Journal of University of Shanghai for Science and Technology ISSN: 1007-6735

Review: Chronopharmacology; A Biological Rhythm

1 2 3 4
Pooja P. Dahale * , Vijay R. Chakote , Siddesh V Rokade , Shrikant C. Bhosale

Department of Pharmaceutics

Mr. Vijay R. Chakote 2, SVERI College of pharmacy, Pandharpur, Maharashtra, India

B.Pharmacy Final year Students

3 4
Siddesh V Rokade , Shrikant C. Bhosale , Indrayani Institute of Pharmaceutical Education &

Research, Talegaon dabhade, Pune

Corresponding author

Pooja P. Dahale

Lecturer, MCP, Nilanga, Latur Maharashtra

EmailId:vijayrchakote@gmail.com

ContactNo.9970747432

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1.Introduction;

Chronopharmacology is the study of how the effects of drugs vary with biological timing and

endogenous periodicities.

The goal is to improve our understanding of periodic and thus predictable (e.g. circadian)

changes in both desired effects (chronoeffectiveness) and tolerance (chronotolerance) of

medications. Dosing time-dependent changes also include quantification of parameters

characterizing endogenous circadian rhythms (CR), in terms of pharmacologic effects, e.g. the

24-h adjusted mean (M), the period , the amplitude (A, the peak-to-trough difference), and the

acrophase , the peak time location in the 24-h scale). Chronopharmacology became recognized

as a scientific domain of investigation only in the early 1970s. For conventionally trained

pharmacologists, it was not clear that predictable temporal variations of effects and disposition

of agents (e.g. medications, hormones, and toxic substances) are governed by endogenous

biological rhythms rather than by changes of external factors. On the 24-h scale (as well as on

the yearly scale) there are peaks and troughs of physiological variables that are not randomly

distributed; their respective locations correspond to a temporal organization controlled by a set

of pacemakers (so-called biological clocks) became recognized as a scientific domain of

investigation only in the early 1970s.

2. CONCEPT OF CHRONOPHARMACOLOGY:

CHRONOKINETICS;

Chronokinetics are defined as dosing time-dependent and predictable (rhythmic) changes in

parameters used to characterize the pharmacokinetics (or the bioavailability) of a drug, e.g.

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maximum concentration (Cmax), span of time to reach Cmax (tmax), area under the

concentration-time-curve (AUC), and half-life.

Chronokinetics of certain drugs may involve changes from a mono- to a multicompartmental

model as a function of drug dosing time. Chronokinetics of drugs have been validated for many

animal species including humans, with both acute and chronic administration even for sustained

release having a half-life long as 84 h.

Fig; Chronokinetics

2.1 Mechanisms Underlying Chronokinetic Changes;

With related to physical properties of drugs (e.g. hydrophilicity, lipophilicity, and solubility),

circadian changes in biosystems have been explored and even modulated with regard to their

absorption (e.g. speed of gastric emptying and intake from gut, lung, and skin), distribution

(e.g., blood flow through an organ and binding capacity of plasma proteins) metabolic rates

relative to liver functions, and excretion relative to kidney functions (e.g. glomerular filtration,

tubular reabsorption, and urinary pH).Proper mathematical formulas have been used to calculate

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the absorption and excretion rate constants, the clearance, and the volume of distribution from

pharmacokinetic data to validate dosing time-related changes.

3.MECHANISM OF CHRONOPHARMACOLOGY;

The basic unit of circadian timekeeping is the cell. Even in very complex organisms, most cells

contain autonomous circuitry for circadian oscillations.

Generally speaking, this mechanism is comprised of negative feedback loops of transcription

and translation: activation of a repressor gene results in its later repression by its own protein

product, and the instability of this repressor insures this repression is short lived, so that a new

cycle can begin.

 In mammals, the principal activators within this system are the CLOCK and BMAL1

proteins and their homolog, which dimerize and bind to certain elements to activate

transcription of a large number of circadian genes.

 Among these circadian genes are loci encoding the PERIOD and CRYPTOCHROME

families of repressor proteins (PER1-3 and CRY1-2), whose products multimerize and

suppress the CLOCK.

BMAL1 activating complex;

At each of these steps, additional precision and regulatory finesse is achieved through

interaction with a wide range of auxiliary proteins: kinases that phosphorylate clock proteins to

modify their stability or activity.

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An example of this is seen in how evening doses of antihypertensive therapy can be used to

prevent morning rises in blood pressure. The evening dose of the drug may thus be well timed

with diurnal changes in blood pressure, preventing diurnal worsening of hypertension.

