Abstract
The transporter hypothesis is one of the most popular hypotheses of drug-resistant epilepsy (DRE). P-glycoprotein (P-gp), a channel protein at the blood–brain barrier (BBB), plays an important role in the transport of some anti-seizure drugs from brain tissue into vessels, which reduces drug concentrations and diminishes the effects of drug treatment. We performed this study to test whether P-gp is overexpressed in DRE and identify ways to prevent and reverse DRE. In this study, we established a phenytoin (PHT)-resistant mouse model and revealed that P-gp was overexpressed at the BBB in PHT-resistant mice. The P-gp inhibitor nimodipine decreased the resistance of phenytoin. Antioxidative preventive treatment with N-acetylcysteine (NAC) prevented the mice from entering a PHT-resistant state, and NAC therapy tended to reverse PHT resistance into sensitivity. We were also able to induce PHT resistance by activating the Nrf2/P-gp pathway, which indicates that oxidative stress plays an important role in drug resistance. Taken together, these findings suggest that antioxidative therapy may be a promising strategy for overcoming DRE.
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The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
References
Amin ML (2013) P-glycoprotein inhibition for optimal drug delivery. Drug Target Insights 7:27–34. https://doi.org/10.4137/DTI.S12519
Asadi-Pooya AA, Razavizadegan SM, Abdi-Ardekani A et al (2013) Adjunctive use of verapamil in patients with refractory temporal lobe epilepsy: a pilot study. Epilepsy Behav 29:150–154. https://doi.org/10.1016/j.yebeh.2013.07.006
Ashraf T, Kao A, Bendayan R (2014) Functional expression of drug transporters in glial cells: potential role on drug delivery to the CNS. Adv Pharmacol 71:45–111. https://doi.org/10.1016/bs.apha.2014.06.010
Bales KR, O’Neill SM, Pozdnyakov N et al (2016) Passive immunotherapy targeting amyloid-beta reduces cerebral amyloid angiopathy and improves vascular reactivity. Brain 139:563–577. https://doi.org/10.1093/brain/awv313
Bauer B, Hartz AM, Pekcec A et al (2008) Seizure-induced up-regulation of P-glycoprotein at the blood-brain barrier through glutamate and cyclooxygenase-2 signaling. Mol Pharmacol 73:1444–1453. https://doi.org/10.1124/mol.107.041210
Beaulieu E, Demeule M, Ghitescu L et al (1997) P-glycoprotein is strongly expressed in the luminal membranes of the endothelium of blood vessels in the brain. Biochem J 326:539–544. https://doi.org/10.1042/bj3260539
Binvignat O, Olloquequi J (2020) Excitotoxicity as a target against neurodegenerative processes. Curr Pharm Des 26:1251–1262. https://doi.org/10.2174/1381612826666200113162641
Boulay AC, Saubamea B, Decleves X et al (2015) Purification of mouse brain vessels. J Vis Exp e53208. https://doi.org/10.3791/53208
Chen Z, Brodie MJ, Liew D et al (2018) Treatment outcomes in patients with newly diagnosed epilepsy treated with established and new antiepileptic drugs: a 30-year longitudinal cohort study. JAMA Neurol 75:279–286. https://doi.org/10.1001/jamaneurol.2017.3949
Chen Z, Shi T, Zhang L et al (2016) Mammalian drug efflux transporters of the ATP binding cassette (ABC) family in multidrug resistance: a review of the past decade. Cancer Lett 370:153–164. https://doi.org/10.1016/j.canlet.2015.10.010
Chi X, Huang C, Li R et al (2017) Inhibition of mTOR pathway by rapamycin decreases P-glycoprotein expression and spontaneous seizures in pharmacoresistant epilepsy. J Mol Neurosci 61:553–562. https://doi.org/10.1007/s12031-017-0897-x
De Sarro G, Ferreri G, Gareri P et al (2003) Comparative anticonvulsant activity of some 2,3-benzodiazepine derivatives in rodents. Pharmacol Biochem Behav 74:595–602. https://doi.org/10.1016/s0091-3057(02)01040-7
Enrique A, Goicoechea S, Castano R et al (2017) New model of pharmacoresistant seizures induced by 3-mercaptopropionic acid in mice. Epilepsy Res 129:8–16. https://doi.org/10.1016/j.eplepsyres.2016.10.012
Fiest KM, Sauro KM, Wiebe S et al (2017) Prevalence and incidence of epilepsy: a systematic review and meta-analysis of international studies. Neurology 88:296–303. https://doi.org/10.1212/WNL.0000000000003509
Gaitatzis A, Johnson AL, Chadwick DW et al (2004) Life expectancy in people with newly diagnosed epilepsy. Brain 127:2427–2432. https://doi.org/10.1093/brain/awh267
