|Year : 2013 | Volume
| Issue : 4 | Page : 243-246
Three-way, three-period, crossover bioequivalence study of single oral dose of three brands of 300 mg phenytoin sodium tablets marketed in India, on healthy Indian human volunteers
Maulik S Doshi1, Anuja A Naik2, Mohit R Mehta2, Nithya J Gogtay1, Urmila M Thatte1, Mala D Menon2
1 Department of Clinical Pharmacology, Seth G S Medical College and KEM Hospital, Mumbai, India
2 Department of Pharmaceutics, Bombay College of Pharmacy, Kalina, Santacruz (E), Mumbai, India
|Date of Web Publication||10-Oct-2013|
Mala D Menon
Bombay College of Pharmacy, Kalina, Santacruz (E), Mumbai - 400 098
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To compare the bioavailability of two brands of phenytoin sodium tablets available in the Indian market using Eptoin TM as the reference. Materials and Methods: A randomized, assessor-blind, three-way crossover design study was carried out over a period of 6 months after approval from the Institutional Review Board (IRB). Twenty-two healthy male participants received a single oral 300 mg oral tablet of either of the formulations with a 2-week washout. Blood samples were collected predose and at regular intervals postdose. Plasma phenytoin levels were estimated by high-performance liquid chromatography. Calculation of C max , AUC 0-t , and AUC 0-∞ was done by the linear trapezoidal rule and 90-110% margin (90% confidence interval (CI)) was used to assess bioequivalence. Results: Twenty volunteers completed the study. It was seen that the log-transformed values of C max , AUC 0-t , and AUC 0-∞ of the test formulations were not within the specified limits. Conclusion: Bioinequivalence of available phenytoin brands indicates that switching brands could lead to variations in blood concentrations and thus impact safety and efficacy. If a brand switch is done for any reason, stringent drug-level monitoring is advised.
Keywords: Bioequivalence, bioavailability, healthy volunteer, phenytoin sodium
|How to cite this article:|
Doshi MS, Naik AA, Mehta MR, Gogtay NJ, Thatte UM, Menon MD. Three-way, three-period, crossover bioequivalence study of single oral dose of three brands of 300 mg phenytoin sodium tablets marketed in India, on healthy Indian human volunteers. J Pharmacol Pharmacother 2013;4:243-6
|How to cite this URL:|
Doshi MS, Naik AA, Mehta MR, Gogtay NJ, Thatte UM, Menon MD. Three-way, three-period, crossover bioequivalence study of single oral dose of three brands of 300 mg phenytoin sodium tablets marketed in India, on healthy Indian human volunteers. J Pharmacol Pharmacother [serial online] 2013 [cited 2019 Oct 18];4:243-6. Available from: http://www.jpharmacol.com/text.asp?2013/4/4/243/119709
| Introduction|| |
Epilepsy is a common chronic neurological disorder with a prevalence of 559/100,000 population and incidence of more than 100/100,000 population in the developing countries.  Pharmacotherapy remains the mainstay of treatment and although several new drugs have been introduced in the past decade, drugs like phenytoin continue to be widely prescribed in India.  Being an old drug, as many as 26 generic versions of phenytoin are available in the market for physicians to choose from.  Brand substitution for drugs like phenytoin, which follows nonlinear kinetics, could lead to loss of seizure control or adverse events due to alterations in bioavailability resulting from changes in excipients and formulation factor. ,,,, Cost savings following switch to a generic product needs to be balanced against the possibility of changes in plasma concentrations, lower efficacy, adverse events, and poor adherence. 
In spite of the large number of generic phenytoin brands available in India, only one study has compared the bioavilability of commonly prescribed formulations.  Phenytoin continues to remain the first drug of choice for the treatment of epilepsy in India. In view of being an old drug, it does not undergo mandatory bioequivalence studies before marketing. It thus becomes important to compare the oral bioavailability of different marketed formulations periodically. Hence, the present study was carried out to compare bioavailability of a single 300 mg dose of two brands of phenytoin available in the Indian market using Eptoin TM (74% market share) as the reference. 
| Materials and Methods|| |
The study was carried out after obtaining approval from the Institutional Review Board and registration at the Clinical Trial Registry of India (CTRI/2011/05/001709). Written informed consent was taken from all participants.
This was a randomized, double-blind (and assessor-blind) crossover bioequivalence study, with a three-treatment, three-period design. A Latin Square (computer generated [www.randomization.com]) randomization was used.
