Clinical pharmacokinetics of hypnotics

Trichloroethanol, an active metabolite of chloral hydrate, modulates tetrodotoxin-resistant Na+ channels in rat nociceptive neurons

BACKGROUND

Chloral hydrate is a sedative-hypnotic drug widely used for relieving fear and anxiety in pediatric patients. However, mechanisms underlying the chloral hydrate-mediated analgesic action remain unexplored. Therefore, we investigated the effect of 2',2',2'-trichloroethanol (TCE), the active metabolite of chloral hydrate, on tetrodotoxin-resistant (TTX-R) Na⁺ channels expressed in nociceptive sensory neurons.

METHODS

The TTX-R Na⁺ current (I_Na) was recorded from acutely isolated rat trigeminal ganglion neurons using the whole-cell patch-clamp technique.

RESULTS

Trichloroethanol decreased the peak amplitude of transient TTX-R I_Na in a concentration-dependent manner and potently inhibited persistent components of transient TTX-R I_Na and slow voltage-ramp-induced I_Na at clinically relevant concentrations. Trichloroethanol exerted multiple effects on various properties of TTX-R Na⁺ channels; it (1) induced a hyperpolarizing shift on the steady-state fast inactivation relationship, (2) increased use-dependent inhibition, (3) accelerated the onset of inactivation, and (4) retarded the recovery of inactivated TTX-R Na⁺ channels. Under current-clamp conditions, TCE increased the threshold for the generation of action potentials, as well as decreased the number of action potentials elicited by depolarizing current stimuli.

CONCLUSIONS

Our findings suggest that chloral hydrate, through its active metabolite TCE, inhibits TTX-R I_Na and modulates various properties of these channels, resulting in the decreased excitability of nociceptive neurons. These pharmacological characteristics provide novel insights into the analgesic efficacy exerted by chloral hydrate.

Extracorporeal treatment for barbiturate poisoning: recommendations from the EXTRIP Workgroup

The EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup conducted a systematic review of barbiturate poisoning using a standardized evidence-based process to provide recommendations on the use of extracorporeal treatment (ECTR) in patients with barbiturate poisoning. The authors reviewed all articles, extracted data, summarized key findings, and proposed structured voting statements following a predetermined format. A 2-round modified Delphi method was used to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. 617 articles met the search inclusion criteria. Data for 538 patients were abstracted and evaluated. Only case reports, case series, and nonrandomized observational studies were identified, yielding a low quality of evidence for all recommendations. Using established criteria, the workgroup deemed that long-acting barbiturates are dialyzable and short-acting barbiturates are moderately dialyzable. Four key recommendations were made. (1) The use of ECTR should be restricted to cases of severe long-acting barbiturate poisoning. (2) The indications for ECTR in this setting are the presence of prolonged coma, respiratory depression necessitating mechanical ventilation, shock, persistent toxicity, or increasing or persistently elevated serum barbiturate concentrations despite treatment with multiple-dose activated charcoal. (3) Intermittent hemodialysis is the preferred mode of ECTR, and multiple-dose activated charcoal treatment should be continued during ECTR. (4) Cessation of ECTR is indicated when clinical improvement is apparent. This report provides detailed descriptions of the rationale for all recommendations. In summary, patients with long-acting barbiturate poisoning should be treated with ECTR provided at least one of the specific criteria in the first recommendation is present.

Enhanced elimination in acute barbiturate poisoning - a systematic review

CONTEXT

Despite a worldwide decline in barbiturate use, cases of acute poisoning with severe toxicity are still noted, particularly in developing countries. Severe poisonings often require prolonged admission to an intensive care unit, so enhanced elimination might be useful to hasten recovery. Information regarding the efficacy of these techniques for individual barbiturates is not available in standard textbooks.

OBJECTIVE

To determine the evidence supporting the effect of enhanced elimination and its role in the management of acute barbiturate poisoning.

METHODS

A systematic review was conducted using broad search criteria in three databases. All potentially relevant articles were obtained, and reference lists were manually reviewed. Ninety-four publications fulfilling inclusion criteria were located. Studies were classified as controlled or uncontrolled, and clinical and pharmacokinetic end points were manually extracted. If not directly stated, standard pharmacokinetic methods were used to calculate the clearance and efficiency of enhanced elimination techniques for each barbiturate and tabulated for direct comparison. PROSPECTIVE CONTROLLED CLINICAL TRIALS: Two of the 94 publications were prospective controlled studies (only one stated that allocation was via blinded randomisation), and both assessed the effect of multiple-dose activated charcoal for acute phenobarbital poisoning. These studies demonstrated enhanced elimination with a decrease in elimination of half-life from approximately 80 to 40?h, but only one study reported clinical benefits. UNCONTROLLED SERIES AND SINGLE CASE REPORTS: Sufficient data to determine the clearance due to enhanced elimination were available in only 52 of these papers. Barbiturate clearances by enhanced elimination varied markedly among studies. While extracorporeal modalities appeared to increase the direct clearance of many barbiturates, there was insufficient information to confirm a clinical benefit.

CONCLUSIONS

There is limited evidence to support the use of enhanced elimination in the treatment of poisoning with most barbiturates. There is no role for urine alkalinisation, while multiple-dose activated charcoal may be useful for most phenobarbital and possibly primidone poisonings. Extracorporeal techniques appear to enhance elimination, but the clinical benefits, relative to the potential complications and cost, are poorly defined. Extracorporeal techniques such as haemodialysis and haemoperfusion can be considered for patients with life-threatening barbiturate toxicity such as refractory hypotension.

