Depression of synaptic transmission by diphenylhydantoin

Worsening of myasthenia due to antiepileptic, antipsychotic, antidepressant, and sedative medication: An estimation of risk based on reporting frequency

BACKGROUND AND PURPOSE

Many drugs can worsen myasthenia symptoms. The clinician usually relies on cautionary lists compiled according to case reports. We intended to provide a quantitative basis for a risk comparison within the groups of antiepileptic, antidepressant, neuroleptic, and sedative drugs.

METHODS

We extracted adverse drug reaction (ADR) counts (total and myasthenia related) for drugs from these groups and calculated the reporting odds ratio (ROR) within the drug groups from the World Health Organization pharmacovigilance database. For a given drug, the ROR was increased above 1 if the proportion of myasthenia-related ADRs for this drug was larger than the same proportion for the rest of drugs in that same group. If the 95% confidence interval of ROR was >1, this was taken as a signal for a higher risk of the given drug as compared to the average of the respective group.

RESULTS

Gabapentin, sertraline, citalopram, lithium, and amisulpride had a signal for the ROR to be increased above 1 within their respective groups. Bupropion, desvenlafaxine, duloxetine, escitalopram, and paroxetine had ROR values <1. For all other drugs, 1 was within the ROR confidence interval.

CONCLUSIONS

For gabapentin and lithium, the analysis of RORs confirmed case reports and cautionary lists. For a number of antidepressant drugs associated with a higher-than-average risk, no case reports exist substantiating our results. For these drugs, special attention should be paid to this risk. The remarkable difference between citalopram and escitalopram could prompt experimental work to confirm differential influence of the two preparations on neuromuscular transmission.

Pathomechanisms and Clinical Implications of Myasthenic Syndromes Exacerbated and Induced by Medical Treatments

Myasthenic syndromes are typically characterized by muscle weakness and increased fatigability due to an impaired transmission at the neuromuscular junction (NMJ). Most cases are caused by acquired autoimmune conditions such as myasthenia gravis (MG), typically with antibodies against the acetylcholine receptor (AChR). Different drugs are among the major factors that may complicate pre-existing autoimmune myasthenic conditions by further impairing transmission at the NMJ. Some clinical observations are substantiated by experimental data, indicating that presynaptic, postsynaptic or more complex pathomechanisms at the NMJ may be involved, depending on the individual compound. Most robust data exist for the risks associated with some antibiotics (e.g., aminoglycosides, ketolides, fluoroquinolones) and cardiovascular medications (e.g., class Ia antiarrhythmics, beta blockers). Apart from primarily autoimmune-mediated disorders of the NMJ, de novo myasthenic manifestations may also be triggered by medical treatments that induce an autoimmune reaction. Most notably, there is growing evidence that the immune checkpoint inhibitors (ICI), a modern class of drugs to treat various malignancies, represent a relevant risk factor to develop severe and progressive medication-induced myasthenia via an immune-mediated mechanism. From a clinical perspective, it is of utmost importance for the treating physicians to be aware of such adverse treatment effects and their consequences. In this article, we aim to summarize existing evidence regarding the key molecular and immunological mechanisms as well as the clinical implications of medication-aggravated and medication-induced myasthenic syndromes.

From neuroscience to application in neuropharmacology: A generation of progress in electrophysiology

A continuum from neuronal cellular/subcellular properties to system processes appears to exist in many instances and to allow privileged approaches in neuroscience and neuropharmacology research. Brain signals and the cholinergic and GABAergic systems, in vivo and in vitro evidence from studies on the retina, or the "gamma band" oscillations in neuron membrane potential/spiking rate and neuronal assemblies are examples in this respect. However, spontaneous and stimulus-event-related signals at any location and time point reflect brain state conditions that depend on neuromodulation, neurotransmitter interaction, hormones (e.g., glucocorticois, ACTH, estrogens) and neuroendocrine interaction at different levels of complexity, as well as on the spontaneous or experimentally-induced changes in metabolism (e.g., glucose, ammonia), blood flow, pO2, pCO2, acid/base balance, K activity, etc., that occur locally or systemically. Any of these factors can account for individual differences and/or changes over time that often are (or need to be) neglected in pharmaco-EEG studies or are dealt with statistically and by controlling the experimental conditions. As a result, the electrophysiological effects of neuroactive drugs are to an extent non-specific and require adequate modeling and precise correlation with independent parameters (e.g., drug kinetics, vigilance, hormonal profile or metabolic status, etc.) to avoid biased results in otherwise controlled studies.

Therapeutic drug monitoring of old and newer anti-epileptic drugs

The aim of the present paper is to provide information concerning the setting up and interpretation of therapeutic drug monitoring (TDM) for anti-epileptic drugs. The potential value of TDM for these drugs (including carbamazepine, clobazam, clonazepam, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pheneturide, phenobarbital, phenytoin, primidone, tiagabine, topiramate, valproic acid, vigabatrin and zonisamide) is discussed in relation to their mode of action, drug interactions and their pharmacokinetic properties. The review is based upon available literature data and on observations from our clinical practice. Up until approximately 15 years ago anti-epileptic therapeutics were restricted to a very few drugs that were developed in the first half of the 20th century. Unfortunately, many patients were refractory to these drugs and a new generation of drugs has been developed, mostly as add-on therapy. Although the efficacy of the newer drugs is no better, there is an apparent improvement in drug tolerance, combined with a diminished potential for adverse drug interactions. All new anticonvulsant drugs have undergone extensive clinical studies, but information on the relationship between plasma concentrations and effects is scarce for many of these drugs. Wide ranges in concentrations have been published for seizure control and toxicity. Few studies have been undertaken to establish the concentration-effect relationship. This review shows that TDM may be helpful for a number of these newer drugs.

