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Dvořáčková E, Pilková A, Matoulek M, Slanař O, Hartinger JM. Bioavailability of Orally Administered Drugs After Bariatric Surgery. Curr Obes Rep 2024; 13:141-153. [PMID: 38172482 DOI: 10.1007/s13679-023-00548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Oral drug absorption after bariatric surgery is likely to be altered, but the impact of different bariatric surgery procedures on individual drugs is not uniform. The aim of this article is to describe factors influencing the bioavailability of orally administered drugs after bariatric surgery and to provide readers with practical recommendations for drug dosing. We also discuss the medications that may be harmful after bariatric surgery. RECENT FINDINGS The fundamental factors for enteral drug absorption are the production of gastric acid; the preserved length of the intestine, i.e., the size of the absorption surface and/or the preserved enterohepatic circulation; and the length of common loop where food and drugs are mixed with digestive enzymes and bile acids. Bypassing of metabolizing enzymes or efflux pumps and changes in intestinal motility can also play an important role. Significant changes of drug absorption early after the anatomic alteration may also be gradually ameliorated due to gradual intestinal adaptation. The most affected drugs are those with low or variable bioavailability and those undergoing enterohepatic circulation. Attention should also be paid to oral drug formulations, especially in the early postoperative period, when immediate-release and liquid formulations are preferred. The changes in oral bioavailability are especially clinically meaningful in patients treated with drugs possessing narrow therapeutic index (e.g., oral anticoagulants, levothyroxine, and anticonvulsants) or in acute conditions (e.g., anti-infectives); nevertheless, it may also influence the therapeutic value of chronic therapy (e.g., antidepressants. antihypertensives, antiplatelets, statins, PPIs, contraceptives, and analgesics); therapeutic effect of chronic therapy is further influenced by pharmacokinetic alterations resulting from weight loss. Therapeutic drug monitoring, periodical clinical evaluation, and adequate dose adjustments are necessary. Due to safety reasons, patients should avoid oral bisphosphonates, regular use of non-steroidal anti-inflammatory drugs, and, if possible, corticosteroids after bariatric surgery.
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Affiliation(s)
- Eliška Dvořáčková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Clinical Pharmacy, Hospital Na Františku, Prague, Czech Republic
| | - Alena Pilková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Matoulek
- Third Internal Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Miroslav Hartinger
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
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Liu JT, Brown CS, Mara KC, Riker RR, Rabinstein AA, Fraser GL, May TL, Armstrong KJ, Seder DB, Gagnon DJ. Derivation and Validation of a New Equation for Estimating Free Valproate Concentration in Critically Ill Adult Patients. Crit Care Explor 2023; 5:e0987. [PMID: 37868026 PMCID: PMC10586844 DOI: 10.1097/cce.0000000000000987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Abstract
IMPORTANCE Protein binding of valproate varies among ICU patients, altering the biologically active free valproate concentration (VPAC). Free VPAC is measured at few laboratories and is often discordant with total VPAC. Existing equations to predict free VPAC are either not validated or are inaccurate in ICU patients. OBJECTIVES We designed this study to derive and validate a novel equation to predict free VPAC using data from ICU patients and to compare its performance to published equations. DESIGN Retrospective cohort study. SETTING Two academic medical centers. PARTICIPANTS Patients older than 18 years old with concomitant free and total VPACs measured in the ICU were included in the derivation cohort if admitted from 2014 to 2018, and the validation cohort if admitted from 2019 to 2022. MAIN OUTCOMES AND MEASURES Multivariable linear regression was used to derive an equation to predict free VPAC. Modified Bland-Altman plots and the rate of therapeutic concordance between the measured and predicted free VPAC were compared. RESULTS Demographics, median free and total VPACs, and valproate free fractions were similar among 115 patients in the derivation cohort and 147 patients in the validation cohort. The Bland-Altman plots showed the new equation performed better (bias, 0.3 [95% limits of agreement, -13.6 to 14.2]) than the Nasreddine (-9.2 [-26.5 to 8.2]), Kodama (-9.7 [-30.0 to 10.7]), Conde Giner (-7.9 [-24.9 to 9.1]), and Parent (-9.9 [-30.7 to 11.0]) equations, and similar to Doré (-2.0 [-16.0 to 11.9]). The Doré and new equations had the highest therapeutic concordance rate (73%). CONCLUSIONS AND RELEVANCE For patients at risk of altered protein binding such as ICU patients, existing equations to predict free VPAC are discordant with measured free VPAC. A new equation had low bias but was imprecise. External validation should be performed to improve its precision and generalizability. Until then, monitoring free valproate is recommended during critical illness.
