Pharmacotoxicology entails the study of the consequences of

toxic Toxicity is the degree to which a chemical substance or a particular mixture of substances can damage an organism. Toxicity can refer to the effect on a whole organism, such as an animal, bacterium, or plant, as well as the effect on a sub ...

exposure to

pharmaceutical A medication (also called medicament, medicine, pharmaceutical drug, medicinal drug or simply drug) is a drug used to diagnose, cure, treat, or prevent disease. Drug therapy ( pharmacotherapy) is an important part of the medical field and ...

drug A drug is any chemical substance that causes a change in an organism's physiology or psychology when consumed. Drugs are typically distinguished from food and substances that provide nutritional support. Consumption of drugs can be via inhala ...

s and agents in the

health care Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health pr ...

field. The field of pharmacotoxicology also involves the treatment and prevention of pharmaceutically induced

side effects In medicine, a side effect is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse effects, it can also apply to beneficial, but unintended, consequenc ...

. Pharmacotoxicology can be separated into two different categories:

pharmacodynamics Pharmacodynamics (PD) is the study of the biochemical and physiologic effects of drugs (especially pharmaceutical drugs). The effects can include those manifested within animals (including humans), microorganisms, or combinations of organisms ...

(the effects of a drug on an organism), and

pharmacokinetics Pharmacokinetics (from Ancient Greek ''pharmakon'' "drug" and ''kinetikos'' "moving, putting in motion"; see chemical kinetics), sometimes abbreviated as PK, is a branch of pharmacology dedicated to determining the fate of substances administered ...

(the effects of the organism on the drug).

Mechanisms of Pharmaceutical Drug Toxicity

There are many mechanisms by which pharmaceutical drugs can have toxic implications. A very common mechanism is covalent binding of either the drug or its metabolites to specific enzymes or receptor in tissue-specific pathways that then will elicit toxic responses. Covalent binding can occur during both on-target and off-target situations and after

biotransformation Biotransformation is the biochemical modification of one chemical compound or a mixture of chemical compounds. Biotransformations can be conducted with whole cells, their lysates, or purified enzymes. Increasingly, biotransformations are effected w ...

On-target toxicity.

On-target toxicity is also referred to as mechanism-based toxicity. This type of adverse effect that results from pharmaceutical drug exposure is commonly due to interactions of the drug with its intended target. In this case, both the therapeutic and toxic targets are the same. To avoid toxicity during treatment, many times the drug needs to be changed to target a different aspect of the illness or symptoms.

Statins Statins, also known as HMG-CoA reductase inhibitors, are a class of lipid-lowering medications that reduce illness and mortality in those who are at high risk of cardiovascular disease. They are the most common cholesterol-lowering drugs. Low ...

are an example of a drug class that can have toxic effects at the therapeutic target (

HMG CoA reductase HMG-CoA reductase (3-hydroxy-3-methyl-glutaryl-coenzyme A reductase, official symbol HMGCR) is the rate-controlling enzyme (NADH-dependent, ; NADPH-dependent, ) of the mevalonate pathway, the metabolic pathway that produces cholesterol and o ...

Immune Responses

Some pharmaceuticals can initiate allergic reactions, as in the case of

penicillins Penicillins (P, PCN or PEN) are a group of β-lactam antibiotics originally obtained from ''Penicillium'' moulds, principally '' P. chrysogenum'' and '' P. rubens''. Most penicillins in clinical use are synthesised by P. chrysogenum using ...

. In some people, administration of penicillin can induce production of specific antibodies and initiate an immune response. Activation of this response when unwarranted can cause severe health concerns and prevent proper immune system functioning. Immune responses to pharmaceutical exposure can be very common in accidental contamination events.

Tamoxifen Tamoxifen, sold under the brand name Nolvadex among others, is a selective estrogen receptor modulator used to prevent breast cancer in women and treat breast cancer in women and men. It is also being studied for other types of cancer. It has b ...

