Principles of

Clinical Pharmacology
 Use of Positron
Emission Tomography
(PET) in
Pharmacokinetics

Dr. Robert Innis, MD, PhD

Molecular Imaging Branch
National Institute of Mental Health
National Institutes of Health
Positron Emission Tomography:
Tool to Study Pharmacokinetics and
to Facilitate Drug Development

Robert B. Innis, MD, PhD

Molecular Imaging Branch
National Institute Mental Health
 Outline of Talk
1. PET has high sensitivity and specificity
2. PET used in therapeutic drug development
3. Pharmacokinetic modeling of plasma concentration
and tissue uptake can measure receptor density
4. Study drug distribution: block distribution to
periphery and increase distribution to brain
5. Study drug metabolism: inhibit defluorination
Imaging Receptors with PET
Positron Emission Tomography
 PET vs. MRI
PET MRI
Spatial
2 – 6 mm << 1 mm
Resolution

Sensitivity 10-12 M 10-4 M

Temporal
minutes <1 sec
Resolution

Radionuclide (11C): high sensitivity

Ligand (raclopride): high selectivity
Radioligand [11C]raclopride: high sensitivity
& selectivity
Radioligand = Drug + Radioactivity

1. Drug administered at tracer doses

a) No pharm effects
b) Labels <1% receptors
c) Labeled subset reflects entire population
2. Radioligand disposed like all drugs
a) Metabolism & distribution
3. Radiation exposure
NIH Rodent PET Camera
18F bone uptake rat

Developed By: Mike Green & Jurgen Seidel

 PET: Tool in Therapeutic
Drug Development

• Determine dose and dosing interval

• Identify homogeneous group
• Biomarker for drug efficacy
 Lazabemide blocks [11C]deprenyl
binding to monoamine-oxidase-B (MAO-B)

Selegilene is more potent and longer acting

than lazabemide
 PET: Tool in Therapeutic
Drug Development

• Determine dose and dosing interval

• Identify homogeneous group
• Biomarker for drug efficacy
Dopamine Transporter: Located on DA Terminals
Removes DA from Synapse
SPECT Imaging of Dopamine Transporter
in Caudate and Putamen of Human Brain
Dopamine Transporter SPECT
in Parkinson’s Disease:
Decreased, asymmetrical,
loss in putamen > caudate

Healthy Parkinson Stage 1

Dopamine Transporter SPECT
in Parkinson’s Disease:
Decreased, asymmetrical,
loss in putamen > caudate

Healthy Parkinson Stage 1

 PET: Tool in Therapeutic
Drug Development

• Determine dose and dosing interval

• Identify homogeneous group
• Biomarker for drug efficacy
Serial Dopamine Transporter Imaging in a Parkinson Patient

Institute for Neurodegenerative Disorders

 PET Imaging of Amyloid:
Biomarker for Alzheimer’s Disease
 Outline of Talk
1. PET has high sensitivity and specificity
2. PET used in therapeutic drug development
3. Pharmacokinetic modeling: plasma concentration and
tissue uptake
4. Study drug distribution: “peripheral” benzodiazepine
receptor
5. Study drug metabolism: inhibit defluorination
 Brain Uptake of [18F]Fluoxetine:
Measures Density of Serotonin Transporters &
Affinity of Fluoxetine
Patient Healthy
Brain Drug

AUC=32 AUC=16

Time Time
 Brain Uptake of [18F]Fluoxetine:
Measures Density of Serotonin Transporters &
Affinity of Fluoxetine
Patient Healthy
Brain Drug

AUC=32 AUC=16

Time Time
Patient Healthy
Inject Activity 20 mCi 10 mCi
 Brain Uptake of [18F]Fluoxetine:
Measures Density of Serotonin Transporters &
Affinity of Fluoxetine
Patient Healthy
Brain Drug

AUC=32 AUC=16

Time Time
Patient Healthy
Inject Activity 20 mCi 20 mCi
 Brain Uptake of [18F]Fluoxetine:
Measures Density of Serotonin Transporters &
Affinity of Fluoxetine
Patient Healthy
Brain Drug

