Chapter 2: Literature Review

Biotransformation

Biotransformation refers to the metabolic alteration of the drugs and xenobiotic

chemicals in the body to render nonpolar compounds polar so that they are not

reabsorbed in the renal tubules and excreted (Tripathi, 2013). Xenobiotic

biotransformation is accomplished by a small number of enzymes with broad substrate

specificities. It is divided into two reactions which are Phase I reactions and Phase II

reactions. Phase I reactions are responsible for unmasking or introducing a polar

functional which therefore increase the compound’s hydrophilicity. Glucuronidation,

sulfonation, acetylation, methylation and conjugation with glutathione are examples of

phase II reactions which usually result in increased hydrophilicity as well as elimination.

All of the drug biotransformation reactions are catalyzed by enzymes. Phase I reactions

are dominated by the cytochrome P450 system in particular, the CYP1, CYP2, CYP3,

and CYP4 families are central to xenobiotic metabolism (Gibson & Skett, 2001). Phase

II metabolism by glutathione S-transferases, Uridine 5′-diphospho(UDP)-

glucuronosyltransferases, sulfotransferases, N-acetyltransferases, and epoxide

hydrolases typically generates excretable hydrophilic metabolites.

Cytochrome P450 (CYP)

The cytochrome P450 system is a protein that contains heme as a prosthetic group

which plays a fundamental role in the metabolism of drugs and other xenobiotics

(Estabrook, 2003). Understanding the hemoprotein is essential for health professionals

as it is the origin of drug-drug interactions. Cytochrome P450 is a superfamily of

enzymes that function as monooxygenases which are classified by similar gene

sequences in which they are assigned a family number and a subfamily letter for

example CYP3A4. Drugs that have a similar metabolic pathway have potential drug-

drug interactions (Nelson, 2009). Not all the drugs have CYP activity, however drugs or

herbs with CYP activity can either inhibit or induce a specific CYP enzymatic pathway

therefore altering the metabolism as well as the pharmacokinetics of concurrently

administered agents. Drugs and herbs that hinder the enzymatic pathway of CYP may

result in increased concentrations of other drugs metabolized by the same pathway

leading to drug toxicity. On the other hand, drugs and herbs that induce an enzymatic

pathway of CYP may reduce the concentrations of drugs metabolized by the same

pathway leading to subtherapeutic drug levels.

CYP3A4

Cytochrome P450 family 3 subfamily A member is the most important of all CYP450

enzymes and it is estimated that it metabolizes almost half of all the drugs on the

market. CYP3A4 is mainly located in the liver and small intestines and is the most

abundant cytochrome in these organs. The levels of Many of the drugs are either

moderate or potent inhibitors of CYP3A4 thus drug-drug interactions involving CYP3A4

are relatively common (Danhof et al, 2013). Like any other CYP enzyme CYP3A4 is

also sensitive to enzyme induction and many drugs as well as herbs are known to be

CYP3A4 inducers. These inducers tend to reduce plasma concentrations of CYP3A4

substrates reducing or diminishing the therapeutic effect of the drug. This type of drug

interaction is more frequently encountered than realized because it may be simply

attributed to lack of patient compliance. Many drugs and herbs that are CYP3A4

substrates, inhibitors, and inducers are also substrates, inhibitors, or inducers of the

ABC transport protein known as P-glycoprotein. Many drug interactions, therefore,

involve additive effects of both CYP3A4 and P-glycoprotein (Horn & Hansten, 2008).

Some medicines which are substrates of CYP3A4 have low oral bioavailability due to

intestinal metabolism. The bioavailability of these substrates is dramatically changed by

inhibition, induction or saturation of CYP3A4 (Kato, 2008).

