1
|
Mastrocco A, Prittie J, West C, Clark M. A review of the pharmacology and clinical applications of levetiracetam in dogs and cats. J Vet Emerg Crit Care (San Antonio) 2024; 34:9-22. [PMID: 37987141 DOI: 10.1111/vec.13355] [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: 07/17/2022] [Revised: 09/15/2022] [Accepted: 10/18/2022] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To review and summarize the pharmacology of the antiepileptic drug (AED), levetiracetam (LEV), and to discuss its clinical utility in dogs and cats. DATA SOURCES Veterinary and human peer-reviewed medical literature and the authors' clinical experience. SUMMARY LEV is an AED with mechanisms of action distinct from those of other AEDs. In people and small animals, LEV exhibits linear kinetics, excellent oral bioavailability, and minimal drug-drug interactions. Serious side effects are rarely reported in any species. LEV use is gaining favor for treating epilepsy in small animals and may have wider clinical applications in patients with portosystemic shunts, neuroglycopenia, and traumatic brain injury. In people, LEV may improve cognitive function in patients with dementia. CONCLUSION LEV is a well-tolerated AED with well-documented efficacy in human patients. Although its use is becoming more common in veterinary medicine, its role as a first-line monotherapy in small animal epileptics remains to be determined. This review of the human and animal literature regarding LEV describes its role in epileptic people and animals as well as in other disease states and provides recommendations for clinical usage.
Collapse
Affiliation(s)
- Alicia Mastrocco
- Department of Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Jennifer Prittie
- Department of Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Chad West
- Department of Neurology, The Animal Medical Center, New York, New York, USA
| | - Melissa Clark
- Department of Internal Medicine, Gulf Coast Veterinary Specialists, Houston, Texas, USA
| |
Collapse
|
2
|
Pitton Rissardo J, Fornari Caprara AL, Casares M, Skinner HJ, Hamid U. Antiseizure Medication-Induced Alopecia: A Literature Review. MEDICINES (BASEL, SWITZERLAND) 2023; 10:35. [PMID: 37367730 DOI: 10.3390/medicines10060035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
Background: Adverse effects of antiseizure medications (ASMs) remain one of the major causes of non-adherence. Cosmetic side effects (CSEs) are among the most commonly reported side effects of ASMs. In this context, alopecia is one of the CSEs that has a high intolerance rate leading to poor therapeutical compliance. Methods: We performed a literature review concerning alopecia as a secondary effect of ASMs. Results: There are 1656 individuals reported with ASM-induced alopecia. Valproate (983), lamotrigine (355), and carbamazepine (225) have been extensively reported. Other ASMs associated with alopecia were cenobamate (18), levetiracetam (14), topiramate (13), lacosamide (7), vigabatrin (6), phenobarbital (5), gabapentin (5), phenytoin (4), pregabalin (4), eslicarbazepine (3), brivaracetam (2), clobazam (2), perampanel (2), trimethadione (2), rufinamide (2), zonisamide (2), primidone (1), and tiagabine (1). There were no reports of oxcarbazepine and felbamate with drug-induced alopecia. Hair loss seen with ASMs was diffuse and non-scarring. Telogen effluvium was the most common cause of alopecia. A characteristic feature was the reversibility of alopecia after ASM dose adjustment. Conclusions: Alopecia should be considered one important adverse effect of ASMs. Patients reporting hair loss with ASM therapy should be further investigated, and specialist consultation is recommended.
Collapse
Affiliation(s)
- Jamir Pitton Rissardo
- Medicine Department, Federal University of Santa Maria, Santa Maria 97105-900, Brazil
| | | | - Maritsa Casares
- AdventHealth Orlando Neuroscience Institute, 615 E Princeton Street, Suite 540, Orlando, FL 32803, USA
| | - Holly J Skinner
- AdventHealth Epilepsy at Orlando, 615 E Princeton Street, Suite 540, Orlando, FL 32803, USA
| | - Umair Hamid
- Department of Neurology, College of Medicine, University of Illinois, Peoria, IL 61605, USA
| |
Collapse
|
3
|
Campbell C, McCormack M, Patel S, Stapleton C, Bobbili D, Krause R, Depondt C, Sills GJ, Koeleman BP, Striano P, Zara F, Sander JW, Lerche H, Kunz WS, Stefansson K, Stefansson H, Doherty CP, Heinzen EL, Scheffer IE, Goldstein DB, O'Brien T, Cotter D, Berkovic SF, Sisodiya SM, Delanty N, Cavalleri GL. A pharmacogenomic assessment of psychiatric adverse drug reactions to levetiracetam. Epilepsia 2022; 63:1563-1570. [PMID: 35298028 PMCID: PMC9321556 DOI: 10.1111/epi.17228] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Levetiracetam (LEV) is an effective antiseizure medicine, but 10%-20% of people treated with LEV report psychiatric side-effects, and up to 1% may have psychotic episodes. Pharmacogenomic predictors of these adverse drug reactions (ADRs) have yet to be identified. We sought to determine the contribution of both common and rare genetic variation to psychiatric and behavioral ADRs associated with LEV. METHODS This case-control study compared cases of LEV-associated behavioral disorder (n = 149) or psychotic reaction (n = 37) to LEV-exposed people with no history of psychiatric ADRs (n = 920). All samples were of European ancestry. We performed genome-wide association study (GWAS) analysis comparing those with LEV ADRs to controls. We estimated the polygenic risk scores (PRS) for schizophrenia and compared cases with LEV-associated psychotic reaction to controls. Rare variant burden analysis was performed using exome sequence data of cases with psychotic reactions (n = 18) and controls (n = 122). RESULTS Univariate GWAS found no significant associations with either LEV-associated behavioural disorder or LEV-psychotic reaction. PRS analysis showed that cases of LEV-associated psychotic reaction had an increased PRS for schizophrenia relative to contr ols (p = .0097, estimate = .4886). The rare-variant analysis found no evidence of an increased burden of rare genetic variants in people who had experienced LEV-associated psychotic reaction relative to controls. SIGNIFICANCE The polygenic burden for schizophrenia is a risk factor for LEV-associated psychotic reaction. To assess the clinical utility of PRS as a predictor, it should be tested in an independent and ideally prospective cohort. Larger sample sizes are required for the identification of significant univariate common genetic signals or rare genetic signals associated with psychiatric LEV ADRs.
