Antiepileptic drugs and markers of vascular risk

Increased vascular risk factors, atherosclerosis, and psychological distress among Indian adults with refractory epilepsy in comparison to well-controlled epilepsy

OBJECTIVE

Comparison of cardiovascular risk factors, atherosclerosis, and psychological distress among adults with refractory versus well-controlled epilepsy.

METHODS

The cross-sectional study consisted of two groups of 40 people each: Group I - People with well-controlled epilepsy, Group II - People with refractory epilepsy. Age- and gender-matched people of 20-50 years were recruited. People who were diabetic, smokers, hypertensive, alcoholic, pregnant, with infections, and lactating women were excluded from the study. Biochemical parameters, fasting glucose, lipid profile, fasting insulin, leptin, adiponectin, Lp[a], hsCRP, TyG INDEX, HOMA1-%S, HOMA1-IR, HOMA1-%B, QUICKI, FIRI, AIP, AC, CLTI, MLTI, CRI-I, CRI-II, and CIMT were estimated. Stress levels [PSS-10, GAD-7 & PHQ-9] were assessed based on the scoring system from the questionnaires.

RESULTS

The existence of metabolic syndrome, levels of triglycerides, TyG index, MDA, OSI, CIMT, AIP, and stress scores [PSS-10, GAD-7 & PHQ-9] were significantly higher in the refractory-epilepsy group in comparison to the well-controlled group. There were associations between LDL -C and CIMT as well as between GAD-7 and CIMT among all the study subjects. There were no significant differences in the levels of glucose homeostasis parameters, hsCRP, leptin, adiponectin, and Lp[a] between the two groups. Based on the ROC analysis, MDA [AUC = 0.853] and GAD-7 [AUC = 0.900] are useful in the differential diagnosis of the study groups.

CONCLUSION

People with refractory epilepsy had increased levels of vascular risk factors, atherosclerosis, and stress levels compared to people with well-controlled epilepsy. Suitable disease management and therapeutic approaches to address cardiovascular and psychological distress could be planned out among people with refractory epilepsy to improve their quality of life.

Topiramate treatment during the peripubertal period does not alter aortic endothelial function in female Wistar rats

AIMS

This study aimed to evaluate the short- and long-term adverse effects of blood pressure (BP), vascular endothelial function, and estrogen receptor (ERα and ERβ) modulation on endothelial function in female Wistar rats treated with topiramate (TPM), an antiepileptic drug, during the peripubertal period.

MATERIALS AND METHODS

Female Wistar rats were treated with TPM (41 mg/kg) or water (CTR group) by gavage from postnatal day (PND) 28 to 50 (peripubertal phase). At the end of the treatment, the TPM and CTR rats were divided into two groups and evaluated after 24 h or from PND 85 (adulthood). The rats were evaluated for: thoracic aorta reactivity to phenylephrine (Phenyl), acetylcholine (ACh), and sodium nitroprusside (SNP); aortic ring reactivity after ERα and ERβ antagonism; and BP.

KEY FINDINGS

It was observed that vascular response to Phenyl, ACh, and SNP was similar between TPM and CTR rats in the short- and long-term evaluations. In addition, the ER antagonism did not interfere with aortic contraction or relaxation in either TPM or CTR.

SIGNIFICANCE

Taken together, the results show that TPM treatment during the peripubertal period does not alter aortic endothelial function and its estrogen modulation via classic ER in female Wistar rats, suggesting that TPM treatment in this period is safe for the vascular system.

Association of Dementia Risk With Focal Epilepsy and Modifiable Cardiovascular Risk Factors

Importance

Epilepsy has been associated with cognitive impairment and potentially dementia in older individuals. However, the extent to which epilepsy may increase dementia risk, how this compares with other neurological conditions, and how modifiable cardiovascular risk factors may affect this risk remain unclear.

Objective

To compare the differential risks of subsequent dementia for focal epilepsy compared with stroke and migraine as well as healthy controls, stratified by cardiovascular risk.

Design, Setting, and Participants

This cross-sectional study is based on data from the UK Biobank, a population-based cohort of more than 500 000 participants aged 38 to 72 years who underwent physiological measurements and cognitive testing and provided biological samples at 1 of 22 centers across the United Kingdom. Participants were eligible for this study if they were without dementia at baseline and had clinical data pertaining to a history of focal epilepsy, stroke, or migraine. The baseline assessment was performed from 2006 to 2010, and participants were followed up until 2021.

Exposures

Mutually exclusive groups of participants with epilepsy, stroke, and migraine at baseline assessment and controls (who had none of these conditions). Individuals were divided into low, moderate, or high cardiovascular risk groups based on factors that included waist to hip ratio, history of hypertension, hypercholesterolemia, diabetes, and smoking pack-years.

Main Outcomes and Measures

Incident all-cause dementia; measures of executive function; and brain total hippocampal, gray matter, and white matter hyperintensity volumes.

Results

Of 495 149 participants (225 481 [45.5%] men; mean [SD] age, 57.5 [8.1] years), 3864 had a diagnosis of focal epilepsy only, 6397 had a history of stroke only, and 14 518 had migraine only. Executive function was comparable between participants with epilepsy and stroke and worse than the control and migraine group. Focal epilepsy was associated with a higher risk of developing dementia (hazard ratio [HR], 4.02; 95% CI, 3.45 to 4.68; P < .001), compared with stroke (HR, 2.56; 95% CI, 2.28 to 2.87; P < .001), or migraine (HR, 1.02; 95% CI, 0.85 to 1.21; P = .94). Participants with focal epilepsy and high cardiovascular risk were more than 13 times more likely to develop dementia (HR, 13.66; 95% CI, 10.61 to 17.60; P < .001) compared with controls with low cardiovascular risk. The imaging subsample included 42 353 participants. Focal epilepsy was associated with lower hippocampal volume (mean difference, -0.17; 95% CI, -0.02 to -0.32; t = -2.18; P = .03) and lower total gray matter volume (mean difference, -0.33; 95% CI, -0.18 to -0.48; t = -4.29; P < .001) compared with controls. There was no significant difference in white matter hyperintensity volume (mean difference, 0.10; 95% CI, -0.07 to 0.26; t = 1.14; P = .26).

Conclusions and Relevance

In this study, focal epilepsy was associated with a significant risk of developing dementia, to a greater extent than stroke, which was magnified substantially in individuals with high cardiovascular risk. Further findings suggest that targeting modifiable cardiovascular risk factors may be an effective intervention to reduce dementia risk in individuals with epilepsy.

The therapeutic effects of lacosamide on epilepsy-associated comorbidities

Epilepsy is a chronic neurological disorder associated with severe social and psychological effects, and most epilepsy patients often report at least one comorbidity. Accumulating evidence have suggested that lacosamide, a new generation of anti-seizure medications, may exhibit efficacy in the management of both epilepsy and its related comorbidities. Therefore, this narrative review aimed to elucidate the recent advancements regarding the therapeutic role of lacosamide in epilepsy-associated comorbidities. The possible pathophysiological mechanisms between epilepsy and epilepsy-associated comorbidities have been also partially described. Whether lacosamide improves cognitive and behavioral functions in patients with epilepsy has not been conclusively established. Some studies support that lacosamide may alleviate anxiety and depression in epilepsy patients. In addition, lacosamide has been found to be safe and effective in the treatment of epilepsy in people with intellectual disabilities, epilepsy of cerebrovascular etiology, and epilepsy associated with brain tumors. Moreover, lacosamide treatment has demonstrated fewer side effects on other systems. Hence, future larger and higher quality clinical studies are needed to further explore both the safety and efficacy of lacosamide in the treatment of epilepsy-associated comorbidities.

Comparison of myocardial perfusion between the users of two antiepileptic medications: valproate vs. carbamazepine

Objectives

The prevalence of coronary artery disease (CAD) is high in patients with epilepsy using antiepileptic drugs (AED). Epilepsy, AED, or the type and duration of AED use , may contribute to higher CAD risk.In this study, myocardial perfusion imaging (MPI) was compared between patients using carbamazepine and valproate.

Method

Out of 73 patients receiving carbamazepine or valproate monotherapy for more than 2 years, visited at a tertiary referral clinic, 32 patients participated in a 2-day stress and rest phases MPI. For each phase, 15-25 mCi 99mTc-MIBI was injected, at peak exercise or by pharmacologic stimulation for the stress phase. SPECT with cardiac gating was done by a dual-head gamma camera and processed and quantified. Scans with at least one definite reversible hypo-perfusion segment were considered abnormal.

