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Systemic bioavailability of

ocularly applied 1% atropine


eyedrops
Timo Kaila1, Juha-Matti Korte2 and K. Matti Saari2
1 2
Department of Pharmacology and Clinical Pharmacology and Department of
Ophthalmology, University of Turku, Turku, Finland

ABSTRACT.
Purpose: To investigate the pharmacological basis of systemic effects of atro- reviewed earlier (Kentala 1991). Approxi-
pine eyedrops, we estimated the bioavailability of ophthalmic 1% atropine solu- mately two-thirds of atropine is metab-
tion in healthy volunteers. olized in the liver (Kalser & McLain
Methods: In a randomized crossover study we administered 0.3 mg atropine 1970). Urine excretion is the main route
either intravenously or ocularly to six healthy volunteers. The plasma concen- of elimination in man (Kalser 1971).
trations of the biologically active atropine enantiomer, 1-hyoscyamine, were de- The basis for the systemic anticholin-
termined using a muscarinic cholinoceptor binding assay. ergic effects of atropine eyedrops is the ab-
Results: The mean area under the curve from zero to infinitum (AUC0–≤) for sorption of the l-hyoscyamine from the eye
into the systemic circulation. The lack of
1-hyoscyamine was 1.862∫0.580 mg/L ¡ hr after intravenous, and 1.092∫0.381
literature on the systemic bioavailability
ml/L ¡ hr after ocular administration (mean∫s.d, nΩ6), respectively. The mean
of atropine eyedrops is mainly due to the
bioavailability was 63.5∫28.6% (mean∫SD, nΩ6; min 19%, max 95%). Large
fact that plasma l-hyoscyamine levels after
interindividual differences characterized the absorption and elimination phases ocular atropine application are below the
of 1-hyoscyamine kinetics. The terminal half-life (t1/2b) of 1-hyoscyamine in detection limit of ordinary analytical tech-
plasma was not affected by the route of drug administration. niques. Because the kinetics of the active
Conclusion: The systemic bioevailability of 1-hyoscyamine was considerable and and inactive atropine enantiomer differ
may explain the systemic anticholinergic side effects reported in association from one another (Kentala et al. 1990), the
with the clinical use of atropine eyedrops. bioavailability measurements should be
carried out using methods measuring pref-
Key words: anticholinergic agents – atropine – bioavailability – enantiomer – hyoscyamine – mus- erentially the biologically active enanti-
carinic cholinoceptor – radioligand binding assay. omer, l-hyoscyamine.
In this study we determined plasma l-
Acta Ophthalmol. Scand. 1999: 77: 193–196 hyoscyamine concentrations using a sen-
Copyright c Acta Ophthalmol Scand 1999. ISSN 1395-3907 sitive radioligand binding assay. The sys-
temic bioavailability of l-hyoscyamine
was estimated by administering 0.3 mg
atropine in a randomized and crossover

A tropine eyedrops are used to produce


a longlasting mydriasis and cyclo-
plegia in the eye (Brown 1990). In the
which consists of two enantiomers, l-hy-
oscyamine and d-hyoscyamine. Only the
l-enantiomer binds with a high affinity to
fashion either as an intravenous bolus in-
jection or as a 1% eyedrop instilled in the
eye of the healthy volunteers.
literature there are no published data on muscarinic acetylcholine receptors, is
the systemic bioavailability of topically biologically active and responsible for the
applied ocular anticholinergic agents in therapeutic and anticholinergic side ef- Materials and Methods
humans, although these drugs frequently fects of atropine (Brown 1990). After ad-
produce systemic side effects, such as ministration of racemic d,l-atropine no Subjects and study design
dryness of mouth or inhibition of conversion between the two enantiomers Six healthy medical students, one male
sweating, and sometimes also more severe takes place during and after absorption and five female, entered the study after
adverse reactions, such as disturbances in (Kentala 1991). Atropine is a potent giving their informed written consent.
the mental and cardiac functions (Brown compound and is known to antagonize Their age varied between 24 and 29 years
1990; Baker & Farley 1958). In children human muscarinic cholinoceptor actions (mean 25.5∫2.2 years) and weight be-
even cases of death have been ascribed to at plasma concentrations less than 100 tween 56 and 75 kg (mean 64.3∫7 kg).
the systemic toxicity of atropine eyedrops pg/ml (Brown 1990; Lahdes et al. 1988; Demographic data of the subjects is
(Hoefnagel 1961). Kentala et al. 1990). shown in Table 1. All subjects were deter-
Atropine is a belladonna alkaloid The metabolism of atropine has been mined to be in good general health on the

