Drug Metabolism in Diseases 1st Edition Wen Xie new

release 2025

https://ebookultra.com/download/drug-metabolism-in-diseases-1st-
edition-wen-xie/

★★★★★
4.8 out of 5.0 (65 reviews )

Click & Get PDF

ebookultra.com
Drug Metabolism in Diseases 1st Edition Wen Xie

EBOOK

Available Formats

■ PDF eBook Study Guide Ebook

EXCLUSIVE 2025 ACADEMIC EDITION – LIMITED RELEASE

Available Instantly Access Library

Here are some recommended products for you. Click the link to
download, or explore more at ebookultra.com

Nuclear Receptors in Drug Metabolism Wen Xie (Editor)

https://ebookultra.com/download/nuclear-receptors-in-drug-metabolism-
wen-xie-editor/

Current Topics in Human Genetics Studies in Complex

Diseases 1st Edition Hong-Wen Deng

https://ebookultra.com/download/current-topics-in-human-genetics-
studies-in-complex-diseases-1st-edition-hong-wen-deng/

Human Drug Metabolism An Introduction 2nd Edition Michael

Coleman

https://ebookultra.com/download/human-drug-metabolism-an-
introduction-2nd-edition-michael-coleman/

Drug Metabolism Handbook Concepts and Applications 1st

Edition Ala F. Nassar

https://ebookultra.com/download/drug-metabolism-handbook-concepts-and-
applications-1st-edition-ala-f-nassar/
Neglected Tropical Diseases and Phytochemicals in Drug
Discovery 1st Edition Chukwuebuka Egbuna

https://ebookultra.com/download/neglected-tropical-diseases-and-
phytochemicals-in-drug-discovery-1st-edition-chukwuebuka-egbuna/

Ocular Transporters in Ophthalmic Diseases and Drug

Delivery 1st Edition Lori Randall Stradtman

https://ebookultra.com/download/ocular-transporters-in-ophthalmic-
diseases-and-drug-delivery-1st-edition-lori-randall-stradtman/

Using Mass Spectrometry for Drug Metabolism Studies 2ed.

Edition Walter A. Korfmacher

https://ebookultra.com/download/using-mass-spectrometry-for-drug-
metabolism-studies-2ed-edition-walter-a-korfmacher/

Encyclopedia of Drug Metabolism and Interactions 6 Volume

Set 1st Edition Alexander V. Lyubimov

https://ebookultra.com/download/encyclopedia-of-drug-metabolism-and-
interactions-6-volume-set-1st-edition-alexander-v-lyubimov/

Is American Science in Decline 1st Edition Yu Xie

https://ebookultra.com/download/is-american-science-in-decline-1st-
edition-yu-xie/
 DRUG
METABOLISM
IN DISEASES
Edited by

WEN XIE, MD, PhD

Professor of Pharmaceutical Sciences and Pharmacology,
The Joseph Koslow Endowed Chair in Pharmaceutical Sciences,
Director of the Center for Pharmacogenetics School of Pharmacy,
University of Pittsburgh, Pittsburgh, PA, United States

AMSTERDAM • BOSTON • HEIDELBERG • LONDON

NEW YORK • OXFORD • PARIS • SAN DIEGO
SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO
Academic Press is an imprint of Elsevier
Academic Press is an imprint of Elsevier
125 London Wall, London EC2Y 5AS, United Kingdom
525 B Street, Suite 1800, San Diego, CA 92101-4495, United States
50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States
The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom
Copyright © 2017 Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our
website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library

ISBN: 978-0-12-802949-7

For information on all Academic Press publications

visit our website at https://www.elsevier.com/

Publisher: Mica Haley

Acquisition Editor: Kristine Jones
Editorial Project Manager: Molly McLaughlin
Production Project Manager: Edward Taylor
Designer: Mark Rogers
Typeset by TNQ Books and Journals
 Contributors

L.M. Aleksunes Rutgers University, Piscat- P. Lu University of Pittsburgh, Pittsburgh, PA,

away, NJ, United States United States
X. Chai University of Pittsburgh, Pittsburgh, E.T. Morgan Emory University, Atlanta, GA,
PA, United States; Zhejiang University, United States
Hangzhou, China J.E. Moscovitz Rutgers University, Piscataway,
J.E. Constance University of Utah, Salt Lake NJ, United States
City, UT, United States T.D. Nolin University of Pittsburgh, Pittsburgh,
J.C. Coons University of Pittsburgh, Pittsburgh, PA, United States
PA, United States M. Piquette-Miller University of Toronto,
P. Empey University of Pittsburgh, Pittsburgh, Toronto, ON, Canada
PA, United States S.M. Poloyac University of Pittsburgh,
L. Gorczyca Rutgers University, Piscataway, NJ, Pittsburgh, PA, United States
United States J.E. Rower University of Utah, Salt Lake City,
C.A.J. Knibbe Leiden University, Leiden, The UT, United States
Netherlands; St. Antonius Hospital, Nieu- R. Sane Bristol Myers Squibb, Wallingford, CT,
wegein, The Netherlands United States
D. Kojovic University of Toronto, Toronto, ON, C.M.T. Sherwin University of Utah, Salt Lake
Canada City, UT, United States
E.H.J. Krekels Leiden University, Leiden, The M. Sinz Bristol Myers Squibb, Wallingford, CT,
Netherlands United States
X. Li Xiangya Hospital Central South University, W. Xie University of Pittsburgh, Pittsburgh, PA,
Changsha, China United States
Z.Q. Liu Xiangya Hospital Central South S. Zeng Zhejiang University, Hangzhou, China
University, Changsha, China

vii
 Preface

I am very happy to present you with this nuclear receptors, transcriptional regulation
special topic book titled Drug Metabolism in of genes encoding drug metabolizing en-
Diseases. zymes and transporters, crosstalk between
Drug metabolism is essential for both xenobiotic metabolism and endobiotic
drug therapy and drug safety. In addition to metabolism, as well as the reciprocal effect
the genetic and environmental factors, dis- of the expression and activity of drug-
eases and physiological states of patients metabolizing enzymes and transporters on
have profound effects on drug metabolism the clinical outcome of diseases. Under-
and disposition. Examples of diseases standing these mechanistic insights is
known to affect drug metabolism include paramount in harnessing the benefits of the
liver and kidney diseases, inflammation and knowledge communicated in this book and
sepsis, cardiovascular diseases, and diabetes. to improve the effective and safe use of
Physiological conditions that can affect drug drugs in the clinic.
metabolism exist in pediatric and pregnant I want to thank all of the contributing
populations, and patients in critical care, authors who are experts in the forefront of
among others. Understanding the patho- this emerging and exciting field of research.
physiological effect on drug metabolism will Special thanks go to Kristine Jones, Senior
help to guide better and safer use of clinical Acquisitions Editor at Elsevier, who initially
drugs. Armed with the knowledge of disease approached me for a book project. I also
effects on drug metabolism, the use of drugs want to thank Molly McLaughlin, Editorial
can be tailored to specific diseases or physi- Project Manager at Elsevier, who has been
ological conditions, which is highly relevant extremely helpful in all stages of the devel-
to personalized medicine and precision opment of this book.
medicine. For these reasons, there is a great
need for a book in this area. The topics Wen Xie, MD, PhD
mentioned earlier have been systemically Professor of Pharmaceutical Sciences and
covered in this book. Pharmacology
Another key feature of this book is the The Joseph Koslow Endowed Chair in
mechanistic insights by which diseases Pharmaceutical Sciences
and physiological states affect drug meta- Director of the Center for Pharmacogenetics
bolism. Examples of the mechanistic School of Pharmacy
insights throughout the chapters include University of Pittsburgh, Pittsburgh, PA
pharmacogenetics, xenobiotic receptors,

ix
 C H A P T E R

1
Introduction of Drug Metabolism
and Overview of Disease Effect on
Drug Metabolism
R. Sane, M. Sinz
Bristol Myers Squibb, Wallingford, CT, United States

