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Lin CH, Ho CJ, Chen SY, Lu YT, Tsai MH. Review of pharmacogenetics of antiseizure medications: focusing on genetic variants of mechanistic targets. Front Pharmacol 2024; 15:1411487. [PMID: 39228521 PMCID: PMC11368862 DOI: 10.3389/fphar.2024.1411487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 08/08/2024] [Indexed: 09/05/2024] Open
Abstract
Antiseizure medications (ASMs) play a central role in seizure management, however, unpredictability in the response to treatment persists, even among patients with similar seizure manifestations and clinical backgrounds. An objective biomarker capable of reliably predicting the response to ASMs would profoundly impact epilepsy treatment. Presently, clinicians rely on a trial-and-error approach when selecting ASMs, a time-consuming process that can result in delays in receiving alternative non-pharmacological therapies such as a ketogenetic diet, epilepsy surgery, and neuromodulation therapies. Pharmacogenetic studies investigating the correlation between ASMs and genetic variants regarding their mechanistic targets offer promise in predicting the response to treatment. Sodium channel subunit genes have been extensively studied along with other ion channels and receptors as targets, however, the results have been conflicting, possibly due to methodological disparities including inconsistent definitions of drug response, variations in ASM combinations, and diversity of genetic variants/genes studied. Nonetheless, these studies underscore the potential effect of genetic variants on the mechanism of ASMs and consequently the prediction of treatment response. Recent advances in sequencing technology have led to the generation of large genetic datasets, which may be able to enhance the predictive accuracy of the response to ASMs.
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Affiliation(s)
- Chih-Hsiang Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chen-Jui Ho
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shih-Ying Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yan-Ting Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
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Roberti R, Assenza G, Bisulli F, Boero G, Canafoglia L, Chiesa V, Di Bonaventura C, Di Gennaro G, Elia M, Ferlazzo E, Giordano A, La Neve A, Liguori C, Meletti S, Operto FF, Pietrafusa N, Puligheddu M, Pulitano P, Rosati E, Sammarra I, Tartara E, Vatti G, Villani F, Russo E, Lattanzi S. Adjunctive cenobamate in people with focal onset seizures: Insights from the Italian Expanded Access Program. Epilepsia 2024. [PMID: 39140704 DOI: 10.1111/epi.18091] [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: 05/21/2024] [Revised: 07/27/2024] [Accepted: 07/29/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE This study was undertaken to assess the effectiveness/tolerability of adjunctive cenobamate, variations in the load of concomitant antiseizure medications (ASMs) and predictors of clinical response in people with focal epilepsy. METHODS This was a retrospective study at 21 centers participating in the Italian Expanded Access Program. Effectiveness outcomes included retention and responder rates (≥50% and 100% reduction in baseline seizure frequency). Tolerability/safety outcomes included the rate of treatment discontinuation due to adverse events (AEs) and their incidence. Total drug load was quantified as the number of concomitant ASMs and total defined daily dose (DDD). Concomitant ASMs were also classified according to their mechanism of action and pharmacokinetic interactions to perform explorative subgroup analyses. RESULTS A total of 236 subjects with a median age of 38 (Q1-Q3 = 27-49) years were included. At 12 months, cenobamate retention rate was 78.8% and responders were 57.5%. The seizure freedom rates during the preceding 3 months were 9.8%, 12.2%, 16.3%, and 14.0% at 3, 6, 9, and 12 months. A higher percentage of responders was observed among subjects treated with clobazam, although the difference was not statistically significant. A total of 223 AEs were recorded in 133 of 236 participants, leading to cenobamate discontinuation in 8.5% cases. At 12 months, a reduction of one or two concomitant ASMs occurred in 42.6% and 4.3% of the subjects. The median total DDD of all concomitant ASMs decreased from 3.34 (Q1-Q3 = 2.50-4.47) at baseline to 2.50 (Q1-Q3 = 1.67-3.50) at 12 months (p < .001, median percentage reduction = 22.2%). The highest rates of cotreatment withdrawal and reductions in the DDD were observed for sodium channel blockers and γ-aminobutyric acidergic modulators (above all for those linked to pharmacokinetic interactions), and perampanel. SIGNIFICANCE Adjunctive cenobamate was associated with a reduction in seizure frequency and in the burden of concomitant ASMs in adults with difficult-to-treat focal epilepsy. The type of ASM associated did not influence effectiveness except for a favorable trend with clobazam.
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Affiliation(s)
- Roberta Roberti
- Science of Health Department, Magna Graecia University, Catanzaro, Italy
| | - Giovanni Assenza
- Department of Medicine and Surgery, Research Unit of Neurology, Università Campus Bio-Medico, Rome, Italy
- Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Francesca Bisulli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Istituto di Ricovero e Cura a Carattere Scientifico Istituto delle Scienze Neurologiche di Bologna, full member of the European Reference Network EpiCARE, Bologna, Italy
| | - Giovanni Boero
- Complex Structure of Neurology Hospital Santissima, Annunziata, Taranto, Italy
| | - Laura Canafoglia
- Epilepsy Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milan, Italy
| | - Valentina Chiesa
- Epilepsy Center, Azienda Socio Sanitaria Territoriale Santi Paolo Carlo, Milan, Italy
| | | | | | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico, Troina, Italy
| | - Edoardo Ferlazzo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
- Great Metropolitan Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Alfonso Giordano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Angela La Neve
- Dipartimento di Biomedicina Traslazionale e Neuroscienze, University Hospital of Bari "A. Moro", Bari, Italy
| | - Claudio Liguori
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Neurology Unit, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Stefano Meletti
- Neurophysiology Unit and Epilepsy Center, Azienda Ospedaliero Universitaria, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena and Reggio Emilia, Italy
| | | | - Nicola Pietrafusa
- Clinical and Experimental Neurology, full member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Monica Puligheddu
- Epilepsy Center, Neurology Unit, Azienda Ospedaliero Universitaria, Cagliari, Italy
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | | | - Ilaria Sammarra
- Institute of Neurology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Elena Tartara
- Istituto di Ricovero e Cura a Carattere Scientifico Mondino Foundation, Epilepsy Center, full member of European Reference Network EpiCARE, Pavia, Italy
| | - Giampaolo Vatti
- Unità Operativa Complessa Neurology and Clinical Neurophysiology, University Hospital of Siena, Siena, Italy
| | - Flavio Villani
- Division of Clinical Neurophysiology and Epilepsy Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Martino, Genoa, Italy
| | - Emilio Russo
- Science of Health Department, Magna Graecia University, Catanzaro, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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Paprocka J, Steinborn B, Krygier M, Winczewska-Wiktor A, Przyslo L, Hutny M, Hoffman-Zacharska D, Mazurkiewicz H, Kochanowska I, Zebrowska J, Zawadzka M, Piasecki L, Mazurkiewicz-Beldzinska M. Genotype-phenotype correlations in Polish patients with SCN8A-related epilepsy: A multicentre observational study. Seizure 2024; 120:201-209. [PMID: 39047613 DOI: 10.1016/j.seizure.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Voltage-gated sodium channels are involved in the initial depolarisation of neurones. As such, they play important roles in neurotransmission. Variants in the genes encoding these channels may lead to altered functionality and neurodevelopmental disorders. Pathogenic variants of SCN8A, which encodes the voltage-gated Na+ channel Nav1.6, have been associated with various encephalopathies characterised by developmental delay and epileptic seizures. Herein, we discuss the genotype-phenotype associations in a group of 17 novel Polish patients with SCN8A mutations, further expanding the molecular and phenotypic spectrum of SCN8A-related diseases. METHODS The participants were recruited from five clinical centres in Poland. Pathogenic and likely pathogenic SCN8A variants were identified using a next-generation sequencing (NGS) panel and exome sequencing, respectively. Magnetic resonance imaging (MRI) and electroencephalography (EEG) recordings were performed to obtain relevant clinical data on brain malformations and epileptic seizures. RESULTS Three phenotypes were observed in the study group: developmental and epileptic encephalopathy, early onset epileptic encephalopathy, and neurodevelopmental disorders without epilepsy. Patients in the first two phenotypic subgroups presented with epileptic seizures within the first few months of life. Their semiology evolved with age, comprising mostly tonic, clonic, and tonic-clonic seizures, with eyelid myoclonia, myoclonic seizures, and epileptic spasms. The most prevalent neurological feature was developmental delay. Alterations in muscle tone were more frequent than in previous reports. CONCLUSIONS Seventeen patients with 11 novel mutations in SCN8A had alterations in muscular tone accompanied by typical features of SCN8A-related encephalopathies (i.e., developmental delay and a wide range of seizures).
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Affiliation(s)
- Justyna Paprocka
- Department of Pediatric Neurology, Medical University of Silesia, Katowice, Poland.
| | | | - Magdalena Krygier
- Department of Developmental Neurology, Medical University of Gdansk, Gdansk, Poland
| | | | - Lukasz Przyslo
- Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Michał Hutny
- Student's Scientific Society, Department of Pediatric Neurology, Medical University of Silesia, Katowice, Poland
| | | | - Hanna Mazurkiewicz
- Clinic of Pediatric Neurology, Institute of Mother and Child, Warsaw, Poland
| | - Iwona Kochanowska
- Individual Medical Practice in Pediatric Neurology, Szczecin, Poland
| | - Joanna Zebrowska
- Clinic of Pediatric Neurology, Institute of Mother and Child, Warsaw, Poland
| | - Marta Zawadzka
- Department of Developmental Neurology, Medical University of Gdansk, Gdansk, Poland
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Li M, Jin Y, Wu J, Zhao M, Yu K, Yu H. Arbidol, an antiviral drug, identified as a sodium channel blocker with anticonvulsant activity. Br J Pharmacol 2024. [PMID: 38982721 DOI: 10.1111/bph.16496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 05/24/2024] [Accepted: 05/30/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND AND PURPOSE Sodium channel blockers (SCBs) have traditionally been utilized as anti-seizure medications by primarily targeting the inactivation process. In a drug discovery project aiming at finding potential anticonvulsants, we have identified arbidol, originally an antiviral drug, as a potent SCB. In order to evaluate its anticonvulsant potential, we have thoroughly examined its biophysical properties as well as its effects on animal seizure models. EXPERIMENTAL APPROACH Patch clamp recording was used to investigate the electrophysiological properties of arbidol, as well as the binding and unbinding kinetics of arbidol, carbamazepine and lacosamide. Furthermore, we evaluated the anticonvulsant effects of arbidol using three different seizure models in male mice. KEY RESULTS Arbidol effectively suppressed neuronal epileptiform activity by blocking sodium channels. Arbidol demonstrated a distinct mode of action by interacting with both the fast and slow inactivation of Nav1.2 channels compared with carbamazepine and lacosamide. A kinetic study suggested that the binding and unbinding rates might be associated with the specific characteristics of these three drugs. Arbidol targeted the classical binding site of local anaesthetics, effectively inhibited the gain-of-function effects of Nav1.2 epileptic mutations and exhibited varying degrees of anticonvulsant effects in the maximal electroshock model and subcutaneous pentylenetetrazol model but had no effect in the pilocarpine-induced status epilepticus model. CONCLUSIONS AND IMPLICATIONS Arbidol shows promising potential as an anticonvulsant agent, providing a unique mode of action that sets it apart from existing SCBs.
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Affiliation(s)
- Min Li
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Yuchen Jin
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Jun Wu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Miao Zhao
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Kexin Yu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Haibo Yu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
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5
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Johnson JP, Focken T, Karimi Tari P, Dube C, Goodchild SJ, Andrez JC, Bankar G, Burford K, Chang E, Chowdhury S, Christabel J, Dean R, de Boer G, Dehnhardt C, Gong W, Grimwood M, Hussainkhel A, Jia Q, Khakh K, Lee S, Li J, Lin S, Lindgren A, Lofstrand V, Mezeyova J, Nelkenbrecher K, Shuart NG, Sojo L, Sun S, Waldbrook M, Wesolowski S, Wilson M, Xie Z, Zenova A, Zhang W, Scott FL, Cutts AJ, Sherrington RP, Winquist R, Cohen CJ, Empfield JR. The contribution of Na V1.6 to the efficacy of voltage-gated sodium channel inhibitors in wild type and Na V1.6 gain-of-function (GOF) mouse seizure control. Br J Pharmacol 2024. [PMID: 38922847 DOI: 10.1111/bph.16481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/19/2024] [Accepted: 05/15/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND AND PURPOSE Inhibitors of voltage-gated sodium channels (NaVs) are important anti-epileptic drugs, but the contribution of specific channel isoforms is unknown since available inhibitors are non-selective. We aimed to create novel, isoform selective inhibitors of Nav channels as a means of informing the development of improved antiseizure drugs. EXPERIMENTAL APPROACH We created a series of compounds with diverse selectivity profiles enabling block of NaV1.6 alone or together with NaV1.2. These novel NaV inhibitors were evaluated for their ability to inhibit electrically evoked seizures in mice with a heterozygous gain-of-function mutation (N1768D/+) in Scn8a (encoding NaV1.6) and in wild-type mice. KEY RESULTS Pharmacologic inhibition of NaV1.6 in Scn8aN1768D/+ mice prevented seizures evoked by a 6-Hz shock. Inhibitors were also effective in a direct current maximal electroshock seizure assay in wild-type mice. NaV1.6 inhibition correlated with efficacy in both models, even without inhibition of other CNS NaV isoforms. CONCLUSIONS AND IMPLICATIONS Our data suggest NaV1.6 inhibition is a driver of efficacy for NaV inhibitor anti-seizure medicines. Sparing the NaV1.1 channels of inhibitory interneurons did not compromise efficacy. Selective NaV1.6 inhibitors may provide targeted therapies for human Scn8a developmental and epileptic encephalopathies and improved treatments for idiopathic epilepsies.