AUC=32 AUC=16

Time Time
Patient Healthy
Inject Activity 20 mCi 20 mCi
Weight 50 kg 100 kg
 Brain Uptake of [18F]Fluoxetine:
Measures Density of Serotonin Transporters &
Affinity of Fluoxetine
Patient Healthy
Brain Drug

AUC=32 AUC=16

Time Time
Patient Healthy
Inject Activity 20 mCi 20 mCi
Weight 100 kg 100 kg
 Brain Uptake of [18F]Fluoxetine:
Measures Density of Serotonin Transporters

Patient Healthy
Brain Drug

AUC=32 AUC=16

Time Time
Patient Healthy
Inject Activity 20 mCi 20 mCi
Weight 100 kg 100 kg
Liver disease Yes No
 Binding Potential (BP): Receptor Density * Affinity
BP equals uptake in brain relative to how much drug
is delivered via arterial plasma.
Brain Drug

AUC=16
Area Brain Curve
BP =
Area Plasma Curve
Plasma Drug

16
BP = =8
2

AUC=2
Time
 Binding Potential: Independent of Injected Dose *
Double Plasma Input =>Double Brain Response
*If ligand does not saturate receptors - i.e., if tracer doses used
AUC=32
Brain Drug

BP 1st Time =
16 = 8
2

AUC=16 32
BP 2nd Time = 4 = 8
Plasma Drug

AUC=4

AUC=2
Time
Major Point of PET Pharmacokinetics
(in words)
• Plasma pharmacokinetics provides a
limited view of what’s happening to drug in
plasma.
• PET provides a limited view of what’s
happening to drug in tissue.
• Concurrent measurement of drug in
plasma and of drug in tissue allows
quantitation of the target of drug action
– i.e., receptor.
 Pharmacokinetics: Pharmacodynamics: Receptor
Drug in plasma
& Drug acts at receptor Density
Plasma Drug

Brain Drug
Receptor
& Density

Time Time
 Outline of Talk
1. PET has high sensitivity and specificity
2. PET used in therapeutic drug development
3. Pharmacokinetic modeling: plasma concentration and
tissue uptake
4. Study drug distribution: “peripheral” benzodiazepine
receptor
5. Study drug metabolism: inhibit defluorination
 Translocator Protein (18 kDa)
a.k.a. “peripheral benzodiazepine receptor”
1. Mitochondrial protein highly expressed in
macrophages and activated microglia
2. Exists in periphery and brain
3. Multiple potential functions: steroid
synthesis, nucleotide transport
4. Distinct from typical benzodiazepine
GABAA receptor in brain
5. Marker for cellular inflammation
 Receptor Blockade [11C]PBR28 in Monkey Brain:
more radioligand in plasma and brain
BASELINE RECEPTORS BLOCKED
500
500
in putamin (%SUV)
Conc radioactivity

400 BP = 130 mL/cm3 400 BP = 1.7 mL/cm3

300 300

200
200
BRAIN
100 100

0 0
0 40 80 120 0 40 80 120
in plasma (%SUV)
Conc [ C]PBR28

1000 1000

100 100
11

PLASMA
10 10

1 1
0 40 80 120 0 40 80 120
Time (min) Time (min)
 Receptor blockade displaces from lung & kidney.
Drives more to brain but doesn’t bind there.

Baseline
Lungs Heart
Kidneys Spleen

Brain
Blocked
PK11195 10 mg/kg

2 min 25 min 115 min

Human with low uptake is similar to monkey with receptor blockade
A) regular healthy subject 400
B) odd healthy subject
250

Brain activity (%SUV)

Brain activity (%SUV)
200 300

150
200
100
100
50

0 0
0 40 80 120 0 40 80 120
Time (min) Time (min)
C) normal monkey D) pre-blocked monkey
500

Brain activity (%SUV)

Brain activity (%SUV)

300
400

200 300

200
100
100

0 0
0 40 80 120 0 40 80 120
Time (min) Time (min)
 No Binding to [11C]PBR28 in Brain and Periphery
Lungs
Heart
Normal Binding

Kidneys
Spleen

2 min 26 min 103 min

No Binding
(~10% subjects)
 TSPO rs6971 polymorphism causes
differential affinity for PBR28
• Ala to Thr substitution

• Allelic frequency ~ 30%.

