycin (Cu bi cin )

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Daptomycin is a fermentation product having a cyclic lipopeptide structure. It is primarily active against Gram-positive infections, especially those involved in skin/skin structure infections. It is given IV but must be administered over a period of 30 minutes or more. It binds to cell membranes and causes depolarization, which interrupts protein, DNA, and RNA synthesis. Daptomycin is bactericidal. Although resistance can be achieved in vitro, resistance has been slow to emerge in the clinic. Patients should be monitored for muscle pain or weakness, because some incidence of elevated serum creatinine phosphokinase is associated with its use. A small number of clinical trial patients also developed conditions related to decreases in nerve conduction (e.g., paresthesias and Bell's palsy). Daptomycin is eliminated primarily by the kidney, so dose adjustment may be necessary in cases of renal insufficiency.

Streptogramin s T he streptogramins are a group of natural occurring antibiotics isolated from Streptomyces pri sti naspri al i s. T he streptogramin antibiotics consist of A-type molecules and B-type molecules, which when combined have a synergistic activity. T he mechanism of action of the two different types of molecules appear to be quite different.

Quinupristin/Dalfopristin A drug combination of the streptogramins, quinupristin and dalfopristin was approved for IV use in the treatment of infections caused by vancomycin-resistant Enterococcus faeci um bacteremia as well as skin/skin structure infections caused by MRSA and methicillin-sensitive Streptococcus pyogenes. Certain strains of E. faeci um are resistant to essentially all P.1080 other antibiotics, including vancomycin. T he streptogramin type A compound dalfopristin binds to the 50S ribosomal subparticle, resulting in a conformational change in the substrate. It appears that dalfopristin binding creates a high-affinity binding site for quinupristin, accounting for the synergy. Its site of action appears to be similar to that of chloroamphenicol, with effects on both the 30S and 50S subparticles. Quinupristin, the type B streptogramin, binds to the 50S subparticle overlapping the sites occupied by the macrolides and lincosamides (MLS B compounds) (Fig. 38.24). As a result, resistance to the later two classes of antibiotics confers resistance to quinupristin but not to dalfopristin. T he two drugs are bacteriostatic when administered individually but act synergistically when combined (quinupristin:dalfopristin, 30:70 w/w) to produce a bactericidal effect. T he combination is found to inhibit protein synthesis. Synercid is a strong inhibitor of the CYP3A4 isozyme, and a number of drug interactions are to be expected. Although the combination does not appear to prolong the QT c interval, it inhibits the metabolism of a number of agents that have been shown to have this effect, so concomitant administration should be avoided. Synercid also can produce a number of other adverse effects, including infusion site reactions (e.g., pain, edema, and inflammation), arthralgia and myalgia, and hyperbilirubinemia.

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Polymyxin B Polymyxin B is produced by fermentation of Baci l l us pol ymyxa. It is separated from a mixture of related cyclic peptides and is primarily active against Gram-negative microorganisms. It apparently binds to phosphate groups in bacterial cytoplasmic membranes and disrupts their integrity. It is used IM or IV as a sulfate salt to treat serious urinary tract infections, meningitis, and septicemia, primarily caused by Pseudomonas aerugi nosa, but some other Gram-negative bacteria also will respond. Irrigation of the urinary bladder with solutions of polymyxin B sulfate is employed as well by some to reduce the incidence of infections subsequent to installation of indwelling catheters. Additionally, it is used ophthalmically to treat infections by P. aerugi nosa. When given parenterally, the drug is neuro- and nephrotoxic and, therefore, is employed only after other drugs have failed.

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Bacitracin

Bacitracin is a mixture of similar peptides produced by fermentation of the bacterium Baci l l us subti l i s. T he A-type component predominates. Its mode of action is to inhibit both peptidoglycan biosynthesis at a late stage (probably at the dephosphorylation of the phospholipid carrier step) and disruptions of plasma membrane function. It is predominantly active against Gram-positive microorganisms, and parenteral use is limited to IM injection for infants with pneumonia and empyema caused by staphylococci resistant to other agents. It is rather neuro- and nephrotoxic and, therefore, is used in this manner with caution. Bacitracin also is widely employed topically to prevent infection in minor cuts, scrapes, and burns. P.1081

Lin ezolid

Linezolid is the first member of the oxazolidinone class of agents and represents a new synthetic class of antibacterials. It is active primarily against Gram-positive aerobic organisms and is indicated for treatment of MRSA, nosocomial pneumonia, community-acquired pneumonia, complicated and uncomplicated skin/skin structure infections because of susceptible organisms, and vancomycin-resistant Enterococcus faeci um infections. T he mechanism of action is inhibition of protein synthesis, but at a stage different from that of other protein synthesis inhibitors. T he oxazolidinones bind to the 23S rRNA of the 50S subparticle to prevent formation of a functional 70S initiation complex (Fig. 38.24). It is considered to be bacteriostatic against enterococci and staphylococci but bacteriocidal against streptococci. Resistance to oxazolidinones is encountered in the clinic because of a mutation in the 23S rRNA. T his is believed to distort the linezolid binding site. Gram-negative microorganisms are intrinsically resistant to linezolid because of the presence of endogenous efflux pumps that keep it from accumulating in the cells. Linezolid is well absorbed orally and is generally well tolerated; however, some severe cases of reversible blood dyscrasias have been noted, resulting in a package insert warning that complete blood counts should be monitored weekly, especially in patients with poorly draining infections and who are receiving prolonged therapy with the drug. Some

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interference with monoamine oxidase action has been seen, so patients should be cautious about ingesting tyramine-rich foods. Coadministration with adrenergic and serotonergic agents also is unadvisable. Additionally, lactic acidosis has been reported in patients receiving linezolid. Significant oxidative metabolism of the morpholine ring occurs but is not caused by cytochrome P450, so it does not interfere with other drugs metabolized by this system. Significant activity is underway to prepare and evaluate other oxazolidinone analogues.

Mu pirocin

Mupirocin is a member of a group of lipid acids produced by fermentation of Pseudomonas fl uorescens. It can only be used topically because of hydrolysis in vivo that inactivates the drug. It has an intrinsically broad spectrum, but its primary indication is topical use against staphylococcal and streptococcal skin infections. It is commonly used nasally in infection control programs to eradication nasal colonization by MRSA. Mupirocin binds to bacterial isoleucyl transfer-RNA synthase, preventing incorporation of isoleucine into bacterial proteins. Resistance is caused by alterations of the synthase target such that the enzyme still functions but does not bind mupirocin.

Case Study Victor ia F. Roche S. William Zito MR is an 87-year-o ld , widowe d woman living in a f ac ility de signe d f or healthy s eniors capable of ind ependent care. An unus ually co ld and harsh winte r has c urtailed the numb er of f ield trips and o utings that co uld be planned, but the Ac tivitie s Direc tor has engag ed the residents in many pop ular ind oor events, s uc h as line d ancing, “ c hairobics ” e xercise se ss ions, b oard games , and music al e nte rtainment. MR is a regular p articipant in thes e ac tivities , bec ause she g ets lonely in her apartme nt and thoroughly enjoys the stimulation of inte rac ting with he r f ellow res id ents (plus p artaking of the ref re shments serve d). Rec ently, there has bee n an outbreak o f c ommunity-acq uired pneumonia in the f acility, and unf o rtunately, MR has f allen victim. Althoug h normally indep end ent, she is so mewhat f rail and was s uf f ic iently ill to re quire short-term ho spitalizatio n to id entif y ap prop riate therapy. The of f ending o rganism was co nf irme d to be Strep toc occ us pn eum on i ae, and the physic ian wo uld like to maintain her on parenteral therapy f or a f ew d ays bef o re sending her home on oral med ic atio n. MR is c onc erned abo ut out-of -p ocket co sts, be cause he r late husband' s ins uranc e c overage, which s he has be en able to maintain, does not have a very e xtensive drug plan. MR' s me dic al history inc ludes a s evere penic illin allergy and lactose intoleranc e , and her current medic ations include e xtendedrele as e alp razolam (1 mg at b edtime f o r mild anxiety), simvastatin (Zoco r, 20 mg q.d . in the e venings ) f or dyslip id emia, and lo w-dos e mic ronized es tradiol (0 .5 mg q.d .), alo ng with Viactive c alcium c hews (t.i.d .) to minimize b one loss . He r renal and hep atic f unc tion is sub optimal, as would b e expe cted in s omeone of her ad vanc ed ye ars . Conside r the structures o f the antibiotic s drawn b elo w, and prepare to make a therap eutic reco mmendation.

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1. I de ntif y the therape utic problem(s) in whic h the p harmac is t' s intervention may bene f it the patient. 2. I de ntif y and p rio ritize the patient-s pecif ic f actors that must b e c ons idere d to achieve the des ired therapeutic outcomes. 3. Conduct a thoroug h and me chanistically oriente d s tructure–ac tivity analysis of all therapeutic alternatives pro vided in the c as e. 4. Evaluate the SAR f ind ings ag ains t the patient-s pec if ic f ac tors and de sired therapeutic outc omes , and make a therape utic de cision. 5. Counsel your patie nt.

P.1082

Suggested Readings Albert A. Selective T oxicity. 6th Ed. New York: Chapman and Hall, 1979.

Association Franciaise las Enseignants de Chemie T herapeutique. Medicaments Antibiotiques. Paris: T ec & Doc Lavoisier, 1992:2

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Bartmann K. Antitubercular drugs. In: Handbook of Experimental Pharmacology. New York: SpringerVerlag, 1988:84.

Burnet M, White DO. Natural History of Infectious Disease. 4th Ed. New York: Cambridge University Press, 1975.

Dax SL. Antibacterial Chemotherapeutic Agents. New York: Blackie Academic and Professional, 1997.

de Kruif P. Microbe Hunters. New York: Pocket Books, 1965 (Original Edition, New York: Harcourt, Brace, 1926).

Demain AL, Solomon NA, ed. Antibiotics Containing the β-Lactam Structure, Vols 1 and 2, Handbook of Experimental Pharmacology, Vol 67. New York: Springer-Verlag, 1983.

Drug Information. Bethesda, MD: American Society of Health-Systems Pharmacists, 2005.

Gale EF, Cundliffe E, Reynolds PE, et al., eds. T he Molecular Basis of Antibiotic Action. New York: Wiley, 1981:2.

Garrett L. T he Coming Plague. New York: Penguin, 1994.

Hitchings GH. Inhibition of folate metabolism in chemotherapy: the origins and uses of cotrimoxole. In: Hitchings GH, ed. Handbook of Experimental Pharmacology. New York: Springer, 1983:64.

Hlavka JJ, Boothe JH. T he T etracyclines. In: Handbook of Experimental Pharmacology. New York: Springer-Verlag, 1985:78.

Kuhlmann J, Dalhoff A, Zeiler H-J. Quinolone antibacterials. In: Handbook of Experimental Pharmacology. New York: Springer, 1998:127.

Kucers A, Bennet N McK. T he Use of Antibiotics, 4th Ed. Philadelphia: Lippincott, 1987.

Levy SB. T he Antibiotic Paradox. New York: Plenum Press, 1992.

Lukacs G, Ohno M, eds. Recent Progress in the Chemical Synthesis of Antibiotics. New York: SpringerVerlag, 1990.

Mandell GL, Douglas RG, Bennett JE. Principles and Practice of Infectious Disease, 3rd Ed. New York: Churchill Livingston, 1990.

T he Medical Letter on Drugs and T herapeutics, Handbook of Antimicrobial T herapy. New Rochelle, NY: T he Medical Letter, 1993.

Mitscher LA. T he Chemistry of T etracycline Antibiotics. New York: Decker, 1978.

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Mitscher LA, Georg GI, Motohashi N. Antibiotic and antimicrobial drugs. In: DF Smith, ed. Handbook of Stereoisomers: T herapeutic Drugs. Boca Raton, FL: CRC Press, 1989:199–234.

Morin RB, Gorman M, eds. Chemistry and Biology of β-Lactam Antibiotics, Vols 1–3. New York: Academic Press, 1982.

Nagarajan R, ed. Glycopeptide Antibiotics. New York: Marcel Dekker, 1994.

Omura S, ed. Macrolide Antibiotics. New York: Academic Press, 1984.

Perlman D, ed. Structure–Activity Relationships among the Semisynthetic Antibiotics. New York: Academic Press, 1977.

Plempel M, Otten H. Walter/Heilmeyerís Antibiotika Fibel: Antibiotika und Chemotherapie, 5th Ed. Stuttgart: Georg T hieme Verlag, 1982.

Pratt WB. Fundamentals of Chemotherapy. New York: Oxford University Press, 1973. P.1083 Rosebury T . Microbes and Morals. New York: Balantine Books, 1976.

Ryan F. T he Forgotten Plague: How the Battle Against T uberculosis was Won—and Lost. Boston: Little, Brown and Co., 1993.

Sheehan JC. T he Enchanted Ring: T he Untold Story of Penicillin. Cambridge, MA: MIT Press, 1982.

Stewart GW. T he Penicillin Group of Drugs. Amsterdam: Elsevier, 1965.

Sutcliffe J, Georgopapadakou NH, eds. Emerging T argets in Antibacterial and Antifungal Chemotherapy. New York: Chapman and Hall, 1992.

Umezawa H, Hooper IR, eds. Aminoglycoside antibiotics. In: Handbook of Experimental Pharmacology. New York: Springer-Verlag, 1982:62.

Verderame M. ed. Handbook of Chemotherapeutic Agents, Vols. 1 and 2. Boca Raton, FL: CRC Press, 1986:1–2.

Whelton A, Neu HC, eds. T he Aminoglycosides. New York: Dekker, 1982.

Wolfson JS, Hooper DC, eds. Quinolone Antimicrobial Agents. 2nd Ed. Washington, DC: American Society for Microbiology, 1993.

Zinsser H. Rats, Lice, and History. Boston: Little, Brown and Co., 1950.

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Chapter 39 Antiparasitic Agents Thom as L. Le m ke

Drugs cov ered in this chapter: Dr u g tr e atment of ame biasis, g ia rd ia sis, tr ich omo niasis Diloxanide f uro ate Metro nidazole Nitazoxanide Tinid azole T r e atment o f p neu mocy stis Atovaquone Pe namid ine is ethio nate Sulf amethoxazo le– trime tho prim Trime trexate gluc uronate T r e atment o f tr ypa nos omiasis Be nznidazole Ef lornithine Melars o prol Niturtimo x Pe ntamidine is e thionate Suramin s odium T r e atment o f leishman ia sis So dium s tib ogluc onate An timalar ials Atovaquone –prog uanil Chlo roq uine Halof antrine Mef loq uine Pyrimethamine Quinine An th elmin tics Albe ndazole Diethylc arbamazine

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I vermec tin Mebe ndazo le Oxamniq uine Praziquantel Pyrantel p amoate Thiabe ndazo le Sc abicides a nd pe diculocide s Cro tamiton Lindane Pe rme thrin Pyre thrin

General Considerations An introduction to the topic of parasitic diseases usually emphasizes two points. First, parasitic infections affect huge numbers of individuals. It is estimated that well over 1 billion people are infected worldwide. Second, the majority of these parasitic infections are found in developing nations, in which the cost of health care is the dominant factor that determines whether the patient is (or is not) treated. T he incidence of some parasitic diseases may exceed 80% of the population. T he high cost of drug discovery and the low incidence of many of the parasitic infections in affluent Western countries have combined to reduce the incentive for both the study of the diseases and the development of effective therapy. T his may be changing, however, because of global travel, improved communications, and growth of the developing countries, leading to an increased demand for more effective treatments. T he diseases associated with parasitic infections represent a large and diverse number of conditions, some common and some relatively unheard of by the general population. Included under the title of parasitic infections are the numerous types of protozoal infections: amebiasis, giardiasis, babesiosis, Chagas' disease, leishmaniasis, malaria, sleeping sickness, toxoplasmosis, trichomoniasis, and pneumocystosis (also considered to be a fungal infection). Helminth infections (worms) also are considered to be parasitic infections and may be caused by any of three classes of helminths: nematodes, cestodes, and trematodes. Insect infections, such as scabies, lice (pediculosis), and chiggers, also are considered to be parasitic infections.

Protozoal Diseases Amebiasis Amebiasis is a disease of the large intestine caused by Entamoeba hi stol yti ca. T he disease occurs mainly in the tropics, but it also is seen in temperate climates. Amebiasis may be carried without significant symptoms or may lead to severe, life-threatening dysentery. T he organism exists in one of two forms, the motile trophozoite form or the dormant cyst form. T he trophozoite form is found in the intestine or wall of the colon and may be expelled from the body with the stools. T he cyst form is encased by a chitinous wall that protects the organism from the environment, including chlorine used in water purification; thus, the organism may be transmitted through contaminated water and foods. It is the cyst form that is responsible for transmission of the disease. T he cyst is spread by direct person-to-person contact and is commonly associated with living conditions in which poor personal hygiene, poor sanitation, poverty, and ignorance

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exist. T he hosts may be rendered susceptible to infection by preexisting conditions, such as protein malnutrition, pregnancy, HIV infection, or high carbohydrate intake. Under these conditions, the organism is capable of invading body tissue. T he protozoal invasion is not well understood. but it does appear to involve the processes indicated in T able 39.1. Symptoms may range from intermittent P.1085 diarrhea (foul-smelling loose/watery stools) to tenderness and enlargement of the liver (with the extraintestinal form) to acute amoebic dysentery. Many patients may experience no symptoms, and the organism remains in the bowels as a commensal organism.

Clinica l Sign ific anc e Parasitic infections affect more than half the world's population and are responsible for significant health complications, especially in underdeveloped areas. Drug therapy for parasitic infections is quite challenging to practitioners for multiple reasons. Many practitioners lack experience with these agents and are unfamiliar with the toxicities and monitoring parameters associated with these drugs. Certain agents are available in only a limited number of countries, and opinions regarding safety and efficacy vary greatly among practitioners. Understanding the medicinal chemistry, pharmacodynamics, and pharmacokinetics of these agents is of utmost importance. Despite efforts of vaccine development, drug therapy remains the most effective means to control parasitic infections. Limited introduction of new antiparasitic agents and drug shortages make the treatment of parasitic infestations challenging. Understanding which drugs work at different parts of the life cycle of the parasite also must be taken into consideration. Furthermore, the use of many antiparasitic agents are associated with toxicities, including precipitating severe inflammatory reactions, which may then be treated with anti-inflammatory agents and other supportive measures. Laura Gerard Pharm.D. BCPS Cl i ni cal Assi stant Professor, Department of Cl i ni cal Sci ence & Admi ni strati on, Uni versi ty of Houston Col l ege of Pharmacy.

Giardiasis Giardiasis is a disease that shows considerable similarity to amebiasis. It is caused by Gi ardi a l ambl i a, an organism that may be found in the duodenum and jejunum. T he organism exists in a motile trophozoite form and an infectious cyst form. T he cyst form can be deposited in water (lives up to 2 months), and the contaminated water may then be ingested by the human. T he trophozoite, if expelled from the gastrointestinal (GI) tract, normally will not survive. Gi ardi a l ambl i a is the single most common cause of waterborne diarrhea in the United States. Giardiasis is a common disease among campers who drink water from contaminated streams. It also may be spread between family members, children in day care centers, and dogs and their masters. T he organism can attach to the mucosal wall via a ventral sucking disk, and similar to amebiasis, the patient may be asymptomatic or develop watery diarrhea, abdominal cramps, distention and flatulence, anorexia, nausea, and vomiting. Usually, the condition is self limiting in 1 to 4 weeks.

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Table 39.1. Entamoeba Histolytidavasion of Host

Trichomoniasis T richomoniasis is a protozoal infection caused by Tri chomonas vagi nal i s, which exists only in a trophozoite form. T he organs most commonly involved in the infection include the vagina, urethra, and prostate; thus, the disease is considered to be a venereal infection. T he condition is transmitted by sexual contact, and it is estimated that trichomoniasis affects 180 million individuals worldwide. Infections in the male may be asymptomatic, whereas in the female, the symptoms may consist of vaginitis, profuse and foul-smelling discharge, burning and soreness on urination; and vulvar itching. Diagnosis is based on microscopic identification of the organism in fluids from the vagina, prostate, or urethra.

Pneumocystis T he organism responsible for pneumocystis (pneumocystosis) in humans is Pneumocysti s cari ni i . It has the morphologic P.1086 characteristics of a protozoan (i.e., lack of ergosterol in its cell membrane), but its rRNA and mitochondrial DNA pattern resembles that of fungi. Acute pneumocystis rarely strikes healthy individuals, although the organism is harbored in a wide variety of animals and most humans without any apparent adverse effect. Pneumocysti s cari ni i becomes active only in those individuals who have a serious impairment of their immune systems. T hus, the organism is considered to be an opportunistic pathogen. More recently, this disease has appeared in patients with AIDS, 80% of whom ultimately contract P. cari ni i pneumonia (PCP), as one of the main causes of death. T he disease also occurs in those receiving immunosuppressive drugs to prevent rejection following organ transplantation or for the treatment of malignant disease. Additionally, pneumocystis is seen in malnourished infants whose immunologic systems are impaired. T he disease is thought to be transmitted via an airborne route. T he disease is characterized by a severe pneumonia caused by rapid multiplication of the organisms, almost exclusively in lung tissue, with the organism lining the walls of the alveoli and gradually filling the alveolar spaces. Untreated, the acute form of the disease generally is fatal. Even patients who recover from pneumocystosis are at risk of recurrent episodes. Patients with AIDS experience a recurrence rate of approximately 50%.

Organisms that Commonly Cause Vaginitis

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Vaginitis als o may be c aus ed by Ha em oph i l us v ag i na l i s (b ac te ria) o r Ca ndi da al bi c ans (f ungus ), whic h are treated dif f erently f rom the protozoal inf ec tio n.

Extrapulmonary pneumocystosis—that is, pneumocystosis outside of the lungs—also is known to exist and may be more common than presently recognized. T his infection may be complicated by the presence of coinfectious organisms. Fortunately, drug therapy utilized for treatment of the pulmonary infection is beneficial for the extrapulmonary condition, although intravenous (IV) administration of the drugs may be necessary.

Tritryps T hree protozoan pathogens that belong to the family T rypanosomatidae, the order Kinetoplastida, and the genus Trypanosoma are Lei shmani a major, which is responsible for leishmaniasis; Trypanosoma brucei , which is responsible for African trypanosomiasis (African sleeping sickness); and Trypanosoma cruzi , which is responsible organism for Chagas' disease. Referred to as the “ tritryps,” these eukaryotic organisms share characteristic subcellular structures of a kinetoplast and glycosomes, are unicellular motile protozoa, are transmitted by various insect vectors, and infect mammalian hosts. T he genomes of tritryps have recently been reported (1,2,3). T ogether, they infect hundreds of millions of people annually.

Trypanosomiasis (4) T here are two distinct forms of trypanosomiasis: Chagas' disease, and African sleeping sickness.

Chagas' disease Chagas' disease, also known as American trypanosomiasis, is caused by the parasitic protozoa Trypanosoma cruzi and is found only in the Americas, primarily in Brazil but also in the southern United States. T he protozoa lives in mammals and is spread by the bloodsucking insect known as the reduviid bug, assassin bug, or kissing bug. T he insect becomes infected by drawing blood from an infected mammal and releasing the protozoa with discharged feces. T he pathogen then enters the new host through breaks in the skin. Inflammatory lesions are seen at the site of entry. T he disease also may be spread through transfusion with contaminated blood. Signs of initial infection may include malaise, fever, anorexia, and skin edema at the site where the protozoa entered the host. T he disease ultimately may invade the heart, where after decades of infection with chronic Chagas' disease, the patient may experience an infection-associated heart attack. It is estimated that 5% of the Salvadorian and Nicaraguan immigrants to the United States may have chronic Chagas' disease.

African trypanosomiasis African trypanosomiasis, or sleeping sickness, is caused by several subspecies of Trypanosoma brucei (T. brucei rhodesi ense [east African sleeping sickness] and T. brucei gambi ense [west African sleeping sickness]). In this case, the infected animal is bitten by the bloodsucking tsetse fly, which in turn transmits the protozoa via inoculation during a subsequent bite of a human. T he protozoa, initially present in the gut of the vector. appears in the salivary gland for inoculation during the subsequent biting of a human. It is estimated that some 50 million people are at risk of African sleeping sickness, with 300,000 to 500,000 cases occurring in sub-Saharan Africa each year. T he infection progresses through two stages. Stage I may present as fever and high temperatures lasting several days; hematologic and immunologic changes occur during this stage. Stage II occurs after the organism enters the central nervous system (CNS) and may involve symptoms suggesting the disease name—daytime somnolence, loss of spontaneity, halting speech, listless gaze, and extrapyramidal signs (e.g., tremors and choreiform movements). A breakdown of neurological function leading to coma and death may occur. Death may occur within weeks if

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untreated (T. brucei rhodesi ense) or only after several years (T. brucei gambi ense). It should be noted that the sole source of energy for the trypanosomal organism is glycolysis, which in turn may account for the hypoglycemia seen in the host. In addition, the migration of the organism into the CNS may be associated with the organism's search for a rich source of available glucose.

Leishmaniasis Leishmaniasis is a disease caused by a number of protozoa in the genus Lei shmani a. T he protozoa may be harbored in diseased rodents, canines, and various other mammals and transmitted from the infected mammal to man by bites from female sandflies of the genus Phl ehotomus and then appears in one of four major clinical syndromes: visceral leishmaniasis, cutaneous leishmaniasis, mucocutaneous leishmaniasis, or diffuse cutaneous leishmaniasis. P.1087 T he sandfly, the vector involved in spreading the disease, breeds in warm, humid climates; thus, the disease is more common in the tropics. As many as 12 million individuals, worldwide are infected by this organism. T he visceral leishmaniasis, also known as kala azar (black fever), is caused by Lei shmani a donovani . T his form of the disease is systemic and is characterized in patients by fever, typically nocturnal, diarrhea, cough, and enlarged liver and spleen. T he skin of the patient may become darkened. Without treatment, death may occur in 20 months and is commonly associated with diarrhea, superinfections, or GI hemorrhage. Visceral leishmaniasis is most commonly found in India and Sudan. Both cutaneous and monocutaneous leishmaniasis are characterized by single or multiple localized lesions. T hese slow-healing and, possibly, painful ulcers can lead to secondary bacterial infections. T he Old World cutaneous leishmaniasis is caused by Lei shmani a topi ca, which is found most commonly in children and young adults in regions bordering the Mediterranean, the Middle East, Southern Russia, and India. Lei shmani a major is endemic to desert areas in Africa, the Middle East, and Russia, whereas Lei shmani a aethi opi ca is found in the Kenyan highlands and Ethiopia. T he New World disease caused by Lei shmani a peruvi ana, Lei shmani a brazi l i ensi s, and Lei shmani a panamensi s is found in South and Central America, whereas Lei shmani a mexi cana may be endemic to southcentral T exas. T he incubation period for cutaneous leishmaniasis ranges from a few weeks to several months. T he slow-healing lesions may be seen on the skin in various regions of the body depending on the specific strain of organism. Usually, these conditions exhibit spontaneous healing, but this also may occur over an extended period of time (1–2 years).

M alaria Malaria is transmitted by the infected female Anophel es mosquito. T he specific protozoan organisms causing malaria are from the genus Pl asmodi um. Only 4 of approximately 100 species cause malaria in humans. T he remaining species affect birds, monkeys, livestock, rodents, and reptiles. T he four species that affect humans are Pl asmodi um fal ci parum, Pl asmodi um vi vax, Pl asmodi um mal ari ae, and Pl asmodi um oval e. Concurrent infections by more than one of these species are seen in endemically affected regions of the world. Such multiple infections further complicate patient management and the choice of treatment regimens. Malaria affects as many as 500 million humans globally and causes more than 2 million deaths annually. It is estimated that a third of these fatalities occur in children younger than 5 years. Although this disease is found primarily in the tropics and subtropics, it has been observed far beyond these boundaries. Malaria has essentially been eradicated in most temperate-zone countries. However, more than

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1,000 cases of malaria were documented recently in U.S. citizens returning from travel abroad. T oday, malaria is found in most countries of Africa, Central and South America, and Southeast Asia. It is reported to be on the increase in Afghanistan, Bangladesh, Brazil, Burma, Cambodia, Colombia, China, Iran, India, Indonesia, Mexico, the Philippines, T hailand, and Vietnam. Infection from plasmodia can cause anemia, pulmonary edema, renal failure, jaundice, shock, cerebral malaria, and if not treated in a timely manner, even death.

Types of Malaria Malarial infections are known according to the species of the parasite involved.

Plasmodium falciparum Infection with Pl asmodi um fal ci parum has an incubation period (time from mosquito bite to clinical symptoms) of 1 to 3 weeks (average, 12 days). T he P. fal ci parum life cycle in humans begins with the bite of an infected female mosquito. T he parasites in the sporozoite stage enter the circulatory system, through which they can reach the liver in approximately 1 hour. T hese organisms grow and multiply 30,000- to 40,000-fold by asexual division within liver cells in 5 to 7 days. T hen, as merozoites, they leave the liver to reenter the blood stream and invade the erythrocytes, or red blood cells (RBCs), where they continue to grow and multiply further for 1 to 3 days. Specific receptors on the surface of the erythrocytes serve as binding sites for the merozoite. T hese infected RBCs rupture, releasing merozoites in intervals of approximately 48 hours. Chemicals released by the ruptured cell in turn cause activation and release of additional substances associated with the patient's symptoms. T he clinical symptoms include chills, fever, sweating, headaches, fatigue, anorexia, nausea, vomiting, and diarrhea. Some of the released merozoites are sequestered in vital organs (brain and heart), where they continue to grow. Recurrence of the clinical symptoms on alternate days leads to the terminology of tertian malaria. T he P. fal ci parum parasite also can cause RBCs to clump and adhere to the wall of blood vessels. Such a phenomenon has been known to cause partial obstruction and, sometimes, restriction of the blood flow to vital organs like the brain, liver, and kidneys. Reinfection of RBCs can occur, allowing further multiplication and remanifestation of the malaria symptoms. Some merozoites develop into male and female sexual forms, called gametocytes, which can then be acquired by the female mosquito after biting the infected human. Gametocytes mature in the mosquito's stomach to form zygotes. Growth of the zygotes leads to the formation of oocysts (spherical structures located on the outside wall of the stomach). Sporozoites develop from the oocysts, are released into the body cavity of the mosquito, and migrate to the salivary gland of the insect, from which they can be transmitted to another human following a mosquito bite. T he life cycle of the malaria parasites is shown in the Figure 39.1. T he genome of the P. fal ci parum is now known and is expected to provide potential new P.1088 avenues for drug development. Genome information also is expected to give insight regarding the mechanisms of resistance and improve drug treatment.

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Fig. 39.1. Life cycle of malarial protozoa.

Plasmodium vivax Pl asmodi um vi vax (benign tertian) is the most prevalent form of malaria. It has an incubation period of 1 to 4 weeks (average, 2 weeks). T his form of malaria can cause spleen rupture and anemia. Relapses (renewed manifestations of erythrocytic infection) can occur. T his results from the periodic release of dormant parasites (hypnozoites) from the liver cells. T he erythrocytic forms generally are considered to be susceptible to treatment.

Plasmodium malariae Pl asmodi um mal ari ae is responsible for quartan malaria. It has an incubation period of 2 to 4 weeks (average, 3 weeks). T he asexual cycle occurs every 72 hours. In addition to the usual symptoms, this form also causes nephritis. T his is the mildest form of malaria and does not relapse. T he RBC infection associated with P. mal ari ae can last for many years. T he P. mal ari ae is quite unlikely to become resistant.

Plasmodium ovale Infection with Pl asmodi um oval e has an incubation period of 9 to 18 days (average, 14 days). Relapses have been known to occur in individuals infected with this plasmodium. T he relapse may be indicative of ovale tertian malaria and is associated with the ability of the organism to lie dormant in hepatic tissue for extended periods of time.

Types of Chemotherapy Tissue schizonticides T hese drugs eradicate the exoerythrocytic liver-tissue stages of the parasite, which prevents the

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parasite's entry into the blood. Drugs of this type are useful for prophylaxis. Some tissue schizonticides can act on the long-lived tissue form (hypnozoites of P. vi vax and P. oval e) and, thus, can prevent relapses.

Blood schizonticides T hese drugs destroy the erythrocytic stages of parasites and can cure cases of falciparum malaria or suppress relapses. T his is the easiest phase to treat, because drug delivery into the blood stream can be accomplished rapidly.

Gametocytocides Agents of this type kill the sexual forms of the plasmodia (gametocytes), which are transmittable to the Anophel es mosquito, thereby preventing transmission of the disease.

Sporontocides (sporozooiticides) T hese drugs act against sporozoites and are capable of killing these organisms as soon as they enter the bloodstream following a mosquito bite. It should be noted that antimalarials may operate against more than one form of the organism and may be effective against one species of plasmodium but lack efficacy against others. In addition, antimalarial drugs may be classified according to their structural types.

General Approaches to Protozoal T herapy Amebiasis and Giardiasis T he most appropriate approach for treatment of this type of protozoal infection is through prevention. Because the infection usually occurs by consumption of contaminated drinking water and food, avoidance is the key to prevention. Drinking bottled water, or boiling or disinfecting the water, will reduce the risk. Improvement in personal hygiene and general sanitation also are beneficial.

Trypanosomiasis, Leishmaniasis, and M alaria For these diseases that are spread by insect vectors, the use of insecticides, protective clothing, and insect repellents can greatly reduce the incidence of the disease. Unfortunately, many of these protozoal infections also P.1089 can infect other hosts beside humans; thus, even the most successful insect irradiation methods cannot destroy all the reservoirs of the protozoa. T he use of insect repellents and protective clothing may be useful for visitors to regions with endemic infections, but these procedures may prove to be ineffective for those living in the area. For such individuals, early detection and drug therapy is the method of treatment.

Drug T herapy for Protozoal Infections Treatment of Amebiasis, Giardiasis, and Trichomoniasis Metronidazole (Flagyl, Metryl, Satric)

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Metronidazole was initially introduced for the treatment of vaginal infections caused by Tri chomonas vagi nal i s but has since been shown to be effective for treatment of amebiasis, giardiasis, and anaerobic bacterial infections, including Cl ostri di um di ffi ci l e.

Mechanism of action Despite the availability of metronidazole since the late 1950s, the mechanism of action of the drug is still unknown. It generally is agreed that metronidazole is a pro-drug and that anaerobic organisms reduce the nitro group in metronidazole to a hydroxylamine, as shown in Figure 39.2, during which a reactive derivative or reactive species are produced that cause destructive effects on cell components (i.e., DNA, proteins, and membranes). Specifically, DoCampo (5) has reported that nitroaryl compounds (nitroimidazoles, metronidazole; nitrofurans, nifurtomox) are reduced to nitro radical anions, which in turn react with oxygen to regenerate the nitroaryl and the superoxide radical anion (Fig. 39.3). Further reduction of superoxide radical anion leads to hydrogen peroxide and homolytic cleavage of the latter leads to hydroxyl radical formation. Superoxide radical anion, hydrogen peroxide, and hydroxyl radicals are referred to as reactive oxygen species (ROS) and are the reactive substances that are implicated in damage to critical cellular components of the parasite.

Metabolism Liver metabolism of metronidazole leads to two major metabolites: hydroxylation of the 2-methyl group to 2-hydroxymethylmetronidazole (HM), and oxidation to metronidazole acetic acid (6). Both compounds possess biological activity. Additionally, HM is found in the urine as glucuronide and sulfate conjugates. In addition, a small amount of metronidazole is oxidized to acetamide, a known carcinogen in rats but not in humans, and to the oxalate derivative shown in Figure 39.4 (7).

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Fig. 39.2. Metabolic activation of metronidazole.

Fig. 39.3. Formation of ROS from nitroaryl compounds.

Pharmacokinetics (6) Metronidazole is available in a variety of dosage forms, including IV, oral, rectal, and vaginal suppositories. T he bioavailability of metronidazole is nearly 100% when administered orally but is significantly less when administered via the rectal route (67–82%) or the vaginal route (19–56%). T he drug is not bound to plasma protein. Distribution of the drug is fairly uniform through out the body, including mother's milk.

Therapeutic application Metronidazole is considered to be the drug of choice for treatment for the protozoal infections amebiasis (intestinal and extraintestinal), giardiasis, and trichomoniasis (8). It is the drug of choice for treatment of the Gram-positive bacilli Cl ostri di um di ffi ci l e and in combination is an alternative therapy for Hel i cobacter pyl ori infections (9). T he common side effects exhibited with metronidazole include abdominal distress, a metallic taste, and a disulfiram-like effect if taken with alcohol. T he drug is reported to be carcinogenic in mice, possibly related to the metabolite acetamide, and as a result should not be used during the first trimester of pregnancy.

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Fig. 39.4. Metabolism of metronidazole.

P.1090

Tinidazole (Tindamax)

T inidazole has recently been approved by the U.S. Food and Drug Administration (FDA) for the treatment of amebiasis, giardiasis, and trichomoniasis. It also appears to be highly effective against Hel i cobacter pyl ori infections, although it is not approved for this use. T he drug is rapidly and completely absorbed following oral administration and can be administered with food to reduce GI disturbance. T inidazole has a mechanism of action that parallels that of metronidazole as well as a similar metabolic pathway leading to hydroxylation at the 2-methyl group catalyzed by CYP3A4. Basically, tinidazole appears to mimic the actions of metronidazole, although there are reports that it is effective against some protozoa which are resistant to metronidazole.

Nitazoxanide (Alinia)

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Nitazoxanide (NT Z) has been approved as an orphan drug for the treatment of diarrhea in children (age, 1–11 years) and is associated with giardiasis, but it also is approved for diarrhea caused by crytosporidiosis in patients with AIDS. Crytosporidiosis is a protozoal infection caused by Cryptospori di um parvum. T he condition is uncommon in healthy individuals but can be life-threatening in immunosuppressed patients and those with HIV infections.

Mechanism of action (10) Nitazoxanide is a pro-drug that is metabolically converted into the deactylated drug tizoxanide (T IZ) (Fig. 39.5). T he T IZ then undergoes a four-electron reduction of the 5-nitro group giving various short-lived intermediates, which may include the hydroxylamine derivative. It is these reduced products that represent the active form of NT Z. Whereas these intermediates would suggest that NT Z has the same mechanism of action as metronidazole, this does not appear to be the case. Nitazoxanide is thought to inhibit the enzyme pyruvate:ferredoxin oxidoreductase in Tri chomonas vagi nal i s, Entamoeba hi stol yti ca, and Cl ostri di um perfi ngens. T he results of this inhibition is disruption of the bioenergetics of these organisms. Unlike metronidazole and tinidazole, which fragment DNA and are suspected mutagenic agents, NT Z and T IZ do not cause DNA fragmentation and are not considered to be mutagenic. T his might be associated with the higher redox potential found for NT Z, a nitrothiazole, in comparison with very low redox potential found for the nitroimidazoles, such as metronidazole and tinidazole. Additional metabolites of T IZ also includes the glucuronide, which shows some biological activity, and small amounts of an aromatic hydroxylation product (Fig. 39.5).

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Fig. 39.5. Metabolic activation of nitazoxanide.

Pharmacokinetics Nitazoxanide is available as powder that is reconstituted and dispensed as an oral suspension. T he drug is well absorbed from the GI tract and rapidly metabolized, with elimination products appearing in the urine and feces. T he only identified products in the plasma are T IZ and its glucuronide (11). T he product can be taken with food.

Therapeutic application Although NT Z has only been approved for treatment of diarrhea in children caused by Gi ardi a l ambl i a and diarrhea caused by Cryptospori di um parvum, the drug may soon be approved for adults suffering from diarrhea caused Gi ardi a l ambl i a. In addition, the drug has been shown to be effective against the protozoa Entamoeba hi stol yti ca and Tri chomonas vagi nal i s, the bacteria Hel i cobacter pyl ori and Cl ostri di um perfri ngens, and various helminths, including Ascari s l umbri coi des, Enterobi us vermi cul ari s, Ancyl ostoma doudenal e, and Strongyl oi des stercoral i s (12).

Diloxanide Furoate

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Diloxanide furoate (available from the Centers for Disease Control and Prevention [CDC]) is prescribed for the treatment of asymptomatic amebiasis but is ineffective as a single agent for the extraintestinal form of the disease. T he drug is P.1091 administered orally and is hydrolyzed in the gut to give diloxanide, which is considered to be the active drug. Diloxanide is the only form identified in the bloodstream. T he drug is found in the urine as the glucuronide (Fig. 39.6).

Fig. 39.6. Metabolism of diloxanide furoate.

Treatment of Pneumocystis (13,14) Sulfamethoxazole-Trimethoprim; Cotrimoxazole (Bactrim, Septra, Cotrim) T he combination of sulfamethoxazole and trimethoprim has proven to be the most successful method for treatment and prophylaxis of pneumocystis in patients with AIDS. T his combination was first reported as being effective against PCP in 1975, and by 1980, it had become the preferred method of treatment, with a response rate of 65 to 94%. T he combination is effective against both pneumocystic pneumoni a and the extrapul monary di sease. Pneumocysti s cari ni i appears to be especi al l y suscepti bl e to the sequenti al bl ocki ng acti on of cotri mazol e, whi ch i nhi bi ts both the i ncorporati on of p-ami nobenzoi c aci d (PABA) i nto fol i c aci d as wel l as the reducti on of di hydrofol i c aci d to tetrahydrofol i c aci d by di hydrofol ate reductase (DHFR). (A detai l ed di scussi on of the mechani sm of acti on and the structure–acti vi ty rel ati onshi p of these drugs can be found i n Chapter 38.) Dependi ng on the severi ty of the i nfecti on, the combi nati on i s admi ni stered i n doses of 20 mg/kg/day of tri methopri m and 100 mg/kg/day of sul famethoxazol e i n four di vi ded doses over a peri od of 14 to 21 days. The i nci dence of si de effects of thi s combi nati on are hi gh and, general l y, refl ects the effects of the sul fa drug component. Si de effects may be si gni fi cant enough to termi nate treatment.

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Pentamidine Isethionate (Pentam 300, Nebupent)

Orphan Drug Product Daps one p lus trimethoprim als o has b een utilized f o r the tre atment of p neumoc ys tis , with ef f e c tivene s s nearly eq ual to that o f c otrimazole.

Pentamidine is available as the water-soluble isethionate salt, which is used both IV and as an aerosol. T he drug can be used via the intramuscular route, but significant complications have been reported and. therefore, this route of administration is not recommended. T he drug has fungicidal and antiprotozoal activity, but today, it is used primarily for treatment of PCP.

Mechanism of action T he mechanism of action of pentamidine is not known with certainty, but strong evidence supports various mechanisms of action for pentamidine. Pentamidine selectively binds to the DNA in trypanosoma parasite (see below). Pentamidine has also been shown to inhibit topoisomerase in Pneumocysti s cari ni i , which leads to double-strand cleavage of DNA in trypanosoma (12,13,14). It has been suggested that pentamidine's mechanism of action may be different in different organisms and, therefore, that the actions reported for trypanosoma may not carry over to pneumocystis.

Pharmacokinetics Pentamidine must be administered IV and, after multiple injections daily or on alternate days, accumulates in body tissue. Plasma concentrations were measured up to 8 months following a single, 2-hour IV infusion. T he accumulation aids in treatment as well as in prophylaxis. T he drug shows poor penetration of the CNS.

Therapeutic application Pentamidine is used as a second-line agent either by itself or in combination for the treatment and prophylaxis of PCP. For prophylaxis, the aerosol form of the drug is indicated and has minimum toxicity. T he limitation of pentamidine—that is, the need for IV administration—may be associated with the potential for severe toxicity, which includes breathlessness, tachycardia, dizziness, headache, and vomiting. T hese symptoms may occur in as many as 50% of the patients. T hese effects are thought to be associated with a too rapid IV administration, resulting in the release of histamine.

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Atov aquone (Mepron)

Atovaquone, a chemical with structural similarity to the ubiquinone metabolites, was initially synthesized and investigated as an antimalarial, a use for which it has recently gained acceptance when used in combination therapy with other antimalarial agents. T oday, its usefulness is primarily directed toward the treatment of PCP.

Mechanism of action Atovaquone is thought to produce its antiparasitic action by virtue of its ability to P.1092 inhibit the mitochondrial respiratory chain. More specifically, atovaquone is a ubiquinone reductase inhibitor, inhibiting at the cytochrome bc 1 complex (15). T his action leads to a collapse of the mitochondrial membrane potential. T he compound shows stereospecific inhibition, with the trans isomer being more active than the ci s isomer.

Pharmacokinetics Atovaquone is poorly absorbed from the GI tract because of its poor water solubility and high fat solubility, but the absorption can be significantly increased if taken with a fat-rich meal. T he drug is highly bound to plasma protein (94%) and does not enter the CNS in significant quantities. It is not significantly metabolized in humans and is exclusively eliminated in feces via the bile.

Therapeutic applications With as many as 70% of patients with AIDS developing pneumocystis and, of these, nearly 60% of the patients on cotrimoxazole developing serious side effects to this combination, atovaquone is an important alternative drug (16). Atovaquone also has been reported to be effective for the treatment of toxoplasmosis caused by Toxopl asma gondi i , although it has not been approved for this use.

Trimetrexate Glucuronate (Neutrexin)

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T rimetrexate (T MQ) has been approved for the treatment of Pneumocysti s cari ni i in patients with AIDS and also exhibits antiprotozoal activity against Trypanosoma cruzi . T he drug is available as a single-ingredient medication, but it can be administered along with folinic acid in much the same way that methotrexate is administered with calcium leucovorin in cancer chemotherapy. T rimetrexate is a derivative of methotrexate.

Mechanism of action T rimetrexate is considered to be a nonclassical folate antagonist, whereas methotrexate, the structurally similar analogue of T MQ, is a classical folate antagonist. T he difference between these two drugs is that methotrexate, with its polar glutamate side chain, is transported into the cell via a carrier-mediated transport system, whereas T MQ, without the glutamate moiety, is absorbed by the cell via a passive diffusion. Once in the cell, T MQ inhibits DHFR. T rimetrexate binds to Pneumocysti s cari ni i DHFR 1,500 times more strongly than trimethoprim and somewhat more strongly than methotrexate. It also has been reported that T MQ readily enters the P. cari ni i cell because of the lipophilic nature of this drug (17). Methotrexate and leucovorin are not able to enter the cell, however, because the cell membrane of P. cari ni i does not possess the transporter protein (17).

Therapeutic application T rimetrexate, when combined with the cytoprotective agent leucovorin, is more effective and better tolerated than pentamidine in the treatment of PCP (18). Because the first- and second-line agents are successful in only 50 to 75% of these cases, and because adverse reactions severely limit the use of some of the older agents, T MQ may offer some advantages in treatment. T rimetrexate is administered by IV infusion over 60 to 90 minutes and should be combined with the cytoprotective drug leucovorin. T he leucovorin protects against bone marrow suppression and against renal and hepatic dysfunction. Leucovorin administration should continue for 72 hours after the last dose of T MQ. Additionally, T MQ has been reported to be effective in the treatment of Chagas' disease.

Treatment of Trypanosomiasis (19) Suramin Sodium (Av ailable from the CDC)

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Introduced into therapy for the treatment of early trypanosomiasis in the 1920s, suramin, a bis-hexasulfonatednaphthylurea, is still considered to be the drug of choice for treatment of non-CNS-associated African trypanosomiasis.

Mechanism of action T he mechanism of action of suramin is unproven, but the drug is known to have a high affinity for binding to a number of critical enzymes in the pathogen. Among the enzymes to which suramin has been shown to bind are several dehydrogenases and kinases. As a result of binding, suramin has been shown to be an inhibitor of DHFR, a crucial enzyme in folate metabolism, and thymidine kinase. In addition, suramin is an inhibitor of glycolytic enzymes in Trypanosoma brucei , with binding constants much lower than those seen in mammalian cells. Inhibition of glycolysis would be expected to block energy sources of the pathogen, leading to lysis. Whether one or more of these inhibitor actions represent the toxic action of suramin on the pathogen remains unproven.

Pharmacokinetics Suramin sodium is a water-soluble compound that is poorly absorbed via oral administration and must be administered IV in multiple injections. P.1093 Because of it highly ionic nature, suramin will not cross the blood-brain barrier and, therefore, is ineffective for the treatment of trypanosomal infections that reach the CNS. In addition, suramin is tightly bound to serum albumin. Despite this binding, the drug is preferentially absorbed by trypanosomes through a receptor-mediated endocytosis of serum protein. Because the drug remains in the bloodstream for an extended period of time, suramin has value as a prophylactic drug.

Therapeutic application Seramin sodium is effective against east African trypanosomiasis, but it has limited value against west African trypanosomiasis. As indicated, because the drug will not enter the CNS, the drug is only useful for the treatment of early stages of the disease. T he drug exhibits a wide variety of

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side effects, which can be severe in debilitated individuals, and include nausea, vomiting, and fatigue.

Pentamidine, Isethionate (Pentam 300, Nebupent) First introduced as a therapy for trypanosomiasis in 1937, pentamidine is now used in a variety of protozoal and fungal infections and, as such, finds use in the treatment of trypanosomiasis, leishmaniasis, and pneumocystis (PCP). T he drug is primarily used for treatment of PCP. When used for trypanosomiasis, pentamidine is only effective against Trypanosoma brucei rhodesi ense (east African sleeping sickness) and, even then, only during the early stage of the disease,. because the drug does not readily cross the blood-brain barrier.

Mechanism of action As indicated above, several biochemical actions have been reported for pentamidine. T he drug has been shown to bind to DNA through hydrogen-bonding of the amidine proton and AT -rich regions of DNA. More specifically, pentamidine binds to the N-3 of adenine, spans four to five base pairs, and binds to a second adenine to form interstrand cross-bonding (20). In addition to and, possibly, separate from this action, pentamidine appears to be a potent inhibitor of type II topoisomerase of mitochondria DNA (kinetoplast DNA) of the trypanosoma parasite (21). T he mitochondrial DNA is a cyclic DNA. T his inhibition leads to double-stand breaks in the DNA and linearization of the DNA. T he relationship between binding to specific regions of the DNA and inhibition of topoisomerase is unclear. In the case of Trypanosoma brucei , resistant strains are common. It is thought that resistance develops through an inability of the drug to reach the mitochondrial DNA (22). T ransport into the mitochondria is a carrier-mediated process, with the absence of carrier in the resistant strains.

Eflornithine (Ornidyl)

Metcalf et al. (23) reported the synthesis of eflornithine (difluoromethyl ornithine [DFMO]) in 1978. T heir interest arose from the desire to prepare ornithine decarboxylase (ODC) inhibitors as tools for studying the role of polyamines as regulators of growth processes. Ornithine decarboxylase catalyzes the conversion of ornithine to putrescine (1,4-diaminobutane), which in turn leads to the formation of the polyamines, spermine, and spermidine. It was not until 1980 that Bacchi et al. (24) demonstrated the potential of DFMO in the treatment of trypanosomiasis.

Mechanism of action Difluoromethyl ornithine is a suicide inhibitor of ODC, a pyridoxal phosphate–dependent enzyme,

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as shown in Figure 39.7. Evidence suggests that cysteine-360 in ODC is the site of eflornithine alkylation (25). Alkylation of ODC blocks the synthesis of putrescine, the rate-determining step in the synthesis of polyamines. Mammalian ODC also may be inhibited, but because the turnover of ODC is so rapid in mammals, eflornithine does not produce serious side effects.

Pharmacokinetics Eflornithine may be administered either IV or orally. Administration IV requires large doses and frequent dosing, whereas poor oral absorption and rapid excretion because of the zwitterionic nature of the drug (an amino acid) has limited that route of administration. T he drug does not bind to plasma protein and enters the CNS readily, most likely via an amino acid transport system. As a result, the drug can be used for both early and late stages of trypanosomiasis.

Therapeutic application Eflornithine is indicated for the treatment of west African trypanosomiasis caused by P.1094 Trypanosoma brucei gambi ense but has proven to be ineffective against east African trypanosomiasis. T he cause of this ineffectiveness remains a mystery, although evidence suggests that in the resistant organism, endogenous ornithine plus increased activity of S-adenosylmethionine decarboxylase allows sufficient synthesis of spermidine and spermine to support cell division, thus bypassing the need for organism-synthesized ornithine (26). Side effects reported for eflornithine consist of anemia, diarrhea, and leukopenia.

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Fig. 39.7. Inhibition of ornithine decarboxylase (Enz-Cys-SH) by eflornithine.

Nifurtimox (Lampit)

Another of the nitroaryl compounds, nifurtimox has proven to be useful as a drug for the treatment of trypanosomiasis. It is one of two drugs approved for use in treatment of Chagas' disease.

Mechanism of action

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As discussed for metronidazole, nifurtimox is thought to undergo reduction followed by oxidation and, in the process, generate ROS, such as the superoxide radical anion, hydrogen peroxide, and hydroxyl radical (Fig. 39.3) (5). T hese species are potent oxidants, producing oxidative stress that may produce damage to DNA and lipids that may affect cellular membranes. In addition, Henderson et al. (27) have reported that nifurtimox inhibits trypanothione reductase, which results in the inhibition of trypanothione formation (93% inhibition). T rypanothione is a critical protective enzyme found uniquely in trypanosomal parasites.

Therapeutic application Nifurtimox is the drug of choice for the treatment of acute Chagas' disease. T he drug is not effective for the chronic stages of the disease. In the acute stage, the drug has an 80% cure rate. Side effects of the drug include hypersensitivity reactions, GI complications (nausea and vomiting), myalgia, and weakness.

Benznidazole (Rochagan)

Benznidazole is the second of the drugs approved for treatment of Chagas' disease. Like nifurtimox, it is effective against the circulating form of Trypanosoma cruzi during the acute phase of the disease, but also like nifurtimox, it is ineffective during the chronic stage of the disease.

Mechanism of action Studies suggest that benznidazole does not catalyze the formation of ROS and, therefore, has a mechanism of action different from that of nifurtimox. It has been proposed that benznidazole undergoes an one-electron transfer to the nitro group, which in turn dismutates to give back the nitroimidazole and a nitrosoimidazole (28). T he latter product may then undergo an electrophilic addition to trypanothione, which leads to depletion of trypanothione, an essential enzyme system in the Trypanosoma cruzi (Fig. 39.8).

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Fig. 39.8. Proposed mechanism of action of benznidazole.

Benznidazole is not available in the United States but is available in South American countries. It is administered orally in a tablet form.

Melarsoprol (Av ailable from the CDC)

Knowingly or unknowingly, arsenic-containing drugs have been used for treatment of parasitic conditions for thousands of years. In the late 1800s and early 1900s, Paul Ehrlich introduced the use of trivalent arsenicals. Melarsoprol, an organoarsenical, came into use in the late 1940s, and it remains the first-choice drug in the treatment of trypanosomiasis. Until 1990, it also was the only treatment for late-stage sleeping sickness.

Mechanism of action It is known that trivalent arsenic reacts rapidly and reversibly with sulfhydryl-containing proteins, as shown in Figure 39.9. It generally is accepted that the enzyme with which melarsoprol reacts is an enzyme involved in glycolysis, and as a result, inhibition of pyruvate kinase occurs. It is argued, however, that the inhibition may not occur at pyruvate kinase but, rather, at a step before the pyruvate kinase. Blockage of glycolysis would be expected to lead to loss of motility and cell lysis. More recently, Fairlamb et al. (29) have proposed a mechanism of action that results in the inhibition of trypanothione reductase through the formation of a stable complex between melaroprol and trypanothione. Melarsoprol P.1095 reacts with the cysteine sulfhydryl of trypanothione to form the stable adduct shown in Figure 39.10. Supportive of this mechanism is the synergistic action of melarsoprol with eflornithine (DMFO). T wo drugs that produce sequential blockage of the synthesis of trypanothione.

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Fig. 39.9. Mechanism of action of trivalent arsenic compounds with trypanosome organism.

Pharmacokinetics Melarsoprol is administered IV in multiple doses and multiple sessions. Its major metabolite in humans is the lipophilic melarsen oxide, which can penetrate into the CNS. T his metabolite apparently is responsible for the protein-binding characteristic for melarsoprol.

Fig. 39.10. Structure of melarsoprol trypanothione complex.

Therapeutic application Melarsoprol is the drug of choice for the treatment of late-stage meningoencephalitic trypanosomiasis caused by the west and east African strains of the disease. Because the drug has the potential for serious nervous system toxicities (e.g., convulsions, acute cerebral edema, and coma), the drug usually is administered in a hospital setting with supervision. An additional problem with melarsoprol is the development of resistance by the parasite.

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Treatment of Leishmaniasis Sodium Stibogluconate (Pentostam, Av ailable from the CDC)

Leishmaniasis was first described in the medical literature by Deishman and Donovan in 1903, and shortly after that, the use of antimony-based drugs were introduced as therapeutic agents to treat the condition (30). Although the structure of sodium stibogluconate is commonly drawn as shown, the actual compound probably is much more complex. T he drug is a water-soluble preparation that is administered IM or IV. Pentavalent antimony compounds are thought to inhibit bioenergetic processes in the pathogen, with catabolism of glucose and inhibition of glycolytic enzymes being the primary sites of action (glucose catabolism is inhibited by 86–94%). T his in turn results in inhibition of adenosine triphosphate (AT P)/guanosine triphosphate formation. Sodium sibogluconate is the drug of choice for the treatment of most forms of leishmaniasis (or meglumine antimonate, another pentavalent antimony agent). T he recommended dose is 20 mg antimony/kg/day, not to exceed 850 mg antimony/day. A number of other drugs have been reported to be effective in the treatment of leishmaniasis, and these include pentamidine, amphotericin B, paromomycin, alkylphosphocholine analogues, rifampicin, and ketoconazole (31,32).

Treatment of M alaria

Quinine, was the first known antimalarial. It is a 4-quinolinemethanol derivative bearing a substituted quinuclidine ring. T he use of quinine in Europe began in the seventeenth century, after the Incas of Peru informed the Spanish Jesuits about the antimalarial properties of the bark of an

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evergreen mountain tree they called quinquina (later called cinchona, after Dona Franciscoa Henriquez de Ribera [1576–1639], Countess of Chinchon and wife of the Peruvian Viceroy). T he bark, when made into an aqueous solution, was capable of curing most forms of malaria. It was listed in the London Pharmacopeia of 1677. T he alkaloid derived from it, quinine, was isolated in the mid-1820s. Quinine, a very bitter substance, has been used by millions of malaria sufferers. Recently, it has been employed successfully to treat chloroquine-resistant strains of Pl asmodi um fal ci parum and is considered to be the drug of choice for these resistant strains. A second class of chemicals that played a role in the development of synthetic antimalarials were the 9-aminoacridines. 9-Aminoacridine itself was known to exhibit antibacterial activity, whereas a derivative of 9-aminoacridine synthesized in 1934, quinacrine, was found to possess weak antimalarial activity. With the beginning of World War II and concern about an interruption in the supply of cinchona bark from the East Indies, a massive effort was begun to search for synthetic alternatives to quinine and to develop more effective antimalarial agents than quinacrine. With a basic understanding of the structure–activity relationship of quinine (see Quinine) and the chemical similarities seen with quinacrine, it is easy to visualize the relationship between these agents and the synthetic antimalarials. T he 4-aminoquinolines, chloroquine and hydroxychloroquine, are structurally similar to the right half of quinacrine (Fig. 39.11). T he 8-aminoquinolines, pamaquine and P.1096 primaquine, retain the methoxyquinoline nucleus of quinine and quinacrine (Fig. 39.12). T he quinoline-4-methanols, mefloquine and halofantrine, show similarity to the 4-quinolinemethanol portion of quinine (Fig. 39.12).

Fig. 39.11. Structural similarity between quinacrine and the 4-aminoquinolines.

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4-Substituted Quinolines Five compounds may be considered within this class of drugs: quinine, chloroquine and hydroxychloroquine, mefloquine, and halofantrine (Figs. 39.11 and 39.12). T hese compounds not only share a structural similarity but also are thought to have similar mechanisms of action, are effective on the same stage of the parasite, and may share similar mechanisms of resistance.

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Fig. 39.12. Structural similarity between quinine and the 8-aminoquinolines () and between quinine and the quinoline-4-methanols ().

Mechanism of action T he mechanism of action of chloroquine has been studied in depth, and the results of these studies have been assumed to be applicable to the other 4-substituted quinolines (33). Various mechanisms of actions have been offered to explain the action of this class of drugs, including the DNA intercalation mechanism, the weak base hypothesis, and the ferriprotoprophyrin hypothesis. T he present understanding about the mechanism of action would appear to utilize various aspects of each of these previous mechanisms. It is known that hemoglobin is transported into the food vacuoles of the plasmodium, where digestion of the hemoglobin supplies the organism with a source of amino acids. One of the products of this digestion is free heme, a substance toxic to the plasmodium cells, which in the plasmodium vacuole is polymerized to hemozoin. It has been demonstrated that the quinolines bind to hemozoin through a drug–heme complex in which the aromatic quinoline ring π-bonds to the porphyrin nucleus (34). T his drug–heme complex caps the growing hemozoin polymer, thus blocking further extension of the polymer. T he result of this complexation is that newly formed, free toxic heme is now present, which leads to the death of the plasmodium. T he accumulation of the 4-substituted quinolines in the acidic food vacuoles (pH 4.8–5.2) is based on the fact that these drugs are weak bases, as indicated by their pK a values. T he extracellular fluid of the parasite is at pH 7.4, and as a result, the weak base will move toward the more acidic pH of the vacuoles, reaching concentrations hundreds of times those in the plasma. Additionally, the binding of the quinoline to the heme draws additional quantities into the vacuole.

Mechanism of resistance A limiting factor for most of the antimalarial drugs is the development of resistant strains of plasmodium. It should be noted that resistance differs from region to region, and in some cases, a resistant strain may develop to a particular drug without that drug ever having been introduced to the region (possible cross-resistance). T he development of resistance is thought to be a spontaneous gene mutation. Several mechanisms of resistance appear to be operating. One of these mechanisms is based on the Pl asmodi um fal ci pari um chloroquine-resistance transporter (pfrcrt) mechanism, which is sufficient and necessary to impart resistance (35). A gene encodes for a transmembrane transporter protein found in the membrane of the food vacuole. Multiple mutations within a specific region this gene result in reduced accumulation of chloroquine, resulting from the increased efflux of the drug. Additional transporter proteins also may be involved in resistance. P.1097 Rapid metabolism of the antimalarials by resistant strains of plasmodium also might be considered to play a significant role in the development of resistance. It has been shown that cytochrome P450 activity parallels increased resistance to specific drugs.

Therapeutic application T he 4-substituted quinolines are referred to as rapidly acting blood schizonticides, with activity against plasmodium in the erythrocytic stage. Chloroquine is the drug of choice, but unfortunately, the incidence of chloroquine-resistance infections are extremely common today. T he spread of chloroquine resistance has reached almost all malarious areas of the world. In addition, multidrug-

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resistant and cross-resistant strains of plasmodium are now common. T he drug of choice for the treatment of malaria caused by Pl asmodi um fal ci parum, Pl asmodi um oval e, Pl asmodi um vi vax, and Pl asmodi um mal ari ae in regions infected by chloroquine-resistant P. fal ci parum is quinine, in combination with traditional antibiotics, mefloquine, or various other combinations as alternative treatment agents (T able 39.2). Of interest is the observation that after years of nonuse of chloroquine, a reemergence of chloroquine-sensitive parasites has been found. T he 4-substituted quinolines, depending on the specific drug in question, also may be used for prophylaxis of malaria. T wo types of prophylaxis are possible: causal prophylaxis, and suppressive prophylaxis. T he former prevents the establishment of hepatic forms of the parasite, whereas the latter eradicates the erythrocytic parasites but has no effect on the hepatic forms. Several of the 4-substituted quinolines are effective suppressive prophylactics.

Table 39.2. Guidelines for Treatment of Malaria in the United Statesa Clinical Diagnosis Sensitivity

Drug Recommendation

Uncomplicated malaria

Chloroquine sensitive

Chloroquine phosphate

P. falciparum

Chloroquine resistant or unknown

A. Quinine sulfate + one of the following: Doxycycline Tetracycline Clindamycin B. Atovaquone– proquanil C. Mefloquine

Uncomplicated malaria


Chloroquine phosphate


Chloroquine phosphate + Primaquine phosphate

Chloroquine resistant

A. Quinine sulfate + doxycycline, or Tetracycline + Primaquine phosphate

P. malariae Uncomplicated malaria

P. vivax or P. ovale Uncomplicated malaria P. vivax

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B. Mefloquine + Primaquine phosphate

Severe malaria

Chloroquine sensitive/resistant

Quinidine gluconate + one of the following: Doxycycline Tetracycline Clindamycin

a

Information taken from CDC Guideline for Treatment of Malaria in the United States. For more details, including infectious region and dosing, see http://www.cdc.gov/malaria/pdf/treatmenttable.pdf.

Specific 4-substituted quinolines Quin in e Quinine is the most prevalent alkaloid present in the bark extracts (~ 5%) of cinchona. Four stereochemical centers exist in the molecule (at C-3, C-4, C-8, and C-9) (Fig. 39-9). Quinine (absolute configuration of 3R:4S:8S:9R), quinidine (absolute configuration of 3R:4S:8R:9S), and their optical isomers all have antimalarial activity, whereas their C-9 epimers (i.e., the epi-series having either 3R:4S:8R:9R or 3R:4S:8S:9S configurations) are inactive. Modification of the secondary alcohol at C-9, through oxidation, esterification, or similar processes, diminishes activity. T he quinuclidine portion is not necessary for activity; however, an alkyl tertiary amine at C-9 is important. Quinine is metabolized in the liver to the 2′-hydroxy derivative, followed by additional hydroxylation on the quinuclidine ring, with the 2,2′-dihydroxy derivative as the major metabolite. T his metabolite has low activity and is rapidly excreted. T he metabolizing enzyme of quinine is CYP3A4. With the increased use of quinine and its use in combination with other drugs, the potential for drug interactions based on the many known substrates for CYP3A4 (see Chapter 10) is of concern (36). A quinine overdose causes tinnitus and visual disturbances; these side effects disappear on discontinuation of the drug. Quinine also can cause premature contractions during the late stages of pregnancy. Although quinine is suitable for parenteral administration, this route is considered to be hazardous because of its ability to cause hemolysis. Quinidine, the (+ )-isomer of quinine, has been shown to be more effective in combating the disease, but it has undesirable cardiac side effects. P.1098

Chloroqu ine (Aralen ) Chloroquine is the most effective of the hundreds of 4-aminoquinolines synthesized and tested during World War II as potential antimalarials. Structure–activity relationships demonstrated that the chloro at the 8-position increased activity, whereas alkylation at C-3 and C-8 diminished activity. T he replacement of one of its N-ethyl groups with an hydroxyethyl produced

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hydroxychloroquine, a compound with reduced toxicity that is rarely used today except in cases of rheumatoid arthritis. Chloroquine is commonly administered as the racemic mixture, because little is gained by using the individual isomers. T he drug is well absorbed from the GI tract and distributed to many tissues, where it is tightly bound and slowly eliminated. T he drug is metabolized by N-dealkylation by CYP2D6 and CYP3A4 isoforms. It has been reported that the level of metabolism correlates closely with the degree of resistance. T he suggestion has been made to coadminister chloroquine with CYP2D6 and CYP3A4 inhibitors to potentate activity and reduce resistance. Although this may be possible, it is not commonly practiced. Chloroquine is an excellent suppressive agent for treating acute attacks of malaria caused by Pl asmodi um vi vax and Pl asmodi um oval e. T he drug also is effective for cure and as a suppressive prophylactic for the treatment of Pl asmodi um mal ari ae and susceptible Pl asmodi um fal ci parum. Chloroquine generally is a safe drug, with toxicity occurring at high doses of medication if the drug is administered too rapidly via parenteral routes. With oral administration, the side effects primarily are GI effects, mild headache, visual disturbances, and urticaria.

Mefloqu in e (Lariam) (37) Mefloquine, which was synthesized with the intent of blocking the site of metabolism in quinine with the chemically stable CF 3 group, exists as four optical isomers of nearly equal activity. T he drug is active against chloroquine-resistant strains of plasmodium, yet cross-resistance is not uncommon. Metabolism is cited as the possible mechanism of resistance. Mefloquine is slowly metabolized through CYP3A4 oxidation to its major inactive metabolite, carboxymefloquine (Fig. 39.13). Most of the parent drug is excreted unchanged into the urine. Its coadministration with CYP3A4 inhibitors (e.g., ketoconazole) has increased the area under the curve for mefloquine by inhibiting its metabolism to carboxymefloquine. Mefloquine is only available in an oral dosage form, which is well absorbed. T he presence of food in the GI tract affects the pharmacokinetic properties of the drug, usually enhancing absorption. T he lipophilic nature of the drug accounts for the extensive tissue binding and low clearance of total drug, although the drug does not accumulate after prolonged administration. T he drug has a high affinity for erythrocyte membranes.

Additional Therapeutic Indications for Chloroquine Chloroq uine als o is pres c ribed f or treatment of rhe umatoid arthritis , dis c oid lup us erythemato s us , and photos e ns itivity dis eas es .

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Fig. 39.13. Plasmodium falciparum metabolism of mefloquine.

Mefloquine is an effective suppressive prophylactic agent against Pl asmodi um fal ci parum both in nonimmune populations (travelers coming into regions of malaria) and in resident populations. T he drug also has high efficacy against falciparum malaria, with a low incidence of recrudescence. T he drug is ineffective against sexual forms of the organism. T he incidence of side effects with mefloquine is considered to be high. T he effects are classified as neuropsychiatric, GI, dermatologic, and cardiovascular. T he neuropsychiatric effects may be serious (e.g., suicidal tendencies or seizures) or minor (e.g., dizziness, vertigo, ataxia, and headaches). Gastrointestinal side effects included nausea, vomiting, and diarrhea, whereas the dermatologic effects include rash, pruritus, and urticaria. Finally, cardiovascular side effects may include bradycardia, arrhythmias, and extrasystoles.

Halofan trine (Hafan ) Halofantrine (38,39), a member of the 9-phenanthrenemethanol class (Fig. 39.12), originally came out of a synthesis program dating to World War II, but this particular agent was not fully developed until the 1960s. Halofantrine has one chiral center and has been separated into its enantiomers. T here appears to be little difference between the enantiomers; thus, the drug is used as a racemic mixture. Halofantrine is considered to be an alternative drug for treatment of both chloroquine-sensitive and chloroquine-resistant Pl asmodi um fal ci parum malaria, but its efficacy in mefloquine-resistant malaria may be questionable. T he drug is metabolized via N-dealkylation to desbutylhalofantrine by CYP3A4 (Fig. 39.14). T he metabolite appears to be several-fold more active than the administered drug. At present, halofantrine is only available in a tablet form, which has significant implications as it relates to its P.1099 insolubility and drug absorption (bioavailability). Animal studies have shown that following oral administration, the drug is eliminated in feces, suggesting poor oral absorption. Its oral suspensions leads to as much as 30% lower plasma levels of the drug in comparison with the tablet. A micronized form of the drug has shown improved bioavailability. Its administration with or without food in the stomach also leads to considerable variation in plasma levels. A high lipid content in a meal taken 2 hours before dosing leads to a substantial increases in the rate and extent of absorption. Several cases of drug treatment failure appear to be related to poor absorption. Incomplete absorption and, as a result, low plasma levels, may play a role in the development of organism resistance. T he elimination half-life of halofantrine and desbutylhalofantrine tend to be prolonged, which may be another factor in the development of resistance. Low levels of the drug may increase the likelihood of augmenting the emergence of halofantrine resistance.

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Fig. 39.14. Metabolism of halofantrine.

Absorption problems with halofantrine cannot be solved by increasing the dosage of halofantrine because of significant toxicity problems. T oxicity, although minimal with short-term low doses, can be severe with high doses of halofantrine. Gastrointestinal side effects include nausea, vomiting, diarrhea, and abdominal pain. Cardiovascular toxicity include orthostatic hypotension and dose-dependent lengthening of QT c intervals.

8-Aminoquinolines Pamaquine, an 8-aminoquinoline, was first introduced for treatment of malaria in 1926 and has since been replaced with primaquine (Fig. 39.12). Primaquine is active against latent tissue forms of Pl asmodi um vi vax and Pl asmodi um oval e, and it is active against the hepatic stages of Pl asmodi um fal ci parum. T he drug is not active against erythrocytic stages of the parasite but does possess gametocidal activity against all strains of plasmodium.

Mech an ism of Action T he mechanism of action of the 8-aminoquinolines is unknown, but primaquine can generate ROS via an autoxidation of the 8-amino group. T he formation of a radical anion at the 8-amino group has been proposed by Augusto et al. (40). As a result, cell-destructive oxidants, such as hydrogen peroxide, superoxide, and hydroxyl radical, can be formed, as shown in Figure 39.3, leading to oxidative damage to critical cellular components.

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Lumef antrine is a de rivative of halof antrine that has b een reported to exhibit antimalarial ac tivity when c ombined with artemether in the tre atment of multidrug-res is tant Pl as m od i u m fa l c i pa ri um . No evid enc e of c ardio toxic ity has bee n rep orted with this c ombination, whic h may o f f er promis e f or s uc c es s f ul treatment o f res is tant organis ms .

Fig. 39.15. Metabolism of primaquine.

Metabolism Primaquine is almost totally metabolized by CYP3A4 (99%), with the primary metabolite being carboxyprimaquine (Fig. 39.15) (41). T race amounts of N-acetylprimaquine plus aromatic hydroxylation and conjugation metabolites also have been reported.

Th erapeu tic Application Primaquine is classified as the drug of choice for the treatment of relapsing vivax and ovale forms of malaria and will produce a radical cure of the condition. It is recommended that the drug be combined with chloroquine to eradicate the erythrocytic stages of malaria. Primaquine is not given for long-term treatment because of potential toxicity and sensitization. T he sensitivity appears

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most commonly in individuals who have glucose-6-phosphate dehydrogenase deficiency. In these cases, hemolytic anemia may develop.

Pyrimethamine

Pyrimethamine (Daraprim) is a potent inhibitor of DHFR (42). T he drug has been shown to have a significantly higher affinity for binding to the DHFR of plasmodium than to the host enzyme (> 1,000 times in Pl asmodi um berghei ) and, as a result, has been used to selectively treat plasmodium infections. T he combination of pyrimethamine with a long-acting sulfonamide, sulfadoxine, which blocks dihydrofolate synthesis by blocking incorporation of PABA into the dihydrofolate, is called Fansidar, which produces sequential blockage of tetrahydrofolate synthesis similar to that reported for treatment of bacterial infections (see Chapter 38). Pl asmodi um enzymes catalyzing folic acid synthesis differ from those enzymes found in other organisms. A single bifunctional protein present in Pl asmodi um sp. catalyzes the phosphorylation of 6-hydroxymethyl-7,8-hydropterin P.1100 (a pyrophosphokinase) and the incorporation of PABA into dihydropteroic acid. A second bifunctional enzyme catalyzes the reduction of dihydropteroic acid and thymidylic acid synthesis. As a result, the drug combination (Fansidar) appears to have improved drug-mediated disruption of folic acid in Pl asmodi um sp. (35,43). T his combination has been used with quinine for the treatment and prevention of chloroquine-resistant malaria (Pl asmodi um fal ci parum, Pl asmodi um oval e, Pl asmodi um vi vax, and Pl asmodi um mal ari a). T he combination therapy (Fansidar) has the added advantage of being inexpensive, which is essential for successful therapy in developing countries. When used on its own, pyrimethamine is a blood schizonticide without effects on the tissue stage of the disease. T he mechanism of resistance to the folate inhibitor combination has been shown to be associated with point mutations in both DHFR and the dihydropteroate synthase enzymes (35).

Atovaquone-Proguanil

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Atovaquone was originally developed as an antimalarial, but because of the high failure rate (~ 30%), it is not prescribed as a single chemical entity but, rather, is used to treat pneumocystis (see page 1092). More recently, however, atovaquone has been combined with proquanil as an effective prophylactic and therapeutic antimalarial (35). T he two drug together (Malarone) exhibit synergy in which proguanil reduces the effective concentration of atovaquone needed to damage the mitochondrial membrane and atovaquone increases the effectiveness of proguanil but not its active metabolite (for the mechanism of action of atovaquone, see page 1091). Proguanil was developed decades earlier as a folic acid antagonist and functions as a pro-drug. T he active form of proguanil is cycloguanil, which acts as a DHFR inhibitor (Fig. 39.16). Later, this discovery led to the development of pyrimethamine. Resistance to atovaquone used as a monotherapy may have been associated with the pharmacokinetics of the drug. Atovaquone is quite lipophilic and has slow uptake, resulting in the pathogen experiencing low concentrations of the drug over an extended period of time, both of which encourage the development of resistance. A single-point mutation appears to be sufficient for resistance (44). T o date, resistance to the combination has not been reported.

Fig. 39.16. Activation of proguanil leading to cycloguanil.

Artemisinins (45,46,47,48)

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T he most recent additions to the drug therapy for malaria are artemisinin and its derivatives. Isolated from Artemi si a annua (qinghao, sweetworm wood), this material has been used by Chinese herbalists since 168 BC. Artemisinin and the synthetic and semisynthetic derivatives, artemether, arteflene, and artesunate, are active by virtue of the endoperoxide.

Mech an ism of Action T he artemisinins appear to kill the parasite by a free radical mechanism—not by the generation of ROS but, rather, by virtue of a free radical associated with the endoperoxide, possibly involving a carbon radical. Evidence points toward activation of the endoperoxide via an iron-dependent mechanism. T he resulting free radical selectively targets sarcoplasmic/endoplasmic reticulum Ca 2+ -AT Pase of the Pl asmodi um fal ci parum (PfAT P6), altering calcium stores (49). T he artemisinins actually may form covalent adducts to specific membrane-associated proteins after concentrating in infected erythrocytes.

Therapeutic application T he artemisinins are hydrophobic in nature with the exception of artesunate, which is available as a water-soluble hemisuccinate salt, and are partitioned into the membrane of the plasmodium. T hese compounds have gametocytocidal activity as well as activity against all asexual stages of the parasites. T hese agents are short acting, with relatively short half-lives. Little or no crossresistance has been reported, with the drugs rapidly clearing the blood of parasites. T he drugs have limited availability in the United States, but they are being utilized elsewhere as commercial or experimental agents, often in combination therapy. Combination therapy has the goal of reducing resistance with the hope for synergism and, when combined with longer-acting drugs, P.1101 an improved therapy. Among the combinations reportedly used are artesunate–fosmidomycin, artemether–lumefantrine (Coartem), amodiaquine–artesunate, chloroquine–artemisinin, and artesunate–sulfadoxine–pyrimethamine (50). T hese combinations are referred to as artemisinin-based combination therapy (ACT ). T hese ACT s have been reported to show cure rates

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of greater than 90%. T he fixed-dose combination Coartem has been used in more than 10 million treatments, with significant increases being forecast.

Helm inth Infections Helminthiasis, or worm infestation, is one of the most prevalent diseases—and one of the most serious public health problems—in the world. Many worms are parasitic in humans and cause serious complications. Hundreds of millions (if not billions) of human infections by helminths exist worldwide, and with increased world travel and immigration from developing countries, one might expect to see this pattern of infection continue. It is estimated that one-fourth of the world population may be infected. It is interesting to note that helminths differ from many other parasites in that these organisms multiply outside of the definitive host and have the unique ability to evade host immune defenses for reasons that are not fully understood. As a result, helminth infections tend to be chronic, possibly lasting for the entire lifetime of the host (for a discussion of the uniqueness of helminth infections, see Maizels et al. in Suggested Readi ngs). Helminths that infect human hosts are divided into two categories, or phyla: Platyhelminths (flatworms), and Aschelminths or nematodes (roundworms). T he flatworms include the classes Cestode (tapeworms) and T rematode (flukes or schistosomes). T he nematode class includes helminths common to the United States: roundworm, hookworm, pinworm, and whipworm. T hese worms are cylindrical in shape, with significant variations in size, proportion, and structure.

Nematode Infections Ancylostomiasis or Hookworm Infection T he two most widespread types of hookworm in humans are the American hookworm (Necator ameri canus) and the “ Old World” hookworm (Ancyl ostoma doudenal e). T he life cycles of both are similar. T he larvae are found in the soil and are transmitted either by penetrating the skin or being ingested orally. T he circulatory system transports the larvae via the respiratory tree to the digestive tract, where they mature and live for 9 to 15 years if left untreated. T hese worms feed on intestinal tissue and blood. Infestations cause pulmonary lesions, skin reactions, intestinal ulceration, and anemia. T he worms are most prevalent in regions of the world with temperatures of 23 to 33°C, abundant rainfall, and well-drained, sandy soil.

Enterobiasis or Pinworm Infection (Enterobius Vermicularis) T hese worms are widespread in temperate zones and are a common infestation of households and institutions. T he pinworm lives in the lumen of the GI tract, attaching itself by the mouth to the mucosa of the cecum. Mature worms reach 10 mm in size. T he female migrates to the rectum, usually at night, to deposit her eggs. T his event is noted by the symptom of perianal pruritus. T he eggs infect fingers and contaminate nightclothes and bed linen, where they remain infective for up to three weeks. Eggs resist drying and can be inhaled with household dust to continue the life cycle. Detection of the worm in the perianal region can be accomplished by means of a cellophane tape swabbed in the perianal region in the evening. T he worms may be visible with the naked eye. T he eggs can be collected in a similar manner but can only be seen under a microscope.

Ascariasis or Roundworm Infections (Ascaris lumbricoides) T hese roundworms are common in developing countries, with the adult roundworm reaching 25 to 30 cm in length and lodging in the small intestine. Some infections are without symptoms, but abdominal discomfort and pain are common with heavy infestation. Roundworm eggs are released into the soil, where they incubate and remain viable for up to 6 years. When the egg is ingested, the larvae are released in the small intestine, penetrate the intestinal walls, and are carried via the blood to the lungs. T he pulmonary phase of the disease lasts approximately 10 days, with the

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larvae passing through the bronchioles, bronchi, and trachea before being swallowed and returning to the small intestine. Some patients have reported adult worms exiting the esophagus through the oral cavity, and it is not unusual for live ascaris to be expelled with a bowel movement. Poor or lacking sanitary facilities expose the population to infestation through contaminated foods and beverages.

Trichuriasis or Whipworm Infections (Trichuris trichiura) Infections by this parasite are caused by swallowing eggs from contaminated foods and beverages. T he eggs are passed with the feces from an infected individual. T hese eggs may live in the soil for many years. T he ingested eggs hatch in the small intestine, and the larvae embed in the intestinal wall. T he worms then migrate to the large intestine, where they mature. Adult worms, which reach approximately 5 cm in length, thread their bodies into the epithelium of the colon. T hey feed on tissue fluids and blood. Infections from this worm cause symptoms of irritation and inflammation of the colonic mucosa, abdominal pain, diarrhea, and distention. Infections can last 5 or more years if not treated. Whipworm infections are commonly seen in individuals returning from visits to the subtropics and are more common in rural areas of the southeastern United States.

Trichinosis or Trichina Infection (Trichinella spiralis) Tri chi nel l a spi ral i s produces an infection that may be both intestinal and systemic. T he worm is found in muscle P.1102 meat, where the organism exists as an encysted larvae. T raditionally, the worm has been associated with domestic pork that feeds on untreated garbage. More recently, outbreaks have occurred in individuals eating infected game, such as wild boar, bear, or walrus. T richinosis infections are more likely to occur after consumption of homemade pork or wild-game sausages. After ingestion, the larvae are released from the cyst form and then migrate into the intestinal mucosa. After maturation and reproduction, the newly released larvae penetrate the mucosal lining and are distributed throughout the body, where they enter skeletal muscle. During the adult intestinal stage, diarrhea, abdominal pain, and nausea are the most common symptom, whereas the muscular form of the disease has symptoms that may include muscle pain and tenderness, edema, conjunctivitis, and weakness.

Filariasis T he term “ filariasis” denotes infections with any of the Filarioidea, although it is commonly used to refer to lymphatic-dwelling filariae, such as Wuchereri a bancrofti , Brugi a mal ayi , and Brugi a ti mori . Other filarial infections include Loa l oa and Onchocerca vol vul us. T he latter two are known as the eyeworm and the river blindness worm, respectively. Elephantiasis is the most common disease associated with filariasis. T hese parasites vary in length from 6 cm for brugia to 50 cm for onchocerca. T he incubation periods also vary from 2 months for brugia to 12 months for bancroftian filaria. It is estimated that 400 million persons are infected with human filarial parasites. Depending on the specific organism, various intermediate hosts are involved in spreading the infection. Mosquitoes are involved with the spread of Wuchereri a bancrofti , Brugi a mal ayi , and Brugi a ti mori , whereas the female blackfly spreads river blindness. T he larvae released by the female filaria are referred to as microfilariae and commonly may be found in the lymphatics.

Cestode and Trematode Infections Cysticercosis or Tapeworm Infection Helminths of this class that are of concern as potential parasites in humans include:

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Be e f tape w orm (Taenia saginata). T his worm is found worldwide and infects people who eat undercooked beef. T he worm reaches a length of more than 5 m, and it contains approximately 100 segments/m. Each of these segments contains its own reproductive organs. Pork tape w orm (Taenia solium). Pork tapeworms sometimes are called bladder worms and occasionally are found in uncooked pork. T he worm attaches itself to the intestinal wall of the human host. T he adult worm reaches 5 m in length and, if untreated, survives in the host for many years. Dw arf tape w orm (Hymenolepis nana). T his infection is transmitted directly from one human to another without an intermediate host. Hymenol epi s nana reaches only 3 to 4 cm in length. It is found in temperate zones, and children are most frequently infected. Fish tape w orm (Diphyllobothrium latum). T he fish tapeworm reaches a length of 10 m and contains approximately 400 segments/m. T hese tapeworms attach themselves to the intestinal wall and rob the host of nutrients. T hey especially absorb vitamin B 12 and folic acid. Depletion of these critical nutrients, especially vitamin B 12 , can lead to pernicious anemia. T apeworm eggs are passed in the patient's feces, and contamination of food and drink may result in transmission of the infection.

Schistosomiasis or Blood Flukes T hree primary trematode species cause schistosomiasis in humans: Schi stosoma hematobi um, Schi stosoma mansoni , and Schi stosoma japoni cum. Infections result from the penetration of normal skin by living (free-swimming) cercaria (the name given to the infectious stage of the parasite) with the aid of secreted enzymes. T he cercaria develop to preadult forms in the lungs and skin. T hen, these parasites travel in pairs via the bloodstream and invade various tissues. T he adult worm reaches approximately 2 cm in length. T he female deposits her eggs near the capillary beds, where granulomas form. Some of the eggs will move into the lumen of the intestines, bladder, or ureters and are released into the environmental surrounding, where the parasite will seek out the intermediate snail vector. Asexual reproduction occurs in the snail. After a period of time, the cercaria are again released from the snail to continue the cycle. T he patients might experience headache, fatigue, fever, and GI disturbances during the early stages of the disease. Hepatic fibrosis and ascites occur during later stages. Untreated patients can harbor as many as 100 pairs of worms. Untreated worms can live 5 to 10 years within the host. It is estimated that as many as 200 million persons worldwide are infected with schistosomes. Depending on the species of schistosome, the disease is found in parts of South America, the Caribbean Islands, Africa, and the Middle East.

Drug Therapy for Helminth Infections (51) Helminths represent a biologically diverse group of parasitic organisms differing in size, life cycle, site of infection (local and systemic), and susceptibility to chemotherapy. With such variation in infectious organisms, it is not surprising that the drugs used to control helminth infections also represent a varied group of chemical classes. As indicated in T able 39.3, the drugs may have fairly narrow spectra of activity (pyrantel pamoate) or a broad spectra of activity (benzimidazoles).

Benzimidazoles T he benzimidazoles (T able 39.4) are a broad-spectrum group of drugs discovered in the 1960s with activity against GI helminths. Several thousand benzimidazoles have been synthesized and screened for anthelmintic P.1103

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activity, with albendazole, mebendazole, and thiabendazole representing the benzimidazole marketed today. T he development and chemistry of this class of agents has been reviewed by T ownsend and Wise (52).

Table 39.3. Therapeutic Application of Anthelmintics for Specific Helminth Infections

Mechanism of action T wo mechanisms have been proposed to account for the action of the benzimidazoles. Fumarate reductase is an important enzyme in helminths that appears to be involved in oxidation of NADH to NAD. T he benzimidazoles are capable of inhibiting fumarate reductase (53). Inhibition of fumarate reductase ultimately uncouples oxidative phosphorylation, which is important in AT P production.

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Table 39.4. Benzimidazole Anthelmintics

A second mechanism and, probably, the primary action of the benzimidazoles is associated with the ability of these drugs to bind to the protein tubulin and, thus, prevent tubulin polymerization to microtubules (54,55). T ubulin is a dimeric protein that is in dynamic equilibrium with the polymeric microtubules. Binding to the tubulin prevents the self-association of subunits and creates a “ capping” of the microtubule at the associating end of the microtubule. T he microtubulin continues to dissociate from the opposite end, with a net loss of microtubule length. What is interesting is the unique selectivity of the benzimidazoles. It has been shown that benzimidazole also can bind to mammalian tubulin, but when used as anthelmintics, these drugs are destructive to the helminth, with minimal toxicity to the host. It has been suggested that the selectivity is associated with differing pharmacokinetics between binding to the two different tubulin proteins.

Metabolism T he benzimidazoles have limited water solubility and, as a result, are poorly absorbed from the GI tract (a fatty meal will increase absorption). Poor absorption may be beneficial, because the drugs are used primarily to treat intestinal helminths. T o the extent that the drugs are absorbed, they undergo rapid metabolism in the liver and are excreted in the bile (Fig. 39.17) (56,57). In most cases, the parent compound is rapidly and nearly completely metabolized with oxidative and hydrolytic processes predominating. T he Phase I oxidative reaction commonly is a cytochrome P450–catalyzed reaction, which may then be followed by a Phase II conjugation.

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Fig. 39.17. Metabolism of benzimidazoles.

P.1104 Albendazole is unique in two ways. First, the presence of a thioether substituent at the five position increases the likelihood of sulfur oxidation. Second, the initial metabolite, albendazole sulfoxide, is a potent anthelmintic. T his initial oxidation is catalyzed principally (70%) by CYP3A4 and CYP1A2 and(30%) by flavin-containing monooxygenase, giving rise to a compound that is bound to plasma protein. T his intermediate has an expanded utility in that it has been shown to be active against the hydatid cyst found in echinococciasis, a tapeworm disease (58). Further oxidation by cytochrome P450 leads to the inactive sulfone. Additional metabolites of the sulfone have been reported that include carbamate hydrolysis to the amine and oxidation of the 5-propyl side chain. T hese reactions occur only to a minor extent. Metabolism of mebendazole occurs primarily by reduction of the 5-carbonyl to a secondary alcohol, which greatly increases the water solubility of this compound. An additional Phase I metabolite resulting from carbamate hydrolysis has been reported as well. Both the secondary alcohol and the amine are readily conjugated (a Phase II metabolism). Evidence would suggest that the anthelmintic activity of mebendazole resides in the parent drug and none of the metabolites. T hiabendazole is metabolized through aromatic hydroxylation at the five position catalyzed by CYP1A2. T he resulting phenol is conjugated to 5-hydroxythiabendazole glucuronide and 5-hydroxythiabendazole sulfate, respectively. T he initial metabolite, along with minor amount of N 1 -methylthiabendazole (from a methylation Phase II reaction), have been reported to be teratogenic in mice and rats.

Therapeutic application

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As indicated in T able 39.3, mebendazole and albendazole have a wide spectrum of activity against intestinal nematodes. T he drugs are useful and effective against mixed infections. T he adverse reactions commonly are GI in nature (nausea, vomiting, and diarrhea). Both drugs have been reported to be teratogenic in rats and, therefore, should not be used during the first trimester of pregnancy. A third drug of this class is thiabendazole, which remains of some value in treatment of strongyloidiasis, as an alternate drug, and cutaneous larva migrans (creeping eruption), for which it is the drug of choice. T hiabendazole commonly is used in veterinary medicine. T he drug is less commonly used because of associated toxicity. T hiabendazole has been reported to cause Stevens-Johnson syndrome and has the potential for hepatotoxicity and crystalluria.

Diethylcarbamazine (Hetrazan)

Discovered in the 1940s, diethylcarbamazine (DEC) has proven to be especially effective as a filaricidal agent. T he incidence of filariasis among American troops during World War II necessitated a search for drugs with an antifalarial spectrum of activity. T he once-popular piperazine also was discovered during these initial screenings. Although chemically similar, the activity again helminths is quite different. Piperazine is active against nematodes, whereas DEC is active against falaria and microfalaria (59).

Mechanism of action Although studied extensively, the mechanism of action of DEC remains unknown. Diethylcarbamazine appears to be the active form of the drug, with a very rapid onset of action (within minutes), but of interest is the fact that the drug is inactive in vitro, suggesting that activation of a cellular component is essential to the filaricidal action. T hree mechanisms have been suggested. T he first is involvement of blood platelets triggered by the action of filarial excretory antigens. A complex reaction is thought to occur between the drug, the antigen, and platelets (60). Although these authors were unable to show a direct action of the drug on the microfalaria, a more recent study showed that DEC produced morphological damage to the microfalaria. T he damage consisted of the loss of the cellular sheath, exposing antigenic determinants to immune defense mechanisms. Severe damage then occurred to microfalaria organelles, leading to death (61). T he second is inhibition of microtubule polymerization and disruption of preformed microtubules (62). T he third is interference with arachidonic acid metabolism (63). Diethylcarbamazine is known to have anti-inflammatory action, which appears to involve blockage at cyclooxygenase and leukotriene A4 synthase (leukotriene synthesis). T his action appears to alter vascular and cellular adhesiveness and cell activation. T his latter action would suggest a possible relationship between the first and third mechanism.

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Metabolism T he metabolism of DEC leads to the compounds shown in Figure 39.18 plus trace amounts of methylpiperazine and piperazine. Nearly all of the metabolites appear in the urine. As much as 10 to 20% of the drug is excreted unchanged. As indicated by the rapid action of the drug, it would appear that none of the metabolites are involved in the therapeutic action of DEC.

Therapeutic application Diethylcarbamazine citrate is freely soluble in water, is rapidly absorbed, and is effective against microfalariae. T he drug does not appear to be effective against the adult worm. In general, the drug has mild adverse effects, but under some conditions, it P.1105 may produce serve adverse reactions, including anaphylactic reactions, intense pruritus, and ocular complications (64). T he severe anaphylactic reaction is known as the Mazzotti reaction, and it appears to be an immune response related to the presence of dead microfilariae. T his reaction is more common in individuals who have a high-load microfilarial infection, and it may preclude the use of DEC in some patient populations (51).

Fig. 39.18. Metabolism of diethylcarbamazine (DEC).

Iv ermectin (Mectizan)

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Extracted from the soil actinomycete Streptomyces avermi ti l i s, the natural avermectins are 16-membered macrocyclic lactones that, on reduction of the C 22- 23 double bond, give rise to ivermectin (IVM), which is an 80:20 mixture of dihydroavermectin B 1α and B 1β , respectively. T he natural avermectins have minimal biological activity, but IVM has proven to be quite beneficial in the treatment of various nematode infections.

Mechanism of action T wo mechanisms of action are thought to be involved in the action of IVM (51,65). T he first is an indirect action in which motility of microfalaria is reduced, which in turn allows cytotoxic cells of the host to adhere to the parasite, resulting in elimination from the host. T his action may occur by virtue of the ability of IVM to act either as a γ-aminobutyric acid (GABA) agonist or as an inducer of chloride ion influx, leading to hyperpolarization and muscle paralysis. T he chloride ion influx appears to be the more plausible mechanism (66). Recently, it has been shown that IVM binds irreversibly to the glutamate-gated chloride channel of the nematode Haemonchus contortus, whereas the channel is in an open conformation. T he binding then remains locked in the open conformation, allowing ions to cross the membrane, leading to the paralytic action of IVM (67). T he result of this action is a rapid decrease in microfilarial concentrations. A second action of IVM leads to the degeneration of microfilariae in utero. T his action would result in fewer microfilariae being released from the female worms, and it occurs over a longer period of time. T he presence of degenerated microfilariae in utero prevents further fertilization and production of microfilariae.

Metabolism Ivermectin is rapidly absorbed, is bound to a great extent to plasma protein, and is excreted in the urine or feces either unchanged or as the 3′-O-demethyl-22,23-dihydroavermectin B 1α or as the dihydroavermectin B 1α monosaccharide. T he absorption of IVM is significantly affected by the presence of alcohol. Administration of IVM as an alcoholic solution may result in as much as a 100% increase in absorption.

Therapeutic application Although IVM has activity against a variety of microfalaria, including Wuchereri a bancrofti , Brugi a mal ayi , Loa l oa, and M ansonel l a ozzardi , as well as activity against Strongyl oi des stercoral i s, the drug is used primarily in the treatment of onchocerciasis (African river blindness) caused by Onchocerca vol vul us. It is estimated that 20 million people are affected by this condition and an

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additional 123 million are at risk of the infection. T he drug is effective against both the eyeworm as well as skin infections of O. vol vul us. Ivermectin has the distinct advantage over DEC in that IVM can be used as a single dose (150 µg/kg) once a year (although there is support for dosing every 6 months), has far less likelihood of causing the potentially fatal anaphylactic reaction (Mazzotti reaction), and can be used for mass treatment programs.

Praziquantel (Biltricide)

Praziquantel (PZQ) is an isoquinoline derivative with most of the biological activity found in the levo enantiomer. T he compound has no activity against nematodes, but it is highly effective against cestodes and trematodes.

Mechanism of action More than one mechanism of action may exist for PZQ, possibly depending on the type of parasite being treated. T he mechanism of action appears to involve Ca 2+ redistribution either directly or indirectly. In the case of helminths found in the lumen of the host (cestode infection), the drug leads to muscle contraction and paralysis, leading in turn to worm expulsion. Additionally, PZQ has been shown to inhibit phosphoinositide metabolism, which by an undetermined mechanism leads to the worm paralysis (68). With intravascular-dwelling schistosomes, PZQ leads to drug-induced damage of the tegument of the worm. As a result, antigens in the helminth are subject to attack by immune antibodies of the host (69,70). An antigen–antibody immunological reaction leads to the death of the parasite. Finally, PZQ affects glycogen content and energy metabolism (71,72).

Metabolism Praziquantel is rapidly absorbed and undergoes hepatic first-pass metabolism. T he metabolites are P.1106 either less active or inactive and consist of hydroxylated compounds. In the serum, the major metabolite appears to be the monohydroxylated 4-hydroxycyclohexylcarboxylate, whereas in the urine, 50 to 60% of the initial PZQ exists as dihydroxylated products (Fig. 39.19) (73). T hese hydroxylation reactions are catalyzed by CYP2B6 and CYP3A4. T he metabolites would be expected to exist in the conjugated form in the urine.

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Fig. 39.19. Metabolism of praziquantel (PZQ).

Therapeutic application PZQ is the drug of choice for treatment of schistosomiasis and liver flukes (trematode and cestode infections). T he drug is stage specific, with activity against the invasive stages, which includes the cercariae and young schistosomula and the mature worms, but not against the liver stages. Although an approved drug, PZQ is considered to be an investigational drug by the U.S. FDA in the treatment of schistosomiasis and liver flukes. T he drug has a bitter taste and, therefore, should not be chewed. T he side effects usually are not severe and consist of abdominal discomfort (pain and diarrhea). Mounting evidence suggests that resistance may become a significant problem.

Oxamniquine (Mansil, Vansil)

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Oxamniquine was originally investigated in the 1960s and was found to have limited antiprotozoal activity, with activity against Schi stosoma mansoni but no activity against the other two schistosomal organisms. In addition, the drug is stage specific, with activity against cercariae and very young schistosomula and adult worms. For reasons that remain unknown, the drug is more effective against adult male worms than against female worms. T he drug has structural similarity to hycanthone, which is no longer used because of severe toxicity and teratogenic effects.

Mechanism of action Oxamniquine is activated via esterification to a biological ester that spontaneously dissociates to an electrophile, which alkylates the helminth DNA, leading to irreversible inhibition of nucleic acid metabolism (Fig. 39.20) (72). Resistant helminths do not esterify oxamniquine; therefore, activation does not occur. Other metabolic reactions consist of oxidative reactions, leading to inactivation (Fig. 39.20). T he metabolites are excreted primarily in the urine.

Therapeutic application Oxamniquine is readily absorbed following oral administration and has a relatively short half-life. T he drug has been highly effective against Schi stosoma mansoni native to Brazil, where it is marketed under the trade name Mansil. It also is beneficial against West African S. mansoni and is supplied under the trade name Vansil. Side effects are minimal, with transient dizziness being reported. T he major drawback is high cost. Encouraging outcomes have been reported with the combination of oxamniquine and PZQ.

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Fig. 39.20. Metabolism of oxamniquine accounting for the mechanism of action and inactivation.

P.1107

Pyrantel Pamoate (Antiminth)

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Pyrantel was first reported for its anthelmintic activity in 1966 (74). Although it has activity against most intestinal roundworm infections, it has not been approved by the U.S. FDA for several of these infestations. It is considered to be the drug of choice in the treatment of pinworms. T he drug is used as the pamoate salt, which is quite insoluble and, as a result, is not readily absorbed. T his property improves the usefulness of the drug for treatment of intestinal helminths. In addition to its value in treating enterobiasis, the drug is effective for hookworm and roundworm (ascariasis) infections. Pyrantel acts as a depolarizing neuromuscular blocking agent that activates nicotinic receptors and inhibits cholinesterase, ultimately leading to worm paralysis.

Ectoparasitic Infections T wo parasitic organisms that cause common topical infections are Sarcoptes scabi ei , which is responsible for scabies, and Pedi cul us humanus, which is responsible for lice infections.

Scabies Scabies, commonly referred to as the “ seven year itch,” is a condition caused by Sarcoptes scabi ei , or the itch mite. T he condition commonly is spread by direct, person-to-person contact, although the organism is capable of living for 2 to 3 days in clothing, bedding, or house dust. Sharing of clothing is a common means whereby the condition spreads. T he organism burrows into the epidermis, usually in the folds of the skin of the fingers, the elbows, female breast, penis, scrotum, and buttocks. T he female parasite lays eggs in the skin, which then hatch and mature to adults. T he itch mite can live for 30 to 60 days. T he infections are most common in children, but they also may be found in adults in institutional settings. T he primary symptom of severe itching may foster secondary infections at the site of scratching. Because of the potential for spread to other members of a family, it is common to treat all members of the family. T his will prevent reinfection from a second family member after successful therapy of the first family member.

Lice Pediculosis or lice is caused by any of the parasites Pedi cul us humanus capi ti s, the head louse; Pedi cul us humanus corpori s, the body louse; or Phthi ri us pubi s, the crab louse (found in the genital area). Lice are bloodsucking insects that live for 30 to 40 days on the body of the host. T he organisms reproduce, and the female lays her eggs, the nits, which become attached to hair. T he nits are white in color and hatch in 8 to 10 days. For the parasite to live, it must feed on blood, which it sucks through punctures in the skin. A hypersensitivity reaction occurs at these puncture sites, which then leads to pruritus, host scratching, and possible secondary infection. In addition to the scalp and skin, the eyebrows, eyelids, and beard may become sites of infection. T he transfer of infection can occur through person-to-person contact and from infected clothing,

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on which the organism can survive for up to 1 week. T he sharing of clothing is a common means for the spread of body lice. Head lice are quite common among children in grade school, whereas crab lice are common among individuals who are sexually active. T reatment of family members is recommended, and clothing and bed linen should be removed and washed in very hot water.

Drug Therapy for Scabies and Pediculosis Lindane (Kwell)

Chlorination and reduction of benzene leads to a mixture of hexachlorocyclohexanes. T he insecticidal activity resides primarily in the γ-isomer of hexachlorocyclohexane (γ-benzene hexachloride). T he compound is thought to produce its insecticidal action by virtue of a CNS stimulatory action that occurs by blockage of GABA. T he compound is readily absorbed through the chitinous exoskeleton of the parasite. Unfortunately, lindane also is readily absorbed through intact human skin, especially the scalp, and has the potential for systemic neurotoxicity in the host. Infants and children and, possibly, the elderly are most prone to the neurotoxic effects of the drug. Because the lindane is quite lipophilic and, is applied to the scalp as a shampoo, it may be absorbed where upon it can readily enter the CNS of the patient producing signs of neurotoxicity (convulsions, dizziness, clumsiness, and unsteadiness). T he drug is available in a lotion and a shampoo and is recommended for the treatment of both pediculosis and scabies. When using the lotion topically, it should be applied to dry skin, covering the entire surface and being left in place for 8 hours. T he lindane then should be removed by washing thoroughly. If the shampoo is used for Pedi cul osi s capi ti s, the hair should be cleaned of oil and dried before application of the lindane shampoo. T he shampoo is then worked into the hair and scalp, being applied in such a way as to prevent other parts of the body from coming into contact with the drug. After approximately 4 minutes, the drug is removed by washing with P.1108 water, and the hair is dried and then combed with a fine-toothed comb to remove nits.

Pyrethrum and Pyrethroids T he naturally occurring pyrethrums have been used as insecticides since the 1800s. T hese compounds are extracted from the flowering portion of the Chrysanthemum plant. T he flowers produced in Kenya have, on average, 1.3% pyrethrins. T hese pyrethrum extracts are a major agricultural product for that country.

Chemistry T he Chrysanthemum extract is a mixture of ester consisting of the acids chrysanthemic and

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pyrethric and the alcohols pyrethrolone and cinerolone (Fig. 39.21). T he esters are prone to hydrolysis and oxidation and, as a result, should be stored in the cold and protected from light. Because of the high cost, limited availability, and rapid degradation, synthetic derivatives have been investigated. T he result has been the preparation of pyrethroids, the synthetic derivatives of pyrethrins. T he compound used therapeutically is permethrin, which exists as a 60:40 mixture of trans:ci s isomers.

Mechanism of action (75,76,77,78) T he pyrethrins and pyrethroids (permethrin) are nerve membrane sodium channel toxins that do not affect potassium channels. T he compounds bind to specific sodium channel proteins and slow the rate of inactivation of the sodium current elicited by membrane depolarization and, as a result, prolong the open time of the sodium channel. At low concentrations, the pyrethroids produce repetitive action potentials and neuron firing; at high concentrations, the nerve membrane is depolarized completely and excitation blocked. T he receptor interaction of the pyrethrums with the sodium channel complex is stereospecific and dependent on the stereochemistry of the carboxylic acid. In the case of the pyrethroids, the most active isomers are the 1R,3-ci s- and 1R,3-trans-cyclopropanecarboxylates. T he 1S-ci s- and -trans-isomers are inactive and actually are antagonists to the action of the 1R-isomers.

Fig. 39.21. Structures of pyrethrum and pyrethroid.