Collapse
Affiliation(s)
- Ciarán Campbell
- FutureNeuro Research Centre, RCSI Dublin, Dublin, Ireland.,Department of Pharmacy and Biomolecular Science, RCSI Dublin, Dublin, Ireland
| | - Mark McCormack
- Department of Pharmacy and Biomolecular Science, RCSI Dublin, Dublin, Ireland
| | - Sonn Patel
- Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caragh Stapleton
- Department of Pharmacy and Biomolecular Science, RCSI Dublin, Dublin, Ireland
| | - Dheeraj Bobbili
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Roland Krause
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Chantal Depondt
- Laboratory of Experimental Neurology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Graeme J Sills
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Bobby P Koeleman
- Division of Neurosciences, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Pasquale Striano
- Paediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Federico Zara
- Paediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy.,IRCSS, "G. Gaslini" Institute, Genova, Italy
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.,Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Bucks, UK
| | - Holger Lerche
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Wolfram S Kunz
- Department of Epileptology, University of Bonn, Bonn, Germany
| | - Kari Stefansson
- deCODE Genetics/Amgen, Inc., Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Colin P Doherty
- FutureNeuro Research Centre, RCSI Dublin, Dublin, Ireland.,Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Erin L Heinzen
- School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ingrid E Scheffer
- Royal Children's Hospital, University of Melbourne, Melbourne, Victoria, Australia.,Florey Institute and Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Medicine (Neurology), Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - David B Goldstein
- Institute for Genomic Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Terence O'Brien
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - David Cotter
- FutureNeuro Research Centre, RCSI Dublin, Dublin, Ireland.,Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Samuel F Berkovic
- Department of Medicine (Neurology), Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | | | - Sanjay M Sisodiya
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Bucks, UK
| | - Norman Delanty
- FutureNeuro Research Centre, RCSI Dublin, Dublin, Ireland.,Department of Pharmacy and Biomolecular Science, RCSI Dublin, Dublin, Ireland.,Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Gianpiero L Cavalleri
- FutureNeuro Research Centre, RCSI Dublin, Dublin, Ireland.,Department of Pharmacy and Biomolecular Science, RCSI Dublin, Dublin, Ireland
| |
Collapse
|
4
|
Rathore C, Patel K, Satishchandra P. Current concepts in the management of idiopathic generalized epilepsies. Ann Indian Acad Neurol 2022; 25:35-42. [PMID: 35342251 PMCID: PMC8954322 DOI: 10.4103/aian.aian_888_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 11/15/2022] Open
Abstract
Idiopathic generalized epilepsies (IGEs) are a group of epilepsies characterized by an underlying genetic predisposition and a good response to antiseizure medicines (ASMs) in the majority of the patients. Of the various broad-spectrum ASMs, valproate is the most effective medicine for the control of seizures in IGEs. However, with the availability of many newer ASMs and evidence showing the high teratogenic potential of valproate, the choice of ASMs for IGEs has become increasingly difficult, especially in women of the child-bearing age group. In this article, we review the current evidence regarding the efficacy and safety of various ASMs in patients with IGEs and provide practical guidelines for choosing appropriate ASMs in various subgroups of patients with IGEs.
Collapse
|
5
|
Steinhoff BJ, Klein P, Klitgaard H, Laloyaux C, Moseley BD, Ricchetti-Masterson K, Rosenow F, Sirven JI, Smith B, Stern JM, Toledo M, Zipfel PA, Villanueva V. Behavioral adverse events with brivaracetam, levetiracetam, perampanel, and topiramate: A systematic review. Epilepsy Behav 2021; 118:107939. [PMID: 33839453 DOI: 10.1016/j.yebeh.2021.107939] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE To understand the currently available post-marketing real-world evidence of the incidences of and discontinuations due to the BAEs of irritability, anger, and aggression in people with epilepsy (PWE) treated with the anti-seizure medications (ASMs) brivaracetam (BRV), levetiracetam (LEV), perampanel (PER), and topiramate (TPM), as well as behavioral adverse events (BAEs) in PWE switching from LEV to BRV. METHODS A systematic review of published literature using the Cochrane Library, PubMed/MEDLINE, and Embase was performed to identify retrospective and prospective observational studies reporting the incidence of irritability, anger, or aggression with BRV, LEV, PER, or TPM in PWE. The incidences of these BAEs and the rates of discontinuation due to each were categorized by ASM, and where possible, weighted means were calculated but not statistically assessed. Behavioral and psychiatric adverse events in PWE switching from LEV to BRV were summarized descriptively. RESULTS A total of 1500 records were identified in the searches. Of these, 44 published articles reporting 42 studies met the study criteria and were included in the data synthesis, 7 studies were identified in the clinical trial database, and 5 studies included PWE switching from LEV to BRV. Studies included a variety of methods, study populations, and definitions of BAEs. While a wide range of results was reported across studies, weighted mean incidences were 5.6% for BRV, 9.9% for LEV, 12.3% for PER, and 3.1% for TPM for irritability; 3.3%* for BRV, 2.5% for LEV, 2.0% for PER, and 0.2%* for TPM for anger; and 2.5% for BRV, 2.6% for LEV, 4.4% for PER, and 0.5%* for TPM for aggression. Weighted mean discontinuation rates were 0.8%* for BRV, 3.4% for LEV, 3.0% for PER, and 2.2% for TPM for irritability and 0.8%* for BRV, 2.4% for LEV, 9.2% for PER, and 1.2%* for TPM for aggression. There were no discontinuations for anger. Switching from LEV to BRV led to improvement in BAEs in 33.3% to 83.0% of patients (weighted mean, 66.6%). *Denotes only 1 study. CONCLUSIONS This systematic review characterizes the incidences of irritability, anger, and aggression with BRV, LEV, PER, and TPM, and it provides robust real-world evidence demonstrating that switching from LEV to BRV may improve BAEs. While additional data remain valuable due to differences in methodology (which make comparisons difficult), these results improve understanding of the real-world incidences of discontinuations due to these BAEs in clinical practice and can aid in discussions and treatment decision-making with PWE.
Collapse
Affiliation(s)
- Bernhard J Steinhoff
- Epilepsiezentrum Kork, Landstraße 1, 77694 Kehl, Kehl-Kork; Albert-Ludwigs University of Freiburg, Department of Neurology and Clinical Neurophysiology, Freiburg, Germany.
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, 6410 Rockledge Drive, #610, Bethesda, MD 20817, USA.
| | - Henrik Klitgaard
- UCB Pharma, Allee de la Recherche 60, 1070 Anderlecht, Brussels, Belgium.
| | - Cédric Laloyaux
- UCB Pharma, Allee de la Recherche 60, 1070 Anderlecht, Brussels, Belgium.
| | - Brian D Moseley
- University of Cincinnati, Department of Neurology and Rehabilitation Medicine, Stetson Building, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, USA
| | | | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-12, Haus 95, Frankfurt a.M., 60528, Germany.
| | - Joseph I Sirven
- Mayo Clinic, Neurology and Neurosurgery, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
| | - Brien Smith
- OhioHealth Physician Group, 3430 OhioHealth Pkwy, 4th Floor North, Columbus, OH 43202, USA.
| | - John M Stern
- University of California, Department of Neurology, 300 Medical Plaza Driveway, Suite B200, Los Angeles, CA 90095, USA.
| | - Manuel Toledo
- Epilepsy Unit. Neurology Department, Hospital Vall d'Hebron, Servicio de Neurologia, Passeig de la Vall d'Hebron 119, Barcelona, 08035, Spain.
| | - Patricia A Zipfel
- MicroMass, an Ashfield Company, 100 Regency Forest Dr, Cary, NC, USA.
| | - Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitario y Politecnico La Fe, Avenida Fernando Abril Martorell 106, Valencia 46026, Spain
| |
Collapse
|
6
|
Ballvé A, Salas‐Puig J, Quintana M, Campos D, Llauradó A, Raspall M, Fonseca E, Abraira L, Santamarina E, Toledo M. Levetiracetam as first-line monotherapy for Idiopathic Generalized Epilepsy in women. Acta Neurol Scand 2021; 143:407-412. [PMID: 33452703 DOI: 10.1111/ane.13389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/20/2020] [Accepted: 12/01/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Levetiracetam (LEV) is effective in Idiopathic Generalized Epilepsy (IGE) and seems to be a good alternative to valproic acid in women of childbearing age. However, there is lack of approval for this indication as monotherapy. The aim of this study is to assess the efficacy of LEV as a first-line therapy in this population. METHODS The study is a descriptive analysis of women aged between 16 and 45 years old diagnosed with IGE and treated with LEV as first-line monotherapy. Minimum follow-up was 24 months. RESULTS 26 women. Mean age: 25.4 years (17-43). 14 Juvenile Myoclonic Epilepsy; 8 Tonic-Clonic Seizures Alone; 4 Juvenile Absence. Mean follow-up: 68.3 months (24-120). 11 patients (40.7%) continued to take LEV as monotherapy, of which 10 were seizure-free, and three (11.5%) continue to be seizure-free after withdrawing LEV. 12 patients (46.2%) required a change of treatment: 25% (3/12) due to lack of efficacy, 42% (5/12) due to adverse effects and 33% (4/12) due to both. Irritability was the most frequent adverse effect. At the last assessment, three patients (11.5%) continued to have seizures despite polytherapy. Estimated retention rates were 78.1% at one year (SE 7.3%) and 51% at 5 years (SE 9.8%). Estimated median retention time is 72 months (CI 95%: 50.9-93.1). CONCLUSION LEV could be an effective drug as first-line treatment for IGE in women of childbearing potential. The adverse effects are its main limitation. Comparative studies are needed in order to establish it for this indication.
Collapse
Affiliation(s)
- Alejandro Ballvé
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
| | - Javier Salas‐Puig
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
| | - Manuel Quintana
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Epilepsy Research Group Vall d'Hebron Research Institute (VHIR Barcelona Spain
- Medicine Department Universitat Autònoma de Barcelona Barcelona Spain
| | - Daniel Campos
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
| | - Arnau Llauradó
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
| | - Miquel Raspall
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Department of Paediatric Neurology Vall d'Hebron University Hospital Barcelona Spain
| | - Elena Fonseca
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Epilepsy Research Group Vall d'Hebron Research Institute (VHIR Barcelona Spain
- Medicine Department Universitat Autònoma de Barcelona Barcelona Spain
| | - Laura Abraira
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Epilepsy Research Group Vall d'Hebron Research Institute (VHIR Barcelona Spain
- Medicine Department Universitat Autònoma de Barcelona Barcelona Spain
| | - Estevo Santamarina
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Epilepsy Research Group Vall d'Hebron Research Institute (VHIR Barcelona Spain
- Medicine Department Universitat Autònoma de Barcelona Barcelona Spain
| | - Manuel Toledo
- Epilepsy Unit Neurology Department Vall d'Hebron University Hospital Barcelona Spain
- Epilepsy Research Group Vall d'Hebron Research Institute (VHIR Barcelona Spain
- Medicine Department Universitat Autònoma de Barcelona Barcelona Spain
| |
Collapse
|
7
|
Mostacci B, Ranzato F, Giuliano L, La Neve A, Aguglia U, Bilo L, Durante V, Ermio C, Monti G, Zambrelli E, Lodi MAM, Galimberti CA. Alternatives to valproate in girls and women of childbearing potential with Idiopathic Generalized Epilepsies: state of the art and guidance for the clinician proposed by the Epilepsy and Gender Commission of the Italian League Against Epilepsy (LICE). Seizure 2020; 85:26-38. [PMID: 33418162 DOI: 10.1016/j.seizure.2020.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/12/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Following recent European Medication Agency restrictions on valproate (VPA) use in girls and women of childbearing potential (WOCP), the Commission on Epilepsy and Gender of the Italian League against Epilepsy integrated current literature and legislative data in order to provide clinicians with guidance on antiseizure medication (ASM) prescription for Idiopathic Generalized Epilepsies (IGEs) in this population, avoiding VPA. We reviewed the updated literature on ASMs and examined the teratogenicity of those showing efficacy in IGEs. For all relevant ASMs, we considered the indications for use and the pregnancy and contraception-related recommendations given in the Italian Summary of Product Characteristics (SmPC) and on the websites of the European Medicines Agency (EMA) and other European Union (EU) countries' regulatory agencies. With the exception of absence seizures, the literature lacks high quality studies on ASMs in IGEs. In girls and WOCP, levetiracetam and lamotrigine should be considered the first-choice drugs in Generalized Tonic-Clonic Seizures Alone and in Juvenile Myoclonic Epilepsy, lamotrigine in Juvenile Absence Epilepsy, and ethosuximide in Childhood Absence Epilepsy. Although supported by the literature, several ASMs are off label, contraindicated or burdened by special warnings in pregnancy. Some discrepancies emerged between the various SmPC warnings for different brands of the same active principle. We provided a therapeutic algorithm for each IGE syndrome and highlighted the need for revised prescription rules, consistent with the latest literature data, uniformity of SmPC warnings for the same active principle, and more data on the efficacy of new ASMs in IGEs and their safety in pregnancy.
Collapse
Affiliation(s)
- Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy(2)
| | | | - Loretta Giuliano
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy.
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Umberto Aguglia
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy
| | - Leonilda Bilo
- Epilepsy Center, University of Napoli "Federico II", Napoli, Italy
| | - Vania Durante
- Ospedale "A. Perrino" di Brindisi- UO Neurologia, Brindisi, Italy
| | - Caterina Ermio
- Department of Neuroscience, "S. Giovanni Paolo II" Hospital, Lamezia Terme, Catanzaro, Italy
| | - Giulia Monti
- Neurology Unit, Ospedale Ramazzini di Carpi, AUSL di Modena, Italy
| | - Elena Zambrelli
- Epilepsy Center, ASST SS. Paolo e Carlo, San Paolo Hospital, Milano, Italy
| | - Monica Anna Maria Lodi
- Pediatric Neurology Unit and Epilepsy Center, Department of Neuroscience, Fatebenefratelli e Oftalmico, Hospital, Milano, Italy
| | | |
Collapse
|
8
|
Abstract
Common genetic generalised epilepsy syndromes encountered by clinicians include childhood and juvenile absence epilepsies, juvenile myoclonic epilepsy and generalised tonic-clonic seizures on awakening. Treatment of these syndromes involves largely the use of broad-spectrum antiseizure drugs. Those effective for the generalised epilepsies include sodium valproate, phenobarbital, ethosuximide, clobazam, clonazepam, lamotrigine, levetiracetam, topiramate, zonisamide and, more recently, perampanel and brivaracetam. Results from the few rigorous studies comparing outcomes with drugs for genetic generalised epilepsies show valproate to be the most effective. The majority of patients with genetic generalised epilepsy syndromes will become seizure free on antiseizure monotherapy; those for whom control proves elusive may benefit from combination regimens. Early counselling regarding management may assist the patient to come to terms with their diagnosis and improve long-term outcomes. Treatment can be lifelong in some individuals, although others may remain seizure free without medication. Choice of antiseizure medication depends on the efficacy for specific seizure types, as well as tolerability. For patients prescribed comedication, drug interactions should be considered. In particular, for young women taking oral hormonal contraceptives, ≥ 200 mg/day of topiramate can decrease the circulating concentration of ethinylestradiol and ≥ 12 mg/day of perampanel can induce levonorgestrel metabolism. The use of valproate in women of childbearing potential is limited by associated teratogenic and neurodevelopmental effects in offspring. Given that valproate is often the antiseizure drug of choice for genetic generalised epilepsies, this creates a dilemma for patients and clinicians. Decision making can be aided by comprehensive assessment and discussion of treatment options. Psychiatric comorbidities are common in adolescents and adults with genetic generalised epilepsies. These worsen the prognosis, both in terms of seizure control and quality of life. Attendant lifestyle issues can impact significantly on the individual and society. Frontal lobe dysfunction, which can present in patients with juvenile myoclonic epilepsy, can adversely affect the long-term outlook, regardless of the nature of seizure control. Ongoing management requires consideration of psychosocial and behavioural factors that can complicate diagnosis and treatment. An assured supportive attitude by the neurologist can be an important contributor to a positive outcome. The mechanisms underlying genetic generalised epilepsies, including genetic abnormalities, are unclear at present. As the pathophysiology is unravelled, this may lead to the development of novel therapies and improved outcomes for patients with these syndromes.
