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Saint-Maxent M, Juette T, Parent J, Castel A, Parmentier T. Factors influencing serum concentrations of levetiracetam in dogs with epilepsy. J Vet Intern Med 2024. [PMID: 38888491 DOI: 10.1111/jvim.17128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/17/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Factors affecting serum concentrations of levetiracetam in dogs are unknown and could affect the efficacy of levetiracetam in controlling seizures in dogs with epilepsy. HYPOTHESIS/OBJECTIVES Higher PO doses of levetiracetam will be needed in dogs to achieve serum concentrations shown to be effective in humans. Determine factors that could influence serum levetiracetam concentrations and justify dose adjustment in some epileptic dogs. ANIMALS Sixty-nine client-owned dogs with epilepsy treated with levetiracetam alone or in combination, based on 127 trough serum concentration measurements of levetiracetam. METHODS Retrospective cohort study. Linear mixed models were used to assess the effect of patient signalment and concurrent drug administration on serum concentrations of levetiracetam and the effect of serum concentration of levetiracetam on seizure frequency reduction. RESULTS The PO dose of levetiracetam significantly explained changes in serum levetiracetam concentration, and this causal link was stronger with monotherapy (R2 = 0.59, P < .001). Phenobarbital significantly decreased serum levetiracetam concentration in a dose dependent manner (R2 = 0.30, P = .003). Based on our model, a levetiracetam dosage of 99-216 mg/kg/day is necessary to obtain a serum levetiracetam concentration of 20 μg/mL when used alone or concurrently with 7 mg/kg/day of phenobarbital. No other factors were found to influence serum levetiracetam concentrations. No therapeutic range could be identified. CONCLUSION AND CLINICAL IMPORTANCE Our data suggest that a dosage of 99-216 mg/kg/day of levetiracetam is needed to achieve a serum concentration known to be therapeutically effective in humans, especially when administered concomitantly with phenobarbital.
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Affiliation(s)
- Marine Saint-Maxent
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
| | - Tristan Juette
- Vice-décanat à la Recherche, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
| | - Joane Parent
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
| | - Aude Castel
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
| | - Thomas Parmentier
- Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
- Centre Interdisciplinaire de Recherche sur le Cerveau et L'apprentissage (CIRCA), Université de Montréal, Montreal, Quebec, Canada
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Zimmerman KO, Wu H, Maharaj A, Turner A, Chen JY, Hornik CD, Arnold S, Muller W, Al-Uzri A, Meyer M, Shiloh-Malawsky Y, Taravath S, Lakhotia A, Joshi C, Jackman J, Hornik CP. Pharmacokinetics and Proposed Dosing of Levetiracetam in Children With Obesity. J Pediatr Pharmacol Ther 2023; 28:693-703. [PMID: 38094673 PMCID: PMC10715382 DOI: 10.5863/1551-6776-28.8.693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/26/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVE Characterize levetiracetam pharmacokinetics (PK) in children with obesity to inform dosing. METHODS Children 2 to <21 years old receiving standard of care oral levetiracetam across two opportunistic studies provided blood samples. Levetiracetam plasma PK data were analyzed with a nonlinear mixed-effects modeling approach. Indirect measures for body size and covariates were tested for model inclusion. Individual empirical Bayesian estimates using the final model parameters were compared by obesity status. Monte Carlo simulation using total body weight was performed in children with normal estimated glomerular filtration rate to identify dosing for children with obesity that resulted in comparable exposures to normal weight adults and children after receiving label dosing. RESULTS The population PK model was developed from 341 plasma concentrations from 169 children. A 1-compartment model best fit the data with fat-free mass as a significant covariate. Compared with children with normal weight, children with obesity had significantly lower body weight-normalized clearance (median [range], 4.77 [1.49-10.44] and 3.71 [0.86-13.55] L/h/70 kg, respectively). After label dosing with the oral formulation in children with obesity 4 to <16 years old, maximum and minimum steady-state concentrations were higher (25% and 41%, respectively [oral solution] and 27% and 19%, respectively [tablet]) compared with children with normal weight. Comparable exposures between children with and without obesity were achieved with weight-tiered dosing regimens of <75 kg or ≥75 kg. CONCLUSIONS Weight-tiered dosing for levetiracetam oral solution and tablets for children with obesity 4 to <16 years old results in more comparable exposures to children of normal weight.
