Benzodiazepines: clinical pharmacology and therapeutic use

Synthesis of 1,3,5-Triazepines and Benzo[f][1,3,5]triazepines and Their Biological Activity: Recent Advances and New Approaches

This review article discusses the recent progress in synthesizing seven-membered ring 1,3,5-triazepine and benzo[f][1,3,5]triazepine derivatives. These derivatives can be either unsaturated, saturated, fused, or separated. This review covers strategies and procedures developed over the past two decades, including cyclo-condensation, cyclization, methylation, chlorination, alkylation, addition, cross-coupling, ring expansions, and ring-closing metathesis. This review discusses the synthesis of 1,3,5-triazepine derivatives using nucleophilic or electrophilic substitution reactions with various reagents such as o-phenylenediamine, 2-aminobenzamide, isothiocyanates, pyrazoles, thiazoles, oxadiazoles, oxadiazepines, and hydrazonoyl chloride. This article systematically presents new approaches and techniques for preparing these compounds. It also highlights the biological importance of benzo[f][1,3,5]triazepine derivatives, which have been used as drugs for treating nervous system diseases. This review aims to provide researchers with the necessary information to create and develop new derivatives of these compounds as quickly as possible.

Benzodiazepine analysis by an improved LC-MS/MS method illustrates usage patterns in Washington State

BACKGROUND

The standard approach for benzodiazepine detection often includes immunoassay followed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The illicit use of non-prescribed benzodiazepines has been trending up nationally.

METHODS

We developed and validated an improved LC-MS/MS assay for benzodiazepine detection in urine. We expanded the testing panel by adding five drugs to the previous panel of ten. We determined the prevalence of individual benzodiazepines in our patient population. Immunoassay results were compared with LC-MS/MS to evaluate assay performance.

RESULTS

Clonazepam and alprazolam were the most common benzodiazepines present. Etizolam and flualprazolam were also prevalent in Washington State. Compared with the LC-MS/MS assay, the immunoassay had variable cross-reactivity, which explained false negative and false positive immunoassay results. The inclusion of new drugs in the LC-MS/MS panel significantly reduced the incidence of immunoassay results interpreted as falsely positive.

CONCLUSION

New illicit benzodiazepines have emerged regionally and nationally. The inclusion of novel drugs in LC-MS/MS assay was helpful in properly characterizing the epidemiology of benzodiazepine use in our patient population. This information will lead to better assay result interpretations and patient care, and our experiences provide a roadmap for other clinical laboratories looking to expand their testing menu or transition to new instrumentation.

Dimeric Benzodiazepines as Peptide Mimetics to Overcome p53-Dependent Drug Resistance of Tumors

Benzodiazepines that consist of one α- and one β-amino acid residues linked together in a seven-membered heterocyclic ring could be treated as small, rigid, cyclic dipeptides capable of exhibiting a wide range of biological activities. During our research on novel analogues of anthramycin, a tricyclic antibiotic benzodiazepine, we developed the synthesis of two benzodiazepine dimers, obtained through the cyclization of appropriate linear tripeptides. The synthesized compounds were tested on a panel of seven cancer and normal cell lines. The developed molecules exhibited promising cytotoxic activity against the lung cancer cell lines A549 and NCI-H1299 and the epidermoid carcinoma cell line A-431. Moreover, they showed significant selectivity compared to the reference cell lines (BJ-human normal skin fibroblasts and MRC-5-human normal lung cell line). When tested on two isogenic cell lines, HCT116 and HCT116p53^-/- (colon cancer), contrary to cisplatin being used as a positive control, the obtained compounds showed a cytotoxic effect independent of the p53 protein status. For the above reasons, the obtained compounds can be considered a new group of promising anticancer agents, useful in the fight against p53-dependent drug resistance in cancers. They can also be treated as convenient, leading structures suitable for further optimization and searching for more active and selective molecules.

Metal-bio functionalized bismuthmagnetite [Fe3-x Bi x O4/SiO2@l-ArgEt3 +I-/Zn(ii)]: a novel bionanocomposite for the synthesis of 1,2,4,5-tetrahydro-2,4-dioxobenzo[b][1,4]diazepine malononitriles and malonamides at room temperature and under sonication

In this work, a new magnetized composite of bismuth (Fe3-x Bi x O4) was prepared and functionalized stepwise with silica, triethylargininium iodide ionic liquid, and Zn(ii) to prepare a multi-layered core-shell bio-nanostructure, [Fe3-x Bi x O4/SiO2@l-ArgEt3 +I-/Zn(ii)]. The modified bismuth magnetic amino acid-containing nanocomposite was characterized using several techniques including Fourier-transform infrared (FT-IR), X-ray fluorescence (XRF), vibrating sample magnetometer (VSM), field-emission scanning electron microscopy (FESEM), energy dispersive X-ray analysis (EDAX), thermogravimetric/differential scanning calorimetric (TGA/DSC) analysis, X-ray photoelectron spectroscopy (XPS), Brunauer-Emmett-Teller (BET), and inductively coupled plasma-optical emission spectrometry (ICP-OES). The magnetized bionanocomposite exhibited high catalytic activity for the synthesis of 1,2,4,5-tetrahydro-2,4-dioxobenzo[b][1,4]diazepine malononitriles via five-component reactions between 1,2-phenylenediamines, Meldrum's acid, malononitrile, aldehydes, and isocyanides at room temperature in ethanol. The efficacy of this protocol was also examined to obtain malonamide derivatives via pseudo six-component reactions of 1,4-phenylenediamine, Meldrum's acid, malononitrile, aldehydes, and isocyanides. When the above-mentioned MCRs were repeated under the same conditions with the application of sonication, a notable decrease in the reaction time was observed. The recovery and reusability of the metal-bio functionalized bismuthmagnetite were examined successfully in 3 runs. Furthermore, the characteristics of the recovered Fe3-x Bi x O4/SiO2@l-ArgEt3 +I-/Zn(ii) were investigated though FESEM and EDAX analysis.

