E. J. Triggs

Pharmacokinetics and Therapeutic Drug Monitoring of Gentamicin in the Elderly

Gentamicin is frequently used in elderly patients as serious infection, particularly Gram-negative bacilli, remains one of the major health problems experienced by this age group. A number of physiological changes in drug disposition occur with ageing and potentially these can affect gentamicin pharmacokinetics. In particular, there is a measurable decline in renal function, especially after the aged of 65. Any differences in drug distribution with age are apparently not reflected in gentamicin disposition data, as patients of varying ages have similar volumes of distribution.Seriously ill patients with infections frequently require treatment with many different drugs. Of note, the combination of gentamicin and a β-lactam antibacterial can result in inactivation. However, there appears to be no published data describing detrimental or beneficial pharmacokinetic interactions between gentamicin and drugs used in the elderly. Nonetheless, gentamicin should be used cautiously in order to prevent potential exacerbation of its nephrotoxicity and/or ototoxicity. Such problems may occur as a result of coadministration with, for example, amphotericin, cisplatin, vancomycin, foscarnet, nonsteroidal anti-inflammatory drugs or furosemide (frusemide). The presence of concurrent disease in aged patients (e.g. malignancy, fluid balance disorders and sepsis) may cause problems. In sepsis, for example, the volume of distribution of gentamicin may be increased; however, other pharmacokinetic data are contradictory and inconclusive.Like other aminoglycosides, gentamicin has a narrow therapeutic index and therapeutic drug monitoring has proven to be beneficial, particularly in vulnerable populations such as the elderly. Moreover, there is substantial pharmacokinetic variability in these patients. Recent data support the use of extended interval or once daily doses of gentamicin. It has been suggested that because of a lack of studies for this regimen in the elderly, specific recommendations cannot yet be made. We would argue that some recommendations for its cautious adoption in aged patients could be justified. Suggested procedures for the once daily administration of gentamicin include the use of the ‘Hartford’ nomogram and the targeted area under the concentration-time curve.The susceptibility of the elderly to aminoglycoside-related nephrotoxicity (and probably ototoxicity) may arise from a decline in renal function and an impaired capacity for cellular repair and regeneration. However, of greater importance is the duration of aminoglycoside therapy and the concomitant use of other nephrotoxic drugs.Further confirmation of the utility and tolerability of the once daily regimen and other possible approaches to gentamicin therapy in the elderly are essential.

USE OF METHOTREXATE IN OLDER PATIENTS : A RISK-BENEFIT ASSESSMENT

SummaryMethotrexate is eliminated almost entirely by the kidneys. The risk of methotrexate toxicity is therefore increased in patients with poor renal function, most likely as a result of drug accumulation. Declining renal function with age may thus be an important predictor of toxicity to methotrexate.Up to 60% of all patients who receive methotrexate for rheumatoid arthritis (RA) discontinue taking it because of adverse effects, most of which occur during the first year of therapy. Gastrointestinal complications are the most common adverse effects of methotrexate, but hepatotoxicity, haematological toxicity, pulmonary toxicity, lymphoproliferative disorders and exacerbation of rheumatic nodules have all been reported. Decreased renal function as a result of disease and/or aging appears to be an important determinant of hepatic, lymphoproli ferative and haematological toxicity. Concomitant use of low doses of folic acid has been recommended as an approach to limiting toxicity.Interactions between methotrexate and several nonsteroidal anti-inflammatory drugs have been reported, but they may not be clinically significant. However, caution is advised in the use of such combinations in patients with reduced renal function. More serious toxicities (e.g. pancytopenia) may result when other inhibitors of folate utilisation [e.g. cotrimoxazole (trimethoprim-sulfamethoxazole)] or inhibitors of renal tubular secretion (e.g. probenecid) are combined with methotrexate.Before starting low dose methotrexate therapy in patients with RA, a full blood count, liver function tests, renal function tests and chest radiography should be performed. Blood counts and liver function tests should be repeated at regular intervals. Therapeutic drug monitoring of methotrexate has also been suggested as a means of limiting toxicity.Patients with RA usually respond very favourably to low dose methotrexate therapy, and the probability of patients continuing their treatment beyond 5 years is greater than for other slow-acting antirheumatic drugs. Thus, given its sustained clinical utility and relatively predictable toxicity profile, low dose methotrexate is a useful addition to the therapy of RA.

