January 1999 Pharmacokinetic Considerations in Obesity
Contribution from Division of Pharmaceutical Sciences, College of Pharmacy and Graduate Center for Toxicology, University ofKentucky, Lexington, Kentucky 40536-0082.
Final revised manuscript received October 26, 1998.
Accepted for publication October 28, 1998. Introduction
There have been several references reviewing the causes
and pharmacological implications of obesity.6-12 These
Obesity is a disease characterized as a condition result-
show the effects of obesity on the pharmacokinetics of drugs
ing from the excess accumulation of body fat. In conjunction
in obese subjects; however, there have been considerable
with increased stores of body fat, obesity has also been
advances in the understanding of obesity, particularly in
associated with increased mortality influenced by increased
the genetic causes and changes in genetic expression
incidence of hypertension, atherosclerosis and coronary
asssociated with obesity. This article will attempt to
artery disease, diabetes, cancers of the breast, colon,
comprehensively review current knowledge regarding obe-
prostate, endometrium, ovary, and cervix, and decreased
sity ranging from genetic and nutritional animal studies
overall survivability when compared with nonobese
to pharmacokinetic studies of specific drugs in humans.
counterparts.1-5 As a consequence, obese individuals gen-erally require more therapeutic intervention earlier in lifethan nonobese individuals. A very important consideration
Obesity and Drug Absorption
for pharmacological treatment of obese individuals is thepossible discrepancies between obese and nonobese indi-
The effects of obesity on absorption and overall bioavail-
viduals in pharmacokinetic and/or pharmacodynamic ac-
ability is poorly understood. In contrast to expected de-
tivities of a drug. Changes in pharmacokinetic parameters
creases in bioavailability associated with increased splanch-
such as volume of distribution or clearance can significantly
nic blood flow in obesity,23 the bioavailability of midazolam13
alter the pharmacologic impact of a drug; therefore, it is
and propanolol,14 two compounds with moderate to high
important to characterize the properties of drugs in obese
hepatic extraction, was shown not to be significantly
different between obese and lean individuals. Body weightwas shown to have no effect on the bioavailability of
The direct causes of obesity are difficult to discern due
cyclosporine in renal transplant recipients.15 No statisti-
to the plethora of physiological changes associated with
cally significant difference in the bioavailability of dexfen-
obesity. Furthermore, characterizing metabolic and genetic
fluramine could be established between obese and normal-
differences between obese and nonobese individuals has
weight individuals.16 Overall, studies indicate no significant
proven complex resulting in broad scale attempts to study
difference in absorption between obese and lean subjects.
genetic and nutritional models of obesity in animals. Theseanimal models can be used to help determine the possiblecauses and effects of obesity in humans resulting in
Obesity and Drug Distribution
possible agents to attenuate the causes and effects ofobesity.
The volume of distribution of a drug is dependent on a
number of factors including tissue size, tissue permeability,plasma protein binding, and the affinity of drugs for a
* Corresponding author: Tel: 606-257-5736. Fax: 606-257-7564.
tissue compartment.17 These factors can be affected by the
1999, American Chemical Society and
Journal of Pharmaceutical Sciences / 1 American Pharmaceutical Association
physical and chemical properties of a drug in addition to
have volumes of distribution that decrease when corrected
the presence of many disease states. Obesity is a disease
for TBW.42,43 These decreased volumes of distribution when
state associated with changes in plasma protein binding
corrected for TBW indicate that these drugs distribute less
constituents18,19 and increases in adipose tissue mass and
into excess adipose tissue. Bisoprolol was shown to have
lean body mass,20 organ mass,21,22 cardiac output,23,24,25
an increased apparent volume of distribution but decreased
cardiac size and blood volume,23,24 and splanchnic blood
volume when corrected for TBW. The authors concluded
flow23 relative to normal-weight individuals.
that these parameters indicated that bisoprolol distributed
A general trend has been observed for predicting changes
primarily into excess lean body mass relative to excess
in volume of distribution in obese subjects. Increasingly
lipophilic substances, based upon the octanol/water lipid
Plasma protein binding is an important determinant of
partitioning coefficients (LPC), are generally increasingly
a drugs pharmacokinetics. Changes in the concentrations
affected by obesity. Less lipophilic compounds, with lower
of plasma binding proteins or alterations in the affinity of
LPCs, generally have little to no change in volume of
plasma proteins for substrate could affect the movement
distribution with obesity. There are exceptions to this
of drug into tissue compartments. The major plasma
generalization: cyclosporine, a highly lipophilic compound
proteins are albumin, primarily responsible for binding
with a relatively large volume of distribution, has been
acidic drugs, R1-acid glycoprotein (AAG), primarily respon-
shown in separate experiments to have comparable abso-
sible for binding basic drugs, and lipoproteins. Studies have
lute volumes of distribution (Vdss) in both obese and normal-
shown that drugs primarily bound by albumin (e.g., thio-
pental27 and phenytoin18,19,44) show no significant changes
The effect of high lipid partition coefficients in barbitu-
in protein binding in obese individuals; however, the
rates was demonstrated by Cheymol8 when increasing LPC
binding of drugs to AAG have been shown to increase and
were correlated with increases in distribution into adipose
decrease in obesity. Benedek et al.19 showed a significant
tissue. Thiopental27 and diazepam,11,28 with corresponding
increase in AAG concentrations in obese individuals with
LPC values of 67629 and 309,30 show significant increases
concomitant decreases in the free fractions of propanolol,
in volume of distribution (Vdss) for obese individuals relative
principally bound by AAG. Cheymol et al.45 showed no
to normal-weight individuals. In both cases, the volume of
significant differences in AAG between obese and lean
distribution increased for both absolute volume of distribu-
individuals; however, a decrease in volume of distribution
tion and when normalized for total body weight. However,
of propanolol was observed which was more consistent with
the absolute distribution (Vdss) of digoxin31 and procain-
increased plasma protein binding. Derry et al.46 also
amide32 has been shown to remain relatively consistent
observed an increase in AAG with no change in the plasma
between obese and normal-weight individuals despite
free fraction of triazolam, a drug principally bound by AAG.
