Pharmacology of Antiepileptic Drugs
Pharmacology of Antiepileptic Drugs
Pharmacology of Antiepileptic Drugs
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<strong>Pharmacology</strong> <strong>of</strong> <strong>Antiepileptic</strong> <strong>Drugs</strong><br />
Melanie K. Tallent, Ph.D.<br />
tallent@drexel.edu
Basic Mechanisms Underlying<br />
Seizures and Epilepsy<br />
Seizure: the clinical manifestation <strong>of</strong> an<br />
abnormal and excessive excitation and<br />
synchronization <strong>of</strong> a population <strong>of</strong> cortical<br />
neurons<br />
Epilepsy: a disease characterized by<br />
spontaneous recurrent seizures<br />
Epileptogenesis: sequence <strong>of</strong> events that<br />
converts a normal neuronal network into an<br />
epileptic network
Simple<br />
Complex<br />
Partial Seizures<br />
localized onset can be determined<br />
Secondary generalized
Simple Partial Seizure<br />
• Focal with minimal spread <strong>of</strong> abnormal<br />
discharge<br />
• normal consciousness and awareness are<br />
maintained
Complex Partial Seizures<br />
Local onset, then spreads<br />
Impaired consciousness<br />
Clinical manifestations vary with site <strong>of</strong><br />
origin and degree <strong>of</strong> spread<br />
– Presence and nature <strong>of</strong> aura<br />
– Automatisms<br />
– Other motor activity<br />
Temporal lobe epilepsy<br />
most common
Secondarily Generalized Seizures<br />
Begins focally, with or without focal neurological<br />
symptoms<br />
Variable symmetry, intensity, and duration <strong>of</strong> tonic<br />
(stiffening) and clonic (jerking) phases<br />
Typical duration up to 1-2 minutes<br />
Postictal confusion and somnolence
In generalized seizures,<br />
both hemispheres are<br />
widely involved from<br />
the outset.<br />
Manifestations <strong>of</strong> the<br />
seizure are<br />
determined by the<br />
cortical site at which<br />
the seizure arises.<br />
Present in 40% <strong>of</strong> all<br />
epileptic Syndromes.<br />
Generalized Seizures
Generalized seizures<br />
• Absence seizures (Petit mal): sudden onset and<br />
abrupt cessation; brief duration, consciousness is<br />
altered; attack may be associated with mild clonic<br />
jerking <strong>of</strong> the eyelids or extremities, postural tone<br />
changes, autonomic phenomena and automatisms<br />
(difficult diagnosis from partial); characteristic 2.5-3.5<br />
Hz spike-and wave pattern<br />
• Myoclonic seizures: myoclonic jerking is seen in a<br />
wide variety <strong>of</strong> seizures but when this is the major<br />
seizure type it is treated differently to some extent from<br />
partial leading to generalized
Generalized Seizures (cont)<br />
• Atonic seizures: sudden loss <strong>of</strong> postural tone;<br />
most <strong>of</strong>ten in children but may be seen in adults<br />
• Tonic-clonic seizures (grand mal): major<br />
convulsions with rigidity (tonic) and jerking<br />
(clonic), this slows over 60-120 sec followed by<br />
stuporous state (post-ictal depression)
Generalized Tonic-Clonic Tonic Clonic Seizures<br />
• Recruitment <strong>of</strong> neurons throughout the cortex<br />
• Major convulsions, usually with two phases:<br />
• 1) Tonic phase: muscles will suddenly tense up, causing the<br />
person to fall to the ground if they are standing.<br />
• 2) Clonic phase: muscles will start to contract<br />
• and relax rapidly, causing convulsions<br />
• Convulsions:<br />
− motor manifestations<br />
− may or may not be present during seizures<br />
− excessive neuronal discharge<br />
• Convulsions appear in Simple Partial and Complex Partial<br />
Seizures if the focal neuronal discharge includes motor centers;<br />
they occur in all Generalized Tonic-Clonic Seizures regardless <strong>of</strong><br />
the site <strong>of</strong> origin.<br />
• Atonic and absence Seizures are non-convulsive<br />
•
Video<br />
http://www.youtube.com/watch?v=frWcJJkXQFM
Status Epilepticus<br />
