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Wu C, Wu H, Zhou Y, Liu X, Huang S, Zhu S. Effectiveness analysis of three-drug combination therapies for refractory focal epilepsy. Neurotherapeutics 2024; 21:e00345. [PMID: 38490875 PMCID: PMC11070276 DOI: 10.1016/j.neurot.2024.e00345] [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: 09/09/2023] [Revised: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
Selecting appropriate antiseizure medications (ASMs) for combination therapy in patients with drug-resistant epilepsy (DRE) is a complex task that requires an empirical approach, especially in patients receiving polytherapy. We aimed to analyze the effectiveness of various three-drug combinations in a group of patients with DRE under real-world conditions. This single-center, longitudinal observational study investigated patients with drug-resistant focal epilepsy who received three-drug regimens in the outpatient clinic of Tongji Hospital from September 2019 to December 2022. The effectiveness of each triple regimen was evaluated by the seizure-free rate and within-patient ratio of the seizure frequency (a seizure frequency ratio [SFR]<1 indicated superior efficacy). The independent t-test or Mann-Whitney U test was used for effectiveness analysis, and P values were adjusted by the Benjamini-Hochberg method for multiple comparisons. A total of 511 triple trials comprising 76 different regimens were conducted among 323 enrolled patients. Among these triple regimens, lamotrigine (LTG)/valproic acid (VPA)/topiramate (TPM) was the most frequently prescribed (29.4%, n = 95). At the last clinical visit, 14.9% (n = 48) of patients achieved seizure freedom after receiving triple therapy. LTG/VPA/TPM and LTG/VPA/levetiracetam (LEV) exhibited the highest seizure-free rates at 17.9% and 12.8%, respectively. These two regimens also had significantly lower median SFRs of 0.48 (interquartile range [IQR], 0.17-0.85; adjusted P < 0.001) and 0.63 (IQR, 0.21-1.04; adjusted P < 0.01), respectively. LTG/VPA/perampanel (PER) was another promising regimen that showed marginal effectiveness (median SFR = 0.67; adjusted P = 0.053). LTG/VPA/phenobarbital had the highest incidence of regimen-specific side effects (40.0%, 4/10), while the incidence of side effects from LTG/VPA/LEV was minimal (5.1%, 2/39). In conclusion, LTG/VPA/TPM and LTG/VPA/LEV exhibited superior efficacy and good tolerability in treating patients with DRE. Our results provide preliminary insights into the selection of ASMs for three-drug combination therapies in this clinically challenging population.
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Affiliation(s)
- Chunmei Wu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Huiting Wu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Yingying Zhou
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Xiaoyan Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Shanshan Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China.
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China.
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Liu P, An J, Wu H. Evaluation of the Effect of Eslicarbazepine Acetate on the Pharmacokinetics of Perampanel in Rats by Isotope-Dilution-UHPLC-MS/MS. Drug Des Devel Ther 2022; 16:4091-4099. [DOI: 10.2147/dddt.s392934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
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Huang Y, Xu H, Wang P, Gu R, Li X, Xu Y, Wang J, Qiao S, Shi D, Gao Z, Li J. Identification of Guaifenesin-Andrographolide as a Novel Combinatorial Drug Therapy for Epilepsy Using Network Virtual Screening and Experimental Validation. ACS Chem Neurosci 2022; 13:978-986. [PMID: 35333519 DOI: 10.1021/acschemneuro.1c00774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Combinatorial drug therapy has attracted substantial attention as an emerging strategy for the treatment of diseases with complex pathological mechanisms. We previously developed a potentially universal computational screening approach for combination drugs and used this approach to successfully identify some beneficial combinations for the treatment of heart failure. Herein, this screening approach was used to identify novel combination drugs for the treatment of epilepsy in an approved drug library. The combination of guaifenesin-andrographolide was first discovered as a promising therapy with synergistic anticonvulsant activities in maximal electroshock (MES)- and subcutaneous pentylenetetrazol (sc-PTZ)-induced epilepsy models in vivo. The studies of network analysis, fluorescence imaging, and N-methyl-d-aspartate (NMDA)-induced cytotoxicity further revealed that guaifenesin-andrographolide might synergistically affect NMDA receptors and then alleviate the pathogenesis of epilepsy. Therefore, we report that the combination of guaifenesin-andrographolide exerts effects against epilepsy through a novel synergistic mechanism and is thus a potential treatment for epilepsy, providing a promising mechanism for the design of novel combinatorial drug treatments against epilepsy.