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Affiliation(s)
- Kanecia O. Zimmerman
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Huali Wu
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Anil Maharaj
- Pharmaceutical Sciences (AM), The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Turner
- Undergraduate Student (AT), North Carolina State University, Raleigh, NC
| | - Jia-Yuh Chen
- Senior Biostatistician (JYC), The EMMES Corporation, Rockville, MD
| | - Chi D. Hornik
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Susan Arnold
- Department of Neurology and Neurotherapeutics (SA), University of Texas Southwestern Medical Center Dallas, Dallas, TX
| | - William Muller
- Infectious Disease (WM), Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Amira Al-Uzri
- Pediatric Nephrology (AA-U), Oregon Health and Science University, Portland, OR
| | - Marisa Meyer
- Pediatric Critical Care (MM), Nemours Children’s Health, Wilmington, DE
| | - Yael Shiloh-Malawsky
- Department of Neurology (YS-M), University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Arpita Lakhotia
- Pediatric Neurology (AL), Norton Children’s Hospital and University of Louisville, Louisville, KY
| | - Charuta Joshi
- Pediatric Neurology (CJ), The Children’s Hospital Colorado, Aurora, CO
| | - Jennifer Jackman
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
| | - Christoph P. Hornik
- Department of Pediatrics (KOZ, CDH, CPH), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute (KOZ, HW, CDH, JJ, CPH), Duke University, Durham, NC
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Shi M, Liu C, He L, Wu H, Wu Y. Therapeutic drug monitoring and the therapeutic reference range of levetiracetam for Chinese patients: Problems and issues. Seizure 2023; 109:26-33. [PMID: 37192596 DOI: 10.1016/j.seizure.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/18/2023] Open
Abstract
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.
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Affiliation(s)
- Min Shi
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang 050051, China; Graduate School, Hebei Medical University, Shijiazhuang 050017, China
| | - Chenxi Liu
- Graduate School, Hebei Medical University, Shijiazhuang 050017, China
| | - Lien He
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang 050051, China
| | - Huizheng Wu
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang 050051, China
| | - Yin Wu
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang 050051, China; Graduate School, Hebei Medical University, Shijiazhuang 050017, China.
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Kriechbaumer SRP, Jurina K, Wielaender F, Schenk HC, Steinberg TA, Reese S, Buhmann G, Doerfelt S, Potschka H, Fischer A. Pregabalin Add-On vs. Dose Increase in Levetiracetam Add-On Treatment: A Real-Life Trial in Dogs With Drug-Resistant Epilepsy. Front Vet Sci 2022; 9:910038. [PMID: 35873699 PMCID: PMC9298511 DOI: 10.3389/fvets.2022.910038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Epilepsy is a common neurological disorder affecting 0.6–0.75% of dogs in veterinary practice. Treatment is frequently complicated by the occurrence of drug-resistant epilepsy and cluster seizures in dogs with idiopathic epilepsy. Only few studies are available to guide treatment choices beyond licensed veterinary drugs. The aim of the study was to compare antiseizure efficacy and tolerability of two add-on treatment strategies in dogs with drug-resistant idiopathic epilepsy. The study design was a prospective, open-label, non-blinded, comparative treatment trial. Treatment success was defined as a 3-fold extension of the longest baseline interseizure interval and to a minimum of 3 months. To avoid prolonged adherence to a presumably ineffective treatment strategy, dog owners could leave the study after the third day with generalized seizures if the interseizure interval failed to show a relevant increase. Twenty-six dogs (mean age 5.5 years, mean seizure frequency 4/month) with drug-resistant idiopathic epilepsy and a history of cluster seizures were included. Dogs received either add-on treatment with pregabalin (PGB) 4 mg/kg twice daily (14 dogs) or a dose increase in levetiracetam (LEV) add-on treatment (12 dogs). Thirteen dogs in the PGB group had drug levels within the therapeutic range for humans. Two dogs in the PGB group (14.3%; 2/14) and one dog in the LEV group (8.3%; 1/12) achieved treatment success with long seizure-free intervals from 122 to 219 days but then relapsed to their early seizure frequency 10 months after the study inclusion. The overall low success rates with both treatment strategies likely reflect a real-life situation in canine drug-resistant idiopathic epilepsy in everyday veterinary practice. These results delineate the need for research on better pharmacologic and non-pharmacologic treatment strategies in dogs with drug-resistant epilepsy.
