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Endoplasmic Reticulum
Hepatic smooth endoplasmic reticulum contains cytochrome P450
(CYP450) enzyme superfamily (more than 50 different CYPs have been
found in humans) that metabolize foreign substances – “xenobiotics”,
i.e. medicinal drugs, pesticides, fertilizers and other chemicals
ingested by humans
Ritter JM, Lewis LD, Mant TG, Ferro A. A Textbook of Clinical Pharmacology and Therapeutics 5th Ed. London: Hodder Arnold, 2008.
Marc Imhotep Cray, M.D. 11
Phase I Metabolism: Oxidation
Microsomal oxidation causes aromatic or aliphatic
hydroxylation, deamination, dealkylation or S-
oxidation
Reactions all involve
Reduced nicotinamide adenine dinucleotide phosphate
(NADPH),
Molecular oxygen, and
One or more of a group of CYP450 haemoproteins which
act as a terminal oxidase in oxidation reaction (or can
involve other mixed function oxidases, e.g. flavin-
containing monooxygenases or epoxide hydrolases)
Marc Imhotep Cray, M.D. 12
Mechanism of reaction
In the overall reaction, drug is oxidized and oxygen is reduced
to water Reducing equivalents are provided by nicotinamide
adenine dinucleotide phosphate
(NADPH), and generation of this cofactor is coupled to
cytochrome P-450 reductase
For example Overall reaction for aromatic hydroxylation
can be described as:
Wecker L, Crespo L , et al. Brody’s Human Pharmacology : Molecular to Clinical , 5th ed. Philadelphia, PA: Mosby-Elsevier, 2010.
Figure 2–7;22.
Marc Imhotep Cray, M.D. 14
Phase I Metabolism: Reduction & Hydrolysis
Reduction
Reduction requires reduced NADP-cytochrome-c
reductase or reduced NAD-cytochrome b5
reductase
Hydrolysis
Meperidine is de-esterified to meperidinic acid by
hepatic membrane-bound esterase activity
Wecker L, Crespo L , et al. Brody’s Human Pharmacology : Molecular to Clinical , 5th ed.
Philadelphia, PA: Mosby-Elsevier, 2010. Figure 2–7;23.
Marc Imhotep Cray, M.D. 16
Phase I Metabolism
Non-endoplasmic Reticulum Drug Metabolism
Oxidation
Oxidation of ethanol to acetaldehyde is catalyzed by- cytosolic enzyme
–alcohol dehydrogenase whose substrates also include vitamin A
Monoamine oxidase (MAO) is a membrane-bound mitochondrial
enzyme that oxidatively deaminates primary amines to aldehydes
which are further oxidized to carboxylic acids or ketones
o Monoamine oxidase is found in liver, kidney, intestine and nervous tissue
o MAO substrates include catecholamines (dopamine, norepinephrine and
epinephrine), tyramine, phenylephrine and tryptophan derivatives (5-
hydroxytryptamine and tryptamine)
Oxidation of purines by xanthine oxidase (e.g. 6-mercaptopurine is
inactivated to 6-thiouric acid) is non-microsomal
Hydrolysis
o Esterases catalyze hydrolytic conversions of many drugs
• Examples include cleavage of suxamethonium by plasma
cholinesterase, an enzyme that exhibits pharmacogenetic variation
• hydrolysis of aspirin (acetylsalicylic acid) to salicylate, and
• hydrolysis of enalapril to enalaprilat
Marc Imhotep Cray, M.D. 18
Phase II Metabolism (Transferase Reactions)
Amino Acid Reactions
Glycine and glutamine are amino acids chiefly involved in
conjugation reactions in humans
Glycine forms conjugates with nicotinic acid and
salicylate, whilst
Glutamine forms conjugates with 4-aminosalicylate
Ritter JM, Lewis LD, Mant TG, Ferro A. A Textbook of Clinical Pharmacology and Therapeutics 5th Ed. London: Hodder
Arnold, 2008.
