dr. Prajogo Wibowo, M.

Kes

The phases of drug delivery 1. Drug administration phase Enteral, Parenteral, etc. 2. Pharmacokinetic phase Absorption, Distribution, Metabolism, Excretion 3. Pharmacodynamic phase

Time of drug administration is determined by properties of drug 1. Sensitive againts gastric pH/ gastric irritating drug (e.g. NSAIDs) 2. The absorption interfered by food (e.g. ampicillin) 3. Modify gastrointestinal physiology (e.g. atropine) 4. Possibility of drug interaction (e.g. paracetamol with phenobarbital) 5. Fluctuation of gastrointestinal tract secretion (e.g. antacide with tetracycline)

Pharmacokinetics describes actions of the body on drugs, including the principles of drug absorption, distribution, biotransformation (metabolism), and excretion.
Pharmacodynamics deals with the study of the biochemical and physiological effects of drugs on the body and their mechanisms of action, includes the principles of receptor interactions, mechanisms of therapeutics and toxic action, and close-response relationships.

Absorption is movement of drug from its site of administration to systemic circulation.

The rate and efficacy of absorption depend on Route of administration-The intravenous route is most effective Blood flow-Highly vascularized organs such as the small intestine have the the greates absorbing ability Surface area available-Absorption of a drug is directly proportional to the surface area available Solubility of a drug-The ratio of hydrophilic to lipophilic properties (partition coefficient) that a drug has will determine whether the drug can permeate cell membranes. Drug-drug interactions-When given in combination, drug can either enhance or inhibit one anothers absorption pH-A drugs acidity or alkalinity affects its charge, which affects absorption.

Most drugs are weak acids or bases that are present in solution as both the nonionized and ionized species. The nonionized molecules usually are more lipid-soluble and can diffuse readily across the cell membrane. In contrast, the ionized molecules usually are unable to penetrate the lipid membrane because of their low lipid solubility.

The site of absorption for oral administration is in small intestine, (except alcohol is in stomach) Factors affecting gastrointestinal absorption 1. Gastrointestinal motility has a large effect (e.g. loperamid: decrease, metoclopramide: increase) 2. Gastrointestinal contain-A meal is often slowly absorbed, but there are some exceptions. 3. Drug formulated-Particle size and formulation have major effects on absorption. Therapeutic drugs are formulated pharmaceutically to produce desired absorption characteristic. There are many drug forms (tablet, capsule, matrix tablet, enteric coated tablet, coated tablet with delayed release, drops, mixture, effervescent, solution, and suspension) 4. Physicochemical factors-drug interaction affect drug absorption. Tetracyclin binds strongly to calcium therefore milk prevent its absorption. Colestyramine binds several drugs. 5. Charateristic of drugs-Aminoglycoside (Streptomycin) is very poorly absorbed because water soluble.

Distribution: The process by which a drug leaves the bloodstream and enters the interstitium or the cells of the tissues.

Factors affecting drug distribution: 1. Circulation (blood flow) 2. Capillary structure (barrier) - Central Nervous System (Blood Brain Barrier) - Placenta barrier - Testis barrier 3. Chemical structure of the drugs

Metabolism can be defined as the alteration of the chemical structure of the drug by enzyme. The liver is the principal organ of drug metabolism. Other tissues that display considerably activity include the gastrointestinal tract, the lungs, the skin, and the kidneys.

Factors affecting drug metabolism Genetic factor-influence enzyme levels Age & sex-The ability to metabolize drugs is lower in neonatus and elderly patient. Liver function-Alcoholic hepatitis, cirrhosis, acut viral, hemochemochromatosis, and drug induced hepatitis may impair drug metabolism Diet & environmental factors-Charcoal-broiled food (inducer), grape juice (inhibitor), cigarette smokers (inducer), pesticide may induce or inhibit other drug metabolism Drug interaction drug inhibitor, reduced metabolism of other drugs drug inducer, induced metabolism of other drugs or its own metabolism

1st pass metabolism

a condition in which the metabolism of drug occurs before reaching the Site Of Action (systemic circulation).

