Class of 2007 Abstract / Objectives: To compare the cost-effectiveness of amitriptyline, divalproex, propranolol, and topiramate in the prophylactic treatment of migraine headaches based on published data. Methods: A MEDLINE search was done to identify all randomized, controlled clinical trials evaluating the efficacy of amitriptyline, divalproex, propranolol, and topiramate in the prophylactic treatment of migraine headaches. Results from these studies were then combined with drug cost and health care service costs related to treatment failure and adverse events to assess the relative cost-effectiveness of each medication. A decision tree model was created and Monte Carlo simulation was done to determine each products cost-effectiveness. Results: Amitriptyline was both most effective and least costly of the four treatment regimens studied. The mean costs for a 90 day treatment of each of the four respective medications were found to be: amitriptyline $62, divalproex $450, propranolol $91, and topiramate $802. An acceptability curve demonstrated that amitriptyline was most cost-effective 90% of the time, propranolol 10% of the time, and divalproex and topiramate were never the most cost-effective treatment. Conclusions: Among the most common medications used for migraine prophylaxis are amitriptyline, divalproex, propranolol, and topiramate. Based upon this analysis, amitriptyline was found to be the most cost-effective medication. Therefore, it is logical from the perspective of a managed-care organization to recommend amitriptyline as a first-line agent for migraine prophylaxis.

Class of 2015 Abstract / Objectives: To retrieve data from RCTs for lorcaserin and phentermine and topiramate combination on weight loss, BMI reduction, and other factors from the placebo groups and to determine if there is a difference in weight loss between those groups. Methods: Design: Meta-analysis Inclusion criteria: RCTs that compared lorcaserin or phentermine/topiramate to placebo as submitted to the FDA and posted to the FDA website. The studies needed to report weight loss or BMI values at baseline and post-treatment. Measures: The primary dependent variables were weight lost in kilograms, change in BMI, and percent who achieved 5% weight loss in the placebo arm. Data Collection: A standardized data collection form was used to extract data from the selected trials. Data was independently extracted by 3 researchers and discrepancies were resolved by consensus. Data Analysis: Data was analyzed by constructing a forest plot of the amount of weight lost in the placebo arm stratified by type of drug. A funnel plot and Kendall’s tau were used to assess publication bias. Heterogeneity was assessed with I2. The a priori alpha level was 0.05. Results: Statistically significant weight loss was achieved in the placebo arm in all 6 RCTs Weight loss was consistent across type of study Lorcaserin studies, mean = 2.42 kg Phentermine/topiramate studies, mean = 2.14 kg Overall rate of 5% weight loss was 0.32 No data was reported on actual caloric intake or actual quantity of exercise Funnel plot and Kendall’s tau (p = 0.85) indicated there was no publication bias There was heterogeneity in the lorcaserin studies resulting from one study reporting a large effect Conclusions: Participants in the placebo arm lost weight with monthly counseling on calorie intake and exercise, however, actual caloric intake or quantity of exercise that resulted in the weight loss is unknown.

Epilepsy is one of the most common neurological disorders worldwide. This neurological disorder is characterized by spontaneous recurrent seizures and impacts about 65 million people globally. As there is no cure for epilepsy, the treatment goal for patients is seizure management, and ultimately seizure freedom. The first line of defense in seizure management is anti-epileptic drugs, which aim to restore the excitatory and inhibitory balance in the brain. Unfortunately, about 30% of people with epilepsy are drug resistant, a number which has remained unchanged despite the increasing amount of anti-epileptic drugs. This leads patients to seek alternative treatments, which include surgery, vagus nerve stimulation, or diet alterations such as the ketogenic diet. Due to the invasiveness of surgeries, difficulty to maintain specialty diets, or lack of effectiveness of these treatments in some patients, additional therapies are needed. The gut-brain axis is a bidirectional communication network connecting the central and enteric nervous systems. Part of this network includes communication via the gut microbiota. The gut microbiota consists of all the microorganisms living in the gut, including bacteria, viruses, and fungi. It is involved in aiding nutrient absorption, promoting the maturation of immune cells and functions, and protection against pathogens. There is growing interest in the role of the gut microbiome in human health and disease. Studies have shown that patients with epilepsy have altered gut microbiomes compared to healthy controls, and that gut microbiome alteration can impact seizure frequencies. These exciting findings have ignited research on the potential therapeutic role of the gut microbiome in epilepsy. Although studies have explored the impact of alterations in the gut microbiome on seizure activity, they have not studied how anti-epileptic drugs may contribute to this relationship. Thus, this dissertation explores the role of the commonly prescribed anti-epileptic drug topiramate on the gut microbiome. Fecal samples of mice treated with topiramate were analyzed using 16S ribosomal RNA gene sequencing. Analysis revealed that topiramate ingestion increased the probiotic bacteria