Farmacocinetica

Rafael Barra Pezo PhD.

 Que es la Farmacocinetica?
La farmacocintica estudia los procesos y factores que determinan la cantidad de frmaco
presente en el sitio en que debe ejercer su efecto biolgico en cada momento, a partir de la
aplicacin del frmaco sobre el organismo vivo.

Anlisis de las concentraciones de frmacos y sus metabolitos en los lquidos orgnicos. El

movimiento de los frmacos est sometido a leyes formulables por modelos matemticos.
Su conocimiento proporciona importante informacin para valorar o predecir la accin
teraputica o txica de un frmaco.
Liberacion Cada prosceso descrito posee representaciones graficas tipicas y
modelos matematicos.
Absorcion
Caracteristicas fisicoquimicas del
Distribucion farmaco

Metabolismo Biodispinibilidad
Excrecion. Sustancias Excipientes

Membranas biologicas o
compratimentos.
 Receptores Farmacologicos
Farmacos pueden modificar respuestas celulares intrinsecas. No generar nuevas funciones
celulares.
Implica la existencia de components celulares que respondan a los farmacos, por union
reversible ( en algunos casos irreversibles).
Sitios especificos e inespecificos de union.
Las molculas con que los frmacos son capaces de interactuar selectivamente,
generndose como consecuencia de ello una modificacin constante y especfica en la
funcin celular, se denominan receptores farmacolgicos.

Los receptores son estructuras macromoleculares de naturaleza proteica, asociadas a veces

a radicales lipdicos o hidrocarbonados, que se encuentran localizados en gran nmero en
las membranas externas de las clulas, en el citoplasma y en el ncleo celular. Entre las
respuestas funcionales que los receptores pueden desencadenar destacan:
a) Modificaciones de los movimientos de iones y, como consecuencia, de los potenciales
bioelctricos, en cuyo caso el receptor suele estar ligado a canales inicos.
b) Cambios en la actividad de mltiples enzimas, cuando el receptor est conectado a
estructuras membranosas o intercelulares capaces de mediar reacciones qumicas, como
 Existen Farmacos que utilizan otras vas o receptores atpicos.

a) los frmacos que actan inhibiendo la actividad de diversas

enzimas (p. ej., la ATPasa Na+/K+-dependiente o la
monoaminooxidasa);

b) los quelantes, que fijan diversos cationes;

c) los frmacos que son anlogos estructurales de sustancias

endgenas y que actan como falsos sustratos de enzimas (p. ej., los
anlogos de bases pricas y pirimidnicas, con actividad
antineoplsica)

d) los que interfieren en la actividad de los transportadores ligados a

los sistemas de recaptacin de los neurotransmisores.
 Interaccion Farmaco- Receptor
Afinidad entre farmaco y receptor. Formacion de enlaces quimicos (P de H, vander
Walls, interacciones ionicas, etc.) entre el farmaco (ligando) y receptor.
Especificidad, discriminar entre diferentes moleculas (singularidad de la interaccion
farmaco-receptor).
Tratamiento Matematico de receptors.

En equilibrio ambos component son

iguales. Iguales velocidades de
formacion y separacion
 La concentracin de frmaco necesaria para fijarse a la mitad de los receptores es

igual a la constante de disociacin. Como su inversa es la afinidad, cuanto menor sea

esta concentracin, mayor ser la afinidad de fijacin.

La afinidad de un frmaco por su receptor tiene que ser alta, con valores acordes con

los rangos de concentracin alcanzados por ese frmaco en los tejidos.

Si a la concentracin de frmaco
fijado [AR] se la denomina B, a la
concentracin total de receptores
[AR] + [R] se la designa Bmx y a
la concentracin de A libre (no
unido a receptores) se la denomina
F, de acuerdo con la ecuacin [3]:
Representacion de Scatchard
Las causas ms frecuentes de este fenmeno son: a) la existencia de ms de un sitio de fijacin en
la poblacin marcada, con valores de afinidad diferentes, y b) interacciones de tipo cooperativo: la
fijacin de cada molcula del radioligando afecta la fijacin de las sucesivas molculas, bien de
forma favorecedora (cooperatividad positiva, curva hacia arriba) o perturbadora (cooperatividad
negativa, curva hacia abajo).

nH es el coeficiente de
Hill

Valores de nH
inferiores a la unidad
indican la existencia
de ms de un sitio de
unin o bien la de
cooperatividad
negativa.
 Curvas de competicion

Perfiles de afinidad

Este tipo de anlisis tiene especial

inters para: a) confirmar que un
nuevo
producto, que en estudios
funcionales parece actuar mediante
un receptor determinado, se fija de
manera especfica
a l y b) detectar subtipos de
receptores, basndose en el
 Agonista y Antagonista
La union del farmaco con el receptor, incluso especifica y con afinidad, no es
suficiente para que se desencadene una function cellular.

El frmaco debe tener la capacidad de modificar la molcula receptora en la

forma necesaria a fin de que se desencadene un efecto. La capacidad del frmaco
para modificar el receptor e iniciar una accin es lo que define su eficacia.

Agonista .
Antagonista.

Comunmente se definen sitios de alta y baja afinidad de unin (normalmente los

agonistas se unen a sitios de alta afinidad y antagonistas a ambos).

Utilizando agonistas y antagonistas s epueden diferenciar subtipos de familias de

receptors.
 Regulacion de receptores
Todos los receptores se encuentran sometidos
a un recambio cellular turn-over.

Fenomenos de adaptacion

Up regulation y Down regulation.

Desensibilizacion de receptores. Si ocurre

rapidamente se denomina Tolerancia aguda o
taquifilaxia. Si ocurre en el transcurso de dias
se denomina tolerancia cronica.

Desensibilizacion homologa y Desensibilizacion

heterologa.

Hipersensibilidad de Receptores. Aumento de

 Curva Dosis efecto
Relacin entre ocupacin de receptores y
respuesta farmacolgica

Ea: Corresponde a la intensidad del efecto

farmacologico

Emax: efecto biologico maximo

e: Eficacia, capacidad del farmaco de generar

una respuesta biologica.

La eficacia (e) es una magnitud relacionada,

por una parte, con la capacidad intrnseca de A
para generar el estmulo y, por la otra, con el
nmero total de receptores existentes en el
sistema. Por ello, puede considerarse que:

e = Rt
una constante propia del frmaco, que indica
 La posicin lateral de la curva a lo
largo del eje de abscisas indica la
potencia y se relaciona con la
afinidad del frmaco por su receptor.
A mayor potencia, menor cantidad
de frmaco ser necesaria para
conseguir un efecto determinado.
En el caso terico en que f es lineal,
la concentracin de frmaco
necesaria para conseguir la mitad
del efecto mximo expresa la KD y,
por lo tanto, la afinidad. Dicha
concentracin se denomina dosis
eficaz 50 o DE50.
 Receptores de reserva
Evidencia demuestra que no es
necesario ocupar todos los
receptores para conseguir el
maximo efecto biologico.
Esta magnitud es variable
dependiendo de la eficacia de
un farmaco.
A medida que la funcin f se
aparta de la linealidad y se
utilizan frmacos agonistas
capaces de producir respuestas
con bajos niveles de ocupacin,
los valores de DE50 y KD se
separan, y la estimacin
funcional de la afinidad a partir
de la DE50 de la curva dosis-
efecto se vuelve inexacta.
 Agonistas y antagonistas
Antagonistas

De lo expuesto anteriormente se deduce

que la eficacia intrnseca de diversos
agonistas en un mismo sistema puede ser
diferente y, por lo tanto, stos pueden
producir efectos iguales con proporciones
de ocupacin diferentes. En este sentido,
se puede diferenciar, al menos, entre
agonistas completos, aquellos altamente
eficaces, capaces de producir efectos con
una baja proporcin de receptores
ocupados, y agonistas parciales, aquellos
que presentan bajos niveles de eficacia y
producen efectos mximos menores que
el agonista completo. La utilizacin de los
primeros permite identificar la existencia
de una poblacin de receptores de
reserva, que se reduce claramente
Agonistas parciales
las curvas se cruzan en el punto que
corresponde a la eficacia mxima del
agonista parcial. La respuesta al agonista
completo o puro a concentraciones por
debajo de las que corresponden al punto de
cruce, en presencia del agonista parcial, no
llega a ser aditiva (entre agonista puro y
agonista parcial)

A concentraciones de agonista puro por

encima del punto de cruce, la respuesta
total ser inferior a la que correspondera si
no estuviera presente el agonista parcial: es
entonces cuando el agonista parcial muestra
plenamente su capacidad antagonista
 Antagonismo NO-competitivo
El antagonista B acta sobre un sitio de
fijacin ntimamente relacionado con el
receptor, pero diferente del de
reconocimiento del agonista, se produce
un fenmeno de antagonismo no
competitivo.

