This study examined the effects of metyrapone on the overall elimination of acetaminophen and on the individual processes principally responsible for elimination, the formation of acetaminophen sulfate and glucuronide. Because acetaminophen pharmacokinetics are nonlinear above a threshold dose, experiments were designed to investigate acetaminophen elimination in the linear (30 mg/kg) and nonlinear (150 mg/kg) ranges to assess possible effects of metyrapone on conjugating enzymes and on cofactor availability. Prior treatment with 400 mg/kg metyrapone tartrate decreased total clearance of acetaminophen over 30% in the linear range (25.4 +/- 2.0 vs. 36.2 +/- 3.7 ml/min/kg in controls; p less than 0.01) and over 40% in the nonlinear range of disposition (4.42 +/- 1.07 vs 7.76 +/- 1.37 ml/min/kg in controls, p less than 0.01). Partial clearance to acetaminophen glucuronide was decreased by metyrapone in each dose range. Partial clearance to acetaminophen sulfate also declined in each dose range but statistically so only after 150 mg/kg. Metyrapone decreased the renal clearance of acetaminophen sulfate and glucuronide when these conjugates were formed in vivo after acetaminophen administration. However, metyrapone failed to impair the renal clearance of acetaminophen glucuronide when preformed metabolites were administered directly. The utility of metyrapone as a specific inhibitor of oxidative drug metabolism appears to be limited for drugs such as acetaminophen by concomitant inhibition of competing conjugation pathways, which account for the majority of drug elimination.