Metabolism of carbamazepine by CYP3A6: a model for in vitro drug interactions studies.

Carbamazepine (CBZ) is widely used in the treatment of epilepsy. The drug is principally metabolized by CYPs to 10, 11-epoxy carbamazepine (CBZ-E) but this metabolite more toxic than the parent drug, does possess anticonvulsant properties. In humans, CYP3A4, CYP2C8 and CYP1A2 have been shown to be implicated in CBZ biotransformation. Our purpose was to establish an experimental model to determine the interaction of CBZ with other antiepileptic drugs. We first identified the CYP isoforms that metabolized CBZ in rabbit. We used liver microsomes from rabbit treated with various compounds known to induce principally some CYPs subfamilies. Having tested all the compounds we demonstrated that only the animals treated with CYP3A inducers were able to metabolize CBZ strongly. The CBZ biotransformation was inhibited by anti CYP3A antibodies. All the CYP3A subfamily substrates specifically decrease CBZ-E formation. In our experiment we did not observe any inhibition with CYP2C substrate. These data provide evidence that in rabbit the CYP3A subfamily is primarily involved in CBZ metabolism. Using this model we investigated the interaction of CBZ with phenobarbital, phenytoin, ethosuccimide, primidone, progabide, vigabatrin and lamotrigine.

[Drug resistant epilepsy in Senegal: therapeutic, clinical and socioeconomic factors]. / Epilepsies pharmacorésistantes au Sénégal: facteurs thérapeutiques, cliniques et socio-économiques.

The aim of our study was to emphasize factors which support pharmaco-resistance in Senegal. For this purpose, 23 patients with partial or generalized epilepsy were studied, after determining the plasmatic concentration of the antiepileptic drugs. The aetiologies were numerous: encephalitis, injuries, neonatal encephalitis. All patients were under traditional treatment before coming to the hospital. So antiepileptic drugs were taken a long time after the beginning of epilepsy later, they were Phenobarbital, Carbamazepine, Phenytoin, and Valproic acid. Only seven patients had sufficient plasmatic level of the antiepileptic drug. The low socio-economic conditions of patients which limit the choice of the most adapted drug in each case, is one of the most important reason of the pharmaco-resistance. Another factor of the pharmaco-resistance is cultural and is linked with the absence of notion of chronic disease necessitating long and regular treatment in senegalese traditional society.

Carbamazepine intoxication with negative myoclonus after the addition of clobazam.

We report a case a carbamazepine (CBZ) intoxication with negative myoclonus that occurred 4 weeks after clobazam (CLB) had been added to a stable regimen of CBZ and topiramate (TPM). Both CBZ and CBZ-epoxide (CBZ-E) blood levels were elevated, and the symptoms resolved quickly when CBZ dosage was reduced and CLB discontinued. CLB was reintroduced a year later with the patient's consent, and the time course of the interaction was studied: CBZ and CBZ-E levels increased slowly over 12 days. The interaction is thus probably related to the progressive increase in Nor-CLB.

Steady state pharmacokinetics of carbamazepine-phenobarbital interaction in patients with epilepsy.

Two carbamazepine (CBZ) tablet formulations (conventional, CBZ-CO, or controlled release, CBZ-CR) are commonly prescribed in monotherapy or in comedication with phenobarbital (PB) in the treatment of epilepsies. This study compares the pharmacokinetics of CBZ-CO against CBZ-CR in patients with epilepsies chronically treated with CBZ in monotherapy or CBZ-PB in bitherapy, the effect of PB on CBZ-CO and CBZ-CR pharmacokinetic parameters, and the effect of the two formulations of CBZ on PB pharmacokinetic parameters. The absorption rate constant (Ka), apparent steady state volume of distribution (Vdss/F), and apparent total clearance (CL/F) were computed with the APIS software using blood level profiles from 34 patients divided into four groups: patients receiving either CBZ-CO or CBZ-CR in monotherapy, or CBZ-CO or CBZ-CR in comedication with PB. The results show that the lowest dispersion of pharmacokinetic parameters was in patients receiving CBZ-CR in monotherapy. The CBZ formulation alters CBZ Ka, (Vdss/F) and (CL/F) values. CBZ (CL/F) also depends on the treatment (presence or absence of comedication by PB). In patients receiving PB in comedication with CBZ, the formulation of CBZ has no effect on PB pharmacokinetic parameters. These changes may be clinically significant and should be taken into account.

