## Factors That Alter Clearance

Body Surface Area (BSA)

Most literature values for clearance are expressed as volume/kg/time or as volume/70 kg/time. There is some evidence, however, that drug clearance is best adjusted on the basis of BSA rather than weight.

The patient’s BSA can be obtained from a nomogram, estimated from below:

BSA in m2 = [(Patient’s Weight in Kg / 70 kg)^0.7]*(1.73 m2)

or

BSA in m2 = (W^0.425)(H^0.725)*0.007184

The following formulas can be used to adjust the clearance values reported in the literature for specific patients. There are other equations one can use depending on units used in the literature for clearance.

• Patient’s Cl = (Literature Cl per m2)(Patient’s BSA)
• Patient’s Cl = (Literature Cl per 70 kg) (Patient’s BSA / 1.73 m2)
• Patient’s Cl = (Literature Cl per 70 kg)(Patient’s Weight in Kg / 70 kg)
• Patient’s Cl = (Literature Cl per kg)(Patient’s Weight in kg)

When patients do not differ significantly from 70 kg, the difference between using weight versus BSA becomes less significant.

The underlying assumption in using weight or BSA to adjust clearance is that the patient’s liver and kidney size (and hopefully function) vary in proportion to these physical measurements. This may not always be the case; therefore, clearance values derived from the patient populations having a similar age and size should be used whenever possible. If the patient’s weight is reasonably close to 70 kg (BSA = 1.73 m2), the patient’s calculated clearance will be similar whether weight or BSA are used to calculate clearance. If, however, the patient’s weight differs significantly from 70 kg, then the use of weight or surface area is likely to generate substantially different estimates of the patient’s clearance. When a patient’s size is substantially greater or less than the standard 70 kg, or 1.73 m2, a careful assessment t should be made to determine if the patient’s body stature is normal, obese, or emaciated. In obese and emaciated patients, neither weight nor surface area is likely to be helpful in predicting clearance, since the patient’s body size will not reflect the size or function of the liver and kidney.

Plasma Protein Binding

For highly protein-bound drugs, diminished plasma protein binding is associated with a decrease in reported steady-state plasma drug concentrations (total of unbound plus free drug) for any given dose that is administered. It would be misleading, however, to assume that because the calculated clearance is increased, the amount eliminated per unit of time has increased. Actually the amount eliminated per unit of time equals is the production of both Cl and C. In summary, when the same daily dose of a drug is given in the presence of diminished protein binding, an amount equal to that dose will be eliminated from the body each day at steady state despite a diminished steady-state plasma concentration and an increase in the calculated clearance. This is one way to explain the un-changed RE (rate of elimination). In another way to explain, when Css ave changes, the free or unbound fraction of drug in the plasma generally increases (even though Css ave decreases) with diminished plasma protein binding. As a result, the amount of free drug eliminated per unit of time remains unchanged.

And also what is important is that the pharmacologic effect achieved will be similar to that produced by the higher serum concentration observed under normal protein binding conditions. This example re-emphasizes the principle that clearance alone is not a good indicator of the amount of drug eliminated per unit of time (RE).

Extraction Ratio

The direct proportionality between calculated clearance and fraction unbound (fu) does not apply to drugs that are so efficiently metabolized or excreted that some (perhaps all) of the drug bound to plasma protein is removed as it passes through the eliminating organ. In this situation the plasma protein acts as a “transport system” for the drug, carrying it to the eliminating organs, and clearance becomes dependent on the blood or plasma flow to the eliminating organ. To determine whether the clearance for a drug with significant plasma binding will be influenced primarily by blood flow or plasma protein binding, its extraction ratio is estimated and compared to its fu value.