Reactive metabolites of the anticonvulsant drugs and approaches to minimize the adverse drug reaction

Several generations of antiepileptic drugs (AEDs) are available in the market for the treatment of seizures, but these are amalgamated with acute to chronic side effects. The most common side effects of AEDs are dose-related, but some are idiosyncratic adverse drug reactions (ADRs) that transpire due to the formation of reactive metabolite (RM) after the bioactivation process. Because of the adverse reactions patients usually discontinue the medication in between the treatment. The AEDs such as valproic acid, lamotrigine, phenytoin etc., can be categorized under such types because they form the RM which may prevail with life-threatening adverse effects or immune-mediated reactions. Hepatotoxicity, teratogenicity, cutaneous hypersensitivity, dizziness, addiction, serum sickness reaction, renal calculi, metabolic acidosis are associated with the metabolites of drugs such as arene oxide, N-desmethyldiazepam, 2-(1-hydroxyethyl)-2-methylsuccinimide, 2-(sulphamoy1acetyl)-phenol, E-2-en-VPA and 4-en-VPA and carbamazepine-10,11-epoxide, etc. The major toxicities are associated with the moieties that are either capable of forming RM or the functional groups may itself be too reactive prior to the metabolism. These functional groups or fragment structures are typically known as structural alerts or toxicophores. Therefore, minimizing the bioactivation potential of lead structures in the early phases of drug discovery by a modification to low-risk drug molecules is a priority for the pharmaceutical companies. Additionally, excellent potency and pharmacokinetic (PK) behaviour help in ensuring that appropriate (low dose) candidate drugs progress into the development phase. The current review discusses about RMs in the anticonvulsant drugs along with their mechanism vis-a-vis research efforts that have been taken to minimize the toxic effects of AEDs therapy.

Effects of the α2/α3-subtype-selective GABAA receptor positive allosteric modulator KRM-II-81 on pain-depressed behavior in rats: comparison with ketorolac and diazepam

This study examined effects of the α2/α3-subtype-selective GABAA receptor positive allosteric modulator KRM-II-81 in an assay of pain-related behavioral depression. Adult, male Sprague-Dawley rats responded for electrical brain stimulation in a frequency-rate intracranial self-stimulation (ICSS) procedure. Intraperitoneal injection of 1.8% lactic acid served as an acute noxious stimulus to depress ICSS. Effects of KRM-II-81 were evaluated in the absence and presence of the acid noxious stimulus. The NSAID ketorolac and the benzodiazepine diazepam were tested as comparators. Neither ketorolac nor KRM-II-81 altered ICSS in the absence of the acid noxious stimulus; however, diazepam produced facilitation consistent with its abuse liability. Ketorolac blocked acid-induced depression of ICSS, and effects of 1.0 mg/kg ketorolac lasted for at least 5 h. KRM-II-81 (1.0 mg/kg) produced significant antinociception after 30 min that dissipated by 60 min. Diazepam also attenuated acid-depressed ICSS, but only at doses that facilitated ICSS when administered alone. The lack of ketorolac or KRM-II-81 effects on ICSS in the absence of the acid noxious stimulus suggests low abuse liability for both compounds. The effectiveness of ketorolac to block acid-induced ICSS depression agrees with clinical analgesic efficacy of ketorolac. KRM-II-81 produced significant but less consistent and shorter-acting antinociception than ketorolac.

Abuse-related effects of subtype-selective GABAA receptor positive allosteric modulators in an assay of intracranial self-stimulation in rats

RATIONALE

GABA_A positive allosteric modulators (GABA_A PAMs), such as diazepam and zolpidem, are used clinically for anxiety and insomnia, but abuse liability is a concern. Novel GABA_A PAMS may have lower abuse liability while retaining clinical utility.

OBJECTIVE

The present study compared abuse-related effects of the non-selective GABA_A PAM diazepam, the α1-selective GABA_A PAM zolpidem, and three novel GABA_A PAMs (JY-XHe-053, XHe-II-053, and HZ-166) using intracranial self-stimulation (ICSS) in rats. These novel compounds have relatively low efficacy at α1-, α2-, and α3-containing GABA_A receptors, putative in vivo selectivity at α2/α3-containing GABA_A receptors, and produce anxiolytic-like effects with limited sedation in non-human primates.

METHODS

Adult, male Sprague-Dawley rats (n = 17) were each implanted with a bipolar electrode in the medial forebrain bundle and trained to respond under a fixed-ratio 1 schedule of reinforcement for electrical brain stimulation. The potency and time course of effects were compared for diazepam (0.1-10 mg/kg), zolpidem (0.032-3.2 mg/kg), and the three novel compounds (JY-XHe-053, XHe-II-053, and HZ-166; all 3.2-32 mg/kg).

RESULTS

Zolpidem and diazepam produced transient facilitation of ICSS at small doses and more sustained rate-decreasing effects at larger doses. JY-XHe-053 and HZ-166 produced weak and inconsistent ICSS facilitation, whereas XHe-II-053 had no effect on ICSS.