Ursodeoxycholate improves hepatobiliary dysfunction induced by valproate-carbamazepine treatment in the rat.

Carbamazepine (CBZ) and valproate (VPA) are commonly used antiepileptic drugs. These drugs, either alone or combined, may produce hepatotoxicity. We report results of a biochemical and histological study of the liver in rats treated for eight days with VPA (500 mg/Kg/day), CBZ (200 mg/Kg/day) and VPA plus CBZ. A hepatoprotective bile salt, ursodeoxycholate (UDC, 60 mg/Kg/day) was given as a supplement to rats treated with the VPA+CBZ combination. VPA strongly modified the biliary biochemical parameters inducing hypercholeresis and hyposecretion of phospholipids. Microscopically, hepatocytes showed intense vacuolation of the peripheral cytoplasm and alterations of the mitochondrial matrix. CBZ produced increased choleresis but had no effect on biliary lipid parameters. Ultrastructurally, CBZ induced marked proliferation of the smooth endoplasmic reticulum of hepatocytes. The VPA+CBZ association produced a combination of the alterations induced independently by each drug. In both bile and plasma, increased CBZ-epoxide and decreased VPA levels were observed. The addition of UDC restored the biliary phospholipid secretion, decreased cytoplasmic vacuoles and mitochondrial alterations, and diminished the hypertrophy of smooth endoplasmic reticulum, indicating a clear beneficial effect of UDC on hepatobiliary dysfunction induced by the VPA+CBZ combination. Furthermore, the supplementation with UDC did not significantly change the plasma levels of the antiepileptic drugs.

Improvement of cyclosporin A-induced cholestasis by tauroursodeoxycholate in a long-term study in the rat.

Cyclosporin A is an essential immunosuppressive drug, but it is potentially toxic to the kidney and liver. Ursodeoxycholic acid, a hydrophilic bile acid, has been reported to improve cholestasis in liver disease in man. The purpose of this work was to examine whether tauroursodeoxycholate could reduce cyclosporin A-induced hepatic or renal injuries in the rat. After randomization into three groups (N = 8), rats received daily for 17 days: cyclosporin A intraperitoneally alone (30 mg/kg) or cyclosporin A intraperitoneally and tauroursodeoxycholate (60 mg/kg) by gavage; control received the cyclosporin A excipient. Under tauroursodeoxycholate, cholestatic parameters (bile flow, bile salt secretion, serum bile salts, serum bilirubin) improved significantly without affecting cyclosporin A blood levels, and excretion of the drug and its metabolites in bile increased by 47%. Serum creatinine levels were better preserved, although not significantly. These results show that tauroursodeoxycholate prevents cyclosporin A-induced cholestasis in long-term treatment in rats, possibly by facilitating the drug elimination in bile.

Diminution of an acute cyclosporin-induced cholestasis by tauroursodeoxycholate in the rat.

CsA is a commonly used immunosuppressive drug known to possibly induce cholestatic side effects. Ursodeoxycholic acid (UDC), a nonhepatotoxic bile acid, has proved to be efficient for several types of cholestasis. The aim of this experiment was to evaluate the ability of tauroursodeoxycholate (TUDC) in preventing CsA-induced cholestasis on bile duct-cannulated rats. After bile flow stabilization, a bolus of 30 mg/kg CsA was given i.v. to one group (n = 7) and was associated with a 2 mumol/kg/min TUDC infusion in another group (n = 7). The control group was injected with CsA-solvent. CsA, as used here, had a rapid and marked cholestatic effect. However, both bile flow and bile salt secretion were significantly enhanced in the TUDC group when compared to the CsA alone-treated group and showed no difference with the solvent control group. In addition, TUDC significantly increased elimination of CsA and its metabolites in bile. In contrast to what was found for endogenous bile salts, TUDC uptake was not affected by CsA. The anticholestatic effect of TUDC probably resulted from preventing CsA-induced hepatocyte membrane damage and from easing biliary excretion of CsA. Such properties could be helpful for CsA-treated liver recipients who are especially exposed to cholestatic problems, and thus, to toxic CsA accumulation in the liver. Moreover, regulation of CsA elimination might prevent, in part, its general toxicity.

