The first-line antiepileptic drug carbamazepine: Reaction with biologically relevant free radicals

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.

Zebrafish toxicological screening could aid Leishmaniosis drug discovery

BACKGROUND

Recently a screen from a library of 1.8 million compounds identified in vitro a potent activity of the 2-aminobenzimidazoles series against Leishmania infantum, the etiological agent responsible by over 20.000 deaths each year. Several analogs were synthesized and in vitro tested through an optimization program, leading to a promising 2-aminobenzimidazoles derived compound (2amnbzl-d) that was progressed to in vivo mice studies. However, the not expected toxic effects prevented its progression to more advanced preclinical and clinical phases of drug development. Due to limitations of cell models in detecting whole organism complex interactions, 90% of the compounds submitted to pre-clinical tests are reproved. The use of Zebrafish embryo models could improve this rate, saving mammals, time and costs in the development of new drugs. To test this hypothesis, we compared 2amnbzl-d with two compounds with already established safety profile: carbamazepine and benznidazole, using an embryo Zebrafish platform based on acute toxicity, hepatotoxicity, neurotoxicity and cardiotoxicity assays (Pltf-AcHpNrCd).

RESULTS

Tests were performed blindly, and the results demonstrated the presence of lethal and teratogenic effects (CL50%: 14.8 µM; EC50%: 8.6 µM), hepatotoxic in concentrations above 7.5 µM and neurotoxic in embryos exposed to 15 µM of 2amnbzl-d. Nevertheless, benznidazole exposition showed no toxicity and only the 100 µM of carbamazepine induced a bradycardia.

CONCLUSIONS

Results using Pltf-AcHpNrCd with zebrafish reproduced that found in the toxicological tests with mammals to a portion of the costs and time of experimentation.

Tryptophanol-Derived Oxazolopyrrolidone Lactams as Potential Anticancer Agents against Gastric Adenocarcinoma

Gastric cancer is one of the deadliest cancers in modern societies, so there is a high level of interest in discovering new drugs for this malignancy. Previously, we demonstrated the ability of tryptophanol-derived polycyclic compounds to activate the tumor suppressor protein p53, a relevant therapeutic target in cancer. In this work, we developed a novel series of enantiomerically pure tryptophanol-derived small molecules to target human gastric adenocarcinoma (AGS) cells. From an initial screening of fourteen compounds in AGS cell line, a hit compound was selected for optimization, leading to two derivatives selective for AGS gastric cells over other types of cancer cells (MDA-MB-231, A-549, DU-145, and MG-63). More importantly, the compounds were non-toxic in normal cells (HEK 293T). Additionally, we show that the growth inhibition of AGS cells induced by these compounds is mediated by apoptosis. Stability studies in human plasma and human liver microsomes indicate that the compounds are stable, and that the major metabolic transformations of these molecules are mono- and di-hydroxylation of the indole ring.

Carbamazepine at environmentally relevant concentrations caused DNA damage and apoptosis in the liver of Chinese rare minnows (Gobiocypris rarus) by the Ras/Raf/ERK/p53 signaling pathway

To assess genetoxicity and the underlying mechanisms of carbamazepine (CBZ) toxicity in fish, adult Chinese rare minnows (Gobiocypris rarus) were exposed to 1, 10, and 100 μg/L CBZ for 28 d. Comet assays indicated that hepatic DNA damage was significantly increased in groups of minnows exposed to CBZ at all concentrations in a dose-dependent manner compared to those of the control groups (p < 0.05). Liver levels of 8-hydroxydeoxyguanosine (8-OHdG) were significantly increased at 10 and 100 μg/L CBZ (p < 0.05). TUNEL assays indicated that the average apoptotic rates of the livers of female and male minnows were significantly increased following exposure to CBZ at all concentrations for 28 d (p < 0.05). Significant increases in caspase 3 and 9 activities after CBZ exposure at all concentrations and caspase 8 at 10 and 100 μg/L CBZ exposure reflected the presence of mitochondrial apoptosis (p < 0.05). The mRNA levels of gadd45a, mdm2, casp3 and casp9 in female and male minnows exposed to CBZ at all concentrations were significantly increased compared with those in the control groups (p < 0.05). Significant increases in the levels of p21 in female minnows exposed to 1 and 100 μg/L CBZ, p53 in female minnows at all CBZ treatments and bcl2 in male minnows exposed to 1 and 100 μg/L CBZ were observed, indicating p53 pathway activation. The inhibition of ras levels in females and males exposed to CBZ at all concentrations and increased levels of raf1 in males exposed to CBZ at all concentrations indicated Ras/Raf1/MAPK (ERK) activation. Therefore, the present study demonstrates that CBZ at environmentally relevant levels induces DNA damage and apoptosis in Chinese rare minnows by the Ras/Raf/ERK/p53 signaling pathway.

