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Objectives: Our aim was to investigate the effect of etoricoxib on the anticonvulsant activity of phenytoin and diazepam against seizure models in mice. In addition the acute adverse effect of etoricoxib was assessed with a chimney test., Methods: The maximal seizure pattern was induced in mice by giving an alternating current of 50 mA for 0.2 s, while chemical seizures were induced by intraperitoneal injection of pentylenetetrazole at its CD97 dose (97% convulsive dose for the clonic phase). Test drug was administered 45 min before the electrical or chemical induction of seizures in combination with conventional antiepileptics. The ability of the test drug to reduce or abolish the extensor phase of maximal electroshock and clonic-type seizures in the chemical induction method was selected as anti-seizure criteria., Key Findings: Concurrent treatment with etoricoxib at an oral dose of 10 mg/kg reduced the anticonvulsant potency of phenytoin. The protective effects of diazepam against pentylenetetrazole-induced convulsions was significantly increased and the mortality rate was reduced by concurrent treatment with etoricoxib (10 mg/kg p.o.) when compared with diazepam groups. No neurotoxic effect was observed with etoricoxib (10 mg/kg p.o.) and it had no impact on motor coordination in the chimney test in mice. Etoricoxib applied at its highest dose (10 mg/kg) significantly enhanced the free plasma levels of diazepam whereas the free plasma levels of phenytoin were significantly reduced., Conclusions: The obtained results suggest that the preferential cyclooxygenase-2 inhibitor etoricoxib significantly reduced the anticonvulsant action of phenytoin and significantly increased the beneficial action of diazepam against maximal electroshock and pentylenetetrazole-induced convulsions in a mouse model.

Diphenylhydantoin (DPH), which is clinically used in the treatment of epilepsy, inhibits glucose-induced insulin release from pancreatic islets by a mechanism that remains unknown. In the present study, DPH is shown to suppress glucose-induced insulin release concentration-dependently. In dynamic experiments, 20 microm DPH suppressed 16.7 mm glucose-induced biphasic insulin release. DPH also suppressed insulin release in the presence of 16.7 mm glucose, 200 microm diazoxide, and 30 mm K+ without affecting the intracellular Ca2+ concentration. DPH suppressed ATP content and mitochondrial membrane hyperpolarization in the presence of 16.7 mm glucose without affecting glucose utilization, glucose oxidation, and reduced nicotinamide adenine dinucleotide phosphate fluorescence. DPH increased cytoplasmic pH in the presence of high glucose, but the increase was abolished under Na+ -deprived conditions and HCO3- -deprived conditions, suggesting that Na+ and HCO3- transport across the plasma membrane are involved in the increase in cytoplasmic pH by DPH. Alkalization by adding NH4+ to the extracellular medium also suppressed insulin release, ATP content, and mitochondrial membrane hyperpolarization. Because ATP production from the mitochondrial fraction in the presence of substrates was decreased by increased pH in the medium, DPH suppresses mitochondrial ATP production by reducing the H+ gradient across mitochondrial membrane. Using permeabilized islets, the increase in pH was shown to decrease Ca2+ efficacy at a clamped concentration of ATP in the exocytotic system. Taken together, DPH inhibits glucose-induced insulin secretion not only by inhibiting mitochondrial ATP production, but also by reducing Ca2+ efficacy in the exocytotic system through its alkalizing effect on cytoplasm.

Here we present a preclinical model to assess drug-drug interactions due to inhibition of glucuronidation. Treatment with the antiepileptics phenobarbital (PB) or phenytoin (PH) has been associated with increased incidence of acetaminophen (APAP) hepatotoxicity in patients. In human hepatocytes, we found that the toxicity of APAP (5 mM) was increased by simultaneous treatment with phenobarbital (2 mM) or phenytoin (0.2 mM). In contrast, pretreatment with PB for 48 h prior to APAP treatment did not increase APAP toxicity unless both drugs were present simultaneously. Cells treated with APAP in combination with PB or PH experienced decreases in protein synthesis as early as 1 h, ultrastructural changes by 24 h, and release of liver enzymes by 48 h. Toxicity correlated with inhibition of APAP glucuronidation. PB or PH also inhibited APAP glucuronidation in rat and human liver microsomes and expressed human UGT1A6, 1A9, and 2B15. As with intact hepatocytes, PB and PH were neither hydroxylated nor glucuronidated, suggesting the direct inhibition of UGTs. Our findings suggest that, in multiple drug therapy, an inhibitory complex between UGT and one of the drugs can lead to decreased glucuronidation and increased systemic exposure and toxicity of a coadministered drug.

Although it has not been demonstrated yet, phenytoin is expected to reduce efavirenz exposure through coinduction of cytochrome P450 (CYP) 3A4 and CYP2B6. Conversely, efavirenz has been shown in vitro to inhibit the enzymes responsible for phenytoin metabolism, CYP2C9 and CYP2C19. We report a case in which a potential bidirectional drug interaction between phenytoin and efavirenz resulted in lower-than-expected efavirenz concentrations and elevated phenytoin levels. Therapeutic drug monitoring was used in this case to ensure adequate efavirenz exposure.

