Clinical practice. Initial management of epilepsy

The Role of Pharmacists' Interventions in Increasing Medication Adherence of Patients With Epilepsy: A Scoping Review

OBJECTIVES

Epilepsy is a chronic disease that requires long-term treatment and intervention from health workers. Medication adherence is a factor that influences the success of therapy for patients with epilepsy. Therefore, this study aimed to analyze the role of pharmacists in improving the clinical outcomes of epilepsy patients, focusing on medication adherence.

METHODS

A scoping literature search was conducted through the ScienceDirect, PubMed, and Google Scholar databases. The literature search included all original articles published in English until August 2023 for which the full text was available. This scoping review was carried out by a team consisting of pharmacists and neurologists following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews and the Joanna Briggs Institute guidelines, including 5 steps: identifying research questions, finding relevant articles, selecting articles, presenting data, and compiling the results.

RESULTS

The literature search yielded 10 studies that discussed pharmacist interventions for patients with epilepsy. Five articles described educational interventions involving drug-related counseling with pharmacists. Two articles focused on similar pharmacist interventions through patient education, both verbal and written. Three articles discussed an epilepsy review service, a multidisciplinary intervention program involving pharmacists and other health workers, and a mixed intervention combining education and training with therapy-based behavioral interventions.

CONCLUSIONS

Pharmacist interventions have been shown to be effective in improving medication adherence in patients with epilepsy. Furthermore, these interventions play a crucial role in improving other therapeutic outcomes, including patients' knowledge of self-management, perceptions of illness, the efficacy of antiepileptic drugs in controlling seizures, and overall quality of life.

Effect of Mobile Health Applications on Improving Self-Management Knowledge and Seizure Control in Epilepsy Patients: A Scoping Review

OBJECTIVES

Mobile health app-based interventions are increasingly being developed to support chronic disease management, particularly for epilepsy patients. These interventions focus on managing stress, monitoring drug side effects, providing education, and promoting adherence to medication regimens. Therefore, this scoping review aims to assess how mobile health applications improve epilepsy patients' knowledge and seizure control, and to identify the features of these apps that are frequently used and have proven to be beneficial.

METHODS

This scoping review was conducted using scientific databases such as ScienceDirect, PubMed, and Google Scholar, adhering to the Joanna Briggs Institute guidelines. The review framework consisted of five steps: identifying research questions, finding relevant articles, selecting articles, presenting data, and compiling the results. The literature search included all original articles published in English from 2013 to 2023.

RESULTS

Among six articles that discussed mobile applications for epilepsy patients, all featured similar functionalities, including education on epilepsy management and seizure monitoring. Four of the articles highlighted behavioral interventions, such as reminder systems, designed to improve medication adherence. The remaining two articles focused on a side-effect reporting system that enabled doctors or health workers to evaluate and regularly monitor adverse effects.

CONCLUSIONS

This scoping review reveals that mobile health applications employing a combination of educational and behavioral interventions for epilepsy patients significantly improve knowledge about patient self-management and medication adherence. These interventions can prevent seizures, increase awareness, enable better activity planning, improve safety, and reduce the frequency of seizures and side effects of antiepileptic drugs.

Improving antiepileptic drug tolerability among patients living with epilepsy: the impact of pharmaceutical care services

Therapeutic management of epilepsy is usually long term; thus, patient tolerability of prescribed antiepileptic drugs should be a major consideration as it affects compliance to therapy. The aim of this study was to determine the impact of pharmaceutical care services on antiepileptic drug tolerability among patients living with epilepsy. This study was an open, randomized, controlled, longitudinal and two-arm parallel prospective study with a 6-month patient follow-up period. Patients were recruited from the neurology and medical out-patient clinics of two selected epilepsy referral centres. Recruited patients were randomized into one of the two study groups: pharmaceutical care (PC) or usual care (UC) groups. Patients in the UC group received the usual care provided in the hospitals, while patients in the PC group received PC services in addition to the usual care provided in the hospitals. The impact of PC on patient tolerability of antiepileptic drugs was evaluated using a patient judged antiepileptic drug tolerabiltity scale. The evaluation was done at baseline (pre-intervention), 3 months and 6 months post-intervention. Patients in the PC group had a significantly lower antiepileptic drug tolerability score than those of the UC group at 3 months and 6 months - (Pre-intervention: 0.97 versus 1.13; t = -1.081; p = 0.281), (3 months: 1.13 versus 0.71; t = 3.084; p = 0.001), (6 months: 1.00 versus 0.60; t = 3.083; p = 0.001), indicating a significant improvement in the tolerability of antiepileptic drugs among those in the PC group over time. Pharmaceutical care interventions that included education and counseling services significantly improved tolerability of antiepileptic drugs among patients living with epilepsy.

