Jamie G. Barnhill

Clinical pharmacokinetics of imipramine and desipramine in alcoholics and normal volunteers

Recently detoxified men with alcohol dependence (n = 15) and healthy volunteers (n = 14) were administered oral and intravenous imipramine and desipramine. Alcoholics had significantly greater total body clearance of imipramine (0.93 vs. 0.48 L/hr/kg; P < 0.05) and desipramine (1.00 vs. 0.62 L/hr/ kg; P < 0.05) than did control subjects. Intrinsic clearance of unbound imipramine was greater in the alcoholic group (19.80 vs. 6.56 L/hr/kg; P < 0.05), as was the intrinsic clearance of unbound desipramine (14.52 vs. 9.05 L/hr/kg; P < 0.05). The mean elimination half‐life for imipramine was significantly decreased in alcoholics (8.7 vs. 19.9 hours after intravenous infusion and 10.9 vs. 19.6 hours after oral administration; P < 0.05). The mean elimination half‐life for desipramine was decreased in alcoholics after intravenous infusion (16.5 vs. 22.4 hours; P < 0.05). Unbound fractions of drug in plasma were decreased in the alcoholic group for both imipramine and desipramine after both routes of administration. α1‐Acid glycoprotein levels were elevated in the alcoholic group whereas total protein and albumin levels did not differ between groups. These findings suggest that recently detoxified alcoholics may require higher doses of imipramine than do nonalcoholic subjects. Desipramine clearance was affected to a lesser degree than imipramine, suggesting that from a pharmacokinetic standpoint it may be the preferred drug for the treatment of alcoholics with depression. Periodic monitoring of plasma levels may be required for recently abstinent alcoholics treated with antidepressants.

The human pharmacokinetics of oral ingestion of glucosamine and chondroitin sulfate taken separately or in combination.

OBJECTIVE As part of the National Institutes of Health (NIH)-sponsored Glucosamine/Chondroitin sulfate Arthritis Intervention Trial (GAIT) our objective here was to examine (1) the pharmacokinetics (PK) of glucosamine (GlcN) and chondroitin sulfate (CS) when taken separately or in combination as a single dose in normal individuals (n=29) and (2) the PK of GlcN and CS when taken as a single dose after 3 months daily dosing with GlcN, CS or GlcN+CS, in patients with symptomatic knee pain (n=28). METHODS The concentration of GlcN in the circulation was determined by established fluorophore-assisted carbohydrate electrophoresis (FACE) methods. The hydrodynamic size and disaccharide composition of CS chains in the circulation and dosage samples was determined by Superose 6 chromatography and FACE. RESULTS We show that circulating levels of CS in human plasma are about 20 microg/ml. Most significantly, the endogenous concentration and CS disaccharide composition were not detectably altered by ingestion of CS, when the CS was taken alone or in combination with GlcN. On the other hand, the Cmax (single-dose study) and AUC values (multiple-dose study) for ingested GlcN were significantly reduced by combination dosing with CS, relative to GlcN dosing alone. CONCLUSIONS We conclude that pain relief perceived following ingestion of CS probably does not depend on simultaneous or prior intake of GlcN. Further, such effects on joint pain, if present, probably do not result from ingested CS reaching the joint space but may result from changes in cellular activities in the gut lining or in the liver, where concentrations of ingested CS, or its breakdown products, could be substantially elevated following oral ingestion. Moreover, since combined dosing of GlcN with CS was found to reduce the plasma levels seen with GlcN dosing alone, any improved pain relief by combination dosing cannot be explained by higher circulating concentrations of GlcN.

Modulation of benzodiazepine receptor binding in mouse brain by adrenalectomy and steroid replacement.

