Pharmacokinetic and pharmacodynamic drug interactions during treatment with vigabatrin.

Pharmacokinetic drug interactions take place when one drug interacts with another at the level of metabolism, absorption or excretion. Pharmacodynamic interactions take place at the level of receptor sites, where they may have additive or potentiating effects. Vigabatrin is relatively free of pharmacokinetic interactions, and though it is associated with about a 20% decrease in serum levels of concomitantly administered phenytoin, the reduction is of little clinical significance. The mechanism underlying this effect is unknown. Because vigabatrin increases GABA-mediated inhibition in the brain (an action that is believed to account for its anticonvulsant effects), it might be expected to potentiate the CNS effects of benzodiazepines and alcohol. However, very sensitive eye movement studies have failed to detect any evidence of such an interaction. Overall, vigabatrin appears to be remarkably free of drug interactions. As a result, it is easier to use in clinical practice than older anti-epilepsy agents. Perhaps the most important finding of the interaction studies with vigabatrin is that there is no need for patients receiving the drug to be told to avoid alcohol.

Effect of single doses of sodium valproate on serum phenytoin levels and protein binding in epileptic patients.

Our study underlines the importance of performing protein binding interaction studies in vivo. Predictions from in vitro studies may be misleading because they may not take into account the kinetics of the drug in the whole animal. Probably the most important clinical implication of these findings is that total serum phenytoin levels may fall when sodium valproate is added to therapy and this may lead to an increase in dose under the mistaken belief that the effect of the drug has been reduced. Since it is the bound and not the free drug which is reduced, phenytoin intoxication may result from this misguided action.

Is phenytoin metabolism dose-dependent by enzyme saturation or by feedback inhibition?

The suggestion from animal experiments that phenytoin metabolism may be dose-dependent in man due to feedback inhibition by the major metabolite, 5-(p-hydroxyphenyl)-5-phenylhydantoin, was examined in 3 normal subjects by measuring phenytoin clearance during an intravenous infusion of the metabolite and during a control infusion of solvent. Clearance was measured using both carbon-labeled and unlabeled phenytoin. The infusion of metabolite did not produce any consistent change of phenytoin clearance, suggesting that feedback inhibition does not occur in man.

Effect of atenolol, metoprolol, and propranolol on isoproterenol-induced tremor and tachycardia in normal subjects.

The effect of single oral doses of atenolol (100 mg), metoprolol (100 mg), propranolol (40 mg), and placebo on exercise tachycardia and on heart rate and finger tremor responses to graded injections of isoproterenol was investigated in six normal subjects. Propranolol was more potent than atenolol and metoprolol in suppressing the increase in heart rate and tremor amplitude produced by isoproterenol, even though at the dose used it was the least effective of all three drugs in decreasing exercise tachycardia. Although these data are consistent with the hypothesis that the suppression of isoproterenol-induced tremor is mediated by antagonism of peripheral beta 2-adrenergic receptors, the possibility that a separate action other than beta-blockade may contribute to the tremorolytic action of propranolol cannot be excluded. The potential usefulness of examining the effect of beta-adrenoceptor blocking drugs on isoproterenol-induced tremor and tachycardia in cardioselectivity studies is discussed.

Propranolol and sotalol as antagonists of isoproterenol-enhanced physiologic tremor.

Six normal subjects were studied after graded bolus injections of isoproterenol. Log dose-response curves for increases in both heart rate (mostly beta 1), and amplitude of physiologic tremor (beta 2) were constructed for each subject in the control state and 2 hr after 10 or 40 mg propranolol, 200 mg sotalol, or placebo. All heart rate curves were shifted to the right in an approximately parallel fashion by all active treatments (40 mg propranolol greater than 200 mg sotalol greater than 10 mg propranolol). The tremor curve was also shifted to the right by 10 mg propranolol in an approximately parallel fashion and to the same extent as the heart rate curve (both dose-ratios = 6.1), but the tremor curves after both 40 mg propranolol and 200 mg sotalol appeared to be flattened as well as shifted laterally. We conclude that whereas it may be possible that 10 mg propranolol acts as a competitive antagonist of isoproterenol at beta 2-sites in skeletal muscle, 40 mg propranolol and 200 mg sotalol must have additional actions in reducing isoproterenol tremor. The possibilities are discussed.

