Professional Documents
Culture Documents
The end result of this lack of coordinated effort on optimizing drug use was drug
misuse, abuse, and serious untoward effects. The situation was compounded
by increased number of therapeutic agents, information explosion, heavy
advertisement, and increased availability.
During the latter part of '60s, a number of healthcare and Pharmacy leaders in
United States, concerned about these unresolved issues in drug use, started to
press for changes in Pharmacy practice and education. Greater emphasis was
placed on the "clinical' involvement of the Pharmacists with the intent of making
them take more responsibility for the safe and appropriate use of drugs in
society. Hence, the birth of Clinical Pharmacy.
• sub-therapeutic dosage*
• over-dosage *
• drug-drug interactions*
• improper drug product selections*
• untreated indications
• failure to receive medications
• adverse drug reactions
• medication use without indications
The Pharmacist as a professional entrusted to assure the safe and effective use
of medicines has to have some minimum or entry-level abilities ( competencies)
that will enable him/her carry out these functions.
The professional bodies and the examining boards have established minimum
requirements that a Pharmacist must meet before being allowed to practice
legally. These minimum requirements are presented as competency statements.
(Ref:NAPLEX or Basic Pharmacokinetic text Makoid et al).
It soon became apparent that when a standard dose of certain drugs was given
to a population of patients they exhibited varying Pharmacological responses.
This response ranged from having no therapeutic effect (under-dose) to showing
overt toxic effect (over-dose).This led to the thinking that specific patient factors
must be responsible for these outcomes since all the patients received the same
amount of drug. It also indicated that the amount of drug reaching the respective
receptors responsible for the Pharmacologic effect could be varying between
patients.
The study of these specific patient factors and the use of such knowledge in
optimizing drug therapy in individual patients is the basis of Pharmacokinetics
discipline. The most important uses of Pharmacokinetic principles in optimizing
drug therapy are to determine:
The rationale for the discipline is based on the demonstration that the intensity of
the pharmacological action of many drugs correlates better with plasma
concentration than with dosage.
Given that these are higher-order thinking skills the best known methods to
achieve them is through comprehending the concepts through engaged-learning
and mastery of the skills through quizzes.
In this course there will be a focus on the development of the basic tools and
their use in designing drug dosage regimens. The factors that affect that the
interpretation a pharmacokinetic study in an individual patient will be
addressed under Clinical Pharmacokinetics course.
6. Ensure all library assignments are completed and submitted before the
deadline
REQUIRED: YES
BULLETIN
DESCRIPTION: Pharmacokinetics is the mathematics of the time course of
Absorption, Distribution, Metabolism, and Excretion (ADME) of
drugs in the body. The biological, physiological, and
physicochemical factors which influence the transfer processes of
drugs in the body thus influence the rate and extent of ADME of
those drugs in the body. In many cases, pharmacological and
toxicological actions are related to plasma concentration of drugs.
Consequently, through the study of pharmacokinetics, the
pharmacist will be able to individualize therapy for the patient.
COURSE
OBJECTIVES:
ACTIVE LEARNING
METHODS: Activiy 1) Group based case study format with recitation of
problem sets and discussion of selected topics from prearranged
reading as well as student participation in problem solving.
Activiy 2) Group based evaluation of current pharmacokinetic
literature applying the tools learned in the course will be an integral
part of the teaching process as well as the examination procedure.
GRADING: The School of Pharmacy and Health Professions default grading
system will NOT be utilized in this course.
The assessment will be as follows:
Activity Weight
Prequizes (1 / lesson) (0)
One minute paper (1 / lesson) (0)
Quizes (16) 10%
Library Assignments (2) 10%
Exam 1 (course objective 1) 30%
Exam 2 (course objectives 2,3) 50%
The latest policies, including those regarding students with disabilities and misconduct can be
found on the School's web site at http://spahp.creighton.edu/Acad_SAffairs/policies.asp. Each
student is responsible for becoming familiar with all of the latest policies.
“Faculty reserve the right to make changes in a course as necessary and those
changes must be submitted to the Curriculum Committee within 30 days.”
The course syllabus is a topic by topic outline as follows:
Course Objective 1) Given a patient pharmacokinetic profile, the student shall calculate the
pharmacokinetic parameters.
