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Winter Y, Abou Dargham R, Patiño Tobón S, Groppa S, Fuest S. Cenobamate as an Early Adjunctive Treatment in Drug-Resistant Focal-Onset Seizures: An Observational Cohort Study. CNS Drugs 2024; 38:733-742. [PMID: 39096467 PMCID: PMC11316687 DOI: 10.1007/s40263-024-01109-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Cenobamate (CNB) is a new antiseizure medication (ASM) to treat drug-resistant, focal-onset seizures. Data on its use in early therapy lines are not yet available, and clinicians frequently consider CNB to be a later ASM drug choice. We investigated the efficacy and safety of CNB as an early adjunctive treatment in drug-resistant, focal-onset seizures. METHODS The study population were patients with drug-resistant, focal-onset seizures who were initiated with CNB after they did not respond to two or three lifetime ASMs, including all prior and concomitant ASMs. These patients were matched (1:2) by sex, age, and seizure frequency to controls who were initiated with any ASM other than CNB. All participants participated in the Mainz Epilepsy Registry. We evaluated the retention rate after 12 months of CNB and after each new adjunctive ASM in the control group. In addition, seizure freedom and the response rate (reduction of seizure frequency by ≥ 50% from baseline) after 12 months were estimated. RESULTS We included 231 patients aged 44.4 ± 15.8 years. Of these, 33.3% (n = 77) were on CNB, 19.0% (n = 44) on valproate (VPA), 17.3% (n = 40) on lacosamide (LCS), 16.4% (n = 38) on levetiracetam (LEV), and 13.9% (n = 32) on topiramate (TPM). The highest retention rate after 12 months since the beginning of the early adjunctive therapy was observed on CNB (92.0%), compared with LCS (80.0%), LEV (73.3%), VPA (68.2%), or TPM (62.5%) (p < 0.05). Seizure freedom and response rate were also the best on CNB (19.5% and 71.4%, respectively) compared with other ASMs (8.3% and 52.5%, respectively; p < 0.05). No significant differences in adverse events between CNB and other ASMs were observed. CONCLUSIONS Our study provides evidence that CNB is an effective ASM with a good safety profile in the early therapy lines of drug-resistant, focal-onset seizures. This data should support medical decision making in the management of patients with refractory epilepsy. CLINICAL TRIAL ID NCT05267405.
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Affiliation(s)
- Yaroslav Winter
- Mainz Comprehensive Epilepsy and Sleep Medicine Center, Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
- Department of Neurology, Philipps-University Marburg, Marburg, Germany.
| | - Raya Abou Dargham
- Mainz Comprehensive Epilepsy and Sleep Medicine Center, Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Susana Patiño Tobón
- Mainz Comprehensive Epilepsy and Sleep Medicine Center, Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sven Fuest
- Department of Neurology, Hephata Klinik, Schwalmstadt, Germany
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Lu Y, Lin M, Ou S, Sun L, Qian K, Kuang H, Wu Y. Astragalus polysaccharides ameliorate epileptogenesis, cognitive impairment, and neuroinflammation in a pentylenetetrazole-induced kindling mouse model. Front Pharmacol 2024; 15:1336122. [PMID: 38405667 PMCID: PMC10884767 DOI: 10.3389/fphar.2024.1336122] [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] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 02/27/2024] Open
Abstract
Background: Epilepsy is a prevalent neurological disease where neuroinflammation plays a significant role in epileptogenesis. Recent studies have suggested that Astragalus polysaccharides (APS) have anti-inflammatory properties, which make them a potential candidate for neuroprotection against central nervous system disease. Nevertheless, the extent of their effectiveness in treating epilepsy remains enigmatic. Therefore, our study aims to investigate the potential of APS to mitigate epileptogenesis and its comorbidities by exploring its underlying mechanism. Methods: Initially, we employed pentylenetetrazol-induced seizure mice to validate APS' effectiveness. Subsequently, we employed network pharmacology analysis to probe the possible targets and signaling pathways of APS in treating epilepsy. Ultimately, we verified the key targets and signaling pathways experimentally, predicting their mechanisms of action. Results: APS have been observed to disturb the acquisition process of kindling, leading to reduced seizure scores and a lower incidence of complete kindling. Moreover, APS has been found to improve cognitive impairments and prevent hippocampal neuronal damage during the pentylenetetrazole (PTZ)-kindling process. Subsequent network pharmacology analysis revealed that APS potentially exerted their anti-epileptic effects by targeting cytokine and toll-like receptor 4/nuclear factor kappa B (TLR4/NF-κB) signaling pathways. Finally, experimental findings showed that APS efficiently inhibited the activation of astrocytes and reduced the release of pro-inflammatory mediators, such as interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α). In addition, APS impeded the activation of the TLR4/NF-κB signaling cascade in a PTZ-induced kindling mouse model. Conclusion: The outcomes of our study suggest that APS exerts an impact on epileptogenesis and mitigates cognitive impairment by impeding neuroinflammatory processes. The mechanism underlying these observations may be attributed to the modulation of the TLR4/NF-κB signaling pathway, resulting in a reduction of the release of inflammatory mediators. These findings partially agree with the predictions derived from network pharmacology analyses. As such, APS represents a potentially innovative and encouraging adjunct therapeutic option for epileptogenesis and cognitive deficit.
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Affiliation(s)
- Yuling Lu
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Minglin Lin
- Department of Colorectal and Anal Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Sijie Ou
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Lanfeng Sun
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Kai Qian
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Huimin Kuang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Yuan Wu
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
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Matias M, Santos AO, Silvestre S, Alves G. Fighting Epilepsy with Nanomedicines-Is This the Right Weapon? Pharmaceutics 2023; 15:pharmaceutics15020306. [PMID: 36839629 PMCID: PMC9959131 DOI: 10.3390/pharmaceutics15020306] [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] [Received: 12/08/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Epilepsy is a chronic and complex condition and is one of the most common neurological diseases, affecting about 50 million people worldwide. Pharmacological therapy has been, and is likely to remain, the main treatment approach for this disease. Although a large number of new antiseizure drugs (ASDs) has been introduced into the market in the last few years, many patients suffer from uncontrolled seizures, demanding the development of more effective therapies. Nanomedicines have emerged as a promising approach to deliver drugs to the brain, potentiating their therapeutic index. Moreover, nanomedicine has applied the knowledge of nanoscience, not only in disease treatment but also in prevention and diagnosis. In the current review, the general features and therapeutic management of epilepsy will be addressed, as well as the main barriers to overcome to obtain better antiseizure therapies. Furthermore, the role of nanomedicines as a valuable tool to selectively deliver drugs will be discussed, considering the ability of nanocarriers to deal with the less favourable physical-chemical properties of some ASDs, enhance their brain penetration, reduce the adverse effects, and circumvent the concerning drug resistance.
