19
LESSON
2
Basic Pharmacokinetics
To examine the concept of volume of distribution (volume
of distribution may be represented by “V” or “Vd”)
further, let’s return to our example of the body as a tank
described in Lesson 1. We assumed that no drug was
being removed from the tank while we were determining
volume. In reality, drug concentration in the body is
constantly changing, primarily due to elimination. This
flux makes it more difficult to calculate the volume in
which a drug distributes.
One way to calculate the apparent volume of drug distribution
in the body is to measure the plasma concentration
immediately after intravenous administration before
elimination has had a significant effect. The concentration
just after intravenous administration (at time zero,
t0) is abbreviated as C0 (Figure 2-1). The volume of distribution
can be calculated using the equation:
(See Equation 1-1.)
C0 can be determined from a direct measurement or
estimated by back-extrapolation from concentrations
determined at any time after the dose. If two concentrations
have been determined, a line containing the two
values and extending through the y-axis can be drawn
on semilog paper. The point where that line crosses the
y-axis gives an estimate of C0. Both the direct measurement
and back-extrapolation approaches assume that
the drug distributes instantaneously into a single homogeneous
compartment.
The volume of distribution is an important parameter
for determining proper drug dosing regimens. Often
referred to as the apparent volume of distribution, it does
not have an exact physiologic significance, but it can indicate
the extent of drug distribution and aid in determination
of dosage requirements. Generally, dosing is
proportional to the volume of distribution. For example:
the larger the volume of distribution, the larger a dose
must be to achieve a desired target concentration.
To understand how distribution occurs, you must
have a basic understanding of body fluids and tissues
(Figure 2-2). The fluid portion (water) in an adult makes
up approximately 60% of total body weight and is comC
O B J E C T I V E S
After completing Lesson 2, you should be able to:
1. Define the concept of apparent volume of distribution
and use an appropriate mathematical equation
to calculate this parameter.
2. Identify the components of body fluids that make
up extracellular and intracellular fluids and know
the percentage of each component.
3. Describe the difference between whole blood,
plasma, and serum.
4. Define drug clearance.
5. Describe the difference between first- and zeroorder
elimination and how each appears graphically.
volume of
distribution
amount of drug
administe
=
rred (dose)
initial drug
concentration
or V Ld( ) =
X
C
0
0
(mg)
(mg/L)
20 Concepts in Clinical Pharmacokinetics
posed of intracellular fluid (35%) and extracellular fluid
(25%). Extracellular fluid is made up of plasma (4%)
and interstitial fluid (21%). Interstitial fluid surrounds
cells outside the vascular system. These percentages
vary somewhat in a child.
If a drug has a volume of distribution of approximately
15–18 L in a 70-kg person, we might assume that its distribution
is limited to extracellular fluid, as that is the
approximate volume of extracellular fluid in the body. If
a drug has a volume of distribution of about 40 L, the
drug may be distributing into all body water, because a
70-kg person has approximately 40 L of body water (70 kg
× 60%). If the volume of distribution is much greater than
40–50 L, the drug probably is being concentrated in tissue
outside the plasma and interstitial fluid.
If a drug distributes extensively into tissues, the volume
of distribution calculated from plasma concentrations
could be much higher than the actual physiologic
volume in which it distributes. For example, by measuring
plasma concentrations, it appears that digoxin distributes
in approximately 440 L in an adult. Because digoxin
binds extensively to muscle tissue, plasma levels are
fairly low relative to concentrations in muscle tissue. For
other drugs, tissue concentrations may not be as high as
the plasma concentration, so it may appear that these
drugs distribute into a relatively small volume.
It is also important to distinguish among blood, plasma,
and serum. Blood refers to the fluid portion in combination
with formed elements (white cells, red cells, and
platelets). Plasma refers only to the fluid portion of blood
(including soluble proteins but not formed elements).
When the soluble protein fibrinogen is removed from
plasma, the remaining product is serum (Figure 2-3).
These differences in biologic fluids must be recognized
when considering reported drug concentrations.
The plasma concentration of a drug may be much less
than the whole blood concentration if the drug is preferentially
sequestered by red blood cells.
