Phenytoin metabolism to 5-(4-hydroxyphenyl)-5-phenylhydantoin (HPPH) in man, cat and rat in vitro and in vivo, and susceptibility to phenytoin-induced gingival overgrowth

Interspecies differences in phenytoin (PHT) metabolism to 5-(4-hydroxyphenyl)-5-phenylhydantoin (HPPH) were examined in human, cat and rat hepatic microsomes in vitro. Rat liver microsomes were 25 and 650 times more efficient at the conversion of PHT to HPPH than human and cat liver microsomes, respectively. Sulphaphenazole (83%) and tolbutamide (TOL) (64%) were the most potent inhibitors of HPPH formation in human liver microsomes, while ciprofloxacin (27%), enoxacin (27%) and TOL (26%) produced the greatest inhibition in cat liver microsomes. TOL was tested for its effect on HPPH formation and gingival overgrowth in cats in vivo. Eight cats received PHT sodium (4 mg/kg/d) and another 8 cats received PHT sodium together with TOL (20 mg/kg/d) for 10 wk. Six cats (75%) in the PHT group and 4 cats (50%) in the PHT & TOL group developed significant gingival overgrowth by the end of the study. However, the extent and incidence of the overgrowth were similar in the 2 groups. There were no significant differences in mean AUC 0-10 weeks for plasma PHT (552.90 +/- 29.6 micrograms.d/mL [PHT alone] vs. 582.41 +/- 24.49 micrograms.d/mL [PHT & TOL]) and unconjugated HPPH (1016.4 +/- 295.5 ng.d/mL [PHT alone] vs. 1174.5 +/- 397.2 ng.d/mL [PHT & TOL]) concentrations between the 2 groups of cats. Neither PHT nor HPPH were detectable in the plasma of 8 rats which received PHT (4 mg/kg/d) over a 10-wk period. The rats showed no sign of gingival inflammation (mean gingival index = 0) or gingival overgrowth (mean gingival overgrowth index = 0). Thirty-six adult epileptic patients on chronic PHT therapy were examined; 17 (47%) of the patients demonstrated clinically significant overgrowth. The mean steady-state plasma PHT concentration was comparable to, and the mean plasma unconjugated HPPH concentration 5-fold greater than, that observed in the cats. The results suggest that the rapid metabolism and elimination of PHT and HPPH in the rat may enable it to become more resistant towards developing gingival overgrowth, compared to the cat and man.

Teratological interaction between the bis-triazole antifungal agent fluconazole and the anticonvulsant drug phenytoin

Previous studies implicated the cytochrome P450 (CYP) system as critical in the teratogenic bioactivation of phenytoin (PHT). Fluconazole (FCZ) is an antifungal bis-triazole with potent inhibitory effect on the principal CYP-dependent metabolic pathway of PHT. In this study an in vivo experimental model was used to evaluate the potential ability of FCZ (2, 10, or 50 mg/kg intraperitoneally) to modulate PHT (65 mg/kg intraperitoneally) teratogenesis on day 12 (plug day = day 1) Swiss mice. PHT alone elicited embryocidal and malformative effects, with cleft palate as the major malformation. Pretreatment with the nonembryotoxic dosage of 10 mg FCZ/kg potentiated PHT-induced teratogenesis, as indicated by a twofold (from 6.2% to 13.3%) increment of cleft palate incidence (P < 0.05). Combined treatment with 50 mg FCZ/kg plus PHT resulted in a statistically significant (P < 0.05) increment of the resorption incidence recorded after PHT-alone exposure, but possibly as a consequence of the increased embryolethality, in the loss of the potentiative effect on PHT teratogenesis. Although the mechanistic nature of teratological interaction between FCZ and PHT remains to be established, these results may not support CYP system-mediated metabolic conversion as the mechanistic component of PHT teratogenesis.

