Hepatic clearance/enzymes

B. Perfusion of the brain is preserved when hemorrhage occurs. Thus, a greater proportion of the initial dose of anesthetic should appear in the brain, and a dose smaller than what is needed for a normovolemic patient is all that is required. Also, since flow to tissues associated with redistribution of the drug and termination of anesthesia is compromised, anesthesia should be deep and extended. Titrate this patient to a safe level of effect. While poor perfusion of the liver may reduce the exposure of drugs to metabolic enzymes, most intravenous anesthetics rely very little on hepatic clearance to terminate the anesthetic effect when a single bolus is administered. Furthermore, the question implies a direct influence of blood pressure on the efficiency of hepatic enzymes, and there is no evidence to support such a contention. Option C is not true. The opposite of option D is true. No evidence exists that binding of anesthetics is altered by these conditions. 

Chronic alcohol ingestion can cause cirrhosis, reducing hepatic CYP enzyme concentration and liver mass, and causing portacaval shunting. These effects will result in increased plasma drug levels due to both greater bioavailability (due to reduced first pass metabolism) and due to decreased clearance. Thus, dose adjustment is necessary and should be guided by TDM when possible. 

Increased clearance of steroid hormones due to induction of hepatic biotransformation enzymes following chemical exposure often has been cited as a possible mechanism by which toxicants could lower circulating testosterone or 17/3-estradiol levels. While enhanced clearance of sex steroids has been demonstrated following chemical exposure and induction of hepatic biotransformation enzymes, elegant feedback control mechanisms tend to ensure that more hormone is produced and homeostasis is maintained (Figure 17.2). Enhanced clearance of sex steroids can contribute to endocrine disruption if the toxicity also results in impaired hormone synthesis (i.e., gonadal toxicity or interference with the feedback control of hormone synthesis). 2,3,7,8-Tetrachlorodibenzodioxin appears to lower circulating sex steroid levels via this dual effect. 

From either a Cp or In Cp versus time plot, one feature is immediately clear the drug concentration drops over time. This process is called elimination and is determined by clearance (CL). Clearance is the process of removal of drug from the bloodstream. As was discussed in Chapter 3, clearance occurs primarily either through filtration of a drug by the kidneys (renal clearance, CLR) or metabolism of a drug in the liver by the action of enzymes (hepatic clearance, CLH). Other clearance processes are possible, but CLR and CLh normally comprise the large majority of total clearance (CLy or simply CL) (Equation 7.6). 

If the rate of elimination decreases in Scheme 7.2, then what happens to clearance Clearance is unchanged. For each 4.0-second pass, the liver clears 50 mL (CLh = 12.5 mL/s) out of the total 100 mL of blood that flows through the organ. Literally, 50% of the blood volume is cleared, so the actual impact is a decrease in Cp by 50%. While clearance is constant, the effect of clearance on Cp varies with Cp. Clearance depends on the action of metabolic enzymes on the drug and, at very high drug concentrations, the enzymes can become saturated with substrate. Under these conditions, which are rare, clearance is not constant. Therapeutic concentrations of modem drugs are normally well below the concentrations required to saturate liver enzymes. The tubular secretion and reabsorption processes in the kidneys can also be saturated and affect renal clearance. As with hepatic clearance, variable renal clearance is rare. 

Due to its mathematical simplicity, most in vitro-in vivo correlations are based on a homogeneous, well-stirred model for the liver such that all metabolic enzymes in the liver are exposed to the same drug concentration [266]. Under steady-state conditions, the predicted hepatic clearance CLh for this model is... 

Lipid-soluble drugs tend to be taken up by the liver and are said to have high first-pass metabolism, which depends on hepatic blood flow. Metabolism of drugs with low hepatic clearance depends on hepatic enzyme capacity. 

It has been demonstrated that hepatic extraction ratio (ER) is also influenced by blood flow. A number of mathematical models have been proposed to explain this observation, but the simplest model, and the one that is easiest to apply to clinical practice, is the well stirred or venous equilibrium model (Equation 5.3). This model relates hepatic clearance to hepatic blood flow (Q), the fraction of drug concentration that is unbound in plasma (fu) and the intrinsic clearance of the unbound drug (Clyint) [1]. Intrinsic clearance represents the maximum clearance of drug in the absence of any restrictions caused by blood flow, binding or access to the metabolising enzymes. The model states that ... 

ETOPOSIDE ANTIEPILEPTICS - PHENYTOIN, PHENOBARBITAL Significantly i plasma concentrations of etoposide (clearance may be >170%) and considerable risk of loss of therapeutic efficacy Due to potent induction of the hepatic microsomal enzymes that metabolize etoposide Do not co-administer. Consider use of alternative antiepileptics that do not induce hepatic microsomal enzymes, e.g. valproic acid... 

Child-Pugh clinical classification scheme (Table 7.5). Serum albumin concentrations were of greatest predictive value for two of the drugs shown in the table. However, this marker was not correlated with the hepatic clearance of lansoprazole, and a combination of all three laboratory tests was better correlated with hepatic clearance of atorvastatin than was serum albumin alone. Serum concentrations of aspartate aminotransferase (AST) or alanine transaminase (ALT) were not correlated with hepatic drug clearance, as might be expected from the fact that these enzymes reflect hepatocellular damage rather than hepatocellular function. 

Absorption of theophylline from the gastrointestinal tract is usually rapid and complete. Some 90% is metabolised by the liver and there is evidence that the process is saturable at therapeutic doses. The tis 8 h, with substantial variation, and it is prolonged in patients with severe cardiopulmonary disease and cirrhosis. Obesity and prematurity are associated with reduced rates of elimination, whereas tobacco smoking enhances theophylline clearance by inducing hepatic P450 enzymes. Because of these pharmacokinetic factors and low therapeutic index, monitoring of the plasma theophylline concentration is necessary to optimise its therapeutic effect and minimise the risk of adverse reactions the optimum concentration range is 10-20 mg/1 (55-110 mmol/1). 

An example of low-extraction drug is when the capacity of the liver to metabolize a drug is small relative to the rate of presentation (ACLuint diffusion problems to the enzyme site. Under these conditions, hepatic clearance approximates... 

Numerous metabolic pathways involving mixed-fimction oxidases, esterases, transferases, and hydroxylases exhibit selectivity toward stereoisomeric substrates. Of all disposition differences that stereoisomers may display, the greatest stereoselectivity is expected in biotransformation, because of the specificity of metabolic enzymes and isoenzymes. The overall differences in hepatic clearance of stereoisomers reflect not only differences in intrinsic clearance (activity of drug metabolizing enzymes) for the isomers but also the steric effects of plasma protein binding and hepatic blood flow. 

Hepatic Clearance Patients with significant hepatic dysfunction would be expected to have a decreased ability to metabolize or clear drugs. An increase in liver enzymes (aspartate aminotransferase [ASTI, alanine aminotransferase [ALT], and alkaline phosphatase [AlkPhos]) or an increase in bilirubin, prothrombin time and a decrease in serum albumin usually indicates hepatic dysfunction. 

---