Effect of topiramate on glucocorticoid receptor mediated action

Childhood adversity and epigenetic regulation of glucocorticoid signaling genes: Associations in children and adults

Early childhood experiences have lasting effects on development, including the risk for psychiatric disorders. Research examining the biologic underpinnings of these associations has revealed the impact of childhood maltreatment on the physiologic stress response and activity of the hypothalamus-pituitary-adrenal axis. A growing body of literature supports the hypothesis that environmental exposures mediate their biological effects via epigenetic mechanisms. Methylation, which is thought to be the most stable form of epigenetic change, is a likely mechanism by which early life exposures have lasting effects. We present recent evidence related to epigenetic regulation of genes involved in hypothalamus-pituitary-adrenal axis regulation, namely, the glucocorticoid receptor gene (nuclear receptor subfamily 3, group C, member 1 [NR3C1]) and FK506 binding protein 51 gene (FKBP5), after childhood adversity and associations with risk for psychiatric disorders. Implications for the development of interventions and future research are discussed.

Immunomodulatory treatments in epilepsy

The role of immunity and inflammation appears to be an integral part of the pathogenic processes associated with some seizures, particularly with refractory epilepsy. Prompt treatment with immunotherapy may lead to better outcomes. Immune treatment options for treatment of epilepsy include therapies such as corticosteroids, immunoglobulins, plasmapheresis, or steroid-sparing drugs such as azathioprine. Recent alternatives have included even more aggressive treatment with cyclophosphamide, anti-pre-B-lymphocyte monoclonal antibody rituximab, and monoclonal antibodies such as efalizumab or natalizumab, which are presently used for other inflammatory disorders. Randomized controlled trials of immunotherapy in presumed autoimmune epilepsy are needed to provide further support for the rapid use of immunotherapy in patients with immune mediated epilepsy.

Lymphocyte glucocorticoid receptor expression level and hormone-binding properties differ between war trauma-exposed men with and without PTSD

OBJECTIVE

Posttraumatic stress disorder (PTSD) has been shown to be associated with altered glucocorticoid receptor (GR) activity. We studied the expression and functional properties of the receptor in peripheral blood mononuclear cells (PBMCs) from non-traumatized healthy individuals (healthy controls; n=85), and war trauma-exposed individuals with current PTSD (n=113), with life-time PTSD (n=61) and without PTSD (trauma controls; n=88). The aim of the study was to distinguish the receptor alterations related to PTSD from those related to trauma itself or to resilience to PTSD.

METHODS

Functional status of the receptor was assessed by radioligand binding and lysozyme synthesis inhibition assays. The level of GR gene expression was measured by quantitative PCR and immunoblotting.

RESULTS

Current PTSD patients had the lowest, while trauma controls had the highest number of glucocorticoid binding sites (Bmax) in PBMCs. Hormone-binding potential (Bmax/KD ratio) of the receptor was diminished in the current PTSD group in comparison to all other study groups. Correlation between Bmax and KD that normally exists in healthy individuals was decreased in the current PTSD group. Contrasting Bmax data, GR protein level was lower in trauma controls than in participants with current or life-time PTSD.

CONCLUSIONS

Current PTSD is characterized by reduced lymphocyte GR hormone-binding potential and by disturbed compensation between Bmax and hormone-binding affinity. Resilience to PTSD is associated with enlarged fraction of the receptor molecules capable of hormone binding, within the total receptor molecule population in PBMCs.

Relationship of a common polymorphism of the glucocorticoid receptor gene to traumatic memories and posttraumatic stress disorder in patients after intensive care therapy

OBJECTIVE

Glucocorticoids play a major role in the consolidation and retrieval of traumatic information. They act through the glucocorticoid receptor, for which, in humans, several polymorphisms have been described. In particular, the BclI single-nucleotide polymorphism is associated with hypersensitivity to glucocorticoids and with susceptibility to development of major depression. Furthermore, in patients with posttraumatic stress disorder carrying the BclI GG genotype, cortisol levels were lower and showed an inverse relationship to posttraumatic stress disorder symptom intensity. Here, we studied the association of the BclI polymorphism with plasma cortisol levels, traumatic memories, posttraumatic stress disorder symptoms, and health-related quality of life outcomes in 126 patients undergoing cardiac surgery and intensive care unit therapy.

DESIGN

Prospective observational study.

SETTING

Cardiovascular intensive care unit in a university hospital.

PATIENTS

A total of 126 patients undergoing cardiac surgery and intensive care unit treatment.

INTERVENTIONS

No interventions were performed.

