Add-on treatment with verapamil in pharmacoresistant canine epilepsy.

PURPOSE: Verapamil add-on treatment has been suggested as a novel therapeutic concept for overcoming transporter-mediated pharmacoresistance. Efficacy data have been limited so far to case reports in individual epileptic patients. Therefore, we aimed to thoroughly evaluate the efficacy and tolerability of verapamil add-on treatment. METHODS: In a prestudy in healthy Beagle dogs the tolerability of verapamil add-on treatment was investigated. The efficacy of verapamil was then evaluated in 11 dogs with phenobarbital-resistant epilepsy. KEY FINDINGS: Verapamil add-on treatment (6.2-7.3 mg/kg) did not affect phenobarbital concentrations in plasma or cerebrospinal fluid. Side effects observed in healthy as well as in epileptic dogs comprised bradycardia and a decrease in blood pressure. Therefore, we had to limit the dosage to 1-1.5 mg/kg in the main study. In phenobarbital nonresponders, verapamil failed to improve seizure control. Verapamil treatment was discontinued prematurely in five animals due to worsening of seizure control or lack of an effect. In the remaining animals, seizure frequency tended to increase during the verapamil add-on phase, reaching a mean of two seizures per month compared to the pre-verapamil phase with phenobarbital monotherapy (mean of 1.4 seizures per month). In view of the detrimental effects in the majority of the dogs, the study had to be discontinued and no further animals were enrolled. SIGNIFICANCE: The failure of the maximum tolerated dosage to improve seizure control in dogs with phenobarbital-resistant epilepsy argues against the suitability of verapamil add-on treatment to overcome pharmacoresistance. Deterioration of seizure control in some individual animals suggests that verapamil might also exert unfavorable effects on seizure thresholds or its spread.

The influence of C3435T polymorphism of ABCB1 gene on penetration of phenobarbital across the blood-brain barrier in patients with generalized epilepsy.

BACKGROUND: Epilepsy is refractory to medical treatment in about one-third of the patients. The exact pathological mechanism of epilepsy pharmacoresistance is still unclear, but a decreased antiepileptic drug (AED) uptake into the brain is suspected to play a role. P-glycoprotein (Pgp), a transmembrane transporter encoded by ABCB1 gene and located at the endothelial cells of the blood-brain barrier (BBB), has been associated with epilepsy pharmacoresistance. OBJECTIVE: To analyze the effect of two ABCB1 gene polymorphisms, C3435T and G2677T/A, on phenobarbital (PB) concentrations in the cerebrospinal fluid (CSF) and serum (S) and to assess the relationship of ABCB1 polymorphisms to phenobarbital penetration across BBB in vivo and seizure frequency. METHODS: CSF PB and S PB concentrations were measured in 60 patients with idiopathic primary generalized epilepsy receiving phenobarbital monotherapy. CSF/S PB concentration ratio was calculated as an index of phenobarbital penetration across BBB. The patients were genotyped for the ABCB1 gene C3435T and G2677T/A polymorphisms. Seizure frequency was recorded during the 6-month phenobarbital monotherapy. RESULTS: Patients with different C3435T polymorphism had significantly different CSF PB concentrations and CSF/S PB concentration ratio. In comparison with CT heterozygotes and TT homozygotes, CC homozygotes had a significantly lower CSF PB concentration (p=0.006) and CSF/PB concentration ratio (p<0.001). G2677T/A polymorphism showed no such effect (p=0.466). CC genotype and low CSF/S PB concentration ratio correlated with increased seizure frequency. CONCLUSIONS: C3435T polymorphism of ABCB1 gene was demonstrated in vivo to significantly influence the CSF/S PB concentration ratio and seizure frequency.

Microdialysis sampling of carbamazepine, phenytoin and phenobarbital in subcutaneous extracellular fluid and subdural cerebrospinal fluid in humans: an in vitro and in vivo study of adsorption to the sampling device.

