Strategies for the development of drugs for pharmacoresistant epilepsies

Protective Role of Capsaicin in Neurological Disorders: An Overview

Different pathological conditions that begin with slow and progressive deformations, cause irreversible affliction by producing loss of neurons and synapses. Commonly it is referred to as 'protein misfolding' diseases or proteinopathies and comprises the latest definition of neurological disorders (ND). Protein misfolding dynamics, proteasomal dysfunction, aggregation, defective degradation, oxidative stress, free radical formation, mitochondrial dysfunctions, impaired bioenergetics, DNA damage, neuronal Golgi apparatus fragmentation, axonal transport disruption, Neurotrophins (NTFs) dysfunction, neuroinflammatory or neuroimmune processes, and neurohumoral changes are the several mechanisms that embark the pathogenesis of ND. Capsaicin (8-Methyl-N-vanillyl-6-nonenamide) one of the major phenolic components in chili peppers (Capsicum) distinctively triggers the unmyelinated C-fiber and acts on Transient Receptor Potential Vanilloid-1, which is a Ca²⁺ permeable, non-selective cation channel. Several studies have shown the neuroprotective role of capsaicin against oxidative damage, behavioral impairment, with 6-hydroxydopamine (6-OHDA) induced Parkinson's disease, pentylenetetrazol-induced seizures, global cerebral ischemia, and streptozotocin-induced Alzheimer's disease. Based on these lines of evidence, capsaicin can be considered as a potential constituent to develop suitable neuro-pharmacotherapeutics for the management and treatment of ND. Furthermore, exploring newer horizons and carrying out proper clinical trials would help to bring out the promising effects of capsaicin to be recommended as a neuroprotectant.

Region-specific differences and areal interactions underlying transitions in epileptiform activity

Key points

Local neocortical and hippocampal territories show different and sterotypical patterns of acutely evolving, epileptiform activity.

Neocortical and entorhinal networks show tonic–clonic‐like events, but the main hippocampal territories do not, unless it is relayed from the other areas.

Transitions in the pattern of locally recorded epileptiform activity can be indicative of a shift in the source of pathological activity, and may spread through both synaptic and non‐synaptic means.

Hippocampal epileptiform activity is promoted by 4‐aminopyridine and inhibited by GABA_B receptor agonists, and appears far more sensitive to these drugs than neocortical activity.

These signature features of local epileptiform activity can provide useful insight into the primary source of ictal activity, aiding both experimental and clinical investigation.

Abstract

Understanding the nature of epileptic state transitions remains a major goal for epilepsy research. Simple in vitro models offer unique experimental opportunities that we exploit to show that such transitions can arise from shifts in the ictal source of the activity. These transitions reflect the fact that cortical territories differ both in the type of epileptiform activity they can sustain and in their susceptibility to drug manipulation. In the zero‐Mg²⁺ model, the earliest epileptiform activity is restricted to neocortical and entorhinal networks. Hippocampal bursting only starts much later, and triggers a marked transition in neo‐/entorhinal cortical activity. Thereafter, the hippocampal activity acts as a pacemaker, entraining the other territories to their discharge pattern. This entrainment persists following transection of the major axonal pathways between hippocampus and cortex, indicating that it can be mediated through a non‐synaptic route. Neuronal discharges are associated with large rises in extracellular [K⁺], but we show that these are very localized, and therefore are not the means of entraining distant cortical areas. We conclude instead that the entrainment occurs through weak field effects distant from the pacemaker, but which are highly effective at recruiting other brain territories that are already hyperexcitable. The hippocampal epileptiform activity appears unusually susceptible to drugs that impact on K⁺ conductances. These findings demonstrate that the local circuitry gives rise to stereotypical epileptic activity patterns, but these are also influenced by both synaptic and non‐synaptic long‐range effects. Our results have important implications for our understanding of epileptic propagation and anti‐epileptic drug action.

Local neocortical and hippocampal territories show different and sterotypical patterns of acutely evolving, epileptiform activity.

Neocortical and entorhinal networks show tonic–clonic‐like events, but the main hippocampal territories do not, unless it is relayed from the other areas.

Transitions in the pattern of locally recorded epileptiform activity can be indicative of a shift in the source of pathological activity, and may spread through both synaptic and non‐synaptic means.

Hippocampal epileptiform activity is promoted by 4‐aminopyridine and inhibited by GABA_B receptor agonists, and appears far more sensitive to these drugs than neocortical activity.

These signature features of local epileptiform activity can provide useful insight into the primary source of ictal activity, aiding both experimental and clinical investigation.

The Ethanol Fraction of White Rose Petal Extract Abrogates Excitotoxicity-Induced Neuronal Damage In Vivo and In Vitro through Inhibition of Oxidative Stress and Proinflammation

Since oxidative stress and inflammation are involved in seizure-related neurotoxicity, the neuroprotective effect of a white rose (Rosa hybrida) petal extract (WRPE) in mice that are challenged with kainic acid (KA) were examined using behavioral epileptiform seizures as well as biochemical and morphological parameters of oxidative stress and inflammation. WRPE (50–200 mg/kg) was orally administered to male ICR mice for 15 days, and intraperitoneally challenged with KA (30 mg/kg). Seizure activity, lipid peroxidation, inflammatory cytokines, and related enzymes were analyzed in the brain tissue, in addition to the morphological alterations in the hippocampal pyramidal neurons. Separately, antioxidant ingredients in WRPE were analyzed, and antioxidant, anti-inflammatory, and neuroprotective activities of WRPE were investigated in HB1.F3 human neural stem cells (NSCs) to elucidate underlying mechanisms. Total polyphenol and flavonoid contents in WRPE were 303.3 ± 15.3 mg gallic acid equivalent/g extract and 18.5 ± 2.2 mg catechin/g extract, respectively. WRPE exhibited strong radical-scavenging activities and inhibited lipid peroxidation in vitro, and protected glutamate-induced cytotoxicity in NSCs by suppressing inflammatory process. Treatment with WRPE attenuated epileptiform seizure scores to a half level in KA-challenged mice, and decreased hippocampal pyramidal neuronal injury and loss (cresyl violet and DAPI staining) as well as astrocyte activation (GFAP immunostaining). Lipid peroxidation was inhibited, and mRNA expression of antioxidant enzymes (GPx, PHGPx, SOD1, and SOD2) were recovered in the brain tissues. Inflammatory parameters (cytokines and enzymes) including NF-kB, IL-1β, TNF-α, IL-6, HMGB1, TGF-β, iNOS, COX2, and GFAP mRNAs and proteins were also down-regulated by WRPE treatment. Taken together, the results indicate that WRPE could attenuate KA-induced brain injury through antioxidative and anti-inflammatory activities.