Probabilistic approach to the establishment of maximal content limits of impurities in drug formulations: the case of parenteral diphenylhydantoic acid

Diphenylhydantoic acid (DPHA) is a degradation product in parenteral formulations of the anticonvulsant phenytoin and the prodrug fosphenytoin. DPHA has also been reported to be a minor metabolite of phenytoin. Levels found in the urine of various species, including humans, after oral or intravenous (iv) phenytoin ranged from undetected to a few percent of administered dose. In the present analysis, the toxicologic profile of DPHA was integrated with exposure data in order to characterize its safety under recommended clinical regimens of fosphenytoin administration. In preclinical safety studies, DPHA was without effect in the Ames assay and at concentrations up to 3000 microg/plate in the presence or absence of metabolic activation, and in the in vitro micronucleus test with acute and 2-week repeated dose studies in Wistar rats at iv doses up to 15 mg/kg. In 4-week studies conducted in rats and dogs receiving fosphenytoin containing DPHA levels up to 1.1%, and in an in vitro structural chromosome aberration test with DPHA levels up to 2.0%, all findings were consistent with known effects of phenytoin (such as CNS signs and increased liver weight), and none were attributed to DPHA. Reports in the literature indicate that in murine in vivo and in vitro models, DPHA has much lower potential for reproductive toxicity than phenytoin. A no-observed-effect level (NOEL) of 15 mg/kg established from the 2-week study in rats was used with probabilistic techniques to estimate tolerable daily doses (TDDs) of DPHA. In this approach, interspecies correction was performed by allometrically scaling the NOEL based on a distributional power of body weight while intraindividual variability was accounted for by selecting the lower percentiles of the population-based distribution of TDDs. The results indicate that a DPHA content limit of 3.0% in an administered dose of fosphenytoin is unlikely to cause adverse effects in patients.

Optimization of a heterogeneous reaction system for the production of optically active D-amino acids using thermostable D-hydantoinase

A thermostable D-hydantoinase from Bacillus stearothermophilus SD-1 was previously mass-produced by batch cultivation of the recombinant E. coli harboring the gene encoding the enzyme (Lee et al., 1997). In this work, we attempted to optimize the process for the production of N-carbamoyl-D-p-hydroxyphenylglycine, which is readily hydrolyzed to D-p-hydroxyphenylglycine under acidic conditions, from 5-(4-hydroxyphenyl)hydantoin using the mass-produced D-hydantoinase. In an effort to overcome the low solubility of the substrate, enzyme reaction was carried out in a heterogeneous system consisting of a high substrate concentration up to 300 g/L. In this reaction system, most of substrate is present in suspended particles. Optimal temperature and pH were determined to be 45 degrees C and 8.5, respectively, by taking into account the reaction rate and conversion yield. When the free enzyme was employed as a biocatalyst, enzyme loading higher than 300 unit/g-substrate was required to achieve maximum conversion. Use of whole cell enzyme resulted in maximum conversion even at lower enzyme loadings than the free enzyme, showing 96% conversion yield at 300 g/L substrate. The heterogeneous reaction system used in this work might be applied to the enzymatic production of other valuable compounds from a rarely water-soluble substrate.

The effects of genetic polymorphisms of CYP2C9 and CYP2C19 on phenytoin metabolism in Japanese adult patients with epilepsy: studies in stereoselective hydroxylation and population pharmacokinetics

PURPOSE

The aim of this study was to clarify the effects of genetic polymorphisms of cytochrome P450 (CYP) 2C9 and 2C19 on the metabolism of phenytoin (PHT). In addition, a population pharmacokinetic analysis was performed.

METHODS

The genotype of CYP2C9 (Arg144/Cys, Ile359/Leu) and CYP2C19(*1, *2 or *3) in 134 Japanese adult patients with epilepsy treated with PHT were determined, and their serum concentrations of 5-(4-hydroxyphenyl)-5-phenylhydantoin (p-HPPH) enantiomers, being major metabolites of PHT, were measured. A population pharmacokinetic analysis (NONMEM analysis) was performed to evaluate whether genetic polymorphism of CYP2C9/19 affects the clinical use of PHT by using the 336 dose-serum concentration data.

RESULTS

The mean maximal elimination rate (Vmax) was 42% lower in the heterozygote for Leu359 allele in CYP2C9, and the mean Michaelis-Menten constants (Km) in the heterozygous extensive metabolizers and the poor metabolizers of CYP2C19 were 22 and 54%, respectively, higher than those without the mutations in CYP2C9/19 genes. (R)- and (S)-p-HPPH/PHT ratios were lower in patients with mutations in CYP2C9 or CYP2C19 gene than those in patients without mutations.