Temporal Expression of Neuroinflammatory and Oxidative Stress Markers and Prostaglandin E2 Receptor EP2 Antagonist Effect in a Rat Model of Epileptogenesis

Traumatic brain injury (TBI) in patients results in a massive inflammatory reaction, disruption of blood-brain barrier, and oxidative stress in the brain, and these inciting features may culminate in the emergence of post-traumatic epilepsy (PTE). We hypothesize that targeting these pathways with pharmacological agents could be an effective therapeutic strategy to prevent epileptogenesis. To design therapeutic strategies targeting neuroinflammation and oxidative stress, we utilized a fluid percussion injury (FPI) rat model to study the temporal expression of neuroinflammatory and oxidative stress markers from 3 to 24 h following FPI. FPI results in increased mRNA expression of inflammatory mediators including cyclooxygenase-2 (COX-2) and prostanoid receptor EP2, marker of oxidative stress (NOX2), astrogliosis (GFAP), and microgliosis (CD11b) in ipsilateral cortex and hippocampus. The analysis of protein levels indicated a significant increase in the expression of COX-2 in ipsilateral hippocampus and cortex post-FPI. We tested FPI rats with an EP2 antagonist TG8-260 which produced a statistically significant reduction in the distribution of seizure duration post-FPI and trends toward a reduction in seizure incidence, seizure frequency, and duration, hinting a proof of concept that EP2 antagonism must be further optimized for therapeutic applications to prevent epileptogenesis.

Epilepsy in patients with schizophrenia: Pathophysiology and basic treatments

Schizophrenia is a chronic psychiatric disorder that may lead to epilepsy. However, there are limited findings on the issues. This narrative review aimed to provide a practical perspective on epilepsy in patients with schizophrenia using the current treatment systems for epilepsy. While there has been a debate on the relationship between epilepsy and schizophrenia, i.e., antagonism, affinity, and coincidence, recent large cohort studies have revealed a high frequency of epilepsy in patients with schizophrenia (4-5 times higher than that of general population). The high incidence observed is likely to be due to the bidirectionality between epilepsy and schizophrenia and additional schizophrenia-related conditions, e.g., antipsychotic drugs (APD), substance abuse, and head injury. As for symptomatology of epilepsy, only one small-size study showed that seizures of patients with schizophrenia are equivalent to those of patients without schizophrenia. Patients with schizophrenia exhibit the first seizure in their twenties or later, which are mostly focal seizures. Most of seizures in patients with schizophrenia can be controlled with conventional antiepileptic drugs. Few patients with schizophrenia develop treatment-resistant epilepsy. However, since drug interactions can be more complicated due to multiple conditions, such as pre-existing polypharmacy, heavy smoking, irregular eating, and comorbid metabolic disorders, cautious monitoring for clinical symptoms is required. To improve seizure control and adherence, non-pharmacological approaches are also recommended. Thus far, for seizure treatments in patients with schizophrenia, we have to use many empirical findings or substitute certain findings from population without schizophrenia because evidence is insufficient. The accumulation of clinical findings may contribute to the development of efficient treatment systems.

OUP accepted manuscript

Metabolism regulates neuronal activity and modulates the occurrence of epileptic seizures. Here, using two rodent models of absence epilepsy, we show that hypoglycaemia increases the occurrence of spike-wave seizures. We then show that selectively disrupting glycolysis in the thalamus, a structure implicated in absence epilepsy, is sufficient to increase spike-wave seizures. We propose that activation of thalamic AMP-activated protein kinase, a sensor of cellular energetic stress and potentiator of metabotropic GABA_B-receptor function, is a significant driver of hypoglycaemia-induced spike-wave seizures. We show that AMP-activated protein kinase augments postsynaptic GABA_B-receptor-mediated currents in thalamocortical neurons and strengthens epileptiform network activity evoked in thalamic brain slices. Selective thalamic AMP-activated protein kinase activation also increases spike-wave seizures. Finally, systemic administration of metformin, an AMP-activated protein kinase agonist and common diabetes treatment, profoundly increased spike-wave seizures. These results advance the decades-old observation that glucose metabolism regulates thalamocortical circuit excitability by demonstrating that AMP-activated protein kinase and GABA_B-receptor cooperativity is sufficient to provoke spike-wave seizures.

