Pharmacodynamics of the anticonvulsant effect of oxazepam in aging BN/BiRij rats

Status Epilepticus in an Internal Medicine Ward: Different Patients Therefore Distinct Approaches

Background Status epilepticus (SE) is a medical condition that bestows substantial morbidity and mortality. Literature is scarce regarding SE in elderly patients, particularly in the context of internal medicine wards. Aim To characterize SE patients admitted to an internal medicine ward, identify potential outcome predictors and differences between young and elderly, as well as convulsive (CSE) and non-convulsive SE (NCSE) patients. Methods We enrolled 135 consecutive patients in an observational, retrospective cohort study. We established elderly patients as more than 64 years old and defined worse prognosis as a modified Rankin Scale (mRS)>4. Results The SE population was 73% elderly, and 75% presented with NCSE, mainly metabolic, idiopathic, or vascular SE. The intra-hospital mortality was 51%, and 62% had an mRS>4 at discharge. NCSE and electroencephalogram (EEG) with paroxysmal activity at discharge were predictive of a worse prognosis. Elderly patients had increased disability at admission, most had NCSE (81%), and the SE etiology differed with more idiopathic and vascular causes. In the elderly, mortality was increased, as was the number of patients with mRS>4 at discharge. NCSE patients had the more neurodegenerative disease (30%) and presented predominantly with vascular and anoxic causes. Morbidity and mortality were also increased in the NCSE group. There was no difference in the antiepileptic drugs used or in the percentage of patients achieving an EEG with no paroxysmal activity between the subpopulations. Conclusion SE in elderly patients should be addressed distinctly. Current approaches based on the strategies used for standard CSE have shown little or no efficacy overall.

Aging models of acute seizures and epilepsy

Aged animals have been used by researchers to better understand the differences between the young and the aged brain and how these differences may provide insight into the mechanisms of acute seizures and epilepsy in the elderly. To date, there have been relatively few studies dedicated to the modeling of acute seizures and epilepsy in aged, healthy animals. Inherent challenges to this area of research include the costs associated with the purchase and maintenance of older animals and, at times, the unexpected and potentially confounding comorbidities associated with aging. However, recent studies using a variety of in vivo and in vitro models of acute seizures and epilepsy in mice and rats have built upon early investigations in the field, all of which has provided an expanded vision of seizure generation and epileptogenesis in the aged brain. Results of these studies could potentially translate to new and tailored interventional approaches that limit or prevent the development of epilepsy in the elderly.

Animal models of geriatric epilepsy

Geriatric epilepsy is a significant clinical problem that has not been studied adequately in animal models. This chapter will review the available literature with particular attention to models that have demonstrated how acute seizures and epilepsy in aged animals differ from those of younger animals. Studies include several strains of mice [e.g., El, DBA, senescence-accelerated mouse (SAM), Cacnb4 knockout] as well as acute seizure models in common strains of aged mice. Aged rats (including Fischer 344, Wistar, and Sprague-Dawley) have been used in acute seizure, lesion, and epilepsy models. This area of research remains largely unexplored and therefore provides numerous opportunities for new investigations.

The effect of chronic lorazepam administration in aging mice

To assess benzodiazepine tolerance in aged animals, lorazepam or vehicle was administered chronically to male Crl: CD-1(ICR)BR mice. Pharmacodynamic and neurochemical endpoints were examined on days 1 and 14 of drug administration. There was no age-related significant difference in plasma lorazepam levels. Young and middle-aged animals demonstrated behavioral tolerance to lorazepam, while the aged animals showed a similar trend which failed to reach significance. In addition, aged animals also showed a trend toward tolerance to the anticonvulsant effects of lorazepam. There were no changes in alpha1 mRNA levels in cortex or hippocampus following administration of lorazepam when compared to vehicle-treated animals in any age group. Aged animals, however, had an initial increase in alpha1 mRNA expression in cortex and hippocampus on day 1 of vehicle treatment followed by decreased expression on day 14. These age-related changes were abolished by lorazepam administration. In summary, age-related sensitivity to the effects of lorazepam was not demonstrated in the present study. However, comparison of these data to other studies indicates that the effect of chronic benzodiazepine treatment may be specific to the benzodiazepine administered, the technique used to quantify mRNA expression changes, the subunits of the GABA(A) receptor investigated and the brain region analyzed. The phenomenon of benzodiazepine sensitivity in the elderly is an area of research which remains controversial and may well be compound specific. Determining benzodiazepines that do not produce pharmacodynamic sensitivity, such as lorazepam, may allow more careful prescribing and dosing of these drugs, and perhaps even the development of specific agents which could avoid this sensitivity.