– Prevalence of homozygotes ~ 9%

• Codominant expression
– HAB - high affinity binding
– LAB - low affinity binding
– MAB - reduced binding (mixed affinity states)
Owen, JCBFM 2012
TSPO imaging in Alzheimer’s disease
• Neuroinflammation a proposed contributor to
Alzheimer’s disease pathology
– Unclear if early or late phenomenon

• Prior TSPO PET studies have shown conflicting

results in AD and mild cognitive impairment

• PBR28 an improved TSPO radioligand

– Genotype correction expected to detect differences in
TSPO density in AD, MCI, and controls
Increased TSPO in Alzheimer’s Disease:
Compared to Controls and MCI

Control Mild Cognitive Alzheimer

Impairment
Kreisl, Brain. 20
[11C]PBR28 binding correlates with clinical severity
across Alzheimer’s disease spectrum

[11C]PBR28 binding (standardized)

r = 0.590
p = 0.001

Clinical Dementia Rating Scale –

Sum of Boxes score (standardized)
Alzheimer’s disease as a continuum

Jack CR Jr, Lancet Neurology 2010

 Longitudinal [11C]PBR28 study
• Objective: Determine if TSPO binding increases
during progression of AD and normal aging

• Methods:
– 14 patients (5 AD + 9 MCI at baseline) and 8 controls
returned for follow up

– [11C]PBR28 data analyzed using cerebellar ratio

method (60 – 90 min scan data)
– Image data analyzed with correction for partial volume
effects
[11C]PBR28 binding increased
in patients but not in controls
P
r
ecu
ne
us

[11C]PBR28 binding (SUVR) 2

.
0
Patients

1
.
5

Controls
1
.
0
Fo line

up
se

w
lo
Ba
 Results: [11C]PBR28 binding increased
in patients but not controls
Inferior parietal lobule
Patients s
l
o
r
t
n
o
C

[1 C]PBR28bind g(SUVR)
[11C]PBR28 binding (SUVR)

2.5 5
.
2

2.0 0
.
2

1.5 5
.
1

1.0 0
.
1
0 2 4 6 0246
Years from baseline scan o
r
f
s
r
a
e
Ys
a
b
me
n
i
l
ea
c
sn
Increased [11C]PBR28 binding correlates
with increased clinical severity
Inferior parietal lobule

2
Change in [ C]PBR28
binding (standardized)

1
11

-1 R = 0.717
P = 0.004
-2

-2 -1 0 1 2
Change in CDR-SB (standardized)
Conclusions from Alzheimer’s disease study
• Cross-sectional study: Neuroinflammation occurs after
conversion of MCI to AD and worsens with disease
progression.
Biomarker of disease severity

• Longitudinal study: [11C]PBR28 increases in AD but not in

controls and correlates with disease progression.
Biomarker of disease progression
 PET Imaging of P-gp:
an efflux transporter that protects brain
but also causes drug resistance

Robert B. Innis, MD, PhD

Molecular Imaging Branch
National Inst. Mental Health
 Permeability-glycoprotein (P-gp):
Efflux Transporter

1. Transports drugs out of cells in many

locations – e.g., brain and testes
2. Specific component of blood-brain barrier
3. Loperamide (Imodium®) is a potent opiate
that acts on gut to slow motility – but no
actions in brain.
4. Over expressed in half of tumors resistant
to chemotherapy
 P-gp Transport in Human Body

Direction
of transport
MDR = multi-drug resistance
Kannan Clin Pharm Therap 2009
P-glycoprotein removes lipophilic substrates
directly from the plasma membrane.
substrate

OUTSIDE

+ P-gp
+

INSIDE
[11C]dLop: brain uptake much higher in
P-gp KO than in wild type mice
MRI WT P-gp KO

100
Conc Activity (%SUV)

80
P-gp KO
60

40

20 WT

0
0 25 50 75 100
Time (min)
 P-gp blockade increases uptake of [11C]dLop
in monkey brain but not in pituitary.

