[Analysis of the valproic acid-meropenem interaction in hospitalised patients]

Effect of a Declined Plasma Concentration of Valproic Acid Induced by Meropenem on the Antiepileptic Efficacy of Valproic Acid

OBJECTIVE

This study aimed to indicate whether a declined plasma concentration of valproic acid (VPA) induced by co-administration of meropenem (MEPM) could affect the antiepileptic efficacy of VPA.

METHODS

We retrospectively reviewed data of hospitalized patients who were diagnosed with status epilepticus or epilepsy between 2010 and 2019. Patients co-administered VPA and MEPM during hospitalization were screened and assigned to the exposure group, while those co-administerd VPA and other broad-spectrum antibiotics were allocated to the control group.

RESULTS

The exposure group and control group included 50 and 11 patients, respectively. With a similar dosage of VPA, the plasma concentration of VPA significantly decreased during co-administration (24.6 ± 4.3 μg/mL) compared with that before co-administration (88.8 ± 13.6 μg/mL, p < 0.0001), and it was partly recovered with the termination of co-administration (39.8 ± 13.2 μg/mL, p = 0.163) in the exposure group. The inverse probability of treatment weighting estimated the treatment efficacy via changes in seizure frequency, seizure duration, and concomitant use of antiepileptic drugs, which were not significantly different between the exposure and control groups. In the exposure group, there was no significant differences in seizure frequency between the periods of before-during and before-after (p = 0.074 and 0.153, respectively). Seizure duration during VPA-MEPM co-administration was not significantly different from that before co-administration (p = 0.291).

CONCLUSIONS

In this study, the reduced plasma concentration of VPA induced by the co-administration of MEPM did not affect the antiepileptic efficacy of VPA. This conclusion should be interpreted with caution, and more research is warranted.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2000034567. Registered on 10 July 2020.

Nosocomial Pneumonia in the Era of Multidrug-Resistance: Updates in Diagnosis and Management

Nosocomial pneumonia (NP), including hospital-acquired pneumonia in non-intubated patients and ventilator-associated pneumonia, is one of the most frequent hospital-acquired infections, especially in the intensive care unit. NP has a significant impact on morbidity, mortality and health care costs, especially when the implicated pathogens are multidrug-resistant ones. This narrative review aims to critically review what is new in the field of NP, specifically, diagnosis and antibiotic treatment. Regarding novel imaging modalities, the current role of lung ultrasound and low radiation computed tomography are discussed, while regarding etiological diagnosis, recent developments in rapid microbiological confirmation, such as syndromic rapid multiplex Polymerase Chain Reaction panels are presented and compared with conventional cultures. Additionally, the volatile compounds/electronic nose, a promising diagnostic tool for the future is briefly presented. With respect to NP management, antibiotics approved for the indication of NP during the last decade are discussed, namely, ceftobiprole medocaril, telavancin, ceftolozane/tazobactam, ceftazidime/avibactam, and meropenem/vaborbactam.

Effect of drug interactions between carbapenems and valproate on serum valproate concentration: a systematic review and meta-analysis

Background: Concurrent use of valproate and carbapenem antibiotics may decrease serum valproate concentration (SVC). This study evaluated the effects of carbapenem-valproate drug interactions. Research design and methods: We screened PubMed, EMBASE, and Cochrane databases for eligible prospective or retrospective studies that evaluated the effect of concurrent use of carbapenem and valproate compared with valproate alone on SVC. Primary outcomes were the change in SVC from before the addition of the carbapenem to the SVC during the use of carbapenems and after carbapenem discontinuation, and seizure-related outcomes. Secondary outcomes were the influence of valproate or carbapenem dose on SVC and Drug Interaction Probability Scale scores. Results: Twelve studies (633 patients) were included. Compared with valproate alone, combination treatment with carbapenem substantially decreased mean SVC (mean difference, -43.98 mg/L; 95% confidence interval, -48.18 to -39.78). The onset of SVC decreases was within 1-3 days following carbapenem initiation. Seizure frequency increased by 26.3% during combination treatment. No difference was found in mean SVC between the different doses of valproate or carbapenem during combination treatment. Mean SVC increased to similar pre-carbapenem level within 1 to 2 weeks after carbapenem discontinuation. Conclusions: The drug interaction between valproate and carbapenem causes substantial SVC decreases, even to subtherapeutic levels, which may increase the risk of seizures.