Results

Seventeen patients received carbamazepine monotherapy and 15 valproates. Age and duration of AED use were similar between the groups. Two scans were abnormal (6.3%) both in valproate group (13.3%). Duration of AED use was higher in patients with abnormal scans. In patients receiving monotherapy >2 years, the frequency of abnormal MPI was similar between groups (P-value=0.12). In patients receiving monotherapy > 5 years, prevalence of abnormal MPI was higher in the valproate group (28.6% vs. 0.0%; P-value=0.042). Considering valproate subgroup, ischemic patients had higher duration of AED use, comparing with the normal patients (17.0±4.2 vs. 6.4±4.8, P-value=0.014).

Conclusion

MPIs were abnormal in patients receiving valproate after 5 years compared to patients receiving carbamazepine. Long-term valproate use may increase the risk of CAD.

Metabolic syndrome and its associated factors among epileptic patients at Dessie Comprehensive Specialized Hospital, Northeast Ethiopia; a hospital-based comparative cross-sectional study

INTRODUCTION

Metabolic syndrome is a group of metabolic risk factors which are associated with an increased risk of cardiovascular disease and type2 diabetes. Nowadays, several studies have shown that the burden of metabolic syndrome is increasing among epileptic patients, and leads to MS-associated complications, including cardiovascular disease. However, getting published documents has been limited in Ethiopia and the study area. Therefore, we aimed to analyze the magnitude and associated factors of metabolic syndrome among epileptic patients in Dessie Comprehensive Specialized Hospital in compression with respective controls.

METHODS

Hospital-based comparative cross-sectional study design was implemented from June 25 to August 20, 2021. A total of 204 participants with an equal number of cases and controls (n = 102 each) were included. The data was collected through face-to-face interviews and biochemical analyses such as fasting blood glucose and lipid profiles were done through the enzymatic technique. The magnitude of metabolic syndrome was determined using both National Cholesterol Education Program Adult Treatment Panel III and International Diabetes Federation definition criteria. The STATA version 14 was used for statistical data analysis, and a comparison of categorical and continuous variables was done with χ2 and an independent t-test, respectively. The multivariable binary logistic regression analysis was used to identify factors associated with metabolic syndrome, and variables having a P-value of <0.05 were considered statistically significant.

RESULT

The prevalence of metabolic syndrome among the epileptic group was (25.5% in National Cholesterol Education Program Adult Treatment Panel III and 23.5% in International Diabetes Federation criteria), whereas it was 13.7% in National Cholesterol Education Program Adult Treatment Panel III and 14.7% in International Diabetes Federation criteria among control groups. According to the International Diabetes Federation criteria, low physical activity (adjusted odds ratio = 4.73, 95% CI: 1.08-20.68), taking multiple antiepileptic drugs (adjusted odds ratio = 8.08, 95% CI: 1.52-42.74), having a total cholesterol level of ≥ 200 mg/dl (adjusted odds ratio = 5.81, 95%: 1.32-41.13) and body mass index (adjusted odds ratio = 1.57, 95% CI = 1.16-2.11) were significantly associated with metabolic syndrome among epileptic participants. Applying National Cholesterol Education Program Adult Treatment Panel III criteria, taking multiple antiepileptic drugs (adjusted odds ratio = 6.81, 95% CI: 1.29-35.92), having a total cholesterol level > 200 mg/dl (adjusted odds ratio = 7.37, 95% CI: 1.32-41.13) and body mass index (adjusted odds ratio = 1.53, 96% CI: 1.16-2.01) were also significantly associated.

CONCLUSION

The prevalence of metabolic syndrome among epileptic patients was higher than that of control groups and reaches statistically significant by National Cholesterol Education Program Adult Treatment Panel III. Being on multiple antiepileptic drugs, body mass index, having low physical activity and raised total cholesterol were significantly associated with metabolic syndrome among the epileptic group. Therefore, it is better to focus on controlling weight, having sufficient physical exercise, and regular monitoring of total cholesterol levels in epileptic patients.

Identification of factors associated with new-onset vascular disease in patients admitted for video-EEG monitoring: A longitudinal cohort study

OBJECTIVE

People with epilepsy are at a higher risk of developing vascular disease. Understanding the risk factors in observational studies is hampered by the challenge in separating epilepsy-related risk and treatment-related risk, and uncertainty in the epilepsy diagnosis. This study aimed to identify factors associated with risk of subsequent vascular disease in patients with video-EEG monitoring (VEM) confirmed epilepsy.

METHODS

We included patients with a diagnosis of epilepsy and nonepileptic disorders between January 1, 1995, and December 31, 2015. Incident cardiovascular, cerebrovascular, and peripheral vascular disease was determined by linkage to a state-wide hospital admissions database between 1st July 1994 and 28th February 2018. Incidence was compared with the general population.

RESULTS

1728 patients (59.7% female, median age 35 years) underwent VEM, and were followed up for a median of 9.2 years (range 2.2-22.9 years). Eight-hundred and thirty -two were diagnosed with epilepsy and 896 nonepileptic disorders. The incidence of cerebrovascular disease was higher in both patients with epilepsy (incidence rate ratio [IRR] 1.78, p = 0.001) and with nonepileptic disorders (IRR 1.61, p < 0.001) than in the general population. Patients who took valproic acid (VPA) were at a lower risk of vascular disease than those taking enzyme-inducing antiseizure medications (EIASM, subdistribution hazard ratio [SHR] 0.42, p = 0.013), and those taking neither VPA nor EIASM (SHR 0.47, p = 0.03). There was no difference in the incidence of vascular disease between patients with epilepsy and those without epilepsy (SHR 0.94, p = 0.766). Factors associated with increased risk included age (SHR 1.04, p < 0.001), male sex (SHR 1.50, p = 0.017), and smoking (SHR 1.68, p = 0.017).

SIGNIFICANCE

In this study, both patients with epilepsy and without epilepsy had increased vascular risk. This suggests that the increased risk may be in part due to factors not directly related to epilepsy, such as EIASM use and vascular risk factors.

Long-Term Effects of Antiseizure Medications

Most patients with epilepsy will benefit from seizure control with one of an array of chronic antiseizure medications. Knowledge of the potential long-term effects of these medications is critical to prevent adverse consequences on overall health. Antiseizure medications vary in their capacities to affect the brain and peripheral nerves, hormones, bone mineralization, cardiovascular risk, renal health, hepatic, hematological, and dermatological systems. Understanding of pathophysiology and population risk has evolved, although most of the data available are still on older generation antiseizure medications such as phenytoin, carbamazepine, and valproic acid. The enzyme-inducing properties of some antiseizure medications make their effects on cardiovascular risk and bone health detrimental. Few clear guidelines exist for monitoring long-term effects of medication therapy for epilepsy. When selecting an antiseizure medication, consideration should be given to the individual patient's risks of adverse consequences on other organ systems. During monitoring of patients on chronic therapy, screening tools such as metabolic panels and bone density measurements can help stratify risk and guide management.

Complications associated with the use of enzyme-inducing and non-enzyme-inducing anti-seizure medications in the Japanese population: A retrospective cohort study

OBJECTIVE

Enzyme-inducing anti-seizure medications (EIASMs) may contribute to the development of complications such as fracture and cardiovascular disease. The objective of the study was to determine whether the use of EIASMs is associated with a higher risk of fracture and cardiovascular outcome in young Japanese patients with epilepsy.

METHOD

Adult patients diagnosed with epilepsy and initiated a monotherapy with an anti-seizure medication (ASM) between 2008 and 2018 were included in the study. The primary outcomes were the occurrence of acute myocardial infarction (AMI) or stroke. The secondary outcome was fracture. We performed a propensity score-matched analysis (1:1) to control for imbalances in patient characteristics, and the matched hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models.

RESULT

Of the 7115 eligible patients, 626 (8.79%) initiated treatment with EIASMs. The median age of the patients was 44 years (interquartile range: 31-54 years), and 56.2% were male. Propensity score matching generated 626 matched pairs of patients treated with EIASMs and non-EIASMs. There were no significant differences in the risk of stroke (EIASM group: n = 28[4.47%], non-EIASM group: n = 22[3.51%], HR: 1.47, 95% CI: 0.79-2.72, p = 0.22) or fracture (EIASM group: n = 7[1.12%], non-EIASM group: n = 5[0.80%], HR: 1.00, 95% CI: 0.29-3.45, p = 1.00) between the two groups. The hazard ratio for the occurrence of AMI could not be calculated due to the small number of events (EIASM group: n = 0[0.00], non-EIASM group: n = 2[0.32]).