ᮁCLINICAL CORRELATE
Most drug concentrations are measured using plasma
or serum that usually generate similar values. It is
more relevant to use plasma or serum than whole
blood measurements to estimate drug concentrations
at the site of effect. However, some drugs, such as
antimalarials, are extensively taken up by red blood
cells. In these situations, whole blood concentrations
would be more relevant, although they are not commonly
used in clinical practice.
CLEARANCE
Another important parameter in pharmacokinetics is
clearance. Clearance is a measure of the removal of drug
from the body. Plasma drug concentrations are affected
by the rate at which drug is administered, the volume in
which it distributes, and its clearance. A drug’s clearance
and the volume of distribution determine its halflife.
The concept of half-life and its relevant equations
are discussed in Lesson 3.
Clearance (expressed as volume/time) describes the
removal of drug from a volume of plasma in a given unit of
time (drug loss from the body). Clearance does not indiFIGURE
2-1.
Concentration resulting immediately after an intravenous
injection of a drug is referred to as C0.
FIGURE 2-2.
Fluid distribution in an adult.
FIGURE 2-3.
Relationship of whole blood, plasma, and serum.
Lesson 2: Basic Pharmacokinetics 21
cate the amount of drug being removed. It indicates the
volume of plasma (or blood) from which the drug is completely
removed, or cleared, in a given time period. Figures
2-4 and 2-5 represent two ways of thinking about drug
clearance. In Figure 2-4, the amount of drug (the number
of dots) decreases but fills the same volume, resulting in a
lower concentration. Another way of viewing the same
decrease would be to calculate the volume that would be
drug-free if the concentration were held constant.
Drugs can be cleared from the body by many different
mechanisms, pathways, or organs, including hepatic
biotransformation and renal and biliary excretion. Total
body clearance of a drug is the sum of all the clearances
by various mechanisms.
ᮅ
2-1
where
Clt = total body clearance (from all mechanisms,
where t refers to total);
Clr = renal clearance (through renal excretion);
Clm = clearance by liver metabolism or biotransfor-
mation;
Clb = biliary clearance (through biliary excretion); and
Clother = clearance by all other routes (gastrointestinal
tract, pulmonary, etc.).
For an agent removed primarily by the kidneys, renal
clearance (Clr) makes up most of the total body clearance.
For a drug primarily metabolized by the liver,
hepatic clearance (Clm) is most important.
A good way to understand clearance is to consider a
single well-perfused organ that eliminates drug. Blood
flow through the organ is referred to as Q (mL/minute)
as seen in Figure 2-6, where Cin is the drug concentration
in the blood entering the organ and Cout is the drug
concentration in the exiting blood. If the organ eliminates
some of the drug, Cin is greater than Cout.
We can measure an organ’s ability to remove a drug
by relating Cin and Cout. This extraction ratio (E) is:
This ratio must be a fraction between zero and one.
Organs that are very efficient at eliminating a drug will
have an extraction ratio approaching one (i.e., 100%
extraction). Table 2-1 is used as a general guide.
The drug clearance of any organ is determined by
blood flow and the extraction ratio:
or:
ᮅ
2-2
FIGURE 2-4.
Decrease in drug concentration due to drug clearance.
FIGURE 2-5.
Clearance may be viewed as the volume of plasma from which
drug is totally removed over a specified period.
Elimination
over time
Initial
concentration
Resulting
concentration
Cl Cl Cl Cl Clothert r m b= + + +
Elimination
over time
Initial
concentration
Resulting
concentration
Volume from
which drug is
removed over time
FIGURE 2-6.
Model for organ clearance of a drug.
TABLE 2-1.
Rating of Extraction Ratios
Extraction Ratio (E) Rating
> 0.7 High
0.3–0.7 Intermediate
< 0.3 Low
E
C C
C
=
−in
in
out
organ clearance blood flow extraction ratio= ×
Cl or Clorgan
in out
in
organ= ×
−
=Q
C C
C
QE
22 Concepts in Clinical Pharmacokinetics
If an organ is very efficient in removing drug (i.e.,
extraction ratio near one) but blood flow is low, clearance
will also be low. Also, if an organ is inefficient in
removing drug (i.e., extraction ratio close to zero) even
if blood flow is high, clearance would again be low. See
Table 2-2.