Differential actions of ethanol and trichloroethanol at sites in the M3 and M4 domains of the NMDA receptor GluN2A (NR2A) subunit

BACKGROUND AND PURPOSE

Alcohol produces its behavioural effects in part due to inhibition of N-methyl-d-aspartate (NMDA) receptors in the CNS. Previous studies have identified amino acid residues in membrane-associated domains 3 (M3) and 4 (M4) of the NMDA receptor that influence ethanol sensitivity. In addition, in other alcohol-sensitive ion channels, sedative-hypnotic agents have in some cases been shown to act at sites distinct from the sites of ethanol action. In this study, we compared the influence of mutations at these sites on sensitivity to ethanol and trichloroethanol, a sedative-hypnotic agent that is a structural analogue of ethanol.

EXPERIMENTAL APPROACH

We constructed panels of mutants at ethanol-sensitive positions in the GluN2A (NR2A) NMDA receptor subunit and transiently expressed these mutants in human embryonic kidney 293 cells. We used whole-cell patch-clamp recording to assess the actions of ethanol and trichloroethanol in these mutant NMDA receptors.

KEY RESULTS

Ethanol sensitivity of mutants at GluN2A(Ala825) was not correlated with any physicochemical measures tested. Trichloroethanol sensitivity was altered in two of three ethanol-insensitive mutant GluN2A subunits: GluN2A(Phe637Trp) in M3 and GluN2A(Ala825Trp) in M4, but not GluN2A(Met823Trp). Trichloroethanol sensitivity decreased with increasing molecular volume at Phe637 or increasing hydrophobicity at Ala825 and was correlated with ethanol sensitivity at both sites.

CONCLUSIONS AND IMPLICATIONS

Evidence obtained to date is consistent with a role of GluN2A(Ala825) as a modulatory site for ethanol and trichloroethanol sensitivity, but not as a binding site. Trichloroethanol appears to inhibit the NMDA receptor in a manner similar, but not identical to, that of ethanol.

Criminal poisoning: drug-facilitated sexual assault

Drug-facilitated sexual assault (DFSA) is a complex and ever-prevalent problem presenting to emergency departments. Emergency personnel should consider DFSA in patients who are amnestic to the specific details of the event following a reported sexual assault. The presence of ethanol or a positive routine drug screen in a sexual assault victim does not exclude the potential of a surreptitious drug being present. In addition, a negative routine drug screen does not exclude all potential agents that are used in DFSA. This article discusses agents reported in DFSA. It is imperative for emergency personnel to clearly document the history and the presenting signs and symptoms to assist laboratory personnel to hone in and detect the correct agent used in a DFSA.

Barbiturate activation and modulation of GABA(A) receptors in neocortex

We determined if anesthetic and anti-epileptic barbiturates inhibit neurons by different mechanisms. Current- and voltage-clamp recordings were made from somatosensory neurons of neocortex and some thalamocortical neurons in coronal brain slices of rats. We compared effects of pentobarbital, amobarbital, and phenobarbital on inhibitory postsynaptic currents (IPSCs) mediated by gamma-aminobutyric acid (GABA), input conductance, and evoked action potential firing. In neocortex, pentobarbital (EC(50)=41 microM) and amobarbital (EC(50)=103 microM) increased the decay time constant of GABA(A)ergic IPSCs. At higher concentrations, pentobarbital and amobarbital shunted firing by increasing input conductance through agonism at GABA(A) receptors. At anti-epileptic concentrations, phenobarbital increased the IPSC decay time constant (EC(50)=144 microM), and shunted firing by agonism at GABA(A) receptors (EC(50)=133 microM). In thalamocortical neurons, similar concentrations of phenobarbital had negligible effects on GABA(A)ergic IPSCs, conductance, and firing. In contrast to their thalamic actions, barbiturates inhibit neocortical neurons mostly through GABA receptors. Neocortical enhancement of inhibition by pentobarbital and amobarbital, combined with actions on thalamocortical neurons, may contribute to redundant mechanisms of anesthesia. The ability of phenobarbital at anti-epileptic concentrations to inhibit neocortical firing by direct activation and modulation of GABA(A) receptors relates to its specialized therapeutic effects.

The effect of chloral hydrate on the in-vitro T3 binding to adult rat cerebral nuclei

Chloral hydrate is a widely used hypnotic drug for children and animals but the possible interactions of its sedative action and thyroid hormones has not been investigated. In this study the effect of chloral hydrate on the in-vitro binding of triiodothyronine (T3) to cerebral nuclei of adult rats and on the thyroid hormones' synaptosomal and plasma availability were examined. Our results show that during deep anaesthesia caused by a single intraperitoneal administration of chloral hydrate (100 mg kg(-1)), the maximal number of nuclear thyroid hormone receptors (Bmax) and the equilibrium dissociation constant (Kd) were decreased. These changes returned to normal values when rats woke up (2(1/2)h after chloral hydrate administration). Plasma or synaptosomal levels of thyroid hormones were unaffected during chloral hydrate treatment. Our study demonstrates that the nuclear T3 binding in adult rat brain is affected by the sedative action of chloral hydrate.