Metabolism A property that enhances the usefulness of the pyrethrums and pyrethroids is that these compounds are highly toxic to the ectoparasites but relatively nontoxic to mammals if absorbed. T he apparent lack of toxicity is associated with the rapid metabolism of these drugs through

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hydrolysis and or oxidation (Fig. 39.22) (79,80). T he nature of the metabolism (i.e., hydrolysis versus oxidation) is dependent on the structure of the pyrethrins or pyrethroids. Oxidation of the trans-methyl of the isobutylene in the carboxyl moiety initially gives an alcohol, which then proceeds to the carboxylic acid, whereas epoxidation of the terminal alkene of the alcohol portion of pyrethrin I gives either the 1,2-diol or the 1,4-diol. No ester hydrolysis is reported. Permethrin is hydroxylated on the terminal aromatic ring at either the 4- or 2-position, is oxidized on the methyl group of the dimethylcyclopropane, and is hydrolyzed at the ester moiety. T he rapid breakdown of these agents also accounts for their low persistence in the environment.

Therapeutic application Pyreth rins (A-200, RID) Because of the high cost and rapid degradation of the pyrethrins, they usually are combined with piperonyl butoxide, a synergist (Fig. 39.21). Piperonyl butoxide has no insecticidal activity in it own right but is thought to inhibit the cytochrome P450 enzyme of the insect, thus preventing an oxidative inactivation of the pyrethrins by the parasite. T he combination is used in a 10:1 ratio of piperonyl butoxide to pyrethrins. T he mixture is used for treatment of Pedi cul us humanus capi ti s, Pedi cul us humanus corpori s, and Phthi ri us pubi s. Various dosage forms are available, including a gel, shampoo, and topical solution. P.1109

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Fig. 39.22. Metabolism of pyrethrin I and permethrin.

Permethrin (Nix-1% lotion , Elimite-5% Cream) Permethrin, because of its increased stability and its availability synthetically, is not used with a synergist. T he compound is used in a 1% lotion for the treatment of pediculosis capitis and in a 5% cream as a scabicide.

Crotamiton

Crotamiton is available as a 10% cream for the treatment of scabies, although it is less effective than pyrethrins or permethrin (81,82). Because crotamiton may need to be applied a second time for successful treatment of scabies but the pyrethrins or permethrin require a single application, poor patient compliance with crotamiton may reduce its effectiveness. T he advantage of crotamiton over lindane comes from the fact that lindane has potential neurotoxicity if absorbed especially in infants and children, whereas crotamiton has less systemic neurotoxicity. T he most common side effect reported for crotamiton is skin irritation. P.1110

Case Study Victor ia F. Roch e S. William Zito CQ is a s trap ping , 6-f oot, 62-year-old, Cauc as ian male who pres ents to the emerge nc y room with c omplaints of abdominal dis tention, f latulenc e, inte rmittent ab dominal c ramping, and diarrhe a. I n addition, he s ays he has not had his c us tomary energy e ver s inc e he c ame bac k f ro m a f is hing trip to the Great L akes . On f urther inq uiry, CQ reveals that he is an avid f ly f is herman and has had great s uc c es s in c atc hing a “ trophy” s almo n on lig ht tac kle . Although he ge nerally p rac tic es c ons ervation by re leas ing the f is h he c atc hes , he re c alls that on one oc c as ion, he kep t a f is h s o that the c o ok at the res ort he was s taying at c ould te ac h him how to make his s pe c ialty of Sc andinavian f is h balls . To ge t the tas te jus t right, CQ re c alls that he had to tas te the mixture bef ore he c oo ked it. Hearing this , the phys ic ian s us p ec ts that CQ may have inges ted a f is h tapeworm, whic h was s ubs eq uently c onf irmed by f inding ope rc ulate eggs (egg s with a lid ) of the c es tod e, Di p hy l l o bothri um l atu m , in the patie nt' s f ec es on mic ros c o pic examinatio n. Yo u have the f ollowing antiparas itic ag ents in

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your hos pital f o rmulary. W hic h would be the bes t c hoic e f or this c as e?

1. I dentif y the therape utic problem(s ) in whic h the pharmac is t' s intervention may be nef it the patie nt. 2. I dentif y and prio ritize the patient-s pec if ic f ac tors that mus t be c o ns idered to ac hie ve the des ire d the rap eutic outc omes . 3. Conduc t a tho ro ugh and mec hanis tic ally oriented s truc ture–ac tivity analys is of all therapeutic alte rnatives provided in the c as e . 4. Evaluate the s truc ture–ac tivity relations hip f indings ag ains t the patient-s p ec if ic f ac tors and d es ire d therap eutic outc omes , and make a the rap eutic dec is ion. 5. Couns e l your p atient.

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82. Amer M, El-Ghariband I. Permethrin versus crotamiton and lindane in the treatment of scabies. Int J Dermatol 1992;31:357–358.

Suggested Readings Freeman CD, Klutman EE, Lamp KC. Metronidazole: a therapeutic review and update. Drugs 1997;54:679–708.

Maizels RM, Bundy DAP, Selkirk ME, et al. Immunological modulation and evasion by helminth parasites in human populations Nature 1993;365:797–805.

Wilson JD, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 12th Ed. New York: McGraw-Hill, 1991:772.

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Chapter 40 Antifungal Agents Robe rt K. Griffith

Drugs cov ered in this chapter: Polyen es Amphotericin B Natamyc in Nys tatin Azo les Fluc onazole I trac onazole Ketoc onazo le Pos ac onazole Terco nazole Voric onazole Allyl amines Butenaf ine Naf tif ine Terbinaf ine Eschin ocand ins Anidulaf ingin Cas pof ungin Mic af ungin Ciclopirox Fluc ytos ine Griseof ulvin Halogrogin Tolnaf tate Undec ylenic ac id

Introduction Until recently, chemotherapy of fungal infections has lagged far behind chemotherapy of bacterial infections. T his lack of progress has resulted, in part, because the most common fungal infections in humans have been relatively superficial infections of the skin and mucosal membranes and potentially lethal deep-seated infections have been quite rare. Because most humans with a normally functioning immune system are able to ward off invading fungal pathogens with little difficulty, the demand for improvements in antifungal therapy has been small. Immunocompromised patients, however, are very susceptible to invasive fungal infections. T he onset of the AIDS epidemic, combined with the increased use of powerful immunosuppressive drugs for organ transplants and cancer chemotherapy, has resulted in a greatly increased incidence of life-threatening fungal infections and a corresponding increase in demand for new agents to treat these infections. T he number of effective antifungal agents available is quite small compared to those available to treat bacterial infections, but research in this area is quite active. Several new agents have been introduced in the last few years.

Fungal Diseases T he fungal kingdom includes yeasts, molds, rusts, and mushrooms. Most fungi are saprophytic, which means that they live on dead organic matter in the soil or on decaying leaves or wood. A few of these fungi can cause opportunistic infections if they are introduced into a human through wounds or by inhalation. Some of these infections can be fatal. T here are relatively few

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obligate animal parasites (i.e., microorganisms that can only live on mammalian hosts) among the fungi, although Candi da al bi cans is commonly found as part of the normal flora of the gastrointestinal tract and vagina. T he obligatory parasites are limited to dermatophytes that have evolved to live on/in the keratin-containing hair and skin of mammals, where they cause diseases such as ringworm and athletes foot. (Ringworm is not caused by a parasitic worm but, rather, is named for the ring-like appearance of this fungal infection of the skin.) A detailed description of fungal infections is beyond the scope of this book, but comprehensive treatises are available (1). Most fungal infections are caused primarily by various yeasts and molds. Yeasts, such as the opportunistic pathogen Candi da al bi cans and the bakers' yeast Saccharomyces cerevi si ae, typically grow as single oval cells and reproduce by budding. Candi da al bi cans and some other pathogenic yeasts also can grow in multicellular chains called hyphae. Infection sites may contain both yeast and hyphal forms of the microorganism. Molds, such as Tri chophyton rubrum, one of the causative agents of ringworm, grow in clusters of hyphae called a mycelium. All fungi produce spores, which may be transported by direct contact or through the air. Although most topical fungal infections are readily treated, the incidence of life threatening systemic fungal infections, including those caused by yeasts such as Candi da al bi cans and molds such as Aspergi l l us fumi gans are increasing, and mortality remains high (2).

Dermatophytes Dermatophytes are fungi causing infections of skin, hair, and nails (3). T he dermatophytes obtain nutrients from attacking the cross-linked structural protein keratin, which other fungi cannot use as a food source. Dermatophytic infections, known as tinea, are caused by various species of three genera (Tri chophyton, M i crosporum , and Epi dermophyton) and are named for the site of infection rather than for the causative organism. T inea capitis is a P.1113 fungal infection of the hair and scalp. T inea pedis refers to infections of the feet, including athlete's foot, tinea manuum to fungal infection of the hands, tinea cruris to infection of the groin (jock itch), and tinea unguium to infection of the fingernails. Athlete's foot in particular may be an infection involving several different fungi, including yeasts. T inea unguium, also known as onychomycosis, whether of the fingernails or toenails, can be particularly difficult to treat, because the fungi invade the nail itself. Appropriate drug therapy prevents the fungus from spreading to the newly formed nail. Penetration of drugs into previously existing nail is problematic, however, and with some drug regimens, the infection is not cured until an entirely new, fungus-free nail has grown in. Because this can take months, patient compliance with a lengthy drug regimen can be a problem.

Clin ical Significan ce Antifungal agents include diverse compounds with varied actions. A few key examples can highlight the importance of medicinal chemistry to clinical practice. Knowledge regarding the molecular structure of polyene antifungal agents, such as amphotericin B, is essential in understanding how they work. T hese agents are macrocyclic lactones with distinct hydrophilic and lipophilic regions. One of the putative mechanisms of polyene action involves the formation of pores in the fungal cell membrane. T he lipophilic regions of the polyene molecules facilitate the binding to the cell membrane sterols. T he hydrophilic portions of the molecule align to create a hydrophilic pore in the sterol-containing cell membrane. As a result, there is membrane depolarization and increased membrane permeability and, eventually, fungal cell death. T he lipophilic regions of amphotericin B also contribute to its poor solubility in aqueous solutions. T he traditional intravenous formulation of amphotericin B includes a dispersing agent, deoxycholate, which facilitates formation of the required micellular dispersion when administered in a 5% dextrose in water solution. 5-Flucytosine (5-FC) is an analogue of the natural pyrimidine cytosine that is converted to 5-fluorouracil (5-FU) in susceptible fungi. Formation of 5-FU is essential to the antimycotic effect of 5-FC; 5-FU acts as a pyrimidine antimetabolite and is phosphorylated to the cytotoxic agent 5-fluorodeoxyuridine monophosphate. All of these facts are commonly emphasized in a medicinal chemistry sequence, and readers probably are aware that 5-FU is a chemotherapeutic agent that causes myelosuppression as its major toxicity. T herefore, it should not be surprising that the same side effect can be seen in patients receiving 5-FC. T he newest antifungals, the echinocandins, are macromolecular structures with high molecular weights (> 1,000 dalton), which a student can easily visualize by looking at the chemical structure. T heir relatively low volume of distribution in the body can be partially explained by their size. Clinically, these agents have not achieved high concentrations in the central nervous system and the vitreous chamber of the eye, two compartments that are subject to fungal invasion. Douglas Slain Pharm.D. BCPS Associ ate Professor, Col l ege of Pharmacy, West Vi rgi ni a Uni versi ty

Yeasts T he most common cause of yeast infections is Candi da al bi cans, which is part of the normal flora in a significant portion of the population where it resides in the oropharynx, gastrointestinal tract, vagina, and surrounding skin (4). It is the principal cause of vaginal yeast infections and oral yeast infections (thrush). T hese commonly occur in mucosal tissue when the normal population of flora has been disturbed by treatment of a bacterial infection with an antibiotic or when growth conditions are

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changed by hormonal fluctuations, such as occur in pregnancy. Candi da al bi cans can cause infections of the skin and nails, although the latter are not common. In persons with healthy immune systems, Candi da infections are limited to superficial infections of the skin and mucosa. In persons with impaired immune systems, however, Candi da al bi cans also may cause deep-seated systemic infections, which can be fatal. Several other infections with Candi da species occur, including C. tropi cal i s, C. krusei , C. parapsi l osi s, and C. gl abrata (also known as Torul opsi s gl abrata). T hese organisms are becoming more common and often do not respond to antifungal therapy as readily as Candi da al bi cans. Cryptococcus neoformans is a yeast commonly found in bird droppings, particularly pigeon droppings (5). When dust contaminated with spores is inhaled by persons with a competent immune system, the organism causes a minor, self-limiting, lung infection. Such infections frequently are mistaken for a cold, and medical treatment is not sought. In immunocompromised persons, however, the organism can be carried by the circulatory system from the lungs to many other organs of the body, including the central nervous system (CNS). Infection of the CNS is uniformly fatal unless treated. Although most yeast infections are caused by various species of Candi da or Cryptococcus, other yeasts also can cause infections in humans, including M al assezi um furfur, Tri chosporon bei gel i i , and Bl astoschi zomyces capi tatus (6). T hese infections are relatively rare, and they are difficult to treat.

Thermally Dimorphic Fungi (Endemic M ycoses) T hermally dimorphic fungi are saprophytes that grow in one form at room temperature and in a different form in P.1114 a human host at 37°C (7). T he most common infectious agents are Bl astomyces dermati ti dus, Paracocci di odes brasi l i ensi s, Cocci di oi des i mmi tus, and Hi stopl asma capsul atum, the causative agents of blastomycosis, paracoccidiomycosis, coccidiomycosis (valley fever), and histoplasmosis, respectively. All these organisms live in soil and cause disease through inhalation of contaminated dust. T he resulting lung infections are often mild and self-limiting, but they may progress on to a serious lung infection. T he circulatory system may transport the organisms to other tissues, where the resulting systemic infection may be fatal. Bl astomyces dermati ti dus is endemic to southcentral United States and P. brasi l i ensi s to Central and South America, where it is the most common cause of fungal pulmonary infections. Cocci di oi des i mmi tus is endemic to the dry areas of the southwestern United States and northern Mexico. It is particularly prevalent in the San Joaquin Valley of California, hence the name valley fever. Hi stopl asma capsul atum is endemic to the Mississippi and Ohio River valleys of the United States, where nearly 90% of the population tests positive for exposure to the organism.

M olds Various Aspergi l l us species are found worldwide and are virtually ubiquitous in the environment. T he most common organisms causing disease are A. fumi gatus, A. ni ger, and A. fl avus. Several other Aspergi l l us species are known to cause infection, and some, such as A. ni dul ans, are becoming more common. Aspergi l l us spp. very rarely cause disease in persons with normal immune systems but are very dangerous to persons with suppressed immune systems. Because Aspergi l l us spores are everywhere, inhalation is the most common route of inoculation, but infection through wounds, burns, and implanted devices (e.g., catheters) also is possible. Nosocomial (hospital-derived) aspergillosis is a major source of infection in persons with leukemia and in those receiving organ or bone marrow transplants. Aspergillosis of the lungs may be contained, but systemic aspergillosis has a high mortality rate. Zygomycosis (mucormycosis) is a term used to describe infections caused by the genera Rhi zopus, M ucor, and Absi di a of the fungal order Mucorales (8). As with several other opportunistic fungal pathogens, these soil microorganisms generally are harmless to those with a competent immune system but can cause rapidly developing, fatal infections in an immunosuppressed patient. T hese organisms can infect the sinus cavity, from which they spread rapidly to the CNS. Blood vessels also may be attacked and ruptured. Zygomycoses spread rapidly and are often fatal.

Biochem ical T argets for Antifungal Chem otherapy Antifungal chemotherapy depends on biochemical differences between fungi and mammals (9,10). Unlike bacteria, which are prokaryotes, both fungi and mammals are eukaryotes, and the biochemical differences between them are not as great as one might expect. At the cellular level, the greatest difference between fungal cells and mammalian cells is that fungal cells have cell walls but that mammalian cells do not. Inhibitors of bacterial cell wall biosynthesis, such as penicillins and cephalosporins, have provided many powerful antibacterial agents with little toxicity to humans. T he fungal cell wall therefore is a logical target for a similar class of drugs, which would be expected to be potent antifungals yet have little human toxicity. Only recently, however, have a few potent inhibitors of fungal cell wall biosynthesis become available for clinical use (11). Other targets for antifungal agents include inhibitors of DNA biosynthesis, disruption of mitotic spindles, and general interference with intermediary metabolism. T he difference between fungal and mammalian cells that is most widely exploited, however, is that the cell membranes of fungi and mammals contain different sterols. Sterols are important structural components of fungal and mammalian cell membranes and are critical to the proper functioning of many cell membrane enzymes and ion-transport proteins. Mammalian cell membranes contain cholesterol as the sterol component, whereas fungi contain ergosterol (12).

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Although the two sterols are quite similar, the side chains are slightly different, and when three-dimensional models are constructed, the ring system of ergosterol is slightly flatter because of the additional double bonds in the B ring. Nevertheless, with only a few exceptions, this difference in sterol components provides the biochemical basis of selective toxicity for most of the currently available antifungal drugs.

Polyene M embrane Disruptors—Amphotericin B, Nystatin, and Congeners Before the mid-1950s, effective antifungal therapy was limited to topical applications of undecylenic acid derivatives, mixtures of benzoic acid and salicylic acid, and a few other agents of modest efficacy. No reliable treatments existed for the few cases of deep-seated systemic fungal infections that did occur. T he discovery of the polyene antifungal agents, however, provided a breakthrough into both a new class of antifungal agents and the first drug to be effective against deep-seated fungal infections. T he polyenes are macrocyclic lactones with distinct hydrophilic and lipophilic regions. T he hydrophilic region contains several alcohols, a carboxylic acid, and usually, a sugar. T he P.1115 lipophilic region contains, in part, a chromophore of four to seven conjugated double bonds. T he number of conjugated double bonds correlates directly with antifungal activity in vitro and, inversely, with the degree of toxicity to mammalian cells. T hat is, not only are the compounds with seven conjugated double bonds, such as amphotericin B, approximately 10-fold more fungitoxic, they are the only ones that may be used systemically.

Mechanism of Action T he polyenes have an affinity for sterol-containing membranes, insert into the membranes, and disrupt membrane functions.

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T he membranes of cells treated with polyenes become leaky, and eventually, the cells die because of the loss of essential cell constituents, such as ions and small organic molecules. Polyenes have a demonstrably higher affinity for membranes containing ergosterol over cholesterol-containing membranes. T his is the basis for their greater toxicity to fungal cells. Some evidence suggests that the mechanism of insertion differs between the types of cells. Polyene molecules may insert individually into ergosterol-containing membranes but require prior formation of polyene micelles before inserting into cholesterol-containing membranes.

Specific Drugs Nystatin Nystatin, the first clinically useful polyene antifungal antibiotic, is a conjugated tetraene isolated from cultures of the bacterium Streptomyces noursei in 1951. Nystatin is an effective topical antifungal against a wide variety of organisms and is available in a variety of creams and ointments. Nystatin is too toxic to be used systemically, but because very little drug is absorbed following oral administration, it may be administered by mouth to treat fungal infections of the mouth and gastrointestinal tract (T able 40.1). Although nystatin itself was not a breakthrough in systemic antifungal therapy, the search for other polyenes led to the discovery of a polyene that can be used systemically.

Amphotericin B Amphotericin B, which as a heptaene has low enough toxicity to mammalian cells to permit intravenous (IV) administration, was discovered in 1956. Amphotericin B is, nevertheless, a very toxic drug and must be used with caution. Adverse effects include fever, shaking chills, hypotension, and severe kidney toxicity. Despite its toxicity, amphotericin B is considered to be the drug of choice for many systemic, life-threatening fungal infections. T he drug cannot cross the blood-brain barrier and must be administered intrathecally for treatment of fungal infections of the CNS. Closely related heptaenes are candicidin, hamycin, and trichomycin. T he nephrotoxicity of amphotericin B has been a serious drawback to the use of this drug since its introduction. Recently, however, the toxicity of the drug has been decreased substantially by changes in formulation (T able 40.2). T he polyenes are only sparingly soluble in water, and amphotericin B has long been formulated as a complex with deoxycholic acid for IV administration. More recently developed formulations of amphotericin B, such as liposomal encapsulation and lipid complexes, have dramatically decreased the toxicity of the drug to humans, which permits higher plasma levels to be employed. T he mechanisms by which the new formulations decrease the toxicity are not entirely clear, but altered distribution is clearly a factor. Because the blood vessels at the site of infection are more permeable than those of normal tissue, the large suspended particles of the lipid formulations can penetrate the site of infection more readily than they can penetrate healthy tissue. T he result is selective delivery of drug to the site of infection. Some evidence also indicates that the newer formulations transfer amphotericin B to ergosterol-containing fungal cells more efficiently than to cholesterol-containing mammalian cells.

Natamycin Natamycin, a tetraene, is available in the United States as a 5% suspension applied topically for the treatment of fungal infections of the eye (T able 40.1).

Ergosterol Biosynthesis Inhibitors A schematic of fungal ergosterol biosynthesis starting from squalene is shown in Figure 40.1. T he biosynthetic pathway has been simplified to emphasize steps important to the action of currently employed antifungal drugs. T he last nonsteroidal precursor to both ergosterol and cholesterol is the hydrocarbon squalene. Squalene is converted to squalene epoxide by the enzyme squalene epoxidase. Squalene epoxide is then cyclized to lanosterol, the first steroid in the biosynthetic pathway. T he P.1116 steps involved in converting the side chain of lanosterol to the side chain of ergosterol, and the steps in removal of the geminal dimethyl groups on position 4, are not shown, because none of these reactions is targeted by clinically employed antifungal agents.

Table 40.1. Topical Antifungals Chemical Class Allylamine

Generic Name

Trade Name

Dosage Form

Butenafine

Lotrimin Ultra Mentax

1% cream

Naftifine

Naftin

1% cream, gel

Terbinafine

Lamisil

1% cream

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Lamisil DermGel

10 mg/g gel

Various

1% cream, solution

Absorbine Athletes' Foot Cream

1% cream

Genaspor

1% cream

Tinactin

1% cream, solution, powder, spray powder, spray liquid

Aftate

1% gel, spray powder, spray liquid

Cruex

1% cream

Lotrimin AF

1% cream, lotion, solution

Desenex

1% cream

Various

1% cream

Spectazole

1% cream

Sertaconazole

Ertaczo

2% cream

Ketoconazole

Nizoral

2% cream, shampoo

Miconazole

Micatin

2% cream, powder, spray powder, spray liquid

Monistat-Derm

2% cream

Maximum Strength Desenex

2% cream

Fungoid Creme

2% cream

Lotrimin AF

2% powder, spray powder

Zeasorb AF

2% cream

Prescription Strength Desenex

2% spray liquid

Tolnaftate (thiocarbamate)

Imidizole

Clotrimazole

Econazole

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Fungoid Tincture

2% solution

Oxiconazole

Oxistat

1% cream, lotion

Sulconazole

Exelderm

1% cream, solution

Triazole

Terconazole

Terazol

Topical 0.4–0.8% cream, suppository

Polyene

Nystatin

Mycostatin

100,000 U/g cream, ointment, powder

Nilstat

100,000 U/g cream, ointment

Nystex

100,000 U/g cream, ointment

Natamycin

Alcon

5% ophthalmic suspension

Ciclopirox

Loprox

0.77% cream, gel, suspension 1% shampoo

Penlac

8% nail lacquer

Haloprogin

Halotex

1% cream, solution

Undecylenic Acid

Protectol Medicated

15% powder

Caldesene

10% powder

Cruex

10% powder

Cruex Aerosol

19% powder

Desenex

25% powder

Phicon F

8% cream

Various

2–25% creams, powders, ointments

Misc.

A key step in conversion of lanosterol to both cholesterol and ergosterol is removal of the 14α-methyl group. T his reaction is carried out by a cytochrome P450 (CYP450) enzyme, 14α-demethylase. T he mechanism of this reaction involves three successive hydroxylations of the 14α-methyl group, converting it from a hydrocarbon through the alcohol, aldehyde, and carboxylic acid oxidation states (Fig. 40.2). T he methyl group is eliminated as formic acid to afford a double bond between C-14 and C-15 of the D ring. T his enzyme is the primary target of the azole antifungal agents discussed below. Eventually, either before or after modification of the side chain, the ∆

14

double bond is reduced by a ∆

14

-reductase to form a

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trans ring juncture between the C and D rings. Several steps later, the double bond between C-8 and C-9 is isomerized to a ∆ 8

7

7

double bond by the enzyme ∆ ,∆ -isomerase. Many of the steps are identical to those involved in mammalian cholesterol biosynthesis, and the basis for selective toxicity to fungal cells will be discussed under the specific agents.

Azoles—Imidazoles and Triazoles Azole antifungal agents are the largest class of antimycotics available today, with more than 20 drugs on the market. Some are primarily used topically to treat superficial dermatophytic and yeast infections (T able 40.1), whereas others are administered orally for the treatment of systemic fungal infections (T able 40.2). T he oral P.1117 bioavailability of some azoles, in contrast to amphotericin B, combined with their generally broad-spectrum of activity has led to their widespread use in treating a variety of serious infections. T he characteristic chemical feature of azoles from which their name is derived is the presence of a five-membered aromatic ring containing either two or three nitrogen atoms. Imidazole rings have two nitrogens and triazoles three. In both cases, the azole ring is attached through N 1 to a side chain containing at least one aromatic ring. Imidazole-containing agents are shown in Figure 40.3 (for triazoles, see Fig. 40.6).

Table 40.2. Systemic Antifungal Agents Chemical Class

Generic Name

Trade Name

Dosage Form

Allylamine

Terbinafine

Lamisil

250-mg tablets

Imidazole

Ketoconazole

Various

200-mg tablets

Nizoral

200-mg tablets

Fluconazole

Diflucan

50-, 100-, 150-, and 200-mg tablets; 350-mg (10 mg/mL reconst.) powder for oral suspension; 100- and 200-mL (2 mg/mL) solution for injection

Voriconazole

Vfend

50- and 200-mg tablets; 200-mg powder for injection; 45-g (40 mg/mL reconst.) powder for oral suspension

Itraconazole

Various

100-mg capsules

Sporanox

100-mg capsules; 10 mg/mL injection solution; 10 mg/mL oral solution

Caspofungin

Cancidas

50- and 70-mg powder for injection

Anidulafungin

Eraxis

50-mg powder for injection

Micafungin

Mycamine


Amphotericin B

Amphocin (desoxycholate)


Fungizone (desoxycholate)


Triazole

Echinocandins

Polyene

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Misc.

Abelcet (lipid complex)

100 mg/20 mL suspension, single-use vials

Amphotec (cholesteryl)

50 mg/20 mL and 100 mg/50 mL powder, single-use vials

AmBisome (liposomal)

Powder, single-use vials

Flucytosine

Ancobon

250- and 500-mg capsules

Griseofulvin

Fulvicin, Grifulvin, Grisactin

250- and 500-mg microsize tablets; 125- to 330-mg ultramicrosize tablets

Fig. 40.1. Ergosterol biosynthesis from squalene, with key steps shown in the simplified figure. Enzymatic steps known to be the site of action of currently employed antifungal agents are indicated by a heavy black arrow and a number.

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Fig. 40.2. Demethylation of the 14α-methyl group from lanosterol carried out by the cytochrome P450 enzyme sterol 14α-demethylase (CYP51). The mechanism involves three successive heme-catalyzed insertions of activated oxygen into the three carbon-hydrogen bonds of the 14α-methyl group, which raises the oxidation state of the methyl group to a carboxylic acid. The group is finally eliminated as formic acid to create a double bond between carbons 14 and 15.

P.1118

Fig. 40.3. Imidazole antifungal agents.

Mechanism of Action All the azoles act by inhibiting ergosterol biosynthesis through inhibition of the 14α-demethylase discussed above under ergosterol biosynthesis (Fig. 40.1, Site 2). T he basic N3 atom of the azole forms a bond with the heme iron of the CYP450 prosthetic group in the position normally occupied by the activated oxygen (Fig. 40.4). T he remainder of the azole antifungal forms bonding interactions with the apoprotein in a manner that determines the relative selectivity of the drug for the fungal

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demethylase versus other CYP450 enzymes. Inhibition of the 14α-demethylase results in accumulation in the fungal cell membrane of sterols still bearing a 14α-methyl group. T hese sterols do not have the exact shape and physical properties of the normal membrane sterol ergosterol. T his results in permeability changes, leaky membranes, and malfunction of membrane-imbedded proteins. T hese effects taken together lead to fungal cell death. Because biosynthesis of the mammalian membrane sterol cholesterol also employs a CYP450 14α-demethylase, why do 14α-methyl sterols not accumulate in human cell membranes? T he reason is in the relative strength of inhibition of the same enzyme from different species. For example, the median inhibitory concentration (IC 50 ) for ketoconazole against the enzyme from Candi da al bi cans is approximately 10 -9 M versus approximately 10 -6 M for the human enzyme. T his three orders of magnitude difference in strength of inhibition provides the therapeutic index with respect to this particular enzyme. As discussed below, however, many of the azoles are powerful inhibitors of other mammalian CYP450 enzymes. T he early azole antifungal drugs were all either extensively and rapidly degraded by first-pass metabolism or P.1119 too toxic for systemic use. As a result, only those drugs with reduced or slow first-pass metabolism (ketoconazole, fluconazole, itraconazole, voriconazole, and posaconazole) are used systemically. T he other azoles (clotrimazole, tioconazole, terconazole, butoconazole, econazole, oxiconazole, sulconazole, miconazole, and ketoconazole) are available in a variety of creams and ointments for topical treatments of dermatophytic infections and intravaginal use for vaginal yeast infections. (T able 40.1).

Fig. 40.4. Mechanism of azole/CYP450 binding. The basic nitrogen of azole antifungal agents forms a bond to the heme iron of CYP450 enzymes, preventing the enzyme from oxidizing its normal substrates. Ketoconazole is representative of the azole antifungals.

Specific drugs Ketocon azole Ketoconazole (Fig. 40.3), an imidazole, was the first orally active antifungal azole to be discovered and, as a consequence, has been widely studied and employed for the treatment of systemic fungal infections, primarily candidiasis. Ketoconazole has little effect on Aspergi l l us or Cryptococcus. Ketoconazole is highly dependent on low stomach pH for absorption, and antacids or drugs that raise stomach pH will lower the bioavailability of ketoconazole. As with other azoles, it is extensively metabolized by microsomal enzymes (Fig. 40.5). All the metabolites are inactive. Evidence that CYP3A4 plays a significant role in metabolism of ketoconazole is that coadministration of CYP3A4 inducers, such as phenytoin, carbamazepine, and rifampin, can cause as much as a 50% reduction in levels of ketoconazole (13). Ketoconazole also is a powerful inhibitor of human CYP3A4 and, as a consequence, has many serious interactions with other drugs. For example, coadministration of ketoconazole with the hypnotic triazolam results in a 22-fold increase in triazolam's area under the curve (AUC) and a sevenfold increase in half-life. Interestingly, CYP3A4 also is present in the gut and may contribute substantially to the metabolism of many drugs, such as the immunosuppressant agent cyclosporine, thus the potential for drug–drug P.1120 interaction (see box). Ketoconazole is a weak inhibitor of CYP2C9, which is the enzyme responsible for the metabolism of several narrow therapeutic index drugs, such as warfarin and phenytoin. As better systemic agents have become available, ketoconazole's clinical use has become limited to topical applications in a variety of dosage forms, including creams, lotions, suppositories, and shampoos.

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Fig. 40.5. Extensive metabolism of ketoconazole involving hydrolysis of the N-acetyl by a deacetylase. The oxidation reactions are catalyzed by CYP3A4 and a flavin-linked mixedfunction oxidase. All metabolites are inactive.

Ketoconazole and Cyclosporine—A Clinical Useful Drug Interaction Cyc los porine is an immunos uppres sive agent us ed in trans plant patients to help pre vent organ rejec tion. Although ef f ec tive, c yc los porine therapy is extreme ly expensive and the drug ap pears to b e approximately 20% bioavailable f ollowing an oral dose. This low bioavailability res ults f rom the metabolism of c yc los porine by the CYP450 s ys tem to a number of metabolites. Early reports of c oad ministration of ketoc onazole with c yc los porine des c ribed exc es sive advers e ef f ec ts attributable to cyclo sporine toxicity. Fro m this and knowledge about the ef f ec ts of ketoconazole on CYP450-mediated metabolis m, inves tigators hypothes ized that a muc h lower dos e of c yclos porine co uld be given c oncomitantly with ketoc onazole, produc ing blood leve ls of c yclos porine equivalent to those seen with the higher dos e at a f rac tion of the c os t. I n f act, it appears that ketoc onazole given c onc urre ntly with c yc los porine may allow up to an 80% reduction in cyclos porine dos e.

Itracon azole Itraconazole was, along with fluconazole, one of the first triazoles introduced into clinical use (Fig. 40.6) (14). Itraconazole's oral bioavailability is variable and is influenced by food and stomach pH, a strongly acidic pH being required for good absorption. Like ketoconazole, itraconazole is extensively metabolized by CYP3A4 following oral administration, and levels are markedly reduced by coadministration of the CYP3A4-inducers phenytoin, carbamazepine. and rifampin (13). Additionally, like ketoconazole, itraconazole has been demonstrated to be a strong inhibitor of CYP3A4 (15). T his interaction has proven to be of clinical significance because the risk of developing rhabdomyolysis following lovastatin or simvastatin therapy with coadministration of itraconazole (16,17,18). Itraconazole therefore is likely to have serious interactions with any other drug metabolized by CYP3A4. Again like ketoconazole, itraconazole appears to have little or no effect on CYP2C9-mediated metabolism of warfarin and phenytoin.

T erconazole T erconazole (Fig. 40.6) is a close analogue of ketoconazole and itraconazole. It is approved only for the treatment of vaginal candidiasis and is not used systemically (T able 40.1) (19,20).

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Fluconazole Fluconazole (Fig. 40.6), which was introduced at the same time as itraconazole, differs from ketoconazole and itraconazole in that it is equally bioavailable when given orally or IV. T wo major advantages of fluconazole over other antifungal agents are that it can cross the blood-brain barrier and has efficacy against Cryptococcus neoformans (21). Fluconazole also differs in that it is only a weak inhibitor of CYP3A4 but a strong inhibitor of CYP2C9 (22). For instance, fluconazole doubles the AUC of (S)-warfarin (the active enantiomer) and greatly prolongs the prothrombin time in patients receiving warfarin anticoagulant therapy (23). Because warfarin has such a narrow therapeutic index and excessive anticoagulation can be extremely harmful, this interaction is considered to be of major clinical significance. Fluconazole also decreases the metabolism of the CYP2C9 substrate phenytoin, an antiepileptic agent that also has a narrow therapeutic index (24). Depending on the dose of fluconazole, coadministration with phenytoin can result in a 75 to 150% increase in the phenytoin AUC, and numerous case reports have documented substantial adverse effects following this regimen. Fluconazole also will inhibit CYP3A4, though not to the same degree as ketoconazole and itraconazole. Fluconazole exhibits a dose-dependent inhibition of triazolam metabolism (a CYP3A4 reaction) causing as much as a fourfold increase in triazolam AUC.

Fig. 40.6. Triazole antifungal agents.

Voricon azole Voriconazole (Fig. 40.6) is a fluconazole analogue that was developed to overcome some of the limitations of fluconazole (25) and does, indeed, have a broader spectrum of activity than fluconazole, having activity against Aspergi l l us and fluconazoleresistant strains of Candi da and Cryptococcus (26). Voriconazole is orally absorbed and penetrates the blood-brain barrier. Unfortunately, voriconazole is extensively metabolized CYP450 enzymes (F ig. 40.7) and is an inhibitor of CYP2C19, CYP2C9, and CYP3A4, leading to many drug interactions (27,28). Voriconazole exhibits nonlinear, saturable kinetics, and because CYP2C19 exhibits genetic polymorphisms, plasma levels can be higher in poor metabolizers versus extensive metabolizers (29,30). P.1121

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Fig. 40.7. Major metabolic products resulting from CYP450 metabolism of voriconazole.

Posacon azole Posaconazole (Fig. 40.6), a recently introduced triazole, has a number of advantages over previous agents (31,32). Posaconazole has a wide spectrum of activity compared to other azoles, particularly against Aspergi l l us and other increasingly common nosocomial infections resistant to treatment by other antifungal drugs (32). Posaconazole is metabolized primarily by Phase II glucuronide conjugation and has little interaction with the oxidative CYP450 enzymes (33). T hus, posaconazole should have far fewer drug interactions than the other azole antifungal agents. Posaconazole is structurally similar to itraconazole and saperconazole, but it contains a tetrahydrofuran ring in place of the dioxolan ring of those agents, which may account for some of its unique properties.

Allyl Amines and Other Squalene Epoxidase Inhibitors T he group of agents generally known as allyl amines[34] strictly includes only naftifine and terbinafine, but because butenafine and tolnaftate function by the same mechanism of action, they are included in this class and are shown in Figure 40.8. One can, of course, consider the benzyl group of butenafine to be bio-isosteric with the allyl group of naftifine and terbinafine. T olnaftate, a much older drug, is chemically a thiocarbamate but has the same mechanism of action as the allyl amines. T hese drugs have a more limited spectrum of activity than the azoles and are effective only against dermatophytes. T herefore, they are employed in the treatment of fungal infections of the skin and nails (35).

Mechanism of action All of the drugs in Figure 40.8 act through inhibition of the enzyme squalene epoxidase (Fig. 40.1, Site 1). Inhibition of this enzyme has two effects, both of which appear to be involved in the fungitoxic mechanism of this class (36). First, inhibition of squalene epoxidase results in a decrease in total sterol content of the fungal cell membrane. T his decrease alters the physicochemical properties of the membrane, resulting in malfunctions of membrane-imbedded transport proteins involved in nutrient transport and pH balance. Second, inhibition of squalene epoxidase results in a buildup within the fungal cell of the hydrocarbon squalene, which is itself toxic when present in abnormally high amounts. Mammals also employ the enzyme squalene epoxidase in the biosynthesis of cholesterol, but a desirable therapeutic index arises from the fact that the fungal squalene epoxidase enzyme is far more sensitive to the drugs than the corresponding mammalian enzyme. T erbinafine has a K i of 0.03 µM versus squalene epoxidase from Candi da al bi cans but only 77 µM versus the same enzyme from rat liver—a 2,500-fold difference (37).

Specific drugs

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Naftifine Naftifine (Fig. 40.8) was the first allyl amine to be discovered and marketed (34). It is subject to extensive first-pass metabolism to be orally active and, consequently, is only available in topical preparations (T able 40.1). T he widest use of naftifine is against various tinea infections of the skin.

T erbin afin e T erbinafine (Fig. 40.8) is available in both topical and oral dosage forms (T ables 40.1 and 40.2) and is effective against a variety of dermatophytic P.1122 infections when employed topically or systemically (38). A unique property of terbinafine is its effectiveness in the treatment of onychomycoses (nail infections) (39). Given orally, the highly lipophilic drug redistributes from the plasma into the nail bed and into the nail itself, where the infection resides (40), making terbinafine superior to other agents for treating this particular type of infection. T erbinafine is extensively metabolized by several CYP450 enzymes, including CYP1A2, CYP2C19, CYP2C9, CYP2C8, CYP3A4, and CYP2B6 (41). Because there are so many pathways for terbinafine metabolism, inhibition of any one has very little effect on overall clearance of the drug, although drugs that inhibit several CYP450 enzymes, such as cimetidine, can increase terbinafine plasma levels. Although not a substrate for the enzyme, terbinafine is a strong inhibitor of CYP2D6 and can have significant interactions with drugs that are metabolized by this enzyme, such as codeine and desipramine (22,42).

Fig. 40.8. The squalene epoxidase inhibitors, allyl amines. Naftifine was the first drug shown to act by inhibition of squalene epoxidase, as does the much older thinocarbamate, tolnaftate.

Azole Antifungals in Agriculture

Every year, f ungal inf ec tions of crops c aus es hundreds of millions of dollars worth of damage to a wide variety of f ood and other crops . Bef ore the development of ef f ec tive agric ultural antif ungals , c ro p dis eas es were the c aus e of s everal major f amines. The inf amous I rish Potato Famine of the nineteenth c entury was caus ed by a patho genic f ungus , Phytophera i nfes tans . Tens of thous ands of people s tarved to death, and thousands mo re emigrated to the United

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States to esc ape the f amine. Today, both imidazole and triazole antif ungal agents , s uch as imazalil and propic onazole, are among the mos t ef f ec tive c rop-protec tion agents known. More than 20 azole antif ungals are used f or c rop protec tion, and a repres entative s ample is s hown. The mec hanis m of action of the agric ultural antif ungals is identical to that of the agents used f or mammalian inf ec tions . I n f ac t, they bear a remarkable resemblanc e to antif ungal drugs employed in treating human dis ease.

Butenafine and Tolnaftate Butenafine and tolnaftate, like naftifine (Fig. 40.8), are only available in topical preparation for the treatment of dermatophytic infections (T able 40.1). T olnaftate has been marketed in a variety of nonprescription drug preparations for decades. Butenafine, discovered more recently, has a somewhat wider spectrum of activity than tolnaftate. For example, butenafine is active against superficial Candi da al bi cans infections, which are not affected by tolnaftate (43).

Agricultural Antifungal Morpholines

J us t as there are s everal c las s es of drugs to tre at human f ungal inf ec tions, there are s everal c lass es of “ drugs ” to treat f ungal phytopathogens . The morpholines, f enpropimorph and tridemorph, are not us ed to treat human d iseas e but have wide utility in protec ting c rops f rom phytopathogenic f ungi.

Morpholines

Amorolfine is the only drug in this class that is employed clinically in the treatment of human fungal infections. Amorolfine is not currently available in the United States, but it is marketed in Europe and Asia for the topical treatment of dermatophytic infections (44). Morpholine antifungals inhibit ergosterol biosynthesis by acting on the enzymes ∆

14

8

7

-reductase and ∆ ,∆ -isomerase (Fig. 40.1,

Site 3 and 4) (45). Inhibition of these enzymes results in incorporation into fungal cell membranes of sterols retaining either a ∆

14

8

double bond, a ∆ double bond, or both. None of these will have the same overall shape and physicochemical properties as

the preferred sterol, ergosterol. As with the antifungals already discussed, this results in membranes with altered properties and malfunctioning of membrane-embedded proteins.

Inhibitors of Cell Wall Biosynthesis—Echinocandins T he most notable difference between fungal and mammalian cells is that fungi have a cell wall and mammals do not. Drugs interfering with cell wall biosynthesis would be expected to be relatively nontoxic to mammals. Such drugs have been the foundation of antibacterial therapy since the discovery of penicillin and the development of dozens of effective penicillins and

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cephalosporins. Only recently, however, have a few drugs affecting fungal cell wall biosynthesis become available. Echinocandins, a group of cyclic peptides with long lipophilic side chains and sometimes called lipopeptides, have been under investigation for a number of years (Fig. 40.9) (46). Echinocandins interfere with cell wall biosynthesis through inhibition of the enzyme β-1,3-glucan synthase. β-Glucan is an important polymer component of many fungal cell walls, and reduction in the glucan content severely weakens the cell wall, leading to rupture of the fungal cell. P.1123

Fig. 40.9. Echinocandins.

Caspofungin, Anidulafungin, and Micafungin Recently, three semisynthetic echinocandins have been approved for use in treating life-threatening systemic fungal infections (47). T hese are caspofungin, anidulafungin, and micafungin (Fig. 40.9). T hese drugs represent the first class of antifungal agents with a novel mechanism of action to be marketed in more than 30 years and are a very valuable contribution to therapy for systemic fugal infections. T hey are effective against a variety of Candi da species that have proven to be resistant to other agents as well as effective against azole-resistant Aspergi l l us. T herefore, these drugs are truly life-saving for those afflicted with these previously resistant fungi. Unfortunately these echinocandins are not effective against Cryptococcus neoformans. None of these drugs is orally active, and all must be administered by IV infusion. Because of limited hepatic metabolism, drug–drug interactions are not a problem. Caspofungin is metabolized by hydrolysis in two portions of the hexapeptide ring (Fig. 40.10) (48), whereas anidulafungin does not appear to be actively metabolized but rather slowly degrades (49). Micafungin is metabolized by a sulfotransferase and by catechol-O-methyltransferase (COMT ), but no significant drug interactions are known (50).

Fig. 40.10. Metabolic products formed from caspofungin.

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Drugs Acting Through Other M echanisms Flucytosine Flucytosine is a powerful antifungal agent used in the treatment of serious systemic fungal infections, such as Cryptococcus neoformans and Candi da spp (T able 40.2). Flucytosine itself is not cytotoxic but, rather, is a pro-drug that is taken up by fungi and metabolized to 5-fluorouracil (5-FU) by fungal cytidine deaminase (Fig. 40.11) (51). T hen, 5-FU is converted to 5-fluorodeoxyuridine, which as a thymidylate synthase inhibitor interferes with both protein and RNA biosynthesis. 5-Fluorouracil is cytotoxic and is employed in cancer chemotherapy (see Chapter 42). Human cells do not contain cytosine deaminase and, therefore, do not convert flucytosine to 5-FU. Some intestinal flora, however, do convert the drug to 5-FU, so human toxicity does result from this metabolism. Resistance rapidly develops to flucytosine when used alone, so it is almost always used in conjunction with amphotericin B. Use of flucytosine has declined since the discovery of fluconazole.

Griseofulv in

Griseofulvin is an antifungal antibiotic produced by an unusual strain of Peni ci l l i um (52). It is used orally to treat P.1124 superficial fungal infections, primarily fingernail and toenail infections, but it does not penetrate skin or nails if used topically (T able 40.2). When given orally, however, plasmaborne griseofulvin becomes incorporated into keratin precursor cells and, ultimately, into keratin, which cannot then support fungal growth. T he infection is cured when the diseased tissue is replaced by new, uninfected tissue, which can take months. T he mechanism of action of griseofulvin is through binding to the protein tubulin, which interferes with the function of the mitotic spindle and, thereby, inhibits cell division. Griseofulvin also may interfere directly with DNA replication. Griseofulvin is gradually being replaced by newer agents (53).

Fig. 40.11. Flucytosine, a pro-drug, is converted by fungal cytosine deaminase to 5-fluorouracil (5-FU). This reaction does not occur in mammalian cells. A further transformation of 5-FU to the actual cytotoxic agent, 5-fluorodeoxyuridine monophosphate (5-FdUMP), also occurs.

Haloprogin

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Haloprogin is an iodinated acetylene active against dermatophytes (54). Haloprogin is only used for topical applications (T able 40.1). T he mechanism of haloprogin is not clear, but it appears to lead to nonspecific metabolic disruption. It has been demonstrated to interfere with DNA biosynthesis and cell respiration.

Ciclopirox

Ciclopirox is a hydroxylated pyridinone that is employed for superficial dermatophytic infections, principally onychomycosis. Ciclopirox has a unique mechanism of action through chelation of polyvalent cations, such as Fe

3+

, which causes inhibition of a

number of metal-dependent enzymes within the fungal cell. Although ciclopirox has been available for more than 30 years, a new formulation of an 8% lacquer has been recently introduced for treating nail infections (55).

Undecylenic Acid

Undecylenic acid is widely employed, frequently as the zinc salt, in over-the-counter preparations for topical treatment of infections by dermatophytes (T able 40.1) (56). Undecylenic acid is fungistatic that acts through a nonspecific interaction with components in the fungal cell membrane. P.1125

Case Study Victo r ia F. Roch e S. William Zito

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KK is a 4 2-year-o ld, Brazilian-born executive who works f or Ronald Stump, an internationally f amous inves tment mogul and entrepreneur who mentors (and gene rous ly rewards ) go -getters like KK. KK's c areer potential s eemed unlimited until he acq uired AI DS f rom a previous partner who was unaware of his HI V-pos itive s tatus at the time of their relations hip. T he las t year has been tough f or KK, who has always be en athletic, adventurous , and s eemingly indes truc tible, but he has f allen ill s everal times in the past 12 months with bac terial and viral inf ec tions, including a particularly nas ty c ase of poststreptococ c al nephritis . He is c urrently on antiviral the rapy that includes indinavir sulf ate (Crixivan, 800 mg every 8 hours ) and zidovudine (Retrovir, 300 mg b.i.d.). Although he is s till able to work and is managing f airly well, he is f earf ul about the antic ipated f inal outc ome of his diseas e and is employing s piritual and nontraditional s trategies in an attempt to heal. As part o f this holis tic approac h to healing, KK f lew to the Amazon and s pent two nights alone on the edge of the jungle, s eeking ins ight and peace through ref lec tion and prayer. All he took in with him was his medic ation and a s uf f icient amount of f ood and water to las t f or 48 hours . He f elt saf e, however, bec ause he was within a 20-minute walk of a tribal community and co uld sound an alarm that would alert p eople in c as e of danger or an emergenc y. He s lept und er the stars , pulling up ground vegetation into a “natural” bed each night. He f elt emotio nally res tored af ter the exp erienc e—until it became known that he had inhaled dus t c ontaminated with the s oil f ungus P. bras i l i ens i s and a s pec ies of As perg i l l us mold. He is now in the c ritic al care wing of your hos pital with a dis s eminated f ungal inf ection. The therapeutic plan is to s tart him on an appropriate I V antif ungal agent s upplemented with oral therapy. Cons ider the s truc tures of the antif ungal agents d rawn be low, and id entif y s uitable parenteral and oral antif ungal drug produc ts f or KK.

1. I dentif y the therapeutic problem(s ) in whic h the pharmac is t's intervention may benef it the p atie nt. 2. I dentif y and prioritize the patient-spec if ic f ac tors that mus t be cons idered to ac hieve the des ired the rapeutic outc omes . 3. Cond uc t a thorough and mec hanis tic ally oriented s tructure–ac tivity analys is of all therapeutic alternatives

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provided in the cas e. 4. Evaluate the s truc ture–ac tivity relations hip f indings agains t the patient-s pec if ic f actors and des ired therapeutic outc omes , and make a therapeutic dec is ion. 5. Couns el your patient.

P.1126

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Chapter 41 Antimycobacterial Agents Thom as L. Le m ke

Drugs cov ered in this chapter: Antimyc ob ac te rial ag e nts Antitub e rc ulin d rug s C ap re o myc in C yc o se rine Ethamb uto l Ethio namid e I s o niazid Kanamycin Para aminob e nzo ic ac id Pyrazinamid e R if amp in R if ap e ntine Stre p to myc in MAC the rap y Azithro myc in C larithro myc in L e p ro static d rug s C lo f azimine D ap s o ne R if amp in Thalid o mid e

General Considerations Mycobacteria are a genus of acid-fast bacilli belonging to the Mycobacteriaceae, which include the organisms responsible for tuberculosis and leprosy as well as a number of other, less common diseases. Characteristic of mycobacteria is the fact that these organisms tend to be slow-growing, difficult to stain, and when they are stained with basic dye, can resist decolorization with acid alcohol. T he staining characteristics relate to the abnormally high lipid content of the cell wall. In fact, the cell wall or cell envelope of the mycobacterium holds the secret to many of the characteristics of this genus of organisms. T he cell envelope is unique in both structure and complexity. It has been suggested that the cell envelope is responsible for

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mycobacterium pathogenicity or virulence, multiple drug resistance, cell permeability, immunoreactivity and inhibition of antigen responsiveness, as well as disease persistence and recrudescence. In addition, several of the successful chemotherapeutic agents are know to inhibit the cell envelope synthesis as their mechanism of action. It is no wonder that significant effort has been put forth to define the chemical structure of the mycobacterium cell envelope. A series of papers were presented and reported in 1991 dealing with the topic of the structure and functions of the cell envelope of mycobacterium (1). As illustrated in Figure 41.1, the mycobacterial cell envelope contains, on the interior surface, a plasma membrane similar to that found in most bacteria. A conventional peptidoglycan layer affording the organism rigidity appears next. T his layer is composed of alternating N-acetyl-D-glucosamines (Glu) linked to N-glycoyl-D-muramic acids (Mur) through 1–4 linkages that, in turn, is attached to the peptido chain of D-alanine (A), D-glutamine (G), meso-diaminopimelic acid (DP), and L-alanine (A). A novel disaccharide phosphodiester linker made up of N-acetyl-D-glucosamine and rhamnose connects the muramic acid to a polygalactan and polyarabinose chain. T he latter polysaccharides are referred to as the arabinogalactan (AG) portion of the cell envelope. T he manner in which the arabinosyl and galactosyl resides are arranged is still under investigation. It is known that the arabinosyl chains terminate in mycolic acid residues. (T he mycolates will be discussed in more detail later in this chapter.) Noncovalently bound to the mycolates are a number of free nonpolar and polar lipids (the phthiocerol lipids and the glycopeptidolipids, respectively). Finally, spanning from the interior, embedded in the plasma membrane, to the exterior is the lipoarabinomannan (LAM) polymer. As indicated, this unit is composed of polyarabinose, polymannan, and various lipids attached through a phosphatidylinositol moiety (2,3).

Specific Diseases Leprosy (Hansen's Disease) T hroughout the Bible, one finds reference to the condition of leprosy, such as that described in Levi ti cus: “ [I]s there any flesh in the skin of which there is a burn by fire, and the quick flesh of the burn becomes a bright spot, reddish white or white,…and if the hair in the bright spot is turned white, and it appears deeper than the skin, it is leprosy broken out in the burn.” Associated with the disease was a belief that individuals suffering from this disease were unclean. T oday, leprosy (Hansen's disease) is recognized as a chronic granulomatous infection caused by M ycobacteri um l eprae. T he disease may consist of lepromatous leprosy, tuberculoid leprosy, or a condition with characteristics between these two poles and referred to as borderline leprosy. T he disease is more common in tropical countries but is not limited to warm climate regions. It is thought to afflict some 10 to 20 million individuals. Children appear to be the most susceptible population, but the signs and symptoms usually do not occur until much later in life. T he incubation period usually is P.1128 three to five years. T he disease is contagious, but the infectiousness is quite low. Personto-person contact appears to be the means by which the disease is spread, with entrance into the body occurring through the skin or the mucosa of the upper respiratory tract. Skin and peripheral nerves are the regions most susceptible to attack.

Clinic a l Signific a nc e Diseases caused by mycobacteria, such as tuberculosis and M ycobacteri um avi um– i ntracel l ul are complex, are of great concern to both health care workers and the public. Understanding the infectivity and pathophysiology of mycobacteria and the medicinal

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chemistry of the antimicrobials in the complex treatment of mycobacterial infections can help to facilitate a clinician's pharmacotherapy decisions. Mycobacteria are very-slow-growing organisms that grow both intracellularly and extracellularly. Because of their growth, the treatment of mycobacterial infections, especially tuberculosis, requires long-term treatment with a combination of agents to effectively eradicate the disease and prevent resistance. In addition, many of these agents are associated with significant side effects and drug interactions. A good understanding about the medicinal chemistry of the antimycobacterial agents helps the clinician to determine the most effective and safe combination for an individual patient. T he continuing interest in the study of the medicinal chemistry of antimycobacterial agents is prudent in the development of newer and safer agents. Researchers are continuously looking for agents that have more rapid antimycobacterial activity as well as lower resistance and fewer side effects. T he discovery of such agents would have a significant effect on increasing the eradication of this worldwide epidemic. Shorter-course therapies would lead to an increase in patient compliance and possible decrease in mycobacterial resistance. As newer and more effective therapies are developed, clinicians will need to stay informed of these therapies, such as their pharmacokinetic and pharmacodynamic profiles, so that their patients can get the most optimal and effective treatment. Elizabeth Coyle, Pharm.D. Cl i ni cal Assi stant Professor, Department of Cl i ni cal Sci ences & Admi ni strati on, Uni versi ty of Houston Col l ege of Pharmacy

T he first signs of the disease consist of hypopigmented or hyperpigmented macules. Additionally, anesthetic or paresthetic patches may be experienced by the patient. Neural involvement in the extremities ultimately leads to muscle atrophy, resorption of small bones, and spontaneous amputation. When facial nerves are involved, corneal ulceration and blindness may occur. T he identification of M . l eprae in skin or blood samples is not always possible, but the detection of the antibody to the organism is an effective diagnostic test, especially for the lepromatous form of the disease.

Tuberculosis T uberculosis (T B) is a disease that has been known from the earliest of recorded history. It is characterized as a chronic bacterial infection caused by M ycobacteri um P.1129 tubercul osi s, an acid-fast, aerobic bacillus with the previously discussed, unusual cell wall. T he cell wall has a high lipid content, resulting in a high degree of hydrophobicity and resistance to alcohol, acids, alkali, and some disinfectants. After staining with a dye, the M . tubercul osi s cell wall cannot subsequently be decolorized with acid wash, thus the characteristic of being an acid-fast bacillus. It is estimated that today, one-third to one-half of the world population is infected with M . tubercul osi s, leading to approximately 6% of all deaths worldwide (~ 2 million deaths) (4,5). T uberculosis is the leading worldwide cause of mortality resulting from an infectious bacterial agent. A steady decline in the reported cases of T B had been occurring in the United States from the 1950s until 1985. From 1985 until 1988, however, this decline leveled off, but beginning in 1989, an increase was noted. In 1991, the Centers for Disease Control and Prevention (CDC) reported 25,701 new cases of T B. T oday, the press and professional publications announce the “ epidemic” spread of T B. T he resurgence has been linked to urban crowding, homelessness, immigration, drug abuse, the disappearance of preventive-medicine health clinics, crowded prisons, and the AIDS epidemic. “ Most alarming is the emergence of multidrug-resistant T B” (MDR-T B) (6). Before 1984, only 10% of the organisms isolated from patients with T B were resistant to any drug. In 1984, 52% of the organisms were resistant to at

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least one drug, and 32% were resistant to more than one drug. MDR-T B may have a fatality rate as high as 50%. As a result of MDR-T B, isolates of M . tubercul osi s should be tested for antimicrobial susceptibility. In fact, drug resistance is encountered in patients who have never been treated with any of the T B drugs.

Fig. 41.1. Diagrammatic representation of the cell wall/cell envelope of mycobacterium.

M ycobacteri um tubercul osi s is transmitted primarily via the respiratory route. T he organism appears in water droplets expelled during coughing, sneezing, or talking. Either in the droplet form or as the desiccated airborne bacilli, the organism enters the respiratory tract. T he infectiousness of an individual will depend on the extent of the disease, the number of organisms in the sputum, and the amount of coughing. Usually, within 2 weeks of beginning therapy, the infected individual will no longer be infectious. T B is a disease that mainly affects the lungs (80–85% of the cases), but M . tubercul osi s can spread through the bloodstream and the lymphatic system to the brain, bones, eyes, and skin (extrapulmonary T B). In pulmonary T B, the bacilli reach the alveoli and are ingested by pulmonary macrophages. Substances secreted by the macrophages stimulate surrounding fibroblasts to enclose the infection site, leading to formation of granulomas or tubercles. T he infection, thus contained locally, may lie dormant, encapsulated in a fibrotic lesion, for years and then reappear later. Extrapulmonary T B is much more common in HIV-infected patients (40–75%). Because of the effect of the AIDS virus on the immune system, all HIV-infected individuals should be screened for T B, and if infected, the patient should be treated for T B before an active infections develops. Patients with HIV infection and T B are 100-fold more likely of developing an active infection than noninfected patients. Individuals diagnosed with active T B should be counseled and tested for HIV, because the T B may have developed in conjunction with the weakened immune system seen in the patient with HIV infection.

M ycobacterium Avium–Intracellulare Complex

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M ycobacteri um avi um and M ycobacteri um i ntracel l ul are are atypical acid-fast bacilli that are ubiquitous in the environment and usually considered to be nonpathogenic in healthy individuals. Unfortunately, in immune-compromised individuals, these and possibly other, unidentified mycobacteria cause severe, life-threatening infections. Disseminated M ycobacteri um avi um– i ntracel l ul are complex (MAC) is the most common bacterial opportunistic infection seen in patients with AIDS and the third most common opportunistic infection behind candidal esophagitis and primary Pneumocysti s cari ni i pneumonia reported in patients with AIDS. Between 1981 and 1987, and before the availability of effective antiretroviral medication, the incidence of MAC was reported as 5%. T oday, approximately half of all patients with AIDS develop an infection caused by MAC. T he lungs are the organs most commonly involved in patients without AIDS, but the infection may involve bone marrow, lymph nodes, liver, and blood in patients with AIDS. T he CD4 T -lymphocyte count is used as a predictor for risk of disseminated MAC; a count of less than 50 cells/mm 3 in an HIV-infected person (adult or adolescent) is an indication of a potential infection and a recommendation for chemoprophylaxis. T he MAC organisms grow within macrophages; therefore, the drug must be capable of penetration of the macrophage. T reatment of MAC, both prophylactically and for diagnosed infections, requires the use of multidrug therapy, and for disseminated MAC, this treatment is for the life of the patient.

General Approaches to Drug T herapy T he mycobacteria have a number of characteristics in common, but it is important to recognize that the species vary widely in their susceptibility to the different drugs and that, in turn, this may relates to significant differences in the organisms. Some species, such as M . tubercul osi s, are very slow-growing, with a doubling time of approximately 24 hours, whereas others, such as M ycobacteri um smegmati s, doubles in 2 to 3 hours. T he pathogenic mycobacterial organism can be divided into organism that are actively metabolizing and rapidly growing; semidormant bacilli, which exhibit spurts of metabolism bacilli in acid pH; and dormant or persisters. T he latter characteristic is the most problematic and responsible for treatment failures. Most current T B drugs are those that are effective against actively metabolizing and rapidly growing bacilli. T hus, P.1130 successful chemotherapy calls for drugs with bactericidal action against all stages of the organisms—but especially against the persisters. T he use of combination therapy over an extended period of time is one answer to successful treatment.

Drug T herapy for T uberculosis Drug therapy for the treatment of T B has been greatly hampered by the development of MDR-T B and the lack of new classes of drugs. In fact, no new drugs have been developed in the last 40 years. T he only change in the treatment of T B has been the strategy of using direct observed treatment (DOT ), with an emphasis on patient-centered care (7). Additionally, whereas the course of treatment has been reduced, through the use of drug combinations, to 6 months, patient compliance continues to be a serious problem, which in turn may be associated with the development of bacterial resistance.

First-Line Agents Isoniazid (Isonicotinic Acid Hydrazide, Nydrazid, Laniazid)

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Isoniazid (INH) is a synthetic antibacterial agent with bactericidal action against M . tubercul osi s. T he drug was discovered in the 1950s as a beneficial agent effective against intracellular and extracellular bacilli, and it generally is considered to be the primary drug for treatment of M . tubercul osi s. Its action is bactericidal against replicating organisms, but it appears to be only bacteriostatic at best against semidormant and dormant populations. After treatment with INH, M . tubercul osi s loses its acid fastness, which may be interpreted as indicating that the drug interferes with cell wall development.

Mechanism of action Although extensively investigated, the mechanism of action of INH has remained unknown until recently. New investigations into mechanisms of bacterial resistance have shed light on the molecular mechanism of action of INH (8). It generally is recognized that INH is a pro-drug that is activated through an oxidation reaction catalyzed by an endogenous enzyme (9). T his enzyme, katG, which exhibits catalase-peroxidase activity, converts INH to a reactive species capable of acylation of an enzyme system found exclusively in M . tubercul osi s. Evidence in support of the activation of INH reveals that INH-resistant isolates have decreased catalase activity and that the loss of catalase activity is associated with the deletion of the catalase gene, katG. Furthermore, reintroduction of the gene into resistant organisms results in restored sensitivity of the organism to the drug. Reaction of INH with catalase-peroxidase results in formation of isonicotinaldehyde, isonicotinic acid, and isonicotinamide, which can be accounted for through the reactive intermediate isonicotinoyl radical or isonicotinic peroxide, as shown in Figure 41.2 (10). Evidence has been offered both for and against the reaction of catalase-peroxidase activated INH with a portion of the enzyme inhA, which is involved in the biosynthesis of the mycolic acids (Fig. 41.3) (11,12,13). T he mycolic acids are important constituents of the mycobacterial cell wall in that they provide a permeability barrier to hydrophilic solutes. T he enzyme inhA, produced under the control of the i nhA gene, is an NADH-dependent, enoyl reductase protein thought to be involved in double-bond reduction during fatty acid elongation (Fig. 41.4). Isoniazid specifically inhibits long-chain fatty acid synthesis (> 26 carbon atoms). It should be noted that the mycolic acids are α-branched lipids having a “ short” arm of 20 to 24 carbons and a “ long” arm of 50 to 60 carbons. It has been proposed that INH is activated to an electrophilic species that acylates the four position of the NADH (Fig. 41.5, on page 1132). T he acylated NADH is no longer capable of catalyzing the reduction of unsaturated fatty acids, which are essential for the synthesis of the mycolic acids (14,15,16).

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Fig. 41.2. Reaction products formed from catalase-peroxidase reaction with isoniazid (INH).

P.1131

Fig. 41.3. Mycolic acids.

Structure–activity relations

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An extensive series of derivatives of nicotinaldehyde, isonicotinaldehyde, and substituted isonicotinic acid hydrazide have been prepared and investigated for their tuberculostatic activity. Isoniazid hydrazones were found to possess activity, but these compounds were shown to be unstable in the gastrointestinal (GI) tract, releasing the active isonicotinic acid hydrazide (i.e., INH). T hus, it would appear that their activity resulted from the INH and not from the derivatives (17,18). Substitution of the hydrazine portion of INH with alkyl and aralkyl substituents resulted in a series of active and inactive derivatives (19,20,21,22). Substitution on the N-2 position resulted in active compounds (R1 and/or R2 = alkyl; R3 = H), whereas any substitution of the N-1 hydrogen with alkyl groups destroyed the activity (R1 and R2 = H; R3 = alkyl). None of these changes produced compounds with activity superior to that of INH.

Metabolism Isoniazid is extensively metabolized to inactive metabolites (Fig. 41.6, on page 1132) (23,24). T he major metabolite is N-acetylisoniazid. T he enzyme responsible for acetylation, cytosolic N-acetyltransferase, is produced under genetic control in an inherited autosomal fashion. Individuals who possess high concentrations of the enzyme are referred to as rapid acetylators, whereas those with low concentrations are slow acetylators. T his may result in a need to adjust the dosage for fast acetylators. T he N-acetyltransferase is located primarily in the liver and small intestine. Other metabolites include isonicotinic acid, which is found in the urine as a glycine conjugate, and hydrazine. Isonicotinic acid also may result from hydrolysis of acetylisoniazid, but in this case, the second product of hydrolysis is acetylhydrazine. Acetylhydrazine is acetylated by N-acetyltransferase to the inactive diacetyl product. T his reaction occurs more rapidly in rapid acetylators. T he formation of acetylhydrazine is significant in that this compound has been associated with the hepatotoxicity, which may occur during INH therapy. Acetylhydrazine has been postulated to serve as a substrate for microsomal P450, resulting in the formation of a chemical that is capable of acetylating liver protein, in turn resulting in the liver necrosis (25). It has been suggested that a hydroxylamine intermediate is formed that results in an active acetylating agent (Fig. 41.7, on page 1132). T he acetyl radical/cation acylates liver protein.

Pharmacokinetics Isoniazid is readily absorbed following oral administration. Food and various antacids, especially aluminum-containing antacids, may interfere with or delay the absorption; therefore, it is recommended that the drug be taken on an empty stomach. T he drug is well distributed to body tissues, including infected tissue. A long-standing concern about the use of INH during

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preventive therapy for latent T B has been the high incidence of hepatotoxicity. Recent studies have concluded that, excluding patients over 35 years of age, if relevant clinical monitoring is employed, the rate of hepatotoxicity is quite low (26). T he risk of hepatotoxicity is associated with increasing age and appears to be higher in women than in men.

Rifamycin Antibiotics T he rifamycins are members of the ansamycin class of natural products produced by Streptomyces medi terranei . T his chemical class is characterized as molecules with an P.1132 aliphatic chain forming a bridge between two nonadjacent positions of an aromatic moiety. While investigating the biological activity of the naturally occurring rifamycins (B, O, and S), a spontaneous reaction gave the biologically active rifamycin SV, which was later isolated from natural sources. Rifamycin SV was the original rifamycin antibiotic chosen for clinical development (27). Semisynthetic derivatives are prepared via conversion of the natural rifamycins to 3-formylrifamycin, which is derivatized with various hydrazines to give products such as rifampin (RIF) and rifapentine. Rifampin and rifapentine have significant benefit over previously investigated rifamycins in that they are orally active, are highly effective against a variety of both Gram-positive and Gram-negative organisms, and have high clinical efficacy in the treatment of T B. T he rifamycin antibiotics are active against both growing and slow-metabolizing, nongrowing bacilli.

Fig. 41.4. Enoylthioester. ACP, acyl carrier (protein) reduction catalyzed by NADH and inhA.

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Fig. 41.5. Acylation of NADH and NADH-dependent enoylacyl protein (inhA).

Mechanism of action T he rifamycins inhibit bacterial DNA-dependent RNA polymerase (DDRP) by binding to the β-subunit of the enzyme and are highly active against rapidly dividing intracellular and extracellular bacilli. Rifampin is active against DDRP from both Gram-positive and Gram-negative bacteria, but because of poor penetration of the cell wall of Gram-negative organisms by RIF, the drug has less value in infections caused by such organisms. Inhibition of DDRP leads to blocking the initiation of chain formation in RNA synthesis. It has been suggested that the naphthalene ring of the rifamycins π-π bonds to an aromatic amino acid ring in the DDRP protein (28). T he DDRP is a metalloenzyme that contains two zinc atoms. It is further postulated that the oxygens at C-1 and C-8 of a rifamycin can chelate to a zinc atom, which increases the binding to DDRP, and finally, the oxygens at C-21 and C-23 form strong hydrogen bonds to the DDRP. T he binding of the rifamycins to DDRP results in the inhibition of the RNA synthesis. Specifically, RIF has been shown to inhibit the elongation of full-length transcripts, but it has no effect on transcription initiation (8). Resistance develops when a mutation occurs in the gene responsible for the β-subunit of the RNA polymerase (rpoB gene), resulting in an inability of the antibiotic to readily bind to the RNA polymerase (29).

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Fig. 41.6. Metabolism of isoniazid.

Structure–activity relationship A large number of derivatives of the naturally occurring rifamycins have been prepared (30). From these compounds, the following generalizations can be made concerning the structure– activity relationship (SAR): 1) Free -OH groups are required at C-1, C-8, C-21, and C-23; 2) these groups appear to lie in a plane and to be important binding groups for attachment to DDRP, as previously indicated; 3) acetylation of C-21 and/or C-23 produces inactive compounds; 4) reduction of the double bonds in the macro ring results in a progressive decrease in activity; and 5) opening of the macro ring also gives inactive compounds. T hese latter two changes greatly affect the conformational structure of the rifamycins, which in turn P.1133 decreases binding to DDRP. Substitution at C-3 or C-4 results in compounds with varying degrees of antibacterial activity. T he substitution at these positions appears to affect transport across the bacterial cell wall. A compound incorporating such substitution is the benzoxazinorifamycin KRM-1648, which is proceeding through clinical investigation. In vitro studies have shown rapid tissue sterilization and encouraging results concerning combination therapy for T B and, possibly, MAC.

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Fig. 41.7. Acylating metabolite of isoniazid.

Metabolism Rifampin and rifapentine are readily absorbed from the intestine, although food in the tract may affect absorption. Rifampin's absorption may be reduced by food in the intestine; therefore, the drug should be taken on an empty stomach (24). Intestinal absorption of rifapentine has been reported to be enhanced when taken after a meal (31). Neither drug appears to interfere with the absorption of other antituberculin agents, but there are conflicting reports on whether INH affects absorption of RIF. T he major metabolism of RIF and rifapentine is deacetylation, which occurs at the C-25 acetate (Fig. 41.8). T he resulting product, desacetylrifampin and desacetylrifapentine, are still active antibacterial agents. T he majority of both desacetyl products are found in the feces, but desacetylrifampin glucuronide may be found in the urine as well. 3-Formylrifamycin SV has been reported as a second metabolite following both RIF and rifapentine administration. T his product is thought to arise in the gut from an acid-catalyzed hydrolysis reaction. Formylrifamycin is reported to possess a broad spectrum of antibacterial activity (32).

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Fig. 41.8. Metabolism and in vitro reactions of rifampin.

Physicochemical properties Rifampin and rifapentine are red-orange, crystalline compounds with zwitterionic properties. T he presence of the phenolic groups results in acidic properties (pK a ~ 1.7), whereas the piperazine moiety gives basic properties (pK a ~ 7.9). T hese compounds are prone to acid hydrolysis, giving rise to 3-formylrifamycin SV, as indicated above. Rifampin and presumable rifapentine are prone to air oxidation of the p-phenolic groups in the naphthalene ring to give the p-quinone (C-1,4 quinone) (Fig. 41.8). Rifampin, rifapentine, and their metabolites are excreted in the urine, feces (biliary excretion), saliva, sweat, and tears. Because these agents have dye characteristics, one may note discoloration of the body fluids containing the drug. Notably, the tears may be discolored, and permanent staining of contact lenses may occur.

Therapeutic application Rifampin (Rifadin, Rimactane)

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With the introduction of RIF in 1967, the duration of combination therapy for the treatment of T B was significantly reduced (from 18 to 9 months). Rifampin is nearly always used in combination with one or more other antituberculin agents. T he drug is potentially hepatotoxic and may produce GI disturbances, rash, and thrombocytopenic purpura. Rifampin is known to induce hepatic microsomal enzymes (cytochrome P450) and may decrease the effectiveness of oral contraceptives, corticosteroids, warfarin, quinidine, methadone, zidovudine, clarithromycin, and the azole antifungal agents (see Chapter 10) (33). Because of the decreased effectiveness of protease inhibitors and nonnucleoside reverse transcriptase inhibitors used in the treatment of HIV, the CDC has recommended avoidance of RIF in treatment of HIV-infected patients presently on these HIV therapies.

Rifapen tin e (Priftin) Rifapentine is the first new agent introduced for the treatment of pulmonary T B in the last 25 years. T he drug's major advantage over RIF is the fact that when used in combination therapy, rifapentine can be administered twice weekly during the “ intense” phase of therapy, followed by once-a-week administration during the “ continuous” phase. In contrast, RIF normally is administered daily during the “ intense” phase, followed by twice-a-week dosing during the “ continuous” phase. Because relapse and the emergence of resistant strains of bacteria are associated with poor patient compliance, reduced dosing is expected to increase compliance. Initial clinical studies actually showed that the relapse rates in patients treated with rifapentine (10%) were higher than those in the patients treated with RIF (5%). It was found that poor compliance with the nonrifamycin antituberculin agents was responsible for the increased relapse (31). P.1134 Rifapentine is readily absorbed following oral administration and is highly bound to plasma protein (97.7% vs. 80% for RIF). Related to the higher plasma binding, refapentine has a longer mean elimination half-life (13.2 hours in healthy male volunteers) in comparison with the half-life reported for RIF (~2–5 hours). Greater than 70% of either drug is excreted in the feces. Rifapentine generally is considered to be more active than rifampin and can be used in patients with varying degrees of hepatic dysfunction without the need for dose adjustment (34). T his drug, similar to what is seen with RIF, induces hepatic microsomal enzymes (cytochrome P450 3A4 and 2C8/9). Rifapentine has been reported to be teratogenic in rats and rabbits (31).

Pyrazinamide

Pyrazinamide (pyrazinecarboxamide) was discovered while investigating analogues of

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nicotinamide. Pyrazinamide is a bio-isoster of nicotinamide and possesses bactericidal action against M ycobacteri um tubercul osi s. Pyrazinamide has become one of the more popular antituberculin agents despite the fact that resistance develops quickly. Combination therapy, however, has proven to be an effective means of reducing the rate of resistant strain development. T he activity of pyrazinamide is pH dependent with good in vivo activity at pH 5.5, but the compound is nearly inactive at neutral pH.

Rifaximin (Xifaxan)

R ec e ntly, the U.S. Fo o d and Drug Ad minis tratio n (U.S. FDA ) has ap p ro ve d the re le ase o f rif aximin, a rif amyc in antib io tic , f o r the tre atme nt o f trave le rs' d iarrhe a (TD) c aus e d b y e nteroto xig e nic Es c h e ri c h i a co l i . Altho ug h the drug is no t inte nd e d f o r the tre atme nt of TD , the re are ind ic atio ns that the drug may b e e f f e c tive as a p ro phylac tic ag ent. R if aximin is ad minis tere d o rally, with le s s than 0.4 % abs o rp tion; the re f o re , its actio ns are limite d to the GI tract. I ts me c hanis m o f ac tion is e s s entially the same as that o f o the r re if amc yin antib io tic s (3 5 ).

Mechanism of action T he mechanism of action of pyrazinamide is unknown, but recent findings suggest that pyrazinamide may be active either totally or in part as a pro-drug. Susceptible organisms produce pyrazinamidase, which is responsible for conversion of pyrazinamide to pyrazinoic acid intracellularly (8). Mutation in the pyrazinamidase gene (pncA) results in resistant strains of M . tubercul osi s (36). Pyrazinoic acid has been shown to possess biological activity at a pH 5.4 or lower, in contract in vitro tests that show pyrazinoic acid is 8- to 16-fold less active than pyrazinamide (37). Pyrazinoic acid may lower the pH in the immediate surroundings of the M . tubercul osi s to such an extent that the organism is unable to grow, but this physicochemical property appears to account for only some of the activity. T he protonated pyrazinoic acid also can permeate the mycobacterial membrane to lower the pH of the cytoplasm. Recent evidence suggests that pyrazinoic acid decreases membrane potential in older, nonreplicating bacilli, thus decreasing membrane transport, and interferes with the energetics of the membrane (38).

Structure–activity relationship Previous structural modification of pyrazinamide has proven to be ineffective in developing

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analogues with increased biological activity. Substitution on the pyrazine ring or use of alternate heterocyclic aromatic rings have given compounds with reduced activity (39). More recently, using quantitative SAR, a series of analogues have been prepared with improved biological activity. T he requirements for successful analogues include 1) provision for hydrophilicity to allow sufficient plasma concentrations such that the drug can be delivered to the site of infection, 2) lipophilicity to allow penetration into the mycobacterial cell, and 3) susceptibility to hydrolysis such that the pro-drug is unaffected by the “ extracellular” enzymes but is readily hydrolyzed at the site of action. T wo compounds have been found that meet these criteria: tert-butyl 5-chloropyrazinamide, and 2′-(2′-methyldecyl) 5-chloropyrazinamide (40).

Metabolism Pyrazinamide is readily absorbed after oral administration, but little of the intact molecule is excreted unchanged (Fig. 41.9). T he major metabolic route consists of hydrolysis by hepatic microsomal pyrazinamidase to pyrazinoic acid, which may then be oxidized by xanthine oxidase to 5-hydroxypyrazinoic acid. T he latter compound may appear in the urine either free or as a conjugate with glycine (23). P.1135

Fig. 41.9. Metabolism of pyrazinamide.

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Therapeutic application Pyrazinamide has gained acceptance as an essential component in combination therapy for the treatment of T B (component of Rifater with INH and RIF). T he drug is especially beneficial in that it is active against semidormant intracellular tubercle bacilli that are not affected by other drugs (7,34). Evidence suggests that pyrazinamide is active against nonreplicating persister bacilli. T he introduction of pyrazinamide combinations has reduced treatment regimens to 6 months from the previous 9-month therapy. T he major serious side effect of pyrazinamide is the potential for hepatotoxicity. T his effect is associated with dose and length of treatment. Pyrazinamide is not affected by the presence of food in the GI tract or by the use of aluminum-magnesium antacids (41).

Ethambutol (Myambutol)

Ethambutol (EMB), an ethylenediiminobutanol, is administered as its (+ )-enantiomer, which is 200- to 500-fold more active than its (–)-enantiomer. T he difference in activity between the two isomers suggests a specific receptor for its site of action. Ethambutol is a water-soluble, bacteriostatic agent that is readily absorbed (75–80%) following oral administration.

Mechanism of action T he mechanism of action of EMB remains unknown, although mounting evidence suggests a specific site of action for EMB. It has been known for some time that EMB affects mycobacterial cell wall synthesis; however, the complicated nature of the mycobacterial cell wall has made pinpointing the site of action difficult. In addition to the peptidoglycan portion of the cell wall, the mycobacterium have a unique outer envelop consisting of arabinofuranose and galactose (AG), which is covalently attached to the peptidoglycan and an intercalated framework of lipoarabinomannan (LAM) (Fig. 41.1). T he AG portion of the cell wall is highly branched and contains distinct segments of galactan and distinct segments of arabinan. At various locations within the arabinan segments (terminal and penultimate), the mycolic acids are attached to the C-5′ position of arabinan (42,43). Initially, T akayama et al. (44) reported that EMB inhibited the synthesis of the AG portion of the cell wall. More recently, it has been reported that EMB inhibits the enzymes arabinosyl transferase. One action of arabinosyl transferase is to catalyze the polymerization of D-arabinofuranose, leading to AG (45,46). Ethambutol mimics arabinan, resulting in a buildup of the arabinan precursor β-D-arabinofuranosyl1-monophosphoryldecaprenol and, as a result, a block of the synthesis of both AG and LAM (Fig. 41.10) (47). T he mechanism of resistance to EMB involves a gene overexpression of arabinosyl transferase, which is controlled by the embAB gene (48).

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Fig. 41.10. Site of action of ethambutol (EMB) in cell wall synthesis.

T his mechanism of action also accounts for the synergism seen between EMB and intracellular drugs, such as RIF. Damage to the cell wall created by EMB improves the cell penetration of the intracellular drugs, resulting in increased biological activity.

Structure–activity relationship An extensive number of analogues of EMB have been prepared, but none has proven to be superior to EMB itself. Extension of the ethylene diamine chain, replacement of either nitrogen, increasing the size of the nitrogen substituents, and moving the location of the alcohol groups are all changes that drastically reduce or destroy biological activity.

Metabolism T he majority of the administered EMB is excreted unchanged (73%), with no more than 15% appearing in the urine as either Metabolite A or Metabolite B (Fig. 41.11). Both metabolites are devoid of biological activity.

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Fig. 41.11. Metabolism of ethambutol.

P.1136

Streptomycin

Streptomycin (ST M) was first isolated by Waksman and coworkers in 1944 and represented the first biologically active aminoglycoside. T he material was isolated from a manure-containing soil sample and, ultimately, was shown to be produced by Streptomyces gri seus. T he structure was proposed and later confirmed by Kuehl et al. (49) in 1948. Streptomycin is water soluble, with basic properties. T he compound usually is available as the trihydrochloride or sesquisulfate salt, both of which are quite soluble in water. T he hydrophilic nature of ST M results in very poor absorption from the GI tract. Orally administered ST M is recovered intact from the feces, indicating that the lack of biological activity results from poor absorption and not chemical degradation.

Mechanism of action T he mechanism of action of ST M and the aminoglycosides in general has not been fully elucidated. It is known that the ST M inhibits protein synthesis, but additional effects on

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misreading of an mRNA template and membrane damage may contribute to the bactericidal action of ST M. Streptomycin is able to diffuse across the outer membrane of M ycobacteri um tubercul osi s and, ultimately, to penetrate the cytoplasmic membrane through an electrondependent process. T hrough studies regarding the mechanism of drug resistance, it has been proposed that ST M induces a misreading of the genetic code and, thus, inhibits translational initiation. In ST M-resistant organisms, two changes have been discovered: First, S12 protein undergoes a change in which the lysine present at amino acids 43 and 88 in ribosomal protein S12 is replaced with arginine or threonine, and second, the pseudoknot conformation of 16S rRNA, which results from intramolecular base pairing between GCC bases in regions 524 to 526 of the rRNA to CGG bases in regions 505 to 507, is perturbed (50). It is thought that S12 protein stabilizes the pseudoknot, which is essential for 16S rRNA function. By some yet-to-be-defined mechanism, ST M interferes with one or both of the normal actions of the 16S protein and 16S rRNA.

Structure–activity relationship All the aminoglycosides have very similar pharmacologic, pharmacodynamic, and toxic properties, but only ST M and, to a lesser extent, kanamycin are used to treat T B. T his is an indication for the narrow band of structurally allowed modifications giving rise to active analogues. Modification of the α-streptose portion of ST M has been extensively studied. Reduction of the aldehyde to the alcohol results in a compound, dihydrostreptomycin, that has activity similar to ST M but with a greater potential for producing delayed, severe deafness. Oxidation of the aldehyde to a carboxyl group or conversion to Schiff base derivatives (oxime, semicarbazone, or phenylhydrazone) results in inactive analogues. Oxidation of the methyl group in α-streptose to a methylene hydroxy gives an active analogue that has no advantage over ST M. Modification of the aminomethyl group in the glucosamine portion of the molecule by demethylation or by replacement with larger alkyl groups reduces activity; removal or modification of either guanidine in the streptidine nucleus also decreases activity.

Metabolism No human metabolites of ST M have been isolated in the urine of patients who have been administered the drug, with approximately 50 to 60% of the dose being recovered unchanged in the urine (24). Metabolism appears to be insignificant on a large scale, but it is implicated as a major mechanism of resistance. One problem with ST M that was recognized early was the development of resistant strains of M ycobacteri um tubercul osi s. Combination drug therapy was partially successful in reducing this problem, but over time, resistance has greatly reduced the value of ST M as a chemotherapeutic agent for treatment of T B. Various mechanisms may lead to the resistance seen in M . tubercul osi s. Permeability barriers may result in ST M not being transported through the cytoplasmic membrane, but the evidence appears to suggest that enzymatic inactivation of ST M represents the major problem. T he enzymes responsible for inactivation are adenyltransferase, which catalyzes adenylation of the C-3 hydroxyl group in the N-methylglucosamine moiety to give the O-3-adenylated metabolite, and phosphotransferase, which phosphorylates the same C-3 hydroxyl to give O-3-phosphorylate metabolite (Fig. 41.12). T his latter reaction appears to be the most significant clinically. T he result of these chemical modifications is that the metabolites produced will not bind to ribosomes.

Second-Line Agents A number of drugs, including ethionamide, p-aminosalicylic acid, cycloserine, capreomycin, and kanamycin, are considered to be second-line agents (it should be noted that some authorities classify ST M as a second-line agent). T hese agents are active antibacterial agents, but they usually are less well tolerated or have a higher incidence of adverse effects. T hese agents are

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utilized in cases of resistance, retreatment, or intolerance to the first-line drugs.

Ethionamide (Trecator-SC)

P.1137

Fig. 41.12. Metabolism of streptomycin (STM) as a mechanism of resistance.

T he synthesis of analogues of isonicotinamide resulted in the discovery of ethionamide and a homologue in which the ethyl group is replaced with a propyl (prothionamide). Both compounds have proven to be bactericidal against M ycobacteri um tubercul osi s and M ycobacteri um l eprae.

Mechanism of action Evidence has been presented suggesting that the mechanism of action of ethionamide is similar to that of INH (see Mechanism of action under Isoni azi d) (11,15). Similar to INH, ethionamide is considered to be a pro-drug, which is converted via oxidation by catalase-peroxidase to an active

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acylating agent, ethionamide sulfoxide, which in turn inactivates the inhA enoyl reductase enzyme (Fig. 41.13). In the case of ethionamide, it has been proposed that the ethionamide sulfoxide acylates Cys-243 in inhA protein.

Metabolism Ethionamide is orally active but is not well tolerated in a single large dose (> 500 mg). T he GI irritation can be reduced by administration with meals. Additional side effects may include central nervous system (CNS) effects, hepatitis, and hypersensitivities. Less than 1% of the drug is excreted in the free form, with the remainder of the drug appearing as one of six metabolites. Among the metabolites are ethionamide sulfoxide, 2-ethylisonicotinamide, and the N-methylated6-oxodihydropyridines (Compounds A, B, and C in Fig. 41.14) (51).

p-aminosalicylic Acid

Once a very popular component in T B therapy, p-aminosalicylic acid (PAS) is utilized as a second-line agent today. A combination of bacterial resistance and severe side effects has greatly reduced is value. As a bacteriostatic agent, PAS is used at a dose of up to 12 g/day, which causes considerable GI irritation. In addition, hypersensitivity reactions occur in 5 to 10% of the patients, with some of these reactions being life-threatening.

Mechanism of action p-aminosalicylic acid is thought to act as an antimetabolite interfering with the incorporation of p-aminobenzoic acid into folic acid. When coadministered with INH, PAS is found to reduce the acetylation of INH, itself being the substrate for acetylation, thus increasing the plasma levels of INH. T his action may be especially valuable in patients who are rapid acetylators.

Metabolism p-aminosalicylic acid is extensively metabolized by acetylation of the amino group and by conjugation P.1138 with glucuronic acid and glycine at the carboxyl group. It is used primarily in cases of resistance, retreatment, and intolerance of other agents and is available from the CDC.

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Fig. 41.13. Mechanism of action of ethionamide.

Fig. 41.14. Metabolism of ethionamide.

Cycloserine (Seromycin)

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Cycloserine is a natural product isolated from Streptomyces orchi daceus as the D-(+ )-enantiomer.

Mechanism of action D-Cycloserine is considered to be the active form of the drug, having its action associated with the ability to inhibit two key enzymes, D-alanine racemase and D-alanine ligase. D-Alanine is an important component of the peptidoglycan portion of the mycobacterial cell wall. Mycobacterium are capable of utilizing natural occurring L-alanine and converting the L-alanine to D-alanine via the enzyme D-alanine racemase. T he resulting D-alanine is coupled with itself to form a D-alanine–D-alanine complex under the influence of D-alanine ligase, and this complex is incorporated into the peptidoglycan of the mycobacterial cell wall (Fig. 41.15). D-Cycloserine is a rigid analogue of D-alanine; therefore, it competitively inhibits the binding of D-alanine to both of these enzymes and its incorporation into the peptidoglycan (Fig. 41.15) (52). Resistance is associated with an over expression of D-alanine racemase.

Side effects Cycloserine is readily absorbed after oral administration and is widely distributed, including the CNS. Unfortunately, D-cycloserine binds to neuronal N-methylasparate receptors and, in addition, affects synthesis and metabolism of γ-aminobutyric acid, leading to complex series of CNS effects. As a second-line agent, cycloserine should only be used when retreatment is necessary or when the organism is resistant to other drugs. Cycloserine should not be used as a single drug; it must be used in combination.

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Fig. 41.15. Sites of action of D-cycloserine: 1, D-alanine racemase; 2, D-alanine ligase.

Capreomycin (Capastat)

Capreomycin is a mixture of four cyclic polypeptides, of which capreomycin Ia (R = OH) and Ib (R = H) make up 90% of the mixture. Capreomycin is produced by Streptomyces capreol us and is quite similar to the antibiotic viomycin. Little, if anything, is known about its mechanism of action, but if the chemical and pharmacological similarity to viomycin carries over to the mechanism of action, then one might expect something similar. Viomycin is a potent inhibitor of protein synthesis, particularly that which depends on mRNA at the 70S ribosome (53). Viomycin blocks chain elongation by binding to either or both the 50S or 30S ribosomal subunits. A

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Chapter 42 Cancer and Chemotherapy V ictoria F. Roche

Drugs cov ered in this chapter: DNA alkylating agents Chloramb ucil Cyclophosphamid e Es tramustine I f osf amide Mechlorethamine Melphalan Thio tepa Nitrosoureas Carmustine Lomustine Streptozocin Procarbazine and triazenes Dac arbazine Procarbazine Temozolomid e Miscellaneous alkylating agents Altretamine Busulf an Organoplatinum complexes Carboplatin Cisplatin Oxaliplatin Satrap latin Antibiotics Bleomycin Dac tinomyc in Daunorub icin Doxorubicin Epirub icin I darubic in Mitoxantrone

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Mitomyc in Valrubic in Antimetabolites DNA polymeras e inhibitors Cladribine Clof arab ine Cytarabine Fludarabine Gemcitabine Pyrimidine antagonists Capec itabine Floxuridine Fluoro urac il Metho trexate Pemetrexed Purine antagonis ts Mercaptopurine Thioguanine Miscellaneous antime tabolites Hydroxyurea Pentostatin Mitosis I nhibitors Doce taxel Etoposide I rinotec an Paclitaxel Teniposide Topotecan Vinblastine Vinc ris tine Vinore lbine Miscellaneous anticancer agent Azacitidine

Introduction Overview Healthy cells are under strict biochemical control for growth and differentiation. Cells divide and proliferate under the influence of various growth stimulators and are subject to arrested growth (senescence) and programmed cell death (apoptosis). In cancer, these regulatory processes have gone awry, and cells grow and divide uncontrollably, consuming energy and losing both structure and function because of an inability to adequately differentiate. T o add insult to injury, rampant cell division is accompanied by disabled cell-death

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processes, leading first to cellular immortality and, eventually, to genetic instability. T he causes of cancer are many and varied (e.g., chemical, environmental, viral, and mutagenic), but all ultimately lead to an aberration in the expression of proto-oncogenes, the products of which control normal cell life. When these genes mutate to become oncogenes in a sequential, multistep process, cancer results. Oncogenes (e.g., myc and ras) can either overexpress or underexpress regulatory biochemicals, resulting in preferential and accelerated cellular growth. Concomitantly, tumor suppressor genes (e.g., anti-oncogenes like p53, p21, p IN K4A , and reti nobl astoma) can be inhibited (1). Initially, tumors grow exponentially, taking a consistent amount of time for every doubling of the tumor cell population size. In fact, the majority of a cancer cell's lifetime is spent before the tumor presents clinically. Initially, growth is very rapid (doubling time measured in days), but doubling time can slow to weeks or months as the tumor ages (2) because of increasingly poor vascularization and the resulting decrease in access to blood and essential nutrients.

Selected Definitions Oncogenes and Tumor Suppressor Genes Oncogenes are regulators of cellular communication with the outside environment. T hey are derived through the mutation of proto-oncogenes, which are normal and ubiquitous genes involved in the regulation of homeostatic cellular functions. Mutations in proto-oncogenes can occur as spontaneous point mutations, inherited germline mutations, chromosomal rearrangements or through augmentation of gene expression. Regardless of the mutational mechanism, when the mutated oncogenes are P.1148 stimulated by exposure to chemical, environmental, or viral carcinogens, they produce proteins that are either wrongly expressed within their normal cell or expressed in inappropriate tissues. In either case, cellular proliferation leading to cancer results (1,3).

Clinical Significance Chemotherapy has significantly changed the treatment of cancer since the first agents were studied in the 1940s. Understanding the chemical mechanism of action for traditional chemotherapeutic agents, including whether the agent is cell-cycle specific or cell-cycle nonspecific, is important so that administration can be planned accordingly and coadministration of agents with similar toxicities can be avoided. T he disadvantage of traditional chemotherapeutic agents is the inability of the agent to recognize the difference between normal cells and cancer cells. So, although the agents may shrink or eliminate the tumor, the treatment is accompanied by many unwanted side effects. T here are numerous examples in which a chemical understanding of the chemotherapeutic agent is needed. For example, hydration with chloride-containing fluid is necessary with cisplatin to keep cisplatin in its inactive form in the kidneys and to avoid renal toxicity. Another example can be found when using cyclophosphamide or ifosfamide. T he dissociation of aldophosphamide produces the active compound phophoramide mustard, but it also produces acrolein, which can cause significant damage to the bladder. T his bladder damage, or hemorrhagic cystitis, can be prevented with the use of mesna, which inactivates the effects of acrolein in the bladder. Understanding the chemical basis for the toxicities seen with chemotherapy is imperative in managing or preventing them in clinical practice. Kelly Nystrom, Pharm.D., BCOP Assi stant Professor, Pharmacy Practi ce Department, School of Pharmacy and Heal th Professi ons, Crei ghton Uni versi ty

T umor suppressor genes are intended to keep oncogenes in check by halting uncontrolled cellular growth. In direct opposition to oncogenes, which induce cancer when stimulated or amplified, tumor suppressor genes promote cancer when inactivated or attenuated. T wo of the most prevalent tumor suppressor genes involved in the generation of cancer are p53 and reti nobl astoma, or Rb. When either of these two suppressor genes

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loses function, the negative control on cellular proliferation is lifted and cells gain immortality (an essential quality of a cancer cell). T he loss or disruption of function of the p53 tumor suppressor gene is found in approximately half of human cancers and is a harbinger of a poor prognosis. Oncogenes and tumor suppressor genes that have been linked to specific types of cancer are identified in T able 42.1. T able 42.2 relates oncogenic markers of selected cancers to disease prognosis and treatment strategy.

Cell Cycle When cells reproduce, they do so via a very specific game plan known as the cell cycle. Cell division (mitosis) kicks off the cycle, and after a period of 30 to 60 minutes, the cells go into either a resting phase (called G 0 ) or a presynthetic (gap) phase (called G 1 ), in which enzyme production occurs in preparation for de novo nucleic acid synthesis. Production of DNA then occurs in an S phase that can last up to 20 hours. T he S phase is followed by a gap phase (G 2 ), in which RNA, critical proteins, and the mitotic spindle apparatus are generated for the next mitotic (M) phase (3,4). T his is important to our discussion, because some anticancer agents are specific for a certain phase of the cell cycle. For example, antimetabolite antineoplastics damage cells in the S phase, whereas mitosis inhibitors pack their greatest cell-killing punch in the M phase. T he administration of cell-cycle phase– specific antineoplastics is carefully planned so that the drug encounters cancer cells at their most vulnerable moments. Other antineoplastic agents are toxic to cells regardless of cycle phase (e.g., DNA alkylating agents and most antineoplastic antibiotics). T hese cell-cycle phase–nonspecific agents can be administered at any time that is feasible for the provider and convenient for the patient. In general, cancer cells undergoing rapid division are most vulnerable to the cytotoxic action of antineoplastic agents, and antineoplastic therapy holds its greatest P.1149 promise for positive outcomes if initiated when the tumor is small but growing aggressively. Conversely, slow-growing tumors with a high percentage of cells remaining in the G 0 phase (e.g., nonsmall cell lung cancer) often are nonresponsive to standard chemotherapy (4). If the tumor is not detected until it is quite large, therapy also can be compromised by inefficient or substandard drug delivery because of poor tumor vascularization.

Table 42.1. Oncogenic Origin of Selected Cancers (1,3)

Cancer Type

Common Oncogenic or Tumor Suppressor Gene Origin

Chronic myelogenous leukemia

bcr-abl proto-oncogene translocation

Follicular lymphoma

bcl-2 amplification, myc mutation

Sporadic thyroid cancer

ret mutation

Colorectal and gastric cancer

APC gene mutation

Familial breast and ovarian cancer

BRCA1, BRCA2 mutation

Invasive ductal breast cancer

HER-2 amplification

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Familial melanoma

p16 INK4A mutation

Childhood neuroblastoma and small cell lung cancer

N-myc amplification

Leukemia, breast, colon, gastric, and lung cancer

c-MYC amplification

Renal cell cancer

Von Hippel-Lindaugene (VHL) dysfunction

Table 42.2. Oncogenic M arkers and Therapeutic Strategies in Selected Cancers (1)

Cancer Type

Oncogenic Marker

Prognosis/Responsiveness to Chemotherapy Approach

Breast cancer

HER-2 amplification

Poor

Aggressive chemotherapy, targeted therapy

Acute myelogenous leukemia

t(8;21) or inv(16) translocation

Good

Standard chemotherapy

Acute lymphocytic leukemia

bcr-abl rearrangement

Poor

Bone marrow transplantation

Metastasis Metastasis refers to the process by which malignant cells leave the parent tumor, migrate to distant sites, and invade new tissue. T he primary metastatic “ highways” utilized by meandering cancer cells are the blood and lymph fluids. Sloughed cells must find a biological environment with all of their essential growth factors in place before they can put down roots and evolve into a full-fledged metastatic tumor. Because many distinct and interdependent steps must be accomplished to establish metastatic disease, the process has been termed the “ metastatic cascade” (5). Fortunately, there are many opportunities within the cascade for the body to mount a successful defense and destroy the potential invaders.

Cancer Staging Clinicians need to have a common language through which to communicate about disease severity to make the best team-based decisions about the relative risks and benefits of treatment options. In the T NM cancer staging classification, the severity of solid tumor neoplastic growth is characterized by the size of the tumor mass (T 1 –T 4 ), the extent of lymph node involvement (N 1 –N 3 ), and whether distant metastasis has occurred (M 0 or M 1 ). T he higher the subscripted number in each of these parameters, the more advanced and/or disseminated the disease. T aken together, the T NM characteristics of a tumor can be translated into a comprehensive staging scale ranging from I (localized) to IV (metastatic). T he intermediate disease severity

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stages indicate local (Stage II) or regional (Stage III) tissue invasion (3). Staging is an essential prerequisite for the prediction of prognosis and the identification of the most appropriate treatment plan and optimal dosing regimen (2).

Response Criteria In this era of patient-centered, team-based care, it is equally beneficial to quantify a patient's clinical response to therapy in a manner that is consistent and universally understood by all health care providers. Five discrete anticancer therapy response categories have been defined, with criteria established for each (3). Whereas “ cure” is obviously the most noble goal, it is very difficult to achieve in most types of cancer. “ Cure” for all cancers except breast and melanoma equates to no evidence of disease for a minimum of 5 years. More commonly, the response category viewed as the pinnacle is “ complete response,” in which the patient has no evidence of cancer for at least 1 month following the cessation of therapy but where relapses are still possible. A “ partial response” is claimed when tumor size or disease severity has been cut at least in half and there is no evidence of new lesions at the primary site or elsewhere. If this level of clinical improvement is not reached, yet the patient has experienced significant attenuation of symptoms and/or enhancement of quality of life, the response is termed “ clinical benefit.” A less optimistic response category is “ stable disease,” in which tumor size or disease severity has changed by 25% or less in either direction. Most dire is “ progression,” a category that is characterized by tumor growth or worsening disease severity at the 25% or higher level.

Historical Background (6) “ T hose who have not been trained in chemistry or medicine, which after all is only applied chemistry, may not realize how difficult the problem of [cancer] treatment really is. It is almost, not quite, but almost as hard as finding some agent that will dissolve away the left ear, say, yet leave the right ear unharmed: so slight is the difference between the cancer cell and its normal ancestor.” T hus wrote noted cancer researcher and physician Dr. William H. Woglom in a monograph published by the American Association for the Advancement of Science in 1947 (7). Although somewhat predictive of what we now know to be true regarding the relationship between resident genes and oncogenes, Dr. Woglom's rather gloomy prognosis of our ability to meet cancer on its own ground and beat it was underpinned by centuries of unsuccessful attempts to treat neoplastic disease with toxic metals, including lead, arsenic, silver, zinc, antimony, mercury, and bismuth. T he era of more promising chemotherapy was just on the horizon, however, even as Woglom penned his words of therapeutic woe. P.1150 Among the first nonmetallic therapeutic agents to show benefit in the treatment of cancer was cortisone and, later, prednisone. In the 1940s, these glucocorticoids were shown to induce tumor regression in a laboratory cancer model (murine lymphosarcoma) and in acute leukemia. In the same decade, the retrospective recognition that World War I soldiers exposed to sulfur mustard gas, used as an agent of war, suffered from damaged lymphoid tissue and bone marrow led to the development of the cytotoxic nitrogen mustards for the treatment of lymphoma. Chemists then used their scientific understanding of mustard reactivity to design agents that were either “ superpotent” and nonselective (e.g., highly toxic) or of lower reactivity so as to provide oral activity and less systemic toxicity. T he discovery in 1940 that p-aminobenzenesulfonamide was effective against streptococcal infections ushered in the era of antimetabolite chemotherapy. T he development of antifolate antineoplastics, which were shown to be effective in combating childhood leukemias, got its start in the late 1940s. In the mid- to late-1950s, on the heels of the success of antifolates, came the development of antimetabolites based on the structures of endogenous purine and pyrimidine bases. Perhaps the most exciting discovery in this regard was the recognition that a very simple analogue of the endogenous pyrimidine uracil (5-fluorouracil) was a potent inhibitor of deoxythymidine monophosphate biosynthesis and that inhibiting the production of this essential nucleotide produced positive results in patients suffering from colon, stomach, pancreatic, and breast cancers. Antimetabolites that target DNA polymerase (e.g., cytarabine) were conceptualized and synthesized in the late 1950s and subsequently shown to be effective in acute myeloblastic leukemia. T he antibiotic antineoplastics came into clinical utility when the highly toxic actinomycin (discovered in the

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1940s) was found to be effective in the treatment of human testicular cancer and uterine choriocarcinoma. Other natural anticancer antibiotics, such as bleomycin, subsequently were found to be active against various hematological cancers and solid tumors (1960s), which led to the development of semisynthetic analogues with both high potency and wider margins of safety in more recent times. T he antimitotic vinca alkaloids vincristine and vinblastine were shown to have activity against Hodgkin's disease and acute lymphoblastic leukemia around the same time that the antibiotic antineoplastics were being developed. Cancer chemotherapy appears to have come full circle since the “ metal-intense Renaissance,” because some of the newest anticancer drugs to join the U.S. market are organometallic platinum complexes. T he activity of cisplatin (the first such complex to be commercially available) against lymphosarcoma and solid tumors of the head, neck, and reproductive organs was first noted in the early 1970s. T he fortuitous discovery of organoplatinum complexes in the treatment of cancer is attributed to Dr. Barnett Rosenberg, who was studying the impact of electromagnetic radiation on bacterial cell growth using platinum electrodes. He followed up on the astute observation that the bacteria exposed to the electrodes experienced profound changes in cellular structure, which ultimately were attributed to the in situ generation of cisplatin. Both Pt(II) and Pt(IV) analogues of cisplatin, which offer high potency coupled with lower resistance potential and fewer use-limiting side effects (e.g., oto-, nephro-, and hematotoxicity), are currently on the market and in clinical trials. In addition to organometallics, the efficacy of sex hormones and hormone antagonists in fighting hormone-dependent cancers (e.g., estrogen receptor–positive breast cancer or prostate cancer) and the advent of therapeutic biological response modifiers with direct antiproliferative effects (e.g., interferons) has added significantly to the therapeutic options available to providers and the cancer patients for whom they care. Despite the wide range of antineoplastic agents currently available, it has been estimated that more than half of all patients with cancer ultimately succumb to their disease (8). Novel therapies based on an in-depth understanding of the molecular mechanisms involved in the complex cascade of events we call cancer are urgently needed. Fortunately, molecular targets for focused chemotherapeutic interventions are being discovered with increasing regularity, opening the door for the scientifically grounded development of new drugs. T he critical role of computer-based technology in facilitating the ability of chemists to conceptualize and visualize molecular interactions between potential drugs and putative receptor targets that lead to rational drug design and development, as well as in analyzing and managing the overwhelming amounts of data that are generated from these studies, cannot be underestimated. Likewise, the availability of viable tumor cell lines has facilitated a disease-specific orientation to the hunt for more effective therapies. Currently, there are tumor cell lines for lung, colon, breast, and kidney cancers, as well as for melanoma and leukemia (8). Several monoclonal antibodies targeted to tumor cell antigens or proteins critical to cellular proliferation (e.g., human epidermal growth factor, vascular endothelial growth factor, tyrosine kinase, and proteasomes) have found their way to the U.S. market. In addition, several new targets for anticancer drug development currently are being actively explored by biomedical scientists (1,3). For example, cancer cells overexpress the enzyme telomerase, which inhibits the natural destruction of chromosomal telomeres (DNA caps), leading to unwanted cellular immortality. T elomerase inhibitors would be expected to reestablish cellular senescence and to halt uncontrolled cell division by maintaining the integrity of the telomeres and are being pursued as a new biochemical approach to disease attenuation or control. Other potential antineoplastic drug targets being seriously investigated are aberrant genes or enzymes unique to specific tumors and P-glycoprotein, which is overexpressed in P.1151 many cancers as a result of an amplified mdr-1 gene and responsible for the rapid ejection of antineoplastic agents from target cells. Other multidrug resistance–associated proteins (the MRP family) involved in this devastating rebound of the cancer cell also are being investigated as potential sites of therapeutic intervention. T he intense focus on resistance molecules such P-glycoprotein is warranted, because patients whose tumors express this efflux-promoting protein respond poorly to chemotherapy and have a poor prognosis (2).