Lactobacillus johnsonii in the gut microbiome. In addition, cotreatment of topiramate and Lactobacillus johnsonii reduced seizure susceptibility in a pentylenetetrazol-kindling seizure model. Moreover, cotreatment increased the butyrate producing family Lachnospiraceae and subsequently increased the neuroprotective SCFA, butyrate in the gut microbiome. Importantly, cotreatment also resulted in an increased GABA/glutamate ratio in the cortex of mice that underwent pentylenetetrazol-kindling. These results are the first to demonstrate that the anti-seizure effect of topiramate may be facilitated by the modulation of the gut microbiota via increasing butyrate and altering the GABA/glutamate ratio in the cortex. Lastly, this work highlights the potential for probiotics as an adjuvant therapy in seizure management. / Doctor of Philosophy / Epilepsy is one of the most common neurological disorders worldwide. This neurological disorder is characterized by spontaneous recurrent seizures and impacts about 65 million people globally. As there is no cure for epilepsy, the treatment goal for patients is seizure management, and ultimately seizure freedom. The first line of defense in seizure management is anti-epileptic drugs, which aim to restore the excitatory and inhibitory balance in the brain. Unfortunately, about 30% of people with epilepsy are drug resistant, a number which has remained unchanged despite the increasing amount of anti-epileptic drugs. Due to this unmet need, epilepsy patients utilize alternative treatments, which include surgery, vagus nerve stimulation, or diet modifications such as the ketogenic diet. Due to the invasiveness of surgeries, difficulty to maintain specialty diets, or lack of effectiveness of these treatments in some patients, additional therapies are needed. The gut microbiota consists of all the microorganisms living in the gut, including bacteria, viruses, and fungi, which can be both harmful and helpful. In healthy individuals, the gut microbiota coexists in a balance that prevents diseases and helps the host, however, disruptions in this balance can lead to susceptibility to several diseases. As a result, researchers are increasingly interested in the role of the gut microbiota in human health and disease. In epilepsy, the gut microbiome is altered compared to healthy individuals, and gut microbiome alterations can impact seizure activity. This has led researchers to investigate the potential therapeutic role of the gut microbiome in epilepsy. Although studies have explored the impact of alterations in the gut microbiome on seizure activity, they have not studied how anti-epileptic drugs may contribute to this relationship. Thus, this dissertation explores the role of the commonly prescribed anti-epileptic drug topiramate on the gut microbiome. The results demonstrate that topiramate increases probiotic bacteria in the gut microbiome of mice. Moreover, this probiotic bacterium facilitates topiramate in reducing the susceptibility to seizures in a mouse model by resulting in a beneficial gut microbiome and restoring excitatory and inhibitory balance to the brain. These results are the first to demonstrate that the anti-seizure effect of topiramate may be facilitated by the gut microbiome. Lastly, this work highlights the potential for probiotics as an adjuvant therapy in seizure management.

The studies in this thesis research were conducted to investigate if sensitivity to induced cortical spread depression (CSD) or the consequence of a CSD event is affected by sumatriptan induced latent sensitization. Previous studies in our lab showed persistent exposure of sumatripan to rats produced a latent state of sensitization. Using persistent sumatripan exposed rats as a model for medication overuse headache, behavior, electrical stimulation threshold to provoke a CSD event and the immunoreactivity of c-Fos in the trigeminal nucleus caudalis (TNC) were characterized. Current results showed no statistical difference of electrically induced CSD thresholds in anesthetized rats measured at day 20 in sumatripan exposed rats compared with saline treated rats. Topiramate (80 mg/kg, i.p.) used clinically for prophylaxis of migraine headache significantly increased CSD threshold in both saline and sumatriptan infused rats. CSD events appear to be associated with trigeminal vascular system activation in TNC because c-Fos expression significantly enhanced in rats with electrically stimulated CSD events. As compared to saline treated rats, sumatriptan-exposed rats demonstrated a significantly higher number of c-Fos positive cells following the electrically stimulated CSD event. Under environmental stress (bright light), sumatripan exposed rats demonstrated decreased response thresholds to periorbital and hindpaw tactile stimuli (i.e., allodynia) and enhanced c-Fos expression in TNC. A single dose of topiramate (80 mg/kg, i.p.) reversed environmental stress induced allodynia and c-Fos over-activity. Taken together, these results suggest that latent sensitization induced by persistent sumatripan exposure seems not correlated to the threshold of electrically stimulated CSD in current model. However, CSD enhanced the responses of trigeminal system in rats with sumatriptan-induced latent sensitization. The protective effects of topiramate shown in this model may be related to blocking the initiation of CSD events resulting from environmental stimulation as well as inhibiting the consequences of CSD events in primary afferents. These findings correlate with clinical observations of protective effects of topiramate for migraine prophylaxis.