The influence of age on the pharmacokinetics of the antiepileptic agent oxcarbazepine.

The disposition of oxcarbazepine was studied in 12 young and 12 elderly healthy male and 12 young and 12 elderly healthy female volunteers, with emphasis on the influence of age. Oxcarbazepine was administered as a single dose of either 300 mg (men) or 600 mg (women), followed by multiple-dose (300 mg) administration twice a day for 7 days (men) or 6 days (women). Semilogarithmic plasma concentration-time curves showed an increasing decline at decreasing concentrations. Accumulation of the pharmacologically active metabolite monohydroxycarbamazepine was found to be more than one would anticipate on the basis of linear and unchanged pharmacokinetics. Saturation did not seem to occur at the level of renal excretion. No apparent differences between male and female volunteers were observed. A significant higher maximum concentration, higher area under the curve parameters, and a lower elimination rate constant were observed in the elderly. These observations are in line with a smaller renal clearance of monohydroxycarbamazepine in the elderly group. In a clinical situation, these age-related differences are not likely to have important implications. In general, treatment with oxcarbazepine was well tolerated.

Clinical pharmacokinetics of phenytoin.

Phenytoin is a relatively insoluble weak acid, usually administered as the sodium salt. Bioavailability is dependent upon particle size and problems of generic inequivalence have therefore arisen, particularly in Scandinavia. The drug has a moderately large volume of distribution and is approximately 90% bound to plasma proteins. Clinically important displacement can be caused by bilirubin and several drugs, particularly sodium valproate, which is often combined with phenytoin. Displacement will lower the total serum concentration but will little affect the free drug concentration. The metabolism of phenytoin to the major metabolite, 5-(p-hydroxyphenyl)-5-(phenylhydantoin, is saturable, giving rise to a non linear dose-serum concentration relationship. Therefore, the dose range compatible with a therapeutic serum concentration is narrow within subjects, and monitoring serum concentrations is of particular value in dosage tailoring. In renal failure, the binding of phenytoin to plasma proteins is reduced and therefore a lower range of serum drug concentrations is compatible with therapeutic control. In liver disease, binding may also be impaired but delayed metabolism may occur in addition. During pregnancy the serum concentration may fall progressively as pregnancy advances, probably due to an increased rate of metabolism. Phenytoin readily crosses the placenta, and is metabolised rapidly by the neonate exposed in utero.

Pharmacokinetics of phenylethylmalonamide (PEMA) after oral and intravenous administration.

The pharmacokinetics of phenylethylmalonamide (PEMA), one of the major metabolites of the antiepileptic drug primidone, have been studied in 6 healthy volunteers after administration of single 500mg intravenous and oral doses. Following intravenous administration, after a very short distributive phase (t1/2 = 0.23-0.53h), the decline of the log-PEMA concentration with respect to time appeared linear. The pharmacokinetic parameters, calculated according to a 1-compartment open model, showed the following values (mean +/- SD): terminal half-life, 15.7 +/- 3.4h; apparent volume of distribution, 0.69 +/- 0.10 L/kg; total serum clearance, 31.3 +/- 6.6 ml/h/kg. After oral administration, peak serum concentrations occurred at 0.5 to 4 hours and the oral bioavailability was 86.4 to 95.9%.

Effect of dose increments on serum carbamazepine concentration in epileptic patients.

The effect of progressive dose increments on the steady-state serum concentration of carbamazepine has been investigated prospectively in 20 adult institutionalised epileptic patients receiving long term therapy with the drug. In all but 1 subject, a strong positive correlation between the serum carbamazepine concentration and the prescribed daily dose was found. The relationship appeared to be linear over the dosage range examined (600 to 1400mg in most patients). In some patients, a trend was observed for the extrapolated regression lines to yield positive y-axis intercepts. The latter were significantly different from zero in 3 patients. Although these findings suggest that the relationship between serum carbamazepine concentration and dose may be curvilinear over the lower range of doses, further studies are required to clarify this point.

