Microextraction combined with microderivatization for drug monitoring and protein modification analysis from limited blood volume using mass spectrometry

In the clinic, ethosuximide is commonly used to treat generalized absence seizures but has recently been repurposed for other diseases. Because of adverse effects and drug interactions, high-throughput therapeutic drug monitoring of ethosuximide is necessary. Microextraction is a simple, effective, rapid, and low consumption of organic solvents method for sample preparation. In this study, microderivatization-increased detection (MDID)-combined microextraction was used to detect ethosuximide by mass spectrometry. Ethosuximide is a difficult to retain and ionize compound in the C18 nano-flow column and ionization interface, respectively. Hence, we developed a fast method for detecting ethosuximide in human plasma by using the MDID strategy (within 2 min). Chemical microderivatization parameters were studied and optimized to increase the sensitivity of ethosuximide detection at trace levels. The linear range for the analysis of ethosuximide in 10 μL plasma was 5-500 μg/mL with a coefficient of determination (r²) ≥ 0.995. The precision and accuracy of intraday and interday analyses of ethosuximide were below 13.0%. Furthermore, modifications of major proteins in plasma and blood cells, induced by ethosuximide, were identified. The proposed method effectively utilizes microliter samples to detect drug plasma concentrations under suitable microextraction procedures toward the eco-friendly goal of low consumption of organic solvents. Graphical abstract ᅟ.

Anti-epileptogenesis: Electrophysiology, diffusion tensor imaging and behavior in a genetic absence model

The beneficial effects of chronic and early pharmacological treatment with ethosuximide on epileptogenesis were studied in a genetic absence epilepsy model comorbid for depression. It was also investigated whether there is a critical treatment period and treatment length. Cortical excitability in the form of electrical evoked potentials, but also to cortico-thalamo-cortical network activity (spike-wave discharges, SWD and afterdischarges), white matter changes representing extra cortico-thalamic functions and depressive-like behavior were investigated. WAG/Rij rats received either ethosuximide for 2 months (post natal months 2-3 or 4-5), or ethosuximide for 4 months (2-5) in their drinking water, while control rats drank plain water. EEG measurements were made during treatment, and 6 days and 2 months post treatment. Behavioral test were also done 6 days post treatment. DTI was performed ex vivo post treatment. SWD were suppressed during treatment, and 6 days and 2 months post treatment in the 4 month treated group, as well as the duration of AD elicited by cortical electrical stimulation 6 days post treatment. Increased fractional anisotropy in corpus callosum and internal capsula on DTI was found, an increased P8 evoked potential amplitude and a decreased immobility in the forced swim test. Shorter treatments with ETX had no large effects on any parameter. Chronic ETX has widespread effects not only within but also outside the circuitry in which SWD are initiated and generated, including preventing epileptogenesis and reducing depressive-like symptoms. The treatment of patients before symptom onset might prevent many of the adverse consequences of chronic epilepsy.

Ethosuximide, valproic acid, and lamotrigine in childhood absence epilepsy

BACKGROUND

Childhood absence epilepsy, the most common pediatric epilepsy syndrome, is usually treated with ethosuximide, valproic acid, or lamotrigine. The most efficacious and tolerable initial empirical treatment has not been defined.

METHODS

In a double-blind, randomized, controlled clinical trial, we compared the efficacy, tolerability, and neuropsychological effects of ethosuximide, valproic acid, and lamotrigine in children with newly diagnosed childhood absence epilepsy. Drug doses were incrementally increased until the child was free of seizures, the maximal allowable or highest tolerable dose was reached, or a criterion indicating treatment failure was met. The primary outcome was freedom from treatment failure after 16 weeks of therapy; the secondary outcome was attentional dysfunction. Differential drug effects were determined by means of pairwise comparisons.

RESULTS

The 453 children who were randomly assigned to treatment with ethosuximide (156), lamotrigine (149), or valproic acid (148) were similar with respect to their demographic characteristics. After 16 weeks of therapy, the freedom-from-failure rates for ethosuximide and valproic acid were similar (53% and 58%, respectively; odds ratio with valproic acid vs. ethosuximide, 1.26; 95% confidence interval [CI], 0.80 to 1.98; P=0.35) and were higher than the rate for lamotrigine (29%; odds ratio with ethosuximide vs. lamotrigine, 2.66; 95% CI, 1.65 to 4.28; odds ratio with valproic acid vs. lamotrigine, 3.34; 95% CI, 2.06 to 5.42; P<0.001 for both comparisons). There were no significant differences among the three drugs with regard to discontinuation because of adverse events. Attentional dysfunction was more common with valproic acid than with ethosuximide (in 49% of the children vs. 33%; odds ratio, 1.95; 95% CI, 1.12 to 3.41; P=0.03).

CONCLUSIONS

Ethosuximide and valproic acid are more effective than lamotrigine in the treatment of childhood absence epilepsy. Ethosuximide is associated with fewer adverse attentional effects. (ClinicalTrials.gov number, NCT00088452.)