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Affiliation(s)
- Ji Tong Liu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
| | | | | | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
- Maine Medical Center Research Institute, Portland, ME
| | - Kaitlin J Armstrong
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Department of Pharmacy, Maine Medical Center, Portland, ME
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
- Maine Medical Center Research Institute, Portland, ME
| | - David J Gagnon
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Maine Medical Center Research Institute, Portland, ME
- Department of Pharmacy, Maine Medical Center, Portland, ME
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Mhaimeed N, Mhaimeed N, Shad MU. Pharmacokinetic mechanisms underlying clinical cases of valproic acid autoinduction: A review. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2022. [DOI: 10.1016/j.jadr.2022.100426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Brown CS, Liu J, Riker RR, Mara KC, Rabinstein AA, Fraser GL, May TL, Seder D, Gagnon DJ. Evaluation of Free Valproate Concentration in Critically Ill Patients. Crit Care Explor 2022; 4:e0746. [PMID: 37942235 PMCID: PMC10631734 DOI: 10.1097/cce.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Protein binding of valproate is variable in ICU patients, and the total valproate concentration does not predict the free valproate concentration, even when correcting for albumin. We sought to quantify valproate free concentration among ICU patients, identify risk factors associated with an increasing free valproate concentration, and evaluate the association between free valproate concentration with potential adverse drug effect. DESIGN Retrospective multicenter cohort study. SETTING Two academic medical centers. PATIENTS Patients greater than or equal to 18 years of age with concomitant free and total valproate concentrations collected in the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two-hundred fifty-six patients were included in the study, with a median age of 56 years (42-70) and 65% of patients were male. The median total valproate concentration was 53 µg/mL (38-70 µg/mL), the free valproate concentration was 12 µg/mL (7-20 µg/mL), and the free fraction was 23.6% (17.0-33.9%). Therapeutic discordance between the free and total valproate concentration occurred in 70% of patients. On multivariable analysis, increased free valproate concentration was associated with higher total valproate concentration (per 5 µg/mL increase, increase 1.72 µg/mL, 95% CI, 1.48-1.96) and lower serum albumin (per 1 g/dL decrease, increase 4.60 µg/mL, 95% CI, 2.71-6.49). There was no association between free valproate concentration and adverse effects. CONCLUSIONS The valproate total and free concentration was discordant in the majority of patients (70%). Increased valproate free concentration was associated with hypoalbuminemia and total valproate concentration. Clinical decisions based on total valproate concentration may be incorrect for many ICU patients. Prospective, controlled studies are needed to confirm these findings and their clinical relevance.
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Affiliation(s)
| | - JiTong Liu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | | | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
| | - David Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
| | - David J Gagnon
- Tufts University School of Medicine, Boston, MA
- Department of Pharmacy, Maine Medical Center, Portland, ME
- Maine Medical Center Research Institute, Portland, ME
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Lin K, Cao VFS, Au C, Dahri K. Clinical Pharmacokinetic Monitoring of Free Valproic Acid Levels: A Systematic Review. Clin Pharmacokinet 2022; 61:1345-1363. [PMID: 36040614 DOI: 10.1007/s40262-022-01171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Current guidelines recommend therapeutic drug monitoring as a critical component of valproic acid (VPA) therapy. Due to high protein binding, the active unbound (free) portion of VPA can be misrepresented by total VPA serum levels in certain clinical scenarios. Monitoring free VPA serum levels may be warranted when assessing the clinical response to VPA therapy. OBJECTIVES The aims were to conduct a systematic review to identify a therapeutic range for free VPA serum levels; to explore the correlation of free VPA serum levels with clinical toxicity and therapeutic benefit; and to examine predictors of discordance between free and total VPA levels. METHODS Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, BIOSIS Previews, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from the time of database inception to June 20, 2021. Randomized controlled trials and observational studies that evaluated any patient receiving VPA with free VPA level monitoring were included. RESULTS Of 189 citations, we identified 27 relevant studies, which included 14 observational studies, two case series, and 11 case reports. Three studies provided a therapeutic range for free VPA levels between 20 and 410 μmol/L. Two studies suggested the occurrence of hyperammonemia and thrombocytopenia at free VPA serum levels above 60 µmol/L and 103.3 µmol/L, respectively. Two studies suggested an upper limit for neurotoxicity at free VPA serum levels of 70 µmol/L and 207.9 µmol/L. Hypoalbuminemia was identified as a predictor of therapeutic discordance. CONCLUSIONS This review demonstrates a paucity of data informing the clinical utility of free VPA serum levels. Further high-quality trials are needed to validate an optimal therapeutic range for free VPA levels.
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Affiliation(s)
- Kevin Lin
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Vivien F S Cao
- Department of Pharmacy, Vancouver General Hospital, Vancouver, BC, Canada.
| | - Charles Au
- Lower Mainland Pharmacy Services, Vancouver, BC, Canada
| | - Karen Dahri
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada.,Department of Pharmacy, Vancouver General Hospital, Vancouver, BC, Canada
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Singu BS, Morrison H, Irengeya L, Verbeeck RK. Therapeutic drug monitoring of phenytoin and valproic acid in critically ill patients at Windhoek Central Hospital, Namibia. Afr J Lab Med 2022; 11:1628. [PMID: 35937763 PMCID: PMC9350491 DOI: 10.4102/ajlm.v11i1.1628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 04/14/2022] [Indexed: 11/19/2022] Open
Abstract
Background Phenytoin and valproic acid, anticonvulsants, have a low therapeutic index and are highly plasma protein bound, mainly to albumin. Hypoalbuminaemia is common in critically ill patients and increases the unbound drug concentration. Thus, monitoring unbound rather than total plasma drug concentrations is recommended to optimise the dosing of these drugs. Objective This retrospective study determined unbound plasma concentrations of phenytoin and valproic as a more accurate value of drug levels than total plasma drug concentrations. Methods Total plasma concentrations were retrieved for 56 Intensive Care Unit patients for phenytoin and 93 for valproic acid. Total drug concentrations were converted to unbound concentrations using a serum albumin-based normalising equation. Results Total phenytoin plasma concentration was below (41.1% of patients), within (46.4%) or above (12.5%) the therapeutic range (10 μg/mL – 20 μg/mL). However, the predicted unbound plasma concentration of phenytoin was above the therapeutic range (1 μg/mL – 2 μg/mL) in the majority of patients (57.1%). For valproic acid, the total plasma concentration of most patients (87.1%) was below the therapeutic range (50 μg/mL – 100 μg/mL); among remaining patients (12.9%), it was within the therapeutic range. In the majority of patients (91.4%), the predicted unbound plasma concentration of valproic acid was between 2.5 μg/mL and 20 μg/mL. Conclusion The usefulness of monitoring the total phenytoin or valproic acid levels for dose optimisation is limited as it is an inaccurate indicator of a patient’s drug therapeutic state. Thus, the unbound plasma drug concentrations should be quantified experimentally or predicted in resource-limited settings.
