BASIC PHARMACOKINETICS - CHAPTER 8: Bioavailability

CHAPTER 8 Bioavailability, Bioequivalence,
and Drug Selection
Author: Rasma Chereson

Reviewer: Umesh Banakar
OBJECTIVES
1. Given sufficient data to compare an oral product with another oral product or an
IV product, the student will estimate (III) the bioavailability (compare AUCs) and
judge (VI) professional acceptance of the product with regard to bioequivalence
(evaluate (VI) AUC, T p and ( Cp ) max ).
2. The student will write (V) a professional consult using the above calculations.
3. The student will be able to calculate (III) the absolute bioavailability of drug prod-
ucts.
4. The student will be able to discuss (II) the various factors affecting bioavailability.
5. The student will be able to discuss (II) the various methods of assessing bioavail-
ablity.
6. The student will be able to discuss (II) In Vivo / In Vitro Correlations.
7. The student will be able to enumerate (II) FDA requirements regarding bioequiva-
lence.
8. The student shall be able to utilize (III) the FDA “Orange Book” to make drug
product selections.
9. The student shall be able to discuss (II) and utilize (III) reasonalble guidelines
regarding drug product selections.
Basic Pharmacokinetics REV. 99.4.25 8-1

Copyright © 1996-1999 Michael C. Makoid All Rights Reserved http://kiwi.creighton.edu/pkinbook/
Bioavailability, Bioequivalence, and Drug Selection
8.1 Bioavailability, Bioequivalence and Drug Product Selection

Bioavailability and bioequivalence of drug products, and drug product selection
have emerged as critical issues in pharmacy and medicine during the last three
decades. Concern about lowering health care costs has resulted in a tremendous
increase in the use of generic drug products; currently about one half of all pre-
scriptions written are for drugs that can be substituted with a generic product (1).
Over 80% of the approximately 10,000 prescription drugs available in 1990 were
available from more than one source (2). With the increasing availability and use
of generic drug products, health care professionals are confronted with an
ever-larger array of multisource products from which they must select those that
are therapeutically equivalent.
This phenomenal growth of the generic pharmaceutical industry and the abun-
dance of multisource products have prompted some questions among many health
professionals and scientists regarding the therapeutic equivalency of these prod-
ucts, particularly those in certain critical therapeutic categories such as anticonvul-
sants and cardiovasculars (1, 3-5). Inherent in the currently accepted guidelines
for product substitution is the assumption that a generic drug considered to be
bioequivalent to a brand-name drug will elicit the same clinical effect. As straight-
forward as this statement regarding bioequivalence appears to be, it has generated
a great deal of controversy among scientists and professionals in the health care
field. Numerous papers in the literature indicate that there is concern that the cur-
rent standards for approval of generic drugs may not always ensure therapeutic
equivalence (6-18).
The availability of different formulations of the same drug substance given at the
same strength and in the same dosage form poses a special challenge to health care
professionals, making these issues very relevant to pharmacists in all practice set-
tings. Since pharmacists play an important role in product-selection decisions,
they must have an understanding of the principles and concepts of bioavailability
and bioequivalence.
8.1.1 RELATIVE AND ABSOLUTE BIOAVAILABILITY
Bioavailability is a pharmacokinetic term that describes the rate and extent to

which the active drug ingredient is absorbed from a drug product and becomes
available at the site of drug action. Since pharmacologic response is generally
related to the concentration of drug at the receptor site, the availability of a drug
from a dosage form is a critical element of a drug product's clinical efficacy. How-
ever, drug concentrations usually cannot be readily measured directly at the site of

action. Therefore, most bioavailability studies involve the determination of drug

concentration in the blood or urine. This is based on the premise that the drug at
the site of action is in equilibrium with drug in the blood. It is therefore possible to
obtain an indirect measure of drug response by monitoring drug levels in the blood
or urine. Thus, bioavailability is concerned with how quickly and how much of a
drug appears in the blood after a specific dose is administered. The bioavailability
of a drug product often determines the therapeutic efficacy of that product since it
affects the onset, intensity and duration of therapeutic response of the drug. In
most cases one is concerned with the extent of absorption of drug, (that is, the frac-
tion of the dose that actually reaches the bloodstream) since this represents the
"effective dose" of a drug. This is generally less than the amount of drug actually
administered in the dosage form. In come cases, notably those where acute condi-
tions are being treated, one is also concerned with the rate of absorption of a drug,
since rapid onset of pharmacologic action is desired. Conversely, these are
instances where a slower rate of absorption is desired, either to avoid adverse
effects or to produce a prolonged duration of action.
"Absolute" bioavailability, F, is the fraction of an administered dose which actually

reaches the systemic circulation, and ranges from F = 0 (no drug absorption) to F =
1 (complete drug absorption). Since the total amount of drug reaching the sys-
temic circulation is directly proportional to the area under the plasma drug concen-
tration as a function of time curve (AUC), F is determined by comparing the
respective AUCs of the test product and the same dose of drug administered intra-
venously. The intravenous route is the reference standard since the dose is, by def-
inition, completely available.
AUC ev
F = ----------------
- (EQ 8-1)
AUC iv
(where AUCEV and AUCIV are, respectively, the area under the plasma concentra-
tion-time curve following the extravascular and intravenous administration of a
given dose of drug. Knowledge of F is needed to determine an appropriate oral
dose of a drug relative to an IV dose.
"Relative" or “Comparative” bioavailability refers to the availability of a drug

product as compared to another dosage form or product of the same drug given in
the same dose. These measurements determine the effects of formulation differ-
ences on drug absorption. The relative bioavailability of product A compared to
product B, both products containing the same dose of the same drug, is obtained by
comparing their respective AUCs.
AUC
RelativeBioavailabilty = ---------------A (EQ 8-2)
AUC B

where drug product B is the reference standard. When the bioavailability of a

generic product is considered, it is usually the relative bioavailability that is
referred to. A more general form of the equation results from considering the pos-
sibility of different doses,
AUC Generic
-----------------------------
Dose Generic
ComparativeBioavailability = ----------------------------- (EQ 8-3)
AUC Brand
-------------------------
Dose Brand
The difference between absolute and relative bioavailability is illustrated by the

following hypothetical example. Assume that an intravenous injection (Product
A) and two oral dosage forms (Product B and Product C), all containing the same
dose of the same drug, are given to a group of subjects in a crossover study. Fur-
thermore, suppose each product gave the values for AUC indicated in Table 8-1 on
page 4.
TABLE 8-1. Data for Absolute and Relative Bioavailability
Drug Product Area Under the Curve (mcg/ml) x hr
A Intravenous injection 100
B Oral dosage form, brand or reference standard 50
C Oral dosage form, generic Product 40
The F for Product B and Product C is 50% (F = 0.5) and 40% (F = 0.4), respec-
tively. However, when the two oral products are compared, the relative bioavail-
ability of Product C as compared to Product B is 80%.
8.1.2 FACTORS INFLUENCING BIOAVAILABILITY
Before the therapeutic effect of an orally administered drug can be realized, the
drug must be absorbed. The systemic absorption of an orally administered drug in
a solid dosage form is comprised of three distinct steps:
1. disintegration of the drug product
2. dissolution of the drug in the fluids at the absorption site
3. transfer of drug molecule across the membrane lining the gastrointestinal tract into the systemic
circulation.

Any factor that affects any of these three steps can alter the drug's bioavailability
and thereby its therapeutic effect. While there are more than three dozen of these
factors that have been identified (19-38), the more significant ones are summarized
here.
The various factors that can influence the bioavailability of a drug can be broadly
classified as dosage form-related or patient-related. Some of these factors are
listed in Table 8-2 on page 5 and Table 8-3 on page 5, respectively.
TABLE 8-2 Bioavailability Factors related to the dosage form
Physicochemical properties of the drug Formulation and manufacturing variables

Particle size Amount of disintegrant
Crystalline structure Amount of lubricant
Degree of hydration of crystal Special coatings
Salt or ester form Nature of diluent
Compression force
TABLE 8-3 Bioavailability Factors Related to the patient
Physiologic factors Interactions with other substances

Variations in absorption power along GI tract Food
Variations in pH of GI fluids Fluid volume
Gastric emptying rate Other drugs
Intestinal motility
Perfusion of GI tract
Presystemic and first-pass metabolism
Age, sex, weight
Disease states
The physical and chemical characteristics of a drug as well as its formulation are
of prime importance in bioavailability because they can affect not only the absorp-
tion characteristics of the drug but also its stability. Since a drug must be dissolved
to be absorbed, its rate of dissolution from a given product must influence its rate
of absorption. This is particularly the case for sparingly soluble drugs. All the fac-
tors listed in Table 8-2 on page 5 can alter the dissolution rate of the drug, its bio-
availability, and ultimately, its therapeutic performance.
One of the more important factors that affects the dissolution rate of slowly dis-
solving substances is the surface area of the dissolving solid (39). Peak blood lev-
els occurred much faster with the smaller particles than the larger ones, primarily

as a result of their faster dissolution rate. Particle size can also have a significant
effect on AUC(40). Serum levels of phenytoin after administration of equal doses
containing micronized (formulation G) and conventional (formulation F) drug
were measured. Based on the AUC, almost twice as much phenytoin was
absorbed after the micronized preparation (40).
There are numerous reports of the effects of formulation and processing variables
on the dissolution of active ingredients from drug products; an apparently inert
ingredient may affect drug absorption. For example, magnesium stearate, a lubri-
cant, commonly used in tablet and capsule formulations, is water-insoluble and
water-repellent. Its hydrophobic nature tends to retard drug dissolution by pre-
venting contact between the solid drug and the aqueous GI fluids. Thus, increas-
ing the amount of magnesium stearate in the formulation results in a slower
dissolution rate of the drug, and decreased bioavailability(34) .
The nature of the dosage form itself may have an effect on drug absorption charac-
teristics. The major pharmaceutical dosage forms for oral use are listed in Table 8-
4 on page 6 in order of decreasing bioavailability of their active ingredients. The
decreasing bioavailability is related to the number of steps involved in the absorp-
tion process following administration. The greater the number of steps a product
must undergo before the final absorption step, the slower is the availability and the
greater is the potential for bioavailability differences to occur. Thus, solutions
(elixirs, syrups, or simple solutions) generally result in faster and more complete
absorption of drug, since a dissolution step is not required. Enteric-coated tablets,
on the other hand, do not even begin to release the drug until the tablets empty
from the stomach, resulting in poor and erratic bioavailability.
TABLE 8-4 Bioavailability and oral Dosage Forms
Fastest availability Solutions

Suspensions
Capsules
Tablets
Coated tablets
Slowest availability Controlled-release formulations
Bioavailability studies with pentobarbital from various dosage forms show the
absorption rate of pentobarbital after administration in various oral dosage forms
decreased in the following order: aqueous solution > aqueous suspension of the
free acid > capsule of the sodium salt > tablet of the free acid (41).
In addition to the dosage form-related factors identified above, bioavailability may

also be affected by a variety of physiologic and clinical factors related to the
patient (Table 8-3 on page 5). Considerable inter-subject differences in the bio-

availability of some drugs have been observed. These can often be attributed to
individual variations in such factors as GI motility, disease state and concomi-
tantly-administered food or drugs.
One example of the myriad of physiologic factors that can affect the bioavailability
of an orally-administered drug is a patient's gastric emptying rate. Since the prox-
imal small intestine is the optimum site for drug absorption, a change in the stom-
ach emptying rate is likely to alter the rate, and possibly the extent, of drug
absorption. Any factor that slows the gastric emptying rate may thus prolong the
onset time for drug action and reduce the therapeutic efficacy of drugs that are pri-
marily absorbed from the small intestine. In addition, a delay in gastric emptying
could result in extensive decomposition and reduced bioavailability of drugs that
are unstable in the acidic media of the stomach (e.g. penicillins and erythromycin).
Differences in stomach emptying among individuals have been implicated as a

major cause of variations in the bioavailability of some drugs, particularly those
with acid-resistant enteric coatings. In a study (42), after the administration of 1.5
g acetaminophen to 14 patients, the maximum plasma concentration ranged from
7.4 to 37 mcg/ml, and the time to reach the maximum concentration ranged from
30 to 180 minutes. Both these parameters of bioavailability were linearly related
to the gastric emptying half-life found in each patient.
There are numerous factors that affect gastric emptying rate (Table 8-5 on page 8)
(43). Factors such as a patient's emotional state, certain drugs, type of food
ingested and even a patient's posture can alter the time course and extent of drug
absorption.

TABLE 8-5 Factors influencing Gastric Emptying Rate
INFLUENCE ON GASTRIC
FACTOR EMPTYING RATE
Increased viscosity of stomach contents decreased
Body position
lying on left side decreased
Emotional state
stress increased or decreased
depression decreased
anxiety increased
Activity, exercise decreased
Type of meal
fatty acids, fats decreased
carbohydrates decreased
amino acids decreased
pH of stomach contents
decreased decreased
increased increased
Disease states
gastric ulcers decreased
Crohn's disease decreased
hypothyroidism decreased
hyperthyroidism increased
Drugs
atropine decreased
propantheline decreased
narcotic analgesics decreased
amitriptyline decreased
metoclopramide increased
Since drugs are generally administered to patients who are ill, it is important to
consider the effects of the disease process on the bioavailability of the drug. Dis-
ease states, particularly those involving the GI tract, such as celiac disease, Crohn's
disease, achlorhydria, and hypermotility syndromes can certainly alter the absorp-
tion of a drug (32). In addition, some diseases concerning the cardiovascular sys-
tem and the liver may also alter circulating drug levels after oral dosing.
Drugs are frequently taken with food, and patients often use mealtimes to remind
them to take their medications. However, food can have a significant effect on the
bioavailability of drugs. The influence of food on drug absorption has been recog-

nized for some time, and several reviews have been published on the influence of
food on drug bioavailability (30-32, 36, 44). Food may influence drug absorption
indirectly, through physiological changes in the GI tract produced by the food,
and/or directly, through physical or chemical interactions between the drug mole-
cules and food components. When food is ingested, stomach emptying is delayed,
gastric secretions are increased, stomach pH is altered, and splanchnic blood flow
may increase. These may all affect bioavailability of drugs. Food may also inter-
act directly with drugs, either chemically (e.g. chelation) or physically, by adsorb-
ing the drug or acting as a barrier to absorption. In general, gastrointestinal
absorption of drugs is favored by an empty stomach, but the nature of drug-food
interactions is complex and unpredictable; drug absorption may be reduced,
delayed, enhanced or unaffected by the presence of food. Table 8-6 on page 9
summarizes some of the studies that have indicated the effect of food on the bio-
availability of a variety of drugs.
TABLE 8-6 Effect of Food on Drug Absorption
Reduced Absorption Delayed Absorption Increased Absorption

Ampicillin Acetaminophen Chlorothiazide
Aspirin Aspirin Diazepam
Atenolol Cephalosporins (most) Griseofulvin
Captopril Diclofenac Hydralazine
Erythromycin Digoxin Labetalol
Ethanol Furosemide Metoprolol
Hydrochlorothiazide Nitrofurantoin Nitrofurantoin
Penicillins Sulfadiazine Propranolol
Tetracyclines (most) Sulfisoxazole Riboflavin
Source: Ref. 32
The effect of food and type of diet on the bioavailability of erythromycin is shown
in a study by Welling (45). The absorption of the antibiotic is significantly
reduced when it is administered with food compared with its absorption under fast-
ing conditions. This reduced absorption is primarily a result of degradation of the
acid-labile erythromycin due to prolonged retention in the stomach.
Delayed absorption due to food has been demonstrated in the case of cephradine in
a study by Mischler (46). Similar results have been observed with other oral ceph-
alosporins.
Some drugs demonstrate enhanced bioavailability in the presence of food. This

has been attributed to a variety of factors, including improved compound solubility
and more time for dissolution because of delayed gastric emptying. In the case of

highly metabolized agents, such as propranolol and metoprolol, the enhanced

availability may be due to increased splanchnic blood flow causing reduced
first-pass clearance. The circulating levels of these drugs dosed under fasting and
non-fasting conditions have been presented in a study by Melander (47).
The volume of fluid with which an orally administered dose is taken can also affect
a drug's bioavailability. Drug administration with a larger fluid volume will gener-
ally improve its dissolution characteristics and may also result in more rapid stom-
ach emptying. Thus, more efficient and more reliable drug absorption can be
expected when an oral dosage form is administered with a larger volume of fluid.
(45) .
Interactions between drugs can have a significant effect on the bioavailability of

one or both drugs. Such interactions may be direct, as in chelation of tetracycline
by polyvalent metal ions in antacids or the adsorption of digoxin by
cholestyramine resin, or indirect, as with the increased rate of acetaminophen
absorption due to the increased gastric emptying rate produced by metoclopra-
mide. Most of the reported drug-drug interactions have resulted in a reduction in
the rate and/or extent of drug absorption, the most frequent causes being complex-
ing of a drug with other substances, reduced GI motility and alterations in drug
ionization (24, 30, 32, 48, 49). Table 8-7 on page 10 summarizes the major mech-
anisms of GI drug interactions affecting bioavailability.
TABLE 8-7 Drug interactions affecting absorption
1. Change in gastric or intestinal pH

