298-46-4

Raw materials And Preparation Products

Hazard Information

Material Safety Data Sheet(MSDS)

Questions And Answer

• Overview

  Carbamazepine (CBZ) is an irninostilbene derivative, structurally similar to the tricyclic antidepressants. Chemically. CBZ is a neutral, liposoluble compound that can easily pass the bloodlbrain barrier and other membranes in the body. Developed and marketed for the treatment of epileptic seizures and trigeminal neuralgia, CBZ has been utilized more and more frequently in the last decade to treat psychiatric disorders.
  Carbamazepine was first evaluated as a potential treatment in manic depressive psychosis by Takezaki and Hanaoka (1971)^[1], and Okuma et al. (1973)^[2]. In 1979, Okuma et al.^[3] performed the first double-blind trial of carbamazepine in comparison with the antipsychotic chlorpromazine in mania and found that 70% and 60% of patients improved respectively. A further placebo-controlled double-blind study replicated the antimanic properties of carbamazepine under controlled circumstances (Ballenger and Post, 1980). There have since been many studies demonstrating the efficacy of carbamazepine in treating the acute manic and depressive symptoms of bipolar disorder, as well as in prophylaxis^{[4, 5]}.
  
  Figure 1 the chemical structure of carbamazepine
  Carbamazepine is a first- generation antiepileptic drug (AED) known with the proprietary brand name of Tegretol® (Novartis, Basel) in the UK and USA (Fig. 3.2). Oxcarbazepine is a second- generation AED supplied under the proprietary brand name of Trileptal® (Novartis, Basel) in the UK and USA (Fig. 3.3). Eslicarbazepine is a third- generation AED sold under the proprietary brand names of Zebinix® (Eisai, Hatfield) in the UK and Aptiom® (Sunovion, Marlborough, MS) in the USA.;

• Indication

  Carbamazepine has been used to treat many types of epilepsies since the early sixties^[6]. The psychotropic properties of the drug were soon recognized and prompted studies in psychiatric disorders. Today, the main indications for CBZ in psychiatry are the treatment of acute manic states and the prophylaxis of recurrence in bipolar disorders^[7]. The clinical studies reviewed consistently reported a CBZ success rate in acute manic states and recurrence prophylaxis in bipolar disorders ranging from 50 to 65%. More recent works confirmed the success rate in acute manic states^[8], whereas data for the long-term prophylaxis of recurrence were more variable, and in general less positive^[9]. Post et al. (1993) ^[10] suggested that poor long-term CBZ efficacy might be due to tolerance development and, on the basis of the CBZ action in experimental models. Speculated that periods of drug "holiday" may restore its efficacy. A similar warning has been reported for the long-term prophylactic efficacy of lithium^[11].
  Evidence of some positive action of CBZ in unipolar depression has also been reported^[12]. More recently. Cullen et al. (1991) ^[13] retrospectively analyzed 16 melancholic patients who received CBZ alone or in combination with other psychotropic drugs. Seven patients had a moderate to marked improvement, but treatment had to be discontinued in five due to side effects. Stuppaeck et al. (1993) ^[14], in open observations in 15 patients with unipolar depression, concluded that CBZ had a positive effect in 11 patients.
  Other psychiatric syndromes for which CBZ has been proved or suggested to be useful include aggressive agitation in demented patients^[15]. Super-sensitivity psychosis^[16], and alcohol^[17] and benzodiazepine withdrawal syndromes^[18]. In panic disorders, CBZ has been reported to attenuate panic attacks in subjects with underlying EEG abnormalities^[19]. However, in the only controlled trial in 14 patients with panic disorders, CBZ was no better than placebo^[20]. Recommendations
  • Seizure types: first line (generalized tonic- clonic seizures, focal seizures), adjunctive (focal seizures), contraindicated (generalized tonic- clonic seizures if there are absence or myoclonic seizures, or if juvenile myoclonic epilepsy is suspected, tonic/ atonic seizures, absence seizures, myoclonic seizures).
  • Epilepsy types: first line (epilepsy with generalized tonic- clonic seizures only, benign epilepsy with centrotemporal spikes, Panayiotopoulos syndrome, late- onset childhood occipital epilepsy), adjunctive (benign epilepsy with centrotemporal spikes, Panayiotopoulos syndrome, late- onset childhood occipital epilepsy), contraindicated (absence syndromes, juvenile myoclonic epilepsy, idiopathic generalized epilepsy, Dravet syndrome, Lennox– Gastaut syndrome).
  • Psychiatry: prophylaxis of manic- depressive phases in patients with bipolar disorder unresponsive to lithium therapy; treatment of alcohol withdrawal symptoms (unlicensed).
  • Neurology: treatment of paroxysmal pain in trigeminal neuralgia and diabetic neuropathy (unlicensed).
  ;

