A design for the prospective evaluation of the efficacy and toxicity of antiepileptic drugs in adults

The design for the comparative evaluation of the efficacy and toxicity of phenobarbital, phenytoin, primidone, and carbamazepine is outlined. A double-blind prospective study of a sufficient number of patients can determine the optimum drug to use initially for partial and generalized tonic-clonic seizures in adults. The rationale for methods defines the major parameters that should be addressed in order to determine optimum drug for longterm seizure therapy. Major problems in the function of such a project include aspects of sample size attainment, screening/recruitment, non-drug-related losses, and adjustments to the ongoing protocol. The design, with modifications, can be used to study other antiepileptic drugs and other types of seizures.

Interaction between valproic acid and carbamazepine: an in vitro study of protein binding

Valproic acid (VPA) is highly bound to plasma protein (92-96%) and is likely to compete with carbamazepine (CBZ), another drug that is bound extensively (75%). CBZ protein binding was evaluated in vitro by ultrafiltration at concentrations within the therapeutic range (6, 8, and 12 micrograms/ml), while also varying VPA concentrations (0, 50, and 100 micrograms/ml). Using ultrafiltration, we found a significant elevation (p less than 0.01) in free and percent-free CBZ for every CBZ concentration tested as the total VPA concentration increased. Maximal effect was evident at 12 micrograms/ml CBZ. The free fraction increased from 23.5% free CBZ controls (2.85% micrograms/ml free) to 29.5% free CBZ (3.56% micrograms/ml free), with 100 micrograms/ml VPA a 25% increase in free CBZ. This in vitro study demonstrates that VPA competes with CBZ for plasma protein binding sites, resulting in a significant increase in free CBZ that may be clinically important.

Valproic acid and ethosuximide interaction

The addition of valproic acid to ethosuximide in treatment to prevent seizures caused increased serum concentration of ethosuximide in four of five patients observed. Ethosuximide levels increased from 73 to 112 microgram/ml (53% higher), with concomitant toxicity. Both were reversed by reduction of the ethosuximide dose from 27.4 to 20.4 mg/kg. Serum concentrations of these two drugs should be monitored closely when they are given together.

Reversible trifluoroacetic acid-induced conformational changes in glycophorin A as detected by proton nuclear magnetic resonance spectroscopy

High-field (270 MHz) 1H-NMR has been employed to study the solution conformation of glycophorin A, a sialoglycoprotein which spans the human erythrocyte membrane. Glycophorin A is one of the most fully characterized integral membrane proteins known, making it an excellent model for the study of membrane-bound proteins. This protein consists of three distinct domains: a glycosylated extracellular N-terminus, a hydrophobic intramembranous segment, and a polar cytoplasmic C-terminus. These domains contain aromatic residues which serve as convenient 1H-NMR conformational probes. The aromatic region of the NMR spectrum of glycophorin A in 2H2O shows single, well-resolved His and Tyr resonances. No resonances are observed, however, for the Phe residues which are located in or near the hydrophobic domain. These observations suggest that considerable heterogeneity with respect to segmental motions exists within the protein. This is consistent with circular dichroism data showing the intramembranous segment to be completely helical with the extremities of the protein being predominantly random coils. The helix of the hydrophrobic domain is remarkably resistant to conventional denaturing conditions including variations in pH, and temperature, and treatment with guanidine hydrochloride. However, in trifluoroacetic acid, which strongly solvates peptide backbones, there is extensive reversible unfolding of the helical structure as evidenced by the appearance of Phe resonances. Solvent titration experiments indicate that approximately a 1 : 1 volume ratio of trifluoroacetic acid to 2H2O is required to initiate unfolding of the helix.

