Epilepsy and Antiseizure Drugs
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Questions and Answers

Which of the following drugs, primarily used to treat seizures, decrease glutamate release by acting on the synaptic protein SV2A?

  • Levetiracetam (correct)
  • Topiramate
  • Phenytoin
  • Ethosuximide
  • Vigabatrin elevates GABA levels by enhancing the response of GABAA receptors to GABA.

    False (B)

    Match each drug with its primary mechanism of action:

    Phenytoin = Blocks Na+ channels and decreases glutamate release Tiagabine = Blocks GABA re-uptake Gabapentin = Reduces calcium currents (T-type) Topiramate = Alters phosphorylation state at the synapse and blocks Na+ channels

    Which of the following antiseizure drugs primarily enhance the response of GABAA receptors to GABA?

    <p>Phenobarbital (A)</p> Signup and view all the answers

    Phenytoin's mechanism of action in preventing seizures primarily involves:

    <p>Modifying ionic conductance by specifically blocking sodium channels. (D)</p> Signup and view all the answers

    Levetiracetam directly blocks voltage-gated sodium channels to reduce neuronal excitability.

    <p>False (B)</p> Signup and view all the answers

    Phenytoin follows zero-order kinetics at therapeutic concentrations, allowing for predictable dose adjustments.

    <p>False (B)</p> Signup and view all the answers

    Match the following antiseizure drugs with their primary mechanisms of action:

    <p>Phenytoin = Blocks voltage-gated sodium channels Retigabine = Enhances the opening of potassium channels Tiagabine = Blocks GABA re-uptake Levetiracetam = Modifies release of GABA and glutamate by acting on synaptic protein SV2A</p> Signup and view all the answers

    Match the following antiseizure drug characteristics with their corresponding descriptions.

    <p>First order kinetics = The rate of drug elimination is directly proportional to the concentration Fosphenytoin = A prodrug of phenytoin Sodium channels = Target of phenytoin and fosphenytoin Diplopia = A common adverse effect of Phenytoin</p> Signup and view all the answers

    Which of the drugs listed below inhibits GABA-transaminase, leading to increased GABA levels in the synapse?

    <p>Vigabatrin (A)</p> Signup and view all the answers

    Which of the following is NOT a primary approach to antiseizure drug discovery?

    <p>Promoting acetylcholine release. (D)</p> Signup and view all the answers

    Current antiseizure drugs are generally considered curative rather than palliative.

    <p>False (B)</p> Signup and view all the answers

    Vigabatrin's mechanism of action in treating seizures is most closely associated with which of the following enzymatic effects?

    <p>Preventing the breakdown of GABA by inhibiting GABA transaminase. (D)</p> Signup and view all the answers

    All drugs classified as 'tricyclics' (carbamazepine, oxcarbazepine, and eslicarbazepine) primarily exert their antiseizure effects by enhancing GABA-mediated chloride influx.

    <p>False (B)</p> Signup and view all the answers

    Match each antiseizure medication with its primary mechanism of action:

    <p>Valproic Acid = Blocks sodium channels Tiagabine = Blocks the re-uptake of GABA Gabapentin = Blocks calcium channels Clonazepam = Increases chloride influx via GABA receptors</p> Signup and view all the answers

    Which of the following statements accurately describes the mechanism of action of vigabatrin?

    <p>It irreversibly inhibits GABA aminotransferase (GABA-T), preventing GABA degradation. (B)</p> Signup and view all the answers

    Primidone's anticonvulsant activity is solely attributed to its direct action on sodium channels, independent of its metabolites.

    <p>False (B)</p> Signup and view all the answers

    Match each antiseizure drug with its primary mechanism of action:

    <p>Lamotrigine = Blocks sodium channels and decreases glutamate release Gabapentin = Binds to alpha 2 gamma subunit of voltage-gated Ca channels, reducing glutamate release Levetiracetam = Modifies synaptic release of GABA and glutamate from storage vesicles Tiagabine = Inhibits GABA uptake, increasing GABA levels in the brain</p> Signup and view all the answers

    A patient on carbamazepine exhibits diplopia and ataxia. While these are common side effects, what other potentially serious idiosyncratic reaction should the healthcare provider monitor for?

