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Mori F, Saretta F, Riscassi S, Caimmi S, Bottau P, Liotti L, Franceschini F, Bianchi A, Valluzzi RL, Crisafulli G, Caffarelli C. Risk factors for drug hypersensitivity reactions in children. Ital J Pediatr 2024; 50:127. [PMID: 39010141 PMCID: PMC11247891 DOI: 10.1186/s13052-024-01694-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/25/2024] [Indexed: 07/17/2024] Open
Abstract
Drug hypersensitivity reactions are common in children. Risk factors predisposing to IgE-mediated drug allergies and delayed drug reactions are a matter of debate. Gender, age, previous reactions to the same drug or to another drug, reduced drug metabolism, chronic diseases, polypharmacy, drug doses are linked with the onset of hypersensitivity reactions in some children. Novel advances in genetic polymorphisms can rapidly change the approach to the prevention of reactions since gene testing can be a useful screening test for severe cutaneous adverse reactions. Viral infections may act as cofactors in susceptible individuals. Polypharmacy, high doses, repeated doses and parental route of administration are also risk factors. Clinicians should take into account risk factors to allow the risk-benefit balance to be maintained.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139, Florence, Italy
| | - Francesca Saretta
- Dipartimento Materno-Infantile, SC Pediatria, Ospedale Latisana-Palmanova, Azienda Sanitaria Universitaria Friuli Centrale, 33100, Udine, Italy
| | - Sara Riscassi
- UOC Di Pediatria, Ospedale Bolzano, Azienda Sanitaria Dell'Alto Adige, Bolzano, 39100, Italy
| | - Silvia Caimmi
- SC Di Pediatria, Fondazione IRCSS Policlinico San Matteo, 27100, Pavia, Italy
| | - Paolo Bottau
- UOC Di Pediatria E Neonatologia, Ospedale Imola (BO), Imola, 40026, Italy
| | - Lucia Liotti
- UOC Pediatria, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", 60100, Ancona, Italy
| | | | - Annamaria Bianchi
- UOC Pediatria, Azienda Ospedaliera San Camillo Forlanini, 00152, Rome, Italy
| | - Rocco Luigi Valluzzi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Giuseppe Crisafulli
- Dipartimento Materno-Infantile, UOC Pediatria, University of Messina, Messina, 98122, Italy
| | - Carlo Caffarelli
- Department of Medicine and Surgery, Clinica Pediatrica, Azienda Ospedaliera-Universitaria, University of Parma, 43123, Parma, Italy.
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Qiu F, Huang Y, Dziegielewska KM, Habgood MD, Saunders NR. Effects of co-administration of lamotrigine on valproate transfer across the placenta and its brain entry in developing Genetic Absence Epilepsy Rats from Strasbourg (GAERS). Eur J Neurosci 2024. [PMID: 38978299 DOI: 10.1111/ejn.16452] [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] [Received: 03/14/2024] [Revised: 05/23/2024] [Accepted: 06/10/2024] [Indexed: 07/10/2024]
Abstract
During development, embryos and foetuses may be exposed to maternally ingested antiseizure medications (ASM), valproate and lamotrigine, essential in some patients to control their epilepsy symptoms. Often, the two drugs are co-administered to reduce required doses of valproate, a known potential teratogen. This study used Genetic Absence Epilepsy Rat from Strasbourg to evaluate transfer of valproate and lamotrigine across late gestation placenta and their entry into cerebrospinal fluid (CSF) and brain of developing rats, in mono- and combination therapies. Animals at embryonic day (E) 19, postnatal day (P) 0, 4 and 21, and adults were administered valproate (30 mg/kg) or lamotrigine (6 mg/kg) with their respective [3H]-tracers, either alone or in combination. In chronic experiments, females consumed valproate-containing diet from 2 weeks prior to mating until offspring were used at E19 and P0. Drugs were injected 30 min before blood, CSF and brain samples were collected from terminally anaesthetised animals. Radioactivity in samples was measured. In acute monotherapy brain entry of valproate was higher in foetal than postnatal animals, correlating with its plasma protein binding. Brain entry of lamotrigine was not age-dependent. Combination therapy enhanced entry of lamotrigine into the adult brain but had no effects on brain and CSF entry of valproate. Following chronic valproate exposure, placental transfer of valproate decreased in combination therapy; however, foetal brain entry increased. Results suggest that during pregnancy, the use of combination therapy of valproate and lamotrigine may mitigate overall foetal exposure to valproate but potential risks to foetal brain development are less clear.
