European Journal of
Europ. J. clin. Pharmacol. 12, 367-373 (1977)
Effect of Exercise on the Serum Level and Urinary Excretion
of Tetracycline, Doxycycline and Sulphamethizole
P. Ylitalo, H. Hinkka, and P.J. Neuvonen
Department of Biomedical Sciences, University of Tampere, Tampere, and Department of Clinical Pharmacology,
University of Helsinki, Helsinki, Finland
Summary. The serum level and urinary excretion of
sulphamethizole, tetracycline and doxycycline were
studied in healthy volunteers subjected to intensive
exercise and bed rest in a cross-over trial. Each
group consisted of 7-8 subjects. The exercise or bed
rest began 15 min before oral administration of the
drug and was continued for the following 4 hours.
During exercise serum drug concentration and the
area under the serum concentration-time curve for
each agent was significantly higher (p<0.05) than
the corresponding values at rest Exercise greatly
suppressed the renal excretion of tetracycline and
doxycycline, but the decrease alone appeared insuf-
ficient to account for the pronounced increase in
serum drug concentration. Total drug excretion in
urinewas unchanged. Thus, it seemed most unlikely
that overall absorption from the gastrointestinal
tract had been altered by exercise. However, the
rate of absorption appeared to be more rapid in the
exercise than in the rest period. Marked haemocon-
centration was not produced by the exercise. In ad-
dition to changes in absorption and elimination
rates, alteration in the volume of distribution might
contribute to the higher serum drug concentration
during exercise. Therefore, the level of physical ac-
tivity should be considered in the interpretation of
pharmacokinetic data both in clinical practice and in
pharmacokinetic studies.
Key words: Sulphamethizole, tetracycline, doxycyc-
line, rest, exercise, pharmacokinetics, excretion, ab-
sorption
The physical activity of patients during drug therapy
is usually low, but if the disease does not restrict
activity, there will be moderate or occasionally in-
Clinical Pharmacology
© by Springer-Verlag 1977
tense exercise during normal daily life. Physical
stress and even the maintenanance of an upright
position have been reported in some instances to in-
crease the serum level of drugs (Schmidt and
Roholt, 1966; Levy, 1967; Gamble, 1975). In gen-
eral, however, very little attention has been paid to
the effect of physical activity, even though agents
with a narrow therapeutic range have often been ad-
ministered. A study has been made therefore, of the
extent to which exercise can alter serum concentra-
tion of drugs after conventional oral dose. The de-
pendence of serum drug level during exercise on al-
teration in urinary excretion of the drug and on pos-
sible haemoconcentration was also evaluated. Be-
cause of their particular pharmacokinetic properties,
three different types of antimicrobial agents were
chosen for the investigation - sulphamethizole, tet-
racycline and doxycycline.
Material and Methods
The serum concentration and urinary excretion of
sulphamethizole, tetracycline and doxycycline were
studied in healthy medical students subjected to
physical exercise and bed rest in a cross-over trial.
Each group consisted of 7-8 volunteers of both
sexes, ranging in age from 22 to 28 years, and in
weight from 51 to 79 kg. The subjects had no his-
tory of gastrointestinal, liver or kidney disease, and
none admitted taking any other medication. The in-
terval between trials was at least 7 days. Before tak-
ing the drug the subjects fasted for 4 h. Two sup
phamethizole tablets (each consisting of sul-
phamethizole 500 mg, Starisil ®, Star Ltd., Tam-
pere), one tetracycline tablet (tetracycline chloride,
corresponding to tetracycline 500 mg, Oricyclin®,
Orion Ltd., Helsinki) or two doxycycline capsules
368
(doxycycline chloride, each corresponding to doxy-
cycline 100 mg, Doximycin ®, Orion Ltd., Helsinki)
were given orally with water 100 ml under supervi-
sion to each volunteer. Subjects were not allowed to
drink for 1.5 h or to eat for 5 h after taking the
drug. They were also asked to abstain from alcoholic
beverages until the last blood samples had been
taken.
The physical exercise consisted of a basket-ball
match which began 15 min before taking the drug