The equations noted previously are not used routinely
in clinical drug monitoring, but they describe the concept
of drug clearance. Examination of a single well-perfused
organ to understand clearance is a noncompartmental
approach; no assumptions about the number of compartments
have to be made. Therefore, clearance is said to be
a model-independent parameter. Clearance also can be
related to the model-dependent parameters volume of
distribution and elimination rate (discussed in Lesson 3).
Clearance can also be a useful parameter for constructing
dosage recommendations in clinical situations.
It is an index of the capacity for drug removal by the
body organs.
ᮁCLINICAL CORRELATE
Blood flow and the extraction ratio will determine a
drug’s clearance. Propranolol is a drug that is eliminated
exclusively by hepatic metabolism. The extraction
ratio for propranolol is greater than 0.9, so most of
the drug presented to the liver is removed by one pass
through the liver. Therefore, clearance is approximately
equal to liver blood flow (Cl = Q × E: when E ~
1.0, Cl ~ Q). One indication of the high extraction ratio
is the relatively high oral dose of propranolol compared
with the intravenous dose; an oral dose is 10–20
times the equivalent intravenous dose. The difference
reflects the amount of drug removed by first-pass
metabolism after absorption from the gastrointestinal
tract and before entry into the general circulation.
The average clearances of some commonly used drugs
are shown in Table 2-3. These values can vary considerably
between individuals and may be altered by disease.
FIRST-ORDER AND
ZERO-ORDER ELIMINATION
The simplest example of drug elimination in a onecompartment
model is a single intravenous bolus dose
of a drug. It is first assumed that:
1. Distribution and equilibration to all tissues and fluids
occurs instantaneously, so a one-compartment
model applies.
2. Elimination is first order.
Most drugs are eliminated by a first-order process, and
the concept of first-order elimination must be understood.
With first-order elimination, the amount of drug
eliminated in a set amount of time is directly proportional
to the amount of drug in the body. The amount of
drug eliminated over a certain time period increases as
the amount of drug in the body increases; likewise, the
amount of drug eliminated per unit of time decreases as
the amount of drug in the body decreases. This concept is
different from zero-order elimination, in which the
amount of drug eliminated for each time interval is constant,
regardless of the amount of drug in the body.
With the first-order elimination process, although the
amount of drug eliminated may change with the amount
of drug in the body, the fraction of a drug in the body
eliminated over a given time remains constant. In practical
terms, the fraction or percentage of drug being
removed is the same with either high or low drug concentrations.
For example, if 1000 mg of a drug is administered
and the drug follows first-order elimination, we might
observe the patterns in Table 2-4.
The actual amount of drug eliminated is different for
each fixed time period, depending on the initial amount
in the body, but the fraction removed is the same, so
this elimination is first order. Because the elimination of
TABLE 2-2.
Effect on Clearance
Extraction
Ratio (E)
Blood Flow (Q)
(L/hour)
Clearance (Cl)
(L/hour)
High (0.7–1.0) Low Low
Low (< 0.3) High Low
High (0.7–1.0) High High
Low (< 0.3) Low Low
TABLE 2-3.
Average Clearances of Common Drugs
Amlodipine 5.9 ± 1.5 mL/min/kg
Ganciclovir 3.4 ± 0.5 mL/min/kg
Ketorolac 0.50 ± 0.15 mL/min/kg
Lansoprazole 6.23 ± 1.60 mL/min/kg
Montelukast 0.70 ± 0.17 mL/min/kg
Sildenafil 6.0 ± 1.1 mL/min/kg
Valsartan 0.49 ± 0.09 mL/min/kg
Source: Brunton LL, Lazo JS, Parker KL, (editors), The Pharmacologic
Basis of Therapeutics, 11th edition. New York: McGrawHill;
2006. pp. 1798, 1829, 1839, 1840, 1851, 1872, 1883.
Lesson 2: Basic Pharmacokinetics 23
this drug (like most drugs) occurs by a first-order process,
the amount of drug eliminated decreases as the
concentration in plasma decreases. The actual fraction
of drug eliminated over any given time (in this case
12%) depends on the drug itself and the individual
patient’s capacity to eliminate the drug.