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Table 1. Demographic data of tho volunteers. reach the maximum (tmax) were recorded
from the individual plasma concen-
Subject Sex Age yrs Weight kg Height cm
tration-time curves. The area under the
A female 24 68 170 plasma concentration curve (AUC) from
B female 29 56 165 time zero to infinity was calculated using
C female 24 67 179 the linear trapezoidal rule. The AUC
D female 27 60 170 from the time of last measured 1-hyoscy-
E female 24 60 173 amine concentration to infinity was cal-
F male 24 75 192 culated using the slope of the log plasma
Mean 25.5 64.3 174.8 concentration vs time curve in the ter-
SD 2.2 7.0 9.6 minal elimination phase (Cbt ). The
bioavailability of the ocular atropine (F)
was calculated by comparing the
AUC0–≤ values for the intravenous and
basis of medical history, physical exami- to the lower cul-de-sac of the eye. The AUC0–≤ocular
ocular atropine: FΩ ¿100.
nation, electrocardiogram (ECG) and eyedrops were administered with an ad- AUC0–≤iv
routine laboratory safety tests including justable Finnpipette (Labsystems Co., Total clearance (CL) was obtained from
blood hemoglobin, serum creatinine, Helsinki, Finland) for laboratory use. An Dose
serum alanine transaminase and fasting interval of two weeks was kept between the formula CLΩ . The half-live for
AUC≤
blood glucose. Prior to the initiation of the intravenous and ocular drug adminis- the terminal elimination phase (t21b) was
the study, the study protocol and the tration. Venous blood samples of 5 ml calculated using a two or three exponen-
written informed consent form were ap- were taken for l-hyoscyamine analysis at tial model of log-linear least squares fit-
proved by the Joint Commission on Eth- 3, 5, 8, 10, 15, 20, 30 and 50 minutes, and ting model in the SIPHAR software
ics of the University of Turku and the 1, 1 1/2, 2, 3, 4, 5, 6, 7 and 8 hours after (SIMED, Creteil, France).
Turku University Central Hospital. drug dosing. Plasma l-hyoscyamine con-
The study was carried out using a ran- centrations were analyzed with a radiore-
domized crossover design. The volunteers ceptor binding assay (RRA) measuring
fasted from midnight and abstained from drug binding to rat neuronal muscarinic
smoking on the testing days. Alcohol in- cholinoceptors (Lahdes et al. 1988). The Statistical analysis
take and use of any medication was pro- detection limit of the radioreceptor bind- The parameters measured are given in the
hibited for 48 hours prior to the session. ing assay for l-hyoscyamine in plasma text as means∫SD (nΩ6). The differences
The subjects came two different times to was 20 pg/ml. The intra-assay and in- in the heart rate and blood pressure be-
the laboratory. An intravenous cannula terassay coefficient of variation (CV) in tween intravenous and ocular administra-
was inserted in a forearm vein for blood the concentration range of 20–2000 pg/ml tion groups were statistically tested using
sampling. After randomization the sub- was less than 10%. analysis of variance (ANOVA). The effect
jects received 0.3 mg atropine either in 0.3 The systolic and diastolic blood press- of repeated measurements in different ex-
ml of intravenous atropine sulphate ures and heart rate were recorded with an aminations as also the interactions of
(Atropin 1 mg/ml inject, Leiras Pharma- automatic measuring device (sphygmo- these effects with grouping variables were
ceuticals, Turku, Finland) given as a bo- manometer BP–203 M II, Nippon Kohn- tested using analysis of repeated measure-
lus injection into the opposite forearm en Co., Japan). ments. The calculations in repeated meas-
vein, or in 30 ml of 1% atropine sulphate urements ANOVA were performed with
ophthalmic solution (Oftan Atropin 10 Kinetic calculations general linear model procedure. The dif-
mg/ml eyedrops, Star Pharmaceuticals, The maximal plasma concentration ferences were considered significant at
Tampere, Finland) instilled unilaterally (Cmax) and the corresponding time to p∞0.05.

Table 2. Pharmacokinetic parameters of 1-hyoscyamine after intravenous and ocular application of 0.3 mg atropine.

AUCiv AUCocul CLiv CLocul t21 betaiv t12 betaocul Cmaxocul Tmaxocul
Subject ng/ml ¡ h ng/ml ¡ h F% ml/min/kg ml/min/kg (h) (h) pg/ml min

A 1.56 1.25 80 2.4E-05 2.9E-05 4.1 2.7 275 30


B 1.67 1.12 67 2.7E-05 3.9E-05 4.3 2.9 330 60
C 1.86 0.36 19 2E-05 1E-04 2 1.5 166 5
D 1.15 1.09 95 2.8E-05 2.8E.05 3.6 3.6 265 8
E 1.51 1.21 80 2.8E-05 3.6E-05 1.3 2 345 60
F 3 1.2 40 1.1E-05 1.1E-05 2.5 2 355 3
Mean 1.79 1.02 63.5 2.3E-05 4E-05 2.97 2.45 288.33 27.67
SD 0.64 0.33 28.6 6.5E-06 3.1E-05 1.22 0.76 72.91 26.85

The systemic bioavailability (F) was calculated using the formula: F%ΩAUCocular/AUCiv ¡ 100.
Clearance (CL) refers to the total clearance, CLΩD/AUC. T12 beta refers to the half-life in the terminal phase of plasma elimination kinetics. The
half-lifes of ocular atropine are approximates, because the complex patterns of drug absorption did not allow an exact determination of the
parameter. Cmax refers to the maximal plasma concentration and Tmax refers to the time required to reach Cmax after ocular application.