It has been found in clinical practice that the serum level of phenytoin, of which metabolism is mediated by hepatic CYP2C enzymes, was markedly elevated by co-administration of 5-fluorouracil (5-FU) and doxifluridine (5'-deoxy-5-fluorouridine; 5'-DFUR), a prodrug of 5-FU, but the detailed mechanisms are unclear. A study using rats was undertaken to examine the effects of 5-FU and 5'-DFUR on phenytoin metabolism in hepatic microsomes and phenytoin pharmacokinetics in-vivo. Neither 5-FU nor 5'-DFUR exhibited direct inhibitory effects on hepatic microsomal phenytoin p-hydroxylation, a major metabolic route catalysed by CYP2C in rats, as in humans. 5-FU and 5'-DFUR were injected intraperitoneally into male rats as single doses (1.68 mmol kg(-1)) and repeated doses (0.24 mmol kg(-1) for 7 days). Control rats received vehicle alone. A significant reduction in the activity of phenytoin p-hydroxylation was observed 4 days after the last administration irrespective of the agents and their treatment regimens, although the activity was unchanged on Day 1. Pharmacokinetic analysis of phenytoin revealed that the elimination rate constant and the total clearance was decreased by 70-75% in both the 5'-DFUR-treated and 5-FU-treated rats, indicating that the decrease in the metabolic capacity of phenytoin was responsible for the change in phenytoin disposition in-vivo. On the other hand, 5-FU significantly depressed the total P450 content, NADPH cytochrome c reductase activity and activities of progesterone hydroxylations. However, the depressive effects of 5'-DFUR were not very potent relative to those of 5-FU, which can be explained by the fact that 5-FU is derived from 5'-DFUR to only a small extent. According to a recent report, phenytoin p-hydroxylation and progesterone 2alpha-/21-hydroxylations share common CYP2C enzymes as their catalysts. Because there was a difference in the modulation profiles between phenytoin p-hydroxylation and progesterone 2alpha-/21-hydroxylations after exposure to 5'-DFUR, 5'-DFUR might modulate phenytoin metabolism without loss of catalytic ability for other substrates, unlike 5-FU. The present study suggested that the down-regulation of hepatic CYP2C enzymes occurs by 5-FU exposure even at a low level, and provided a fundamental explanation for the drug interaction encountered in clinical practice.

Our aim was to study the effects of phenobarbital, phenytoin and ethosuximide on epileptic afterdischarges induced by cortical stimulation in rats. Fifteen-second series of low-frequency (8 Hz) rhythmic stimulation of the sensorimotor cortex were applied in rats with chronically implanted electrodes. Intervals between the stimulation series were at least 10 min and intensity was increased in a step-wise manner. Threshold current intensities were estimated for movements directly induced by stimulation, epileptic afterdischarges of the spike-and-wave type, clonic seizures accompanying this type of afterdischarge and transition into the limbic type of afterdischarge. Phenobarbital, phenytoin and ethosuximide were administered intraperitoneally before the first stimulation series. Phenobarbital (20, 40 and 80 mg kg(-1)) significantly increased the thresholds for the first three phenomena in a dose-dependent manner. Transition into the limbic afterdischarge was influenced only by the highest dose. Phenytoin (60 mg kg(-1)) only increased the thresholds insignificantly and ethosuximide (125 mg kg(-1)) was ineffective. We concluded that our model is useful for testing anticonvulsant effects. Results with three antiepileptic drugs correspond with their efficacy against myoclonic seizures in man.

The effects of chronic administration of phenytoin, a common anticonvulsive drug, on immune responses were studied in mice. Anti-keyhole limpet haemocyanin (KLH) IgE antibody response after KLH-immunization was enhanced in phenytoin-treated mice. Proliferative responses of spleen cells induced with KLH, concanavalin A (ConA), lipopolysaccharide and anti-CD3 antibody were reduced in phenytoin-treated mice. Accessory function of spleen adherent cells on ConA-induced T cell proliferative response was reduced in phenytoin-treated mice. KLH-induced IL-4 production of spleen cells was enhanced, while IFN-gamma production was reduced in phenytoin-treated mice. In addition, production of IL-1 alpha, but not IL-6 and IL-12 by spleen adherent cells from phenytoin-treated mice was reduced. Natural killer cell activity was reduced in phenytoin-treated mice. These results suggest that phenytoin treatment preferentially induces a Th2 type response. We also observed that plasma ACTH and corticosterone levels were increased in phenytoin-treated mice, and speculated that phenytoin might act directly and indirectly, through HPA axis activation, on the immune system to modulate Th1/Th2 balance.

Glycine, which has weak anticonvulsant properties, has been shown to potentiate the activity of several antiepileptic drugs but not phenytoin. Recently, studies have shown that N-(benzyloxycarbonyl)glycine (Z-glycine) antagonized seizures more than glycine in addition to possessing activity in the maximal electroshock test, a convulsive model in which glycine is inactive. In the present study esters of 3-hydroxymethylphenytoin, a phenytoin prodrug, and Z-glycine as well as the homologous N-(benzyloxycarbonyl)-omega-amino acids, Z-beta-alanine and Z-gamma-aminobutyric acid (Z-GABA), were prepared and tested for their anticonvulsant and acute neurotoxic activities. The phenytoin prodrugs were obtained by esterification of bis(2-oxo-3-oxazolidinyl)-phosphinic acid chloride-mediated esterification of 3-hydroxymethylphenytoin with the respective N-benzyloxycarbonyl-protected amino acid. The Z-glycine-phenytoin ester was the most active anticonvulsant derivative. Compared with phenytoin the compound exhibited a decreased median effective dose (ED50) in the MES test and an increased median toxic dose (TD50), resulting in an significantly improved protective index expressed as the ratio between TD50 and ED50. The present data suggest that covalent binding of phenytoin to Z-glycine results in an improved pharmacological profile of the drug.

The effect of phenytoin on the disposition of DL-3-hydroxy-3-ethyl-3-phenylpropionamide (HEPP) has been studied in New Zealand white rabbits. Plasma HEPP levels decreased when the drug was administered with phenytoin. The area under the plasma concentration-time curve was reduced by 56.49% (from 43.23+/-7.0 to 18.81+/-2.03 microg h mL(-1)), the elimination half-life was also significantly (P<0.01) reduced (from 2.68+/-0.35 to 1.04+/-0.07 h) and the clearance was increased (from 0.35 to 0.81 L h(-1) kg(-1)). In-vitro protein binding to bovine serum albumin (BSA) and plasma was evaluated by equilibrium dialysis. Plasma protein binding was low (between 33.69 and 37.43% at concentrations ranging from 6.25 to 100 microg mL(-1)). The compound binds preferentially to albumin with an association constant (Ka) of 3.81 x 10(3) M(-1) at 37 degrees C. The results suggest a pharmacokinetic interaction between phenytoin and HEPP, probably on the drug-metabolizing enzyme system in the liver.

The influence of the anticonvulsive drug phenytoin on the periodontal tissues during orthodontic tooth movement in the rat was studied. The experimental and the control group each consisted of 10 Sprague-Dawley rats. The test group was injected daily with phenytoin during the experimental period of 6 weeks. A fixed appliance for expansion was applied on the first molars in both groups after 2 weeks (day 15). At the end of the experiment (day 42), radiographic measurements revealed less tooth movement in the phenytoin-treated rats. Compared to the control group, significant histologic changes in the periodontal tissues such as increased density of fibroblasts, decreased number of osteoclasts in contact with alveolar bone wall of the pressure side and deeper layer of non-mineralized osteoid on the tension side were observed in the phenytoin group.