relatively high LPC values,29,33 and the distribution of
These results indicate the possibility that plasma protein
digoxin decreased in obese individuals when normalized
binding affinity may change in obesity without changes in
to actual body weight.31 Others have shown that digoxin
protein concentrations. The plasma protein binding of
does not have extensive distribution into adipose tissue.34
verapamil, also associated with AAG binding, was un-
These results are supportive of the explanation by Christoff
changed between obese and nonobese individuals.47 Due
et al.32 that the high LPC values are too low to enhance
to higher triglyceride and cholesterol levels common in
distribution into adipose tissue. Ritschell and Kahl33 have
obesity, lipoprotein levels may be elevated in obese indi-
developed equations based upon several parameters (i.e.,
viduals; however the ramifications of elevated lipoprotein
LPC, plasma protein binding, ionization, normal-weight
levels has been poorly studied and is not well understood
volume of distribution, and body weight parameters) to
help determine volume of distribution in obese individuals,
The clearance of drugs can also be affected by obesity,
but there has been little further experimental support of
though increases in clearance do not necessarily reflect
changes in the half-life of a drug. The half-life of a drug
Polar compounds have been shown to have several
can be related to both volume of distribution and clearance
different relationships between body weight and volume
of distribution. Theophylline, shown not to correlate wellwith ideal body weight (IBW) or total body weight (TBW),35,36
was shown to adhere well to the following power equationsuggested by Rizzo et al.:37
The half-life of a drug may increase without changes in
clearance. Abernathy et al.48 showed a significant increase
in the plasma half-life of desmethyldiazepam without
changes in clearance. Rather, the change in half-life was
Several authors38,39 agree that a better relationship
attributed to the increase in volume of distribution in obese
between aminoglycoside volume of distribution and body
individuals. LeJeunne et al.42 demonstrated increased
weight is given in the following equation proposed by Bauer
absolute volume of distribution (Vdss) and increased clear-
ance of bisoprolol with no change in plasma half-life inobese versus nonobese individuals. These studies demon-strate the interrelationships between half-life, volume of
V (in liters) ) (0.26 L/kg)[IBW + (CF × AW)]
distribution, and clearance as well as indicates the useful-ness of volume of distribution and clearance over plasma
where CF is a correction factor between 0.2 and 0.5 and
Neuromuscular agents are another group of generally
polar compounds. The best method of calculating dosing
Obesity and Drug Clearance
strategies might be to base calculations on IBW. In onestudy, it was shown that the absolute volume of distribu-
Changes in Metabolic Enzymes in Obese Humanss
tion (Vdss) of atracurium is unchanged in obese individu-
Measuring changes in hepatic metabolizing enzymes in
als.41 At the same time, the volume of distribution corrected
humans is difficult due to the general lack of enzyme
for TBW decreased. Some lipophilic substances, such as the
specific markers of metabolic activity. As a result, relation-
-adrenergic receptor blockers bisoprolol and nebivolol, also
ships are usually drawn between pharmacokinetic behavior
2 / Journal of Pharmaceutical Sciences
of a drug in humans and measured metabolic enzyme levels
Using drugs that are primarily transformed via Phase
in animals. Important considerations are presented by the
II conjugation pathways, glucuronidation and sulfation
fact that fatty infiltration characterizes the livers of most
have been shown to increase in obese individuals. The
individuals.49 This fatty infiltration generally resembles
clearance of oxazepam and lorazepam, benzodiazepines
mild alcoholic hepatitis in moderately obese individuals,49
excreted primarily in the form of glucuronide conjugates,
but morbidly obese individuals have markedly increased
was shown to increase in obese individuals.54 In another
liver damage.50 These factors could have a significant
study, acetaminophen clearance was shown to increase
impact on the metabolic activity of the liver thereby
with obesity,55 though not as significantly as the increases
dictating the importance of characterizing metabolism in
shown with oxazepam and lorazepam.54 It has been shown
obese individuals. There are some determinants of meta-
that acetaminophen is eliminated as both a glucuronide
bolic activity in humans that are generally considered as
and sulfate conjugate in humans56 whereas oxazepam and
definitive markers for enzyme levels that have been used
lorazepam are excreted primarily as glucuronide conju-
to show differences between obese and normal-weight
gates. It is likely that obesity affects different pathways
individuals. These markers and the effects of obesity are
through different mechanisms and levels: where glucu-
discussed in the following paragraphs. Unless stated
ronidation might be significantly enhanced, sulfation may
otherwise, clearance parameters are not normalized for
only be slightly to moderately enhanced due to obesity.
Other evidence supporting differential regulation of
It was previously thought that hepatic oxidative me-
Phase II pathways are studies showing that the clearance
tabolism was essentially unchanged in the obese individual
of salicylate57 and procainamide32 is not significantly
when compared to a normal-weight individual. Caraco et
different between obese and lean individuals. Salicylate is
al.51 used obese and lean volunteers to evaluate the
conjugated to the glycine, phenolic, and acyl glucuronide,
pharmacokinetics of antipyrine, a marker for hepatic
and procainamide is primarily acetylated. Together these
oxidative metabolism. In the obese group, plasma half-life
results indicate that these pathways may not be signifi-
increased, apparent volume of distribution increased (but
cantly affected by obesity in humans.
decreased when corrected for TBW), and the clearance
Another interesting consideration in determining the
remained unchanged. When volunteers were enrolled in a
metabolic activity of obese individuals is considering
weight reduction program, obese individuals showed de-
changes in metabolism in tissues other than the liver;
creased half-life, decreased volume of distribution (in-
specifically, due to the significant increase in adipose tissue
creased when corrected for TBW), and a nonsignificant
in obese individuals, changes in metabolism within adipose
increase in clearance after losing weight. The nonsignifi-
tissue could be significant. Rafecas et al.,58 using white
cant changes in clearance indicate that the oxidative
adipose tissue from obese and lean patients, observed an
pathways employed by the liver for antipyrine metabolism
increase in insulin cleavage in obese subjects relative to
remain unchanged between obese and normal-weight
normal-weight subjects. In the absence of reduced glu-
individuals; however, antipyrine undergoes extensive he-
tathione, no insulin was cleaved, indicating that glu-
patic oxidative metabolism through multiple oxidative
tathione transhydrogenase, present in white adipose tissue,
pathways, and a change in singular pathways would be
was likely the only enzyme responsible for insulin cleavage
within white adipose tissue. The authors stated that
Metabolism of chlorzoxazone to 6-hydroxychlorzoxazone
hyperinsulinemia common in obesity may be offset by the
has been used as a marker for hepatic cytochrome P450
substantial increase in adipose tissue possessing high
(CYP) 2E1 activity in humans. O′Shea et al.94 showed
intrinsic insulin cleaving activity. The results of this study
increased chlorzoxazone clearance in obese individuals as
point to the possibility that adipose tissue might play a
well as increased formation clearance of 6-hydroxychlor-
significant role in energy regulation in obese individuals.
