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Use of an immobilised human serum albumin HPLC column as a probe of drug-protein interactions: the reversible binding of valproate.

The reversible binding of valproate to human serum albumin determines a decrease of the binding of ligands that selectively bind to site I, site II, and bilirubin binding site. The binding inhibition was followed by displacement chromatography methodology using increasing concentrations of the competitor, i.e. valproate, in the mobile phase. Significant binding inhibition was observed for drugs binding at site I and site II. The greater displacement was observed for the more retained enantiomer of benzodiazepines and profens. A reduction of the affinity was observed also in the case of phenol red, this compound being selected as representative of bilirubin binding site. Difference circular dichroism spectroscopy was also used to characterise the binding of valproate to human serum albumin. This antiepilectic drug was proved to affect the binding at site I, II, and bilirubin binding site. The data have physiological relevance because significant inhibition of the binding resulted at clinic concentrations of valproate.

Circular Dichroism↗

Phenobarbital, primidone and sodium valproate in the prophylaxis of febrile convulsions.

Of 196 children with febrile convulsions, 6.9 were placed on phenobarbital, 4-5 mg/kg/day b.i.d., and 32 on primidone, 15-20 mg/kg/day b.i.d. The remaining 95 children were given sodium valproate; the dosage was 20-25 mg/kg/day b.i.d. in 38 of them, 20-25 mg/kg/day t.i.d. in 24 of them, and 30 mg/kg/day b.i.d. in 33 patients. Recurrence rate of febrile convulsions during one year were not statistically different among these five groups. However, the dosage regimen of valproate of 20-25 mg/kg/day b.i.d. was relatively inferior to the other regimens of valproate in the prophylactic effect. This may be explained by the facts that when the same daily dosage of sodium valproate was given, the daily fluctuation of plasma levels was greater with the b.i.d.-regimen than with the t.i.d.-regimen, and that when the dosage interval was the same, the minimum plasma level of the day was lower with the smaller daily dosage regimen than with the larger one.

Child, Preschool↗

Weight gain associated with valproate in childhood.

Weight gain is a common side effect of valproate treatment. Several mechanisms have been suggested for its pathophysiology; of these, impairment of beta-oxidation of fatty acids and increased insulin secretion have been supported by clinical studies. To investigate whether changes in carnitine and insulin levels had a role in the weight gain occurring with valproate treatment in children, 20 patients with epilepsy were randomly assigned to receive either carnitine or placebo supplementation in addition to valproate. After a follow-up period of 3 months, weight gain was observed in both groups. The mean insulin concentration and insulin/glucose ratios increased. Weight gain did not correlate with carnitine levels. These results suggest that weight gain during valproate treatment is not related to a decrease in carnitine levels. However, an increase in insulin levels together with a decrease in glucose levels may cause weight gain, possibly by stimulating appetite.

Adolescent↗

Valproate therapy: predisposition to bone fracture?

A 13-year-old girl on valproate therapy had 20 fractures over a 4-year period between the ages of 5 years and 9 years. Once valproate was withdrawn, no further fractures occurred over the ensuing 4 years. Three other children manifested at least two fractures while on valproate antiepileptic therapy. These reports suggest that valproate, along with other known causes of demineralization (e.g., lack of exercise, diet, and genetic factors), predisposes patients to fractures.

Adolescent↗

Valproate enhances N-cadherin production in Xenopus embryos.

Xenopus embryos were exposed to valproate (0, 20, 40, 80 mg/l) either before or after neural tube closure. The embryos were then homogenized and fractionated by gel electrophoresis, and N-cadherin was detected and measured with quantitative immunoblotting. Findings indicated that valproate exposure increased N-cadherin production in a dose-dependent manner. Embryos exposed prior to neural tube closure tended to be more sensitive to the effects of valproate. These findings suggest that alterations in N-cadherin-mediated adhesion or morphogenesis may partially explain the teratogenic mechanism of valproate.

Animals↗

Hyperandrogenism, postprandial hyperinsulinism and the risk of PCOS in a cross sectional study of women with epilepsy treated with valproate.