Phenytoin blocks retinal ganglion cell death after partial optic nerve crush

Phenytoin is a well-characterized sodium channel blocker in widespread use as an anticonvulsant. In 1972, Becker and co-workers reported that phenytoin could reverse visual field loss from glaucoma. The authors therefore explored whether phenytoin could protect retinal ganglion cells from optic nerve crush. The optic nerve of Long-Evans rats was partially crushed; animals were given a single dose of either intraperitoneal phenytoin or vehicle. A third group underwent sham optic nerve crush. In a second set of experiments, the effect of phenytoin was compared to the N -methyl- D -receptor antagonist, memantine. Retinal ganglion survival was evaluated 1 week later. In addition, the effect of memantine and phenytoin on glutamate-induced intracellular calcium fluxes was evaluated.Phenytoin and memantine significantly reduced ganglion cell loss after optic nerve crush, and blunted the rise in intracellular calcium seen after administration of glutamate. Co-administration of the two agents, however, did not increase ganglion cell survival, and had no effect on ganglion cell calcium fluxes. Phenytoin can preserve retinal ganglion cells after partial optic nerve crush. This effect was not additive with a glutamate antagonist, suggesting that both agents alone are equally protective at saving the same population of ganglion cells at risk. In fact, the neuroprotective effect of the combined administration of phenytoin and memantine was significantly less than either of the two drugs alone. Phenytoin is known to decrease neuronal firing and neurotransmitter release; this may underlie its ability to serve as a neuro-protectant in this experimental paradigm.

Established antiepileptic drugs

Despite the recent entry into the market-place of a range of new pharmacological treatments for epilepsy, most patients still receive the standard antiepileptic drugs. This review considers the clinical place and practical use of these agents. Detailed consideration is given to carbamazepine, phenytoin, sodium valproate, phenobarbital and ethosuximide, with lesser emphasis on primidone, clobazam and clonazepam. Individualization of therapy, polypharmacy, refractory epilepsy, therapeutic drug monitoring, pregnancy, withdrawing treatment, epilepsy prophylaxis and referral to an epilepsy centre are also discussed. The paper concludes with a statement of 12 basic rules in prescribing established antiepileptic drugs.

Effects of vigabatrin on motor potentials evoked with magnetic stimulation

We studied the effect of an acute loading dose of vigabatrin on threshold of motor responses and duration of silent period elicited with cortical magnetic stimulation in normal subjects. In contrast to phenytoin, vigabatrin does not increase the motor threshold of first dorsal interosseus muscle. We also show that, although vigabatrin increases GABA concentrations in the central nervous system, duration of silent period studied at various stimulus intensities is not modified after vigabatrin administration.

Basis of the antiseizure action of phenytoin

1. Phenytoin has been used with much clinical success against all types of epileptiform seizures, except petit mal epilepsy, for over 50 years. Its mechanism of action, however, is still open to interpretation. 2. Several potential targets for phenytoin action have been identified within the central nervous system. These include the Na-K-ATPase, the GABAA receptor complex, ionotropic glutamate receptors, calcium channels and sigma binding sites. 3. To date, though, the best evidence hinges on the inhibition of voltage-sensitive Na+ channels in the plasma membrane of neurons undergoing seizure activity. Quieter nerve cells are far less affected. Moreover, the fact that phenytoin also has important cardiac antiarrhythymic effects and can inhibit Na+ influx into cardiac cells supports the idea that the primary target of phenytoin is, indeed, the Na+ channel.

Chronic phenytoin induced impairment of learning and memory with associated changes in brain acetylcholine esterase activity and monoamine levels

Groups of adult, male, Wistar rats were administered phenytoin (DPH) at 5, 12.5, 25, 50, or 75 mg/kg i.p. for 21 days. The learning and memory of these rats were assessed using the T-maze and passive avoidance tests. The plasma DPH levels, acetylcholine esterase (AChE) activity in different brain regions, and the levels of monoamines in the hippocampus were measured. The results indicate that DPH below the therapeutic plasma level did not significantly impair learning and memory. Correspondingly, no changes were noted in the brain 5-HT or AChE activity. However, DPH, at therapeutic plasma concentrations (i.e., 10.5 micrograms/ml in the dosage range of 50 and 75 mg/kg, respectively), significantly impaired learning and memory in rats. The impaired learning and memory functions were associated with increased 5-HT levels and decreased AChE activity in the hippocampus. With a dose of 75 mg/kg DPH, there was a reduction in the AChE activity in the striatum, in addition to hippocampus. It is conjectured that the neurochemical changes brought about by DPH at therapeutic plasma levels may account for the impairment of learning, memory, and cognitive functions in epilepsy.