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Affiliation(s)
- Yunyuan Huang
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontier Science Research Base of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Haiyan Xu
- CAS Key Laboratory of Receptor Research, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Pei Wang
- CAS Key Laboratory of Receptor Research, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Rurong Gu
- CAS Key Laboratory of Receptor Research, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Xiaokang Li
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontier Science Research Base of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Yixiang Xu
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontier Science Research Base of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Jiqun Wang
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontier Science Research Base of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Sicong Qiao
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontier Science Research Base of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Donglei Shi
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontier Science Research Base of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
| | - Zhaobing Gao
- CAS Key Laboratory of Receptor Research, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Jian Li
- State Key Laboratory of Bioreactor Engineering, Shanghai Frontier Science Research Base of Optogenetic Techniques for Cell Metabolism, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai 200237, China
- Yunnan Key Laboratory of Screening and Research on Anti-pathogenic Plant Resources from West Yunnan, College of Pharmacy, Dali University, Dali 671000, China
- Clinical Medicine Scientific and Technical Innovation Center, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200092, China
- Key Laboratory of Tropical Biological Resources of Ministry of Education, College of Pharmacy, Hainan University, Haikou 570228, Hainan, China
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Chen W, Jin B, Aung T, He C, Chen C, Wang S, Ding Y, Ding F, Wang C, Li H, Jiang B, Zheng Z, Dai H, Zhu J, Geng Y, Ding M, Wang S. Response to antiseizure medications in epileptic patients with malformation of cortical development. Ther Adv Neurol Disord 2021; 14:17562864211050027. [PMID: 34671424 PMCID: PMC8521419 DOI: 10.1177/17562864211050027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background Malformation of cortical development (MCD) is one of the most common causes of pharmacoresistant epilepsy. Improving the knowledge of antiseizure medications (ASMs) treatment response in epileptic patients with MCD is crucial for optimal treatment options, either pharmacological therapy or non-pharmacological intervention. Aim To investigate the patterns of medical treatment outcome and the predictors for seizure freedom (SF) with ASM regimens in epilepsy caused by MCD. Methods The epileptic patients with MCD were consecutively enrolled from March 2013 to June 2019. SF was defined as no seizures for at least 12 months or three times the longest pretreatment inter-seizure interval, whichever was longer. Outcomes were classified into three patterns: pattern A: patients achieved SF at one point and remained so throughout follow-up; pattern B: patients' seizures fluctuated between periods of SF and relapse; pattern C: SF never attained. The terminal SF was defined if the patients remained SF at the last follow-up visit. Results A total of 164 epileptic patients with MCD were included. Pattern A was observed in 22, pattern B in 42, and pattern C in 100 patients. SF was ever achieved in 64 (pattern A and B) patients. Twenty-nine patients had terminal SF after a median follow-up time of 4.3 years. With continuing ASM treatment, seizure relapse risk was very low after a 5-year seizure-free period. The pretreatment seizure frequency was the only independent predictor for pattern A and seizure relapse. Sodium channel blockers monotherapy (33.8%) was more effective than levetiracetam (4.5%) in rendering SF in the initial ASM regimen. Conclusion Medical treatment can be successful in a minority of epileptic patients with MCD, and pretreatment seizure frequency helps to predict the treatment outcome. An unequal efficacy of ASMs in epilepsy caused by MCD suggests etiological evaluation is vital in the management of focal epilepsy.