A single 300 mg dose of phenytoin sodium (three tablets of 100 mg each) was used. Eptoin was the reference (supplied by Abbott India Ltd.) and local brands B and C (generic formulations of phenytoin purchased from the retail market by the investigator) were tested in the present study. All formulations had more than 6 months of shelf life.
Twenty-two healthy male volunteers were enrolled after obtaining written and informed consent. Two volunteers withdrew consent during the course of the study and were excluded from the analysis. Inclusion criteria: Volunteers who were aged 18-45 years; body weight within 20% of the ideal body weight; normal physical examination (done within 2 weeks of the study), biochemical and hematologic test values (done within 1 week of the study), urine examination, and ECG - all within normal limits; HBsAg (Australia antigen) negativity; HIV negativity; and agreement to abstain from caffeine on the day of the study and from alcohol and any other medications for 48 h prior to entry into the study and during the course of the study. Exclusion criteria: History of chronic alcohol consumption or drug addiction or intercurrent or concurrent diseases, history of allergy or hypersensitivity to phenytoin sodium, consumption of tobacco in any form, participation in a new drug study in the past 6 months and in a bioavailability or any study of a marketed drug in the past 3 months, blood donation in the past 3 months, and any drug intake in the past 15 days or intake of an enzyme-inducing agent in the past 30 days.
Following inclusion, volunteers were admitted and fasted over night. Three 100 mg tablets (300 mg single dose) were administered together on an empty stomach by a pharmacist under the supervision of the investigator. Standardized meals were given 1, 4, and 12 h after drug intake. Blood samples were collected at the following time points: 0, 1, 2, 3, 4, 5, 6, 8, 10, 12, 24, 36, 48, 60, and 72 h and collected into heparinized tubes. Plasma was separated and stored at -70°C until pending analysis.
Pharmacokinetics and statistical analysis
PK Solution version 2.0 (Summit Research Centre, USA) were used to calculate pharmacokinetic parameters, which included C max , t max , AUC 0-t , and AUC 0-∞ . Area under the plasma concentration-time curve from time 0 to time t (AUC 0-72 ) was calculated by trapezoidal rule. Area under the plasma concentration − time curve from time 0 to infinity (AUC 0-∞ ) where AUC = AUC 0-t + C t /k, where C t was the last measurable drug concentration at 72 h and k was the terminal elimination rate constant calculated using noncompartmental analysis.
Results of the three formulations were compared by analysis of variance (ANOVA) using Statistical Analysis Software (SAS) version (SAS Institute Inc., USA) 9.3 to observe effect of formulation, period, and sequence. Formulations were considered bioequivalent to reference formulation if their log (ln)-transformed values fell within 90% and 110% of the reference.
A specific reverse-phase high-performance liquid chromatography (HPLC) method for estimation of phenytoin without any interference from blank plasma was developed and validated for accuracy, precision, linearity, and stability as per US Food and Drug Administration (FDA) guidelines, May 2001. Dionex equipped with P680 HPLC pump, ASI-100 automated sample injector, UVD340U detector and Chromeleon software (Thermo Fisher India Pvt. Ltd.) and Inertsil column (C 18 150 × 4.6 mm, 5 μm) (GL Sciences, Inc. USA). Mobile phase consisted of water pH adjusted to 5.0 with 50 mM KH 2 PO 4 (S.D. Fine, India): Methanol (Merck, India) (45:55) at flow rate of 1 ml/min with total run time for each sample 12 min. The samples were analyzed at detection wavelength of 220 nm using carbamazepine (Abbott India Ltd.) as internal standard. The lowest limit of quantification on the calibration curve that gave accuracy and precision within 20% of guideline limit was 0.5 μg/ml, while the lowest limit of detection was 0.1 μg/ml. The assay was found to be linear over the concentration range of 0.5-20 μg/ml. The samples were injected in duplicates. To ensure quality control (QC) of the assay, QC samples, Lower limit of quantification (low QC sample - 0.5 μg/ml), one near the center (middle QC sample - 8 μg/ml), and one near the upper boundary of the standard curve (high QC sample - 20 μg/ml) representing the entire range of the standard curve along with the calibration curve were included in between each run. Along with the QC samples, each assay also included eight concentrations of the standard curve, blank sample, and one standard sample.
| Results|| |
The mean age of the participants was 25.9 ± 3.09 years. The mean weight, height, and body mass index (BMI) were 65.3 ± 7.07 kg, 170.3 ± 6.82 cm, and 22.54 ± 2.06 kg/m 2 , respectively.