Effects of diphenylhydantoin on motor potentials evoked with magnetic stimulation

We studied the effect of an acute loading dose of diphenylhydantoin (DPH) on motor responses elicited with cortical magnetic stimulation in normal subjects. DPH increased significantly the motor threshold activation of ADM, APB, FDI and biceps. The motor threshold increase was of greater magnitude for the proximal muscle. Spinal soleus alpha-motoneuron pool excitability assessed by H-reflex was increased significantly suggesting that the motor threshold increase is related to a supraspinal effect of the drug. Our study demonstrates that the motor threshold increase observed after DPH administration occurs not only in epileptic patients but also in normal subjects.

In vivo and in vitro effects of phenytoin (PHT) on ATPases and [14C]-PHT binding in synaptosomes and mitochondria from rat cerebral cortex

The effect of phenytoin (PHT) on Na(+)-K(+)-ATPase and Mg(2+)-ATPase activities and on [14C]-PHT binding in vitro to synaptosomal and mitochondrial subcellular fractions from rat cerebral cortex was studied after chronic PHT treatment. Synaptosomal and mitochondrial fractions were characterized with plasma membrane and mitochondrial enzymatic markers. Synaptosomal Na(+)-K(+)-ATPase was not affected in vitro by PHT 1-200 microM or by chronic treatment with 2-50 mg/kg/day of the unlabeled drug for 8 days. Mitochondrial Mg(2+)-ATPase was significantly stimulated by PHT after chronic treatment with 5 mg/kg/day for 8 days; reaching maximal effect (76%), at 10-25 mg/kg. PHT had no effect on mitochondrial Mg(2+)-ATPase when added in vitro. [14C]-PHT binding in vitro to the subcellular fractions was determined by dialysis to assess in vivo binding of the unlabeled PHT during chronic treatment. Indeed, [14C]-PHT bound to synaptosomes was significantly reduced by chronic PHT treatment from 218 +/- 10 to 119 +/- 11 pmol/mg protein after 1 week of treatment; a similar effect was obtained after 2-3 weeks with 10 mg/kg/day. Mitochondrial fraction bound 117 +/- 10 pmol/mg protein labeled PHT. Chronic treatment with unlabeled PHT also reduced the amount of [14C]-PHT bound to 19.9 +/- 2.2 pmol/mg protein. These results show slow reversible PHT in vivo binding to synaptosomes and mitochondrias from rat cerebral cortex, supporting the idea that the modulatory action of PHT on Na+ and Ca2+ permeabilities are mediated through these slow reversible binding proteins. The data also suggest a possible role of intrasynaptosomal mitochondria in [Ca2+]i buffering.

Effects of monotherapy and polytherapy on the blink reflex in epileptic patients

We performed the blink reflex (BR) in 20 normal volunteers, 13 epileptic patients receiving antiepileptic drug (AED) monotherapy, and 13 epileptic patients receiving AED polytherapy. Comparison of R1, ipsilateral and contralateral R2 and VIIth nerve latencies in the three groups showed no statistically significant differences R1 and VIIth nerve latencies among the three groups. There were statistically significant differences between the polytherapy group and the monotherapy and control groups in comparisons of ipsilateral and contralateral R2. There were no significant differences between the monotherapy group and the control group for ipsilateral and contralateral R2. We hypothesized that AED polytherapy might interfere with synaptic transmission in the polysynaptic pathway of the blink reflex, prolonging the latency of R2. These results provide further evidence of the pathophysiologic effects associated with polytherapy in epileptic patients.

Phenytoin-induced resistance to vecuronium

Chronic phenytoin therapy causes resistance to some nondepolarising muscle relaxants. We have confirmed that this resistance is seen with vecuronium and suggest that at least a week of phenytoin therapy is required for a significant effect to develop. The mechanism of this resistance is not known. We have shown that an exaggerated rise in serum potassium after succinylcholine does not occur in patients with demonstrated resistance to vecuronium from chronic phenytoin therapy. This would suggest that significant extrajunctional acetylcholine receptor proliferation is an unlikely mechanism.

Phenytoin reduces suxamethonium-induced myalgia

A prospective, randomised trial was undertaken in 60 healthy adults to determine the efficacy of intravenously administered phenytoin in doses of 5 mg.kg-1 for the prevention of suxamethonium-induced fasciculations, a rise in serum K+ and myalgia. This was compared with tubocurarine pretreatment and no pretreatment (control group). Phenytoin pretreatment significantly reduced myalgia from 45% (nine patients) in the control group to 10% (two patients) (p less than 0.05). It also decreased the duration and mean intensity of fasciculations. Incidentally, phenytoin was also found to decrease significantly mean serum Na+ levels (p less than 0.001) both at 5 and 20 min after administration. Tubocurarine pretreatment (3 mg) resulted in a significant decrease in fasciculations, but myalgia, which occurred in five patients, remained the same. No significant correlation was found between muscle fasciculations, postoperative myalgia and K+ changes, but patients with myalgia had a significant decrease in mean serum Na+ levels at 5 and 20 min after suxamethonium (p less than 0.01).