SIGNIFICANCE

Our cohort study did not find increased risk of the occurrence of stroke, AMI, or fracture hospitalization with the use of enzyme-inducing ASMs. Although the findings suggested that exposure to EIASMs does not appear to increase the risk of complications in young patients, caution should be taken as patients with epilepsy tend to take medication in the long run.

Application Value of Serum Metabolic Markers for Cognitive Prediction in Elderly Epilepsy

BACKGROUND AND STUDY AIMS

Elderly epilepsy is the third most common chronic disease that affects metabolism either alone or through antiepileptic drugs (AEDs). Here, we focus on whether neurocognitive profiles in elderly epilepsy and its treatment are linked to metabolic conditions.

PATIENTS AND METHODS

Elderly patients with epilepsy without cognitive impairment (n = 78) and with cognitive impairment (n = 75) were enrolled. C-reactive protein (CRP) and metabolic markers (triglyceride (TG), total cholesterol (TC), high-density lipoprotein (HDL-c), low-density lipoprotein (LDL-c), albumin, fasting glucose (Glu) and glycosylated hemoglobin (HbA1c)) were measured. Serum markers were modeled using logistic regression analysis.

RESULTS

TG, TC, fasting glucose, HbA1c and CRP were significantly increased (p < 0.05, 0.05, 0.001, 0.001, 0.01, respectively) in elderly epilepsy, whereas HDL-c, LDL-c and serum albumin were decreased (p < 0.001, 0.001, 0.001) in elderly epilepsy. TG, TC, fasting Glu, HbA1c and CRP were significantly elevated (p < 0.05, 0.001, 0.001, 0.001, 0.001, respectively) in epilepsy with cognitive impairment, whereas HDL-c, LDL-c and serum albumin were decreased (p < 0.001, 0.001, 0.001). The abnormal glycolipid profile was predominated in AED-treated patients. The regression model combined with TG, LDL-c, HDL-c and albumin performed better (area under the ROC curve was 0.824) in AED-treated patients.

CONCLUSION

The relevant relationship between glycolipid profile and cognitive impairment with epilepsy was described, and the logistic regression model based on serum TG, LDL-c, HDL-c and albumin is reported and may serve as promising diagnostic markers for elderly epilepsy with cognitive impairment. Additionally, a specific emphasis on the complex role of altered lipid metabolism and AEDs is made.

Modifiable Risk Factors of Dementia in Older Adults With Epilepsy: An Opportunity to Flatten the Curve?

A Nationwide, Retrospective, Data-Linkage, Cohort Study of Epilepsy and Incident Dementia

Schnier C, Duncan S, Wilkinson T, Mbizvo GK, Chin RFM. Neurology. 2020;95(12):e1686-e1693. doi:10.1212/WNL.0000000000010358

Objective:

To determine the association of epilepsy with incident dementia by conducting a nationwide, retrospective data-linkage, cohort study to examine whether the association varies according to dementia subtypes and to investigate whether risk factors modify the association.

Methods:

We used linked health data from hospitalization, mortality records, and primary care consultations to follow up 563 151 Welsh residents from their 60th birthday to estimate dementia rate and associated risk factors. Dementia, epilepsy, and covariates (medication, smoking, comorbid conditions) were classified with the use of previously validated code lists. We studied rate of dementia and dementia subtypes in people with epilepsy (PWE) and without epilepsy using (stratified) Kaplan-Meier plots and flexible parametric survival models.

Results:

PWE had a 2.5 (95% confidence interval [CI] 2.3-2.6) times higher hazard of incident dementia, a 1.6 (95% CI 1.4-1.8) times higher hazard of incident Alzheimer disease (AD), and a 3.1 (95% CI 2.8-3.4) times higher hazard of incident vascular dementia (VaD). A history of stroke modified the increased incidence in PWE. PWE who were first diagnosed at ≤25 years of age had a dementia rate similar to that of those diagnosed later in life. PWE who had ever been prescribed sodium valproate compared to those who had not were at higher risk of dementia (hazard ratio [HR] 1.6, 99% CI 1.4-1.9) and VaD (HR 1.7, 99% CI 1.4-2.1) but not AD (HR 1.2, 99% CI 0.9-1.5).

Conclusion:

PWE compared to those without epilepsy have an increased dementia risk.

Impact of carbamazepine on vitamin D levels: A meta-analysis

PURPOSE

There are longstanding concerns about the impact of enzyme-inducing anti-seizure medications (ASMs) on vitamin D, an important molecule in both bone metabolism and inflammation pathways. The relationship between chronic use of carbamazepine and vitamin D levels has been studied, but no comprehensive review to inform practitioners and policymakers is currently available. We performed a meta-analysis on studies that measured 25-hydroxyvitamin D (25OHD) levels in persons taking carbamazepine to determine whether this drug significantly reduces circulating 25OHD.

PRINCIPAL RESULTS

From a literature search of the terms "carbamazepine" and "vitamin D", we identified 12 studies that measured 25OHD levels in persons on carbamazepine monotherapy groups and controls. Persons taking carbamazepine had significantly lower 25OHD levels than persons not taking carbamazepine. The average 25OHD levels of carbamazepine-treated patients across all studies was 21.8 ng/mL (IQR 15.4,26.0) whereas 25OHD levels of control subjects was 28.0 ng/mL (IQR 20.8,30.4). The weighted difference of means was 4.00 ng/mL of 25OHD. Neither age nor sex nor duration of carbamazepine therapy had a significant impact on this finding. The effect was similar irrespective of whether the comparator group consisted of healthy controls or epilepsy patients taking non-inducing medications.

MAJOR CONCLUSIONS

Carbamazepine use is associated with a reduction of 25OHD levels. In combination with other literature establishing the problematic metabolic effects of carbamazepine, this meta-analysis provides additional evidence in favor of the use of alternative ASMs as first-line agents. At minimum, vitamin D supplementation should be strongly considered for patients prescribed carbamazepine.

Association of Enzyme-Inducing Antiseizure Drug Use With Long-term Cardiovascular Disease

Importance

Enzyme-inducing antiseizure medications (eiASMs) have been hypothesized to be associated with long-term risks of cardiovascular disease.

Objective

To quantify and model the putative hazard of cardiovascular disease secondary to eiASM use.

Design, Setting, and Participants

This cohort study covered January 1990 to March 2019 (median [IQR] follow-up, 9 [4-15], years). The study linked primary care and hospital electronic health records at National Health Service hospitals in England. People aged 18 years or older diagnosed as having epilepsy after January 1, 1990, were included. All eligible patients were included with a waiver of consent. No patients were approached who withdrew consent. Analysis began January 2021 and ended August 2021.

Exposures

Receipt of 4 consecutive eiASMs (carbamazepine, eslicarbazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, rufinamide, or topiramate) following an adult-onset (age ≥18 years) epilepsy diagnosis or repeated exposure in a weighted cumulative exposure model.

Main Outcomes and Measures

Three cohorts were isolated, 1 of which comprised all adults meeting a case definition for epilepsy diagnosed after 1990, 1 comprised incident cases diagnosed after 1998 (hospital linkage date), and 1 was limited to adults diagnosed with epilepsy at 65 years or older. Outcome was incident cardiovascular disease (ischemic heart disease or ischemic or hemorrhagic stroke). Hazard of incident cardiovascular disease was evaluated using adjusted propensity-matched survival analyses and weighted cumulative exposure models.

Results

Of 10 916 166 adults, 50 888 (0.6%) were identified as having period-prevalent cases (median [IQR] age, 32 [19-50] years; 16 584 [53%] female), of whom 31 479 (62%) were diagnosed on or after 1990 and were free of cardiovascular disease at baseline. In a propensity-matched Cox proportional hazards model adjusted for age, sex, baseline socioeconomic status, and cardiovascular risk factors, the hazard ratio for incident cardiovascular disease was 1.21 (95% CI, 1.06-1.39) for those receiving eiASMs. The absolute difference in cumulative hazard diverges by more than 1% and greater after 10 years. For those with persistent exposure beyond 4 prescriptions, the median hazard ratio increased from amedian (IQR) of 1.54 (1.28-1.79) when taking a relative defined daily dose of an eiASM of 1 to 2.38 (1.52-3.56) with a relative defined daily dose of 2 throughout a maximum of 25 years' follow-up compared with those not receiving an eiASM. The hazard was elevated but attenuated when restricting analyses to incident cases or those diagnosed when older than 65 years.

Conclusions and Relevance

The hazard of incident cardiovascular disease is higher in those receiving eiASMs. The association is dose dependent and the absolute difference in hazard seems to reach clinical significance by approximately 10 years from first exposure.