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Affiliation(s)
- James P Johnson
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Thilo Focken
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Parisa Karimi Tari
- Department of In Vivo Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Celine Dube
- Department of In Vivo Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Samuel J Goodchild
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | | | - Girish Bankar
- Department of In Vivo Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Kristen Burford
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Elaine Chang
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Sultan Chowdhury
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Jessica Christabel
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Richard Dean
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Gina de Boer
- Department of Compound Properties, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Christoph Dehnhardt
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Wei Gong
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Michael Grimwood
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Angela Hussainkhel
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Qi Jia
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Kuldip Khakh
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Stephanie Lee
- Department of Compound Properties, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Jenny Li
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Sophia Lin
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Andrea Lindgren
- Department of Compound Properties, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Verner Lofstrand
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Janette Mezeyova
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Karen Nelkenbrecher
- Department of In Vivo Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Noah Gregory Shuart
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Luis Sojo
- Department of Compound Properties, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Shaoyi Sun
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Matthew Waldbrook
- Department of In Vivo Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Steven Wesolowski
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Michael Wilson
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Zhiwei Xie
- Department of In Vitro Biology, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Alla Zenova
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Wei Zhang
- Department of Chemistry, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | | | - Alison J Cutts
- Scientific Affairs, Xenon Pharmaceuticals, Inc, Burnaby, British Columbia, Canada
| | - Robin P Sherrington
- Executive Team, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Raymond Winquist
- Executive Team, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - Charles J Cohen
- Executive Team, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
| | - James R Empfield
- Executive Team, Xenon Pharmaceuticals Inc, Burnaby, British Columbia, Canada
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Sánchez JD, Gómez-Carpintero J, González JF, Menéndez JC. Twenty-first century antiepileptic drugs. An overview of their targets and synthetic approaches. Eur J Med Chem 2024; 272:116476. [PMID: 38759456 DOI: 10.1016/j.ejmech.2024.116476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/19/2024]
Abstract
The therapeutic use of the traditional drugs against epilepsy has been hindered by their toxicity and low selectivity. These limitations have stimulated the design and development of new generations of antiepileptic drugs. This review explores the molecular targets and synthesis of the antiepileptic drugs that have entered the market in the 21st century, with a focus on manufacturer synthesis.
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Affiliation(s)
- J Domingo Sánchez
- Unidad de Química Orgánica y Farmacéutica, Departamento de Química en Ciencias Farmacéuticas, Facultad de Farmacia, Universidad Complutense, 28040, Madrid, Spain
| | - Jorge Gómez-Carpintero
- Unidad de Química Orgánica y Farmacéutica, Departamento de Química en Ciencias Farmacéuticas, Facultad de Farmacia, Universidad Complutense, 28040, Madrid, Spain
| | - Juan F González
- Unidad de Química Orgánica y Farmacéutica, Departamento de Química en Ciencias Farmacéuticas, Facultad de Farmacia, Universidad Complutense, 28040, Madrid, Spain
| | - J Carlos Menéndez
- Unidad de Química Orgánica y Farmacéutica, Departamento de Química en Ciencias Farmacéuticas, Facultad de Farmacia, Universidad Complutense, 28040, Madrid, Spain.
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7
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Peña-Ceballos J, Moloney PB, Kilbride RD, Naggar HE, Widdess-Walsh P, Delanty N. Oligoepilepsy and lifelong seizure susceptibility in epilepsy with generalized tonic-clonic seizures alone: Experience at an adult tertiary center. Epilepsy Res 2024; 202:107362. [PMID: 38652996 DOI: 10.1016/j.eplepsyres.2024.107362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Epilepsy with generalized tonic-clonic seizures alone (GTCA) is the least studied syndrome within the idiopathic generalized epilepsy (IGE) spectrum. We characterize a large cohort of adult patients with GTCA to understand natural history and drug responsiveness. METHODS In this retrospective single-center study using our epilepsy electronic record, we evaluated clinical characteristics, seizure outcomes, anti-seizure medication (ASM) response including seizure recurrence after ASM withdrawal, and sex differences in a cohort of GTCA patients aged ≥17 years. RESULTS Within a cohort of 434 IGE patients, 87 patients (20 %) with GTCA were included. The mean age was 34.9 years (range 17-73 years). Forty-six patients (52.8 %) were females. Seventy-two patients (82.8 %) were seizure-free and 15 (17.2 %) had active epilepsy over the previous 12 months. Thirty-four patients (39.1 %) had ≤5 lifetime seizures, aligning with a prior definition of 'oligoepilepsy'. Sixty-five patients (74.7 %) were treated with monotherapy, 19 (21.8 %) were treated with polytherapy, and three were not taking any ASM. Levetiracetam (37.9 %) was the most commonly prescribed ASM, followed by lamotrigine (32.1 %) and valproate (31 %). Seventeen patients (19.5 %) attempted to withdraw their ASM. The rate of seizure recurrence after ASM withdrawal was 88.2 % (15/17), including two patients who relapsed more than 20 years after ASM discontinuation. Females had more seizures in their lifetime and had trialed more ASM compared to males. SIGNIFICANCE GTCA has a relatively good prognosis, with most patients becoming seizure-free on monotherapy. The high rate of seizure recurrence after ASM withdrawal supports lifetime seizure susceptibility. We found potential sex differences in seizure outcomes and ASM response, although further research is needed to validate this finding.
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Affiliation(s)
| | - Patrick B Moloney
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
| | | | - Hany El Naggar
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
| | | | - Norman Delanty
- Department of Neurology, Beaumont Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland.
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8
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R AB, K SR, Chandran D, Hegde S, Upadhya R, Se PK, Shenoy S, Devi V, Upadhya D. Cell-specific extracellular vesicle-encapsulated exogenous GABA controls seizures in epilepsy. Stem Cell Res Ther 2024; 15:108. [PMID: 38637847 PMCID: PMC11027552 DOI: 10.1186/s13287-024-03721-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/05/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Epilepsy affects ∼60 million people worldwide. Most antiseizure medications in the market act on voltage-gated sodium or calcium channels, indirectly modulating neurotransmitter GABA or glutamate levels or multiple targets. Earlier studies made significant efforts to directly deliver GABA into the brain with varied success. Herein, we have hypothesized to directly deliver exogenous GABA to the brain with epilepsy through extracellular vesicles (EVs) from human GABA-producing cells and their progenitors as EVs largely mimic their parent cell composition. METHODS Human neural stem cells (NSCs), medial ganglionic eminence (MGE) cells, and GABAergic interneurons (INs) were generated from induced pluripotent stem cells (iPSCs) and characterized. EVs were isolated from NSCs, MGE cells, and INs and characterized for size and distribution, morphological features, and molecular markers. Exogenous GABA was passively loaded to the isolated EVs as a zwitterion at physiological pH, and the encapsulated dose of GABA was quantified. Epilepsy was developed through status epilepticus induction in Fisher rats by administration of repeated low doses of kainic acid. The extent of the seizures was measured for 10 h/ day for 3-6 months by video recording and its evaluation for stage III, IV and V seizures as per Racine scale. EVs from INs, MGE cells, and NSCs encapsulated with exogenous GABA were sequentially tested in the 4th, 5th, and 6th months by intranasal administration in the rats with epilepsy for detailed seizure, behavioral and synapse analysis. In separate experiments, several controls including exogenic GABA alone and EVs from INs and MGE cells were evaluated for seizure-controlling ability. RESULTS Exogenic GABA could enter the brain through EVs. Treatment with EVs from INs and MGE cells encapsulated with GABA significantly reduced total seizures, stage V seizures, and total time spent in seizure activity. EVs from NSCs encapsulated with GABA demonstrated limited seizure control. Exogenic GABA alone and EVs from INs and MGE cells individually failed to control seizures. Further, exogenic GABA with EVs from MGE cells improved depressive behavior while partially improving memory functions. Co-localization studies confirmed exogenous GABA with presynaptic vesicles in the hippocampus, indicating the interaction of exogenous GABA in the brain with epilepsy. CONCLUSION For the first time, the study demonstrated that exogenous GABA could be delivered to the brain through brain cell-derived EVs, which could regulate seizures in temporal lobe epilepsy. It is identified that the cellular origin of EVs plays a vital role in seizure control with exogenous GABA.
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Affiliation(s)
- Abhijna Ballal R
- Centre for Molecular Neurosciences, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Shivakumar Reddy K
- Centre for Molecular Neurosciences, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Divya Chandran
- Centre for Molecular Neurosciences, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Sumukha Hegde
- Centre for Molecular Neurosciences, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Raghavendra Upadhya
- Manipal Centre for Biotherapeutics Research, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Praveen Kumar Se
- Department of Pharmacology, Manipal Tata Medical College, Jamshedpur, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Smita Shenoy
- Department of Pharmacology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Vasudha Devi
- Department of Pharmacology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Dinesh Upadhya
- Centre for Molecular Neurosciences, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India.
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9
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D'Onofrio G, Roberti R, Riva A, Russo E, Verrotti A, Striano P, Belcastro V. Pharmacodynamic rationale for the choice of antiseizure medications in the paediatric population. Neurotherapeutics 2024; 21:e00344. [PMID: 38521667 PMCID: PMC11070715 DOI: 10.1016/j.neurot.2024.e00344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024] Open
Abstract
In the landscape of paediatric epilepsy treatment, over 20 anti-seizure medications (ASMs) have gained approval from Drug Regulatory Agencies, each delineating clear indications. However, the complexity of managing drug-resistant epilepsy often necessitates the concurrent use of multiple medications. This therapeutic challenge highlights a notable gap: the absence of standardized guidelines, compelling clinicians to rely on empirical clinical experience when selecting combination therapies. This comprehensive review aims to explore current evidence elucidating the preferential utilization of specific ASMs or their combinations, with a primary emphasis on pharmacodynamic considerations. The fundamental objective underlying rational polytherapy is the strategic combination of medications, harnessing diverse mechanisms of action to optimize efficacy while mitigating shared side effects. Moreover, the intricate interplay between epilepsy and comorbidities partly may influence the treatment selection process. Despite advancements, unresolved queries persist, notably concerning the mechanisms underpinning drug resistance and the paradoxical exacerbation of seizures. By synthesizing existing evidence and addressing pertinent unresolved issues, this review aims to contribute to the evolving landscape of paediatric epilepsy treatment strategies, paving the way for more informed and efficacious therapeutic interventions.
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Affiliation(s)
- Gianluca D'Onofrio
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Roberta Roberti
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | - Antonella Riva
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Emilio Russo
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | | | - Pasquale Striano
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
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10
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Eyal S. Tuning Sodium Channel Blockers to the Near-Atomic Level. Epilepsy Curr 2024; 24:123-125. [PMID: 39280048 PMCID: PMC11394411 DOI: 10.1177/15357597231225065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024] Open
Abstract
[Box: see text]
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Affiliation(s)
- Sara Eyal
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem
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11
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Feys O, Wens V, Rovai A, Schuind S, Rikir E, Legros B, De Tiège X, Gaspard N. Delayed effective connectivity characterizes the epileptogenic zone during stereo-EEG. Clin Neurophysiol 2024; 158:59-68. [PMID: 38183887 DOI: 10.1016/j.clinph.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/11/2023] [Accepted: 12/19/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVE Single-pulse electrical stimulations (SPES) can elicit normal and abnormal responses that might characterize the epileptogenic zone, including spikes, high-frequency oscillations and cortico-cortical evoked potentials (CCEPs). In this study, we investigate their association with the epileptogenic zone during stereoelectroencephalography (SEEG) in 28 patients with refractory focal epilepsy. METHODS Characteristics of CCEPs (distance-corrected or -uncorrected latency, amplitude and the connectivity index) and the occurrence of spikes and ripples were assessed. Responses within the epileptogenic zone and within the non-involved zone were compared using receiver operating characteristics curves and analysis of variance (ANOVA) either in all patients, patients with well-delineated epileptogenic zone, and patients older than 15 years old. RESULTS We found an increase in distance-corrected CCEPs latency after stimulation within the epileptogenic zone (area under the curve = 0.71, 0.72, 0.70, ANOVA significant after false discovery rate correction). CONCLUSIONS The increased distance-corrected CCEPs latency suggests that neuronal propagation velocity is altered within the epileptogenic network. This association might reflect effective connectivity changes at cortico-cortical or cortico-subcortico-cortical levels. Other responses were not associated with the epileptogenic zone, including the CCEPs amplitude, the connectivity index, the occurrences of induced ripples and spikes. The discrepancy with previous descriptions may be explained by different spatial brain sampling between subdural and depth electrodes. SIGNIFICANCE Increased distance-corrected CCEPs latency, indicating delayed effective connectivity, characterizes the epileptogenic zone. This marker could be used to help tailor surgical resection limits after SEEG.