CONCLUSIONS

Although the hydroxylation capacity of PHT was impaired with mutations of CYP2C9/19, the impairment was greater for CYP2C9. In view of the clinical use of PHT, two important conclusions were derived from this population study. First, the serum PHT concentration in patients with the Leu359 allele in CYP2C9 would increase dramatically even at lower daily doses. Second, the patients with CYP2C19 mutations should be treated carefully at higher daily doses of PHT.

A common anticonvulsant binding site for phenytoin, carbamazepine, and lamotrigine in neuronal Na+ channels

Phenytoin, carbamazepine, and lamotrigine are anticonvulsants frequently prescribed in seizure clinics. These drugs all show voltage-dependent inhibition of Na+ currents, which has been implicated as the major mechanism underlying the antiepileptic effect. In this study, I examine the inhibition of Na+ currents by mixtures of different anticonvulsants. Quantitative analysis of the shift of steady state inactivation curve in the presence of multiple drugs argues that one channel can be occupied by only one drug molecule. Moreover, the recovery from inhibition by a mixture of two drugs (a fast-unbinding drug plus a slow-unbinding drug) is faster, or at least not slower, than the recovery from inhibition by the slow-unbinding drug alone. Such kinetic characteristics further strengthen the argument that binding of one anticonvulsant to the Na+ channel precludes binding of the other. It also is found that these anticonvulsants are effective inhibitors of Na+ currents only when applied externally, not internally. Altogether these findings suggest that phenytoin, carbamazepine, and lamotrigine bind to a common receptor located on the extracellular side of the Na+ channel. Because these anticonvulsants all have much higher affinity to the inactivated state than to the resting state of the Na+ channel, the anticonvulsant receptor probably does not exist in the resting state. Thus, there may be correlative conformational changes for the making of the receptor on the extracellular side of the channel during the gating process.

A capillary GC-MS method for analysis of phenytoin and [13C3]-phenytoin from plasma obtained from pulse dose pharmacokinetic studies

Stable isotope analogues of phenytoin are useful for pulse dose pharmacokinetic studies in epilepsy patients. A simultaneous assay was developed to quantitate phenytoin (5,5-diphenylhydantoin) and its stable isotope analogue [13C3]-phenytoin (5,5-diphenyl-2,4,5-13C3-hydantoin) from plasma. Quantitation was achieved by GC-MS analysis of liquid/liquid extracted plasma samples, with [2H10]-phenytoin (5,5-di(pentadeuterophenyl)-hydantoin) as an internal standard. The total coefficients of variance (C.V.t) were < 7% for phenytoin (2.5-40 micrograms ml-1) and < 10.3% for [13C3]-phenytoin (0.1-6.0 micrograms ml-1). The accuracy of the assay varied from 87.8-100.1% (phenytoin, 2.5-40 micrograms ml-1) and 89.6-116.3% ([13C3]-phenytoin, 0.02-6.0 micrograms ml-1). The assay was tested under in vivo conditions by administration of a pulse dose of the stable isotope analogue to a single rat dosed to steady-state with fosphenytoin, a phenytoin prodrug. The results of the in vivo experiment demonstrate the usefulness of this assay for future pharmacokinetic studies in special population epilepsy patients.

Cytochrome P4502C9: an enzyme of major importance in human drug metabolism

Accumulating evidence indicates that CYP2C9 ranks amongst the most important drug metabolizing enzymes in humans. Substrates for CYP2C9 include fluoxetine, losartan, phenytoin, tolbutamide, torsemide, S-warfarin, and numerous NSAIDs. CYP2C9 activity in vivo is inducible by rifampicin. Evidence suggests that CYP2C9 substrates may also be induced variably by carbamazepine, ethanol and phenobarbitone. Apart from the mutual competitive inhibition which may occur between alternate substrates, numerous other drugs have been shown to inhibit CYP2C9 activity in vivo and/or in vitro. Clinically significant inhibition may occur with coadministration of amiodarone, fluconazole, phenylbutazone, sulphinpyrazone, sulphaphenazole and certain other sulphonamides. Polymorphisms in the coding region of the CYP2C9 gene produce variants at amino acid residues 144 (Arg144Cys) and 359 (Ile359Leu) of the CYP2C9 protein. Individuals homozygous for Leu359 have markedly diminished metabolic capacities for most CYP2C9 substrates, although the frequency of this allele is relatively low. Consistent with the modulation of enzyme activity by genetic and other factors, wide interindividual variability occurs in the elimination and/or dosage requirements of prototypic CYP2C9 substrates. Individualisation of dose is essential for those CYP2C9 substrates with a narrow therapeutic index.