zoxazone from chlorzoxazone. The increase in chlorzox-
Further evidence suggests that adipose tissue may play a
azone clearance was attributed to increased CYP2E1
role in the increased clearance of prednisolone in obese
activity associated with obesity. The authors further stated
men.59 The interconversion of prednisolone and prednisone
that the increase in CYP2E1 activity may predispose obese
is dependent on 11-hydroxysteroid dehydrogenase, an
individuals to CYP2E1-mediated toxicities associated with
enzyme present in adipose tissue; therefore, the increase
the production of toxic metabolites from environmental
in adipose tissue may provide an alternative site of
The formation of 6 -hydroxycortisol and N-methyleryth-
In a series of studies, the pharmacokinetics of carbam-
romycin from cortisol and erythromycin has been shown
azepine was evaluated in obese subjects before and after
to provide a general marker for cytochrome P450 3A
significant weight reduction60 and in obese versus lean
activity in humans.52,53 Hunt et al.52 performed a study in
subjects.61 In the first study, obese subjects were monitored
volunteers to monitor the metabolism of cortisol and
to establish the pharmacokinetic parameters of carbam-
erythromycin to 6 -hydroxycortisol and N-methylerythro-
azepine, and then each subject was entered into a weight
mycin. Using these parameters as measures of CYP3A
reduction program, regulating diet and exercise, after
activity in humans, it was found that a negative correlation
which the same pharmacokinetic parameters were assessed
existed between percent IBW and N-methylerythromycin
and compared for each individual. After significant weight
production. In contrast, cortisol metabolism showed no
reduction, the formerly obese individuals had a decreased
negative correlation between percent IBW and urinary 6 -
plasma half-life, increased clearance, decreased absolute
hydroxycortisol/cortisol ratios. The authors thought that
volume of distribution (Varea) with respect to bioavailabil-
similar correlations should be drawn between percent IBW
ity, and no significant change in Varea when normalized
and N-methylerythromycin and percent IBW and 6 -
for total body weight. In the second study, relative to
hydroxycortisol/cortisol ratios. Another study by Hunt et
normal-weight individuals, obese individuals had increased
al.53 supported changes in CYP activity in humans by
absolute volume of distribution (Varea), increased plasma
showing a negative correlation between erythromycin
half-life, and unchanged clearance values. The disparity
N-demethylation and percent IBW in elderly subjects.
between changes in clearance remains unexplained, but it
These contrasting studies demonstrate the difficulties
is important to note that obesity may be associated with
associated with correlations between specific markers of
changes in blood flow or metabolic activity. Further com-
drug metabolism and specific CYP isoform modulation.
parison between the two studies indicates that, for car-
Journal of Pharmaceutical Sciences / 3
bamazepine, the increased volume of distribution and half-
be altered resulting in differential pharmacotherapeutic
life associated with obesity may involve reversible processes
effects in obese individuals as compared to lean individuals.
that may disappear following weight reduction. Changes in Metabolic Enzymes in Obese Animals Changes in Renal Function in Obese Humans
The influence of pathophysiologic and morphologic
Elimination of a drug through the kidney can be ac-
changes associated with obesity on hepatic metabolism is
counted for by glomerular filtration, tubular secretion, and
not well understood. Before the late 1980s, studies cor-
tubular reabsorption; however, there are several discrep-
relating obesity-associated changes with either hepatic
ancies regarding the influence of obesity on these functions.
drug metabolizing enzymes (e.g., hepatic cytochrome P450)
Davis et al.62 and Stockholm et al.63 have independently
or drug markers (e.g., antipyrine) were nonexistent. In
shown increases in glomerular filtration, measured using
1989, Corcoran et al.12 showed no significant difference in
creatinine clearance, in obese women as compared to
CYP concentrations between obese and lean rats; however,
normal-weight women. Dionne et al.64 has also shown
total CYP increased per liver in the obese overfed rat.
increased creatinine clearance in obese subjects when
Beginning in the early 1990s, studies began showing
compared to historical values of creatinine clearance;
changes in hepatic CYP resulting from obesity using both
however, Ducharme et al.65 showed decreased glomerular
animal models and human markers. Studies dating as far
filtration via creatinine clearance in obese individuals from
back as the 1970s have indicated changes in Phase II
a patient population study of vancomycin pharmacokinet-
metabolism pathways associated with obesity. The follow-
ics. Reiss et al.66 and Allard et al.67 showed no significant
ing paragraphs describe differences in Phase I and Phase
difference between creatinine clearance in obese versus
II metabolism in obese animal models.
nonobese individuals. There are also discrepancies between
Research has been conducted to determine the effects of
studies of drug primarily excreted by glomerular filtration.
either genetically or nutritionally induced obesity in mice
Historical evidence has shown that the aminoglycoside
and rats. Irizar et al.76 observed decreased total CYP
antibiotics68 including gentamicin69,70 and vancomycin71 are
expression in genetically obese (fa/fa) Zucker rats. When
associated with increased clearance in obese individuals;
expressed as CYP activities per nmol of total CYP, CYP1A,
however, recent evidence has shown that vancomycin
CYP2B, CYP2E, CYP3A, and CYP4A were shown to
clearance is unchanged in obese individuals greater than
increase in obese rats using specific substrates. Absolute
1.3 times their IBW.64 One possible explanation for these
CYP activities increased for CYP1A and CYP3A in obese
discrepancies might be due to the difference in extent of
rats whereas the increase in expression of other CYP
obesity and/or associated renal pathology.
isoforms resulted primarily due to the decrease in overall
Tubular function (i.e., tubular secretion and tubular
CYP levels. Anti-mouse CYP2D antibodies showed a de-
reabsorption) in the kidney is often difficult to ascertain;
crease in apoprotein in obese rats when compared with
thus, conclusions regarding tubular function are often
normal rats. The investigators indicated the possibility that
indirect. Changes in tubular function have been indicated
reduced growth hormone (reduced in obese male animals
in several studies. The renal clearance of ciprofloxacin,67
and shown to be partially responsible for the regulation of
cimetidine,72,73 procainamide,32,45 and lithium66 has been
CYP3A expression) caused the increase in CYP3A activity.