Robust isocratic high performance liquid chromatographic method for simultaneous determination of seven antiepileptic drugs including lamotrigine, oxcarbazepine and zonisamide in serum after solid-phase extraction

A rapid, simple and robust method is presented for the simultaneous determination of seven antiepileptic drugs (AEDs), including primidone, phenobarbital, phenytoin, carbamazepine with its two major metabolites carbamazepine-10,11-epoxide and carbamazepine-10,11-(trans)-dihydrodiol and the new AEDs lamotrigine, hydroxycarbazepine (active metabolite of oxcarbazepine) and zonisamide in serum by high performance liquid chromatography (HPLC)-diode array detector (DAD). After solid-phase extraction, separation is achieved on an Alltima 3C18 analytical column using isocratic elution with a mixture of acetonitrile, methanol and phosphate buffer at 45 degrees C. The method is exhaustively validated, including experimental design in combination with statistical evaluation (ANOVA) to study the robustness of chromatography and sample preparation. Commonly co-administered antiepileptic drugs do not interfere with the method. Intra-day precision (RSD<1.9%), linearity, lower limit of quantitation (LOQ<0.065 mg/l) and robustness make the method suitable for daily therapeutic drug monitoring and pharmacokinetic studies.

Simple and rapid micellar electrokinetic capillary chromatographic method for simultaneous determination of four antiepileptics in human serum

A very rapid and simple MEKC method was developed for the simultaneous determination of four antiepileptic drugs, ethosuximide (Etho), primidone (Pri), phenytoin (Pht) and carbamazepine (Cbz) in human serum. Sample analysis required only 100 microL of human serum which only needed to be centrifuged, decanted and combined with the running buffer [5.3 mM Na(2)HPO(4)/3.2 mM borax buffer (pH 9.5) containing 55 mM SDS and 3.5% (v/v) acetone]. The analysis was performed in only 10 min into fused-silica capillaries (57 cm total length with 50 microm i.d. and 50 cm to the detector) using the MEKC methodology with diode-array detection at 220 nm. The calibration graphs were established for ethoximide, primidone, phenytoin and carbamazepine between 0 and 20 mg/L. Recoveries were between 85 and 87%. The simplicity of the proposed methodology makes it suitable for routine clinical use, especially for epileptic patients on polytherapy.

Influence of vigabatrin, a novel antiepileptic drug, on the anticonvulsant activity of conventional antiepileptics in pentetrazole-induced seizures in mice

Vigabatrin is a novel antiepileptic drug, which increases GABA levels by irreversible inhibition of GABA-aminotransferase. The aim of this study was to evaluate the effects of vigabatrin on the anticonvulsant activity of valproate, ethosuximide and clonazepam against pentetrazole-induced seizures in mice. In addition, the effects of antiepileptic drugs alone or in combination with vigabatrin were studied on motor performance and long-term memory. Chemical seizures were induced by subcutaneous injection of pentetrazole at its CD(97) and defined as a clonus of the whole body with an accompanying loss of righting reflex, lasting for over 3 s. Vigabatrin inhibited the clonic pentetrazole-induced seizures and ED(30) of the drug was 879 mg/kg. Vigabatrin (at the subthreshold dose of 250 mg/kg) potentiated the protective activity of ethosuximide, reducing its ED(30) from 142 to 95 mg/kg against clonic seizures induced by pentetrazole, but simultaneously elevated its plasma level. The protective activity of valproate and clonazepam remained almost unchanged. However, vigabatrin (250 mg/kg) decreased TD(30) (50% toxic dose - corresponding to the impairment of motor coordination in 50% of the animals) of ethosuximide and clonazepam from 549 and 3.84 to 460 and 1.1 mg/kg, respectively, in the chimney test. Vigabatrin (250 mg/kg) did not influence TD(30) value of valproate in this test. Vigabatrin (at the dose of 250 mg/kg) did not impair long-term memory in combination with antiepileptics. Potentiation of the ethosuximide's protective activity was apparently due to a pharmacokinetic interaction. Consequently, no pharmacodynamic interactions between vigabatrin and the studied conventional antiepileptic drugs were evident.

Targeting thalamic nuclei is not sufficient for the full anti-absence action of ethosuximide in a rat model of absence epilepsy

Absence epilepsy is characterised by recurrent periods of physical and mental inactivity coupled to bilateral, synchronous spike and wave discharges (SWDs) on the electroencephalogram. The mechanism of action of ethosuximide (ETX), a drug specific for absence seizures, is believed to involve a reduction in the low threshold T-type Ca(2+) current in thalamocortical and nucleus reticularis thalami (NRT) neurones, although other electrophysiological data have questioned this. Here, we employed a genetic rat model of absence seizures to investigate the effects of directly administering ETX to the thalamus.SWDs were immediately and substantially reduced (approximately 90%) by systemic administration of ETX (177-709 micromol/kg), or by bilateral microinfusion into the thalamus of the GABA(B) antagonist, CGP 36742 (5-27 nmol per side). However, infusion of ETX (1-200 nmol per side) into the ventrobasal complex or the NRT resulted in a reduction of SWDs that was delayed (30-60 min) and less marked (approximately 50%). Administration of ETX (0.2 mM to 1M) to a greater volume of thalamus by reverse microdialysis also produced significant but delayed reduction of SWDs at concentrations >1mM. Only at 5mM were seizures significantly reduced (approximately 70%) within 30 min of administration. These results suggest that targeting of the thalamus alone may be insufficient for an immediate and full anti-absence action for ETX. Concomitant or exclusive actions in the cortex remain a possibility.

