Professional Documents
Culture Documents
Antiepileptic Drugs
American Epilepsy Society
P-Slide 1
Definitions
P-Slide 2
Antiepileptic Drug
P-Slide 3
History of Antiepileptic
Drug Therapy in the U.S.
1857 - Bromides
1912 - Phenobarbital
1937 - Phenytoin
1954 - Primidone
1960 - Ethosuximide
P-Slide 4
History of Antiepileptic
Drug Therapy in the U.S.
1974 - Carbamazepine
1975 - Clonazepam
1978 - Valproate
1993 - Felbamate, Gabapentin
1995 - Lamotrigine
1997 - Topiramate, Tiagabine
1999 - Levetiracetam
2000 - Oxcarbazepine, Zonisamide
P-Slide 5
Antiepileptic Drug Therapy
Structures of Commonly Used AEDs
P-Slide 7
Antiepileptic Drug Therapy
Structures of Commonly Used AEDs
Levetiracetam
Oxcarbazepine
Zonisamide
P-Slide 8
Antiepileptic Drug Therapy
Structures of Commonly Used AEDs
■ Pregabalin
P-Slide 9
Cellular Mechanisms of
Seizure Generation
P-Slide 10
AEDs: Molecular and
Cellular Mechanisms
Phenytoin, Carbamazepine
• Block voltage-dependent sodium channels at high firing
frequencies
Barbiturates
• Prolong GABA-mediated chloride channel openings
• Some blockade of voltage-dependent sodium channels
Benzodiazepines
• Increase frequency of GABA-mediated chloride channel
openings
P-Slide 11
AEDs: Molecular and
Cellular Mechanisms
Felbamate
• May block voltage-dependent sodium channels at high
firing frequencies
• May modulate NMDA receptor via strychnine-insensitive
glycine receptor
Gabapentin
• Increases neuronal GABA concentration
• Enhances GABA mediated inhibition
Lamotrigine
• Blocks voltage-dependent sodium channels at high firing
frequencies
• May interfere with pathologic glutamate release
P-Slide 12
AEDs: Molecular and
Cellular Mechanisms
Ethosuximide
• Blocks low threshold, “transient” (T-type) calcium channels
in thalamic neurons
Valproate
• May enhance GABA transmission in specific circuits
• Blocks voltage-dependent sodium channels
Vigabatrin
• Irreversibly inhibits GABA-transaminase
P-Slide 13
AEDs: Molecular and
Cellular Mechanisms
Topiramate
• Blocks voltage-dependent sodium channels at high firing
frequencies
• Increases frequency at which GABA opens Cl- channels
(different site than benzodiazepines)
• Antagonizes glutamate action at AMPA/kainate receptor
subtype
• Inhibition of carbonic anydrase
Tiagabine
• Interferes with GABA re-uptake
P-Slide 14
AEDs: Molecular and
Cellular Mechanisms
Levetiracetam
• Binding of reversible saturable specific binding site
• Reduces high-voltsge- activated Ca2+ currents
• Reverses inhibition of GABA and glycine gated currents
induced by negative allosteric modulators
Oxcarbazepine
• Blocks voltage-dependent sodium channels at high firing
frequencies
• Exerts effect on K+ channels
Zonisamide
• Blocks voltage-dependent sodium channels and
T-type calcium channels P-Slide 15
AEDs: Molecular and
Cellular Mechanisms
Pregabalin
• Increases neuronal GABA
• Increase in glutamic acid decarboxylase
• Decrease in neuronal calcium currents by binding of alpha 2
delta subunit of the voltage gated calcium channel
P-Slide 16
The GABA System
The GABA
system and its
associated
chloride channel
P-Slide 18
The Cytochrome P-450
Enzyme System
Inducers Inhibitors
phenobarbital erythromycin
primidone nifedipine/verapamil
phenytoin trimethoprim/sulfa
carbamazepine propoxyphene
tobacco/cigarettes cimetidine
valproate
P-Slide 19
The Cytochrome P-450
Enzyme System
P-Slide 20