The purpose of the study was to determine if binding of the drugs to the sampling equipment during microdialysis would influence the results for carbamazepine, phenytoin and phenobarbital. In vitro experiments with microdialysis catheters and separate parts of catheters were performed to estimate the degree of drug binding to the dialysis equipment. A mathematical model to calculate drug binding and recovery is proposed. In vivo protein unbound carbamazepine concentrations in subcutaneous extracellular fluid at different flow rates (6 patients), unbound carbamazepine (1 patient) and unbound phenobarbital (I patient) in subdural cerebrospinal fluid and subcutaneous extracellular fluid were estimated and the in vivo data were compared to the in vitro results and data generated by the mathematical model. Binding to the soft outlet polyurethane tubing was extensive and variable for phenytoin, which precluded in vivo testing, but limited and more predictable for carbamazepine and phenobarbital. None of the three compounds bound to the hard internaltubing. Phenytoin and phenobarbital did not bind to the dialysis membrane, while a small degree of binding may be present for carbamazepine. In vivo estimates of carbamazepine protein unbound subcutaneous extracellular concentrations by microdialysis, adjusted for binding to the plastic tubing, were 81% of protein unbound plasma concentrations. In single case studies, subdural cerebrospinal fluid and subcutaneous extracellular levels of carbamazepine and phenobarbital were similar and when corrected for binding to the plastic tubings they were also close to protein unbound plasma concentrations. Microdialysis can be used for reliable estimations of protein unbound carbamazepine and possibly phenobarbital concentrations when drug binding to the plastic tubing is considered. Reliable estimation of unbound phenytoin is not possible at present.

Blood and cerebrospinal fluid pharmacokinetics of primidone and its primary pharmacologically active metabolites, phenobarbital and phenylethylmalonamide in the rat.

Primidone is a clinically useful antiepileptic drug that is metabolised to two pharmacologically active metabolites phenobarbital and phenylethylmalonamide. As data on the inter-relationship between the systemic and central nervous system pharmacokinetics of primidone and its metabolites are sparse, we have investigated their temporal inter-relationship using a freely behaving rat model which allows repeated sampling of blood (100 microl) and cerebrospinal fluid (CSF; 20 microl). After administration, by intraperitoneal injection (50, 100 or 200 mg/kg), primidone rapidly appeared in both serum (Tmax mean range 1.5-2.5 h) and CSF (Tmax mean range 2.0-3.5 h), suggesting ready penetration of the blood-brain-barrier. This was also the case for phenylethylmalonamide and phenobarbital but peak concentration occurred later. Primidone, phenylethylmalonamide and phenobarbital concentrations rose linearly and dose-dependently in both serum and CSF. The mean free fraction (free/total concentration ratio) for primidone, phenylethylmalonamide and phenobarbital was 0.86, 0.97 and 0.88, respectively, and, as their respective mean CSF/serum ratio values were 0.73, 1.06 and 0.65, it would suggest that equilibration between the blood and CSF compartments is rapid. CSF mean t(1/2) values for primidone, phenylethylmalonamide and phenobarbital were similar to those of sera and essentially paralleled the pattern seen in sera.

Pharmacodynamics of phenobarbital anesthesia and pentylenetetrazol-induced maximal seizures in a rat model of neoplastic spinal cord compression.

The purpose of this investigation was to determine whether paraplegia induced by neoplastic cord compression affects the pharmacodynamics of phenobarbital general anesthesia or of pentylenetetrazol (PTZ)-induced convulsions. Paraplegic rats harboring a thoracolumbar epidural tumor, or an identical hindlimb tumor mass, received an i.v. infusion of phenobarbital until the onset of anesthesia. At that point, the phenobarbital concentrations in the CSF and serum were measured. Similarly, PTZ was infused until the onset of maximal seizures. It was found that changes related to systemic tumor growth and newly developed paraplegia due to neoplastic spinal cord compression did not attenuate the pharmacodynamics of phenobarbital. However, sustained paraplegia of 4 days' duration reduced CNS sensitivity to the hypnotic action of the barbiturate as evidenced by the higher cerebrospinal fluid phenobarbital concentration required to induce anesthesia (170 +/- 31 vs 125 +/- 20 mg/L; P < 0.05). On the other hand, sustained paraplegia did not affect brain threshold concentration for PTZ-induced seizures.