A medida que se incrementa la

concentracin
del antagonista, el desplazamiento hacia
la derecha
se acompaa de una progresiva reduccin
Antagonismo
del efecto Irreversible
Mximo.
Union no reversible con receptor.
Curvas similares a las de antagonism no
competitive
Dependiente del tiempo de exposicion.
Antagonismo Funcional

Dos frmacos, A y B, actan sobre

diferentes receptores, generando
respuestas sobre un mismo sistema
efector, puede suceder que de la
interaccin de B con su receptor resulte
una accin que impida o interfiera en la
respuesta provocada por A al unirse al
suyo.

Antagonismo Quimico
 Farmacocinetica
Pharmacokinetics is the study of the time
course (i.e., kinetics) of absorption,
distribution, metabolism, and excretion
(ADME) of drugs and their metabolites in the
body.

Pharmacodynamics. intensity and time

course of pharmacological response or
therapeutic outcome is known as
pharmacodynamics.

pharmacodynamics (PD) can be defined as

the quantitative study of pharmacological,
biochemical, physiological, and therapeutic
effects of a drug and their mechanism of
action on living structures, in vivo, in vitro,
and in situ.

population pharmacokinetics
 Paracelso and Dosis concept
Amount of xenobiotic at a site of administration, which will be subjected to the
physiological processes of ADME.

Administration- extremely related to the administration route.

Distribution
Metabolization
Excretion

Alle Ding sind Gift und nichts ohn Gift; allein die Dosis macht, das ein Ding kein Gift ist. [All
substances are poisons; there is none which is not a poison. The right dose differentiates a poison
from a remedy.]
 Diffusion trough compartments

Human body cam be treated like

several different aqueous
compartments separated by
lipophilic membranes.
Hydrophobocity of drug
Size of the drug
There are four main ways by which
small molecules cross cell
membranes
by diffusing directly through the lipid
by combination with a solute carrier
(SLC) or other membrane
transporter
by diffusing through aqueous pores
formed by special proteins
(aquaporins) that traverse the lipid
by pinocytosis.
 Lipophilic nature of drugs.
Diffusion coefficient varies very little for the majority of drugs. However the partition coefficient
(lipid/ aqueous) is very important for the diffusion and penetration of the drugs. Many
pharmacokinetic characteristics of a drug such as rate of absorption from the gut, penetration into
different tissues and the extent of renal elimination can be predicted from knowledge of a drugs
lipid solubility.

[A] and [B] Figures show the concentration profile in a lipid membrane separating two aqueous
compartments. A lipid-soluble drug [A] is subject to a much larger transmembrane concentration
gradient (Cm) than a lipid-insoluble drug [B]. It therefore diffuses more rapidly, even though the
 pH and ionization

For a weak base, B, the ionisation pH partition and ion trapping

reaction is:

Ionisation affects not only

the rate at which drugs
permeate membranes but
also the steady-state
distribution of drug
molecules between aqueous
compartments, if a pH
Charged species normally do not pass trough
difference exists between
lipid membranes them.
Uncharged species, in most cases, are lipophilic
and diffuse trough membranes.
 Theoretical partition of a weak acid
(aspirin) and a weak base (pethidine)
between aqueous compartments
(urine, plasma and gastric juice)
according to the pH difference
between them. Numbers represent
relative concentrations (total plasma
concentration = 100). It is assumed
that the uncharged species in each
case can permeate the cellular barrier
separating the compartments, and
therefore reaches the same
concentration in all three. Variations in
the fractional ionisation as a function
pH partition and ion trapping
of pH give rise to the large total
concentration differences with respect
pH partition is not the main
to plasma.
determinant of the site of absorption of
drugs from the gastrointestinal tract.

The enormous absorptive surface area

of the villi and microvilli in the ileum
compared with the much smaller
absorptive surface area in the stomach
There are several important consequences of pH partition:
Free-base trapping of some antimalarial drugs (e.g.
chloroquine) in the acidic environment in the food
vacuole of the malaria parasite.
Urinary acidification accelerates excretion of weak bases
and retards that of weak acids.
Urinary alkalinisation has the opposite effects: it reduces
excretion of weak bases and increases excretion of weak
acids.
Increasing plasma pH (e.g. by administration of sodium
bicarbonate) causes weakly acidic drugs to be extracted
from the CNS into the plasma. Conversely, reducing
plasma pH (e.g. by administration of a carbonic
anhydrase inhibitor such as acetazolamide) causes
weakly acidic drugs to become concentrated in the CNS,
increasing their neurotoxicity. This has practical
consequences in choosing a means to alkalinise urine in
treating aspirin overdose: bicarbonate and
acetazolamide each increase urine pH and hence
increase salicylate elimination, but bicarbonate reduces
whereas acetazolamide increases distribution of
salicylate to the CNS.
CARRIER-MEDIATED TRANSPORT; Solute carrier transport (SLC) and
ATP binding cassette (ABC) transporter.
The SLC are
ubiquous
however, the
main sites where
SLCs, including
OCTs and OATs,
are expressed
and carrier-
mediated drug
transport is
important are:
the bloodbrain
barrier
the
gastrointestinal
tract
the renal tubule
the biliary tract
the placenta.
Human organic cation transporter 2 (OCT2) mediates cisplatin nephrotoxicity. OCT2 is expressed in
kidney whereas OCT1 is expressed in liver. Cisplatin (100 mol/l) influences the activity of OCT2 but not
of OCT1, each expressed in a cultured cell line [A], whereas the less nephrotoxic drugs carboplatin and
oxaliplatin do not. Cisplatin similarly influences OCT2 activity in fresh human kidney tubule cells but not
in fresh hepatocytes or kidney cells from diabetic patients who are less susceptible to cisplatin
nephrotoxicity [B]. Cisplatin accumulates in cells that express OCT2 [C] and causes cell death [D].
Cimetidine competes with cisplatin for OCT2 and concentration dependently protects against cisplatin-
induced apoptosis [D] cimetidine concentrations are in mol/l. (Data redrawn from Ciarimboli G et al.
2005 Am J Pathol 167, 14771484.)
 BINDING OF DRUGS TO PLASMA PROTEINS
At terapheutic concentrations in plasma the free fraction
could be less than 1%.
The unbound to plasma proteins correspond to the
pharmacologically active protein.
Such seemingly small differences in protein binding (e.g.
99.5% versus 99.0%) can have large effects on free drug
concentration and drug effect.
The most important plasma protein in relation to drug binding
is albumin which binds many acidic drugs (e.g. warfarin, non-
steroidal anti-inflammatory drugs, sulfonamides) and a
smaller number of basic drugs (e.g. tricyclic antidepressants
and chlorpromazi
-globulin.
The amount of a drug that is bound to protein depends on
three factors:
the concentration of free drug
its affinity for the binding sites
the concentration of protein.
The usual concentration of albumin in plasma is about 0.6
mmol/l (4 g/100 ml). With two sites per albumin molecule, the
drug-binding capacity of plasma albumin would therefore be
 PARTITION INTO BODY FAT AND OTHER TISSUES
Fat represents a large, non-polar compartment.
For some drugs with hydrophilic characteristic is meaningless the contribution
of fat. Morphine. All do pass trough lipid bi-layers, does not accumulate in
body fat. However for drugs with lipophilic behavior (Thiopental ), the body fat
should be considered has a important accumulation body compartment. This
has important consequences that limit its usefulness as an intravenous
anaesthetic to short-term initiation (induction) of anaesthesia, and it has
been replaced by propofol even for this indication in many countries.
When lipid-soluble drugs are given chronically, however, accumulation in body
fat is often significant (e.g. benzodiazepines.
Body fat is not the only tissue in which drugs can accumulate. Chloroquine
an antimalarial drug has a high affinity for melanin and is taken up by the
retina, which is rich in melanin granules, accounting for chloroquines ocular
toxicity.
Tetracyclines accumulate slowly in bones and teeth, because they have a high
affinity for calcium, and should not be used in children for this reason.
 DRUG ABSORPTION AND ROUTES OF
Main routes of drug ADMINISTRATION
administration and
elimination.

Absorption is defined as the

passage of a drug from its
site of administration into
the plasma.

The main routes of

administration are:
oral
sublingual
rectal
application to other
epithelial surfaces (e.g. skin,
cornea, vagina and nasal
mucosa)
inhalation
injection
subcutaneous
intramuscular
intravenous
 ORAL ADMINISTRATION
Few drugs are absorbed in the
mouth, normally hydrophobic, like
e.g. organic nitrates, and
buprenorphine.
Mayory of the drugs are absorbed in
the intestine.
Passive transfer at a rate determined
by the ionization and lipid solubility
of the drug molecules.
Strong bases of pKa 10 or higher are
poorly absorbed, as are strong acids
of pKa less than 3, because they are
fully ionized.
Curare quaternary ammonium.
In some cases occur carrier-mediated
transport. Eg levodopa.
 FACTORS AFFECTING GASTROINTESTINAL ABSORPTION

gut content (e.g. fed versus fasted)

gastrointestinal motility
splanchnic blood flow
particle size and formulation
physicochemical factors, including some drug
interactions.

