Flow- and voltage-dependent blocking effect of ethosuximide on the inward rectifier K⁺ (Kir2.1) channel.

Absence seizures are manifestations of abnormal thalamocortical oscillations characterized by spike-and-wave complexes in EEG. Ethosuximide (ETX) is one of the principal medications against absence seizures. We investigate the effect of ETX on the Kir2.1 channel, a prototypical inward rectifier K(+) channel possibly playing an important role in the setting of neuronal membrane potential. We demonstrate that the outward currents of Kir2.1 channels are significantly inhibited by intracellular ETX. We further show that the movement of neutral molecule ETX in the Kir2.1 channel is accompanied by ∼1.2 K(+), giving rise to the vivid voltage dependence of ETX unbinding rate. Moreover, the apparent affinity (K d ) of ETX in the channels are decreased by single-point mutations involving M183, E224, and S165, and especially by double mutations involving T141/S165, which always also disrupt the flux-coupling feature of ETX block. Molecular dynamics simulation demonstrates narrowing of the pore at ∼D172 by binding of ETX to S165 or T141. ETX block of the Kir2.1 channels may cause a modest but critical depolarization of the relevant neurons, decreasing available T-type Ca(2+) channels and consequently lessening pathological thalamocortical burst discharges.

The effects of lamotrigine and ethosuximide on seizure frequency, neuronal loss, and astrogliosis in a model of temporal-lobe epilepsy.

OBJECTIVE: The putative neuroprotective and disease-modifying effects of lamotrigine (LTG) and ethosuximide (ESM) were investigated in the lithium-pilocarpine (Li-Pc) model of temporal-lobe epilepsy (TLE) in rats. Then, spontaneous recurrent seizures (SRS), neuronal loss and astrogliosis were assessed. METHODS: Status Epilepticus (SE) was induced by Li-Pc in five experimental groups: 24 h after SE, all rats received twice daily either a low (10 mg/kg) or high (20 mg/kg) dose of LTG, or a low (25 mg/kg) or high (50 mg/kg) dose of ESM, or solvent. The sixth group (control) did not receive Li-Pc and was given twice daily injections with solvent only. Drug administration lasted for 7 d. Rats were systematically observed in the 5th and 6th weeks, after that the brains were prepared for histology. RESULTS: LTG dose-dependently decreased the frequency of SRS, and restricted neuronal loss, as well as astrogliosis in the hippocampus compared with the untreated SE control group. However, ESM had none of the above-mentioned effects. CONCLUSION: LTG had protective as well as disease-modifying effects in this TLE model. It was revealed that the disease-modifying effects were accompanied by the prevention of neuronal loss and astrogliosis. ESM was devoid of antiepileptogenic and its accompanying histological effects in this TLE model, in contrast to the antiepileptogenic effects found in the genetic absence epilepsy models, suggesting that different mechanisms are involved in the different models for epileptogenesis and antiepileptogenesis.

Ethosuximide kinetics: possible interaction with valproic acid.

Ethosuximide kinetics were determined in six normal healthy adults after a single dose (phase 1) and at steady-state (phase 2). After the completion of phase 2, valproic acid was added to the ethosuximide regimen (phase 3) to assess the possibility of drug interaction. Between phases 1 and 2 total clearance fell from 13.1 to 11.1 ml/hr/kg (P less than 0.05) and nonrenal clearance fell from 10.1 to 8.3 ml/hr/kg (P less than 0.05). When valproic acid was added (phase 3) there was no further change in total or nonrenal clearance (11.2 and 8.3 ml/hr/kg). To assess the possibility of nonlinear ethosuximide kinetics a review was conducted of patients who received ethosuximide as sole therapy for absence seizures. Of 106 patients, 10 met the required criterion that defined steady state. Data from seven of the 10 patients showed evidence of a nonlinear relationship when steady-state ethosuximide concentrations were plotted against dose.

Kinetics of a carbamazepine-ethosuximide interaction.

Carbamazepine and ethosuximide are used together to treat epileptic mixed-seizure patterns. Since carbamazepine has been shown to induce drug-metabolizing enzyme(s) in the liver, it follows that carbamazepine may alter ethosuximide disposition. Six normal subjects took one 250-mg ethosuximide capsule twice each day for 55 consecutive doses (study days 1 to 28) and one 200-mg carbamazepine tablet each evening from study days 11 to 27. Plasma samples were collected on study days 10, 17, 21, and 28. Mean steady-state concentrations of ethosuximide declined by 17% from a preinduction (study day 10) level of 32.2 +/- 5.6 micrograms/ml to a postinduction level of 26.8 +/- 5.2 micrograms/ml on study day 28. Ethosuximide clearance increased (alpha = 0.05) between study days 10 and 28 from 0.664 +/- 0.120 to 0.800 +/- 0.0154 l/hr. The time course of induction was analyzed using a kinetic induction theory. Ethosuximide half-life was lowered from mean - 53.7 +/- 11.5 hr (before induction) to mean = 44.6 +/- 10.7 hr (after induction); the difference between some subjects was large. These data show that ethosuximide disposition is altered by carbamazepine.

