General Pharmacology

By;

Abebe E. (Assisatant Professor)

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 BRIEF HISTORY OF PHARMACOLOGY
 Medicaments have, since time immemorial, been
used for treating diseases in humans and animals.
 Belief in the curative powers of plants and certain
substances rested exclusively upon traditional
knowledge (empirical information not subjected
to critical examination)
 Claudius Galen (AD 129–200): First attempted to consider
the theoretical background of pharmacology.

“The empiricists say that all is found by

experience. We, however, maintain that
it is found in part by experience, in part
by theory. Neither experience nor theory
alone is apt to discover all.”
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 Theophrastus von Hohenheim (1493–1541), aka Paracelsus: Rejected the irrational concoctions and mixtures of medieval medicine.

 Johann Jakob Wepfer (1620–1695): Was the first to verify by animal experimentation assertions about pharmacological or toxicological actions

“If you want to explain any poison properly,

what then is not a poison? All things are
poison, nothing is without poison; the dose
alone causes a thing not to be poison.”

“I pondered at length. Finally I resolved

to clarify the matter by experiments.”

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 Rudolf Buchheim (1820–1879), Estonia: Founded the
first institute of pharmacology
 T. Frazer (1840–1920), Scotland: Structure–activity
relationships
 J. Langley (1852–1925), England: Drug receptors
 P. Ehrlich (1854–1915), Germany: Selective toxicity
 Alexander J. Clarke (1885–1941), England: first
formalized receptor theory by applying the Law of
Mass Action to drug–receptor interactions.

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 General Pharmacology
 Pharmacology came from the Greek words
“Pharmacon” meaning drug and “logos” meaning
discourse in.
 Pharmacology is the science that deals with properties
and effects of drugs in relation to their interaction with
living systems.
 Drugs are chemical substances that interact with human
and/or animal body to exert their effects, and intended
for prophylactic, diagnostic and treatment purposes.

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• It also includes history,sourse,physicochemical properties,dosage
forms,methods of administration, absorbtion, distribution,
mechanism of action, biotransformation, excretion,clinical uses and
adverse effects of drugs.
• Pharmacodynamics: - is the study of the biological and therapeutic effects
of drugs.i.e ”what the drug does to the body”.
• Pharmacokinetics: - is the study of the absorbtion, distribution,
metabolism and excretion (ADME) of drugs.i.e “what the body does to the
drug”.
• Pharmacotherapeutics: deals with the proper selection & use of drugs for
the prevention and treatment of disease.
• Toxicology: is a science of poisons. Many drugs in large doses can act as
poison. Poisons are substances that cause harmful, dangerous or fatal
sympthoms in living organisms.
SOURCES OF DRUGS

1. Minerals: Liquid parafine, Magnesium sulphate, Magnesium

trisilcate, etc.

2. Animals: Insuline, thyroid extract, heparine, antitoxine sera, etc.

3. Plants: Morphine, digoxine, atropine, castor oil etc.

4. Synthetic sources: Asprine, sulphonamides, paracetamol etc.

5. Micro organisms: Penicilline, streptomycine etc.

6. Genetic engineering: Human insuline, human growth hormone etc.

DRUG NOMENCLATURE

• A drug generally has three categories of names:

1. Chemical name: - describes the substance chemically. E.g. 1-

(Isopropyl amino)-3-(1-naphthyloxy) propane-2-ol.

This is cumbersome and not suitable for use in prescribing.

2. Non-proprietary (generic) name: - It is the name accepted by a

competent scientific body.e.g Mebendazole.

3. Proprietary (Brand) name:-It is the name assigned by the

manufacture(s) and its property or trade mark.One drug may have a
multiple proprietary names.
 Pharmacokinetics
 Pharmacokinetics deals with absorption, distribution,
metabolism and excretion of drugs.
 To produce its characteristic effects, a drug must be
present in appropriate concentration at its site of action.
 Concentration at the site of action depends on
absorption, distribution, binding or localization in
tissues, biotransformation, and excretion.
 All the pharmacokinetic processes involve passage of
drug through membranes.

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THE MOVEMENT OF DRUG MOLECULES ACROSS
CELL BARRIERS
• Cell membranes: barriers between aqueous
compartments in the body
• Gastrointestinal mucosa or renal tubule: a layer of
cells tightly connected to each other
 Molecules must traverse at least two cell membranes to
pass from one side to the other
 Vascular endothelium: more complicated
 Gaps between endothelial cells are packed with a loose
matrix of proteins that act as filters, retaining large
molecules and letting smaller ones through.

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 Contd….
 Some organs (e.g. CNS and the placenta), have tight
junctions between the cells
 Prevent potentially harmful molecules from leaking from the
blood into these organs
 Have major pharmacokinetic consequences for drug distribution
 Other organs (e.g. the liver and spleen) have endothelium
which is discontinuous, allowing free passage between
cells.
 Fenestrated endothelium occurs in endocrine glands, facilitating
transfer of hormones or other molecules through pores in the
endothelium

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• There are four main ways by which small molecules
cross cell membranes:
 diffusing directly through the lipid
 diffusing through aqueous pores
 transmembrane carrier proteins that bind a molecule on one
side of the membrane then changes conformation and
releases it on the other
 by endocytosis

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 Passive diffusion
The major mechanism for absorption of drugs.

The driving force for this process is the concentration

gradient or electrochemical gradient

Fick’s first law of diffusion: drug molecules diffuse

from a region of higher concentration to one of lower
concentration until equilibrium is attained

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Influence of pH on passive diffusion: The pH partition
hypothesis states that the process of absorption is governed by:
 The dissociation constant (pKa) of the drug
 The lipid solubility of the unionized drug
 The pH of the absorption site
Most drugs are either weak acids or weak bases that are
present, as both nonionized and ionized species.
The nonionized molecules are usually more lipid soluble &
diffuse more easily than the ionized species
The transmembrane distribution of a weak electrolyte usually
is determined by its pKa and the pH gradient across the
membrane.

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 For weak acids
HA H+ + A,
 For weak bases
BH+ H+ + B,
 Very weak acids (pKa  8) are essentially unionized at all
pH values and therefore their absorption is rapid and
independent of GI pH.
 Acids in the pKa range 2.5 to 7.5 are better absorbed from
acidic conditions of stomach (where pH  pKa) where
they largely exist in unionized form.
 Stronger acids with pKa  2.5 are ionized in the entire pH
range of GIT and remain poorly absorbed.