Collapse
Affiliation(s)
- Linda J Stephen
- West Glasgow Ambulatory Care Hospital, Dalnair St, Glasgow, G3 8SJ, UK.
| | | |
Collapse
|
9
|
Tabrizi N, Zarvani A, Rezaei P, Cheraghmakani H, Alizadeh-Navaei R. Levetiracetam in genetic generalized epilepsy: A prospective unblinded active-controlled trial. Epilepsy Res 2019; 157:106214. [PMID: 31627041 DOI: 10.1016/j.eplepsyres.2019.106214] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the efficacy and tolerability of levetiracetam (LEV) versus valproate (VPA) monotherapy in adults with genetic generalized tonic-clonic seizures alone (GTCS) and juvenile myoclonic epilepsy (JME). METHODS This study was an open-label, active-controlled trial with a two-parallel-group design. Outcome measures including withdrawal rate and seizure freedom rate at 26th weeks and time to withdrawal, and time to first seizure were compared between LEV and VPA groups. Furthermore, tolerability and development of adverse events (AEs) were investigated and analyzed. RESULTS One hundred and three patients enrolled the study. 71.1% of patients in LEV group and 29.3% in VPA group were female. By the end of 26th week, seizure freedom rate and withdrawal rate were 88.9% and 8.9% in LEV group and 86.2% and 10.3% in VPA group with no significant difference. Time to first seizure was longer in VPA group (p = 0.32) and time to withdrawal favored LEV (p = 0.51). At least one AE was reported in 37.7% of patients in LEV group and 55.1% in VPA group. The most common AEs were psychiatric symptoms and dizziness in those on LEV and weight gain and dyspepsia in VPA group. CONCLUSION LEV has similar efficacy and acceptable safety in comparison to VPA in short-term treatment of patients with genetic GTCS and JME, and it could be considered as an alternative to VPA particularly in women of reproductive age.
Collapse
Affiliation(s)
- Nasim Tabrizi
- Neurology department, Mazandaran University of medical sciences, Sari, Iran.
| | - Ashraf Zarvani
- Neurology department, Mazandaran University of medical sciences, Sari, Iran
| | - Parisa Rezaei
- Neurology department, Mazandaran University of medical sciences, Sari, Iran
| | | | - Reza Alizadeh-Navaei
- Gastrointestinal Cancer Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| |
Collapse
|
10
|
Abstract
Juvenile myoclonic epilepsy (JME) is both a frequent and a very characteristic epileptic syndrome with female preponderance. Treatment of JME in women of childbearing potential must consider multiple factors such as desire for pregnancy, use of contraception, seizure control and previously used antiepileptic drugs (AEDs). Approximately 85% of cases are well controlled with valproate, which remains the reference AED in JME but is nowadays considered unsafe for the expecting mother and her fetus. The prescription of valproate is now severely restricted in women of childbearing potential but may still be considered, at the lowest possible dose and when pregnancies can be reliably planned, with temporary alternatives to valproate prescribed before fertilization. Alternatives have emerged, especially lamotrigine and levetiracetam, but also topiramate, zonisamide, and recently perampanel, but none of these AEDs can be considered fully safe in the context of pregnancy. In special settings, benzodiazepines and barbiturates may be useful. In some cases, combination therapy, especially lamotrigine and levetiracetam, may be useful or even required. However, lamotrigine may have the potential to aggravate JME, with promyoclonic effects. Carbamazepine, oxcarbazepine and phenytoin must be avoided. Valproate, levetiracetam, zonisamide, topiramate if the daily dose is ≤ 200 mg and perampanel if the daily dose is ≤ 10 mg do not affect combined hormonal contraception. Lamotrigine ≥ 300 mg/day has been shown to decrease levonorgestrel levels by 20% but does not compromise combined hormonal contraception. Patients with JME taking oral contraceptive should be counselled on the fact that the estrogenic component can reduce concentrations of lamotrigine by over 50%, putting patients at risk of increased seizures. Pregnancy is a therapeutic challenge, and the risk/benefit ratio for the mother and fetus must be considered when choosing the appropriate drug. Lamotrigine (< 325 mg daily in the European Registry of Antiepileptic Drugs in Pregnancy) and levetiracetam seem to be comparatively safer in pregnancy than other AEDs, especially topiramate and valproate. Plasma concentration of lamotrigine and levetiracetam decreases significantly during pregnancy, and dosage adjustments may be necessary. With persisting generalized tonic-clonic seizures, the combination of lamotrigine and levetiracetam offer the chance of seizure control and lesser risks of major congenital malformations. The risk of malformation increases when valproate or topiramate are included in the drug combination. In one study, the relative risk of autism and autism spectrum disorders (ASD) in children born to women with epilepsy (WWE) treated with valproate were, respectively, 5.2 for autism and 2.9 for ASD versus 2.12 for autism and 1.6 for ASD in WWE not treated with valproate. More studies are needed to assess the risk of autism with AEDs other than valproate. The current knowledge is that the risk appears to be double that in the general population. In patients with JME, valproate remains an essential and life-changing agent. The consequences of a lifetime of poorly controlled epilepsy need to be balanced against the teratogenic risks of valproate during limited times in a woman's life. The management of JME in WWE should include lifestyle interventions, with avoidance of sleep deprivation, and planned pregnancy.
Collapse
|
11
|
Gul A, Mehreen S. Levetiracetam efficacy on frontal lobe dysfunctions and anger rumination in patients with epilepsy. Epilepsy Behav 2018; 85:28-31. [PMID: 29906698 DOI: 10.1016/j.yebeh.2018.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/26/2022]
Abstract
This study compared the frontal lobe functioning and anger rumination between patients with epilepsy and healthy individuals. The second objective was to examine the efficacy of levetiracetam therapy on frontal lobe dysfunctions and anger rumination in patients with epilepsy. Participants (50 patients with epilepsy and 50 healthy individuals) completed the Frontal Assessment Battery (FAB) and Anger Rumination Scale (ARS). The patients had two testing sessions: pre- and post-levetiracetam therapies. The results showed that patients with epilepsy had frontal lobe dysfunctions in contrast with healthy individuals. Patients with epilepsy had higher anger rumination than healthy individuals. Compared with baseline performance, frontal lobe dysfunctions and anger rumination were significantly reduced after three months of levetiracetam therapy in patients with epilepsy. It is concluded that levetiracetam therapy may be beneficial in improving frontal lobe functioning and anger rumination thought pattern in patients with epilepsy. However, further studies are required to confirm this evidence.