Lecture Topic
Lecture Topic
Lecture Topic
Quizes 11- 15
65
Conceptual
questions
Due
Midnight
3/23/03
03/10- SPRING
03/14 BREAK
Main
Observation: Interpret
Plasma Level Plasma Drug
How much? Level
Rate in? Concentration (Level)
Rate out?
Other: Factors
Renal Hepatic Distribn Dialysis Rate Affecting
Lungs out Rate out
Others: E M D Gut
Renal exc
Cr Cl
Basic PK Clinical PK
Tools Factors/interpretation.
Plasma PD
Level Response
Indirect Predict
tool Outcome
As stated before the rationale for pharmacokinetics is based on the fact that plasma or
serum concentrations of certain life-saving drugs can be related to their pharmacologic
activity.It is an indirect tool for predicting therapeutic outcomes. Once this relationship
has been quantified through pharmacokinetic theories Pharmacists are then able to design
dosage regimens that would result in predictable therapeutic outcomes.
From the above diagram 1 it should be evident that plasma concentration is basically
determined by two rate processes: the rate at which the drug appears in plasma and the
rate at which the drug is eliminated from plasma.
The rate of appearance in plasma(input) is in turn determined by the rate of absorption for
oral products or rate of administration for parenteral (IV) products.On the other hand the
rate of elimination from plasma is determined by the rate of metabolism and or excretion.
For drugs with significant distribution the initial decline in plasma concentration may be
due to distribution.
The most basic questions Basic pharmacokinetics seeks to answer is:how much drug is
required to be given any one time(dose)? and often should this be given.The how much
question will be addressed by volume of distribution concept and how often by the rate
concepts.
Basic Pharmacokinetics, therefore, addresses the basic tools and clinical
Pharmacokinetics the applications of these tools in the clinical setting,In addition,Clinical
Pharmacokinetics addresses the factors that affect interpretation.These would be factors
that affect the rate of drug input and elimination i.e affecting ADME.
In order that the pharmacokinetic concepts addressed in the subsequent sections are well
understood models that depict these concepts are given below. A water tank that has an
inlet and outlet best represents drug input into the blood circulation and subsequent
distribution in the body.The body can be seen as the tank and volume into which the drug
is distributed(Vd) can be seen as the volume of the tank.
The drug plasma concentration can be likened to the water level(pressure).Just as the rate
of water flow will depend on the water level so will the rate of drug elimination depend
on the plasma level(concentration).The higher the water level the higher the rate of water
flow and vice versa.This is a first-order rate of flow or elimination as the rates depend on
the level.A summary of the features of the water tank model and the respective
pharmacokinetic concepts to which they relate is given below in table 1.
Table 1
A pictorial illustration of the model is shown in diagram 2 with a plasma Vs time graph
appended below it for comparison.
DIAGRAM 2 WATER TANK MODEL ILLUSTRATING Vd, Cpss ,Ra and Re
Ra Ra Ra Ra Rate of
Administration (Ra)
Volume of
Distribution (Vd)
A B C D E F
Plasma Conc.(Cp)
Re Rate of
Elimination (Re)
Ra>>Re Ra =Re Ra = Re Ra=0 Elimination Only.
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9
Once absorption is complete, as is in the case of oral dosage forms (with respect to the
tank once the inlet pipe is closed) the rate of elimination will decline as the Plasma
concentration drops(with respect to the tank as the water level drops the outflow rate of
drops too due to decreasing pressure).
Note:The time time it takes for the drug to be fully eliminated depends on the half-life of
the drug.The shorter the half- life(i.e the bigger the elimination constant) the shorter the
the time to be completely eliminated from the body.
The time to reach a steady state also depends on half-life. A shorter half-life means a
bigger elimination rate constant(K) i.e a bigger outflow rate. It therefore follows that the
increase in elimination rate matches the absorption rate faster in a case of a drug with a
big elimination constant if compared to a drug with a smaller elimination constant. Hence
a steady state is reached faster in this case.The reverse is true for a drug with a long half-
life in which a longer time is required to reach a steady state.
Elimination rate constant K
Note: The Fraction of water eliminated per hour is a constant despite the changing rate of
elimination. For example if water is run at 100L/hour and 10L is drained in the first hour,
the fraction drained will 10L/100L=0.1h-1 which is the same as 20L/200L=0.1h-1.In the
latter the total amount lost is more, however.
