Carbamazepine

Neuropathic pain management: a focused review of current treatments and novel data from main ongoing clinical trials

INTRODUCTION

Neuropathic pain (NP) remains a significant challenge in clinical practice, requiring a sophisticated pharmacotherapeutic strategy for effective symptom management. This review provides a comprehensive analysis of the current pharmacological treatments for NP, focusing on their efficacy, mechanism of action, and therapeutic potential. Additionally, it evaluates ongoing clinical trials investigating novel drugs and therapeutic approaches, highlighting emerging trends and future directions in NP management.

AREAS COVERED

This review examines first- to third-line therapeutic modalities for NP, critically analyzing their efficacy, safety profiles, and clinical applications. It also includes an overview of ongoing clinical trials exploring innovative pharmacological therapies. A thorough literature review was conducted using the MEDLINE database without temporal limitations, offering a detailed assessment of established and emerging treatments.

EXPERT OPINION

While current pharmacological options offer significant symptom relief, their overall effectiveness in managing NP remains limited, highlighting the need for further therapeutic advancements. Staying informed about emerging therapies and clinical trials is vital to enhancing patient care and quality of life. The future of NP management lies in optimizing individualized treatment strategies, refining therapeutic approaches, and fostering interdisciplinary collaboration. Close monitoring of outcomes and continued research are essential for advancing understanding and improving the precision of NP therapies.

A case report describing myocardial ischaemia as a side effect of carbamazepine overdose

Background

Overdoses of carbamazepine may occur due to various reasons. The summary of product characteristics of carbamazepine includes information about the possibility of side effects after taking this drug. However, the symptoms described do not include coronary vasospasm, which occurred in the case described. Making such a diagnosis is a key element in therapeutic management, as it changes further clinical decisions.

Case summary

A 46-year-old patient was admitted to the hospital for disorders of consciousness following an overdose of carbamazepine. On the second day, the patient exhibited respiratory distress. Subsequently, the patient was transferred to the intensive care unit, intubated, and placed on mechanical ventilation. On the same day, the patient experienced recurrent cardiac arrhythmias in the form of pulseless ventricular tachycardia and ventricular fibrillation; the patient was resuscitated and defibrillated eight times. Due to a rapid decline in cardiac output coupled with persistent electrocardiographic changes and haemodynamic instability, the patient underwent urgent coronary angiography. The procedure revealed a spasm in the initial segment of the circumflex branch of the left coronary artery, which subsequently resolved following nitroglycerin administration. Subsequent to the implementation of this therapeutic approach, a reduction in the demand for norepinephrine and dobutamine was achieved. In the following days, the patient's general condition improved. The patient was discharged home while maintaining full cognitive capacity and cardiovascular and respiratory fitness.

Discussion

In the case described, the expeditious performance of a cardiological diagnostic evaluation played a pivotal role in achieving therapeutic success, enabling the prompt initiation of appropriate treatment.

The Effect of Neuropsychiatric Drugs on the Oxidation-Reduction Balance in Therapy

The effectiveness of available neuropsychiatric drugs in the era of an increasing number of patients is not sufficient, and the complexity of neuropsychiatric disease entities that are difficult to diagnose and therapeutically is increasing. Also, discoveries about the pathophysiology of neuropsychiatric diseases are promising, including those initiating a new round of innovations in the role of oxidative stress in the etiology of neuropsychiatric diseases. Oxidative stress is highly related to mental disorders, in the treatment of which the most frequently used are first- and second-generation antipsychotics, mood stabilizers, and antidepressants. Literature reports on the effect of neuropsychiatric drugs on oxidative stress are divergent. They are starting with those proving their protective effect and ending with those confirming disturbances in the oxidation-reduction balance. The presented publication reviews the state of knowledge on the role of oxidative stress in the most frequently used therapies for neuropsychiatric diseases using first- and second-generation antipsychotic drugs, i.e., haloperidol, clozapine, risperidone, olanzapine, quetiapine, or aripiprazole, mood stabilizers: lithium, carbamazepine, valproic acid, oxcarbazepine, and antidepressants: citalopram, sertraline, and venlafaxine, along with a brief pharmacological characteristic, preclinical and clinical studies effects.