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Affiliation(s)
- Fiona Qiu
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Yifan Huang
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Katarzyna M Dziegielewska
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark D Habgood
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Norman R Saunders
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Badillo-Ramírez I, Janssen SAJ, Soufi G, Slipets R, Zór K, Boisen A. Label-free SERS assay combined with multivariate spectral data analysis for lamotrigine quantification in human serum. Mikrochim Acta 2023; 190:495. [PMID: 38036694 PMCID: PMC10689517 DOI: 10.1007/s00604-023-06085-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023]
Abstract
Considering the need for a more time and cost-effective method for lamotrigine (LTG) detection in clinics we developed a fast and robust label-free assay based on surface-enhanced Raman scattering (SERS) for LTG quantification from human serum. The optimization and application of the developed assay is presented showing the: (i) exploration of different methods for LTG separation from human serum; (ii) implementation of a molecular adsorption step on an ordered Au nanopillar SERS substrate; (iii) adaptation of a fast scanning of the SERS substrate, performed with a custom-built compact Raman spectrometer; and (iv) development of LTG quantification methods with univariate and multivariate spectral data analysis. Our results showed, for the first time, the SERS-based characterization of LTG and its label-free identification in human serum. We found that combining a miniaturized solid phase extraction, as sample pre-treatment with the SERS assay, and using a multivariate model is an optimal strategy for LTG quantification in human serum in a linear range from 9.5 to 75 μM, with LoD and LoQ of 3.2 μM and 9.5 μM, respectively, covering the suggested clinical therapeutic window. We also showed that the developed assay allowed for quantifying LTG from human serum in the presence of other drugs, thereby demonstrating the robustness of label-free SERS. The sensing approach and instrumentation can be further automated and integrated in devices that can advance the drug monitoring in real clinical settings.
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Affiliation(s)
- Isidro Badillo-Ramírez
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, 2800, Kongens Lyngby, Denmark.
- BioInnovation Institute Foundation, 2200, Copenhagen N, Denmark.
| | - Selina A J Janssen
- Molecular Biosensing for Medical Diagnostics (MBx), Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB, Eindhoven, The Netherlands
| | - Gohar Soufi
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, 2800, Kongens Lyngby, Denmark
- BioInnovation Institute Foundation, 2200, Copenhagen N, Denmark
| | - Roman Slipets
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, 2800, Kongens Lyngby, Denmark
- BioInnovation Institute Foundation, 2200, Copenhagen N, Denmark
| | - Kinga Zór
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, 2800, Kongens Lyngby, Denmark
- BioInnovation Institute Foundation, 2200, Copenhagen N, Denmark
| | - Anja Boisen
- Center for Intelligent Drug Delivery and Sensing Using Microcontainers and Nanomechanics (IDUN), Department of Health Technology, Technical University of Denmark, 2800, Kongens Lyngby, Denmark
- BioInnovation Institute Foundation, 2200, Copenhagen N, Denmark
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Espinosa-Aguilar EJ, Piña-Ballantyne SA, Espinosa-Aguilar KL, Tun-Pisté JC, Calderón-Garcidueñas AL. Steven-Johnson Syndrome Induced by Lamotrigine and Valproic Acid in a Pediatric Patient: A Case Report. Cureus 2023; 15:e41267. [PMID: 37533620 PMCID: PMC10390704 DOI: 10.7759/cureus.41267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2023] [Indexed: 08/04/2023] Open
Abstract
Steven-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are part of a spectrum of severe cutaneous adverse reactions, secondary to infections or drug-induced. Although the use of antiseizure medications (ASMs) is a risk factor for the development of SJS/TEN, primary care physicians are not familiar with these cases in some countries. We report a case of SJS associated with ASMs in a nine-year-old girl with a history of difficult-to-control epilepsy, who required adjustment and change in medications.
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Affiliation(s)
| | | | | | - Juan-Carlos Tun-Pisté
- Internal Medicine, Hospital General de Especialidades "Dr. Javier Buenfil Osorio", Campeche, MEX
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Hoppe B, Weber Y, Wolking S. [Interactions between anti-seizure medications and recommendations for combination treatment]. DER NERVENARZT 2023; 94:149-158. [PMID: 36695895 DOI: 10.1007/s00115-022-01434-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/26/2023]
Abstract
Pharmacotherapy is the most important pillar in the treatment of epilepsies. In approximately 50% of epilepsy patients monotherapy with anti-seizure medications (ASM) is insufficient. The knowledge of specific drug interactions in combination therapies is essential to recognize and avoid adverse side effects up to relevant therapy risks, including loss of efficiency and intoxication. Interactions can be of a pharmacokinetic or pharmacodynamic nature. Some effects of interactions in combination therapies can also be advantageous. Therapeutic drug monitoring in serum is not necessary for all ASMs and should be used rationally: however, it should be performed consistently if the indications are present. This review article provides fundamental knowledge about the most relevant interactions between ASMs and the indications for therapeutic drug monitoring.
