Pharmacokinetics of New Antiepileptic Drugs

Summary: This article surveys the pharmacokinetic parameters for the new antiepileptic drugs (AEDs): felba-mate, gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and vigabatrin. Compared to the pharmaco kinetics of standard AEDs, these new AEDs have progressed in terms of (a) longer half-lives, permitting once-or twice-daily dosing, (b) greatly reduced potential for drug interactions, thus increasing ease of treatment, and (c) general lack of hepatic enzyme induction, which facilitates polytherapy as well as other aspects of treatment.     

Tiagabine in Clinical Practice

Summary: Among the newly introduced antiepileptic drugs (AEDs), tiagabine (TGB) stands out as a compound with a well-understood and documented mechanism of action. It is a lipophilic derivative of nipecotic acid that blocks γ-aminobutyric acid (GABA) reuptake by inhibition of the GAT-1 transportation system, and that has no other significant pharmacodynamic effect. The relationship between intake and blood levels is linear. Usual daily maintenance doses range from 20 to 50 mg. It is completely absorbed by the gastrointestinal tract, and its half-life is ∼7–9 h. TGB is sensitive to enzyme induction: when coprescribed with enzyme-inducing AEDs, its half-life is shortened to 2–3 h, whereas the daily dosage has to be increased into the upper range. It should be given 3 times per day. Placebo-controlled, double-blind, add-on studies conducted in patients with drug-resistant focal epilepsies have demonstrated its efficacy and overall safety. The clinical benefits appear to persist over time. Data on its use in monotherapy are scanty. The efficacy and tolerability of TGB in the pediatric age still remain to be investigated adequately. In daily practice, TGB appears to be a safe drug, but mild to moderate side effects are frequently seen, especially during titration: these include dizziness and fatigue, and are clearly abated when the drug is absorbed during meals. Titration should be especially slow, no faster than 5 mg weekly. Clinicians also should beware of the possible occurrence of confusion, which may be misdiagnosed as absence status, a short-lasting, quickly reversible central nervous system–related side effect that appears to be correlated with the peak plasma concentrations of TGB. Particularly beneficial indications for TGB and/or AED associations including TGB have not been pointed out, but there is a hint that it works best in temporal lobe epilepsies.     

Tiagabine is neuroprotective in the N171-82Q and R6/2 mouse models of Huntington's disease

Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder characterized by chorea, incoordination, and shortened life-span, and by huntingtin inclusions and neurodegeneration. We previously screened the 1040 FDA-approved compounds from the NINDS compound library and found that a compound, nipecotic acid, significantly reduced mutant huntingtin aggregations and blocked cell toxicity in an inducible cell model of HD. Because nipecotic acid does not cross the blood–brain barrier (BBB), we studied its analogue, tiagabine, which is able to cross the BBB, in both N171-82Q and R6/2 transgenic mouse models of HD. Tiagabine was administered intraperitoneally at 2 and 5 mg/kg daily in HD mice. We found that tiagabine extended survival, improved motor performance, and attenuated brain atrophy and neurodegeneration in N171-82Q HD mice. These beneficial effects were further confirmed in R6/2 HD mice. The levels of tiagabine at effective doses in mouse serum are comparable to the levels in human patients treated with tiagabine. These results suggest that tiagabine may have beneficial effects in the treatment of HD. Because tiagabine is an FDA-approved drug, it may be a promising candidate for future clinical trials for the treatment of HD.     

Interactions between tiagabine and conventional antiepileptic drugs in the rat model of complex partial seizures

This study evaluated the interactions between tiagabine (TGB) and three conventional antiepileptic drugs (AEDs): valproate (VPA), carbamazepine (CBZ), and phenobarbital (PB) in amygdala-kindled rats, a reliable model of complex partial seizures in humans. Isobolographic analysis of interactions revealed that TGB interacted additively with all tested conventional AEDs for the fixed-ratio combinations of 1:3, 1:1, and 3:1. Evaluation of pharmacokinetic interactions between AEDs revealed that the observed additivity was pharmacodynamic in nature. TGB did not affect the plasma and brain concentrations of VPA, CBZ and PB. Similarly, none of the studied conventional AEDs changed the plasma or brain levels of TGB. Also, TGB, VPA, CBZ, and PB administered alone (at their median effective doses) and in combinations at the fixed-ratio of 1:1 did not impair motor performance evaluated in the chimney test. In conclusion, additivity between TGB and conventional AEDs in amygdala-kindled rats and lack of bidirectional pharmacokinetic interactions suggest that TGB appears to be a valuable drug for an add-on therapy of refractory complex partial seizures in humans.     