Collapse
Affiliation(s)
- Amara Gul
- The Islamia University of Bahawalpur, Pakistan.
| | | |
Collapse
|
12
|
Yozawitz E, Stacey A, Pressler RM. Pharmacotherapy for Seizures in Neonates with Hypoxic Ischemic Encephalopathy. Paediatr Drugs 2017; 19:553-567. [PMID: 28770451 DOI: 10.1007/s40272-017-0250-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Seizures are common in neonates with moderate and severe hypoxic ischemic encephalopathy (HIE) and are associated with worse outcomes, independent of HIE severity. In contrast to adults and older children, no new drugs have been licensed for treatment of neonatal seizures over the last 50 years, because of a lack of controlled clinical trials. Hence, many antiseizure medications licensed in older children and adults are used off-label for neonatal seizure, which is associated with potential risks of adverse effects during a period when the brain is particularly vulnerable. Phenobarbital is worldwide the first-line drug and is considered standard of care, although there is a limited evidence base for its efficacy. Second-line agents include phenytoin, benzodiazepines, levetiracetam, and lidocaine. These drugs are discussed in more detail along with two emerging drugs (bumetanide and topiramate). More safety, pharmacokinetic, and efficacy data are needed from well-designed clinical trials to develop safe and effective antiseizure regimes for the treatment of neonatal seizures in HIE.
Collapse
Affiliation(s)
- Elissa Yozawitz
- Department of Neurology and Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Arthur Stacey
- UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, Great Ormond Street, London, WC1N 3JH, UK. .,Clinical Neurosciences, UCL- Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
| |
Collapse
|
13
|
Faulkner MA. Spotlight on perampanel in the management of seizures: design, development and an update on place in therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2921-2930. [PMID: 29042752 PMCID: PMC5634370 DOI: 10.2147/dddt.s122404] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose Perampanel is a first-in-class antiepileptic medication approved for the treatment of partial (focal) seizures, and as adjunctive treatment for primarily generalized tonic–clonic seizures. The pharmacology, efficacy data, adverse-effect profile, pharmacokinetics and place in therapy are reviewed. Summary Perampanel is indicated for use in patients with epilepsy who are 12 years of age or older. It is the first medication designed specifically to be a non-competitive antagonist at post-synaptic α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptors. Efficacy in refractory seizures has been established, and ongoing efficacy demonstrated by post-marketing data. The drug is completely absorbed, and exhibits a half-life that allows for once-daily administration in doses up to 12 mg/day. Drug interactions are minimal, but increased doses may be necessary when given with strong inducers of cytochrome P450 enzymes, including when perampanel is co-administered with other antiepileptics that exhibit this property. The most common adverse effects noted in both clinical trials and post-marketing are dizziness and somnolence. Psychiatric and behavioral adverse events have been documented in both adult and pediatric patients, including those with no corresponding diagnostic history. Conclusion Perampanel is a novel adjunctive antiepileptic medication that is an effective option for adolescents and adults with partial seizures, and primarily generalized tonic–clonic seizures uncontrolled with other medications.
Collapse
Affiliation(s)
- Michele A Faulkner
- Department of Pharmacy Practice.,Department of Neurology, Creighton University Schools of Pharmacy and Medicine, Omaha, NE, USA
| |
Collapse
|
14
|
A Systematic Appraisal of Neurosurgical Seizure Prophylaxis: Guidance for Critical Care Management. J Neurosurg Anesthesiol 2017; 28:233-49. [PMID: 26192247 DOI: 10.1097/ana.0000000000000206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Clinical decisions are often made in the presence of some uncertainty. Health care should be based on a combination of scientific evidence, clinical experience, economics, patient value judgments, and preferences. Seizures are not uncommon following brain injury, surgical trauma, hemorrhage, altered brain metabolism, hypoxia, or ischemic events. The impact of seizures in the immediate aftermath of injury may be a prolonged intensive care stay or compounding of the primary injury. The aim of brain injury management is to limit the consequences of the secondary damage. The original intention of seizure prophylaxis was to limit the incidence of early-onset seizures. However, clinical trials have been equivocal on this point, and there is concern about the adverse effects of antiepileptic drug therapy. This review of the literature raises concerns regarding the arbitrary division of seizures into early onset (7 d) and late onset (8 d and beyond). In many cases it would appear that seizures present within 24 hours of the injury or after 7 days, which would be outside of the scope of current seizure prophylaxis guidance. There also does not appear to be a pathophysiological reason to divide brain injury-related seizures into these timeframes. Therefore, a solution to the conundrum is to reevaluate current practice. Prophylaxis could be offered to those receiving intensive care for the primary brain injury, where the impact of seizure would be detrimental to the management of the brain injury, or other clinical judgments where prophylaxis is prudent. Neurosurgical seizure management can then focus attention on which agent has the best adverse effect profile and the duration of therapy. The evidence seems to support levetiracetam as the most appropriate agent. Although previous reviews have identified an increase cost associated with the use of levetiracetam, current cost comparisons with phenytoin demonstrate a marginal price differential. The aim of this review is to assimilate the applicable literature regarding seizure prophylaxis. The final guidance is a forum upon which further clinical research could evaluate a new seizure prophylaxis paradigm.
Collapse
|
15
|
Beach SR, Gomez-Bernal F, Huffman JC, Fricchione GL. Alternative treatment strategies for catatonia: A systematic review. Gen Hosp Psychiatry 2017; 48:1-19. [PMID: 28917389 DOI: 10.1016/j.genhosppsych.2017.06.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/19/2017] [Accepted: 06/22/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Catatonia is a commonly encountered syndrome, affecting 10-20% of various psychiatric populations and carrying significant medical co-morbidities. However, there are few established alternative treatment strategies when benzodiazepines are ineffective and electroconvulsive therapy is unavailable. OBJECTIVE The authors systematically review evidence for alternative treatment strategies for catatonia using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. METHOD The authors conducted a search of PubMed database from 1983 to August 2016 to identify articles. Eligible reports presented cases involving treatment of catatonia using modalities other than benzodiazepines or electroconvulsive therapy. RESULTS The authors identified 72 articles, comprising 98 individual cases. N-methyl-d-aspartate-receptor antagonists, anti-epileptic drugs, and atypical antipsychotic agents appeared to have the largest number of reports supporting their effectiveness and safety in treating catatonia patients. CONCLUSIONS Based on the case report literature, the authors propose an updated algorithm for catatonia treatment in cases where benzodiazepines fail and electroconvulsive therapy is not available.
Collapse
Affiliation(s)
- Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | | | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Gregory L Fricchione
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| |
Collapse
|
16
|
Brodie MJ. Tolerability and Safety of Commonly Used Antiepileptic Drugs in Adolescents and Adults: A Clinician's Overview. CNS Drugs 2017; 31:135-147. [PMID: 28101765 DOI: 10.1007/s40263-016-0406-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This paper discusses the issues surrounding the tolerability and safety of the commonly used antiepileptic drugs (AEDs) in adolescents and adults. The content includes dose-related adverse effects, idiosyncratic reactions, behavioural and psychiatric comorbidities, chronic problems, enzyme induction and teratogenesis. Twenty-one AEDs are discussed in chronological order of their introduction into the UK, starting with phenobarbital and ending with brivaracetam. Wherever possible, advice is given on anticipating, recognising and managing these issues and thereby improving the lives of people with epilepsy, most of whom will need to take one or more of these agents for life. Avoidance of side effects will increase the possibility of achieving and maintaining long-term seizure freedom. Alternatively, adverse events from AEDs will substantially reduce quality of life and often result in higher healthcare costs.
