Disease-Modifying Antirheumatic Drugs part 2

Methotrexate

Methotrexate is now considered the DMARD of first choice to treat rheumatoid arthritis and is used in 50–70% of patients. It is active in this condition at much lower doses than those needed in cancer chemotherapy.

Mechanism of Action

Methotrexate's principal mechanism of action at the low doses used in the rheumatic diseases probably relates to inhibition of aminoimidazolecarboxamide ribonucleotide (AICAR) transformylase and thymidylate synthetase, with secondary effects on polymorphonuclear chemotaxis. There is some effect on dihydrofolate reductase and this affects lymphocyte and macrophage function, but this is not its principal mechanism of action. Methotrexate has direct inhibitory effects on proliferation and stimulates apoptosis in immune-inflammatory cells. Additionally, inhibition of proinflammatory cytokines linked to rheumatoid synovitis has been shown, leading to decreased inflammation seen with rheumatoid arthritis.

Pharmacokinetics

The drug is approximately 70% absorbed after oral administration. It is metabolized to a less active hydroxylated metabolite, and both the parent compound and the metabolite are polyglutamated within cells, where they stay for prolonged periods. Methotrexate's serum half-life is usually only 6–9 hours, although it may be as long as 24 hours in some individuals. Methotrexate's concentration is increased in the presence of hydroxychloroquine, which can reduce the clearance or increase the tubular reabsorption of methotrexate. This drug is excreted principally in the urine, but up to 30% may be excreted in bile.

Indications

Although the most common methotrexate dosing regimen for the treatment of rheumatoid arthritis is 15–25 mg weekly, there is an increased effect up to 30–35 mg weekly. The drug decreases the rate of appearance of new erosions. Evidence supports its use in juvenile chronic arthritis, and it has been used in psoriasis, psoriatic arthritis, ankylosing spondylitis, polymyositis, dermatomyositis, Wegener's granulomatosis, giant cell arteritis, systemic lupus erythematosus, and vasculitis.

Adverse Effects

Nausea and mucosal ulcers are the most common toxicities. Progressive dose-related hepatotoxicity in the form of enzyme elevation occurs frequently, but cirrhosis is rare (< 1%). Liver toxicity is not related to serum methotrexate concentrations, and liver biopsy follow-up is only recommended every 5 years. A rare hypersensitivity-like lung reaction with acute shortness of breath is documented, as are pseudolymphomatous reactions. The incidence of gastrointestinal and liver function test abnormalities can be reduced by the use of leucovorin 24 hours after each weekly dose or by the use of daily folic acid, although this may decrease the efficacy of the methotrexate. This drug is contraindicated in pregnancy.

Mycophenolate Mofetil

Mechanism of Action

Mycophenolate mofetil (MMF) is converted to mycophenolic acid, the active form of the drug. The active product inhibits cytosine monophosphate dehydrogenase and, secondarily, inhibits T-cell lymphocyte proliferation; downstream, it interferes with leukocyte adhesion to endothelial cells through inhibition of E-selectin, P-selectin, and intercellular adhesion molecule 1

Indications

MMF is effective for the treatment of renal disease due to systemic lupus erythematosus and may be useful in vasculitis and Wegener's granulomatosis. Although MMF is occasionally used at a dosage of 2 g/d to treat rheumatoid arthritis, there are no well-controlled data regarding its efficacy in this disease.

Rituximab

Mechanism of Action

Rituximab is a chimeric monoclonal antibody that targets CD20 B lymphocytes. This depletion takes place through cell-mediated and complement-dependent cytotoxicity and stimulation of cell apoptosis. Depletion of B lymphocytes reduces inflammation by decreasing the presentation of antigens to T lymphocytes and inhibiting the secretion of proinflammatory cytokines. Rituximab rapidly depletes peripheral B cells although this depletion neither correlates with efficacy nor with toxicity.

