Analysis of CSF amino acids in young patients with generalised refractory epilepsy during an add-on study with lamotrigine

Dogs as a Natural Animal Model of Epilepsy

Epilepsy is a common neurological disease in both humans and domestic dogs, making dogs an ideal translational model of epilepsy. In both species, epilepsy is a complex brain disease characterized by an enduring predisposition to generate spontaneous recurrent epileptic seizures. Furthermore, as in humans, status epilepticus is one of the more common neurological emergencies in dogs with epilepsy. In both species, epilepsy is not a single disease but a group of disorders characterized by a broad array of clinical signs, age of onset, and underlying causes. Brain imaging suggests that the limbic system, including the hippocampus and cingulate gyrus, is often affected in canine epilepsy, which could explain the high incidence of comorbid behavioral problems such as anxiety and cognitive alterations. Resistance to antiseizure medications is a significant problem in both canine and human epilepsy, so dogs can be used to study mechanisms of drug resistance and develop novel therapeutic strategies to benefit both species. Importantly, dogs are large enough to accommodate intracranial EEG and responsive neurostimulation devices designed for humans. Studies in epileptic dogs with such devices have reported ictal and interictal events that are remarkably similar to those occurring in human epilepsy. Continuous (24/7) EEG recordings in a select group of epileptic dogs for >1 year have provided a rich dataset of unprecedented length for studying seizure periodicities and developing new methods for seizure forecasting. The data presented in this review substantiate that canine epilepsy is an excellent translational model for several facets of epilepsy research. Furthermore, several techniques of inducing seizures in laboratory dogs are discussed as related to therapeutic advances. Importantly, the development of vagus nerve stimulation as a novel therapy for drug-resistant epilepsy in people was based on a series of studies in dogs with induced seizures. Dogs with naturally occurring or induced seizures provide excellent large-animal models to bridge the translational gap between rodents and humans in the development of novel therapies. Furthermore, because the dog is not only a preclinical species for human medicine but also a potential patient and pet, research on this species serves both veterinary and human medicine.

Comparison and effects of acute lamotrigine treatment on extracellular excitatory amino acids in the hippocampus of PTZ-kindled epileptic and PTZ-induced status epilepticus rats

In this communication, the effect of acute treatment with lamotrigine (LTG) was investigated on release of main excitatory amino acids (EAA) such as glutamate (Glu) and aspartate (Asp) in the hippocampus of pentylenetetrazol (PTZ)-induced and PTZ-kindled freely moving rats using micro dialysis. The results show that, levels of Glu and Asp significantly increased in the rat hippocampus during the seizure/interical periods for PTZ-status epilepticus (SE) and PTZ-kindled epileptic (EP) rats. The levels of Glu and Asp increased more in EP rat hippocampus than in SE rat hippocampus. After administration of 20 mg/kg LTG, the levels of Glu and Asp significantly decreased in the SE and EP rat hippocampus. The results indicate that: (a) excitability of the PTZ-kindled epileptogenic model is higher than that of the status epilepticus model; (b) the modulation of LTG on the EAA neurotransmitters certainly plays an important role in antiepileptic efficacy, especially in PTZ-kindled epileptic model where the release of EAA was influenced more markedly by acute application of 20 mg/kg LTG.

Cerebrospinal fluid GABA concentration: relationship with impulsivity and history of suicidal behavior, but not aggression, in human subjects

The objective of this study was to assess the relationship between cerebrospinal fluid concentrations of the neurotransmitter gamma-aminobutyric acid (GABA) and measures of impulsivity and related behaviors (aggression and suicidality) in healthy volunteer and personality disordered subjects. CSF GABA levels, and measures of impulsivity, aggression, and history of suicidal behavior were obtained by morning lumbar puncture in 57 healthy volunteer subjects and in subjects with personality disorder. CSF GABA levels were not found to correlate with measures of aggression but were found to correlate directly with measures of impulsivity; e.g., a composite measure of impulsivity in all subjects (r=0.35, df=46, P=0.015) and in personality disordered subjects examined separately (r=0.39, df=30, P=0.029). In the personality disorder group, CSF GABA levels were higher among subjects with a history of suicidal behavior compared with those without this history. These data suggest that central GABAergic function correlates directly with impulsiveness and history of suicidal behavior, but not aggressiveness, in personality disordered subjects. This may be consistent with observations that high doses of benzodiazepines can lead to "behavioral disinhibition" in human subjects. Further work assessing this and other aspects of the central GABA system in personality disordered subjects are warranted.