In terms of mass of drug eliminated the same arguments holds and the fraction of mass
eliminated will a constant but the amount eliminated will depend on the initial amount
(concentration.). This fraction is defined as the elimination rate constant.
DIAGRAM 3 THE MOP MODEL
Cleared
Volume/hr Vd
= CL
5L
10L
10L
5L
A B C
Clearance is defined as the volume of plasma cleared of the drug in unit time.The above
model, diagram 3 ,depicts the elimination(clearing process) as a mop.Think of a situation
where the drug molecules are mopped from the top of a container but without
redistribution (B) of the molecules. Clearance can be thought as the theoretical volume
that ‘ appears’ to be cleared, being a fraction of the volume of distribution.
Rather looking at the elimination process as a loss in mass; in this case a drop of 10 units
to 5 units , in clearance the volume which contains the eliminated mass is considered
were the concentration remained the same. In this case the volume that will contain 5
units of the drug at the concentration of 1 unit /ml. However, in the real situation, the
concentration does drop as shown in C.
DIAGRAM 4
THE ADSORPTION MODEL
Drug
Absorption
molecules
Rate in(Ra)
mass
50mg/hr
Central
Compartment Vd
Hypothetical
Cleared 100L
Plasma Clearance Conc
Organs 5mg/L
Clearance
Vol cleared/hr
A more realistic model is the adsorption model ,diagram 4 above.The organs of clearance
are depicted as adsorption agents where fluid that contains a drug flows through but
returns back in a loop.The a mount of fluid remains the same.The volume cleared of the
drug per unit time will depend on the adsorptive capacity (intrinsic clearance of the
organ).This volume may be defined as a fraction of volume of distribution(Vd).The
fraction cleared(eliminated) as defined before is the elimination rate constant K.
Therefore clearance is a product of K and Vd.
CL = K*Vd
Lecture No: 2&
3
Objectives:
Given Patient data construct a graph & Compute a slope of: (Blooms Level IV)
1. Response Vs Concentration
2. Response Vs Time
3. Concentration Vs Time
4. Compute any of the above slopes when given any two data sets (or slopes)
1.00
0.90
Response( as Fraction)
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0.0 1.0 2.0 3.0 4.0 5.0
Conc.
Observation: The above graph (diagram 1) is hyperbolic; the intensity appears to vary
with concentration until some maxima, the asymptote of the curve.
Theory: The occupation theory has been applied to explain this observation. It assumes
that as more receptors are occupied by drug molecules, a greater pharmacologic response
is obtained until a maximum response is reached.(see diagram 3 below for illustration of
theory)
The above hyperbolic curve can not be used to develop theories as the slope changes with
the concentration. If we are using a graph paper we would require a linear relationship to
determine the slope upon which the theories are based. These slopes are proportionality
constants that quantify the relationships. The data, therefore, must be further manipulated
to give a linear relationship.
There are three ways the data can be handled to give a linear relationship:
(a) Use a linear Scale (Cartesian) graph: Response(Y axis) & Ln Conc. (X axis)
(b) Use a Semi-log scale where abscissa is the log scale: Response(Y axis) & Conc. (X
axis)
(c)Using a computer program: Excel
DIAGRAM 2
100%
80%
Linear
20%
1 2 3 Ln ( Conc.)
Resp
Table 1: Hypothetical Patient data set showing range for linear plot.
= or < 80%
A number of disease conditions require prolonged drug therapy beyond the first dose. It
is important ,therefore, to establish how soon, following a dose, the therapeutic effect
wears out(reaching MEC) so that the subsequent dose may be given(Ref: Multiple
dosing) .A good example is epilepsy where continued drug therapy is indicated so that
the patient remains seizure- free. Hence this relationship is necessary for establishing the
dosing interval, a vital parameter used for designing dosages in Therapeutics.
Plot Response data on Y axis and Time on X axis using a regular Cartesian scale.
See example below.
The slope may be obtained in three ways:
1. Rule of thumb approach
Connect two points, the first being the beginning of the straight part of the curve and the
second being the end of the straight portion. see diagram)
If all data fall on the line then it is a perfect fit(very rare) and if all the points fall on one
side then the line is not a straight !Compute the slope ,dR/dt by rise/run method
Using data points from the straight line created BUT not from the original data. The
method is rarely used.