Collapse
Affiliation(s)
- Martin J Brodie
- Epilepsy Unit, West Glasgow ACH-Yorkhill, Dalnair Street, Glasgow, G3 8SJ, Scotland, UK.
| |
Collapse
|
17
|
|
18
|
Trinka E, Steinhoff BJ, Nikanorova M, Brodie MJ. Perampanel for focal epilepsy: insights from early clinical experience. Acta Neurol Scand 2016; 133:160-72. [PMID: 26506904 PMCID: PMC4738453 DOI: 10.1111/ane.12529] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 12/25/2022]
Abstract
Perampanel is approved for adjunctive therapy of focal epilepsy with or without secondarily generalized seizures in patients aged >12 years. This narrative review uses real-world and clinical trial data to elucidate perampanel's role in the clinic. Audit data show good tolerability with perampanel and higher freedom-from-seizure rates in elderly vs younger patients. When using perampanel in elderly patients, special attention should be given to comorbidities and co-medication to avoid potential interactions or adverse events. Slower titration is generally recommended, and seizure control should be reassessed at a dose of 4 mg before further dose increases. Perampanel efficacy is similar in adolescents and adults; however, somnolence, nasopharyngitis, and aggression are more frequent in adolescents vs the overall population. Individualized and slow-dose titration can minimize adverse events. Low serum concentrations of perampanel may occur in patients also receiving some enzyme-inducing anti-epileptic drugs; a perampanel dose increase may be required. Adverse events of importance with perampanel include dizziness; anger, aggression, and hostile behavior (particularly in adolescents); and falls (particularly in patients >65 years). An individualized approach to dosing, including slower up-titration and bedtime dosing, reduces dizziness risk. Other drugs may cause or aggravate dizziness; reducing concomitant drugs may be necessary when up-titrating perampanel. It would seem clinically appropriate to give due consideration to avoiding use in patients with a history of anger or hostile/aggressive behavior. The possibility of such behaviors should be discussed with patients before starting perampanel, with monitoring during up-titration. Slower up-titration of perampanel in older patients helps reduce fall risk.
Collapse
Affiliation(s)
- E. Trinka
- Department of Neurology Christian Doppler Medical at the Paracelsus Medical University Salzburg Centre for Cognitive Neuroscience Salzburg Austria
| | | | - M. Nikanorova
- Children's Department Danish Epilepsy Centre Dianalund Denmark
| | | |
Collapse
|
19
|
Zhidkova IA, Karlov VA, Vlasov PN. Perampanel in pharmacotherapy of focal epilepsy: the efficacy and tolerability in routine clinical practice. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:82-88. [DOI: 10.17116/jnevro20161169282-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
20
|
Rektor I, Schachter SC, Arya R, Arzy S, Braakman H, Brodie MJ, Brugger P, Chang BS, Guekht A, Hermann B, Hesdorffer DC, Jones-Gotman M, Kanner AM, Garcia-Larrea L, Mareš P, Mula M, Neufeld M, Risse GL, Ryvlin P, Seeck M, Tomson T, Korczyn AD. Third International Congress on Epilepsy, Brain, and Mind: Part 2. Epilepsy Behav 2015; 50:138-59. [PMID: 26264466 DOI: 10.1016/j.yebeh.2015.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 07/07/2015] [Indexed: 01/01/2023]
Abstract
Epilepsy is both a disease of the brain and the mind. Here, we present the second of two papers with extended summaries of selected presentations of the Third International Congress on Epilepsy, Brain and Mind (April 3-5, 2014; Brno, Czech Republic). Humanistic, biologic, and therapeutic aspects of epilepsy, particularly those related to the mind, were discussed. The extended summaries provide current overviews of epilepsy, cognitive impairment, and treatment, including brain functional connectivity and functional organization; juvenile myoclonic epilepsy; cognitive problems in newly diagnosed epilepsy; SUDEP including studies on prevention and involvement of the serotoninergic system; aggression and antiepileptic drugs; body, mind, and brain, including pain, orientation, the "self-location", Gourmand syndrome, and obesity; euphoria, obsessions, and compulsions; and circumstantiality and psychiatric comorbidities.
Collapse
Affiliation(s)
- Ivan Rektor
- Masaryk University, Brno Epilepsy Center, St. Anne's Hospital and School of Medicine and Central European Institute of Technology (CEITEC), Brno, Czech Republic
| | - Steven C Schachter
- Consortia for Improving Medicine with Innovation and Technology, Harvard Medical School, Boston, MA, USA.
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shahar Arzy
- Department of Neurology, Hadassah Hebrew University Medical Center, Jerusalem, Israel; The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hilde Braakman
- Academic Center for Epileptology, Kempenhaeghe & Maastricht UMC, Sterkselseweg 65, 5591 VE Heeze, The Netherlands
| | | | - Peter Brugger
- Neuropsychology Unit, Department of Neurology, University Hospital Zürich, Zurich, Switzerland
| | - Bernard S Chang
- Departments of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Alla Guekht
- Russian National Research Medical University, Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - Bruce Hermann
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Dale C Hesdorffer
- Gertrude H. Sergievsky Center and Department of Epidemiology, Columbia University, NY, USA
| | - Marilyn Jones-Gotman
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Canada
| | - Andres M Kanner
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Luis Garcia-Larrea
- NeuroPain Lab, Centre for Neuroscience of Lyon, Inserm U1028, Hôpital Neurologique, 59Bd Pinel 69003 Lyon, France
| | - Pavel Mareš
- Institute of Physiology, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Marco Mula
- Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St George's Hospital & Institute of Medical and Biomedical Sciences, St George's University of London, London, UK
| | - Miri Neufeld
- EEG and Epilepsy Unit, Department of Neurology, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Philippe Ryvlin
- Department of Clinical Neurosciences, CHUV, Lausanne, Switzerland; TIGER, Lyon's Neuroscience Research Center, INSERM U1028, CNRS5292 Lyon, France
| | - Margitta Seeck
- Neurology Service, Hòpitaux Universitaires de Genève, Genève, Switzerland
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Amos D Korczyn
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| |
Collapse
|
21
|
Giráldez BG, Toledano R, García-Morales I, Gil-Nagel A, López-González FJ, Tortosa D, Ojeda J, Serratosa JM. Long-term efficacy and safety of lacosamide monotherapy in the treatment of partial-onset seizures: A multicenter evaluation. Seizure 2015; 29:119-22. [DOI: 10.1016/j.seizure.2015.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 04/01/2015] [Accepted: 04/03/2015] [Indexed: 01/27/2023] Open
|
22
|
Packer RMA, Nye G, Porter SE, Volk HA. Assessment into the usage of levetiracetam in a canine epilepsy clinic. BMC Vet Res 2015; 11:25. [PMID: 25889090 PMCID: PMC4328478 DOI: 10.1186/s12917-015-0340-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 01/22/2015] [Indexed: 11/23/2022] Open
Abstract
Background Retrospective studies can complement information derived from double-blinded randomized trials. There are multiple retrospective studies reporting good efficacy and tolerability of the anti-epileptic drug levetiracetam (LEV) in human patients with epilepsy; however, reports of LEV's tolerability and efficacy in dogs with epilepsy remain limited. The purpose of this retrospective study was to describe the use of LEV in a canine epilepsy clinic and determine the long-term efficacy and tolerability of LEV in veterinary clinical practice. The electronic database of a UK based referral hospital was searched for LEV usage in dogs with seizures. Information and data necessary for the evaluation were obtained from a combination of electronic and written hospital records, the referring veterinary surgeons’ records and telephone interviews with dog owners. Only dogs that were reportedly diagnosed with idiopathic epilepsy were included in the study. Results Fifty-two dogs were included in this retrospective study. Two treatment protocols were recognised; 29 dogs were treated continuously with LEV and 23 dogs received interval or pulse treatment for cluster seizures. LEV treatment resulted in 69% of dogs having a 50% or greater reduction of seizure frequency whilst 15% of all the dogs were completely free from seizures. Seizure frequency reduced significantly in the whole population. No dog was reported to experience life-threatening side effects. Mild side effects were experienced by 46% of dogs and a significantly higher number of these dogs were in the pulse treatment group. The most common side-effects reported were sedation and ataxia. Conclusions LEV appears to be effective and well tolerated for reduction of seizures.
