Therapeutic Drug Monitoring Of Carbamazepine Research Articles

Magnetic solid-phase extraction-based surface-enhanced Raman spectroscopy for label-free therapeutic drug monitoring of carbamazepine and clozapine in human serum

Determination of antiepileptic drugs and antipsychotics in human serum is significant in individualized drug administration and therapeutic drug monitoring (TDM). In this study, we developed a rapid label-free TDM method for the antiepileptic drug carbamazepine (CBZ) and the antipsychotic clozapine (CLO) in human serum. This detection strategy is based on the combination of surface-enhanced Raman scattering (SERS) and magnetic solid-phase extraction (MSPE). Initially, Fe3O4@SiO2@MIL-101(Fe) nanocomposites were synthesized by the layer-by-layer self-assembly method and characterized using scanning electron microscopy, transmission electron microscopy, X-ray diffraction, Brunauer–Emmett–Teller, ultraviolet–visible, and Fourier transform infrared analyses. Subsequently, CBZ and CLO were detected in human serum using Fe3O4@SiO2@MIL-101(Fe) as the solid-phase extraction adsorbent and Ag nanoparticles as SERS substrates. The potential of the MSPE–SERS method for the label-free TDM of CBZ and CLO was then investigated. Fe3O4@SiO2@MIL-101(Fe) prevents magnetic particle aggregation and demonstrates rapid magnetic separation capability that simplifies the pretreatment process and reduces interference from complex matrices. Its large surface area can effectively enrich targets in complex matrices, thereby improving the SERS detection sensitivity. The linearity between CBZ and CLO was excellent over the concentration range of 0.1–100 µg/mL (calculated as the intensity of the SERS characteristic peaks of CBZ and CLO at 728 cm and 1054 cm−1, respectively), with correlation coefficients (R2) of 0.9987 and 0.9957, and detection limits of 0.072 and 0.12 µg/mL, respectively. The recoveries of CBZ with CLO ranged from 94.0 % to 105.0 %, and their relative standard deviations were <6.8 %. Compared to other assays, the developed MSPE–SERS method has the advantages of simple sample pretreatment, rapid detection, and good reproducibility, which provides a novel approach for the TDM of other drugs.

Ultrafast and high-throughput quantitative analysis of carbamazepine in human plasma by direct analysis in real time tandem mass spectrometry coupled with solid phase extraction to eliminate matrix effects

Therapeutic drug monitoring of carbamazepine is necessary for its clinical application with the purpose to reach therapeutic concentration and reduce the risk of concentration-dependent toxicity. An ultrafast analytical assay for quantification of carbamazepine in human plasma was developed and validated based on direct analysis in real time tandem mass spectrometry (DART-MS/MS). After reversed phase solid phase extraction with Waters Oasis HLB, carbamazepine and internal standard carbamazepine-D2N15 were monitored by positive ion mode followed by multiple reaction monitoring (MRM) of the transitions at m/z 237.1→194.0 and 240.1→196.2, respectively. The DART-MS/MS method is ultrafast and high-throughput and the analytical time for each sample is only 0.4 min. The assay was linear in the concentration range 0.50–30 μg/mL and intra- and inter-day accuracies were within ± 15% and trueness were < 13.9% at all concentrations. The method was successfully applied to therapeutic drug monitoring of carbamazepine in human plasma.

Simultaneous Determination of Lamotrigine and Carbamazepine in Plasma Using Ultrasound-Assisted Emulsification Microextraction-High Performance Liquid Chromatography

A simple, fast and efficient method based on ultrasound-assisted emulsification microextraction (USAEME) followed by HPLC has been developed for simultaneous determination of Carbamazepine (CBZ) and Lamotrigine (LTG) in biological samples. The influence of different parameters affecting the USAEME procedure was evaluated to optimize the efficiency of the process. At these conditions, validation of the proposed method was performed based on European medicines agency guidelines. The proposed method showed good linearity in plasma samples ranging from 0.25 to 6 µg/mL and 0.13 to 6 µg/mL (R2 ≥ 0.99) for CBZ and LTG, respectively. The precision of the proposed method was evaluated for repeatability which was ≤12% (n = 5). The detection limits of 0.06 and 0.05 µg/mL were obtained for CBZ and LTG, respectively. The proposed method can be applied as an effective technique for therapeutic drug monitoring of CBZ and LTG in plasma of epileptic patients.