Central analgesic effect of valproate in patients with epilepsy.

Clinical practitioners have often observed in the course of their daily work that the pain thresholds of epileptic patients seem to differ from those of healthy subjects. These patients can suffer from quite severe traumatic lesions without apparently experiencing any pain. Previous studies have shown that the absence of pain is due to treatment, since most antiepileptic drugs also have analgesic effects. In the present study, it was proposed to assess the pain thresholds of 15 epileptic patients (with tonic-clonic seizures generalized at outset) treated with valproate, by measuring the leg flexion nociceptive reflex (or RIII reflex) threshold: the stimulation threshold at which this reflex is triggered is known to be correlated with the pain threshold. The results were compared with 15 control subjects. The nociceptive threshold of the patients with valproate treatment was significantly higher than that of the control population. The nociceptive threshold was also in good correlation with the valproate plasma level. These data are discussed from the point of view of the gaba-ergic system and mechanisms possibly involved.

Steady state pharmacokinetics of conventional versus controlled-release carbamazepine in patients with epilepsy.

The purpose of the present study was to compare the pharmacokinetic parameters of two carbamazepine (CBZ) tablet formulations (conventional (CBZ-CO) and controlled-release (CBZ-CR)) in patients with epilepsy receiving the drug as monotherapy or polytherapy. The absorption rate constant (Ka), steady-state volume of distribution (Vdss) and total clearance (CL) were computed with the APIS software using 31 blood level profiles from 23 patients who were divided into four groups: patients receiving CBZ-CO in polytherapy, the same patients switched to CBZ-CR in the same polytherapy conditions, patients receiving CBZ-CO in monotherapy and patients receiving CBZ-CR in monotherapy. The four groups were compared in order to assess the significance of differences in Ka, Vdss, CL and diurnal fluctuations of plasma CBZ concentration. The results show a significant decrease of the Ka in the CBZ-CR groups compared to the CBZ-CO groups, both on monotherapy and on polytherapy. The comparison between the monotherapy and polytherapy groups shows increases of Vdss and CL, both in CBZ-CO and CBZ-CR polytherapy groups. Dispersion of pharmacokinetic data was higher in patients on CBZ-CO; among patients on CBZ-CR, dispersion was lowest in the monotherapy group. Clinical improvement was found in four of eight patients switched from CBZ-CO to CBZ-CR. CBZ-CR is therefore a valuable alternative to CBZ-CO.

Interactions between clobazam and standard antiepileptic drugs in patients with epilepsy.

We retrospectively collected plasma level assessments performed in 96 adult patients with epilepsy on stable monotherapy, including 9 patients on clobazam (CLB), 34 on carbamazepine (CBZ), 24 on phenobarbital (PB), 9 on phenytoin (PHT), and 20 on valproate (VPA); these results were compared to those obtained in 54 adult patients on stable bitherapy with the association of CLB with either CBZ (n = 17), PB (n = 17), PHT (n = 5), or VPA (n = 15). Our results show that CLB has no significant effect on the level to dose ratio (LDR) of CBZ, PB, PHT, or VPA. Conversely, CBZ, PB, and PHT significantly decrease the LDR of CLB. CBZ and PHT significantly increase the LDR of N-desmethylclobazam (NCLB), the major metabolite of CLB. A significant increase in the NCLB/CLB ratio was found in CBZ + CLB, PB + CLB, and PHT + CLB bitherapies. These findings are of clinical significance: clobazam is useful as adjunctive treatment in human epilepsy and is often chosen as the benzodiazepine adjunctive drug in chronic resistant epilepsy. Sedative side effects may occur, especially in patients treated by a CBZ + CLB or PHT + CLB bitherapy, and both CLB and NCLB plasma levels should be monitored in such patients.

Distribution of carbamazepine and its epoxide in blood compartments in adolescent and adult epileptic patients.