Treatment of rats with phenytoin (DPH), an anti-epileptic drug, results in lower tissue thyroid hormone (TH) levels and interferes with the metabolic pathway of TH. To test the hypothesis that DPH affects the enterohepatic cycle of TH and, thus, the kinetics of TH turnover, we performed a kinetic experiment (three-compartment analysis) and a steady-state, double-isotope equilibrium experiment in rats treated for 3 weeks with DPH (50 mg/kg body weight per day) and in untreated controls. This included measurements of TH and TH metabolite levels, as well as the activities of enzymes involved in the TH metabolic pathway. DPH treatment resulted in a decrease in the production of thyroxine (T4) (by 25%) and tri-iodothyronine (T3) (by 37%), a decrease in the T3 concentration in all three pools, and a redistribution of T4 from the fast to the slow pool. The amount of T4 increased in intestinal contents and feces by 66% and 71% respectively. Expressed as a fraction of daily TH disposal, fecal loss of T4 was enhanced from 10 to 23% and that of T3 from 16 to 21%. An increase in T4 and T3 UDP-glucuronyltransferase activities was observed, suggesting that the increased fecal loss of T4 and T3 is secondary to an increased biliary output of their glucuronides. The reduced secretion of TH and increased fecal clearance during DPH treatment can lead in the long run to depletion of TH stores.

Fosphenytoin sodium is reviewed, and its safety is compared with that of phenytoin. After i.v. or i.m. injection, fosphenytoin, a phenytoin prodrug, is rapidly hydrolyzed to phenytoin. Free-phenytoin concentrations equivalent to those obtained with i.v. phenytoin can be achieved with fosphenytoin given at equimolar loading doses by selecting the appropriate rate of fosphenytoin administration. Fosphenytoin can be expected to interact with the same drugs that interact with phenytoin. The dosage is expressed as phenytoin sodium equivalents (PE). The standard loading dose for adults with status epilepticus is 15-20 mg PE/kg i.v. infused at 100-150 mg/min; i.m. administration is not recommended for this condition. For nonemergency situations, a 10- to 20-mg PE/kg loading dose can be given i.v. or i.m. Fosphenytoin has advantages over phenytoin injection that are related to its greater aqueous solubility, which obviates the extreme alkalinity, propylene glycol, and ethanol needed in the injectable phenytoin formulation. Intravenous fosphenytoin has been associated with less soft-tissue injury and fewer adverse effects in general than phenytoin. Fosphenytoin, when administered i.m., is completely absorbed, is relatively well tolerated, and provides more predictable serum drug concentrations than i.m. phenytoin. Fosphenytoin offers practical and clinical advantages over i.v. phenytoin.

Treatment of rats with phenytoin (DPH), an anti-epileptic drug, results in lower tissue thyroid hormone (TH) levels. To investigate if this is accompanied by tissue hypothyroidism, rats were treated for 3 weeks with DPH (50 mg/kg body wt in food). Thyroid hormone-dependent parameters were measured, and the results were compared to those of control rats and to those of athyreotic rats substituted with thyroxine + triiodothyronine (Tx + TH) to reach the same plasma TH levels as DPH-treated rats. These rats were mildly hypothyroid with regard to their TH and TSH levels and TH-dependent parameters. Both DPH and Tx + TH led to a decrease in plasma thyroxine (T4) and triiodothyronine (T3) (+/-70% of the control). The percentage free T4 was unchanged. Plasma thyrotropin (TSH) was increased only in the Tx + TH rats (sixfold). For DPH rats, pituitary hormone content was not different from the control; growth hormone was lower and TSH was higher in Tx + TH rats. In DPH and Tx + TH rats, an increase in hepatic T4 and T3 uridine-diphosphate glucuronyltransferase activity was found, likewise indicating a change in the metabolic pathway of TH. Hepatic iodothyronine deiodinase (ID) type I activity decreased in Tx + TH rats but did not alter in DPH rats. Hepatic alpha-glycerophosphate dehydrogenase (alpha-GPD) decreased in DPH and Tx + TH rats. Malic enzyme in liver was enhanced in DPH rats. In the brains of DPH rats the level of alpha-GPD activity was raised; in Tx + TH it was lowered. The ID type II activity in the brain was reduced in DPH rats, but ID type III did not change for either group. Total body oxygen consumption increased in DPH rats (13%); it decreased in Tx + TH rats (9%). Our results show that DPH causes changes comparable to mild hypothyroidism. The lack of or a diminished hypothyroid response can be explained as the attenuating agonistic effect of DPH, which is supported by O2 consumption, brain ID type II and alpha-GPD activities. The T4 content was reduced by 30% in thyroid digests; this, together with a reduced T4 secretion, can lead to serious hypothyroxinemia during prolonged DPH treatment.

Recent reports indicate that the topical administration of phenytoin to cutaneous wounds can promote repair. However, isolated skin cells (keratinocytes and fibroblasts) in vitro have varied in their response to phenytoin, giving rise to apparently contradictory results. We have examined how the structure of the extracellular matrix in which human dermal fibroblasts are grown in vitro can influence the response of these cells to phenytoin. The results indicate that, when fibroblasts are embedded within freely-contracting, relaxed, types I collagen matrices, they are insensitive to phenytoin treatment. However, if fibroblasts are grown in collagen matrices which are nonretracting and under tension, phenytoin (5-50 micrograms/ml) significantly (P < 0.01) stimulates cell proliferation, and inhibits collagenase activity in a dose- and time-dependent manner. The fact that the effects of phenytoin on dermal fibroblasts are biphasic and influenced by the surrounding matrix may help to explain why in vitro investigations with phenytoin give rise to inconsistent data. It also suggests that the matrix alterations which accompany wound healing may modulate the effects of phenytoin on dermal fibroblasts.