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Affiliation(s)
- Odile Feys
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB) - Hôpital Erasme, Department of Neurology, Bruxelles, Belgium; Université Libre de Bruxelles (ULB), ULB Neuroscience Institute (UNI), Laboratoire de Neuroanatomie et Neuroimagerie translationnelles (LN(2)T), Bruxelles, Belgium.
| | - Vincent Wens
- Université Libre de Bruxelles (ULB), ULB Neuroscience Institute (UNI), Laboratoire de Neuroanatomie et Neuroimagerie translationnelles (LN(2)T), Bruxelles, Belgium; Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB) - Hôpital Erasme, Department of Translational Neuroimaging, Bruxelles, Belgium
| | - Antonin Rovai
- Université Libre de Bruxelles (ULB), ULB Neuroscience Institute (UNI), Laboratoire de Neuroanatomie et Neuroimagerie translationnelles (LN(2)T), Bruxelles, Belgium; Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB) - Hôpital Erasme, Department of Translational Neuroimaging, Bruxelles, Belgium
| | - Sophie Schuind
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB) - Hôpital Erasme, Department of Neurosurgery, Bruxelles, Belgium
| | - Estelle Rikir
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB) - Hôpital Erasme, Department of Neurology, Bruxelles, Belgium
| | - Benjamin Legros
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB) - Hôpital Erasme, Department of Neurology, Bruxelles, Belgium
| | - Xavier De Tiège
- Université Libre de Bruxelles (ULB), ULB Neuroscience Institute (UNI), Laboratoire de Neuroanatomie et Neuroimagerie translationnelles (LN(2)T), Bruxelles, Belgium; Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB) - Hôpital Erasme, Department of Translational Neuroimaging, Bruxelles, Belgium
| | - Nicolas Gaspard
- Université libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB) - Hôpital Erasme, Department of Neurology, Bruxelles, Belgium; Université Libre de Bruxelles (ULB), ULB Neuroscience Institute (UNI), Laboratory of Experimental Neurology, Bruxelles, Belgium; Yale University, Department of Neurology, New Haven, CT, USA
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12
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Biehl A, Taube M, Kotloski RJ, Kopacek K, Jones J, Gidal BE. Lamotrigine use and potential for adverse cardiac effects: A retrospective evaluation in a Veteran population. Epilepsy Behav 2023; 149:109496. [PMID: 37925869 DOI: 10.1016/j.yebeh.2023.109496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To identify the impact of lamotrigine (LTG) on cardiac rhythm and conduction abnormalities for Veterans, an especially vulnerable population. BACKGROUND In October 2020 the US Food and Drug Administration (FDA) added a new warning to the label of lamotrigine (Lamictal™) regarding its potential to cause cardiac rhythm and conduction abnormalities [1]. This warning came following in vitro data which suggested Class IB antiarrhythmic effects occurring at clinically achievable concentrations of lamotrigine [2]. However, it is unclear whether the in vitro findings will result in adverse clinical outcomes. Our objective was to assess for evidence for adverse clinical outcomes in a vulnerable population and examine for subtler signs of an association between lamotrigine and cardiac rhythm disturbances. METHODS A retrospective chart review was conducted using records between 10-01-2017 and 07-06-2021, identifying patients at the William S. Middleton Memorial Veterans Hospital who were prescribed lamotrigine. Data collected included: dates of lamotrigine initiation or discontinuation, lamotrigine dosing over the time of the prescription and maximum lamotrigine dose, any cardiac-related ICD-10-CM codes or a history of a cardiology appointment, EKGs with any abnormalities or changes, any concomitantly prescribed medications with known potential to cause cardiac abnormalities, any cardiac deaths. This retrospective chart review was approved by the University of Wisconsin-Madison Institutional Review Board. RESULTS Two hundred and thirty-three (189 male) patients with a lamotrigine prescription and 41.2 % (n = 96) of these patients had an EKG performed while prescribed lamotrigine. The average age of patients was 64.3 ± 13.0 (range 29 to 90) years and mean maximum lamotrigine daily dose was 250.8 ± 148.2 mg (range 25 to 800 mg). Nearly half (47.9 %, 46/96) of the patients were prescribed a concomitant sodium channel blocking medication in addition to lamotrigine. Eighty-four of the patients (87.5 %, 84/96) had a cardiac diagnosis, while 12 (12.5 %, 12/96) did not. A total of 12 deaths occurred within the review period, with two cardiac deaths from congestive heart failure. Four cases did not have information on cause of death. No LTG-associated cardiac adverse effects were noted as part of clinical care, though rash was noted in 5 cases. A total of 7 (7.3 %, 7/96) patients were found to have EKG abnormalities potentially related to lamotrigine, including 7.1 % (6/84) of those with a cardiac diagnosis and 8.3 % (1/12) of those without a cardiac diagnosis. CONCLUSIONS While recent FDA warnings have suggested caution regarding cardiac complications associated with lamotrigine based on in vitro studies, the clinical implications are uncertain. Despite selecting a particularly vulnerable population, this retrospective chart review did not identify any deaths due to cardiac rhythm or conduction causes, nor demonstrate unambiguous cardiac complications related to lamotrigine. Even using permissive criteria (including any prolonged PR or QTc) to examine for subtle effects, only a low incidence (<10 %) of potential complications was found. Broader implications of this study are limited by the number of patients included and the retrospective nature of the study. Therefore, further studies are warranted to evaluate a link between cardiac complications and the use of lamotrigine, including the role of concomitant medications such as other sodium channel blocking agents and psychotropic medications.
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Affiliation(s)
- Alexis Biehl
- Wm. S. Middleton Memorial Veterans Hospital, Department of Pharmacy, 2500 Overlook Terrace, Madison, WI 53705, United States; University of Wisconsin School of Pharmacy, 777 Highland Ave, Madison, WI 53705, United States
| | - Maralena Taube
- Wm. S. Middleton Memorial Veterans Hospital, Department of Pharmacy, 2500 Overlook Terrace, Madison, WI 53705, United States
| | - Robert J Kotloski
- Wm. S. Middleton Memorial Veterans Hospital, Department of Neurology, 2500 Overlook Terrace, Madison, WI 53705, United States
| | - Karen Kopacek
- University of Wisconsin School of Pharmacy, 777 Highland Ave, Madison, WI 53705, United States
| | - John Jones
- Wm. S. Middleton Memorial Veterans Hospital, Department of Neurology, 2500 Overlook Terrace, Madison, WI 53705, United States
| | - Barry E Gidal
- University of Wisconsin School of Pharmacy, 777 Highland Ave, Madison, WI 53705, United States.
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13
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Chang MC, Park D. Algorithm for multimodal medication therapy in patients with complex regional pain syndrome. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2023; 40:S125-S128. [PMID: 37434359 DOI: 10.12701/jyms.2023.00360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/15/2023] [Indexed: 07/13/2023]
Abstract
Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a clinical entity characterized by classic neuropathic pain, autonomic involvement, motor symptoms, and trophic changes in the skin, nails, and hair. Although various therapeutic modalities are used to control CRPS-related pain, severe pain due to CRPS often persists and progresses to the chronic phase. In this study, we constructed an algorithm for multimodal medication therapy for CRPS based on the established pathology of CRPS. Oral steroid pulse therapy is recommended for initial pain management in patients with CRPS. Oral steroid therapy can reduce peripheral and central neuroinflammation, contributing to the development of neuropathic pain during the acute and chronic phases. If steroid pulse therapy offers poor relief or is ineffective, treatment to control central sensitization in the chronic phase should be initiated. If pain persists despite all drug adjustments, ketamine with midazolam 2 mg before and after ketamine injection can be administered intravenously to inhibit the N-methyl D-aspartate receptor. If this treatment fails to achieve sufficient efficacy, intravenous lidocaine can be administered for 2 weeks. We hope that our proposed drug treatment algorithm to control CRPS pain will help clinicians appropriately treat patients with CRPS. Further clinical studies assessing patients with CRPS are warranted to establish this treatment algorithm in clinical practice.
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Affiliation(s)
- Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | - Donghwi Park
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Daegu, Korea
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Huang J, Fan X, Jin X, Teng L, Yan N. Dual-pocket inhibition of Na v channels by the antiepileptic drug lamotrigine. Proc Natl Acad Sci U S A 2023; 120:e2309773120. [PMID: 37782796 PMCID: PMC10576118 DOI: 10.1073/pnas.2309773120] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/01/2023] [Indexed: 10/04/2023] Open
Abstract
Voltage-gated sodium (Nav) channels govern membrane excitability, thus setting the foundation for various physiological and neuronal processes. Nav channels serve as the primary targets for several classes of widely used and investigational drugs, including local anesthetics, antiepileptic drugs, antiarrhythmics, and analgesics. In this study, we present cryogenic electron microscopy (cryo-EM) structures of human Nav1.7 bound to two clinical drugs, riluzole (RLZ) and lamotrigine (LTG), at resolutions of 2.9 Å and 2.7 Å, respectively. A 3D EM reconstruction of ligand-free Nav1.7 was also obtained at 2.1 Å resolution. RLZ resides in the central cavity of the pore domain and is coordinated by residues from repeats III and IV. Whereas one LTG molecule also binds to the central cavity, the other is found beneath the intracellular gate, known as site BIG. Therefore, LTG, similar to lacosamide and cannabidiol, blocks Nav channels via a dual-pocket mechanism. These structures, complemented with docking and mutational analyses, also explain the structure-activity relationships of the LTG-related linear 6,6 series that have been developed for improved efficacy and subtype specificity on different Nav channels. Our findings reveal the molecular basis for these drugs' mechanism of action and will aid the development of novel antiepileptic and pain-relieving drugs.
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Affiliation(s)
- Jian Huang
- Department of Molecular Biology, Princeton University, Princeton, NJ08544
| | - Xiao Fan
- Department of Molecular Biology, Princeton University, Princeton, NJ08544
| | - Xueqin Jin
- Beijing Frontier Research Center for Biological Structures, State Key Laboratory of Membrane Biology, Tsinghua-Peking Joint Center for Life Sciences, School of Life Sciences, Tsinghua University, Beijing100084, China
| | - Liming Teng
- Beijing Frontier Research Center for Biological Structures, State Key Laboratory of Membrane Biology, Tsinghua-Peking Joint Center for Life Sciences, School of Life Sciences, Tsinghua University, Beijing100084, China
| | - Nieng Yan
- Department of Molecular Biology, Princeton University, Princeton, NJ08544
- Beijing Frontier Research Center for Biological Structures, State Key Laboratory of Membrane Biology, Tsinghua-Peking Joint Center for Life Sciences, School of Life Sciences, Tsinghua University, Beijing100084, China
- Shenzhen Medical Academy of Research and Translation, Shenzhen, Guangdong Province518107, China
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15
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Trinka E, Rocamora R, Chaves J, Koepp MJ, Rüegg S, Holtkamp M, Moreira J, Fonseca MM, Castilla-Fernández G, Ikedo F. Lipid profile with eslicarbazepine acetate and carbamazepine monotherapy in adult patients with newly diagnosed focal seizures: post hoc analysis of a phase III trial and open-label extension study. Ther Adv Neurol Disord 2023; 16:17562864231193530. [PMID: 37675038 PMCID: PMC10478566 DOI: 10.1177/17562864231193530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/20/2023] [Indexed: 09/08/2023] Open
Abstract
Background Antiseizure medications can have negative effects on plasma lipid levels. Objectives To evaluate plasma lipid changes in patients with newly diagnosed focal epilepsy treated with eslicarbazepine acetate (ESL) or controlled-release carbamazepine (CBZ-CR) monotherapy during a phase III, randomized, double-blind (DB) trial and 2 years of ESL treatment in an open-label extension (OLE). Design Post hoc analysis of a phase III trial and OLE study. Methods Proportions of patients with elevated levels of total cholesterol and low-density lipoprotein (LDL) cholesterol were assessed at DB baseline, OLE baseline (last visit of DB trial), and end of OLE. Results A total of 184 patients received ESL monotherapy during the OLE: 96 received ESL monotherapy in the DB trial and 88 patients received CBZ-CR monotherapy. The proportions of patients with elevated total cholesterol and LDL cholesterol increased significantly during the DB trial in those treated with CBZ-CR monotherapy [total cholesterol, +14.9% (p < 0.001); LDL cholesterol, +11.5% (p = 0.012)] but decreased significantly after switching to ESL monotherapy in the OLE [total cholesterol, -15.3% (p = 0.008); LDL cholesterol, -11.1% (p = 0.021)]. No significant changes were observed in those treated with ESL monotherapy during the DB trial and OLE. At the end of the DB trial, between-group differences (ESL-CBZ-CR) in the proportions of patients with elevated total and LDL cholesterol were -13.6% (p = 0.037) and -12.3% (p = 0.061), respectively; at the end of the OLE, these between-group differences were -6.0% (p = 0.360) and -0.6% (p = 1.000), respectively. Conclusion A lower proportion of patients with newly diagnosed focal epilepsy had increased levels of total and LDL cholesterol, compared to baseline, following monotherapy with ESL versus CBZ-CR; after switching from CBZ-CR to ESL, the proportions of patients with increased levels decreased significantly. Registration ClinicalTrials.gov NCT01162460/NCT02484001; EudraCT 2009-011135-13/2015-001243-36.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of the European Reference Centre EpiCARE, Ignaz Harrerstrasse 79, Salzburg A-5020, Austria
- Neuroscience Institute, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria
- Institute of Public Health, Medical Decision-Making and HTA, UMIT – Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria
| | - Rodrigo Rocamora
- Hospital del Mar Medical Research Institute, Barcelona Spain
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar, Barcelona, Member of the European Reference Centre EpiCARE, Spain
- Faculty of Health and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - João Chaves
- Department of Neurology, Hospital Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mathias J. Koepp
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
| | - Stephan Rüegg
- Department of Neurology, Hospital of the University of Basel and University of Basel, Basel, Switzerland
| | - Martin Holtkamp
- Department of Neurology, Epilepsy-Center Berlin-Brandenburg, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Fábio Ikedo
- Bial – Portela & Cª, S.A., Coronado, Portugal
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O'Dwyer R, Foster E, Leppik I, Kwan P. Pharmacological treatment for older adults with epilepsy and comorbid neurodegenerative disorders. Curr Opin Neurol 2023; 36:117-123. [PMID: 36762636 DOI: 10.1097/wco.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW An increased interest in epilepsy in older adults has emerged as the global population ages. The purpose of this article is to review the literature regarding the pharmacological treatment of epilepsy in older adults, highlighting issues specifically pertinent to those living with comorbid neurodegenerative disorders. RECENT FINDINGS Although new original research remains sparse, in the last 5 years, there has been a growing number of studies addressing the relationship between epilepsy and neurodegenerative disorders. Accurate diagnosis is incredibly challenging with electroencephalogram findings often requiring circumspect interpretation. Older individuals are often excluded from or under-represented in clinical trials, and there are sparse guidelines offered on the management of these patients, with even less available in reference to those with neurodegenerative comorbidities. SUMMARY We propose that seizures occurring earlier in the neurodegenerative process should be treated aggressively, with the goal to inhibit neuro-excitotoxicity and the associated neuronal loss. By strategically choosing newer antiseizure medications with less adverse effects and a holistic approach to treatment, a patient's time living independently can be conserved. In addition, we advocate for original, multinational collaborative research efforts.