    <p>Erythematous skin rash (B)</p> Signup and view all the answers

    Pregabalin directly acts on GABA receptors to exert its anticonvulsant effects.

    <p>False (B)</p> Signup and view all the answers

    Besides seizures, for what other condition is pregabalin specifically approved?

    <p>peripheral neuropathy</p> Signup and view all the answers

    Valproic acid's discovery as an anticonvulsant was serendipitous; it was initially used as a ______ in drug studies.

    <p>solvent</p> Signup and view all the answers

    Which property makes primidone distinct from other barbiturates?

    <p>It is biotransformed into phenobarbital, which contributes to its therapeutic effect (A)</p> Signup and view all the answers

    Which of the following antiseizure drugs directly enhances the opening of potassium channels?

    <p>Retigabine (B)</p> Signup and view all the answers

    Fosphenytoin is an active form of phenytoin and directly blocks sodium channels without requiring metabolic conversion.

    <p>False (B)</p> Signup and view all the answers

    What is the primary mechanism of action of vigabatrin in controlling seizures?

    <p>inhibits GABA-transaminase</p> Signup and view all the answers

    Levetiracetam modulates synaptic transmission by binding to synaptic vesicle protein ____________.

    <p>SV2A</p> Signup and view all the answers

    Which of the following drugs is NOT a benzodiazepine but a benzodiazepine derivative?

    <p>Clobazam (B)</p> Signup and view all the answers

    Tiagabine elevates GABA levels in the synapse by directly inhibiting the synthesis of GABA.

    <p>False (B)</p> Signup and view all the answers

    Besides its action on GABAA receptors, which other receptor type does felbamate affect?

    <p>NMDA</p> Signup and view all the answers

    The antiseizure drug ______________ is known for enhancing slow inactivation of sodium channels, potentially offering a unique mechanism for seizure control.

    <p>lacosamide</p> Signup and view all the answers

    Which antiseizure drug's mechanism primarily involves antagonism of AMPA receptors?

    <p>Perampanel (A)</p> Signup and view all the answers

    What is the primary mechanism of action for ethosuximide in controlling seizures?

    <p>Inhibition of T-type calcium channels (B)</p> Signup and view all the answers

    The anti-seizure drug __________, derived from Cannabis sativa, has an unknown mechanism of action for seizure control and is non-psychoactive.

    <p>Cannabidiol (A)</p> Signup and view all the answers

    What is the primary mechanism by which ethosuximide exerts its antiseizure effect?

    <p>Inhibition of T-type calcium channels (B)</p> Signup and view all the answers

    What is the primary advantage of using fosphenytoin over phenytoin in emergency situations?

    <p>Reduces pain at the injection site (A)</p> Signup and view all the answers

    The antiseizure drug _______ is a prodrug that is converted to phenobarbital in the body.

    <p>Primidone (A)</p> Signup and view all the answers

    Common adverse drug reactions (ADR) associated with phenytoin use, affecting a significant number of patients, are:

    <p>All of the above (@)</p> Signup and view all the answers

    What was the first antiseizure drug that did not have sedative properties?

    <p>Phenytoin (A)</p> Signup and view all the answers

    Topiramate's mechanism of action involves altering what process at the synapse?

    <p>GABAergic inhibition (A), Substitute monosaccharides (B), Sodium ion blocking (D)</p> Signup and view all the answers

    Unlike many antiseizure medications that act on sodium or GABA channels, topiramate influences neuronal activity through its effects on the process of __________.

    <p>Phosphorylation (A)</p> Signup and view all the answers

    What is the primary mechanism of action of ethosuximide in treating absence seizures?

    <p>Reducing calcium influx through T-type calcium channels (C)</p> Signup and view all the answers

    Carbamazepine induces microsomal liver enzymes (CYP), which can cause its half-life to ______ after chronic usage.

    <p>Decrease (A)</p> Signup and view all the answers

    Flashcards

    Voltage-gated sodium channel blockers

    Drugs that block Na+ channels, decreasing glutamate release.