Metabolism of ethosuximide.

Twenty subjects, in a double-blind, controlled, rising dose study, were given ethosuximide either once daily or 3 times daily. Steady-state plasma levels and urinary throughput were proportional to dose and were equivalent whether the daily dose was given as a single or divided dose. This finding adds validity to consideration of the single daily dose regimen as a therapeutic possiblity. The metabolic principles should be considered both in patient management and in the treatment of overdosage.

Anticonvulsants during pregnancy and lactation. Transplacental, maternal and neonatal pharmacokinetics.

Few data are available on placental transfer of anticonvulsants during early pregnancy. Nevertheless, it has been demonstrated that at this early stage of gestation, considerable amounts of phenytoin, primidone/phenobarbitone and carbamazepine as well as some of their metabolites are already present in fetal tissues. Potentially reactive metabolites of anticonvulsants can be formed by the fetal liver and accumulate in some organs. At term, most anticonvulsants are present in neonatal plasma in concentrations similar to those in maternal plasma. Valproic acid, on the other hand, can accumulate in fetal blood, for still unknown reasons. Elimination by the neonate is variable and is dependent on several factors, such as clinical state, pre- or perinatal enzyme induction, absorption of the drugs and their plasma protein binding. Neonatal acquisition of anticonvulsants via breast-feeding does not seem to be harmful for the neonate. In the case of phenobarbitone, however, the drug may accumulate in nursing neonates to levels approaching or even exceeding those of their mothers. Significant drug levels can also build up in neonates and infants nursed by carbamazepine- and ethosuximide-treated mothers. This review contains relevant pharmacokinetic data on anticonvulsant drugs widely used during pregnancy and the neonatal period. The differences between pregnant and non-pregnant adults as well as between neonates and older age groups are emphasized. Some pharmacokinetic data are correlated with clinical manifestations, such as seizure frequency, neonatal depression and withdrawal symptoms.

Clinical pharmacokinetics in infants and children.

Wide variations in drug dose recommendations for children of the same or different ages reflect the inadequacy of data on pharmacokinetics and pharmacodynamics in children. Selected aspects of available literature on pharmacokinetics of drugs used in older infants and children has been reviewed with special attention to calculation of an age-appropriate dose. During the neonatal period and early infancy the elimination of many drugs that are excreted in the urine in unchanged form is restricted by the immaturity of glomerular filtration and renal tubular secretion. On the other hand, in late infancy and/or in childhood, a similar or greater rate of elimination from plasma than in adults has been observed for many drugs, notably digoxin, phenobarbitone, phenytoin, carbamazepine, ethosuximide, diazoxide, clindamycin and propoxyphene. Consistent with this, it has been shown that some drugs exhibit a lower plasma level/dose ratio in infancy and early childhood as compared with the adult. This is true for phenobarbitone, phenytoin and ethosuximide. Some age groups of children remain uninvestigated with regard to pharmacokinetics, even for the drugs reviewed. Therefore, pediatric therapy remains empirically based for many drugs.

Clinical pharmacokinetics of anticonvulsants.