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Affiliation(s)
- Rebecca O'Dwyer
- Rush Epilepsy Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Emma Foster
- Central Clinical School, Monash University
- Neurology Department, The Alfred, Melbourne, Victoria, Australia
| | - Ilo Leppik
- MINCEP Epilepsy Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Patrick Kwan
- Central Clinical School, Monash University
- Neurology Department, The Alfred, Melbourne, Victoria, Australia
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Costa B, Vale N. Understanding Lamotrigine's Role in the CNS and Possible Future Evolution. Int J Mol Sci 2023; 24:ijms24076050. [PMID: 37047022 PMCID: PMC10093959 DOI: 10.3390/ijms24076050] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
The anti-epileptic drug lamotrigine (LTG) has been widely used to treat various neurological disorders, including epilepsy and bipolar disorder. However, its precise mechanism of action in the central nervous system (CNS) still needs to be determined. Recent studies have highlighted the involvement of LTG in modulating the activity of voltage-gated ion channels, particularly those related to the inhibition of neuronal excitability. Additionally, LTG has been found to have neuroprotective effects, potentially through the inhibition of glutamate release and the enhancement of GABAergic neurotransmission. LTG's unique mechanism of action compared to other anti-epileptic drugs has led to the investigation of its use in treating other CNS disorders, such as neuropathic pain, PTSD, and major depressive disorder. Furthermore, the drug has been combined with other anti-epileptic drugs and mood stabilizers, which may enhance its therapeutic effects. In conclusion, LTG's potential to modulate multiple neurotransmitters and ion channels in the CNS makes it a promising drug for treating various neurological disorders. As our understanding of its mechanism of action in the CNS continues to evolve, the potential for the drug to be used in new indications will also be explored.
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Affiliation(s)
- Bárbara Costa
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
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18
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Han QT, Yang WQ, Zang C, Zhou L, Zhang CJ, Bao X, Cai J, Li F, Shi Q, Wang XL, Qu J, Zhang D, Yu SS. The toxic natural product tutin causes epileptic seizures in mice by activating calcineurin. Signal Transduct Target Ther 2023; 8:101. [PMID: 36894540 PMCID: PMC9998865 DOI: 10.1038/s41392-023-01312-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 10/12/2022] [Accepted: 01/06/2023] [Indexed: 03/11/2023] Open
Abstract
Tutin, an established toxic natural product that causes epilepsy in rodents, is often used as a tool to develop animal model of acute epileptic seizures. However, the molecular target and toxic mechanism of tutin were unclear. In this study, for the first time, we conducted experiments to clarify the targets in tutin-induced epilepsy using thermal proteome profiling. Our studies showed that calcineurin (CN) was a target of tutin, and that tutin activated CN, leading to seizures. Binding site studies further established that tutin bound within the active site of CN catalytic subunit. CN inhibitor and calcineurin A (CNA) knockdown experiments in vivo proved that tutin induced epilepsy by activating CN, and produced obvious nerve damage. Together, these findings revealed that tutin caused epileptic seizures by activating CN. Moreover, further mechanism studies found that N-methyl-D-aspartate (NMDA) receptors, gamma-aminobutyric acid (GABA) receptors and voltage- and Ca2+- activated K+ (BK) channels might be involved in related signaling pathways. Our study fully explains the convulsive mechanism of tutin, which provides new ideas for epilepsy treatment and drug development.
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Affiliation(s)
- Qing-Tong Han
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Wan-Qi Yang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Caixia Zang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Linchao Zhou
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Chong-Jing Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Xiuqi Bao
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Jie Cai
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Fangfei Li
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Qinyan Shi
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Xiao-Liang Wang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China
| | - Jing Qu
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China.
| | - Dan Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China.
| | - Shi-Shan Yu
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100050, China.
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19
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Chen YS, Lai MC, Chen TS, Tseng YH, Li YJ, Huang CW. Effectiveness and Safety of Lacosamide, A Third-generation Anti-seizure Medication, for Poststroke Seizure and Epilepsy: A Literature Review. Curr Neuropharmacol 2023; 21:2126-2133. [PMID: 37340744 PMCID: PMC10556369 DOI: 10.2174/1570159x21666230616114255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 06/17/2023] Open
Abstract
Advances in stroke treatment have resulted in a dramatic reduction in stroke mortality. Nevertheless, poststroke seizures and epilepsy are issues of clinical importance affecting survivors. Additionally, stroke is the most common cause of epilepsy in older adults. Although numerous antiseizure medications exist, studies are needed to provide robust evidence of the efficacy and tolerability of these medicines for treating poststroke seizures and epilepsy. Crucially, the newer generations of antiseizure medications require testing. Lacosamide, a third-generation antiseizure medication approved for treating localization-related epilepsy, has a novel mechanism of selectively enhancing the slow inactivation of sodium channels. This literature review evaluated whether lacosamide is effective and safe for the treatment of poststroke seizures and epilepsy. This review critically analyzed studies published in major academic databases (Pubmed, Embase, and Cochrane Library) from inception through June 2022 regarding the interaction of lacosamide with poststroke seizures and epilepsy. We included clinical prospective, retrospective, and case studies on patients with poststroke seizure and epilepsy, lacosamide as a treatment for seizures, neuroprotection in animal models of seizures, and the safety of lacosamide when coadministering anticoagulants. Clinical studies revealed lacosamide to be an effective antiseizure medication with high efficacy and tolerability in patients with poststroke seizures and epilepsy. In animal models, lacosamide proved effective at seizure reduction and neuroprotection. Pharmacokinetic studies demonstrated the safety of lacosamide when coadministering conventional and new anticoagulants. The literature suggests that Lacosamide is a promising candidate antiseizure medication for patients with poststroke seizures and epilepsy.
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Affiliation(s)
- Yu-Shiue Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan, Taiwan
| | - Tsang-Shan Chen
- Department of Neurology, Tainan Sin-Lau Hospital, Tainan, Taiwan
| | - Yung-Hsin Tseng
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya Jhen Li
- Kun-Yen Medical Library, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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20
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Lemus HN, Sarkis RA. Epilepsy care in nursing facilities: Knowledge gaps and opportunities. Epilepsy Behav 2023; 138:108997. [PMID: 36442262 DOI: 10.1016/j.yebeh.2022.108997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
Epilepsy in the elderly is a complex disease, often underdiagnosed, and inadequately treated. It requires a multi-disciplinary approach and care coordination especially if the patient resides in a nursing facility. Episodes of loss of consciousness falls, or amnestic events in those living in a nursing facility require a detailed description and an urgent assessment to rule out an epileptic seizure. Prompt recognition of seizures and the implementation of treatment protocols in those with recurrent seizures are needed to prevent unnecessary emergency visits. Although there is a myriad of antiseizure medications (ASM) to treat seizures, clinicians should be aware of common interactions, side effects, and changes in pharmacodynamics with age. There is a limited number of ASMs that have been properly studied in clinical trials to assess tolerability and efficacy in the elderly, and an over-reliance on enzyme-inducing ASMs. Strategies to improve the knowledge of health care providers include electronic resources, treatment protocols, and improving awareness of the efficacy, drug-drug interaction, and short-term and long-term monitoring of ASM side effects.
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Affiliation(s)
| | - Rani A Sarkis
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
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21
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Tabrizi N, Sharifi-Razavi A. Potential risk of liver injury in epileptic patients during COVID-19 pandemic. World J Virol 2022; 11:467-476. [PMID: 36483103 PMCID: PMC9724200 DOI: 10.5501/wjv.v11.i6.467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/08/2022] [Accepted: 10/27/2022] [Indexed: 11/23/2022] Open
Abstract
Most of the antiseizure medications (ASMs) are metabolized in liver and many of them particularly first-generation ASMs have the potential to increase liver enzymes or induce liver injury. Hence, treatment of new onset seizures or epilepsy by ASMs during the course of coronavirus disease 2019 (COVID-19), which could potentially be complicated by hepatic dysfunction, is a challenging clinical issue. Intravenous form of levetiracetam which has no significant hepatic metabolism or drug-drug interaction is often a favorable option to control seizures in acute phase of COVID-19. Administration of enzyme inducer ASMs and valproate with the well-known hepatotoxicity and common drug interactions is not generally recommended. In patients with epilepsy who are under control with potentially hepatotoxic ASMs, close observation and cautious dose reduction or drug switch should be considered if any evidence of hepatic impairment exists. However, risks of possible breakthrough seizures should be weighed against benefits of lowering the hazard of liver injury. In patients with epilepsy who receive polytherapy with ASMs, transient dose modification with the tendency to increase the dose of ASMs with more favorable safety profile and less drug interaction and decrease the dose of drugs with main hepatic metabolism, high protein binding, potential to cause liver injury and known drug-drug reaction should be considered. Finally, decision making should be individualized based on patients' conditions and course of illness.
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Affiliation(s)
- Nasim Tabrizi
- Department of Neurology, Mazandaran University of Medical Sciences, Sari 4815838477, Iran
| | - Athena Sharifi-Razavi
- Department of Neurology, Mazandaran University of Medical Sciences, Sari 4815838477, Iran
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22
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Lai MC, Wu SN, Huang CW. Rufinamide, a Triazole-Derived Antiepileptic Drug, Stimulates Ca 2+-Activated K + Currents While Inhibiting Voltage-Gated Na + Currents. Int J Mol Sci 2022; 23:ijms232213677. [PMID: 36430153 PMCID: PMC9697614 DOI: 10.3390/ijms232213677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/27/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022] Open
Abstract
Rufinamide (RFM) is a clinically utilized antiepileptic drug that, as a triazole derivative, has a unique structure. The extent to which this drug affects membrane ionic currents remains incompletely understood. With the aid of patch clamp technology, we investigated the effects of RFM on the amplitude, gating, and hysteresis of ionic currents from pituitary GH3 lactotrophs. RFM increased the amplitude of Ca2+-activated K+ currents (IK(Ca)) in pituitary GH3 lactotrophs, and the increase was attenuated by the further addition of iberiotoxin or paxilline. The addition of RFM to the cytosolic surface of the detached patch of membrane resulted in the enhanced activity of large-conductance Ca2+-activated K+ channels (BKCa channels), and paxilline reversed this activity. RFM increased the strength of the hysteresis exhibited by the BKCa channels and induced by an inverted isosceles-triangular ramp pulse. The peak and late voltage-gated Na+ current (INa) evoked by rapid step depolarizations were differentially suppressed by RFM. The molecular docking approach suggested that RFM bound to the intracellular domain of KCa1.1 channels with amino acid residues, thereby functionally affecting BKCa channels' activity. This study is the first to present evidence that, in addition to inhibiting the INa, RFM effectively modifies the IK(Ca), which suggests that it has an impact on neuronal function and excitability.
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Affiliation(s)
- Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan
| | - Sheng-Nan Wu
- Department of Physiology, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (S.-N.W.); (C.-W.H.)
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (S.-N.W.); (C.-W.H.)
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23
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Qiu Y, O’Neill N, Maffei B, Zourray C, Almacellas-Barbanoj A, Carpenter JC, Jones SP, Leite M, Turner TJ, Moreira FC, Snowball A, Shekh-Ahmad T, Magloire V, Barral S, Kurian MA, Walker MC, Schorge S, Kullmann DM, Lignani G. On-demand cell-autonomous gene therapy for brain circuit disorders. Science 2022; 378:523-532. [PMID: 36378958 PMCID: PMC7613996 DOI: 10.1126/science.abq6656] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Several neurodevelopmental and neuropsychiatric disorders are characterized by intermittent episodes of pathological activity. Although genetic therapies offer the ability to modulate neuronal excitability, a limiting factor is that they do not discriminate between neurons involved in circuit pathologies and "healthy" surrounding or intermingled neurons. We describe a gene therapy strategy that down-regulates the excitability of overactive neurons in closed loop, which we tested in models of epilepsy. We used an immediate early gene promoter to drive the expression of Kv1.1 potassium channels specifically in hyperactive neurons, and only for as long as they exhibit abnormal activity. Neuronal excitability was reduced by seizure-related activity, leading to a persistent antiepileptic effect without interfering with normal behaviors. Activity-dependent gene therapy is a promising on-demand cell-autonomous treatment for brain circuit disorders.
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Affiliation(s)
- Yichen Qiu
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Nathanael O’Neill
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Benito Maffei
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Clara Zourray
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
- Department of Developmental Neurosciences, Zayed Centre for Research Into Rare Disease in Children, GOS−Institute of Child Health, University College London, London, UK
| | - Amanda Almacellas-Barbanoj
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Jenna C. Carpenter
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Steffan P. Jones
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Marco Leite
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Thomas J. Turner
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Francisco C. Moreira
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Albert Snowball
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Tawfeeq Shekh-Ahmad
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Vincent Magloire
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Serena Barral
- Department of Developmental Neurosciences, Zayed Centre for Research Into Rare Disease in Children, GOS−Institute of Child Health, University College London, London, UK
| | - Manju A. Kurian
- Department of Developmental Neurosciences, Zayed Centre for Research Into Rare Disease in Children, GOS−Institute of Child Health, University College London, London, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Matthew C. Walker
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Stephanie Schorge
- Department of Neuroscience, Physiology and Pharmacology University College London, London, UK
| | - Dimitri M. Kullmann
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Gabriele Lignani
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
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24
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Wang Q, Xu Y, Chen Y, Wu X, Ge Y, Zhu G. Effectiveness and safety of perampanel as adjunctive therapy among Chinese patients with focal-onset epilepsy: A real-world prospective observational study. Epilepsy Behav 2022; 136:108937. [PMID: 36215830 DOI: 10.1016/j.yebeh.2022.108937] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Perampanel (PER) has previously been shown to be effective and tolerable when used as an adjunctive therapy for patients with focal-onset seizures (FOS). This study aimed to evaluate the effect of PER as adjunctive therapy for patients with FOS in the Chinese population under real-world conditions for 1 year. METHODS A prospective, single-center, 1-year observational study was conducted at Huashan Hospital, enrolling both under age (≥4 years old) and adult patients with FOS. Response to PER was assessed at 3-, 6-, and 12-month checkpoints by analyzing the 50 % responder rate, the seizure-free rate, and reduction in seizure frequency. RESULTS One hundred and eight patients (mean age: 26.6 years, 56.5 % males) with FOS were included, with seventy-six patients finishing the 1-year follow-up (retention rate: 70.4 %, mean PER dose: 4.3 mg/day). The seizure frequency was reduced significantly at 3, 6, and 12 months relative to baseline (p < 0.001 for each seizure type). At 12 months, the responder rate was 65.8 %, and the seizure-free rate was 39.5 %. A significantly higher responder rate was found in patients with focal to bilateral tonic-clonic seizures (p = 0.024), among which the percentage of patients with sleep-related epilepsy was significantly high (p = 0.045). Responders had a lower number of concomitant anti-seizure medications (ASMs) than the non-responders (p = 0.009). Drug-related adverse events (AEs) were reported in 37 % of patients, mostly mild or moderate, and the patients who experienced AEs had a higher daily dose of PER than those who did not (p = 0.026). CONCLUSION Perampanel, an add-on therapy for focal-onset seizures, was found to be effective and tolerable in Chinese patients at 12 months.