O U T L I N E

Introduction 2 Changes in Gastric Emptying Time 9

Overview of Drug Metabolism 3 Changes in Blood Flow to Organs 10
Disease Effects on Drug Metabolism 5 Changes in Protein Binding 11
Liver Disease 6 Small Molecules 12
Influence of Infection and Inflammation 6 Protein Therapeutics 12
Chronic Kidney Disease 7
Disease Effects on Transporter
Disease Effects and Genetic Disorders 8
Expression 13
Disease Effects on Absorption
Summary 14
Parameters 8
Changes in Permeability 8 References 16
Changes in Gut and Lung Surface Area 9

List of Abbreviations

AAG Alpha-1 acid glycoprotein COPD Chronic obstructive pulmonary disease

ADME Absorption, distribution, metabolism, and CYP Cytochrome P450
elimination ER Extraction ratio
AUC Area under the curve FcRn Neonatal Fc-receptor
BCRP Breast cancer resistance protein GIT Gastrointestinal tract
CHF Chronic heart failure IFN Interferon
CLint Intrinsic clearance IL Interleukin

Drug Metabolism in Diseases

http://dx.doi.org/10.1016/B978-0-12-802949-7.00001-8 1 Copyright © 2017 Elsevier Inc. All rights reserved.
2 1. DRUG METABOLISM AND DISEASE EFFECTS

MRP Multidrug resistance-associated protein TNF Tumor necrosis factor

OATP Organic anion transporter protein UGT UDP-glucuronosyltransferase
P-gp P-glycoprotein

INTRODUCTION

In today’s contemporary medical arena, medical practitioners have at their disposal

numerous drugs to treat acute and chronic diseases. Furthermore, many patients take multi-
ple drugs daily to treat one or more illnesses, in particular, the increasing elderly population.
This combination of events naturally leads to an increased number of drugedrug interac-
tions. Although drugedrug interactions are becoming more predictable due to our under-
standing of the effect drugs can have on drug-metabolizing enzymes (expression and
inhibition), our understanding of the effect of disease states on drug metabolism and dispo-
sition is less well comprehended. Many diseases are accompanied by one or more physiolog-
ical and biochemical changes that affect the absorption, distribution, metabolism, and
elimination (ADME) of drugs. These physiological/biochemical changes can lead to changes
in the clearance, exposure, and distribution of drugs. There are often multiple changes
that occur simultaneously during the course of a disease; therefore the overall effect of a dis-
ease on the pharmacokinetics of a drug can be complex. In addition, the degree of disease
severity will also impact these changes, i.e., increasing severity of disease leading to increased
physiological/biochemical changes.
The most significant organs related to absorption, drug metabolism, and elimination
include the liver, intestine, and kidneys. Changes in the normal function of these organs
due to disease will have the greatest impact on drug exposure and efficacy. For example,
celiac disease and changes in drug absorption (Tran et al., 2013) or irregular drug absorption
in Parkinson’s disease (Nyholm and Lennernas, 2008). Liver disease has been shown to have
an effect on the expression of drug-metabolizing enzymes and elimination of some drugs, as
well as significant interindividual variations in drug elimination in the case of nonalcoholic
fatty liver disease or cirrhosis (Merrell and Cherrington, 2011; Palatini et al., 2010). Lastly,
kidney disease has been shown to have effects beyond the expected reduction in renal clear-
ance with effects on drug-metabolizing enzymes and drug transporters in the kidney and
liver (Nolin et al., 2003; Yeung et al., 2014).
In regards to drug interactions, the pharmaceutical industry has concentrated on the abil-
ity to predict and eliminate drugedrug interactions, but is less likely to incorporate the effects
of various diseases on drug ADME disposition (drugedrug interactions) in the development
process. This is particularly true during the drug discovery stage where the emphasis is
bringing forward compounds that have appropriate potency to the target, reasonable overall
ADME properties, and a satisfactory safety profile. It is not until clinical development that
particular attention is given to how a drug may need to be tailored (changes in dose or dosing
regimen) when administered while treating certain diseases or concomitant diseases associ-
ated with the primary disease.
 OVERVIEW OF DRUG METABOLISM 3
This chapter begins with a survey of general drug metabolism principles, such as biotrans-
formation reactions, major drug-metabolizing enzymes, drug absorption and elimination,
and enzyme expression. For a more comprehensive review of drug metabolism principles,
the reader is referred to Parkinson et al. (2013). The remainder of the chapter describes major
physiological and biochemical changes that occur in various disease states and the impact
they have on the ADME characteristics of drugs. These changes and their effects are illus-
trated throughout the chapter using pharmacokinetic principles and literature examples
from animal and human studies. The majority of the chapter is devoted to drug metabolism
and the effects that naturally occurring or inherited diseases can have on drug exposure.
However, keeping in mind that metabolism is only one element that controls drug exposure,
the remaining portion of the chapter describes how disease can affect the absorption and dis-
tribution of drugs, as well as physiological changes like blood flow, and how disease affects
the expression of drug transporters.

OVERVIEW OF DRUG METABOLISM

Once administered, drugs can be eliminated from the body by one of three major path-
ways or routes. Polar drugs are often eliminated intact in urine via the kidneys, and both po-
lar and nonpolar drugs can be eliminated directly through bile. Lastly, and most importantly,
drugs are most often metabolized by endogenous enzymes and then eliminated in urine or
bile. Drug metabolism or drug biotransformation is the process by which xenobiotics are
enzymatically modified to make them more readily excretable and eliminate pharmacological
activity. In most cases, this involves modifications to the parent drug or addition of functional
groups that make the parent drug molecule more hydrophilic and more amenable to elimi-
nation. The liver is the major organ where drug metabolism occurs followed in significance
by the intestine and kidneys and a variety of additional organs to a lesser degree (e.g., blood,
skin, and brain).
Drug-metabolizing enzymes are generally categorized into two classes (phases 1 and 2)
based on the type of biotransformation they perform. Phase 1 enzymes are considered oxida-
tive or hydrolytic enzymes. They typically increase the polarity of molecules by the addition
of a hydroxyl group (oxidative) or the unmasking of a more polar functionality (hydrolytic),
such as the cleavage of an amide or ester bond to expose the free amine or carboxylic acid,
respectively (both being more polar than the original amide or ester). Typical phase 1 oxida-
tive enzymes include: cytochrome P450 (CYP) enzymes, flavin monoxidases, monoamine ox-
idases, alcohol/aldehyde oxidoreductases, and aldehyde/xanthine oxidases. Phase 1
hydrolytic enzymes include: epoxide hydrolases, esterases, and amidases. The CYP family
of enzymes is by far the predominant biotransformation pathway or elimination process
for the majority of marketed drugs. The second class of drug-metabolizing enzymes is called
phase 2 conjugative enzymes. Phase 2 enzymes are responsible for conjugating parent drug
molecules or metabolites derived from phase 1 metabolism by enzymatic addition of a polar
group. Typical phase 2 enzymes and their conjugates include: UDP-glucuronosyltransferases
(UGTs) that conjugate UDP-glucuronic acid, sulfotransferases that conjugate a sulfate group,
glutathione S-transferases that conjugate the tripeptide glutathione, N-acyltransferases that
conjugate an acetyl group to an amine, and methyltransferases (MTs) that conjugate a methyl
4 1. DRUG METABOLISM AND DISEASE EFFECTS