Drug interactions of natural supplements in dermatology: a review

Limited information is available on the drug-drug interactions of natural supplements in dermatology. Many natural supplements are available over the counter, but drug-drug interactions can occur. This study reviews the clinical use and drug interactions of six natural supplements commonly recommended in dermatology: nicotinic acid (nicotinamide), polypodium leucotomos (heliocare), turmeric, horse chestnut seed extract, zinc, and N-acetylcysteine. We reviewed the drug-drug interactions of each supplement using the PubMed database and IBM Micromedex. For nicotinic acid, zinc, horse chestnut, and N-acetylcysteine, IBM Micromedex generated 11, 23, one, and two results, respectively. Further review of literature from PubMed identified two drug interactions with polypodium leucotomos, two with turmeric, and two more with zinc. Notable interactions included an increased risk of myopathy and rhabdomyolysis when nicotinic acid is taken by patients using statins, an increased risk of bleeding associated with horse chestnut seed, especially when used in combination with warfarin, and reduced plasma concentration in many drugs when taken with zinc. Furthermore, N-acetylcysteine may interfere with concentrations of other medications used in the psychiatric setting, and polypodium leucotomos and turmeric may interfere with the CYP metabolic pathway, which may affect drugs metabolized by this pathway. Prior to recommending a treatment, dermatologists should foster awareness of these interactions. In order to advance the practice as a whole, research should continue to evaluate the drug interactions of these natural supplements.

Ozonation of carbamazepine and its main transformation products: product determination and reaction mechanisms

Carbamazepine (CBZ) is a recalcitrant pharmaceutical often detected in wastewater and in the environment. CBZ can be removed from wastewater through advanced oxidation treatment methods such as ozonation. In this study, CBZ and its transformation product 1-(2-benzaldehyde)-(1H,3H)-quinazoline-2,4-dione (BQD) were ozonated, and the formation and transformation of their ozonation products were investigated using liquid chromatography coupled to ion trap mass spectrometry and high-resolution mass spectrometry as well as nuclear magnetic resonance (NMR). The main products, 1-(2-benzaldehyde)-4-hydro-(1H,3H)-quinazoline-2-one (BQM) and BQD were quantified using isolated standards and LC-UV. Of the original CBZ concentration, 74% was transformed into BQM and 83% of BQM was further transformed into BQD. Both products are more stable than CBZ and could still be detected after 240 min of ozonation. Another major product, 2,2'-azanediyldibenzaldehyde (TP225) was for the first time identified using NMR. Twelve further CBZ products were identified.

CNS function and dysfunction during exposure to hyperbaric oxygen in operational and clinical settings

Hyperbaric oxygen (HBO2) is breathed during hyperbaric oxygen therapy and during certain undersea pursuits in diving and submarine operations. What limits exposure to HBO2 in these situations is the acute onset of central nervous system oxygen toxicity (CNS-OT) following a latent period of safe oxygen breathing. CNS-OT presents as various non-convulsive signs and symptoms, many of which appear to be of brainstem origin involving cranial nerve nuclei and autonomic and cardiorespiratory centers, which ultimately spread to higher cortical centers and terminate as generalized tonic-clonic seizures. The initial safe latent period makes the use of HBO2 practical in hyperbaric and undersea medicine; however, the latent period is highly variable between individuals and within the same individual on different days, making it difficult to predict onset of toxic indications. Consequently, currently accepted guidelines for safe HBO2 exposure are highly conservative. This review examines the disorder of CNS-OT and summarizes current ideas on its underlying pathophysiology, including specific areas of the CNS and fundamental neural and redox signaling mechanisms that are thought to be involved in seizure genesis and propagation. In addition, conditions that accelerate the onset of seizures are discussed, as are current mitigation strategies under investigation for neuroprotection against redox stress while breathing HBO2 that extend the latent period, thus enabling safer and longer exposures for diving and medical therapies.