4.BIOLOGICAL RHYTHM;

Chronobiology

Science that studies the biological rhythms or the science dealing with phenomenon of

rhythmicity in living organisms.

4.1 CIRCADIAN RHYTHMS OF LIVER ENZYMES

Radzialowski&Bousquetdemonstrated CR in hepatic drug-metabolizing enzymes of rodents.

Temporarily variations of various oxidative reactions catalyzed by the monoxygenase system

have been reported for substrates such as aminopyrine,paranitroanisole, hexobarbital and 4-

dimethyaminobenzene, aniline, benzphetamine,benzpyrene, imipramine, etc.

The oxidative reaction was peaking in the middle of the (nocturnal) activity span. Moreover, it

has also been demonstrated that CR of corticosterone adrenal secretion control CR of involved

enzymes.

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Fig; Circadian rhythms of liver

4.2 CIRCADIAN RHYTHMS IN PLASMA PROTEIN BINDING OF

DRUGS

The phenomenon of CR in plasma protein binding of drugs was first demonstrated for cortisol

and thereafter for its synthetic analogs CR in plasma total proteins, albumin, globulins, etc,

related to liver activity, induces circadian changes in the (active) fraction of drugs and

hormones.

.For example; A normal circadian rhythm of plasma corticosterone given as;

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Fig; Circadian rhythm of plasma corticosterone

In the rat the peak time of protein binding occurs during the (nocturnal) activity spans for

disopyramide, lidocaine, and carbamazepine which also correspond to the peak time of plasma

proteins.

4.3 Circadian Rhythms of Receptors

CR have been documented and quantified in various receptors and organs, e.g. brain and heart

in rats and blood cells in human. In all cases a CR was observed for the number of binding sites

rather than for binding capacity of sites. Statistically significant 24-h rhythms occurred in all

receptors studied byWirz-Justice and coworker as well as by others using homogenates from the

whole rat forebrain. In addition, waveform, amplitude, and acrophase of these circadian

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changes vary with the time of year, even though rats have been kept synchronized with a

defined and constant LD cycle.

These rhythms are endogenous because they persist under constant environmental conditions

without a known zeitgeber and also when animals are deprived of sleep. The pattern of a

receptor rhythm may change from one brain region to another.

For example, the pattern can be different from the same ligand in different nuclei of the

hypothalamus. In rats, receptor rhythms vary according to strain and even within the same

strain from different breeding lines. Binding to a given ligand in a defined brain region varies

with age, leading to changes in CR parameters such as amplitude, acrophase shift, and/or 24-h

mean.

However, the circadian amplitude in the number of certain receptors is sometimes not large

enough to explain fully the impressive magnitude of an observed change in chronesthesy.

4.4. Circadian rhythm in neuroendocrine system;

The high-amplitude circadian rhythms in the hypothalamic–pituitary–adrenocortical (HPA) and

autonomic nervous systems contribute to the day–night difference in airway caliber and risk of

NBA. In diurnally active asthmatics, serum cortisol con-centration is greatest around the

commencement of day time activity and lowest during the middle of the nighttime . Serum

epinephrine concentration increases rapidly following morning awakening and reaches peak

level by the middle of the activity period. It declines thereafter and reaches lowest concentration

during sleep, when cholinergic (vagal) dominates . Cortisol exerts anti-inflammatory effect and

it up-regulates β-receptor function; epinephrine induce s bronchodilation and exerts a stabilizing

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effect on the mast cellmembrane, thereby retarding the release of pro-inflammatory mediator

substances

Thus, the high-amplitude circadian rhythms in cortisol and epinephrine are thought to

contribute significantly the day–night variation in airway inflammation, reactivity, and caliber.

Several investigations suggest that some aspects of the HPA may be abnormal in NBA. The

adrenal cortex of those prone to NBA may be less responsive to corticotrophin stimulation than

those mostly prone to daytime BA or in normal controls .Moreover, cortisol binding and steroid

responsiveness seem tobe impaired in NBA, resulting in impaired inhibition of tissue

inflammatory processes .

The hormone melatonin synthesized and circulated almost exclusively during the darkness of

nighttime while asleep. Melatonin plays a central role in biological clock function. Melatonin

also exerts pro-inflammatory effects, and accumulating evidence suggestions may contribute to

the exacerbation of airway inflammation and consequent airway hyperreactivity in NBA

patients.