Therapeutic drug monitoring and methods of quantitation for carbamazepine

Carbamazepine is an early anticonvulsant still used today in the treatment of several forms of epilepsy. An active metabolite in the human body contributes to its pharmacological effect. Carbamazepine metabolism has high inter-individual variability, such that it is relatively difficult to establish a direct link between dose and concentration, or between concentration and pharmacological effect. Carbamazepine is thus a good candidate for therapeutic drug monitoring (TDM). Good UV specific absorbance and high plasmatic concentrations allow for the use of UV detection, which is often more accessible than other methods of detection. This paper presents several methods used for the detection of carbamazepine in plasma, methods that are capable of detecting drug and metabolites at adequate levels/ acceptance criteria. These methods have possible application not only in pharmacokinetic, bioequivalence, and permeability studies, but also in the therapeutic drug monitoring of carbamazepine.

Therapeutic drug monitoring and methods of quantitation for carbamazepine

Carbamazepine is an early anticonvulsant still used today in the treatment of several forms of epilepsy. An active metabolite in the human body contributes to its pharmacological effect. Carbamazepine metabolism has high inter-individual variability, such that it is relatively difficult to establish a direct link between dose and concentration, or between concentration and pharmacological effect. Carbamazepine is thus a good candidate for therapeutic drug monitoring (TDM). Good UV specific absorbance and high plasmatic concentrations allow for the use of UV detection, which is often more accessible than other methods of detection. This paper presents several methods used for the detection of carbamazepine in plasma, methods that are capable of detecting drug and metabolites at adequate levels/ acceptance criteria. These methods have possible application not only in pharmacokinetic, bioequivalence, and permeability studies, but also in the therapeutic drug monitoring of carbamazepine.

Determination of serum carbamazepine concentration using dried blood spot specimens for resource-limited settings

ABSTRACTObjectives: Carbamazepine (CBZ) is a commonly used anti-epileptic in rural hospitals in India. These hospitals lack the facilities to measure CBZ concentration; however, in larger hospitals this is performed using high performance liquid chromatography (HPLC). Dried blood spot (DBS) represents a feasible matrix for safe transportation by post/courier. This study was to determine whether the concentration of CBZ in serum can be predicted from that measured in DBS using an inexpensive HPLC method and inexpensive standard filter paper.Methods: CBZ in serum and DBS from 80 epileptic patients were measured using a validated HPLC assay. The data was then randomly divided into two groups; simple Deming regression was performed with the first group and validation was performed using the second.Results: There was a good correlation between the serum and DBS concentrations (r = 0.932) in the first group. The regression equation obtained was: predicted serum concentration = DBS concentration x 0.83 + 1.09. In the validation group, the correlation between the predicted and actual serum concentrations was also good (r = 0.958), and the mean difference between them was only 0.28 μg/ml (p = 0.8062). The imprecision and bias in both the groups were acceptable.Conclusion: Using inexpensive materials, serum CBZ concentrations can be accurately predicted from DBS specimens. This method can be recommended for the therapeutic drug monitoring of CBZ in resource-limited settings.

Measurement and Comparison of Carbamazepine Plasma Levels for Assessment of Compliance, Safety and Toxicity

