Lack of accumulation of midazolam in plasma and lipoprotein fractions during intravenous lipid infusions in patients on artificial respiration

Selected pharmacokinetic issues of the use of antiepileptic drugs and parenteral nutrition in critically ill patients

OBJECTIVES

To conduct a systematic review for the evidence supporting or disproving the reality of parenteral nutrition- antiepileptic drugs interaction, especially with respect to the plasma protein-binding of the drug.

METHODS

The articles related to the topic were identified through Medline and PubMed search (1968-Feburary 2010) for English language on the interaction between parenteral nutrition and antiepileptic drugs; the search terms used were anti-epileptic drugs, parenteral nutrition, and/or interaction, and/or in vitro. The search looked for prospective randomized and nonrandomized controlled studies; prospective nonrandomized uncontrolled studies; retrospective studies; case reports; and in vitro studies. Full text of the articles were then traced from the Universiti Sains Malaysia (USM) library subscribed databases, including Wiley-Blackwell Library, Cochrane Library, EBSCOHost, OVID, ScienceDirect, SAGE Premier, Scopus, SpringerLINK, and Wiley InterScience. The articles from journals not listed by USM library were traced through inter library loan.

RESULTS

There were interactions between parenteral nutrition and drugs, including antiepileptics. Several guidelines were designed for the management of illnesses such as traumatic brain injuries or cancer patients, involving the use of parenteral nutrition and antiepileptics. Moreover, many studies demonstrated the in vitro and in vivo parenteral nutrition -drugs interactions, especially with antiepileptics.

CONCLUSIONS

There was no evidence supporting the existence of parenteral nutrition-antiepileptic drugs interaction. The issue has not been studied in formal researches, but several case reports and anecdotes demonstrate this drug-nutrition interaction. However, alteration in the drug-free fraction result from parenteral nutrition-drug (i.e. antiepileptics) interactions may necessitate scrupulous reassessment of drug dosages in patients receiving these therapies. This reassessment may be particularly imperative in certain clinical situations characterized by hypoalbuminemia (e.g., burn patients).

Inhibitory Effects of Amino-Acid Fluids on Drug Binding to Site II of Human Serum Albumin in Vitro

The effects of amino-acid fluids on ligand binding to human serum albumin (HSA) were investigated by fluorescence and ultrafiltration techniques. Warfarin and dansylsarcosine were used as the site marker fluorescence probes for site I and site II of HSA, respectively. Amino-acid fluids specifically decreased the fluorescence intensity induced by dansylsarcosine-HSA binding without any effects on that induced by warfarin-HSA binding. The ultrafiltration technique clarified that the free fraction of the site II drug, diazepam, in human serum was increased in the presence of amino-acid fluids, while no effect was observed in the free fraction of the site I drug, warfarin. The potencies of the effect on binding to site II, observed by fluorescence and ultrafiltration techniques, correlated well with the L-tryptophan contents in amino-acid fluids or with those in L-tryptophan solutions. Based on the comparison between the effects of amino-acid fluids and L-tryptophan solutions, we confirmed that L-tryptophan in amino-acid fluids specifically inhibits drug binding to site II of HSA.

The Effect of Parenteral Nutrition Fluids on the Binding of Therapeutic Drugs to Human Serum In Vitro

The competitive binding of seven therapeutic drugs (carbamazepine, phenytoin, phenobarbital, procainamide, quinidine, theophylline, and valproic acid) to human serum and to five commonly used parenteral nutrition fluids in vitro was studied using equilibrium dialysis. For five of the drugs, all parenteral nutrition fluids bound less drug than human serum-phenobarbital (up to 14% less), phenytoin (up to 46% less), procainamide (up to 43% less), quinidine (up to 25% less), and valproic acid (up to 77% less)-suggesting that the presence of these fluids might increase the free fraction of these drugs in vivo. For carbamazepine, the fluids bound up to 82% more drug, suggesting that the presence of these fluids might decrease the free fraction of this drug in vivo. For theophylline, the fluids produced a minimal (no more than 5%) effect on binding to serum. The administration of parenteral nutrition fluids may significantly alter the free (active) fraction of some therapeutic drugs.