2. Eyeball approach
Connect the first and the last data point on the straight portion of curve ensuring that
they are as many points above the line as they are below. compute the slope,dR/dt by
using rise of run method.
3. Linear regression approach
In this approach the least- square method is used to obtain the line of best fit
(regression line).The use of computer programs e.g excel obviates the need to carry
laborious calculations. The Response data between 20 and 80% is used in computing the
slope.
To obtain a slope dR/dt follow the method described (Response Vs Concentration) above
for using excel spread sheet. REMEMBER YOU DO NOT NEED TO FORMAT X
AXIS AS TIME IS PLOTTED ON A REGULAR CARTESIAN SCALE
Making the connections
Selecting the right dosing
interval
From Objective 2 above, it was established that response declines with time.
This is because of a corresponding decline in concentration of the active drug.
By determining the rate of decline of concentration i.e. the rate of elimination (slope) we
are able to predict:
(a) The time it takes an initial concentration to drop to some desired
concentration
(b) A resultant concentration given an initial concentration and the time of
drug exposure. A good example when such prediction could be necessary is
when a loading dose is desirable in an emergency in a patient who already has been
taking the drug. Knowledge of the existing drug level would be necessary for calculating
the loading dose. But in the absence of laboratory levels the prediction of what the
concentration could be can be made done if the initial concentration and elimination rate
constant or half-life is known.
Establishing the relationships between plasma concentration and time, therefore, is
central to the field of Pharmacokinetics.
LnC
K= LnC1-LnC2
t1-t2
Y axis (log)
(a)Slope= C1-C2
t1-t2 (b) Converting into Ln, K= LnC1-LnC2
t t1-t2
t
10
CONC(MG/L)
6
0
0.00 5.00 10.00 15.00 20.00 25.00 30.00
TIME(HRS)
D Y regular E
(iii)Logarithmic (D&E) (Regular Scale) R R X Log R
(Semi log)
LnC C
dR = dR * dLnC
dt dLnC dt
Needless to say, as discussed above all the three parameters: Concentration, Time and
Response are interrelated.
By rearranging the above equation the elimination rate constant K, can be obtained using
the response slopes .By using Ln( dose ) instead of dLnC in the response Vs
concentration slope(dR/LnC) the elimination rate constant can be obtained without
obtaining biological fluid samples.
Objective 1
Describe(1)the Pharmacokinetic model used to develop the
Pharmacokinetic theories, stating all the assumptions of the model
Conceptually, drugs move out dynamically, in and out of compartments. Rate constants
represent the overall rate processes of drug entry into and exit from the compartment. At
any time ,the amount of drug in the body is simply the sum of drug present in the central
compartment plus the drug present in the tissue compartment(peripheral compartment).
Remember, the drug administered as bolus has to be accounted for. Matter is neither
destroyed nor created!
It is important to note that while accounting for the administered drug in human beings
we are only able to look at the plasma events i.e. the concentration. Unlike in animals
where we could estimate the amount of drug in the liver by taking a liver issue we can not
do the same in human beings. So we rely mainly ON THE PLASMA.
If were able to do such tissue estimates Physiological models could be more appropriate.
Finally, there are two main types of compartment models, i.e. one compartment and two
compartment models (see figure below) This course will only be addressing the one
compartment model.
Model 1 1
K
One-Compartment IV
1
Model 2 Ka K
One- compartment
Oral-First order
Absorption
As explained above Models are mathematical explanations to the theories. Provided these
concepts give us good predictions there would be no need to know the complex
biological processes. However, it is important to note that there are limitations to this
model for it does not shade any more light into the drug kinetic processes in the body.
For example
1. We know that the drug may not be instantaneously mixed in the “compartment” as the
model assumes. The central compartment represents the plasma and the highly perfused
tissues that rapidly equilibrate with the drug. Instantaneous and homogenous mixing is
not possible.
2.We know that in one compartment model we assume the drug is only being
eliminated* (one way arrow)and none is coming in from the peripheral compartment, a
case we know not to be true as there is some distribution into the peripheral(tissue)
compartment. In one-compartment open model, mathematically ,this distribution is
insignificant.