Normally the drug swallowed are intented to

be absorbed and have systemic effects,
however in some cases is desirable local
effects. eg. Vancomycin is very poorly
absorbed, and is administered orally to
eradicate toxin-forming Clostridium difficile
from the gut lumen in patients with
pseudomembranous colitis. Mesalazine is a
formulation of 5-aminosalicylic acid in a pH-
dependent acrylic coat that degrades in the
terminal ileum and proximal colon, and is
used to treat inflammatory bowel disease
affecting this part of the gut.
 Bioavailability and bioequivalence
bioavailability is used to indicate the
fraction (F) of an orally administered dose
that reaches the systemic circulation as
intact drug, taking into account both
absorption and local metabolic degradation.
F is measured by determining the plasma
drug concentration versus time curves in a
group of subjects following oral and (on a
separate occasion) intravenous
administration .
The areas under the plasma concentration
time curves (AUC) are used to estimate F as
AUCoral/ AUCintravenous.
Bioavailability relates only to the total
proportion of the drug that reaches the
systemic circulation and neglects the rate
of absorption.
 Other administration routes
SUBLINGUAL ADMINISTRATION: Absorption directly from the oral cavity is
sometimes useful. when a rapid response is required, particularly when the drug is
either unstable at gastric pH or rapidly metabolised by the liver. Glyceryl trinitrate
and buprenorphine. Drugs absorbed from the mouth pass directly into the systemic
circulation without entering the portal system, and so escape first-pass metabolism
by enzymes in the gut wall and liver.
RECTAL ADMINISTRATION: Rectal administration is used for drugs that are
required either to produce a local effect. This route can be useful in patients who are
vomiting or are unable to take medication by mouth.
APPLICATION TO EPITHELIAL SURFACES: used when a local effect on the skin is
required (e.g. topically applied steroids). Notwithstanding in some cases systemic
absortion is considerable and can have therapeutic application, for example in local
application of rub-on gels of non-steroidal anti-inflammatory agents such as
ibuprofen. Some organophosphate insecticides can be absorbed.
Nasal Spray: Some peptide hormone analogues, for example of antidiuretic hormone and of
gonadotropin-releasing hormone.
Eye drops: dorzolamide is a carbonic anhydrase inhibitor that is given as eye drops to lower
ocular pressure in patients with glaucoma.
 DISTRIBUTION OF DRUGS IN THE BODY
BODY FLUID COMPARTMENTS.
The equilibrium pattern of distribution
between the various compartments will
therefore depend on:

permeability across tissue barriers

binding within compartments
pH partition
fat : water partition.

To enter the transcellular compartments

from the extracellular compartment, a
drug must cross a cellular barrier, a
particularly important example being
the bloodbrain barrier.
 THE BLOODBRAIN BARRIER
Concept of Blood-Brain Barrier
Anatomy
inflammation can disrupt the integrity of the bloodbrain barrier,
allowing normally impermeant substances to enter the brain.

Domperidone, an antiemetic dopamine-receptor antagonist,that does

not penetrate the blood brain barrier but does access the
chemoreceptor trigger zone, to be used to prevent the nausea caused
by dopamine agonists such as apomorphine when these are used to
treat advanced Parkinsons disease.
Methylnaltrexone bromide is a peripherally acting -opioid-receptor
antagonist used in treating opioid-induced constipation in patients
requiring opioids as part of palliative care. It has limited
gastrointestinal absorption and does not cross the bloodbrain barrier,
so does not block the desired CNS opioid effects.

Several peptides, including bradykinin and enkephalins, increase

blood brain barrier permeability. There is interest in exploiting this to
improve penetration of anticancer drugs during treatment of brain
tumours. In addition, extreme stress renders the bloodbrain barrier
permeable to drugs such as pyridostigmine, which normally act
peripherally.
 VOLUME OF DISTRIBUTION

DRUGS LARGELY CONFINED TO THE PLASMA

COMPARTMENT: The plasma volume is about 0.05 l/kg
body weight. A few drugs, such as heparin, are confined to
plasma because the molecule is too large to cross the
capillary wall easily.

DRUGS DISTRIBUTED IN THE EXTRACELLULAR

COMPARTMENT: The total extracellular volume is about 0.2
l/kg, and this is the approximate Vd for many polar
compounds, such as vecuronium, gentamicin and
carbenicillin. These drugs cannot easily enter cells
because of their low lipid solubility, and they do not traverse
the bloodbrain or placental barriers freely.

DISTRIBUTION THROUGHOUT THE BODY WATER:Total

body water represents about 0.55 l/kg. This approximates
the distribution of many drugs that readily cross cell
membranes, such as phenytoin and ethanol.
 DRUG INTERACTIONS CAUSED BY ALTERED ABSORPTION: Gastrointestinal absorption could be
slowed by drugs that inhibit gastric emptying, such as atropine or opiates, or accelerated by drugs
that hasten gastric emptying (e.g. metoclopramide;
Alternatively, drug A may interact physically or chemically with drug B in the gut in such a way as to
inhibit absorption of B . Ca2+ and Fe2+ each form insoluble complexes with tetracycline that retard
their absorption; colestyramine, a bile acid-binding resin, binds several drugs (e.g. warfarin,
digoxin), preventing their absorption if administered simultaneously. Another example is the addition
of adrenaline (epinephrine) to local anaesthetic injections; the resulting vasoconstriction slows the
absorption of the anaesthetic, thus prolonging its local effect (Ch. 43).

DRUG INTERACTIONS CAUSED BY ALTERED DISTRIBUTION: One drug may alter the distribution
of another, by competing for a common binding site on plasma albumin or tissue protein, but such
interactions are seldom clinically important unless accompanied by a separate effect on drug
elimination.

Toxicity from the transient increase in concentration of free drug before the new steady state is
reached.
If dose is being adjusted according to measurements of total plasma concentration, it must be
appreciated that the target therapeutic concentration range will be altered by co-administration of a
displacing drug.
When the displacing drug additionally reduces elimination of the first, so that the free concentration
is increased not only acutely but also chronically at the new steady state, severe toxicity may ensue.
 Drug metabolism and
elimination
Overview:
phases 1 and 2 of
drug metabolism
(cytochrome P450 )
monooxygenase
system .
biliary excretion
and enterohepatic
recirculation of
drugs.
drug interactions.
 A Drug could be eliminated by 2process metabolism y excretion.
Metabolism involve catabolism and/or anabolism od a drug, and
excretion involves elimination of the drug from the organism by one
or several of the following routes:
the kidneys
the hepatobiliary system
the lungs (important for volatile/gaseous anaesthetics).
Milk (excretion into milk can sometimes be important because of
effects on the baby ).

Lypohylic drugs are not easily eliminated. Normally are metabolized

to a more polar moieties. This product are eliminated in the urine
normally
Drug metabolism occurs predominantly in the liver, especially by
the cytochrome P450 (CYP) system
 Drug Metabolism
Animals have evolved complex systems
The two phases of drug metabolism that detoxify foreign chemicals
(xenobiotics), including carcinogens and
toxins present in poisonous plants.
Drug metabolism involves two kinds of
reaction, known as phase 1 and phase 2,
which often occur sequentially.
PHASE 1 REACTIONS

Phase 1 reactions (e.g. oxidation,

reduction or hydrolysis) are catabolic,
and the products are often more
chemically reactive and hence,
paradoxically, sometimes more toxic or
carcinogenic than the parent drug.
Involves introduction of a reactive group
(funtionalization.)
This group then serves as the point of
attack for the conjugating system to
attach a substituent such as glucuronide
 THE P450 MONOOXYGENASE
SYSTEM
Cytochrome P450 enzymes are haem
proteins, comprising a large family
(superfamily) of related but distinct
enzymes.