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Affiliation(s)
- Mariana Matias
- CICS-UBI—Health Sciences Research Centre, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
- Correspondence: (M.M.); (A.O.S.); Tel.: +351-275-329-002 (M.M.); +351-275-329-079 (A.O.S.)
| | - Adriana O. Santos
- CICS-UBI—Health Sciences Research Centre, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
- Correspondence: (M.M.); (A.O.S.); Tel.: +351-275-329-002 (M.M.); +351-275-329-079 (A.O.S.)
| | - Samuel Silvestre
- CICS-UBI—Health Sciences Research Centre, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
- CNC—Centre for Neuroscience and Cell Biology, University of Coimbra, 3004-517 Coimbra, Portugal
| | - Gilberto Alves
- CICS-UBI—Health Sciences Research Centre, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
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Ilan Y. Next-Generation Personalized Medicine: Implementation of Variability Patterns for Overcoming Drug Resistance in Chronic Diseases. J Pers Med 2022; 12:jpm12081303. [PMID: 36013252 PMCID: PMC9410281 DOI: 10.3390/jpm12081303] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 12/14/2022] Open
Abstract
Chronic diseases are a significant healthcare problem. Partial or complete non-responsiveness to chronic therapies is a significant obstacle to maintaining the long-term effect of drugs in these patients. A high degree of intra- and inter-patient variability defines pharmacodynamics, drug metabolism, and medication response. This variability is associated with partial or complete loss of drug effectiveness. Regular drug dosing schedules do not comply with physiological variability and contribute to resistance to chronic therapies. In this review, we describe a three-phase platform for overcoming drug resistance: introducing irregularity for improving drug response; establishing a deep learning, closed-loop algorithm for generating a personalized pattern of irregularity for overcoming drug resistance; and upscaling the algorithm by implementing quantified personal variability patterns along with other individualized genetic and proteomic-based ways. The closed-loop, dynamic, subject-tailored variability-based machinery can improve the efficacy of existing therapies in patients with chronic diseases.
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Affiliation(s)
- Yaron Ilan
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem POB12000, Israel
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Suwanpakdee P, Saksritavee B, Likasitthananon N, Simasathien T, Deesudchit T, Khongkhatithum C, Viravan S, Nabangchang C. Perampanel as adjunctive therapy in drug resistant epilepsy in adolescents and children waiting for epilepsy surgery: A multicenter observational study in Thailand. Seizure 2022; 100:103-108. [PMID: 35820301 DOI: 10.1016/j.seizure.2022.06.015] [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: 03/14/2022] [Revised: 06/10/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022] Open
Abstract
PURPOSE To evaluate the effectiveness and tolerability of perampanel (PER) in real-world settings in patients between 1 month and 18 years of age with drug resistant epilepsy (DRE) waiting for epilepsy surgery. METHODS In this multicenter study, patients between 1 month and 18 years of age with DRE treated with PER between January 2020 and June 2021 were selected. The study outcome was effectiveness of PER treatment reported as reduction in seizure frequency and seizure freedom rate. Effectiveness was assessed at 30, 60, 90, 120, 150 and 180 days after initiation of PER. Tolerability profiles were reported as adverse events according to the observations of the patients' family members and physician. RESULTS Eighty-five patients treated with PER were included in the study. The mean initial dose and mean maximum dose of adjunctive PER was 2 mg/day and 5.8 mg/day, respectively. The mean seizure frequency (rate/week) was 41.3, 25.4, 18.9, 14.3, 11.2, 11.1 and 8.9 seizures at baseline, 30, 60, 90, 120, 150 and 180 days, respectively; the reduction in the mean seizure frequency at all timepoints was significant compared at the baseline (p<0.001). At 180 days, ≥75% seizure reduction was seen in 64.9% (37/57) of the patients and seizure freedom was achieved in 36.8% (21/57). Drowsiness, ataxia, and behavioral changes were the common adverse events observed, and these improved after the dose of PER was reduced. No discontinuation of PER was required due to side effects or intolerance. CONCLUSION In real-world settings, PER is well tolerated and effective in seizure control in pediatric and adolescent patients with DRE.
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Affiliation(s)
- Piradee Suwanpakdee
- Division of Pediatric Neurology, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - Burachat Saksritavee
- Division of Pediatric Neurology, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - Napakjira Likasitthananon
- Division of Pediatric Neurology, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - Thitiwan Simasathien
- Division of Pediatric Neurology, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - Tayard Deesudchit
- Division of Pediatric Neurology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chaiyos Khongkhatithum
- Division of Pediatric Neurology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sorawit Viravan
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Charcrin Nabangchang
- Division of Pediatric Neurology, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand.
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Kang KW, Lee H, Shin JY, Moon HJ, Lee SY. Trends in Prescribing of Antiseizure Medications in South Korea: Real-World Evidence for Treated Patients With Epilepsy. J Clin Neurol 2022; 18:179-193. [PMID: 35274836 PMCID: PMC8926764 DOI: 10.3988/jcn.2022.18.2.179] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/21/2022] Open
Abstract
Background and Purpose We investigated the trends in the prescribing of antiseizure medication (ASM) over a 9-year period, and provide real-world data regarding ASM prescriptions of patients with epilepsy in South Korea. Methods This study used data in the Korean National Health Information Database for the period from 2009 to 2017. We included 18 oral ASMs, which were classified into older and newer ASMs based on them first becoming available on the market before or after 1991, respectively. The annual trends in ASM prescriptions were plotted over the 9-year study period, and changes in these trends were evaluated as average annual percentage changes (AAPCs) using Poisson regression. Age- and sex-stratified analyses were also conducted. Results Overall, the proportion of prescriptions involving polytherapy with three or more ASMs increased from 10.08% in 2009 to 10.99% in 2017 (AAPC=0.9%, p<0.001) over the 9-year study period. Among monotherapies, although valproate (VPA) was the most frequently prescribed ASM, the prescription rate of levetiracetam (LEV) steadily increased regardless of age and sex over the study period. The monotherapy prescription trends differed depending on age and sex. In the five most frequently used ASM combination regimens, the prescription rates of VPA/LEV, LEV/oxcarbazepine, and LEV/lamotrigine regimens showed increasing tendencies. In contrast, prescription rates for all combined regimens of older ASMs declined over time in all age groups. Conclusions This is the first epidemiological study of the changes in prescription trends for ASM in South Korea based on nationwide data from 2009 to 2017. We found progressive increases in the use of newer ASMs for both monotherapy and duotherapy, and for polytherapy with three or more ASMs over the 9-year study period.
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Affiliation(s)
- Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Hyesung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, Korea
- Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Hye-Jin Moon
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Seo-Young Lee
- Department of Neurology, Kangwon National University School of Medicine, Chuncheon, Korea
- Medical Bigdata Convergence, Kangwon National University, Chuncheon, Korea
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Vyas P, Tulsawani R, Vohora D. Dual Targeting by Inhibition of Phosphoinositide-3-Kinase and Mammalian Target of Rapamycin Attenuates the Neuroinflammatory Responses in Murine Hippocampal Cells and Seizures in C57BL/6 Mice. Front Immunol 2021; 12:739452. [PMID: 34887852 PMCID: PMC8650161 DOI: 10.3389/fimmu.2021.739452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022] Open
Abstract
Emerging evidence suggests the association of seizures and inflammation; however, underlying cell signaling mechanisms are still not fully understood. Overactivation of phosphoinositide-3-kinases is associated with both neuroinflammation and seizures. Herein, we speculate the PI3K/Akt/mTOR pathway as a promising therapeutic target for neuroinflammation-mediated seizures and associated neurodegeneration. Firstly, we cultured HT22 cells for detection of the downstream cell signaling events activated in a lipopolysaccharide (LPS)-primed pilocarpine (PILO) model. We then evaluated the effects of 7-day treatment of buparlisib (PI3K inhibitor, 25 mg/kg p.o.), dactolisib (PI3K/mTOR inhibitor, 25 mg/kg p.o.), and rapamycin (mTORC1 inhibitor, 10 mg/kg p.o.) in an LPS-primed PILO model of seizures in C57BL/6 mice. LPS priming resulted in enhanced seizure severity and reduced latency. Buparlisib and dactolisib, but not rapamycin, prolonged latency to seizures and reduced neuronal loss, while all drugs attenuated seizure severity. Buparlisib and dactolisib further reduced cellular redox, mitochondrial membrane potential, cleaved caspase-3 and p53, nuclear integrity, and attenuated NF-κB, IL-1β, IL-6, TNF-α, and TGF-β1 and TGF-β2 signaling both in vitro and in vivo post-PILO and LPS+PILO inductions; however, rapamycin mitigated the same only in the PILO model. Both drugs protected against neuronal cell death demonstrating the contribution of this pathway in the seizure-induced neuronal pyknosis; however, rapamycin showed resistance in a combination model. Furthermore, LPS and PILO exposure enhanced pAkt/Akt and phospho-p70S6/total-p70S6 kinase activity, while buparlisib and dactolisib, but not rapamycin, could reduce it in a combination model. Partial rapamycin resistance was observed possibly due to the reactivation of the pathway by a functionally different complex of mTOR, i.e., mTORC2. Our study substantiated the plausible involvement of PI3K-mediated apoptotic and inflammatory pathways in LPS-primed PILO-induced seizures and provides evidence that its modulation constitutes an anti-inflammatory mechanism by which seizure inhibitory effects are observed. We showed dual inhibition by dactolisib as a promising approach. Targeting this pathway at two nodes at a time may provide new avenues for antiseizure therapies.