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Affiliation(s)
- Barbara Hoppe
- Sektion Epileptologie, Klinik für Neurologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Yvonne Weber
- Sektion Epileptologie, Klinik für Neurologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.,Abteilung Neurologie mit Schwerpunkt Epileptologie, Hertie Institut für Klinische Hirnforschung, Universität Tübingen, Tübingen, Deutschland
| | - Stefan Wolking
- Sektion Epileptologie, Klinik für Neurologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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Estrogen profile- and pharmacogenetics-based lamotrigine dosing regimen optimization: Recommendations for pregnant women with epilepsy. Pharmacol Res 2021; 169:105610. [PMID: 33857625 DOI: 10.1016/j.phrs.2021.105610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/04/2021] [Accepted: 04/08/2021] [Indexed: 01/16/2023]
Abstract
During pregnancy, various physiological changes occur that can alter the pharmacokinetics of antiepileptic drugs, such as lamotrigine (LTG). Anticipating the change in LTG dose required to achieve a pre-pregnancy target concentration is challenging. This study aimed to develop a refined population pharmacokinetic (PopPK) model of LTG in pregnant women with epilepsy (WWE) to identify factors explaining the variability in pharmacokinetics and to establish a model-informed individualized dosing regimen. On that basis, a coarsened model containing only clinical variables was also developed to examine its predictive performance compared to the refined model. In total, 322 concentration-time points from 51 pregnant WWE treated with LTG were employed to establish a refined PopPK model that included endogenous estrogen profiles, variants of candidate genes encoding LTG-metabolizing enzymes and -transporter proteins, and other clinical variables and a coarsened model that included only clinical variables, respectively. Data from an additional 11 patients were used for external validation of these two models. A nonlinear mixed-effect modeling approach was used for PopPK analysis of LTG. The standard goodness-of-fit method, bootstrap, normalized prediction distribution errors and external evaluation were adopted to estimate the stability and predictive performance of the candidate models. Akaike information criterion (AIC) was used to compare the goodness of fit between these two models. A lower AIC indicates a better fit of the data and the preferred model. Recommended dosing regimens for pregnant WWE were selected using Monte Carlo simulation based on the established optimal model. In the refined PopPK model, the population mean of apparent LTG clearance (CL/F) in pregnant WWE was estimated to be 2.82 L/h, with an inter-individual variability of 23.6%. PopPK analysis indicated that changes in estrogen profile during pregnancy were the predominant reason for the significant variations in LTG-CL/F. Up to the 3rd trimester, the concentration accumulation effect of E2 increased LTG-CL/F by 5.109 L/h from baseline levels. Contrary to effect of E2, E3 as the main circulating estrogen in pregnancy with a peak value of 34.41 ng/mL is 1000-fold higher than that in non-pregnancy reduced LTG-CL/F by 1.413 L/h. In addition, the UGT2B7 rs4356975 C > T and ABCB1 rs1128503 A > G variants may contribute to a better understanding of the inter-individual variability in LTG-CL/F. LTG-CL/F was 1.66-fold higher in UGT2B7 rs4356975 CT or TT genotype carriers than in CC genotype carriers. In contrast, ABCB1 rs1128503 GG genotype carriers had only 71.9% of the LTG-CL/F of AA or AG genotype carriers. In the coarsened PopPK model, the gestational age was a promising predictor of changes in LTG-CL/F. When comparing these two models, the refined PopPK model was favored over the coarsened PopPK model (AIC = -30.899 vs. -20.017). Monte Carlo simulation based on optimal PopPK model revealed that the LTG dosage administered to carriers of the UGT2B7 rs4356975 CT or TT genotype required a 33-50% increase to reach the pre-pregnancy target concentration, and carriers of the ABCB1 rs1128503 GG genotype required a 33-66% lower dose of LTG than carriers of the ABCB1 rs1128503 AA or AG genotype. Changes in estrogen profile during pregnancy was a better predictor of variations in LTG-CL/F than gestational age. The developed model based on estrogen profile and pharmacogenetics can serve as a foundation for further optimization of dosing regimens of LTG in pregnant WWE.