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Affiliation(s)
- Qinyue Wang
- Department of Neurology, Huashan Hospital, Fudan University, China
| | - Ye Xu
- Department of Neurology, Huashan Hospital, Fudan University, China
| | - Yuncan Chen
- Department of Neurology, Huashan Hospital, Fudan University, China
| | - Xunyi Wu
- Department of Neurology, Huashan Hospital, Fudan University, China; National Center for Neurological Disorders, Shanghai, China.
| | - Yan Ge
- Department of Neurology, Huashan Hospital, Fudan University, China; National Center for Neurological Disorders, Shanghai, China
| | - Guoxing Zhu
- Department of Neurology, Huashan Hospital, Fudan University, China; National Center for Neurological Disorders, Shanghai, China
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25
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Zhou X, Chen Z, Xiao L, Zhong Y, Liu Y, Wu J, Tao H. Intracellular calcium homeostasis and its dysregulation underlying epileptic seizures. Seizure 2022; 103:126-136. [DOI: 10.1016/j.seizure.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 11/10/2022] [Indexed: 11/13/2022] Open
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26
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Yao N, Huang S, Huang A, Song H. Analysis of influencing factors on monohydroxylated derivative of oxcarbazepine plasma concentration in children with epilepsy. Eur J Clin Pharmacol 2022; 78:1667-1675. [PMID: 36006433 DOI: 10.1007/s00228-022-03373-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/12/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to investigate the factors affecting the plasma concentration of monohydroxylated derivative (MHD) of oxcarbazepine (OXC) in children with epilepsy. METHODS We recruited 125 children with epilepsy who received OXC monotherapy. Among them, 16 single nucleotide polymorphisms were detected by MassARRAY genotyping technology to evaluate the influence of related factors on the plasma concentration of OXC monotherapy. MHD is the main active metabolite of OXC, and its plasma concentration was measured by high-performance liquid chromatography (HPLC). RESULTS Bivariate correlation analysis revealed that concentration-dose ratio (CDR) increased with weight, and the corresponding maintenance dose decreased with weight (r=0.317, P=0.001 for CDR; r=-0.285, P=0.000 for OXC maintenance dose). The duration of seizure was found to be associated with CDR (0.90 ± 0.36 vs 0.74 ± 0.26 μg·kg/mg/mL for ≥6 years vs <1 year, P=0.028; 0.90 ± 0.36 vs 0.64 ± 0.21 μg·kg/mg/mL for ≥6 years vs 1-3 years, P=0.004; 0.90 ± 0.36 vs 0.69 ± 0.18 μg·kg/mg/mL for ≥6 years vs 3-6 years, P=0.031). The CDR of patients with ABCB1 rs1045642 mutation homozygous GG type is higher than heterozygous AG type (0.79 ± 0.30 vs 0.68 ± 0.20 μg·kg/mg/mL for AG vs GG, P=0.032). CONCLUSION This study clarified the association of weight, duration of seizure, and gene polymorphisms of ABCB1 rs1045642 with MHD plasma concentration in children with epilepsy.
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Affiliation(s)
- Nannan Yao
- Department of Pharmacy, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Shan Huang
- Department of Pharmacy, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Aiwen Huang
- Department of Pharmacy, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China.
| | - Hongtao Song
- Department of Pharmacy, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China.
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27
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Efficacy and safety of antiseizure medication in post-stroke epilepsy. Seizure 2022; 100:109-114. [PMID: 35834881 DOI: 10.1016/j.seizure.2022.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/03/2022] [Accepted: 07/05/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Specific antiseizure medications (ASM) would improve the outcome in post-stroke epilepsy (PSE). The aim of this multicenter observational study was to compare different antiseizure monotherapies in PSE. METHODS We collected the data from 207 patients with PSE who did not change their initial antiseizure monotherapy during the period of 12 months. Efficacy was assessed by a standardized three month seizure frequency and seizure freedom. Safety was estimated by the reported side effects. RESULTS The mean three month seizure frequency was 1.9 ± 3.1 on eslicarbazepine, 2.1 ± 3.2 on lacosamide, 3.4 ± 4.4 on levetiracetam, 4.3 ± 6.8 on lamotrigine, and 5.1 ± 7.3 on valproate (p < 0.05 for eslicarbazepine or lacosamide in comparison with levetiracetam, lamotrigine and valproate, respectively). The lowest seizure frequency and the highest seizure freedom was observed on ASMs acting via the slow inactivation of sodium channels in comparison to other mechanisms of action (0.7 ± 0.9 vs 2.2 ± 2.4, p < 0.01). Among side effects, the most frequently reported were vertigo (25%) and tiredness (15.9%). They were similar in all investigated groups of ASM. The independent factors increasing seizure frequency that were identified in multiple regression analyses were increased size of infarction, cortical involvement, hemorrhagic transformation, neurological deficits at admission and functional impairment. Administration of ASM with the mechanism of action via the slow inactivation of sodium channels was an independent factor decreasing the seizure frequency. CONCLUSION Our data show that antiseizure medications acting via the slow inactivation of sodium channels, such as lacosamide and eslicarbazepine, are well tolerated and might be associated with better seizure control in PSE.
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28
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Gallego MDC, García MA. Acute Carbamazepine Intoxication. Neurol Int 2022; 14:614-618. [PMID: 35893284 PMCID: PMC9331306 DOI: 10.3390/neurolint14030049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/21/2022] [Accepted: 07/05/2022] [Indexed: 02/04/2023] Open
Abstract
Carbamazepine is an anticonvulsant drug with multiple mechanisms of action, which condition the presence of a characteristic clinical picture after the overingestion of the drug. We expose a case report about a patient who, in the context of an attempted suicide, presented acute intoxication by benzodiazepines and carbamazepine, presenting the characteristic clinical picture of fluctuations in the level of consciousness, even presenting gaze deconjugation, almost unreactive coma and generalized hypotonia.
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Affiliation(s)
- María Dolores Calabria Gallego
- IBSAL, Institute for Biomedical Research of Salamanca, 37007 Salamanca, Spain
- Neurology Department, Universitary Hospital of Salamanca, 37007 Salamanca, Spain;
- Correspondence:
| | - Mónica Alañá García
- Neurology Department, Universitary Hospital of Salamanca, 37007 Salamanca, Spain;
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29
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Characterization in Inhibitory Effectiveness of Carbamazepine in Voltage-Gated Na + and Erg-Mediated K + Currents in a Mouse Neural Crest-Derived (Neuro-2a) Cell Line. Int J Mol Sci 2022; 23:ijms23147892. [PMID: 35887240 PMCID: PMC9321339 DOI: 10.3390/ijms23147892] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 12/18/2022] Open
Abstract
Carbamazepine (CBZ, Tegretol®) is an anticonvulsant used in the treatment of epilepsy and neuropathic pain; however, several unwanted effects of this drug have been noticed. Therefore, the regulatory actions of CBZ on ionic currents in electrically excitable cells need to be reappraised, although its efficacy in suppressing voltage-gated Na+ current (INa) has been disclosed. This study was undertaken to explore the modifications produced by CBZ on ionic currents (e.g., INa and erg-mediated K+ current [IK(erg)]) measured from Neuro-2a (N2a) cells. In these cells, we found that this drug differentially suppressed the peak (transient, INa(T)) and sustained (late, INa(L)) components of INa in a concentration-dependent manner with effective IC50 of 56 and 18 μM, respectively. The overall current–voltage relationship of INa(T) with or without the addition of CBZ remained unchanged; however, the strength (i.e., ∆area) in the window component of INa (INa(W)) evoked by the short ascending ramp pulse (Vramp) was overly lessened in the CBZ presence. Tefluthrin (Tef), a synthetic pyrethroid, known to stimulate INa, augmented the strength of the voltage-dependent hysteresis (Hys(V)) of persistent INa (INa(P)) in response to the isosceles-triangular Vramp; moreover, further application of CBZ attenuated Tef-mediated accentuation of INa(P)’s Hys(V). With a two-step voltage protocol, the recovery of INa(T) inactivation seen in Neuro-2a cells became progressively slowed by adding CBZ; however, the cumulative inhibition of INa(T) evoked by pulse train stimulation was enhanced during exposure to this drug. Neuro-2a-cell exposure to CBZ (100 μM), the magnitude of erg-mediated K+ current measured throughout the entire voltage-clamp steps applied was mildly inhibited. The docking results regarding the interaction of CBZ and voltage-gate Na+ (NaV) channel predicted the ability of CBZ to bind to some amino-acid residues in NaV due to the existence of a hydrogen bond or hydrophobic contact. It is conceivable from the current investigations that the INa (INa(T), INa(L), INa(W), and INa(P)) residing in Neuro-2a cells are susceptible to being suppressed by CBZ, and that its block on INa(L) is larger than that on INa(T). Collectively, the magnitude and gating of NaV channels produced by the CBZ presence might have an impact on its anticonvulsant and analgesic effects occurring in vivo.
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James AD, Leslie TK, Kaggie JD, Wiggins L, Patten L, Murphy O'Duinn J, Langer S, Labarthe MC, Riemer F, Baxter G, McLean MA, Gilbert FJ, Kennerley AJ, Brackenbury WJ. Sodium accumulation in breast cancer predicts malignancy and treatment response. Br J Cancer 2022; 127:337-349. [PMID: 35462561 PMCID: PMC9296657 DOI: 10.1038/s41416-022-01802-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Breast cancer remains a leading cause of death in women and novel imaging biomarkers are urgently required. Here, we demonstrate the diagnostic and treatment-monitoring potential of non-invasive sodium (23Na) MRI in preclinical models of breast cancer. METHODS Female Rag2-/- Il2rg-/- and Balb/c mice bearing orthotopic breast tumours (MDA-MB-231, EMT6 and 4T1) underwent MRI as part of a randomised, controlled, interventional study. Tumour biology was probed using ex vivo fluorescence microscopy and electrophysiology. RESULTS 23Na MRI revealed elevated sodium concentration ([Na+]) in tumours vs non-tumour regions. Complementary proton-based diffusion-weighted imaging (DWI) linked elevated tumour [Na+] to increased cellularity. Combining 23Na MRI and DWI measurements enabled superior classification accuracy of tumour vs non-tumour regions compared with either parameter alone. Ex vivo assessment of isolated tumour slices confirmed elevated intracellular [Na+] ([Na+]i); extracellular [Na+] ([Na+]e) remained unchanged. Treatment with specific inward Na+ conductance inhibitors (cariporide, eslicarbazepine acetate) did not affect tumour [Na+]. Nonetheless, effective treatment with docetaxel reduced tumour [Na+], whereas DWI measures were unchanged. CONCLUSIONS Orthotopic breast cancer models exhibit elevated tumour [Na+] that is driven by aberrantly elevated [Na+]i. Moreover, 23Na MRI enhances the diagnostic capability of DWI and represents a novel, non-invasive biomarker of treatment response with superior sensitivity compared to DWI alone.
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Affiliation(s)
- Andrew D James
- Department of Biology, University of York, York, UK
- York Biomedical Research Institute, University of York, York, UK
| | | | - Joshua D Kaggie
- Department of Radiology & NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | | | - Lewis Patten
- Department of Mathematics, University of York, York, UK
| | | | - Swen Langer
- Bioscience Technology Facility, Department of Biology, University of York, York, UK
| | | | - Frank Riemer
- Mohn Medical Imaging and Visualization Centre, Haukeland University Hospital Bergen, Bergen, Norway
| | - Gabrielle Baxter
- Department of Radiology & NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Mary A McLean
- Department of Radiology & NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Fiona J Gilbert
- Department of Radiology & NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Aneurin J Kennerley
- York Biomedical Research Institute, University of York, York, UK
- Department of Chemistry, University of York, York, UK
| | - William J Brackenbury
- Department of Biology, University of York, York, UK.
- York Biomedical Research Institute, University of York, York, UK.