Among a sample of 43 women with epilepsy treated for at least 2 years with valproate (n=22) or other antiepileptic drugs (AEDs) (n=21), polycystic ovary syndrome (PCOS) was diagnosed in three women, two of them were treated with valproate. Although the rate of PCOS and of menstrual disturbances, weight body mass index (BMI) and waist to hip ratio as well as fasting blood glucose levels, fasting insulin, proinsulin and C-peptide values was similar in this small sample of women treated with valproate and other AEDs, valproate exposure was associated with higher androgen levels, higher postprandial (pp) insulin and proinsulin levels, as well as lower cholesterol and low density lipoprotein (LDL) cholesterol levels. The pronounced increase in pp insulin levels during VPA treatment may indicate an effect of the fatty acid derivate VPA on pancreatic islet cells.

Adult↗

Inhibition of [3H]alpha-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid [AMPA] binding by the anticonvulsant valproate in clinically relevant concentrations: an autoradiographic investigation in human hippocampus.

The interaction of the anticonvulsant valproate with AMPA glutamate receptors in human post mortem hippocampus was investigated. At concentrations of > or = 100 microM valproate decreased binding of 40 nM [3H]AMPA to 45+/-56% of control level (CA 1). Clinically effective brain concentrations for valproate are estimated at 100-200 microM. Our results thus provide evidence that the anticonvulsant effects of valproate may partially be caused by interaction with AMPA receptors.

Aged↗

Circadian rhythm of embryotoxicity induced by sodium valproate in mice.

The influence of dosing time on embryotoxicity of valproate was investigated in ICR (Institute of Cancer Research, USA) mice under light-dark (12:12) cycle. A significant circadian rhythm was shown for embryotoxicity, with the highest value at 17:00 and the lowest at 01:00. No significant difference between injection at 17:00 and 01:00 was demonstrated for valproate concentrations in the embryo. The rhythm in the embryotoxicity seems to be related to the rhythm in the sensitivity to the drug. Embryotoxicity and valproate concentrations were significantly higher on gestational day 13 than day 7. The timing of drug administration (i.e., gestational stage and circadian phase) appears to be essential in the study of embryotoxicity of valproate in mice.

Animals↗

Chronic lithium and sodium valproate both decrease the concentration of myoinositol and increase the concentration of inositol monophosphates in rat brain.

One of the mechanisms underlying lithium's efficacy as a mood stabilizer in bipolar disorder has been proposed to be via its effects on the phosphoinositol cycle (PI cycle), where it is an inhibitor of the enzyme converting inositol monophosphates to myoinositol. In contrast, sodium valproate, another commonly used mood stabilizer, appears to have no direct effects on this enzyme and was thus believed to have a different mechanism of action. In the present study, high-resolution nuclear magnetic resonance (NMR) spectroscopy was used to study the chronic effects of both lithium and sodium valproate on the concentrations of myoinositol and inositol monophosphates in rat brain. As predicted, lithium-treated rats exhibited a significant increase in the concentration of inositol monophosphates and a significant decrease in myoinositol concentration compared to saline-treated controls. However, unexpectedly, sodium valproate administration produced exactly the same results as lithium administration. These novel findings suggest that both lithium and sodium valproate may share a common mechanism of action in the treatment of bipolar disorder via actions on the PI cycle.

Animals↗

Effects of chronic lithium and sodium valproate on concentrations of brain amino acids.

The present study was designed to determine if the mood stabilizers, lithium and valproate, have common effects on concentrations of amino acid neurotransmitters which may be related to their mechanisms of action. Two separate groups of rats were administered therapeutic doses of lithium, sodium valproate, or saline for 2 weeks. Whole brain extracts were then examined using either high-field 1H NMR spectroscopy or HPLC. Both drugs decreased whole brain concentrations of aspartate, glutamate, and taurine while brain concentrations of gamma-aminobutyric acid (GABA) and alanine decreased following chronic sodium valproate administration but not following chronic lithium administration. These findings indicate that lithium and sodium valproate share common effects on the concentrations of certain amino acid neurotransmitters in whole brain which may be related to their mechanisms of action in bipolar disorder.

Alanine↗

Lamotrigine monotherapy improves health-related quality of life in epilepsy: a double-blind comparison with valproate.