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Affiliation(s)
- Bonifasius S Singu
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Helen Morrison
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Lydia Irengeya
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Roger K Verbeeck
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
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Nasreddine W, Atweh SF, Beydoun AA, Dirani M, Nawfal O, Beydoun A. Predicting the occurrence of thrombocytopenia from free valproate levels: A prospective study. Seizure 2021; 94:33-38. [PMID: 34864249 DOI: 10.1016/j.seizure.2021.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/03/2021] [Accepted: 11/13/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The likelihood of valproate (VPA) induced thrombocytopenia increases with higher VPA levels. In critically ill patients, the biological active free VPA level cannot be predicted from the total serum level. In this study, we evaluated the relationship between trough free VPA serum levels and concomitant platelet counts and assessed risk factors for the development of thrombocytopenia with the aim of generating a formula specifying the probabilities of developing thrombocytopenia based on trough free serum VPA levels. METHODS Trough free VPA levels and concomitant platelet counts were collected from a large cohort of patients who participated in a prospective VPA monotherapy trial. Significant variables associated with thrombocytopenia in a univariate analysis were evaluated in a multivariate model. A receiver operator curve was performed to compute the trough free VPA levels with the greatest discriminating power in predicting thrombocytopenia. RESULTS 844 trough free VPA levels and concomitant platelet counts obtained from 264 patients were analyzed. In a multivariate analysis, trough free VPA levels, gender, and baseline platelet counts were significantly associated with thrombocytopenia. Using stepwise regression and multivariate logistic regression analyses, we generated gender-specific formulas for predicting platelet counts and probabilities of developing thrombocytopenia. The trough free VPA with the greatest discriminating power to predict platelet values ≤ 100,000/μL was 16.65 µg/mL. CONCLUSIONS The generated model was based on trough free VPA levels and achieved high sensitivity and specificity. Our results are therefore generalizable and can be applied to estimate the probability of developing thrombocytopenia in critically ill patients.
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Affiliation(s)
- Wassim Nasreddine
- American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh 1107 2020 Beirut, Lebanon
| | - Samir F Atweh
- American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh 1107 2020 Beirut, Lebanon
| | - Adnan A Beydoun
- American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh 1107 2020 Beirut, Lebanon
| | - Maya Dirani
- American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh 1107 2020 Beirut, Lebanon
| | - Omar Nawfal
- American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh 1107 2020 Beirut, Lebanon
| | - Ahmad Beydoun
- American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh 1107 2020 Beirut, Lebanon.
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Wu X, Li H, Dong W, Yang X, Jin Y, Gong Y, Zhang Z, Liu X. Determination of Free Valproic Acid Concentration in 569 Clinical Samples by LC-MS/MS After Hollow Fiber Centrifugal Ultrafiltration Treatment. Ther Drug Monit 2021; 43:789-796. [PMID: 33990504 DOI: 10.1097/ftd.0000000000000903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To perform therapeutic drug monitoring of total and free plasma valproic acid (VPA) concentrations in clinical samples and to analyze the related factors. METHODS The total VPA concentration in plasma was determined by ultrahigh-performance liquid chromatography with precolumn derivatization with α-bromoacetophenone, and the free VPA concentration was determined by liquid chromatography-tandem mass spectrometry after the plasma was treated by hollow fiber centrifugal ultrafiltration. Regression analysis was performed to examine the associations between free plasma VPA, total plasma VPA, and the plasma protein binding rate. The impact of individual situations, outpatient or inpatient factors, and drug combinations on VPA concentrations were examined. RESULTS Of the 569 clinical samples, 268 were inpatients and 301 were outpatients, and the total VPA concentration in 138 cases (24.2%) was lower than the effective treatment concentration range; the total and free VPA concentrations in outpatient samples were 11.0% and 26.1% higher than those of inpatients, respectively. There was no linear relationship between the free and total VPA concentrations. The relationship equation between the plasma protein binding rate and free VPA concentrations was as follows: Y = 0.0255X2 - 1.1357X + 97.429 (r = 0.8011). The total and free VPA concentrations were significantly decreased after the coadministration of phenobarbital (83.7% and 64.3% of the control group, P < 0.05) or carbapenem antibiotics (32.0% and 32.7% of the control group, P < 0.05). CONCLUSIONS The total VPA concentrations in patients with epilepsy at our hospital was lower than the effective treatment concentration range, which was inadequate for epilepsy control; the total VPA concentrations of outpatients were higher than those of inpatients; as phenobarbital affects VPA metabolism, therapeutic drug monitoring is recommended. Carbapenem antibiotic coadministration with VPA should be avoided because carbapenem antibiotics can lead to the failure of VPA antiepileptic treatment.