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Steinhoff BJ, Ben-Menachem E, Brandt C, García Morales I, Rosenfeld WE, Santamarina E, Serratosa JM. Onset of efficacy and adverse events during Cenobamate titration period. Acta Neurol Scand 2022; 146:265-275. [PMID: 35711112 PMCID: PMC9545218 DOI: 10.1111/ane.13659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/17/2022] [Accepted: 05/23/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Cenobamate is an antiseizure medication (ASM) approved in Europe as adjunctive therapy for adults with inadequately controlled focal seizures. This post hoc analysis reports onset of efficacy and characterizes time to onset, duration, and severity of the most common treatment-emergent adverse events (TEAEs) during cenobamate titration. MATERIALS & METHODS Adult patients with uncontrolled focal seizures taking 1 to 3 concomitant ASMs were randomized to receive adjunctive cenobamate or placebo (double-blind studies C013 and C017) or cenobamate (open-label study C021). Outcome assessments included efficacy (median percentage change in seizure frequency and onset [studies C013 and C017]) and safety (onset, duration, and severity of TEAEs [all studies]). RESULTS Onset of efficacy was observed by Weeks 1 to 4 of titration in studies C013 and C017 which used a faster titration schedule than study CO21. In study C013, the median percentage seizure frequency reduction was 36.7% in patients receiving cenobamate versus 16.3% in those taking placebo (p = .002); in study C017, significant differences in seizure frequency emerged in Week 1 and continued throughout titration between all cenobamate groups and placebo (p < .001). The most commonly reported TEAEs were somnolence, dizziness, fatigue, and headache, with first onset of each reported as early as Week 1; however, the majority resolved. CONCLUSIONS Reductions in seizure frequency occurred during titration with initial efficacy observed prior to reaching the target dose. These reductions were regarded as clinically meaningful because they may indicate early efficacy at lower doses than previously expected and had a considerable impact on patient quality of life. Long-term treatment with adjunctive cenobamate was generally safe and well-tolerated.
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Affiliation(s)
- Bernhard J Steinhoff
- Department for Adults, Kork Epilepsy Center, Kehl-Kork, Germany.,Department of Neurology and Clinical Neurophysiology and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Elinor Ben-Menachem
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Christian Brandt
- Department of General Epileptology, Bethel Epilepsy Centre, Mara Hospital, University Hospital for Epileptology, Bielefeld, Germany
| | - Irene García Morales
- Servicio de Neurología, Programa de Epilepsia, Hospital Ruber Internacional, Madrid, Spain
| | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, Missouri, USA
| | - Estevo Santamarina
- Epilepsy Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - José M Serratosa
- Epilepsy Unit, Department of Neurology, Fundación Jiménez Díaz, Madrid, Spain
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Terman SW, Youngerman BE, Choi H, Burke JF. Antiseizure medication treatment pathways for US Medicare beneficiaries with newly treated epilepsy. Epilepsia 2022; 63:1571-1579. [PMID: 35294775 PMCID: PMC9314094 DOI: 10.1111/epi.17226] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study was undertaken to characterize antiseizure medication (ASM) treatment pathways in Medicare beneficiaries with newly treated epilepsy. METHODS This was a retrospective cohort study using Medicare claims. Medicare is the United States' federal health insurance program for people aged 65 years and older plus younger people with disabilities or end-stage renal disease. We included beneficiaries with newly treated epilepsy (International Classification of Diseases codes for epilepsy/convulsions 2014-2017, no ASM in the previous 2 years). We displayed the sequence of ASM fills using sunburst plots overall, then stratified by mood disorder, age, and neurologist prescriber. We tabulated drug costs for each pathway. RESULTS We included 21 458 beneficiaries. Levetiracetam comprised the greatest number of pill days (56%), followed by gabapentin (11%) and valproate (8%). There were 22 288 unique treatment pathways. The most common pathways were levetiracetam monotherapy (43%), gabapentin monotherapy (10%), and valproate monotherapy (5%). Gabapentin was the most common second- and third-line ASM. Whereas only 2% of pathways involved first-line lacosamide, those pathways accounted for 19% of cost. Gabapentin and valproate use was increased and levetiracetam use was decreased in beneficiaries with mood disorders compared to beneficiaries without mood disorders. Levetiracetam use was increased and gabapentin, valproate, lamotrigine, and topiramate use was decreased in beneficiaries aged >65 years compared with those aged 65 years or less. Lamotrigine, levetiracetam, and lacosamide use was increased and gabapentin use was decreased in beneficiaries whose initial prescriber was a neurologist compared to those whose prescriber was not a neurologist. SIGNIFICANCE Levetiracetam monotherapy was the most common pathway, although substantial heterogeneity existed. Lacosamide accounted for a small percentage of ASMs but a disproportionately large share of cost. Neurologists were more likely to prescribe lamotrigine compared with nonneurologists, and lamotrigine was prescribed far less frequently than may be endorsed by guidelines. Future work may explore patient- and physician-driven factors underlying ASM choices.
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Affiliation(s)
- Samuel W. Terman
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Brett E. Youngerman
- Department of NeurosurgeryColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Hyunmi Choi
- Department of NeurologyColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - James F. Burke
- Department of NeurologyOhio State UniversityColumbusOhioUSA
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Villamar MF, Sarkis RA, Pennell P, Kohane I, Beaulieu-Jones BK. Severity of Epilepsy and Response to Antiseizure Medications in Individuals with Multiple Sclerosis: Analysis of a Real-World Dataset. Neurol Clin Pract 2022; 12:e49-e57. [DOI: 10.1212/cpj.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 04/26/2022] [Indexed: 11/15/2022]
Abstract
ABSTRACTBackground and objectives:Epilepsy is an important comorbidity that affects outcomes for people with multiple sclerosis (MS). However, it is unclear if seizure severity among individuals with coexistence of multiple sclerosis and epilepsy (MS+E) is higher than in those with other focal epilepsies. Our goal was to compare the overall severity of epilepsy in individuals with MS+E versus those with focal epilepsy without MS (E-MS) as defined by seizure-related healthcare utilization, frequency and duration of status epilepticus, and frequency of antiseizure medication (ASM) regimen changes.Methods:In this hypothesis-generating study, we analyzed a U.S. commercial nationwide de-identified claims dataset with > 86 million individuals between 1/1/2008 and 8/31/2019. Using validated algorithms, we identified adults with E-MS and those with MS+E. We compared the number and length of seizure-related hospital admissions, the number of claims and unique days with claims for status epilepticus, and the rates of ASM regimen changes between the MS+E and the E-MS groups.Results:During the study period, 66,708 individuals with E-MS and 537 with MS+E had ≥ 2 years of coverage after their initial diagnosis of epilepsy. There was no difference between the MS+E and E-MS groups in the percentage of individuals admitted for seizures and/or status epilepticus. However, MS+E with seizure-related admissions had more admissions and longer hospital stays than those with E-MS. MS+E who experienced status epilepticus had more unique days with status epilepticus claims compared to E-MS. MS+E were more likely to have ASM regimen changes in Year 2 after the initial diagnosis of epilepsy and had more ASM changes during Year 2 compared to E-MS. Among individuals with MS+E, there were no differences in our measures of seizure severity for those treated with sodium channel blockers/modulators versus other ASM classes.Discussion:This study supports the notion that individuals with MS+E can have more severe epilepsy than those with E-MS. Seizure severity among individuals with MS+E treated with sodium-channel blockers/modulators versus other ASM classes shows no significant differences.Classification of evidence:This study provides Class III evidence that individuals with MS+E can have more severe epilepsy than those with E-MS.
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Ingleby-Talecki L, van Dijkman SC, Oosterholt SP, Della Pasqua O, Winter C, Cunnington M, Rebar L, Forero-Schwanhaeuser S, Patel V, Cooper JA, Bahinski A, Chaudhary KW. Cardiac sodium channel inhibition by lamotrigine: in vitro characterization and clinical implications. Clin Transl Sci 2022; 15:1978-1989. [PMID: 35579204 PMCID: PMC9372421 DOI: 10.1111/cts.13311] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 11/26/2022] Open
Abstract
Lamotrigine, approved for use as an antiseizure medication as well as the treatment of bipolar disorder, inhibits sodium channels in the brain to reduce repetitive neuronal firing and pathological release of glutamate. The shared homology of sodium channels and lack of selectivity associated with channel blocking agents can cause slowing of cardiac conduction and increased proarrhythmic potential. The Vaughan‐Williams classification system differentiates sodium channel blockers using biophysical properties of binding. As such, Class Ib inhibitors, including mexiletine, do not slow cardiac conduction as measured by the electrocardiogram, at therapeutically relevant exposure. Our goal was to characterize the biophysical properties of NaV1.5 block and to support the observed clinical safety of lamotrigine. We used HEK‐293 cells stably expressing the hNaV1.5 channel and voltage clamp electrophysiology to quantify the potency (half‐maximal inhibitory concentration) against peak and late channel current, on‐/off‐rate binding kinetics, voltage‐dependence, and tonic block of the cardiac sodium channel by lamotrigine; and compared to clinically relevant Class Ia (quinidine), Ib (mexiletine), and Ic (flecainide) inhibitors. Lamotrigine blocked peak and late NaV1.5 current at therapeutically relevant exposure, with rapid kinetics and biophysical properties similar to the class Ib inhibitor mexiletine. However, no clinically meaningful prolongation in QRS or PR interval was observed in healthy subjects in a new analysis of a previously reported thorough QT clinical trial (SCA104648). In conclusion, the weak NaV1.5 block and rapid kinetics do not translate into clinically relevant conduction slowing at therapeutic exposure and support the clinical safety of lamotrigine in patients suffering from epilepsy and bipolar disorder.
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Affiliation(s)
| | | | | | | | | | | | - Linda Rebar
- GSK US Regulatory Affairs, Collegeville, PA 19426, USA
| | | | - Vickas Patel
- Former GSK Employee, Collegeville, PA 19426, USA
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Sivathamboo S, Liu Z, Sutherland F, Minato E, Casillas-Espinosa P, Jones NC, Todaro M, Seneviratne U, Cahill V, Yerra R, French C, Nicolo JP, Perucca P, Kwan P, Sparks P, O'Brien TJ. Serious Cardiac Arrhythmias Detected by Subcutaneous Long-term Cardiac Monitors in Patients With Drug-Resistant Epilepsy. Neurology 2022; 98:e1923-e1932. [PMID: 35387849 DOI: 10.1212/wnl.0000000000200173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 01/21/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Epilepsy is associated with an increased risk of cardiovascular disease and premature mortality, including sudden unexpected death in epilepsy (SUDEP). Serious cardiac arrythmias might go undetected in routine epilepsy and cardiac investigations. METHODS This prospective cohort study aimed to detect cardiac arrhythmias in patients with chronic drug-resistant epilepsy (≥5 years duration) using subcutaneous cardiac monitors for a minimum follow-up duration of 12 months. Participants with known cardiovascular disease or those with abnormal 12-lead ECGs were excluded. The device was programmed to automatically record episodes of tachycardia ≥140 beats per minute (bpm), bradycardia ≤40 bpm for ≥3 seconds, or asystole ≥3 seconds. FINDINGS Thirty-one patients underwent subcutaneous cardiac monitoring for a median recording duration of 2.2 years (range 0.5-4.2). During this time, 28 patients (90.3%) had episodes of sustained (≥30 seconds) sinus tachycardia, 8/31 (25.8%) had sinus bradycardia, and 3 (9.7%) had asystole. Three patients (9.7%) had serious cardiac arrhythmias requiring additional cardiac interventions. Among them, 2 patients had prolonged sinus arrest and ventricular asystole (>6 seconds), leading to pacemaker insertion in one, and another patient with epileptic encephalopathy had multiple episodes of recurrent nonsustained polymorphic ventricular tachycardia and bundle branch conduction abnormalities. The time to first detection of a clinically significant cardiac arrhythmia ranged between 1.2 and 26.9 months following cardiac monitor insertion. DISCUSSION Implantable cardiac monitors detected a high incidence of clinically significant cardiac arrhythmias in patients with chronic drug-resistant epilepsy, which may contribute to the incidence of premature mortality, including SUDEP.
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Affiliation(s)
- Shobi Sivathamboo
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Zining Liu
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Fiona Sutherland
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Erica Minato
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Pablo Casillas-Espinosa
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Nigel C Jones
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Marian Todaro
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Udaya Seneviratne
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Varduhi Cahill
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Raju Yerra
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Christopher French
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - John-Paul Nicolo
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Piero Perucca
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Patrick Kwan
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Paul Sparks
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
| | - Terence J O'Brien
- From the Department of Neuroscience, Central Clinical School (S.S., Z.L., P.C.-E., N.C.J., M.T., C.F., J.-P.N., P.P., P.K., T.J.O.), Monash University; Department of Neurology (S.S., P.C.-E., N.C.J., M.T., J.-P.N., P.P., P.K., T.J.O.), The Alfred Hospital, Melbourne; Department of Medicine (S.S., P.C.-E., N.C.J., M.T., V.C., R.Y., C.F., J.-P.N., P.K., T.J.O.), The Royal Melbourne Hospital, The University of Melbourne; Departments of Neurology (S.S., F.S., M.T., V.C., R.Y., C.F., J.-P.N., P.P., P.K., T.J.O.) and Cardiology (F.S., P.S.), The Royal Melbourne Hospital, Parkville; Department of Neurology (E.M., U.S.), Monash Medical Centre, Clayton, Australia; Academic Neurology Unit (V.C.), Royal Hallamshire Hospital, University of Sheffield, Division of Neuroscience and Experimental Psychology (V.C.), School of Biological Sciences, University of Manchester, UK; Department of Medicine (P.P.), Austin Hospital, The University of Melbourne; and Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Austin Health, Heidelberg, Australia
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Halimeh M, Yang Y, Sheehan T, Vieluf S, Jackson M, Loddenkemper T, Meisel C. Wearable device assessments of antiseizure medication effects on diurnal patterns of electrodermal activity, heart rate, and heart rate variability. Epilepsy Behav 2022; 129:108635. [PMID: 35278938 DOI: 10.1016/j.yebeh.2022.108635] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/04/2022] [Accepted: 02/19/2022] [Indexed: 11/03/2022]
Abstract
Patient-generated health data provide a great opportunity for more detailed ambulatory monitoring and more personalized treatments in many diseases. In epilepsy, robust diagnostics applicable to the ambulatory setting are needed as diagnosis and treatment decisions in current clinical practice are primarily reliant on patient self-reports, which are often inaccurate. Recent work using wearable devices has focused on methods to detect and forecast epileptic seizures. Whether wearable device signals may also contain information about the effect of antiseizure medications (ASMs), which may ultimately help to better monitor their efficacy, has not been evaluated yet. Here we systematically investigated the effect of ASMs on different data modalities (electrodermal activity, EDA, heart rate, HR, and heart rate variability, HRV) simultaneously recorded by a wearable device in 48 patients with epilepsy over several days in the epilepsy long-term monitoring unit at a tertiary hospital. All signals exhibited characteristic diurnal variations. HRV, but not HR or EDA-based metrics, were reduced by ASMs. By assessing multiple signals related to the autonomic nervous system simultaneously, our results provide novel insights into the effects of ASMs on the sympathetic and parasympathetic interplay in the setting of epilepsy and indicate the potential of easy-to-wear wearable devices for monitoring ASM action. Future work using longer data may investigate these metrics on multidien cycles and their utility for detecting seizures, assessing seizure risk, or informing treatment interventions.