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Affiliation(s)
- Wei Chen
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China Department of Neurology, Linhai Second People's Hospital, Taizhou, China
| | - Bo Jin
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Thandar Aung
- Epilepsy Center, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Chenmin He
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Cong Chen
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shan Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yao Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fang Ding
- Department of Neurology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Chao Wang
- Department of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hong Li
- Department of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Biao Jiang
- Department of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhe Zheng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junming Zhu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Meiping Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuang Wang
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, 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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Gambardella A, Tinuper P, Acone B, Bonanni P, Coppola G, Perucca E. Selection of antiseizure medications for first add-on use: A consensus paper. Epilepsy Behav 2021; 122:108087. [PMID: 34175662 DOI: 10.1016/j.yebeh.2021.108087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/21/2021] [Accepted: 05/22/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION When monotherapy used alone or sequentially fails to achieve seizure control, a trial of combination therapy may be considered. OBJECTIVE To define optimal criteria to guide choice of an antiseizure medication (ASM) for use as first add-on. METHODS A standardized Delphi procedure was applied to produce a list of consensus statements. First, an Expert Board consisting of 5 epileptologists agreed on a set of 46 statements relevant to the objective. The statements were then finalized through an iterative process by a Delphi Panel of 84 Italian pediatric and adult neurologists with expertise in the management of epilepsy. Panel members provided anonymous ratings of their level of agreement with each statement on a 9-point Likert scale. RESULTS Consensus, defined as agreement by at least 80% of Panel members, was reached for 36 statements. Medication-related factors considered to be important for drug selection included efficacy, tolerability and safety, interaction potential, mechanism of action, and ease of use. The need to optimize adherence and to tailor drug selection to individual characteristics was emphasized. CONCLUSIONS Choice of an ASM for first add-on requires consideration of many factors, many of which also apply to choose initial treatment. Factors more specifically relevant to add-on use include drug interaction potential and the preference for an ASM with a different mechanism of action.
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Affiliation(s)
| | - Paolo Tinuper
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | | | - Paolo Bonanni
- IRCCS Eugenio Medea Scientific Institute, Epilepsy Unit, Conegliano, Italy
| | - Giangennaro Coppola
- Department of Medicine, Surgery, Odontoiatry, Medical School of Salerno, University of Salerno, Italy
| | - Emilio Perucca
- Division of Clinical and Experimental Pharmacology, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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Peng Q, Ma M, Gu X, Hu Y, Zhou B. Evaluation of Factors Impacting the Efficacy of Single or Combination Therapies of Valproic Acid, Carbamazepine, and Oxcarbazepine: A Longitudinal Observation Study. Front Pharmacol 2021; 12:641512. [PMID: 34017250 PMCID: PMC8129194 DOI: 10.3389/fphar.2021.641512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/13/2021] [Indexed: 12/16/2022] Open
Abstract
Objective: This study aimed to determine the efficacy and clinical factors related to the pharmacodynamics of single or combination therapies of valproic acid (VPA), carbamazepine (CBZ), and oxcarbazepine (OXC), three commonly used anti-epileptic drugs (AEDs) in China. Methods: The study evaluated the records of 2027 outpatients in a Changsha hospital, located in China, from December 23, 2015 to October 28, 2019. The baseline seizure frequency was assessed during the first visit. AED efficacy was determined based on the reduction in seizures from baseline at the subsequent visits. Multivariable ordinal regression analysis was used to determine the association between the clinical factors (demographic characteristics, clinical features, and medication situation) and AED efficacy. For validation, the clinical efficacies of AEDs were compared as both single agents and in combinations. Differences in adverse effect (AEs) categories were analyzed by Chi-square between AED groups. Results: Records of patients receiving VPA, CBZ, and OXC were evaluated. Serum concentrations of VPA and CBZ is significantly correlated with efficacy (OR 1.030 [1.024–1.037], p < 0 0.0001; OR 1.250 [1.146–1.63], p < 0.0001, respectively) and OXC efficacy correlated to the serum concentration of the metabolite 10,11-dihydro-10-hydroxy-carbazepine (monohydroxy derivative, MHD) serum concentrations (OR 1.060 [1.031–1.089], p < 0.0001). Significant differences existed between females and males in VPA efficacy (OR 1.318 [1.033–1.682], p = 0.027). After validation, VPA, in combination with OXC (OR 1.93 [1.38–2.70], p<0.001), or with VGB (Vigabatrin) (OR 2.36 [1.38–2.70], p = 0.002), showed significantly better efficacy than as a single agent. OXC efficacy was also affected by the duration of epilepsy (OR 0.965 [0.946–0.984], p < 0.001). Additionally, the efficacies of OXC and VPA were also affected by the seizure type. Seizure reduction improved significantly with an increasing number of pharmacists’ educations in the first three visits period. There were no differences in AEs incidence among these 3 AEDs except for Psychiatric (0.02) and nervous system disorders (0.0001). Conclusion: Serum concentrations of VPA and CBZ may positively affect their efficacies, while OXC efficacies are correlated to MHD serum concentrations. The efficacy of VPA was higher in females compared to males. VPA-OXC and VPA-VGB combinations had higher efficacies compared to monotherapy. Besides, OXC efficacy is probably reducing by the duration of epilepsy. Additionally, VPA efficacy for focal or generalized seizures is superior to mixed-type seizures. OXC was more effective for focal seizures compared to mixed-type ones. Education provided by pharmacists improved the seizures to some extent, and there were no significant differences between most categories of adverse effects for the investigated AEDs.