Phenytoin therapy is a well recognized cause of gingival hyperplasia, a condition characterized by increased gingival collagen synthesis, and may also cause acromegalic-like facial features. Based on these clinical findings suggestive of anabolic actions, we sought to test the hypothesis that phenytoin acts on normal bone cells to induce osteogenic effects. To test the direct actions of phenytoin on human bone cells, we measured the dose responses to phenytoin for [3H]thymidine incorporation, cell number, alkaline phosphatase specific activity, and collagen synthesis in human hip bone-derived cells. Phenytoin significantly and reproducibly increased [3H]thymidine incorporation, cell number, alkaline phosphatase specific activity, and collagen synthesis in a biphasic manner with optimal stimulatory doses between 5-10 mumol/L. Thus, micromolar concentrations of phenytoin can act directly on human bone cells to stimulate osteoblast proliferation and differentiation. We next sought to test the hypothesis that phenytoin stimulates bone formation in humans in vivo. Accordingly, three serum biochemical markers of bone formation, i.e. osteocalcin, skeletal alkaline phosphatase, and procollagen C-terminal extension peptide, were measured in 39 male epileptic patients, 20-60 yr of age, with an average duration of phenytoin therapy of 10.5 +/- 1.62 yr (mean +/- SEM). In this group of patients, the mean serum phenytoin level was 9.56 +/- 0.90 mg/L (mean +/- SEM; equivalent to 34.9 +/- 3.3 mumol/L). Thirty apparently healthy male subjects of similar age and taking no medication were included as controls. Serum calcium, 25-hydroxyvitamin D3, and PTH levels in the phenytoin-treated patients were not significantly different from those in the age-matched controls and were within the clinical laboratory normal range of our hospitals, indicating that the patients did not develop hypocalcemia, vitamin D deficiency, or secondary hyperparathyroidism. Serum levels of osteocalcin, skeletal alkaline phosphatase, and procollagen peptide in the phenytoin-treated patients were significantly increased compared to those in the age-matched subjects; in each case these biochemical markers were significantly correlated with the serum phenytoin level, but not with the dose or duration of phenytoin treatment. These findings are consistent with the interpretation that phenytoin increases the bone formation rate in humans in vivo.(ABSTRACT TRUNCATED AT 400 WORDS)

The anticonvulsant activity of phenytoin-lipid conjugates obtained by covalent binding of 3-hydroxy-methylphenytoin to dimyristoylglycerides via a succinidyl linkage, to 2-(1,3-dimyristoylglyceryl)butyric acid and to 3-myristoyl-2-myristoylmethylpropionic acid was evaluated in the maximal electroshock (MES) test and the seizure threshold test with subcutaneous pentetrazol. The phenytoin-lipid conjugates were less active than the parent drug in the MES test after intraperitoneal administration as suspensions, but exhibited comparable activity when injected as a solution in dimethylsulphoxide. They also protected mice from MES-induced seizures following oral administration of aqueous suspensions of the compounds or when incorporated into emulsions. The anticonvulsant activity could be correlated to in-vitro pancreatic lipase-mediated hydrolysis. The bis-deacyl derivatives were at least as active but in some cases also more toxic than phenytoin. Oral administration of two of the lipid conjugates resulted in a faster onset of the anticonvulsant activity compared with the administration of an equimolar dose of phenytoin itself. All compounds were inactive in the subcutaneous pentetrazol test. It is concluded that the lipids act as prodrugs of phenytoin, which is generated by lipolysis upon oral administration.

The expression and ligand binding characteristics of sigma-receptors in human placental syncytiotrophoblast and choriocarcinoma cells were investigated using haloperidol as a ligand. Haloperidol bound to purified placental brush border membranes with high affinity; the apparent dissociation constant for the process was about 3 nM. These binding sites were not related to dopamine (D2) and serotonin (5-HT2) receptors nor to serotonin and norepinephrine transporters. The ligands of sigma-receptors [3.g. (+)-3-(3-hydroxyphenyl)N-(1-propyl)piperidine, 1,3-di-(2-tolyl)guanidine, clorgyline, rimcazole, and dexromethorphan] were very potent in competing with haloperidol for the binding sites. The binding sites were detected not only in the brush border membrane, but also in intracellular membranes. The rank order of potency of various sigma-receptor ligands to inhibit haloperidol binding indicated that placental sigma-receptors belong to the sigma 1 subtype. Cocaine and its analog RTI-55 [2 beta-carbomethoxy-3 beta-(4-iodophenyl-) tropane] inhibited the binding of haloperidol to placental membranes with appreciable potency. The steroid hormones, progesterone and testosterone, were also potent inhibitors, and the inhibition constant for progesterone was 0.3 microM, a concentration much smaller than that found in plasma during pregnancy. The inhibition was competitive. beta-Estradiol and a number of other steroids were relatively much weaker inhibitors than progesterone and testosterone. Phenytoin and neuropeptide-Y did not interact with sigma-receptors in placenta. The choriocarcinoma cell line JAR was also found to express sigma-receptors in the plasma membrane as well as in intracellular membranes. The characteristics of the receptors in this cell were qualitatively similar to those of the receptors in normal placenta, including subtype identity and interaction with cocaine and progesterone. Interestingly, however, all sigma-receptor ligands interacted with the receptors in the JAR cell with much higher affinity than with the receptors in normal placenta. It is concluded that the placental syncytiotrophoblast and choriocarcinoma cells express cocaine-sensitive sigma-receptors and that progesterone is most likely an endogenous ligand for these receptors.

Some years ago, we reported that colloid goiters could be produced experimentally in mice and rats by injection of TSH over a few days in the presence of ample iodine supply. This clearly showed that colloid accumulation and intense TSH stimulation are not mutually exclusive. In the present study, large colloid goiters, sharing many morphological and biochemical characteristics with human colloid goiters, were induced in rats and mice by treatment with 5,5-diphenyl-2-thiohydantoin (DPTH). This drug increases fecal loss of thyroid hormone and inhibits conversion of T4 to T3. Thus, DPTH raises TSH and induces macrofollicular colloid-rich goiters. In contrast to this, goiters induced by combined treatment with methimazole (MMI) or sodium perchlorate and DPTH are microfollicular, although serum TSH is increased to the same level as in rats treated with DPTH alone. The degree of iodine organification obviously determines if the follicle will sprout and form daughter follicles or if it will expand its hull. Thyroglobulin content of DPTH goiters is lower than that of normal glands but considerably higher than after MMI treatment, whereas total iodine content of DPTH goiters is only slightly lower than in normal glands, but also much higher than in MMI goiters. In DPTH goiters, a high proportion of total iodine is in the particulate fraction which probably contains the periodic acid Schiff-positive bodies floating in the colloid of DPTH treated glands. Acute DPTH administration does not inhibit iodide organification, but after treatment with DPTH for 1 day, chromatography suggests some inhibition of iodine organification and hormone synthesis by DPTH, but much less than by MMI. DPTH treatment causes considerable tissue damage and repair, such as follicular cell necrosis and invasion of the colloid by macrophages and granulation tissue. Therefore, DPTH goiters might well be a useful model not only for colloid goiter formation but also for inflammatory processes in the thyroid gland.