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Affiliation(s)
- Sandra R. P. Kriechbaumer
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- AniCura Small Animal Clinic Haar, Haar, Germany
| | | | - Franziska Wielaender
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Henning C. Schenk
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- Small Animal Clinic Lüneburg, Lüneburg, Germany
| | | | - Sven Reese
- Department of Veterinary Sciences, Institute of Anatomy, Histology and Embryology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gesine Buhmann
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Stefanie Doerfelt
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- AniCura Small Animal Clinic Haar, Haar, Germany
| | - Heidrun Potschka
- Department of Veterinary Sciences, Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andrea Fischer
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- *Correspondence: Andrea Fischer
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Keene JC, Wainwright M, Morgan LA, Mietzsch U, Musa N, Bozarth XL, Natarajan N. Retrospective Evaluation of First-line Levetiracetam use for Neonatal Seizures after Congenital Heart Defect repair with or without Extracorporeal Membrane Oxygenation. J Pediatr Pharmacol Ther 2022; 27:254-262. [PMID: 35350164 DOI: 10.5863/1551-6776-27.3.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Levetiracetam (LEV) efficacy for neonatal seizures is debated. We evaluated LEV as a first line anti-seizure medicine (ASM) in neonates following neonatal congenital heart defect (CHD) repair who did not require extracorporeal membrane oxygenation (ECMO) vs neonates who required ECMO. METHODS A single center retrospective review of neonates with CHD from 2015 to 2020 was conducted. Neonates were included if seizures were present on continuous EEG after CHD repair either on or off ECMO, and they received LEV as a first line ASM. Primary outcomes were seizure resolution with LEV, adverse events and response to subsequent ASM. RESULTS Eighteen total neonates were evaluated, 10 with seizures post-CHD repair who did not require ECMO and 8 who required ECMO. In the non-ECMO cohort, nine of ten were successfully treated with LEV monotherapy with no adverse events. In comparison, the eight neonates who required ECMO had a higher initial seizure burden (1.6% vs 17%, p=0.003), were more likely to have injury on neuroimaging (12.5 vs 75%, p= 0.04), and all neonates required multiple ASMs. Seizure burden did not decrease with LEV, but significantly decreased with phenobarbital and fosphenytoin (14.4% and 10.5%, p = 0.024). CONCLUSIONS Neonates with CHD and seizures on and off ECMO demonstrated divergent seizure characteristics including seizure burden and response to LEV. LEV may reduce neonatal seizure burden after uncomplicated CHD repair. However, in neonates requiring ECMO, multiple ASMs were required. A prospective evaluation of ASM efficacy and safety in this high-risk population is urgently needed.
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Affiliation(s)
- Jennifer C Keene
- University of Washington, Department of Neurology, Division of Child Neurology (JK, MW, LM, XB, NN), Seattle, WA
| | - Mark Wainwright
- University of Washington, Department of Neurology, Division of Child Neurology (JK, MW, LM, XB, NN), Seattle, WA
| | - Lindsey A Morgan
- University of Washington, Department of Neurology, Division of Child Neurology (JK, MW, LM, XB, NN), Seattle, WA
| | | | - Ndidi Musa
- Division of Pediatric Critical Care Medicine (NM), Seattle, WA
| | - Xiuhua L Bozarth
- University of Washington, Department of Neurology, Division of Child Neurology (JK, MW, LM, XB, NN), Seattle, WA
| | - Niranjana Natarajan
- University of Washington, Department of Neurology, Division of Child Neurology (JK, MW, LM, XB, NN), Seattle, WA
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Liparoti G, Burchiani B, Mencaroni E, Tripodi D, Di Cara G, Verrotti A. Individualizing doses of antiepileptic drugs. Expert Opin Drug Metab Toxicol 2022; 18:219-233. [PMID: 35523739 DOI: 10.1080/17425255.2022.2075342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This review aims to identify the optimal therapeutic dosage of anti-epileptic drugs in terms of efficacy and safety in patients with multiple comorbidities. AREAS COVERED We have analyzed changes in terms of pharmacokinetics and pharmacodynamics of Brivaracetam, Carbamazepine, Lacosamide, Lamotrigine, Levetiracetam, Topiramate, Valproate, and Zonisamide in liver disease, chronic kidney disease, and in patients admitted to intensive care unit. Our literature search covers the past 5 years. We used PubMed, Google Scholar, and EMBASE database's to support our article. EXPERT OPINION To ensure that the patient with seizure receives the best treatment in relation to their comorbidities, careful clinical-laboratory monitoring is necessary to maximize effectiveness while maintaining safety, especially in the case of polytherapy.