2. Change in gastrointestinal motility
3. Change in gastrointestinal perfusion
4. Interference with mucosal function (drug-induced malabsorption syndromes)
5. Chelation
6. Exchange resin binding
7. Aadsorption
8. Solution in poorly absorbable liquid
Source: Ref. 23
An example of a direct interaction between drugs affecting bioavailability is the

interaction between iron and tetracycline. This is a well-documented and clini-
cally significant interaction which can result in a dramatic reduction in serum con-
centration of tetracycline (50).
The above potential sources of alteration in a drug's bioavailability must be kept in

mind when attempting to evaluate the relative performance of drug products on the

basis of studies performed with healthy human volunteers. These studies are gen-
erally performed under tightly-controlled fasting conditions in the absence of other
drugs. In practice, however, drugs are seldom taken under such ideal conditions,
and the factors leading to changes in drug absorption must be taken into consider-
ation.
8.1.3 METHODS OF ASSESSING BIOAVAILABILITY
Bioavailability testing is a means of predicting the clinical efficacy of a drug; the

estimation of the bioavailability of a drug in a given dosage form is direct evidence
of the efficiency with which a dosage form performs its intended therapeutic func-
tion.
The bioavailability of a drug substance formulated into a pharmaceutical product

is fundamental to the goals of dosage form design and essential for the clinical effi-
cacy of the medication. Thus, bioavailability testing, which measures the rate and
extent of drug absorption, is a way to obtain evidence of the therapeutic utility of a
drug product. Bioavailability determinations are performed by drug manufacturers
to ensure that a given drug product will get the therapeutic agent to its site of
action in an adequate concentration. Bioavailability studies are also carried out to
compare the availability of a drug substance from different dosage forms or from
the same dosage form produced by different manufacturers.
In-vivo methods One method for assessing the bioavailability of a drug product is through the dem-
onstration of a clinically significant effect. However, such clinical studies are
complex, expensive, time-consuming and require a sensitive and quantitative mea-
sure of the desired response. Further, response is often quite variable, requiring a
large test population. Practical considerations, therefore, preclude the use of this
method except in initial stages of development while proving the efficacy of a new
chemical entity.
Quantification of pharmacologic effect is another possible way to assess a drug's

bioavailability. This method is based on the assumption that a given intensity of
response is associated with a particular drug concentration at the site of action;
e.g., variation of miotic response intensity can be directly related to the oral dose
of chlorpromazine. However, monitoring of pharmacologic data is often difficult,
precision and reproducibility are difficult to establish, and there are only a limited
number of pharmacologic effects (e.g. heart rate, body temperature, blood sugar
levels) that are applicable to this method.
Because of these limitations, alternative methods have been developed to predict

the therapeutic potential of a drug. The current method to assess the clinical per-
formance of a drug involves measurement of the drug concentrations in the blood

or urine. In such studies a single dose of the drug product is administered to a

panel of normal, healthy adult (18- to 35-year old) subjects. Blood and/or urine
samples are collected over a period of time following administration and are ana-
lyzed for drug content. Based on the blood concentration as a function of time
and/or urinary excretion profile, inferences are drawn regarding the rate and extent
of absorption of the drug. These studies are relatively easy to conduct and require
a limited number of subjects.
Blood level studies- Blood level studies are the most common type of human bioavailability studies,
and are based on the assumption that there is a direct relationship between the con-
centration of drug in blood or plasma and the concentration of drug at the site of
action. By monitoring the concentration in the blood, it is thus possible to obtain
an indirect measure of drug response. Following the administration of a single
dose of a medication, blood samples are drawn at specific time intervals and ana-
lyzed for drug content. A profile is constructed showing the concentration of drug
in blood at the specific times the samples were taken . The key parameters to note
are:
∞
1. AUC , The area under the plasma concentration-time curve, The AUC is proportional to the
0
total amount of drug reaching the systemic circulation, and thus characterizes the extent of
absorption.
2. Cmax , The maximum drug concentration. The maximum concentration of drug in the plasma
is a function of both the rate and extent of absorption. Cmax will increase with an increase in
the dose, as well as with an increase in the absorption rate.
3. Tmax , The time at which the Cmax occurs. The Tmax reflects the rate of drug absorption, and
decreases as the absorption rate increases.
Bioavailability (the rate and extent of drug absorption) is generally assessed by the
determination of these three parameters.
Since the AUC is representative of, and proportional to, the total amount of drug
absorbed into the circulation, it is used to quantitate the extent of drug absorption.
The calculation of AUC has been discussed in Chapter 4. A variety of pharmacok-
inetic methods have been suggested for the calculation of absorption rates (51-56).
For clinical purposes, it is generally sufficient to determine Cmax and Tmax. If all
other factors are constant, such as the extent of absorption and rate of elimination,
then Cmax is proportional to the rate of absorption and Tmax is inversely propor-
tional to the absorption rate. Thus, the faster the absorption of a drug the higher
the maximum concentration will be and the less time it will take to reach the max-
imum concentration.
Urinary Excretion Data - An alternative bioavailability study measures the cumulative amount of unchanged
drug excreted in the urine. These studies involve collection of urine samples and
the determination of the total quantity of drug excreted in the urine as a function of

time. These studies are based on the premise that urinary excretion of the
unchanged drug is directly proportional to the plasma concentration of total drug.
Thus, the total quantity of drug excreted in the urine is a reflection of the quantity
of drug absorbed from the gastrointestinal tract. Consider the following example:
two products, A and B, each containing 100 mg of the same drug are administered
orally. A total of 80 mg of drug is recovered in the urine from Product A, but only
40 mg is recovered from Product B. This indicates that twice as much drug was
absorbed from Product A as from Product B. (The fact that neither product
resulted in excretion of the entire dose might be due to the existence of other routes
of elimination, e.g. metabolism).
This technique of studying bioavailability is most useful for those drugs that are
not extensively metabolized prior to urinary elimination. As a rule-of-thumb,
determination of bioavailability using urinary excretion data should be conducted
only if at least 20% of a dose is excreted unchanged in the urine after an IV dose
(56). Other conditions which must be met for this method to give valid results
include:
1. the fraction of drug entering the bloodstream and being excreted intact by the kidneys must
remain constant.
2. collection of the urine has to continue until all the drug has been completely excreted (five times
the half-life 1).
Urinary excretion data are primarily useful for assessing extent of drug absorption,
although the time course for the cumulative amount of drug excreted in the urine
can also be used to estimate the rate of absorption. In practice, these estimates are
subject to a high degree of variability, and are less reliable than those obtained
from plasma concentration-time profiles (57). Thus, urinary excretion of drug is
not recommended as a substitute for blood concentration data; rather, these studies
should be used in conjunction with blood level data for confirmatory purposes.
Single-dose versus Most bioavailability evaluations are made on the basis of single-dose administra-
Multiple-Dose- tion. The argument has been made that single doses are not representative of the
actual clinical situation, since in most instances, patients require repeated adminis-
tration of a drug. When a drug is administered repeatedly at fixed intervals, with
the dosing frequency less than five half-lives, drug will accumulate in the body and
eventually reach a plateau, or a steady-state
At steady-state, the amount of drug eliminated from the body during one dosing
interval is equal to the available dose (rate in = rate out); therefore, the area under
the curve during a dosing interval at steady-state is equal to the total area under the
curve obtained when a single dose is administered. This AUC can therefore be
1. Half life is defined as the length of time required to lose 50% of the drug in the body, assuming first order elimination.

used to assess the extent of absorption of the drug, as well as its absolute and rela-
tive bioavailability.
Multiple-dose administration has several advantages over single-dose bioavailabil-

ity studies, as well as some limitations. These are summarized in Table 8-8 on
page 14 (54, 59).
TABLE 8-8 Multiple dose vs. single dose studies in bioavailability studies
Advantages:
• Eliminates the need to extrapolate the plasma concentration profiles to obtain the total AUC
after a single dose
• Eliminates the need for a long wash-out period between doses
• More closely reflects the actual clinical use of the drug
• Allows blood levels to be measured at the same concentrations encountered therapeutically
• Because blood levels tend to be higher than in the single-dose method, quantitative determina-
tion is easier and more reliable
• Saturable pharmacokinetics, if present, can be more readily detected at steady-state
Limitations:
• Requires more time to complete
• More difficult and costly to conduct (requiring prolonged monitoring of subjects
• Greater problems with compliance control
• Greater exposure of subjects to the test drug, increasing the potential for adverse reactions
When a drug obeys linear, first-order kinetics, it is possible to estimate the results
that would be obtained during multiple dosing from single-dose studies. Projec-
tion is easily made with regard to the extent of absorption, using the AUC follow-
ing a single dose. Results from bioequivalence studies indicate that conclusions on
the extent of absorption as assessed by the AUC can be made equally well on the
basis of a single or multiple dose study (60). Assessing the rate of absorption dur-
ing multiple-dosing from single-dose studies has presented a greater problem.
Although a number of single-dose characteristics have been suggested as indica-
tors of rate of absorption during multiple dosing (e.g. percent peak-trough fluctua-
tion and percent peak-trough swing), results of bioequivalence studies indicate that
only the plateau time (the time during which the concentration exceeds 75% of the
maximum concentration, t 75% Cmax) and the residual concentration at the end of
the dose interval produce consistent results in assessing the rate of absorption in
single- and multiple-dose studies (54, 61).
In the case of drugs exhibiting nonlinear kinetics, establishing a linear relationship

between single- and multiple-dose bioavailability data has proven to be a difficult
task. Thus, it has been recommended that for drugs with either saturable elimina-
tion or a nonlinear first-pass effect, steady-state studies be carried out to assess
their bioavailability (62).

8.1.4 STUDY DESIGN
Bioavailability studies involve the administration of the test dosage form to a panel
of subjects, after which blood and/or urine samples are collected and analyzed for
drug content. Based on the concentration profile of the drug, a judgement is made
regarding the rate and extent of absorption of the drug. Normally, the study is con-
ducted in a group of healthy, male subjects who are of normal height and weight,
and range in age from 18 to 35 years (6). Questions have been raised regarding the
extent to which such a population reflects the performance of a given drug product
in a actual patient population. At first glance, it would seem that bioavailability
should be determined in patients actually suffering from the disease for which the
drug is intended, or in patients representative of the age and sex of subjects who
would be using the drug. However, there are several very good reasons for using
healthy volunteers rather than patients. In bioavailability studies, it is assumed
that there are no physiologic changes in the subjects during the course of the study.
If actual patients were used, this would not be a valid assumption, due to possible
changes in the disease state. Another potential problem with using patients is that
many patients take more than one drug. This could result in a drug-drug interac-
tion which could influence the bioavailability of the test drug. In addition, diet and
fluid volume intake, both of which can influence a drug's bioavailability are more
difficult to control in a patient population than in a panel of healthy test subjects.
In general, it is more difficult with patients to have a standardized set of conditions
which are necessary for a dependable bioavailability study. However, it must be
recognized that factors that may affect a drug's performance in a patient population
may not be detected in a group of healthy subjects. Thus, it is best to conduct a
separate study in patients to determine if the disease, for which the drug is intended
to be used, alters the bioavailability of the drug.
Other important considerations in the methodology of a bioavailability study are

sample size, period of trial, and sampling. For statistical purposes, twelve subjects
are considered to be a minimum sample size. Otherwise there will not be enough
data to draw valid conclusions (63). The bioavailability testing period should be of
a sufficient length of time to ensure that drug absorption has been completed. This
length of time is at least three times the half-life of the drug; generally a period of
four to five times the half-life is used (63, 64). Blood samples should be taken
with sufficient frequency to permit an accurate determination of tmax, Cmax and
AUC.
8.1.5 IN-VITRO DISSOLUTION AND BIOAVAILABILITY
Pharmaceutical scientists have for many years been attempting to establish a corre-
lation between some physicochemical property of a dosage form and the biological

availability of the drug from that dosage form. The term commonly used to
describe this relationship is "in-vitro/in-vivo correlation" (65). Specifically, it is
felt that if such a correlation could be established, it would be possible to use
in-vitro data to predict a drug's in-vivo bioavailability. This would drastically
reduce, or in some cases, completely eliminate the need for bioavailability tests.
The desirability for this becomes clear when one considers the cost and time
involved in bioavailability studies as well as the safety issues involved in adminis-
tering drugs to healthy subjects or patients. It would certainly be preferable to be
able to substitute a quick, inexpensive in-vitro test for in-vivo bioavailability stud-
ies. This would be possible if in-vitro tests could reliably and accurately predict
drug absorption and reflect the in-vivo performance of a drug in humans.
Disintegration Tests- The early attempts to establish an indicator of drug bioavailability focused on dis-
integration as the most pertinent in-vitro parameter. The first official disintegra-
tion test appeared in the United States Pharmacopeia (USP) in 1950. However,
while it is true that a solid dosage form must disintegrate before significant disso-
lution and absorption can occur, meeting the disintegration test requirement only
insures that the dosage form (tablet) will break up into sufficiently small particles
in a specified length of time. It does not ensure that the rate of solution of the drug
is adequate to produce suitable blood levels of the active ingredient. Therefore,
while the test for tablet disintegration is very useful for quality control purposes in
manufacturing, it is a poor index of bioavailability.
Dissolution Tests- Since a drug must go into solution before it can be absorbed, and since the rate at
which a drug dissolves from a dosage form often determines its rate and/or extent
of absorption, attention has been directed at the dissolution rate. It is currently
considered to be the most sensitive in-vitro parameter most likely to correlate with
bioavailability.
Official dissolution tests - There are two official USP dissolution methods: Apparatus 1, (basket method),
and Apparatus 2 (paddle method). For details of these dissolution tests, the reader
is recommended to consult USPXXII/NFXVII (66).
Dissolution tests are an extremely valuable tool in ensuring the quality of a drug
product. Generally, product-to-product variations are due to formulation factors,
such as particle size differences, excessive amounts of lubricant and coatings.
These factors are reactive to dissolution testing. Thus, dissolution tests are very
effective in discriminating between and within batches of drug product(s). The
dissolution test, in addition, can exclude definitively any unacceptable product.
Limitations of There are, however, problems with in-vitro dissolution testing which should be
dissolution tests- noted - problems which make correlation with in- vivo availability difficult. The
first is related to instrument variance and the absence of a standard method. The
tests described in the USP are but a few of the large number of dissolution methods
proposed to predict bioavailability. Since the dissolution rate of a dosage form is
dependent on the methodology used in the dissolution test, changes in the appara-

tus, dissolution medium, etc., can dramatically modify the results. Table 8-9 on
page 17 lists some of the factors related to the dissolution testing device that can
affect the dissolution rate of the drug.
TABLE 8-9 Device factors affecting dissolution
1. Degree of agitation
2. Size and shape of container
3. Composition of dissolution medium
• pH
• ionic strength
• viscosity
• surface tension
4. Temperature of dissolution medium
5. Volume of dissolution medium
6. Evaporation
7. Hydrodynamics (flow pattern)
Source: Ref. 67
Another significant problem is related to the difference between the in-vitro and
in-vivo environments in which dissolution occurs. In-vitro studies are generally
carried out under controlled conditions in one, or perhaps two, standardized sol-
vents. The in-vivo environment (the gastrointestinal tract), on the other hand, is a
continuously changing, complex environment. There are many variables which
can affect the dissolution rate of a drug in the gastrointestinal tract, including pH,
enzyme secretions, surface tension, motility, presence of other substances and
absorption surfaces (68). Thus, drugs frequently dissolve in the body at rates quite
different from those observed in an in-vitro test situation. Most of the official dis-
solution tests tend to be acceleration dissolution tests which bear limited or no
relationship with in-vivo dissolution.
Adding to the complexity of correlating dissolution with in-vivo absorption are

factors such as drug-drug interactions, age, food effects, health, genetic back-
ground, biorhythm and physical activity (32, 69). All these factors may have an
effect on the rate and extent of absorption of a drug. Thus, the in-vivo environ-
ment is far more complex, variable, and unpredictable than any in-vitro test envi-
ronment, making in-vitro / in-vivo correlations very difficult. A simple dissolution
test in a standardized vehicle cannot reflect the in vivo absorption of a drug across a
population (70).
Parameters used- Proper selection of the in-vitro and in-vivo parameters to be correlated is critical
in achieving a meaningful correlation. The in-vitro parameter should be selected
that has the greatest effect on the absorption characteristics of the drug (71). There
are several approaches to establishing a correlation between the dissolution of a

drug in in- vitro and the bioavailability of a drug in-vivo. The in-vitro - in-vivo
correlative methods used most often are of the single-point type where the dissolu-
tion rate (expressed as the percent of drug dissolved in a given time, or the time
required for a given percent of the drug to dissolve) is correlated to a certain
parameter of the bioavailability. Examples of in-vivo parameters used include
Cmax, AUC, time to reach half-maximal plasma concentration, the average
plasma concentration after 0.5 or 1 hour, maximum urinary excretion rate, and
cumulative percent excreted in urine after a given time (71- 78). According to
Wagner, the best in-vitro variable to use is the time for 50 percent of the drug to
dissolve, and the best variable from in-vivo data to use is the time for 50 percent of
the drug to be absorbed (79).
Ideally, one would hope to find a linear relationship between some measurement of
the dissolution test and some measurement based on bioavailability studies.
Unfortunately, most attempts to accomplish this objective have failed.
8.1.6 IN-VITRO / IN-VIVO CORRELATION STUDIES-
There have been many attempts to establish in-vitro / in-vivo correlations for a
large variety of drugs. Some of these studies have been summarized by Welling,
Banakar, and Abdou (71, 80-82).
While there are many published examples of satisfactory correlations between

absorption parameters and in-vitro dissolution tests, most studies have resulted in
poor, or moderate, in-vitro - in-vivo correlations, often involving agreement with
only one of the critical bioavailability parameters. Moreover, the positive correla-
tions that have been found generally apply only to the specific formulation studied.
There have been instances where the dissolution rates or various formulations of
the same drug have been significantly different, yet little or no difference was
observed in their bioavailability parameters (83-85). There have also been cases
where a drug has failed to meet compendia dissolution standards but has demon-
strated adequate bioavailability (86). Welling states: "To the writer's knowledge,
there have been no studies that have accurately correlated in- vitro and in-vivo data
to the point that the use of upper and lower limits for in-vitro dissolution parame-
ters can be confidently used to predict in-vivo behavior and, therefore, to replace
in-vivo testing" (71).
Even if an in-vitro test could be designed that would accurately reflect the dissolu-
tion process in the gastrointestinal tract, dissolution is only one of many factors
that affect a drug's bioavailability. For example, saturable presystemic metabolism
may affect the extent of drug absorption, but this would not be predicted by an

in-vitro test. Dissolution studies also would not predict poor bioavailability due to
instability in gastric fluid or complexation with another drug or food component.
Thus, the ultimate evaluation a drug product's performance under the conditions
expected in clinical therapy must be an in-vivo test; a dissolution test is unlikely to
entirely replace bioavailability testing (70, 87, 88). In-vitro methods are important
in the development and optimization of dosage forms while in-vivo tests are essen-
tial in obtaining information on the behavior of medication in living organisms.
One cannot be substituted for the other (69).

8.2 Bioequivalence
Definitions With the phenomenal increase in the availability of generic drugs in recent years,
the issues of bioavailability and bioequivalence have received increasing attention.
In order for a drug product to be interchangeable with the pioneer (innovator or
brand name) product, it must be both pharmaceutically equivalent and bioequiva-
lent to it. According to the FDA, "pharmaceutical equivalents" are drug products
that contain identical active ingredients and are identical in strength or concentra-
tion, dosage form, and route of administration (89). However, pharmaceutical
equivalents do not necessarily contain the same inactive ingredients; various man-
ufacturers' dosage forms may differ in color, flavor, shape, and excipients. The
terms "pharmaceutical equivalents" and "chemical equivalents" are often used
interchangeably.
"Bioequivalence" is a comparison of the bioavailability of two or more drug prod-

ucts. Thus, two products or formulations containing the same active ingredient are
bioequivalent if their rates and extents of absorption are the same. When a new
formulation of an existing drug is developed, its bioavailability is generally evalu-
ated relative to the standard formulation of the originator. Indeed, a bioequiva-
lence trial against the standard formulation is the key feature of an Abbreviated
New Drug Application (ANDA) submitted to the Food and Drug Administration
by a manufacturer who wishes to produce a generic drug. For a generic drug to be
considered bioequivalent to a pioneer product, there must be no statistical differ-
ences (as specified in the accepted criteria) between their plasma concentra-
tion-time profiles. Because two products rarely exhibit absolutely identical
profiles, some degree of difference must be considered acceptable, as will be dis-
cussed later.
Since the concentration of a drug in blood is used as an assessment of its clinical

performance, inherent in the demonstration that two preparations containing
equivalent amounts of the same drug produce similar concentrations of the drug
entity in blood is the assumption that they will elicit equivalent drug responses.
Thus, two products that are deemed to be bioequivalent are also assumed to be
therapeutically equivalent, and therefore interchangeable. This principle is funda-
mental to the concept of bioequivalence and is the basic premise on which it is
founded.
In general, the FDA considers two products to be "therapeutic equivalents" if they

each meet the following criteria (90):
1. they are pharmaceutical equivalents,
2. they are bioequivalent (demonstrated either by a bioavailability measurement or an in vitro stan-
dard),

3. they are in compliance with compendial standards for strength, quality, purity and identity,
4. they are adequately labelled, and
5. they have been manufactured in compliance with Good Manufacturing Practices as established
by the FDA.
Background The first intimations of bioequivalence problems with multi-source drug products
were given by early investigations of the availability of vitamins, aspirin, tetracy-
cline, and tolbutamide (91-97). In 1974, after an extensive review of the bioavail-
ability of drugs, Koch-Weser concluded that " . . . among drugs thus far tested
bioinequivalence of different drug products has been far more common than
bioequivalence" (98). Of particular note were the studies involving digoxin; the
findings of these investigations sparked the discussion about bioequivalence
assessment that still continues today. Significant differences were seen in the bio-
availability of digoxin not only between products supplied by different companies,
but also between lots obtained from the same manufacturer (99). Because of the
narrow therapeutic range for this drug, and because the drug is utilized in the treat-
ment of cardiac patients, these findings generated a great deal of concern.
Similar reports of bioinequivalence and therapeutic inequivalence appeared for

other drugs as well, including phenytoin, phenylbutazone, chloramphenicol, tolb-
utamide and thyroid (6). The clinical significance of these reported differences in
bioavailability relates to the therapeutic index of the drug, the dose of the drug and
the nature of the disease. In 1973 the Ad Hoc Committee on Drug Product Selec-
tion of the American Pharmaceutical Association published a list of drugs with a
potential for therapeutic inequivalence based on reported evidence of bioinequiva-
lence (100). The drugs fall in three categories: "high," "moderate," or "low risk"
based on the clinical implications (Table 8-10 on page 22).