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Fig; Circadian Rhythm InNeuro-Endocrine System

4.5;Chronokinetic Changes Can Be Either Sex or Age Related, as Well as

Phenotype Related;

In both sexes, large-amplitude CR of plasma AUC were found in studies with four different

dosing times. However, both the amplitude and the 24-h mean were larger in women than in

men. Dosing time-dependent changes in tmax>Cmax, and AUC of sustained-release

indomethacin (NSAID) have been demonstrated in young adults but not in elderly subjects.The

polymorphism in the human potency to acetylate some drugs (e.g. isoniazid, procainamide, and

hydralazine) . With regard to these genetic factors, comparison between slow and rapidacetyltor

types of healthy young subjects has shown statistically significant differences in the

chronokinetic pattern of isoniazid.

4.6;Circadian Rhythm in Asthma;

Nighttime worsening of asthma has been historically recognized. A Roman physician in the

fifth century, CaeliusAurelianus, noted: “On the heavy breathing and wheezing which is called

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Asthma by the Greeks, this disease is a burden during the winter and at night more than during

the day or the spring .Clinically, asthma exacerbations frequently occur in the early hours of the

morning, around 4:00 a.m. Dyspnea-induced nighttime awakening occurs in more than 75% of

respondents in a large survey of individuals with asthma . In a 1-year review and a 2.5-year

review of deaths due to asthma in adults, approximately 70% of asthma-related deaths occurred

between 12:00 a.m. and 6:0 a.m.Physiologically, airway caliber and inflammation also follow

circadian patterns. Peak expiratory flow (PEF) as a measure of airway obstruction has been

shown to fluctuate over a 24-hour period in both healthy patients and patients with asthma.

Airway obstruction worsens during the night, with patients with asthma having a 51% larger

change in PEF during nighttime than control patients . In addition, Bonnet and colleagues

revealed the circadian variation of airway responsiveness, with maximum bronchial

responsiveness to methacholine and histamine bronchial challenge at 3:00 a.m. and 4:00 a.m.

When trans bronchial biopsies were performed in patients with and without asthma at 4:00 p.m.

(when lung function is optimal) and 4:00 a.m. (when airflow limitation is highest), the tissue

biopsies of nocturnal patients with asthma had a pronounced circadian variation in alveolar

eosinophil number per unit volume, with a significantly higher eosinophil number at 4:00 a.m.

than 4:00 p.m. Broncho-alveolar lavage (BAL) studies show higher numbers of macrophages,

neutrophils, lymphocytes, and CD4+ T cells have also been reported in alveolar tissue at 4:00

a.m. than at 4:00 p.m. The increase in inflammatory cells correlates with the overnight increase

in airflow obstruction.

For example-Methyl prednisolone causes no suppression during a day(If given between 8:00 –

16:00) as shown in below figure.

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Fig; Circadian Rhythm In Asthma

5; THE CIRCADIAN CLOCK

Many biological functions wax and wane in cycles that repeat each day, month, or year. Such

patterns do not reflect simply an organism’s passive response to environmental changes. Rather,

they reflect the organism’s biological rhythms: i.e. its ability to keep track of time and to direct

changes in function accordingly. Because the Earth rotates on its axis, it presents two

environments, i.e. light and darkness; because the earth’s axis of rotation is tilted, durations of

daily periods of darkness and light vary during the course of the year.

Through evolution, animals have responded to these environmental changes by adapting to

them. This is the origin of biological rhythms that repeat approximately every 24 hours, called

circadian rhythms.

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Fig; Circadian Clock- A rhythm of life

6.THE CARDIOMYOCYTES CIRCADIAN CLOCK;

Circadian clocks have been described in all CV-relevant cell types, including cardiomyocytes.

But what might be the role of this mechanism in the heart? A general concept is that circadian

clocks confer the selective advantage of anticipation, temporally partitioning biological

processes in a manner that allows a cell/organ to respond appropriately to fluctuations in the

environment over the 24-h day. What might the heart need to anticipate? Over the course of the

day, the heart must contend with two major behavioural cycles; sleep-wake and fasting-feeding

cycles.

These cycles are associated with profound fluctuations in energetic demand, neural stimulation,

hormones, nutrients, oxygen tension, body temperature, and shear stress. How might the

cardiomyocyte clock simultaneously anticipate oscillations in all these factors? Consistent with

its transcriptional nature, circadian clocks often govern cellular functions through modulation of