shown to increase in obese individuals. Since the renal
These results illustrate the possible ramifications of geneti-
excretion of ciprofloxacin,92 cimetidine,95 and procaina-
cally induced obesity; however, parallels to humans are
mide32 involves primarily glomerular filtration and tubular
difficult to establish due to difficulty in characterizing the
secretion, the increases in renal clearance of ciprofloxacin,
genetic causes of obesity in humans.
cimetidine, and procainamide accompanied by a dispro-
An alternative model of obesity uses nutritional modula-
portionate increase in glomerular filtration supports in-
tion to induce obesity. Salazar et al.79 previously reported
creased tubular secretion in obese individuals. Renal
an increase in CYP2E1 in obese overfed rats. Raucy et al.77
clearance of lithium primarily involves glomerular filtra-
used overfed Sprague Dawley rats to observe the effects of
tion and tubular reabsorption;93 consequently, the increase
obesity on the expression of CYP2E1. Following 52 weeks
in the renal clearance of lithium with no increase in
of nutritional overfeeding, obese rats showed increased
glomerular filtration66 supports decreased tubular reab-
total CYP relative to control rats, unchanged CYP reduc-
tase and cytochrome b5, increased CYP2E1, and unchangedCYP2C11 and CYP3A. A strong correlation was also shownbetween CYP2E1 activity and CYP2E1 protein immunoblot
Obesity and Drug Pharmacodynamics
staining thereby reducing the significance of posttransla-tional modifications common to CYP2E1. The authors
A final but equally important consideration when devel-
further indicated that ketosis, often implicated as the
oping a dosing strategy for an individual involves the
mechanism by which CYP2E1 is increased, is likely not
consideration of drug efficacy. Obese subjects were shown
the primary mechanism of upregulation due to the fact that
to have increased sensitivity to triazolam as measured by
no significant increases were observed in CYP2B1 or CYP
a sedation score upon administration of a second dose.46
reductase activities also commonly associated with ketosis.
The same dose of triazolam was used for both obese and
Contrasting the genetic versus nutritional models, there
nonobese individuals. Varin et al.41 showed that even
appears to be a different mechanism of metabolic regula-
though obese individuals were exposed to significantly
tion influenced by either genetic expression or metabolic
higher plasma concentrations of atracurium, no change was
changes resulting in possible functional (i.e., enzymatic
seen in the duration of neuromuscular blockade. The
expression) and morphological (i.e., fatty infiltration in the
authors attributed this change in sensitivity to a combina-
liver associated with obesity) changes in obese rats. The
tion of protein binding effects and desensitization of
importance of these factors could easily manifest itself by
acetycholine receptors. Desensitization of acetylcholine
causing possible increases in toxicity following drug ad-
receptors has been associated with chronic inactivity.74,75
ministration such as with the increased acetaminophen
It is important to note that, with the plethora of probable
genetic and nutritional changes associated with obesity,
Chaudhary et al.80 provided evidence that glucuronida-
changes in receptor expression or affinity for ligand could
tion increased and sulfation pathways were unaffected in
4 / Journal of Pharmaceutical Sciences
the genetically obese Zucker rat. Using acetaminophen as
clearance, volume of distribution, bioavailability, or phar-
a substrate for glucuronidation and sulfation, the investi-
macodynamics may affect the toxic potential of a drug.
gators observed no difference between urinary excretion
Additionally, changes in excretion mechanisms can alter
of acetaminophen sulfate and increased urinary excretion
the toxicity of a compound by either increasing exposure
of acetaminophen glucuronide in the genetically obese
through decreased clearance or vice-versa. One study by
Zucker rat when compared to normal-weight rats. No
Georgiadis et al.91 observed the possible increases or
change was observed for γ-glutamyl cysteine synthetase;
decreases on the toxicity associated with the administration
however, total glutathione and UDPGT increased in obese
of a plethora of highly toxic chemotherapeutic agents to
rats relative to normal-weight rats. This is an important
obese versus lean subjects with small-cell lung cancer.
observation indicating that obese rats might have higher
According to the study, no correlation could be established
conjugation and detoxification pathways, but there is some
between obesity and increased toxicity for patients receiv-
discrepancy to this conclusion in that Barnett et al.81
ing cyclophosphamide, methotrexate, lomustine, etoposide,
observed lower glutathione-S-transferase and total glu-
and cisplatin. Perhaps the most important conclusion to
tathione in genetically obese (ob/ob) mice indicating pos-
be drawn from the information presented in this article is
sibly higher susceptibility to toxicity in obese mice. The
that each drug behaves differently. Predicting toxicity
ob/ob mouse model associates noninsulin dependent dia-
associated with obesity is very difficult if not impossible.
betes with obesity which likely manifests differential
The best approach for pharmacotherapeutics in obese
enzymatic expression mechanisms than nondiabetes-as-
individuals is to use previous knowledge and be conserva-
sociated obesity. Consequently, direct correlations between
tive. Careful monitoring of the obese patient is necessary
the two models is impossible, but the observation should
when administering drugs with a small therapeutic index.
be made that there are several presently unidentifiedmechanisms involved in obesity that could possibly resultin the regulation and differential expression of many
enzymes. An argument against the possibility that obese
Using the parameters of volume of distribution and
rats might have higher glutathione conjugation capacity
clearance, a therapeutic dosing strategy can be developed
is the fact that others have shown increased acetaminophen
for a drug. Consequently, the effects of physiological
toxicity in obese rats indicative of depeted glutathione.78
disorders on these parameters is important for accurate
Sastre et al.82 used an overfed Wistar rat and Swiss mice
pharmacotherapeutics. Regarding obesity, the volume of
model to demonstrate that overfed mice had lower levels
distribution has been shown to change in many situations.
of both reduced glutathione and oxidized glutathione than
Generally, more lipophilic compounds are affected by
chow fed mice. This study seemed to parallel the study by
obesity to a greater extent than hydrophilic compounds.