Adrenal steroids alter neuronal excitability in the central nervous system (CNS), and evidence from in vitro studies indicates that at least some of these effects are mediated by the GABAergic system. Benzodiazepine receptor binding, among other sites on the GABA complex, has been implicated in steroid-induced alterations in the CNS. To investigate the modulation of benzodiazepine receptor binding by adrenal steroids, we examined receptor binding determined by an in vivo technique in mice after adrenalectomy, hypophysectomy and after replacement with several naturally occurring and synthetic steroids. Benzodiazepine receptor binding was substantially augmented in cortex, hypothalamus, and hippocampus in mice 1 week after adrenalectomy, and these increases appeared to be due to increased receptor number rather than changes in apparent affinity. Similar results in cortex were found after hypophysectomy. Replacement with physiologic, but not lower doses, of corticosterone reversed the changes induced by adrenalectomy. Chronic treatment with deoxycorticosterone also returned binding to control values, but chronic administration with dexamethasone, aldosterone and dihydroprogesterone did not alter binding after adrenalectomy. Adrenalectomy did not alter non-specific binding or GABA concentrations in cortex, and delivery of radioligand did not appear to be affected. These results indicate that adrenal steroids modulate benzodiazepine receptor binding in vivo, perhaps via the CR subtype of corticosteroid receptors. The steroid-benzodiazepine interaction may be especially important in the stress response.

Pharmacokinetics and Clinical Effects of Alprazolam Following Single and Multiple Oral Doses in Patients With Panic Disorder

The anxiolytic triazolobenzodiazepine alprazolam was administered to six male patients, aged 26 to 46 years, with panic disorder or agoraphobia (with panic attacks) to assess clinical effects and steady‐state pharmacokinetics following multiple dosing at three levels: 3.0 mg/d, 6.0 mg/d, and 9.0 mg/d. Multiple‐dose kinetics of alprazolam were compared with alprazolam disposition after a 1.0‐mg oral dose in the same patients. Kinetic variables after the single dose were very similar to those reported previously for healthy young male volunteers. Mean values were peak plasma concentration, 19 ng/mL; time of peak, 1.33 hours after dosage; elimination half‐life, 10.0 hours; total oral clearance, 1.11 mL/min/kg. During multiple dosage, mean steady‐state plasma concentrations (Css) was proportional to dosing rate, and steady‐state clearance was independent of dosage. Clinical improvement was rapid, with the greatest decrement in symptoms at the 3‐mg/d dosage, at a mean Css of 30 ng/mL. Further improvement was not seen at 6 mg/d (Css 62 ng/mL), or at 9 mg/d (Css, 103 ng/mL). Side effects, however, were directly related to dosage and plasma level, and increased progressively in number at the 3‐, 6‐, and 9‐mg/d dosage levels. Thus, the disposition of alprazolam in young male patients with panic disorder is essentially identical to that in healthy male volunteers of similar age. Alprazolam clearance is independent of dose and plasma concentration up to daily doses of at least 9 mg/d, with steady‐state plasma level proportional to dosing rate.

Chondroitin Product Selection for the Glucosamine/Chondroitin Arthritis Intervention Trial

OBJECTIVE To select a high-quality chondroitin dosage form and/or an appropriate source of sodium chondroitin for the National Institutes of Healths Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT). DESIGN Controlled experimental trials. SETTING Laboratory. PATIENTS OR PARTICIPANTS Not applicable. INTERVENTIONS Commercially available chondroitin products were reviewed, and purified sodium chondroitin from two suppliers was evaluated through tests (infrared and near-infrared identification, moisture content, pH, optical rotation, color and clarity of aqueous solutions prepared from the powders, protein contamination, total residue following ignition and nitrogen content, determination of sodium chondroitin molecular weight, disaccharide analysis, and measurement of chondroitin, sodium, and total glycosaminoglycan content) and an onsite supplier audit. MAIN OUTCOME MEASURES Purity, potency, and quality of sodium chondroitin powders. RESULTS No commercially available chondroitin product was deemed appropriate for use in GAIT. Samples of sodium chondroitin powder from two suppliers exhibited similar disaccharide and glycosaminoglycan content. Each contained approximately 2% hyaluronic acid and 8%-9% unsulfated disaccharide. Potency was inconsistent across groups, which might have resulted from different analytical methods and choice of reference standard. Mean potency obtained by five separate methods ranged from 82.2% to 95.5% for one supplier, 92.5% to 110.1% for another, and 95.1% to 112.5% for a commercially obtained reference standard. Critical issues raised by the results include choice of reference standard, selection of assay method, and the consistent appearance of an unidentifiable contaminant present in all three lots from one supplier. CONCLUSION This blinded study determined methods to identify acceptable agents and provided results, which, in addition to regulatory compliance supplier audits, formed the basis for chondroitin product selection in GAIT.

