Arzneimittel-Forschung 2007-01-01

Pharmacokinetics of tilidine and naloxone in patients with severe hepatic impairment.

Ulrich Brennscheidt, Ulrike Brunnmüller, Dietfried Proppe, Peter Thomann, Klaus-Ulrich Seiler

Index: Arzneimittelforschung 57(2) , 106-11, (2007)

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Abstract

The objective of the present study was to evaluate the pharmacokinetics of tilidine (CAS 20380-58-9), naloxone (CAS 465-65-6) and tilidine metabolites after administration of a single oral dose of a solution containing 100 mg tilidine hydrochloride and 8 mg naloxone hydrochloride (equivalent to 1.44 ml Valoron N solution) to patients with severe hepatic impairment. The investigation was carried out as an open single-dose study in 8 patients suffering from liver cirrhosis. Patients qualified for study enrollment if they had a Child-Pugh score of > or = 7 and a mono-ethyl-glycine-xylidide (MEGX) 15-min test value < 50 ng/ ml. Blood samples were taken over a period of 28 h and analyzed for the prodrug tilidine, its active metabolite nortilidine, bisnortilidine, and naloxone (total and non-glucuronidated fraction). Pharmacokinetic parameters were compared with data from a previous study performed in healthy volunteers. Tilidine, nortilidine and unconjugated naloxone pharmacokinetic parameters showed a high variability between patients. Compared to previous results obtained in healthy volunteers, maximum plasma concentration (Cmax) of nortilidine was reduced by 44%, whereas elimination half-life (t1/2) was prolonged by factor 2. The area under the curve (AUC) showed a slight reduction of approximately 20%. For total naloxone, no relevant change was observed. However, in contrast to the results obtained in healthy subjects, unconjugated naloxone could be measured in plasma from patients with cirrhosis, possibly due to a reduced glucuronidation capacity of the liver in these patients. In conclusion, severe hepatic impairment has a relatively minor influence on the exposure (AUC) to the active metabolite of tilidine (i.e., nortilidine). However, a straightforward interpretation of the results was confounded by pronounced variability in nortilidine pharmacokinetics. In individual patients with severely affected liver function, satisfactory analgesia with tilidine/naloxone oral solution might not be achieved because of insufficient formation of nortilidine and insufficient inactivation of naloxone.