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Affiliation(s)
- Mustafa Halimeh
- Computational Neurology, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany
| | - Yonghua Yang
- Hospital of Xi'an Jiaotong University, Pediatric Department, Shaanxi, China
| | | | | | | | | | - Christian Meisel
- Computational Neurology, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany.
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Ribbenstedt A, Posselt M, Benskin JP. Toxicometabolomics and Biotransformation Product Elucidation in Single Zebrafish Embryos Exposed to Carbamazepine from Environmentally-Relevant to Morphologically Altering Doses. Chem Res Toxicol 2022; 35:431-439. [PMID: 35166526 PMCID: PMC8941598 DOI: 10.1021/acs.chemrestox.1c00335] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Indexed: 12/27/2022]
Abstract
Toxicometabolomics and biotransformation product (bioTP) elucidation were carried out in single zebrafish (ZF) embryos exposed to carbamazepine (CBZ). Exposures were conducted in 96-well plates containing six CBZ concentrations ranging from 0.5 μg/L to 50 mg/L (n = 12 embryos per dose). In the 50 mg/L dose group, 33% of embryos developed edema during the exposure (120 hpf), while hatching was significantly delayed in three of the lower-dose groups (0.46, 3.85, and 445 μg/L) compared to the control at 48 hpf. Toxicometabolomic analysis together with random forest modeling revealed a total of 80 significantly affected metabolites (22 identified via targeted lipidomics and 58 via nontarget analysis). The wide range of doses enabled the observation of both monotonic and nonmonotonic dose responses in the metabolome, which ultimately produced a unique and comprehensive biochemical picture that aligns with existing knowledge on the mode of action of CBZ. The combination of high dose exposures and apical endpoint assessment in single embryos also enabled hypothesis generation regarding the target organ for the morphologically altering insult. In addition, two CBZ bioTPs were identified without additional exposure experiments. Overall, this work showcases the potential of toxicometabolomics and bioTP determination in single ZF embryos for rapid and comprehensive chemical hazard assessment.
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Affiliation(s)
- Anton Ribbenstedt
- Department of Environmental
Science, Stockholm University, 114 18 Stockholm, Sweden
| | - Malte Posselt
- Department of Environmental
Science, Stockholm University, 114 18 Stockholm, Sweden
| | - Jonathan P. Benskin
- Department of Environmental
Science, Stockholm University, 114 18 Stockholm, Sweden
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Suzuki T, Natsume J, Kumai S, Maki Y, Yamamoto H, Numoto S, Narahara S, Kubota T, Tsuji T, Kato T, Yamada K, Maruyama K, Okumura A, Takahashi Y, Kidokoro H. Effectiveness of lacosamide in children and young adults previously treated with other sodium channel blockers. Epilepsy Behav 2021; 125:108397. [PMID: 34814035 DOI: 10.1016/j.yebeh.2021.108397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This multicenter study examined the effectiveness and tolerability of lacosamide (LCM) for children and young adults with epilepsy, particularly in patients who had previously been treated with other sodium channel blockers (SCBs) and the difference in effectiveness and tolerability when using other concomitant SCBs. METHODS We retrospectively studied the clinical information of patients aged <30 years given LCM to treat epilepsy. The effectiveness and adverse events (AEs) of LCM and the other SCBs were investigated. Factors related to the effectiveness and AEs of LCM, such as the number of antiepileptic drugs (AEDs) tried before LCM and concomitantly used SCBs, were also studied. RESULTS We enrolled 112 patients (median age = 11 years). One year after starting LCM, 29% of the patients were seizure free, and 50% had a ≥50% seizure reduction. Of the patients, 17% experienced AEs, the most common being somnolence. A ≥50% seizure reduction was observed for LCM in 30% of patients in whom other SCBs had not been effective. Lacosamide produced a ≥50% seizure reduction in 35% of the patients taking one concomitant SCB. By contrast, no patients had ≥50% seizure reduction, and 33% developed AEs, when LCM was administered concomitantly with two SCBs. CONCLUSIONS Lacosamide was effective in 30% of children and young adults in whom other SCBs had not been effective. The effectiveness of LCM may differ from that of other SCBs, and it is worth trying in patients with epilepsy resistant to other AEDs.
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Affiliation(s)
- Takeshi Suzuki
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jun Natsume
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Developmental Disability Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Sumire Kumai
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuki Maki
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Yamamoto
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Numoto
- Department of Pediatrics, Aichi Medical University, Nagakute, Japan
| | - Sho Narahara
- Department of Pediatrics, Anjo Kosei Hospital, Anjo, Japan
| | - Tetsuo Kubota
- Department of Pediatrics, Anjo Kosei Hospital, Anjo, Japan
| | - Takeshi Tsuji
- Department of Pediatrics, Okazaki City Hospital, Okazaki, Japan
| | - Toru Kato
- Department of Pediatrics, Okazaki City Hospital, Okazaki, Japan
| | - Keitaro Yamada
- Department of Pediatric Neurology, Central Hospital, Aichi Developmental Disability Center, Kasugai, Japan
| | - Koichi Maruyama
- Department of Pediatric Neurology, Central Hospital, Aichi Developmental Disability Center, Kasugai, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Kidokoro
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Cerulli Irelli E, Morano A, Fanella M, Orlando B, Salamone EM, Giallonardo AT, Di Bonaventura C. Reconsidering the role of selective sodium channel blockers in genetic generalized epilepsy. Acta Neurol Scand 2021; 144:647-654. [PMID: 34314016 DOI: 10.1111/ane.13509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/09/2021] [Accepted: 07/16/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Selective sodium channel blockers (SSCBs) have a limited use in genetic generalized epilepsy (GGE), due to their well-known risk of seizure worsening. Although their therapeutic potential in GGE has been suggested by recent evidence, electro-clinical data supporting their prescription are lacking. We aimed to investigate SSCB safety and effectiveness in a GGE cohort. METHODS Subjects who received SSCBs and had ≥5-year follow-up were enrolled. Lamotrigine was excluded from analysis due to its broader pharmacodynamic spectrum and its better-documented efficacy in GGE. RESULTS Fifty-six patients (median follow-up 28.5 years) were included. The most used SSCB was carbamazepine in 40 subjects. At the last medical observation, only 9 subjects were still receiving SSCBs. The occurrence of generalized polyspike-wave discharges (GPSWDs) predicted reduced SSCB retention in Cox multivariate analysis. A seizure reduction ≥50% occurred in 53.5% (30/56) of subjects when considering all seizure types; however, the proportion of responders increased to 67.9% when considering only generalized tonic-clonic seizures (GTCS). GPSWDs were significantly associated with a reduced response rate, whereas GGE with GTCS only syndrome with a better outcome. The switch from SSCBs to antiseizure medications licensed for GGE improved seizure control in 65% of patients. Seizure worsening was reported in 5/56 patients; juvenile myoclonic epilepsy and a family history of epilepsy were significantly associated with seizure aggravation. CONCLUSION SSCBs appeared effective on GTCS, but epilepsy aggravation and unsatisfactory control of other seizure types were not uncommon. Our study contributes to identifying new clinical and EEG variables associated with SSCB effectiveness and safety which may help neurologists in patients' management.
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Affiliation(s)
- Emanuele Cerulli Irelli
- Epilepsy Unit Department of Human Neurosciences Policlinico Umberto I Sapienza University of Rome Italy
| | - Alessandra Morano
- Epilepsy Unit Department of Human Neurosciences Policlinico Umberto I Sapienza University of Rome Italy
| | - Martina Fanella
- Epilepsy Unit Department of Human Neurosciences Policlinico Umberto I Sapienza University of Rome Italy
| | - Biagio Orlando
- Epilepsy Unit Department of Human Neurosciences Policlinico Umberto I Sapienza University of Rome Italy
| | - Enrico M Salamone
- Epilepsy Unit Department of Human Neurosciences Policlinico Umberto I Sapienza University of Rome Italy
| | - Anna T Giallonardo
- Epilepsy Unit Department of Human Neurosciences Policlinico Umberto I Sapienza University of Rome Italy
| | - Carlo Di Bonaventura
- Epilepsy Unit Department of Human Neurosciences Policlinico Umberto I Sapienza University of Rome Italy
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Dell'Aquila J, Soti V. Treating Status Epilepticus: Phenytoin Versus Levetiracetam. Cureus 2021; 13:e18515. [PMID: 34659919 PMCID: PMC8492029 DOI: 10.7759/cureus.18515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 11/25/2022] Open
Abstract
For decades, phenytoin has been the drug of choice for the treatment of epilepsy but also the second-line treatment for status epilepticus (SE). However, newer antiepileptic drugs (AEDs) have emerged as safer alternatives for the suppression of seizures. Consequently, phenytoin has recently fallen under scrutiny in the research world, prompting many studies to compare its efficacy to these other drugs, most notably levetiracetam. Levetiracetam is a second-generation AED, which is gaining wide clinical use as the second-line agent in treating SE patients. This review focuses on several clinical studies that have directly compared the effectiveness of phenytoin and levetiracetam in suppressing SE seizure activity. Additionally, this review highlights several advantages of using levetiracetam over phenytoin in this clinical context.
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Affiliation(s)
| | - Varun Soti
- Pharmacology and Therapeutics, Lake Erie College of Osteopathic Medicine, Elmira, USA
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Lin CH, Ho CJ, Lu YT, Tsai MH. Response to Sodium Channel blocking Antiseizure medications and coding polymorphisms of Sodium Channel genes in Taiwanese epilepsy patients. BMC Neurol 2021; 21:367. [PMID: 34556045 PMCID: PMC8459515 DOI: 10.1186/s12883-021-02395-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background Many antiseizure medications (ASMs) control seizures by blocking voltage-dependent sodium channels. Polymorphisms of sodium channel genes may affect the response to ASMs due to altering the effect of ASMs on blocking sodium channels. Methods We conducted a retrospective study of epilepsy patients followed up at the Neurological Department of Kaohsiung Chang Gung Memorial Hospital, Taiwan between January 2010 and December 2018. We categorized the patients into response, partial response, and failure to sodium channel blocking ASM groups. Sodium channel blocking ASMs included phenytoin, carbamazepine, lamotrigine, oxcarbazepine, lacosamide, zonisamide, topiramate, and valproic acid. A subgroup of predominant sodium channel blocking ASMs included phenytoin, carbamazepine, lamotrigine, oxcarbazepine, and lacosamide. Associations between the response of ASMs and single-nucleotide polymorphisms of SCN1A, SCN1B, SCN2A, and SCN9A were analyzed. Results Two hundred Taiwanese patients and 21 single-nucleotide polymorphisms among SCN1A, SCN1B, SCN2A, and SCN9A were evaluated. We found allele C of rs55742440 in SCN1B was statistically significantly associated with not achieving seizure-free with sodium channel blocking ASMs. For the predominant sodium channel blocking ASMs group, no SNPs were associated with the response of ASMs. Conclusion Single-nucleotide polymorphism in SCN1B was associated with the response to sodium channel blocking ASMs. This highlights the possibility that beta subunits may affect the function of sodium channels and resulted in different responsiveness to ASMs. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02395-2.
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Affiliation(s)
- Chih-Hsiang Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Colleague of Medicine, Chang Gung University, Kaohsiung, Kaohsiung City, 83301, Taiwan
| | - Chen-Jui Ho
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Colleague of Medicine, Chang Gung University, Kaohsiung, Kaohsiung City, 83301, Taiwan
| | - Yan-Ting Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Colleague of Medicine, Chang Gung University, Kaohsiung, Kaohsiung City, 83301, Taiwan
| | - Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Colleague of Medicine, Chang Gung University, Kaohsiung, Kaohsiung City, 83301, Taiwan. .,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Lou S, Cui S. Drug treatment of epilepsy: From serendipitous discovery to evolutionary mechanisms. Curr Med Chem 2021; 29:3366-3391. [PMID: 34514980 DOI: 10.2174/0929867328666210910124727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/17/2021] [Accepted: 07/21/2021] [Indexed: 11/22/2022]
Abstract
Epilepsy is a chronic brain disorder caused by abnormal firing of neurons. Up to now, using antiepileptic drugs is the main method of epilepsy treatment. The development of antiepileptic drugs lasted for centuries. In general, most agents entering clinical practice act on the balance mechanisms of brain "excitability-inhibition". More specifically, they target voltage-gated ion channels, GABAergic transmission and glutamatergic transmission. In recent years, some novel drugs representing new mechanisms of action have been discovered. Although there are about 30 available drugs in the market, it is still in urgent need of discovering more effective and safer drugs. The development of new antiepileptic drugs is into a new era: from serendipitous discovery to evolutionary mechanism-based design. This article presents an overview of drug treatment of epilepsy, including a series of traditional and novel drugs.