Neurometabolic effects of ACTH on free amino compounds in opsoclonus-myoclonus syndrome

To evaluate the possible role of central free amino compounds in pediatric opsoclonus-myoclonus syndrome (OMS), 21 cerebrospinal fluid (CSF) amino compounds were measured by an amino acid analyzer or mass spectroscopy in 74 anesthetized children, 54 with OMS and 20 age-matched neurological controls. In OMS, only phosphoethanolamine was increased compared to controls; OMS severity and duration had significant converse effects on alanine and phosphoethanolamine. In contrast, corticotropin (ACTH) treatment was associated with increased alanine and phenylalanine, and decreased taurine compared to controls and untreated OMS, and increased glutamine, lysine, ornithine, and tyrosine compared to untreated OMS. Other than low taurine, these effects were not found with corticosteroid treatment, and non-steroidogenic immunotherapy had no effect. The ACTH dose-association was most apparent for alanine and phosphoethanolamine, but lysine and ornithine were also higher in the high-dose ACTH group. There were no significant disease- or treatment-associated perturbations in GABA, glycine, or other amino acids. These data suggest a unique pattern of ACTH effects on non-neurotransmitter CSF amino compounds, for the most part not shared by steroids.

Changes in amino acids and nitric oxide concentration in cerebrospinal fluid during labor pain

This study analyzes the relationship between amino acids and pain perception during active labor. Cerebrospinal fluid (CSF) levels of the excitatory amino acids (EAAs)-glutamate, aspartate and their amide forms, inhibitory amino acids (IAAs)-glycine, gamma-amino butyric acid (GABA) and taurine and nitric oxide (NO) related compounds-arginine and citrulline (by-product of NO synthesis) were compared between pregnant women at term pregnancy with labor pain (n = 38) and without labor pain (Caesarian section; n = 30). The levels of aspartate, glycine, GABA and citrulline were significantly higher; whilst taurine was significantly lower in the labor pain group. These findings suggest that aspartate and NO are associated with labor pain. An inhibitory role for the IAA taurine and a pronociceptive role for glycine in labor pain are proposed.

Add-on lamotrigine treatment and plasma glutamate levels in epilepsy: Relation to treatment response

We investigated the effects of add-on lamotrigine treatment on plasma glutamate (Glu) levels, in 29 epileptic patients. Plasma Glu levels were determined by high-performance liquid chromatography at baseline and at 1 and 3 months post-treatment. In patients with a seizure reduction of > or = 66% a decrease of Glu at month 1 was noted, followed by return to baseline levels at month 3. In the remaining patients a gradual increase of Glu was noted throughout the 3 months of the study. The above findings indicate that an excellent clinical response to add-on lamotrigine may be characterized by a statistically significant, yet transient decrease of plasma Glu levels, while increasing Glu levels may accompany a response that is moderate at best. The combination of lamotrigine with valproate was more frequent in patients with excellent clinical response and tended to result in glutamate decrease.

Potential mechanisms of action of lamotrigine in the treatment of bipolar disorders

Based on the mood-stabilizing properties of carbamazepine and valproate, new anticonvulsants have been explored for use in bipolar disorders. One such agent, lamotrigine, has a novel clinical profile in that it may "stabilize mood from below," as it appears to maximally impact depressive symptoms in bipolar disorders. In this paper, we review the mechanisms of action of lamotrigine in an effort to understand the basis of its distinctive clinical use in the management of bipolar disorders as well as its diverse antiseizure effects. We consider lamotrigine mechanisms, emphasizing commonalities and dissociations among actions of lamotrigine, older mood stabilizers, and other anticonvulsants. Although ion channel effects, especially sodium channel blockade, may importantly contribute to antiseizure effects, such actions may be less central to lamotrigine thymoleptic effects. Antiglutamatergic and neuroprotective actions are important candidate mechanisms for lamotrigine psychotropic effects. Lamotrigine has a variable profile in kindling and contingent tolerance experiments and does not appear to have robust gamma-aminobutyric acid or monoaminergic actions. Lamotrigine intracellular signaling effects warrant investigation. Although lamotrigine mechanisms overlap those of other mood-stabilizing anticonvulsants, important dissociations suggest candidate mechanisms, which could contribute to lamotrigine's distinctive psychotropic profile.