Regional pressure differences in the left ventricle

Theoretically, if blood is to have directional flow and different magnitudes of velocity, pressure should be distributed in the left ventricle (LV) as a function of both space and time. Thus, regional pressure differences (RPD) were examined in the LV of 20 open-chested dogs. High-fidelity transducers were implanted through stab wounds at three positions in the LV: the base (B), equator (EQ), and apex (APX). Simultaneous, high-fidelity LV pressures were compared in each region under rest conditions and during graded infusions of isoproterenol and propranolol. In the baseline condition, there were slight but significant differences between the APX and B in end-diastolic pressure (EDP), peak systolic pressure (PSP), peak dp/dt and Vmax. At rest, the largest RPD between the APX and B in PSP was 9 mm Hg (mean +/- 1 SE = 2.1 +/- 0.5), and the largest during diastole was 5.1 mm Hg (mean +/- 1 SE = 1.2 +/- 0.4); the largest difference in Vmax was 30.5% (mean +/- 1 SE = 10.8 +/- 2.4). During isoproterenol infusion the RPD in PSP were accentuated; the largest seen was 84 mm Hg between APX and B (mean +/- 1 SE = 15.7 +/- 4.5). The largest difference in Vmax between B and APX was 188% (mean +/- 1 SE = 48.5 +/- 9.4). Propranolol obliterated these RPD. These results indicate that there are significant RPD in the LV cavity; during systole the highest pressures decrease sequentially from the apex to the equator and to the base; during diastole these RPD are of lesser magnitude. These RPD affect all derived pressure indices, and these changes can be increaed or decreased by drug intervention. These results are important for two reasons: 1) the position of catheters in the LV cavity is important when pressure-dependent LV parameters are compared in different conditions; and 2) in any force balance analysis of the left ventricle it is important to note that force generation by the left ventricle is an active process that transmits regional pressure differences to the LV cavity.

Nuclear magnetic resonance determinations of permeation coefficients for maleic acid in phospholipid vesicles

Lipid bilayer permeation coefficients for the neutral maleic acid molecule and the maleate monoanion have been determined by proton magnetic resonance techniques. Phosphatiydylcholine-cholesterol (2:1) unilamellar vesicles were prepared having an initial maleate anion concentration gradient stabilized by coupling to an impermeant potassium counterion. The coupling was released by addition of valinomycin, and the time evolution of external pH, internal pH, and maleate concentration followed using nuclear magnetic resonance areas and chemical shifts. Transport rate equations were numerically integrated to fit the date, yielding best fit permeation coefficients of 4 X 10(-9) and 4 X 10(-5) cm/s for maleate monoanion and maleic acid, respectively.

Valproic acid in epilepsy: clinical and pharmacological effects

The antiepileptic drug valproic acid was studied in an open clinical trial as adjunct medication for 23 patients with uncontrolled seizures of a generalized or partial type. Two-thirds of the patients experienced reduction in seizure frequency ranging from 25 to 100%. Extensive testing revealed no evidence of serious systemic toxicity due to the drug. Minor side effects (e.g., nausea, vomiting, or sedation) were usually transient. Sodium valproate syrup and valproic acid in capsules gave equivalent mean low (23.3 microgram/ml) and maximum (42.5 microgram/ml) serum concentrations. The drug had a relatively short half-life of 8.7 hours, necessitating administration in divided daily doses. During initiation of valproate therapy there was evidence of a decline in total serum phenytoin concentration (16.5 to 10.2 microgram/ml; p less than 0.001) while the percentage of free phenytoin increased (10.9 to 20%). The quantity of unbound phenytoin was relatively stable throughout. This observation was interpreted as a drug interaction: valproic acid competed with phenytoin for access to plasma protein binding sites.

Evaluation of liposome-entrapped radioactive tracers as scanning agents. Part 1: Organ distribution of liposome (99mTc-DTPA) in mice

We describe the use of liposomes as a delivery system for radiopharmaceutical localization. Liposomes [99mTc-DTPA] were injected intravenously in mice and showed preferential uptake in the liver and spleen. There was a steady decline of activity in all organs, suggestive of destruction of liposomes with subsequent release of 99mTc-DTPA into the circulation. Alteration of uptake from liver to spleen, lung, and bone marrow was achieved by prior loading of the circulation with nonradioactive liposomes. The same effect was produced in dogs and demonstrated with scintigraphy. We also showed scintigraphically in dogs how 99mTc-DTPA, when administered entrapped in liposomes, follows the pattern of distribution of liposomes. Liposomes seem to be suitable carriers for radiopharmaceuticals. Further studies should show the possibility of directing liposomes to specific targets.