A phase 2, double-blind, placebo-controlled trial of a valproate/lithium combination in ALS patients.

BACKGROUND: Few treatments are currently available for amyotrophic lateral sclerosis (ALS). A combination of lithium carbonate and valproic acid (VPA-Li) was shown to inhibit motor neuron death and delay disease progression. METHODS: Outpatients with a typical ALS presentation were enrolled in a randomized, placebo-controlled trial to assess the efficacy of orally administered VPA-Li. Changes in a functional scale score (ALSFRS-R) and survival rate were chosen as primary outcome variables. Secondary outcome variables included BMI, respiratory monitoring, quality of life, and a global impression of the treatment. RESULTS: Out of 42 patients enrolled, 20 individuals receiving VPA-Li and 18 on placebo treatment were included in the final analysis. Forty-five percent of patients receiving VPA-Li completed the trial, whereas only 22.22% of patients in the placebo group attended the final visit 18 months later (P = 0.09). Major changes in the ALSFRS-R score were observed, including a decrease of 1.195 points/month in the placebo group (95% CI: 0.7869-1.6031) and of 0.5085 under VPA-Li treatment (95% CI: 0.2288-0.7882) between months 6 and 14. Adverse events included bad mouth taste, constipation, and anorexia. Survival rate, body weight, and quality of life were positive outcomes by the end of the trial despite a high sample reduction, especially in the placebo group. The inclusion of 212 subjects in each group would confirm these differences. CONCLUSIONS: Combined VPA-Li treatment associated with slower ALS progression and better secondary outcomes. This dual treatment overcame the futility threshold and merits further investigation in ALS.

Low Serum Tryptophan Levels as an Indicator of Global Cognitive Performance in Nondemented Women over 50 Years of Age.

Aging is a physiological decline process. The number of older adults is growing around the world; therefore, the incidence of cognitive impairment, dementia, and other diseases related to aging increases. The main cellular factors that converge in the aging process are mitochondrial dysfunction, antioxidant impairment, inflammation, and immune response decline, among others. In this context, these cellular changes have an influence on the kynurenine pathway (KP), the main route of tryptophan (Trp) catabolism. KP metabolites have been involved in the aging process and neurodegenerative diseases. Although there are changes in the metabolite levels with age, at this time, there is no study that has evaluated cognitive decline as a consequence of Trp catabolism fluctuation in aging. The aim of this study was to evaluate the relation between the changes in Trp catabolism and cognitive impairment associated with age through KP metabolites level alterations in women over 50 years of age. Seventy-seven nondemented women over 50 years old were examined with a standardized cognitive screening evaluation in Spanish language (Neuropsi), Beck anxiety inventory (BAI), and the geriatric depression scale (GDS). Also, serum levels of Trp, kynurenine (Kyn), kynurenic acid (KYNA), and 3-hydroykynurenine (3-HK) and the glutathione ratio (GSH/GSSG) were measured. Results showed a negative correlation between age and Trp levels and a positive correlation between age and KYNA/Trp and 3-HK/Trp ratios. The level of cognitive impairment showed a significant positive association with age and with kynurenine pathway activation and a significant negative correlation with Trp levels. The GSH/GSSG ratio correlated positively with Trp levels and negatively with Kyn/Trp and 3-HK/Trp ratios. The depression score correlated negatively with Trp and positively with the 3-HK/Trp ratio. We concluded that KP activation increases with age and it is strongly associated with the level of cognition performance in nondemented women over 50 years of age.

Relevance of Alternative Routes of Kynurenic Acid Production in the Brain.

The catabolism of tryptophan has gained great importance in recent years due to the fact that the metabolites produced during this process, with neuroactive and redox properties, are involved in physiological and pathological events. One of these metabolites is kynurenic acid (KYNA), which is considered as a neuromodulator since it can interact with NMDA, nicotinic, and GPR35 receptors among others, modulating the release of neurotransmitters as glutamate, dopamine, and acetylcholine. Kynureninate production is attributed to kynurenine aminotransferases. However, in some physiological and pathological conditions, its high production cannot be explained just with kynurenine aminotransferases. This review focuses on the alternative mechanism whereby KYNA can be produced, either from D-amino acids or by means of other enzymes as D-amino acid oxidase or by the participation of free radicals. It is important to mention that an increase in KYNA levels in processes as brain development, aging, neurodegenerative diseases, and psychiatric disorders, which share common factors as oxidative stress, inflammation, immune response activation, and participation of gut microbiota that can also be related with the alternative routes of KYNA production, has been observed.