A double-blind randomized clinical trial in amyotrophic lateral sclerosis using lamotrigine: effects on CSF glutamate, aspartate, branched-chain amino acid levels and clinical parameters

OBJECTIVES

A study was conducted to examine the effect of lamotrigine (LTG) in amyotrophic lateral sclerosis (ALS).

MATERIAL AND METHODS

Patients were entered in a double-blind, placebo-controlled, crossover study. None of the patients were treated with riluzole, which was not approved for treatment of ALS in Sweden when the study started. After randomization, each patient was treated with placebo or LTG 300 mg daily, followed by a washout period and a second treatment period.

RESULTS

Thirty patients completed the study and were included in the analysis of the primary outcome, which was measured with clinical scales. The cerebrospinal fluid (CSF) levels of glutamate, aspartate, branched-chain amino acids and LTG were also measured. Changes for glutamate, valine and LTG were found during the progression of the disease. The clinical parameters and the levels of CSF amino acids were similar for the two treatment groups.

CONCLUSION

No clinical effect of LTG on ALS progression could be found.

Effect of lamotrigine on plasma GABA levels in healthy humans

Lamotrigine, a new anticonvulsant, has been reported to be useful in treating bipolar depression, rapid cycling, and other phases of bipolar disorder. However, the mechanism of action underlying its efficacy in mood disorders is still not known. Since there is evidence for gamma-aminobutyric acid (GABA) involvement in the pathophysiology and treatment response of patients with bipolar disorder, this study was designed to examine the effect of lamotrigine on plasma GABA levels in healthy humans. Eleven healthy volunteers with no lifetime history of psychiatric illness or family history in first-degree relatives were recruited. Each subject received lamotrigine 100 mg/day for 1 week. Blood samples for assay of plasma levels of GABA were taken from each subject before and after administration of lamotrigine. Plasma GABA levels were analyzed using high-pressure liquid chromatography (HPLC) with fluorescence detection after derivatization with o-phthaldialdehyde (OPA). We found no significant difference in the plasma GABA levels of the study subjects before and after treatment with lamotrigine. The finding of this study suggests that lamotrigine in the dose used in this study does not appear to enhance GABA levels in humans.

The effect of lamotrigine on epileptiform discharges in young patients with drug-resistant epilepsy

PURPOSE

In a double-blind crossover study with lamotrigine (LTG), we investigated a possible relationship between the clinical responses and changes of the amount of epileptiform activity in EEG.

METHODS

Twelve patients, aged 4-21 years, with generalized drug-resistant epilepsy who had responded to LTG, completed the study. Twenty-four-hour video-EEGs were taken during control, placebo, and drug phases. The amounts of epileptiform discharges were estimated and compared with the clinical effects.

RESULTS

The duration of periods of repeated epileptiform discharges was significantly reduced during the LTG phase compared with the placebo phase (n = 12, p = 0.04). Ten patients showed a reduction of the amount of epileptiform discharges in the LTG phase by a mean of 81% (range, 17-100%). Periods of repeated epileptiform discharges with duration longer than 30 s were significantly reduced in length (p = 0.03) and number (p = 0.04) during the LTG phase compared with the placebo phase. Shorter periods of epileptiform discharges and the numbers of single epileptiform discharges were not affected. In five patients there was a seizure reduction (>/=50%) concomitant with the reduction of epileptiform discharges in the EEG. The behavior improved during LTG treatment in all patients. The patients became more alert, and their concentration and performance improved, according to their parents and the medical personnel.

CONCLUSIONS

LTG in dosages of 1-8 mg/kg body weight was found to depress relatively long episodes of interictal, repetitive, epileptiform activity in young patients with drug-resistant epilepsy, whereas short episodes were not affected. It depressed seizures in about half of the patients studied but gave improvements of behavior in all patients.