Drogas anticonvulsivantes en suero y líquido cefalorraquideo de pacientes epilépticos: cuantificación por cromatografía líquida / Anticonvulsant drugs in serum and crebrospinal fluid of epileptical patients: liquid chromatography measurement

Se desarrolló un procedimiento de cromatografía líquida de alta presión para cuantificar simultáneamente varias drogas anticonvulsivantes en el suero y líquido cefalorraquídeo de 20 pacientes. Los coeficientes de correlación para las concentraciones en ambos líquidos decarbamazepina, fenobarbital y fenitoína fueron r=0,8588 (p<0,01), r=0,9721 (p<0,01) y r=0,9289 (p<0,01), respectivamente. Las concentraciones de cada droga en líquido cefalorraquídeo representaron porcentajes de la concentración en suero, comparables a los referidos en la literatura. Las concentraciones séricas de carbamazepina en los pacientes sin barbitúricos asociados fueron mayores que las de aquellos bajo politerapia con barbitúricos, independientemente de la dosis. La fenitoína y las concentraciones de fenobarbital en suero y líquido cefalorraquídeo. Estos resultados aqpoyan el uso de la monoterapia para tratar las epilepsias

Gender differences in the pharmacodynamics of barbiturates in rats.

There is considerable evidence of gender differences in the pharmacokinetics of numerous drugs, particularly in rodents, but very limited information concerning the effect of gender on pharmacodynamic characteristics (concentration-activity relationships). In this study, heptabarbital or phenobarbital was administered to male and female rats and the concentrations of these drugs in the brain, cerebrospinal fluid and serum at onset or offset of loss of righting reflex were determined. For heptabarbital, offset concentrations were determined in Lewis rats and onset concentrations in Wistar rats. Onset concentrations of phenobarbital were determined in Wistar rats. In all cases, the barbiturate concentrations in males were significantly lower than those in females at the pharmacologic endpoint. The biologic (serum) half-life of heptabarbital is much shorter in males (approximately 10 min) than in females (approximately 90 min) and this pharmacokinetic difference is reflected by the considerably longer duration of effect of the drug in females.

Kinetics of drug action in disease states. XXXII: Effect of experimental hypertension on the pharmacodynamics of phenobarbital in rats.

The purpose of this investigation was to determine the effect of experimental hypertension on the concentrations of phenobarbital required to produce a defined hypnotic effect (loss of righting reflex) in adult, female Lewis rats. Hypertension was induced with deoxycorticosterone acetate (DOCA), administered by im injection (first experiment) or by pellet implant (second experiment), and 1% NaCl in the drinking water. There were two control groups: one that received im injections of water or a drug-free pellet implant plus 1% NaCl in the drinking water, the other that received water injections or drug-free pellet implants and no NaCl in the drinking water. These treatments were carried out for 3 months and resulted in appreciable elevation of blood pressure and increased heart weight in the DOCA + NaCl-treated (but not in the NaCl alone) rats. All animals then received an infusion of phenobarbital until onset of loss of righting reflex. The concentrations of phenobarbital in the serum, serum water, brain, and CSF of the hypertensive rats at the pharmacologic endpoint did not differ significantly from corresponding concentrations in the control groups (except for a marginal difference of the drug concentration in serum water between the DOCA pellet group and the drug-free pellet control group). It is concluded that DOCA-induced hypertension has no apparent effect on the sensitivity of the central nervous system to the hypnotic action of a barbiturate in female rats.

Phenobarbital for treatment of seizures in preterm infant: a new administration scheme.

The serum concentration of phenobarbital used as an anticonvulsant was monitored in 30 preterm babies. The therapeutic serum concentration was achieved with a loading dose of 20 mg/kg i.v., 10 min after administration. Thirty-six hours after loading, it was possible to maintain therapeutic serum levels with a daily intramuscular dose of 5 mg/kg, avoiding toxicity. A comparison of CSF and serum concentrations indicated that the drug passage to CSF is rapid and depends on a brain lesion. Serum monitoring of phenobarbital is important in preterm neonates under 30 weeks gestation and/or with severe pathological complications.

Staggered stable isotope administration technique for study of drug distribution.

By infusing intravenously a series of different stable isotope labeled forms of a drug at different times prior to performing a single collection of a body fluid via puncture (or tissue via biopsy), one can obtain the same information about a drug's distribution as would be obtained by infusing a single dose of drug and performing serial collections of fluid (or tissue). Application of this technique of "staggered stable isotope administration" is illustrated with a study of entry of phenobarbital into the cerebrospinal fluid of a dog. Advantages and disadvantages of this technique are discussed.

Kinetics of drug action in disease states. II. Effect of experimental renal dysfunction on phenobarbital concentrations in rats at onset of loss of righting reflect.