Rituximab has shown benefit in the treatment of rheumatoid arthritis refractory to anti-TNF agents. It has been approved for the treatment of active rheumatoid arthritis when combined with methotrexate.

Pharmacokinetics

Rituximab is given as two intravenous infusions of 1000 mg, separated by 2 weeks. It may be repeated every 6–9 months, as needed. Repeated courses remain effective. Pretreatment with glucocorticoids given intravenously 30 minutes prior to infusion (usually 100 mg of methylprednisolone) decreases the incidence and severity of infusion reactions.

Indications

Rituximab is indicated for the treatment of moderately to severely active rheumatoid arthritis in combination with methotrexate in patients with an inadequate response to one or more TNF- antagonists.

Adverse Effects

About 30% of patients develop rashes with the first 1000 mg treatment; this incidence decreases to about 10% with the second infusion and progressively decreases with each course of therapy thereafter. These rashes do not usually require discontinuation of therapy although urticarial or anaphylactoid reactions, of course, preclude further therapy. Immunoglobulins (particularly IgG and IgM) may decrease with repeated courses of therapy and infections can occur, although they do not seem directly associated with the decreases in immunoglobulins. Rituximab has not been associated with activation of tuberculosis, nor with the occurrence of lymphomas or other tumors. Other adverse effects, eg, cardiovascular events, are rare.

Sulfasalazine

Mechanism of Action

Sulfasalazine is metabolized to sulfapyridine and 5-aminosalicylic acid, and it is thought that the sulfapyridine is probably the active moiety when treating rheumatoid arthritis (unlike inflammatory bowel disease). Some authorities believe that the parent compound, sulfasalazine, also has an effect. In treated arthritis patients, IgA and IgM rheumatoid factor production are decreased. Suppression of T-cell responses to concanavalin and inhibition of in vitro B-cell proliferation have also been documented. In vitro studies have shown that sulfasalazine or its metabolites inhibit the release of inflammatory cytokines, including those produced by monocytes or macrophages, eg, interleukins-1, -6, and -12, and TNF- . These findings suggest a possible mechanism for the clinical efficacy of sulfasalazine in rheumatoid arthritis.

Pharmacokinetics

Only 10–20% of orally administered sulfasalazine is absorbed, although a fraction undergoes enterohepatic recirculation into the bowel where it is reduced by intestinal bacteria to liberate sulfapyridine and 5-aminosalicylic acid. Sulfapyridine is well absorbed while 5-aminosalicylic acid remains unabsorbed. Some sulfasalazine is excreted unchanged in the urine whereas sulfapyridine is excreted after hepatic acetylation and hydroxylation. Sulfasalazine's half-life is 6–17 hours.

Indications

Sulfasalazine is effective in rheumatoid arthritis and reduces radiologic disease progression. It has been used in juvenile chronic arthritis and in ankylosing spondylitis and its associated uveitis. The usual regimen is 2–3 g/d.

Adverse Effects

Approximately 30% of patients using sulfasalazine discontinue the drug because of toxicity. Common adverse effects include nausea, vomiting, headache, and rash. Hemolytic anemia and methemoglobinemia also occur, but rarely. Neutropenia occurs in 1–5% of patients, while thrombocytopenia is very rare. Pulmonary toxicity and positive double-stranded DNA are occasionally seen, but drug-induced lupus is rare. Reversible infertility occurs in men, but sulfasalazine does not affect fertility in women. The drug does not appear to be teratogenic.

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Disease-Modifying Antirheumatic Drugs

DMARDs

Careful clinical and epidemiologic studies have shown that rheumatoid arthritis is an immunologic disease that causes significant systemic effects which shorten life in addition to the joint disease that reduces mobility and quality of life. NSAIDs offer mainly symptomatic relief; they reduce inflammation and the pain it causes and often preserve function, but they have little effect on the progression of bone and cartilage destruction. Interest has therefore centered on finding treatments that might arrest—or at least slow—this progression by modifying the disease itself. The effects of disease-modifying therapies may take 6 weeks to 6 months to become evident although some biologics are effective within 2 weeks; generally, they are slow-acting compared with NSAIDs.

