Pethidine, metabolism

Pentazocine has been successfully used to relieve labour pain [201] and its obstetric use in place of pethidine is favoured by,its apparent inferior ability to pass the placental barrier [206]. A clinical trial of (+)- and (-)-pentazocine adds to the rare number of examples in which optical enantiomorphs have been evaluated [207]. In post-operative patients, response to 60 mg of the dextro isomer was less than that to 5 mg of morphine, while 25—29 mg of (-)-pentazocine was as effective as 10 mg of morphine. Hence most of the activity of the race-mate resides in the laevo isomer, as anticipated from results in animals [208]. Several studies of the distribution, excretion and metabolism of pentazocine have been made. Peak levels of the tritium-labelled drug (and its c/s-3-chloroallyl analogue) were present in the C.N.S. of a cat within 40 minutes of intramuscular administration [209], the comparable figure for morphine being 2 hours [210]. 

It is a cleavage of drug molecule by taking up a molecule of water. The most hydrolytic enzymes are found outside the endoplasmic reticulum, and in higher concentrations in liver, kidney and plasma. The metabolism of an ester by an enzyme esterase results in the formation of an acid and alcohol. The examples are meperidine, procaina-mide, pethidine and lidocaine etc. Meperidine is catalyzed by esterases to be changed into meperidinic acid and procainamide is catalyzed by amidases. 

The rates of metabolism are also impaired in vitamin deficiency states (especially vitamin A, vitamin B, C and E). Starvation in mice leads to decrease in the rates of metabolism of certain drugs like pethidine, acetanilide, hexobarbitone etc. Ethanol increases the hepatic content of monooxygenase enzymes and cytochrome P450 on chronic ingestion. 

Pethidine is metabolized chiefly in the liver, to mainly meperidinic acid and minor metabolite norpethidine, which are conju-... 

The biotransformation of the phenylpiperidines is primarily by hepatic phase I metabolism, catalysed by cytochrome P-450 isoenzymes. The elimination of alfentanil is significantly slowed in patients treated with erythromycin, a P-450 inhibitor, with delayed recovery and prolonged postoperative respiratory depression (Bartkowski and McDonnell 1990). Apart from pethidine and phenoperidine, none of the phenylpiperidines has pharmacologically active metabolites. 

Pharmacokinetic properties Pethidine (Mather and Meffin, 1978) has a faster onset and a shorter duration of action than morphine. After oral administration about 50% of the drug is eliminated by first-pass metabolism. N-demethylation yields the active metabolite nor-pethidine, and hydrolytic cleavage the inactive metabolites pethidinic and nor-pethidinic acid. The half-life of pethidine is about 3- 6 h. Nor-pethidine has a much slower elimination with a half life of up to 20 h. 

Suggest, by means of chemical equations and/or notes, feasible initial steps for the metabolism of each of the following compounds (a) pethidine and... 

Metabolic N-demethylation of methadone occurs since incubation of levo methadone with rat liver slices results in the formation of formaldehyde at a rate only marginally less than that obtained with pethidine as substrate. °2) The reason for the failure of early attempts to isolate the corresponding secondary amine is now well established as due to the facile cyclization of N-desmethylmethadone to a pyrroline derivative. Chemical studies have confirmed the cyclic structure 3 (13) the corresponding free base is an exocyclic alkene 2 that exists as an approximately 50 50 mixture of c-t isomers.(14)... 

Pethidine Mean 50 40-50 3-6 0.6-27 (pH dependent, less with higher pH) No information [47] Extensive in liver via hydrolysis and N-demethylation, followed by partial conjugation. First pass metabolism of 47-61% Yes. Norpethidine which is half as potent an analgesic, but potent convulsant -causes tremor and seizures Fong half-life, up to 20 hours Cleared renally... 

MAOIs PETHIDINE, MORPHINE, PHENOPERIDINE, DEXTROMETHORPHAN Two types of reaction are reported 1. Risk of serotonin syndrome with dextromethorphan, pethidine or tramadol and MAOIs 2. Depressive - respiratory depression, hypotension, coma Type 1 reactions are attributed to inhibition of reuptake of serotonin -more common with pethidine, phenoperidine, dextromethorphan. Type II reactions are attributed to MAOI inhibition of metabolism of opioids - more common with morphine Avoid co-administration do not give dextromethorphan, pethidine or tramadol for at least 2 weeks after cessation of MAOI... 

