Marc LeBel

The disposition of fluoxetine but not sertraline is altered in poor metabolizers of debrisoquin

Substrates and inhibitors of the cytochrome P450 isozyme CYP2D6 have overlapping structural characteristics. Two prototype serotonin uptake inhibitors, sertraline and fluoxetine, share these structural criteria and have been identified as potent inhibitors of CYP2D6 in vitro. The current study was undertaken to investigate whether genetically determined CYP2D6 activity alters the disposition of sertraline or fluoxetine or both.

Ciprofloxacin: chemistry, mechanism of action, resistance, antimicrobial spectrum, pharmacokinetics, clinical trials, and adverse reactions.

Ciprofloxacin, considered a benchmark when comparing new fluoroquinolones, shares with these agents a common mechanism of action: inhibition of DNA gyrase. While ciprofloxacin demonstrated a fairly good activity against gram‐positive bacteria, it is against gram‐negative organisms that it proved to be more potent than other fluoroquinolones. It is the most active quinolone against Pseudomonas aeruginosa, with MIC90s on the order of 0.5 μg/ml. When given orally, ciprofloxacin exhibited 70% bioavailability and attained peak serum levels ranging between 1.5 and 2.9 μg/ml after a single 500‐mg dose. Nineteen percent of an oral dose was excreted as metabolites in both urine and feces. In most cases, body fluids and tissue concentrations equaled or exceeded those in concurrent serum samples. In clinical trials, oral and intravenous ciprofloxacin yielded similar clinical and bacteriologic results compared to standard therapy in a wide array of systemic infections, including lower and upper urinary tract infections; gonococcal urethritis; skin, skin structure, and bone infections; and respiratory tract and gastrointestinal tract infections. Major benefits with the oral form of this quinolone are expected in chronic pyelonephritis and bone infections, and in pulmonary exacerbations in patients with cystic fibrosis. Emergence of ciprofloxacin‐resistant microorganisms has been noted in clinical practice, primarily Pseudomonas aeruginosa and Staphylococcus aureus. The most frequent side effects are related to the gastrointestinal tract; but attention should be given to adverse central nervous system effects.

Intravenous ciprofloxacin disposition in obesity

The pharmacokinetics of ciprofloxacin and its metabolite 1 (desethyleneciprofloxacin) were studied in 17 obese men (mean age, 29.2 ± 7.5 years; mean weight, 110.7 ± 20.2 kg; mean body mass index, 36.4 ± 3.9 kg/m2) and 11 control subjects (men of normal weight; mean age, 25.0 ±5.1 years; mean weight, 71.8 ± 9.9 kg; mean body mass index, 23.3 ± 2.4 kg/m2). Each subject received a single 400 mg intravenous dose of ciprofloxacin infused over 1 hour. Ciprofloxacin total clearance was significantly increased in obese subjects compared with control subjects (897.44 ± 159.57 versus 744.44 ± 120.51 ml/min, respectively; p < 0.05). Ciprofloxacin renal clearance in obese subjects (637.58 ± 128.89 ml/min) was 29% higher than in control subjects (495.47 ± 137.85 ml/min; p < 0.05). The elimination half‐life values of ciprofloxacin and desethyleneciprofloxacin were not statistically different between groups. Ciprofloxacin steady‐state volume of distribution (Vss) was significantly larger in obese group (269.17 ± 51.64 versus 219.03 ± 35.80 L; p < 0.01) compared with the control group, and when it was normalized by total body weight, obese subjects exhibited lower Vss/kg than control subjects (2.46 ± 0.42 versus 3.06 ± 0.31 L/kg; p < 0.001). These findings indicate that ciprofloxacin is distributed less to adipose tissue than to other tissues, but partial distribution to adipose tissue does occur. To normalize the volume of distribution of obese subjects to that of normal weight subjects, 45% of excess weight (total body weight minus ideal body weight) must be added to the ideal body weights of obese subjects.