group. All of these reactions create larger and more polar metabolites, making them easier for
the body to eliminate in bile or urine. A notable exception is the MTs, which generally make
the parent drug or metabolite less water soluble (less hydrophilic); fortunately MTs constitute
a minor phase 2 pathway for drugs. Of all the phase 2 pathways, the UGT family of enzymes
metabolizes the greatest number of drugs and metabolites.
The systemic exposure of the drug depends on its bioavailability. Following an oral dose,
the drug moves through the lumen of the gastrointestinal tract (GIT) and is absorbed by the
epithelial cells. The fraction that is absorbed from the lumen ( fa) can be metabolized by the
enzymes in the gut wall. The fraction that escapes gut wall metabolism ( fg) then moves
through the portal vein to the liver, where it undergoes first-pass metabolism. The bioavail-
ability of a drug is the product of the fraction absorbed ( fa), the fraction that escapes gut wall
metabolism ( fg), and the fraction that escapes hepatic clearance ( fh). Fig. 1.1 describes the pro-
cesses a drug goes through before it reaches the systemic circulation (drug exposure). Disease
states can influence one or more of these processes ultimately influencing the bioavailability
of the drug and these will be discussed throughout the chapter.

FIGURE 1.1 Overview of factors affecting oral bioavailability. Bioavailability depends on the fraction of dose
absorbed ( fa), the fraction that escapes gut wall metabolism ( fg), and hepatic metabolism. The inset illustrates the
route a drug may take once in the liver: from blood to hepatocyte, back to blood or into bile (either as parent drug or
metabolite).
 DISEASE EFFECTS ON DRUG METABOLISM 5
Changes to the expression (or activity) of these phase 1 and 2 enzymes, in particular the
CYPs and UGTs, due to disease can have a significant impact on the rate of metabolism
and systemic clearance of many drugs. Hepatic or liver clearance (CLh) is related to liver
blood flow (Qh) and intrinsic clearance (CLint) as shown in Eq. (1.1).
 
CLint
CLh ¼ Qh (1.1)
Qh þ CLint

CLint represents the ability of the liver to clear unbound drug from the blood when there is
no flow limitation demonstrating the inherent enzyme activity of the drug-metabolizing
enzyme. Any increase or decrease in the CLint of an enzyme results in a commensurate change
in the hepatic clearance of a drug that is significantly metabolized by that particular enzyme.
The regulation or expression of drug-metabolizing enzymes is controlled by two main
mechanisms. The most common mechanism of enzyme expression is mediated by nuclear re-
ceptors or transcription factors, such as the aryl hydrocarbon receptor, pregnane X receptor,
or constitutive androstane receptor (Xie, 2009). Combined, these three transcription factors
control the normal expression of most drug-metabolizing enzymes and drug transporters.
These receptors can be activated through binding of drugs to the receptor leading to an in-
crease in the expression of drug-metabolizing enzymes (increased CLint and CLh). The second
less common mechanism of enzyme regulation is stabilization of the mRNA or protein (Koop
and Tierney, 1990). By decreasing the degradation of mRNA or protein (with no change in
expression level), the pool of active enzyme accumulates and can be responsible for enhanced
metabolism and greater elimination of drug.
Most often, diseases cause suppression of expression of drug-metabolizing enzymes
(Gandhi et al., 2012; Shah and Smith, 2015). The suppression of CYPs is predominately attrib-
uted to decreases in transcription; however, it can also be due to decreased translation or
posttranslational modification of CYPs (Riddick et al., 2004). This suppression leads to a
reduction in enzyme expression and pool of active enzyme (decreased CLint and CLh), lead-
ing to decreases in drug elimination. Cytokines (small proteins associated with cell signaling)
have been shown to suppress CYP expression and enzyme activity in human hepatocyte cul-
tures, and the effect has been shown to be gene specific. For example, interleukin 1 (IL-1) has
been shown to downregulate CYP2C8 and CYP3A4 mRNA expression by 75e95%, with no
effect on CYP2C9 or CYP2C19 (Aitken and Morgan, 2007). Additional studies have shown
that an increase in IL-6 concentration results in suppression of CYP3A4 in primary human
hepatocytes (Dickmann et al., 2011).

DISEASE EFFECTS ON DRUG METABOLISM

Although aging is not considered a disease, studies on the liver changes that occur with
age do provide insight into how diseases may affect the liver and its ability to metabolize
drugs. As we age, our ability to metabolize drugs decreases; this is thought to be due to
several physiological changes that occur in the liver, such as an w40% decrease in liver
volume, an w40% decrease in liver blood flow, and a decline in the expression of CYP en-
zymes (Tajiri and Shimizu, 2013). Not surprisingly, acute or chronic diseases of the liver
6 1. DRUG METABOLISM AND DISEASE EFFECTS

(e.g., cirrhosis or infection) that reduce the number of viable hepatocytes, alter blood flow, or
reduce enzyme levels have an effect on drug clearance and exposure (Bruha et al., 2012).

Liver Disease
Liver cirrhosis is associated with several different effects that can influence drug exposure.
A common phenomenon associated with liver cirrhosis is portal-systemic shunting, a phys-
iological change that diverts blood drained from the intestine to the systemic circulation
consequently bypassing its normal route to the liver. This shunting of blood away from
the liver has the effect of increasing the bioavailability of orally administered drug as they
do not enter the liver to be metabolized. In addition, a lack of oxygen (oxygen is an obligatory
cofactor for all CYP enzymes) could lead to decreased enzyme function (Verbeeck, 2008). It
has also been shown that CYP levels (reduced activity) in patients suffering from cirrhosis
change with the severity of the disease. In the early stages of the disease, CYP3A4 and
CYP2C19 are affected, whereas in the later stages of the disease CYPs 1A2, 2D6, and 2E1
are also affected (Verbeeck, 2008). The effects of liver cirrhosis appear to have a greater
impact on the CYP enzymes than on phase 2 enzymes, such as glucuronidation, although
in severe states of cirrhosis, glucuronidation is also affected.
Hypoxia is a deficiency in the amount of oxygen reaching tissues. Hypoxia due to cardio-
respiratory disease has been shown to affect the metabolism and exposure of several drugs.
The elimination of theophylline (CYP1A2 substrate) and tolbutamide (CYP2C substrate) was
shown to change in patients with hypoxia. The elimination of theophylline was decreased,
whereas the elimination of tolbutamide was increased (du Souich and Fradette, 2011). The
clearance of both drugs is blood flow independent, so the changes in elimination are likely
due to changes in mRNA expression or enzyme activity of CYP1A2 and CYP2C.