Seizure-induced reduction in PIP3 levels contributes to seizure-activity and is rescued by valproic acid

Phosphatidylinositol (3–5) trisphosphate (PIP₃) is a central regulator of diverse neuronal functions that are critical for seizure progression, however its role in seizures is unclear. We have recently hypothesised that valproic acid (VPA), one of the most commonly used drugs for the treatment of epilepsy, may target PIP₃ signalling as a therapeutic mode of action. Here, we show that seizure induction using kainic acid in a rat in vivo epilepsy model resulted in a decrease in hippocampal PIP₃ levels and reduced protein kinase B (PKB/AKT) phosphorylation, measured using ELISA mass assays and Western blot analysis, and both changes were restored following VPA treatment. These finding were reproduced in cultured rat hippocampal primary neurons and entorhinal cortex–hippocampal slices during exposure to the GABA(A) receptor antagonist pentylenetetrazol (PTZ), which is widely used to generate seizures and seizure-like (paroxysmal) activity. Moreover, VPA's effect on paroxysmal activity in the PTZ slice model is blocked by phosphatidylinositol 3-kinase (PI3K) inhibition or PIP₂ sequestration by neomycin, indicating that VPA's efficacy is dependent upon PIP₃ signalling. PIP₃ depletion following PTZ treatment may also provide a positive feedback loop, since enhancing PIP₃ depletion increases, and conversely, reducing PIP₃ dephosphorylation reduces paroxysmal activity and this effect is dependent upon AMPA receptor activation. Our results therefore indicate that PIP₃ depletion occurs with seizure activity, and that VPA functions to reverse these effects, providing a novel mechanism for VPA in epilepsy treatment.

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In vivo seizure induction (using kainic acid) reduces hippocampal PIP₃ levels.

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In vivo seizure induction (using kainic acid) reduces hippocampal phospho-PKB levels.

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Valproic acid protects against these reductions under seizure conditions only.

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Similar regulation is seen with PTZ-induced in vitro seizure activity.

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Seizure-induced PIP₃ reduction causes a feedback activation of seizure activity.

The antiepileptic drug valproic acid and other medium-chain fatty acids acutely reduce phosphoinositide levels independently of inositol in Dictyostelium

Valproic acid (VPA) is the most widely prescribed epilepsy treatment worldwide, but its mechanism of action remains unclear. Our previous work identified a previously unknown effect of VPA in reducing phosphoinositide production in the simple model Dictyostelium followed by the transfer of data to a mammalian synaptic release model. In our current study, we show that the reduction in phosphoinositide [PtdInsP (also known as PIP) and PtdInsP₂ (also known as PIP₂)] production caused by VPA is acute and dose dependent, and that this effect occurs independently of phosphatidylinositol 3-kinase (PI3K) activity, inositol recycling and inositol synthesis. In characterising the structural requirements for this effect, we also identify a family of medium-chain fatty acids that show increased efficacy compared with VPA. Within the group of active compounds is a little-studied group previously associated with seizure control, and analysis of two of these compounds (nonanoic acid and 4-methyloctanoic acid) shows around a threefold enhanced potency compared with VPA for protection in an in vitro acute rat seizure model. Together, our data show that VPA and a newly identified group of medium-chain fatty acids reduce phosphoinositide levels independently of inositol regulation, and suggest the reinvestigation of these compounds as treatments for epilepsy.

Capsaicin prevents kainic acid-induced epileptogenesis in mice

Epilepsy is a neurodegenerative disease with periodic occurrences of spontaneous seizures as the main symptom. The aim of this study was to investigate the neuroprotective effects of capsaicin, the major ingredient of hot peppers, in a kainic acid (KA)-induced status epilepticus model. After intraperitoneal injections of KA (30mg/kg) in 8-week-old male ICR mice, the animals were treated subcutaneously with capsaicin (0.33mg/kg or 1mg/kg) and then examined for any anti-ictogenic, hypothermic, antioxidative, anti-inflammatory, and anti-apoptotic effects of the capsaicin treatment 3 days after KA treatment. KA injections significantly enhanced neurodegenerative conditions but co-injection with capsaicin reduced the detrimental effects of KA in a dose-dependent manner in mice. The co-administered group that received KA and 1mg/kg of capsaicin showed significantly decreased behavioral seizure activity and body temperature for 3h and also remarkably blocked intense and high-frequency seizure discharges in the parietal cortex for 3 days compared with those that received KA alone. Capsaicin treatment significantly diminished the levels of oxidant activity and malondialdehyde concentration and increased the antioxidant activity in the blood and brain of KA-treated mice. In addition, capsaicin significantly lowered the KA-induced increase in the concentration of the cytokines IL-1β and TNF-α in the brain. Furthermore, co-treatment of KA and capsaicin (1mg/kg) resulted in considerably decreased apoptotic cell death in the cornu ammonis sections of the hippocampus compared with that seen in the KA-alone group. These findings indicate that capsaicin is preventative for the epileptogenesis induced by KA in mice.

Difficulties in Treatment and Management of Epilepsy and Challenges in New Drug Development

Epilepsy is a serious neurological disorder that affects around 50 million people worldwide. Almost 30% of epileptic patients suffer from pharmacoresistance, which is associated with social isolation, dependent behaviour, low marriage rates, unemployment, psychological issues and reduced quality of life. Currently available antiepileptic drugs have a limited efficacy, and their negative properties limit their use and cause difficulties in patient management. Antiepileptic drugs can provide only symptomatic relief as these drugs suppress seizures but do not have ability to cure epileptogenesis. The long term use of antiepileptic drugs is limited due to their adverse effects, withdrawal symptoms, deleterious interactions with other drugs and economic burden, especially in developing countries. Furthermore, some of the available antiepileptic drugs may even potentiate certain type of seizures. Several in vivo and in vitro animal models have been proposed and many new antiepileptic drugs have been marketed recently, but large numbers of patients are still pharmacoresistant. This review will highlight the difficulties in treatment and management of epilepsy and the limitations of available antiepileptic drugs and animal seizure models.