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Affiliation(s)
- Xikun Wu
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Abstract
Purpose of this review This review presents current therapy for seizures in the intensive care unit. The reader is provided with recent evidence regarding the use of EEG in determining treatment for acute seizures. Proposed treatment approaches for seizures and status epilepticus are provided. Controversies and complexity of selecting treatments are discussed. Recent findings Critical Care EEG Monitoring Research Consortium analyzed the association of periodic and rhythmic electroencephalographic patterns with seizures and found that lateralized and generalized periodic discharges and lateralized rhythmic delta were associated with increased seizure risk. Applications using modified EEG techniques have demonstrated more rapid feedback to the ICU than was previously possible. Summary Accurate diagnosis and efficient treatment of seizures in the ICU is challenging due to patient factors, complexities of antiepileptic drug therapy, and the required expertise for EEG interpretation. Selection of optimally effective therapy for seizures or status epilepticus depends on multiple factors, making collaboration between neurophysiologists and the ICU team of paramount importance.
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Affiliation(s)
- Jane G Boggs
- Comprehensive Epilepsy Center, Wake Forest University, Winston-Salem, NC USA
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A Novel Correction Equation Avoids High-Magnitude Errors in Interpreting Therapeutic Drug Monitoring of Phenytoin Among Critically Ill Patients. Ther Drug Monit 2021; 42:617-625. [PMID: 32049893 DOI: 10.1097/ftd.0000000000000739] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Phenytoin has a narrow therapeutic index and the potential of under-treatment or toxicity. Available equations are used to correct for the impact of hypoalbuminemia on unbound (free) phenytoin levels. The authors aimed to determine the accuracy of equations used to estimate free phenytoin in hospitalized patients and assess the impact of using additional clinical data. METHODS Concurrently measured total and free phenytoin levels in hospitalized patients (2014-2018) were retrospectively evaluated, excluding those from patients on renal replacement therapy and valproic acid. Differences between actual and estimated free phenytoin levels by the original (Original WTZ), Anderson-modified, and Kane-modified Winter-Tozer equations were assessed using Pearson correlations and Bland-Altman analysis. Thereafter, a population-derived formula was developed and validated in a testing cohort. RESULTS In the 4-year training cohort (n = 81), the Original WTZ equation had the smallest mean difference of all equations. A higher mean difference [-0.362 mcg/mL (95% CI -0.585 to -0.138) vs. -0.054 mcg/mL (95% CI -0.186 to 0.078)] was observed in intensive care unit (ICU) patients compared with non-ICU patients. A cross-validated multivariable model improved the accuracy of free phenytoin estimation in ICU and non-ICU patients, even in the separate testing cohort (n = 52) with respective mean differences of -0.322 mcg/mL (95% CI -0.545 to -0.098) and -0.025 mcg/mL (95% CI -0.379 to 0.329) and was superior to the Original WTZ [mean difference -0.858 mcg/mL (95% CI -1.069 to -0.647) vs. -0.106 mcg/mL (95% CI -0.362 to 0.151), respectively]. CONCLUSIONS Free phenytoin levels in hospitalized patients cannot be accurately determined using available estimation equations, particularly in critically ill patients. Combining ICU status and other available clinical data can improve therapeutic drug monitoring and prevent high-magnitude errors, particularly when free phenytoin assays are not readily available.
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The Effect of Plasma Protein Binding on the Therapeutic Monitoring of Antiseizure Medications. Pharmaceutics 2021; 13:pharmaceutics13081208. [PMID: 34452168 PMCID: PMC8401952 DOI: 10.3390/pharmaceutics13081208] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/27/2021] [Accepted: 07/27/2021] [Indexed: 12/17/2022] Open
Abstract
Epilepsy is a widely diffused neurological disorder including a heterogeneous range of syndromes with different aetiology, severity and prognosis. Pharmacological treatments are based on the use, either in mono- or in polytherapy, of antiseizure medications (ASMs), which act at different synaptic levels, generally modifying the excitatory and/or inhibitory response through different action mechanisms. To reduce the risk of adverse effects and drug interactions, ASMs levels should be closely evaluated in biological fluids performing an appropriate Therapeutic Drug Monitoring (TDM). However, many decisions in TDM are based on the determination of the total drug concentration although measurement of the free fraction, which is not bound to plasma proteins, is becoming of ever-increasing importance since it correlates better with pharmacological and toxicological effects. Aim of this work has been to review methodological aspects concerning the evaluation of the free plasmatic fraction of some ASMs, focusing on the effect and the clinical significance that drug-protein binding has in the case of widely used drugs such as valproic acid, phenytoin, perampanel and carbamazepine. Although several validated methodologies are currently available which are effective in separating and quantifying the different forms of a drug, prospective validation studies are undoubtedly needed to better correlate, in real-world clinical contexts, pharmacokinetic monitoring to clinical outcomes.
