Gösta Nyberg

Concentration‐related pharmacodynamic effects of thioridazine and its metabolites in humans

To measure cardiac and other effects of thioridazine and relate these to the plasma concentration of the parent drug and its principal metabolites.

Preparation of serum and plasma samples for determination of tricyclic antidepressants: effects of blood collection tubes and storage.

Summary: The effects were tested of eight common types of blood collection tubes and two types of “plasma separators” on the stability of the tricyclic antidepressants amitriptyline, imipramine, clomipramine, and their monodemethylated metabolites in venous blood samples. Although EDTA-containing Venoject lavender and Vacutainer lavender tubes seemed to give the most stable plasma samples, and Venoject red the most stable serum samples, the differences were too small to have practical consequences. Vacutainer royal blue collection tubes gave significant losses of < 20% of some of the substances. The tubes with serum separator gel or filter proved unsuitable, since they were responsible for losses of < 40%. The losses were not caused by redistribution between blood cells and plasma but occurred mainly as a result of contact between the contents and the caps of the tubes. Experiments with freezing, thawing, and storage of samples showed that freshly sampled blood could be stored at room temperature for 24 h in Venoject green tubes without significant losses. Serum samples could be stored at refrigerator temperature for 4 weeks without important losses. Freezing, thawing, and storage at - 20°C did not influence the serum or plasma concentrations.

Determination of free fractions of tricyclic antidepressants.

SummaryThe plasma protein binding of amitriptyline, imipramine, clomipramine, and their primary demethylated metabolites were studied by means of a method combining dialysis and gas chromatography. Equilibrium in dialysis of serum containing amitriptyline and its metabolite nortriptyline was attained in about 0.5 h with the drug dissolved in the serum compartment, and in about 2 h with the drug passing from the buffer to the serum compartment.The calculation of free fractions was influenced by variations with dialysis time in the volumes of serum and buffer. Increase of pH in serum increased the protein binding of the weakly basic drugs studied, and made the Donnan distribution effects more pronounced. At pH 7.4, the Donnan effect was negligible.Binding parameters for the 6 tricyclic antidepressant substances studied were estimated for the binding to α1-acid glycoprotein and for total binding in serum. For α1-acid glycoprotein, the k-values ranged from 1·105 to 8·105 M−1, and for pooled serum from 0.4·105 to 8·105 M−1. The determined number of binding sites on the α1-acid glycoprotein was, on average 0.87 for the 6 substances. In serum, the binding capacity was 2–14 times the concentration of α1-acid glycoprotein.

Quantitative analysis of tricyclic antidepressants in serum from psychiatric patients

A method for the quantitative analysis of tricyclic antidepressants in the serum of psychiatric patients is described. The method can be used for determining amitriptyline, nortriptyline, imipramine, demethyllimipramine, clomipramine, demethylclomipramine, trimipramine and protriptyline. The method consists in a series of extraction steps followed by gas chromatography with flame-ionization detector. The drugs are determined in their native state. The internal standard method is used for the quantitation.

Amitriptyline and amitriptyline metabolites in blood and cerebrospinal fluid following human overdose.

The toxicokinetics of amitriptyline were studied in nine patients admitted to hospital in Matthew-Lawson Coma Scale grade III-IV after an estimated ingestion of 1-5 g amitriptyline. Gastric lavage was performed and 50 g activated charcoal were given orally. Venous blood samples were taken on admission and at 1, 2, 4, 8, and 24 h, and in some patients at 36 and 48 h after admission. Arterial blood samples were taken at 1, 4, 8, and 24 h after admission. Lumbar punctures were performed 1 h after admission in 8 patients and again 4 h later in 5 patients. A urine sample was screened for other drugs. The bound and unbound fraction of amitriptyline and its metabolites nortriptyline, E and Z forms of 10-OH-amitriptyline and nortriptyline were analyzed in plasma, whole blood, red blood cells, and cerebrospinal fluid using an HPLC technique. The T1/2 alpha and T1/2 beta for amitriptyline were 1.5 - 3.1 and 15 - 43 h respectively. The rate of elimination of amitriptyline was not dose-dependent. The arteriovenous differences in the total amitriptyline+nortriptyline concentration were maximal in patients admitted soon after intake of drugs. Amitriptyline concentrations in cerebrospinal fluid were quantitatively similar to the unbound amitriptyline concentration in blood. The highest cerebrospinal fluid amitriptyline concentration was 506 nmol/L. There were large individual differences in plasma, blood and cerebrospinal fluid concentrations between different individuals. Repeated quantitative analysis of amitriptyline and its metabolites is unlikely to contribute to the clinical management of most patients with amitriptyline overdose.