Activation and attenuation of apoptosis of CD4+ T cells following in vivo exposure to two common environmental toxicants, trichloroacetaldehyde hydrate and trichloroacetic acid

Exposure to occupationally relevant concentrations of the environmental pollutant, trichloroethylene (TCE), in the drinking water of autoimmune-prone MRL+/+ mice has been shown to promote the generation of lupus and autoimmune hepatitis in association with the activation of Interferon-gamma (IFN-gamma)-producing CD4+ T cells. Since blocking TCE metabolism suppressed the TCE-induced alteration in immune function, the present study was initiated to determine whether the major metabolites of TCE, trichloroacetaldehyde hydrate (TCAH) and trichloroacetic acid (TCA) could also mediate these immunoregulatory affects in vivo. TCAH and TCA were administered to the drinking water of MRL+/+ mice for 4 weeks. CD4+ T cells from TCAH and TCA-treated MRL+/+ mice, unlike CD4+ T cells from control mice, demonstrated functional and phenotypic signs of activation, as evidenced by increased IFN-gamma production in association with the increased percentage of CD62L(lo) CD4+ T cells. Interestingly, it was also found that the CD4+ T cells from the TCAH and TCA-treated mice showed a decreased susceptibility to the activation-induced cell death (AICD) form of apoptosis following re-stimulation in vitro. By demonstrating that TCAH and TCA can activate CD4+ T cells and inhibit their apoptosis following in vivo exposure represents a mechanism by which environmental toxicants may induce or accelerate the development of autoimmune disease.

Trichloroethanol enhances the activity of recombinant human TREK-1 and TRAAK channels

Human TREK-1 and TRAAK (hTREK-1 and hTRAAK) are the recently cloned tandem pore-domain potassium channels that are highly expressed in the central nervous system (CNS). The roles of 2P domain K+ channels in general anesthesia and neuroprotection have been proposed recently. We have investigated the ability of 2,2,2-trichloroethanol (an active metabolite of the general anesthetic chloral hydrate (CH)) to modulate the activity of hTREK-1 and hTRAAK channels expressed heterologously in Chinese hamster ovary cells by using whole-cell patch-clamp recording. Trichloroethanol potentiated hTREK-1 and hTRAAK channel activity in a reversible, concentration-dependent manner. The parent compound CH also augmented the activity of both the channels reversibly. CH activation of hTREK-1 was transient followed by a rapid inhibition, whereas hTRAAK activation was not followed by inhibition. Deletions of the carboxy terminal domain (Delta89, Delta100 and Delta119) of hTREK-1 did not abolish sensitivity to TCE (20 mM) suggesting that C-terminal tail is not essential for the activation of hTREK-1 by TCE. The hTREK-1 currents consisted of an instantaneous and a time-dependent component. The time-dependent current was reduced by trichloroethanol (20 mM). Our findings identify TREK-1 and TRAAK channels as molecular targets for trichloroethanol and suggest that activation of these channels might contribute to the CNS depressant effects of CH.

Is there a rationale for prescription of benzodiazepines in the elderly? Review of the literature

Benzodiazepines (BZDs) constitute the most widely used symptomatic treatment of insomnia and anxiety. Many of these drugs are associated with adverse effects, such as daytime sedation and dependence with continued use. There is a concern about the rationale for and extent of benzodiazepine (BZD) use in the elderly. The sedation due to BZD use is a main risk factor for falls and other accidents. Impaired cognitive function with continuous use appears to be a major side effect. There is a general awareness that BZD use is inappropriate in many patients, and therefore discontinuation should be recommended whenever possible. Moreover, long-term use of these drugs should be actively discouraged. Although no unanimous recommendations concerning the optimal duration of the withdrawal process exist, BZDs may easily be withdrawn during a short period in most patients who are habituated to a low dose, if an initial phase with dose reduction and psychological support are provided. Alternative approaches involve sleep hygiene guidelines, behavioural treatment and psychotherapy tailored to the needs of the individual patient.

Sedation for pediatric dental patients

There are few areas of dental therapeutics as controversial as the pharmacologic management of fearful and uncooperative pediatric dental patients. A pediatric dentist is faced with one of the most difficult tasks in our profession: maximizing comfort and cooperation while minimizing risks and costs of dental care for the unmanageable child. Pharmacosedation provides the means for children to avoid psychologically traumatic experiences that might inhibit regular oral health care when they become adults. By controlling disruptive behaviors, the pediatric dentist is able to provide quality dental care in an environment that is pleasant for the child, the parent, and the practitioner.

Anesthetic methods in rats determine outcome after experimental focal cerebral ischemia: mechanical ventilation is required to obtain controlled experimental conditions

OBJECTIVE

Anesthetic agents, pH, blood gases and blood pressure have all been found to influence the pathophysiology of experimental stroke. In experimental research, rats are predominantly used to investigate the effects of focal cerebral ischemia. Chloral hydrate, applied intraperitoneally (i.p.), and halothane, applied via face-mask in spontaneously breathing animals or via endotracheal tube in mechanically ventilated animals are popular methods of anesthesia. We investigated the potential of these anesthetic methods to maintain physiologic conditions during focal cerebral ischemia and their influence on postischemic mortality and histological outcome.

METHODS

Thirty male Sprague-Dawley rats were subjected to 90 min of middle cerebral artery occlusion by insertion of an intraluminal thread and assigned to one of three groups (n=10 each): (A) chloral hydrate i.p./spontaneously breathing; (B) halothane in 70:30 (%) N2O/O2 via face-mask/spontaneously breathing; and (C) halothane in 70:30 (%) N2O/O2 via endotracheal tube/mechanically ventilated. Physiologic parameters were measured before, during, and after ischemia. Infarct volume was histologically assessed after 7 days.

RESULTS

All anesthetic techniques except mechanical ventilation via an endotracheal tube resulted in considerably fluctuating blood gases levels, hypercapnia, acidosis and low blood pressure. All spontaneously breathing animals (groups A and B) exhibited a higher postischemic mortality and significantly larger infarct volumes than group C with intubated and ventilated animals.

