title: Mild hypothermia alters midazolam pharmacokinetics in normal healthy volunteers.
abstract: The clinical use of therapeutic hypothermia has been rapidly expanding due to evidence of neuroprotection. However, the effect of hypothermia on specific pathways of drug elimination in humans is relatively unknown. To gain insight into the potential effects of hypothermia on drug metabolism and disposition, we evaluated the pharmacokinetics of midazolam as a probe for CYP3A4/5 activity during mild hypothermia in human volunteers. A second objective of this work was to determine whether benzodiazepines and magnesium administered intravenously would facilitate the induction of hypothermia. Subjects were enrolled in a randomized crossover study, which included two mild hypothermia groups (4 degrees C saline infusions and 4 degrees C saline + magnesium) and two normothermia groups (37 degrees C saline infusions and 37 degrees C saline + magnesium). The lowest temperatures achieved in the 4 degrees C saline + magnesium and 4 degrees C saline infusions were 35.4 +/- 0.4 and 35.8 +/- 0.3 degrees C, respectively. A significant decrease in the formation clearance of the major metabolite 1'-hydroxymidazolam was observed during the 4 degrees C saline + magnesium compared with that in the 37 degrees C saline group (p < 0.05). Population pharmacokinetic modeling identified a significant relationship between temperature and clearance and intercompartmental clearance for midazolam. This model predicted that midazolam clearance decreases 11.1% for each degree Celsius reduction in core temperature from 36.5 degrees C. Midazolam with magnesium facilitated the induction of hypothermia, but shivering was minimally suppressed. These data provided proof of concept that even mild and short-duration changes in body temperature significantly affect midazolam metabolism. Future studies in patients who receive lower levels and a longer duration of hypothermia are warranted.
authors.affiliation: Department of Emergency Medicine, Emergency Responder Human Performance Laboratory, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
authors.forename: David
authors.initials: D
authors.lastname: Hostler
authors.forename: Jiangquan
authors.initials: J
authors.lastname: Zhou
authors.forename: Michael A
authors.initials: MA
authors.lastname: Tortorici
authors.forename: Robert R
authors.initials: RR
authors.lastname: Bies
authors.forename: Jon C
authors.initials: JC
authors.lastname: Rittenberger
authors.forename: Philip E
authors.initials: PE
authors.lastname: Empey
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Kochanek
authors.forename: Clifton W
authors.initials: CW
authors.lastname: Callaway
authors.forename: Samuel M
authors.initials: SM
authors.lastname: Poloyac
mesh_terms: D000328:Adult; D019540:Area Under Curve; D001831:Body Temperature / Q000187:drug effects; D003198:Computer Simulation; D018592:Cross-Over Studies; D051544:Cytochrome P-450 CYP3A / Q000378:metabolism; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D007035:Hypothermia / Q000139:chemically induced / Q000378:metabolism*; D007262:Infusions, Intravenous; D008278:Magnesium Sulfate / Q000008:administration & dosage / Q000494:pharmacology; D008297:Male; D008874:Midazolam / Q000031:analogs & derivatives / Q000378:metabolism / Q000493:pharmacokinetics*; D008954:Models, Biological; D010599:Pharmacokinetics; D012965:Sodium Chloride / Q000008:administration & dosage / Q000494:pharmacology; D013696:Temperature; D055815:Young Adult
chemical_list: D012965:Sodium Chloride; D008278:Magnesium Sulfate; C040081:1-hydroxymethylmidazolam; D051544:Cytochrome P-450 CYP3A; D008874:Midazolam