Effects of Rifabutin and Rifampicin on the Pharmacokinetics of Ethinylestradiol and Norethindrone

This open‐label, randomized, three‐way crossover study of 28 healthy premenopausal women was conducted to compare the impact of concomitant rifabutin and rifampicin on the safety, pharmacokinetics, and pharmacodynamics of the oral contraceptives ethinylestradiol and norethindrone (Ortho‐Novum 1/35; Ortho Pharmaceutical, Raritan, NJ). Each participant received oral contraceptives daily for 21 days for the first control cycle, then was randomized to one of two sequences to receive oral contraceptives with concomitant rifampicin and rifabutin at equal doses of 300 mg/day for 10 days. Ethinylestradiol, norethindrone, follicle stimulating hormone (FSH), luteinizing hormone (LH), progesterone, rifampicin, and rifabutin (and metabolite) were measured in plasma over the same time frames in all three cycles. Safety was assessed from before the beginning to the end of each cycle. Twenty‐two subjects completed all three cycles. Compared with the control cycle, rifabutin and rifampicin significantly altered the disposition of the oral contraceptive. Area under the concentration—time curve from 0 to 24 hours (AUC0–24) and maximum plasma concentration (Cmax) of ethinylestradiol decreased by 64% and 42%, respectively, after coadministration with rifampicin and by 35% and 20%, respectively, after coadministration with rifabutin. The AUC0–24 of norethindrone decreased by 60% and 20% after coadministration with rifampicin and rifabutin, respectively. Unlike progesterone levels, FSH and LH levels increased during coadministration with rifampicin and rifabutin. The incidence of spotting was significantly higher after coadministration with rifampicin (36.4%) and rifabutin (21.7%) than during the control cycle (3.7%). Although both rifampicin and rifabutin affected the pharmacokinetics of ethinylestradiol and norethindrone, the magnitude of this effect was more pronounced with rifampicin. Likewise, the fact that the highest incidence of spotting occurred with rifampicin was consistent with higher metabolic induction by rifampicin. Despite the fact that there was no change in progesterone levels, it is recommended that patients be advised to use additional contraceptive methods while receiving rifabutin or rifampicin with oral contraceptives to prevent inadvertent pregnancy.

Pharmacokinetics and pharmacodynamics of ciprofloxacin in cystic fibrosis patients.

The pharmacokinetics and blister fluid penetration of oral ciprofloxacin were compared in 11 cystic fibrosis (CF) patients who had sputum colonization but were asymptomatic and in 12 healthy volunteers after a single dose (500 mg) and at steady state (500 mg every 8 h). The antibacterial effect of ciprofloxacin therapy was also evaluated by bacterial counts of colonizing pathogens in the respiratory secretions of CF patients. The CF patients were 15.9% lighter in weight than the controls (P less than 0.05). After a single dose, the elimination half-life of ciprofloxacin was decreased by a third in the CF patients as compared with the controls (2.62 versus 3.93 h, respectively; P less than 0.01). This was the result of a diminished apparent volume of distribution in CF subjects. Interestingly, we observed no statistically significant difference in total apparent and renal clearances between the groups. Suction-induced blister fluid penetration was not different between CF patients and healthy volunteers. In CF patients, ciprofloxacin exhibited levels in respiratory secretions above the reported MIC for Pseudomonas aeruginosa: 1.36 and 1.86 micrograms/ml at 2 h after a single dose and at steady state, respectively. An important fall (mean, 3.9 log10/ml) in the log titer in 10 patients with P. aeruginosa in their respiratory secretions was observed after 5 days of treatment. However, this improvement was short-lived; the secondary increase in bacterial counts observed in five patients and the development of five resistant strains were causes for concern. The pharmacokinetic results presented here showed that ciprofloxacin should be administered every 8 or even every 6 h in CF patients.

The effect of timing of a standard meal on the pharmacokinetics and pharmacodynamics of the novel atypical antipsychotic agent ziprasidone

Study Objective. To evaluate the influence of a high‐fat meal on the pharmacokinetics and pharmacodynamics of the novel atypical antipsychotic drug ziprasidone.

Tissue penetration of ciprofloxacin after single and multiple doses.

The pharmacokinetics and the suction-induced blister fluid penetration of ciprofloxacin were compared after a single dose (500 mg) and after multiple dosing (500 mg q8h for 13 doses). Significantly higher peak levels of ciprofloxacin in serum were observed after multiple dosing (3.51 versus 2.26 micrograms/ml; P less than 0.01). Increased elimination half-life occurred after multiple dosing; this seems to be mostly related to decreased systemic clearance secondary to a diminished nonrenal clearance (240.0 versus 125.0 ml/min). Ciprofloxacin appeared rapidly in the blister fluid, and the percentage of penetration (AUC0-tBF/AUC0-t serum) yielded values of 88.8 versus 84.7% after single and multiple doses, respectively. Ciprofloxacin levels in serum and blister fluid at the end of the dosing interval (8 h) were superior or almost superior to MICs for sensitive organisms including Pseudomonas aeruginosa. Comparative studies of ciprofloxacin metabolite excretion after multiple doses in healthy subjects and in renal insufficiency patients are needed.