• More than 30 minutes <strong>of</strong> continuous seizure<br />
activity<br />
• Two or more sequential seizures spanning<br />
this period without full recovery between<br />
seizures<br />
• Medical emergency
<strong>Antiepileptic</strong> Drug<br />
A drug which decreases the frequency and/or<br />
severity <strong>of</strong> seizures in people with epilepsy<br />
Treats the symptom <strong>of</strong> seizures, not the<br />
underlying epileptic condition<br />
Goal—maximize quality <strong>of</strong> life by minimizing<br />
seizures and adverse drug effects<br />
Currently no “anti-epileptogenic” drugs<br />
available
Therapy Has Improved Significantly<br />
• “Give the sick person some blood from a<br />
pregnant donkey to drink; or steep linen in it, dry<br />
it, pour alcohol onto it and administer this”.<br />
– Formey, Versuch einer medizinischen Topographie<br />
von Berlin 1796, p. 193
Current Pharmacotherapy<br />
• Just under 60% <strong>of</strong> all people with epilepsy can<br />
become seizure free with drug therapy<br />
• In another 20% the seizures can be drastically<br />
reduced<br />
• ~ 20% epileptic patients, seizures are refractory<br />
to currently available AEDs
Choosing <strong>Antiepileptic</strong> <strong>Drugs</strong><br />
Seizure type<br />
Epilepsy syndrome<br />
Pharmacokinetic pr<strong>of</strong>ile<br />
Interactions/other medical conditions<br />
Efficacy<br />
Expected adverse effects<br />
Cost
General Facts About AEDs<br />
• Good oral absorption and bioavailability<br />
• Most metabolized in liver but some excreted<br />
unchanged in kidneys<br />
• Classic AEDs generally have more severe CNS<br />
sedation than newer drugs (except<br />
ethosuximide)<br />
• Because <strong>of</strong> overlapping mechanisms <strong>of</strong> action,<br />
best drug can be chosen based on minimizing<br />
side effects in addition to efficacy
Classification <strong>of</strong> AEDs<br />
Classical<br />
• Phenytoin<br />
• Phenobarbital<br />
• Primidone<br />
• Carbamazepine<br />
• Ethosuximide<br />
• Valproate (valproic acid)<br />
• Trimethadione (not currently<br />
in use)<br />
Newer<br />
• Lamotrigine<br />
• Felbamate<br />
• Topiramate<br />
• Gabapentin/Pregabalin<br />
• Tiagabine<br />
• Vigabatrin<br />
• Oxycarbazepine<br />
• Levetiracetam<br />
• Fosphenytoin
Side effect issues<br />
• Sedation - especially with barbiturates<br />
• Cosmetic - phenytoin<br />
• Weight gain – valproic acid, gabapentin<br />
• Weight loss - topiramate<br />
• Reproductive function – valproic acid<br />
• Cognitive - topiramate<br />
• Behavioral – felbamate, leviteracetam<br />
• Allergic - many
Cellular Mechanisms <strong>of</strong><br />
Seizure Generation<br />
emedicine.com
Targets for AEDs<br />
• Increase inhibitory neurotransmitter system—<br />
GABA<br />
• Decrease excitatory neurotransmitter system—<br />
glutamate<br />
• Block voltage-gated inward positive currents—<br />
Na + or Ca ++<br />
• Increase outward positive current—K +<br />
• Many AEDs pleiotropic—act via multiple<br />
mechanisms
Epilepsy—Glutamate<br />
Epilepsy Glutamate<br />
The brain’s major excitatory neurotransmitter<br />
Two groups <strong>of</strong> glutamate receptors<br />
– Ionotropic—fast synaptic transmission<br />
• NMDA, AMPA, kainate<br />
• Gated Ca ++ and Gated Na+ channels<br />
– Metabotropic—slow synaptic transmission<br />
• Regulation <strong>of</strong> second messengers (cAMP and<br />
Inositol)<br />
• Modulation <strong>of</strong> synaptic activity<br />
Modulation <strong>of</strong> glutamate receptors<br />
– Glycine, polyamine sites, Zinc, redox site
Epilepsy—Glutamate<br />
Epilepsy Glutamate
Glutamate Receptors as AED Targets<br />
• NMDA receptor sites as targets<br />
– Ketamine, phencyclidine, dizocilpine block channel<br />
and have anticonvulsant properties but also<br />
dissociative and/or hallucinogenic properties; open<br />
channel blockers.<br />
• AMPA receptor sites as targets<br />