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 Very weak bases (pKa  5) are essentially unionized
at all pH values and therefore have a rapid absorption
which is independent of pH.
 Bases in the pKa range of 5 to 11 are better absorbed
from the relatively alkaline conditions of the intestine
where they largely exist in unionized form.
 Stronger bases with pKa  11 are ionized in the entire
pH range of the GIT and therefore are poorly
absorbed.

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18
 Carrier Mediated Transport
Involves binding of the drug to specific receptors on the
membrane for translocation into the cytoplasm
Characteristics of carrier mediated transport
 Selectivity
 Competitive inhibition by chemical congeners
 Requires energy
 Saturability
 Movement against electrochemical gradient
Active transport: when movement is against
concentration gradient
Facilitated diffusion: movement of drugs is along
concentration gradient but in a much faster rate than
simple diffusion.
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Filtration or Pore Transport
Is passage through the water filled pores in
membranes
It is accelerated by the hydrodynamic flow of water
occurring under hydrostatic or osmotic pressure
gradient
Drug should be water soluble and of smaller
molecular size than the diameter of the pores.

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Drug Absorption

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Drug Absorption: Describes the rate at which a drug leaves
its site of administration and the extent to which this occurs.

Bioavaillability is a term used to indicate the extent to

which a drug reaches its site of action or a biological fluid
from which the drug has access to its site of action.

Absorption takes place through one or combination of the

process described earlier

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Factors That Modify Absorption
Drug solubility at the site of absorption

Dosage form

Local condition at the site of action

Drug concentration at the site of absorption

Circulation to the site of absorption

Area of the absorbing surface

The route of administration

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• The main mechanism of most drug absorption in GI tract is:
A. Active transport (carrier-mediated diffusion)
B. Filtration (aqueous diffusion)
C. Endocytosis and exocytosis
D. Passive diffusion (lipid diffusion)
• What kind of substances can’t permeate membranes by
passive diffusion?
A. Lipid-soluble
B. Non-ionized substances
C. Hydrophobic substances
D. Hydrophilic substances

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DRUG DISTRIBUTION

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 Drug distribution is the process by which absorbed
drug or drug directly introduced into the circulation
is carried to various interstitial and cellular fluids.
 Possible Modes of Drug Distribution:
 Following its uptake into the
body, the drug is distributed in
the blood (1)
 and through it, the drug may be
restricted to the extracellular
space (plasma volume plus
interstitial space) (2)
 or it may also extend into the
intracellular space (3).
 certain drugs may bind strongly
to tissue structures (4).

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• Apparent volume of distribution: The concentration
(c) of a solution corresponds to the amount (D) of
substance dissolved in a volume (V); thus, c = D/V

• If the dose of drug (D) and its plasma concentration (c)

are known, a volume of distribution (V) can be
calculated from

• However, this represents an apparent (notional) volume

of distribution (Vapp), because an even distribution in
the body is assumed in its calculation.

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• Homogeneous distribution will not occur if drugs are bound to
membranes of cell or intracellular organelles; or are stored
within organelles.
• In these cases, plasma concentration, cp, becomes small and V
can exceed the actual size of the available fluid volume
• Clinical prediction:
– If Vd = 2L, you can assume drug is distributed in plasma only

– If Vd = 18L, you can assume drug is distributed in plasma and tissues

– If Vd > 46L, the drug is likely stored in a depot because the body only contains 40-
46L of fluid

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 Tissue Distribution
• is determined by the partitioning of drug between blood
and the specific tissue, which in turn depends on
 Lipid solubility of drugs
 pH gradient between plasma and the tissue (ion trapping)
 The relative binding of drug to plasma proteins and tissue
macromolecules
• Some tissues act as storage sites by accumulating the
drug and releasing it slowly over a period of time

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 WHAT IS THE EFFECT OF ION TRAPPING
ON DRUG DISTRIBUTION?

Compartment Compartment
with Low pH with High pH

Unionized Unionized
Weak Acid Weak Acid
Higher total
concentration
of weak acid
Ionized Ionized
Weak Acid
Weak Acid

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 Factors Affecting Distribution of Drugs
Physico-chemical properties of drugs
 Lipid solubility of the drug
 pKa of the drug
 Degree of plasma protein binding (Albumin-vs- α-1 acid gp)
Physiological factors
 Rate of blood flow
 Tissue uptake
Presence of barriers
 BBB
 Placental barrier
 Testicular barrier

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 Redistribution
Termination of drug effect usually is by
biotransformation and excretion, but it may also result
from redistribution of the drug from its site of action
into other tissues or sites.

E.g. Redistribution
of thiopental after
an intravenous
bolus
administration.

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What do you think is the clinical significance of
drug distribution?
DRUG BIOTRANSFORMATION
(METABOLISM)

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• Drug biotransformation is a process by which drugs are
chemically changed in the body to facilitate excretion of drugs
by rendering them more polar or by conjugating them with
highly polar molecules.
 Every tissue has some ability to metabolize drugs (i.e. GI
tract, lungs, skin, kidneys); however, the liver is the
principal organ for drug metabolism
• Biotransformation may lead to one of the following:
 Inactive or less active metabolite
 Metabolite with same activity as the parent drug
 More active compounds (prodrugs are employed to improve bioavailability
(e.g. enalapril), mask unpleasant odor/taste, alter drug solubility and/or
provide site specific delivery)
 Toxic compounds (e.g. acetaminophen overdose)

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 Pattern of Biotransformation
Biotransformation reactions are classified as phase I
and phase II reactions
Phase I (functionalization or non-synthetic) reactions
 Introduce or expose a functional group on the parent drug.
 Generally result in the loss of pharmacological activity,
although there are examples of retention, enhancement or
alteration of activity.
 If not excreted rapidly, the products of phase I
biotransformation undergo phase II conjugation reaction.
 Prominent reactions in this category include oxidation,
reduction and hydrolysis

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Phase II (conjugation or synthetic) reactions
 Lead to the formation of a covalent linkage between a
functional group on the parent compound with endogenous
substrates (glucuronic acid, sulfate, amino acids, glutathione
or acetate).
 Form highly polar conjugates which are generally inactive and
are rapidly excreted in the urine or feces
 Is a saturable process
 Higher molecular weight conjugated metabolites are mostly
excreted in the bile

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The two phases of drug metabolism

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 Drug Metabolizing Systems
• Biotransformations are enzymatic in nature

• The cytochrome P450 enzyme system is the major in

terms of catalytic versatility and the number of drugs it
metabolizes to inactive or active metabolites.
• CYP450 is found highly concentrated in liver
endoplasmic reticulum (microsomes)