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Wu X, Dong W, Li H, Yang X, Jin Y, Zhang Z, Jiang Y. CYP2C9*3/*3 Gene Expression Affects the Total and Free Concentrations of Valproic Acid in Pediatric Patients with Epilepsy. Pharmgenomics Pers Med 2021; 14:417-430. [PMID: 33859491 PMCID: PMC8043849 DOI: 10.2147/pgpm.s301893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/16/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To perform therapeutic drug monitoring (TDM) of total and free plasma valproic acid (VPA) concentrations in pediatric patients with epilepsy and to analyze related factors. Patients and Methods Pediatric epileptic patients treated in 2015-2019 in our hospital were assessed. Total and free plasma VPA concentrations were obtained by UPLC and LC-MS/MS, respectively. Regression analysis was performed to examine the associations of free plasma VPA with total plasma VPA and plasma protein binding rate. The impacts of individual situation, CYP2C9 genotype, and drug combination on VPA concentration were examined. Results Of the 251 patients, 81 had lower total concentrations than effective therapeutic levels; 86 and 31 patients had infections and central nervous system dysplasia, respectively. VPA's daily doses and free drug concentrations were significantly lower in the CYP2C9 *3/*3 genotype group versus the CYP2C9 *1/*3 and CYP2C9 *1/*1 groups (P<0.05). Free and total VPA concentrations were linked by Y = 0.0004 X2 + 0.042 X + 0.3035 (r=0.6981); VPA plasma protein binding rate and free VPA concentration were related by Y = 0.0003 X2 - 0.0127 X + 0.9777 (r=0.8136). Both total and free VPA concentrations were significantly decreased in patients simultaneously administered phenobarbital, meropenem and biapenem (P<0.05), with therapeutic failure after meropenem/biapenem co-administration. Conclusion Free VPA amounts have nonlinear relationships with total VPA amounts and plasma protein binding rate in epileptic children. Additionally, CYP2C9 *3/*3 expression affects VPA metabolism. Since phenobarbital affects VPA metabolism, TDM is recommended. Meanwhile, carbapenem-co-administration with VPA should be prohibited.
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Affiliation(s)
- Xikun Wu
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Weichong Dong
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Haoran Li
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Xiuling Yang
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Yiran Jin
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Zhiqing Zhang
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Ye Jiang
- Pharmacy College, Hebei Medical University, Shijiazhuang City, People's Republic of China
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Brown CS, Rabinstein AA, Nystrom EM, Britton JW, Singh TD. Antiseizure Medication use in Gastric Bypass Patients and Other Post-Surgical Malabsorptive States. Epilepsy Behav Rep 2021; 16:100439. [PMID: 33997757 PMCID: PMC8093413 DOI: 10.1016/j.ebr.2021.100439] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/25/2021] [Accepted: 02/28/2021] [Indexed: 11/02/2022] Open
Abstract
Healthcare professionals are encountering an increasing number of patients who have undergone bariatric surgeries. Antiseizure medications (ASM) have a narrow therapeutic window, and patients with malabsorptive states receiving ASM present a complex situation as the pharmacokinetics of these drugs have only been studied in patients with a normal functioning gastrointestinal tract. Patients with malabsorptive states may have altered pharmacokinetics, and there is limited literature to guide drug selection and dosage adjustment in patients with malabsorptive states. This review highlights pharmacokinetic parameters of common ASM, and considerations when managing patients on them. The effect of pH, lipophilicity, absorption, and metabolism should be taken into account when selecting and managing ASMs in this patient population. Based on these parameters, levetiracetam, and topiramate have fewer issues referable to absorption related to bariatric surgery while oral formulations of phenytoin, carbamazepine, oxcarbamazepine and valproic acid have reduced absorption due to effects of bariatric surgery based on the pharmacokinetic properties of these medications. Extended formulations should be avoided and ASM serum concentrations should be checked before and after surgery. The care of patients with epilepsy who are scheduled to undergo bariatric surgery should be guided by a multidisciplinary team including a pharmacist and a neurologist who should be involved in the adjustment of the ASMs throughout the pre-surgical and post-surgical periods.
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Affiliation(s)
- Caitlin S. Brown
- Department of Pharmacy, Mayo Clinic, Rochester, MN, United States
| | | | - Erin M. Nystrom
- Department of Pharmacy, Mayo Clinic, Rochester, MN, United States
| | | | - Tarun D. Singh
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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14
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Wang D, Champion-Lyons E, Neyens R, Bohm N, Caddell B, Babic N. The Effect of Sample Handling on Free Valproic Acid Levels. J Appl Lab Med 2020; 6:645-653. [PMID: 33249432 DOI: 10.1093/jalm/jfaa181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/09/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Valproic acid (VPA) is a broad-spectrum anticonvulsant drug. Under normal conditions, this drug is highly protein bound. However, in patients with hypoalbuminemia, the free fraction can increase substantially while the total VPA levels remain in therapeutic range. The neurologic activity and toxicity of the drug are directly related to free drug levels. METHODS Our in-house free VPA assay was validated using 20 patient samples obtained from a reference laboratory (RL1). It was further evaluated by parallel testing with RL1 using samples collected from our patients. Subsequently, sample handling effects were investigated by comparing free VPA levels measured in our laboratory to 3 selected RLs with different sample transportation conditions. RESULTS No significant bias was observed between the in-house assay (y) and RL1 (x) assay in free VPA measurement (y = 1.12x + 0.072, r = 0.994). However, patient samples collected in our institution and sent to RL1 revealed significant negative bias (y = 0.776x - 3.861, r = 0.954). A large discrepancy in free VPA levels was further observed from identical aliquots of the same samples transported to 3 RLs in different conditions. CONCLUSIONS Our study demonstrated that sample handling has significant impact on free VPA levels. The observed magnitude of variation exceeds a clinically acceptable limit and could alter clinical decisions.
