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Chhabra N, Vanood A, Hoerth MT, Sanchez CV, O'Carroll CB. Can Pyridoxine Successfully Reduce Behavioral Side Effects from Levetiracetam?: A Critically Appraised Topic. Neurologist 2023; 28:349-352. [PMID: 37083708 DOI: 10.1097/nrl.0000000000000496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND Levetiracetam is a commonly used anti-seizure medication, with the development of neuropsychiatric symptoms being the most common side effect. Preliminary literature describes the improvement of these symptoms with pyridoxine, mostly within the pediatric population. However, randomized control trial data investigating this relationship is sparse. OBJECTIVE The objective of this study was to critically assess evidence regarding the role of pyridoxine in the treatment of neuropsychiatric symptoms from levetiracetam. METHODS The objective was addressed through the development of a structured, critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, medical librarians, clinical epidemiologists, and content experts in the field of epilepsy. RESULTS A randomized, placebo-controlled clinical trial was selected for critical appraisal. This trial compared pyridoxine versus placebo for the treatment of neuropsychiatric symptoms from levetiracetam in a pediatric population and included 105 patients (46/105 received pyridoxine, 59/105 received placebo). It found that both groups had a significant reduction in behavioral symptoms at the 2-,4-and 6-week time points ( P <0.05). However, the authors noted that the pyridoxine group had almost double the relative reduction when compared with the placebo group at all time points: 1.9 at 2 weeks, 2.0 at 4 weeks, and 1.8 at 6 weeks ( P =0.001). CONCLUSIONS This study suggests that pyridoxine for the treatment of levetiracetam-induced behavioral side effects may result in modest improvement, although many limitations prevent conclusive results. There remains a need for a double-blinded, randomized control trial in both the adult and pediatric populations.
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Pisani F, Spagnoli C. What are the considerations when initiating treatment for epilepsy in children? Expert Rev Neurother 2023; 23:1081-1096. [PMID: 38032395 DOI: 10.1080/14737175.2023.2288107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION There is a very wide spectrum of epilepsies and developmental and epileptic encephalopathies that affect children, from self-limited forms, not necessarily requiring treatment, to severe drug-resistant ones. AREAS COVERED In this perspective, the authors discuss the main factors to consider before drug prescription in children, considering the most recent clinical research, including age, seizure type, epilepsy syndrome, etiology, efficacy and safety profile, comorbidities, gender, available formulations, costs and drug coverage, and regulatory issues. The literature search was conducted through a PubMed search on antiseizure medications for patients aged 0-18, with respect to each of the aforementioned factors, and by checking the reference lists of relevant papers. EXPERT OPINION The most expanding field of research and innovation for clinical practice is precision medicine, which addresses the holistic treatment of genetic epilepsies and developmental and epileptic encephalopathies. It achieves this by addressing their detrimental effects on synapses, neurotransmission, and cellular signaling pathways with the double aim to treat seizures and to rescue neurodevelopmental trajectories, but also the issue of adverse events and drug resistance through pharmacogenomics.
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Affiliation(s)
- Francesco Pisani
- Human Neurosciences Department, Sapienza University of Rome, Rome, Italy
| | - Carlotta Spagnoli
- Child Neurology and Psychiatry Unit, Department of Pediatrics, Presidio Ospedaliero Santa Maria Nuova, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Tang D, Quan C, Huang S, Wei F. Integrating LC-MS and HS-GC-MS for the metabolite characterization of the Chinese medicinal plant Platostoma palustre under different processing methods. Front Nutr 2023; 10:1181942. [PMID: 37275652 PMCID: PMC10235517 DOI: 10.3389/fnut.2023.1181942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/18/2023] [Indexed: 06/07/2023] Open
Abstract
Platostoma palustre (or Mesona chinensis Benth) is an important medicinal and edible plant in China and Southeast Asian countries. To study the effects of different processing methods on the quality, nutrition, and flavor of P. palustre, we adopted the LC-MS and HS-GC-MS to compare the influences of tedding (S), sweating (M), and drying (H) on the metabolites and volatile substances of P. palustre. Biochemical determinations revealed that the M treatment could promote the accumulation of the contents of total sugar, soluble sugar, and total pectin compared with the H and S treatments but decrease the total flavonoid contents. LC-MS and HS-GC-MS uncovered 98 differential metabolites and 27 differential volatile substances among the three treatments, respectively. Overall, the M treatment facilitated the stabilization and improvement of the quality of polysaccharides and volatile substances, while the H treatment could promote the level of amino acids in P. palustre. The current study provided a theoretical reference for establishing standardized processing methods and sustaining the quality stability of P. palustre in future.