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Affiliation(s)
- Giulia Liparoti
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | | | | | - Domenico Tripodi
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio"of Chieti-Pescara, Chieti, Italy
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Keene JC, Morgan LA, Abend NS, Bates SV, Bauer Huang SL, Chang T, Chu CJ, Glass HC, Massey SL, Ostrander B, Pardo AC, Press CA, Soul JS, Shellhaas RA, Thomas C, Natarajan N. Treatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units. Pediatr Neurol 2022; 128:67-74. [PMID: 34750046 DOI: 10.1016/j.pediatrneurol.2021.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/12/2021] [Accepted: 10/04/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Seizures are a common neonatal neurologic emergency. Many centers have developed pathways to optimize management. We evaluated neonatal seizure management pathways at level IV neonatal intensive care units (NICUs) in the United States to highlight areas of consensus and describe aspects of variability. METHODS We conducted a descriptive analysis of 11 neonatal seizure management pathways from level IV NICUs that specialize in neonatal neurocritical care including guidelines for electroencephalography (EEG) monitoring, antiseizure medication (ASM) choice, timing, and dose. RESULTS Study center NICUs had a median of 70 beds (interquartile range: 52-96). All sites had 24/7 conventional EEG initiation, monitoring, and review capability. Management pathways uniformly included prompt EEG confirmation of seizures. Most pathways included a provision for intravenous benzodiazepine administration if either EEG or loading of ASM was delayed. Phenobarbital 20 mg/kg IV was the first-line ASM in all pathways. Pathways included either fosphenytoin or levetiracetam as the second-line ASM with variable dosing. Third-line ASMs were most commonly fosphenytoin or levetiracetam, with alternatives including topiramate or lacosamide. All pathways provided escalation to continuous midazolam infusion with variable dosing for seizures refractory to initial medication trials. Three pathways also included lidocaine infusion. Nine pathways discussed ASM discontinuation after resolution of acute symptomatic seizures with variable timing. CONCLUSIONS Despite a paucity of data from controlled trials regarding optimal neonatal seizure management, there are areas of broad agreement among institutional pathways. Areas of substantial heterogeneity that require further research include optimal second-line ASM, dosage, and timing of ASM discontinuation.
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Affiliation(s)
- Jennifer C Keene
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington.
| | - Lindsey A Morgan
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Nicholas S Abend
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Sara V Bates
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah L Bauer Huang
- Division of Pediatric & Developmental Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Taeun Chang
- Neurology, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, San Francisco, San Francisco, California
| | - Shavonne L Massey
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Betsy Ostrander
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Andrea C Pardo
- Ann & Robert H. Lurie Children's Hospital, Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Craig A Press
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Janet S Soul
- Department of Neurology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Renée A Shellhaas
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Niranjana Natarajan
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
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WHAT IS THE THERAPEUTIC REFERENCE RANGE FOR LEVETIRACETAM? Ther Drug Monit 2022; 44:363-365. [DOI: 10.1097/ftd.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/02/2022] [Indexed: 11/25/2022]
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Pillay-Fuentes Lorente V, Bekker A, Kali GTJ, Lloyd LG, Van der Merwe AW, Abulfathi AA, Decloedt EH. The Pharmacokinetics of Crushed Levetiracetam Tablets Administered to Neonates. J Trop Pediatr 2021; 67:6296315. [PMID: 34114632 DOI: 10.1093/tropej/fmab041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Intravenous phenobarbital remains the first-line therapy in the management of neonatal seizures. Shortages of intravenous phenobarbital in South Africa necessitated the addition of oral levetiracetam as part of management of neonatal seizures. OBJECTIVE We evaluated the pharmacokinetics of crushed immediate-release levetiracetam tablets administered to neonates to terminate seizures. METHODS A prospective, observational study of neonates admitted with seizures to Tygerberg Hospital. Participants received crushed levetiracetam (diluted in saline) given orally or via naso-/orogastric tube. At steady-state, pharmacokinetic sampling was performed at pre-dose, 1.5, 2.5 and 4 h post-dose. Maximum concentration (Cmax), time to Cmax (Tmax), trough concentrations (Ctrough) and area under the concentration-time curve (AUC0-12) were calculated using non-compartmental analysis. Seizure termination and safety profiles were documented. RESULTS Nineteen participants were grouped into three dosing ranges: (i) 5-15 mg/kg/12-hourly, (ii) 15-25 mg/kg/12-hourly and (iii) 25-35 mg/kg/12-hourly. Range 1 demonstrated AUC0-12 167.0 ± 45.6 h*μg/mL, Cmax 19.19 ± 4.12 μg/mL and Ctrough 9.99 ± 3.86 µg/mL. Range 2, AUC0-12 316.5 ± 108.4 h*μg/mL, Cmax 35.12 ± 10.54 µg/mL and Ctrough 19.25 ± 8.48 µg/mL. Range 3, AUC0-12 290.9 (range 176.14-405.59) h*μg/mL, Cmax 36.11 (range 27.58-44.64) µg/mL and Ctrough 13.03 (2.98-23.07) µg/mL. Seizures terminated in 17/19 (90%) neonates by day 3 and 19/19 (100%) by day 4 post-levetiracetam initiation. CONCLUSION Crushed levetiracetam