Kynurenine pathway metabolites and enzymes involved in redox reactions.

Oxido-reduction reactions are a fundamental part of the life due to support many vital biological processes as cellular respiration and glucose oxidation. In the redox reactions, one substance transfers one or more electrons to another substance. An important electron carrier is the coenzyme NAD+, which is involved in many metabolic pathways. De novo biosynthesis of NAD+ is through the kynurenine pathway, the major route of tryptophan catabolism, which is sensitive to redox environment and produces metabolites with redox capacity, able to alter biological functions that are controlled by redox-responsive signaling pathways. Kynurenine pathway metabolites have been implicated in the physiology process and in the physiopathology of many diseases; processes that also share others factors as dysregulation of calcium homeostasis, mitochondrial dysfunction, oxidative stress, inflammation and cell death, which impact the redox environment. This review examines in detail the available evidence in which kynurenine pathway metabolites participate in redox reactions and their effect on cellular redox homeostasis, since the knowledge of the main factors and mechanisms that lead to cell death in many neurodegenative disorders and other pathologies, such as mitochondrial dysfunction, oxidative stress and kynurenines imbalance, will allow to develop therapies using them as targets. This article is part of the Special Issue entitled 'The Kynurenine Pathway in Health and Disease'.

Mitochondrial dysfunction related to cell damage induced by 3-hydroxykynurenine and 3-hydroxyanthranilic acid: Non-dependent-effect of early reactive oxygen species production.

The kynurenines 3-hydroxyanthranilic acid (3-HANA) and its precursor 3-hydroxykynurenine (3-HK) are metabolites derived from tryptophan degradation. 3-HK, has been related to diverse neurodegenerative diseases including Huntington's, Alzheimer's and Parkinson's diseases that share mitochondrial metabolic dysregulation. Nevertheless, the direct effect of these kynurenines on mitochondrial function has not been investigated despite it could be regulated by their redox properties that are controversial. A body of literature has suggested a ROS mediated cell death induced by 3-HK and 3-HANA. On the other hand, some works have supported that both kynurenines have antioxidant effects. Therefore, the aim of this study was to investigate 3-HK and 3-HANA effects on mitochondrial and cellular function in rat cultured cortical astrocytes (rCCA) and in animals intrastriatally injected with these kynurenines as well as to determinate the ROS role on these effects. First, we evaluated 3-HK and 3-HANA effect on cellular function, ROS production and mitochondrial membrane potential in vivo and in vitro in rCCA. Our results show that both kynurenines decreased MTT reduction in a concentration-dependent manner together with mitochondrial membrane potential. These observations were accompanied with increased cell death in rCCA and in circling behavior and morphological changes of injected animals. Interestingly, we found that ROS production was not increased in both in vitro and in vivo experiments, and accordingly lipid peroxidation (LP) was neither increased in striatal tissue of animals injected with both kynurenines. The lack of effect on these oxidative markers is in agreement with the ·OH and ONOO(-) scavenging capacity of both kynurenines detected by chemical combinatorial assays. Altogether, these data indicate that both kynurenines exert toxic effects through mechanisms that include impairment of cellular energy metabolism which are not related to early ROS production.

The L-kynurenine-probenecid combination reduces neuropathic pain in rats.