Benzodiazepine Receptor Binding of Triazolobenzodiazepines In Vivo: Increased Receptor Number with Low‐Dose Alprazolam

Abstract: Triazolobenzodiazepines are in clinical use as hypnotics and anxiolytics. We analyzed in vivo receptor binding and brain concentrations of alprazolam, triazolam, and estazolam. Drug concentrations measured in the cerebral cortex 1 h after administration were directly proportional to dose for all three compounds. In vivo receptor binding, as defined by the specific uptake of [3H]Ro 15–1788, decreased with increasing doses of estazolam and triazolam, a finding indicating dose‐related increases in receptor occupancy due to these compounds. Triazolam was substantially more potent, with an IC50 value of 16 ng/g, compared with 117 ng/g for estazolam. At higher doses of alprazolam (>0.2 mg/kg), receptor binding by [3H]Ro 15–1788 likewise decreased with increasing dose of the former drug. However, at lower doses of alprazolam (0.02–0.05 mg/kg), which resulted in cortex concentrations of 2–7 ng/g, receptor binding was increased above control values in cortex, hypothalamus, and hippocampus but not in several other brain regions. Binding returned to control values at doses of ≤0.01 mg/kg. Similar results were obtained in time course studies. At 8 and 10 h after a dose of 1 mg/kg i.p., corresponding to cortex concentrations of 2.7–7 ng/g, receptor binding was increased compared with controls. Similarly, at 1, 2, and 3 h after a single dose of 0.05 mg/kg, corresponding to cortex concentrations of 3.7–5.8 ng/g, receptor binding was also increased. The apparent affinity of benzodiazepine receptors for clonazepam in mice receiving alprazolam (0.05 mg/kg) was unchanged from that in untreated control mice, an observation suggesting that low doses of alprazolam increased receptor number. The brain concentration vs. receptor occupancy relationships for triazolam and estazolam resemble those for other benzodiaze‐pines, but alprazolam appears to be anomalous in that low brain concentrations increase benzodiazepine receptor number.

Differential modulation of benzodiazepine receptor binding by ethanol in LS and SS mice

The LS and SS lines of mice were initially selected based on sedative responses to ethanol, but have been found to differ in response to a variety of hypnotics and anesthetics. These differences do not appear to be due to pharmacokinetic factors and several lines of evidence suggest involvement of the GABAergic system. To examine an important component of this system, the benzodiazepine receptor, we analyzed benzodiazepine receptor binding in vivo in LS and SS mice, and modulation of receptor binding by three interventions known to increase binding in other strains: pentobarbital, defeat stress, and ethanol. Receptor binding was determined by specific uptake of [3H]-Ro15-1788. Receptor binding was increased in cortex and hippocampus of LS mice compared to SS mice, with the increase in cortex most likely due to increased receptor number rather than a change in apparent affinity. Pentobarbital (30 mg/kg IP) induced similar increases in binding in both lines in several brain regions. Defeat stress caused increased binding in several brain regions of both SS and LS mice, with greater binding in cortex of LS mice. In contrast, ethanol at 3 doses (0.5, 1, and 2 g/kg) led to greater increases in binding in SS mice compared to LS mice in most brain regions. None of the interventions altered nonspecific binding. Ethanol concentrations were slightly greater in plasma and brain of LS mice. These results indicate differences in benzodiazepine receptor binding in LS and SS mice, with differential modulation of binding by ethanol but not by pentobarbital or stress. These differences may contribute to differential pharmacodynamic responses in the two lines of mice.