Not all drug oxidation reactions

involve the P450 system. Some
drugs are metabolised in plasma
(e.g. hydrolysis of suxamethonium
by plasma cholinesterase; lung (e.g.
various prostanoids; or gut (e.g.
tyramine, salbutamol.
Ethanol is metabolised by a soluble
cytoplasmic enzyme, alcohol
dehydrogenase, in addition to
CYP2E1
 PHASE 2 REACTIONS
Phase 2 reactions are synthetic
(anabolic) and involve conjugation (i.e.
attachment of a substituent group),
which usually results in inactive
products, although there are exceptions.
Phase 2 reactions take place mainly in
the liver. If a drug molecule or Phase 1
product has a suitable handle (e.g. a
hydroxyl, thiol or amino group), it is
susceptible to conjugation.
The chemical group inserted may be
glucuronyl, sulfate, methyl or acetyl.
Glucuronidation involves the formation
of a high-energy phosphate (donor)
compound, uridine diphosphate
glucuronic acid (UDPGA), from which
glucuronic acid is transferred to an
electron-rich atom (N, O or S) on the
substrate, forming an amide, ester or
thiol bond. UDP-glucuronyl transferase,
 STEREOSELECTIVITY
Drugs such as sotalol,
warfarin and
cyclophosphamide.
Racemic compounds that
differ in the metabolism of
every isomeric form.
Inhibition of drug
metabolism by another
isomeric form. This rise
several clinically important
drug interactions.
Drug toxicity could be
related to only one of the
isomers
 Inhibition and induction of P450
Inhibitors of P450 differ in their
selectivity towards different isoforms of
the enzyme, and are classified by their
mechanism of action.
quinidine is a potent competitive
inhibitor of CYP2D6.
Non-competitive inhibitors include
drugs such as ketoconazole.

A number of drugs, such as rifampicin,

ethanol and carbamazepine,
increase the activity of microsomal
oxidase and conjugating systems when
administered repeatedly.
DRUG INTERACTIONS
DUE TO ENZYME
INDUCTION OR
INHIBITION
DRUG INTERACTIONS DUE TO ENZYME INDUCTION OR INHIBITION
Some drugs have the
capability of induce
ezyme metabolism
degradation of another
drugs.
Adverse clinical
outcomes from such
interactions are very
diverse Including
seizures due to loss of
anticonvulsant
effectiveness,
The antibiotic rifampicin, given for 3 days,
unwanted pregnancy
reduces the effectiveness of warfarin as an
from loss of oral anticoagulant.
contraceptive action.
thrombosis (from loss of Conversely, enzyme induction can increase
toxicity of a second drug if the toxic effects are
effectiveness of
mediated via an active metabolite.
warfarin) or bleeding Paracetamol (acetaminophen) toxicity is a
(from failure to case in point (see Fig. 57.1): this is caused by its
recognise the need to CYP metabolite N-acetyl-p-benzoquinone imine.
reduce warfarin dose Consequently, the risk of serious hepatic injury
 INTERACTIONS CAUSED BY ENZYME INHIBITION
Such effects can be
clinically important and are
major considerations in the
treatment of patients with
HIV infection with triple and
quadruple therapy, because
several protease inhibitors
are potent CYP inhibitors.
Several inhibitors of drug
metabolism influence the
metabolism of different
stereoisomers selectively.
 DRUG AND METABOLITE EXCRETION
BILIARY EXCRETION AND ENTEROHEPATIC
CIRCULATION
Liver cells transfer various substances, including
drugs, from plasma to bile by means of transport
systems similar to those of the renal tubule; these
include organic cation transporters (OCTs), organic
anion transporters (OATs) and P-glycoproteins (P-gp).
enterohepatic circulation. The result is a reservoir
of recirculating drug that can amount to about 20%
of total drug in the body, prolonging drug action.
Examples where this is important include morphine
(Ch. 42) and ethinylestradiol (Ch. 35). Several
drugs are excreted to an appreciable extent in bile.
Vecuronium (a non-depolarising muscle relaxant;
Ch. 13) is an example of a drug that is excreted
mainly unchanged in bile. Rifampicin (Ch. 51) is
absorbed from the gut and slowly deacetylated,
retaining its biological activity.
RENAL EXCRETION OF DRUGS AND
METABOLITES
RENAL CLEARANCE
This is defined as the volume of plasma
containing the amount of substance that is
removed from the body by the kidneys in unit
time. It is calculated from the plasma
concentration, Cp, the urinary concentration, Cu,
and the rate of flow of urine, Vu, by the
equation:
CLren varies greatly for different drugs, from
less than 1 ml/min to the theoretical maximum
set by the renal plasma flow, which is
approximately 700 ml/min, measured by p-
aminohippuric acid (PAH) clearance (renal
extraction of PAH approaches 100%).
 Three fundamental processes account for renal drug excretion:
1. glomerular filtration
2. active tubular secretion
3. passive reabsorption (diffusion from the concentrated tubular
fluid back across tubular epithelium).

GLOMERULAR FILTRATION
Glomerular capillaries allow drug molecules of molecular weight
below about 20 kDa to pass into the glomerular filtrate.

TUBULAR SECRETION
Drug molecules are transferred to the tubular lumen by two
independent and relatively non-selective carrier systems. One of
these, the OAT, transports acidic drugs in their negatively charged
anionic form (as well as various endogenous acids, such as uric
acid), while an OCT handles organic bases in their protonated
cationic form.
The OAT carrier can transport drug molecules against an
electrochemical gradient, and can therefore reduce the plasma
concentration nearly to zero, whereas OCT facilitates transport
down an electrochemical gradient. Unlike glomerular filtration,
carrier-mediated transport can achieve maximal drug clearance
even when most of the drug is bound to plasma protein.
probenecid was developed originally to prolong the action of
penicillin by retarding its tubular secretion.
These exemplify a relatively small but
important group of drugs (Table 9.8)
that are not inactivated by
metabolism, the rate of renal
elimination being the main factor that
determines their duration of action.
These drugs have to be used with
special care in individuals whose renal
function may be impaired, including
the elderly and patients with renal
disease or any severe acute illness.
 DRUG INTERACTIONS DUE TO ALTERED DRUG EXCRETION

The main mechanisms by which one drug can affect the

rate of renal excretion of another are by:
altering protein binding, and hence filtration
inhibiting tubular secretion
altering urine flow and/or urine pH.

INHIBITION OF TUBULAR SECRETION

Probenecid (Ch. 26) was developed to inhibit secretion of
penicillin and thus prolong its action.

ALTERATION OF URINE FLOW AND PH

Diuretics tend to increase the urinary excretion of other
drugs and their metabolites, but this is seldom immediately
clinically important.

loop and thiazide diuretics indirectly increase the proximal

tubular reabsorption of lithium (which is handled in a
similar way to Na+), and this can cause lithium toxicity in
patients treated with lithium carbonate for mood disorders
 Antineoplasicos
Definition of Cancer.
Uncontrolled multiplication and spread of abnormal forms in the bodys own
cells.
World leading second cause of death.
The appearance of these abnormal characteristics reflects altered patterns of
gene expression in the cancer cells, resulting from inherited or acquired
mutations.
There are 3 main treatments for the cancer:
Surgical excision
Irradiation
Chemotherapy.
Conventional cytotoxic drugs act on all cells and rely on a small margin of
selectivity to be useful as anticancer agents, but the scope of cancer therapy
has now broadened to include drugs that affect either the hormonal regulation
of tumour growth, or the defective cell cycle controls that underlie malignancy.
 THE PATHOGENESIS OF CANCER

Cancer cells manifest, to varying degrees, four characteristics that

distinguish them from normal cells. These are:
uncontrolled proliferation
de-differentiation and loss of function
invasiveness
metastasis.

A normal cell can transform into a cancer cell due to an acquired or

inherited mutation. For example, exposition to viruses or mutagens
induce carcegogenic transformation of cells. However, carcinogenesis is a
complex multistage process, usually involving more than one genetic
change as well as other, epigenetic factors that do not themselves
produce cancer but which increase the likelihood that the genetic
mutation(s) will eventually result in cancer.
There are two main categories of relevant genetic change:
The activation of proto-oncogenes to oncogenes. Proto-
oncogenes are genes that normally control cell division,
apoptosis and differentiation, but which can be converted to
oncogenes that induce malignant change by viral or
carcinogen action.
The inactivation of tumour suppressor genes. Normal cells
contain genes that suppress malignant change termed
tumour suppressor genes (anti-oncogenes) and mutations of
these genes are involved in many different cancers. The loss
of function of tumour suppressor genes can be the critical
event in carcinogenesis.

