Antiepileptic drug prescription in Dutch children from 2006–2014 using pharmacy-dispensing data

Hepatotoxicity of newer antiseizure medications in children: an overview and disproportionality analysis of VigiBase

BACKGROUND

We aimed to characterize newer antiseizure medications (ASMs)-induced hepatotoxicity in children and identify signals of disproportionate reporting of hepatotoxicity-related adverse drug events (ADEs).

RESEARCH DESIGN AND METHODS

Case reports reported to VigiBase were accessed using Empirica™ Signal software. To summarize characteristics of the retrieved cases, descriptive statistics were used. A disproportionality analysis was conducted using the Multi-item Gamma Poisson Shrinker algorithm, which calculates Empirical Bayesian Geometric Mean value and its lower and upper 95% confidence limits (EB05 and EB95, respectively). EB05 > 2, N > 0 was considered a signal.

RESULTS

Based on 870 analyzed cases, a higher proportion of cases was reported in girls than in boys and in patients aged 2-11 years than in other age groups. Most cases were serious. In 25 cases, hepatotoxicity resulted in death. A high proportion of patients (n = 275, 31.61%) experienced hypersensitivity reactions, mostly due to lamotrigine. The disproportionality analysis yielded 17 signals concerning felbamate, lamotrigine, levetiracetam, oxcarbazepine, stiripentol, and topiramate. Four signals were for severe liver injury and concerned felbamate, lamotrigine, levetiracetam, and topiramate. Gender-biased reporting frequency was detected for four ASM-ADE combinations.

CONCLUSION

Our results should serve to raise clinicians' awareness about the potential association between several newer ASMs and drug-induced liver injury in children.

Therapeutic drug monitoring and the therapeutic reference range of levetiracetam for Chinese patients: Problems and issues

BACKGROUND

Levetiracetam (LEV) is widely used in the clinical monotherapy or multi-drug combination treatment of seizures due to its good tolerability and efficacy. Due to a lack of large-scale clinical studies, the relationship between levetiracetam concentrations, disease activity and adverse is unclear, limiting the usefulness of therapeutic drug monitoring (TDM) based LEV plasma levels. This study was intended to investigate factors influencing the pharmacokinetics of and the appropriate reference range of LEV concentration using available LEV TDM data.

METHODS

A rapid, accurate and sensitive high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS) method was established to determine LEV plasma concentrations. In this study, the levetiracetam plasma concentration monitoring data from 352 samples (taken from 248 patients) were used to explore the relationship between levetiracetam dose, age, combined administration with other antiseizure medications in patients with epilepsy.

RESULTS

Age and combined administration emerged as important affecting factors for the correlation of LEV concentration and dose. The correlation between concentration and dose was better in monotherapy. Combined administration may affect LEV concentration, especially when LEV is combined with oxcarbazepine, which might decrease the LEV concentration.

CONCLUSION

These findings emphasize the need to monitor LEV routinely LEV, especially among children and older adults when other antiseizure comedications are prescribed in the treatment regimen. LEV TDM is a well-established tool for the management of patients with epilepsy.

Indications and prescribing patterns of antiseizure medications in children in New Zealand

AIM

To determine indications and prescribing patterns for antiseizure medications (ASMs) in children by age, sex, and socioeconomic status.

METHOD

This retrospective study searched the New Zealand database of ASM prescriptions dispensed to individuals aged 18 years or under during 2015 in three regions of New Zealand (48% paediatric population). Medical records were reviewed by a paediatric neurologist for indication. ASMs were grouped into old or new (1993 onwards).

RESULTS

In total, 2594 children (0 to 18 years, mean age 11 years 2 months, median 12 years; 51% male) were dispensed 3557 ASMs for seizures (76%), pain (6%), headache (5%), mental health (3%), and movement disorders (2%). After 10 years of age, lamotrigine was more likely and valproate less likely to be prescribed in females than males. No sex difference was observed for valproate prescriptions for non-seizure indications. Topiramate prescriptions increased in adolescent females. Prescriptions for non-seizure indications increased from 7% in children aged 6 years or under to 31% in 16- to 18-year-olds. The proportion of children receiving a new ASM compared to an old ASM was greater in children from higher than lower socioeconomic areas.