These therapies include methotrexate, a T-cell-modulating biologic (abatacept), azathioprine, chloroquine and hydroxychloroquine, cyclophosphamide, cyclosporine, leflunomide, mycophenolate mofetil, a B-cell cytotoxic agent (rituximab), sulfasalazine, and the TNF- -blocking agents. These drugs comprise both biologically derived and nonbiologic agents and will be listed alphabetically, independent of origin. Gold salts, which were once extensively used, are no longer recommended because of their significant toxicities and questionable efficacy.

Abatacept

Mechanism of Action

Abatacept is a costimulation modulator that inhibits the activation of T cells. After a T cell has engaged an antigen-presenting cell (APC), a signal is produced by CD28 on the T cell that interacts with CD80 or CD86 on the APC, leading to T-cell activation. Abatacept (which contains the endogenous ligand CTLA-4) binds to CD80 and 86, thereby inhibiting the binding to CD28 and preventing the activation of T cells.

Pharmacokinetics

Abatacept is given as an intravenous infusion in three initial doses (day 0, week 2, and week 4), followed by monthly infusions. The dose is based on body weight, with patients weighing less than 60 kg receiving 500 mg, those 60–100 kg receiving 750 mg, and those more than 100 kg receiving 1000 mg. Dosing regimens in any adult group can be increased if needed. The terminal serum half-life is 13–16 days. Coadministration with methotrexate, NSAIDs, and corticosteroids does not influence abatacept clearance.

Indications

Abatacept can be used as monotherapy or in combination with other DMARDs in patients with moderate to severe rheumatoid arthritis who have had an inadequate response to other DMARDs. It reduces the clinical signs and symptoms of rheumatoid arthritis, including slowing of radiographic progression. It is also being tested in early rheumatoid arthritis.

Adverse Effects

There is a slightly increased risk of infection (as with other biologic DMARDs), predominantly of the upper respiratory tract. Concomitant use with TNF- antagonists is not recommended due to the increased incidence of serious infection with this combination. Infusion-related reactions and hypersensitivity reactions, including anaphylaxis, have been reported but are rare. Anti-abatacept antibody formation is infrequent (< 5%) and has no effect on clinical outcomes. The incidence of malignancies is similar to placebo with the exception of a possible increase in lymphomas. The role of abatacept in this increase is unknown.

Azathioprine

Mechanism of Action

Azathioprine acts through its major metabolite, 6-thioguanine. 6-Thioguanine suppresses inosinic acid synthesis, B-cell and T-cell function, immunoglobulin production, and interleukin-2 secretion.

Pharmacokinetics

The metabolism of azathioprine is bimodal in humans, with rapid metabolizers clearing the drug four times faster than slow metabolizers. Production of 6-thioguanine is dependent on thiopurine methyltransferase (TPMT), and patients with low or absent TPMT activity (0.3% of the population) are at particularly high risk of myelosuppression by excess concentrations of the parent drug if dosage is not adjusted.

Indications

Azathioprine is approved for use in rheumatoid arthritis and is used at a dosage of 2 mg/kg/d. Controlled trials show efficacy in psoriatic arthritis, reactive arthritis, polymyositis, systemic lupus erythematosus, and Behçet's disease.

Adverse Effects

Azathioprine's toxicity includes bone marrow suppression, gastrointestinal disturbances, and some increase in infection risk, lymphomas may be increased with azathioprine use. Rarely, fever, rash, and hepatotoxicity signal acute allergic reactions.