MEASUREMENTS AND MAIN RESULTS

Validated questionnaires were used to quantify end points. Measurements were taken 1 day before and 1 wk and 6 months after cardiac surgery. Homozygous carriers of the BclI G allele (n = 21) had significantly lower preoperative plasma cortisol levels and more long-term traumatic memories from intensive care unit therapy at 6 months after cardiac surgery than heterozygous carriers or noncarriers (1.9 ± 1.4 vs. 1.0 ± 1.2, p = .01). Anxiety was significantly more common as a long-term traumatic memory in homozygous BclI G allele carriers than in heterozygous carriers or noncarriers (57% vs. 35%, p = .03). Posttraumatic stress disorder symptom scores were significantly higher at discharge from the intensive care unit in homozygous BclI G allele carriers than in heterozygous carriers or noncarriers. Only heterozygous carriers or BclI G allele noncarriers had a significant gain in health-related quality of life physical function at 6 months after cardiac surgery (p < .01). Baseline values were not statistically different between carriers of the different BclI alleles.

CONCLUSION

Homozygous BclI G allele carriers are at risk for traumatic memories, posttraumatic stress disorder symptoms, and lower health-related quality of life after cardiac surgery and intensive care unit therapy. The BclI single-nucleotide polymorphism may help to identify individuals at need for tailored medical care.

Treatment of civilian and combat-related posttraumatic stress disorder with topiramate

OBJECTIVE

To evaluate the use of topiramate for the treatment of posttraumatic stress disorder (PTSD).

DATA SOURCES

Ovid MEDLINE (1950 to June week 4, 2010), International Pharmaceutical Abstracts (1970 to May 2010), ISI Web of Science (1945 to July 3, 2010), and Iowa Drug Information Service (searched July 6, 2010) were searched using the terms posttraumatic stress disorder and topiramate. Guidelines and other sources were identified from bibliography searches.

STUDY SELECTION AND DATA EXTRACTION

All English-language human studies and case reports that evaluated the use of topiramate for treatment of PTSD were evaluated.

DATA SYNTHESIS

One case report, 1 case series, 2 open-label trials, and 1 placebo-controlled trial that used topiramate (monotherapy or adjunct) to treat civilian PTSD were identified and evaluated. The case report and case series reported subjective reduction of symptoms, and the open-label trials reported a significant reduction in PTSD Checklist-Civilian score. The placebo-controlled trial found no significant difference in Clinician-Administered PTSD Scale (CAPS) score. One open-label trial and 2 placebo-controlled trials that used topiramate in combat-related PTSD were identified and evaluated. The open-label trial reported a significant reduction in CAPS score, and 1 placebo-controlled trial reported a statistically significant difference in CAPS score. However, the other placebo-controlled trial found no significant differences. In some of the trials evaluated, the clinical significance of outcomes reported is difficult to determine. Adverse effects were reported throughout the trials but generally were not considered serious.

CONCLUSIONS

Based on the limited evidence available, topiramate is a possible alternative or adjunct option for patients with PTSD that is refractory to standard treatments.

The antidepressant desipramine requires the ABCB1 (Mdr1)-type p-glycoprotein to upregulate the glucocorticoid receptor in mice

The mechanisms by which antidepressants regulate the hypothalamic-pituitary-adrenal (HPA) axis are still unknown. The ABCB1-type multiple drug resistance (MDR) p-glycoprotein (PGP) regulates the HPA axis by limiting the access of glucocorticoids to the brain in mice and humans. Previous work in cell cultures has found that antidepressants enhance glucocorticoid receptor (GR) function in vitro by inhibiting MDR PGP, and therefore by increasing the intracellular concentration of glucocorticoids-but this model has never been tested directly in animals. Here, the tricyclic antidepressant, desipramine (20 mg/kg/day, i.p., for seven days), was administered to abcb1ab MDR PGP knockout mice (congenic on the FVB/N background strain) and to FVB/N controls. The hippocampal mRNA expression of GR, mineralocorticoid receptor (MR), MDR (Mdr1a) PGP, and 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) were measured, together with plasma corticosterone levels. In FVB/N controls, desipramine induced a significant upregulation of GR mRNA in the CA1 region (+31%; p=0.045); in contrast, in abcb1ab (-/-) mice, desipramine induced a significant downregulation of GR mRNA in the CA1 region (-45%; p=0.004). MR mRNA expression was unaltered. Desipramine decreased corticosterone levels in both FVB/N controls and in abcb1ab (-/-) mice, but in abcb1ab (-/-) mice the effects were smaller. Specifically, in FVB/N controls (but not in abcb1ab (-/-) mice), desipramine reduced corticosterone levels not only compared with saline-treated mice but also compared with the 'physiological' levels of untreated mice (-39%; p=0.05). Finally, desipramine reduced Mdr1a mRNA expression across all hippocampus areas (-9 to -23%), but had no effect on 11beta-HSD1 mRNA expression. These data support the notion that the MDR PGP is one of the molecular targets through which antidepressants regulate the HPA axis.

Can childhood trauma predict response to topiramate in borderline personality disorder?