INTERPRETATION

Our results highlight a need for focused ASM teratogenicity messaging to clinicians prescribing ASMs for non-seizure indications. In addition, to improve equity of epilepsy care, it is critical for health policies to consider socioeconomic factors that impact on ASM prescribing.

Trends in prescription of anti-seizure medicines for Japanese pediatric outpatients during 2013-2019

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We investigated trends in ASM prescriptions with children in Japan during 2013–2019.

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Valproic acid, carbamazepine, and levetiracetam were most commonly prescribed.

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A decline in valproic acid and carbamazepine prescriptions was observed.

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An increase in levetiracetam prescriptions was observed.

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ASM prescription in Japan has shifted toward the use of recently available ASMs.

Temporal trends in prescriptions of anti-seizure medicines (ASMs) for children, including newer ASMs, are unclear. We investigated ASM prescription trends for pediatric outpatients in Japan. The MDV analyzer® was used to analyze the MDV database containing de-identified hospital administrative data. Administrative data as of June 2021 including pediatric outpatients (0–17 years) with epilepsy, visiting 123 acute diagnostic procedure combination hospitals during 2013–2019, were used. Annual ASMs prescription trends were calculated, based on proportions. The Cochran–Armitage trend test evaluated the proportion of prescriptions for each ASM. ASMs most often prescribed were valproic acid, carbamazepine, and levetiracetam, regardless of sex. In girls, the proportion of valproic acid and carbamazepine prescriptions decreased from 37.93% to 26.84%, and from 24.80% to 15.78%, respectively (p < 0.0001). Conversely, the proportion of levetiracetam prescriptions increased from 6.40% to 28.18% (p < 0.0001). In boys, the proportion of valproic acid and carbamazepine prescriptions decreased, from 36.58% to 32.20% and from 26.42% to 16.85%, respectively (p < 0.0001). The proportion of levetiracetam prescriptions increased from 5.64% to 23.02% (p < 0.0001). Overall, the proportion of valproic acid and carbamazepine prescriptions declined, whereas levetiracetam prescriptions increased. Trends in ASM prescriptions among pediatric outpatients with epilepsy in Japan have shifted towards more recently available ASMs.

Rational Small Molecule Treatment for Genetic Epilepsies

Genetic testing has yielded major advances in our understanding of the causes of epilepsy. Seizures remain resistant to treatment in a significant proportion of cases, particularly in severe, childhood-onset epilepsy, the patient population in which an underlying causative genetic variant is most likely to be identified. A genetic diagnosis can be explanatory as to etiology, and, in some cases, might suggest a therapeutic approach; yet, a clear path from genetic diagnosis to treatment remains unclear in most cases. Here, we discuss theoretical considerations behind the attempted use of small molecules for the treatment of genetic epilepsies, which is but one among various approaches currently under development. We explore a few salient examples and consider the future of the small molecule approach for genetic epilepsies. We conclude that significant additional work is required to understand how genetic variation leads to dysfunction of epilepsy-associated protein targets, and how this impacts the function of diverse subtypes of neurons embedded within distributed brain circuits to yield epilepsy and epilepsy-associated comorbidities. A syndrome- or even variant-specific approach may be required to achieve progress. Advances in the field will require improved methods for large-scale target validation, compound identification and optimization, and the development of accurate model systems that reflect the core features of human epilepsy syndromes, as well as novel approaches towards clinical trials of such compounds in small rare disease cohorts.

Characteristics of adverse drug reactions associated with antiepileptics at a tertiary children's hospital in Japan: A retrospective observational cohort study

OBJECTIVE

The aim of this study was to explore the prescription pattern of antiepileptics and the relationship between antiepileptics and adverse drug reactions (ADRs) in a Japanese population.

METHODS

A retrospective observational cohort study was conducted by reviewing the medical records of patients who visited or were admitted to a single tertiary care center between January 2011 and June 2019, were treated with antiepileptics, and developed allergic ADRs associated with these drugs.