Chloroquine & Hydroxychloroquine

Mechanism of Action

Chloroquine and hydroxychloroquine are used mainly in malaria and in the rheumatic diseases. The mechanism of the anti-inflammatory action of these drugs in rheumatic diseases is unclear. The following mechanisms have been proposed: suppression of T-lymphocyte responses to mitogens, decreased leukocyte chemotaxis, stabilization of lysosomal enzymes, inhibition of DNA and RNA synthesis, and the trapping of free radicals.

Pharmacokinetics

Antimalarials are rapidly absorbed and 50% protein-bound in the plasma. They are very extensively tissue-bound, particularly in melanin-containing tissues such as the eyes. The drugs are deaminated in the liver and have blood elimination half-lives of up to 45 days.

Indications

Antimalarials are approved for rheumatoid arthritis, but they are not considered very effective DMARDs. Dose-response and serum concentration-response relationships have been documented for hydroxychloroquine and dose-loading may increase rate of response. Although antimalarials improve symptoms, there is no evidence that these compounds alter bony damage in rheumatoid arthritis at their usual dosages (up to 6.4 mg/kg/d for hydroxychloroquine or 200 mg/d for chloroquine). It usually takes 3–6 months to obtain a response. Antimalarials are often used in the treatment of the skin manifestations, serositis, and joint pains of systemic lupus erythematosus, and they have been used in Sjögren's syndrome.

Adverse Effects

Although ocular toxicity may occur at dosages greater than 250 mg/d for chloroquine and greater than 6.4 mg/kg/d for hydroxychloroquine, it rarely occurs at lower doses. Nevertheless, ophthalmologic monitoring every 6–12 months is advised. Other toxicities include dyspepsia, nausea, vomiting, abdominal pain, rashes, and nightmares. These drugs appear to be relatively safe in pregnancy.

Cyclophosphamide

Mechanism of Action

Cyclophosphamide's major active metabolite is phosphoramide mustard, which cross-links DNA to prevent cell replication. It suppresses T-cell and B-cell function by 30–40%; T-cell suppression correlates with clinical response in the rheumatic diseases

Indications

Cyclophosphamide is active against rheumatoid arthritis when given orally at dosages of 2 mg/kg/d but not when given intravenously. It is used regularly to treat systemic lupus erythematosus, vasculitis, Wegener's granulomatosis, and other severe rheumatic diseases.

Cyclosporine

Mechanism of Action

Through regulation of gene transcription, cyclosporine inhibits interleukin-1 and interleukin-2 receptor production and secondarily inhibits macrophage–T-cell interaction and T-cell responsiveness. T-cell-dependent B-cell function is also affected.

Pharmacokinetics

Cyclosporine absorption is incomplete and somewhat erratic, although a microemulsion formulation improves its consistency and provides 20–30% bioavailability. Grapefruit juice increases cyclosporine bioavailability by as much as 62%. Cyclosporine is metabolized by CYP3A and consequently is subject to a large number of drug interactions.

Indications

Cyclosporine is approved for use in rheumatoid arthritis and retards the appearance of new bony erosions. Its usual dosage is 3–5 mg/kg/d divided into two doses. Anecdotal reports suggest that it may be useful in systemic lupus erythematosus, polymyositis and dermatomyositis, Wegener's granulomatosis, and juvenile chronic arthritis.

Adverse Effects

Cyclosporine has significant nephrotoxicity, and its toxicity can be increased by drug interactions with diltiazem, potassium-sparing diuretics, and other drugs inhibiting CYP3A. Serum creatinine should be closely monitored. Other toxicities include hypertension, hyperkalemia, hepatotoxicity, gingival hyperplasia, and hirsutism.

Leflunomide

Mechanism of Action

Leflunomide undergoes rapid conversion, both in the intestine and in the plasma, to its active metabolite, A77-1726. This metabolite inhibits dihydroorotate dehydrogenase, leading to a decrease in ribonucleotide synthesis and the arrest of stimulated cells in the G₁ phase of cell growth. Consequently, leflunomide inhibits T-cell proliferation and production of autoantibodies by B cells. Secondary effects include increases of interleukin-10 receptor mRNA, decreased interleukin-8 receptor type A mRNA, and decreased TNF- –dependent nuclear factor kappa B (NF- B) activation.

