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`EXHIBIT 1039, Petitioner TWi
`IPR2023-00049, -00050
`
`

`

`1 Graw-Hill
`
`wH1U
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`man and G1lm n' TH PH
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`2001 19%, 1990 19 5 1980, 1975, 1970 196 . 19 5, 1941 b The
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`Goodman and G Iman
`the phllnTUIC lo I
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`Joel G Hardman Lee I
`llred Goodman Gilman
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`2001030728
`
`EXHIBIT 1039, Petitioner TWi
`IPR2023-00049, -00050
`
`

`

`20
`
`icld, an l' pn:,,ion l01 clc1111111cc
`the 1)1 •,II\ of chmirn111011. C 1,
`th' 01 ',Ill 111 quc,111rn
`()I th drug h
`
`l fll~<lll = <J l
`
`(' I
`
`]
`
`Q
`
`l:.
`
`( I 8)
`
`1 111 l·quatnm ( I 8) can be ,ere, red
`,
`Th' ' P''-'''11)11 l
`1 )
`the c,tr,1ct1on r,1t10 tor the drug (E).
`h ) a
`
`qua(cid:173)
`learance. The concept, developed in
`~ patk
`twn ~ 1-, ) have important implications for drugs that are
`the liver. on,idcr a drug that is efficiently
`eliminated b
`removed from the blood by hepatic processe ·- metaboli sm
`and/or ex retion of drng into the bile. ln thi s in ·tance, the
`concentration of drug in the blood leaving the liver will
`be lO\\, the extraction ratio will approach unity, and the
`clearance of the drug from blood will become limited by
`that are cleared efficiently by
`hepatic blood flow. Drug
`the liver (e.g., drug. in Appendix II with y temic clear(cid:173)
`ance greater than 6 ml• min- 1 • kg- 1, such a diltiazem,
`imipramine, lidocaine, morphine, and propranolol) are re(cid:173)
`stricted in their rate of elimination, not by intrahepatic
`proce e , but by the rate at which they can be transported
`in the blood to the liver.
`
`Additional complexities also have been con idered. For ex(cid:173)
`ample, the equation presented above do not account for dru~
`binding to components of blood and tis ues, nor do they permit
`an e timation of the intrinsic ability of the liver to eliminate a
`drug in the absence of limitations imposed by blood flow, termed
`intrinsic clearance. In biochemical terms and under first-order
`conditions, intrinsic clearance is a measure of the ratio of the
`Michaelis-Menten kinetic parameters for the eliminating pro(cid:173)
`cess, i.e., v,,./K,,.. Extensions of the relationships of Equation
`(1-8) to include expressions for protein binding and intrinsic
`clearance have been proposed for a number of models of he(cid:173)
`patic elimination (see Morgan and Small~ood, 199~)- _All _ of
`these models indicate that, when the capacity of the elt,rnnaung
`organ to metabolize the drug is large in comparison with the rate
`of presentation of drug, clearance will approximate the organ'
`blood flow. In contrast, when the metabolic capability is small
`in comparison to the rate of drug presentation, clearance will be
`proportional to the unbound fraction of drug in blood and the
`drug's intrinsic clearance. Appreciation of these concepts allows
`uoder&tanding of a number of possibly puzzling experimental
`results For example, enzyme induction or hepatic di ease may
`cbao,e ,_ ,:ate of drug metabolism in an isolated hepatic mi(cid:173)
`system but not change ~learan_ce in the who(e
`a dnlg with a high extracuon ratio, clearance 1s
`ftow, and changes in intrinsic clearance due
`mit'af'<livl-.m
`or hepatic disease should have lillle effect.
`s·
`wi•11159 with high extraction ratios, changes in pro-
