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Wang F, Wang Y, Zhang QY, Hu KY, Song YJ, Yang L, Fei F, Xu CL, Cui SL, Ruan YP, Wang Y, Chen Z. Small-molecule caspase-1 inhibitor CZL80 terminates refractory status epilepticus via inhibition of glutamatergic transmission. Acta Pharmacol Sin 2024; 45:1381-1392. [PMID: 38514863 PMCID: PMC11192899 DOI: 10.1038/s41401-024-01257-0] [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: 11/15/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
Status epilepticus (SE), a serious and often life-threatening medical emergency, is characterized by abnormally prolonged seizures. It is not effectively managed by present first-line anti-seizure medications and could readily develop into drug resistance without timely treatment. In this study, we highlight the therapeutic potential of CZL80, a small molecule that inhibits caspase-1, in SE termination and its related mechanisms. We found that delayed treatment of diazepam (0.5 h) easily induces resistance in kainic acid (KA)-induced SE. CZL80 dose-dependently terminated diazepam-resistant SE, extending the therapeutic time window to 3 h following SE, and also protected against neuronal damage. Interestingly, the effect of CZL80 on SE termination was model-dependent, as evidenced by ineffectiveness in the pilocarpine-induced SE. Further, we found that CZL80 did not terminate KA-induced SE in Caspase-1-/- mice but partially terminated SE in IL1R1-/- mice, suggesting the SE termination effect of CZL80 was dependent on the caspase-1, but not entirely through the downstream IL-1β pathway. Furthermore, in vivo calcium fiber photometry revealed that CZL80 completely reversed the neuroinflammation-augmented glutamatergic transmission in SE. Together, our results demonstrate that caspase-1 inhibitor CZL80 terminates diazepam-resistant SE by blocking glutamatergic transmission. This may be of great therapeutic significance for the clinical treatment of refractory SE.
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Affiliation(s)
- Fei Wang
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Yu Wang
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Qing-Yang Zhang
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Ke-Yu Hu
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Ying-Jie Song
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Lin Yang
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Fan Fei
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Ceng-Lin Xu
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Sun-Liang Cui
- Key Laboratory of Medical Neurobiology of The Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, 310058, China
| | - Ye-Ping Ruan
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Yi Wang
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China.
- Key Laboratory of Medical Neurobiology of The Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, 310058, China.
| | - Zhong Chen
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Department of Neurology, The First Affiliated Hospital, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China.
- Key Laboratory of Medical Neurobiology of The Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, 310058, China.
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Becker LL, Gratopp A, Prager C, Elger CE, Kaindl AM. Treatment of pediatric convulsive status epilepticus. Front Neurol 2023; 14:1175370. [PMID: 37456627 PMCID: PMC10343462 DOI: 10.3389/fneur.2023.1175370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Status epilepticus is one of the most common life-threatening neurological emergencies in childhood with the highest incidence in the first 5 years of life and high mortality and morbidity rates. Although it is known that a delayed treatment and a prolonged seizure can cause permanent brain damage, there is evidence that current treatments may be delayed and the medication doses administered are insufficient. Here, we summarize current knowledge on treatment of convulsive status epilepticus in childhood and propose a treatment algorithm. We performed a structured literature search via PubMed and ClinicalTrails.org and identified 35 prospective and retrospective studies on children <18 years comparing two and more treatment options for status epilepticus. The studies were divided into the commonly used treatment phases. As a first-line treatment, benzodiazepines buccal/rectal/intramuscular/intravenous are recommended. For status epilepticus treated with benzodiazepine refractory, no superiority of fosphenytoin, levetirazetam, or phenobarbital was identified. There is limited data on third-line treatments for refractory status epilepticus lasting >30 min. Our proposed treatment algorithm, especially for children with SE, is for in and out-of-hospital onset aids to promote the establishment and distribution of guidelines to address the treatment delay aggressively and to reduce putative permanent neuronal damage. Further studies are needed to evaluate if these algorithms decrease long-term damage and how to treat refractory status epilepticus lasting >30 min.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Gratopp
- Department of Pediatric Pneumonology, Immunology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Prager
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian E. Elger
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Beta Clinic, Bonn, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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3
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Byun JI. Management of convulsive status epilepticus: recent updates. ENCEPHALITIS 2023; 3:39-43. [PMID: 37469676 PMCID: PMC10295829 DOI: 10.47936/encephalitis.2022.00087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/31/2022] [Accepted: 11/15/2022] [Indexed: 07/21/2023] Open
Abstract
Convulsive status epilepticus (SE) is a medical emergency associated with high morbidity and mortality. Recently, clinical trials and meta-analyses investigating medical treatment of SE have been published. Benzodiazepine is well known as the first-line treatment for SE. Recent evidence suggests the equivalence of intravenous fosphenytoin, valproate, and levetiracetam for treatment of established SE. There is lack of evidence regarding treatment for refractory SE. Intravenous midazolam is commonly used, and recent evidence supports the use of ketamine. Additional studies are needed to improve the management of convulsive SE.