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-12-13T16:20:32Z No. of bitstreams: 1 klausrubackbertges.pdf: 271934 bytes, checksum: 2ea9402302ece8a694d772243b639a2d (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-12-15T14:11:46Z (GMT) No. of bitstreams: 1 klausrubackbertges.pdf: 271934 bytes, checksum: 2ea9402302ece8a694d772243b639a2d (MD5) / Made available in DSpace on 2016-12-15T14:11:46Z (GMT). No. of bitstreams: 1 klausrubackbertges.pdf: 271934 bytes, checksum: 2ea9402302ece8a694d772243b639a2d (MD5) Previous issue date: 2008-02-23 / O topiramato (TPM) é um fármaco relativamente novo e foi empregado inicialmente no tratamento da epilepsia. Mais recentemente, inseriu-se na terapêutica da migrânea e de diversas condições clínicas, dentre elas, alguns distúrbios comportamentais. É uma droga sabidamente GABAérgica, anti-glutamatérgica e modifica os efeitos da dopamina no sistema nervoso central, podendo assim, alterar os níveis de ansiedade e a atividade locomotora. Esse estudo avalia seu efeito agudo no comportamento espontâneo de camundongos suíços no teste da arena em campo aberto, administrando-se dose única intraperitoneal (10 mg/kg), enfatizando atividade locomotora e ansiedade. Vinte animais foram divididos em 2 grupos, o grupo tratado recebeu TPM e o controle soro fisiológico. Após 30 minutos, foi realizado o teste do campo aberto, observando-se diversas variáveis que abordam locomoção e ansiedade, como número de quadrados explorados, tempo de imobilidade, velocidade escalar média, frequências e tempos de rearing e de grooming, bem como os tempos de permanência na área central e na periferia do aparato pelos animais. Os resultados apontam um aumento considerável do número de quadrados explorados e da velocidade escalar média no grupo tratado. Os tempos de imobilidade foram praticamente os mesmos entre os grupos, assim como os tempos de permanência na área central e na periferia. A frequência e o tempo de rearing foram um pouco maiores no grupo controle, ao contrário do que aconteceu com o grooming. Concluindo, a administração de TPM aumentou consideravelmente a atividade locomotora espontânea dos animais, pois houve aumento significante do número de quadrados explorados e da velocidade escalar média (p < 0,1). Não houve efeito ansiolítico aparente, já que não ocorreu diferença significante entre os tempos de permanência na área central e na periferia do aparato, bem como entre os tempos de imobilidade (p > 0,1). Não houve diferença significante entre as frequências e os tempos de rearing e de grooming (p > 0,1). / The topiramate (TPM) is a relatively new drug and was originally used for the treatment of epilepsy. More recently entered in the therapeutic of migraine and various clinical conditions including some behavioral disorders. It is a known GABAergic and antiglutamatergic drug and modifies the effects of dopamine in the central nervous system and can thus change the levels of anxiety and the locomotor activity. This study evaluates its acute effect on the spontaneous behavior of Swiss mice in the open field arena test managing single intraperitoneal dose (10 mg/kg), emphasizing locomotor activity and anxiety. Twenty animals were divided into 2 groups, the treated group received TPM and the control saline. After 30 minutes the open field test was applied observing several variables that address locomotion and anxiety such as number of exploited squares, time of immobility, average scalar speed, frequencies and times of rearing and grooming, and also times of stay in the central area and in the periphery of apparatus by the animals. Results showed a considerable increase in the number of exploited squares and in the average scalar speed in the treated group. The times of immobility were virtually the same between the groups, as well as the times of stay in the central area and in the periphery. The frequency and time of rearing were slightly higher in the control group, contrary to what happened with the grooming. In conclusion, the administration of TPM considerably increased the spontaneous locomotor activity of the animals showed by a significant increase in the number of exploited squares and in the average scalar speed (p < 0.1). There was no apparent anxiolytic effect, as no significant difference occurred between the times of stay in the central area and in the periphery of the apparatus, as well as between the times of immobility (p > 0.1). There was no significant difference between the frequencies and the times of rearing and grooming (p > 0.1).

A estratégia mais amplamente utilizada no tratamento da epilepsia é a farmacoterapia. Entretanto cerca de 30% dos pacientes mesmo utilizando o fármaco adequado para o seu diagnóstico não respondem ao tratamento proposto, sendo então diagnosticados com epilepsia refratária. Entre as drogas antiepilépticas (DAE) utilizadas no tratamento da epilepsia refratária encontra-se o topiramato (TPM). O objetivo do presente estudo foi avaliar a concentração plasmática (Cp) do TPM verificando a influência da dose prescrita (mg/Kg/dia), sexo, idade e o uso de outras DAE sobre a mesma, correlacionando-a com a frequência de crises epilépticas, reações adversas, qualidade de vida e adesão a farmacoterapia. Este estudo observacional transversal foi realizado com 37 pacientes com epilepsia refratária em uso de TPM atendidos no Ambulatório de Epilepsia de Difícil Controle do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. As variáveis de interesse foram qualidade de vida (Quality of Life in Epilepsy - QOLIE-31), reações adversas ao medicamento (RAM) (Liverpool Adverse Event Profile - LAEP), adesão a farmacoterapia (Modified Morisky Scale - MMS), tipo de crise epiléptica, tipo de epilepsia, frequência das crises, características farmacoterapêuticas e