Carbamazepine is one of the most frequently prescribed antiepileptic drugs and influence of genetic differences, sex, age and race on the plasma levels of carbamazepine and its metabolites is well known. The objective of this study was to assess and compare the compliance, safety and toxicity in different age and gender groups of Chinese epileptic patients on the basis of therapeutic drug monitoring results of carbamazepine, since Han-Chinese are at higher risk of developing serious and fatal adverse effects when exposed to carbamazepine. The therapeutic drug monitoring results of carbamazepine in epileptic patients, obtained with validated methods were complied, evaluated and compared for compliance, safety and toxicity in different age and gender groups of Chinese epileptic patients. The therapeutic drug monitoring results of males and females were separately compiled and thereafter each gender group was further divided into children, adults and elderly as different age group. All age groups in both gender groups were evaluated for therapeutic, sub-therapeutic and toxic ranges. It was found that 45% of samples of total samples had sub-therapeutic levels and 55% of all samples had carbamazepine levels in therapeutic range, and none of gender and age group found in toxic range. Compared to males, female samples were more in number of sub-therapeutic levels. Populations of children males and children females were having more samples in sub-therapeutic levels as compared to adult and elderly males and females, respectively. However, it needs further evaluation. The findings of present study revealed that majority of patients were in sub- therapeutic levels. It is suggested that regularly therapeutic drug monitoring of carbamazepine should be performed and dose of carbamazepine in epileptic patients should be adjusted only after therapeutic drug monitoring results in order to assess the compliance, optimize the efficacy, safety and minimize the toxicity.

A LC-MS/MS method for therapeutic drug monitoring of carbamazepine, lamotrigine and valproic acid in DBS.

Therapeutic drug monitoring of antiepileptic drugs in children with epilepsy assists for personalized drug therapy but require numerous patient visits for venous blood sampling. DBS is an alternative matrix applicable to home sampling which can save time and reduce stress for this patient group. A fast LC-MS/MS method for quantification of carbamazepine, lamotrigine and valproic acid based on DBS sampling was developed. The method showed linearity in therapeutically relevant concentration ranges and compatible with unknown volume sampling and expected hematocrit range of the patient group. A LC-MS/MS method for the three most commonly used antiepileptic drugs has been fully validated and clinically applied on DBSs from patients at the neuropediatric clinic at Karolinska University Hospital.

Therapeutic drug monitoring of carbamazepine and its metabolite in children from dried blood spots using liquid chromatography and tandem mass spectrometry

Carbamazepine (CBZ) is a first-line drug for the treatment of different forms of epilepsy and the first choice drug for trigeminal neuralgia. CBZ is metabolized in the liver by oxidation into carbamazepine-10,11-epoxide (CBZE), its major metabolite which is equipotent and known to contribute to the pharmacological activity of CBZ. The aim of the present study was to develop and validate a reliable, selective and sensitive liquid chromatography–tandem mass spectrometry method for the simultaneous quantification of CBZ and its active metabolite in dried blood spots (DBS). The extraction process was carried out from DBS using methanol–water–formic acid (80:20:0.1, v/v/v). Chromatographic elution was achieved by using a linear gradient with a mobile phase consisting of acetonitrile–water–0.1% formic acid at a flow rate of 0.50mL/min. The method was linear over the range 1–40mg/L and 0.25–20mg/L for CBZ and CBZE, respectively. The limit of quantification was 0.75mg/L and 0.25mg/L for CBZ and CBZE. Intra-day and inter-day assay precisions were found to be lower than 5.13%, 6.46% and 11.76%, 4.72% with mean percentage accuracies of 102.1%, 97.5% and 99.2%, 97.8% for CBZ and CBZE. We successfully applied the method for determining DBS finger-prick samples in paediatric patients and confirmed the results with concentrations measured in matched plasma samples. This novel approach allows quantification of CBZ and its metabolite from only one 3.2mm DBS disc by LC–MS/MS thus combining advantages of DBS technique and LC–MS/MS in clinical practice.

Liquid chromatographic assay based on microextraction by packed sorbent for therapeutic drug monitoring of carbamazepine, lamotrigine, oxcarbazepine, phenobarbital, phenytoin and the active metabolites carbamazepine-10,11-epoxide and licarbazepine.