Twelve patients receiving therapy with an azole agent (ketoconazole, itraconazole, and/or fluconazole) for systemic mycoses experienced drug interactions with rifampin, phenytoin, and/or carbamazepine resulting in substantial decreases in azole concentrations in serum. All four patients receiving azoles and concurrent phenytoin and/or carbamazepine failed to respond to treatment or suffered a relapse of their fungal infection. Four of five patients with cryptococcosis who received itraconazole and rifampin responded despite decreases in their serum itraconazole concentrations; synergy between itraconazole and rifampin was documented by in vitro analysis of inhibition and of killing of Cryptococcus neoformans isolates from all patients receiving this combination. In contrast, two patients with coccidioidomycosis failed to respond to itraconazole/rifampin. Moreover, two patients with cryptococcosis suffered a relapse or persistence of seborrheic dermatitis while receiving itraconazole/rifampin. The latter combination showed synergy in vitro in the inhibition of the mycelial phase of Coccidioides immitis and, to a lesser extent, of the pathogenic spherule phase of this fungus; synergy in the killing of C. immitis was not noted, nor was synergy seen against Malassezia furfur, the purported etiologic agent of seborrheic dermatitis. These findings illustrate several drug interactions that may affect clinical outcome and that must be considered in the management of antifungal therapy.

It has been reported that phenytoin induces gingival and connective tissue hyperplasia and may be of use in wound healing. In this study the effect of phenytoin on human epidermal keratinocytes and skin fibroblasts has been investigated in vitro. Cell cultures were exposed to increasing concentrations of phenytoin from 10(-9) to 10(-4) M in the presence of 1 and 10% serum supplemented medium. In addition the effect of phenytoin on epidermal cell migration (epiboly) has been investigated using organ culture of human skin. No stimulation of cell growth was observed, and only a mild toxicity affecting keratinocytes was seen at the highest concentrations. Similarly, no effect on epidermal cell migration in vitro was observed. The lack of a direct effect in vitro suggests that any in-vivo effect was not the result of interaction between phenytoin and keratinocytes or fibroblasts but possibly due to indirect modulation via other cell types, such as inflammatory or lymphoreticular cells.

We studied the effect of 5,5'-diphenylhydantoin (phenytoin, DPH) on the metabolism of thyroid hormones, the intracellular concentration of T4, and the source and concentration of T3. Two groups of six male Wistar rats received a continuous infusion of 10 ml saline/rat. day. One group received DPH in their food (50 mg/kg BW) for 20 days. For both groups [125I]T4 and [131I]T3 were added to the infusion fluid for the last 10 and 7 days, respectively. At isotopic equilibrium the rats were bled and perfused. Compared to the controls, plasma T4 and T3 in the DPH group were reduced (22% and 31%, respectively); TSH did not change. The rate of production of T4 and the plasma appearance rate for T3 were decreased. Thyroidal T3 production was markedly reduced. From the increased [125I]T3/[125I]T4 ratio for plasma, it follows that total body conversion was enhanced. The tissue T4 concentrations decreased in parallel with the plasma T4 level. Total T3 was reduced in all organs. In tissues in which local conversion does not occur, i.e. heart and muscle, the decrease reflected the decrease in plasma T3. In the liver both plasma-derived T3 and locally produced T3 were diminished. In cerebellum and brain the plasma-derived T3 pool was even smaller than was expected from the decrease in plasma T3. This was partly compensated by an increase in local conversion. Only for these two organs was the decrease in the tissue/plasma ratio for [131I]T3 significant. Our results suggest tissue hypothyroidism, caused by a decrease in the production of T4 and T3, which is partly compensated by increased conversion in several organs. The transport of T3 into cerebellum and brain is disturbed, which can be attributed to the mode of action of DPH.

I evaluated Amerlex (Amersham International), Coat-A-Count (Diagnostic Products Corporation), Gammacoat (Clinical Assays), Immophase (Corning Medical), and Liquisol (Damon Diagnostics) radioimmunoassay kits for determinations of free thyroxin concentration in sera. Kit results for free thyroxin and the free thyroxin index and thyroxin/thyroglobulin ratio were compared for patients with thyroid disease and for subjects with normal and altered thyroglobulin binding capacity. Values for free thyroxin, free thyroxin index, and thyroxin/thyroglobulin clearly distinguished hyperthyroid and hypothyroid patients from euthyroid subjects. Each free thyroxin kit showed that fewer euthyroid patients with increased or decreased thyroglobulin binding capacity had values outside of normal limits than was indicated by kits for either free thyroxin index or thyroxin/thyroglobulin. The free thyroxin kits not only provided a better overall index of thyroid status in euthyroid patients who had alterations in thyroglobulin binding capacity than either of the indirect assessments of free thyroxin, but also supplied similar diagnostic information in thyroid disease.