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Extrahepatic microsomal enzymes
(oxidation, conjugation)

Hepatic microsomal enzymes

(oxidation, conjugation)

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42
NADP+ Drug
CYP Fe+3
CYP e -

R-Ase Drug
PC Drug OH
NADPH

CO CYP Fe+3
CO
CYP-Fe+2 CYP Fe+2 Drug OH
Drug h
Drug
e-
O2
CYP Fe+2 H2O
O2 Drug
2H+

Electron flow in microsomal drug oxidizing system

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 Enzyme Induction
 Exposure to certain drugs and environmental
pollutants is associated with an increased synthesis of
CYP450 and hence increased rate of
biotransformation.
 Induction brings about decreased bioavailability of
parent drug and increased concentration of metabolite
which depending on the pharmacological activity can
result in either decreased activity or toxicity.
 Induction of metabolism of ethinylestradiol by
rifampicin and phenobarbitone and the associated loss
in contraceptive potency of ethinylestradiol.

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 Enzyme Inhibition
 Competition between two or more drugs for the active
site of the same metabolizing enzyme may lead to a
decrease in the metabolism of one of these agents,
depending on the relative concentration of each substrate
and their affinities for the enzyme.
 Some drugs bind tightly to the Cytochrome P450 heme
iron and reduce the metabolizing activity of the enzymes.
 It results in elevated levels of the parent drug and hence
prolonged pharmacological effect and an increased
incidence of drug-induced toxicity.

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 Factors Affecting Drug Biotransformation
 Genetic polymorphism
 Disease conditions especially of the major drug
metabolizing sites.
 Age
 Predisposing factors to enzyme induction or
inhibition.

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 Clinical Significance:
– First-pass (PRESYSTEMIC) metabolism
– Altered pharmacological action (Asprin vs salicylic acid)
– Toxic metabolites (paracetamol, safe but not too safe when…!)
– Use of ethanol in methanol and ethylene glycol Poisoning (the better
of two evils!)
– Terfenadine vs fexofenadine (offsetting the loss!)
– Alcoholism: (Why are Orientals less into it?)
– CYP 2D6, beta blockers and…in Ethiopians: (Why we, in Ethiopia,
need more clinical pharmacists/clinical researchers!)
– CYP 2C19 (Why do Asian physicians prescribe lower doses of
Diazepam than those of the West?)
– INH toxicity: fast vs slow metabolisers (a double edged sword!)

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Acetominophen Metabolism

~60%
~35%

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Drug Excretion

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Drug excretion is the elimination (passage out) of a
systemically absorbed drug from the body in the form
of metabolites or unchanged drug.
The kidneys are the main organ of excretion of drugs
and their metabolites.
Other routes of drug elimination:
 lungs: for volatile substances
 Sweat: for volatile oils
 Bile and colon (for conjugated large molecular weight drug
or metabolite)
 Saliva
 tears

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 Renal Excretion (water soluble substances)
 The amount of drug or its metabolites ultimately present in urine is the
cumulative effect of glomerular filtration, tubular reabsorption and
tubular secretion.
 Glomerular filtration: depends on
 Plasma protein binding: for a drug to be filtered through the glomerulas, it
should not bind to plasma proteins.
 Rate of blood flow
 Passive tubular reabsorption
 Drugs should be in their non-ionized form to undergo passive reabsorption.
Hence, polar drugs are more readily excreted through the kidneys.
 Active tubular secretion
 An active process which can be inhibited by drugs which use the same
transport mechanism. E.g. probenecid prolongs the t½ of penicillins.

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 Biliary Excretion
 The liver secretes about 1 L of bile daily

 Drugs with mol wt lower than those of most protein

reach the hepatic extracellular fluid from where they are
transported into hepatocytes by carrier-mediated
systems and passive diffusion (more lipophilic drugs).
 Drugs Pass into bile through selective systems with only
few drugs crossing by diffusion.

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 Most drugs secreted by the liver into the bile are not
reabsorbed
 Once in the intestine, most are usually passively
reabsorbed that the drugs will reenter the blood that
perfuse the intestine and again be carried to the liver
(enterohepatic recirculation)
 Conjugation (esp. glucuronidation) generally enhances
biliary excretion since it both
 Introduces a strong polar (i.e., anionic) center
 Increases its molecular weight
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 Conjugated drugs are hydrolyzed by gut enzymes such
as -glucuronidase for reabsorption.
 Liver disease or injury usually impairs bile secretion and
hepatic drug metabolism
 Antibiotics may alter the intestinal flora which diminish
the presence of sulfatase and glucuronidase-containing
bacteria decreasing enterohepatic recirculation.

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 Pulmonary excretion
 Any volatile material, irrespective of its route of
administration, has the potential for pulmonary excretion
 The rate of loss of gases depends on the rate of respiration
and pulmonary blood flow, degree of solubility of the gas
in blood

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 Sweat and Saliva
 Excretion depends on the diffusion of un-ionized lipid-
soluble form across the epithelial cells of the glands.
 Quantity excreted is determined by the pKa of the drug and
the pH of the secretions formed in the glands
 Excretion into sweat may be responsible for the skin
reactions caused by some therapeutic agents
 Substances excreted into saliva are usually swallowed
 Excretion of drugs into saliva accounts for the drug
taste of certain compounds given by IV.

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 Excretion in Milk
 Concentration of drugs in milk depends on many
factors, including
 amount of drug in the maternal blood

 lipid solubility of the drug

 Drug’s degree of ionization

 The extent of its active excretion

 Milk is more acidic (pH 6.5) than plasma, hence basic

drugs are more concentrated in this fluid.

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• What do you think is the clinical significance
of drug excretion?
Routes of Drug Administration

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Drugs are administered for either their action
in the locality of their administration or for
general systemic purpose.

