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Metronidazole Problems and Solutions Review

Sabah Jawad Salih, Ph. D. Pharm. Chem; NCDCR, Baghdad, Iraq1.

Introduction
Metronidazole (Fig. 1), 2-methyl-5-nitroimidazole-1-ethanol is the most useful of a group of
antiprotozoal nitroimidazole derivatives. Metronidazole was first marked for the topical
treatment of Trichomonas vaginalis. It has been shown to be effective orally against both the
acute and carrier states of the disease (1a). The drug also possesses useful amebicidal activity and
is effective against both intestinal and hepatic amebiasis. It has also been found of use in the
treatment of such other protozoal diseases as giardiasis and balantidiasis.

OH

N
O

N N+

Fig.1-1
O-

Because of its bactericidal action, Metronidazole has become an important agent for the
treatment of serious infections (e.g. septicemia, pneumonia, peritonitis, pelvic infections,
abscesses, meningitis) caused by anaerobic bacteria (2).
The common characteristic of microorganisms (bacteria and protozoa) sensitive to
Metronidazole is that they are anaerobic. It has been speculated that a reactive intermediate
formed in the microbial reduction of the 5-nitro group of Metronidazole covalently binds to the
DNA of the microorganism, triggering the lethal effect. Potential reactive intermediates include
the nitroxide, nitroso, hydroxylamine, and amine. The ability of Metronidazole to act as a
radiosensitizing agent is also related to its reductive potential (1a).

Physical Properties of Metronidazole


Metronidazole is a white or yellowish, crystalline powder, slightly soluble in water, in acetone, in
alcohol and in methylene chloride, very slightly soluble in ether. It have melting point of 159 –
163oC (3).
Metronidazole is stable in air but is light sensitive. Despite its low solubility, Metronidazole is
well absorbed following oral administration (1a). Its oral bioavailability is about 99%.

1 sabahjawad@aol.com
Metronidazole is a weak base. Although it is administered parenterally only as the free base by
slow intravenous infusion, Metronidazole for injection is supplied in two forms: a ready-to-inject
100ml solution containing 5mg of base per ml; and a hydrochloride salt as 500mg of a sterile
lyophilized powder (3).

History
The azole antifungals include two broad classes, imidazoles and triazoles. Both share the same
antifungal spectrum and mechanism of action. The systemic triazole is more slowly metabolized
and has less effective on human sterol synthesis than do the imidazoles (4a). The discovery of
azomycin (2-nitroimidazole) (Fig. 2) in 1955 and the demonstration of its trichomonacidal
properties by Horie led to the chemical synthesis and biological testing of Metronidazole and
many nitroimidazoles by Jacob et al (1957)(5). Metronidazole was found to have particularly high
activity in vitro and in vivo against Trichomonas Vagilanis and Entamoeba Histolytica by Cosar
et al. (1959)(4b).

N
O-

N+
N
H
O
Fig.1-2

Mechanism of Action and Resistance


The mechanism of action of the nitroimidazoles is reflected in a selective toxicity to anaerobic or
microaerophilic microorganisms and for anoxic or hypoxic cell.
Metronidazole can be considered a prodrug in the sense that it requires metabolic activation by
sensitive organisms. Once the drug has diffused into the cells, the nitro group accepts electrons
from electron-transport proteins with sufficiently low negative redox potentials, e.g.
flavoproteins in mammalian cells and ferredoxins or their equivalent in protozoa and bacteria.
The source of electrons for the reduction may be a number of nicotinamide adenine dinucleotide
phosphate (NADPH) or sulfide. The antimicrobial activity of Metronidazole probably results
from the formation of labile, chemically reactive intermediates formed during the four-electron
reduction of the nitro group to the corresponding hydroxylamine. The molecular steps by which
these intermediates destroy cells have not been elucidated but probably involve reaction with
cellular macromolecules such as DNA, proteins and membranes (4a). Early work established that
Metronidazole inhibits DNA synthesis in Trichomonas Vaginalis and Clostridium Bifermentans
and causes degradation of existing DNA in the latter microorganism. Further studies with
mammalian DNA indicate that reduced Metronidazole causes a loss of the helical structure of
DNA, strand breakage, and impairment of DNA function. These findings are consistent with the
antimicrobial and mutagenic effect of Metronidazole and its ability to potentiate the effects of
radiation on hypoxic tumor cells (6&7).
Nitroimidazole resistance genes were detected in 2% of 1,502 clinical Bacteroides Fragili; group
strains (8). Moore et al (2004) found that several chromosomal loci have been implicated in
resistance to Metronidazole(9).