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Affiliation(s)
- Danfeng Tang
- Guangxi Key Laboratory of Medicinal Resources Protection and Genetic Improvement, Guangxi Botanical Garden of Medicinal Plants, Nanning, China
- National Traditional Chinese Medicine Inheritance and Innovation Center, Guangxi Botanical Garden of Medicinal Plants, Nanning, China
| | - Changqian Quan
- Guangxi Key Laboratory of Medicinal Resources Protection and Genetic Improvement, Guangxi Botanical Garden of Medicinal Plants, Nanning, China
- National Traditional Chinese Medicine Inheritance and Innovation Center, Guangxi Botanical Garden of Medicinal Plants, Nanning, China
| | - Suhua Huang
- College of Pharmacy, Guangxi Medical University, Nanning, China
| | - Fan Wei
- Guangxi Key Laboratory of Medicinal Resources Protection and Genetic Improvement, Guangxi Botanical Garden of Medicinal Plants, Nanning, China
- National Traditional Chinese Medicine Inheritance and Innovation Center, Guangxi Botanical Garden of Medicinal Plants, Nanning, China
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Besag FMC, Vasey MJ, Sen A. Current evidence for adjunct pyridoxine (vitamin B6) for the treatment of behavioral adverse effects associated with levetiracetam: A systematic review. Epilepsy Behav 2023; 140:109065. [PMID: 36791631 DOI: 10.1016/j.yebeh.2022.109065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/17/2022] [Accepted: 12/17/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Levetiracetam (LVT), while an effective treatment for multiple seizure types, is associated with a high incidence of neuropsychiatric adverse events (NPAEs). In predominantly retrospective studies, supplementation with pyridoxine/vitamin B6 (PN) was associated with improvement in NPAEs in some people. A previous review highlighted a lack of double-blind, controlled trials of PN for the treatment of NPAEs in individuals treated with LVT. The current paper updates the findings from the previous review to include evidence from studies published since June 2019. METHODS An updated systematic review of the published literature was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, the Cochrane Library, and Google Scholar were searched to identify studies published between June 2019 and 2nd November 2022 in which supplementary PN was initiated for the treatment of LVT-associated NPAEs. All study types were eligible. The risk of bias in randomized trials was assessed using the Cochrane risk-of-bias tool. RESULTS Seven additional studies were identified: two double-blind, randomized controlled trials (RCTs), four retrospective studies, and one retrospective case series. One RCT reported significant improvements from baseline in behavioral adverse events (BAEs) in both the intervention (PN) group and the low-dose control group (both p < 0.05), with a significantly greater improvement in the intervention group (p < 0.001). In the second RCT, differences in BAE severity between PN and placebo groups at the endpoint were not statistically significant. In one retrospective study, subjective irritability was reported to have improved from baseline in 9/20 individuals (45%) treated with supplementary PN. Data for systematic assessments (PHQ-9 and GAD-7) were available for 10 individuals. Assessment by PHQ-9 showed that six individuals improved, two worsened and two had no change. Based on the GAD-7, three people improved, two worsened and five had no change. In the second retrospective study, 18/41 individuals (44%) who commenced PN following the emergence of BAEs showed "significant" improvement. In a separate group of individuals with pre-existing behavioral problems in whom PN treatment was initiated at the same time as commencing LVT, 3/18 (16.7%) developed BAEs. This compared with 79/458 people (17.2%) who were initially treated only with LVT. The third retrospective study compared treatment-related irritability in individuals who had been treated with both LVT and perampanel, either sequentially or concomitantly. Two people who developed irritability while receiving LVT monotherapy were able to continue treatment with the addition of PN. The fourth study reported a significantly lower LVT discontinuation rate in individuals taking PN and a higher rate of improved behavior in those who were able to continue LVT. The case series reported improvements in behavioral symptoms in six people within two to three weeks of commencing supplementary PN. CONCLUSION Data published within the last three years add to earlier evidence suggesting that PN might be effective in the treatment of NPAEs associated with LVT. However, the quality of evidence remains poor and only a few prospective trials have been published. Data from placebo-controlled trials are still largely lacking. Currently, there is insufficient evidence to justify any firm recommendation for PN supplementation to treat NPAEs associated with LVT. Further well-designed, prospective trials are warranted.
