Effect of gestational age on levels of serum alkaline phosphatase isoenzymes in healthy pregnant women.

OBJECTIVES: To confirm that the bone isoenzyme of alkaline phosphatase (ALP) contributes significantly to the increased ALP in normal pregnancy, and to determine the gestational age at which the increase occurs. METHODS: Cross-sectional determinations of serum total, bone and placental ALP were carried out in 67 normal pregnant women. The results were compared with those of 18 normal age-matched non-pregnant controls using Student's t-test. RESULTS: At both 31-32 weeks and 38 weeks of gestation, serum activities of bone ALP were increased significantly (P < 0.05 and P < 0.001, respectively) when compared with controls. The percentage contribution of bone ALP to the total was higher at 31-32 weeks and lower at 38 weeks when compared with the contribution from placental ALP. CONCLUSION: Knowledge of time of elevation of serum bone ALP activity in normal pregnancy will be helpful in the interpretation of elevated serum total ALP activity during pregnancy.

Copper-64 metabolism in two patients with non-Wilsonian movement disorders and copper deficiency.

Copper-64 studies are presented of 2 patients with non-Wilsonian movement disorder and with abnormal copper handling. Both patients differed from the usual phenotype of non-Wilsonian low copper movement disorder as they had choreiform movement disorders with an onset in the first decade; one patient lacked significant intellectual impairment. Both patients had reduced serum total copper and marginal free copper and caeruloplasmin levels, and both patients were capable of incorporating 64Cu2+ into caeruloplasmin but the second case did so at markedly reduced level. Both showed slightly increased basal and stimulated urinary copper loss compared to normal controls with the rate in patient 1 being capable of leading to copper depletion. Liver copper content was normal in both cases. These 2 patients add to the reports of cases with copper deficiency and movement disorder in whom copper chelation therapy is unlikely to be beneficial.

Isoenzymes of alkaline phosphatase in epileptic patients receiving carbamazepine monotherapy.

The effects of carbamazepine monotherapy were investigated in 20 female and 21 male epileptic patients to determine whether treatment would induce an increase in serum alkaline phosphatase (ALP) activity, a known effect of many anticonvulsant drugs. Serum total ALP activity was increased in nine out of the 41 patients (22%), serum bone ALP activity was increased in 10 (24%), and serum non-bone ALP activity was increased in three (7%). There was no significant difference when the mean of the patients' serum total ALP was compared with that of the controls. Twenty per cent of the patients with increased serum bone ALP had normal serum total ALP, indicating that increased serum bone isoenzyme activity may precede an increase in the total enzyme activity. This should be considered when interpreting results of increased total ALP in epileptic patients.

Antiepileptic drugs, hepatic enzyme induction and raised serum alkaline phosphatase isoenzymes.

Thirteen patients with epilepsy on long-term antiepileptic drug therapy and who had a persistently raised serum alkaline phosphatase (ALP) activity were investigated biochemically. Twelve patients had a raised liver ALP-isoenzyme activity and in nine of these the bone ALP-isoenzyme activity was normal. Gamma-glutamyl transferase (gamma GT) levels were raised in 12 patients. Two patients were hypoglycaemic. One patient fitted the biochemical parameters for subclinical osteomalacia. The resultant clinical picture showed 75% of patients with borderline hypocalcaemia, raised liver ALP, raised gamma GT and normal bone ALP activities in whom 1,25 dihydroxy-cholecalciferol (1,25-DHCC; vitamin D) therapy would be inappropriate, whilst 1,25-DHCC therapy might be considered for those with borderline hypocalcaemia and a raised bone ALP activity (three patients). No evidence was found of hepatotoxicity or drug induced cholestasis. It is considered that the induction of liver microsomal enzymes by antiepileptic drugs could include liver ALP (as opposed to bone ALP) as well as gamma GT and the inactivation pathways for 1,25 DHCC.

Cerebral depression due to propylene glycol in a patient with chronic epilepsy--the value of the plasma osmolal gap in diagnosis.

A case of propylene glycol poisoning is described in a 39 year old woman which resulted in her admission to hospital in status epilepticus. She had had a long-standing history of uncontrollable epilepsy. The diagnosis of propylene glycol poisoning resulted directly from the finding of a high plasma osmolal gap on admission. This finding would have been missed if later samples only had been analysed. Plasma osmolality and the osmolal gap should be considered first line investigations in patients presenting with metabolic acidosis and cerebral signs and symptoms. Since her discharge from hospital a year ago the patient has had no further seizures.