Effects of anticonvulsant drugs on axonal conduction in mammalian corpus callosum

The frequency-dependent effect of various anticonvulsant drugs on the conduction in central axons was studied in the corpus callosum of rat and guinea pig brain slices from the parietal region. Extracellularly recorded compound action potentials (CAPs) were evoked by either single stimulus or high frequency stimulation (40-80 Hz). The CAP in rats consisted of an early component (fast axons, 1.2-1.8 m/s) and a late component (slow axons, 0.5-0.7 m/s), while in the guinea pig only the slow phase was observed. Diphenylhydantoin increased the latency of a single response by 10%, and had no effect on the CAP amplitude. In contrast, both phenobarbital and pentobarbital reduced the amplitude of singly evoked CAPs. Stimulation at high frequency alone decreased the CAP amplitude by 10-20%. Identical stimulation in the presence of the drugs further suppressed the CAP amplitude by an additional 31%, with varying degree of drug efficacy. The depressant effect was significant for the slow axons but the fast axons were virtually unaffected by any of the drugs. The results are consistent with the hypothesis that the antiepileptic drugs DPH, Phe and Pnt may block axonal conduction from an epileptic focus into neighbouring areas of the brain.

Acute effects of diphenylhydantoin on peripheral and central somatosensory conduction

We studied the acute effects of an intravenous loading dose of DPH (16 mg/kg body weight) on peripheral and central somatosensory conduction in 10 normal volunteers. Somatosensory evoked potentials were recorded before and at regular intervals after DPH infusion. There was no effect on peripheral conduction. DPH significantly delayed N13 peak latency without changing conduction in the posterior spinal columns. Although the N13-N20 interpeak interval remained stable because of the parallel shift of the 2 peaks, the central conduction time measured from onset latencies of N11 and N20 significantly increased. We conclude that acute administration of DPH at serum levels below 30 micrograms/ml induces a reversible delay of synaptic transmission in spinal and central somatosensory structures.

Calcium binding protein (calbindin-D28k) and glutamate decarboxylase gene expression after kindling induced seizures

In order to determine whether calcium binding protein (calbindin-D28k or CaBP) and glutamate decarboxylase (GAD) may be involved in the process underlying the generation of seizure activity, changes in CaBP protein and mRNA and in GAD mRNA were examined in the kindling model of epilepsy. Following amygdaloid (AK) and commissure (CK) kindling significant decreases in the concentration of CaBP of 20% and 30%, respectively, were specifically observed in the hippocampal formation. However, using a cDNA specific to mammalian CaBP, Northern analysis of poly(A+) RNA and slot blot analysis of total RNA revealed no changes in the levels of CaBP mRNA in hippocampus, subcortical area (including amygdala, substantia nigra and striatum) or cerebellum of rats sacrificed 30 min, 1 h, 6 h or 24 h after the last kindled seizure. Similarly when these blots were reprobed with a cDNA specific to mammalian GAD, no changes in GAD gene expression were observed. However, fos gene expression was markedly enhanced at 1 h after seizure. We also tested whether changes in CaBP or GAD mRNA could be detected at any of the various stages of the kindling process. Slot blot analysis of cortex, subcortical structures and hippocampus revealed no changes in CaBP or GAD mRNA during the course of commissure kindling. In situ hybridization studies with GAD and CaBP 35S-labeled antisense probes also indicated no obvious changes upon visual analysis of autoradiographs. However, when silver grains were counted, significant changes in GAD mRNA in individual cells in hippocampus and substantia nigra were noted after kindling induced epilepsy. Our results indicate that, unlike fos gene expression, prominent alterations in GAD and CaBP mRNA in gross brain regions (as measured by slot blot and Northern blot analyses) are not observed in the kindling process. However, our in situ hybridization studies suggest that changes in GAD mRNA in individual cells may be involved in the process underlying kindling induced seizure activity.

Magnetic motor-evoked potentials in epilepsy: effects of the disease and of anticonvulsant medication

Magnetic motor-evoked potentials were recorded in 53 patients with medically intractable, mainly temporal lobe epilepsy and compared with potentials of 110 healthy volunteers. The motor-evoked potentials were reevaluated in 16 of the 53 patients after substantial reduction of antiepileptic drug doses. The objective was to assess the effect of epilepsy and of anticonvulsant medication on the central motor system. In subjects receiving antiepileptic treatment, cortical threshold intensities were markedly elevated and peripheral latencies were prolonged. Cortical threshold intensities and peripheral latencies decreased to approach control values after anticonvulsant medication was reduced but were increased in patients treated with 2 or 3 anticonvulsant agents instead of 1. Additionally, high levels of interictal epileptiform activity and a high frequency of seizures significantly decreased the central motor conduction time and, in part, threshold intensities. The central motor conduction time was further diminished after reduction of anticonvulsant treatment and increased when several drugs were administered. The duration of epilepsy, the location of the epileptic focus, and the type of the epileptic seizure did not affect motor-evoked potentials. Conclusively, central motor pathways are endogenously facilitated by epileptiform activity even if clinical signs of their involvement are absent. Anticonvulsant medication exerts major reversible effects on magnetic motor-evoked potentials.

Mechanisms of antiepileptic drug action

Animal seizure models, in vitro preparations of cell cultures and tissue slices, and an unravelling of some of the basic mechanisms underlying epileptogenesis and epilepsy have furthered the understanding of mechanisms of action of antiepileptic drugs at the cellular and subcellular levels. Nevertheless, the mechanism of action of most antiepileptic drugs in clinical use is incompletely understood. Multiple physiologic mechanisms are altered by antiepileptic drugs. Some of these drugs, such as phenytoin and carbamazepine, decrease sustained repetitive firing and post-tetanic potentiation through their blocking effects on the sodium channel. Benzodiazepines and barbiturates enhance GABA-mediated inhibition. Many antiepileptic drugs inhibit calcium influx and calcium-mediated secondary effects at supratherapeutic concentrations. Newer drugs that inhibit excitatory receptors or enhance various forms of inhibition are presently under investigation.