About 30 tumour suppressor genes and 100 dominant

oncogenes have been identified.
Cellular systems affected by cancer.
growth factors, their receptors and signalling pathways
The cell cycle transducers, for example cyclins, cyclin-
dependent kinases (cdks) or the cdk inhibitors
The apoptotic machinery that normally disposes of
abnormal cells
Telomerase expression
Local blood vessels, resulting from tumour-directed
angiogenesis.
 GENERAL PRINCIPLES OF CYTOTOXIC ANTICANCER DRUGS

Most current anticancer drugs, particularly cytotoxic agents, affect only one characteristic
aspect of cancer cell biology cell division but have no specific inhibitory effect on
invasiveness, the loss of differentiation or the tendency to metastasis.
Furthermore, because their main target is cell division, they will affect all rapidly dividing
normal tissues, and therefore are likely to produce, to a greater or lesser extent, the
following general toxic effects:
bone marrow toxicity (myelosuppression) with decreased leukocyte production and thus
decreased resistance to infection
impaired wound healing
loss of hair (alopecia)
damage to gastrointestinal epithelium (including oral mucous membranes)
depression of growth in children
sterility
teratogenicity
carcinogenicity because many cytotoxic drugs are mutagens.
Rapid cell destruction also entails extensive purine catabolism, and urates may
precipitate in the renal tubules and cause kidney damage.
 Cytotoxic drugs. These include:
alkylating agents and related compounds, which act by forming covalent bonds with
DNA and thus impeding replication
antimetabolites, which block or subvert one or more of the metabolic pathways
involved in DNA synthesis
cytotoxic antibiotics, i.e. substances of microbial origin that prevent mammalian cell
division
plant derivatives (e.g. vinca alkaloids, taxanes, camptothecins): most of these
specifically affect microtubule function and hence the formation of the mitotic spindle.
Hormones, of which the most important are steroids (e.g. glucocorticoids, Ch. 33) as
well as drugs that suppress oestrogen synthesis (e.g. aromatase inhibitors) or the
secretion of male sex hormones (e.g. gonadorelin analogues, Ch. 35) or antagonise
hormone action (e.g. oestrogen and androgen antagonists, Ch. 35).
Protein kinase inhibitors: these drugs inhibit the protein kinases (usually tyrosine
kinases but sometimes others) involved in growth factor receptor signal transduction.
They are increasingly used in a range of specific malignancies (see Krause & van
Etten, 2005).
Monoclonal antibodies: of growing importance in particular types of cancer.
Miscellaneous agents that do not easily fit into the above categories.
 ALKYLATING AGENTS AND RELATED COMPOUNDS
Alkylating agents and related compounds contain
chemical groups that can form covalent bonds with
particular nucleophilic substances in the cell (such as
DNA).

With alkylating agents themselves, the main step is the

formation of a carbonium ion a carbon atom with only
six electrons in its outer shell. Such ions are highly
reactive and react instantaneously with an electron
donor such as an amine, hydroxyl or sulfhydryl group.
Most of the cytotoxic anticancer alkylating agents are
bifunctional, i.e. they have two alkylating groups .

Their main impact is seen during replication (S phase),

when some zones of the DNA are unpaired and more
susceptible to alkylation. This results in a block at G2 and
subsequent apoptotic cell death.

All alkylating agents depress bone marrow

function and cause hair loss and gastrointestinal
disturbances.
 Nitrogen mustards
First World War,5 their basic formula (R-N-bis-
(2-chloroethyl)). In the body, each 2-
chloroethyl side-chain undergoes an
intramolecular cyclisation with the release of a
Cl. The highly reactive ethylene immonium
derivative so formed can interact with DNA.

Cyclophosphamide is probably the most

commonly used alkylating agent. It is inactive
until metabolised in the liver by the P450
mixed function oxidases.
It has a pronounced effect on lymphocytes and
can also be used as an immunosuppressant.
 Nitrosoureas: Examples include lomustine and carmustine. As they are lipid
soluble and cross the bloodbrain barrier, they are used to treat tumours of the brain
and meninges. However, most nitrosoureas have a severe cumulative depressive
effect on the bone marrow that starts 36 weeks after initiation of treatment.
Other alkylating agents: Busulfan has a selective effect on the bone marrow,
depressing the formation of granulocytes and platelets in low dosage and of red cells
in higher dosage. It has little or no effect on lymphoid tissue or the gastrointestinal
tract. It is used in chronic granulocytic leukaemia.
Dacarbazine: a prodrug, is activated in the liver, and the resulting compound is
subsequently cleaved in the target cell to release an alkylating derivative. Unwanted
effects include myelotoxicity and severe nausea and vomiting.
Procarbazine: inhibits DNA and RNA synthesis and interferes with mitosis at
interphase. Its effects may be mediated by the production of active metabolites. It
causes disulfiram-like actions with alcohol, exacerbates the effects of central
nervous system depressants and, because it is a weak monoamine oxidase inhibitor,
can produce hypertension if given with certain sympathomimetic agents. Other
alkylating agents in clinical use include hydroxycarbamide, mitobronitol, thiotepa
and treosulfan.
 Platinum compounds: Cisplatin is a water-
soluble planar coordination complex
containing a central platinum atom
surrounded by two chlorine atoms and two
ammonia groups. Its action is analogous to
that of the alkylating agents.

When it enters the cell, Cl dissociates,

leaving a reactive complex that reacts with
water and then interacts with DNA.

Cisplatin has revolutionised the treatment of

solid tumours of the testes and ovary.
Therapeutically, it is given by slow
intravenous injection or infusion. It is
seriously nephrotoxic, and strict regimens of
hydration and diuresis must be instituted. It
has low myelotoxicity but causes very severe
nausea and vomiting.
 ANTIMETABOLITES
Folate antagonists: The main folate antagonist is methotrexate, one of
the most widely used antimetabolites in cancer chemotherapy. Folates are
essential for the synthesis of purine nucleotides and thymidylate, which in
turn are essential for DNA synthesis and cell division. The main action of the
folate antagonists is to interfere with thymidylate synthesis.
 Methotrexato

It has low lipid solubility and thus does not readily cross the blood
brain barrier.
Methotrexate is also used as an immunosuppressant drug to treat
rheumatoid arthritis, psoriasis and other autoimmune conditions.
Unwanted effects include depression of the bone marrow and
damage to the epithelium of the gastrointestinal tract. Pneumonitis
can occur.
High doses , 10 times over recommended (in resistant patients) can
lead to nephrotoxicity.
High-dose regimens must be followed by rescue with folinic acid (a
form of FH4).
Pyrimidine analogues
Fluorouracil, an analogue of
uracil, also interferes with DTMP
synthesis. The result is
inhibition of DNA but not RNA or
protein synthesis.
The main unwanted effects are
gastrointestinal epithelial
damage and myelotoxicity. Two
other drugs, capecitabine and
tegafur, are metabolised to
fluorouracil.
 Cytarabine (cytosine arabinoside) is an
analogue of the naturally occurring
nucleoside 2-deoxycytidine. The drug
enters the target cell and undergoes the
same phosphorylation reactions as the
endogenous nucleoside to give cytosine
arabinoside trisphosphate, which inhibits
DNA polymerase.
The main unwanted effects are on the
bone marrow and the gastrointestinal
tract. It also causes nausea and vomiting.
Gemcitabine, an analogue of cytarabine,
has fewer unwanted actions, mainly an
influenza-like syndrome and mild
myelotoxicity. It is often given in
combination with other drugs such as
cisplatin.
 Purine analogues
The main anticancer purine
analogues include cladribine,
clofarabrine, fludarabine,
pentostatin, nelarabrine,
mercaptopurine and
tioguanine.
Fludarabine is metabolised to the
trisphosphate and inhibits DNA
synthesis by actions similar to
those of cytarabine.
It is myelosuppressive. Pentostatin
has a different mechanism of
action.
This action interferes with critical
pathways in purine metabolism
and can have significant effects on
cell proliferation.
 PLANT DERIVATIVES
Several naturally occurring plant products exert potent
cytotoxic effects and have a use as anticancer drugs.
Vinca alkaloids
The vinca alkaloids are derived from the Madagascar
periwinkle (Catharanthus roseus).
The principal members of the group are vincristine,
vinblastine and vindesine. Vinflumine, a fluorinated
vinca alkaloid, and vinorelbine are semisynthetic vinca
alkaloids with similar properties.
The drugs bind to tubulin and inhibit its polymerisation into
microtubules, preventing spindle formation in dividing cells
and causing arrest at metaphase. Their effects become
manifest only during mitosis. They also inhibit other cellular
activities that require functioning microtubules, such as
leukocyte phagocytosis and chemotaxis, as well as axonal
transport in neurons.
Vincristine has very mild myelosuppressive activity but is
neurotoxic and commonly causes paraesthesias (sensory
changes), abdominal pain and weakness.
Vinblastine is less neurotoxic but causes leukopenia, while
 Paclitaxel and related compounds
Taxanes are the active component.
The group includes paclitaxel and the semi-
synthetic derivatives docetaxel and
cabazitaxel.
These agents act on microtubules, stabilising
them (in effect freezing them) in the
polymerised state, achieving a similar effect to
that of the vinca alkaloids.
They are generally used to treat breast and lung
cancer and paclitaxel, given with carboplatin, is
the treatment of choice for ovarian cancer.
Unwanted effects, which can be serious, include
bone marrow suppression. Resistant fluid
retention (particularly oedema of the legs) can
occur with docetaxel. Hypersensitivity to these
compounds is common and requires
pretreatment with corticosteroids and
antihistamines.
Camptothecins.
The camptothecins irinotecan and
topotecan, isolated from the stem of the
tree Camptotheca acuminata, bind to and
inhibit topoisomerase I .
Diarrhoea and reversible bone marrow
depression occur but, in general, these
alkaloids have fewer unwanted effects than
most other anticancer agents.
Etoposide
Etoposide is derived from mandrake root
(Podophyllum peltatum).
it may act by inhibiting mitochondrial
function and nucleoside transport, as well
as having an effect on topoisomerase II.
Unwanted effects include nausea and
 HORMONES
Tumours arising in hormone-sensitive tissues (e.g. breast, uterus,
prostate gland) may be hormone-dependent, an effect related to the
presence of hormone receptors in the malignant cells. Their growth
can be inhibited by hormone agonists or antagonists, or by agents
that inhibit the synthesis of the hormone.