The extraction ratio is the fraction of the drug presented to the eliminating organ that is cleared after a single pass through that organ. It can be estimated by dividing the blood or plasma clearance of a drug by the blood or plasma flow to the elimination organ. At rest, the blood flow to the liver via the portal vein is at a rate of 1300 mL/min, and the other 500 mL/min is suppled by the hepatic artery. If the extraction ratio exceeds the free fraction (fu), then the plasma proteins are acting as a transport system and clearance will not change in proportion to fu. If, however, the extraction ratio is less than fu, clearance is likely to increase by the same proportion that fu changes. This approach does not take into account other factors that may affect clearance such as red blood cell binding, elimination from red blood cells, or changes in metabolic function.

Renal and Hepatic Function

Drugs can be eliminated or cleared as unchanged drug through the kidney (renal clearance) and by metabolism in the liver (metabolic clearance). These two routes of clearance are assumed to be independent of one another and additive.

Clt = Clm + Clr (total Cl = metabolic CI + renal Cl)

Because the kidneys and liver function independently, it is assumed that a change in one does not affect the other. Thus, Clt can be estimated in the presence of renal or hepatic failure or both. Because metabolic function is difficult to quantitate, Clt is most commonly adjusted when there is decreased renal function:

A clearance that has been adjusted for renal function can be used to estimate the maintenance dose for a patient with diminished renal function. This adjusted clearance equation, however, is only valid if the drug’s metabolites are inactive and if the metabolic clearance is indeed unaffected by renal dysfunction as assumed. A decrease in the function of an organ of elimination is most significant when that organ serves as the primary route of drug elimination. However, as the major elimination pathway becomes increasingly compromised, the “minor” pathway becomes more significant because it assumes a greater proportion of the total clearance. For example, a drug that is usually 67% eliminated by the renal route and 33% by the metabolic route will be 100% metabolized in the event of complete renal failure; the total clearance, however, will only be one-third of the normal value.

As an alternative to adjusting Clt to calculate dosing rate, one can substitute fraction of the total clearance that is metabolic and renal for Clm and Clr. Using this technique the equation below can be derived.

The Dosing Rate Adjustment Factor can be used to adjust the maintenance dose for a patient with altered renal function.

Most pharmacokinetic adjustments for drug elimination are based on renal function because hepatic function is usually more difficult to quantitate. Elevated liver enzymes do reflect liver damage but are not a good measure of function. Hepatic function is often evaluated using the prothrombin time (or INR), serum albumin concentration, and serum bilirubin concentration. Unfortunately, each of these laboratory tests is affected by variables other than altered hepatic function. For example, the serum albumin may be low due to decreased protein intake or increased renal or GI loss, as well as decreased hepatic function. Although liver function tests do not provide quantitative data, pharmacokinetic adjustments must still take into consideration liver function because this route of elimination is important for a significant number of drugs.

Cardiac Output

Cardiac output also affects drug metabolism. Hepatic or metabolic clearances for some drugs can be decreased by 25% to 50% in patients with congestive heart failure. For example, the metabolic clearances of theophylline and digoxin are reduced by approximately one-half in patients with congestive heart failure. Since the metabolic clearance for both of these drugs is much lower than the hepatic blood or plasma flow (low extraction ratio), it would not have been predicted that their clearances would have been influenced by cardiac output or hepatic blood flow to this extent. The decreased cardiac output and resultant hepatic congestion must, in some way, decrease the intrinsic metabolic capacity of the liver.

## Creatinine Clearance Estimation – Steady State

Different from most drug administration regimens, creatinine is constantly produced and released into plasma by the body muscle mass. Because many drugs are partially or totally eliminated by the kidney, an accurate estimation of renal function is an important component in the application of pharmacokinetics to designing drug therapy regimens. Creatinine clearance as determined by a urine collection and corresponding plasma sample is considered by many clinicians to be the most accurate test of renal function. In the clinical setting, the time delay and the difficulty in obtaining the 24-hour creatinine collection limit the utility of the 24-hour urine collection. In addition, all too often, the urine collection is inaccurate because a portion is accidentally discarded or the time of collection is shorter or longer than requested. Perhaps, the most common error is an incomplete collection, which will result in an underestimation of renal function. Because decisions with regard to drug dosing must often be made quickly, several authors have suggested a variety of methods by which creatinine clearance (ClCr) can be estimated using a serum creatinine value. The most accurate of these equations include serum creatinine, body weight or size, age, and gender.