Barnett et al.81 using a genetically obese mouse model in
More lipophilic compounds are associated with increases
that both models show a decreased propensity of obese mice
in volume of distribution in obesity; however, there are
for glutathione dependent conjugation and protection
exceptions to this relationship. High LPC values did not
against cellular insult. The contrast mentioned before
correspond with markedly increased volumes of distribu-
between obese Zucker rats and obese mice is also likely
tion for digoxin,31 procainamide,32 and cyclosporine.15,26
influenced by species specific differences in obesity, another
Consequently, prior knowledge of the effects of obesity on
complication in the elucidation and parallel application of
specific drugs is essential for accurate dosing strategies
obesity associated mechanisms involved in pharmacoki-
based upon volume of distribution; generalizations among
similar groups of drugs does not always result in proper
Contrasting the nutritional versus genetic models of
physiologic responses between obese and lean individuals.
obesity, differences can be seen between genetic obesity and
The clearance of a compound depends on the metabolic
nutritional obesity for both Phase I and Phase II enzymatic
activity of characteristic enzymes that may be affected by
pathways. It should be noted that genetically induced
obesity or diseases associated with obesity. Changes have
obesity is targeted for a specific gene, but nutritional
been noted in both humans and animals for various CYP
obesity can have effects on multiple genes that in turn can
isozymes using either direct measurements (in animals)
effect the expression of many other genes. Consequently,
or through the use of metabolic markers (in humans) such
the pathways associated with nutritional obesity may be
as antipyrine or erythromycin. In addition, obesity has been
more variable and harder to elucidate. On the other hand,
associated with increased glucuronidation with question-
several current reviews83-86 cover the genetic causes and
able effects on sulfation. Changes between obese and lean
effects of obesity should the reader be interested in
subjects have also been observed for antioxidant systems
broadening his/her knowledge of the genetic influences of
including glutathione and catalase. It is important to note
obesity. Using genetic models, obesity has been linked to
the variability in characterizing metabolic changes in
deficiencies in leptin, a hormone shown to be secreted by
obesity. Given the numerous possible genetic and environ-
adipocytes87 that reduces body weight and food intake in
mental influences, predicting changes in metabolic activity
both obese and nonobese animals.88 Research into the
can be difficult. Furthermore, there are possibilities that
interactions of leptin with the body and the effects of
similar concentrations of a drug at its site of action may
obesity on leptin levels is generating volumes of new
not elicit a similar response between obese and lean
information into the molecular mechanisms of obesity and
subjects, thereby making accurate therapeutic modifica-
the possibilities that obesity might be under hormonal
tions more difficult for obese individuals.
control. Several reviews89,90 evaluate the current under-
Renal function, particularly glomerular filtration, has
standing of leptin and its relationship with the body.
been shown to change with obesity. Increased glomerularfiltration in some studies has been contradicted by de-
Pharmacotherapeutic Toxicity in Obesity
creases in glomerular filtration in other studies. Thesediscrepancies illustrate the possible ramifications of dif-
The toxicity of substances can change with obesity. With
ferent degrees of obesity, with morbidly obese individuals
possible increases in metabolism such as with the CYP
exhibiting different responses than moderately obese in-
system, drugs can be converted to toxic metabolites at
dividuals. The effects of obesity on the toxicology of specific
higher rates; however, toxic drugs may also be converted
compounds is questionable depending upon not only the
to inactive metabolites at higher rates. Changes in the
presence of enzymes that create toxic metabolites, but also
Journal of Pharmaceutical Sciences / 5
depending upon the presence of enzymes that remove toxic
25. de Divitiis, O.; Fazio, S.; Petitto, M.; Maddalena, G.; Con-
metabolites from the body. In conclusion, a safe therapeutic
taldo, F.; Mancini, M. Obesity and cardiac function. Circula- tion 1981, 64, 477-482.
protocol for obese individuals should be based upon existing
26. Yee, G. C.; Lennon, T. P.; Gmur, D. J.; Cheney, C. L.; Oeser,
therapeutic information as well as careful monitoring of
D.; Deeg, H. J. Effect of obesity on CSA disposition. Trans-
the patient during pharmacologic intervention. plantation 1988, 45, 649-651.
27. Jung, D.; Mayersohn, M.; Perrier, D.; Calkins, J.; Saunders:
R. Thiopental disposition in lean and obese patients under- going surgery. Anesthesiology 1982, 56, 269-274. References and Notes
28. Abernethy, D. R.; Greenblatt, D. J.; Divoll, M.; Shader, R. I.
Prolonged accumulation of diazepam in obesity. J Clin
1. Lew, E. A. Mortality and weight: Insured lives and the
Pharmacol 1983, 23, 369-376.
Americal Cancer Society studies. Ann. Intern. Med. 1985,
29. Leo, A.; Hansch, C.; Elkin, D. Partition coefficients and their
uses. Chem. Rev. 1971, 71, 525-616.
2. Pi-Sunyer, F. X. Medical hazards of obesity. Ann. Intern. Med.
30. Arendt, R. M.; Greenblatt, D. J.; Divoll, M.; Abernethy, D. 1993, 119, 655-660.
R.; Giles, H. G.; Sellers, E. M. Predicting in vivo benzodiaz-
3. Suissa, S.; Pollack, M.; Spitzer, W.; Margolese, R. Body size
epine distribution based upon in vitro lipophilicity. Clin.
and breast cancer prognosis: a statistical explanation of the
Pharmacol. Ther. 1982, 31, 200-201.
discrepancies. Cancer Res. 1989, 49, 3113-3116.
31. Abernethy, D. R.; Greenblatt, D. J.; Smith, T. W. Digoxin
4. Seine, R. T.; Rosen, P. P.; Rhodes, P.; Lesser, M. L.; Kinne,
disposition in obesity: clinical pharmacokinetic investigation.
D. W. Obesity at diagnosis of breast carcinoma influences
Am. Heart J. 1981, 102, 740-744.
duration of disease-free survival. Ann. Intern. Med. 1992,
32. Christoff, P. B.; Conti, D. R.; Naylor, C.; Jusko, W. J.
Procainimide disposition in obesity. Drug Intell. Clin. Pharm.
5. Bastarrachea, J.; Hortobagyi, G. N.; Smith, T. L.; Kan, S. 1983, 23, 369-376.
W.; Buzdar, A. U. Obesity as an adverse prognostic factor
33. Ritchel, W. A.; Kaul, S. Prediction of apparent volumes of
for patients receiving adjuvant chemotherapy for breast
distribution in obesity. Methods Find Exp Clin Pharmacol
cancer. Ann. Intern. Med. 1994, 119, 18-25. 1986, 8, 239-247.