Pharmacokinetic Distribution & Metabolism


The pharmacokinetic properties of Metronidazole and its two major metabolites have been
investigated intensively by Lau et al. in 1992. The drug usually is completely and promptly
absorbed after oral administration, reaching concentrations in plasma of about 10μg/ml (4c) or less
in 1-3 hours (10) for most susceptible protozoa and bacteria. Repeated doses every 6 to 8 hours
result in some accumulation of the drug (4c). Also a dose of modified- release Metronidazole
composition given once daily (11). The half-life of Metronidazole in plasma is about 8 hours, and
its volume of distribution is approximately that of total body water. About 10% of the drug is
bound to plasma proteins. Metronidazole penetrates well into body tissues and fluids, including
vaginal secretions, seminal fluids, saliva, and breast milk. Therapeutic concentrations also are
achieved in cerebrospinal fluid (4).
Both unchanged Metronidazole and several metabolites are excreted in various proportions in the
urine after oral administration of the parent compound. The liver is the main site of metabolism,
and this accounts for over 50% of the systemic clearance of the drug. The two principles (Fig. 3)
metabolites result from oxidation of side chains; both are anti-trichomonal activity. Formation of
glucuronides also is observed (4c). The activity of hydroxy metabolite is 65% of the activity of the
parent drug (12).

O
H2
H2C C OH H2C C OH

O2N N N
CH2OH O2N
CH3

N
N
(a) Hydroxy metabolite (b) Acid metabolite

Fig.1-3: 2 major oxidative products of Metronidazole (12).

Side Effects
The common side effects of Metronidazole metallic, bitter taste in the mouth (10) and abdominal
pain. Other serious and rare side effects include pseudomembranous colitis and seizures (13).
An unusually rapid development of peripheral neuropathy due to Metronidazole was also
reported (14). Metronidazole is a lipid-soluble drug, so it has significant penetration into the
central nervous system (15b) that leads to central nervous system symptoms like dizziness,
headache and sensory neuropathies (10).
Metronidazole may produce a disulfiram-like reaction. Disulfiram, which used in the treatment
of alcoholism, inhibits aldehyde dehydrogenase so whenever ethanol is consumed acetaldehyde
accumulates and produces an intensely unpleasant reaction (16).
(17a)
Metronidazole is mutagenic in some strains of bacteria and carcinogenic in rodents (fungi) .
Tumors have been induced in rats and mice (18).

Therapeutic Uses
Metronidazole cures genital infections with Trichomonas vaginalis in both females and males in
a high percentage of cases (19).
Metronidazole is an effective amebicide and has become the agent of choice for the treatment of
all symptomatic forms of amebiasis. Treatment with Metronidazole is least effective when the
drug is administered to an asymptomatic passer of cysts, probably because absorption occurs
higher in the gastrointestinal tract (4e).
Metronidazole has become the drug of choice for the treatment of giardiasis. It is extremely
useful for treatment of serious infections due to susceptible anaerobic bacteria, including
Bacteroids, Clostridium, Fusobacterium, Peptococcus, Peptostreptococcus, Eubacterium and
Helicobacter (4f).
The nitro group of Metronidazole is able to serve as an electron accepter, forming reduced
cytotoxic compounds that bind to protein and DNA, resulting in cell death (15b).
Metronidazole is usually given intravenously for these indications. The drug has been employed
for the prophylaxis of postsurgical abdominal and pelvic infections and for the treatment of
endocarditis caused by Bacteroides fragilis. Recent studies by Hopkins and Morris in 1994, have
suggested that Metronidazole therapy may benefit some patients with peptic ulcers who are
infected with Helicobacter pylori (4g).