The relationship between phenytoin pharmacokinetics and the CYP2C19 genotype in Japanese epileptic patients

The relationship between the phenytoin pharmacokinetics, expressed by the mean of the Michaelis-Menten equation and the CYP2C19 genotype was investigated in 16 Japanese epileptic patients treated with phenytoin. Between genetically (S)-mephenytoin poor and extensive metabolizers, there were no differences in the Michaelis-Menten parameters. But divided into genotype groups, Vmax values were 3.9 +/- 0.4, 5.3 +/- 0.7, and 5.7 +/- 1.4 mg/kg/day for the patients with the m2 allele, with the m1 allele, and with neither the m1 or m2 allele, respectively. In the patients with the m2 allele of CYP2C19, the Vmax value was significantly lower than in those without the m2 allele. It is possible that the m2 allele of CYP2C19 may be one of the factors of slow phenytoin metabolism, and its frequency may underlie the ethnic difference in phenytoin metabolism between Japanese and white individuals.

Fosphenytoin

Fosphenytoin is a phenytoin prodrug that has been introduced to overcome some of the problems and limitations associated with parenteral phenytoin sodium administration. Fosphenytoin is a phosphate ester prodrug that is converted to phenytoin in vivo by peripheral esterases. Fosphenytoin has several advantages and disadvantages that should be considered when selecting its use in place of parenteral phenytoin. Advantages with fosphenytoin include better tolerability, improved safety, better stability, ability for intramuscular administration, and faster infusion rates. Disadvantages with fosphenytoin include rate and dose related paresthesias and pruritus, delayed decreases in blood pressure, the potential for therapeutic drug monitoring errors, and higher drug acquisition costs. In general, given the pros and cons of the new drug, fosphenytoin offers an attractive alternative for parenteral phenytoin in select individuals.

Phenytoin toxicity in an older patient with slow metabolism and atypical presentation

Phenytoin toxicity occurred in an older man who received a dosage of 300 mg/day. The patient developed high serum phenytoin concentrations from this common adult dosage, with symptoms of functional decline and altered mental status. These behaviors were perceived as sun-downing and were treated with haloperidol. A long hospitalization was required.

Inhibition of CYP2C9 by selective serotonin reuptake inhibitors in vitro: studies of phenytoin p-hydroxylation

AIMS

Inhibition of cytochrome P450 (CYP) activity by selective serotonin reuptake inhibitors (SSRIs) has frequently been reported with regard to pathways mediated by CYP2D6, CYP3A4/5, and CYP1A2. Little data exist on the capability of SSRIs to inhibit CYP2C9.

METHODS

We investigated the effect of SSRIs on p-hydroxylation of phenytoin (PPH), an established index reaction reflecting CYP2C9 activity, in an in vitro assay using liver tissue from six different human donors.

RESULTS

In control incubations (without inhibitor), 5-(p-hydroxy-phenyl)-5-phenylhydantoin (HPPH) formation rates were: Vmax 0.023 nmol min(-1) mg(-1); Km 14.3 microM. Average inhibition constants (Ki) differed significantly among the SSRIs, with fluvoxamine having the lowest Ki (6 microM) followed by R-fluoxetine (13 microM), norfluoxetine (17 microM), RS-fluoxetine (19 microM), sertraline (33 microM), paroxetine (35 microM), S-fluoxetine (62 microM), and desmethylsertraline (66 microM). Thus, assuming comparable molar concentrations at the site of inhibition, fluvoxamine can be expected to have the highest probability of interfering with the metabolism of CYP2C9 substrates. S-fluoxetine is on average a 5 fold weaker CYP2C9 inhibitor than either R-fluoxetine or the racemic mixture.