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Affiliation(s)
- Preeti Vyas
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Rajkumar Tulsawani
- Defense Institute of Physiology & Allied Science, Defense Research and Development Organization, New Delhi, India
| | - Divya Vohora
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
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Maadarani O, Bitar Z, Ashkanani A, Elzoueiry M, Elhabibi M, Gohar M, Almuwaizri M, Shoeb S, Alsaddah J. Cardiac Sodium Channel Blockade Due to Antiepileptic Drug Combination. Eur J Case Rep Intern Med 2021; 8:002839. [PMID: 34790627 DOI: 10.12890/2021_002839] [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: 08/20/2021] [Accepted: 08/26/2021] [Indexed: 11/05/2022] Open
Abstract
Drugs that inhibit voltage-dependent sodium channels are commonly used to treat epilepsy. Old and novel antiepileptic drugs are used either as monotherapy or in combination to control epilepsy. For a long time, carbamazepine has been used as the first choice for the treatment of simple and complex partial seizures. In the USA, lacosamide was approved in October 2008 as an adjunctive treatment for partial-onset seizures. We describe the effect of two sodium channel blockers on the heart of a patient with epilepsy. LEARNING POINTS Approximately 30% of patients with epilepsy require combination therapy with antiepileptic drugs for seizure reduction.Lacosamide and carbamazepine are both sodium channel blockers but exert their effects through different mechanisms.Electrocardiogram monitoring is necessary when lacosamide and carbamazepine are used together as this combination may predispose to seizures, conduction abnormalities and dysrhythmia.
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Affiliation(s)
- Ossama Maadarani
- Internal Medicine Department, Ahmadi Hospital, Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Zouheir Bitar
- Internal Medicine Department, Ahmadi Hospital, Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Abdelaziz Ashkanani
- Internal Medicine Department, Ahmadi Hospital, Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Mahmoud Elzoueiry
- Internal Medicine Department, Ahmadi Hospital, Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Mohamad Elhabibi
- Internal Medicine Department, Ahmadi Hospital, Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Mohamad Gohar
- Internal Medicine Department, Ahmadi Hospital, Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Mohamad Almuwaizri
- Nursing Department, Ahmadi Hospital, Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Sania Shoeb
- Internal Medicine Department, Al Salam Hospital, Kuwait
| | - Jadan Alsaddah
- Department of Cardiology, Chest Diseases Hospital, Kuwait
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Löscher W. Single-Target Versus Multi-Target Drugs Versus Combinations of Drugs With Multiple Targets: Preclinical and Clinical Evidence for the Treatment or Prevention of Epilepsy. Front Pharmacol 2021; 12:730257. [PMID: 34776956 PMCID: PMC8580162 DOI: 10.3389/fphar.2021.730257] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/04/2021] [Indexed: 01/09/2023] Open
Abstract
Rationally designed multi-target drugs (also termed multimodal drugs, network therapeutics, or designed multiple ligands) have emerged as an attractive drug discovery paradigm in the last 10-20 years, as potential therapeutic solutions for diseases of complex etiology and diseases with significant drug-resistance problems. Such agents that modulate multiple targets simultaneously are developed with the aim of enhancing efficacy or improving safety relative to drugs that address only a single target or to combinations of single-target drugs. Although this strategy has been proposed for epilepsy therapy >25 years ago, to my knowledge, only one antiseizure medication (ASM), padsevonil, has been intentionally developed as a single molecular entity that could target two different mechanisms. This novel drug exhibited promising effects in numerous preclinical models of difficult-to-treat seizures. However, in a recent randomized placebo-controlled phase IIb add-on trial in treatment-resistant focal epilepsy patients, padsevonil did not separate from placebo in its primary endpoints. At about the same time, a novel ASM, cenobamate, exhibited efficacy in several randomized controlled trials in such patients that far surpassed the efficacy of any other of the newer ASMs. Yet, cenobamate was discovered purely by phenotype-based screening and its presumed dual mechanism of action was only described recently. In this review, I will survey the efficacy of single-target vs. multi-target drugs vs. combinations of drugs with multiple targets in the treatment and prevention of epilepsy. Most clinically approved ASMs already act at multiple targets, but it will be important to identify and validate new target combinations that are more effective in drug-resistant epilepsy and eventually may prevent the development or progression of epilepsy.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany, and Center for Systems Neuroscience Hannover, Hannover, Germany
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Zaccara G, Lattanzi S, Brigo F. Which treatment strategy in patients with epilepsy with focal seizures uncontrolled by the first anti-seizure medication? Epilepsy Behav 2021; 121:108031. [PMID: 33992932 DOI: 10.1016/j.yebeh.2021.108031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
There is no definite proven or accepted strategy in the management of patients with focal epilepsy uncontrolled by the first anti-seizure medication (ASM). Clinical studies failed to find a significant difference in efficacy or tolerability between alternative monotherapy and/or adjunctive therapy in these patients. A second ASM is often added, the efficacy of the combination is assessed, and the dose of the first drug can be gradually reduced and withdrawn. If seizures recur, the effective combination therapy can be reinstated. In this review, we discussed experimental and clinical data about the efficacy and tolerability of the most frequently used combinations of ASMs. Animal studies suggested that the most favorable combinations are those between ASMs with different or multiple mechanisms of action, whereas combining drugs with similar pharmacodynamic properties is often associated with additive or infra-additive efficacy and additive or synergistic toxicity. Clinical studies have shown that levetiracetam (LEV) can be favorably combined with the sodium channel blockers (SCBs) lacosamide (LCM) and lamotrigine (LTG). Lamotrigine is particularly effective when associated with valproate (VPA) and possibly with LEV and topiramate (TPM). Carbamazepine (CBZ) has negative pharmacokinetic interactions with several ASMs and should not be combined with other SCBs; it could be effectively and safely combined with gabapentin (GBP) and LEV. Valproic acid has enzyme inhibiting properties and can be cautiously used with SCBs; its combination with TPM or zonisamide (ZNS) may be associated with higher toxicity.