CONCLUSIONS

Intra- and postischemic physiologic parameters such as blood pressure, pH, and blood gases critically determine outcome after focal cerebral ischemia. Although anesthesia by halothane via face-mask allowed better control of depth of anesthesia than chloral hydrate, we have found this method to be unsatisfactory due to insufficient control of ventilation and waste of anesthetic gases. Experiments with rats requiring normal physiologic parameters should be performed under conditions of controlled mechanical ventilation and sufficient analgesia.

Chloral hydrate for progressive myoclonus epilepsy: a new look at an old drug

This study demonstrates that chloral hydrate can be used to control daytime myoclonic exacerbations. It reports on four patients with progressive myoclonus epilepsy--three with Unverricht-Lündborg disease (EPM1) and one with progressive external ophthalmoplegia (PEO)--all of whom were taking more than one antiepileptic drug. Response to the liquid formulation was faster than response to the capsule and was preferred by the patients. The unusual feature was less than expected sedation or development of tolerance even at daily doses above 500 mg administered for years. Because chloral hydrate helped to improve quality of life, it should be made available to patients with progressive myoclonus epilepsy as adjunctive therapy. Recent evidence of interactions with various excitatory and inhibitory amino acid neurotransmitter-operated ion channels as a mechanism of action may provide insight into altered neurotransmission in progressive myoclonus epilepsy.

Dichloroacetate: population pharmacokinetics with a pharmacodynamic sequential link model

Dichloroacetate (DCA) is a small molecule that reduces ambient concentrations of lactate in man. It was the purpose of this study to develop pharmacokinetic and pharmacodynamic models for determination of a dose for a pivotal Phase III clinical trial of DCA in patients with traumatic brain injury (TBI). Population pharmacokinetic and pharmacodynamic models were developed for DCA using NONMEM software. The pharmacokinetic data were fit to a physiologic two-compartment model, and the pharmacodynamic data were fit to an indirect physiologic response model. Simulations were employed to evaluate various dosing strategies for consideration in a pivotal Phase III clinical trial of DCA. For the pharmacokinetic model, it was discovered that the clearance of DCA decreased on multiple dosing from 4.82 L/h to 1.07 L/h and that the pharmacokinetics and pharmacodynamics in TBI patients could not be predicted from normal volunteers. Population pharmacokinetic modeling and simulation of the expected effects of several dosing strategies were useful procedures for designing a Phase III trial.

Inhibition by chloral hydrate and trichloroethanol of AMPA-induced Ca(2+) influx in rat cultured cortical neurones

The effects of chloral hydrate and its main metabolite 2,2, 2-trichloroethanol were investigated on the (S)-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA)-induced rise of intracellular Ca(2+) concentration ([Ca(2+)](i)) in cultured non-pyramidal cortical neurones of rats by using single-cell fura-2 microfluorimetry. AMPA elicited a concentration-dependent effect that peaked at 300 microM (EC(50), 7. 5 microM). Responses to AMPA (30 microM) were markedly inhibited by superfusion with chloral hydrate (IC(50), 4.5 mM) or trichloroethanol (IC(50), 0.9 mM). By contrast, ethanol (100 mM) caused only slight inhibition. In conclusion, the results demonstrate that chloral hydrate and especially its metabolite trichloroethanol, inhibit the AMPA-induced rise of [Ca(2+)](i) by depressing the entry of Ca(2) into cortical neurones via the AMPA receptor-channel.

General anaesthetic actions on ligand-gated ion channels

The molecular mechanisms of general anaesthetics have remained largely obscure since their introduction into clinical practice just over 150 years ago. This review describes the actions of general anaesthetics on mammalian neurotransmitter-gated ion channels. As a result of research during the last several decades, ligand-gated ion channels have emerged as promising molecular targets for the central nervous system effects of general anaesthetics. The last 10 years have witnessed an explosion of studies of anaesthetic modulation of recombinant ligand-gated ion channels, including recent studies which utilize chimeric and mutated receptors to identify regions of ligand-gated ion channels important for the actions of general anaesthetics. Exciting future directions include structural biology and gene-targeting approaches to further the understanding of general anaesthetic molecular mechanisms.

Trichloroethanol impairs NMDA receptor function in rat mesencephalic and cortical neurones

The effects of 2,2,2-trichloroethanol, the active compound of the sedative-hypnotic chloral hydrate, were investigated on N-methyl-D-aspartate (NMDA)-induced increases in intracellular Ca2+ concentration ([Ca2+]i) in cultured mesencephalic and cortical neurones by means of the fura-2 method. Trichloroethanol inhibited the NMDA response in a concentration-dependent manner in cortical (IC50 = 2.76 mM) and mesencephalic neurones (IC50 = 1.12 mM), with a maximum effect of approximately 85 and 94%, respectively. Ethanol was considerably less potent than trichloroethanol. In conclusion, the trichloroethanol-induced impairment of NMDA receptor function may contribute to the sedative-hypnotic properties of chloral hydrate.

Alpha subunit isoform influences GABA(A) receptor modulation by propofol

We have investigated the role of the alpha subunit in the modulation of gamma-aminobutyric acid type A (GABA(A)) receptors by the general anesthetic propofol, using whole-cell patch clamp recordings made from distinct stable fibroblast cell lines which expressed only alpha1beta3gamma2 or alpha6beta3gamma2 GABA(A) receptors. At clinically relevant anesthetic concentrations, propofol potentiated submaximal GABA currents in alpha1beta3gamma2 receptors to a far greater degree than those in alpha6beta3gamma2 receptors. The alpha subunit influenced the efficacy of propofol for modulation, but not its potency. In contrast, direct gating of the ion channel by propofol, in the absence of GABA, was significantly larger in the alpha6 than the alpha1 containing receptors. The potentiation of submaximal GABA by trichloroethanol, and the potentiation and direct gating by methohexital was also studied, and showed the same relative trends as propofol.