Pharmacokinetics of Ciprofloxacin in Elderly Subjects

The pharmacokinetics of single‐dose oral ciprofloxacin 500 mg was ascertained in 12 elderly and 12 young subjects. Mean age of the elderly volunteers was 75.4 years and the mean measured creatinine clearance in this group was 40.7 ml/min. Serum and saliva were collected in serial order for 24 hours (elderly) and 10 hours (young), and assayed for ciprofloxacin by high‐performance liquid chromatography. The geriatric subjects had higher serum levels throughout the sampling period, with a peak level of 3.24 ± 0.79 versus 2.26 ± 0.75 μg/ml for the younger group (p < 0.005; one‐way analysis of variance). A twofold increase in the ciprofloxacin half‐life may be partly explained by a decrease in the glomerular filtration rate, as shown by slower ciprofloxacin renal clearance (152.4 ± 54.2 vs 395.6 ± 139.0 for elderly and young subjects respectively; p < 0.001). We concluded that in elderly patients, ciprofloxacin should be administered at an interval not less than every 12 hours to prevent accumulation and eventually toxicity.

Determination of ciprofloxacin in biological samples by reversed-phase high performance liquid chromatography.

Previously reported high performance liquid chromatography (HPLC) assays for ciprofloxacin have used cumbersome fluorescence detection. UV absorbance is more commonly used for assay of antibiotics. Separation of ciprofloxacin and nalidixic acid (internal standard) was achieved using UV absorption at 313 nm, and a reversed phase C-18 Nova-Pak column. The mobile phase consisted of 35% phosphate buffers adjusted to pH 7.4, 65% methanol, and 5.5 mM hexadecyltrimethylammonium bromide. Retention times were 4.3 and 7.3 min, respectively, for ciprofloxacin and nalidixic acid. Serum sample preparation involved protein precipitation with acetonitrile (1:2), followed by methylene chloride and 2-propanol extraction (90:10). After evaporation, reconstitution with a minimal volume of mobile phase allowed for 5X concentration of the sample. The sensitivity limit of the assay was 0.06 microgram/ml. The response was linear from 0.125 to 10.0 micrograms/ml (r greater than 0.999). The coefficient of variation for day-to-day analysis was less than 5.3%, and the recovery was 55%. When compared with microbiological assay in serum, the correlation coefficient was 0.922 (n = 58). This HPLC method using UV detection provided comparable results to those obtained by fluorimetry. Data from three pharmacokinetic studies showed this method to be reliable and accurate.

Suction-induced blister fluid penetration of cefdinir in healthy volunteers following ascending oral doses.

The pharmacokinetics and suction-induced blister fluid penetration of cefdinir following single oral administrations of 200, 300, 400, and 600 mg were studied in 16 healthy young male volunteers according to a Latin square design. Plasma, blister, and urine samples were assayed by high-pressure liquid chromatography. We observed a nonlinear relationship (P = 0.02) between the dose and the maximum concentration in plasma as well as between the dose and the area under the concentration-time curve (AUC) in plasma (P < 0.001), which may be indicative of a limited absorption process. This resulted in a lower AUC value than expected as well as a smaller fraction of cefdinir excreted unchanged at a dose of 600 mg. Renal clearance decreased with increasing doses (P < 0.006; analysis of variance with the Latin square design and Games-Howell procedure). Maximal cefdinir concentrations in blister fluid were delayed compared with concentrations in plasma. Blister fluid penetration measured by the ratio of the AUC in blister fluid to the AUC in plasma was extensive (92.4 to 108.4%). Cefdinir concentrations in blister fluid remained equal to or higher than the concentrations in plasma from 6 to 12 h following cefdinir administration. On the basis of the concentrations in blister fluid and the in vitro MIC data, we estimated that cefdinir at 200 to 400 mg administered twice daily would be adequate to treat uncomplicated skin infections caused by Streptococcus pyogenes. Seven volunteers experienced episodes of light-to-moderate diarrhea. These adverse events occurred irrespective of dose.