and continued for 50 min every hour for 4 consecu-
tive hours. The intensity of exercise was controlled
by measuring heart rate and blood pressure during
the course of the match. The rest period consisted of
rest in bed for the same time.
For determination of the serum level of sul-
phamethizole and tetracycline, blood samples were
taken at 0, 0.5, 1.5, 3, 5 and 16 h after administra-
tion. Because of the longer half-life of doxycycline,
blood samples in the doxycycline group were taken
at 0, 0.5, 1, 2, 4, 8, 24 and 48 h. Immediately after
the collection of samples, the serum was separated
by centrifugation. In the sulphamethizole and tet-
racycline groups urine was collected 0-1.5, 1.5-3,
3-5 and 5-16 h after giving the drug. In the doxy-
cycline group the urine collection periods were 0-2,
2-4, 4-8, 8-24 and 24-48 h. The samples taken just
before drug administration served as blanks in the
determination of drug concentration. Both serum
and urine samples were stored below - 2 0 ° C until
analyzed.
Haematocrit was measured in heparinized glass
capillaries after centrifugation, and blood pressure
(BP) by a brachial cuff. Urine pH was determined
with a pH meter immediately after the urine collec-
tion.
For estimation of total sulphonamide concentra-
tion (sulphamethizole + conjugates) in serum and
urine, samples were subjected to acid hydrolysis
(Richterich, 1965). The concentration of sulphon-
amide in the hydrolysate and of unconjugated sul-
phamethizole was estimated spectrophotometrically
(Unicam SP 1800 Ultraviolet Spectrophotometer)
according to the method of Bratton and Marshall
(1939). Unconjugated protein "unbound sul-
phamethizole was measured using the procedure de-
scribed by Saris et al. (1969). Tetracycline and dox-
ycycline concentration in serum and urine were
analysed spectrophotofluorometrically (Hitachi-Per-
kin-Elmer MPF-3 spectrophotofluorometer) by the
method of Kohn (1961).
Means and standard errors (SEM) were calcu-
lated, and the statistical significance of the differ-
ence between the means of the corresponding exer-
cise and rest groups was estimated by the t-test for
P. Ylitalo et al.: Exercise and Drug Handling
paired observations. Areas under serum concen-
tration-time curves were determined by the
trapezoidal rule.
Results
Changes in Certain Haemodynamic Parameters and
in Urine Excretion as a Result of Exercise
During the exercise period heart rate was 130-140
beats/rain. Even 4 h after exercise had ceased the
heart rate was slightly but significantly higher than
that after the rest period (Fig. 1 A). In general, sys-
tolic BP was also significantly higher during exer-
cise, whereas diastolic BP remained unchanged
(Fig. 1B).
Despite some fluid loss when the exercised sub-
jects perspired but were not allowed to drink,
haematocrit values remained almost unchanged
(Fig. 1C).
Exercise caused striking suppression of the rate
of urine excretion. After exercise the excretion rate
did not differ from that during the rest period
(Fig. 2 A). The pH of the urine decreased markedly
during the 4 h exercise period and subsequently it
returned to the value found during the rest period
(Fig. 2 a).
Serum Levels of the Drugs and their Excretion into
Urine
The concentration of total sulphonamides (sul-
phamethizole + conjugates), unconjugated sul-
phamethizole and unconjugated protein-unbound
sulphamethizole in serum tended to be higher dur-
ing the exercise than during rest. At 1.5 and 3 h af-
ter drug administration, the differences between the
groups were significant (Fig. 3 A). Exercise also in-
creased the peak concentration (the mean of indi-
vidual peak concentrations) of total and unconju-
gated sulphonamide (Table 1). Moreover, the differ-
ence between the areas under the serum concen-
tration-time curves was significant for total, uncon-
jugated and unconjugated protein-unbound sul-
phonamide.
Exercise also increased the serum level of tet-
racycline and doxycycline, the elevation being more
striking in the doxycycline group (Fig. 3 B), i. e. ex-
ercise resulted in an increase in peak drug concen-
tration and in the area under the serum concen-
tration-time curves (Table 1).
The excretion both of tetracycline and doxycyc-
line was significantly decreased by exercise
(Fig. 4 B). However, after exercise the slope of the
A HEART RATE