• Dosage and administration

  Carbamazepine dosages employed in the various pathologies are similar: in most cases therapeutic effects are obtained at doses of 10 to 20 mg/kg/day. Age has only a limited effect on CBZ disposition, but children may need a slightly higher dosage (in mg/kg). No dosage adjustments are required in relation to patient's sex or other genetic factors. Treatment should be started at low dosages (3 - 5 mg/kg/day) and increased progressively by a similar amount every 5-7 days, until the desired clinical effect is obtained or persistent side effects appear. This approach will determine the lowest effective (or the maximum tolerated) dose and reduce the incidence of dose-dependent side effects, which are more frequent and more troublesome for the patient at the beginning of therapy^[15]. If tolerance is poor but the drug seems to be clinically effective, an even slower titration may prove useful. Treatment of acute manic states, however, may require a faster titration at the cost of an increased frequency of side effects^[16]. A daily dose administered in conventional tablets or oral suspension should be divided into 3-4 intakes to avoid excessive fluctuations of plasma concentration; alternatively, slow-release preparations can be used. In some countries a chewable tablet formulation (100 mg) is available, which may be convenient in children^[13].
  • Epilepsy—immediate release: 100– 200 mg od/ bd, increased by 100– 200 mg every 14 days; usual maintenance 800– 1200 mg daily, in divided doses (max. 2000 mg daily).
  • Epilepsy— prolonged release: 50– 200 mg bd, increased by 100– 200 mg every 14 days; usual maintenance 800– 1200 mg daily, divided into two doses (max. 2000 mg daily).
  • Bipolar disorder— immediate release: 400 mg daily, in divided doses, increased by 100– 200 mg every 14 days; usual maintenance 400– 600 mg daily, in divided doses (max. 1600 mg daily).
  • Bipolar disorder—prolonged release: 200 mg bd, increased by 100– 200 mg every 14 days; usual maintenance 200– 300 mg bd (max. 1600 mg daily).
  If stopping carbamazepine, patients with bipolar disorder need to reduce the dose gradually over a period of at least 4 weeks. ;

• Plasma levels monitoring

  Correlations between dosages and plasma levels of carbamazepine, as well as between plasma levels, and clinical efficacy or tolerability, are rather tenuous. However, monitoring of the plasma levels (therapeutic range in the treatment of epilepsy 4–12 mg/ L) may be useful in selected conditions, such as a dramatic increase in seizure frequency/ verification of patient compliance, during pregnancy, in suspected absorption disorders, in suspected toxicity due to polymedication. ;

• Cautions

  • Patients with a history of hepatic porphyrias.
  • Patients with a history of bone marrow depression.
  • Patients with atrioventricular block.
  • Patients with a history of haematological reactions to other drugs.
  • Patients with susceptibility to angle- closure glaucoma.
  • Patients with skin reactions.
  • Patients with cardiac disease.
  • Patients with absence and myoclonic seizures.
  ;

