Role of nitric oxide in the convulsive seizures induced by fluoroquinolones coadministered with 4-biphenyl acetic acid

Seizure suppression through manipulating splicing of a voltage-gated sodium channel

Voltage-gated persistent sodium current (INaP) is a tractable target for antiepileptic drugs. Using a strategy focused on INaP reduction, Lin et al. identify 95 regulators of voltage-gated sodium channel splicing for which RNAi knockdown reduces seizure duration in Drosophila. Manipulation of splicing regulators could improve control of epilepsy.

Seizure can result from increased voltage-gated persistent sodium current expression. Although many clinically-approved antiepileptic drugs target voltage-gated persistent sodium current, none exclusively repress this current without also adversely affecting the transient voltage-gated sodium current. Achieving a more selective block has significant potential for the treatment of epilepsy. Recent studies show that voltage-gated persistent sodium current amplitude is regulated by alternative splicing offering the possibility of a novel route for seizure control. In this study we identify 291 splicing regulators that, on knockdown, alter splicing of the Drosophila voltage-gated sodium channel to favour inclusion of exon K, rather than the mutually exclusive exon L. This change is associated with both a significant reduction in voltage-gated persistent sodium current, without change to transient voltage-gated sodium current, and to rescue of seizure in this model insect. RNA interference mediated knock-down, in two different seizure mutants, shows that 95 of these regulators are sufficient to significantly reduce seizure duration. Moreover, most suppress seizure activity in both mutants, indicative that they are part of well conserved pathways and likely, therefore, to be optimal candidates to take forward to mammalian studies. We provide proof-of-principle for such studies by showing that inhibition of a selection of regulators, using small molecule inhibitors, is similarly effective to reduce seizure. Splicing of the Drosophila sodium channel shows many similarities to its mammalian counterparts, including altering the amplitude of voltage-gated persistent sodium current. Our study provides the impetus to investigate whether manipulation of splicing of mammalian voltage-gated sodium channels may be exploitable to provide effective seizure control.

Seizures associated with fluoroquinolones

OBJECTIVE

To report two cases of seizures following administration of levofoxacin and ciprofloxacin.

CASE SUMMARY

A 75-year-old white woman admitted to the hospital was prescribed levofloxacin for ischemic toes. After receiving three doses of oral levofloxacin, the patient experienced a seizure. One month later, the patient was rechallenged with ciprofloxacin and again experienced a seizure. The patient was hypomagnesemic and had elevated serum creatinine at the time of both seizures, and was hyponatremic during the second seizure. A 74-year-old white woman admitted to the hospital was prescribed levofloxacin for bacterial pneumonia. After five doses, the patient experienced a seizure. The woman had no electrolyte imbalances at the time of the seizure and no history of a seizure disorder.

DISCUSSION

Quinolone antibiotics vary in their ability to induce seizures, with trovafloxacin having the greatest potential and levofloxacin possibly having the least potential. Neither patient had a history of a previous seizure disorder. Electrolyte imbalances are common with previous reports of fluoroquinolone-induced seizures.

CONCLUSIONS

Although levofloxacin monotherapy has not been implicated in inducing seizures, it appears to be the causative agent in the second case. In the first case, the quinolones may have been a necessary, but not sufficient, cause in a patient with electrolyte abnormalities. Risk factors for fluoroquinolone-induced seizures may Include seizure history, electrolyte imbalances,dose unadjusted for renal insufficiency, and concomitant treatment with agents that lower the seizure threshold.

The role of nitrergic system in lidocaine-induced convulsion in the mouse

The effects of N-nitro-L-arginine-methyl ester (L-NAME) a nitric oxide (NO) synthase inhibitor and L-arginine, a NO precursor, were investigated on lidocaine-induced convulsions. In the first experiment, four groups of mice received physiological saline (0.9%), L-arginine (300 mg/kg, i.p.), L-NAME (100 mg/kg, i.p.) and diazepam (2 mg/kg), respectively. Thirty minutes after these injections, all mice received lidocaine (50 mg/kg, i.p.). In the second experiment, four groups of mice received similar treatment in the first experiment, and 30 min after these injections, all mice received a higher dose of lidocaine (80 mg/kg). L-NAME (100 mg/kg, i.p.) and diazepam (2 mg/kg) significantly decreased the incidence of lidocaine (50 mg/kg)-induced convulsions. In contrast, the L-arginine treatment increased the incidence of lidocaine (80 mg/kg, i.p.)-induced convulsions significantly. These results may suggest that NO is a proconvulsant mediator in lidocaine-induced convulsions.

