1. Introduction
Oral drug delivery is the most comfortable and commonly utilized route for administering drugs, with about
of all dosage forms in the worldwide market being oral [
1,
2]. It has attracted attention due to its unique advantages, including sustained and controllable delivery, ease of administration, feasibility for solid formulations, patient compliance, and an intensified immune response in the case of vaccines [
3].
However, the extent and rate of drug absorption from the gastrointestinal (GI) tract into the bloodstream is a complex process that is influenced by various factors categorized into three main classes [
4] (
Figure 1). The first class encompasses the physicochemical and biological properties of the drug, including solubility, pKa, chemical and biological stability, and lipophilicity. The second class involves the physiological and anatomical properties of the GI tract, such as pH levels, gastric emptying rates, transit times through the small and large bowel, concentrations of micelles, active transport mechanisms, efflux processes, and gut wall metabolism. The third class comprises formulation factors, including dosage form, particle size distribution, and the properties of various delivery systems such as solutions, tablets, capsules, suspensions, emulsions, gels, and modified-release formulations.
Given this complexity, designing an oral formulation capable of achieving an appropriate pharmacokinetic profile for new drugs or optimizing existing drug formulations necessitates a methodology to estimate the extent and dynamics of absorption [
5]. However, conducting extensive in vivo evaluations in preclinical species can be both costly and time-consuming, as it provides information specific to the conditions under which the experiments were conducted. Moreover, inter-species differences may result in unreliable predictions of oral bioavailability in humans when relying solely on in vivo animal data.
Mathematical models for oral drug absorption have increasingly influenced the development of oral drug delivery products over the past two decades, reducing the failure rate of new drugs due to poor drug-like properties from
during the 1990s to approximately
toady [
6]. Over the years, various types of mathematical models have been developed, generally falling along a spectrum between data-driven, mechanism-based, and first-principles models. In its purest form, a data-driven model utilizes solely the observed data of the phenomena it represents. For example, characterizing the distribution and statistical properties of a measured variable is a data-driven model. Mechanism-based models describe the dynamics of the system by detailing the kinetics of the relevant processes after simplifications. For example, the Michaelis-Menten approximation [
7] is often used to describe the metabolism rate of the hepatic enzyme CYP3A4, which is involved in the metabolism of many drugs, rather than detailing its full set of reactions [
8]. Conversely, first-principles models rely solely on fundamental principles (such as thermodynamics, conservation of mass, energy and momentum) to describe system dynamics and estimate parameters. For instance, the Einstein-Stokes equation can be used to calculate the diffusion coefficient of a dye in still water [
9]. Different model types have advantages and disadvantages regarding the questions at hand. This work aims to review the different types and provide insights into their strengths and weaknesses.
2. Overview of The Physiology and Mechanisms of Human Oral Drug Absorption
Oral drug delivery commences with the administration of a drug formulation to the buccal cavity (
Figure 2). The buccal/sublingual is an attractive route of delivery for some highly water-soluble and absorbable drugs[
10], due to its high compliance, avoiding the hepatic first-pass metabolism, and quick onset [
11]. In the following, we will provide an overview of the absorption in the buccal/sublingual route, for further details see [
12,
13,
14,
15].
Following the disintegration of the buccal/sublingual formulation, the drug has to dissolve in the limited volume of human saliva (0.8 to 1.1mL, [
11]) and permeate the epithelium. The buccal epithelium has a surface area of approximately
[
13], and it consists of 40 – 50 layers, only a few of which are shown in the schematics that describe the Buccal/sublingual absorption route in
Figure 2.
The permeation of drugs across the epithelium and into the bloodstream occurs through various mechanisms, which involve either passive or active transport [
16]. Passive transport is facilitated by the concentration gradient across the membrane and can occur through either the cell membrane (transcellular transport) or the paracellular pathway, where the drug traverses intercellular spaces. The paracellular route primarily facilitates the absorption of hydrophilic drugs, while transcellular transport is predominant for lipophilic compounds[
15]. Additionally, active transport mechanisms, such as carrier-mediated transport, contribute to the transportation of certain drugs across the oral mucosa [
13,
17].