CONCLUSIONS

These findings are consistent with published case reports describing SSRI-related increments in plasma phenytoin levels. Because phenytoin has a narrow therapeutic index, plasma levels should be closely monitored when SSRIs are coadministered.

Anticonvulsant hypersensitivity syndrome

Anticonvulsant hypersensitivity syndrome (AHS) is an uncommon but potentially fatal adverse effect that can occur from exposure to phenytoin, carbamazepine, or phenobarbital. It has diverse clinical features and a variable presentation which results in a delay in making the diagnosis. The syndrome commonly begins within 3 weeks after initiation of an anticonvulsant. Patients typically present with a constellation of fever, usually followed by the development of a rash of variable severity and type, and lymphadenopathy. In patients presenting with these features, the clinician should have a high index of suspicion for AHS.

Initiation of phenytoin teratogenesis: pharmacologically induced embryonic bradycardia and arrhythmia resulting in hypoxia and possible free radical damage at reoxygenation

The aim of this study was to investigate if phenytoin has the capacity to induce embryonic hypoxia mediated via adverse effects on the embryonic heart. Mouse embryos of different strains (CD-1, C57B1/6J and A/J) as well as Sprague Dawley (SD) rat embryos were cultured in vitro (in 75-80% rat serum) by the whole embryo technique. Effects on the heart were examined on gestational day 10 for mouse embryos and days 11 and 13 for rat embryos. Phenytoin was dissolved in water to give concentrations of 50-800 microM. In the mouse embryo studies, phenytoin caused a concentration-dependent decrease in embryonic heart rate in all three strains, with a slight decrease at 100 microM (2-7%) and a more pronounced effect at 200 microM (approximately 20%). Temporary or permanent cardiac arrest occurred in 86% of the CD-1 embryos at 500 microM, in 67% of the C57B1/6JM at 400 microM, and in all A/J embryos at 300 microM. Arrhythmias was observed in 8% in CD-1 embryos at 200 microM, in 18% at 150 microM in C57B1/6J embryos, and in 67% of the A/J embryos at 100 microM (lowest tested concentrations where arrhythmias occurred). In rat embryos, a concentration-dependent decrease in heart rate was observed on both days 11 and 13 at similar concentrations as in the mouse embryo studies. In a separate experiment, the effects on the heart rate of free phenytoin (not serum protein bound) were examined in rat embryos cultured in serum-free medium. Already at 12 microM a significant decrease in heart rate was observed. Altogether, the results support the hypothesis that phenytoin teratogenicity is initiated by pharmacologically induced embryonic hypoxia. A genetic susceptibility to the adverse effects of phenytoin on the embryonic heart may be of importance to explain strain and species differences in phenytoin teratogenicity.

Bioactivation of phenytoin by human cytochrome P450: characterization of the mechanism and targets of covalent adduct formation

The cytochrome P450-dependent covalent binding of radiolabel derived from phenytoin (DPH) and its phenol and catechol metabolites, 5-(4'-hydroxyphenyl)-5-phenylhydantoin (HPPH) and 5-(3',4'-dihydroxyphenyl)-5-phenylhydantoin (CAT), was examined in liver microsomes. Radiolabeled HPPH and CAT and unlabeled CAT were obtained from microsomal incubations and isolated by preparative HPLC. NADPH-dependent covalent binding was demonstrated in incubations of human liver microsomes with HPPH. When CAT was used as substrate, covalent adduct formation was independent of NADPH, was enhanced in the presence of systems generating reactive oxygen species, and was diminished under anaerobic conditions or in the presence of cytoprotective reducing agents. Fluorographic analysis showed that radiolabel derived from DPH and HPPH was selectively associated with proteins migrating with approximate relative molecular weights of 57-59 kDa and at the dye front (molecular weights < 23 kDa) on denaturing gels. Lower levels of radiolabel were distributed throughout the molecular weight range. In contrast, little selectivity was seen in covalent adducts formed from CAT. HPPH was shown to be a mechanism-based inactivator of P450, supporting the contention that a cytochrome P450 is one target of covalent binding. These results suggest that covalent binding of radiolabel derived from DPH in rat and human liver microsomes occurs via initial P450-dependent catechol formation followed by spontaneous oxidation to quinone and semiquinone derivatives that ultimately react with microsomal protein. Targets for covalent binding may include P450s, though the catechol appears to be sufficiently stable to migrate out of the P450 active site to form adducts with other proteins. In conclusion, we have demonstrated that DPH can be bioactivated in human liver to metabolites capable of covalently binding to proteins. The relationship of adduct formation to DPH-induced hypersensitivity reactions remains to be clarified.

