Subcutaneous Use of Lacosamide

Subcutaneous Levetiracetam Administration in Latino Patients on Home Care

Background: Levetiracetam has a favorable pharmacology profile to be used subcutaneously. However, its subcutaneous use is still considered off-label as this is beyond its license. The evidence base for its safety, tolerability, and efficacy is limited to observational studies. Objectives: To report the safety and efficacy of subcutaneous levetiracetam in Latino patients on home care. Design: Observational retrospective case series study. Subjects: Consecutive sample of Latino adults with life-limiting illnesses. Methods: A case series framework with 4 domains (selection, ascertainment, causality, and reporting) to ensure reporting quality was used. Additionally, 8 relevant outcomes established in a previous comprehensive review, were collected and reported. Adverse reactions were documented using the Common Terminology Criteria for Adverse Events. Results: Fifteen Latino patients with oncological and non-oncological diagnoses received subcutaneous levetiracetam for a mean of 21 days on home care. Levetiracetam was most frequently initiated subcutaneously due to loss of the oral route. The average dosage of subcutaneous levetiracetam was 1200 mg. Only 1 patient required a dose adjustment, and only 2 patients experienced a total of 5 seizures during the therapy trial. No adverse reactions were reported. Conclusions: Subcutaneous levetiracetam appears to be effective and safe. This case series of Latino patients in home care expands the evidence of its use in the home care setting. The preliminary data reported by now on multiple case series warrants robust trials.

Emerging Trends in Neuropalliative Care: A Palliative Approach to Epilepsy and Seizure Management in Adults

Management of severe (drug-resistant) epilepsy and epilepsy in other serious illnesses is multidimensional and requires consideration of both physical symptoms and psychosocial distress that require individualized treatment. Palliative care offers a holistic approach to disease that focuses on all dimensions of suffering to maintain quality of life. Integration of a palliative care mind- and skillset in the management of severe epilepsy and epilepsy in other serious illnesses can provide person-centered care and support for families and caregivers.

Brain tumor-associated epilepsies in adulthood: Current state of diagnostic and individual treatment options

Brain tumors are one of the most frequent causes of structural epilepsy and set a major burden on treatment costs and the social integrity of patients. Although promising oncological treatment strategies are already available, epileptological treatment is often intractable and requires lifelong epileptological care. Therefore, treatment strategies must be adapted to age-related needs, and specific aspects of late-onset epilepsy (LOE) must be considered. The practical implementation of individual decisions from tumor boards and the current state of the art in scientific knowledge about pathological mechanisms, modern diagnostic procedures and biomarkers, and patient-individualized treatment options into practical epileptological disease management is a prerequisite. This narrative review focuses on the current work progress regarding pathogenesis, diagnosis, and therapy. Exemplarily, interdisciplinary approaches for optimized individualized therapy will be discussed, emphasizing the combination of neurological-epileptological and oncological perspectives.

Subcutaneous lacosamide for continuous focal seizures

Management of continuous focal seizure activity provides a unique challenge in palliative medicine. In cases where the patient is conscious and would prefer to remain so, we need to balance seizure-control with the sedating side effects of anti-seizure medications. Here we present a case in which subcutaneous lacosamide was given as part of a multi-modal treatment regime for a patient with continuous focal seizure activity. Lacosamide is a relatively new anti-seizure medication, that, unlike some anticonvulsants, has few drug interactions, is relatively non-sedating, and has physicochemical properties compatible with administration by the subcutaneous route. This case report adds to the very limited existing literature on the administration of lacosamide by the subcutaneous route. We conclude that lacosamide potentially provides an attractive option to contribute to the individualised care of this group of patients, and it may also have a role in the management of neuropathic pain where the enteral route is not available.

Short subcutaneous infusions for symptom control in palliative medicine

OBJECTIVES

To investigate the efficacy and safety of short subcutaneous infusions (SSCIs) for refractory symptoms in the palliative setting.

METHODS

A retrospective chart review of SSCIs in a single palliative care centre over an 18-month period. All clinical notes, medication administration records and infusion monitoring documentation were examined to ascertain therapeutic aim, efficacy and tolerability.

RESULTS

111 patients received one or more SSCIs, 28 in the community and 83 in the inpatient hospice (21% of all admissions). SSCIs were used for a wide variety of reasons including loading doses (to achieve steady state and, thus, symptom relief, sooner), as required doses (for medications too irritant to give as bolus SC injections) and regular maintenance doses (where continuous subcutaneous infusion (CSCI), were unnecessary). 84 single drug SSCIs types and 51 admixtures SSCIs types (2 or more medications) were given. One infusion was poorly absorbed, but SSCIs were otherwise well tolerated.