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Affiliation(s)
- Shengying Lou
- Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou. China
| | - Sunliang Cui
- Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou. China
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Serafini R. How much can medical management alone improve the outcome of adult drug-resistant epilepsy? An exploratory study on possibilities and limitations of combining multiple therapeutic actions. Epilepsy Behav 2021; 122:108065. [PMID: 34243142 DOI: 10.1016/j.yebeh.2021.108065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/03/2021] [Accepted: 05/08/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Failure to control epileptic seizures with two medications, adequately chosen and dosed, indicates drug-resistant epilepsy (DRE). The chance of pharmacologically controlling seizures is low for patients with DRE and uncontrolled seizures who are not candidates for surgery, who have already undergone surgery, or who already had a vagus nerve stimulator (VNS) placed. Patients experiencing these conditions must instead rely on medical management of their seizures, and there is no breakthrough solution on the horizon. Medical care of DRE might be optimized by systematically considering factors that promote and inhibit breakthrough seizures. For example, seizure control could be enhanced through measures such as increasing the frequency of follow-up visits, tracking treatment plan compliance, treating sleep disorders, rational polypharmacy, adjusting drug administration to achieve higher levels when seizures are more likely and educating patients on seizure triggers. A systematic and simultaneous implementation of all of these measures is likely to yield a sizable, clinically relevant, improvement. This paper presents an exploratory study on the effects of implementing such an approach, specifically evaluating this method's impact on seizure frequency. METHODS I performed a retrospective chart review of 659 consecutive adult patients with epilepsy followed up at the University of Utah and at the Salt Lake City VA Medical center using the multimodal approach described above. I identified 27 patients who had DRE and uncontrolled seizures and in whom a medical management optimization protocol was implemented. I measured these patients' seizure frequency at the beginning and the end of the study period and compared the results with those of a matching control group of 48 patients. RESULTS The optimization protocol did not increase the number of seizure-free patients with DRE; however, it was effective in minimizing seizure frequency in patients whose seizures remained uncontrolled. Among these patients, the median seizure frequency dropped by 64% in the optimization group but did not change in the control group. CONCLUSIONS Despite the high occurrence of DRE, there is no accepted protocol for the related medical management. This paper describes an effective approach that can be implemented in a clinically relevant and readily achievable manner.
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Affiliation(s)
- Ruggero Serafini
- Department of Neurology, University of Utah Clinical Neuroscience Center, George E. Wahlen VA Medical Center, 175 North Medical Drive East, 5th Floor, Salt Lake City, UT 84132, USA.
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Pal R, Kumar B, Akhtar MJ, Chawla PA. Voltage gated sodium channel inhibitors as anticonvulsant drugs: A systematic review on recent developments and structure activity relationship studies. Bioorg Chem 2021; 115:105230. [PMID: 34416507 DOI: 10.1016/j.bioorg.2021.105230] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 12/28/2022]
Abstract
Voltage-gated sodium channel blockers are one of the vital targets for the management of several central nervous system diseases, including epilepsy, chronic pain, psychiatric disorders, and spasticity. The voltage-gated sodium channels play a key role in controlling cellular excitability. This reduction in excitotoxicity is also applied to improve the symptoms of epileptic conditions. The effectiveness of antiepileptic drugs as sodium channel depends upon the reversible blocking of the spontaneous discharge without blocking its propagation. There are number of antiepileptic drug(s) which are in pipeline to flour the market to conquer abnormal neuronal excitability. They inhibit the seizures through the inhibition of complex voltage- and frequency-dependent ionic currents through sodium channels. Over the past decade, the sodium channel is one of the most explored targets to control or treat the seizure, but there has not been any game-changing discovery yet. Although there are large numbers of drugs approved for the treatment of epilepsy, however they are associated with several acute to chronic side effects. Many research groups have tirelessly worked for better therapeutic medication on this popular target to treat epileptic seizures. The review quotes briefly the developments of the approved examples of sodium channel blockers as anticonvulsant drugs. Medicinal chemists have tried the design and development of some more potent anticonvulsant drugs to minimize the toxicity that are discussed here, and an emphasis is given for their possible mechanism and the structure-activity relationship (SAR).
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Affiliation(s)
- Rohit Pal
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga 142001, Punjab, India
| | - Bhupinder Kumar
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga 142001, Punjab, India
| | - Md Jawaid Akhtar
- Department of Pharmaceutical Chemistry, College of Pharmacy, National University of Science and Technology, PO620, PC 130 Azaiba, Bousher, Muscat, Sultanate of Oman
| | - Pooja A Chawla
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga 142001, Punjab, India.
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Taleb A, Zhou YP, Meng LT, Zhu MY, Zhang Q, Naveed M, Li LD, Wang P, Zhou QG, Meng F, Han F. New application of an old drug proparacaine in treating epilepsy via liposomal hydrogel formulation. Pharmacol Res 2021; 169:105636. [PMID: 33932606 DOI: 10.1016/j.phrs.2021.105636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 01/06/2023]
Abstract
Proparacaine (PPC) is a previously discovered topical anesthetic for ophthalmic optometry and surgery by blocking the central Nav1.3. In this study, we found that proparacaine hydrochloride (PPC-HCl) exerted an acute robust antiepileptic effect in pilocarpine-induced epilepsy mice. More importantly, chronic treatment with PPC-HCl totally terminated spontaneous recurrent seizure occurrence without significant toxicity. Chronic treatment with PPC-HCl did not cause obvious cytotoxicity, neuropsychiatric adverse effects, hepatotoxicity, cardiotoxicity, and even genotoxicity that evaluated by whole genome-scale transcriptomic analyses. Only when in a high dose (50 mg/kg), the QRS interval measured by electrocardiography was slightly prolonged, which was similar to the impact of levetiracetam. Nevertheless, to overcome this potential issue, we adopt a liposome encapsulation strategy that could alleviate cardiotoxicity and prepared a type of hydrogel containing PPC-HCl for sustained release. Implantation of thermosensitive chitosan-based hydrogel containing liposomal PPC-HCl into the subcutaneous tissue exerted immediate and long-lasting remission from spontaneous recurrent seizure in epileptic mice without affecting QRS interval. Therefore, this new liposomal hydrogel formulation of proparacaine could be developed as a transdermal patch for treating epilepsy, avoiding the severe toxicity after chronic treatment with current antiepileptic drugs in clinic.
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Affiliation(s)
- Abdoh Taleb
- Key Lab of Cardiovascular and Cerebrovascular Medicine, Drug Target and Drug Discovery Center, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Ya-Ping Zhou
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Ling-Tong Meng
- Key Lab of Cardiovascular and Cerebrovascular Medicine, Drug Target and Drug Discovery Center, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Ming-Yi Zhu
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Qiao Zhang
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Muhammad Naveed
- Key Lab of Cardiovascular and Cerebrovascular Medicine, Drug Target and Drug Discovery Center, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Lian-Di Li
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Peng Wang
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Jiangsu Simcere Pharmaceutical Co., Ltd., Nanjing 210042, China
| | - Qi-Gang Zhou
- Key Lab of Cardiovascular and Cerebrovascular Medicine, Drug Target and Drug Discovery Center, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China; Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China; Sir Run Run Hospital, Nanjing Medical University, Nanjing 211166, Jiangsu Province, China.
| | - Fan Meng
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China; State Key Laboratory of Translational Medicine and Innovative Drug Development, Jiangsu Simcere Pharmaceutical Co., Ltd., Nanjing 210042, China.
| | - Feng Han
- Key Lab of Cardiovascular and Cerebrovascular Medicine, Drug Target and Drug Discovery Center, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China; Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China.
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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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Aledo-Serrano Á, Gómez-Iglesias P, Toledano R, Garcia-Peñas JJ, Garcia-Morales I, Anciones C, Soto-Insuga V, Benke TA, Del Pino I, Gil-Nagel A. Sodium channel blockers for the treatment of epilepsy in CDKL5 deficiency disorder: Findings from a multicenter cohort. Epilepsy Behav 2021; 118:107946. [PMID: 33848848 DOI: 10.1016/j.yebeh.2021.107946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/21/2021] [Accepted: 03/21/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study was aimed to analyze the effectiveness of sodium channel blockers (SCBs) in CDKL5 deficiency disorder (CDD)-related epilepsy. METHODS A retrospective, observational study was performed, including patients with CDD diagnosis evaluated between 2016 and 2019 at three tertiary Epilepsy Centers. Demographic, electroclinical and genetic features, as well as ASM treatments and their outcomes were analyzed, with special focus on SCBs. RESULTS Twenty-one patients evaluated at three tertiary Epilepsy Centers were included, of which 19 presented with epilepsy (90.5%); all had pathogenic mutations of CDKL5. Six patients (31.6%) were classified as SCB responders (more than 50% reduction), four being currently seizure free (mean seizure-free period of 8 years). Most frequent SCB drugs were oxcarbazepine (OXC), carbamazepine (CBZ), and lacosamide (LCM). None of them presented relevant adverse events. In contrast, three patients showed seizure aggravation in the non-responder group. When comparing both groups, responders had statistically significant younger age at SCB treatment and epilepsy onset, higher proportion of focal epileptiform activity and less frequent history of West syndrome. CONCLUSIONS The results of this study indicate that treatment with SCBs might be effective and safe in a subset of patients with CDD-related epilepsy.
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Affiliation(s)
- Ángel Aledo-Serrano
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain; Epilepsy Unit. Neuroscience Department, Corachan Clinic, Barcelona, Spain.
| | | | - Rafael Toledano
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain; Epilepsy Unit, Neurology Department, Ramon y Cajal University Hospital, Madrid, Spain
| | - Juan Jose Garcia-Peñas
- Department of Pediatric Neurology, Niño Jesus University Children's Hospital, Madrid, Spain
| | - Irene Garcia-Morales
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain; Epilepsy Unit. Neurology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Carla Anciones
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain
| | - Victor Soto-Insuga
- Department of Pediatric Neurology, Niño Jesus University Children's Hospital, Madrid, Spain
| | - Timothy A Benke
- Departments of Pediatrics, Neurology, and Pharmacology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Isabel Del Pino
- Principe Felipe Research Center (Centro de Investigación Principe Felipe, CIPF), Valencia, Spain
| | - Antonio Gil-Nagel
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain
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Portale A, Comella M, Salomone G, Di Nora A, Marino L, Leonardi R, Praticò AD, Falsaperla R. The Spectrum of KCNQ2- and KCNQ3-Related Epilepsy. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Abstract
KCNQ genes encode for a family of six transmembrane domains, single pore-loop, and K+ channel α-subunits that have a wide range of physiological correlates. In the brain, KCNQ2 and KCNQ3 heteromultimers are thought to underlie the M-current which is essential in raising the threshold for firing an action potential; mutations in these genes may cause several types of infantile epilepsies. KCNQ2-related disorders represent a continuum of overlapping neonatal epileptic phenotypes that range from KCNQ2 benign familial neonatal epilepsy (BFNE), a seizure disorder that occur in children who typically have a normal psychomotor development and are inherited as an autosomal dominant trait, to KCNQ2 early-onset epileptic encephalopathy (EOEE) as the result of a de novo pathogenic variant. KCNQ3-related disorders are rarer and include BFNE, benign familial infantile epilepsy and KCNQ3-related epileptic encephalopathy with intellectual disability with or without seizures and/or cortical visual impairment. For both KCNQ2- and KCNQ3-related disorders, it is possible to use several drugs for different classes of mutations (i.e., gain of function vs. loss of function), and usually their effects vary in relation to the clinical presentation and the phenotype of the patient. However, KCNQ2-EOEE patients have a worse response to treatment than KCNQ2-BFNE patients and usually become drug resistant with multiple daily seizures.
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Affiliation(s)
- Anna Portale
- Unit of Pediatrics, Avola Hospital, Siracusa, Italy
| | - Mattia Comella
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giulia Salomone
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alessandra Di Nora
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Lidia Marino
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Roberta Leonardi
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| | - Andrea D. Praticò
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Unit of Neonatal Intensive Care and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
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Karlov VA, Vlasov PN, Kozhokaru AB, Orlova AS. [The efficacy and tolerability of extended release carbamazepine in adult patients with new-onset epilepsy using epileptiform activity index]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:31-38. [PMID: 33834715 DOI: 10.17116/jnevro202112103131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the efficacy and tolerability of extended release carbamazepine (finlepsin-retard and tegretol CR) in adult patients with new-onset focal epilepsy (FE) with the assessment of epileptiform activity index (EAI). MATERIAL AND METHODS The study included 62 patients (38 (61.3%) men and 24 (38.7%) women) with new-onset FE aged ≥18 years (mean age 42.9±18.4 years). All patients underwent video-ECG-monitoring with EAI assessment at each visit. Treatment efficacy was assessed using the criteria of seizure absence (medically induced remission), seizure rate decrease by >50% (responders), seizure rate decrease by <50% - insufficient efficacy, retention on treatment and seizure rate increase compared to baseline and/or development of new type of seizures (aggravation). Overall study period was 12 months. RESULTS By the end of the 12-month follow-up period, there was a 4.3-fold decrease of the total EAI compared to baseline (p<0.001). Retention on carbamazepine treatment during 12 months was achieved in 61.3% (n=38) patients; medically induced remission - in 40.3% (n=25); seizure rate decrease by >50% - in 21.0% (n=13). In 29.1% (n=18) of patients, treatment change was performed; double-drug therapy, including carbamazepine, was prescribed in 9.6% (n=6) of patients. Incidence of adverse events was 29.1% (n=18). CONCLUSIONS Carbamazepine is an effective and promising drug for initial monotherapy of FE. Its use in the treatment of FE results in a 4.3-fold decrease of EAI (p<0.001), which reflects the efficacy of treatment. EAI is an additional objective measure of treatment efficacy.
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Affiliation(s)
- V A Karlov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - P N Vlasov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A B Kozhokaru
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - A S Orlova
- Sechenov First Moscow State Medical Univesity, Moscow, Russia
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The Efficacy and Safety of Lacosamide for Bipolar Depression: A 12-Week Open-Label Pilot Trial. J Clin Psychopharmacol 2021; 41:204-206. [PMID: 33666402 DOI: 10.1097/jcp.0000000000001347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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