Hormones or their analogues that have inhibitory actions on target

tissues can be used in treatment of tumours of those tissues.

Such procedures alone rarely effect a cure but do retard tumour

growth and mitigate the symptoms of the cancer, and thus play an
important part in the clinical management of sex hormone-dependent
tumours.
 Glucocorticoids
Glucocorticoids such as prednisolone have marked inhibitory effects on lymphocyte proliferation
and are used in the treatment of leukaemias and lymphomas.
Glucocorticoids mitigate some of the side effects of anticancer drugs, such as nausea and vomiting,
making them useful as supportive therapy when treating other cancers, as well as in palliative care.

Oestrogens
Diethylstilbestrol and ethinyloestradiol are still occasionally used in the palliative treatment of
androgen-dependent prostatic tumours. These tumours can also be treated with gonadotrophin-
releasing hormone analogues.

Progestogens
Progestogens such as megestrol, norehisterone and medroxyprogesterone have a role in
treatment of endometrial cancer.
Gonadotrophin-releasing hormone analogues
analogues of the gonadotrophin-releasing hormones, such as goserelin, buserelin, leuprorelin
and triptorelin, can, when administered chronically, inhibit gonadotrophin release. These agents
are therefore used to treat advanced breast cancer in premenopausal women and prostate cancer.
The effect of the transient surge of testosterone secretion that can occur in patients treated in this
way for prostate cancer must be prevented by an antiandrogen such as cyproterone. Degaralix is
a gonadotrophin-releasing hormone antagonist used for the treatment of prostate cancer.
 Somatostatin analogues.
Analogues of somatostatin such as octreotide and lanreotide, are used to relieve the
symptoms of neuroendocrine tumours, including hormone-secreting tumours of the
gastrointestinal tract such as VIPomas, glucagonomas, carcinoid tumours and gastrinomas.

HORMONE ANTAGONISTS.
In addition to the hormones themselves, hormone antagonists can also be effective in the
treatment of several types of hormone-sensitive tumours.

Antioestrogens
tamoxifen, is remarkably effective in some cases of hormone-dependent breast cancer and may
have a role in preventing these cancers. In breast tissue, tamoxifen competes with endogenous
oestrogens for the oestrogen receptors and therefore inhibits the transcription of oestrogen-
responsive genes. Other oestrogen receptor antagonists include toremifene and fulvestrant.
Unwanted effects are similar to those experienced by women following the menopause.
Potentially more serious are hyperplastic events in the endometrium, which may progress to
malignant changes, and the risk of thromboembolism.
Aromatase inhibitors such as anastrozole, letrozole and exemestane, which suppress the
synthesis of oestrogen from androgens in the adrenal cortex (but not in the ovary), are also
effective in the treatment of breast cancer in postmenopausal (but not in premenopausal)
women,
 Antiandrogens
The androgen antagonists
flutamide, cyproterone and
bicalutamide may be used
either alone or in combination
with other agents to treat
tumours of the prostate. They are
also used to control the
testosterone surge (flare) that is
seen when treating patients with
gonadorelin analogues.
 MONOCLONAL ANTIBODIES
In some cases, binding of the antibody to its target activates the hosts immune
mechanisms and the cancer cell is killed by complement-mediated lysis or by killer
T cells.
Other monoclonal antibodies attach to and inactivate growth factors or their
receptors on cancer cells, thus inhibiting the survival pathway and promoting
apoptosis.
Unlike most of the cytotoxic drugs described above, they offer the prospect of
highly targeted therapy without many of the side effects of conventional
chemotherapy. This advantage is offset in most instances as they are often given in
combination with more traditional drugs. Several monoclonals are in current clinical
use. Their high cost is a significant problem.
Rituximab: is a monoclonal antibody that is used (in combination with other
chemotherapeutic agents) for treatment of certain types of lymphoma. It is
effective in 4050% of cases when combined with standard chemotherapy.
Unwanted effects include hypotension, chills and fever during the initial infusions
and subsequent hypersensitivity reactions. A cytokine release reaction can occur
and has been fatal. The drug may exacerbate cardiovascular disorders.
 Trastuzumab (Herceptin) is a humanised murine monoclonal antibody that binds to
an oncogenic protein termed HER2 (the human epidermal growth factor receptor 2), a
member of the wider family of receptors with integral tyrosine kinase activity. Tumour
cells, in about 25% of breast cancer patients, overexpress this receptor and the
cancer proliferates rapidly. Early results show that trastuzumab given with standard
chemotherapy has resulted in a 79% 1-year survival rate in treatment-naive patients
with this aggressive form of breast cancer. The drug is often given with a taxane such
as docetaxel. Unwanted effects are similar to those with rituximab.
Bevacizumab is a humanised monoclonal antibody that is used for the treatment of
colorectal cancer but would be expected to be useful for treating other cancers too. It
neutralises VEGF (vascular endothelial growth factor), thereby preventing the
angiogenesis that is crucial to tumour survival. A closely related preparation is also
given by direct injection into the eye to retard the progress of acute macular
degeneration (AMD), a common cause of blindness associated with increased retinal
vascularisation.
Catumaxomab attaches to an epithelial adhesion molecule, EpCAM, which is
overexpressed in some malignant cells. The antibody binds to this adhesion molecule
and also to T lymphocytes and antigen-presenting cells, thus facilitating the action of
the immune system in clearing the cancer.
 PROTEIN KINASE INHIBITORS
Imatinib; is a small-molecule inhibitor of signalling pathway
kinases. It inhibits an oncogenic cytoplasmic kinase (Bcr/Abl),
considered to be a unique factor in the pathogenesis of chronic
myeloid leukaemia (CML). Unwanted effects include
gastrointestinal symptoms (pain, diarrhoea, nausea), fatigue,
headaches and sometimes rashes. Resistance to imatinib,
resulting from mutation of the kinase gene, is a growing
problem. It results in little or no cross-resistance to other
kinase inhibitors.
 TARGETS FOR DRUG ACTION
The molecular target in general
can be broadly divided into:
receptors
ion channels
enzymes
transporters (carrier molecules).
Ion channels, are essentially
gateways in cell membranes that
selectively allow the passage of
particular ions, and that are
induced to open or close by a
variety of mechanisms.

ligand-gated channels and

voltage-gated channels.
 By binding to the channel protein itself, either to the ligand-binding (orthosteric) site of ligand-gated channels, or to other
(allosteric) sites, or, in the simplest case, exemplified by the action of local anaesthetics on the voltage-gated sodium
channel (see Ch. 43), the drug molecule plugs the channel physically (Fig. 3.1B), blocking ion permeation. Examples of
drugs that bind to allosteric sites on the channel protein and thereby affect channel gating include:
benzodiazepine tranquillisers (see Ch. 44). These drugs bind to a region of the GABAA receptor chloride channel
complex (a ligand-gated channel) that is distinct from the GABA binding site and facilitate the opening of the channel by the
inhibitory neurotransmitter GABA (see Ch. 38).
vasodilator drugs of the dihydropyridine type (see Ch. 22), which inhibit the opening of L-type calcium channels (see Ch.
4)
sulfonylureas (see Ch. 31) used in treating diabetes, which act on ATP-gated potassium channels of pancreatic -cells
and thereby enhance insulin secretion.
2. By an indirect interaction, involving a G protein and other intermediaries (see p. 30).
3. By altering the level of expression of ion channels on the cell surface. For example gabapentin reduces the insertion of
neuronal calcium channels into the plasma membrane (Ch. 45).
A summary of the different ion channel families and their functions is given below.
Enzymes.