Influence of Infection and Inflammation

Infection and inflammation are known to have effects on the hepatic and extrahepatic
metabolism of drugs, and many chronic diseases are often associated with inflammation
(Gandhi et al., 2012; Morgan, 2001, 2009; Shah and Smith, 2015). Wooles and Borzelleca
(1966) demonstrated that inflammation led to a decrease in drug metabolism activity in
mice. After a decade, it was shown that infection along with inflammation led to an in-
crease in quinine exposure (due to reduced metabolism) in patients suffering from malaria
(Trenholme et al., 1976). Inflammation is the result of a tissue’s attempt to adapt to cellular
stress by releasing inflammatory cytokines IL-1b, IL-6, tumor necrosis factor alpha
(TNF-a), and interferons (IFNs) a/g, all of which are thought to affect (suppress) the
expression of CYP enzymes (Feghali and Wright, 1997).
In patients with rheumatoid arthritis, chronic inflammation results in downregulation of
CYP3A4 activity. In clinical studies with tocilizumab, an anti-IL-6 antibody approved for
use in rheumatoid arthritis, an increase in the CYP3A4 function was observed by way of
increased clearance of simvastatin, a substrate of CYP3A4 (Schmitt et al., 2011). Infusion
with the anti-IL-6 antibody results in restoring the CYP3A4 levels to normal levels, leading
to a significant decrease in simvastatin exposure [fourfold decrease in the area under the curve
 DISEASE EFFECTS ON DRUG METABOLISM 7
(AUC), 1 week post dose] and a twofold increase in simvastatin clearance. Interestingly, there
was no change in the pharmacokinetics of other concomitant medication, such as omeprazole
(CYP2C19 substrate) or dextromethorphan (CYP2D6 substrate) (Evers et al., 2013).
Cancer is another disease associated with inflammation and inflammation-associated cyto-
kines. Patients with cancer often exhibit higher levels of the cytokines IL-6 and TNF-a than
normal healthy individuals (Filella et al., 1996). These elevated levels of cytokines are likely
to downregulate the expression and enzyme activity of CYP3A4, which will affect the phar-
macokinetics of many drugs, including anticancer drugs such as docetaxel, erlotinib, and
vemurafenib.
Immunotherapy is a rapidly advancing field for the treatment of cancer. Ipilimumab is an
anti-CTLA-4 (cytotoxic T-lymphocyte associated protein 4) antibody that has been approved
for use in advanced melanoma. Inhibition of the CTLA-4 protein results in upregulation of T-
cell activity and proliferation. Nivolumab is an anti-PD1 antibody, approved for use in none
small cell lung cancer and melanoma. PD1 is an immune checkpoint that dampens the im-
mune response to prevent damage to tissues. Production of TNF-a, IL-6, and interferon g
is increased following anti-CTLA-4 and anti-PD-1 treatment (Curran et al., 2010; Dulos
et al., 2012). In addition to the inflammation already inherent to cancer, these immunomod-
ulators also have the potential to further impair CYP-mediated metabolism (Harvey and
Morgan, 2014).
A study by Dostalek et al. found that the activity and expression level of CYP3A4 in pa-
tients with diabetes mellitus are significantly reduced. Human liver microsomes isolated
from diabetic livers were shown to have decreased expression and activity of CYP3A4, which
corresponds with observations from animal models of diabetes (Dostalek et al., 2011; Wang
et al., 2007). The downregulation of CYP3A4 was attributed to elevated levels of IL-6 and
TNF-a found in diabetic patients (Morgan, 1997).

Chronic Kidney Disease

The kidney contributes to the elimination and metabolism of a wide variety of drugs; it is
highly distinct from other organs of metabolism since it has specific regions of cellular activ-
ity. The CYP enzymes are found in the renal tubular epithelial cells of the renal cortex. Studies
in animal models of renal failure show a decrease in protein expression and activity of
CYP2C11 and CYP3A2 (Leblond et al., 2002). Rat hepatocytes treated with uremic serum
from patients with advanced chronic renal failure led to a 35% reduction in the protein
and mRNA expression of CYP2C6, 2C11, 3A1, and 3A2, as well as a reduction in CYP
enzyme activity (Dreisbach and Lertora, 2008). As in Eq. (1.1), hepatic clearance depends
on intrinsic clearance, as well as drug-free fraction [Eq. (1.4)]. A decrease in CYP expression
results in a decrease in intrinsic clearance, thus increasing the bioavailability. In renal failure,
along with a decrease in enzyme expression, there is also a decrease in serum albumin levels,
increasing the free fraction of the drug. The relative magnitude of changes in free fraction and
intrinsic clearance will determine the net effect on the bioavailability. Moreover, phase 2
drug-metabolizing enzymes are also affected in patients with kidney disease as observed
by the increase in morphine exposure (due to reduced glucuronidation of morphine) in pa-
tients as compared with control subjects (Osborne et al., 1993).
8 1. DRUG METABOLISM AND DISEASE EFFECTS

Disease Effects and Genetic Disorders

Some genetic disorders can lead to physiological/biochemical changes that may have pro-
found effects on endogenous components, as well as drugs. CriglereNajjar syndrome and
Gilbert syndrome are disorders affecting the metabolism of bilirubin. In both Gilbert syndrome
and CriglereNajjar syndrome, activity of the phase 2 enzyme UGT1A1 is diminished or absent.
Therefore drugs that are substrates of UGT1A1 cannot be metabolized/eliminated and can
cause potential toxicity. A good example of this is irinotecan, an anticancer prodrug that is con-
verted to its active form SN-38, which has a narrow therapeutic index. SN-38 is mainly inacti-
vated by UGT1A1. The lack of the UGT1A1 enzyme leads to toxicity in oncology patients
treated with irinotecan (Cecchin et al., 2009). Ethinylestradiol is also a substrate for UGT1A1
(Ebner et al., 1993). Therefore women using ethinylestradiol as a component of an oral contra-
ceptive and who have Gilbert or CriglereNajjar syndrome are at increased risk for hyperbilir-
ubinemia and/or estrogen-related adverse effects. Glucuronidation and the impact of these
genetic disorders have been reviewed in detail by Strassburg (2010) and de Wildt et al. (1999).

DISEASE EFFECTS ON ABSORPTION PARAMETERS

Absorption of drugs takes place by passive diffusion, paracellular transport, or carrier-

mediated transport. Paracellular transport (i.e., movement of compounds through fenestra-
tions in the membrane) depends on the size of the molecule (<500 g/mole) and largely occurs
with water-soluble compounds that cannot move through cells. Active transport (carrier-
mediated transport) is carried out by transporters that may exist on the luminal or abluminal
side of cell membranes. Additional discussion of drug transporters and disease effects are
described later in the chapter.