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Affiliation(s)
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
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Fattorusso A, Matricardi S, Mencaroni E, Dell'Isola GB, Di Cara G, Striano P, Verrotti A. The Pharmacoresistant Epilepsy: An Overview on Existent and New Emerging Therapies. Front Neurol 2021; 12:674483. [PMID: 34239494 PMCID: PMC8258148 DOI: 10.3389/fneur.2021.674483] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/27/2021] [Indexed: 12/21/2022] Open
Abstract
Epilepsy is one of the most common neurological chronic disorders, with an estimated prevalence of 0. 5 - 1%. Currently, treatment options for epilepsy are predominantly based on the administration of symptomatic therapy. Most patients are able to achieve seizure freedom by the first two appropriate drug trials. Thus, patients who cannot reach a satisfactory response after that are defined as pharmacoresistant. However, despite the availability of more than 20 antiseizure medications (ASMs), about one-third of epilepsies remain drug-resistant. The heterogeneity of seizures and epilepsies, the coexistence of comorbidities, and the broad spectrum of efficacy, safety, and tolerability related to the ASMs, make the management of these patients actually challenging. In this review, we analyze the most relevant clinical and pathogenetic issues related to drug-resistant epilepsy, and then we discuss the current evidence about the use of available ASMs and the alternative non-pharmacological approaches.
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Affiliation(s)
- Antonella Fattorusso
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | - Sara Matricardi
- Child Neurology and Psychiatry Unit, Children's Hospital “G. Salesi”, Ospedali Riuniti Ancona, Ancona, Italy
| | - Elisabetta Mencaroni
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | | | - Giuseppe Di Cara
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS “G. Gaslini” Institute, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Alberto Verrotti
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
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12
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Załuska-Ogryzek K, Marzęda P, Wróblewska-Łuczka P, Florek-Łuszczki M, Plewa Z, Bojar H, Zolkowska D, Łuszczki JJ. Interactions among Lacosamide and Second-Generation Antiepileptic Drugs in the Tonic-Clonic Seizure Model in Mice. Int J Mol Sci 2021; 22:ijms22115537. [PMID: 34073930 PMCID: PMC8197343 DOI: 10.3390/ijms22115537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/26/2022] Open
Abstract
Combination therapy with two or three antiseizure medications (ASMs) is sometimes a preferred method of treatment in epilepsy patients. (1) Background: To detect the most beneficial combination among three ASMs, a screen test evaluating in vivo interactions with respect to their anticonvulsant properties, was conducted on albino Swiss mice; (2) Methods: Classification of interactions among lacosamide (LCM) and selected second-generation ASMs (lamotrigine (LTG), pregabalin (PGB), oxcarbazepine (OXC), and topiramate (TPM)) was based on the isobolographic analysis in the mouse maximal electroshock-induced seizure (MES) model. Interactions among LCM and second-generation ASMs were visualized using a polygonogram; (3) Results: In the mouse MES model, synergy was observed for the combinations of LCM + TPM + PGB and LCM + OXC + PGB. Additivity was reported for the other combinations tested i.e., LCM + LTG + TPM, LCM + LTG + PGB, LCM + LTG + OXC, and LCM + OXC + TPM in this seizure model. No adverse effects associated with triple ASM combinations, containing LCM and second-generation ASMs were observed in mice; (4) Conclusions: The combination of LCM + TPM + PGB was the most beneficial combination among the tested in this study, offering synergistic suppression of tonic-clonic seizures in mice subjected to the MES model. Both the isobolographic analysis and polygonogram method can be recommended for experimental epileptology when classifying interactions among the ASMs.
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Affiliation(s)
- Katarzyna Załuska-Ogryzek
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland; (K.Z.-O.); (P.M.); (P.W.-Ł.)
| | - Paweł Marzęda
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland; (K.Z.-O.); (P.M.); (P.W.-Ł.)
| | - Paula Wróblewska-Łuczka
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland; (K.Z.-O.); (P.M.); (P.W.-Ł.)
| | | | - Zbigniew Plewa
- Department of General, Oncological and Minimally Invasive Surgery, 1st Military Clinical Hospital, 20-048 Lublin, Poland;
| | - Hubert Bojar
- Department of Toxicology and Food Safety, Institute of Rural Health, 20-090 Lublin, Poland;
| | - Dorota Zolkowska
- Department of Neurology, UC Davis School of Medicine, Sacramento, CA 95816, USA;
| | - Jarogniew J. Łuszczki
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland; (K.Z.-O.); (P.M.); (P.W.-Ł.)
- Isobolographic Analysis Laboratory, Institute of Rural Health, 20-090 Lublin, Poland
- Correspondence: ; Tel.: +48-81-448-65-03
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13
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Zaccara G, Lattanzi S, Russo E. Pharmacokinetic drug interactions between antiseizure medications and drugs for comorbid diseases in children with epilepsy. Expert Opin Drug Metab Toxicol 2021; 17:595-610. [PMID: 33709868 DOI: 10.1080/17425255.2021.1903429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Nearly 80% of children with epilepsy have one or more chronic comorbidities that require specific drug treatments in several cases. Drug-drug interactions (DDIs) between antiseizure medications (ASMs) and all other drugs (NON-ASMs) used to treat comorbid diseases may have serious consequences.Areas covered: All potential DDIs between 27 ASMs and all NON-ASMs used for oral chronic treatment of those disorders most often comorbid with epilepsy in children were searched for drug compendia. Clinical evidence of the identified DDIs was also searched in the literature. Forty-eight drugs have been identified as potential DDIs with at least one ASM. Most important DDIs are between some ASMs and omeprazole and pantoprazole (drugs for gastrointestinal disorders), ibuprofen and cyclobenzaprine (drugs for musculoskeletal disorders), loratidine, lumacaftor/ivacaftor, montelukast, and theophylline (drugs for respiratory system), levothyroxine, liothyronine and several corticosteroids (systemic hormonal preparations), almotriptan, dihydroergotamine, ergotamine, and several antipsychotics, antidepressants and anxiolytics (drugs for nervous diseases). Clinical evidence of the predicted DDIs was found in a minority of cases.Expert opinion: Treatment of children with epilepsy should be decided considering treatment of both seizures and comorbid diseases and aimed at minimizing the risk of DDIs between ASMs and NON-ASMs.
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Affiliation(s)
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
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14
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Singh S, Singh TG, Rehni AK. An Insight into Molecular Mechanisms and Novel Therapeutic Approaches in Epileptogenesis. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2021; 19:750-779. [PMID: 32914725 DOI: 10.2174/1871527319666200910153827] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/22/2022]
Abstract
Epilepsy is the second most common neurological disease with abnormal neural activity involving the activation of various intracellular signalling transduction mechanisms. The molecular and system biology mechanisms responsible for epileptogenesis are not well defined or understood. Neuroinflammation, neurodegeneration and Epigenetic modification elicit epileptogenesis. The excessive neuronal activities in the brain are associated with neurochemical changes underlying the deleterious consequences of excitotoxicity. The prolonged repetitive excessive neuronal activities extended to brain tissue injury by the activation of microglia regulating abnormal neuroglia remodelling and monocyte infiltration in response to brain lesions inducing axonal sprouting contributing to neurodegeneration. The alteration of various downstream transduction pathways resulted in intracellular stress responses associating endoplasmic reticulum, mitochondrial and lysosomal dysfunction, activation of nucleases, proteases mediated neuronal death. The recently novel pharmacological agents modulate various receptors like mTOR, COX-2, TRK, JAK-STAT, epigenetic modulators and neurosteroids are used for attenuation of epileptogenesis. Whereas the various molecular changes like the mutation of the cell surface, nuclear receptor and ion channels focusing on repetitive episodic seizures have been explored by preclinical and clinical studies. Despite effective pharmacotherapy for epilepsy, the inadequate understanding of precise mechanisms, drug resistance and therapeutic failure are the current fundamental problems in epilepsy. Therefore, the novel pharmacological approaches evaluated for efficacy on experimental models of epilepsy need to be identified and validated. In addition, we need to understand the downstream signalling pathways of new targets for the treatment of epilepsy. This review emphasizes on the current state of novel molecular targets as therapeutic approaches and future directions for the management of epileptogenesis. Novel pharmacological approaches and clinical exploration are essential to make new frontiers in curing epilepsy.