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Mori F, Blanca-Lopez N, Caubet JC, Demoly P, Du Toit G, Gomes ER, Kuyucu S, Romano A, Soyer O, Tsabouri S, Atanaskovic-Markovic M. Delayed hypersensitivity to antiepileptic drugs in children. Pediatr Allergy Immunol 2021; 32:425-436. [PMID: 33205474 DOI: 10.1111/pai.13409] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antiepileptic drugs (AEDs) are widely used for the treatment of epilepsy, but they can be associated with the development of mainly delayed/non-immediate hypersensitivity reactions (HRs). Although these reactions are usually cutaneous, self-limited, and spontaneously resolve within days after drug discontinuation, sometime HR reactions to AEDs can be severe and life-threatening. AIM This paper seeks to show examples on practical management of AED HRs in children starting from a review of what it is already known in literature. RESULTS Risk factors include age, history of previous AEDs reactions, viral infections, concomitant medications, and genetic factors. The diagnostic workup consists of in vivo (intradermal testing and patch testing) and in vitro tests [serological investigation to exclude the role of viral infection, lymphocyte transformation test (LTT), cytokine detection in ELISpot assays, and granulysin (Grl) in flow cytometry. Treatment is based on a prompt drug discontinuation and mainly on the use of glucocorticoids. CONCLUSION Dealing with AED HRs is challenging. The primary goal in the diagnosis and management of HRs to AEDs should be trying to accurately identify the causal trigger and simultaneously identify a safe and effective alternative anticonvulsant. There is therefore an ongoing need to improve our knowledge of HS reactions due to AED medications and in particular to improve our diagnostic capabilities.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatric Medicine, Meyer Children's Hospital, Florence, Italy
| | | | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| | - Pascal Demoly
- Département de Pneumologie et Addictologie, Centre Hospitalier Universitaire de Montpellier, Hôpital Arnaud de Villeneuve, univ Montpellier, Montpellier, France.,Institut Pierre-Louis D'épidémiologie et de Santé Publique, Équipe EPAR, Sorbonne Université, INSERM, Paris, France
| | - George Du Toit
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St Thomas', London, UK.,Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Eva R Gomes
- Allergy Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy.,Fondazione Mediterranea G.B. Morgagni, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Sophia Tsabouri
- Department of Paediatrics, Faculty of Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Wagle SR, Kovacevic B, Walker D, Ionescu CM, Shah U, Stojanovic G, Kojic S, Mooranian A, Al-Salami H. Alginate-based drug oral targeting using bio-micro/nano encapsulation technologies. Expert Opin Drug Deliv 2020; 17:1361-1376. [PMID: 32597249 DOI: 10.1080/17425247.2020.1789587] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Oral delivery is the most common administrated drug delivery path. However, oral administration of lipophilic drugs has some limitations: they have poor dose-response due to low and varied dissolution kinetics and oral bioavailability with sub-optimal dissolution within the aqueous gastrointestinal microenvironment. Therefore, there is a need for robust formulating methods that protect the drug until it reaches to its optimum absorption site, allowing its optimum pharmacological effects via increasing its intestinal permeation and bioavailability. AREA COVERED Herein, we provide insights on orally administered lipophilic drug delivery systems. The detailed description of the obstacles associated with the oral bioavailability of lipophilic drugs are also discussed. Following this, techniques to overcome these obstacles with much emphasis on optimal safety and efficacy are addressed. Newly designed ionic vibrational jet flow encapsulation technology has enormous growth in lipophilic drug delivery systems, which is discussed thereafter. EXPERT OPINION Researchers have shown interest in drug's encapsulation. A combination of drug-bile acid and microencapsulation methods can be one promising strategy to improve the oral delivery of lipophilic drugs. However, the most critical aspect of this approach is the selection of bile acids, polymer, and encapsulation technology.
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Affiliation(s)
- Susbin Raj Wagle
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University , Perth, Western Australia, Australia
| | - Bozica Kovacevic
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University , Perth, Western Australia, Australia
| | - Daniel Walker
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University , Perth, Western Australia, Australia
| | - Corina Mihaela Ionescu
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University , Perth, Western Australia, Australia
| | - Umar Shah
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University , Perth, Western Australia, Australia.,School of Molecular and Life Sciences, Faculty of Science and Engineering, Curtin University , Perth, WA, Australia
| | - Goran Stojanovic
- Faculty of Technical Sciences, University of Novi Sad , Novi Sad, Serbia
| | - Sanja Kojic
- Faculty of Technical Sciences, University of Novi Sad , Novi Sad, Serbia
| | - Armin Mooranian
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University , Perth, Western Australia, Australia
| | - Hani Al-Salami
- Biotechnology and Drug Development Research Laboratory, School of Pharmacy and Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University , Perth, Western Australia, Australia
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9
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Chávez-Castillo CE, Medellín-Garibay SE, Milán-Segovia RDC, Rodríguez-Leyva I, Romano-Moreno S. Dosing Recommendations Based on Population Pharmacokinetics of Lamotrigine in Mexican Adult Patients With Epilepsy. J Pharm Sci 2020; 109:2902-2908. [DOI: 10.1016/j.xphs.2020.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/29/2020] [Accepted: 05/29/2020] [Indexed: 11/16/2022]
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Vázquez M, Guevara N, Maldonado C, Guido PC, Schaiquevich P. Potential Pharmacokinetic Drug-Drug Interactions between Cannabinoids and Drugs Used for Chronic Pain. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3902740. [PMID: 32855964 PMCID: PMC7443220 DOI: 10.1155/2020/3902740] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/27/2020] [Accepted: 07/31/2020] [Indexed: 12/18/2022]
Abstract
Choosing an appropriate treatment for chronic pain remains problematic, and despite the available medication for its treatment, still, many patients complain about pain and appeal to the use of cannabis derivatives for pain control. However, few data have been provided to clinicians about the pharmacokinetic drug-drug interactions of cannabinoids with other concomitant administered medications. Therefore, the aim of this brief review is to assess the interactions between cannabinoids and pain medication through drug transporters (ATP-binding cassette superfamily members) and/or metabolizing enzymes (cytochromes P450 and glucuronyl transferases).
