Every-12-hour administration of extended-release divalproex in patients with epilepsy: impact on plasma valproic acid concentrations

Extended-release drug formulations for the treatment of epilepsy

INTRODUCTION

Extended-release (ER) preparations are either available or have been tested for several antiepileptic drugs (AEDs). Indeed, they may be helpful in improving efficacy, tolerability, adherence, compared to the corresponding immediate release (IR) preparations available. The use of ER preparations has been advocated in women of childbearing age and is - depending on the drug - especially helpful in patients who are treated in combination with enzyme inducing AEDs as well as in children.

AREAS COVERED

Clinical and pharmacokinetic studies on ER formulations of AEDs were identified by a PubMed literature research. Further references were added from the authors' personal knowledge and from the reference lists of the identified studies. Reviews and expert commentaries were included, where necessary.

EXPERT OPINION

Unfortunately, studies providing direct comparisons of ER and IR formulations of a given drug are only available for a handful of drugs. ER preparations are especially helpful in drugs with a short elimination half-life and concentration-depending efficacy and tolerability.

Pharmacokinetic Variability of Drugs Used for Prophylactic Treatment of Migraine

In this review, we evaluate the variability in the pharmacokinetics of 11 drugs with established prophylactic effects in migraine to facilitate 'personalized medicine' with these drugs. PubMed was searched for 'single-dose' and 'steady-state' pharmacokinetic studies of these 11 drugs. The maximum plasma concentration was reported in 248 single-dose and 115 steady-state pharmacokinetic studies, and the area under the plasma concentration-time curve was reported in 299 single-dose studies and 112 steady-state pharmacokinetic studies. For each study, the coefficient of variation was calculated for maximum plasma concentration and area under the plasma concentration-time curve, and we divided the drug variability into two categories; high variability, coefficient of variation >40%, or low or moderate variability, coefficient of variation <40%. Based on the area under the plasma concentration-time curve in steady-state studies, the following drugs have high pharmacokinetic variability: propranolol in 92% (33/36), metoprolol in 85% (33/39), and amitriptyline in 60% (3/5) of studies. The following drugs have low or moderate variability: atenolol in 100% (2/2), valproate in 100% (15/15), topiramate in 88% (7/8), and naproxen and candesartan in 100% (2/2) of studies. For drugs with low or moderate pharmacokinetic variability, treatment can start without initial titration of doses, whereas titration is used to possibly enhance tolerability of topiramate and amitriptyline. The very high pharmacokinetic variability of metoprolol and propranolol can result in very high plasma concentrations in a small minority of patients, and those drugs should therefore be titrated up from a low initial dose, depending mainly on the occurrence of adverse events.

Therapeutic drug monitoring with valproate–Why product selection is an important factor

There is a modest collection of literature describing the pharmacokinetic and clinical differences between the extended-release form of divalproex sodium (Depakote ER®) and the delayed-release form (Depakote®). Published articles are quick to espouse the extended-release formulation, especially in the setting of seizure control. Reasons commonly cited include a longer dosing interval, improved patient compliance, a more consistent pharmacokinetic profile, and fewer side effects. There are fewer articles discussing these differences in the context of treating mental illnesses, namely bipolar affective disorder. This article aims to compare these two formulations of divalproex with a special focus on their pharmacokinetic profiles, uses in psychiatric illness, and the role of therapeutic drug monitoring. The patient case that follows will describe a scenario in which a patient was prescribed each formulation during an acute hospitalization.

Valproic acid causes proteasomal degradation of DICER and influences miRNA expression

Valproic acid (VPA) is a commonly used drug to treat epilepsy and bipolar disorders. Known properties of VPA are inhibitions of histone deacetylases and activation of extracellular signal regulated kinases (ERK), which cannot fully explain VPA's clinical features. We found that VPA induces the proteasomal degradation of DICER, a key protein in the generation of micro RNAs. Unexpectedly, the concentration of several micro RNAs increases after VPA treatment, which is caused by the upregulation of their hosting genes prior to DICER degradation. The data suggest that a loss of DICER protein and changes in micro RNA concentration contributes to the clinical properties of VPA. VPA can be used experimentally to down regulate DICER protein levels, which likely reflects a natural regulation of DICER.

Extended-release antiepileptic drugs: a comparison of pharmacokinetic parameters relative to original immediate-release formulations

Many antiepileptic drugs (AEDs) have short half-lives with large fluctuations in peak-to-trough plasma concentrations. Consequences of these pharmacokinetic (PK) properties may include adverse events (AEs) and breakthrough seizures, potentially leading to poor adherence. To address these challenges, newer formulations of these AEDs have been developed using unique extended-release (ER) technologies. These technologies extend the dosing interval such that dosing frequency can be minimized, which may improve patient adherence. Available ER formulations have the potential to minimize the spikes in maximum plasma concentrations (C(max) ) at steady-state that often contribute to AEs during treatment with immediate-release (IR) products. In so doing, tolerability advantages may lead to increased AED effectiveness by improving adherence and allowing higher doses if clinically indicated. Direct PK comparison studies of IR and ER formulations (e.g., carbamazepine, divalproate sodium, lamotrigine, oxcarbazepine, levetiracetam, and phenytoin) have found that dose-normalized ER formulations may or may not be bioequivalent to their IR counterparts, but most ER formulations have a lower fluctuation index ([C(max) -C(min) ]/C(avg) ) compared with the IR versions. This results in flatter concentration-time plots. Not all ER preparations improve the various PK parameters to the same extent, and PK nuances may impact the effectiveness, tolerability, and adherence rates of various ER formulations.