The purpose of this investigation was to determine if renal dysfunction is associated with an alteration in the concentration-pharmacologic activity relationship of phenobarbital (PB). Adult female rats (congruent to 200 g) were pretreated with uranyl nitate or subjected to bilateral ureteral ligation to produce renal dysfunction. Saline-injected and sham-operated rats, respectively, served as controls. PB (0.824 mg/min) was infused i.v. until the animals lost their righting reflex (LRR). Renal dysfunction reduced the total dose of PB required to produce LRR, the concentrations of total and free (unbound) PB in serum and the concentrations of PB in brain and cerebrospinal fluid at onset of LRR. Results were quantitatively similar in both experimental models of impaired renal function. Concomitant infusion of p-hydroxyphenobarbital (the major metabolite of PB) and PB in rats with uranyl nitrate-induced renal dysfunction had no effect on the PB concentrations at onset of LRR. When PB was infused at different rates (either 0.412, 0.824, 2.04 or 4.12 mg/min), rats with renal dysfunction had increasing concentrations of PB at onset of LRR with increasing infusion rate, not only in serum and brain but also (unlike normal rats) in cerebrospinal fluid. Thus, renal dysfunction is associated with increased sensitivity to PB and with a change in the kinetic relationship between PB in cerebrospinal fluid and in the biophase.

[Concentration of phenobarbital in biological fluids during the treatment of epilepsy patients]. / O kontsentratsii fenobarbitala v biologicheskikh zhidkostiakh pri lechenii bol'nykh épilepsiei.

Using gas liquid chromatography, the authors studied phenobarbital levels in the blood and cerebrospinal fluid of 41 epileptic patients following the administration of this anticonvulsant alone. The data obtained showed variations in the concentration of blood phenobarbital at various time intervals after the intake of the drug and a certain correlation between its level and the therapeutic effect. The ratio of phenobarbital level in the cerebrospinal fluid to that in the blood indicates that phenobarbital penetrates the blood-brain barrier. Fluctuations in the blood phenobarbital content from one administration to another is important for selecting its optimal dosage and the interval between intakes.

Pharmacokinetics and relative bioavailability of intramuscular phenobarbital sodium or acid in infants.

Phenobarbital pharmacokinetics after a single intramuscular dose of approximately 10 mg/kg of phenobarbital sodium or acid were studied in twelve infants with febrile convulsions. The mean peak time after phenobarbital sodium (0.92 hr) was significantly (p less than 0.01) shorter than that after phenobarbital acid (5.83 hr), whereas the mean peak levels (16.2 vs 13.8 microgram/ml) did not reach statistical difference (p less than 0.2) between both dosage forms. The values of the absorption rate constant and the area under the curves calculated from 0- to up to 6-hr periods were significantly higher (P less than 0.001 to 9.005) after the sodium form. There were no significant differences in such parameters as t1/2, Vd/F, and C1/F between the two preparations. The overall mean values of these variables were: t1/2, 64.0 hr, Vd/F, 0.667 1/kg, and C1/F, 0.136 m1/min/kg. Some delay in rising phenobarbital concentration in cerebrospinal fluid (CSF) as compared with that in plasma after phenobarbital sodium was observed, though the absolute values of phenobarbital concentrations in CSF were similar from both dosage forms around the time when peak plasma levels were attained.

Antiepileptic drug distribution in cerebral cortex, ammon's horn, and amygdala in man.

Significant correlations in the concentrations of phenobarbital, phenytoin, and carbamazepine in the brain, plasma, and cerebrospinal fluid were found in 12 surgically treated epileptic patients. These findings confirm the clinical reliability of monitoring anticonvulsant drug plasma levels as part of the routine management of epilepsy. Phenobarbital, phenytoin, and carbamazepine are uniformly distributed in the gray and white matter in different brain areas (except for a higher concentration of phenobarbital in the rhinencephalic structures in comparison with the corresponding temporal neocortex) and in normal and scar tissue. In these 12 patients, all of whom were medically resistant, molar cortex concentration of phenobarbital and phenytoin was at "therapeutic" levels or even higher. These data suggest that in therapy-resistant patients, despite cerebral drug concentrations of the same therapeutic level as, or higher than, those present in medically controlled patients, anticonvulsant drugs are pharmacologically ineffective.