Creatinine Pharmacokinetics

The pharmacokinetics of creatinine is presented in far more detail elsewhere, but a brief overview is necessary. Creatinine is a metabolic by-product of muscle, and its rate of formation (RA) is primarily determined by an individual’s muscle mass or lean body weight. It varies, therefore, with age (lower in the elderly) and gender (lower in the females). For any given individual, the rate of creatinine production is assumed to be constant. Once creatinine is released from muscle into plasma, it is eliminated almost exclusively by renal glomerular filtration. Any decrease in the glomerular filtration rate ultimately results in a rise in the serum creatinine level until a new steady state is reached and the amount of creatinine cleared per day equals the rate of production. In other words, at steady state, the rate in must equal the rate out. Since the rate of creatinine production remains constant even when renal clearance diminishes, the serum creatinine must rise until the product of the clearance and the serum creatinine again equals the rate of production.

Creatinine, RA = RE

Estimating Creatinine Clearance from Steady-State Serum Creatinine Concentrations

Basic Rationale

The degree to which a steady-state serum creatinine rises is inversely proportional to the decrease in creatinine clearance. Therefore, the new creatinine clearance can be estimated by multiplying a normal ClCr value by the fractional change in the serum creatinine: normal SCr/patient’s SCrss. For the 70-kg man, it can be assumed that the normal SCr is 1.0 mg/dL and that the corresponding ClCr is 120 mL/min.

New ClCr = (120 mL/min) [1 mg/dL / SCr ss] (Equation 1)

On the basis of this concept, one can see that each time the serum creatinine doubles, the creatinine clearance falls by half and that small changes in the serum at low concentrations are of much greater consequence than equal changes in the serum creatinine at high concentrations. To illustrate, if a patient with a normal serum creatinine of 1.0 mg/dL is reported to have a new steady-state serum creatinine of 2 mg/dL, the creatinine clearance has decreased from 120 to 60 mL/min. However, if a patient with chronic renal dysfunction has a usual serum creatinine of 4 mg/dL (ClCr = 30 mL/min), a similar 1.0 mg/dL increase in the serum creatinine to 5 mg/dL would result in a small drop in the ClCr (6 mL/min) and a new clearance value of 24 mL/min. However, at some point even small changes in ClCr can be physiologically significant to the patient. As an example, for a patient with a creatinine clearance of 100 mL/min to have their renal function decline by 10 mL/min is of very little consequence, but for a patient with a creatinine clearance of 15 mL/min, a 10 mL/min decrease would probably change their clinical status from a patient with very poor renal function to a patient who would require dialysis.

The estimation of ClCr from SCr ss alone is reasonably satisfactory as long as the patient’s daily creatinine production is average (i.e., 20 mg/kg/day); the patient weighs approximately 70 kg and the serum creatinine is at steady state (i.e., not rising or falling). These conditions are usually present in the young healthy adult, but young healthy adults are not the typical patients for whom pharmacokinetic manipulations are most useful.

Adjusting to Body Size: Weight or Body Surface Area

To account for any changes in creatinine production and clearance that may result from a difference in body size, Equation 1 can be modified to compensate for any deviation in BSA from the 70-kg patient (1.73 m2):

The patient’s BSA can be obtained from a nomogram, estimated from Equation 2:

BSA in m2 = [(Patient’s Weight in Kg / 70 kg)^0.7]*(1.73 m2)

or calculated from the following equation:

BSA in m2 = (W^0.425)(H^0.725)*0.007184

where BSA is in meters squared (m2), W is weight in kilograms, and H is the patient’s height in centimeters.