A new, sensitive and fast high-performance liquid chromatography-diode-array detection assay based on microextraction by packed sorbent (MEPS/HPLC-DAD) is herein reported, for the first time, to simultaneously quantify carbamazepine (CBZ), lamotrigine (LTG), oxcarbazepine (OXC), phenobarbital (PB), phenytoin (PHT), and the active metabolites carbamazepine-10,11-epoxide (CBZ-E) and licarbazepine (LIC) in human plasma. Chromatographic separation of analytes and ketoprofen, used as internal standard (IS), was achieved in less than 15min on a C18-column, at 35°C, using acetonitrile (6%) and a mixture (94%) of water-methanol-triethylamine (73.2:26.5:0.3, v/v/v; pH 6.5) pumped at 1mL/min. The analytes and IS were detected at 215, 237 or 280nm. The method showed to be selective, accurate [bias ±14.8% (or ±17.8% in the lower limit of quantification)], precise [coefficient variation ≤9.7% (or ≤17.7% in the lower limit of quantification)] and linear (r(2)≥0.9946) over the concentration ranges of 0.1-15μg/mL for CBZ; 0.1-20μg/mL for LTG; 0.1-5μg/mL for OXC and CBZ-E; 0.2-40μg/mL for PB; 0.3-30μg/mL for PHT; and 0.4-40μg/mL for LIC. The absolute extraction recovery of the analytes ranged from 57.8 to 98.1% and their stability was demonstrated in the studied conditions. This MEPS/HPLC-DAD assay was successfully applied to real plasma samples from patients, revealing to be a cost-effective tool for routine therapeutic drug monitoring of CBZ, LTG, OXC, PB and/or PHT.

Slow Carbamazepine Clearance in a Nonadherent Malay Woman With Epilepsy and Thyrotoxicosis

The authors describe a case of a 37-year-old Malay lady with an unusually slow carbamazepine clearance, which may be related to genetic polymorphisms of drug metabolizing enzymes and transporters. When given a small daily dose of 200 mg immediate-release carbamazepine, this patient experienced drowsiness. Subsequently, she reduced her carbamazepine dose to 200 mg twice a week (on Mondays and Fridays), resulting in poor seizure control. At the same time, the patient was diagnosed with hyperthyroidism and was given carbimazole and propranolol. Hyperthyroidism and the concurrent use of these antihyperthyroid agents may have further slowed down the metabolism of carbamazepine. Therapeutic drug monitoring of carbamazepine was carried out, and a slow carbamazepine clearance of 1.45 L·h⁻¹ per 70 kg was observed. Genotyping of selected genetic variants in CYP3A4, CYP3A5, EPHX1, ABCB1, and ABCC2 revealed that she has CYP3A5*3/*3 and ABCB1 3435-CC genotypes. Both genotypes have been shown to be associated with higher adjusted mean serum carbamazepine concentration in Chinese and Korean patients with epilepsy. Physicians should be vigilant about the risk of adverse effects among patients with a slow carbamazepine clearance, especially in Malays. Simulations of carbamazepine dosing regimen based on the pharmacokinetic parameters of this patient were performed to allow individualization of drug therapy.

Estimation of Carbamazepine and Carbamazepine-10,11-Epoxide Concentrations in Plasma Using Mathematical Equations Generated With Two Carbamazepine Immunoassays

Carbamazepine is metabolized to an active metabolite known as carbamazepine-10,11-epoxide, or simply the "epoxide" metabolite. The presence of this metabolite can have clinically significant implications in therapeutic drug monitoring of carbamazepine, but accurate quantification of the epoxide metabolite is currently limited to chromatographic techniques. In this study, mathematical equations are proposed for the estimation of carbamazepine and epoxide metabolite concentrations based on values generated by common carbamazepine immunoassays. Three immunoassays were studied: particle-enhanced turbidimetric inhibition immunoassay (PETINIA, Siemens Healthcare Diagnostics, Deerfield, IL), ADVIA Centaur (Siemens Healthcare Diagnostics), and a cloned enzyme donor immunoassay (CEDIA; Roche, Indianapolis, IN). Equations were based on observed cross-reactivity of epoxide with the PETINIA (average, 96.2%; range, 86.6%-105.7%) and epoxide cross-reactivity with the ADVIA Centaur assay (average, 6.5%; range, 5.3%-7.7%). In addition, equations were developed using average cross-reactivity of epoxide with the PETINIA and with the CEDIA. Values determined by calculation correlated well with carbamazepine and epoxide concentrations in supplemented and patient samples, for which values of carbamazepine (2.2-12.0 microg/mL [9-51 micromol/L]) and the epoxide metabolite (0.6-2.4 microg/mL) were also verified by liquid chromatography-tandem mass spectrometry.