– Since it is the “workhorse” receptor can anticipate<br />
major sedative effects
Felbamate<br />
• Antagonizes the glycine site on the NMDA<br />
receptor and blocks Na+ channels*<br />
• Very potent AED lacking sedative effect (unlike<br />
nearly all other AEDs)<br />
• Associated with rare but fatal aplastic anemia,<br />
hence is restricted for use only in extreme<br />
refractory epilepsy
Topiramate<br />
• Acts on AMPA receptors, blocking the glutamate binding<br />
site, but also blocks kainate receptors and Na+<br />
channels, and enhances GABA currents (highly<br />
pleiotropic*)<br />
• Used for partial seizures, as an adjunct for absence and<br />
tonic-clonic seizures (add-on or alternative to phenytoin)<br />
• Very long half-life (20h)
Epilepsy—GABA<br />
Epilepsy GABA<br />
Major inhibitory neurotransmitter in the<br />
CNS<br />
Two types <strong>of</strong> receptors<br />
– GABAA —post-synaptic, specific<br />
recognition sites, CI- channel<br />
– GABAB —presynaptic autoreceptors,<br />
also postsynaptic, mediated by K +<br />
currents
GABA Receptor<br />
A
Clonazapam<br />
• -Benzodiazepine used for absence seizures<br />
(and sometimes myoclonic): “fourth-line AED”<br />
• -Most specific AED among benzodiazepines,<br />
appearing to be selective for GABAA activation<br />
in the reticular formation leading to inactivation<br />
<strong>of</strong> T-type Ca2+ channels, hence its useful for<br />
absence seizures<br />
• -Sedating; May lose effectiveness due to<br />
development <strong>of</strong> tolerance (≤6 months)
Lorazapam and Diazepam<br />
• Benzodiazepines used as first-line treatment for<br />
status epilepticus (delivered IV – fast acting)<br />
• Sedating
Phenobarbital<br />
– Barbiturate used for partial seizures, especially in<br />
neonates. Oldest <strong>of</strong> the currently used AEDs<br />
– Very strong sedation; Cognitive impairment;<br />
Behavioral changes<br />
– Very long half-life (up to ~5days); #Induces P450<br />
– Tolerance may arise; Risk <strong>of</strong> dependence<br />
– Primidone, another barbiturate metabolized to<br />
Phenobarbital, and Phenobarbital are now seldom<br />
used in initial therapy, owing to side-effects
AEDs That Act Primarily on GABA<br />
Tiagabine<br />
– Interferes with GABA re-uptake<br />
Vigabatrin (not currently available in US)<br />
– elevates GABA levels by irreversibly inhibiting<br />
its main catabolic enzyme, GABAtransaminase
Na+ Channels as AED Targets<br />
• Neurons fire at high frequencies during seizures<br />
• Action potential generation is dependent on Na+<br />
channels<br />
• Use-dependent or time-dependent Na+ channel<br />
blockers reduce high frequency firing without<br />
affecting physiological firing
Na +<br />
A = activation gate<br />
I = inactivation gate<br />
Anticonvulsants:<br />
Mechanisms <strong>of</strong> Action<br />
Voltage-gated sodium channel<br />
I<br />
Open Inactivated<br />
Carbamazepine<br />
Phenytoin<br />
McNamara JO. Goodman & Gilman’s. 9th ed. 1996:461-486.<br />
Na +<br />
X<br />
Na + Na +<br />
I<br />
Lamotrigine<br />
Valproate
AEDs That Act Primarily on Na+<br />
Phenytoin, Carbamazepine<br />
– Block voltage-dependent sodium channels at high firing<br />
frequencies—use dependent<br />
Oxcarbazepine<br />
– Blocks voltage-dependent sodium channels at high<br />
firing frequencies<br />
– Also effects K+ channels<br />
Zonisamide<br />
Channels<br />
– Blocks voltage-dependent sodium channels and T-type<br />
calcium channels
Phenytoin<br />
• First-line for partial seizures; some use for tonicclonic<br />
seizures<br />
• Highly bound to plasma proteins – displaced by<br />
Valproate; #Induces P450 resulting in increase<br />
in its own metabolism, but its metabolism is also<br />
increased by alcohol, diazepam<br />
• Sedating<br />
• Fosphenytoin: Prodrug for Phenytoin, used for<br />
IM injection
Carbamazapine<br />
• A tricyclic antidepressant used for partial<br />
seizures; some use in tonic-clonic seizures<br />
• #Induces P450 resulting in increase in its own<br />