Progress report on new antiepileptic drugs: a summary of the Eigth Eilat Conference (EILAT VIII)

The Eigth Eilat Conference on New Antiepileptic Drugs (AEDs)-EILAT VII, took place in Sitges, Barcelona from the 10th to 14th September, 2006. Basic scientists, clinical pharmacologists and neurologists from 24 countries attended the conference, whose main themes included a focus on status epilepticus (epidemiology, current and future treatments), evidence-based treatment guidelines and the potential of neurostimulation in refractory epilepsy. Consistent with previous formats of this conference, the central part of the conference was devoted to a review of AEDs in development, as well as updates on marketed AEDs introduced since 1989. This article summarizes the information presented on drugs in development, including brivaracetam, eslicarbazepine acetate (BIA-2-093), fluorofelbamate, ganaxolone, huperzine, lacosamide, retigabine, rufinamide, seletracetam, stiripentol, talampanel, valrocemide, JZP-4, NS1209, PID and RWJ-333369. Updates on felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine and new extended release oxcarbazepine formulations, pregabalin, tiagabine, topiramate, vigabatrin, zonisamide and new extended release valproic acid formulations, and the antiepileptic vagal stimulator device are also presented.

Does It Really Matter When a Blood Sample for Valproic Acid Concentration is Taken Following Once-Daily Administration of Divalproex-ER?

Divalproex sodium extended-release (divalproex-ER) is a novel formulation intended for once-daily oral administration, either morning or evening. Questions have risen concerning the optimal time for obtaining a blood sample for valproic acid (VPA) concentration in relation to the dose. Trough sampling is easily achieved just before a morning daily dose, but the best time to sample after an evening daily dose is unclear, because collecting a blood sample 21 to 24 hours later may be limited by the operational hours of the laboratory. This investigation provides practical guidance regarding blood sample timing. Steady-state plasma VPA concentration-time profiles from 5 published divalproex-ER studies (healthy subjects and epilepsy patients) were analyzed. The concentration-time profile for each subject/patient was expressed as a percentage of his/her trough concentration and summary statistics computed. Typically, when taking divalproex-ER once daily in the morning, a blood sample collected 21 to 24 hours later is expected to have a concentration within 3% of the trough value. Conversely, for divalproex-ER dosed once-daily in the evening, for example 8 PM, a blood draw 12 to 15 hours later (ie, 8 to 11 AM) will give a plasma VPA concentration value that is 18% to 25% higher, on average, than the trough value. However, waiting longer, (for example 18 to 21 hours, ie 2 to 5 PM) will result in concentration values that are merely 3% to 13% higher than trough values, which may provide acceptable information for monitoring purposes. The greatest deviation from trough VPA concentration occurs around the peak, that is 3 to 15 hours after a once-daily divalproex-ER dose; sampling during this time period is recommended only if a clinical need exists to test for a higher VPA concentration. Despite the apparent smoothness of the VPA concentration-time profile after a once-daily divalproex-ER dose, the timing of the blood sample does matter and impacts the proper interpretation of the VPA concentration.

Functional Half-Life is a Meaningful??Descriptor of Steady-State??Pharmacokinetics of??an??Extended-Release Formulation of??a??Rapidly Cleared Drug

BACKGROUND

For many drugs, steady-state concentration-time profiles are often not optimally characterised by the intrinsic terminal elimination half-life for various reasons, including multiexponential disposition with minimal contribution of the terminal phase to steady-state exposure or use of controlled-release formulations with extended zero- or mixed zero-/first-order absorption. In such cases, 'effective' or 'functional' half-life (t((1/2)F)) has often been used to characterise steady-state pharmacokinetics. Valproic acid, commonly used in neuropsychiatry, has an elimination half-life of 4-16 hours in different populations (children vs adults, enzyme-induced vs uninduced). Divalproex-ER, a once-daily extended- release divalproex sodium formulation, is designed to release valproic acid over >18 hours. Hence the steady-state divalproex-ER concentration-time profiles have small peak-trough fluctuations that are not optimally characterised by valproic acid elimination half-life. In this study, the value of t((1/2)F) was calculated to characterise divalproex-ER steady-state concentration-time profiles.

METHODS

The value of t((1/2)F), defined as the time taken for the concentration to drop by one-half during a dosing interval (tau) at steady state, was derived using steady-state maximum (C(max)) and minimum (C(min)) plasma concentration and tau values, and calculated as ln(2)/(ln [C(max)/C(min)]/tau). The t((1/2)F) values of valproic acid in adult hepatic enzyme-uninduced healthy subjects and enzyme-induced epilepsy patients were calculated from five pharmacokinetic studies in which divalproex-ER was administered once daily for 6-14 days.

RESULTS

The estimated geometric mean t((1/2)F) in uninduced adults was 40.0 hours versus the expected elimination half-life of 12-16 hours in this population (including patients on valproic acid monotherapy); for induced patients, t((1/2)F) was 26.9 hours versus the expected elimination half-life of 6-12 hours.

CONCLUSION

The t((1/2)F) of valproic acid optimally characterises the expected steady-state C(max) to C(min )decrease of 33% in uninduced and 45% in induced adults following once-daily administration of divalproex-ER.