CONCLUSIONS

These results support a key role for α1-containing GABA_A receptors in mediating GABA_A PAM-induced ICSS facilitation. These results are concordant with drug self-administration studies in monkeys in suggesting that GABA_A PAMs with low α1 efficacy and putative α2/α3 selectivity have lower abuse liability than high-efficacy non-selective or α1-selective GABA_A PAMs.

Geriatric Depression

Depression in the elderly is more common than once thought, especially in nursing home settings, where as many as 25% of residents can exhibit signs and symptoms of depression. Depression in the elderly can have a significant impact on overall health and desired outcome. The depressed elderly patient has been shown to have worsened prognosis of concomitant medical conditions, increased use of health care, decreased recovery time, and more likelihood to experience accelerated physical deterioration. Suicide represents the most serious complication of depression of the older depressed individual. The elderly are at a disproportionate risk for suicide attempts and are more likely to be successful. Diagnosis should be made using Diagnostic and Statistical Manual of Mental Disorders(4th ed.) (DSMIV) criteria, and clinicians should use standardized rating scales such as the Geriatric Depression Scale to assist in monitoring the severity of depressive symptoms and the efficacy of antidepressant treatment. Several treatment options are available to the clinician and include psychotherapy, electroconvulsive therapy, older antidepressants such as the tricyclics, and newer more tolerable therapies such as the serotonin reuptake inhibitors. Drug therapy should be individualized and should take into account the pharmacokinetic and pharmacodynamic changes that are associated with normal aging.

Advances in 1,2,4-triazepines chemistry

This review reports the chemistry of 1,2,4-triazepines. Heterocyclic 1,2,4-triazepines are mono and fused cycles.

N-Paranitrophénylhydrazono-α-(2-méthyl-benzimidazol-1-yl)glyoxylate d'éthyle

There are two independent mol-ecules in the asymmetric unit of the title compound {systematic name: ethyl 2-(2-methyl-1H-benzimidazol-1-yl)-2-[2-(4-nitro-phen-yl)hydrazinyl-idene]ethano-ate}, C(18)H(17)N(5)O(4). Each mol-ecule and its inversion-related partner are linked by a pair of inter-molecular N-H⋯N hydrogen bonds, forming inversion dimers in the crystal structure.

Written information about individual medicines for consumers

BACKGROUND

Medicines are the most common intervention in most health services. As with all treatments, those taking medicines need sufficient information: to enable them to take and use the medicines effectively, to understand the potential harms and benefits, and to allow them to make an informed decision about taking them. Written medicines information, such as a leaflet or provided via the Internet, is an intervention that may meet these purposes.

OBJECTIVES

To assess the effects of providing written information about individual medicines on relevant patient outcomes (knowledge, attitudes, behaviours and health outcomes) in relation to prescribed and over-the-counter medicines.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, The Cochrane Library, PsycINFO and other databases to March 2007. We handsearched five journals' tables of contents, and the reference lists of included studies, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of medicine users, comparing written medicines information with no written medicines information; or trials that compared two or more styles of written medicines information. We only included trials that measured a knowledge, attitudinal or behavioural outcome. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data relating to the interventions, methods of the trials, and outcome measures; and reconciled differences by discussion. Heterogeneity of interventions and outcomes measured meant that data synthesis was not possible. The results are presented in narrative and tabular format.

MAIN RESULTS

We included 25 RCTs involving 4788 participants. Six of twelve trials showed that written information significantly improved knowledge about a medicine, compared with no written information. The inability to combine results means we cannot conclude whether written information was effective for increasing knowledge. The results for attitudinal and behavioural outcomes were mixed. No studies showed an adverse effect of medicines information.

AUTHORS' CONCLUSIONS

The combined evidence was not strong enough to say whether written medicines information is effective in changing knowledge, attitudes and behaviours related to medicine taking. There is some evidence that written information can improve knowledge. The trials were generally of poor quality, which reduces confidence in the results. Trials examining the effects of written information need to be better designed and use consistent and validated outcome measures. Trials should evaluate internet-based medicines information. It is imperative that written medicines information be based on best practice for its information design and content, which could improve its effectiveness in helping people to use medicines appropriately.

Gas-phase reactivity of 2,7-dimethyl-[1,2,4]-triazepine thio derivatives toward Cu+ cation: a DFT study

The gas-phase interactions of 2,7-dimethyl-[1,2,4]-triazepine and its thio derivatives with Cu+ were studied through the use of high-level density functional theory (DFT) calculations. The structure of all possible tautomers and their conformers was optimized at the B3LYP/6-31G(d) level of theory. Final energies were obtained at the B3LYP/6-311+G(2df,2p) level. It has been found that the direct association of Cu+ occurs at the oxygen atom attached to position 3 in the case of the dioxo derivative and at the sulfur atom in all other cases. For the dithio derivatives, the global minimum of the PES corresponds to the structure in which the metal ion bridges between the heteroatom at position 3 and the nitrogen atom at position 4 of the corresponding enolic tautomer, forming a four-membered ring structure; for the dioxo derivative, this conformer competes with the ketone tautomer. Moreover, the isomerization processes leading from the most stable adduct to the other stable conformers were investigated. Among all the considered compounds, the 3,5-dithiotriazepines-Cu+ is found to be the one that associates Cu+ more tightly in the gas phase. The calculated Cu+ binding energies show a good correlation with the experimental proton affinities.