Anticonvulsant therapy was among the first areas to benefit from clinical pharmacokinetic studies. The most important advantage is that the frequent interindividual variation in the plasma level/dose ratio for these drugs can be circumvented by plasma level monitoring. For several anticonvulsants the brain concentration is shown to parallel the plasma concentration. Phenytoin (diphenylhydantoin) is stil the most important anticonvulsant and the one for which kinetics have been thoroughly investigated in man. These investigations have revealed several reasons for the wellknown difficulties in using this drug clinically. The absorption rate and fraction are very much dependent on the pharmaceutical preparation, and changes of brand may alter the plasma level of phenytoin in spite of unaltered dose. The elimination capacity is saturable causing dose dependent kinetics, which again means disproportional changes in plasma level with changes in dose. Great individual variations exist in the rate of metabolism, and several pharmacokinetic drug interactions are known. As an optimum therapeutic plasma concentration range has been established monitoring plasma levels must be strongly advocated. Interpretation of plasma levels in uraemic patients must take into account decreased protein binding of the drug. Carbamazepine is probably as effective as phenytoin. The elimination is a first order process, but the rate of metabolism increases after a few weeks' treatment. An active metabolite (epoxide) may be the cause of some side-effects. Combined treatment with other anticonvulsant drugs decreases the half-life and more frequent dosing may be necessary. An optimum therapeutic concentration range has been suggested and plasma monitoring is advocated, along with that of the active metabolite, the epoxide. Phenobarbitone is still much used but its kinetics have been investigated to a lesser extent. The main problem is the variability in the rate of elimination. In children the half-life of phenobarbitone is only half of that in adults. An optimum therapeutic plasma range has been established and monitoring is recommended. Primidone may have an anticonvulsant activity in itself, but its main metabolite is phenobarbitone. The relatively rapid elimination of primidone is offset by the long half-life of phenobarbitone. An optimum therapeutic range has been suggested, but plasma level monitoring must include determination of phenobarbitone. Ethosuximide. The clinical pharmacokinetics of this important petit mal anticonvulsant is not well known. It has a relatively long half-life (in adults 2 to 3 days; in children shorter). An optimum therapeutic range has been suggested, and routine monitoring of plasma levels may be recommended. Diazepam exerts a repid anticonvulsant activity when the plasma concentration exceeds approximately 500ng/ml after intravenous injection. The kinetic pattern is complex in man. Clonazepam. The clinical pharmacokinetics are still not fully investigated but a therapeutic range has been suggested...

Drug interactions with valproic acid.

Valproic acid undergoes drug-drug interactions with most of the commonly used anticonvulsants. Since it possesses a wide range of indications, concomitant use with other anticonvulsants, and hence interactions, are not infrequent. Many of these interactions are reciprocal and may have important therapeutic consequences. Valproate acts as a protein binding displacer and/or metabolic inhibitor with respect to a number of other anticonvulsants (phenobarbitone, primidone, phenytoin). Inhibition of metabolism would, in most instances, result in a decrease of the dose requirements of the affected drugs. Valproate is a low clearance drug primarily eliminated by metabolism. Its metabolism is highly inducible by some of the major anticonvulsants (e.g. carbamazepine, phenytoin). Valproate is also highly protein bound in plasma and thus is displaced by salicylates and free fatty acids. However, displacement alone, unlike induced metabolism, should not affect the drug's dose-response relationship.

Preparation and characterization of polyethyl-2-cyanoacrylate nanocapsules containing antiepileptic drugs.

Biocompatible and biodegradable colloidal drug delivery systems can be obtained by means of in situ polymerization of alkylcyanoacrylate. In particular, nanocapsules of polyethylcyanoacrylate (PECA) were prepared by adding the monomer to an organic phase, consisting of Miglyol 812 and an organic solvent (ethanol, acetone or acetonitrile), and subsequently mixing the organic phase with an aqueous phase containing Pluronic F68 at different concentrations. The possible mechanism of formation and the influence of preparation conditions on the quality of nanocapsule formulations were investigated by freeze-fracture electron microscopy and laser light scattering using both the inverse Laplace transform and the standard cumulant analysis for data fitting. High-quality nanocapsule systems were obtained using an aprotic fully water-miscible organic solvent such as acetone. The presence of ethanol led to the formation of both nanospheres and nanocapsules. The concentrations of nonionic surfactant in the aqueous phase of monomer in the organic phase did not influence the kind of colloidal suspension obtained. The oil simply plays the role of monomer support. The diameter of PECA nanoparticles (nanospheres and nanocapsules) ranged from 100 to 400 nm. Three antiepileptic drugs (Ethosuximide, 5,5-diphenyl hydantoin and carbamazepine) were entrapped in PECA nanocapsules. The loading capacity of PECA nanocapsules, prepared using acetone as organic solvent, varied from 1% to 11% (drug/dried material) as a function of the solubility (affinity) of the different drugs with the oil core. This parameter also influenced the release from PECA nanocapsules, which was slower for drugs with a higher affinity for Miglyol 812. By encapsulating the three antiepileptic drugs in the PECA nanocapsules, it was possible to achieve controlled drug release. The mechanism of drug release from PECA nanocapsules was mainly diffusion from the oil core through the intact polymer barrier.

Use of MULTDOS for pharmacokinetic analysis of ethosuximide data during repetitive administration of single or divided daily doses.

MULTDOS, a computer method to curve fit data obtained on multiple dosing, was used with either the 1969 or 1974 version of the NONLIN program to compare the pharmacokinetic parameters of ethosuximide during repetitive administration of single or divided daily doses. Elimination rate constants, excretion rate constants, and apparent volumes of distribution were similar between the two dosing regimens and essentially identical between the two nonlinear regression programs.