• Pharmacodynamics

  Carbamazepine given in conventional tablets shows a mean peak concentration time during chronic treatment of about 4 hours, with an estimated oral bioavailability of 80-90%^[21]. Carbamazepine is readily distributed in the body with an apparent volume of distribution (estimated on the presumption of a 100% oral bioavailability) of 0.8 2.0 /kg. Brain concentrations are about 1.21.4 times those in plasma and the breast milk/ total plasma level ratio is about 0.4 ^[22]. In plasma, CBZ binds to circulating proteins, mostly albumin and a1-acid glycoprotein. The bound fraction is about 70-80% and is constant in the interval of plasma concentrations normally observed in therapy^[23].
  Carbamazepine is mainly eliminated through hepatic metabolism by microsomal enzymes of the cytochrome P450 family. The main metabolites are epoxy-CBZ and 10.11-dihydro, 10,lldihydroxy carbarnazepine (CBZ-DIOL). In man, the hydroxylated derivatives are conjugated with glucuronic acid and excreted by the kidneys. Small amounts of unmodified CBZ are found in feces and in urine^[24]. Quantitatively, the main urinary metabolite is CBZ-DIOL, which is, however, inactive. Carbamazepine-l0, 11-epoxideh as anticonvulsant potency similar to the parent drug, and has comparable efficacy in trigerninal neuralgia in man. After repeated dose, CBZ induces its own metabolism and its half-life is reduced by about 50%. Changing, for example, from 36 hours at the beginning of therapy to 21 hours after 3 weeks of treatment. Patients treated with other enzyme-inducing drugs may have a CBZ half-life as short as 5 16 hours. Children present a slightly higher CBZ clearance^[21]. ;

• Interactions

  With AEDs
  • Plasma concentration of carbamazapine is increased by vigabatrin, whereas plasma concentration of the active metabolite carbamazepine 10,11- epoxide is increased by primidone and valproate (reduce carbamazepine dose to avoid increased risk of toxicity).
  • Plasma concentration of carbamazapine is reduced by cytochrome P450 3A4 inducers (including eslicarbazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, and, possibly, clonazepam).
  • Carbamazapine is a cytochrome P450 3A4 inducer and can decrease the plasma concentration of clobazam, clonazepam, ethosuximide, lamotrigine, oxcarbazepine, primidone, tiagabine, topiramate, valproate, and zonisamide.
  • Co- administration of levetiracetam has been reported to increase carbamazepine- induced toxicity; cross- sensitivity has been reported with oxcarbazepine and phenytoin.
  With other drugs
  • Plasma concentration of carbamazapine is reduced by cytochrome P450 3A4 inducers aminophylline, cisplatin, doxorubicin, St John wort (Hypericum perforatum), isotretinoin, rifampicin, and theophylline (consider increasing the dose of carbamazapine).
  • Plasma concentration of carbamazapine is increased by cytochrome P450 3A4 inhibitors: acetazolamide, azoles (antifungals), cimetidine, ciprofloxacine, danazol, dextropropoxyphene, diltiazem, fluoxetine, fluvoxamine, isoniazid, loratadine, macrolide antibiotics, olanzapine, omeprazole, paroxetine, protease inhibitors (antivirals), trazodone, and verapamil. Plasma concentration of the active metabolite carbamazepine- 10,11- epoxide is increased by progabide, quetiapine, valnoctamide, and valpromide.
  • Carbamazepine is a cytochrome P450 3A4 inducer and can decrease the plasma concentration of albendazole, alprazolam, aprepitant, aripiprazole,atorvastatin, bromperidol, buprenorphine, bupropion, calcium channel blockers (e.g. felodipine), cerivastatin, ciclosporin, citalopram, clozapine, corticosteroids (e.g. prednisolone, dexamethasone), cyclophosphamide, digoxin, doxycycline, everolimus, haloperidol, hormonal contraceptives (oestrogens and progesterones), imatinib, itraconazole, ivabradine, lapatinib, levothyroxine, lovastatin, methadone, mianserin, olanzapine, oral anticoagulants (e.g. warfarin), paliperidone, paracetamol (acetaminophen), protease inhibitors (antivirals), quetiapine, rifabutin, risperidone, sertraline, simvastatin, tacrolimus, tadalafil, temsirolimus, theophylline, tramadol, trazodone, tricyclic antidepressants, voriconazole, and sirolimus.
  With alcohol/food
  • Drinking alcohol may affect patients more than usual; eating grapefruit, or drinking grapefruit juice, may increase chance of experiencing adverse effects.
  ;