A new potential AED, carisbamate, substantially reduces spontaneous motor seizures in rats with kainate-induced epilepsy

PURPOSE

Animal models with spontaneous epileptic seizures may be useful in the discovery of new antiepileptic drugs (AEDs). The purpose of the present study was to evaluate the efficacy of carisbamate on spontaneous motor seizures in rats with kainate-induced epilepsy.

METHODS

Repeated, low-dose (5 mg/kg), intraperitoneal injections of kainate were administered every hour until each male Sprague-Dawley rat had experienced convulsive status epilepticus for at least 3 h. Five 1-month trials (n = 8-10 rats) assessed the effects of 0.3, 1, 3, 10, and 30 mg/kg carisbamate on spontaneous seizures. Each trial involved six AED-versus-vehicle tests comprised of carisbamate or 10% solutol-HS-15 treatments administered as intraperitoneal injections on alternate days with a recovery day between each treatment day.

RESULTS

Carisbamate significantly reduced motor seizure frequency at doses of 10 and 30 mg/kg, and caused complete seizure cessation during the 6-h postdrug epoch in seven of the eight animals at 30 mg/kg. The effects of carisbamate (0.3-30 mg/kg) on spontaneous motor seizures appeared dose dependent.

CONCLUSIONS

These data support the hypothesis that a repeated-measures, crossover protocol in animal models with spontaneous seizures is an effective method for testing AEDs. Carisbamate reduced the frequency of spontaneous motor seizures in a dose-dependent manner, and was more effective than topiramate at reducing seizures in rats with kainate-induced epilepsy.

Kinetic changes and modulation by carbamazepine on voltage-gated sodium channels in rat CA1 neurons after epilepsy

AIM

To study whether the functional properties of sodium channels, and subsequently the channel modulation by carbamazepine (CBZ) in hippocampal CA1 neurons can be changed after epileptic seizures.

METHODS

We used the acutely dissociated hippocampal CA1 pyramidal cells from epilepsy model rats 3 weeks and 3 months respectively after kainate injection, and whole-cell voltage-clamp techniques.

RESULTS

After long-term epileptic seizures, both sodium channel voltage-dependence of activation and steady-state inactivation shifted to more hyperpolarizing potentials, which resulted in the enlarged window current; the membrane density of sodium current decreased and the time constant of recovery from inactivation increased. CBZ displayed unchanged efficacy on sodium channels, with a similar binding rate to them, except that at higher concentrations, the voltage shift of inactivation was reduced. For the short-term kainate model rats, no differences were detected between the control and epilepsy groups.

CONCLUSION

These results indicate that the properties of sodium channels in acutely dissociated hippocampal neurons could be changed following long-term epilepsy, but the alternation might not be enough to induce the channel resistance to CBZ.

Protective effect of vineatrol against kainic acid induced seizures, oxidative stress and on the expression of heat shock proteins in rats

The aim of the present study was to evaluate the effect of an antioxidant vineatrol against kainic acid-induced seizures, markers of oxidative stress and expression of heat shock protein in brain. In rats, kainic acid (10 mg/kg i.p.) induced long lasting seizures, associated behavioral symptoms and brain damage and significantly increased level of brain malondialdehyde (MDA) (283 +/- 42 nmol/g wet tissue) as compared to control (173.3 +/- 10.2 nmol/g wet tissue). Pretreatment (5 min) of vineatrol (10, 20 and 40 mg/kg i.p.) could not inhibit the convulsions though the latency was significantly increased with 20 and 40 mg/kg. However when the drug was administrated 5 min prior and repeated at 30 and 90 min after kainic acid there was significant reduction in incidence of convulsions. The brain MDA levels were also found to be significantly attenuated, however the glutathione levels were not different in control, kainic acid and vineatrol treated animals. Expression of heat shock protein (HSP) 72 was observed in the kainic acid per se group indicating neurotoxicity as compared to the control group and was reduced by vineatrol. The study suggests the potential use of vineatrol in status epilepticus.

Molecular Pharmacology of Topiramate: Managing Seizures and Preventing Migraine

Topiramate is a neuromodulatory compound with stabilizing properties that was initially introduced for the management of partial seizures. Topiramate has been demonstrated to modify several receptor-gated and voltage-sensitive ion channels, including voltage-activated Na+ and Ca2+ channels and non-NMDA receptors. These receptors have been implicated in the pathophysiology of both epilepsy and migraine. The pharmacological mechanisms of action for topiramate that may explain its antiepileptic and migraine preventive activities will be discussed in this review. In addition, the potential relationship between the molecular activities of topiramate and its efficacy in epilepsy and migraine prevention will be emphasized.

Caffeic acid phenethyl ester exerts a neuroprotective effect on CNS against pentylenetetrazol-induced seizures in mice

Since overexcitation of excitatory amino acid is an important mechanism in seizure genesis wherein free radicals have recently been suggested to play a critical role, we explored the effects of caffeic acid phenethyl ester (CAPE) administration in pentylenetetrazole (PTZ)-induced seizure in mice. CAPE prevents the oxidative damage in brain tissue induced by PTZ, scavenging reactive oxygen species (ROS). Our results demonstrate that CAPE treatment which prevents free radical production and ameliorates seizure severity may be useful at least as an adjunctive treatment of seizure disorders.

Inhibition of sustained repetitive firing in cultured hippocampal neurons by an aqueous fraction isolated from Delphinium denudatum

In this report we investigated the effects of the aqueous fraction (AF) isolated from Delphinium denudatum on sustained repetitive firing in cultured neonatal rat hippocampal pyramidal neurons. Blockade of SRF is one of the basic mechanisms of antiepileptic drugs (AED) at the cellular level. The effects of aqueous fraction (0.2-0.6 mg/ml) were compared with the prototype antiepileptic drug, phenytoin (PHT). Using the whole cell current-clamp technique, sustained repetitive firing was elicited in neurons by a depolarizing pulse of 500 ms duration, 0.3 Hz and 0.1-0.6 nA current strength. Similar to phenytoin, aqueous fraction reduced the number of action potentials (AP) per pulse in a concentration-dependent manner until no action potentials were elicited for the remainder of the pulse. There was a corresponding use-dependent reduction in amplitude and Vmax (velocity of upstroke) of action potentials. The Vmax and amplitude of the first action potential was not affected by phenytoin, while aqueous fraction exhibited concentration-dependent reduction. At 0.6 mg/ml aqueous fraction reduced Vmax to 58-63% and amplitude to 16-20% of the control values. The blockade of sustained repetitive firing by aqueous fraction was reversed with hyperpolarization of membrane potential (-65 to -75 mV) while depolarization of membrane potential (-53 to -48 mV) potentiated the block. The results suggest that aqueous fraction blocks sustained repetitive firing in hippocampal neurons in a use-dependent and voltage-dependent manner similar to phenytoin. However, unlike phenytoin, which interacts preferably with the inactive state of the Na+ channel, the compounds present in aqueous fraction apparently also interact with the resting state of the Na+ channels as suggested by dose-dependent reduction of Vmax and amplitude of first AP. We conclude that aqueous fraction contains potent anticonvulsant compounds.

