10

Nonlinear Pharmacokinetics

In most cases, at therapeutic doses, the change in the amount of drug in the body or the
change in its plasma concentration due to absorption, distribution, binding, metabolism or
excretion, is proportional to its dose, whether administered as a single dose or as multiple
doses. In such situations, the rate processes are said to follow first-order or linear
kinetics and all semilog plots of C versus t for different doses, when corrected for dose
administered, are superimposable. This is called as principle of superposition. The
important pharmacokinetic parameters viz. F, Ka, KE, Vd, ClR and ClH which describe
the time-course of a drug in the body remain unaffected by the dose i.e. the
pharmacokinetics is dose-independent.
In some instances, the rate process of a drug’s ADME are dependent upon carrier or
enzymes that are substrate-specific, have definite capacities, and susceptible to saturation
at high drug concentration. In such cases, an essentially first-order kinetics transform
into a mixture of first-order and zero-order rate processes and the pharmacokinetic
parameters change with the size of the administered dose. The pharmacokinetics of such
drugs are said to be dose-dependent. Other terms synonymous with it are mixed-order,
nonlinear and capacity-limited kinetics. Drugs exhibiting such a kinetic profile are
sources of variability in pharmacological response.
There are several tests to detect nonlinearity in pharmacokinetics but the simplest ones
are –
1. Determination of steady-state plasma concentration at different doses. If the
steady-state concentrations are directly proportional to the dose, then linearity in
the kinetics exists. Such proportionality is not observable when there is
nonlinearity.
2. Determination of some of the important pharmacokinetic parameters such as
fraction bioavailable, elimination half-life or total systemic clearance at different
doses of the drug. Any change in these parameters which are usually constant, is
indicative of nonlinearity.

CAUSES OF NONLINEARITY
Nonlinearities can occur in drug absorption, distribution, metabolism and excretion.
Drug Absorption
Nonlinearity in drug absorption can arise from 3 important sources –
1. When absorption is solubility or dissolution rate-limited e.g. griseofulvin. At
higher doses, a saturated solution of the drug is formed in the GIT or at any other
extravascular site and the rate of absorption attains a constant value.
2. When absorption involves carrier-mediated transport systems e.g. absorption of
riboflavin, ascorbic acid, cyanocobalamin, etc. Saturation of the transport system
at higher doses of these vitamins results in nonlinearity.
 3. When presystemic gut wall or hepatic metabolism attains saturation e.g.
propranolol, hydralazine and verapamil. Saturation of presystemic metabolism of
these drugs at high doses leads to increased bioavailability.
The parameters affected will be F, Ka, Cmax and AUC. A decrease in these
parameters is observed in the former two cases and an increase in the latter case. Other
causes of nonlinearity in drug absorption are changes in gastric emptying and GI blood
flow and other physiologic factors. Nonlinearity in drug absorption is of little
consequence unless availability is drastically affected.
Drug Distribution
Nonlinearity in distribution of drugs administered at high doses may be due to –
1. Saturation of binding sites on plasma proteins e.g. phenylbutazone and naproxen.
There is a finite number of binding sites for a particular drug on plasma proteins
and, theoretically, as the concentration is raised, so too is the fraction unbound.
2. Saturation of tissue binding sites e.g. thiopental and fentanyl. With large single
bolus doses or multiple dosing, saturation of tissue storage sites can occur.
In both cases, the free plasma drug concentration increases but Vd increases only in
the former case whereas it decreases in the latter. Clearance is also altered depending
upon the extraction ratio of the drug. Clearance of a drug with high ER is greatly
increased due to saturation of binding sites. Unbound clearance of drugs with low ER is
unaffected and one can expect an increase in pharmacological response.
Drug Metabolism
The nonlinear kinetics of most clinical importance is capacity-limited metabolism since
small changes in dose administered can produce large variations in plasma concentration
at steady-state. It is a major source of large intersubject variability in pharmacological
response.
Two important causes of nonlinearity in metabolism are –
1. Capacity-limited metabolism due to enzyme and/or cofactor saturation. Typical
examples include phenytoin, alcohol, theophylline, etc.
2. Enzyme induction e.g. carbamazepine, where a decrease in peak plasma
concentration has been observed on repetitive administration over a period of
time. Autoinduction characterized in this case is also dose-dependent. Thus,
enzyme induction is a common cause of both dose- and time-dependent kinetics.
Saturation of enzyme results in decreased ClH and therefore increased Css. Reverse is
true for enzyme induction. Other causes of nonlinearity in biotransformation include
saturation of binding sites, inhibitory effect of the metabolite on enzyme and pathologic
situations such as hepatotoxicity and changes in hepatic blood flow.
Drug Excretion
The two active processes in renal excretion of a drug that are saturable are –
1. Active tubular secretion e.g. penicillin G. After saturation of the carrier system, a
decrease in renal clearance occurs.
 2. Active tubular reabsorption e.g. water soluble vitamins and glucose. After
saturation of the carrier system, an increase in renal clearance occurs.
Other sources of nonlinearity in renal excretion include forced diuresis, changes in
urine pH, nephrotoxicity and saturation of binding sites.
Biliary secretion, which is also an active process, is also subject to saturation e.g.
tetracycline and indomethacin.