A thyroid hormone-binding substance (TBGw) similar to serum T4-binding globulin (TBG) has been identified in the whey fraction of human breast milk. TBGw coeluted with serum TBG, as determined by Bio-Gel P-100 chromatography, and has an isoelectric point of 4.2-4.8, similar to that of serum TBG. The affinity constant of TBGw for T4 was similar to that of serum TBG(Ka, 1.54 +/- 0.38 X 10(9) M-1). Marked inhibition of TBGw binding of [125I]T4 was achieved by the addition of 1.5 X 10(-3) M 8-anilino-1-naphthalene-sulfonic acid. An albumin-like low affinity site (Ka, greater than 10(7) M-1) was also found. RIA of whey concentrates serially diluted in TBG-depleted serum indicated nearly identical binding curves for TBGw and TBG, with slopes of 2.33 (n = 15; r = 0.947) and 2.54 (n = 7; r = 0.996), respectively. Using a specific TBG RIA, a TBGw concentration of 0.29 +/- 0.08 microgram/ml (mean +/- SD) in breast milk (n = 26) was determined. Paired serum and whey specimens from individuals between 6 and 20 weeks of lactation were analyzed by TBG RIA; in these individuals, mean serum TBG concentrations were 25.0 +/- 3.4 micrograms/ml (n = 7); corresponding TBGw levels were 0.26 +/- 0.08 micrograms/ml (n = 7), i.e. approximately 1% of serum levels. Nonetheless, linear regression analysis of the data revealed no significant correlation between serum and whey TBG concentrations in these individuals.

The effects of itraconazole, a triazole antifungal agent, on cytochrome P450 were investigated by measuring the anti-convulsant activity of phenytoin in mice, and zoxazolamine paralysis time, tolbutamide clearance, and plasma dicoumarol concentrations after a single injection of dicoumarol, in rats. Itraconazole, given either as a single dose of 5 or 10 mg/kg, or daily at these levels for five days, had no significant effect on any of the measures. The drug therefore appears to be free of enzyme inhibiting or inducing activity, although an effect on other cytochrome P450 isozymes can not be discounted. Thus itraconazole may possibly show fewer clinically significant drug interactions at the level of hepatic mixed function oxidase than other azole antifungal agents.

Diphenylthiohydantoin (DPTH) is a potent goitrogenic compound and produces goiters in rats. Like methimazole, DPTH depresses plasma T4 and T3 concentrations and elevates plasma T4 and T3 concentrations and elevates plasma TSH concentration. Unlike methimazole, however, DPTH does not suppress thyroidal radioiodine uptake and thyroid hormone synthesis, although the monoiodotyrosine to diiodotyrosine ration is elevated by DPTH. DPTH does not inhibit thyroidal radioiodine release or augment the degradation of thyroid hormone. DPTH depresses an increase of plasma T4 and T3 in thyroidectomized rats maintained on T4 or T3 by augmenting fecal excretion of hormones. In addition, DPTH decreases conversion of T4 to T3 in vitro. It is suggested that DPTH is a unique goitrogen which acts at two different extrahyroidal sites, viz. fecal loss of thyroid hormone and conversion of T4 to T3.

Since 5,5'-diphenylhydantoin (DPH) decreases specific nuclear receptor binding of T3, the possibility that DPH might affect thyroid activity was examined by measurement of the activity of rat hepatic cytosol malic enzyme (ME) and mitochondrial alpha-glycerophosphate dehydrogenase (alpha-GPD) after DPH administration. Groups of athyreotic rats, prepared by thyroidectomy and 131I administration, were injected with vehicle (V), DPH, T3, or a combined dose of DPH and T3 for 48 h. The rats were then killed, and liver fractions were prepared for the measurement of ME and alpha-GPD activities. Compared with the V group, DPH treatment resulted in a significant increase in mean ME activity in four experiments; the mean ME activity for all studies was 2.2-fold greater than that of the V group (P less than 0.001). A significant increase in mean alpha-GPD activity was not observed in DPH-treated rats. T3 treatment resulted in a mean 31.5-fold increase in ME activity and a 10.9-fold increase in alpha-GPD activity. The magnitude of T3 induction of both enzymes was substantially attenuated by simultaneous injection of DPH, to 54-66% of the activity induced by T3 alone (P less than 0.001). Pair-feeding a T3-injected group and the DPH plus T3 group did not result in a decrease in the activity of either enzyme. Moreover, the observed changes did not appear to result from alterations in enzyme determinations or from significant changes in cytosol or mitochondrial protein concentration, cytosol T3, or plasma glucose. Although DPH-induced changes in the fractional rate of enzyme metabolism cannot be excluded, it is possible that changes in enzyme activities observed after DPH injection resulted from an interaction between DPH and the nuclear T3 receptor. If so, based on the effects observed in the present studies, DPH might be classified as a partial thyroid agonist.

The immunological response of mice submitted to hydantoin treatment was determined. Hydantoin reduced the absolute number of spleen cells in treated animals and did not modify spleen cells reactivity to concanavalin A, although the response to SRBC challenge, as measured by the Jerne plaque-forming cell technique, was significantly decreased. Following these findings, the influence of hydantoin on carcinogenesis was evaluated by using the model of urethane-induced lung adenomas in SWR mice. Treatment with hydantoin significantly reduced the incidence of the induced adenomas. We confirmed that hydantoin modifies the immune response of the host mainly by depressing its humoral function and we have shown that this effect was associated with an inhibitory effect on tumour induction.

The extrathyroidal metabolism of T4, T3, rT3, and 3',5'-diiodothyronine (3',5'-T2) was studied before and after treatment with 350 mg phenytoin (DPH) daily for 14 days in six hypothyroid patients receiving constant L-T4 replacement. The total and free serum concentrations of the four iodothyronines were reduced by approximately 30% during DPH treatment, whereas the free fractions in serum were unaltered. Concomitantly, serum TSH increased 137% (P less than 0.02). The production rate (PR) of T4 decreased 16% (P less than 0.005), indicating decreased intestinal absorption (bioavailability) of oral L-T4 during DPH treatment. The fractional rate of 5'-deiodination of T4 to T3 increased from 27% to 31% (P less than 0.05), whereas the rate of 5-deiodination of T4 to rT3 decreased from 45% to 25% (P less than 0.05). The urinary excretion of free and conjugated T4 was 2.3% of the T4 PR and was unaffected by DPH. Thus, the amount of T4 metabolized through nondeiodinative pathways apart from urinary excretion increased from 25% to 44% (P less than 0.05). The apparent distribution volume (Vd) of T4 increased (P less than 0.05), whereas the pool size was unchanged. The PR of T3 did not change during DPH treatment, nor did the mean transit time or the cellular clearance. The rT3 PR was reduced by 54% (P less than 0.02) during DPH treatment. Concomitantly, the transit time increased 10-fold (P less than 0.05), whereas Vd and pool size increased 5-fold (P less than 0.01 and P less than 0.05, respectively). The turnover of 3',5'-T2, in contrast to that of the other iodothyronines, did not change significantly during DPH treatment. T3 formation from T4 was measured in liver microsomal fractions from rats treated for 8 days with DPH and was almost identical to that in untreated animals. The data demonstrate that DPH in therapeutic concentrations did not affect serum protein binding of the iodothyronines. DPH reduced the intestinal absorption of T4 and increased the nondeiodinative metabolism of T4. The resulting decrease in total and free serum T4 and T3 was associated with an increase in serum TSH, demonstrating reduced negative feedback on the pituitary. Our data do not support the assumption that DPH induces increased hepatic deiodinating enzyme activity.(ABSTRACT TRUNCATED AT 400 WORDS)