Safety and Tolerability: No adverse events were seen.
[Table 1] summarizes C max (μg/ml), t max (h), AUC 0-t (μg h/ml), and AUC 0-∞ (μg h/ml). [Table 2] shows the 90% confidence intervals (CIs) of the ratios (test/reference) for the ln-transformed values of C max (as an index of rate of absorption), AUC 0-t , and AUC 0-∞ (as an index of the extent of absorption). The 90% CIs for the corresponding ratios of ln-transformed values of C max , AUC 0-t , and AUC 0-∞ were not within the 90-110% range. The lower and upper limits for 90% CIs for AUC 0-72 for drug B were 91 and 192; and for drug C, they were 103 and 205. Likewise, for AUC 0-∞ they were 88 and 239 for drug B; and 96 and 201 for drug C. The limits of C max for drug B were 92 and 175; and for drug C, they were 98 and 179. The phenytoin mean plasma concentration versus time curves of Eptoin TM , drugs B and C are presented in [Figure 1], [Figure 2], [Figure 3] and [Figure 4]. Period effect and sequence effect for C max , AUC 0-t , and AUC 0-∞ and formulation effect for C max and AUC 0-∞ were not found significant (P > 0.05). Formulation effect for AUC 0-t was observed significant (P = 0.03).
|Figure 2: Mean plasma concentration-time curve of EptoinTM showing standard deviation value|
Click here to view
|Figure 3: Mean plasma concentration-time curve of drug B showing standard deviation value|
Click here to view
|Figure 4: Mean plasma concentration-time curve of drug C showing standard deviation value|
Click here to view
|Table 1: Pharmacokinetic parameters after single oral dose of 300 mg of phenytoin sodium|
Click here to view
|Table 2: 90% CIs of the ratios (test/reference) for the log-transformed values of pharmacokinetic parameters|
Click here to view
| Discussion|| |
The present study compared bioequivalence of a single 300 mg oral dose of two generic formulations of phenytoin (B and C) with Eptoin TM as reference in 20 healthy Indian male volunteers in a tertiary care center. It was observed that the ln-transformed values of C max , AUC 0-t , and AUC 0-∞ (90% CI) of B and C brands were not within the 90% and 110% limits of Eptoin TM . 
Several authors have studied bioavailability of phenytoin sodium in either volunteers or patients. ,, In a study conducted on 17 patients in the United Kingdom, significant differences in generic formulations were found, leading to the conclusion that switching of brands can lead to breakthrough seizures or adverse effects.  Another group has compared bioavailability of three different brands of phenytoin with the innovator drug in 16 Thai healthy volunteers, and their results indicated that out of three brands, two brands were not bioequivalent to the innovator drug, and therefore, advised avoidance of brand interchanging.  Several researchers have reported adverse impact of brand switching of various generic antiepileptic drugs and advocated avoidance of it. ,,,, Brand switching is especially important in a country like India with the availability of at least 26 generics at varying costs ($1.5-4/100 tablets). , The less-expensive phenytoin generics, in spite of bioequivalence, may not always have therapeutic equivalence, and thus, breakthrough seizures or adverse events could result. ,
Eptoin TM was selected as a reference product in this study as it is a widely prescribed antiepileptic medicine. The comparators B and C were also similarly chosen (14% and 2% market share, respectively).  In the present study, the sample size of 20 was chosen as per Indian regulatory requirement and was also similar to other studies. ,, It was observed, in this study, that brands B and C were not bioequivalent to the reference product Eptoin TM . Several reasons could explain these variations, including the different excipients in the different formulations.
This study confirms the findings of a previous study performed on 12 healthy volunteers where the authors compared bioavailability of three brands of phenytoin (Dilantin TM , Epsolin TM , and M-toin TM ) to a reference product (Eptoin TM ).  Overall, it was seen in both the studies that changing of brands can lead to alteration in the phenytoin plasma concentration. ,,, Hence, switching of brands should be avoided once the patient is stabilized with one medication. If switching is done, then it should be followed by therapeutic drug monitoring.  One of the limitations of this study is the noninclusion of female participants, although we have found, in another study, that the number of females consenting to participate in nontherapeutic studies is limited. 