Ultraviolet-visible spectroscopic study of 3,5-dithio-2,7-dimethyl-[1,2,4]-triazepine: qualitative analysis of tautomeric behaviour

Room temperature UV-vis absorption spectra of the tautomeric system 3,5-dithio-2,7-dimethyl-[1,2,4]-triazepine in solution, in acetonitrile (CH3CN), are measured at different water volume percentages. The comparison of the obtained measures to the calculated allowed absorption transitions, using ZINDO/S package, reveals the coexistence of all the tautomeric forms in aprotic polar solution with a high dominance of the dithione form. The solute-water hydrogen bond, which seems to be of 1:n-type, favours the dithiol and monothiol conformers to the detriment of the dithione one. Further experimental investigations lead to the result that standing at ambient Laboratory conditions in the dark favours the dithione tautomeric isomer, while standing at indirect sunlight shifts the tautomeric equilibrium away from this species.

Alprazolam-Related Deaths in Palm Beach County

Alprazolam is a commonly prescribed benzodiazepine. The abuse of benzodiazepines is most frequently seen in conjunction with the abuse of other drugs. Only rare fatalities have been attributed to alprazolam alone. We undertook a retrospective review of cases investigated by the Palm Beach County Medical Examiner's Office in which postmortem toxicologic studies indicated the presence of alprazolam, to further study the pattern of alprazolam abuse. Our review consisted of 178 cases, including 87 in which death was attributed to combined drug toxicity, 2 to alprazolam toxicity alone, 44 to trauma, 12 to natural causes, and 33 to another drug or drugs. Cocaine and methadone were the most common cointoxicants in the cases of combined drug toxicity, while heroin was less frequently detected. There was considerable overlap in the postmortem blood alprazolam concentrations among the groups. The overlapping ranges of concentrations of alprazolam detected indicate that it may be difficult to define a lethal alprazolam range, and that it may not be possible to determine the actual role of alprazolam as a causal factor in cases of combined drug toxicity. This study confirms that alprazolam alone is rarely a cause of death, and that alprazolam abuse usually occurs within a polydrug use pattern. The high incidence of cocaine as a cointoxicant has not been previously reported.

Imidazo[2,1-b]thiazepines: synthesis, structure and evaluation of benzodiazepine receptor binding

As a continuation of our search for new ligands acting on benzodiazepine receptors among the fused 2-thiohydantoin derivatives, a series of 5-substituted imidazo[2,1-b]thiazepines was synthesized and investigated in radioligand binding studies at the benzodiazepine binding site of GABA(A) receptors in rat brain cortical membranes. Among ortho-substituted 5-arylidene-imidazo[2,1-b]thiazepines compounds could be identified which exhibit affinity for the benzodiazepine binding site at low micromolar concentrations. X-ray structure analyses for two compounds (6ae and 6ag) have been performed. In order to analyze the structure-activity relationships, 3D models of all compounds have been completed (using X-ray data). Physicochemical properties calculated (log P and log D) as well as experimental thin layer chromatography data were examined.

Imidazo-thiazine, -diazinone and -diazepinone derivatives. Synthesis, structure and benzodiazepine receptor binding

In our search for new compounds acting on benzodiazepine receptors among the fused 2-thiohydantoin derivatives, a series of arylidene imidazo[2,1-b]thiazines was synthesized. The 1,2- and 2,3- cyclized derivatives of mono- and di-substituted Z-5-arylidene-2-thiohydantoins were examined (the X-ray crystal structure of Z-2-cinnamylidene-6,7-dihydro-5H-imidazo[2,1-b][1,3]thiazin-3(2H)-one was determined) and compared with the diphenyl derivatives. To investigate the influence of the type of annelated ring on the biological activity, imidazo[2,1-b]pyrimidinone and imidazo[2,1-b]diazepinone derivatives were obtained. The method used in annelation (1,2- and 2,3-cyclized isomers with the exception of fused arylidene imidazothiazines), the substitution pattern (arylidene towards diphenyl) as well as the character of the annelated ring had minor influence on the benzodiazepine receptor affinity of the investigated compounds. It appears that the greatest influence on the biological activity has the character and position of the substituents on the arylidene ring.

Evidence suggesting that gonadal hormones influence benzodiazepine withdrawal-induced weight loss in rats

1. In experimental animals, benzodiazepine (BZ) withdrawal syndrome includes anorexia and acute weight loss. The literature shows several sex-based differences in the expression of BZ dependence; however, the authors did not find studies dealing with the influence of gonadal hormones on BZ withdrawal-induced weight loss. Thus, this study was designed to investigate the effects of castration on diazepam (DZ) withdrawal-induced weight loss in rats. 2. Male (260-330 g) or female (220-260 g) Wistar rats were anesthetized with ether and submitted to surgical castration or sham-operation. Seven days later, recovered from the surgery, the animals were injected i.p. with DZ (4 mg kg-1 day-1) or appropriate vehicle (VEH; 2 ml kg-1 kg-1 day-1) for 28 days. In the next 7 days, the rats received the same doses of DZ (four groups) or VEH (eight groups). Weights of all animals were recorded daily to the nearest gram at 09:00 h. To assess the degree of weight loss and make statistical comparisons, weights over days 29-34 were expressed as percentage of those recorded in the morning of day 28. 3. Sham-operated female rats from the group DZ-VEH showed a small but statistically significant weight loss on days 29 and 30 (P < 0.05) when compared with groups VEH-VEH and DZ-DZ. Ovariectomized rats, however, did not show any significant change in body weight from days 29-34. 4. Sham-operated male rats did not exhibit any significant weight loss after DZ withdrawal. Orchidectomized animals, however, showed a small but statistically significant weight loss on day 31 (P < 0.05) when compared with groups VEH-VEH and DZ-DZ. 5. These results show a gonadal influence on DZ withdrawal-induced weight loss in Wistar rats; in particular, they also suggest that female hormones (progesterone and/or estrogen) facilitate whilst male hormones inhibit this phenomenon.