Exploiting cannabinoid and vanilloid mechanisms for epilepsy treatment

This review focuses on the possible roles of phytocannabinoids, synthetic cannabinoids, endocannabinoids, and "transient receptor potential cation channel, subfamily V, member 1" (TRPV1) channel blockers in epilepsy treatment. The phytocannabinoids are compounds produced by the herb Cannabis sativa, from which Δ⁹-tetrahydrocannabinol (Δ⁹-THC) is the main active compound. The therapeutic applications of Δ⁹-THC are limited, whereas cannabidiol (CBD), another phytocannabinoid, induces antiepileptic effects in experimental animals and in patients with refractory epilepsies. Synthetic CB₁ agonists induce mixed effects, which hamper their therapeutic applications. A more promising strategy focuses on compounds that increase the brain levels of anandamide, an endocannabinoid produced on-demand to counteract hyperexcitability. Thus, anandamide hydrolysis inhibitors might represent a future class of antiepileptic drugs. Finally, compounds that block the TRPV1 ("vanilloid") channel, a possible anandamide target in the brain, have also been investigated. In conclusion, the therapeutic use of phytocannabinoids (CBD) is already in practice, although its mechanisms of action remain unclear. Endocannabinoid and TRPV1 mechanisms warrant further basic studies to support their potential clinical applications. This article is part of the Special Issue "NEWroscience 2018".

Real-world hospitalization risk in patients with epilepsy treated with perampanel

AIM

The aim of this study was to evaluate the risk of hospitalization and emergency department admission following initiation of perampanel treatment in patients with epilepsy.

METHODS

This study is a retrospective longitudinal cohort study (Optum® Clinformatics® Datamart). Patients 4 to 11 years of age with a diagnosis of partial onset seizures or ≥12 years of age with primary generalized tonic-clonic seizures who had ≥1 perampanel prescription between 1/1/2014 and 3/31/2018 were eligible for the study. Additionally, patients were required to have 12-months of continuous enrollment before (pre-) and after (post-) the date of the first perampanel prescription (index-date). One-year relative-risks of all-cause and epilepsy-related hospitalizations and emergency department (ED) visits were estimated following initiation of perampanel treatment. Outcomes were also evaluated among a subsets of patients who were adherent to perampanel treatment, defined as a Medication Possession Ratio (MPR) ≥80%.

RESULTS

A total of 320 patients were included in the study, mean age 38.2 ± 19 years, 56.6% female. In the overall population, the relative risks of hospitalizations or ED visits after perampanel initiation were not significantly different. Among the 145 patients who had an MPR ≥80%, initiation of perampanel treatment resulted in a significantly lower risk of epilepsy-related hospitalization (relative risk [RR] = 0.68, confidence interval [CI] [0.47, 0.98]), all-cause ED visits (RR = 0.80, CI [0.66, 0.98]), and epilepsy-related ED visits (RR = 0.74, CI [0.57, 0.95]) in the follow-up period.

CONCLUSIONS

Adherence to perampanel treatment was associated with significant reductions in one-year hospitalizations and ED visit risk in real world settings.

Beneficial Effects of Ibuprofen on Pentylenetetrazol-induced Convulsion

Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) that is commonly used as an anti-inflammatory, anti-pyretic, and analgesic. Although some studies have focused on the anti-inflammatory and anti-pyretic properties of ibuprofen during febrile convulsions, only one has investigated its antiepileptic effects. In the present study, we aimed to investigate the effects of ibuprofen in rats exposed to pentylenetetrazol (PTZ)-induced seizures. In total, 48 rats were randomly divided in two groups: Group A for electroencephalography (EEG) recordings and Group B for behavioral assessment. All EEG recordings and behavioral assessment protocols were performed. In addition, groups were compared in terms of prostaglandin F2 alfa (PGF2α) levels in the brain. We demonstrated the beneficial effects of the administration of ibuprofen in PTZ-induced seizures in rats via the following findings: spike percentages and Racine convulsion scale values were significantly lower and first myoclonic jerk (FMJ) onset times were significantly higher in the ibuprofen-administered groups. Moreover, PGF2α levels in the brain were significantly higher in the saline and PTZ 70 mg/kg group than in the control and PTZ 70 mg/kg and 400 mg/kg ibuprofen groups. Our study is the first to demonstrate the beneficial effects of ibuprofen on seizures through behavioral, EEG, and PGF2α brain assessments. Ibuprofen can be used for epilepsy and febrile seizures safely and without inducing seizures. However, further experimental and clinical studies are needed to confirm our results.

