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Jang Y, Moon J, Kim N, Kim TJ, Jun JS, Shin YW, Chang H, Kang HR, Lee ST, Jung KH, Park KI, Jung KY, Chu K, Lee SK. A new rapid titration protocol for lamotrigine that reduces the risk of skin rash. Epilepsia Open 2021; 6:394-401. [PMID: 34033264 PMCID: PMC8166783 DOI: 10.1002/epi4.12495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/04/2021] [Indexed: 11/21/2022] Open
Abstract
Objective Lamotrigine is one of the most widely used antiepileptic drugs, but it has a critical issue of a skin rash if the starting dose is too high or the escalation rate is too rapid. We investigated the efficacy and safety of a novel and rapid titration protocol for lamotrigine that takes only 11 days to reach a daily dose of 200 mg. Methods We prospectively enrolled 33 adult patients (age 18‐85) who were diagnosed with epilepsy and started lamotrigine administration for the first time at a single tertiary hospital. Our new protocol starts with a subthreshold dose of the drug and then administers a stepwise‐incremental dose until reaching the full therapeutic dose within 11 days. Results Of 29 patients analyzed, only two (6.9%) experienced idiosyncratic skin rash before the first follow‐up visit at 2 weeks (±3 days). In addition, a therapeutic concentration was reached in more than 75% of studied patients after 2 weeks of lamotrigine administration. Significance These findings demonstrate the value of the novel tolerance induction protocol for lamotrigine, which could widen the available application of lamotrigine in various situations. However, this study is a preliminary study limited by a small number of patients and its nonrandomized and open‐label design, so the current protocol needs more rigorous clinical evaluations before the application to the real clinical setting.
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Affiliation(s)
- Yoonhyuk Jang
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Jangsup Moon
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea.,Rare Disease Center, Department of Genomic Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Narae Kim
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Tae-Joon Kim
- Department of Neurology, Ajou University School of Medicine, Suwon, South Korea
| | - Jin-Sun Jun
- Department of Neurology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Yong-Won Shin
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Hyeyeon Chang
- Department of Neurology, Konyang University Hospital, Daejeon, South Korea
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Soon-Tae Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Keun-Hwa Jung
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea
| | - Ki-Young Jung
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Kon Chu
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Sang Kun Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
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Mani R, Monteleone C, Schalock PC, Truong T, Zhang XB, Wagner ML. Rashes and other hypersensitivity reactions associated with antiepileptic drugs: A review of current literature. Seizure 2019; 71:270-278. [PMID: 31491658 DOI: 10.1016/j.seizure.2019.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 12/14/2022] Open
Abstract
This article provides an overview of the pathogenesis and risk factors associated with antiepileptic drug (AED) hypersensitivity reactions, provides prescribing guidelines that may minimize the risk of antiepileptic induced rashes, and discusses treatment options for rashes. Articles indexed in PubMed, Science Citation, and Google Scholar (January 1946-March 2019) were systematic searched using the following key terms: hypersensitivity, rash, antiepileptic, epilepsy, cross-sensitivity, desensitization, patch testing and supplemented with our clinical experiences. Additional references were identified from a review of literature citations. AEDs are associated with cutaneous adverse reactions. Aromatic AEDs and higher titration rates are associated with increased risk of hypersensitivity reaction. Patient characteristics, underlying health conditions, and genetic variations may increase the likelihood of a hypersensitivity reaction. Once a hypersensitivity reaction occurs, the likelihood of cross sensitivity to another AED increases, especially among other aromatic AEDs. Withdrawal of the causal agent and initiation of a lower risk agent usually leads to resolution of symptoms. Desensitization protocols may be an option for patients whose seizures only respond to the AED causing the rash.
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Affiliation(s)
- Ram Mani
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
| | - Catherine Monteleone
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
| | - Peter C Schalock
- Department of Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, United States.
| | - Thu Truong
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers the State University of New Jersey, Piscataway, NJ United States.
| | - Xiao B Zhang
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers the State University of New Jersey, Piscataway, NJ United States.
| | - Mary L Wagner
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers the State University of New Jersey, Piscataway, NJ United States.
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Lee B, Yu HJ, Kang ES, Lee M, Lee J. Human leukocyte antigen genotypes and trial of desensitization in patients with oxcarbazepine-induced skin rash: a pilot study. Pediatr Neurol 2014; 51:207-14. [PMID: 25079569 DOI: 10.1016/j.pediatrneurol.2014.03.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/21/2014] [Accepted: 03/22/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Skin rash associated with specific antiepileptic drugs occurs not infrequently and it usually necessitates discontinuation of the causative drugs. An alternative strategy is to desensitize the individual to the offending drug. We checked the human leukocyte antigen genotypes and conducted a pilot study to investigate the usefulness and safety of desensitization in pediatric patients with skin rash associated with oxcarbazepine. METHODS We enrolled 19 patients with epilepsy who had discontinued oxcarbazepine because of skin rash despite an initial good response and then became refractory to other antiepileptic drugs along with an individual with paroxysmal kinesigenic dyskinesia with a similar situation. High-resolution HLA-A and -B genotyping was performed to investigate the genetic risk. The desensitization began with 0.1 mg daily reaching 120 mg on the thirty-first day. Thereafter, the dose was increased at a rate of 12 mg/day. RESULTS Nineteen patients completed the desensitization protocol to a target dosage over 2-5 months. Five patients developed itching and erythema during desensitization, but the symptoms disappeared after withholding a dose increment transiently. There were no human leukocyte antigen genotypes relevant to aromatic antiepileptic drug-induced severe hypersensitivity reactions. The seizure frequency was reduced to less than at baseline in 18 individuals. CONCLUSION This study demonstrated 95% efficacy, including 42% seizure-free patients and the favorable tolerability of desensitization to oxcarbazepine in patients with intractable epilepsy and one patient with paroxysmal kinesigenic dyskinesia. Screening for sensitive human leukocyte antigen types and exclusion of severe hypersensitivity reactions should precede desensitization.
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Affiliation(s)
- Bolyun Lee
- Department of Pediatrics, Pusan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hee Joon Yu
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Munhyang Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeehun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Abstract
Allergic drug reactions occur when a drug, usually a low molecular weight molecule, has the ability to stimulate an immune response. This can be done in one of two ways. The first is by binding covalently to a self-protein, to produce a haptenated molecule that can be processed and presented to the adaptive immune system to induce an immune response. Sometimes the drug itself cannot do this but a reactive breakdown product of the drug is able to bind covalently to the requisite self-protein or peptide. The second way in which drugs can stimulate an immune response is by binding non-covalently to antigen presenting or antigen recognition molecules such as the major histocompatibility complex (MHC) or the T cell receptor. This is known as the p-I or pharmacological interaction hypothesis. The drug binding in this situation is reversible and stimulation of the response may occur on first exposure, not requiring previous sensitization. There is probably a dependence on the presence of certain MHC alleles and T cell receptor structures for this type of reaction to occur.
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Affiliation(s)
- Richard Warrington
- Section of Allergy & Clinical Immunology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.
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