Table 42.3. Estimated 2005 Incidence and M ortality of Common Cancers (3) Prostate/Breast M en Women

M en

Lung Women

Colorectal M en Women

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Incidence

M ortality

232,090

211,240

93,010

79,560

71,820

73,470

(33%)

(32%)

(13%)

(12%)

(10%)

(11%)

30,350

40,410

90,490

73,020

28,540

27,750

(10%)

(15%)

(31%)

(27%)

(10%)

(10%)

In the future, it is hoped that clinicians will be able to generate a genetic expression profile for each patient with cancer to help them predict response to all possible therapies and to guide pharmacotherapy selection.

Disease State Cancers generally can be classified as lymphatic, epithelial, nerve, or connective tissue related, and tumor nomenclature is based on tissue of origin as follows: carcinoma (epithelial origin), sarcoma (muscle or connective tissue origin), leukemia and lymphoma (lymphatic or hematologic origin), and glioma (neural origin). T he risk of developing epithelial-derived cancers increases with age.

Incidence Approximately 1.3 million cases of cancer are diagnosed each year in the United States, resulting in an estimated 570,280 annual deaths (3). T he most commonly acquired cancers include those of the prostate, breast, lung, colon, and rectum. Lung cancer is the most fatal and is responsible for approximately 160,000 deaths each year. T hese prominent cancers (prostate/breast, lung, and colorectal) occur with very similar frequency in men and women, and little gender-related differences in mortality are noted (T able 42.3). Some geographical differences in incidence have been noted, with lung cancer being more prevalent in rural southern U.S. states, and breast and colon cancer more commonly diagnosed in the “ northeast corridor” of the United States (9).

Table 42.4. The American Cancer Society's M ajor Warning Signs of Cancer (10,11) Cancer Warning Signs in Adults

Cancer Warning Signs in Children

Change in bowel or bladder habits

Continued, unexplained weight loss

A sore that does not heal

Frequent headaches, with vomiting

Unusual bleeding or discharge

Localized pain or persistent limping

Thickening or lump in breast or elsewhere

Any unusual mass or swelling

Indigestion or difficulty in swallowing

Sudden eye or vision changes

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Obvious change in a wart or mole

Recurrent or unexplained fever

Nagging cough or hoarseness

Excessive bruising or bleeding Noticeable paleness or loss of energy

Signs and Symptoms T he clinical manifestations of cancer can vary widely depending on type and stage of neoplastic disease. T he American Cancer Society has been promulgating its list of the major warning signs of cancer for decades (T able 42.4) (10,11). Patients are well-served by being familiar with these early warning signs, because cancer is most effectively treated when diagnosed before more life-threatening symptoms appear. One readily recognized symptom of cancer is persistent weight loss (especially in children), and severe, unrelenting pain is a hallmark symptom of cancer in the later stages. Solid tumors can become palpable or observable masses when the cancer is advanced.

Biochemical Bases and Causes of Cancer Currently, it is understood that cancer is caused by mutations in “ resident” or normal genes rather than by the introduction of foreign genes into otherwise healthy systems (1,3). T he single-gene theory of cancer (where a single mutation could result in neoplastic disease) has been abandoned in favor of the multiple mutation prerequisite, and complex gene pathways, interactions, and communications are now the focus of study in the understanding of P.1152 malignant processes and their treatments. Once determined, the “ mutational profile” of malignant cells may very well predict such parameters as disease severity, most promising therapeutic interventions, and clinical outcome.

Table 42.5. RNA and DNA Viruses Associated with Cancer Development (12,13) RNA Virus

Cancer

Human T-lymphotrophic virus

Adult T-cell leukemia (ATL)

Hepatitis C

Hepatocellular carcinoma (HCC)

DNA Virus

Cancer

Hepadnavirus

Hepatocellular carcinoma (HCC)

Papillomavirus

Skin cancer, cervical cancer

Epstein-Barr virus

Burkett's lymphoma, Hodgkin's disease, anaplastic nasopharyngeal carcinoma, gastric cancer

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Herpesvirus

Karposi's sarcoma

T he development of cancer occurs in four discrete steps or phases. In the initiation phase, exposure to a precipitating carcinogen prompts irreversible mutation in a number of different genes. T he prom otion phase is a time during which mutated cells arising from altered genes grow preferentially compared to normal cells. T his preferential growth can result from continued exposure to the original carcinogen or from promotion by environmental “ accelerants.” T his stage is reversible, so cancer sometimes can be avoided with appropriate changes in diet and lifestyle. T he transform ation phase is the 5- to 20-year progression of a mutated cell to a cancer cell. Cellular proliferation, clonal colony development, tissue invasion and destruction, and metastasis defines the final progre ssion phase of cancer development (3). As previously mentioned, the genetic mutations leading to the diseases that we call cancer can be stimulated by a variety of chemical, environmental, and viral triggers. Both RNA retroviruses and DNA viruses have been implicated in human cancer causation (T able 42.5), although many more DNA than RNA viruses have oncogenic potential (12,13). Individuals in certain occupations may be at enhanced risk for the development of some cancers because of unavoidable exposure to carcinogenic chemicals (9). Perhaps the best-known example of occupationally induced cancer involves exposure to asbestos, which has been conclusively linked with the development of lung, pleural, and peritoneal malignancies. Miners exposed to radon also are at a significantly enhanced risk for the development of lung cancer, as are individuals exposed through their work to soot, tars, hexavalent chromium, and nickel-containing compounds. T he aromatic amines β-naphthylamine and 4-aminobiphenyl are known to induce bladder cancer, and exposure to the common organic solvent benzene has been linked to the development of leukemia.

Table 42.6. Some Environmental Precipitants of Cancer (9) Environmental Cancer Precipitant

Cancer Type

Tobacco

Lung, oral, bladder, pancreatic, stomach, and renal cancer

Alcohol

Liver, rectal. and breast cancer

Tobacco plus alcohol

Oral cancers

Radon

Lung cancer

Halogenated compounds

Bladder cancer

Immunosuppressive agents

Lymphoma

Herbicides

Lymphoma

Ionizing or ultraviolet radiation

Leukemia, breast, thyroid, lung, and skin cancer

Environmental carcinogens are all around us (T able 42.6). Fortunately, however, individuals can do many

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things to protect themselves from exposure or from negative consequences of limited exposure. T he chemicals deposited in the lungs from inhaling cigarette smoke are the primary cause of lung cancer in the United States, but smokers who quit decrease their risk for this often-fatal cancer by 67% or more after 10 smoke-free years (9). Nonsmokers can protect themselves from the cancer-promoting effects of secondhand smoke by removing themselves from smoke-filled environments, although this is not always as simple as it sounds. Smoking combined with alcohol has a synergistic effect in promoting the development of oral cancer. In addition to quitting smoking, abstaining from alcohol or drinking in moderation is a choice that individuals can make in an effort to decrease their overall risk of developing cancer. Other measures that patients can take to minimize the risk of cancer from environmental causes include protection from damaging ultraviolet rays through the use of high-SPF sunscreens and the consumption of foods that are low in fat but rich in carotenoids, vitamins A and C, folate, selenium, and/or fiber (9).

General T herapeutic Approaches Overview Cancer treatment can be comprised of surgery, radiation, antineoplastic chemotherapy, and/or therapy with biological response modifiers, which stimulate the patient's own immunological defense mechanisms. Surgery and radiation (ionizing, thermal, or photodynamic) are favored for isolated or localized cancers; chemotherapy and biological response modifiers (with or without surgery and/or radiation) are reserved for disseminated or systemic cancers. Chemotherapy also can be used after surgery and/or radiation as an “ insurance policy” against microscopic metastatic disease (adjuvant therapy) or before surgery to decrease the size of the mass to be removed (neoadjuvant therapy). Unfortunately, cancer cells do not simply “ lie down” in the face of chemotherapeutic intervention. Rather, these aggressive cells fight back in an attempt to retain their P.1153 immortality. Some cancer cells acquire resistance to anticancer drugs by down-regulating enzymes essential for drug transport or for the activation of antineoplastic pro-drugs or by up-regulating enzymes involved in inactivating biotransformation. As noted previously, other mechanisms of biochemical retaliation include down-regulation of target enzymes, altered drug uptake and efflux mechanisms (e.g., amplification of the gene that encodes for P-glycoprotein or the multidrug resistance–associated protein), inhibition of cellular repair proteins, and apoptosis inhibition (2,3,4).

Cancer Chemotherapy T he word “ antineoplastic” means “ against new growth.” In general, the mechanism of cytotoxic action for all antineoplastic agents is interference with cellular synthesis or the function of RNA, DNA, and the proteins that sustain life. All antineoplastic agents are poisons, because they are designed to kill cells. An ideal antineoplastic, however, would be both tissue specific (i.e., would only target the diseased organ or physiological system) and cell specific (i.e., would only destroy malignant cells), leaving healthy cells and organ systems alone. Unfortunately, the ideal is not yet the reality, because currently available anticancer drugs are highly and, often, generally toxic, especially for cells with short half-lives. For example, nonspecific destruction of the rapidly dividing cells of the gastrointestinal (GI) tract leads to the severe nausea and vomiting associated with cancer chemotherapy, whereas alopecia and fatigue (as well as susceptibility to infection) are the result of the destruction of rapidly dividing cells in hair follicles and bone marrow, respectively. Factors such as the extent and severity of the disease, individual sensitivity to the antineoplastic mechanism employed by the drugs selected for use, and the kinetics controlling drug transport and cell-cycle specificity all impact the chance for chemotherapeutic success (2). Because cancer chemotherapy often is given in several courses or “ rounds,” with an interval of several days or weeks in between to permit attenuation of side effects, three distinct aspects of drug dosing must be considered when determining the impact of antineoplastic therapy on overall patient welfare. First, the dose that ideally should be given per course has been identified for each commonly employed antineoplastic agent but can be altered significantly by individual patient health status (e.g., hepatic, renal, cardiovascular, hematopoietic, pulmonary, and/or other comorbidities), activity/performance status, genetic makeup, and the nature and anticipated severity of side effects. Each round of antineoplastic therapy kills a given percentage of cancer cells with each administration (“ cell kill hypothesis” ), and the percentage killed rises proportionally

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4

with the dose of drug. If chemotherapy can shrink the tumor to 10 or fewer cells, normal host defense systems usually are capable of eradicating them (2,3). T herefore, the dose of drug that comes as close as possible to the recommended dose is the goal. Expect significant interpatient variation in response to the same chemotherapeutic regimen secondary to individual genetics, level of debilitation, extent of tissue invasion, critical organ system function (including bone marrow), and past exposure to chemotherapeutic agents. An ever-growing understanding of genetic polymorphism and its impact on the biosynthesis of target proteins and metabolizing enzymes is helping health care providers make wiser decisions about antineoplastic therapy and drug regimens. T he length of the “ drug-free” interval is the second important drug-dosing consideration, because a shorter interval (or higher dose intensity—the “ one-two punch” ) is associated with a more aggressive inhibition of tumor growth. Often, however, patients cannot tolerate the debilitating side effects (e.g., myelosuppression) without a prolonged interval between rounds. T he advent of genetically engineered biological response modifiers, such as granulocyte colony-stimulating factor, which boosts the ability of bone marrow to produce neutrophils, has had a positive impact on optimizing dosing intensity/density. Finally, many chemotherapeutic agents produce serious chronic or delayed toxicities that may be irreversible, particularly in heart, lung, and kidneys, which demands that the total cumulative dose be taken into account when designing the regimen. T he ultimate balancing act is to give the patient as much antineoplastic drug as normally is recommended in the time frame most likely to kill the greatest percentage of cancer cells without inducing intolerable or life-threatening toxicity in healthy organs and tissues. Armed with the knowledge of the biochemical and/or molecular basis of toxicity, the pharmacist is in an excellent position to employ appropriate pharmacotherapeutic agents to attenuate unavoidable side effects. One approach for minimizing unwanted toxicity is to employ a chemotherapeutic regimen of several drugs that act by distinct mechanisms and/or precipitate different side effects. Attacking the tumor with different therapeutic “ guns” should permit a lower dose of each to be used compared to single-agent therapy, and it should target a larger variety of the mutant cells that comprise the tumor. Minimizing side effect overlap provides a greater chance that the patient will be able to tolerate therapy and accommodate a shorter interval between courses (2,3). As previously noted, it is essential that the oncology pharmacist be well versed in the pharmacotherapy-based management of severe pain, infection, and the nausea, vomiting, and fatigue associated with chemotherapy. T he provision of contemporary and valid drug information to patients and families is essential, as is assistance in helping with the interpretation of information that patients and loved ones secure either through their health care providers or independently (e.g., from the Internet). P.1154

T herapeutic Classes of Anticancer Drugs DNA Cross-Linking Agents (Alkylators and Organic M etallics) T he primary target of DNA cross-linking agents is the actively dividing DNA molecule. T he DNA cross-linkers + are all extremely reactive electrophilic (δ ) structures. When encountered, the nucleophilic groups on various 7

DNA bases (particularly, but not exclusively, the N of guanine) readily attack the electrophilic drug, resulting in irreversible alkylation or complexation of the DNA base. Some DNA alkylating agents, such as the nitrogen mustards and nitrosoureas, are bifunctional, meaning that one molecule of the drug can bind two distinct DNA bases. Most commonly, the alkylated bases are on different DNA molecules, and interstrand DNA cross-linking through two guanine N 7 atoms results. T he DNA alkylating antineoplastics are not cell-cycle specific, but they are more toxic to cells in the late G 1 or S phases of the cycle. T his is the time when DNA is unwinding and exposing its nucleotides, enhancing the chance that vulnerable DNA functional groups will encounter the electrophilic antineoplastic drug and launch the nucleophilic attack that leads to its own destruction. T he DNA alkylators have a great capacity for inducing both mutagenesis and carcinogenesis; in other words, they can promote cancer in addition to treating it. Organometallic antineoplastics (platinum coordination complexes) also cross-link DNA, and many do so by binding to adjacent guanine nucleotides, called diguanosine dinucleotides, on a single strand of DNA. T his leads to intrastrand DNA cross-linking. T he anionic phosphate group on a second strand of DNA stabilizes

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the drug-DNA complex and makes the damage to DNA replication irreversible. Some organometallic agents also damage DNA through interstrand cross-linking.

Nitrogen Mustards and Aziridine-Mediated Alkylators

Nitrogen mustards are bis(β-haloalkyl)amines. T he term “ bis” means two, and the “ halo” (short for “ halogen” ) in the nomenclature is invariably chlorine. T he two chlorine atoms dramatically decrease the basic strength of the amino nitrogen through a strong negative inductive effect. As a result, the un-ionized conjugate of these drugs predominates at physiological pH. T his is intentional, because it is the unionized amine (with its lone pair of electrons) that allows the formation of the highly electrophilic aziridinium ion, which is the reactive DNA-destroying intermediate generated by all true mustards.

Mechanism of action T he mechanism of action of the nitrogen mustards (14) is depicted in Figure 42.1. In step 1, the lone pair of electrons on the un-ionized amino group conducts an intramolecular nucleophilic attack at the β-carbon of the mustard, displacing chloride ion and forming the highly electrophilic aziridinium ion intermediate, a quaternary amine salt. T he carbon atoms of this strained cyclic structure are highly electrophilic P.1155 because of the strong negative inductive effect of the positively charged nitrogen atom.

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Fig. 42.1. DNA destruction through nitrogen mustard-mediated alkylation.

In step 2, a DNA nucleophile conducts an intermolecular nucleophilic attack, which breaks the aziridine ring and alkylates DNA. Although guanine is the preferred nucleic acid base involved in the alkylation reaction, adenine also is known to react. Of critical importance is the fact that the lone pair of electrons on the mustard nitrogen is regenerated when the aziridine ring cleaves. Steps 3 and 4 are simply repetitions of steps 1 and 2, respectively, involving the second arm of the mustard and a second molecule of DNA. Ultimately, two molecules of DNA will be cross-linked through the carbon atoms of what was once the nitrogen mustard. Finally, hydrolytic depurination (step 5) cleaves the bound guanine residues from the DNA strand. T his is an attempt to liberate the DNA from the mustard's covalent “ stranglehold,” but the DNA released from this mustard trap is damaged and unable to replicate. Cell death is the inevitable result. If this is happening in a tumor cell, the therapeutic goal has been accomplished. If it is happening in a healthy cell, particularly one with a short half-life, then the patient may experience side effects that can be use-limiting.

Structure–activity relationships T he structure of nitrogen mustards differs only in the nature of the third group (R) attached to the amino nitrogen. T his group, which can be either aliphatic or aromatic, is the prime determinant of chemical reactivity, oral bioavailability, and the nature and extent of side effects. An aliphatic nitrogen substituent (e.g., CH 3 ) will push electrons to the amine through σ bonds. T his electronic enrichment enhances the nucleophilic character of the lone pair of electrons and increases the speed at which the δ + β-carbon of the mustard will be attacked. Whether in a tumor cell or a healthy cell, the aziridinium ion, as soon as it forms, will react with unpaired DNA and/or other cell nucleophiles, such as electron-rich SH, OH, and NH groups of amino acids on enzymes or membrane-bound receptors. T he body's water also can react with (and inactivate) the aziridinium ion. T he intra- and intermolecular reactions designated as steps 1 through 4 in Figure 42.1 happen so rapidly that almost no chance exists for tissue or cell specificity, which means a greatly increased risk of serious side effects and use-limiting toxicity. Conversely, an aromatic nitrogen substituent (e.g., phenyl) conjugated with the mustard nitrogen will stabilize the lone pair of electrons through resonance. Resonance delocalization significantly slows the rate of intramolecular nucleophilic attack, aziridinium ion formation, and DNA alkylation. Aromatic mustards have a reactivity sufficiently controlled to permit oral administration and attenuate the severity of side effects. T he higher stability also provides the chance for enhanced tissue selectivity by giving the intact mustard time to reach malignant cells before generating the electrophilic aziridinium ion. Nitrogen mustards can decompose in aqueous media through formation of the inactive dehalogenated diol shown in Figure 42.2. Both the mustard nitrogen (pathway a) and the oxygen of water (pathway b) can act as nucleophiles to advance this degradative process. T he decomposition reactions can be inhibited if the nucleophilic character of these atoms is eliminated through protonation, so buffering solutions to a slightly acidic pH helps to enhance stability in aqueous solution.

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Fig. 42.2. Aqueous decomposition of nitrogen mustards.

Specific drugs Mech loreth amin e Hydroch loride Mechlorethamine is the only aliphatic nitrogen mustard currently on the U.S. market (Fig. 42.3). Its use is limited by extremely high reactivity, which leads to rapid and nonspecific alkylation of cellular nucleophiles and excessive toxicity. It is a severe vesicant, and if accidental skin contact occurs, the drug must be inactivated with 2% sodium thiosulfate (Na 2 S 2 O 3 ) solution. T his reagent reacts with the mustard to create an inactive, highly ionized, and water-soluble thiosulfate ester that can be washed away (Fig. 42.4). T he affected tissue also should be treated with an ice compress for 6 to 12 hours. Mechlorethamine is marketed in hydrochloride salt form to provide water solubility for intravenous (IV) or intracavitary administration. T he strong electron-withdrawing effect of the two chlorine atoms reduces the pK a of mechlorethamine to 6.1, which gives a ratio of un-ionized to ionized drug forms of approximately 20:1 at pH 7.4. T his agent is too reactive for oral administration and too toxic to use alone. In addition to severe nausea and vomiting, myelosuppression (lymphocytopenia and granulocytopenia), and alopecia, it can cause myelogenous leukemia with extended use because of its mutagenic/carcinogenic effects on bone marrow stem cells. Mechlorethamine is still used in regimens for cancers of the blood (e.g., Hodgkin's disease, chronic myelocytic, or chronic lymphocytic leukemia); fortunately, however, safer and still highly potent antineoplastic agents are now available. P.1156

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Fig. 42.3. DNA cross-linking agents.

Melph alan T his aromatic mustard, used primarily in the treatment of multiple myeloma, is able to stabilize the lone pair of electrons on the mustard nitrogen through resonance with the conjugated phenyl ring, slowing the formation of the reactive aziridinium ion. T he L-isomer of the amino acid Phe was purposefully incorporated into this antineoplastic agent (Fig. 42.3), because naturally occurring L–amino acids are preferentially transported into cells by the action of specific amino acid carrier proteins. It was assumed that the L-Phe would act as a homing device and actively transport the toxic mustard inside the tumor cells, but some studies indicate that melphalan enters cells through facilitated diffusion rather than by active transport (15). Because the lone pair of electrons of melphalan (and other aromatic mustards) is less reactive, there is a greater opportunity for distribution to cancer cells and a decreased incidence of severe side effects. T here is a lower incidence of nausea and vomiting compared to mechlorethamine, but patients still experience myelosuppression, which can P.1157 be severe. T his drug also is mutagenic and can induce leukemia.

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Fig. 42.4. Mechlorethamine inactivation by sodium thiosulfate.

Melphalan is orally active, but absorption can be erratic. Absorption is decreased with food, but dosing regimens do not demand an empty stomach. T he drug can be formulated for IV administration, but the risk of serious side effects is higher. Melphalan distributes into body water, so toxicity can be pronounced in dehydrated patients or in those with renal dysfunction. Dehydration can be corrected, but dosage adjustments should be considered in patients with renal disease.

Ch lorambu cil Like melphalan, chlorambucil (Fig. 42.3) has good oral bioavailability, which is decreased in the presence of food, and the potential to induce nonlymphocytic leukemia. T his drug is active intact and also undergoes β-oxidation to provide an active phenylacetic acid mustard metabolite, which is responsible for some of the observed antineoplastic activity. It is used in the palliative treatment of chronic lymphocytic leukemia, malignant lymphoma, and Hodgkin's disease.

Estramu stin e Ph osph ate Sodiu m T his resonance-stabilized, mustard-like antineoplastic agent utilizes an estradiol carrier (Fig. 42.3) to selectively deliver drug to steroid-dependent prostate tissue, and its use is limited to the palliative treatment of progressive prostate cancer. T he essential 17β-OH group has been esterified with phosphoric acid, and the C 3 -phenol has been carbamylated. T he body still, however, transports the basic steroidal pharmacophore into cells. T he ionized sodium phosphate ester of the active 17β-OH group makes the compound water soluble and able to distribute in the blood. T he ester is readily cleaved during absorption to provide the active 17β-OH. T he nitrogen mustard moiety of estramustine is incorporated into a carbamate group made from the

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C 3 -phenolic OH group of the estradiol structure. T he resonance and negative induction capabilities of the carbamate extensively delocalize the lone pair of electrons on the mustard nitrogen. T his stabilizes the lone pair in the same qualitative way that conjugation with the phenyl ring of melphalan and chlorambucil does, and it is very slow to attack the electrophilic β-carbon. Because the formation of the aziridinium ion is significantly delayed, DNA alkylation is controlled, and the drug can be given orally. Estramustine is considered to be a weak alkylating agent, and its primary mechanism of antineoplastic action actually is inhibition of cellular mitosis. T he carbamate group containing the mustard moiety can be cleaved in vivo to generate estradiol (Fig. 42.5). T his is obviously not desired, because the chemically reactive mustard is being detached from the carrier molecule designed to take it to the prostatic tumor cell. T he normal metabolites of estradiol (conjugates of estradiol and estriol) are found in the feces. T he formation of active estrogens is why this drug is not used to treat estrogen-dependent tumors (e.g., estrogen-dependent breast cancer). T he liberated estradiol also can increase blood pressure and induce blood clots, leading to myocardial infarction. Fortunately, the myocardial infarctions usually are nonfatal, but the drug should be used with extreme caution in men who are predisposed to clotting disorders or who have a history of cerebral vascular disease or coronary artery disease. Hepatotoxicity also is associated with estramustine use.

Fig. 42.5. Estramustine metabolism.

Cycloph osph amide Cyclophosphamide (Fig. 42.3) is a prodrug, antineoplastic agent requiring activation by metabolic and nonmetabolic processes (Fig. 42.6). T he initial metabolic step is mediated primarily by CYP2B6 (and, to a much lower extent, by CYP3A4) and involves hydroxylation of the oxazaphosphorine ring to generate a carbinolamine (16). T his hydroxylation reaction must occur before the molecule will be transported into cells. CYP3A4 (but not CYP2B6) also catalyzes an inactivating N-dechloroethylation reaction, which yields highly nephrotoxic and neurotoxic chloroacetaldehyde (16). Chloroacetaldehyde toxicity is accompanied by glutathione depletion, indicating that, as expected, this electrophilic by-product alkylates Cys residues of critical cell proteins (17). Alkylation of Lys, adenosine, and cytidine residues also is possible. T he CYP-generated carbinolamine undergoes nonenzymatic hydrolysis to provide the aldophosphamide either in the bloodstream or inside the cell. If this hydrolysis occurs extracellularly, the aldophosphamide is still able to penetrate cell membranes to reach the intracellular space. Once inside the cell, acrolein (a highly reactive α,β-unsaturated aldehyde) splits off, generating phosphoramide mustard. With a pK a of 4.75, the mustard will be persistently anionic at intracellular pH and trapped inside the cell. T he fate of phosphoramide mustard is varied. Most of it cyclizes to form the quaternary aziridinium ion, which alkylates DNA in the manner of all mustards. Some of it will decompose, losing phosphoric acid (H 3 PO 4 ) P.1158

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and ammonia (NH 3 ) and leaving the naked bis(β-chloroethyl)amine mustard. T his secondary amine cyclizes in a manner similar to the tertiary phosphoramide mustard, forming a tertiary aziridine (rather than a quaternary aziridinium) species. T he free tertiary aziridine can protonate at intracellular pH to provide the cationic aziridine species, which is in equilibrium with the free-base form. Some electrophilic character is lost, but the carbon atoms in both forms are still δ

+

enough to attract DNA nucleophiles, albeit less vigorously. T he net

result of this attack is DNA alkylation and cell death.

Fig. 42.6. Cyclophosphamide metabolism.

T he need for metabolic activation in the liver means lowered GI toxicity and less nonspecific toxicity for cyclophosphamide compared with other DNA alkylating agents, but cyclophosphamide is not without its toxic effects. Acrolein, generated during the formation of phosphoramide mustard, is a very electrophilic and highly reactive species and causes extensive damage to cells of the kidney and bladder. Potentially fatal acute hemorrhagic cystitis is a significant risk of cyclophosphamide therapy. Bladder damage from acrolein results from attack by Cys sulfhydryl groups at the δ + terminal carbon of the acrolein structure, resulting in renal cell alkylation and cell death. Physiological results can include severe hemorrhage, sclerosis, and on occasion, induction of bladder cancer. Acrolein also damages the nephron, particularly when used in high doses, in children, in patients with only one kidney, or when coadministered with other nephrotoxic agents (e.g., cisplatin). T o minimize the risk of bladder toxicity from acrolein, fluids should be forced and the bladder irrigated. Mesna (Mesnex) also is available as adjuvant therapy in case of overt toxicity or as a prophylactic protectant. A sulfhydryl reagent, mesna competes with Cys residues for the alkylating arolein, as shown in Figure 42.7. Mesna concentrates in the bladder and will prevent damage to those cells. It does not concentrate to any appreciable extent in the nephron and, therefore, is not good protection against cyclophosphamide-induced nephrotoxicity. As effective as mesna is for preventing acrolein-induced urotoxicity, it does little to spare the kidney and nerve cells from chloroacetaldehyde, the other toxic by-product of cyclophosphamide metabolism (18). Luckily, only approximately 10% of a standard dose of cyclophosphamide undergoes the dechloroethylation reaction, although this percentage can rise if higher doses are used (16). Cyclophosphamide most commonly is used in combination with other antineoplastic agents to treat a wide range of neoplasms, including leukemias and malignant lymphomas, multiple myeloma, ovarian adenocarinoma, and breast cancer. T he drug is metabolized in the liver P.1159 and is eliminated via the kidney, with approximately 15% of a given dose being excreted unchanged. Doses should be reduced in patients with levels of creatinine clearance less than 30 mL/min. Interestingly, hepatic dysfunction does not seem to alter metabolism of this drug, but caution should be exercised in patients with inhibited cytochrome P450 (CYP450) enzymes or with a combination of factors that could negatively impact drug activation/inactivation pathways.

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Fig. 42.7. Sulfhydryl alkylation by acrolein.

Ifosfamide T his cyclophosphamide analogue has the two arms of the mustard on different nitrogen atoms (Fig. 42.3). Ifosfamide also requires metabolic activation (Fig. 42.8), but this time it is the CYP3A4 isoform that converts the majority of the dose to the carbinolamine, with CYP2B6 taking on a minor, supporting role (19). Because ifosfamide has a lower affinity for the hydroxylating CYP3A4 and CYP2B6 enzymes, presumably as a result of steric hindrance, bioactivation proceeds at a slower rate (20). Doses three- to fourfold higher than cyclophosphamide are required to achieve the same antineoplastic result. Unlike cyclophosphamide, dechloroethylation is a significant metabolic pathway for ifosfamide, and approximately 45% of a standard dose will undergo this inactivating and toxicity-inducing biotransformation. CYP3A4 catalyzes approximately 70% of ifosfamide dechloroethylation, with CYP2B6 taking care of the remainder (16). T he fact that this reaction can occur in the renal tubule, generating chloroacetaldehyde right in the nephron, contributes to its significantly higher nephrotoxicity (20). Ultimately, both chloroalkyl groups are lost before the compound is excreted. It bears repeating that there is a significantly higher risk of bladder toxicity and nephrotoxicity with ifosfamide than with cyclophosphamide. T his is because: Significantly more chloroacetaldehyde is generated through CYP3A4- and CYP2B6-mediated dechloroethylation. T his biotransformation can take place in the nephron, which places the toxic by-product right where it will do the most damage. Ifosfamide is more water soluble than cyclophosphamide and will concentrate in the renal system. Between 20 and 50% of a dose is excreted unchanged in the urine. Acrolein also is formed when this alkylator generates the cytotoxic aziridiniun ion. Higher doses must be administered to achieve the same degree of antineoplastic action, so more molecules of acrolein and chloroacetaldehyde will be produced. Because acrolein is formed, the same precautions against hemorrhagic cystitis that were previously outlined for cyclophosphamide must be taken: hydrate well, irrigate thoroughly, and administer with mesna. As previously stated, mesna will not prevent chloroacetaldehyde-induced toxicity.

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Fig. 42.8. Ifosfamide metabolism.

P.1160 Ifosamide currently is used as “ third-line” therapy against testicular cancer, although it also has shown activity in a number of solid tumors and hematologic cancers. Patients on ifosfamide (but not cyclophosphamide) commonly exhibit central nervous system (CNS) toxicity. In severe forms, CNS depression can progress to coma and death.

T h iotepa T hiotepa (Fig. 42.3), a tertiary aziridine, is less reactive than quaternary aziridinium compounds and is classified as a weak alkylator. It is possible for the nitrogen atoms to be protonate before reacting with DNA (a positively charged aziridine is more reactive than the un-ionized aziridine), but the electron-withdrawing effect of the sulfur atom decreases the pK a to approximately six, which keeps the percentage ionized at pH 7.4 relatively low. T hiotepa undergoes oxidative desulfuration, forming an active cytotoxic metabolite known as T EPA (triethylenephosphoramide). T his antineoplastic agent is most commonly employed in the treatment of ovarian and breast cancers, as well as papillary carcinoma of the bladder.

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T hiotepa and the T EPA metabolite readily enter the CNS after systemic administration, leading to dizziness, blurred vision, and headaches. More critically, these agents also are severe myelosuppressants and can induce leukopenia, thrombocytopenia, and anemia. Patients treated with thiotepa are at high risk for infection and hemorrhage. Oral absorption is unreliable, so thiotepa is given IV or can be instilled intravesically in the treatment of bladder cancer. Even when administered locally in bladder cancer, high levels of this lipophilic drug reach the systemic circulation, resulting in bone marrow depression. Patients have died from myelosuppression after intravesically administered thiotepa. T he drug also causes damage to the hepatic and renal systems. Dose and/or administration frequency should be increased slowly, even if the initial response to the drug is sluggish, or unacceptable toxicity may result.

Nitrosoureas Mechanism of action T he nitrosoureas are unstable structures that decompose readily in the aqueous environment of the cell. Nonenzymatic fragmentation is stimulated by the loss of proton from the urea moiety. Cyclization of the resultant anion to an unstable oxazolidine (pathway A) is followed by decomposition to vinyl diazotic acid and a substituted isocyanate, both of which release a gaseous fragment (nitrogen and carbon dioxide, respectively) to generate cytotoxic electrophiles (Fig. 42.9). Vinyl carbocation, acetaldehyde, and 2-chloroethylamine generated from the 2-chloroethylisocyanate moiety of carmustine are all capable of alkylating DNA in the standard manner (21). A second decomposition mechanism (pathway B) ultimately produces an electrophilic 2-chloroethylcarbocation capable of DNA alkylation at guanine-N 7 and O 6 as well as an isocyanate that can carbamylate amino acid residues (e.g., Lys).

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Fig. 42.9. Nitrosourea decomposition to active electrophiles.

Specific drugs Carmu stin e an d Lomu stin e Carmustine and lomustine are both highly lipophilic chloroethylnitrosourea analogues marketed for use in brain tumors and Hodgkin's disease. Carmustine also has shown value in the treatment of non-Hodgkin's lymphoma and multiple myeloma, and it is given IV or incorporated into biodegradable wafers that are implanted directly into the CNS after tumor resection. T he high lipophilicity of carmustine precludes a totally

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aqueous IV formulation, and the drug is administered in 10% ethanol. Although carmustine degrades within 15 minutes of IV administration, lomustine is stable enough for oral use and is marketed in capsule form. Carmustine also can P.1161 decompose in vitro if exposed to temperatures around 90°F. Pure carmustine is a low-melting solid, but the decomposed product is an oil and, therefore, is readily detected. Vials of carmustine that appear oily should be discarded. Both carmustine and lomustine can induce thrombocytopenia and leukopenia, leading to hemorrhage and massive infection. Acute (as well as potentially fatal delayed) pulmonary toxicity also is a risk. Pulmonary toxicity is dose-related, and individuals who received the drug in childhood or early adolescence are at higher risk for the delayed reaction. T he grand mal seizures that are possible from the wafer formulation of carmustine appear to result from the wafer rather than from the nitrosourea.

Streptozocin T he glucopyranose moiety of streptozocin confers both islet cell specificity and high water solubility to this nitrosourea-based antineoplastic. As a result, it is used exclusively in metastatic islet cell carcinoma of the pancreas and is administered IV in D5W or normal saline. Lacking the 2-chloroethyl substituent of carmustine and lomustine, it is much less reactive as a DNA alkylating agent, and myelotoxicity is relatively rare but not unknown. Cumulative, dose-related renal toxicity can be severe or fatal, however, and 67% of patients receiving this drug will exhibit some kidney-related pathology. Good hydration is essential to successful therapy, and kidney function should be monitored weekly.

Procarbazine and Triazenes Mechanism of action Procarbazine and the triazenes dacarbazine and temozolomide act by different mechanisms, but they all exert an antineoplastic effect through the O 6 -methylation of guanine nucleotides. O 6 -methylguanine pairs preferentially with thymine, and these “ mispairs” prompt point mutations during subsequent DNA replication cycles and trigger cell destruction through the activation of the normal postreplication mismatch repair (MMR) system. Patients who are able to repair this damage through the action of O 6 -alkylguanineDNA-alkyltransferase, which transfers the offending CH 3 group to a Cys residue on the alkyltransferase protein, will exhibit resistance to these agents, whereas those who underexpress this protein should respond well (22). Because the alkyltransferase is irreversibly inactivated in the DNA rescue process, enzyme depletion (and subsequent loss of DNA repair capability) is a significant risk. Procarbazine metabolism involves CYP1A and CYP2B enzymes (23), and DNA alkylation operates through a free radical mechanism (Fig. 42.10). T he major degradation pathway involves benzylic oxidation of azoprocarbazine, producing methylhydrazine that generates a methyl radical through an unstable diazene intermediate (24,25) In addition to O 6 , the reactive methyl radical formed can alkylate the C 8 and N 7 positions of guanine. In contrast, the triazenes methylate DNA guanine via diazomethane and/or methyl carbocation generated in situ. Although temozolomide is converted to the diazomethane precursor 3-methyl-(triazen-l-yl) imidazole-4-carboxamide (MT IC) through nonenzymatic mechanisms, the conversion of dacarbazine to MT IC depends on the action of CYP1A1 and CYP1A2 enzymes, with a smaller contribution by CYP2E1 (Fig. 42.11) (23,26). T he O 6 and N 7 positions of guanine are the most vulnerable to triazene methylation.

Specific drugs Procarbazin e T his methyl radical generator is utilized predominantly in the treatment of Hodgkin's disease. It is administered as part of a multidrug regimen that also includes a nitrogen mustard (mechlorethamine), a mitosis inhibitor (vincristine), and prednisone. It is administered as capsules and is well absorbed after oral administration. Procarbazine is extensively metabolized in the liver, and 70% of an administered dose is excreted in the urine as N-isopropylterephthalamic acid (Fig. 42.10). In addition to P.1162

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methylating DNA guanine residues, it is proposed to inhibit the de novo synthesis of proteins and nucleic acids. Procarbazine inhibits monoamine oxidase, leading to several significant and potentially fatal drug–drug and drug–food interactions. Facial flushing and other disulfiram-like symptoms are noted when alcohol is concomitantly consumed, because the drug also inhibits enzymes involved in ethanol metabolism.

Fig. 42.10. Procarbazine metabolism and mechanism of action.

Fig. 42.11. Metabolic activation of triazenes.

Dacarbazin e T his DNA methylating agent is administered IV as a single agent in the treatment of malignant melanoma and in combination with other agents in the treatment of metastatic melanoma. Approximately 40% of the drug is

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excreted unchanged, but both the 5-aminoimidazole-4-carboxamide (AIC, formed through the action of CYP1A enzymes) and the carboxylic acid (AIC hydrolysis product) are major urinary metabolites (Fig. 42.11). Leukopenia and thrombocytopenia are the most common side effects and may be fatal. Patients also are at risk for hepatotoxicity, including hepatocellular necrosis.

T emozolomide T his imidazolotetrazine derivative is administered orally in capsule form for the treatment of glioblastoma multiforme or in patients with anaplastic astrocytoma who have not responded to procarbazine or the nitrosoureas. Oral absorption is rapid and complete. T he CYP450 enzymes are not extensively involved in temozolomide metabolism, and less than 6% of the drug is excreted unchanged in the urine. Women clear the drug less effectively than men and have a higher incidence of severe neutropenia and thrombocytopenia in the initial therapy cycle. Food decreases temozolomide absorption, and myelosuppression is the most significant adverse effect.

Miscellaneous DNA Alkylating Agents Altretamine T his unique structure (Fig. 42.3) is believed to damage tumor cells through the production of the weakly alkylating species formaldehyde, a product of CYP450-mediated N-demethylation. Administered orally, altretamine is extensively metabolized on first pass, producing primarily mono- and didemethylated metabolites. Additional demethylation reactions occur in tumor cells, releasing formaldehyde in situ before the drug is excreted in the urine. T he carbinolamine (methylol) intermediates of CYP450-mediated metabolism also can generate electrophilic iminium species that are capable of reacting covalently with DNA guanine and cytosine residues as well as protein (Fig. 42.12). Iminium-mediated DNA cross-linking and DNA-protein interstrand cross-linking, mediated through both the iminium intermediate and formaldehyde, have been demonstrated (27,28), although the significance of DNA cross-linking on altretamine antitumor activity is uncertain. Resistance to altretamine has been shown to parallel resistance to formaldehydeinduced cytotoxicity (27). Its use currently is restricted to patients with ovarian cancer who have not responded to organoplatinum therapy. T he toxicities induced by altretamine are GI, neurologic, and hematologic in nature.

Busulfan Chemically, busulfan is classified as an alkyl sulfonate (Fig. 42.3). One or both of the methylsulfonate ester 7 moieties can be displaced by the nucleophilic N of guanine, leading to monoalkylated and cross-linked DNA, as shown in Figure 42.13. T he extent of alkyl sulfonate–mediated DNA interstrand cross-linking has been shown to vary with the length of the alkyl chain between sulfonate esters, with the tetramethylene-containing

busulfan showing less interstrand cross-linking capability than hexamethylene, methylene, or octamethylene analogues (29). P.1163 Intrastrand cross-linking also occurs, preferentially at 5′-GA-3′ but also at 5′-GG-3′ sequences (30). Alkylation of Cys sulfhydryl groups is yet another mechanism of cytotoxicity. Busulfan is used in the treatment of chronic myelogenous leukemia and can be administered either orally or by IV infusion. Serious bone marrow hypoplasia and myelosuppression are possible with this agent, and recovery from busulfaninduced pancytopenia can take up to 2 years.

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Fig. 42.12. Altretamine metabolism and mechanism of action.

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Fig. 42.13. Busulfan-mediated DNA alkylation.

Organoplatinum Complexes Mechanism of action Organoplatinum antineoplastic agents contain an electron-deficient metal atom that acts as a magnet for electron-rich DNA nucleophiles. Like nitrogen mustards, organoplatinum complexes are bifunctional and can accept electrons from two DNA nucleophiles. Intrastrand cross-links most frequently occur between adjacent guanine residues referred to as diguanosine dinucleotides (60–65%) or adjacent guanine and adenine residues (25–30%). Interstrand cross-linking, which occurs much less frequently (1–3%), usually involves guanine and adenine bases (31). All the currently marketed organoplatinum anticancer agents are Pt(II) complexes with square-planar geometry, although an octahedral Pt(IV) complex currently is undergoing clinical trials.

Platinum is inherently electron deficient, but the net charge on the organometallic complex is zero because of the contribution of electrons by two of the four ligands bound to the parent structure. Most commonly, the electron-donating ligand is chloride. Before reacting with DNA, the electron-donating ligands most commonly are displaced through nucleophilic attack by cellular water. When the displaced ligands are chloride anions (e.g., in cisplatin), the chloride-poor environment of the tumor cell facilitates the process, driving the generation of the active, cytotoxic hydrated forms (Fig. 42.14). Because the original ligands leave the metal with their electrons, the hydrated organoplatinum molecule has a net positive charge (32). T he hydrated platinum analogues are readily attacked by DNA nucleophiles (e.g., the N 7 of adjacent guanine residues) because of the net positive charge that has P.1164 been regained on the Pt atom (Fig. 42.14). T he DNA bases become coordinated with the platinum, and in the ci s configuration, DNA repair mechanisms are unable to correct the damage. T he net result is a major change in DNA conformation such that base pairs that normally engage in hydrogen-bond formation are not permitted to interact. T he two ammine ligands of the complex are bound irreversibly to the Pt atom through very strong coordinate covalent bonds. T hey cannot be displaced by DNA nucleophiles, but they do stabilize the cross-linked DNA-platinum complex by forming strong ion–dipole bonds with the anionic phosphate residues on DNA.

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Fig. 42.14. Cisplatin activation and DNA cross-linking.

Specific drugs Cisplatin T he simplest of the organometallic antineoplastic agents, cisplatin is utilized IV in the treatment of metastatic testicular and ovarian cancer and advanced bladder cancer. It is rapidly hydrated, resulting in a short plasma half-life of less than 30 minutes. It is eliminated predominantly via the kidney, but approximately 10% of a given dose undergoes biliary excretion. It is highly nephrotoxic and can cause significant damage to the renal tubules, especially in patients with preexisting kidney disease or one kidney or who are concurrently receiving other nephrotoxic drugs (e.g., cyclophosphamide or ifosfamide). Dosages should be reduced in any of the above situations. Clearance decreases with chronic therapy, and toxicities can manifest at a late date. T o proactively protect patients against kidney damage, patients should be hydrated with chloride-containing solutions. Saline or mannitol diuretics can be administered to promote continuous excretion of the drug and its hydrated analogues. Sodium thiosulfate, which accumulates in the renal tubules, also has been used to neutralize active drug in the kidneys in an effort to avoid nephrotoxicity (Fig. 42.15). T he reaction of sodium thiosulfate with cisplatin in the serum is much slower, because the drug does not concentrate there and what is there is very strongly bound to serum proteins. T he very strong protein binding explains why dialysis, even when prolonged, cannot rescue patients from cisplatin toxicity. Myelosuppression and ototoxicity, including irreversible hearing loss, also can occur with cisplatin use. Cisplatin is a very severe emetogen, and vomiting almost always will occur unless antiemetic therapy is coadministered. Cisplatin and the other organoplatinum anticancer agents react with aluminum and cannot be administered through aluminum-containing needles. T he drug is photosensitive, is packaged in amber bottles, and must be protected from light.

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Fig. 42.15. Cisplatin inactivation by sodium thiosulfate.

Carboplatin Carboplatin (Fig. 42.3), another square planar Pt(II) complex, forms the same cytotoxic hydrated intermediate as cisplatin but does so at a slower rate, making it a less potent chemotherapeutic agent. T he ultimate damage done to cells as a result of carboplatin use, however, approaches that of cisplatin. T he plasma half-life of carboplatin is 3 hours, and the drug is less extensively bound to serum proteins. Excretion is predominantly renal, and doses must be reduced in patients with kidney disease. Suppression of platelets and white blood cells is the most significant toxic reaction of carboplatin use. T his drug induces fewer nonhematological toxicities (e.g., emesis, nephrotoxicity, and ototoxicity) compared to cisplatin, and it is approved for use only in the treatment of ovarian cancer. Unlabeled uses include combination therapy in lung, testicular, and head and neck cancers.

Oxaliplatin T his Pt(II) complex loses oxalic acid as oxalate anion ( - OOC-COO - ) in vivo to form the mono- and dihydrated diaminocyclohexane (DACH) platinum analogues shown in Figure 42.16. T he trans-(R,R)-DACH structure serves as the carrier for the cytotoxic hydrated platinum and extends into the major groove of DNA when the DNA-Pt complex forms (33). Hydrophobic DNA intrusion is believed to contribute to the cytotoxicity of this organometallic agent. Oxaliplatin engages primarily in intrastrand cross-linking with diguanosine dinucleotides, adjacent A-G nucleotides, and guanines that are separated by one nucleotide (G-X-G). Interstrand cross-linking, although less common, also occurs. T he adduct formed between oxaliplatin and DNA diguanosine dinucleotides is conformationally distinct from the adduct formed with cisplatin. Specifically, whereas the cisplatin diguanosine dinucleotide adduct bends the DNA by 60 to 80° and presents a relatively wide minor groove, the oxaliplatin adduct produces a 31° bend with a comparatively narrow minor groove (34). P.1165 T his distinct oxaliplatin conformation is believed to result from the steric impact of the (R,R)-DACH carrier, which orients the hydrogen atoms on the ammine ligands such that the ci s-NH 3 can form a hydrogen bond with a guanine-O 6 , a bond that the inactive (S,S)-isomer is unable to form (35). T he conformation of the oxaliplatin-DNA adduct is much less likely to be recognized by MMR proteins, and the effectiveness of oxaliplatin in MMR-deficient cells is believed to be responsible for the lack of resistance that has plagued cisplatin and carboplatin (36,37). Oxaliplatin often retains activity in patients who are no longer responding to the “ first-generation” organometallics and also is significantly less mutagenic, nephrotoxic, hematotoxic, and ototoxic than cisplatin. Excretion is via the kidney.

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Fig. 42.16. Activation of oxaliplatin.

Oxaliplatin decomposes in alkaline media and should not be coadministered with drugs that will increase the pH of the IV solution. Oxaliplatin is used in the treatment of metastatic colon or rectal cancer, either alone or in combination with 5-fluorouracil. Pulmonary fibrosis and peripheral sensory neuropathies that can be life-threatening are known to occur. It has been proposed that the latter adverse effect is caused by oxalate-based chelation of intracellular Ca 2+ , which inhibits voltage-gated sodium channels in sensory nerve cells (38). T his hypothesis is supported by the observation that infusions of calcium or magnesium salts can significantly attenuate oxaliplatin-induced neuropathy without compromising therapeutic efficacy (39). In the future, exploitation of genetic differences in the expression of various repair proteins, growth factors, and metabolizing enzymes may allow the tailoring of oxaliplatin therapy based on an individual's pharmacogenetic profile (37).

Satraplatin T his newest organometallic agent (Fig. 42.3) currently is in clinical trials as a second-line agent for the treatment of hormone-refractory prostate cancer (36). T here is hope that it also will find value in ovarian cancer and small cell lung cancer. Satraplatin is a Pt(IV) complex. As with the Pt(II) complexes, the platinum has no net charge in the parent drug, because its original + 4 charge has been “ neutralized” by the donation of four electrons from the chloride and acetate ligands. Unlike the square-planar Pt(II) complexes currently on the market, it is active by the oral route. It is metabolized quickly in whole blood, producing up to six metabolites. T he major metabolite is the desacetoxy analogue. As with other organoplatinum complexes, the diaquo form is active. At this early stage, the toxicity profile appears to be mild, with dose-related myelosuppression, particularly neutropenia and thrombocytopenia, being the major use-limiting side effect.

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Antibiotics T he antibiotic antineoplastics (Fig. 42.17) are a broad category of natural or semisynthetic compounds that block DNA transcription by nicking and/or inducing point mutations in the DNA strand and/or by inhibiting enzymes critical to the DNA replication process. Antibiotic antineoplastics that interact directly with DNA first intercalate the double-stranded helix by inserting between the base pairs and forming strong noncovalent interactions with DNA bases. T he highly stabilized complex deforms and uncoils the DNA, prohibiting proper replication. T o bulldoze its way between the bonded DNA strands, a segment of the antibiotic must have the trigonal coplanar geometry guaranteed by aromaticity. Many of the antineoplastic antibiotic compounds inhibit topoisomerase II, an enzyme responsible for maintaining proper DNA structure during replication and transcription to RNA. T opoisomerase II normally cleaves DNA during the replication phase but repairs its own damage after replication is complete. T opoisomerase II inhibitors act to stimulate the cleavage reaction but inhibit the DNA resealing activity of the enzyme, leaving the DNA irreversibly damaged and unable to replicate. Yet another proposed mechanism of cytotoxic action is the generation of cytotoxic free radicals that cause single-strand breaks in DNA. One antibiotic (mitomycin) is capable of alkylating DNA, a mechanism more commonly associated with the nitrogen mustard antineoplastics but which is entirely predictable from the nucleophilic aziridine ring found within the structure of this anticancer agent.

Anthracyclines and Anthracenediones Anthracycline antineoplastic antibiotics are very closely related to the tetracycline antibacterials. Structurally, they are glycosides and contain a sugar portion (L-daunosamine) and a nonsugar organic portion. T he nonsugar portion of glycosides is generically referred to as an aglycone. In anthracyclines, the aglycone moiety is specifically called anthracyclinone or anthroquinone.

Mechanism of action As previously mentioned, DNA intercalation initiates the antineoplastic action of the anthracyclines. T he anthracyclinone portion of the structure, particularly rings B, C, and D, is large and predominantly aromatic. T his flat ring system slides between the two DNA strands, orienting itself in a perpendicular fashion relative to the long axis of DNA. Once intercalated, the anthracycline-DNA complex is stabilized through van P.1166 der Waals, hydrophobic, and hydrogen bonds. Binding is best in DNA regions that are rich in guanine and cytosine bases.

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Fig. 42.17. Anticancer antibiotics.

T he protonated 3′-amino group on the daunosamine sugar has long been thought to stabilize the intercalated complex through interaction with an anionic DNA phosphate, but investigators recently have proposed that this substituent may link covalently to the C 2 -NH 2 of guanine via a methylene bridging unit provided by formaldehyde (40). Regardless of the interaction, the daunosamine amino group is believed to play a crucial role in orchestrating the DNA sequence specificity of the intercalation process (41). T he loss or epimerization of the 3′-amino moiety decreases, but does not destroy, DNA binding. In fact, the antitumor activity of these drugs is related more to the proper positioning and stabilization of the drug at its binding site than to the actual affinity of the drug for the DNA (41,42). Even though DNA intercalation is required before the antineoplastic action of the anthracyclines can be realized, it alone does not kill the cell. Rather, the predominant cytotoxic effect is topoisomerase II inhibition. Anthracyclines bind to the DNA-enzyme complex in the area close to the DNA cleavage site. T hey stabilize a ternary cleavable complex that allows the DNA to be cut and covalently linked to topoisomerase T yr residues but that does not permit the cleaved DNA to reseal. T he aromatic portion of the anthracyclinone ring system and the daunosamine sugar bind to DNA, whereas the anthracyclinone A ring is believed to bind with the topoisomerase II enzyme (41). Removal of the 4-OCH 3 group found on all natural anthracycline anticancer products increases antitumor activity by facilitating the intercalation process and directing the binding of the dauosamine sugar in a way that stabilizes the ternary complex and promotes the cleavage (but not the resealing) of DNA (42). T he daunosamine sugar is known to bind in the minor groove of DNA at the DNA-topoisomerase interface, but specific binding interactions between drug functional groups and topoisomerase residues have yet to be fully elucidated. Because a small P.1167 number of anthracycline-induced DNA breaks can result in a high level of cell death, it has been

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hypothesized that the site of DNA cleavage, which contains an essential T -A dinucleotide, is particularly lethal to the cell (43).

Mechanism of cardiotoxicity A very important mechanism of use-limiting anthracycline cardiotoxicity involves the formation of cytotoxic free radicals. A free radical is a highly reactive species with an unpaired electron. Of particular importance to -

the antineoplastic action of these drugs is the formation of the superoxide radical anion (·O 2 ) and the hydroxyl radical (·OH), both of which are formed via reduction of the anthracyclinone quinone (ring C) to hydroquinone by NADPH/CYP450 reductase. T he mechanism by which cytotoxic free radicals are generated is shown in Figure 42.18. When NADPH/CYP450 reductase reduces the quinone ring to a hydroquinone, superoxide radical anions (·O 2 ) are generated. Superoxide radical anions react to generate hydrogen peroxide (H 2 O 2 ), a reaction that

requires protons and is catalyzed by the enzyme superoxide dismutase in a Cu 2+ mediated process. T he fate of this hydrogen peroxide dictates the degree of cytotoxicity observed from the anthracycline. In the presence of the enzyme catalase, hydrogen peroxide is rapidly converted to water and oxygen, which obviously are harmless chemicals as far as the body is concerned. In the presence of ferrous ion (Fe

2+

),

however, hydrogen peroxide is converted into the highly toxic hydroxyl radical through a process called the Fenton reaction. Hydroxyl radicals promote single-strand breaks in DNA, which is therapeutically desirable to treat the uncontrolled growth of cancer cells. Anthracycline anticancer agents also are known to interfere with normal ferritin-iron mobilization, resulting in iron accumulation (44). T he anthracyclines chelate strongly with di- and trivalent cations, including intracellular Fe 2+ , so the generation of cytotoxic hydroxyl radicals after the initial NADPH/CYP450 reductase reduction is essentially guaranteed. Hydroxide anion and ferric ion also are formed during the production of hydroxyl radicals.

T he generation of hydroxyl radicals inside the tumor cell might augment the antineoplastic effect of the anthracyclines, but such generation is uncommon at standard antineoplastic doses (43). T hese cytotoxic radicals are generated within the heart, however, leading to acute and often severe cardiotoxicity. Cardiac tissue is particularly vulnerable to free radical damage by the anthracyclines because it does not contain the catalase enzyme (45). When hydrogen peroxide forms in the myocardium, it has no choice but to go down the Fenton pathway. Cardiac toxicity is the major use-limiting side effect of anthracycline use, but coadministration of dexrazoxane (an antioxidant and iron chelator) has been shown to lower its incidence (46). A role for nitric oxide metabolism, particularly nitric oxide synthase, in anthracycline-mediated cardiotoxicity recently has been proposed (47). In the future, nitric oxide metabolic enzymes may be key targets for drugs that, when coadministered with anthracyclines, could lower the risk of cardiotoxicity.

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Fig. 42.18. Anthracycline-medicated free radical formation.

P.1168 Although the rate of quinone metabolism influences the risk of acute anthracycline-induced cardiotoxicity, metabolism at C 13 is believed to be responsible for the severe and chronic cardiotoxicity that some patients experience. T he C 13 -carbonyl is reduced to the active secondary alcohol via cytosolic aldoketoreductase enzymes (Fig. 42.19), and the larger the R group, the slower this reaction and the longer the duration of antineoplastic action. T he C 13 -substituents found on most marketed anthracyclines include CH 3 (daunorubicin and idarubicin) and CH 2 OH (doxorubicin and epirubicin). Before excretion, anthracyclines are further metabolized to their aglycones, followed by O-dealkylation of the C 4 methoxy ether (if present) and conjugation with either glucuronic acid or sulfate. T he active secondary alcohol metabolites formed by aldoketoreductase induce a prolonged inhibition of calcium loading, opens a selective ion channel leading to increased cytosolic levels of Ca 2+ in the sarcoplasmic reticulum, and inhibits Na + ,K + –adenosine triphosphatase action in the sarcolemma. Collectively, these cellular events can induce a chronic cardiomyopathy that presents as severe congestive heart failure involving systolic and diastolic dysfunction (44). Chronic anthracycline-induced congestive heart failure can manifest without warning years after therapy, and it often is unresponsive to therapeutic intervention. T hose at highest risk include the very young or very old, those with underlying cardiovascular disease, those receiving high cumulative doses, and those being treated with cyclophosphamide. Because toxicity is dose-dependent, patients with liver dysfunction who cannot adequately metabolize and clear the anthracycline also are at risk. Dosage adjustments in patients with liver disease must be made to avoid life-threatening toxicity.

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Fig. 42.19. Anthracycline metabolism.

Additional side effects In addition to cardiac toxicity, all anthracycline antineoplastics can cause severe myelosuppression (especially leukocytopenia) as well as moderate to severe nausea and vomiting, mucositis leading to hemorrhage and potentially fatal infection, and alopecia. Side effects are dose-dependent. Most of the anthracyclines are orally inactive and must be given by IV injection. T hey are highly necrotic to skin and, if extravasation occurs, can cause such severe blistering and ulceration that skin excision, followed by plastic surgery, may be indicated. T he anthracyclines contain photosensitive phenolic groups that must be protected from light and air. T he highly conjugated structure imparts a reddish-orange color to these compounds (implied in the name “ rubicin” ), which is maintained when these compounds are excreted in the urine. Patients should be warned that the reddish urine they will experience is not hemorrhagic but, rather, simply the result of the conjugated chemistry of this class of drugs.

Specific drugs Doxoru bicin Hydroch loride T he C 13 substituent of doxorubicin is hydroxymethyl (Fig. 42.17), which retards the action of cytosolic aldoketoreductase and slows the conversion to the equally active, but chronically cardiotoxic, doxorubicinol. T his contributes to the longer duration of action compared to analogues that have CH 3 at this position (e.g., daunorubicin). Doxorubicin is highly lipophilic and concentrates in the liver, lymph nodes, muscle, bone marrow, fat, and skin. Elimination is triphasic, and the drug has a terminal half-life of 30 to 40 hours. T he majority of an administered dose is excreted in the feces. Doxorubicin is utilized either alone or in combination therapy to treat a wide range of neoplastic disorders, including hematologic cancers and solid tumors in breast, ovary, stomach, bladder, and thyroid gland. A liposomal formulation of doxorubicin (Fig. 42.17) is used in the treatment of AIDS-related Kaposi's sarcoma

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and organoplatinum-resistant ovarian cancer. Liposomes are taken up selectively into tumor cells, presumably because of their persistence in the bloodstream and enhanced permeability of tumor vascular membranes. In liposomal form, the drug is protected against enzymes that generate cardiotoxic free radicals, although this form of the drug can still induce potentially fatal congestive heart failure. Clinical experience with the liposomal formulation is limited, and few studies comparing the long-term toxicity with that of conventional doxorubicin therapy have been conducted. T herefore, all precautions outlined for the use of doxorubin also are employed when the liposomal formulation is used. T he half-life of Doxil is extended to approximately 55 hours, and it is administered in doses ranging from 20 to 50 mg/m2 every 3 to 4 weeks. T he area under the curve of the liposomal formulation is approximately threefold that of the P.1169 free drug formulation. It is cleared more slowly than conventional doxorubicin and generates very little of the doxorubicinol metabolite. Significant side effects have occurred when the liposomal formulation is erroneously dispensed, so pharmacists must be vigilant when interpreting therapeutic orders.

Epiru bicin Hydroch loride T his stereoisomer of doxorubicin has the 4′-hydroxy group of the daunosamine sugar oriented in the β-position (Fig. 42.17). Epirubicin will be slowly reduced to the active C 13 alcohol (epirubicinol), giving it a 30- to 38-hour half life, which is similar to that of doxorubicin. Unlike doxorubicinol, however, which was equally active with doxorubicin, epirubicinol has only one-tenth the activity of its parent drug and is not believed to contribute significantly to the therapeutic action of this agent. Cleavage of the epimerized sugar will occur before excretion, generating an aglycone that is indistinguishable from that generated by doxorubicin. Although excretion is primarily biliary, dosage reduction in severe renal impairment, as well as in hepatic dysfunction, is warranted. Epirubicin is indicated for use in breast cancer, and the starting dose is 100 to 120 mg/m2 (compared to a 2

starting dose of 60–75 mg/m for doxorubicin). T he side effects and precautions are as outlined previously for doxorubicin, although there is a lower risk of serious myocardial toxicity or myelotoxicity.

Valru bicin Chemically, valrubicin differs from its doxorubicin parent by the addition of a C 14 -valerate ester and a 3′-trifluoroacetamide (Fig. 42.17). T he carbon-rich valerate obviously is lipophilic, and acylation of the daunosamine amino group makes the 3′-substituent un-ionizable. Both of these structural changes promote a more rapid and extensive penetration into tumor cells. Valrubicin currently has orphan drug status in the treatment of bacille Calmette-Guérin (BCG)–refractory bladder cancer (the total patient population is ~ 1,000 individuals) and is used with patients for whom surgical intervention would result in high morbidity or death. It is administered directly into the bladder through a catheter (intravesically). T he lipophilic drug is water insoluble, but it dissolves in an aqueous vehicle that includes polyoxyethylene glycol and ethanol. T he patient retains the drug in the bladder for 2 hours, then voids the solution in the normal fashion. Valrubicin is active as administered, and despite the fact that hydrolysis of the ester and trifluoroacetamide can be envisioned, it is excreted essentially unchanged. Less than 1% of an administered dose is absorbed systemically, so there is essentially no exposure to metabolizing enzymes. T he reduced C 13 -alcoholic metabolite does not form to any appreciable extent during the 2-hour treatment period. T herapy is considered to be almost exclusively local, and there is little risk for cardiac toxicity, bone marrow suppression, drug–drug interactions, or other side effects. T he most commonly reported adverse reactions are abdominal pain, urinary tract infection, hematuria, and dysuria. Systemic exposure to the drug and its metabolites would, of course, be greater in patients whose bladder wall integrity has been compromised by disease, and these patients should not receive valrubicin.

Dau n oru bicin Hydroch loride T he absence of the OH group at C 14 in daunorubicin (Fig. 42.17) results in a faster conversion to the equally active and chronically cardiotoxic C 13 -ol metabolite (daunorubicinol) compared to hydroxymethyl-substituted anthracyclines like doxorubicin. T he 18.5-hour terminal half-life of daunorubicin is approximately half that of doxorubicin, and the terminal half-life of the active daunorubicinol metabolite is 26.7 hours. Excretion is approximately 40% biliary and 25% urinary. Daunorubicin is administered IV at a dose of 45 mg/m 2 for the

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treatment of lymphocytic and nonlymphocytic leukemia. T he toxicity and side-effect profile of this anthracycline is similar to that of doxorubicin, and all previously identified precautions apply. T he citrate salt of daunorubicin is marketed as a liposomal formulation (Fig. 42.17), which promotes the use of this agent in solid tumors. Like Doxil (the liposomal formulation of doxorubicin), DaunoXome is indicated 2

for use in AIDS-related Kaposi's sarcoma and is administered IV at a dose of 40 mg/m every 2 weeks. T he pharmacokinetic profiles of Doxil and DaunoXome are similar.

Idaru bicin Hydroch loride Idarubicin (Fig. 42.17) is the 4-desmethoxy analogue of daunorubicin. T he loss of the C 4 -ether flattens the D ring, facilitating intercalation between DNA base pairs. In turn, this orients the daunosamine sugar in the minor groove in a way that better stabilizes the ternary complex between drug, DNA, and topoisomerase (42). T he loss of the 4-methoxy moiety also makes this compound more lipophilic than either doxorubicin or daunorubicin. T his results in a better penetration into tumor cells and an enhanced antineoplastic potency. Increased rates of remission have been noted with the use of idarubicin compared to other anthracyclines antineoplastic agents. Unlike its congeners, idarubicin shows significant oral bioavailability and is lipophilic enough to penetrate the blood-brain barrier. Currently, however, it is given only by the IV route and is not used in the treatment of brain cancer. Its primary indication is in acute myeloid leukemia, and it is administered in combination with other antileukemic drugs. Idarubicin is reduced by aldoketoreductases to idarubicinol, which is as active as the parent drug. Because there is no aromatic methoxy group, there is no O-dealkylation to the C 4 -phenol. T he major metabolite is free, unconjugated idarubicinol. T he half-lives of both idarubicin and idarubicinol are 22 and 45 hours, respectively. Idarubicin is administered IV at a dose of 10 to 12 mg/m2 /day for 3 to 4 days, and the idarubicinol metabolite can still be found in therapeutic concentrations in P.1170 the blood 8 days after administration. Like other anthracyclines, excretion primarily is fecal, with a lesser dependence on renal elimination. Some authors have shown that idarubin is transported into cardiac tissue via a saturable transporter and that the coadministration of methylxanthines (e.g., caffeine) can increase both myocardial drug concentrations and the risk of idarubicin-induced cardiotoxicity (48).

Mitoxan tron e Hydroch loride Chemically, mitoxantrone is classified as an anthracenedione (Fig. 42.17). T he sugar moiety is missing, but the cationic side-chain amino nitrogens could bind to the anionic phosphate residue of the DNA backbone in the same fashion that the cationic L-daunosamine amino group of the true anthracyclines has been presumed to do. T his molecule has the structural features needed to intercalate DNA and inhibit topoisomerase II, but the enhanced stability of the quinone ring (possibly through an increased potential for intramolecular hydrogen bonding) makes the ring highly resistant to NADPH/CYP450 reductase. T his limits the formation of the superoxide radicals that are required for the generation of the highly toxic hydroxyl radical. In addition, there is no active cardiotoxic metabolite to induce chronic toxicity by disrupting the flow of myocardial cations. T he chance of cardiovascular toxicity from mitoxantrone is significantly decreased, although patients who have been previously treated with anthracycline antineoplastics may still be at risk. It is thought that any observed myocardial toxicity may be operating through mechanisms other than the generation of cytotoxic radicals.

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In addition, the risk of ulceration and necrosis on extravasation, as well as of nonmarrow-related toxicities such as nausea, vomiting, mucositis, and alopecia, is significantly less than observed with true anthracyclines. T here is a significant risk of bone marrow suppression, however. T he risk of myelosuppression increases with dose, but it can be observed even when low doses are used. Mitoxantrone excretion primarily is biliary. Both the unchanged drug and inactive metabolites resulting from N-dealkylation, deamination, and oxidation of the resultant aldehyde to the carboxylic acid are observed. Both arms of the structure can be metabolized, leading to mono- or dicarboxylic acid metabolites (Fig. 42.20), which are excreted as the glucuronide conjugate. T he conjugated metabolites are an intense, dark blue in color and will result in blue-green urine. T he whites of the eyes and, in some cases, the skin also may take on a bluish cast.

Fig. 42.20. Mitoxantrone metabolism.

Mitoxantrone is used in combination with other agents during the initial treatment of acute nonlymphocytic leukemia and hormone-refractory prostate cancer. Recent studies have shown that mitoxantrone also decreases the rate of relapse and disease progression in patients with multiple sclerosis (49). Although too toxic for use in patients with primary progressive disease, it is available for the treatment of chronic progressive, progressive relapsing, or deteriorating relapsing-remitting multiple sclerosis.

Miscellaneous Antibiotics Dactinomycin Dactinomycin (Fig. 42.17) has two pentapeptide lactones attached to an aromatic (and, therefore, flat) actinocin (or phenoxazinone) structure. It is capable of intercalating DNA and binds preferably between guanine and cytosine residues on a single DNA strand. T his interaction results in DNA elongation and distortion, commonly referred to as a point mutation. When sliding between adjacent DNA base pairs, the actinocin orients itself perpendicular to the main DNA axis, allowing the pentapeptide lactone units to bind to residues in the minor groove of DNA through hydrophobic and hydrogen bonds. An affinity-enhancing bond between the threonine carbonyl oxygen and a protonated C 2 -amino group of guanine also forms. Other hydrogen, hydrophobic, and van der Waals (π-stacking) interactions form between the lactone and DNA residues, particularly guanine and cytosine. T he binding of the actinocin and polypeptide lactone portions of dactinomycin to DNA is cooperative, meaning that the binding of one unit facilitates the binding of the other, most likely by promoting an optimal

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orientation. T his significantly enhances drug-DNA affinity. T he binding of dactinomycin to DNA, although noncovalent, is much stronger than that observed with the anthracyclines. Drug dissociation from DNA is slow, leading to a pseudoirreversible effect. As a result of very strong DNA binding interactions, topoisomerase II is inhibited, which results in nonrepairable double-strand breaks in DNA. T ranscription and translation processes are blocked, P.1171 resulting in a decrease in de novo RNA (especially mRNA) and protein synthesis. T he p-benzoquinoneimine segment of dactinomycin renders the molecule vulnerable to NADPH/CYP450 reductase. Free radicals can be generated, and additional single-strand DNA breaks can result. T he loss of either aromatic methyl group results in a loss of activity. T he reason for this profound impact on pharmacological action and therapeutic utility is unknown.

Dactinomycin is used for the treatment of various solid tumors and muscle-related cancers. It induces severe side effects, and nausea and vomiting can be use-limiting. Myelosuppression also is common and, most often, is the dose-limiting toxic effect. T he drug usually is given by the IV route, but toxicity can be limited if the tumor can be perfused with drug (assuming minimal distribution into the general circulation). Dactinomycin is a severe blistering agent, and extravasation can cause irreversible and profound tissue damage. T he side effects of radiation therapy are significantly exaggerated by the concurrent use of dactinomycin. T he drug's 36-hour half-life is the result of a very high affinity for DNA, a large volume of distribution, and minimal metabolic breakdown. Dactinomycin is photosensitive and must be protected from light.

Mitomycin As shown in Figure 42.21, mitomycin is activated through a bioreductive process utilizing NADPH/CYP450 reductase and/or NAD(P)H quinone oxidoreductase 1 (NQ 01 reductase), an enzyme expressed in many neoplastic cells (50,51). T hrough these enzymes, the quinone ring of mitomycin is readily reduced to the hydroquinone, generating superoxide radicals in the process that ultimately will be converted to cytotoxic hydroxyl radicals through the Fenton reaction. As previously discussed, hydroxyl radicals induce singlestrand breaks in DNA. Formation of the hydroquinone is followed by aromatization to the indole ring through the loss of methanol. Both the electrophilic aziridine ring and the δ + methylene group adjacent to the carbamate ester are vulnerable to attack by DNA nucleophiles, such as the 2-NH 2 group of guanine or the 4-NH 2 group of cytosine, resulting in cross-linked DNA and cell death. Mitomycin is administered IV in the treatment of disseminated adenocarcinoma of the stomach or pancreas, and it has been used intravesically in superficial bladder cancer. Biotransformation pathways are saturable, and approximately 10% of an administered dose is eliminated unchanged via the kidneys. Myelosuppression is the major use-limiting side effect of this drug, which is slow to manifest but quite prolonged in duration. Severe skin necrosis can occur on extravasation, and potentially fatal pulmonary toxicities have been noted as well. Mitomycin can induce hemolytic uremia accompanied by irreversible renal dysfunction and thrombocytopenia, and the drug should not be administered to patients with serum creatinine levels greater than 1.7 mg/dL. Severe bronchospasm also has been noted in patients treated with vinca alkaloids who also are receiving (or who have previously received) mitomycin.

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Fig. 42.21. Mitomycin metabolism.

Bleomycin sulfate T he commercially available bleomycin drug product is a mixture of naturally occurring glycopeptides, predominantly bleomycin A2 (Fig. 42.17). T he aromatic bithiazole ring system can intercalate DNA, but unlike most of the antibiotics discussed thus far, the molecule does not inhibit topoisomerase II. Rather, intercalation positions bleomycin for DNA destruction via cytotoxic free radicals. T he disaccharide, polyamine, imidazole, and pyrimidine structures are very electron rich and readily chelate intracellular Fe 2+ . Once chelated, Fe 2+ is oxidized to Fe 3+ , with a concomitant reduction of bound oxygen, and both superoxide and hydroxyl radicals are generated. T he free radicals cleave deoxyribose and cause single-strand breaks in DNA, most commonly between guanine-cytosine or guanine-thymine residues. When the cyclic deoxyribose sugar breaks, it forms a highly electrophilic base propenal that inactivates essential cellular proteins by alkylating nucleophilic Cys residues (Fig. 42.22). Reduced glutathione is proposed to serve a protective role by acting as propenal scavenger and, until depleted, saves cellular proteins from alkylation (52). P.1172

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Fig. 42.22. Alkylation of Cys residues by hydroxyl radical–generated base propenals.

Bleomycin is a natural product isolated from Streptomyces verti ci l l us. It normal l y i s chel ated wi th Cu 2+ , whi ch must be removed vi a catal yti c reducti on before marketi ng. Thi s i ncreases the cost of the drug, but i t frees up the cri ti cal bl eomyci n functi onal groups for chel ati on wi th i ntracel l ul ar ferrous i ron. T he action of bleomycin is terminated through the action of bleomycin hydrase, a cytosolic aminopeptidase that cleaves the terminal amide moiety to form the inactive carboxylate metabolite (Fig. 42.23). T he metabolic replacement of the electron-withdrawing amide with an electron-donating carboxylate increases the pK a of the α-amino group, which normally interacts with DNA in the un-ionized conjugate form. After hydrolysis, the ratio of ionized to un-ionized forms of this critical amine increases approximately 126-fold, destroying DNA affinity and leading to the loss of therapeutic action. Drug destruction via the bleomycin hydrase pathway is rapid, and tumors will be resistant to bleomycin if they contain high concentrations of the enzyme. Conversely, tumors that are poor in bleomycin hydrase (e.g., squamous cell carcinoma) respond well to this agent. Bleomycin hydrase is found in all tissues except skin and lung. Approximately 10% of patients who are

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administered bleomycin will experience potentially fatal pulmonary fibrosis, which can occur during therapy or several months following termination of therapy, often without warning. Some studies have shown that the copper-complexing agent tetrathiomolybdate can reduce the risk of bleomycin-induced fibrosis by inhibiting the action of copper-dependent inflammatory cytokines (53). Erythema and hypertrophic modifications in skin also are common side effects that manifest after 2 to 3 weeks of bleomycin therapy. Bleomycin is used IV in the palliative treatment of squamous cell head and neck cancers, testicular and other genital carcinomas, and Hodgkin's and non-Hodgkin's lymphoma. It is excreted via the kidneys, and serum concentrations of active drug are increased in patients with renal disease. T he elimination half-life can rise from 2 to 4 hours to more than 20 hours in renal failure, resulting in significant toxicity, especially pulmonary toxicity. Dosage adjustments are warranted. Unlike many antineoplastic agents, bleomycin does not suppress the bone marrow, and it often is given in combination with compounds that do, so that the dose of all P.1173 drugs can be optimized. Nausea and vomiting also are relatively mild, but approximately 1% of lymphoma patients who are treated with bleomycin will experience an immediate or delayed, severe idiosyncratic reaction that mimics anaphylaxis.

Fig. 42.23. Bleomycin hydrase mediated inactivation of bleomycin.

Antimetabolites T he antineoplastic agents discussed thus far have all damaged existing DNA and inhibited its ability to replicate. T he antimetabolites, on the other hand, most commonly stop the de novo synthesis of DNA by inhibiting the formation of the nucleotides that make up these life-sustaining polymers. We will see that the rate-limiting enzymes of nucleotide biosynthesis often are the primary target for the antimetabolites, because inhibition of this key enzyme is the most efficient way to shut down any biochemical reaction sequence. Antimetabolites also are capable of inhibiting other enzymes required in the biosynthesis of DNA, and many can arrest chain elongation by promoting the incorporation of false nucleotides into the growing DNA strand. T he antimetabolites serve as false substrates for critical nucleotide biosynthesis enzymes. T hese enzyme inhibitors are structurally “ dolled up” to look like a super attractive version of the normal (endogenous) substrate. Speaking anthropomorphically, through a form of chemical entrapment, they entice the enzymes to choose them over the endogenous substrate, and once they do, the antimetabolites bind them irreversibly. If the building block nucleotides cannot be synthesized, then DNA synthesis (and tumor growth) is stopped dead in its tracks. If tumor growth is arrested, then metastasis slows, and the patient has a fighting chance for remission and/or cure. Antimetabolite antineoplastics are categorized by the class of nucleotide they inhibit. Purine antagonists

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inhibit the synthesis of the purine-based nucleotides adenylate monophosphate (AMP) and guanylate monophosphate (GMP), and the pyrimidine antagonists stop the production of the pyrimidine-based nucleotides, primarily deoxythymidine monophosphate (dT MP).

Pyrimidine Antagonists: dTMP Synthesis Inhibitors dTMP biosynthesis Looked at simply, dT MP is produced via C 5 -methylation of deoxyuridine monophosphate (dUMP). T he rate-limiting enzyme of the dT MP synthetic pathway is the sulfhydryl-containing thymidylate synthase, with 5,10-methylenetetrahydrofolate (5,10-methylene-T HF) serving as the methyl-donating cofactor. All dT MP synthesis inhibitors will inhibit thymidylate synthase either directly or indirectly, and this will result in a “ thymineless death” in actively dividing cells. Without dT MP and its deoxythmidine triphosphate metabolite, DNA will fragment, and the cell will die. T o truly understand how an antimetabolite inhibits a biochemical pathway, we must first understand completely how the pathway normally functions. A quick look at the dT MP synthesis pathway (Fig. 42.24) will confirm that our “ simple methylation reaction” is comprised of several important steps, each of which is analyzed in turn below. T he synthase enzyme is very large and contains a deep pocket for the binding of both substrate and cofactor. P.1174 It may be illuminating to think of this binding pocket like a big cooking pot. Once the “ ingredients” are added (substrate and cofactor), the process of making the product (dT MP) can begin. T he active site binding motifs for both substrate and cofactor are highly conserved among all thymidylate synthase enzymes, regardless of source (54). Whereas early studies on substrate binding were conducted with bacteria-derived synthases, the human enzyme (hT S) has now been crystallized and some binding residues identified (55). With regard to substrate binding (hT S sequence numbers given where known):

Fig. 42.24. Synthesis of deoxythmidine monophosphate (dTMP).

Four Arg residues at positions 50, 218, 175′, and 176′ form electrostatic bonds with the anionic 5′-phosphate of the substrate.

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T yr (H-donor) and His (H-acceptor) residues form hydrogen bonds with the deoxyribose 3′-OH. T he main-chain amide of aspartate (Asp 218 ) forms a hydrogen bond with the pyrimidine C 2 carbonyl oxygen. His

196

forms a hydrogen bond with the pyrimidine C 4 carbonyl oxygen.

An Asn residue (H-acceptor) forms a hydrogen bond with the pyrimidine C 3 -NH. Cys

195

forms a transient covalent bond with C 6 of the pyrimidine ring.

T he glutamate tail of 5,10-methylene-T HF binds to Lys and His residues of the synthase. Oxygen atoms of leucine (Leu 221 ) and phenylalanine (Phe 225 ) interact with the p-aminobenzoic acid component of the folate, whereas Asp 218 , His, and Ile residues interact with additional cofactor functional groups (55,56). T he binding of both substrate and cofactor promotes a conformational change in the synthase protein and causes the N-terminal portion of the synthase to change its location, which covers the opening of the binding “ pot” like a big lid. T he conformational change brings the folate cofactor “ face to face” with the dUMP substrate, properly orienting all key functional groups for the reaction to come. T he C 6 position of the dUMP substrate is surrounded by electron-withdrawing nitrogen and oxygen atoms, leaving it highly electrophilic (δ + ) and ready to be attacked by the nucleophilic Cys 195 of the synthase. T he Cys sulfhydryl group launches an intermolecular nucleophilic attack, forming a new covalent bond between the sulfur and C 6 of the substrate (step 1). T he bond that breaks in response to this attack is the 5,6-double bond of dUMP, which attacks the methylene group of the cofactor (step 2). With the release of the N 10 nitrogen the cofactor imidazolidine ring breaks (step 3). T aken together, steps 1 to 3 generate a ternary complex of enzyme, substrate and cofactor (Fig. 42.24). A series of reactions involving bond breaking and bond making are shown in Figure 42.24, leading to formation of dT MP, 7,8-dihydrofolate (7,8-DHF), and regenerated thymidylate synthase. T he C 5 -H abstraction by N 10 of the cofactor (step 4) is essential for synthesis of dT MP. T o complete the biochemical cycle, 7,8-DHF must be reduced to T HF via dihydrofolate reductase (DHFR) utilizing NADPH. Finally, T HF is converted to 5,10-methylene-T HF through the action of serine hydroxymethyltransferase and vitamin B 6 . With the enzyme and cofactor both regenerated, and with plenty of dUMP stored in cellular pools, the cell is ready to synthesize another molecule of dT MP. T his happens at a regular pace in healthy cells and at an uncontrolled rate in tumor cells.

Direct inhibitors of thymidylate synthase (Fig. 42.25) Flu orou racil T o bind to thymidylate synthase, this fluorinated pyrimidine prodrug must be converted to its deoxyribonucleotide form (Fig. 42.26). T he active form of fluorouracil differs from the endogenous substrate only by the presence of the 5-fluoro group, which holds the key to the cell-killing action of this drug. T he C 6 position of the false substrate is significantly more electrophilic than normal because of the strong electronwithdrawing effect of the C 5 fluorine. T his greatly increases the rate of attack by Cys 195 , resulting in a very fast formation of a fluorinated ternary complex (Fig. 42.27). T he small size of the fluorine atom assures no steric hindrance to the formation of this false complex. T he next step in the pathway required the abstraction of the C 5 -H (as proton) by N 10 of the cofactor, but this is no longer possible. Not only is the C 5 -fluorine bond stable to cleavage, the fluorine atom and N 10 would repel one another because they are both electron rich. T he false ternary complex cannot break down, no product is formed, no cofactor is released, and most importantly, the rate-limiting enzyme (thymidylate synthase) is not regenerated. Because dT MP can no longer be synthesized, the cell will die. Fluorouracil is administered IV in the palliative treatment of colorectal, breast, stomach, and pancreatic cancers. Patients are treated for four consecutive days, followed by treatment on odd-numbered days up to a maximum of 12 days. Fluorouracil is rapidly cleared from the bloodstream, and although up to 20% of a dose is excreted unchanged in the urine, most undergoes hepatic catabolism via a series of enzymes that includes the polymorphic dihydropyrimidine dehydrogenase (Fig. 42.28). Patients who are genetically deficient in this enzyme will experience a more pronounced effect from this drug and are at significant risk for use-limiting

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toxicity (57). In general, women clear fluorouracil faster than men do. Dosage adjustments usually are not required in hepatic or renal dysfunction. Major toxicities are related to bone marrow depression, stomatitis/esophagopharyngitis, and potential GI ulceration. Nausea and vomiting are common. Solutions of fluorouracil are light sensitive, but discolored products that have been properly stored and protected from light are still safe to use.

Floxu ridin e T his deoxyribonucleoside prodrug (Fig. 42.26) is bioconverted via 2′-deoxyuridine kinase–mediated phosphorylation to the same active 5-fluoro-dUMP structure generated in the multistep biotransformation of P.1175 fluorouracil. It is given by intra-arterial infusion for the palliative treatment of GI adenocarcinoma that has metastasized to the liver and that cannot be managed surgically.

Fig. 42.25. Antimetabolites.

Capecitabin e Although capecitabine is a carbamylated analogue of cytidine (Fig. 42.29), the drug actually is another 5-fluoro-dUMP prodrug. Given orally, it is extensively metabolized to fluorouracil, which is then converted to the active fluorinated deoxyribonucleotide as previously described. T hymidine phosphorylase, an enzyme involved in this biotransformation, is much more active in tumors than in normal tissue, which improves the tumor-selective generation of fluorouracil. Levels of active drug in the tumor can be up to 3.5-fold higher than in surrounding tissue (58), leading to a lower incidence of side effects compared to fluorouracil therapy. Because capecitabine is biotransformed to fluorouracil, it follows the same catabolic and elimination pathways (Fig. 42.28) reported for 5-fluorouracil. Doses should be attenuated in moderate to severe renal impairment, and the caution relative to the augmented risk of toxicity in patients with dihydropyrimidine dehydrogenase deficiency applies. Capecitabine is indicated for use as first-line therapy in patients with colorectal cancer. It also is used alone

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or in combination with docetaxel in patients with metastatic breast cancer who have experienced disease progression or recurrence after anthracycline therapy. Given b.i.d. in tablet form, the total daily dose is calculated based on patient body surface area and is taken 30 minutes after eating to avoid food-induced decreases in absorption. In addition to bone marrow suppression, nausea, and vomiting, the drug can induce severe diarrhea and a potentially disabling disorder termed “ hand-and-foot syndrome” (palmar-plantar erythrodysethesia). Capecitabine inhibits CYP2C9 and, along with competition for serum protein binding sites, results in clinically significant drug–drug interactions with both warfarin and phenytoin. T he interaction with warfarin can result in potentially fatal bleeding episodes, which can appear within days of combination therapy or be delayed up to 1 month after discontinuation of capecitabine therapy.

Indirect inhibitors of thymidylate synthase Meth otrexate Methotrexate (Fig. 42.25) is a folic acid antagonist structurally designed to compete successfully with 7,8-DHF for the DHFR enzyme. T he direct inhibition of DHFR causes cellular levels of 7,8-DHF to build P.1176 up, which in turn results in feedback (indirect) inhibition of thymidylate synthase. Methotrexate also is effective in inhibiting glycine amide ribonucleotide (GAR) transformylase (see Fig. 42.31), a key enzyme in the synthesis of purine nucleotides. T ake note of the structural differences between methotrexate and DHF, because these differences will be important to an understanding of the chemical mechanism of this anticancer agent.

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Fig. 42.26. Activation of fluorouracil and floxuridine.

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Fig. 42.27. Mechanism of action of fluorouracil.

It has been proposed that the N 5 position of DHF is protonated by a Glu 30 of DHFR (59) and, in cationic form, binds to DHFR Asp 27 through an electrostatic bond (Fig. 42.30). N 5 is the strongest base in the DHF structure, in part because of attenuating the impact of the C 4 carbonyl on electron density around N 1 . Additional affinity-enhancing interactions between enzyme and substrate also have been identified (60,61), and once bound, the substrate 5,6-double bond is positioned close to the NADPH cofactor so that the transfer of hydride can proceed.

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Fig. 42.28. Fluorouracil metabolism.

P.1177

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Fig. 42.29. Capecitabine activation.

In contrast, the C 4 amino substituent of methotrexate enriches electron density at N 1 through π-electron donation, increasing its basic character between 10- and 1,000-fold and promoting protonation by Glu 30 at the expense of N 5 . Because N 1 and N 5 are across the pteridine ring from one another, the interaction of N 1 with the DHFR Asp 27 will effectively stand the false substrate “ on its head” relative to the orientation of 7,8-DHF (Fig. 42.30) (61,62). With the 5,6-double bond of methotrexate 180° away from the bound NADPH cofactor (61) and stabilized by the fully aromatic pteridine ring, the possibility for reduction is eliminated. T he DHFR enzyme will be pseudoirreversibly bound to a molecule it cannot reduce, which ties up the DHFR enzyme and prevents the conversion of DHF to T HF. In turn, this halts the synthesis of the 5,10-methylene-T HF cofactor required for dT MP biosynthesis and causes feedback inhibition of the thymidylate synthase enzyme. T he cell will die a “ thymineless death.” Methotrexate can be given orally in the treatment of breast, head and neck, and various lung cancers as well as in non-Hodgkin's lymphoma. T he sodium salt form also is marketed for IV, intramuscular, intra-arterial, or intrathecal injection. Oral absorption is dose-dependent and peaks at 80 mg/m2 because of site saturation. T he monoglutamate tail of methotrexate permits active transport into cells, with carrier-mediated transport predominating at serum concentration levels lower than 100 µM. Once inside the cell, methotrexate undergoes a polyglutamation reaction that adds several anionic carboxylate groups to trap the drug at the

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site of action. Polyglutamation is more efficient in tumor cells than in healthy cells and, therefore, may promote selective toxicity of this drug. Cancer cells can become resistant to methotrexate over time which may involve impaired transport across tumor cell membranes, enhanced efflux from the tumor cell, and attenuated polyglutamation rates. T he polyglutamated drug will be hydrolyzed back to the parent structure before renal elimination. Up to 90% of an administered dose of methotrexate is excreted unchanged in the urine within 24 hours.

Fig. 42.30. Misorientation of methotrexate of dihydrofolate reductase (DHFR).

Methotrexate toxicity can occur with high doses if “ third space” fluids allow drug to accumulate in ascites and pleural effusions and/or when renal excretion is impaired by kidney disease. When used in high doses, methotrexate and its 7-hydroxymetabolite (which has a three- to fivefold lower water solubility) can precipitate in the renal tubule, causing damaging crystalluria. Methotrexate- induced lung disease is a particularly critical problem, because it can arise at any time and at any dose, and it can even be fatal. Methotrexate use also can precipitate severe GI side effects, including ulcerative stomatitis and hemorrhagic enteritis, leading to intestinal perforation. Potentially fatal skin reactions are a risk as well. As a Category X teratogen, this drug should not be given to women who are pregnant or planning to become pregnant. If severe methotrexate toxicity occurs, reduced folate replacement therapy with 5-formyltetrahydrofolate P.1178 (leucovorin) must be initiated as soon as possible. Leucovorin generates the folate cofactors needed by DHFR and GAR transformylase to ensure the continued synthesis of pyrimidine and purine nucleotides in healthy cells. “ Leucovorin rescue” therapy often is given as prophylaxis after high-dose methotrexate therapy.

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Pemetrexed Pemetrexed (Fig. 42.25) is a novel multitarget antifolate used by the IV route for the treatment of advanced or metastatic nonsmall cell lung cancer and in combination with cisplatin in malignant pleural mesothelioma. Like methotrexate, it is actively transported into tumor cells through reduced folate carriers and, in polyglutamated form, inhibits the synthesis of pyrimidine and purine-based nucletotides by disrupting folatedependent metabolic processes (63). In addition to DHFR, this pyrrolopyrimidine-based inhibitor binds tightly to thymidylate synthase and GAR transformylase (64,65). Patients on pemetrexed must take folate and vitamin B 12 supplements to reduce the risk of bone marrow suppression (neutropenia, thrombocytopenia, and anemia) and GI side effects. Pretreatment with corticosteroids can reduce the risk of drug-induced skin rash. Pemetrexed has a half-life of 3.5 hours and is excreted primarily unchanged via the kidneys. Significant cross-resistance has been noted between pemetrexed and other pyrimidine and folate antagonists (63).

Purine Antagonists: Amidophosphoribosyl Transferase Inhibitors AMP and GMP biosynthesis T he rate-limiting enzyme in the synthesis of purine nucleotides is amidophosphoribosyl transferase (also known as phosphoribosylpyrophosphate amido transferase), which is a major target for one of the two thiolcontaining purine anticancer antimetabolites on the U.S. market. T he pathway outlining the normal synthesis of AMP and GMP is provided in Figure 42.31. It is important to recognize that the rate-limiting step is the first of the pathway; if that step is inhibited, no other step can proceed. Also, note that the rate-limiting transferase enzyme works on a phosphorylated ribose substrate. Because phosphorylated ribose is a component of every intermediate in the pathway, no enzyme in the sequence will function without its presence. Finally, note the reaction in the pathway catalyzed by GAR transformylase, which requires the methyl-donating 10-formyltetrahydrofolate. As previously mentioned, this step is inhibited by methotrexate.

Thiopurine metabolism T he two currently marketed purine anticancer agents are both 6-thio analogues of the endogenous purine bases guanine and purine, also known as inosine (Fig. 42.25). T hey are prodrugs and must be converted to ribonucleotides by hypoxanthine guanine phosphoribosyl transferase (HGPRT ) before they can exert their cytotoxic actions. Mercaptopurine, acting through a methylated ribonucleotide metabolite, inhibits the target amidophosphoribosyl transferase enzyme, leading to the true antimetabolic effect of lowered AMP and GMP biosynthesis (Fig. 42.32). A second mechanism of antineoplastic activity for mercaptopurine (and the predominant mechanism for thioguanine) involves the incorporation of di- and triphosphate deoxy- and ribonucleotides generated within the tumor cell into DNA and RNA, respectively (66). T his illicit substitution further inhibits elongation of the strands and promotes apoptosis. T hiopurines are metabolized by S-methylation via the polymorphic enzyme thiopurine methyl transferase (T PMT ) with S-adenosylmethionine serving as cofactor. T he methylated thiopurine bases cannot react with HGPRT and, therefore, cannot form the active false ribonucleotides. Drug manufacturers take this into

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account when establishing dosing regimens. T he active false ribonucleotide 6-thioinosinic acid also is subject to extensive T PMT -catalyzed methylation. T he S-methyl-6-thioinosinic acid metabolite is a potent inhibitor of the amidophosphoribosyl transferase enzyme and contributes to the cytotoxic action of the parent drug (Fig. 42.32). In contrast, little or no 6-methylthioguanylic acid is produced inside the cell (66,67). T hiopurine methyl transferase is polymorphic in humans, and some individuals do not express this protein to any significant extent (68). Patients who are poor T PMT metabolizers (e.g., 10% of Caucasians, but also evident in other races) will not experience the activity-attenuating metabolic effect and will generate more active ribonucleotide per dose than patients with normal or excessive levels of the enzyme will. T he T PMT genotype of patients should be assessed before initiating thiopurine therapy, because poor metabolizers are at a high risk of life-threatening myelosuppression from elevated levels of false ribonucleotides, even when standard doses are administered (67). In addition, the accumulation of mutagenic thiopurine-based ribonucleotides puts these patients at higher risk for secondary malignancies (66). T hiopurines can still be used in poor T PMT metabolizers, but the dose should be decreased significantly (e.g., 10- to 15-fold) and white blood cell counts monitored vigilantly. Extensive T PMT metabolizers, who represent up to 90% of patients on thiopurine therapy, will form lower amounts of apoptotic 6-thiolated ribonucleotides. In the case of mercaptopurine, the molecules of ribonucleotide generated will be methylated very rapidly to the antimetabolic 6-methylthioinosinic acid, thus enhancing sensitivity to the drug (67). In contrast, extensive T PMT metabolizers show a decreased sensitivity to thioguanine, P.1179 because there is no compensatory increase in the formation of methylated ribonucleotide to offset the decreased production of 6-thioguanylic acid (66).

Fig. 42.31. Biosynthetic scheme for the synthesis of purines.

Xanthine oxidase competes with T PMT for mercaptopurine (but not for thioguanine) and converts it to

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inactive 6-thiouric acid, which is excreted in the urine (Fig. 42.33) (68). 6-T hioinosinic acid also is subject to metabolism via the xanthine oxidase pathway, ultimately forming the same inactive metabolite. Allopurinol, which inhibits xanthine oxidase and increases levels of active 6-thioinosinic acid, can be coadministered with mercaptopurine to increase its duration of action and effective antineoplastic potency. T he dose of mercaptopurine can be cut approximately in half when coadministered with allopurinol. Coadministration of allopurinol with thioguanine is not warranted, because the impact of xanthine oxidase on its metabolic degradation is minor.

Specific drugs Mercaptopu rin e Mercaptopurine (Fig. 42.32) is used in the treatment of acute lymphatic and myelogenous leukemias. It is available in an oral dosage form, but absorption can be erratic and is reduced by the presence of food. T he drug is extensively metabolized on first pass and excreted by the kidneys. Bone marrow suppression is the major use-limiting toxicity, although the drug can be hepatotoxic in high doses. Dosage adjustments should be considered in the face of renal or hepatic impairment. Because the major mechanism of action of mercaptopurine is inhibition of de novo purine nucleotide biosynthesis rather than apoptosis secondary to the incorporation of false nucleotides into DNA, there is a lower risk for mutagenesis and secondary malignancy compared to thioguanine (66).

T h iogu an in e T hiogunanine (Fig. 42.32) is administered orally in the treatment of nonlymphocytic leukemias. Like mercaptopurine, absorption is incomplete and variable, and the toxicity profiles are similar except where previously noted.

DNA Polymerase/DNA Chain Elongation Inhibitors Five halogenated and/or ribose-modified DNA nucleoside analogues are marketed for the treatment of a wide P.1180 variety of hematologic cancers and solid tumors (Fig. 42.25). T hese agents have complex and multifaceted mechanisms. All include inhibition of DNA polymerase and/or DNA chain elongation among their actions, however, and all must be converted to triphosphate nucleotides before activity is realized. As nucleosides, they are actively taken up into cells via a selective nucleoside transporter protein, so tumors deficient in this transporter system will be resistant to these anticancer agents. Once inside the cell, specific kinases conduct the essential phosphorylation reactions. In active triphosphate form, they can be mistakenly incorporated into the growing DNA chain, thus arresting further elongation, and/or inhibit enzymes essential for DNA synthesis.

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Fig. 42.32. Thiopurine metabolism leading to activation and inactivation.

Fig. 42.33. Xanthine oxidase inactivation of mercaptopurine and 6-thioinosinic acid.

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Fig. 42.34. Cytarabine metabolism.

All drugs in this group are administered IV, are excreted via the kidneys, and induce myelosuppression as their major use-limiting side effect.

Cytarabine and Gemcitabine Both of these cytidine-based anticancer agents (Fig. 42.25) undergo initial phosphorylation by deoxycytidine kinase to the monophosphate with subsequent phosphorylations catalyzed by pyrimidine monophosphate and diphosphate kinases. Cytaribine, an arabinoside, is catabolized by cytidine and deoxycytidylate (deoxycytidine monophosphate) deaminases to inactive uracil analogues (Fig. 42.34). T he significantly longer half-life of gemcitabine (19 hours) compared to conventional cytarabine (3.6 hours) is caused by the inhibitory action of the difluorodeoxycytidine triphosphate metabolite on the potentially degradative deoxycytidine monophosphate deaminase enzyme (58). Gemcitabine elimination is gender-dependent, with women having the greater risk for toxicity because of lower renal clearance. Gemcitabine is indicated in the treatment of breast, pancreatic, and nonsmall cell lung cancers. Cytarabine, which can be administered subcutaneously and intrathecally in addition to IV, is used in the treatment of various leukemias. A liposomal formulation of cytarabine is available for the treatment of lymphomatous meningitis.

Fludarabine, cladribine, and clofarabine Like their pyrimidine counterparts, these 3-halogenated adenosine-based nucleosides undergo conversion to the active triphosphate nucleotides (Fig. 42.25) after active transport into tumor cells. All are initially phosphorylated by P.1181

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deoxycytidine kinase, and cells with high levels of this enzyme should respond well to these agents. T he C 2 -halogen renders the molecules relatively resistant to the degradative action of adenosine deaminase, and a significant fraction of the dose is eliminated unchanged via the kidneys. Fludarabine, an arabinoside, actually is marketed as the monophosphate nucleotide to enhance water solubility for IV administration, but this group is cleaved rapidly in the bloodstream, allowing the free nucleoside to take advantage of the nucleoside-specific transporting proteins. Cladribine is indicated in the treatment of hairy cell leukemia, whereas fludarabine phosphate is utilized in chronic lymphocytic leukemia. In addition to myelosuppression, fludarabine phosphate can induce hemolytic anemia, and severe CNS toxicity has been noted with high doses. Clofarabine is used in acute lymphoblastic leukemia patients of 21 years or less who have failed with at least two previous regimens. In addition to inhibiting DNA chain elongation, this drug also inhibits ribonucleotide reductase and facilitates the release of proapoptotic proteins from mitochondria. T he rapid attenuation of leukemia cells after administration of this agent can result in a condition known as tumor lysis syndrome, and respiratory and cardiac toxicities can occur secondary to cytokine release. T oxicity can progress to potentially fatal capillary leak syndrome and organ failure, and patients should receive IV fluids for the entire 5-day course of therapy to minimize risk of serious adverse events.

Miscellaneous Antimetabolites Pentostatin Pentostatin (Fig. 42.25) is a ring-expanded purine ribonucleoside that inhibits adenosine deaminase and is used in the treatment of hairy cell leukemia. T he elevated levels of deoxyadenosine triphosphate that result from inhibition of this degradative enzyme inhibit the action of ribonucleotide reductase (the enzyme that converts ribose diphosphate to deoxyribose diphosphate), thus halting DNA synthesis within the tumor cell.

Hydroxyurea Hydroxyurea (Fig. 42.25) blocks the synthesis of DNA by trapping a tyrosyl free radical species at the catalytic site of ribonucleotide reductase, thereby inhibiting the enzyme that converts ribonucleotide diphosphates into their corresponding deoxyribonucleotides. It is used orally for the treatment of melanoma, metastatic or inoperable ovarian cancer, resistant chronic myelocytic leukemia, and as an adjunct to radiation in the treatment of squamous cell carcinoma and cancer of the head and neck. Hydroxyurea increases the effectiveness of radiation therapy through its selective toxicity to cells in the radiation-resistant S phase and by stalling the cell cycle in the G 1 stage, in which radiation therapy does the greatest damage. It addition, hydroxyurea thwarts the normal damage-repair mechanisms of surviving cells. Hydroxyurea has excellent oral bioavailability (80–100%), and serum levels peak within 2 hours of consuming the capsules. If a positive response is noted within 6 weeks, toxicities generally are mild enough to permit long-term or indefinite therapy on either a daily or every-3-day basis. Leukopenia and, less commonly, thrombocytopenia and/or anemia are the most serious adverse effects. Excretion of the unchanged drug and the urea metabolite is via the kidneys. T he carbon dioxide produced as a by-product of hydroxyurea metabolism is excreted in the expired air.

M itosis Inhibitors T he mitotic process depends on the structural and functional viability of microtubules (polymeric heterodimers consisting of isotypes of α- and β- tubulin proteins). T hese distinct but nearly identical 50-kDa proteins lie adjacent to one another within the tubule and “ roll up” to form an open, pipe-like cylinder akin to a hollow peppermint candy stick. A γ-tubulin protein is found at the organizational center of the microtubule. T he nature of the tubulin isotypes found in the microtubule are conserved throughout specific tissues within a given species and will impact the cell's sensitivity to mitosis inhibitors. During cell division, tubulin undergoes intense, sporadic, and alternating periods of structural growth and erosion known as “ dynamic instability.” T he proteins alternatively polymerize and depolymerize through 2+ guanosine triphosphate– and Ca -dependent processes. Polymerization involves the addition of tubulin dimers to either end of the tubule, although the faster-growing (+ )-end is more commonly involved. Polymerization results in tubular elongation, whereas depolymerization results in the shortening of the

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structure. T he frenetic alteration in structure, facilitated by microtubule-associated proteins (MAPs), ultimately allows the formation of the mitotic spindle and the attachment to chromosomes that is a prerequisite to cell division. Inhibiting the essential hyperdynamic changes in microtubular structure results in mitotic arrest and apoptosis. T wo classes of mitosis inhibitors currently are marketed for the treatment of cancer, taxanes, and vinca alkaloids.

Taxanes Anticancer taxanes initially were isolated from the bark of the Pacific yew (Taxus brevi fol i a) but are now produced semisynthetically from an inactive natural precursor found in the leaves of the European yew (Taxus baccata) a renewable resource. T axanes bind to polymerized (elongated) β-tubulin at a specific receptor site located within the tubular lumen. At standard therapeutic doses (which should lead to intracellular concentrations of 1–20 µM), taxane-tubulin binding renders the microtubules resistant to depolymerization and prone to polymerization (69). T his promotes the elongation phase of microtubule dynamic instability at the expense of the shortening phase, and it inhibits the disassembly of the tubule into the mitotic spindle. In turn, this interrupts the normal process of cell division. At these concentrations, extensive polymerization causes the formation of large and P.1182 dense aberrant structures, known as asters, that contain stabilized microtubule bundles.

Fig. 42.35. Mitosis inhibitors.

Chemistry and receptor binding Chemically, diterpenoid taxanes consist of a 15-membered tricyclic taxane ring system

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(tricyclo[9.3.1.0]pentadecane) fused to an oxetane (D) ring and contain an esterified β-phenylisoserine side chain at C 13 . As shown in Figure 42.35, the two marketed taxane antineoplastics differ in substitution pattern at C 10 (acetate ester or secondary alcohol) and C 13 (benzamido or t-butoxycarboxamido). T he taxane ring system often is conceptualized as having “ northern” and “ southern” halves. T he “ southern” segment is critical to receptor binding, whereas the “ northern” section ensures the proper conformation of essential functional groups, including the C 13 -isoserine side chain (with its C 1 -carbonyl, free C 2 -(R)-OH and C 3 -(S)-benzamido or t-butoxycarboxamido groups), the benzoyl and acetyl esters at C 2 and C 4 , respectively, and the intact oxetane ring (70,71,72). T he key taxane-tubulin binding interactions are identified in T able 42.7, utilizing paclitaxel as ligand (70,73,74). Paclitaxel interacts at the β-tubulin binding site in a folded (“ T ” or “ butterfly” ) conformation, that places C 2 -benzoyl and the C 3 -benzamido groups in close proximity (70). T heir independent intermolecular engagement with a critical β-tubulin His residue, however, which is perfectly positioned between them, keeps them from interacting with one another. T he oxetane ring of taxanes, although capable of enhancing receptor affinity through hydrogen bonding (72,73), is believed to serve a more critical role in properly orienting the C 4 -acetyl moiety for P.1183 interaction within its hydrophobic binding pocket (71). T he C 1 -OH also promotes conformational stability through intramolecular interaction with the carbonyl oxygen of the C 2 benzoyl moiety (70). T he areas of the paclitaxel structure where steric influences are most critical to receptor binding have been identified (72).