A sensitive gas chromatographic/mass spectrometric method for the resolution and quantification of ethosuximide enantiomers in biological fluids

A modified specific, sensitive and reproducible chiral gas chromatographic (GC) method for the resolution and quantification of ethosuximide enantiomers in urine and plasma was developed. The samples were extracted by liquid-liquid extraction, using diethylether and the enantiomers were separated and quantified on a chiral gas chromatographic column (25QC2 / CYDEX- beta 0.25). The method involved the use of GC/MS instrumentation for the acquisition of data in the electron impact selective-ion monitoring mode, collecting ions characteristic of both ethosuximide and alpha, alpha - dimethyl - beta - methylsuccinimide, the internal standard and of mass-to-charge ratio (m/z) exactly equal to 55 and 70 units. The limit of quantitation of the method was 2.5 microg/ml for both urine and plasma with both enantiomers. The method proved to be linear, precise and reproducible in the 5-300 microg/ml concentration range for urine samples and in the 10-250 microg/ml concentration range for plasma samples. Future research work envisaged the application of this method in pharmacokinetic and pharmacodynamic studies.

Trace analysis of ethosuximide in human plasma with a chemically removable derivatizing reagent and high-performance liquid chromatography

A simple and sensitive liquid chromatographic method is described for the determination of ethosuximide in human plasma, as a highly sensitive derivative. Ethosuximide spiked in plasma was extracted with toluene and derivatized with a chemically removable derivatizing reagent, 2-(2-naphthoxy)ethyl 2-[1-(4-benzyl)piperazyl]ethanesulfonate, in a homogeneous system, using magnesium oxide as base catalyst. The resulting derivative was separated on a LiChrospher diol column with 1.2% isopropanol in n-hexane as the mobile phase and using coumarin as the internal standard. Several parameters affecting the extraction/derivatization of ethosuximide from spiked plasma were investigated. The linear range for the determination of ethosuximide in spiked plasma was over 30-700 nmol/ml. For ethosuximide in plasma, the detection limit (signal-to-noise ratio=3; sample size, 10 microl) was about 9 pmol; the relative standard deviation was 6.4% for intra-day assay (n=6) and 9.2% for inter-day assay (n=6) and the relative recovery was found greater than 94%.

Ethosuximide is effective in the treatment of epileptic negative myoclonus in childhood partial epilepsy

The aim of our study was to evaluate the effectiveness of ethosuximide in the treatment of epileptic negative myoclonus, a motor disorder that can occur in childhood partial epilepsy. We introduced ethosuximide in nine patients with partial epilepsy of varying etiology (idiopathic, cryptogenic, symptomatic) who presented with epileptic negative myoclonus. The drug was added to the patients' preexisting antiepileptic drugs, which were maintained unchanged for the following 6 months. Epileptic negative myoclonus disappeared in all patients 15 to 30 days after ethosuximide was started. Plasma ethosuximide levels ranged from 55 to 89 micrograms/mL. The clinical response was not influenced by the patients' preexisting treatment or by the etiology of the epilepsy. No side effects were observed, and none of the patients presented a recurrence of epileptic negative myoclonus during follow-up. Furthermore, in five patients we observed the disappearance of partial seizures; in the remaining patients seizures were reduced by more than 75%. Electroencephalograms showed a decrement or disappearance of focal paroxysmal abnormalities. Our results suggest that ethosuximide is effective in the treatment of epileptic negative myoclonus and that it should be considered as a first-choice drug in the treatment of this motor disorder.

A potential anti-asthmatic drug, CR 2039, enhances the anticonvulsive activity of some antiepileptic drugs against pentetrazol in mice

CR 2039 (4-(1H-tetrazol-5-yl)-N-[4-(1H-tetrazol-5-yl]phenylbenzam ide), in doses of 10, 20, and 100 mg/kg i.p., did not modify the seizure pattern observed after subcutaneous pentetrazol, administered at its CD97 of 90 mg/kg for the clonic phase. However, when combined with antiepileptic drugs, this phenylbenzamide derivative (20 mg/kg) converted the subprotective doses of ethosuximide (100 mg/kg) or valproate (100 mg/kg) against the clonic phase into anticonvulsive ones. The protection observed was comparable to that noted after doubling the doses of these antiepileptics. Also, a combination of valproate (100 mg/kg) with CR 2039 (10 mg/kg) resulted in a clear-cut protection against clonic seizures induced by pentetrazol. The protective efficacy of clonazepam was not affected by the phenylbenzamide derivative up to 40 mg/kg. The potentiation of the anticonvulsive activity of ethosuximide or valproate was not accompanied by increased adverse effects, evaluated in the chimney test (motor coordination) and passive avoidance task (long-term memory). Finally, CR 2039 (20 mg/kg) did not alter the plasma levels of the antiepileptic drugs studied, which speaks against a pharmacokinetic mechanism in the observed results. In conclusion, CR 2039 seems devoid of a hazardous influence of the anti-asthmatic drug, aminophylline, on the anticonvulsive effects of conventional antiepileptics.

Effect of enzyme inducing anticonvulsants on ethosuximide pharmacokinetics in epileptic patients

1. To assess the effect of enzyme inducing anticonvulsants on ethosuximide pharmacokinetics, plasma ethosuximide concentrations after a single oral dose (500 mg) of the drug were compared in 12 healthy control subjects and 10 epileptic patients receiving chronic therapy with phenobarbitone, phenytoin and/or carbamazepine. 2. Compared with controls, epileptic patients showed markedly shorter ethosuximide half-lives (29.0 +/- 7.8 vs 53.7 +/- 14.3 h, means +/- s.d., P < 0.001) and higher apparent oral clearance (CL/F) values (15.3 +/- 3.8 vs 9.2 +/- 1.9 ml kg-1 h-1, P < 0.001). The apparent volume of distribution (V/F) of ethosuximide was slightly lower in the patients than in controls (0.6 +/- 0.1 vs 0.7 +/- 0.1 l kg-1, P < 0.05). 3. These findings provide evidence that ethosuximide elimination is increased by enzyme inducing anticonvulsants, the effect probably being mediated by stimulation of cytochrome CYP3A activity. 4. The enhancement of ethosuximide clearance in patients comedicated with enzyme inducing anticonvulsants is likely to be clinically relevant. Higher ethosuximide dosages will be required to achieve therapeutic drug concentrations in these patients.

