Six-month evaluation of Carbatrol (extended-release carbamazepine) in complex partial seizures.

We evaluated the use of a new, controlled-release capsule form of carbamazepine, Carbatrol capsules, in an open-label, multicenter study of 124 patients with complex partial seizures. Ninety-one percent of the patients successfully completed the 6-month trial with good seizure control, with a significant improvement in quality of life. We conclude that switching patients with complex partial seizures from multiple daily-dose carbamazepine to twice-daily Carbatrol on a milligram-to-milligram basis is relatively safe.

Pharmacokinetic evaluation of twice-daily extended-release carbamazepine (CBZ) and four-times-daily immediate-release CBZ in patients with epilepsy.

PURPOSE: A new capsule dosage form of carbamazepine (CBZ) has been developed, consisting of three different types of beads (immediate-release, extended-release, and enteric-release) that may be taken sprinkled on food or swallowed for easy administration. We compared the pharmacokinetics of the extended-release dosage form of CBZ (Carbatrol capsules) twice daily with the conventional immediate-release formulation of CBZ four times daily. METHODS: The randomized, double-blind, two-way, cross-over study was conducted at two sites, with a planned sample size of 24 adult patients with epilepsy. Each treatment was administered for 2 weeks. At the end of the 2-week period, blood samples were obtained hourly for a 24-h period. RESULTS: The 90% confidence intervals (CI) of the ratio of the means of the extended-release formulation twice daily to the immediate-release formulation four times daily were within the range of 0.80-1.25 for each of the pharmacokinetic parameters for CBZ and for the summation of CBZ and CBZ-epoxide (CBZ-E). There was no difference in the frequency of seizures between treatment (p = 0.103). CONCLUSIONS: Our results demonstrate that extended-release CBZ twice daily was bioequivalent to immediate-release CBZ four times daily, with regard to CBZ levels and summation of CBZ and CBZ-E levels, based on the pharmacokinetic parameters evaluated. Substituting one formulation for the other did not cause patients to have a significant change in seizure frequency.

Butyrylcholinesterase: an enzyme antidote for cocaine intoxication.

Cocaine-associated toxicity is the result of effects on the cardiovascular and central nervous systems. Since the primary route of cocaine inactivation is enzymatic degradation by butyrylcholinesterase (BChE), we sought to determine if the administration of purified human enzyme would ameliorate the lethal effects of cocaine. While the cardiovascular, autonomic or central nervous systems were unaffected by BChE, the enzyme reduced the adverse effects of cocaine including hypertension, hyperactivity and convulsions. BChE decreased both the brain and blood levels of cocaine and shifted the metabolites towards the production of the inactive product ecgonine methyl ester and away from the physiologically active metabolites, norcocaine and benzoylecgonine. We conclude that BChE would appear to be an ideal antidote in the treatment of cocaine intoxication and has potential therapeutic application.

Plasma butyrylcholinesterase activity and cocaine half-life differ significantly in rhesus and squirrel monkeys.

In vitro studies have implicated butyrylcholinesterase (BChE, E.C.3.1.1.8) as the major enzyme for metabolizing cocaine in humans, but little is known about endogenous BChE activity in monkeys and other animals often used in preclinical studies of cocaine. We compared BChE activity in 18 rhesus and 11 squirrel monkeys, using the colorimetric method of Ellman with butyrylthiocholine as substrate, and in vitro cocaine half-life in pooled plasma samples measuring cocaine concentrations over 60 minutes by GC-MS. Rhesus monkeys had a significantly higher plasma BChE activity than squirrel monkeys (8.2 +/- 0.5 U/L vs. 2.8 +/- 0.5 U/L), and a three-fold shorter in vitro cocaine half-life (20.1 min vs. 60.2 min). BChE activity in rhesus monkeys was comparable to the activity reported in humans. There was no significant influence of age, weight, or prior cocaine exposure. These results indicate that BChE level can vary between species of non-human primates, a factor that should be taken into account when studying drugs such as cocaine which are metabolized by BChE.

The treatment of neurosarcoidosis with cyclosporine.