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Affiliation(s)
- Jung-Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
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4
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Llauradó A, Campos D, Quintana M, Ballvé A, Fonseca E, Abraira L, Giffreu A, Toledo M, Santamarina E. Reponse of second-line treatment in focal status epilepticus: A tertiary hospital experience. Epilepsy Res 2022; 185:106988. [PMID: 35907324 DOI: 10.1016/j.eplepsyres.2022.106988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/02/2022] [Accepted: 07/16/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the response to various antiseizure medications (ASMs) in the treatment of focal status epilepticus (SE) in the established phase, and the effect of administering several ASMs prior to sedation. METHODS All SE cases in patients aged > 16 years treated with non-BZDs ASMs were prospectively collected in our centre from February 2011 to April 2019. In total, 281 episodes were analysed. RESULTS Median age at SE onset was 65.1 years; 47 % were focal motor and 53 % focal non-motor episodes. SE cessation was achieved in 79 % episodes with second-line drugs, whereas a third line (anesthetics) was required in 47 episodes. SE cessation was achieved in only 27 % with the first ASM, 48 % with the second, and 51 % with the third. Prompt resolution of the SE episode with a first or second ASM was associated with a better outcome than episodes requiring a larger number of drugs (p = 0.024). The first option in our sample was levetiracetam in 70 % of cases. Among the total of non-responding SE cases treated with levetiracetam as the first ASM option, 107 were subsequently given lacosamide (seizure cessation in 53.3 %) and 34 valproic acid (seizure cessation in 29.4 %) (p = 0.015). CONCLUSION Our findings further support the notion that early termination of SE with a first or second ASM confers a better functional outcome. The large difference in response between the first ASM and consecutive ones suggests that the sum of different ASMs might be the key to resolving focal SE.
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Affiliation(s)
| | - Daniel Campos
- Epilepsy Unit. Hospital Vall Hebron, Barcelona, Spain
| | | | | | - Elena Fonseca
- Epilepsy Unit. Hospital Vall Hebron, Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit. Hospital Vall Hebron, Barcelona, Spain
| | | | - Manuel Toledo
- Epilepsy Unit. Hospital Vall Hebron, Barcelona, Spain
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5
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Zha J, Li M, Kong R, Lu S, Zhang J. Explaining and Predicting Allostery with Allosteric Database and Modern Analytical Techniques. J Mol Biol 2022; 434:167481. [DOI: 10.1016/j.jmb.2022.167481] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 12/17/2022]
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Klowak JA, Hewitt M, Catenacci V, Duffett M, Rochwerg B, Jones K, Choong K. Levetiracetam Versus Phenytoin or Fosphenytoin for Second-Line Treatment of Pediatric Status Epilepticus: A Meta-Analysis. Pediatr Crit Care Med 2021; 22:e480-e491. [PMID: 33710073 DOI: 10.1097/pcc.0000000000002703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To synthesize the available evidence examining the efficacy and safety of levetiracetam compared with phenytoin or fosphenytoin in benzodiazepine-refractory pediatric status epilepticus. DATA SOURCES We searched (from inception until April 27, 2020) Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials. STUDY SELECTION Two reviewers, independently and in duplicate, screened citations and manuscripts for eligible randomized controlled trials. DATA EXTRACTION AND SYNTHESIS Independently and in duplicate, we performed data abstraction, risk of bias assessment, and certainty assessment using Grading of Recommendations, Assessment, Development, and Evaluation. We performed meta-analyses using random-effect models or, if insufficient data, presented findings narratively. RESULTS We identified seven randomized controlled trials (n = 1,575). Pooled analysis demonstrated low certainty evidence for no difference of levetiracetam on time to seizure cessation (mean difference, -3.11 min; 95% CI, -6.67 to 0.45), early seizure cessation (relative risk, 1.09, 95% CI, 0.95-1.26), or late seizure cessation (relative risk, 1.05; 95% CI, 0.93-1.18). Adverse event outcomes were limited by low event numbers. We found low certainty evidence for less respiratory depression with levetiracetam (relative risk, 0.28; 95% CI, 0.12-0.69). CONCLUSIONS The efficacy of levetiracetam is comparable with phenytoin or fosphenytoin in children with benzodiazepine-refractory status epilepticus (low certainty evidence). Levetiracetam may cause less respiratory depression. Clinicians and guideline developers should weigh safety profiles when choosing between these agents.