Synthesis of Metronidazole
Nitration of 2-methylimidazole (1) affords a mixture of the 4-and 5-nitro isomers (2, 3). It has
been found empirically that alkylation of the mixture (2, 3) in non polar solvents favors
formation of the product from the 5-nitro isomer. Conversely, alkylation of the performed anion
in solvents such as DMF favors the 4-nitro product. Alkylation of the 5(4)-nitro compound with
chlorohydrin leads to Metronidazole (4) (scheme 1) (20), which extracted firstly with water then
alkalinized and extracted with chloroform and finally recrystallized from ethyl acetate (5) & (21).
Alkylation step can be run with an epoxide in base (22).
N N NH

CH3 O2N CH3 O2N CH3


N N N
H H

(1) (2) (3)

O2N CH3
N

CH2CH2OH

Scheme (1-1): Synthesis of Metronidazole (20). (4)

Problems and Solutions


Nearly all therapeutic agents possess various physicochemical and biological properties, some
desirable and others undesirable. In general, the pharmaceutical world is concerned with
minimizing the number and magnitude of undesirable properties of a drug while retaining the
desirable therapeutic activity.
Improvement of drug efficiency can be accomplished by biological, physical, or chemical means.
The biological approach entitles varying the route of administration. Examples include the
injectable route to optimize onset of action, maximize bioavailability (enhanced blood levels),
and eliminate gastric irritation and acid-catalyzed drug degradation. Versatility is severely
limited when utilizing the biological approach, because alternative routes of administration are
frequently unavailable and are always less convenient than oral administration (23a).

Physicochemical approach
A greater degree of flexibility of drug modification is offered by the physical approach,
commonly referred to as dosage form design. The highest degree of flexibility in altering drug
efficacy, however, is offered by the chemical approach.
Drug derivatization has been long recognized as an important means of producing better
pharmaceuticals. These drug derivatives can be broadly classified derivatives into two
categories: irreversible or reversible. Irreversible derivatives or analogs are usually synthesized
for finding a similar, new, biologically active entity possessing increased potency, a broader
spectrum of activity, or some other desirable property not possessed by the parent compound (23b).
A reversible drug derivative utilizes a chemical moiety of proven biological activity (the parent
molecule) and seeks to deliver it to the site of action while overcoming some inherent drawback
to the use of the parent compound.
Any number of inherent disadvantages may preclude the use of the parent drug molecule in
clinical practice. Among those properties considered disadvantageous in a drug molecule are
bitterness or tartness, offensive odor, gastric or intestinal upset and irritant, pain on injection,
lack of absorption, slow or rapid metabolism, and lack of stability in the bulk state, the dosage
form, or in vivo (i.e. gastric instability).
In many cases, undesirable properties in a drug molecule can not be overcome by conventional
pharmaceutical formulation or route of administration changes, so the method of choice becomes
reversible derivative formulation. In the intelligent design of reversible drug derivatives, it is
necessary to consider two questions (23c):
1. What structural modification(s) of the parent molecule are necessary
to reduce or eliminate the particular undesirable effect?
2. What conditions are available in vivo (enzyme, pH… etc) to
regenerate the parent molecule from the derivative?
Appendix (I) showed some examples of drugs whose properties have been successfully modified
are provided in tables (23d).