Several observations (See Vondracek et al. [
18], and reference therein) support the presence of the cytochrome P450 (CYP) family in the buccal epithelium. The CYP family of enzymes is responsible for the oxidative metabolism of numerous endogenous and exogenous chemicals [
18]. Consequently, some drugs that permeate the epithelium via the transcellular route may undergo metabolism, potentially reducing their bioavailability.
The buccal/sublingual route might be less preferable for poorly water-soluble drugs, which comprise approximately
of the drugs in the market. This is because the low solubility of the drugs, combined with the relatively small surface area, and short residence time, due to accidental swallowing and dilution with saliva[
19], might limit their absorption. To increase the relevancy of this route, there is an effort to develop a novel delivery method that would increase drug solubility [
11,
20,
21,
22,
23], or increase the residence time by developing formulations based on bioadhesive polymers[
19].
Hence, the majority of the formulations are intended for absorption in the gastrointestinal tract (GIT), and reach the stomach after their ingestion (
Figure 2). The stomach, resembling a bean-shaped muscular bag, serves as both a reservoir and a regulator for transfer to the small intestine (SI) via the pylorus sphincter [
24]. Physiological conditions within the stomach vary depending on its contents [
25]. In fasted state, the stomach typically maintains a pH of approximately 1-3 [
3,
25], possesses a surface area of roughly 3.5
[
1], and contains 200-250mL of luminal fluids [
25,
26] containing specific enzymes crucial for food digestion [
16]. Under these conditions, solid dosage forms such as tablets, capsules, and pellets may remain in the stomach for up to 2 hours [
27], while the emptying rate of liquid solutions is proportional to the stomach content volume (e.g., first order), with a half-emptying time (
) typically ranging from 5 to 20 minutes [
26,
28].
After a meal, the pH of the stomach increases to between
and
, and its volume increases to
or higher [
25]. Under these conditions, the residence time of solid dosage can be 3-5 hours[
27], while the emptying rate of fluids becomes constant (e.g. zero order), and may last approximately 120 minutes[
26], depending on the caloric intake (low- and high-fat) of the meal[
25,
26]. For further information on the stomach anatomy and physiology in the presence or the absence of food see Cheng et al. [
25]. The drug is emptied from the stomach to the small intestine (SI).
The SI is a lengthy (280cm) and narrow tube (
diameter, [
24]) that is primarily responsible for drug and nutrient absorption [
24,
29]. It connects to the stomach via the pylorus sphincter at one end and to the large intestine through the ileocecal sphincter at the other. Anatomically, the SI is segmented into three distinct regions: the Duodenum (20cm long), the Jejunum (104cm long), and the Ileum (156cm long) [
24]. Surface area amplification within the intestinal fluid contact occurs through three structures: large folds, finger-like projections (villi), and smaller protrusions (microvilli) [
24,
29]. Large folds are typically located between the mid-duodenum and mid-ileum, with their size and density decreasing along the SI. Similarly, the amplification of villi and microvilli diminishes along the length of the SI [
24,
30]. This results in a surface area of approximately
[
3,
24]. The pH increases gradually along the SI from 5.5 in the Duodenum to 7-9 in the distal ileum [
3,
25]. The contents of the SI are propelled toward the ileocecal valve through the contraction of its walls. The transit time is 3-4 hours independent of the presence of food, and the form of the pharmaceutical formulation (tablets, pellets, and liquids) [
27].