The Cytochrome P-450
Isozyme System
The enzymes most involved with drug
metabolism
Nomenclature based upon homology of amino
acid sequences
Enzymes have broad substrate specificity, and
individual drugs may be substrates for several
enzymes
The principle enzymes involved with AED
metabolism include CYP2C9, CYP2C19,
CYP3A4
P-Slide 21
Drug Metabolizing Enzymes:
UDP- Glucuronyltransferase (UGT)
P-Slide 22
Drug Metabolizing
Isozymes and AEDs
P-Slide 23
Enzyme Inducers/Inhibitors:
General Considerations
P-Slide 24
Pharmacokinetic Principles
P-Slide 25
AED Inducers: General
Considerations
Results from synthesis of new enzyme
Tends to be slower in onset/offset than inhibition
interactions
Broad Spectrum Inducers:
− Carbamazepine
− Phenytoin
− Phenobarbital/primidone
Selective CYP3A Inducers:
− Felbamate, Topiramate, Oxcarbazepine
P-Slide 26
Inhibition
P-Slide 27
AED Inhibitors
Valproate
− UDP glucuronosyltransferase (UGT)
⇑ plasma concentrations of Lamotrigine, Lorazepam
− CYP2C19
⇑ plasma concentrations of Phenytoin, Phenobarbital
Topiramate & Oxcarbazepine
− CYP2C19
⇑ plasma concentrations of Phenytoin
Felbamate
− CYP2C19
⇑ plasma concentrations of Phenytoin, Phenobarbital
P-Slide 28
Hepatic Drug Metabolizing
Enzymes and Specific AED
Interactions
P-Slide 29
Isozyme Specific Drug
Interactions
Category CYP3A4 CYP2C9 CYP2C19 UGT
P-Slide 30
Therapeutic Index
• Limited data
• Broad generalization
• Individual differences
P-Slide 31
Steady State and Half Life
P-Slide 33
AED Serum Concentrations
P-Slide 34
Potential Target Range of AED
Serum Concentrations
P-Slide 35
Potential Target Range of AED
Serum Concentrations
P-Slide 36
AEDs and Drug Interactions
Although many AEDs can cause pharmacokinetic
interactions, several agents appear to be less
problematic.
P-Slide 37
Pharmacodynamic Interactions
P-Slide 38
Pharmacokinetic Interactions:
Possible Clinical Scenarios
P-Slide 39
Pharmacokinetic Factors
in the Elderly
P-Slide 41
Pharmacokinetics in Pregnancy
Faster metabolism
P-Slide 42
Adverse Effects
Acute dose-related—reversible
Idiosyncratic—
• uncommon rare
• potentially serious or life threatening
P-Slide 43
Acute, Dose-Related Adverse
Effects of AEDs
P-Slide 44
Acute, Dose-Related Adverse
Effects of AEDs (cont.)
P-Slide 45
Idiosyncratic Adverse
Effects of AEDs
Rash, Exfoliation
Signs of potential Stevens-Johnson syndrome
Hepatic Damage
• Early symptoms: abdominal pain, vomiting, jaundice
• Laboratory monitoring probably not helpful in early
detection
• Patient education
• Fever and mucus membrane involvement
P-Slide 46
Idiosyncratic Adverse
Effects of AEDs
Hematologic Damage
(marrow aplasia, agranulocytosis)
• Early symptoms: abnormal bleeding, acute onset of fever,
symptoms of anemia
• Laboratory monitoring probably not helpful in early
detection
• Patient education
P-Slide 47
Long-Term Adverse
Effects of AEDs
Neurologic:
• Neuropathy
• Cerebellar syndrome
Endocrine/Metabolic Effects
• Vitamin D – Osteomalacia, osteoporosis
• Folate – Anemia, teratogenesis
• Altered connective tissue metabolism or growth
Facial coarsening
Hirsutism
Gingival hyperplasia
P-Slide 48
Pharmacology Resident
Case Studies
P-Slide 49
Pharmacology Resident
Case Studies
P-Slide 50
Case #1 – Pediatric Con’t
P-Slide 51
Case #1 – Pediatric Con’t
P-Slide 52
Case #1 – Pediatric Con’t
P-Slide 53
Case #1 – Pediatric Con’t
P-Slide 54