The effects of monotherapy with lamotrigine on health-related quality of life were compared with those of valproate monotherapy in a randomized, double-blind trial designed to evaluate treatment-emergent weight changes in patients with epilepsy. At the end of 8 months of treatment, significantly more patients using lamotrigine compared with valproate experienced quality-of-life improvements on the Health Perceptions (42% vs 15%), Energy/Fatigue (47% vs 28%), and Social Isolation (35% vs 16%) subscales of the Quality of Life in Epilepsy-89 (QOLIE-89) questionnaire (P<0.05). Compared with valproate-treated patients, lamotrigine-treated patients were four times more likely to experience improvement in Health Perceptions, 2.3 times more likely to experience improvement in Energy/Fatigue, and 2.8 times more likely to experience improvement in Social Isolation (P<0.05). These quality-of-life improvements are consistent with the improvements in mood measured with the Beck Depression Inventory, the Cornell Dysthymia Rating Scale, and the Profile of Mood States among patients receiving lamotrigine. These data show that lamotrigine monotherapy provides benefits over valproate monotherapy in improving several aspects of health-related quality of life in patients with epilepsy. The observation that quality-of-life improvements during lamotrigine monotherapy occurred concurrently with improvements in mood suggests that the quality-of-life and mood changes may be causally related.

Journal Article↗

Treatment of Parkinson's disease with sodium valproate: clinical, pharmacological, and biochemical observations.

Because there is biochemical evidence of decreased GABAergic function in Parkinson's disease, sodium valproate, an inhibitor of GABA catabolism, was administered to eight Parkinsonian patients. Valproate treatment did not significantly alter any Parkinsonian feature, but tended to increase the dyskinesia in the "on-off" patients. The increased dyskinesias were not a result of altered peripheral metabolism of L-dopa. Despite obtaining high plasma levels of valproate, no consistent alteration of CSF GABA levels could be demonstrated. Thus, in these patients, an effect of valproate on GABA metabolism is unproven, and in turn, the role of GABA in Parkinsonism and dyskinesia uncertain.

Aged↗

Sodium valproate in the treatment of the intractable childhood epileptic.

Sixty-five children with seizure disorders, who had been treated with multiple anticonvulsants but were poorly controlled, were selected from the Montreal Children's Hospital Convulsive Disorder Clinic and Neurology Service and were treated with sodium valproate (valproate). All types of seizure disorders were included in the group. Rapid oral absorption of the drug lead to peak plasma levels in one to three hours (later peaks occurring if administered after meals). A mean plasma half-life of 12.8 hours was calculated. Correlation between oral dose and plasma levels was poor. The side effects which occurred in this study were trivial. Drug interactions occurred with phenobarbital, diphenylhydantoin and clonazepam. Sixty percent of patients had a greater than 50% reduction in seizure frequency with sodium valproate, but the best response was in generalized absence seizures. Since all types of seizures responded to some degree, a trial of sodium valproate is warranted in intractable seizure disorders of childhood regardless of classification.

Adolescent↗

Does EEG predict response to valproate versus lithium in patients with mania?

A number of factors may suggest that a patient with mania may respond to valproate or to lithium. However, prediction of which patients will respond to either medication remains difficult. In this study nonepileptiform EEG abnormalities in responders to each medication were investigated. Six of 20 patients (30%) responsive to lithium but not to valproate had nonepileptiform EEG abnormalities while 14 of 20 patients (70%) responsive to valproate but not to lithium had nonepileptiform EEG abnormalities. Patients presenting with mania and EEG abnormalities, particularly sharp activity, are statistically more likely (chi2 = 4.9, df = 1, p = .027) to respond to valproate than to lithium. Whether such a finding will also hold true for other anticonvulsants used to treat mania remains to be seen.

Acute Disease↗

Increased sensitivity to the anticonvulsant effect of valproate in aging BN/BiRij rats.

The aim of the present investigations was to study the influence of increasing age on the pharmacodynamics of valproate in BN/BiRij rats, applying a threshold for electrically induced localized seizure activity as a measure of the anticonvulsant effect. Seven groups of healthy male BN/BiRij rats were used, aged 3, 6, 12, 19, 25, 31, and 37 months. Individual plasma concentration versus anticonvulsant effect relationships were determined during a continuous intravenous infusion of sodium valproate at a rate of 5.5 mg/min/kg. The infusion was terminated when the anticonvulsant effect intensity had reached the maximum attainable level or at a total infusion time of three hours. A nonlinear relationship between valproate concentration and anticonvulsant effect intensity was observed with no maximal effect in the concentration range up to 1200 mg.L-1. With increasing age a parallel shift in the concentration versus anticonvulsant effect relationships toward lower concentrations occurred. Thus increasing age appears to be associated with an increased sensitivity to the anticonvulsant effect of valproate.