Effect of denzimol on carbamazepine and carbamazepine-10,11-epoxide concentrations in serum, liver, spleen and different brain regions of the rat: an inhibitory metabolic interaction.

The effect of denzimol (DNZ) on the disposition of carbamazepine (CBZ) and its primary metabolite carbamazepine-10,11-epoxide (CBZ-E) in serum, liver, spleen and seven brain regions of the rat was assessed. Coadministration with DNZ for 5 or 10 days resulted in an increase in CBZ and a decrease in CBZ-E concentrations in serum, liver and spleen, consistent with a metabolic (hepatic cytochrome P450 mono-oxygenases) inhibitory interaction. After 15 days of co-administration the concentration of CBZ-E was also increased in these tissues, suggestive of epoxide hydratase inhibition in addition. The magnitude of these concentration changes was much greater in the brain indicating that the total serum concentration of CBZ or CBZ-E may not be a reliable index of the neuropharmacological severity of CBZ-DNZ interaction.

Carbamazepine and carbamazepine-10,11-epoxide pharmacokinetics in an overdose patient.

A case report on a 13-year-old girl with idiopathic grand mal epilepsy who ingested 34 g carbamazepine (CBZ) and 80 mg clonazepam is presented. The patient survived but suffered severe temporary neurological toxicity characteristic of CBZ. CBZ was 79.6 +/- 2.8% bound to serum protein and carbamazepine-10,11-epoxide (CBZ-E) binding was essentially concentration dependent. CBZ and CBZ-E elimination half-lives were 26 and 16.5 h respectively. An inhibitory metabolic interaction with the co-ingested clonazepam is suggested.

Total and free serum concentrations of carbamazepine and carbamazepine-10,11-epoxide in children with epilepsy.

Simultaneous steady-state serum total and free (non-protein-bound) concentrations of carbamazepine and carbamazepine-10,11-epoxide were measured in 68 patients under the age of 21 years with epilepsy (44 males, 24 females; mean age, 11.8 +/- 4.5 years). Thirty patients were maintained on monotherapy with carbamazepine. Mean serum total carbamazepine and carbamazepine-10,11-epoxide concentrations obtained were 7.0 +/- 2.4 mg/L (29.5 +/- 10.0 mumol/L) and 1.5 +/- 0.6 mg/L (5.9 +/- 2.6 mumol/L), respectively. Mean serum-free carbamazepine and carbamazepine-10,11-epoxide concentrations obtained were 1.3 +/- 0.5 mg/L (5.7 +/- 2.1 mumol/L) and 0.5 +/- 0.3 mg/L (2.2 +/- 1.1 mumol/L), respectively. Binding of carbamazepine and carbamazepine-10,11-epoxide was 81% +/- 3% and 62% +/- 10%, respectively. There was no significant difference in binding between male and female patients or those maintained on monotherapy and polytherapy. Age correlated significantly with carbamazepine binding but not with carbamazepine-10,11-epoxide binding. Free concentrations of carbamazepine and carbamazepine-10,11-epoxide correlated significantly with total carbamazepine and total carbamazepine-10,11-epoxide concentrations, respectively, indicating that the binding capacities of both carbamazepine and carbamazepine-10,11-epoxide are constant at serum total carbamazepine concentrations within the quoted therapeutic range.

Factors influencing simultaneous concentrations of total and free carbamazepine and carbamazepine-10, 11-epoxide in serum of children with epilepsy.

Various factors that may influence the simultaneous concentration of total and free carbamazepine (CBZ) and carbamazepine-10,11-epoxide (CBZ-E) in serum of 68 children (mean age 11.8 +/- 4.5 years) with epilepsy were assessed. Separation of free and bound drug fractions was achieved by ultrafiltration, and CBZ and CBZ-E concentrations were determined using a sensitive high pressure liquid chromatographic technique. Thirty children were on CBZ monotherapy. Both total CBZ and CBZ-E serum concentrations correlated significantly with their respective free serum concentrations. CBZ was 81 +/- 3% and CBZ-E 63 +/- 9% bound. There was no correlation between the CBZ dose and either CBZ total or free serum concentrations. A statistically significant correlation was, however, observed between CBZ dose and simultaneous CBZ-E total and free concentrations. CBZ total and free concentrations correlated significantly with those of total CBZ-E. A significant negative correlation was observed between age and total (r = -0.49, p less than 0.01) and free (r = -0.43, p less than 0.025) CBZ-E/CBZ ratios. Concomitant drug therapy (phenytoin, phenobarbitone, and sodium valproate) significantly elevated CBZ-E/CBZ ratios.