• Special populations

  Hepatic impairment
  • Metabolism impaired in advanced liver disease.
  Renal impairment
  • Use with caution.
  Pregnancy
  • Developmental disorders and malformations (including spina bifida), as well as other congenital anomalies (including craniofacial defects, such as cleft lip/ palate, cardiovascular malformations, hypospadias, and anomalies involving various body systems) have been reported in association with the use of carbamazepine during pregnancy. In women of childbearing age carbamazepine should, wherever possible, be prescribed as monotherapy, because the incidence of congenital abnormalities in the offspring of women treated with a combination of antiepileptic drugs is greater (especially if valproate is part of the polytherapy).
  • Pregnant women with epilepsy should be treated with minimum effective doses of carbamazepine and monitoring of plasma levels is recommended (aiming at the lower side of the therapeutic range, as there is evidence to suggest that the risk of malformation with carbamazepine may be dose- dependent).
  • Should a woman on carbamazepine decide to breastfeed, the infant should be monitored for possible adverse effects, as carbamazepine can be excreted in considerable amounts in breastmilk, which in combination with slow infantile elimination can result in plasma concentrations at which pharmacological effects occur. Since there have been reports of cholestatic hepatitis in neonates exposed to carbamazepine during antenatal and or during breastfeeding, breastfed infants of mothers treated with carbamazepine should be carefully observed for adverse hepatobiliary effects.
  ;

• Mode of action

  The many effects of CBZ on the central nervous system include: the ability to bind to neuron membrane sodium channels when they are in the inactivated state, slowing the speed of reactivation and thus reducing the neuron's capacity of high frequency firing^[25]; selective interaction with adenosine receptors and modification of the activity of second messengers like CAMP and cGMP and modification of various neurotransmitter systems^[26]. An interesting aspect of CBZ action on the brain is the apparent selectivity for the limbic system, a feature that may provide an anatomical basis for both the psychotropic action of the drug and its efficacy in psychomotor epilepsies.
  Carbamazepine is characterized by a good behavioural and cognitive profile in patients with epilepsy. Overall, adverse psychiatric effects (especially irritation, agitation, depression) are rarely reported in this patient population. Moderate cognitive problems affecting attention, memory, and language have occasionally been reported (especially at high doses). ;

• Psychiatric use

  Carbamazepine was approved as a treatment for acute mania in 2004, decades after it was recognized as an effective alternative to lithium in the management of bipolar illness. Data from open- label trials suggest that carbamazepine is effective in the prophylaxis of bipolar disorder or acute mania, but may be less effective than valproate or lithium. However, carbamazepine has been suggested to be a better alternative for atypical manifestations of bipolar disorder, such as rapid cycling course, mood- incongruent delusions, or in the presence of other co- morbid psychiatric or neurological conditions. Carbamazepine may also be effective in unipolar depression, whereas its utility in schizophrenia is uncertain. In rarer cases, carbamazepine has been used to treat aggressive behaviour and to facilitate sedatives/ alcohol withdrawal, but there is no solid evidence to date to establish its efficacy in this domain. To summarize, evidence is strongest to support the mood stabilizing properties of carbamazepine. ;