A kindling model of pharmacoresistant temporal lobe epilepsy in Sprague-Dawley rats induced by Coriaria lactone and its possible mechanism

PURPOSE

The aim of this study was to develop a new animal model of pharmacoresistant temporal lobe epilepsy (TLE) by repeated intramuscular injection of Coriaria lactone (CL) at subthreshold dosages and to explore the mechanisms that might be involved.

METHODS

Healthy male Sprague-Dawley rats (n = 160) were randomized into four groups during the kindling process: three groups (n = 50 for each group) received CL injection at subthreshold dosages (1.25, 1.5, and 1.75 mg/kg, respectively), and ten received normal saline (NS) injection as a control group. The maximal human adult dosage of carbamazepine (CBZ), valproate (VPA), and phenytoin (PHT) was administered as monotherapy to different groups of kindled rats for 1 month (n = 20 for each group). Changes in EEG recording, seizure number, intensity (expressed as grade 1-5 according to Racine stage), and duration, including spontaneous seizures during different interventions, were compared. The expression of P-170, a multiple drug resistance gene (MDR1) encoding P-glycoprotein, was measured in brain samples from different groups of experimental rats by using an image analysis and measurement system (ImagePro-Plus 4.0).

RESULTS

A total of 70 (46.7%) rats were fully kindled with a median of 15 (seven to 20) CL injections. Electrocorticogram (ECoG) including hippocampal (EHG) monitoring revealed the temporal lobe origins of epileptiform potentials, which were consistent with the behavioral changes observed. Spontaneous seizures occurred with frequency and diurnal patterns similar to those of human TLE. The antiepileptic drugs (AEDs) tested lacked a satisfactory seizure control. The maximal P-170 expression was in the kindled rats with AED treatment; the next highest was in the kindled rats without AED intervention. Nonkindled SD rats with CL injection also had increased P-170 expression compared with control SD rats.

CONCLUSIONS

The study provided a simple and stable animal TLE kindling model with pharmacoresistant properties. The pharmacoresistance observed in the kindled rats to CBZ, VPA, and PHT at maximal human adult dosages together with the increased P-170 expression was a distinct feature of this model. This model might be used in further investigations of the mechanisms involved in pharmacoresistant TLE and for developing new AEDs.

New strategies for the identification of drugs to prevent the development or progression of epilepsy

During the last decade, several new antiepileptic drugs (AEDs) have been introduced in Europe, the United States, or other parts of the world. Although the antiepileptic efficacy of these drugs is not superior to that of older AEDs, some of the new drugs offer advantages in terms of improved tolerability, ease of use, and reduced interaction potential with other drugs. However, the new AEDs have only a modest impact on patients with refractory epilepsies, so that about one third of patients with epilepsy continue to have seizures with current pharmacotherapies. Thus, there is a continuing need for new medical therapies in epilepsy. During the Workshop on "New Horizons in the Development of Antiepileptic Drugs" (November 28-29, 2001, Philadelphia, PA), one topic dealt with the critical re-evaluation of previous preclinical strategies for the discovery and the development of new AEDs. The discussion of this session, which was chaired by the authors, is summarized in this article. Main issues of the discussion were whether epilepsy is a progressive disease and whether refractory epilepsy is preventable, the use of acute versus chronic animal models in the discovery and development of new AEDs, models for drug-resistant epilepsy, mechanisms of drug resistance, alterations in adverse effect potential of AEDs by epilepsy, and advances in pharmacogenomics and our understanding of pharmacologic responsiveness in epilepsy. Overall, it was felt that the current preclinical strategies for the discovery and development of new AEDs have to be redefined in order to identify agents that are clearly superior to current medications.

Animal models of limbic epilepsies: what can they tell us?

In this review, we have provided an overview of the implementation and characteristics of some of the most prevalent models of temporal lobe epilepsy in use in laboratories around the world today. These include spontaneously seizing models with status epilepticus as the initial precipitating injury (including the kainate, pilocarpine, and electrical stimulation models), kindling, and models of drug refractoriness. These models share various features with one another, and also differ in many aspects, providing a broader representation of the full spectrum of clinical limbic epilepsies. We have also provided a brief introduction into how animal models of temporal lobe epilepsy facilitate use of modern state-of-the-art techniques in neurobiology to address critical questions in the pathogenesis of epilepsy.

Protective effect of trans-resveratrol against kainic acid-induced seizures and oxidative stress in rats

Overexcitation of excitatory amino acid is an important mechanism in seizure genesis wherein free radicals have recently been suggested to play a critical role. Thus, intervention by antioxidants can be a potential beneficial approach in the treatment of epilepsy. The present study was undertaken to see the effect of trans-resveratrol, a potent antioxidant, against kainic acid-induced seizures, and effect on markers of oxidative stress in brain. Kainic acid, 10 mg/kg ip, induced long-lasting seizures and associated symptoms. The brain level of malondialdehyde (MDA) was found to be significantly raised after kainic acid administration (295 +/- 18 nmol/g wet tissue) as compared to control (195 +/- 26 nmol/g wet tissue). Pretreatment (5 min) of single dose of trans-resveratrol (40 mg/kg i.p.) could not inhibit the convulsions though the latency was significantly increased. When multiple doses of trans-resveratrol were injected in two-dose schedules in different animals (20 and 40 mg/kg ip, 5 min prior and repeated 30 and 90 min after kainic acid), there was significant reduction in incidence of convulsions in both treatment schedules. The brain MDA levels were found to be significantly attenuated in the trans-resveratrol-treated groups (multiple doses of 20 and 40 mg/kg) as compared to the kainic acid alone. However, the glutathione level in control, kainic acid- and trans-resveratrol-treated animals were not significantly different. The protective effect of trans-resveratrol against kainic acid-induced convulsions and the attenuation of raised MDA level suggest the potential use of antioxidants at least as adjunct therapy in epilepsy.