TABLE 8-10 Drugs with various risk potential for inequivalence
High Risk Potential Moderate Risk Potential Low or Negligible Risk

Potential
aminophylline amphetamines acetaminophen
aspirin (when used in high dose (sustained-release) codeine
levels) ampicillin ferrous sulfate
bishydroxycoumarin chloramphenicol hydrochlorothiazide
digoxin chlorpromazine ephedrine
dipheylhydantoin (phenytoin) digitoxin isoniazid
para-aminosalicylic acid erythromycin meprobamate
prednisolone griseofulvin penicillin VK
prednisone oxytetracycline sulfisoxazole
quinidine penicillin G (buffered)
warfarin pentobarbital
phenylbutazone
phenacetin
potassium chloride (solid dosage
forms)
salicylamide
secobarbital
sulfadiazine
tetracycline
tolbutamide
The concern about the bioinequivalence of some drugs led to the establishment in
1974 of the Drug Bioequivalence Study Panel of the Office of Technology Assess-
ment (OTA). The objective was to ensure that drug products of the same physical
and chemical composition would produce similar therapeutic effects. Among the
11 recommendations of the Panel was the conclusion that not all chemical equiva-
lents were interchangeable, but the goal of interchangeability was achievable for
most oral drug products (101). The Report recommended that a system should be
organized as rapidly as possible to generate an official list of interchangeable drug
products. The OTA Report, as well as the growing awareness within the scientific
and regulatory communities of bioavailability problems with marketed drug prod-
ucts, focused the attention of the FDA on bioequivalence and bioavailability prob-
lems and issues.

8.2.1 BIOEQUIVALENCE REGULATIONS
In 1977, the FDA implemented a series of bioavailability and bioequivalence regu-

lations which formed the basis of subsequent discussion, if not controversy, of
therapeutic equivalency of drug products (102). The regulations are divided into
two separate regulations; Subpart B - Procedures for Determining the Bioavail-
ability of Drug Products and Subpart C - Bioequivalence Requirements. While
Table 11 summarizes the key provisions of the bioavailability regulations, those
for bioequivalence requirements are summarized in Table 8-11 on page 23.
TABLE 8-11 Key provisions for bioavailabilty regulations
1. Defines bioavailability in terms of both the rate and extent of drug absorption.
2. Describes procedures for determining the bioavailability of drug products.
3. Sets forth requirements for submission of in vivo bioavailability data.
4. Sets forth criteria for waiver of human in vivo bioavailability studies.
5. Provides general guidelines for the conduct of in vivo bioavailability studies.
6. Imposes a requirement for filing an Investigational New Drug Application.
Source: Ref. 103
Criteria for establishing The 1977 Bioequivalence regulations set forth the following criteria and evidence
a bioequivalence supporting the establishment of a bioequivalence requirement for a given drug
requirement - product:
1. Evidence from well-controlled clinical trials or controlled observations in patients that such
products do not give comparable therapeutic effects.
2. Evidence from well-controlled bioequivalence studies that such products are not bioequivalent
drug products.
3. Evidence that the drug products exhibit a narrow therapeutic ratio, (e.g., there is less than a
two-fold difference in the median lethal dose (LD50) and median effective dose (ED50) value
or have less than a two-fold difference in the minimum toxic concentration and minimum effec-
tive concentrations in the blood), and safe and effective use of the drug product requires careful
dosage titration and patient monitoring.
4. Competent medical determination that a lack of bioequivalence would have a serious adverse
effect in the treatment or prevention of a serious disease or condition.
5. Physicochemical evidence of any of the following:
a. The active drug ingredient has a low solubility in water--e.g., less than 5 mg/ml.
b. The dissolution rate of one or more such products is slow--e.g., less than 50 percent in
thirty minutes when tested with a general method specified by an official compendium or the
FDA.
c. The particle size and/or surface area of the active drug ingredient is critical in determining
bioavailability.

d. Polymorphs, solvates, complexes, and such, exist that could contribute to poor dissolution
and may affect absorption.
e. There is a high excipient/active drug ratio present in the drug product--e.g., greater than 5
to 1.
f. The presence of specific inactive ingredients (e.g. hydrophilic or hydrophobic excipients)
that either may be required for absorption of the active drug or may interfere with such absorp-
tion.
6. Pharmacokinetic evidence of any of the following:
a. The drug is absorbed in large part in a particular segment of the gastrointestinal tract or is
absorbed from a localized site.
b. Poor absorption of the drug, even when it is administered as a solution--e.g., less than 50
percent compared to an intravenous dose.
c. The drug undergoes first-pass metabolism in the intestinal wall or liver.
d. The drug is rapidly metabolized or excreted, requiring rapid dissolution and absorption for
effectiveness.
e. The drug is unstable in specific portions of the gastrointestinal tract, requiring special
coatings and formulations--e.g., enteric coatings, buffers, film coatings--to ensure adequate
absorption.
f. The drug follows nonlinear kinetics in or near the therapeutic range, and the rate and
extent of absorption are both important to bioequivalence.
Types of Bioequivalence In the event that a drug meets one or more of the above six criteria, a bioequiva-
Requirements lence requirement is established. The requirement could be either an in-vivo or an
in-vitro investigation, as specified by the FDA. The types of bioequivalence
requirements include the following:
1. An in-vivo test in humans.
2. An in-vivo test in animals that has been correlated with human in- vivo data.
3. An in-vivo test in animals that has not been correlated with human in- vivo data.
4. An in-vitro bioequivalence standard, i.e., an in-vitro test that has been correlated with human
in-vivo bioavailability data.
5. A currently available in-vitro test (usually a dissolution rate test) that has not been correlated
with human in-vivo bioavailability data.
The regulations state that in-vivo testing in humans would generally be required if
there is well-documented evidence that pharmaceutical equivalents intended to be
used interchangeably meet one of the first three criteria used to establish a
bioequivalence requirement:
1. The drug products do not give comparable therapeutic effects.
2. The drug products are not bioequivalent.
3. The drug products exhibit a narrow therapeutic ratio (as described above), and safe and effec-
tive use of the product requires careful dosage titration and patient monitoring.

Criteria for waiver of Although a human in-vivo test is considered to be preferable to other approaches
evidence of in-vivo for the most accurate determination of bioequivalence, there is a provision in the
bioavailability - 1977 regulations for waiver of an in-vivo bioequivalence study under certain cir-
cumstances. For some drug products, the in-vivo bioavailability of the drug may
be self-evident or unimportant to the achievement of the product's intended pur-
poses. The FDA will waive the requirement for submission of in-vivo evidence of
bioavailability or bioequivalence if the drug product meets one of the following
criteria:
1. The drug product is a solution intended solely for intravenous administration, and contains the
active drug ingredient in the same solvent and concentration as an intravenous solution that is
the subject of an approved full New Drug Application (NDA).
2. The drug product is a topically applied preparation intended for local therapeutic effect.
3. The drug product is an oral dosage form that is not intended to be absorbed, e.g., an antacid.
4. The drug product is administered by inhalation and contains the active drug ingredient in the
same dosage form as a drug product that is the subject of an approved full NDA.
5. The drug product is an oral solution, elixir, syrup, tincture or other similar soluble form, that
contains an active drug ingredient in the same concentration as a drug product that is the subject
of an approved full NDA and contains no inactive ingredient that is known to significantly
affect absorption of the active drug ingredient.
6. The drug product is a solid oral dosage form (other than enteric-coated or controlled-release)
that has been determined to be effective for at least one indication in a Drug Efficacy Study
Implementation (DESI) notice and is not included in the FDA list of drugs for which in vivo
bioequivalence testing is required.
7. The drug product is a parenteral drug product that is determined to be effective for at least one
indication in a DESI notice and shown to be identical in both active and inactive ingredients for-
mulation, with a drug product that is currently approved in an NDA. (Excluded from the waiver
provision are parenteral suspensions and sodium phenytoin powder for injection.)
According to the regulations, the bioavailability of certain drug products may be

demonstrated by evidence obtained in-vitro in lieu of in-vivo data. Thus, the FDA
also permits waiver of the in-vivo requirements if a drug product meets one of the
following criteria:
1. The drug product is one for which only an in-vitro bioequivalence requirement has been
approved by the FDA.
2. The drug product is in the same dosage form, but in a different strength, and is proportionally
similar in its active and inactive ingredients to another drug product made by the same manufac-
turer and the following conditions are met:
a. the bioavailability of this other product has been demonstrated
b. both drug products meet an appropriate in-vitro test approved by the FDA
c. the applicant submits evidence showing that both drug products are proportionally similar
in their active an inactive ingredients.
3. The drug product is shown to meet an in-vitro test that assures bioavailability, i.e., an in-vitro
test that has been correlated with in-vivo data.

4. The drug product is a reformulated product that is identical, except for color, flavor, or preserva-
tive, to another drug product made by the same manufacturer, and both of the following condi-
tions are met:
a. the bioavailability of the other product has been demonstrated.
b. both drug products meet an appropriate in vitro test approved by the FDA.
5. The drug product contains the same active ingredient and is in the same strength and dosage
form as a drug product that is the subject of an approved full NDA or Abbreviated New Drug
Application (ANDA) and both drug products meet an appropriate in-vitro test that has been
approved by the FDA.
Although the above list of criteria for waiver of an in-vivo bioavailability study is
quite lengthy, currently virtually all new tablet or capsule formulations from which
measurable amounts of drug or metabolites are absorbed into the systemic circula-
tion require a human bioequivalence study for approval (104).
TABLE 8-12 Key Provisions for bioequivalence requirements
1. Defines procedures for establishing a bioequivalence requirement.

2. Sets forth criteria to establish a bioequivalence requirement.
3. Describes types of bioequivalence requirements.
4. Sets forth requirement for in-vitro batch testing and certification.
5. Describes requirements for marketing a drug product subject to a bioequivalence requirement.
6. Sets forth requirements for in-vivo testing of a drug product not meeting an in-vitro bioequiv-
alence standard.
Source: Ref. 103
8.2.2 STUDY DESIGN
A single-dose bioequivalency study is generally performed in normal, healthy,

adult volunteers. The subject population should be selected carefully, so that prod-
uct formulations, and not intersubject variations, will be the only significant deter-
minants of bioequivalence (105). A minimum of 12 subjects is recommended,
although 18 to 24 subjects are used to increase the data base for statistical analysis.
The test and the reference products are usually administered to the subjects in the
fasting state (overnight fast for at least 10 hours, plus 2 to 4 hours after administra-
tion of the dose), unless some other approach is more appropriate for valid scien-
tific reasons. These subjects should not take any other medication for one week
prior to the study or during the study. The bioavailability is determined by the col-
lection of either blood samples or urine samples over a period of time and mea-
surement of the concentration of drug present in the samples.
Generally, a crossover study design is used. Using this method, both the test and
the reference products are compared in each subject, so that inter-subject variables,

such as age, weight, differences in metabolism, etc., are minimized. Each subject
thus acts as his own control. Also, with this design, subjects' daily variations are
distributed equally among all dosage forms or drug products being tested.
The subjects are randomly selected for each group and the sequence of drug
administration is randomly assigned. The administration of each product is fol-
lowed by a sufficiently long period of time to ensure complete elimination of the
drug (washout period) before the next administration. The washout period should
be a minimum of 10 half-lives of the administered drug (106). A waiting period of
one week between administration is usually an adequate washout period of most
drugs.
With a drug requiring a washout period of one week, a typical randomized two-
way crossover bioequivalency study is shown in Table 8-13 on page 27.
TABLE 8-13 Two way cross over design
Treatment
Groupa Week 1 Week 2
I A B
II B A
a
10 subjects per group
Assuming that the in-vivo performances of the two formulations are to be com-
pared by examining their blood level profiles, one must be certain that an adequate
number of blood samples are taken. Blood samples should be drawn with suffi-
cient frequency to provide an accurate characterization of the drug concentra-
tion-time profile from which tmax, Cmax and AUC can be determined. Typically,
a total of 10 to 15 sampling times might be required (107). Moreover, all samples
should be taken at the same time for both the test and the reference product to per-
mit proper statistical analysis.
Additional features which contribute to good study design include:

1. All drug samples obtained for the test and reference preparations should be analyzed by the
same method.
2. Identical test conditions must be used for the two groups of subjects. For example, the types of
foods, fluid intake, physical activity, and posture should all be rigidly controlled in the study.
3. The physical characteristics of the subjects (such as age, height, weight, and health) should be
standardized.

Several important questions have been raised specifically regarding the design of
the bioequivalence tests. One of these deals with the selection of the appropriate
reference standard, since this is a critical component of a protocol (6, 108). Nor-
mally, the reference product is that available from the innovator company holding
the New Drug Application. However, in cases where there may be some question
as to the bioavailability of such a product, the study may utilize a solution of the
drug instead of or in addition to the marketed product. The use of a solution can,
of course, result in some difficulty in interpretation of the data: a solid dosage
form, when compared to a solution, will usually exhibit a lower Cmax and a longer
tmax. The clinical significance of these differences may be difficult to assess.
In some instances, the FDA must designate a specific product as the reference
standard from among two or more possible products; e.g., Proventil® tablets, 4 mg
(Schering), not Ventolin® tablets 4 mg (Allen and Hanburys), is the reference
product in bioequivalence studies of albuterol sulfate conventional tablets (108).
Advantages of Multiple- Another important question is whether the bioequivalence trial should compare
dose vs. single dose single doses of the formulations or if it should compare "steady-state" conditions
studies: reached after multiple dosing. It would seem that multiple dosing would be the
logical choice for drugs intended for long-term use since this would give a more
realistic comparison in view of the way in which the drug is normally adminis-
tered. Other advantages of conducting a multiple-dose study over a single-dose
study include (54, 59):
1. Multiple-dosing eliminates the long washout periods required between single-dose administra-
tions. The switch-over from one formulation to the other can take place in steady state.
2. Single-dose studies may pose problems of sufficiently long sampling periods in order to get reli-
able estimates of terminal half-life, which is needed for correct calculation of the total AUC.
3. Multiple-dose studies yield higher concentrations of drug in the blood, making accurate mea-
surement easier. In addition, since drug concentrations need to be measured only over a single
dosing interval at steady state, the need to measure lower concentrations during a disposition
phase is avoided.
4. Multiple-dosing studies can be conducted in patients, rather than healthy volunteers, allowing
the use of higher doses.
5. Usually, smaller intersubject variability is observed in steady-state studies, which may permit
the use of fewer subjects.
6. Nonlinear pharmacokinetics, if present, can be more readily detected at steady-state following
multiple-dosing.
Thus, for some drug products, multiple-dose bioequivalence studies are appropri-
ate and should be performed. In fact, according to one of the conclusions of the
Bio- International '92 conference on the bioequivalence of highly variable drugs, a
multiple-dose study is required in the case of compounds exhibiting nonlinear
pharmacokinetics (110). The circumstances under which a multiple-dose study
may be required are summarized in the regulations (109):

1. When there is a difference in the rate of absorption but not in the extent of absorption.
2. When there is excessive variability in bioavailability from subject to subject.
3. When the concentration of the active moiety in the blood resulting from a single dose is too low
for accurate determination.
4. When the drug product is a controlled-release dosage form.
On the other hand, multiple-dose bioequivalence studies are undesirable in some

respects. Healthy subjects should not be dosed with any drug for an extended
period of time (59). Multiple-dose studies are also generally more difficult to
carry out, especially with regard to ensuring subject compliance with dosing and
dietary restrictions. Therefore, most bioequivalence studies are conducted as sin-
gle-dose studies. Multiple-dose studies should be performed only when a sin-
gle-dose study is not a reliable indicator of bioavailability (111).
8.2.3 ASSESSMENT OF BIOEQUIVALENCE
In order for different formulations of the same drug substance to be considered

bioequivalent, they must be equivalent with respect to the rate and extent of drug
absorption. Thus, the two predominant issues involved in the assessment of
bioequivalence are: the pharmacokinetic parameters that best characterize the rate
and extent of absorption and, the most appropriate method of statistical analysis of
the data.
Pharmacokinetic criteria With regard to the choice of the appropriate pharmacokinetic characteristics,
Westlake suggests comparisons of the formulations should be made with respect to
only those parameter(s) of the blood level profile that possess some meaningful
relation to the therapeutic effect of the drug (107). Since the AUC is directly pro-
portional to the amount of drug absorbed, this pharmacokinetic parameter is most
commonly used to characterize the extent of absorption, both in single- and multi-
ple- dose studies.
The choice of an appropriate pharmacokinetic characteristic for the rate of absorp-

tion is still being discussed with considerable controversy (112, 113). Although a
broad array of methods exists for calculating absorption rates (e.g. moment analy-
sis, deconvolution procedures and curve-fitting), the most commonly used param-
eters are peak concentration (Cmax) and time to peak concentration (tmax).
Although these parameters have been observed to have significant variances and
may be difficult to determine accurately, they remain the parameters generally
requested as rate characteristic by most regulatory authorities for immedi-
ate-release products (112).
Statistical criteria After a bioequivalence study is conducted and the appropriate parameters are
determined, the pharmacokinetic data must be examined according to a set of pre-
determined criteria to confirm or refute the bioequivalency of the test and refer-

ence formulations. That is, one must determine whether the test and reference
products differ within a predefined level of statistical significance. Since the sta-
tistical outcome of a bioequivalence study is the primary basis of the decision for
or against therapeutic equivalence of two products, it is critically important that the
experimental data be analyzed by an appropriate statistical test.
In the early 1970s, bioequivalence was usually determined only on the basis of
mean data. Mean AUC and Cmax values for the generic product had to be within
+20% of those of the reference (innovator) product (108). Although the 20% value
was somewhat arbitrary, it was felt that for most drugs, a 20% change in the dose
would not result in significant differences in the clinical response to drugs (114).
A relatively common misconception is that current regulatory standards still allow
this difference of 20% in the means of the pharmacokinetic variables (Cmax and
AUC) of the test and reference formulations. The FDA's statistical criteria for
approval of generic drugs now requires the application of confidence limits to the
mean data, using an analysis known as the two one-sided tests procedure (115).
This change came about as a result of the conclusion of the FDA Bioequivalence
Task Force in 1986 that the use of a 90% confidence interval based on the two
one-sided t-tests approach was the best available method for evaluating bioequiva-
lence (111).
Westlake was the first to suggest the use of confidence intervals as a means of test-
ing for bioequivalence (116). Recognizing that no two products will result in iden-
tical blood-level profiles, and that there will be differences in mean values between
products, Westlake pointed out that the critical issue was to determine how large
those differences could be before doubts as to therapeutic equivalence arose (107,
117). A test formulation was considered to be bioequivalent to a reference formu-
AUC test Cp max test
lation if 0.8 < ------------------- < 1.2 and 0.8 < -------------------- < 1.2 . (119). By this proce-
AUC ref Cp max ref
dure, if test and reference products were not bioequivalent (i.e. means differed by
more than 20%), there was a 5% chance of concluding that they are bioequivalent.
The current FDA guidelines are that two formulations whose rate and extent of
absorption differ by -20%/+25% or less are generally considered bioequivalent
(90). In order to verify that the -20%/+25% rule is satisfied, the two one-sided sta-
tistical tests are carried out: one test verifies that the bioavailability of the test
product is not too low and the other to show that it is not too high. The current
practice is to carry out the two one-sided tests at the 0.05 level of significance.
Computationally, the two one-sided tests are carried out by computing a 90% con-
fidence interval. For approval of an ANDA, a generic manufacturer must show
that the 90% confidence interval for the ratio of the mean response (usually AUC