Table 42.7. Paclitaxel–β-Tubulin Binding Interactions (70,73,74) Paclitaxel Functional Group C 2 -benzoyl phenyl

β-Tubulin Binding Residues Leu 217 , Leu 219 , His 229 ,

Interaction Hydrophobic

Leu 230 C 2 -benzoyl carbonyl

Arg 278

Hydrogen bond

C 3′ -benzamido-NH

Asp 26

Hydrogen bond

C 3′ -benzamido carbonyl

His 229

Hydrogen bond

C 3′ -phenyl

Ala 233 , Ser 236 , Phe 272

Hydrophobic

C 4 -acetyl

Leu 217 , Leu 230 , Phe 272 ,

Hydrophobic

Leu 275 C 7 -OH

Thr 276 , Ser 277 , Arg 278

Hydrogen bond

C 12 -CH 3

Leu 217 , Leu 230 , Phe 272 ,

Hydrophobic

Leu 275

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C 2′ -OH

Arg 369 , Gly 370 (NH)

Hydrogen bond

C 1′ -carbonyl

Gly 370 (NH)

Hydrogen bond

Oxetane oxygen

Thr 276 (NH)

Hydrogen bond

Taxane metabolism T he taxanes are metabolized to significantly less cytotoxic metabolites by CYP450 enzymes. In humans, CYP2C8 bioconverts paclitaxel to 6α-hydroxypaclitaxel, the major metabolite, which is 30-fold less active than the parent structure (75,76,77). CYP3A4 mediates the formation of additional minor p-hydroxylated metabolites of the benzamido and benzoyl at C 3′ and C 2 respectively (Fig. 42.36), and the 10-desacetyl metabolite has been documented in urine and plasma. Docetaxel is oxidized exclusively by CYP3A4/5, with CYP3A4 having a 10-fold higher affinity for the drug than CYP3A5. T he major metabolite, known as hydroxydocetaxel, is the hydroxymethyl derivative of the 3′-t-butoxycarboxamide side chain (77). Hydroxydocetaxel is further oxidized and cyclized to isomeric oxazolidinediones before excretion. T he elimination of taxanes is predominantly biliary.

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Fig. 42.36. Taxane metabolism.

T he metabolic patterns of these closely related structures are distinct, and it has been hypothesized that the C 13 side chain plays a major role in positioning the compounds in the catalytic site of CYP450 enzymes. Specifically, the 3′-phenyl ring of paclitaxel has been proposed to properly orient C 6 for hydroxylation through π-stacking interactions with CYP2C8 active site residues while decreasing affinity for CYP3A4 binding groups. T he hydrophobic character of the 10-acetoxy group, found in paclitaxel, enhances CYP450mediated hydroxylation two- to fivefold by facilitating substrate binding or augmenting catalytic capability. Both isoforms are impacted by the presence of this ester, often to the same extent (77).

Epothilones Low water solubility is a significant drawback to the therapeutic utility of the taxanes. T his is particularly true of paclitaxel, which has a more lipophilic acetate moiety at C 10 compared to docetaxel's more polar hydroxyl group. Paclitaxel must be administered in a vehicle of 50% alcohol/50% polyoxyethylated caster oil, which can lead to an enhanced risk of hypersensitivity reactions (dyspnea, hypotension, angioedema, and uticaria)

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in patients not pretreated with H 1 and H 2 antagonists and dexamethasone (78). In addition, high P-glycoprotein–mediated cellular efflux of both taxane anticancer agents can result in drug resistance. T o overcome these problems, epothilone B (Fig. 42.37), a 16-membered macrolide structurally unrelated to the taxanes but with functional groups properly positioned to mimic critical tubulin-binding groups, is being actively investigated for use in a variety of solid tumor and hematologic cancers. Epothilone B binds with very high affinity to the taxane binding site on polymerized β-tubulin, and it acts through the same cytotoxic P.1184 mechanism. In addition to enhanced water solubility and a lack of P-glycoprotein affinity, epothilone is more efficiently produced through fermentation with the myxobacterium Sorangi um cel l ul osum and has a higher antineoplastic potency (74,79,80).

Fig. 42.37. Receptor binding-matched epothilone B and paclitaxel functional groups.

Specific drugs Paclitaxel Paclitaxel (Fig. 42.35), which is claimed to be “ the best-selling anticancer drug in history” (70), is indicated for IV use in combination with cisplatin as first-line therapy for advanced ovarian and nonsmall cell lung cancer. It also is used alone or in combination with the fluorouracil prodrug capecitabine in anthracyclineresistant metastatic breast cancer. Paxclitaxel's ability to up-regulate thymidine phosphorylase, one of capecitabine's activating enzymes, is the rationale behind the combination therapy (81). Solution (T axol, Onxol) and albumin-bound (Abraxane) formulations are available and cannot be used interchangeably. Abraxane also has been employed in various solid tumors of the GI and genitourinary tracts. Solution-based infusions generally are administered over 3 to 24 hours and can be passed through an in-line, 0.22-µm filter to reduce vehicle-related cloudiness. T he albumin-bound form is given over 30 minutes and should be well-mixed (but not filtered) to ensure complete suspension of the protein–drug particles. T he major use-limiting adverse effect of paclitaxel is dose-dependent myelosuppression, particularly

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neutropenia, and first doses may need to be decreased in patients with hepatic dysfunction. Subsequent dose reductions, if any, should be tailored to individual response. T he drug should not be given to patients 3 who have baseline neutrophil counts below 1,500 cells/mm . T he albumin-bound formulation also is associated with sensory neuropathy. As noted above, all patients receiving solution-based paclitaxel should be pretreated with antihistamines and a corticosteroid to minimize the risk of potentially fatal hypersensitivity

reactions. Paclitaxel is a Category D teratogen and carries a high risk of fetal intrauterine mortality. Both male and female patients are advised not to attempt conception while on this drug. Due caution should be observed when coadministering paclitaxel with drugs that inhibit or compete for metabolizing enzymes, particularly CYP2C8 (e.g., 17α-ethinylestradiol and diazepam).

Docetaxel T he indications for docetaxel (Fig. 42.35) generally mirror those of paclitaxel, although docetaxel is not used in ovarian cancer. It has greater water solubility than paclitaxel because of presence of the free C 10 -OH group, and it is formulated with polysorbate 80 rather than with polyoxyethylated castor oil. Hypersensitivity reactions are still possible, and all patients should receive corticosteroid premedication. In addition to neutropenia and teratogenicity, this taxane can induce significant fluid retention, and 2-kg weight gains are not uncommon. Although rare, onycholysis also has been reported. Drug–drug interactions have been noted when docetaxel is coadministered with drugs that inhibit or compete for CYP3A4 enzymes (e.g., “ azole” antifungals, erythromycin, and cyclosporine) (82).

Vinca Alkaloids Several alkaloids found naturally in Catharanthus roseus (periwinkle) have potent antimitotic activity. In opposition to the taxoids, vinca alkaloids halt cell division by inhibiting polymerization. T hey bind at the interface of two heterodimers within the inner tubular lumen at a single high-affinity site on the (+ )-end of the tubules and attenuate the uptake of the guanosine triphosphate essential to tubule elongation (83). Simultaneous binding to α- and β-tubulin results in protein cross-linking, which promotes a stabilized protofilament structure (84). Inhibition of microtubule elongation occurs at “ substoichiometric” concentrations, at which alkaloid occupation of only 1 to 2% of the total number of high-affinity sites can result in up to a 50% inhibition of microtubule assembly (85). At high concentrations, when alkaloid binding to high-affinity sites becomes stoichiometric and lower-affinity binding sites on the tubule wall also are occupied, microtubular depolymerization is stimulated, leading to the exposure of additional alkaloidal binding sites and resulting in dramatic changes in microtubular conformation. Spiral aggregates, protofilaments, and highly structured crystals form, and the mitotic spindle ultimately disintegrates (69,81). T he loss of the directing mitotic spindle promotes chromosome “ clumping” in unnatural shapes (balls and stars), leading to cell death (78). Other nonmitotic toxicities related to the microtubule-disrupting action of the vinca alkaloids include inhibition of axonal transport and secretory processes and disturbances in platelet structure and function (85).

Chemistry T he specific chemical nature of the vinca binding site remains elusive because of difficulties encountered in binding assay development and implementation as well as in data analysis. It is known that the active site is close to residue 339 and residue 390 on α- and β-tubulin, respectively (86). Of the three marketed vinca alkaloids (vincristine, vinblastine, and vinorelbine), vincristine binds most tightly, whereas vinblastine has the lowest affinity (85). Because vinca alkaloids enter cells by simple passive diffusion, unbound vinorelbine and vinblastine (being more lipophilic than vincristine) may be more extensively taken up into tissues. Vincristine, however, is cleared more slowly from the system and has the longest terminal half-life of the three agents, resulting in a more prolonged tumor cell exposure (69,85). Like the taxanes, tumor resistance to vinca alkaloids is mediated through P-glycoprotein. T he vinca alkaloids are complex structures composed of two polycyclic segments known as catharanthine (or velbanamine) and vindoline (Fig. 42.35), both of which are essential for high-affinity tubulin binding. T he three commercially available anticancer alkaloids differ in the P.1185 length of the alkyl chain bridging positions 6′ and 9′ of the catharanthine moiety (methylene or ethylene), in the substituents at position 4′ (olefin or tertiary alcohol), and in the N 1 vindoline indole nitrogen (methyl or formyl). Although subtle, these structural changes lead to significant differences in clinical spectrum,

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potency, and toxicity. For example, vincristine's relative lack of bone marrow toxicity at standard therapeutic doses makes it popular in combination therapy with more myelosuppressive anticancer agents, whereas vinblastine's relative lack of neurotoxicity permits its coadministration with cisplatin. It is known that acetylation of either hydroxyl group destroys antineoplastic activity. Reduction of the vindoline olefinic linkage greatly attenuates action (78). T he C 18′ -methoxycarbonyl, as well as the stereochemistry at positions 18′ and 2′, also are believed to be critical to activity (87). Vinca alkaloids undergo O 4 -deacetylation to yield metabolites equally or more active than the parent drug. T hey also are subject to extensive CYP3A4-mediated metabolism before biliary excretion, although the structures of these metabolites are currently unknown (88,89,90).

Specific drugs Vin cristin e Vincristine (Fig. 42.35) is marketed as the sulfate salt and is given by the IV bolus or continuous infusion routes in the treatment of acute leukemia and various Hodgkin's and non-Hodgkin's lymphomas. T oxicity often is more pronounced by the latter route. Elimination is triphasic, with the first phase (5 minutes) representing rapid uptake into tissues and the last phase (85 hours) representing release back to the plasma from tubulin-containing cells. Because the drug is extensively metabolized in the liver, patients with hepatic dysfunction are at an increased risk for toxicity, and dosage reductions should be considered. T he most significant dose-limiting adverse effect is neurotoxicity, which can manifest initially as numbness and painful paresthesias in the extremities and progress to muscular pain, severe weakness, and loss of coordination. Patients can experience constipation secondary to intestinal neurotoxicity, which may require treatment with cathartics. Myelosuppression is not particularly problematic, because it occurs at doses higher than those that can be tolerated. As previously noted, coadministration with mitomycin can induce acute or delayed pulmonary toxicity characterized by severe bronchospasm. All vinca alkaloids are severe vesicants that can induce necrosis, cellulitis, and/or thrombophlebitis. Proper needle placement before administration should be assured to eliminate the risk of extravasation. Unlike the tissue damage caused by the vesicant action of nitrogen mustards and antibiotic antineoplastics, cold exacerbates tissue destruction. If extravasation occurs, apply heat for 1 hour fours time a day for 3 to 5 days, coupled with local hyaluronidase injections. Vinca alkaloids are all Category D teratogens and are fatal if administered by the intrathecal route.

Vin blastin e In addition to the hematologic indications that it shares with vincristine, vinblastine sulfate (Fig. 42.35) has found utility in the treatment of advanced testicular carcinoma (often in combination with bleomycin), advanced mycosis fungoides, Kaposi's sarcoma, and histiocytosis X. Leukopenia is the dose-limiting side effect, and dose reductions are warranted in patients with serum bilirubin levels greater than 3 mg/dL. T he drug-related impact on erythrocyte and thrombocyte levels usually is insignificant. Like vincristine, it is administered as an IV bolus or infusion. T he initial elimination half-life of 3.7 minutes is similar to vincristine, but the 24.8-hour terminal half-life is significantly shorter.

Vin orelbin e Vinorelbine tartrate (Fig. 42.35) is used alone or in combination with cisplatin for first-line treatment of nonsmall cell lung cancer. T his semisynthetic alkaloid is unique in having oral bioavailability (85), but it currently is available only for IV injection. T he initial phase elimination half-life is on par with that observed for vincristine and vinblastine, and the terminal phase half-life is between 28 and 44 hours. Although dose-limiting granulocytopenia is the major adverse effect, potentially fatal interstitial pulmonary changes have been noted, and patients with symptoms of respiratory distress should be promptly evaluated. As with all vinca alkaloids, elimination is primarily hepatobiliary, and dosage reduction should be considered in patients with liver dysfunction.

Estramu stin e Because this anticancer agent contains a carbamylated nitrogen mustard moiety (Fig. 42.3), it is most commonly classified as a DNA alkylator; however, it is now known that its primary mechanism of

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antineoplastic action is inhibition of mitosis. Estramustine binds to MAP-4, prompting dissociation of this protein from the microtubule and promoting depolymerization and disassembly. It also can bind directly to αand β-tubulin at a site distinct from the vinca alkaloid and taxane binding sites, although paclitaxel exerts a noncompetitive inhibition of estramustine binding to tubulin. A specific estramustine binding protein in prostate tissue is believed to facilitate its action in the treatment of metastatic carcinoma of the prostate. Estramustine has a low affinity for the β m tubulin isotype, which often is overexpressed in estramustineresistant prostatic neoplasms as one defense against this therapeutic intervention (81,91).

Topoisomerase Poisons Epipodophyllotoxins T he epipodophyllotoxins (Fig. 42.38) are semisynthetic glycosidic derivatives of podophyllotoxin, the major component of the resinous podophyllin isolated from the dried roots of the American mandrake or mayapple plant (Podophyl l um pel tatum). Although these compounds are capable of binding to tubulin and inhibiting mitosis, their primary mechanism of antineoplastic action is poisioning topoisomerase II, a mechanism that they share P.1186 with anthracyclines and dactinomycin (discussed with the antibiotic antineoplastics under Anti bi oti cs). T opoisomerase IIα has two distinct DNA-independent binding sites for the epipodophyllotoxins, one within the catalytic domain and a second within the N-terminal AT P-binding domain (92). Once bound, the toxins stabilize the cleavable ternary drug-enzyme-DNA complex, stimulating DNA ligation but inhibiting resealing. T he DNA-topoisomerase fragments accumulate in the cell, ultimately resulting in apoptosis. T he RNA transcription processes also are disrupted by the interaction of epipodophyllotoxins with topoisomerase IIα (93).

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Fig. 42.38. Topoisomerase poisons.

Epipodophyllotoxins are cell-cycle specific and have their most devastating impact on cells in the S or early G 2 phase. For this reason, doses are divided and administered over several days. Resistance is multifaceted and involves down-regulation of topoisomerase IIα, attenuation of enzymatic activity levels, development of novel DNA repair mechanisms, and P-glycoprotein–mediated cellular efflux.

Chemistry Structurally, the two marketed epipodophyllotoxins, etoposide and teniposide, differ only in the nature of one β-D-glucopyranosyl substituent (methyl or thienyl, respectively). Both are highly water insoluble, but teniposide's higher lipophilicity facilitates cellular uptake and results in a 10-fold enhancement of potency (93). T he need for solubility enhancers, such as polysorbate 80 (T ween, etoposide) or polyoxyethylated castor oil (Cremophor EL, teniposide), in IV formulations puts patients at risk for hypersensitivity reactions that can manifest as hypotension and thrombophlebitis. Epinephrine, antihistamines, and corticosteroids often are coadministered to minimize risk. A water-soluble phosphate ester analogue of etoposide can be administered in standard aqueous vehicles, permitting higher doses than the oil-modified formulations would allow. T he phosphate ester is rapidly cleaved to the free alcohol in the blood.

Metabolism Epipodophyllotoxins are subject to metabolic transformation before renal and nonrenal elimination (Fig. 42.39). Etoposide is stable enough for oral administration, although a dose approximately twice that of the IV formulation must be administered. T eniposide is more extensively metabolized, presumably because of its enhanced ability to penetrate into hepatocytes, and no oral dosage form is marketed. Both drugs undergo lactone hydrolysis to generate the inactive hydroxy acid as the major metabolite, but the parent drugs also can be transformed by CYP3A4-catalyzed O-demethylation and Phase II glucuronide or sulfate conjugation.

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Phase II metabolism accounts for between 5 to 22% of the dose. Clinically significant interactions between epipodophyllotoxins and CYP3A4 inducers, such as phenytoin, phenobarbital, and St. John's wort, have been documented, and coadministration can enhance antineoplastic drug clearance by as much as P.1187 77%. Conversely, CYP3A4 inhibitors, such as cyclosporine or macrolide antibiotics, can decrease clearance, leading to unwanted toxicity.

Fig. 42.39. Epipodophyllotoxin metabolism.

T he catechol metabolite can oxidize to a reactive orthoquinone, and both have been proposed to promote topoisomerase-mediated DNA cleavage, potentially enhancing the risk of the translocations that result in therapy-induced acute myeloid leukemia in children treated with these drugs. Epipodophyllotoxin-induced leukemia occurs in 2 to 12% of patients and is believed to result from translocation of the M LL gene at chromosome band 11q23. T he mean latency period of 2 years is shorter than the 5- to 7-year latency for leukemia induced by DNA alkylators, and the drug-induced cancer often is resistant to standard treatment (including bone marrow transplantation) (94). Other serious adverse effects include dose-limiting mucositis and myelosuppression, particularly leukopenia. Alopecia is common, and nausea and vomiting, most noticeable with the oral dosage form, generally are mild.

Specific drugs Etoposide

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Etoposide (Fig. 42.38) is utilized in the treatment of small cell lung cancer and in combination with other agents in refractory testicular cancer. Both IV and oral formulations are available. Oral bioavailability is concentration dependent and runs approximately 50% for the 50-mg capsule. Little first-pass metabolism is noted with the gelatin capsule dosage form. T he drug is more than 96% protein bound, undergoes biphasic elimination, and has a terminal half-life of 4 to 11 hours. Approximately 35 to 45% of a dose is eliminated via the kidneys, with less than 6% excreted in feces. T he drug should be used with caution in patients with renal or liver disease. Specifically, doses should be decreased in patients with creatinine clearance of less than 50 mL/min or bilirubin levels of greater than 1.5 mg/dL, and the drug should not be used in patients with bilirubin levels of greater than 3.1 mg/dL. Organoplatinum anticancer agents (e.g., cisplatin) decrease etoposide clearance, especially in children. If used in combination, administration must be separated by at least 2 days.

T en iposide T eniposide (Fig. 42.38) is used in combination with other agents for the treatment of refractory childhood acute lymphoblastic leukemia. Compared to etoposide, it is more tightly protein bound (> 99%), more extensively metabolized, more slowly cleared (terminal half-life, 5–40 hours), and less dependent on renal elimination (10–21%). Exposure to heparin can cause teniposide to precipitate, so lines must be thoroughly flushed before and after teniposide administration. T he drug also can spontaneously precipitate, particularly if solutions are overagitated, and patients receiving 24-hour infusions should be monitored for blockage of access catheters. T eniposide and etoposide are Category D teratogens and, if at all possible, should not be used in women of childbearing years.

Camptothecins Mechanism of action Camptothecins are chiral, extensively conjugated, amine-containing pentacyclic lactones (Fig. 42.38). T he biological target of camptothecins is topoisomerase I (rather than the topoisomerase II enzyme that serves as the receptor for the anthracyclines, dactinomycin and epipodophyllotoxins), but the mechanism of antineoplastic action is qualitatively similar (stabilization of a cleavable ternary DNA-enzyme complex that does not permit the resealing of nicked DNA). Although the fragmented DNA is capable of resealing in the absence of drug, when DNA replication forks encounter the fragmented DNA, a double-stranded DNA break occurs, killing the cell. T he binding of camptothecins occurs in such a way as to stabilize a covalent DNA-topoisomerase bond at the 723 on the human enzyme). T he binding pocket, located within the DNA point of single-strand breakage (T yr strand, is revealed only after the normal DNA nicking has occurred, explaining why these poisons preferentially bind to the enzyme-DNA complex rather than to unoccupied DNA or enzyme. T he flat camptothecin ring system intercalates DNA at the site of cleavage, mimicking a DNA base pair (95). T he crystal structures of human ternary complexes involving the parent camptothecin alkaloid, camptothecin, and the semisynthetic analogue, topotecan (Fig. 42.38), have been solved, and important drug–protein interacting

entities are noted in T able 42.8 (95,96). T he bulky substituents at C 7 , C 9 , and C 10 of the marketed compounds, which project into the major groove of DNA, do not hinder binding. Camptothecins are most potent in cells undergoing active DNA replication and cell division (e.g., they are S-phase specific). Mechanisms of resistance are similar to those discussed for other drugs and include down-regulation or mutation of the target enzyme, down-regulation of enzymes needed for drug activation, and cellular efflux. Breast cancer resistance protein and multidrug resistance (MDR)-associated proteins, such as MAP-2 and MAP-3, rather than P-glycoprotein, appear to mediate resistance to these agents (78,93).

Chemistry T he parent camptothecin alkaloid, isolated from bark of Camptotheca acumi nate, has antitumor activity, but its limited water solubility necessitated delivery as P.1188 the sodium salt of the significantly less active hydrolyzed lactone. Lactonization of the hydroxy acid in acidic urine was significant, and elevated levels of active intact alkaloid in the kidney accounted for the hemorrhagic cystitis induced by this compound. Currently marketed analogues have a basic side chain incorporated at either C 9 (tocotecan) or C 10 (irinotecan), allowing the formation of water-soluble salts of the

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intact semisynthetic alkaloid. At pH 7.4, the active lactone exists in equilibrium with the hydroxy acid hydrolysis product, with the direction dictated by the extent of binding to serum albumin. T he preferential protein binding of the lactone, which occurs with irinotecan, shifts the equilibrium to favor the production of the more active lactone, thus enhancing potency.

Table 42.8. Topotecan–Topoisomerase I Interactions (95,96) Topotecan Functional GroupTopoisomerase I Residue Pyridine N 1

Arg 364

C 10 -OH

Enzyme associated water (H-bond)

C 17 -pyridone carbonyl

Asn 722

C 20 -OH

Asp 533 (H-bond)

C 21 -lactone carbonyl

Tyr 723 -phosphate, Lys 532

Specific drugs Irin otecan Hydroch loride In combination with fluorouracil, this prodrug camptothecin (Fig. 42.38) analogue is considered to be first-line therapy in the treatment of metastatic colorectal cancer. It also has shown efficacy in small cell and nonsmall cell lung cancers when used in combination with cisplatin. Given IV, the drug is slowly bioactivated in the liver through hydrolysis of the C 10 -carbamate ester. T he catalyzing enzyme is a saturable carboxylesterase known as irinotecan-converting enzyme. Levels of active metabolite, known as SN-38 (Fig. 42.40), are 50- to 100-fold lower than the parent drug, but preferential protein binding of the lactone (95%) permits significant plasma levels of the optimally active SN-38 compared to the hydroxy acid metabolite. SN-38 has a terminal half-life of 11.5 hours (compared to 5.0–9.6 hours for the prodrug parent) and is glucuronidated at the C 10 phenol before elimination. CYP3A4 also cleaves the terminal piperidine ring through oxidation at the α-carbons, followed by hydrolysis of the resultant amides, producing inactive metabolites. Excretion of the parent drug and metabolites is renal (14–37%) and, to a lesser extent, biliary. Delayed diarrhea induced by irinotecan is dose-limiting and potentially fatal, and vigorous loperamide therapy should be instituted at the first sign of symptoms. Acute diarrhea is attributed to the drug's ability to inhibit acetylcholinesterase and can be addressed through anticholinergic pretreatment. Pretreatment also helps patients to avoid “ cholinergic syndrome,” a collection of annoying side effects that include flushing, sweating, blurred vision, lacrimation, and less commonly, bradycardia. Camptothecins also are myelosuppressive, and neutropenia can be severe, particularly in patients with elevated bilirubin levels. Extensive biotransformation also demands cautious use of irinotecan in patients with hepatic dysfunction. Prophylactic antiemetic therapy should be given at least 30 minutes before the administration of irinotecan to minimize the nausea and vomiting associated with this anticancer agent.

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Fig. 42.40. Irinotecan metabolism.

T opotecan Hydroch loride T his active camptothecin analogue (Fig. 42.38) is used by the IV route in the treatment of ovarian and small cell lung cancer that has not responded to first-line therapy. Myelosuppression, particularly neutropenia, is use-limiting and has precluded combination therapy with other bone marrow-suppressing drugs. T hrombocytopenia and anemia occur in approximately one-third of treated patients. Schedules that call for daily (for 5 days) administration also can result in serious mucositis and diarrhea. T opotecan elimination is biphasic, with a terminal half-life of 2.0 to 3.5 hours. Lactone hydrolysis is rapid, and binding to serum proteins is limited to between 25 and 40%. CYP3A4-mediated N-dealkylation to monoand didealkylated metabolites occurs to a limited extent, and the O-glucuronides that form at multiple points along the metabolic path are excreted via the kidney (Fig. 42.41). Extensive renal clearance demands dosage adjustment in patients with kidney disease. Because both topotecan and irinotecan are metabolized by CYP3A4, the potential for drug–drug interactions must be evaluated. Reduced clearance was noted when azole antifungal agents and cyclosporine were coadministered with irinotecan, and accelerated clearance P.1189

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was observed when topotecan was coadministered with CYP3A4 inducers, such as phenobarbital and phenytoin.

Fig. 42.41. Topotecan metabolism.

M iscellaneous Anticancer Agents: DNA Demethylators

Azacitidine In contrast to the DNA alkylating agents discussed earlier in this chapter, one nucleic acid–based chemotherapeutic agent, azacitidine, blocks abnormal cellular proliferation by dealkylating (specifically

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demethylating) DNA residues on genes responsible for differentiation and growth. T he hypomethylation effect sometimes can restore normal gene function while selectively killing cells that have stopped responding to the body's cellular proliferation control processes. Azacitidine is given subcutaneously for the treatment of myelodysplastic syndrome, and serum levels generally are maximized within 30 minutes. T he parent drug and its metabolites are excreted in the urine. Azacitidine is carcinogenic and teratogenic in rodents, and leukopenia, thrombocytopenia, and neutropenia are the most common reasons for drug discontinuation or dosage reduction.

Other Chemotherapeutic Approaches Hormone Therapy Glucocorticoids (e.g., prednisone and methylprednisolone) commonly are administered with anticancer agents to suppress lymphocytic activity and to enhance the chance of success in the treatment of leukemias and lymphomas. In addition, some tumors, such as estrogen-dependent breast cancer, endometrial cancer, and metastatic cancer of the prostate, depend on the presence of sex hormones for viability. In these neoplastic diseases, the use of steroid receptor antagonists, synthesis inhibitors, or gonadotropin secretion inhibitors, either alone or in combination with other antineoplastic drugs, is a common approach to chemotherapeutic care. Antiestrogens (e.g., tamoxifen), antiandrogens (e.g., flutamide), progestins (e.g., megestrol acetate), aromatase inhibitors (e.g., exemestane), and luteinizing hormone–releasing hormone agonists (e.g., leuprolide acetate) are all available for use in managing hormone-dependent tumors and often are employed after surgery, radiation therapy, and/or other chemotherapy. (Readers are referred to Chapters 45 and 46 for a more detailed discussion of the hormone agonists and antagonists currently used in the treatment of cancer.)

Enzyme Therapy Exogenous asparagine is essential to the survival of malignant lymphocytic leukemia cells, because these cells lack asparagine synthetase enzymes. L-Asparaginase (also known as L-asparagine amidohydrolase) or its derivatives can be added to the chemotherapeutic regimen of patients with leukemia to deplete serum asparagine by hydrolysis to aspartate and ammonia. Being deprived of this avenue for asparagine acquisition, tumor cells die from an inability to synthesize essential proteins. Normal cells, which contain asparagine synthetase, are able to synthesize this essential nutrient and can withstand therapy.

Biological Response Modifiers Several human or recombinant antiproliferative proteins are currently in use for the treatment of cancer. Interleukin-2, interferons, BCG vaccine, tyrosine kinase, epidermal growth factor, proteasome inhibitors, and several monoclonal antibodies directed against tumor cell antigens now augment the cancer chemotherapeutic arsenal. (Readers are directed to Chapter 5 for a more in-depth discussion of the peptides and proteins available for the treatment of neoplastic disease.) P.1190

Case Study Victor ia F. Roche S. William Zito PR is a 37-year-old Portuguese man who survived W ilms' tumor during his childhood. Unf ortunately, the chemotherapy used to treat his neoplasm induced a d elayed and d rug-res is tant c ardiomyopathy that ultimately resulted in a suc cess f ul heart transplant when he was 25. Although he was managing f airly well, PR was rec ently dealt another health-related blow with a diagno sis of bladder c ance r. The cancer was disco vered last week and, although aggressive, appears to still be localized to the bladder. He is deeme d not to be a candidate f or s urgery. PR' s c urrent pharmac otherapy includes c yc losp orine (an immunos uppress ant that is metabolized predominantly by, and also inhibits , CYP3A4) and low-dose prednisone. I n addition to the organoplatinum complex cis platin, his oncologist wants to c onstruct a chemotherap eutic regimen that combines an antimetabolite, a topois omerase I I inhibitor, and a mitosis inhibitor. Review the structure–activity relationships o f the f ollowing f ive antineoplastic structures in pre paration f or your reco mmendation.

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1. I dentif y the therapeutic problem(s) in whic h the pharmac is t' s interventio n may benef it the patient. 2. I dentif y and prioritize the patient-sp ecif ic f ac tors that must be c onsidered to achieve the desired therapeutic outc omes. 3. Cond uct a thorough and mec hanistic ally oriented struc ture–activity analys is of all therape utic alternatives provided in the c ase. 4. Evaluate the s truc ture– activity relationship f ind ings against the patient-spec if ic f actors and desired therapeutic outc omes, and make a therapeutic decision. 5. Counsel your p atient, and advise the phys ic ian.

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74. Manetti F, Maccari L, Corelli F, et al. 3D QSAR models of interactions between β-tubulin and microtubule stabilizing antimitotic agents (MSAA): A survey on taxanes and epothilones. Curr T opics Med Chem 2004;4:203–217.

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75. Vaclavikova R, Soucek P, Svobodova L, et al. Different in vitro metabolism of paclitaxel and docetaxel in humans, rats, pigs, and minipigs. Drug Metab Dispos 2004;32:666–674.

76. Vaclavikova R, Horsky S, Simek P, et al. Paclitaxel metabolism in rat and human liver microsomes is inhibited by phenolic antioxidants. Naunyn-Schmiedelbergs Arch Pharmacol 2003;368:200–209.

77. Cresteil T , Monsarrat B, DuBois J, et al. Regioselective metabolism of taxoids by human CYP3A4 and 2C8: structure–activity relationship. Drug Metab Dispos 2002;39:438–445.

78. Chabner BA., Ryan DP, Paz-Ares L, et al. Antineoplastic agents. In: Hardman JG, Limbird LE, eds. Goodman & Gilman's T he Pharmacological Basis of T herapeutics. 10th Ed. New York: McGraw-Hill, 2001:1389–1459.

79. Buey RM, Diaz JF, Andreu JM, et al. Interaction of epothilone analogues with the paclitaxel binding site: relationship between binding affinity, microtubule stabilization, and cytotoxicity. Chem Biol 2004;11:225–236.

80. Altmann K-H. Epothilong B and its analogues: a new family of anticancer agents. Mini Rev Med Chem 2003;3:149–158.

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85. Beck WT , Cass CE, Houghton PJ. Microtubule-targeting anticancer drugs derived from plants and microbes: vinca alkaloids, taxanes, and epothiolones. In: Bast RC Jr, Kufe DW, Pollock RE, Weichselbaum RR, Holland JF, Frei E III, eds. Holland-Frei Cancer Medicine. 5th Ed. Hamilton, Ontario: BC Decker, 2000:680–698.

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Chapter 43 Antiviral Agents and Protease Inhibitors Patrick M. Woste r

Drugs cov ered in this chapter: Ac yclovir Ad ef ovir d ip ivoxil Amantadine Cido f ovir Cytarabine Famc ic lo vir Fo mivirs e n Fo s carnet Ganc ic lo vir I d oxuridine I nterf ero n Ribavirin Rimantadine Trif luoro thymidine Valac yc lo vir Vidarabine Ne uraminidase inhib ito rs Enf uvirtid e Os eltamivir p ho s phate Z anamivir Antire tro viral age nts Nuc le os id e re vers e trans c rip tas e inhibitors Ab acavir Didanos ine Emtric itabine L amivud ine Stavudine T enof o vir d is op roxil Z alc itab ine Z ido vud ine No nnuc leo s id e re vers e trans c riptas e inhib ito rs De lavird ine Ef avire nz Ne virapine Pro te as e inhibitors

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Ampre navir Atazanavir F os ampre navir I ndinavir L op inavir/rito navir Ne lf inavir Ritonavir Saq uinavir T ipraq navir

Introduction Viruses are the smallest of the human infectious agents, ranging in size from approximately by 20 to 300 nm in diameter (1,2). T hey contain one kind of nucleic acid, either RNA or DNA, as their entire genome, which codes for a variety of enzymes and other proteins used in replication and transmission of the organism. It can be argued that a virus does not qualify as a true life form, because it is nothing more than a nucleic acid strand with associated proteins and cannot move under its own power. When it attaches itself to a host cell, however, it internalizes itself and forces the host to make additional copies of the virus, demonstrating a clear reproductive plan. During replication, it utilizes host cellular biochemicals and processes and, thus, in a sense, takes in “ nutrients” to survive and multiply. In some cases, viruses respond to external conditions and escape the immune response by integrating into the host DNA, demonstrating the ability to respond to external stimuli. Although viruses are simple organisms, they are a significant causative agent for numerous human diseases and, as such, represent one of the major challenges in the area of drug discovery. Agents that are used clinically for a variety of viral diseases act by targeting processes that are specific to the virus, such as a unique viral enzyme, or a necessary process, such as transcription. T o date, however, no drug has been discovered that is truly curative for viral infection. In addition, because viruses have the ability to undergo mutations, resistance to existing therapies can develop. T he discovery of new antiviral agents is thus an important ongoing effort in medicinal chemistry.

Virus Structure and Classification (1,2) Numerous species of virus that infect bacteria, plants, and animals have been identified, and they exhibit a remarkable range of diversity. All viruses exist as obligate cellular parasites, and as such, they do not need to possess the complex biochemical machinery that is characteristic of higher organisms. T hey do, however, have a defined macromolecular structure that is designed to protect them from the environment and to facilitate their entry into cells. T he basic subunit of a virus is its genome, which can be made up of either DNA or RNA. T he nucleic acid portion of a virus can be single or double stranded and may be present in linear or circular form. Viral genomic DNA or RNA often is associated with basic nucleoproteins and may be surrounded by a symmetrical protein known as a capsid. T he capsid is made up of repeating structural units known as protomers, which themselves are made up of nonidentical protein subunits. T he combination of the nucleic acid core and the capsid is called the nucleocapsid, and in some cases, this comprises the entire virus. In other cases, the nucleocapsid structure is surrounded by a lipid-containing membrane that is derived during viral maturation, when the virus undergoes budding through the host cell membrane. T he complete viral particle, with P.1194 or without an envelope, is called the virion. Viral architecture can be grouped into three types based on the arrangement of morphologic subunits, and each virus exhibits cubic (icosahedral) symmetry, helical symmetry, or a complex structure. Icosahedral virions are symmetrical structures that contain 20 surfaces, each of which is an equilateral triangle. A sufficient number of capsid structural units must be employed in the icosahedron to make a capsid large enough to encapsulate the viral genome. Morphologic units called capsomeres are seen on the surface of icosahedral viral particles. T hese structures are clusters of polypeptides, but they do not necessarily correspond to the chemically defined

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structural units. Some viruses arrange their structural subunits into a standard helical formation. In viruses with helical symmetry, protein subunits systematically bind to the viral nucleic acid, ultimately forming a nucleocapsid helix. T he filamentous nucleocapsid is then coiled inside a lipid-containing envelope. Unlike icosahedral virions, the regular, periodic interaction between capsid protein and viral nucleic acid prevents the formation of “ empty” helical particles. Finally, some viral particles, such as the large and complex poxviruses, do not exhibit cubic or helical symmetry but, instead, form more complicated structures that can be spherical, brick-shaped, or ovoid. A subset of complex viruses are called pleomorphic viruses, in that they assume multiple, complex morphologies.

Clin ica l S ign ific an ce Antiviral agents include diverse compounds with varied actions. A thorough clinical understanding about most of these compounds is dependent on a basic appreciation of biochemistry and medicinal chemistry. Viruses are mainly composed of either RNA or DNA nucleic acid strands. As such, one of the most ideal targets for treating viral pathogens has been the inhibition of viral replication. Successful viral replication is dependent on enzyme-mediated transcription of viral RNA or DNA. A significant number of antiviral agents, including HIV nucleoside reverse transcriptase inhibitors and a majority of antiherpes agents, are designed to be “ false” substrates of viral transcription enzymes. It is through competitive inhibition that these agents are able to fulfill their intended effect. T heir chemical structures are similar to naturally occurring substrate nucleoside purines (adenosine and guanosine) and pyrimidines (thymidine and cytidine). T heir incorporation, however, will lead to termination of replication. T hese nucleoside antiviral agents typically require triphosphorylation to become active intracellularly. It is important to recognize that resistance to these antiviral medications can develop when genetic mutations alter the ability of viral enzymes to phosphorylate the drugs. Drugs like cidofovir and tenofovir are nucleotide analogues, which means they are already monophosphorylated. As a result, these agents can maintain activity against viruses that have developed resistance to other nucleoside agents through certain resistant mutations. In clinical practice, HIV antiretroviral regimens usually require a pair of nucleoside reverse transcriptase inhibitors in the regimen. It is of paramount importance that combinations of “ like” nucleosides analogues (i.e., two thymidines, two cytosines, etc.) are not used together, because they have displayed antagonism and reduced viral load suppression. Nonnucleoside reverse transcriptase inhibitors are not structurally related to nucleic purines and pyrimidines; therefore, they do not act as substrates of the target enzyme. Protease inhibitors, which are the most potent antiretroviral agents currently available, were the end result of coordinated chemical design and structure-based computational analysis of the protease enzyme. With identification of the protease crystalline structure and identification of active binding sites, scientists were able to create compounds that would fit the protease enzyme with strong affinity and cause an inhibition of protease function. T he clinical impact of these man-made drugs is regarded by many as being the greatest single advance in the treatment of HIV infection. Douglas Slain, Pharm.D., BCPS Associ ate Professor, Col l ege of Pharmacy, West Vi rgi ni a Uni versi ty

Viral taxonomy is complex, and viruses are classified according to a number of factors, including morphology, properties of the genome (i.e., DNA versus RNA, single strand versus double strand, linear or circular, and sense or antisense), physicochemical properties, structure of associated proteins, replication strategy, and so on. Viruses are separated into major groups called families, with names that end in the suffix -viridae, and then into genera that end in -virus. T hus, poxviruses are in the family Poxviridae and in the genus Poxvi rus. A comparison of the genetic and structural features of viral families with members that can infect humans appears in T able 43.1.

Viral Replication, Cellular effects, and Pathogenesis (2,3)

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As mentioned above, all viruses exist as obligate intracellular parasites, and as such, they rely on the cellular machinery of the host for their growth, development, and replication. T o synthesize the proteins needed for viral replication, the organism must be capable of producing usable mRNA in sufficient quantities to compete with host mRNA for protein synthesis. During viral replication, all of the macromolecules required by the virus are synthesized in a highly organized sequence. T he replication cycle (Fig. 43.1) begins when the intact virion binds to a host cell through electrostatic adsorption to a specific “ receptor” P.1195 P.1196 site. T his process is known as the attachment phase. Attachment is most likely a fortuitous event resulting from structural complementarity between the exterior structure of the virion and a normal cell surface structure on the host cell. For example, HIV binds to the CD4 receptor on cells of the immune system, rhinoviruses bind ICAM-1, and Epstein-Barr virus (EBV) recognizes the CD21 receptor on B cells. When attachment has been achieved, the virion enters the penetration phase, the process by which it gains entry into the host cell. Penetration may occur by receptor-mediated endocytosis, fusion of the viral envelope with the cell membrane, or in some cases, direct penetration of the membrane. Following penetration of the cell, viruses must be uncoated, resulting in either the naked nucleic acid or the nucleocapsid form, which usually contains polymerase enzymes. After they have been uncoated, viruses are no longer infectious.

Table 43.1. Characteristics of Virus Families Containing M embers that

Family

Examples

Genome

Capsid SymmetrySize (nm

Parvoviridae

Parvovirus B19

ssDNA, sense or antisense

Icosa

18–26

Papillomaviridae

Human papilloma (wart)virus; polyoma virus; SV 40

dsDNA, circular DNA

Icosa

55

Adenoviridae

Multiple types (40 adenoviruses/mastadenovirus)

dsDNA

Icosa

70–90

Hepadnaviridae

Hepadnavirus, hepatitis B virus

dsDNA, circular, one ss region

Icosa

40–48

Herpesviridae

Herpes simplex I and II; varicella-zoster; herpes zoster; cytomegalovirus; Epstein-Barr virus

dsDNA

Icosa

150–200

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Poxviridae

Variola; vaccinia

dsDNA

Comp

230–400

Picornaviridae

Hepatitis A virus; poliovirus; enterovirus; rhinovirus, coxsackie virus A and B

ssRNA, sense

Icosa

28–30

Astroviridae

Astrovirus

ssRNA, sense

Icosa

28–30

Caliciviridae

Norwalk virus

ssRNA, sense

Icosa

27–40

Togaviridae

Rubella virus; alphavirus, arbovirus

ssRNA, sense

Icosa

50–70

Flaviviridae

Hepatitis C virus; arbovirus; yellow fever virus; dengue virus; West Nile virus

ssRNA, sense

Comp

40–60

Coronaviridae

Coronavirus

ssRNA, sense

Comp

120–160

Retroviridae

HIV-I and -II; lentavirus; human T-cell lymphotropic viruses

ssRNA as dimer

Comp

80–100

Arenaviridae

Arenavirus

ssRNA, antisense

Comp

50–300

Orthomyxoviridae

Influenza virus A, B, and C

ss RNA, antisense

Hel

80–120

Bunyaviridae

Hantavirus

ssRNA, antisense

Hel

80–120

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Rhabdoviridae

Rhabdovirus; rabies virus; encephalitis virus

ssRNA, antisense

Hel

75–180

Paramyxoviridae

Syncytial virus; parainfluenza virus

ssRNA, antisense

Hel

150–300

Filoviridae

Marburg virus; Ebola virus

ssRNA, antisense

Hel

80–800

Reoviridae

Rheovirus; rotavirus; orbivirus

dsRNA, in 10–12 pieces

Icosa

60–80

Prion

Prion proteinaceous material

None

NA

NA

ds, double-stranded; ss, single-stranded; Icos, icosahedral; Comp, complex; Hel, heli

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Fig. 43.1. Steps involved in the viral life cycle. (Adapted from Brooks GF, Butel JS, Morse SA, et al. Jawetz, Melnick, and Adelberg's Medical Microbiology. 23rd Ed. New York: McGraw-Hill, 2004; with permission. Copyright 2004 The McGraw-Hill Companies, Inc.)

Once the virus has penetrated the cell and uncoated, it enters a segment of its life cycle known as the eclipse period, the length of which varies with the type of virus. During this time, the virus utilizes host resources to replicate and produce necessary viral proteins. Cells that can support viral reproduction are called permissive. As a result, the infection is known as a productive infection, because it results in new viral particles. When new infectious viral particles are produced, host cellular metabolism may be completely directed toward the production of viral products, resulting in destruction of the cell. In other cases, host cell metabolism is not dramatically altered, and the infected cell can survive. During viral reproduction, up to 100,000 new virions can be produced, and the replication cycle can vary from a few hours to more than 3 days. Some cells types, called nonpermissive, are unable to support the reproduction of an infective virion, resulting in an abortive infection. Abortive infections also occur when the virus itself is defective. Either situation can lead to a latent infection, where the viral genome may persist in a surviving host cell. As will be described below, such an infection can lead to the transformation of a cell from normal to malignant.

DNA Virus T he strategies used by various viruses to replicate vary widely, but all are characterized by the need to transcribe mRNA that is suitable for translation of viral proteins. Several pathways lead to the required

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mRNA, after which the host enzymes and raw materials are used to make viral proteins. Early viral proteins used in replication are synthesized immediately after infection, whereas late proteins used to produce the complete virion structure are synthesized after viral nucleic acid synthesis. Most DNA viruses contain double-stranded DNA as their genome and, thus, can replicate using host cell machinery to P.1197 produce mRNA directly. Papillomavirus, adenovirus, and herpesvirus are replicated in the host nucleus and, thus, use transcriptional enzymes of the host (i.e., DNA-dependent RNA polymerase) to synthesize mRNA. T his mRNA is then translated to form proteins needed by the virus, including enzymes (e.g., DNA-dependent DNA polymerase) used to produce progeny DNA copies. T hese progeny DNA strands are infectious. By contrast, poxviruses replicate in the cytoplasm using a mechanism that is not well understood, wherein the genome initially is transcribed by a viral enzyme in the virion core. Parvoviruses contain a single-stranded DNA genome and must synthesize double-stranded DNA in the host nucleus before synthesis of mRNA and translation of proteins. T his process may or may not require a helper virus, such as herpes simplex. T he hepatitis B viral genome, comprised of double-stranded DNA, contains numerous gaps that must be repaired using a DNA polymerase packaged in the virion before transcription to form mRNA.

RNA Virus Compared to DNA viruses, those viruses with RNA-based genomes have evolved a wide variety of reproductive strategies. T he single-stranded RNA viruses may be divided into three groups that differ in the method by which the RNA genome is utilized. In all three groups, the RNA genome must serve two functions: to be translated to form protein, and to be replicated to form progeny RNA strands. T he first group is comprised of viruses such as picornaviruses, flaviviruses, and togaviruses that have an RNA genome that can be used directly as mRNA. Viral RNA that can be used as mRNA is by convention termed (+ ) or sense-strand RNA. In most cases (e.g. picornaviruses), this sense-strand RNA binds to the host ribosome shortly after entering the cell, where it is read and used to produce a single polypeptide called the polyprotein. T he polyprotein is then processed by autocatalysis and various proteolytic enzymes to produce the required viral proteins. In some cases (e.g. togaviruses), only a portion of the RNA genome is available to be translated by the host ribosome. Following the initial translation of the sense strand, it serves a second function—namely, to serve as a template for the synthesis of a (–) or antisense strand via an RNA-dependent RNA polymerase. T his antisense strand then can be used to produce additional sense-strand RNAs that are infectious and also can serve as mRNA. T hese progeny sense-strand RNAs are then packaged into an intact virion before transmission to another host cell. T he second group of single-stranded RNA viruses, including orthomyxoviruses, bunyaviruses, arenaviruses, paramyxoviruses, filoviruses, and rhabdoviruses, all contain an antisense RNA genome that can be used only for transcription of new RNA. All antisense RNA viruses contain an RNA transcriptase as part of their virion, because the host cell does not have this type of RNA-dependent RNA polymerase. During the first round of genome expression, a series of short sense-strand RNAs are made, which are then translated to form the required viral enzymes for replication. Ultimately, these enzymes are used to produce a full-length sense RNA strand, which is then used to make multiple copies of the antisense viral genome. T he progeny antisense DNA strands by themselves are not infectious, because they have not yet been packaged with the required RNA transcriptase. When the progeny antisense RNA has been synthesized, it is packaged into an intact virion, in which form it becomes infectious before transmission to another cell. T he third group of RNA viruses are the retroviruses, in which single-stranded RNA exists as a dimer of a sense and an antisense strand. T he genomic RNA strands can be base-paired, although the structure of this complex is not well understood, or the strands can be hydrogen-bonded to other macromolecules in the virion. Retroviral genomic RNA serves a single function—namely, to act as a template for the formation of double-stranded viral DNA. Host cells do not contain an enzyme that can form DNA from viral RNA; thus, the virion of a retrovirus must contain a reverse transcriptase (RT ) enzyme as well as various host tRNA molecules. T ranscription of the genome begins when a complex of RT and tRNA binds to the viral genome. A complimentary DNA strand is then synthesized using one of the host tRNAs as a primer, and the original RNA strand is digested by RNAse H and viral ribonuclease packaged in the virion. A

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complimentary DNA strand is then synthesized, and the resulting double-stranded DNA is translocated to the nucleus, where viral enzymes incorporate genome-length viral DNA into the host genome. In some cases, the viral portion of the genome can remain dormant for long periods, or it may be immediately used to make progeny viral RNA, a process that is catalyzed by host RNA polymerase II. T ranscription produces both shortened segments that are used to make polyproteins and full-length progeny RNA. T he polyproteins are processed to form various viral proteins, whereas the full length RNA is packaged into an infectious virion.

Virus Protein In addition to replication of the viral genome, a number of other structures associated with the complete virion also can be made. A number of viral proteins may be synthesized that have important functions in the structure, transmission, and survival of the virus. T hese proteins can protect the genetic material in the virus from destruction by nucleases, participate in the attachment process, and provide structure and symmetry to the virion. In addition, in certain cases where the virus requires an enzymatic process for which there is no host enzyme, a virion may include enzymes, such as RNA polymerases or a RT . Some viruses require a lipid envelope that contains transmembrane proteins specifically coded for by the virus and which envelopes the genetic material P.1198 during viral budding. Viral envelopes contain glycoproteins that are involved in cell recognition during attachment to the host cell. T hese glycoproteins often reflect the composition of glycoproteins in the host cell. T hey are a determinant of the antigenic nature of viruses and, thus, facilitate recognition by the immune system of the host. Depending on their composition, however, they also can help the virus to elude neutralization by the immune system.

Cellular Egress Viruses use one of two strategies for exiting infected cells. Nonenveloped viruses (e.g., picornaviruses and rheoviruses) complete their maturation by assembling into their corresponding virion within the cell nucleus or the cytoplasm. For example, picornaviruses assemble by clustering 60 copies of each of three viral proteins, called VP0, VP1, and VP3, into a structure called a procapsid. Viral RNA is then packaged into the procapsid, and proteolytic cleavage of VP0 produces two new viral proteins, called VP2 and VP4. T he resulting conformational change produces a stable and symmetrical structure that shields the genome from degradation by host nucleases. In most cases, destruction of the host cell is required when the virion exits. Enveloped viruses (i.e., all antisense RNA viruses, togaviruses, flaviviruses, coronaviruses, hepadnaviruses, herpesviruses, and retroviruses) contain proteins that carry signal sequences and markers that cause them to be inserted into the inner and outer surfaces of the host cell cytoplasmic membrane. Viral proteins on the outer surface are glycosylated using host enzymes, then displace host cell surface proteins and collect into patches. Viral nucleocapsids that recognize proteins on the inner surface of the membrane, where they bind, are engulfed by the patch area of the membrane. T he completed virion exits the cell by budding and release into the extracellular space. Viral egress can have a variety of effects on the host cell, ranging from destruction of the cell to minimal noncytolytic effects. Herpesviruses differ from other enveloped viruses in the manner in which they form their envelope. T he nucleocapsid is formed in the nucleus, and final maturation of the virion occurs only on the inner surface of the host cell membrane, forming vesicles that are stored in between the inner and outer aspect of the cell membrane. Egress of the herpesvirus vesicle always occurs through destruction of the host cell.

Virus Pathogenesis A complete discussion of viral pathogenesis is beyond the scope of this chapter. In general, however, the symptoms of a viral infection may be considered to arise from the response to viral replication and cell injury in the host. T hese responses range from asymptomatic or subclinical to severe clinical manifestations, and they may be either local or systemic. Understanding the biochemical events that produce viral diseases can aid in the design of effective and specific therapies. Not surprisingly, viral pathogenesis occurs in distinct steps: 1) viral entry into the host and primary viral replication, 2) viral spread, 3) cellular injury and host immune response, 4) viral clearance or establishment of persistent

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infection, 5) and viral shedding. Most viruses enter the host through the respiratory or gastrointestinal (GI) tract, but they also may penetrate the skin, urogenital tract, or conjunctiva. In a few cases, viral particles can enter through direct injection (e.g., HIV and hepatitis) or through insect bites (arboviruses). When a local infection occurs, the virus replicates near the site of entry, and the underlying tissue is not affected. Some viruses, however, are able to migrate to other sites, usually through the bloodstream or lymphatic system, to produce systemic infections. When infection occurs at a remote site, most viruses demonstrate tissue or organ preference (e.g. herpesvirus localizes in nerve ganglia, and the rabies virus migrates to the central nervous system [CNS]). Localization of a virus in a particular tissue can be the result of cell receptor specificity or can arise because a virus may be activated by proteolytic enzymes in a specific cell type. Clinical disease develops through a complex series of events when virus-infected cells are destroyed or their function is impaired, and some symptoms, such as malaise and anorexia, can result from host responses, such as cytokine release. Disease-mediated damage may become chronic when cell types that do not regenerate (e.g., brain tissue) are involved. Ultimately, the host either succumbs to the infection; develops a chronic, latent, or subclinical infection; or completely recovers. In chronic infections, the virus can be continuously detected at low levels, and either mild or no clinical symptoms may present. By contrast, latent infections are those in which the virus persists for extended periods of time in an inactive form or a location not exposed to the immune response. Intermittent flare-ups of clinical disease can occur, during which time infectious virus can be detected. Subclinical infections are those that give no overt sign of their presence. Humoral and cell-mediated immunity, interferon and other cytokines, and other host defense factors, depending on the type of virus, are common mediators of recovery and begin to develop very soon after infection. Infiltration with mononuclear cells and lymphocytes is responsible for the inflammatory reaction in uncomplicated viral lesions. Virus-infected cells can be lysed by T lymphocytes through recognition of viral polypeptides on the cell surface, and humoral immunity protects the host against reinfection by the same virus. Neutralizing antibodies that are directed against capsid proteins can prevent viral infection by disrupting viral attachment or uncoating. Interestingly, viruses have evolved a variety of survival tactics that serve to suppress or evade the host immune response. Because viruses are obligate intracellular parasites, a method of transmission from one host to another is required for survival of the species. T hus, during an active infection, shedding of the infectious virion into the environment is P.1199 a required step in the life cycle of the virus and ensures transmission of the virus to new hosts. Shedding usually occurs at the same site where the infection was initiated and can occur at various stages in the disease course.

Viral Diseases HIV (4,5) T he human immunodeficiency virus (HIV-1) was first identified in 1979 and was found to be the cause of acquired immune deficiency syndrome (AIDS) in 1981. Since that time, AIDS had become a serious worldwide epidemic that continues to expand. T he Joint United Nations Program on HIV/AIDS estimated that by the end of 2005, a total of 40.3 million people worldwide were living with HIV/AIDS, the majority having been infected through heterosexual contact. It is estimated that in 2005, more than 3.1 million people died of AIDS, and 4.9 million new cases of HIV were diagnosed, including more than 700,000 children (6). T he incidence of the disease varies by location, with sub-Saharan Africa having the highest incidence. Because it is sexually transmitted, a high percentage of infected individuals are young adult workers, and as such, the disease has a significant economic impact in some regions. In addition, infected mother-to-fetus transmission occurs between 13 and 40% of the time. Although a variety of drugs have been developed for treating patients with AIDS, none has proven to be successful in curing the disease. T he basic difficulty experienced with this viral infection is the ability of virus to mutate, leading to rapid drug resistance. T he HIV-1 genome consists of two identical, 9.2-kb, single-stranded RNA molecules within the virion, each of which contains information for only nine genes. Following infection of the host cell, the persistent form of the HIV-1 genome is proviral double-stranded DNA. Mature HIV virions are spherical and consist

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of a lipid bilayer membrane surrounding a nucleocapsid that contains genomic RNA, a viral protease, RT , an integrase, and some other cellular factors. T he HIV life cycle is depicted in Figure 43.2, and begins when the viral extracellular protein gp120 attaches to the CD4 receptor on T lymphocytes. Following attachment, the viral envelope and host cell membrane are fused, and the nucleocapsid is released into the cytoplasm. T he nucleocapsid is uncoated, and the resulting RNA serves as a substrate for RT , producing a proviral double-stranded DNA that migrates to the nucleus and is incorporated into host DNA by integrase. T his DNA is not expressed in resting T lymphocytes, but when the cell is activated, proviral DNA is transcribed by host RNA polymerase II. T he viral RNA and proteins are transported to the cell membrane, where they assemble, form a viral bud, and are released from the lymphocyte membrane. T his produces an immature virion, and processing of the viral surface proteins by HIV protease then affords the mature, infectious virus. Approximately 50% of HIV infections are asymptomatic, whereas the other 50% produce flu-like symptoms within 4 weeks. During this initial phase, viral titers are very high but then decline as specific antibodies are formed. T he latent period is mediated by factors that are not well understood and can last several years. During this time, viral replication continues, and the level of CD4-positive T lymphocytes steadily declines. Eventually, the patient's immune system becomes compromised, resulting in a variety of opportunistic infections. RT sometimes makes mistakes reading the viral RNA sequence, leading to mutations in the virus and changes in the structure of the surface proteins. T hus, vaccines, which induce the production of antibodies that recognize and bind to very specific viral surface molecules, are P.1200 unlikely to be effective in HIV therapy. As will be discussed below, other viral processes, such as reverse transcription and proteolytic processing, are viable targets for small molecule therapy.

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Fig. 43.2. Replicative cycle of HIV. (1) The virus gp120 protein binds to CD4 resulting in fusion of the viral envelope and the cellular membrane and the release of viral nucleocapsid into the cytoplasm. (2) The nucleocapsid is uncoated, and viral RNA is reverse transcribed by reverse transcriptase (RT). (3) The resulting double-stranded proviral DNA migrates into the cell nucleus and is integrated into the cellular DNA by integrase (IN). (4) Proviral DNA is transcribed by the cellular RNA polymerase II. (5) The mRNAs are translated by the cellular polysomes. (6) Viral proteins and genomic RNA are transported to the cellular membrane and assemble. Immature virions are released, and polypeptide precursors are processed by the viral protease (PR) to produce mature vital particles. (Adapted from Sierra S, Kupfer B, Kaiser R. Basics of the virology of HIV-1 and its replication. J Clin Virol 2005;34:233; with permission from Elsevier.)

Kaposi's sarcoma is a common complication of AIDS and has been shown to arise from a complex interaction between HIV and the human herpesvirus (HHV)-8. T his disease presents as a reddish or purple lesion on various areas of the skin and, in the advanced state, may involve the lungs or GI tract.

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HHV-8 does not work alone but, rather, in combination with a patient's altered response to cytokines and the HIV-1 transactivating protein T at, which promotes the growth of endothelial cells. HHV-8 can then encode interleukin-6 viral proteins, which are specific cytokines that stimulate cell growth in the skin. HHV-8 further destroys the immune system by directing a cell to remove the major histocompatibility complex (MHC-1) proteins that protect it from invasion. T hese proteins are then transferred to the interior of the cell and are destroyed, leaving the cell unguarded and vulnerable to pathogens that normally would be cleared by the immune system. It recently has been discovered that xCT , the 12-transmembrane light chain of the human cystine/glutamate exchange transporter system, serves as a receptor for internalization of HHV-8 (7).

Herpesvirus (2) T he herpesvirus family contains several of the most important human pathogens and are responsible for causing a spectrum of common diseases. A common and significant feature of the herpesviruses is their ability to establish lifelong, persistent infections in their hosts and to undergo periodic reactivation. Herpesviruses possess a large number of genes, and some of the resulting proteins are targets for antiviral chemotherapy. T he herpesviruses that commonly infect humans include herpes simplex virus (HSV)-1 and -2, varicella-zoster virus (VZV), cytomegalovirus (CMV), EBV, HHV-6 and -7, and Kaposi's sarcoma–associated HHV-8 (also known as KSHV). Herpesviruses are large viruses that have identical morphology and consist of a core of linear, double-stranded DNA surrounded by a protein coat that exhibits icosahedral symmetry and has 162 capsomeres. T he genome is large and encodes at least 100 different proteins, including polypeptides involved in viral structure, the viral envelope, and enzymes involved in nucleic acid metabolism, DNA synthesis, and protein regulation. Oral cold sores and genital herpes infections are caused by HSV-1 and -2, respectively. T hese viruses can establish a latent infection in the ganglia of nerves that supply the site of the primary infection, and the latent disease is reactivated by a number of stress factors. It is estimated that virtually 100% of adult humans are infected with HSV-1, although many infections are subclinical and asymptomatic. T he varicella virus is the cause of chickenpox, and the herpes zoster virus is responsible for shingles. Human CMV infection rarely causes disease in healthy people, but when infection occurs in adulthood, it may cause an infectious mononucleosis–like illness. Primary infection with the EBV is the cause of infectious mononucleosis, and this virus is thought to be a factor in the development of Burkitt's lymphoma and other malignancies. Human herpesvirus-6 is thought to cause roseola and mononucleosis, whereas HHV-7 probably is not involved in any human diseases. T he role of HHV-8 in the pathogenesis of Kaposi's sarcoma has been discussed above.

Hepatitis (2) Viral hepatitis is a systemic disease but primarily involves the liver. Hepatitis A virus (HAV) is responsible for infectious hepatitis, and hepatitis B virus (HBV) is associated with serum hepatitis. Hepatitis C virus (HCV) is a common cause of posttransfusion hepatitis. Another viral agent, hepatitis E virus (HEV), causes an enterically transmitted form of hepatitis. On occasion, disease can arise from hepatic infection with yellow fever virus, CMV, EBV, HSV, rubella virus, and the enteroviruses. Viral hepatitis usually involves acute inflammation of the liver, fever, nausea, vomiting, and jaundice, and all forms of hepatitis produce identical histopathologic lesions in the liver during acute disease. HAV is a member of the picornavirus family and carries a single-stranded RNA genome; only one strain of the virus exists. T he onset of HAV hepatitis occurs within 24 hours, in contrast to the slower onset of clinical symptoms with HBV and HCV infection. Complete recovery occurs in most cases of hepatitis A, and chronic infection never occurs. HBV is classified as a hepadnavirus with a double-stranded, circular DNA genome. T he outcome of HBV infection ranges from complete recovery to progression to chronic hepatitis and, rarely, death. HBV establishes chronic infections, especially in infants; 80 to 95% of infants and young children infected with HBV become chronic carriers and are at high risk of developing hepatocellular carcinoma. In adults, 65 to 80% of infections are asymptomatic, and 90 to 95% of all patients recover completely. HCV is a positive-stranded RNA flavivirus and exists in at least six major genotypes. Most cases of posttransfusion hepatitis are caused by HCV, and these infections usually are subclinical, with minor elevation of liver enzymes and a low incidence of jaundice. However, 70 to 90% of HCV-infected patients develop chronic hepatitis, and many are at risk of progressing to chronic active hepatitis and cirrhosis decades later. HEV is transmitted enterically and occurs in epidemic form in developing countries, where

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water supplies sometimes are contaminated with feces. T he disease is more severe in adults than in children, who usually are asymptomatic.

Influenza (2) Respiratory illnesses commonly known as colds and flu account for more than half of all acute illnesses in the United States each year. Influenza viruses belong to the orthomyxoviridae family and are a major source of P.1201 morbidity and mortality caused by respiratory disease. Outbreaks of infection can occur in global epidemics that have resulted in millions of deaths worldwide. Genetic mutations often cause antigenic changes in the structure of viral surface glycoproteins, making influenza viruses extremely difficult to control. T hree immunologic types of influenza viruses are known and are termed influenza A, B, and C. Antigenic changes are very common in influenza A, which is responsible for the majority of influenza epidemics. Influenza B undergoes more infrequent antigenic changes and is less often the cause of an influenza epidemic, whereas influenza C are antigenically stable and cause only mild illness in immunocompetent individuals. T he viruses carry a single-stranded, negative-sense RNA genome that has eight segments in influenza A and B. Influenza C contains only seven segments of RNA and lack a neuraminidase gene (see below). T he complete virion in each type contains nine different structural proteins. A nucleoprotein associates with viral RNA to form a ribonucleoprotein structure that makes up the viral nucleocapsid. T hree other large proteins are bound to the viral ribonuclear protein and are responsible for RNA transcription and replication. A matrix protein also is included in the virion that forms a shell underneath the viral lipid envelope and comprises approximately 40% of all viral protein. T he influenza virion structure also includes a lipid envelope derived from the host cell. T his envelope contains two viral surface glycoproteins called hemagglutinin and neuraminidase (NA). Mutations cause antigenic changes in the structure of these two surface glycoproteins; thus, they are the main determinants of antigenicity and host immunity. T he ability of the virus to change the structure of hemagglutinin on the virus surface primarily is responsible for the continual evolution of new strains, sometimes leading to subsequent influenza epidemics. Neuraminidase is an enzyme that removes sialic acid from surface glycoproteins during viral maturation and is required to produce infectious particles and lower the viscosity of the mucin layer of the respiratory tract. Influenza virus spreads through airborne droplets or contact with contaminated hands or surfaces and has an incubation period that varies from 1 to 4 days. T ransmission of the virus, however, begins to occur 24 hours before to the onset of symptoms. Interferon is detectable in respiratory secretions at the onset of symptoms, and the host response to interferon response contributes to recovery. Antibodies and other cell-mediated responses are seen 1 to 2 weeks after infection. It is well established that secondary infections from other viruses or bacteria can occur, and Reye's syndrome, an acute encephalopathy occurring in children and adolescents, is a rare complication of influenza B, influenza A, herpesvirus, and VZV infections. T he chances of contracting Reye's syndrome are increased when salicylates are used in children suffering from influenza and related respiratory diseases.

Tumor Viruses (2,8,9,10,11,12) Viruses are etiologic factors in the development of several types of human tumors, most notably cervical cancer and liver cancer. At least 15% of all human tumors worldwide have a viral cause. T umor viruses can be found in both the RNA and DNA virus kingdoms (13). T he list of human viruses presently known to be involved in tumor development includes four DNA viruses (EBV, certain papilloma viruses, HBV, and the Kaposi's sarcoma–associated HHV-8), and two RNA viruses (adult T -cell leukemia virus [HT LV-1] and HCV). T umor viruses alter cellular behavior through the use of a small amount of genetic information, employing two general strategies. T he tumor virus either introduces a new “ transforming gene” into the cell (direct- acting), or the virus alters the expression of a preexisting cellular gene or genes (indirectacting). In both cases, normal regulation of cellular growth processes is lost. Viruses alone cannot act as carcinogens, and other events are necessary to disable regulatory pathways and checkpoints to produce transformed, malignant cells. T he processes used in the transformation of host cells by human tumor viruses are very diverse. Cellular transformation may be defined as a stable, heritable change in the growth control of cells that

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results in tumor formation. T ransformation from a normal to a neoplastic cell generally requires the retention of viral genes in the host cell. In the majority of cases, this is accomplished by the integration of certain viral genes into the host cell genome. Retroviruses incorporate their proviral DNA, formed through the action of RT , into host cell DNA. By contrast, DNA tumor viruses integrate a portion of the DNA of the viral genome into the host cell chromosome. All RNA tumor viruses are members of the retrovirus family and belong to one of two classes (9,10,12). Class I RNA viruses are direct-transforming and carry an oncogene obtained through accidental incorporation from the host cell. No class I RNA viruses are known to produce tumors in humans. Class II or chronic RNA tumor viruses are weakly transforming and do not carry host cell–derived oncogenes. T he two known cancer-causing retroviruses in humans act indirectly. T hey often act by inserting their proviral DNA into the immediate neighborhood of a host cellular oncogene. HT LV-1 acts in this manner, thus increasing the number of preneoplastic cells and facilitating secondary cellular changes leading to transformation. DNA tumor virus strains exist among the papilloma-, polyoma-, adeno-, herpes-, hepadna-, and poxvirus groups (11). DNA tumor viruses encode viral oncoproteins that are important for viral replication but also affect cellular growth control pathways. For example, inactivation of the retinoblastoma gene (Rb) and the p53 pathway by viral transforming proteins is a common strategy used by papovaviruses and adenoviruses. As mentioned above, all DNA tumor viruses kill their host cell when the infectious virion is released to infect other cells. T hus, transformation and tumorigenicity are entirely dependent on a host cell interaction with the virus that does not involve viral spread to other cells, and cells transformed by DNA tumor viruses depend on the continued expression of the virally encoded oncogene. P.1202 Recent studies have revealed that the human tumor viruses EBV, HHV-8, human papillomavirus, HBV, HCV, and HT LV-1 express proteins that are targeted to the mitochondria (8). Because the mitochondria play a critical role in energy production, cell death, calcium homeostasis, and redox balance, these proteins have profound effects on host cell physiology. Further study of these proteins and their interactions with mitochondria will aid in the understanding the mechanisms of viral replication and tumorigenesis and could reveal important new targets for anti-tumor therapy.

Prion Diseases (14,15,16) Although they are not viruses, the infective proteins known as prions have sufficient similarities to viruses to warrant their discussion in this chapter. Prions are small proteins that have been shown to cause a variety of transmissible spongiform encephalopathies, which are rare neurodegenerative disorders typified by symptoms in the CNS, such as spongiform changes, neuronal loss, glial activation, and accumulation of amyloid aggregates of an abnormally folded host protein. Human prion diseases include kuru, Creutzfeldt-Jakob disease (variant, sporadic, familial and iatrogenic), GerstmannSträussler-Scheinker syndrome, and fatal familial insomnia. T he disease in cattle known as bovine spongiform encephalopathy and the related disease scrapie exhibit similar pathologic features. Following exposure, prions accumulate in lymphoid tissue, such as the spleen, lymph nodes, tonsils, and Peyer's patches (specialized lymphoid follicles located in the submucosa of the small intestine). T his accumulation of the infectious agent is necessary for invasion of the CNS. In humans, the incubation period of the disease can vary between 18 months and 40 years. Prions appear to be variant, improperly folded versions of a normal cellular protein called PrP c , a 30- to 35-kDa protein with two sites for c

N-glycosylation that is anchored in the neuronal cell membrane. PrP protein contains three α-helices, a short β-pleated sheet region, and a long, unstructured portion that comprises half the molecule. T he variant, infectious form of the protein is known as PrP

sc

c

and is produced autocatalytically from PrP .

Prion diseases are always fatal, with no known cases of remission or recovery. T he host shows no inflammatory response or immune response and no production of interferon, and there is no effect on host B-cell or T -cell function. At present, there are no effective agents to treat prion diseases.

Viral Chem otherapy General Approaches (17,18)

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T he principles involved in the design of antiviral agents are similar to those used in the design of all chemotherapeutic agents. Drugs in this category are targeted to some process in the virus that is not present in the host cell. T he earliest examples of antiviral agents did not achieve this goal, and these drugs were toxic at therapeutic levels or had a limited spectrum of activity. A variety of factors make the design of effective antiviral agents difficult, including their ability to undergo antigenic changes, the latent period during which there are no symptoms, and their reliance on host enzymes and other processes. T his problem is compounded by the facts that host immunity is not well understood and that symptoms of viral infection may not appear until replication is complete and the viral genome has been incorporated into infected cells. Nonetheless, the continuing identification of new targets for antiviral agents provides new avenues for the discovery of small molecule therapies. T he following section includes information regarding currently marketed antiviral compounds that have been designed in eight general areas: Agents that disrupt virus attachment to host cell receptors, penetration, or uncoating Agents that inhibit virus-associated enzymes, such as DNA polymerases and others Agents that inhibit viral transcription Agents that inhibit viral translation Agents that interfere with viral regulatory proteins Agents that interfere with glycosylation, phosphorylation, sulfation, and so on. Agents that interfere with the assembly of viral proteins Agents that prohibit the release of viruses from cell surface membranes T he remainder of this chapter deals primarily with small molecule antiviral agents that have been approved by the U.S. Food and Drug Administration (FDA) and are clinically effective in the treatment of viral infection. Immunizing biological agents, such as vaccines as well as antineoplastic agents with antiviral activity, are not covered. Some compounds used primarily in the treatment of bacterial infections, such as rifampicin, bleomycin, adriamycin, and actinomycin, also inhibit viral replication. T hese antibiotics do not affect the transcription or translation of viral mRNA, however, and are only effective in high concentrations. T herefore, such antibiotics are not commonly used for viral infections. T here is a continuing need for new antiviral agents, primarily because viral infections are not curable after the virus invades the host cell and begins to replicate. Vaccines are effective, but they are only able to prevent an infection, and only then in cases where specific virus strains are involved. For example, immunization against influenza, which is a yearly routine in many parts of the world, can only provide immunity against the specific strains that are represented in that preparation. New virulent strains may arise from nonhuman sources, such as the so-called swine flu or avian flu viruses, and currently available vaccines would have no effect against these new strains. With regard to small molecule antiviral agents, the ideal drug would have broad-spectrum antiviral activity, completely inhibit viral replication, maintain efficacy against mutant P.1203 viral strains, and reach the target organ without interfering with normal cellular processes or the immune system of the host.

Table 43.2. Antiviral Agents Interfering with Cellular Penetration and Early Replication Generic Name Amantadine

Trade Name Symmetrel

Spectrum of Activity Influenza A

Dosage Form Capsule (100 mg), Syrup (50 mg/5 mL)

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Rimantadine

Flumadine

Influenza A

Capsule (100 mg)

Interferon-α 2a

Roferon A, Alferon, Intron, Wellferon

Chronic hepatitis, CMV, HSV, papillomavirus, rhinovirus, and others

Injectable (3, 5, 10, 18, 25, and 50 million units/mL)

Interferon-α 2b

Interon A

Chronic hepatitis B and C, many other viruses

Injectable (3, 5, 10, 18, 25, and 50 million units/mL)

Interferon-γ

Actimmune

Zanamavir

Relenza

Influenza A and B

Inhaled powder (5 mg)

Oseltamivir

Tamiflu

Influenza A and B

Capsule (75 mg)

Enfurtizide

Fuzeon

HIV

Adult: 90 mg SQ b.i.d. Children (6–16 years): 2 mg/kg SQ b.i.d.

Injectable (100 µg/0.5 mL)

CMV, cytomegalovirus; HSV, herpes simplex virus, SQ, subcutaneous.

Agents Inhibiting Virus Attachment, Penetration, Uncoating, and Early Viral Replication (Table 43.2) Amantadine

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Mechanism of action Amantadine hydrochloride (1-adamantanamine hydrochloride) is a symmetric, tricyclic, primary amine that inhibits penetration of RNA viral particles into the host cell (19). It also inhibits the early stages of viral replication by blocking the uncoating of the viral genome and the transfer of nucleic acid into the host cell.

Clinical application Amantadine is clinically effective in preventing and treating all type A strains of influenza, particularly type A2 strains of Asian influenza virus, and to a lesser extent, German measles (rubella) or atoga virus. It also shows in vitro activity against influenza B, parainfluenza (paramyxovirus), respiratory syncytial virus (RSV), and some RNA viruses (murine, Rous, and Esh sarcoma viruses). Many prototype influenza A viruses of different human subtypes (H1N1; Fort Dix; H2N2, Asian type; and H3N2, Hong Kong type) also are inhibited by amantadine hydrochloride both in vitro and in animal model systems. If given within the first 48 hours of onset of symptoms, amantadine hydrochloride is effective in respiratory tract illness resulting from influenza A (but not influenza B), adenoviruses, and RSV.

Pharmacokinetics Amantadine is well absorbed orally, and the usual dosage for oral administration is 100 mg twice daily. T he drug has been approved as a capsule, tablet, and syrup for the treatment of keratoconjunctivitis caused by HSV infection. Amantadine hydrochloride oral solution should not be kept in a freezer but, rather, should be stored in a tight container at 15 to 30°C. Capsules and tablets should be protected from moisture and light. A 100 mg oral dose produces blood serum levels of 0.3 mg/mL within 1 to 8 hours. Maximum tissue concentration is reached in 48 hours when a 100 mg dose is given every 12 hours. In healthy adults receiving a 25, 100, or 150 mg dose of the drug twice daily, steady-state trough plasma concentrations were 110, 302, or 588 mg/mL, respectively. Usually, no neurotoxicity is observed if the plasma level of amantadine is no more than 1.00 mg/mL. Amantadine crosses the blood-brain barrier and is distributed in saliva, nasal secretions, and breast milk (20). Approximately 90% of the drug is excreted unchanged by the kidney, primarily through glomerular filtration and tubular secretion, and there are no reports of metabolic products. Acidification of urine increases the rate of amantadine excretion. T he half-life of the drug is 15 to 20 hours in patients with normal renal function.

Side effects Generally, the drug has low toxicity at therapeutic levels but may cause severe CNS symptoms, such as nervousness, confusion, headache, drowsiness, insomnia, depression, and hallucinations. T he GI side effects include nausea, diarrhea, constipation, and anorexia. Convulsions and coma occur with high doses and in patients with cerebral arteriosclerosis and convulsive disorders. Chronic toxicity with

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amantadine is unexpected, because few side effects have been experienced when the drug has been used in long-term therapy for Parkinson's disease. Some serious reactions, however, include depression, orthostatic hypotension, psychosis, urinary retention, and congestive heart failure. Amantadine hydrochloride should be used with caution in patients who have a history of epilepsy, severe arteriosclerosis, liver diseases, and eczematoid dermatitis. Because amantadine does not appear to interfere with the immunogenicity of inactivated influenza A vaccine, patients may continue the use of amantadine for 1 week after influenza A vaccination. A P.1204 virus that is resistant to amantadine has been obtained in cell culture and from animals, but these reports are not confirmed in humans.

Rimantadine

Mechanism of action Rimantadine hydrochloride (α-methyl-1-adamantanemethylamine hydrochloride) is a synthetic adamatane derivative that is structurally and pharmacologically related to amantadine (21,22). It appears to be more effective than amantadine hydrochloride against influenza A, with fewer CNS side effects. Rimantadine hydrochloride is thought to interfere with virus uncoating by inhibiting the release of specific proteins. It may act by inhibiting RT or the synthesis of virus-specific RNA, but it does not inhibit virus adsorption or penetration. It appears to produce a virustatic effect early in the virus replication. It is used widely in Russia and Europe.

Clinical application Rimantadine hydrochloride has activity against most strains of influenza A, including H1N1, H2N2, and H3N2, but it has no activity against influenza B virus. It is used for prevention of infection caused by various human, animal, or avian strains of influenza A virus in adults and children. T he side effects are nightmares, hallucinations, and vomiting. T he most common side effects of rimantadine are associated with the CNS and the GI tract. Rimantadine is metabolized in the liver, and approximately 20% is excreted unchanged as hydroxylated compound.

Pharmacokinetics T he half-life of rimantadine in adults ranges from 24 to 36 hours. More than 90% of rimantadine doses were absorbed in 3 to 6 hours. Steady-state plasma concentrations are from 0.10 to 2.60 mg/mL at doses of 3 mg/kg/d in infants to doses of 100 mg twice daily in the elderly. Nasal fluid concentrations of rimantadine at steady state were 1.5-fold higher than plasma concentration.

Interferon (23,24) Isaacs and Lindenmann discovered interferon in 1957. When they infected cells with viruses, interference

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with the cellular effects of viral infection were observed. Interferon was subsequently isolated and found to protect the cells from further infection. When interferon was administered to other cells or animals, it displayed biological properties such as inhibition of viral growth, cell multiplication, and immunomodulatory activities. T hese results led to the speculation that interferon may be a natural antiviral factor, possibly formed before antibody production, and may be involved in the normal mechanism of resistance displayed against viral infection. Some investigators relate interferon to the polypeptide hormones and suggest that interferon functions in cell-to-cell communication by transmitting specific messages. Recently, antitumor and anticancer properties of interferon have evoked worldwide interest in the possible use of this agent in therapy for viral diseases, cancer, and immunodeficiency disorders. Host cells synthesize interferons in response to various inducers.

Interferon induction Because viruses were found to induce the release of interferon, efforts were made to induce the production or release of interferon in humans by the administration of chemical “ inducers” (25). Various small molecules (substituted propanediamine) and large polymers (double-stranded polynucleotides) were used to induce interferons. Statolon, a natural double-stranded RNA produced in Peni ci l l i um stol oni ferum culture, and a double-stranded complex of polyriboinosinic acid and polyribocytidylic acid (poly I:C) have been used as nonviral inducers for releasing preformed interferons. A modification of poly I:C stabilized with poly-L-lysine and carboxymethylcellulose (poly ICLC) has been used experimentally in humans. Clinically, it has prevented coryza when used locally in the nose and conjunctival sacs. T his substance is a better interferon inducer than poly I:C. Another interferon inducer is ampligen, a polynucleotide derivative of poly I:C with spaced uridines. It has anti-HIV activity in vitro and is an immunomodulator.

Other chemical inducers, such as pyran copolymers, tilorone, diethylaminoethyl dextran, and heparin, also have been used. T ilorone is an effective inducer of interferon in mice, but it is relatively ineffective in humans. Initial use of interferon and its inducers instilled intranasally after rhinovirus exposure was successful in the prevention of respiratory diseases. T he clinical success of interferon and its inducers has not yet been established, although they may play a significant role in cell-mediated immunity to viral infections and cancer. Disadvantages of interferon use include unacceptable side effects, such as fever, headache, myalgias, leukopenia, nausea, vomiting, diarrhea, hypotension, alopecia, anorexia, and weight loss.

Interferon structure Interferon consists of a mixture of small proteins with molecular weights ranging from 20,000 to 160,000 daltons. T hey are glycoproteins that exhibit species-specific antiviral activity. Human interferons are classified into three types (26): α, β, and γ. T he P.1205 α-type is secreted by human leukocytes (white blood cells and non–T lymphocytes), and the β-type is secreted by human fibroblasts. Lymphoid cells (T lymphocytes), which either have been exposed to a

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presensitized antigen or have been stimulated to divide by mitogens, secrete interferon-α. Interferon-γ also is called “ immune'' interferon. Interferons are active in extremely low concentrations (for more details, see Chapter 6).

Clinical application Interferon has been tested for use in chronic HBV infection, herpetic keratitis, herpes genitalis, herpes zoster, varicella-zoster, chronic hepatitis, influenza, and common cold infections. Other uses of interferon are in the treatment of cancers, such as breast cancer, lung carcinoma, and multiple myeloma. Interferon has had some success when used as a prophylactic agent for CMV infection in renal transplant recipients. T he scarcity of interferon and the difficulty in purifying it have limited clinical trials. Supplies have been augmented by recombinant DNA technology, which allows cloning of the interferon gene (27), although the high cost still hinders clinical application. T he U.S. FDA has approved recombinant interferon-α 2a , -α 2b and -γ for the treatment of hairy cell leukemia (a rare form of cancer), AIDS-related Kaposi's sarcoma, and genital warts (condyloma acuminatum). Subcutaneous injection of recombinant interferon-α 2b has been approved for the treatment of chronic hepatitis C. Some foreign countries have approved interferon-α for the treatment of cancers, such as multiple myeloma (cancer of plasma cells), malignant melanoma (skin cancer), and Kaposi's sarcoma (cancer associated with AIDS). Both interferon-β- and -γ as well as interleukin-2 may be commercial drugs of the future for the treatment of cancers and viral infections, including genital warts and the common cold.

Mechanism of action Although interferons are mediators of immune response, different mechanisms for the antiviral action of interferon have been proposed. Interferon-α possesses broad-spectrum antiviral activity and acts on virus-infected cells by binding to specific cell surface receptors. It inhibits the transcription and translation of mRNA into viral nucleic acid and protein. Studies in cell-free systems have shown that the addition of adenosine triphosphate and double-stranded RNA to extracts of interferon-treated cells activates cellular RNA proteins and a cellular endonuclease. T his activation causes the formation of translation inhibitory protein, which terminates production of viral enzyme, nucleic acid, and structural proteins (28). Interferon also may act by blocking synthesis of a cleaving enzyme required for viral release.

Pharmacokinetics T he pharmacokinetics of interferon is not well understood. Maximum levels in blood after intramuscular injection was obtained in 5 to 8 hours. Interferon does not penetrate well into cerebrospinal fluid (CSF). Oral administration of interferon does not indicate a detectable serum level, and as such, oral administration is clinically ineffective. After intramuscular or subcutaneous injection, drug concentration in plasma is dose related. Clinical use of interferon is limited to topical administration (nasal sprays) for prophylaxis and treatment of rhinovirus infections. Adverse reactions and toxicity include influenza-like syndrome of fever, chills, headache, myalgias, nausea, vomiting, diarrhea, bone marrow suppression, mental confusion, and behavioral changes. Intranasal administration produces mucosal friability, ulceration, and dryness.

Neuraminidase Inhibitors (29) T he role played by the surface glycoproteins hemagglutinin, an enzyme that is important for viral binding to host cell receptors via a terminal sialic acid residue, and neuraminidase (NA), an enzyme that is involved in various aspects of activation of influenza viruses, was discussed above. Freshly shed viral particles are coated with sialic acid residues. Neuraminidase is found in both influenza A and B viruses and is thought to be involved in catalytically cleaving glycosidic bonds between terminal sialic acid residues and adjacent sugars on hemagglutinin. T he cleavage of sialic acid bonds facilitates the spread of viruses by enhancing adsorption to cell surface receptors and, thus, increases the infective level of the virus. In the absence of sialic acid cleavage from hemagglutinin, viral aggregation or inappropriate binding to hemagglutinin will occur, interfering with the spread of the infection. Neuraminidase also appears to play a role in preventing viral inactivation by respiratory mucus.

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Mechanism of action Because neuraminidase plays such an important role in the activation of newly formed viruses, it is not surprising that the development of neuraminidase inhibitors has become an important potential means of inhibiting the spread of viral infections. X-ray crystallography of neuraminidase has shown that whereas the amino acid sequence in the neuraminidase from various viruses is considerably different, the sialic acid binding site is quite similar for influenza A and B viruses. In addition, it is believed that the hydrolysis of sialic acid proceeds through a oxonium cation-stabilized carbonium ion, as shown in Figure 43.3. Mimicking the transition state with novel carboxylic derivatives of sialic acid has led to the development of transition state–based inhibitors (30). T he first of these compounds, 2-deoxy2,3-dehydro-N-acetylneuraminic acid (DANA) (Fig. 43.4), was found to be an active neuraminidase inhibitor but lacked specificity for viral neuraminidase. On determination of the crystal structure of neuraminidase, more sophisticated measurements of the binding site for sialic acid lead to the development of zanamivir and later oseltamivir.

Specific drugs Zan amivir Crystallographic studies of DANA (Fig. 43.4) bound to neuraminidase defined the receptor site to P.1206 which the sialic acid portion of the virus binds. T hese studies suggested that substitution of the 4-hydroxy with an amino group or the larger guanidino group should increase binding of the inhibitor to neuraminidase. T he 4-amino derivative was found to bind to a glutamic acid (Glu 119 ) in the receptor through a salt bridge, whereas the guanidino was able to form both a salt bridge to Glu 119 and a charge– charge interaction with Glu

227

. T he result of these substitutions was a dramatic increase in binding

capacity to neuraminidase of the amino and guanidino derivatives, leading to effective competitive inhibition of the enzyme. T he result has been the development of zanamivir (Fig. 43.4) as an effective agent against influenza A and B viruses.

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Fig. 43.3. Neuraminidase-catalyzed removal of a sialic acid residue from a glycoprotein chain. GP, glycoprotein; NA, neuraminidase.

Fig. 43.4. Sialic acid derivatives 2-deoxy-2,3-dehydro-N-acetylneuraminic acid (DANA), zanamir, and oseltamivir phosphate, which act as inhibitors of neuraminidase.

Zanamirvir is effective when administered via the nasal, intraperitoneal, and intravenous (IV) routes, but it is inactive when given orally (T able 43.2). Animal studies have shown 68% recovery of the drug in the urine following intraperitoneal administration, 43% urinary recovery following nasal administration, and only 3% urinary recovery following oral administration. Human data gave results similar to those obtained in animal models. Human efficacy studies with nasal drops or sprays demonstrated that the drug was effective when administered before and after exposure to influenza A or B virus. When given before viral inoculation, the drug reduced viral shedding, infection, and symptoms. When administered beginning at either 26 or 32 hours after inoculation, there was a reduction in shedding, viral titer, and fever. Presently, the drug is available as a dry powder for oral inhalation by adults and adolescents who have been symptomatic for no more than 2 days. Zanamirvir is able to more rapidly resolve influenza symptoms and to improve recovery (from 7 days with placebo to 4 days with treatment). Additional studies have suggested the prophylactic benefit of zanamirvir when administered to family members after one member of the family developed flu-like symptoms. As a result, the manufacturer has submitted an application for the use of the drug for the prevention of influenza A and B infections.

Oseltamivir Ph osph ate X-ray crystallographic studies further demonstrated that additional binding sites exist between neuraminidase and substrate involving the C-5 acetamido carbonyl and an arginine (Arg 152 ); the C-2 carboxyl and arginines at 118, 292, and 371; and the potential for hydrophobic binding to substituents at C-6 (with glutamic acid, alanine, arginine, and isoleucine). Structure–activity relationship studies showed that maximum binding occurred to neuraminidase when C-6 was substituted with the 3-pentyloxy side chain, such as the one found in oseltamivir. In addition, esterification with ethanol gave rise to a

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compound that is orally effective. Oseltamivir (Fig. 43.4) was approved as the first orally administered neuraminidase inhibitor used against influenza A and B viruses (T able 43.2). T he drug is indicated for the treatment of uncomplicated acute illness caused by influenza infection. Recently, the drug has been approved for prevention of influenza A and B infections in adults, adolescents, and children 1 year of age and older. T he drug is effective in treating influenza if administered within 2 days after onset of symptoms. T he recommended dose is 75 mg twice daily for 5 days. T he prophylactic dose is 75 mg taken once daily for 7 days in adults and teenagers, with lower doses for children 1 year or older (dosed based on body weight). Oseltamivir is readily absorbed from the GI tract following oral administration. It is a prodrug that is extensively metabolized in the liver, undergoing ester hydrolysis to the active carboxylic acid P.1207 (Fig. 43.5). T wo oxidative metabolites also have been isolated, with the major oxidation product being the ω-carboxylic acid (31). Side effects with oseltamivir are minor, consist of nausea and vomiting, and occur primarily in the first two days of therapy.

Fig. 43.5. Metabolism of oseltamivir by deethylation and ω-oxidation.

En fu virtide (32,33)

Entry inhibitors, also known as fusion inhibitors, are a new class of drugs for the treatment of HIV

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infection, and enfuvirtide is the first compound of this family to be approved for clinical use. Enfuvirtide is an oligo peptide consisting of 36 amino acids. It is a synthetic peptide that mimics an HR2 fragment of gp41, blocking the formation of a six-helix bundle structure that is critical in the fusion of the HIV-1 virion to a CD4-positive T lymphocyte. Specifically, it binds to the tryptophan-rich region of the gp41 protein. Enfuvirtide is used in combination with other antiretrovirals and works against a variety of HIV-1 variants, but it is not active against HIV-2. Resistance to enfuvirtide can develop when the virus produces changes in a 10-amino-acid domain between residues 36 to 45 in the gp41 HIV surface glycoprotein.

Table 43.3. Antiviral Agents Interfering with Viral Nucleic Acid Replication

Generic Name Acyclovir

Common Name Acyclo-G

Valacyclovir

Spectrum of Trade Name Activity

Dosage Form

Zovirax

HSV-1, HSV-2, VZV, EBV

5% Ointment, injectable (5 mg/mL), capsule (200 mg), tablet (400 and 800 mg), suspension (200 mg/5 mL)

Valtrex

HSV-1, VZV, CMV

Tablet (500 mg)

Cidofovir

HPMPC

Vistide

CMV, HSV-1, HSV-2, VZV, CMV, EBV

Injectable (75 mg/mL)

Cytarabine

Ara-C

Cytosar

Herpes zoster

Injectable (10, 20, 50, and 100 mg/mL)

Famciclovir

FCV

Famvir

HSV, VZV, EBV, chronic HBV

Tablet (125, 250, and 500 mg)

Vitravene

CMV retinitis

Injectable (6.6 mg/mL)

Fomivirsen

Foscarnet

PFA

Foscavir

CMV retinitis, HSV

Injectable (24 mg/mL)

Ganciclovir

DHPG

Cytovene, Vitrasert

CMV retinitis

Injectable (50 mg/mL), capsule (250 and 500 mg),

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insert (4.5 mg/insert) Idoxuridine

5-IUDR

Ribavirin

Herplex

HSV keratitis

0.1% Solution, 0.5% ointment

Virazole

RSV, influenza A and B, HIV-1, parainfluenza

Aerosol (20 mg/mL)

Trifluorothymidine

TFT, FT3

Viroptic

HSV-1

1% Solution

Vidarabine

Ara-A

Vira A

HSV-1, HSV-2

3% Ointment (monohydrate)

Hepsera

HBV

Tablet (10 mg)

Adefovir dipivoxil

CMV, cytomegalovirus; EBV, Epstein-Barr virus; HBV, hepatitis B virus; HSV, herpes simplex virus; VZV, varicella-zoster virus.

T he drug is administered twice daily as a subcutaneous injection and has a complex absorption pattern. Enfuvirtide is highly bound to plasma protein (~ 92%) and is prone to proteolytic metabolism. Adverse reactions are common at the site of injection (e.g., pain, erythema, and pruritus) and insomnia.

Agents Interfering with Viral Nucleic Acid Replication (Table 43.3) Acyclovir and Valacyclovir

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Mechanism of action Acyclovir is a synthetic analogue of deoxyguanosine in which the carbohydrate moiety is acyclic (34). Because of this difference in structure as compared to other antiviral compounds (idoxuridine, vidarabine, and P.1208 trifluridine), acyclovir possesses a unique mechanism of antiviral activity. T he mode of action of acyclovir consists of three consecutive mechanisms (35). T he first of these mechanisms involves conversion of the drug to active acyclovir monophosphate within cells by viral thymidine kinase (Fig. 43.6). T his phosphorylation reaction occurs faster within cells infected by herpesvirus than in normal cells, because acyclovir is a poor substrate for the normal cell thymidine kinase. Acyclovir is further converted to di- and triphosphates by a normal cellular enzyme called guanosine monophosphate kinase. In the second mechanism, viral DNA polymerase is competitively inhibited by acyclovir triphosphate with a lower median inhibition concentration (IC50) than that for cellular DNA polymerase. Acyclovir triphosphate is incorporated into the viral DNA chain during DNA synthesis. Because acyclovir triphosphate lacks the 3′-hydroxyl group of a cyclic sugar, it terminates further elongation of the DNA chain. T he third mechanism depends on preferential uptake of acyclovir by herpes-infected cells as compared to uninfected cells, resulting in a higher concentration of acyclovir triphosphate and leading to a high therapeutic index between herpes-infected cells compared to normal cells. Acyclovir is active against certain herpesvirus infections. T hese viruses induce virus-specific thymidine kinase and DNA polymerase, which are inhibited by acyclovir. T hus, acyclovir significantly reduces DNA synthesis in virus-infected cells without significantly disturbing the active replication of uninfected cells.

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Fig. 43.6. Metabolic reactions of valacyclovir and acyclovir.

Clinical application Acyclovir has potent activity against several DNA viruses including HSV-1, the common cause of labial herpes (cold sore), and HSV-2, the common cause of genital herpes (36). Varicella-zoster virus and some isolates of EBV are affected to a lesser extent by acyclovir. On the other hand, CMV is less sensitive to acyclovir, which has no activity against vaccinia virus, adenovirus, and parainfluenza infections. An ointment containing 5% acyclovir has been used in a regimen of five times a day for up to 14 days for the treatment of herpetic keratitis and of primary and recurrent infections of herpes genitalis. Mild pain, transient burning, stinging, pruritus, rash, and vulvitis have been noted. T he U.S. FDA has approved topical and IV acyclovir preparations for initial herpes genitalis and HSV-1 and HSV-2 infections in immunocompromised patients (37). In these individuals, early use of acyclovir shortens the duration of viral shedding and lesion pain. Oral doses of 200 mg of acyclovir, taken five times a day for 5 to 10 days, have not proven to be successful because of the low bioavailability of current preparations. Oral doses of 800 mg of the drug given five times daily for 7 to 10 days have been approved by the U.S. FDA for the treatment of herpes zoster infection. T his treatment shortens the duration of viral shedding in chickenpox and shingles. T he IV injection of the drug (given 10 mg/kg three times a day for 10 to 12 days) has been approved for the treatment of herpes simplex encephalitis (38). Excessive and high doses of acyclovir have, however, caused viruses to develop resistance to the drug. T his resistance results from reduction of virus-encoded thymidine kinase, which does not effectively activate the drug.

Pharmacokinetics Pharmacokinetic studies show that IV dose administration of 2.5 mg/kg of acyclovir results in peak plasma concentrations of 3.4 to 6.8 mg/mL (39,40). T he bioavailability of acyclovir is 15 to 30%, and it is metabolized to 9-carboxymethoxymethylguanine, which is inactive (Fig. 43.6). Plasma protein binding averages 15%, and approximately 70% of acyclovir is excreted unchanged in the urine by both glomerular filtration and tubular secretion. T he half-life of the drug is approximately 3 hours in patients with normal renal function. In an individual with renal diseases, the half-life of the drug is prolonged. T herefore, acyclovir dosage adjustment is necessary for patients with renal impairment. Because of its low molecular weight and protein binding, acyclovir is easily dialyzed. T hus, a full dose of the drug should be given after hemodialysis. It should be infused slowly, over at least 30 minutes, to avoid acute transient and reversible renal failure. Acyclovir easily penetrates the lung, brain, muscle, spleen, uterus, vaginal mucosa, intestine, liver, and kidney. Acyclovir has relatively few side effects, except that IV injection causes reversible renal dysfunction and irritation, inflammation, and pain at the injection site. Infusion sites therefore should be inspected frequently and changed after every 72 hours. T he drug is slightly toxic to bone marrow at P.1209 higher doses. Less frequent side effects are nausea, vomiting, headache, skin rashes, hematuria, arthralgia, and insomnia. Valacyclovir hydrochloride is an amino acid ester pro-drug of acyclovir that exhibits antiviral activity only after metabolism first in the intestine walls or liver to acyclovir and then conversion to the triphosphate, as shown in Figure 43.6 (41). Structurally, it differs from acyclovir by the presence of the amino acid valine attached to the 5′-hydroxyl group of the nucleoside. Valacyclovir's benefit comes from an increased GI absorption, resulting in higher plasma concentrations of acyclovir, which normally is poorly absorbed from the GI tract. As with acyclovir, valacyclovir is active against HSV-1, VZV, and CMV (T able 43.3) because of its affinity for the viral form of the enzyme thymidine kinase. Oral valacyclovir is used for the treatment of acute, localized herpes zoster (shingles) in immunocompetent patients and may be given without meals. It also is used for the initial and recurrent episodes of genital herpes infections. T he adverse effects are similar to acyclovir, which include nausea, headache, vomiting, constipation, and anorexia. T he binding of valacyclovir to human plasma proteins ranges between 13.5 to 17.9%. T he plasma elimination half-life of acyclovir is 2.5 to 3.3 hours. T he bioavailability of valacyclovir

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hydrochloride is 54%, compared to approximately 20% for oral acyclovir, and it is as effective as acyclovir in decreasing the duration of pain associated with posttherapeutic neuralgia and episodes of genital lesion healing.

T he related analogue 6-deoxyacyclovir is a prodrug form of acyclovir that is activated through metabolism by xanthine oxidase. T his drug, which has improved solubility characteristics compared to acyclovir, is used for the treatment of VZV infection.

Cidofovir

Mechanism of action Cidofovir is a synthetic acyclic pyrimidine nucleotide analogue of cytosine (42). It is a phosphorylated nucleotide that is additionally phosphorylated by host cell enzymes to its active intracellular metabolite, cidofovir diphosphate. T his reaction occurs without initial virus-dependent phosphorylation by viral nucleoside kinases. It has antiviral effects by interfering with DNA synthesis and inhibiting viral replication.

Pharmacokinetics T opical cidofovir (0.2%) is as effective as trifluridine (1%) in reducing HSV-1 shedding and healing time in rabbits with dendritic keratitis. Cidofovir is administered IV, topically, and by ocular implant (T able 43.3). Peak plasma concentration of 3.1 to 23.6 mg/mL is achieved with doses of 1.0 to 10.0 mg/kg, respectively. T he terminal plasma half-life is 2.6 hours, and 90% of the drug is excreted in the urine. It has a variable bioavailability (2–26%).

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Clinical application Cidofovir is active against herpesviruses, including HSV-1 and HSV-2, VZV, CMV, and EBV. It is effective against acyclovir-resistant strains of HSV and ganciclovir-resistant strains of CMV. Cidofovir is a long-acting drug for the treatment of CMV retinitis in patients with AIDS when given as an IV infusion or an intravitreal injection. It is not a curative drug, and its benefit over foscarnet or ganciclovir is yet to be determined. T he major adverse effect is nephrotoxicity, which appears to result in renal tubular damage. Concomitant administration of cidofovir with probenecid is contraindicated because of increased risk of nephrotoxicity.

Cytarabine

Mechanism of Action Cytarabine is a pyrimidine nucleoside related to idoxuridine (43). It is used primarily as an anticancer rather than an antiviral agent. Cytarabine acts by blocking the utilization of deoxycytidine, thereby inhibiting the replication of viral DNA. T he drug is first converted to mono-, di-, and triphosphates, which interfere with DNA synthesis by inhibiting both DNA polymerase and the reductase that promotes the conversion of cytidine diphosphate into its deoxy derivatives.

Clinical application Cytarabine is used to treat Burkitt's lymphoma and both myeloid and lymphatic leukemias. Its antiviral use is in the treatment of herpes zoster (shingles) infection (T able 43.3). It also is used to treat herpetic keratitis and viral infections resistant to idoxuridine. T he drug generally is used topically, but it has been given by IV injection to individuals with serious herpesvirus infection (44). Cytarabine is deaminated rapidly in the body to an inactive compound, arabinosyluracil, which is excreted in P.1210 the urine. T he half-life of the drug in plasma is 3 to 5 hours. T he toxic effects of cytarabine are chiefly on bone marrow, the GI tract, and the kidney. T he drug is not given during the early months of pregnancy because of its teratogenic and carcinogenic effects in animals.

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Fig. 43.7. Metabolic activation of famciclovir.

Famciclovir Mechanism of action Famciclovir (Fig. 43-7) is a synthetic purine nucleoside analogue related to guanine (45,46). It is the diacetyl 6-deoxy ester of penciclovir, which is structurally related to ganciclovir. Its pharmacological and microbiological activities are similar to those of acyclovir. Famciclovir is a prodrug of penciclovir, which is formed in vivo by hydrolysis of the acetyl groups and oxidation at the 6-position by mixed function oxidases. Penciclovir and its metabolite penciclovir triphosphate possess antiviral activity resulting from inhibition of viral DNA polymerase.

Clinical application Famciclovir is active against recurrent HSV (genital herpes and cold sores), VZV, and EBV but is less active against CMV (T able 43.3). It is used in the treatment of recurrent localized herpes zoster and genital herpes in immunocompetent adults, and it also is promising for the treatment of chronic HBV reinfection after liver transplantation.

Pharmacokinetics Famciclovir can be given with or without food. T he most common adverse effects are headache and GI disturbances. Concomitant use of famciclovir with probenecid results in increased plasma concentrations of penciclovir. T he recommended dose of famciclovir is 500 mg every 8 hours for 7 days. T he absolute bioavailability of famciclovir is 77%, and the area under plasma concentration–time curve (AUC) is 86 µg/mL. Famciclovir with digoxin increased plasma concentration of digoxin to 19% as compared to digoxin given alone.

Fomivirsen Fomivirsen sodium is used to treat CMV, which causes opportunistic retinitis in patients with AIDS. Such patients respond to fomivirsen but not to other treatment for CMV retinitis, which leads to blindness (47). Fomivirsen is the first antisense oligonucleotide agent that has been approved as an alternative medicine for patients with CMV retinitis for whom other agents did not work (see Chapter 8, Fomivirsen). It works by inhibiting the synthesis of proteins responsible for the regulation of viral gene expression that is involved in infection of CMV retinitis. Fomivirsen works only in the eye in which it is injected. It is not recommended if cidofovir is used within the last 2 to 4 weeks because of increased risk of eye inflammation. Fomivirsen is given in two induction doses, followed by monthly maintenance doses, each being 330 µg administered by intravitreal injection. It can cause increased pressure in the eye that

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requires treatment by an ophthalmologist. Fomivirsen also is used in the treatment of Crohn's disease and certain cancers. It causes eye inflammation, abnormal vision, cataract, eye pain, and retinal problems. In addition, it causes several other side effects, such as stomach pain, headache, fever, infection, rash, vomiting, and liver dysfunction.

Foscarnet

Foscarnet sodium is a trisodium phosphoformate hexahydrate that inhibits DNA polymerase of herpesviruses, including CMV and retroviral RT (48). It is not phosphorylated into an active form by viral host cell enzymes. T herefore, it has the advantage of not requiring an activation step before attacking the target viral enzyme.

Clinical application Foscarnet sodium was approved by the U.S. FDA for the treatment of CMV retinitis in patients with AIDS. In combination with ganciclovir, the results have been promising, even in progressive disease with ganciclovir-resistant strains. Foscarnet sodium also is effective in the treatment of mucocutaneous diseases caused by acyclovir-resistant strains of HSV and VZV in patients with AIDS. Foscarnet sodium is administered IV at 60 mg/kg three times a day for initial therapy and at 90 to 120 mg/kg daily for maintenance therapy (T able 43.3). T he plasma-half life is 3 to 6 hours. Foscarnet sodium penetrates into the CSF and the eye. T he drug is neurotoxic, and common adverse effects include phlebitis, anemia, nausea, vomiting, and seizures. Foscarnet sodium carries the risk of severe hypocalcemia, especially with concurrent use of IV pentamidine. Foscarnet sodium used with zidovudine (ZDV) has an additive effect against CMV and acts synergistically against HIV.

Ganciclovir

P.1211

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Mechanism of action Ganciclovir sodium is an acyclic deoxyguanosine analogue of acyclovir (49). Ganciclovir inhibits DNA polymerase. Its active form is ganciclovir triphosphate, which is an inhibitor of viral rather than of cellular DNA polymerase. T he phosphorylation of ganciclovir does not require a virus-specific thymidine kinase for its activity against CMV. T he mechanism of action is similar to that of acyclovir; however, ganciclovir is more toxic than acyclovir to human cells.

Clinical significance Ganciclovir has greater activity than acyclovir against CMV and EBV infection in immunocompromised patients. It also is active against HSV infection and in some mutants that are resistant to acyclovir. In patients with AIDS, ganciclovir stopped progressive hemorrhagic retinitis and symptomatic pneumonitis related to CMV infection. Ganciclovir is absorbed and phosphorylated by infection-induced kinases of HSV and VZV infections. Common side effects are leukopenia, neutropenia, and thrombocytopenia. Ganciclovir with ZDV causes severe hematologic toxicity. Ganciclovir is available only as an IV infusion, because its oral bioavailability is poor (T able 43.3). It is given in doses of 5 mg/kg twice daily for 14 to 21 days. When ganciclovir is given by IV administration, concentrations of the drug in the CSF and the brain vary from 25 to 70% of the plasma concentration. After minimal metabolism, ganciclovir is excreted in the urine. In adults with normal renal function, the serum half-life of the drug is approximately 3 hours. Ganciclovir has been approved by the U.S. FDA for the treatment of CMV retinitis in immunocompromised patients and in patients with AIDS.