Effect of acute and chronic exposure to lovastatin on the anticonvulsant action of classical antiepileptic drugs in the mouse maximal electroshock-induced seizure model

Numerous studies indicate neuroprotective activity of statins, commonly used cholesterol lowering drugs in epilepsy and several other neurological diseases. Promising anti-convulsant and neuroprotective effects of statins, attributed to their anti-excitotoxic and anti-inflammatory action were reported in several animals' seizure models. To determine the effects of acute (single) and chronic (once daily for 7 consecutive days) administration of lovastatin on the protective activity of four classical antiepileptic drugs such as carbamazepine, phenobarbital, phenytoin and valproate in the mouse maximal electroshock seizure model. Seizure activity (maximal electroconvulsions) in mice were generated by alternating current delivered via ear-clip electrodes. Adverse-effect profile of lovastatin combinations with the tested antiepileptic drugs was assessed in the chimney test (motor performance). Total brain concentrations of antiepileptic drugs were evaluated with the fluorescence polarization immunoassay technique as a measure of the pharmacokinetic interaction between drugs. Lovastatin administered acutely or chronically (5-20 mg/kg) did not significantly affect the threshold for electroconvulsions in mice. Acute lovastatin (10 mg/kg) significantly enhanced the anticonvulsant effect of valproate, which was accompanied with a 34% significant increase in total brain concentration of valproate. Acute lovastatin in combination with phenytoin impaired motor performance by notably decreasing the TD50 value of phenytoin. Chronic lovastatin (10 mg/kg) markedly enhanced the anticonvulsant potential of phenytoin. Acute lovastatin increased anticonvulsant action of valproate but also significantly raised level of valproate in brain after combined administration suggesting pharmacokinetic nature of interaction. The combinations of chronic lovastatin combined with phenytoin can potentially enhance the anticonvulsant potency of phenytoin.

Predicting the risk of stroke in patients with late-onset epilepsy: A machine learning approach

BACKGROUND

The goal of this cohort study was to estimate the predictors for ischemic stroke in patients with epilepsy in a large database containing data from general practitioners in Germany using machine learning methods.

METHODS

This retrospective cohort study included 11,466 patients aged ≥ 60 years with an initial diagnosis of epilepsy in 1182 general practices in Germany between January 2010 and December 2018 from the IQVIA Disease Analyzer database. The Sub-Population Optimization and Modeling Solutions (SOMS) tool was used to identify subgroups at a higher risk of stroke than the overall population with epilepsy based on 37 different variables.

RESULTS

A total of seven variables were considered important. Four co-diagnoses (diabetes, hypertension, heart failure, and alcohol dependence) were by far the strongest predictors with a combined predictive ability of more than 90%, whereby diabetes (41.4%) was the strongest predictor, followed by hypertension (35.0%) and heart failure (11.8%). The predictive importance of male gender was only 1.5%, and age was not recognized as an important predictor. Finally, the prescribed AEDs levetiracetam, with a predictive importance of 5.0%, and valproate, with 2.7%, were found to be weak predictors.

CONCLUSION

The stroke risk in patients with epilepsy was relatively high and could be predicted based on comorbidities such as diabetes mellitus, hypertension, heart failure, and alcohol dependence. Knowing and addressing these factors may help reduce the risk of stroke in patients with epilepsy.

Epileptic heart: A clinical syndromic approach

Prevention of premature death in patients with chronic epilepsy remains a major challenge. Multiple pathophysiologic factors have been implicated, with intense investigation of cardiorespiratory mechanisms. Up to four in five patients with chronic epilepsy exhibit cardiovascular comorbidities. These findings led us to propose the concept of an "epileptic heart," defined as "a heart and coronary vasculature damaged by chronic epilepsy as a result of repeated surges in catecholamines and hypoxemia leading to electrical and mechanical dysfunction." Among the most prominent changes documented in the literature are high incidence of myocardial infarction and arrhythmia, altered autonomic tone, diastolic dysfunction, hyperlipidemia, and accelerated atherosclerosis. This suite of pathologic changes prompted us to propose for the first time in this review a syndromic approach for improved clinical detection of the epileptic heart condition. In this review, we discuss the key pathophysiologic mechanisms underlying the candidate criteria along with standard and novel techniques that permit evaluation of each of these factors. Specifically, we present evidence of the utility of standard 12-lead, ambulatory, and multiday patch-based electrocardiograms, along with measures of cardiac electrical instability, including T-wave alternans, heart rate variability to detect altered autonomic tone, echocardiography to detect diastolic dysfunction, and plasma biomarkers for assessing hyperlipidemia and accelerated atherosclerosis. Ultimately, the proposed clinical syndromic approach is intended to improve monitoring and evaluation of cardiac risk in patients with chronic epilepsy to foster improved therapeutic strategies to reduce premature cardiac death.

Epilepsy, antiepileptic drugs, and the risk of major cardiovascular events

OBJECTIVE

This study was undertaken to determine whether epilepsy and antiepileptic drugs (including enzyme-inducing and non-enzyme-inducing drugs) are associated with major cardiovascular events using population-level, routinely collected data.

METHODS

Using anonymized, routinely collected, health care data in Wales, UK, we performed a retrospective matched cohort study (2003-2017) of adults with epilepsy prescribed an antiepileptic drug. Controls were matched with replacement on age, gender, deprivation quintile, and year of entry into the study. Participants were followed to the end of the study for the occurrence of a major cardiovascular event, and survival models were constructed to compare the time to a major cardiovascular event (cardiac arrest, myocardial infarction, stroke, ischemic heart disease, clinically significant arrhythmia, thromboembolism, onset of heart failure, or a cardiovascular death) for individuals in the case group versus the control group.

RESULTS

There were 10 241 cases (mean age = 49.6 years, 52.2% male, mean follow-up = 6.1 years) matched to 35 145 controls. A total of 3180 (31.1%) cases received enzyme-inducing antiepileptic drugs, and 7061 (68.9%) received non-enzyme-inducing antiepileptic drugs. Cases had an increased risk of experiencing a major cardiovascular event compared to controls (adjusted hazard ratio = 1.58, 95% confidence interval [CI] = 1.51-1.63, p < .001). There was no notable difference in major cardiovascular events between those treated with enzyme-inducing antiepileptic drugs and those treated with non-enzyme-inducing antiepileptic drugs (adjusted hazard ratio = .95, 95% CI = .86-1.05, p = .300).

SIGNIFICANCE

Individuals with epilepsy prescribed antiepileptic drugs are at an increased risk of major cardiovascular events compared with population controls. Being prescribed an enzyme-inducing antiepileptic drug is not associated with a greater risk of a major cardiovascular event compared to treatment with other antiepileptic drugs. Our data emphasize the importance of cardiovascular risk management in the clinical care of people with epilepsy.

Bioinformatics and system biology approach to identify the influences of COVID-19 on cardiovascular and hypertensive comorbidities

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected individuals that have hypertension or cardiovascular comorbidities have an elevated risk of serious coronavirus disease 2019 (COVID-19) disease and high rates of mortality but how COVID-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$19$\end{document} and cardiovascular diseases interact are unclear. We therefore sought to identify novel mechanisms of interaction by identifying genes with altered expression in SARS-CoV-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$2$\end{document} infection that are relevant to the pathogenesis of cardiovascular disease and hypertension. Some recent research shows the SARS-CoV-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$2$\end{document} uses the angiotensin converting enzyme-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$2$\end{document} (ACE-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$2$\end{document}) as a receptor to infect human susceptible cells. The ACE2 gene is expressed in many human tissues, including intestine, testis, kidneys, heart and lungs. ACE2 usually converts Angiotensin I in the renin–angiotensin-aldosterone system to Angiotensin II, which affects blood pressure levels. ACE inhibitors prescribed for cardiovascular disease and hypertension may increase the levels of ACE-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$2$\end{document}, although there are claims that such medications actually reduce lung injury caused by COVID-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$19$\end{document}. We employed bioinformatics and systematic approaches to identify such genetic links, using messenger RNA data peripheral blood cells from COVID-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$19$\end{document} patients and compared them with blood samples from patients with either chronic heart failure disease or hypertensive diseases. We have also considered the immune response genes with elevated expression in COVID-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$19$\end{document} to those active in cardiovascular diseases and hypertension. Differentially expressed genes (DEGs) common to COVID-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$19$\end{document} and chronic heart failure, and common to COVID-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$19$\end{document} and hypertension, were identified; the involvement of these common genes in the signalling pathways and ontologies studied. COVID-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$19$\end{document} does not share a large number of differentially expressed genes with the conditions under consideration. However, those that were identified included genes playing roles in T cell functions, toll-like receptor pathways, cytokines, chemokines, cell stress, type 2 diabetes and gastric cancer. We also identified protein–protein interactions, gene regulatory networks and suggested drug and chemical compound interactions using the differentially expressed genes. The result of this study may help in identifying significant targets of treatment that can combat the ongoing pandemic due to SARS-CoV-\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$2$\end{document} infection.