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Affiliation(s)
- Marta Vázquez
- Departamento de Ciencias Farmacéuticas, Facultad de Química, Universidad de la República, Montevideo, Uruguay
| | - Natalia Guevara
- Departamento de Ciencias Farmacéuticas, Facultad de Química, Universidad de la República, Montevideo, Uruguay
| | - Cecilia Maldonado
- Departamento de Ciencias Farmacéuticas, Facultad de Química, Universidad de la República, Montevideo, Uruguay
| | - Paulo Cáceres Guido
- Unidad de Farmacocinética Clínica, Farmacia, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Paula Schaiquevich
- Medicina de Precisión, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
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11
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Koristkova B, Grundmann M, Brozmanova H, Kacirova I. Lamotrigine drug interactions in combination therapy and the influence of therapeutic drug monitoring on clinical outcomes in paediatric patients. Basic Clin Pharmacol Toxicol 2019; 125:26-33. [DOI: 10.1111/bcpt.13203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/15/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Blanka Koristkova
- Department of Clinical Pharmacology, Faculty of Medicine; University of Ostrava; Ostrava Czech Republic
- Department of Clinical Pharmacology; Department of Laboratory Diagnostics; University Hospital Ostrava; Ostrava Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine; University of Ostrava; Ostrava Czech Republic
| | - Hana Brozmanova
- Department of Clinical Pharmacology, Faculty of Medicine; University of Ostrava; Ostrava Czech Republic
- Department of Clinical Pharmacology; Department of Laboratory Diagnostics; University Hospital Ostrava; Ostrava Czech Republic
| | - Ivana Kacirova
- Department of Clinical Pharmacology, Faculty of Medicine; University of Ostrava; Ostrava Czech Republic
- Department of Clinical Pharmacology; Department of Laboratory Diagnostics; University Hospital Ostrava; Ostrava Czech Republic
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12
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Han X, Huang J, Lv J, Ma L, Peng L, Wang J, Nie X, Xia L, Zan X. The influence of concomitant antiepileptic drugs on lamotrigine serum concentrations in Northwest Chinese Han population with epilepsy. PLoS One 2019; 14:e0210600. [PMID: 30645607 PMCID: PMC6333349 DOI: 10.1371/journal.pone.0210600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/28/2018] [Indexed: 11/26/2022] Open
Abstract
Objective The aims of this study were to identify the influencing factors such as gender, age, dose and combinations of other antiepileptic drugs (AEDs), especially in triple combinations on the pharmacokinetic of Lamotrigine (LTG) in epilepsy patients of Northwest Chinese Han population. Methods Data of the LTG concentration and clinical information were analyzed retrospectively from a therapeutic drug monitoring (TDM) database at the Clinical Pharmacy Laboratory of Xi’an Central Hospital between January 1, 2016 and January 1, 2018. The independent-sample t-test, one-way ANOVA analysis and Bonferroni and Tamhane T3 post-hoc test, the stepwise multivariate regression analysis were adopted by IBM SPSS, version 22.0. Results 226 serum samples met the inclusion criteria and were evaluated. The mean LTG serum concentration was 5.48±3.83 μg/mL. There were no gender differences (P = 0.64), and there were no significant effects by age on LTG serum concentration after age stratification (3–14 years old, 14-45 years old, 45–59 years old) (P = 0.05). Multiple regression analysis showed that the daily LTG dose and co-administration of other AEDs significantly affected LTG serum concentrations. Combination with enzyme-inducer AEDs, the mean steady-state LTG concentration could be decreased by 30.73% compared with LTG monotherapy. Among enzyme-inducer AEDs, particularly strong inducer Carbamazepine (CBZ) could decrease the mean LTG concentration by 53.65%, but weak inducer AEDs such as Oxcarbazepine (OXC) and Topiramate (TPM) had no effect, Valproic acid (VPA) could increase the mean LTG concentration by 93.95%, and the inducer only partially compensated for the inhibitory effect of VPA in triple combination. Conclusions There were no significant gender and age effects, but the LTG daily dose and co-administration of other AEDs significantly affected LTG serum concentration. Combination with enzyme-inducer AEDs, especially CBZ could significantly decrease LTG serum concentrations, VPA could significantly increase LTG serum concentrations, and the inducer only partially compensated for the inhibitory effect of VPA in triple combination. In the clinical setting, these findings can help to estimate LTG concentrations and adjust dosage and evaluate adverse drug reactions.