Frequency-dependent actions of benzodiazepines on GABAA receptors in cultured murine cerebellar granule cells

1. Miniature IPSCs recorded from cultured murine cerebellar granule cells increased in half-width and amplitude following application of the benzodiazepine (BDZ) Flunitrazepam (Flu, 1 microM). The increase in the half-width was much greater than that in the amplitude. 2. Five-millisecond applications of 1 mM GABA to nucleated outside-out patches elicited rapidly rising biexponentially decaying responses that resembled IPSCs. Flu had no effect on the amplitude of such responses, but consistently slowed their deactivation by approximately 50%. This effect was reversed by Flu washout or application of the BDZ antagonist Ro15-1788. The partial inverse agonist. Ro15-4513 speeded deactivation and depressed peak current amplitude by 23 +/- 12%. 3. The EC50 for GABA was between 45 and 50 microM. At submaximally effective agonist concentrations, Flu increased response amplitude and slowed response deactivation. Both effects were present in all cells taken from young cultures (4-7 days in vitro) but the latter was absent in 55% of the neurones obtained from older cultures (14-27 days in vitro). 4. With 120 ms applications of 20 microM GABA, responses activated monoexponentially (time constant, 39.8 +/- 2.8 ms) and deactivated biexponentially (time constants, 40.4 +/- 2.1 and 251 +/- 15 ms). Application of Flu slowed both activation and deactivation. The latter effect arose from an increased contribution of the slower component of decay. 5. Desensitization of responses to 1 mM GABA was biexponential, with time constants of 47 +/- 11 and 479 +/- 49 ms. Flu speeded desensitization by decreasing both fast and slow time constants. GABAA receptor desensitization consistently slowed subsequent deactivation. No significant relationship between the level of desensitization and the amount of slowing of deactivation produced by Flu was found. 6. Responses to paired 5 ms applications of 1 mM GABA indicated that the slowing of deactivation and the speeding of desensitization produced by Flu combine to generate a marked frequency dependence in the actions of this BDZ. Thus when compared with control responses, GABA-induced charge transfer was only enhanced by Flu during the first of two successive agonist applications.

Anticonvulsant pharmacodynamics and disposition of triazolam in rats

Triazolam (TZ) is a triazolobenzodiazepine used in the treatment of insomnia that possesses significant anticonvulsant properties. Despite the widespread use of this drug, detailed pharmacokinetic-pharmacodynamic information is lacking, especially with respect to inhibition of seizure activity. TZ disposition has been described previously by methods with limited specificity, and the concentration-anticonvulsant effect relationship has not been characterized. The current studies were undertaken to examine TZ disposition with a specific HPLC method, and to evaluate the relationship between anticonvulsant effect and concentration in Sprague-Dawley rats. TZ pharmacokinetics were characterized after bolus or infusion administration; in a separate experiment, TZ pharmacodynamics were assessed with pentylenetetrazol-induced seizures. The systemic disposition of TZ could be described with a two-compartment model; systemic clearance ranged from 2.45 to 5.30 L/h/ kg, steady-state volume of distribution ranged from 2.10 to 4.02 L/kg, and mean residence time ranged from 47 to 65 min. The concentration-effect relationship was well described by a simple Emax model: Emax, expressed as the ratio of post-TZ to pre-TZ threshold convulsant doses of pentylenetetrazol, was 9.9 +/- 0.7, and the EC50 values were 10.0 +/- 4.6 ng/mL and 34.8 +/- 9.0 ng/g in serum and whole brain tissue, respectively. Under single-dose conditions, TZ is a very potent anticonvulsant in the rat pentylenetetrazol seizure model.

Pharmacokinetics and anticonvulsant effect of a new hypnotic, CL 284,846, in rats

PURPOSE

CL 284,846 (CL846) is an investigational non-benzodiazepine agent with hypnotic, anxiolytic, myorelaxant and anticonvulsant properties. This study assessed the pharmacokinetics and anticonvulsant action of CL846 in female Sprague-Dawley rats.

METHODS

CL846 pharmacokinetics were examined after either an iv bolus dose (2.5 mg/kg) or a 6-hr infusion (0.4 mg/kg/hr). CL846 pharmacodynamics were evaluated with a pentylenetetrazol (PTZ) infusion 5 min after a CL846 in bolus dose (0 to 10 mg/kg). CL846 and the derived metabolite CL 284,859 (CL859) concentrations in serum and brain tissue were determined by HPLC with fluorescence detection.

RESULTS

Both the steady-state volume of distribution (1636 +/- 162 and 1804 +/- 293 ml/kg, after bolus and infusion administration, respectively) and systemic clearance (19.1 +/- 7.1 and 22.2 +/- 4.3 ml/min/kg for bolus and infusion administration, respectively) were high. No differences in pharmacokinetic parameters were noted between the two modes of administration. The relationship between anticonvulsant effect and brain/serum concentrations was well described by an Emax model. CL846 was as effective as triazolam in antagonizing PTZ-induced seizures.