Population pharmacokinetics and pharmacodynamics of oral levodopa in parkinsonian patients

Objective: The population pharmacokinetics and pharmacodynamics of a standardised oral test dose of levodopa have been determined in patients with mild to severe Parkinson’s disease using parametric, non-linear mixed effect modelling with the program NONMEM. Levodopa plasma concentration data and motor effect behaviour (tapping times) were obtained from 46 patients, for whom a total of 970 observations were available (approximately 21 pharmacokinetic and pharmacodynamic observations per patient). The pharmacokinetic-pharmacodynamic model used was a one-compartment first-order absorption model linked to the sigmoid EMax representation of the Hill equation via an equilibration rate-constant, ke0. The model was also tested via a reduction in the number of pharmacokinetic and pharmacodynamic data points to a total of four to eight per patient. Results:In the final regression models the Hoehn and Yahr (HY) status of the patient and duration of disease (DUR) were found to be important determinants of the pharmacodynamic parameters for levodopa. The pharmacokinetic parameters were not significantly affected by any covariates. A test group of 16 additional parkinsonian patients was used to evaluate the predictive performance of the population parameters. The predictive performance of the pharmacokinetic-pharmacodynamic modelling using the full and reduced data sets was evaluated in NONMEM using posthoc, Bayesian forecasting. Statistically insignificant bias existed among predicted and observed levodopa concentrations, whereas the pharmacodynamic model underpredicted the observed tapping times. There was little difference in the pharmacokinetic-pharmacodynamic predictive performance among results for the full and the reduced data sets.Conclusion:In a clinical setting knowledge of the population pharmacokinetic and pharmacodynamic parameters for oral levodopa may prove useful in estimating the duration of the drug’s beneficial motor activity in patients with mild to severe Parkinson’s disease (Hoehn and Yahr status I–IV).

High-performance liquid chromatographic assay of cefotaxime, desacetylcefotaxime and ceftriaxone in rat plasma

A simple and selective high-performance liquid chromatographic method is described for the analysis of the cephalosporins cefotaxime (CXM), desacetylcefotaxime (DACXM) and ceftriaxone (CFX) in rat plasma. Plasma was deproteinized with methanol, and the supernatant was directly injected into the chromatograph and monitored at 254 nm. For determination of the unbound drugs, a centrifugal ultrafiltration method was employed. The calibration curves were linear (r = 0.999) from 2.5 to 500 micrograms/ml; the detection limits were 100 ng/ml for DACXM and 250 ng/ml for CXM and CFX. The method was not interfered with by other plasma components, nor by barbital sodium or caffeine, and has been applied to study the pharmacokinetics of the cephalosporins in rats.

Plasma concentrations of bupivacaine after wound infiltration of an 0.5% solution after inguinal herniorrhaphy: a preliminary study

SummaryAfter routine inguinal herniorrhaphy we gave 12 patients a wound infiltration regimen of bolus doses of 20 ml of 0.5% bupivacaine via a catheter within the wound and rectally administered indomethacin (100 mg).Peak venous plasma bupivacaine concentrations ranged from 0.07 mg·l−1 to 1.14mg·l−1 (mean (SD) 0.47 (0.33) mg·l−1), and occurred at between 0.25 and 2 h after the first dose. Plasma concentrations were well below the toxic threshold of 4 mg·l−1 and there was no accumulation. The regimen provided satisfactory analgesia. There were no wound infections nor signs of toxicity.

Determination of nitrazepam and temazepam in plasma by high-performance liquid chromatography.

A rapid and simple high-performance liquid chromatographic analysis of nitrazepam in plasma with temazepam as an internal standard is described here. Alternatively, this assay method can also be used to determine temazepam plasma concentrations with nitrazepam as the internal standard. Chloroform was used as an organic solvent for the extraction process. The percentage recoveries of nitrazepam and temazepam were 79% and 85%, respectively. The coefficient of variation of the within-day precision of the assay procedure at a concentration equal to 50 ng/ml of nitrazepam was 2.4% (n = 5), and that for day-to-day precision at the same concentration was 4.7% (n = 5). Calibration curves for nitrazepam and temazepam were linear over their therapeutic ranges. Pharmacokinetic parameters obtained with this method after a single oral dose of 5 mg of nitrazepam in five normal subjects were comparable to results obtained in previous studies.