6. Cheymol, G. Clinical pharmacokinetics of drugs in obesity:
34. Doherty, J. E.; Perkins, W. H.; Flanigan, W. J. The distribu-
an update. Clin Pharmacokinet. 1993, 25, 103-114.
tion and concentration of tritiated digoxin in human tissues.
7. Blouin, R. A.; Chandler, M. H. H. Special pharmacokinetic
Ann. Intern. Med. 1967, 66, 116-124.
considerations in the obese. Applied pharmacokinetics: prin-
35. Rohrbaugh, T. M.; Danish, M.; Ragni, M. C.; Yaffe, S. J. The
ciples of therapeutic drug monitoring, 3rd ed.; Evans, W. E.,
effect of obesity on apparent volume of distribution of
Schentag, J. J., Jusko, W. J., Ed.; Applied Therapeutics:
theophylline. Pediatr. Pharmacol. 1982, 2, 75-83.
Vancouver, B.C., 1992; pp 11.3-11.20.
36. Gal, P.; Jusko, W. J.; Yurchak, A. M.; Franklin, B. A.
8. Cheymol, G. Drug pharmacokinetics in the obese. Fundam.
Theophylline disposition in obesity. Clin. Pharmacol. Ther.Clin. Pharmacol. 1988, 2, 239-256. 1978, 23, 438-444.
9. Blouin, R. A.; Kolpek, J. H.; Mann, H. J. Influence of obesity
37. Rizzo, A.; Mirabella, A.; Bonanno, A. Effect of body weight
on drug disposition. Clin. Pharmacy 1987, 6, 706-714.
on the volume of distribution of theophylline. Lung 1988, 166,
10. Abernethy, D. R.; Greenblatt, D. J. Drug disposition in obese
humans: an update. Clin. Pharmacokinet. 1986, 11, 199-
38. Schwartz, S. N.; Pazin, G. J.; Lyon, J. A.; Ho, M.; Pasculle,
A. W. A controlled investigation of the pharmacokinetics of
11. Abernethy, D. R.; Greenblatt, D. J.; Divoll, M.; Harmatz, J.
gentamicin and tobramycin in obese subjects. J Infect. Dis
S.; Shader, R. I. Alterations in drug distribution and clear-
1978, 138, 499-505.
ance due to obesity. J Pharmacol. Exp. Ther. 1981, 217, 681-
39. Blouin, R. A.; Mann, H. J.; Griffen, W. O., Jr; Bauer, L. A.;
Record, K. E. Tobramycin pharmacokinetics in morbidly
12. Corcoran, G. B.; Salazar, D. E.; Sorge, C. L. Pharmacokinetic
obese patients. Clin. Pharmacol. Ther. 1979, 26, 508-512.
characteristics of the obese overfed rat model. Int. J. Obes.
40. Bauer, L. A.; Blouin, R. A.; Griffen, W. O., Jr; Bauer, L. A.;
1989, 13, 69-79.
Record, K. E. Amikacin pharmacokinetics in morbidly obese
13. Greenblatt, D. J.; Abernethy, D. R.; Locniskar, A.; Harmatz,
patients. Am. J. Hosp. Pharm. 1980, 3, 519-522.
J. S.; Limjuco, R. A.; Shader, R. I. Effect of age, gender, and
41. Varin, F.; Ducharme, J.; Theoret, Y.; Besner, J. G.; Bevan,
obesity on midazolam kinetics. Anesthesiology 1984, 61, 27-
D. R.; Donati, F. Influence of extreme obesity on the body
disposition and neuromuscular blocking effect of atracurium.
14. Bowman, S. L.; Hudson, S. A.; Simpson, G.; Munro, J. F.;
Clin. Pharmacol. Ther. 1990, 48, 18-25.
Clements, J. A. A comparison of the pharmacokinetics of
42. Le Jeunne, C. L.; Poirier, J. M.; Cheymol, G.; Ertzbischoff,
propanolol in obese and normal volunteers. Br. J. Clin.
O.; Engel, F.; Hugues, F. C. Pharmacokinetics of intravenous
Pharmacol. 1986, 21, 529-532.
bisoprolol in obese and nonobese volunteers. Eur. J. Clin.
15. Flechner, S. M.; Kolbeinsson, M. E.; Tam, J.; Lum, B. The
Pharmacol. 1991, 41, 171-174.
impact of body weight on cyclosporine pharmacokinetics in
43. Cheymol, G.; Woestenborghs, R.; Snoeck, E.; Ianucci, R.; Le
renal transplant recipients. Transplantation 1989, 47, 806-
Moing, J. P.; Naditch, L.; Levron, J. C.; Poirier, J. M.
Pharmacokinetic study and cardiovascular monitoring of
16. Cheymol, G.; Weissenburger, J.; Poirier, J. M.; Gellee, C. The
nebivolol in normal and obese subjects. Eur. J. Clin. Phar-
pharmacokinetics of dexfenfluramine in obese and nonobese
macol. 1997, 51, 493-498.
subjects. Br. J. Clin. Pharmacol. 1995, 39, 684-687.
44. Abernethy, D. R.; Greenblatt, D. J. Phenytoin disposition in
17. Rowland, M.; Tozer, T. N. Clinical Pharmacokinetics: Con-
obesity. Arch. Neurol. 1985, 42, 468-471. cepts and Applications, 2nd ed.; Lea and Febiger: Philadel-
45. Cheymol, G. Comparative pharmacokinetics of intravenous
propanolol in obese and normal volunteers. J. Clin. Phar-
18. Benedek, I. H.; Fiske, W. D., III; Griffen, W. O.; Bell, R. M.;
macol. 1987, 27, 874-879.
Blouin, R. A.; McNamara, P. J. Serum alpha1-acid glycopro-
46. Derry, C. L.; Kroboth, P. D.; Pittenger, A. L.; Kroboth, F. J.;
tein and the binding of drugs in obesity. Br. J. Clin.
Corey, S. E.; Smith, R. B. Pharmacokinetics and pharmaco-
Pharmacol. 1983, 16, 751-754.
dynamics of triazolam after two intermittent doses in obese
19. Benedek, I. H.; Blouin, R. A.; McNamara, P. J. Serum protein
and normal-weight men. J. Clin. Psychopharmacol. 1995, 15,
binding and the role of increased alpha1-acid glycoprotein
in moderately obese male subjects. Br. J. Clin. Pharmacol.
