Drug Elimination


Article Author:
Aaron Garza
Sharon Park


Article Editor:
Remek Kocz


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
9/28/2019 10:02:51 PM

Definition/Introduction

Drug elimination is the sum of the processes of removing an administered drug from the body.  In the pharmacokinetic ADME scheme (absorption, distribution, metabolism, and excretion) it is frequently considered to encompass both metabolism and excretion.   Hydrophobic drugs, to be excreted, must undergo metabolic modification making them more polar. Hydrophilic drugs, on the other hand, can undergo excretion directly, without the need for metabolic changes to their molecular structures. 

Although many sites of metabolism and excretion exist, the chief organ of metabolism is the liver, while the organ primarily tasked with excretion is the kidney.  Any significant dysfunction in either organ can result in accumulation of the drug or its metabolites in toxic concentrations.  

A variety of other factors impacts elimination — intrinsic drug properties, such as polarity, size, or pH.  Also, other factors include genetic variation among individuals, disease states affecting other organs, and pathways involved in the way the drug distributes through the body, such as first-pass metabolism.

Issues of Concern

Drug elimination is the removal of an administered drug from the body. It is accomplished in two ways, either by excretion of an unmetabolized drug in its intact form or by metabolic biotransformation followed by excretion.  While excretion is primarily carried out by the kidneys, other organ systems are involved as well. Similarly, the liver is the primary site of biotransformation, yet extrahepatic metabolism takes place in a variety of organ systems affecting multiple drugs. 

Given the multiple organ systems and the variety of metabolic transformations present, drug elimination can entail a significant degree of complexity. Hydrophilic drugs are typically directly excreted by the kidneys, while the hydrophobic drugs undergo biotransformation before excretion. The purpose here is twofold – biotransformation serves to both detoxify the exogenous substances as well as to increase their hydrophilicity, ensuring their elimination via the kidneys. 

Two broad metabolic pathways of hepatic drug transformation exist.  Phase I is the direct modification of the target molecule, whereas phase II entails conjugation of the target to a polar molecule of low molecular weight. Phase I prepares the drug to enter phase II, but single-phase metabolism also exists.[1][2]

Phase I involves oxidation, reduction, and hydrolysis of the exogenous molecule. These reactions are accomplished by hepatic microsomal enzymes, which reside in the smooth endoplasmic reticulum of the hepatocytes. Best known among them is the cytochrome P450 system, whose enzymes are predominantly involved in oxidative metabolism.  Within the cytochrome P450 family (CYP), the enzyme responsible for the metabolism of more than 50% of existing drugs is the CYP34A. Its activity encompasses various classes of medications, including opioids, immunosuppressants, antihistamines, and benzodiazepines. The enzymes can also be induced and inhibited by a variety of substances they interact with, including pharmaceuticals. The increase in metabolic activity with CYP induction results in diminished activity of drugs targeted by that particular isoform. Conversely, CYP inhibition will result in increased drug plasma concentration, potentially leading to toxicity. The CYP3A4 is induced by phenytoin, phenobarbital, and St. John's wart, while diltiazem, erythromycin, and grapefruit inhibit it.  Caution is therefore necessary when administering CYP3A4-metabolized drugs in the presence of any of the inhibitors or inducers.[3][4]

Phase II consists of covalent bonding of polar groups to nonpolar molecules to render them water-soluble and allow renal or biliary excretion. Target molecules enter phase II directly or via initial processing through phase I. A variety of polar adjuncts is transferred, including amino acids, glucuronic acid, glutathione, acetate, and sulfate.  Glucuronidation is one of the major pathways of phase II biotransformation. The UDP-glucuronosyltransferase enzyme family performs this activity. Typically, glucuronide derivatives possess less or no activity of the original drug, but in some cases, pharmacologically active compounds result. Morphine-6-glucuronide is a phase II metabolite of morphine with significant analgesic activity. As with the CYP enzymes, inducers, and inhibitors of phase II, enzymes exist and may influence the efficacy of drugs that rely on conjugation before excretion.

The first-pass effect is a feature of hepatic metabolism that also plays a role in the elimination of multiple drugs. Here, the enteric consumed drugs are exposed directly to the liver via the portal vein, where they undergo biotransformation before entering the systemic circulation. This activity reduces the bioavailability and needs to be factored into the dose administered to the patient. Intravenously administered drugs are not subject to the first-pass effect.

Extrahepatic drug metabolism takes place in the GI tract, kidneys, lungs, plasma, and skin.

Renal excretion completes the process of elimination that begins in the liver. Polar drugs or their metabolites get filtered in the kidneys and typically do not undergo reabsorption.[5] They subsequently get excreted in the urine.  Urinary pH has a significant impact on excretion, as drug ionization changes depending on the alkaline or acidic environment. Increased excretion occurs with weakly acidic drugs in basic urine, and weakly basic drugs in acidic urine.

Excretion in the bile is another significant form of drug elimination.  The liver can actively secrete ionized drugs with a molecular weight greater than 300 g/mol into bile, from where they reach the digestive tract and are either eliminated in feces or reabsorbed as part of the enterohepatic cycle.    

Other pathways of excretion include the lungs, breast milk, sweat, saliva, and tears.[6][7][8][9]

Clinical Significance

Hepatic diseases, such as liver cirrhosis, affect drugs eliminated via the liver. Compromise of phase I and II metabolic pathways will lead to increased half-lives of long-acting drugs, contributing to toxicity.  The decline in plasma protein in the setting of liver disease can lead to an increase in unbound drug fraction in plasma.  As liver disease increases in severity, the dose of a drug must be reduced to obtain the same effect. Changes in liver perfusion can also affect the metabolism of drugs. States of decreased blood flow to the liver, such as shock, hypovolemia, or hypotension, can lead to a decline in metabolic rate.