We report on a woman with borderline personality disorder and a history of childhood trauma that showed significant clinical response with low dosage of topiramate. We propose that topiramate changed some of the main features of this disorder, such as catastrophic reaction to real or imaginary abandonment or rejection, improving adaptive functioning. We hypothesize that topiramate might facilitate memory extinction, therefore decreasing emotional and behavioural reactivity.

Effect of sertraline on glucocorticoid sensitivity of mononuclear leukocytes in post-traumatic stress disorder

This study examined the effects of sertraline (SER) on glucocorticoid sensitivity in mononuclear leukocytes (MNL) from eight subjects with current post-traumatic stress disorder (PTSD) and nine comparison subjects. In all, 60 ml of blood was withdrawn by venipuncture at 0800, and MNL were isolated from blood and divided into two portions: the first contained live cells incubated with a series of concentrations of dexamethasone (DEX); the second contained cells incubated with similar concentrations of DEX+2 muM SER. Group difference in the concentrations of DEX required to inhibit lysozyme activity by 50% were evaluated under conditions of DEX-only and DEX+SER using analysis of covariance (ANCOVA). A significant Group x Condition interaction reflected that SER altered the lysozyme IC(50-DEX) in the direction of decreasing sensitivity to glucocorticoids in PTSD while having no uniform effect in cells from comparison subjects. The data provide support for the idea that glucocorticoid receptors might be more responsive to antidepressants in PTSD than in persons without PTSD. Insofar as increased sensitivity to glucocorticoids has been linked with PTSD, the actions of SER on the lysozyme IC(50-DEX) suggest that this medication may target a biologic alteration associated with PTSD pathophysiology.

Topiramate in treatment of depressive and anger symptoms in female depressive patients: a randomized, double-blind, placebo-controlled study

BACKGROUND

Depression is associated with increased aggression and diminished ability and quality of life. The goal of this study was to compare the efficacy of topiramate in influencing depressive symptoms, aggression, ability, and health related quality of life in depressive women.

METHODS

We conducted a randomized, double-blind, placebo-controlled 10-week study of topiramate in 64 female subjects from the general population who met criteria for recurrent major depressive disorder. Primary outcome measures were changes on the Hamilton Depression Rating Scale (HDRS), the State-Trait Anger Expression Inventory (STAXI), the Test of Attention (d2), and the SF-36 Health Survey (SF-36).

RESULTS

According to the intent-to-treat principle, a significant difference on the HDRS (P=0.02), all scales of STAXI (all P<0.001), Total efficiency of d2 (P<0.001), and on most scales of SF-36 (P between 0.15 and <0.001) were observed in the topiramate-treated subjects comprised the placebo group. The reduction in expression of anger correlated significantly with changes on the HDRS, and several scales of d2 and SF-36. Additional weight loss, which was significantly more pronounced in the topiramate group than in those treated with a placebo, was ascertained (difference in weight loss between the two groups: 4.2 kg, P<0.001). All the patients tolerated topiramate relatively well.

LIMITATIONS

Only moderately ill women were included.

CONCLUSIONS

Topiramate appears to be an effective agent in the reduction of depressive symptoms and anger and in the improvement of ability and health-related quality of life in depressive women. Additional weight loss can be expected.

Enhanced sensitivity to glucocorticoids in peripheral mononuclear leukocytes in posttraumatic stress disorder

BACKGROUND

The aim of this study was to determine whether there is increased responsiveness to corticosteroids in posttraumatic stress disorder (PTSD) by examining the differential effects of dexamethasone (DEX) on the inhibition of lysozyme activity.

METHODS

60 mL of blood was withdrawn at 8:00 am, and mononuclear leukocytes were isolated from the blood of 26 men with, and 18 men without, PTSD. An aliquot of live cells was incubated with a series of concentrations of DEX to determine the rate of inhibition of lysozyme activity; a portion of cells was frozen for the determination of glucocorticoid receptors (GR).

RESULTS

Subjects with PTSD showed evidence of a greater sensitivity to glucocorticoids as reflected by a significantly lower mean concentration (nmol/L) of dexamethasone at which 50% of lysozyme activity is inhibited (IC(50-DEX)) (PTSD+ = 4.9 +/-.53; PTSD- group = 7.2 +/-.64). The lysozyme IC(50-DEX) was significantly correlated with age at exposure to the first traumatic event in subjects with PTSD (r =.44, n = 26, p =.025). The number of cytosolic glucocorticoid receptors was also correlated with age at exposure to the focal traumatic event (r = -.44, n = 25, p =.03) in PTSD.

CONCLUSIONS

This is the first in vitro demonstration of an alteration in target tissue sensitivity to glucocorticoids in PTSD. The lower lysozyme IC(50-DEX) might be related to the risk factor of prior exposure to trauma.