Infrequent Monitoring of the Effects of Valproate and Carbamazepine Therapy in Patients With Epilepsy in Nigeria

Background

Carbamazepine and valproate are widely used in the treatment of epileptic seizures. However, these agents exhibit certain adverse effects including hematopoietic disorders (carbamazepine) and severe hepatotoxicity (valproate).

Purpose

To determine the extent of monitoring of the hematologic effects of carbamazepine as well as the extent of monitoring of the hepatic effects of valproate in patients with epilepsy receiving treatment with these agents.

Method

A cross-sectional antiepileptic drug use study using case notes of patients with epilepsy managed at the neurologic clinics of 2 tertiary medical facilities in Nigeria between January and December 2017.

Results

Carbamazepine was the most frequently prescribed antiepileptic drug (48.24%), followed by valproate (29.34%) and levetiracetam (9.24%). Pretreatment monitoring of hematologic effect was carried out in only 61.11% of patients placed on carbamazepine therapy while follow-up monitoring was done in 3.7% of these patients. Also, in patients placed on valproate therapy, pretreatment and follow-up monitoring of the hepatic effect was done in only 33.71% and 19.0% of the patients, respectively.

Conclusions

The extent of monitoring of the hematologic effects of carbamazepine, as well as the hepatic effects of valproate in the cohort studied, is poor.

Refining General Principles of Antiepileptic Drug Treatments for Epilepsy

Antiepileptic drugs (AEDs) are the primary treatment strategy for epilepsy. As the use of AEDs has become more widespread and diverse over the past century, it has become necessary to refine the associated prescription strategies. This prompted the Drug Committee of the Korean Epilepsy Society to perform a systemic review of both international and domestic guidelines as well as literature related to medical treatment of epilepsy, and prepared a series of reviews to provide practical guidelines for clinicians to follow. This article is the first in a series on AED treatments for epilepsy in South Korea.

HDAC (Histone Deacetylase) Inhibitor Valproic Acid Attenuates Atrial Remodeling and Delays the Onset of Atrial Fibrillation in Mice

Supplemental Digital Content is available in the text.

Background:

A structural, electrical and metabolic atrial remodeling is central in the development of atrial fibrillation (AF) contributing to its initiation and perpetuation. In the heart, HDACs (histone deacetylases) control remodeling associated processes like hypertrophy, fibrosis, and energy metabolism. Here, we analyzed, whether the HDAC class I/IIa inhibitor valproic acid (VPA) is able to attenuate atrial remodeling in CREM-IbΔC-X (cAMP responsive element modulator isoform IbΔC-X) transgenic mice, a mouse model of extensive atrial remodeling with age-dependent progression from spontaneous atrial ectopy to paroxysmal and finally long-lasting AF.

Methods:

VPA was administered for 7 or 25 weeks to transgenic and control mice. Atria were analyzed macroscopically and using widefield and electron microscopy. Action potentials were recorded from atrial cardiomyocytes using patch-clamp technique. ECG recordings documented the onset of AF. A proteome analysis with consecutive pathway mapping identified VPA-mediated proteomic changes and related pathways.

Results:

VPA attenuated many components of atrial remodeling that are present in transgenic mice, animal AF models, and human AF. VPA significantly (P<0.05) reduced atrial dilatation, cardiomyocyte enlargement, atrial fibrosis, and the disorganization of myocyte’s ultrastructure. It significantly reduced the occurrence of atrial thrombi, reversed action potential alterations, and finally delayed the onset of AF by 4 to 8 weeks. Increased histone H4-acetylation in atria from VPA-treated transgenic mice verified effective in vivo HDAC inhibition. Cardiomyocyte-specific genetic inactivation of HDAC2 in transgenic mice attenuated the ultrastructural disorganization of myocytes comparable to VPA. Finally, VPA restrained dysregulation of proteins in transgenic mice that are involved in a multitude of AF relevant pathways like oxidative phosphorylation or RhoA (Ras homolog gene family, member A) signaling and disease functions like cardiac fibrosis and apoptosis of muscle cells.

Conclusions:

Our results suggest that VPA, clinically available, well-tolerated, and prescribed to many patients for years, has the therapeutic potential to delay the development of atrial remodeling and the onset of AF in patients at risk.