CONCLUSIONS

SSCIs appear to be a promising additional option for administering medicines that are too irritant or large in volume for SC bolus injection. For medications with longer half-lives (eg, phenobarbital, valproate, levetiracetam), SSCI loading doses would be expected to achieve steady state and, thus, symptom relief, sooner than CSCIs alone.

Subcutaneous lacosamide for seizures

The management of seizures at the end of life is vital for patient comfort and to reduce carer distress. The use of high -dose subcutaneous benzodiazepines is standard, but not always effective. We present a case where lacosamide was used subcutaneously to prevent seizure activity.

Brain tumor related epilepsy: pathophysiological approaches and rational management of antiseizure medication

Background

Brain tumor related epilepsy (BTRE) is a common complication of cerebral tumors and its incidence is highly dependent on the type of tumor, ranging from 10–15% in brain metastases to > 80% in low grade gliomas. Clinical management is challenging and has to take into account aspects beyond the treatment of non-tumoral epilepsy.

Main body

Increasing knowledge about the pathophysiology of BTRE, particularly on glutamatergic mechanisms of oncogenesis and epileptogenesis, might influence management of anti-tumor and BTRE treatment in the future. The first seizure implies the diagnosis of epilepsy in patients with brain tumors. Due to the lack of prospective randomized trials in BTRE, general recommendations for focal epilepsies currently apply concerning the initiation of antiseizure medication (ASM). Non-enzyme inducing ASM is preferable. Prospective trials are needed to evaluate, if AMPA inhibitors like perampanel possess anti-tumor effects. ASM withdrawal has to be weighed very carefully against the risk of seizure recurrence, but can be achievable in selected patients. Permission to drive is possible for some patients with BTRE under well-defined conditions, but requires thorough neurological, radiological, ophthalmological and neuropsychological examination.

Conclusion

An evolving knowledge on pathophysiology of BTRE might influence future therapy. Randomized trials on ASM in BTRE with reliable endpoints are needed. Management of withdrawal of ASMs and permission to drive demands thorough diagnostic as well as neurooncological and epileptological expertise.

Is Therapeutic Drug Monitoring of Lacosamide Needed in Patients with Seizures and Epilepsy?

Lacosamide is an antiepileptic drug (AED) that has linear pharmacokinetics, predictable blood concentrations, and few drug interactions, setting it apart from other AEDs that require vigorous therapeutic drug monitoring (TDM) such as phenytoin and carbamazepine. However, there have been reports of altered lacosamide pharmacokinetics in some populations. The purpose of this review is to determine whether lacosamide pharmacokinetics are altered in certain patient populations, suggesting the need for TDM. A literature search of Medline, Scopus, Embase, and Cochrane trials was conducted on January 3, 2019 (and then updated on September 2, 2019) to search for articles relevant to the TDM or pharmacokinetics of lacosamide. A total of 56 relevant articles were found and included in this review. Dose of lacosamide is linearly correlated with plasma concentrations and efficacy. However, currently there is no well-established reference range. Overall, the recommended reference ranges varied from 2.2 to 20 mg/L. Lacosamide has very few clinically relevant drug-drug interactions; however, there seems to be a significant drug interaction between lacosamide and enzyme-inducer AEDs. Based on available literature, it appears that lacosamide pharmacokinetics may be altered in severe renal dysfunction, in patients on dialysis and with extremes of age. More evidence is currently needed on lacosamide pharmacokinetics in pregnancy and critical illness. While it is not practical to utilize TDM for all patients, TDM may be useful in patients taking enzyme-inducer AEDs, in patients with decreased renal function or on dialysis, and older adults.

Levetiracetam

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Practical Management of Epileptic Seizures and Status Epilepticus in Adult Palliative Care Patients

In terminally ill patients, paroxysmal or episodic changes of consciousness, movements and behavior are frequent. Due to ambiguous appearance, the correct diagnosis of epileptic seizures (ES) and non-epileptic events (NEE) is often difficult. Treatment is frequently complicated by the underlying condition, and an approach indicated in healthier patients may not always be appropriate in the palliative care setting. This article provides recommendations for diagnosis of ES and NEE and treatment options for ES in adult palliative care patients, including aspects of alternative administration routes for antiepileptic drugs such as intranasal, subcutaneous, or rectal application.