Absorption
Probably the most fruitful area of reversible derivatization is the improvement of passive drug
absorption through epithelial tissue. Many studies involving in vivo, in situ, and in vitro systems
have been conducted to elucidate the role of chemical structure in drug absorption.
Nearly all of the empiricisms and theories in current use agree that the addition of a hydrophobic
group to a compound usually increases its absorption. It is also agreed that this increase in the
absorption is a direct consequence of the increase in the biological lipid-water partition
coefficient resulting from the added hydrophobic moiety.
From both the physicochemical and the biological point of view, octanol-water is the most
extensive studied system (23e).
Homologous series are particularly well studied for studying transport because the alkyl group
usually does not interfere with the interaction of the active portion of the molecule and the
receptor site.
Because of the wide variety of reasons for a decline in activity with increasing chain length, no
single equation can explain all available data. Hansch and Clayton and Yalkowsky and Flynn
listed about a dozen possible reasons for this decline. These reasons can be broadly classified
into those that are dependent upon a biological parameter (e.g., enzyme specificity,
conformational distortion of the active site, metabolism, and poisoning of enzymes) and those
that are related to some physical properties (e.g., solubility, complex formation, micelle
formation, partitioning into inert phases, and binding to inert surface). The former are the most
difficult to correlate by simple theories (23f).

Solubility
The primary role of solubility in determining drug absorption is obvious since only the drug that
is in solution is available for absorption. Since virtually any structural modification that alters
solubility will also alter ionization and partitioning, it is somewhat difficult to provide clear cut
examples of the relationship between solubility and absorption.
For homologous series, solubility in aqueous media generally decreases by a factor of 4.0 for
each methylene unit. Branched alkyl moieties decrease aqueous solubility to a lesser extent than
linear chains.
Dissociation behavior, however, is important in designing reversible derivatives when the linkage
involves the ionizable group.
If absorption is to be increased by adjusting hydrophobicity, a linkage must be selected that will
remain intact until absorption is complete, with subsequent release of the parent molecule into
the bloodstream or at some specified tissue. To choose such linkage rationally, an awareness of
what linkage-cleaving enzymes are present in the gastrointestinal tract, the liver, the blood, and
the various body tissues is necessary (23g).

Solutions for Metronidazole absorption and solubility using physicochemical approaches


Many physicochemical approaches were used to solve these problems. A practical way of
administering a parenteral dose of Metronidazole has not been available since the solubility of
Metronidazole in aqueous solution is only about 100mg/10ml and a practical dosage unit is in the
500-650mg/10ml range. Those skilled in the art recognize the practical advantages of a single
injectable dose of below 5ml as opposed to the large volume of solution which would be needed
to administer a 500-650mg dose of Metronidazole in aqueous solution.
Attempts have been made to improve the solubility of Metronidazole in various ways as
illustrated by the following examples:
1. Methods of solubilizing Metronidazole in water by mixing with gentisic acid
in a ratio of 1:4 (24).
2. Method of solubilizing Metronidazole in water with N, N-
dimethylacetamide/ethanol or propylene glycol/2, 2-dimethyl-1, 3-dioxolane-4methanol as co-
solvents (25).
However, these methods have two drawbacks. Firstly, the solubility of Metronidazole is only
augmented to 500-650mg/ 10ml; and secondly, both require large amount of substances that are
foreign to human body.
Another conceivable solution to the problem is to administer Metronidazole in the form of a
derivative which has the desired solubility and which, after parenteral administration, is cleaved
by the organism to yield Metronidazole. Such a derivative could be an ester prepared from a
pharmacologically acceptable acid, for example:
1. Several esters of Metronidazole with mono- or dicarboxylic aliphatic or aromatic acids (24).
2. Esters of Metronidazole with carbamic acid. These derivatives have the following general
formula:

R1
N N
O
N

R2
N+ O- O

O
Fig.1-4

Where R represents halogen or alkyl of one through four carbon atoms, R1 represents hydrogen,
alkyl of one through five carbon atoms, or hydroxyl, and R2 represents hydrogen or alkyl of one
through five carbon atoms (26).
3. Esters of Metronidazole with 4-toluene-sulphonic acid as an
intermediate product (24).
4. Ester of Metronidazole with methane sulphonic acid (24).
Unfortunately, all of these esters are even less soluble in water than Metronidazole itself.
5. Half-esters of Metronidazole with dicarboxylic acid: the sodium salt of
the half-ester with succinic has the required solubility in water. However, the cleavage of the
ester in blood serum after parenteral administration is very slow and the compound itself is
microbiologically inactive (24).
6. Monoester of phosphonic acid with Metronidazole.
The salt of this ester with pharmacologically acceptable cations are very soluble in water.
Although this ester may turn out to be a clinically useful prodrug, published data indicated a
rather slow rate of conversion to Metronidazole in vivo. Furthermore, the bioavailability to rats
of Metronidazole occurring after administration of the phosphate ester is significantly lower than
that obtained with Metronidazole at the same dosage level, which indicates the excretion of some
unchanged phosphate ester (27).
The antitrichomonal activity of several water-soluble Prodrug esters of Metronidazole seemed to
be correlated with the release rate of the parent drug and with the hydrophobicity of the spacer
(28)
.
7. Amino acid esters with Metronidazole.
Another type of water-soluble ester derivatives is esters with an ionizable amino function in the
acid portion.
Aminocarboxylic acid esters with Metronidazole are soluble in water and that acid addition salts
are very soluble in water.
Table (1) shows the half-lives for the hydrolysis to Metronidazole of a series of such
Metronidazole esters in 80% human plasma (pH 7.4) and in 0.05M phosphate buffer (pH 7.4) at
37oC (24).
Table (1)
Ester T1/2 inhuman plasma (min) T1/2 buffer (min) Ref.
N,N-dimethyl glycinate 12 250 24
Glycinate 41 115 24
N-propylglycinate 8 90 24
3-aminopropionate 207 315 24
3-dimethyl aminopropionate 46 52 24
4-dimethyl aminobutyrate 334 580 24
4-methyl-1-piperazinoacetate 523 1720 24
Monosuccinate 580 580 29
Hemimaleinate 5500 Not available 30
Hemiglutarate 5500 Not available 30
Acetate 1380 24000 31
Propionate 192 30420 31
Butyrate 27 53400 31
Valerate 12.6 48120 31
Caproate 12 51720 31

Some detailed examples of useful Metronidazole esters Prodrug:

Metronidazole phosphate – a water-soluble prodrug for parenteral solutions of Metronidazole:


Metronidazole phosphate behaves as a zwitterionic compound in an acidic medium with a
minimum solubility at pH 2.0. At pH 7, its solubility was approximately 50 times that of
Metronidazole. The phosphate ester was so soluble at pH higher than 7 that it was difficult to
measure the solubility accurately. In human serum, the hydrolysis of Metronidazole phosphate
followed zero-order kinetics at an initial concentration of 0.25 mg/ml or higher, presumably due
to enzyme saturation (0.035mg/ml/h at 37oC). Subcutaneous administration of Metronidazole
phosphate to rats produced a blood level of bioactivity comparable to that observed after
administration of Metronidazole (32).

Metronidazole phosphate salts:


These salts include Metronidazole phosphate dipotassium salt, Metronidazole phosphate
disodium salt, Metronidazole phosphate ammonium salt, Metronidazole phosphate aluminum
salt, and Metronidazole phosphate amine salts.
These compounds are water soluble and can be prepared in dosage forms that the insoluble
Metronidazole could not. Additionally, the compounds exhibit chemical stability in solutions.
The compounds are administered orally, parenterally, vaginally and rectally for systemic
actions(27).
Metronidazole twin ester prodrugs: Synthesis, physicochemical properties, hydrolysis kinetics
and antigiardial activity:
A series of identical twin esters of Metronidazole was synthesized and evaluated as potential
prodrugs with improved physicochemical and pharmacokinetic properties. The synthesis of the
twin ester was achieved by interaction of Metronidazole with the respective dicarboxylic acid
anhydride or their dichloride. The lipophilicity of Metronidazole and the prodrugs, expressed as
Rm values, were determined using reversed-phase TLC and revealed enhanced lipophilic
properties compared with Metronidazole. All the synthesized prodrugs were proved to be
chemically stable at acidic pH (t ½ ~ 13-40h). In vivo evaluation studies of Metronidazole and its
twin esters in mice and in rabbits revealed that the prodrugs have been absorbed almost
unhydrolyzed with considerable higher plasma level. These results suggest that the synthesized
identical twin esters may be useful as a promising new prodrug form of Metronidazole for oral
delivery (33).
Design of water-soluble, solution-stable and biolabel prodrug of Metronidazole for parenteral
administration: N-substituted aminomethyl benzoate esters:
Various N-substituted aminoethyl benzoate esters of Metronidazole were synthesized and
evaluated as water-soluble prodrugs with the aim of developing preparations suitable for
intravenous injection. The esters showed all a high solubility in weakly acidic solutions and were
further characterized by possessing a high stability in such high such solutions allowing long-
term storage combined with high susceptibility to undergo enzymatic hydrolysis in plasma. Half-
lives of hydrolysis in 80% human plasma were found to be less than 1 min. for some esters.
These compounds (the 4-(morpholinomethyl) benzoate and 3-[(4-methylpiperazin-1-yl) methyl]
benzoate esters) were predicted to possess shelf-lives of more than 10 years in aqueous solutions
of pH 4.0 and at 25oC. These properties regarded solubility; chemical stability and enzymatic
liability make N-substituted aminomethyl benzoate esters a promising new prodrug type for
Metronidazole as well as for other slightly soluble drugs containing an esterifiable hydroxyl
group (34).
Synthesis of Metronidazole amino acid ester prodrugs with enhanced water solubility:
N, N-diethylglycinate hydrochloride and 4-ethyl piperazinoacetate derivatives displayed higher
aqueous solubility, which exceeded that of the parent drug by factors of approximately 140 and
100 respectively. All the esters revealed lower log P values than Metronidazole except for the 4-
phenyl piperazinoacetate derivative, which was 6.5 times more lipophilic than Metronidazole.
The kinetics of the esters were studied in aqueous phosphate buffer (pH 7.4) and 80% human
plasma at 37oC. In all cases the hydrolysis followed pseudo-first-order kinetics and resulted in a
quantitative reversion to Metronidazole as evidenced by HPLC analysis (35).

Another series of various water-soluble amino acid esters of Metronidazole:


Eight amino acid esters of Metronidazole were synthesized and it was found that the
hydrochloride of Metronidazole N, N-dimethyl glycinate appears to be the most promising
prodrug candidate as a parenteral delivery form of Metronidazole (36) & (37).

Ester of Metronidazole with N, N-dimethylglycine :


The novel compounds exhibited favorable solubility in water. The solubility in water of the
hydrochloride of Metronidazole N, N-dimethylglycinate exceeds 50% w/v or 1.7M at 20 oC, the
pH of the 1-20% w/v being 4.4-4.6. The solubility of Metronidazole in aqueous solutions of
pH>3 and at 20oC is 1% or 0.058M (24).

PEG-Metronidazole conjugates:
Metronidazole was conjugated to linear or branched polyethylene glycol of 5,000, 10,000 and
20,000 Dalton. An ester linkage between polymer and drug was used in the coupling to yield a
polymeric prodrug. The modification allowed overcoming the known Metronidazole solubility
problem leading us to obtain a bioconjugate more suitable for parenteral administration. It was
found that molecular weight and shape of polyethylene glycol is critical for the prodrug stability
(38)
.

Solutions for Metronidazole organoleptic properties:


As mentioned previously, some of the main problems of Metronidazole – as a drug – are its bitter
taste, odor and GI disturbance. Many organoleptic approaches were used to solve these
problems, like:
Acylbenzoate esters of Metronidazole:
The design and synthesis of a series of chain and cyclic acylbenzoate of Metronidazole are the
aim of this research. The esters are designed to be both lipophilic and reactive in their hydrolysis
reactions. The increasing of lipophilicity of these esters will improve the taste of the drug due to
not dissolving in saliva. The alkaline hydrolysis of the chain 2-acylbenzoates is relatively rapid,
employing an intramolecular catalytic route (39).