150

._=
E
~'~,,100

J:l

50

I ~ I I = I I I = [ //f I I
0 2 4 6 8 24 48
L~exercise { hours

B BLOOD PRESSURE

140

120

E 100
E

80

0 2 4 6 8 24 48
t--.--exercise ~ hours

C HAEMATOCRIT
5¢

4~

Fig. 1. A. Heart rate during exercise (e e) and

L rest (e . . . . . e) conditions (mean +_ SEM;

n = 18); **p<0.01 and ***p<0.001. B. Systolic
and diastolic blood pressures during exercise
(= . ) and rest (e . . . . . e) (mean _+ SEM;
n = 8); *p<0.05 and **p<0.01. C. Haematocrit
0 2 4 6 8 24 48 during exercise (e e) and rest (e . . . . --~)
L--exercise ~' hours (mean + SEM; n = 8)
 370 P. Ylitalo et al.: Exercise and Drug Handling

f
f EXCRETION RATE OF URINE

40 \ I,,,, j ......................
I

20

t | I .~f t t I
~0 1~12 3 5 8 16 24 48
exercise ,~ hours

URINE pH

6.0 C
[
2:
Q.

5.0

Fig. 2. A. Urine excretion rate during exercise

(¢ =) and rest (e . . . . --t) (mean + SEM;
I I I I I //t I I I n = 8); ***p<0.001. B. Urine pH during exercise
0 1~]2 3 5 8 16 24 48 (® =) and rest (e . . . . . e) (mean + SEM;
~- exercise. J hours n = 8); **p<0.01 and ***p<0.001

Table 1. Peak serum concentration and area under the serum concentration-time curves of sulphamethizole (for 16 h), tetracycline (for
16 h) and doxycycline (for 48 h), and their cumulative excretion in urine (means -+ SEM)

Drugs Peak drug concentration Area under the serum Total excretion of
in serum c concentration-time curve drug in urine

Rest Exercise Rest Exercise Rest Exercise

btg/ml ~tg/ml ~tg X m1-1 x h ~tg x m1-1 X h mg mg

Sulphamethizole
total 40-+2.7 65+9.6 a 252_+23 382_+53 a 793-+59 864-+60
unconjugated 39_+3.0 61_+8:1 ~ 242_+20 361_+50 a 731+63 805__+56
unconjugated
protein-unbound 15_+2.0 23-+4.0 75_+7.0 121_+17 ~
Tetracycline 4.7+_0.6 5.2+_0.5 b 49+6.2 57+5.1 b 134+16 123+14
Doxycycline 4.8-+0.3 6.5-+-0.6 b 81_+5.3 106_+3.4 b 107+7.0 95-+8.0

p<O.05 and b p<O.O1 compared to the corresponding rest values.

c Mean of individual peak concentrations.
P. Ylitalo et al.: Exercise and Drug Handling 371

A SULPHAMETHIZOLE CONCENTRATION IN SERUM

60

20

0 '
i
(
i .....; .... i
11~
--exercise
3
t
5
.....

hours
....... _..

16

B TETRACYCLINEAND DOXYCYCLINE CONCENTRATION IN SERUM

Fig. 3, A. Total (e), unconjugated (=), and uncon-

jugated protein-unbound (A) sulphamethizote con-
centrations in serum during exercise ( ) and
rest ( - - - - ) (mean _+ SEM; n = 7); *p<0.05 and
**p<0.01. B. Tetracycline (e) and doxycycline (#)
concentration in serum during exercise ( ..........) and
0 1V2 3 5 8 16 24 48
rest (. . . . -) (mean +_ SEM; n = 8); *p<0.05,
--exercise. J hours **p<0.01 and ***p<0.001

cumulative excretion curve in the exercise group was
parallel to that in the rest group, and there was no
difference in the total excretion of these agents be-
tween the exercise and rest conditions. The excre-
tion of sulphamethizole in the urine of the exercise
group did not differ from that of the rest group at
any time (Fig. 4 A).
Discussion
The exercise programme in the present study was
a basket ball match between healthy subjects. The
intensity of the exercise corresponded to maximal or
submaximal stress. Exercise of this intensity is occa-
sionally achieved in training and by hard-working
outpatients when their disease does not restrict
physical activity.
In the present study, exercise resulted in a mod-
erate increase in serum concentration and in the
area under the serum concentration-time curves for
sulphamethizole, tetracycline and doxycycline. This
observation agrees with the finding that plasma
diazepam and benzylpenicillin concentration after
intramuscular injection is higher in exercised than in
bedridden subjects (Schmidt and Roholt, 1966;
Gamble, 1975).
Since about 80% of the administered sul-
phamethizole was excreted in urine within 16 h, and
since there was no significant difference between the
exercise and rest values, a possible alteration in total
absorption could not explain the difference in serum
drug concentration. In addition, the irrecoverable
fraction of the drug was too small to explain an in-
crease of this magnitude by change in excretion via
routes other than the kidneys.
Although there was probably no difference be-
372 P. Ylitalo et al.: Exercise and Drug Handling