We directly compared the competitor potency for serum T4 binding of 11 nonsteroidal antiinflammatory drugs; the diuretics furosemide, ethacrynic acid, and bumetanide; diphenylhydantoin; the cholecystographic contrast agents iopanoate and ipodate; and six long-chain nonesterified fatty acids (NEFA) using equilibrium dialysis. To avoid artefacts that occur in competitor studies with diluted serum or isolated binding proteins, we used undiluted normal serum, with drugs added at concentrations that achieved high therapeutic total and free serum levels at equilibrium. Drug addition was based on the measured free fraction of each drug in serum. The free T4 fraction in normal serum (Tris buffer, pH 7.4; 37 C) was between 1.40 X 10(-4) and 1.53 X 10(-4). Drug-induced increases in T4 free fraction were: fenclofenac, 90%; aspirin, 62%; meclofenamic acid, 39%; diflunisal, 37%; mefenamic acid, 31%; and furosemide, 31%. Significant increases of 7-15% occurred with diclofenac, flufenamic acid, phenylbutazone, and diphenylhydantoin. Indomethacin, ketoprofen, tolmetin, ethacrynic acid, bumetanide, iopanoate, and ipodate were inactive at the concentrations studied. Addition of 2.0 mmol/L oleic acid had a negligible effect, but 3.5 mmol/L oleic acid inhibited T3 and T4 binding significantly. Other long chain NEFA (addition of 1.5 mmol/L) gave increases in free T4 fraction as follows: arachidonic acid, 26%; linolenic acid, 23%; and linoleic acid, 11%. Stearic and palmitic acids were inactive. The effect of 5 mmol/L oleic acid in serum could be reproduced by addition of 0.5 mmol/L to serum diluted 1:10, indicating that protein binding of NEFA is the major determinant that limits their competitor potency. These findings provide a basis for anticipating which potential inhibitors may cause important changes in serum thyroid hormone binding. The time course of such effects will be influenced by the pharmacokinetics of the inhibitor itself as well as the equilibrium findings described here.

Five-month-old lean and obese Zucker rats were fasted for up to 7 days (lean rats) or 28 days (obese rats), and serum total and free T4 and T3 concentrations, percent free T4 and T3 by equilibrium dialysis, and the binding of [125I] T4 to serum proteins by gel electrophoresis were measured. In the lean rats, a 4- or 7-day fast resulted in significant decreases in serum total and free T4 and T3 concentrations. There was a decrease in the percent free T3 after 7 days of starvation. In contrast, a 4- or 7-day fast did not alter any of these variables in the obese rats. However, after 14 or more days of starvation, serum total T4 and T3 concentrations increased, and the percent free T4 and T3 decreased, resulting in no change in the serum free T4 or T3 concentrations in the obese rats. The percent of [125I]T4 bound to serum thyronine-binding globulin increased and the percent bound to thyronine-binding prealbumin decreased with the duration of the fast in both the lean and obese rats. The increase in serum thyronine-binding globulin binding of T4 can explain the increase in serum total T4 and T3 concentrations, the decrease in percent free T4 and T3, and the normal free hormone concentration in the long term fasted obese rats. The findings in the lean rats appear to be due to a combination of the known central hypothyroidism that occurs during 4-7 days of fasting and the fasting-induced changes in T4 binding in serum. Changes in T4 and T3 binding in serum during fasting in the rat must be considered when the effects of fasting on serum concentrations of the thyroid hormones, thyroid hormone kinetics, and the peripheral action of the thyroid hormones are evaluated.

We present a monoclonal IgG1 antibody, KiMy1R, which is specific for macrophages and their derivatives in the lymphatic tissue of the rat, and evaluate the distribution of subsets of mononuclear cells in popliteal and para-aortal lymph nodes of Wistar rats after injection of 50 mg DPH into the hindpads. Compared with resting lymphatic tissue and lymph nodes of animals treated with phenobarbital, DPH induced a significant increase (P less than 0.01) of the proportion of phagocytic cells. Furthermore, the soluble antigen alkaline phosphatase was traced after inoculation into the footpads of rats: in locoregional lymph nodes the percentage (mean 12.8/10(3] and the total number (mean 476 x 10(3) cells/lymph node) of cells with membrane-bound or intracytoplasmic alkaline phosphatase, as detected by a monoclonal anti-alkaline phosphatase antibody, were significantly higher (P less than 0.001) in animals pretreated with DPH than in rats pretreated with phenobarbital (mean 2.1/10(3); 31.2 x 10(3) cells/lymph node) and in untreated animals (mean 1.9/10(3); 4.1 x 10(3) cells/lymph node). If verified in humans, the effect of DPH in enhancing the number and function of macrophages and other antigen-presenting cells may exert favourable effects in patients with impairment of the mononuclear phagocytic system.

