Site of Excretion

Numerous drugs are able to either enhance or inhibit the excretion of other drugs. For example, sodium bicarbonate enhances the excretion of phenobarbital. Probenecid interferes with the active secretion of penicillin and hence prolongs its half-life. Probenecid s uricosuric effects are counteracted by acetylsalicylic acid, which also possesses a uricosuric effect. When given concomitantly, both are excreted (see Chapter 24). 

---

The compound in the portal blood is transported to the liver, which usually is the major site of metabolism for pharmaceuticals. In the liver there is usually one, or more, of three principal fates for the drug either metabolism excretion into the bile or return to the blood for distribution to the other tissues of the body. These other tissues may also be sites of metabolism or, particularly in the case of the kidney, sites of excretion. 

Excretion is tlie process by which the parent drug and its metabolites are removed from the body fluids before elimination occurs. The most important site of drug excretion is die kidney. Extrarenal sites of excretion include die liver, lung, mammary gland, sweat gland, salivary glands, and intestinal mucosa. 

The principal site of excretion that is liable to drag interactions is in the kidney. The classic example is forced alkaline diuresis using intravenous sodium... 

Calcium is excreted in both feces and urine, about 80% of the total amount excreted being in feces and 20% in the urine. Fecal calcium consists of unabsorbed calcium together with calcium which has been absorbed and re-excreted. It has been generally assumed that the large intestine is the major site of excretion into the intestines, but recent experiments with radioactive calcium have demonstrated that in the rat all segments of the intestinal tract are active in this function with the small intestine predominating. Calcium is excreted in urine mainly as chlorides and phosphates, and in feces as phosphate, carbonate, and soaps. 

The final component of toxicokinetics is the elimination of the chemical from the body. This is the process of excretion. The major sites of excretion in mammals are the kidneys (via urine) and the GIT (through feces). (We will look more closely at the two major sites of excretion.) Lesser methods include excretion (from the mother, not the fetus) into breast milk (already discussed), excretion through the lungs via exhalation, and excretion through sweat and saliva. 

Table 3. Primary Sites of Absorption and Excretion of Mineral Nutrients...

Factors controlling calcium homeostasis are calcitonin, parathyroid hormone(PTH), and a vitamin D metabolite. Calcitonin, a polypeptide of 32 amino acid residues, mol wt - SGOO, is synthesized by the thyroid gland. Release is stimulated by small increases in blood Ca " concentration. The sites of action of calcitonin are the bones and kidneys. Calcitonin increases bone calcification, thereby inhibiting resorption. In the kidney, it inhibits Ca " reabsorption and increases Ca " excretion in urine. Calcitonin operates via a cyclic adenosine monophosphate (cAMP) mechanism. 

Pharmacokinetics is the study of how the body affects an adiriinistered dmg. It measures the kinetic relationships between the absorption, distribution, metaboHsm, and excretion of a dmg. To be a safe and effective dmg product, the dmg must reach the desired site of therapeutic activity and exist there for the desired time period in the concentration needed to achieve the desired effect. Too Htde of the dmg at such sites yields no positive effect ( MTC) leads to toxicity (see Fig. 1). For intravenous adininistration there is no absorption factor. Total body elimination includes both metabohc processing and excretion. 

Pharmacodynamics is the study of dmg action primarily in terms of dmg stmcture, site of action, and the biochemical and physiological consequences of the dmg action. The availabiUty of a dmg at its site of action is deterrnined by several processes (Fig. 1), including absorption, metaboHsm, distribution, and excretion. These processes constitute the pharmacokinetic aspects of dmg action. The onset, intensity, and duration of dmg action are deterrnined by these factors as well as by the avadabihty of the dmg at its receptor site(s) and the events initiated by receptor activation (see Drug delivery). 