Analytical performance evaluation of ADVIA Chemistry Carbamazepine_2 assay: minimal cross‐reactivity with carbamazepine 10, 11‐epoxide and none with hydroxyzine or cetirizine

Carbamazepine is an anticonvulsant requiring routine therapeutic drug monitoring. Recently, Siemens Healthcare Diagnostic Division released a new carbamazepine assay: ADVIA Chemistry Carbamazepine_2 (Carbamazepine_2) for application on ADVIA analyzers. We evaluated the analytical performance of this assay as well as its potential cross-reactivities with carbamazepine 10, 11-epoxide, hydroxyzine, and cetirizine. The within-run and between-run precisions of the Carbamzepine-2 assay were <6% and limit of detection was 0.5 microg/ml using ADVIA 1800 analyzer. The assay was linear up to a carbamazepine concentration of 20.0 microg/ml. The new method compared well with a widely used carbamazepine EMIT 2000 assay on the Hitachi 917 analyzer. Using 75 patients' specimens (where carbamazepine concentrations varied from 0.5 to 21.7 microg/ml) and carbamazepine EMIT 2000 as the reference method (x-axis), we observed the following regression equation: y=1.04 x+0.32 (r=0.99). The new carbazepine_2 method was not affected by a hemoglobin concentration of 1,000 mg/dl, conjugated or unconjugated bilirubin concentration of 60 mg/dl, and triglyceride concentration of 1,000 mg/dl. In addition, this assay showed no cross-reactivity with hydroxyzine or cetirizine and demonstrated minimal cross-reactivity with carbamazepine 10, 11-epoxide. We conclude that the ADVIA Chemistry carbamazepine_2 assay has adequate precision and accuracy for routine therapeutic drug monitoring of carbamazepine in clinical laboratories.

Quantification of carbamazepine, carbamazepine-10,11-epoxide, phenytoin and phenobarbital in plasma samples by stir bar-sorptive extraction and liquid chromatography

A sensitive and reproducible stir bar-sorptive extraction and high-performance liquid chromatography-UV detection (SBSE/HPLC-UV) method for therapeutic drug monitoring of carbamazepine, carbamazepine-10,11-epoxide, phenytoin and phenobarbital in plasma samples is described and compared with a liquid:liquid extraction (LLE/HPLC-UV) method. Important factors in the optimization of SBSE efficiency such as pH, extraction time and desorption conditions (solvents, mode magnetic stir, mode ultrasonic stir, time and number of steps) assured recoveries ranging from 72 to 86%, except for phenytoin (62%). Separation was obtained using a reverse phase C 18 column with UV detection (210 nm). The mobile phase consisted of water:acetonitrile (78:22, v/v). The SBSE/HPLC-UV method was linear over a working range of 0.08–40.0 μg mL −1 for carbamazepine, carbamazepine-10,11-epoxide and phenobarbital and 0.125–40.0 μg mL −1 for phenytoin, The intra-assay and inter-assay precision and accuracy were studied at three concentrations (1.0, 4.0 and 20.0 μg mL −1). The intra-assay coefficients of variation (CVs) for all compounds were less than 8.8% and all inter-CVs were less than 10%. Limits of quantification were 0.08 μg mL −1 for carbamazepine, carbamazepine-10,11-epoxide and phenobarbital and 0.125 μg mL −1 for phenytoin. No interference of the drugs normally associated with antiepileptic drugs was observed. Based on figures of merit results, the SBSE/HPLC-UV proved adequate for antiepileptic drugs analyses from therapeutic levels. This method was successfully applied to the analysis of real samples and was as effective as the LLE/HPLC-UV method.

Determination of carbamazepine and carbamazepine-10,11-epoxide in human serum and plasma by micellar electrokinetic capillary chromatography in the absence of electroosmosis.