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Affiliation(s)
- Qilin Peng
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
| | - Mubai Ma
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
| | - Xurui Gu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
| | - Yani Hu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
| | - Boting Zhou
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China.,The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, China
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Łukawski K, Czuczwar SJ. Developing precision treatments for epilepsy using patient and animal models. Expert Rev Neurother 2020; 21:1241-1250. [PMID: 33339471 DOI: 10.1080/14737175.2021.1866989] [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: 10/22/2022]
Abstract
Introduction: Phenytoin was the first antiepileptic drug (AED) discovered in an animal model of seizures whose clinical efficacy was subsequently confirmed. This clearly indicated that a search for other AEDs had to consider animal studies.Areas covered: Main seizure tests used for the evaluation of possible anticonvulsive activity of potential anticonvulsants and their predictive values have been reviewed. Procedures used for the estimation of antiepileptogenic effects have been also included.Expert opinion: First-line seizure models comprise maximal electroshock (MES)-, pentylenetetrazol (PTZ)- and kindling-induced convulsions in rodents. The MES test may be considered as a convenient and easy model of generalized tonic-clonic seizures, PTZ test - as a model of generalized myoclonic seizures and to a certain degree - absence seizures. Kindled seizures (for example, from amygdala) may be regarded as a model of focal seizures. Some tests have been suggested for the search of AEDs effective in drug-resistant seizures - for instance, 6 Hz (44 mA) test or intrahippocampal kainate model of mesial temporal lobe epilepsy. There are also recommendations from experimental epileptology on synergistic AED combinations for patients with drug-resistant seizures. The clinical evidence on this issue is scarce and favors a combined treatment with valproate + lamotrigine.
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Affiliation(s)
- Krzysztof Łukawski
- Department of Physiopathology, Institute of Rural Health, Lublin, Poland.,Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
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Boleti APDA, Frihling BEF, E Silva PS, Cardoso PHDO, de Moraes LFRN, Rodrigues TAA, Biembengute MEF, Koolen HHF, Migliolo L. Biochemical aspects and therapeutic mechanisms of cannabidiol in epilepsy. Neurosci Biobehav Rev 2020; 132:1214-1228. [PMID: 33031814 DOI: 10.1016/j.neubiorev.2020.09.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/12/2022]
Abstract
Epilepsy is a chronic neurological disease characterized by recurrent epileptic seizures. Studies have shown the complexity of epileptogenesis and ictogenesis, in which immunological processes and epigenetic and structural changes in neuronal tissues have been identified as triggering epilepsy. Cannabidiol (CBD) is a major active component of the Cannabis plant and the source of CBD-enriched products for the treatment of epilepsy and associated diseases. In this review, we provide an up-to-date discussion on cellular and molecular mechanisms triggered during epilepsy crises, and the phytochemical characteristics of CBD that make it an attractive candidate for controlling rare syndromes, with excellent therapeutic properties. We also discuss possible CBD anticonvulsant mechanisms and molecular targets in neurodegenerative disorders and epilepsy. Based on these arguments, we conclude that CBD presents a biotecnological potential in the anticonvulsant process, including decreasing dependence on health care in hospitals, and could make the patient's life more stable, with regard to neurological conditions.