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Affiliation(s)
- Xiaonian Han
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
- * E-mail:
| | - Jing Huang
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
| | - Jianhua Lv
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
| | - Li Ma
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
| | - Lirong Peng
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
| | - Jinping Wang
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
| | - Xiaojing Nie
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
| | - Li Xia
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
| | - Xin Zan
- Department of Clinical Pharmacy, Xi’an Central Hospital, Xi’an, China
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A Physiologically Based Pharmacokinetic Model for Optimally Profiling Lamotrigine Disposition and Drug–Drug Interactions. Eur J Drug Metab Pharmacokinet 2018; 44:389-408. [DOI: 10.1007/s13318-018-0532-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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14
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Lamotrigine-Valproic Acid Interaction Leading to Stevens-Johnson Syndrome. Case Rep Med 2018; 2018:5371854. [PMID: 30228819 PMCID: PMC6136509 DOI: 10.1155/2018/5371854] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/05/2018] [Indexed: 11/17/2022] Open
Abstract
Lamotrigine (LTG) is currently indicated as adjunctive therapy for focal and generalized tonic-clonic seizures and for treatment of bipolar disorder and neuropathic pain. A common concern with LTG in children is the frequency of appearance of skin rash. The intensity of this adverse effect can vary from transient mild rash to Stevens–Johnson syndrome (SJS), which can be fatal mainly when LTG is coadministered with valproic acid (VPA). Hereby, we present the case of an 8-year-old boy who suffered from SJS and other complications two weeks after LTG was added to his VPA treatment in order to control his seizures. VPA is known to decrease LTG clearance via reduced glucuronidation. In this case, the minor elimination pathway of LTG would play a more important role, and the formation of an arene oxide metabolite would be enhanced. As this reactive metabolite is detoxified mainly by enzymatic reactions, involving microsomal epoxide hydrolase and/or GSH-S-transferases and these enzymes are polymorphically expressed in humans, arene oxide toxicity is increased when epoxide hydrolase or GSH-S-transferases is either defective or inhibited or a depletion of intracellular glutathione levels is taking place. VPA can cause inhibition of epoxide hydrolase enzymes and/or depletion of glutathione levels leading to adverse cutaneous reactions.
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Baldoni AO, Freitas-Lima P, Alexandre V, Ferreira FIDS, Martinez EZ, Queiroz RHC, Sakamoto AC, Pereira LRL. Influence of the clinical profile of patients with refractory epilepsy on lamotrigine plasma concentration. BRAZ J PHARM SCI 2018. [DOI: 10.1590/s2175-97902018000200246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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16
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Leary E, Sheth RD, Gidal BE. Time course of reversal of valproate-mediated inhibition of lamotrigine. Seizure 2018; 57:76-79. [PMID: 29574285 DOI: 10.1016/j.seizure.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/02/2018] [Accepted: 03/04/2018] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Conversion to lamotrigine (LTG) monotherapy from sodium valproate (VPA) is complicated by the robust pharmacokinetic interaction between the two AEDs. This study examined changes in LTG serum concentrations immediately following VPA discontinuation. METHODS Ten healthy female and male adult subjects were initiated on LTG (Lamictal) 10 mg orally every morning for 30 days and VPA (Depakote ER) 500 mg orally every morning for 14 days. Morning trough (pre-dose) venous blood samples were obtained for determination of LTG and VPA concentrations on study days 14, 15, 16, 18, 20, 22, 24, 26, 28, and 30. Following the collection of the blood sample on day 15, VPA was discontinued. RESULTS Despite stable LTG dosage serum concentrations on study day 20, 22, 24, 26, and 28, all were significantly lower compared to baseline (p < 0.05). CONCLUSIONS These observations demonstrate that the pharmacokinetic interaction between LTG and VPA is reversible, and that de-inhibition appears to follow a predictable time course. Complete offset, or reversal of this interaction takes place 10-14 days after VPA discontinuation. Our data also confirms the observation that LTG oral clearance may be inhibited by very low concentrations of VPA. These data support the conversion algorithm suggested by the manufacturer, and provide guidance to the clinician. These data provide clinically useful information in developing a dosing algorithm for converting patients to LTG monotherapy.
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Affiliation(s)
- Emili Leary
- Dept. of Pharmacy, Marshfield Clinic, Marshfield, WI, United States
| | - Raj D Sheth
- Nemours Children's Health Systems-Jacksonville & Department of Neurology, Mayo Clinic - College of Medicine, 807 Children's Way, Jacksonville, FL, 32207, United States
| | - Barry E Gidal
- University of Wisconsin - Madison, School of Pharmacy and Department of Neurology, 777 Highland Ave, Madison, WI, 53705, United States.