Metronidazole benzoate (Benzoyl Metronidazole):


The benzoic acid ester of Metronidazole (Fig.1-5) is much less soluble that parent drug because
of bulky non-polar group, the matter that the taste of drug. The ester is not very stable in the
body.
(40),
Non-specific esterase activity in the gut cleaves the ester to benzoic acid and Metronidazole
(41) & (42)
.
O
O

H2C C O

O2N N
CH3

N
Fig.1-5: Benzoyl Metronidazole (43).

Nicotinic acid ester and Nalidixic acid ester of Metronidazole:


Nicotinic acid ester and nalidixic acid ester of Metronidazole are bitterless but less soluble than
Metronidazole are bitterless but less soluble than Metronidazole, therefore, they can be
formulated in suspension dosage form for an oral delivery. Beside the advantage of dispensing
both Metronidazole and nalidixic acid in one dosage form instead of dispensing each separately,
this is the case in genitor-urinary tract infections (44).

Metronidazole prodrugs approaches to colon targeted drug delivery systems


Covalent linkage of the drug with a carrier as:
 Dextran conjugates: Dextran ester prodrugs of Metronidazole have been prepared and
characterized. The kinetics of hydrolysis of Metronidazole monosuccinate dextran ester
conjugates in aqueous solution over the pH range 6.61-7.8 (37oC) has been investigated,
and demonstrated by HPLC the degradation of the dextran conjugates proceeds through
parallel formation of Metronidazole and Metronidazole monosuccinate. The regeneration
rates of the latter compounds followed first-order kinetics. The hydrolysis in aqueous
solution was specific base catalyzed (45).
 Inclusion complexation of Metronidazole benzoate with β-cyclodextrin and its depression
of anhydrate-hydrate transition in aqueous suspension: Metronidazole benzoate was
found to form an inclusion complex with β-cyclodextrin (β-CyD) in aqueous solution and
in the solid phase. By inclusion clinically used anhydrous form of the compound to the
monohydrate occurring in aqueous suspensions was inhibited as was the marked crystal
growth resulting from the phase transition. Besides increasing the physical stability of
Metronidazole benzoate suspensions the complexation with β-CyD protected the drug
against photochemical degradation and decreased the rate of hydrolysis (46).
 Amino-acid conjugates: Due to the hydrophilic nature of polar groups like NH2 and
COOH, that is present in the proteins and their basic units (i.e. the amino acids), they
reduce the membrane permeability of amino acids and proteins. Various prodrugs have
been prepared by the conjugation of drug molecules to these polar-non essential- amino
acids, such as tyrosine, glycine, methionine and glutamic acid. These prodrugs were
found to be metabolized to their drugs by the microorganisms of the intestinal flora of
experimental animals. The prodrugs were absorbed into the systemic circulation from the
upper GIT and hence it proved unsuitable for delivery of the drugs to the colon. By
increasing the hydrophilicity and chain length of the carrier amino acid, the conjugate
will show splendid results with minimal absorption and degradation in the upper
gastrointestinal tract and will be suitable for colon targeted delivery for the drug (47).

Metronidazole Prodrugs for Topically Application

Alpha Hydroxyacid Esters for Skin Aging:


Alpha hydroxyacid esters of Metronidazole and some other drugs on topical application induced
increased skin thickness due to new biosynthesis of dermal components. Such dermal effects are
desirable for topical use and treatment of aging including age spot and skin lines (48).

Series of aliphatic esters of Metronidazole:


The ability of Metronidazole (acetate, propionate, butyrate, valerate and caproate) to improve
cutaneous delivery of Metronidazole has been investigated. The experimental data demonstrate
that no single ester derivative can be selected with optimal properties. Due to the relatively small
variation in permeation rate of the compounds, however, the butyrate ester seems to fulfill the
requirements of good permeation characteristics as well as a quick conversion to Metronidazole
(t1/2 in skin homogenate is 1.0 at 37oC) (31) & (49).