, a

selective estrogen receptor modulator Selective estrogen receptor modulators (SERMs), also known as estrogen receptor agonist/antagonists (ERAAs), are a class of drugs that act on the estrogen receptor (ER). A characteristic that distinguishes these substances from pure ER agonists ...

, has been shown to alter the humoral adaptive immune response in gilthead seabream. In this case, pharmaceuticals can produce adverse effects not only in humans, but also in organisms that are unintentionally exposed.

Off-target toxicity

Adverse effects at targets other than those desired for pharmaceutical treatments often occur with drugs that are nonspecific. If a drug can bind to unexpected proteins, receptors, or enzymes that can alter different pathways other than those desired for treatment, severe downstream effects can develop. An example of this is the drug eplerenone (aldosterone receptor antagonist), which should increase aldosterone levels, but has shown to produce atrophy of the prostate.

Bioactivation

Bioactivation Activation, in chemistry and biology, is the process whereby something is prepared or excited for a subsequent reaction. Chemistry In chemistry, "activation" refers to the reversible transition of a molecule into a nearly identical chemical or ...

is a crucial step in the activity of certain pharmaceuticals. Often, the parent form of the drug is not the active form and it needs to be metabolized in order to produce its therapeutic effects. In other cases, bioactivation is not necessarily needed for drugs to be active and can instead produce reactive intermediates that initiate stronger adverse effects than the original form of the drug. Bioactivation can occur through the action Phase I metabolic enzymes, such as

cytochrome P450 Cytochromes P450 (CYPs) are a superfamily of enzymes containing heme as a cofactor that functions as monooxygenases. In mammals, these proteins oxidize steroids, fatty acids, and xenobiotics, and are important for the clearance of various co ...

or peroxidases. Reactive intermediates can cause a loss of function in some enzymatic pathways or can promote the production of

reactive oxygen species In chemistry, reactive oxygen species (ROS) are highly reactive chemicals formed from diatomic oxygen (). Examples of ROS include peroxides, superoxide, hydroxyl radical, singlet oxygen, and alpha-oxygen. The reduction of molecular oxygen () p ...

, both of which can increase stress levels and alter homeostasis.

Drug-drug interactions

Drug-drug interactions can occur when certain drugs are administered at the same time. Effects of this can be additive (outcome is greater than those of one individual drug), less than additive (therapeutic effects are less than those of one individual drug), or functional alterations (one drug changes how another is absorbed, distributed, and metabolized). Drug-drug interactions can be of serious concern for patients who are undergoing multi-drug therapies. Coadministration of

chloroquine Chloroquine is a medication primarily used to prevent and treat malaria in areas where malaria remains sensitive to its effects. Certain types of malaria, resistant strains, and complicated cases typically require different or additional medi ...

, an anti-malaria drug, and statins for treatment of cardiovascular diseases has been shown to cause inhibition of

organic anion-transporting polypeptide Members of the Organo Anion Transporter (OAT) Family (organic-anion-transporting polypeptides, OATP) are membrane transport proteins or 'transporters' that mediate the transport of mainly organic anions across the cell membrane. Therefore, OATPs ...

s (OATPs) and lead to systemic statin exposure.

Pharmacotoxicity Examples

There are many different pharmaceutical drugs that can produce adverse effects after biotransformation, interaction with alternate targets, or through drug-drug interactions. All pharmaceuticals can be toxic, depending on the dose.

Acetaminophen

Acetaminophen Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...

(APAP) is a very common drug used to treat pain. High doses of acetaminophen has been shown to produce severe

hepatotoxicity Hepatotoxicity (from ''hepatic toxicity'') implies chemical-driven liver damage. Drug-induced liver injury is a cause of acute and chronic liver disease caused specifically by medications and the most common reason for a drug to be withdrawn fr ...

after being biotransformed to produce reactive intermediates. Acetaminophen is metabolized by CYP2E1 to produce

NAPQI NAPQI, also known as NAPBQI or ''N''-acetyl-''p''-benzoquinone imine, is a toxic byproduct produced during the xenobiotic metabolism of the analgesic paracetamol (acetaminophen). It is normally produced only in small amounts, and then almost imme ...