Effect of phenytoin on sodium and calcium currents in hippocampal CA1 neurons of phenytoin-resistant kindled rats

About 20-30% of patients with epilepsy continue to have seizures despite carefully monitored treatment with antiepileptic drugs. The mechanisms explaining why some patients' respond and others prove resistant to antiepileptic drugs are poorly understood. It has been proposed that pharmacoresistance is related to reduced sensitivity of sodium channels in hippocampal neurons to antiepileptic drugs such as carbamazepine or phenytoin. In line with this proposal, a reduced effect of carbamazepine on sodium currents in hippocampal CA1 neurons was found in the rat kindling model of temporal lobe epilepsy (TLE), i.e. a form of epilepsy with the poorest prognosis of all epilepsy types in adult patients. To address directly the possibility that neuronal sodium currents in the hippocampus play a crucial role in the pharmacoresistance of TLE, we selected amygdala-kindled rats with respect to their in vivo anticonvulsant response to phenytoin into responders and nonresponders and then compared phenytoin's effect on voltage-activated sodium currents in CA1 neurons. Furthermore, in view of the potential role of calcium current modulation in the anticonvulsant action of phenytoin, the effect of phenytoin on high-voltage-activated calcium currents was studied in CA1 neurons. Electrode-implanted but not kindled rats were used as sham controls for comparison with the kindled rats. In all experiments, the interval between last kindled seizure and ion channel measurements was at least 5 weeks. In kindled rats with in vivo resistance to the anticonvulsant effect of phenytoin (phenytoin nonresponders), in vitro modulation of sodium and calcium currents by phenytoin in hippocampal CA1 neurons did not significantly differ from respective data obtained in phenytoin responders, i.e. phenytoin resistance was not associated with a changed modulation of the sodium or calcium currents by this drug. Compared to sham controls, phenytoin's inhibitory effect on sodium currents was significantly reduced by kindling without difference between the responder and nonresponder subgroups. Further studies in phenytoin-resistant kindled rats may help to elucidate the mechanisms that can explain therapy resistance.

In vivo evidence for P-glycoprotein-mediated transport of phenytoin at the blood-brain barrier of rats

PURPOSE

The multidrug transporter P-glycoprotein (P-gp) is expressed at high levels in a variety of tissues such as the endothelial cells of the blood-brain barrier (BBB) capillaries, where it is thought to be involved in the exclusion of various drugs from the capillary endothelial cells, blocking their entry into brain. It was previously shown that pharmacoresistant partial epilepsy is associated with an increased expression of P-gp in brain capillary endothelium and astrocytes, leading to the hypothesis that increased P-gp expression may be involved in medically intractable epilepsy. However, it is not known whether the distribution of antiepileptic drugs (AEDs) into the brain is limited by P-gp. We used in vivo microdialysis in freely moving rats to study whether the concentration of the major AED phenytoin (PHT) in the extra-cellular fluid (ECF) of the cerebral cortex can be enhanced by inhibition of P-gp.

METHODS

Three different P-gp inhibitors, sodium cyanide, verapamil, and PSC 833, were used. These drugs were given via the microdialysis probe in the right frontal cortex, while a probe in the left cortex served as vehicle control side. Perfusion with the inhibitor started 15-60 min before systemic (i.p.) administration of PHT, 50 mg/kg.

RESULTS

PHT rapidly entered the brain ECF compartment, but ECF plasma ratios at time of maximal ECF levels were only approximately 0.04. All P-gp inhibitors significantly increased the ECF concentrations of PHT after local administration, indicating that P-gp in the BBB normally limits the distribution of PHT into the brain parenchyma. Cremorphor EL, the vehicle used to administer PSC, also was able to increase ECF PHT, which is explained by the previously reported inhibitory effect of cremophor on P-gp.

CONCLUSIONS

Provided that multidrug transporters such as P-gp also are involved in the BBB outward transport of other AEDs, increased expression of multidrug transporters, leading to inadequate accumulation of AEDs in the brain, would be a likely explanation for pharmacoresistant epilepsy.

Anticonvulsant activities of the FS-1 subfraction isolated from roots of Delphinium denudatum

Delphinium denudatum Wall. (Ranunculaceae) is a medicinal herb used for the treatment of epilepsy in the subcontinent. The present study reports the anticonvulsant activities in the maximal electroshock test (MEST) and subcutaneous pentylenetetrazole (PTZ), bicuculline (BIC), picrotoxin (PIC)-induced seizures of the FS-1 subfraction (FS-1) that was obtained by purification of an aqueous fraction isolated from the roots of D. denudatum. In CF 1 mice, FS-1 (600 mg/kg i.p.) exhibited very potent anticonvulsant activity that was comparable to the effects of the well-known antiepileptic drug phenytoin (20 mg/kg) in MEST and protected 100% animals from hind limb tonic extension phase of this model. FS-1 also suppressed PTZ-induced threshold seizure and the loss of the righting reflex with tonic fore and hind limb extension by 100%, similar to the antiepileptic drug valproic acid (350 mg/kg). BIC-induced seizures were suppressed in 80% of the animals. FS-1 exhibited weak anticonvulsant effect on PIC-induced seizures, however, it significantly reduced mortality and delayed the onset of seizures. FS-1 had no effect on strychnine (STN)-induced extensor seizures. The results demonstrate the broad and potent anticonvulsant activity of the compounds in FS-1 of D. denudatum.

Proof of efficacy trials: choosing the dose

It is apparent from current usage of antiepileptic drugs (AEDs) and from retrospective review of their drug development programmes, that the doses currently used in clinical practice differ from those which were used in clinical trials. This raises the question of how dose and titration schedules are selected in early development. An integral component of a drug development programme should be an assessment of dose response. The International Council on Harmonization of Technical Requirements for the Registration of Pharmaceuticals for Human Use [1994. Guidelines for industry: Dose-response information to support drug registration. ICH-E4. Federal Register] regulatory guidelines suggest that, at a minimum, three elements of dosing should be characterised: a maximum well tolerated dose, a minimum effective dose, and an appropriate rate of titration. Several specific designs can be utilised to assess dose response, which fall broadly into four categories, namely free titration, forced titration and dose escalation, parallel dose response, and dose reduction studies. In addition to these standard approaches, concentration-defined trials are an alternative in some circumstances and have been used with success in the development of newer AEDs. The designs chosen to address these elements are dependent upon the phase of development of the drug, and the severity of the disease, however, it is clear that conducting dose response studies earlier in the development programme may reduce the number of failed Phase 3 studies.