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Affiliation(s)
- Shareen Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | | | - Ashish Kumar Rehni
- Cerebral Vascular Disease Research Laboratories, Department of Neurology and Neuroscience Program, University of Miami School of Medicine, Miami, Florida 33101, United States
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15
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Löscher W, Potschka H, Sisodiya SM, Vezzani A. Drug Resistance in Epilepsy: Clinical Impact, Potential Mechanisms, and New Innovative Treatment Options. Pharmacol Rev 2020; 72:606-638. [PMID: 32540959 PMCID: PMC7300324 DOI: 10.1124/pr.120.019539] [Citation(s) in RCA: 346] [Impact Index Per Article: 86.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Epilepsy is a chronic neurologic disorder that affects over 70 million people worldwide. Despite the availability of over 20 antiseizure drugs (ASDs) for symptomatic treatment of epileptic seizures, about one-third of patients with epilepsy have seizures refractory to pharmacotherapy. Patients with such drug-resistant epilepsy (DRE) have increased risks of premature death, injuries, psychosocial dysfunction, and a reduced quality of life, so development of more effective therapies is an urgent clinical need. However, the various types of epilepsy and seizures and the complex temporal patterns of refractoriness complicate the issue. Furthermore, the underlying mechanisms of DRE are not fully understood, though recent work has begun to shape our understanding more clearly. Experimental models of DRE offer opportunities to discover, characterize, and challenge putative mechanisms of drug resistance. Furthermore, such preclinical models are important in developing therapies that may overcome drug resistance. Here, we will review the current understanding of the molecular, genetic, and structural mechanisms of ASD resistance and discuss how to overcome this problem. Encouragingly, better elucidation of the pathophysiological mechanisms underpinning epilepsies and drug resistance by concerted preclinical and clinical efforts have recently enabled a revised approach to the development of more promising therapies, including numerous potential etiology-specific drugs (“precision medicine”) for severe pediatric (monogenetic) epilepsies and novel multitargeted ASDs for acquired partial epilepsies, suggesting that the long hoped-for breakthrough in therapy for as-yet ASD-resistant patients is a feasible goal.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany (W.L.); Center for Systems Neuroscience, Hannover, Germany (W.L.); Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany (H.P.); Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom (S.S); and Department of Neuroscience, Mario Negri Institute for Pharmacological Research Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy (A.V.)
| | - Heidrun Potschka
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany (W.L.); Center for Systems Neuroscience, Hannover, Germany (W.L.); Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany (H.P.); Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom (S.S); and Department of Neuroscience, Mario Negri Institute for Pharmacological Research Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy (A.V.)
| | - Sanjay M Sisodiya
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany (W.L.); Center for Systems Neuroscience, Hannover, Germany (W.L.); Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany (H.P.); Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom (S.S); and Department of Neuroscience, Mario Negri Institute for Pharmacological Research Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy (A.V.)
| | - Annamaria Vezzani
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany (W.L.); Center for Systems Neuroscience, Hannover, Germany (W.L.); Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University, Munich, Germany (H.P.); Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom (S.S); and Department of Neuroscience, Mario Negri Institute for Pharmacological Research Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy (A.V.)
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16
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The role of chronobiology in drug-resistance epilepsy: The potential use of a variability and chronotherapy-based individualized platform for improving the response to anti-seizure drugs. Seizure 2020; 80:201-211. [DOI: 10.1016/j.seizure.2020.06.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 12/16/2022] Open
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17
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Sheikh SR, Thompson N, Frech F, Malhotra M, Jehi L. Quantifying the burden of generalized tonic-clonic seizures in patients with drug-resistant epilepsy. Epilepsia 2020; 61:1627-1637. [PMID: 32658343 DOI: 10.1111/epi.16603] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Compared to other seizure types, generalized tonic-clonic (GTC) seizures may be disproportionately related to increased morbidity, and reducing seizure frequency could translate into improvements across measures of morbidity in medically treated patients with drug-resistant epilepsy (DRE). The primary objective of this analysis was to quantify the burden of patients with DRE who experience GTC seizures (GTC+) compared to patients with DRE who do not experience GTC seizures (GTC-). METHODS Adult patients from the Cleveland Clinic Epilepsy Center-Neurological Institute from 2012-2016 with DRE with epilepsy for at least 1 year were eligible for inclusion and were divided into GTC ± groups based on whether the patient had experienced a GTC seizure in the year preceding the first visit. Epilepsy duration, comorbidities, antiepileptic drug use, patient-reported outcomes (PROs) and seizure type, frequency, and etiology were captured. Generalized linear models, negative binomial regression, logistic regression, and linear regression were used as appropriate for multivariate analyses. RESULTS A total of 379 patients met inclusion criteria and had data at 1-year follow-up after their baseline visit (192 GTC+ and 187 GTC-). Although DRE patients experiencing GTC seizures had fewer seizures per day over the preceding 6 months than those not experiencing GTC seizures, seizure severity and levels of depression and anxiety were greater. GTC+ patients who reported five or more seizures in the preceding 4 weeks had 82% lower odds (1-0.18 = 0.82) of working than patients with no seizures. SIGNIFICANCE Patients with DRE experience a significant burden and decreased quality of life. Multivariate analysis is necessary to understand the complex relationship between seizure type, frequency, and impact on health-related quality of life (HRQoL) and changes over time. Effective treatments to reduce the burden for DRE patients who experience GTC seizures continue to be needed.
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Affiliation(s)
- Shehryar R Sheikh
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Nicholas Thompson
- Cleveland clinic neurological institute, Cleveland clinic, Cleveland, OH, USA
| | - Feride Frech
- Neurology Business Group, Eisai, Inc., Woodcliff Lake, NJ, USA
| | - Manoj Malhotra
- Neurology Business Group, Eisai, Inc., Woodcliff Lake, NJ, USA
| | - Lara Jehi
- Cleveland clinic neurological institute, Cleveland clinic, Cleveland, OH, USA
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Vyas P, Tulsawani RK, Vohora D. Loss of Protection by Antiepileptic Drugs in Lipopolysaccharide-primed Pilocarpine-induced Status Epilepticus is Mediated via Inflammatory Signalling. Neuroscience 2020; 442:1-16. [PMID: 32592825 DOI: 10.1016/j.neuroscience.2020.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/22/2022]
Abstract
The evidences from various studies show the association of peripheral and neuronal inflammation with complex pathophysiology of status epilepticus (SE). In this view, the present work attempted to develop a model of neuronal inflammation mediated SE by combining both epileptic and inflammatory components of the disease and also to mimic SE co-morbid with systemic inflammation by peripheral administration of the lipopolysaccharide (LPS) 2 h prior to the pilocarpine (PILO) induction in C57BL/6 mice. We evaluated the anti-convulsant and neuroprotective effects of 7-day prophylactic treatment with three conventional anti-epileptic drugs (Sodium valproate, SVP 300 mg/kg p.o.; Carbamazepine CBZ 100 mg/kg p.o.; Levetiracetam; LEV 200 mg/kg p.o.) of widespread clinical use. Morris water maze and Rota rod tests were carried out 24-h post-exposure to evaluate the neurobehavioral co-morbidities associated with neuroinflammation-mediated status epilepticus. Upon priming with LPS, the loss of protection against PILO-induced seizures was observed by SVP and CBZ, however, LEV showed protection by delaying the seizures. Dramatic elevation in the seizure severity and neuronal loss demonstrated the possible pro-convulsant effect of LPS in the PILO model. Also, the decreased cytokine levels by the AEDs showed their association with NF-κB, IL-1β, IL-6, TNF-α and TGF-β pathways in PILO model. The loss of protective activities of SVP and CBZ in LPS+PILO model was due to increased cytokine levels associated with over-activation of neuroinflammatory pathways, however, partial efficacy of LEV is possibly due to association of other neuroinflammatory mechanisms. The current work provides direct evidence of the contribution of increased peripheral and neuronal inflammation in seizures via regulation of inflammatory pathways in the brain.