Pharmacokinetics

Leflunomide is completely absorbed and has a mean plasma half-life of 19 days. A77-1726, the active metabolite of leflunomide, is thought to have approximately the same half-life and is subject to enterohepatic recirculation. Cholestyramine can enhance leflunomide excretion and increases total clearance by approximately 50%.

Indications

Leflunomide is as effective as methotrexate in rheumatoid arthritis, including inhibition of bony damage. In one study, combined treatment with methotrexate and leflunomide resulted in a 46.2% ACR20 response compared with 19.5% in patients receiving methotrexate alone.

Adverse Effects

Diarrhea occurs in approximately 25% of patients given leflunomide, although only about 3–5% discontinue the drug because of this effect. Elevation in liver enzymes also occurs. Both effects can be reduced by decreasing the dose of leflunomide. Other adverse effects associated with leflunomide are mild alopecia, weight gain, and increased blood pressure. Leukopenia and thrombocytopenia occur rarely. This drug is contraindicated in pregnancy.

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Sedative-Hypnotics Pharmacokinetics

Pharmacokinetics:

Absorption and Distribution

The rates of oral absorption of sedative-hypnotics differ depending on a number of factors, including lipophilicity. For example, the absorption of triazolam is extremely rapid, and that of diazepam and the active metabolite of clorazepate is more rapid than other commonly used benzodiazepines. Clorazepate, a prodrug, is converted to its active form, desmethyldiazepam (nordiazepam), by acid hydrolysis in the stomach. Most of the barbiturates and other older sedative-hypnotics, as well as the newer hypnotics (eszopiclone, zaleplon, zolpidem), are absorbed rapidly into the blood following oral administration.

Lipid solubility plays a major role in determining the rate at which a particular sedative-hypnotic enters the central nervous system. This property is responsible for the rapid onset of central nervous system effects of triazolam, thiopental, and the newer hypnotics.

All sedative-hypnotics cross the placental barrier during pregnancy. If sedative-hypnotics are given during the predelivery period, they may contribute to the depression of neonatal vital functions. Sedative-hypnotics are also detectable in breast milk and may exert depressant effects in the nursing infant.

Biotransformation

Metabolic transformation to more water-soluble metabolites is necessary for clearance of sedative-hypnotics from the body. The microsomal drug-metabolizing enzyme systems of the liver are most important in this regard, so elimination half-life of these drugs depends mainly on the rate of their metabolic transformation.

Benzodiazepines

Hepatic metabolism accounts for the clearance of all benzodiazepines. The patterns and rates of metabolism depend on the individual drugs. Most benzodiazepines undergo microsomal oxidation (phase I reactions), including N-dealkylation and aliphatic hydroxylation catalyzed by cytochrome P450 isozymes, especially CYP3A4. The metabolites are subsequently conjugated (phase II reactions) to form glucuronides that are excreted in the urine. However, many phase I metabolites of benzodiazepines are pharmacologically active, some with long half-lives. For example, desmethyldiazepam, which has an elimination half-life of more than 40 hours, is an active metabolite of chlordiazepoxide, diazepam, prazepam, and clorazepate. Alprazolam and triazolam undergo -hydroxylation, and the resulting metabolites appear to exert short-lived pharmacologic effects because they are rapidly conjugated to form inactive glucuronides. The short elimination half-life of triazolam (2–3 hours) favors its use as a hypnotic rather than as a sedative drug.