and Cmax) of its product to that of the innovator is within the limits of 0.8 to 1.25.
Since these tests are carried out at the 0.05 level of significance, there is no more
than a 5% chance that they will be approved as equivalent if they differ by as much
or more than is allowed by the equivalence criteria (-20%/+25%).
Since this test requires that the 90% confidence interval of the difference between
the means be within a range of -20%/+25%, it is more stringent than simply requir-
ing the comparison of the test and reference products' AUC and Cmax to be within
the 80 to 125% range. If the mean response of the generic product in the study
population is near 20% below or 25% above the innovator mean, one or both of the
confidence limits will fall outside the acceptable range and the product will fail the
bioequivalence test. Thus, the confidence interval requirement ensures that the
difference in mean values for AUC and Cmax will actually be less than -20%/
+25%. It should be pointed out that the standards vary among drugs and drug
classes. For example, antipsychotic agents may fall within a 30% variation and
antiarrhythmic agents may be allowed a 25% variation (122).
The actual differences between brand and generic products observed in bioequiva-
lence studies have been reported to be small. The FDA has stated that for
post-1962 drugs approved over a two-year period under the Waxman-Hatch bill
(1984), the mean bioavailability difference between the generic and pioneer prod-
ucts has been about 3.5% (120). In addition, 80% of the generic drugs approved
by the FDA between 1984 and 1986 differed from the innovator products by an
observed difference of only +5%. Such differences are small when compared to
other variables of drug therapy and would not be expected to produce clinically
observable differences in patient response.
8.2.4 CONTROVERSIES AND CONCERNS IN BIOEQUIVALENCE
The design, performance and evaluation of bioequivalence studies have received a

great deal of attention over the past decade from academia, the pharmaceutical
industry and regulatory agencies. A number of concerns and questions have been
raised about the conduct of bioequivalence studies as well as the guidelines and
criteria used to determine bioequivalence (112). Many of these concerns were trig-
gered by the passage of the Drug Price Competition and Patent Term Restoration
Act (The Waxman-Hatch Amendments) by Congress in 1984. This Act provided
for an expedited approval by the FDA of generic drugs, thereby expanding the
potential generic market for prescription generic drugs (121). Shortly after the
passage of this Act, numerous published reports appeared in the scientific litera-
ture questioning the FDA's ability to ensure that generic drugs were equivalent to
the brand name drugs they were copying. Most of the concerns of the scientific
community centered around adequate standards for evaluation of bioequivalence

and correlation between bioequivalence and therapeutic equivalence. Some of the

issues and concerns that were raised are summarized in Table 8-14 on page 32 (8,
13).
TABLE 8-14 Issues and Concerns regarding bioequivalence
• Correct analysis of drugs in biological fluids

• Appropriate choice of pharmacokinetic parameters to assess bioequivalence
• Generalizing results obtained in healthy volunteers to patients
• Problems involved in extrapolating from single-dose studies to steady-state
• Importance of evaluating active metabolites
• Inadequate statistical criteria to evaluate bioequivalency
• Bioequivalence does not always ensure therapeutic equivalence
• Lack of clear guidelines for evaluation of bioequivalence
At the center of the controversy were the methods and criteria used by the FDA to
determine bioequivalence. Assessment of bioequivalence was done on the basis of
mean data: mean AUC and Cmax values for the generic product had to be within
+20% of those of the innovator product for approval. A statistical test was
employed to assess the power of the test to detect a 20% mean difference in treat-
ments. For drugs that could not meet the statistical criteria because of inherent
variability, another rule was used, the so-called "75/75" rule: that in at least 75%
of the subjects, the test formulation must fall within the range of 75% to 125% of
the reference standard to be considered equivalent (122). It was felt by many that
these rules permitted too much variability in the bioavailability of test drugs and
could result in therapeutic failure or increased risk of side effects (4, 15, 123).
Statistically, the power approach and the 75/75 rule were shown to have poor per-
formance characteristics and bioequivalence evaluation based on these methods
was discontinued by the FDA in 1986. In their place, the Agency currently
employs the two one-sided tests procedure, as previously discussed.
Although the decision of bioequivalence is now made in a more statistically valid

way and the associated concerns have diminished somewhat, some important
questions and controversies in bioequivalence remain. These are primarily cen-
tered around study design, the criteria used to establish or refute equivalence, and
the assumption that products that are bioequivalent are therapeutically equivalent.
One criticism of bioequivalence testing is that it is almost always done in a panel

of young, healthy male volunteers rather than in the target population for which the
drug is intended. Clearly, the performance of a drug product in a 20-year-old male
will not be the same as in an 85-year-old woman. Serious concerns have been

raised that different results would be observed in elderly patients, in women, in

patients with diseases of the gastrointestinal tract, and in patients with diminished
renal or hepatic function. However, although factors such as age and disease state
might affect the actual observed concentrations of drug, the products being com-
pared should be affected in a similar fashion, and one can still be compared to the
other. If two products show an equivalent level in healthy volunteers, their levels
should be elevated to the same extent in patients with impaired hepatic function.
Thus, they can still be compared to each other. Healthy male volunteers are gener-
ally used in bioequivalence studies to assure a homogeneous study population and
to permit focus on formulation factors that might affect bioavailability. In addi-
tion, healthy subjects are more likely to remain stable during the study. The condi-
tion of actual patients might change due to the disease resulting in greater
variability in the data. The FDA does recognize the possibility that some condi-
tions could cause two products that are bioequivalent in healthy subjects to be bio-
inequivalent in certain patients and is prepared to modify its guidelines if
necessary.
A study design-related area of concern is average versus individual bioavailability.

Current procedures assess equivalence in terms of average bioavailabilities, and do
not address within-subject equivalence. In recent years, there has been increased
interest expressed in the variability of response, particularly variability within an
individual. This has given rise to the most recent controversy in bioequivalence
assessment, namely whether average bioequivalence is adequate to allow inter-
changeability of drugs in an individual (112). Anderson and Hauck believe that a
different, more stringent, notion of bioequivalence, referred to as individual
bioequivalence, is needed to provide assurance that an individual patient can be
switched from one formulation to another (124).
The second major area of controversy has focused on the criteria used to determine
bioequivalence. Implicit in the FDA guidelines is the assumption that a -20%/
+25% change in mean serum concentration of drugs can be safely tolerated. How-
ever, there is little documentation demonstrating whether 20% variation in bio-
availabilities does or does not affect the safety and efficacy of drugs. There are
certain critical therapeutic categories (Table 8-15 on page 34) in which minor fluc-
tuations in blood levels may have a substantial impact on therapeutic outcome or
toxicity (125, 126). In view of this, some scientists believe that the FDA should be
more stringent, requiring the mean values for AUC to be within 10% rather than
20%/25%. The Bioequivalence Task Force, in its 1988 report, concluded that for
certain drugs or drug classes, there is clinical evidence that may indicate a need for
tighter limits than the then-generally applied +20% rule (111). The Task Force
recommended that the Agency consider using as an "additional nonstatistical crite-
rion" a mean difference in AUC of +10%; however, this additional criterion would
not be essential to ensuring drug bioequivalence.

TABLE 8-15 Critical Therapeutic Catagories of Drugs
Category Example
Cardiovascular drugs digoxin
Anticonvulsants phenytoin
Bronchodilating agents theophylline
Oral anticoagulants warfarin
In general, the choice of the appropriate bioequivalence range should be done on

clinical grounds; for a drug with a narrow therapeutic range, more stringent limits
should be considered. On the other hand, the current requirements for Cmax for
some drugs may be too stringent, considering the difficulty in accurately estimat-
ing this value. For example, it has been suggested that the acceptable bioequiva-
lence range for Cmax for fast-releasing nifedipine formulations should be 70% to
130%, rather than the usual 80% to 125%. In light of this, many, including the
Pharmaceutical Research and Manufacturers of America (formerly the Pharmaceu-
tical Manufacturers Association [PMA]), feel that the FDA should repudiate its
-20%/+25% rule and develop drug-by- drug bioequivalence criteria (127).
A third source of controversy in bioequivalence is the very foundation on which

the whole concept of bioequivalence is based: the central assumption is that if two
products are shown to be bioequivalent by currently accepted standards, then they
are also therapeutically equivalent, and thus interchangeable. A number of critics
have challenged this "bioequivalence = therapeutic equivalence" equation, point-
ing out that this relationship has not been conclusively established for most drugs
(9, 13, 16, 128). These terms are, in fact, not interchangeable; bioequivalence
means that two products have basically superimposable blood level curves (within
specified limits) while therapeutic equivalence means the products produce similar
effects. There may be situations where two products have similar blood concentra-
tions, yet if the drug has a narrow therapeutic range, they may have significantly
different therapeutic effects. On the other hand, there may be products which have
widely varying blood level profiles, but exhibit very little difference in their clini-
cal effect. This might be the case for drugs with a wide therapeutic range. In addi-
tion, the therapeutic efficacy of some drugs is not necessarily related to their blood
levels, e.g., some psychoactive drugs, where the end point of drug effects is psy-
chological and behavioral response (129).

Williams suggests several ways that the integrity of a bioequivalence study as a

prediction of therapeutic equivalence could be assessed (104). One way involves
the performance of specific clinical studies to confirm that products shown to be
bioequivalent in healthy subjects would be bioequivalent in the patient population
as well. A second way suggested is through post-marketing surveillance of thera-
peutic response produced by different formulations of the same drug under actual
conditions of use. A third method is based on anecdotal reports. Williams points
out that none of these methods have been systematically employed to confirm cur-
rent bioequivalence methodology.
Thus, a number of problems remain in the bioequivalence process which should be

addressed. FDA scientists themselves have readily acknowledged the existence of
shortcomings in the bioequivalence testing program. However, a great deal of
progress has been made in this area in the last twenty years. The improved design
of the studies, the interpretation of the data, the increased scientific rigor of the
acceptance criteria, as well as the more rigorous auditing and inspection program
have made bioequivalence data an appropriate and valid means of approving
generic drug products.
8.2.5 GENERIC DRUGS AND PRODUCT SELECTION
Generic drug utilization has increased dramatically in the last 20 years. In 1975,
approximately 9% of all prescription drugs dispensed were generic versions (130).
This percentage rose to 20% in 1984, and 40% in 1991. It has been variously esti-
mated that the generic share of all new prescriptions will be 46% to 65% in 1995
(131-133).
This rise of generics has not gone altogether smoothly, however; the popularity of
generic drugs took a sharp downturn in 1989 when scandal rocked the generic drug
industry. This involved illegal and unethical acts by some generic drug companies
-- payoffs to FDA employees and fraudulent drug-approval test -- aimed at getting
drugs approved ahead of other firms (134-138).
Although these events did shake the confidence of pharmacists, physicians and the
public in the quality of generic drugs and cast a shadow over generics generally,
these concerns were relatively short-lived. Numerous surveys conducted one to
two years after the scandal unfolded indicated that confidence in generic drugs had
been regained and that the generic industry was in better shape with pharmacists
than it had been before the scandal occurred (139-146). Given the seriousness of
the events, the speed with which generics came back was impressive. This was
due in part to the FDA's reaction to the scandal: a multilevel reorganization of its
generic drug operations and a comprehensive inspection of the leading manufac-

turers of generic drugs (134, 140, 147, 148). It was felt that this stringent FDA
review of generics proved the overall integrity of the companies that emerged with
a clean bill of health. After a sharp drop in the use of generic drugs in 1989, they
began to rise nearly as quickly as they fell, and by mid-1990, sales of generics
were approaching their previous record high (141).
This trend in generic drug utilization is expected to continue its upward spiral, with
newly generic drugs coming to market at an increasing rate. There are several fac-
tors that have contributed to this period of considerable growth in the generic drug
industry. One major factor was the passage of the Drug Price Competition and
Patent Term Restoration Act (Waxman-Hatch Act) in 1984. This act, by eliminat-
ing the requirement for clinical safety and efficacy testing for generics of drugs
introduced after 1962, greatly expedited the entry of generic drugs into the market-
place. The purpose of this act was to facilitate generic competition and thereby
reduce health care costs. This act significantly expanded the number of drugs eli-
gible to be manufactured as generics. Another factor fueling the surge of generic
products is the abundance of brand name drugs whose patents began expiring in
1986. Between 1991 and 1994, patents expired on brand-name drugs whose com-
bined annual sales totaled $10 billion (141). These include Procardia®, Ceclor®,
Tagamet®, Cardizem®, Feldene®, Naprosyn®, and Xanax®. All told, more than
100 drugs worth upwards of $25 billion in sales will have come off patent by the
year 2000 (149). Table 8-16 on page 37 lists some recent and impending patent
expirations (150, 151). As a result of these patent expirations on popular drugs,
there has been an explosion of new generic drug applications.

TABLE 8-16 Recent and pending patent expirations
Brand Name Generic Name Patent Expiration Date*
Procardia Nifedipine 1991

Tenormin Atenolol 1991
Ceclor Cefaclor 1992
Cardizem Diltiazem 1992
Feldene Piroxicam 1992
Naprosyn Naproxen 1993
Xanax Alprazolam 1993
Tagamet Cimetidine 1994
Seldane Terfenadine 1994
Micronase Glyburide 1994
Capoten Captopril 1995
Zantac Ranitidine 1995
Trental Pentoxifylline 1997
Noroxin Norfloxacin 1998
*Extentions may be granted
Perhaps the major factor promoting generic drug utilization is the increased atten-
tion to containing health-care costs. Pushed by a drive for lower-cost medication
by federal and state governments, private insurers, corporate benefit managers,
regulatory agencies and consumer groups, generic drug usage is at a peak. Addi-
tional impetus could come from health care reform, wherein generic drugs are
viewed as a key to controlling pharmaceutical costs. Managed care programs are
expected to cover more than 70% of all outpatient prescriptions by the end of the
decade, with an accompanying greater demand for generic products (152). Thus
the demand for generic drugs will continue to rise, in a climate that favors health
care reform, lower- cost medications and broad-based prescription benefits (153).
With the increasing availability of generic drugs, pharmacists are called upon more
and more often to select a patient's drug product from a myriad of multisource
products. The pharmacist's role in product selection has increased dramatically in
the past decade and the proper selection of multisource drug products has become
a major professional responsibility of pharmacists. Although most pharmacists do
not, realistically, evaluate the bioequivalence of two products from blood level
data, professional judgement does need to be exercised; and this requires an under-
standing and application of the biopharmaceutical principles discussed.

8.2.6 THE ORANGE BOOK
One of the factors that led to the widespread repeal of the state anti-substitution
laws in the 1970's was an effort by the states to contain drug costs and the estab-
lishment of maximum allowable costs (MACs) for reimbursement of drugs under
Medicaid. By allowing the pharmacist to select the manufacturer of a drug, the
less- expensive generic version could be dispensed. However, before the pharma-
cist could knowledgeably select a generic drug, he had to know which generics
were bioequivalent to the innovator product and thus, interchangeable. (There was
substantial evidence at this time that not all pharmaceutically equivalent products
were bioequivalent). To answer this need, the states began preparing either posi-
tive or negative formularies, often turning to the FDA for assistance in this under-
taking.
In response to the many requests for assistance from the states in developing their
formularies, the FDA Commissioner notified state officials of FDA's intent to pro-
vide a list of all prescription drug products that have been approved as being safe
and effective, along with therapeutic equivalence determinations for multisource
prescription products. This list, entitled Approved Drug Products with Therapeu-
tic Equivalence Evaluations, more commonly known as "The Orange Book" was
first published in 1980 and is now in its 14th edition. It is published annually and
updated monthly. The Orange book is generally considered to be the most reliable
guide for determining which drug products are therapeutically equivalent.
The Prescription Drug Products List contains:

1. all the drug products approved by the FDA as being safe and effective under the Federal Food,
Drug and Cosmetic Act, and
2. 2.the therapeutic equivalence evaluations for all approved multisource prescription drug prod-
ucts (those pharmaceutical equivalents available from more than one manufacturer).
Currently, multisource products comprise almost 80% of the approximately 10,000

drugs on the Prescription Drug Product List. The therapeutic evaluation for these
products have been prepared to serve as information and advice to state health
agencies, pharmacists and prescribers to promote knowledgeable drug product
selection and to foster containment of health costs.
8.2.7 THERAPEUTIC EQUIVALENCE
Drug products are considered to be therapeutic equivalents if they are pharmaceu-

tical equivalents and if they can be expected to have the same clinical effect when
administered to patients as specified in the labeling (90). In general, the FDA

evaluates as therapeutically equivalent those drug products that satisfy the follow-
ing general criteria:
1. They are approved as safe and effective.
2. They are pharmaceutical equivalents; i.e. they
a. contain identical amounts of the same active ingredient in the same dosage form and route
of administration, and
b. meet compendial and other applicable standards for quality, purity, strength and identity.
3. They are bioequivalent. Bioequivalence may be established by either an in-vivo or in-vitro test,
depending on the drug. If the drug presents a known or potential bioequivalence problem then
an appropriate standard must be met which demonstrates a comparable rate and extent of
absorption.
4. They are adequately labeled.
5. They are manufactured in compliance with Current Good Manufacturing Practice regulations.
The FDA believes that drug products meeting the above criteria are therapeutically
equivalent and can be substituted with the full expectation that the substituted
product will produce the same therapeutic effect as the prescribed product.
8.2.8 THERAPEUTIC EQUIVALENCE EVALUATION CODES-
The FDA uses a two-letter coding system for multisource products. The first letter
in the code allows users to determine whether a particular product has been evalu-
ated therapeutically equivalent to other pharmaceutically equivalent products. The
second letter in the code provides additional information about the basis of FDA's
evaluation. The various categories are summarized in Table 8-17 on page 40.