    SV2A modulating drugs

    Drugs that act on synaptic protein SV2A to modify glutamate release.

    Calcium current reducers

    Drugs that reduce T-type calcium currents, decreasing Ca++ entry.

    GABA response enhancers

    Drugs that enhance the response of GABAA receptors to GABA.

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    Cannabidiol's unknown mechanism

    Cannabidiol, derived from cannabis, controls seizures but its action is unknown.

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    Epilepsy

    A neurological disorder characterized by seizures.

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    Seizures

    Episodes of abnormal brain activity due to neuron discharge.

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    GABA transmission

    Inhibitory neurotransmission enhanced by certain antiseizure drugs.

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    Glutamate transmission

    Excitatory neurotransmission diminished by some antiseizure drugs.

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    Phenytoin

    First antiseizure drug without sedative properties, blocks sodium channels.

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    Fosphenytoin

    A prodrug of phenytoin that reduces injection pain.

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    Therapeutic levels of Phenytoin

    Optimal drug concentration 10-20 µg/mL for effectiveness.

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    Common ADRs of Phenytoin

    Adverse effects include diplopia, ataxia, and gingival hyperplasia.

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    Carbamazepine

    A tricyclic compound blocking sodium channels, used for seizures.

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    Phenobarbital

    An early antiseizure drug that prolongs GABA receptor activity.

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    Primidone

    Converted into phenobarbital, providing its therapeutic effects.

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    Vigabatrin

    Irreversible GABA-T inhibitor increasing GABA levels.

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    Lamotrigine

    Blocks sodium channels and reduces glutamate release.

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    Gabapentin

    GABA analog that reduces glutamate release via calcium channels.

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    Ethosuximide

    Cyclic ureide effective against absence seizures, works on calcium.

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    Valproic Acid

    Blocks sodium currents; effective against absence seizures.

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    Benzodiazepines

    Used in status epilepticus; major side effects include sedation and tolerance.

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    Lacosamide

    Amino acid derivative that slows activation of sodium channels.

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    Drugs blocking Na+ channels

    Drugs that reduce glutamate release by blocking voltage-gated sodium channels.

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    SV2A protein

    Proteins targeted by levetiracetam to modify glutamate release.

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    Drugs enhancing K+ channels

    Retigabine enhances the opening of potassium channels in the neurons.

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    T-type calcium currents

    Drugs like ethosuximide, gabapentin, and pregabalin decrease calcium entry through T-type channels.

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    Phosphorylation at synapses

    Topiramate alters phosphorylation to affect synaptic activity.

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    GABAA receptor response

    Drugs like phenobarbital enhance responses of GABAA receptors to GABA, increasing inhibition.

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    GABA-transaminase inhibition

    Vigabatrin inhibits GABA-transaminase, raising GABA levels in the brain.

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    GABA Receptors

    Proteins that respond to the neurotransmitter GABA, increasing chloride influx and inhibiting neuron activity.

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    Tiagabine

    A medication that inhibits the re-uptake of GABA, increasing its availability in the brain.

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    Felbamate

    A drug that potentiates GABAA and blocks NMDA receptors.

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    Cyclic ureide analogs

    A class of antiseizure drugs including ethosuximide, phensuximide, and methosuximide that reduce T-type calcium currents.

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    Levetiracetam

    A drug that acts on synaptic protein SV2A to modify glutamate release.

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    Retigabine

    A drug that enhances the opening of potassium channels.

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    Topiramate

    A drug that alters the phosphorylation state at the synapse.

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    Study Notes

    Epilepsy and Antiseizure Drugs

    • Epilepsy affects 1% of the global population, with 500,000 patients in the US alone.
    • Antiseizure drugs are successful in around 80% of patients.
    • Episodes of abnormal cerebral neuron discharge cause seizures.
    • Epilepsy can stem from various causes, including neoplasms, head injuries, fevers, or unknown factors.
    • Treatment selection depends on the epilepsy type.

    Drug Development Approaches for Epilepsy

    • Drug discovery involves three approaches:
      • Enhancing GABA (inhibitory) transmission
      • Reducing glutamate (excitatory) transmission
      • Modifying ionic conductance.
    • Current drugs primarily provide symptom relief rather than a cure.