A disadvantage of using only weight or BSA is that the elderly or emaciated patients who have a reduced muscle mass do not have a “normal” creatinine clearance of 120 mL/min/1.73 m2 with a serum creatinine value of 1.0 mg/dL. For this reason, it may be erroneous to assume that a SCr of 1.0 mg/dL is indicative of a creatinine clearance of 120 mL/min/1.73 m2 in these individuals.

On average, as patients age, their muscle mass represents a smaller proportion of their total weight and creatinine production is decreased (Table 5). There are a number of equations that consider age, gender, body size, and serum creatinine when calculating or estimating creatinine clearance for adults. Although all these methods are similar and equivalent in clinical practice, the most common method used by clinicians is probably the one proposed by Cockcroft and Gault.

ClCr for males (mL/min) = (140 – Age)(Weight) / [(72)(SCr ss)] [Equation 3]

ClCr for females (mL/min) = (0.85)(140 – Age)(Weight) / [(72)(SCr ss)] [Equation 4]

where age is in years, weight is in kg, and serum creatinine is in mg/dL. Equation 3 and 4 calculate creatinine clearance as mL/min for the patient’s characteristics entered into the equation.

The two most critical factors to consider when using Equation 3 and 4 are the assumptions that the serum creatinine is at steady state and the weight, age, and gender of the individual reflect normal muscle mass. For example, when estimating a creatinine clearance for an obese patient, an estimate of the non-obese or ideal body weight (IBW) should be used in Equation 3 and 4. This estimate can be based on IBW tables or the following equations.

TBW Significantly Larger than IBW

Ideal Body Weight for males in kg = 50 + (2.3)(Height in Inches > 60) [Equation 5]

Ideal Body Weight for female in kg = 45 + (2.3)(Height in Inches > 60) [Equation 6]

It should be pointed out, however, that an IBW derived from a patient’s height, as in Equation 5 and 6, may not represent the actual non-obese weight of a patient. Although there are some potential flaws in estimating the non-obese weight from height, the IBW is usually preferable to using the actual weight [total body weight (TBW)] when a patient is markedly obese. As a clinical guideline, one approach is to make an adjustment for IBW if the patient’s actual weight is > 120% of their IBW.

There are studies indicating that TBW overestimates and IBW underestimates renal function in the morbidly obese patient. It has been suggested that an adjusted body weight between IBW and TBW be used to estimate renal function in obese individuals. While this adjustment factor is variable, 40% of the excess weight is commonly used:

Adjusted Body Weight = IBW + (0.4)(TBW – IBW) [Equation 7]

where IBW is the patient’s ideal body weight in kg as calculated from Equation 5 and 6, and TBW is the patient’s total body weight in kg.

There are other factors not considered in these equations for IBW and Adjusted Body Weight. As an example, in patients with extensive spacing of fluid (i.e., edema or ascites), the liters (kilograms) of excess third-space fluid should probably not be included in the patient’s estimate of TBW. As an example, consider a 5-foot 4-inch male patient weighting 75 kg and having an estimated 15 kg of edema and ascitic fluid. Using the patient’s height (64 inches) and weight (75 kg) might suggest that the patient is more than 120% over his IBW and therefore “clinically obese” for the purposes of doing pharmacokinetic calculations.

For this patient, IBW = 59.2, TBW/IBW = 127%. However, the patient is not obese but rather has a significant amount of interstitial fluid accumulated. This is obvious if we subtract the excessive third-space fluid weight of 15 kg from his total weight of 75 kg, resulting in a weight of 60 kg. Clearly, the difference between the “non-excess third-space fluid weight” of 60 kg and the estimated IBW of 59.2 kg is so small that the patient would not be considered clinically obese.

Likewise, when calculating an Adjusted Body Weight, it would be the patient’s weight minus any significant third-space fluid weight that would be used in Equation 7. The excessive third-space fluid weight may or may not be important to consider in making pharmacokinetic calculations. As an example, significant third-space fluid does contribute to the apparent volume of distribution for some drugs, but is unlikely to be an important contributor to volume of distribution if the apparent volume of distribution is large or if there is significant plasma protein binding.