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Affiliation(s)
- Frank M C Besag
- Child and Adolescent Mental Health Services, East London NHS Foundation Trust, Bedford, UK; School of Pharmacy, University College London, London, UK; Department of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | | | - Arjune Sen
- Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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Rubinos C, Bruzzone MJ, Blodgett C, Tsai C, Patel P, Hianik R, Jadav R, Boudesseul J, Liu C, Zhu H, Wilson SE, Olm-Shipman C, Meeker R, Hirsch LJ. Association of Serum Pyridoxal Phosphate Levels with Established Status Epilepticus. Neurocrit Care 2023; 38:41-51. [PMID: 36071331 DOI: 10.1007/s12028-022-01579-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/27/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The objective of this study was to determine the prevalence of pyridoxine deficiency, measured by pyridoxal phosphate (PLP) levels, in patients admitted to the hospital with established (benzodiazepine-resistant) status epilepticus (SE) (eSE) and to compare to three control groups: intensive care unit (ICU) patients without SE (ICU-noSE), non-ICU inpatients without SE (non-ICU), and outpatients with or without a history of epilepsy (outpatient). METHODS This retrospective cohort study was conducted at the University of North Carolina Hospitals and Yale New Haven Hospital. Participants included inpatients and outpatients who had serum PLP levels measured during clinical care between January 2018 and March 2021. The first PLP level obtained was categorized as normal (> 30 nmol/L), marginal (≤ 30 nmol/L), deficient (≤ 20 nmol/L), and severely deficient (≤ 5 nmol/L). RESULTS A total of 293 patients were included (52 eSE, 40 ICU-noSE, 44 non-ICU, and 157 outpatient). The median age was 55 (range 19-99) years. The median PLP level of the eSE group (12 nmol/L) was lower than that of the ICU-noSE (22 nmol/L, p = 0.003), non-ICU (16 nmol/L, p = 0.05), and outpatient groups (36 nmol/L, p < 0.001). Patients with eSE had a significantly higher prevalence of marginal and deficient PLP levels (90 and 80%, respectively) than patients in each of the other three groups (ICU-noSE: 70, 50%; non-ICU: 63, 54%; outpatient: 38, 21%). This significantly higher prevalence persisted after correcting for critical illness severity and timing of PLP level collection. CONCLUSIONS Our study confirms previous findings indicating a high prevalence of pyridoxine deficiency (as measured by serum PLP levels) in patients with eSE, including when using a more restricted definition of pyridoxine deficiency. Prevalence is higher in patients with eSE than in patients in all three control groups (ICU-noSE, non-ICU, and outpatient). Considering the role of pyridoxine, thus PLP, in the synthesis of γ-aminobutyric acid and its easy and safe administration, prospective studies on pyridoxine supplementation in patients with eSE are needed.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA.
| | - Maria Jose Bruzzone
- Department of Neurology, University of Florida, Gainesville, FL, CB 7025, USA
| | - Courtney Blodgett
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Carolyn Tsai
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Puja Patel
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Rachel Hianik
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Rakesh Jadav
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Chuning Liu
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - Hongtu Zhu
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - Susan E Wilson
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Casey Olm-Shipman
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Rick Meeker
- Department of Neurology, Division of Critical Care Neurology and Division of Epilepsy, University of North Carolina at Chapel Hill, 170 Manning Drive, Physician Office, Chapel Hill, NC, USA
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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Cheraghmakani H, Rezapour M, Asghari F, Alizadeh-Navaei R, Ghazaeian M, Tabrizi N. Pyridoxine for treatment of levetiracetam-induced behavioral adverse events: A randomized double-blind placebo-controlled trial. Epilepsy Behav 2022; 136:108938. [PMID: 36228485 DOI: 10.1016/j.yebeh.2022.108938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/27/2022] [Accepted: 09/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Levetiracetam is a broad-spectrum antiseizure medication with known behavioral side effects. The possible beneficial effect of pyridoxine on improvement of these psychiatric problems has been suggested in few previous studies. This clinical trial aimed to investigate the effect of pyridoxine on behavioral side effects of levetiracetam in adult patients with epilepsy. METHODS This study was a randomized double-blind placebo-controlled clinical trial on 53 adult patients with epilepsy with behavioral side effects after treatment by levetiracetam. Patients who met the study criteria were randomized to receive 40 mg/day pyridoxine or placebo. Their psychiatric state was surveyed by SCL-90-R questionnaire before and three weeks after initiation of treatment. RESULTS There were no statistically significant differences in the behavioral adverse effects between the pyridoxine-treated group and the placebo group. CONCLUSION Although this study showed no statistically significant beneficial effects of pyridoxine on the behavioral adverse effects of levetiracetam, placebo-controlled trials with a larger size and higher doses are needed to determine whether it is effective or not.