| Conclusion|| |
Switching of brands in already stabilized patients can lead to alteration of plasma concentration of phenytoin in view of the fact that brands are not bioequivalent. In India, drug plasma concentration monitoring is not routinely carried out and thus switching should be avoided. Where unavoidable, it should be accompanied by therapeutic drug monitoring coupled with clinical observation.
| References|| |
|1.||Bharucha NE. Epidemiology of Epilepsy in India. Epilepsy 2003;44:9-11. |
|2.||Gogtay NJ, Dalvi SS, Mhatre RB, Kirodian BG, Gupta AH, Jadhav SP, et al. A randomized, crossover, assessor-blind study of the bioequivalence of a single oral dose of 200 mg of four formulations of phenytoin sodium in healthy, normal Indian volunteers. Ther Drug Monit 2003;25:215-20. |
|3.||Different phenytoin generic brands. Available from: http://www.mims.com/India/drug/search/phenytoin?page=3. [Last accessed on 2012 Jul 20]. |
|4.||Chen SS, Allen J, Oxley J, Richens A. Comparative bioavailability of phenytoin from generic formulations in the united kingdom. Epilepsia 1982;23:149-52. |
|5.||Gidal BE, Tomson T. Debate: Substitution of generic drugs in epilepsy: Is there cause for concern?. Epilepsia 2008;49:56-62. |
|6.||Wilder BJ, Leppik I, Hietpas TJ, Cloyd JC, Randinitis EJ, Cook J. Effect of food on absorption of Dilantin Kapseals and Mylan extended phenytoin sodium capsules. Neurology 2001;57:582-9. |
|7.||Krämer G, Biraben A, Carreno M, Guekht A, de Haan GJ, Jedrzejczak J, et al. Current approaches to the use of generic antiepileptic drugs. Epilepsy Behav 2007;11:46-52. |
|8.||ORG IMS MAT 2010. |
|9.||Cadd DJ. FDA Reviews narrow therapeutic index requirement. Hosp Pharm 2011;46:829. |
|10.||Suthisisang C, Payakachat N, Chulavatnatol S, Towanabut S. Bioavailability of phenytoin sodium capsules available in Thailand. Part II: In vivo study. J Med Assoc Tha 1998;81:64-70. |
|11.||Soryal I, Richens A. Bioavailability and dissolution of proprietary and generic formulations of phenytoin. J. Neurol Neurosurg Psychiatry 1992;55:688-91. |
|12.||Guberman A, Corman C. Generic substitution of brand name antiepileptics drugs: a survey. Can J Neurol Sci 2000;27:37-43. |
|13.||Burkhardt RT, Leppik IE, Blesi K, Scott S, Gapany SR, Cloyd JC. Lower phenytoin serum levels in persons switched from brand to generic phenytoin. Neurology 2004;63:1494-6. |
|14.||Wilner AN. Therapeutic equivalency of generic antiepileptic drugs: Results of a survey. Epilepsy Behav 2004;5:995-8. |
|15.||Haskins LS, Tomaszewski KJ, Crawford P. Patient and physician reactions to generic antiepileptic substitution in the treatment of epilepsy. Epilepsy Behav 2005;7:98-105. |
|16.||Berg MJ, Gross RA, Haskins LS, Zingaro WM, Tomaszewski KJ. Generic substitution in the treatment of epilepsy: Patient and physician perceptions. Epilepsy Behav 2008;13:693-9. |
|17.||Various phenytoin generics brands and cost. Available from: http://www.medguideindia.com/find_brand_by_samepid.php?similarpid=958,1995. [Last accessed 2012 Aug 11]. |
|18.||Borgherini G. The bioequivalence and therapeutic efficacy of generic versus brand-name psychoactive drugs. Clin Ther 2003;25:1578-92. |
|19.||Gogtay NJ, Thatte UM, Kulkarni PS. Frequency and causes for exclusion from randomization of healthy volunteers screened for a phase 1 study in India. Natl Med J India 2012;25:18-20. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]
|This article has been cited by|
||Des ruptures de stock aux conséquences parfois graves : l’exemple de la phénytoïne, à propos de 7 cas
| ||Marine Auffret,Louise Tyvaert,Marie-Laure Laroche,Bertrand Godet,Roland Peyron,Claire Guy,Hélène Géniaux,Caroline Pécriaux,Bernadette Baldin,Johana Béné,Sophie Gautier |
| ||Thérapie. 2015; 70(4): 377 |
|[Pubmed] | [DOI]|