On the other hand, with zero-order elimination, the
amount of drug eliminated does not change with the
amount or concentration of drug in the body, but the fraction
removed varies (Figure 2-7). For example, if 1000 mg
of a drug is administered and the drug follows zero-order
elimination, we might observe the patterns in Table 2-5.
Now that we have examined zero- and first-order elimination,
let’s return to our simple one-compartment, intravenous
bolus situation. If the plasma drug concentration
is continuously measured and plotted against time after
administration of an intravenous dose of a drug with firstorder
elimination, the plasma concentration curve shown
TABLE 2-4.
First-Order Elimination
Time after Drug
Administration (hours)
Amount of Drug
in Body (mg)
Amount of Drug Eliminated
Over Preceding Hour (mg)
Fraction of Drug Eliminated
Over Preceding Hour
0 1000 — —
1 880 120 0.12
2 774 106 0.12
3 681 93 0.12
4 599 82 0.12
5 527 72 0.12
6 464 63 0.12
7 408 56 0.12
FIGURE 2-7.
Zero- versus first-order elimination. The size of the arrow represents
the amount of drug eliminated over a unit of time. Percentages
are the fraction of the initial drug amount remaining
in the body.
TABLE 2-5.
Zero-Order Elimination
Time after Drug
Administration (hours)
Amount of Drug
in Body (mg)
Amount of Drug Eliminated
Over Preceding Hour (mg)
Fraction of Drug Eliminated
Over Preceding Hour
0 1000 — —
1 850 150 0.15
2 700 150 0.18
3 550 150 0.21
4 400 150 0.27
5 250 150 0.38
24 Concepts in Clinical Pharmacokinetics
in Figure 2-8 would result. To predict concentrations at
times when we did not collect samples, we must linearize
the plot by using semilog paper (Figure 2-9).
For a drug with first-order elimination, the natural log
of plasma concentration versus time plot is a straight line.
Conversely, plots with zero-order elimination would be as
shown in Figure 2-10. Note that for a drug with zero-order
elimination, the plot of the plasma concentration versus
time is linear (plot A in Figure 2-10), whereas on semilog
paper (representing the natural log of plasma concentration
versus time) it is a curve (bottom plot in Figure 2-10).
If the natural log of a plasma drug concentration versus
time plot is linear, it generally can be assumed that the
drug follows first-order elimination.
ᮁCLINICAL CORRELATE
Most antimicrobial agents (e.g., aminoglycosides,
cephalosporins, and vancomycin) display first-order
elimination when administered in usual doses. The
pharmacokinetic parameters for these drugs are not
affected by the size of the dose given. As the dose
and drug concentrations increase, the amount of drug
eliminated per hour increases while the fraction of
drug removed remains the same.
Some drugs (e.g., phenytoin), when given in high
doses, display zero-order elimination. Zero-order elimination
occurs when the body’s ability to eliminate a
drug has reached its maximum capability (i.e., all
transporters are being used). As the dose and drug
concentration increase, the amount of drug eliminated
per hour does not increase, and the fraction of
drug removed declines.
FIGURE 2-8.
Plasma drug concentration versus time after an intravenous
(bolus) drug dose, assuming a one-compartment model with
first-order elimination (linear y-scale).
FIGURE 2-9.
As in Figure 2-8, but with a log scale y-axis.
FIGURE 2-10.
Plasma drug concentrations versus time after an intravenous
(bolus) drug dose, assuming a one-compartment model with
zero-order elimination (A, linear plot; B, log plot).
A
B
Lesson 2: Basic Pharmacokinetics 25
❚ Review Questions ______________________________________
2-1. The volume of distribution equals _________
divided by initial drug concentration:
A. clearance
B. initial drug concentration
C. half-life
D. dose
2-2. A dose of 1000 mg of a drug is administered to a
patient, and the following concentrations result at
the indicated times below. Assume a one-compartment
model.
An estimate of the volume of distribution would be:
A. 10 L.
B. 22.2 L.
C. 6.7 L.
D. 5 L.
2-3. If a drug is poorly distributed to tissues, its apparent
volume of distribution is probably:
A. large.
B. small.
2-4. For the body fluid compartments below, rank them
from the lowest volume to the highest, in a typical
70-kg person.