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Affiliation(s)
- Dan Wang
- Department of Pathology and Laboratory Medicine, Beaumont Health, Royal Oak, MI 48073, USA
| | - Elizabeth Champion-Lyons
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Ron Neyens
- Department of Pharmacy, Medical University of South Carolin, Charleston, SC 29425, USA
| | - Nicole Bohm
- Department of Pharmacy, Medical University of South Carolin, Charleston, SC 29425, USA
| | - Brittany Caddell
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Nikolina Babic
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
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15
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Fisch U, Baumann SM, Semmlack S, Marsch S, Rüegg S, Sutter R. Accuracy of Calculated Free Valproate Levels in Adult Patients With Status Epilepticus. Neurology 2020; 96:e102-e110. [PMID: 33055270 DOI: 10.1212/wnl.0000000000011000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/20/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the accuracy of an equation in adult patients with status epilepticus that calculates the free concentration of serum valproic acid (fVPA) from the total concentration of serum valproic acid (tVPA) and serum albumin. METHODS All adult patients with status epilepticus who were treated at a Swiss academic medical center between 2005 and 2018 with concurrent measurements of tVPA, fVPA, and serum albumin were included. fVPA was categorized as subtherapeutic, therapeutic (5-10 mg/L), or supratherapeutic. Agreement was defined as the proportion of measured and calculated fVPA falling within the same category. RESULTS Of 676 patients with status epilepticus, 104 had 506 measurements, with a median of 3 (interquartile range [IQR] 1.5-6.5) per patient. The median tVPA was 43.5 mg/L (27.4-63.6), with measured fVPA 9.1 mg/L (4.5-14.7) and calculated fVPA 10.1 mg/L (7.0-13.0), respectively. The median deviation of calculated from measured fVPA was -0.8 mg/L (-3.2 to 2.5) with 336 measurements >1 mg/L. While the association between measured and calculated fVPA was linear (regression coefficient 1.1, 95% confidence interval 0.9-1.2, p < 0.0001), the agreement on effective drug levels did not match in 39.8% of measurements regardless of serum albumin levels, with calculated fVPA overestimating measured fVPA in 30.4%. tVPA and serum albumin independently influenced the accuracy of the calculated fVPA in the multivariable model. CONCLUSIONS Calculated fVPA is inaccurate when using the proposed equation in adult patients with status epilepticus, calling for drug monitoring based on measured fVPA in this context.
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Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland.
| | - Sira M Baumann
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
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Factors to influence the accuracy of albumin adjusted free valproic acid concentration. J Formos Med Assoc 2020; 120:1114-1120. [PMID: 32978045 DOI: 10.1016/j.jfma.2020.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is recommended during treatment with valproic acid (VPA), as is the measurement of free VPA concentration (MfVPA). However, MfVPA is unavailable in many institutions. Based on the highly protein-bound characteristics of VPA, an albumin-adjusted formula has been proposed to predict free VPA concentration (PfVPA). Nevertheless, the factors affecting the accuracy of this formula remain unknown, as does the concordance between MfVPA and PfVPA. METHODS Adult patients receiving VPA and undergoing TDM were enrolled. Free and total serum concentration (TVPA) were categorized as subtherapeutic, therapeutic, or supratherapeutic based on the reference range of 5-15 and 50-100 μg/mL, respectively. Concordance was defined as MfVPA and PfVPA, or MfVPA and TVPA, falling within the same category. Multivariate logistic regression with generalized estimating equation was adopted to identify factors affecting concordance, and the receiver operating characteristic curve was applied to determine the cutoff values of predictors. RESULTS A total of 98 data points from 51 participants were included for analysis. The concordance of MfVPA and PfVPA, and MfVPA and TVPA, was 72% and 44%, respectively. Blood urea nitrogen (BUN) (0.97 [0.95-0.99], P = 0.01) and TVPA (0.97 [0.95-0.99], P = 0.02) had a significant influence on the concordance of MfVPA and PfVPA. The cutoff values of TVPA and BUN for the accuracy of the albumin-adjusted formula were 56.4 μg/mL and 51.05 mg/dL, respectively. CONCLUSION If MfVPA is not available, the albumin-adjusted formula should be applied before VPA dosage adjustment when TVPA is < 56.4 μg/mL and BUN is < 51.05 mg/dL.
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Abstract
OBJECTIVES The purpose of this critical narrative review is to discuss common indications for ordering serum albumin levels in adult critically ill patients, evaluate the literature supporting these indications, and provide recommendations for the appropriate ordering of serum albumin levels. DATA SOURCES PubMed (1966 to August 2020), Cochrane Library, and current clinical practice guidelines were used, and bibliographies of retrieved articles were searched for additional articles. STUDY SELECTION AND DATA EXTRACTION Current clinical practice guidelines were the preferred source of recommendations regarding serum albumin levels for guiding albumin administration and for nutritional monitoring. When current comprehensive reviews were available, they served as a baseline information with supplementation by subsequent studies. DATA SYNTHESIS Serum albumin is a general marker of severity of illness, and hypoalbuminemia is associated with poor patient outcome, but albumin is an acute phase protein, so levels vacillate in critically ill patients in conjunction with illness fluctuations. The most common reasons for ordering serum albumin levels in intensive care unit (ICU) settings are to guide albumin administration, to estimate free phenytoin or calcium levels, for nutritional monitoring, and for severity-of-illness assessment. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Because hypoalbuminemia is common in the ICU setting, inappropriate ordering of serum albumin levels may lead to unnecessary albumin administration or excessive macronutrient administration in nutritional regimens, leading to possible adverse effects and added costs. CONCLUSIONS With the exception of the need to order serum albumin levels as a component of selected severity-of-illness scoring systems, there is little evidence or justification for routinely ordering levels in critically ill patients.