Update on the pathophysiology of the epilepsies

The pathophysiology of convulsive and non-convulsive epilepsies is discussed in its primary generalised forms. Focal, clinical and experimental epilepsies, with emphasis placed on the temporal lobe epilepsies (TLE) and their pathophysiologies are also reviewed. Neurotransmitters and neuromodulators and between them, the second messenger systems are considered in the generation, maintenance or inhibition of the epileptic discharge. Action mechanisms of the more classic antiepileptic drugs are briefly summarized along with the therapeutic strategies that might achieve the final control of abnormal discharges, including genetic control as a promising alternative in the current state of research. We emphasized the study of all type of glutamate and GABA receptors and their relation with mRNA editing in the brain. Some of the genetic studies which have been so fruitful during the last ten years and which have brought new insights regarding the understanding of epileptic syndromes are summarized in this article.

Valproate: a reappraisal of its pharmacodynamic properties and mechanisms of action

Valproate is currently one of the major antiepileptic drugs with efficacy for the treatment of both generalized and partial seizures in adults and children. Furthermore, the drug is increasingly used for therapy of bipolar and schizoaffective disorders, neuropathic pain and for prophylactic treatment of migraine. These various therapeutic effects are reflected in preclinical models, including a variety of animal models of seizures or epilepsy. The incidence of toxicity associated with the clinical use of valproate is low, but two rare toxic effects, idiosyncratic fatal hepatotoxicity and teratogenicity, necessitate precautions in risk patient populations. Studies from animal models on structure-relationships indicate that the mechanisms leading to hepatotoxicity and teratogenicity are distinct and also differ from the mechanisms of anticonvulsant action of valproate. Because of its wide spectrum of anticonvulsant activity against different seizure types, it has repeatedly been suggested that valproate acts through a combination of several mechanisms. As shown in this review, there is substantial evidence that valproate increases GABA synthesis and release and thereby potentiates GABAergic functions in some specific brain regions, such as substantia nigra, thought to be involved in the control of seizure generation and propagation. Furthermore, valproate seems to reduce the release of the epileptogenic amino acid gamma-hydroxybutyric acid and to attenuate neuronal excitation induced by NMDA-type glutamate receptors. In addition to effects on amino acidergic neurotransmission, valproate exerts direct effects on excitable membranes, although the importance of this action is equivocal. Microdialysis data suggest that valproate alters dopaminergic and serotonergic functions. Valproate is metabolized to several pharmacologically active metabolites, but because of the low plasma and brain concentrations of these compounds it is not likely that they contribute significantly to the anticonvulsant and toxic effects of treatment with the parent drug. By the experimental observations summarized in this review, most clinical effects of valproate can be explained, although much remains to be learned at a number of different levels of valproate's mechanisms of action.

Clinical aspects and biological bases of drug-resistant epilepsies

The definition of drug-resistant epilepsy (DRE) is elusive and still controversial owing to some unresolved questions such as: how many drugs should be tried before a patient is considered intractable; to which extent side-effects may be acceptable; how many years are necessary before establishing drug resistance. In some cases, the view of epilepsy as a progressive disorder constitutes another important issue. Despite the use of new antiepileptic drugs (AEDs), intractable epilepsy represents about 20-30% of all cases, probably due to the multiple pathogenetic mechanisms underlying refractoriness. Several risk factors for pharmacoresistance are well known, even if the list of clinical features and biological factors currently accepted to be associated with difficult-to-treat epilepsy is presumably incomplete and, perhaps, disputable. For some of these factors, the biological basis may be common, mainly represented by mesial temporal sclerosis or by the presence of focal lesions. In other cases, microdysgenesis or dysplastic cortex, with abnormalities in the morphology and distribution of local-circuit (inhibitory) neurons, may be responsible for the severity of seizures. The possible influence of genes in conditioning inadequate intraparenchimal drug concentration, and the role of some cytokines determining an increase in intracellular calcium levels or an excessive growth of distrophic neurites, constitute other possible mechanisms of resistance. Several hypotheses on the mechanisms involved in the generation of DRE have been indicated: (a) ontogenic abnormalities in brain maturation; (b) epilepsy-induced alterations in network, neuronal, and glial properties in seizure-prone regions such as the hippocampus; (c) kindling phenomenon; (d) reorganization of cortical tissue in response to seizure-induced disturbances in oxygen supply. Such hypotheses need to be confirmed with suitable experimental models of intractable epilepsy that are specifically dedicated, which have until now been lacking.

Pattern and pharmacology of propagating epileptiform activity in mouse cerebral cortex

Multiple extracellular recording electrodes were used to study the intra- and interhemispheric spread of stimulus-evoked epileptiform responses in adult mouse neocortical slices. Bath application of 20 microM bicuculline methiodide induced epileptiform activity that propagated at approximately 0.08 m/s over several millimeters in rostro-caudal and medio-lateral direction within the ipsilateral hemisphere and across the corpus callosum to the contralateral hemisphere. A vertical incision from layer II to subcortical regions did not prevent the spread to remote cortical regions, indicating that layer I plays a major role in the lateral propagation of epileptiform activity. The intra- and interhemispheric spread was not influenced by application of an N-methyl-d-aspartate (NMDA) receptor antagonist, but blocked by an antagonist acting at the (+/-)-alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA)-type glutamate receptor. The potential role of potassium channel activation in controlling the generation or spread of epileptiform activity was tested by applying the potassium channel opener cromakalim and the serotonin type 1A (5-HT1A) receptor agonist (+/-)-8-hydroxydipropylaminotetralin (8-OH-DPAT) to the disinhibited slices. Whereas cromakalim reduced the neuronal excitability and blocked all epileptiform responses, 8-OH-DAPT did not affect the activity pattern. Our results suggest that propagating epileptiform activity in disinhibited neocortical structures is predominantly mediated by activation of AMPA receptors and controllable by activation of a voltage-dependent potassium current.