Impact of carbamazepine on SMARCA4 (BRG1) expression in colorectal cancer: modulation by KRAS mutation status

SMARCA4 is a gene traditionally considered a tumor suppressor. Recent research has however found that SMARCA4 likely promotes cancer growth and is a good target for cancer treatment. The drug carbamazepine, an autophagy inducer, was used on colorectal cancer cell lines, HCT1116 and Hke3 (KRAS mutant and wildtype). Our study finds that Carbamazepine affects SMARCA4 levels and that this effect is different depending on the KRAS mutation status. This study analyzes the effect of carbamazepine on early-stage autophagy via ULK1 as well as simulates the docking of carbamazepine on KRAS, depending on the mutation status. Our study highlights the therapeutic uses of carbamazepine on cancer, and we propose that carbamazepine in conjunction with other chemotherapies may prove useful in targeting KRAS-mutated colorectal cancer.

Efficacy and safety of pregabalin vs carbamazepine in patients with central post-stroke pain

OBJECTIVE

To compare the efficacy and safety of pregabalin and carbamazepine in patients with central post-stroke pain (CPSP).

METHODS

Patients included in the study were randomly assigned to either flexible-dose pregabalin treatment group or carbamazepine treatment group. The primary efficacy variable was face visual analog scale (F-VAS), the second efficacy assessment was used to assess the effect of treatment on mental health by Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD).

RESULTS

The mean baseline pain score F-VAS was 6.47 in the pregabalin group and 6.58 in carbamazepine treatment group. F-VAS was significantly lower in the pregabalin group (1.64) than (3.94) carbamazepine treatment group after treatment. Pregabalin was significantly superior to carbamazepine in endpoint assessments on the HAMA and HAMD after treatment. F-VAS and HAMD were showed efficacy as early as week 2 and maintained for whole duration of the study. The average pregabalin dose in the 12-week study was 214.6 (150-375) mg/day. The mean dose (range) of carbamazepine received by the patients was 275.0 (200-400) mg/day. Mild or moderate, typically transient, somnolence and dizziness were the most common adverse events (AES). The differences of the side effects between the two groups were not significant.

CONCLUSIONS

Pregabalin, but not carbamazepine, may be effective in improving F-VAS, HAMA and HAMD in patients with CPSP.

Status epilepticus resulted in rhabdomyolysis-induced AKI associated with hepatotoxicity induced by synergistic carbamazepine and diazepam: A case report

RATIONALE

Rhabdomyolysis is a serious complication of status epilepticus (SE) caused by muscle cell damage and can lead to a life-threatening acute kidney injury (AKI).

PATIENT CONCERNS

A 35-year-old man with a history of seizures treated with 3 different antiepileptic drugs (carbamazepine, lamotrigine, and levetiracetam) presented with SE. The patient received 5 doses of diazepam to control the SE in another hospital and was transferred to our emergency due to AKI.

DIAGNOSES

Laboratory tests corresponded with rhabdomyolysis-induced AKI and disseminated intravascular coagulation. Thereafter, the decrease in renal excretion of both drugs (diazepam and carbamazepine) caused acute liver injury and neurotoxicity. The carbamazepine concentration was 16.39 mcg/mL, which considered in toxic level, despite using the usual dose.

INTERVENTIONS

The patient was treated with hydration and sodium bicarbonate, however; severe AKI mandated a hemodialysis session.

OUTCOMES

The diuresis started to increase, kidney and liver functions improved, and altered mental status reversed.

LESSONS

This case alerts physicians to consider the synergistic drug side effects and interactions, especially when patients present with impaired liver or kidney functions. The reduction in metabolism or excretion of drugs can cause an increase in serum concentrations and induce toxicity, even when the drug intake at the usual dose.

The Effect of Carbamazepine on Performance, Carcass Value, Hematological and Biochemical Blood Parameters, and Detection of Carbamazepine and Its Metabolites in Tissues, Internal Organs, and Body Fluids in Growing Rabbits

Antiepileptic drugs (e.g., carbamazepine; CBZ) are widely prescribed for various conditions beyond epilepsy, including neurologic and psychiatric disorders. These medications can have both favorable and unfavorable impacts on mood, anxiety, depression, and psychosis. CBZ has been found at low concentrations (in the unit of nanograms per liter) in rivers, surface water, and even drinking water. As a result, when reclaimed wastewater is used for irrigation in agricultural ecosystems, CBZ can be reintroduced into the environment. That is why we tested different doses of CBZ in rabbits' feed as the meat is consumed in every community, has no religious barriers, and the potential risk of consuming meat which has been exposed to CBZ treatment is not known. Also, the evidence of the effect of CBZ on rabbits is missing. Mainly, the CBZ doses affected the count of leukocytes and other blood traits, meaning the higher the dose, the higher the reduction. Moreover, there were only low amounts of CBZ in rabbits' meat or tissues when they were exposed to the treatment.

