Clearance hepatic intrinsic

It is important to remember that absolute oral bioavailability is a function of both absorption and first-pass metabolism. Therefore, a linear approach to predicting absolute oral bioavailability based on a single parameter, such as rate or extent of absorption (fraction of dose absorbed or estimated dose absorbed) or the rate of metabolism (microsomal or hepatic intrinsic clearance), may result in an inaccu-... 

Fig. 2.1 Schematic illustrating hepatic extraction with Q, blood flow and Cf intrinsic clearance (metabolism).

An alternative approach to relying simply upon allometric approaches for metaboli-cally-cleared compounds is to take into consideration their relative stability in vitro. Clearance by P450 enzymes observed in hepatic microsomes from different species provides a measure of the relative intrinsic clearance in different species. Using the equation for the well-stirred model ... 

The equation can be solved for intrinsic clearance (Clj) based upon systemic clearance (Clj) obtained after i.v. administration and hepatic blood flow (Q) in the test species. Intrinsic clearance in man can then be estimated based upon relative in vitro microsomal stabibty and the equation solved to provide an estimate for human systemic clearance. Hence this approach combines aUometry (by considering differences in organ blood flow) and species-specific differences in metabolic clearance. 

As observed in Figure 9.4 the intrinsic clearance (as represented by oral unbound clearance CIqu) of UK-147,535 shows an allometric relationship between the rat, dog and man. This would indicate that the transporter protein involved is conserved across these species and has similar affinity. However, marked reduction in clearance in the rabbit suggests the absence, or marked alteration, of the responsible protein in the hepatic sinusoidal membrane of this species. This finding may explain the common observation of reduced biliary excretion of acidic compounds in rabbits compared to other species [24, 25]. 

In a first step the scaling of intrinsic clearances determined in rat hepatocytes was compared to in vivo clearance. When taking account of non-linearity, the estimated hepatic metabolic clearance values were in reasonable agreement with observed total clearances, which ranged from 7 to 35 mL/min/kg, and it was considered reasonable to estimate the expected clearances in human by a similar scaling of human hepatocyte data. The error around the mean predicted human clearance was based on the variability seen in different batches of human hepatocytes. 

Figure 6 Well-stirred model of hepatic clearance. The exchange of a drug between plasma and hepatocyte and its removal from this cell involves an unbound compound. Intrinsic clearance, CLint, relates the rate of the elimination (by formation of metabolites, CLint>f, and secretion of unchanged compound into bile, CLint5ex) to the unbound drug in the cell, CUr Cbout and CUout are the bound and unbound concentrations of the drug leaving the liver at total concentration Cout.

Figure 7 Influence of changes in (a) organ blood flow on clearance, (b) fraction of the drug unbound in plasma (/u) on extraction ratio, and (c) intrinsic clearance on extraction ratio as predicted by the well-stirred model of hepatic clearance.

Obach RS. Prediction of human clearance of twenty-nine drugs from hepatic microsomal intrinsic clearance data an examination of in vitro half-life approach and nonspecific binding to microsomes. Drug Metab Dispos 1999 27 1350-1359. 

Figure 2 Simulation of the effect of enzyme induction on oral midazolam AUC. Hepatic extraction in the absence of an inducer was set at 0.44. The initial intestinal extraction was varied from 0.0 to 0.9. The inducer was assumed to cause an equivalent change in hepatic and intestinal intrinsic clearance. Mucosal and hepatic plasma flows were assumed to be 240 and 780 mL/min. Simulations were obtained from Eq. (6), assuming an initial intestinal extraction ratio of 0.00, 0.07, 0.27, 0.43, 0.60, and 0.88.

If we now turn to inhibitory interactions, fourfold reductions in hepatic and intestinal intrinsic clearance may cause up to a 16-fold increase in systemic AUC... 

Note that the effect of the inhibitor in the liver is independent of blood flow. This is not the case for the intestine, where the relative magnitude of mucosal blood flow compared with the baseline mucosal intrinsic clearance and the apparent intrinsic clearance in the presence of inhibitor must be considered. When the baseline mucosal intestinal intrinsic clearance is negligible compared to mucosal blood flow (i.e., negligible mucosal extraction), Eq. (11) will collapse into a much simpler and better recognized equation for a hepatic inhibitory interaction (3). 

In turn the steady-state enzyme concentration in the liver determines the baseline hepatic intrinsic clearance, CLint, for the metabolism of a drug substrate by the enzyme. When substrate concentration, S, is low relative to the Michaelis constant, Km, for a particular biotransformation,... 

For a drug that is eliminated exclusively by the liver and that is completely absorbed following oral administration, the intrinsic clearance can be related to the area under the plasma concentration-time curve (AUCp0) if the well-stirred model of hepatic elimination is assumed (81,82) ... 

The O-deethylation of phenacetin is CYPlA2-mediated and results in the liberation of acetaldehyde that is subsequently metabolized to acetate and then CO2. Thus, a breath test based on the use of phenacetin labeled with 14C in the 1-position of the ethyl side chain could function to assess CYP1A2 activity. Early studies demonstrated the feasibility of this approach and its potential application to evaluating hepatic function (65,66). No extensive validation was attempted, so it is difficult to determine how well this test reflects the enzyme s intrinsic clearance, rather than perhaps some other determinant, such as liver blood flow. However, the situation appears to be moot since phenacetin is no longer an approved dmg worldwide because of its renal side effects following chronic dosing accordingly, further studies of this approach are unlikely. 

The extent to which the liver successfully eliminates a xenobiotic from the blood is determined by the intrinsic clearance of the liver (Clh) and the rate at which the xenobiotic is presented to it (i.e., the hepatic blood flow Qh ). This gives the overall hepatic extraction ratio (E) for the compound, as shown in Equation 11.3 ... 

Obach RS. 1997. Nonspecific binding to microsomes impact on scale-up of in vitro intrinsic clearance to hepatic clearance as assessed through examination of warfarin, imipramine, and propranolol. Drug Metab Dispos 25 1359-1369. 

Riley RJ, McGinnity DF, Austin RP. 2005. A unified model for predicting human hepatic, metabolic clearance from in vitro intrinsic clearance data in hepatocytes and microsomes. Drug Metab Dispos 33 1304—1311. 

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 ... 

However, in severe hepatic disease, not only is hepatic blood flow reduced but the degree of liver damage may influence intrinsic clearance to the extent that it also affects total drug clearance. Consequently, patients with hepatic disease are at particular risk of developing adverse effects to high extraction ratio drugs. 

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