Effects of calcium channel blocking agents on neostigmine-induced fasciculations

Male Sprague-Dawley rats were anesthetized with pentobarbital and prepared for monitoring contractions of the gastrocnemius muscle evoked by stimulation of the sciatic nerve. Animals received atropine prior to a dose of neostigmine of 0.02 mg/kg i.v. The effects on contractile strength and the number of fasciculations in a 2-min period were assessed. Pretreatment with phenytoin, 20 mg/kg, reduced the number of fasciculations to 32% of control without altering contractile strength. Both nifedipine and nitrendipine, 1 mg/kg each, virtually abolished fasciculations without altering twitch strength. Verapamil, 4 and 8 mg/kg, depressed fasciculation frequency to 50% of control without affecting pre-neostigmine twitch height. The dihydropyridine calcium blocking agents did however reduce the neostigmine-induced augmentation of contraction strength. These data suggest that a calcium-mediated current at presynaptic motor endings participates in the generation of repetitive nerve terminal discharges leading to muscle fasciculations.

The effect of acutely administered phenytoin on vecuronium-induced neuromuscular blockade

Phenytoin was administered intravenously in a dose of 10 mg kg to a group of patients in whom steady state neuromuscular blockade had been established with an infusion of vecuronium. A control group of patients were given 0.9% saline instead of phenytoin. Administration of phenytoin produced significant augmentation of neuromuscular blockade (p less than 0.001). The possible mechanism of this effect is discussed.

Antiepileptic drug actions

Antiepileptic drugs (AEDs) vary in their efficacy against generalized tonic-clonic, myoclonic, and absence seizures, suggesting different mechanisms of action. Phenytoin (PHT), carbamazepine (CBZ), and valproate (VPA) reduced the ability of mouse central neurons to sustain high-frequency repetitive firing of action potentials (SRF) at therapeutic free serum concentrations. Phenobarbital (PB) and the benzodiazepines (BZDs), diazepam (DZP), clonazepam (CZP), and lorazepam (LZP), also reduced SRF, but only at supratherapeutic free serum concentrations achieved in treatment of generalized tonic-clonic status epilepticus. These AEDs interact with sodium channels to slow the rate of recovery of the channels from inactivation. The BZDs and PB enhanced gamma-aminobutyric acid (GABA) responses evoked on mouse central neurons by binding to two different sites on the GABAA receptor channel. BZDs increased the frequency of GABA receptor channel openings. In contrast, barbiturates increased the open duration of these channels. VPA enhanced brain GABA concentration and may enhance release of GABA from nerve terminals. Ethosuximide (ESM) reduced a small transient calcium current which has been shown to be involved in slow rhythmic firing of certain neurons. Reduction of SRF, enhancement of GABA-ergic inhibition, and reduction of calcium current may be, in part, the bases for AED action against generalized tonic-clonic, myoclonic, and absence seizures, respectively.

Mechanisms of anticonvulsant drug action. I. Drugs primarily used for generalized tonic-clonic and partial epilepsies

The mechanisms by which the clinically effective anticonvulsant drugs act include effects on neurotransmitter action, effects on repetitive neuronal firing mechanisms, effects on neuronal networks, and effects on neuronal ionic transport. The combination of effects possessed by each individual agent along with its pharmacokinetic properties determine the usefulness of each agent. Phenytoin, carbamazepine and phenobarbital are effective in generalized tonic-clonic and partial epilepsies. Phenytoin exerts important effects on neuronal sodium and calcium ion transport, reduces repetitive firing, reduces excitation in neuronal networks of the brainstem reticular formation, and produces some decrease in the effect of the inhibitory transmitter, gamma-aminobutyric acid (GABA). Carbamazepine blocks repetitive firing mechanisms, reduces excitation in neuronal networks with some effect on sodium and potassium ion transport, and has effects on the actions of norepinephrine, adenosine and perhaps acetylcholine. Phenobarbital enhances the action of GABA with some reduction of repetitive firing and reduces excitation in reticular formation neuronal networks.

Effect of diphenylhydantoin on drug and calcium induced contractions of isolated rat uterus: a comparative study with nifedipine

The sustained contractions induced by K+, acetylcholine (ACh) and oxytocin (Ot) were inhibited in a concentration-dependent fashion by diphenylhydantoin (DPH) and nifedipine (NIF) in the following order of sensitivity: K+ greater than ACh greater than Ot. Previous incubation of DPH and NIF produced a non-competitive antagonism towards ACh and Ot-induced contractions. Increasing of calcium (Ca2+) concentration (0.2-1.5 mM) completely reverse the inhibitory effect of DPH and NIF, suggesting a competitive type of antagonism, between Ca2+ and DPH. A clear difference between DPH and NIF actions was observed when the K+-depolarizing solution was used. In this condition, DPH caused a parallel and concentration-related rightward displacement of the dose-response curves of Ca2+ (pA2 = 4.91 +/- 0.1), while NIF produced a rightward displacement allied to a significant reduction of the Ca2+ maximal response. DPH, but not NIF, produced a concentration-dependent relaxation in sustained contraction induced by Ca2+ (1 mM) in depolarized tissue.