TABLE 8-17 Therapuetic equivalency codes
"A" Drug Products "B" Drug Products
Drug products the FDA considers to be therapeutically equivalent; i.e. drug Drug products the FDA does not consider to be therapeutically equivalent; i.e.
products for which: drug products for which actual or potential bioequivalence problems have not
1. There are no actual or potential bioequivalence problems. These are been resolved by adequate evidence of bioequivalence. Often the problem is
designated as: with specific dosage forms rather than with the active ingredient. These products
AA Products in conventional dosage forms are classified as "B" for one of three reasons:
AN Solutions and powders for 1. The active ingredients or dosage forms have documented or potential
aerosolization bioequivalence problems, and no adequate studies demonstrating
bioequivalence have been submitted.
AO Injectable oil solutions
2. The quality standards are inadequate or the FDA has insufficient
AP Injectable aqueous solutions
basis to determine therapeutic equivalence.
AT Topical products
3. The drug product is under regulatory review.
2. Actual or potential bioequivalence problems have been resolved via
These products are designated as:
adequate in vivo and/or in vitro tests. These are designated as AB.
BC Controlled-release tablets, capsules and injectables
BD Active ingredients and dosage forms with documented

bioequivalence problems
BE Delayed-release oral dosage forms (e.g. enteric-coated

products)
BN Products in aerosol-nebulizer drug delivery systems
BP Active ingredients and dosage forms with potential

bioequiva-
lence problems
BR Suppositories or enemas that deliver drugs for systemic

absorption
BS Products having drug standard deficiencies
BT Topical products with bioequivalence issues
BX Insufficient data to determine therapeutic equivalence
B* Drug products requiring further FDA investigation and

review to determine equivalence

There are two basic categories into which multisource drugs have been placed, "A"
or "B". Drug products rated "A" are products that the FDA considers to be thera-
peutically equivalent to the pharmaceutically equivalent original product. These
fall into one of two classes:
1. There are no known or suspected bioequivalence problems.
2. Actual or potential bioequivalence problems have been resolved with adequate in vivo and/or in
vitro evidence supporting bioequivalence.
Category "B" consists of drug products that the FDA does not at this time consider
to be therapeutically equivalent to the pharmaceutically equivalent reference prod-
uct. Certain types of products are rated B by virtue of their specialized dosage
forms. For example, controlled-release dosage forms are rated BC, unless
bioequivalence data have been submitted as evidence of equivalence. In this case,
the product would be coded AB.
The fact that a product is in the "B" category does not mean it should not be dis-
pensed; it simply means that a B rated product should not be substituted for a phar-
maceutically equivalent product. For example, glyburide is marketed as
Micronase® and DiaBeta® by two different manufacturers. Both these products
are clinically effective, but because bioequivalence between the two has not been
studied, they are B rated and are not interchangeable.
To avoid possible significant variations among generic drugs as a result of compar-

ison to different reference drugs, the FDA began designating a single reference
listed drug against which all generic versions must be shown to be bioequivalent.
The reference listed drug is identified by the symbol "+" in the Prescription Drug
Product List. This symbol was used for the first time in the 1993 edition of the
Orange Book.
Limitations and Although the Orange Book is a very valuable reference for pharmacists perform-
exclusions- ing drug product selection, it has certain limitations, which must be recognized. It
was not intended to serve as a single comprehensive reference on all multisource
drugs. Many prescription drug products are not listed in the Orange Book, making
evaluation of their therapeutic equivalence difficult, if not impossible. Exclusion
of a drug from the Orange Book means that the FDA has not evaluated its safety,
efficacy and quality. Table 18 lists the classes of products excluded from the
Orange Book. Because the equivalence of these excluded products is unknown,
interchanging of these products should be avoided.

TABLE 8-18 Drug Products excluded from the Orange Book
1. Drugs marketed before the passage of the Federal Food, Drug, and Cosmetic Act of 1938. These are not
included because the FDA has not reviewed these drugs for safety and efficacy and does not have the necessary
information to make therapeutic equivalence evaluations.
Examples: digoxin, morphine, codeine, thyroid, levothyroxine, phenobarbital and nitroglycerin
2. Drugs for which the FDA has no NDA or ANDA on file.

Examples: Anusol-HC®, Naldecon® (and their generic counterparts)
3. Drugs still undergoing Drug Efficacy Study Implementation (DESI) review. These are drugs that were
marketed between 1938 and 1962 on the basis of safety, but not efficacy. Although most of these drugs have
been reviewed and are listed in the Orange Book, there are still a number of these pre-1962 drugs which have
not yet been classified as "effective" under the DESI program, and are not listed.
Examples: nitroglycerin controlled-release capsules, pentaerythritol tetranitrate, isocarboxazid,
hydrocortisone-iodochlorhydroxyquin cream
In addition, nitroglycerin transdermal patches are still undergoing efficacy studies, and are not listed in the
Orange Book.
Another limitation of the Orange Book that all pharmacists should be aware of is
that the drug listings contain the names of only the companies that actually hold an
approved NDA or ANDA; they may not be the same as the actual manufacturer or
distributor. It is fairly common practice for a drug to be manufactured pursuant to
an NDA or an ANDA but distributed under license agreement by another com-
pany. In this instance, the distributor would not be listed in the Orange Book.
Since pharmacists are, understandably, generally unaware of the name of the actual
holder of the NDA or ANDA, it is often difficult for them to determine the thera-
peutic equivalence of a particular multisource product if it is not listed in the
Orange Book. For example, there are over thirty manufacturers and distributors
marketing approved, therapeutically equivalent versions of furosemide 40 mg tab-
lets (154). However, only twelve of these companies are actually listed in the
Orange book, since these are the actual holders of an NDA or ANDA. Therefore,
the pharmacist would have to verify the therapeutic equivalence evaluation of the
non-listed products by obtaining the information from the manufacturer, packager,
or supplier.
Legal status and The Orange Book per se has no legal status. The FDA stresses that it is a source of
pharmacists' information and advice on drug product selection, but it does not mandate the drug
responsibility- products which may be dispensed nor the products that should be avoided. Thus,
the Orange Book does not carry the weight of regulation or law, and the FDA
assumes no liability for drug products selected on the basis of its equivalence eval-
uation.
The Orange Book points out that "FDA evaluation of therapeutic equivalence in no
way relieves practitioners of their professional responsibilities in prescribing and
dispensing such products with due care." There are circumstances where pharma-

cists will have to exercise professional care and sound judgement in selecting a
drug product for a particular patient. Although two products may be rated as being
therapeutically equivalent in the Orange Book, they may not be equally suitable
for a particular patient. Drugs that share the "A" code may still vary in ways that
could affect patient acceptance. They may differ in shape, color, taste, scoring,
configuration, packaging, preservatives, expiration time, and in some instances,
labeling. If products with such differences are substituted for each other, there is
potential for patient confusion or decreased patient acceptance. For example, a
patient may be sensitive to an inert ingredient in one product that another product
does not contain. Or, a patient may become confused if the color or shape of a
product varies from that to which he has become accustomed. A patient may reject
the administration of a substituted product because of differences in taste or
appearance. When such characteristics of a specific product are important in the
treatment of a particular patient, the pharmacist should select a product with these
considerations in mind as well as bioequivalence.
Despite its limitations and shortcomings, the Orange Book is a very useful guide
for rational product selection. Pharmacists can utilize the information presented
there, in combination with sound professional judgment, to make decisions on
behalf of their patients regarding the choice of the most appropriate drug product.

8.3 Drug Product Selection

Multisource drug product selection has become a very important component of
contemporary pharmacy practice. The National Prescription Audit (NPA) has, for
some years now, been chronicling the heightened role played by pharmacists in the
selection of which brand (or generic version) of a multiple-source drug will be dis-
pensed to the patient. From 1983 through 1993, the pharmacist's role in selecting
brand or generic products for dispensing has increased dramatically, as shown in
Table 19. In the first half of 1993, pharmacists controlled 41% of dispensing deci-
sions, as compared to 16% in 1983. It is evident that the substitution trend is
strong and is continuing to gain ground. This expansion of pharmacy's province in
brand choice decisions is the result of several factors: economic pressures for
lower prescription costs, repeal of anti- substitution laws and increased acceptance
of generics by patients, physicians and pharmacists. Perhaps the most significant
factor in escalating the overall level of pharmacists' brand choice decisions has
been the expiration of the patents of high- volume pioneer brands, as previously
discussed. This has resulted in significant expansion in the potential for pharma-
cist choice.
TABLE 8-19 Pharmacist’s Brand Selection
Year Percent of all new prescriptions involving

pharmacists brand choicea
1983 16
1984 18
1985 20
1986 23
1987 25
1988 27
1989 30
1990 32
1991 34
1992 38
Jan.-June 1993 41

8.3.1 CONSIDERATIONS IN SELECTING A MANUFACTURER
The selection of a pharmaceutical manufacturer of a multisource product has

become an important professional responsibility for pharmacists. This responsibil-
ity has become an especially critical part of a pharmacists role in light of the
increasing number of generic products available and in light of some of the prob-
lems that have occurred in the generic drug industry (the "generic drug scandal" of
1989). The pharmacist is entrusted by the public to select manufacturers that offer
the best quality at the best price.
So how does the phar- Thoughtful selection of a multisource drug product is not an easy task, and
macist select the manu- requires a consideration of not only the drug product itself, but also the manufac-
facturer of a multisource turer, and in some cases, the patient. Several options are open to the pharmacist
drug product? What
performing drug product selection: to select a product solely on the basis of eco-
factors should be con-
sidered? nomics, to select a product on the basis of the reputation of the manufacturer, or to
make a decision based on product bioequivalence and quality and on the basis of
the product's conformity with official compendial standards and with those estab-
lished by the FDA. The first option, while offering a financial advantage, does not
provide assurance of therapeutic efficacy. The second option, although subjective,
is easily applied and does offer a degree of security to the pharmacist. The third
option is the most challenging to the pharmacists, requiring the application of prin-
ciples of biopharmaceutics and pharmacokinetics in arriving at a decision. Ideally,
the pharmacist should take into consideration all the above options when selecting
a drug product for a patient.
When pharmacists were asked which factors are most important to them in select-
ing a manufacturer of a generic product, the primary criteria indicated were the
reputation and quality of the company (159-162). Bioequivalence to the
brand-name product was also ranked as being an important factor in product selec-
tion. However, the most frequently used sources for assessing bioequivalence
were manufacturer reputations (based previous experience) and product literature
provided by the distributing company. Company-sponsored material must be care-
fully evaluated. Unfortunately, promotional literature does not generally contain
sufficient data to permit rational analysis of whether or not products are bioequiva-
lent (163). Also, relying on personal methods of information gathering for assess-
ing bioequivalence is not very reliable. Interestingly, only 23% of pharmacists
reported using the Orange Book in assessing bioequivalence (161). Selection of
drug products should be based on sound scientific and clinical grounds. Develop-
ments in the science of pharmacokinetics and the related area of bioavailability
have given pharmacists the tools necessary to make sound choices among multi-
source products. In response to the profession's need for information and advice
on how to select appropriate drug products from multiple sources, the American
Pharmaceutical Association formed a Bioequivalency Working Group to establish
guidelines for product selection (Table 8-20 on page 47) (164). This Group made

recommendations of factors that pharmacists should consider when selecting drug

products to be dispensed to their patients. If pharmacists consider the factors indi-
cated as part of the professional judgement process when making drug product
selections, it is likely that the best interest of the patients will be served.
The appropriate selection of a generic drug product involves much more than just
cost considerations or reliance on state and federal laws and regulations. It
requires a knowledge of the drug entity and its physical and chemical properties,
the condition to be treated, and its significance, and the history and attitude of the
manufacturer. One of the criteria often used to evaluate a manufacturer's record is
the number and type of recalls of that company's products. Product selection may
also require taking into consideration the patient, the disease, previous drug ther-
apy, and duration of therapy before a decision is made. Gagnon presented a
step-by-step analysis procedure that pharmacists can use in evaluating multisource
suppliers of a pharmaceutical product (Table 8-21 on page 49) (165). Using this
procedure, each manufacturer is rated in each area listed, thus enabling the phar-
macist to make the most rational choice.

TABLE 8-20 Guidelines for product selection
DISPENSING DECISIONS
? State Rules and Regulations. Pharmacists should be cognizant of legal requirements that address the issue of drug product selection. Many states have positive or negative
formularies to provide guidance in drug product selection.
? Bioequivalency Information/Orange Book Ratings. Only products with proven bioequivalency should be selected to be dispensed in lieu of the innovator product.
Products that are listed in the FDA's Approved Drug Products and Therapeutic Equivalence Evaluations (the Orange Book) as "A" rated should be selected when such products
are available. For pre-1938 drugs, the selection should be based on data obtained from the literature, because bioequivalency testing is not required by the FDA for these
drug products.
? Dosage Form. The type of dosage form should be considered whenever one drug product is selected from among multisource drug products. This is especially true with
extended or delayed release medications.
? Previous Drug Use. Two questions should be considered regarding previous drug product usage. First, is the prescribed drug a continuation of already successful therapy?
If it is, the impact of any change in source of the medication should be considered. The pharmacist should also know which product the patient was using previously, including
any medications in the hospital if the patient was recently discharged. Second, was the original product dispensed a generic product? If so, preference should be given to
continuing to dispense the same generic product from the same source.
? Patient Status. The pharmacist should consider how well controlled the patient is and how susceptible that patient might be to small changes in drug absorption. If a
patient has labile control or has experienced great difficulty in achieving control, the pharmacist should continue therapy with a product from a single source throughout therapy.
? Diseases. The seriousness of the disease and its potential impact on the patient may influence the pharmacist's willingness to change products.
? Drug Class or Category. Drugs with narrow therapeutic ranges and with known clinically significant bioavailability problems should be substituted with care and/or after
discussion with the prescriber.
? Cost. The cost of the product , while an important consideration, should be a secondary consideration in selecting among products judged by the pharmacist to be
bioequivalent.
? Patient Opinion. An informed patient, cooperating with a physician and pharmacist in his or her drug therapy, is an important element in ensuring the best possible
therapeutic outcomes. The pharmacist should take into account the patient's need when selecting from multisource drug products and inform the patient of any potential
consequences associated with alternate product selections.
PURCHASE DECISIONS
? Current State Laws and Regulations. Some states have positive or negative formulary systems that place regulatory restrictions on the products considered therapeutically
equivalent. The state formulary may not always be in agreement with classifications listed in the FDA's Orange Book. Therefore, pharmacists should be familiar with both.
? Bioequivalency Information/Orange Book. Products shown to be bioequivalent through reference to the Orange Book or other reliable source of bioequivalency
information are preferred. Purchase decisions for drugs marketed prior to 1938 should be based on data obtained from the literature or the manufacturer, because bioequivalency
testing may not be required by the FDA for these drug products.
? Drug Category. Greater attention should be given to purchasing strategies for drug products used for serious or life-threatening diseases and in situations where therapeutic
activity of the product is confined to a narrow range of biologic fluid concentration.
? Availability. A continuous supply from the same manufacturer is essential even in the event that the distributor has changed to ensure that refills of prescriptions will
contain the same product as originally dispensed. However, in those instances when the manufacturer of a generic drug product has to be changed, care should be exercised
to ensure that the new drug product is equivalent to the formerly stocked drug product.
? Supplier's Reputation. The reputation of the manufacturer in terms of its ability to adhere to good manufacturing practices (GMP) that ensure that each dosage form is
manufactured correctly and in a consistent manner is an important consideration. When purchasing a product from a distributor rather than directly from the manufacturer,
the procedure used by that supplier in selecting manufacturers for multisource products is also an important consideration. Establishment Inspection Reports and recall
reports are available from FDA through a Freedom of Information (FOI) request. These are valuable tools in this decision.
? Cost.


TABLE 8-21 Evaluation of Multi-source Suppliers
Factors and Cues
Product Information
• Size(s) available
• Dosage form(s) available
• Bioequivalence data results using Orange Book
• Existence of identification codes on solid dosage forms
• Average number of months between product receipt and expiration date
• Results of cost-effectiveness information from manufacturer
• Complete product literature provided from manufacturer
• Strength(s) available
• State/federal formulary rules, e.g., MAC limits
Economics
• Price(s)
• Deals and other discounts
• Terms of sale
• Clear and equitable pricing policy
• Large sizes available at discount prices
Product Quality
• NDA/ANDA on file at FDA
• Pharmaceutical elegance of products, e.g., broken tablets, powder in bottles
• Less than 3 year FDA on-site inspection
• Results of on-site FDA inspection
• Company willing to allow pharmacist to inspect plant
• Results of quality control analysis
• Company willing to supply samples for testing
• Product acceptance by physicians
• Product acceptance by patients
Service Quality
• Returns policy
• Rapid resolution of complaints
• Company product availability record
• Liability protection policy
• Terms of unconditional guarantee
• Company commitment to education of practitioners
• Availability of company representative
• Existence of 24-hour emergency customer service telephone number
• Product availability through wholesalers
• Ease of placing orders
• Company customer information center, including an 800 number
Company Reputation
• Number of recalls in last 3 years
• Severity of recalls in last 3 years
• Who initiated recalls (FDA or company)
• Company has a recall strategy
• Other regulatory actions against company
• Company has wide product line
• FDA quality assurance profile
• Company has crisis communication strategy

Pharmacists have the responsibility of correctly selecting and dispensing multi-

source products that will have the greatest likelihood of achieving a positive thera-
peutic outcome in a cost-effective manner. The more information pharmacists
have about a product and its manufacturer, the more likely they will be to make the
most appropriate choice. Price cannot be the single factor in selecting a product. It
is also clear, as Joseph Oddis stated, "Rational drug product selection entails far
more than simply consulting the FDA's Orange Book or looking at the price cata-
logue" (166).
8.3.2 SPECIAL CASES
While in most situations selection of drug products that are therapeutically equiva-
lent can be done without undue complications, there are some circumstances
where problems could occur. Depending on the drug, its formulation, the disease
being treated, and the condition of the patient, generic substitution may not be
advisable. Some of these special situations require extra attention and handling by
the pharmacist.
There are a number of drugs that could present problems when interchanged.
Drugs that are poorly water soluble may have inherent problems with rate and
extent of dissolution, resulting in poor or variable bioavailability. Drugs that are
potent and thus present in very low amounts in a dosage form could present prob-
lems due to formulation factors. Some dosage forms may have inherent bioavail-
ability problems, such as controlled-release products. And drugs which are
considered "critical" also need special consideration. "Critical" drugs have been
defined as drugs with a narrow therapeutic range, where a change in plasma con-
centration might result in adverse clinical outcome; drugs that are considered pri-
marily for control of a disease rather than for alleviation of temporary symptoms;
and drugs that have inherent or historical bioavailability or bioequivalence prob-
lems (8, 19). Seven classes of drugs have been identified that have demonstrated
bioequivalence problems or, because of the nature of the product, have the poten-
tial for creating therapeutic problems if product interchange is permitted (Table 8-
22 on page 51) (167-168).

TABLE 8-22 Catagories of drugs with demonstrated bioequivalence problems
Digitalis glycosides
- digoxin
Warfarin anticoagulants
Theophylline products
Thyroid preparations (including levothyroxine)
Conjugated and esterified estrogens
Antiarrhythmic agents
- quinidine salts
- procainamide
Anticonvulsants
- phenytoin
- carbamazepine
- primidone
There have been numerous reports of drugs implicated in therapeutic problems due
to bioinequivalence difficulties. In addition to those in the categories given in
Table 8-22 on page 51, these include furosemide, propranolol, diazepam, pred-
nisone, nitrofurantoin, and amitriptyline (20, 126, 167, 169-180). Although the
documentation implicating these drugs in therapeutic failures due to bioavailabil-
ity problems is primarily anecdotal in nature (and thus disregarded by the FDA),
the performance of these products should still be closely observed and monitored,
and care should be taken when selecting drugs from these categories.
In addition to "critical" drugs, critical patients and critical diseases have also been
identified when special care should be taken in performing product selection (8,
166). Critical patients are the very old and the very young, those suffering from
multiple diseases who are managed with multiple drugs, and those who live alone,
making observation of adverse drug effects unlikely. Critical diseases are gener-
ally chronic in nature and difficult to stabilize, where drug-disease interactions can
present major problems (e.g. congestive heart failure, asthma, diabetes, cardiac
disorders, and psychoses). In all the above special "critical" circumstances, there
is a high risk of therapeutic problems, and product selection requires extra atten-
tion and precautions. In fact, product substitution and interchange in these cases is
generally discouraged. Once a product (brand or generic) has been selected for a
course of therapy, the pharmacist should not change to a different product if it can
be avoided. If interchange is performed, it should be done only with the utmost
care, and the patient should be monitored for any adverse outcomes.