A CUMULATIVE EXCRETION OF SULPHAMETHIZOLE

1000

800

600

400

200

0 i i i ! L
0 1~ 3 5 8 16
--exercise t hours

B CUMULATIVE EXCRETION OF TETRACYCLINE AND DOxYCYCLINE

200 _

160 f

~120 Jl~

Fig. 4. A. Cumulative excretion of total (e) and

0 1~ 3 5 8 16
--exercise | hours
unconjugated (n) sulphamethizole in urine during
exercise ( ) and rest (. . . . -) (mean + SEM;
n = 7). B. Cumulative excretion of tetracycline (o)
and doxycycline (~) in urine during exercise
( ) and rest (. . . . - ) (mean +_+_SEM; n = 8);
24 48 *p<0.05, **p<0.01 and ***p<0.001

tween exercise and rest groups in total absorption of
the drugs, the rate of absorption might well have
been influenced by the exercise. Gastric emptying
rate might be affected by posture and by physical
activity. The absorption of all the drugs studied ap-
peared to be more rapid during exercise than during
bed rest, as indicated by the initial serum concentra-
tion data. If absorption is rapid and elimination de-
layed, higher peak serum values and a larger area
under serum concentration-time curve would be ex-
pected than after slow absorption and rapid elimina-
tion.
Tetracycline and doxycycline are more or less
completely absorbed after oral administration. In
addition to the kidneys, other elimination routes,
especially the gastrointestinal tract, are of import-
ance (Kunin and Finland, 1961; Fabre et al., 1966;
nen and Penttil/i, 1974). In previous experiments,
exercise has been reported to decrease the renal
excretion of such drugs as pralidoxime and p-
aminohippurate (Schwartz et al., 1973). In the pres-
ent study, decreased renal excretion of doxycycline
and tetracycline during exercise contributed to some
extent to their increased serum concentrations. Af-
ter the 4 h exercise period, the renal excretion of
doxycycline was about one fifth of that during the
corresponding period of bed rest. The reduction in
drug excretion may be partly explained by the di-
minished urine production rate, but was also contri-
buted to by the reduction in urine pH, which has
been shown to reduce the renal clearance of tet-
racycline and doxycycline (Jaffe et al., 1973 and
1974). Thus, during exercise there might be
a marked discrepancy between the urinary excretion
P. Ylitalo et al.: Exercise and Drug Handling
tration-time curve. Therefore, physical activity
should be controlled during drug absorption studies.
Marked haemoconcentration as a result of cycle
pedalling has been found to occur within 40 min in
untrained females (Senay and Fortney, 1975). In
addition, exercise, as well as hydrostatic pressure in
the lower parts of the upright body, can cause plas-
ma water to enter the interstitial space (Krnig and
Lemp, 1966; Dettli and Spring, 1966). In the pres-
ent experiments, haematocrit values tended to in-
crease initially during exercise, but decreased to bed
rest level after 2 h of exercise. This decrease was
due, presumably, to the fact that subjects were al-
lowed to drink freely 1.5 h after drug administra-
tion. Thus, the increased serum drug level could not
be explained by a marked decline in plasma volume.
Physical activity and even an upright position
strikingly alter the circulation in many tissues (Wade
et al., 1956; Beveg~rd et al., 1960; Barcroft, 1963;
Selkurt, 1963). The net effect may be a decrease in
total transport of a drug from the blood to the other
tissues which would otherwise remove or store it.
On the other hand, a marked increase in the dis-
tribution volume of pralidoxime and p-aminohippu-
rate has been found in volunteers subjected to mod-
erate exercise for 3 h (Schwartz et al., 1973). Thus,
alterations in the volume of distribution, in metabol-
ism, and in extrarenal elimination cannot be ex-
cluded as possible explanations for the present find-
ings.
The results suggest that intensive exercise will
increase the serum concentration of many drugs. Al-
though exercise of lower intensity will certainly
modify serum drug concentrations to a lesser extent,
the present findings point strongly to need to con-