has comparable pharmacokinetics to historical data. No pharmacokinetic differences were observed between oral vs. naso-/orogastric administration. Crushed levetiracetam tablets can be considered for neonates in low-resource settings where intravenous and syrup access is limited. LAY SUMMARY Intravenous preparations of antiepileptic medications are used in the management of neonatal seizures. Various established standard of care intravenous antiepileptic medicines are unavailable nationally and internationally due to reasons outside our control. This stock shortage included intravenous phenobarbitone which is the first-line treatment for paediatric seizures. Due to phenobarbital shortage, levetiracetam has been identified by the neonatologists at Tygerberg Hospital, Cape Town, South Africa, as a suitable treatment option due to its efficacy and safety profile. However, intravenous levetiracetam and oral syrup is not registered in South Africa. Levetiracetam tablets are being crushed, dissolved and administered to neonates. There are no data available on the absorption of crushed levetiracetam tablets administered to neonates via a nasogastric tube. This study characterized the pharmacokinetic profile of crushed levetiracetam administered to neonates. We selected neonates receiving levetiracetam from the neonatal wards at Tygerberg hospital and drew blood to analyse the levetiracetam concentrations at 4 different time points. We found that the overall exposure of crushed levetiracetam tablets were comparable to the exposures achieved in historical data of the unaltered formulations. We concluded that crushed levetiracetam tablets can be considered for neonates in low resource settings where intravenous and syrup access is limited.
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Affiliation(s)
- Veshni Pillay-Fuentes Lorente
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Gugu T J Kali
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Lizel G Lloyd
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Alma W Van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Ahmed A Abulfathi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa.,Department of Clinical Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, College of Medical Sciences, University of Maiduguri, Maiduguri 600004, Nigeria
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
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Efficient Determination of Trace Thionyl Chloride in the Antiepileptic Levetiracetam by Pyrolysis Combined with Ion Chromatography. Chromatographia 2020. [DOI: 10.1007/s10337-020-03951-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Harby SA, Nassra RA, Mekky JF, Ali SM, Ismail CA. Correlation of levetiracetam concentration in peripheral blood mononuclear cells with clinical efficacy: A sensitive monitoring biomarker in patients with epilepsy. Seizure 2020; 78:71-77. [DOI: 10.1016/j.seizure.2020.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 02/20/2020] [Accepted: 03/14/2020] [Indexed: 12/11/2022] Open
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Therapeutic Drug Monitoring of Newer Antiepileptic Drugs: A Randomized Trial for Dosage Adjustment. Ann Neurol 2019; 87:22-29. [DOI: 10.1002/ana.25641] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 11/08/2019] [Accepted: 11/09/2019] [Indexed: 12/18/2022]
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Gulcebi MI, Kendirli T, Turgan ZA, Patsalos PN, Onat Yilmaz F. The effect of serum levetiracetam concentrations on therapeutic response and IL1-beta concentration in patients with epilepsy. Epilepsy Res 2018; 148:17-22. [PMID: 30326332 DOI: 10.1016/j.eplepsyres.2018.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/07/2018] [Accepted: 09/26/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Assessment of the relevance between serum drug concentration to its therapeutic response is a valid monitoring strategy for the clinical efficacy of antiepileptic drugs (AEDs). Levetiracetam (LEV) is a broad spectrum AED with a possible anti-inflammatory effect. We aimed to determine the relationship between LEV concentrations and its therapeutic response, and the effect of LEV on IL1-beta concentrations in patients with epilepsy. METHODS Patients on monotherapy (n = 7) or polytherapy (n = 15) with LEV for their seizures management were included. Blood samples of each patient were collected: just before LEV intake, 1 h, 2 h, 4 h and 8 h following the last dose. Serum LEV concentrations were measured by liquid chromatography mass spectrometry and IL1-beta concentrations by chemiluminescent immunometric assay. Concentration to dose (C/D) ratio values was used for analyses. LEV concentrations were compared between responders (≤1 seizure/month) and non-responders (>1 seizure/month) and patients with or without adverse reactions. IL1-beta concentrations before and at 2 h following LEV ingestion were compared in order to detect the effect of the increase in serum LEV concentration on IL1-beta. RESULTS Although there was no change in LEV (C/D) ratio or LEV maximum concentration (Cmax)/D ratio of the responders and non-responders, the C/D ratio following 1 h of LEV intake (2.17 ± 0.59 kg.day/L) and Cmax/D ratio (2.25 ± 0.56 kg.day/L) in the patients with adverse effects was significantly higher than for the patients without adverse effects (1.09 ± 0.12 kg.day/L and 1.49 ± 0.14 kg.day/L respectively). A statistically significant decrease was found in the IL1-beta concentration to LEV (C/D) ratio with the increase in LEV concentration in patients on LEV monotherapy. CONCLUSION The possible relationship between LEV Cmax and its therapeutic response or IL1-beta concentrations may be an importance indication of LEV antiepileptic efficacy. Consequently, monitoring LEV Cmax values may enhance LEV adherence because patients would be less likely to develop adverse effects.