CONCLUSIONS

Under the conditions of the present study, CL846 pharmacokinetics were linear and stationary. Further evaluation of the anticonvulsant properties of CL846 is warranted, including the potential development of tolerance, which is well known for benzodiazepines.

Benzodiazepines as antidepressants: does GABA play a role in depression?

Benzodiazepines, the most widely prescribed psychotropic drugs, are often used in patients with depressive disorders, either alone or in combination with standard antidepressants. This review evaluates the efficacy of benzodiazepines (alprazolam, diazepam, chlordiazepoxide) as established in acute-phase, randomized controlled trials (RCTs) in major depressive disorder. Metaanalyses using intent-to-treat, as well as adequate treatment exposure samples, revealed an overall efficacy of 47-63% and a drug-placebo difference of 0-27% for all benzodiazepines. Alprazolam, the best studied of the benzodiazepines, had a 27.1% (sd = 6.1%) greater response than placebo, which is comparable to standard antidepressants. Alprazolam, in particular, may be a useful treatment option for patients in whom standard antidepressant medications are contraindicated, poorly tolerated, or possibly ineffective. Alprazolam may have a more rapid onset of action for some patients. Benzodiazepines do not primarily affect biogenic amine uptake or metabolism, although they do augment gamma-amino butyric acid (GABA) activity. The antidepressant efficacy of benzodiazepines, which are GABAA receptor agonists, is consistent with the GABA theory of depression.

High-risk drugs in the elderly population

Drug therapy in elderly patients is affected by age-related changes in distribution and elimination and is further complicated by the increased sensitivity aged persons have to many of the effects of medications. Medications are often necessary in the elderly population, but care should be made to properly monitor these patients, especially those taking multiple drugs. Nurses, who are at the front lines of health care in all areas of practice, should be aware of drugs that may be high risk for use in the elderly and monitor these patients carefully for signs and symptoms of toxicity.

Treatment of depressive outpatients with lorazepam, alprazolam, amytriptyline and placebo

This randomized double-blind study in 342 mildly to moderately depressive outpatients investigated the antidepressant effectiveness and speed of action of lorazepam, alprazolam and amitriptyline versus placebo. Six weeks of drug treatment were followed by a drug taper period, a control period with placebo and a control period without placebo, of 2 weeks duration each. Clinical improvement was assessed by rating scales (Clinical Global Impressions, Hamilton Rating Scales for Depression and Anxiety) and patient's self-ratings (Patient's Global Impressions, Self-rating Depression Scale and Visual Analogue Scale). At the end of week 6 all active drugs showed similar efficacy which was significantly superior to placebo. Compared to placebo, onset of efficacy was earlier on benzodiazepines than on amitriptyline . While tapering by decreasing the dosage, replacing drug with placebo and finally discontinuing placebo, clear withdrawal phenomena were not seen, but 20% of patients, equally distributed to all treatment groups, did not want to stop taking tablets after replacing drug with placebo. Drop-out rate during the treatment period was very low (9%). Significantly interfering adverse effects were seen in 27 patients, without predominance in one of the active drug groups.

Optimizing sedation following major vascular surgery: a double-blind study of midazolam administered by continuous infusion

A randomized, double-blind study was undertaken to determine the dose requirements, recovery characteristics, and pharmacokinetic variables of midazolam given by continuous infusion for sedation in patients following abdominal aortic surgery. Thirty subjects, 50-75 yr, scheduled to undergo aortic reconstructive surgery, entered the study. Following a nitrous oxide-isoflurane-opioid anaesthetic technique, patients were randomly allocated to receive one of three loading doses (0.03, 0.06 or 0.1 mg.kg-1) and initial infusion rates (0.5, 1.0 or 1.5 micrograms.kg-1.min-1) of midazolam, corresponding to groups low (L), moderate (M) and high (H). The infusion of midazolam was adjusted to maintain sedation levels of "3, 4 or 5," which permitted eye opening in response to either verbal command or a light shoulder tap, using a seven-point scale ranging from "0" (awake, agitated) to "6" (asleep, non-responsive). Additionally morphine was given in increments of 2.0 mg iv prn for analgesia. On the morning after surgery, midazolam was discontinued, and the tracheas were extubated when patients were awake. Blood samples were taken during, and at increasing intervals for 48 hr following discontinuation of the infusion, and analyzed by gas chromatography. The desired level of sedation was maintained during more than 94% of the infusion period in all three groups, with a maximum of three dose adjustments per patient, for treatment which lasted 16.3 +/- 0.6 hr. There was, however, an increase in both the infusion rates and mean plasma concentrations from Group L to Group H (P < 0.05), which corresponded to an inverse relationship of morphine requirements during the period of sedation (P < 0.05, Group H vs Group L). Optimal midazolam infusion rates and resulting plasma concentrations at the times the infusions were discontinued (in parentheses) were as follows-Group L: 0.60 +/- 0.18 microgram.kg-1.min-1 (76 +/- 32 ng.mL-1), Group M: 0.90 +/- 0.52 microgram.kg-1.min-1 (133 +/- 71 ng.mL-1), and Group H: 1.34 +/- 0.69 microgram.kg-1.min-1 (206 +/- 106 ng.mL-1). Times to awakening were longer in Group H: 3.1 +/- 3.4 hr, than in Group L: 1.1 +/- 0.8 h, P < 0.05. Pharmacokinetic variables were found to be dose-independent over the range of infusion rates. Mean values were t1/2 beta = 4.4 +/- 1.5 hr, CL = 5.94 +/- 1.69 mL.min-1.kg-1, Vd = 3.13 +/- 1.07 L.kg-1.(ABSTRACT TRUNCATED AT 400 WORDS)

Safety and side-effects of alprazolam. Controlled study in agoraphobia with panic disorder

BACKGROUND

The widespread use of benzodiazepines has led to increasing recognition of their unwanted effects. The efficacy of alprazolam and placebo in panic disorder with agoraphobia, and the side-effect and adverse effect profiles of both drug groups were measured.