Idoxuridine

Mechanism of action Idoxuridine is a nucleoside containing a halogenated pyrimidine and is an analogue of thymidine (49). It acts as an antiviral agent against DNA viruses by interfering with their replication based on the similarity of structure between thymidine and idoxuridine. Idoxuridine is first phosphorylated by the host cell virusencoded enzyme thymidine kinase to an active triphosphate form. T he phosphorylated drug inhibits cellular DNA polymerase to a lesser extent than HSV DNA polymerase, which is necessary for the synthesis of viral DNA. T he triphosphate form of the drug is then incorporated during viral nucleic acid synthesis by a false pairing system that replaces thymidine. When transcription occurs, faulty viral proteins are formed, resulting in defective viral particles (51).

Clinical application Idoxuridine is available as ophthalmic drops (0.1%) and ointment (0.5%) for the treatment of HSV keratoconjunctivitis, the leading cause of blindness in the United States (T able 43.3). Because of its

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poor solubility, the drug is ineffective in the treatment of labial or genital HSV or of cutaneous herpes zoster infection. Idoxuridine in dimethyl sulfoxide (DMSO), however, has been used in mucocutaneous HSV infection of the mouth and nose. Because DMSO facilitates drug absorption and also has some therapeutic effect, a 40% solution of idoxuridine in DMSO is more effective than idoxuridine used without this vehicle. T herefore, the U.S. FDA approved idoxuridine only for topical treatment of herpes simplex keratitis, and it is more effective in epithelial than in stromal infections. It is less effective for recurrent herpes keratitis, probably because of the development of drug-resistant virus strains. Adverse reactions of idoxuridine include such local reactions as pain, pruritus, edema, burning, and hypersensitivity. Systemic administration of idoxuridine by IV injection may be given in an emergency, but this leads to bone marrow toxicities, such as leukopenia, thrombocytopenia, and anemia. It also may induce stomatitis, nausea, vomiting, abnormalities of liver functions, and alopecia. Idoxuridine has a plasma half-life of 30 minutes and is rapidly metabolized in the blood to idoxuracil and uracil.

Additional Hydrogenated Uridines

Othe r halo ge nated uridine d erivative s have b ee n rep o rted to e xhib it antiviral ac tivity. Fluo ro de oxyuridine has in vitro antiviral activity b ut is no t us ed in c linic al prac tic e. Bro mo de oxyuridine is use d in s ub ac ute sc le ros ing panenc ep halitis , a de adly, virus -induc ed CNS d ise ase . T his ag ent app e ars to inte rf ere with DNA s ynthes is in the s ame way as ido xuridine . The 5 ′-amino analog ue o f id oxurid ine (5 -io do -5′ -amino -2 ′,5 ′-d ide oxyurid ine ) is a b etter antiviral ag ent than ido xurid ine , and it is les s to xic. I t is me tabo lize d in he rpe svirus -inf ec te d ce lls o nly by thymidine kinas e to di- and trip hos pho ramidate s. Thes e metab olite s inhib it HSV-sp ec if ic late RNA transc rip tio n, c aus ing re duc tio n of les s inf ec tive ab normal viral pro te ins . 5 -Bromo 2 ′-de o xyurid ine has an action s imilar to that o f o the r io d inate d co mpo und s . No ne o f thes e c omp ounds are co mme rcially available in the United State s.

P.1212

Ribavirin

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Mechanism of action Ribavirin, a guanosine analogue, has broad-spectrum antiviral activity against both DNA and RNA viruses (52,53). It is phosphorylated by adenosine kinase to the triphosphate, resulting in the inhibition of viral specific RNA polymerase, disrupting messenger RNA and nucleic acid synthesis.

Clinical application Ribavirin is highly active against influenza A and B viruses and the parainfluenza group of viruses, genital herpes, herpes zoster, measles, and acute hepatitis types A, B, and C. Aerosolized ribavirin has been approved by the U.S. FDA for the treatment of lower respiratory tract infections (bronchiolitis and pneumonia) and serious RSV infections, but it can cause cardiopulmonary and immunologic disorders in children (T able 43.3). Ribavirin inhibits in vitro replication of HIV-1. Clinically, ribavirin has been shown to delay the onset of full-blown AIDS in patients with early symptoms of HIV infection. Some viruses are less susceptible, such as poliovirus, herpesviruses excluding varicella, vaccinia, mumps, reovirus, and rotavirus. A randomized, double-blind study of aerosolized ribavirin treatment of infants with RSV infections indicated significant improvement in the severity of infection, with a decrease in viral shedding (54).

Pharmacokinetics Oral or IV forms of ribavirin are useful in the prevention and treatment of Lassa fever. T he oral bioavailability is approximately 45%, and the serum half-life is 9 hours. Peak plasma level after 1 hour is 1 to 3 mg/mL. Intravenous administration of the drug has higher peak plasma levels. Aerosol preparation delivery of drug (0.8 mg/kg/hour) produced drug levels in respiratory secretions of 50 to 200 mg/mL (T able 43.3). T he clinical benefits of this agent are yet to be confirmed. Its few side effects generally are limited to GI disturbances, such as nausea, vomiting, and diarrhea. T he drug is contraindicated in patients with asthma because of deterioration of pulmonary function. Viral strains susceptible to ribavirin have not been found to develop drug resistance, as is the case with other antiviral agents, such as acyclovir, idoxuridine, and bromovinyldeoxyuridine.

Trifluorothymidine

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Mechanism of action T rifluorothymidine is a fluorinated pyridine nucleoside structurally related to idoxuridine (55). It has been approved by the U.S. FDA and is a potent, specific inhibitor of replication of HSV-1 in vitro. Its mechanism of action is similar to that of idoxuridine. Like other antiherpes drugs, it is first phos-phorylated by thymidine kinase to mono-, di-, and triphosphate forms, which are then incorporated into viral DNA in place of thymidine to stop the formation of late virus mRNA and subsequent synthesis of the virion proteins.

Clinical application T rifluorothymidine, because of its greater solubility in water, is active against HSV-1 and HSV-2. It also is useful in treating infections caused by human CMV and VZV infections (T able 43.3). T he advantage of use of this agent over idoxuridine is its high topical efficacy in the cure of primary keratoconjunctivitis and recurrent epithelial keratitis. It also is useful for difficult cases of herpetic iritis and established stromal keratitis.

Pharmacokinetics T rifluorothymidine is available as a 1% ophthalmic solution, which is effective in dendritic ulcers. Generally, a 1% eye solution of trifluorothymidine is well tolerated. Cross-hypersensitivity and crosstoxicity between trifluorothymidine, idoxuridine, and vidarabine are rare. T he most frequent side effects are temporary burning, stinging, localized edema, and bone marrow toxicity. It is less toxic but more expensive than idoxuridine. T rifluorothymidine, when given IV, shows a plasma half-life of 18 minutes and is excreted in the urine either unchanged or as the inactive metabolite 5-carboxyuracil.

Vidarabine

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P.1213

Mechanism of action Vidarabine is an adenosine nucleoside obtained from cultures of Streptomyces anti bi oti cus (56). Cellular enzymes convert vidarabine to mono-, di-, and triphosphate derivatives that interfere with viral nucleic acid replication, specifically inhibiting the early steps in DNA synthesis. T his agent was used originally as an antineoplastic drug. Its antiviral effect is, in some cases, superior to that of idoxuridine or cytarabine.

Clinical application Vidarabine is used mainly in human HSV-1 and HSV-2 encephalitis, decreasing the mortality rate from 70 to 30%. Whitley et al. (57) reported that early vidarabine therapy is helpful in controlling complications of localized or disseminated herpes zoster in immunocompromised patients. Vidarabine also is useful in neonatal herpes labialis or genitalis, vaccinia virus, adenovirus, RNA viruses, papovavirus, CMV, and smallpox virus infections. Given the efficacy of vidarabine in certain viral infections, the U.S. FDA approved a 3% ointment for the treatment of herpes simplex keratoconjunctivitis and recurrent epithelial keratitis, and a 2% IV injection for the treatment of herpes simplex encephalitis and herpes zoster infections (T able 43.3). A topical ophthalmic preparation of vidarabine is useful in herpes simplex keratitis but shows little promise in herpes simplex labialis or genitalis. T he monophosphate esters of vidarabine are more water-soluble and can be used in smaller volumes and even intramuscularly. T hese esters are under clinical investigation for the treatment of hepatitis B, systemic and cutaneous herpes simplex, and herpes zoster virus infections in immunocompromised patients.

Pharmacokinetics Vidarabine is deaminated rapidly by adenosine deaminase, which is present in serum and red blood cells. T he enzyme converts vidarabine to its principal metabolite, arabinosyl hypoxanthine (ara-HX), which has weak antiviral activity (Fig. 43.8) (58). T he half-life of vidarabine is approximately 1 hour, whereas ara-HX has a half-life of 3.5 hours. T he drug is detected mostly in the kidney, liver, and spleen, because 50% of it is recovered in the urine as ara-HX. Levels of vidarabine in CSF fluid are 50% of those in the plasma. T he most common side effects of vidarabine are GI disturbances, such as anorexia, nausea, vomiting, and diarrhea. T he CNS side effects include tremors, dizziness, pain syndromes, and seizures. Bone marrow suppression is reported at higher doses. Because vidarabine is reported to be mutagenic, carcinogenic, and teratogenic in animal studies, its use in pregnant women is to be avoided. Allopurinol and theophylline may interfere with the metabolism of vidarabine at higher doses because of the xanthine oxidase metabolism of vidarabine. T herefore, this agent should be avoided or given with caution to patients receiving these medications concurrently. Also, adjustment of the dose is necessary in patients with renal insufficiency.

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Fig. 43.8. Metabolism of vidarabine.

Adefovir Dipivoxil (59)

Mechanism of action Adefovir dipivoxil is an orally active prodrug indicated for the treatment of chronic hepatitis B. T he drug is hydrolyzed by extracellular esterases to produce adefovir, which in turn is phosphorylated by adenylate kinase to adefovir diphosphate, which inhibits HBV DNA polymerase. Incorporation of adefovir into viral DNA also leads to DNA chain termination. As shown in Figure 43.9, adefovir dipivoxyl is activated in two steps involving an esterase that exposes a free phosphate group (adefovir), followed by addition of a second phosphate by adenylate kinase to form adefovir diphosphate, the active form of the drug.

Pharmacokinetics Adefovir is poorly absorbed orally, but the bioavailability of adefovir dipivoxil reaches approximately 59%. T he drug is absorbed to an equal extent with or without the presence of food. Adefovir is excreted renally unchanged.

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Fig. 43.9. Activation of the pro-drug adeflovir dipivoxyl by esterase and adenylate kinase.

P.1214

Methisazone: An Agent Affecting Translation of Ribosomes

Histo ric ally, me this azo ne was one of the f irst antiviral c o mpo und s us e d in c linic al p ractice . Me thisazone (60 ) ac ts by inte rf ering with the trans lation o f mRNA me s sage at the rib os ome, p reve nting p rote in s ynthes is . Ultimate ly, it pro d uc ed a d ef e ct in prote in inco rp oratio n into the virus. Altho ug h viral DNA inc reas es and hos t c e lls are d amag ed , an inf ec tious virus is not p rod uc e d. Methis azo ne d is playe d ac tivity ag ains t p oxviruse s , inc luding vario la and vacc inia (6 1). So me RNA viruse s , s uc h as rhinovirus es , e c ho viruse s, reo viruse s , inf luenza, parainf luenza, and p oliovirus es , als o were inhib ite d. Methis azo ne is no t availab le in the Unite d S tates and app ears to have minimal use f ulnes s tod ay.

Clinical application Adefovir dipivoxil joins interferon and lamivudine in the treatment of chronic HBV. It can be used singly or

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in combination with lamivudine. Early clinical studies indicate benefit of the use of adefovir dipivoxil to treat lamivudine-resistant HBV with a low level of resistant virus developing to monotherapy with adefovir dipivoxil.

Antiretroviral (Anti-HIV) Agents Including Protease Inhibitors (62,63) T here can be no permanent cure of AIDS without the prevention or elimination of HIV infection, but patients with AIDS can prolong their life if the disease is diagnosed early and treatment is promptly initiated. Initial HIV treatment requires specific drugs that inhibit RT and HIV protease (i.e., protease inhibitors [PIs]). In advanced HIV infection, AIDS is complicated by other organisms that proliferate in immunocompromised hosts, known as opportunistic infections. Such patients are treated symptomatically with a variety of drugs depending on the opportunistic infections (64,65,66). Anti-HIV agents have side effects, but patients can be managed by a careful monitoring of the drugs. Opportunistic diseases include infections by parasites, bacteria, fungi, and viruses. Neoplasms, including Kaposi's sarcoma and Burkitt's lymphoma, also commonly occur. Anti-HIV agents are classified according to the mode of action. T he drugs inhibiting RT interfere with replication of HIV and stop synthesis of infective viral particles. T hey are further classified into nucleoside and nonnucleoside RT inhibitors. T he drugs inhibiting HIV protease inactivate RT activity and block release of viral particles from the infected cells. T he chemistry, pharmacokinetics, side effects, toxicity, and drug interactions of RT inhibitors and PIs are discussed below.

Nucleoside Rev erse Transcriptase Inhibitors (67,68,69) T he synthesis of viral DNA under the direction of RT requires the availability of purines and pyrimidine nucleosides and nucleotides. T herefore, it is not surprising that a variety of chemical modifications of natural nucleosides have been investigated. T wo such modifications have resulted in active drugs. Removal of the 3′-hydroxyl group of the deoxynucleosides has given rise to dideoxyadenosine (didanosine is the prodrug for this derivative) (70,71), dideoxycytodine (72,73,74), and didehydrodideoxythymidine (75). Replacement of the 3′-deoxy with an azido group has given 3′-azidothymidine (76,77,78,79) and 3′-azidouridine (no longer used as a drug) (80). All of these drugs have similar mechanisms of action in that their incorporation into the viral DNA will ultimately lead to chain-terminating blockade because of the lack of a 3′-hydroxyl needed for the DNA propagation.

Zidovudine

Mech an ism of Action Zidovudine (AZT , ZDV) is an analogue of thymidine in which the azido group is substituted at the 3-carbon atom of the dideoxyribose moiety. It is active against RNA tumor viruses (retroviruses) that are the causative agents of AIDS and T -cell leukemia. Retroviruses, by virtue of RT , direct the synthesis of a provirus (DNA copy of a viral RNA genome). Proviral DNA integrates into the normal cell DNA, leading to

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the HIV infection. Zidovudine is converted to 5′-mono-, di-, and triphosphates by the cellular thymidine kinase. T hese phosphates are then incorporated into proviral DNA, because RT uses ZDV-triphosphate as a substrate. T his process prevents normal 5′,3′-phosphodiester bonding, resulting in termination of DNA chain elongation because of the presence of an azido group in ZDV. T he multiplication of HIV is halted by selective inhibition of RT and, thus, viral DNA polymerase by ZDV-triphosphate at the required dose concentration. Zidovudine is a potent inhibitor of HIV-1, but it also inhibits HIV-2 and EBV.

Clin ical Application Zidovudine is used in AIDS and AIDS-related complex (ARC) to control opportunistic infections by raising absolute CD4 lymphocyte counts. It was first synthesized in 1964 (81), and its biological activity was reported in 1974 (82). In 1986, Yarchoan et al. (83) demonstrated application of ZDV in clinical trials of AIDS and related diseases. Zidovudine is recommended in the control of the disease in asymptomatic patients in whom absolute CD4 lymphocyte counts are less than 200/mm3 . It prolongs the life of patients affected with P.1215 Pneumocysti s cari ni i pneumonia and improves the condition of patients with advanced ARC by reducing the severity and frequency of opportunistic infections. Substantial benefits are obtained when the drug is given after the CD4 cell counts fall to less than 500/mm3 . T herefore, ZDV is used in early and advanced symptomatic treatment of patients with AIDS or ARC. Use with other RT inhibitors or in combination with PIs is more beneficial when resistance to ZDV occurs. Human immunodeficiency virus attacks susceptible cells and interacts mainly with CD4 cell surface proteins of helper T cells. As discussed above, the viral glycoprotein gp120 forms a complex with CD4 receptor on host cells and enters the cells by endocytosis. T he sequence of events is shown in Figure 43.2. Ultimately, the immune system of the host is altered, and symptoms of AIDS appear. Patients with AIDS have symptoms such as high fever, weight loss, lymphadenopathy, chronic diarrhea, myalgias, fatigue, and night sweats. Zidovudine is given in such conditions; however, the drug is toxic to the bone marrow and causes macrocytic anemia, neutropenia, and granulocytopenia. Other adverse reactions include headache, insomnia, nausea, vomiting, seizures, myalgias, and confusion.

Ph armacokin etics Zidovudine is available in various dosage forms for oral or IV administration (T able 43.4). For asymptomatic adults, the initial recommended dosage is 1,200 mg daily (200 mg every 4 hours), which is reduced to 600 mg daily (100 mg every 4 hours) for patients with advanced disease. T he maintenance dose is 600 mg daily in symptomatic patients. Zidovudine is sensitive to heat and light because of its azide group and should be stored in colored bottles at 15 to 25°C. It is well absorbed through the GI tract, and it concentrates in the body tissues and fluids, including the CSF. T he bioavailability of the drug was found to be approximately 65%. Its half-life is approximately 1 hour. Intravenous doses of 2.5 mg/kg or oral doses of 5 mg/kg yielded peak plasma concentrations of 5 mmol/L. Plasma protein binding was approximately 30%. Most of the drug is converted to its inactive glucuronide metabolite and is excreted unchanged through urine. Additionally, ZDV crosses the blood-brain barrier. Pentamidine, dapsone, amphotericin B, flucytosine, and doxorubicin may increase the toxic effects of ZDV. Probencid prolongs the plasma half-life of the drug.

Table 43.4. HIV Reverse Transcriptase Inhibitors

Generic Name

Common Name Trade Name Dosage Form Nucleoside Reverse Transcriptase Inhibitors

Zidovudine

AZT

Retrovir

Tablet (300 mg), Capsule

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ZDV

(100 mg), syrup (50 mg/5 mL), injectable (10 mg/mL)

Didanosine

ddI

Dideoxyadenosine

ddA

Zalcitabine

ddC

Hivid

Tablet (0.375 mg)

Stavudine

D4T

Zerit

Capsule (15, 20, 30, and 40 mg), powder for oral solution (1 mg/mL)

Lamivudine

3TC

Epivir

Tablet (150 mg), solution (10 mg/mL)

Epivir HBV


Ziagen


Tenofovir disoproxil

Viread

Tablet (300 mg)

Emtricitabine

Emtriva

Caplet (200 mg)

Abacavir

ABC

Videx

Tablet (25, 50, 100, 150, and 200 mg) Powder for oral solution (100, 167, and 250 mg)

Nonnucleoside Reverse Transcriptase Inhibitors Nevirapine Delavirdine Efavirenz

DLV

Viramune

Tablet (200 mg)

Rescriptor

Tablet (100 mg)

Sustiva

Capsule (50, 100, and 200 mg)

Didanosine

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Mech an ism of Action Didanosine (ddl) is a purine dideoxynucleoside, which is an analogue of inosine. Chemically, it is 2′,3′-dideoxyinosine, and it differs from inosine by having hydrogen atoms in place of the 2′- and 3′-hydroxyl groups on the ribose ring. Didanosine is a pro-drug that is bioactivated by metabolism to dideoxyadenosine triphosphate, which is a competitive inhibitor of viral RT and is incorporated into the developing viral DNA in place of deoxyladenosine triphosphate. As such, this agent causes chain termination because of the absence of a 3′-hydroxyl group. Didanosine inhibits HIV RT and exerts a virustatic effect on the retroviruses. Combined with ZDV, antiretroviral activity of ddI is increased.

Ph armacokin etics Didanosine has a plasma half-life of 1.5 hours and is given in a 200 mg dose twice daily. Oral bioavailability of the drug is approximately 25% at doses of 7 mg/kg or less. Didanosine significantly decreased p24 antigen levels and increased CD4 cell counts. Viral resistance to ddI occurred after treatment for 1 year. Didanosine is less toxic than ZDV. T he CSF fluid/plasma P.1216 ratio of ddI is 0.2. Didanosine is ultimately converted to hypoxanthine, xanthine, and uric acid through the usual metabolic pathway for purines (Fig. 43.10). T he latter is a nontoxic metabolic product.

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Fig. 43.10. Metabolism of didanosine.

Didanosine is given in advanced HIV infection, ZDV intolerance, or significant clinical/immunologic deterioration. T he major side effects of ddI are painful peripheral neuropathy and pancreatitis. Some of the minor side effects include abdominal pain, nausea, and vomiting. T he use of products, such as pentamidine, sulfonamides, and cimetidine, should be avoided with ddI. T he combination of ddI with ZDV is beneficial, however, because these drugs have different toxicity profile.

Zalcitabine, lamivudine, and emtricitabine T hese three synthetic pyrimidine nucleoside analogues are quite similar in structure and in mechanism of action (Fig. 43.11). T he three compounds differ from 2′-deoxycytidine in that the 3′-hydroxymethylene group of 2′-deoxyriboribose moiety is replaced with either a methylene or a sulfur atom. Additionally, in the case of emtricitabine, the C 5 hydrogen is replaced with a fluoro atom. In all three cases, these drugs act as pro-drugs and must first be phosphorylated to the respective 5′-triphosphates derivatives, which are the active forms. T he resulting triphosphates compete with the normal substrate (deoxycytidine5′-triphosphate) for incorporation into the viral DNA by inhibiting HIV RT , which ultimately leads to termination of viral DNA elongation.

Fig. 43.11. Deoxycytidine analogues as nucleoside reverse transcriptase inhibitors.

Zalcitabin e Zalcitabine (ddC) (T able 43.4) is a useful alternate drug to ZDV and is given in combination with ZDV when CD4 cell counts fall to less than 300 cells/mm3 . Monotherapy with ddC is more active than ZDV. Its oral bioavailability is 87%, and its plasma half-life is approximately 1 hour. It has side effects, such as stomatitis, rash, fever, malaise, arthritis, and arthralgia. In low doses (0.005 mg/kg every 4 hours), ddC produces sustained decrease in p24 antigen level and increase in CD4 cell counts. T he CSF fluid/plasma ratio of ddC is 0.2. Following oral administration, bioavailability of ddC is less than 80%, which is further reduced when

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taken with food. T he mean maximum plasma concentration of the drug also is reduced from 25.2 to 15.5 ng/mL when the drug was taken with food. Dideoxyuridine is the major metabolite in urine and feces. T he drug penetrates the blood-brain barrier. T he major toxicity of ddC is peripheral neuropathy, in which case it should be discontinued. In some cases, pancreatitis occurs when given alone or in combination with ZDV.

Lamivu din e (84) Lamivudine (3T C) (Fig. 43.11) usually is given with other antiretroviral agents, such as ZDV or D4T . 3T C at a dose of 600 mg/day reduced HIV cells by 75%, and in combination with ZDV, the reduction in viral load was 94%. 3T C is rapidly absorbed through the GI tract. Its bioavailability is approximately 86% after oral administration of 2 mg/kg twice daily; peak serum 3T C concentration is approximately 2 mg/mL. 3T C binding to human plasma is approximately 36%. In vivo, it is converted to the trans sulfoxide metabolite, although a majority of the drug is eliminated unchanged in urine. T he U.S. FDA approved 3T C in combination with ZDV for the treatment of disease progression caused by HIV infection. T he combinations of 3T C with ddI, ddC, or D4T also are used for advanced HIV infection. Such combinations have the ability to delay resistance to ZDV and restore ZDV sensitivity in patients with AIDS. Recently, oral therapy with lower doses of 3T C (T able 43.4) has been approved by the U.S. FDA for the treatment of chronic hepatitis B. Peripheral neuropathy and GI disturbances are the major side effects of 3T C. T he minor side effects are nausea, vomiting, and diarrhea.

Emtricitabin e (85) Emtricitabine (Fig. 43.11) is an orally active nucleoside RT inhibitor that is administered once daily. T he (–)-enantiomer is the most active form of the drug, although the (+ )-isomer also is active. T he drug is not bound to plasma protein, and approximately 86% is excreted unchanged in the urine. T he only P.1217 metabolites identified consist of the 3′-sulfoxide and the 2′-O-glucuronide. Emtricitabine is reported to be more active than lamivudine, with a low level of resistance developing when used in combination therapy with efavirenz and didanosine.

Stavudine

Stavudine (D4T ) is a pyrimidine nucleoside analogue that has significant activity against HIV-1 after intracellular conversion of the drug to a D4T -triphosphate. It differs in structure from thymidine by the replacement of the 3′-hydroxyl group with a hydrogen atom and a double bond in the 2′,3′-positions on the deoxyribose ring. It decreases p24 antigen and raised CD4 cell counts. D4T is beneficial for patients where CD4 cell counts do not decrease to less than 300 cells/mm 3 with ZDV and ddI. It is more effective than ZDV or ddC in treating patients by delaying the progression of HIV infection. It is recommended for patients with advanced HIV infection.

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Ph armacokin etics D4T is rapidly absorbed, and absolute bioavailability in adults is 85% at an oral dose of 4 mg/kg (T able 43.4). A peak plasma concentration occurs in dose-dependent manner within 1 hour. It can be taken with food. T he apparent volume distribution after oral dose is 66 L. T he plasma half-life of D4T is approximately 1.5 hours, and the intracellular half-life of D4T -triphosphate is 3.5 hours. It is less toxic to bone marrow but causes peripheral neuropathic toxicity. T he side effects include pain, tingling, and numbness in the hands and feet.

Abacavir

Abacavir sulfate (ABC) was approved in 1998 as a nucleoside RT inhibitor to be used in combination with other drugs for the treatment of HIV and AIDS. T he drug is extensively metabolized via stepwise phosphorylation to 5′-mono-, di-, and triphosphate. Abacavir is well absorbed (> 75%) and penetrates the CNS. T he drug can be taken without regard to meals. T he drug does not show any clinically significant drug–drug interactions. Abacavir has been reported to produce life-threatening hypersensitivity reactions. T he major use of abacavir appears to be in combination with other nucleoside RT inhibitors. A fixed-combination product has recently been approved by the U.S. FDA consisting of 300 mg of ABC, 150 mg of 3T C, and 300 mg of ZDV (T rizivar). T he combination has been shown to be superior to other combinations in reducing viral load as well as to show improvement in CD4 cell count. T he most common adverse effects reported with abacavir include headache, nausea, vomiting, malaise, and diarrhea.

Tenofovir disoproxil (86)

T enofovir disoproxil is a prodrug in a manner similar to that of adefovir dipivoxil. In both cases, the phosphate esters are removed through the action of plasma esterase, leading in this case to tenofovir,

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which differs from adefovir by the presence of the indicated methyl group (Fig. 43.9). T enofovir disoproxil exhibits good bioavailability (25%), which is improved in the presence of food (35%). T he drug is approved for the treatment of HIV infections in adult patients. T enofovir diphosphate is an HIV RT inhibitor. T he active form of tenofovir is the tenofovir diphosphate, which competes with dAT P for incorporation into viral DNA, and when incorporated, tenofovir diphosphate results in premature termination of DNA growth and inhibition of DNA polymerase. T enofovir disoproxil is indicated for treatment-experienced patients with HIV-1. T he drug also appears to be effective in treatment-naive patients, but initial approval is for treatment-experienced patients. T he drug is administered as one tablet taken once daily (T able 43.4). It is recommended that the drug be combined with other RT inhibitors or HIV PIs, which results in additive or synergistic activity.

Nonnucleoside RT Inhibitors T he U.S. FDA recently approved several nonnucleosides that inhibit RT activity. T hey are used with nucleoside drugs to obtain synergistic activity in decreasing the viral load and increasing the CD4 cell count. T hese drugs are primarily designed and synthesized by protein structure–based drug design methodologies. T heir use as monotherapy may be limited because of rapid onset of resistance and hypersensitivity reactions. Interaction of nonnucleoside drugs, however, with other PIs, such as saquinavir, indinavir, and ritonavir, is being investigated. Also, interaction of these P.1218 drugs with clarithromycin, ketoconazole, rifabutin, and rifampin are currently being studied. Nonnucleosides that inhibit RT activity are discussed below.

Nevirapine

Nevirapine and its analogues exhibit antiretroviral effect against azothymidine-resistant HIV strains (87). Nevirapine in combination with ZDV and ddI produced approximately 18% higher CD4 cell counts and a decrease in viral load compared with patients who took ZDV and ddI. Nevirapine is recommended with nucleosides for patients infected with HIV-1 who have experienced clinical or immunologic deterioration. T he significant side effects of nevirapine are liver dysfunction and skin rashes.

Mech an ism of Action Nevirapine is a dipyridodiazepinone derivative that binds directly to RT . T hus, it blocks RNA- and DNA-dependent polymerase activities by causing a disruption of the enzyme's catalytic site. T he activity of nevirapine does not compete with template or nucleoside triphosphate. T he HIV-2 RT and human DNA polymerases are not inhibited by nevirapine. T he 50% inhibitory concentration ranged within 10 to 100 nM against HIV-1.

Ph armacokin etics Nevirapine is rapidly absorbed after oral administration, and its bioavailability is approximately 95%.

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Peak plasma nevirapine concentrations of 2 ± 0.4 mg/mL (7.5 mM) are obtained in 4 hours following a single 200 mg dose (T able 43.4). Following multiple doses, nevirapine concentrations appear to increase linearly in the dose range of 200 to 400 mg/day. Nevirapine is approximately 60% bound to plasma proteins in the plasma concentration range of 1 to 10 mg/mL. It readily crosses the placenta and is found in breast milk. Nevirapine is metabolized as glucuronide conjugates of hydroxylated metabolites, which are excreted in urine. In vivo, ketoconazole did not produce any significant inhibitory effect on nevirapine metabolism. T he plasma concentrations of nevirapine were elevated or reduced in patients receiving cimetidine or rifabutin, respectively.

Delavirdine

Delavirdine, a bisheteroarylpiperazine derivative, is a potent nonnucleoside RT inhibitor of activity specific for HIV-1 (88). T he U.S. FDA has approved this drug for use in combination with other anti-HIV agents (T able 43.4). In Phase I/II study trials, it demonstrated sustained improvements in CD4 cell counts, p24 antigen levels, and RNA viral load. Promising results were obtained when the drug was used in two- or three-drug combinations with nucleoside drugs. Combination of delavirdine with ddI, ddC, or ZDV demonstrated additive or synergistic effects. Delavirdine with ZDV, however, was more beneficial in early HIV infection. Combinations of nevirapine and delavirdine had an antagonistic effect on HIV-1 RT inhibition.

Mech an ism of Action Delavirdine directly inhibits RT and DNA-directed DNA polymerase activities of HIV-1 after the formation of the enzyme–substrate complexes, thereby causing chain-termination effects.

Ph armacokin etics Delaviradine is rapidly absorbed by oral administration and peak plasma concentration was obtained in 1 hour. Administration of delaviridine at 400 mg three times daily resulted in peak plasma concentration of 45 mM. T he single dose bioavailability of delaviridine tablets relative to oral solution was approximate 85%. T he 50% inhibitory concentration for delavirdine against RT activity was 6.0 nM. Delaviridine is extensively bound to plasma protein (~ 98%). It is metabolized to its N-desisopropyl metabolite in liver, and the pharmacokinetics is nonlinear. Clarithromycin, rifabutin, or ergot alkaloid derivatives are predicted to increase plasma concentration of delaviridine. Skin rashes are the major side effect of delavirdine therapy. Cross-resistance between delavidine and PIs, such as indinavir, nelfinavir, ritonavir, and saquinavir, is unlikely because of action on different enzyme targets.

Efavirenz

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Efavirenz is a nonnucleoside RT inhibitor that is a potent inhibitor of wild-type as well as resistant mutant HIV-1 (89). Inhibition of up to 95% is reported for efavirenz at concentrations of 1.5 mM. In combination with indinavir, a mean reduction in HIV RNA of 1.68 log and an increase in CD4 cell counts of 96 cells/mm3 have been reported. Coadministration of efavirenz with indinavir reduced the indinavir concentration (AUC) by approximately 35%. Efavirenz is administered once a day and can be used as a substitute for indinavir in combination therapy with standard drugs, such as ZDV and 3T C. Because it is given once a day, it cuts down the number of pills that a patient with AIDS must swallow. In the current cocktail therapy used for patients with AIDS, efavirenz is a good option to reduce the many side effects of cocktail therapy. It is administered to both adults and children and may be less expensive than indinavir. P.1219 T he side effects of efavirenz include dizziness, insomnia, impaired concentration, abnormal dreams, and drowsiness. T he most common adverse effect is a skin rash. Other side effects are diarrhea, headache, and dizziness. Efavirenz is recommended to be taken at bedtime with or without food. Patients on efavirenz should avoid driving or operating machinery and the intake of high fat meals. It should always be taken in combination with at least one other anti-HIV agent. Efavirenz is contraindicated with midazolam, triazolam, or ergot derivatives.

HIV Protease Inhibitors (Table 43.5) (90) T he HIV protease is an enzyme that is essential for viral growth and that mediates the posttranslational modification of core proteins into structural proteins. T he structural proteins p7, p9, p17, and p24, which play important roles in infectivity of HIV, are products of a pol gene. T he HIV genome contains various regions designated as genes, such as the gag and gag-pol genes, that are translated as polyproteins and form immature viral particles. T hese precursor protein molecules are cleaved by a viral pol -encoded asparti c protei nase to form the desi red structural protei ns of the mature vi ral parti cl e. The HIV protease al so acti vates RT and pl ays an i mportant rol e i n the rel ease of i nfecti ous vi ral parti cl es. Thus, an area of consi derabl e i nterest has been the devel opment of drugs that act as i nhi bi tors of protease and pol gene. Such i nhi bi tors act on HIV protease and prevent posttransl ati onal processi ng and buddi ng of i mmature vi ral parti cl es from the i nfected cel l s. Thi s group of drugs represents a major breakthrough i n the treatment of HIV when used i n combi nati on wi th RT i nhi bi tors, and thei r devel opment i s one of the most si gni fi cant advances i n medi ci nal chemi stry.

Mechanism of action T he HIV protease exists as a dimer in which each monomer contains one of two conserved aspartate residues at the active site. Drugs that inhibit HIV protease are designed as transition-state mimetics that align at the active site of HIV-1 protease, as defined by three-dimensional crystallographic analysis of the protein structure. A number of oligopeptide-like analogues have been synthesized that differentially inhibit viral and mammalian aspartic proteases, and the most useful of these are selective for the viral

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enzyme HIV-1 protease. Structurally, these agents are either peptidomimetic and nonpeptide compounds. T heir effectiveness is related to their ability to inhibit the gag-pol gene, which processes p24, p55, and p160. Consequently, the infectivity of HIV-1 is diminished.

Table 43.5. HIV Protease Inhibitors

Generic Name

Common Name

Saquinavir

Trade Name

Dosage Form(mg/unit)

Invirase

Capsule (200 mg)

Fortovase

Capsule (200 mg)

Ritonavir

RTV

Norvir

Capsule (200 mg)

Indinavir

IDV

Crixivan

Capsule (200 and 400 mg)

Nelfinavir

NFV

Viracept

Tablet (250 mg), powder (50 mg/g)

Amprenavir

APV

Agenerase

Capsule (50 and 150 mg), solution (15 mg/mL)

Lopinavir/ritonavir

LPV/r

Kaletra

Capsule (133.3/33.3 mg), solution (80/20 mg/mL)

Atazanavir

ATZ

Reyataz

Capsule (150 and 200 mg)

Fosamprenavir

Fos-APV

Lexiva

Tablet (700 mg)

Tipranavir

TPV

Aptivus

Capsule (250 mg)

Although some compounds exhibit both in vitro and in vivo antiviral activities, optimization of their pharmacokinetic and pharmacodynamic properties has presented major problems. In view of the great demand for successful anti-AIDS drugs, the U.S. FDA has approved nine drugs as PIs under the accelerated approval process.

Metabolism T he PIs have a high potential for drug interactions, stemming from the fact that they are substrates for and inhibitors of the CYP3A4 enzyme system. As a result, concurrent use of PIs with other drugs metabolized by CYP3A4 may be contraindicated, and in some cases, the drug interactions can be life-threatening. T he most potent cytochrome P450 (CYP450) inhibitor in this class is ritonavir (used to

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advantage in combination with lopinavir); followed by indinavir, nelfinavir, and amprenavir as moderate inhibitors; and by saquinavir as the least potent inhibitor. Drug interactions have been reported with bepridil, dihydroergotamine, and a number of benzodiazepines. Marked increase in activity of amiodarone, lidocaine (systemic), quinidine, the tricyclic antidepressants, and warfarin might be expected. Other interactions have been reported to include rifampin, rifabutin phenobarbital, phenytoin, dexamethasone, or carbazepine. Because the PIs are themselves metabolized by CYP450, their action may be altered by other agents that induce or inhibit this system. In the case of rifabutin, which inhibits CYP3A4 in the gut, relative bioavailability of the PIs is increased, and the dose of the PIs may need to be decreased.

Resistance Resistance to the transition-state peptidomimetic PIs has already become problematic. Resistance is associated with point mutations among various amino acids within the peptide chain of the HIV protease. Single-amino-acid mutations reduce the activity of P.1220 the PIs, but total resistance appears to require multiple mutations. T he most susceptible mutations consist of Leu 33 to Ile, Val, or Phe; Val 82 to Ala, Phe, Leu, or T hr; Ile 84 to Val; and Leu 90 to Met. T hese changes are referred to a PI resistance–associated mutations. T he presence of one or two such mutations leads to reduced susceptibility, whereas five or more mutations can lead to resistance.

Specific drugs Saqu in avir

Saquinavir mesylate was the first PI approved by the U.S. FDA in December 1995 (91,92). It is a carboxamide derivative that is specifically designed to inhibit HIV protease, thus preventing posttranslational formation of viral proteins. It contains a hydroxyethylamine moiety rather than the Phe-Pro scissile bond present in the normal substrate for HIV protease.

Clinical Application Saquinavir is used in the treatment of advanced HIV infection in selected patients. Saquinavir is used concomitantly with either ZDV in untreated patients or ddC in patients previously treated with prolonged ZDV therapy. Although combined therapy did not slow progression of disease, CD4 cell counts were increased in patients infected with HIV in the United States and European countries. T riple therapy with saquinavir, ZDV, and ddC has been more effective than double therapy with saquinavir plus ZDV or ddC. T hus, combination therapy slowed disease progression and mortality. T he IC50 concentration of saquinavir in both acutely and chronically infected cells was 1 to 30 nM. In combination with ZDV, ddC, or ddI, the activity of saquinavir was increased without increased cytotoxicity. T he resistance of HIV isolates to saquinavir was observed as a result of substitution

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mutations in the HIV protease at amino acid positions 48 (glycine to valine) and 90 (leucine to methionine).

Pharmacokinetics T he bioavailability of saquinavir in a single, 600 mg dose following a high-fat meal was shown to be approximately 4%. Approximately 30% of a 600 mg dose of saquinavir reached the liver, where it showed first-pass metabolism. T he poor bioavailability is associated with intestinal metabolism catalyzed by CYP3A4 and, possibly, CYP3A5. Additionally, P-glycoprotein found in intestinal epithelial cells acts as an efflux pump interfering with saquinavir absorption. T he metabolites, mono- and dihydroxylated compounds (Fig. 43.12), are not active (93). Approximately 88 and 19% of a 600 mg oral dose was found in the feces and urine, respectively. T he volume distribution following IV administration of a 12 mg dose of saquinavir was 700 L. T he drug is 98% bound to plasma proteins, and a very low concentration of saquinavir was found in the CSF. As compared to multiple dosing, the steady-state AUC was 2.5-fold higher than that observed after a single dose of 600 mg in HIV-infected patients after a meal. Saquinavir has a plasma half-life of approximately 1.8 hours. Although the saquinavir hard-gel capsule used in combination with other antiretroviral drugs reduces the risk of disease progression or death, it has limited bioavailability. T o overcome this limitation, the U.S. FDA has approved saquinavir soft-gel capsules. Saquinavir is well tolerated in combination with ZDV and/or ddC, and it has few side effects. Gastrointestinal disturbances, however, have been common adverse effects. Saquinavir also has a few mild side effects, such as headache, rhinitis, nausea, and diarrhea.

Fig. 43.12. Major metabolic products from saquinavir.

Riton avir

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Ritonavir is another HIV PI and was approved by the U.S. FDA in March 1996 (94). Ritonavir is a peptidomimetic inhibitor of both the HIV-1 and HIV-2 proteases. A 50% reduction in viral replication was obtained at 3.8 to 153 nM of ritonavir. P.1221

Fig. 43.13. Major metabolic products from CYP3A4 metabolism of ritonavir.

Pharmacokinetics After a 600 mg dose of an oral solution, peak concentrations of ritonavir were obtained in approximately 2 or 4 hours under fasting or nonfasting conditions, respectively. Under nonfasting conditions, peak ritonavir concentrations decreased 23%, and the extent of absorption decreased 7% relative to fasting conditions. In two separate studies, the capsule and oral solution indicated AUC values of 129.5 ± 47.1

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and 129.0 ± 39.3 mg/h/mL, respectively, when a 600 mg dose was given under nonfasting conditions. Five ritonavir metabolites have been isolated from human urine and feces, the most significant of which are shown in Figure 43.13 (95). T he isopropylthiazole oxidation product was the major active metabolite (M2). As with saquinavir, ritonavir is metabolized by CYP3A4 and is an inhibitor of the CYP450 system. Ritonavir is contraindicated with various compounds, such as astemizole, cisapride, clarithromycin, desipramine, ethinyl estradiol, rifabutin, several of the statins, sulfamethoxazole, and trimethoprim, because of increased concentrations of these drugs in the plasma as a result of inhibited oxidative metabolism as well as the fact that several of these drugs are CYP450 inducers. Ritonavir is the most potent PI in its ability to inhibit CYP450 and the efflux pump P-glycoprotein; as a result, the potential for severe drug interactions is quite great. Ritonavir alone or in combination with 3T C, ZDV, saquinavir, or ddC increased CD4 cell counts and decreased HIV RNA particle levels. Cross-resistance between ritonavir and RT inhibitors is unlikely because of the different mode of action and enzyme involved. Common adverse reactions, such as nausea, diarrhea, vomiting, anorexia, abdominal pain, and neurologic disturbances, have been reported with the use of ritonavir alone or in combination with other nucleoside analogues. Ritonavir is used for the treatment of advanced HIV infection, including opportunistic infections. In combination with nucleoside drugs, ritonavir has reduced the risk of mortality and clinical progression. Because of the strong CYP450-inhibiting effects of ritonavir, the drug has found value when used in fixed-dosage combinations with other PIs to block their metabolism and act as a booster for these drugs (lopinavir/ritonavir and tipranavir/ritonavir). In these cases, ritonavir is used in a subtherapeutic dose but boosts the effectiveness of the coadministered drug. T he utilization of ritonavir in a therapeutic dose for treating HIV infections appears to be decreasing, but its utilization as a booster drug is finding favor.

In din avir

Indinavir sulfate, a pentanoic acid amide derivative, was approved by the U.S. FDA in March 1996 (96). T he 95% inhibitory concentration against laboratory-adapted HIV variants, primary clinical isolates and clinically resistant virus to indinavir analogues, is 25 to 100 nM in drug combination studies with ZDV and ddI. In some patients, however, HIV has shown resistance to ritonavir. T his resistance is caused by mutation of the virus that is correlated with the expression of amino acid substitutions in the viral protease. Cross-resistance to indinavir is observed with other PIs but not with the RT inhibitor. For this reason, indinavir is beneficial with ZDV and other nucleoside drugs.

Pharmacokinetics Indinavir is rapidly absorbed in fasting patients, and plasma peak concentration is observed in approximately 1 hour. At a dose of 800 mg every 8 hours, peak plasma concentration is approximately 300 nM. T he drug is approximately 60% bound to human plasma proteins. Indinavir is metabolized via oxidation and glucuronide conjugation (M1 in Fig. 43.14). At least seven metabolites have been

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identified, with the conjugate being the major metabolite (97). T hese metabolites were recovered in feces and urine, with approximately 20% of the drug excreted in the urine. T he half-life of indinavir is approximately 1.8 hours. Because of indinavir's metabolism, a number of drug interactions are possible. Indinavir interacts with rifabutin or ketoconazole, leading to increased or decreased indinavir concentration, respectively, in the blood plasma. Administration of drug combinations of indinavir with antiviral nucleoside analogues, cimetidine, quinidine, trimethoprim/sulfamethoxazole, fluconazole, or isoniazid resulted in an increased activity of indinavir. Indinavir is P.1222 contraindicated in patients taking triazolam or midazolam, because the inhibition of metabolism of these drugs may result in prolonged sedation, nephrolithiasis, asymptomatic hyperbilirubinemia and GI problems (anorexia, constipation, dyspepsia, and gastritis). T he usual oral dose for indinavir alone or in combination with other antiviral agents is one 800 mg capsule every 8 hours. T he drug is well absorbed if given on an empty stomach or 1 hour before or 2 hours after a light meal with water. T he dose is reduced to 600 mg every 8 hours if given concurrently with ketoconazole. Indinavir activity is increased when combined with RT inhibitors.

Fig. 43.14. Metabolic products formed from indinavir.

Nelfin avir

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Nelfinavir mesylate is a peptidomimetic drug that is effective in HIV-1 and HIV-2 wild-type and ZDV-resistant strains, with median effective dose concentrations ranging from 9 to 60 nM (95% effective dose, 0.04 mg/mL) (98). After IV administration, the elimination half-life of nelfinavir was approximately 1 hour. In combination with D4T , nelfinavir reduced HIV viral load by approximately 98% after 4 weeks. It is well tolerated when used with azole antifungals (ketoconazole, fluconazole, or itraconazole) or macrolide antibiotics (erythromycin, clarithromycin, or azithromycin); however, it causes diarrhea and other side effects common to nonnucleoside drugs. Following oral administration, nelfinavir peak levels in plasma ranged from 0.34 mg/mL (10 mg/kg in the dog) to 1.7 mg/mL (50 mg/kg in the rat). In the dog, nelfinavir was slowly absorbed, and bioavailability was 47%. T he drug appeared to be metabolized in the liver, and the major excretory route was in feces.

Ampren avir

Amprenavir is the fifth in a series of PIs to be approved for marketing in the United States. Although it is structurally unique from the previous agents, its pharmacological profile does not appear to differ significantly from those of the previously marketed agents. Early studies suggest that a different resistance profile may exist and that the drug may be effective against some resistant strains of HIV. Side effects appear to be more common than with other PIs and include nausea, vomiting, paresthesia, depression, and rash. Because amprenavir is a sulfonamide, there is some concern regarding crosssensitivity with antibacterial sulfonamides. T his has not been reported, but care should be taken if sensitivity to trimethoprim/sulfamethoxazole, used in Pneumocysti s cari ni i pneumonia, is reported. P.1223 Amprenavir is rapidly absorbed following oral administration and may be taken with or without food. High-fat meals decrease the absorption of the drug and, therefore, should be avoided. T he product is available in capsule and liquid form. T he recommended adult and adolescent dose of 1,200 mg twice

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daily requires the patient to take eight capsules (150 mg each) twice daily. T he liquid preparation is recommended for children between 4 and 12 years of age or for patients 13 to 16 years of age who weigh less than 50 kg. T he dose is 22.5 mg/kg twice daily or 17 mg/kg three times a day. Because this preparation contains the excipient propylene glycol, it is not recommended for children less than 4 years of age and certain other individuals who are unable to metabolize this alcohol.

Lopin avir/Riton avir

Recently, the U.S. FDA has approved the release of lopinavir/ritonavir combination in patients who have not responded to other regimens for treatment of HIV. T he product is available in a soft-gelatin capsule containing 133.3 mg of lopinavir and 33.3 mg of ritonavir as well as in oral solutions containing 80 mg/mL of lopinavir and 20 mg/mL of ritonavir. T he small amount of ritonavir is not expected to have antiretroviral activity; rather, the ritonavir is meant to increase the plasma concentrations of lopinavir by inhibiting lopinavir's metabolism by CYP3A4 (ritonavir acts as a booster). T hese drugs, in combination with other antiretroviral agents, have been approved for use in adults as well as in patients between the ages of 6 months and 12 years. T his is the first PI to be indicated for the very young.

Atazan avir (99)

Atazanavir is an antiretroviral agent approved for use in combination with other antiretroviral agents for the treatment of HIV infections. Atazanavir is a peptidomimetic transition-state inhibitor that targets HIV-1 protease and reduces the viral replication and, thus, the virulence of HIV-1. Similar to saquinavir, ritonavir, indinavir, nelfinavir, amprenavir, and lopinavir, the drug is used in combination with RT inhibitors to produce excellent efficacy in patients with AIDS.

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Pharmacokinetics Atazanavir is dosed orally once daily, thus reducing “ pill burden,” and it appears to have minimal impact on lipid parameters but does increase total bilirubin. T he drug is well absorbed when administered orally with food (bioavailability, ~ 68%). T he drug is highly bound to plasma protein (86%) and is metabolized by CYP3A isoenzyme. Atazanavir is a moderate inhibitor of CYP3A, and potential drug–drug interactions are possible with CYP3A inhibitors and inducers.

Fosampren avir (100)

Fosamprenavir calcium has been approved for the treatment of HIV in adults when used in combination with other anti-HIV drugs. It is a prodrug that, on hydrolysis by serum phosphatases, gives rise to amprenavir, which is a peptidomimetic transition-state inhibitor that targets HIV-1 protease and reduces the viral replication and, thus, the infectiousness of HIV-1. It is commonly administered in combination with RT inhibitors to produce excellent efficacy in patients with AIDS. T he drug is administered as two 700 mg tablets twice daily or, in combination with ritonavir, can be given as two 700 mg tables once daily or one 700 mg tablet twice daily. As a result, formaprenavir lowers the “ pill burden” in patients with AIDS.

T ipran avir (101,102,103,104)

T ipranavir was released as a nonpeptide PI in June 2005 for the treatment of HIV in adults. T he drug was derived through a structure-based design and differs significantly from the design of the previously discussed transition-state peptidomimetics. T ipranavir appears to be bound to the same active site of HIV-1 protease as the peptidomimetics P.1224

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are, but because of its different chemical structure, cross-resistance is significantly less than that seen between the peptidomimetics. T he drug suppresses viral replication in various strains of HIV-1 in vitro, and when combined with azothymidine or delaviridine, synergistic activity is noted in vitro. T ipranavir has an advantage over the other PIs in that it is not as strongly bound to plasma protein as the earlier PIs are, a property that reduces the 90% inhibition concentration. T ipranavir is administered with a booster dose of ritonavir. T he tipranavir/ritonavir must be taken with other anti-HIV drugs. Normal dosing consists of 500 mg of tipranavir and 200 mg of ritonavir twice daily. Whereas tipranavir is a substrate for CYP3A4, in the presence of ritonavir very little metabolism of tipranavir occurs, although the combination leads to induction of P-glycoprotein, which may increase the bioavailability of tipranavir. By itself, tipranavir exhibits increased absorption in the presence of food. Initially, tipranavir was available as the disodium salt, but it was demonstrated that the free acid, in the form of a self-emulsifying drug delivery system (soft-gel capsules), showed improved bioavailability. Drug interactions occur between tipranavir and fluconazole and between tipranavir and clarithromycin, increasing the AUC over a 12 hour period for tipranavir by 56 and 59%, respectively. Care should be taken when administering tipranavir with CYP450 inhibitors and inducers, because clinically significant interactions are possible. Coadministration of tipranavir with antacids decreases the tripranavir AUC by up to 33%. T he most common side effects reported for tipranavir consist of diarrhea and nausea. T hese adverse events may be significant enough to lead to drug discontinuance.

Combination Drug Therapy (105,106) Combination drug therapy for viral infections is another approach currently under investigation. T he synergistic antiviral effects of rimantadine with ribavirin and tiazofurin against influenza B virus and of ganciclovir (DHPG) with foscarnet against HSV-1 and HSV-2 are noteworthy. T he synergistic action of either trifluorothymidine or acyclovir with leukocyte interferon has been used in the topical treatment of human herpetic keratitis. During the past decade, research into combination antiretroviral therapy for patients with AIDS has made remarkable progress. T he first approved drug for HIV-infected patients, ZDV, produced bone marrow toxicity. T o overcome toxic effects, combinations of ZDV with foscarnet, ddC, or ddI have been used. Such combination therapy indicated improved efficacy and decreased side effects as compared to either drug when used alone. T he combination of ZDV with interferon-α has been used to treat patients with AIDS-related Kaposi's sarcoma. T his combination drug therapy delayed emergence of ZDV-resistant HIV strains. A combination of granulocyte-macrophage colony-stimulating factor with ZDV and interferon-α has been successful in managing treatment-related cytopenia in HIV-infected patients. T he advantages of combination therapy include therapeutic antiviral effect, decreased toxicity, and low incidence of drug-resistant infection. In recent years, emergence of drug resistance has been demonstrated in patients receiving single antiviral agent therapy. Resistance to amantadine, acyclovir, ribavirin, ganciclovir, ZDV and other antiviral agents is noteworthy. Combined antiretroviral drug therapy serves different purposes. It prolongs the life of patients with AIDS; removes drug resistance, and/or reduces the toxicity of drugs. With these objectives, successful combinations of ZDV have been reported with ddC, ddI, 3T C, or D4T . Recently, combination of nucleosides drugs (ZDV, ddC, ddI, and 3T C) are used with PIs (saquinavir, indinavir, and ritonavir) for delaying HIV infection. Combined nucleoside drugs are known to delay progression of HIV infection. Antiretroviral therapy includes nucleosides or nonnucleoside RT inhibitors and PIs. T hese drugs inhibit HIV replication at different stages of viral infection. Nucleoside and nonnucleoside drugs inhibit RT by preventing RNA formation or viral protein synthesis. Nonnucleoside drugs inhibit RT by inactivating the catalytic site of the enzyme. T he PIs act after HIV provirus has integrated into the human genome. T hese drug inhibit protease, which is an enzyme responsible for cleaving viral precursor polypeptides into effective virions. T hus, PIs combined with RT inhibitors act by a synergistic mechanism to interrupt HIV replication. T wo-drug combinations, such as ZDV plus ddI or ddC, 3T C and ZDV, and D4T plus ddI, have been

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successful in raising CD4 cell counts and decreasing HIV RNA viral load. T riple-drug therapy consisting of ZDV, 3T C, and one PI (indinavir, ritonavir, or nelfinavir) has been more effective than double-drug therapy consisting of two nonnucleoside analogue combinations. Also, fewer opportunistic infections were noted when patients took the three-drug combination. Additionally, ZDV can be combined with immunomodulators to increase immunologic response in patients with AIDS. Zidovudine has been combined with interferon-α to obtain synergistic activity of the drug. An ideal approach of combined antiretroviral drug therapy would be drugs acting at different stages of HIV cell replication.

Investigational Antiviral Agents: Short Interfering RNA (107) T he field of directed RNA interference (RNAi) has rapidly developed into a highly promising approach for specifically interrupting gene function to alleviate disease pathology. RNAi is a mechanism for silencing gene expression that has been conserved through evolution in eukaryotes ranging from plants to humans. In this process, double-stranded duplexes of 21 to 25 P.1225 nucleotides in length are created from a parent double-stranded RNA molecule. T hese short interfering RNAs (siRNAs) direct the cell to cleave target mRNAs that share sequence identity with the siRNAs. Many research groups are attempting to develop RNAi therapies that induce the degradation of target mRNA involved in inherited or acquired disorders. T his technology is especially well-suited to treating viral infections, and numerous examples now illustrate that a wide range of viruses can be inhibited with RNAi, both in vitro and in vivo. Antiviral RNAi therapies can be tailored to the biochemical characteristics of each pathogen and can be made more specific through choice of delivery vehicle, route of administration, selection of gene targets, and regulation of RNAi induction. As has been mentioned above, successful antiviral therapeutics possess the ability to discriminate virus from host. Because viruses rely extensively on host cell machinery for many functions and activities involved in viral replication, however, they offer a very limited number of therapeutic targets. Because RNAi specifically targets a short stretch of viral nucleic acids rather than a viral protein, even a small viral genome can provide a large number of potential targets.

Case Study Victo ria F . Roc he S. Willia m Zito Yo u are an Ore go n pharmac is t me ntoring the A merican Pharmac is t A ss o ciation Ac ade my of Stud ent P harmacists c hap te r of a loc al p harmacy s c ho ol in its s ervice o utre ach p rog ram with an area s he lte r f o r abus ed wo men. T his she lte r se rves abo ut 5 0 wome n and their childre n, as s is ting the women with work p lac eme nts when nee de d and pro viding d ay c are s e rvice s and transp ortation to area s cho ols f o r the kids . A ll re s ide nts have b re akf ast to ge the r at 6 :3 0 A M, and d inne r is o f f ere d at 6:0 0 PM. with abo ut three -q uarte rs of the f amilie s partaking o n any g iven e ve ning . V arious co mmunity gro ups make s ure the p antry is we ll stoc ked , and o ne has p rovid e d s up plie s o f asp irin and other ove r-the-c ounter pro duc ts f or as -nee de d us e by the she lte r's c lie nts. The c o rpo rate he ad quarte rs o f S ea Mis t, a c o mpany that marke ts p ro duc ts mad e f rom lo cally gro wn c ranb erries , has s elec te d this s helter as the p rimary b enef iciary o f its c o mmunity s ervic e co mmitment, and it provid es the res id ents with es se ntially limitles s quantitie s o f its p rod uc ts , inc luding c ranb erry juic e (enjo yed o f ten b y mos t o f thos e living at the s helter). A rec ent o utbre ak of inf lue nza A has struc k your c ommunity, and altho ug h only a f e w re side nts o f the shelter have b e co me ill, yo u and the MD who also d onates her se rvic es to the f ac ility realize that all the res id ents (inc luding the c hild ren) are at ris k. Be cause o f a nationwid e sho rtag e of vac c ine, vac cinatio n of the re side nts is no t p os s ible, b ut to ge ther, yo u are trying to se c ure s uf f icient q uantities o f an o rally active, antiviral ag ent to tre at and /or pro te ct the s e p atie nts . T he Se a Mis t e mploye es have vo luntee re d to c ove r the co st of any med ic atio n no t d onated by the manuf acture r. Taking ad vantage o f a “ teac hab le mome nt” in clinic al prac tic e, yo u as k your A SP stud ents who are c urrently taking med ic inal c he mis try to id entif y the be s t age nt of the f o ur struc tural cho ic es s ho wn b elo w to mee t the ne ed s of this d ive rse p op ulation.

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1. I d entif y the therap eutic p rob le m(s) in whic h the p harmacist's interve ntion may be nef it the p atient. 2. I d entif y and p rio ritize the patie nt-sp e cif ic f ac to rs that mus t b e c o ns id ere d to ac hieve the d es ire d the rape utic outc ome s . 3. Co nduct a tho ro ug h and mec hanis tic ally o rie nte d struc ture– activity analys is of all therap eutic alte rnative s pro vid ed in the cas e. 4. Evaluate the s truc ture –activity re latio ns hip f ind ing s ag ains t the patie nt-sp e cif ic f ac to rs and d es ire d the rape utic outc ome s , and make a therap eutic d ec is io n. 5. Co uns el your p atients .

P.1226

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properties and therapeutic use in major superficial and systemic mycosis in immunocompromised patients. Drugs 1995;50:658–690.

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84. Perry CM, Faulds D. Lamivudine. A review of its antiviral activity, pharmacokinetic properties, and therapeutic efficacy in the management of HIV infection. Drugs 1997;53:657–680.

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86. Barditch-Crovo P, Deeks SG, Collier A, et al. Phase I/II trial of the pharmacokinetics, safety, and antiretroviral activity of tenofovir disoproxil fumarate in human immunodeficiency virus-infected adults. Antimicrob Agents Chemother 2001;45:2733–2739.

87. T an B, Ratner L. T he use of new antiretroviral therapy in combination with chemotherapy. Curr Opin Oncol 1997;9:455–464.

88. Freimuth WW. Delaviridine mesylate, a potent nonnucleoside HIV-1 reverse transcriptase inhibitor. Adv Exp Med Biol 1996;394:279–289.

89. Graul A, Rabasseda X, Castaner J. Efavirenz. Drugs of the Future 1998;23: 133–141.

90. Deeks SG, Volberding PA. HIV-1 protease inhibitors. AIDS Clin Rev 1997–1998:145–185.

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96. Deeks SG, Smith M, Holodniy M, et al. HIV-1 protease inhibitor: a review for clinician. JAMA 1997;277:145–153.

97. Balani SK, Arison BH, Mathai L, et al. Metabolites of L-735,524, a potent HIV-1 protease inhibitor, in human urine. Drug Metab Dispos 1995;23:266–270.

98. Perry CM, Benfield P. Nelfinavir. Drugs 1997;54:81–88.

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Chapter 44 Asthma and Chronic Obstructive Pulmonary Disease S. William Zito

Drugs cov ered in this chapter: β 2 -Adr e ne r gic Agonis ts Alb utero l Bito lte ro l me s ylate Ep ine phrine (A dre nalin) Fe no tero l hyd ro b ro mid e Fo rmo tero l f umarate I s o e tharine hyd ro c hlo rid e Me tap ro te re no l sulf ate Salme te ro l xinaf o ate Te rb utaline s ulf ate Antimus c a r inic s I p ratro pium hyd ro bro mid e Tio tro pium b ro mid e M e thy lx an thin es D yp hylline The o p hylline Adr e noc or tic oids Be c lo me thas o ne d ip ro p io nate Bud e s onid e Flunis o lid e Flutic aso ne p rop io nate Hyd ro co rtis one Me thylp re d nis o lo ne Mo me taso ne f uroate Pre d niso lo ne Triamc ino lo ne ac e tonid e M a s t c ell de gr a nula tion inhibitor s C romo lyn s od ium Ne d o c ro mil so d ium

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Le uk otr ie ne modife r s Mo nte lukast Zaf irlukas t Zileutin M onoc lona l an ti-IgE a ntibody Omalizumab

Asthm a Epidemiology Asthma is a Greek word that is derived from the verb “ aasein,” meaning to pant or exhale with open mouth. T he earliest use of the term as a medical condition dates back to Ancient Greece, in Hippocrates' Corpus Hi ppocrati cum (1). T he incidence of asthma is greatest in the developed world, and there has been an increase in asthma over the last two decades in the United States (2). According to 2002 U.S. population data gathered by the National Center for Health Statistics, the number of people who were ever diagnosed with asthma by a health professional (lifetime prevalence) is 30.8 million (111 per 1,000). Of that number, it is estimated that 20 million people are currently under treatment and that as many as 12 million had an asthma attack in the 12 months before the survey. Children aged 0 to 17 years have the highest rate of asthma (83 per 1,000), but the rate decreases significantly in adults, indicating that many children “ outgrow” the disease. Race and gender seem to play a role in the prevalence of asthma. Puerto Ricans, blacks, and Native Americans have an asthma prevalence much higher than in Caucasians. T he high Puerto Rican incidence is masked when they are included among all Hispanics. Boys have a higher incidence of asthma than girls; however, this reverses in adulthood, when females show a 30% higher prevalence compared to males. Asthma causes a significant loss of schooldays and workdays and results in nearly 2 million visits to the emergency department each year. If asthma is not controlled, it can result in death: almost 5,000 people died from asthma in 2002. Blacks had an asthma death rate more than 200% higher than that in Caucausians, and women had a death rate 40% higher than males. T hese data reinforce the influence of race and gender on the morbidity and mortality of asthma and point out the fact that asthma is a significant public health burden in the United States (3).

Etiology, Signs, and Symptom s Asthma is a complex disorder involving biochemical, autonomic, immunologic, infectious, environmental, and psychological factors to varying degrees in different individuals. Patients with asthma demonstrate recurrent episodes of paroxysmal dyspnea, wheezing, and cough. Most asthmatic attacks are short-lived, with the patient being free from symptoms between exacerbations. Some patients may have persistent difficulty breathing that does not respond to any treatment and that is believed to be the result of airway remodeling (4). T he National Institutes of Health (NIH) Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (EPR-2) simply defines asthma as a chronic inflammatory response of the airways (5). T he most common form of asthma is allergic asthma (atopic or extrinsic asthma), and it is associated with environmental allergens, such as plant pollens, house dust mites (Dermatophagoi des fari nae), domestic pet dander, molds, and foods. T he less common form, intrinsic asthma, has no known allergic cause and usually occurs in adults older than 35 years. Intrinsic asthma may result from an autonomic dysfunction characterized by excess cholinergic

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and/or tachykinin activity, but this hypothesis has never been proven (6). Aside from environmental allergens, an asthmatic attack may be precipitated by P.1231 respiratory infection, exercise, polyps, drugs (e.g., aspirin and β-adrenergic antagonists), and environmental pollutants (e.g., sulfur dioxide, cigarette smoke, and occupational chemicals). In predisposed individuals, emotional stress and drugs or foods that contain tartrazine, sulfites, and preservatives also can precipitate an asthmatic onset (7).

Clinic a l Signific a nc e T he therapeutic approach to the management of asthma and chronic obstructive pulmonary disease (COPD) has changed dramatically over the past several decades. T reatment guidelines have evolved based on a better understanding of these disease states as well as on the development of newer and more efficacious treatment modalities through the application of structure–activity relationships (SARs) of chemical lead compounds. Although both disease states are characterized by pulmonary obstruction and chronic inflammation, the nature of such pulmonary abnormalities differ between the two conditions. T raditional therapy had focused on the symptomatic relief of airflow obstruction through the use of bronchodilators, such as adrenergic agonists and anticholinergics. T oday, however, greater emphasis is placed on managing the underlying inflammation and minimizing disease progression. T he current therapeutic approach to managing these diseases includes the use of rapidly acting drugs to relieve acute symptoms as well as maintenance medications to minimize inflammation and control long-term symptoms. Short-acting adrenergic agonists are the agents most commonly used to manage acute exacerbations of these disease states. Although effective, older agents, such as epinephrine and isoproterenol, were limited in their pharmacokinetic profile as well as in their lack of pulmonary selectivity. Modifying the chemical structure of these compounds, however, has resulted in the development of agents with significant clinical advantages in terms of duration of action and adverse effect profiles. Similarly, the application of SAR principles to the development of anti-inflammatory agents, such as corticosteroids, leukotriene antagonists, and mast-cell stabilizers, has lead to the availability of superior long-term controlling agents in terms of potency, pharmacokinetic profile, and safety. In treating patients with asthma and COPD clinicians should be mindful of the SARs of those agents being employed. T he application of these principles should be used to determine the most appropriate drug therapy in light of patient-specific needs and desired therapeutic outcomes. Additionally, clinicians can look forward to the availability of newer and more clinically appropriate agents for the management of asthma and COPD as research in medicinal chemistry results in the development of increasingly selective drug entities and improved receptor targeting modalities. Joseph V. Etzel Pharm.D. Assi stant Dean of Student Affai rs, Associ ate Cl i ni cal Professor of Pharmacy, Col l ege of Pharmacy & Al l i ed Heal th Professi ons, St. John's Uni versi ty, Jamai ca, New York

Why has there been a marked increase in asthma in affluent industrialized countries? T o answer this question, recent thought has focused on the “ hygiene hypothesis,” which implicates an imbalance of T H 1 and T H 2 lymphocytes as a major cause of the increased prevalence of asthma

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(8). T he T H 1 lymphocytes are the type of CD4+ T lymphocyte associated with defense against bacterial infection, whereas the T H 2 type predominates in allergic inflammation. T he hypothesis claims that because bacterial infections have significantly decreased in industrialized nations, there is an imbalance, in susceptible children, in favor of the T H 2 -type lymphocytes, and this imbalance therefore favors allergic asthma (9). Asthma frequently occurs in families, and studies have shown that this results, at least in part, from mutually shared genes (10,11). Asthma is a complex disorder and lacks a mendelian genetic pattern, so it is difficult to study. T o date, however, genetic research indicates that what is inherited is the susceptibility to develop asthma. It is clear that genes alone are not responsible for the development of asthma, because environmental factors also play a major role. Numerous genes on various chromosomes have been linked to asthma. T able 44.1 shows several gene products that may influence the development of asthma (10,11,12,13,14,15). In reality, however, there is little correlation between gene expression and clinical symptoms. T he one exception to this is the low-expression allele of macrophage migration inhibitory factor (MIF), which has been shown to have a strong association with patients that have mild asthma (16). Drug development of MIF inhibitors might lead to future treatments for asthma.

Table 44.1. Putative Asthma Associated Gene Products Gene Products β 2 -Adrenergic receptor Interleukin-4, -5, -9, and -13 Interleukin-4 receptor α (Il-4Rα) β Chain of the high-affinity IgE receptor (FcεRIβ) Tumor necrosis factor α (TNFα) Major histochemical complex (MHC) T-cell receptor α/δ complex ADAM33 (a disintegrin and metalloproteinase) Dipeptidyl peptidase 10 PHD finger protein 11 Prostanoid DP1 receptor Macrophage migration inhibitory factor (MIF)

P.1232

Pathogenesis of Asthm a For a long time, asthmatic symptoms were thought to be the result of airway smooth muscle abnormalities, resulting in episodic bronchoconstriction. T oday, however, it is clear that the constriction of bronchial smooth muscle is only one of many effects of chronic airway inflammation. Evidence of inflammation appears very soon after the onset of symptoms; therefore, treatment algorithms for asthma now emphasize quick relief of the bronchoconstriction and the amelioration of the underlying inflammation (17). Inflammation in asthma is characterized by mucous plugging, epithelial shedding, basement membrane thickening, inflammatory cell infiltration, and smooth muscle hypertrophy and hyperplasia (Fig. 44.1). An acute extrinsic asthmatic attack begins when mast cells become activated. Activation of mast cells occurs when an antigen cross-links with immunoglobulin (Ig) Es on their surface. T his IgE complex triggers mast cell degranulation, leading to the rapid release of inflammatory mediators, such as histamine, prostaglandins, leukotrienes, and cytokines

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(including tumor necrosis factor α and interleukins). T he initial attack generally resolves within an hour; however, a second phase begins 4 to 6 hours after exposure and can last up to 24 hours. T his late phase is a result of recruitment of additional inflammatory cells, primarily eosinophils, by the release of cytokines from macrophages and T H 2 -type lymphocytes in the lower lung (18).

Fig. 44.1. Pictorial summary of asthma pathogenesis.

Clinical Evaluation Most patients with asthma are asymptomatic between acute exacerbations. T he onset of symptoms can be sudden or gradual and frequently can occur during the night or early in the morning. Acute symptoms include shortness of breath, wheezing or whistling at the end of exhalation, cough, and chest tightness. Patients with chronic and poorly controlled asthma develop barrel chest and diminished diaphragm movement, both of which are evidence of chronic pulmonary hyperinflation. Acute asthmatic attacks may be mild, moderate, or severe depending on the degree of airway

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obstruction. T he determination of the degree of airflow obstruction is accomplished by pulmonary function testing. T he most common pulmonary function test utilizes spirometry, which measures the rate at which the lung changes volume during forced breathing maneuvers. T he most important spirometric measure is the forced vital capacity (FVC). T his requires the patient to exhale as rapidly and as completely as possible after a maximal inhalation. Normal lungs generally can empty their volume in 6 seconds or less. When airflow is obstructed, however, the expiratory time may increase by as much as fivefold. In practice, the forced expiratory volume in the first second of expiration (FEV1 ) is measured and compared to the FVC and then recorded as the ratio of FEV1 to FVC (FEV1 /FVC) (Fig. 44.2) (measurement is done by means P.1233 of a spirometer). Healthy persons normally can expel at least 75% of their FVC in the first second. Deceases in the FEV1 /FVC ratio indicate obstruction, and a decrease below 40% indicates severe asthma (17,18).

Fig. 44.2. Spirometric comparison of normal and severe asthma. FEV1 , forced expiratory volume in 1 second; FVC, forced vital capacity.

A more convenient way to measure airway obstruction is to determine the peak expiratory flow (PEF) rate. T he PEF rate correlates well with the FEV1 ; can be determined using inexpensive, handheld, peak flow meters; and is easily and simply measured at home. T he PEF rate is the maximal rate of flow that is produced through forced expiration. Peak flow meters come with a chart that lists predicted PEF rates based on the patient's age, gender, and height. T he patient or clinician can then compare the determined PEF rate with the predicted PEF rate and make an evaluation regarding the severity of an asthmatic attack. T he PEF rate or the FEV1 , along with the frequency of daytime and nighttime symptoms, forms the basis for the classification of the severity of an asthmatic attack. T able 44.2 shows the severity classification of asthma established by the NIH Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (EPR-2) (5).

General T herapeutic Approaches to T he T reatm ent and Managem ent of Asthm a Asthma symptoms are caused by bronchoconstriction and inflammation, and approaches to treatment are directed at both these physiological problems. T herefore, drugs that affect adrenergic/cholinergic bronchial smooth muscle tone and drugs that inhibit the inflammatory process are used to treat and control asthma symptoms. In the normal lung, bronchiole smooth

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muscle tone results from the balance between the bronchoconstrictive effects of the cholinergic system and the bronchodilating effects of the adrenergic system on the smooth muscles of the bronchioles. Pharmacological treatment of asthmatic bronchoconstriction consists of either increasing adrenergic tone with an adrenergic agonist or inhibiting cholinergic tone with an anticholinergic agent.

Table 44.2. Classification of Asthma Severity (5)

Step 1 (Mild Step 2 (M ild Intermittent) Persistent)

Step 3 (M oderate Persistent)

Step 4 (Severe Persistent)

Frequency of symptoms Days

≤2/week

3–6/week

Daily

Continual

Nights

≤2/month

3–4/month

≥5/month

Frequent

PEF or FEV1

≥80%

≥80%

>60% 30%

FEV1 , forced expiratory volume in 1 second; PEF, peak expiratory flow.

T he inflammatory effects seen in asthma result from the release of physiologically active chemicals from a variety of inflammatory cells. Pharmacological treatment, therefore, uses anti-inflammatory drugs (corticosteroids), mast cell stabilizers, leukotriene modifiers, and IgE monoclonal antibodies. Figure 44.3 depicts the overall approach to the pharmacological treatment of asthma. T herapeutic management of asthma requires the use of quickly acting drugs to relieve an acute attack as well as drugs that control symptoms over the long-term. T he current approach to asthma management utilizes a stepwise approach (5). T he quick-reliever medication is almost always an inhaled short-acting β 2 -adrenergic agonist, whereas controller drugs are inhaled corticosteroids, long-acting β 2 -agonists, leukotriene modifiers, cromolyn sodium, and/or methylxanthines. T he dose, route of administration, and number of controller drugs depends on the severity of the patient's disease. T able 44.3 shows the stepwise approach to asthma management based on disease severity.

T herapeutic Classes of Drugs Used to T reat Asthm a and Chronic Obstructive Pulm onary Disease

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β 2 -Adrenergic Agonists Introduction What structural features make a drug an adrenergic agonist? What features make it a selective β 2 -agonist? T he answers to these questions lie in the structural relationship P.1234 of a drug to that of norepinephrine (NE), the physiological neurotransmitter of the sympathetic branch of the autonomic nervous system. Drugs that act on postsynaptic sympathetic receptors in the same way as NE are called sympathomimetics or, more commonly, adrenergic agonists. T he related natural agonist epinephrine (EPI; adrenalin) is the predominant adrenergic hormone produced in the chromaffin cells of the adrenal medulla. Epinephrine interacts just like NE at all adrenergic receptors.

Fig. 44.3. Overview of pharmacological treatment for asthma.

Chemistry and Biochemistry of Norepinephrine and Epinephrine

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Chemically, NE is classified as a catecholamine. A catechol is a 1,2-dihydroxybenzene, and NE is a β-hydroxyethylaminodihydroxybenzene. Epinephrine is the N-methyl derivative of NE, and they both have acidic and basic functional groups. Physiologically, however, they behave as a base, being more than 90% protonated at pH 7.4 (pK a = 9.6) and functioning as an ionized acid.

Table 44.3. Stepwise M edication M anagement of Asthma All Patients: Short-Acting Inhaled Severity Long-Term β 2 -Agonist as Needed for Acute Episodes Classification Control Mild Intermittent

No daily medication needed

(Step 1)

A course of systemic steroid may be necessary to treat a severe episode

Mild Persistent

Low-dose inhaled steroid

(Step 2)

Other treatment options: Cromolyn/nedocromil OR Leukotriene modifier OR Sustained-release theophylline

Moderate

Low- to medium-dose inhaled steroid

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Persistent

PLUS an inhaled long-acting β 2 -agonist

(Step 3)

Other treatment options: Medium-dose inhaled steroid PLUS cromolyn/nedocromil OR Medium-dose inhaled steroid PLUS leukotriene modifier OR Medium-dose inhaled steroid PLUS sustainedrelease theophylline

Severe Persistent (Step 4)

High-dose inhaled steroid PLUS a long-acting bronchodilator PLUS one or more of the following: Oral long-acting β 2 -agonist Sustained-release theophylline Oral steroid Leukotriene modifier

Norepinephrine is biosynthesized in the neurons of both the central nervous system and the autonomic nervous system, whereas EPI is formed in the chromaffin cells of the adrenal medulla. Both NE and EPI are derived from L-tyrosine by a series of enzyme-catalyzed reactions (Fig. 44.4 depicts the overall pathway). L-T yrosine hydroxylase hydroxylates the meta position of L-tyrosine, producing L-dihydroxyphenylalanine (L-DOPA) and is the rate-limiting step. T he L-DOPA is then decarboxylated by L-aromatic amino acid decarboxylase to form dopamine, which is converted to NE by the action of dopamine β-hydroxylase. Dopamine β-hydroxylase occurs in storage vesicles of the nerve ending, and the NE formed is stored there until it is released into the synaptic cleft. In the chromaffin cells, the formed NE is converted to EPI by N-methylation catalyzed by phenylethanolamine N-methyltransferase.

Termination of Neurotransmission Stimulated adrenergic neurons release NE into the synaptic cleft, which then binds reversibly with receptors to produce a characteristic adrenergic response. T ermination of the adrenergic response occurs primarily by reuptake (uptake-1) into the presynaptic neuron; however, diffusion away from the receptors and extracellular metabolism also occurs to a limited extent. T he NE that is taken back up into the presynaptic neuron is P.1235 either used again as a neurotransmitter or is metabolized by mitochondrial monoamine oxidase (MAO). T he extraneuronal NE that diffuses away from the neurons is either metabolized by

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catechol O-methyl transferase (COMT ) in situ or reaches the circulatory system and is metabolized by COMT and MAO in various tissues, most importantly the liver, gastrointestinal (GI) tract, and the lungs. Figure 44.5 depicts the possible metabolic pathways for both NE and EPI. It is important to note that agonists that are resistant to MAO and/or COMT have greater oral availability and longer duration of action.

Fig. 44.4. The biosynthesis of norepinephrine and epinephrine from tyrosine.

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Fig. 44.5. Metabolic pathways for norepinephrine and epinephrine.

Adrenergic Receptors T he adrenergic receptors have long been pharmacologically classified as α or β based on their interaction with NE, EPI, and the adrenergic prototype, isoproterenol (19). P.1236

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As mentioned above, NE and EPI are nonselective and interact with all adrenergic receptors, but isoproterenol selectively interacts only with the β-receptors. T he adrenergic receptors have been further divided into three groups, α 1 , α 2 and β, each of which has been further divided into three receptor subtypes based on their organ distribution and physiologic activities (20). T herefore, there are now a total of nine adrenergic receptor subtypes, but the most important in relation to the treatment of asthma and chronic obstructive pulmonary disease (COPD) are the β 1 and β 2 subtypes that are found primarily in the heart and the lung, respectively. As may be deduced from T able 44.4, adrenergic agonists that are selective for the β 2 subtype will cause bronchial dilation and might be expected to relieve the bronchospasm of an asthmatic attack. Nonselective β-agonists, however, will have stimulatory cardiac effects and, therefore, would have limited use in cardiac patients with asthma.

Adrenergic Receptor Structure and Agonist Interactions T he adrenergic receptors are a member of the guanine nucleotide binding regulatory protein– coupled receptor family more commonly referred to as G protein–coupled receptors. T hey affect biological activity by releasing secondary messenger molecules inside the cell after they bind an extracellular agonist. T his process usually is referred to as signal transduction and is common to hormone and neurotransmitter receptors found in the muscarinic, serotonergic, dopaminergic, and adrenergic systems. All the G protein–coupled receptors are structurally similar, being comprised of seven transmembrane α-helix bundles. T he helices are connected by short stretches of hydrophilic residues, which form multiple loops in the intracellular and extracellular domains. T he G proteins generally are bound to the third intracellular loop and imbedded in the inner membrane (Fig. 44.6).

Table 44.4. Physiological Response in Relationship to β-receptor Subtype and Organ Site Receptor Subtype β1

Organ Location Heart

Response Increased rate and force Increased conduction velocity

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β2

Bronchiole smooth muscle

Dilation

Intestine

Decreased motility

Liver

Increased gluconeogenesis Increased glycogenolysis

Uterus

Contraction

Lungs

Bronchial dilation

Fig. 44.6. Representation of the G protein–coupled receptor.

All the β-adrenergic receptors are coupled to adenylate cyclase via specific G stimulatory proteins (Gs). When agonist binds to the β-adrenergic receptors, the α-subunit migrates through the membrane and stimulates adenylate cyclase to form cyclic adenosine monophosphate (cAMP) from adenosine triphosphate. Once formed in the cell, cAMP activates protein kinase A, which catalyzes the phosphorylation of numerous proteins, thereby regulating their activity and leading to characteristic cellular responses. T he intracellular enzyme phosphodiesterase (PDE) hydrolyzes cAMP to form AMP and terminates its action (Fig. 44.7). A great deal of research has been done to identify the binding residues of the adrenergic receptors. Molecular modeling methods have been used to construct three-dimensional models for agonist complexes with the β-adrenergic receptors. T he picture that has emerged is that NE binds ionically via its protonated amine to Asp-113 in helix 3 and hydrogen bonds to both

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hydroxyls of the catechol ring with Ser-204 and Ser-207 in helix 5. T hat binding limits configurational and rotational freedoms, which allows reinforcing van der Waals interactions between the aromatic ring with residues Phe-290 in helix 6 and Val-114 in helix 3. T he N-alkyl substituents are believed to fit into a P.1237 pocket formed between aliphatic residues in helix 6 and helix 7. Stereochemistry also plays an important role in receptor binding. T he β-carbon in NE/EPI is chiral and can be either R or S in configuration. Endogenous NE/EPI exists in the R configuration so that the β-hydroxyl oriented toward the receptor Asn-293. (Fig. 44.8) (21,22).

Fig. 44.7. β-Adrenergic receptor G protein coupling to adenylate cyclase.

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Fig. 44.8. Ligand binding to key residues in the adrenergic receptor.

Adrenergic Agonist Structure–Activ ity Relationships T he fundamental pharmacophore for all adrenergic agonists is a substituted β-phenylethylamine (T able 44.5). T he nature and number of substituents on the pharmacophore influences whether an analogue will be direct-acting or indirect-acting or have a mixture of direct and indirect action. In addition, the nature and number of substituents also influences the specificity for the β-receptor subtypes. Direct-acting adrenergic agonists bind the β-adrenergic receptors just like NE/EPI, producing a sympathetic response. Indirect-acting agonists cause their effect by a number of mechanisms. T hey can stimulate the release of NE from the presynaptic terminal, inhibit the reuptake of released NE, or inhibit the metabolic degradation of NE by neuronal MAO (i.e., MAO inhibitors). Mixed-acting agonists work as their name implies (i.e., they have both direct and indirect abilities). T able 44.5 shows the relationship between substituents and the mechanisms of action by adrenergic agonists.

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Table 44.5. Relationship of Substituents to Adrenergic Agonist M echanism of Action

Relationship of Structure to α- or β-Receptor Selectivity T he substituents on the amino group (R 1 ) determines α- or β-receptor selectivity. As was noted above, when the N-substituent was changed from hydrogen (NE) to methyl (EPI) to isopropyl, the receptor affinity went from nonselective for NE/EPI to β-selective for isopropyl. T herefore, one can say that the larger the bulk of the N-substituent, the greater the selectivity for the β-receptor. As a matter of fact, if R 1 is t-butyl or aralkyl, there is complete loss of α-receptor affinity, and the β-receptor affinity shows preference for the β 2 -receptor. It must be said that receptor selectivity is dose related, and when the dose is high enough, all selectivity can be lost. Substituents on the α-carbon (R 2 ) other than hydrogen will show an increased duration of action, because they make the compound resistant to metabolism by MAO. In addition, if the substituent is ethyl, there is a selectivity for the β 2 -receptor, which is enhanced by a bulky N-substituent. Interestingly, α-methyl substitution shows a slight β-receptor enhancement and only for the S-configuration. For an adrenergic agonist to demonstrate significant β 2 -receptor selectivity, there needs to be in addition to the bulky N-substituent an appropriately substituted phenyl ring. T he currently

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marketed adrenergic agonists contain a resorcinol ring, a salicyl alcohol moiety, or a m-formamide group (Fig. 44.9). In addition, these ring configurations are resistant to COMT metabolism and will increase the duration of action.

Specific Adrenergic Drugs Used to Treat Asthma For a more detailed discussion of the chemistry of adrenergic agents, see Chapter 13.

Fig. 44.9. Ring configurations that contribute to β 2 -receptor selectivity.

P.1238

Epinephrine (Adrenalin)

T he combination of the catechol nucleus, the β-hydroxyl group, and the N-methyl give EPI a direct action and a strong affinity for all adrenergic receptors. Epinephrine and all other catechols are chemically susceptible to oxygen and other oxidizing agents, especially in the presence of bases and light, quickly decomposing to inactive quinones. T herefore, all catechol drugs are stabilized with antioxidants and dispensed in air-tight amber containers. Epinephrine is ultimately metabolized by COMT and MAO to 3-methoxy-4-hydroxy-mandelic acid (vanillylmandelic acid), which is excreted as the sulfate or glucuronide in the urine (Fig. 44.5).

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Only a very small amount is excreted unchanged. Epinephrine usually is administered slowly by intravenous (IV) injection to relieve acute asthmatic attacks not controlled by other treatments. Intravenous injection produces an immediate response. Use of EPI with drugs that enhance cardiac arrhythmias (digitalis or quinidine) is not recommended. T ricyclic antidepressants and MAO inhibitors will potentiate the effects of EPI on the heart. Epinephrine should be used with caution in individuals suffering from hyperthyroidism, cardiovascular disease, hypertension, or diabetes. Adverse effects include palpitations, tachycardia, sweating, nausea and vomiting, respiratory difficulty, dizziness, tremor, apprehension, and anxiety.

Isoetharine Hydrochloride

T he α-ethyl group confers β 2 -selectivity, and the β-hydroxyl group and catechol nucleus makes this a direct-acting drug. It is susceptible to COMT metabolism; however, the α-ethyl group inhibits MAO. T herefore, one would expect some oral activity. Isoetharine is dispensed as a solution only for inhalation administration to treat reversible bronchospasm of asthma. It has fallen into relative disuse, because with high doses, there is a significant incidence of cardiovascular (β 1 -receptor) adverse effects and it has a low β 2 -receptor potency compared to newer β 2 -selective agonists. It has a 2- to 4-minute onset of action when inhaled and a duration of action of 3 hours. Isoetharine has adverse effects similar to those of EPI, including palpitations, tachycardia, nausea and vomiting, dizziness, tremor, and headache. Isoetharine may cause decreased levels of theophylline when coadministered. Cardiovascular effects are a concern when isoetharine is taken with other asthma drugs.

Metaproterenol Sulfate

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Metaproterenol is a direct-acting resorcinol analogue of isoproterenol. T he N-isopropyl is β-directing, and the combination with the resorcinol ring system enhances the selectivity for the β 2 -receptors. It is the least potent of the β 2 -selective agonists, however, most likely because of the poor β 2 -selectivity of the isopropyl group. It has good oral bioavailability being resistant to COMT and only slowly metabolized by MAO. When administered orally, it has an onset of approximately 30 minutes with a 4-hour duration. Inhaled metaproterenol can have an onset as quick as 5 minutes; however, it can be as long as 30 minutes in susceptible individuals. Metaproterenol is available in tablet, syrup, and inhalation dosage forms and is recommended for bronchial asthma attacks and treatment of acute asthmatic attacks in children 6 years of age and older (5% solution for inhalation only). Metaproterenol has the same adverse effect profile as other adrenergic agonists, but with a decreased incidence of arrhythmias.

Terbutaline Sulfate

T erbutaline is the N-t-butyl analogue of metaproterenol and, as such, would be expected to have a more potent β 2 -selectivity. When compared to metaproterenol, terbutaline has a threefold greater potency at the β 2 -receptor. Like metaproterenol, it is resistant to COMT and slowly metabolized by MAO, therefore having good oral bioavailability with similar onset and duration. T erbutaline is available as tablets and solutions for injection and inhalation. Adverse effects are similar to other P.1239 direct-acting β 2 -selective agonists, however, with a greater incidence of palpitations.

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Fig. 44.10. Esterase hydrolysis of bitolterol.

Bitolterol Mesylate Bitolterol is a prodrug that releases colterol on activation by esterases in the lung (Fig. 44.10). Colterol is a direct-acting agonist, and the N-t-butyl group makes it β 2 -selective with a binding potency equivalent to that of isoetharine and terbutaline. T he ester form is lipophilic, which helps to keep it local in the lung and resistant to COMT , which tends to increase its duration of action. Onset begins 2 to 4 minutes after administration, and the effect can last as long as 8 hours. It has a adverse effect profile similar to that of other β 2 -selective agonists, with less drowsiness and restlessness compared to other direct-acting agonists.

Albuterol

Albuterol has the N-t-butyl and a salicyl alcohol phenyl ring, which gives it optimal β 2 -selectivity. It is resistant to COMT and slowly metabolized by MAO, giving it good oral bioavailability. Its onset by inhalation is within 5 minutes, with a duration of action between 4 and 8 hours. It currently is the drug of choice for relief of the acute bronchospasm of an asthmatic attack. Levalbuterol is the R-(–)-isomer of albuterol and is available only in solution to be administered via nebulizer. Because it is the active isomer, the dose is fourfold less than that of albuterol.

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Pirbuterol is the pyridine isostere of albuterol. It has pharmacokinetics similar to albuterol but is half as potent at the β 2 -receptor. Pirbuterol is only available as an inhaler, whereas albuterol comes in tablet, syrup, solution, and aerosol formulations. Adverse effects of pirbuterol are nervousness, tremor, and headache, which is less than the profile for albuterol, which adds nausea, vomiting, dizziness, hypertension, insomnia, tachycardia, and palpitations.

Salmeterol Xinafoate

Salmeterol has an N-phenylbutoxyhexyl substituent in combination with a β-hydroxyl group and a salicyl phenyl ring for optimal direct-acting β 2 -receptor selectivity and potency. Salmeterol has the greatest receptor affinity of all the adrenergic agonists. It is resistant to both MAO and COMT and that, together with its increased lipophilicity, gives salmeterol a long duration of action. It is postulated that the phenylbutoxyhexyl N-substituent binds outside of the receptor site and keeps the active pharmacophore moiety in position for prolonged stimulations. It is available only as a powder for inhalation, with a 20-minute onset of action, which lasts for 12 hours. It is used as a controller for the long-term treatment of asthma and is not recommended for quick relief of an acute attack. It also is available in combination with the steroid fluticasone proprionate (Advair Diskus). T here was a small but significant increase in asthma-related deaths among patients receiving salmeterol during a large clinical trial. Subgroup analyses suggested that the risk may be greater in black patients compared with Caucasian patients (23).

Formoterol Fumarate

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Formoterol has a β-directing N-isopropyl-p-methoxyphenyl group and a unique m-formamide and p-hydroxyphenyl P.1240 ring, which provides selectivity for β 2 -receptors. It is resistant to MAO and COMT , making it a long-acting agonist. Formoterol has a more rapid onset as compared to salmeterol while maintaining the same long duration of action. T his is believed to result from formoterol's greater water solubility, allowing it to get to the receptor sites faster, whereas its moderate lipophilicity keeps it in the lungs longer. It is indicated for the long-term maintenance treatment of asthma and for patients with symptoms of nocturnal asthma who require regular treatment with inhaled, short-acting, β 2 -agonists. It is not indicated for patients whose asthma can be managed by occasional use of inhaled, short-acting, β 2 -agonists. Formoterol is available only as a powder in a capsule for administration via the aerosolizer. Patients should be cautioned not to take the capsules orally and to keep them in a safe place to avoid accidental oral administration.

Fenoterol Hydrobromide

Fenoterol is an investigational drug in the United States that has been in use in Europe since 1970. It is the p-hydroxyphenyl derivative of metaproteronol, and the combination of the resorcinol ring and the bulky p-hydroxyphenyl isopropyl group on the nitrogen gives fenoterol significant β 2 -receptor selectivity. It has approximately half the affinity for the β 2 -receptor as compared to albuterol. T he resorcinol ring is resistant to COMT metabolism, and the bulky nitrogen substituent greatly retards MOA metabolism as well giving fenoterol a reasonable oral bioavailability with pharmacokinetics similar to albuterol (i.e., rapid onset and a 4- to 6-hour duration of action after oral inhalation).

Antimuscarinics Introduction Acetylcholine is the endogenous neurotransmitter of the parasympathetic nervous system. T he parasympathetic nerve fibers are found in both the autonomic and central nervous systems. T hese fibers are classified into those that are stimulated by muscarine and those that are stimulated by nicotine. Nicotine, an alkaloid from Ni coti ana tabacum, stimulates preganglionic fibers in both the parasympathetic and sympathetic systems as well as the somatic motor fibers of the skeletal system. Muscarine, an alkaloid from the poisonous mushroom Amani ta muscari a, stimulates postganglionic parasympathetic fibers with receptors found on autonomic effector

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cells. T he central nervous system has fibers that contain both nicotinic and muscarinic receptors. In this chapter, we are most interested in the drugs that block the muscarinic fibers (antimuscarinics), because blocking them results in cardiovascular, mydriatic, antispasmodic, antisecretory, and bronchodilatory effects.

Biochemistry and Metabolism of Acetylcholine Acetylcholine is the ester formed between acetylcoenzyme A and choline by the action of choline acetyltransferase in the presynaptic cholinergic neurons. Most of the choline used to biosynthesize acetylcholine comes via uptake from the synaptic space, where it is produced from the hydrolysis of acetylcholine by acetylcholinesterase, a serine hydroxylase. Additionally, some choline is biosynthesized in the presynaptic neurons from serine (Fig. 44.11). Once formed, acetylcholine is stored in vesicles from which it is released on stimulation. T he duration of action of acetylcholine is very short, because it is rapidly hydrolyzed by the acetylcholinesterase present in the synaptic space. T his hydrolysis is a straightforward splitting of the acetylcholine into acetic acid and choline; however, the way this happens is very interesting and begins by the proper binding of acetylcholine in the catalytic pocket. Binding of the cationic N-end to tyrosine, glutamate, and tryptophan via a combination of π-cation and electrostatic forces places the acyl head of acetylcholine in the correct position for attack by the serine hydroxyl group (Fig. 44.12). Once properly bound, the hydrolysis actually involves two hydrolytic steps. T he first step is the hydrolysis of acetylcholine by nucleophilic attack at the carbonyl carbon by the serine hydroxyl group, which liberates choline and leaves the enzyme acetylated. A triad formed between glutamine, histidine, and the serine at the catalytic site activates the serine for the nucleophilic attack. T he second step is the hydrolysis of the acetylated enzyme by water to regenerate the free enzyme. T he water is activated by hydrogen-bonding to the histidine residue, which increases the nucleophilic character of P.1241 the oxygen of water. T he activated water attacks the electrophilic carbonyl carbon of the acetyl group to generate acetate and regenerate the free hydroxyl group of serine (Fig. 44.13) (24).

Fig. 44.11. Biosynthesis of acetylcholine.

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Fig. 44.12. Binding of acetylcholine in the catalytic site of acetylcholinesterase.

Muscarinic Receptor Structure and Agonist/Antagonist Interactions T he muscarinic receptors are considered to be part of the superfamily of G protein–coupled receptors. T hey consist of seven transmembrane helices and are linked to their G protein through interaction with the second and third intracellular loops (25). T here are five subtypes of receptor, designated M 1–5 , and the odd-numbered receptors (M 1 , M 3 , and M 5 ) are coupled to the G q /G 11 class. T his class of receptors activate intracellular phospholipase C to hydrolyze phosphatidylinositol 4,5-diphosphate to diacylglycerol and inositol triphosphate as intracellular messengers. T he even-numbered receptors (M 2 and M 4 ) are coupled to the G i /G o class, which mediates the inhibition of adenylate cyclase (Fig. 44.14).

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Fig. 44.13. The role of the triad formed between glutamine, histidine, and serine in the hydrolysis of acetylcholine by acetylcholinesterase.

T able 44.6 lists the physiologic action of the M 3 receptors. Because the M 3 receptors cause bronchiole constriction, they counterbalance the bronchiole dilation of the β 2 -adrenergic receptors in the lung, resulting in maintenance of bronchiole tone. T his forms the basis for the therapeutic use of inhaled antimuscarinics, because they block cholinergic bronchiole constriction and allow P.1242 adrenergic bronchiole dilation to help overcome the pulmonary constriction associated with an asthmatic attack.

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Fig. 44.14. Comparison of the role of G protein in odd- and even-numbered muscarinic receptors.

Affinity labeling and mutagenic studies have established that acetylcholine binds to its receptor in a narrow region of the circular arrangement of the seven transmembrane helices approximately 10 to 15 angstroms away from the membrane surface. T he cationic nitrogen of acetylcholine binds to the anionic carboxylate of an Asp located in helix 3 (26). As depicted in Figure 44.15, the ionic interaction is stabilized by hydrogen-bonding with a T yr in helix 5 and a T hr in helix 5. It is postulated that muscarinic antagonists (see Structure–Activity Relationships of Antimuscarinic Agents below) bind to the Asp and contain hydrophobic substituents that bind to a hydrophobic pocket in the receptor, which does not allow the change in conformation needed to transfer the agonist signal to the coupled G protein (27).

Table 44.6. Physiological Action Associated with the M 3 M uscarinic Receptors Organ

M 3 -Receptor Effect

Eye Iris circular muscle

Contracts

Ciliary muscle

Contracts

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Heart Sinoatrial node

Decelerates

Atrial contractility

Decelerates

Bronchiole smooth muscle

Contracts

Gastrointestinal tract Smooth muscle

Contracts

Secretions

Increases

Sphincters

Relaxes

From Katzung B. Introduction to autonomic pharmacology. In: Katzung B, ed. Basic and Clinical Pharmacology. 8th Ed. New York: Lange Medical Books/McGraw-Hill, 2001:75–191; with permission.

Fig. 44.15. Acetylcholine binding to residues in the muscarinic

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receptor.

Structure–Activ ity Relationships of Antimuscarinic Agents T he structural pharmacophore for all antimuscarinic drugs is an acetylcholine analogue in which the acetyl methyl group is substituted with at least one phenyl ring. T his pharmacophore generally is classified as an amino alcohol ester. T he ester function can be replaced with different moieties to produce different classes of antimuscarinic drugs. When the ester function is replaced by an ether function, the amino alcohol ether class is produced. When the ester function is replaced by a saturated carbon, the amino alcohols are obtained when R 1 is a hydroxyl group, and the amino amides are obtained when R 1 is an amido group (Fig. 44.16). T he classic chemical prototype for the antimuscarinics is atropine, an alkaloid from Atropa bel l adonna. Buried within its structure is the amino alcohol ester pharmacophore, where R 1 is a hydroxymethyl group, R 2 is a hydrogen, and the nitrogen is part of a bicyclic ring system called tropine (Fig. 44.17).

Fig. 44.16. The pharmacophore for all classes of antimuscarinic agents.

P.1243

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Fig. 44.17. Atropine is an example of the amino alcohol ester class of antimuscarinic agents.

Although atropine does not have a quaternary nitrogen, the nitrogen is protonated at physiologic pH; therefore, it can bind to the anionic Asp residue in the muscarinic receptor. T he nitrogen is not absolutely necessary for activity and can be replaced with a carbon atom. T his leads to a substantial lose of binding affinity, however, and there are no marketed drugs with this configuration. T he nitrogen can be substituted with alkyl groups, and methyl is the optimal size. When the nitrogen is made quaternary, the molecule loses its oral availability but leads to compounds that can be administered effectively by inhalation. T he asterisks in atropine (Fig. 49.17) refer to chiral carbons. When stereochemistry is present in the amino alcohol moiety (tropine), there is little difference between the activities of the R- and S-configurations. When stereochemistry is found in the acid moiety, however, the R configuration is approximately 100-fold more active than the S-isomer. T his indicates the importance of the binding role for the phenyl ring in causing the uncoupling of the G protein, which leads to receptor inhibition (28).

Specific Antim uscarinic Drugs Used to Treat Asthma For a more detailed discussion of the chemistry of cholinergic agents, see Chapter 12.

Ipratropium Hydrobromide

Ipratropium is the N-isopropyl analogue of atropine. Its quaternary cationic nature makes it highly hydrophilic and poorly absorbed from the lungs after inhalation via solution or aerosol. Much of an inhaled dose is swallowed. T here is no significant absorption, however, and the bronchodilation effect can be considered to be a local, site-specific effect. Ipratropium is indicated primarily for the relief of bronchospasms associated with COPD (chronic obstructive pulmonary disease) and has seen little application for the treatment of asthma. It also is administered by nasal spray for the relief of rhinorrhea associated with the common cold and

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perennial rhinitis. Inhaled ipratropium has a 15-minute onset of action and a rather short duration of action ( LT C 4 = LT E 4 , whereas the cysLT 2 receptors show an affinity profile of LT C 4 = LT D 4 > LT E 4 . Both receptor types occur in the lungs and spleen. T he cysLT 1 receptor is found only in the placenta and small intestines, whereas the cysLT 2 receptor occurs only in the heart, lymph nodes, and brain. T he incomplete overlap of tissue distribution along with their distinct ligandbinding properties suggests the cysLT 1 receptors and the cysLT 2 receptors might serve different functions in vivo (41), and because the cysLT 1 receptors are inhibited by selective antagonists, they have importance in the treatment of leukotriene related bronchoconstriction in asthma.

Leukotriene Modifier Drugs T wo approaches to the development of leukotriene modifiers have been taken. T he first approach was to block their biosynthesis by looking for compounds that inhibit one or more of the enzymes involved in the biochemical pathway. T he second approach was to identify antagonists with selective affinity for the cysLT 1 receptors. P.1257

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Leukotriene Biosynthesis Inhibitors T he search for orally active 5-lipoxygenase inhibitors has resulted in only a few classes of compounds that are effective in animals and humans with the N-hydroxyureas, yielding a useful product (42). T he 5-lipoxygenase inhibitors block the production of LT B 4 as well as LT C 4 , LT D 4 , and LT E 4 , thereby decreasing both the bronchoconstrictive and chemotactic effects of the leukotrienes.

Zileutin

Zileutin is the first N-hydroxyurea 5-lipoxygenase inhibitor to be marketed. It is the ethylbenzothienyl derivative of N-hydroxyurea and occurs as the racemic mixture of R-(+ )- and S-(–)-enantiomers, both of which are pharmacologically active. T he N-hydroxyl group is essential for inhibitory activity, with the benzothienyl group contributing to its overall lipophilicity. Zileutin is rapidly absorbed orally and is 93% protein bound in the plasma. Metabolism occurs in the liver, with the inactive O-glucuronide being the major metabolite, along with less than 0.5% inactive N-dehydroxylated and unchanged zileutin. T he glucuronidation is stereoselective, with the S-isomer being metabolized and eliminated more quickly (43). Greater than 90% of an oral dose is bioavailable, and 95% is excreted as metabolites in the urine, with a half-life of 2.5 hours, thus requiring four-times-a-day dosing. Zileutin increases the plasma levels of propranolol, theophylline, and warfarin, and dosing of these drugs should be reduced and the serum levels monitored carefully in patients taking both drugs. T he most serious side effect of zileutin is elevation of liver enzymes; if symptoms of liver dysfunction (e.g., nausea, fatigue, pruritis, jaundice, or flu-like symptoms) occur, the drug should be discontinued.

Leukotriene receptor antagonists T he search for leukotriene receptor antagonists began without the aid of ligand–receptor binding data and took the form of three approaches. T hese included the design of leukotriene structural analogues, quinoline analogues, and the random screening of compounds. T he combination of these efforts led to a simple SAR: T he lipophilic tetraene tail of LT D 4 can be mimicked by a variety of more stable aromatic rings, the thioether of the glycinylcysteinyl dipeptide can be replaced by an alkyl carboxylic acid, and the C 1 carboxylate of LT D 4 needs to be retained. Additional research focusing on the three-dimensional requirements for antagonist binding to the cysLT receptors further clarified that the pharmacophore needs to consist of an acidic or negative ionizable functional group, a hydrogen-bond acceptor function, and three hydrophobic regions (44). Based on this background, synthetic efforts resulted in the development of montelukast and zafirlukast as cysLT 1 receptor antagonists. Figure 44.34 demonstrates how both

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these antagonists fit the pharmacophore model.

Montelukast

Montelukast was developed from other weakly antagonistic quinoline derivatives. A number of changes can be made to the structure without the loss of activity. T hese include changing the double bond between the two aromatic rings to an ether linkage, reducing the quinoline ring, changing the chlorine to a fluorine, and/or exchanging the sulfur for an amide group. Montelukast is a high-affinity, selective antagonist of the cysLT 1 receptor. It is rapidly absorbed orally, with a bioavailability of 64%. Montelukast is 99% bound to plasma proteins and is extensively metabolized in the P.1258 liver by CYP3A4 and CYP2C9 to oxidated products. CYP3A4 oxidizes the sulfur and the C-21 benzylic carbon, whereas CYP2C9 is selectively responsible for the methyl hydroxylation. Figure 44.35 shows the primary metabolic pathway for montelukast in humans (45). More than 86% of an oral dose is eliminated as metabolites through the bile. Montelukast did not demonstrate any significant adverse effects greater than placebo in clinical trials; however, because it is metabolized by the cytochrome P450 (CYP450) enzymes, its plasma levels should be monitored when coadministered with CYP450-inducing drugs, such as phenobarbital, rifampin, and phenytoin. Montelukast is available in tablet, chewable tablet, and granules for administration mixed with food.

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Fig. 44.34. Interaction of montelulast and zafirlukast with cysteinyl leukotriene (cysLT) receptor model.

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Fig. 44.35. Metabolism of montelukast.