Strategies in the synthesis of dibenzo[b,f]heteropines

The dibenzo[b,f]azepine skeleton is important in the pharmaceutical industry, not only in terms of existing commercial antidepressants, anxiolytics and anticonvulsants, but also in reengineering for other applications. More recently, the potential of the dibenzo[b,f]azepine moiety in organic light emitting diodes and dye-sensitized solar cell dyes has been recognised, while catalysts and molecular organic frameworks with dibenzo[b,f]azepine derived ligands have also been reported. This review provides a brief overview of the different synthetic strategies to dibenzo[b,f]azepines and other dibenzo[b,f]heteropines.

Induction of clastogenesis and gene mutations by carbamazepine (at its therapeutically effective serum levels) in mammalian cells and the dependence on human CYP2B6 enzyme activity

Carbamazepine (CBZ, an antiepileptic) is metabolized by multiple CYP enzymes to its epoxide and hydroxides; however, whether it is genotoxic remains unclear. In this study, molecular docking (CBZ to CYPs) and cytogenotoxic toxicity assays were employed to investigate the activation of CBZ for mutagenic effects, in various mammalian cell models. Docking results indicated that CBZ was valid as a substrate of human CYP2B6 and 2E1, while not for CYP1A1, 1A2, 1B1 or 3A4. In the Chinese hamster (V79) cell line and its derivatives genetically engineered for the expression of human CYP1A1, 1A2, 1B1, 2E1 or 3A4 CBZ (2.5 ~ 40 μM) did not induce micronucleus, while in human CYP2B6-expressing cells CBZ significantly induced micronucleus formation. In a human hepatoma C3A cell line, which endogenously expressed CYP2B6 twofold higher than in HepG2 cells, CBZ induced micronucleus potently, which was blocked by 1-aminobenzotriazole (inhibitor of CYPs) and ticlopidine (specific CYP2B6 inhibitor). In HepG2 cells CBZ did not induce micronucleus; however, pretreatment of the cells with CICTO (CYP2B6 inducer) led to micronucleus formation by CBZ, while rifampicin (CYP3A4 inducer) or PCB126 (CYP1A inducer) did not change the negative results. Immunofluorescent assay showed that CBZ selectively induced centromere-free micronucleus. Moreover, CBZ induced double-strand DNA breaks (γ-H2AX elevation, by Western blot) and PIG-A gene mutations (by flowcytometry) in C3A (threshold being 5 μM, lower than its therapeutic serum concentrations, 17 ~ 51 μM), with no effects in HepG2 cells. Clearly, CBZ may induce clastogenesis and gene mutations at its therapeutic concentrations, human CYP2B6 being a major activating enzyme.

Biosensors technology for anti-epileptic drugs

A broad group of antiepileptic drugs (AEDs) often controls the frequency of seizures. Given the variability of pharmacokinetics, narrow target range, and the difficulty of identifying signs of toxicity from laboratory responses, therapeutic monitoring of AEDs plays a vital role in optimizing drug administration. Nanomaterials, especially biosensor-based methods, can facilitate the analysis of these agents with unique advantages such as rapid analysis, sensitivity, selectivity, and low cost. This review describes recent advances in biosensors developed to analyze AEDs. First, we described common electrochemical measurement techniques and types of deposited electrode substrates. Additionally, various chemical and biological modifiers to improve the sensitivity and selectivity of the sensor have been categorized and briefly described. Finally, the prospects for developing an electrochemical platform for quantifying AEDs are presented.

Consensus of the Brazilian Headache Society (SBCe) for the Prophylactic Treatment of Episodic Migraine: part I

The Brazilian Headache Society (Sociedade Brasileira de Cefaleia, SBCe, in Portuguese) nominated a Committee of Authors with the aim of establishing a consensus with recommendations regarding prophylactic treatment for episodic migraine based on articles published in the worldwide literature, as well as personal experience. Migraine affects 1 billion people around the world and more than 30 million Brazilians. In addition, it is an underdiagnosed and undertreated disorder. It is well known within the medical community of neurologists, and especially among headache specialists, that there is a need to disseminate knowledge about prophylactic treatment for migraine. For this purpose, together with the need for drug updates and to expand knowledge of the disease itself (frequency, intensity, duration, impact and perhaps the progression of migraine), this Consensus was developed, following a full online methodology, by 12 groups who reviewed and wrote about the pharmacological categories of the drugs used and, at the end of the process, met to read and establish conclusions for this document. The drug classes studied were: anticonvulsants, tricyclic antidepressants, monoclonal anti-calcitonin gene-related peptide (anti-CGRP) antibodies, beta-blockers, antihypertensives, calcium channel inhibitors, other antidepressants (selective serotonin reuptake inhibitors, SSRIs, and dual-action antidepressants), other drugs, and polytherapy. Hormonal treatment and anti-inflammatories and triptans in minimum prophylaxis schemes (miniprophylaxis) will be covered in a specific chapter. The drug classes studied for part I of the Consensus were: anticonvulsants, tricyclic antidepressants, monoclonal anti-CGRP antibodies, and beta-blockers.