Kinetics and metabolism of chloral hydrate in children: identification of dichloroacetate as a metabolite

Chloral hydrate was introduced into therapeutics more than 100 years ago, and since then a number of kinetic and metabolic studies have been conducted on this drug. Trichloroethanol, its glucuronide and trichloroacetic acid have been identified as the metabolites of chloral hydrate. We now report the identification of dichloroacetate as a major product of chloral hydrate metabolism in children, in addition to trichloroethanol and trichloroacetic acid. Furthermore, pretreatment of children with chloral hydrate appears to retard the plasma clearance of dichloroacetate.

Responses of rat substantia nigra dopamine-containing neurones to (-)-HA-966 in vitro

1. Extracellular single unit recording techniques were used to compare the effects of (-)-3-amino-1-hydroxypyrrolidin-2-one ((-)-HA-966) and (+/-)-baclofen on the activity of dopamine-containing neurones in 300 microns slices of rat substantia nigra. Electrophysiological data were compared with the outcome of in vitro binding experiments designed to assess the affinity of (-)-HA-966 for gamma-aminobutyric acid (GABAB) receptors. 2. Bath application of (-)-HA-966 produced a concentration-dependent inhibition of dopaminergic neuronal firing (EC50 = 444.0 microM; 95% confidence interval: 277.6 microM - 710.1 microM, n = 27) which was fully reversible upon washout from the recording chamber. Although similar effects were observed in response to (+/-)-baclofen, the direct-acting GABAB receptor agonist proved to be considerably more potent than (-)-HA-966 (EC50 = 0.54 microM; 95% confidence interval: 0.44 microM - 0.66 microM, n = 29) in vitro. 3. Low concentrations of chloral hydrate (10 microM) were without effect on the basal firing rate of nigral dopaminergic neurones but significantly increased the inhibitory effects produced by concomitant application of (-)-HA-966. 4. The inhibitory effects of (-)-HA-966 were completely reversed in the presence of the GABAB receptor antagonists, CGP-35348 (100 microM) and 2-hydroxysaclofen (500 microM). Bath application of CGP-35348 alone increased basal firing rate. However, the magnitude of the excitation (9.2 +/- 0.3%) was not sufficient to account for the ability of the antagonist to reverse fully the inhibitory effects of (-)-HA-966. 5. (-)-HA-966 (0.1-1.0 mM) produced a concentration-dependent displacement of [3H]-GABA from synaptic membranes in the presence of isoguvacine (40 microM). However, the affinity of the drug for GABAB binding sites was significantly less than that of GABA (0.0005 potency ratio) and showed no apparent stereoselectivity. 6. These results indicate that while (-)-HA-966 appears to act as a direct GABAB receptor agonist in vitro, its affinity for this receptor site is substantially less than that of GABA or baclofen and unlikely to account for the depressant actions of this drug which occur at levels approximately ten fold lower in vivo.

Spectroscopic analysis of the binding of amylobarbitone, secbutobarbitone, pentobarbitone, phenobarbitone and quinalbarbitone to human serum albumin

The binding of five barbiturates: amylobarbitone, secbutobarbitone, pentobarbitone, phenobarbitone and quinalbarbitone to human serum albumin (HSA) was studied by difference spectroscopy and spectrofluorimetric titrations. There were no changes in the HSA spectral properties. Our result suggest that there are two classes of binding sites on HSA for these barbiturates. A detailed investigation of the effect of their binding to HSA by deconvoluted spectra, suggests that the interaction of barbiturate-HSA takes place principally on the subdomain IIIA of HSA.

Determination of chloral hydrate and its metabolites (trichloroethanol and trichloracetic acid) in human plasma and urine using electron capture gas chromatography

Capillary gas chromatography with electron capture detection is described for the quantification of chloral hydrate (CH) and is metabolites trichloroethanol (TCE) and trichloroacetic acid (TCA) in 0.1-1 mL of plasma samples. The method, with 2,2'-dichloroethanol (DCE) as internal standard, involved extraction of chloral hydrate and trichloroethanol with diethyl ether and methylation of trichloroacetic acid with 3-methyl-1-tolyltriazene (MTT), followed by diethyl ether extraction. The method has a detection limit of 5 ng/mL for CH and TCE and 10 ng/mL for TCA and also allows the determination of TCE-glucuronide in 0.1-1 mL of plasma samples. It exhibits good linearity and precision. The method was applied to samples of plasma from a neonate after a single dose of 40 mg/kg of chloral hydrate and from an adult after a single dose of 6.25 mg/kg.