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Affiliation(s)
- Hamed Cheraghmakani
- Neurology Department, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Rezapour
- Psychiatry and Behavioural Sciences Research Center, Addiction Institute, Department of Psychiatry, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Faezeh Asghari
- Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Reza Alizadeh-Navaei
- Gastrointestinal Cancer Research Center, Non-communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Monireh Ghazaeian
- Pharmaceutical Research Center, Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Nasim Tabrizi
- Neurology Department, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
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Lob K, Bassell-Hawkins J, Patil R, Nie D, Bartolini L. Vitamin B6 decreases the risk of levetiracetam discontinuation in children with epilepsy: A retrospective study. Epilepsy Behav 2022; 134:108839. [PMID: 35839645 DOI: 10.1016/j.yebeh.2022.108839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/14/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Levetiracetam (LEV) is an anti-seizure medication (ASM) known to have significant behavioral side effects in children with epilepsy. These side effects may be improved by supplemental vitamin B6 (pyridoxine) use. Our research aimed to study risk factors for LEV side effects and the role of vitamin B6 in altering this risk. METHODS We retrospectively analyzed the demographic and clinical profile of all pediatric patients on LEV treatment between July 2019 and December 2020. T-tests, Chi-square and Fisher exact tests were used to assess predictors of LEV discontinuation. A p-value of <0.05 was considered statistically significant. RESULTS 150/240 (62%) children were on additional medications besides LEV for epilepsy management. Thirty-five percent children reported side effects, especially behavioral and mood concerns. Of the patients who reported side effects on LEV, 71% were taking vitamin B6 (n = 59). The rate of LEV discontinuation was significantly lower for children on vitamin B6 than children not taking B6, regardless of monotherapy or polypharmacy (49% v 88% respectively, p = 0.001). Over half of the patients who were able to remain on LEV reported improved behavior with B6 supplementation as compared to those who were unable to continue LEV (17/30, 57% versus 0/26, 0%; p < 0.001). CONCLUSIONS Levetiracetam side effects significantly impact the tolerability of this ASM in children with epilepsy. Our results suggest that vitamin B6 supplementation can significantly reduce the odds of discontinuing LEV due to its behavioral side effects.
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Affiliation(s)
- Karen Lob
- The Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA.
| | | | - Rachit Patil
- The Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA; Department of Pediatrics, Hasbro Children's Hospital, 593 Eddy St, Providence, RI 02903, USA.
| | - Duyu Nie
- The Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA; Department of Pediatrics, Hasbro Children's Hospital, 593 Eddy St, Providence, RI 02903, USA.
| | - Luca Bartolini
- The Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA; Department of Pediatrics, Hasbro Children's Hospital, 593 Eddy St, Providence, RI 02903, USA.
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García FG, Cardon M, Cardon AL. Observations Regarding Recently Published Amelioration of Levetiracetam-Induced Behavioral Side Effects by Pyridoxine. Pediatr Neurol 2022; 126:56. [PMID: 34740133 DOI: 10.1016/j.pediatrneurol.2021.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Francesca G García
- Department of Neurology, Division of Child Neurology, University of New Mexico, Albuquerque, New Mexico
| | - Meeta Cardon
- Assistant Professor, Division of Child Neurology, University of New Mexico, Albuquerque, New Mexico
| | - Aaron L Cardon
- Assistant Professor, Division of Child Neurology, University of New Mexico, Albuquerque, New Mexico.
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