The interplay of epilepsy with impaired mitophagy and autophagy linked dementia (MAD): A review of therapeutic approaches

The duration and, age of dementia have been linked to a higher risk of seizures. The exact mechanism that drives epileptogenesis in impaired mitophagy and autophagy linked dementia (MAD) is fully defined after reviewing the Scopus, Publon, and Pubmed databases. The epileptogenesis in patients with Alzheimer's disease dementia (ADD) and Parkinson's disease dementia (PDD) is due to involvement of amyloid plaques (Aβ), phosphorylated tau (pTau), Parkin, NF-kB and NLRP3 inflammasome. Microglia, the prime protective and inflammatory cells in the brain exert crosstalk between mitophagy and inflammation. Several researchers believed that the inflammatory brain cells microglia could be a therapeutic target for the treatment of a MAD associated epilepsy. There are conventional antiepileptic drugs such as gabapentin, lamotrigine, phenytoin sodium, carbamazepine, oxcarbazepine, felbamate, lamotrigine, valproate sodium, and topiramate are prescribed by a psychiatrist to suppress seizure frequency. Also, the conventional drugs generate serious adverse effects and synergises dementia characteristics. The adverse effect of carbamazepine is neurotoxic and also, damages haemopoietic system and respiratory tract. The phenytoin treatment causes cerebellar defect and anemia. Dementia and epilepsy have a complicated relationship, thus targeting mitophagy for cure of epileptic dementia makes sense. Complementary and alternative medicine (CAM) is one of the rising strategies by many patients of the world, not only to suppress seizure frequency but also to mitigate dementia characteristics of patients. Therefore our present review focus on the interplay between epilepsy and MAD and their treatment with CAM approaches.

Fabrication and Evaluation of Transdermal Delivery of Carbamazepine Dissolving Microneedles

This project aims to prepare hydrogel microneedle patches (MNs) as a painless method to deliver carbamazepine transdermally. This can be used as a sustained release system that offers the advantages of lower gastrointestinal side effects and avoids the first-pass metabolism of the drug. MNs were composed of two medicated layers, a microneedle layer and a base layer. MNs were fabricated using polyvinyl alcohol with or without polyvinylpyrrolidone Kollidon 30 as a matrix polymer and in the presence of selected solubilizing agent (polyethylene glycol 400, Tween 80, or α-tocopherol polyethylene glycol). Freezing-thawing cycle was evaluated as one of the processing parameters that may affect the drug release. The MNs were evaluated for their weight variation, base thickness, and content uniformity. The physicochemical compatibility between carbamazepine and the polymers was estimated by Fourier transform infrared spectroscopy, differential scanning calorimetry, thermogravimetric analysis, and X-ray powder diffraction. Evaluation for the in vitro release studies and ex vivo permeation studies was performed. The prepared MNs were flexible, clear, and uniform in weight, base thickness, and drug content. Physicochemical characterizations showed that carbamazepine was amorphous in most of the MNs. In vitro release and ex vivo permeation studies of carbamazepine were significantly higher for MNs containing a combination of 1:1 w/w of PEG 400 and Tween 80 as solubilizing agents where the release was extended over 96 h, with the release of 85.2% and 59.6% permeation percentage compared to other MNs. A significant effect of the freezing-thawing cycle on the release profile of the drug was observed. The hydrogel MNs are shown to be stable under the studied storage conditions.

Carbamazepine drug reaction involving high fevers during the COVID-19 era

Carbamazepine has demonstrated anticonvulsant properties and is used for a variety of indications in psychiatry and neurology. Total daily doses typically range from 200 to 1200 mg/d, generally divided into 2 doses. Carbamazepine has a broad side-effect profile but is not typically thought to produce high fevers in the absence of a hypersensitivity syndrome. This is a case of a probable adverse drug reaction to carbamazepine consisting of fever without severe major organ involvement. In this instance, a patient in a manic episode with psychotic features was briefly transferred to a COVID-19 unit to rule out coronavirus infection before the fever resolved.

Efficacy and Safety of Anticonvulsants for the Inpatient Treatment of Alcohol Withdrawal Syndrome: A Systematic Review and Meta-analysis

AIM

To examine the efficacy and safety of antiepileptic drugs (AED) for the inpatient treatment of patients with moderate to severe alcohol withdrawal syndrome (AWS).