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Affiliation(s)
- Medine I Gulcebi
- Department of Medical Pharmacology, School of Medicine, University of Marmara, Istanbul, Turkey
| | - Tansel Kendirli
- Department of Neurology, School of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Zehra Asik Turgan
- Department of Medical Pharmacology, School of Medicine, University of Marmara, Istanbul, Turkey
| | - Philip N Patsalos
- Department of Clinical & Experimental Epilepsy, NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, United Kingdom; Therapeutic Drug Monitoring Unit, Chalfont Centre for Epilepsy, Chalfont St. Peter, United Kingdom
| | - Filiz Onat Yilmaz
- Department of Medical Pharmacology, School of Medicine, University of Marmara, Istanbul, Turkey.
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Kanemura H, Sano F, Ohyama T, Aihara M. Efficacy of levetiracetam for reducing rolandic discharges in comparison with carbamazepine and valproate sodium in rolandic epilepsy. Seizure 2018; 62:79-83. [PMID: 30308427 DOI: 10.1016/j.seizure.2018.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The main purpose of this study was to compare the efficacy of levetiracetam (LEV) with the older antiepileptic drugs (AEDs) for preventing atypical evolution in children with Rolandic epilepsy (RE). Accordingly, the present study compared the efficacy of older AEDs (carbamazepine (CBZ) and valproate sodium (VPA)) with LEV in reducing rolandic discharges (RDs) on interictal electroencephalogram (EEG) in children with RE. METHODS Patients in this heterogenous study were subdivided into CBZ, VPA and LEV groups in accordance with the initial monotherapy. The CBZ and VPA groups were studied retrospectively, but the LEV group was studied prospectively. Appearances of discharges were counted and these rates were computed. In comparison with the baseline RD frequency, EEG response to AED treatment was classified such as complete disappearance and response (≥50% reduction in RD frequency). The time taken to attain complete disappearance or response in EEG responders was assessed for each AED treatment group. RESULTS Responders comprised 10 (11.2%) of the 89 patients treated with CBZ, 41 (56.2%) of the 73 patients with VPA, and 25 (71.4%) of the 35 patients with LEV. Mean interval to achievement of EEG response in the CBZ, VPA, and LEV groups were 36.3, 23.1, and 14.7 months, respectively. EEG response was achieved significantly more rapidly with LEV than with CBZ (p < 0.001) or VPA (p < 0.005). Seizure control was not significantly different in all 3 investigated drugs. CONCLUSIONS LEV seems to be superior to CBZ and VPA in its ability to suppress RDs in children with RE.
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Affiliation(s)
- Hideaki Kanemura
- Department of Paediatrics, Faculty of Medicine, Graduate School, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan.