MICHAELIS MENTEN EQUATION

The kinetics of capacity-limited or saturable processes is best described by Michaelis-
Menten equation:
dC Vmax C
(10.1)
dt K m C

Where, –dC/dt = rate of decline of drug concentration with time,

Vmax = theoretical maximum rate of the process, and
Km = Michaelis constant.
Three situations can now be considered depending upon the values of Km and C:
1. When Km = C
Under this situation, the equation 10.1 reduces to:
dC Vmax
(10.2)
dt 2

i.e. the rate of process is equal to one-half its maximum rate (Fig. 10.1).

Fig. 10.1 A plot of Michaelis-Menten equation (elimination rate dC/dt versus

concentration C). Initially, the rate increases linearly (first-order) with
 concentration, becomes mixed-order at higher concentration and then reaches
maximum (Vmax) beyond which it proceeds at a constant rate (zero-order).

2. When Km >> C
Here, Km + C Km and the equation 10.1 reduces to:
dC Vmax C
(10.3)
dt Km

The above equation is identical to the one that describes first-order elimination of a
drug where Vmax/Km = KE. This means that the drug concentration in the body that
results from usual dosage regimens of most drugs is well below the Km of the
elimination process with certain exceptions such as phenytoin and alcohol.
3. When Km << C
Under this condition, Km + C C and the equation 10.1 will become:
dC
Vmax (10.4)
dt

The above equation is identical to the one that describes a zero-order process i.e. the
rate process occurs at a constant rate Vmax and is independent of drug concentration e.g.
metabolism of ethanol.
Estimation of Km and Vmax
The parameters of capacity-limited processes like metabolism, renal tubular secretion and
biliary excretion can be easily defined by assuming one-compartment kinetics for the
drug and that elimination involves only a single capacity-limited process.
The parameters Km and Vmax can be assessed from the plasma concentration-time
data collected after i.v. bolus administration of a drug with nonlinear elimination
characteristics.
Rewriting equation 10.1.
dC Vmax C
(10.1)
dt K m C

Integration of above equation followed by conversion to log base 10 yields:

C0 - C Vmax
log C log C0 (10.5)
2.303 K m 2.303 K m

A semilog plot of C versus t yields a curve with a terminal linear portion having slope

–Vmax/2.303Km and when back extrapolated to time zero gives Y-intercept log C0 (see
Fig. 10.2). The equation that describes this line is:
 Vmax
log C log C 0 (10.6)
2.303 K m
Fig. 10.2 Semilog plot of a drug given as i.v. bolus with nonlinear elimination and that
fits one-compartment kinetics.
At low plasma concentrations, equations 10.5 and 10.6 are identical. Equating the two
and simplifying further, we get:

C0 - C C0
log (10.7)
2.303 K m C0
Km can thus be obtained from above equation. Vmax can be computed by
substituting the value of Km in the slope value.
An alternative approach of estimating Vmax and Km is determining the rate of change
of plasma drug concentration at different times and using the reciprocal of the equation
10.1. Thus:
1 Km 1
(10.8)
dC/dt Vmax C m Vmax

where Cm = plasma concentration at midpoint of the sampling interval. A double

reciprocal plot or the Lineweaver-Burke plot of 1/(dC/dt) versus 1/Cm of the above
equation yields a straight line with slope = Km/Vmax and y-intercept = 1/Vmax.
A disadvantage of Lineweaver-Burke plot is that the points are clustered. More
reliable plots in which the points are uniformly scattered are Hanes-Woolf plot (equation
10.9) and Woolf-Augustinsson-Hofstee plot (equation 10.10).
Cm Km Cm
(10.9)
dC/dt Vmax Vmax
dC dC/dt K m
Vmax (10.10)
dt Cm
 The above equations are rearrangements of equation 10.8. Equation 10.9 is used to
plot Cm/(dC/dt) versus Cm and equation 10.10 to plot dC/dt versus (dC/dt)/Cm. The
parameters Km and Vmax can be computed from the slopes and y-intercepts of the two
plots.
Km and Vmax from Steady-State Concentration
When a drug is administered as a constant rate i.v. infusion or in a multiple dose regimen,
the steady-state concentration Css is given in terms of dosing rate DR as:
DR C ss Cl T (10.11)

where DR = Ro when the drug is administered as zero-order i.v. infusion and it is equal
to FXo/ when administered as multiple oral dosage regimen (F is fraction bioavailable,
Xo is oral dose and is dosing interval).
At steady-state, the dosing rate equals rate of decline in plasma drug concentration and
if the decline (elimination) is due to a single capacity-limited process (for e.g.
metabolism), then;
Vmax Css
DR (10.12)
K m Css

A plot of Css versus DR yields a typical hockey-stick shaped curve as shown in Fig.
10.3.