Phenytoin reduces early acetylcholine release after depolarization

Phenytoin 10 microM inhibits the K-evoked release of acetylcholine (ACh) from synaptosomes, a process which is biphasic. Phenytoin acts only on the early phase of release. Replacement of external Na with Li does not modify phenytoin's effect. Phenytoin augments the spontaneous release of ACh from resting synaptosomes but this effect is eliminated in Li media. It is likely that phenytoin reduces K-evoked Ca uptake and the Na/Ca exchange by separate mechanisms.

The action of valproate on spontaneous epileptiform activity in the absence of synaptic transmission and on evoked changes in [Ca2+]o and [K+]o in the hippocampal slice

The effects of valproate (VPA) on neuronal excitability and on changes in extracellular potassium ([K+]o) and calcium ([Ca2+]o) were investigated with ion selective-reference electrode pairs in area CA1 of rat hippocampal slices. Field potential responses to single ortho- and antidromic stimuli were unaltered by VPA (1-5 mM). The afferent volley evoked in the Schaffer-commissural fibers was also unaffected. In contrast, VPA (1 mM) depressed frequency potentiation and paired pulse facilitation markedly. Decreases in [Ca2+]o induced either by repetitive stimulation or by application of the excitatory amino acids N-methyl-D-aspartate and quisqualate were reduced, and the latter results suggest that VPA interferes with postsynaptic Ca2+ entry. When synaptic transmission was blocked by lowering [Ca2+]o (0.2 mM) and elevating [Mg2+]o (7 mM), prolonged afterdischarges elicited by antidromic stimulation were blocked by VPA. VPA also suppressed the spontaneous epileptiform activity seen when [Ca2+]o was lowered to 0.2 mM, without elevating [Mg2+]o. The amplitudes of the rises in [K+]o induced by repetitive orthodromic stimulation were only slightly depressed and those elicited by antidromic stimulation were generally unaltered by VPA, as were laminar profiles of stimulus-evoked [K+]o signals. These results indicate that VPA has membrane actions in addition to known effects on excitatory and inhibitory transmitter pools.

Phenytoin dephosphorylates the catalytic subunit of the (Na+,K+)-ATPase in C57/BL mice

The effects of phenytoin, a potent antiepileptic drug, on the active transport of cations within membranes remain controversial. To assess the direct effects of phenytoin on the Na+,K+ pump, we studied the drug's influence on the phosphorylation of partially purified (Na+,K+)-ATPase from mouse brain. (Na+,K+)-ATPase subunits were resolved by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Phenytoin, in vitro, decreased net phosphorylation of the (Na+,K+)-ATPase catalytic subunit in a dose-dependent manner (approximately 50% at 10(-4) M). When the conversion of E1-P to E2-P, e.g., the two major phosphorylated conformational states of (Na+,K+)-ATPase, was blocked by oligomycin or N-ethylmaleimide, phenytoin had no effect. The results suggest that phenytoin acts on the phosphatasic component of the reaction cycle, decreasing the phosphorylation level of the enzyme.

Phenytoin: mechanisms of its anticonvulsant action

Phenytoin is a major anticonvulsant drug that is very effective in controlling a wide variety of seizure disorders while impairing neurological function little, if at all. Early work suggested the hypothesis that the drug's effects were due to a selective block of high-frequency neuronal activity. This theory is reevaluated in the light of accumulated observations on the effects of phenytoin in many neuronal and synaptic preparations. Most of these observations can be explained by a use- and frequency-dependent suppression of the sodium action potential by phenytoin, with a consequent filtering out of sustained high-frequency neuronal discharges and synaptic activity. The molecular mechanism for this is a voltage-dependent blockade of membrane sodium channels responsible for the action potential. Through this action, phenytoin obstructs the positive feedback that underlies the development of maximal seizure activity, while normal brain activity, proceeding at lower neuronal firing rates, is spared its depressant action. Other mechanisms of action that may contribute to the drug's efficacy and selectivity are also discussed.

Frequency-dependent action of phenytoin on lamprey spinal axons

The effect of the antiepileptic drug phenytoin (diphenylhydantoin, DPH) was tested on the conduction of intracellularly recorded action potentials in lamprey giant reticulospinal axons. When the isolated spinal cord was exposed to 80 microM DPH for up to 4 h, no significant effect was seen on the amplitude or conduction velocity of the action potential, although the maximum rate of rise was reduced from 247.8 to 149.6 V/s after 1 h. However, at higher stimulus frequencies both the amplitude and conduction velocity of the action potential were reduced progressively during a 500 stimulus train. The reduction was greater the higher the stimulus frequency, and was reversed upon return to 1 Hz stimulation. At frequencies greater than 40 Hz an all-or-none block developed. This also developed sooner the higher the stimulus frequency. Axons bathed in drug-free solutions did not show this effect at stimulus frequencies up to 100 Hz. Similar effects were seen in 16 microM DPH when the spinal cord was exposed to the drug overnight. This is close to the human therapeutic CSF level. The frequency-dependent depression of the action potential was greatly potentiated by increasing the extracellular potassium concentration from 2.1 to 5 mM. Under these conditions the axons rapidly developed block at stimulus frequencies as low as 2 Hz, and this was not reversible during a 5 h wash. In the absence of DPH, 5 mM potassium produced a 4-5 mV depolarization, but did not induce a frequency-dependent block. This effect of potassium may be important to the therapeutic effect of DPH because during epileptiform activity the extracellular K+ increases several fold.