Drug interactions

Drug interactions can be defined as the alteration of a response to one drug by either

another drug or an herb when they are administered concurrently or in quick succession

(Tripathi, 2013). The alteration can either be qualitative or quantitative. In quantitative

the response is either increased or reduced in intensity whereas in qualitative a different

type of response is produced. The possibility of drug interaction arises whenever a

patient prescribed more than one drug or concurrently using herbs and drugs. However,

a number of conditions are treated with a combination of drugs which complement each

other to produce a synergistic effect for example a combination of an analgesic and an

antibiotic to treat a painful infective condition. A drug interaction can also be referred to

as a change in the action or side effects of a drug caused by concomitant administration

with a food, beverage, herb or another drug. These are complicated due to the fact that

multiple chemical components are involved and these components possess diverse

pharmacological activities. Drug interactions occur when one chemical or substance

affects the way in which another drug is absorbed, distributed, metabolized and

eliminated from the system (Bakare-Odunola et al. 2008). Herbs may affect the
behavior of the concomitantly used drugs by changing their absorption, distribution,

metabolism and excretion which potentially cause changes in drug levels and activity

leading to either therapeutic failure or toxicity. With more and more popular use of

herbal medicines, herb-drug interactions have become an increasingly safety issue in

the clinical application of conventional drugs. Also, there may be unquantified

interactions between conventional drugs and herbal medicines (Koury 2003).

Pharmacokinetic interactions

These are modifications that happens when either a drug or herb affects the absorption,

distribution, metabolism or excretion of another. These pharmacokinetic interactions are

becoming increasingly a clinical issue with more and more popular use of herbal

medicines concurrently with conventional medicines as well as patients being

prescribed more than one pharmacologically active drug. Absorption of a drug can be

altered by a second pharmacologically active substance which changes the pH or the

gut motility. Competition for binding protein binding sites in the plasma also affects the

absorption and distribution of drugs especially if one drug is replaced by another drug

which shared the same binding site for example salicylic acid and penicillin on albumin

(Persky, 2013). A number of drugs and other chemicals stimulate microsomal enzymes

which are responsible for the biotransformation of drugs in the liver, with the usual

effects being to either reduce the pharmacological response or increase toxic effects.

Absorption Interactions

Certain herbs such as ginger as well as other drugs are prokinetic agents that is they

enhance gastric motility or simply increases the speed with which a substance passed

through the intestines. These prokinetic agents reduce absorption because if a drug is
available in the digestive tract’s absorption zone for a limited time its plasma

concentration will decrease. However. Drugs and substances that decrease intestinal

motility ensure that a drug is present in the digestive tract’s absorption zone for a longer

time thus the blood concentration will increase.

Every drug requires an optimum specific pH for absorption, some require an acidic

environment for example the acidic stomach pH and others require the basic pH of the

intestines. Any changes in the pH could affect the absorption for example taking a drug

that increases the pH such as Zalcitabine greatly inhibits the absorption of antacids if

they taken simultaneously or in quick succession. To avoid interactions such as this, a

gap of two to five hours between taking the two drugs is usually adequate.

Formation of non-absorbable or non-soluble complexes between two drugs is also

another type of an absorption interaction. The presence of ions can cause some drugs

to chelate thus making them more difficult to absorb. This interaction is very common

with tetracyclines and dairy products due to the presence of calcium ions.

Transport and distribution interactions.

The main interaction mechanism is competition between drugs for plasma protein

transports. The affinity of the protein for the drugs also influences the transport as well

as the distribution of the drugs. Drug-drug interactions have been reported to either

inhibit or induce transport which thus leads to alteration in transport and distribution of

drugs. Drugs which have been observed to possess inhibition the transport of drugs are

erythromycin, probenecid and cimetidine.

Metabolic interactions
A number of drug interactions are due changes in drug metabolism and the notable

system these interactions target is the cytochrome P450 enzyme system. When two

drugs are administered concurrently and one of the drugs (X) is metabolized by a CYP

P450 enzyme while the other inhibits the enzyme’s activity (drug Y) , this therefore

means that the former drug (X) will remain with very high levels in the plasma for a

longer period since its inactivation is reduced. As a result of enzymatic inhibition, the

higher levels of the drug will cause an increase in the drug’s response and can also

cause toxicity.

If drug X is metabolized by a cytochrome P450 enzyme and another drug (Y)

simultaneously administered induces the enzyme’s activity, the concentration in blood of

drug X would rapidly decrease quickly. The resulting falling concentration will decrease

in the drug’s effect leading to therapeutic failure.