Heat treatment of human serum to inactivate HIV does not alter protein binding of selected drugs

Human immunodeficiency virus (HIV) may be transmitted via certain biological fluids, particularly blood. To minimize the risk of accidental exposure, the virus may be inactivated by heat treatment of blood, plasma, or serum samples at 54-56 degrees C for 5 h. The objective of this study was to determine whether heat treatment of human serum alters the protein binding of model compounds. Diazepam, phenytoin, and digitoxin were selected for investigation because they bind to three different sites on human serum albumin (HSA); propranolol also was examined since it binds to both HSA and alpha 1-acid glycoprotein. The unbound fraction of selected drugs was measured by ultrafiltration at 37 degrees C after addition of each compound to either untreated or heat-treated serum. The percentage unbound in serum for diazepam, phenytoin, digitoxin, and propranolol was not significantly different between the untreated and heat-treated samples. Therefore, heat treatment of serum does not appear to alter the binding characteristics at these four binding sites and would not be expected to lead to erroneous unbound concentration estimates and inappropriate adjustments in drug therapy.

[Chiral separation of racemic 5-(p-hydroxyphenyl)-5-phenylhydantoin by RP-HPLC using eluents containing beta-cyclodextrin]

A chiral RP-HPLC method was developed to assay the 5-(p-hydroxyphenyl)-5-Phenylhydantoin (p-HPPH) enantiomers, the major metabolite of antiepileptic drug phenytoin, in rat hepatic microsomes. A 50 mm FLC-C8 column was used as the analytical column, beta-cyclodextrin (beta-CD) as chiral mobile phase additive and phenobarbital as the internal standard. The detection wavelength was 250 nm. The linear range of p-HPPH enantiomers was 0.5-110 mg/L. The detection limit was 5 ng (S/N = 3). The recoveries of S- and R-p-HPPH were 93.6% +/- 2.8% and 94.7% +/- 1.8% respectively. The RSD within day and between days were less than 2%. The concentration of beta-CD played an important role in separating chiral enantiomers. When the concentration of beta-CD was between 8.8 and 13.2 mmol/L the resolution of p-HPPH enantiomers had the largest value Rs = -1.1. In this work, 8.8 mmol/L beta-CD solution (4 g beta-CD, 6 g urea, and 1.5 g ammonium acetate in 400 mL water) was selected in considering some factors such as column efficiency, solubility of beta-CD etc. Urea can increase the solubility of beta-CD. When urea: beta-CD = 1:1-1.5:1 (g/g), the solubilization of beta-CD was significant. Methanol concentration in mobile phase affected retention time, resolution of p-HPPH enantiomers and solubility of beta-CD.

Carbamazepine inhibition of neuronal Na+ currents: quantitative distinction from phenytoin and possible therapeutic implications

Carbamazepine and phenytoin, two of the most commonly prescribed antiepileptic drugs, have been proposed to share a similar mechanism of action by use-dependent inhibition of Na+ channels. The proposed similar mechanism of action, however, cannot explain the common clinical experiences that the two drugs are different; in some patients, one drug may be more effective than the other. This may occur even when optimal therapeutic concentrations are reached with both medications in plasma or the cerebrospinal fluid. In this study, we show that the action of the two drugs on Na+ channels are quantitatively very different. The affinity between inactivated Na+ channels and carbamazepine (apparent dissociation constant approximately 25 microM) is approximately 3 times lower than that of phenytoin, yet the binding rate constant of carbamazepine onto the inactivated Na+ channels is approximately 38,000 M(-1)/sec(-1), or approximately 5 times faster than that of phenytoin. It is speculated that carbamazepine may be more effective than phenytoin in treating seizures whose ictal depolarization shift is relatively short, whereas a better response to phenytoin may imply abnormal discharges characterized by more prolonged depolarization.