Transporters: In many cases, hydrolysis of ATP provides the energy for transport of substances against their electrochemical
gradient. Such transport proteins include a distinct ATP binding site, and are termed ABC (ATP-binding cassette)
transporters. multi-drug resistance (MDR) transporters that eject cytotoxic drugs from cancer and microbial cells, conferring
resistance to these therapeutic agents .
Receptor Proteins- Cloning of
receptors
In the 1970s, pharmacology entered a new phase when receptors,
which had until then been theoretical entities, began to emerge as
biochemical realities following the development of receptor-
labelling techniques.
Receptors are proteins normally embedded in membrane lipid and
thus have proven very difficult to crystallise.
Obtaining crystals of a protein allows its structure to be analysed at
very high resolution by X-ray diffraction techniques.
Now that the genes have been clearly identified, the emphasis has
shifted to characterising the receptors pharmacologically and
determining their molecular characteristics and physiological
functions.
 TYPES OF RECEPTOR
Receptors elicit many different types of cellular effect.
Some of them are very rapid, such as those involved in
synaptic transmission, operating within milliseconds,
whereas other receptor-mediated effects, such as those
produced by thyroid hormone or various steroid
hormones, occur over hours or days.

Based on molecular structure and the nature of this

linkage (the transduction mechanism), we can
distinguish four receptor types, or superfamilies
 Type 1: ligand-gated ion channels (also known as ionotropic receptors).
Typically, these are the receptors on which fast neurotransmitters act.
Type 2: G protein-coupled receptors (GPCRs). These are also known as
metabotropic receptors or 7-transmembrane (7-TM or heptahelical)
receptors. They are membrane receptors that are coupled to intracellular
effector systems primarily via a G protein. They constitute the largest
family, and include receptors for many hormones and slow transmitters.
Type 3: kinase-linked and related receptors. This is a large and
heterogeneous group of membrane receptors responding mainly to protein
mediators. They comprise an extracellular ligand-binding domain linked to
an intracellular domain by a single transmembrane helix. In many cases,
the intracellular domain is enzymatic in nature (with protein kinase or
guanylyl cyclase activity).
Type 4: nuclear receptors. These are receptors that regulate gene
transcription. Receptors of this type also recognize many foreign molecules,
inducing the expression of enzymes that metabolize them.
 Molecular structure of the receptors

Despite the individual differences between the members of a family of receptors the general
structure and the attached transduction signal machinery is moistly similar
 There are subtypes of receptors in a same family and
regularly new members and isoforms are described.
www.guidetopharmacology.org

TYPE 1: LIGAND-GATED ION CHANNELS

For the general description of ligand-gated ion channel structure we use has a model the
nicotinic acetylcholine receptor, which we find at the skeletal neuromuscular junction.

Als o called the Cis loop receptor

Another exmaples of this family are:

GABAA and glycine receptors
5-HT3
ionotropic glutamate receptors (Ch. 38) and purinergic P2X receptors (Chs 16 and 39) that
differ in several respects from the nicotinic acetylcholine receptor.
Nicotinic Receptor
 consists of a pentameric assembly of different subunits, of
which there are four types, termed , , and , each of
molecular weight (Mr) 4058 kDa. The subunits show
marked sequence homology, and each contains four
membrane-spanning -helices, inserted into the
membrane as shown in
The pentameric structure (2, , , ) possesses two
acetylcholine binding sites, each lying at the interface
between one of the two subunits and its neighbour.
Both must bind acetylcholine molecules in order for the
receptor to be activated. This receptor is sufficiently large
to be seen in electron micrographs, and Figure 3.4B shows
its structure, based mainly on a high-resolution electron
diffraction study (Miyazawa et al., 2003). Each subunit
spans the membrane four times, so the channel comprises
The gating mechanism
Receptors of this type control the fastest synaptic events in the nervous
system, in which a neurotransmitter acts on the postsynaptic membrane of a
nerve or muscle cell and transiently increases its permeability to particular
ions.

Most excitatory neurotransmitters, such as acetylcholine at the

neuromuscular junction or glutamate in the central nervous system, cause an
increase in Na+ and K+ permeability and in some instances Ca2+
permeability.
At negative membrane potentials this results in a net inward current carried
mainly by Na+, which depolarises the cell and increases the probability that
it will generate an action potential. The action of the transmitter reaches a
peak in a fraction of a millisecond, and usually decays within a few
milliseconds.
TYPE 2: G PROTEIN-COUPLED
RECEPTORS
The abundant GPCR family comprises many of the receptors that are familiar to
pharmacologists, such as muscarinic AChRs, adrenoceptors, dopamine
receptors, 5-HT receptors, opioid receptors, receptors for many peptides, purine
receptors and many others, including the chemoreceptors involved in olfaction
and pheromone detection, and also many orphans (see Fredriksson & Schith,
2005). Many neurotransmitters, apart from peptides, can interact with both
GPCRs and ligand-gated channels, allowing the same molecule to produce fast
(through ligand-gated ion channels) and relatively slow (through GPCRs) effects.
Individual peptide hormones, on the other hand, generally act either on GPCRs
or on kinase-linked receptors (see below), but rarely on both, and a similar
choosiness applies to the many ligands that act on nuclear receptors.7
The human genome includes genes encoding about 400 GPCRs (excluding
odorant receptors), which constitute the commonest single class of targets for
therapeutic drugs, and it is thought that many promising therapeutic drug
targets of this type remain to be identified. For a short review, see Hill (2006)
 Molecular structure
G protein-coupled receptors consist of a single polypeptide chain, usually of 350400 residues, but can in some cases
be up to 1100 residues. The general anatomy is shown in Figure 3.3B. Their characteristic structure comprises seven
transmembrane -helices, similar to those of the ion channels discussed above, with an extracellular N-terminal
domain of varying length, and an intracellular C-terminal domain.
GPCRs are divided into three distinct families. There is considerable sequence homology between the members of one
family, but little between different families. They share the same seven transmembrane helix (heptahelical) structure,
but differ in other respects, principally in the length of the extracellular N-terminus and the location of the agonist
binding domain (Table 3.2). Family A is by far the largest, comprising most monoamine, neuropeptide and chemokine
receptors. Family B includes receptors for some other peptides, such as calcitonin and glucagon. Family C is the
smallest, its main members being the metabotropic glutamate and GABA receptors (Ch. 38) and the Ca2+-sensing
receptors8 (see Ch. 36).
 Site-directed mutagenesis experiments show that the
third cytoplasmic loop is the region of the molecule that
couples to the G protein, because deletion or modification
of this section results in receptors that still bind ligands
but cannot associate with G proteins or produce
responses. Usually, a particular receptor subtype couples
selectively with a particular type of G protein, and
swapping parts of the cytoplasmic loop between different
receptors alters their G protein selectivity.
Phosphorylation of serine and threonine residues on the
C-terminal tail and other intracellular domains by
intracellular kinases can result in receptor desensitisation
(see p. 36).
For small molecules, such as noradrenaline
(norepinephrine) and acetylcholine, the ligand-binding
domain of class A receptors is buried in the cleft between
the -helical segments within the membrane (Figs 3.3B
and 3.7), similar to the slot occupied by retinal in the
rhodopsin molecule Peptide ligands, such as substance P
(Ch. 18), bind more superficially to the extracellular loops,
as shown in Figure 3.3B. From crystal structures and
single-site mutagenesis experiments, it is possible to map
the ligand-binding domain of these receptors, and the
hope is that it may soon be possible to design synthetic
ligands based on knowledge of the receptor site structure
an important milestone for the pharmaceutical industry,
which has relied up to now mainly on the structure of
endogenous mediators (such as histamine) or plant
alkaloids (such as morphine) for its chemical inspiration.9
 PROTEASE-ACTIVATED RECEPTORS
Most GPCR are activated by diffusible ligands, however some receptor are activated by cleavage of
extracellular domain.
Four types of protease-activated receptors (PARs) have been identified.
A PAR molecule can be activated only once, because the cleavage cannot be reversed, so continuous
re-synthesis of receptor protein is necessary. Inactivation occurs by a further proteolytic cleavage
that frees the tethered ligand, or by desensitisation, involving phosphorylation, after which the
receptor is internalised and degraded, to be replaced by newly synthesised protein.
 G PROTEINS AND THEIR ROLE
G poteins present 3 subunits , and .
Guanine nucleotides bind to the subunit, which has enzymic (GTPase) activity, catalysing
the conversion of GTP to GDP.
The and subunits remain together as a complex.
In the resting state, the G protein exists as an trimer, with GDP occupying the site on the
subunit.
When a GPCR is activated by an agonist molecule, a conformational change occurs, involving
the cytoplasmic domain of the receptor, inducing a high affinity interaction of and the
receptor, causing the bound GDP to dissociate and to be replaced with GTP (GDP GTP
exchange), which in turn causes dissociation of the G protein trimer, releasing GTP and
subunits; these are the active forms of the G protein, which diffuse in the membrane and can
associate with various enzymes and ion channels, causing activation of the target.
Association of or subunits with target enzymes or channels can cause either activation or
inhibition, depending on which G protein is involved.
G protein activation results in amplification, because a single agonistreceptor complex can
activate several G protein molecules in turn, and each of these can remain associated with the
effector enzyme for long enough to produce many molecules of product.
Signalling is terminated when the hydrolysis of GTP to GDP occurs through the GTPase activity
of the subunit.
Four main classes of G protein (Gs, Gi, Go and Gq) are of pharmacological importance

Gs and Gi produce, respectively, stimulation and inhibition of the enzyme adenylyl cyclase

The subunits of these G proteins differ in structure. One functional difference that has been
useful as an experimental tool to distinguish which type of G protein is involved in different
situations concerns the action of two bacterial toxins, cholera toxin and pertussis toxin.