The metabolism of ethosuximide.

The metabolism of the antiepileptic drug ethosuximide (3-ethyl-3-methylpyrollidine-2,5-dione) (I) in animals and humans is reviewed. Chiral aspects of the metabolism of ethosuximide are discussed. Clarification of the precise nature of the hydroxymetabolites of ethosuximide is presented.

Chiral aspects of the human metabolism of ethosuximide.

Ethosuximide is a chiral drug substance primarily indicated for the treatment of absence seizures. This drug is used clinically as the racemate. The human urinary metabolites of ethosuximide (I) have been studied using chiral gas chromatography (GC) and gas chromatography/mass spectrometry (GC/MS). The metabolites identified were the previously reported unchanged ethosuximide (I) enantiomers, all four stereoisomers of 2-(1-hydroxyethyl)-2-methylsuccinimide (II), and the four stereoisomers of 2-ethyl-3-hydroxy-2-methylsuccinimide (III). Through chemical derivatization methodology and GC/MS (using electron impact ionization [EI] and chemical ionization [CI] techniques) two enantiomers of a previously unreported metabolite of ethosuximide, 2-ethyl-2-hydroxymethylsuccinimide (VI), have been identified.

Chiral aspects of the metabolism of ethosuximide.

Ethosuximide is a chiral drug substance primarily indicated for the treatment of absence seizures. This drug is used clinically as the racemate. The urinary metabolites of ethosuximide (following i.p. administration of the racemate or individual enantiomers to rats) have been studied using chiral gas chromatography (GC) and gas chromatography-mass spectroscopy (GCMS). The metabolites identified were unchanged ethosuximide enantiomers, all four stereoisomers of 2-(1-hydroxyethyl)-2-methylsuccinimide, and a single stereoisomer of 2-ethyl-3-hydroxy-2-methylsuccinimide [derived from (R)-ethosuximide]. Preliminary quantitative studies indicate a degree of stereoselectivity in the fate of ethosuximide since the ratio of (R)- to (S)-ethosuximide in the urine was found to be 0.77:1 (0-24 h sample), 0.64:1 (24-48 h sample), and 0.83:1 (48-72 h sample). This would suggest that the (R)-isomer is preferentially metabolised. Results obtained following the administration of individual enantiomers of ethosuximide indicate that the 2-(1-hydroxyethyl)-2-methylsuccinimide diastereoisomers derived from (R)-ethosuximide are produced in approximately equal proportions [ratio 1.05:1 (0-24 h sample), 1.10:1 (24-48 h sample)], whilst those from (S)-ethosuximide are produced in unequal proportions [ratio 1.65:1 (0-24 h sample), 1.74:1 (24-48 h sample)].

Single sample estimate of ethosuximide clearance.

Ethosuximide was administered in single oral doses (ca. 15 mg/kg) to each of 12 healthy, male subjects. Serial blood and salivary ethosuximide concentrations were measured by a polarization immunofluorescence technique. The following parameters were estimated: CL/F, V/F, and plasma disappearance t1/2. Mean (+/- SD) values were 0.0091 (+/- 0.0023) l X h-1 X kg-1, 0.063 (+/- 0.12) l X kg-1, and 48.8 (+/- 9.3) h, respectively. Estimates of CL/F (CL/F) were calculated from single plasma or single salivary measurements. When V/F was set at 0.63 l X kg-1 and the 120-h plasma concentration was used, CL/F was 0.0091 (+/- .0018) l X h-1 X kg-1. CL/F was 0.0089 (+/- .0020) when the 120-h salivary concentration was used. These data demonstrate that under specified conditions ethosuximide clearance (CL/F) can be estimated from a single measurement of ethosuximide in either plasma or saliva, thereby permitting ethosuximide to be used safely and noninvasively as a probe of hepatic mixed function oxidase activity in humans.

Ethosuximide in human milk and in plasma of a mother and her nursed infant.

1 The concentrations of ethosuximide were measured in the milk and in the plasma of a nursing mother and her infant during a period of 4.5 months after delivery. 2 The maternal and the infant's plasma concentrations rose after delivery. 3 The milk concentration ethosuximide was similar to that in maternal plasma on the third day after delivery. During the following 2 months the average milk/maternal plasma concentration ratio was 0.80. The rise in ethosuximide concentration in milk during the first month was steeper than that in infant's plasma, which may be due to an increase in the infant's clearance of the drug. 4 Even if the infant has subtherapeutic plasma concentrations it is recommended to control the levels in infants that are nursed by ethosuximide-treated mothers when nursing has been established.