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Affiliation(s)
- Jennifer Ann Klowak
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- McMaster Children's Hospital, Hamilton, ON, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Pediatric Neurology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Mark Hewitt
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Vanessa Catenacci
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- McMaster Children's Hospital, Hamilton, ON, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Pediatric Neurology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kevin Jones
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Division of Pediatric Neurology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Karen Choong
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Division of Pediatric Critical Care, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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7
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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8
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Huertas González N, Barros González A, Hernando Requejo V, Díaz Díaz J. Focal status epilepticus: a review of pharmacological treatment. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:757-766. [DOI: 10.1016/j.nrleng.2019.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 02/27/2019] [Indexed: 11/16/2022] Open
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9
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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Charalambous M, Volk HA, Van Ham L, Bhatti SFM. First-line management of canine status epilepticus at home and in hospital-opportunities and limitations of the various administration routes of benzodiazepines. BMC Vet Res 2021; 17:103. [PMID: 33663513 PMCID: PMC7934266 DOI: 10.1186/s12917-021-02805-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/16/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Marios Charalambous
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium.
| | - Holger A Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, 30559, Hannover, Germany
| | - Luc Van Ham
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
| | - Sofie F M Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
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11
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Llauradó A, Quintana M, Ballvé A, Campos D, Fonseca E, Abraira L, Toledo M, Santamarina E. Factors associated with resistance to benzodiazepines in status epilepticus. J Neurol Sci 2021; 423:117368. [PMID: 33652289 DOI: 10.1016/j.jns.2021.117368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate factors related to benzodiazepine (BZD) resistance in status epilepticus (SE) with a focus on their relationship with the etiology of the episode. METHODS All SE cases in patients aged >16 years treated with BZDs were prospectively collected in our center from February 2011 to April 2019. The registry included demographics, SE type and etiology, the timing and duration of BZD administration, and the outcome. In total, 371 episodes were analyzed. RESULTS Median age at SE onset was 61.3 years; the most frequent etiology was acute symptomatic (55.8%). SE with prominent motor symptoms occurred in 63.3%. Median time to BZD administration was 2 h. We studied the correlation between two-time variables: time from SE onset to BZD administration and time from BZD administration to resolution of SE (response); we observed that timely administration correlated with a faster response in patients with prominent motor symptoms (p = 0.017), SE due to a chronic structural cerebral lesion (p = 0.004), and patients with a history of seizures (p = 0.013). In these subgroups (prominent motor symptoms or chronic structural lesion) BZD administration within the first 4.5 h was highly associated with shorter post-BZD SE duration (p < 0.001). SIGNIFICANCE The relationship between prompt BZD administration and subsequent duration of SE was found to depend to some extent on the etiology of the episode: patients with chronic structural lesions and those with previous epilepsy responded faster to BZDs. Semiology may have also its impact, as the presence of prominent motor symptoms showed also a faster response.
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Affiliation(s)
- Arnau Llauradó
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Alejandro Ballvé
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Daniel Campos
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Elena Fonseca
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain.
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12
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Byun JI, Kim DW, Kim KT, Yang KI, Lee ST, Seo JG, No YJ, Kang KW, Kim D, Cho YW, Kim JM. Treatments for Convulsive and Nonconvulsive Status Epilepticus in Adults: An Expert Opinion Survey in South Korea. J Clin Neurol 2021; 17:20-25. [PMID: 33480194 PMCID: PMC7840316 DOI: 10.3988/jcn.2021.17.1.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE The aim of this study was to survey the expert opinions on treatments for convulsive status epilepticus (CSE) and nonconvulsive status epilepticus (NCSE) in adults. METHODS Forty-two South Korean epileptologists participated in this survey. They completed an online questionnaire regarding various patient scenarios and evaluated the appropriateness of medications used to treat CSE and NCSE. RESULTS Initial treatment with a benzodiazepine (BZD) followed by either a second BZD or an antiepileptic drug (AED) monotherapy was the preferred treatment strategy. More than two-thirds of the experts used a second BZD when the first one failed, and consensus was reached for 84.8% of the survey items. The preferred BZD was intravenous (IV) lorazepam for the initial treatment of status epilepticus. IV fosphenytoin and IV levetiracetam were chosen for AED monotherapy after the failure of BZD. The treatments for NCSE were similar to those for CSE. Continuous IV midazolam infusion was the treatment of choice for iatrogenic coma in refractory CSE, but other AEDs were preferred over iatrogenic coma in refractory NCSE. CONCLUSIONS The results of this survey are consistent with previous guidelines, and can be cautiously applied in clinical practice when treating patients with CSE or NCSE.