Collapse
Affiliation(s)
- Rowena M A Packer
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, AL97TA, UK.
| | - George Nye
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, AL97TA, UK.
| | - Sian Elizabeth Porter
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, AL97TA, UK.
| | - Holger A Volk
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, AL97TA, UK.
| |
Collapse
|
23
|
Peyrl A, Weichert N, Kühl JS, Ebell W, Hernáiz Driever P. Levetiracetam as a possible cause of secondary graft failure after allogenic hematopoietic stem cell transplantation. Eur J Paediatr Neurol 2015; 19:75-7. [PMID: 25468262 DOI: 10.1016/j.ejpn.2014.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 09/22/2014] [Accepted: 10/11/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Levetiracetam is increasingly used as antiepileptic drug (AED) of choice in children as well as in adults with complex diseases due to its lack of interactions and a large spectrum of action. Secondary graft failure, i.e. loss of donor cells after initial engraftment, is a relatively uncommon but serious and life-theatening complication after pediatric hematopoietic stem cell transplantation. METHODS AND RESULTS We report a case of secondary graft failure after hematopoietic stem cell transplantation for treatment-related myelodysplastic syndrome during antiepileptic treatment with levetiracetam. Exclusion of all other possible etiologies left levetiracetam as the most likely cause of the imminent complete secondary graft failure after hematopoietic stem cell transplantation. Furthermore, the blood cell count improved just a few days after cessation of levetiracetam medication. CONCLUSION Thus, we recommend that in case of secondary graft failure after hematopoietic stem cell transplantation, all possible causes should carefully be excluded, including adverse events through new generation AED agents. Switching to different AEDs with less harming effect on bone marrow function should strongly be considered.
Collapse
Affiliation(s)
- Andreas Peyrl
- Department of Pediatric Oncology/Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Nina Weichert
- Department of Pediatric Oncology/Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jörn-Sven Kühl
- Department of Pediatric Oncology/Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfram Ebell
- Department of Pediatric Oncology/Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Pablo Hernáiz Driever
- Department of Pediatric Oncology/Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
24
|
Shcherbakova N, Rascati K, Brown C, Lawson K, Novak S, Richards KM, Yoder L. Factors associated with seizure recurrence in epilepsy patients treated with antiepileptic monotherapy: A retrospective observational cohort study using US administrative insurance claims. CNS Drugs 2014; 28:1047-58. [PMID: 25086640 DOI: 10.1007/s40263-014-0191-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few studies examine predictors of seizures in medically treated patients with epilepsy receiving antiepileptic monotherapy using a large patient population. OBJECTIVE Our objective was to identify clinical, medication, and demographic factors associated with seizure recurrence in medically treated patients with epilepsy receiving one of four antiepileptic monotherapy regimens: lamotrigine, levetiracetam, oxcarbazepine, or topiramate. STUDY DESIGN A retrospective cohort study was conducted using Innovus Invision™ Data Mart paid medical and prescription US commercial insurance claims data from January 2007 to September 2010. METHODS Patients aged 18-64 years with a primary or secondary diagnosis of epilepsy and one or more prescription claim for an antiepileptic drug (AED) pre-index were included. The primary outcome was incidence of a seizure or seizure-related event, defined as an emergency room visit, ambulance service use, or inpatient hospitalization medical claim with a primary or secondary diagnosis of epilepsy during the 1-year follow-up. The factors included AED adherence, somatic comorbidity (measured via Charlson Comorbidity Index), mental health comorbidity, pre-index seizure, type of epilepsy diagnosis, presence of AED-interacting medications and any bioequivalent AED switch. The covariates included age, gender, and geographic region of residence. RESULTS A total of 5.3 % (166/3,140) of patients on AED monotherapy had experienced a seizure or a seizure-related event requiring urgent care at 1-year follow-up. The multivariate analysis of the combined cohort showed that pre-index seizures/seizure-related events (odds ratio [OR] 4.23; 95 % confidence interval [CI] 2.77-6.46), any mental health comorbidity (OR 3.50; 95 % CI 2.14-5.70), and Charlson Comorbidity Index ≥1 (OR 2.91; 95 % CI 1.98-4.28) were significantly associated with post-index seizures/seizure-related events. Patients residing in Northeastern USA had a higher likelihood of a post-index seizure (OR 1.90; 95 % CI 1.17-3.08) than patients residing in the Southern region of the USA. Bioequivalent AED switch, type of epilepsy diagnosis, AED adherence, and presence of AED-interacting medications were not associated with seizure recurrence in the combined cohort analysis (p > 0.05). CONCLUSIONS Epilepsy patients with comorbid conditions (both mental and somatic diseases) and prior seizures were more likely to experience seizures at 1-year follow-up. Non-adherent patients and patients with bioequivalent AED switches appeared to show no increased likelihood of seizure at follow-up. Clinicians may consider these findings before starting or transitioning to an AED monotherapy.
Collapse
Affiliation(s)
- Natalia Shcherbakova
- Department of Pharmaceutical and Administrative Sciences, College of Pharmacy, Western New England University, 1215 Wilbraham Road, Springfield, MA, 01119, USA,
| | | | | | | | | | | | | |
Collapse
|
25
|
Stepanova D, Beran RG. Measurement of levetiracetam drug levels to assist with seizure control and monitoring of drug interactions with other anti-epileptic medications (AEMs). Seizure 2014; 23:371-6. [PMID: 24630809 DOI: 10.1016/j.seizure.2014.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/31/2014] [Accepted: 02/10/2014] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Levetiracetam (LEV) therapeutic range (20-40mg/L) and potential drug interactions were assessed in people with epilepsy (PWE). METHOD Fifty-two PWE had LEV and concomitant medications [carbamazepine (CBZ); valproate (VPA); lamotrigine (LTG)] blood levels measured and compared to seizure activity. Lacosamide (LCM) levels were unavailable. Adopted therapeutic ranges were: 20-40mg/L - LEV; 25-50μmol/L - total CBZ; 6-13μmol/L - free CBZ; 300-750μmol/L - total VPA; 30-75μmol/L - free VPA; and 40-60μmol/L - LTG. Seizure-freedom was assessed and patients followed for almost two years. RESULTS 23 of 52 PWE (44%) used LEV monotherapy and 16/23 (70%) had 'therapeutic' LEV with 13/16 (81%) seizure-free. 29 of 52 (56%) used polytherapy and 16/29 (55%) had 'therapeutic' LEV with 7/16 (44%) seizure-free. 11 of 29 (38%) used CBZ: 4/11 (36%) had therapeutic mean LEV levels and 7/11 (64%) were seizure-free. Fourteen (48%) used VPA: 9/14 (64%) had therapeutic mean LEV levels and 8/14 (57%) were seizure-free. 13 of 29 (45%) used LTG: 8/13 (62%) had therapeutic mean LEV levels and 5/13 (38%) were seizure-free. LEV did not alter CBZ, but CBZ affected LEV. LEV elevated VPA free levels but not VPA total levels. Dosage/concentration was lowered with polytherapy. CONCLUSION LEV range (20-40mg/L) assisted epilepsy management and anti-epileptic medication interactions were suggested with polytherapy thus possibly explaining the impaired efficacy of LEV with polytherapy.