Carbamazepine (CBZ) used in the treatment of epilepsy, is metabolized in man to an active metabolite: carbamazepine 10-11 epoxide (CBZ-E). CBZ and CBZ-E concentrations in the different blood compartments (plasma ultrafiltrate, plasma proteins, and red blood cells (RBC)) of epileptic patients on CBZ monotherapy were assessed using HPLC. The highest CBZ and CBZ-E level to dose ratios were observed in the RBC. For CBZ and CBZ-E significant correlations were found between some blood compartments particularly between RBC and plasma ultrafiltrate. The measurement of CBZ and CBZ-E in all blood compartments may be interesting in uncontrolled patients and in patients presenting side-effects which cannot be explained by total plasma concentration values.

Nociceptive threshold in patients with epilepsy.

Clinical practitioners have often observed in the course of their daily work that the pain thresholds of epileptic patients seem to differ from those of healthy subjects. These patients can suffer from quite severe traumatic lesions without apparently experiencing any pain. Since they are usually under treatment for epilepsy, it is difficult to determine whether the absence of pain is due to these patients' epileptic condition or to its treatment, since most antiepileptic drugs also have analgesic effects. In the present study, it was proposed to assess the pain thresholds of 15 epileptic patients (10 with tonic-clonic seizures generalized at outset and 5 with temporal lobe epilepsy), by measuring the leg flexion nociceptive reflex (or RIII reflex) threshold: the stimulation threshold at which this reflex is triggered is known to be correlated with the pain threshold. The nociceptive threshold of the patients with generalized epilepsy was not found to differ from that of the control population, whereas that of the patients with temporal lobe epilepsy was spontaneously high and was not reversed upon injecting naloxone. These data are discussed from the point of view of the pain pathways and mechanisms possibly involved.

Epilepsy, antiepileptic drugs, and malformations in children of women with epilepsy: a French prospective cohort study.

We conducted a prospective study of teratogenic effects of antiepileptic drugs (AEDs) in pregnant women with epilepsy in southeast France, comparing malformation rates with those collected by a birth defects registry. We evaluated isolated microcephalies separately. Malformations were seen in 7% of infants of mothers with epilepsy (IME) and in 1.36% of the general population. No significant relationship was found between type and severity of epilepsy and occurrence of malformations or isolated microcephaly. Valproate and phenytoin were the most teratogenic (all malformations). None of the malformations observed in IME whose mothers received valproate, phenytoin, or phenobarbital was seen in IME not exposed to the respective AEDs. Phenytoin plus phenobarbital was more teratogenic than phenobarbital alone. Benzodiazepines, prescribed only in combinations, had a borderline, nonspecific effect on microcephaly.

GABAA sodium independent receptor sites in a strain of rats presenting generalized non-convulsive seizures.

The role of gamma-aminobutyric acid (GABA), a major inhibitor neurotransmitter in the central nervous system (CNS), is well established in the genesis and the control of epilepsies. The purpose of this work was to study the binding parameters of the Na(+)-independent GABA receptors in the brain of a strain of rats presenting spontaneous generalized non-convulsive seizures. The high- and low-affinity binding sites were evaluated in cerebral cortex, cerebellum, and hippocampus using [3H]muscimol. No significant modification was observed for the Bmax and the Kd of high-affinity binding sites, although a slight decrease of Bmax was noted in the three brain areas in rats with seizures. Concerning the low-affinity binding sites, significant decreases were observed in the values of Bmax in the cortex, cerebellum, and hippocampus of animals with spontaneous seizures, without modification of Kd values. Such changes could be considered to be involved in some of the physiological and behaviour activities observed in this strain of rats.

[Serum beta-glucuronidase activity in patients with epilepsy]. / Etude de l'activité de la bêta-glucuronidase sérique chez le malade épileptique.

Little information is available on the effect produced by antiepileptic drugs on the serum beta-glucuronidase activity. According to recent findings, beta-glucuronidase serum levels are increased in patients with epilepsy just before the beginning of seizures and remain increased during several weeks; this it is suggested that determination of this enzyme could be important in the provision and the treatment of seizures. The purpose of the present study attempts to understand these changes. Our study was carried out on 49 adult healthy subjects and 48 adult epileptic patients receiving anticonvulsant therapies. Serum beta-glucuronidase activity was determined by a simplified procedure employing phenolphtalein glucuronic acid as substrate. The mean +/- SEM of serum beta-glucuronidase activity in treated patients (40.93 +/- 5.01 MSU/ml) was significantly higher than those of the healthy subjects (25.04 +/- 3.40 MSU/ml). In conclusion, the relationship between changes in serum enzyme activity, seizures and anticonvulsant therapies suggests that the determination of serum beta-glucuronidase activity presents a weak interest in predicting or treating seizures.