The large intestine (LI) resembles an imperfect cylinder, approximately 1.5 meters long, with a diameter ranging from 4 to 8 centimeters [
3,
31], and has a surface area of approximately
[
1]. Its roles encompass the absorption of electrolytes and water, fermentation of unused energy substrates, immune system priming, production and absorption of vitamins and hormones, fecal transport to the rectum, and fecal storage until elimination [
31]. Anatomically, the LI is segmented into four major parts: the ascending colon or cecum (20-25cm), the transverse colon (40-45cm), the descending colon (10-15cm), and the sigmoid colon (35-40cm) [
31]. The pH within the colon varies slightly across different regions: 6.2-7.4 in the cecum, 5-8 in the transverse colon, 6-8 in the descending colon, and 7-8 in the sigmoid colon [
31]. Undigested food is transferred from the small intestine to the cecum, resulting in initially liquid feces that gradually solidify as they traverse the LI [
31]. Transit time through the LI is highly variable, influenced by factors such as diet, stress, mobility, medication, illness, and gender [
32], estimated to range between 5 to 73 hours [
33].
A solid formulation releases the drug as it progresses through the gastrointestinal tract (GIT). The rate of drug release from a formulation and its dissolution along the GIT depends on several factors, including the properties of the formulation itself, the physicochemical properties of the drug, and the composition of the GIT fluids. Formulations are frequently categorized according to the pattern of drug release from tablets, which commonly includes immediate-release, modified-release, and delayed-release formulations [
34]. Immediate-release formulations rapidly release the drug after administration and represent the most prevalent type of tablet. Examples include disintegrating, chewable, effervescent, sublingual, and buccal tablets [
34]. Modified-release formulations are designed to release the drug over time, and in delayed-release formulations the drug is liberated from the tablet sometime after administration, often to protect the drug from the gastric environment[
34]. See Taylor and Aulton [
34] and Alqahtani et al. [
1] for an extensive review on oral drug formulations, and Homayun et al. [
3] for a review on advances and upcoming technologies in oral administration.
When the drug that was released from the formulation is solid, it must dissolve in the GIT fluids before it can permeate the intestinal epithelium and reach the blood. The dissolution rate of the drug depends on the powder distribution size [
30,
35], the charge of the drug, and the pH of the environment in which it dissolves[
5]. Following food intake, bile secretions from the gall bladder aid the dissolution and permeation of lipophilic compounds[
36].
After dissolution, the drug becomes susceptible to chemical and biological degradation within the lumen of the GIT (
Figure 2, Gastrointestinal route). Chemical degradation can occur under fasted conditions post-administration due to the harsh acidic environment within the stomach [
3]. Biological degradation may occur in the stomach through gastric enzymes such as pepsin and gelatinase, as well as in the upper SI via digestive enzymes secreted by the pancreas, including lipases (fat degradation), amylase (starch degradation), peptidases (peptide disintegration), and trypsin (protein decomposition) [
3]. Additionally, brush-border metabolism occurs on the surface of the SI by enzymes present within the brush-border membrane, such as Isomaltase, alkaline phosphatase, sucrose, and other peptidases [
1]. Further degradation may arise from the intestinal flora of the colon, primarily located in the lower portion of the GI tract [
1].
The permeation of free drugs through the gastrointestinal (GIT) epithelium occurs through mechanisms similar to those described for the buccal/sublingual absorption route. Specifically, drugs are absorbed either passively (via transcellular or paracellular routes) or through active transporters [
3,
4]. Unlike the buccal/sublingual epithelium, the GIT epithelium is arranged in a single-column layer (monolayer), primarily composed of enterocytes [
1]. These cells express efflux transporters from the ATP-binding cassette (ABC) superfamily, along with cytochrome P450 (CYP) enzymes responsible for intracellular metabolism.