Therapeutic drug monitoring of carbamazepine (CBZ), a widely used antiepileptic drug, is required for optimization of pharmacotherapy with this drug and for assessment of the patient's compliance to therapy. The suitability of employing micellar electrokinetic capillary chromatography (MEKC) in the absence of electroosmosis for the determination of CBZ and its main metabolite carbamazepine-10,11-epoxide (CBZE) in extracts of human serum and plasma is reported. Using micelles formed by dodecyl sulfate, analyses performed in untreated fused-silica capillaries at acidic pH and in commercially available coated capillaries under application of reversed polarity are compared. Uncoated and polyvinyl alcohol coated capillaries proved to be unsuitable for this purpose, whereas capillaries coated with linear polyacrylamide and N-acryloylaminoethoxyethanol and operated at pH 7.6 are shown to provide high-quality and reliable data on a short time scale. Assay performance is discussed via statistical analysis of the data produced from a set of quality control sera that contain up to 14 different drugs and via analysis of patient samples. Intraday and interday imprecision data for concentrations between 4.0 and 84 microM are demonstrated to be < 10%. Run times are shown to be < 50% compared to those observed in conventional MEKC at alkaline pH (i.e., in the presence of electroosmosis).

Therapeutic Drug Concentration Monitoring Using Saliva Samples

In the last 30 years there has been great interest in the use of saliva in therapeutic drug monitoring. Numerous investigators have suggested that saliva be used as an alternative body fluid for the therapeutic drug monitoring of anticonvulsant drugs. Not only can saliva be obtained easily on multiple occasions with minimal discomfort to the patient but, more importantly, useful relationships exist between the saliva and blood concentrations of the most commonly used anticonvulsant drugs. The measurement of anticonvulsant drug concentrations in saliva has been applied to pharmacokinetic and pharmacodynamic studies, and for therapeutic drug monitoring in a variety of seizure disorders. However, this simple and non-invasive method is not widely accepted in clinical practice. Several recent developments in sample collection and analytical methods, and the growing interest in free drug concentrations, provide a renewed impetus for saliva sampling for therapeutic drug monitoring of anticonvulsant drugs. Salivary flow rates vary significantly both between individuals and under different conditions. The use of stimulated saliva has several advantages over resting saliva. The salivary flow rate and pH, sampling conditions, contamination and many other pathophysiological factors may influence the concentrations of the medication in saliva. However, under standardised and well-controlled sampling condition, therapeutic drug monitoring of anticonvulsant drugs in saliva can be useful for determining compliance with medication in paediatric patients, for analysing the concentration of free drug and in situations where repeated sampling is necessary. Saliva is an alternative matrix for the therapeutic drug monitoring of carbamazepine, phenytoin, primidone and ethosuximide because the concentrations of these medications in saliva reflect the concentrations of the drug in serum. This is not the case for valproic acid (valproate sodium) and some controversy exists for phenobarbital. Further studies are required to assess the clinical value of monitoring anticonvulsant drugs and their metabolites in saliva, to examine the influence of pathophysiological factors on salivary drug concentrations, to improve the design of special devices to reproducibly and conveniently collect saliva samples, and to develop and use new analytical methods to achieve more sensitive and accurate results.

Micellar electrokinetic capillary chromatography for therapeutic drug monitoring of carbamazepine and its main metabolites

In carbamazepine (CBZ) therapy the concomitant monitoring of concentrations of CBZ and its metabolites is strictly recommended, primarily to avoid toxic side effects. Currently, clinical routine monitoring of CBZ is accomplished by high-performance liquid chromatography or immunological methods. In this study a micellar electrokinetic capillary chromatographic (MECC) method was developed for routine drug monitoring of CBZ and its main metabolites, carbamazepine 10,11-diol and carbamazepine 10,11-epoxide, in human serum or plasma samples. The MECC method enabled baseline separation of all analytes within 2.5 min. The assay revealed sufficient precision and sensitivity and the results of either an automated HPLC or the MECC chromatography assay were in good agreement ( r=≥0.97). The maximum deviation for CBZ was 0.26 μ M.