Pharmacist's Drug product selection has been and continues to be a primary and chal-
professional lenging professional responsibility of pharmacists. It is one where the pharmacist
responsibility- must exercise professional care and sound judgement to make decisions on behalf
of the patient to maximize safety and efficacy, while minimizing cost. Pharmacists
have a professional obligation to patients to take whatever steps are necessary to
assure themselves that the medicines they are dispensing are safe and effective.
Although some of this activity is currently constrained by bureaucratic and regula-
tory restrictions that often discourage, or entirely prevent, individual professional
evaluation and initiative, with a greater appreciation and understanding of the sci-
entific, clinical, and regulatory issues that form the basis of the process, pharma-
cists can make decisions that result in better patient care. Pharmacists must take
steps to ensure the quality and integrity of the drug products dispensed to their
patients. To accomplish this, pharmacists must look to pharmaceutical manufac-
turers to supply them with a quality product they can trust. Thus, the manufacturer
of a multisource product must be carefully selected to ensure that the products they
supply are of proper quality. If necessary, pharmacists should conduct independent
research into the reputation and integrity of the manufacturer, or, if products are
purchased through a buying group, should make sure that established policies and
guidelines are in place to review multisource products. When considering pur-
chasing drug products, the pharmacist should request the manufacturer to provide
certain documentation and information, and should then evaluate this information
(see Table 23).
TABLE 8-23 Considerations when evaluating a Multi-Source vendor
1.Willingness to supply requested information

2.Bioavailability and bioequivalence data
3.Dissolution testing results
4.FDA bioequivalence rating
5.The actual manufacturer of the product, if not the supplier
6.FDA inspection reports
7.History of the manufacturer's recall record
8.Willingness of the manufacturer to permit on-site visitations
9.Evaluate economic considerations such as price, shipping, terms, discounts, insurance, return policies, and packagng.
And finally, pharmacists can counsel the patients on the importance of

using the same drug product throughout a course of therapy, even though they
might go to a different pharmacy. To further emphasize this, it has been suggested
that the initial prescription and subsequent refills of a drug product considered
questionable for interchange should contain auxiliary labeling that stresses the
importance of continuing to use that product (167).
Drug product selection is an important professional responsibility, but it is

not an easy task. It requires the pharmacist to use his/her current knowledge, and

all the currently available information in order to arrive at and render a decision
regarding the most appropriate product to use for a specific patient.

8.4 Summary
With the dramatic increase in the availability and utilization of generic drug prod-
ucts in recent years, pharmacists are being faced with an ever-increasing array of
multisource products. Appropriate selection of a product from the plethora of
products on the market is not always an easy task; the quality of the drug product
must be considered, as well as the cost. The principles of biopharmaceutics indi-
cate that the formulation and method of manufacture of a drug product can have a
marked effect on the bioavailability of the active ingredient. Thus, generic equiva-
lents may not necessarily be therapeutically equivalent. Guidelines and criteria
have been established by the FDA to help judge whether one product can be sub-
stituted for another with assurance of equivalent therapeutic effect.
For pharmacists to provide informed product selection, it is essential that

they be knowledgeable about, and familiar with, these guidelines and criteria. This
requires an understanding of bioavailability, bioequivalence, and how they are
determined. The pharmacist can serve a major role in ensuring that only high qual-
ity products are dispensed, and in this way help reduce health care costs without
compromising quality of care.
Acknowledgment The author gratefully acknowledges the assistance of Umesh V. Banakar in the
preparation of this manuscript.

8.4.1 QUESTIONS
1. The term bioavailability refers to the
a. dissolution of a drug in the gastrointestinal tract.
b. amount of drug destroyed in the liver by first-pass metabolism.
c. distribution of drug to the body tissues over time.
d. relationship between the physical and chemical properties of a drug and its systemic
absorption.
e. measurement of the rate and amount of drug that reaches the systemic circulation.
2. The bioavailability of various drug products can be evaluated by comparing their plasma con-
centration-time curves. The three most important parameters of comparison that can be
obtained directly from the curves are
a. biologic half-life (t1/2), absorption rate constant, area under the curve (AUC).
b. time of peak concentration (tmax), absorption rate constant, elimination rate constant.
c. maximum drug concentration (Cmax), time of peak concentration (tmax), duration of action.
d. area under the curve (AUC), time of peak concentration (tmax), maximum drug concentration
(Cmax).
e. rate of elimination, area under the curve (AUC), rate of absorption.
3. Two products are bioequivalent if they

a. contain the same amount of the same active ingredient.
b. have equal areas under the curve after the administration of the same dose.
c. have the same value for Cmax after administration of the same dose.
d. have equivalent rates and extents of absorption of the drug after administration of equal
doses.
e. are pharmaceutically equivalent.
4. If an oral capsule formulation of drug A produces a plasma concentration- time curve having
the same area under the curve (AUC) as that produced by an equivalent dose of drug A given
intravenously, it can generally be concluded that:
a. there is no advantage to the IV route.
b. the absolute bioavailability of the capsule formulation is equal to 1.
c. the capsule formulation is essentially completely absorbed.
d. the drug is very rapidly absorbed.
e. b and c are correct.
5. 5.Which of the following is NOT a criterion for therapeutic equivalence of two products,
according to the FDA?
a. They must be pharmaceutical equivalents.

b. All ingredients - active and inactive - must be the same.

c. They have been manufactured in compliance with Good Manufacturing Practices.
d. They are bioequivalent.
e. They are approved as safe and effective by the FDA.
6. A test oral formulation has the same area under the plasma concentration- time curve as the ref-
erence formulation. This means that the two formulations
a. are bioequivalent by definition.
b. deliver the same total amount of drug to the body but are not necessarily bioequivalent.
c. are bioequivalent if they both meet USP dissolution standards.
d. deliver the same total amount of drug to the body and are, therefore, bioequivalent.
e. have the same rate of absorption.
7. In-vitro dissolution rate studies on drug products are useful in bioavailability evaluations only if
they can be correlated with
a. in-vivo bioavailability studies in humans.
b. the chemical stability of the drug.
c. USP disintegration requirements.
d. in-vivo studies in at least three species of animals.
e. the therapeutic response observed in patients.
8. Which of the following statements regarding bioequivalence is TRUE?

a. If the mean AUC and Cmax values for a generic product are within + 20% of those of the ref-
erence product, the two products are bioequivalent.
b. If we can be 90% certain that the mean values of AUC and Cmax for two products are within
80% to 125% of each other, then the two products are considered bioequivalent.
c. Bioequivalence studies are generally conducted in a panel of patients consisting of the tar-
get population for which the drug is intended.
d. Bioequivalence studies are generally conducted as multiple-dose studies utilizing the
cross-over design.
e. If two products are shown to be bioequivalent, we can always say with certainty that they
will be therapeutically equivalent.

9. 9.Which of the following statements about the FDA Orange Book is TRUE?
a. Drugs that are excluded from the Orange Book are not safe and effective and should not be
dispensed.
b. It contains therapeutic equivalence evaluations for all the drugs approved by the FDA.
c. Products placed in the "B" category should not be dispensed.
d. The Orange Book is an official compendium, and pharmacists can legally only dispense
those products listed as bioequivalent.
e. The drug listings contain the names of only the companies that actually hold an approved
NDA or ANDA for a drug.
10. 10.Growth in the utilization of generic drug products can be attributed to

a. passage of the 1984 Waxman-Hatch Act.
b. expiration of patents of many popular brand products.
c. pressures to reduce health care costs.
d. the growth of managed health care organizations.
e. all of the above.
8.4.2 ANSWERS TO QUESTIONS
1. e
2. d
3. d
4. e
5. b
6. b
7. a
8. b
9. e
10. e

8.5 Bioavailibility Equations

The following set of equations were used to solve the bioavailability problem set.
The problem sets for the first two drugs have been done for you. The others are
done exactly the same way. The answers follow the problems.
AUMC iv
1. MRT iv = --------------------- as discussed in chapter 4.
AUC iv
1
2. k = ---------------
-
MRT iv
3. ln 2
t 1 ⁄ 2 = --------
k
4. Cp 0iv = AUC ⋅ k
Dose iv
5. Vd = ----------------
-
Cp 0iv
– kt
6. Cp iv = Cp 0 e
AUC oral Dose iv

7. f = --------------------- ⋅ -----------------
Dose oral AUC iv
AUMC po
8. MRT po = ----------------------
- as discussed in chapter 4
AUC po
9. MAT po = MRT po – MRT iv
1
10. k a = ------------
MAT
k
ln  ----a-
k
11. t p = ----------------
ka – k

ka – kt –k t
12. Cp max = fD
------ ⋅ ------------- ⋅ (e p – e a p )
V ka – k
( AUC generic ) ⁄ ( Dose generic )

14. Relative Bioavailability (R.B. or C.B.) = ---------------------------------------------------------------------
-
( AUC Brand ) ⁄ ( Dose Brand )
15. Bioequivalent: Yes if all three:
0.80 < CB < 1.25
t p generic
0.80 < -------------- < 1.25
tp brand
C p max –g eneric
0.80 < -----------------------
- < 1.25
C p max – b rand

8.6 Problems

Caffeine (Problem 8 - 1)
Problem Submitted By: Maya Leicht AHFS 00:00.00
Problem Reviewed By: Vicki Long GPI: 0000000000
Aramaki, S., et al., "Pharmacokinetics of caffeine and its metabolites in horses after intravenous, intramuscular, or oral adminis-
tration", Chem Pharm Bull, Vol. 30, No. 11, (1991), p. 2999 - 3002.
This study deals with the pharmacokinetics of caffeine. Caffeine doses of 2.5 mg/kg were administered both intrave-
nously and orally to horses with an average weight of about 500 kg. A summary of the some of data obtained from this
experiment is given below. Fill in the empty cells.
TABLE 8-24 Caffeine
Parameter IV Oral Solution Brand Tablet Generic Tablet Bioequivalence

Dose (mg/kg) 2.5 2.5 2.5 2.5
63.1 60.7 60 57
AUC  -------- ⋅ hr
ug
 mL 
1442 1556.8 1600 1723

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
 mL
Vd (L)
Cp at 1 hour  --------
ug
 mL
Cpmax  -------
ug-
 mL
Tmax (hr)
Relative Bioavailability
Generic Equivalent (Yes / No)

Cefetamet Pivoxil (Problem 8 - 2)

Ducharme, M., et. al., "Bioavailability of syrup and tablet formulations of cefetamet pivoxil", Antimicrobial Agents and Chemo-
therapy, Vol. 37, No. 12, (1993), p. 2706 - 2709.
Cefetamet pivoxil is a prodrug of cefetamet. This study compares the bioavailability of cefetamet pivoxil in tablet
form versus syrup form. A summary of the some of data obtained from this experiment is given below. Fill in the
approprate cells.
.

Dose (mg) 250 500 500 500
30.64 53.68 50 47
AUC  -------- ⋅ hr
ug
 mL 
101.66 191.64 205.6 225.3

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
 mL
Vd (L)
Cp at 1 hour  --------
ug
 mL
Cpmax  -------
ug-
 mL
Tmax (hr)

Cefixime (Problem 8 - 3)
Faulkner, R. ,et al., "Absolute bioavailability of cefixime in man", Journal of Clinical Pharmacology, Vol. 28 (1988), p. 700 - 706.
Cefixime is a broad-spectrum cephalosporin which is active against a variety of gram positive and gram nega-
tive bacteria. In this study, sixteen subjects each received a 200 mg intravenous dose and then a 200 mg capsule with a
washout period between the administration of each dosage form. A summary of the some of data obtained from this
experiment is given below.
From the preceding data, please calculate the following:
Parameter IV Brand Capsule Generic Capsule Bioequivalence

Dose (mg) 200 200 200
47 23.6 20.2
AUC  -------- ⋅ hr
ug
 mL 
183.3 162.8 187.5

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
 mL
Vd (L)
Cp at 1 hour  -------
ug-
 mL
Cpmax  --------
ug
 mL
Tmax (hr)

Ceftibuten (Problem 8 - 4)
"The pharmacokinetics of ceftibuten in humans"
Ceftibuten is a new oral cephalosporin with potent activity against enterobacteriaceae and certain gram posi-
tive organisms. In this study two groups received either a 400 mg oral dosage form of ceftibuten or a 200 mg iv bolus
dose of ceftibuten. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 200 400 400 400
75.2 65.9 64.2 64
AUC  -------- ⋅ hr
ug
 mL 
211.2 213.4 220 208

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
 mL
Vd (L)
Cp at 1 hour  --------
ug
 mL
Cpmax  --------
ug
mL
Tmax (hr)

Cimetidine (Problem 8 - 5)
Sandborn, W., et al., "Pharmacokinetics and pharmacodynamics of oral and intravenous cimetidine in seriously ill patients", Jour-
nal of Clinical Pharmacology, Vol. 30, (1990), p. 568 - 571.
Cimetidine is a histamine receptor antagonist which is used in the treatment of gastric and duodenal ulcer dis-
ease. In this study, patients received 300 mg of cimetidine as an iv bolus on the first day and data was collected. On
the second day, the patients received 300 mg orally and data was collected. A summary of the some of data obtained
from this experiment is given below.
Parameter IV Brand Tablet Generic Tablet Bioequivalence

Dose (mg) 300 300 300
3.81 2.48 2.50
AUC  -------- ⋅ hr
ug
 mL 
5.33 11.73 10.73

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
 mL
Vd (L)
Cp at 1 hour  --------
ug
 mL
Cpmax  --------
ug
mL
Tmax (hr)

Diurnal Variability in Theophylline Bioavailability (Problem 8 - 6)

Bauer, L., Gibaldi, M., and Vestal, R., "Influence of pharmacokinetic diurnal variation on bioavailability estimates", Clinical Phar-
macokinetics, vol. 9, (1984), p. 184 - 187.
This article discusses the effects of diurnal variation on the bioavailability and clearance of theophylline. In
this study patients received a 500 mg dose every 12 hours either orally or by iv bolus. A summary of the some of data
obtained from this experiment for the time period between midnight and noon is given below.

Dose (mg) 500 500 500 500
160.25 144.58 140 144
AUC  -------- ⋅ hr
ug
 mL 
1821 1662 1785 1700

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
 mL
Vd (L)
Cp at 1 hour  --------
ug
 mL
Cpmax  --------
ug
mL
Tmax (hr)

cis-5-Fluoro-1-[2-Hydroxymethyl-1,3-Oxathiolan-5-yl] Cytosine
(FTC) (Problem 8 - 7)
Frick, L. , et al., "Pharmacokinetics, oral bioavailability, and metabolic disposition in rats of (-)-cis-5-Fluoro-1-[2-Hydroxyme-
thyl-1,3-Oxathiolan-5-yl] Cytosine, a nucleoside analog active against human immunodeficiency virus and hepatitis B virus", Anti-
microbial Agents and Chemotherapy, Vol. 37, No. 11, (1993), p. 2285 - 2292.
FTC is a 2',3'-didoexynucleoside analog that may be useful against HIV and HBV. In this study, rats with an
average weight of 270 g were given either iv or oral doses of 100 mg/kg. A summary of the some of data obtained

Dose (mg/kg) 100 100 100
265 168 175
AUC  -------- ⋅ hr
ug
 mL 
19514 12600 13125

AUMC  -------- ⋅ hr 
ug 2
mL
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
mL
Vd (L)
Cp at 1 hour  --------
ug
 mL
Cpmax  -------
ug-
 mL
Tmax (hr)

Hydromorphone (Problem 8 - 8)
Vallner, J., et al., "Pharmacokinetics and bioavailability of hydromorphone following intravenous and oral administration to
human subjects", Journal of Clinical Pharmacology, Vol. 21, (1981), p. 152 - 156.
Hydromorphone hydrochloride is an analog of morphine which has about seven times the effect of morphine
when given intravenously. In this study, volunteers were given a 2 mg intravenous dose and a 4 mg oral dose of hydro-
morphone on separate days. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 2 4 4
83 87.2 96
AUC  ------ ⋅ hr
ug
L 
289.4 401 432

AUMC  ------ ⋅ hr 
ug 2
L 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  ------
ug
 L
Vd (L)
Cp at 1 hour  ------
ug
 L
Cpmax  ug
------
 L
Tmax (hr)

Isosorbide Dinitrate (Problem 8 - 9)

Straehl, P. and Galeazzi, R., "Isosorbide dinitrate bioavailability , kinetics, and metabolism", Clinical Pharmacology and Thera-
peutics, Vol. 38m (1985), p. 140 - 149.
Isosorbide dinitrate is used in the treatment of angina pectoris, vasospastic angina, and congestive heart failure.
In this study volunteers received a 5 mg intravenous dose given over 5 minutes and a 10 mg tablet. The different dos-
age forms were separated by a washout period. A summary of the some of data obtained from this experiment is given
below.

Dose (mg/kg) 5 10 10
370.3 158 165
AUC  ug
------ ⋅ hr
L 
487 310 305

AUMC  ug
------ ⋅ hr 
2
L 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  ------
ug
 L
Vd (L)
Cp at 1 hour  ug
------
 L
Cpmax  ------
ug
 L
Tmax (hr)

Ketanserin (Problem 8 - 10)

Kurowski, M., "Bioavailability and pharmacokinetics of ketanserin in elderly subjects", Journal of Clinical Pharmacology, Vol. 28,
(1988), p. 700 - 706.
Ketanserin is a 5-hydroxytryptamine S2-antagonist. This study focuses on the kinetics of Ketanserin in the
elderly. Subjects were given either a 10 mg intravenous dose or a 40 mg oral tablet. A summary of the some of data
obtained from this experiment is given below.

Dose (mg) 10 40 40
247 520 400
AUC  -------- ⋅ hr
ng
 mL 
3991 8922 8922

AUMC  -------- ⋅ hr 
ng 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ng
 mL
Vd (L)
Cp at 1 hour  --------
ng
 mL
Cpmax  --------
ng
mL
Tmax (hr)

Methotrexate (Problem 8 - 11)

Seideman, P., et al., " The pharmacokinetics of methotrexate and its 7-hydroxy metabolite in patients with rheumatoid arthritis",
British Journal of Clinical Pharmacology, 35 (1993), p. 409 - 412.
The drug Methotrexate is a folic acid which has been shown to inhibit dihydrofolate reductase. The impor-
tance of this drug at present is mostly seen in the area of oncology, but lately it has been used for rheumatoid arthritis.
Methotrexate has a molecular weight of 454.4. In this study, the drug was administered both by IV bolus and orally as
a 15 mg dose. The following data was obtained:

Dose (mg) 15 15 15
2752 2708 2700
AUC  nmole
---------------- ⋅ hr
 L 
15887 18400 18500

AUMC  nmole
---------------- ⋅ hr 
2
 L 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  ----------------
nmole
 L 
Vd (L)
Cp at 1 hour  nmole
----------------
 L 
Cpmax  ----------------
nmole
 L 
Tmax (hr)

Moclobemide (Problem 8 - 12)

Schoerlin, M. et al., "Disposition kinetics of moclobemide, a new MAO-A inhibitor, in subjects with impaired renal function", Jour-
nal of Clinical Pharmacology, Vol. 30 (1991), p. 272 - 284.
Moclobemide is an antidepressant agent that reversibly inhibits the A-isozyme of the monoamine oxidase
enzyme system. In this study, single IV and oral doses were administered to a patient. A summary of the some of data

Dose (mg) 150 100 100
2.58 1.70 1.52
AUC  -------- ⋅ hr
ug
 mL 
6.35 5.91 5.90

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
 mL
Vd (L)
Cp at 1 hour  --------
ug
 mL
Cpmax  --------
ug
mL
Tmax (hr)

Nalbuphine (Problem 8 - 13)

Nalbuphine hydrochloride is an agonist-antagonist opiod which is used for its analgesic actions. In this study,
volunteers were given single doses of four different nalbuphine forms. The data below focuses on a 10 mg iv dose and
a 45 mg dose of an oral solution. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 10 45 40 40
86.9 70.3 62.5 60
AUC  -------- ⋅ hr
ng
 mL 
288 306 280 270

AUMC  -------- ⋅ hr 
ng 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ng
 mL
Vd (L)
Cp at 1 hour  --------
ng
 mL
Cpmax  --------
ng
mL
Tmax (hr)

Nefazodone (Problem 8 - 14)

Shukla, U. et al., "Pharmacokinetics, absolute bioavailability, and disposition of nefazodone in the dog", Drug Metabolism and
Disposition, Vol. 21, No. 3, (1993), p. 502 - 507.
Nefazodone was given to four healthy, adult, male beagles with an average weight of 11.0 kg. Each dog was
given a 10 mg/kg dose as a either a intravenous injection or as an oral solution or tablet. A summary of the some of
data obtained from this experiment is given below.