ABC transporters, including P-glycoprotein (P-gp, MDR1, ABCB1), multi-drug resistance-associated proteins (MRPs), and breast cancer resistance protein (BCRP, ABCG2), function to limit the intracellular accumulation of their substrates by facilitating efflux out of cells [
37]. These efflux transporters, along with CYP enzymes, exhibit overlapping substrate specificity. Their combined action prolongs drug exposure to CYP enzymes while maintaining low concentrations, thereby preventing saturation [
1,
38]. This mechanism can limit the bioavailability of many drugs and may lead to drug-drug interactions, as some drugs can inhibit either P-gp or CYP enzymes [
1]. See Murakami et al. [
37] for an extensive review of efflux proteins in the intestine, and Alqahtani et al. [
1] for further discussion on the metabolic barriers to absorption.
Following absorption in the GIT, the drug reaches the portal vein and passes through the liver before it reaches the systemic circulation [
1,
38,
39,
40,
41]. As the drug passes through the liver, it might be metabolized by the hepatocytes of the liver that expresses the CYP, as well as other enzymes (first-pass metabolism). This first-pass metabolism represents a major metabolic barrier to drugs administrated through the gastrointestinal route [
1].
7. Discussion
Oral drug delivery is favored as a route for administering drugs due to its non-invasive nature, convenience, and high patient compliance[
1,
2]. However, the physiological, physical, and chemical intricacies of the oral route pose challenges in developing new formulations and ensuring the acceptable bioavailability of new drug candidates. Since the experimental trial-and-error approach is expensive, mathematical models were developed over the past few decades as valuable tools for integrating experimental data, thus reducing the number of required experiments [
162].
A Mathematical model is designed to address a certain problem, by taking as input the data that the modeler deemed as relevant and producing the desired output. Over the years, different approaches were taken to develop model, namely data-driven, mechanism-based, and first-principles models (
Table 1). Each approach address a different problem domain.
Data-driven models, including conventional PK, QSAR, ML, and DL models, are essentially ’black-box’ systems that correlate specific inputs to outputs. Consequently, these models require a substantial dataset, operating on the assumption that the information within the data is sufficient for classifying or predicting new data. Essentially, they interpolate data from the provided dataset, making them suitable for high-throughput screening. However, due to their ’black-box’ nature, understanding the reasons for mispredictions—and therefore finding ways to correct them—can be challenging.
Mechanism-based models, including quasi-equilibrium, steady-state, and PBPK models, incorporate physical and chemical principles while simplifying the dynamics of various physiological processes. Developing a mechanism-based model involves the modeler’s decision on the importance of different processes and their mathematical description, often relying on in vivo or in vitro experimental data, as well as other mathematical models. When model predictions deviate from experimental data, the modeler is prompted to explore new hypotheses or increase the detail in process descriptions, thus guiding the selection and conducting of new experiments. Consequently, the development process is iterative, as new processes are introduced into the model and hypotheses are examined. For example, Arav and Zohar [
140] recently developed a PBPK dispersion model for the absorption of levodopa following its administration in a controlled release formulation. The presence of dissolved levodopa in the stomach induces a ’lag’ in gastric emptying. Incorporating this feature in the model was essential to obtain the erratic plasma concentrations reported during the first hours after administration. Moreover, using the model, it was possible to dispute the common hypothesis of an ’absorption window’ in the upper SI and to show that levodopa is equally absorbed along the entire SI. These results were then used to optimize the release rate of controlled release formulations. Thus, as models developed under this approach require more details, they are less suited for high-volume screening.
First-principles models, such as molecular dynamics and continuum models, offer highly detailed physicochemical representations that address processes governed by physical and chemical phenomena. These models are employed to tackle various challenges, such as comprehending the flow field induced by the contraction of the small intestine (SI) walls, or optimizing the structure of nanoparticles. Due to their high complexity, both mathematically and numerically, these models are typically constrained by spatial and temporal scales. Consequently, the primary distinction between Mechanism-based models and First-principles models lies in their focus: Mechanism-based models primarily operate on an organ scale or larger (e.g., multiple organs or the body scale), whereas First-principles models concentrate on an organ scale or smaller (e.g., flow in an organ, tissue, cellular, or atomic level).