Binding of thioridazine and thioridazine metabolites to serum proteins

SummaryThe binding constants of the binding between thioridazine and its metabolites, side-chain sulfoxide, sidechain sulfone and ring sulfoxide, on the one hand, and the plasma proteins, α1-acid glycoprotein, albumin and total serum proteins, on the other, were determined. The binding constants between the drug substances and α1-acid glycoprotein were found to be about a thousand times higher than the binding constants between the drug substances and albumin. The binding constants of whole serum were close to those of α1-acid glycoprotein. Analysis of the binding data indicated competition between thioridazine and its metabolites.A number of drug substances were screened for possible binding interaction with thioridazine and its metabolites. Tricyclic antidepressants and propranolol significantly increased the free concentration of thioridazine. Also salicyclic acid and the plasticizing agent, TBEP, had this effect.

Concentrations of thioridazine and thioridazine metabolites in erythrocytes

The concentrations of thioridazine and its main metabolites in erythrocytes from 61 thioridazine-treated patients were determined by gas-liquid chromatography. The mean and range of the erythrocyte concentrations, expressed as percentage of the corresponding plasma concentrations, were: thioridazine, 5.1% (2.0–10.6); side-chain sulfoxide, 5.6% (1.6–10.4); side-chain sulfone, 3.3% (1.1–6.8); ring sulfoxide 2.7% (0.8–4.9). The erythrocyte and plasma concentrations were significantly correlated. The erythrocyte/plasma concentration ratios, all the erythrocyte concentrations, but none of the plasma concentrations except ring sulfoxide were significantly positively correlated to the dose of thioridazine. The erythrocyte/plasma concentration ratio was not correlated to age. In vitro experiments indicated no clinically relevant erythrocyte-mediated oxidation of thioridazine.

Total plasma concentrations, red blood cell concentrations, and radioreceptor assay values compared with unbound plasma concentrations of thioridazine and thioridazine metabolites in psychiatric patients.

Summary Neuroleptic drug concentrations at the receptor sites are likely to be reflected more closely by the unbound than by the total plasma concentrations. The aim of this study was to establish whether or not the unbound plasma concentrations of thioridazine and its main nonconjugated metabolites show a stronger correlation to the red blood cell (RBC) concentration than to the total plasma concentration of the drug. The total and unbound plasma concentrations and the RBC concentrations of thioridazine and its metabolites were therefore determined in thioridazine-treated patients. “Calculated unbound concentration values” were derived from the determined total concentrations of the drug, the concentrations of drug-binding proteins, and previously determined k values. Since the RBC concentrations showed the best correlation to the unbound plasma values, they may be a more accurate tool than the total plasma concentrations for monitoring thioridazine treatment. The determined unbound plasma concentrations were better correlated to the calculated unbound concentrations than to the total plasma concentrations. The total plasma concentrations, but neither the unbound plasma nor the RBC concentrations, were significantly correlated to the concentrations of the drug-binding protein α1-acid glycoprotein. Radioreceptor assay values were strongly correlated to the weighted sum of the total and unbound plasma concentrations of thioridazine and its metabolites.

Unbound plasma concentrations, total plasma concentrations, and red blood cell concentrations of thioridazine and its main metabolites: an in vitro study

SummaryThe relationships between, on the one hand, the unbound plasma concentrations of thioridazine and thioridazine metabolites and, on the other, the total plasma concentrations and the red blood cell concentrations were studied in vitro. The relationships between the unbound and total plasma concentrations were curvilinear, while those between the unbound concentrations and the red blood cell concentrations within a broad range were closer to rectilinear. Profound changes were seen in the relationship between unbound and total plasma concentrations at varying concentrations of α1-acid glycoprotein, while the rectilinear relationship between the unbound plasma concentrations and the red blood cell concentrations remained essentially unchanged.