metabolism;<br />
• Sedating; Agranulocytosis and Aplastic anemia<br />
(elderly); Leukopenia (10% <strong>of</strong> patients);<br />
Hyponatremia; Nausea and visual disturbances
Oxcarbazapine<br />
• Newer drug, closely related to Carbamazapine,<br />
approved for monotherapy, or add-on therapy in<br />
partial seizures<br />
• May also augment K+ channels*<br />
• Some #induction <strong>of</strong> P450 but much less than<br />
that seen with Carbamazapine<br />
• Sedating but otherwise less toxic than<br />
Carbamazapine
Zonisamide<br />
• Used as add-on therapy for partial and<br />
generalized seizures<br />
• -Also blocks T-type Ca2+ channels*<br />
• -Very long half-life (1-3days)
Lamotrigine<br />
• Add-on therapy, or monotherapy for refractory<br />
partial seizures<br />
• Also inhibits glutamate release and (perhaps)<br />
Ca2+ channels (=pleiotropic*)<br />
• Metabolism affected by Valproate,<br />
Carbamazapine, Phenobarbital, Phenytoin<br />
• Less sedating than other AEDs; (Severe<br />
dermatitis in 1-2% <strong>of</strong> pediatric patients)
Ca 2+ Channels as Targets<br />
• General Ca2+ channel blockers have not proven<br />
to be effective AEDs.<br />
• Absence seizures are caused by oscillations<br />
between thalamus and cortex that are generated<br />
in thalamus by T-type (transient) Ca 2+ currents
Ethosuximide<br />
• Acts specifically on T-type channels in thalamus,<br />
and is very effective against absence seizures.<br />
• Long half-life (~40h)<br />
• Causes GI disturbances; Less sedating than<br />
other AEDs
Gabapentin and its second generation<br />
derivative Pregabalin<br />
• -Act specifically on calcium channel subunits<br />
called α2δ1. It is unclear how this action leads to<br />
their antiepileptic effects, but inhibition <strong>of</strong><br />
neurotransmitter release may be one<br />
mechanism<br />
• -Used in add-on therapy for partial seizures and<br />
tonic-clonic seizures<br />
• -Less sedating than classic AEDs
What about K+ channels?<br />
• K+ channels have important inhibitory control over<br />
neuronal firing in CNS—repolarizes membrane to<br />
end action potentials<br />
• K+ channel agonists would decrease<br />
hyperexcitability in brain<br />
• So far, the only AED with known actions on K+<br />
channels is valproate<br />
• Retiagabine is a novel AED in clinical trials that<br />
acts on a specific type <strong>of</strong> voltage-dependent K+<br />
channel (M-channel)
Valproate (Valproic Acid)<br />
• First-line for generalized seizures, also used for<br />
partial seizures<br />
• Also blocks Na+ channels and enhances<br />
GABAergic transmission (highly pleiotropic*)<br />
• Highly bound to plasma proteins; #Inhibits P450<br />
• CNS depressant; GI disturbances; hair loss;<br />
weight gain; teratogenic; (rare: hepatotoxic)
Regulation <strong>of</strong> Neurotransmitter release<br />
• Several AED have actions that result in the<br />
regulation <strong>of</strong> neurotransmitter release from the<br />
presynaptic terminal, such as lamotrigine, in<br />
addition to their noted action on ion channels or<br />
receptors.<br />
• Levetiracetam appears to have as its primary<br />
action the regulation <strong>of</strong> neurotransmitter release<br />
by binding to the synaptic vesicle protein SV2A:
Levetiracetam<br />
• -Add-on therapy for partial seizures<br />
• -Short half-life (6-8h)<br />
• -CNS depression
Pleiotropic AEDs<br />
• Many AEDs act on multiple targets, increasing<br />
their efficacy<br />
• Felbamate, lamotrigine, topirmate, valproate
Drug Interactions<br />
• Many AEDs are notable inducers <strong>of</strong> cytochrome<br />
P450 enzymes and a few are inhibitors.<br />
• Of the classic AEDs, phenytoin, carbamazipine,<br />
phenobarbital, and primidone are all strong<br />
inducers <strong>of</strong> cytochrome P450 enzymes. They<br />
are autoinducers, in other words they increase<br />
their own metabolism.<br />
• Valproate inhibits cytochrome P450 enzymes.