Disposition of anticonvulsants in childhood.

There have been great advances in our understanding of the childhood epilepsies within recent years and at the same time there has been increasing awareness of the pharmacokinetic properties of the anticonvulsant drugs. It has been increasingly recognised that pharmacokinetic parameters of anticonvulsants are not constant, but are subject to influences by a number of physiological variables over which age is a major determinant. As changes in pharmacokinetic parameters will alter dosage requirements, dosage regimens cannot be transferred from one age group to another without the risk of underdosing or overdosing. Drug monitoring techniques are being increasingly used as a guide to correct dosing but knowledge of the limitations of monitoring is as important as knowledge of potential benefits for monitoring to be used correctly. An overview of the important pharmacokinetic properties of anticonvulsant drugs is provided, with emphasis on findings in children where such data are available.

Quality control of drug assays.

Previously published work relating to quality control of drug assays has dealt mainly with interlaboratory comparisons. It is suggested that participants in external quality assessment schemes wil derive the maximum benefit from their participation if a suitable intralaboratory quality control scheme is established. Such a scheme should be capable of providing estimates of within- and between-batch imprecision over the concentration range for which the assay is used and give an indication of the development of systematic error (relative to previous performance). A scheme using serum pools at 3 concentrations, each to be analysed at least in duplicate, is recommended. Adaptations of this scheme, to be used when the number of patient samples per batch does not justify this number of control samples, are discussed in relation to various analytical situations. A ratio of 1 control sample to 10 patient samples is considered reasonable. The interpretation of results from external quality assessment schemes using performance indices, graphical assessment of 'bias' and standard deviation interval (SDI = bias divided by standard deviation) and the statistical evaluation of proportional and additive error by linear regression (least squares) analysis is discussed. In some cases it has been possible, from the results of interlaboratory studies, to show that a particular method will not generally give satisfactory results when compared either with other currently available methods, e.g. UV - spectrophotometric methods for phenobarbitone, phenytoin, carbamazepine and theophylline, or on the grounds of clinical requirements, e.g. doubling dilution broth techniques for gentamicin. Improvement in intralaboratory reproducibility would facilitate the identification of technical factors contributing to interlaboratory variation.

Steady-state pharmacokinetics of phenytoin from routinely collected patient data.

Previously reported routine phenytoin clinical pharmacokinetic data from Japan, England, and Germany were analysed to estimate population pharmacokinetic parameters. There were 780 steady-state phenytoin concentrations and associated dosage rates (mg/day) from 322 patients. The patient group spanned paediatric and adult ages, mean age being 18.4 +/- 17.3 (SD) years; 53% were males. The data were analysed using NONMEM, a computer programme designed for population pharmacokinetic analysis. Estimates of the influence of age, gender, data source, height and weight on the maximum elimination rate (Vm) and Michaelis-Menten constant (Km) were obtained. The Vm and Km of a 70 kg adult male European were estimated to be 415 mg/day and 5.7 mg/L, respectively. Vm is not influenced by gender, age or data source. The parameters of a power function of height and weight were estimated to adjust Vm for body size. The best function adjusts Vm in proportion to weight to the 0.6 power; height contains no useful information. Km is not influenced by gender. The Km for patients less than 15 years old is 43% less than that of older patients. The Km of Japanese patients appears to be 23% less than that for European patients. Even after adjustments for age, etc., apparent Vm and Km vary unpredictably among individuals with a coefficient of variation between 10 to 20% and approximately 50% respectively.

The action of general anaesthetic agents on root responses of the frog isolated spinal cord.