sociodemográficas, obtidas por meio de instrumentos na entrevista com o paciente ou em prontuário. Além disso, amostras de sangue de todos os participantes foram coletadas para dosagem da Cp de TPM, lamotrigina e DAEs de primeira geração em uso. O trabalho foi aprovado pelo Comitê de Ética em Pesquisa da Faculdade de Ciências Farmacêuticas de Ribeirão Preto-USP (nº 030/2014). A idade média dos pacientes foi 40 anos (DP 10,7) e apresentavam prevalentemente epilepsia focal sintomática (73,0%) e crises parciais complexas (67,6%). Em relação ao perfil farmacoterapêutico, 97,3% dos pacientes estavam em politerapia, sendo o esquema farmacoterapêutico mais prevalente a associação entre TPM, carbamazepina e clobazam (29,8%). A Cp de 83,8% dos pacientes em uso de TPM encontraram-se abaixo do intervalo de referência recomendado (5,0 -20,0 mg/L), sendo a Cp média de 3,21 mg/L (DP 2,76). A dose prescrita (mg/Kg/dia) e o uso concomitante de indutores do metabolismo do TPM explicaram 69,0% da variabilidade da Cp do TPM: estimou-se que o aumento na dose de 1,0 mg/Kg/dia tenha promovido o aumento de 0,68 mg/L na Cp do TPM, enquanto o uso de indutores esteve relacionado a uma redução de 2,97 mg/L (p?0,001). Os pacientes com Cp < 5,0 mg/L apresentaram o número médio de crises epilépticas maior do que aqueles com Cp no intervalo de referência (p<0,001). A pontuação média do LAEP foi de 40,5 (DP 10,1) e a sonolência, problemas de memória e o nervosismo e/ou agressividade foram as reações adversas mais prevalentes. Com relação à qualidade de vida o escore médio obtido no QOLIE-31 foi de 47,7 (DP 15,2), sendo que a preocupação com as crises e a função social foram os domínios que apresentaram maior comprometimento na qualidade de vida dos pacientes. Ademais, foram encontradas evidências de uma relação inversa entre RAM e a qualidade de vida, sendo que o aumento de um ponto no escore do LAEP reduz o escore do QOLIE-31 em 0,91 pontos. Finalmente, segundo resultados do MMS, 62,2% dos pacientes eram aderentes ao tratamento medicamentoso. Em conclusão a dose prescrita e o uso de DAE indutoras do metabolismo do TPM influenciaram a Cp deste fármaco, a qual afetou o controle das crises epilépticas. Diante disto sugere-se a monitorização terapêutica como uma ferramenta para a otimização da farmacoterapia e da resposta clínica. / The most widely used strategy in epilepsy treatment is pharmacotherapy. However, near 30% of all patients, even though receiving the appropriate drug, do not respond to recommended treatment. Among the antiepileptic drugs (AED) used for the treatment of refractory epilepsy there is topiramate (TPM). The aim of this study was to evaluate TPM\'s plasma concentration (Cp) and to verify the influence of some variables [prescribed dose (mg/Kg/day), sex, age and other AED in use] on it, as well as correlate TPM\'s Cp with the frequency of epileptic crises, adverse events, quality of life and adherence to pharmacotherapy. This cross-sectional study enrolled 37 patients diagnosed with refractory epilepsy in use of TPM attended at the Epilepsy of Difficult Control\'s ambulatory of the Ribeirão Preto Medical School University Hospital. The investigated variables were quality of life (Quality of Life in Epilepsy - QOLIE-31), adverse drug reactions (ADR) (Liverpool Adverse Event Profile - LAEP), adherence to pharmacotherapy (Modified Morisky Scale - MMS), type of epileptic crisis, type of epilepsy, frequency of crises, pharmacotherapeutic and sociodemographic characteristics, all of them obtained through medical records and/or face to face interview. Moreover, blood samples of all patients were collected in order to measure Cp of TPM, lamotrigine and first generation AEDs in use. The study was approved by the Research Ethics Committee of the School of Pharmaceutical Sciences of Ribeirão Preto-USP (nº 030/2014). The patients\' mean age was 40 years (SD 10.7) and they showed predominantly symptomatic focal epilepsy (73.0%) and partial complex seizures (67.6%). Considering the pharmacotherapeutic profile, 97.3% of them were under polytherapy, in which the most prevalent regimen consisted in the combination of TPM, carbamazepine and clobazam (29.8%). From all patients in use of TPM, the mean Cp for this drug was 3.21 mg/L (SD 2.76) and 83.8% presented values below the recommended reference range (5.0 mg/L). The prescribed dose (mg/Kg/day) and concomitant use of TPM\'s metabolism inducers explained 69.0% of TPM\'s Cp variability: it was estimated that an increment of 1.0 mg/Kg/day in the dosage of TPM has lead to an increase of 0.68 mg/L in its Cp, while the use of inducers was related to a decrease of 2.97 mg/L (p?0.001). Patients with Cp < 5.0 mg/L showed a larger mean number of crises than those whose Cp was within the reference range (p<0.001). The LAEP\'s mean score was 40.5 (SD 10.1) and somnolence, memory problems and nervousness and/or agitation were the most common adverse events. Regarding quality of life, QOLIE-31\'s mean score was 47.7 (SD 15.2), wherein concern about the crisis and social role were the areas related to greater impairment in patients\' quality of life. Furthermore, we found evidences of an inverse relationship between ADR and quality of life in which the one point increase in LAEP score reduced QOLIE-31 score in 0.91 point. Finally, according to MMS results, 62.2% of patients were adherent to their treatment. In conclusion prescribed dose and concomitant use of AEDs that induced TPM\'s metabolism influenced on this drug\'s Cp, which seemed to affect epileptic seizures control. Thus, we suggest the use of therapeutic drug monitoring of TPM as a tool for pharmacotherapy optimization so as to improve the clinical response in these patients.