Six patients with refractory neurosarcoidosis were enrolled in a 12-month open-label trial to investigate the safety and efficacy of cyclosporine therapy. Patients were stabilized on a corticosteroid dose, randomized to a low-dose or high-dose cyclosporine group (with appropriate target whole blood cyclosporine levels) for 6 months, and assessed by prospectively defined studies. The corticosteroid dose was adjusted as clinically tolerated. We found that the corticosteroid dose could be lowered to 30% to 58% of the initial stabilization dose in conjunction with cyclosporine therapy, at the time of maximal clinical and laboratory improvement. However, four patients deteriorated while using corticosteroids and cyclosporine; one of these patients died. At the time of clinical deterioration, the prednisone dose ranged from 6 to 22.5 mg daily (or the equivalent). No serious toxic effects developed from cyclosporine therapy. Cyclosporine treatment is a reasonably safe and effective adjunct to corticosteroid therapy for patients with refractory neurosarcoidosis, although clinical deterioration can occur despite combination therapy.

A double-blind study of the effectiveness of cyclosporine in amyotrophic lateral sclerosis.

In a double-blind placebo-controlled trial of cyclosporine in amyotrophic lateral sclerosis, no differences were observed in the monthly rate of progression or the relative risk of progression in comparing 38 patients randomized to the placebo group and 36 patients randomized to the cyclosporine group. In comparing three subgroups of patients, cyclosporine appeared to benefit men who entered the study within 18 months of the onset of first symptoms, whereas it was of no value to women or to men who entered later than 18 months. For the men with recent onset of disease, the relative risk of progression was 0.403; the monthly rate of progression was 5.2 +/- 1.1 points with placebo and 3.5 +/- 0.7 points with cyclosporine. These provocative results support the need for a full study of cyclosporine in men with recent onset of disease.

Preliminary results of a double-blind, randomized, placebo-controlled trial of cyclosporine in myasthenia gravis.

We randomly assigned 20 patients with progressively worsening generalized myasthenia gravis of recent onset whose illness was not controlled by anticholinesterase therapy to treatment with either cyclosporine (6 mg per kilogram of body weight per day) or placebo. Patients who had been treated with thymectomy, steroids, or other immunosuppressive agents were excluded. The duration of treatment was 12 months. Disease activity was assessed by quantified strength testing and by measurements of antihuman acetylcholine-receptor antibody. Patients were assessed at 6 months and 12 months, or at the following early end points: drug failure (doubling of creatinine), treatment failure (respiratory or swallowing difficulty), or protocol violation (stopping medication for more than five days). At six months, patients in the cyclosporine group had had significantly more objective improvement in strength; one early end point had been reached (drug failure; no treatment failures). In the placebo group, three early end points had been reached (all treatment failures). The decline in titers of acetylcholine-receptor antibody was larger in the treated group, although the difference was not statistically significant. At the end of the study (after 12 months of treatment or arrival at an earlier end point), improvement in strength and reduction in titers of anti-receptor antibody continued to be greater in the cyclosporine group. Nephrotoxicity occurred in three patients receiving cyclosporine but was nonprogressive with a reduction in dosage and reversible with discontinuation of the drug. These results are preliminary and need confirmation, but we conclude that cyclosporine is probably an effective therapy in some patients with myasthenia gravis.

Neurotransmitter abnormalities in patients with motor neuron disease.

In 22 patients with motor neuron disease (MND), the mean concentration of serotonin (5HT) in platelets was slightly increased, platelet monoamine oxidase (MAO) activity was significantly increased, and plasma concentrations of total and both free and bound tryptophan were significantly decreased. Though platelet MAO activity was positively correlated with concentrations of 5HT, independent causal mechanisms are probable. When patients were rated according to severity, highest values of platelet 5HT and MAO activity were found in the most severely affected group, whereas concentrations of both total and protein-bound tryptophan were most decreased. Changes in concentrations of 5HT and tryptophan may reflect compensatory changes in response to degeneration of motor neurons or to interruption of their monoaminergic innervation.

Blood tryptophan metabolism in chronic schizophrenics.