Seizures and Epilepsy After Stroke: Epidemiology, Biomarkers and Management

Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug-drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors.

Enzyme-inducing antiseizure medication utilization in patients with epilepsy and vascular risk factors

OBJECTIVES

Several lines of evidence have suggested that exposure to enzyme-inducing antiseizure medications (EIASMs) may result in the subsequent development of hyperlipidemia, a well-known risk factor for vascular disease. This may be an issue of concern particularly in the context of additional comorbid vascular risk factors. We therefore aimed to investigate trends of and associations with the use of these medications among adult patients with epilepsy.

METHODS

The cross-sectional Medical Expenditure Panel Survey (MEPS) was interrogated to ascertain the prevalence of use of EIASMs by noninstitutionalized adult patients with epilepsy in the United States between the years 2004 and 2015. Any patient prescribed carbamazepine, phenytoin, phenobarbital, or primidone within a given year was defined as having been prescribed an EIASM. Trends over three-year epochs were evaluated with univariate logistic regression, while associations with demographic factors, vascular risk factors, and vascular disease were evaluated using a chi-square test corrected for survey design as well as multivariate logistic regression.

RESULTS

A total of 2281 (unweighted) patients were identified, representing 1,781,237 individuals. Between 2004 and 2015, 45.9% (95% confidence interval [CI]: 42.4%-49.4%) were prescribed EIASMs. Approximately one-quarter of patients aged 65 years and above used EIASMs compared with 18.5% of younger patients (odds ratio [OR]: 1.83, 95% CI = 1.27-2.65). Female patients (OR = 0.61, 95% CI = 0.47-0.79) and those with heart disease (OR: 0.63, 95% CI = 0.45-0.89) were significantly less likely to be prescribed EIASMs. Among those prescribed EIASMs, 38.9% had hypertension, 12.2% had diabetes, 61.6% were overweight or obese, 17.3% heart disease, 17.2% had a history of a cerebrovascular event, and 28.5% had diagnosed hyperlipidemia. Nonetheless, between 2004-2006 and 2013-2015, the odds of EIASM prescription decreased significantly (OR: 0.39, 95% CI: 0.28-0.55).

CONCLUSIONS

A substantial proportion of patients with comorbid vascular disease or vascular risk factors (e.g., hypertension and older age) is prescribed EIASMs. This could potentially increase patients' risk for subsequent negative outcomes such as cardiovascular or cerebrovascular disease. Though utilization of these medications has decreased, further efforts toward increasing use of newer antiseizure medications (ASMs) that are not associated with similar risks may be warranted.

Recent advancement in the discovery and development of anti-epileptic biomolecules: An insight into structure activity relationship and Docking

Although there have been many advancements in scientific research and development, the cause of epilepsy still remains an open challenge. In spite of high throughput research in the field of anti-epileptic drugs, efficacy void is still prevalent before the researchers. Researchers have persistently been exploring all the possibilities to curb undesirable side effects of the anti-epileptic drugs or looking for a more substantial approach to diminish or cure epilepsy. The drug development has shown a hope to medicinal chemists and researchers to carry further research by going through a substantial literature survey. This review article attempts to describe the recent developments in the anti-epileptic agents, pertaining to different molecular scaffolds considering their structure-activity relationship, docking studies and their mechanism of actions.

Impact of enzyme-inducing anti-epilepsy drugs on lipid levels in elderly patients with epilepsy

It has been speculated that patients with epilepsy in elderly is increasing. The effect of enzyme-inducing antiepileptic drugs (EIAED) on lipid metabolism is well known. However, the study in elderly subjects has been rarely conducted. Furthermore, it has not been directly assessed whether EIAED use causes the change of lipid levels from normal range to abnormal range. Adult patients with epilepsy (235 on EIAED, 213 on non-EIAED) were divided by age (20-64, 65-74 and 75 over years old). Longitudinal change (before starting AED, in 3 and 6 months after starting AED) of serum total cholesterol (TC), triglyceride (TRIG), HDL cholesterol (HDL-C), LDL cholesterol (LDL-C) and non-HDL cholesterol (non-HDL-C) were retrospectively analyzed using mixed models. The risk of change of lipid levels from normal range to abnormal range was also assessed by logistic regression analysis. Comparison between patients with EIAED use (EIAED group) and patients with non-EIAED use (non-EIAED group) revealed significant differences. non-EIAED group was set as reference. Differences in least square mean (LSM), 95 % confidence interval (CI) and P value in analysis of LDL-C and non-HDL-C levels (1 × 10^-2) were as follows: 0.23 (0.10 ∼ 0.36), P < 0.001, 0.22 (0.09 ∼ 0.33), P = 0.001 in patients with age 65-74. In patients of age over 75, those were 0.08 (0.01 ∼ 0.15), P = 0.038, 0.17 (0.07 ∼ 0.26), P < 0.001, respectively. In patients with age 65-74, odds ratios (ORs) (95 % CI) in change of TC, LDL and non-HDL-C level from normal range to abnormal range were 32.28 (1.83-567.05), 48.43 (2.69-869.05), 12.04 (1.29-111.88), respectively. In patients with age 75 over, odds ratios (ORs) (95 % CI) in change of TC, LDL and non-HDL-C level from normal range to abnormal range were 46.02 (2.77-762.89), 5.53 (1.27-23.94), 2.38 (1.01-10.76), respectively. EIAED use had significant impact on changes in lipid levels in elderly patients. Furthermore, we could assess the impact of switching AED from EIAED to levetiracetam (LEV) in 36 patients including elderly. Switching AED from EIAED to LEV had significant impact in reducing TC, TRIG, LDL-C and non-HDL-C in both younger adult and elderly patients.

Management of antiepileptic drug-induced nutrition-related adverse effects

Although antiepileptic drugs (AEDs) are mainstay of the treatment of epilepsy, they are associated with significant adverse effects. The present study reviews the adverse effects of AEDs on some of the nutrition-related issues, including bone health, body weight, glucose and lipid metabolism, vitamin homeostasis, antioxidant defense system, and pregnancy. This paper also provides some nutritional recommendations for people with epilepsy. Patients with epilepsy should be regularly evaluated with regard to their nutrition status and any possible nutritional problems. Daily intake of adequate amounts of all nutrients from various sources should be encouraged, especially for vulnerable groups such as children, adolescents, elderly, and pregnant women. When necessary, preventative or therapeutic supplementation with appropriate micronutrients could be helpful. Graphical abstract.

Epilepsy and aging

The intersection of epilepsy and aging has broad, significant implications. Substantial increases in seizures occur both in the elderly population, who are at a higher risk of developing new-onset epilepsy, and in those with chronic epilepsy who become aged. There are notable gaps in our understanding of aging and epilepsy at the basic and practical levels, which have important consequences. We are in the early stages of understanding the complex relationships between epilepsy and other age-related brain diseases such as stroke, dementia, traumatic brain injury (TBI), and cancer. Furthermore, the clinician must recognize that the presentation and treatment of epilepsy in the elderly are different from those of younger populations. Given the developing awareness of the problem and the capabilities of contemporary, multidisciplinary approaches to advance understanding about the biology of aging and epilepsy, it is reasonable to expect that we will unravel some of the intricacies of epilepsy in the elderly; it is also reasonable to expect that these gains will lead to further improvements in our understanding and treatment of epilepsy for all age groups.

Increased risk of stroke and myocardial infarction in patients with epilepsy: A systematic review of population-based cohort studies

OBJECTIVE

The objective of the study was to review the current epidemiological evidence about the relationship between epilepsy and increased risk of cardio- and cerebrovascular events.

METHODS

We systematically searched MEDLINE (from inception to 19th October 2018) to identify population-based cohort studies evaluating the risk of subsequent stroke or myocardial infarction (MI) in patients with epilepsy without history of prior cerebrovascular disease in comparison with subjects without epilepsy.