Trichloroethanol potentiation of gamma-aminobutyric acid-activated chloride current in mouse hippocampal neurones

1. The action of 2,2,2-trichloroethanol on gamma-aminobutyric acid (GABA)-activated Cl- current was studied in mouse hippocampal neurones in tissue culture by use of whole-cell patch-clamp recording. 2. Trichloroethanol increased the amplitude of currents activated by 1 microM GABA or 0.1 microM muscimol. Trichloroethanol, 1-25 mM, potentiated current activated by 1 microM GABA in a concentration-dependent manner with an EC50 of 3.0 +/- 1.4 mM and a maximal response (Emax) of 576 +/- 72% of control. 3. Trichloroethanol potentiated currents activated by GABA concentrations < 10 microM, but did not increase the amplitude of currents activated by concentrations of GABA > or = 10 microM. Despite marked potentiation of currents activated by low concentrations of GABA, trichloroethanol did not significantly alter the EC50, slope, or Emax of the GABA concentration-response curve. 4. Trichloroethanol, 5 mM, potentiated GABA-activated current in neurones in which ethanol, 10-500 mM, did not. The effect of trichloroethanol was not altered by the putative ethanol antagonist, Ro 15-4513. Trichloroethanol did not potentiate currents activated by pentobarbitone. 5. In the absence of exogenous GABA, trichloroethanol at concentrations > or = 2.5 mM activated a current that appeared to be carried by Cl- as its reversal potential changed with changes in the Cl- gradient and as it was inhibited by the GABAA antagonists, bicuculline methiodide and picrotoxin. 6. Since trichloroethanol is thought to be the active metabolite of chloral hydrate and other chloral derivative anaesthetics, potentiation of the GABA-activated current in central nervous system neurones by trichloroethanol may contribute to the sedative/hypnotic effects of these agents.

Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds

This Grand Rounds will review the problem of alcoholism and prescription drug abuse in the elderly. Several case vignettes will be presented. The pharmacology of alcohol and potentially addictive prescription medications will be reviewed. The clinical presentation of and psychiatric symptoms associated with these disorders will be discussed. The process of addiction and issues regarding the clinical evaluation of the elderly addict will be discussed. The medical complications of these disorders will be reviewed, followed by a discussion of guidelines for the appropriate use of these drugs in the elderly. The grand rounds will conclude with a discussion of the treatment of patients with these disorders.

Noninvasive breathing analysis: repetitive chloral hydrate in neonatal guinea pigs

A noninvasive method was used to record neonatal breathing, heart rate (HR), and the electroencephalogram (EEG) in guinea pig pups. Neonates were randomly assigned at birth to chloral hydrate (CH) or placebo (PLA) treatment. Treatments were administered 30 min before each study on days 1, 3, 5, 7, 14, and 21 after birth. Animals were studied while they breathed room air followed by air with 5% CO2 and 30% O2. CH decreased breathing frequency (f) and inspiratory minute volume (VI), but not tidal volume (VT) during the first week (P less than 0.05), and reduced the rate of growth throughout the study (P less than 0.01), whereas breathing of CO2 increased f, VT, VI, HR, and the relative power in the delta frequency band of the EEG. The percent change in VI induced by CO2, however, was not affected by drug treatment. There was a significant day of life effect on all breathing parameters and HR. CH has cumulative effects on breathing and growth that should be considered when it is used as a sedative for repeated neonatal studies in guinea pigs.

Pharmacokinetics and anticonvulsant activity of three monoesteric prodrugs of valproic acid

The pharmacokinetics of valproic acid (VPA) were compared in dogs with those of the prodrugs ethyl valproate (E-VPA), trichloroethyl valproate (T-VPA), and valproyl valproate (V-VPA). Valproic acid, E-VPA, T-VPA, and V-VPA were administered intravenously and orally to six dogs at equimolar doses. The three VPA prodrugs were rapidly converted to VPA. The biotransformation was complete in the case of E-VPA and T-VPA but was only partial in the case of V-VPA. Because of the rapid conversion to the parent drug, after administration of the prodrugs, VPA plasma levels did not yield a sustained-release profile. Further, the anticonvulsant activity of prodrugs was compared in mice to that of VPA and valpromide (VPD). The anticonvulsant activity of E-VPA, T-VPA, and V-VPA was less than that of VPA.

Demethylation pathways in caffeine metabolism as indicators of variability in 1,1,1-trichloroethane oxidation in man

Twenty volunteers were exposed to 191 +/- 7 p.p.m. 1,1,1-trichloroethane or 50 +/- 2 p.p.m. perchloroethylene vapour for 6 hr. They were then evaluated for their rate of caffeine metabolism, mephenytoin hydroxylation and debrisoquine hydroxylation. Seven subjects were identified as 'fast acetylators' of caffeine and one person as a slow metabolizer of debrisoquine. The "slow acetylators" exposed to perchloroethylene excreted an average of 3.83 +/- 0.35 mg trichloroacetic acid within 24 hr (N = 13, +/- S.E.) and the 'fast acetylators' 3.58 +/- 0.48 mg (N = 7, +/- S.E.). The excretion of trichloroethanol by the same persons after 1,1,1-trichloroethane exposure was 14.1 +/- 1.12 mg and 16.7 +/- 1.48 mg, respectively. The excretion of trichloroacetic acid in the latter exposure varied significantly between the seven 'fast' and 13 'slow acetylators' (0.43 +/- 0.08 mg versus 1.03 +/- 0.19 mg; +/- S.E.; P = 0.037). A multiple linear regression analysis confirmed this association when other factors, such as body weight, creatinine clearance, smoking habit and alcohol consumption, were taken into account. One volunteer proved to be a poor hydroxylator of debrisoquine and excreted half the amount of trichloroacetic acid in the perchloroethylene exposure and half the amount of trichloroethanol in the 1,1,1-trichloroethane exposure compared to the others. A reduction in the solvent metabolism could thus be predicted by the debrisoquine test. On the other hand, the caffeine test predicted faster oxidation of trichloroethanol which could be of toxicological and pharmacological importance e.g. in the clinical use of chloral.

Determination of chloral hydrate metabolism in adult and neonate biological fluids after single-dose administration

A simple, rapid and sensitive electron-capture gas chromatographic method has been developed for the simultaneous determination of chloral hydrate, trichloroethanol and trichloroacetic acid in biological fluids. The described method is applicable to single-dose pharmacokinetic studies of chloral hydrate in the adult. The method also meets the important requirement of using very small sample volumes and is sufficiently sensitive and reliable for disposition studies in the neonate.