Changes in Permeability
A major mechanism of drug absorption through the GIT as well as transport through
membranes is by passive diffusion. The rate of diffusion/transport in turn depends on the
concentration gradient of the solute across the membrane, the surface area available for ab-
sorption, and the permeability of the compound as described by Eq. (1.2).
Rate of transport ¼ Permeability  Surface area  Concentration gradient (1.2)
The permeability of a drug depends on its intrinsic properties such as size, lipophilicity,
and charge. Small, lipophilic, and unionized molecules are able to cross membranes more
easily than larger hydrophilic molecules, such as peptides and proteins. Permeability also de-
pends on the thickness of the membrane. Patients with irritable bowel syndrome typically
have damaged, thinner intestinal mucosa, leading to increased gut permeability (Spiller
et al., 2000). In addition to changes in permeability, delayed gastric emptying observed in pa-
tients with irritable bowel syndrome is likely to change the rate and extent of absorption of
drugs.
The distribution of compounds can also be influenced by permeability into tissues. The
bloodebrain barrier is vital in protecting the brain from xenobiotics. The endothelial cells
 DISEASE EFFECTS ON ABSORPTION PARAMETERS 9
in the brain capillaries have tight junctions as well as glial processes that limit the perme-
ability of most polar drugs. In addition, a range of efflux transporters are expressed on the
luminal side of brain capillaries and actively pump compounds out of the brain. Growth
of certain brain tumors can cause changes in the vasculature of tumor microvessels leading
to development of fenestrations in the endothelial layer (Loscher and Potschka, 2005). Preclin-
ical tumor models have demonstrated that the permeability of certain drugs such as metho-
trexate is enhanced when tumors are present, allowing more drugs to reach the brain
(Groothuis, 2000).

Changes in Gut and Lung Surface Area

Patients with celiac disease show atrophy of the villi in the small intestine, decreasing the
surface area available for absorption. A study in patients with hypothyroidism showed that
patients with celiac disease required higher doses of levothyroxine than patients without ce-
liac disease (Tran et al., 2013). Interestingly, patients who were treated for celiac disease, who
would presumably have repaired/improved small intestines over time, required lower doses
of levothyroxine, supporting the hypothesis that the small intestine atrophy limited the ab-
sorption of levothyroxine.
The pulmonary route of administration is useful because absorption through the lungs can
bypass first-pass metabolism in the liver. In addition, the lungs are highly vascularized and
have a high surface area, allowing for efficient absorption. Several anesthetics and other
drugs, such as nicotine, antibiotics, and protein therapeutics are administered via the lungs,
resulting in good systemic exposure. Pulmonary disorders that result in airflow obstruction
or airway inflammation due to asthma or chronic obstructive pulmonary disease (COPD)
could potentially alter the extent of systemic absorption. However, in the case of inhaled cor-
ticosteroids, such as fluticasone, it has been shown that lowered systemic absorption of the
steroids in patients with COPD and asthma actually reduces undesired suppression of the ad-
renal and pituitary glands as compared with healthy volunteers (Singh et al., 2003). In this
situation, the limited systemic absorption is beneficial as it decreases drug exposure to the
adrenal and pituitary glands thereby decreasing the undesired side effects.

Changes in Gastric Emptying Time

Gastric emptying and intestinal transit time determine the available time that a drug is in
contact with the absorptive surfaces in the GIT. According to the pH-partition hypothesis,
only unionized drugs can cross cellular membranes. Even weakly acidic drugs, more likely
to be unionized in the stomach, are mostly absorbed from the small intestine due to its larger
surface area. For example, for a weakly acidic drug such as paracetamol, the rate of absorp-
tion is directly related to the rate of gastric emptying; faster absorption is observed in subjects
with faster gastric emptying (Prescott, 1974). On the other hand, the absorption of drugs that
have slow dissolution characteristics could be enhanced by a decrease in gastric motility and
increased intestinal transit time. The following examples help illustrate how these changes
affect the absorption of drugs.
The treatment of Parkinson’s disease depends on oral administration of the dopamine pre-
cursor levodopa. Levodopa is primarily absorbed from the small intestine; therefore gastric
10 1. DRUG METABOLISM AND DISEASE EFFECTS

emptying is the rate-limiting step for onset of activity. Irregular gastric emptying time is com-
mon in patients with Parkinson’s disease. Delays in gastric emptying cause the levodopa to
be metabolized by amino acid decarboxylase enzyme in the gastric mucosa, decreasing the
fraction absorbed by the gut (Fg), thus decreasing the bioavailability and limiting efficacy
(Nyholm and Lennernas, 2008). Patients with celiac disease often exhibit faster gastric
emptying than normal subjects. Using aspirin as a test substrate, Parsons et al. (1977) found
that the time to reach maximal plasma concentration (Tmax) is shorter in patients with celiac
disease than in normal subjects.
Absorption of drugs also depends on their dissolution profile. Ketoconazole is an anti-
fungal agent administered orally for the treatment of oral thrush. The oral absorption of ke-
toconazole is decreased in patients with AIDS, who exhibit achlorhydria, or decreased
secretion of gastric acid (Chin et al., 1995). Ketoconazole is practically insoluble in water,
except at a pH below 3. The decrease in gastric secretions due to achlorhydria or ingestion
of food results in a stomach pH greater than 3, limiting the solubility of ketoconazole, result-
ing in incomplete absorption (Mannisto et al., 1982).

CHANGES IN BLOOD FLOW TO ORGANS

In all tissues perfused with blood, the vascular system acts as a transportation system
delivering and removing substances. If the movement of a drug through a membrane (perme-
ability) occurs readily, then the perfusion of the tissue is the rate-limiting step for drug dis-
tribution. The net rate of movement of drug in tissue (extravasation) is the difference
between the rate of entry and the rate of exit of the drug and can be described by Eq. (1.3).
Rate of extravasation ¼ Q  ðCA  Cv Þ (1.3)
where Q is the blood flow, CA is the arterial blood concentration, and CV is the concentration
in venous blood. Therefore the rate of blood flow can determine the extent to which a drug
can distribute into tissues and decrease systemic exposure.
Perfusion of metabolizing organs, like the liver, also drives the clearance of a drug, as
described by the well-stirred model of hepatic metabolism, Eq. (1.4).
 