 The formation of active metabolites has complicated studies on the pharmacokinetics of the benzodiazepines in humans because the elimination half-life of the parent drug may have little relation to the time course of pharmacologic effects. Benzodiazepines for which the parent drug or active metabolites have long half-lives are more likely to cause cumulative effects with multiple doses. Cumulative and residual effects such as excessive drowsiness appear to be less of a problem with such drugs as estazolam, oxazepam, and lorazepam, which have relatively short half-lives and are metabolized directly to inactive glucuronides.The metabolism of several commonly used benzodiazepines including diazepam, midazolam, and triazolam is affected by inhibitors and inducers of hepatic P450 isozyme.

Pharmacokinetic Properties of Some Benzodiazepines and Newer Hypnotics in Humans.

Drug Tmax1 (hours)   t1/22 (hours)   Comments Alprazolam 1–2 12–15 Rapid oral absorption Chlordiazepoxide 2–4 15–40 Active metabolites; erratic bioavailability from IM injection Clorazepate 1–2 (nordiazepam) 50–100 Prodrug; hydrolyzed to active form in stomach Diazepam 1–2 20–80 Active metabolites; erratic bioavailability from IM injection Eszopiclone 1 6 Minor active metabolites Flurazepam 1–2 40–100 Active metabolites with long half-lives Lorazepam 1–6 10–20 No active metabolites Oxazepam 2–4 10–20 No active metabolites Temazepam 2–3 10–40 Slow oral absorption Triazolam 1 2–3 Rapid onset; short duration of action Zaleplon < 1 1–2 Metabolized via aldehyde dehydrogenase Zolpidem 1–3 1.5–3.5 No active metabolites

¹Time to peak blood level.

²Includes half-lives of major metabolites.

Barbiturates

With the exception of phenobarbital, only insignificant quantities of the barbiturates are excreted unchanged. The major metabolic pathways involve oxidation by hepatic enzymes to form alcohols, acids, and ketones, which appear in the urine as glucuronide conjugates. The overall rate of hepatic metabolism in humans depends on the individual drug but (with the exception of the thiobarbiturates) is usually slow. The elimination half-lives of secobarbital and pentobarbital range from 18 to 48 hours in different individuals. The elimination half-life of phenobarbital in humans is 4–5 days. Multiple dosing with these agents can lead to cumulative effects.

Newer Hypnotics

After oral administration of the standard formulation, zolpidem reaches peak plasma levels in 1.6 hours. A biphasic release formulation extends plasma levels by approximately 2 hours. Zolpidem is rapidly metabolized to inactive metabolites via oxidation and hydroxylation by hepatic cytochromes P450 including the CYP3A4 isozyme. The elimination half-life of the drug is 1.5–3.5 hours, with clearance decreased in elderly patients. Zaleplon is metabolized to inactive metabolites mainly by hepatic aldehyde oxidase and partly by the cytochrome P450 isoform CYP3A4. The half-life of the drug is about 1 hour. Dosage should be reduced in patients with hepatic impairment and in the elderly. Cimetidine, which inhibits both aldehyde dehydrogenase and CYP3A4, markedly increases the peak plasma level of zaleplon. Eszopiclone is metabolized by hepatic cytochromes P450 (especially CYP3A4) to form the inactive N-oxide derivative and weakly active desmethyleszopiclone. The elimination half-life of eszopiclone is approximately 6 hours and is prolonged in the elderly and in the presence of inhibitors of CYP3A4 (eg, ketoconazole). Inducers of CYP3A4 (eg, rifampin) increase the hepatic metabolism of eszopiclone.

Excretion

The water-soluble metabolites of sedative-hypnotics, mostly formed via the conjugation of phase I metabolites, are excreted mainly via the kidney. In most cases, changes in renal function do not have a marked effect on the elimination of parent drugs. Phenobarbital is excreted unchanged in the urine to a certain extent (20–30% in humans), and its elimination rate can be increased significantly by alkalinization of the urine. This is partly due to increased ionization at alkaline pH, since phenobarbital is a weak acid with a pK_a of 7.4.