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Affiliation(s)
- Jung Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University, School of Medicine, Seoul, Korea
| | - Dong Wook Kim
- Department of Neuroloy, Konkuk University School of Medicine, Seoul, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Yong Won Cho
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.
| | - Jae Moon Kim
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea.
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Kobata H, Hifumi T, Hoshiyama E, Yamakawa K, Nakamura K, Soh M, Kondo Y, Yokobori S. Comparison of diazepam and lorazepam for the emergency treatment of adult status epilepticus: a systemic review and meta-analysis. Acute Med Surg 2020; 7:e582. [PMID: 33489240 PMCID: PMC7809602 DOI: 10.1002/ams2.582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/04/2020] [Accepted: 09/19/2020] [Indexed: 11/15/2022] Open
Abstract
Status epilepticus (SE) is a life‐threatening medical and neurological emergency. Prompt recognition and treatment are essential to stop the seizure and improve patient outcomes. To elucidate which benzodiazepine should be used as the first‐line treatment, a systemic search of the PubMed, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi databases was carried out to identify randomized controlled trials (RCTs) comparing i.v. administration of lorazepam and diazepam used for adult SE. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Only two RCTs were finally analyzed among 2182 papers extracted. The SE definitions, inclusion criteria, and doses of the drugs differed in the two studies. Of 204 patients included, 103 and 101 patients were allocated to the lorazepam and diazepam groups, respectively. The pooled risk ratio (RR) and confidence interval (CI) for lorazepam treatment on seizure cessation (two RCTs, n = 204) showed a significantly superior effect of lorazepam over diazepam (RR, 1.24; 95% CI, 1.03–1.49). No statistically significant relationship was found for mortality (two RCTs, n = 204) (RR 0.43; 95% CI, 0.43–6.90), poor neurological outcome (one RCT, n = 134) (RR, 1.10; 95% CI, 0.59–2.04), hypotension (one RCT, n = 70) (RR, 2.68; 95% CI, 0.11–63.61), and respiratory depression (two RCTs, n = 204) (RR, 1.07; 95% CI, 0.48–2.48). The certainty of the evidence was rated as very low. The results of this meta‐analysis of RCTs showed that i.v. lorazepam was better than i.v. diazepam for the cessation of adult SE.
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Affiliation(s)
- Hitoshi Kobata
- Osaka Mishima Emergency Critical Care Center Takatsuki Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Eisei Hoshiyama
- Department of Emergency and Critical Care Medicine and Neurology Dokkyo Medical University Mibu Japan
| | - Kazuma Yamakawa
- Department of Emergency Medical Care Osaka Medical College Takatsuki Japan
| | | | - Mitsuhito Soh
- Department of Emergency and Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Yutaka Kondo
- Department of Emergency and Disaster Medicine Juntendo University Urayasu Hospital Urayasu Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
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Brigo F, Del Giovane C, Nardone R, Trinka E, Lattanzi S. Intravenous antiepileptic drugs in adults with benzodiazepine-resistant convulsive status epilepticus: A systematic review and network meta-analysis. Epilepsy Behav 2019; 101:106466. [PMID: 31462385 DOI: 10.1016/j.yebeh.2019.106466] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/28/2019] [Indexed: 12/19/2022]
Abstract
AIM The aim of this study was to estimate the comparative efficacy and safety of antiepileptic drugs (AEDs) in adults with benzodiazepine-resistant convulsive status epilepticus (SE). METHODS MEDLINE, CENTRAL, ClinicalTrials.gov, and Opengrey.eu were searched (from inception to 3rd April, 2018) for randomized controlled trials (RCTs) of AEDs used intravenously to treat benzodiazepine-resistant SE in adults. Efficacy outcomes were SE cessation within 1 h from drug administration and seizure freedom at 24 h. Safety outcomes were respiratory depression and hypotension. Effect sizes were estimated by network meta-analyses within a frequentist framework. The hierarchy of competing interventions was established using the surface under the cumulative ranking curve (SUCRA) and mean ranks. RESULTS Five RCTs were considered, involving 349 patients. Included interventions were valproate (VPA; 20-30 mg/kg), phenytoin (PHT; 20 mg/kg), diazepam (DZP; 0.2 mg/kg, then 4 mg/h), phenobarbital (PHB; 20 mg/kg, then 100 mg every 6 h), lacosamide (LCM; 400 mg), and levetiracetam (LEV; 20 mg/kg); PHB was superior to PHT, VPA, DZP, LEV, and LCM with respect to SE cessation and performed better than VPA, DZP, and LCM in the achievement of seizure freedom at 24 h. No differences were noted between drugs in the occurrence of respiratory depression and hypotension. According to SUCRA, PHB had the greatest probabilities of being best in the achievement of SE control and seizure freedom, whereas VPA and LCM ranked best for the safety outcomes. CONCLUSIONS Our study suggests that high-dose PHB is effective in controlling SE and preventing seizure recurrence, and LCM and VPA could be better tolerated options. Further head-to-head comparative studies are strongly required to provide more definitive evidence. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Bolzano, Italy; Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy.