METHODS

We searched in databases and gray literature to include randomized controlled clinical trials in adults that compare the use of AED versus placebo or any other medication. Studies that did not specify severity or were performed on an outpatient basis were excluded. The outcomes were improvement of symptoms, delirium tremens, seizures and adverse events. Two researchers independently selected the references, extracted the data and assessed the risk of bias. A qualitative synthesis was made and, when the heterogeneity was mild or moderate, a meta-analysis was performed. The quality of the evidence obtained was evaluated with the Grading of Recommendations Assessment, Development and Evaluation tool.

RESULTS

In total, 26 studies with 1709 patients were included. No benefit is described in withdrawal syndrome severity measured by scales or in the development of delirium tremens. The only possible meta-analysis showed that there are no differences in the incidence of seizures (risk ratio [RR] = 1.0; confidence interval (CI) 95% 0.76-1.33), even when compared with placebo (RR = 0.95; CI95% 0.57-1.57). There were also no differences in adverse events, although a higher proportion of some mild cases were described with the use of carbamazepine and valproic acid.

CONCLUSIONS

The routine use of AED is not suggested in the treatment of patients with moderate or severe AWS unless indicated for comorbidity (weak recommendation against using moderate quality of evidence).

Anticonvulsant and neuroprotective effects of carbamazepine-levetiracetam adjunctive treatment in convulsive status epilepticus rat model: Inhibition of cholinergic transmission

This study evaluated the anticonvulsant and neuroprotective effects of carbamazepine (CBZ), levetiracetam (LEV), and CBZ + LEV adjunctive treatment in convulsive status epilepticus (CSE) rat model. Twenty-five male Wistar rats were randomized into five groups (n = 5). Groups I and II received 0.2 ml of normal saline intraperitoneally (i.p), while groups III-V received CBZ (25 mg/kg i.p), LEV (50 mg/kg i.p) or combination of sub-therapeutic doses of CBZ (12.5 mg/kg i.p) and LEV (25 mg/kg i.p). Thirty minutes later, seizure was kindled with pilocarpine hydrochloride (350 mg/kg) in group II-V rats. Seizure indices, markers of excitotoxicity, and astroglioses were determined, while the hippocampal morphometry was also evaluated. The data was analysed using descriptive and inferential statistics, while the results were presented as mean ± SEM in graphs or tables, and the level of significance was taken at p < 0.05. The anticonvulsant treatments delayed the inception of seizure indices (p = 0.0006), while the percentage mortality decreased significantly (p = 0.0001) in all the treatment groups. The hippocampal concentrations of acetylcholine, malondialdehyde, and tissue necrotic factor-alpha decreased significantly (p = 0.0077) in all the treated group relative to the positive control. The reactive astrogliosis in the hippocampus (CA 1) increased significantly (p = 0.0001) compared with the control but abrogated in all the treatment groups relative to the positive control. The anticonvulsant and neuroprotective effects are in this order: LEV < CBZ + CBZ < CBZ. The drug efficacy is attributable to the inhibition of cholinergic transmission.

Inhibition of Nav1.7 channel by a novel blocker QLS-81 for alleviation of neuropathic pain

Voltage-gated sodium channel Nav1.7 robustly expressed in peripheral nociceptive neurons has been considered as a therapeutic target for chronic pain, but there is no selective Nav1.7 inhibitor available for therapy of chronic pain. Ralfinamide has shown anti-nociceptive activity in animal models of inflammatory and neuropathic pain and is currently under phase III clinical trial for neuropathic pain. Based on ralfinamide, a novel small molecule (S)-2-((3-(4-((2-fluorobenzyl) oxy) phenyl) propyl) amino) propanamide (QLS-81) was synthesized. Here, we report the electrophysiological and pharmacodynamic characterization of QLS-81 as a Nav1.7 channel inhibitor with promising anti-nociceptive activity. In whole-cell recordings of HEK293 cells stably expressing Nav1.7, QLS-81 (IC50 at 3.5 ± 1.5 μM) was ten-fold more potent than its parent compound ralfinamide (37.1 ± 2.9 μM) in inhibiting Nav1.7 current. QLS-81 inhibition on Nav1.7 current was use-dependent. Application of QLS-81 (10 μM) caused a hyperpolarizing shift of the fast and slow inactivation of Nav1.7 channel about 7.9 mV and 26.6 mV, respectively, and also slowed down the channel fast and slow inactivation recovery. In dissociated mouse DRG neurons, QLS-81 (10 μM) inhibited native Nav current and suppressed depolarizing current pulse-elicited neuronal firing. Administration of QLS-81 (2, 5, 10 mg· kg-1· d-1, i.p.) in mice for 10 days dose-dependently alleviated spinal nerve injury-induced neuropathic pain and formalin-induced inflammatory pain. In addition, QLS-81 (10 μM) did not significantly affect ECG in guinea pig heart ex vivo; and administration of QLS-81 (10, 20 mg/kg, i.p.) in mice had no significant effect on spontaneous locomotor activity. Taken together, our results demonstrate that QLS-81, as a novel Nav1.7 inhibitor, is efficacious on chronic pain in mice, and it may hold developmental potential for pain therapy.