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17
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Lamotrigine Drug Interactions in Combination Therapy and the Influence of Therapeutic Drug Monitoring on Clinical Outcomes of Adult Patients. Ther Drug Monit 2017; 39:543-549. [DOI: 10.1097/ftd.0000000000000433] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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18
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Acute Respiratory Distress Syndrome and Lamotrigine: A Case Report. PSYCHOSOMATICS 2017; 58:313-316. [PMID: 28222856 DOI: 10.1016/j.psym.2016.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 12/14/2016] [Accepted: 12/14/2016] [Indexed: 11/23/2022]
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19
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Determination of Magnesium Valproate and Its Process Related Impurities by Ultraperformance Liquid Chromatography. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2014; 2014:412704. [PMID: 27355082 PMCID: PMC4897345 DOI: 10.1155/2014/412704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 04/27/2014] [Accepted: 04/28/2014] [Indexed: 11/17/2022]
Abstract
A selective ultraperformance liquid chromatographic (UPLC) method for the determination of magnesium valproate and its process related impurities has been developed. The method includes reversed-phase Acquity BEH C18 column with 100 mm × 2.1 mm i.d. and 1.7 µ particle size. The mobile phase consists of acetonitrile and 5 mM ammonium dihydrogen orthophosphate with pH = 3.0 at 45 : 55 isocratic elution. The flow rate was set at 0.3 mL/min and UV detection was performed at 215 nm. A system suitability test (SST) was developed to govern the quality of the separation. The developed method has been validated further with respect to linearity, accuracy, precision, selectivity, LOD, LOQ, and robustness. Different batches of samples were examined using this method; the method proved to be successful when applied to analyze a marketed magnesium valproate formulation.
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Influence of the UGT2B7 -161C>T polymorphism on the population pharmacokinetics of lamotrigine in Thai patients. Eur J Clin Pharmacol 2012; 69:1285-91. [PMID: 23263737 DOI: 10.1007/s00228-012-1449-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 10/31/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVES A high inter-individual variability in the pharmacokinetics of lamotrigine has been observed. Lamotrigine is primarily metabolized by UGT1A4 and UGT2B7, both of which show genetic polymorphisms. Both genetic and non-genetic factors may influence the pharmacokinetics of lamotrigine. The aim of this study was to determine the pharmacokinetic parameters of lamotrigine and to investigate the effect of genetic variants of UGT1A4 and UGT2B7 and various non-genetic factors on its pharmacokinetics. METHODS Four single nucleotide polymorphisms (SNPs; UGT1A4 142 T>G, UGT1A4 70C>T, UGT2B7 372A>G, UGT2B7 -161C>T) were identified using the TaqMan Allelic Discrimination Assay. Data were analyzed using NONMEM. Model evaluation was performed using the bootstrap approach and predictive check. RESULTS A total of 116 samples were obtained from 75 patients and included in the population analysis. The use of enzyme inducers, valproic acid, and the UGT2B7-161 C>T SNP were found to significantly influence lamotrigine apparent clearance (CL/F). Lamotrigine CL/F in patients carrying the UGT2B7 -161 CT or TT SNP was 18% lower than that in patients carrying the UGT2B7 -161 CC SNP. CONCLUSION Both genetic and non-genetic factors were found to influence lamotrigine pharmacokinetics. These factors should be considered when determining lamotrigine dosing. The model presented here could be useful for lamotrigine dose adjustment in clinical practice.
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Yamamoto Y, Inoue Y, Matsuda K, Takahashi Y, Kagawa Y. Influence of concomitant antiepileptic drugs on plasma lamotrigine concentration in adult Japanese epilepsy patients. Biol Pharm Bull 2012; 35:487-93. [PMID: 22466551 DOI: 10.1248/bpb.35.487] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Lamotrigine (LTG) is an antiepileptic drug (AED) that was approved in Japan in 2008. We evaluated the influence of AEDs that induce hepatic enzymes (including phenytoin (PHT), phenobarbital (PB), carbamazepine (CBZ)), valproic acid (VPA), and various combinations of these drugs, on plasma LTG concentration in adult Japanese epilepsy patients. A total of 621 patients (mean age 34.4±11.8 years) were evaluated retrospectively. We calculated the concentration to dose ratio (CD ratio) for LTG with different AED regimens, and employed multiple regression analysis to determine factors influencing the LTG concentration. There was a linear correlation between the dose and concentration of LTG in patients treated with LTG (group I), LTG+VPA (group II), LTG+inducers (group III), or LTG+VPA+inducers (group IV). The mean CD ratio of patients on LTG monotherapy was 1.43±0.4 (μg/mL)/(mg/kg). When LTG was combined with VPA, the CD ratio increased about 2.2-fold, but there was no significant correlation between the CD ratio and VPA concentration. The mean CD ratios calculated in patients receiving LTG+PHT, LTG+PB, and LTG+CBZ were 0.56, 0.84, and 0.91, respectively. Addition of PHT significantly reduced the CD ratio in a concentration-dependent manner, in comparison with PB and CBZ (p<0.005 and p<0.001, respectively). Stepwise multiple regression analysis showed that the coefficient of determination of groups I, II, III, and IV were 0.94, 0.94, 0.90, and 0.91, respectively. In the clinical setting, these findings can help to estimate LTG concentrations and predict the inducing or inhibiting effects of concomitant AEDs.
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Affiliation(s)
- Yoshiaki Yamamoto
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Japan.