Effects of repeated seizure induction on seizure activity, post-ictal and interictal behavior

Individual variability and numerous interactions between pharmacokinetics, pharmacodynamics, and homeostatic factors complicate the study of the anticonvulsant effect in animal models of seizure activity. In theory, both individual variability and the contribution of these factors to the anticonvulsant effect can be determined by following the time course of the pharmacological response and the corresponding plasma concentrations in individual animals. Currently, there are several formal pharmacokinetic-pharmacodynamic models available for the analysis of such data, which yield accurate estimates of drug intrinsic activity and potency. However, most models of seizure activity are not suited for such an approach, either because they can be applied only once, or because the expression of seizures is not constant over time. In addition, the induction of seizures constitutes repeated jeopardy to the animals, which may profoundly change behavior and interfere in the anticonvulsant response as well as in different physiological processes. In this paper, we compare ictal, post-ictal, and interictal behavior in three different models of seizure activity in rats, namely, the electroconvulsive shock, amygdala kindling and the cortical stimulation model (CSM). The methods were compared in the same way as they are currently in use for the assessment of antiepileptic drug effect. Our results show that repeated seizure activity induced by cortical stimulation does not exacerbate ictal activity (eye closure, jerk, gasp, forelimb clonus, and hind-limb tonus) nor post-ictal behavior (chewing and freezing), while producing less serious changes in interictal behavior (walk, lean, upright rearing, exploratory, grooming, and rest) than kindling or electroconvulsive shock. We conclude that seizures induced by cortical stimulation are reproducible and qualitatively similar to kindling seizures. Our results also suggest that the electroconvulsive shock model is not suited for pharmacokinetic-pharmacodynamic studies and that the assessment of interictal behavior may contribute to the evaluation of overall antiepileptic drug effect in seizure disorders.

Seizure patterns in kindling and cortical stimulation models of experimental epilepsy

A large number of animal models has been proposed for the evaluation of the anticonvulsant effect of antiepileptic drugs. Various seizure patterns are produced and differences are frequently observed in anticonvulsant effect estimates obtained for the same drug in different models. The incidence of seizures and the threshold for the induction are usually the only measures used for the determination of the anticonvulsant effect. However, behavioural components expressed during seizures induced by different means are likely to differ considerably. The aim of this study was to provide a detailed behavioural description of ictal and post-ictal components in two models of electrically induced seizure activity: kindling and cortical stimulation model (CSM). Seizure activity was induced in two groups of 6 Wistar-derived rats. Ictal and post-ictal behaviours were recorded on video tape and quantified using a computer supported frame-by-frame encoding of the behavioural components. We encoded the duration and rate of occurrence of the following behavioural items: whisker movements, eye closure, myoclonic jerk, facial gasping, forelimb clonus, forelimb tonus, hindlimb tonus, immobility and chewing. It appears that both models are, in many respects, qualitatively similar. However, the models differ quantitatively. Behavioural expression of seizure activity differs in the following respects: (1) the total duration of the seizure induced by cortical stimulation is shorter than by kindling; (2) seizure activity in the CSM occurs mainly during stimulation, while in amygdala kindling, it occurs thereafter; and (3) seizures evoked in the CSM comprise relatively less violent behavioural items than in the amygdala kindling. The evaluation of the ictal and post-ictal behavioural components suggests that behavioural analysis could assist in the detection of differences in the mechanisms of action of antiepileptic drugs. In addition, observational measures can also be used to assess animal distress inflicted by different experimental procedures.