    Antiseizure Drug Chemistry

    • Sixteen different antiseizure drugs are clinically approved.
    • Thirteen of these fall into these categories:
      • Barbiturates
      • Hydantoins
      • Oxazolidinediones
      • Succinimides
      • Acetylureas

    Phenytoin and Fosphenytoin

    • Phenytoin (diphenylhydantoin) was the first significant anti-seizure medication without sedative properties, discovered in 1938.
    • Fosphenytoin, a prodrug, eliminates pain at injection sites.
    • The drug inhibits repetitive action potential firing and sodium channel activity in axons.
    • Therapeutic levels range from 10-20µg/mL.
    • Common side effects include diplopia (double vision), ataxia, and gingival hyperplasia.

    Carbamazepine

    • Structure similar to phenytoin, also blocks sodium channels.
    • Induces liver enzymes, potentially affecting drug half-life.
    • Common side effects include diplopia and ataxia, and potentially an erythematous skin rash.

    Phenobarbital

    • An older (first line) antiseizure medication, along with bromide.
    • Has derivatives such as mephobarbital and metharbital.

    Primidone

    • Metabolizes into phenobarbital and phenylethylmalonamide, thereby impacting activity.
    • Common side effects are related to phenobarbital.

    Vigabatrin

    • Irreversible inhibitor of GABA aminotransferase (GABA-T).
    • Increases GABA brain levels
    • Potential side effect: visual disturbances in roughly one-third of patients.

    Lamotrigine

    • Primarily affects sodium channels and modulating glutamate release.
    • Common side effects include rash, diplopia, and headache.

    Gabapentin and Pregabalin

    • Analogs of GABA, but act on different pathways
    • Primarily used for pain or peripheral neuropathies, and affect calcium regulation.

    Lacosamide

    • Slows Na channel activation.
    • Commonly used to treat various seizure types.

    Levetiracetam

    • Modifies synaptic release of GABA and glutamate.

    Tiagabine

    • Inhibits GABA reuptake, boosting GABA levels.

    Topiramate

    • A monosaccharide derivative, having effects on sodium channels regulation and modulates GABA activity.

    Zonisamide

    • A sulfonamide derivative targeted toward sodium channels.

    Ethosuximide

    • Structurally cyclic ureide, impacting calcium currents.
    • Effective for absence seizures.

    Valproic Acid (and Sodium Valproate)

    • A carboxylic acid derivative affecting sodium currents.
    • Has been associated with hepatic toxicity.

    Benzodiazepines (Diazepam, Lorazepam, Clonazepam)

    • Primarily used for status epilepticus (seizure control).
    • Act on GABA sites.
    • Common side effects are tolerance and sedation.

    Miscellaneous Antiseizure Drugs

    Other drugs with diverse mechanisms, including; Lamotrigine, Rufinamide, Zonisamide, Lacosamide, Felbamate, Trimethadione, Perampanel and Stiripentol.

    Summary of Antiseizure Drug Mechanisms

    • Drugs targeted at sodium channels: These drugs block sodium channels and reduce glutamate release.
    • Drugs modulating synaptic protein SV2A: These drugs modify the release of glutamate.
    • Potassium channel enhancement: Drugs that improve potassium channel function.
    • Reduction of calcium currents: Drugs reducing certain types of calcium current (e.g., T-type).
    • Alterations of synaptic phosphorylation: These drugs change the phosphorylation state at synapses.
    • Modulation of GABA response: Drugs amplifying GABA reception or reducing GABA breakdown.

    Drug Categories Based on Mechanism of Action

    Several categories based on their mechanism of action, including the primary target of these drugs.

    Drug Classification by Structure

    A categorized approach based on the chemical structure of the drugs.

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    Description

    This lesson explores epilepsy, its causes, and the mechanisms of antiseizure drugs. It covers drug development approaches focusing on GABA and glutamate transmission and discusses the chemistry of various antiseizure drugs, including barbiturates and hydantoins. Also covered are Phenytoin and Fosphenytoin.

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