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Knowles SR, Dewhurst N, Shear NH. Anticonvulsant hypersensitivity syndrome: an update. Expert Opin Drug Saf 2012; 11:767-78. [DOI: 10.1517/14740338.2012.705828] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Andersson ML, Björkhem-Bergman L, Lindh JD. Possible drug-drug interaction between quetiapine and lamotrigine--evidence from a Swedish TDM database. Br J Clin Pharmacol 2011; 72:153-6. [PMID: 21651616 DOI: 10.1111/j.1365-2125.2011.03941.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIM The aim of the present study was to investigate a previously proposed interaction between quetiapine and lamotrigine resulting in reduced serum quetiapine concentrations. METHODS Data on 402 patients subjected to analysis of quetiapine concentration in serum were extracted from a routine therapeutic drug monitoring database. Among these patients, those concomitantly treated with lamotrigine (n= 22) were identified and matched with 22 controls receiving quetiapine while unexposed to lamotrigine. The dose-corrected quetiapine concentrations (C : D ratios) in the two groups were compared in both paired and unpaired analyses. RESULTS Patients co-treated with lamotrigine had a lower mean C : D ratio (0.71, 95% CI 0.46, 0.97) compared with controls (1.64, 95% CI 1.00, 2.28). Dose-corrected quetiapine concentrations were 58% lower in patients co-medicated with lamotrigine. CONCLUSIONS This study indicates that lamotrigine exposure is associated with substantially reduced serum concentrations of quetiapine, possibly due to induced glucuronidation. These findings need to be confirmed in experimental studies.
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Affiliation(s)
- Marine L Andersson
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital, Huddinge, Karolinska Institutet, 141 86 Stockholm, Sweden.
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Lalic M, Pilipovic A, Golocorbin-Kon S, Gebauer-Bukurov K, Bozic K, Mikov M, Cvejic J. Comparison of dissolution profiles and serum concentrations of two lamotrigine tablet formulations. Drugs R D 2011; 11:53-60. [PMID: 21410295 PMCID: PMC3585764 DOI: 10.2165/11588260-000000000-00000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: The aim of this study was to investigate the extent of variations in lamotrigine serum concentrations between two immediate-release tablet formulations. Data were compared with in vitro difference and similarity tests on dissolution profiles of the two formulations. Methods: Dissolution characteristics of formulations A (reference) and B (test) were evaluated at three points spanning the physiologic pH range (pH 1.2, pH 4.5, pH 6.8). A model-independent approach of difference (f1) and similarity (f2) tests were applied to dissolution data. A clinical study was performed with 16 patients who were divided into two groups — one group received formulation A (n=9) and the other received formulation B (n=7). Lamotrigine steady-state concentrations were determined by high-performance liquid chromatography on a reverse-phase column. Results: There were no statistically significant differences in lamotrigine serum concentrations between the two groups, although formulation B had slightly higher mean concentration values (formulation A: 3.97±4.1 μg/mL; formulation B: 5.78±2.7 μg/mL). Dissolution profiles of the two formulations were similar in the pH 1.2 dissolution medium; however, the dissolution profiles of formulation B were outside the dissolution limit (≥85% at 15 minutes) in the pH 4.5 and 6.8 dissolution media. Conclusions: No significant changes in the serum concentrations of lamotrigine were seen between the two investigated formulations. There is no evidence to suggest that the differences in dissolution profiles at pH 4.5 and pH 6.8 affect the therapeutic efficacy of the formulations. It is evident that the doses of test formulation given to the patients were higher as a consequence of common assumption that generic products have a lower absorption rate, which is proven unnecessary in this study. This investigation was a pilot study and thus further investigations with a larger sample size are necessary to determine if there is a connection between dissolution profiles and the therapeutic effect of investigated formulations.
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Affiliation(s)
- Mladena Lalic
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Novi Sad, Republic of Serbia
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Błaszczyk B, Czuczwar SJ. Efficacy, safety, and potential of extended-release lamotrigine in the treatment of epileptic patients. Neuropsychiatr Dis Treat 2010; 6:145-50. [PMID: 20505846 PMCID: PMC2874338 DOI: 10.2147/ndt.s6515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Epilepsy is a frequent, chronic disease demanding long-term medication with antiepileptic drugs (AEDs). When slow release formulations of AEDs are used the chance of compliance and control of seizures is increased. Lamotrigine (LTG) is a broad spectrum antiepileptic drug (AED), effective against both generalized and partial seizures. Its immediate-release formulation (LTG-IR) requires twice-daily dosing. In contrast, an extended-release formulation (LTG-XR) may be given once daily, providing a flatter dose-concentration curve with apparently lower maximum serum levels. Simplified dosing positively affects compliance and LTG-XR has a similar profile of efficacy and tolerability to LTG-IR. Rashes, including Stevens-Johnson syndrome, are the most serious adverse effect impacting 0.8% of pediatric patients. Thus, LTG-XR should be discontinued upon the appearance of rash.
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