Elevated free fatty acid concentrations in lipemic sera reduce protein binding of valproic acid significantly more than phenytoin

Higher concentrations of free valproic acid and phenytoin have been reported in patients with uremia and liver disease. Free fatty acids also displace valproic acid and phenytoin. This is a study of the magnitude of displacement of valproic acid and phenytoin from protein binding by free fatty acid in lipemic sera. Higher concentrations of free fatty acids in lipemic sera affected protein binding of valproic acid significantly more than that of phenytoin. Supplementing normal sera with free fatty acids also increased the free concentrations of both valproic acid and phenytoin as expected, but the observed effect was several times higher in magnitude with valproic acid. There was an increased free fraction of valproic acid in patients who received valproic acid and had hypertriglyceridemia. In a patient with uremia, there was also a significant increase in free valproic acid concentration after routine hemodialysis caused by an increase in free fatty acid concentration secondary to hemodialysis. Increased protein binding of valproic acid in sera was observed after treatment with activated charcoal because charcoal can remove free fatty acid. Because higher free fatty acid concentration significantly affects protein binding of valproic acid, careful monitoring of free valproic acid in patients with lipid disorder may be beneficial.

Effects of pregnancy on various pathways of human antiepileptic drug metabolism

Ratios of phenytoin and carbamazepine doses to steady-state plasma concentrations of the drugs (apparent clearances) increase in pregnant women. Mean phenytoin clearance to urinary unconjugated p-hydroxyphenytoin increased from 0.28 +/- SD 0.18 to 0.74 +/- SD 0.37 L/day in 13 pregnant women; mean clearance to p-hydroxyphenytoin glucuronide increased proportionately less (15.25 +/- SD 5.43 to 31.94 +/- SD 16.30 L/day), the proportion of the metabolite that was conjugated falling from 98.4 +/- SD 0.72% to 97.65 +/- SD 0.67%. Mean clearances to urinary phenytoin and phenytoin-dihydrodiol did not increase. In 10 epileptic women, mean clearances of carbamazepine to urinary (a) carbamazepine-10,11-epoxide (1.66 +/- SD 1.2 to 3.70 +/- SD 2.09 L/day), (b) unconjugated carbamazepine-10,11-trans-diol (33.93 +/- SD 10.21 to 47.01 +/- SD 19.58 L/day). (c) unconjugated carbamazepine-acridan (0.24 +/- SD 0.12 to 0.47 +/- SD 0.34 L/day), and (d) unconjugated 2-hydroxy-carbamazepine (0.08 +/- SD 0.09 to 0.66 +/- SD 1.14 L/day) all increased during pregnancy. Mean clearance to unconjugated 3-hydroxy-carbamazepine decreased (0.53 +/- SD 0.25 to 0.18 +/- SD 0.23 L/day). In contrast, mean clearances of carbamazepine to the glucuronides of its first stage metabolites (carbamazepine-diol, 2- and 3-hydroxy-carbamazepine and carbamazepine-acridan, respectively) did not increase in pregnancy. The conversion of carbamazepine to carbamazepine-epoxide increased proportionately more than the conversion of carbamazepine-epoxide to carbamazepine-diol. Pregnancy was thus associated with increased microsomal oxidations of phenytoin and carbamazepine, without proportionate increases in the subsequent hydrolysis of carbamazepine-10,11-epoxide and in the O-glucuronidations of the earlier stage metabolites.

Relative binding of acetaminophen, lidocaine, phenobarbital, phenytoin, quinidine, and theophylline to human tissues in vitro

The relative binding of acetaminophen, lidocaine, phenobarbital, phenytoin, quinidine, and theophylline to human tissues in vitro was studied using equilibrium dialysis. Pooled human serum plus homogenates of brain, heart, liver, and placenta were incubated at 4 degrees C with each drug at concentrations of 5 and 10 mmol/L. The percent binding of each drug to each tissue was calculated. Binding of 5% or less was considered to be negligible. By drug, the following relative binding orders were observed for those tissues demonstrating binding: acetaminophen (heart > brain, serum); lidocaine (no appreciable binding observed); phenobarbital (serum only); phenytoin (heart and liver equally; serum not studied); quinidine (serum > liver > brain, placenta); and theophylline (serum > liver). By matrix, serum bound all drugs studied except for lidocaine. Liver bound only phenytoin, quinidine, and theophylline; heart bound only acetaminophen and phenytoin; brain bound only acetaminophen and quinidine; and placenta bound only quinidine.