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Affiliation(s)
- Ana Paula de A Boleti
- S-InovaBiotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, 79117-900, Campo Grande, MS, Brazil
| | - Breno Emanuel F Frihling
- S-InovaBiotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, 79117-900, Campo Grande, MS, Brazil
| | - Patrícia Souza E Silva
- S-InovaBiotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, 79117-900, Campo Grande, MS, Brazil
| | - Pedro Henrique de O Cardoso
- S-InovaBiotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, 79117-900, Campo Grande, MS, Brazil
| | - Luiz Filipe R N de Moraes
- S-InovaBiotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, 79117-900, Campo Grande, MS, Brazil
| | - Thiago Antônio A Rodrigues
- S-InovaBiotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, 79117-900, Campo Grande, MS, Brazil
| | | | - Hector Henrique F Koolen
- Grupo de Estudos em Metabolômica e Espectrometria de Massas, Universidade do Estado do Amazonas - UEA, Manaus, Brazil
| | - Ludovico Migliolo
- S-InovaBiotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, 79117-900, Campo Grande, MS, Brazil; Programa de Pós-graduação em Biologia Celular e Molecular, Universidade Federal da Paraíba, João Pessoa, Brazil; Programa de Pós-graduação em Bioquímica, Universidade Federal do Rio Grande do Norte, Natal, Brazil.
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Liu T, Kotha RR, Jones JW, Polli JE, Kane MA. Fast liquid chromatography-tandem mass spectrometry method for simultaneous determination of eight antiepileptic drugs and an active metabolite in human plasma using polarity switching and timed selected reaction monitoring. J Pharm Biomed Anal 2019; 176:112816. [DOI: 10.1016/j.jpba.2019.112816] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/06/2019] [Accepted: 08/16/2019] [Indexed: 11/15/2022]
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Lee BI, Park KM, Kim SE, Heo K. Clinical opinion: Earlier employment of polytherapy in sequential pharmacotherapy of epilepsy. Epilepsy Res 2019; 156:106165. [PMID: 31351239 DOI: 10.1016/j.eplepsyres.2019.106165] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/07/2019] [Indexed: 01/22/2023]
Abstract
Modern pharmacotherapy for epilepsy consists of orderly, sequential drug trials, in which antiepileptic drugs (AEDs) are chosen under the concept of individual patient-oriented (or - tailored) pharmacotherapy. Although monotherapy has been established as the preferred mode of AEDs therapy in both newly diagnosed and drug resistant epilepsies, there are still lack of evidence to favor either monotherapy or polytherapy in epilepsy, which has generated continuing controversies on the preferred mode of pharmacotherapy. However, each mode of pharmacotherapy may have both advantages and disadvantages, which are different and variable related to individual case scenario. We conducted a brief comparative overview between monotherapy and polytherapy to provide clues for earlier employment of polytherapy in each steps of sequential drug trials. Previous claims about the advantages of monotherapy over polytherapy are not supported but gradually losing its ground by the introduction of a large number of drugs carrying pharmacological advantages for combination therapy. Current evidence stresses the importance of combining drugs having synergistic interactions for better outcome of polytherapy, which has not been considered in previous clinical investigations comparing monotherapy and polytherapy. It is likely that a significant improvement in the outcome of current AEDs therapy is feasible by earlier employment of polytherapy as well as identification of combination drug regimens carrying synergistic interactions. At present, lamotrigine(LTG) and valproate(VPA) combination regimen is the only well documented synergistic regimen, but there are a long-list of candidate regimens requiring future trials in appropriate designs.
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Affiliation(s)
- Byung In Lee
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea.
| | - Kang Min Park
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Sung Eun Kim
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Kyoung Heo
- Department of Neurology, Yonsei University College of Medicine, Severance Hospital, Epilepsy Research Institute, Seoul, Republic of Korea
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Abstract
Introduction: Brivaracetam (BRV) is an analog of levetiracetam (LEV) with 15-30 times greater affinity to SV2A and greater brain permeability than LEV. These properties have stimulated interest in its clinical trial data and post-marketing experience. Areas covered: The authors provide a background on epilepsy and its treatment, discuss the racetam family of antiepileptic drugs to which BRV belongs, and then discuss BRV properties and its efficacy and tolerability in the treatment of epilepsy. Expert opinion: While preclinical data suggest a broad spectrum of efficacy, BRV is only approved for focal epilepsy. The recommended starting dose is 100 mg per day, but in the absence of urgency, it may be prudent to start at 50 mg per day, considered the lowest effective dose. There was no added benefit when BRV was used adjunctively with LEV in clinical trials. However, post-marketing data suggest that some patients may experience improved seizure control when switching from LEV. Behavioral adverse effects seemed less common than with LEV, and most patients switched to BRV after experiencing behavioral adverse effects on LEV reported improvement. Prior or anticipated intolerability to LEV is the strongest indication for BRV in clinical practice.