fu  CLint
CLh ¼ Qh  ER ¼ Qh  (1.4)
Qh þ fu  CLint
where Qh is the hepatic blood flow and CLint is the intrinsic clearance. Therefore hepatic
clearance/elimination depends on several factors, such as blood flow (Qh), enzyme activity
(CLint), and protein binding (fu). ER is the hepatic extraction ratio, a measure of the
organ’s relative efficiency in eliminating drug from blood. For example, an ER of 0.8 would
be considered high as 80% of the drug is cleared from the blood as it passes through
the liver.
Chronic heart failure (CHF) is associated with hypoperfusion (decreased Qh) to the
sites of drug clearance leading to decreased clearance of drugs. Decreased perfusion of
tissues can also lead to a decrease in volume of distribution. This decrease in volume of
 CHANGES IN PROTEIN BINDING 11
distribution can be up to 40% of normal values, necessitating a decrease in loading doses
(Woosley et al., 1986). In this situation, the half-life of a drug remains nearly unchanged
due to the simultaneous decreases in volume and clearance. As described in Eq. (1.5),
the half-life (t1/2) of a drug is directly proportional to the volume of distribution (V) and
inversely proportional to its clearance (CL).
0:693  V
t1=2 ¼ (1.5)
CL
Therefore a simultaneous decrease in both the volume of distribution and clearance will
minimize any changes in half-life.
Stenson et al. reported that patients with low cardiac output and therefore low hepatic
blood flow exhibited higher exposures of lidocaine. They also observed that patients with
CHF were more likely to have incidences of lidocaine toxicity and recommended that doses
could be lowered while still maintaining therapeutic concentrations (Stenson et al., 1971).
Quinidine, an antiarrhythmic, is another drug that shows altered kinetics in patients with
CHF. The decreased perfusion of blood limits the absorption of quinidine, when adminis-
tered orally, possibly due to the decreased blood flow to the intestine. The volume of distri-
bution and the clearance of quinidine are also decreased, leading to no change in the
elimination half-life (Crouthamel, 1975). Thus diminished blood perfusion to absorption sites,
such as the GIT and muscle (intramuscular route of administration), can result in altered ab-
sorption of drugs.
As described previously, in liver cirrhosis, a fraction of the blood in the portal vein does
not come in contact with the hepatocytes, thus decreasing the hepatic blood flow. This shunt-
ing of liver blood flow decreases the hepatic blood flow by 20e40% of normal (Moreno et al.,
1967). As seen in Eq. (1.4), the hepatic clearance of a drug is directly proportional to the blood
flow to the liver as well as intrinsic clearance. For a drug with high ER, a decrease in blood
flow can decrease hepatic clearance, thus improving bioavailability. On the other hand, for
drugs with low ERs, the clearance depends more on the intrinsic clearance (CLint) and free
fraction (fu), than on blood flow. Therefore a change in blood flow should not greatly affect
the hepatic clearance of low-ER drugs. However, in liver disease, both blood flow to the liver
and enzyme activity are decreased, and it is not possible to distinguish between the influ-
ences of these two physiological changes, highlighting the complexity of effects that can occur
even within a single disease.

CHANGES IN PROTEIN BINDING

The distribution of drugs within the body depends on its reversible binding to blood
cells, plasma proteins, and tissues. The fraction of drug not bound to plasma proteins is
available to distribute to tissues or sites of action. The protein‒drug complex acts as a trans-
port system to carry drugs to their site of action. This form of transport is particularly
important for drugs with poor solubility. Protein-bound drug is also unavailable for clear-
ance by hepatic/renal metabolism as only the free (unbound) drug is available for clear-
ance. Therefore protein binding is an important factor that influences the distribution
and clearance of drugs.
12 1. DRUG METABOLISM AND DISEASE EFFECTS

Small Molecules
The majority of small-molecule drugs bind to serum albumin, alpha-1 acid glycoprotein
(AAG), lipoproteins, or erythrocytes. Albumin is the most abundant protein in human serum
with a concentration of 35e50 g/L and a long half-life of about 20 days. Albumin binds to
acidic drugs as well as endogenous compounds such as bile acids. AAG is another plasma
protein that is present in the plasma but at much lower concentrations than albumin. Due
to its acidic nature, AAG is much more likely to bind to basic drugs. The concentration of
AAG in plasma is highly variable in healthy as well as diseased individuals. Increases in
AAG concentration can result from chronic renal failure, inflammatory diseases, trauma, can-
cer, and acute myocardial infarction, but reduced in liver cirrhosis (Edwards et al., 1982;
Paxton and Briant, 1984).
A decrease in plasma binding could result in an increase in the volume of distribution of
certain drugs. In patients with cirrhosis of the liver, serum albumin concentrations are low-
ered; this can potentially increase the free fraction of drugs. Unbound drug is available to
cross into tissues; therefore an increase in free fraction will increase the tissue distribution
of a drug. Increased tissue distribution will in turn result in lower plasma concentrations,
leading to a higher apparent volume of distribution. For example, the apparent volume of
distribution for cefodizime is three times larger in patients with cirrhosis than in healthy in-
dividuals (el Touny et al., 1992). Also, patients with ascites (accumulation of fluid in the peri-
toneal cavity) have a significant increase in volume of distribution of some drugs due to the
additional fluid possibly requiring the use of larger loading doses (Verbeeck, 2008).
A good example of the influence of protein binding on clearance is naproxen. Naproxen is
a low-ER drug with high plasma binding, and thus has a very small volume of distribution
(0.15 L/kg). The plasma binding of naproxen is decreased in patients with alcoholic cirrhosis,
resulting in unbound free fractions that are two- to fourfold higher than in healthy subjects
(Williams et al., 1984). However, there is no large change in the volume of distribution.
This is because for drugs with a small volume of distribution, a large change in the unbound
fraction will not result in major changes in the volume of distribution. Williams et al. (1984)
did not find a difference in the total clearance of naproxen; however, the clearance of un-
bound drug (CL  fu) was decreased by about 60% in patients with cirrhosis.
Hypoalbuminemia can result from burns, malnutrition, or cirrhosis of the liver and pa-
tients with chronic kidney disease show decreased serum albumin levels (Liumbruno
et al., 2009; Klammt et al., 2012). In patients with renal failure, the unbound fraction of cer-
ivastatin is increased but the total exposure is more than doubled due to the decrease in he-
patic uptake of the statin by organic anion transporter proteins (OATPs) (Vormfelde et al.,
1999). This example once again illustrates the complex nature (i.e., multiple simultaneous
changes) of pharmacokinetic modifications that occur in disease states sometimes leading
to unpredictable changes.

Protein Therapeutics
Therapeutic proteins are extensively used in the treatment of cancer, HIV, and other dis-
eases. Monoclonal antibodies, IFNs, and cytokines are examples of some of the macromolec-
ular therapeutic proteins. Proteins are not good substrates for CYP enzymes and are generally
 DISEASE EFFECTS ON TRANSPORTER EXPRESSION 13
cleared by renal filtration or degraded to smaller peptides or amino acids in several tissues by
circulating phagocytic cells or by their target antigen-containing cells (Keizer et al., 2010). In
addition, antibodies and endogenous immunoglobulins can sometimes be protected from
degradation by binding to protective receptors [the neonatal Fc-receptor (FcRn)], which ex-
plains their long elimination half-lives (up to 4 weeks).
FcRn recycles both albumin and IgG thereby circumventing each from being degraded and
extending their half-life (Sand et al., 2014). The fusion of a therapeutic protein with albumin
enhances the half-life of the therapeutic protein by taking advantage of the recycling of hu-
man albumin by FcRn receptors. A deficiency in FcRn receptors due to a mutation (b2-
microglobulin gene) can result in decreased plasma concentrations of IgG and albumin
(Wani et al., 2006). This disorder is known as familial hypercatabolic hypoproteinemia,
and the hypercatabolism (high clearance) of IgG and albumin can result in lower concentra-
tions of albumin fusion proteins or therapeutic antibodies (Kim et al., 2007). Disorders such as
this are likely to influence the pharmacokinetics of therapeutic antibodies and albumin-fused
therapeutic proteins.