Gil-Martins E, Barbosa DJ, Silva V et al (2020) Dysfunction of ABC transporters at the blood-brain barrier: Role in neurological disorders. Pharmacol Ther 213:107554. https://doi.org/10.1016/j.pharmthera.2020.107554
He SM, Li R, Kanwar JR et al (2011) Structural and functional properties of human multidrug resistance protein 1 (MRP1/ABCC1). Curr Med Chem 18:439–481. https://doi.org/10.2174/092986711794839197
Hocht C, Lazarowski A, Gonzalez NN et al (2007) Nimodipine restores the altered hippocampal phenytoin pharmacokinetics in a refractory epileptic model. Neurosci Lett 413:168–172. https://doi.org/10.1016/j.neulet.2006.11.075
Janmohamed M, Lawn N, Spilsbury K et al (2021) Starting a new anti-seizure medication in drug-resistant epilepsy: Add-on or substitute? Epilepsia 62:228–237. https://doi.org/10.1111/epi.16765
Kalilani L, Sun X, Pelgrims B et al (2018) The epidemiology of drug-resistant epilepsy: a systematic review and meta-analysis. Epilepsia 59:2179–2193. https://doi.org/10.1111/epi.14596
Kwan P, Brodie MJ (2000) Early identification of refractory epilepsy. N Engl J Med 342:314–319. https://doi.org/10.1056/NEJM200002033420503
Laxer KD, Trinka E, Hirsch LJ et al (2014) The consequences of refractory epilepsy and its treatment. Epilepsy Behav 37:59–70. https://doi.org/10.1016/j.yebeh.2014.05.031
Lazarowski A, Ramos AJ, Garcia-Rivello H et al (2004) Neuronal and glial expression of the multidrug resistance gene product in an experimental epilepsy model. Cell Mol Neurobiol 24:77–85. https://doi.org/10.1023/b:cemn.0000012726.43842.d2
Lhatoo SD, Johnson AL, Goodridge DM et al (2001) Mortality in epilepsy in the first 11 to 14 years after diagnosis: multivariate analysis of a long-term, prospective, population-based cohort. Ann Neurol 49:336–344
Li Y, Chen J, Zeng T et al (2014) Expression of HIF-1alpha and MDR1/P-glycoprotein in refractory mesial temporal lobe epilepsy patients and pharmacoresistant temporal lobe epilepsy rat model kindled by coriaria lactone. Neurol Sci 35:1203–1208. https://doi.org/10.1007/s10072-014-1681-0
McCagh J, Fisk JE, Baker GA (2009) Epilepsy, psychosocial and cognitive functioning. Epilepsy Res 86:1–14. https://doi.org/10.1016/j.eplepsyres.2009.04.007
Mohanraj R, Norrie J, Stephen L et al (2006) Mortality in adults with newly diagnosed and chronic epilepsy: a retrospective comparative study. Lancet Neurol 5:481–487. https://doi.org/10.1016/s1474-4422(06)70448-3
Moshe SL, Perucca E, Ryvlin P et al (2015) Epilepsy: new advances. Lancet 385:884–898. https://doi.org/10.1016/S0140-6736(14)60456-6
Murray CJ, Vos T, Lozano R et al (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380:2197–2223. https://doi.org/10.1016/S0140-6736(12)61689-4
Pascaud C, Garrigos M, Orlowski S (1998) Multidrug resistance transporter P-glycoprotein has distinct but interacting binding sites for cytotoxic drugs and reversing agents. Biochem J 333(Pt 2):351–358. https://doi.org/10.1042/bj3330351
Racine RJ (1972) Modification of seizure activity by electrical stimulation. II Motor Seizure Electroencephalogr Clin Neurophysiol 32:281–294. https://doi.org/10.1016/0013-4694(72)90177-0
Reddy DS (2020) Brain structural and neuroendocrine basis of sex differences in epilepsy. Handb Clin Neurol 175:223–233. https://doi.org/10.1016/b978-0-444-64123-6.00016-3
Reyes RC, Cittolin-Santos GF, Kim JE et al (2016) Neuronal glutathione content and antioxidant capacity can be normalized in situ by n-acetyl cysteine concentrations attained in human cerebrospinal fluid. Neurotherapeutics 13:217–225. https://doi.org/10.1007/s13311-015-0404-4
Shao Y, Wang C, Hong Z et al (2016) Inhibition of p38 mitogen-activated protein kinase signaling reduces multidrug transporter activity and anti-epileptic drug resistance in refractory epileptic rats. J Neurochem 136:1096–1105. https://doi.org/10.1111/jnc.13498
Sharp CD, Hines I, Houghton J et al (2003) Glutamate causes a loss in human cerebral endothelial barrier integrity through activation of NMDA receptor. Am J Physiol Heart Circ Physiol 285:H2592-2598. https://doi.org/10.1152/ajpheart.00520.2003
Sharp CD, Houghton J, Elrod JW et al (2005) N-methyl-D-aspartate receptor activation in human cerebral endothelium promotes intracellular oxidant stress. Am J Physiol Heart Circ Physiol 288:H1893-1899. https://doi.org/10.1152/ajpheart.01110.2003
Silva R, Vilas-Boas V, Carmo H et al (2015) Modulation of P-glycoprotein efflux pump: induction and activation as a therapeutic strategy. Pharmacol Ther 149:1–123. https://doi.org/10.1016/j.pharmthera.2014.11.013