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Safety range of free valproic acid serum concentration in adult patients. PLoS One 2020; 15:e0238201. [PMID: 32877431 PMCID: PMC7467252 DOI: 10.1371/journal.pone.0238201] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 08/11/2020] [Indexed: 01/09/2023] Open
Abstract
Background Therapeutic drug monitoring (TDM) is recommended during valproic acid (VPA) use, and total serum concentration has been widely adopted. However, the free form of VPA is responsible for its pharmacologic and toxic effects, and the total and free concentrations are highly discordant because of VPA’s highly protein bound and saturable binding characteristics. Therefore, free VPA monitoring is increasingly advocated. Nevertheless, the correlation between free VPA concentration and associated adverse effects remains unknown. Objective To determine the optimal safety range of free VPA concentration in adult patients. Materials and methods This prospective cohort study enrolled adult patients undergoing VPA therapy with TDM. Patient characteristics, VPA use, and adverse effects (thrombocytopenia, hyperammonemia, and hepatotoxicity) were recorded. A multivariate logistic regression model was applied to identify the predictors of adverse effects, and the receiver operating characteristic curve was applied to locate the cutoff point of free VPA concentration. Results A total of 98 free serum concentrations from 51 patients were included for final analysis. In total, 31 (31.6%), 27 (27.6%), and 4 (4.1%) episodes of hyperammonemia, thrombocytopenia, and hepatotoxicity were observed, respectively. Free VPA concentration was a predicting factor for thrombocytopenia but not for hyperammonemia. A free VPA concentration of >14.67 mcg/mL had the greatest discriminating power (area under the curve = 0.77) for the occurrence of thrombocytopenia. Conclusions A free VPA serum concentration of 14.67 mcg/mL had the optimal discriminating power for the occurrence of thrombocytopenia. Ammonemia should be monitored even if free VPA concentration is within the safety range.
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19
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Prediction of Serum-Free and Cerebrospinal Fluid Valproic Acid Levels in Patients With Hypoalbuminemia After Craniotomy. Ther Drug Monit 2020; 42:610-616. [DOI: 10.1097/ftd.0000000000000749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Jennings VA, Scott GB, Rose AMS, Scott KJ, Migneco G, Keller B, Reilly K, Donnelly O, Peach H, Dewar D, Harrington KJ, Pandha H, Samson A, Vile RG, Melcher AA, Errington-Mais F. Potentiating Oncolytic Virus-Induced Immune-Mediated Tumor Cell Killing Using Histone Deacetylase Inhibition. Mol Ther 2019; 27:1139-1152. [PMID: 31053413 PMCID: PMC6554638 DOI: 10.1016/j.ymthe.2019.04.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 04/08/2019] [Accepted: 04/08/2019] [Indexed: 02/09/2023] Open
Abstract
A clinical oncolytic herpes simplex virus (HSV) encoding granulocyte-macrophage colony-stimulating factor (GM-CSF), talimogene laherparepvec, causes regression of injected and non-injected melanoma lesions in patients and is now licensed for clinical use in advanced melanoma. To date, limited data are available regarding the mechanisms of human anti-tumor immune priming, an improved understanding of which could inform the development of future combination strategies with improved efficacy. This study addressed direct oncolysis and innate and adaptive human immune-mediated effects of a closely related HSV encoding GM-CSF (HSVGM-CSF) alone and in combination with histone deacetylase inhibition. We found that HSVGM-CSF supported activation of anti-melanoma immunity via monocyte-mediated type I interferon production, which activates NK cells, and viral maturation of immature dendritic cells (iDCs) into potent antigen-presenting cells for cytotoxic T lymphocyte (CTL) priming. Addition of the histone deacetylase inhibitor valproic acid (VPA) to HSVGM-CSF treatment of tumor cells increased viral replication, viral GM-CSF production, and oncolysis and augmented the development of anti-tumor immunity. Mechanistically, VPA increased expression of activating ligands for NK cell recognition and induced expression of tumor-associated antigens, supporting innate NK cell killing and CTL priming. These data support the clinical combination of talimogene laherparepvec with histone deacetylase inhibition to enhance oncolysis and anti-tumor immunity.
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Affiliation(s)
- Victoria A Jennings
- The Institute of Cancer Research, Division of Radiotherapy and Imaging, Chester Beatty Laboratories, London SW3 6JB, UK; Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
| | - Gina B Scott
- Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
| | - Ailsa M S Rose
- Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
| | - Karen J Scott
- Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
| | - Gemma Migneco
- Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
| | - Brian Keller
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Katrina Reilly
- Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
| | - Oliver Donnelly
- Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
| | - Howard Peach
- St James's University Hospital, Leeds LS9 7TF, UK
| | - Donald Dewar
- St James's University Hospital, Leeds LS9 7TF, UK
| | - Kevin J Harrington
- The Institute of Cancer Research, Division of Radiotherapy and Imaging, Chester Beatty Laboratories, London SW3 6JB, UK
| | - Hardev Pandha
- Leggett Building, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7WG, UK
| | - Adel Samson
- Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
| | | | - Alan A Melcher
- The Institute of Cancer Research, Division of Radiotherapy and Imaging, Chester Beatty Laboratories, London SW3 6JB, UK.