Appropriately treating insomnia with triazolam

Insomnia is a problem that extends beyond the nighttime. People who experience sleep disturbances complain that they stay awake for a long time before they fall asleep. They may wake up several times during the night and cannot return to sleep and/or they wake up early in the morning. As a result, they feel sleepy during the day and are less alert. Various forms of insomnia are described that require--as much as possible--an individualized treatment approach. Besides sleeping hygiene, benzodiazepines certainly occupy a place in the treatment of insomnia. Triazolam, a triazolobenzodiazepine, closely approaches the characteristics of an ideal hypnotic: pharmacological activity at the level of the receptors, moderate absorption, short-acting, and rapid elimination. It is effective and safe if prescribed correctly and at the appropriate dosage.

Relationship between the metabolism of antipyrine, hexobarbital and theophylline in patients with liver disease as assessed by a 'cocktail' approach

Antipyrine (AP), hexobarbital (HB) and theophylline (TH) were administered simultaneously ('cocktail' design) to 24 patients with various types of liver disease. Clearance (Cl) of AP, HB and TH and formation clearance of the AP-metabolites 3-hydroxymethylantipyrine (HMA), norantipyrine (NORA) and 4-hydroxyantipyrine (OHA) were determined and correlation coefficients and orthogonal least-squares regression lines calculated between the clearance and formation clearance parameters. The results were compared with those obtained in a study in which the same 'cocktail' was administered to 26 healthy control subjects. In the patients ClAP, ClHB and ClTH were 23.0 +/- 14.3 ml min-1, 206 +/- 128 ml min-1 and 39.9 +/- 26.1 ml min-1 respectively. All values were considerably lower than those found in the control subjects. With regard to AP metabolism preferential impairment of NORA formation was observed. Relatively high correlation coefficients were found between ClAP, ClHB and ClTH, which suggests, like the results of orthogonal regression analysis, a strong correlation between total metabolism of these probe drugs. Therefore it is likely that impairment in oxidation in patients with liver disease not only leads to reduction in clearance but also to reduced substrate selectivity of cytochrome P-450 isozymes.

Non-specific prolongation of the effects of general depressants by pyrazole and 4-methylpyrazole

The liver alcohol dehydrogenase inhibitors, pyrazole and 4-methylpyrazole, have been tested for their ability to prolong drug-induced sleep times in mice. Both drugs (at 1 mmol kg-1 i.p.) prolonged the duration of loss of righting reflex following chloral hydrate, pentobarbitone, barbitone, temazepam and halothane, but not diethyl ether. This suggests that the effects of these pyrazoles are not specific to the inhibition of liver alcohol dehydrogenase.

Mechanisms of depressant drug action/interaction

Whereas the effects of individual psychotropic drugs depend upon drug type, route of administration, dose, and frequency of use, as well as unique subject (patient) variables, the actions achieved by two or more psychotropics taken concurrently are complicated by their influence upon each other. Interactions may be antagonistic, additive, or synergistic and are frequently predictable, given a basic understanding of the kinetic and dynamic characteristics for each drug. This knowledge should enable rational interpretation, therapeutic intervention, and possible prevention of polydrug toxicity. Classically, pharmacodynamic drug interaction is described in terms of common receptor activation or antagonism. This limited view is inadequate in the present context and should be broadened to encompass all of the mechanistic elements that initiate, transduce, and amplify neuronal membrane action. Thus, although psychotropic drugs may compete for a limited number of specific binding sites, as the opiates do, they may also interact through allosteric mechanisms and nonspecific modulation of the receptor environment or subsequent effector cell mechanisms. Drugs in the depressant class often act synergistically in these ways. Through consideration of nonreceptor mediated interaction, we can more fully appreciate the potentiation that occurs between seemingly unrelated substances (e.g., antihistamines and ethanol) and the ability or lack thereof to medically treat such interactions specifically. The pharmacokinetic determinants of drug action provide many opportunities for synergy between psychotropic drugs. Each process is a fertile substrate. Absorption from the gastrointestinal tract is sensitive to drugs that alter peristaltic motility and glandular secretion. Those that inhibit motility tend to delay the rate, if not the extent, of absorption and consequently reduce peak intensity and prolong duration of the psychotropic effect. Serum albumin binding can be a vital point of interaction for drugs with high intrinsic binding affinity (e.g., 98% for methadone); displacement of a small amount of bound drug by a competing substance may increase the free drug concentration severalfold and thereby potentiate its actions(s). Psychotropic drug effects would last for days and even weeks, were it not for the body's ability to synthetically alter drug molecule configuration. This process takes place primarily in the liver where oxidative reactions are frequently catalyzed by the mixed function oxidase system.(ABSTRACT TRUNCATED AT 400 WORDS)

The pharmacokinetics of methohexital in young and elderly subjects

The pharmacokinetics of methohexital were investigated in ten young adult volunteers and in seven young and seven elderly patients. The latter two groups underwent enflurane and nitrous oxide anesthesia and surgery. Each subject received a bolus dose of 2 mg/kg of methohexital intravenously. Plasma levels of the drug were measured for 8 h after injection by gas chromatography using a nitrogen detector. Anesthesia (combined with surgery) and increase in age did not separately affect the kinetics of the drug; however, the elimination half-life was longer in the elderly patients group than in the young non-anesthetized volunteers.

