Nonlinear kinetics and pharmacologic response to mibefradil

Background Increasing oral doses of mibefradil (10 to 320 mg) decrease its apparent oral clearance; however, intravenous doses up to 80 mg do not reduce its systemic clearance. This study aimed to understand the mechanisms underlying the zero‐order kinetics of mibefradil. Methods A group of 10 normotensive volunteers received 50 mg/day oral mibefradil for 8 days and, on days 1 and 8, 5 mg deuterated mibefradil by infusion. Ten additional volunteers observed the same protocol with a daily oral dose of 100 mg mibefradil. Serial blood samples were withdrawn, and mibefradil plasma concentrations were assayed by liquid chromatography–mass spectrometry. Blood pressure and heart rate were measured for 4 hours, and an ECG was performed 2 hours after drug administration. Results Repeated oral administration of 50 mg mibefradil generated zero‐order kinetics secondary to a decrease in mibefradil systemic clearance. Compared with the 50‐mg dose, single and repeated oral doses of 100 mg further decreased mibefradil clearance. Mibefradil bioavailability was not affected by increasing mibefradil doses. Mean diastolic blood pressure was decreased by single and repeated doses of 100 mg to the same extent. Repeated doses of 100 mg reduced heart rate and prolonged the PR and QTc, changes that were associated with mibefradil plasma concentrations. Conclusions Repeated doses of 50 mg or doses of 100 mg mibefradil generated zero‐order kinetics secondary to a decrease in hepatic extraction of the drug. Zero‐order kinetics did not affect the response‐concentration relationship of mibefradil. (Clin Pharmacol Ther 2000;67:249–57.) Clinical Pharmacology & Therapeutics (2000) 67, 249–257; doi: 10.1067/mcp.2000.104616