Ginger

Zingiber officinale Roscoe, commonly known as ginger is a member of the

Zingiberaceae family which is widely used as a culinary herb and as a complimentary

medicine for many common ailments. The species Zingiber officinale originates from the

south eastern of Asia and it is not known to occur wild (Tauscher et al, 2006). Ginger is

a perennial reed-like herb with annual leafy stems and asymmetric flowers. The ginger

rhizome can grow upto 1.5 metres in height. The rhizome produces clusters of white

and pink flower buds that bloom into yellow flowers. The dried ginger rhizomes are

shown in Fig 2.1 below.

The chemical analysis of ginger shows that it contains over 100 constituents. The major

constituents in ginger rhizomes are carbohydrates (50-70%), lipids about 3-7% and the

remaining are terpenes and phenolic compounds. The terpene components of ginger

include manly sesquiterpenes such as Zingiberene, β-bisabolene, α-farnesene, β-

sesquiphellandrene, and α-curcumene as well as a smaller number of monoterpenes

such as amphene, β-phellandrene, cineole, geraniol, curcumene, citral,

terpineol and borneol. Gingerols, paradols and shogaol are the phenolic components of

ginger as shown in figure 2.2 below and among these phenolic compounds gingerols

(23-25%) and shogaol (18-25%) are found in higher quantity than others.
Use of Ginger as a traditional medicine.

According to folklore ginger has been used as both a spice and as medicine since

ancient times. Ginger said to act directly on the gastrointestinal system to relieve

emesis as well as nausea. Thus, it is used to prevent nausea resulting from

chemotherapy, motion sickness, and surgery. Ginger is also used to treat various types

of other GI problems like morning sickness, colic, upset stomach, gas, bloating,

heartburn, flatulence, diarrhea, loss of appetite, and dyspepsia. According to Indian

Ayurvedic medicinal system, ginger is recommended to enhance the digestion of food.

The ginger rhizome is also famed for its antioxidant properties. Besides the conditions

above, ginger has been reported as a pain relief for arthritis, muscle soreness, chest

pain, low back pain, stomach pain, and menstrual pain. It can be used for treating upper

respiratory tract infections, cough, and bronchitis. As an anti-inflammatory agent, it is

recommended for joint problems. Fresh juice of ginger has been shown to treat skin

burns. Active component of ginger is used as a laxative and antacid medication. It is

also used to warm the body for boosting the circulation and lowering high blood

pressure. Because of its warming effect, ginger acts as antiviral for treatment of cold

and flu. Ginger is also used as a flavoring agent in foods and beverages and as a

fragrance in soaps and cosmetics. Ginger is also used as a complimentary remedy

responsible for prevention and treatment of liver disease (Tyagi & Prasad, 2015).

Ginger is also said to elicits antinociceptive properties and potentiates morphine-

induced analgesia (Sepehvand et al, 2010).

Ginger and the CYP 3A4

Ginger has been widely used as both a culinary spice and a herb for minor ailments like

nausea, dyspepsia, pain and motion sickness. Ginger is especially important in

gastrointestinal disturbances because of its prokinetic property. The mechanism of

action is that it is an agonist of cholinergic receptors expressed in the gastrointestinal

tract thus it binds to the receptors enhancing gastrointestinal motility (Ghayur & Gilani,

2005). The major component of ginger that is responsible for many pharmacological

effects is the phenolic compound with a pungent flavour, gingerol. From previous

studies done, the inhibitory potential of 25 μg/ml water extracts was reported to be 70%

and 88% on human CYP 2D6 and 3A4 (Foster et al, 2003). Kimura et al (2010) and Kim

et al (2012) also found CYP inhibitory effects with 5 μg/ml ethanolic extracts of Ginger

on human microsome CYP 1A2, 2D6 and 3A4.