Altered ratio of carbamazepine-10,11-epoxide/carbamazepine in plasma of children: evidence of anticonvulsant drug interaction.

A method of measuring carbamazepine-10,11-epoxide (CBZ-10,11-EPOX) has been developed and used to monitor plasma concentrations in children suffering from various forms of epilepsy. Children stabilised on standard doses of CBZ alone showed a ratio of CBZ-10,11-EPOX/CBZ of 18.92 +/- 8.08, expressed as a percentage of the CBZ concentration, while those on multiple-drug therapy (with the exception of benzodiazepines and phenobarbitone) showed both increased values of CBZ-10,11-EPOX/CBZ ratio and increased absolute concentrations of CBZ-10,11-EPOX in plasma. These changes correlated with clinical side-effects which could not be attributed to CBZ itself or to the other drugs administered concurrently.

Correlation between plasma carbamazepine-10,11-epoxide concentration and drug side-effects in children with epilepsy.

Ninety children with epilepsy were treated with carbamazepine (CBZ) alone or with other anticonvulsant drugs. Side-effects were noted in 14 patients. When 25 patients treated with CBZ alone (group 1) were compared with 27 on CBZ and sodium valproate (group 2) and with 38 on CBZ and one or more other anticonvulsants (group 3), the incidence of side-effects was two in group 1 (of whom one patient had a toxic plasma level of CBZ), but 12 in groups 2 and 3 combined. In all but three of the 14 patients with side-effects, plasma levels of CBZ were within the 'therapeutic range'. A significant difference was found between the carbamazepine-10,11-epoxide (CBZ-10,11-EPOX) levels in plasma and CBZ-10,11-EPOX/CBZ ratio in patients with and without side-effects. For five patients on CBZ and other drugs, changes in treatment resulted in changes in side-effects, and also in CBZ-10,11-EPOX levels. Three of these patients showed an interaction between CBZ and sodium valproate, with a correlation between plasma CBZ-10,11-EPOX and side-effects when either drug was introduced or withdrawn, the plasma levels of CBZ itself and of sodium valproate being within the 'therapeutic range'.

Regional studies of changes in brain fatty acids following experimental ischaemia and reperfusion in the gerbil.

Regional studies of brain phospholipid metabolism were carried out during a period of ischaemia induced in the gerbil by bilateral carotid occlusion for 60 min. The associated changes in free fatty acids (FFAs) during this period and following recirculation for up to 180 min were noted. Following ischaemia there was a generalised rise in the levels of all FFAs with no selective release of either the unsaturated (arachidonic and docosahexaenoic) or saturated (palmitic and stearic) fatty acids. There were no observed differences between the brain regions studied, which is in contrast to previously reported observations for prostaglandins. There was also no indication of any specific phospholipid fraction being involved in FFA release. This would indicate that the release of FFAs from phospholipids is a nonspecific event, probably due to the action of hydrolytic lipases. Restoration of the circulation resulted in a short, sharp increase (within 5 min) in all FFAs, but in contrast to the observations during ischaemia alone there was a relatively larger rise in the unsaturated FFAs as compared to the saturated FFAs. Following this increase there was a gradual general decline in all FFA levels until 180 min of reperfusion. Since there was no preferential depletion of unsaturated FFAs during reperfusion, when free radical attack is considered to be at its maximum, it is our opinion that free radical peroxidation is unlikely to explain the pathology described in our model.

Metabolic interactions of phenytoin in the rat: effect of coadministration with the anticonvulsant drugs sodium valproate, sulthiame, ethosuximide or phenobarbital.

Rats were administered with 50 mg/kg phenytoin (PHT), twice a day, for five consecutive days and with a second anticonvulsant drug in addition for a further five days. Analysis of 24 hr urine samples for content of unmetabolized PHT and its major metabolite 5-(p-hydroxyphenyl)-5-phenylhydantoin (pHPPH) indicates that PHT hydroxylation was significantly inhibited by sulthiame coadministration since during the test period (days 6-10) the concentrations of PHT and pHPPH in urine were significantly increased and decreased respectively. In contrast, sodium valproate, ethosuximide and phenobarbital had no significant effect on the urinary excretion pattern of PHT. These data correlate with changes in plasma and brain PHT concentrations.