Zafirlukast

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Zafirlukast is an indole derivative with a sulfonamide group that fulfills the need for an ionizable moiety on the pharmacophore. A large number of analogues have been prepared; however, they all resulted in a decrease in antagonist activity. Zafirlukast, like montelukast, is a selective antagonist for the cysLT 1 receptor and antagonizes the bronchoconstrictive effects of all leukotrienes (LT C 4 , LT D 4 , and LT E 4 ). Zafirlukast is well absorbed orally; however, food will decrease its absorption by as much as 40%. Zafirlukast is primarily metabolized in the liver by CYP2C9 and CYP3A4 to hydroxylated metabolites (46). Zafirlukast also has been shown to undergo carbamate hydrolysis, followed by N-acetylation. Additionally, zafirlukast in known to produce an idiosyncratic hepatotoxicity in susceptible patients. T his is appears to result from the formation of an electrophilic α,β-unsaturated iminium intermediate evidenced by the formation of a glutathione adduct on the methylene carbon bridging the indole ring to the methoxybenzene moiety of the molecule (47). Figure 44.36 summarizes the metabolism of zafirlukast. More than 90% if its metabolites are excreted in the feces, with the remaining found in the urine. Zafirlukast inhibits CYP3A4 and CYP2C9 in concentrations equivalent to clinical plasma levels and, therefore, should be used with caution in patients taking drugs metabolized by these enzymes. Specifically, coadministration with warfarin results in a significant increase in prothrombin time. Other drugs metabolized by CYP2C9 are phenytoin and carbamazepine. In P.1259 addition, CYP3A4-metabolized drugs are cyclosporine, cisapride, and the dihydropyridine class of calcium channel blockers. Of particular interest is the fact that aspirin increases the plasma levels of zafirlukast, and theophylline decreases the plasma levels of zafirlukast. Care should be taken when coadministering with erythromycin, because this decreases the bioavailability of zafirlukast. Zafirlukast is only available in tablet formulations.

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Fig. 44.36. Metabolism of zafirlukast to oxidative products and a glutathione adduct.

M onoclonal Anti-IgE Antibody Introduction T he pathophysiology of allergic asthma, as already discussed, involves the dendritic processing of the allergen, which ultimately results in the production of allergen-specific IgE by activated B lymphocytes. T he IgE binds to high-affinity (FcεRI) receptors on mast cells. T he site where IgE binds to the receptor is located on the Fc fragment area of the C-ε-3 region, hence the acronym FcεRI (Fig. 44.37A). Subsequent allergen exposure causes cross-linking of bound IgE molecules, which triggers degranulation of these cells, resulting in the release of asthma mediators. Monoclonal anti-IgE antibody development is designed to moderate the role of IgE in activating mast cells, thereby decreasing the severity of allergic asthmatic attacks, and may have beneficial effects in treating seasonal allergic rhinitis.

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Omalizumab Dev elopment and Pharmacology Omalizumab is a monoclonal antibody developed through somatic cell hybridization techniques and was identified as a murine anti-human IgE antibody, originally called MAE11 (48). It is designed to interact with the site that binds to FcεRI on mast cells. Additional amino acid sequences have been incorporated into the antibody so that a humanized product resulted that only differs by 5% nonhuman amino acid residues. In vitro, omalizumab has been shown to complex with free IgE, forming trimers consisting of a 2:1 complex of IgE to omalizumab or a 1:2 complex of IgE to omalizumab. In addition, larger complexes also are formed, consisting of a 3:3 ratio of each (Fig. 44.37B). Omalizumab does not bind to IgE already bound to mast cells and, therefore, does not cause the degranulation that might be expected from such interaction. T hus, omalizumab effectively neutralizes free IgE and, aside from the obvious decrease of available IgE, also causes the down-regulation of FcεRI receptors on the mast cell surface, resulting in a decrease of IgE bound to the mast cell. P.1260

Fig. 44.37. (A) Graphic representation of IgE binding to the FCεRl on a mast cell. (B) Graphic representation of immune complexes formed between omalizumab. Hexamers predominate when components are in a 1:1 ratio, and the trimers predominate when one of the components is in excess.

Omalizumab (Xolaire) T he clinical role for omalizumab is in the treatment of allergic asthma. It is approved for the treatment of adults and adolescents 12 years of age and older whose symptoms are not controlled with inhaled glucocorticoids and who have a positive skin test for airborne allergens. T he bioavailability after subcutaneous administration is 62%, with slow absorption resulting in

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peak serum levels in 7 to 8 days from a single dose. Steady-state plasma concentration is reached in 14 to 29 days with multiple dosing regimens. T he elimination of omalizumab is not clearly understood; however, studies have determined that intact IgE is excreted via the bile and that omalizumab:IgE complexes are cleared faster than uncomplexed omalizumab and slower than free IgE. T his means that over time, total IgE concentrations (free and complexed IgE) increase, because the complex is cleared more slowly. T he metabolism of omalizumab is not known, and the clearance of the complex is similar to the liver elimination of another immunoglobulin, IgG. T he reticuloendothelial system degrades IgG, and it is believed that the same process occurs for the omalizumab:IgE complex. Omalizumab is available as a lyophilized powder for injection in single-use, 5-mL vials.

Chronic Obstructive Lung Disease Definition and Epidem iology Chromic obstructive lung disease is characterized by persistent breathing difficulty that is not completely reversible and is progressive over time. It usually is the result of an abnormal inflammatory response to airborne toxic chemicals. T hus, COPD is a general term and most commonly refers to chronic bronchitis and emphysema. Asthma is considered to be a disease entity unto itself and is not included in the definition of COPD. Both COPD and asthma are both considered to be inflammatory diseases; however, the nature of the inflammation is different. Asthma is associated with the release of inflammatory mediators from mast cells and eosinophils, whereas chronic bronchitis is primarily associated with neutrophils and emphysema with alveoli damage. In addition, asthma is more often than not allergenic, whereas chronic bronchitis and emphysema have no allergic component. Finally, it is uncommon for asthma to be associated with smoking, whereas there is a very high incidence of both chronic bronchitis and emphysema in smokers. Patients with COPD display a variety of symptoms, ranging from chronic productive cough to severe dyspnea requiring hospitalization. Other chronic illnesses, including cardiac, endocrine, and renal disease, often occur along with COPD in many patients. In the United States, COPD is the fourth leading cause of death, being responsible for more than 100,000 deaths per year (49). It has been estimated that between 16 and 24 million people in the United States have COPD and that those with chronic bronchitis outnumber those with emphysema. Rates of COPD-related death among women have tripled over the last 30 years, and this is being attributed to their increase in smoking. Chronic obstructive pulmonary disease is recognized as a global health problem, and in 2001, the NIH and the World Health Organization developed the Global Initiative for Chronic Lung Disease (GOLD) guidelines, which present only evidence-based recommendations for the treatment of COPD (50,51).

Pathogenesis T he single most important risk factor for the development of COPD is smoking. It is estimated that 85% of COPD cases are attributable to cigarette smoking. Not all people who smoke, however, develop the disease, which means other factors are involved. It seems that genetics, environmental pollutants, and infection along with bronchial hyperreactivity all play an important role. Cigarette smoke attracts inflammatory cells into the lungs and stimulates the release of the proteolytic enzyme elastase. Elastase breaks down elastin, which is a needed structural component of lung tissue. Normally, the lung is protected from elastase by an inhibitor, α 1 -antitrypsin (AT T ). Cigarette smoke, however, causes an abnormal amount of elastase to be produced that AT T P.1261

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cannot counter, leading to lung damage. Smokers with an inherited deficiency of AT T have a greatly increased risk of developing emphysema, especially at an early age. Patients with COPD show an accelerated decline in lung function (50–90 mL FEV1 /year) as compared to nonsmokers (20–30 mL/year) (see earlier discussion of FEV under General T herapeutic Approaches to the T reatment and Management of Asthma). Patients with COPD who stop smoking slow down the progression of the disease. Unfortunately, however, they do not improve, because the symptoms are an indication of irreparable lung tissue damage. T he role of other risk factors for developing COPD is not clear. Air pollution and occupational exposure to gases and particulates from the incomplete combustion of coal, diesel, and gasoline are related to the development of cough and sputum, but development of COPD seems to occur only in susceptible individuals. Passive cigarette smoke comes from the burning end of the cigarette and actually is higher in toxic substances compared with exhaled smoke. It has been established that respiratory infections as well as cough and sputum production are more common in children who live in households where one or both parents smoke. Chinese and Afro-Caribbean races have a reduced incidence of COPD, whereas COPD in American blacks is on the rise (49). Permanent destructive enlargement of the airspaces distal to the terminal bronchioles without obvious fibrosis is the pathological characteristic of emphysema. On the other hand, chronic bronchitis is characterized by hypersecretion of mucus, most of which is produced by the trachea and first branches of the bronchi. T he smaller bronchi and terminal bronchioles, however, are the site of the increased airway resistance in chronic bronchitis. In the early stages of chronic bronchitis, the mucus and inflammation contribute to “ smoker's cough,” with little effect on airway obstruction. As inflammation continues, cell wall edema and the production of large amounts of mucus contribute to airway narrowing and the difficulty in breathing associated with COPD. Even though bronchospasm may seem to be involved in COPD, there is little related pathogenesis. Chronic obstructive pulmonary disease is a disease of the small airways and their adjacent alveoli. In chronic bronchitis, there are structural changes in the small airways as a result of persistent inflammatory irritation, which leads to airway narrowing. Emphysema on the other hand is the result of loss of lung elastic recoil because of inflammation and alveolar wall destruction. Both diseases often occur together, with one predominate over the other. An important clinical manifestation between chronic bronchitis and emphysema is that there is significant hypoxia and carbon dioxide retention with chronic bronchitis, which does not happen with emphysema. Because of this, emphysema patients are referred to as “ pink puffers,” whereas patients with chronic bronchitis are called “ blue bloaters” (52).

Pharmacotherapy All the medications used to treat COPD have already been covered in the previous section on asthma. T he GOLD guidelines base their treatment protocols on a classification of disease severity divided into five stages (50,51). Stages O and I are defined as “ at risk” (O) and mild COPD (I). In stage O, the patient has normal lung function, with chronic cough and sputum production. T reatment at this stage is to counsel the patient to reduce risks and, especially, to stop smoking. In stage I, there is minor airway limitation, characterized as FEV1 /FVC < 70% but FEV1 ≥ 80% of the predicted value. Stage I treatment is to use a short-acting bronchodilator, usually as needed, but regular use is effective in patients with concurrent asthma. T he most frequently used short-acting bronchodilator is the β 2 -agonist albuterol, although pirbuterol and the anticholinergic ipratropium can be just as effective, but with a slightly longer onset of action. T he patient also should take precautions to avoid bacterial or viral infections by receiving vaccinations against influenza and pneumococcal pneumonia. Stage II COPD is a moderate disease condition in which the patient demonstrates shortness of breath on exertion and spirometry reveals FEV1 /FVC < 70% and FEV1 between 50 and 80% of the predicted value. Stage II drug treatment requires the addition of a long-acting bronchodilator

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along with the short-acting bronchodilator. Salmeterol and formoterol are long-acting β 2 -agonists, and tiotropium is the long-acting anticholinergic most often used. Alternatively, the addition of ipratropium along with the short-acting β 2 -agonist also can be effective at this stage. Extendedrelease theophylline is an option for patients who do not receive adequate relief of symptoms or who cannot tolerate other bronchodilators. Stage III is a severe form of COPD, with FEV1 /FVC < 70% and FEV1 between 30 and 50% of the predicted value. T he patient experiences increasing dyspnea that affects his or her ability to perform routine tasks (i.e., climbing stairs). A course of oral glucocorticoids (i.e., prednisone) may be used to control a severe attack. T he role of inhaled glucocorticoids is not clearly established, and no evidence suggests that an inhaled glucocorticoid has any advantage in patients who can maintain their FEV1 with bronchodilators. As of this writing, no inhaled glucocorticoids are approved for the treatment of COPD; however, there is one combination formulation of fluticasone propionate and salmeterol dosage (250 µg/50 µg) approved for twice-daily administration. Stage IV is the most severe form of COPD, with airflow restriction of FEV1 /FVC < 70% and FEV1 < 30% of the predicted value along with chronic respiratory failure. At this stage, the patient is experiencing debilitating exacerbations that are not controlled by medication and requires P.1262 daily oxygen for respiratory failure. Surgery also is an option, but it is not without serious risks. Surgical options include bullectomy (removal of large blebs in the lungs), lung transplant (uncommon), and lung volume reduction surgery (removal of lung sections affected by emphysema). Patients with emphysema that is associated with AT T deficiencies can receive weekly IV infusions of to maintain acceptable antiprotease activity that can minimize their disease progression. T he three approved AT T products are Aralast, Prolastin, and Zemaira. Because these protein products are derived from human plasma, there is the risk of transmission of viral infection and Creutzfeldt-Jakob disease.

New Drug Classes for Treatment of Asthma and COPD Phosphodiesterase Inhibitors Introduction A number of important therapeutic agents owe their pharmacological action to their ability to inhibit the enzyme PDE. In the treatment of asthma, theophylline, at least in part, relaxes bronchospasm by relaxing bronchiole smooth muscles; amrinone and milrinone are ionotropic agents that relax vasculature, causing vasodilation; sildenafil and vardenafil relax smooth muscle of the vasculature in the penis; dipyramidole inhibits platelet aggregation; and the alkaloid papaverine relieves smooth and cardiac muscle spasms through its ability to inhibit PDE. T hese pharmacological effects are the result of inhibiting the ability of PDE to break down cAMP and cGMP and prolong their action as secondary messengers within a variety of cell types throughout the body. T he PDE inhibitors also are implicated in an anti-inflammatory role by increasing cAMP and cGMP levels in cell types associated with the release of inflammatory chemicals from T and B cells, monocytes, neutrophils, and eosinophils. T his last discovery is the impetus to develop new PDE inhibitors to treat asthma (eosinophils) and COPD (neutrophils).

New Phosphodiesterase Inhibitors Progress in the development of PDE inhibitors to treat COPD and asthma awaited the basic pharmacological research that identified the specific PDE isoforms associated with inflammatory

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cells so that selective inhibitors could be designed and synthesized (53). (For additional discussion of PDE inhibitors and the structural characteristics of the PDE4 binding site, see Chapter 17.) As mentioned earlier, there are 11 families of PDEs, with PDE4 being associated with inflammatory processes. Specifically, three PDE4 subtypes (PDE4A, PDE4B, and PDE4D) are found in inflammatory cells (with PDE4B being predominant). T herefore, recent efforts in this area have been directed toward the development and synthesis of selective PDE4 inhibitors. T wo PDE4 inhibitors are being investigated for their possible use in treating asthma and COPD. In the United States, cilomilast is being investigated for the treatment of COPD, and in Europe, roflumilast is being investigated for the treatment of both asthma and COPD.

Cilomilast

Cilomilast contains the dialkoxyphenyl ring characteristic of selective PDE4 inhibitors. T he ether oxygens hydrogen bond to a glutamine in the binding pocket, and the cyclopentyl ring adds additional hydrophobic interactions. T he oxygen atoms of the carboxyl group form hydrogen bonds with water that is coordinated with Mg 2+ located in the distal end of the binding pocket. Orally administered cilomilast is 96% bioavailable. Food does not interfere with the overall absorption; however, food does slow down the rate. Cilomilast is 99% bound to albumin in the plasma and is metabolized in the liver by CYP2C8. T he metabolism is extensive and results in oxidation, carboxyl group glucuronidation, and dealkylation of the cyclopentyl group, followed by glucuronidation or sulfation. A major difficulty with cilomilast is that in therapeutic doses, patients during clinical trials have experienced significant diarrhea and nausea. T hese effects appear to be tolerable and, theoretically, result from its inhibition of the PDE4D receptor subtype.

Roflumilast

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T he PDE4 receptor binding of roflumilast is similar to that of cilomilast. T he dialkylphenyl oxygens hydrogen bonds to a glutamine deep inside the binding pocket. T he diflouromethoxy group and the cyclopropyl group contribute hydrophobic bonds; however, the cyclopentyl group on cilomilast makes far more interactions compared with the cyclopropyl group. T he water molecule coordinated to the Mg 2+ hydrogen bonds to the dichloropyridyl group just like the carboxylic acid oxygens in cilomilast. T hese structural differences make roflumilast a more potent inhibitor than cilomilast toward PDE4B (54). Roflumilast is well absorbed on oral administration and has a half-life of 10 hours. Roflumilast is metabolized in the liver to its N-oxide derivative, which also is a PDE4 inhibitor, and it has a plasma half-life of 20 hours (see Chapter 17). Roflumilast is currently undergoing clinical trials in Europe for use in the treatment of both asthma and COPD.

Case Study Vic tor ia F. Roc he S. Willia m Zito BJ is a L as Ve g as b lackjac k d e ale r. He is a 3 8 -ye ar-o ld C auc asian man who has mild inte rmittent asthma tre ated with inhale d alb utero l f o r o cc asio nal e xac e rb atio ns. He wo rks nights and sle e p s d uring the day. He s ho ws up at the e me rg e ncy ro o m e arly o ne mo rning c o mp laining that he is no t s le e ping we ll late ly. He s ays he wakes up ab o ut o nc e a we e k g asp ing f or b re ath. I n ad d ition, he has b e e n having inc re as e d e pis o d e s o f acute as thma d uring his jo b, which have caus ed him to use his inhaler at leas t onc e a night. He f ind s that his c lie nts are d is turb e d b y his whe e zing and audib le g urg ling , and he f e ars he will lo se his jo b unle ss s ome thing is d o ne ab o ut it. On f urthe r inq uiry, yo u d e te rmine that BJ is taking p he nyto in (10 0 mg t.i.d .) to c o ntro l the e p ile p s y he has had sinc e he was an ad o le s c ent. The atte nd ing p hysic ian d ete rmine s that BJ 's asthma has p ro g re s se d to the mild p e rs is te nt s tag e and wants to p re sc rib e an app ro p riate me d ic atio n. Evaluate the f o llo wing cho ice s f o r us e in this c as e .

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1. I d e ntif y the therap e utic p ro b le m(s ) in whic h the p harmacis t's inte rve ntio n may b e nef it the p atie nt. 2. I d e ntif y and p rio ritize the p atie nt-s p ec if ic f ac tors that mus t b e co ns id e re d to ac hie ve the d e s ire d the rape utic o utco me s. 3. C ond uct a tho ro ug h and me c hanistic ally o rie nte d s truc ture -ac tivity analys is o f all the rap e utic alte rnative s p ro vid e d in the c ase . 4. Evaluate the SAR f ind ing s ag ains t the p atie nt sp e c if ic f acto rs and d e sire d the rap e utic o utc o me s and make a the rap e utic d e c isio n. 5. C ouns el your p atie nt.

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Chapter 45 Men's Health Duane D. Mille r Robe rt W. Brue gge m e ie r Jam e s T. Dalton

Drugs cov ered in this chapter: T estos ter on e pr o duc ts Oral tes tosterone Methyltestos terone Fluoxymes terone T estos terone este rs T ransd ermal patches T ransd ermal gels Buccal Anabo lic ag ents Nandrolone Oxand rolone Oxymetholo ne Stanozolol T estolactone α 1 -Adr ener g ic An tago nists Alf uzos in Doxazosin T ams ulosin T erazo sin Antian dr og ens Bicalutamide F lutamide Nilutamide In hibito r s of a ndr o gen biosy nthe sis 5 α-Re ductase inhib itors Finas teride Dutas teride 1 7α-Hydroxylase/1 7,20-lyase inhibitors L uteinizing ho rmone–rele asing hormo ne ag onists

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Buse relin Gose relin Leup rolide Dr ugs for tr e atme nt of e r ectile dys function Phosp hodie steras e-5 inhibitors Sildenaf il Varde naf il Tadalaf il Other Drugs Prostagland in E 1 Papaverine Phentolamine

Introduction T his chapter focuses on the physiology, pharmacology, metabolism, and structure–activity relationships for therapeutic and emerging classes of drugs that are used almost exclusively in men. Major differences in endocrine hormones and the anatomy and physiology of the reproductive system and genitourinary tract between males and females make men uniquely susceptible to a variety of disorders, including aging-related androgen insufficiency (hypogonadism and andropause), prostate and testicular cancer, benign prostatic hyperplasia (BPH), and erectile dysfunction (ED). T he majority of these disorders and their treatments are associated with the male sex hormones (i.e., androgens), their pharmacological target (i.e., the androgen receptor [AR]), and the tissues that rely on the androgens. Prostate problems are common in older men, particularly those aged 50 years and older. A man may have prostate problems for a number of reasons, including an infection of the prostate (prostatitis), a noncancerous enlargement of the prostate (BPH), or prostate cancer, the second most common cancer in men. Risk of prostate cancer increases with age; approximately 70 percent of all cases of the disease are diagnosed in men aged 65 years and older. Prostate problems often are discovered by men themselves. T he signs of prostate problems include frequent urge to urinate, blood in the urine, painful or burning urination, difficulty urinating, or inability to urinate. Aging-related androgen insufficiency (male hypogonadism) is a physiological condition characterized by the inability of the testes to produce sufficient testosterone to maintain sexual function, muscle strength, bone mineral density, and fertility (spermatogenesis). One in five men older than 50 years will exhibit symptoms of this condition. Symptoms of aging-related androgen insufficiency may include lethargy or decreased energy, decreased libido or interest in sex, ED (with loss of erections), muscle weakness and aches, inability to sleep, hot flashes, night sweats, depression, infertility, thinning of bones or bone loss, and cardiovascular disease. By the time that men are between the ages of 40 and 55 years, some may experience a phenomenon similar to the female menopause, called andropause. Whether andropause is more common than hypogonadism in the aging male is a matter for debate. T he decline in testosterone occurs very gradually in men over several decades and may be accompanied by loss of bone mass (osteoporosis), loss of muscle mass and strength, and changes in fat distribution, cholesterol levels, spermatogenesis, sexual performance, quality of life, and impotence (i.e., ED). Studies show that a decline in testosterone actually can put men at risk for other health problems, such as heart disease and weak bones. Psychological stress, alcohol abuse, injuries or surgery, medications, obesity and infections, tobacco, and drugs, such as decongestants, antihypertensives, tranquilizers, statins, or antiseizure agents, can contribute to the

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onset of these conditions. T here is no way of predicting who will experience the symptoms of androgen insufficiency that are of sufficient severity to seek medical help; neither is it predictable at what age the symptoms of aging-related androgen insufficiency will occur in a particular individual. Each man's symptoms also may be different. Because all this happens at a time of life when many men begin to question their values, accomplishments, and direction in life, it often is difficult to realize that the changes occurring are related to more than just external conditions. P.1266

Clin ical Signific ance Significant research is currently underway in the area of men's health. In less than a decade, we have gone from having minimally effective pharmacological agents for erectile dysfunction (ED) to having several options. T he widespread use of these phosphodiesterase (PDE5) inhibitors is acknowledged by the fact that Viagra (sildenafil) was one of the T op 200 drugs dispensed in 2004. T here are advantages and disadvantages to each of these PDE5 inhibitors. Some can be taken with food and other cannot. Some have optimal durations of action, and others are much shorter. All, however, have been known to have adverse effects and drug interactions in common. Some of these adverse effects can be rather severe, and the drug interactions with nitrates can be fatal. T he development of newer, more effective, and less deleterious agents is essential for ED. Agents that are more selective for PDE5 and avoid other PDEs are critical to this endeavor. By studying the structure–activity relationships between the PDEs and the inhibitors, this can be achieved. Minor changes to the side chains or functional groups of the currently available PDE inhibitors can potentially eliminate the adverse effects and drug interactions that limit the use of these agents. As new agents become available, clinicians continually compare and contrast these new agents to the ones that are currently available in an effort to improve patient care. T his is an ongoing, joint effort by chemists and clinicians alike to optimize patient care either indirectly or directly by continually making adjustments to either chemical structures or therapeutic treatment plans for the patient. Catherine L. Hatfield Pharm.D. Cl i ni cal Assi stant Professor, Department of Cl i ni cal Sci ences and Admi ni strati ons, Uni versi ty of Houston, Col l ege of Pharmacy

Now that men are living longer, there is heightened interest in aging-related androgen insufficiency, its risks for other health problems, and its treatment. T esticular cancer is the most common form of cancer among males aged 15 to 44 years and is approximately four times more common in white men than in African–American men. After motor vehicle accidents and suicide, cancer is the leading cause of death in this age group, followed by homicide, heart disease, and HIV. T esticular cancer is known as “ young man's cancer.” Early detection is the key to survival. T esticular cancer is androgen-dependent, with a very fast onset. because the tumors can be very aggressive. When the cancer is confined to the testicles, there often is no pain, but by the time pain develops, it often is a sign that the cancer has already spread. Survival rates increase significantly if treatment has begun before the cancer has a chance to metastasize. T esticular cancer most often is discovered by men. T herefore, all men should conduct testicular self-examinations at least monthly and, preferably, every time they shower for any changes or lumps and to see a doctor immediately if any changes noted. T he diagnosis is noninvasive and involves using ultrasound to look at the density, size, and shape of the testicles and other masses in the scrotum.

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Men who experience any of these symptoms associated with the prostate, aging-related androgen insufficiency, and testicular cancer should see a doctor to find out the cause of the problem and to talk about possible treatment. T he discovery and clinical development of selective estrogen receptor modulators transformed the therapeutic use of estrogens (1). Similarly, nonsteroidal selective AR modulators (SARMs), with the ability to selectively stimulate or maintain muscle and bone mass or to reduce prostate mass in BPH without the androgenic effects of testosterone and 5α-dihydrotestosterone (DHT ), now are leading a similar revolution in the therapeutic use of androgens. T he discovery of SARMs not only provides a potentially significant therapeutic advance for androgen replacement therapy but also provides model compounds to further study the molecular mechanism of action of the AR (2). Results from in vitro and in vivo animal studies suggest that the therapeutic promise of SARMs as a treatment of muscle wasting, osteoporosis, hormonal male contraception, and BPH may be soon realized. T estosterone and its metabolite, DHT , are the primary endogenous androgens and play crucial physiological roles in establishing and maintaining the male phenotype (3). T heir actions are essential for the differentiation and growth of male reproductive organs, initiation and regulation of spermatogenesis, and control of male sexual behavior. In addition, androgens are important for the development of male characteristics in certain extragenital structures, such as muscle, bone, hair, larynx, skin, lipid tissue, and kidney (4). In females, the precise physiological roles of androgens are not completely understood, but the aging-related decline in circulating androgen levels has been linked to symptoms such as decreased libido and sexuality, lack of vigor, diminished well-being, and loss of bone mineral density in postmenopausal women (5,6,7).

T he Sex Horm ones T he sex steroid hormones are steroid molecules that are necessary for reproduction in females and males and that affect the development of secondary sex characteristics in both sexes. T he sex steroids are comprised of three P.1267 classes: estrogens, progestins, and androgens (Fig. 45.1). T he two principal classes of female sex steroid hormones are estrogens and progestins (for further discussion, see Chapter 46). Chemically, the naturally occurring estrogens are C-18 steroids and have in common a planar unsaturated A ring with a 3-phenolic group that aids in separation and purification from nonphenolic substances. T he most potent endogenous estrogen is estradiol (Fig. 45.1). T he naturally occurring progestins are C 21 steroids and have in common a 3-keto-4-ene structure in the A ring and a ketone at the C-21 position. T he most potent endogenous progestin is progesterone (Fig. 45.1). T he principal class of the male sex steroid hormone is the androgens. T he naturally occurring androgens are C-19 steroids and have in common oxygen atoms (as either hydroxyl or ketone groups) at both the C-3 and C-17 positions. T he potent androgen found in the blood is testosterone (Fig. 45.1), with the more potent metabolite formed in certain androgen target tissues being DHT (Fig. 45.1). All three classes of endogenous steroids are present in both males and females. T he production and circulating plasma levels of estrogens and progestins are higher in females, however, and the production and circulating plasma levels of androgens are higher in males.

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Fig. 45.1. The sex hormones.

Discovery of Androgens One of the early and unusual experiments with testicular extracts was carried out in 1889 by the French physiologist Brown-Séquard. He administered such an extract to himself and reported that he felt an increased vigor and capacity for work (8). In 1911, Pézard showed that extracts of testicular tissue increase comb growth in capons (9). Early attempts to isolate pure male hormones from the testes failed, because only small amounts are present in this tissue. T he earliest report of an isolated androgen was presented by Butenandt (10) in 1931. He isolated 15 mg of crystalline androsterone from 15,000 L of human male urine. A second crystalline compound, dehydroepiandrosterone, which has weak androgenic activity, was isolated by Butenandt and Dannenberg (11) in 1934. During the following year, testosterone was isolated from bull testes by David et al. (12). T his hormone was shown to be 6 to 10 times as active as androsterone. Shortly after testosterone was isolated, Butenandt and Hanisch (13) reported its synthesis. In that same year, extracts of urine from males were shown to cause nitrogen retention as well as the expected androgenic effects (14). Many steroids with androgenic activity have subsequently been synthesized. Steroid hormones may have many potent effects on various tissues, and slight chemical alterations of androgenic steroids may increase some of these effects without altering others. T estosterone was the first androgen to be used clinically for its anabolic activity. New sources of the hormone were needed, however, because only 270 mg could be isolated from a ton of bull testes (15). Commercially, testosterone is prepared from various steroids, including sarsasapogenin, diosgenin, and certain androgens found in stallion urine. Because of its androgenic action, testosterone is limited in its use in humans as an anabolic steroid. Many steroids were synthesized in an attempt to separate the androgenic and the anabolic actions. Because testosterone had to be given parenterally, it also was desirable to find orally active agents. In the United States, most of the androgens and anabolic steroid products are subject to control by the U.S. Federal Control Substances Act as amended by the Anabolic Steroid Control Act of 1990 as Schedule III drugs.

Androgen Physiology T he overall physiological effects of endogenous androgens are contributed by testosterone and its

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active metabolites, DHT and estradiol. T estosterone and DHT execute their actions predominantly through the AR, which belongs to the nuclear receptor superfamily and functions as a liganddependent transcription factor. Circulating testosterone is essential for the differentiation and growth of male accessory reproductive organs (e.g., prostate and seminal vesicles), control of male sexual behavior, and the development and maintenance of male secondary characteristics that involve muscle, bone, larynx, and hair. Healthy young adult men produce approximately 3 to 10 mg of testosterone per day, with circulating plasma levels ranging from approximately 500 to 1,000 ng/dL in eugonadal (normal) men. Circulating testosterone participates in the feedback regulation of androgen production by the hypothalamus- pituitary-testis axis, as shown in Figure 45.2. T estosterone, luteinizing hormone (LH), and LH-releasing hormone (LHRH; a.k.a. gonadotropin-releasing hormone) constitute the elements of a negative feedback control mechanism, whereby testosterone controls its own release. Low circulating testosterone levels increase the hypothalamic secretion of LHRH, which leads to increased production of LH and, consequently, increased testosterone production by the Leydig cells. More than 95% of circulating testosterone is synthesized and secreted by the Leydig P.1268 cells in the testes. High testosterone levels, on the other hand, inhibit LHRH release, thus suppressing both LH secretion and testosterone secretion. T he LHRH is released from the hypothalamus in short, intermittent pulses every 2 hours and at greater magnitude in the morning, which in turn stimulates the pulsatile secretion of LH and follicle-stimulating hormone (FSH) from the pituitary. Follicle-stimulating hormone stimulates the Sertoli cells controlling spermatogenesis and development of the testis. T hus, testosterone secretion likewise is pulsatile and diurnal, with the highest concentration occurring at approximately 8:00 AM and the lowest at approximately 8:00 PM. In older men, especially those older than 60 years, the body does not produce enough testosterone that is needed to do all the intended work, and the testosterone levels remain relatively constant, without the morning pulses observed in young adult men. Average plasma testosterone concentrations in older men peak in the morning, with daily ranges of approximately 300 to 550 ng/dL by 70 years of age. T he diurnal cycling is blunted as men age (16). In women, testosterone levels range from 15 to 100 ng/dL. Starting at approximately 40 years of age, testosterone levels drop by approximately 10 percent every decade. In the normal functioning of the male hormonal system, 97 to 98% of plasma testosterone is bound to sex hormone binding globulin, making it unavailable to the body's tissues. T he remaining 2 to 3% is known as “ bioavailable” or free testosterone. Furthermore, the receptor sites where testosterone must bind to be effective also can be occupied by estradiol, an estrogen also found in men that increases with age and body weight.

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Fig. 45.2. Hypothalamus-pituitary-testicular axis. (+), positive control; (–), negative feedback control.

In the testis, FSH directly interacts with FSH receptors expressed in Sertoli cells and stimulates spermatogenesis, whereas LH indirectly stimulates spermatogenesis through testosterone synthesized by Leydig cells. T estosterone and its aromatized metabolite (estradiol) negatively regulate circulating levels of testosterone in the hypothalamus and pituitary. Activin and inhibin produced by Sertoli cells stimulate or inhibit, respectively, the secretion of FSH from the pituitary (17). High concentrations of intratesticular testosterone are essential for the initiation and maintenance of spermatogenesis, as evidenced by the infertility of hypogonadal men. Results from both animal models and humans, however, support the idea that both FSH and testosterone are required to achieve quantitative and qualitative spermatogenesis. Androgens also are needed for the development of secondary sex characteristics. T he male voice deepens because of thickening of the laryngeal mucosa and lengthening of the vocal cords. In both men and women, they play a role first in stimulating the growth of hair on the face, arms, legs, and pubic areas and later in the recession of the male hairline. T he fructose content of human semen and both the size and the secretory capacity of the sebaceous glands also depend on the levels of testosterone. T estosterone causes nitrogen retention by increasing the rate of protein synthesis and muscle mass while decreasing the rate of protein catabolism. T he positive nitrogen balance therefore results from both decreased catabolism and increased anabolism of proteins that are used in male sex accessory apparatus and muscle. T he actions of androgen in the reproductive tissues, including prostate, seminal vesicle, testis, and accessory structures, are known as the androgenic effects, whereas the nitrogen-retaining effects of androgen in muscle and bone are known as the anabolic effects. Although the precise mechanism of androgen action on muscle remains unknown, the common hypothesis is that androgens promote muscle protein synthesis. Evidence supports the idea that testosterone supplementation increases muscle protein synthesis in elderly men (18) and young hypogonadal men (19). Also, androgen-induced increases in muscle mass appear to arise from muscle fiber hypertrophy rather than hyperplasia (i.e., cellular enlargement rather than cellular

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proliferation) (20). T he thickness and linear growth of bones are stimulated and, later, limited by testosterone because of closure of the epiphyses. Androgens affect bone mineral density by changing overall osteoblast (bone-forming cell) activity and osteoclast (bone-resorbing cell) activity, resulting from changes in the total number of each cell type and individual cell functional capacity (21,22). Androgens seem to have the ability to decelerate the bone remodeling cycle and tilt the focal balance of that cycle toward bone formation. T he loss of androgens is thought to increase the rate of bone remodeling by removing the restraining effects on osteoblastogenesis and osteoclastogenesis.

Androgen Biosynthesis T he major pathways for the biosynthesis of the sex steroid hormones are summarized in Figure 45.3. Cholesterol is P.1269 stored in endocrine tissues and is converted to androgen, estrogen, or progesterone when the tissue is stimulated by a gonadotropic hormone. Androgens (male sex hormones) primarily are synthesized from cholesterol in the testes, whereas estrogens are biosynthesized chiefly in the ovary in mature, premenopausal women. T his is not surprising, because androgens are intermediates in the biosynthesis of estrogens. In the liver, androgens are formed from C-21 steroids. During pregnancy, the placenta is the main source of estrogen biosynthesis and pathways for production change (23,24). Small amounts of these hormones also are synthesized by the adrenal cortex, the hypothalamus, and the anterior pituitary in both sexes. T he major source of estrogens in both postmenopausal women and men is adipose tissue (25).

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Fig. 45.3. Biosynthesis of androgens and other sex steroid hormones. The enzymes involved in this biosynthesis are (a) side-chain cleavage, (b) 17α-hydroxylase (c) 5-ene-3β-hydroxysteroid dehydrogenase, (d) 3-oxosteroid-4,5-isomerase, (e) 17,20-lyase, (f) 17β-hydroxysteroid dehydrogenase, (g) aromatase, (h) estradiol dehydrogenase, and (i) 5α-reductase.

Luteinizing hormone binds to its receptor on the surface of the Leydig cells to initiate testosterone biosynthesis. As in other endocrine cells, the binding of gonadotropin activates the G S signal transduction pathway, increasing intracellular cyclic adenosine monophosphate (cAMP) levels via activation of adenylate cyclase. One of the processes influenced by elevated cAMP levels is the

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activation of cholesterol esterase, which cleaves cholesterol esters and liberates free cholesterol. T he free cholesterol is then converted in mitochondria to pregnenolone via the side-chain cleavage reaction (Fig. 45.3). Pregnenolone is converted by 17α-hydroxylase to 17α-hydroxypregnenolone and then to dehydroepiandrosterone (DHEA; a C-19 steroid) via 17-20 lyase, which involves cleavage of the C-17 to C-20 carbon–carbon bond and loss of the 17β-acetyl side chain (26). T he 17α-hydroxylase is found in the endoplasmic reticulum membrane and is comprised of the cytochrome P450 17α protein and the ubiquitous NADPH-cytochrome P450 reductase. Cytochrome P450 17α is expressed by the CYP17 gene found on chromosome 10 in humans. Alternatively, progesterone can be formed from pregnenolone via the action of 5-ene-3β-hydroxysteroid dehydrogenase and P.1270 3-oxosteroid-4,5-isomerase. T hese same enzymes are responsible for the conversion of DHEA to the 17-ketosteroidal androgen, androstenedione.

Fig. 45.4. Aromatase mechanism.

T estosterone is formed by reduction of the 17-ketone of androstenedione by 17β-hydroxysteroid dehydrogenase (27,28). T estosterone and androstenedione are metabolically interconvertible. Loss of the C-19 angular methyl group and aromatization of the A ring of testosterone or androstenedione is catalyzed by the microsomal cytochrome P450 enzyme complex, called aromatase, and results in the C-18 steroids—namely, 17β-estradiol or estrone, respectively—as shown in Figure 45.4. 17β-Estradiol and estrone are metabolically interconvertible, catalyzed by estradiol dehydrogenase. Research interests in the aromatization reaction continue to expand from basic endocrinology and reproductive biology studies to aromatase inhibition for the treatment of estrogen-dependent cancers, as illustrated in several conferences and reviews (29,30,31,32). Androstenedione is the preferred substrate for aromatization, and three molecules of NADPH and three molecules of oxygen are necessary for conversion of one molecule of androgen to estrogen (33). T he most potent endogenous androgen is the 5α-reduced steroid, DHT , which is biosynthesized by two 5α-reductase isoforms, T ype 1 and T ype 2 (Fig. 45.1). T ype 1 5α-reductase is expressed predominantly in sebaceous glands of the skin, scalp, and liver. T ype 1 5α-reductase is responsible for approximately one-third of the circulating DHT . T ype 2 5α-reductase is found primarily in prostate, seminal vesicles, epididymides, genital skin (scrotum), hair follicles, and liver, and it is responsible for two-thirds of the circulating DHT . Approximately 6 to 8% of testosterone is converted to DHT . 5α-Reductase has been found in both the microsomal fraction and the nuclear membrane of homogenized target tissues, and it catalyzes an irreversible reduction reaction, which requires

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NADPH as a cofactor, that provides the α-hydrogen at C-5 (34,35). Conversion to DHT amplifies the action of testosterone by three to five times because of the greater binding affinity of DHT as compared to testosterone for the ARs (36).

Androgen Metabolism T estosterone can be metabolized in either its target tissues or the liver (37,38,39), as shown in Figure 45.5. In androgen target tissues, testosterone can be converted to physiologically active metabolites. In the prostate gland, skin, and liver (40), testosterone is reduced to DHT by 5α-reductase (T ypes 1 and 2) (41). On the other hand, a small amount of testosterone (0.3%) also can be converted to estradiol by aromatase through cleavage of the C-19 methyl group, and aromatization of ring A, which mainly occurs in adipose tissue. T his process also occurs in the ovaries of women. In men, approximately 80% of the circulating estrogen arises from aromatization of testosterone in the adipose tissue (42), with the other 20% being secreted by the Leydig cells in the testes (43). Both 5α-reduction and aromatization are irreversible processes. In addition to these pathways, testosterone also can be further inactivated in the liver through reduction and oxidation, followed by glucuronidation and renal excretion. It can be metabolized to androstenedione through oxidation of the 17β-OH group and to androstanedione with 5α-reduction of ring A. Androstanedione can be further converted to androsterone after 3-keto group reduction. Alternatively, androstenedione also can be converted to etiocholanolone through 5β- and 3-keto reduction. Similarly, DHT can be converted to androstanedione, androsterone, and androstanediol (44). After the administration of radiolabeled testosterone, approximately 90% of the radioactivity is found in the urine, and 6% is recovered in the feces through enterohepatic circulation (45). Major urinary metabolites include androsterone and its 5α-diastereoisomer etiocholanolone, both of which are inactive metabolites. T hey are excreted mainly as glucuronide conjugates or, to a lesser extent, as sulfate conjugates (46). T he reduction of testosterone to its ci s A/B ring juncture (5β) conformation, etiocholanolone, explains its complete loss of activity, because the ci s A/B ring no longer has affinity for the AR, as shown in Figure 45.6. Most of the other metabolites mentioned above undergo extensive glucuronidation of P.1271 the 3α- or 17β-OH groups as well, either in the target tissues or in the liver (46), and are further excreted in the urine. T herefore, following oral administration, the plasma testosterone half-life is less than 30 minutes because of extensive hepatic metabolism. Approximately 90% of an oral dose of testosterone undergoes first-pass metabolism before it reaches the systemic circulation. A number of minor metabolites of testosterone also have been isolated from urine and identified as 5α-androstanes and 5β-androstanes with a 3α-hydroxyl function. Most 17-ketosteroids isolated from the urine result from catabolism of the adrenocorticoids rather than from metabolism of androgens.

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Fig. 45.5. Testosterone metabolism. G, glucuronide; HSD, hydroxy steroid dehydrogenase; UGT, uridine diphosphoglucuronosyltransferase.

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Fig. 45.6. Conformations of dihydrotestosterone (DHT), testosterone (T), and etiocholanolone A and B rings.

Mechanism s of Androgen Action T estosterone, DHT , and other androgens execute their actions predominantly through the AR. T he AR is mainly expressed in androgen target tissues, such as the prostate, skeletal muscle, liver, and central nervous system, with the highest expression level being observed in the prostate, adrenal gland, and epididymis (47). T estosterone binds preferentially to the AR in muscle, bone, brain, and bone marrow, whereas DHT binds to the AR in genitalia, prostate, skin, and hair follicles. It is a member of the steroid and nuclear receptor superfamily, which is composed of more than 100 members and continues to grow. Among this large family of proteins, only five vertebrate steroid receptors (estrogen, progesterone, androgen, glucocorticoid, and mineralocorticoid receptors) are known. Like other steroid receptors, AR is a soluble protein that functions as an intracellular transcriptional factor. T he P.1272 AR function is regulated by the binding of androgens, which initiates sequential conformational changes of the receptor that affect receptor–protein interaction and receptor–DNA interactions (48). T he AR gene is more than 90 kb long and codes for a protein of 919 amino acids that has three major functional domains, as illustrated in Figure 45.7. T he N-terminal domain, which serves a modulatory function, is encoded by exon 1 (1,586 bp). T he DNA binding domain (DBD) is encoded by exons 2 and 3 (152 and 117 bp, respectively). T he ligand binding domain (LBD) is encoded by five exons, which vary from 131 to 288 bp in size. T here also is a small hinge region between the DBD and LBD. T wo transactivation functions have been identified. T he N-terminal activation function (AF1) is not conserved in sequence and is ligand-independent (constitutively active), whereas the C-terminal activation function (AF2) is conserved in sequence and functions in a ligand-dependent manner (49). A nuclear localization signal spans the region between the DBD and the hinge region. Similar to the other steroid receptors, unbound AR is mainly located in the cytoplasm and associated with a complex of heat shock proteins through interactions with LBD (50). On agonist binding (51), AR goes through a series of conformational changes: T he heat shock proteins dissociate from AR, and the transformed AR undergoes dimerization, phosphorylation, and translocation to the nucleus, which is mediated by the nuclear localization signal, as shown in Figure 45.7. T ranslocated receptor

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then binds to androgen-response elements (AREs) in DNA, which are characterized by a six-nucleotide half-site consensus sequence 5′-T GT T CT -3′ spaced by three random nucleotides and are located in the promoter or enhancer region of AR gene targets. Recruitment of other transcription coregulators (including coactivators and corepressors) and transcriptional machinery further ensures the transactivation of AR-regulated gene expression. All these complicated processes are initiated by the ligand-induced conformational changes in the LBD.

Fig. 45.7. Structural domains of the androgen receptor gene and protein.

Ligand-induced AR conformational changes provide the structural basis for the recruitment of cofactor proteins and transcriptional machinery, which also is required for the assembly of AR-mediated transcription complexes (52), as shown in Figure 45.8. T he formation of an activation complex is known to involve AR, coactivators, and RNA polymerase II recruitment to both the enhancer and promoter, whereas the formation of a repression complex involves factors bound only at the promoter and not at the enhancer. Because the formation of a functional AF2 region provides a structural basis for ligand-induced protein–protein interaction, ligand-specific recruitment of coregulators might be crucial for the agonist or antagonist activity of AR ligands. Binding of DNA also is required for AR-regulated gene expression, which is known as the classic genomic function of AR. T he ARE half-site sequence can be arranged either as inverted repeats or as direct repeats (52,53), and AR recognizes and binds to the ARE site through two zinc fingers located in the DBD. Like other steroid receptors, ligand-bound AR forms homodimers and appears to form “ head-to-head” dimers (54) even when it is bound to the direct repeats of ARE. Selective recognition of specific ARE sequences could be regulated by ligand binding (55) and/or the presence of other transcriptional factors, which bind to their own DNA binding sites as well (combinatorial regulation) (56). Besides the genomic pathway, the nongenomic pathway of AR also has been reported in oocytes (57), skeletal muscle cells (58), osteoblasts (59,60), and prostate cancer cells (61,62). As compared to the genomic pathway, the nongenomic actions of steroid receptors are characterized by the rapidity of the action, which varies from seconds to an hour or so, and by interaction with plasma membrane–associated signaling pathways (63). Nevertheless, the structural basis for nongenomic action is direct interactions between AR and cytosolic proteins from different signaling pathways, which could be closely P.1273

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related to the ligand-induced conformational change of the LBD or, indirectly, the N-terminal domain. Functionally, the nongenomic action of androgen involves either rapid activation of kinase-signaling cascades or modulation of intracellular calcium levels, which could be related to stimulation of gap junction communication, neuronal plasticity, and aortic relaxation (64). Separation of the genomic and nongenomic functions of steroid receptors using specific ligands also was proposed as a new strategy to achieve tissue selectivity (63,65).

Fig. 45.8. Mechanism of androgen action. The androgen receptor (AR) is maintained in an inactive complex by heat shock protein (HSP) 70, HSP 90, and corepressors (CoR). On ligand binding, it homodimerizes and enters the nucleus. The receptor is basally phosphorylated (P) in the absence of hormone, and hormone binding increases the phosphorylation status of the receptor. The AR binds to the androgen-response element (ARE) on the promoter of androgen responsive genes, leading to the recruitment of coactivators (CoA) and general transcription factors (GTF), leading to gene transcription.

Drugs Used in the T reatm ent of Aging-Related Androgen Insufficiencies M ale Hypogonadism Male hypogonadism (testosterone deficiency) is the inability of the testes to produce sufficient testosterone to maintain sexual function, muscle strength, bone mineral density, and fertility (spermatogenesis). In men, there is a gradual decline of approximately 1% per year in the production of testosterone beginning around 40 years of age. For most men, testosterone levels naturally decline with advancing age but still remain within the physiological range throughout their lifetimes, causing no significant problems. Approximately 20% of men older than age 60 years and 30 to 40% of men older than 80 years have plasma testosterone levels indicative of hypogonadism (< 325 ng/dL). Male hypogonadism is most commonly primary hypogonadism (testicular failure to produce testosterone for various reasons), secondary hypogonadism (hypothalamic-pituitary failure to stimulate testicles to produce testosterone), or a combination of both.

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T estosterone and structurally related steroidal androgens have been used for decades to treat male hypogonadism, Klinefelter's syndrome (a chromosomal abnormality resulting in testicular dysfunction), anemia secondary to chronic renal failure, aplastic anemia, protein wasting diseases associated with cancer, burns, traumas, AIDS, short stature, breast cancer (as an antiestrogen), or hereditary angioedema (46). However, these agents have been demoted to the therapy of final resort because of serious hepatotoxicity and the recent development of more effective therapies (e.g., erythropoietin, aromatase inhibitors, and taxanes). Although severe hypogonadism is uncommon, aging-related androgen insufficiency is much more frequent. Low endogenous testosterone concentrations are associated with sarcopenia and frailty arising from decreased fat-free mass, lessened muscle strength, and reduced bone mineral density (osteoporosis). Low testosterone concentrations also are associated with decreased sexual libido and ED. More than 30 million men older than 40 years in the United States are estimated to suffer from ED. Although androgens are not essential for erection (66), transdermal and intramuscular (IM) testosterone replacement therapy often is employed in hypogonadal men with ED (67). Furthermore, selective phosphodiesterase (PDE5) inhibitors that increase penile blood flow are considered to be the treatment of choice for men with ED. Hormone replacement therapy with testosterone in aging men also improves body composition, bone and cartilage metabolism, and memory and cognition, and it even decreases cardiovascular risk (68). P.1274 Low testosterone concentrations frequently are seen in patients with ED, aging, type II diabetes, HIV/AIDS, osteoporosis, depression, obesity, alcohol abuse, anabolic steroid abuse, chronic inflammatory disease, cancer, and glucocorticoid use.

Andropause Andropause was first described in the medical literature in the 1940s, but the ability to diagnose it is relatively new. T he idea that men, as well as women, might be subject to sex hormone fluctuations in later life has been a topic of debate among endocrinologists and men's health professionals (69). Andropause affects men between the ages of 40 and 55 years, but unlike women, men do not have a clear-cut signpost, such as the cessation of menstruation to mark this transition. Men's “ transition” may be much more gradual and expand over many decades, and men will very likely experience andropausal symptoms to include ED, loss of muscle mass, irritability, generalized fatigue, and even problems with memory and cognition. A decline in testosterone levels will occur in virtually all men, and there is no way of predicting who will experience andropausal symptoms of sufficient severity to seek medical help. It is estimated that 30% of men in their fifties, and up to 50% of men older than 65 years, will have testosterone levels low enough to cause noticeable symptoms. Once andropause is discovered, the process of replacing the missing testosterone is either by injection, locally applied hormone gel, transdermal patch, or implanted cartridge.

Testosterone Replacement Therapy T he acceptance of testosterone replacement therapy (T RT ) has been hampered by the lack of orally active preparations with good efficacy and, particularly, a safe profile (70). Progress has been limited over the last three decades in developing synthetic molecules that could separate the desirable physiological functions normally regulated by endogenous androgens from the undesirable or dose-limiting side effects. T he abuse of synthetic anabolic steroids by athletes and body builders has contributed to the general perception of certain undesirable side effects, such as aggressive behavior, liver toxicity, acne or impotency.

Table 45.1. Testosterone Replacement Therapy Benefits

Risks

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Improved sexual performance and desire

Stimulated growth of preexisting prostate cancer

More energy and improved quality of life

Greater chance for benign prostatic hyperplasia

More energy and sense of well-being

Increased hemoglobin levels to above the physiological range

Increased bone mineral density Improved muscle mass strength

Problems with voiding; symptoms includes poor urine flow and hesitancy before urinating

Improved (lower) low-density lipoprotein profile

Increased potential for liver damage from oral preparations Sleep apnea (stopping of breathing during sleep)

Decreased irritability and depression

Breast tenderness and swelling (gynecomastia)

Improved cognitive function

Testicular shrinkage (testicular atrophy)

Increased hemoglobin levels to the physiological range

Infertility (decreased spermatogenesis) Skin reaction from patches or gel

Thickened body hair and skin

Pain, soreness, or bruising from injection Increased fluid retention Increased skin problems (acne, oily skin) Increased body hair

Current androgenic formulations for T RT largely are restricted to injectable formulations of testosterone esters, transdermal delivery formulations (scrotal or nonscrotal patches or gel), or buccal testosterone. Marketed injectable forms of testosterone esters (e.g., testosterone enanthate, propionate, or cypionate) produce undesirable fluctuations in testosterone blood levels, with supraphysiological concentrations early and subphysiological levels toward the end of the period before the next injection. T hese fluctuations provide an unsatisfactory benefits profile and, in some cases, undesired side effects. Skin patches provide a better blood level profile of testosterone, but skin irritation and daily application limit the usefulness and acceptability of this form of therapy. Oral

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preparations such as fluoxymesterone and 17α-methyltestosterone are not currently used because of concerns about liver toxicity linked to the 17α-alkyl group and because of somewhat lower efficacy (70). T hus, these oral androgens are considered to be obsolete and do not represent a viable form of therapy.

Benefits and Risks of Testosterone Replacement Therapy Multiple large-scale and long-term clinical trials of T RT have been conducted in aging men to evaluate the risk–benefit ratio of T RT in aging men, but no agreement exists regarding the benefits and risks of T RT (T able 45.1) (for review, see (69,70). T he potential benefits of T RT include increase in bone mineral density as well as improvement in muscle mass and strength, cognitive function, mood, and sexual function. T he potential risks of T RT , however, including those in the cardiovascular system, blood (e.g., hematocrit and hemoglobin levels), and prostate, are routinely experienced. An P.1275 emerging class of drugs known as SARMs may soon transform the therapeutic landscape of androgen use by selectively stimulating anabolic targets and avoiding steroid- related side effects. Because of the long-term effects of T RT in otherwise healthy men remain unclear, the Institute of Medicine recommends that T RT not be used to prevent or to relieve the physical or psychological effects of aging (71). Clearly, T RT is beneficial for hypogonadal men with androgen insufficiency to restore sexual function and muscle strength, to prevent bone loss, and to protect against heart disease (atherosclerosis) (70). Increasing testosterone levels with T RT , however, may pose problems by stimulating the growth of the prostate. Long-term T RT could cause prostate gland enlargement, which might fuel the growth of prostate cancer that is already present and could cause breast enlargement in men (gynecomastia). T his is especially worrisome, because prostate cancer is common in older men and many men may have prostate cancer that is undiagnosed. In elderly men, testosterone effects on muscle mass and strength have not been consistent or impressive, possibly because of the low dosages used in clinical trials. T he high correlation between the dose (and plasma concentration) and the anabolic actions of androgen in muscle suggests that androgen administration of higher doses in elderly men may significantly increase muscle mass and strength, but high doses might increase the adverse effects and the aromatization of testosterone to estrogen.

Types of Testosterone Replacement Therapy Several types of T RT exist. Choosing a specific therapy depends on the patient's preference of a particular delivery system, the side effects, and the cost. T ypes include injection, transdermal, buccal mucosal, and oral (T able 45.2).

Injection Because orally administered testosterone is ineffective in the treatment of male androgen insufficiency syndromes as a result of extensive presystemic first-pass metabolism, IM injections bypass the problems of first-pass metabolism. Intramuscular testosterone injections are depot esters that undergo differing rates of in vivo ester hydrolysis to release free testosterone over an extended period of time. T ypically, the depot esters are administered IM into a large muscle once every 2 to 4 weeks depending on the depot ester used (T able 45.2). T hey are safe, effective, and the least expensive androgen preparations available. T he major disadvantage with the IM route for the depot esters is that testosterone plasma concentrations exhibit a saw-toothed pattern, with supraphysiological levels within 2 to 4 days following the IM injection and subphysiological levels before the next injection. A more satisfactory physiological replacement therapy without the fluctuations in free testosterone plasma levels would be to IM administer a lower dose (i.e., 100 mg) on a weekly or biweekly schedule. Because IM injection of testosterone or its esters causes local

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irritation, the rate of absorption may be erratic. Among the esters of testosterone available for IM administration include the 17β-propionate, 17β-enanthate, and the cypionate (17β-cyclopentylpropionate) (Fig. 45.9). T estosterone enanthate and cypionate are the depot esters commonly used with comparable pharmacokinetics. T estosterone enanthate (Delasteryl) is formed by esterification of the 17β-hydroxy group of testosterone with heptanoic acid and testosterone cypionate with cyclopentanepropionic acid. Sterile solutions of these esters are available in a suitable vegetable oil, such as cottonseed oil. Unlike oral testosterone, with a half-life of 10 to 100 minutes, IM testosterone administration avoids first-pass metabolism. Generally, the amount of sex hormone binding globulin in plasma determines the distribution of testosterone between free and bound forms, and free testosterone concentrations determine the drug's half-life. T he bulky cypionate and enanthate esters of testosterone have a duration of action of up to 2 to 4 weeks, whereas the shorter propionate ester has a shorter duration of action of 1 to 2 weeks. Doses may be adjusted by aiming for midphysiological (400–600 ng/dL) testosterone values after 1 week or at the low end (300–400 ng/dL) just before the next injection is due.

Transdermal T ransdermal T RT systems are, perhaps, the most commonly used systems for delivering testosterone to bypass the rapid first-pass metabolism associated with oral testosterone. Clinical studies have shown that these formulations are effective forms of testosterone replacement, with peak response within 3 to 6 months. Discontinue use of the transdermal formulation if the desired response is not reached within this time period. Skin irritation is more common with the transdermal formulations, with more than 50% experiencing some form of skin irritation at some point during the treatment. Pretreatment with corticosteroid creams (not with the ointment) has been shown to reduce the severity and incidence of skin irritation without significantly affecting testosterone absorption from the formulation. With the transdermal formulations, testosterone levels were maintained within physiological values, and a beneficial effect was observed on general mood and sexual functioning. A plasma concentration in the midphysiological range (400–600 ng/dL) is the goal.

Matrix-T ype Transdermal Systems T his type of patch (scrotal patch; T estoderm®) must be applied to dry, clean (shaven) scrotal skin, which is 5 to 30 times more permeable to testosterone than other skin sites, every 24 hours to produce an adequate testosterone plasma concentration. T he matrix system is described as a “ drugin-adhesive film,” in which the drug is located on the adhesive layer of the film; thus, it is thinner and less bulky than the reservoir system. T he advantage of the matrix system is that it produces supraphysiological levels of DHT P.1276 P.1277 because of the high 5α-reductase enzyme activity of the scrotal tissue. T he patches have an occlusive backing that prevents sex partners from coming in contact with the active drug. A matrix transdermal system will not produce adequate plasma testosterone concentrations if applied to nonscrotal skin. Plasma testosterone concentrations are reached in approximately 2 to 4 hours. Although testosterone is absorbed throughout a 24-hour period, concentrations do not simulate the circadian rhythm of endogenous testosterone in normal (eugonadal) males. Within 24 hours after application of the matrix system, plasma testosterone concentration gradually falls to 60 to 80% of the peak plasma concentration, and when the system is removed, testosterone plasma concentration declines to baseline within 2 hours. Inadequate scrotal size and adherence problems are limitations. Skin irritation does occur in those with sensitive scrotal skins.

Table 45.2. Testosterone Products and Properti Product

Trade Name

Onset of

Duration Time to

Time to

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Peak Steady-State Response of Action Peak Conc. Conc. Methyltestosterone

Android Testred Virilon Oreton Methyl

—

24 hours

2h

—

Fluoxymesterone Android-F

Halotestin

—

24 hours

—

—

Testosterone undecanoate

Andriol

6 hours

10 hours

~6 hours

—

Testosterone propionate

Testex

6–24 hours

1–2 wks

3–36 hours

—

Testosterone cypionate

Andronate Depotestosterone Depotest

6–24 hours

2–4 weeks

24 hours

—

Testosterone enanthate

Andro-LA Andryl Delatesteryl Delatest Everone Testamone Testrin-PA

6–24 hours

2–4 weeks

24 hours

—

Trandermal patches

Androderm Testoderm TTS Testoderm

3–6 months

24 hours

2–4 hours

2–3 days

Transdermal gels

AndroGel Testim

3–6 months

5 days

4 (2–6) hours

2–3 days

Buccal muscosal

Striant

—

24 hours

5 (0.5–12) hours

2–3 days

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a

Thonpson Healthcare, Inc. Micromedex Healthcare Series. Available at: http://www.Thom

Fig. 45.9. Testosterone esters and synthetic testosterone derivatives.

Reservoir-T ype Transdermal Systems T he reservoir-type patch (nonscrotal patch; Androderm, T estoderm T T S) is not applied to scrotal skin but, rather, to the abdomen, back, thighs, or upper arms every 24 hours (see T able 45.4 for dosage strength). T his type of patch is membrane-controlled for the drug to diffuse continuously over 24 hours from the reservoir into the skin. T hus, this type of patch is thicker than the matrix (scrotal) patch. T he patches have an occlusive backing that prevents sex partners from coming in contact with the active drug. T he site of the application is rotated at 7-day intervals between applications to lessen skin reactions at the same application site. T he advantage of the reservoir transdermal system is that it achieves normal testosterone circadian rhythm as seen in younger men, peaking in the morning and decreasing throughout the rest of the day. T he reservoir-type patch, when applied to nonscrotal skin, produced physiological DHT and estradiol plasma concentrations. Steady-state plasma concentrations of testosterone, which are approximately 10 times baseline values, are reached in about 6 hours (range, 4–10 hours depending on application patch location), which then fall to 60 to 80% of the peak plasma concentration within 24 hours after application of the transdermal system. T hus, physiological plasma testosterone concentrations are maintained over 24 hours with this type of patch. Drug accumulation does not occur with repeated applications. When the system is removed, testosterone plasma concentrations decline to baseline within 2 hours. A usual dose for the reservoir-type transdermal results in the systemic absorption of 2 to 10 mg daily in hypogonadal men.

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Gel T estosterone gel (AndroGel, T estim) is a 1% testosterone hydroalcoholic gel that provides continuous transdermal delivery of testosterone for 24 hours once the gel is rubbed into the skin on the lower abdomen, upper arm, or shoulder; do not apply to scrotal tissue (T able 45.2). Because there is a continuous release of testosterone over 24 hours, the normal circadian rhythm is not observed. As the gel dries, approximately 10% of the testosterone is absorbed through the skin. Gel application of T RT appears to cause fewer skin reactions than occur with the patches. Avoid showering or bathing for several hours after an application to ensure adequate absorption. A potential side effect of the gel is the possibility of transferring the medication to your partner; skin-to-skin contact should be avoided either until the gel is completely dry or by covering the area after an application. Following the application of 5 g of gel, which will deliver 50 mg of testosterone, the mean peak testosterone concentrations are reached in approximately 2 hours, which are about two to three times baseline values. For optimum results, the gel is best applied in the evening to allow P.1278 maximum concentration to occur early in the morning hours. Doses of the gel may be adjusted by aiming for midphysiological (400–600 ng/dL) testosterone values after 1 week. When the gel treatment is discontinued, plasma testosterone levels remain in the physiological range for 24 to 48 hours, then return to their pretreatment levels within 5 days following the last application. An increase in plasma testosterone can be observed within 30 minutes of application. Plasma concentrations approximate the steady-state level by the end of the first 24 hours and are at steady state by the second or third day of dosing.

Buccal Mu cosal Striant is a gel-like substance that adheres to the gumline, which softens to deliver physiological amounts of testosterone to the systemic circulation, thereby producing circulating testosterone concentrations in hypogonadal males that approximate physiological levels seen in healthy young men (400–700 ng/dL). One buccal system (30 mg) is applied to the gum region twice daily, morning and evening, approximately 12 hours apart. Because there is a continuous release of testosterone over 24 hours, the normal circadian rhythm is not observed. Peak plasma testosterone concentrations are reached within 10 to 12 hours and are stable within a few days of the buccal preparation. T he buccal preparation is difficult for patients to get used to, because the side effects may include gum irritation or pain, bitter taste, or headache. A study found that this form of T RT delivers a steadier dose of testosterone throughout the day without significant adverse effects, comparable to the gel.

Oral Orally administered testosterone is ineffective in the treatment of male androgen deficiency syndromes because of extensive presystemic first-pass metabolism, primarily to inactive 17-ketosteroid, etiocholanolone and androsterone, and androstanediol metabolites in the gastrointestinal mucosa during absorption and in the liver (Fig. 45.5). Oral administration results in supraphysiological elevations of testosterone and undesirable variability of plasma concentrations. T he plasma half-life of testosterone is less than 30 minutes. Generally, the amount of sex hormone binding globulin in plasma determines the distribution of testosterone between free and bound forms, and free testosterone concentrations determine the drug's half-life. Approximately 90% of a dose of testosterone is metabolized, and its metabolites are excreted in the urine primarily as glucuronide conjugates, with approximately 6% of a dose being excreted in the feces as unmetabolized testosterone. Comparative dosage ranges for testosterone and its synthetic preparations are shown in T able 45.2. T aking testosterone orally (Android, T estred) is not recommended for long-term replacement. Oral testosterone may cause an unfavorable cholesterol profile and increase your risk of blood clots and heart and liver problems. T he androgenic activity of lipophilic long-chain ester testosterone 17β-undecanoate (Android

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T estocaps is not approved for use in the United States) (Fig. 45.9) has been attributed to formation of testosterone via systemic ester hydrolysis of lymphatically transported testosterone undecanoate (72). Its oral bioavailability was approximately 3%. Lymphatically transported testosterone undecanoate accounted for between 90 and 100% of the systemically available ester and that 83 and 85% of the systemically available testosterone resulted from systemic hydrolysis of lymphatically transported testosterone undecanoate. T hese data demonstrate that intestinal lymphatic transport of testosterone undecanoate produces increased systemic exposure of testosterone by avoiding the extensive first-pass hepatic metabolism responsible for the inactivation of testosterone after oral administration. T estosterone also has been compressed into 75- or 200-mg testosterone pellets, which release 1 to 3 mg of testosterone/day. One to two pellets are implanted under the skin, typically in the buttocks or abdomen, through a special needle under local anesthesia. T hey usually are replaced every 3 to 4 months. Although the pellets have been used experimentally for approximately 15 years, the use of testosterone pellets is not approved by the U.S. Food and Drug Administration. Reportedly, the pellets offer the advantage of very consistent testosterone blood levels. Some users have reported problems with the pellets working their way out from under the skin.

Synthetic Derivatives of Testosterone Some of the early studies with androgens included structural modifications of the naturally occurring hormones to avoid first-pass metabolism. Blocking the metabolism of the 17β-hydroxy group with substituents in the 17α-position resulted in androgens with an increased bioavailability and duration of action when given orally. T he synthetic androgens include methyltestosterone and fluoxymesterone (Fig. 45.9). T he long-term use of oral androgens has been related to liver cancer.

17α-Methyltestosterone T he synthesis of 17α-methyltestosterone made available a compound that was orally active (73) in daily doses between 10 and 50 mg, which is equivalent to a 400 mg oral dose of testosterone. T he presence of a 17α alkyl group reduces susceptibility to hepatic oxidative metabolism, thereby increasing oral bioavailability by slowing metabolism. Following oral administration, methyltestosterone is well absorbed from the gastrointestinal tract, with a half-life of approximately 3 hours. T his drug has the androgenic and anabolic activities of testosterone. Although orally active, it is more effective when administered sublingually. T he alkylated oral androgens should be viewed as potentially hepatotoxic and should not be used. P.1279

Fluoxymesterone By substituting a 9α-fluoro group onto an analog of 17α-methyltestosterone, fluoxymesterone has 20 times the anabolic and 10 times the androgenic activity of 17α-methyltestosterone (Fig. 45.9) (73). It has a mean half-life of 9 hours, and less than 5% of the drug is excreted unchanged. An adverse effect of fluoxymesterone is sodium and water retention that could lead to edema.

Structure–Activity Relationships of Steroidal Androgens For a substance to have androgenic activity, it must contain a steroid skeleton (74). Oxygen functional groups normally occurring at positions 3 and 17 are not essential, because the basic nucleus, 5α-androstane, has androgenic activity (Fig. 45.1). T his appears to be the minimal structural requirement for hormonal activity. For derivatives of etiocholane, in which the hydrogen is in the 5β-position, thereby affording a ci s A/B ring juncture, no active androgens and anabolic agents are known (74). Generally, both ring expansion (to form homo derivatives by inserting a methylene group into one of the rings in the steroid nucleus) or ring contraction (by removing a methylene group) significantly reduces or destroys the androgenic and anabolic activities. Introduction of a 3-ketone function or a 3α-OH group enhances androgenic activity. A hydroxyl group

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in the 17α-position of androstane contributes no androgenic or anabolic activity; no known substituent can approach the effectiveness of a 17β-OH group. Evidence indicates that the longeracting esters of the 17β-OH compounds are hydrolyzed in vivo to the free alcohol, which is the active species. It is thought that the 17β-oxygen atom is important for attachment to the receptor site and that 17α-alkyl groups are important for preventing metabolic changes at this position (73). Such 17α-substituents render the compounds orally active. Increasing the length of the alkyl side chain at the 17α-position, however, resulted in decreased activity, and the incorporation of other substituents, such as the 17α-ethynyl group, produced compounds with useful progestational activity (progestins) (see Chapter 46), such as ethisterone. Attaching an isoxazole ring to ethisterone produced danazol (Danatrol, Danocrine), which exhibited potent antigonadotropic properties, weak androgen and anabolic properties, and no estrogen or progestin activity. As a gonadotropin inhibitor, danazol suppresses the surge of LH and FSH from the pituitary, thus suppressing ovarian steroidogenesis. For this reason, it is used in the treatment of endometriosis. Previous treatment of endometriosis had been surgical or medical, with progestins or a combination of estrogen and progestin. Danazol is metabolized by CYP3A4 to its inactive metabolite, 2-hydroxymethylethisterone.

Several modifications of 17α-methyltestosterone lead to potent, orally active anabolic agents. T wo hydroxylated analogs include oxymesterone (Fig. 45.9) and oxymetholone (Fig. 45.10). T hese drugs have at least three times the anabolic and half the androgenic activity of testosterone (73). Halogen substitution produces compounds with decreased activity except when inserted into positions 4 or 9 (e.g., fluoxymesterone). Replacement of a carbon atom in position 2 by oxygen has produced the only clinically successful heterocyclic steroid among a number of azasteroids and oxasteroids. Some of the 2-oxasteroids are potent anabolic agents. Introduction of a sp 2 hybridized carbon atom into the A ring renders the ring more planar, and in turn, this may be responsible for greater anabolic activity. T he 19-norsteroids are of interest, because these agents seem to produce a more favorable ratio of anabolic to androgenic activity. Vida (73) has extensively reviewed the replacement of various hydrogens on the androgen steroid skeleton by other functional groups. It appears that certain substitutions at positions 1, 2, 7, 17, and 18 may result in compounds with favorable activities that will be of clinical importance.

Adverse effects

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T estosterone replacement therapy can have undesirable side effects depending on the type of delivery system used. T he adverse effects from oral testosterone include stomach upset, headache, acne, increased hair growth on the face or body, jaundice (liver toxicity), anxiety, change in sex drive, sleeplessness, increased urination, depression, enlargement of breasts, and increased frequency and duration of erections (46). Breast enlargement can develop because testosterone can be converted to estradiol via aromatase. Other adverse effects include water retention, liver toxicity, cardiovascular disease, sleep apnea, and prostate enlargement. T hese risks are relatively uncommon when the dosage is closely monitored to maintain physiological plasma testosterone concentrations. T estosterone replacement therapy is contraindicated in men with carcinoma of the breast or with known or suspected carcinoma of the prostate. T herefore, pretreatment screening for any prostate dysfunction is mandatory before starting T RT .

Anabolic Agents Because complete dissociation of anabolic and androgenic effects is not possible, many of the actions of anabolic P.1280 steroids are similar to those of androgens. Comparative dosage ranges for the anabolic steroids are shown in T able 45.2.

Fig. 45.10. Anabolic steroids.

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Selenium dioxide dehydrogenation of 17α-methyltestosterone yields the 1,4-diene analogue, methandrostenolone, as shown in Fig. 45.10, which has several-fold the anabolic activity of the starting material. It has low androgenic activity but, apparently, can produce mammogenic effects in men. T hese effects are thought to result from estrogenic metabolites. T he 17α-alkylated anabolic steroids in clinical use are oxandrolone (Anavar, Oxandrin), oxymetholone (Anadrol-50), stanozolol (Winstrol), nandrolone decanoate (Deca-Durabolin, Hybolin), and phenpropionate, as shown in Figure 45.10. A 2-oxasteroid analogue of 17α-methyltestosterone is oxandrolone, which contains a lactone in the A ring (oxygen bio-isostere of ring A) and, therefore, is susceptible to in vivo hydrolysis. It has three times the anabolic activity of 17α-methyltestosterone but exhibits slight androgenic activity (75). A pyrazole heterocyclic compound used for its anabolic effects is stanozolol (75). T he anabolic steroid oxymetholone is used primarily to stimulate production of erythropoietin in the treatment of anemias resulting from bone marrow failure. T estolactone (T eslac), a 18-oxasteroid, is a D-homo-oxoandrostandienedione analogue, with ring D being a 6-membered lactone ring. Although testolactone possesses some anabolic activity with weak androgenic effects, it is used primarily in the treatment of breast cancer as a noncompetitive irreversible inhibitor of aromatase to suppress the formation of estrogens that would stimulate the growth of breast tissue (46). It is primarily excreted in the urine unchanged, but it is metabolized in the liver by partial reduction of the 4-ene double bond in ring A to the 5β-metabolite (ci s A/B ring juncture). T estolactone is available in both parenteral and oral forms. Alkylation in the 1, 2, 7, and 18 positions of the androstane molecule generally increases anabolic activity (73). One of these derivatives, methenolone acetate, is an example of a potent anabolic agent that does not have an alkyl substituent at the 17α-position. A halogenated anabolic agent used in about the same dosage is chlortestosterone acetate. Androgens, having no methyl group in position 10 of the steroid nucleus, are an important class of anabolic agents often referred to as the 19-norandrogens, as shown in Fig. 45.10. T he removal of the 19-CH 3 group of the androgen results in reduction of its androgenic properties but retention of its anabolic, tissue-building properties. T hese steroids can be synthesized by the Birch reduction of the aromatic A ring of a 3-methoxy estrogen to a 2,5(10)-estradiene. Cleavage of the enol ether with HCl results in the 19-nortestosterone derivative. In animal assays, 19-nortestosterone has about the same anabolic activity as the propionate ester of testosterone, but its androgenic activity is much lower. Because 19-nortestosterone showed some separation of anabolic and androgenic activities, related analogues were synthesized and biologically investigated. T wo of the more potent members of the series are norethandrolone and ethylestrenol, are shown in Figure 45.10. Norethandrolone has a better ratio of anabolic to P.1281 androgenic activity than either 19-nortestosterone or 17α-methyl-19-nortestosterone does (46). Both androgenic and progestational side effects have been observed with this agent. Ethylestrenol is more potent than norethandrolone as an anabolic agent and is used in a dosage of 4 mg per day orally. Nandrolone phenpropionate and nandrolone decanoate are esters of 19-nortestosterone, as shown in Figure 45.10, that when administered IM, slow in vivo hydrolysis of the ester occurs releasing free 19-nortestosterone over a prolonged period. Nandrolone decanoate is the longer-acting ester intended for deep IM injection, preferably into the gluteal muscle, in the treatment of anemia associated with renal insufficiency. Nandrolone phenpropionate has a shorter duration of action than the decanoate and is used in the treatment of metastatic breast cancer in women.

Abuse of Steroidal Anabolic Agents to Enhance Athletic Performance Performance-enhancing substances are now a point of major interest for athletes, government, and news media. T hese substances are having a major impact on sports and the public in general. It

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appears that we are headed for much greater antidoping efforts in sports. A great deal of interest has recently been shown in “ designer” anabolic steroids for their high-muscle-building effects, as shown in Fig. 45.11. T etrahydrogestrinone and desoxymethyltestosterone (DMT ), as shown in Figure 45.11, brought a great deal of interest to the performance-enhancing area, because their use was very difficult to detect (77,78). T etrahydrogestrinone is thought to have been derived from gestrinone, a substance that has been used for the treatment of a variety of gynecological disorders. T etrahydrogestrinone also is related to trenbolone, which has been used by body builders and by ranchers to build up cattle before marketing. Before tetrahydrogestrinone, both gestrinone and trenbolone had been on the banned anabolic steroid list of the International Olympic Committee. T etrahydrogestrinone was very difficult to trace, however, because it was unstable under the normal conditions of testing for anabolic steroids. Once a suitable assay was developed, it was possible to go back and test samples of athletes around the world, and several were found to have taken tetrahydrogestrinone.

Fig. 45.11. Illegal anabolic agents.

Nonsteroidal Androgens Selectiv e Androgen Receptor Modulators In the past several years, the successful marketing and clinical application of selective estrogen receptor modulators (see Chapter 46) has raised the possibility of developing selective ligands for other members of the nuclear receptor superfamily. T he concept of SARMs (2,78,79) also emerged —namely, a compound that is an antagonist or weak agonist in the prostate but agonist in the bone and muscle and is orally available with low hepatotoxicity. For an ideal SARM, the antagonist or weak agonist activity in the prostate will reduce concern for the potential to stimulate nascent or undetected prostate cancer; whereas the strong agonist activity in the muscle and bone can be used to treat muscle-wasting conditions, hypogonadism, and/or aging-related frailty. Currently, research on SARMs is in its early stages—namely, preclinical discovery and the early phase of clinical development. Phase II studies planned for the next 2 to 3 years, however, should reveal the true promise of this exciting new therapeutic class of drugs. T he SARM pharmacophores can be classified into four categories: N-arylpropionamide (81,82), bicyclic hydantoin (83), tricyclic quinolines (84), and tetrahydroquinoline (85) analogs, as shown in

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Figure 45.12. T hese nonsteroidal AR ligands are not substrates for aromatase or 5α-reductase but exhibit affinity as full AR agonists in anabolic organs (e.g., muscle and bone) or as partial AR agonists in androgenic tissues (e.g., prostate and seminal vesicles).

Structure–activity relationships for the N-arylpropionamides T he majority of published preclinical research has focused on a series of N-arylpropionamide analogues as AR agonists or partial agonists, utilizing the key structural elements of bicalutamide, an androgen antagonist (see below for a comparison of both structures) (2,81,82). A P.1282 series of chiral bicalutamide analogs, which bear electron-withdrawing groups (either a cyano or a nitro group at the 4-position and a trifluoromethyl group at the 3-position) in ring A, with a fluoro or acetylamino substituents at the para position in ring B (R 2 ) demonstrated high in vitro AR binding affinity and in vivo androgenicity and anabolic activity in rats (86,87). T he R-isomer analogs which have a trifluoromethyl group instead of an Me group at the R2 position exhibited higher AR binding affinity and more potent activity than their corresponding S-isomers (88). T he sulfide analogs (replacement of ether oxygen with sulfur) exhibited greater AR binding affinity, except that hepatic oxidation of the sulfur linkage led to rapid in vivo inactivation and reduced efficacy. Partial androgen agonist activity was observed when position 3 of ring A was substituted with a trifluoromethyl group (89). Replacing the aromatic ring A with a heterocyclic ring derivative failed to retain AR binding affinity, which probably arose from steric hinderance on binding with the AR; however, a heterocyclic B ring retained AR binding affinity. Small size electron-withdrawing moieties at R2, such as fluoro, chloro, nitro, or cyano groups, are optimum. Because aromatic nitro groups are associated with hepatotoxicity, the nitro group was replaced with a nonreducible electron-withdrawing group (i.e., a cyano group), which gave the most potent and efficacious N-arylpropionamide SARM with favorable pharmacokinetic properties. As evidenced from structure–activity relationship studies, minor differences in ligand structure can lead to either agonist or antagonist activity. Full or partial agonist binding to AR is influenced by stereoisomeric conformation as well as by steric and electronic effects of the substituents. Molecular modeling of N-arylpropionamide AR ligands was used in conjunction with pharmacology, pharmacodynamics, pharmacokinetics, and metabolism to examine and optimize structural properties.

Fig. 45.12. Selective adrenergic receptor modulators.

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Results from in vitro and in vivo animal studies suggest that the therapeutic promise of SARMs as treatment for muscle wasting, osteoporosis, hormonal male contraception, BPH, or other conditions associated with aging or androgen deficiency—without unwanted side effects associated with testosterone—may be soon realized (2,79). T he AR specificity and lack of steroidal-related side effects clearly distinguish these drugs from their steroidal predecessors and open the door for expanded clinical use of androgens. As the molecular mechanisms of action of SARMs on target tissues become more fully understood, the discovery of novel SARMs and expansion into broader therapeutic applications will be more feasible. Currently, research concerning SARMs is in preclinical discovery and the early phase of clinical development with the expectations that SARMs with the beneficial pharmacological activity of androgens without the unwanted side effects will provide individual patients who have various androgen-dependent disorders with a significantly improved quality of life.

T reatm ent of Prostatic Diseases Diseases of the prostate represent some of the greatest threats to men's health. Incidence rates for BPH escalate rapidly with age, from approximately 50% of men at age 50 years to approximately 90% at age 90 years in the United States. Drugs that inhibit the metabolism of testosterone to DHT (i.e., 5α-reductase inhibitors) (90) or block urethral constriction (α 1 -adrenergic receptor antagonists) (91) are used as front-line treatment for urinary obstruction associated with BPH. Surgery also commonly is performed as treatment for early-stage prostate cancer (i.e., prostatectomy) and transurethral resection of the prostate, making these some of the most common surgeries performed on men. Prostate cancer is the most common noncutaneous cancer and remains the second leading cause of death from cancer in American men (92). Androgen receptor antagonists (i.e., antiandrogens) and LHRH (or gonadotropin-releasing hormone) analogs are routinely used for medical management of patients with early stage prostate cancer, whereas patients with advanced prostate cancer are treated with anticancer chemotherapy.

Benign Prostatic Hyperplasia Benign prostatic hyperplasia is the noncancerous proliferation of the prostate gland. T he major problem associated with BPH is lower urinary tract symptoms. Approximately 80% of men will develop BPH within their lifetime. Although the cause of BPH is not well understood, it occurs mainly in older men, and it does not develop in men whose testes were removed before puberty. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Animal studies have suggested that BPH may result from the increased concentration of estrogen or DHT within the gland, which promotes cell growth (93). Men who do not produce DHT do not develop BPH (94). T he symptoms of BPH stem from obstruction of the urethra by an enlarged prostate and the gradual

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loss of bladder function, which results in incomplete emptying of the bladder. T he symptoms of BPH vary, but the most common symptoms involve changes or problems with urination. T he typical symptoms of BPH are obstructive (e.g., poor urine stream, dribbling, and large residual urine volume) and irritative (e.g., hesitancy, increased frequency of urination, and nocturia), which can significantly P.1283 compromise the quality of life for men. T he enlarging prostate increases the adrenergic tone of the prostate in patients with BPH, which results in further tightening of the urethra. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, a long period of immobility, or the ingestion of over-the-counter cold or allergy medicines that contain a sympathomimetic decongestant drug or anticholinergics. Severe BPH can cause serious problems over time, including urinary retention and strain on the bladder, which can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence. Before and during adulthood, DHT plays a critical role in determining prostate size, and multiple lines of evidence suggest the importance of DHT in the development of BPH (95,96). For instance, BPH does not develop in males with certain type 2 5α-reductase mutations or in males with very low levels of androgen because of prepubertal castration or hypopituitarism-related hypogonadism. Moreover, clinical treatment of BPH either by chemical or surgical castration or by type 2 5α-reductase inhibitor (e.g., finasteride) induces apoptosis of epithelial cells, which in turn significantly decreases the volume of the prostate (96). Recently, the role of age-dependent changes in the intraprostatic hormonal environment in the development of BPH was evaluated (90). Despite the aging-related decrease in testosterone and intraprostatic DHT production, an increased estradiol/DHT ratio was observed in the aging human prostate, which can be relevant to the development of BPH. Furthermore, estradiol is capable of inducing precancerous lesions and prostate cancer in aging dogs (97). T herefore, T RT in older men raises concern regarding acceleration of BPH and/or prostate cancer.

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Fig. 45.13. α 1 -Adrenergic antagonists for treatment of benign prostatic hyperplasia.

Surgical procedures often are used to reduce a large prostate mass, but there are early pharmacological treatments of BPH with an α 1 -adrenergic blocker, a 5α-reductase inhibitor, and phytotherapy. T he α 1 -adrenergic antagonists treat the increased adrenergic tone of the sympathetic nervous system by relaxing the muscles at the neck of the bladder and in the prostate, thereby reducing the pressure on the urethra and increasing the flow of urine (91). T hey do not cure BPH but, rather, help to alleviate some of the symptoms. Approximately 60% of men find that symptoms improve significantly within the first 2 to 3 weeks of treatment with an α 1 -antagonist. In addition to alfuzosin and tamsulosin, which are the first-line α 1 -adrenergic antagonists, other α 1 -antagonists include doxazosin and terazosin, which also have been used to treat high blood pressure. T amsulosin and alfuzosin are uroseletive α 1 -adrenergic antagonists developed specifically to treat BPH. T he 5α-reductase inhibitors work by suppressing the production of intraprostatic DHT , thereby reducing the size of the prostate (90). Finasteride and dutasteride are the most commonly used drugs for this purpose. Unlike α 1 -antagonists, 5α-reductase inhibitors are able to reverse BPH to some extent and so may delay the need for surgery. Several months of treatment may be needed before the benefit is noticed.

α 1 -Adrenergic Antagonists Mechanism of action α 1 -Adrenoceptors are widely distributed in the human body and play important P.1284 physiological roles (see Chapter 13). Of the three α 1 -adrenoceptor subtypes (α 1A, α 1B , and α 1D ), α 1A-adrenoceptors are expressed in prostate and urethral tissue and mediate smooth muscle contraction. T he fact that a single α 1A -adrenoceptor subtype is found in the prostatic and urethral smooth muscle cells led to the design of drugs with uroselectivity for this receptor subtype. T hus, alfuzosin (an aminoquinazoline) and tamsulosin (an N-substituted, catecholamine-related sulfonamide) were designed for the treatment of BPH, as shown in Figure 45.13 (96). Doxazosin and terazosin, along with prazosin, originally were used as antihypertensives but also were found to be effective for the treatment of BPH based on their common mechanism of action. A comparison of the affinities (K i , nM) of the α 1A-adrenoceptor antagonists (T able 45.3) did not show substantial differences for the quinazoline α 1A-antagonists (alfuzosin, doxazosin, and terazosin) but some uroselectivity for tamsulosin (91). Although in vitro studies showed subtype uroselectivity, in vivo studies showed that those α 1A-adrenoceptor antagonists without adrenoceptor subtype selectivity, such as alfuzosin and doxazosin, showed uroselectivity (terazosin was not uroselective), whereas tamsulosin, which exhibited in vitro selectivity for the α 1A-adrenoceptor, did not show the expected in vivo uroselectivity (99). T hese differences between in vitro and in vivo studies suggest that these drugs modify urethral pressures in a manner that is not correlated with their selectivity for the cloned α 1A-adrenoceptor subtypes. It is apparent that the existing α 1A-adrenoceptor antagonists have different in vivo pharmacological profiles that are not yet predictable from their receptor based on the current state of knowledge regarding the α 1A-adrenoceptor classification (99). T hus, tamsulosin and alfuzosin are first-line drugs for the treatment of BPH and have no utility in treating hypertension, because they have fewer cardiovascular effects than terazosin and doxazosin. T heir clinical profiles are related to their pharmacokinetic differences (T able 45.3). Improvements in urine flow occur 4 to 8 hours after the first dose and in BPH symptoms after 1 week.

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Table 45.3. Some Properties and Pharmacokinetics of the α-Adrenergic Antagonists Drug

Alfuzosin

Doxazosin

Tamsulosin

Terazosin

Trade Name

Uroxatral

Cardura

Flomax

Hytrin

cLogPa

-1.0 ± 0.4

0.7 ± 0.4

2.2 ± 0.4

-1.0 ± 0.4

log Da (pH 7)

-1.3

-0.5

-0.5

-1.0

Oral Bioavailability (%)

65

65 (62–69)

90 fasted

90

Onset of Action (weeks)b

48

18–36

>24

>18

Protein binding (%)

82–90

98

94

95

Time to Peak Conc. (hours)

1–2

2–5

4–5

1

Volume of Distribution (L/kg)

2.5–3.2

1.0–3.4

18

25–30

Elimination Half-life (hours)

3–10

18–22

9–13 14–15 elderly

9–12

Cytochrome Isoforms

3A4

3A4

3A4, 2D6

—

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Excretion (%)

K i (nmol/L) for α 1A

69 feces

63–65 feces

21 feces

55–65 feces

24–30 urine (metabolites)

~20 urine

76 urine

30 urine

~10 unchanged

10 unchanged

10–20 unchanged

2.7

0.5

2.5

2.4

a

Chemical Abstracts, American Chemical Society, calculated using Advanced Chemistry Development (ACD/Labs) Software V8.14 for Solaris (1994–2006 ACD/Labs). b

Time for improvement in urine flow observed.

Adverse reactions In patients with BPH, the most common adverse effects for α 1 -adrenergic antagonists are related to vasodilation, including dizziness, orthostatic hypotension, headache, and tachycardia, which occurred during the first 2 weeks of treatment (46). T herefore, a dose titration usually is required, especially in patients older than 60 years. T hese cardiovascular side effects are attributed to a nonselective blockade of α 1 -adrenoceptors present in vascular smooth muscle in addition to the required blockade of α 1 -adrenoceptors in prostate. No first-dose effect and fewer vasodilatory adverse events have been reported with the sustained-release formulations, which occur more frequently with the immediate-release formulation At higher doses, orthostatic hypotension occurs more frequently. T he first-dose phenomenon of orthostatic hypotension and syncope has been reported occasionally in elderly patients and in those concurrently receiving calcium antagonists, diuretics, and β-blockers.

Quinazolines Prazosin was the first selective quinazoline α 1 -blocker to be discovered in the late 1960s as an antihypertensive. Alfuzosin, doxazosin, and terazosin are structurally similar (a 4-amino6,7-dimethoxyquinazoline ring system) but differ in the attached side chain as a piperazine ring or open-chain analogue as shown in Figure 45.13. T he other structural differences are the acyl groups attached to the second nitrogen of the piperazine or the aminopropyl chain. T he differences in these groups afford P.1285 dramatic differences in some of the pharmacokinetic properties for these agents (see T able 45.5). Perhaps most significant are the long half-lives and durations of action for these drugs that permit once-a-day dosing and, generally, lead to increased patient compliance. Alfuzosin is a first-line uroselective drug for the treatment of BPH, but with no utility in treating hypertension, because it has fewer cardiovascular effects than terazosin and doxazosin. Alfuzosin is hepatically metabolized by 7-O-demethylation and N-dealkylation, primarily by CYP3A4 to inactive metabolites. In patients with moderate or severe hepatic insufficiency, a reduction in clearance

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resulted in a three to four times increase in its plasma concentrations, which may require a reduction in dose. Doxazosin is primarily metabolized by 7-O-demethylation, hydroxylation of the benzdioxan ring, and oxidation of the piperazine ring to inactive metabolites. In patients with renal insufficiency, the elimination half-life was not significantly different from healthy volunteers. T erazosin is similarly metabolized via 7-O-demethylation and N-dealkylation to four metabolites: 6and 7-O-demethyl terazosin, the piperazine derivative of terazosin, and the diamine metabolite of the piperazine compound.

Catecholamine-Sulfonamide T amsulosin exhibits uroselectivity and is a first-line drug for the treatment of BPH, with no utility for treating hypertension, because of its fewer cardiovascular effects. T amulson is O-deethylated by CYP3A4 to phenolic metabolites that are conjugated to glucuronide or sulfate before renal excretion and by O-demethylation and 3′-hydroxylation to catechol metabolites that also are conjugated with glucuronide and sulfate.

5α-Reductase Inhibitors T he development of BPH requires a combination of intraprostatic DHT and the aging process. Although not elevated in BPH, levels of DHT in the prostate remain at a physiological levels with aging despite a decrease in plasma testosterone. Adult males with genetically inherited, type 2 5α-reductase deficiency also have decreased DHT levels. T hese 5α-reductase–deficient males have a small prostate gland throughout life and do not develop BPH. Except for the associated urogenital defects that are present at birth, no other clinical abnormalities related to 5α-reductase deficiency have been observed in these individuals.

Mechanism of action Inhibitors of DHT biosynthesis can result in a decrease in both circulating target-tissue DHT concentrations, thus blocking its androgenic action in these tissues. T he critical enzyme targeted for DHT inhibition is 5α-reductase, which converts testosterone to DHT . T he first agent to demonstrate 5α-reductase inhibition was a progestin analogue, medrogesterone (100) (Fig. 45.14). T wo azasteroid-17-amide derivatives of medrogesterone have been developed as potent irreversible inhibitors of 5α-reductase and approved for the treatment of BPH: finasteride, a selective inhibitor of type 2 5α-reductase (101,102), and dutasteride, a nonselective inhibitor of type 1 and type 2 5α-reductase (103) (Fig. 45.14). T hus, the inhibition of type 2 5α-reductase suppresses the metabolism of testosterone to DHT , resulting in significant decreases in plasma and intraprostatic DHT concentrations (102,103,104).

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Fig. 45.14. 5α-Reductase inhibitors for the treatment of benign prostatic hyperplasia.

Finasteride and dutasteride are both mechanism-based inhibitors of type 1 and type 2 5α-reductase isoenzymes that inactivate 5α-reductase by an apparent irreversible modification of 5α-reductase (105,106). T he inhibition constants (median inhibitory concentrations [IC 50s ]) in T able 45.5 suggest that finasteride is 30 times more selective for type 2 5α-reductase, whereas dutasteride appears to be approximately 10 times more potent as an inhibitor of type 2 5α-reductase than as a inhibitor of type 1 5α-reductase. T he reduction of finasteride to dihydrofinasteride proceeds through an enzymebound, NADP-dihydrofinasteride adduct (see Chapter 5) (105). T he mechanism- based inhibition explains the exceptional potency and specificity of finasteride and dutasteride in the treatment of BPH. T his concept of mechanism-based inhibition may have application to the development of other inhibitors of pyridine nucleotide–linked enzymes.

Drug interactions Because finasteride and dutasteride are metabolized primarily by CYP3A4, the CYP3A4 inhibitors, such as ritonavir, ketoconazole, verapamil, diltiazem, cimetidine, and ciprofloxacin, may increase the drugs' blood levels and, possibly, cause drug–drug interactions. Clinical drug interaction studies have shown no pharmacokinetic or pharmacodynamic interactions between dutasteride and tamsulosin or terazosin, warfarin, digoxin, and cholestyramine.

Finasteride T he selective inhibition of the type 2 5α-reductase isozyme produces a rapid reduction in plasma DHT concentration, reaching 65% suppression within 24 hours of administering a 1-mg oral tablet (106). At steady state, finasteride suppresses DHT levels by approximately 70% in plasma and by as much as 85 to 90% in the prostate. T he remaining DHT in the prostate likely is the result of type 1 5α-reductase. T he mean circulating levels P.1286 of testosterone and estradiol remained within their physiological concentration range. Long-term therapy with finasteride can reduce clinical significant end points of BPH, such as acute urinary retention or surgery. Finasteride is most effective in men with large prostates. Finasteride has no affinity for the AR and no androgenic, antiandrogenic, estrogenic, antiestrogenic, or progestational effects.

Pharmacokinetics T he mean oral bioavailability of finasteride is 65%, as shown in T able 45.4, and is not affected by food (99). Approximately 90% of circulating finasteride is bound to plasma proteins. Finasteride has been found to cross the blood-brain barrier, but levels in semen were undetectable (< 0.2 ng/mL). Finasteride is extensively metabolized in the liver, primarily via CYP3A4 to two major metabolites: monohydroxylation of the t-butyl side chain, which is further metabolized via an aldehyde intermediate to the second metabolite, a monocarboxylic acid (Fig. 45.15). T he metabolites show approximately 20% the inhibition of finasteride for 5α-reductase. T he mean terminal half-life is approximately 5 to 6 hours in men between 18 and 60 years of age and 8 hours in men older than 70 years of age. Following an oral dose of finasteride, approximately 40% of the dose was excreted in the urine as metabolites and approximately 57% in the feces. Even though the elimination rate of finasteride is decreased in the elderly, no dosage adjustment is necessary. No dosage adjustment is necessary in patients with renal insufficiency. A decrease in the urinary excretion of metabolites was observed in patients with renal impairment, but this was compensated for by P.1287

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an increase in fecal excretion of metabolites. Caution should be used during administration to patients with liver function abnormalities, because finasteride is metabolized extensively in the liver.

Table 45.4. Some Properties and Pharmacokinetics of the 5α-Reductases Drugs

Finasteride

Dutasteride

Trade Name

Proscar

Avodart

cLogPa

3.2 ± 0.4

5.6 ± 0.6

log Da (pH 7)

3.2

5.6


65 (26–170)

60 (40–94)

Onset of Action (hours)

5 weeks

Protein binding (%)

90

99


—

2–3

Volume of Distribution (L/kg)

76 (44–96)

300–500


5–6 (18–60 yr) >8 for 60+ yr

5 weeks

Cytochrome Isoforms

3A4

3A4

Active M etabolites

None

6-p-OH

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Excretion (%)

57 feces and 40 urine as metabolites

40 feces metabolites 5 unmetabolized urine

IC50 (nmol/L)

313 Type 1

3.9 Type 1

11 Type 2

1.8 Type 2

a

Chemical Abstracts, American Chemical Society, calculated using Advanced Chemistry Development (ACD/Labs) Software V8.14 for Solaris (1994–2006ACD/Labs).

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Fig. 45.15. Metabolites of finasteride and dutasteride.

Dutasteride Similar to finasteride, dutasteride is a competitive and mechanism-based inhibitor not only of type 2 but also of type 1 5α-reductase isoenzymes, with which stable enzyme-NADP adduct complexes are formed, inhibiting the conversion of testosterone to DHT (106). T he suppression of both type 1 and type 2 isoforms results in greater and more consistent reduction of plasma DHT than that observed for finasteride (107,108,109). T he more effective dual inhibition of type 1 and type 2 5α-reductase isoforms lowers circulating DHT to a greater extent than with finasteride and shows advantages in treating BPH and other disease states (e.g., prostate cancer) that are DHT -dependent. T he maximum effect of 0.5 mg daily doses of dutasteride on the suppression of DHT is dose-dependent and is observed within 1 to 2 weeks. After 2 weeks of 0.5 mg daily dosing, median plasma DHT concentrations were reduced by 90%, and after 1 year, the median decrease in plasma DHT was 94% (108,109). T he median increase in plasma testosterone was 19% but remained within the physiological range. T he drug also reduced serum prostatic specific antigen by approximately 50% at 6 months and total prostate volume by 25% at 2 years. Dutasteride produced improvements in quality of life and peak urinary flow rate and reduction of acute urinary retention without the need for surgery. T he main side effects are ED, decreased libido, gynecomastia, and ejaculation disorders. Long-term use (> 4 years), however, did not reveal increased onset of sexual side effects. In addition, the combination of dutasteride and tamsulosin is well-tolerated and has the added advantage of rapid symptomatic relief.

Pharmacokinetics Following oral administration, peak plasma concentrations of dutasteride occurs in approximately 2 to 3 hours, with a bioavailability of approximately 60% (T able 45.4), and no meaningful reduction in absorption with occurs with food (107). Dutasteride is highly bound to plasma proteins 99%. T he concentrations of dutasteride in semen averaged approximately 3 ng/mL, with no significant effects of on DHT plasma levels of sex partners. Dutasteride is extensively metabolized in humans by CYP3A4 to three major metabolites: 4′-hydroxydutasteride and 1,2-dihydrodutasteride, which are less potent than parent drug, and 6′-hydroxydutasteride, which is comparable to the parent drug as an inhibitor of both T ype 1 and T ype 2 5α-reductases. Dutasteride and its metabolites were excreted mainly (40%) in feces as dutasteride-related metabolites. T he terminal elimination half-life of dutasteride is approximately 5 weeks. Because of its long half-life, plasma concentrations remain detectable for up to 4 to 6 months after discontinuation of treatment. No dose adjustment is necessary in elderly patients, even though its half-life increased with age from approximately 170 hours in men between 20 and 49 years to 300 hours in men older than 70 years (102). No adjustment in dosage is necessary for patients with renal impairment.

Phytotherapy A number of plant extracts are popularly used to alleviate BPH, although formal evidence that they are effective is often scanty (110). Extracts of the saw palmetto berry (Serenoa repens) are widely used for the treatment of BPH, often as an alternative to pharmaceutical agents. In a national survey conducted in 2002, 1.1% of the adult male population in the United States, or approximately 2.5 million males, reported using saw palmetto. T he herb is widely used in Europe, where half of the German urologists prefer prescribing plant-based extracts rather than synthetic drugs. T he most common nonstandardized preparation used is either the hexane-extract (Permixon®) or the ethanol or carbon dioxide extraction of the dried ripe fruit from the American dwarf saw palmetto plant (Serenoa repens), which is rich in fatty acids and plant sterols. T he plant sterols appear to be the primary

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active constituents. T he U.S. Pharmacopeia states that the liposterolic extract product should contain 70 to 95% fatty acids and 0.2 to 0.5% sterols. Other substances in the extracts include polyprenic compounds and flavonoids. T he usual therapeutic dose of the extracts is 320 mg daily. Serenoa repens had been popular in the United States during the 19th century as a treatment for a variety of urogenital disorders and had been mentioned as a treatment for prostate problems as early as 1899. Research into the effects of S. repens in many European countries appeared to confirm a positive action on BPH. T he mechanism of action for the saw palmetto is not clearly established, but the sterols may have, as one mechanism of action, the inhibition of 5α-reductase and a decrease in DHT production. T herapeutic results should be expected in 6 to 8 weeks, but clinical efficacy is observed with BPH for 6 months or longer. T he liposterolic extract is largely devoid of the side effects noted for prescription BPH drugs. Although most previous randomized trials of saw palmetto have reported small improvements in the symptoms of BPH or in urinary flow rates, these studies were limited by the small numbers of subjects enrolled, their short duration, failure to use standardized products, their failure to use standard outcome measures, and the lack of information from participants concerning how effectively the placebo was blinded. Using widely accepted outcome measures from the American Urological Association (AUA) and a matched placebo capsule, a randomized, 1-year, double-blind saw palmetto trial (funded by the National Institutes of Health National Institute on Complementary and Alternative Medicine) was performed to determine the efficacy of saw palmetto for the treatment of BPH (111) A total of 225 men aged P.1288 50 years and older with documented disease received 160 mg of a standardized saw palmetto extract twice a day or a matching-placebo capsule. Over the course of a year, the men made eight office visits and were evaluated for assessment of AUA standardized changes which induced maximal urine flow, postvoid residual urine volume, prostate size, and other health-related outcomes. In contrast to most previous studies, this study reported no significant benefit of saw palmetto on urinary symptoms in terms of objective measures of BPH over a 1-year period. Despite the differences between these studies, the weight of evidence suggests that saw palmetto may induce mild to moderate improvements in urinary symptoms and flow measures. Other Western herbs that have been investigated for the treatment of BPH include pumpkin seeds (Cucurbi ta pepo), nettle root (Urti ca di oi ca or Urti ca urens), bee pollen (particularly that from the rye plant), African potato (tubers of Hypoxi s rooperi ), and the African tree Pygeum afri canum, also known as Prunus afri canum. In most cases, but particularly with pumpkin seeds and African potato, the main active components are sterols, such as β-sitosterol, which also has been used for BPH. T riterpenoids in Pygeum sp. also have been proposed to be active components, potentially having the action of reducing prostate swelling. Among the Chinese herbs recommended for BPH, the iridoid glycosides may be the active components from plantago seed, catalpol from rehmannia, and morroniside from cornus (an ingredient in the rehmannia formulas). Iridoids have not been found in the Western herbal therapies for BPH and represent a potential new area for future investigation. Iridoids are the recognized active constituents of the Western herb chaste tree berry (Vi tex agnus costus), which has been shown to reduce prolactin levels in women; elevated prolactin may be a risk factor for prostate enlargement in men. T riterpenoids found in vaccaria and alisma (an ingredient in rehmannia formulas) could contribute to their therapeutic effects in a manner similar to that suggested for pygeum.

Prostatic Cancer Prostate cancer is the second leading cause of death in the United States and is the most commonly diagnosed cancer in American males (92). Prostate cancer is more common in African-American males, in whom it tends to be more aggressive and progressive, leading to advanced disease. T he incidence of prostate cancer increases with age. T raditional treatments for prostate cancer include surgery (radical prostatectomy), radiotherapy, hormonal therapy, chemotherapy, cryosurgery (tissue

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is frozen to kill cancer cells), or watchful waiting. Ever since Huggins and Hodges won the 1966 Nobel Prize for describing the relationship between testosterone and prostate cancer, androgen deprivation has become an important component in the treatment of prostate cancer by providing what amounts to chemical castration, reducing the need for testicular surgery. T esticular surgery (bilateral orchiectomy) to prevent testosterone production was once the standard treatment for advanced prostate cancer. Although this surgery is not a cure, it may delay the advance of the disease. Refinements in the therapy have occurred since this time, including androgen deprivation with antiandrogens, 5α-reductase inhibitor combinations, intravenous bisphosphonate infusions, and chemotherapy for advanced cases. If the cancer is no longer responding to hormonal treatment, chemotherapy may be tried for advanced disease. Because prostate cancer typically grows slowly and causes no symptoms, the prostate-specific antigen (PSA) test is most often used as a screening test for prostate cancer, although it also may be used to evaluate and manage other prostate problems. Screening tests are able to detect prostate cancer at an early stage, but it is not clear whether this earlier detection and consequent earlier treatment leads to any change in the natural history and outcome of prostate cancer. T he PSA screening test cannot tell the difference between prostate cancer and other prostate problems. T he PSA is a protein made by the prostate tissue. Men with prostate cancer often have elevated PSA levels, because the cancer cells make excessive amounts of this protein.

Antiandrogens (Androgen Antagonists) T reatment for advanced prostate cancer involves the use of hormone-blocking drugs called antiandrogens. T he goal of antiandrogen therapy is to block the effects of testosterone and DHT on ARs. Antiandrogens, however, are not a cure for prostate cancer. Nonsteroidal antiandrogens (Fig. 45.16), such as flutamide, nilutamide, and bicalutamide, are referred to as pure antiandrogens, because they bind exclusively to AR and, thus, are devoid of antigonadotropic, antiestrogenic, and progestational effects (112). T hese agents have advantages over steroidal antiandrogens, such as megesterol acetate or cyproterone acetate (Fig. 45.17), in terms of specificity, selectivity, and pharmacokinetic properties. Antiandrogens block the binding of DHT at the AR and, when administered with an androgen, blocks or diminishes the effectiveness of androgens in androgen-sensitive tissues. Such compounds have shown potential therapeutic use in the treatment of acne, virilization in women, and hyperplasia and neoplasia of the prostate (113). Several steroidal and nonsteroidal agents have demonstrated antiandrogenic activity. Cyproterone acetate suppresses gonadotropin release and binds with high affinity to the AR (114,115). Oxendolone also acts by competing for the receptor binding sites (116). A novel AR antagonist, WIN 49,596, has been described (117) which contains a fused pyrazole ring at carbons 2 and 3 of the steroid nucleus. A potent nonsteroidal antiandrogen, flutamide, has been shown to compete with DHT for the AR (118). Its hydroxylated metabolite is a more powerful antiandrogen in vivo, and it has a higher affinity for the receptor than the parent compound (119). P.1289

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Fig. 45.16. Nonsteroidal antiandrogens.

