Clinical Information

Zonisamide (Zonegran) is approved as adjunctive therapy for partial seizures refractory to therapy with traditional anticonvulsants. Zonisamide is the pharmacologically active agent; its metabolites are not active. Essentially 100% of the zonisamide dose is absorbed. Approximately 88% of circulating zonisamide is bound to erythrocytes. The relationship between the serum level and dose is not linear because erythrocyte-bound zonisamide is inactive and binding varies with blood concentration. Time to peak zonisamide concentration is 2 to 6 hours; time to peak is delayed by coadministration with food to 4 to 6 hours. Zonisamide is metabolized by N-acetyl transferase (NAT1), cytochrome P450 3A4 (CYP3A4), and uridine diphosphate glucuronosyltransferase (UDPGT). Zonisamide is eliminated in the urine predominantly as the parent drug (35%), N-acetyl zonisamide (15%), and as the glucuronide ester of reduced zonisamide (50%). Coadministration of drugs that affect NAT1, CYP3A4, and UDPGT activity, such as phenytoin and carbamazepine, will decrease zonisamide concentration.

A typical zonisamide dose administered to an adult is 400 to 600 mg/day, administered in 2 divided doses. The apparent volume of distribution of zonisamide is 1.5 L/kg. Approximately 40% of the zonisamide circulating in the serum is bound to proteins. Zonisamide protein binding is unaffected by other common anticonvulsant drugs. The elimination half-life from plasma is 50 to 60 hours; the elimination half-life from erythrocytes is over 100 hours. Since zonisamide is cleared predominantly by the kidney, the daily dosage of zonisamide given to patients with a creatinine clearance below 20 mL/min should be reduced.(1,2)

Serum level monitoring is recommended for all patients to ensure appropriate dosing because:

-Patient response correlates with serum level.

-Serum level does not correlate with dose because of concentration-dependent erythrocyte binding.

-Elimination is affected by coadministration of drugs that affect NAT1, CYP3A4, and UDPGT.

-Kidney function affects elimination.

The most common toxicity associated with excessive serum level is drowsiness. Adverse effects not related to serum level include rash, increased serum creatinine and alkaline phosphatase, kidney stone formation, and bruising.