Third-space fluid weight is unlikely to contribute to and should not be used when initial estimates of clearance are made. However, while not directly influencing clearance, it is possible that the presence of ascites or edema may indicate the presence of a disease process that is known to alter clearance.

TBW Significantly Smaller than IBW

Patients who weigh significantly less than their IBW or are emaciated also require special consideration when estimating renal function. While it may seem counterintuitive, a creatinine clearance calculated for an emaciated subject using the patient’s weight also tends to over predict the patient’s creatinine clearance. This is because patients who are emaciated tend to have a disproportionally greater loss in muscle mass than TBW. Consequently, serum creatinine in the denominator of Equation 3 and 4 decreases more than the weight in the numerator, resulting an overestimate of creatinine clearance. For this reason, if the patient’s actual weight is less than their IBW, the actual weight should be used when calculating creatinine clearance in emaciated subjects. Even then, the creatinine clearance is likely to be overestimated.

Low Serum Creatinine Level

In addition, it has been suggested that when serum creatinine values are < 1.0 mg/dL, more accurate predictions of creatinine clearance can be obtained if these levels are upwardly adjusted or normalized to a value of 1.0 mg/dL. This suggestion is based on the assumption that low serum creatinine values are related to small muscle mass and a decreased creatinine production rather than to an unusually large creatinine clearance. It is a common practice for clinicians to normalize serum creatinine values < 1 to 1 mg/dL. However, there is evidence suggesting that using the actual serum creatinine values of < 1 mg/dL result in more accurate estimates of creatinine clearance. Because of this continuing controversy and the difficulty in estimating creatine clearance accurately, it is important to use clinical judgement in evaluation the risk versus the benefit of drug therapy. When a serum creatinine of < 1mg/dL is used in Equation 3 and 4, most clinicians would recommend setting an upper limit for creatinine clearance. As an example, a 50-year-old man weighing 60 kg with a serum creatinine of 0.5 mg/dL would have a calculated creatinine clearance of 150 mL/min if the serum creatinine of 0.5 mg/dL is used. And a value of 75 mL/min if the serum creatinine is normalized to 1 mg/dL.

Even if the first method is used, many clinicians would suggest that an upper limit for a calculated creatinine clearance should be set at somewhere near 120 mL/min. Of course in specific situations (e.g., very large, non-obese, young healthy male patient), a creatinine clearance of more than 120 mL/min might be appropriate to consider. Therefore, whether to normalize a patient’s serum creatinine and whether there should be some upper limit for the calculated value of creatinine clearance should be dictated by clinical judgement rather than a specific rule.

Estimating Time to Reach a Steady-State Serum Creatinine Level

All the above methods for estimating ClCr require a steady-state serum creatinine concentration. When a patient’s renal function suddenly changes, some period of time will be required to achieve a new steady-state serum creatinine concentration. In this situation, it is important to be able to estimate how long it will take for the SCr to reach steady state. If a rising serum creatinine is used in any of the previous equations, the patient’s creatinine clearance will be overestimated.

As presented earlier, half-life is a function of both the volume of distribution and clearance. If the volume of distribution of creatinine (0.5 to 0.7 L/kg) is assumed to remain constant, the time required to reach 90% of steady state in patient with normal renal function is less than 1 day. As an example, the average 70-kg patient with a creatinine clearance of 120 mL/min (7.2 L/hr) with a volume of distribution for creatinine of 45.5 L (0.65 L/kg) would be expected to have a creatinine t1/2 of 4.4 hours.