47. Abernethy, D. R.; Schwartz, J. B. Verapamil pharmacody-
1984, 18, 941-946.
namics and disposition in obese hypertensives J. Cardiovasc.
20. Kjellberg, J.; Reizenstein, P. Body composition in obesity. Pharmacol. 1988, 11, 209-215. Acta Med. Scand. 1970, 188, 161-169.
48. Abernethy, D. R.; Greenblatt, D. J.; Divoll, M.; Shader, R. I.
21. Naeye, R. L.; Rode, P. The sizes and numbers of cells in
Prolongation of drug half-life due to obesity: studies of
visceral organs in human obesity. Am. J. Clin. Pathol. 1970,
desmethyldiazepam (clorazepate). J. Pharm. Sci. 1982, 7,
22. Smith, H. L. The relation of the weight of the heart to the
49. Sherlock, S. Diseases of the liver biliary system, 7th ed.;
weight of the body and of the weight of the heart to age. Am.
Blackwell Scientific Publications: Boston, 1985, p 384. Heart J. 1928, 4, 79-93.
50. Vaughan, R. W. Definitions and risks of obesity. In Anes-
23. Alexander, J. K.; Dennis, E. W.; Smith, W. G.; Amad, K. H.;
thesia and the Obese Patient; Brown, B. R., Ed.; 1982; F. A.
Duncan, W. C.; Austin, R. C. Blood volume, cardiac output,
and disposition of systemic blood flow in extreme obesity.
51. Caraco, Y.; Zylber-Katz, E.; Berry, E. M.; Levy, M. Antipyrine
Cardiovasc. Res. Cent. Bull. 1962-1963, 1, 39-44.
disposition in obesity: evidence for negligible effect of obesity
24. Alexander, J. K. Obesity and cardiac performance. Am. J.
on hepatic oxidative metabolism. Eur. J. Clin. Pharmacol.Cardiol. 1964, 14, 860-865. 1995, 47, 525-530. 6 / Journal of Pharmaceutical Sciences
52. Hunt, C. M.; Watkins, P. B.; Saenger, P.; Stave, G. M.;
75. Gronert, G. A. Disuse atrophy with resistance to pancuro-
Barlascini, N.; Watlington, C. O.; Wright, J. T.; Guzelian, P.
nium. Anesthesiology 1981, 55, 547-549.
S. Heterogeneity of CYP3A isoforms metabolizing erythro-
76. Irizar, A.; Barnett, C. R.; Flatt, P. R.; Ioannides, C. Defective
mycin and cortisol. Clin. Pharmacol. Ther. 1992, 51, 18-23.
expression of cytochrome P450 proteins in the liver of the
53. Hunt, C. M.; Westerkam, W. R.; Stave, G. M.; Wilson, J. A.
genetically obese zucker rat. Eur. J. Pharmacol. Environ.
P. Hepatic cytochrome P-4503A (CYP3A) activity in the
Toxicol. Pharmacol. Sect. 1995, 293, 385-393.
elderly. Mech. Aging Dev. 1992, 64, 189-199.
77. Raucy, J. L.; Lasker, J. M.; Kraner, J. C.; Salazar, D. E.;
54. Abernethy, D. R.; Greenblatt, D. J.; Divoll, M.; Shader, R. I.
Lieber, C. S.; Corcoran, G. B. Induction of cytochrome
Enhanced glucuronide conjugation of drugs in obesity: stud-
P450IIE1 in the obese overfed rat. Mol. Pharmacol. 1991,
ies of lorazepam, oxazepam, and acetaminophen. J. Lab.Clin. Med. 1983, 101, 873-880.
78. Corcoran, G. B.; Wong, B. K. Obesity as a risk factor in drug-
55. Abernethy, D. R.; Divoll, M.; Greenblatt, D. J.; Ameer, B.
induced organ injury: increased liver and kidney damage
Obesity, sex, and acetaminophen disposition. Clin. Pharma-
by acetaminophen in the obese overfed rat. J. Pharmacol.col. Ther. 1982, 31, 783-790. Exp. Ther. 1987, 241, 921-927.
56. Cummins, A. J.; King, K. L.; Martin, B. K. A kinetic study
79. Salazar, D. E.; Sorge, C. L.; Corcoran, G. B. Obesity as a risk
of drug elimination: the excretion of paracetamol and its
factor for drug-induced organ injury VI: increased hepatic
metabolites in man. Br. J. Pharm. Chem. 1967, 29, 150-
P450 concentration and microsomal ethanol oxidizing activity
in the obese overfed rat. Biochem. Biophys. Res. Commun.
57. Greenblatt, D. J.; Abernethy, D. R.; Boxenbaum, H. G.;
1988, 157, 315-320.
Matlis, R.; Ochs, H. R.; Harmatz, J. S.; Shader, R. I. Influence
80. Chaudhary, I. P.; Tuntaterdtum, S.; McNamara, P. J.;
of age, gender, and obesity on salicylate kinetics following
Robertson, L. W.; Blouin, R. A. Effect of genetic obesity and
doses of aspirin. Arthritis Rheum 1986, 29, 971-980.
phenobarbitol treatment on the hepatic conjugation path-
58. Rafecas, I.; Fernandez-Lopez, J. A.; Salinas, I.; Formiguera,
ways. J. Pharmacol. Exp. Ther. 1993, 265, 1333-1338.
X.; Remesar, X.; Foz, M.; Alemany, M. Insulin degradation
81. Barnett, C. R.; Abbott, R. A.; Bailey, C. J.; Flatt, P. R.;
by adipose tissue is increased in human obesity. J. Clin.
Ioannides, C. Cytochrome P450-dependent mixed-function
Endocr. Metab. 1995, 80, 693-695.
oxidase and glutathione-S-transferase activities in spontane-
59. Milsap, R. L.; Plaisance, K. I.; Jusko, W. J. Prednisolone
ous obesity diabetes. Biochem. Pharmacol. 1992, 43, 1868-
disposition in obese men. Clin. Pharmacol. Ther. 1984, 36,
82. Sastre, J.; Pallardo, F. V.; Llopis, J.; Furukawa, T.; Vina, J.
60. Caraco, Y.; Zylber-Katz, E.; Berry, E. M.; Levy, M. Significant
R.; Vina, J. Glutathione depletion by hyperphagia-induced
weight reduction in obese subjects enhances carbamazepine
obesity. Life Sci. 1989, 45, 183-187.
elimination. Clin. Pharmacol. Ther. 1992, 51, 501-506.