| | - Fumikazu Sano
- Department of Paediatrics, Faculty of Medicine, Graduate School, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan
| | - Tetsuo Ohyama
- Department of Paediatrics, Faculty of Medicine, Graduate School, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan
| | - Masao Aihara
- Graduate Faculty of Interdisciplinary Research, Graduate School, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan
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Barnes Heller H, Granick M, Van Hesteren M, Boothe DM. Serum levetiracetam concentrations and adverse events after multiple dose extended release levetiracetam administration to healthy cats. J Vet Intern Med 2018; 32:1145-1148. [PMID: 29671898 PMCID: PMC5980453 DOI: 10.1111/jvim.15129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/19/2018] [Accepted: 03/07/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Multiple dose administration of antiepileptic drugs to cats presents a challenge for owners. Extended release levetiracetam (XRL) has once daily recommended dosing interval, but multiple dose administration of XRL has not been evaluated in cats. OBJECTIVE Evaluate serum levetiracetam concentrations and adverse clinical effects after 11 days of once daily XRL administration to healthy cats. ANIMALS Nine healthy privately owned cats, body weight ≥ 5 kg METHODS: Extended release levetiracetam (500 mg/cat) was administered PO q24h for 10 days. On day 11, blood was collected at trough, 4, 6, and 8 hours after tablet administration. Owners maintained records of adverse effects throughout study. Levetiracetam was quantitated in serum using immunoassay validated in cats. RESULTS Median dose 94.3 mg/kg q24h. Median (range) trough, 4, 6, and 8 hour serum levetiracetam concentrations were 7.0 (2.3-14.1), 82.6 (7.8-125.3), 92.3 (13.3-97.3), and 72 (22.8-96.4) μg/mL, respectively. Peak was not observed in 4 cats because of missed samples (n = 2) and failure to reach maximal concentration (Cmax ) by 8 hours (n = 2). Median time of maximal concentration (Tmax ) for the remaining 5 cats 5.2 (range 4-6) hours. Adverse effects were minimal and included ataxia (n = 1), sedation (n = 1), and vomiting or regurgitation (n = 1). All signs resolved without dose adjustment or additional treatment. CONCLUSIONS AND CLINICAL IMPORTANCE Mean trough serum levetiracetam concentrations were ≥5 μg/mL and adverse effects were minimal throughout dosing period, indicating that the drug was well tolerated. Once daily XRL (500 mg/cat) administration may provide an easier alternative to 3 times daily dosing of intermediate-release levetiracetam for epileptic cats.
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Abstract
Given the distinctive characteristics of both epilepsy and antiepileptic drugs (AEDs), therapeutic drug monitoring (TDM) can make a significant contribution to the field of epilepsy. The measurement and interpretation of serum drug concentrations can be of benefit in the treatment of uncontrollable seizures and in cases of clinical toxicity; it can aid in the individualization of therapy and in adjusting for variable or nonlinear pharmacokinetics; and can be useful in special populations such as pregnancy. This review examines the potential for TDM of newer AEDs such as eslicarbazepine acetate, felbamate, gabapentin, lacosamide, lamotrigine, levetiracetam, perampanel, pregabalin, rufinamide, retigabine, stiripentol, tiagabine, topiramate, vigabatrin, and zonisamide. We describe the relationships between serum drug concentration, clinical effect, and adverse drug reactions for each AED as well as the different analytical methods used for serum drug quantification. We discuss retrospective studies and prospective data on the serum drug concentration-efficacy of these drugs and present the pharmacokinetic parameters, oral bioavailability, reference concentration range, and active metabolites of newer AEDs. Limited data are available for recent AEDs, and we discuss the connection between drug concentrations in terms of clinical efficacy and nonresponse. Although we do not propose routine TDM, serum drug measurement can play a beneficial role in patient management and treatment individualization. Standardized studies designed to assess, in particular, concentration-efficacy-toxicity relationships for recent AEDs are urgently required.
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Affiliation(s)
- Shery Jacob
- Department of Pharmaceutics, College of Pharmacy, Gulf Medical University, University Street, P.O.Box No.4184, Ajman, UAE.
| | - Anroop B Nair
- Department of Pharmaceutics, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
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Chen YC, Zhu GY, Wang X, Shi L, Du TT, Liu DF, Liu YY, Jiang Y, Zhang X, Zhang JG. Anterior thalamic nuclei deep brain stimulation reduces disruption of the blood-brain barrier, albumin extravasation, inflammation and apoptosis in kainic acid-induced epileptic rats. Neurol Res 2017; 39:1103-1113. [PMID: 28918702 DOI: 10.1080/01616412.2017.1379241] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective The therapeutic efficacy of anterior thalamic nuclei deep brain stimulation (ATN-DBS) against seizures has been largely accepted; however, the effects of ATN-DBS on disruption of the blood-brain barrier (BBB), albumin extravasation, inflammation and apoptosis still remain unclear. Methods Rats were distributed into four treatment groups: physiological saline (PS, N = 12), kainic acid (KA, N = 12), KA-sham-DBS (N = 12) and KA-DBS (N = 12). Seizures were monitored using video-electroencephalogram (EEG). One day after surgery, all rats were sacrificed. Then, samples were prepared for quantitative real-time PCR (qPCR), western blot, immunofluorescence (IF) staining, and transmission electron microscopy to evaluate the disruption of the BBB, albumin extravasation, inflammation, and apoptosis. Result Because of the KA injection, the disruption of the BBB, albumin extravasation, inflammation and apoptosis were more severe in the KA and the KA-sham-DBS groups compared to the PS group (all Ps < 0.05 or < 0.01). The ideal outcomes were observed in the KA-DBS group. ATN-DBS produced a 46.3% reduction in seizure frequency and alleviated the disruption of the BBB, albumin extravasation, inflammatory reaction and apoptosis in comparison to the KA-sham-DBS group (all Ps < 0.05 or < 0.01). Conclusion (1) Seizures can be reduced using ATN-DBS in the epileptogenic stage. (2) ATN-DBS can reduce the disruption of the BBB and albumin extravasation. (3) ATN-DBS has an anti-inflammatory effect in epileptic models.