Factors Affecting Biodisposition

The biodisposition of sedative-hypnotics can be influenced by several factors, particularly alterations in hepatic function resulting from disease or drug-induced increases or decreases in microsomal enzyme activities.

In very old patients and in patients with severe liver disease, the elimination half-lives of these drugs are often increased significantly. In such cases, multiple normal doses of these sedative-hypnotics can result in excessive central nervous system effects.

The activity of hepatic microsomal drug-metabolizing enzymes may be increased in patients exposed to certain older sedative-hypnotics on a long-term basis. Barbiturates (especially phenobarbital) and meprobamate are most likely to cause this effect, which may result in an increase in their hepatic metabolism as well as that of other drugs. Increased biotransformation of other pharmacologic agents as a result of enzyme induction by barbiturates is a potential mechanism underlying drug interactions. In contrast, benzodiazepines and the newer hypnotics do not change hepatic drug-metabolizing enzyme activity with continuous use.

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Opioid Analgesics Pharmacokinetics

Some properties of clinically important opioids are summarized in following table:

Common Opioid Analgesics.

Generic Name Receptor Effects1   Approximately Equivalent Dose (mg) Oral:Parenteral Potency Ratio Duration of Analgesia (hours) Maximum Efficacy delta mu kappa Morphine2   +++ + 10 Low 4–5 High Hydromorphone +++ 1.5 Low 4–5 High Oxymorphone +++ 1.5 Low 3–4 High Methadone +++ 10 High 4–6 High Meperidine +++ 60–100 Medium 2–4 High Fentanyl +++ 0.1 Low 1–1.5 High Sufentanil +++ + + 0.02 Parenteral only 1–1.5 High Alfentanil +++ Titrated Parenteral only 0.25–0.75 High Remifentanil +++ Titrated3   Parenteral only 0.054   High Levorphanol +++ 2–3 High 4–5 High Codeine ± 30–60   High 3–4 Low Hydrocodone5   ± 5–10 Medium 4–6 Moderate Oxycodone2,6   ± 4.57   Medium 3–4 Moderate Propoxyphene (+, very weak) 60–1207   Oral only 4–5 Very low Pentazocine ± + 30–507   Medium 3–4 Moderate Nalbuphine –– ++ 10 Parenteral only 3–6 High Buprenorphine ± –– –– 0.3 Low 4–8 High Butorphanol ± +++ 2 Parenteral only 3–4 High

¹+++, ++, +, strong agonist; ±, partial agonist; –, ––, antagonist.

²Available in sustained-release forms, morphine (MSContin); oxycodone (OxyContin).

³Administered as an infusion at 0.025–0.2 mcg/kg/min.

⁴Duration is dependent on a context-sensitive half-time of 3–4 minutes.

⁵Available in tablets containing acetaminophen (Norco, Vicodin, Lortab, others).

⁶Available in tablets containing acetaminophen (Percocet); aspirin (Percodan).

⁷Analgesic efficacy at this dose not equivalent to 10 mg of morphine

Absorption

Most opioid analgesics are well absorbed when given by subcutaneous, intramuscular, and oral routes. However, because of the first-pass effect, the oral dose of the opioid (eg, morphine) may need to be much higher than the parenteral dose to elicit a therapeutic effect. Considerable interpatient variability exists in first-pass opioid metabolism, making prediction of an effective oral dose difficult. Certain analgesics such as codeine and oxycodone are effective orally because they have reduced first-pass metabolism. Nasal insufflation of certain opioids can result in rapid therapeutic blood levels by avoiding first-pass metabolism. Other routes of opioid administration include oral mucosa via lozenges, and transdermal via transdermal patches. The latter can provide delivery of potent analgesics over days.