`tei DIIIUll&A•J..111 cli&eaSC or competitive binding interaction,
`should uv, illNl!ll'4',_..,. on clearance. In contrast, changes in in(cid:173)
`trinsic c ~ ,ad protein binding will affect the clearance of
`drugs with low intriJJsic clearances and, thus, extraction ratio,,
`but changes in blood flow should have little effect (Wilkinson
`and Shand, 1975).
`
`learance of a drug results in
`I
`• h
`Rena c
`the urine; changes mt e pharrna-
`.
`' lcuru11cc,
`1
`I( ,
`I
`I d '
`s
`1111
`. such rn
`,sea e a so may
`due to rena
`11ncuruncc LIS
`.
`H
`. s of drugs
`,,., u ,,
`f clearance concepts. owever, the
`.
`cokinctic propcrtrc.
`t'
`I • terms O
`•
`filtration, active secre ion, and
`t
`• ,
`be cxplaine( 1n
`that relate O
`•
`f filt
`•
`ration of
`'derecL The rate o
`Co ,r1nlicutt0ns
`•
`t be const
`"
`rcabsorption mus n the volume of fluid tha~ is filtered in
`bound concentrat10n of drug in
`0 drug depends O
`filt eel
`lus and the un
`•
`• The
`•
`er
`d to protem ts not
`the glomeru
`lasma, since drug bdoun by the Jcidney will depend on
`•
`rug
`of
`•
`P
`ce by the transporters mvolvec1
`rate of secretton.
`, b' d'
`d
`• t ins1c clearan
`'
`rug s m mg to
`ffected by the
`.
`the drug s in r
`in active sec~etionh;sd:gree of saturation of these trans(cid:173)
`f delivery of the drug to the secretory
`plasma proteins, t
`orters, and the rate O
`es 1·nvolved in drug reabsorption
`.
`d. •
`process
`P
`st be considered. The influence
`'d
`site. In ad ttJOn,
`from the tubular flu~ mb_u di'ng blood flow, and the num-
`rotein 10
`•
`'
`hrons are analogous to the example
`of changes ~n P
`r ·nation
`ber of functt0nal nep .
`•
`given above for hepattc e ,mi
`
`0
`
`Distribution
`'b t·on Volume is a second fundamen-
`.
`Volume of Dtstn u 1
`•
`.
`•
`that is u eful in cons1denng proce es of
`I
`(V)
`•
`-
`.
`tal parameter
`re ates
`The volume of d1stnbut10n
`. .
`.
`•
`druo d1spos1t1o n.
`f dru o in the body to the concentration of
`•
`the amount o
`o
`drug (C) in the blood or pla ma, dependmg ~pon the
`fluid mea ured. This volume doe not nece anly refer
`to an identifiable phy iological volume, but merely to the
`fluid volume that would be required to contain all of the
`in the blood
`drug in the body at the ame concentration a
`or plasma:
`
`(l-9)
`
`V = a mo unt of drug in body/ C
`the ex(cid:173)
`A drug' volume of distribution, therefore. reflect
`tent to which it i pre ent in extrava cular ti ue . The plasma
`volume of a typical 70-kg man i 3 liters, blood volume 1
`about 5.5 liters, extracellular fluid volume out ·ide the pla ·ma i
`12 liters, and the volume of total body water 1s approximately
`42 liters. However, many drug exhibit volumes ot distribution
`far in excess of the e value . For example, if 500 µg ot digoxin
`were in the body of a 70-kg ubject, a plasma conl·entration
`of approximately 0.75 ng/ml would be observed. Dividing the
`amount of drug in the body by the plasma concentrntion yields
`a volume of distribution for digoxm ot about 6 -o litc:r-,, or a
`value almost ten times greater than the total body volume of
`a 70-kg man. In fa t, digoxin di,tribute, preferentially to mus•
`cle and adipo e tissue and to its specific n:ccptors, leaving a
`that are
`very small amount of dmg m the plasma. For drug
`ext~n,1vel) bound to plasma protein, but that arc not bound
`lo llss~e component\, the \'Olume of di,1ribu11on \\ 111 approach
`that ol the plasma volume In contrast, certain drug h:ne high
`111 the
`volumes of d1stribu11on even though mo,t of the dni
`
`EXHIBIT 1039, Petitioner TWi
`IPR2023-00049, -00050
`
`

