Chronopharmacokinetics: implications for drug treatment

Nearly all functions of the human body are organized across the 24 hours of the day. This is also true for functions involved in the regulation of pharmacokinetics such as gastric absorption and emptying, gastro-intestinal perfusion, and liver and kidney functions. Several clinical studies, performed in a cross-over design, have provided evidence that the pharmacokinetics of mainly lipophilic drugs can be circadian phase-dependent. These studies show that after oral dosing, peak drug concentration (Cmax) is, in general, higher or time-to-peak (tmax) shorter after morning, compared with evening application. A few studies performed with both immediate-release and sustained-release preparations (isosorbide-5-mononitrate, nifedipine) gave evidence that only the immediate-release formulation displayed circadian time-dependent pharmacokinetics, but not the sustained-release form. Most importantly, pharmacodynamic studies performed in parallel revealed that the effects, as well as the dose-response relationship, can be circadian phase-dependent, an observation which has an impact on pharmacokinetic/pharmacodynamic modelling. Moreover, this can be of relevance because the onset of certain diseases (e.g., bronchial asthma, coronary infarction, angina pectoris, rheumatic complaints) is not randomly distributed across the 24-h scale. In conclusion, there is now convincing evidence that the time-of-day has to be taken into account both in clinical pharmacokinetic and pharmacodynamic studies.