O topiramato (TPM) é um fármaco antiepiléptico utilizado para o controle de crises epilépticas generalizadas e parciais em adultos e crianças. A determinação da concentração plasmática do TPM em associação com as observações clínicas é de suma importância, uma vez que permite o ajuste individual da dose administrada ao paciente, diminuindo a incidência de reações adversas e melhorando a adesão ao tratamento. No presente trabalho, dois métodos bioanalíticos foram desenvolvidos e validados para análise do TPM em amostras de plasma, por eletroforese capilar utilizando os detectores DAD (detecção indireta) e C4D Lite (detecção condutométrica). A análise eletroforética para ambos os métodos foi realizada em um capilar de sílica fundida de 75 ?m de diâmetro interno e 40 cm de comprimento efetivo. O eletrólito de corrida foi composto por trietanolamina (TEA) 15 mmol L-1 para a detecção condutométrica e TEA 15 mmol L-1, ácido 3,5 dinitrobenzóico (DNB) 5 mmol L-1 e brometo de cetiltrimetilamônio (CTAB) 0,4 mmol L-1 para detecção indireta. As injeções foram feitas no modo hidrodinâmico a 0,8 psi por 5 segundos e a tensão aplicada foi de -20 e 20 kV para detecção indireta e condutométrica, respectivamente. Nestas condições, o TPM migrou em 2,5 min. O preparo das amostras foi realizado por extração líquido-líquido (LLE), usando éter metil-terc-butílico (MTBE) como solvente extrator e utilizando 500 e 200 ?L de plasma para o método com detecção indireta e condutométrica, respectivamente. Os métodos foram validados de acordo com os guias oficiais da Agência Nacional de Vigilância Sanitária e European Medicine Agency e apresentaram linearidade no intervalo de concentração plasmática de 1-30 ?g mL-1 e valores de precisão e exatidão abaixo de 15 %, além de serem seletivos. Assim, ambos os métodos foram aplicados com sucesso em amostras de plasma de pacientes em tratamento com o TPM. Embora os detectores universais geralmente apresentem um maior limite de detecção comparado com detectores seletivos, o método com detecção condutométrica desenvolvido neste trabalho apresentou como vantagem maior sensibilidade em relação método indireto (DAD). Além disso, apresentou também vantagens como simplicidade e baixo custo, mostrando viabilidade na aplicação para análises de rotina. / Topiramate (TPM) is an antiepileptic drug that has been used as an agent for the control of partial and generalized seizures in both adults and children patients. The determination of the plasmatic concentration of TPM in association with clinical observations is of utmost importance for the individual adjustment of the administered dose to the patient. In the present work, two bioanalytical methods have been developed and validated for TPM analysis in plasma samples by capillary electrophoresis using DAD (indirect detection) and C4D Lite detectors (conductometric detection). The electrophoretic analysis for both methods were performed on a fused silica capillary of 75 ?m of internal diameter and 40 cm effective length. The background electrolyte was composed of triethanolamine (TEA) 15 mmol L-1 for conductometric detection and TEA 15 mmol L-1, 3,5 dinitrobenzoic acid (DNB) 5 mmol L-1 and cetyltrimethylammonium bromide (CTAB) 0.4 mmol -1 for indirect detection. The injections were carried out in hydrodynamic mode, at 0.8 psi for 5 seconds, and the voltage applied were -20 e 20 kV for indirect and conductometric detection, respectively. Under these conditions, TPM migrated in 2.5 min. The sample preparation was carried out by liquid liquid extraction (LLE) using methyl tert-butyl ether (MTBE) as solvent, and using 500 and 200 ?L of plasma samples for direct and conductometric detection, respectively. The methods were validated according to the official guides of the Agência Nacional de Vigilância Sanitária and European Medicine Agency, and showed linearity in plasmatic concentration range of 1-30 mg L-1, precision and accuracy values below 15%, beside selectivity. Both methods have been applied successfully to analysis of plasma samples of patients in treatment with TPM. Although universal detectors have a higher quantification limit compared with selective detectors, the method with conductometric detection developed in this work presented greater sensitivity than indirect method (DAD). Furthermore, it also presented advantages such as simplicity and low cost, showing feasibility in applying to routine analysis.