RESULTS

A total of 16,641 records were screened, and 6 studies were included. Data on the risk of subsequent stroke and MI were provided by five and two studies, respectively. The adjusted hazard ratios (_adjHRs) of subsequent ischemic stroke for patients with epilepsy ranged from 1.09 (95% confidence interval (CI): 1.00-1.19) to 2.85 (95% CI: 2.49-3.26). Two studies assessing the incidence of hemorrhagic stroke showed an increased risk in patients with epilepsy (_adjHR: 3.30; 95% CI: 2.46-4.43 and _adjHR: 2.27; 95% CI: 1.80-2.85). The _adjHRs of subsequent MI ranged between 1.09 (95% CI: 1.00 to 1.19) and 1.48 (95% CI: 1.31-1.67). Age, hypertension, MI, diabetes, hyperlipidemia, and arteriosclerosis were significantly associated with the increase in stroke risk. A gradient between the antiepileptic drug (AED) dose and risk of subsequent stroke was found. In comparison with carbamazepine (CBZ), oxcarbazepine (OXC) was associated with an increased risk of stroke and valproate (VPA) with a reduction in risk of stroke and MI, whereas no significant associations with vascular disease were found for phenobarbital (PB), lamotrigine (LMT), phenytoin (PHT), clonazepam (CLZ), and clobazam (CLB).

CONCLUSIONS

Patients with epilepsy are at higher risk of subsequent stroke and MI in comparison with subjects without epilepsy. Although individual AEDs may carry different risks of cardio- and cerebrovascular disease, the clinical relevance of the metabolic effects of the enzyme-inducing AEDs is still uncertain. This article is part of the Special Issue "Seizures & Stroke".

The Impact of Antiepileptic Drugs on Thyroid Function in Children with Epilepsy: New Versus Old

OBJECTIVES

To investigate the effects of traditional antiepileptic drugs (AEDs) versus newer AEDs on the thyroid hormone profile of children with epilepsy.

MATERIALS & METHODS

A total of 80 children with epilepsy were included in this study and were divided into two groups. Group 1 included 40 children with epilepsy on traditional AEDs, and group 2 included 40 children with epilepsy on newer AEDs. Forty healthy children were also included as the control group (group 3). We analyzed the serum levels of free triiodothyronine (FT3), free thyroxine (FT4), and thyroid stimulating hormone (TSH).

RESULTS

In epileptic children treated with traditional drugs, there was a significant reduction in the serum level of FT4 and a significant increase in TSH concentration, compared to the control group (P<0.001). Conversely, epileptic children treated with newer AEDs showed no significant changes in the serum concentrations of FT3, FT4, and TSH, compared to the control group.

CONCLUSION

Traditional AEDs have more significant effects on thyroid hormone profile, compared to newer AEDs.

Markers of bone and lipid metabolism with eslicarbazepine acetate monotherapy

OBJECTIVE

To evaluate the impact of eslicarbazepine acetate (ESL) monotherapy on markers of bone and lipid metabolism.

METHODS

We conducted a post-hoc analysis of data pooled from two Phase III, dose-blind, conversion-to-ESL (1600 mg and 1200 mg) monotherapy studies in patients with focal seizures. Laboratory measurements included lipids (total cholesterol [TC]; high-density lipoprotein cholesterol [HDL-C]; low-density lipoprotein cholesterol; and triglycerides) and markers of bone metabolism (alkaline phosphatase; 25-hydroxyvitamin D; osteocalcin; and parathyroid hormone [PTH]); measurements were taken at baseline, Week 18, and Month 12, and analyzed according to enzyme-inducing antiepileptic drugs (EIAEDs) use at baseline (+EIAED and -EIAED subgroups).

RESULTS

Data from 337 treatment-compliant patients were used for the Week 18 analyses (+EIAED subgroup, n = 119; -EIAED subgroup, n = 218); data from 161 treatment-compliant patients were used for the Month 12 analyses (+EIAED subgroup, n = 53; -EIAED subgroup, n = 108). At baseline, alkaline phosphatase and PTH concentrations were higher in the + EIAED versus -EIAED subgroup. Changes from baseline in markers of bone turnover were generally insignificant, except for some elevation in alkaline phosphatase in the -EIAED subgroup (18 weeks and 12 months) and osteocalcin in both subgroups (18 weeks only). Regarding lipids, TC and HDL-C concentrations were higher in the + EIAED versus -EIAED subgroup at baseline. Concentrations of markers of lipid metabolism fell in the + EIAED group and rose in the -EIAED group, reaching very similar values that were intermediate between the -EIAED and + EIAED baseline values.

CONCLUSIONS

Based on this retrospective analysis, ESL seems to have had only a modest and primarily clinically insignificant impact on plasma lipids. More prospective data are needed to definitively ascertain the effects of ESL on bone metabolism.

Mood stabilisers and risk of stroke in bipolar disorder

BACKGROUND

Research on the risk of stroke following the use of mood stabilisers specific to patients with bipolar disorder is limited.AimsIn this study, we investigated the risk of stroke following the exposure to mood stabilisers in patients with bipolar disorder.

METHOD

Data for this nationwide population-based study were derived from the Taiwan National Health Insurance Research Database. Among a retrospective cohort of patients with bipolar disorder (n = 19 433), 609 new-onset cases of stroke were identified from 1999 to 2012. A case-crossover study design utilising 14-day windows was applied to assess the acute exposure effect of individual mood stabilisers on the risk of ischaemic, haemorrhagic and other types of stroke in patients with bipolar disorder.

RESULTS

Mood stabilisers as a group were significantly associated with the increased risk of stroke in patients with bipolar disorder (adjusted risk ratio, 1.26; P = 0.041). Among individual mood stabilisers, acute exposure to carbamazepine had the highest risk of stroke (adjusted risk ratio, 1.68; P = 0.018), particularly the ischaemic type (adjusted risk ratio, 1.81; P = 0.037). In addition, acute exposure to valproic acid elevated the risk of haemorrhagic stroke (adjusted risk ratio, 1.76; P = 0.022). In contrast, acute exposure to lithium and lamotrigine did not significantly increase the risk of any type of stroke.

CONCLUSIONS

Use of carbamazepine and valproic acid, but not lithium and lamotrigine, is associated with increased risk of stroke in patients with bipolar disorder.Declaration of interestNone.

Concentrations of the Selected Biomarkers of Endothelial Dysfunction in Response to Antiepileptic Drugs: A Literature Review

Epilepsy is a disease arising from morphological and metabolic changes in the brain. Approximately 60% of patients with seizures can be controlled with 1 antiepileptic drug (AED), while in others, polytherapy is required. The AED treatment affects a number of biochemical processes in the body, including increasing the risk of cardiovascular diseases (CVDs). It is indicated that the duration of AED therapy with some AEDs significantly accelerates the process of atherosclerosis. Most of AEDs increase levels of homocysteine (HCys) as well as may affect concentrations of new, nonclassical risk factors for atherosclerosis, that is, asymmetric dimethylarginine (ADMA) and homoarginine (hArg). Because of the role of these parameters in the pathogenesis of CVD, knowledge of HCys, ADMA, and hArg concentrations in patients with epilepsia treated with AED, both pediatric and adult, appears to be of significant importance.

Impact of carbamazepine, lamotrigine, and levetiracetam on vascular risk markers and lipid-lowering agents in the elderly

OBJECTIVE

To examine serologic markers of vascular risk under treatment with commonly used antiepileptic drugs (AEDs) in the elderly in a randomized setting, and to determine whether the reduced exposure to hydroxymethylglutaryl-CoA reductase inhibitors ("statins") caused by carbamazepine reduces the effectiveness of the drugs as lipid-lowering agents.

METHODS

Standard lipid fractions, lipoprotein(a), and C-reactive protein (CRP) were examined in a subset of those participating in the STEP-ONE trial, in which elderly patients with new epilepsy were randomized to treatment with carbamazepine, lamotrigine, or levetiracetam. Separate comparisons were made by individual AED, among those treated with statins, and, for CRP, among those treated with anti-inflammatory drugs.

RESULTS

One hundred ninety-four patients had the aforementioned serologic measurements. In patients not taking statins, those treated with carbamazepine had higher total cholesterol than those treated with levetiracetam (+16.6 mg/dL, P = 0.053), with values from patients on lamotrigine intermediate, whereas cholesterol fractions were subject to drug-gender interactions which did not show a consistent pattern. Lipoprotein(a) was significantly lower in lamotrigine patients than in the carbamazepine and levetiracetam groups. After accounting for the effects of steroids, CRP was higher in carbamazepine patients than in other patients. Patients taking a statin had lower lipid levels than those not taking a statin regardless of AED, but the differences between statin-treated and non-statin-treated patients were much larger (50%-100% or more) in the lamotrigine and levetiracetam groups than in the carbamazepine group (P = 0.035 for interaction effect of statin use and AED on total cholesterol).