Dose (mg/kg) 10 10 10 10
6023 829 800 700
AUC  -------- ⋅ hr
ng
 mL 
29283 4875 4800 4500

AUMC  -------- ⋅ hr 
ng 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ng
 mL
Vd (L)
Cp at 1 hour  --------
ng
 mL
Cpmax  --------
ng
mL
Tmax (hr)

Ondansetron (Problem 8 - 15)

Colthup, P., et al., "Determination of ondansetron in plasma and its pharmacokinetics in the young and elderly", Journal of Phar-
maceutical Sciences, Vol. 80, No. 9(1991), p. 868 - 871.
Ondansetron is a 5-hydroxyltryptamine compound which is useful in treating the nausea and vomiting which is
caused by the use of chemotherapy and radiation in the cancer patients. In order to determine the absolute bioavailabil-
ity of oral Ondansetron, doses of 8 mg were given to two groups. One group received an oral dose and the other group
received an intravenous dose. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 8 8 8
246.5 139 145
AUC  -------- ⋅ hr
ng
 mL 
1138 795 870

AUMC  -------- ⋅ hr 
ng 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ng
 mL
Vd (L)
Cp at 1 hour  --------
ng
 mL
Cpmax  --------
ng
mL
Tmax (hr)

Omeprazole (Problem 8 - 16)

Anderson, T., et al, "Pharmacokinetics of various single intravenous and oral doses of omeprazole", Eur Journal of Clinical Phar-
macology, 39, (1990), p. 195 - 197.
Omeprazole (mw: 345.42) is an agent which inhibits gastric acid secretion from the parietal cell. It is useful in
treating such problems as ulcers and gastroesophageal reflux disease. One group received an iv bolus dose and the
other group received an oral dose. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 20 40 40
µmole 3.2 3.5 3.0

AUC  ---------------- ⋅ hr
 L 
µmole 3.2 5.25 4.5

AUMC  ---------------- ⋅ hr 
2
 L 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
µmole
Cp0  ----------------
 L 
Vd (L)
µmole
Cp at 1 hour  ----------------
 L 
µmole
Cpmax  ----------------
 L 
Tmax (hr)

Paroxetine (Problem 8 - 17)

Lund, J., et al., "Paroxetine: pharmacokinetics and cardiovascular effects after oral and intravenous single doses in man", Journal
of Pharmacology and Toxicology, Vol. 51, (1982), p. 351 - 357.
Paroxetine kinetics and cardiovascular effects were studied in male subjects after single oral doses of 45 mg
and slow intravenous infusion of 23 - 28 mg. A summary of the some of data obtained from this experiment is given
below.

Dose (mg) 28 45 45
467 750 675
AUC  -------- ⋅ hr
ng
 mL 
6671 11250 10463

AUMC  -------- ⋅ hr 
ng 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ng
 mL
Vd (L)
Cp at 1 hour  --------
ng
 mL
Cpmax  -------
ng-
 mL
Tmax (hr)

Ranitidine (Problem 8 - 18)

Garg, D., et al., "Pharmacokinetics of ranitidine in patients with renal failure", Journal of Clinical Pharmacology, Vol. 26 (1986),
p. 286 - 291.
Ranitidine is an agent used in the treatment of peptic ulceration. In this study, ten patients with renal failure
received either a 50 mg intravenous bolus dose or a 150 mg tablet. A summary of the some of data obtained from this

Dose (mg) 50 150 150
5159 6422 6753
AUC  -------- ⋅ hr
ng
 mL 
53415 78752 84413

AUMC  -------- ⋅ hr 
ng 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ng
 mL
Vd (L)
Cp at 1 hour  --------
ng
 mL
Cpmax  --------
ng
mL
Tmax (hr)

Sulpiride (Problem 8 - 19)

Bressolle, F., Bres, J., and Faure-Jeantis, A., "Absolute bioavailability , rate of absorption, and dose proportionality of sulpiride in
humans", Journal of Pharmaceutical Sciences ,Vol. 81, No. 1 (1992), p. 26 - 32.
Sulpiride is a substituted benzamine antipsychotic. In this study, the drug was administered to two groups.
The first group received a 200 mg oral dose and the second group received a 100 mg intravenous infusion. A summary
of the some of data obtained from this experiment is given below.

Dose (mg) 100 200 200 200
8.27 8.79 8.6 8.0
AUC  -------- ⋅ hr
ug
 mL 
79.1 87.3 91.1 84.5

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr)
MAT (hr)
ke (hr-1)
ka (hr-1)
Cp0  --------
ug
 mL
Vd (L)
Cp at 1 hour  --------
ug
 mL
Cpmax  --------
ug
mL
Tmax (hr)

8.7 Solutions
8.7.1 “CAFFEINE” ON PAGE 61

Aramaki, S., et al., "Pharmacokinetics of caffeine and its metabolites in horses after intravenous, intramuscular, or oral adminis-
tration", Chem Pharm Bull, Vol. 30, No. 11, (1991), p. 2999 - 3002.
This study deals with the pharmacokinetics of caffeine. Caffeine doses of 2.5 mg/kg were administered both intrave-
nously and orally to horses with an average weight of about 500 kg. A summary of the some of data obtained from this
experiment is given below. Fill in the empty cells.
TABLE 8-25 Caffeine

Dose (mg/kg) 2.5 2.5 2.5 2.5
63.1 60.7 60 57
AUC  -------- ⋅ hr
ug
 mL 
1442 1556.8 1600 1723

AUMC  -------- ⋅ hr 
ug 2
 mL 
MRT (hr) 22.9 25.7 26.7 30.2

MAT (hr) 2.79 3.81 7.36
ke (hr-1) 0.0438
ka (hr-1) 0.358 0.262 0.136

2.76
Cp0  --------
ug
 mL
V d (L/kg) 0.91
2.64 0.78 0.59 0.31
Cp at 1 hour  -------
ug-
 mL
f 0.96 0.95 .90

2.76 1.98 1.83 1.45 0.79
Cpmax  --------
ug
 mL
Tmax (hr) 6.69 8.19 12.1 1.5

Relative Bioavailability 0.95
Generic Equivalent (Yes / No) NO

2
⋅ h-
1442ug ---------------
MRT = AUMC mL
1. ------------------ = ---------------------------- = 22.9 hours
AUC 2
⋅ h-
63.1ug ---------------
mL
1 = -------------
1 = 0.044 h – 1
2. k = ------------
MRT 22.9h
ln 2 = 0.693
3. t 1 ⁄ 2 = -------- --------------------- = 15.75h
k –1
0.044h
⋅ h ⋅ 0.0044h – 1 = 2.76 -------
Cp 0 = AUC ⋅ k = 63.1 ug ug-
4. -------------
mL mL
5. The horses have an average weight of 500 kg.
Dose = 2.5 mg
------- ⋅ 500kg = 1250mg
kg
ug- = 2.78 mg
Cp 0 = 2.78 ------- -------
mL L
2.5mg ⁄ kg = 0.91 -----

Vd = Dose 1250mg- = 449.6L = ------------------------- L-
------------- = -------------------
Cp 0 mg mg kg
2.78 ------- 2.78-------
L L
=  2.78 -------
– kt ug- ( e – 0.044 ( 1 ) ) = 2.64 -------
ug-
6. Cp = Cp0 e
mL mL
⋅h
AUC oral Dose iv 60 ug ------------- 2.5 mg -------
mL kg = 0.95
7. f = --------------------- ⋅ ----------------- = -------------------- ⋅ ------------------------
Dose oral AUC iv ⋅h
2.5 mg ------- 63.1ug -------------
kg mL
2
ug ⋅ h -
1556.8 ---------------
= AUMC mL - = 25.7h
8. MRT po ------------------ = --------------------------------
AUC ug ⋅h
60.7-------------
mL
Where AUMC is that which is given for the oral dose.
Where AUC is that which is given for the oral dose.
9. MAT po = MRT po – MRT iv = 25.7h – 22.9h = 2.79h

10.
1 = ---------
k a = ------------ 1 - = 0.358hr – 1
MAT 2.79
 0.358hr – 1
k
ln  -----
a ln  ------------------------
k  0.044h
–1

11. tp = ---------------- = ------------------------------------------------------ = 6.7hr
ka – k –1 –1
0.358hr – 0.044hr
–1
fD ka – ktp katp 0.96 ⋅ 1250mg 0.358hr –( 0.044 ⋅ 6.7 ) – ( 0.358 ⋅ 6.7 )
12. Cp max = ------ ⋅ -------------- ⋅ ( e –e ) = ----------------------------------- ⋅ ------------------------------------------------- ⋅ ( e ⋅e )
V ka – k 449L –1
( 0.358 – 0.044 )hr
generic ( AUC ) ⁄ ( Dose

generic )
-
 57  -------
ug- ⋅ hr  ⁄  2.5 mg -------
  mL    km
CB = ------------------------------------------------------------- = 0.95
 60  -------
ug    mg
  mL- ⋅ hr  ⁄  2.5 ------- km
14. Bioequivalent: Yes if all three = Yes:
0.80 < CB < 1.25 CB = 0.95 = Yes
t p generic t p generic
0.80 < -------------- < 1.25 -------------- = 12.1hr
---------------- = 1.5 = NO
tp brand t pbrand 8.19hr
ug-
C p max –g eneric C p max –g eneric 1.45 -------
mL- = 0.79 = NO
0.80 < -----------------------
- < 1.25 ------------------------ = ------------------
C p max – b rand C p max –b rand ug-
1.83 -------
mL

8.7.2 “CEFETAMET PIVOXIL” ON PAGE 62

Ducharme, M., et. al., "Bioavailability of syrup and tablet formulations of cefetamet pivoxil", Antimicrobial Agents and Chemo-
therapy, Vol. 37, No. 12, (1993), p. 2706 - 2709.
Cefetamet pivoxil is a prodrug of cefetamet. This study compares the bioavailability of cefetamet pivoxil in tablet
form versus syrup form. A summary of the some of data obtained from this experiment is given below. Fill in the
approprate cells.
.

Dose (mg) 250 500 500 500
30.64 53.68 50 47
AUC  -------
ug- ⋅ hr
 mL 
101.66 191.64 205.6 225.3

AUMC  -------
ug- ⋅ hr 2
 mL 
MRT (hr) 3.32 3.57 4.11 4,79

MAT (hr) 0.252 0.794 1.48
ke (hr-1) 0.301
ka (hr-1) 3.97 1.26 0.678

9.23
Cp0  --------
ug
 mL
Vd (L) 27.1
6.83 12.62 9.03 5.91
Cp at 1 hour  -------
ug-
 mL
f 0.88 0.82 0.77

9.23 13.1 9.6 7.4 0.77
Cpmax  --------
ug
 mL
Tmax (hr) 0.70 1.49 2.15 1.44

2
mg ⋅ h
101.66 -----------------
MRT = AUMC L
1. ------------------ = ---------------------------------- = 3.32 hours
AUC 2
mg ⋅ h
30.64 -----------------
L
Where AUMC is that which is given for the intravenous dose.
Where AUC is that which is given for the intravenous dose.

1 1 –1
2. k = ------------ = ------------- = 0.301 h
MRT 3.32h
ln 2 = ---------------------
0.693 = 2.3h
3. t 1 ⁄ 2 = --------
k –1
0.301h
⋅ h- ⋅ 0.301h – 1 = 9.22 mg
4. Cp 0 = AUC ⋅ k = 30.64 mg
-------------- -------
L L
V d = Dose 250mg
5. ------------- = ------------------ = 27.06L
Cp 0 9.24mg -------
L
=  9.24 mg
------- ( e
– 0.301 ( 1 )
) = 6.84mg
– kt
6. Cp = Cp 0 e -------
L L
⋅ h-
AUC oral Dose iv 53.68mg --------------
7.
L - ⋅ ----------------------------
f = --------------------- ⋅ ----------------- = ---------------------------- 250mg - = 0.876
Dose oral AUC iv 500mg ⋅ h-
30.64 mg --------------
L
2
mg ⋅ h
191.64 -----------------
= AUMC L
8. MRT po ------------------ = ---------------------------------- = 3.57h
AUC mg ⋅ h
53.68 ---------------
L
Where AUMC is that which is given for the oral dose.
Where AUC is that which is given for the oral dose.
9. MAT po = MRT po – MRT iv = 3.57h – 3.32h = 0.252hr
1 = ------------
1 - = 3.97hr – 1
10. k a = ------------
MAT 0.252
 4.0h – 1 
k
ln  ----a-
ln  --------------------- 
k  0.301h – 1
11. t p = ---------------- = ------------------------------------------- = 0.7h
ka – k –1 –1
4.0h – 0.301h
–1
12. Cp max = fD ka ⋅ ( e – kt – e –k a t ) = 0.88
------ ⋅ -------------- ( 500mg ) ⋅ ---------------------------------------------
-------------------------------- 3.97hr - ⋅ (e
– 0.301 ( 0.7 )
–e
– 3.97 ( 0.7 )
) = 13.1mg
-------
V ka – k 27.1L –1 L
( 3.97 – 0.301 )hr
generic ( AUC ) ⁄ ( Dose

generic )
-

 47  -------
ug 
  mL- ⋅ hr  ⁄ 500mg
CB = -------------------------------------------------------- = 0.94
 50  -------
ug 
  mL- ⋅ hr  ⁄ 500mg
14. Bioequivalent: Yes if all three = Yes:
0.80 < CB < 1.25 CB = 0.94 = Yes
t p generic t p generic
0.80 < -------------- < 1.25 -------------- = 2.15hr
---------------- = 1.44 = NO
tp brand t pbrand 1.49hr
ug-
C p max –g eneric C p max – g eneric 7.4 -------
0.80 < -----------------------
- < 1.25 mL
------------------------ = ---------------- = 0.77 = NO
C p max – b rand C p max– b rand ug-
9.6 -------
mL

8.7.3 “CEFIXIME” ON PAGE 63

Faulkner, R. ,et al., "Absolute bioavailability of cefixime in man", Journal of Clinical Pharmacology, Vol. 28 (1988), p. 700 - 706.
Cefixime is a broad-spectrum cephalosporin which is active against a variety of gram positive and gram nega-
tive bacteria. In this study, sixteen subjects each received a 200 mg intravenous dose and then a 200 mg capsule with a
washout period between the administration of each dosage form. A summary of the some of data obtained from this

Dose (mg) 200 200 200
47 23.6 20.2
AUC  -------- ⋅ hr
ug
 mL 
183.3 162.8 187.5

AUMC  -------- ⋅ hr 
ug 2
mL
MRT (hr) 3.9 6.9 9.3

MAT (hr) 3.0 5.38
ke (hr-1) 0.256
ka (hr-1) 0.334 0.186

12.1
Cp0  --------
ug
mL
Vd (L) 16.6
9.3 1.5 0.77
Cp at 1 hour  --------
ug
 mL
f 0.50 0.43
12.1 2.5 1.6 0.64
Cpmax  -------
ug-
 mL
Tmax (hr) 3.4 4.6 1.33


8.7.4 “CEFTIBUTEN” ON PAGE 64

"The pharmacokinetics of ceftibuten in humans"
Ceftibuten is a new oral cephalosporin with potent activity against enterobacteriaceae and certain gram posi-
tive organisms. In this study two groups received either a 400 mg oral dosage form of ceftibuten or a 200 mg iv bolus
dose of ceftibuten. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 200 400 400 400
75.2 65.9 64.2 64
AUC  -------
ug- ⋅ hr
 mL 
211.2 213.4 220 208

AUMC  -------
ug- ⋅ hr 2
 mL 
MRT (hr) 2.94 3.24 3.43 3.25

MAT (hr) 0.297 0.485 0.309
ke (hr-1) 0.390
ka (hr-1) 3.37 2.06 3.24

25.6
Cp0  -------
ug-
 mL
Vd (L) 7.8
18.2 16.9 15.3 16.4
Cp at 1 hour  --------
ug
 mL
f 0.44 0.42 0.43

25.6 17.3 15.3 16.7 1.09
Cpmax  --------
ug
 mL
Tmax (hr) 0.76 1.05 0.78 0.74

Relative Bioavailability 1

8.7.5 “CIMETIDINE” ON PAGE 65

Sandborn, W., et al., "Pharmacokinetics and pharmacodynamics of oral and intravenous cimetidine in seriously ill patients", Jour-
nal of Clinical Pharmacology, Vol. 30, (1990), p. 568 - 571.
Cimetidine is a histamine receptor antagonist which is used in the treatment of gastric and duodenal ulcer dis-
ease. In this study, patients received 300 mg of cimetidine as an iv bolus on the first day and data was collected. On
the second day, the patients received 300 mg orally and data was collected. A summary of the some of data obtained

Dose (mg) 300 300 300
3.81 2.48 2.50
AUC  -------
ug- ⋅ hr
 mL 
5.33 11.73 10.73

AUMC  -------
ug- ⋅ hr 2
 mL 
MRT (hr) 1.40 4.73 4.29

MAT (hr) 3.33 2.89
ke (hr-1) 0.715
ka (hr-1) 0.300 0.346

2.72
Cp0  -------
ug-
 mL
Vd (L) 110
1.33 0.32 0.37
Cp at 1 hour  --------
ug
 mL
f 0.65 0.66
2.72 0.40 0.44 1.1
Cpmax  --------
ug
 mL
Tmax (hr) 2.1 2.0 0.94

Relative Bioavailability 1
Generic Equivalent (Yes / No) YES

8.7.6 “DIURNAL VARIABILITY IN THEOPHYLLINE BIOAVAILABILITY”

ON PAGE 66
Bauer, L., Gibaldi, M., and Vestal, R., "Influence of pharmacokinetic diurnal variation on bioavailability estimates", Clinical Phar-
macokinetics, vol. 9, (1984), p. 184 - 187.
This article discusses the effects of diurnal variation on the bioavailability and clearance of theophylline. In
this study patients received a 500 mg dose every 12 hours either orally or by iv bolus. A summary of the some of data
obtained from this experiment for the time period between midnight and noon is given below.