These toxins, which are enzymes, catalyse a conjugation reaction (ADP ribosylation) on the
subunit of G proteins. Cholera toxin acts only on Gs, and it causes persistent activation. Many of
the symptoms of cholera, such as the excessive secretion of fluid from the gastrointestinal
epithelium, are due to the uncontrolled activation of adenylyl cyclase that occurs. Pertussis toxin
specifically blocks Gi and Go by preventing dissociation of the G protein trimer.
 TARGETS FOR G PROTEINS
adenylyl cyclase, the enzyme responsible for cAMP formation

phospholipase C, the enzyme responsible for inositol phosphate and diacylglycerol

(DAG) formation

ion channels, particularly calcium and potassium channels

Rho A/Rho kinase, a system that regulates the activity of many signalling pathways
controlling cell growth and proliferation, smooth muscle contraction, etc.

mitogen-activated protein kinase (MAP kinase), a system that controls many cell
functions, including cell division.
 cAMP is a nucleotide synthesised within the cell from ATP by the action of a
membrane-bound enzyme, adenylyl cyclase. It is produced continuously and
inactivated by hydrolysis to 5-AMP by the action of a family of enzymes
known as phosphodiesterases
Many different drugs, hormones and neurotransmitters act on GPCRs and
increase or decrease the catalytic activity of adenylyl cyclase, thus raising
or lowering the concentration of cAMP within the cell. In mammalian cells
there are 10 different molecular isoforms of the enzyme, some of which
respond selectively to Gs or Gi
A common pthway of the AMPc is brought about by the activation of protein
kinases by cAMP primarily protein kinase A (PKA) in eukaryotic cells.
Protein kinases regulate the function of many different cellular proteins by
controlling protein phosphorylation.
increased cAMP production in
response to -adrenoceptor
activation affects enzymes
involved in glycogen and fat
metabolism in liver, fat and
muscle cells. The result is a
coordinated response in
which stored energy in the
form of glycogen and fat is
made available as glucose to
fuel muscle contraction.

As mentioned above,
receptors linked to Gi rather
than Gs inhibit adenylyl
cyclase, and thus reduce
cAMP formation. Examples
include certain types of
mAChR (e.g. the M2 receptor
of cardiac muscle), 2
adrenoceptors in smooth
muscle and opioid receptors.
Adenylyl cyclase can be
 Most are weakly inhibited by drugs such as
methylxanthines (e.g. theophylline and caffeine; see
Chs 28 and 48). Rolipram (used to treat asthma; Ch.
28) is selective for PDE4, expressed in inflammatory
cells; milrinone (used to treat heart failure; Ch. 21) is
selective for PDE3, which is expressed in heart muscle;
sildenafil (better known as Viagra; Ch. 35) is selective
for PDE5, and consequently enhances the vasodilator
effects of nitrous oxide (NO) and drugs that release NO,
whose effects are mediated by cGMP (see Ch. 20).
 The phospholipase C/inositol phosphate system
One particular member of the PI family,
namely phosphatidylinositol (4,5)
bisphosphate (PIP2), which has
additional phosphate groups attached
to the inositol ring, plays a key role.
PIP2 is the substrate for a membrane-
bound enzyme, phospholipase C
(PLC), which splits it into diacylglycerol
(DAG) and inositol (1,4,5) trisphosphate
(IP3;), both of which function as second
messengers as discussed below (p. 35)
 Inositol phosphates and intracellular calcium

Inositol (1,4,5) trisphosphate (IP3) is a water-soluble mediator that is released into

the cytosol and acts on a specific receptor the IP3 receptor which is a ligand-
gated calcium channel present on the membrane of the endoplasmic reticulum.
IP3 can be converted inside the cell to the (1,3,4,5) tetraphosphate, IP4, by a
specific kinase. The exact role of IP4 remains unclear, but some evidence
suggests that it, and also higher inositol phosphates, may play a role in controlling
gene expression.

Diacylglycerol and protein kinase C

Diacylglycerol is produced as well as IP3 whenever receptor-induced
PI hydrolysis occurs. The main effect of DAG is to activate a protein
kinase, protein kinase C (PKC), which catalyses the phosphorylation
of a variety of intracellular proteins. DAG, unlike the inositol
phosphates, is highly lipophilic and remains within the membrane.
There are at least 10 different mammalian PKC subtypes, which
have distinct cellular distributions and phosphorylate different
 Ion channels as targets for G proteins
Another major function of G protein-coupled receptors is to
control ion channel function directly by mechanisms that do
not involve second messengers such as cAMP or inositol
phosphates. Direct G proteinchannel interaction, through the
subunits of Gi and Go proteins, appears to be a general
mechanism for controlling K+ and Ca2+ channels.
Similar mechanisms operate in neurons, where many
inhibitory drugs such as opioid analgesics reduce excitability
by opening certain K+ channels known as G protein-
activated inwardly rectifying K+ channels (GIRK) or by
inhibiting voltage-activated N and P/Q type Ca2+ channels
and thus reducing neurotransmitter release (see Chs 4 and
42).
GPCR desensitisation
In summary..
The simple dogma that underpins much of our current understanding
of GPCRs, namely, one GPCR gene one GPCR protein one
functional GPCR one G protein one response is showing distinct
signs of wear. In particular:
one gene, through alternative splicing, RNA editing, etc., can give rise
to more than one receptor protein
one GPCR protein can associate with others, or with other proteins
such as RAMPs, to produce more than one type of functional receptor
different agonists may affect the receptor in different ways and elicit
qualitatively different responses
the signal transduction pathway does not invariably require G
proteins, and shows cross-talk with tyrosine kinase-linked receptors.
 TYPE 3: KINASE-LINKED AND
RELATED RECEPTORS
They are activated by a wide variety of protein mediators,
including growth factors and cytokines, and hormones such as
insulin and leptin, whose effects are exerted mainly at the level
of gene transcription.
large proteins consisting of a single chain of up to 1000
residues, with a single membrane-spanning helical region,
linking a large extracellular ligand-binding domain to an
intracellular domain of variable size and function.
Over 100 such receptors have been cloned, and many
structural variations exist.
They play a major role in controlling cell division, growth,
differentiation, inflammation, tissue repair, apoptosis and
immune responses
 The main types are as follows
Receptor tyrosine kinases (RTKs):
this group incorporate a tyrosine
kinase moiety in the intracellular region.
They include receptors for many growth
factors, such as epidermal growth
factor and nerve growth factor.
Receptor serine/threonine kinases:
This smaller class is similar in structure
to RTKs but they phosphorylate serine
and/or threonine residues rather than
tyrosine. The main example is the
receptor for transforming growth
factor (TGF).
Cytokine receptors. lack intrinsic
enzyme activity. When occupied, they
activate various tyrosine kinases, such
as Jak (the Janus kinase).
 ANTIMETABOLITES

Folate antagonists.
The main folate antagonist is
methotrexate, one of the
most widely used
antimetabolites in cancer
chemotherapy.

The main action of the folate

antagonists is to interfere with
thymidylate synthesis.
 SPECIAL DRUG DELIVERY SYSTEMS

Prodrugs
biologically erodible nanoparticles
antibodydrug conjugates
packaging in liposomes
coated implantable devices.
 Also, fluorescence methods have been developed to
study the kinetics of ligand binding and subsequent
conformational changes associated with activation (see
Lohse et al., 2008; Bockenhauer et al., 2011).
 Routes of administration

First Category: There are four groups (AD) of routes of administration in this category; they all
share a common feature of having a biological barrier. The structure of some barriers can be as
complex as the gastrointestinal wall and some as basic as sublingual or rectal mucosa.
Xenobiotics must pass through these barriers to reach the systemic circulation and exhibit the
expected or unexpected systemic effect.
Second Category: The routes of administration in this category circumvent the barriers, and are
used for immediate onset of action and direct access to the systemic circulation.
Third Category: Interaction of xenobiotics with the skin can lead to local and/or systemic effect.
In addition to the physicochemical characteristics of xenobiotics and their vehicle, environmental
 Fourth Category:
Specialized routes of
administration for
achieving local and
targeted therapy are
included in this category.
Although the intended use
of these routes is mostly to
achieve local or targeted
effect, nonetheless a
portion of administered
dose may reach the
systemic circulation and
exhibit systemic effect.