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Raffaele Nardone
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Bolzano, Italy; Department of Neurology, Christian Doppler Klinik, University Hospital Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, University Hospital Paracelsus Medical University, Salzburg, Austria; Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, UMIT, Hall in Tyrol, Austria
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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Crawshaw AA, Cock HR. Medical management of status epilepticus: Emergency room to intensive care unit. Seizure 2019; 75:145-152. [PMID: 31722820 DOI: 10.1016/j.seizure.2019.10.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 12/22/2022] Open
Abstract
In convulsive status epilepticus (SE), achieving seizure control within the first 1-2 hours after onset is a significant determinant of outcome. Treatment is also more likely to work and be cost effective the earlier it is given. Initial first aid measures should be accompanied by establishing intravenous access if possible and administering thiamine and glucose if required. Calling for help will support efficient management, and also the potential for video-recording the events. This can be done as a best interests investigation to inform later management, provided adequate steps to protect data are taken. There is high quality evidence supporting the use of benzodiazepines for initial treatment. Midazolam (buccal, intranasal or intramuscular) has the most evidence where there is no intravenous access, with the practical advantages of administration outweighing the slightly slower onset of action. Either lorazepam or diazepam are suitable IV agents. Speed of administration and adequate initial dosing are probably more important than choice of drug. Although only phenytoin (and its prodrug fosphenytoin) and phenobarbitone are licensed for established SE, a now considerable body of evidence and international consensus supports the utility of both levetiracetam and valproate as options in established status. Both also have the advantage of being well tolerated as maintenance treatment, and possibly a lower risk of serious adverse events. Two adequately powered randomized open studies in children have recently reported, supporting the use of levetiracetam as an alterantive to phenytoin. The results of a large double blind study also including valproate are also imminent, and together likely to change practice in benzodiazepine-resistant SE.
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Affiliation(s)
- Ania A Crawshaw
- Specialist Trainee Neurology, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Hannah R Cock
- Professor of Epilepsy & Medical Education, Consultant Neurologist. Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, and Institute of Medical & Biomedical Education, St George's University of London, London, UK.
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16
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Abstract
As the inhibitory γ-aminobutyric acid-ergic (GABAergic) transmission has a pivotal role in the central nervous system (CNS) and defective forms of its synapses are associated with serious neurological disorders, numerous versions of caged GABA and, more recently, photoswitchable ligands have been developed to investigate such transmission. While the complementary nature of these probes is evident, the mechanisms by which the GABA receptors can be photocontrolled have not been fully exploited. In fact, the ultimate need for specificity is critical for the proper synaptic exploration. No caged allosteric modulators of the GABAA receptor have been reported so far; to introduce such an investigational approach, we exploited the structural motifs of the benzodiazepinic scaffold to develop a photocaged version of diazepam (CD) that was tested on basolateral amygdala (BLa) pyramidal cells in mouse brain slices. CD is devoid of any intrinsic activity toward the GABAA receptor before irradiation. Importantly, CD is a photoreleasable GABAA receptor-positive allosteric modulator that offers a different probing mechanism compared to caged GABA and photoswitchable ligands. CD potentiates the inhibitory signaling by prolonging the decay time of postsynaptic GABAergic currents upon photoactivation. Additionally, no effect on presynaptic GABA release was recorded. We developed a photochemical technology to individually study the GABAA receptor, which specifically expands the toolbox available to study GABAergic synapses.
