CLINICAL CHEMISTRY 2

TOXICOLOGY How Xenobiotics cause Toxicity

- is the study of the adverse effects of - Some xenobiotics cause toxicity by
chemical agents on biological systems. disrupting normal cell functions:
 Bind and damage proteins (structural
Toxicologists: enzymes)
 Involved in the recognition,  Bind and damage DNA (mutations)
identification, and quantitation of hazard  Bind and damage lipids
 Develops standards and regulations to  React in the cell with oxygen to form
protect health and environment “free radicals” which damage lipid,
 Involved in the safety assessment and protein, and DNA.
use of data as basis for regulatory
control of hazards Types of Toxic Effects
 Determines risk associated with the use  Death – arsenic, cyanide
of chemicals  Organ Damage – ozone, lead
 Mutagenesis – UV light
Risk Assessment:  Carcinogenesis – benzene, asbestos
 Hazard Identification  Teratogenesis – thalidomide
 Whether Physical, Chemical, Biological
 Dose Response Assessment Target Organ Toxicity
 Biological System  Central Nervous System – lead
 Exposure Assessment  Immune System – isocyanates
 Effect or Response  Liver – ethanol, acetaminophen
 Risk Characterization  Respiratory Tract – tobacco smoke,
 Exposure situation asbestos, ozone
 Eye – UV light (sunlight)
Major Factors that influence toxicity  Kidney – metals
 Route of administration  Skin – UV light, gold, nickel
 Duration and Frequency of Exposure  Reproductive System –
 Dose or concentration dibromochloropropane