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Affiliation(s)
- Ying-Chuan Chen
- a Department of Neurosurgery , Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Guan-Yu Zhu
- a Department of Neurosurgery , Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Xiu Wang
- a Department of Neurosurgery , Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Lin Shi
- a Department of Neurosurgery , Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Ting-Ting Du
- a Department of Neurosurgery , Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - De-Feng Liu
- a Department of Neurosurgery , Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Yu-Ye Liu
- a Department of Neurosurgery , Beijing Tiantan Hospital, Capital Medical University , Beijing , China
| | - Yin Jiang
- b Department of Functional Neurosurgery , Beijing Neurosurgical Institute, Capital Medical University , Beijing , China
| | - Xin Zhang
- b Department of Functional Neurosurgery , Beijing Neurosurgical Institute, Capital Medical University , Beijing , China
| | - Jian-Guo Zhang
- a Department of Neurosurgery , Beijing Tiantan Hospital, Capital Medical University , Beijing , China.,b Department of Functional Neurosurgery , Beijing Neurosurgical Institute, Capital Medical University , Beijing , China.,c Beijing Key Laboratory of Neurostimulation , Beijing , China
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Levetiracetam Clinical Pharmacokinetic Monitoring in Pediatric Patients with Epilepsy. Clin Pharmacokinet 2017; 56:1267-1285. [DOI: 10.1007/s40262-017-0537-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Gupta V, Gupta K, Singh G, Kaushal S. An Analytical Study to Correlate Serum Levels of Levetiracetam with Clinical Course in Patients with Epilepsy. J Neurosci Rural Pract 2017; 7:S31-S36. [PMID: 28163500 PMCID: PMC5244057 DOI: 10.4103/0976-3147.196445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction: With the advancement of therapeutics, newer antiepileptic drugs (AEDs) like Levetiracetam (LEV), with good therapeutic efficacy and tolerability are available. But unfortunately, therapeutic drug monitoring is not routinely done in India for these drugs. Objectives: The objective of this study is to determine the range of serum levels of LEV in patients at stabilized doses and correlate them with their clinical course. Materials and Methods: Patients with epilepsy and started on LEV were enrolled from the Neurology Department after the Ethics Committee approval. Serum levels of LEV were estimated using high-performance liquid chromatography and correlated with patient demographics, dosage, dosage forms, concomitant AEDs, compliance of the patient, therapeutic effect, adverse drug reactions (ADRs), and suspected toxicity. Results: Serum levels of LEV ranged from 0.4 to 102.2 μg/ml at different time points and demonstrated a negligible positive correlation with age of the patients (r = 0.12) but negligible negative correlation with bodyweight (r = −0.19). No conclusive relationship could be established for dose, gender, dosage forms, clinical efficacy (seizure frequency), ADRs, and toxicity. Compliance was verified in all the patients. Levels were found to reduce with the use of concomitant enzyme inducer drugs (56.78%) whereas increase with valproic acid (7.8%). Conclusion: These findings emphasize the need for monitoring the serum levels of newer AEDs like LEV considering the various parameters studied here, so as to maintain the therapeutic efficacy by preventing under or over dosage and to generate a broader database of serum levels of LEV in the Indian population to help appropriate prescribing with more confidence.
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Affiliation(s)
- Varun Gupta
- Department of Pharmacology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Kanchan Gupta
- Department of Pharmacology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Gagandeep Singh
- Department of Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sandeep Kaushal
- Department of Pharmacology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Tekgül H, Gencpinar P, Çavuşoğlu D, Dündar NO. The efficacy, tolerability and safety of levetiracetam therapy in a pediatric population. Seizure 2016; 36:16-21. [DOI: 10.1016/j.seizure.2016.01.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 11/29/2022] Open
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