Under these conditions, 90% of steady state should be achieved in approximately 15 hours (3.3 t1/2s). However, if the same patient had a creatinine clearance of 10 mL/min (0.6 L/min), the creatinine t1/2 would be 52.5 hours and more than a week would be required to ensure that steady state had been achieved. One useful approach, that helps clinicians to make relatively rapid assessments of SCr, is to remember that as a drug (in this case creatinine) concentration is accumulating toward steady state, half of the total change will occur in the first half-life. Therefore, two serum creatinine concentrations obtained several hours apart (8 to 12 hours) that appear to be similar (i.e., not increasing or declining significantly) and that represent reasonably normal renal function probably represent steady-state conditions. As renal function declines, proportionately longer intervals between creatinine measurements are required to assure that steady-state conditions exits.

In clinical practice, patients occasionally have a slowly increasing serum creatinine. As an example, a patient might have the following serum creatinine concentrations on 4 consecutive days: 1, 1.2, 1.6, and 1.8 mg/dL. First, it should be recognized that the increase in serum creatinine from day 1 to day 2 could be due to assay error alone, as the absolute error for most creatinine assays is +- 0.1 to 0.2 mg/dL. Also, given that the t1/2 of creatinine at concentrations in the range of 1 to 2 mg/dL is approximately 4 to 8 hours, steady state should have been achieved in the first day. Therefore, the continued increase in serum creatinine probably reflects ongoing changes in creatinine clearance over the 4 days. The difficult clinical issue is not what the creatinine clearance is on each of the 4 days, but rather what it will be tomorrow, what is the cause, and how to prevent or minimize the ongoing renal damage.

## Pharmacokinetics Series – Clearance and Maintenance Dose

Clearance and Maintenance Dose

Clearance can be thought of as the intrinsic ability of the body or its organs of elimination (usually the kidneys and the liver) to remove drug from the blood or plasma. Clearance is expressed as a volume per unit of time. It is important to emphasise that clearance is not an indicator of how much drug is being removed; it only represents the theoretical volume of blood or plasma which is completely cleared of drug in a given period. The amount of drug removed depends on the plasma concentration of drug and the clearance.

As steady state, the rate of drug administration (RA) and the rate of drug elimination (RE) must be equal, so that, RA = RE. Because RA can be described as (S)(F)(Dose/τ), and the RE equals to (Cl)(Css ave), we get the formula for Cl as Cl = (S)(F)(Dose/τ)/(Css ave) [Equation 1].

If an estimate for clearance is obtained from the literature, the clearance formula of [Equation 1] can be rearranged and used to calculate the rate of administration or maintenance dose that will produce a desired average plasma concentration of (Css ave) at steady state: Maintenance Dose = (Cl)(Css ave)(τ)/[(S)(F)] [Equation 2].

Attention must be paid that the units of all factors in these formulas must be consistent.

Factors Affecting Clearance

Body Surface Area/Weight

Most literature values for clearance are expressed as volume/kg/time or as volume/70 kg/time. There is some evidence, however, that drug clearance is best adjusted on the basis of BSA rather than weight. BSA can be calculated using BSA in m2 = (Patient’s Weight in kg/70 kg)0.7(1.73 m2) [Equation 3] or it can be obtained from various charts and nomograms. The value of a patient’s weight divided by 70 taken to the 0.7 power is an attempt to scale or size a patient as a fraction of the average 1.73 m2 or 70-kg individual. Weight divided by 70 taken to the 0.7 power has no units and should be thought of as the fraction of the average-size person.

As an example, a 7-kg patient has a weight ratio relative to 70 kg of 0.1 and, therefore, may be thought of as having a size and thus a metabolic and renal capacity that is one-tenth of the average 70-kg person (7 kg/70 kg = 0.1). If the same weight individual was compared to the 70-kg standard using weight to the 0.7 power, the ratio becomes 0.2 or 20%, (7 kg/70 kg)0.7 = 0.2. Therefore in these two examples, the difference between  0.1 and 0.2 is large. However, when patients do not differ significantly from 70 kg, the difference between using weight versus weight to the power 0.7 (BSA) becomes less significant.