• Adverse reactions and precaution

  The most common manifestations of acute CBZ toxicity at therapeutic dosages involve the central nervous and gastrointestinal systems (sedation. nystagmus, diplopia, ataxia, dizziness, nausea, vomiting, constipation, diarrhea) ^[27]. Dry mouth may occur as a consequence of some anticholinergic action of the drug. These symptoms respond to a dose reduction and, due to tolerance development, usually abate during treatment. Carbamazepine may induce involuntary movements such as myoclonic and choreoathetoid jerks, dystonia and asterixis^[28]. Carbarnazepine has negative chmnotropic and dromotropic effects on cardiac conduction and may induce various types of bradyarrhythmia or even a complete atrioventricular block^[28]. These dangerous complications are usually observed in elderly patients or patients with a preexisting impairment of cardiac conduction, are concentration-related, and require dose reduction or drug suspension.
  During pregnancy, important modifications of CBZ kinetics may occur, requiring plasma concentration monitoring and, possibly, dosage adjustment^[22]. CBZ enters breast milk (milk/plasma ratio of about 0.4)and a transfer of 1-4 mg/day of drug from mother to child takes place during nursing^[22]. Concentrations in the breast-fed infant should not normally exceed 0.5 1.0 ug/ml, but somewhat higher concentrations, up to 4.7 ~ug /ml one case, have occasionally been reported^[22]. These findings suggest that breast-feeding is not to be discouraged and that it should be discontinued only if the newborn shows signs of distress, such as blunted suck reflex. ;