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genes that are not core clock components (termed clock output genes; CCGs). Selective genetic

disruption of the cardiomyocyte circadian clock indicates that this molecular mechanism

regulates up to 10% of the cardiac transcriptone; known functions of CCGs in the heart span

processes as diverse as signal transduction and ion homeostasis, to metabolism. The latter

serves as an excellent example, illustrating the importance of temporal partitioning. Metabolic

flux analysis reveals that the cardiomyocyte clock promotes oxidative metabolism at the sleep-

wake transition (in anticipation of increased energetic demand upon awakening), augments

nutrient storage towards the end of the awake period (in anticipation of the upcoming fast

during the sleep period), and increases cellular constituent turnover at the beginning of the sleep

period (facilitating repair/renewal of the myocardium prior to awakening).Moreover, the

myocardium exhibits clock-dependent rhythms in responsiveness to various stimuli/stresses,

including adrenergic stimulation, insulin, and fatty acids. At a functional level, both time-of-

day-dependent oscillations in heart rate and contractility are attenuated in mice following

genetic disruption of the cardiomyocyte circadian clock; underscoring the importance of this

mechanism in orchestrating critical processes in the heart, these mice develop an age-onset

dilated cardiomyopathy and exhibit reduced lifespan.

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Fig; Cardiomyocytes- A Circadian Clock

7; WHY THE EFFECT OF A DRUG CHANGES AS A FUNCTION OF THE TIME OF

DAY?

An orderly timed circadian system implies that every function occurs at a specific moment in

the temporal reference scale. In view of this, it is not unreasonable that xenobiotics will have

differential effects as a function of the time of day.

Chronopathology describes the time-dependent effect of a pathological agent to cause the

disease.

Chronopharmacology analyzes the time-dependent variations in response to a pharmacological

agent.

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Chronotoxicology describes the daily changes in the activity of toxic agent on a given organism.

That the activity of any pharmaceutical agent varies as a function of time of day of

administration is in contradiction to the homeostatic principle that holds that a given agent will

always produce the same effect providing that a constant concentration is kept in circulation.

8;RELEVANCE OF CHRONOPHARMACOLOGY IN SLEEP

Human sleep, its duration, and organization depend on its circadian phase and, therefore,

chronopharmacology is relevant in the treatment of sleep disorders. Insomnia is one of the most

common of these disorders, prevalent among elderly people (40–70% of the aged population

reports sleep complaints) and causing impairment of both general physical and mental health.

Nearly 30–40% of the adult population suffers from insomnia and, since it is associated with

significant distress and functional decline, its treatment is advocated with top priority.

Indeed, the pharmacological treatment of insomnia has remained the most widely used

treatment for decades, despite concerns about its long-term effectiveness, habituation, tolerance,

and potential complications, especially in elderly people. Chronic hypnotic exposure can also

carry additional risks of physical or behavioral dependence, withdrawal, rebound insomnia, and

increased mortality.

9.CIRCADIAN RHYTHM SLEEP DISORDER;

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Two components, homeostatic drive and circadian drive, interact with each other and regulate

the sleep-wake cycle . The sleep-wake cycle is controlled by sleep homeostasis. The desire to

sleep increases gradually with extended wakefulness and decreases during sleep.

Additionally, sleep and wakefulness occur in turn, and the timing of their occurrence is

controlled by the circadian clock system.

Circadian rhythm sleep disorders (CRSDs) are defined by a persistently or recurrently

disturbed sleep pattern. CRSD is attributed etiologically to alterations of the circadian

timekeeping system and or a misalignment between endogenous circadian rhythm and

exogenous factors that affect sleep timing . The intrinsic circadian period (τ, the free-running

period of circadian rhythms in the absence of external cues) is considered to be a critical factor

in the pathophysiology of CRSD.

Fig ; Circadian sleep disorder

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10.CHRONOTHERAPY;

Biological rhythms are considered in the rational use of therapeutic agents to optimize the

treatment of several diseases. One of the objectives of chronotherapy is to restore the lost

temporal order found in chronic diseases. This objective implies that the dose and time of the

administration of a drug should be rational and looking to reestablish the lost temporal order.

Another objective is to optimize the use of a pharmacological agent so that the smallest amount

possible is used at the appropriate time (highest efficacy and lowest undesired effects). For an

effective chronotherapy, the results of chronotolerance and chronoefficacy of a drug must be

taken into consideration. In addition, the rhythmic variations of signs and symptoms of the

disease should be considered. For example, the well-known peak incidence of myocardial

infarction (MI) in the morning hours has led to the timely administration of drugs such as

aspirin to prevent it. However, in Southern populations with a ‘siesta’ habit, a second peak in

MI incidence is detectable after nap time. Therefore, this should be taken into consideration

when dealing with preventive interventions in these populations. It is as important to give

aspirin to reduce the risk of platelet aggregation and thrombosis in the morning as in the

evening to cover the two periods of susceptibility to MI.