Ritter JM, Lewis LD, Mant TG, Ferro A. A Textbook of Clinical Pharmacology and Therapeutics
Marc Imhotep Cray, M.D. 5th Ed. London: Hodder Arnold, 2008. 30
Enzyme Inhibition
Allopurinol, methotrexate, ACE-I, NSAIDs and many others,
exert their therapeutic effects by enzyme inhibition
Apart from such direct actions, inhibition of drug-
metabolizing enzymes by a concurrently administered drug
can lead to drug accumulation and toxicity
For example, cimetidine, an antagonist at histamine H2-receptor,
also inhibits drug metabolism via CYP450 system and potentiates
actions of unrelated CYP450 metabolized drugs, such as warfarin
and theophylline
Other potent CYP3A4 inhibitors include azoles (e.g. fluconazole,
ketoconazole) and HIV protease inhibitors (e.g. ritonavir)
Ritter JM, Lewis LD, Mant TG, Ferro A. A Textbook of Clinical Pharmacology and Therapeutics
5th Ed. London: Hodder Arnold, 2008.
Ritter JM, Lewis LD, Mant TG, Ferro A. A Textbook of Clinical Pharmacology and Therapeutics 5th
Marc Imhotep Cray, M.D. Ed. London: Hodder Arnold, 2008. 35
Mechanism of
presystemic clearance
After drug enters enterocyte it can
undergo metabolism, excretion into
intestinal lumen, or transport into
portal vein
Similarly, hepatocyte may accomplish
metabolism and biliary excretion prior
to entry of drug and metabolites to
systemic circulation
NB: P-glycoprotein is expressed on apical aspect of
enterocyte and on canaliculi aspect of hepatocyte.
It serves as a drug efflux pump, thus limiting availability
of drug to the systemic circulation. Roden MD. Principles of Clinical Pharmacology. In: Longo DL, Fauci AS, et al.
Harrison's Principles of Internal Medicine,18th Ed. New York, NY: McGraw-Hill,
2012. Figure 5-3; 35.
Presystemic Metabolism (3)
RoA and presystemic metabolism markedly influence pattern of
drug metabolism
For example,
When salbutamol used for asthmatic ratio of unchanged
drug to metabolite in urine is 2:1 after IV administration
o But 1:2 after an PO dose
Propranolol undergoes substantial hepatic presystemic
metabolism small doses given orally are completely
metabolized before they reach systematic circulation
o After IV administration, area under plasma concentration–time
curve (bioavailability) is proportional to dose administered and
passes through origin
Marc Imhotep Cray, M.D. 37
Propranolol AUC: PO vs IV
Area under blood conc.–time curve
after PO and IV admin. of
propranolol to humans in various
doses
T is apparent threshold for
propranolol following oral
administration
o After PO admin relationship, although
linear, does not pass through origin
o There is a threshold dose (T) below
which measurable concs. of
propranolol not detectable in
systemic venous plasma
Ritter JM, Lewis LD, Mant TG, Ferro A. A Textbook of Clinical
Pharmacology and Therapeutics 5th Ed. London: Hodder Arnold, 2008.
Fox SI. Human Physiology 14th ed. New York, NY: McGraw-Hill, 2016.
Pathogenesis:
A metabolite of APAP (N-acetyl-p-benzoquinoneimine = NAPQI)
binds glutathione in liver and causes hepatic necrosis when
stores of glutathione are exhausted
usual pathway of elimination is overwhelmed and NABQI (highly
hepatotoxic) is formed by CYP1A2, 2E1 and CYP3A4 metabolism
Renal failure from ATN can also occurs renal failure without
liver failure is rare
Marc Imhotep Cray, M.D. 48
APAP poisoning case discussion cont.
Risk factors for acetaminophen toxicity:
Alcoholics and patients on drugs that induce hepatic enzymes
are at greater risk of toxicity b/c of ↑ production of toxic
metabolite of APAP
some relevant drugs are anticonvulsants, rifampin, and St John’s
wort