Alteration of carbamazepine pharmacokinetics in patients with traumatic brain injury

All patients admitted to a rehabilitation unit with closed-head injury over a 3-year period were reviewed for carbamazepine use exceeding 30 days in the hospital. Nine patients met the study inclusion criteria for age and duration of carbamazepine therapy. On review of the dose:serum concentration relationship, significant changes were noted in four patients. An initial increase in the dose:serum concentration ratio during the first few months of therapy was thought to reflect the well-known auto-induction of carbamazepine metabolism. However, unexplainable decreases in the dose:serum concentration occurred in the following months, and suggested alteration of carbamazepine pharmacokinetics in patients with traumatic brain injury. The finding may be important in determining the optimal approach to therapeutic drug monitoring of carbamazepine in brain-injured patients.

The influence of polytherapy on the relationships between serum carbamazepine and its metabolites in epileptic children

The influence of polytherapy on the relationships between the age, weight, carbamazepine (CBZ) dose, total clearance and intrinsic clearance, with concentrations, concentration ratios and level/dose ratios of CBZ, carbamazepine-10,11-epoxide (CBZ-E) and trans-10,1 l-dihydroxy-10,11-dihydro-carbamazepine (CBZ-H) are investigated. Three groups of patients with CBZ monotherapy, or receiving CBZ polytherapy by taking CBZ and valproic acid (VPA) or CBZ plus other antiepileptic drugs (AEDs) were studied. The significant correlations between serum CBZ concentrations and CBZ dose in patients taking CBZ alone were no longer significant in patients with polytherapy and the positive associations between serum CBZ-E concentrations and CBZ dose were lost in patients with CBZ + VPA. Only the concentrations of CBZ-H had significant correlations with CBZ dose in all three groups of patients. Results from this relationship study indicate a heteroinduction effect of other AEDs on CBZ metabolism and a relatively weak influence on CBZ-E elimination. Data also suggest that there is a block in the biotransformation from CBZ-E to CBZ-H in patients taking CBZ + VPA, presumably caused by the inhibition effect of VPA on epoxide hydrolase. Therapeutic drug monitoring of CBZ will benefit from the knowledge obtained from the relationship study.

Determination of Total and Free Carbamazepine and the Principal Metabolites in Serum by High-Performance Liquid Chromatography with Photodiode-Array Detection

A precise and accurate high-performance liquid chromatography (HPLC) method has been established for the simultaneous analysis of carbamazepine (CBZ), carbamazepine-10,11-epoxide (CBZ-E), and trans-10,11-dihydroxy-10,11-dihydro-CBZ (CBZ-H) in serum samples and their ultrafiltrates. CBZ and its metabolites are eluted in a 3-microM ODS-Hypersil column (250 x 2 mm) at a column temperature of 40 degrees C. The mobile phase is a mixture containing potassium phosphate buffer-acetonitrile-methanol (110:50:30, vol/vol/vol) at a flow rate of 0.2 ml/min. Signals are monitored by a photodiodearray detector with a main sample wavelength of 215 nm and a bandwidth of 10 nm. Coefficients of variation (CVs) for within- and between-day are within 5%, with the recovery rates ranging from 98.16 to 104.64%. This method has the necessary sensitivity and linearity for routine therapeutic monitoring of both total and free CBZ and its principal metabolites. Total serum concentrations of CBZ, CBZ-E, and CBZ-H obtained from 55 epileptic children were 12.58 +/- 4.42, 2.45 +/- 1.22, and 5.83 +/- 3.17 (mean +/- SD, micrograms/ml), respectively. Levels of free CBZ, CBZ-E, and CBZ-H were 2.59 +/- 0.93, 1.05 +/- 0.57 and 3.73 +/- 1.87, respectively. Free fractions of CBZ, CBZ-E, and CBZ-H were 20.98 +/- 4.34, 42.63 +/- 8.21, and 65.41 +/- 7.80%, respectively. CBZ-H and CBZ-E had larger CVs than did CBZ (54.34 and 49.75 vs 35.15%, respectively, for total levels, and 50.31 and 54.46 vs 36.22%, respectively, for free levels), as well as higher free fractions. Determination of both total and free concentrations and free fractions of CBZ and its metabolites, as well as their ratios, should provide additional needed information for therapeutic drug monitoring of CBZ.