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Brigo F, Lattanzi S, Nardone R, Trinka E. Intravenous Brivaracetam in the Treatment of Status Epilepticus: A Systematic Review. CNS Drugs 2019; 33:771-781. [PMID: 31342405 DOI: 10.1007/s40263-019-00652-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Brivaracetam is a high-affinity synaptic vesicle glycoprotein 2A ligand with high brain permeability and rapid onset of action. These properties make brivaracetam potentially an ideal compound in the emergency setting. OBJECTIVE The objective of our study was to review the evidence about the clinical efficacy and tolerability of intravenous brivaracetam in the treatment of status epilepticus. METHODS We systematically searched MEDLINE, EMBASE, Google Scholar, ClinicalTrials.gov, and conference proceedings to identify studies evaluating intravenous brivaracetam as treatment for status epilepticus of any type in patients of any age. Searches were conducted on 3 December, 2018. RESULTS Seven studies were included (37 patients; aged 22-85 years; 21 were female). The type and etiology of status epilepticus varied across studies. The number of drugs used prior to brivaracetam to treat status epilepticus ranged from 1 to 8. The time from status epilepticus onset to brivaracetam administration ranged from 0.5 h to 105 days. The initial brivaracetam dose ranged from 50 to 400 mg. In case series, the proportion of patients achieving clinical status epilepticus cessation when brivaracetam was administered as the last drug varied from 27 to 50%; in case reports, all patients had status epilepticus cessation. The time from brivaracetam administration to status epilepticus cessation ranged from 15 min to 94 h. No serious adverse effects were reported. CONCLUSIONS The available data suggested that brivaracetam can be a safe treatment option in patients with status epilepticus. The current evidence is however hampered by several confounding factors, and controlled studies are warranted to define the actual benefit of brivaracetam for the treatment of status epilepticus.
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Affiliation(s)
- Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Bolzano, Italy. .,Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy.
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Raffaele Nardone
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Bolzano, Italy.,Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria.,Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, UMIT, Hall in Tyrol, Austria
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Husni A, Lailatussifa R, Isnansetyo A. Sargassum hystrix as a Source of Functional Food to Improve Blood Biochemistry Profiles of Rats under Stress. Prev Nutr Food Sci 2019; 24:150-158. [PMID: 31328119 PMCID: PMC6615359 DOI: 10.3746/pnf.2019.24.2.150] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/22/2019] [Indexed: 02/05/2023] Open
Abstract
This study was conducted to determine the influence of Sargassum hystrix powder (SHP) as an alternative source of functional food for treating in vivo stress by measuring levels of glucose, triacylglycerol, total cholesterol, and cortisol, and liver histopathology. Wistar rats aged 3 months and weighing 150~200 g were divided into 7 groups: normal control, fasting control, negative control (stress without adaptogen), and 4 experimental conditions (stress+0.18 mg/kg diazepam, stress+450 mg/kg pellet, stress+mixture of pellet with SHP 450 mg/kg, and stress+450 mg/kg of SHP). Intake of liquids and and body weight were measured daily. Blood samples were collected on day 0 (baseline), day 5, and day 10 to analyze levels of glucose, triacylglycerol, cholesterol, and cortisol. On day 10, rats were euthanized and livers were collected to observe the severity of inflammation. The results indicated that rats receiving SHP 450 mg/kg and the mixture of pellet with SHP 450 mg/kg showed a similar ability as those receiving diazepam 0.18 mg/kg to cope with stress, indicated by an improvement in all blood biochemistry parameters. Supplementation with SHP 450 mg/kg can be used as an alternative source of functional food for overcoming oxidative stress, as indicated by its ability to improve levels of blood glucose, triacylglycerol, total cholesterol, and cortisol, and to improve liver histology by decreasing severity of liver inflammation.
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Affiliation(s)
- Amir Husni
- Department of Fisheries Faculty of Agriculture, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
| | - Radipta Lailatussifa
- Department of Fisheries Faculty of Agriculture, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia.,Sidoarjo Marine and Fisheries Polytechnic, Sidoarjo 61254, Indonesia
| | - Alim Isnansetyo
- Department of Fisheries Faculty of Agriculture, Universitas Gadjah Mada, Yogyakarta 55281, Indonesia
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Huertas González N, Barros González A, Hernando Requejo V, Díaz Díaz J. Focal status epilepticus: a review of pharmacological treatment. Neurologia 2019; 37:S0213-4853(19)30044-1. [PMID: 31072691 DOI: 10.1016/j.nrl.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/29/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency associated with high morbidity and mortality. One prognostic factor is the type of SE. The purpose of this review is to analyse the most recent recommendations of different scientific societies and expert groups on the treatment of SE, and the latest studies, to assess the literature on the management of focal SE. METHODS We searched PubMed for studies published between 1 August 2008 and 1 August 2018 on the pharmacological treatment of focal SE and its different types in adults. RESULTS We identified 29 publications among reviews, treatment guidelines, meta-analyses, clinical trials, and case series on the treatment of SE. Only 3 of them accounted for whether SE was focal or generalised; 4 focused exclusively on focal SE, and 7 differentiated between convulsive and non-convulsive SE and also record the presence of focal seizures. Treatment recommendations for focal SE do not differ from those of generalised SE in stages I and II: initially intravenous lorazepam or diazepam, if the intravenous route is available, and otherwise intramuscular midazolam, followed by intravenous phenytoin, valproate, levetiracetam, or lacosamide if seizures persist. Use of anaesthetic drugs should be delayed for as long as possible in patients with refractory focal SE. CONCLUSIONS The available scientific evidence is insufficient to claim that pharmacological treatment of focal SE should be different from treatment for generalised SE. More studies with a greater number of patients are needed.