A estratégia mais amplamente utilizada no tratamento da epilepsia é a farmacoterapia. Entretanto cerca de 30% dos pacientes mesmo utilizando o fármaco adequado para o seu diagnóstico não respondem ao tratamento proposto, sendo então diagnosticados com epilepsia refratária. Entre as drogas antiepilépticas (DAE) utilizadas no tratamento da epilepsia refratária encontra-se o topiramato (TPM). O objetivo do presente estudo foi avaliar a concentração plasmática (Cp) do TPM verificando a influência da dose prescrita (mg/Kg/dia), sexo, idade e o uso de outras DAE sobre a mesma, correlacionando-a com a frequência de crises epilépticas, reações adversas, qualidade de vida e adesão a farmacoterapia. Este estudo observacional transversal foi realizado com 37 pacientes com epilepsia refratária em uso de TPM atendidos no Ambulatório de Epilepsia de Difícil Controle do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. As variáveis de interesse foram qualidade de vida (Quality of Life in Epilepsy - QOLIE-31), reações adversas ao medicamento (RAM) (Liverpool Adverse Event Profile - LAEP), adesão a farmacoterapia (Modified Morisky Scale - MMS), tipo de crise epiléptica, tipo de epilepsia, frequência das crises, características farmacoterapêuticas e sociodemográficas, obtidas por meio de instrumentos na entrevista com o paciente ou em prontuário. Além disso, amostras de sangue de todos os participantes foram coletadas para dosagem da Cp de TPM, lamotrigina e DAEs de primeira geração em uso. O trabalho foi aprovado pelo Comitê de Ética em Pesquisa da Faculdade de Ciências Farmacêuticas de Ribeirão Preto-USP (nº 030/2014). A idade média dos pacientes foi 40 anos (DP 10,7) e apresentavam prevalentemente epilepsia focal sintomática (73,0%) e crises parciais complexas (67,6%). Em relação ao perfil farmacoterapêutico, 97,3% dos pacientes estavam em politerapia, sendo o esquema farmacoterapêutico mais prevalente a associação entre TPM, carbamazepina e clobazam (29,8%). A Cp de 83,8% dos pacientes em uso de TPM encontraram-se abaixo do intervalo de referência recomendado (5,0 -20,0 mg/L), sendo a Cp média de 3,21 mg/L (DP 2,76). A dose prescrita (mg/Kg/dia) e o uso concomitante de indutores do metabolismo do TPM explicaram 69,0% da variabilidade da Cp do TPM: estimou-se que o aumento na dose de 1,0 mg/Kg/dia tenha promovido o aumento de 0,68 mg/L na Cp do TPM, enquanto o uso de indutores esteve relacionado a uma redução de 2,97 mg/L (p?0,001). Os pacientes com Cp < 5,0 mg/L apresentaram o número médio de crises epilépticas maior do que aqueles com Cp no intervalo de referência (p<0,001). A pontuação média do LAEP foi de 40,5 (DP 10,1) e a sonolência, problemas de memória e o nervosismo e/ou agressividade foram as reações adversas mais prevalentes. Com relação à qualidade de vida o escore médio obtido no QOLIE-31 foi de 47,7 (DP 15,2), sendo que a preocupação com as crises e a função social foram os domínios que apresentaram maior comprometimento na qualidade de vida dos pacientes. Ademais, foram encontradas evidências de uma relação inversa entre RAM e a qualidade de vida, sendo que o aumento de um ponto no escore do LAEP reduz o escore do QOLIE-31 em 0,91 pontos. Finalmente, segundo resultados do MMS, 62,2% dos pacientes eram aderentes ao tratamento medicamentoso. Em conclusão a dose prescrita e o uso de DAE indutoras do metabolismo do TPM influenciaram a Cp deste fármaco, a qual afetou o controle das crises epilépticas. Diante disto sugere-se a monitorização terapêutica como uma ferramenta para a otimização da farmacoterapia e da resposta clínica. / The most widely used strategy in epilepsy treatment is pharmacotherapy. However, near 30% of all patients, even though receiving the appropriate drug, do not respond to recommended treatment. Among the antiepileptic drugs (AED) used for the treatment of refractory epilepsy there is topiramate (TPM). The aim of this study was to evaluate TPM\'s plasma concentration (Cp) and to verify the influence of some variables [prescribed dose (mg/Kg/day), sex, age and other AED in use] on it, as well as correlate TPM\'s Cp with the frequency of epileptic crises, adverse events, quality of life and adherence to pharmacotherapy. This cross-sectional study enrolled 37 patients diagnosed with refractory epilepsy in use of TPM attended at the Epilepsy of Difficult Control\'s ambulatory of the Ribeirão Preto Medical School University Hospital. The investigated variables were quality of life (Quality of Life in Epilepsy - QOLIE-31), adverse drug reactions (ADR) (Liverpool Adverse Event Profile - LAEP), adherence to pharmacotherapy (Modified Morisky Scale - MMS), type of epileptic crisis, type of epilepsy, frequency of crises, pharmacotherapeutic and sociodemographic characteristics, all of them obtained through medical records and/or face to face interview. Moreover, blood samples of all patients were collected in order to measure Cp of TPM, lamotrigine and first generation AEDs in use. The study was approved by the Research Ethics Committee of the School of Pharmaceutical Sciences of Ribeirão Preto-USP (nº 030/2014). The patients\' mean age was 40 years (SD 10.7) and they showed predominantly symptomatic focal epilepsy (73.0%) and partial complex seizures (67.6%). Considering the pharmacotherapeutic profile, 97.3% of them were under polytherapy, in which the most prevalent regimen consisted in the combination of TPM, carbamazepine and clobazam (29.8%). From all patients in use of TPM, the mean Cp for this drug was 3.21 mg/L (SD 2.76) and 83.8% presented values below the recommended reference