Effect of phenytoin on [3H]norepinephrine release from synaptosomes

Phenytoin reduces depolarization-linked [3H]norepinephrine release from rat brain synaptosomes. When choline chloride was substituted for NaCl the phenytoin effect was attenuated but still significant. This is consistent with the theory that phenytoin reduces both Na and Ca influx during depolarization.

Frequency-dependent effects of phenytoin on frog junctional transmission: presynaptic mechanisms

The action of the antiepileptic drug, phenytoin, on junctional transmission at various frequencies of synaptic activation was studied in frog nerve-muscle preparation. Intracellular recordings were made from muscle end-plates, and extracellular focal and subsendothelial recordings were obtained from motor nerve terminals and their parent axons, respectively. When the motor nerve was stimulated at 100-200 Hz, exposure to the drug (0.1-0.3 mM) induced intermittent failures of junctional transmission which appeared faster as the rate of stimulation was increased. At these and at lower stimulation frequencies (30-50 Hz), in which failures of transmission occurred only rarely, phenytoin markedly limited the buildup of end-plate potential amplitude during the period of repetitive nerve stimulation (tetanic potentiation). Several lines of evidence suggest that both drug effects are consequent to a frequency-dependent depression of the action potential at motor axons and terminals, which could lead to an intermittent conduction block at the higher rates of stimulation. The selective action of phenytoin on high frequency synaptic transmission may contribute to the specificity shown by this drug in suppressing epileptic seizures while sparing neuronal activity.

Suppression by phenytoin of convulsant-induced afterdischarges at presynaptic nerve terminals

The mechanisms underlying the induction of afterdischarges at presynaptic nerve terminals by convulsant aminopyridines and their suppression by the anticonvulsant drug phenytoin were studied at the frog neuromuscular preparation. Addition of aminopyridine to the perfusing solution induced the appearance of afterdischarges in motor nerve fibres following their primary response to a single nerve stimulus. The afterdischarges seemed to originate at or near the nerve terminals and to propagate both antidromically and orthodromically. The latter resulted in repetitive activation of the neuromuscular synapse. Focal recordings of nerve terminal potentials suggested that aminopyridines may induce afterdischarges by slowing spike repolarization and thereby producing a prolonged depolarization of nerve terminals. Phenytoin suppressed the aminopyridine-induced afterdischarges and the resultant repetitive excitation of the postsynaptic muscle fibres. This effect of phenytoin was associated with a depression of the action potential at the motor nerve terminals but not at their parent axons. These results single the presynaptic nerve terminals as preferential sites for convulsant and anticonvulsant actions.

Effect of antiepileptic drugs on short-latency somatosensory evoked potentials

Short-latency somato sensory evoked potentials (SEPs) were recorded in 45 freshly diagnosed cases of epilepsy before starting treatment. Follow-up recordings were made 6 weeks and 3 months after diphenylhydantoin, carbamazipine and phenobarbitone monotherapy were started. Serum drug levels were monitored. Both amplitude and latency of the initial component (N20) remained unchanged and were identical to a group of 30 age- and sex-matched normal individuals in whom SEPs were recorded during the period of study.

Effect of phenytoin on intracellular calcium and intracellular protein changes during pentylenetetrazole-induced bursting activity in snail neurons

Effects of phenytoin (PHT) on the intracellular calcium and intracellular protein changes during pentylenetetrazole (PTZ)-induced bursting activity in the neurons of the Japanese land snail Euhadra peliomphala were examined. In the examination with a computer controlled electron probe X-ray microanalyzer, PHT clearly inhibited the intracellular calcium shift induced by PTZ as well as the calcium binding state change near the cell membrane. PHT also clearly inhibited the intracellular protein changes induced by PTZ. PHT, however, did not show any change in the transmembrane ionic currents such as the sodium current, calcium current and potassium current. These findings suggest that one of the main sites of anticonvulsant action of PHT is pathologically changed intracellular calcium movement and intracellular protein changes during seizure discharge.

Effects of anticonvulsants on spontaneous epileptiform activity which develops in the absence of chemical synaptic transmission in hippocampal slices

Spontaneous epileptiform activity (SEA) develops in area CA1 of hippocampal slices, when the Ca2+ concentration in the perfusate is lowered to 0.2 mM, at which level evoked chemical synaptic transmission is blocked. We investigated the effects of different anticonvulsants on this autonomous activity, in order to determine whether the antiepileptic effect can be ascribed to an influence on neuronal excitability. Carbamazepine was the most effective to block SEA at concentrations of 1-15 microM. Phenobarbital and phenytoin depressed SEA at concentrations of 25 microM. Valproate was effective at concentrations of 2-5 mM. Midazolam, a water-soluble benzo-diazepine agonist and the N-methyl-D-aspartate antagonists, DL-alpha-aminoadipic acid and 2-amino-7-phosphonoheptanoic acid were ineffective in blocking SEA suggesting that they exert their antiepileptic action by interference with synaptic mechanisms.

Drugs that may exacerbate myasthenia gravis

Myasthenia gravis is an uncommon disease. The emergency physician should be cautious when prescribing medications to myasthenics for problems not related to myasthenia gravis. We have discussed some of those agents (Figure 3) that are recognized to cause exacerbation of MG or that may have the potential to exacerbate MG. We recommend that management of any medical or surgical problem of the myasthenic be done in consultation with a managing neurologist, and that either early follow-up or admission is necessary when these agents are used in the patient with myasthenia gravis.