• References

  1. Takezaki H, Hanaoka M (1971). The use of carbamazepine (Tegretol) in the control of manic-depressive psychosis and other manic-depressive states. Clinical Psychiatry 13, 173–183.
  2. Okuma T, Kishimoto A, Inoue K, Matsumoto H, Ogura A, Matsushita T, Nakao T, Ogura C (1973). Anti-manic and prophylactic effects of carbamazepine (Tegretol) on manic-depressive psychosis: a preliminary report. Folia Psychiatrica et Neurologica 27, 283–297.
  3. Okuma T, Inanaga K, Otsuki S, Sarai K, Takahashi R, Hazama H, Mori A, Watanabe M (1979). Comparison of the antimanic efficacy of carbamazepine and chlorpromazine : a double-blind controlled study. Psychopharmacology 66, 211–217.
  4. Brambilla P, Barale F, Soares JC (2001). Perspectives on the use of anticonvulsants in the treatment of bipolar disorder. International Journal of Neuropsychopharmacology 4, 421–446.
  5. Post RM, Ketter TA, Denicoff K (1996a). The place of anticonvulsant therapy in bipolar illness. Psychopharmacology 128, 115–129.
  6. Loiseau. P, B. Duche: Carbamazepine. Clinical use. In: Levy, R H., E E. Dreifus. R H. Mattson, B. S. Me1drum.J. K. Penly (eds.): Antiepileptic drugs. Raven Press. New York 7989 p. 553-554
  7. Michels. R. P. M. Marzuk: Progress in psychiatry. N. Engl. J. Med. 329 (1993) 628 -638
  8. Okuma, 1, I. Yamashita, R Takahashi, H. Itoh, S. Otsuki. S. Watanabe. S. Sarai. H. Hazama. K. Inanaga: Comparison of the antimanic efficacy of carbamazepine and lithium carbonate by doubleblind controlled study. Pharmacopsychiatry 23 (1990) 143-150
  9. Small, J. G., M. H. Klapper, V. Milstein.].]. Kellmans, M.J. Miller.]. D. Marhenke, I. E Small: Carbamazepine compared with lithium in the treatment of mania. Arch. Gen. Psych. 48 (1991) 915-921
  10. Post, R M., 1 A. Ketter, P. J. Pauaglia. M. S. George, L. MamngelI, K. Denicoff: New developments in the use of anticonvulsants as mood stabilizers. Neuropsychobiology 27 (1993) 132-137
  11. Maj, M., R Pimzzi. D. Kemali: Long-term outcome of lithium prophylaxis in patients initially classified as complete responders. Psychopharmacology 98 (1989) 535-538
  12. Evans, R W., C. T. Gualtieri: Carbamazepine: a neurological and psychiatric profile. Clin. Neuropharrnacol. 8 (1985) 221 -241
  13. Cullen. M., P. Mitchell, H. Brodaty, I? Royce, G. Parker, I. Hickie. K Wilhelm: Carbamazepine for treatment-resistant melancholia. J. Clin. Psychiatry 52 (1991) 472-476
  14. Stuppaeck, C. H., C H. Barnas, K. Hackenberg, C. H. Miller. W. W. Neischhacker: Carbamazepine monotherapy in the treatment of alcohol withdrawal. Int. Clin. Psychopharmacol. 5 (1990)2 73 -278
  15. Gleason, R P, L, S. Schneider: Carbamazepine treatment of agitation in Alzheimer's outpatients refractory to neuroleptics. J. Clin. Psychiatry 51 (1990) 115118
  16. Chouinard G.. S. Sultan: Treatment of supersensitivity psychosis with antiepileptic drugs: report of a series of 43 cases. Psychopharmacol. Bull. 26 (1990) 337-341
  17. Stuppaeck, C. H., C H. Barnas, K. Hackenberg, C. H. Miller. W. W. Neischhacker: Carbamazepine monotherapy in the treatment of alcohol withdrawal. Int. Clin. Psychopharmacol. 5 (1990)2 73 -278
  18. Garcia. B.. E. Zaborras, V. Arease. G. Obeso, I. jimena, P. DeJuana, T. Bermejo: Interaction between isoniazid and carbamazepine potentiated by cimetidine. DlCP 26 (1992) 841
  19. Keck, F. E. jr, S. L McElroy. K. C. Tugrul. J. A. Bennett,. M. R. Smith: Antiepileptic drugs for the treatment of panic disorder. Neurobiology 27 (1993) 150-153
  20. Uhde, Z W.. M. B. Stein, R. M. Post: Lack of efficacy of carbamazepine in the treatment of panic disorder. Am. J. Psychiatry 145 (1988) 1104-1109
  21. Morselli, P. L: Carbamazepine. Absorption, distribution and excretion. In: Levy, R H., E E Dreifuss, R H. Mattson, B. S. Me1drum.J. K. Penry (eds.): Antiepileptic Drugs. Raven Press, New York 1989 p. 473-490
  22. Nau. H., W. Ku hnz, H. J. Egger. D. Rating, H. Helge: Anticonvulsants during pregnancy and lactation. Transplacental, maternal and neonatal pharmacokinetics. Clin. Pharmacokinet. 7 (1982) 508543
  23. Contin, M., R Riva, E Albani. E. Perucca. G. Lamonfanara, A. Banrui: a1-acid glycoprotein concentration and serum protein binding of carbamazepine and carbamazepine 10,ll-epoxide in children with epilepsy. Eur. J. Clin. Pharmacol. 29 (1985) 211 -214
  24. Faigle.J. W., K. E Feldmann: Carbamazepine Biotransformation In: Levy. R. H.. E E. Dreifuss, R H. Mattson, B. 5. Me1dnrm.j. K. Penry (eds.): Antiepileptic Drugs. Raven Press, New York 1989, p.491 – 504
  25. Macdonald, R. L: Carbamazepine. Mechanisms of action. In: Levy, R H.. E. Dreifiss, R H. Mattson. B. S. Meldrum,]. K. Penry (eds.): Antiepileptic drugs. Raven Press. New York 1989, p. 447-471
  26. Motohashi. N.: Gaba receptor alterations after chronic lithium administration. Comparison with carbamazepine and sodium valproate. Prog. Neuro-psychophannacol. Biol. Psychiatry 16 (1992) 571 – 579
  27. Askrnark, H.. B. E. Wiholm: Epidemiology of adverse reactions to carbamazepine as seen in a spontaneous reporting system. Acta Neurol. Scand. 81 (1990) 131 -140
  28. Gram L, P K. jensen: Carbarnazepine Toxicity. In: Levy. R. H., R. Mattson, B. Meldrum, J. K Pen% E E. Dreifuss (eds.): Antiepileptic Drugs. Raven Press. New York 1989, p. 555-565
  ;

Spectrum Detail

Well-known Reagent Company Product Information

Supplier

Related Products