Concomitant measures of blood indole metabolism were conducted in 33 chronic schizophrenics who showed significantly elevated mean platelet serotonin (5-HT) values and lower platelet monoamine oxidase (MAO) and plasma amine oxidase activities than normals. When subdivided according to Research Diagnostic Criteria diagnosis, the 20 chronic undifferentiated (CU) schizophrenics showed these same deviations from normal; the 13 chronic paranoid (CP) schizophrenics also had significantly higher mean 5-HT values but significantly lower plasma concentrations of total and bound tryptophan. In CP schizophrenics, platelet MAO activity, but not plasma amine oxidase activity, was significantly lower than in CU schizophrenics and controls. Hyperserotonemia occurred in 11 of the chronic patients (33%); nine were CU schizophrenics. In the latter, total tryptophan concentration was significantly lowered. Hyperserotonemia was not associated with reduced liver tryptophan pyrrolase activity or platelet MAO or plasma amine oxidase activities; rather, it may be a consequence of enhanced tissue tryptophan uptake and utilization.

Blood monoamine metabolism in Huntington's disease.

In 25 patients with Huntington's disease (HD), the mean blood concentration of serotonin (5-HT) and percentage of plasma free tryptophan were significantly increased while plasma concentrations of total and protein-bound tryptophan were significantly decreased. The pattern of changes in tryptophan concentrations was related to clinical severity but not to 5-HT levels. Platelet monoamine oxidase (MAO) activity was significantly increased in patients with HD; kinetic and marker enzyme studies suggested an increased enzyme concentration. Offspring at risk for HD also had elevated platelet MAO activity but normal concentrations of blood 5-HT and plasma tryptophan. In ten patients, plasma epinephrine concentrations were significantly increased; plasma dopamine and norepinephrine concentrations were positively related to MAO activity. The finding of peripheral neurotransmitter abnormalities in HD raises the question of an interaction between CNS and peripheral processes or a systemic disorder of neurotransmitter metabolism.

CTP-phosphatidic acid cytidyltransferase from Saccharomyces cerevisiae. Partial purification, characterization, and kinetic behavior.

CTP-phosphatidic acid cytidyltransferase catalyzes the formation of CDP-diglyceride from CTP and phosphatidic acid. The enzyme was solubilized from crude mitochondrial membrane by treatment with digitonin and was further purified by chromatography on DEAE-Sephadex, quaternary aminoethyl (QAE) Sephadex, and Sepharose 6B columns. At this stage the enzyme, enriched 550-fold over crude cell homogenate, still remains associated with phospholipid and has an estimated approximate molecular weight of 400,000 on the basis of gel filtration chromatography. Sodium dodecyl sulfate polyacrylamide gel electrophoresis of the 550-fold enriched enzyme yielded two major protein bands having molecular weights of 45,000 and 19,000. The enzyme exhibits an absolute dependence on Triton X-100, a sharp Mg2+ dependence with an optimum at 20 mM, and a pH optimum of 6.5 for activity. The product of the CTP-phosphatidic acid cytidyl-transferase reaction has been isolated and identified as CDP-diglyceride, both for the crude enzyme preparation as well as for the 550-fold enriched enzyme. CTP-phosphatidic acid cytidyltransferase is capable of catalyzing the reverse reaction in the presence of pyrophosphate, utilizing CDP-diglyceride as substrate. The product of the reverse reaction was identified as CTP. Kinetic analysis of the behavior of CTP-phosphatidic acid cytidyltransferase was performed at three different stages of its purification. Initial analysis of the data yielded biphasic behavior in double reciprocal plots with respect to both substrates. Hill plots of the data indicated the presence of negative cooperativity. A detailed analysis of the kinetic behavior was performed on the enzyme purified 550-fold. The data suggest a mechanism involving two distinct cycles of catalysis, responsive to homotropic modification, with different affinities for both substrates. Further analysis of the kinetic behavior in the presence of inhibitors (dCTP and PPi) yielded a reaction order for the entrance of substrates and departure of products from the reaction cycles. The high affinity site catalyzes the reaction via a double displacement mechanism and is the predominant form at low concentrations of substrates. At high concentrations of substrates the low affinity site starts contributing significantly to the reaction velocity with an ordered single displacement mechanism. In each case CTP is the first substrate to attach and PPi is the first product released.