BACKGROUND: l-Kynurenine has antinociceptive effects in acute and inflammatory pain. This study determined the effect of l-kynurenine and its metabolite (kynurenic acid) on rats subjected to neuropathic pain. METHODS: L5/L6 spinal nerve ligation induced tactile allodynia as measured with von Frey filaments using the up-down method. High-performance liquid chromatography and Western blot analysis determined kynurenic acid levels and expression of kynurenine amino transferase II (KAT II), respectively. RESULTS: l-Kynurenine (50-200 mg/kg, i.p.) or probenecid (100 mg/kg, i.p.) did not affect allodynia in neuropathic rats. In contrast, l-kynurenine (50-200 mg/kg, i.p.) in combination with probenecid (100 mg/kg, i.p.), an inhibitor of organic anion transport, reversed allodynia. Furthermore, intrathecal kynurenic acid (1-30 µg) reversed allodynia. Probenecid (100 mg/kg, i.p.) supplementation enhanced the maximal antiallodynic effect of intrathecal kynurenic acid (10 µg). Only the combined administration of l-kynurenine (200 mg/kg)/probenecid (100 mg/kg) increased the kynurenic acid concentration in cerebrospinal fluid. KAT II is expressed in dorsal root ganglia and dorsal spinal cord. KAT II expression was unchanged by the spinal nerve ligation or l-kynurenine/probenecid combination. The kynurenine/probenecid combination did not affect motor activity. CONCLUSIONS: l-Kynurenine produces its antiallodynic effect in the central nervous system through kynurenic acid. This effect may result from blockade of N-methyl-d-aspartate receptors. KAT II is expressed in dorsal root ganglion and dorsal spinal cord. Combined l-kynurenine and probenecid therapy has the potential to reduce neuropathic pain in humans.

Population pharmacokinetics of albendazole in patients with neurocysticercosis.

OBJECTIVES: To determine a population pharmacokinetic model of the antihelmintic drug, albendazole, and identify the factors influencing the pharmacokinetic parameters in patients with neurocysticercosis. METHODS: A prospective study was performed in 90 patients receiving 30 mg/kg/day of albendazole for 8 days. Blood samples were collected at steady state. Plasma concentrations of albendazole sulfoxide, the main active metabolite of albendazole, were determined by HPLC. The population pharmacokinetics analysis was performed using non-linear mixed-effect modeling (NONMEM). A one-compartment model with first order absorption and elimination was used. RESULTS: Body weight was included empirically on CL/F and V/F using an allometric relationship. Although none of the investigated covariates had a significant influence on the pharmacokinetic parameters of albendazole, the final model identified two subpopulations on the bioavailability parameter. One subpopulation comprising of 27% of the total population had a bioavailability of 28%, with the remaining subpopulation defined to have complete bioavailability. The CL/F and V/F for a standard 70 kg individual was determined to be 51.6 l/h and 4560 l, respectively. Interindividual variability in CL/F was 32%; the residual unexplained variability was 32%. CONCLUSIONS: The considerable variability reported in albendazole pharmacokinetics and plasma concentrations is likely due to issues related to bioavailability. With one-fourth of the population absorbing as little as 30% of the drug relative to others, low drug exposures might be responsible for treatment failures. Therapeutic drug monitoring may be warranted to optimize the eradication of the infecting parasite.

Albendazole trial at 15 or 30 mg/kg/day for subarachnoid and intraventricular cysticercosis.

Thirty-six patients with subarachnoid and intraventricular cysticercosis were randomly assigned to receive albendazole at 15 or 30 mg/kg/day plus dexamethasone for 8 days. Results favored a higher dose, with larger cyst reduction on MRI at 90 and 180 days and higher albendazole sulfoxide levels in plasma. An albendazole course at 30 mg/kg/day combined with corticosteroids is safe and more effective than the usual dose. A single treatment was insufficient in intraventricular and giant cysts.

Plasma level monitoring of oxcarbazepine in epileptic patients.

BACKGROUND: Despite the wide use of oxcarbazepine (OXC) there is little data concerning the usefulness of plasma level monitoring with this drug in Mexican patients with epilepsy. The purpose of the present study was to determine whether OXC levels correlate with dose, age, weight, or drugs used concomitantly. METHODS: Plasma levels of the antiepileptic drug OXC were evaluated in 214 patients with epilepsy. In each patient, plasma MHD (10-hydroxycarbazepine, the main metabolite of OXC) concentration was determined. Additionally, plasma protein binding was determined in 30 patients and affinity to red blood cells (RBCs) was evaluated in 50 patients. RESULTS: Our results showed that the mean plasma level of MHD was 15.34 microg/mL, mean protein binding ranged between 30-40%, and the mean RBC concentration was 18.38 microg/mL. A relationship between dose/weight and plasma concentration was found (r = 0.5149, p <0.001). In addition, a linear relationship between plasma and RBC concentration was established (r = 0.8806, p <0.0001). CONCLUSIONS: These results suggest that for OXC, routine RBC concentrations are not necessary to make drug adjustments.