Pharmacological and histological characterisation of nicotine-kindled seizures in mice

The present study reports that it is possible to induce kindling by repeated injections of nicotine. The newly characterised nicotine-kindling model was compared with that of pentylenetetrazole (PTZ) kindling. Mice were kindled by repeated injection of PTZ (37 mg/kg), or nicotine (2.3 mg/kg), and the effect of the anti-epileptic drugs (AED) levetiracetam (LEV), tiagabine (TGB) and phenytoin (PHT) on seizures in kindled and naive mice were investigated. C-Fos immunoreactivity (Fos IR) was used to investigate differences in neuronal activity pattern between PTZ-, nicotine kindled and naive animals. PTZ kindled animals mainly showed increased Fos IR in limbic regions, whereas Fos IR in nicotine kindled animals was increased in the entorhinal cortex, medial habenula and the compact part of substantia nigra. Fully kindled PTZ-induced seizures were inhibited by LEV (ED50=13.6+/-7.8 mg/kg), TGB (ED50=0.3+/-0.04 mg/kg) but not PHT (ED50>40 mg/kg) whereas fully kindled nicotine-induced seizures were inhibited by LEV (ED50=1.4+/-0.4 mg/kg), TGB (ED50=0.3+/-0.06 mg/kg) and PHT (ED50=9.2+/-2.4 mg/kg). These differences in efficacy of AEDs were not due to changes in plasma levels in the various models. In conclusion, repeated administration of nicotine can induce a kindling-like phenomenon and the model showed significantly different Fos IR pattern and pharmacology to that of PTZ kindling.     

Isobolographic characterisation of interactions among selected newer antiepileptic drugs in the mouse pentylenetetrazole-induced seizure model

The aim of this study was to characterise the types of interactions between gabapentin (GBP), tiagabine (TGB) and three second-generation antiepileptic drugs (AEDs) with different mechanisms of action (felbamate [FBM], loreclezole [LCZ], and oxcarbazepine [OXC]) by isobolographic analysis. Anticonvulsant and acute neurotoxic adverse effect profiles of combinations of GBP and TGB with other AEDs at fixed ratios of 1:3, 1:1 and 3:1 were investigated in pentylenetetrazole (PTZ)-induced seizures and the chimney test (as a measure of motor impairment) in mice so as to identify optimal combinations. Protective indices (PIs) and benefit indices (BIs) were calculated for each combination in order to properly classify the investigated interactions. Isobolographic analysis revealed that only the combination of GBP with OXC at the fixed ratio of 1:1 exerted supra-additive (synergistic) interaction (P<0.05) against PTZ-induced seizures. The other combinations tested between GBP and OXC (1:3 and 3:1), as well as all combinations of GBP with FBM or LCZ (1:3, 1:1 and 3:1) were additive in the PTZ test. Similarly, all combinations of TGB with FBM LCZ, and OXC (at the fixed ratios of 1:3, 1:1 and 3:1) were associated with additive interactions against PTZ-induced seizures in mice. In the chimney test, the isobolographic analysis revealed that the combinations of GBP and OXC (at the fixed ratios of 1:3 and 1:1), GBP and LCZ (at 1:1), as well as TGB and OXC (at 1:3 and 1:1) were sub-additive (antagonistic; P<0.05 and P<0.01). In contrast, only one combination tested (TGB and LCZ at the fixed ratio of 1:1) was supra-additive (synergistic; P<0.05) in the chimney test, whereas the other combinations of GBP and TGB with OXC, FBM, and LCZ displayed barely additivity. Based upon the current preclinical data, GBP and OXC appear to be a particularly favourable combination. Also, the combinations of GBP with FBM, GBP with LCZ, and TGB with OXC are beneficial. In contrast, during the combining of TGB with FBM, or TGB with LCZ, the utmost caution is advised because of their unfavourable profiles in this preclinical study.The results of this study were presented in part at the Thirty years of cooperation between German and Polish pharmacologists, new perspectives in the common Europe—Bialowieza, Poland, 18–21 September 2003 (abstract in Pol J Pharmacol (2003) 55:500–501).     