range (5.0 mg/L). The prescribed dose (mg/Kg/day) and concomitant use of TPM\'s metabolism inducers explained 69.0% of TPM\'s Cp variability: it was estimated that an increment of 1.0 mg/Kg/day in the dosage of TPM has lead to an increase of 0.68 mg/L in its Cp, while the use of inducers was related to a decrease of 2.97 mg/L (p?0.001). Patients with Cp < 5.0 mg/L showed a larger mean number of crises than those whose Cp was within the reference range (p<0.001). The LAEP\'s mean score was 40.5 (SD 10.1) and somnolence, memory problems and nervousness and/or agitation were the most common adverse events. Regarding quality of life, QOLIE-31\'s mean score was 47.7 (SD 15.2), wherein concern about the crisis and social role were the areas related to greater impairment in patients\' quality of life. Furthermore, we found evidences of an inverse relationship between ADR and quality of life in which the one point increase in LAEP score reduced QOLIE-31 score in 0.91 point. Finally, according to MMS results, 62.2% of patients were adherent to their treatment. In conclusion prescribed dose and concomitant use of AEDs that induced TPM\'s metabolism influenced on this drug\'s Cp, which seemed to affect epileptic seizures control. Thus, we suggest the use of therapeutic drug monitoring of TPM as a tool for pharmacotherapy optimization so as to improve the clinical response in these patients.

<p>Although much research has focused on cognitive ability and the genetic and environmental factors that might influence it, this aspect of human nature is still far from being well understood. It has been well-established that certain factors such as age and education have significant impacts on performance on most cognitive tests, but the effects of variables such as cognitive pastimes and strategies used during testing have generally not been assessed. Additionally, no genetic variant has yet been unequivocally shown to influence the normal variation in cognitive ability of healthy individuals. Candidate gene studies of cognition have produced conflicting results that have not been replicable, and genome-wide association studies have not found common variants with large influences on this trait.</p><p>Here, we have recruited a large cohort of healthy volunteers (n=1,887) and administered a brief cognitive battery utilizing diverse, common, and well-known tests. In addition to providing standard demographic information, the subjects also filled out a questionnaire that was designed to assess novel factors such as whether they had seen the test before, in what cognitive pastimes they participated, and what strategies they had used during testing. Linear regression models were built to assess the effects of these variables on the test scores. I found that the addition of novel covariates to standard ones increased the percent of the variation in test score that was explained for all tests; for some tests, the increase was as high as 70%.</p><p>Next, I examined the effects of genetic variants on test scores. I first performed a genome-wide association study using the Illumina HumanHap 550 and 610 chips. These chips are designed to directly genotype or tag the vast majority of the common variants in the genome. Despite having 80% power to detect a common variant explaining at least 3-6% (depending on the test) of the variation in the trait, I did not find any genetic variants that were significantly associated after correction for multiple testing. This is in line with the general findings from GWA studies that single common variants have a limited impact on complex traits.</p><p>Because of the recent technological advances in next-generation sequencing and the apparently limited role of very common variants, many human geneticists are making a transition from genome-wide association study to whole-genome and whole-exome sequencing, which allow for the identification of rarer variants. Because these methods are currently costly, it is important to utilize study designs that have the best chance of finding causal variants in a small sample size. One such method is the extreme-trait design, where individuals from one or both ends of a trait distribution are sequenced and variants that are enriched in the group(s) are identified. Here, I have sequenced the exomes of 20 young individuals of European ethnicity: 10 that performed at the top of the distribution for the cognitive battery and 10 that performed at the bottom. I identified rare genetic variants that were enriched in one extreme group as compared to the other and performed follow-up genotyping of the best candidate variant that emerged from this analysis. Unfortunately, this variant was not found to be associated in a larger sample of individuals. This pilot study indicates that a larger sample size will be needed to identify variants enriched in cognition extremes.</p><p>Finally, I assessed the effect of topiramate, an antiepileptic drug that causes marked side effects in certain cognitive areas in certain individuals, on some of the healthy volunteers (n=158) by giving them a 100 mg dose and then administering the cognitive test two hours later. I compared their scores at this testing session to those at the previous session and calculated the overall level to which they were affected by topiramate. I found that the topiramate blood levels, which were highly dependent on weight and the time from dosing to testing, varied widely between individuals after this acute dose, and that this variation explained 35% of the variability in topiramate response. A genome-wide association study of the remaining variability in topiramate response did not identify a genome-wide significant association.