SIGNIFICANCE

Here, we demonstrate that carbamazepine significantly interferes with the ability of statins to lower total cholesterol, thus making it a poor choice for hyperlipidemic patients or those with cardiovascular disease. Native AED effects on lipids were inconsistent and subject to drug-gender interaction, in contrast with other studies; further investigation is necessary to determine if these latter findings are genuine or spurious.

Psychotropic use and risk of stroke among patients with bipolar disorders: 10-year nationwide population based study

OBJECTIVES

To investigate the association between psychotropic agents (including antipsychotics, antidepressants and mood stabilizers) and risk of stroke among patients with bipolar disorders.

METHODS

We conducted a disease risk score-matched nested case-control study and identified patients with bipolar disorders (ICD-9 codes: 296.0x, 296.1x, 296.4x, 296.5x, 296.6x, 296.7x, 296.80, 296.81 or 296.89) from the National Health Insurance Research Database in Taiwan. Among them, we identified 1232 cases (981 were ischemic stroke and 251 were hemorrhagic stroke) and 5314 disease risk score-matched controls. Conditional logistic regression model equations were applied to determine the effect of psychotropic agents on stroke risk among patients with bipolar disorders.

RESULTS

The results indicated that overall use of psychotropic agents was associated with an increased risk of stroke (adjusted odds ratio [AOR] = 1.82; 95% confidence interval [CI]: 1.56-2.13). When classifying psychotropic agents into antipsychotics, antidepressants and mood stabilizers, respectively, a significant positive association was found for users of antipsychotics (AOR = 1.98; 95% CI = 1.53-2.56), antidepressants (AOR = 1.44; 95% CI = 1.16-1.79), and mood stabilizers (AOR = 1.89; 95% CI = 1.22-2.93). Combined use of psychotropic agents was associated with higher risk of stroke than monotherapy (AOR = 2.62; 95% CI = 1.98-3.45).

DISCUSSIONS

The results support our hypothesis that psychotropic use is associated with increased risk of stroke among patients with bipolar disorders. The stroke risks are higher among patients with polypharmacy than those with monotherapy. These findings warrant further investigation to confirm and replicate the findings using different methodologies and populations, and to mitigate residual confounding.

Coronary heart disease risk in patients with schizophrenia: a Lebanese cross-sectional study

Background:

Coronary heart disease (CHD) is a leading cause of premature death in patients with schizophrenia. CHD risk in Lebanese patients with schizophrenia remains unknown.

Objectives:

To (i) evaluate CHD risk of patients with schizophrenia in Lebanon; and (ii) detect the modifiable and non-modifiable factors affecting this risk.

Methods:

Cross-sectional study of 329 patients with schizophrenia aged 20–75 years. Ten-year hard CHD risk was calculated using the Framingham risk score. A logistic regression was conducted taking the dichotomous hard CHD (<10% and ≥10%) as the dependent variable.

Results:

Ten-year hard CHD risk was low (<10%) in 60.8% of patients, intermediate (10–20%) in 31.6%, and high (>20%) in 7.6%. Multivariate analysis showed that the mean 10-year hard CHD risk was 8.76±6.92 (10.82±6.83 in men and 3.18±2.90 in women). Ten-year hard CHD risk was higher in patients with the metabolic syndrome (odds ratio [OR] 2.67, confidence interval [CI] 1.54–4.64), a longer duration of schizophrenia (OR 1.03, CI 1.01–1.05), a history of other medical illnesses (OR 2.02, CI 1.18–3.47), and in those participating in art therapy (OR 2.13, CI 1.25–3.64) or therapeutic education (OR 1.93, CI 0.93–4.01). Ten-year hard CHD risk was lower in patients receiving risperidone (OR 0.23, CI 0.08–0.68), any anti-epileptic (OR 0.41, CI 0.24–0.73), or any benzodiazepine (OR 0.33, CI 0.17–0.66) medication.

Conclusion:

CHD is prevalent in patients with schizophrenia in Lebanon. Physicians are recommended to monitor the components of the metabolic syndrome to identify patients with increased risk of cardiovascular diseases.

Assessment of atherosclerotic risk among patients with epilepsy on valproic acid, lamotrigine, and carbamazepine treatment

OBJECTIVE

To compare the long-term effects of carbamazepine (CBZ), valproic acid (VPA), and lamotrigine (LTG) as monotherapy on the markers of vascular risk.

METHODS

The present cross-sectional study was carried out at the Department of Neurology, Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan, from 2012 to 2013. We selected 120 adult patients with epilepsy and 40 control subjects. The patients with epilepsy were divided into 3 groups according to the use of antiepileptic drugs (AEDs) (CBZ, n = 40; VPA, n = 40; and LTG, n = 40). All participants` total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-c), very low-density lipoprotein cholesterol (VLDL-c), high-density lipoprotein cholesterol (HDL-c), ratio of TC/HDL-c, ratio of LDL-c/HDL-c, body mass index (BMI), and blood pressure was determined.

RESULTS

In patients with epilepsy, CBZ and VPA treatment caused a noteworthy increase in the concentrations of TG, TC, and LDL-c compared with LTG treatment and the control group (p<0.001). The HDL-c significantly decreased in CBZ, VPA, and LTG-treated patients as compared with controls (p<0.001). The ratio of LDL-c/HDL-c and TC/HDL-c significantly increased in VPA- and CBZ-treated groups compared with the LTG-treated, and control group, while the ratio was also considerably elevated in patients treated with CBZ as compared with the patients treated with VPA. The weight and BMI of the patients treated with AEDs were higher (p<0.01).

CONCLUSION

Patients with epilepsy on CBZ or VPA have changed vascular risk markers that may lead to atherosclerosis, while LTG-treated patients have less alteration in lipid profile.

Trimetazidine potentiates the antiepileptic activity and ameliorates the metabolic changes associated with pentylenetetrazole kindling in rats treated with valproic acid

Oxidative stress is implicated in epileptogenesis as well as in the metabolic changes associated with increased risk of atherosclerotic vascular disease in epilepsy. The present work investigated the impact of the antioxidant trimetazidine (TMZ) on the antiepileptic activity of valproic acid (VPA) and on the metabolic and histological changes in hippocampal, aortic, and hepatic tissues associated with epilepsy and (or) VPA. Rats were divided into non-pentylenetetrazole (non-PTZ) group subdivided into control and VPA-treated groups, and PTZ-treated group subdivided into PTZ, PTZ/VPA, PTZ/TMZ, and PTZ/VPA + TMZ groups. VPA treatment in PTZ rats resulted in an antioxidant effect with improvement in oxidative stress, metabolic and histopathological changes induced by PTZ in hippocampus, aortic, and hepatic tissues. TMZ exhibited anticonvulsant activity and potentiated the anticonvulsant effect of VPA. Combination of TMZ with VPA induced a greater reduction in oxidative stress, improvement in the metabolic and histopathological changes compared to VPA treatment. In contrast, VPA administration in non-PTZ-treated rats induced a pro-oxidative effect, associated with metabolic and histopathological changes in aortic and hepatic tissues. These findings suggest that co-administration of TMZ with VPA in epilepsy might antagonize not only the oxidative stress associated with epilepsy but might also counteract a potential pro-oxidative effect of VPA.

The heart of epilepsy: Current views and future concepts

Cardiovascular (CV) comorbidities are common in people with epilepsy. Several mechanisms explain why these conditions tend to co-exist including causal associations, shared risk factors and those resulting from epilepsy or its treatment. Various arrhythmias occurring during and after seizures have been described. Ictal asystole is the most common cause. The converse phenomenon, arrhythmias causing seizures, appears extremely rare and has only been reported in children following cardioinihibitory syncope. Arrhythmias in epilepsy may not only result from seizure activity but also from a shared genetic susceptibility. Various cardiac and epilepsy genes could be implicated but firm evidence is still lacking. Several antiepileptic drugs (AEDs) triggering conduction abnormalities can also explain the co-existence of arrhythmias in epilepsy. Epidemiological studies have consistently shown that people with epilepsy have a higher prevalence of structural cardiac disease and a poorer CV risk profile than those without epilepsy. Shared CV risk factors, genetics and etiological factors can account for a significant part of the relationship between epilepsy and structural cardiac disease. Seizure activity may cause transient myocardial ischaemia and the Takotsubo syndrome. Additionally, certain AEDs may themselves negatively affect CV risk profile in epilepsy. Here we discuss the fascinating borderland of epilepsy and cardiovascular conditions. The review focuses on epidemiology, clinical presentations and possible mechanisms for shared pathophysiology. It concludes with a discussion of future developments and a call for validated screening instruments and guidelines aiding the early identification and treatment of CV comorbidity in epilepsy.