Distribution

The uptake of opioids by various organs and tissues is a function of both physiologic and chemical factors. Although all opioids bind to plasma proteins with varying affinity, the drugs rapidly leave the blood compartment and localize in highest concentrations in tissues that are highly perfused such as the brain, lungs, liver, kidneys, and spleen. Drug concentrations in skeletal muscle may be much lower, but this tissue serves as the main reservoir because of its greater bulk. Even though blood flow to fatty tissue is much lower than to the highly perfused tissues, accumulation can be very important, particularly after frequent high-dose administration or continuous infusion of highly lipophilic opioids that are slowly metabolized, eg, fentanyl.

Metabolism

The opioids are converted in large part to polar metabolites (mostly glucuronides), which are then readily excreted by the kidneys. For example, morphine, which contains free hydroxyl groups, is primarily conjugated to morphine-3-glucuronide (M3G), a compound with neuroexcitatory properties. The neuroexcitatory effects of M3G do not appear to be mediated by receptors but rather by the GABA/glycinergic system. In contrast, approximately 10% of morphine is metabolized to morphine-6-glucuronide (M6G), an active metabolite with analgesic potency four to six times that of its parent compound. However, these relatively polar metabolites have limited ability to cross the blood-brain barrier and probably do not contribute significantly to the usual CNS effects of morphine given acutely. Nevertheless, accumulation of these metabolites may produce unexpected adverse effects in patients with renal failure or when exceptionally large doses of morphine are administered or high doses are administered over long periods. This can result in M3G-induced CNS excitation (seizures) or enhanced and prolonged opioid action produced by M6G. CNS uptake of M3G and, to a lesser extent, M6G can be enhanced by coadministration with probenecid or with drugs that inhibit the P-glycoprotein drug transporter. Like morphine, hydromorphone is metabolized by conjugation, yielding hydromorphone-3-glucuronide (H3G), which has CNS excitatory properties. However, hydromorphone has not been shown to form significant amounts of a 6-glucuronide metabolite.

The effects of these active metabolites should be considered in patients with renal impairment before the administration of morphine or hydromorphone, especially when given at high doses.

Esters (eg, heroin, remifentanil) are rapidly hydrolyzed by common tissue esterases. Heroin (diacetylmorphine) is hydrolyzed to monoacetylmorphine and finally to morphine, which is then conjugated with glucuronic acid.

Hepatic oxidative metabolism is the primary route of degradation of the phenylpiperidine opioids (meperidine, fentanyl, alfentanil, sufentanil) and eventually leaves only small quantities of the parent compound unchanged for excretion. However, accumulation of a demethylated metabolite of meperidine, normeperidine, may occur in patients with decreased renal function and in those receiving multiple high doses of the drug. In high concentrations, normeperidine may cause seizures. In contrast, no active metabolites of fentanyl have been reported. The P450 isozyme CYP3A4 metabolizes fentanyl by N-dealkylation in the liver. CYP3A4 is also present in the mucosa of the small intestine and contributes to the first-pass metabolism of fentanyl when it is taken orally. Codeine, oxycodone, and hydrocodone undergo metabolism in the liver by P450 isozyme CYP2D6, resulting in the production of metabolites of greater potency. For example, codeine is demethylated to morphine. Genetic polymorphism of CYP2D6 has been documented and linked to the variation in analgesic response seen among patients. Nevertheless, the metabolites of oxycodone and hydrocodone may be of minor consequence because the parent compounds are currently believed to be directly responsible for the majority of their analgesic actions. In the case of codeine, conversion to morphine may be of greater importance because codeine itself has relatively low affinity for opioid receptors. As a result, patients may experience either no significant analgesic effect or an exaggerated response based on differences in metabolic conversion. For this reason, routine use of codeine, especially in pediatric age groups, is being reconsidered.

Excretion

Polar metabolites, including glucuronide conjugates of opioid analgesics, are excreted mainly in the urine. Small amounts of unchanged drug may also be found in the urine. In addition, glucuronide conjugates are found in the bile, but enterohepatic circulation represents only a small portion of the excretory process.

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Posted in: CNS acting drugs,opoid analgesics