Aging↗

Transdermal reverse iontophoresis of valproate: a noninvasive method for therapeutic drug monitoring.

PURPOSE: The objectives of this work were (a) to explore the potential of transdermal reverse iontophoresis for therapeutic drug monitoring and (b) to develop an "internal standard" calibration procedure so as to render the technique completely noninvasive. METHODS: A series of in vitro iontophoresis experiments was performed in which the subdermal concentration of sodium valproate was varied from 21 microM to 1 mM. Glutamic acid was also introduced into the subdermal donor at a fixed concentration to act as an "internal standard" for the calibration method. RESULTS: Both valproate and glutamate anions were recovered, as expected, at the anodal receptor chamber. The iontophoretic extraction flux of valproate was linearly correlated with the subdermal concentration. Glutamate flux was constant. It follows that the ratio of extracted fluxes (valproate/glutamate) was directly dependent upon (a) the subdermal valproate concentration and (b) the subdermal concentration ratio (valproate/glutamate), offering a means, thereby, to a completely noninvasive methodology. CONCLUSIONS: This work demonstrates the potential of reverse iontophoresis for noninvasive therapeutic monitoring. The simultaneous quantification of the analyte of interest and of an "internal standard" renders the withdrawal of a blood sample unnecessary.

Administration, Cutaneous↗

Sodium valproate in the management of painful neuropathy in type 2 diabetes - a randomized placebo controlled study.

OBJECTIVE: To study the effectiveness and safety aspects of sodium valproate in the management of painful neuropathy in patients of type 2 diabetes mellitus. MATERIAL AND METHODS: A randomized double-blind placebo controlled trial of sodium valproate was done in type 2 diabetic patients to assess its efficacy and safety in the management of painful neuropathy. We screened 60 patients but eight patients could not complete the study; hence, the present study was done on 52 patients. Each patient was assessed by clinical examination, pain score by short form of the McGill pain questionnaire (SF-MPQ) and electrophysiological examination, which included motor and sensory nerve conduction velocity, amplitude and H-reflex initially and at the end of 1 month of treatment. RESULTS: Significant improvement was noticed in the pain score of patients receiving sodium valproate in comparison to patients receiving placebo at the end of 1 month (P < 0.05). The changes in electrophysiological data were not significant. The drug was well tolerated by all patients except one who developed a raised aspartate transaminase (AST)/alanine transaminase (ALT) level after 15 days of treatment. CONCLUSION: Sodium valproate is a well-tolerated drug and provides significant subjective improvement in painful diabetic neuropathy. These data provide a basis for future trials of longer duration in a larger group of patients.

Adult↗

Mitochondrial diseases represent a risk factor for valproate-induced fulminant liver failure.

We report on 3 siblings (2 females and 1 male) with chronic progressive external ophthalmoplegia (CPEO), compatible with inherited mitochondrial cytopathy. The younger of the two sisters died at the age of 37 due to progressive respiratory failure. The older one presented with a status epilepticus at the age of 39 and was treated with valproate. Five months after the start of treatment, she developed fulminant liver failure and died. The brother has suffered from CPEO since early childhood but has had so far no other symptoms of a mitochondrial disease. A muscle biopsy from the younger sister revealed ragged-red fibers and decreased activities of complex I and IV of the respiratory chain but no pathogenic mutations in the mitochondrial tRNA genes or in several locations in the coding region of the mitochondrial genome. In the older sister's liver (obtained post-mortem), mitochondrial DNA was fragmented and could not be investigated. The clinical presentation and the biochemical findings suggest that all 3 siblings suffered from a mitochondrial cytopathy. Since mitochondrial cytopathies and valproate-induced fulminant liver failure are both rare events, an association between them is likely. Mitochondrial diseases should therefore be considered as a risk factor for valproate-induced liver failure and be excluded before treatment with valproate.

Adult↗