Cytochrome P450-dependent drug oxidation activities in liver microsomes of various animal species including rats, guinea pigs, dogs, monkeys, and humans

Levels of cytochrome P450 (P450 or CYP) proteins immunoreactive to antibodies raised against human CYP1A2, 2A6, 2C9, 2E1, and 3A4, monkey CYP2B17, and rat CYP2D1 were determined in liver microsomes of rats, guinea pigs, dogs, monkeys, and humans. We also examined several drug oxidation activities catalyzed by liver microsomes of these animal species using eleven P450 substrates such as phenacetin, coumarin, pentoxyresorufin, phenytoin, S-mephenytoin, bufuralol, aniline, benzphetamine, ethylmorphine, erythromycin, and nifedipine; the activities were compared with the levels of individual P450 enzymes. Monkey liver P450 proteins were found to have relatively similar immunochemical properties by immunoblotting analysis to the human enzymes, which belong to the same P450 gene families. Mean catalytic activities (on basis of mg microsomal protein) of P450-dependent drug oxidations with eleven substrates were higher in liver microsomes of monkeys than of humans, except that humans showed much higher activities for aniline p-hydroxylation than those catalyzed by monkeys. However, when the catalytic activities of liver microsomes of monkeys and humans were compared on the basis of nmol of P450, both species gave relatively similar rates towards the oxidation of phenacetin, coumarin, pentoxyresorufin, phenytoin, mephenytoin, benzphetamine, ethylmorphine, erythromycin, and nifedipine, while the aniline p-hydroxylation was higher and bufuralol 1'-hydroxylation was lower in humans than monkeys. On the other hand, the immunochemical properties of P450 proteins and the activities of P450-dependent drug oxidation reactions in dogs, guinea pigs, and rats were somewhat different from those of monkeys and humans; the differences in these animal species varied with the P450 enzymes examined and the substrates used. The results presented in this study provide useful information towards species-related differences in susceptibilities of various animal species regarding actions and toxicities of drugs and xenobiotic chemicals.

Valproate metabolites in high-dose valproate plus phenytoin therapy

PURPOSE

We wished to determine the relation between liver function, beta-, and omega-, and omega-1-oxidation metabolites and 4-en-valproate (VPA).

METHODS

We measured the serum levels of VPA and its metabolites in children and adolescent receiving high-dose VPA plus phenytoin (PHT) therapy using gas chromatography-mass spectrometry with selected ion monitoring (GC/MS/ SIM).

RESULTS

In high-dose VPA plus PHT polytherapy, the total VPA serum concentration was distinctly low, the concentrations of total beta-oxidation metabolites were decreased, the percentage values of VPA (percent of VPA) of total beta-oxidation metabolites were increased, and the E-2-en-VPA/3-keto-VPA ratios were decreased, as compared with those in high-dose VPA monotherapy. In high-dose VPA plus PHT polytherapy, 4-en-VPA (microM) was decreased and the concentrations of [omega + (omega-1)]-oxidation metabolites (microM) were decreased as compared with those in high-dose VPA monotherapy. In high-dose VPA plus PHT, serum glutamic-oxaloacetic transaminase (GOT), glutamic-pyruvic transaminase (GPT) and lactic dehydrogenase (LDH) did not correlate significantly with the ¿beta/omega + (omega-1)¿ metabolites ratio and 4-en-VPA levels, but serum GOT, GPT, and LDH were increased as compared with those in high-dose VPA therapy. We were not able to establish a significant relation between the formation of metabolites of VPA metabolites and liver dysfunction in patients receiving high-dose VPA and PHT concurrently.

CONCLUSIONS

Metabolic levels do not appear to be a reliable predictor of hepatotoxicity in children receiving pharmacological antiepileptic drug (AED) therapy.