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Fig; Circadian analysis of Myocardial Infaraction(MI)

11.CHRONERGY;

The term chronergy was introduced to designate rhythmic (temporally predictable) differences

in effects of drugs on the organism as a whole Chronergy has a neutral meaning that includes

rhythmic changes of both desired (effectiveness) and undesired (toxicity and its counterpart,

tolerance) effects. Obviously, temporally predictable dependencies in either effectiveness or

tolerance of a drug are based on both its chronokinetics and the chronesthesy of the target

system. Let us consider again studies of unfractionated heparin.

The anticoagulant effect was at its trough around 08.00 h and at its peak around the middle of

the nocturnal rest span, with a circadian amplitude of 40%. The chronokinetics of the drug were

documented by Decousus et al ,using labeled heparin. A statistically significant CR in plasma

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clearance was observed, with a peak at 14.00 h and a trough at 08.00 h and a rather small

amplitude with regard to that of the anticoagulant effect. Therefore, chronokinetic changes are

not likely to explain observed CR in anticoagulant effects.

Further studies have shown time dependencies in effects of heparin in vitro, e.g. coagulation

tests between blood specimens sampled at 10.00 h and at midnight from the same subjects.

Statistically significant differences were observed in APTT and TT with greater anticoagulant

effect at midnight than at 10.00h.

In this case, as in many others, the chronesthesy of the target system rather than the

chronokinetics of the drug appears to be the key phenomenon.

12.CHRONESTHESY;

The term chronesthesy was used first to designate rhythmic (temporally predictable) changes in

the susceptibility or the sensitivity of a target system to a drug, which cannot be explained by

chronokinetic changes. Later on, taking into account many experimental findings, we proposed,

with Labrecque and Smolensky thatchronesthesy be considered the chronopharmacologic

counterpart of the pharmacodynamic concept. Apart from the fact that

chronopharmacodynamics is a rather cumbersome and long word, it deals basically with

mechanisms of time-related variation in effects and metabolism of drugs in healthy organisms.

Since metabolic processes have already been taken into account when referring to

chronokinetics, chronesthesy, chronoeffectiveness, and chronotolerance, the term

chronopharmacodynamics does not add further precision or specification. It can be used,

however, if it helps understand the meaning of chronesthesy.

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Therefore, chronokinetics and chronesthesy are complementary concepts andchronesthesy

itself designates circadian and other rhythmic changes in the susceptibility of a target system. In

human subjects the target can be a tissue, e.g. the skin (CR in epidermal skin reaction to

intradermal injection of histamine with a nocturnal peak) , the bronchial tree (CR of the

bronchial response to acetylcholine as well as beta-agonists among other agents, inhaled in the

form of aerosol) ,or the stomach (number of mucosal lesions quantified by fibroscopy is twice

greater after morning [10.00 h] than evening [20.00 h] ingestion of 1 g of acetylsalicylic acid) .

Experiments in laboratory rodents have also shown that the target biosystem may be located

either at the molecular level of the receptors or in different subcellular systems (e.g. membrane

structure and enzyme systems).

13.CONCLUSION;

The widespread awareness of the importance of the time of day on pharmacology can readily be

illustrated.

The influence of the time of day on drug efficacy and toxicity is not surprising considering that

most mammalian physiology is affected by the circadian clock. Currently, most approaches

consider the relevance of dosing time for drug effects to recommend a standard best time for

drug administration in populations with well-synchronized circadian physiology. Recently

acquired knowledge on the circadian timing system and the availability of new experimental

and computational models and new delivery technologies allows for the identification of the

key clock and clock-controlled components that influence the dynamics of drug effects.

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14.REFERENCES;

1.Ko CH, Takahashi JS. Molecular components of the mammalian circadian clock. Hum Genet

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2.Levi F, Schibler U. Circadian rhythms: mechanisms and therapeutic implications. Annu Rev

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3.Dardente H, Cermakian N. Molecular circadian rhythms in central and peripheral clocks in

mammals.

4.Reinberg, A., Halberg, F. 1971. Circadian chronophapharmacology.Annu. Rev. Pharmacol.

5.Radzialowski, F. M., Bousquet, W. F. 1968. Daily rhythmic variations in hepatic drug

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The Clocks That Time Us. Cambridge, MA: Harvard Univ. Press. 448 pp.

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Neurobiology, ed. J. Aschoff, 4:311-48. New York: Plenum. 488 pp

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10. Petit, E., Milano, G., Levi, F., Thyss, A., Bailleul, F., Schneider, M. 1988. Circadian-

varying plasma concentration of 5-fluorouracil during 5-day continuous venous infusion at

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