Excretion

The procces by which a drug or metabolite is removed from the body

The routes of excretion Renal urine is one of the most common routes of excretion Fecal Lung/respiration-primarily for anesthetic gases and vapors Breast milk Skin Hair (e.g. arsen)

TERMINOLOGY
Adverse Reaction Unintended and unwanted effect occurs at the doses normally given in man for prophylactic, diagnostic, or therapeutic purposes Adverse Drug Reaction Monitoring The systematic reporting, recording and evaluation of certain or all adverse reaction to drug

POST MARKETING SURVEILLANCE (PMS) ADR monitoring is only part of the totally of post-marketing surveillance which may provide data both on efficacy and safety

NATIONAL MONITORING CENTRE

The national centre for ADR monitoring is a government agency or body to which reports of suspected or proven ADRs can be sent. The Centre evaluates the reports in the light of all published and unpublished data available to it and feeds back its conclusions to the reporters and to health professionals

MONITOR
A monitor is a physician, pharmacist or other designated health professional who has agreed to undertake certain task in connection with the reporting of original data to the National Centre

Classification of ADRs
(Etiological Basis) Reaction due to inherent anomalies Acquired patient abnormalities Anomalies of drug presentation and administration Drug interaction

Classification of ADRs (Etiological Basis) A. Reactions due to inherent anomalies

1.

Drug allergy (hypersensitivity) - Immunological mechanism - Characteristic : a. uncorrelated with the known pharmacological properties b. Predictable c. Repeated exposure will cause recurrences of the reactions Included : skin rash, angioneurotic edema, serum sickness, and anaphylaxis or asthma

Classification of ADRs (Etiological Basis) A. Reactions due to inherent anomalies

2. Genetically determined ADRs : Reaction due to altered : a. Pharmacokinetic handling of the drug b. Tissue responsiveness

Classification of ADRs (Etiological Basis) B. Acquired patient abnormalities

Due to the presence of intecurrent illness which may unmask pharmacological effect that are not apparent in normal individuals, exp. : Hemorrhage of perforation in peptic ulcers due to aspirin or corticosteroid Hypoglycemia due to oral anti diabetes

Classification of ADRs (Etiological Basis) C. Anomalies of drug presentation and administration Excessive response, alteration in bioavailability or an inappropriate method of administration Potential sources of ADRs : abnormalities of the drug : decomposition of its active. Solubilizers, stabilizers, colourizers in pharmaceutical preparations

Classification of ADRs (Etiological Basis) D. Drug Interaction

> 1 drug given at the same time DI : unwanted effects and certain benefits

The mechanism and predisposing factors of ADRs :

Onset of reaction Age Pathophysiological condition Amount of drug administered

Sex Previous history of allergy Multiple drug therapy Racial or genetic factors

Mechanisms of Interaction

Direct physical or chemical interaction of more than one drug given concomitantly Altered GI absorption, competition for protein binding sites or receptors or metabolism of a drug by induction, activation, or inhibition of drug metabolism enzyme Alteration of acid-base equilibrium, thereby influencing drug distribution and renal clearance Alteration of hemodynamics or renal function that influences rates of renal excretion

Reaction should be reported

ADRs previously unknown to the reporters Serious or life-threatening ADRs Cases of suspected dependence Cases of suspected due to drug interaction

Methods of ADRs Monitoring

Incidental reporting Systematic voluntary reporting Intensive hospital monitoring Record linkage Mandatory or compulsory Monitoring Limited Monitoring Release

Methods of ADRsM
Spontaneou Simple & chip s Large R. populations Rare & delayed ADR Systematic Chip Valuntary Large R. populations All drugs Early warning Spread easily Incomplete reported Frequency cant be evaluated

Early warning Is doubt Low Participate-on Of health professions

Methods of ADRsM
Intensive Determine The Hospital Incidence of ADR M. And risk factors Record linkage May find chronic, congenital, and malignancy ADRs Large of cost Limited population Delayed ADR cant be find The tremendous amount of data Not identical terminology incomplete record

Methods of ADRsM
Mandatory/ The report Compulsor exsist y (Rules) M. Ideal for the hospital Limited Frequency of Monitoring ADR can be determined Release Accurate report is doubted

Limited of drug and period/time

ALGORITM OF CAUSAL RELATIONSHIP BETWEEN DRUGS AND ADRS

Onset of ADRs after Appropriate drug use Yes DECHALLENGE Yes ADRs decrease
No Causal relationship REMOTE

No

Causal relationship REMOTE

No

Causal relationship POSSIBLE

 Yes RECHALLENGE Yes ADRs Appearing again Yes Causal Relationship HIGHLY PROBABLE

PROBABLE No

No

ADRs could not happened because of clinical situation Yes

No

Causal relationship POSSIBLE