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Affiliation(s)
- Preeti Vyas
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Raj Kumar Tulsawani
- Defense Institute of Physiology & Allied Science, Defense Research and Development Organization, New Delhi, India
| | - Divya Vohora
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India.
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Łuszczki JJ, Kondrat-Wróbel M, Zagaja M, Karwan S, Bojar H, Plewa Z, Florek-Łuszczki M. Sub-additive (antagonistic) interaction of lacosamide with lamotrigine and valproate in the maximal electroshock-induced seizure model in mice: an isobolographic analysis. Pharmacol Rep 2020; 72:1288-1296. [PMID: 32507997 PMCID: PMC7550287 DOI: 10.1007/s43440-020-00117-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/20/2020] [Accepted: 05/29/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND Launching polytherapy with two or three antiseizure drugs (ASDs) in patients with epilepsy is still problematic. The choice of ASDs to combine them together is usually based on clinicians' experience and it requires knowledge about mechanisms of action of the studied ASDs and their drug-drug interactions, whose nature may be favorable, neutral or unfavorable. To characterize three-drug interaction among lacosamide (LCM), lamotrigine (LTG) and valproate (VPA), the type I isobolographic analysis was used. The antiseizure effects of three-drug combination were analyzed in a model of maximal electroshock-induced seizures (MES) in albino Swiss mice. MATERIALS AND METHODS The seizure activity in mice was evoked by alternating current stimulation (25 mA, 500 V, 50 Hz, 0.2 s). Both, the type I isobolographic analysis and the test of parallelism of dose-response effects of the ASDs were used so as to properly classify interaction among three ASDs, administered in a fixed ratio combination of 1:1:1. RESULTS The three-drug mixture of LCM, LTG and VPA at the fixed ratio of 1:1:1 protected the experimental mice from MES-induced seizures; however, the reported interaction was sub-additive (antagonistic; p < 0.01) with isobolography. CONCLUSION The antagonistic pharmacodynamic interaction among LCM, LTG and VPA in the MES test in mice cannot be transferred to clinical settings and this unfavorable combination should not be recommended for patients with epilepsy.
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Affiliation(s)
- Jarogniew J Łuszczki
- Department of Pathophysiology, Medical University, Jaczewskiego 8b, 20-090, Lublin, Poland. .,Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland.
| | - Maria Kondrat-Wróbel
- Department of Pathophysiology, Medical University, Jaczewskiego 8b, 20-090, Lublin, Poland
| | - Mirosław Zagaja
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland
| | | | - Hubert Bojar
- Department of Toxicology and Food Safety, Institute of Rural Health, Lublin, Poland
| | - Zbigniew Plewa
- Department of General, Oncological and Minimally Invasive Surgery, 1st Military Clinical Hospital, Lublin, Poland
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Chen P, Hao MM, Zhu J, Yang ZY. Effect of vagus nerve stimulation for the treatment of drug-resistant epilepsy: A protocol of systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20315. [PMID: 32501977 PMCID: PMC7306386 DOI: 10.1097/md.0000000000020315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Drug-resistant epilepsy (DRE) is a very tricky disorder, which greatly affects quality of life in such patients. Relevant studies suggested that vagus nerve stimulation (VNS) has potential benefits for DRE. However, there are inconsistent conclusions. The purpose of this study is to investigate whether VNS is effective and safety for DRE. METHODS To collect comprehensive randomized controlled trials (RCTs), the following electronic databases will be retrieved: MEDLINE, EMBASE, Cochrane Library, Web of Science, PsycINFO, CINAHL, AMED, and China National Knowledge Infrastructure from the commencement of each electronic database up to the present with no language restrictions. Two authors will independently carry out all procedures of literature selection, information collection, and risk of bias assessment. Any objections will be worked out by a third author through consultation. The risk of bias for each included trial will be identified using Cochrane risk of bias tool, and statistical analysis will be performed utilizing RevMan 5.3 software. RESULTS This study will synthesize the data from the present eligible high quality RCTs to assess whether VNS is effective and safety for DRE. CONCLUSION This study will provide systematic evidence of VNS for the treatment of patients with DRE. SYSTEMATIC REVIEW REGISTRATION INPLASY202040086.
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Affiliation(s)
- Peng Chen
- Department of Neurology, The First Hospital of Yulin, Yulin
| | - Mei-mei Hao
- Department of Neurology, Yan’an People's Hospital, Yan’an, China
| | - Jiang Zhu
- Department of Neurology, The First Hospital of Yulin, Yulin
| | - Zeng-ye Yang
- Department of Neurology, Yan’an People's Hospital, Yan’an, China
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Li L, Lin G, Gu H, Yu L, Ni C. Effects of Srxn1 on growth and Notch signalling of astrocyte induced by hydrogen peroxide. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2019; 47:1917-1923. [PMID: 31079497 DOI: 10.1080/21691401.2019.1614016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate the effect of Sulfiredoxin-1 (Srxn1) on astrocyte injury induced by hydrogen peroxide (H2O2). METHODS Observing the changes of H2O2 on contents of lactate dehydrogenase (LDH), malondialdehyde (MDA), superoxide dismutase (SOD) and apoptosis after transfected Srxn1 siRNA into astrocytes. The protein expression of Notch 1, NICD and Hes1, the content of LDH and MDA, the activity of SOD and apoptosis rate of astrocytes after inhibiting or activation of Notch signalling pathway were detected by Western blot, ELISA and flow cytometry, respectively. RESULTS Knockdown of Srxn1 could promote the secretion of LDH and MDA, decrease the activity of SOD and aggravate apoptosis of astrocytes induced by H2O2. The results of Western blot, ELISA assay and flow cytometry indicated that activation of the Notch signalling pathway attenuated the effect of Srxn1 on H2O2-induced oxidative damage and apoptosis of astrocytes. CONCLUSION Srxn1 may protect astrocytes from oxidative stress injury induced by H2O2 by activation of Notch signalling pathway.