(*Elimination is removal of active drug through biotransformation or physical removal
through excretion)
A patient’s Pharmacokinetic parameters are usually characterized by a single IV
Bolus dose a procedure known as pharmacokinetic study.
Dose Vd Unknown
Known Cpo
Known
Having two parameters known (Dose & Cpo) Vd can be worked from the following
equation: Vd = Dose/Cpo
Calculating Vd
How do you calculate Volume of distribution(Vd) using IV bolus data ?
(i)Using the line of best fit in Ln Conc. Vs time graph(or semi-log), extrapolate to get an
intercept on the Y axis as shown below. The intercept on the Y axis will be
Cpo..Calculate Vd using equation: Vd= D/Cpo
GENTAMICIN IV BOLUS
B y = 7.6135e-0.1394x
100
CONC(LOG SCALE)
10
Cpo
1
0.00 10.00 20.00 30.00
0.1
TIME(HRS)
(ii) Using Excel spread sheet plot the time on a logarithmic scale Y axis and display
the equation as already explained in Concentration Vs Time objective above. The
intercept in the equation would be Cpo. Y = I e-Kt is obtained from excel(shown
in above graph). Calculate Vd using equation:
Vd= D/Cpo (I)
(iii) Using excel by getting the exponential equation from an exponential curve as shown
below.The intercept 7.713 would be Cpo.
GENTAMICIN IV BOLUS
A
y = 7.6135e-0.1394x
12
10
8
CONC(MG/L)
6
4
2
0
0.00 5.00 10.00 15.00 20.00 25.00 30.00
TIME(HRS)
Making the connections
How often?
Dosing interval
(b) ELIMINATION RATE CONSTANT( K)
Definition
The rate of elimination of most drugs is a first order process .The elimination rate
constant,K,is a first-order elimination rate constant with units of time -1(e.g. hr-1)
The elimination rate constant represents the sum(all ways) of each elimination
processes e.g. metabolism & excretion for a drug that is eliminated by metabolism
and excretion only.
The elimination rate constant represents the rate of removal of drug from the body.
Having the value of K for a specific drug and patient allows prediction on the dosing
interval.
From the above equation ,values can be set for desired peaks and troughs. In this case
Cp would be the trough(MEC) and in place of Cpo the peak in the equation. We can
then calculate t ,the time between the peak and the trough i.e the dosing interval
provided we know the value of K. The bigger the K the shorter the dosing interval.
8
CONC(MG/L)
2
0
0.00 5.00 10.00 15.00 20.00 25.00 30.00
TIME(HRS)
GENTAMICIN IV BOLUS
B y = 7.6135e
-0.1394x
100
CONC(LOG SCALE)
10
C
1
C21
K
30
25
20
15
10
5
0
0 10 20 30 40 50
Time(min)
100
-0.0634x
y = 57.331e
Conc.(Mcg/Ml)
10
t1/2
t1/2
1
0 10 20 28 30 38 40 50
Time(min)
There are two ways you can calculate half-life:
(a) By first obtaining Elimination constant (K) and solving for t1/2.
You may obtain K using excel explained earlier.
(i) Enter the profile in the spread sheet
(ii) Highlight the data set and click on the chart
(iii) Click on XY scatter
(iv) Click Finish
(v) Right Click on any data point on the graph area
(vi) Select trend line
(vii) Click on exponential trendline.
(viii) Click option
(ix) Click on display formula(see graph
(x) The formula that you will get will represent the first-order rate of
reaction equation:
Cp = Cpoe-Kt
(xi) Solve for t1/2 using the following equation:
t1/2= 0.693
K
You may also obtain K by getting the slope of linear plot of conc Vs time on
a semi-log paper.(Already addressed)
(b) By directly reading off from a linear plot of conc. Vs time
(See graph B above)
Rectangle Trapezoid.
30 Cp last
Cpn+2
25
20
15
A
10 B
5 C
D E F ∞
0
0 10 20 30 40 50
Triangle Rectangle Time(min)
The Stepwise procedure is as follows:
1.Identity the time interval (the interval should be ideally as small as possible lest a big
interval will cause a big curve that will introduce an error in estimating the area of the
triangle.The hypotunse will be curved instead of being straight.