Ethosuximide enantiomers in pregnancy and lactation

A gas-chromatographic method was used to determine plasma concentrations of the ethosuximide enantiomers during three pregnancies in two epileptic women, in samples from the umbilical cord in one, and in breast milk in two patients. The ratio of the two enantiomers of ethosuximide ranged from 1.00 to 1.36 and was apparently unaffected by pregnancy, passage into breast milk, and transfer over the placenta. Hence, determination of total ethosuximide concentrations appear to be sufficient for therapeutic drug monitoring during pregnancy and lactation.

Factors affecting the determination of drugs and endogenous low molecular mass compounds in human serum by micellar electrokinetic capillary chromatography with direct sample injection

Factors influencing the establishment of an analytical window in front of the solubilized proteins in micellar electrokinetic capillary chromatography (MECC) with direct serum injection (DSI) are discussed. Both drugs and endogenous low molecular mass compounds eluting within the analytical window are identified concurrently by multi-wavelength absorption detection. Variables such as the concentration of the micelle forming substance, ionic strength, applied voltage, initial sample zone length, capillary length, selected buffer additives, insufficient renewal of the buffer in the anodic buffer vial and sample matrix are shown to impact MECC of endogenous compounds and model drugs, such as antiepileptics. For two drugs eluting within the analytical window, phenobarbital and ethosuximide, serum levels determined by DSI with external calibration are shown to compare well with levels obtained after liquid-liquid extraction and internal calibration (use of an internal standard). In addition, reproducibility of both assays is excellent. The limit of employing DSI is demonstrated with the determination of the hydrophobic drug phenytoin. Using an automated, commercial instrument and naproxen as model drug, high-speed MECC separations of high reproducibility and with a throughput of 12-15 samples per h are presented.

The use of antiepileptic drug levels in children: a survey of Canadian pediatric neurologists

There are 60 pediatric neurologists in Canada. Replies were received from 56 in response to a survey regarding the use and perceived value of antiepileptic drug (AED) levels. AED levels are frequently ordered and influence clinical care. There were, however, discrepancies among pediatric neurologists regarding the upper and lower limits of the "therapeutic ranges" and the clinical application of levels. We suggest that both the value and use of AED levels needs further study.

Determination of phenobarbital, ethosuximide, and primidone in human serum by micellar electrokinetic capillary chromatography with direct sample injection

The determination of antiepileptic drugs in human serum by micellar electrokinetic capillary chromatography (MECC) with direct sample injection is discussed. Nanoliter quantities of patient sera are applied to the beginning of a fused silica capillary filled with a phosphate/borate buffer (pH 9.2) containing 75 mM sodium dodecylsulfate. Upon application of an electric field along the capillary, endogenous and drug substances are transported toward the cathode and separate into distinct zones which are detected by on-column UV absorption. Phenobarbital, ethosuximide, and primidone are shown to elute in front of the solubilized proteins, thus permitting quantitation of these drugs without any sample pretreatment. For phenobarbital and ethosuximide, MECC data obtained using the external standard method and peak areas as the basis for quantitation are shown to be in excellent agreement with those of nonisotopic immunoassays and, for ethosuximide, also with those of high-performance liquid chromatography. The correlation coefficients (n = 50) are between 0.972 and 0.986. Intraday and interday reproducibility data are 2.0-4.5% and 4.5-8.0%, respectively. For primidone, insufficient samples have been available for a comprehensive comparison of MECC data with those of other analytic techniques.

The effects of cobalt chloride, SKF-525A, and N-(3,5-dichlorophenyl)succinimide on in vivo hepatic mixed function oxidase activity as determined by single-sample plasma clearances

1. Four drugs--antipyrine, theophylline, quinidine, and ethosuximide--were used as probes of in vivo hepatic mixed function oxidase (MFO) activity. Functional MFO activity was evaluated by estimating probe clearances subsequent to pretreatment of rats with either cobalt chloride, SKF-525A, or N-(3,5-dichlorophenyl) succiminide (NDPS). 2. Clearances of each probe were estimated from single plasma concentration measurements. Each pretreatment altered the clearances of this panel of probes in a different way. NDPS pretreatment increased theophylline clearance while slowing quinidine and ethosuximide clearances. SKF-525A slowed all probe clearances except for ethosuximide. Cobalt chloride slowed all probe clearances except for theophylline. 3. The use of multiple probes as substrates for the hepatic cytochrome P-450 system can provide some insight into the functional consequences of xenobiotic exposures on that system. Moreover, xenobiotic-induced functional changes on hepatic MFO when assessed in vivo appear to be modest relative to changes in in vitro activity or hepatic cytochrome P-450 content. This minimally invasive multiprobe method may be useful for assessing xenobiotic influences on human hepatic MFO in vivo.

High-performance liquid chromatographic determination of ethosuximide in plasma

A HPLC method for a rapid determination of ethosuximide in plasma is described. A sample is extracted with ethyl ether from acidic medium with glutethimide as internal standard and injected onto analytical RP-18 column with spectrophotometric monitoring at 244 nm.