The underlying assumption in using weight or surface area to adjust clearance is that the patient’s liver and kidney size (and hopefully function) vary in proportion to these physical measurements (weight or BSA). However, this may not always be the case; therefore, clearance values derived from the patient population having a similar age and size should be used whenever possible. When a patient’s size is substantially greater or less than the standard 70 kg, or 1.73 m2, a careful assessment should be made to determine if the patient’s body stature is normal, obese, or emaciated. In obese and emaciated patients, neither weight nor surface area is likely to be helpful in predicting clearance, since the patient’s body size will not reflect the size or function of the liver and kidney.

Plasma Protein Binding

For highly protein-bound drugs, diminished plasma protein binding is associated with a decrease in reported steady-state plasma drug concentrations (total of unbound plus free drug) for any given dose that is administered. According to Equation 1, a decrease in the denominator, (Css ave), increases the calculated clearance. This actually would be misleading, however, to assume that because the calculated clearance is increased, the amount eliminated of drug per unit of time has increased. Equation 1 assumes that when (Css ave) changes, the free drug concentration, which is available for metabolism and renal elimination, changes proportionately. In actuality the free or unbound fraction of drug in the plasma generally increases with diminished plasma protein binding. As a result, the amount of free drug eliminated per unit of time remains unchanged. This should be apparent if one considers that at steady state, the amount of drug administered per unit of time (RA) must equal the amount eliminated per unit of time (RE). If RA has not changed, RE must remain the same.

In summary, when the same daily dose of a drug is given in the presence of diminished protein binding, an amount equal to that dose will be eliminated from the body each day at steady state despite a diminished steady-state plasma concentration (Css ave) and an increase in the calculated clearance (Cl). This lower plasma concentration (C bound + C free) is associated with a decreased C bound, no change in C free, and as a result there is an increase in the fraction of unbound drug (fu). Therefore, the pharmacologic effect achieved will be similar to that produced by the higher serum concentration observed, under normal protein binding conditions. This example re-emphasizes the principle that clearance alone is not a good indicator of the amount of drug eliminated per unit of time (RE).

Extraction Ratio

The direct proportionality between calculated clearance and fraction unbound (fu) does not apply to drugs that are so efficiently metabolised or excreted that some (perhaps all) of the drug bound to plasma protein is removed as it passes through the elimination organ. In this situation the plasma protein acts as a “transport system” for the drug, carrying it to the eliminating organs, and clearance becomes dependent on the blood or plasma flow to the eliminating organ. To determine whether the clearance for a drug with significant plasma binding will be influenced primarily by blood flow or plasma protein binding, its extraction ratio is estimated and compared to its (fu) value.

The extraction ratio is the fraction of the drug presented to the eliminating organ that is cleared after a single pass through that organ. It can be estimated by dividing the blood or plasma clearance of a drug by the blood or plasma flow to the eliminating organ. If the extraction ratio exceeds the (fu), then the plasma proteins are acting as a transport system and clearance will not change in proportion to (fu). If, however, the extraction ratio is less than (fu), clearance is likely to increase by the same proportion that (fu) changes. This approach does not take into account other factors that may affect clearance such as red blood cell binding, elimination from red blood cells, or changes in metabolic function.

Renal and Hepatic Function

Drugs can be eliminated or cleared as unchanged drug through the kidney and by metabolism in liver. These two routes of clearance are assumed to be independent of one another and additive. A decrease in the function of an organ of elimination is most significant when that organ serves as the primary route of drug elimination. However, as the major elimination pathway becomes increasingly compromised, the “minor” pathway becomes more significant because it assumes a greater proportion of the total clearance. For example, a drug that is usually 67% eliminated by the renal route and 33% by the metabolic route will be 100% metabolised in the event of complete renal failure; the total clearance, however, will only be one-third of the normal value.

Cardiac Output

Cardiac output also affects drug metabolism. Hepatic or metabolic clearances for some drugs can be decreased by 25% to 50% in patients with CHD. For example, the metabolic clearances of theophylline and digoxin are reduced by approximately one-half in patients with CHD. Since the metabolic clearance for both of these drugs is much lower than the hepatic blood or plasma flow (low extraction ratio), it would not have been predicted that their clearances would have been influenced by cardiac output. The decreased cardiac output and resultant hepatic congestion must, in some way, decrease the intrinsic metabolic capacity of the liver.