SSRIs OPIOIDS 1. Possible 1 analgesic effect of oxycodone and tramadol 2. T serotonin effects, including possible cases of serotonin syndrome, when opioids (oxycodone, pethidine, pentazocine, tramadol) are co-administered with SSRIs (fluoxetine and sertraline) 3. SSRIs may t codeine, fentanyl, methadone, pethidine and tramadol levels 1. Uncertain. Paroxetine inhibits CYP2D6, which is required to produce the active form of tramadol. 2. Uncertain 3. SSRIs inhibit CYP2D6-mediated metabolism of these opioids 1. Consider using an alternative opioid 2. Look for signs of T serotonin activity, particularly on initiating therapy 3. Watch for excessive narcotization... 

TCAs OPIOIDS 1. Risk of t respiratory depression and sedation 2. t levels of morphine 3. Case reports of seizures when tramadol was co-administered with TCAs 4. TCAs may t codeine, fentanyl, pethidine and tramadol levels 1. Additive effect 2. Uncertain likely t bioavailability of morphine 3. Unknown 4. TCAs inhibit CYP2D6-mediated metabolism of these opioids 1. Warn patients of this effect. Titrate doses carefully 2. Warn patients of this effect. Titrate doses carefully 3. Consider an alternative opioid 4. Watch for excessive narcotization... 

PHENYTOIN ANALGESICS-OPIOIDS 1.1 efficacy of fentanyl and methadone 2. Risk of pethidine toxicity 1. t hepatic metabolism of fentanyl and methadone, and possibly an effect at the opioid receptor 2. Phenytoin induces metabolism of pethidine, which causes t levels of a neurotoxic metabolite 1. Be aware that the dose of fentanyl and methadone may need to be t 2. Co-administer with caution the effect may be 1 by administering pethidine intravenously... 

IMATINIB ANALGESICS-OPIOIDS May cause t plasma concentrations, with a risk of toxic effects of codeine, dextromethorphan, hydroxycodone, methadone, morphine, oxycodone, pethidine and tramadol Inhibition of CYP2D6-mediated metabolism of these opioids Monitor for clinical efficacy and toxicity. Warn patients to report t drowsiness, malaise or anorexia. Measure amylase and lipase levels if toxicity is suspected. Tramadol causes less respiratory depression than other opiates, but need to monitor BP and blood counts, and advise patients to report wheezing, loss of appetite and fainting attacks. Need to consider 1 dose. Methadone may cause Q-T prolongation the CHM has recommended that patients with heart and liver disease who are on methadone should be carefully monitored for heart conduction abnormalities such as Q-T prolongation on ECG as they may lead to sudden death. Also need to monitor patients on more than 100 mg methadone daily and thus an t in plasma concentrations necessitates close monitoring of cardiac and respiratory function... 

ALFENTANIL, FENTANYL, PETHIDINE, TRAMADOL CIMETIDINE Cimetidine may t fentanyl, pethidine and tramadol levels Cimetidine inhibits CYP2D6-medi-ated metabolism of these opioids. Ranitidine weakly inhibits CYP2D6 Watch for excessive narcotization... 

OPIOIDS OESTROGENS Effect of morphine may be 1 by combined oral contraceptives Hepatic metabolism of morphine ist Be aware that morphine dose may need to be t. Consider using an alternative opioid such as pethidine... 

Disposition in the Body. Absorbed from the gastro-intestinal tract but there is extensive first-pass metabolism bioavailability about 30%. It is metabolised to pethidine and norpethidine. Up to about 5% of a dose is excreted unchanged in the urine, with about 18% as norpethidine and 2% as pethidine, in two to three days. The urinary excretion of unchanged phenoperidine is increased to about 7% when the urine is acidified. 

Hepatic metabolism increases, though not blood flow to the liver. Consequently, there is increased clearance of drugs such as phenytoin and theophylline, whose elimination rate depends on liver enzyme activity. Drugs that are so rapidly metabolised that their elimination rate depends on their delivery to the liver, i.e. on hepatic blood flow, have unaltered clearance, e.g. pethidine. 

Monoamine oxidase inhibitors (MAOI) are not completely selective for MAO and impair the metabolism of tricyclic antidepressants, of some sympathomimetics, e.g. phenylpropanolamine, amfetamine, of opioid analgesics, especially pethidine, and of mercaptopurine. 

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