Thyroid hormones, Sertoli cell proliferation and differentiation in progenies from carbamazepine-treated rat dams during pregnancy and lactation

Carbamazepine (CBZ) is used in the control of seizure and affective disorders, causing hypothyroidism. Thyroid hormones regulate the Sertoli cell proliferation and differentiation. Clinical aspects must be considered since epileptic fertile women need to continuously use CBZ during pregnancy and lactation. This study aimed to evaluate the effects of CBZ on testis development of rat offspring from dams treated during pregnancy/lactation. Rat dams received CBZ (20 mg kg^-1  day^-1 ) or vehicle by intra-peritoneal route during gestation and lactation. Progenies were euthanised at 4, 14, 41, 63 and 93-days post-partum (dpp) for the evaluation of T3, T4 and TSH plasma total levels. Testicular cross sections were submitted to anti-Ki67, anti-PCNA, anti-p27^kip1 and anti-transferrin immunolabelling for the evaluation of Sertoli cells. There was a significant reduction in p27^kip1 -positive Sertoli cell numerical densities and an increase in TSH level at 14 dpp. CBZ exposure affected the volume density of transferrin-positive immunolabelling at 63 dpp. These results suggest that CBZ may cause a dysregulation of the controller system of thyroid hormones homeostasis leading to an increase in the proliferation rate at the neonatal phase and a differentiation delay of the Sertoli cell, culminating in an altered function at late puberty. The occurrence of hypothyroidism cannot be completely discarded.

Lithium for Carbamazepine-Induced Syndrome of Inappropriate Antidiuretic Hormone

OBJECTIVES

To examine the effectiveness of low-dose lithium carbonate for managing carbamazepine-induced hyponatremia.

METHODS

Single case study in an 88 year old man with bipolar illness and vascular dementia who had failed to respond to other mood stabilizers.

RESULTS

The patient had developed hyponatremia on two separate occasions when treated with carbamazepine. Introduction of low-dose lithium resulted in prompt normalization of serum sodium levels, which was maintained for the subsequent 8 weeks.

CONCLUSIONS

Carbamazepine may sometimes be the best or only viable treatment option for patients with bipolar illness or other conditions. When its use is complicated by syndrome of inappropriate ADH, dose reduction and fluid restriction are the simplest options but, if ineffective, addition of lithium may be a feasible, albeit somewhat complicated, alternative.

Carbamazepine induces a bioenergetics disruption to microvascular endothelial cells from the blood-brain barrier

Carbamazepine (CBZ) is a widely employed anti-seizure medication that crosses the blood-brain barrier (BBB) to exert its anti-convulsant action. The effects of CBZ on components of the BBB have yet to be completely delineated. Hence the current study evaluated the effects of CBZ upon mitochondrial functionality of BBB-derived microvascular endothelial cells isolated from Albino rats. The influence of CBZ on cell viability and barrier functions were evaluated by 3-(4,5 dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide (MTT), lactate dehydrogenase, and electrophysiological assays over a drug concentration range of 0.1-1000 μM. Bioenergetics effects were measured via ATP production, mitochondrial complexes I and III activities, lactate production, and oxygen consumption rates (OCRs), and mitochondrial membrane potential, fluidity and lipid content. CBZ was cytotoxic to microvascular endothelial cells in a concentration and duration dependent manner. CBZ significantly diminished the endothelial cell's barrier functions, and impacted upon cellular bioenergetics: reducing mitochondrial complex activities with a parallel decrease in OCRs and increased anaerobic lactate production. CBZ significantly decreased mitochondrial membrane potential and induced an increase of membrane fluidity and decrease in levels of mitochondrial saturated and unsaturated fatty acids. In summary, CBZ disrupted functional activity of BBB endothelial cells via damage and modification of mitochondria functionality at therapeutically relevant concentrations.