Antiandrogens are particularly useful for the treatment of prostate cancer during its early stages. Often, however, prostate cancer advances to a “ hormone-refractory” state, in which the disease progresses in the presence of continued androgen ablation or antiandrogen therapy, suggesting the development of androgen-independent prostate cancer cells or the ability of adrenal androgens to support tumor growth (as discussed above). Instances of antiandrogen withdrawal syndrome also have been reported after prolonged treatment with antiandrogens. Antiandrogen withdrawal syndrome is commonly observed clinically and is defined in terms of the tumor regression or symptomatic relief observed on cessation of antiandrogen therapy. T he AR mutations that result in receptor promiscuity and the ability of these antiandrogens to exhibit agonist activity may account, at least in part, for this phenomenon. For example, hydroxyflutamide and bicalutamide act as AR agonists in AR mutants with an alanine residue at position 877 or leucine residue at position 741 (as opposed to threonine or tryptophan residues, respectively, that are present at these positions in the wild-type AR) (120,121).

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Fig. 45.17. Steroidal antiandrogens.

T he search for nonsteroidal antiandrogens lead to the development of the substituted toluidides, flutamide and bicalutamide, and nilutamide, a hydantoin that is structurally related to the toluidides (Fig. 45.16). T hese compounds are pure antiandrogens and compete with DHT for the human prostate AR. T hey are used in combination with other drugs in the treatment of metastatic prostate cancer. Although these compounds possess no intrinsic hormonal activity, their antiandrogenic mechanism of action is via competitive blockade of ARs for DHT in the hormone-sensitive tumor cells of the prostate (122). As a result of this antagonism, androgen-dependent DNA and protein synthesis is inhibited, causing arrest or regression of the prostatic tumor. Because these nonsteroidal antiandrogens are metabolized extensively in the liver, they should be used with caution in patients who have liver function abnormalities.

Specific drugs Bicalutamide Bicalutamide is a nonsteroidal pure antiandrogen given at a dosage of 150 mg once daily as monotherapy for the treatment of early (localized or locally advanced) nonmetastatic prostate cancer (123). It also can be used at a lower dosage in combination with a LHRH analogue or surgical castration for the treatment of advanced prostate cancer. Bicalutamide is a racemate and its antiandrogenic activity resides almost exclusively in the (R)-enantiomer, which has an approximately fourfold higher affinity for the prostate AR than hydroxyflutamide does. T he (S)-enantiomer has no antiandrogenic activity. (R)-Bicalutamide is slowly absorbed, but absorption is unaffected by food (124). It has a long plasma elimination half-life of 1 week and accumulates approximately 10 times in plasma during daily administration P.1290 (T able 45.5). (S)-Bicalutamide is much more rapidly absorbed and cleared from plasma. At steady state, the plasma levels of (R)-bicalutamide are 100 times higher than those of (S)-bicalutamide. Although mild to moderate hepatic impairment does not affect pharmacokinetics, evidence suggests slower elimination of (R)-bicalutamide in subjects with severe hepatic impairment (124). Bicalutamide metabolites are excreted almost equally in urine and feces, with little or no unchanged drug excreted in urine. Unmetabolized drug predominates in the plasma. Following oral administration, the racemate

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displays stereoselective oxidative metabolism of its (R)-enantiomer, with an elimination half-life of approximately 6 days. (R)-Bicalutamide is cleared almost exclusively by CYP3A4-mediated metabolism, but glucuronidation is the predominant metabolic route for (S)-bicalutamide. No evidence indicates CYP3A4 induction in humans.

Table 45.5. Some Properties and Pharmacokinetics of the Antiandrogens Drugs

Bicalutamide

Flutamide

Nilutamide

Trade Name

Casodex

Eulexin

Nilandron

cLogPa

4.9 ± 0.7

3.7 ± 0.4

3.3 ± 0.6

log D (pH 7)

4.9

3.7

3.3


80–90

—

—

Onset of Action (weeks)b

8–12

2–4

1–2

Duration of Action

8 days

3 months to 2.5 years

1–3 months

Protein binding (%)

96

94–96

80–84


31

2–3

1–4


~6

8 (10 active metabolite) 10 elderly

40–60 60–120 met

Cytochrome Isoforms

3A4

1A2

Flavin monooxygenase, CYP2C

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Active M etabolites

None

2-hydroxy

Yes

Excretion (%)

43 feces

14.0

Camptothecin Captopril

0.6

1

10.8

1

3.7, 9.8

Carbachol

4 4.8

1

Carbenicillin

2.7

1

Carbenoxolone

6.7, 7.1

1

11/5/2008 3:13 AM

6 of 38


Carbinoxamine

8.1

1

Carisoprodol

4.2

4

Carpindolol

8.8

1

7.2

8

Cefaclor

1.5

Cefamandole

2.7

9

Cefazolin

2.1

1

Cefoperazone

2.6

4

Cefotaxime

3.4

4

Cefoxitin

2.2

10

Ceftazidime

1.8, 2.7

4.1

11

Ceftizoxime

2.7

2.1

4

Ceftriaxone

3.2, 4.1

3.2

1

Cefuroxime

4

Cephacetrile

3

Cephalexinb

3.2

1

L-Cephaloglycin

4.6

Cephaloridine

3.4

1

Cephalothin

2.5

1

7.1

1

11/5/2008 3:13 AM

7 of 38


Cephapirin

4

Cephradine

4

Chenodiol

4.3

1,4

Chloral hydrate

10.0

16

Chlorambucil

5.8

4

Chlorcyclizine

2.1, 8.2

1

Chlordiazepoxide

4.8

1

Chlorhexidine

10.8

1

Chlorocresol

9.6

Chloroquin

1 8.1, 9.9

1

8-Chlorotheophylline

8.2

1

Chlorothiazide

6.8, 9.5

1

Chlorpheniramine

9.0

1

Chlorphentermine

9.6

1

Chlorpromazine

9.3

1

Chlorpropamide

4.9

Chlorprothixene Chlortetracyclinec

3.3, 7.4

1 8.8, 7.6

16

9.3

1

11/5/2008 3:13 AM

8 of 38


Chlorthalidone

9.4

Chlorzoxazone

8.3

1 1

Cimetidine

6.8

1

Cinchonine

4.3, 8.4

1

8.8

1

7.5

9

Ciprofloxacin

6.0

Clindamycin Clofibrate

3.5

Clonazepam

10.5

1 1.5

1

Clonidine

8.3

1

Clopenthixol

6.7, 7.6

1

Clotrimazole

4.7

10

Cloxacillin

2.8

1

Clozapine

8.0

1

Cocaine

8.7

1

Codeine

8.2

1

Colchicine

1.9

1

Cromolyn Cyanocobalamin

1.1, 1.9

1 3.4

9

11/5/2008 3:13 AM

9 of 38


Cyclacillin

7.5

4

Cyclazocine

9.4

1

Cyclizine

8.0, 2.5

1

Cyclobarbital

2.7

8.6

1

Cyclobenzapine

8.5

1

Cyclopentamine

11.5

1

Cyclopentolate

7.9

1

Cycloserine

4.5, 7.4

1

Cyclothiazidec

9.1, 10.5

1

Cyproheptadine

8.9

4

Cytarabine

4.3

1

Dacarbazine

4.4

1

Dantrolene

7.5

1

Dapsone

1.3, 2.5

1

Daunorubicin

8.4

1,4

Debrisoquin

11.9

1

Dehydrocholic acid

5.12

Demeclocycline

3.3, 7.2

1 9.4

1

11/5/2008 3:13 AM

10 of 38


Demoxepam

4.5, 10.6

1

Deserpidined

6.7

1

Desipramine

10.4

1

Dextroamphetamine

9.9

1

Dextrobrompheniramine

9.3

1

Dextrochlorpheniramine

9.2

1

Dextrofenfluramine

9.1

1

Dextroindoprofen

4.6

1

Dextromethorphan

8.3

1

Dextromoramide

7.0

1

Diacetylmorphine (heroin)

7.8

1

Diatrizoic acid

3.4

Diazepam Diazoxide

1 3.4

8.5

1 1

Dibenzepin

8.3

8

Dibucaine

8.9

1

Dichlorphenamide

7.4, 8.6

1

Diclofenac

4.5

1

11/5/2008 3:13 AM

11 of 38


Dicloxacillin

2.8

1

Dicoumarol

4.4, 8.0

1

Dicyclomine

9.0

1

Diethazine

9.1

1

Diethylcarbamazepine

7.7

1

Diflunisal

3.0

1

Dihydroergocriptine

6.9

1

Dihydroergocristine

6.9

1

Dihydroergotamine

6.9

1

Dihydrostreptomycin

7.8

1

Dilevolol

9.5

1

Diltiazem

7.7

1

Dimethadione

6.1

Dimethisoquin

1 6.3

1

Dinoproste

4.9

1

Dinoprostone

4.6

1

Diperodon

8.4

11

Diphenhydramine

9.1

1

11/5/2008 3:13 AM

12 of 38


Diphenoxylate

7.1

1

Diphenylpyraline

8.9

1

Dipipanone

8.5

1

Dipyridamole

6.4

1

8.4

1

9.5

1,4

8.9

1

Doxepin

9.0

1

Doxorubicin

8.2, 10.2

1

9.5

1

Doxylamine

4.4, 9.2

1

Droperidol

7.6

1

Emetine

8.2, 7.4

1

Disopyramide

10.2

Dobutamine Dopamine

Doxycycline

10.6

3.4, 7.7

Enalapril

3.0

5.5

1

Enalaprilat

2.3, 3.4

8.0

1

9.6

1

10.0

1

7.3

1

Ephedrine Epinephrine Ergometrine

8.9

11/5/2008 3:13 AM

13 of 38


Ergonovine

6.8

1

Ergotamine

6.4

1

Erythromycin

8.8

1

Estronef

10.8

13

Ethacrynic acid

3.50

1

Ethambutol

6.3, 9.5

1

Ethoheptazine

8.5

1

Ethopropazine

9.6

1

Ethosuximide

9.5

1

Ethoxazolamide

8.1

1

Ethyl biscoumacetate

7.5

1

Ethylmorphine

8.2

1

Ethylnorepinephrine

8.4

1

Etidocaine

7.9

1

10.2

1

4.2

1

Etileprine

9.0

Etomidate Eugenol

9.8

1

Fenclofenac

4.5

1

11/5/2008 3:13 AM

14 of 38


Fenfluramine Fenoterol

10.0

Fenprofen

4.5

Fentanyl

9.1

1

8.6

1 1

8.4

14

Floxuridine

7.4

1

Flubiprofen

4.3

1

Flucloxacillin

2.7

1

Flucytosine

10.7

Flufenamic acid

3.9

10

Flumizole

10.7

1

Flunitrazepam Fluorouracil

2.9

1.8 8.0, 13.0

1

1 1

Flupenthixol

7.8

1

Fluphenazine enanthate

3.5, 8.2

1

Fluphenazine

3.9, 8.1

1

Flupromazine

9.2

1

1.9

1

Flurazepam

8.2

Furosemide

3.9

1

11/5/2008 3:13 AM

15 of 38


Fusidic acid

5.4

Gentamicinb

1 8.2

1

Glibenclamide

5.3

9

Glipizide

5.9

1

Glutethimide

9.2

1

Glyburide

5.3

1

Glycyclamine

5.5

1

Guanethidine

8.3, 11.9

1

Guanoxan

12.3

1

Haloperidol

8.3

1

Hexetidine

8.3

12

Hexobarbital

8.2

Hexylcaine

1 9.1

1

Hexylresorcinol

9.5

1

Hippuric acid

3.6

1

Histamine

5.9, 9.8

1

Homatropine

9.7

1

Hycanthone

3.4

1

11/5/2008 3:13 AM

16 of 38


Hydralazine Hydrochlorothiazide

0.5, 7.1 7.0, 9.2

Hydrocodone

1 1

8.9

1

Hydrocortisone sodium succinate

5.1

1

Hydroflumethiazide

8.9, 10.7

1

Hydromorphone Hydroquinone

8.2 10.0, 12.0

1 1

Hydroxyamphetamine

9.3

1

Hydroxyzine

2.0, 7.1

1

Hyoscyamine

9.7

1

Ibuprofen

5.2

1

Idoxuridine

8.3

1

Imipramine

9.5

1

Indapamide

8.8

5

Indomethacin

4.5

1

Indoprofen

5.8

1

Indoramin

7.7

1

11/5/2008 3:13 AM

17 of 38


Iocetamic acidg

4.1 or 4.3

4

Iodipamide

3.5

1

Iodoquinol

8.0

1

Iopanoic acid

4.8

4

Iprindole

8.2

1

Ipronidazole

2.7

1

Isocarboxazid

10.4

1

Isoniazid

2.0, 3.5, 10.8

1

Isoproterenol

10.1, 12.1

8.6

1

Isoxsuprine

9.8

8.0

1

Kanamycin

7.2

1

Ketamine

7.5

1,11

Ketobemidone

8.7

1

Ketoconazole

2.9, 6.5

1,4

Ketoprofenh

4.8

Labetalol

8.7

Leucovorin

3.1, 8.1, 10.4

1,9 7.4

1 1

11/5/2008 3:13 AM

18 of 38


Levallorphan tartrate

4.5

6.9

1

9.2

1

8.7

1

Levomethorphan

8.3

1

Levomoramide

7.0

1

8.6

1

Levopropoxyphene

6.3

1

Levorphanol

9.2

1

10.1

1

Lidocaine

7.8

1

Lincomycin

7.5

1

Levobunolol Levodopa

Levonordefrin

Levothyroxine

2.3, 9.7, 13.4

9.8

2.2, 6.7

Liothyronine

8.4

Lisinopril

1.7, 3.3, 11.1

1 7.0

1

8.6

1

1.3

1

Loxapine

6.6

1

Lysergide

7.5

1

Loperamide Lorazepam

11.5

11/5/2008 3:13 AM

19 of 38


Maprotiline

10.2

4

Mazindol

8.6

1

Mecamylamine

11.2

1

Mechlorethamine

6.4

1

Meclizine

3.1, 6.2

1

Meclofenamic acid

4.0

Medazepam Mefenamic acid

4 6.2

4.2

1 1

Mepazine

9.3

1

Meperidine

8.7

1

Mephentermine

10.4

1

Mephobarbital

7.7

1

Mepindolol

8.9

1

Mepivacaine

7.7

1

Mercaptomerin

3.7, 5.1

1

Mercaptopurine

7.8

11.0

1

Mesalamine

2.7

5.8

1

Mesna

9.1

1

11/5/2008 3:13 AM

20 of 38


Metaproterenol

11.8

8.8

1

8.6

1

9.5

1

Methadone

8.3

1

Methamphetamine

10.0

1

Methapyrilene

3.7, 8.9

1

Methaqualone

2.5

1

Metaraminol Methacycline

3.5, 7.6

Metharbital

8.2

1

Methazolamide

7.3

1

Methdilazine

7.5

1

Methenamine

4.8

4

Methicillin

3.0

1

Methohexital

8.3

1

Methotrexate

3.8, 4.8

5.6

1

Methotrimeprazine

9.2

1

Methoxamine

9.2

1

Methoxyphenamine

10.1

1

Methyclothiazide

9.4

1

11/5/2008 3:13 AM

21 of 38


Methyl nicotinate

3.1

1

Methyl paraben

8.4

1

Methyl salicylate

9.9

1

Methyldopa

2.3, 10.4, 12.6

9.2

1

Methylergonovine

6.6

1

Methylphenidate

8.8

1

Methylthiouracil

8.2

1

Methyprylon

12.0

1

Methysergide

6.62

1

Metoclopramide

0.6, 9.3

1

Metolazone

9.7

1

Metopon

8.1

1

Metoprolol

9.7

1

Metronidazole

2.6

4

Metyrosine

2.7, 10.1

Mexiletine Mezlocillin Miconazole

1 9.1

2.7

1 1

6.7

1

11/5/2008 3:13 AM

22 of 38


Midazolam

6.2

1

9.5

1

Minoxidil

4.6

4

Mitomycin

10.9

1

Molindone

6.9

1

8.0

1

Minocycline

2.8, 5.0, 7.8

Morphine

9.9

Moxalactam

2.5, 7.7, 10.2

4

Nabiloneb

13.5

9

Nadolol

9.4

Nafcillin

2.7

Nalbuphine

10.0

Nalidixic acid

6.0

5 1

8.7

4 1

Nalorphine

7.8

1

Naloxone

7.9

1

Naphazoline

10.9

1

Naproxen

4.2

Natamycin

4.6

1 8.4

8

11/5/2008 3:13 AM

23 of 38


Neostigmine

12.0

1

4.8

1

Nicotinamide

0.5, 3.4

1

Nicotine

3.1, 8.0

1

Nikethamide

3.5

1

3.2

1

Niacin

2.0

Nitrazepam

10.8

Nitrofurantoin

7.1

Norcodeine

1 5.7

1

Nordefrin

9.8

8.5

1

Norepinephrine

9.8, 12.0

8.6

1,2

Norfenephrine

8.7

1

Normorphine

9.8

1

Nortriptyline

9.7

1

Noscapine

6.2

1

Novobiocin

4.3, 9.1

Nystatini

8.9

5.1

11

Octopamine

9.5

8.9

1

8.4

1

Orphenadrine

1

11/5/2008 3:13 AM

24 of 38


Oxacillin

2.7

Oxazepam

11.6

1 1.8

Oxprenolol

9.5

5

Oxybutynin

7.0

4

Oxycodone

8.9

1

8.5

1

Oxymorphone

9.3

Oxyphenbutazone

4.7

1

Oxypurinol

7.7

1

Oxytetracyclinec

3.3, 7.3

9.1

1

Pamaquine

1.3, 3.5, 10.0

1

Papaverine

6.4

1

Pargyline

6.9

1

Pemoline

10.5

1,2

Penbutololc

9.3

1

7.9

1

Penicillamine

1.8, 10.5

Penicillin G

2.8

1

Penicillin V

2.7

1

Pentamidine

11.4

4

11/5/2008 3:13 AM

25 of 38


Pentazocine

10.0

Pentobarbital

8.1

8.5

2,9 1

Pentoxiphylline

0.3

1

Perphenazine

3.7, 7.8

1

Phenacetin

2.2

1

Phenazocine

8.5

1

Phencyclidine

8.5

2

Phendimetrazine

7.6

1

Phenethicillin

2.8

1

Phenformin

2.7, 11.8

1

Phenindamine

8.3

1

Phenindione

4.1

1

Pheniramine

4.2, 9.3

1

Phenmetrazine

8.5

1

Phenobarbital

7.4

1

Phenolphthalein

9.7

1

Phenolsulfonphthalein

8.1

1

Phenothiazine

2.5

1

11/5/2008 3:13 AM

26 of 38


Phenoxybenzamine

4.4

4

Phenoxypropazine

6.9

1

Phentermine

10.1

1

Phentolamine

7.7

1

Phenylbutazone

4.5

Phenylephrine

10.1

1 8.8

1

Phenylpropanolamine

9.4

1

Phenyltoloxamine

9.1

1

Phenyramidol

5.9

1

Phenytoin

8.3

1

Physostigmine

2.0, 8.2

1

Pilocarpine

1.6, 7.1

1

Pimozide

7.3, 8.6

1

Pindolol

8.8

1

Piperazine

5.6, 9.8

1

Pipradrol

9.7

1

Pirbuterol

3.0, 7.0, 10.3

1

Piroxicam

4.6

1

11/5/2008 3:13 AM

27 of 38


Pivampicillin

7.0

1

Polymyxin

8.9

1

Polythiazide

9.8

1

Practolol

9.5

1

Pralidoxime

7.9

1

Pramoxine

6.2

1

Prazepam

2.9

1

Prazosin

6.5

1

9.5

1

7.9

1

Prenalterol

10.0

Prilocaine Probenecid

3.4

1

Procainamide

9.2

1

Procaine

8.8

1

Procarbazine

6.8

1

Prochlorperazine

3.7, 8.1

1

Promazine

9.4

1

Promethazine

9.1

1

Proparacaine

3.2

11

11/5/2008 3:13 AM

28 of 38


Propiomazine

9.1

1

Propoxycaine

8.6

1

Propoxyphene

6.3

1

Propranolol

9.5

1

Propylhexedrine

10.4

1

Propylthiouracil

7.8

1

Pseudoephedrine

9.5

1

Pyrathiazine

8.9

1

Pyrazinamide

0.5

1

5.0

1

Pyrilamine

4.0, 8.9

1

Pyrimethamine

7.3

1

Pyrrobutamine

8.8

1

Quinacrine

8.2, 10.2

1

Pyridoxine

Quinethazone

8.96

9.3, 10.7

1

Quinidine

4.2, 7.9

1

Quinine

4.2, 8.5

1

Ranitidine

2.3, 8.2

4

11/5/2008 3:13 AM

29 of 38


Rescinnamine

6.4

4

Reserpine

6.6

1

Rifampin

1.7

7.9

1

Rimoterol

10.3

8.7

1

9.0

1

Ritodrine Rolitetracycline

7.4

Rotoxamine

1 8.1

1

Saccharin

1.6

1

Salicylamide

8.2

3

Salicylic acid

3.0, 13.4

1

Salsalate

3.5, 9.8

1,2

Scopolamine

7.6

1

Secobarbital

7.9, 12.6

1

Serotonin

9.8

4.9, 9.1

1

Sotalol

8.5

9.8

1

Sparteine

4.8, 12.0

1

Spiperone

8.3, 9.1

1

Streptozocin

1.3

4

11/5/2008 3:13 AM

30 of 38


Strychnine Succinylsulfathiazole

2.3, 8.0 4.5

Sufentanil

1 1

8.0

4

Sulfacetamide

5.4

1.8

1

Sulfadiazine

6.5

2.0

1

Sulfadimethoxine

6.7

2.0

1

Sulfaguanidine

12.1

2.8

1

Sulfamerazine

7.1

2.3

1

Sulfamethazine

7.4

2.4

1

Sulfamethizole

5.5

2.0

1

Sulfamethoxazole

5.6

Sulfaphenazole

6.5

1.9

1

Sulfapyridine

8.43

2.6

1

Sulfasalazine

2.4, 9.7, 11.8

Sulfathiazole

7.1

Sulfinpyrazone

2.8

1

Sulfisoxazole

5.0

1

Sulindac

4.5

1

1

1

2.4

1

11/5/2008 3:13 AM

31 of 38


Sulpiride

9.1

Sulthiame

10.0

p-Synephrine

10.2

Talbutal

7.8

1 1

9.3

1 1

Tamoxifen

8.9

4

Temazepam

1.6

1

8.8

1

8.4

1

9.7

1

Terbutaline

10.1, 11.2

Tetracaine Tetracycline

3.3, 7.7

Tetrahydrocannabinol (THC)

10.6

2

Tetrahydrozoline

10.5

1

Thenyldiamine

3.9, 8.9

1

Theobromine

10.1

0.1

1

Theophylline

8.6

3.5

1

Thiazbendazole

4.7

4

Thiamine

4.8, 9.0

1

Thiamylal

7.5

1

Thioguanine

8.2

3

11/5/2008 3:13 AM

32 of 38


Thiopental

7.5

1

Thiopropazate

3.2, 7.2

1

Thioridazine

9.5

1

Thiothixene

7.7, 7.9

1

Thiouracil

7.5

Thonzylamine

1 2.2, 9.0

1

10.1

1

L-Thyroxine

2.2, 6.7

Ticarcillin

2.6, 3.4

1

Ticrynafen

2.7

1

Timolol

8.8

1

Timoprazole

3.1, 8.8

1

Tiotidine

6.8

1

Tiprofenic acid

30.0

1

Tobramycin

6.7, 8.3, 9.9

2

Tocainide

7.5

1

Tolamolol

7.9

5

5.7

1

10.3

1

Tolazamide Tolazoline

3.1

11/5/2008 3:13 AM

33 of 38


Tolbutamide

5.4

1

Tolmetin

3.5

1

Tramzoline

10.7

1

Tranylcypromine

8.2

1

Trazodone

6.7

1

Triamterene

6.2

1

Trichlormethiazide

8.6

1

Trifluperazine

3.9, 8.1

1,3

Triflupromazine

9.2

1

Trimeprazine

9.0

1

Trimethobenzamide

8.3

1

Trimethoprim

6.6

3

Trimipramine

8.0

4

Tripelennamine

4.2, 8.7

1

Triprolidine

6.5

1

Troleandomycin

6.6

1

Tromethamine

8.1

1

Tropicamide

5.3

1

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Tuaminoheptane

10.5

1

Tubocurarine

8.1, 9.1

1

9.3

1

Tyramine

10.9

Valproic acid

4.8

1,3

Verapamil

8.9

1

Vidarabine

3.5, 12.5

1

Viloxazine

8.1

1

Vinbarbital

8.0

1

Vinblastine

5.4, 7.4

1

Vincristinej

5.0, 7.4

1

Vindesine

6.0, 7.7

1

Warfarin

5.1

1

Xylometazoline

10.2

1

Zimeldine

3.8, 8.74

1

Miscellaneous organic acids and bases Acetic acid Allylamine

4.8 10.7

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6-Aminopenicillanic acid

2.3

4.9

Ammonia

9.3

Aniline

4.6

Benzoic acid

4.2

Benzyl alcohol

18.0

Benzylamine

9.3

Butyric acid

4.8

Carbonic acid

6.4, 10.4

Citric acid

3.1, 4.8, 5.4

Diethanolamine

8.9

Diethylamine

11.0

Dimethylamine

10.7

p-Dimethylaminobenzoic acid

5.1

Ethanol

15.6

Ethanolamine

9.5

Ethylamine

10.7

Ethylenediamine

7.2, 10.0

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Fumaric acid

3.0, 4.4

Gluconic acid

3.6

Glucuronic acid

3.2

Guanidine

13.6

Imidazole

7.0

Isopropylamine

10.6

Lactic acid

3.9

Maleic acid

1.9

Mandelic acid

3.4

Monochloroacetic acid

2.9

N-propylamine

10.6

Nitromethane

11.0

Phenol

9.9

Phthalic acid

2.9

Resorcinol

9.2, 11.3

Sorbic acid

4.8

Succinimide

9.6

Tartaric acid

3.0, 4.4

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p-Toluidine Trichloroacetic acid

5.3 0.9

Triethanolamine

7.8

Triethylamine

10.7

Tropic acid

4.1

Tropine Uric acid

10.4 5.4

a

Determined in methyl cellosolve/water (8:2 w/w mixture).

b

Determined in 66% dimethylformamide.

c

Determined in 25 to 30% ethanol.

d

Determined in 40% methanol.

e

Prostaglandin F 2α .

f

Spectrophotometric determination.

g

The pK a values of the four optical isomers are 4.1 for two isomers and 4.25 for two isomers. h

Determined in methanol/water (3:1 mixture).

i

Determined in dimethylformamide/water (1:1 mixture).

j

Determined in 33% dimethylformamide.

General References Albert A, Serjeant EP. T he Determination of Ionization Constants of Acids and Bases: A Laboratory Manual. 3rd Ed. New York, Chapman and Hall, 1984.

Florey, K. ed. Analytical Profiles of Drugs Substances. New York: Academic Press, 1978.

Hansch C, Sammes PG, T aylor JB, eds. Comprehensive Medicinal Chemistry, vol 6. Pergamon Press: Oxford, 1990.

O'Neil A, Heckelman PE, Koch C.B, et al. T he Merck Index. 14th Ed. Rahway, NJ: Merck and

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Co, 2006.

Perrin DD, Dempsey B, Serjeant EP. pKa Prediction for Organic Acids and Bases. New York: Chapman and Hall, 1981.

Serjeant EP, Dempsey B. Ionization Constants of Organic Acids in Aqueous Solution. IUPAC Chemical Data Series No. 23. Oxford, UK: Pergamon Press, 1979.

Sinko P. Martin's Physical Pharmacy and Pharmaceutical Sciences. 5th Ed. Baltimore: Lippincott Williams & Wilkins, 2005.

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Appendices

Appendix B. pH Values for Tissue Fluids Dav id A. William s

Table B.1. pH Values for Tissue Fluids Fluid

pH

Aqueous humor

7.2

Blood, arterial

7.4

Blood, venous

7.4

Blood, maternal umbilical

7.3

Cerebrospinal fluid

7.4

Colona Fasting

5–8

Fed

5–8

Duodenuma Fasting

4.4–6.6

Fed

5.2–6.2

Fecesb

7.1 (4.6–8.8)

Ileuma Fasting

6.8–8.6

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Fed

6.8–8.0

Intestine, microsurface

5.3

Lacrimal fluid (tears)

7.4

Milk, breast

7.0

Muscle, skeletalc

6.0

Nasal secretions

6.0

Prostatic fluid

6.5

Saliva

6.4

Semen

7.2

Stomacha Fasting

1.4–2.1

Fed

3–7

Sweat

5.4

Urine

5.8 (5.5–7.0)

Vaginal secretions, premenopause

4.5

Vaginal secretions, postmenopause

7.0

a

Dressman JB, Amidon GL, Reppas C, et al. Dissolution testing as a prognostic tool for oral drug absorption. Pharm Res 1998;15:11–22. b

Value for normal, soft, formed stools. Hard stools tend to be more

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alkaline, whereas watery, unformed stools are acidic. c

Studies conducted intracellularly on the rat.

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A Abacavir 1215 1217 Abarelix 191 Abatacept 997 Abciximab 840 841 Acarbose 101 872 873 Acebutolol 773 Acetaminophen 55 56 256 260 267 295 323 959 963–965 965 Acetazolamide 101 726 727 Acetohexamide 867 868 Acetohydroxamic acid 101 Acetylcholine 26 43 44 Acolbifene 1336–1337 Acrivastine 1016 1018 Acyclovir 101 1207–1209 1207 1208 Adalimumab 994 995 Adefovir Dipivoxil 1207 1213–1214 4,5α-Epoxymorphinans 47 Albendazole 267 1103 1104 Albuterol 393 400 401 405 405 406 1239 Alcohol (ethanol) 272–273 Aldesleukin 138 Aldosterone 882–884 885 886 Alendronate 101 945 946 Alfentanil 267 Alfuzosin 408–409 409 1283 1284 1285 Alicaforsen (ISIS 2302) 206–207 Allopurinol 101 1000–1001 1000 Almotriptan 425 Alosetron 425 425 432 433 436 Alprazolam 267 295 Alteplase 136 138 140–141 842–843 843 Altretamine 1156 1162 Amantadine 687 1203–1204 1203 Amikacin 1067 1068 Amiloride 726 735 4-Aminobenzenesulfonamide 45 p-Aminobenzoic acid (PABA) 28 Aminocaproic acid 101 Aminoglutethimide 101 903 904 Aminoglycosides 1065–1067 Aminorex 643–644 Amiodarone 267 718 718 Amitriptyline 260 267 295 555 557 558 559 560 576 577 580 Amlodipine 267 318 709–711 759 760 763 764 765 Amobarbital 515–516 517 Amoxacillin 1054 Amoxepine 565 Amphetamine 267 322 407 407 640 644–646 Amphotericin B 1114–1115 Ampicillin 1031 1049 1054 Amprenavir 271 1219 1222–1223 Amyl nitrite (isoamyl nitrite) 707–708 707 Amylbarbital 256

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Amylin 197 198 860 862 Anakinra 138 996 Anandamide 460 460 Anastrozole 267 1311 1337 Anidulafungin 1117 1123 1123 Apraclonidine 403 404 Aprepitant 271 Aprobarbital 517 Aprotinin 101 846 Ardeparin 831 Argatroban 832 834 Aripiprazole 614–615 615 Aristolochic acid I 23 Aristolochic acid II 23 Arteether 20 Artemether 20 Artemisinin 20 Articaine 467 468 475 477 Aspart 864 864 Aspartame 447 447 Aspirin 295 836 836 837 954–957 963 965–968 966 967 Astemizole 267 Atazanavir 1219 1223 Atenolol 773 Atomoxetine 267 567 Atorvastatin 101 267 318 807–810 807 812 Atovaquone 1091–1092 Atracurium besylate 388 388 Atropine 18 18 26 381 382 383 385 Azacitidine 1189 Azelastine 1019 1019 Azidothymidine (AZT ) 101 106 107 Azithromycin 1070 1071–1072 1140–1141 1141 Aztreonam 1065 1065

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B Bacampicillin 1054 Bacitracin 101 1080 Baclofen 458 458 693–694 Barbiturates 271 322 Becaplermin 138 Beclomethasone dipropionate 887 894 895 896 1253 Benznidazole 1094 Benzocaine 463 463 467 468 469 471 472 474 475–476 477 Benzodioxanes 46 Benzomorphans 47 Benzylpenicillin 19 1047–1048 1049 1052–1053 Bepridil 267 709–710 759 759 Beraprost 794–795 794 Betamethasone 886 887 888 893 895 Betaxolol 35 773 Bethanechol chloride 373 Betoptic 35 Biapenem 19 19 Bicalutamide 1282 1289–1290 Bisoprolol 267 773 Bitolterol 405–406 1239 1239 Bivalirudin 17 833–834 Bleomycin 1166 1171–1173 Bortezomib 101 Bosentan 792 793 793 Bretylium 718 718 Brimonidine 403 404 Bromocriptine 687–688 688 Budesonide 887 895 896 897 899 1253 Bumetanide 726 732 Bupivacaine 467 468 472 473–474 476–477 Buprenorphine 661 663–664 665 673 Bupropion 267 560 583–585 584 585 Buserelin 1291 Buspirone 318 422 423 Busulfan 267 1156 1162–1163 Butabarbital 517 Butenafine 1116 1122 Butorphanol 664 673

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C Caffeine 260 267 323 Camptothecin 20 21 22 Candesartan 753–756 755 Cannabidiol (CBD) 18 Cannabinoids 267 633–634 633 Canrenone 726 734 Capecitabine 1175 1175 1177 Capreomycin 1138 Captopril 38 101 742–744 743 748 749–750 749 752 Carbachol chloride 373 Carbamazepine 267 271 318 523 526 529 530 531–532 531 532 Carbaryl 377 Carbenicillin 256 1047 1049 1055 Carbenoxolone 295 Carbidopa 101 Carboplatin 1156 1164 Carebastine 1016 1018 1018 Carisoprodol 267 Carmustine 1156 1160–1161 Carteolol 773 Carvedilol 267 776 Caspofungin 20 20 101 1117 1123 1123 Cefaclor 38 1060 1061 Cefadroxil 1058 1059 Cefamandole nafate 1059 Cefazolin 1058 1059 Cefdinir 1062 1063 Cefditoren pivoxil 1062 1063 Cefepime 1063 1063 Cefixime 1062 1063 Cefmetazole 1060 1061 Cefonicid 1059 1060 Cefoperazone 1062 1063 Cefotaxime 1061 1062 Cefotetan 1060 1061 Cefoxitin 1060 1061 Cefpodoxime proxetil 1062 1063 Cefprozil 1060 1061 Ceftazidime 1062 1062 Ceftibuten 1062 1063 Ceftizoxime 1061 1062 Ceftriaxone 1061–1062 Cefuroxime 1059–1060 1060 1060 Celecoxib 267 985–988 985 986 987 Cephalexin 1058 1059 Cephalosporin 1056–1069 1058 Cephapirin 1058–1059 1058 Cephradine 1058 1059 Cerivastatin 267 318 Cetirizine 1014 1016 1017–1018 Cetrorelix acetate 191 Cevimeline 267 374 Chlorambucil 1156 1157

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Chloramphenicol 42 256 1077–1078 Chlordiazepoxide 260 267 295 618 619 622 623–624 Chlormethiazole 295 Chloroprocaine 467 468 476 Chloroquine 267 1096–1098 Chlorothiazide 46 728 730 Chlorpheniramine 37 Chlorpromazine 46 256 267 Chlorpropamide 867 868 Chlorthalidone 730 731 Chlorzoxazone 267 Cholestyramine 804–806 805 Choriogonadotropin 196 Ciclopirox 1116 1124 Cidofovir 1207 1209 Cilastatin 101 Cilomilast 482 485 486 Cilostazol 267 837 838 P.1356 Cimetidine 267 323 1021 Cinacalcet 260 Ciprofloxacin 101 323 Cisapride 267 Cisplatin 1156 1163 1164 Citalopram 267 553 557 560 561 569 570 572 573–574 Cladribine 1175 1180–1181 Clarithromycin 267 318 1070 1071 1140–1141 1141 Clavulanic acid 101 112 1054 Clindamycin 256 267 1072–1073 Clobazam 295 Clobetasol propionate 887 894 895–896 Clofarabine 1175 1180–1181 Clofazimine 1142–1143 1144 Clomiphene citrate 1324–1325 Clomipramine 260 267 557 558 560 564 569 576 578–580 Clonazepam 267 523 524 529 535 535 536 543 Clonidine 303 403–404 778–781 778 780 Clopidogrel 260 267 837 838–839 838 Clotrimazole 271 Cloxacillin 1047 1052 1053 Clozapine 260 267 428 429 437 438 603 613 613 Coartemether 20 Cocaine 267 322 646–647 Codeine 267 662 666–667 666 670 Colchicine 998–999 1000 Colesevelam 804–806 805 Colestipol 804–806 Colony-Stimulating Factors (CSFs) 145–147 Combretastatin A4 phosphate 21 22 Concensus interferon 143 Conjugated Estrogens 1307–1308 1308 Cosyntropin 195 Cromolyn 1009–1010 1255 Crotamiton 1109 Curcumin 22 Cyclobenzaprine 260 267

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Cyclophosphamide 267 1156 1157–1159 1158 Cycloserine 101 1138 1138 Cyclosporin A 22 267 318 Cyproheptadine 322 Cytarabine 1175 1180–1181 1207 1209–1210 Cytokines 136 142–145 147 Cytotec® 35

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D Dacarbazine 1156 1162 Dactinomycin 1166 1170–1171 Dalteparin 831 Dantrolene 694 Dapsone 267 1142–1143 1143 Daptomycin 19 19 20 1079 Darbepoetin alfa 138 Darifenacin 381 383 Daunorubicin 1166 1169 10-Deacetylbaccatin III 21 Decamethonium bromide 386 386 Delavirdine 267 1215 1218 Demeclocycline 1073 1076 Denileukin diftitox 138 Desflurane 493 497 498–499 Desipramine 260 267 550 555 560 562 563 564–565 575 578 Desirudin 833 Deslanatoside C BP 703 Desloratadine 1016 1017 1017 Desmethyldiazepam 295 Desmopressin 195 Desogestrel 267 1308 1316 11-Desoxycorticosterone 883 883 886 889 Detemir 864–865 864 Dexamethasone 267 886 887 888 892–893 Dexfenfluramine 267 Dextromethorphan 39 267 Dezocine 674 Diazepam 256 260 267 295 318 322 529 535 535 536 543 618 619 623 624 692–693 Diazoxide 46 787 787 Diclofenac 267 295 963 973–974 974 Dicloxacillin 1047 1053 Dicumarol 101 256 Didanosine 1215–1216 Dideoxycytidine (ddC) 106–107 Dienogest 1313 1314 1315 1317–1318 Diethylcarbamazine 1104 1104 Diflunisal 968 969 Digitalis products 700–701 700 703 704 Digitoxin 101 295 703 Digoxin 703–705 703 711 714 Dihydroergotamine 414–415 Dihydromorphinone 656 Diloxanide furoate 1090–1091 Diltiazem 267 318 709–711 759 761–765 762 764 766 Diphenhydramine 46 295 507 518 519 Diphenoxylate 322 664 675 Dipyridamole 836 837 837 Discodermolide 21 22 Disopyramide 267 716 Disulfiram 101 Divalproex sodium 267

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DNase—Dornase Alpha (Pulmozyme) 141 Dobutamine 406 407 705 706 Docetaxel 21 267 1182 1183 1184 Dofetilide 718 718 Dolasetron 267 432 433 Donepezil 267 378 Dopamine 394 404 406–407 406 411 Dornase alpha 138 Dothiepin 580 Doxacurium chloride 388 388 Doxazosin 393 408–409 409 775 1283 1284 Doxepin 267 557 560 576 578 Doxorubicin 267 1166 1168–1169 Doxycycline 1073 1073 1076 Doxylamine 518 519 Dronabinol 267 Drospirenone 1313 1314 1315 1317–1318 Duloxetine 260 560 581 581 582–583 584 Dutasteride 1285 1286 1286 1287 Dyphylline 1245

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E Ebastine 318 1016 1018 1018 Echinacea 320 Echothiophate iodide 379 379 Ecteinascidin 743 21 Edrophonium 377 Efavirenz 271 1215 1218–1219 Eflornithine 101 1093–1094 Elcomdetrine 1317–1318 Eletriptan 425 425 Emedastine 1019 1019 Emtricitabine 1215 1216–1217 Enalapril 42 267 744–746 744 748 750 Encainide 267 717 717 Enflurane 267 493 493 497 497 498 499 499 500 Enfuvirtide 1207 Enoxaparin 831 Entacapone 101 687 Ephedrine 39 42 322 400 402 402 405 407 643 Epigallocatechin-3-O-gallate 22 Epinastine 1019 1019 Epinephrine 41 392–394 392 397 400–402 405 1234 1235 1236 Epirubicin 1166 1169 Eplerenone 734 Epoetin alpha 138 Epoprostenol 792 793–794 Epothilone B 21 Eprosartan 754–756 754 755 Eptifibatide 840–841 841 Ergonovine 414 415 Ergot alkaloids 267 Ergotamine 414–415 414 Erlotinib 260 Ertapenem 1064 Erythrityl tetranitrate 707 707 708 Erythromycin 267 271 1070 1071 Erythropoietin 145–146 Erythropoietin–Epoetin Alpha 145 Escitalopram 560 570 574 Esmolol 773 775 Esomeprazole 101 267 1021 1022 Estazolam 509 510 511 Estradiol 51 260 267 1301 1303–1311 Estramustine 1156 1157 1185 Estrogens 267 Eszopiclone 512 513–514 625 625 Etanercept 138 994–995 Ethacrynic acid 726 733 733 Ethambutol 101 1135 Ethanol 267 271 272–273 295 Ethanolamines 46

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Ether 490 491 497 497 Ethinyl estradiol 267 Ethionamide 1136–1137 1138 Ethisterone 1314 1315–1316 Ethosuximide 267 271 272–273 Ethylenediamines 46 Ethynyl estradiol 1307 1308 Etidronate disodium 945 946 Etodolac 101 971 974–975 980 Etomidate 502 Etoposide 267 1186–1187 Etoricoxib 985 986 988 Everolimus 23 Exemastane 1337–1338 Exenatide 17 866 Ezetimibe 804 811–813 812 816

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F Famciclovir 1207 1210 Famotidine 1021 1021 Felbamate 523 537–538 537 541 Felodipine 267 318 323 759 763 764 765 766 Fenfluramine 267 Fenofibric acid 814 815 Fenoprofen 969 976 977 980 Fenoterol hydrobromide 1240 Fentanyl 267 663 664 672 672 Fexofenadine 267 1016–1017 1017 Filgrastim 138 146 Finasteride 101 112 267 1283 1285–1287 1285 1286 Flecainide 267 717 717 Floxuridine 101 1174–1175 1176 Fluconazole 267 1117 1120 Flucytosine 1117 1123 Fludarabine 1175 1180–1181 Fludrocortisone 886 887 888 890 902 Flunisolide 887 895 897 898 1253–1254 Flunitrazepam 295 Fluocinolone acetonide 887 894 895 895 Fluocinonide 887 894 895 Fluorometholone 895 902 Fluoroquinolones 260 Fluorouracil 1174 1175 1176 Fluoxetine 35 267 424 440 440 552 553 557 558 559 560 561 567 569–570 570 571–573 Fluoxymesterone 1277 1279 Fluphenazine 267 Flurandrenolide 894 895 Flurazepam 509 510 510 511 619 624 Flurbiprofen 267 969 976 978 979 980 Flutamide 260 267 1289 1290 1290 Fluticasone propionate 887 895 895 896 900–901 1254 Fluvastatin 267 318 807 808–810 812 Fluvoxamine 260 267 557 560 561 569–571 575–576 Follicle Stimulating Hormone 1301 1304 1324–1328 Follitropin alfa 194 Follitropin alpha 138 140 Follitropin beta 138 140 194 Fomepizole 101 Fomivirsen 205–206 1207 1210 Fondaparinux 101 829 831–832 Formoterol 267 400 406 406 1239–1240 P.1357 Fosamprenavir 1219 1223 Foscarnet 1207 1210 Fosfomycin 101 Fosinopril 746–748 748 750 Frovatriptan 425 425

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Fulvestrant 1336 Furosemide 726 731–732 731

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G Gabaculin 112 Gabapentin 523 529 538 Galanin 596 Galanthamine (Galantamine) 19 19 267 378 Gallium nitrate 951 Ganciclovir 1207 1210–1211 Ganirelix acetate 191 Gemcitabine 101 1175 1180 Gemfibrozil 814–816 814 815 Gemtuzumab ozogamicin 21 Gentamicin 1033 1067 1068 Gestodene 1314 1315 1316 GHB 458–459 458 Ginkgo biloba 320 Ginkgolide 23 Glargine 864 864 Glimepiride 267 867–868 867 Glipizide 267 867 868 869 Glucagon 138 198 Glucocorticoids 271 Glulisine 864 Glyburide 267 867 868 869 Glycylcyclines 1033 1073–1077 1073 Gold salts 989 Gonadotropin-Releasing Hormone 1326–1327 Goserelin 181 189 190 1291 Granisetron 267 432 432 433 Granulocyte colony-stimulating factor 146–147 Griseofulvin 271 1117 1123–1124 Guaifenesin 37 Guanabenz 404 404 778–779 778 780 781 Guanadrel 782 784 784 Guanethidine 782 783–784 Guanfacine 404 404 778–779 778 780 781–782

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H Halcinonide 887 894 895 895 Halobetasol propionate 887 893 894 894 Halofantrine 267 1096 1098–1099 Haloperidol 260 267 Haloprogin 1116 1124 Halothane 267 493 494 495 497 498 499 499 500 Heparin 295 820 822 823 827 828–833 844 847 Hepatitis B vaccine 138 Hexobarbital 256 267 Histrelin acetate 189 190 191 Human chorionic gonadotropin 193 Hydralazine 322 770 785–786 785 Hydrochlorothiazide 730 Hydrocodone 267 Hydrocortisone 267 880 884–886 886 886 887 888–890 1245–1247 1250 Hydroxychloroquine 990 991 Hydroxyurea 1175 1181 Hydroxyzine hydrochloride 34 Hydroxyzine pamoate 34 Hyperforin 23

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I Ibandronate sodium 947 Ibuprofen 38 267 323 963 969 976–977 976 Ibutilide 718 718 Idarubicin 1166 1169–1170 Idoxuridine 1207 1211 Ifosfamide 267 1156 1159–1160 1159 IL-2 fusion protein 144 Iloprost 792 794 795 Imatinib 101 Imiglucerase 138 141–142 Imipenem 1064 Imipramine 260 267 323 551 557 558 559 560 576 577–578 Inamrinone 705–706 788 788 Indapamide 730 731 Indinavir 267 318 1219 1221–1222 Indium pentetreotide 192 Indobufen 836 837 Indomethacin 267 322 957 963 969–971 971 Infliximab 994–995 Insulin 137 138 139 180–181 197–198 855–874 Interferon 138 1198 1201–1205 1214 1224 Interferon α 138 Interferon alfacon-1 138 Interferon β 138 Interleukin 11/Oprelvekin 144–145 Iodide 915–917 920–925 Ipratropium hydrobromide 1243 Irbesartan 267 753–756 755 Irinotecan 21 1186 1188 1188 Isoetharine hydrochloride 1238 Isoflurane 267 493 494 495 497 497 498 498 499 499 Isomethadol 42 Isoniazid 101 256 267 1130–1132 1132 Isoproterenol 395–396 397 400 401 405 Isosorbide 726 726 727 Isosorbide dinitrate 707–708 707 Isotretinoin 267 Isradipine 267 Itraconazole 101 267 1117 1120 Ivermectin 1105 Ixabepilone 21

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K Kanamycin 1067–1068 1139 Kava 320 Ketamine 496 501–502 501 634 635–636 Ketoconazole 267 1116 1117 1119–1120 1119 Ketolides 1069–1072 Ketoprofen 969 976 977 980 Ketoroloc 976 978–979 Ketotifen 1019 1019

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L Labetalol 42 88 267 295 323 776 Lamivudine 1215 1216 Lamotrigine 523 524 529 538–539 543 Lamuvidine 101 Lanatoside C BP 703 Lansoprazole 267 271 1021–1022 1021 1022 Lasofoxifene 944–945 944 Leflunomide 992 992 Lepirudin 101 138 832 833 Letrozole 1311 Leuprolide 189–190 1291 Levetiracetam 523 539 Levobupivacaine 260 476–477 Levocetirizine 1017–1018 Levocobastine 1019 1019 Levodopa 681 685–689 Levorphanol 39 663 664 670 Levothyroxine 923 927 Lidocaine 256 267 295 323 463–464 464 472 474 476 716 716 Lincomycin 1072 1072 Lincosamides 1072 Lindane 1107 Linezolid 1081 Liothyronine 923 927 Liotrix 923 Liraglutide 866 Lisinopril 745–746 748 750 Lispro 864 864 Lithium carbonate 592–593 Lodoxamide 1009 1010 Lofepramine 580–581 580 Lomustine 1156 1160–1161 Loperamide 675 Lopinavir/ritonavir 1219 1223 Loracarbef 1060 1061 Loratadine 318 1016 1017 Lorazepam 295 Lormetazepam 295 Losartan 267 752–756 755 Lovastatin 38 267 318 323 806–811 807 809 812 Loxapine 613 613 Lumiracoxib 985 988 Lutropin alfa 194 1327 Lyme disease vaccine 138

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M Macrolides 1069–1072 Malathion 379–380 Mannitol 726 726 726 727 Maprotiline 267 557 560 562 563 565–566 MDMA 648–649 Mebendazole 1103 1104 Mecamylamine 791 791 Mechlorethamine 1155 1156 Meclizine 35 Meclobemide 267 Meclofenamic acid 979–981 981 Mefenamic acid 267 979 980 981 Mefloquine 267 1096 1098 Megestrol acetate 1308 1314 1315 Melagatran 832 834 834 Melarsoprol 1094–1095 Meloxicam 267 980 983 986 Melphalan 1156–1157 Memantine 687 687 Menotropins 193–194 196 Meperidine 256 267 295 322 664 667 670–671 Mephenytoin 267 271 Mephobarbital 267 Mepivacaine 467 468 476 Meprobamate 256 Mercaptopurine 1175 1178–1179 1180 Meropenem 1064 Mestranol 1307 Metaproterenol sulfate 1238 Metaraminol 400 401 402 402 Metformin 870 Methacholine chloride 373 Methadone 47 267 318 322 661 663 664–665 667 667 671–672 Methamphetamine 267 407 407 643 Methaphenilene 49 Methenamine 1043 1044 Methicillin 1047 1049 1052 1053 Methimazole 924 Methotrexate 101 962 967 989 990 992–993 994 1175–1178 1175 1176 Methoxamine 400 402 402 Methoxyflurane 493 497 498 499 500 Methylaminorex 643–644 N-Methylatropine 26 N-Methyldopamine 41 Methyldopa 404 404 770 777–778 Methylergonovine 414 415 N-Methylmorphine 26 N-Methylnicotine 26 Methylprednisolone 886 887 888 891 907 1252 1253 4-Methylpyrazole 271

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Methyltestosterone 1277 1278–1280 Methysergide 414 415 Metoclopromide 1023 Metocurine 387 Metolazone 730–731 730 Metoprolol 267 773 Metronidazole 1089–1090 1089 Metyrapone 903 903 Metyrosine 101 782 782 Mevastatin 806–809 807 Mexiletine 260 267 716 Mezlocillin 1047 1055 Mibefradil 267 Micafungin 1117 1123 Miconazole 267 Midazolam 267 295 318 Miglitol 101 872 873 Miglustat 101 Milnacipran 557 581 582 594 Milrinone 705–706 705 788 788 Minocycline 1073 1076 Minoxidil 786–787 786 Mirtazapine 260 267 559 585 586 587–588 Misoprostol 1023–1024 1023 P.1358 Mitomycin 1166 1171 Mitoxantrone 1166 1170 Mivacurium chloride 388 388 Mizolastine 1016 1018 Moclobemide 589 591 Modafinil 271 Molindone 615 615 Molsidomine 709 709 Mometasone furoate 887 895–897 895 895 899–900 1254 Monobactams 1065 Montelukast 267 1257–1258 1257 Moricizine 717 717 Morphinans 47 Morphine 26 42 47 268 295 652–653 656 657 661–662 661 663 664 666–667 666 Moxonidine 778–779 Mupirocin 1081 Mycophenolate 22 101

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N Nabumetone 970 971 975–976 Nadolol 38 773 Nafarelin acetate 189 190 Nafcillin 1047 1053 Naftifine 1116 1121 1121 Nalbuphine 663 670 673–674 Naloxone 657 657 670 673 674 Naltrexone 657 657 661 663 670 Nandrolone 1280 1281 Naproxen 39 260 268 969 976 977–978 980 Naratriptan 424 425 425 Natamycin 1115 Nateglinide 268 869 869 Navelbine 268 Nedocromil 1009 1009 1010 Nedocromil sodium 1255 1255 Nefazodone 268 Nelfinavir 101 268 318 1219 1222 Neomycin 1069 Neostigmine 377 Nevirapine 107 268 271 1215 1218 Nicardipine 268 709–711 Nicotine 26 268 323 Nicotinic acid/Niacin 816–817 817 Nifedipine 268 295 318 709–711 759 761 762–763 762 763 764 766 Nilutamide 268 1289 1290 1290 Nimodipine 268 318 Nisoldipine 268 318 759 763–765 763 764 766 Nisoxetine 553 562 566–567 567 Nitazoxanide 1090 1090 Nitisinone 101 Nitrazepam 295 Nitrendipine 268 318 Nitroglycerin 707 Nitrous oxide 490 493 493 497 498 500–501 Nizatidine 1021 1021 Nomogestrel acetate 1320 Norepinephrine 40 295 392–396 392 395 399–402 413–414 643 Norethindrone 271 1308 1313–1314 1316 1317 Norgestimate 1308 1313 1314 1315 1316 Nortriptyline 260 268 295 557 560 562 563 564 565 577 578 Nystatin 1114–1115 1115 1116

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O Oblimersen sodium 207 Octreotide acetate 192 Olanzapine 260 268 428 428 613 613 Olmesartan 753–755 755 756 Olopatadine 1018–1019 Omalizumab 1259–1260 Omeprazole 268 271 1021–1022 1022 Ondansetron 260 268 432 433 433 Oprrelvekin 138 Oral contraceptives 268 Orlistat 101 Oseltamivir 101 Oseltamivir phosphate 1206 1206 Ouabain BP 703 Oxacillin 1052 1053 Oxaliplatin 1156 1164–1165 Oxamniquine 1106 1106 Oxandrolone 1280 1280 Oxaprozin 976 979 980 Oxazepam 295 619 623 624 Oxcarbazepine 271 523 529 531 533 Oxybutynin 381 383 Oxycodone 268 670 670 Oxymetazoline 403 403 Oxymetholone 1280 Oxytetracycline 1073 1076 Oxytocin 195

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P Paclitaxel 20 21 268 1182–1183 1182 1184 Palonosetron 432 433 Pamidronate disodium 945 951 Pancuronium bromide 387 Pantoprazole 268 1021 1022 Papaverine 1296 Parathion 379 Paroxetine 268 557 560 561 569 570 571 573 573 Peginterferon 138 Pegvisomant 138 193 Pemetrexed 101 1175 1178 Pemirolast 1009 1010 Pemoline 643–644 Penbutolol 773 Penicillin 101 Penicillin G 19 34 Penicillins 1028–1056 1045 1047 1049 1049 Pentaerythritol tetranitrate 707 708 Pentamidine isethionate 1091 Pentazocine 322 674 Pentobarbital 256 517 Pentostatin 101 1175 1181 Perchlorate 923 Pergolide 688 688 Permethrin 1108 1109 1109 Perphenazine 268 Phenacetin 268 Phencyclidine (PCP) 634 635–636 Phenelzine 589 590 590 Phenformin 268 Phenmetrazine 322 Phenobarbital 256 271 272 516 517 523 528 529 533–534 543 Phenol 268 Phenothiazines 46 322 Phenoxybenzamine 407–408 408 Phenoxymethyl penicillin 1049 1050 Phentolamine 408 408 415 1296–1297 Phenylbutazone 256 Phenylephrine 37 400 402 402 Phenylisopropylamines 407 4-Phenylpiperidines 47 Phenylpropanolamine 400 407 Phenytoin 256 268 271 295 322 523 525 528 529–531 529 541 716–717 Phosphomycin 1044 1044 Physostigmine 34 99 376 377 Pilocarpine 373–374 Pimozide 268 Pindolol 268 773 Pioglitazone 268 870 871 Pipecuronium bromide 387

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Piperacillin 1047 1055 Pirbuterol 405 405 405 Piroxicam 268 295 323 980 982–983 982 986 Polymyxin B 1080 Posaconazole 1120 1121 Pramipexole 688 688 Pramlintide 865 865 Pramlintide acetate 198 Pranidipine 318 Pravastatin 268 318 807–810 807 809 810 Praziquantel 268 1105 1106 Prazosin 295 408–409 409 775 Prednisolone 886 887 888 888 890–891 891 1252 1253 Prednisone 256 268 886 887 888 890–891 Primidone 271 523 528 529 534–535 543 Probenecid 970 999–1000 Procainamide 715–716 Procarbazine 1156 1161–1162 Progesterone 268 Proguanil 268 Promazine 48 Promethazine 48 Prontosil 45 Propafenone 260 268 717 717 Propantheline 382 383 Propofol 494 501 Propoxyphene 268 665 672 Propranolol 40 260 268 295 322 718 718 773 Propylthiouracil 101 295 924 Prostaglandin E 1 1296 Prostaglandins 322 Protamine 846 Protriptyline 557 562 563 565 Prourokinase 843 Pseudoephedrine 39 42 400 402 402 407 643 Psoralen 271 Pyrantel pamoate 1107 Pyrazinamide 101 1134–1135 Pyrethrin 1108–1109 1108 Pyridostigmine 101 377 Pyrimethamine 1099–1100 1099

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Q Quazepam 509 510 511 Quetiapine 268 613 Quinapril 745 748–749 748 750 752 Quinethazone 730–731 730 Quinidine 268 295 318 704 714 715 Quinine 19 268 295 1095–1098 1095 Quinolones 1040–1043 1040 1042 Quinupristin/dalfopristin 1079–1080

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R Rabeprazole 268 1021 1022 Radioiodine 923 Raloxifene 943–944 Ramelteon 260 512 518 518 Ramipril 745 748–749 748 750 Ranitidine 1021 1021 Rapaglinide 268 Rasagiline 686 686 Reboxetine 557 560 562 566 572 Recombinant factor IX 138 Recombinant factor VIII 138 Remifentanil 672–673 672 Repaglinide 868–869 868 Reserpine 782 782 Resveratrol 22 Retavase 138 Reteplase 141 843 844 Retinoic acid 268 Ribavirin 101 1207 1212 Rifabutin 268 Rifampin 101 268 271 272 1132–1133 Rifamycin 256 Rifapentine 271 1132–1133 Rilmenidine 778–779 Riluzole 260 268 Rimantadine 1203 1204 Risedronate disodium 945 946 Risperidone 268 428 438 613–614 Ritodrine 401 406 Ritonavir 268 271 318 1220–1221 Rituximab 995–996 Rivastigmine 378 Rizatriptan 424 425 425 Rocuronium bromide 387 Rofecoxib 985–988 985 986 987 Roflumilast 482 485 485 486 486 Ropinirole 268 688 Ropivacaine 260 268 473 477 Roprinirole 260 Rosiglitazone 268 870 871 872 Rosuvastatin 807 808–810 809 812

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S Salicylic acid 99 256 Salmeterol 35 268 400 406 406 1239 Saquinavir 268 318 1219 1220 Sargramostim 138 146–147 Satraplatin 1156 1165 Scopolamine 381 382–383 Secobarbital 517 Selegiline 268 686 Sertindole 268 615 615 Sertraline 268 553 557 560 561 569–571 574–575 Sevoflurane 268 493 497 498 499–500 499 Sildenafil 101 268 318 481 482 484–485 484 486 788–789 788 792 1293–1295 Simvastatin 268 318 807–810 807 812 Sodium fluoride 949 Sodium mycophenolate 23 Sodium nitroprusside 790 790 Sodium stibogluconate 1095 Solifenacin 383 Somatrem 138 Somatropin 138 193 Sotalol 718 718 Spectinomycin 1067 1068 Spironolactone 726 734 Stanozolol 1280 1280 Stavudine 1215 1217 St.Johns Wort 271 320 Streptokinase 822 842 843 Streptomycin 1136 1137 Streptozocin 1156 1161 Strychnine 460 460 Succinylcholine chloride 386 386 Sucralfate 1020 1024 Sufentanil 268 656 657 672 672 Sulbactam 1054–1055 Sulfamethoxazole 101 268 Sulfanilamide 28 Sulfinpyrazone 836 837 1000 1000 Sulfonamide 322 1030 1036–1039 1037 1038 Sulfonylureas 866–870 d-Sulforaphane 22 Sulindac 969 971 972 973 Sumatriptan 424–425 425 427 Suprofen 969 978 978 Suramin sodium 1092

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T T acrine 260 268 378 T acrolimus 268 318 T adalafil 481 482 485 486 1292–1295 T amoxifen 268 323 1306 1310 1332 1334 1335 T amsulosin 408–409 409 1283–1284 1283 1284 T egaserod 436 436 T elithromycin 19 20 1070 1072 T elmisartan 753 754–756 756 T emazepam 268 295 509 510 510 511 T emazosin 775 T emozolomide 1156 1162 T enecteplase 138 141 843 844 T eniposide 268 1186 1186 1187 T enofovir disoproxil 1215 1217 T erazosin 393 408–409 409 1283 1284–1285 1284 T erbinafine 101 1116 1117 1121–1122 T erbutaline 400 405 406 1238 T erconazole 1116 1120 T erfenadine 268 1016–1017 1016 T eriparatide 138 196 948 T estolactone 1280 1280 T estosterone 268 1278 T estosterone esters 1274 1277 T etracycline 1033 1073–1077 1073 T etrahydrocannabinol (T HC) 18 T etrahydrozoline 403 403 T halidomide 1143–1144 T heophylline 101 256 260 268 295 323 1234 1244 1244 T hiabendazole 268 1103 1104 3-T hiacytidine (3-T C) 106–107 T hioguanine 1175 1178–1180 T hiopental 295 502 502 T hioridazine 268 T hiotepa 1156 1160 T hyrotropin alfa 138 T iagabine 268 523 526 529 539–540 T icarcillin 1047 1055 T iclopidine 836 838–839 T igecycline 19 19 1077 T imolol 268 773 T inidazole 1090 T iotropium bromide 18 1243 T ipranavir 1223–1224 T irofiban 840 841 841 T izanidine 260 403 404 694 T obramycin 1066 1067 1068 T obutamide 256 T ocainide 716 T olazamide 867 868 868 868 T olazoline 408 408

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T olbutamide 256 268 295 867 868 868 T olcapone 687 T olmetin 973 973 T olnaftate 1116 1121 1121 T olteridine 268 T opiramate 271 523 524 529 540 T opotecan 21 101 1186 1187 1187 1188–1189 T oremifene 1334 1335–1336 1336 T orsemide 268 726 732 T ramadol 268 671 T ranylcypromine 419 419 589 590–591 T razodone 268 440 441 560 585 586–587 587 T reprostinil 792 794 794 T retinoin 268 T riamcinolone 886 887 888 891–892 894 896 T riamcinolone acetonide 887 894–895 895 898 1254 T riameterene 726 T riazolam 268 318 509 510 510 511 T rifluorothymidine 1207 1212 T riflusal 836–837 836 T rilostane 101 903 904 T rimegestone 1313 1314 1315 1317–1318 T rimethaphan 791 791 T rimethoprim 101 1038–1039 10139 T rimetrexate glucuronate 1092 T rimipramine 560 576 578 580 T ripelennamine 46 49 323 T ripolidine 39 T riptorelin pamoate 189 190 T roglitazone 271 870–871 870 871 T roleandomycin 268 T ropisetron 268 432 432 433 435 d-T ubocurarine 26 368 385 387

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U Undecylenic acid 1116 1124 Urofollitropin 194 Urokinase 822 842–843

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V Valacyclovir 1207–1209 1207 Valdecoxib 268 985 986 988 Valproic acid 101 268 323 529 533 540–541 Valrubicin 1166 1169 Valsartan 268 753–756 755 Vancomycin 1053 1078–1080 1078 Vardenafil 268 481 482 485 486 1292–1295 Vasopressin 195 Vecuronium bromide 387 Venlafaxine 268 557 560 581–582 581 585 Verapamil 260 268 295 318 704 709–710 709–711 714 758–759 762 763–765 763 764 766 Vidarabine 1207 1212–1213 Vinblastine 268 1182 1185 Vinca alkaloids 268 Vincristine 268 1182 1184–1185 Vinorelbine 1182 1185 Vitamin K 824–826 825 844 845 845 Voriconazole 268 1117 1120–1121 1120

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W Warfarin 260 268 295 824–827 825 827

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X Ximelagatran 832 834 834

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Y Yohimbine 268 409 409

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Z Zafirlukast 268 1257 1258–1259 1259 Zalcitabine 1215 1216 Zaleplon 268 511–513 512 Zanamivir 1205–1206 Ziconotide 761 Zidovudine 1214–1215 Zileuton 101 260 268 1257 Ziprasidone 613 614 614 Zoledronic acid 945 951 Zolmitriptan 260 425 425 427 Zolpidem 511–513 512 626 Zonisamide 523 528 529 541–542 Zoplicone 268

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A Ab i ni ti o methods 57 Abbreviated New Drug Applications (ANDAs) 334–335 Abortifacients 1321 Absence seizures 524 drugs for 526 542–543 Absence status epilepticus 524–525 Absorption See Drug absorption Abuse, neuronal plasticity and drugs of 649 ACAT inhibitors 803 ezetimbe history of 811 mechanism of action 811–812 metabolism 812 pharmacokinetic parameters 812–813 physiochemical properties 812 Acetylation 290–291 290 291 299 Acetylcholine 1240–1241 action of 1236–1237 biosynthesis of 361 362 1240 conformations of 43–44 1241 1242 early studies of 1240 in local anesthesia 469 metabolism of 361 neurochemistry of 361–362 362 release of 361 sites of action of 1240 1241 sleep/wakefulness and 507 stereochemistry of 1243 storage of 361 structure of 27 structure-activity relationship for 371–373 Acetylcholine antagonists 381–385 1237 See al so Muscarinic antagonists Acetylcholine mimetics 371–374 1234 Acetylcholine receptors 362–363 muscarinic 363–367 363 structure of 367–368 368 Acetylcholinesterase 361 carbamylation of 376 hydrolysis of 375–376 Acetylcholinesterase inhibitors 108 374–381 irreversible (phosphorsylated) 378–381 aging of 379 antidotes for 380–381 insecticidal 379 toxicity of 379–380 mechanism of action of 376 378–379 receptor binding to 87 reversible 376–378 therapeutic applications of 374 Acid/base properties 28 29

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Acid(s) aliphatic, conjugation of 289–290 common 29 conjugate 28 30 HSAB theory 308 ionization of 29 absorption and 215–218 calculation of 30–31 ionizaton of 29 absorption and 218 relative strength of 29 salts of, dissolution of 224–227 225 solubility of 219 224 Acinar cells, thyroid 913 ACT H in adrenocorticoid synthesis 884 in Cushing's disease 882 Action potential 90 465 465 Activated partial thromboplastin time 824 Activation energy 109 Activation-aggregation theory 88 Active site directed irreversible inhibitors 110–111 111 Active transport 214–215 214 Acute bacterial prostatitis 1292 Acute renal failure, drug metabolism in 236 Acyl CoA:cholesterol acyltransferase inhibitors 803 Acyl glucuronides 287 Acylureidopenicillins 1055 Addiction See Drug abuse/addiction Addison's disease 882 Adeno-associated virus vectors 153 154 Adenoma, toxic 921 Adenosine, sleep/wakefulness and 507 Adenosine deaminase, transition-state inhibitors of 110 110 Adenosine monophosphate (AMP) 398 Adenosine triphosphate (AT P) 397 Adenoviral vectors 153–154 153 Adenylate cyclase 94 94 397–398 397 Adenylyl cyclase 94 94 397–398 397 Adiponectin, diabetes mellitus 860 Adjustment disorder with depressed mood 549 ADME studies 77–79 230 Adrenal glands, diseases of 882–883 Adrenaline See Epinephrine Adrenergic drugs 395–399 agonist alpha 402–404 775–776 beta 404–406 706 structure-activity relationships for 402–404 antagonist alpha (See α-adrenergic receptor antagonists) beta (See β-adrenergic receptor antagonists) mixed alpha/beta 411

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commonly used 393 mechanism of action of 392 399–400 399 overview of 392–393 Adrenergic nervous system See Sympathetic nervous system Adrenergic neuron blocking agents 782–784 Adrenergic receptor(s) 90 90 desensitization of 97 effector mechanisms of 397–398 localization of 398–399 postsynaptic 399 presynaptic 398–399 second messengers of 398 stimulation of, tissue response to 399 399 structure 395–398 397 398 subtypes of 95–96 96 97 363 399–400 therapeutic relevance of 399–400 Adrenoceptors See Adrenergic receptor(s) Adrenocorticoid antagonists 903–904 903 Adrenocorticoid(s) 877–908 See al so Corticosteroids adverse effects 907–908 biosynthesis and secretion 1245–1246 1246 biosynthesis of 883–884 885 1304 discovery of 882–883 HPA suppression, duration of 907 intrasanal and inhaled applications 906–907 lipophilicity of 895–896 897 mechanism of action of 880–881 880 881 904–905 1248–1249 metabolism of 884–886 nomenclature 1245 pharmacokinetics of 886–893 886 888 pharmacological effects and clinical applications 905–908 1246–1248 structure-activity relationships for 901–903 901 903 1249–1250 1250 topical applications 906 to treat asthma and COPD 1245–1252 Adrenocorticotropic hormone in adrenocorticoid synthesis 884 in Cushing's disease 882 Afferent neuron 464 464 Affinity conformation and 87–88 definition of 86 stereochemistry and 88–89 Affinity labeling agents for opioid receptors 656 658–659 Affinity labels 110–111 African trypanosomiasis 1086 treatment of 1088–1089 1092–1095 Age bone mass and 935 depression 548 drug metabolism and 295–297 Agonists definition of 86 full (strong) 96

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partial 96 Agriculture antibiotics in 1035–1036 antifungals in 1122 Alanine 177 Albumin, in thyroid hormone transport 917 917 Alcohol dehydrogenase 281 Alcohol(s) acetaminophen interaction with 965 CYP450 induction and 272–273 drug metabolism and 272–273 oxidation of 281 toxicity of 281 Aldehyde dehydrogenase 282 Aldehyde oxidase 282 Aldosterone biosynthesis of 883–884 885 progesterone and 1317 structure of 885 Aliphatic acids, conjugation of 289–290 Aliphatic hydroxylation 274 Alkaloids, plant 381–382 Alkanes, hydroxylation of 274 Alkenes, hydroxylation of 270 270 274 275 275 276 Alkyl amines 1013–1014 1014 Alkyl chains, alterations in 47–48 Alkylaminoketones 373 Alkylating agents, in cancer chemotherapy 1154–1155 Allergens, histamine response to 1006–1007 Allergy to aspirin 967 immediate reaction in 1007 1008 to local anesthetics 469 to penicillin 1052 1055 Allyl amine antifungals 1121–1122 α-Adrenergic receptor(s) 397–398 397 See al so Adrenergic receptor(s) in polyphosphatidylinositol hydrolysis 398 α-Adrenergic receptor(s) agonists 402–404 775–776 structure-activity relationships for 402–404 α-Adrenergic receptor(s) antagonists 407–409 775–776 778–782 general 407–409 selective 409 structure-activity relationships for 407–409 α-Alkyltryptamines 637–638 5α-Androstane 880 α/β-adrenergic receptor(s) antagonists 411 774 776 776 α-Glucosidase inhibitors 872–873 872 Alpha-helix 179 Amebiasis 1084–1085 treatment of 1088 1089–1091 American trypanosomiasis 1086 treatment of 1088–1089 1089–1091 Amidases 180

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Amides, hydrolysis of 284–285 Amines metabolism of 304 oxidative deanimation of 283 Amino acid(s) 119 See al so Peptide(s); Protein(s) central nervous system neurotransmitters criteria 445–446 excitatory 445 446–452 glycine 459–460 historical background 444–445 inhibitory 445 452–459 P.1362 conjugation of 289–290 290 linkage of 117 natural 178 protection of, in peptide synthesis 181–184 182 184 sequence of 119 stereochemistry of 178 structure of 177 178–179 trifunctional, in peptide synthesis 182–184 Aminoacridines 1095 7-Aminocephalosporanic acid (7-ACA) 1056 Aminocyclitols 1065–1069 Aminoglycosides 1065–1069 2-Aminoimidazolines 403 Aminopeptidases 180 4-Aminoquinolines 991–993 8-Aminoquinolines 1099 Aminorex 643–644 Aminotetralins 422 AMP 397–398 AMPA 449 Amphetamine-related agents 551 642–646 Amphoteric compounds 28 Amylin, in diabetes mellitus 860 Amylin agonists, in diabetes mellitus 865 Anabolic steroids 1274 1276 1279–1281 Analeptics 642–646 Analgesics See al so Opioid(s) antipyretic 962–965 definition of 652 early development of 4–5 early investigations of 17–18 opioid 652–676 Ancyl ostoma duodenal e 1090 1101 1103 Ancylostomiasis 1101 treatment of 1102–1107 Androgen antagonists 1281 1288–1290 Androgen receptors 1281–1282 Androgen(s) 1265–1273 See al so specific androgens biosynthesis of 1268–1270 discovery of 1267 mechanism of action of 880 880 1271–1272

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in men 1265 naturally occurring 1274 1276 physiology 1267–1268 structure-activity relationships for 1279 1312–1313 synthetic 1274 in women 1288 1322 Androstane 17β-carbothioates 900–901 Androstane 17β-carboxylates 900–901 Androstenedione 1304 Androstenedione aromatase inhibitors 1310–1311 1310 Androsterone 1269 Anemia 848 Anesthesia definition of 462 general 490–502 (See al so General anesthesia; Volatile anesthetics) local 462–477 (See al so Local anesthetics) Angina pectoris 706–713 drugs for 706–713 calcium channel blockers 709–711 710 758–765 coronary vasodilators 712–713 712 organic nitrates 707–709 707 hyperlipidemia and 802 Angiotensin antagonists 738–739 Angiotensin I 724 740 See al so Renin-angiotensin pathway Angiotensin II 739 740 in adrenocorticoid synthesis 884 cardiovascular effects of 739–740 741 Angiotensin II receptor antagonists development of 752–753 Angiotensin II receptor blockers 752–757 adverse effects of 756 dosages of 756 mechanism of action of 754 metabolism of 755 pharamocokinetics of 755–756 756 physiochemical properties of 754–755 structure-activity relationships for 754 therapeutic applications of 756 types of 752–754 Angiotensin III 739 740 Angiotensin-converting enzyme 742 Angiotensin-converting enzyme (ACE) inhibitors 108–109 109 742–752 adverse effects of 752 binding of 742 in combination products 751 development of 742–746 dicarboxylate-containing 742 744–746 748 dosages of 755 drug interactions with 752 mechanism of action of 746–747 metabolism of 748–749 pharmacokinetics of 748 749–750 physiochemical properties of 747–748

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structure-activity relationships of 747 748 sulfhydryl-containing 742–744 742 therapeutic applications of 750–751 Angiotensinogen 738 740 Angiotensis 740 Anilidopiperidines 664 Aniline hydroxylase 262 264 Animal studies drug discrimination paradigm in 632–633 stimulus antagonism 632 stimulus generalization 632 training drug doses in 632–633 Ankylosing spondylitis 956 Antagonists 86 partial agonists as 96 Anterior pituitary hormone analogs 139–140 Anthracyclines 1165–1170 1167 Anthranilic acids 979–980 979–980 979 Antiandrogens 1281 1288–1290 Antianginal drugs 706–713 beta blockers 711 calcium channel blockers 709–711 710 759–766 organic nitrates/nitrites 707–709 707 Antianxiety drugs See Anxiolytics Antiarrhythmic drugs 713–719 calcium channel blocker 719 759–766 classification of 714–719 715 mechanism of action of 714–719 structure of 719 Antibiotics 1028–1081 1046–1081 agricultural use of 1035–1036 aminocyclitols 1065–1069 aminoglycosides 1065–1069 antitumor 1165–1173 1167 antiviral action of 1202 bacterial cell wall and 1043–1045 1044–1046 bacteriocidal vs. bacteriostatic 1033 biphasic effect of 1034 β-lactam 1046–1052 (See al so β-lactam antibiotics) combinations of 1034–1035 currently available 1046–1081 cyclic peptides 1078–1079 development of 1029–1031 dosing of 1035 eagle effect of 1034 empiric-based therapy with 1032–1033 historical perspective on 1029–1031 initiation of 1035 inoculum effect and 1034 lincosaminides 1072–1073 macrolide 1069–1072 mechanism of action of 1050–1051 microbial persistence and 1034

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microbial resistance to 1030–1031 1033–1034 1051–1052 inoculum effect and 1034 Kirby-Bauer susceptibility disk testing for 1032–1033 microbial susceptibility to 1033–1034 minimum inhibitory concentration of 1033 narrow-spectrum 1031 nomenclature of 1031 overview of 1028–1031 postantibiotic effect of 1034 prophylactic 1035 protein biosynthesis inhibitors 1065–1077 reserve/special purpose 1077–1081 resistance to 1030–1031 1033–1034 rifamycin for MAC complex 1141–1142 for tuberculosis 1131–1134 1134 route of administration of 1035 selection of 1033 serum protein binding of 1035 streptogramins 1079–1080 susceptibility to, Kirby-Bauer test for 1032–1033 tetracyclines 1073–1077 Antibodies See al so Monoclonal antibodies monoclonal 148–151 Anticancer drugs See Cancer chemotherapy Anticholinergics 381–385 See al so muscarinic antagonists acetylcholine as 371–374 antiparkinsonian 689 691 ethanolamine ethers as 1011–1016 1012 for extrapyramidal side effects 605–606 hypnotic 518–519 pharmacokinetic properties of 381 structure-activity relationships for 371–373 382–383 therapeutic applications of 381 Anticoagulants 820–845 conditions requiring 820–824 direct thrombin inhibitors (DT Is) 832–834 heparin-based 828–832 laboratory assessment and monitoring with 824 mechanism of action of 824 825 oral 824–828 825 826 827 recombinant 138 147 structure-activity relationships for 825–826 thyroid effects of 925 toxicity of 844–845 Anticonvulsives See Antiseizure drugs Antidepressants 5-HT 2A receptor antagonist 428–429 herbal therapy 596–597 hypnotics 519 inhibition 560 interactions with other drugs 559 metabolism 559 560

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monoamine oxidase inhibitors 588–591 mood stabilizers 591–594 neuropeptides 594–596 N-Methyl-D-Aspartate antagonists 594 noreinephrine and serotonin reuptake inhibitors (NSRI) 554 norepinephrine and serotonin reuptake inhibitors (NSRI) 576–588 overview of 547–548 555 physicochemical properties 558–559 in psychotherapy 557–558 selective 5-HT reuptake inhibitors 568–576 selective norepinephrine reuptake inhibitors (SNRIs) 560–567 selective serotonin reuptake inhibitor 627 serotonin transporter and 440–441 stereochemistry 558–559 trycyclic, serotonin transporter and 441 Antidiarrheals enkephalinase inhibitor 675 opioid 675 Antiduretic hormone, in urine formation 724 Antiepileptics See Antiseizure drugs Antiestrogens 1309–1311 1310 1334–1336 for breast cancer 1189 for osteoporosis 942–943 Antifungal drugs 1114–1124 allyl amine 1121–1122 azole CYP450 inhibition by 273 biochemical targets for 1114–1124 currently available 1117 ergosterol biosynthesis inhibitors 1115–1122 intravaginal 1119 morpholine 1122 polyene membrane disrupters 1114–1115 topical 1118 Antigoiter assay 926 Antigout agents 998–1001 Antihelminthic drugs 1102–1107 1103 Antihemophilic A factor 847 Antihemophilic B factor 847 Antihemophilic factor, recombinant 138 Antihistamines 1010–1019 antidepressants derived from 552 antiparkinsonian 689 691 antipsychotics developed from 606–607 as antiulcer agents 1021–1022 first-generation 1011 1011–1012 1012–1015 historical perspective on 1010–1011 hypnotic 518–519 second-generation 1016–1019 1017 1017 1018 sedative effects of 606 topical 1018–1019 tricyclic 1014–1016 1015 Anti-HIV drugs 1214–1224 1215 1219

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antiretroviral drugs 1214–1224 1215 mechanism of action of 1199 1214 protease inhibitors 1219–1220 1219 Antihyperlipidemic drugs 798 Antihypertensive drugs adrenergic neuron blocking agents 782–784 β-blocker 711 773 773 774 775 P.1363 calcium channel blocker 759–766 classification of 774 in combination therapy 765 diuretic 722–736 selection of 773–791 symathomimetics mixed-acting 407 sympatholytic centrally acting 776–778 peripherally acting 773 775–776 vasodilator 784–789 Anti-infectives See antimicrobials Antimalarial drugs 1088–1089 1095–1101 8-aminoquinolines 1099 artemisinins 1100–1101 blood schizonticides 1088 currently available 1097–1101 development of 19 1095–1096 gametocytocides 1088 mechanism of action of 1096 plasmodial resistance to 1096–1097 sporontocides 1088 structure of 1096 4-substituted quinolines 1096–1099 therapeutic applications of 1097 tissue schizonticides 1088 Antimetabolites 1173–1178 anticancer 107–108 108 1173–1178 antiretroviral 106 107 competitive enzyme inhibitors as 106 definition of 106 in drug design 99 purine 1178–1179 1179 pyrimidine 1150 Antimicrobials 1028–1081 See al so Antibiotics agricultural use of 1035–1036 bacteriocidal vs. bacteriostatic 1033 biphasic effect of 1034 broad-spectrum 1031 combinations of 1034–1035 currently available 1036–1081 development of 1029–1031 dosing of 1035 eagle effect of 1034 empiric-based therapy with 1031–1032

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experimentally based therapy with 1032–1033 historical perspective on 1029–1031 initiation of 1035 inoculum effect and 1034 microbial persistance and 1034 minimum inhibitory concentration of 1033 narrow-spectrum 1031 natural product-derived 19–20 nomenclature of 1031 overview of 1028–1031 postantibiotic effect off 1034 prophylactic 1035 quinolones 1040–1043 1040 resistance to 1030–1031 1033–1034 inoculum effect and 1034 Kirby-Bauer susceptibility disk testing for 1032–1033 route of administration of 1035 selection of 1033 serum protein binding of 1035 sulfoanamides 1036–1038 1037 1038 1309 susceptibility to 1033–1034 Kirby-Bauer test for 1032–1033 Antimigraine drugs 425 Antimitotic drugs 1184 Antimycobacterial drugs 1129–1144 Antiparasitic drugs 1088–1101 early development of 19 for ectoparasitic infections 1107–1109 for helminthic infections 1102–1107 for protozoal infections 1088–1101 Antiparkinsonian drugs 684–689 691 anticholinergic 689 691 antihistamine 689 691 dopamine receptor agonist 687–689 691 Antiplatelet drugs 834–841 COX-1 inhibitors 836–837 glycoprotein IIb/IIIa receptor antagonists 839–841 mechanism of action of 836 838 new developments 841 new developments in 841 phosphodiesterase inhibitors 837–838 platelet P2Y purinergic receptor 838–839 Antiplatelet drugs PDE3 selective inhibitors 487 Antipodes 39 Antiprogestins 1318 Antiprotozoal drugs 1089–1101 Antipsychotics 601–627 antidopaminergic actions of 603–604 605–606 benzamide derivatives 611–612 benzazepine derivatives 612–613 benzisoxazole 613–615 butyrophenone 609–611

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5-HT 2A receptor antagonist 428–429 5-HT 2C receptor antagonist 429 mechanism of action of 604 605 neuroleptic 605–611 608 (See al so Neuroleptics) Antipyretics 962–965 early development of 4–5 Antipyrine N-demethylase 260 Antiretroviral drugs 1214–1224 1215 in combination therapy 1224 Antirheumatic drugs See al so Nonsteroidal anti-inflammatory drugs disease-modifying 988–997 992 Antiseizure drugs 521–543 for absence seizures 526 542–543 barbituate 528 barbiturate 533–535 benzodiazepene 528 535–537 biotransformation of 528 bis-carbamates 537–542 development of 527–529 drug interactions with 528 historical perspective on 521 hydantoin 528 529–531 ideal 527–528 iminostilbene 531–533 investigational 543 mechanism of action of 525–527 529 for myoclonic seizures 526 543 new-generation 529 overview of 521 oxazolidinedione 542 pharmacokinetics of 529 for status epilepticus 543 structure of 527–529 529 succinimides 542–543 therapeutic applications of 529–542 for tonic-clonic seizures 526 529–542 Antisense therapeutic agents 201–208 binding site 203 currently available 205 208 design of 202–205 204 in development 206–207 future directions for 208 historical perspective on 201–202 mechanism of action of 202–203 204 overview of 201 pharmacokinetis of 205 structure of 203–204 205 208 synthesis of 202 therapeutic applications of 205–207 toxicity of 204–205 207 Antispasmodics 363 See al so Anticholinergics Antithrombin III 847 Antithrombotics See Anticoagulants

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Antithyroid drugs 923–925 Antituberculin drugs 1130–1140 drug resistance and 1129 1139–1140 first-line agents in 1130–1136 guidelines for 1140 second-line agents in 1136–1139 special considerations for 1139–1140 Antitumor antibiotics 1166 in cancer chemotherapy 1165–1173 Antitussives, opioid 676 Antiulcer drugs 1019–1024 Antiviral drugs 1202–1225 antibiotic 1202 anti-HIV 1199 1214–1224 antiretroviral 1214–1224 1215 in combination therapy 1224 development of 1202 investigational 1224–1225 limitations of 1202 overview of 1202–1203 protease inhibitor 1219–1220 1219 Anxiety disorders 615–627 classification of 615–616 diagnostic criteria for 616 etiology of 616 GABA/benzodiazepine receptor complex and 616–617 treatment of 618–627 (See al so Anxiolytics) Anxiolytics 618–627 benzodiazepine 618–624 development of 618 620 mechanism of action of 620–621 621 metabolism of 623 623 stereochemistry of 622–623 structure of 621–622 structure-activity relationships for 621–622 GABAA partial allosteric modulator 624 626 5HT 2A receptor antagonist 428–429 5HT 1A receptors and 626–627 5HT 2B receptor antagonist 429 nonbenzodiazepine 624–626 626–627 selective serotonin reuptake inhibitor 627 serotonin receptor-active 626–627 627 Apolipoproteins 798 800–802 801 Apparent volume of distribution 234–237 Approvable Letter 333 “ Approved Drug Products with T herapeutic Equivalence Evaluations” 335 Arachidonic acid, in prostaglandin synthesis 957–960 958 Arenaviruses 1195 Arginine 177 Arnaud's butterfly model, of calcium homeostatis 935 936 937 Aromatase inhibitors 1310–1311 1310 1311 for breast cancer 1189 1336–1338 for endometriosis 1323

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Aromatic hydrocarbon hydroxylase 263 271–272 Aromatic hydroxylation 257 270 275–276 Aromatic-L-amino acid decarboxylase 394 394 Aromatization, in estrogen biosynthesis 1304 1304 Arrhythmias drug therapy for 713–719 715 715 719 (See al so Antiarrhythmic drugs) etiology of 713 Arsenicals for trypanosomiasis 1094 Artemisinins 1100–1101 Arterial thrombi 821 Arthritis, rheumatoid 956 Artificial chromosomes 160 Arylaliphatic acids 969–979 See al so Non-steroidal anti-inflammatory drugs drug interactions with 970 metabolism of 970 structure-activity relationships for 969–970 structures of 970 Arylalkylamines 641–642 behavioral effects of 649 Arylamines, carcinogenecity of 290 291 Arylcarboxyesterases 284 Arylethanolamines 410 410 412 2-Arylimidazoline α 1 -agonists 402 Aryloxypropanolamines 410 410 412 413 Arylpiperazines 422–423 422 431 Arylpropionic acid derivatives 970–976 2-Arylpropionic acids, metabolism of 290 Asanguinous resuscitation 848–850 Ascariasis 1101 treatment of 1102–1107 Asparagine 177 Aspartic acid 177 Aspergillosis 1114 Asthma 1009–1010 1230–1260 clinical evaluation 1232–1233 comparisons 1233 drug treatment 1233–1260 epidemiology 1230 etiology 1230–1231 pathogenesis 1232 severity, classification of 1233 therapeutic approaches 1233 Atherosclerosis in diabetes mellitus 859 hyperlipidemia and 802–803 803 Atomic interactions, computation of 57 57 See al so Computational chemistry Atonic seizures 524 AT P 397 481 Atrial fibrillation 821 Atrial thrombosis pathophysiology 822–824 Atypicality theory, of psychosis 428–429

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Autoreceptors See al so Receptor(s) dopamine 604 608 neurotransmitter 90 90 Axon, refractoriness of 465 Axon, reractoriness of 466 P.1364 Azole antifungals 1116 1118–1121 CYP450 inhibition by 273

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B Bacterial cell wall biosynthesis, inhibitors of 1044–1046 functions of 1041 of Gram negative bacteria 1045–1046 1045 of Gram positive bacteria 1044–1045 1045 Bacterial microflora, drug metabolism and 254 294 295 303–304 Bacterial persistance 1034 Bacterial resistance 1030–1031 1033–1034 inoculum effect and 1034 Kirby-Bauer susceptibility disk, testing for 1032–1033 Bacteriophages 132 Barbiturates antiseizure 529 533–535 benzodiazepines and 514 in current use 517 dependence on 514–515 hypnotic 514–516 515 516 517 mechanism of action of 514 metabolism of 322 516 516 pharmacologic effects of 514–515 structure-activity relationships of 515–516 515 ultrashort-acting 502 Basal metabolic rate (BMR), thyroid hormones and 918 Base-catalyzed racemization, of proteins 135 Base(s) common 29 conjugate 28 29 ionization of 29 absorption and 215–218 217 218 calculation of 30–31 salts of, dissolution of 48 224–227 solubility of 219 224 Basophils, histamine synthesis in 1005–1006 Beef tapeworm 1102 Behavioral stimulants 642–646 Benzamide derivative antipsychotics 611–612 Benzene hydroxylase 262 264 Benzimidazoles 1102–1104 1103 Benzimidazolones 435 Benzisoxazoles 613–615 Benzoates 435 Benzodiazepine receptor 618–624 620–621 621 624–626 Benzodiazepines antiseizure 529 535–537 anxiolytic 618–624 (See al so Anxiolytics) barbiturates and 514 GABA receptors for 621 625 hypnotic 509–511 510 Benzodioxanes isosteric replacement in 46

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Benzomorphans 664 Benzothiadiazines 728 729 730 Benzyl ester, in peptide synthesis 182 β-Adrenergic receptor agonists 404–407 for asthma 1233–1240 for congestive heart failure 706 structure-activity relationships for 404–407 β-Adrenergic receptor antagonists 410–413 410 412 for angina 711 for arrhythmias 715 717–718 effects of 412 for hypertension 773 773 774 775 lipophilicity of 410 412 nonselective 410 410 pharmacokinetics of 412 selective 410 410 stereochemistry of 413 structure-activity relationships for 410 410 therapeutic applications of 412 for thyrotoxicosis 919 β-Adrenergic receptor(s) 95–96 363 399–400 See al so Adrenergic receptor(s) β-Blockers See β-adrenergic receptor antagonists β-Carboline-3-carboxylic acid ethyl ester (BCCE) 624–625 β-Carboline(s) 624–625 638 β-Casomorphin 654 5β-Cholestane 879 β-Elimination 135 17β-Estradiol 1305 metabolism of 1305 structure of 880 17β-Hydroxysteroid dehydrogenases 1305 β-lactam antibiotics 1046–1065 allergy to 1052 bacterial resistance to 1051–1052 1057 cephalosporins (See al so Cephalosporins) hydrolysis of 1050–1051 1051 penicillins 1046–1052 (See al so Penicillin(s)) receptor binding of 1046 β-lactamase inhibitors 112 112 β-lactamase(s) 1046–1052 1051 bacterial resistance and 1051–1052 in cephalosporin hydrolysis 1057 classification of 1052 microbial resistance to 1051–1052 1057 in penicillin hydrolysis 1048 β-Oxidation 281 284 β-Pleated sheets 178–179 179 Bhang 633 Biguanides 869–870 Bile, drug elimination via 294 Bile acid sequestrants 804–806 805 Bile acids and salts 797 800 Binding, receptor 86–87 86

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Bioactivation 254 276 definition of 254 Bioassay-directed fractionation 16 Bioassays of natural products 16 44–45 in random screening 45 in targeted screening 45 Bioavailability 242–243 calculation of 243 definition of 241 first pass metabolism and 298 301–303 Biodiversity prospecting 14 Bioequivalence 334 Bioinactivation mechanisms 312–313 Bioisosteric replacement 48 49–52 50 classical 50–51 50 nonclassical 51 51 52 Biological activity, methylation and 26 Biological activity, molecular structure and 26–27 Biological membrane See under Membrane Biologics, regulation of 333 Biologics Control Act 327 Biologics License Application 333 Biopharmaceutical properties gastrointestinal physiology and 210–215 211 214 overview of 210 Biopharmaceutics, definition of 210 Biosynthesis 14 combinatorial 17 Biotechnology 115–170 historical perspective on 116 medicinal agents in 134–137 (See al so Biotechnology pharmaceuticals) overview of 116 recombinant DNA technology in 131–133 132 techniques of 134 Biotechnology pharmaceuticals adverse effects of 137 clotting factors 138 147 cytokine 138 142 delivery methods for 136–137 enzyme 138 growth factors 138 hormone 137 138 139–140 immunogenecity of 137 pharamcokinetics of 137 production of (See al so Recombinant DNA technology) properties of 134–137 stability of 134–136 storage and handling of 136 vaccines 138 147 Biotransformation 254 See al so Drug metabolism in drug elimination 233 to metabolite 233–234

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Biphasic effect 1034 Bipolar disorder (manic-depressive illness) 549 Bis-carbamates 537–542 Bismuth-containing preparations, as antiulcer agents 1024 Bisphosphonate analogs 945–946 Bisphosphonate(s) 942 945–946 945 pharmacokinetics of 946 structure-activity relationships for 945–946 Blastomycosis 1114 Bleomycins 1166 1171–1173 Blocking groups, in peptide synthesis 182 Blood clotting See Coagulation Blood flukes 1102 treatment of 1102–1107 Blood substitutes 850–851 Boc blocking group, in peptide synthesis 182 182 183 185 185 Bonds 86–87 covalent 86–87 86 dipole-dipole 32–33 drug-receptor 86–87 enzyme-inhibitor 105 hydrogen 86 solubility and 31–33 33 33 ion-dipole 33 34 ionic 87 peptide 175 176 178 hydrolysis of 179–180 pseudopeptide 187 187 Bone, calcium in 935 Bone mass age and 935 loss of (See al so Osteoporosis) in Paget's disease 942 Bone mineral density, quantification of 938–939 Bone remodeling disorders of 941 normal 938–939 Botanical dietary supplements 23–24 319–320 Bradykinin pathway 740 Breast cancer See al so Cancer estrogens and 1311 hormonal therapy for 1189 1309–1311 1310 1335–1338 (See al so Antiestrogens) hormone-dependent 1331 1333–1338 Brodifacoum 826 Bronchodilation, khellin in 1009 Brönsted-Lowry acid/base theory 28 Brugi a mal ayi 1103 1105 Brugi a ti mori 1102 1103 Brush border 211 Bufadienolides 699 701 Butyrophenone neuroleptics 609–611

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C C cells, thyroid 913–914 Ca 2+ ion channel See Calcium ion channel Caffeine demethylase 260 Cahn-Ingold-Prelog system 178 Calcitonin 935 in hypercalcemia 940 in hypocalcemia 940 structure of 937 Calcium in local anesthesia 464 465 470 transport and storage of 757 in vascular smooth muscle contraction 758 Calcium channel blockers 759–766 adverse effects of 765 766 antianginal 709–711 710 765 antiarrhythmic 715 719 765 benzothiazepine 759 763 classification of 758–760 development of 759 diaminopropanol ether 759 dihydropyridine 759–760 759 759 dosage of 764 drug interactions with 765 766 mechanism of action of 760–762 metabolism of 763–764 pharmacokinetics of 763 764–765 phenylalkylamine 759 763 physiochemical properties of 762–763 structure-activity relationships for 759–760 761 therapeutic applications of 765 Calcium homeostasis 935–951 See al so specific diseases abnormal, diseases associated with 939–942 hormonal regulation of 935–938 937 normal physiology and 938–939 Calcium ion channels See al so Ion channels/ion channel receptors potential-dependent (voltage gated) 758 receptor-operated 758 structure of 758 in vascular smooth muscle contraction 757–758 Calcium phosphate precipitation, in gene therapy 156–157 Calorigenesis, thyroid hormones in 918–919 goiter and 921 C-AMP 397–398 signaling 480 synthesis of 94 94 Cancer 1147–1189 biochemistry of 1151–1152 P.1365 breast estrogens and 1311

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hormonal therapy for 1189 1309–1311 1310 1335–1338 (See al so Antiestrogens) hormone-dependent 1331 1333–1338 cell growth in 1148–1149 chemotherapy for (See Cancer chemotherapy) drug-induced chemical carcinogenesis 314–315 environmental factors in 1152 1152 genetic factors in 1152 hematologic 1150 metastasis in 1149 prostate 1266 hormonal therapy or 1189 radiation therapy for 1150 surgery for 1152 terminology for 1147–1149 testicular 1266 Cancer chemotherapy 1153–1189 1291–1292 advances in 1153 aklylating agents in 1154–1155 antimetabolites in 107–108 108 1173–1178 antimitotic agents in 1181–1185 antitumor antibiotics in 1165–1173 bone-protecting treatments 1292 development of 1147 epipodophyllotoxins in 1185–1187 1186 historical perspective on 1147 hormonal agents in 1189 1309–1311 1310 1335–1338 limitations of 1153 mitosis inhibitors 1181–1185 natural products in 20–22 rescue agents in 1178 topoisomerase poisons 1185–1187 Candidiasis 1119–1120 Cannabinoids 633–634 Capsid, viral 1193–1194 Carbobenzoxy (Cbz) blocking group, in peptide synthesis 183 Carbodiimide coupling reagants, in peptide synthesis 184 Carbohydrates, complex, metabolism of 872 873 Carbonic anhydrase inhibitors as diuretics 725 727–728 for glaucoma 727 Carboxylesterases 284–285 Carboxylic acids, conjugation of 290 290 Carboxypeptidases 180 Carcinogenicity 313–315 Carcinogens/carcinogenesis 313–315 1148 1152 1152 Cardenolides 699 701 Cardiac arrhythmias drug therapy 713–719 715 715 719 (See al so Antiarrhythmic drugs) etiology of 713 Cardiac disease See Heart disease Cardiac drugs 698–706 See al so Cardiovascular drugs antianginals 706–713 antiarrhythmics 713–719

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beta blockers 711 calcium channel blockers 709–711 759–766 cardiac glycosides 698–705 organic nitrates/nitrites 707–709 707 Cardiac drugs PDE3 selective inhibitors 487 Cardiac electrophysiology 715 Cardiac glycosides 698–705 aglycone portion of 699 699 chemistry of 698–705 700 common names of 700 700 development of 17 dosages of 703 703 drug interactions with 704 mechanism of action of 702 metabolism of 703–704 703 pharmacokinetics of 703 pharmacology of 701 701 with potassium salts 702 preparations of 703 sources of 700 700 structure-activity relationships for 702–703 sugars of 699–700 700 toxicity of 704–705 Cardiac stimulants, early development of 5–7 Cardiovascular disease potential-dependent calcium ion channels and 758 renin-angiotensin pathway in 739–742 Cardiovascular drugs See al so Cardiac drugs angiotensin-converting enzyme inhibitors 108–109 742–752 beta blockers 711 calcium channel blockers 709–711 714–719 758–765 diuretics 722–736 natural product-derived 17 organic nitrates/nitrites 707–709 707 Carrier mediated transport 214–215 214 Catalytic receptors 95 Catecholamine, sleep/wakefulness and 506 Catecholamines 392 See al so Adrenergic drugs sleep/wakefulness and 506 Catechol-O-methyltransferase (COMT ) 401 402 Catechol-O-methyltransferase inhibitors 687 Cathinone 643–644 Cationic lipid vectors 157–159 159 Cbz blocking group, in peptide synthesis 181–182 182 CDNA, cloning of 127 Cell cycle 1148–1149 Cell wall, bacterial 1043–1045 Central nervous system amino acid neurotransmitters criteria 445–446 excitatory 445 446–452 glycine 459–460

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historical background 444–445 inhibitory 445 452–459 Central nervous system drugs, natural product-derived 17–18 Central nervous system peptides, sleep/wakefulness and 508 Cephalosporin C 1056 Cephalosporins 1056–1057 allergy to 1057 chemical properties of 1056 classification of 1058 currently available 1058–1065 first-generation 1058–1059 1058 fourth-generation 1063–1065 hydrolysis of 1059 1060 mechanism of action of 1057 metabolism of 1056–1057 1057 microbial resistance to 1057 Kirby-Bauer susceptibility disk testing for 1059 nomenclature for 1058 second-generation 1059–1061 1060 side effects of 1058 therapeutic, applications of 1058 third-generation 1061–1063 Cestode infections 1102 treatment of 1102–1107 1103 C-GMP signaling 480 Chagas' disease 1086 treatment of 1092 Chemical bonds See Bonds Chemicals, carcinogenic 1152 1152 Chemotherapy See Cancer chemotherapy Chimeric hemoglobins 851 Chiral centers, in diastereomers 39–40 Chiral compounds 39 Chloral derivatives 517 Chloride ion channel, general anesthetics and 496 Chloride ion channel, volatile anesthetics and 494–495 Cholecalciferol 937 937 5α-Cholestane 878–880 878 880 Cholesterol in adrenocorticoid biosynthesis 883–884 885 1304 in androgen biosynthesis 1269 in estrogen biosynthesis 1304 1304 estrogen effects on 943 membrane permeability and 211–212 211 metabolism of, thyroid hormones in 918 in pregnenolone biosynthesis 879 883 1304 1304 structure of 879–880 879 synthesis and degradation of 797 799 800 transport of 798 800–802 800 Cholesterol-lowering drugs 803 natural product-derived 17 Cholinergic blockers See anticholinergics

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Cholinergic receptors muscarinic 363–367 363 Cholinesterase 284 Cholinomimetics indirect 374 Chromosome(s) artificial 160 Chronic obstructive lung disease (COPD) definition 1260 epidemiology 1260 pathogenesis 1260–1261 pharmacotherapy 1261–1262 Chronic renal failure, drug metabolism in 236 Chylomicron remnants 800 801 Chymotrypsin 180 Chymotrypsin inhibitors 110–111 111 Cigarette smoking CYP450 induction and 272 drug metabolism and 272 CIP System 40 Ci s-isomer 42 43 Clearance 235–237 hepatic 235 236–237 renal 235 236 total body 235 Clinical trials 331–332 See al so drug design/development ClogP, in solubility prediction 36–38 38 Clonic seizures 524 Cloning 126–134 See al so recombinant DNA technology cDNA 127 genomic 126–127 vectors in 126–127 (See al so vectors) Clotting factors 847 See al so coagulation; speci fi c factors recombinant 138 147 Coagulants 845–848 Coagulation 820 822 See al so anticoagulants cascade 822–824 822 platelets in 830 835 Coagulation factors 847 recombinant 138 Coagulopathy, snake venom-induced 841 Cocaine-related stimulants 646 Coccidiomycosis 1114 Collagen matrix, in bone 935 Colloids 849–850 849 Colony-stimulating factors, recombinant 138 145–147 Coma, diabetic 864 Combinational chemistry definition of 186 virtual 3 66–77 Combinational library 186 Combinational peptide synthesis 186–187 186 Combinatorial biosynthesis 17

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Common component hypothesis 642 Compartment models 231–232 231 232 Complement, in inflammation 955 977 Complementary DNA cloning of 127 Complex carbohydrates, metabolism of 872 873 Computational chemistry 54–66 55–66 See al so molecular modeling ab i ni ti o methods in 57 empirical force fields in 57 61 enthalpy and 55 Hamiltonians in 56–57 Hartree-Fock method in 57 molecular mechanics and 57 pitfalls in 54–55 quantum mechanics in 56–58 57 semiempirical methods in 58 Computed tomography, quantitative, in bone density analysis 938 Concentration See drug concentration Conductance velocity 465–466 Configuration, molecular 39 Conformational isomerism 43–44 44 biologic activity and 47–48 48 Conformation(s) definition of 43 receptor binding and 87–88 in simulation studies 58 Congestive heart failure calcium channel blockers for 759 cardiac glycosides for 698–705 overview of 739–740 renin-angiotensin pathway in 740–741 Conjugate acid 28 Conjugate base 28 29 30 Conjugation 255 See al so drug metabolism, phase 2 reactions in acetylation in 290–291 291 carboxylic acids 290 of cyanide 294 detoxification via 284 of glucuronic acid 285–288 285 286 of glutathione 291–292 291 P.1366 of mercapturic acid 291–292 291 overview of 285 sequential 285–294 285 286 of sulfates 284 288–289 Connective tissue diseases 956 Conn's syndrome 882–883 Consumer Product Safety Commission 330 Contraceptive vaginal ring 1320–1321 Contraceptives nonoral routes 1320 oral 1317 1318–1320 1322–1323 Controlled substance analogs 647–649