`

`- ~ - - - - - - --
`
`- --- -- -- -- - --
`
`CHAPTER 1 PHARMACOKL\IETICS
`
`21
`
`/"2/c~
`V = Dose I C 0
`' '
`p
`
`'O
`
`'
`
`----------~-------
`
`t112
`
`I
`I
`
`I
`I
`I
`
`I
`I
`I•
`I
`
`0
`
`2
`
`4
`
`6
`8
`TIME (hours)
`
`10
`
`12
`
`c~ = 31
`
`1112
`
`Figure 1-4. Plasma conce11tr atio11-time curves Jollowillg · _
`•
`d • •
`,I'
`Ill
`I
`ravenous a 1111111stratw11 OJ a drug (500 mg) to a 70-kg ma11.
`~· ln this example, drug concentrations arc measured
`1n plasma from 2 hours after the dose is a<lministercd.
`The semilogarithmic plot of plasma concentration versus
`trni~ appears to indicate that the drug is eliminate<l from
`a single compartment by a first-order process [Equation
`(1-IO)] with a ha(f.Jifc of 4 hours (k = 0.693/1 112 =
`0. 17~ h- 1
`). The volume of <listribution (V) may be de(cid:173)
`tenmned from the value of Cp obtained by extrapolation
`1? 1 = 0 (q = I 6 µg/ml) . Volume of distribution [Equa(cid:173)
`tion (1-9)] for the one-comportment model is 31.3 liters
`or 0.~S liter/kg (V = dosc/Cp). The clearance for this
`drug 1s 90 ml/min; for none-compartment model, Cl=
`kV. Il. Sampling before 2 hours indicates that, in fnct,
`t~e dru~ follows multiexponential kinetics. The terminal
`d1spos1_t1on half-life is 4 hours, clearance is 84 ml/min
`~Equat10_n (1-5)~. Va,," is 29 liters [Equation (1-11)],
`and V" 1s 26.8 liters. The initial or "central" distribution
`volume for the drug <V1=dose/C,n is 16. 1 liters. The
`example chosen indicates that multicompartment kinetics
`may be overlooked when sampling at early tunes is ne•
`? lected. In this particular case, there is only a I 0% error
`in the estimate of clearance when the multicompartment
`characteristics are ignored. For many drugs multicom(cid:173)
`partmen_t kinetics ~1ay be observed for significant peri(cid:173)
`ods of time, and failure to consider the distribution phase
`can lead to significant errors in estimates of clearance
`and in predictions of the appropriate dosage. Also, the
`difference between the "central" distribution volume and
`other terms reflecting wider distribution is important in
`deciding a loading dose strategy.
`
`in a first-order fashion, as defined in Equation (1-3); that
`is, the amount of drug eliminated per unit of time de(cid:173)
`pends on the amount (concentration) of drug in the body
`compartment. Figure 1-4A and Equation (I-JO) describe
`the decline of plasma concentration with time for a drug
`introduced into this compartment.
`C = (dose/ V) • exp(-kt)
`
`(1-10)
`
`where k is the rate constant for elimination that reflects
`the fraction of drug removed from the compartment per
`unit of time. This rate constant is inversely related to the
`half-life of the drug (k = 0.693/t112),
`idealized one-compmtment model discussed
`The
`above does not describe the entire time course of the
`plasma concentration. That h,, certain tissue reservoirs can
`be distinguished from the central compartment, and the
`drug concentration appears to decay in a manner that can
`be described by multiple exponential terms (see Figure
`is
`the one-compartment ml>del
`l-4B). Nevertheless,
`sufficient to apply to most clinic,tl situations for most
`drugs.
`
`A
`z
`0
`i=
`<(
`a:
`I-
`z
`w
`(.) z:::::-
`OE
`o o,
`(!) 3
`:::) a:
`0
`<(
`~
`Cl)
`5
`
`0..
`
`32
`
`16
`
`8
`
`4
`
`2
`
`B
`z
`0
`~ 16
`a:
`I-z
`w
`(.)
`z=
`OE Oo,
`(!) 3
`::,
`a:
`0
`<(
`2
`Cl)
`5
`
`32
`
`8
`
`4
`
`2
`
`0..
`
`1
`
`0
`
`2
`
`4
`
`8
`6
`TIME (hours)
`
`10
`
`12
`
`circulation is bound to albumin, because these drugs are also
`sequestered elsewhere.
`
`The volume of distribution may vary widely depend(cid:173)
`ing on the relative degrees of binding to plasma and tissue
`proteins, the partition coefficient of the drug in fat, and so
`forth. As might be expected, the volume of distribution for
`a given drug can differ according to patient's age. gender,
`body composition, and presence of disease.
`Several volume terms commonly are used to describe
`drug distribution, and they have been derived in a number
`of ways. The volume of distribution defined in Equation
`0-9) considers the body as a single homogeneous com(cid:173)
`partment. Jn this one-comparm1ent model, all drug admin(cid:173)
`istration occurs directly into the central compartment and
`distribution of drug is instantaneous throughout the vol(cid:173)
`ume (V) . Clearance of drug from this compartment occurs
`
`EXHIBIT 1039, Petitioner TWi
`IPR2023-00049, -00050
`
`