Transient dystonias in three patients treated with tiagabine

PURPOSE: Tiagabine (TGB) is a new antiepileptic drug (AED) with gamma-aminobutyric acid (GABA)ergic mechanism of action. GABAergic compounds may influence the extrapyramidal system, probably via modulation of dopaminergic nigrostriatal neurons. A well-known side effect of TGB is probably dose-related extrapyramidal tremor. To our knowledge, acute dystonias associated with TGB treatment have yet to be described. METHODS: Three patients with transient acute dystonic reactions while taking TGB as add-on therapy with carbamazepine (CBZ) are presented. The focal limb dystonia in one case, an oromandibular dystonia in second, and writer's cramp in third one were observed. RESULTS: In all cases dystonic movements resolved spontaneously without discontinuation of TGB therapy and without any concomitant treatment. CONCLUSIONS: Tiagabine may cause various mild extrapyramidal side effects. All three cases reported were diagnosed with transient possibly drug-related dystonia after increase in TGB dose. It remain unclear whether dystonic movements are specific for patients treated with TGB/CBZ bitherapy.     

Non-convulsive status epilepticus in two patients receiving tiagabine add-on treatment

We report two patients with epileptic syndromes who developed non-convulsive status epilepticus under adjunctive antiepileptic therapy with tiagabine. The paradoxical effect may be the result of a difference in effects between GABA_A and GABA_B receptors, or between GABA receptors in different regions of the brain. Received: 18 February 2000 / Received in revised form: 29 June 2000 / Accepted: 1 August 2000     

The γ-aminobutyric acid (GABA) uptake inhibitor, tiagabine, increases extracellular brain levels of GABA in awake rats

The effect of systemic administration of the γ-aminobutyric acid (GABA) uptake inhibitor, R( − )N-(4,4-di(3-methyl-thien-2-yl)-but-3-enyl) nipecotic acid, hydrochloridc (tiagabine) (previously NO-328), on extracellular GABA levels in the globus pallidus, ventral pallidum and substantia nigra of awake Sprague-Dawley rats was investigated using in vivo microdialysis. Tiagabine was administered in doses of 11.5 or 21.0 mg/kg i.p. (ED₅₀, and ED₈₅ doses, respectively, for inhibiting pentylcnctetrazole-induced tonic seizures). Tiagabine increased the extracellular concentrations of GABA in globus pallidus with peak values 310% of basal level (after 21 mg/kg) and 240% of basal level (after 11.5 mg/kg). A significant increase in extracellular GABA levels was also found in the ventral pallidum (280% increase after 11.5 mg/kg and 350% increase after 21 mg/kg) and in the substantia nigra where the ED₈₅ dose of tiagabine 621 mg/kg) produced a peak value of 200% compared to the basal level. Thus, tiagabine acts as a GABA uptake inhibitor in vivo also.     

Women with Epilepsy: Must Contraception and Pregnan Add to the Burden of Epilepsy?

Summary: In addition to seizure control, women with epilepsy face particular complications associated with menstruation, fertility, contraception, pregnancy, and breastfeeding. With traditional long-term antiepileptic drug (AED) therapy there is a risk of menstrual irregularities, contraceptive failure, and adverse pregnancy outcome. Many women intentionally discontinue AED therapy during pregnancy because of concerns about the risk of fetal malformation and effects on fetal growth and development. However, trauma resulting from seizures is the leading cause of maternal and fetal death in women with epilepsy. In addition, mothers are concerned about the presence of AEDs in breast milk and therefore tend to choose bottle feeding. Clearly, a balance must be achieved between seizure control for the mother and exposure of the fetus or infant to AEDs. Tiagabine (TGB) is a new AED which acts by inhibiting uptake of the neurotransmitter γ-aminobutyric acid into glial cells. Animal studies show that TGB has no toxic effects either on reproductive function or on the developing fetus, although there is still insufficient evidence to permit conclusions from human studies. TGB does not induce hepatic metabolism, and a study in healthy volunteers indicates no interaction with oral contraceptives. It is hoped that the availability of new AEDs such as TGB, with the promise of a better safety profile and a lower propensity for drug interactions, will alleviate the burden for women with epilepsy.