Correlation between ethosuximide brain levels measured by high performance liquid chromatography and its antiepileptic potential

The concentration-time curve of ethosuximide (ESM) in several brain zones of Wistar rats (cortex, midbrain, cerebellum) showed a clear difference from the time course of the drug levels in plasma after administration of 50 mg/kg injected by intraperitoneal route. The brain/plasma ratio in the cortex changes drastically from 2.04 +/- 0.14 (5 m after injection) to 0.14 +/- 0.01 (2 h after injection). Similar behaviour was observed in the brain/plasma ratio of midbrain and cerebellum. The antiepileptic potential of the ESM was closely related to the evolution of the drug time-course in the brain. Reversible opening of the blood-brain barrier modifies the cortex/plasma ratio from 0.14 +/- 0.01 to 0.79 +/- 0.11 (2h after ESM injection). Similar changes were observed in midbrain and cerebellum. The results suggest that the blood-brain barrier plays some part in the time-course of ESM in the brain, and emphasizes the role of brain levels measured by high performance liquid chromatography (HPLC) in clarifying the clinical profile of the drug.

Nonstereoselective disposition of ethosuximide in humans

The total concentration of ethosuximide varied between 80 and 770 mumol/L in plasma samples obtained from 33 patients on long-term treatment with the racemic drug. The ratios between the two enantiomers measured by chiral gas chromatography in the same samples were close to unity (mean +/- SD = 1.06 +/- 0.14; range = 0.76-1.39). This suggests that the disposition of ethosuximide in humans is not stereoselective and that the measurement of total concentrations of ethosuximide is sufficient for therapeutic monitoring.

Development of tolerance to the anticonvulsant effect of valproate but not to ethosuximide in a rat model of absence epilepsy

Ethosuximide and valproic acid were tested for 4 and 2 weeks, respectively, in rats showing the spontaneous spike-wave syndrome. Ethosuximide suppressed the syndrome at plasma concentrations of 75-100 micrograms/ml. High doses of valproate (170 mg/kg i.p., t.i.d.), resulting in plasma concentrations of about 500 micrograms/ml, were necessary to suppress the syndrome, but signs of tolerance to the drug developed from day 5. Tolerance was confined to the number of spike-wave complexes, whereas the duration of the discharges was shortened to 60% of the control value, without there being signs of tolerance. It is assumed that increases in cerebral GABA, induced by the high concentration of valproate, counteracted the anti-absence effect of the drug in this model.

Ethosuximide alters intrathalamic and thalamocortical synchronizing mechanisms: a possible explanation of its antiabsence effect

Effects of systemic administration of a single dose (50 mg/kg) of ethosuximide (ESM) on extracellularly recorded thalamic (nucleus centralis lateralis, CL; nucleus reticularis, RE) and cortical neurons and on cortical EEG activity of acute cats, have been studied. In intact animals ESM led to: (a) desynchronization of cortical EEG activity; (b) reduction of cortical recruiting responses to 6 Hz stimulation of nucleus centralis medialis (CeM); (c) increased firing rate of CL units; and (d) reduction of incremental responses (IRs) of CL neurons to CeM stimulation. In midbrain reticular formation (MRF)-lesioned animals, ESM induced: (a) reduction of cortical spindle waves; (b) increment of their intraburst frequency; (c) reduction of the IR of CL neurons to 3 and 6 Hz CeM stimulation; (d) shortening of the inhibitory period following each response; and (e) no increment of spontaneous firing rate of CL units. Moreover, ESM led to important changes in the spontaneous activity of RE neurons: spike barrages, typical of these neurons in MRF-lesioned animals, became less frequent and of longer duration, being also constituted by longer interspike intervals. However, responses of RE neurons to low frequency CeM stimulation, when present, did not show any incremental phenomenon and appeared unchanged after ESM. Responses of cortical neurons to paired stimuli, applied with different interstimulus intervals, to nucleus ventralis posterolateralis or in animals with isolated cortex, to subcortical white matter, disclosed a reduction of the cortical inhibitory period following the response to the conditioning stimulus. These data suggest that ESM exerts a moderate diffuse anti-inhibitory action at both cortical and thalamic levels and an activating effect on MRF, which could also be accomplished through disinhibition. The reduction of the inhibitory phases in thalamic nuclei would alter spontaneous intrathalamic synchronizing mechanisms, leading to a decreased effectiveness of thalamocortical volleys, which are believed to be fundamental for the appearance of cortical spike and wave discharges. This hypothesis would therefore explain the specific efficacy of ESM against absence seizures.

Simultaneous measurement of ethosuximide and phenobarbital in brain tissue, serum and urine by HPLC

A simple rapid method for simultaneous ethosuximide and phenobarbital assay in brain tissue, serum and urine has been developed. Extraction of samples from brain tissue and serum were performed with dichloromethane at low pH in the presence of an excess of ammonium sulfate. Glucuronide conjugates in urine samples were hydrolyzed by enzymatic cleavage with beta-glucuronidase and then extracted with dichloromethane. The extracts were analyzed using a Spherisorb 5 ODS column and a mixture of acetonitrile, methanol and phosphate buffer (21:24:55, v/v) as eluent. No interference was encountered and the method is both precise and reproducible.