1. The action of volatile and barbiturate general anaesthetic agents on synaptic transmission in the frog isolated spinal cord has been studied by recording ventral root synaptic potentials and spike discharges evoked by volleys in a dorsal root and in the lateral column fibres.2. Some observations on the distribution of the lateral column fibres and the characteristics of the dorsal root potentials have been presented.3. Volatile agents depressed and eventually abolished all components of the ventral root responses. Failure of motoneurone discharge was the result of two factors, a decrease in the slope of the synaptic potential and an elevation of the critical depolarization required to trigger propagated impulses.4. Barbiturate compounds, in contrast, readily abolished polysynaptic components of the ventral root responses, but the short latency discharge produced by lateral column stimulation was potentiated, and was accompanied by a lowering of the firing threshold of motoneurones. The mechanism of this potentiation by barbiturate compounds is discussed.5. It is concluded that volatile agents act predominantly on the initial segment and subsynaptic elements of the motoneurone, whereas barbiturate compounds depress the presynaptic or postsynaptic components of interneuronal synapses.

Microelectrode studies in the frog isolated spinal cord during depression by general anaesthetic agents.

1. Extracellular and intracellular potentials have been recorded from the isolated spinal cord of the frog during depression of synaptic transmission by volatile and barbiturate general anaesthetic agents.2. Volatile agents did not impair conduction in presynaptic terminals in concentrations which completely blocked synaptic transmission.3. Methohexitone consistently impaired conduction in presynaptic terminals long before transmission through polysynaptic pathways was blocked.4. Volatile agents depressed the excitability of the motoneurone membrane, as evidenced by impaired antidromic invasion, reduced excitability to direct stimulation, depression of the synaptic potential and elevation of firing threshold. It is concluded that these actions are responsible for the depressant effect of volatile agents on spinal reflexes.5. Methohexitone produced an increase in the excitability of the motoneurone membrane, as evidenced by enhanced antidromic invasion, increased excitability to direct stimulation and potentiation of short latency responses. Despite this excitatory action, the polysynaptic pathways through the cord were depressed by an action of the drug on conduction in presynaptic terminals.6. It is suggested that the sensitivity of the motoneurone membrane to volatile agents may contribute to the good muscle relaxant properties of these drugs in clinical use.

The effect of the desglycinyl metabolite of remacemide hydrochloride (FPL 12495AA) and dizocilpine (MK-801) on endogenous amino acid release from mouse cortex.

1. In this study the effect of FPL 12495AA, the desglycinyl metabolite of remacemide hydrochloride and dizocilpine (MK-801), on potassium- and veratridine-stimulated release of neurotransmitter amino acids from mouse cortical slices was investigated. 2. Veratridine (20 microM) and potassium (60 mM) produced a preferential release of glutamate and aspartate. Potassium-stimulated release was calcium-dependent, while veratridine-stimulated release was only partially affected by removal of calcium from the medium. 3. FPL 12495AA significantly inhibited veratridine- and potassium-stimulated release of glutamate and aspartate. Lower concentrations of FPL 12495AA were needed to inhibit veratridine-stimulated release of glutamate (12.5 microM) than potassium-stimulated release (100 microM). 4. Dizocilpine significantly inhibited veratridine- and potassium-stimulated release of glutamate and aspartate at concentrations of 100 microM and above. 5. FPL 12495AA and dizocilpine both have an affinity for the ion channel subsite of the N-methyl-D-aspartate (NMDA) receptor. The reduction of potassium-stimulated release of glutamate and aspartate by FPL 12495AA and dizocilpine is probably due to NMDA receptor blockade. 6. FPL 12495AA inhibited veratridine-stimulated release at a concentration of 12.5 microM while dizocilpine was effective only at a concentration of 100 microM. This difference in efficacy is probably due to the higher affinity of FPL 12495AA compared to dizocilpine at the veratridine-binding site on the sodium channel.

The effect of losigamone (AO-33) on electrical activity and excitatory amino acid release in mouse cortical slices.

1. Losigamone is a novel anticonvulsant the mechanism of action of which is not known. This study investigated the effect of losigamone on spontaneous, NMDA- and AMPA-induced depolarizations in the cortical wedge preparation of the DBA/2 mouse (which are susceptible to sound-induced seizures) and on endogenous amino acid release from BALB/c mouse cortical slices. 2. Cortical wedges exhibit spontaneous depolarizations in magnesium-free medium and losigamone was effective in significantly reducing these spontaneous depolarizations at concentrations of 100 microM and above. 3. NMDA-induced depolarizations were significantly reduced by losigamone at concentrations of 25 microM and above. Losigamone had no effect on AMPA-induced depolarizations. 4. Veratridine (20 microM) and potassium (60 mM) were used to stimulate the release of amino acids from mouse cortex. Veratridine-stimulated release of glutamate was significantly reduced by losigamone at concentrations of 100 microM and above, while potassium-stimulated release was significantly reduced by losigamone at 200 microM. 5. NMDA antagonism and inhibition of excitatory amino acid release may contribute to the anticonvulsant effect of losigamone.