Limbic epileptogenesis alters the anticonvulsant efficacy of phenytoin in Sprague-Dawley rats

Studies on the anticonvulsant efficacy of the major antiepileptic drug phenytoin in kindled rats have often reported inconsistent effects. It has been proposed that technical and genetic factors or poor and variable absorption of phenytoin after i.p. or oral administration may be involved in the lack of consistent anticonvulsant activity of phenytoin in this model of temporal lobe epilepsy. We examined if kindling itself changes the anticonvulsant efficacy of phenytoin by testing this drug before and after amygdala kindling in male and female Sprague-Dawley rats. To exclude the possible bias of poor and variable absorption, blood was sampled in all experiments for drug analysis in plasma. The threshold for induction of focal seizures (afterdischarge threshold; ADT) was used for determining phenytoin's anticonvulsant activity. Before kindling, phenytoin, 75 mg/kg i.p., markedly increased ADT in both genders, although the effect was more pronounced in males. Following kindling, the anticonvulsant activity obtained with phenytoin, 75 mg/kg, before kindling was totally lost, and female rats even exhibited a proconvulsant effect upon administration of this dose, indicating that kindling had dramatically altered the anticonvulsant efficacy of phenytoin. Plasma levels of phenytoin were comparable before and after kindling, and were within or near to the 'therapeutic range' known from epileptic patients. When the dose of phenytoin was reduced to 50 or 25 mg/kg i.p., significant anticonvulsant effects on ADT were obtained. When phenytoin, 50 mg/kg, was administered i.p. or i.v. in the same group of fully kindled rats, both anticonvulsant activity and plasma drug levels were comparable with both routes, indicating that the i.p. route is suited for such studies. The data indicate that kindling alters the dose-response of phenytoin in that a high anticonvulsant dose becomes ineffective or proconvulsant after kindling, possibly by an increased sensitivity of the kindled brain to proconvulsant effects of phenytoin which normally only occur at much higher doses. If similar alterations evolve in humans during development of chronic epilepsy, this may be involved in the mechanisms leading to intractability of temporal lobe epilepsy.

Effects of phenytoin, carbamazepine, and gabapentin on calcium channels in hippocampal granule cells from patients with temporal lobe epilepsy

PURPOSE

The anticonvulsants phenytoin (PHT), carbamazepine (CBZ), and gabapentin (GBP) are commonly used in the treatment of temporal lobe epilepsy. Ca2+ current modulation has been proposed to contribute to the antiepileptic activity of these drugs. The purpose of this study was to determine the effects of these anticonvulsants on voltage-dependent calcium channels in pathologically altered neurons from patients with chronic temporal lobe epilepsy.

METHODS

Acutely isolated human hippocampal granule cells were examined by using the whole-cell configuration of the patch-clamp technique.

RESULTS

PHT and CBZ produced a reversible, concentration-dependent inhibition of high-voltage-activated (HVA) Ca2+ currents without affecting voltage-dependent activation. The concentration-response curves of PHT and CBZ indicated maximal inhibition of 35 and 65%, respectively, with half-maximal inhibition being obtained at 89 and 244 microM, respectively. At therapeutic cerebrospinal fluid (CSF) concentrations, HVA currents were not significantly altered by PHT and CBZ. However, PHT but not CBZ showed a reduction of HVA currents of 16% at a therapeutic whole-brain concentration of 80 microM. In contrast to CBZ, PHT produced a small hyperpolarizing shift in the voltage dependence of steady-state inactivation. PHT, 80 microM, shifted the potential of half-maximal inactivation by -3.1 +/- 0.5 mV (p < 0.05). GBP, which was recently found to bind to the alpha2delta subunit of a neuronal Ca2+ channel, showed no modulation of Ca2+ conductances.

CONCLUSIONS

These results suggest that, in contrast to GBP and CBZ, modulation of postsynaptic Ca2+ channels can contribute to the anticonvulsant action of PHT in human hippocampal granule cells.

Comparison of effects of valproate and trans-2-en-valproate on different forms of epileptiform activity in rat hippocampal and temporal cortex slices

PURPOSE

Reducing the extracellular magnesium or calcium or increasing the extracellular potassium induces different patterns of epileptiform activity in the hippocampus and the entorhinal cortex. Although in the low Ca2+ and K+ models, seizure-like events (SLEs) develop in area CA1 of the hippocampus, only short recurrent discharges develop in the low Mg2+ model. In contrast, in low Mg2+, SLEs and late recurrent discharges (LRDs) are observed in the entorhinal cortex.

METHODS

We compared the effects of valproate (VPA) and its major metabolite, trans-2-en-VPA (TVPA), on all these different model activities using extracellular field potential measurements. We also investigated the equilibration time course of VPA in the slice by using VPA-sensitive microelectrodes.

RESULTS

Both drugs reversibly blocked most forms of epileptiform activity. The only exception was the LRDs in the entorhinal cortex. In paired experiments, TVPA appeared to be more effective than VPA bath applied with the same concentration to the same slice. With our measurements of the VPA concentrations in slices, we showed that the concentrations used were close to therapeutic drug levels.

CONCLUSIONS

If TVPA stands the toxicological tests, it might be a useful alternative in the treatment of seizures.

New visions in the pharmacology of anticonvulsion

Seizures are resistant to treatment with currently available anticonvulsant drugs in about 1 out of 3 patients with epilepsy. Thus, there is a need for new, more effective anticonvulsant drugs for intractable epilepsy. Furthermore, because of the inadequacy of the currently available anticonvulsant armamentarium with respect to safety, newly developed drugs should be less toxic than existing drugs. Previous and current strategies for development of novel anticonvulsants with improved efficacy or safety are critically discussed in this review. 'Old drugs' (or 'first generation' drugs), which were developed and introduced between 1910 and 1970, are compared with new anticonvulsants both in terms of clinical efficacy and safety and in terms of mechanisms of action. The new drugs are referred to as 'second generation' drugs, i.e. anticonvulsants which have been introduced into clinical practice in recent years, or 'third generation' drugs, i.e. compounds in the pipeline of development. In spite of some 30 years of 'modern' neuroscientific epilepsy research, most novel, clinically effective second generation anticonvulsants have been found by screening (i.e. serendipity) or structural variation of known drugs and not by rational strategies based on knowledge of processes involved in generation of seizures or in development of epilepsy. An exception are only the GABA (gamma-aminobutyrate)-mimetic drugs vigabatrin and tiagabine and, to some extent, gabapentin, which have been developed by a rational strategy, i.e. the 'GABA hypothesis' of epilepsy. The fact that preclinical seizure models used for identification and development of novel drugs have been originally validated by old drugs, i.e. conventional anticonvulsants, may explain that several of the new drugs possess mechanisms which do not differ from those of the standard drugs. This may also explain that none of the new drugs seems to offer any marked advantage towards the old, first generation drugs with respect to the ultimate goal of drug treatment of epilepsy, i.e. complete control of seizures, although some of the second generation drugs may have benefits in terms of side effects and tolerability. It is to be hoped that the various novel currently used or planned strategies for drug development produce more effective and safe anticonvulsants than previous strategies. This goal can only be achieved by strengthening our understanding of the fundamental pathophysiology of seizure expression and epileptogenesis as theoretical substrates for new pharmacological strategies, and by devising and refining laboratory models for studying new agents obtained by such strategies.