[Quantitative analysis of anticonvulsants by gas-liquid chromatography]

Chromatographic methods of a quantitative determination of phenobarbital, carbamazepine, sodium valproate and ethosuximide in the blood plasma are proposed. The methods are characterized by a good reproducibility and a high sensitivity with a small volume of the sample under study.

Single sample estimate of ethosuximide clearance

Ethosuximide was administered in single oral doses (ca. 15 mg/kg) to each of 12 healthy, male subjects. Serial blood and salivary ethosuximide concentrations were measured by a polarization immunofluorescence technique. The following parameters were estimated: CL/F, V/F, and plasma disappearance t1/2. Mean (+/- SD) values were 0.0091 (+/- 0.0023) l X h-1 X kg-1, 0.063 (+/- 0.12) l X kg-1, and 48.8 (+/- 9.3) h, respectively. Estimates of CL/F (CL/F) were calculated from single plasma or single salivary measurements. When V/F was set at 0.63 l X kg-1 and the 120-h plasma concentration was used, CL/F was 0.0091 (+/- .0018) l X h-1 X kg-1. CL/F was 0.0089 (+/- .0020) when the 120-h salivary concentration was used. These data demonstrate that under specified conditions ethosuximide clearance (CL/F) can be estimated from a single measurement of ethosuximide in either plasma or saliva, thereby permitting ethosuximide to be used safely and noninvasively as a probe of hepatic mixed function oxidase activity in humans.

Fluorescence polarization immunoassay for ethosuximide evaluated and compared with two other immunoassay techniques

We evaluated a new fluorescence polarization immunoassay (FPIA) for ethosuximide in the Abbott TDx and compared results with those by two other ethosuximide immunoassays, EMIT (Syva Co.) and aca (DuPont). The FPIA assay produced within- and between-day CVs of less than 5% at the low, medium, and high ranges of the standard curve. For the ethosuximide FPIA assay the standard curve was stable during the 47 days of the study. By all three methods, we analyzed 100 serum and plasma samples from patients who were receiving ethosuximide. The coefficient of determination (r2) for TDx versus EMIT was 0.973 (slope, 0.96; intercept, -0.80); for TDx vs aca it was 0.985 (slope, 1.00; intercept, -2.44); both relationships were statistically significant (p less than 0.05). Values for patient's specimens were significantly lower by the TDx than by the aca or EMIT methods (p less than 0.05).

Evaluation of treatment in typical absence seizures. The roles of long-term EEG monitoring and ethosuximide

Eleven children with typical absence seizures were studied clinically and by repeated 24-h EEGs with portable cassette tape recorder before and during anticonvulsant treatment. The history, the observation of seizures and the amount of spike-and-wave activity (episodes greater than 3 sec) were studied in relation to the plasma levels. The EEG revealed spike-and-wave episodes, considered as seizures, in a higher frequency than the number of absences reported by the parents. Twenty-four hour EEG recording was however not superior to long term observation by relatives in establishing freedom from absences. The drug primary used was ethosuximide. Eight of eleven children responded completely on this drug, i.e. no absences observed and EEG was normalized. Of two children in whom the therapy was changed to sodium valproate, one responded completely and one partly. The relation between the ethosuximide dosage given and the plasma concentration level was good. Two cases responded at low plasma levels (less than 200 mumol/l). Tonic-clonic seizures occurred in 3/11 children.

The simultaneous determination of five anti-epileptic drugs in plasma by high performance liquid chromatography

A high performance liquid chromatographic (HPLC) method is described for the simultaneous determination in plasma of carbamazepine, ethosuximide, phenobarbitone, phenytoin and primidone. The procedure involved the preliminary extraction of the drugs and the internal standard (hexobarbitone) into a mixture of organic solvents at pH 2. The dried extract was dissolved in methanol and 25 microliter of the concentrate was injected into a liquid chromatograph linked to a reverse-phase column. The drugs and internal standard were eluted from the column by a mixture of methanol and water, as the mobile phase, and detected with a UV spectrophotometer at 204 nm. This HPLC assay, which required 0.5 ml of plasma, was used to determine anti-epileptic drugs levels in 136 mentally-handicapped children suffering from epilepsy. Comparison between different batches of assays showed that recovery of the drugs from plasma varied from 60 to 98% and with a coefficient of variance between 3.8 to 9.8%. Detection limit of the method ranged from 2 micrograms ml-1 for primidone, to 1 microgram ml-1 for the remainder of the anti-epileptic drugs.

Simultaneous measurement of ethosuximide, primidone, phenobarbital, phenytoin, carbamazepine, and their bioactive metabolites by liquid chromatography

A simple, isocratic liquid-chromatographic method was developed for simultaneously measuring ethosuximide, primidone, phenobarbital, phenytoin, carbamazepine, and their bioactive metabolites within 10 min. The chromatographic system involves a Waters' Radial-NOVA PAK C18 reversed-phase column and acetone/methanol/acetonitrile/10 mmol/L phosphate buffer (10/21/8/61 by vol, pH adjusted to 7.95 with NaOH) as mobile phase. The antiepileptic drugs are extracted from 50 microL of serum by mixing with 50 microL of acetonitrile containing 10 mg of tolybarb per liter as internal standard. After centrifugation, 20 microL of the supernate is injected onto the column and eluted with mobile phase at the rate of 2.8 mL/min at ambient temperature. The column effluent is monitored at 200 nm. The method can detect the five antiepileptic drugs in concentrations as low as 0.5 mg/L. Analytical recovery ranges from 98 to 102%. Within-run CV ranged from 2.9 to 5.8% and between-run CV from 4.7 to 7.1%. The method can also be used to measure N-desmethyl-methsuximide, chloramphenicol, and pentobarbital.