2. Use Equation 3 above to estimate AUC for each segment, A,B,C ETC..The total AUC
for a specified period will be the total area of the segments:
AUCA +AUC B + AUC C AUC D…etc
Estimating the TERMINAL area(Area between the last observation(Cplast) and infinity.
At time this are may be required to be included .It is done by extrapolation using the
following formula.
AUC(terminal)= Cplast/K where K the elimination rate constant.
8000
7000
-0.166x
y = 9586.2e
6000
5000
4000 Cpo
K
3000
2000
1000
0
0 5 10 15 20
STEPWISE APPROACH TO CALCULATING AUC USING EXCEL
1.Copy the Conentration- time data set from the spreadsheet provided.
2.Enter zero in the cell above the cell containing the first time recorded.(This will be
zero time for Cpo)
3.Enter infinity symbol ∞ (obtained from insert menu) in the last cell of the time column.
4.Label all the columns(four)as shown above
5.Find the value of K using the data set given .When highlighting the data set DO NOT
INCLUDE THE ROW THAT CONTAINS TIME ZERO!IF YOU DO YOU WOULD
NOT GET YOUR EXPONENTIAL CURVE THAT WILL GIVE K.
6.From the formula also obtain Cpo .Enter the value in the respective cell next to time
zero as shon in the example above.
7.In the third column(AUCtn-tn+1) in the second cell (see example above) enter the
following formula: ( Cpn + Cpn+1)/2 * (tn-tn+1)…….
The first area woulb be time zero and the first recorded time.In this example.Zero time
ant 2 hours
8.Copy this formula and apply to all other remaining cells in the column.
9.The area for all the segments will be done.
10.The last column will contain the cumulative area. You need ,therefore,write the
following formula
COPY THE FIRST AREA and then write the formula.The formula will
=copied area+the second area in the adjacent column the enter.
11.Calculate the terminal area and enter it in the last column.
12.Copy the formula for calculating cumulative area and apply to all cells in the last
column.
13.The last value in the column will you total AUC.
Common errors!
FORGETTING TO ACCOUNT FOR THE FIRST AREA THAT INCLUDES ZERO
TIME AND TERMINAL AREA.
signment:
Quiz 2 Question 6
Hence
MRT= total residence time for all drug molecules = ∫Cp dt*t =AUMC (FIRST MOMENT)
Total number of drug molecules Cp dt AUC (ZERO MOMENT)
AUC and MRT are described as the zero and first moment of the drug concentration time
curve respectively.If you examine the numerator of the above equation the total residence
time is an area ,a product of AUC (zero moment) ,and time t.This second area is referred
to as the area under the first moment curve,AUMC.
For Calculation of AUC refer to AUC objective.
The AUMC may also calculated using the Trapezoidal rule.
Equation
This method is universal as it is applied irrespective of the model When you are not sure
of the model use this method.
2.USING ONE COMPARTMENT MODEL rate constant.
In the case of one compartment model after intravenous administration, the MRT is
equal the reciprocal of the elimination constant.
MRTiv =1/kd
= 1.44t1/2
3.USING A DERIVED RATE CONSTANT K( NON COMPARTMENTALLY).
Note that MRT depends on how the drug is administered.MRT for noninstanteneous
administration (e.g oral) will always be greater than MRT for I.V bolus administration.
Assignment
Quiz 2 Question 7,8,9
(f)Clearance
Definition.
Clearance may be defined as the volume of plasma that is cleared of the drug per unit
time.It is one of the parameters used to describe the rate of drug elimination.The other
parameters being half-life and elimination rate constant.Although all these parameters
describe the same process they give different level of insight and application in
pharmacokinetics.The topic is fully covered under Clearance.
(Clearance may further defined as the fraction of the volume of distribution that is cleared
of the drug.Note that the fraction is K .This same fraction can also be applied to the mass
eliminated per unit time i.e Volume cleared/hr ,Cl =K * Vd,Mass eliminated/hr =K* Xmg
Assignment
Quiz 2 Question 11
C Making the Connections
Lecture 2 How much drug?
Activity 4 How often do you give?
Objectives
Given parent drug urine data:
1.Calculate apparent first-order elimination rate constant K
2.Calculate apparent first- order rate constant for urinary(renal)
excretion of unchanged drug.(ku)
3.Calculate apparent first- order rate constant for metabolism of