Fig. 10.3 Curve for a drug with nonlinear kinetics obtained by plotting the steady-state
concentration versus dosing rates.
To define the characteristics of the curve with a reasonable degree of accuracy, several
measurements must be made at steady-state during dosage with different doses.
Practically, one can graphically compute Km and Vmax in 3 ways:
1. Lineweaver-Burke Plot/Klotz Plot
 Taking reciprocal of equation 10.12, we get:
1 Km 1
(10.13)
DR Vmax Css Vmax

Equation 10.13 is identical to equation 10.8 given earlier. A plot of 1/DR versus 1/Css
yields a straight line with slope Km/Vmax and y-intercept 1/Vmax (see Fig. 10.4).

Fig. 10.4 Lineweaver-Burke/Klotz plot for estimation of Km and Vmax at steady-state

concentration of drug.

2. Direct Linear Plot

Here, the graph is considered as shown in Fig. 10.5. A pair of Css viz. Css,1 and
Css,2 obtained with two different dosing rates DR1 and DR2 is plotted. The points Css,1
and DR1 are joined to form a line and a second line is obtained similarly by joining Css,2
and DR2. The point where these two lines intersect each other is extrapolated on DR axis
to obtain Vmax and on x-axis to get Km.
Fig. 10.5 Direct linear plot for estimation of Km and Vmax at steady-state
concentrations of a drug given at different dosing rates.
3. The third graphical method of estimating Km and Vmax involves rearranging
equation 10.12 to yield:
K m DR
DR Vmax (10.14)
Css

A plot of DR versus DR/Css yields a straight line with slope -Km and Y-intercept
Vmax.
Km and Vmax can also be calculated numerically by setting up simultaneous
equations as shown below:
Vmax Css,1
DR 1 (10.15)
K m Css,1
Vmax Css,2
DR 2 (10.16)
K m Css,2

Combination of the above two equations yields:

DR 2 - DR 1
Km
DR 1 DR 2 (10.17)
Css,1 Css,2
After having computed Km, its subsequent substitution in any one of the two
simultaneous equations will yield Vmax.
 It has been observed that Km is much less variable than Vmax. Hence, if mean Km
for a drug is known from an earlier study, then instead of two, a single measurement of
Css at any given dosing rate is sufficient to compute Vmax.
There are several limitations of Km and Vmax estimated by assuming one-
compartment system and a single capacity-limited process. More complex equations will
result and the computed Km and Vmax will usually be larger when:
1. The drug is eliminated by more than one capacity-limited process.
2. The drug exhibits parallel capacity-limited and first-order elimination processes.
3. The drug follows multicompartment kinetics.
However, Km and Vmax obtained under such circumstances have little practical
applications in dosage calculations.
Drugs that behave nonlinearly within the therapeutic range (for example, phenytoin
shows saturable metabolism) yield less predictable results in drug therapy and possess
greater potential in precipitating toxic effects.

QUESTIONS
1. Define dose-dependent kinetics. Quote simple tests by which it can be detected in a
rate process.
2. Why are drugs that show nonlinearity in pharmacokinetics considered sources of
variability in pharmacological response?
3. What processes of drug ADME are known to show nonlinearity? Give examples.
4. When administered at high doses, how does the pharmacokinetic parameters — t½,
Vd, Cmax, etc. change for drugs known to undergo capacity-limited elimination?
5. What are the limitations in calculating Km and Vmax by assuming one-compartment
model and a single capacity-limited process?
6. Using the following data of a drug having Km of 0.2 mcg/ml and Vmax of 1.0
mcg/ml/hour, determine the concentrations at which the drug shows first-order, zero-
order and mixed-order metabolic rates.
Concentration (mcg/ml) 0.02 0.2 20.0
Metabolic Rate (mcg/ml/H) 0.1 0.5 1.0

7. Theophylline was administered to a patient at dosing rates of 600 mg/day and 1200
mg/day and the respective steady-state concentrations were found to be 9.8 mg/L
and 28.6 mg/l. Find Km and Vmax. Determine the dosing rate to achieve a Css of
15 mg/l.
Answer : Km = 31.14 mg/l, Vmax = 2507 mg/day and DR = 815 mg/day.