[Plasma levels of antiepileptic agents in the treatment of epilepsy]

From a total of 560 different epileptics visited during 16 months, we have practiced 140 plasmatic dosifications of antiepileptic drugs according to EMIT technic. The antiepileptic drugs studied were: PB, DPH, PRM, VPA, CBZ and ESM. In this study only the 70 patients treated with PB in monotherapy or combined with DPH, CBZ, VPA and PRM are considered. From the 70 patients, 45 have been controlled; from them 21 (46,5%) did not reach efficient levels from anyone of the used antiepileptics. From the 70 patients 25 have been partially or bad controlled, 20 of them (80%) had PB in efficient levels, 13 (52%) had the other antiepileptic in efficient levels, 12 (47%) had both antiepileptics in efficient levels and 4 (16%) had no antiepileptic drug in efficient levels in spite of using the efficient dose in mg/Kg/day. The conclusions of this results are: we reached a good effect by using PB alone or combined under the considered efficient levels in a 46.5% of the patients; the bad controlled patients, kept on being bad controlled in spite of having 80% of them PB, the other antiepileptic or both in efficient levels.

Statistical analysis of performance of a liquid chromatographic assay of anticonvulsants involving solvent-demixing extraction and reciprocal internal standardization

Analysis of variance both factorial and nested was used to validate a HPLC method intended for routine clinical assay of ethosuximide, phenobarbital, phenytoin and carbamazepine. Drugs were salted out, together with the solvent, from 0.5 ml acetonitrile-deproteinized plasma samples with 80-90% recovery. The acetonitrile extraction solution contained a known amount of all four drugs. This added amount of any drug was used when absent from plasma as an internal standard for those present and when present as a calibrator. Results showed that assay precision was acceptable (CV 6%) over and above the therapeutic range when additions did not exceed the lower therapeutic plasma level and if as many replications were made as there were drugs to assay. In return for some loss of sensitivity, reciprocal internal standardization provides increased assay reliability owing to the usual availability of more than one internal standard and to easier identification of interfering chromatographic peaks.

Pharmacokinetics of antiepileptic drugs

The rational use of antiepileptic drugs requires the consideration of their pharmacokinetics, which may be influenced by the physiological and pathological factors. Pharmacokinetic interactions between antiepileptic drugs may lead to considerable fluctuation in plasma drug concentration, and monotherapy is often preferable. The absorption of phenytoin depends on pharmaceutical formulation. Phenytoin is highly bound to plasma proteins, thus the changes in the unbound fraction are of clinical significance. The saturation kinetics of its metabolism and drug interactions have further consequences. Carbamazepine is well absorbed and largely metabolized. Due to the autoinduction its half-life shortens in chronic administration. Valproate is highly, but variably bound to plasma proteins. It is eliminated mainly by metabolism. Due to the long half-life of phenobarbital its plasma concentrations change slowly, and time to the steady-state may be up to 30 days, if no loading dose is given. Primidone is partly metabolized to phenobarbital, and at steady-state plasma concentration of phenobarbital often exceeds that of primidone. Diazepam, clonazepam and nitrazepam are largely bound to plasma proteins and extensively metabolized with the half-lives of 20 to 60 hours.

Adaptation of microvolume EMIT assays for theophylline, phenobarbital, phenytoin, carbamazepine, primidone, ethosuximide, and gentamicin to a CentrifiChem chemistry analyzer

We have developed microvolume EMIT procedures for theophylline, phenobarbital, phenytoin, carbamazepine, primidone, ethosuximide, and gentamicin using a centrifugal analyzer (CentrifiChem and Pipettor 1000) to reduce the manufacturer's recommended manual reagent consumption by one-sixth. In addition to developing the EMIT procedure, the performance of the analyzer and pipettor were verified. The analyzer and pipettor are capable of producing within-run precision at a 3-microliters sample volume and 210-microliters analyzer cuvette volume equal to or less than 1.5%. The performance of the EMIT procedures on the analyzer yielded spike drug recoveries of 90.8 to 106.1% for drug concentrations throughout the calibration concentration range of each assay. The percent error on standard reference material of the National Bureau of Standards ranged from a +12.0% to a -0.6% for ethosuximide, phenobarbital, phenytoin, and primidone. Patient comparison data yielded slopes from 0.930 to 1.110 for all assays. The other important feature of the adapted EMIT assay is its simplicity for use on a routine basis.

Simultaneous high performance liquid-chromatographic determination of carbamazepine, carbamazepine-10,11-epoxide, ethosuximide, phenobarbital, phenytoin, primidone and phenylethylmalonamide in plasma

A common methodology is reported for the determination of five major anticonvulsants (carbamazepine, ethosuximide, phenobarbital, phenytoin, primidone) and their active metabolites (carbamazepine-10,11-epoxide, phenylethylmalonamide) in 30 microliters of plasma. After a single step of deproteinisation and extraction with acetonitrile, leading to an almost complete recovery of all the analytes, 5 microliters is injected on a reversed-phase column (Lichrosorb RP-18, 5 microns). The anticonvulsants are eluted isocratically at a column temperature of 50 degrees C with a mobile phase consisting of acetonitrile/phosphate buffer p' 6.9 (40/60 by vol), and monitored at 208 nm. Quantitation, using peak height or peak area, is based on the ratio of analyte to internal standard (allylisobutylbarbital) referenced to a serum-based multiple drug standard. The composition and pH of the mobile phase, temperature of the column, choice of wavelength of detection and size of the column material are crucial for the optimal separation of these five drugs and their two active metabolites in a chromatographic time of only 12 min, without sacrificing high sensitivity and column life.