| | - Fiona Errington-Mais
- Section of Infection and Immunity, Leeds Institute of Medical Research, University of Leeds, Beckett Street, Leeds LS9 7TF, UK
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21
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Faro J, Coppler PJ, Dezfulian C, Baldwin M, Molyneaux BJ, Urban A, Rittenberger JC, Callaway CW, Elmer J. Differential association of subtypes of epileptiform activity with outcome after cardiac arrest. Resuscitation 2019; 136:138-145. [PMID: 30586605 PMCID: PMC6397672 DOI: 10.1016/j.resuscitation.2018.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Epileptiform activity is common after cardiac arrest, although intensity of electroencephalographic (EEG) monitoring may affect detection rates. Prior work has grouped these patterns together as "malignant," without considering discrete subtypes. We describe the incidence of distinct patterns in the ictal-interictal spectrum at two centers and their association with outcomes. METHODS We analyzed a retrospective cohort of comatose post-arrest patients admitted at two academic centers from January 2011 to October 2014. One center uses routine continuous EEG, the other acquires "spot" EEG at the treating physicians' discretion. We reviewed all available EEG data and classified epileptiform patterns. We abstracted antiepileptic drugs (AEDs) administrations from the electronic medical record. We compared apparent incidence of each pattern between centers, and compared outcomes (awakening from coma, survival to discharge, discharge modified Rankin Scale (mRS) 0-2) across EEG patterns and number of AEDs administered. RESULTS We included 818 patients. Routine continuous EEG was associated with a higher apparent incidence of polyspike burst-suppression (25% vs 13% P < 0.001). Frequency of other epileptiform findings did not differ. Among patients with any epileptiform pattern, only 2/258 (1%, 95%CI 0-3%) were discharged with mRS 0-2, although 24/258 (9%, 95%CI 6-14%) awakened and 36/258 (14%, 95%CI 10-19%) survived. The proportions that awakened and survived decreased in a stepwise manner with progressively worse EEG patterns (range 38% to 2% and 32% to 7%, respectively). Among patients receiving ≥3 AEDs, only 5/80 (6%, 95%CI 2-14%) awakened and 1/80 (1%, 95%CI 0-7%) had a mRS 0-2. CONCLUSION We found high rates of epileptiform EEG findings, regardless of intensity of EEG monitoring. The association of distinct ictal-interictal EEG findings with outcome was variable.
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Affiliation(s)
- John Faro
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cameron Dezfulian
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria Baldwin
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Bradley J Molyneaux
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandra Urban
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
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Riker RR, Gagnon D, May T, Fraser G, Seder D. Valproate free serum concentrations: More complex than simple formulas. Seizure 2018; 60:155-156. [PMID: 29990709 DOI: 10.1016/j.seizure.2018.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/19/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Richard R Riker
- Department of Critical Care, Neuroscience Institute, Maine Medical Center, Portland, ME USA.
| | - David Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, ME USA
| | - Teresa May
- Department of Critical Care, Neuroscience Institute, Maine Medical Center, Portland, ME USA
| | - Gilles Fraser
- Departments of Critical Care and Pharmacy, Maine Medical Center, Portland, ME USA
| | - David Seder
- Department of Critical Care, Neuroscience Institute, Maine Medical Center, Portland, ME USA
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23
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Gagnon DJ, Fontaine GV, Riker RR, Fraser GL. Repurposing Valproate, Enteral Clonidine, and Phenobarbital for Comfort in Adult ICU Patients: A Literature Review with Practical Considerations. Pharmacotherapy 2018; 37:1309-1321. [PMID: 28833346 DOI: 10.1002/phar.2017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Provision of adequate sedation is a fundamental part of caring for critically ill patients. Propofol, dexmedetomidine, and benzodiazepines are the most commonly administered sedative medications for adult patients in the intensive care unit (ICU). These agents are limited by adverse effects, need for a monitored environment for safe administration, and lack of universal effectiveness. Increased interest has recently been expressed about repurposing older pharmacologic agents for patient comfort in the ICU. Valproate, enteral clonidine, and phenobarbital are three agents with increasing evidence supporting their use. Potential benefits associated with their utilization are cost minimization and safe administration after transition out of the ICU. This literature review describes the historical context, pharmacologic characteristics, supportive data, and practical considerations associated with the administration of these agents for comfort in critically ill adult patients.
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Affiliation(s)
- David J Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, Maine.,Tufts University School of Medicine, Boston, Massachusetts
| | - Gabriel V Fontaine
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah.,Neurosciences Institute, Intermountain Healthcare, Salt Lake City, Utah.,Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah.,Roseman University College of Pharmacy, South Jordan, Utah
| | - Richard R Riker
- Department of Critical Care Medicine, Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - Gilles L Fraser
- Department of Pharmacy, Maine Medical Center, Portland, Maine.,Tufts University School of Medicine, Boston, Massachusetts.,Department of Critical Care Medicine, Neuroscience Institute, Maine Medical Center, Portland, Maine
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Doré M, San Juan AE, Frenette AJ, Williamson D. Clinical Importance of Monitoring Unbound Valproic Acid Concentration in Patients with Hypoalbuminemia. Pharmacotherapy 2017; 37:900-907. [DOI: 10.1002/phar.1965] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Maxime Doré
- Department of Pharmacy; Hôpital du Sacré-Coeur de Montréal; Montreal Québec Canada
| | | | - Anne Julie Frenette
- Department of Pharmacy; Hôpital du Sacré-Coeur de Montréal; Montreal Québec Canada
- Research Center; Hôpital du Sacré-Coeur de Montréal; Montreal Québec Canada
- Faculty of Pharmacy; University of Montreal; Montreal Québec Canada
| | - David Williamson
- Department of Pharmacy; Hôpital du Sacré-Coeur de Montréal; Montreal Québec Canada
- Research Center; Hôpital du Sacré-Coeur de Montréal; Montreal Québec Canada
- Faculty of Pharmacy; University of Montreal; Montreal Québec Canada
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