Valproate Interaction With Carbapenems: Review and Recommendations

Introduction: Valproic acid is a commonly used antiepileptic drug. Combining valproate derivatives with carbapenem antibiotics is associated with a potential drug interaction that decreases serum concentration of valproate and may expose the patient to uncontrolled seizure risk from valproate subtherapeutic concentration. Raising awareness of this drug interaction among health care providers including emergency department physicians, neurologists, and pharmacists is highly needed. The aim of this article was to review the current literature about the potential drug interaction resulting from combining valproate derivatives with carbapenem antibiotics and to establish therapeutic recommendations regarding their use together. Methods: A review of the literature was conducted using Medline (through PubMed), Ovid, Embase, Cochrane library using the following keywords: valproate, valproic acid, carbapenem, ertapenem, doripenem, meropenem, imipenem, and valproate drug interaction. In addition, a manual search through major journals for articles referenced in PubMed was performed. Related publications from January 1998 till November 2018 were included in the initial search. Relevant publications were reviewed, and data regarding patients, type of carbapenem used, valproic acid dosing and level, interaction severity, and clinical outcome were summarized. Results and Discussion: Few clinical trials and multiple case reports have shown that carbapenem antibiotics including meropenem, ertapenem, imipenem, and doripenem can decrease the serum concentration of valproate derivatives leading to a subtherapeutic serum concentration and seizures in some patients. Valproic acid serum concentration may be significantly decreased with addition of a carbapenem antibiotic but generally return toward normal shortly after discontinuation of the carbapenem antibiotic. Conclusions: Generally, the concurrent use of carbapenem antibiotics with valproate derivatives should be avoided due to the potential of drug-drug interaction that results in subtherapeutic valproate serum concentration. Other antimicrobial agents should be considered as alternatives to carbapenems but if a concurrent carbapenem is necessary, using an additional antiepileptic agent is recommended. Therapeutic drug monitoring of valproate serum concentrations is warranted when a carbapenem-valproic acid combination therapy is unavoidable.

Neurological Adverse Effects Attributable to β-Lactam Antibiotics: A Literature Review

β-lactam antibiotics are commonly prescribed antibiotic drugs. To describe the clinical characteristics, risk markers and outcomes of β-lactam antibiotic-induced neurological adverse effects, we performed a general literature review to provide updated clinical data about the most used β-lactam antibiotics. For selected drugs in each class available in France (ticarcillin, piperacillin, temocillin, ceftazidime, cefepime, cefpirome, ceftaroline, ceftobiprole, ceftolozane, ertapenem and aztreonam), a systematic literature review was performed up to April 2016 via an electronic search on PubMed. Articles that reported original data, written in French, Spanish, Portuguese or English, with available individual data for patients with neurological symptoms (such as seizure, disturbed vigilance, confusional state, myoclonia, localising signs, and/or hallucinations) after the introduction of a β-lactam antibiotic were included. The neurological adverse effects of piperacillin and ertapenem are often described as seizures and hallucinations (>50 and 25% of cases, respectively). Antibiotic treatment is often adapted to renal function (>70%), and underlying brain abnormalities are seen in one in four to one in three cases. By contrast, the neurological adverse drug reactions of ceftazidime and cefepime often include abnormal movements but few hallucinations and seizures. These reactions are associated with renal insufficiency (>80%) and doses are rarely adapted to renal function. Otherwise, it appears that monobactams do not have serious neurological adverse drug reactions and that valproic acid and carbapenem combinations should be avoided. The onset of disturbed vigilance, myoclonus, and/or seizure in a patient taking β-lactam antibiotics, especially if associated with renal insufficiency or underlying brain abnormalities, should lead physicians to suspect adverse drug reactions and to consider changes in antibacterial therapy.

Influence of acylpeptide hydrolase polymorphisms on valproic acid level in Chinese epilepsy patients

BACKGROUND

Concomitant use of meropenem (MEPM) can dramatically decrease valproic acid (VPA) plasma level. It is accepted that inhibition in acylpeptide hydrolase (APEH) activity by MEPM coadministration was the trigger of this drug-drug interaction.

AIM

To investigate the influence of APEH genetic polymorphisms on VPA plasma concentration in Chinese epilepsy patients.

PATIENTS & METHODS

Urinary VPA-d6 β-D-glucuronide concentration was determined in 19 patients with VPA treatment alone (n = 10) or concomitant use with MEPM (n = 9). A retrospective study was performed on 149 epilepsy patients to investigate the influence of APEH polymorphisms rs3816877 and rs1131095 on adjusted plasma VPA concentration (C_VPA) at steady-state.

RESULTS

Urinary VPA-d6 β-D-glucuronide (VPA-G) concentration was increased significantly in patients with MEPM coadministration. The C_VPA of patients carrying the APEH rs3816877 C/C genotype was significantly higher than that of C/T carriers, and the difference was still obvious when stratified by UGT2B7 rs7668258 polymorphism.

CONCLUSION

APEH polymorphism has significant influence on VPA pharmacokinetics in Chinese population.

[Effect of modal computer-based alerts on the prescription of valproic acid and meropenem]

OBJECTIVE

To analyze the effect of modal computer-based alerts on the concomitant prescription of valproic acid (VPA) and meropenem.

MATERIAL AND METHOD

Analytical intervention study conducted in a tertiary hospital for eleven months. Hospitalized patients with a diagnosis of epilepsy and treated with VPA and meropenem in concomitant therapy were included. In the computerized prescription order entry software an automatic non-modal alert was reconverted to a modal one. This was triggered when the physician introduced VPA and meropenem together in the same prescription. To measure the effect of this alert the prescription habits were compared with a previous period in which the alert was not modal.

RESULTS

Modal computer-based alert modified the prescription habit by reducing the number of patients with concomitant treatment from 13 to 4 (P=.046). However, it was notable that the number of requests for VPA serum levels decreased, and the average number of concomitant days of treatment rose from 4.7 to 8.75 in those patients in which none of the drugs was suspended.

CONCLUSIONS

The implementation of modal computer-based alerts reduces patient exposure to concomitant treatment with meropenem and VPA.