Simultaneous very fast liquid-chromatographic analysis of ethosuximide, primidone, phenobarbital, phenytoin, and carbamazepine in serum

We describe a sensitive, specific, and very fast liquid-chromatographic assay for simultaneously determining five anticonvulsants (ethosuximide, primidone, phenobarbital, phenytoin, and carbamazepine) by using commercially available 5- or 3-microns particle size reversed-phase columns and a microflow-cell-equipped ultraviolet detector. The anticonvulsant drugs are extracted from 200 microL of serum containing 50 mg of cyclopal per liter as an internal standard, by elution from a Bond-Elut (Analytichem International, Harbor City, CA 90710) column with 300 microL of methanol. A 5-microL aliquot of the eluate is applied to an analytical column and eluted with a mobile phase of acetonitrile/methanol/phosphate buffer, 20 mmol/L, pH 3.7 (13.5/35/51.5 by vol), at a flow rate of 3.0 mL/min and at 50 degrees C. Detection is at 210 or 195 nm. The chromatography is complete in less than 2.5 min with the 5-microns-particle column, and in less than 1.4 min with the 3-microns-particle column. The sensitivity of the method for all drugs is less than 1 mg/L. Analytical recovery of drugs added to serum ranged from 92 to 109% for concentrations up to 200 mg/L. Between-run precision (CV) ranged from 1.3 to 4.1%.

Logit-log calibration curves for EMIT assays

The logit-log and four-parameter logistic procedures when appropriate for calculation of enzyme-multiplied immunoassay (EMIT) data have the advantage that they can be applied regardless of the kinetic analyzer or reaction conditions. To use these procedures correctly one must determine the change in absorbance at an infinite drug concentration (delta A infinity). The marked variation of delta A infinity with equipment and reaction conditions and the difficulty in determining this value have hindered broad use of these otherwise universally applicable procedures. We have evaluated two simple methods for determining delta A infinity, both based on its equivalence to delta A in the absence of specific antibody: (1) cross-kit reaction using antibody/substrate and enzyme-drug reagents from kits for different drugs, and (2) substitution of an antibody-free substrate reagent with composition based on direct analysis. The cross-kit procedure was tested with EMIT assays for phenobarbital, primidone, phenytoin, carbamazepine, ethosuximide, and theophylline. In some cases an unexpected type of cross-reaction occurred, giving an erroneously low value for delta A infinity. The antibody-free substrate reagent always permitted accurate determination of delta A infinity.

A rapid procedure for the simultaneous estimation of the anticonvulsant drugs, ethosuximide, phenobarbitone, phenytoin, and carbamazepine in serum using high-pressure liquid chromatography

A rapid isocratic high-pressure liquid chromatography procedure for the analysis of ethosuximide, phenobarbitone, phenytoin, and carbamazepine in serum is described. The method employs a single extraction from serum; alumina treatment of this extract eliminates interference from fast-eluting compounds, allowing rapid chromatography. A linear response is obtained for drug concentrations up to three times the upper limit of the therapeutic ranges. Within-batch and between-batch precisions for the means of these ranges varied from 2.2 to 5.5% and from 3.1 to 7.5%, respectively.

Ethosuximide kinetics: possible interaction with valproic acid

Ethosuximide kinetics were determined in six normal healthy adults after a single dose (phase 1) and at steady-state (phase 2). After the completion of phase 2, valproic acid was added to the ethosuximide regimen (phase 3) to assess the possibility of drug interaction. Between phases 1 and 2 total clearance fell from 13.1 to 11.1 ml/hr/kg (P less than 0.05) and nonrenal clearance fell from 10.1 to 8.3 ml/hr/kg (P less than 0.05). When valproic acid was added (phase 3) there was no further change in total or nonrenal clearance (11.2 and 8.3 ml/hr/kg). To assess the possibility of nonlinear ethosuximide kinetics a review was conducted of patients who received ethosuximide as sole therapy for absence seizures. Of 106 patients, 10 met the required criterion that defined steady state. Data from seven of the 10 patients showed evidence of a nonlinear relationship when steady-state ethosuximide concentrations were plotted against dose.

Ethosuximide plasma concentrations: influence of age and associated concomitant therapy

The relationship between oral dose and plasma concentration of ethosuximide was evaluated retrospectively in 198 epileptic patients aged 2.5 to 34 years. Age appears to be a major factor in determining the ethosuximide plasma level/dose (L/D) ratio. Children younger than 10 years had men L/D ratios significantly lower (p less than 0.0003) than adolescents (10 to 15 years of age) and adults (16 to 34 years of age). Associated antiepileptic therapy reduced the ethosuximide L/D ratio: mean ethosuximide L/D ratios were significantly lower in patients also taking primidone (p less than 0.0005) or valproic acid (p less than 0.02). The correlation between the dose of ethosuximide administered and the plasma concentration was significant in the 3 age groups considered (p less than 0.0004), but the wide scattering of individual plasma concentrations makes it impossible to predict what plasma concentration of ethosuximide will be obtained after a given dose. For this reason, routine monitoring of ethosuximide plasma concentrations still appears to be necessary, especially in children and patients on polytherapy.