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Affiliation(s)
- Lan Li
- a Department of Neurology , Second Affiliated Hospital of Dalian Medical University , Dalian City , Liaoning , China
| | - Guangjun Lin
- a Department of Neurology , Second Affiliated Hospital of Dalian Medical University , Dalian City , Liaoning , China
| | - Huizi Gu
- a Department of Neurology , Second Affiliated Hospital of Dalian Medical University , Dalian City , Liaoning , China
| | - Lei Yu
- b Department of Neurology , Dalian Friendship Hospital , Dalian City , Liaoning , China
| | - Changwei Ni
- a Department of Neurology , Second Affiliated Hospital of Dalian Medical University , Dalian City , Liaoning , China
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Lee BI, Park KM, Kim SE, Heo K. Clinical opinion: Earlier employment of polytherapy in sequential pharmacotherapy of epilepsy. Epilepsy Res 2019; 156:106165. [PMID: 31351239 DOI: 10.1016/j.eplepsyres.2019.106165] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/07/2019] [Indexed: 01/22/2023]
Abstract
Modern pharmacotherapy for epilepsy consists of orderly, sequential drug trials, in which antiepileptic drugs (AEDs) are chosen under the concept of individual patient-oriented (or - tailored) pharmacotherapy. Although monotherapy has been established as the preferred mode of AEDs therapy in both newly diagnosed and drug resistant epilepsies, there are still lack of evidence to favor either monotherapy or polytherapy in epilepsy, which has generated continuing controversies on the preferred mode of pharmacotherapy. However, each mode of pharmacotherapy may have both advantages and disadvantages, which are different and variable related to individual case scenario. We conducted a brief comparative overview between monotherapy and polytherapy to provide clues for earlier employment of polytherapy in each steps of sequential drug trials. Previous claims about the advantages of monotherapy over polytherapy are not supported but gradually losing its ground by the introduction of a large number of drugs carrying pharmacological advantages for combination therapy. Current evidence stresses the importance of combining drugs having synergistic interactions for better outcome of polytherapy, which has not been considered in previous clinical investigations comparing monotherapy and polytherapy. It is likely that a significant improvement in the outcome of current AEDs therapy is feasible by earlier employment of polytherapy as well as identification of combination drug regimens carrying synergistic interactions. At present, lamotrigine(LTG) and valproate(VPA) combination regimen is the only well documented synergistic regimen, but there are a long-list of candidate regimens requiring future trials in appropriate designs.
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Affiliation(s)
- Byung In Lee
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea.
| | - Kang Min Park
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Sung Eun Kim
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Kyoung Heo
- Department of Neurology, Yonsei University College of Medicine, Severance Hospital, Epilepsy Research Institute, Seoul, Republic of Korea
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23
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Pimentel J, Lopes Lima JM. Rational polytherapy: Myth or reality? JOURNAL OF EPILEPTOLOGY 2019. [DOI: 10.21307/jepil-2019-003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Park KM, Kim SE, Lee BI. Antiepileptic Drug Therapy in Patients with Drug-Resistant Epilepsy. J Epilepsy Res 2019; 9:14-26. [PMID: 31482053 PMCID: PMC6706642 DOI: 10.14581/jer.19002] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 12/11/2022] Open
Abstract
Antiepileptic drug (AED) therapy starts with an accurate diagnosis of epilepsy and is followed by sequential drug trials. Seizure freedom is largely achieved by the first two drug trials; thus, epilepsy that cannot be controlled after appropriately conducted trials of the first two drugs is defined as drug-resistant epilepsy (DRE). It is still unclear which mode of pharmacotherapy, among monotherapy and polytherapy, shows better outcomes in cases of DRE. However, in a recent large hospital cohort study over past two decades, combination therapy was associated with a progressive increase in seizure-free rate than monotherapy in DRE. The benefits of polytherapy in the management of DRE might be related to the recent introduction of many new AEDs with different and novel mechanisms of action and better pharmacokinetic and tolerability profiles. These new AEDs were introduced to the market after they have proven their superiority over placebos in randomized controlled trials (RCTs) on add-on therapy in patients with DRE. Therefore, polytherapy including these new AEDs in the regimen is the approved mode of treatment for cases of DRE; this has prompted physicians to try various combinations of polytherapy to optimize the clinical outcomes. In addition, the significant discrepancies in AED responder rates between RCTs and real-world practice may support the importance of judicious use of new drugs in polytherapy by experienced epileptologists. Most experts now agree to the concept of “rational polytherapy” consisting of mechanistic combinations of AEDs exerting synergistic interactions and to the importance of continuing trials of different rational polytherapy regimens to improve the outcome of the core population of epilepsy patients in the long term.
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Affiliation(s)
- Kang Min Park
- Department of Neurology and Epilepsy Center, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sung Eun Kim
- Department of Neurology and Epilepsy Center, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Byung In Lee
- Department of Neurology and Epilepsy Center, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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LC-MS/MS-Based Quantification of 9 Antiepileptic Drugs From a Dried Sample Spot Device. Ther Drug Monit 2019; 41:331-339. [DOI: 10.1097/ftd.0000000000000600] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Association between SCN1A polymorphism rs3812718 and valproic acid resistance in epilepsy children: a case-control study and meta-analysis. Biosci Rep 2018; 38:BSR20181654. [PMID: 30413604 PMCID: PMC6435549 DOI: 10.1042/bsr20181654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/31/2018] [Accepted: 11/05/2018] [Indexed: 01/08/2023] Open
Abstract
Resistance to valproic acid (VPA), a first-line antiepileptic drug (AED), is occurring at an alarming rate, particularly in children. Signal nucleotide polymorphisms are considered crucial in this process. Therefore, we investigated whether the SCN1A polymorphism rs3812718 could be associated with VPA resistance. A total of 231 children with epilepsy who were solely administered VPA were enrolled. DNA was extracted from the peripheral blood samples and was genotyped by the Mass Array method. Furthermore, a meta-analysis was conducted between the drug responsive and resistant patients who were exposed to voltage-gated sodium channels. Results revealed that the TT genotype was associated with a higher risk of developing drug resistance (OR = 2.636, 95% CI 1.08–6.433, P = 0.033). After adjusting for the risk factors, a significant difference was still observed between the responsive and resistant groups (OR = 2.861, 95% CI 1.141–7.174, P = 0.025). Moreover, the recessive model was associated with a decreased drug resistance (OR = 0.402, 95% CI 0.167–0.968, P = 0.042) after correcting the risk factors. Meta-analysis of nine studies revealed similar results. In conclusion, our results proved that the rs3812718 TT genotype was associated with a high risk of developing drug resistance, and the recessive model could decrease the risk of VPA resistance.
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RASgrf1, a Potential Methylatic Mediator of Anti-epileptogenesis? Neurochem Res 2018; 43:2000-2007. [PMID: 30242550 DOI: 10.1007/s11064-018-2621-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 08/02/2018] [Accepted: 08/21/2018] [Indexed: 01/02/2023]
Abstract
Epileptogenesis, induced by status epilepticus (SE), is a chronic process, and intervention in this progress may prevent chronic epilepsy. It has been proposed that DNA methylation might be related with epileptogenesis. RASgrf1 has a differentially methylated region at the promoter which can silence gene expression. We have previously observed the down-regulation of RASgrf1 in epilepsy patients and proved that hypermethylation of RASgrf1 reaches maximal level at the latent period in mice after kainate-induced SE (KA mice), with corresponding alteration of RASgrf1 expression. In the present study, N-phthalyl-L-tryptophan (RG108), a DNA methyltransferase inhibitor, was applied in KA mice at latent phase and the behavior, electroencephalogram and pathological changes were observed in chronic phase. Methylation and expression of RASgrf1 were determined by polymerase chain reaction (PCR), western blotting, and bisulfite sequencing PCR. The results showed that the incidence of spontaneous recurrent seizures (SRS) was significantly lower in the RG108 group than the normal saline (NS) group. Subgroup analysis showed significant hypermethylation and lower expression of RASgrf1 in the RG108-SRS subgroup and the NS-SRS subgroup but not in the RG108-NSRS (no SRS) subgroup and the NS-NSRS subgroup compared with the control group. No significant difference was found between the RG108-SRS and NS-SRS subgroups. Meanwhile, hippocampal neuronal loss was observed in RG108-SRS and NS-SRS subgroups. We thus demonstrated that RG108 could modify the progression of epileptogenesis after KA induced SE and prevent chronic epilepsy. Meanwhile, hypermethylation of RASgrf1 after KA induced SE could be reversed with corresponding changes of RASgrf1 expression. Additionally, we speculated that RASgrf1 might be a potential epigenetic mediator in epileptogenesis and chronic epilepsy.