</p><p>In sum, I studied the contributions of both environmental and genetic variables to cognitive ability and cognitive response to topiramate. I found that I could identify environmental variables explaining large proportions of the variation in these traits, but that I could not identify genetic variants that influenced the traits. My analysis of genetic variants was for the most part restricted to the very common ones found on genotyping chips, and this and other studies have generally found that single common genetic variants do not have large affects on complex traits. As we move forward into studies that involve the sequencing of whole exomes and genomes, genetic variants with large effects on these complex traits may finally be found.</p> / Dissertation

SENA JÚNIOR, Diniz Maciel de. Propriedades Vibracionais e Térmicas do Topiramato Cristalino. 2008. 129 f. Tese (Doutorado em Física) - Programa de Pós-Graduação em Física, Departamento de Física, Centro de Ciências, Universidade Federal do Ceará, Fortaleza, 2008. / Submitted by Edvander Pires (edvanderpires@gmail.com) on 2015-05-04T19:42:01Z No. of bitstreams: 1 2008_tese_dmsenajunior.pdf: 1941905 bytes, checksum: cd866cd3390085e83129c5851eaff4d6 (MD5) / Approved for entry into archive by Edvander Pires(edvanderpires@gmail.com) on 2015-05-07T16:55:19Z (GMT) No. of bitstreams: 1 2008_tese_dmsenajunior.pdf: 1941905 bytes, checksum: cd866cd3390085e83129c5851eaff4d6 (MD5) / Made available in DSpace on 2015-05-07T16:55:19Z (GMT). No. of bitstreams: 1 2008_tese_dmsenajunior.pdf: 1941905 bytes, checksum: cd866cd3390085e83129c5851eaff4d6 (MD5) Previous issue date: 2008 / The scientific interest on molecular crystals stems from their great versatility and ease of processing. For pharmaceutically active ingredients, the structure-activity relationship is of major importance. Topiramate, a white and crystalline solid, is a powerful drug efficiently employed to control epilepsy symptoms. The mechanism of action involves a negative modulatory effect on the AMPA/kainate subtypes of glutamate receptors and some types of voltage-gated Na+ and Ca2+ channels, and a positive modulatory effect on some types of GABAA receptors and at least one type of K+ channels in neurons. Despite its pharmacological attributes, the lack of publications regarding its physical-chemical properties in the literature is apparent. In order to fill this gap, a research comprising vibrational spectroscopy techniques (Raman and infrared), thermal analysis (TGA/DTA/DSC), and theoretical calculations, was carried out. With the aid of calculations employing density functional theory (DFT), most of the observed vibrational bands is assigned. Consideration of Raman spectra recorded at temperatures above and below room temperature, as well as under high hydrostatic pressures, indicated maintenance of the orthorhombic crystalline structure under the diverse thermodynamic conditions employed. Thermal analysis, however, showed that, after the melting point, the sample undergoes decomposition in a process comprising three stages, possibly initiated with loss of the sulfamate group by the molecule. This event inspired a theoretical study aimed at promoting the sulfamate group bond breakage in a controlled way by employing a laser instead of heat. This was accomplished by quantum dynamics simulations which showed that, by using a set of ultrashort pulses in the infrared region, it is possible to reach levels close to 70 % dissociation in less than 3 ps. / O interesse científico pelos cristais moleculares resulta da facilidade de processamento destes materiais, e de sua grande versatilidade. No caso de drogas, a relação entre estrutura e atividade é de suma importância. Topiramato, um sólido branco e cristalino, é um fármaco utilizado com bastante eficiência para controlar os sintomas da epilepsia. O mecanismo de ação envolve um efeito modulatório negativo nos receptores de glutamato do subtipo AMPA/kainato e alguns tipos de canais de Na+ e Ca2+ voltagem-dependentes, bem como um efeito modulatório positivo em alguns tipos de receptores GABAA e pelo menos um tipo de canal de K+ nos neurônios. A despeito de suas qualidades farmacológicas, a escassez de trabalhos relacionados às suas propriedades físico-químicas na literatura é evidente. Para ajudar a preencher esta lacuna, uma investigação envolvendo técnicas de espectroscopia vibracional (Raman e infravermelho), análises térmicas (TGA/DTA/DSC), e cálculos teóricos, foi realizada. Com a ajuda de cálculos empregando a teoria do funcional de densidade (DFT), a atribuição da maioria das bandas vibracionais observadas foi realizada. A observação dos espectros Raman obtidos em temperaturas acima e abaixo da ambiente, bem como sob altas pressões hidrostáticas, indicou que a estrutura cristalina ortorrômbica é mantida nas diferentes condições termodinâmicas empregadas. A análise térmica, entretanto, mostrou que, após a fusão, o material sofre decomposição em um processo que envolve três etapas, possivelmente iniciado com a perda do grupo sulfamato pela molécula. Este fato motivou um estudo teórico a fim de modelar a quebra da ligação do sulfamato de maneira controlada, utilizando um laser em lugar de calor. Isto foi realizado com simulações de dinâmica quântica, que mostraram que, através da utilização de uma combinação de pulsos ultracurtos na região do infravermelho, é possível atingir níveis próximos a 70% de dissociação em menos de 3 ps.