Hot liquid extrusion assisted drug-cyclodextrin complexation: a novel continuous manufacturing method for solubility and bioavailability enhancement of drugs

In this study, drug-cyclodextrin (CD) complexes were prepared using hot liquid extrusion (HLE) process with an aim to improve solubility and bioavailability of carbamazepine. Saturation solubility studies of CBZ in water and different pH media showed a pH-independent solubility. Phase solubility studies of CBZ at different molar concentrations of beta-cyclodextrin (β-CD) and hydroxypropyl beta-cyclodextrin (HP-β-CD) indicated A_L-type solubility profile with stability constants of 574 M⁻¹ and 899 M⁻¹ for β-CD and HP-β-CD. Drug-β-CD and drug-HP-β-CD complexes were prepared using HLE process and conventional methods (such as physical mixture, kneading method, and solvent evaporation) as well. Optimized complexes prepared using HLE viz. CBP-4 and CHP-2 showed a solubility of 4.27 ± 0.09 mg/mL and 6.39 ± 0.09 mg/mL as compared to plain CBZ (0.140 ± 0.007 mg/mL). Formation of drug-CD inclusion complexes was confirmed using DSC, FTIR, and XRD studies. Drug release studies indicated highest release of CBZ from CHP-2 (98.69 ± 2.96%) compared to CBP-4 (82.64 ± 2.45%) and plain drug (13.47 ± 0.54%). Complexes prepared using kneading showed significantly lesser drug release (KMB 75.52 ± 2.68% and KMH 85.59 ± 2.80%) as that of CHP-2 and CBP-4. Pre-clinical pharmacokinetic studies in Wistar rats indicated a significant increase in C_max, T_max, AUC, and mean residence time for CHP-2 compared to KMH and plain CBZ. All these results suggest that HLE is an effective method to increase the solubility of poorly water-soluble drugs.

Current challenges and possible future developments in personalized psychiatry with an emphasis on psychotic disorders

A personalized medicine approach seems to be particularly applicable to psychiatry. Indeed, considering mental illness as deregulation, unique to each patient, of molecular pathways, governing the development and functioning of the brain, seems to be the most justified way to understand and treat disorders of this medical category. In order to extract correct information about the implicated molecular pathways, data can be drawn from sampling phenotypic and genetic biomarkers and then analyzed by a machine learning algorithm. This review describes current difficulties in the field of personalized psychiatry and gives several examples of possibly actionable biomarkers of psychotic and other psychiatric disorders, including several examples of genetic studies relevant to personalized psychiatry. Most of these biomarkers are not yet ready to be introduced in clinical practice. In a next step, a perspective on the path personalized psychiatry may take in the future is given, paying particular attention to machine learning algorithms that can be used with the goal of handling multidimensional datasets.

Reduced Zebrafish Transcriptome Atlas toward Understanding Environmental Neurotoxicants

Transcriptomic approaches monitoring gene responses at genome-scale are increasingly used in toxicological research and help to clarify the molecular mechanisms of adverse effects caused by environmental toxicants. However, their applications for chemical assessment are hampered due to high expenses required and more importantly the lack of in-depth data mining and mechanistic perspectives. Here, we described a reduced transcriptome atlas (RTA) approach which integrates transcriptomic data sets and a comprehensive panel of genes generated to represent neurogenesis and the early neuronal development of zebrafish, to determine the potential neurodevelopmental toxicities of environmental chemicals. Transcriptomic data sets of 74 chemicals and 736 related gene expression profiles were integrated resulting in 135 exposure signatures. Chemical prioritization demonstrated four sets of hits to be neurotoxic: neuro-active chemicals (representatively, Valproic acid, VPA and Carbamazepine, CAR), xenoestrogens (Bisphenol A, BPA; Genistein, GEN; 17-α ethinylestradiol, EE2), microcystins (cyanopeptolin, CP1020; microcystin-LR, MCLR) and heavy metals (AgNO₃, AgNPs). The enriched biological pathways and processes were distinct among the four sets, while the overlapping functional enrichments were observed within each set, for example, over 25% differentially expressed genes and four of top five KEGG pathways were shared between VPA and CAR. Furthermore, gene expression index (GEI) analysis demonstrated that a gene panel with 300 genes was sufficient to effectively characterize and cluster chemicals and therefore offer an efficient and cost-effective tool for the prioritization of neurotoxicants. Thus, the RTA approach provides novel insights into the understanding of the in-depth molecular mechanisms of environmental neurotoxicants and can be used as an indication for potential adverse outcomes.