METHOD

In London and Toronto 154 patients who met DSM-III criteria for panic disorder with agoraphobia were randomised to alprazolam or placebo. Subjects in each drug group also received either exposure or relaxation. Treatment was from weeks 0 to 8 and was then tapered from weeks 8 to 16.

RESULTS

Mean alprazolam dose was 5 mg daily. Compared with placebo subjects, alprazolam patients developed more adverse reactions (21% v. 0%) of depression, enuresis, disinhibition and aggression; and more side-effects, particularly sedation, irritability, impaired memory, weight loss and ataxia. Side-effects tended to diminish during treatment but remained significant at week 8. Despite this, the drop-out rate was low.

CONCLUSIONS

Alprazolam caused side-effects and adverse effects during treatment but many patients were willing to accept these.

Factors and conditions affecting the glucuronidation of oxazepam

The aim of the present work was to investigate the impact of disease states and environmental and host factors on the glucuronidation of oxazepam. Glucuronidation represents quantitatively one of the most important metabolic conjugation pathways (phase II) in man for the inactivation and detoxication of xenobiotics and endogenous compounds and the liver is the major site for it to take place. Far less attention has been paid to the conjugation reactions in previous clinical research in this field compared to the immense interest in the oxidative biotransformation pathways (phase I). This fact is mainly due to the latter giving rise to active or reactive metabolites with a toxicological potential. The metabolism of oxazepam expresses exclusively the capacity for glucuronide formation. It was a prerequisite to establish the bioavailability of oxazepam prior to succeeding studies on the oral disposition of the drug. A preparation for intravenous administration was created. Clearance was chosen as measurement of the capacity to glucuronidate oxazepam. Severe decompensated liver disease was associated with a significant decrease in oxazepam clearance, that became even more obvious when corrected for by a diminished binding to plasma proteins. This increase in free fraction of oxazepam was substantial and could mainly be accounted for by low plasma albumin values. The results are in part a settlement with earlier studies on glucuronidation in liver disease and they may undoubtedly be ascribed to the severe degree of liver disease. For the first time it was shown that hypothyroidism led to a decline in the clearance and metabolism of oxazepam and paracetamol that is mainly biotransformed by glucuronidation. It was concluded that the enzymes responsible for glucuronidation in hypothyroidism are under the influence of thyroid hormones as is the case with oxidative enzymes. Further studies focused on the effect of host and environmental factors on glucuronidation. A commercially available very low calorie product for the treatment of obesity resulted in a decrease in oxazepam clearance and a lack of co-factors as a consequence of the low calorie intake was explanatorily proposed. Beta-adrenoceptor antagonists are often prescribed together with other drugs and close knowledge on interactions is mandatory but insufficient in regard of drugs being glucuronidated. Despite the mutual metabolic pathway labetalol exerted no dispositional alterations concerning oxazepam. It was moreover suggested that very elderly subjects between the age of 80 to 94 years had a reduced clearance of oxazepam.(ABSTRACT TRUNCATED AT 400 WORDS)

A placebo controlled double-blind evaluation of the pharmacodynamics of fengabine vs amitriptyline following single and multiple doses in elderly volunteers

1. The effects of fengabine were compared with those of amitriptyline in healthy elderly volunteers. Doses were administered double-blind and assessments were made before and after ingestion. 2. Psychomotor performance and cognitive ability were measured using tests of choice reaction time, tracking, critical flicker fusion threshold, memory scanning and word recognition. Subjective feelings were assessed using the Leeds sleep evaluation questionnaire (LSEQ) and line analogue rating scales (LARS). 3. Pharmacokinetic data suggest that fengabine may induce its own metabolism following repeated dosing. 4. The findings of this study show that fengabine 200 mg and 400 mg does not produce any noticeable behavioural toxicity in elderly volunteers, in contrast to amitriptyline which had a disruptive effect throughout.

Analgesic effect of benzodiazepines and flumazenil

1. In the present work the analgesic effect of benzodiazepines (BZD) and flumazenil (FLU) using the writhing test in mice was studied. 2. Intracerebroventricular administration of BZD exhibited a dose-dependent antinociceptive effect when compared to control value. 3. Intracerebroventricular administration of FLU induced a dose-dependent antinociceptive action that was not antagonized by naloxone (NX). 4. BZD administered as subcutaneous pellets produced an antinociceptive action in the writhing test, when compared to control mice, only at relative high doses and was partially antagonized by naloxone. 5. These findings could be explained assuming that NX and/or FLU have partial agonist properties in a common receptor which mediates the antinociceptive action. 6. The antinociceptive action of BZD could be related to an increased release of adenosine, which by itself has analgesic effects.