Baseline P-gp blockade

Brain

Pituitary

P-gp blocked with DCPQ

 Brain uptake of [11C]dLop increases after
P-gp inhibition and is trapped in monkey brain.

DCPQ

Baseline

DCPQ: 16 mg/kg
 [11C]dLop: Distribution of radioactivity
in healthy male

Brain

Thyroid

Lung
Spleen

Liver
Kidney

Urinary
bladder

3 20 100
Time (min)
Summed early images
(0 – 3 min) show
blood pool.
Minimal brain uptake of [11C]dLop
in healthy human brain
PET Fused MRI

20
Conc radioactivity

15
(%SUV)

10

0
0 20 40 60 80 100
Time after injection (min)
 PET Fused MRI

What is
this?
Extended summed images (0 – 10 min) show
blood pool and tissue accumulation.
 Tariquidar 6 mg/kg increases [11C]dLop by 250%.

%SUV
400
Baseline
B

Tariquidar
6 mg/kg

Kreisl JNM 2010

0
P-gp blockade dose-dependently increases
uptake of [11C]dLop in human brain.
1500
Brain uptake (%SUV • min)

1000

500

0
0 1 2 3 4 5 6 7
Tariquidar I.V. (mg • kg-1)

Kreisl JNM 2010

 Outline of Talk
1. PET has high sensitivity and specificity
2. PET used in therapeutic drug development
3. Pharmacokinetic modeling: plasma concentration and
tissue uptake
4. Study drug distribution: “peripheral” benzodiazepine
receptor
5. Study drug metabolism: inhibit defluorination
 [18F]FCWAY: Defluorination
Bone uptake: human skull at 2 h
 [18F]FCWAY: Defluorination
18F-fluoride ion accumulates in bone
 Miconazole Inhibits Defluorination &
Bone Uptake
[18F]Fluoride
Skull

Brain

Skull Temp Ctx

[18F]FCWAY: Miconazole

Baseline 15 mg/kg 30 mg/kg 60 mg/kg

Disulfiram: Decreases Skull Activity &
Increases Brain Uptake

Baseline Disulfiram
Images at 2 h in same subject. Disulfiram 500 mg PO prior night
 Disulfiram: Decreases skull uptake of fluoride &
Increases brain uptake of [18F]FCWAY

Skull Temporal Cortex

Baseline 500
400
Disulfiram
Mean %SUV

400

Mean %SUV
300
300
200
Disulfiram 200 Baseline
100 100

0 0
0 25 50 75 100 125 0 25 50 75 100 125
Time (min) Time (min)
 Disulfiram: Decreases plasma fluoride &
Increases plasma radiotracer [ 18F]FCWAY

[18F]FCWAY
[18F]fluoride (parent tracer)
1600
2000
1400

Activity (Bq/mL)
1750
Activity (Bq/mL)

1200
1500
1000
1250
800 1000 Disulfiram
600 Baseline 750 Baseline
400 500
Disulfiram
200 250
0 0
0 25 50 75 100 125 0 25 50 75 100 125
Time (min) Time (min)
 Summary
1. PET has high sensitivity and specificity
2. PET used in therapeutic drug development
3. Pharmacokinetic modeling of plasma concentration
and tissue uptake can measure receptor density
4. Study drug distribution: block distribution to
periphery and increase distribution to brain
5. Study drug metabolism: inhibit defluorination
 Self-Assessment Quiz:
True or False?
• Imaging with positron emission tomography (PET)
involves the injection of a radioactively labeled drug
that emits a particle called a positron.
• PET shows the location of radioactivity in a cross
section (or tomograph) of the body.
• PET can be used to quantify the density of specific
proteins in the body.
• Compartmental modeling of PET data typically uses
measurements over time of 1) PET images of the
target tissue and 2) concentrations of unchanged
parent radioligand in plasma.
 Course Directors

Dr. Lisa M. Cordes Dr. William Douglas Figg, Sr

PharmD, BCACP, BCOP PharmD, MBA