Adrenergic control of tendon jerk reflexes in man.

1. Tendon jerk responses and H reflexes were recorded from conscious human volunteers before and after intravenous injection of methylamphetamine, thymoxamine and propranolol, and during intravenous infusion of noradrenaline.2. Methylamphetamine produced a significant increase in the amplitude of the tendon jerk, whereas noradrenaline had no effect in doses which caused a greater pressor response than methylamphetamine.3. Thymoxamine produced a dose-related reduction in the tendon jerk.4. Propranolol had no significant effect on the jerk.5. None of these drugs significantly affected the H reflex.6. It is suggested that central adrenoceptors, possibly alpha in type, exist in man, and that stimulation of these receptors facilitates tendon jerk reflexes by an action on the fusimotor system.

Interactions with antiepileptic drugs.

Most of the currently available antiepileptic drugs have a low therapeutic ratio and therefore a drug interaction causing elevation of the serum level of one of these compounds can readily lead to drug intoxication. Phenytoin, in particular, is vulnerable because its metabolism is dose-related and at therapeutic serum levels the enzyme system involved in its degradation is easily inhibited by concurrent drug administration. As multiple drug therapy has traditionally been practised in the management of epilepsy, clinically important interactions are common. Furthermore, most of the drugs used in the treatment of major epilepsies are potent inducers of hepatic microsomal enzymes and can therefore stimulate the metabolism of concurrently-administered drugs to such an extent that they may be rendered ineffective. The use of one drug alone is recommended, where possible, in the management of epilepsy.

Drug interactions with phenytoin.

Drug interactions with phenytoin are a frequent occurrence, although their clinical relevance has often been overemphasised. Probably the most important of such interactions are those resulting in inhibition of phenytoin metabolism: due to the saturable nature of phenytoin biotransformation even minor degrees of inhibition can produce disproportionate changes in both steady-state serum concentration and the magnitude of pharmacological effect. Phenytoin has marked enzyme-inducing properties and can stimulate the metabolism of many concurrently administered drugs, thereby reducing their therapeutic efficacy. Clinically important examples of such interactions include a reduction of the anticoagulant effect of dicoumarol, a decrease in the prophylactic efficacy of the contraceptive pill and failure of response to various corticosteroid agents when administered therapeutically or diagnostically. Unless complicated by additional mechanisms, plasma protein binding interactions with phenytoin are seldom of clinical significance. However, they may alter considerably the relationship between serum drug concentration and clinical response, a possibility which needs to be taken into account when interpreting serum phenytoin levels in clinical practice.

Micro-vacuolation in rat brains after long term administration of GABA-transaminase inhibitors. Comparison of effects of ethanolamine-O-sulphate and vigabatrin.

Two "suicide" inhibitors of GABA-aminotransferase which are known to raise the concentration of GABA in vivo and to have anti-convulsant properties, have been compared for the extent to which they produce micro-vacuoles in the brains of rats. The compounds gamma-vinyl-GABA (Vigabatrin) and ethanolamine-O-sulphate were administered orally for six months to rats at doses that produced the same increase in brain GABA levels. Micro-vacuolation was found to be present in the brains of animals treated with either compound but to be more severe in those treated with Vigabatrin. A quantitative assessment using computerised image analysis revealed that both the number of vacuoles, and the area occupied by them, was twice as high in the Vigabatrin treated animals as in those treated with ethanolamine-O-sulphate. This quantitative difference could be seen to be due to the fact that in the Vigabatrin treated animals the vacuoles extended into the white matter tracts between the cerebellar folia whereas in those animals treated with ethanolamine-O-sulphate it was confined to the roof nucleus.