## Adjust chemo dose in obese cancer patients

April 3, 2012 — Many obese patients are not receiving optimal doses of chemotherapy because oncologists are calculating doses on the basis of ideal body weight instead of actual body weight. This could compromise survival in the curative setting, say experts who have drawn up new guidelines for the American Society of Clinical Oncology (ASCO).

Cytotoxic chemotherapy (both oral and intravenous) should be calculated using the actual weight of obese cancer patients, especially when the goal of treatment is cure, according to the guidelines, which were published online April 2 in the Journal of Clinical Oncology.

Several studies of practice patterns have found that many obese cancer patients — up to 40% — are being undertreated by chemotherapy because oncologists are administering doses that are lower than what would be calculated from actual body weight. The most likely reasons for this are concerns about adverse effects and long-standing practice patterns.

The new guidelines should ease these fears, said Gary Lyman, MD, MPH, professor of medicine in the division of medical oncology at the Duke Cancer Institute, and cochair of the ASCO expert panel of authors.

“While a chemotherapy dose for an obese patient may be larger than some physicians are accustomed to, they can rest assured that the risk of toxicity associated with chemotherapy dosing based on actual body weight is no greater in obese patients than in nonobese patients with cancer,” he said in a statement.

The larger doses might lead to increased costs and insurance copays, and patients should be warned about this, the guidelines note.

“With the incidence of obesity at an all time high in the United States, as well as in other developed and developing nations, oncologists face this issue more than ever before,” said cochair Jennifer Griggs, MD, MPH, associate professor in internal medicine at the University of Michigan in Ann Arbor. The Centers for Disease Control and Prevention estimates that more than 60% of Americans are overweight, obese, or morbidly obese, the panel notes.

Dr. Griggs is also director of the breast cancer survivorship program at the University of Michigan’s Comprehensive Cancer Center. “There are compelling data in patients with breast cancer that reduced dose-intensity chemotherapy is associated with increased disease recurrence and intensity,” the authors write. Data in other cancers are more limited, but a dose–response relation exists for many responsive malignancies, they add.

Optimal doses of chemotherapy are usually calculated for a patient’s body surface area (BSA), which takes into account both weight and height. However, in practice, it appears that some oncologists are using an “adjusted ideal weight,” which is a compromise between a patient’s actual weight and their ideal weight. This can result in inadequate dosing of the chemotherapy, which could negatively affect clinical outcomes.

Any of the standard formulas for calculating BSA can be used, the panel explains. However, they were developed some time ago, and were not designed for use in obese patients and do not take into account the patient’s sex, the panel notes. Hence, there are ongoing efforts to establish a BSA equation that is suitable for a typical 21st-century population.

Dose Reductions Should Be Consistent

Dose reductions for adverse effects should be made consistently for all patients, the expert panel says. Physicians should follow the same guidelines for scaling back on chemotherapy because of severe adverse effects in both obese and nonobese patients.

There are certain exceptions to this, they note; certain chemotherapies have dose-limiting toxicities. They include vincristine and its potential for neuropathy, bleomycin and lung scarring, and carboplatin and the need to take kidney function into consideration.

Although there are few data, those that are available suggest that toxicity is similar in obese to nonobese cancer patients; in fact, some data suggest that myelosuppression might be less pronounced in obese patients.

One obvious limitation of the new guidelines is the lack of evidence from randomized clinical trials directly addressing the issue of weight-based dosing, the panel acknowledges. However, they add, “given the data that do exist, many consider deliberate random assignment of patients with responsive and potentially curable malignancies to lower and potentially less effective dose intensity to be unethical.”

The authors have disclosed no relevant financial relationships.

J Clin Oncol. Published online April 2, 2012. Abstract