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and the 95% confidence intervals were be-
tween 1.7 and 4.2 after intravenous ad-
ministration and between 1.7 and 3.2
after ocular administration. After ocular
drug application the complex systemic
absorbtion phase interfered with the esti-
mation of terminal half-life values.
There were no statistically significant
differences in the systolic (pΩ0.49) and
diastolic (pΩ0.70) blood pressures and
heart rates (pΩ0.25) between the intra-
venous and ocular treatment groups at
different time levels.
Similarly, there were no statistically
significant differences in the systolic (pΩ
0.59) and diastolic (pΩ0.20) blood press-
ures or heart rates (pΩ0.20) between dif-
ferent time levels inside the treatment
groups (Fig. 2. ANOVA).

Discussion
This is the first study to estimate the
systemic bioavailability of 1% atropine
eyedrops in humans. The systemic bio-
availability of 1-hyoscyamine in the vol-
unteers of this study varied between 19
and 95% with a mean bioavailability of
64%. The large interindividual variation
may be due to the fact that considerable
drug amounts are easily overflown from
the conjunctival sac at the time of eye-
drop instillation. We tried to reduce the
drug losses caused by the overflow by
applying only a 30 m1 volume of oph-
thalmic 1% atropine solution, using a
micropipette.
Therefore the mean 64% bioavail-
ability of 1-hyoscyamine found in this
Fig. 1. Plasma atropine kinetics in subjects A, B, C, D, E and F after intravenous (open circles) study is likely to exceed that of clinical
and ocular (closed squares) application of 0.3 mg atropine. Plasma 1-hyoscyamine concentrations practice in which the average eyedrop size
are given in the logarithmic scale as pg/ml units. may exceed 40 m1. The terminal elimin-
ation rate of 1-hyoscyamine in the plasma
after intravenous and ocular dosing was
of l-hyoscyamine were always detectable similar (Fig. 1).
Results in plasma. The interindividual differences Our subjects did not spontaneously re-
The systemic bioavailability of the biolo- in the rate, extent and duration of the port any systemic side effects after intra-
gically active atropine component, 1-hy- ocular drug absoption were large. The venous or ocular atopine administration.
oscyamine, varied markedly between the initial ocular absorption phase lasted ap- We could detect no atropine effects on
subjects. The bioavailability ranged from proximately one hour. The Cmax values the heart rate or blood pressure. The lack
19 to 95%, with a mean value of after ocular dosing ranged from 166 to of effects was probably due to the low
63.5∫28.6% (mean∫SD, nΩ6). The indi- 355 pg/ml, and tmax values from 3 to 60 dose of atropine (0.3 mg) and the fact
vidual plasma 1-hyoscyamine concen- minutes (Table 2 ). During the terminal that the volunteers in this study were
tration-time curves after intravenous and phase of drug elimination from plasma healthy young adults, who are known to
ocular dosing are presented in Fig. 1, and the l-hyoscyamine levels were surprisingly be more resistant than elderly people and
several pharmacokinetic parameters are similar after intravenous and ocular dos- children to the anticholinergic side effects
presented in Table 2. ing (Fig. 1), although interindivudual dif- of atropine (Brown 1990; Kentala et al.
No l-hyoscyamine was detectable in ferences in the elimination rate were 1990; Kentala et al. 1989).
plasma in the baseline samples. Already large. The average half-life of l-hyoscyam- The cardiac effects of atropine are
three minutes after intravenous and ocu- ine for the terminal elimination phase closely related to plasma 1-hyoscyamine
lar dosing, however, measurable amounts ranged from 1.3 to 4.3 hours (Table 2), concentrations (Kentala et al. 1990). At

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Fig. 2. Systolic (left panel, upper part) and diastolic (left panel, lower part) blood pressure and muscular atropine in elderly people:
heart rate (right panel) after intravenous (open circles) and ocular (closed circles) applications of pharmacokinetic studies using the radiore-
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of 0.3 mg atropine showed any significant Supported by grants from Leiras Co, dose-response curves of atropine in man ex-
effect on blood pressure or heart rate. In Turku, and Paulo Foundation, Helsinki, plained by different functions of M1- and
ordinary clinical practice a single 1% Finland. M2-cholinoreceptors. Naunyn-Schmiedeb-
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atropine, a drug amount which corre-
sponds to a recommended parenteral pre- Received on February 13th, 1998.
Accepted on September 25th, 1998.
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