Many factors such as the nature of the target

tissue, physico-chemical properties of the
drug, the disease state etc.. dictate the route the
drug should be administered

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1. Systemic routes of administration

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 1.1. Oral ingestion

 Refers to the administration of drugs though the mouth,

mostly, for systemic effect. It is the most common
method of drug administration

 Advantages
 Safe, more convenient and economical

 Often painless, need no assistance for administration

 Both solid dosage forms and liquid dosage forms can be

administered

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Disadvantages
Action slower and thus not suitable for emergencies
Unpalatable drugs difficult to administer
Not suitable for uncooperative /unconscious/
vomiting patients
Certain drugs are not absorbed sufficiently
Some drugs are destroyed by digestive juice or liver
enzymes (first pass metabolism)

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 1.2. Parenteral route
 Par = beyond and enteral = intestine
 Drug directly introduced into tissue fluids or blood
without having to cross the intestinal mucosa.
 Routes include
 Intravenous
 Intramuscular Major parenteral routes
 subcutaneous
 Other parenteral routes include
 Intraarterial
 Intrathecal
 Intraarticular

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 Advantages
 Action faster (hence valuable in emergencies)

 Employed in unconscious/uncooperative/vomiting patients

 No interference of food or digestive juice and first pass effect

is bypassed to a certain extent.

 Disadvantages
 Preparation is costlier
 Need of assistance by others during administration

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 Intravenous administration

 Drug injected as a bolus or infused slowly over hours in

one of the superficial veins, the drug directly reaches into
the blood stream and effects are produced immediately
 Only aqueous solutions can be injected

 Dose required is smallest as bioavailability is 100%

 Even large volumes can be infused through this route

 It is the most risky route

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 Intramuscular administration
 Drug is injected in one of the large skeletal muscles:
deltoid, triceps, gluteus maximus, rectus femoris etc.
 Muscle is less richly supplied with sensory nerves and
(mild irritants can be applied) and is more vascular
(absorption is faster)

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 Subcutaneous administration
 The drug is deposited in the loose subcutaneous tissue

 Is richly supplied by nerves (unsuitable for irritant drug

administration) but is less vascularized (slow absorption)
 Self injection is simple

 Oily solution or aqueous suspensions can be injected for

prolonged action

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 1.3. Sublingual administration
 Tablets are placed under the tongue or crushed in the
mouth and spread over the buccal mucosa
 Non polar and hence lipid soluble drugs are rapidly
absorbed
 Drug is protected from first pass metabolism as there is
direct drainage into the superior vena cava.

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 1.4. Rectal administration

 Certain irritant and unpleasant drugs can be put into the

rectum as suppositories or enema for systemic effect.
 This is often useful when oral ingestion is precluded by
vomiting or when the patient is unconscious.
 It is rather inconvenient and embarrassing

 Absorption is slower, irregular and often unpredictable

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 1.5. Pulmonary administration
 Suitable for gaseous and volatile drugs

 Rapid absorption due to large surface area

 Solutions can be atomized and the fine droplets in air

(aerosol) inhaled
 Advantage: Rapid absorption, avoidance of hepatic first
pass loss, local application to the pulmonary system.
 Disadvantage: Poor ability to regulate the dose and
irritation of the pulmonary mucosa

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2. Topical administration

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 Application could be on mucous membranes, skin or
the eye.
 Mucous membranes
 Drugs are applied on the mucous membranes of the
conjunctiva, nasopharynx, oropharynx, vagina and colon
usually for their local effects.
 Absorption through mucous membranes occur readily to
cause systemic effects

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 Skin
 Absorption is proportional to the surface area and lipid
solubility of the drug.
 Conditions that increase cutaneous blood flow enhance
absorption.
 Systemic absorption from skin is sometimes a reason of
toxicity.
 Eye
 Ophthalmic preparations are meant for their local action
 Systemic absorption that results from drainage thought the
nasolacrimal canal is usually undesirable
 Very little is lost through drainage; hence, systemic side effects
are minimized.

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Dosage forms
of
drugs

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• A dosage form of a drug is the form of preparation
designed for administration to the body for the purpose
of diagnosis, prophylaxis and treatment.
• After development of a specific chemical entity for its
pharmacological effects, it is formulated in a form that
is suitable for administration and even efficacy and for
the stability of the drug itself.
• There are different dosage form designs intended for
the various routes of administration.
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 Solid dosage forms
 Tablets:
 tablets are solid dosage forms containing the active
ingredient with or without suitable diluents
 They may be coated or uncoated.

 Coating is intended to mask the contents of the tablet

 Enteric coated: intended for intestinal medications without getting
disintegrated in the stomach.
 Non-enteric coated: intended to mask the unpleasant odour and
taste of a drug.
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 Capsules
 Are solid dosage forms which the solid or liquid drug is
enclosed in a hard or soft soluble gelatin shell to mask its bad
taste and odour. They are intended for internal use.

 Suppositories
 Are solid dosage forms with various sizes and shape for
administration into body cavities (rectum, vagina, and
urethra)
 Rectal suppositories are conical or bullet shaped, vaginal
suppositories spherical, and urethral suppositories pencil
shaped.
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 Semi-solid dosage forms

 Ointments
 Are semi-solid preparations containing the medicinal agent
intended for use for application on skin or mucous membranes
 Creams
 Creams are emulsions for external use as protective or
emollients to soften and sooth.
 Pastes
 Are semi-solid dosage forms of heavy consistency.

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 Liquid dosage forms
 Solutions
 Are liquid preparations prepared by dissolving active medicinal
substance in a solvent. It can be for internal or external use.
 For internal use solutions
 Syrups
 Syrups are semi-solid, viscous, sticky preparations containing medicinal
substance dissolved in a concentrated sugar solution.
 Tinctures: hydroalcoholic or alcoholic solution of vegetable material or
chemical substance. They can also be used for external purpose.
 Elixirs: hydroalcoholic preparations flavoured and sweetened with or
without active substance.
 Injectables 81
 Injectables are sterile preparations for parenteral route.
They may be labeled as
 “for injection”: a sterile powder prepacked in a vial which on the
addition of a suitable vehicle forms a clear solution.
 “injection”: a ready made sterile liquid preparation in an ampoule
or vial.
 “sterile suspension”: a ready made suspension for parenteral uses,
but not for intravenous or intrathecal injection.
 “sterile for suspension”: a sterile powder prepacked in a vial which
on addition of a sterile vehicle is made into a suspension for
parenteral uses, but not for intravenous or intrathecal injection.
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 For external use solutions
 Drops: are aqueous preparations intended for topical
administration to the nose, throat, eye or ear. Eye drops should be
clear and sterile aqueous solutions, adjusted to a suitable pH and
osmotic pressure.
 Gargles: are aqueous solution used to treat disease of the pharynx
or nasopharynx and as deodorant or antiseptic.
 Enemas: are aqueous solutions to be placed in the rectum to
evacuate the bowel or to bring about local or systemic
therapeutic action.
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 Suspensions
 Suspensions are preparations containing drugs,
uniformly dispersed with the help of a dispersing agent.
Every suspension should have a label “shake well before
use”
 Suspensions include
 Emulsions: preparations consisting of two non-miscible liquids,
with an emulsifying agent. They may be used for both internal
and external use.
 Mixtures: preparation of any solid material suspended in a
liquid, and intended for internal use.
 Lotion: an aqueous suspension to be applied without friction,
for soothing, cleansing or antiseptic action on the skin.