Impact of triplicate prescription program on psychotropic prescribing patterns in long-term care facilities

OBJECTIVE

To assess the impact of the effect of the New York state triplicate prescription program on psychotropic prescribing patterns in selected long-term care facilities over a one-year period.

DESIGN

Retrospective study for changes in psychotropic drug use patterns before and after implementation of the triplicate prescription program.

SETTING

Eight private and two public long-term care facilities in the western New York area.

PATIENTS

All residents in the long-term care facilities with complete medical records for a one-year period were reviewed.

OUTCOME MEASUREMENTS

Charts were reviewed for changes in psychotropic drug patterns and incidence in adverse events such as falls, hip fractures, hospital admission, signs or symptoms of benzodiazepine (BZD) withdrawal syndrome, or behavioral outburst.

MAIN RESULTS

BZD use declined precipitously from 25 percent of psychotropic drug orders to 10 percent six months after implementation of the program. The decline in BZD use was accompanied by an increase in the number of orders for alternative psychotropic agents. Although 22 percent of the patients previously receiving BZDs were discontinued from these drugs, more than half of these patients were switched to alternative therapy, including tricyclic antidepressants and antipsychotic drugs. The majority of patients who discontinued BZDs did so without tapering of the dosage; however, few experienced minor withdrawal symptoms and no patient experienced seizures or required hospitalization following discontinuation. The risk of falls, hospital admission for any reason, or combined events was not significantly altered despite a reduction in BZD use. There was a trend, however, for a reduction in falls after implementation of the program.

CONCLUSIONS

This study documents that psychotropic drug prescribing patterns were significantly affected by the triplicate prescription program. BZD use declined; however, use of alternative psychotropic drugs increased. Despite changes in psychotropic prescribing patterns, we found no significant risk of adverse events. Further study to evaluate the long-term effect of alternative psychotropic drugs is necessary.

Effects of serotonergic agents on isolation-induced aggression

A series of serotonergic agents were assessed for their ability to antagonize isolation-induced aggression and their activity to disrupt performance in the rotorod motor coordination test. All compounds with 5-HT1A activity [buspirone, gepirone, ipsapirone, tandospirone (SM-3997), 8-OH-DPAT, Wy-48,723, BMY-7378, Wy-47,846] reduced aggression at doses below those which produced debilitation in the rotorod motor coordination test. In addition, the 5-HT3 antagonist zacopride failed to attenuate aggression or produce debilitation at any of the doses tested; however, the 5-HT2 antagonist ritanserin inhibited aggressive behavior at a high dose which was not debilitating. Benzodiazepines (chlordiazepoxide, diazepam and lorazepam), and antidepressant (desipramine) and an antipsychotic (haloperidol) reduced aggressive behavior only at debilitating doses. Activity at the 5-HT1A receptor, and possibly nonsedative anxiolytic activity, appears to be related to antagonism of isolation-induced aggression.

Single dose pharmacokinetics and pharmacodynamics of oral oxazepam in very elderly institutionalised subjects

The effect of extreme old age on the pharmacokinetics and pharmacodynamics of orally administered oxazepam 15 mg was studied in 10 healthy elderly (age 80-94 years) institutionalised subjects and 10 healthy young controls (age 26-42 years). The total oxazepam clearance was 1.24 (0.91-1.80) ml min-1 kg-1 (median and range) and 1.44 (0.88-2.13) ml min-1 kg-1 in the elderly and young, respectively (NS), and the elimination half-lives were 8.1 (5.5-10.8) h and 5.7 (4.9-6.2) h. respectively (P less than 0.01). The percent of unbound oxazepam was greater in the elderly; 9.8 (8.1-13.3)% as opposed to 5.1 (3.7-5.9)% in the young (P less than 0.0001). Clearance of unbound oxazepam was lower in the elderly, median values being 13.8 (7.1-21.1) ml min-1 kg-1 compared with 30.3 (18.3-41.5) ml min-1 kg-1 in the young (P less than 0.0001). A single 15 mg dose oxazepam decreased the ability of the elderly to perform a finger tapping test at 3 h but not 8 h after drug administration, whereas placebo had no effect at either times. No effect was observed in the young subjects.

Simultaneous modeling of the pharmacokinetic and pharmacodynamic properties of benzodiazepines. II. Triazolam

This study compares the time course of triazolam effects on psychomotor and cognitive skills with triazolam plasma concentrations in a combined pharmacokinetic-pharmacodynamic (sigmoid-Emax) model. Ten male subjects received a single oral dose (1 mg) of triazolam or placebo. The CNS impairment effects were measured by using computerized tracking, body sway, and digit symbol substitution tests, and triazolam plasma concentration was measured by gas chromatography. The drug-induced effect changes lagged behind the plasma drug level changes. The magnitude of the time lag was quantified by the half-time of equilibration between concentrations in the hypothetical effect compartment and the plasma triazolam levels (t 1/2 keo). Essentially the same t 1/2 keo (approximately 6 min) was found for subcritical tracking, body sway, and digit symbol substitution tests. When using the predicted drug concentrations at the effect site, the hysteresis of the plasma concentration-effect disappears, suggesting that the hysteresis is not caused by drug induced tolerance. Moreover, the model allows for estimation of the effect site concentration that causes one-half of the maximal predicted effect (EC50, approximately 5 ng/ml) which is a measure of an individual's sensitivity to triazolam. On the basis of the EC50 values of the effect measures, body sway was slightly less sensitive to triazolam than subcritical tracking and digit symbol substitution tests.