Renal disorders, such as chronic kidney disease, can reduce renal function hindering drug excretion. As kidney function declines with age, drug excretion becomes less efficient, and dosing adjustments may be needed.  Other than direct renal dysfunction, pathologies that impact renal blood flow or urine flow can affect drug elimination as well. Examples of such disorders are congestive heart failure, liver disease, and pathologies affecting antidiuretic hormone release.[10]

Nursing Actions and Interventions

Aging patients experience a decline in both the liver and kidney function. The Beers Criteria have been developed to allow for risk stratification in the older population and is useful when dosing medications in individuals over 65 years of age. Similarly, administration of drugs to patients affected by liver or kidney disease or exhibiting pathologies that may impact those organs must take dose adjustments into account. All drug inserts discuss specific concerns regarding renal and hepatic dosing.[11]

Nursing Monitoring

When taking care of patients with hepatic or renal disease or conditions affecting those organs, nurses must consider the fact that drug elimination may be affected. Drug doses may require reduction, and some drugs may require discontinuation. If the administration of a particular drug is absolutely necessary, careful monitoring for adverse effects is of the essence. In patients unaffected by liver or kidney pathology, the plasma concentration of drugs such as vancomycin or phenytoin still needs monitoring to ensure they remain in the therapeutic window.[12]


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Drug Elimination - Questions

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A 49-year-old former IV drug user who has been clean for the past 11 years and maintained on methadone presents with a two-day history of insomnia, diffuse muscle pains, severe nausea, and diarrhea. He states that he has not taken any additional doses of methadone beyond what he has been prescribed. His pupils are dilated and he appears agitated. He has recently been diagnosed with a seizure disorder and started on phenobarbital. Which of the following is the most likely cause of her symptoms?



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A patient presents to the emergency department with slurred speech and altered mental status after being pulled over by the police. On physical exam, there is nystagmus of her eyes bilaterally. What is the expected progression of elimination of the intoxicating agent in this patient?



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A 17-year-old patient with a history of systemic lupus erythematosus comes in with pain and burning with urination. She is sent home with trimethoprim/sulfamethoxazole. To prevent renal complications, which of the following should be part of the patient's home instructions?



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A patient comes into the emergency department saying that she forgot that she had taken her dose of phenobarbital for the day and just took another dose. To increase the excretion of the phenobarbital, the provider attempts to alkalinize the urine. Which of the following properties make a drug the most excretable by alkalinization of the urine?



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A patient with no past medical history who was recently diagnosed with bipolar disorder is found in her bed unconscious. Her mother states that she has been feeling like "life isn't worth living anymore" and found an empty bottle of her medication next to her bed. She is found to be acidotic, and the emergency team is considering hemodialysis for enhanced elimination of the drug. Which of the following properties of a drug make hemodialysis most useful for elimination?



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A 58-year-old man with hypertension, hyperlipidemia, osteoarthritis, and a long history of alcohol use disorder presents to the preoperative area. On physical exam, he is cachectic, with a pronounced bulging of the flanks, and his eye examination reveals jaundice. He is scheduled to undergo a transjugular intrahepatic portosystemic shunt (TIPS) procedure after which he will be admitted. What adjustments are most appropriate to the morphine doses he will be given to manage his post-procedural pain?



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A 67-year-old woman with a history of extreme obesity, poorly-controlled hypertension, type 2 diabetes maintained only with oral hypoglycemics, stage IV chronic renal failure, rheumatoid arthritis, and gout undergoes a complex revision of a ventral hernia. The anesthetist administers vecuronium as the muscle relaxant at induction. The surgeon begins closing after 1.5 hours, but the patient remains paralyzed. What is the most likely reason for this effect?



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Drug Elimination - References

References

Almazroo OA,Miah MK,Venkataramanan R, Drug Metabolism in the Liver. Clinics in liver disease. 2017 Feb;     [PubMed]
Corsini A,Bortolini M, Drug-induced liver injury: the role of drug metabolism and transport. Journal of clinical pharmacology. 2013 May;     [PubMed]
Bernhardt R, Cytochromes P450 as versatile biocatalysts. Journal of biotechnology. 2006 Jun 25;     [PubMed]
Zeng M,Yang L,He D,Li Y,Shi M,Zhang J, Metabolic pathways and pharmacokinetics of natural medicines with low permeability. Drug metabolism reviews. 2017 Nov;     [PubMed]
Leeson PD, Molecular inflation, attrition and the rule of five. Advanced drug delivery reviews. 2016 Jun 1;     [PubMed]
Transfer of drugs and other chemicals into human milk. Pediatrics. 2001 Sep;     [PubMed]
Johnson HL,Maibach HI, Drug excretion in human eccrine sweat. The Journal of investigative dermatology. 1971 Mar;     [PubMed]
Idkaidek NM, Comparative assessment of saliva and plasma for drug bioavailability and bioequivalence studies in humans. Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society. 2017 Jul;     [PubMed]
Stowe CM,Plaa GL, Extrarenal excretion of drugs and chemicals. Annual review of pharmacology. 1968;     [PubMed]
Asconapé JJ, Use of antiepileptic drugs in hepatic and renal disease. Handbook of clinical neurology. 2014;     [PubMed]
American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015 Nov;     [PubMed]
Brinkmann A,Röhr AC,Köberer A,Fuchs T,Preisenberger J,Krüger WA,Frey OR, [Therapeutic drug monitoring and individual dosing of antibiotics during sepsis : Modern or just     [PubMed]

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