RESULTS

In total, 14,230 unique patients received antiepileptics during the study period. Diazepam was the most frequently used antiepileptic drug (74.8 %), followed by phenobarbital (14.3 %), valproic acid (11.4 %), fosphenytoin (10.0 %), and carbamazepine (7.3 %). Although a trend of increasing prevalence of newer generation antiepileptics was noted, most patients are still treated with older generation antiepileptics. Thirty-two (0.22 %) unique patients experienced ADRs associated with antiepileptics, and the antiepileptic drug most frequently associated with ADRs was carbamazepine, at a rate of 1.4 %. Three patients developed Stevens-Johnson syndrome/toxic epidermal necrolysis, in two of which carbamazepine was implicated. Most patients experienced ADRs associated with aromatic antiepileptics (84.4 %) or older generation antiepileptics (81.3 %).

SIGNIFICANCE

This is the first study to assess the relationship between ADRs and antiepileptics at a tertiary care center in Japan. Based on our results, most patients were prescribed older generation antiepileptics, and most ADR events were linked to the administration of drugs in this category; thus, identification of patients at risk of developing ADRs is critical in order to prevent such events.

Population Pharmacokinetics of Levetiracetam: A Systematic Review

BACKGROUND

Levetiracetam has been widely used as a treatment option for different types of epilepsy in both adults and children. Because of its large between-subject variability, several population pharmacokinetic studies have been performed to identify its pharmacokinetic covariates, and thus facilitate individualised therapy.

OBJECTIVE

The aim of this review was to provide a synopsis for population pharmacokinetic studies of levetiracetam and explore the identified influencing covariates.

METHODS

We systematically searched the PubMed and Embase databases from inception to 30 June 2020. The information on study designs, target population, model characteristics, and identified covariates was summarised. Moreover, the pharmacokinetic profiles were compared among neonates, children, and adults.

RESULTS

Fourteen studies were included, among which two involved neonates, four involved children, two involved both children and adults, and six involved adults only. The median value of apparent clearance for children (0.074 L/h/kg [range 0.038-0.079]) was higher than that for adults (0.054 L/h/kg [range 0.039-0.061]). Body weight was found to significantly influence the apparent clearance and volume of distribution, whereas renal function influenced the clearance. Likewise, coadministration with enzyme-inducing antiepileptic drugs (such as carbamazepine and phenytoin) increased the drug clearance by 9-22%, whereas coadministration with valproate acid decreased it by 18.8%.

CONCLUSION

Levetiracetam dose regimen is dependent on the body size and renal function of patients. Further studies are needed to evaluate levetiracetam pharmacokinetics in neonates and pregnant women.

Trends of anti-seizure medication use in pediatric patients in six cities in China from 2013 to 2018

OBJECTIVES

The aim of this study was to describe the prevalence of the use and prescribing patterns of anti-seizure medications (ASMs) over a six-year period, and to provide real-world evidence on medicine utilization of pediatric patients with epilepsy in China.

METHODS

ASM prescriptions for pediatric patients written from 2013 to 2018 were extracted from the database of the Hospital Prescription Analysis Cooperative Project. Trends of ASM use were analyzed by total prescriptions, cost, age, sex, ASM class and specific ASM. Prescribing patterns of ASMs were also analyzed.

RESULTS

A total of 44,675 ASM prescriptions were extracted for analysis in this study. Throughout the study period, a slight increase of ASM prescriptions was observed from 6170 in 2013 to 8211 in 2018. Children aged between 6 and 18 years, accounted for 78 % of total prescriptions every year. ASM use in boys was about 1.5 times higher than that in girls. Newer ASMs were prescribed more than older ASMs during this period. Sodium valproate was the most frequently prescribed ASM in 2013, and its use decreased in girls in 2016. Levetiracetam increased from 19.10 % in 2013 to 28.09 % in 2018 and became the most common ASM at the end of this study. Meanwhile, the use of oxcarbazepine increased from 19.31 % to 22.04 %, whereas the use of lamotrigine had declined from 18.43 % to 10.72 %. Monotherapy (66.24 %) was more frequently used than combined therapy, which included dual combination (25.80 %) and triple or more combinations (7.96 %).

CONCLUSION

There is an increased ASM prescription trend in childhood usage. Levetiracetam has replaced sodium valproate as the most frequently prescribed ASM in pediatric patients. Newer ASMs with fewer side effects and drug interactions are increasingly utilized, which is consistent with evolving recommendations by the medical community.