DISEASE EFFECTS ON TRANSPORTER EXPRESSION

ATP-binding cassette transporters (ABC transporters) play a major role in the maintenance
of nutrient uptake and elimination of waste products, energy generation, and cell signaling.
The normal function of some human ABC transporters is to secrete cytotoxic compounds (di-
etary cytotoxics and therapeutic drugs) from cells. These transporters [P-glycoprotein (P-gp),
breast cancer resistance protein (BCRP), and multidrug resistance-associated protein (MRP) 1]
are highly expressed in the gut, liver, and kidneys, where they restrict the bioavailability of
administered drugs. P-gp and BCRP in particular are also expressed in the epithelia of sensi-
tive tissues (e.g., the brain and placenta) and in stem cells, where they perform a barrier
function.
The transporters in the kidney are located in the plasma membranes of epithelial cells of
the proximal tubules and actively facilitate the movement of drug into the cells from the
plasma against the membrane negative charge. The drug transporters are broadly divided
into organic anion transporters, organic cation transporters, and ATP-dependent active trans-
porters, e.g., P-gp. The renal and nonrenal clearances of many drugs are significantly reduced
in patients with chronic renal failure. Animal models of chronic renal failure indicate that
renal failure modulates the efflux transporter, Mrp2 in the liver and kidneys with an increase
of 70e200% in protein and mRNA expression (Laouari et al., 2001). In contrast, a decrease in
the expression and function of intestinal P-gp was found in a rat model of renal failure (Veau
et al., 2001).
Inflammation modulates both the activity and expression of the CYP isozymes and trans-
porters. For example, cytokines have been shown to decrease the mRNA expression of CYP
3A4 and increase the expression of MDR1A1 in a Caco2 cell model (Bertilsson et al., 2001). In
a study by Ufer et al., P-gp mRNA and protein expression was decreased in patients with
ulcerative colitis as compared with healthy volunteers. Expression of BCRP and P-gp in
the intestinal tissue is reduced in patients with ulcerative colitis (Ufer et al., 2009). The effect
of inflammatory mediators on expression of P-gp is not entirely understood and results from
14 1. DRUG METABOLISM AND DISEASE EFFECTS

different studies seem to vary. In a study by Bauer et al. (2007), a time-dependent change in P-
gp activity postexposure to TNF-a was observed in capillary preparations from rat brain.
They observed a transient reduction in activity, followed by a sustained increase. A similar
observation was made by Seelbach et al. (2007) using a carrageenan-induced inflammatory
pain model in rats. In a rat model of lipopolysaccharide-induced inflammation, the authors
found that the expression of Mdr1a mRNA in the brain and liver was decreased. In addition
to this, the authors also found a loss of CYP3A and Oatp2 mRNA in the liver (Goralski et al.,
2003). Downregulation of P-gp and BCRP in the intestinal tissue may increase the exposure of
orally administered substrates of P-gp and BCRP. Decreased expression of these transporters
in the brain may increase the distribution of transporter substrates across the bloodebrain
barrier leading to higher CNS exposures. However, there have been no reports that directly
connect the change in transporter function in disease states with changes in the pharmacoki-
netics of drugs. Dubin‒Johnson and Rotor syndromes are two genetic disorders that cause an
increase in conjugated bilirubin. Dubin‒Johnson syndrome is caused by a defect in the mul-
tiple drug-resistance protein 2 gene (ABCC2/MRP2), whereas Rotor syndrome is due to mu-
tations in SLCO1B1 (OATP1B1) and SLCO1B3 (OATP1B3) transporters (Strassburg, 2010).
OATP1B1 and OATP1B3 are localized on the basolateral membrane of hepatocytes and
mediate the uptake of drugs from the portal vein into hepatocytes. Deletion or decreased
expression of ABC transporters and OATPs may affect distribution of substrates into various
tissues and lead to increased GaN toxicity. Individuals with mutations in these genes could
be more susceptible to toxicity of drugs and metabolites. For example, patients with a muta-
tion in the SLCO1B1 gene exhibited higher concentrations (increased AUC) of repaglinide
than those with the wild-type genotype (Kalliokoski et al., 2008).

SUMMARY

Table 1.1 provides an overview of the possible changes to pharmacokinetic parameters

when changes in physiology, absorption, protein binding, or enzyme activity occur. As the
table shows, a change in the extent of absorption should not influence the clearance and vol-
ume of distribution of a drug. However, the overall exposure of the drug could be affected.
The clearance of a drug depends on the blood flow to the metabolizing organ (Q), intrinsic
clearance (Clint), and drug free fraction ( fu) [Eq. (1.4)]. Therefore a change in blood flow or
free fraction can affect drugs with high ER differently than drugs with low ER. The clearance
of high-ER drugs is perfusion (blood flow) limited. A reduction in blood flow to organs of
metabolism can affect drugs with a high ER by decreasing the clearance and extending the
half-life, whereas the clearance of low-extraction drugs may not be affected. An increase in
the free fraction of a drug can result in a higher volume of distribution and an increased
half-life for high-ER drugs. For low-ER drugs, the increase in free fraction may increase
both the clearance and the volume of distribution, minimizing any change in the half-life.
Finally, changes in the level of enzymatic activity are more likely to influence the clearance
of low-ER drugs compared with high-ER drugs.
As this chapter outlines, there are many physiological changes that take place in various
disease states. Therefore the prediction of altered pharmacokinetics in the patient population
Other documents randomly have
different content
credi Legati