Single dose pharmacokinetics of HEPP, a new anticonvulsant in normal healthy volunteers.

The pharmacokinetics and the dose proportionality of a new anticonvulsant compound, HEPP (D,L-3-hydroxy-3-ethyl-3-phenylpropionamide) was studied in healthy male volunteers as part of the pharmacological evaluation for new drugs. Study was performed administering doses of 250, 375, 500 and 625 mg of HEPP to six male volunteers. Blood and urine samples were collected for 72 h postdose and analysed by HPLC. Results showed that in man HEPP is rapidly absorbed from the gastrointestinal tract. Tmax values were between 1.5 and 6.0 h. Plasma mean terminal half-life after the different doses ranged between 15.83 and 27.62 h with an overall harmonic mean value of 22.8. The mean AUC0-infinity and Cmax increased linearly with doses of 250, 375 and 500 mg but not with the dose of 625 mg. The amount of unchanged drug excreted in urine was between 3 and 6% of administered dose which shows an extensive metabolism of the drug.

The distribution of 10-hydroxy carbazepine in blood compartments.

The distribution of 10-hydroxy carbazepine (MHD), the main metabolite of oxcarbazepine (OXC), was investigated in plasma and red cells. After the oral administration of 600mg of OXC to nine healthy volunteers, blood samples were withdrawn for the next 56h and packed red cells were separated from plasma by centrifugation. Also, in vitro studies of plasma binding of MHD were carried out by a dialysis technique. Results showed that the in vitro protein binding was low. The mean bound concentration ranged from 37 to 40%; however, an affinity of MHD to red corpuscles was found. These observations indicate that MHD red blood cell concentrations together with plasma measurements could be useful in cases of inefficacy or toxicity in order to make the appropriate drug adjustments.

Clinical pharmacokinetics of albendazole in children with neurocysticercosis.

The pharmacokinetics of albendazole sulphoxide, the main metabolite of albendazole, were studied in eight children with brain cysticercosis. Albendazole was given as a single oral dose of 15 mg per kg body weight (Zentel suspension; Smith Kline & Beecham, Philadelphia, PA). Blood samples were taken during 24 h and analyzed by high performance liquid chromatography. Plasma levels showed great interindividual variation. Maximum plasma levels for albendazole sulphoxide ranged from 0.2-1.0 microg/mL. A double peak was found in four children. The half-life for albendazole sulphoxide was from 2.3-8.3 hours and mean residence time values were from 5. 1-13.6 hours. These values are shorter than those found in adults. The results suggest that when treating children with neurocysticercosis, albendazole should be administered three times a day rather than twice daily as is currently done in Mexico.

Sensitive high-performance liquid chromatographic assay for praziquantel in plasma, urine and liver homogenates.

A high-performance liquid chromatographic method for the determination of praziquantel in plasma, urine and rat liver homogenates has been developed. It requires 2 ml of biological fluid, an extraction using Sep-Pak cartridges, a 0.05 M phosphate buffer solution (pH 5.0) for equilibrating and washing and ethyl acetate-diisopropyl ether for drug elution. The analysis was performed on an Ultrasphere ODS C18 column with a mobile phase of acetonitrile-water with ultraviolet detection at 217 nm. The results showed that the assay is sensitive (31.2 ng/ml), linear between 0.125 and 4.0 micrograms/ml, precise (coefficient of variation = 10%) and selective with other drugs currently administered with praziquantel.

Pharmacokinetic comparison of two albendazole dosage regimens in patients with neurocysticercosis.

To evaluate two different dosage regimens for albendazole (7.5 mg/kg twice a day or 5.0 mg/kg three times a day), a study was performed in 10 patients with a diagnosis of parenchymal brain cysticercosis. Each patient received both regimens sequentially according to a randomized, crossover design. Blood and urine samples were taken once the drug steady state had been reached. Plasma levels of albendazole sulfoxide at steady state were determined using a HPLC method. In spite of a great intersubject variability observed with both regimens in the area under the curve (AUC) and in the minimum steady-state plasma concentration (Cp min ss), no statistically significant differences were found in these parameters. We suggest that a regimen of 7.5 mg/kg every 12 h can favorably replace the currently used regimen of 5 mg/kg every 8 h.