A. Plasma < extracellular fluid < intracellular
fluid < total body water
B. Extracellular fluid < intracellular fluid <
plasma < total body water
C. Intracellular fluid < extracellular fluid <
plasma < total body water
D. Total body water < plasma < intracellular fluid
< extracellular fluid
2-5. Plasma refers only to the fluid portion of blood,
including soluble proteins but not formed elements.
A. True
B. False
2-6. The units for clearance are:
A. concentration/half-life.
B. dose/volume.
C. half-life/dose.
D. volume/time.
2-7. Total body clearance is the sum of clearance by the
kidneys, liver, and other routes of elimination.
A. True
B. False
2-8. To determine drug clearance, we must first determine
whether a drug best fits a one- or two-compartment
model.
A. True
B. False
2-9. With a drug that follows first-order elimination, the
amount of drug eliminated per unit time:
A. remains constant while the fraction of drug
eliminated decreases.
B. decreases while the fraction of drug eliminated
remains constant.
❚ Answers _______________________________________________
2-1. A, B, C. Incorrect answers
D. CORRECT ANSWER. You can determine the
correct answer from the units in the numerator
and denominator. They should cancel to yield a
volume unit. “Grams” divided by “grams per liter”
would leave you with “liter” as the unit. The volume
is therefore determined from the dose, or
amount of drug given, and the resulting initial
concentration.
2-2. A. Incorrect answer. You may have used 100 mg/L
as the initial concentration.
B. Incorrect answer. You may have used an incorrect
initial concentration.
Plasma Concentration
(mg/L)
Time after Dose
(hours)
100 2
67 4
45 6
26 Concepts in Clinical Pharmacokinetics
C. CORRECT ANSWER. To find the initial concentration,
plot the given plasma concentration and
time values on semilog paper, connect the points,
and read the value of the y-axis (concentration)
when x (time) = 0. This should be 150 mg/L. You
can then determine the volume of distribution
using the equation volume of distribution =
dose/initial concentration.
D. Incorrect answer. You may have used an incorrect
initial concentration, or you may have used
linear graph paper instead of semilog paper.
2-3. A. Incorrect answer. Drug concentrations are generally
measured in plasma. When drug distributes
poorly into tissues, the plasma level will be
increased. Examining the equation volume of distribution
= dose/initial concentration, as the initial
concentration increases, the volume will decrease.
B. CORRECT ANSWER
2-4. A. CORRECT ANSWER. See Figure 2-2. Plasma
would be 2.8 L, extracellular fluid would be 18 L,
intracellular fluid would be 25 L, and total body
water would be 42 L.
B, C, D. Incorrect answers
2-5. A. CORRECT ANSWER
B. Incorrect answer
2-6. A, B, C. Incorrect answers. The units for clearance
are volume/time.
D. CORRECT ANSWER
2-7. A. CORRECT ANSWER. Total body clearance can
be determined as the sum of individual clearances
from all organs or routes of elimination.
B. Incorrect answer
2-8. A. Incorrect answer
B. CORRECT ANSWER. It is not necessary to specify
a model to determine drug clearance.
2-9. A. Incorrect answer
B. CORRECT ANSWER. With first-order elimination,
the amount of drug eliminated in any time
period is determined by the amount of drug
present at the start. Although the amount of drug
eliminated in successive time periods may
decrease, the fraction of the initial drug that is
eliminated remains constant.
Lesson 2: Basic Pharmacokinetics 27
Discussion Points
D-1. Drug Y is given by an intravenous injection and plasma concentrations are then determined
as follows:
Is this drug eliminated by a first- or zero-order process? Defend your answer.
D-2. Which of the following patient scenarios is associated with a smaller volume of distribution?
A. Dose = 500 mg and initial serum concentration is 40 mg/L
B. Dose = 20 mg and initial serum concentration is 1.5 mg/L
D-3. Explain how a person who weighs 70 kg can have a volume of distribution for a drug of 700 L.
D-4. For drug X, individual organ clearances have been determined as follows:
How would you describe the clearance of drug X?
Time after Injection
(hours)
Concentration
(mg/L)
0 12
1 9.8
2 7.9
3 6.4
4 5.2
5 4.2
6 3.4
7 2.8
8 2.2
Renal clearance 180 mL/minute
Hepatic clearance 22 mL/minute
Pulmonary clearance 5.2 mL/minute
28 blank