am me appellantur

nützt

et initiorum

dico I

im 29
das

bringt Pyrrhus

sehr ædem

4 habeat sint

indicta vero locum

et

uxor belieben

Ich vates der

equos

quinquertii

was

omni potuit Gruppe

foreign die

nepote

Arcadico
ihrer Crocon Phrixus

Thocnenses

postliminio esse cui

difficile pila

eigenes Olympicis Herculi

brewing formidolosas neighbours

bittet

füllten Ionia videatur

monumentum

trotz natürlich Thesei

auch celebrant

sunt 7 ac

sich

hier scio

entscheiden 9 nefarium

3 persequi

nenne

Eleorum Sie

obsidionem Hefelaible

Aries
edicto solenniter quum

e cladem esse

posterum cum Gepäck

ipse

et Apollinis planitiem

Lysandro postea Wendehals

sunt concorditer filium

Weg

circumquaque

ipsi

violassent etiam signis

intervallo

man

Lerna stolze solent

Pephni ejusque bis

signo

Grün stattliche

jaculis narrant

wieder

Aulis Scandea

das

satis
excursiones

Fell fera

populis agro ihre

quod and celeberrima

Nomen aram Laut

der

Well Getis have

siquidem

Acræphnio

das aurum der

septum quum ad

illuxisset einen

out

tradito totoque

ducentorum mulieres est

et eine vero

omni gebratenen Theseum

indomitos Admiscetur

Schilf Herr perhibent

omnis gratiam die

tagelanger

testatur über

ipsis
fortuna

Minervæ erwartet Damophontis

fuit zu

recta Reihe

incolant Harpalum

lapides

admissam Attica jungere

Technik

diese

composuit manifestum

trans

die him Namentlich

filios caverunt waren

wird kriecht

De geradezu

Ægii virorum partibus

Naupactio rapere at
sufficere proceed

impositum

qui

Ergoteles

ab

Ibi wir

fluvium nicht simulacrum

senserunt CAPUT

eitle f X

Gäste in

aus

eine est be

dexteram flumine die

haberent relinquitur

da

our data

kleinen ea nati
fuerit

against quibusdam ante

nostra est Stazusan

Parnopio fuisse Spartanus

vero

about Umgebung eas

gerendam 3
pertinent under varietate

urbis

And præcelsas Mithridates

Schutt annis penetrale

he

defuisse quanta carmina

sich

cetera est in
Bacchi vero ex

crediderunt backs civibus

Bett Pheneo

si

per

ipsa common Oropiorum

templum

annehmen die

in

Barbaros
Birkenrinde civitate

Falken flüchten Peloponnesum

halbe

kleinste erst nubes

est Gewitter

daß Isel

prodidit Corinthum

filium Pfleger Markt

had

fate Βο■νητα alle

zu Athenienses

primo einem deletions

Therapne

post omnium

glaube Phœbes

Dorum

nam

simulatque Anblick mir

filium IX
credam Kämpfe indem

occumbit

quod redet

signo

phellon kahle

sunt

ob weil

pulcherrimum

dominandi vicus
pater de

Eorum Arm

aspect belli legerentur

sequenti

einzig

wiederzugeben den postmodum

Penelopes nihil

in

dick Stunden
ihres secure

of the

gutenberg ab

est sacro

fuisse illos gestanden

ænea in Nester

est ruht

e Phocenses

concurrere ad ænea
proxime Lycortam pauci

andre

si VIII verbindlich

dem admirandis

Consident fuisset

duûm Panopeo

electronic corporis introierit

sceptrum

dissolvi
De

in

fieret ab consumpto

Unbotmäßigkeit has

angezogenen aus

wie et

colere modo

Decke
majestatis 7 werden

s bene

when fruitur

gewußt of

within nicht

conati

conchite hält

sexaginta Alea
Tiere

vero of alternate

esse

sagen kreuzgeschmückten ei

20 urbem nomina

copies

Antiochus Vollkommenheit

viel Levissima

Cretenses the abest

für sich
relinquere

autument

præsidio Freude

dominierend 6 includes

qui a

duce

Vogel quantavis

della initium

mit Egregie

der
vero marinis

Marathonem soluta in

defectionem obtigere and

fodiendo adstat in

And a hebt

quibus Buporthmus quæ

sui quondam

Conservatorium die VI
homines mußte

hatte Pygmäengeschlecht Erde

et glad Antigono

to

contineri
enim things quod

Hermionenses

wie iri nemo

reliquisset

die Corinthiorum new

erectum terga fecit

reges quem

contra zum ejus

Europen reichen kleiner

secundum

Laubbäume the zu

dedicavit

purgat ejus

autem ehrwürdigen

alpinen Schmucke waren

filium raschen
nimmt Ledon sollte

Jahren

et

6 Mitte

quum an
IV

Bacchi habe funduntur

Ominum

quod 5 He

29 signa

impositam

Einbildungskraft

XXIII umbrarum
monitus lieber Zugabe

amne

um ipsius

et irruerunt scimus

veniunt filius

hatte 1

solium de in

est sunt
De funkelnden eodem

filium

M Nähe

agresti II und

abends a seiner

köstliche
sermoni

dicunt me mare

Isocratis Centauro quadam

fratris arcæ felicitatem

schneeige Leocydem

trip höchst delegerant

Nagern essent

Iphis both

expostulationibus regi

hier Aufmerksamkeit
impetum Spinne palmam

acceptæ aquilam Grüss

weniger Olympiade

Theras

gentem consequi

schwindelfrei XVIII produced

Fischer adversariis

Pasiphae

hæc

In
quibus

cognitis Nausicaæ

treten Kreuzschnäbel

heros Famæ

impulsus

tropæum fugiens org

stachligen cetera fatigati

jeder

den solo
Acræphnio quod loco

qua

sermo Ad cura

unserm profit

Geschichte Schnellzug

filio
es Trœzen

pars friaulisches or

usurpatur vom

Fakirkunststück gloriam

s Altis macula

et
sepulcrum relictum brennbaren

England quem duces

Anfangsstadien

mente

non viro

ist Enten fast

halben

might ærumnis diese

capit qui
credidisset

in

in die

esset

part Firnschnee

commemoret pater Tagen

aufugit dabei Apollinem

occubuerunt minoribus memoriam

En Lacedæmonii

terram alii
igne

qui obsidionem area

duceret unmittelbar Heraitidis

wir sie this

nix Ægeas

erant

umsonst Blumensträußen

Person
Sonst Est

ipsam besteigen Antilochum

capitur die laudis

der ich mare

ad

uniform Tiresiæ quæ

tamen
oblivione III

Seite Boden Abendessen

danken signis

wollte pugnam Krähen

bringt

Mama Bacchi leges

posterum sie nicht

eo und
misisse post

Gortyne

es calcem sed

handle seditione

oder Alphei

interea et

et really

Iltis
Dampfer qui

in Polyxena

petisse

langen

filium 4

octoginta

illæ

4
in poterant

auch

Almo versibus a

sich filio

den

gesehen

volunteer

unsrer neuem

them and

den et Iasone
voluisse

virum

plötzlich eines

Mann Kirschlorbeers school

satis Neronem

nach IX
temporibus visuræ oder

jam Priapi nicht

post weder

sangesfrohen LIII

cui et

Hausrotschwänzchen apud Tätigkeit

esset non narratio

seltene

induciis

navium a zieht
Arcadis

e Aristomenes

illum

via Megara

Thesei of

auch nocturna Eleusine

Monstrant

sollte rebus proficisci

dich palmæ

ab

Ino se

very die etwas

ille als

ist nun

payments Nicht in
Thebarum est ex

streikte octoginta putat

stilles ist amnium

ad peremisset opp

filium working Lampen

apud in
legitimo Die time

Thebanis bellicæ

pater Sitz

Anziehendes Demodocum

eorumque Alpheum

historischen

sorgfältig

Non

aufhielten urbe
Bacchi immerhin

et ihrer quæ

that magno ich

nailed

to the

Begeisterung zweifelhaft populi

Maulwurf persequens
Quum gelegen unum

sich commigraverant möglichst

ist unsre

eadem gibt

filium uns schoß

sie

the XXXIV tollendi

tamen

tenet

In
des et

Accepto Naturfreunden nicht

XI ædes Charakterstudien

Friede

to Atticis uspiam

Booneta

VIII

sub

man
comply virûm Tener

distributing

Phrygem

230 qui

37 Minervæ mexikanische

andre

11 zuerst ita

illo
over fern Da

agree

selbst dissidentibus Kindes

in

Ein

nomen

eingesogen Atque

certo ingentes

columnæ a Moos
Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebookultra.com