sider physical exercise in interpretation of phar-
macokinetic data either from patients or from heal-
thy volunteers.
Acknowledgements. This work was supported by
grants from the Paulo Foundation, Helsinki and
Emil Aaltonen Foundation, Tampere. We are also
indebted to Star Ltd., Tampere, and Orion Ltd.,
Helsinki, for their valuable help, and above all to
the medical students who took part in the experi-
ments.
References
Barcroft, H.: Circulation in skeletal muscle. In: Handbook of
Physiology. Section 2: Circulation, Vol. 2 (ed. W. F. Hamilton
and P. Dow), pp. 1353-1385. Baltimore: Williams & Wilkins
Co. 1963
Beveghrd, S., Holmgren, A., Jonsson, B.: The effect of body po-
sition on the circulation at rest and during exercise, with spe-
cial reference to the influence on the stroke volume. Acta
physiol, scand. 49, 279-298 (1960)
373
Bratton, A.C., Marshall, E.K., Jr.: A new coupling component
for sulfanilamide determination. J. biol. Chem. 128, 537-550
(1939)
Dettli, L., Spring, P.: Diurnal variations in the elimination rate of
a sulfonamide in man. Helv. reed. acta. 33, 291-306 (1966)
Fabre, J., Pitton, J.S., Kunz, J.P.: Distribution and excretion of
doxycycline in man. Chemotherapia (Basel) 11, 73-85 (1966)
Gamble, J.A.S.: Some factors influencing the absorption of
diazepam. Proc. roy. Soc. Med. 68, 22 (1975)
Jaffe, J.M., Colaizzi, J. L., Poust, R. I., McDonald, R. H., Jr.: Ef-
fect of altered urinary pH on tetracycline and doxycycline ex-
cretion in humans. J. Pharmacokinet. Biopharm. 1, 267-282
(1973)
Jaffe, J.M., Poust, R.I., Feld, S.L., Colaizzi, J.L.: Influence of
repetitive dosing and altered urinary pH on doxycycline ex-
cretion in humans. J. pharm. Sci. 63, 1256-1260 (1974)
Kohn, K.W.: Determination of tetracycline by extraction of
fluorescent complexes. Application to biological materials.
Analyt. Chem. 33, 862-866 (1961)
Krnig, E., Lemp, A.: Plasmavolumen~inderungen durch allt~ig-
liche Belastungen bei Herzgesunden und Herzinsuffizienten.
Klin. Wochenschr. 44, 862-870 (1966)
Kunin, C.M., Finland, M.: Clinical pharmacology of the tetracyc-
line antibiotics. Clin. Pharmacol. Ther. 2, 51--69 (1961)
Levy, G.: Effect of bed rest on distribution and elimination of
drugs. J. pharm. Sci. 56, 928-929 (1967)
Mattila, M.J., Aukee, S., Jussila, J.: Serum levels of tetracycline
and doxycycline after bile resection. 8th International Con-
gress of Chemotherapy, Abstracts, A-288, Athens 1973
Neuvonen, P.J., Penttil~i, O.: Effect of ferrous sulphate on the
half-life of doxycycline in man. Europ. J. clin. Pharmacol. 7,
361-363 (1974)
Richterich, R.: Clinical Chemistry. Theory and Practice.
pp. 284-288. New York, London: Academic Press 1969
Saris, N.-E., Sorto, A., Karonen, S.-L.: On the assays of free,
unconjugated and total sulphonamides. Scand. J. clin.
Lab. Invest. Suppl. 110, 28-31 (1969)
Schmidt, H., Roholt, K.: Penicillin serum concentrations in rela-
tion to exercise. Acta path. microbiol, scand. 68, 396-400
(1966)
Schwartz, R.D., Sidell, F.R.: Effect of heat and exercise on the
elimination of pralidoxime in man. Clin. Pharmacol. Ther. 14,
83-~89 (1973)
Selkurt, E.E.: The renal circulation. Response of renal blood
flow to physiological stress. In: Handbook of physiology. Sec-
tion 2: Circulation, Vol. 2 (ed. W.F. Hamilton and P. Dow),
pp. 1501-1507. Baltimore: Williams & Wilkins Co. 1963
Senay, L.C., Fortney, S.: Untrained females: effects of submaxi-
mal exercise and heat on body fluids. J. appl. Physiol. 39,
643-647 (1975)
Steigbigel, N.H., Reed, C.W., Finland, M.: Absorption and ex-
cretion of five tetracycline analogues in normal young men.
Amer. J. med. Sci. 255, 296-312 (1968)
Wade, O.L., Combes, B., Childs, A.W., Wheeler, H.O., Cour-
nand, A., Bradley, S.E.: The effect of exercise on the
splanchnic blood flow and splanchnic blood volume in normal
man. Clin. Sci. 15, 457-463 (1956)
Received." May 3, 1977, accepted: June 28, 1977
Pauli Ylitalo, M. D.
Dept. of Biomedical Sciences
University of Tampere
Box 607
SF-33101 Tampere 10
Finland