Dose (mg) 500 500 500 500
160.25 144.58 140 144
AUC  -------
ug- ⋅ hr
 mL 
1821 1662 1785 1700

AUMC  -------
ug- ⋅ hr 2
 mL 
MRT (hr) 11.40 11.50 12.75 11.8

MAT (hr) 0.13 1.39 0.44
ke (hr-1) 0.088
ka (hr-1) 7.58 0.721 2.26

14.1
Cp0  -------
ug-
 mL
Vd (L) 35.5
12.9 11.8 6.02 10.7
Cp at 1 hour  --------
ug
 mL
f 0.90 0.87 0.90

14.1 12.1 9.20 11.1 1.21
Cpmax  --------
ug
 mL
Tmax (hr) .059 3.3 1.5 0.45


8.7.7 “CIS-5-FLUORO-1-[2-HYDROXYMETHYL-1,3-OXATHIOLAN-5-YL]
CYTOSINE (FTC)” ON PAGE 67
Frick, L. , et al., "Pharmacokinetics, oral bioavailability, and metabolic disposition in rats of (-)-cis-5-Fluoro-1-[2-Hydroxyme-
thyl-1,3-Oxathiolan-5-yl] Cytosine, a nucleoside analog active against human immunodeficiency virus and hepatitis B virus", Anti-
microbial Agents and Chemotherapy, Vol. 37, No. 11, (1993), p. 2285 - 2292.
FTC is a 2',3'-didoexynucleoside analog that may be useful against HIV and HBV. In this study, rats with an
average weight of 270 g were given either iv or oral doses of 100 mg/kg. A summary of the some of data obtained

Dose (mg/kg) 100 100 100
265 168 175
AUC  -------
ug- ⋅ hr
 mL 
19514 12600 13125

AUMC  -------
ug- ⋅ hr 2
 mL 
MRT (hr) 73.6 75 75

MAT (hr) 1.36 1.36
ke (hr-1) .0136
ka (hr-1) 0.734 0.734

3.6
Cp0  -------
ug-
 mL
Vd (L/kg) 27.7
3.55 1.18 1.23
Cp at 1 hour  --------
ug
 mL
f 0.63 0.66
3.6 2.1 2.2 1.04
Cpmax  --------
ug
 mL
Tmax (hr) 5.54 5.54 1.0


8.7.8 “HYDROMORPHONE” ON PAGE 68

Vallner, J., et al., "Pharmacokinetics and bioavailability of hydromorphone following intravenous and oral administration to
human subjects", Journal of Clinical Pharmacology, Vol. 21, (1981), p. 152 - 156.
Hydromorphone hydrochloride is an analog of morphine which has about seven times the effect of morphine
when given intravenously. In this study, volunteers were given a 2 mg intravenous dose and a 4 mg oral dose of hydro-
morphone on separate days. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 2 4 4
83 87.2 96
AUC  ------ ⋅ hr
ug
L
289.4 401 432
AUMC  ug
------ ⋅ hr 
2
L 
MRT (hr) 3.49 4.60 4.50

MAT (hr) 1.11 1.03
ke (hr-1) 0.287
ka (hr-1) 0.899 0.987

23.8
Cp0  ------
ug
 L
Vd (L) 84
17.9 12.6 14.7
Cp at 1 hour  ug
------
 L
f 0.53 0.56
23.8 14.6 16.6 1.13
Cpmax  ------
ug
 L
Tmax (hr) 1.87 1.77 0.95


8.7.9 “ISOSORBIDE DINITRATE” ON PAGE 69

Straehl, P. and Galeazzi, R., "Isosorbide dinitrate bioavailability , kinetics, and metabolism", Clinical Pharmacology and Thera-
peutics, Vol. 38m (1985), p. 140 - 149.
Isosorbide dinitrate is used in the treatment of angina pectoris, vasospastic angina, and congestive heart failure.
In this study volunteers received a 5 mg intravenous dose and a 10 mg tablet. The different dosage forms were sepa-
rated by a washout period. A summary of the some of data obtained from this experiment is given below.

Dose (mg/kg) 5 10 10
370.3 158 165
AUC  ------ ⋅ hr
ug
L 
487 310 305

AUMC  ------ ⋅ hr 
ug 2
L 
MRT (hr) 1.32 1.96 1.85

MAT (hr) 0.65 0.53
ke (hr-1) 0.760
ka (hr-1) 1.546 1.875

282
Cp0  ug
------
 L
Vd (L) 17.75
132 60.1 66.2
Cp at 1 hour  ------
ug
 L
f 0.21 0.22
282 60.4 67.8 1.12
Cpmax  ------
ug
 L
Tmax (hr) 0.90 0.81 0.90


8.7.10 “KETANSERIN” ON PAGE 70

Kurowski, M., "Bioavailability and pharmacokinetics of ketanserin in elderly subjects", Journal of Clinical Pharmacology, Vol. 28,
(1988), p. 700 - 706.
Ketanserin is a 5-hydroxytryptamine S2-antagonist. This study focuses on the kinetics of Ketanserin in the
elderly. Subjects were given either a 10 mg intravenous dose or a 40 mg oral tablet. A summary of the some of data

Dose (mg) 10 40 40
541 112.5 103.9
AUC  -------
ng- ⋅ hr
 mL 
11700 24900 22900

AUMC  -------
ng- ⋅ hr 2
 mL 
MRT (hr) 21.6 22.1 22.0

MAT (hr) 0.5 0.4
ke (hr-1) 0.0402
ka (hr-1) 2.0 2.5

25.0
Cp0  -------
ng-
 mL
Vd (L) 400
23.9 43.6 42.7
Cp at 1 hour  --------
ng
 mL
f .052 0.48
25.0 47.6 44.5 0.94
Cpmax  --------
ng
 mL
Tmax (hr) 1.93 1.63 0.84


8.7.11 “METHOTREXATE” ON PAGE 71

Seideman, P., et al., " The pharmacokinetics of methotrexate and its 7-hydroxy metabolite in patients with rheumatoid arthritis",
British Journal of Clinical Pharmacology, 35 (1993), p. 409 - 412.
The drug Methotrexate is a folic acid which has been shown to inhibit dihydrofolate reductase. The impor-
tance of this drug at present is mostly seen in the area of oncology, but lately it has been used for rheumatoid arthritis.
Methotrexate has a molecular weight of 454.4. In this study, the drug was administered both by IV bolus and orally as
a 15 mg dose. The following data was obtained:

Dose (mg) 15 15 15
2752 2708 2700
AUC  ---------------- ⋅ hr
nmole
 L 
15887 18400 18500

AUMC  ---------------- ⋅ hr 
nmole 2
L
MRT (hr) 5.77 6.79 6.85

MAT (hr) 1.02 1.08
ke (hr-1) 0.173
ka (hr-1) 0.979 0.927

477
Cp0  ----------------
nmole
L
Vd (L) 69.3
401 265 256
Cp at 1 hour  ----------------
nmole
 L 
f 0.98 0.98
477 323 318 0.98
Cpmax  nmole
----------------
 L 
Tmax (hr) 2.15 2.23 1.04


8.7.12 “MOCLOBEMIDE” ON PAGE 72

Schoerlin, M. et al., "Disposition kinetics of moclobemide, a new MAO-A inhibitor, in subjects with impaired renal function", Jour-
nal of Clinical Pharmacology, Vol. 30 (1991), p. 272 - 284.
Moclobemide is an antidepressant agent that reversibly inhibits the A-isozyme of the monoamine oxidase
enzyme system. In this study, single IV and oral doses were administered to a patient. A summary of the some of data

Dose (mg) 150 100 100
2.58 1.70 1.52
AUC  -------
ug- ⋅ hr
 mL 
6.35 5.91 5.90

AUMC  -------
ug- ⋅ hr 2
 mL 
MRT (hr) 2.46 3.48 3.80

MAT (hr) 1.02 1.42
ke (hr-1) 0.406
ka (hr-1) 0.985 0.704

1.05
Cp0  -------
ug-
 mL
Vd (L) 143
0.698 0.344 0.250
Cp at 1 hour  --------
ug
 mL
f .099 .088
1.05 .037 0.29 .079
Cpmax  --------
ug
 mL
Tmax (hr) 1.53 1.85 1.21


8.7.13 “NALBUPHINE” ON PAGE 73

Nalbuphine hydrochloride is an agonist-antagonist opiod which is used for its analgesic actions. In this study,
volunteers were given single doses of four different nalbuphine forms. The data below focuses on a 10 mg iv dose and
a 45 mg dose of an oral solution. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 10 45 40 40
86.9 70.3 62.5 60
AUC  -------
ng- ⋅ hr
 mL 
288 306 280 270

AUMC  -------
ng- ⋅ hr 2
 mL 
MRT (hr) 3.31 4.35 4.48 4.5

MAT (hr) 1.04 1.17 1.19
ke (hr-1) .0301
ka (hr-1) 0.963 0.858 0.843

26.2
Cp0  -------
ng-
 mL
Vd (L) 381
19.4 11.1 9.2 8.7
Cp at 1 hour  --------
ng
 mL
f 0.180 0.180 0.173

26.2 12.5 10.7 10.2 0.95
Cpmax  --------
ng
 mL
Tmax (hr) 1.76 1.88 1.90 1.01


8.7.14 “NEFAZODONE” ON PAGE 74

Shukla, U. et al., "Pharmacokinetics, absolute bioavailability, and disposition of nefazodone in the dog", Drug Metabolism and
Disposition, Vol. 21, No. 3, (1993), p. 502 - 507.
Nefazodone was given to four healthy, adult, male beagles with an average weight of 11.0 kg. Each dog was
given a 10 mg/kg dose as a either a intravenous injection or as an oral solution or tablet. A summary of the some of
data obtained from this experiment is given below.

Dose (mg/kg) 10 10 10 10
6023 829 800 700
AUC  -------
ng- ⋅ hr
 mL 
29283 4875 4800 4500

AUMC  -------
ng- ⋅ hr 2
 mL 
MRT (hr) 4.86 5.88 6.0 6.43

MAT (hr) 1.02 1.14 1.57
ke (hr-1) 0.210
ka (hr-1) 0.982 0.879 0.638

1238
Cp0  -------
ng-
 mL
Vd (L) 8.07
1009 94.8 85.7 60.7
Cp at 1 hour  --------
ng
 mL
f 0.138 0.133 0.116

1238 112.7 105.6 84.0 0.80
Cpmax  --------
ng
 mL
Tmax (hr) 2.0 2.16 2.62 1.21


8.7.15 “ONDANSETRON” ON PAGE 75

Colthup, P., et al., "Determination of ondansetron in plasma and its pharmacokinetics in the young and elderly", Journal of Phar-
maceutical Sciences, Vol. 80, No. 9(1991), p. 868 - 871.
Ondansetron is a 5-hydroxyltryptamine compound which is useful in treating the nausea and vomiting which is
caused by the use of chemotherapy and radiation in the cancer patients. In order to determine the absolute bioavailabil-
ity of oral Ondansetron, doses of 8 mg were given to two groups. One group received an oral dose and the other group
received an intravenous dose. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 8 8 8
246.5 139 145
AUC  -------
ng- ⋅ hr
 mL 
1138 795 870

AUMC  -------
ng- ⋅ hr 2
 mL 
MRT (hr) 4.62 5.72 6.0

MAT (hr) 1.10 1.38
ke (hr-1) 0.217
ka (hr-1) 0.907 0.723

53.4
Cp0  -------
ng-
 mL
Vd (L) 150
43 15.9 14.7
Cp at 1 hour  --------
ng
 mL
f 0.56 0.59
53.4 19.2 18.8
Cpmax  --------
ng
 mL
Tmax (hr) 2.1 2.4 1.1


8.7.16 “OMEPRAZOLE” ON PAGE 76

Anderson, T., et al, "Pharmacokinetics of various single intravenous and oral doses of omeprazole", Eur Journal of Clinical Phar-
macology, 39, (1990), p. 195 - 197.
Omeprazole (mw: 345.42) is an agent which inhibits gastric acid secretion from the parietal cell. It is useful in
treating such problems as ulcers and gastroesophageal reflux disease. One group received an iv bolus dose and the
other group received an oral dose. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 20 40 40
3.2 3.5 3.0
AUC  µmole
---------------- ⋅ hr
 L 
µmole ⋅ hr 2 3.2 5.25 4.5

AUMC  ----------------
 L 
MRT (hr) 1.0 1.5 1.5

MAT (hr) 0.5 0.5
ke (hr-1) 1
ka (hr-1) 2 2
µmole 3.2
Cp0  ----------------
 L 
Vd (L) 52.4
1.18 1.63 1.40
Cp at 1 hour  µmole
----------------
 L 
f 0.55 0.47
µmole 3.2 1.8 1.5 0.86

Cpmax  ----------------
 L 
Tmax (hr) 0.69 0.69 1


8.7.17 “PAROXETINE” ON PAGE 77

Lund, J., et al., "Paroxetine: pharmacokinetics and cardiovascular effects after oral and intravenous single doses in man", Journal
of Pharmacology and Toxicology, Vol. 51, (1982), p. 351 - 357.
Paroxetine kinetics and cardiovascular effects were studied in male subjects after single oral doses of 45 mg
and slow intravenous infusion of 28 mg. A summary of the some of data obtained from this experiment is given below.

Dose (mg) 28 45 45
467 750 675
AUC  -------- ⋅ hr
ng
 mL 
6671 11250 10463

AUMC  -------- ⋅ hr 
ng 2
 mL 
MRT (hr) 14.3 15 15.5

MAT (hr) 0.72 1.22
ke (hr-1) 0.07
ka (hr-1) 1.40 .082

32.7
Cp0  --------
ng
 mL
Vd (L) 856
30.5 37.9 25.5
Cp at 1 hour  -------
ng-
 mL
f 1 0.90
32.7 44.8 37.6 0.84
Cpmax  --------
ng
 mL
Tmax (hr) 2.25 3.27 1.45


8.7.18 “RANITIDINE” ON PAGE 78

Garg, D., et al., "Pharmacokinetics of ranitidine in patients with renal failure", Journal of Clinical Pharmacology, Vol. 26 (1986),
p. 286 - 291.
Ranitidine is an agent used in the treatment of peptic ulceration. In this study, ten patients with renal failure
received either a 50 mg intravenous bolus dose or a 150 mg tablet. A summary of the some of data obtained from this

Dose (mg) 50 150 150
5159 6422 6753
AUC  -------
ng- ⋅ hr
 mL 
53415 78752 84413

AUMC  -------
ng- ⋅ hr 2
 mL 
MRT (hr) 10.4 12.3 12.5

MAT (hr) 1.91 2.15
ke (hr-1) 0.0966
ka (hr-1) 0.524 0.466

498
Cp0  -------
ng-
 mL
Vd (L) 100
452 240 231
Cp at 1 hour  --------
ng
 mL
f .0415 0.436
498 423 432 1.02
Cpmax  --------
ng
 mL
Tmax (hr) 3.96 4.26 1.07


8.7.19 “SULPIRIDE” ON PAGE 79

Bressolle, F., Bres, J., and Faure-Jeantis, A., "Absolute bioavailability , rate of absorption, and dose proportionality of sulpiride in
humans", Journal of Pharmaceutical Sciences ,Vol. 81, No. 1 (1992), p. 26 - 32.
Sulpiride is a substituted benzamine antipsychotic. In this study, the drug was administered to two groups.
The first group received a 200 mg oral dose and the second group received a 100 mg intravenous infusion. A summary
of the some of data obtained from this experiment is given below.

Dose (mg) 100 200 200 200
8.27 8.79 8.6 8.0
AUC  -------
ug- ⋅ hr
 mL 
79.1 87.3 91.1 84.5

AUMC  -------
ug- ⋅ hr 2
 mL 
MRT (hr) 9.56 9.93 10.6 10.6

MAT (hr) 0.367 1.02 1.0
ke (hr-1) 0.865
ka (hr-1) 2.72 0.972 1.0

0.865
Cp0  -------
ug-
 mL
Vd (L) 116
0.779 0.798 0.526 0.498
Cp at 1 hour  --------
ug
 mL
f 0.53 0.52 0.48

0.865 0.807 0.687 0.643 0.94
Cpmax  --------
ug
 mL
Tmax (hr) 1.24 2.57 2.52 0.98


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BASIC PHARMACOKINETICS - CHAPTER 8: Bioavailability

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CHAPTER 8 Bioavailability, Bioequivalence,

and Drug Selection

Author: Rasma Chereson

Basic Pharmacokinetics REV. 99.4.25 8-1

8.1 Bioavailability, Bioequivalence and Drug Product Selection

8.1.1 RELATIVE AND ABSOLUTE BIOAVAILABILITY

Bioavailability is a pharmacokinetic term that describes the rate and extent to

Basic Pharmacokinetics REV. 99.4.25 8-2

action. Therefore, most bioavailability studies involve the determination of drug

"Absolute" bioavailability, F, is the fraction of an administered dose which actually

"Relative" or “Comparative” bioavailability refers to the availability of a drug

Basic Pharmacokinetics REV. 99.4.25 8-3

where drug product B is the reference standard. When the bioavailability of a

The difference between absolute and relative bioavailability is illustrated by the

Drug Product Area Under the Curve (mcg/ml) x hr

A Intravenous injection 100

B Oral dosage form, brand or reference standard 50

C Oral dosage form, generic Product 40

8.1.2 FACTORS INFLUENCING BIOAVAILABILITY

Basic Pharmacokinetics REV. 99.4.25 8-4

Physicochemical properties of the drug Formulation and manufacturing variables

TABLE 8-3 Bioavailability Factors Related to the patient

Physiologic factors Interactions with other substances

Basic Pharmacokinetics REV. 99.4.25 8-5

Fastest availability Solutions

In addition to the dosage form-related factors identified above, bioavailability may

Basic Pharmacokinetics REV. 99.4.25 8-6

Differences in stomach emptying among individuals have been implicated as a

Basic Pharmacokinetics REV. 99.4.25 8-7

TABLE 8-5 Factors influencing Gastric Emptying Rate

Basic Pharmacokinetics REV. 99.4.25 8-8

Reduced Absorption Delayed Absorption Increased Absorption

Some drugs demonstrate enhanced bioavailability in the presence of food. This

Basic Pharmacokinetics REV. 99.4.25 8-9

highly metabolized agents, such as propranolol and metoprolol, the enhanced

Interactions between drugs can have a significant effect on the bioavailability of

1. Change in gastric or intestinal pH

An example of a direct interaction between drugs affecting bioavailability is the

The above potential sources of alteration in a drug's bioavailability must be kept in

Basic Pharmacokinetics REV. 99.4.25 8-10

8.1.3 METHODS OF ASSESSING BIOAVAILABILITY

Bioavailability testing is a means of predicting the clinical efficacy of a drug; the

The bioavailability of a drug substance formulated into a pharmaceutical product

Quantification of pharmacologic effect is another possible way to assess a drug's

Because of these limitations, alternative methods have been developed to predict

Basic Pharmacokinetics REV. 99.4.25 8-11

or urine. In such studies a single dose of the drug product is administered to a

Basic Pharmacokinetics REV. 99.4.25 8-12

Basic Pharmacokinetics REV. 99.4.25 8-13

Multiple-dose administration has several advantages over single-dose bioavailabil-

In the case of drugs exhibiting nonlinear kinetics, establishing a linear relationship

Basic Pharmacokinetics REV. 99.4.25 8-14

8.1.4 STUDY DESIGN

Other important considerations in the methodology of a bioavailability study are

8.1.5 IN-VITRO DISSOLUTION AND BIOAVAILABILITY

Basic Pharmacokinetics REV. 99.4.25 8-15

Basic Pharmacokinetics REV. 99.4.25 8-16

Adding to the complexity of correlating dissolution with in-vivo absorption are

Basic Pharmacokinetics REV. 99.4.25 8-17

8.1.6 IN-VITRO / IN-VIVO CORRELATION STUDIES-

While there are many published examples of satisfactory correlations between

Basic Pharmacokinetics REV. 99.4.25 8-18

Basic Pharmacokinetics REV. 99.4.25 8-19