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Affiliation(s)
- N Huertas González
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España.
| | - A Barros González
- Servicio de Neurología, Sankt Katharinen Hospital, Frechen, Alemania
| | - V Hernando Requejo
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
| | - J Díaz Díaz
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
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Santamarina E, Abraira L, Toledo M. Update in status epilepticus. Med Clin (Barc) 2019; 153:70-77. [PMID: 30803796 DOI: 10.1016/j.medcli.2019.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 11/25/2022]
Abstract
Status epilepticus (SE) is a neurological emergency that requires urgent antiepileptic therapies, and a rapid treatment of its cause. In recent years, its definition has been updated to adapt it to all types of SE; this update helps to standardise the treatment. The new definition is based on two times: point t1, after which the event will not spontaneously cease, and period t2, after which neuronal damage may appear. There are three lines of treatment: first, benzodiazepines; second, antiepileptic drugs; and third, intravenous anaesthetics. The application of the different lines of treatment raises still unanswered questions, since the prognosis also depends on the aetiology, age and duration. For this reason, different prognostic scales are being developed to help us to assess its evolution and in turn, adapt the aggressiveness of the treatment to each patient.
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Affiliation(s)
- Estevo Santamarina
- Unidad de Epilepsia, Servicio de Neurología, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - Laura Abraira
- Unidad de Epilepsia, Servicio de Neurología, Hospital Universitario Vall d'Hebron, Barcelona, España; Universitat Autònoma de Barcelona, Barcelona, España
| | - Manuel Toledo
- Unidad de Epilepsia, Servicio de Neurología, Hospital Universitario Vall d'Hebron, Barcelona, España
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21
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Brigo F, Lattanzi S, Zelano J, Bragazzi N, Belcastro V, Nardone R, Trinka E. Randomized controlled trials of antiepileptic drugs for the treatment of post-stroke seizures: A systematic review with network meta-analysis. Seizure 2018; 61:57-62. [DOI: 10.1016/j.seizure.2018.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 07/23/2018] [Accepted: 08/02/2018] [Indexed: 12/26/2022] Open
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Perampanel in the treatment of status epilepticus: A systematic review of the literature. Epilepsy Behav 2018; 86:179-186. [PMID: 30076046 DOI: 10.1016/j.yebeh.2018.07.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Perampanel (PER) is a noncompetitive β-amino-3-(5-methyl-3-oxo-1,2-oxazol-4-yl)propionic acid (AMPA) receptor antagonist with demonstrated efficacy in animal models of status epilepticus (SE). We performed a systematic review of the literature to assess the efficacy and tolerability of PER in the treatment of refractory and super-refractory SE. METHODS We searched Medline, Embase, and CENTRAL (accessed from inception to April 30, 2018) to identify studies evaluating oral PER as treatment of SE of any type. We also searched the OpenGrey repository and conference proceedings of international congresses by the International League Against Epilepsy and by the American Epilepsy Society from 2012 onwards. RESULTS Ten articles were included, with a total of 69 episodes of SE occurring in 68 patients (aged 18 to 91 years). The type and etiology of SE varied remarkably across studies. The number of drugs used prior to PER ranged from 1 to 9. The time from SE onset to PER administration ranged from 9.25 h to 35 days. The initial PER dose ranged from 2 to 32 mg. The proportion of patients achieving clinical SE cessation varied from 17% to 100%. The time from PER administration to SE cessation ranged from 1 h to 4 weeks. CONCLUSIONS The currently available evidence supporting the use of PER in SE is weak and hampered by several confounding factors. Further studies should be performed in more clinically homogeneous and larger cohorts to evaluate the efficacy and safety of PER administered in earlier stages of SE, at higher dosages, and at intervals shorter than 24 h.