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Affiliation(s)
- Yamane Makke
- Department of Neurology, Vanderbilt University Medical Center , Nashville , TN , USA
| | - Bassel Abou-Khalil
- Department of Neurology, Vanderbilt University Medical Center , Nashville , TN , USA
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14
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Wu T, Ido K, Ohgoh M, Hanada T. Mode of seizure inhibition by sodium channel blockers, an SV2A ligand, and an AMPA receptor antagonist in a rat amygdala kindling model. Epilepsy Res 2019; 154:42-49. [PMID: 31035244 DOI: 10.1016/j.eplepsyres.2019.03.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE A number of antiepileptic drugs (AEDs) with a variety of modes of action, are effective in treating focal seizures. Several AEDs, such as perampanel (PER), levetiracetam (LEV), lacosamide (LCM), lamotrigine (LTG), and carbamazepine (CBZ), have been shown to elevate the seizure threshold in kindling models. These AEDs are clinically effective, but differences exist in the anti-seizure profiles of drugs with similar modes of action. Therefore, we hypothesized that there are differences in how these AEDs affect seizures. Here, we evaluated the effects of AEDs on various seizure parameters in a rat amygdala kindling model upon stimulation at the after-discharge threshold (ADT) and at three-times the ADT (3xADT) to characterize the differences in the effects of these AEDs. METHODS PER, LEV, LCM, LTG, CBZ, or vehicle was administered intraperitoneally to fully kindled rats. Changes in Racine seizure score, after-discharge duration (ADD), and latency to Racine score 4 generalized seizure (S4L) were measured to assess differences in the modes of seizure inhibition among the AEDs. Stimulation at 3xADT was used to eliminate the influence of any AED-induced elevation of the seizure threshold on these parameters. RESULTS PER, LEV, LCM, LTG, and CBZ significantly reduced the seizure score from Racine score 5 after stimulation at the ADT; this effect was lost with LEV and LTG after stimulation at 3xADT. PER and LEV significantly shortened the ADD when the seizure focus was stimulated at the ADT, whereas LCM, LTG, and CBZ did not. LEV, LCM, LTG, and CBZ failed to shorten the ADD upon stimulation at 3xADT. PER dose-dependently and significantly increased S4L, even at doses that were ineffective for seizure score reduction, after stimulation at both the ADT and 3xADT. LEV and LTG significantly increased S4L after stimulation at the ADT, whereas LCM and CBZ did not significantly increase S4L at any of the doses tested. CONCLUSIONS The sodium channel blockers (LCM, LTG, and CBZ) appeared to act by elevation of the seizure threshold via reduction of neuronal excitability, whereas the AMPA receptor antagonist (PER) and the SV2A ligand (LEV), as well as LTG, exerted their effects through the weakening of synaptic transmission in neuronal networks at the seizure focus. Maintenance of the effect of PER even at 3xADT suggests direct and strong modulation of excitatory synaptic transmission by PER, both at the focus and along the seizure propagation route. These findings may provide further rationale for usage of AEDs beyond their respective modes of action.
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Affiliation(s)
- Ting Wu
- Neurology Tsukuba Research Department, Discovery, Medicine Creation, Neurology Business Group, Eisai Co., Ltd. Japan
| | - Katsutoshi Ido
- Neurology Tsukuba Research Department, Discovery, Medicine Creation, Neurology Business Group, Eisai Co., Ltd. Japan
| | - Makoto Ohgoh
- Neurology Tsukuba Research Department, Discovery, Medicine Creation, Neurology Business Group, Eisai Co., Ltd. Japan
| | - Takahisa Hanada
- Clinical Science Department, Medical Division, Eisai Co., Ltd. Nishigokencho 13-1, Shinjuku-ku, Tokyo 162-0812, Japan.