Pharmacokinetic Considerations<br />
• Most AEDs undergo complete or nearly complete absorption when<br />
given orally.<br />
• Fosphenytoin (prodrug) may be administered intramuscularly if<br />
intravenous access cannot be established in cases <strong>of</strong> frequent<br />
repetitive seizures<br />
• Diazepam (available as a rectal gel) has been shown to terminate<br />
repetitive seizures and can be administered by family members at<br />
home.<br />
• Phenytoin, fosphenytoin, phenobarbital, diazepam, lorazepam and<br />
valproate are available as IV preparations for emergency use.<br />
• Most AEDs are metabolized in the liver (P450) by hydroxylation or<br />
conjugation. These metabolites are then excreted by the kidney.<br />
Gabapentin undergoes no metabolism and is excreted unchanged<br />
by the kidney.
Treatment <strong>of</strong> Epilepsy<br />
• First consideration is efficacy in stopping<br />
seizures<br />
• Because many AEDs have overlapping,<br />
pleiotropic actions, the most appropriate drug<br />
can <strong>of</strong>ten be chosen to reduce side effects.<br />
Newer drugs tend to have less CNS<br />
depressant effects.<br />
• Potential <strong>of</strong> long-term side effects,<br />
pharmokinetics, and cost are other<br />
considerations
Treatment <strong>of</strong> Epilepsy<br />
• Monotherapy is preferred: better patient<br />
compliance, less adverse effects<br />
• Add-on therapy is <strong>of</strong>ten necessary to<br />
eliminate “break-through” or refractory<br />
seizures
Partial seizures<br />
Simple<br />
Complex<br />
Secondary<br />
Generalized<br />
AED Treatment Options<br />
Primary generalized seizures<br />
Tonic-<br />
Clonic<br />
Tonic<br />
phenytoin, carbamazepine, phenobarbital,<br />
gabapentin, oxcarbazepine, pregabalin<br />
Myoclonic<br />
valproic acid, lamotrigine, topiramate,<br />
(levetiracetam, zonisamide)<br />
Atonic Absence<br />
Ethosuximide<br />
Check notes
Status Epilepticus<br />
• More than 30 minutes <strong>of</strong> continuous seizure<br />
activity<br />
• Two or more sequential seizures spanning<br />
this period without full recovery between<br />
seizures<br />
• Medical emergency
• Treatment<br />
Status Epilepticus<br />
– Diazepam, lorazapam IV (fast, short acting)<br />
– Followed by phenytoin, fosphenytoin, or<br />
phenobarbital (longer acting) when control is<br />
established
Alternative Uses for AEDs<br />
• Gabapentin/pregabalin, carbamazepine—neuropathic<br />
pain<br />
• Lamotrogine, carbamazepine—bipolar disorder<br />
• Leviteracitam, valproate, topirimate, gabapentin—<br />
migraine
Questions?