Paracetamol

Paracetamol in an effective analgesia and antipyretic agent that is useful for mild to

severe pain and fever which is very useful in a wide range of clinical conditions. It is the
most commonly used over-the-counter drug which is the first line treatment for pain

management and fever, plays a major role in multimodal analgesia (Jahr et al, 2013).

Generally, paracetamol has an excellent safety profile except in cases of overdose and

few drug-drug interactions. Available as doses for oral, rectal and iv administration with

oral and rectal administration producing analgesia within 40 minutes and maximal effect

at 1hour. The iv paracetamol has rapid onset which occurs within 5 minutes peaking at

45-60 min lasting for about four to seven hours.

Paracetamol is reported to act in a number of central mechanisms with effects on

prostaglandin synthesis, and on opioid, nitric oxide and serotonergic pathways.

Paracetamol is said to indirectly inhibit the production of prostaglandins by acting as a

reducing co-substrate at the peroxidase sites in the metabolism of arachidonic acid.

This therefore blocks the physiologic regeneration of peroxidase inhibiting prostaglandin

production. The serotoninergic pathway is a part of the descending pain modulatory

system. It has been reported that the mechanism of action of paracetamol involves the

activation of descending serotoninergic pathways. Paracetamol works peripherally to

block pain impulse generation and produce antipyresis by acting on the hypothalamus.

Efficacy and dosing of Paracetamol

Paracetamol exhibits greater efficacy with fewer side effects compared to the standard

doses of Tramadol, 10mg i.v morphine and a number of NSAIDS including ibuprofen

and diclofenac. Paracetamol is a useful first-line drug and has a synergistic effect when

used in combination with a number of agents like codeine, tramadol and ibuprofen. The

synergy has improved analgesic effects whilst minimizing the side-effects of the helper

drug. A dose of up to 1g four times a day is recommended with a minimum of four hours
between each administration and six hours for those who have renal impairment. Oral

paracetamol is absorbed by passive transport chiefly by the small bowel. Paracetamol is

metabolized predominantly in the liver by two types of the P450 enzyme system. A

small amount of the drug is oxidized by glucuronidation and sulphation to less toxic

conjugates and another amount is converted to form a highly toxic metabolite, N-acetyl-

p-benzo-quinone imine (NAPQI). In humans, CYP2D6 and CYP3A4 are responsible for

the oxidation of paracetamol to NAPQI. In severe cases of renal impairment, the

pharmacokinetics of paracetamol is delayed and elimination of the conjugation and

sulphation metabolites is three times slower than in healthy subjects.

Ultraviolet visible spectroscopy

UV-vis Spectroscopy is a quantitative technique used to measure how much a chemical

substance absorbs light. This is done by measuring the intensity of light that passes

through a sample with respect to the intensity of light through a reference sample or a

blank. This analysis technique can be used for multiple sample types including liquids,

solids, thin-films and glass. The instrumental technique is also called absorption

spectroscopy or reflectance spectroscopy in part of the ultraviolet and full adjacent

visible spectral regions. This simply means that it utilizes light in the visible and adjacent

ranges.

Principle:

The basic principle behind this analytical procedure is the interaction of light with matter.

As matter absorbs light, it results in an increase in the energy content of the atoms. This
increase in energy content causes the excitation of electrons from the ground to a much

more higher energy state, excited state. The absorbed of visible light by a chemical

compound will produce a light of a distinct spectrum. The basis of uv-vis

spectrophotometry is the Beer-Lambert Law, which states that whenever a beam of

monochromatic light is passed through a solution with an absorbing substance, the

decreasing rate of the radiation intensity along with the thickness of the absorbing

solution is directly proportional to the concentration of the solution in the incident

radiation. The law is expressed in the equation below:

IO
A=log ⁡( )=ECI
I

Where, A stands for the absorbance, I0 refers to the intensity of light upon a sample

cell, l refers to the intensity of light departing the sample cell, C stands for the

concentration of the solute, L stands for the length of the sample cell and E refers to the

molar absorptivity. The figure 2.3 below illustrates the instrumentation of the analytical

technique.
****Do not just copy and paste from text book and journal articles rephrase the

sentences to put in your own words.***References***Numbering figures