Metronidazole Benzoate & its permeation through Skin:


Metronidazole Benzoate permeated more readily through the skin than Metronidazole,
which was ascribed to its higher skin-vehicle partition coefficient. Only hydrolyzed
Metronidazole was detected in the receptor phase (50).

Biological Solutions
The main problems with Metronidazole during formulation are its poor aqueous solubility (~ 1%
w/v at 25oC), and its bitter taste. Many biological approaches were used to solve these problems,
like:

Sugar Coating:
Preparation of sugar-coated tablets and the bioavailability of five commercial sugar-coated
Metronidazole tablets were studied. The bioavailability of Metronidazole from three tablets
showing extremely slow dissolution at pH=5 or 7.5 varied significantly between human subject
having high and low gastric acidity, this due to difference in solubility of Metronidazole
according to pH. However, correlation between bioavailability and dissolution rate were shown
to be poor (51).

Granules-made tablets:
Metronidazole tablets made from granules had higher elastic recovery to plastic compression
ratios (ER/PC) than those from powders but were also less bitter (52).

Suppositories:
Metronidazole was prepared in the form of suppositories in a suspension form. The
bioavailability of Metronidazole has been found to correlate significantly with the rate of
spreading of fatty suppositories but not with the plastic viscosity of the base (53).

Intervaginal preparations:
The biopharmaceutics of intervaginal absorption of Metronidazole via medicated tampons was
analyzed in comparison with a vaginal solution formulation. In vitro release studies of medicated
tampons showed a linear Q- t1/2 relationship observed (Q is the cumulative amount of
Metronidazole released from a unit surface area of a tampon) (54).
A non-flowing composition and method for treatment of an afflicted vagina with low dose of
Metronidazole. This composition includes a buffer system maintaining the composition at a pH
value in the range of about 3.75 to 4.25. The composition can also be used for prophylactic
purpose (55).

Topical Formulation

Aqueous composition containing Metronidazole:


Topical aqueous single-phase compositions comprising a therapeutically effective amount of
Metronidazole; a gelled hydrophilic and water-dispersible polymer having free carboxylic groups
which is a polyacrylic acid polymer having a molecular weight in the range of about 1,250,000 to
about 4,000,000 Dalton; and aqueous solvent for Metronidazole. The concentration of
Metronidazole is at least about 0.1% by weight based on the total weight of composition. The
compositions have improved specific activity and are substantially non-comedogenic, non-
irritating and non-skin-drying. These compositions are useful for treating rosacea and other acne
form dermatological conditions, and certain forms of dermatitis (56).

Gel compositions containing Metronidazole:


An aqueous solution of Metronidazole in which its concentration is higher than 0.75% has been
prepared. The solution contains the solubility enhancer hydroxypropyl-betacyclodextrin and may
additionally contain niacinamide. The composition pertains to the field of topically applied
medications for treatment of skin and mucosal disorders (57).

A foamable composition for topical application of Metronidazole and related active


pharmaceutical ingredients prepared for treatment of rosacea, acne and foul smelling lesions (58).

Metronidazole pledgets:
A dermatological delivery system comprising a topically acceptable, inert support selected from
the group consisting of cotton, rayon, polyester, mohair and others or a combination of more than
one, impregnated with an about 0.1%-2% solution of Metronidazole (59).

Injectable preparations

An injectable solution suitable for systemic treatment of anaerobic infections prepared by


solubilization of 500-650mg Metronidazole in 10 ml of a solvent system. The aqueous buffer
maintaining the pH at 5.0-7.5 (25).
Modified release preparation
Pharmaceutical compositions having a modified release profile for once daily dosing of
Metronidazole have been prepared.

Aqueous composition containing Metronidazole:


An aqueous solution of Metronidazole in which the concentration of Metronidazole is higher
than 0.75% has been prepared. The solution contains a combination of solubility-enhancing
agents, one of which is a cyclodextrin such as beta-cyclodextrin and the second is a compound
other than a cyclodextrin (60) & (61).

Appendix (I)
Some examples of drugs whose properties have successfully modified by prodrug synthesis.