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Dosage regimen

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 Dosage regimen is a systematic way of drug administration.
There are two types: constant and variant dosing
 Constant dosing is employed only for safe and affordable
drugs
 Variant dosing includes
 A loading dose in one or a series of doses that may be given at the
onset of therapy with the aim of achieving the target concentration
rapidly. It is desirable if the time required to attain steady state by the
administration of drug at a constant rate (four elimination half lives)
is long relative to the temporal demands of the condition being
treated.

86
 Use of loading dose has significant disadvantages
I. Sensitive individuals may be exposed abruptly to a toxic
concentration of a drug.

II. If the drug has long half-life. It takes long time for the
concentration to fall if the level achieved was excessive

III. Loading doses tend to be large, and they are often given
parenterally and rapidly; this can be particularly dangerous
if toxic effects occur as a result of action of the drug at sites
that are in rapid equilibrium with plasma.

87
 Maintenace dose: is a dose administered to maintain the
target concentratin of a drug. The amount is equivalent
to dailly excreted dose.

88
Pharmacodynamics

89
Pharmacodynamics studies the physiological and
biochemical effects of drugs and their mechanism of
action
Drugs interact with receptors to produce their
characteristic effects. Receptors are functional
macromolecular components of the organism
 Drugs potentially are capable of altering both the extent
and rate at which any bodily function proceeds
 Drugs do not create effects but instead modulate intrinsic
physiological functions.

90
 Mechanism of Drug Action
 Physical action
 Mass of the drug (in bulk laxatives), adsorptive property (activated
charcoal), osmotic activity (mannitol)
 Chemical action
 Antacids, chelating agents (BAL, calcium disodium edetate)
 Through protein targets:
(Ion channels, carrier molecules, enzymes, receptors)
 Through enzymes
 Drugs alter rate of enzyme catalyzed reactions
 Actions could be
 Stimulation: increased substrate affinity to enzyme
 Inhibition: is a common mode of drug action and could be
 Competitive: drug binds to catalytic site (mostly non-covalently);
reversed by increasing concentration of substrate.
 Noncompetitive: drug binds to a site adjacent to catalytic site and as a
result the catalytic property of the enzyme is lost.

91
 Through receptors
 Receptors in pharmacology denote to a class of macromolecules that
are concerned specifically and directly in chemical signaling between
and within cells.
 Affinity: ability of a ligand to bind to receptors
 Intrinsic activity (efficacy): ability of a ligand to cause change in
receptor conformation upon binding.
 In view of binding, ligands can be
 Agonists: have affinity and intrinsic activity (A=1, IA=1)
 Antagonist: have affinity but no intrinsic activity (A=1, IA=0)
 Partial agonist/antagonist: have affinity but with submaximal
intrinsic activity (A=1, 0<IA<1)
 Inverse agonist: this phenomenon is evident in only some
receptors which are activated spontaneously without ligand
binding (A=1, -1<IA<0)

92
Drug Receptor Theories

93
 Historical Background
 Lucreteus (50 BC) “odours might be conveyed by tiny, invisible
seeds with distinctive shapes in the palate and nostrils”
 J. N. Langley (1905) specific ‘receptive substances’ exist in cells
 Paul Ehrlich (1907)“entities do not act unless attached”.
Biologically active molecules have to be bound in order to be
effective. (Langley’s & Ehrlich’s theories qualitative).
Occupancy Theories
 A.V. Hill
 For the first time applied the law of mass action to the
relationship b/n drug concentration and receptor occupancy at
equilibrium. The law of mass action: the rate of a reaction is
proportional to the product of the concentration of the reactants
KA
A+R AR [A]: Concentration of agonist
KA: Dissociation equilibrium constant
PAR : proportion of receptor occupied by an agonist

94
 A.J. Clark
 Advanced Hill’s theory to “receptor occupancy Vs tissue response”
 Assumed that the magnitude of the response is directly
proportional to the amount of drug bound.
 The pharmacological effect of a drug is directly proportional to the number
of receptors occupied by the drug
 The maximal response is obtained only when all receptors are occupied

 Limitations of Clark's ideas

 Partial agonism was not discussed
 Discrepancies between EC50 and KD (KA) values
 Existence of spare receptors could not be explained

95
E.J. Ariëns
 Divided the biological response into two separate
parameters,
 Affinity which describes the attachment of drugs to receptor and
was assumed to be governed by law of mass action
 Intrinsic activity which was related to the ability of the drug to
induce an effect after binding

 Ariens theory partially discussed partial agonism by

introducing intrinsic activity ()
 Limitations
 Existence of spare receptors could not be explained
  has a maximum value of 1
 Discrepancy between EC50 and KD

96
R.P. Stephenson
 Assumed that the drug-receptor complex provides a stimulus
(S) to the tissue, and the stimulus is directly proportional to
the fraction of receptors occupied.
 The response is then related to the stimulus by an unspecified
function.
 The proportionality factor between the fractional occupancy of
the receptor population and the stimulus was defined as the
efficacy (e).
 The efficacy of a drug refers to the action of the drug in a
particular tissue-it is a measure of the ability of the drug to
produce a response in a given tissue.
 An additional parameter, intrinsic efficacy, was defined to
described the "stimulant activity" of the drug itself,
independent of the tissue.

97
 Stephenson’s Three Hypotheses
1. A maximum effect can be produced by an agonist
when occupying only a small proportion of the
receptors.
2. The response is not linearly proportional to the number
of receptors occupied.
3. Different drugs may have varying capacities to initiate
a response and consequently occupy different
proportions of the receptors when producing equal
responses (referred to as the efficacy)

98
 where e = efficacy and
 = intrinsic efficacy

 Merits of Stephenson proposal

 Efficacy, unlike intrinsic activity, has no upper limit that it is
always possible that an agonist with a greater efficacy than
any existing compound may be discovered.
 There was no assumption as to the nature of the relationship
between receptor occupancy and the response of the tissue.