Phenytoin reduces frequency potentiation of synaptic potentials at the frog neuromuscular junction

The action of the commonly used antiepileptic drug phenytoin on frequency potentials was studied at the frog neuromuscular junction. Whereas the drug, at concentrations of 0.1-0.3 mM, had only a slight effect on EPPs evoked by nerve stimulation at a frequency of 0.5 Hz, it strongly suppressed their potentiation during tetanic nerve stimulation at 30 Hz. The post-tetanic potentiation of the EPPs was also reduced by the drug. These effects occurred without a blockade of invasion of the nerve impulse into the presynaptic terminal during the tetanus, and thus indicate a specific frequency-dependent depressant action of the drug on neurally-evoked transmitter release.

Acetylcholine release from synaptosomes and phenytoin action

The release of labeled acetylcholine from synaptosomes loaded with methyl-[3H]choline has been measured in Krebs-Ringer-Bicarbonate (KRB) media containing either 5.6 or 56 mM KCl. Experiments have been performed in media containing either 1.0 mM Ca or 0 Ca with 1 mM EGTA. Phenytoin, 2 X 10(-4) M, reduced the depolarization-dependent release of acetylcholine in media containing 1.0 mM Ca and 56 mM KCl. It also significantly increased the release of acetylcholine from undepolarized samples in 5.6 mM KCl irrespective of the Ca concentration. The drug did not affect release from synaptosomes depolarized in Ca-free media. These results confirm the hypothesis that phenytoin has a dual effect on transmitter release.

Phenytoin preferentially suppresses epileptiform activity in the superficial cortical layers of the cat

Clinically, phenytoin is thought to be useful in controlling seizure activity by preventing it's spread from the focus to neighboring tissue. Experimentally, it has been suggested that phenytoin's principal action is no longer polysynaptic pathways with primary foci affected less than surrounding tissue. In this study, we present data confirming these basic experimental conclusions in foci induced in striate neocortical layer 4 of the cat. By using discrete penicillin microinjections strategically placed into this most penicillin-sensitive neocortical layer and recording simultaneously from several layers, we have been able to expand upon these conclusions by identifying this differential action at the interlaminar level. Epileptiform activity recorded from superficial laminae bordering layer 4, and into which layer 4's primary projections terminate, is suppressed preferentially by phenytoin. These superficial layers are also those that project into neighboring areas of the cat visual cortex. It would appear, then, that phenytoin begins protecting the cortex from seizure spread at the first synaptic termination into which this layer 4 primary focus projects. A discussion of the basic mechanisms of action that may be responsible for these results is also presented.

Calmodulin systems in neuronal excitability: a molecular approach to epilepsy

Calmodulin is a major Ca2+ -binding protein that may mediate many Ca2+ -regulated processes in neuronal function. Calmodulin is present in the presynaptic nerve terminal in association with synaptic vesicles and in postsynaptic density fractions. Several calmodulin-regulated synaptic biochemical processes have been identified. These results indicate that calmodulin may modulate some aspects of neuronal excitability. Phenytoin, carbamazepine, and the benzodiazepines inhibit Ca2+ -calmodulin-regulated protein phosphorylation and neurotransmitter release by synaptic vesicles. A saturable, stereospecific membrane binding site has been identified for the benzodiazepines. The potency of the benzodiazepines to bind to these sites correlates with their ability to inhibit maximal electroshock-induced seizures. Phenytoin and carbamazepine can displace benzodiazepine binding from these binding sites. Binding to these "anticonvulsant" sites regulates Ca2+ -calmodulin-stimulated membrane protein phosphorylation and depolarization-dependent Ca2+ uptake in intact synaptosome preparations. These results provide evidence that major anticonvulsant drugs regulate Ca2+ -calmodulin systems at the synapse. Kindling alters Ca2+ -calmodulin protein phosphorylation in brain membrane. In addition, alterations in Ca2+ -calmodulin kinase systems have been associated with some strains of seizure-susceptible mice. Thus, evidence from multiple sources suggests that calmodulin-mediated processes may play a role in the development of altered neuronal excitability and in some forms of seizure disorders.

Comparison of phenytoin and phenobarbital effects on far-field auditory and somatosensory evoked potential interpeak latencies

Far-field somatosensory and auditory evoked potential (EP) interpeak latencies were measured in normal controls, epileptics not receiving medications, and epileptics receiving phenytoin, phenobarbital, or both. Phenytoin, but no phenobarbital, was associated with a prolongation of EP interpeak latencies at serum level concentrations over 20 micrograms/ml. Neither carbamazepine nor primidone in smaller series were associated with prolongation of EP interpeak latencies.

Disorders of neuromuscular transmission other than myasthenia gravis

Disorders of neuromuscular transmission in humans are caused by a wide variety of agents including systemic diseases, drugs, environmental toxins, animal envenomation, cations, and hormones. Some are genetically determined. Many are of known etiology. All such disorders interfere with one or more events in the sequence whereby a nerve impulse excites a muscle action potential. In many disorders of neuromuscular transmission, abnormal fatigue occurs, and some cases respond dramatically to treatment. Investigation of the microphysiology, microanatomy, and pharmacology of both normal and diseased neuromuscular junctions has increased our knowledge of these disorders.