Materials may be absorbed by a variety of mechanisms. Depending on the nature of the material and the site of absorption, there may be passive diffusion, filtration processes, faciHtated diffusion, active transport and the formation of microvesicles for the cell membrane (pinocytosis) (61). EoUowing absorption, materials are transported in the circulation either free or bound to constituents such as plasma proteins or blood cells. The degree of binding of the absorbed material may influence the availabiHty of the material to tissue, or limit its elimination from the body (excretion). After passing from plasma to tissues, materials may have a variety of effects and fates, including no effect on the tissue, production of injury, biochemical conversion (metaboli2ed or biotransformed), or excretion (eg, from liver and kidney). 

Possibly the most serious nutrition problem in the United States is excessive food consumption, and many people have experimented with fad diets in the hope of losing excess weight. One of the most popular of the fad diets has been the high-protein, high-fat (low-carbohydrate) diet. The premise for such diets is tantalizing because the tricarboxylic acid (TCA) cycle (see Chapter 20) is the primary site of fat metabolism, and because glucose is usually needed to replenish intermediates in the TCA cycle, if carbohydrates are restricted in the diet, dietary fat should merely be converted to ketone bodies and excreted. This so-called diet appears to work at first because a low-carbohydrate diet results in an initial water (and weight) loss. This occurs because... 

Interactions resulting from a change in the amount of diug reaching the site of action are called pharmacokinetic interactions (Fig. 1). A co-administered diug can affect any of the processes of absorption, distribution, metabolism, and excretion of the original diug, which are determinants of its pharmacokinetic profile [1-3]. 

Urodilatin is a peptide similar to atrial natriuretic peptide, which is produced in the distal tubule of the kidney and promotes sodium excretion and diuresis by acting on receptors localized on the luminal site of the collecting duct of the nephron. 

Sites of storage. When located in one of these, the chemical has no toxic effect, is not metabolized, and is not available for excretion. However, after release from storage, it may travel to sites of action and sites of metabolism. 

For convenience, the processes identified in Figure 2.1 can be separated into two distinct categories toxicokinetics and toxicodynamics. Toxicokinetics covers uptake, distribution, metabolism, and excretion processes that determine how much of the toxic form of the chemical (parent compound or active metabolite) will reach the site of action. Toxicodynamics is concerned with the interaction with the sites of action, leading to the expression of toxic effects. The interplay of the processes of toxicokinetics and toxicodynamics determines toxicity. The more the toxic form of the chemical that reaches the site of action, and the greater the sensitivity of the site of action to the chemical, the more toxic it will be. In the following text, toxicokinetics and toxicodynamics will be dealt with separately. 

From a toxicological point of view, the critical issue is how much of the toxic form of the chemical reaches the site of action. This will be determined by the interplay of the processes of uptake, distribution, metabolism, storage, and excretion. These processes will now be discussed in a little more detail. 

A xenobiotic is said to be stored when it is not available to sites of metabolism or action and is not available for excretion. In other words, it is held in an inert position from a toxicological point of view, where it is not able to express toxic action or to be acted upon by enzymes. A xenobiotic is stored when it is located in a fat depot (adipose tissue), bound to an inert protein or other cellular macromolecule, or simply held in a membrane that does not have any toxicological function (i.e., it does not contain or represent a site of toxic action, neither does it contain enzymes that can degrade the xenobiotic). 

These studies represent the first report of the metabolism of brevetoxins by mammalian systems. PbTx-3 was rapidly cleared from the bloodstream and distributed to the liver, muscle, and gastrointestinal tract. Studies with isolated perfused livers and isolated hepatocytes conflrmed the liver as a site of metabolism and biliary excretion as an important route of toxin elimination. [ H]PbTx-3 was metabolized to several compounds exhibiting increased polarity, one of which appeared to be an epoxide derivative. Whether this compound corresponds to PbTx-6 (the 27,28 epoxide of PbTx-2), to the corresponding epoxide of PbTx-3, or to another structure is unknown. The structures of these metabolites are currently under investigation. 

---