To study the effect of 5,5'-diphenylhydantoin (DPH) on cellular and specific nuclear T3 binding, we have studied the effect of DPH on binding of T3 by rat anterior pituitary in vivo and in cultured GC cells, a rat pituitary tumor cell line that secretes GH. As determined by in vivo displacement techniques, DPH (10 mg/100 g BW daily for 3 days or as a single dose of 20 mg/100 g BW) resulted in a significant decrease in T3 binding by cytosol and specific nuclear sites in rat anterior pituitary. In cultured GC cells, the addition of 400 muM DPH resulted in a 70-80% decrease in specific nuclear T3 binding and a 40-50% decrease in cytosol T3 binding without affecting the rate of T3 equilibration. The effect of DPH was dose dependent between 10 and 400 muM. Similar effects, but of a smaller magnitude, were noted in studies of isolated GC cell nuclei. The maximum percent decrease in specific T3 binding in isolated nuclei was 22% at 400 muM DPH. Scatchard analysis suggested that the DPH-induced decrease in specific nuclear T3 binding was competitive when measured in intact cells; the interaction between DPH and T3 appeared noncompetitive in studies of isolated GC cell nuclei. Other experiments indicated that DPH did not affect the exit rate of T3 from either the cytosol or specific nuclear compartments. The present studies suggest that DPH may decrease the fractional rate of entry of T3 into cultured cells and also inhibit binding of T3 by nuclear receptors. The similarity of effects observed in cultured GC cells and in rat anterior pituitary in in vivo studies suggests that studies in GC cells should be useful for examination of biological changes that result from the interaction between DPH and T3 at nuclear binding sites.

To study the effects of diphenylhydantoin (Dilantin, DPH) on membrane function, DPH was incubated with erythrocytes from normal individuals and from patients with congenital spherocytic hemolytic anemia and osmotic fragility measured. The resulting curves show that DPH reduces the osmotic fragility of normal and spherocytic erythrocytes. In the presence of ouabain, DPH still had a protective effect on erythrocytes even though ouabain alone increases hemolysis of erythrocytes at certain saline concentrations. This study shows that erythrocyte fragility can be manipulated in vitro and provides a basis for studies in vivo.

The metabolic clearance rates (MCR) of methylprednisolone (MP) (no. = 13) and methylprednisolone-21- Na-hemisuccinate (MPHS) (no. = 6) were studied in normal humans using tritium-labeled steroids. The cumulative appearance of the labeled steroid was examined for the whole urine and for three major urinary fractions. The MCR, half-life, and volume of distribution were, respectively, 383 +/- 72 (SD) liters/day, 165 +/- 49 minutes, and 61 +/- 12 liters for MP, and 234 +/- 37, 160 +/- 19, and 41 +/- 6 for MPHS. Diphenylhydantoin (DPH) administered to 4 subjects increased the MCR of MP from 424 +/- 71 to 977 +/- 132 (P less than 0.01), and decreased the half-life from 149 +/- 44 to 69 +/- 7 (P less than 0.001). Similar effects were found with phenobarbital (PB). Diazepam (DZP) had no effect. Major increases in urinary metabolites after DPH and PB were in the unconjugated ethyl acetate fraction, and this suggests that MP metabolism is significantly altered by hepatic microsomal hydroxylation enzyme induction by DHP and PB, but not DZP. This could occur with the formation of a 6beta-hydroxy derivative which could be readily cleared by the kidney. The urinary pattern of excretion for MPHS was similar to that of MP. The MCR of MPHS was affected to a lesser extent by DPH and PB than was the MCR of MP(P less than 0.01). Therefore, the use of hepatic microsomal hydroxylase inducers should be taken into consideration in clinical states in which MP is being used.

Diphenylhydantoin (DPH) depresses serum IgA and IgM concentrations and polyvinyl pyrrolidone (PVP) clearance in mice.

Serum 5-hydroxytryptamine (5-HT) and 5-hydroxyindole acetic acid (5-HIAA) concentrations in control rat offspring increased progressively during the preweaning period reaching adult values by day 21. It has been shown the prenatal phenytoin administration (100 mg kg-1 orally, days 7-19 of pregnancy) increased serum tryptophan and brain tryptophan, 5-HT and 5-HIAA of rat offspring at 3 days of age but not at 4, 15 or 21 days of age. The effect of prenatal phenytoin administration on the offspring at 3 days of age was not observed when these pups were cross-fostered to control mothers at 2 days of age suggesting that the alteration in rain tryptophan metabolism during the development of tryptaminergic neurons in rat offspring, as a result of prenatal phenytoin administration is mediated through changes in lactation or nursing ability of the mothers. It is important that such non-specific factors are controlled when studying the effect of prenatally administered drugs on neonatal brain transmitter concentrations.

The influence of 5,5'-diphenylhydantoin (DPH) on specific T3 binding by rat hepatic nuclear T3 receptors was determined in tissue obtained from euthyroid and athyreotic rats. Nuclear binding of [125I]T3 was determined in isolated liver nuclei 60 min after the injection of DPH (20 mg/100 g BW) or vehicle (V). Mean specific nuclear T3 binding was decreased 14% (P less than 0.01) and 24% (P less than 0.02) from the control value in two experiments with nuclei from euthyroid rats and 23% (P less than 0.02) in nuclei from athyreotic rats. These findings in athyreotic rats and the observation that endogenous nuclear T3 was not increased in euthyroid rats after DPH injection suggested that the observed decrease in specific T3 binding after DPH injection did not result from displacement of endogenous T3 from plasma proteins or other binding sites into the nucleus. Further studies employing isolated nuclei revealed that the DPH-induced decrease in specific nuclear T3 binding appeared independent of duration of incubation up to 90 min and dose related. Maximum inhibition of specific T3 binding was 14.0% (P less than 0.001) and occurred in incubates that contained 320 microM DPH. Moreover, this DPH effect was evident throughout the full range of receptor saturation by T3. Similar effects of DPH were observed in studies using solubilized nuclear T3 receptors. A mean 14.0% decrement (P less than 0.001) in specific T3 binding was observed throughout the 72-h time course of these studies. Moreover, the DPH-induced changes occurred when solubilized receptors were up to 62% saturated with T3. These studies show that DPH injection or addition in vitro results in a 10-20% decrease in specific T3 binding by isolated hepatic nuclei or solubilized hepatic nuclear T3 receptors. This effect of DPH may result from a relatively weak interaction at nuclear sites and the very high concentration of DPH compared to T3 that prevails in DPH-treated animals.

The effects of propranolol and related drugs were investigated on ouabain-induced ventricular tachycardia (VT) in dogs with intact and ablated vagi. Propranolol and UM-272 completely antagonized the ouabain VT in dogs with intact vagi, whereas timolol was ineffective. Bilateral vagotomy completely abolished the effect of UM-272 and reduced the effect of propranolol. Diphenylhydantoin, however, reversed ouabain VT in dogs with both intact and ablated vagi. It is inferred that the vagus plays a significant role in the arrhythmolytic effect of propranolol and UM-272.