Effects of ethanol on drug and metabolite pharmacokinetics

Pharmacokinetic interactions of ethanol with other drugs, including its effects upon drug metabolite disposition, are reviewed in terms of clearance concepts. This approach is particularly useful in understanding the mechanisms of ethanol-drug interactions, i.e. in separating the effects of ethanol upon drug clearance, volume of distribution and plasma protein binding. The application of clearance concepts provides the basis for understanding the qualitative differences in ethanol interactions with low and high hepatic extraction ratio drugs. The effects of short and long term ethanol consumption upon different types of drug metabolism (oxidative, acetylation and glucuronidation) have been considered. Long term ethanol consumption may increase the clearance of a drug by induction of oxidative metabolism whereas short term consumption may decrease the clearance of such a drug. Clearance by N-acetylation appears to be increased in the presence of ethanol, and clearance by conjugation to glucuronic acid is decreased for some drugs by single-dose consumption of ethanol.

Combined hemoperfusion-hemodialysis in severe poisoning: kinetics of drug extraction

We studied the kinetics of drug extraction during a combined hemoperfusion-hemodialysis procedure for treatment of severely poisoned patients. In most drugs studied an overall clearance of 120-180 ml/min (at a blood flow of 200 ml/min) was obtained, the relative contribution of hemoperfusion and hemodialysis being variable. A one-compartment pharmacokinetic model is presented that allows calculation of the optimal treatment time as a function of the extracorporeal clearance and the distribution volume of the toxic agent. For some drugs two-compartment kinetics were observed during treatment. The behaviour during treatment of these drugs is illustrated with computer simulation.

Pharmacokinetics of antiepileptic drugs

The rational use of antiepileptic drugs requires the consideration of their pharmacokinetics, which may be influenced by the physiological and pathological factors. Pharmacokinetic interactions between antiepileptic drugs may lead to considerable fluctuation in plasma drug concentration, and monotherapy is often preferable. The absorption of phenytoin depends on pharmaceutical formulation. Phenytoin is highly bound to plasma proteins, thus the changes in the unbound fraction are of clinical significance. The saturation kinetics of its metabolism and drug interactions have further consequences. Carbamazepine is well absorbed and largely metabolized. Due to the autoinduction its half-life shortens in chronic administration. Valproate is highly, but variably bound to plasma proteins. It is eliminated mainly by metabolism. Due to the long half-life of phenobarbital its plasma concentrations change slowly, and time to the steady-state may be up to 30 days, if no loading dose is given. Primidone is partly metabolized to phenobarbital, and at steady-state plasma concentration of phenobarbital often exceeds that of primidone. Diazepam, clonazepam and nitrazepam are largely bound to plasma proteins and extensively metabolized with the half-lives of 20 to 60 hours.

Drug prescribing in renal failure: dosing guidelines for adults

The data base for rational guidelines to safe, efficacious drug prescribing in adults with renal insufficiency are presented in tabular form. Current medical literature was extensively surveyed to provide as much specific information as possible. When information is lacking, however, recommendations are based on pharmacokinetic variables in normal subjects. Nephrotoxicity, important adverse effects, and special considerations in renal patients are noted. Adjustments are suggested for hemodialysis and peritoneal dialysis when appropriate.

Comparison of the effects of intravenously administered midazolam, triazolam and their hydroxy metabolites

The aim of the study was to compare the pharmacological activity and clinical effect after i.v. administration of midazolam, triazolam and their hydroxy metabolites, and, secondly, to compare the clinical effects of midazolam and triazolam in doses yielding the same duration of action (15 mg and 0.25 mg, respectively). In a randomized, cross-over procedure, six healthy volunteers received one of the following in the morning at approximately weekly intervals: 15 mg midazolam; 9 mg alpha-hydroxy midazolam; 1 mg triazolam; 1 mg alpha-hydroxy triazolam; 1 mg 4-hydroxy triazolam. Tests of drug effect (investigator's assessment, psychometric testing, and self-rating by subjects) were carried out at different times in the 24-h period following administration. Triazolam 0.25 mg was also studied in four of these six subjects to supplement the findings in the cross-over study. Triazolam 1 mg was shown to have the strongest, most long-lasting effect. Midazolam 15 mg had almost the same intensity of effect but this was shorter lasting, i.e. 5 h as against 10 h for 1 mg triazolam. The alpha-hydroxy metabolites had a duration of action about half that of the parent compounds and a less potent effect, and 4-hydroxy triazolam was virtually devoid of effect. The lower 0.25-mg dose of triazolam had about the same duration of action as 15 mg midazolam but did not achieve the same degree of maximum effect as measured by psychometric tests and self-assessment by subjects. The findings of this study indicate that midazolam would be suitable for use in situations in which a brief but intense hypnotic sedative effect is desired.

Quantification of the interaction between barbiturates and alcohol and interpretation of fatal blood concentrations

Barbiturates and alcohol are frequently found in combination in cases of accidental or intentional fatal self-poisoning. Unfortunately, the lack of any precise knowledge concerning their interaction creates difficult problems when an interpretation of toxicological data is sought. 1 In the following work the joint action of single barbiturates and alcohol is examined and a means of quantifying it is presented. 2 The effects of different amounts of alcohol on fatal amylobarbitone, butobarbitone, pentobarbitone, phenobarbitone and quinalbarbitone blood concentrations are compared. 3 Combined alcohol-barbiturate blood concentration curves connecting those concentration pairs equally effective in causing death are used to quantify the increase in toxicity. The quantitative effects of alcohol appear to be greater with the shorter- and longer-acting barbiturates than with the intermediate-acting derivatives. The different modes of interaction are discussed in terms of the physico-chemical and pharmacokinetic properties of the drugs.