99
 Rate Theory
 W.D.M. Paton (1961) postulated that the biological response is
proportional to the rate at which the drug combines with the
receptor--that is, each association of the drug with receptor results
in a quantum of excitation.
 This implies that an agonist must dissociate rapidly from the
receptor to enable other successful associations and subsequent
generation of quanta of excitation.
 An antagonist is assumed to dissociate slowly to prevent the
generation of other quanta of excitation.
 Dissociation rate constant is the factor which determines whether a
drug is an agonist, antagonist or partial agonist (according to the
rate theory).

100
 Allosteric Theory
 Receptors can exist in a variety of discrete conformational states
differing in the ability of that state to produce a response.
 The Monod, Wyman and Changeux model (MWC model, 1965)
assumes that conformational states exist independently of the drug
and that the drug simply controls in which conformational state the
receptor exists. A drug acts as an agonist, antagonist, or partial
agonist depending upon its affinity for active or inactive states
 Koshland, Nemethy, and Filmer model (KNF model, 1966) “the
drug can induce new conformational states in the receptor. A drug
acts as an agonist, antagonist, or partial agonist based on its ability
to induce conformational states that are active or inactive”
101
Signal transduction mechanisms

102
 Signal transduction: process by which stimulus produced as a
result of ligand receptor binding is relayed into the cell.
 Based on molecular structure and on the linkage between the
receptor occupation and the ensuing response, receptors are
classified into:
 Ligand-gated ion channels
 G-protein-coupled receptors (GPCR)
 Kinase-linked receptors
 Nuclear receptors

103
 1. Ligand-gated ion channels
 AKA ionotropic receptors

 They are involved mainly in fast synaptic transmission.

 Ligand binding and channel opening occur on a millisecond

timescale.
 Examples: nicotinic cholinoceptors and gamma-aminobutyric
acid type A (GABAA) receptors

104
The nicotinic acetylcholine receptor, a ligand-gated ion channel

105
 2. G-Protein-Coupled Receptors
 AKA metabotropic receptors
 Comprise seven membrane-spanning segments. One of the
intracellular loops interacts with G-protein .
 G-protein (could be stimulatory or inhibitory): is a membrane
protein comprising three subunits (αβγ), the α-subunit possessing
GTPase activity.
 When the G-protein binds to a ligand-occupied receptor, the α-
subunit dissociates and is free to activate an effector. effector
activation is terminated by hydrolysis of the bound GTP
 Is largest receptor family and includes the muscarinic
acetylcholine receptor, adrenoceptors and neuropeptide
receptors.
106
107
 The main targets for G-proteins, through which GPCRs
control different aspects of cell function
Adenylate cyclase: the enzyme responsible for cAMP
formation
Phospholipase C: the enzyme responsible for
inositoltri hosphate and diacylglycerol formation
Ion channels: particularly calcium and potassium
channels.

108
 2.1. The adenylate cyclase/cAMP system
 cAMP is synthesised within cells from ATP by the action of a
membrane-bound enzyme, adenylate cyclase. It is produced
continuously and inactivated by hydrolysis to 5'-AMP through the
action of phosphodiesterases.
 cAMP regulates the activity of protein kinases which in turn
regulate many aspects of cellular function including, for example,
enzymes involved in energy metabolism, cell division and cell
differentiation; ion transport; ion channels; and the contractile
proteins in smooth muscle.

109
Drug

outside

GPCR plasma
membrane

 cytosol
AC
GDP GTP

GTP GDP ATP cAMP + PPi

110
 2.2. The Phospholipase C/Inositol Phosphate System
 PIP2 is the substrate for a membrane-bound enzyme, PLCβ, which
splits it into diacylglycerol (DAG) and inositol 1,4,5-
trisphosphate (IP3).

 IP3 binds to the IP3 receptor on ligand-gated calcium channel

present on the membrane of the endoplasmic reticulum and cause
release of Ca2+ to the cytosol.
 The main effect of DAG is to activate a membrane-bound protein
kinase, protein kinase C (PKC), which catalyses the
phosphorylation of a variety of intracellular proteins

111
112
 2.3. Ion Channels as Targets for G-proteins
• GPCRs can control ion channel function directly by mechanisms
that do not involve second messengers such as cAMP or IPs
• These actions are produced by direct interaction between the G-
protein subunit and the channel, without the involvement of
second messengers.

113
 3. Kinase-linked receptors
 Responds to protein mediators.
 Comprise an extracellular ligand-binding domain linked to an
enzymatic intracellular domain by a single transmembrane helix.
 Activation involves dimerisation of receptors, followed by
autophosphorylation of tyrosine residues. The phosphotyrosine
residues act as acceptors for a variety of intracellular proteins,
thereby allowing control of many cell functions.
 The enzymatic activity could be protein kinase or guanylate
cyclase.
 Includes receptors for insulin and various cytokines and growth
factors (protein kinase), atrial natriuretic factor (guanylate
cyclase).
114
115
 4. Nuclear Receptors
 Ligands include steroid hormones, thyroid hormones, vitamin
D and retinoic acid.
 Receptors are intracellular proteins, so ligands must first enter
cells.
 Receptors consist of a conserved DNA-binding domain
attached to variable ligand-binding and transcriptional control
domains.
 DNA-binding domain recognizes specific base sequences,
thus promoting or repressing particular genes.
 Effects are produced as a result or\f altered protein synthesis
and, therefore, are slow in onset.

116
117
Dose-Response
Relationship

118
 Is relationship between intensity of drug effect & drug dosage
(drug level)
 Has two components

 Dose-plasma concentration relationship

 Plasma concentration-response relationship

 Quantification of drug level at the site of action is difficult and

hence either the dose administered or its plasma concentration
are considered during quantification.

119
Typical Concentration Vs receptor occupancy curve

120
121
 Plotting logarithmic scale of the concentration on the
x-axis vs occupancy (response) results in a sigmoidal
curve
 Advantages include
 Lineaarity over 20-80% of the occupancy (response)
 It can show a much larger range of concentration

122
Overlapping a log concentration-occupancy curve on a log concentration-response curve reveals three scenarios
Scenario 1

 Identical occupancy and response curves

 KA = EC50 meaning half maximal response at half maximal occupancy
 Maximum response at full occupancy only
123
 Scenario 2

Maximum response attained at sub-maximal occupancy

KA > EC50
This occurs because the transducer mechanism is very effective
at converting drug-response interaction in to response.