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Brigo F, Lattanzi S. Intravenous phenytoin in convulsive status epilepticus: the devil we (think we) know. FUTURE NEUROLOGY 2018. [DOI: 10.2217/fnl-2018-0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Francesco Brigo
- Department of Neurosciences, Biomedicine & Movement Sciences, University of Verona, Verona, Italy, Piazzale L.A. Scuro, 10 - 37134 Verona, Italy
- Division of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental & Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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Dhir A, Rogawski MA. Determination of minimal steady-state plasma level of diazepam causing seizure threshold elevation in rats. Epilepsia 2018; 59:935-944. [PMID: 29682729 PMCID: PMC5934328 DOI: 10.1111/epi.14069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Diazepam, administered by the intravenous, oral, or rectal routes, is widely used for the management of acute seizures. Dosage forms for delivery of diazepam by other routes of administration, including intranasal, intramuscular, and transbuccal, are under investigation. In predicting what dosages are necessary to terminate seizures, the minimal exposure required to confer seizure protection must be known. Here we administered diazepam by continuous intravenous infusion to obtain near-steady-state levels, which allowed an assessment of the minimal levels that elevate seizure threshold. METHODS The thresholds for various behavioral seizure signs (myoclonic jerk, clonus, and tonus) were determined with the timed intravenous pentylenetetrazol seizure threshold test in rats. Diazepam was administered to freely moving animals by continuous intravenous infusion via an indwelling jugular vein cannula. Blood samples for assay of plasma levels of diazepam and metabolites were recovered via an indwelling cannula in the contralateral jugular vein. RESULTS The pharmacokinetic parameters of diazepam following a single 80-μg/kg intravenous bolus injection were determined using a noncompartmental pharmacokinetic approach. The derived parameters Vd , CL, t1/2α (distribution half-life) and t1/2β (terminal half-life) for diazepam were, respectively, 608 mL, 22.1 mL/min, 13.7 minutes, and 76.8 minutes, respectively. Various doses of diazepam were continuously infused without or with an initial loading dose. At the end of the infusions, the thresholds for various behavioral seizure signs were determined. The minimal plasma diazepam concentration associated with threshold elevations was estimated at approximately 70 ng/mL. The active metabolites nordiazepam, oxazepam, and temazepam achieved levels that are expected to make only minor contributions to the threshold elevations. SIGNIFICANCE Diazepam elevates seizure threshold at steady-state plasma concentrations lower than previously recognized. The minimally effective plasma concentration provides a reference that may be considered when estimating the diazepam exposure required for acute seizure treatment.
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Affiliation(s)
- Ashish Dhir
- Department of Neurology, University of California, Davis, Sacramento, CA, USA
| | - Michael A. Rogawski
- Department of Neurology, University of California, Davis, Sacramento, CA, USA
- Department of Pharmacology, School of Medicine, University of California, Davis, Sacramento, CA, USA
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Challenges in the treatment of convulsive status epilepticus. Seizure 2017; 47:17-24. [DOI: 10.1016/j.seizure.2017.02.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 01/09/2023] Open
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25 years of advances in the definition, classification and treatment of status epilepticus. Seizure 2016; 44:65-73. [PMID: 27890484 DOI: 10.1016/j.seizure.2016.11.001] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Status epilepticus (SE) requires not only urgent symptomatic treatment with antiepileptic drugs but also rapid identification and treatment of its cause. This narrative review summarizes the most important advances in classification and treatment of SE. METHOD Data sources included MEDLINE, EMBASE, ClinicalTrials.gov, and back tracking of references in pertinent studies, reviews, and books. RESULTS SE is now defined as "a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1). It is a condition, which can have long-term consequences (after time point t2), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures." A new diagnostic classification system of SE introduces four axes: semiology, aetiology, EEG correlates, and age. For the acute treatment intravenous benzodiazepines (lorazepam, diazepam, clonazepam) and intramuscular midazolam appear as most effective treatments for early SE. In children, buccal or intranasal midazolam are useful alternatives. In established SE intravenous antiepileptic drugs (phenytoin, valproate, levetiracetam, phenobarbital, and lacosamide) are in use. Treatment options in refractory SE are intravenous anaesthetics; ketamine, magnesium, steroids and other drugs have been used in super-refractory SE with variable outcomes. CONCLUSION Over the past 25 years major advances in definition, classification and understanding of its mechanisms have been achieved. Despite this up to 40% of patients in early status cannot be controlled with first line drugs. The treatment of super-refractory status is still an almost evidence free zone.
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