Song X, Gong Z, Liu K et al (2020) Baicalin combats glutamate excitotoxicity via protecting glutamine synthetase from ROS-induced 20S proteasomal degradation. Redox Biol 34:101559. https://doi.org/10.1016/j.redox.2020.101559
Spatt J, Bauer G, Baumgartner C et al (2005) Predictors for negative attitudes toward subjects with epilepsy: a representative survey in the general public in Austria. Epilepsia 46:736–742. https://doi.org/10.1111/j.1528-1167.2005.52404.x
Stepien KM, Tomaszewski M, Tomaszewska J et al (2012) The multidrug transporter P-glycoprotein in pharmacoresistance to antiepileptic drugs. Pharmacol Rep 64:1011–1019. https://doi.org/10.1016/s1734-1140(12)70900-3
Summers MA, Moore JL, McAuley JW (2004) Use of verapamil as a potential P-glycoprotein inhibitor in a patient with refractory epilepsy. Ann Pharmacother 38:1631–1634. https://doi.org/10.1345/aph.1E068
Tang F, Hartz AMS, Bauer B (2017) Drug-resistant epilepsy: multiple hypotheses, few answers. Front Neurol 8:301. https://doi.org/10.3389/fneur.2017.00301
Trinka E (2003) Epilepsy: comorbidity in the elderly. Acta Neurol Scand Suppl 180:33–36. https://doi.org/10.1034/j.1600-0404.108.s180.5.x
Trinka E, Bauer G, Oberaigner W et al (2013) Cause-specific mortality among patients with epilepsy: results from a 30-year cohort study. Epilepsia 54:495–501. https://doi.org/10.1111/epi.12014
Wang X, Campos CR, Peart JC et al (2014) Nrf2 upregulates ATP binding cassette transporter expression and activity at the blood-brain and blood-spinal cord barriers. J Neurosci 34:8585–8593. https://doi.org/10.1523/jneurosci.2935-13.2014
Wang X, Huang S, Jiang Y et al (2018) Reactive astrocytes increase the expression of Pgp and Mrp1 via TNFalpha and NFkappaB signaling. Mol Med Rep 17:1198–1204. https://doi.org/10.3892/mmr.2017.7939
Weiss J, Kerpen CJ, Lindenmaier H et al (2003) Interaction of antiepileptic drugs with human P-glycoprotein in vitro. J Pharmacol Exp Ther 307:262–267. https://doi.org/10.1124/jpet.103.054197
Yu N, Di Q, Liu H et al (2011) Nuclear factor-kappa B activity regulates brain expression of P-glycoprotein in the kainic acid-induced seizure rats. Mediators Inflamm 2011:670613. https://doi.org/10.1155/2011/670613
Yu N, Liu H, Zhang YF et al (2014) Effects of brain IKKbeta gene silencing by small interfering RNA on P-glycoprotein expression and brain damage in the rat kainic acid-induced seizure model. CNS Neurol Disord Drug Targets 13:661–672. https://doi.org/10.2174/18715273113129990106
Yu N, Zhang YF, Zhang K et al (2017) Pregnane X receptor not nuclear factor-kappa B up-regulates P-glycoprotein expression in the brain of chronic epileptic rats induced by kainic acid. Neurochem Res 42:2167–2177. https://doi.org/10.1007/s11064-017-2224-x
Zhang C, Kwan P, Zuo Z et al (2010) In vitro concentration dependent transport of phenytoin and phenobarbital, but not ethosuximide, by human P-glycoprotein. Life Sci 86:899–905. https://doi.org/10.1016/j.lfs.2010.04.008
Acknowledgements
The authors are grateful to The Second Affiliated Hospital of Chongqing Medical University and Chongqing Key Laboratory of Neurology for providing facilities for this work.
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This research was supported by the National Natural Science Foundation of China (82071458).
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Qiankun Liu: Performing the experiments; methodology; writing, original draft; writing, review and editing. You Wang: Ideas; writing, original draft; writing, review and editing; supervision. Dandan Tan: Methodology, performing the experiments. Yong Liu: Ideas, methodology, writing—original draft. Peng Zhang: Data curation, methodology. Limin Ma: Analyze or synthesize study data, writing—review and editing. Minxue Liang: Analyze or synthesize study data, performing the experiments. Yangmei Chen: Ideas, resources, writing—review and editing, Funding acquisition, project administration. All authors read and approved the final manuscript.
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Liu, Q., Wang, Y., Tan, D. et al. The Prevention and Reversal of a Phenytoin-Resistant Model by N-acetylcysteine Therapy Involves the Nrf2/P-Glycoprotein Pathway at the Blood–Brain Barrier. J Mol Neurosci 72, 2125–2135 (2022). https://doi.org/10.1007/s12031-022-02056-0
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DOI: https://doi.org/10.1007/s12031-022-02056-0