124
 Scenario 3

 Sub-maximal response at full occupancy

 Drug-receptor interaction elicits weak signal transducing
mechanism
 KA < EC50

125
 Potency
&
Intrinsic Activity

126
 Potency
• It is a function of EC50
• Drug “a” is more potent than drug “b”
• Drugs “b” and “c” are of equal potency (have equal EC50)
• Configuration of curve with respect to the x-axis gives indication of
potency
 Intrinsic activity (IA)
• Related to the attainment of maximum response
• Drugs “a” and “b” have equal IA while “c” has less IA
• Configuration of curve with respect to the Y-axis gives indication of IA

127
Drug potency does not necessarily mean therapeutic superiority
Other factors such as adverse drug reactions associated with the drug need to be
considered.

128
Effect of Antagonists
on
DRC

129
1. Idealized DRC of an agonist in the
absence (a) and the presence (b, c, d)
of increasing doses of a competitive
antagonist. Shift of the agonist log
concentration-effect curve to the
right, without change of slope or
maximum. Linear relationship
between dose ratio and antagonist
concentration
2. Idealized DRC of an agonist in the
absence (a) and the presence (b, c, d)
of increasing doses of a non-
competitive antagonist.

130
 Selectivity
 Dose response curves can help determine how much selectively a
drug produces a specific desired effect
 DRC for the various responses are made and their EC50 are
determined. The horizontal gap on the graph (the difference
between the EC50 of the various effects) shows the extent of
selectivity of the drug.
 Such a comparison is also employed to define the safety margin;
the horizontal gap between the DRCs of a therapeutic effect and
adverse effect.

131
 Individual Variation
 Drug response curves of same effect (response) from

different individuals is made and compared for EC50

 Sensitive individuals display smaller EC50 value indicating

that smaller dose of a drug produces higher response in

this individuals.

132
 Graded
-vs-
Quantal Response

133
 Graded DRCs
 Response obtained from the administration of graded
dose to a single animal or patient.
 With graded responses, one can obtain a complete dose–
response curve in a single animal or patient.
 EC50 (AKA ED50) is the dose at half maximum response
 The curve is continuous

134
 Quantal DRCs
• Relationship between dose and some specified quantum
of response among all individuals taking the drug
• Effect is either present or absent (all or none)
• E.g. protection of convulsion by anti-epileptic agents.
• Its construction requires that data be obtained from
many individuals.
• ED50 : dose at which 50% of those treated show specific
intensity of effect
• LD50 : Dose at which 50% of those treated die (in
animals)
135
136
 Therapeutic Index
• An estimate of a drugs margin of safety.
• Mathematically:

• A more realistic estimate of drug safety would include a

comparison of the lowest dose that produces toxicity
(LD1) and the highest dose that produces maximal
therapeutic response (ED99)

137
Factors that Modify Drug Effect
and
Drug Dosage

138
 Body weight
 Age
 Infants
• Small volume of body fluid compartment
• Incomplete development of the BBB
• Undeveloped renal system
• Undeveloped enzyme system
 Old people: deteriorated body functions
 Sex
 Women respond faster due to their relative small body size
 Route of administration
 Time of administration
 Physiological variables: fluid and electrolyte balance, acid-base
status, blood flow and body temperature.
139
 Tolerance to drugs
 Pathological factors that alter pharmacokinetics and
pharmacodynamic parameters. Special attention is given to renal
and hepatic problems
 Genetic factors
 Emotional factors
 Environmental
 More of a hypnotic drug is required to induce hypnosis during
day time than during night
 More dose of antihypertensive drug is required to lower blood
pressure in cold weather than in hot one.
 Nutritional state
 Starvation causes decreased protein synthesis (drug
metabolizing enzymes), hence enhanced drug effect.

140
 Drug Interaction
 If two or more drugs are given together they might interact

 Interaction occurs at two stages

 At pharmacokinetic level

At the level of absorption, distribution, biotransformation

or excretion
 At pharmacodynamic level

At the level of receptors and beyond

Pharmaceutical

141
 Types of Drug Interaction
 Synergism: action of a drug increased by another

 Additive

Effect of (A+B) = Effect of A + Effect of B

Side effects are better tolerated as the same synergy might

not work for the adverse effects of the drugs.
 Potentiation (Supraadditive)

Effect of (A+B) > Effect of A + Effect of B

Especially if one is inactive as such

142
 Antagonism: action of one drug inhibits the action of another

 Physical: charcoal and alkaloids

 Chemical: Nitrates and cyanide radicals

 Physiological/functional

Drugs by acting on different receptors to produce opposite

effects. E.g. histamine and adrenaline on bronchial smooth
muscle and blood pressure.
 Pharmacological antagonism

Antagonism takes place at and beyond the receptor which

could be of two types: competetive and non-competetive.
143
 Competitive antagonism

 Same binding site for agonist and antagonist

 It could be

Reversible: where the bond formed between the antagonist

and receptor is weak and reversible
Irreversible: where the bond formed between antagonist
and receptor is covalent.
 Non-competitive antagonism

 Antagonism is at site beyond receptor

144
 Types Therapy
 Physiotherapy
 Psychotherapy
 Drug therapy
 Chemotherapy: drugs used against microbes, parasites, cancer
cells
 Pharmacotherapy: application of drugs for their action on
various body parts. It could be
 Symptomatic treatment
 Curative treatment
 Replacement treatment: substance essential to body
administered
The type of therapy depends on the nature of disease or
illness
145
 Types of Drug Action
 Systemic action Vs local action

 Direct action Vs Indirect action

 Primary action Vs Secondary action

 Selective Vs non-selective action

146
 Drug Adverse Effects and Drug Toxicities
 These are effects not favorable to the patient
 Expected adverse effects
 Side effects: effects observed at therapeutic dose
 Toxic effects: effects observed at larger concentrations
 Acute toxicity: acute administration of larger doses
 Chronic toxicity: usually with prolonged and repeated use of a
drug.
 Unexpected adverse effects
 Hypersensitivity reactions: abnormal response due to antigenic
nature of some drugs
 Allergy
 Anaphylaxis: extreme sensitivity to antigenic substance and
subsequent circulatory collapse
 Idiosyncratic reactions: genetically determined abnormal
reactivity to a drug.
147
 Management of Toxicity
 DOSE of a drug determines whether it has medicinal or toxic
 Poisons affect adversely one or more vital body functions and
only few poisons have specific antidotes.