Potential interactions of the extended-spectrum fluoroquinolones with the CNS

The new generation fluoroquinolones -- sparfloxacin, levofloxacin, grepafloxacin and trovafloxacin -- have been designed to respond to the clinical need for extended antimicrobial cover in the face of increasing global microbial resistance. Their main focus is in the treatment of respiratory infections, particularly those acquired in the community. CNS adverse effects, such as dizziness and headache, are known to occur relatively commonly with some fluoroquinolones and are not, in general, well tolerated by patients. The structural component of the fluoroquinolone molecule believed to be responsible for improved gram-positive activity is also believed to be implicated in the production of CNS adverse effects, including those arising from drug interactions with theophylline and NSAIDs. Inhibition of brain gamma-aminobutyric acid (GABA) receptor binding appears to be a strong indicator of CNS activity, though N-methyl-D-aspartate receptor binding has also been implicated. In accordance with the results of these predictive studies, clinical trials have found sparfloxacin, levofloxacin and grepafloxacin to be associated with a low incidence of CNS events. Trovafloxacin has been found to be associated with a higher incidence of CNS events (particularly lightheadedness and dizziness) than the other 3 agents. Ongoing and future clinical studies will help to define the usefulness of the predictive models, as well as reveal the full CNS adverse event profile of these and other investigational fluoroquinolones.

Involvement of free radicals in cerebral vascular reperfusion injury evaluated in a transient focal cerebral ischemia model of rat

Free radicals have been suggested to be largely involved in the genesis of ischemic brain damage, as shown in the protective effects of alpha-phenyl-N-tert-butyl nitrone (PBN), a spin trapping agent, against ischemic cerebral injury. In the present study, the effects of PBN as well as MCI-186, a newly-developed free radical scavenger, and oxypurinol, an inhibitor of xanthine oxidase, were evaluated in a rat transient middle cerebral aretery (MCA) occlusion model to clarify the possible role of free radicals in the reperfusion injury of brain. The volume of cerebral infarction, induced by 2-h occlusion and subsequent 2-h reperfusion of MCA in Fisher-344 rats, was evaluated. The administration of PBN (100 mg/kg) and MCI-186 (100 mg/kg) just before reperfusion of MCA significantly reduced the infarction volume. In contrast, oxypurinol (100 mg/kg) failed to show any preventive effect on the infarction. These results suggest that free radical formation is involved in the cerebral damage induced by ischemia-reperfusion of MCA, and that hydroxyl radical is responsible for the reperfusion injury after transient focal brain ischemia. It is also suggested that xanthine oxidase is not a major source of free radicals.

Effects of several agents on UVB- and UVA plus systemic fluoroquinolone-induced erythema of guinea pig skin evaluated by reflectance colorimetry

The aim of this study was to clarify the mechanisms underlying the erythema of guinea pig skin induced by ultraviolet (UV) irradiation alone and in combination with a systemic fluoroquinolone (FQ). The effects of several drugs which may modify the actions of some inflammatory mediators and radicals possibly released in the inflamed site on the erythema were examined and compared in an objective and quantitative way by measuring the change in color of the irradiated skin, determined as the change in chroma (C*) with use of reflectance colorimetry. After confirming that the C* value increased in an irradiation dose-dependent manner and reached a plateau 1-2 h after irradiation of UVB alone or UVA coadministered with an FQ, Y-26611 (10 mg/kg, i.p.), guinea pigs were pretreated with indomethacin, butylated hydroxytoluene (BHT) or beta-carotene before, or treated with H1- or H2-receptor antagonist, superoxide dismutase or N omega-nitro-L- arginine methyl ester after UV irradiation, and their inhibitory effects against erythema were evaluated. It was suggested that there are some substantial differences between UVB- and UVA plus FQ-induced erythemas. Although histamine makes little contribution to both types of erythema, metabolites of arachidonic acid catalyzed by cyclooxygenase contribute more to UVB-induced erythema, whereas superoxides take more part in UVA plus FQ-induced erythema. Furthermore, nitric oxide seems to participate in both types of erythema; however, the pretreatment with BHT or beta-carotene was ineffective against both erythemas. From these results, interventions should be directed to powerfully scavenging radicals for prevention and treatment of UV plus FQ-induced phototoxicity.