83. Naggert, J.; Harris, T.; North, M. The genetics of obesity.
61. Caraco, Y.; Zylber-Katz, E.; Berry, E. M.; Levy, M. Carbam-
Curr. Opin. Genet. Dev. 1997, 7, 398-404.
azepine pharmacokinetics in obese and lean subjects. Ann.
84. Pi-Sunyer, F. X. Energy balance: role of genetics and activity. Pharmacother. 1995, 29, 843-847. Ann. N.Y. Acad. Sci. 1997, 819, 29-36.
62. Davis, R. L.; Quenzer, R. W.; Bozigian, H. P.; Warner, C. W.
85. Saladin, R.; Staels, B.; Auwerx, J.; Briggs, M. Regulation of
Pharmacokinetics of ranitidine in morbidly obese women.
ob gene expression in rodents and humans. Horm. Metab.
DICP Ann. Pharmacother. 1990, 24, 1040-1043. Res. 1996, 28, 638-41.
63. Stokholm, K. H.; Brochner-Mortenson, J.; Hoilund-Carlsen,
86. Roberts, S. B.; Greenberg, A. S. The new obesity genes. Nutr.
P. F. Glomerular filtration rate and adrenocortical function
Rev. 1996, 54, 41-49.
in obese women. Int. J. Obes. 1980, 4, 57-63.
87. Zhang, Y.; Proneca, R.; Maffei, M.; Barone, M.; Leopold, L.;
64. Dionne, R. E.; Bauer, L. A.; Gibson, G. A.; Griffen, W. O., Jr;
Friedman, J. M. Positional cloning of the mouse obese gene
Blouin, R. A. Estimating creatinine clearance in morbidly
and its human analogue. Nature 1994, 372, 425-432.
obese patients. Am. J. Hosp. Pharm. 1981, 38, 841-844.
88. Campfield, L. A.; Smith, F. J.; Burn, P. The QB protein
65. Ducharme, M. P.; Slaughter, R. L.; Edwards, D. J. Vanco-
(leptin) pathway: a link between adipose tissue mass and
mycin pharmacokinetics in a patient population: effect of
central neural networks. Horm. Metab. Res. 1996, 28, 619-
age, gender, and body weight. Ther Drug Monit 1994, 16,
89. Considine, R. V.; Caro, J. F. Leptin: genes, concepts, and
66. Reiss, R. A.; Haas, C. E.; Karki, S. D.; Gumbiner, B.; Welle,
clinical perspective. Horm. Res. 1996, 46, 249-256.
S. L.; Carson, S. W. Lithium pharmacokinetics in the obese.
90. Caro, J. F.; Sinha, M. K.; Kolaczynski, J. W.; Zhang, P. L.;
Clin. Pharmacol. Ther. 1994, 55, 392-398.
Considine, R. V. Leptin: the tale of an obesity gene. Diabetes
67. Allard, S.; Kinzig, M.; Boivin, G.; Sorgel, F.; LeBel, M. 1996, 45, 1455-1462.
Intravenous ciprofloxacin disposition in obesity. Clin. Phar-
91. Georgiadis, M. S.; Steinberg, S. M.; Hankins, D. C.; Johnson,
macol. Ther. 1993, 54, 368-373.
B. E. Obesity and therapy related toxicity in patients treated
68. Bauer, L. A.; Edwards, W. A.; Dellinger, E. P.; Simonowitz,
for small-cell lung cancer. J. Nat. Cancer Inst. 1995, 87, 361-
D. A. Influence of weight on aminoglycoside pharmacokinet-
ics in normal weight and morbidly obese patients. Eur. J.
92. Vance-Bryan, K.; Guay, D. R.; Rotschafer, J. C. Clinical
Clin. Pharmacol. 1983, 24, 643-647.
pharmacokinetics of ciprofloxacin. Clin. Pharmacokinet.
69. Korsager, S. Administration of gentamicin to obese patients. 1990, 19, 434-461. Int. J. Clin. Pharmacol. Ther. Toxicol. 1980, 18, 549-553.
93. DePaulo, J. R.; Correa, E. I.; Sapir, D. G. Renal toxicity of
70. Sketris, L.; Lesar, T.; Zaske, D. E.; Cipolle, R. J. Effect of
lithium and its implications. Johns Hopkins Med. J. 1981,
obesity on gentamicin pharmacokinetics. J. Clin. Pharmacol.1981, 21, 228-293.
94. O′Shea, D.; Davis, S. N.; Kim, R. B.; Wilkinson, G. R. Effect
71. Blouin, R. A.; Bauer, L. A.; Miller, D. D.; Record, K. E.;
of fasting and obesity in humans on the 6-hydroxylation of
Griffen, W. O., Jr. Vancomycin pharmacokinetics in normal
chlorzoxazone: a putative probe of CYP2E1 activity. Clin.
and morbidly obese subjects. Antimocrob. Agents Chemother.Pharmacol. Ther. 1994, 56, 359-367. 1982, 21, 575-580.
95. Drayer, D. E.; Romankiewicz, J.; Lorenzo, B.; Reidenberg,
72. Abernethy, D. R.; Greenblatt, D. J.; Matlis, R.; Gugler, R.
M. M. Age and renal clearance of cimetidine. Clin. Pharma-
Cimetidine disposition in obesity. Am. J. Gastroenterol. 1984, col. Ther. 1982, 31, 45-50.
73. Bauer, L. A.; Wareing-Tran, C.; Edwards, W. A.; Raisys, V.;
Ferreri, L.; Jack, R.; Dellinger, E. P. Cimetidine clearance in the obese. Clin. Pharmacol. Ther. 1985, 37, 425-530.
G.W. was supported, in part, by an NIEHS Training Grant
74. Waud, B. E.; Waud, D. R. Turboaurarine sensitivity of the
diaphragm after limb immobilizaiton. Anesth. Analg. 1986, 65, 493-495. Journal of Pharmaceutical Sciences / 7
Use of Small Particles in Ultra High Pressure Liquid Chromatography L. Pereira1, C. Blythe1, R. Sherant2, H. Ritchie1 1Thermo Electron Corporation, Runcorn, UK, 2Thermo Electron Corporation, Bellefonte, PA Abstract Resolution and sensitivity The work presented in this poster demonstrates how 1.9 µm particles facilitate higher resolution, A separation on a 200 x 2.1mm, 5 µm
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