148
 General Procedures in the Management of
Poisoning
 Termination of exposure to the toxic substance
 Allowing to fresh air
 Washing of the eyes and skin
 Induction of emesis (NA in comatose patients)
 Prevention of further absorption of ingested poison
 Use of adsorbent
 Induction of purgation

149
 Maintenance of patient airway and adequate ventilation

 Maintenance of BP and heart beat by fluid infusion, pressor

agents, cardiac stimulants etc
 Hastening elimination of poison

 Promoting diuresis: altering urine pH

 Haemodialysis and haemoperfussion
 Use of Specific Antidotes

150
 Drug Discovery and Development
• With the development of the pharmaceutical industry towards the
end of the 19th century, drug discovery became a highly focused
and managed process.
• Today, the bulk of modern therapeutics, and of modern
pharmacology, is based on drugs that came from the laboratories
of pharmaceutical companies
• The two main stages of the process, are: (i) the discovery phase,
i.e. the identification of a new chemical entity as a potential
therapeutic agent; and (ii) the development phase, during which
the compound is tested for safety and efficacy in one or more
clinical indications, and suitable formulations and dosage forms
devised.

151
 THE DRUG DISCOVERY PHASE
• Given the task of planning a project to discover a new drug
to treat, say, Parkinson's disease, where does one start?
choose a new molecular target.
• Molecular target: drug targets are, with few exceptions,
functional proteins (e.g. receptors, enzymes, transport
proteins).
• When the biochemical target has been decided and the
feasibility of the project has been assessed, the next step is
to find lead compounds
• LEAD FINDING :Large companies will typically maintain a
growing collection of a million or more synthetic
compounds, which will be routinely screened whenever a
new assay is set up.

152
• The present tendency is to use combinatorial
chemistry, which allows families of several hundreds
or thousands of related compounds to be made
simultaneously.
• By coupling such high-speed chemistry to high-
throughput assay systems, the time taken over the
initial lead-finding stage of projects has been reduced
to a few months in most cases, having previously often
taken several years.

153
 The Development Phase
PRECLINICAL and CLINICAL DEVELOPMENT
• Preclinical development is aimed at satisfying all the requirements that
have to be met before a new compound is deemed ready to be tested for
the first time in humans.
• The work falls into four main categories.
– Pharmacological testing to check that the drug does not produce any
obviously hazardous acute effects, such as bronchoconstriction,
cardiac dysrhythmias, blood pressure changes and ataxia. This is
termed Safety Pharmacology.
– Preliminary toxicological testing to eliminate genotoxicity and to
determine the maximum non-toxic dose of the drug. Animals are
checked regularly for weight loss and other gross changes, the
animals so treated are examined minutely post mortem at the end of
the experiment to look for histological and biochemical evidence of
tissue damage.

154
 – Pharmacokinetic testing, including studies on the absorption,
metabolism, distribution and elimination (ADME studies) in
laboratory animals.
– Chemical and pharmaceutical development to assess the
feasibility of large-scale synthesis and purification, to assess the
stability of the compound under various conditions, and to develop
a formulation suitable for clinical studies.
• CLINICAL DEVELOPMENT
• Clinical development proceeds through four distinct phases
– Phase I trials are performed on a small group (normally 20-80) of
normal healthy volunteers, and their aim is to check for safety,
tolerability and pharmacokinetic properties . Phase I studies may
also test for pharmacodynamic effects in volunteers (e.g. does a
novel analgesic compound block experimentally induced pain in
humans? How does the effect vary with dose?).

155
– Phase II studies are performed on groups of patients (normally 100-
300) and are designed to test for efficacy in the clinical situation, and
if this is confirmed, to establish the dose to be used in the definitive
phase III study.
– Phase III studies are the definitive double-blind randomised trials,
commonly performed as multicentre trials on 1000-3000 patients,
aimed at comparing the new drug with commonly used alternatives.
These are extremely costly, difficult to organise, and often take years
to complete, particularly if the treatment is designed to retard the
progression of a chronic disease
– Phase IV studies comprise the obligatory postmarketing surveillance
designed to detect any rare or long-term adverse effects resulting
from the use of the drug in a clinical setting in many thousands of
patients. Such events may necessitate limiting the use of the drug to
particular patient groups, or even withdrawal of the drug

156
157
GENE THERAPY
• Gene therapy = Introduction of normal genes
into cells that contain defective genes to
reconstitute a missing protein product
• GT is used to correct a deficient phenotype so
that sufficient amounts of a normal gene
product are synthesized  to improve a
genetic disorder
• Modification of somatic cells by transferring
desired gene sequences into the genome.
• Somatic cells necessary to ensure that
inserted genes are not carried over to the next
generation.
 Different Delivery Systems are Available
• In vivo versus ex vivo
– In vivo = delivery of genes takes place in the body
– Ex vivo = delivery takes place out of the body, and
then cells are placed back into the body
• In vivo techniques usually utilize viral vectors
– Virus = carrier of desired gene
– Virus is usually “crippled” to disable its ability to cause
disease
– Viral methods have proved to be the most efficient to date
– Many viral vectors can stable integrate the desired gene into
the target cell’s genome
– Problem: Replication defective viruses adversely
affect the virus’ normal ability to spread genes in
the body
• Reliant on diffusion and spread
• Hampered by small intercellular spaces for transport
• Restricted by viral-binding ligands on cell surface 
therefore cannot advance far.
• Ex vivo manipulation techniques
– Electroporation
– Liposomes
– Calcium phosphate
– Gold bullets (fired within helium pressurized gun)
– Retrotransposons (jumping genes – early days)
– Human artificial chromosomes
 Limitations of Gene Therapy
• Gene delivery
– Limited tropism of viral vectors
– Dependence on cell cycle by some viral vectors
(i.e. mitosis required)
• Duration of gene activity
– Non-integrating delivery will be transient
(transient expression)
– Integrated delivery will be stable
• Patient safety
– Immune hyperresponsiveness (hypersensitivity
reactions directed against viral vector components
or against transgenes expressed in treated cells)
– Integration is not controlled  oncogenes may
be involved at insertion point  cancer?
• Gene control/regulation
– Most viral vectors are unable to accommodate full
length human genes containing all of their original
regulatory sequences
– Human cDNA often used  much regulatory
information is lost (e.g. enhancers inside introns)
 – Often promoters are substituted  therefore
gene expression pattern may be very different
– Random integration can adversely affect
expression (insertion near highly methylated
heterogeneous DNA may silence gene expression)
• Expense
– Costly because of cell culturing needs involved in
ex vivo techniques
– Virus cultures for in vivo delivery
– Usually the number of patients enrolled in any
given trial is <20
– More than 5000 patients have been treated in last
~12 years worldwide