A Clinical Study of Toxication Caused by Carbamazepine Abuse in Adolescents

Carbamazepine is known to produce the side effect of euphoria. As such, it lends itself to being a drug of abuse, particularly in the adolescent population. This retrospective study evaluated carbamazepine abuse, treatment course, and associated morbidity in Chinese adolescents. The median dose of carbamazepine resulting in overdose was 2,000 mg (800–5,000). Patients were largely from urban-rural fringe areas (76.47%, 52.94%) with school performance within the last 1/3 range and (52.94%) unsupervised by parents. 35.29% experienced an obvious sense of euphoria. All patients had nervous system symptoms, 6 (35.29%) cases developed coma (GCS < 8), and 5 (29.41%) cases experienced convulsion. Four cases were treated with hemodialysis. The incidence rate in young patients with repeat carbamazepine use and without the supervision of parents was higher than that in first-time users (5/7 versus 4/10), but the difference was not significant. The toxic dose of repeat users was 3428 ± 1035 mg, significantly higher than that of 1470 ± 646 mg in first-time users (P = 0.001). Carbamazepine can produce a sense of euphoria, which is more likely to lead to its abuse and overdose in adolescents. To prevent carbamazepine abuse and overdose will be critical in educating at-risk adolescents and preventing associated morbidities in the future.

Incidence, causative drugs, and economic consequences of drug-induced SJS, TEN, and SJS-TEN overlap and potential drug-drug interactions during treatment: a retrospective analysis at an Indonesian referral hospital

Background

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute life-threatening adverse drug reactions (ADRs) that are commonly caused by medications. Apart from their contribution to morbidity and mortality, these diseases may also present substantial consequences on health care resources. In this study, we aimed to identify the incidence, causative drugs, and economic consequences of these serious ADRs and potential drug–drug interactions (DDIs) during treatment.

Methods

A retrospective study that included 150 patients diagnosed with drug-induced SJS, SJS–TEN overlap, and TEN, from 2009 to 2013 in a referral hospital in West Java Province, Indonesia, was conducted to analyze the causative drugs, cost of illness (COI) as a representation of economic consequences, and potential DDIs during treatment.

Results

The results showed that analgesic–antipyretic drugs were the most frequently implicated drugs. The COIs for SJS, SJS–TEN overlap, and TEN patients were 119.49, 139.21, and 162.08 US dollars per day, respectively. Furthermore, potential DDIs with several therapeutic medications and corticosteroids used to treat SJS, SJS–TEN overlap, and TEN were also identified.

Conclusion

This study showed that analgesic–antipyretic was the major causative drug which contributed to SJS, SJS–TEN overlap, and TEN. Furthermore, our results also showed that SJS, SJS–TEN overlap, and TEN may cause considerable financial consequences to patients.

Studies on photodegradation process of psychotropic drugs: a review

Consumption of psychotropic drugs is still increasing, especially in high-income countries. One of the most crucial consequences of this fact is significant release of them to the environment. Considerable amounts of atypical antipsychotics, benzodiazepines, antidepressants, and their metabolites were detected in river, lake, and sea water, as well as in tissues of aquatic organisms. Their ecotoxicity was proved by numerous studies. It should be noticed that interaction between psychotropic pharmaceuticals and radiation may lead to formation of potentially more toxic intermediates. On the other hand, photo-assisted wastewater treatment methods can be used as an efficient way to eliminate them from the environment. Many methods based on photolysis and photocatalysis were proposed and developed recently; nevertheless, the problem is still unsolved. However, according to recent studies, photocatalysis could be considered as the most promising and far more effective than regular photolysis. An overview on photolytic as well as homogenous and heterogeneous photocatalytic degradation methods with the use of various catalysts is presented. The photostability and phototoxicity of pharmaceuticals were also discussed. Various analytical methods were used for the photodegradation research, and this issue was also compared and summarized. Use of high-resolution multistage mass spectrometry (Q-TOF, ion trap, Orbitrap) was suggested. The combined techniques such as LC-MS, GC-MS, and LC-NMR, which enable qualitative and quantitative analyses in one run, proved to be the most valuable in this case. Assembling of MS/MS spectra libraries of drug molecules and their phototransformation products was identified as the future challenge.

Fragile X syndrome: A review of clinical management

The fragile X mental retardation 1 gene, which codes for the fragile X mental retardation 1 protein, usually has 5 to 40 CGG repeats in the 5' untranslated promoter. The full mutation is the almost always the cause of fragile X syndrome (FXS). The prevalence of FXS is about 1 in 4,000 to 1 in 7,000 in the general population although the prevalence varies in different regions of the world. FXS is the most common inherited cause of intellectual disability and autism. The understanding of the neurobiology of FXS has led to many targeted treatments, but none have cured this disorder. The treatment of the medical problems and associated behaviors remain the most useful intervention for children with FXS. In this review, we focus on the non-pharmacological and pharmacological management of medical and behavioral problems associated with FXS as well as current recommendations for follow-up and surveillance.