Does valproate therapy in epileptic patients contribute to changing atherosclerosis risk factors? The role of lipids and free fatty acids

BACKGROUND

We aimed to demonstrate the relationship between the valproate (VPA) treatment versus lipid and serum free fatty acids (FFAs) profiles to be the potential atherosclerosis risk factor in epileptic patients.

METHODS

Fasting blood samples were taken from 21 adult VPA-treated patients and 21 controls. The profiles of lipids, FFAs, clinical parameters and body mass index (BMI) were evaluated.

RESULTS

No significant differences between the study group and controls were found for any of the studied parameters. However, significant differences in the total cholesterol (CHOL), low-density-lipoprotein cholesterol (LDL), triglycerides, the CHOL/HDL (high-density-lipoprotein cholesterol) ratio, and Atherogenic Index of Plasma were observed for overweight patients when compared to those of normal weight. Patients with uncontrolled epilepsy tended to have significantly lower palmitic acid level than seizure-free patients. Oleic acid was found to be positively correlated with VPA concentration for patients with uncontrolled epilepsy, and with the dose corrected VPA concentration for all the patients. The acid was however negatively correlated with stearic acid for both the controls and the patients with uncontrolled epilepsy. PLS method revealed CHOL, LDL, triglycerides and myristic acid to be positively interrelated for the whole group under the study, whereas these parameters were found to be negatively correlated with VPA concentration, and positively with BMI. Furthermore, high sensitivity C-reactive protein was found to be negatively correlated with palmitic acid levels.

CONCLUSION

Overweight VPA-treated patients are exposed to higher risk of atherosclerosis. Alterations in FFAs are likely to depend on seizures control, and on VPA levels.

Comparative effectiveness of levetiracetam, valproate and carbamazepine among elderly patients with newly diagnosed epilepsy: subgroup analysis of the randomized, unblinded KOMET study

Background

Few clinical trials have evaluated the efficacy and tolerability of antiepileptic drugs (AEDs) as initial monotherapy for elderly patients.

Methods

This post-hoc subgroup analysis of data from an unblinded, randomized, 52-week superiority study (KOMET) compared the effectiveness of levetiracetam (LEV) with extended-release sodium valproate (VPA-ER) and controlled-release carbamazepine (CBZ-CR) as monotherapy in patients aged ≥ 60 years with newly diagnosed epilepsy. The physician chose VPA or CBZ as preferred standard treatment; patients were randomized to standard AEDs or LEV. The primary endpoint was time to treatment withdrawal. Results are exploratory, since KOMET was not powered for a subgroup analysis by age.

Results

Patients (n = 308) were randomized to LEV (n = 48) or VPA-ER (n = 53) in the VPE-ER stratum or to LEV (n = 104) or CBZ-CR (n = 103) in the CBZ-CR stratum. Mean age was 69.6 years, range 60.2–89.9 years (intention-to-treat population n = 307). Time to treatment withdrawal hazard ratio [HR] (95 % confidence interval [CI]) for LEV vs. standard AEDs was 0.44 (0.28–0.67); LEV vs. VPA-ER: 0.46 (0.16–1.33); LEV vs. CBZ-CR: 0.45 (0.28–0.72). Twelve-month withdrawal rates were: LEV vs. standard AEDs, 20.4 vs. 38.7 %; LEV vs. VPA-ER, 10.4 vs. 23.1 %; LEV vs. CBZ-CR, 25.0 vs. 46.6 %. Time to first seizure was similar between LEV and standard AEDs (HR: 0.92, 95 % CI: 0.63–1.35), LEV and VPA-ER (0.77, 0.38–1.56), and LEV and CBZ-CR (1.02, 0.64–1.63). Adverse events were reported by 76.2, 67.3, and 82.5 % of patients for LEV, VPA-ER, and CBZ-CR, respectively. Discontinuation rates due to AEs were 11.3, 10.2, and 35.0 % for LEV, VPA-ER, and CBZ-CR, respectively.

Conclusions

Time to treatment withdrawal was longer with LEV compared with standard AEDs. This finding was driven primarly by the result in the CBZ-CR stratum, which in turn was likely due to the more favorable tolerability profile of LEV. Results of this post-hoc analysis suggest that LEV may be a suitable option for initial monotherapy for patients aged ≥ 60 years with newly diagnosed epilepsy.

Trial registration

ClinicalTrials.gov: NCT00175903; September 9, 2005.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0663-7) contains supplementary material, which is available to authorized users.

Long-term effect of antiepileptic drug switch on serum lipids and C-reactive protein

BACKGROUND

Prior studies have shown that switching patients from inducing antiepileptic drugs (AEDs) to lamotrigine, levetiracetam, or topiramate reduces serum lipids and C-reactive protein (CRP). These studies were all of short duration, and some drugs, such as zonisamide, have not been investigated.

METHODS

We recruited 41 patients taking phenytoin or carbamazepine who were being switched to zonisamide, lamotrigine, or levetiracetam. We measured serum lipids and CRP before the switch, >6weeks after, and >6months after. An untreated control group (n=14) underwent similar measurement. We combined these data with those of our previous investigation (n=34 patients and 16 controls) of a very similar design.

RESULTS

There were no differences in outcome measures between the two inducing AEDs nor among the three noninducing AEDs. Total cholesterol (TC), atherogenic lipids, and CRP were higher under inducer treatment than in controls. All measures were elevated under inducer treatment relative to noninducer treatment, including TC (24mg/dL higher, 95% CI: 17.5-29.9, p<0.001) and CRP (72% higher, 95% CI: 41%-111%, p<0.001). The difference between drug treatments was clinically meaningful for atherogenic lipids (16%, 95% CI: 11%-20%, p<0.001) but small for high-density lipoprotein cholesterol (5%, 95% CI: 1%-9%, p<0.05). All measures were stable between 6weeks and 6months after drug switch.

CONCLUSIONS

We demonstrate that switching from inducing to noninducing AEDs produces an enduring reduction in serum lipids and CRP. These results provide further evidence that inducing AEDs may be associated with elevated vascular disease risk. These are the first vascular risk marker data in patients taking zonisamide, which shows a profile similar to that of other noninducing AEDs.

The New Antiepileptic Drugs: Their Neuropharmacology and Clinical Indications

The administration of antiepileptic drugs (AEDs) is the first treatment of epilepsy, one of the most common neurological diseases. Therapeutic guidelines include newer AEDs as front-line drugs; monotherapy with new AEDs is delivered in Japan. While about 70% of patients obtain good seizure control by taking one to three AEDs, about 60% experience adverse effects and 33% have to change drugs. Compared to traditional AEDs, the prolonged administration of new AEDs elicits fewer adverse effects and fewer drug interactions and their teratogenicity may be lower. These characteristics increase drug compliance and allow combination therapy for drug-resistant epilepsy, although the antiepileptic effects of the new AEDs are not greater than of traditional AEDs. Comorbidities are not rare in epileptics; many adult patients present with stroke and brain tumors. In stroke patients requiring risk control and in chemotherapy-treated brain tumor patients, their fewer drug interactions render the new AEDs advantageous. Also, new AEDs offer favorable side benefits for concurrent diseases and conditions. Patients with stroke and traumatic brain injury often present with psychiatric/behavioral symptoms and cognitive impairment and some new AEDs alleviate such symptoms. This review presents an outline of the new AEDs used to treat adult patients based on the pharmacological activity of the drugs and discusses possible clinical indications from the perspective of underlying causative diseases and comorbidities.

Cognitive deterioration in adult epilepsy: Does accelerated cognitive ageing exist?

A long-standing concern has been whether epilepsy contributes to cognitive decline or so-called 'epileptic dementia'. Although global cognitive decline is generally reported in the context of chronic refractory epilepsy, it is largely unknown what percentage of patients is at risk for decline. This review is focused on the identification of risk factors and characterization of aberrant cognitive trajectories in epilepsy. Evidence is found that the cognitive trajectory of patients with epilepsy over time differs from processes of cognitive ageing in healthy people, especially in adulthood-onset epilepsy. Cognitive deterioration in these patients seems to develop in a 'second hit model' and occurs when epilepsy hits on a brain that is already vulnerable or vice versa when comorbid problems develop in a person with epilepsy. Processes of ageing may be accelerated due to loss of brain plasticity and cognitive reserve capacity for which we coin the term 'accelerated cognitive ageing'. We believe that the concept of accelerated cognitive ageing can be helpful in providing a framework understanding global cognitive deterioration in epilepsy.