, which then causes significant oxidative stress due to increased

(ROS). ROS can cause cellular damage in a multitude of ways, a few of which being DNA and mitochondrial damage and depletion of antioxidant enzymes such as

glutathione Glutathione (GSH, ) is an antioxidant in plants, animals, fungi, and some bacteria and archaea. Glutathione is capable of preventing damage to important cellular components caused by sources such as reactive oxygen species, free radicals, pe ...

. In terms of drug-drug interactions, acetaminophen activates CAR, a nuclear receptor involved in the production of metabolic enzymes, which increases the metabolism of other drugs. This could either cause reactive intermediates/drug activity to persist for longer than necessary, or the drug will be cleared quicker than normal and prevent any therapeutic actions from occurring. Ethanol induces CYP2E1 enzymes in the liver, which can lead to increased NAPQI formation in addition to that formed by acetaminophen.

Aspirin

Aspirin is an

NSAID Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...

used to treat inflammation and pain. Overdoses or treatments in conjunction with other NSAIDs can produce additive effects, which can lead to increased oxidative stress and ROS activity. Chronic exposure to aspirin can lead to CNS toxicity and eventually affect respiratory function.

Anti-depressants

Anti-depressants have been prescribed since the 1950s, and their prevalence has significantly increased since then. There are many classes of anti-depressant pharmaceuticals, such as

selective serotonin reuptake inhibitors Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs increase the extracellul ...

(SSRIs),

monoamine oxidase inhibitors Monoamine oxidase inhibitors (MAOIs) are a class of drugs that inhibit the activity of one or both monoamine oxidase enzymes: monoamine oxidase A (MAO-A) and monoamine oxidase B (MAO-B). They are best known as effective antidepressants, espec ...

(MAOIs), and tricyclic anti-depressants. Many of these drugs, especially the SSRIs, function by blocking the metabolism or reuptake of neurotransmitters to treat depression and anxiety. Chronic exposure or overdose of these pharmaceuticals can lead to seratonin and CNS hyperexcitation, weight changes, and, in severe cases, suicide.

Anti-cancer drugs

Doxorubicin Doxorubicin, sold under the brand name Adriamycin among others, is a chemotherapy medication used to treat cancer. This includes breast cancer, bladder cancer, Kaposi's sarcoma, lymphoma, and acute lymphocytic leukemia. It is often used toge ...

is a very effective anti-cancer drug that causes congestive heart failure while treating tumors. Doxorubicin is an uncoupling agent in that it inhibits proper functioning of complex I of the electron transport chain in mitochondria. It then leads to the production of ROS and the inhibition of ATP production. Doxorubicin has been shown to be selectively toxic to cardiac tissue, although some toxicity has been seen in other tissues as well. Other anti-cancer drugs, such as fluoropyrimidines and

taxanes Taxanes are a class of diterpenes. They were originally identified from plants of the genus ''Taxus'' (yews), and feature a taxadiene core. Paclitaxel (Taxol) and docetaxel (Taxotere) are widely used as chemotherapy agents. Cabazitaxel was FDA a ...

, are extremely effective at treating and reducing tumor proliferation, but have high incidences of cardiac arrhythmias and myocardial infarctions.

References

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External links

PsychRights.org
- 'Psychiatric Polypharmacy: A Word of Caution', Leslie Morrison, MS, RN, Esq, Paul B. Duryea, Charis Moore, Alexandra Nathanson-Shinn, Stephen E. Hall, MD, James Meeker, PhD, DABFT, Charles A. Reynolds, PharmD, BCPP, Protection & Advocacy, Inc. Pharmacology Pharmacy Toxicology