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15
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Consider potential drug interactions when starting combination therapy with antiepileptic drugs. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0525-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Błaszczyk B, Miziak B, Czuczwar P, Wierzchowska-Cioch E, Pluta R, Czuczwar SJ. A viewpoint on rational and irrational fixed-drug combinations. Expert Rev Clin Pharmacol 2018; 11:761-771. [PMID: 30024271 DOI: 10.1080/17512433.2018.1500895] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Considering that there are around 30% of patients with epilepsy resistant to monotherapy, the use of synergistic combinations of antiepileptic drugs is of particular importance. This review shows most beneficial as well as irrational combined treatments both from an experimental and clinical point of view. Areas covered: Preferably, experimental data derived from studies evaluating synergy, additivity, or antagonism by relevant methods, in terms of anticonvulsant or neurotoxic effects and pharmacokinetic data have been considered. Although there have been no randomized clinical trials on this issue, the clinical data have been analyzed from studies on considerable numbers of patients. Case-report studies have been not considered. Expert commentary: The experimental data provide a strong support that co-administration of lamotrigine with carbamazepine is negative, considering the anticonvulsant and neurotoxic effects. Clinical reports do not entirely support this conclusion. Other experimentally documented negative combinations comprise lamotrigine+ oxcarbazepine and oxcarbazepine+ phenytoin. From the experimental and clinical point of view, a combination of lamotrigine+ valproate may deserve recommendation. Other most positive experimental and clinical combinations include carbamazepine+valproate, phenytoin+phenobarbital, carbamazepine+gabapentin, carbamazepine+topiramate, levetiracetam+valproate, levetiracetam+carbamazepine. Certainly, experimental data have some limitations (non-epileptic animals, acute administration of antiepileptic drugs) so all experimental recommendations need a careful clinical evaluation.
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Affiliation(s)
- Barbara Błaszczyk
- a Faculty of Health Sciences , High School of Economics, Law and Medical Sciences , Kielce , Poland
| | - Barbara Miziak
- b Department of Pathophysiology , Medical University of Lublin , Lublin , Poland
| | - Piotr Czuczwar
- b Department of Pathophysiology , Medical University of Lublin , Lublin , Poland.,c 3rd Department of Gynecology , Medical University of Lublin , Lublin , Poland
| | - Ewa Wierzchowska-Cioch
- b Department of Pathophysiology , Medical University of Lublin , Lublin , Poland.,d Department of Neurology , Pope John Paul II Independent Public Provincial Hospital , Zamosc , Poland
| | - Ryszard Pluta
- e Laboratory of Ischemic and Neurodegenerative Brain Research , Mossakowski Medical Research Centre, Polish Academy of Sciences , Warszawa , Poland
| | - Stanisław J Czuczwar
- b Department of Pathophysiology , Medical University of Lublin , Lublin , Poland.,f Department of Physiopathology , Institute of Rural Health , Lublin , Poland
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Banach M, Popławska M, Borowicz-Reutt KK. Amiodarone, a multi-channel blocker, enhances anticonvulsive effect of carbamazepine in the mouse maximal electroshock model. Epilepsy Res 2018; 140:105-110. [PMID: 29329017 DOI: 10.1016/j.eplepsyres.2018.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 12/07/2017] [Accepted: 01/03/2018] [Indexed: 12/11/2022]
Abstract
Cardiac arrhythmia may occur in the course of epilepsy. Simultaneous therapy of the two diseases might be complicated by drug interactions since antiarrhythmic and antiepileptic agents share some molecular targets. The aim of this study was to evaluate the influence of amiodarone, an antiarrhythmic drug working as a multi-channel blocker, on the protective activity of four classical antiepileptic drugs in the maximal electroshock test in mice. Amiodarone at doses up to 75 mg/kg did not affect the electroconvulsive threshold in mice. Acute amiodarone at the dose of 75 mg/kg significantly potentiated the anticonvulsive effect of carbamazepine, but not that of valproate, phenytoin or phenobarbital in the maximal electroshock-induced seizures in mice. The antiarrhythmic agent and its combinations with antiepileptic drugs did not impair motor performance or long-term memory in mice, except for the combination of amiodarone and phenobarbital. Brain concentrations of antiepileptic drugs were not changed. Despite favourable impact of amiodarone on the anticonvulsive action of carbamazepine in the maximal electroshock, co-administration of the two drugs should be carefully monitored in clinical conditions. Further studies are necessary to evaluate effects of chronic treatment with amiodarone on seizure activity and the action of antiepileptic drugs.
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Affiliation(s)
- Monika Banach
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL-20-954, Lublin, Poland
| | - Monika Popławska
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL-20-954, Lublin, Poland
| | - Kinga K Borowicz-Reutt
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL-20-954, Lublin, Poland.
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