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

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

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

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

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

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

<p>Peripheral neuropathy (B)</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 (A)</p> Signup and view all the answers

What is the mechanism of action (MOA) of vigabatrin?

<p>Inhibits GABA-transaminase (C)</p> Signup and view all the answers

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

<p>SV2A (A)</p> Signup and view all the answers

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

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

What percentage of phenytoin is bound to protein?

<p>90% (B)</p> Signup and view all the answers

Which drug class can displace phenytoin from protein and increase free drug levels?

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

What percentage of carbamazepine is protein bound?

<p>70% (C)</p> Signup and view all the answers

Which of the following is the oldest of the antiseizure drugs next to bromide?

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

What percentage of primidone is free and unbound?

<p>70% (C)</p> Signup and view all the answers

Which of the following drugs causes visual field disturbances and is only used when all others fail?

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

What is the most common adverse drug reaction (ADR) of ethosuximide?

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

Which of the following enhances GABA transmission and is utilized in compassionate use for certain types of epilepsy in infancy?

<p>Stiripentol (D)</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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