Collapse
Affiliation(s)
- Daria Stepanova
- Strategic Health Evaluators, Sydney, New South Wales, Australia
| | - Roy G Beran
- Strategic Health Evaluators, Sydney, New South Wales, Australia; Griffith University, Gold Coast and Brisbane, Queensland, Australia; University of New South Wales, Sydney, New South Wales, Australia.
| |
Collapse
|
26
|
Abstract
OPINION STATEMENT Elderly people are one of the fastest-growing populations in the United States, and the incidence of epilepsy in older people is much higher than in other population subgroups. This age group is the most vulnerable because of the increased incidence of multiple medical comorbidities, including stroke. The diagnosis of epilepsy is extremely challenging and often delayed in this age group because of an atypical presentation. Seizures are manifest through extremely vague complaints, such as episodes of altered mental status or memory lapses. Once the diagnosis is established by careful history taking and diagnostic testing, anticonvulsants are the mainstay of treatment. The choice of anticonvulsants in elderly patients requires careful evaluation of medical comorbidities, which vary on an individual basis. This subgroup also is more susceptible to adverse effects because of the physiologic changes in the body due to older age, which affect the pharmacokinetics of most anticonvulsants. The ideal drug in this age group should have linear pharmacokinetics, fewer adverse effects, minimal or no drug-drug interactions, no enzyme induction/inhibition, a long half-life, and minimal protein binding, and should be cost-effective. As such, there is no ideal drug for this patient population, although both older- and newer-generation anticonvulsants are used for long-term treatment. Most newer anticonvulsants have the advantage of a favorable pharmacokinetic profile, minimal or no drug-drug interactions, and fewer adverse events, as well as being well tolerated. The older anticonvulsants still are widely used, because the newer anticonvulsants are much more expensive.
Collapse
|
27
|
Kaufman KR, Bisen V, Zimmerman A, Tobia A, Mani R, Wong S. Apparent dose-dependent levetiracetam-induced de novo major depression with suicidal behavior. EPILEPSY & BEHAVIOR CASE REPORTS 2013; 1:110-2. [PMID: 25667841 PMCID: PMC4150644 DOI: 10.1016/j.ebcr.2013.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 07/12/2013] [Accepted: 07/12/2013] [Indexed: 10/26/2022]
Abstract
Levetiracetam (LEV) is a novel antiepileptic drug (AED) approved for the adjunctive treatment of generalized and partial seizures. LEV has no clinically significant drug interactions and has limited adverse effects. The psychiatric adverse effects of LEV include de novo psychosis, affective disorder, and aggression. LEV-induced suicidal behavior has been reported infrequently with a past history of affective disorders. The authors report an apparent dose/concentration-dependent LEV-induced de novo major depression with near fatal suicide attempt in a patient without prior history of affective disorder. Psychiatric evaluation with emphasis on historic/current affective disorders, impulsive-aggressive behaviors, and assessment of risk factors for suicidal behaviors is indicated in treating patients with epilepsy with LEV. Clinicians should consider therapeutic drug monitoring to optimize therapeutic LEV treatment.
Collapse
Affiliation(s)
- Kenneth R Kaufman
- Department of Psychiatry, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA ; Department of Neurology, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA ; Department of Anesthesiology, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA
| | - Viwek Bisen
- Department of Psychiatry, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA
| | - Aphrodite Zimmerman
- Department of Psychiatry, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA ; Department of Neurology, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA
| | - Anthony Tobia
- Department of Psychiatry, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA ; Department of Internal Medicine, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA
| | - Ram Mani
- Department of Neurology, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA
| | - Stephen Wong
- Department of Neurology, Rutgers - Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA
| |
Collapse
|
28
|
Pohlmann-Eden B, Legg KT. Treatment of first seizure in adults: A comprehensive approach integrating 10 key principles. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.epilep.2013.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
29
|
Quintas R, Raggi A, Giovannetti AM, Pagani M, Sabariego C, Cieza A, Leonardi M. Psychosocial difficulties in people with epilepsy: a systematic review of literature from 2005 until 2010. Epilepsy Behav 2012; 25:60-7. [PMID: 22749606 DOI: 10.1016/j.yebeh.2012.05.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 05/22/2012] [Accepted: 05/23/2012] [Indexed: 11/16/2022]
Abstract
The aims of this paper are to identify factors that influence the psychosocial difficulties (PSDs) that persons with epilepsy experience in their everyday life, to describe their onset and the way they evolve over time, and to analyze the determinants of changes over time and other related variables. Electronic databases were searched for studies published in English between January 2005 and May 2010, and information from thirteen studies was extracted. The most frequent PSDs found in people with epilepsy were depressive symptoms, memory functions, quality of life, anxiety, stigma, locus of control, cognitive functions in general, and emotional functions in general. It can be stated that patients' life areas are affected by cognitive, emotional, and psychological problems. However, the majority of studies focus on isolated PSDs or on the effects of a specific determinant in the course of epilepsy, leaving some gaps that could encourage further research.
Collapse
Affiliation(s)
- Rui Quintas
- Neurology, Public Health and Disability Unit, Scientific Directorate, Neurological Institute Carlo Besta IRCCS Foundation, Milan, Italy.
| | | | | | | | | | | | | |
Collapse
|
30
|
Elberry AA, Felemban RK, Hareeri RH, Kurdi SM. Efficacy and safety of levetiracetam in pediatric epilepsy. Saudi Pharm J 2011; 20:81-4. [PMID: 23960780 DOI: 10.1016/j.jsps.2011.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 06/07/2011] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and tolerability of Levetiracetam (LEV) as an adjunctive therapy in pediatric patients with different generalized epilepsies. DESIGN Chart review of 22 consecutive children age 4-19 years who were treated with LEV for at least 1 year was observed retrospectively. The mean dose rang of LEV was from 250 to 2000 mg. Data were collected on epilepsy type, seizure frequency, concomitant antiepileptic drug and adverse effect. RESULTS Of the 22 patient reviewed, 13 (59%) were boys and 9 (41%) were girls. Predominant seizure types were generalized tonic-clonic seizures 13 (59%) and tonic seizure 6 (27%). Other seizure types included myoclonic seizures 2 (9%) and focal seizure 3 (5%). The results showed 10 (45%) had become free of seizure for almost 7 months to 1 year. Eight of these 10 patients (80%) had normalized EEG. Seizure frequency was reduced in 9 (41%) patients and 3 (14%) patients still had seizure. No side effects were reported related to LEV treated patients except for 1 patient. CONCLUSION Our results confirm that LEV may be an effective adjunctive therapy in treatment of childhood epilepsy, especially tonic-clonic seizure, with possible no evident side effect.
Collapse
Affiliation(s)
- Ahmed A Elberry
- Department of Clinical Pharmacy, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia ; Department of Pharmacology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | | | | | | |
Collapse
|