Antinociceptive action of picrotoxin in the mouse.

Picrotoxin, an antagonist of GABA-associated chloride ionophores with convulsant activity, possesses antinociceptive activity in the hot-plate and writhing tests in the mouse. Analgesia produced by a subconvulsant dose of picrotoxin (0.75 mg/kg, s.c.) was reversed by naloxone (1.0 mg/kg, s.c.), atropine (5 mg/kg, i.p.), and methysergide (10 mg/kg, i.p.) in the jumping reaction (hot-plate test). These data indicate that opiate pathways, as well as cholinergic and serotoninergic pathways could be involved in the mechanism that underlies picrotoxin-induced analgesia. Furthermore, such results should be considered when interpreting the behavioral effects of picrotoxin.

Valproate increases diazepam impregnation selectively in CNS of the rat after subchronic administration.

Valproate-Diazepam association is not unusual in the treatment of epilepsies. The present paper investigates in an experimental study the effect of sodium valproate (VPA) on the regional cerebral level of diazepam (DZP), and the relationship with plasma or erythrocytes amounts after subchronic administration. The VPA addition increases the DZP levels in peripheral and central compartments. The results shows a linear correlation between the drug concentration in all areas studied and the plasmatic or erythrocytic amounts during the CNS - impregnation phase. The VPA influence is greater in the CNS where the DZP impregnation is selectively increased, specially in cortex and cerebellum.

Diazepam: kinetic profiles in various brain areas, plasma and erythrocytes after chronic administration in the rat.

The regional distribution of diazepam (DZP) was established in eleven discrete brain areas in the rat after i.m. chronic treatment (15 days; 5 mg/kg/day). In addition, the kinetic profiles of this drug were investigated in plasma, eryhtrocytes, and three CNS regions (nucleus caudatus, hippocampus, and cerebellum) upon which the pharmacokinetic study was focused. The modifications occuring in plasma-protein binding and erythrocytes binding were reported. In the CNS, the DZP was rapidly distributed; its concentrations and its kinetic profiles were not uniform in the different brain areas studied. The highest amount of DZP was noted in the hypothalamus, while nucleus caudatus and colliculi also presented important DZP levels. Concerning the kinetic parameters after chronic administration, an increase in the elimination half-life time value in central and peripheral compartments, as compared to values reported after acute administration, was observed. The study of cerebral DZP levels as compared with those in the erythrocytes or in plasma suggests a linear correlation in the three CNS areas investigated. These experimental results demonstrate the interest of such studies for psychotropic drug monitoring.

Effects of sodium valproate on diazepam: kinetic profiles in plasma, erythrocytes, and different brain areas in the rat.

The kinetic profiles of diazepam (DZP) were investigated in plasma, erythrocytes, and discrete brain areas in the rat, and the effects of valproic acid (VPA), given as sodium valproate, on kinetic parameters were analyzed. The experiments were performed on two groups of rats treated daily for 15 days, the first receiving only DZP (5 mg/kg/day i.m.), the second treated with DZP (5 mg/kg/day i.m.) and VPA (200 mg/kg/day i.p.). Our results indicate that VPA influences the plasma-protein binding and erythrocyte levels of DZP, as well as its kinetic profile. These data are discussed with regard to the modifications observed in the different brain areas (cerebellum, hippocampus, whole cortex, and pons-medulla) during administration of VPA and DZP. The results presented in this study offer evidence that VPA exerts a peculiar action on the "impregnation" and kinetics of DZP in the CNS, and therefore these findings may be of importance in clinical pharmacology and treatment of epilepsies.

Distribution of sodium valproate and GABA metabolism in CNS of the rat.

The distribution of VPA has been investigated in several brain areas of the rat, and GABA increases were measured. A biphasic exponential decay was observed for VPA; the slowest decrease was noted in the olfactory bulbs and in the hypothalamus where GAD and GABA-T activities were the highest. The data may be correlated with the prolonged effect of VPA in these areas.