Rapidly of Response with respect to Spectrum of Undersided Effects

route of exposure  Allergic reactions
 Intravenous  Chemical allergies
 Inhalation  Idiosyncratic reactions
 Intraperitoneally  Immediate vs. delayed toxicity
 Subcutaneous  Reversible vs. irreversible toxicity
 Intramuscular  Local vs. systemic toxicity
 Intradermal
 Topical
CLINICAL CHEMISTRY 2
Therapeutic Drug Monitoring (TDM) Indicators for therapeutic drug
 Is the use of drug concentration monitoring include:
measurements in body fluids as an aid  Toxicity
to the management of drug therapy for - diagnosing toxicity when the clinical
the cure, alleviation or prevention of syndrome is undifferentiated (unexplained
disease. nausea in a patient taking digoxin)
 The monitoring of therapeutic drugs - Avoiding toxicity (aminoglycoside,
involves measuring drug concentrations cyclosporine)
in plasma, serum or blood. This
information is used to individualize  Dosing
dosage so that drug concentrations can - After dose adjustment (usually after
be maintained within a target range. reaching a steady state)
 Therapeutic drug monitoring is useful - Assessment of adequate loading dose
only for drugs that have a poor (after starting phenytoin treatment)
correlation between dose and clinical - Dose forecasting to help predict a patient‟s
effect (high pharmacokinetic variability). dose requirements (aminoglycosides)
 TDM is not generally helpful in the
routine monitoring of patients. Examples  Monitoring
of this are the measurement of blood  The information required to allow
pressure during antihypertensive interpretation of the result should
theraphy; glucose in patients treated include the time of the sample
with heparin or warfarin, and cholesterol collection, the time of the last dose,
in patients treated with cholesterol- the dosage regimen and the
lowering drugs. indication for drug monitoring.
 Assessing compliance (anticonvulsant
The main reasons for measuring drugs concentrations in patients having
 To ensure that sufficient drug is frequent seizures)
reaching the drug receptor to produce  Diagnosing under treatment (particularly
the desired response (the onset of important for prophylactic drugs such as
which may be delayed) anticonvulsants, immunosuppressants)
 To ensure that drug (or metabolite)  Diagnosing failed therapy (therapeutic
concentrations are not so high as to drug monitoring can help distinguish
produce symptoms or signs of toxicity between ineffective drug treatment, non-
 To guide dosage adjustment in clinical compliance and adverse effects that
situations in which the pharmacokinetics mimic the underlying disease).
are changing rapidly (e.g., in neonates,
children or patients in whom hepatic or Terms
renal function in changing)  Pharmacokinetics may be defined as
 To define the pharmacokinetic what that body does to drugs (the
parameters and concentration effect processes of absorption, distribution,
relationships of new drugs. metabolism and excretion)
 Pharmacodynamics as what the drugs
do to the body (mechanisms of drug
action and
CLINICAL CHEMISTRY 2
biochemical/pathophysiological effects  Accurate information about the
such as tissue responsiveness, patient (name, identification number,
presence of other drugs and disease age, gender and pathology)
states).  The drug therapy (dose, formulation
 Bioavailable fraction – is the fraction of and route of administration, length of
the dose that reaches the blood therapy, date and time of last dose)
 Half-life – the time required to reduce a  The date and time of the sample are
drug level to half of its initial value essential for proper interpretation
 Therapeutic index – the ratio between  Additional information such as the
the minimum toxic and maximum patient‟s weight, renal and hepatic
therapeutic serum concentration function and other prescribed
 Therapeutic range – the difference medication may also be required in
between highest and lowest effective many circumstances.
dosage
 Trough concentration – the lowest Samples
concentration of a drug obtained in the Plasma or Serum is commonly used for
dosing interval drug assays.
 Whole blood: for Cyclosporine,
Commonly Monitored Drugs tacrolimus, sirolimus, as there are large
 Cardioactive drugs:digoxin, shifts of drug between red cells and
procainamide – normalize heart rhythm plasma with storage and temperature
 Antiepileptic: valproic acid, change.
phenobarbital, phenytoin,  Saliva, which gives a measure of the
carbamazepine – treatment of seizures unbound drug concentration, may be a
 Antibiotics: amikacin, gentamicin, useful alternative when blood samples
vancomycin, tobramycin are difficult to collect. Ex: Phenytoin,
 Immunosuppressants: cyclosporine, Lithium, Amitriptyline, Marijuana,
tacrolimus, sirolimus – prevent or Cocaine, Alcohol
minimize the risk of organ  Other Fluids of body
transplantation  Urine: Benzodiazepines
 Antidepressants: nortriptyline,  Sweat: Cocaine & Heroin
desipramine, lithium – increases the  Breath: Alcohol
effect of neurotransmitters
 Bronchdilators: theophylline – CNS  Timing of sample-taking is also
and cardiac stimulant, causes smooth important. Ensure complete absorption
muscle relaxation and diuresis and distribution
 Antineoplastic: methotrexate  For TDM to be meaningful, the patient
 Antipsychotic: promethazine – should be in steady state on the present
produce emotional calmness and mental dose of the drug. However, when
relaxation suspected toxicity is being investigated,
waiting to attain steady state is clearly
Requirements when making a request for contraindicated. The time taken to reach
TDM steady state is determined by the
elimination half-like of the drug. In
CLINICAL CHEMISTRY 2
practice, samples are taken after drug  Storage of samples: Plastic cryovial type
dosing has continued for at least four tubes are acceptable for most assays.
half-lives.  For CSA: Whole blood to be collected in
an EDTA tube.
 Blood specimens for drug monitoring  Analytical methods may be affected by
can be taken at two different times: temperature and all variables should be
during the drug‟s highest therapeutic standardized.
concentration („peak‟ level), or its lowest
(„trough‟ level). Occasionally called Drug criteria to be suitable for
residual levels, trough levels show therapeutic drug monitoring
sufficient therapeutic levels; whereas  Narrow target range
peak levels show toxicity.  Significant pharmacokinetic variability
 A reasonable relationship between
Sample Timing for some important drugs plasma concentrations and clinical
a) Phenytoin: Since phenytoin has a long effects
half-life a single daily dose may be  Established target concentration range
employed and so the timing of  Availability of cost-effective drug assay
concentration monitoring is not critical.
b) Carbamazepine: Its half life may be as
long as 48 hrs. following a single dose.
A trough concentration taken just after a
dose together with a peak level 3 hours
later is ideal.
c) Digoxin: The measurement must be
made at least 6 hours after a dose to
avoid inappropriate high levels.
d) Theophylline: This drug has a narrow
therapeutic index and timing of sampling
is not critical if the patient is receiving
one of the slow release formulations,
wherein through levels should be taken.
e) Lithium: A 12 hrs. sample gives the
most precise guide to dosage
adjustment.
f) Gentamicin: Pre dose peak; 0.5 hrs.
after i.v and 1hr. after i.m,
administration.
 Samples should be collected and
centrifuged as soon as possible.
 Avoid serum-separator tubes because
these may lower drugs concentrations
due to the adsorption of drug into the Antiepileptic Drugs (AEDs)
matrix.  AEDs – valproic acid, phenytoin,
carbamazepine, phenobarbital
CLINICAL CHEMISTRY 2
 Newer AEDs (lamotrigine,
gabapentin, topiramate, Techniques for measurement of TDM
levetiracetam, oxcarbazepine) are Chromatography
not widely monitored  HPLC: High Pressure Liquid
 There is a defined relationship Chromatography: The separation of
between blood concentration and a substance depends on the relative
seizure control. distribution of mixture constituents
 Large individual differences between between two phases, a mobile
dose and blood level phase (carrying the mixture) and a
 CYP450 metabolized, patients on stationary phase.
multiple drugs  GC/MS: Gas Chromatography is a
 Both under-dosing and over-dosing separation method using very high
can result in seizures temperatures to cause sample
vaporization. In mass
Antibiotics spectrophotometry the vaporized
 Most antibiotics (B-lactams, fractions are passed through an
macrolides, quinolones) have a wide electrical field. The molecules can
therapeutic index and do not require be separated on the basis of
monitoring. molecular weight. The pattern of
 Aminoglycosides (gentamicin, separation is unique to each drug
amikacin, streptomycin and and therefore establishes a
tobramycin) are bactericidal, it binds “fingerprint” for identification. GC/MS
to the bacterial ribosome is the gold standard method for the
 Used for treatment of gram (-) identification of drugs of abuse.
bacterial infection, may cause Enzyme Immunoassay
hearing loss  EIA uses a non-radioactive enzyme
 Vancomycin has an inhibitory effect label. The assays are performed in a
on the synthesis of the bacterial cell single step, i.e. only one antibody is
wall and cytoplasmic membrane. It used in the procedure
has a narrow therapeutic index and
toxicity may be severe or irreversible
(nephrotoxic)
 Used for treatment of gram (+)
bacterial infection, administered IV
 Only the trough levels are monitored
to ensure drug is within therapeutic
range
 Chloramphenicol
 Acts on gram (-) bacteria by
inhibition of protein synthesis, unlike
aminoglycosides it can be absorbed
in the GIT
 Toxic effect is blood dyscrasia
CLINICAL CHEMISTRY 2