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Taurine supplementation to anti-seizure drugs as the promising approach to treat pharmacoresistant epilepsy: A pre-clinical study. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.ijep.2017.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AbstractBackground Pharmacoresistance leads to severe, irreversible disabilities and premature death in ∼30% cases of epilepsy despite adequate and appropriate treatment with available anti-seizure drugs (ASDs) without any underlying cause. In light of the large body of evidence which suggests the anti-seizure action of taurine in experimental animals and its wide safety margins in human, supplementation of this inhibitory amino-sulfonic acid to available ASDs seems promising to treat pharmacoresistant epilepsy.Methods We examined the anti-seizure effect of lamotrigine (15 mg/kg), levetiracetam (40 mg/kg), carbamazepine (40 mg/kg), phenytoin (35 mg/kg) & taurine (50, 100 & 200 mg/kg) in lamotrigine pre-treated pentylenetetrazole-kindled mice (LPK) which mimic core features of pharmacoresistant epilepsy, either alone ASDs or in combinations whereby three different doses of taurine were supplemented with tested ASDs.Results Both, the ASDs and the taurine were failed to suppress generalized tonic-clonic seizures in LPK mice. However, taurine supplementation clearly restored the anti-seizure effect of tested ASDs. Further neurochemical studies revealed that higher levels of taurine in the hippocampus and cerebral cortex restored the imbalance between major excitatory neurotransmitters glutamate & its inhibitory counterpart GABA.Conclusions These findings emphasize that supplementation of taurine with ASDs may be useful to treat pharmacoresistant epilepsy. Thus, further clinical validation is encouraged.
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Tsai JJ, Wu T, Leung H, Desudchit T, Tiamkao S, Lim KS, Dash A. Perampanel, an AMPA receptor antagonist: From clinical research to practice in clinical settings. Acta Neurol Scand 2018; 137:378-391. [PMID: 29214650 DOI: 10.1111/ane.12879] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 12/21/2022]
Abstract
Epileptic seizures are refractory to treatment in approximately one-third of patients despite the recent introduction of many newer antiepileptic drugs (AEDs). Development of novel AEDs therefore remains a high priority. Perampanel is a first-in-class non-competitive selective AMPA receptor antagonist with a unique mechanism of action. Clinical efficacy and safety of perampanel as adjunctive treatment for focal seizures with/without secondary generalization (±SG) and primary generalized tonic-clonic (PGTC) seizures have been established in five phase 3 randomized controlled trials (RCTs), and a long-term extension study, and perampanel is approved as monotherapy for focal seizures ±SG in the USA. In patients with focal seizures ±SG, add-on perampanel resulted in median percent reduction in seizure frequency 23.3%-34.5% and ≥50% responder rate 28.5%-37.6%; in PGTC seizures, these results were 76.5% and 64.2%, respectively. Efficacy among adolescents (reduction in seizure frequency 34.8%-35.6%; ≥50% responder rate 40.9%-45.0%) and elderly people (reduction in seizure frequency 12.5%-16.9%; ≥50% responder rate 22.2%-42.9%) is similar to those in adults, and results remain comparable between Asian (reduction in seizure frequency 17.3%-38.0%) and global populations. Perampanel has been extensively studied in real-world clinical practice, with similar efficacy and safety results to the RCTs (≥50% responder rate 12.8%-75.0%; adverse events of somnolence/sedation, dizziness, ataxia, and behavioral changes). Real-world observational studies suggest that perampanel tolerability can be improved by slow titration (2 mg every 2-4 weeks), and bedtime administration can mitigate somnolence and dizziness. Counseling about the potential for behavioral changes and close monitoring are recommended.
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Affiliation(s)
- J.-J. Tsai
- Department of Neurology; National Cheng Kung University Hospital and School of Medicine; National Cheng Kung University; Tainan Taiwan
| | - T. Wu
- Department of Neurology; Chang Gung Memorial Hospital; Chang Gung University; Taoyuan City Taiwan
| | - H. Leung
- Department of Medicine and Therapeutics; Faculty of Medicine; Prince of Wales Hospital; Hong Kong Hong Kong
| | - T. Desudchit
- Department of Paediatrics; King Chulalongkorn Memorial Hospital; Bangkok Thailand
| | - S. Tiamkao
- Integrated Epilepsy Research Group; Department of Medicine; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - K.-S. Lim
- Division of Neurology; Department of Medicine; Faculty of Medicine; University of Malaya; Kuala Lumpur Malaysia
| | - A. Dash
- Eisai Singapore Pte. Ltd.; Singapore
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Association between two SCN1A polymorphisms and resistance to sodium channel blocking AEDs: a meta-analysis. Neurol Sci 2018; 39:1065-1072. [DOI: 10.1007/s10072-018-3308-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/27/2018] [Indexed: 02/04/2023]
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Abstract
Sodium channel blockers have been the mainstay of the pharmacological management of focal and generalised tonic-clonic seizures for more than 70 years. The focus of this paper will be on phenytoin, carbamazepine, lamotrigine, oxcarbazepine, rufinamide, lacosamide and eslicarbazepine acetate. All these antiepileptic drugs have similar efficacy and share similar dose-dependent, adverse effect profiles, although phenytoin, carbamazepine and oxcarbazepine are more likely to cause idiosyncratic reactions than the others. With the exception of lamotrigine, rufinamide and lacosamide, all are enzyme inducers and most are minor teratogens; although data on teratogenicity are sparse with lacosamide and eslicarbazepine acetate. There is increasing evidence that these drugs differ mechanistically, with the newer agents, lacosamide and eslicarbazepine acetate, having their major pharmacological effect on the slow inactivation state of the sodium channel, which may be associated with better tolerability at higher dosage, although hard evidence in support of this observation is currently not available. Rufinamide is licensed only for Lennox-Gastaut syndrome in children aged 4 years and above. There is a move away from using enzyme inducers, particularly phenytoin and carbamazepine, in everyday clinical practice. There seems little doubt, however, that some sodium channel blockers will have an enduring place in the management of epilepsy well into the 21st century.
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Affiliation(s)
- Martin J Brodie
- Epilepsy Unit, West Glasgow ACH-Yorkhill, Dalnair Street, Glasgow, G3 8SJ, Scotland, UK.
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Brodie MJ. Tolerability and Safety of Commonly Used Antiepileptic Drugs in Adolescents and Adults: A Clinician's Overview. CNS Drugs 2017; 31:135-147. [PMID: 28101765 DOI: 10.1007/s40263-016-0406-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This paper discusses the issues surrounding the tolerability and safety of the commonly used antiepileptic drugs (AEDs) in adolescents and adults. The content includes dose-related adverse effects, idiosyncratic reactions, behavioural and psychiatric comorbidities, chronic problems, enzyme induction and teratogenesis. Twenty-one AEDs are discussed in chronological order of their introduction into the UK, starting with phenobarbital and ending with brivaracetam. Wherever possible, advice is given on anticipating, recognising and managing these issues and thereby improving the lives of people with epilepsy, most of whom will need to take one or more of these agents for life. Avoidance of side effects will increase the possibility of achieving and maintaining long-term seizure freedom. Alternatively, adverse events from AEDs will substantially reduce quality of life and often result in higher healthcare costs.
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Affiliation(s)
- Martin J Brodie
- Epilepsy Unit, West Glasgow ACH-Yorkhill, Dalnair Street, Glasgow, G3 8SJ, Scotland, UK.
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