Alterations in Pharmacodynamics of Anxiolytics in Abstinent Alcoholic Men: Subjective Responses, Abuse Liability, and Electroencephalographic Effects of Alprazolam, Diazepam, and Buspirone

Subjective responses, including those associated with abuse liability and changes in frontal electroencephalographic activity, were assessed in abstinent alcoholic men and control subjects after administration of alprazolam, diazepam, buspirone, and placebo. Plasma concentrations of alprazolam, diazepam, and desmethyldiazepam also were determined. Abuse liability scales were elevated for alcoholic participants above control levels after alprazolam and diazepam. Areas under the concentration—time curve differed only for desmethyldiazepam, which was lower for the alcoholic participants. Compared with control subjects, alcoholic participants had greater declines in the absolute power of the alpha band after diazepam challenge. Alcoholic participants, unlike control subjects, had areas under the effect—time curve for alpha and theta bands that were lower after administration of alprazolam or diazepam than they were after receiving placebo. These results suggest that alprazolam and diazepam are more likely to be abused by alcoholic men than by nonalcoholic men and that alcoholic men have enhanced sensitivity to the effects of benzodiazepines on alpha and theta activity.

Abrupt discontinuation of alprazolam and cognitive style in patients with panic disorder: early effects on mood, performance, and vital signs.

Abstract: The objective of this study was to ascertain the relationship of alprazolam plasma levels and an anxiety-prone cognitive style to the characteristics and severity of early withdrawal after abrupt discontinuation of alprazolam in 26 patients with panic disorder. After 8 and 9 weeks of fixed-dose treatment, patients were hospitalized for 24 hours. On 1 admission, ordered at random, treatment was maintained; on the other, placebo was substituted double blind. The Anxious Thoughts and Tendencies questionnaire was administered before treatment. Alprazolam plasma levels were measured 7 times on the day after each admission. Before each blood sampling, the Profile of Mood States and performance tasks were administered, and vital signs were recorded. On the day after abrupt discontinuation of alprazolam, Profile of Mood States anxiety, depression, fatigue, and confusion increased; vigor and elation decreased; speed on the digit symbol substitution task improved; and systolic blood pressure increased substantially over time. High Anxious Thoughts and Tendencies scores were related specifically to more anxiety. Our findings (1) confirm that dysphoric mood, fatigue, low energy, confusion, and elevated systolic blood pressure are part of the early syndrome of withdrawal from alprazolam in patients with panic disorder, notably as the drop in plasma levels approaches 50%; (2) indicate a psychomotor deficit persisting beyond dose stabilization; (3) suggest that an anxiety-prone cognitive style measurable before undertaking treatment may be a risk factor for more severe anxiety upon discontinuation; and (4) provide a rationale for applying cognitive behavior therapy during benzodiazepine taper.

Benzodiazepine Receptor Binding Response to Acute and Chronic Stress Is Increased in Aging Animals

Benzodiazepine receptor binding in vivo, as determined by the uptake of the high-affinity specific benzodiazepine receptor ligand [3H]Ro15-1788, was examined following acute and chronic defeat stress in male mice aged 6 weeks, 7 months and 1 year. Specific uptake in 6-week-old mice was increased from control values only in the cerebellum following acute but not chronic stress. Specific uptake in the cortex and hypothalamus was unchanged from control values following both acute and chronic stress. Seven-month-old mice demonstrated an increased specific uptake in the cortex and cerebellum when measured immediately following both acute stress and the final session of chronic stress. This enhanced binding returned to baseline levels by 24 h after stress. One-year-old mice demonstrated no change in specific uptake when measured after acute stress, while binding was enhanced in all brain regions after the final session of chronic stress. This increased binding was still evident at 24 h after the cessation of chronic stress. Changes in benzodiazepine binding differ as a response to acute and chronic stress, and this response varies markedly with age.