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Convective absorption 211–212 215 Coronary heart disease, hyperlipidemia and 802–803 Coronary vasodilators 712–713 Corticosteroids See al so adrenocorticoid(s); steroids inhaled and intranasal 896–901 897 routes of administration for 886 886 888–889 systemic 886 886 888–889 888 888 topical 886 888 888 893–896 894 895 Corticosterone, structure of 885 Corticotropin-releasing factor, in adrenocorticoid synthesis 884 Corticotropin-releasing factor, neuropeptides 595 Cortisol 903–904 See al so hydrocortisone Coumarin 825–827 825 Coumarin derivatives 825–827 825 Coumestrol 1330 Coupling reagants, in peptide synthesis 184 Covalent bonds enzyme-inhibitor 105 receptor-ligand 86–87 86 COX-2 inhibitors 984–988 Creatinine clearance 237 237 Cretinism 919 921 treatment of 922 Crohn's disease, antisense therapeutic agents for 207 Cryptoccus neoformans 1113 Crystalloids 848–849 849 Cushing's disease 882 Cyanide, conjugation of 294 Cyclic adenosine monophosphate (c-AMP) 397–398 Cyclic nucleotide phosphodiesterases signaling 480 specificity 481–484 482 Cyclic peptides, antibiotic 1078–1079 Cyclooxygenase-2 inhibitors, selective 984–988 985 986 987 CYP1A 259 260 CYP1A1 259 CYP1A2 260 in aromatic hydroxylation 275–276 CYP2A6 261 299 CYP3A in aromatic hydroxylation 275–276 fetal 296 CYP3A4 258 261 262–264 265 300–301 grapefruit juice and 317–319 CYP3A7, fetal 296 CYP2B6 261 CYP2C 261–262 261 262 CYP2C8 261 CYP2C9 261 298 CYP2C19 261 298 CYP2D6 261 262 263 298–299 CYP2E1 in fluorane anesthetic metabolism 278

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in flurane anesthetic metabolism 278 CYP2E1 polymorphism 300 CYP450(s) 256–285 antidepressants and 560 azole antifungals and 1118–1119 1118 in catalysis of endogeneous substances 270 catalytic cycle of 264 268–271 270–271 270 classification of 257–258 260 components of 257 diversity of 258 drug interactions and 273 315–321 evolution of 258 genetic polymorphisms of 258 hydroxylation by 270 275 induction of 271 inhibition of 261 273–274 CYP450 complexation 273 mechanism-based 273–274 reversible 273 metabolically active 258 259–264 259 nomenclature for 258 oxidation by 270 270 274–278 277 reactions catalyzed by 257 257 reactive oxygen species and 269 reduction and oxygenation of 264 270–271 270 structure of 259 subfamilies of 259–264 Cyrochrome P450 257 See al so CYP450(s) Cysteine 177 Cystic fibrosis (CF) 141 Cysticercosis 1102 treatment of 1102–1107 Cytochrme P450 257 See al so CYP450(s) Cytofectins 157–159 157 159 Cytokines inhibitors 993–997 recombinant 138 142–144 Cytomegalovirus infection, antisense therapy for 205 208 Cytoplasmic receptors 95

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D DAMGO 656 DDC coupling reagent, in peptide synthesis 176 184 184 Deep venous thrombosis 820 thrombolytic drugs for 841–845 843 Dehalogenation 277–278 11-Dehydrocorticosterone 879 Dehydroepiandrosterone, in estrogen biosynthesis 1305 Deiodinanases, in thyroid hormone synthesis 917 Delta opioid receptors 655 658 Delta-sleep-inducing peptide (DSIP), sleep/wakefulness and 508 Denaturation, protein 136 11-Deoxycortisol, structure of 885 Deoxyribonucleic acid See DNA Depression 547 See al so antidepressants biological basis 549–551 depressive disorders, types of 548–549 electroconvulsive therapy (ECT ) 597 management guidelines 558 treatment approaches 551–557 Dereplication 16 Dermatophyte infections 1112 treatment for 1114–1124 Dermorphin 654 3-Desacetoxy-7-aminocephalosporanic acid (7-ADCA) 1056 1056 Designer drugs 647–649 Designer estrogens See al so antiestrogens 11-Desoxycorticosterone 879 Detoxification, definition of 282 Dextrorotatory isomers 39–40 Diabetes mellitus 855–860 adiponectin 860 amylin in 860 biochemistry of 858–860 861 complications 859 complications of 859 definitions of 855–857 diagnosis of 860 860 epidemiology of 855 glucagon in 139 860 glucagon-like peptide-1 (GLP-1) 860 historical perspective on 855 insulin 861–865 insulin biosynthesis 861 insulin for 863–865 864 insulin for treatment of 863–864 insulin-like growth factors in 860 non-insulin hormones 865–866 oral hypoglycemic agents 866–874 oral hypoglycemic agents for 866–874 (See al so hypoglycemic agents, oral) pathogenesis of 859

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role of hormones other than insulin 860 signs and symptoms of 860 somatostatin in 860 type 1 855–856 type 2 856 Diabetic coma 864 1,2-Diacylglycerol 1008–1009 Diamine oxidase 283 Diarrhea, drug therapy for 675 Diastereomers 42–43 biological activity of 42–43 42 43 definition of 42 designation and nomenclature of 42–43 receptor binding by 88 88 structure of 39 42–43 42 Dicyclohexylurea (DCU), in peptide synthesis 184 184 Dienophiles 663 Diet CYP450 induction and 272 iodide in, deficiency of 921 Diethylpropion 643–644 Diffuse toxic goiter 921 Diffusion 212–214 Digitalis glycoside 701 Di gi tal i s l anata 700 700 Di gi tal i s purpurea 700 701 Digitoxigenin 699 699 700 Digoxigenin 699 699 700 1,4-Dihydropyridines 759–760 759 759 5α-Dihydrotestosterone 1267 biosynthesis of 1269 1304 structure of 1304 1,25-Dihydroxycholecalciferol 937 938 Diiodo-L-tyrosine 914–915 916 Diiodo-L-tyrosine residues, coupling of 916–917 Diisopropylcarbodiimide (DCI), in peptide synthesis 184 Diisopropylurea (DIU), in peptide synthesis 184 Dimethoxphenylisopropylamines (DMAs) 639 640 641 Dipeptidyl carboxypeptidases 179–180 Diphenylbutyl piperidine neuroleptics 610 Diphosphoglycerate, chimeric hemoglobins and 851 Di phyl l obothri um l atum 1102 1103 Dipole-dipole bonds 32–33 Direct thrombin inhibitors (DT Is) 832 discover and design 832 mechanism of action 832–833 recombinant hirudin derivatives 833–834 Disease-modifying antirheumatic drugs 988–993 992 Dissociation constant (pK 2 ) 29 29 30 percent ionization and 30–31 32 Dissolution See drug dissolution Distomer 89 Distribution coefficient 218 218

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Diuretics 722–736 aldosterone antagonists 726 733–735 carbonic anhydrase inhibitors 725 726 727–728 classification of 725–726 725 development of 725 loop 725 726 731–733 mechanism of action of 725 osmotic 725 726–727 726 pharmacokinetics of 726 phthalimidine derivatives 731 potassium-sparing 725 726 733–735 quinazolinone derivatives 730–731 site of action of 725 structure of 725–726 thiazide 725 726 728 729 730 thiazide-like 725 726 730 DNA cloning of 127 complementary 127 metabolism of 160–165 structure of 117–118 in transcription (See al so T ranscription) DNA probes 133–134 DNA viruses 1193–1194 1196 DNase, recombinant 138 DNase—Dornase Alpha (Pulmozyme) 141 Docetaxel 1184 Dopa decarboxylase 394 Dopamine actions of 680 antipsychotics effects on 603–604 605 auto-oxidation of 682–683 683 biosynthesis of 680 681 in drug addiction 659–660 metabolism of 680 681 in Parkinson's disease 680 regulation of 680 680 681 in self-reward response 659–660 site of action of 1234 1235 sleep/wakefulness and 506 synthesis of 604 608 Dopamine and norepinephrine reuptake inhibitors (DNRI) 554 583–586 Dopamine β-hydroxylase 394 413 Dopamine receptor agonists antiparkinsonian 687–689 for infertility 1326 structure-activity relationships for 687–689 688 690 Dopamine receptor antagonists 603 605 P.1367 Dopamine receptor(s) See al so G protein-coupled receptor(s) antipsychotic effects on 604 autoreceptors 604 608 differentiation of 603–605

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distribution of 604 604 in Parkinson's disease 604 postsynaptic 604–605 presynaptic 604–605 604 in schizophrenia 603–605 structure of 603 subtypes of 604 604 Dopamine transport blockers 646 Dopaminergic pathways 679 680 Dosage drug concentration and 230–231 optimum 230–231 Dose-response relationships 89 90 Downregulation, receptor 97 Downregulation hypothesis 556–557 Drop attacks 524 Drug absorption absorption site pH and 215–218 bioavailability and 241–244 convective 211 215 drug concentration and 213 213 240–241 drug dissolution and 218 218 219–221 224 225 estimation of 242–243 formulations and 211 211 gastrointestinal 210–215 211 238–240 239–240 membrane factors in 211–214 212–215 physiological factors in 212–214 ionization and 215–218 217 218 ion-pair 215 lipid solubility and 211 213 218–219 mechanisms of 212–215 membrane permeability and 211 213 213 partition coefficient and 218–219 218 219 pH-partition hypothesis of 215–219 physiological factors affecting 211 212–214 213 prodrugs and 223 rate of dissolution and 218 219–221 224 factors affecting 219–221 via active transport 214–215 214 via passive diffusion 212–214 213 214 Drug abuse/addiction neurobiology of 659–661 660 rehabilitation in 661 tolerance in 660 withdrawal in 660–661 Drug action duration of 230 nonreceptor 85–86 receptor theory of 27–28 210 selectivity of 27–28 Drug administration extravascular, pharmacokinetics and 230 238–240

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intravascular, pharmacokinetics and 230 232–233 233 intravenous bolus, pharmacokinetics and 237–238 repetitive 245–247 Drug concentration absorption rate and 212–214 213 dosage and 230–231 elimination and 233 235 elimination half-life and 233–234 elimination rate and 233 elimination rate constant and 234 with intravenous infusion 244 244–245 measurement of 227 minimum effective 227 240 minimum inhibitory 1033 minimum toxic 230 one-compartment model for 231 231 peak plasma 240 determination of 241 route of administration and 240–241 therapeutic window and 230 three-compartment model for 231–232 232 two-compartment model for 231 237–238 venous vs. arterial 235 Drug concentration time 233 Drug design/development 26–52 See al so natural products ADME studies in 77–79 230 alkyl chain alteration in 47–48 antimetabolites in 99 for biologics 333 biotechnology in (See al so Biotechnology pharmaceuticals; Recombinant DNA technology) drug metabolism studies in 45 45 functional group modification in 48–51 for generic drugs 333 Good Laboratory Practices regulations and 331 high throughput screening in 15 Institutional Review Board and 331–333 Investigational New Drug Application (INDA) in 331–332 isosteric/bioisosteric replacement in 48–51 48–51 52 lead compound in 13 identification of 47 refinement of 47–48 natural products in 16–23 New Drug Application in 332–333 for orphan drugs 333–334 pharmacophores in 47 47 87 Phase I study in 331 Phase II study in 331 Phase III study in 331–332 pioneers of 1–8 preclinical investigation in 330–331 receptor binding in 89 regulation of 330–331 screening in

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of natural products 15 44–45 of nonsteroidal anti-inflammatory drugs 956–957 random 45 targeted 45 via enzyme inhibition 99–113 (See al so Enzyme inhibition/inhibitors) via observation of side effects 45–46 46 Drug discrimination paradigm 632–633 Drug dissolution See al so solubility absorption and 218 219–221 219 224 225 pH and 224–225 224 surface area and particle size and 226 Drug distribution apparent volume of 234–237 three-compartment model for 231 232 Drug Efficacy Study Implementation Review of 1966 328 Drug elimination 235–237 See al so Clearance; Drug metabolism drug concentration and 233 235 240–241 extraction ratio and 235 half-life and 233 hepatic 235 236–237 243–244 one-compartment model for 231 231 pathways of 294–295 process of 233–234 rate constant (K) for 233–234 rate of 232 235 renal 235 three-compartment model for 231–232 231 232 two-compartment model for 231 231 237–238 via urine 294 Drug Enforcement Administration 330 Drug Importation Act 327 Drug interactions 315–321 CYP450s and 273 315–321 drug metabolism and 315–319 with food 319 with grapefruit juice 317–319 with herbal medicines 319–320 Drug marketing regulations 337 Drug metabolism 253–323 See al so drug elimination acetylation in 290–291 290 291 299 age and 295–297 alcohol and 272–273 amino acid conjugation in 289–290 290 azo reduction in 278 279 bacterial microflora and 254 294 295 303–304 bioactivation and 254 276 bioavailability and 300–304 conjugation in 285–295 (See al so Conjugation) CYP450 in 256–285 (See al so CYP450(s)) dehalogenation in 277–278 278 detoxication and 254 drug interactions and 315–319 in elderly 296

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enterohepatic cycling in 294–295 environmental factors in 256 enzyme induction in 271 enzyme inhibition in 261 273–274 extrahepatic 253 254 302–304 factors affecting 255–256 fetal 296–297 first-pass 254 298 301–303 presystemic 254 300–301 food and 319 gender and 321 genetic factors in 255–256 297–299 genetic polymorphisms and 255–256 297–299 glucuronidation in 285–288 285 286 hepatic 235 236–237 hydroxylation in (See al so Hydroxylation) alicyclic 274 aliphatic 274 alkene 270 274 276 alkyne 269–270 270 274 276 aromatic 269–270 270 275–276 intestinal 303–304 intestinal flora and 254 294 295 303–304 in liver disease 255 256 major pathways of 321 322–323 methylation in 292–294 293 nasal 304 N-dealkylation in 276 277 neonatal 297 nitro reduction in 278 279 N-oxidation in catalyzed by CPY450 276–277 277 catalyzed by flavin monooxygenase 279–280 279 by CPY450 276–277 O-dealkylation in 276 277 277 oral bioavailability and 300–304 oxidation in 256–285 (See al so oxidation) oxidative deanimation in 276 277 pathways of 254–255 peroxidases in 280–281 P-glycoprotein and 301–303 319 pharmacodynamic factors in 256 phase 1 reactions in 254 256–285 phase 2 reactions in 254 285–295 physiologic factors in 255–256 presystemic 243–244 300–301 protein deficiency and 256 pulmonary 304 renal 235 236 S-dealkylation in 277 277 sites of 254 smoking and 272 S-oxidation in

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catalyzed by flavin monooxygenase 279–280 279 stereochemistry and 304–305 stereoselective 305 sulfation in 288–289 toxicity and 305–309 Drug molecules See al so functional groups and under Molecular analysis of 37 properties of, visualization of 55 structure of 56 56 biological activity and 26–27 26 visualization of (See molecular modeling) three-dimensional orientation of 38–39 42–44 Drug recalls 337 Drug receptors See Receptor-drug interactions; receptor(s) Drug regulation 327–330 See al so Food and Drug Administration history of 327–330 Drug solubility See solubility Drug toxicity drug development via 45–46 46 genetic polymorphisms and 297–299 hepatic, dehalogenation and 278 idiosyncratic reactions 309–310 oxidative metabolism and 305–309 Drug transport 213–214 214–215 active (carrier mediated) 214–215 214 via passive diffusion 212–214 213 214 Drug-induced diabetes 857 858 Drug(s) bioequivalent 333 biotechnology-produced (See biotechnology pharmaceuticals) definition of 330 new, definition of 330 physicochemical properties of 28–38 receptors for (See receptor-drug interactions; receptor(s)) Dual energy x-ray absorptiometry, in bone density analysis 938 Dual PPARα and PPARγ coactivators 871–873 Duodenal ulcers, treatment of 1021–1023 P.1368 Duration of action 230 Dwarf tapeworm 1102 Dynorphin 657 Dysrhythmias drug therapy for 713–719 715 715 719 (See al so Antiarrhymthmic drugs) etiology of 713 Dysthymia 549

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E EAA receptors 448–450 metabotropic glutamate receptors 452 Eagle effect 1034 Easson-Stedman hypothesis 40–41 Echinacea 320 Echinocandins 1122–1123 Effector mechanisms of adrenergic receptors 397–398 definition of 397 397 Efferent neuron 464 464 Efficacy definition of 86 89 dose-response relationship and 89 90 E-isomer 42 43 Elastase 180 Elderly depression in 548 drug metabolism in 296 Electroconvulsive therapy (ECT ) 551 597 Electrophiles 310–312 Electroporation 156 Electrostatic interactions, computation of 57 58 Elephantiasis 1102 Elimination, half-life (t 1/2 ) 233–234 Elimination rate 235 Elimination rate constant (K) 233–234 in two-compartment model 238 Empirical force fields 57 58–61 Enantiomers 38 biological activity of 42 definition of 38 designation and nomenclature for 39–40 receptor binding for 41 88–89 88 structure of 39 39 42 Endocrine growth factors recombinant 138 Endocrine therapy, for cancer See al so antiestrogens Endometriosis 1321–1323 Endoneurium 464 464 Endopeptidase 180 Endorphins 654 Endothelin receptor antagonists 792–795 Energy activitation 109 free 55 computation of 56–58 experimental measurement of 58–61 kinetic 57 of molecular systems, computation of 55–66 (See al so Computational chemistry) potential 55

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Energy minimization 62 Enkephalinase inhibitors, antidiarrheal 675 Enkephalins 657–658 structure-activity relationships for 657–658 Entamoeba hi stol yti ca 1084–1085 Enteramine See serotonin Enterobiasis 1101 treatment of 1102–1107 Enterohepatic cycling 295 Enthalpy 55 Enviromics 170 Environmental Protection Agency 330 Enzymatic inhibition 104 Enzymatic reactions 99–100 Enzyme coupled receptors 95 Enzyme induction 271 Enzyme inhibition/inhibitors 99–113 261 273–274 of acetylcholinesterase 108 108 affinity of 104 of angiotensin-converting enzyme 108–109 109 anticancer 107–108 108 antimetabolite 106 106 108 antiretroviral 106 107 CYP450 complexation 273 general concepts 104–105 general concepts of 104–112 historical perspective of 99 irreversible 104–110 110–112 active site directed 110–111 111 mechanism based 111–112 112 mechanism-based 273–274 noncompetitive 104 105 phosphodiesterase 480–486 reversible 105–110 273 competitive 104 105 noncompetitive 104 105 specificity of 100 transition-state analog 109–110 Enzyme(s) action of 105 106 recombinant 138 second messengers and 93 94–95 94 11-Epicortisol 883 Epilepsy 521 See al so antiseizure drugs; seizures Epinephrine 88 90 379 1234 See adrenergic drugs binding site of 397 398 biosynthesis of 392 inhibitors of 413 site of action of 1235 Epipodophyllotoxin 20 Epoxides 307 Erectile dysfunction 480 1292–1297 Ergolines 417 427 431 638

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Ergosterol 1114–1115 Ergosterol biosynthesis inhibitors 1115–1122 Ergot aklaloids 414–415 414 Erythema nodosum leprosum 1142 Erythropoietin, recombinant 145 Esters, hydrolysis of 284–285 1251 Estradiol biosynthesis of 1304 esters of 1307 1309 structure of 1304 Estradiol dehydrogenase 1305 5-α-Estrane 880 Estrogen antagonists 1309–1311 1310 for osteoporosis 942–943 Estrogen receptor modulators, selective 1310 for endometriosis 1323 for osteoporosis 943–945 Estrogen receptor(s) estradiol binding to 1310 1311 Estrogen-dependent breast cancer 1331 1333–1338 Estrogen(s) 1303–1311 See al so speci fi c estrogens biosynthesis of 1304–1305 1304 conjugated 1308–1309 1309 designer (See al so antiestrogens) esterified 1308–1309 1309 mechanism of action of 880 880 1311 metabolism of 1305–1306 1305 nonsteroidal 1309 1309 in oral contraceptives 1317 for osteoporosis 942–945 physiologic effects of 1311 side effects of 1311 steroidal 1307–1309 1308 1309 structure of 880 880 1334 structure-activity relationships for 1309 Estrone 1303–1304 1304–1307 1304 metabolism 1305–1306 Ethanol CPY450 induction and 273 oxidation of 281 toxicity of 281 Ethanoloamine ethers 1011–1016 1012 Ethnobotany 12 13–14 Ethylenediamines 1011 1011–1012 Etiocholanolone 1271 Etriol 1303–1304 Eutomer 89 Exopeptidases 180 Extraction ratio 235 Extrapyramidal nigrostriatal pathway 604 604 612 Extrapyramidal side effects 605 Eye, in diabetes mellitus 859 Eye drops, antihistamine 1018–1019

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Eyeworm 1102 1103

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F Factor IX, recombinant 138 Factor VIII, recombinant 138 Factor XIIIa, in fibrin formation 822 823–824 Farming antibiotics in 1035–1036 antifungals in 1122 Fat See al so lipid(s) glucose uptake into 858 Fat solubility See solubility FDA See Food and Drug Administration Federal Controlled Substances Act (CSA) 328–329 Federal Food, Drug and Cosmetic Act 328 Federal T rade Commission 330 Female reproductive cycle 1302 See al so estrogen(s); progestin(s) Female sex hormones 1301–1338 Females, drug metabolism in 321 Fenamic acids 979–980 979–980 979 Fibrates 804 809 811 adverse effects 815–816 dosage 815 drug interactions 816 mechanism of action 814 metabolism 815 overview 813–814 pharmacokinetic parameters 815 physicochemical properties 814 structure-activity relationships 814 therapeutic applications 815 Fibrin 822 823–824 Fibrin stabilizing factor 847 Fibrinase 847 Fibrinogen 847 Fight or flight response 393 Filariasis 1102 treatment of 1102–1107 First-pass metabolism 254 298 301–303 presystemic 254 Fish tapeworm 1102 Fisher system 40 Fitzgerald factor 847 5-HT 2A receptor antagonist antidepressants 428–429 Flavin monooxygenase catalytic cycle of 279–280 279 isoforms of 279–280 oxidation by 279–280 279 Fletcher factor 847 Flora, intestinal, drug metabolism and 254 295 303–304 Fluorinated hydrocarbons 497–500 See al so volatile anesthetics Fluorinated inhalation anesthetics, toxicity of 278 278

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Fluoroquinolones as antituberculin drugs 1139–1140 1140 Fmoc blocking group, in peptide synthesis 176 182 182 184 185–186 Follicle-stimulating hormone 140 in androgen biosynthesis 1268 in estrogen biosynthesis 1304 for infertility 1326 recombinant 138 Follicular cells, thyroid 913–914 Food CYP450 induction and 272 drug interactions with 319 Food and Drug Administration 328 330 drug recalls by 337 drug seizures by 338 enforcement powers of 337 marketing regulation by 337 new drug approval by 330–335 new drug regulation by 332–333 Orange Book of 335 orphan drug regulation by 333–334 OT C drug regulation by 335–337 Food and Drug Administration Modernization Act 328 329 Fractures, osteoporosis and See Osteoporosis Free energy 55 computation of 56–58 experimental measurement of 58–61 Free radicals 312 Full agonist 96 Functional groups See al so drug molecules acidic 28 29 30 31 analysis 37 base 28 30 characteristics of 37 neutral 30 structure-activity relationships for 45 three-dimensional orientation of 38–39 42–44 water solubilizing potential of 34–36 Fungal infections 1112–1114 dermatophyte 1112–1113 dimorphic fungal 1113–1114 mold 1114 treatment for 1114–1124 yeast 1113 Fungi cell wall of 1114 1122–1123 dimorphic 1113–1114

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G G protein transducers 93–94 93 G protein-coupled receptor(s) 92–95 93 adrenergic 95–96 363 398 muscarinic 363–367 363 (See al so Muscarinic receptors) in signal transduction 364 1236 structure of 421 GABA 452–458 453 455 456 456 antiseizure drugs and 525–527 benzodiazepine hypnotics and 509–510 regulation of 526–527 sleep/wakefulness and 507 synthesis of 526 GABA receptors 526–527 621 625 general anesthetics and 494–495 partial allosteric modulators of 624 subtypes of 621 volatile anesthetics and 496 GABAA antagonists, nonbenzodiazepine 511–512 GABAA receptor 525 GABAB receptor 525 GABA/benzodiazepine receptor complex 620–621 621 GABAnergic neurons, dopamine and 680 681 GABA-transaminase inhibitor 112 112 γ-aminobutyric acid See GABA γ-hydroxybutyrate 458–459 Ganglionic blockers 790–791 Ganglions 385 Ganja 633 Gastric acidity 210–211 Gastric contents, pH of 210–211 Gastric ulcers 1019–1024 1020 treatment of 1021–1023 Gastroesophageal reflux disease 1021 Gastrointestinal drug absorption 210–215 238–240 239–240 See al so drug absorption membrane factors in 211–213 211–214 physiological factors in 212–215 Gastrointestinal membrane See al so under membrane drug absorption and 211–214 215 Gender, drug metabolism and 321 Gene delivery See gene therapy, gene delivery in Gene therapy 152–161 antisense agents in 201–208 (See al so antisense therapeutic agents) artificial chromosomes in 160 calcium phosphate precipitation in 156–157 cationic lipids in 157–159 159 electroporation in 156 gene delivery in 152–161 historical perspective on 152–155 ligand/polylysine/DNA complex in 159–160 nonviral targeted gene transfer in 159–160

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nucleic acid probes in 127–128 134 overview of 152 particle bombardment in 156 steps in 152 vectors in nonviral 155–160 viral 152–155 via nonviral vectors 155–160 via viral vectors 152–155 General anesthesis depth of 491–492 dynamic equilibria in 492 historical perspective on 490 ideal agent for 490 491 reversal of 493 stages of 490–491 General anesthetics administration of 492–493 blood-gas partition coefficients for 493 enantiomers of 494 flammability of 497 GABA receptor and 494–495 496 glutamate and 495–496 496 halogenated hydrocarbon 497 historical perspective on 497 ideal 491 low level chronic exposure to 500 mechanism of action of ion channels and 494–497 496 Meyer-Overton theory of 493–494 metabolism of 493–494 metabolites of 499 minimum alveolar concentration of 493–494 493 NMDA receptor and 495 495 pharmacokinetics of 492–494 potency of 493–494 protein receptors and 494–495 495 short-chain hydrocarbon 497 solubility of 493 stereochemistry of 494 toxicity of 493–494 Generic drugs, regulation of 334 Gene(s) number of 126 structure of 126 tumor suppressor 1148 Genetic disorders gene therapy for (See gene therapy) Genetic engineering See recombinant DNA technology Genetic factors, in drug metabolism 254 Genetic mutations oncogenic 1148–1149 Genetic polymorphisms See polymorphisms

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Genomic cloning 126–127 Genomics-based drug discovery 166–169 Geometric isomers 42 Geometry optimization 57 Gestational diabetes (GDM) 856–857 GHB 458–459 458 Giardiasis 1085 treatment of 1088 1089–1091 Ginkgo Biloba 320 Gitoxigenin 699 699 700 Glaucoma, carbonic anhydrase inhibitors for 727 Glitazones 870–871 870 Glomerular filtration rate 237 722 723 Glucagon, in diabetes mellitus 139 860 Glucagon antagonists, in diabetes mellitus 865 Glucagon-like peptide-1 (GLP-1), in diabetes mellitus 860 Glucagon-like peptide-1 (GLP-1) agonists, in diabetes mellitus 866 Glucocorticoid receptor 904–905 Glucocorticoid(s) 877 See al so adrenocorticoid(s); corticosteroids; speci fi c gl ucocorti coi ds binding 1249 contraindications to 1250 oral, discontinued 877 physiologic effects of 904–905 side effects of 1252 structure-activity relationship 1249–1250 1250 to treat asthma 1252–1254 Glucose levels of control of 859 864 in diabetes mellitus 860 metabolism 858 transporters 858 861 Glucuronidation 285–288 285 286 Glucuronides, toxic 288 Glutamate 446 antiseizure drugs and 526 biosynthesis 446 formation 448 metabotropic receptors 452 receptor subtypes 449 reuptake and metabolism 447–448 synthesis, storage, and release 446–447 Glutamic acid 177 Glutamine 177 Glutathione, conjugation of 291–292 291 Glutathione S-transferase 291–292 Glycine 177 conjugation with 289 Glycoprotein inhibitors 839–841 Glycosaminoglycans 828 Goiter 921 assay 926 toxic 921

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treatment of 922 Goitrogens 925–926 Gold compounds 989–997 990 Golgi apparatus 1005–1006 Gonadotropin analogs 140 Gonadotropin inhibitor 1279 Gonadotropin-releasing hormone 140 Gonadotropin-releasing hormone agonists as anticancer drugs 1189 for endometriosis 1322 Gonadotropin-releasing hormone analogs 140 142 1326–1327 Gonadotropin-releasing hormone antagonists as anticancer drugs 1189 as infertility drug 1326–1327 Good Laboratory Practices regulations 331 Gout 956–957 pathophysiology of 997–998 998 treatment of 998–1001 Gram stains 1031 Grand mal seizures 524 Granulocyte colony-stimulating factor, recombinant 138 142 145–147 Grapefruit juice, drug interactions with 317–319 Grimm's hydride displacement law 48–49 49 Growth factors in cancer 1150 recombinant 138 Growth homone-releasing factor analogs 139–140 Growth hormone, sleep/wakefulness and 507 Growth inhibitors, in cancer 1150 Guanidine derivatives 869–870 Guanylate cyclase 94 Guanylyl cyclase 94

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H Hageman factor 847 Half-life, elimination 233–234 Hallucinogens 429 631–650 See al so pyschomimetic/hallucinogenic agents Halo enol lactones 112 112 Halogenated hydrocarbons 497 See al so volatile anesthetics metabolism of 277–278 278 Hamiltonian 56–57 58 Hansen's disease 1127–1128 drug therapy for 1142–1144 Hard-soft-acids-bases (HSAB) model 308 Hartree-Fock method 57 Hashimoto's disease 921–922 Hashish 633–634 Heart disease See al so under Cardiac; Cardiovascular anticoagulants for 821 (See al so Anticoagulants) congestive heart failure 698 hyperlipidemia 802–803 ischemic calcium channel blockers for 759–766 potential-dependent calcium ion channels and 758 Heart failure See congestive heart failure Heat shock proteins, in steroid action 881 Hel i cobacter pyl ori , peptic ulcer due to 1021 Helminthic infections 1101–1107 Hemaglobin A1C (HbA1C ), diabetes mellitus, glucose control and 859 Hematopoietic growth factor, recombinant 138 145–147 146 Hemoglobins, stroma-free 851 Hemophilia 846 Hemorrhage, thrombolytic-induced 844 Henderson-Hassalbach equation 30–31 Heparin-based anticoagulants chemistry 828–829 high-molecular-weight 830 low-molecular-weight 830–831 mechanism of action 829–830 metabolism 830 newer developments 831–832 pharmacokinetics 830 Hepatic clearance 235 236–237 pre-systemic 243–244 Hepatic disease acetaminophen-induced 965 drug metabolism in 255 256 Hepatic extraction ratio 243–244 Hepatoxicity dehalogenation and 278 drug bioactivation 313 of fluorinated anesthetics 500 of halothane 498 of troglitazone 314

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Herbal medicines See al so under Natural products drug interactions with 319–320 hypnotics 519 Herbal therapy antidepressants 596–597 to treat rheumatoid arthritis 997 Heredity See al so under Gene(s); Genetic Herpes simplex virus, as vector 153 154–155 Herpesviruses 1195 1198 1200 Heteroarylpropionic acid derivatives 970–976 High throughput screening (HT S) 15 High-density lipoproteins 800–802 801 High-molecular-weight kininogen 847 Histamine 1004 1006 comformations of 1004 1006 metabolism of 1005–1006 1007 physiological characteristics of 1005–1007 P.1370 release of 1006–1007 1008 inhibitors of 1009–1010 1010 released, inhibitors of 1010–1019 (See al so Antihistamines) sleep/wakefulness and 506–507 synthesis of 1005–1006 1007 Histamine receptors 1007–1009 agonists and antagonists of 1024–1025 (See al so antihistamines) Histamine-related agonists 1004–1005 1006 Histidine 177 decarboxylation of 1006 1007 Histoplasmosis 1114 HMG-CoA reductase inhibitors 806–811 adverse effects of 810–811 development of 806–807 dosages of 809 drug interactions with 812 mechanism of action of 807–808 807 metabolism of 809 pharmacokinetics of 809–810 809 physiochemical properties of 808–809 structure-activity relationships for 807–808 808 therapeutic applications of 810 Homology modeling 65 Hookworm infection 1101 treatment of 1102–1107 Hormonal hypothesis 551 Hormonal therapy, for cancer 1189 See al so antiestrogens Hormone-responsive elements, in steroid action 881 Hormones commercial available 137 139–140 recombinant 137 138 139–140 HSAB theory 308 5-HT 4 agonists 435 5-HT 2 hypothesis, for hallucinogen action 641–642 hallucinogens and 641–642

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5-HT 1 receptors 420 421–425 422 425 anxiolytics and 626–627 sleep and 506 5-HT 3 receptors 420 430–433 431–433 5-HT 4 receptors 420 433 435–436 5-HT 5 receptors 420 436–437 5-HT 6 receptors 420 437–438 5-HT 7 receptors 420 438–440 5-HT transporter 440–441 5-HT 1A anogists/antagonists 422 5-HT 1B anogists/antagonists 424 5-HT 1D anogists/antagonists 424–425 425 5-HT 1E agnonists/antagonists 427 Human artificial chromosomes 160 Human β 2 adrenergic receptor 397 See al so Adrenergic receptor(s) Human chorionic gonadotropin 1302–1303 1325 Human immunodeficiency virus 1195 1199–1200 1199 proteases 1219–1220 reverse transcriptase 1214 Human immunodeficiency virus infection See al so antisense therapeutic agents antisense therapeutic agents for 205–207 antiviral drugs for (See Antiviral drugs) Human menopausal gonadotropin 1325–1326 Human T -cell lymphotropic virus 1195 Hybridization techniques See al so recombinant DNA technology Hybridoma technology 148–149 Hydantoins 529–531 529 Hydride displacement 48–49 49 Hydrocarbons fluorinated 497–500 toxicity of 498 halogenated 497 metabolism of 277–278 278 short-chain 497 Hydrocortisone metabolism of 884–886 886 structure of 880 885 Hydrogen bonds 87 solubility and 31–33 33 33 Hydrolysis 284–285 Hydroperoxy-eicosatetraenoic acid derivatives 960–961 Hydrophilicity 32 Hydrophobic interactions 87 Hydrophobiticity 32 17α-Hydroxy-11-desoxycorticosterone 879 Hydroxyapatite, in bone 935 8-Hydroxy-2-(di-n-propylamino) tetralin 422 5-Hydroxyindole-3-acetaldehyde 418 419 5-Hydroxyindole-3-acetic acid 418 419 17α-Hydroxylase, inhibition of 1291 Hydroxylation alicyclic 274 aliphatic 274

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of alkanes 274 of alkenes 270–271 270 274 275 276 of alkynes 274 276 aromatic 269–270 270 275–276 by CYP450 270–271 270 274 2-Hydroxymethylethisterone 1279 17α-Hydroxypregnenolone 1305 structure of 885 21-Hydroxyprogesterone, structure of 885 6α-Hydroxyprogesterone, structure of 1312 17α-Hydroxyprogesterones structure of 885 structure-activity relationships for 1312–1313 5-Hydroxytryptophan 419 5-Hydroxytryptophol 418 419 25-hydryoxycholecalciferol 937 Hygienic T able 327 Hymenol epi s nana 1102 1103 Hyperadrenalism 882 Hypercalcemia 940 941 calcitonin for 947–948 Hypercholesterolemia 802 802 diseases caused by 802–803 803 drug therapy for 17 Hyperparathyroidism 941–942 Hypersensitivity to aspirin 967 immediate 1007 1008 to local anesthetics 469 to penicillin 1052 1055 Hypertension drug therapy for 773–791 (See al so antihypertensive drugs) overview of 739–740 769–773 potential-dependent calcium ion channels and 758 in pregnancy 752 primary 739–740 pulmonary arterial drug treatment 791–795 overview 791 symptoms 791 renin-angiotensin pathway in 739–742 secondary 740 Hyperthyroidism 918 919 921–922 See al so thyroid hormone(s) antithyroid drugs for 923–925 Hypertriglyceridemia diseases caused by 802–803 803 drug therapy for 803–804 Hypertriglyceridemias 802 803–804 Hypnotics 504–519 anticholinergic 518–519 antidepressants 519 antihistamine 518–519 barbitruate 514–516

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benzodiazepine 509–511 510 chloral derivative 517 classification of 508–519 development of 5 508 herbal preparations 519 historical perspective on 5 ideal 502 indications for 502 nonbenzodiazepine GABAA , agonist 511–512 overview of 504 piperidinediones 504 sleep physiology and 504–508 (See al so sleep) ureide 528 Hypoadrenalism 905 Hypocalcemia 940 941 Hypoglycemic agents, oral biguanides 869–870 Dual PPARα and PPARγ coactivators 872 first- and second-generation sulfonylureas 867 glitazones 870–871 870 α-glucosidase inhibitors 872 872–873 meglitinides 868–869 rimonabant 873 thiazolidinediones 870–871 870 Hypoparathyroidism 941–942 Hypoprothrombinemia 845 Hypothryoidism 920 See al so T hyroid hormone(s) hormone replacement in 922–923

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I Idiosyncratic drug reactions 309–310 Imidazole antifungals 1116 1118–1121 1118 Imidazoline α 1 -agonists 403 Imiglucerase (Cerezyme) 141–142 Iminostilbenes 531–533 Imipramine 551 Immunodulators, natural product-derived 22–23 Impaired fasting glucose (IFG) 857 Impaired glucose tolerance (IGT ) 857 In vitro fertilization 1323–1324 Indanediones 828 Indolealkylamines 428 hallucinogen 636–638 637 Induced-fit theory 87–88 Infertility 1323–1327 1324 1325 Inflammation chemical mediators of 957–962 958 960 961 nonsteroidal anti-inflammatory drugs for (See nonsteroidal anti-inflammatory drugs) Ing's rule of five 364 372 Injunctions, FDA-supported 338 Inoculum effect 1034 Inositol-1,4,5-triphosphate 1008 Inotropic agents β-adrenergic receptor agonists 706 cardiac glycoside 698–705 Insomnia See al so sleep factors in 505–506 stress-related 504 Institutional Review Board 331 Insulin 137 138 139 analogues 864–865 biosynthesis 861 chemical degradation of 863 in glucose uptake 858 861 metabolism 862 overdose and coma 864 secretion 861 secretion, agents that alter 861 solution structure 862–863 sources 862 stability 863 stability of 863 structure of 862–863 862 863 in treatment of diabetes 863–864 Insulin analogs 864–865 Insulin resistance 858–859 Insulin resistance syndrome 857 Insulin-like growth factor-I, in diabetes mellitus 860 Intercompartmental rate constants 238 Interferon(s)

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recombinant 138 Interleukin-11, recombinant 142 Interleukin-2 fusion protein 142 Interleukin(s) 996 recombinant 142 Intermediate-density lipoproteins 800–802 801 Interstitial drug absorption 211 212 Intestinal P-glycoprotein 301–303 Intestinal villi/microvilli 211 212 Intrauterine devices 1321 Intrauterine insemination (IUI) 1323–1324 Intravenous infusion, drug concentration with 244 244–245 Intrinsic activity 86 Investigational New Drug Application 331–332 Iodide dietary, deficiency of 921 metabolism of 914–915 917 oxidation of 915–916 in thyroid hormone biosynthesis 915–917 917 920 thyroid uptake of 915 Iodine, radioactive thyroid cancer from 922 thyroid imaging with 923 Iodothyronine deiodinases 917 Iodothyronines, release of 917 Iodotyrosines formation of 915–916 residues of, coupling of 916–917 Ion channels/ion channel receptors calcium potential-dependent (voltage gated) 758 cardiovascular disorders and 758 receptor-operated 758 structure of 758 in vascular smooth muscle contraction 757–758 chloride, general anesthetics and 494–495 chloride, volatile anesthetics and 496 general anesthetics and 494–497 496 in impulse propagation 466–467 ligand gated (transmitter gated) 92 94 potassium (See al so ion channels/ion channel receptors) P.1371 general anesthetics and 496 volatile anesthetics and 495 receptor-operated 758 sodium in impulse propagation 466–467 in local anesthesia 470–471 structure of 430 voltage gated (potential-dependent) 758 Ion-dipole bonds 33 34 Ionic bond 87 Ionization

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acid/base 29 29 30 calculation of 30–31 32 drug absorption and 215–218 217 218 solubility and 33–34 Ion-pair absorption 215 Ischemic heart disease calcium channel blockers for 759–766 hyperlipidemia and 802–803 Isogramine 463–464 Isoleucine 177 Isomers conformational 43–44 44 biologic activity and 47–48 48 position, biologic activity and 47–48 48 Isosteric replacement 48–49 48

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J Janus-activated kinases 95

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K K

+

ion channel See potassium ion channel

Kainate 449 Kala azar 1087 Kappa opioid receptors 655 658 Kava 320 K c at inhibitors 111–112 112 Kefauver-Harris Act 328 Kelsey, Frances O. 328 Ketones 435 oxidation of 281 284 Kidney See al so under Renal in diabetes mellitus 859 urine formation in 722–723 723 Kinases 95 Kinetic energy 57 Kininase II See angiotensin-converting enzyme Kirby-Bauer susceptibility disk test 1032–1033

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L Lag time 240 L-Amino acid decarboxylase 418 Lanatosides 700 700 Lanosterol 1116 1117 Latent alkylating agents 111–112 112 Law of mass action, dose-response relationships and 89 Lead compounds definition of 13 identification of 44–45 molecular modeling in 77 refinement of 47–48 Legislation, for drug regulation 327–330 See al so drug regulation Leishmaniasis 1086–1087 treatment of 1088–1089 1093 Lemke's method, for solubility prediction 34–36 Lennox-Gastaut syndrome 524 537 Leprosy 1127–1128 drug therapy for 1142–1144 Leucine 177 Leukemia 1150 Leukotrienes biosynthesis 1255–1256 biosynthesis inhibitors 1256–1258 in inflammation 957–962 960 inhibitors of 973 modifiers 1255–1258 receptors 1256 Leydig's cells 1267–1268 Libido, menopause and 1332 Library combinational 186 Lice and drug therapy for 1107–1109 Ligand-gated ion channels 92 94 Ligand/polylysine/DNA complex, in gene therapy 159–160 Ligand-receptor binding 86–87 See al so receptor-drug interaction; receptor(s) Ligand(s) 86 Light cells, thyroid 913–914 Lincosaminides 1072–1073 Lineweaver-Burk equation 104 Lipid solubility chemical modification for 218–219 219 drug absorption and 211 213 214 218–219 partition coefficient and 218–219 218 Lipid(s) chemistry and biochemistry of 797–802 elevated plasma (See hyperlipidema/hyperlipoproteinemias) metabolism of 798 800–802 800 transport of 798 800–802 800 Lipoproteins 798 800–802 801 classification of 801

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elevated 802–803 802 diseases caused by 802–803 803 high-density 800–802 801 intermediate-density 798 800–802 801 low-density 798 800–802 801 metabolism, nicotinic acid and drug interactions 817 mechanism of action 816–817 overview 816 physicochemical properties 817 side effects 817 therapeutic applications 817 nomenclature for 798 800–802 801 very low-density 798 800–802 801 Lipoxygenases 958 Liver See al so under Hepatic glucose uptake into 858 Loa l oa 1103 Local anesthetics 462–477 acetylcholine and 469 additives to 469 administration of 475 allergy to 469 antiarrhythmic action of 469 714–719 715 719 in current/recent use 467 development of 5 462–464 ideal 464 mechanism of action of 462 470–471 metabolism of 474–475 neuroanatomical considerations for 464 464–466 potassium-enriched 469 preparations of 467–469 resonance forms of 472 472 sodium conductance and 470–471 stereochemistry of 473–474 structure of 468 structure-activity relationships for 471–474 toxicity and side effects of 469 vehicles for 469 LogP in silico prediction 78–79 in solubility prediction 36–38 37 37 Long-acting thyroid stimulator, in Graves' disease 921 Long-chain arylpiperazines 422–423 422 Look-alike drugs 643 Loop diuretics 725 726 731–733 Low-density lipoproteins 798 800–802 801 in atherosclerosis 800 803 L-T ryptophan 177 418 419 Lung disease See chronic obstructive lung disease Lung metabolism 304 Lupus erythematosus 955 Luteinizing hormone 151

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in progesterone biosynthesis 1311 Luteinizing hormone-releasing hormone 151 1291 Luteinizing hormone-releasing hormone agonists, as anticancer drugs 1189 1291 17,20-Lyase, inhibition of 1291 Lysine 177 Lystergamides 638

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M MAC complex 1129 drug therapy for 1140–1142 MAC-Awake 493–494 Macrolide antibiotics 1069–1072 Magic bullet 27 99 Major depression 549 Malaria 1087–1088 drug therapy for 1088–1089 1095–1101 Male osteoporosis 1297 Male sex hormones 1266–1267 See Androgen(s); speci fi c hormones Malignant hyperthermia, in general anesthesia 493–494 MAO-B inhibitors 686 Marijuana 633–634 Marketing regulations 337 Mast cells degranulation of, inhibitors of 1009 1010 1254–1255 histamine in secretion of 1006–1007 storage of 1007 synthesis of 1005–1006 Maturity-onset diabetes of the young 857 857 Maximum plasma concentration 240 determination of 241 Mean residence time (MRT ) 248–249 Mechanism-based inhibition 273–274 irreversible 111–112 112 stabilizers 1255 Medicinal chemistry definition of 26 origins of 1–10 Meglitinides 868–869 Melanocyte-inhibiting factor 596 Melatonin, biosynthesis of 418 419 Membrane permeability 211–214 215 Membrane potential 464–465 465 Membrane structure 211 212–215 Membrane transport 212–215 213–214 Menopause 1327–1331 1332 bone loss in 935 (See al so Osteoporosis) estrogen treatment in 1307–1309 1308 1311 (See al so Estrogen(s)) Menstrual cycle 1302 estrogen effect on 1311 Mental illness classification of 601 pharmacocentric approach to 601 Mercapturic acid, synthesis of 291–292 291 Merrifield's solid phase peptide synthesis method 185–186 185 Mescaline 638 639 Metabolic syndrome 857 857 Metabolite intermediate complexation 273 273

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Metabolites biotransformation to 234 in drug development 45 reactive 310–314 Metabolomics 170 Metastasis 1149 Methanol, toxicity of 281 Methicillin-resistant Staphyl ococcus aureus, (MRSA) 1039 1051 1053 1078–1081 Methionine 177 Methylation 292–294 293 biological activity and 26 26 thiol 293–294 +

1-Methyl-4-phenylpyridinium ion (MPP ), neurotoxicity of 283 1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPT P), neurotoxicity of 282 Methylxanthines 1243–1244 in asthma treatment 1244–1245 sleep/wakefulness and 507 Meyer-Overton theory 493–494 Michaelis-Menten equation 104 Microbial persistance 1034 Microbial resistance 1030–1031 1033–1034 inoculum effect and 1034 Kirby-Bauer susceptibility disk testing for 1032–1033 Microflora, intestinal, drug metabolism and 254 295 303–304 Microsomal ethanol oxidizing system 262 271 Microvilli, intestinal 211 212 Mineralocorticoids 883–884 901 905 See al so adrenocorticoid(s); corticosteroids Minimum effective concentration 230 241 Minimum inhibitory concentration 1032 Minimum toxic concentration 230 Mixed α/β blockers 774 776 776 MlogP, in solubility prediction 36–38 38 Molds 1114 Molecular behavior, computation of See al so computational chemistry Molecular dynamics 58 Molecular mechanics, computation of See al so computational chemistry Molecular modeling ADME prediction 77 computational chemisry and (See al so computational chemistry) computational chemistry and 54–66 55–66 56 conformations in 58 definitions of 54 development of 54 energy minimization in 58 P.1372 graphic display in 55 56 homology 65 mechanics of 54 molecular dynamics in 58 of molecular properties 55 of molecular structure 56 56 Monte Carlo sampling in 66 orbital surface 56

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screening techniques in 77 simulation in 58–61 Molecular properties, visualization of 55 Molecular structure biological structure and 26–27 26 27–28 visualization of (See molecular modeling) Molecule, configuration of 39 Molybdenum hydroxylases, oxidation of 282–283 Monoamine hypothesis 549–551 Monoamine oxidase 283 418 Monoamine oxidase (MAO) inhibitors 301 418–419 adverse effects 589 antidepressants 551 554 588–591 antiparkinsonian 686 drug interactions 321 589–590 foods and 301 589 mechanism of action 589 nonselective 590–591 patient information 590 pharmacokinetics 590 reversible 591 side effects 552 therapeutic uses 590 Monobactams 1065 Monoclonal antibodies 134 148–151 currently available 151 diagnostic applications of 150–151 151 immunogenicity of 150 production of 148–150 149 therapeutic applications of 150 1258–1260 Monoiodo-L-tyrosine 914 915 916 916 Monoiodo-L-tyrosine residues, coupling of 916–917 Monomethoxyphenylisopropylamines 639 Monooxygenases CYP450 (See CYP450(s)) flavin 279–280 279 peroxidase 280–281 Monte Carlo sampling 66 Mood stabilizers 554 591–594 Morphinans 664 Morpholine antifungals 1122 MPP + , neurotoxicity of 283 MPT P, neurotoxicity of 283 683–684 683 Mu opioid receptor agonists clinically available 669–676 receptor binding of 668–669 669 structure-activity relationships for 661–665 Mu opioid receptor antagonists, structure-activity relationships for 665 Mucormycosis 1114 Muscarinic agonists 371–374 structure-activity relationships for 371–373 Muscarinic antagonists 381–385 1240 1241–1242 antiparkinsonian 689 691

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ethanolamine ethers as 1012 for extrapyramidal side effects 605 pharmacokinetic properties of 381 recently discovered 383 385 structure-activity relationships for 382–383 therapeutic applications of 381 Muscarinic cholinergic agents 361 Muscarinic receptors 1241–1242 acetylcholine 363–367 363 function of 363 Ing's rule of five for 364 372 in signal transduction 364–365 structure of 363 363 subtypes of 363–364 Muscle cells, glucose uptake into 858 Muscle relaxants 690–694 693 Muscle spasms drugs for 690–694 693 evaluation of 689–690 Mutagenicity 292 Mutations oncogenic 1148–1149 Mycobacterial infections 1127–1144 drug therapy for 1130–1144 overview of 1127 types of 1127–1129 M ycobacteri um avi um-intracellular complex (MAC) 1129 drug therapy for 1140–1142 Mycolic acids 1130 1131 Mydriatics 381 Myelin sheath 464 464 Myoclonic seizures 524 drugs for 526 543 Myxedema 918 921 treatment of 922

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N Na

+

ion channel See sodium ion channel

NADPH-CYP450 reductase 257 N-Alkylpiperidines 428 N-Alkyltryptamines 636–637 637 Naphthalimides 435 Narcotics See opioid(s) N-Arylanthranilic acids 979–980 979–980 979 Nasal metabolism 304 Natural products 12–24 cardiovascular drugs as 17 definition of 13 development of 16–23 dereplication in 16 high throughput screening in 15 drug interactions with 319–320 early investigations of 1 evaluation of 13–16 44–45 (See al so Drug design/development) future directions for 24 historical perspective on 12–13 as lead compounds 44–45 specimens of collection of 14–15 terminology for 12–13 N-Dealkylation 276–277 277 Necator ameri canus 1101 1103 Nematode infections 1101–1102 treatment of 1102–1107 1103 Neonate, drug metabolism in 297 Neoplasms malignant (See al so Cancer) Nephron, urine formation in 723 723 Nephropathy, diabetic 859 Nephrotoxicity dehalogenation and 278 of fluorinated anesthetics 500 Nerve, peripheral anatomy of 464 464 electrophysiology of 464–465 465 466 Nerve impulse, propagation of 465 466 Nervous system anatomy of 464 464 electrophysiology of 464–465 465 466 sympathetic (See sympathetic nervous system) Neuraminidase inhibitors 1205–1207 1206 Neuroimaging, radiopharmaceuticals in 692 Neuroleptics 605–611 608 antidopaminergic actions of 603 605–606 atypical 605 butyrophenone 609–611 classes of 605–607

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development of 606–607 diphenylbutyl piperidine 610 extrapyramidal side effects of 605 612 long-acting 608–609 608 metabolism of 609 611 pharmacologic effects of 606–607 phenothiazine 606–607 development of 45–46 46 structure-activity relationships for 607–608 thioxanthene 608–609 608 toxicity of 605–606 612 Neuromelanin 683 Neuromuscular blocking agents 385–389 Neuromuscular disorders overview of 679 Parkinson's disease 679–689 spasticity 689–694 Neuronal plasticity, drugs of abuse and 649 Neurons afferent 464 464 efferent 464 464 Neuropeptides 594–596 Neurotoxicity of MPP + 283 of MPT P 283 Neurotransmitter hypothesis 556–557 Neurotransmitters 1234 1236 See al so speci fi c neurotransmi tters amino acid criteria 445–446 excitatory 445 446–452 glycine 459–460 historical background 444–445 inhibitory 445 452–459 anxiety and 616 autoreceptors for 90 in signal transduction 92–95 sleep/wakefulness and 506 sympathetic nervous system 393 New chemical entities (NCEs) See al so drug design/development New drug definition of 330 development of (See drug design/development) New Drug Application 334–335 N-Glucuronides 287 Niacin See nicotinic acid Nicotine, metabolism of 323 Nicotinic acetylcholine receptors 92 367–368 Nicotinic acid drug interactions 817 mechanism of action 816–817 metabolism 817 overview 816 pharmacokinetic parameters 817

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physicochemical properties 817 side effects 817 therapeutic applications 817 Nicotinic antagonists See al so neuromuscular blocking agents historical perspective on 385–386 side effects of 386–387 therapeutic applications of 386 Nicotinic receptor(s) 367–368 1240 acetylcholine 92 367–368 structure of 367–368 Niemann quinoid theory 927 Nigrostriatal pathway 679 680 NIH shift 270 270 Nitrates, antianginal 707–709 707 Nitriles 925 Nitrites, antianginal 707–709 707 Nitro reduction 278 279 Nitrodilators 789–790 Nitrofurantoins 1043 Nitrogen mustards 1154–1155 1154 1155 Nitrosamines 304 Nitrosoureas 1156 1160–1161 1160 Nitrous oxide 500–501 NMDA receptor 635 635 general anesthetics and 492 495–496 495 NMDA receptors 449 450–451 N-Methylation 293 N-Methyl-D-Aspartate antagonists 594 N-Methyl-D-aspartate (NMDA) receptor, general anesthetics and 492 495–496 N-Methyl-D-aspartate (NMDA) receptor, volatile anesthetics and 496 N-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPT P), neurotoxicity of 683–684 N,N'-Dicyclohexylcarbodiimide (DCC), in peptide synthesis 184 184 Nociception 655 Nodal conductance 466–467 Nodes of Ranvier 464 466 Non-Approvable Letter 333 Nonproteinaceous colloids 849–850 849 Nonreceptor drug actions 85–86 Nonsteroidal anti-inflammatory drugs 954–1001 antigout agents 998–1001 1000 aryl- and heteroarylpropionic acid derivatives 970–976 arylalkanoic acids 969–979 disease-modifying antirheumatic drugs 988–997 990 diseases treated by 954–957 956 fenamic acids 979–980 979–980 979 metabolism of 287 oxicams 981–983 982 983 salicylates 965–969 selective COX-2 inhibitors 984–988 selective cyclooxygenase-2 inhibitors 984–988 985 986 987 toxicity of 287 Nontricyclic secondary amine antidepressants 566–567 Noradrenergic presynaptic nerve 555

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Noradrenergic specific serotonergic antidepressants 587–588 19-Norandrostanes 1312–1313 1317 Noreinephrine and serotonin reuptake inhibitors (NSRI) 554 576–588 578 pharmacokinetics 578 P.1373 Norepinephrine 90 90 392 1234 biosynthesis of 393–394 394 inhibitors of 413 metabolism of 394–395 394 release of 394 394 reuptake of 394–395 site of action of 1234 1235 sleep/wakefulness and 506 storage of 394 19-Nortesterones 1315 N-Oxidation by CYP450 276–277 277 by flavin monooxygenase 279–280 279 Noyes-Whitney equations 224 Nucleic acid polymerases 106 Nucleic acid probes 127–128 134 Nucleic acids See al so DNA; RNA Nucleocapsid, viral 1193–1194

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P Paget's disease 942 alendronate for 946 calcitonin for 947–948 Pancreatic hormone analogs 141 Panic attacks 616 627 See al so anxiety disorders Papilomaviruses 1195 Paracoccidiomycosis 1114 Parafollicular cells, thyroid 913–914 Parallel synthesis, peptide 186 186 Paramyxoviruses 1195 Parasitic infections ectoparasitic 1107–1109 helminthic 1101–1107 protozoal 1084–1088 Parasympathetic agents 1240 See al so anticholinergics Parathyroid hormone in bone resorption 937 in calcium homeostasis 935 937 937 excess of 941–942 Parkinson's disease 604 679–689 clinical features of 679 diagnosis of 692 drug therapy for 684–689 etiology of 680–683 683 MPT P in 683–684 683 neuronal cell death in 684 neuropathology of 679 680 681 pathophysiology of 679–680 Partial agonists 96 Particle bombardment 156 Partition coefficient 218–219 218 definition of 36 log of, in solubility prediction 36–38 Partitioning 218–219 Passive diffusion, drug transport via 212–214 213 214 Patent medicines 327 PDEs See phosphodiesterase inhibitors Peak plasma concentration 240 determination of 241 time of occurence of 241 Peak time, determination of 241 Pediculosis 1107–1109 Penicillin binding proteins 1045 1046 Penicillin(s) 1046–1052 allergy to 1052 1055 commercially significant 1047 development of 1046 hydrolysis of 1050–1051 1050 1051 mechanism of action of 1050–1051 1050 1051 metabolism of 1050

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microbial resistance to 1032 1033–1034 1051–1052 Kirby-Bauer susceptibility disk testing for 1032–1033 nomenclature for 1048 penicillinase-resistant oral 1053 parenteral 1053 penicillinase-sensitive oral 1054–1055 parenteral 1055 preparation of 1046–1048 protein binding of 1049–1050 1049 storage of 1049 Penicilloic acid 1048 Pepsin 180 Peptic ulcer disease 1019–1024 1020 treatment of 1021–1023 Peptidases 180 Peptide bonds 176 178 hydrolysis of 179–180 replacement of with pseudopeptide bonds 187 Peptide mimetics 752 753 Peptide synthesis, coupling reagents in 184 Peptide(s) See al so amino acid(s); protein(s) absorption of 180 chemical and physical properties of 178–179 ci s form of 176 conformational features of 178–179 179 definition of 176 drug delivery methods for 179–181 function of 175 historical perspective on 175–176 metabolism of 180–181 reduction of 180 nomenclature for 176 177 peptidase-resistant 179–180 representation of 176 177 retro-inverso 188 188 routes of administration for 180–181 stereochemistry of 178 structure of 177 178–179 178 179 primary 176 secondary 178–179 179 synthesis of 175–176 181–187 advances in 175–176 α-amino group protection in 181–182 bond formation in 184 184 α-carboxyl group protection in 182 combinatorial 186–187 historical perspective on 175–176 solid phase 185–186 in solution 181–184 trifunctional amino acid protection in 182–184 topological modifications of 187–188 187

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trans form of 176 Percent ionization, calculation of 30–31 32 Perchlorate, thyroid imaging with 923 Perfluorochemical blood substitutes 850–851 Perineurium 464 464 Peripheral nerves anatomy of 464 464 465 electrophysiology of 464–465 Permissive hypothesis 551 Peroxidases 280–281 Personalized medicine, pharmacogenomics and 165–170 Pertechnetate, thyroid imaging with 923 Petit mal seizures 524 P-Glycoprotein 301–303 319 placental 296 transporters 561 pH absorption site 215–218 dissolution and 224–225 224 of gastric contents 210–211 intestinal 212 solubility and 224–225 224 tissue fluids 1354 P.1374 pH partition theory 219 Pharmaceutical biotechnology 115–170 See al so biotechnology pharmaceuticals historical perspective on 116 medicinal agents in 134–137 overview of 116 recombinant DNA technology in 134 techniques of 134 Pharmaceutical industry, regulatory oversight of 330 See al so Food and Drug Administration Pharmacogenomics 165–170 Pharmacognosy 12 Pharmacokinetics 229–249 See al so drug absorption; drug distribution; drug elimination; drug metabolism apparent volume of distribution and 234–237 bioavailability 241–244 clearance and 235–237 hepatic 235 236–237 renal 235 236 compartment models for 231–232 231 232 definition of 229–230 dose-dependent 232 elimination half-life and 233 elimination rate constant and 233–234 with extravascular administration 230 238–240 with intravascular administration 230 232–233 233 intravenous infusion 244 linear 232 mean residence time (MRT ) 248–249 non-linear 232 parameters of 229–230

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peak plasma concentration 241 peak time 241 plasma protein binding 247–248 principles of 232 purposes of 229–230 statistical moment analysis 248 Pharmacophores 87 definition of 47 determination of 47 Pharmococentric approach, to mental illness 601 Phase 1 reactions, in drug metabolism 254 256–285 257–285 Phase 2 reactions, in drug metabolism 254 285–295 Phase I studies 331 Phase II studies 331 Phase III studies 331–332 Phenacetin O-demethylase 260 263 Phenmetrazine 643–644 Phenothiazines as antipsychotics 606–608 development of 45–46 606–608 metabolism of 322 Phenoxyphenyl-proplyamine 566–567 567 Phenylalanine 177 Phenylalkylamine hallucinogens 429 636 637 639 Phenylethanolamine agonists α 403 β 404–407 structure-activity relationships for 399 400 Phenylethanolamine-N-methyltransferase 413 Phenylethylamines 639 hallucinogen 636 637 639 Phenylisopropylamines behavioral effects of 649 hallucinogen 636 639 640 stimulant 642–646 4-Phenylpiperidines 664 Phenyltropanes, in Parkinson's disease diagnosis 692 Phobias 615–616 See al so anxiety disorders Phonothiazines as antihistamines 1015–1016 1015 as antipsychotics development of 46–47 Phosphate level 935 Phosphatidylinositol 798 Phosphatidylcholine 257 798 3′-Phosphoadenosine-5′-phosphosulfate (PAPS), in sulfation 288–289 288 Phosphodiesterase 397–398 397 inhibitors for asthma and COPD 1261–1262 enzyme system 480–486 482 for erectile dysfunction 1292–1297 specificity 484–485 Phosphodiesterase inhibitors 787–789 792

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Phospholipase C 94–95 94 398 Phospholipids in local anesthesia 470 synthesis and degradation of 797 800 Phosphonium coupling reagant, in peptide synthesis 184 Phosphorothioate antisense oligonucleotides 203–207 205 See al so antisense therapeutic agents pH-partition hypothesis 215–219 pi values, for solubility prediction 37 Pinworm infection 1101 treatment of 1102–1107 Piperazines 1014 1015 Pituitary hormone analogs 140 pK a (dissociation constant) 29 29 30 215–216 percent ionization and 30–31 32 in silico prediction 80 Placental hormone analogs 142 Plant alkaloids 381–382 Plants, medicinal See natural products Plasma drug concentration See drug concentration Plasma drug concentration time 232–233 233 Plasma extenders 848–851 Plasma protein binding 247–248 Plasma thromboplastin antecedent 847 Plasmid vectors 155 155 Plasminogen 847 Plasminogen activators 842–844 Pl asmodi um fal ci parum 1087–1088 Pl asmodi um mal ari ae 1088 Pl asmodi um oval e 1088 Pl asmodi um vi vax 1088 Platelet-derived growth factor, recombinant 147 Pneumocystis 1085–1086 treatment of 1091–1092 Poison Squad 327 Polyarteritis nodosa 956 Polyene membrane disrupters 1114–1115 Polymorphisms drug metabolism and 254–255 297–299 Polypeptides See peptide(s) Polyphosphatidylinositol, hydrolysis of 398 Pork tapeworm 1102 Position isomers 43 44 biologic activity and 47–48 48 Positron emission tomography, radiopharmaceuticals in 692 Postantibiotic effect 1034 Postsynaptic receptors 90 90 555 Potassium channel openers 786–787 Potassium ion channels See al so Ion channels/ion channel receptors volatile anesthetics and 495 496 Potassium salts, with cardiac glycosides 702 Potassium-sparing diuretics 725 726 733–735 Potency, dose-response relationship and 89 90

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Potential energy 55 56 Potential-dependent ion channels 758 calcium 758 Poxviruses 1195 Preclinical investigation 330–331 Prediabetes 857 Pregnancy fetal drug metabolism in 296–297 hypertension in 756 progesterone in 1312 1317 teratogens in 296 fetal drug metabolism and 296 5α-Pregnane 880 5β-Pregnanediol 1311 Pregnanes 880 1311–1312 Pregnenolone adrenocorticoid biosynthesis from 883–884 885 biosynthesis of 879 883–884 1304–1305 1304 estrogen biosynthesis from 1304–1305 1304 structure of 885 Prehapatic metabolism 243–244 first-pass effect in 254 Prekallikrein factor 847 Prescription Drug User Fee Act 329 333 Presynaptic receptors 90 90 Presystemic metabolism 243–244 300–301 first-pass effect in 254 Price Competition and Patent Restoration Act of 1984 329 Prion diseases 1202 Proaccelerin 847 Probes, nucleic acid 127–128 134 Procainamide, as antiarrhythmic 715–716 715 Proconvertin 847 Prodrugs 223 Progesterone See al so progestin(s) biosynthesis of 1304 1311 functions of 1311 metabolism of 1311 1312 physiologic effects of 1312 structure of 880 885 1304 Progesterone receptor 1317 modulators, for endometriosis 1323 Progesterone responsive elements 1317 Progestin antagonists 1318 Progestin(s) 1311–1318 See al so speci fi c progesti ns biosynthesis of 1311 for endometriosis 1322–1323 mechanism of actions of 880–881 881 1312 metabolism of 1311 1312 in oral conceptives containing only 1320 structure-activity relationships for 1312–1313 synthetic 1313–1314 1313 1315 1317 Prokinetic agents, for peptic ulcer disease 1024

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Prolactin, sleep/wakefulness and 507 Proline 177 Pro-opioid proteins 652 654 Prostacyclin, in inflammation 957–962 960 961 Prostaglandins, in inflammation 957–962 958 960 961 Prostate cancer 1265 See al so cancer hormonal therapy for 1189 1288–1292 Prostatitis 1292 Protease inhibitors 1219–1220 1219 in combination therapy 1224 Protein C 2 847 Protein colloids 849 849 Protein deficiency, drug metabolism and 255 Protein receptors, general anesthetics and 495–496 Protein receptors, volatile anesthetics and 496 Protein S 847 Protein(s) See al so Amino acid(s); Peptide(s) absorption of 180 base-catalyzed racemization of 135 β-elimination in 135 chemical and physical properties of 178–179 ci s form of 176 conformational features of 178–179 179 denaturation of 136 drug delivery methods for 179–181 function of 175 historical perspective on 175–176 hydrolysis of 134–135 instability of 134–136 chemical 134–136 135–136 physical 135–136 metabolism of 180–181 reduction of 180 nomenclature for 176 177 oxidative degradation of 135 posttranslational modifications in 126 routes of administration for 180–181 stereochemistry of 178 structure of 177 178–179 179 primary 176 178 secondary 178–179 synthesis of 123–127 130 thyroid hormones in 919–920 via recombinant DNA 131–133 132 134 trans form of 176 Proteolysis process of 180 reduction of 180 Proteomics 169 Prothrombin 822 823–824 847 Prothrombin time 824 Proton pump inhibitors 1021–1023 1022 1023 Proto-oncogenes 1147–1148

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Protozoal diseases 1084–1088 drug therapy for 1089–1101 Provirus 1214 Pseudohyperparathyroidism 941 Pseudopeptide bonds 187 187 Psoriasis, topical steroids for 894–895 Psychiatric disorders anxiety disorders 618–627 classification of 601 pharmacocentric approach to 601 schizophrenia 601–615 Psychosis 601–615 atypicality theory of 428–429 drug therapy for (See antipsychotics) Psychotherapeutic drugs 601–627 antipsychotic 601–615 (See al so antipsychotics) anxiolytic 618–627 (See al so anxiolytics) Psychotherapy antidepressants 557–558 Psychotomimetic/hallucinogenic agents 631–650 animal studies of 632–633 cannabinoids 633–634 P.1375 classification of 631–632 common component hypothesis for 642 definition of 631 drug discrimination paradigm and 632–633 5-HT 2 , hypothesis for 641–642 indolealkylamine 636–638 637 nonclassical 633–636 PCP-related 634–636 phenylalkylamine 636 638–641 640 Pulmonary arterial hypertension drug treatment 791–795 overview 791 symptoms 791 Pulmonary embolism 820 Pulmonary metabolism 304 Purine antimetabolites 1178–1179 1179 Pyramidine antimetabolites 1150 Pyrazolopyrimidine 513 Pyrazoquinolines 625 Pyrethrins 1108–1109 Pyridoxal phosphate, in histamine formation 1006 1007 Pyrimidine antimetabolites, anticancer 107–108 107 Pyrophosphate 945

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P Paget's disease 942 alendronate for 946 calcitonin for 947–948 Pancreatic hormone analogs 141 Panic attacks 616 627 See al so anxiety disorders Papilomaviruses 1195 Paracoccidiomycosis 1114 Parafollicular cells, thyroid 913–914 Parallel synthesis, peptide 186 186 Paramyxoviruses 1195 Parasitic infections ectoparasitic 1107–1109 helminthic 1101–1107 protozoal 1084–1088 Parasympathetic agents 1240 See al so anticholinergics Parathyroid hormone in bone resorption 937 in calcium homeostasis 935 937 937 excess of 941–942 Parkinson's disease 604 679–689 clinical features of 679 diagnosis of 692 drug therapy for 684–689 etiology of 680–683 683 MPT P in 683–684 683 neuronal cell death in 684 neuropathology of 679 680 681 pathophysiology of 679–680 Partial agonists 96 Particle bombardment 156 Partition coefficient 218–219 218 definition of 36 log of, in solubility prediction 36–38 Partitioning 218–219 Passive diffusion, drug transport via 212–214 213 214 Patent medicines 327 PDEs See phosphodiesterase inhibitors Peak plasma concentration 240 determination of 241 time of occurence of 241 Peak time, determination of 241 Pediculosis 1107–1109 Penicillin binding proteins 1045 1046 Penicillin(s) 1046–1052 allergy to 1052 1055 commercially significant 1047 development of 1046 hydrolysis of 1050–1051 1050 1051 mechanism of action of 1050–1051 1050 1051 metabolism of 1050

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microbial resistance to 1032 1033–1034 1051–1052 Kirby-Bauer susceptibility disk testing for 1032–1033 nomenclature for 1048 penicillinase-resistant oral 1053 parenteral 1053 penicillinase-sensitive oral 1054–1055 parenteral 1055 preparation of 1046–1048 protein binding of 1049–1050 1049 storage of 1049 Penicilloic acid 1048 Pepsin 180 Peptic ulcer disease 1019–1024 1020 treatment of 1021–1023 Peptidases 180 Peptide bonds 176 178 hydrolysis of 179–180 replacement of with pseudopeptide bonds 187 Peptide mimetics 752 753 Peptide synthesis, coupling reagents in 184 Peptide(s) See al so amino acid(s); protein(s) absorption of 180 chemical and physical properties of 178–179 ci s form of 176 conformational features of 178–179 179 definition of 176 drug delivery methods for 179–181 function of 175 historical perspective on 175–176 metabolism of 180–181 reduction of 180 nomenclature for 176 177 peptidase-resistant 179–180 representation of 176 177 retro-inverso 188 188 routes of administration for 180–181 stereochemistry of 178 structure of 177 178–179 178 179 primary 176 secondary 178–179 179 synthesis of 175–176 181–187 advances in 175–176 α-amino group protection in 181–182 bond formation in 184 184 α-carboxyl group protection in 182 combinatorial 186–187 historical perspective on 175–176 solid phase 185–186 in solution 181–184 trifunctional amino acid protection in 182–184 topological modifications of 187–188 187

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trans form of 176 Percent ionization, calculation of 30–31 32 Perchlorate, thyroid imaging with 923 Perfluorochemical blood substitutes 850–851 Perineurium 464 464 Peripheral nerves anatomy of 464 464 465 electrophysiology of 464–465 Permissive hypothesis 551 Peroxidases 280–281 Personalized medicine, pharmacogenomics and 165–170 Pertechnetate, thyroid imaging with 923 Petit mal seizures 524 P-Glycoprotein 301–303 319 placental 296 transporters 561 pH absorption site 215–218 dissolution and 224–225 224 of gastric contents 210–211 intestinal 212 solubility and 224–225 224 tissue fluids 1354 P.1374 pH partition theory 219 Pharmaceutical biotechnology 115–170 See al so biotechnology pharmaceuticals historical perspective on 116 medicinal agents in 134–137 overview of 116 recombinant DNA technology in 134 techniques of 134 Pharmaceutical industry, regulatory oversight of 330 See al so Food and Drug Administration Pharmacogenomics 165–170 Pharmacognosy 12 Pharmacokinetics 229–249 See al so drug absorption; drug distribution; drug elimination; drug metabolism apparent volume of distribution and 234–237 bioavailability 241–244 clearance and 235–237 hepatic 235 236–237 renal 235 236 compartment models for 231–232 231 232 definition of 229–230 dose-dependent 232 elimination half-life and 233 elimination rate constant and 233–234 with extravascular administration 230 238–240 with intravascular administration 230 232–233 233 intravenous infusion 244 linear 232 mean residence time (MRT ) 248–249 non-linear 232 parameters of 229–230

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peak plasma concentration 241 peak time 241 plasma protein binding 247–248 principles of 232 purposes of 229–230 statistical moment analysis 248 Pharmacophores 87 definition of 47 determination of 47 Pharmococentric approach, to mental illness 601 Phase 1 reactions, in drug metabolism 254 256–285 257–285 Phase 2 reactions, in drug metabolism 254 285–295 Phase I studies 331 Phase II studies 331 Phase III studies 331–332 Phenacetin O-demethylase 260 263 Phenmetrazine 643–644 Phenothiazines as antipsychotics 606–608 development of 45–46 606–608 metabolism of 322 Phenoxyphenyl-proplyamine 566–567 567 Phenylalanine 177 Phenylalkylamine hallucinogens 429 636 637 639 Phenylethanolamine agonists α 403 β 404–407 structure-activity relationships for 399 400 Phenylethanolamine-N-methyltransferase 413 Phenylethylamines 639 hallucinogen 636 637 639 Phenylisopropylamines behavioral effects of 649 hallucinogen 636 639 640 stimulant 642–646 4-Phenylpiperidines 664 Phenyltropanes, in Parkinson's disease diagnosis 692 Phobias 615–616 See al so anxiety disorders Phonothiazines as antihistamines 1015–1016 1015 as antipsychotics development of 46–47 Phosphate level 935 Phosphatidylinositol 798 Phosphatidylcholine 257 798 3′-Phosphoadenosine-5′-phosphosulfate (PAPS), in sulfation 288–289 288 Phosphodiesterase 397–398 397 inhibitors for asthma and COPD 1261–1262 enzyme system 480–486 482 for erectile dysfunction 1292–1297 specificity 484–485 Phosphodiesterase inhibitors 787–789 792

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Phospholipase C 94–95 94 398 Phospholipids in local anesthesia 470 synthesis and degradation of 797 800 Phosphonium coupling reagant, in peptide synthesis 184 Phosphorothioate antisense oligonucleotides 203–207 205 See al so antisense therapeutic agents pH-partition hypothesis 215–219 pi values, for solubility prediction 37 Pinworm infection 1101 treatment of 1102–1107 Piperazines 1014 1015 Pituitary hormone analogs 140 pK a (dissociation constant) 29 29 30 215–216 percent ionization and 30–31 32 in silico prediction 80 Placental hormone analogs 142 Plant alkaloids 381–382 Plants, medicinal See natural products Plasma drug concentration See drug concentration Plasma drug concentration time 232–233 233 Plasma extenders 848–851 Plasma protein binding 247–248 Plasma thromboplastin antecedent 847 Plasmid vectors 155 155 Plasminogen 847 Plasminogen activators 842–844 Pl asmodi um fal ci parum 1087–1088 Pl asmodi um mal ari ae 1088 Pl asmodi um oval e 1088 Pl asmodi um vi vax 1088 Platelet-derived growth factor, recombinant 147 Pneumocystis 1085–1086 treatment of 1091–1092 Poison Squad 327 Polyarteritis nodosa 956 Polyene membrane disrupters 1114–1115 Polymorphisms drug metabolism and 254–255 297–299 Polypeptides See peptide(s) Polyphosphatidylinositol, hydrolysis of 398 Pork tapeworm 1102 Position isomers 43 44 biologic activity and 47–48 48 Positron emission tomography, radiopharmaceuticals in 692 Postantibiotic effect 1034 Postsynaptic receptors 90 90 555 Potassium channel openers 786–787 Potassium ion channels See al so Ion channels/ion channel receptors volatile anesthetics and 495 496 Potassium salts, with cardiac glycosides 702 Potassium-sparing diuretics 725 726 733–735 Potency, dose-response relationship and 89 90

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Potential energy 55 56 Potential-dependent ion channels 758 calcium 758 Poxviruses 1195 Preclinical investigation 330–331 Prediabetes 857 Pregnancy fetal drug metabolism in 296–297 hypertension in 756 progesterone in 1312 1317 teratogens in 296 fetal drug metabolism and 296 5α-Pregnane 880 5β-Pregnanediol 1311 Pregnanes 880 1311–1312 Pregnenolone adrenocorticoid biosynthesis from 883–884 885 biosynthesis of 879 883–884 1304–1305 1304 estrogen biosynthesis from 1304–1305 1304 structure of 885 Prehapatic metabolism 243–244 first-pass effect in 254 Prekallikrein factor 847 Prescription Drug User Fee Act 329 333 Presynaptic receptors 90 90 Presystemic metabolism 243–244 300–301 first-pass effect in 254 Price Competition and Patent Restoration Act of 1984 329 Prion diseases 1202 Proaccelerin 847 Probes, nucleic acid 127–128 134 Procainamide, as antiarrhythmic 715–716 715 Proconvertin 847 Prodrugs 223 Progesterone See al so progestin(s) biosynthesis of 1304 1311 functions of 1311 metabolism of 1311 1312 physiologic effects of 1312 structure of 880 885 1304 Progesterone receptor 1317 modulators, for endometriosis 1323 Progesterone responsive elements 1317 Progestin antagonists 1318 Progestin(s) 1311–1318 See al so speci fi c progesti ns biosynthesis of 1311 for endometriosis 1322–1323 mechanism of actions of 880–881 881 1312 metabolism of 1311 1312 in oral conceptives containing only 1320 structure-activity relationships for 1312–1313 synthetic 1313–1314 1313 1315 1317 Prokinetic agents, for peptic ulcer disease 1024

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Prolactin, sleep/wakefulness and 507 Proline 177 Pro-opioid proteins 652 654 Prostacyclin, in inflammation 957–962 960 961 Prostaglandins, in inflammation 957–962 958 960 961 Prostate cancer 1265 See al so cancer hormonal therapy for 1189 1288–1292 Prostatitis 1292 Protease inhibitors 1219–1220 1219 in combination therapy 1224 Protein C 2 847 Protein colloids 849 849 Protein deficiency, drug metabolism and 255 Protein receptors, general anesthetics and 495–496 Protein receptors, volatile anesthetics and 496 Protein S 847 Protein(s) See al so Amino acid(s); Peptide(s) absorption of 180 base-catalyzed racemization of 135 β-elimination in 135 chemical and physical properties of 178–179 ci s form of 176 conformational features of 178–179 179 denaturation of 136 drug delivery methods for 179–181 function of 175 historical perspective on 175–176 hydrolysis of 134–135 instability of 134–136 chemical 134–136 135–136 physical 135–136 metabolism of 180–181 reduction of 180 nomenclature for 176 177 oxidative degradation of 135 posttranslational modifications in 126 routes of administration for 180–181 stereochemistry of 178 structure of 177 178–179 179 primary 176 178 secondary 178–179 synthesis of 123–127 130 thyroid hormones in 919–920 via recombinant DNA 131–133 132 134 trans form of 176 Proteolysis process of 180 reduction of 180 Proteomics 169 Prothrombin 822 823–824 847 Prothrombin time 824 Proton pump inhibitors 1021–1023 1022 1023 Proto-oncogenes 1147–1148

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Protozoal diseases 1084–1088 drug therapy for 1089–1101 Provirus 1214 Pseudohyperparathyroidism 941 Pseudopeptide bonds 187 187 Psoriasis, topical steroids for 894–895 Psychiatric disorders anxiety disorders 618–627 classification of 601 pharmacocentric approach to 601 schizophrenia 601–615 Psychosis 601–615 atypicality theory of 428–429 drug therapy for (See antipsychotics) Psychotherapeutic drugs 601–627 antipsychotic 601–615 (See al so antipsychotics) anxiolytic 618–627 (See al so anxiolytics) Psychotherapy antidepressants 557–558 Psychotomimetic/hallucinogenic agents 631–650 animal studies of 632–633 cannabinoids 633–634 P.1375 classification of 631–632 common component hypothesis for 642 definition of 631 drug discrimination paradigm and 632–633 5-HT 2 , hypothesis for 641–642 indolealkylamine 636–638 637 nonclassical 633–636 PCP-related 634–636 phenylalkylamine 636 638–641 640 Pulmonary arterial hypertension drug treatment 791–795 overview 791 symptoms 791 Pulmonary embolism 820 Pulmonary metabolism 304 Purine antimetabolites 1178–1179 1179 Pyramidine antimetabolites 1150 Pyrazolopyrimidine 513 Pyrazoquinolines 625 Pyrethrins 1108–1109 Pyridoxal phosphate, in histamine formation 1006 1007 Pyrimidine antimetabolites, anticancer 107–108 107 Pyrophosphate 945

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Q Quantitative structure-activity relationships 45 Quantum mechanics, in computational chemistry 56–58 57 Quinazolines 408 Quinolines 435 1095 4-substituted 1096–1099 1096 Quinolones 1040–1043 as antituberculin drugs 1139–1140 1140

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R Racemates 39 designation of 39–40 Racemization, base-catalyzed, of proteins 135–136 Radiation therapy 1150 1152 Radioactive iodine thyroid cancer from 922 thyroid imaging with 923 Radioligands 418 Radiopharmaceuticals, in neuroimaging 692 Rate theory 87 88 Rational drug design See al so drug design/development Reactive metabolites 310–314 Reactive oxygen species 269 Receptor hypothesis 27–28 210 Receptor reserve 96 Receptor sensitivity hypothesis 551 Receptor subtypes 95–96 96 97 Receptor-drug interactions 86–89 86 320 321 activation-aggregation theory of 88 bond types in 86–87 86 conformational change in 87–88 dose-response relationships and 89 90 in drug development 89 induced-fit theory of 87–88 rate theory of 87 stereochemistry of 88–89 88 Receptor-oriented calcium ion channels 758 Receptor(s) 85–98 adrenergic (See Adrenergic receptor(s)) affinity for 86–87 86–89 benzodiazepine 620–621 621 624–625 biological response and 90–95 90 91 catalytic 95 cholinergic 363–385 363 muscarinic 363–367 363 conformational change in 87–88 cytoplasmic 95 definition of 86 desensitization of 97 discovery and elucidation of 85–86 dopamine (See dopamine receptor(s)) dose-response relationships and 89 90 downregulation of 97 dynamic nature of 96–98 enzyme coupled 95 G protein-coupled (See G protein-coupled receptor(s)) GABA 526–527 621 625 general anesthetics and 494–495 496 partial allosteric modulators of 624 subtypes of 526 621

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histamine 1007–1009 1024–1025 ion channel 92 94 ligand gated 92 94 367 structure of 430 ligands for (See al so receptor-drug interactions) muscarinic 1240–1243 (See al so Muscarinic receptors) neurotransmitter 90 90 nicotinic 367–368 1240 acetylcholine 92 367–368 structure of 367–368 NMDA 635 635 general anesthetics and 495 volatile anesthetics and 496 opioid 654–659 postsynaptic 90 90 presynaptic 90 protein, general anesthetics and 495–496 protein, volatile anesthetics and 496 selectivity of 27–28 serotonin (See serotonin receptors) in signal transduction 90 91–92 91 364–365 1236 spare 96 structure of 368 supersensitive 97 upregulation of 97 Recombinant DNA technology cloning in 126–127 (See al so Cloning) vectors for 126–127 DNA/RNA probes in 127–130 134 hybridoma 148–150 monoclonal antibodies in 148–151 pharmaceuticals produced by 137–147 (See al so Biotechnology pharmaceuticals) protein isolation and purification via 133–134 protein synthesis via 133 restriction endonucleases in 127 5α-Reductase, in testosterone metabolism 1269 1270–1271 1271 5α-Reductase inhibitors 1281–1282 1281 1290–1291 Refractoriness 465 466 Renal clearance 235 236 Renal disease, in diabetes mellitus 859 Renal failure, drug metabolism in 236 Renal function, in diabetes mellitus 859 Renin inhibitors 742 742 Renin-angiotensin pathway 739–742 bradykinin pathway and 739 740 in cardiovascular disorders 739–742 components, actions and properties of 738–739 components of, actions and properties of 738–739 740 drugs affecting 741–742 742–752 overview of 738 Reproductive cycle 1301–1303 1302 See Al so Estrogen(s); Progestin(s) Research and development (R&D) See Drug design/development Resting potential 464–465 465

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Restriction endonucleases 127 Retinitis, cytomegalovirus, antisense therapy for 205 208 Retinopathy, diabetic 859 Retro-inverso peptides 188 188 Retroviral vectors 153 153 Retroviruses 1195 1197 Reverse T 914 Reverse transcriptase 1194 HIV 1214 Reye's syndrome 967 Rhabdoviruses 1195 Rheumatic disease(s) 954 956 complement and 956 disease-modifying drugs for 988–997 pathogenesis of 956 therapeutic approach to 962 (See al so nonsteroidal anti-inflammatory drugs) Rheumatic fever 956 Rheumatoid arthritis 956 Ribonucleic acid See RNA Ribosomal RNA 123 Rickets 942 Rifamycin antibiotics for MAC complex 1140–1142 for tuberculosis 1131–1134 1134 Rimonabant 873 Ring equivalents 50 Ring substituents 48 River blindness 1102 1103 RNA antisense 202 (See al so antisense therapeutic agents) ribosomal 123 transcription of (See al so transcription) transfer 123 RNA probes 127–134 RNA viruses 1194 1196 Rodenticides, superwarfarin 826 Roundworm infections 1101 treatment of 1102–1107 RRNA 123 Rule of five 364 372

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S Salicylates 965–969 drug interactions with 967–968 mechanism of action of 965–966 metabolism of 966–967 966 preparations of 968–969 968 side effects of 967 structure-activity relationships for 966 Salts, dissolution of 225–226 225 Sampling, in molecular modeling 63 Sanguinous resuscitation 848 Scabies 1107–1109 Schistosomiasis 1102 treatment of 1102–1107 Schizophrenia diagnostic criteria for 601 dopamine hypothesis of 603–605 dopamine receptors in 603–605 etiology of 601–603 historical perspective on 601 treatment of 605–613 (See al so antipsychotics; neuroleptics) Schwann cell covering 464 464 Screening in molecular modeling 77 of natural products 13–16 44–45 of nonsteroidal anti-inflammatory drugs 956–957 random 45 of synthetic organic compounds 45 targeted 45 S-Dealkylation 277 277 Seasonal affective disorder 549 Second messenger(s) 93 94–95 94 of adrenergic receptors 397–398 cAMP as 397–398 Seizures absence 524 atonic 524 classification of 521–525 522 clonic 524 generalized 523–525 grand mal 524 historical perspective on 521 myoclonic 524 partial 521 522 complex 523 evolution of to generalized seizures 523 simple 522–523 partial (local, focal) 522–523 petit mal 524 in status epilepticus 524–525 tonic 524

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tonic-clonic 524 Selective cyclooxygenase-2 inhibitors (COX-2) 984–988 985 986 987 Selective estrogen receptor modulators 1310 1334–1336 See al so Antiestrogens Selective 5-HT reuptake inhibitors 552 568–576 adverse effects 570 drug interactions 570–571 history of 568 mechanisms of action 568–570 pharmacokinetics 569–570 phenoxyphenylalkylamines 571–574 572 phenylalkylamine 574–575 serotonin hypothesis of depression 568 therapeutic uses 571 Selective norepinephrine reuptake inhibitors (SNRIs) 554 560–567 Selective serotonin reuptake inhibitor (SSRI) 554 576 627 dose, plasma level, potency and serotonin uptake 569 pharmacokinetics 570 serotonin transporter and 440–441 Selective toxicity 27 Self-reward response, in opioid addiction 659–660 Sequence Rule system 40 Serine 177 Serine protease inhibitors 111–112 112 Serotonergic agents, therapeutic applications of 417 Serotonergic presynaptic nerve 555 Serotonin 417–441 action of 419 biosynthesis of 418–419 419 P.1376 historical perspective on 417–418 metabolism of 418–419 419 overview of 417 release of 419 sleep/wakefulness and 506 Serotonin hypothesis of depression 568 Serotonin receptor modulators 586–587 Serotonin receptor-active agents 626–627 627 Serotonin receptors 419–440 See al so G protein-coupled receptors classification of 420–421 420 historical perspective on 419–421 5-HT 1 420 421–425 422 425 5-HT 2 420 427–433 430 5-HT 3 420 430–433 431–433 5-HT 4 420 433 435–436 435 5-HT 5 420 436–437 5-HT 6 420 437–438 5-HT 7 420 438–440 nomenclature for 420–421 420 orphan 420 second messengers for 420 sequence homology of 420 sleep/wakefulness and 506 Serotonin transporter 440–441 440

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Serotoninergic agents 5HT 1A agonists/antagonists 421–425 422 5HT 1B agonists/antagonists 424 5HT 1D agonists/antagonists 424–425 425 5HT 1E agonists/antagonists 427 5HT 1F agonists/antagonists 427 Sex hormone-binding globulin estrogen metabolism and 1306 progestin metabolism and 1311 testosterone metabolism and 1268 Sex hormones 877 1266–1298 1301–1338 See al so speci fi c hormones female 1301–1338 male 1266–1267 mechanism of action of 880–881 881 structure of 880 880 Sexual maturation, estrogens in 1311 S-Glucuronides 287 Sherley Amendment 328 Short-chain hydrocarbons 497 Side effects See al so drug toxicity drug development via 45–46 46–47 Signal transduction 90 91–92 91 364–365 1236 histamine receptors in 1007–1009 Simulation studies 58–61 Single photon emission computed tomography, radiopharmaceuticals in 692 Skeletal muscle relaxants 690–694 693 Sleep age and 505 circadian rhythms and 505 506 CNS peptides and 506–507 drug ingestion and 505 electrophysiology of 504–508 growth hormone and 507 melatonin and 507–508 neurohormonal modulators of 507–508 neurotransmitters and 506 non-REM 504–505 physiology of 504–508 prior sleep history and 505 prolactin and 507 REM 504–505 Sleep cycle 504–508 Sleep disorders 504 Sleeping sickness 1086 treatment of 1088–1089 1089–1091 Small intestine, drug absorption in 211 211 Smoking CYP450 induction and 272 drug metabolism and 272 Parkinson's disease and 682 684 Snake venom, coagulopathy from 841 Sodium ion channels See al so ion channels/ion channel receptors in impulse propagation 466–467

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in local anesthesia 470–471 structure of 758 Solubility absorption rate and 214 219–221 lipid, absorption and 214 218–219 pH and 224–225 224 in silico prediction 80 surface area and particle size and 226 water 31–38 hydrogen bonds and 31–33 33 33 ionization and 33–34 of organic salts 33 prediction of 34–38 Somatostatin, in diabetes mellitus 860 Somatostatin agonists 860 Somatostatin analogs 139 S-Oxidation by CYP450 277 by flavin monooxygenase 279–280 279 Spare receptors 96 Spasmolytics 690–694 693 Spasticity disorders 689–694 drugs for 690–694 693 evaluation of 689–690 Split-and-mix technique 186–187 187 Squalene 1115 1117 Squalene synthase inhibitors 797 St. John's Wort 320 Staphyl ococcus aureus, methicillin-resistant 1051 1053 Statins See HMG-CoA reductase inhibitors Statistical moment analysis 248 Status epilepticus 524–525 drugs for 543 Stereochemistry 38–44 affinity and 88–89 antidepressants 558–559 biological activity and 41 42 definitions for 39–40 designation and nomenclature in 39–40 drug metabolism and 304–305 Stereoisomers 40 biological activity of 41 42 conformation of 43–44 44 definition of 40 designation and nomenclature for 39–40 receptor binding by 88–89 88 structure of 39 Stereoselectivite biotransformation 305 Steroid hormone receptors 881 881 Steroids See al so adrenocorticoid(s); corticosteroids; sex hormones; speci fi c steroi ds anabolic 1274 1276 biosynthesis of 879 883–884 885 ci s form of 879

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classes of 879 880 conformations of 43 43 878–880 878 879 901 mechanism of action of 880–881 881 nomenclature for 877–880 structure of 43 43 877–880 878 879 trans form of 879 Stilbene derivatives 1309 1309 Stimulants 642–646 cocaine-related 646 phenylisopropylamines 642–646 Stimulus antagonism studies 632 Stimulus generalization studies 632 Stomach See under gastric Streptogramins 1079–1080 Strong agonist 96 Strophanthidin 699 700 701 Strophanthus glycosides 701 Strophanthus gratus 700 701 Strophanthus kombe 700 701 Structure-activity relationships 45 quantitative 45 Stuart factor 847 Substance P 596 Succinimides 542–543 Suicide inhibition 273–274 Suicide substrates 112 112 Sulfanilamide antibiotics, structure-activity relationships for 27–28 28 Sulfation 285 288–289 288 glucuronidation and 288 Sulfonamides 1036–1038 1037 See al so Sulfonylureas metabolism of 322 structure-activity relationships for 1142–1143 1142 sulfones and 1142–1143 1142 thyroid effects of 925 Sulfones 1142–1143 Sulfonylureas See al so Sulfonamides first- and second-generation 866–874 Sulfotransferases 289 Sulfur mustards 1154 SULT 1A 289 Superwarfarin rodenticides 826 Surgery cancer 1152 for endometriosis 1323 Sympathetic nervous system fight or flight response and 393 historical perspective on 392 neurotransmitters of (See al so Neurotransmitter) norepinephrine in (See al so Norepinephrine) Sympatholytics centrally acting 776–778 peripherally acting 773 775–776 Syndrome X 857

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Sypathomimetics, mixed acting 407 Systemic lupus erythematosus 956

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T Taeni a sagi nata 1102 1103 Taeni a sol i um 1102 1103 T apeworm infections 1102 T ardive dyskinesia 605–606 612 T eeth, calcium in 935 T enecteplase 141 T eratogenicity 296 T eratogens, fetal drug metabolism and 296 Tert-Butyl ester, in peptide synthesis 182–184 T esticular cancer 1266 1297 T estosterone 1266 1276 biosynthesis of 1268–1270 1304 derivatives of 1274 1276 metabolism of 1270–1271 1271 structure of 880 1304 thyroid effects of 926 T etracyclines 1073–1077 T etrahydrocannabinol (T HC) 633 T hebaine 663 T herapeutic window 230 T hermodynamics, molecular modeling and 61 T hermogenesis, thyroid hormones in 918 goiter and 921 T hiazide diuretics 725 728 729 730 isosteric replacement in 50 T hiazide-like diuretics 725 726 730 T hiazolidinediones 870–871 870 T hiols, methylation of 293–294 T hionamides 924 T hiooxazolidones 925 T hioxanthene neuroleptics 608–609 608 T hree-compartment model, for drug elimination 230–231 231 232 T hreonine 177 T hreshold voltage 465 T hrombokinase 847 T hrombolytic drugs 841–845 843 toxicity of 845 T hrombosis, venous 822–823 thrombolytic drugs for 841–845 843 T hromboxane synthase inhibitors 836–837 T hromboxanes, in inflammation 957–962 960 961 T hrombus 822–823 T hyroglobulin 913 915 920 proteolysis of 917 T hyroid binding globulin 917 917 T hyroid follicular cells 913–914 T hyroid gland cancer of 922 radioiodine in 923 diseases of 921–922

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treatment of 922–926 imaging agents for 923 T hyroid hormone analogs 140 T hyroid hormone(s) 915–921 See al so hyperthyroidism; hypothyroidism; speci fi c hormones analogs of conformations of 929 929 transthyretin receptor model of 929–930 analogues of 926–930 conformations of 929 930 structure-activity relationships for 926–929 927 biosynthesis of 915–917 917 control of 920–921 blood transport of 917–918 917 conformations of 929 929 930 in differentiation 919–920 metabolism of 918 918 natural preparations of 922 physiologic actions of 918–919 in protein synthesis 919–920 synthetic 922–923 T hyroid peroxidase 925 inhibitors of 924 T hyroid storm 921 T hyrotoxic crisis 921 P.1377 T hyrotoxicosis 919 921 antithyroid drugs for 924 radioiodine in 923 T hyrotropin 920 recombinant 138 T hyrotropin-releasing hormone 140 920 T hyroxine (T 4 ) 915 916 see al so thyroid hormone(s) biosynthesis of 915–917 916 conversion to T 3 of 917 deiodination of 917 918 metabolic pathways for 918 918 T inea infections 1112–1113 T issue thromboplastin 847 T LCK 111 111 T PCK 110–111 111 T ogaviruses 1195 T olerance, opioid 660 T onic seizures 524 T onic-clonic seizures 524 drugs for 526 T osyl-lysl-chloromethyl-ketone (T LCK) 111 111 T osyl-phenylalanyl-chloromethyl-ketone (T PCK) 110–111 111 T otal body clearance 235 T ourette's syndrome 611 T oxic adenoma 921 T oxic goiter 921 T oxicity See Drug toxicity T oxins, idosyncratic 309–310

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T PCK 110–111 111 T ranscortin, corticosteroid binding to 888 T ranscription 122–123 123 T ranscriptomics 169 T ransdermal contraceptive patch 1320 T ransduction See signal transduction T ransfer rate constant 238 T ransfer RNA 123 T ransfusion 850–851 Trans-isomer 42 43 T ransition-state analogs 109–110 T ranslation 123 See al so Signal transduction T ransmembrane potential 465 465 7-T ransmembrane proteins 368 T ransmitter-gated ion channels 92 94 T ransthyretin 917 917 T ransthyretin receptor model 929–930 T rematode infections 1102 treatment of 1102–1107 1103 T riazole antifungals 1116 1118–1121 1118 T riazole aromatase inhibitors 1311 1311 T riazolopyridines 624 T richinosis 1101–1102 treatment of 1102–1107 T richloroethanol 517 517 T richomoniasis 1085 treatment of 1102–1107 T richuriasis 1101 treatment of 1102–1107 T ricyclic antidepressants, serotonin transporter and 440–441 T ricyclic secondary amine antidepressants (T CAs) 561–566 adverse effects 564 drug-drug interactions 564 mechanism of action 563 patient information and recommendations 565 pharmacokinetics 563 side effects 564 structure-activity relationship 561–563 therapeutic uses 564 T riglycerides synthesis and degradation of 797 800 transport of 798 800–802 800 T riiodothyronine (T 3 ) 915 916 See al so thyroid hormone(s) biosynthesis of 915–917 916 conversion of T 3 to 917 T rimethoxyphenylisopropylamines (T MAs) 639 640 T ripeptides 176 178 T riphenylethylene analogs 1309 1310 T RNA 123 T rojan horse inhibitors 111–112 T rypanosomiasis 1086 treatment of 1089–1091 T rypsin 180

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T ryptamines 422 435 T ryptophan hydroxylase 418 419 T uberculosis 1128–1129 drug therapy for 1130–1140 first-line agents for 1130–1136 second-line agents in 1136–1139 special considerations in 1139–1140 T umor necrosis factor, recombinant 142 145 T umor suppressor genes 1147–1148 T umors malignant (See al so Cancer) secondary 1149 β-T urns (protein structures) 179 T wo-compartment model, for drug elimination 230–231 231 237–238 T yrosine 177 in dopamine synthesis 604 605 solubility of 34 34 T yrosine hydroxylase 393–394 394 604 604

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U UDP-glucuronosyl transferases (UGT s) 286 287 Ulcer(s), peptic 1019–1024 1020 treatment of 1021–1023 Unipolar depression 549 United States Pharmacopia (USP) 327 Upregulation, receptor 97 Ureides 528 Uric acid, in gout 998 998 Uridine diphosphate glucuronic acid (UDPGA), in glucuronic acid conjugation 285–286 Uridine diphosphate-glucuronosyl transferases (UGT s) 286–287 286 Urine drug elimination via 295 formation of physiology of 722–724 723 regulation of 724 Uronium coupling reagant, in peptide synthesis 184 Uterus estrogen effects on 1311 progestin effects on 1312

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V Vaccines, recombinant 138 147 Valine 177 Valley fever 1114 Vascular disease, in diabetes mellitus 859 Vasodilators arterial 784–789 venous 787–789 Vasopressin 595–596 Vasopressin, in urine formation 724 Vastatins See HMG-CoA reductase inhibitors Vectors cationic lipid 157–159 cloning 126–127 nonviral 155–160 plasmid 155 155 viral 152–155 (See al so viral vectors) Venous thrombi 822–823 thrombolytic drugs for 841–845 843 Venous thromboembolism (VT E) 820 Very low-density lipoproteins 798 800–802 801 Vesicular transporter protein (VGAT ) 453 Villi, intestinal 211 211 Viral infections antisense therapeutic agents for 205–207 (See al so antisense therapeutic agents) causative viruses in 1195 drug therapy for 1202–1225 (See al so antiviral drugs) immune response to 1198 routes of transmission of 1197 types of 1195 1199–1202 Viral vectors 152–155 adeno-associated virus 153 154 adenoviral 153–154 153 herpes simplex virus 153 154–155 retroviral 153 153 Virus, Serum, and T oxins Act 327 Virus(es) see al so viral infections budding of 1193–1194 classification of 1193–1194 1195 DNA 1196 life cycle of 1199 oncogenic 1148 proviruses and 1214 replication of 1194–1199 1196 RNA 1194 1196 structure of 1193–1194 Vitamin D bioactivation of 937 in calcium homeostasis 935 937–938 deficiency of, osteoporosis from 941 in hypoparathyroidism 941

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Vitamin D analogues 941–942 Vitamin D receptors 937–938 Vitamin K, anticoagulants and 825 825 Volatile anesthetics see al so general anesthesia flammability of 497 fluorinated hydrocarbon 497–500 metabolism of 278 278 toxicity of 278 278 Voltage gated ion channels 758 calcium 758 Von Willebrand's disease 846–847

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W Water as amphoteric compound 29 leveling effect of 29 Water solubility 31–38 hydrogen bonds and 31–33 33 33 ionization and 34 of organic salts 33 potential for, of functional groups 36 prediction of 34–38 analytic approach to 36–38 empiric approach to 34–36 Waxman-Hatch Act 329 Whipworm infections 1101 treatment of 1102–1107 Wiley Act 327 Withdrawal, opioid 661 Wolff-Chaikoff block 920 Women drug metabolism in 321 reproductive cycle 1301–1303 1302 (See al so estrogen(s); progestin(s)) sex hormones in 1301–1338 Wucherreri a bancrofti 1102 1103

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X Xanthine dehydrogenase 282–283 Xanthine oxidase 282–283 Xenobiotics definition of 253 metabolism of (See drug metabolism)

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Y Yeast artificial chromosomes 160 Yeast infections 1113 treatment for 1114–1124

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Z Z-isomer 42 Zwitterions, solubility of 34 34 Zygomycosis 1114

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Foye's Principles of Medicinal Chemistry (Lemke, Foye's Principles of Medicinal Chemistry)

Quantum Medicinal Chemistry (Methods and Principles in Medicinal Chemistry)

Practice of Medicinal Chemistry

Medicinal Chemistry

Fundamentals of Medicinal Chemistry

Fundamentals of Medicinal Chemistry

Fundamentals of Medicinal Chemistry

Medicinal applications of coordination chemistry

Medicinal Chemistry of Anticancer Drugs

The Practice of Medicinal Chemistry

Quantum Medicinal Chemistry (Methods and Principles in Medicinal Chemistry, Vol. 17)

Bioinorganic Medicinal Chemistry

Mass Spectrometry in Medicinal Chemistry: Applications in Drug Discovery (Methods and Principles in Medicinal Chemistry)

Quantum Medicinal Chemistry

Chemogenomics in Drug Discovery: A Medicinal Chemistry Perspective (Methods and Principles in Medicinal Chemistry)

Advanced Practical Medicinal Chemistry

Advances in Medicinal Chemistry, Volume 4 (Advances in Medicinal Chemistry)

Progress in Medicinal Chemistry, Volume 45 (Progress in Medicinal Chemistry) (Progress in Medicinal Chemistry)

Medicinal Chemistry An Introduction

Progress in Medicinal Chemistry, Volume 43 (Progress in Medicinal Chemistry)

Advances in Medicinal Chemistry, Volume 4 (Advances in Medicinal Chemistry)

Advances in Medicinal Chemistry, Volume 5 (Advances in Medicinal Chemistry)

Principles of Food Chemistry

Principles of food chemistry

Principles of Polymer Chemistry

Principles of Environmental Chemistry

Principles of Food Chemistry

Principles of Modern Chemistry

Principles of Modern Chemistry

Principles of soil chemistry

Foye's Principles of Medicinal Chemistry (Lemke, Foye's Principles of Medicinal Chemistry)

Quantum Medicinal Chemistry (Methods and Principles in Medicinal Chemistry)

Practice of Medicinal Chemistry

Medicinal Chemistry

Fundamentals of Medicinal Chemistry

Fundamentals of Medicinal Chemistry

Fundamentals of Medicinal Chemistry

Medicinal applications of coordination chemistry

Medicinal Chemistry of Anticancer Drugs

The Practice of Medicinal Chemistry

Quantum Medicinal Chemistry (Methods and Principles in Medicinal Chemistry, Vol. 17)

Bioinorganic Medicinal Chemistry

Mass Spectrometry in Medicinal Chemistry: Applications in Drug Discovery (Methods and Principles in Medicinal Chemistry)

Quantum Medicinal Chemistry

Chemogenomics in Drug Discovery: A Medicinal Chemistry Perspective (Methods and Principles in Medicinal Chemistry)

Advanced Practical Medicinal Chemistry

Advances in Medicinal Chemistry, Volume 4 (Advances in Medicinal Chemistry)

Progress in Medicinal Chemistry, Volume 45 (Progress in Medicinal Chemistry) (Progress in Medicinal Chemistry)

Medicinal Chemistry An Introduction

Progress in Medicinal Chemistry, Volume 43 (Progress in Medicinal Chemistry)

Advances in Medicinal Chemistry, Volume 4 (Advances in Medicinal Chemistry)

Advances in Medicinal Chemistry, Volume 5 (Advances in Medicinal Chemistry)

Principles of Food Chemistry

Principles of food chemistry

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