Animal models of intractable epilepsy

Twenty to 30% of patients with epilepsy develop chronic or intractable epilepsy, i.e. the seizures persist despite accurate diagnosis and carefully monitored treatment with antiepileptic drugs. It is still not known why and how epilepsy becomes an intractable disorder in such patients, while other patients with seemingly identical seizure types can achieve control of seizures with medication. Experimental epilepsy research has generated new neurophysiological, neurochemical and neuropharmacological approaches but is still hampered by a lack of adequate experimental models of chronic intractable epilepsy. An animal model of epilepsy allowing selection of pharmacoresistant and pharmacosensitive subgroups of animals would be a valuable tool to study mechanisms of intractability and to develop more effective treatment strategies. This review concentrates on identifying animal models that mimic patterns of pharmacological resistance in humans with epilepsy. Two models seem to be interesting in this regard, epileptic dogs with different types of spontaneous recurrent seizures and amygdala-kindled rats. In both models, animals which do not respond to repeated or chronic administration of antiepileptic drugs (non-responders) can be separated from animals in whom antiepileptics are effective (responders). Unfortunately, the dog model has several inherent logistical problems, whereas pharmacoresistant subgroups of kindled rats offer a unique tool to study why seizures become intractable, particularly because pathophysiologically processes in these resistant rats can be compared directly with those of kindled rats which respond to treatment. Furthermore, the new rat model can be used to identify predictors of intractability during onset of treatment with an antiepileptic drug and is a valuable addendum to the battery of animal models used in preclinical evaluation of novel drugs. In addition to pharmacoresistant epileptic dogs and kindled rats, several other potential models of intractable epilepsy are described to stimulate and outline areas for future research.

Low brain GABA level is associated with poor seizure control

Low gamma-aminobutyric acid (GABA) concentrations in the cerebrospinal fluid are seen in a variety of epileptic syndromes. Low GABA levels outside of the epileptic focus may facilitate spread of discharges beyond the focus. In vivo measurements of GABA were made by 1H spectroscopy using a 2.1-T magnetic resonance imager-spectrometer and an 8-cm surface coil to measure a 14-cm3 volume in the occipital lobe. Patients with complex partial seizures had lower GABA levels (1.03 mmol/kg of brain; 95% confidence interval [CI], 0.95-1.12; n = 28; p < 0.02) than did subjects without epilepsy (1.18; 95% CI, 1.13-1.24; n = 19). There was a significant association between low GABA levels and recent seizures (correlation coefficient of 0.548, p < 0.01, df of 32). Conversely, patients with well-controlled seizures had higher brain GABA levels than did patients with recent seizures. Patients with seizures within a day of the measurement had lower GABA levels (0.92 mmol/kg; 95% CI, 0.78-1.06; n = 7) than did patients who were seizure free for 5 years or longer (1.28; 95% CI, 1.09-1.47; n = 4). Poor seizure control is associated with low brain GABA levels.

New drugs for the treatment of epilepsy

OBJECTIVES

This article will review current data on the metabolism, interactions, methods of analysis, and adverse effects observed with the use of new anticonvulsant drugs. The role of the laboratory in the provision of therapeutic drug monitoring for these drugs is discussed.

CONCLUSION

Certain of the newer anticonvulsant drugs require therapeutic drug monitoring for their optimal use in the treatment of epileptic seizures. The requirement for therapeutic drug monitoring has not been established for some of these drugs. Many of the newer anticonvulsant drugs, including lamotrigine, felbamate, vigabatrin, and zonisamide, interact clinically with established drugs, such as phenytoin, phenobarbital, carbamazepine, and valproic acid. Introduction of these new drugs will result in the need for more frequent monitoring of the established drugs during polytherapy. The need for a drug-monitoring service for anticonvulsant drugs overall will continue, due to the frequency of drug interactions, the incidence of adverse effects, and concerns about compliance with the dosing regimen in these patients.

gamma-aminobutyric acidA receptor regulation: heterologous uncoupling of modulatory site interactions induced by chronic steroid, barbiturate, benzodiazepine, or GABA treatment in culture

Prolonged administration of anxiolytic, sedative, and anticonvulsant drugs that act through the GABAA receptor (GABAAR) can evoke tolerance and dependence, suggesting the existence of an endogenous mechanism(s) for altering the ability of such agents to interact with the GABAAR. Uncoupling appears to be one such mechanism. This is a decrease in the allosteric interactions between the benzodiazepine (BZD) recognition site and other agonist or modulator sites on the GABAAR, as measured by potentiation of [3H]flunitrazepam ([3H]FNZ) binding. To investigate the mechanism(s) of uncoupling, neuronal cultures were treated chronically with 3 alpha-hydroxy-5 beta-pregnan-20-one (pregnanolone), pentobarbital, flurazepam, or GABA, then tested for enhancement of [3H]FNZ binding by these substances. The results indicate that BZDs, barbiturates, and steroids, as well as GABA itself, are capable of inducing both heterologous and homologous uncoupling. Surprisingly, different chronic drug treatments produce different patterns of homologous and heterologous uncoupling. Chronic exposure to pregnanolone, GABA, flurazepam or pentobarbital induces complete uncoupling of barbiturate-BZD site interactions, partial uncoupling of GABA-BZD site interactions, but different amounts of uncoupling of steroid-BZD site interactions. In addition, the EC50 for pregnanolone-induced homologous uncoupling (1.7 microM) is over an order of magnitude greater than that for heterologous uncoupling of GABA and BZD sites (82 nM). Moreover, heterologous uncoupling by pregnanolone is inhibited by the GABA site antagonist SR-95531, whereas homologous uncoupling by pregnanolone is resistant to SR-95531. Therefore, there are at least two distinct ways in which GABAAR modulatory site interactions can be regulated by chronic drug treatment.