High-performance liquid chromatographic method for the quantitation of bupivacaine, 2,6-pipecoloxylidide and 4'-hydroxybupivacaine in plasma and urine

A high-performance liquid chromatographic method with ultraviolet detection at 210 nm for quantitation of bupivacaine and two of its metabolites from plasma and urine is described. The compounds are extracted into n-hexane-isopropanol (5:1), evaporated and the reconstituted residue injected onto a reversed phase C18 column. Standard curves for all compounds were linear (r2 greater than 0.999) in the range 20-2000 ng/ml, with a limit of detection of 10 ng/ml. The inter-day coefficients of variation ranged between 2.7 and 12.2%. The method was applied to analyse bupivacaine and metabolite concentrations in patients on long-term epidural bupivacaine-fentanyl infusions.

Comparison of plasma levels of canrenone and metabolites after base hydrolysis in young and elderly subjects following single and multiple doses of spironolactone

SummaryPlasma levels of canrenone and ‘total metabolites’ after base hydrolysis were compared in young and elderly subjects following single and multiple doses of spironolactone. After the initial dose on Day 1, plasma levels of canrenone and ‘total metabolites’ were higher in the young than in the elderly group, and significant differences were found between the two age groups in the AUC for both canrenone and ‘total metabolites’. However, these differences between the two age groups diminished after multiple dosing on Day 8, and the steady state predose plasma levels of canrenone and ‘total metabolites’ were significantly higher in the elderly subjects. The accumulation ratios of canrenone and ‘total metabolites’ were significantly higher in the elderly than in the young subjects. Both canrenone and canrenoic acid were extensively bound to plasma protein, but no differences were found between the two age groups in protein binding. Observed differences in plasma levels after single and multiple dosing between young and old subjects may be consequences of many factors such as 1.) a proportionate shift in metabolism with age; 2.) impaired oral absorption of the parent compound; and/or 3.) altered volume of distribution of the drug.

Pharmacokinetics of canrenone and metabolites after base hydrolysis following single and multiple dose oral administration of spironolactone

SummaryThe pharmacokinetics of canrenone and ‘total metabolites’ after base hydrolysis was studied in eight young volunteers following single and multiple dose oral administration of spironolactone. The plasma levels of canrenone and ‘total metabolites’ were fitted to a two-compartment open model with a first-order absorption process. From our eight normal subjects studied, the harmonic mean of the distributive half-life (t1/2α) of canrenone was found to be 1.66 h, and the harmonic mean of the terminal elimination half-life (t1/2β) to be 22.6 h. Harmonic means of the distributive and elimination half-lives of ‘total metabolites’ after base hydrolysis were 2.48 h and 28.8 h respectively. The accumulation ratio of canrenone was 2.53, whereas that of ‘total metabolites’ was 1.89. Despite the fact that spironolactone has been shown to induce hepatic metabolism of other drugs, no evidence of autoinduction was noted in the present study, as plasma levels of canrenone and ‘total metabolites’ were found to obey a linear two-compartment model with reproducible absorption and disposition after single and multiple doses.

The pharmacokinetics of amiloride-hydrochlorothiazide combination in the young and elderly

SummaryThe pharmacokinetics of amiloride and hydrochlorothiazide were studied in 12 healthy young volunteers following a single dose of a fixed combination of amiloride and hydrochlorothiazide and in 11 elderly hypertensive patients at steady-state. Following modelling of the single dose data, simulated steady-state plasma concentrations for the 2 drugs were generated to examine the effect of age and/or hypertension on pharmacokinetics.The apparent systemic plasma clearance for both amiloride and hydrochlorothiazide was significantly reduced in the elderly when compared to the young (from 753 to 325 ml·min−1, amiloride; and from 418 to 157 ml·min−1, hydrochlorothiazide). The plasma concentrations at steady state for both drugs were greatly increased in the elderly patients (Amiloride: from 7 to 25 ng·ml−1, Css,max; from 2 to 8 ng·ml−1, Css,min; and from 4 to 14 ng·ml−1, Cav; Hydrochlorothiazide: from 184 to 651 ng·ml−1, Css,max; from 31 to 121 ng·ml−1, Css,min; and from 89 to 273 ng·ml−1, Cav).The decreased clearance of the diuretics in the elderly was believed due to deterioration of renal function, and there was a significant correlation between the plasma clearance of hydrochlorothiazide and creatinine clearance in both age groups (r=0.62, young;r=0.72, elderly).As a result of the pharmacokinetic findings caution may be indicated in the clinical dosage of the diuretics particularly when in fixed dose combination.