Neurochemical investigation of multiple locally induced seizures using microdialysis sampling: Epilepsy effects on glutamate release

The objective of this study was to develop an in vivo model for locally induced epilepsy. Epilepsy is a prominent neurological disorder that affects millions of people worldwide. Patients may experience either global seizures, affecting the entire brain, or focal seizures, affecting only one brain region. The majority of epileptic patients experience focal seizures but they go undiagnosed because such seizures can be difficult to detect. To better understand the effects of focal epilepsy on the neurochemistry of a brain region with high seizure diathesis, an animal model for locally induced seizures in the hippocampus was developed. In this model, two seizure events were chemically induced by administering the epileptogenic agent, 3-mercaptopropionic acid (3-MPA), to the hippocampus to disturb the balance between excitatory and inhibitory neurotransmitters in the brain. Microdialysis was used for local delivery of 3-MPA as well as for collection of dialysate for neurochemical analyses. Two periods of seizures separated by varying inter-seizure recovery times were employed, and changes in the release of the excitatory transmitter, glutamate, were measured. Significant differences in glutamate release were observed between the first and second seizure episodes. Diminished glutamate biosynthesis, enhanced glutamate re-uptake, and/or neuronal death were considered possible causes of the attenuated glutamate release during the second seizure episode. Biochemical measurements were indicative that a combination of these factors led to the attenuation in glutamate release.

Effects of levetiracetam and valproic acid treatment on liver function tests, plasma free carnitine and lipid peroxidation in childhood epilepsies

BACKGROUND AND AIMS

The relationship between anti-epileptic usage and oxidative damage has not yet been clearly understood. In our study, we investigated oxidative stress parameters, carnitine levels, liver function tests (LFT) and their relationship in epileptic children treated with valproic acid or levetiracetam.

METHOD

LFTs, serum free carnitine and oxidative damage markers and their relations with each other were determined in patients who are on valproic acid or levetiracetam treatment at least for 6 months. 25 patients on therapeutic doses of valproic acid, 26 patients on therapeutic doses of levetiracetam and 26 healthy volunteers as controls were included. LFTs, ammonia, carnitine, lipid peroxidation biomarker malondialdehyde (MDA) and a sensitive marker of DNA damage, 8-hydroxy-2-deoxyguanosine (8-OHdG) levels were measured. Results of patients are compared to healthy controls. The data is evaluated with IBM SPSS Statistics 22.0.

RESULTS

Ammonia and MDA levels were elevated in patients using levetiracetam; 8-OHdG levels were elevated in both patient groups. Carnitine levels were significantly low in patients under valproic acid therapy, however they were not found to be correlated with MDA, 8-OHdG or LFTs. MDA showed positive correlation with ammonia and 8-OHdG in the levetiracetam group.

CONCLUSION

We did not observe hepatotoxicity in patients under therapeutic doses of valproic acid. However, epileptic children under therapeutic doses of levetiracetam showed significantly elevated levels of MDA and 8-OHdG, which is supportive for oxidative damage under levetiracetam therapy. This result was observed for the first time in childhood epilepsies and further studies are needed to understand its mechanism.

HLA-A*11:01 is associated with levetiracetam-induced psychiatric adverse events

Levetiracetam (LEV) is effective for focal and generalized epilepsy and is used worldwide because of its relatively few drug interactions and favorable tolerability. However, some psychiatric adverse events (PAEs) have been reported, resulting in drug withdrawal. The pathophysiology of LEV-induced PAE has not yet been elucidated. In this study, we investigated the relationship between PAEs and human leukocyte antigen (HLA) genes. Eleven epilepsy patients, who developed PAEs after the administration of LEV and spontaneously improved after drug withdrawal, were enrolled retrospectively. Genomic DNA from the peripheral blood was extracted, and four-digit allele genotyping of HLA genes was performed. The genotype frequencies of HLA genes were compared to those of 80 patients in which LEV was well tolerated, as well as to 485 individuals from the general Korean population. The frequency of the HLA-A*1101 allele was significantly higher in the LEV-induced PAEs group compared to both the LEV-tolerant group (p = 0.021, OR 4.80, 95% CI 1.30-17.74) and the general Korean population (p = 0.015, OR 4.62, 95% CI 1.38-15.45). This study is the first attempt at investigating the relationship between the HLA system and LEV-induced PAE. The results of this study suggest that the HLA-A*1101 allele could be a risk factor for the development of PAEs.

Patient reported adverse events among epileptic patients taking antiepileptic drugs

Objective:

The aim of this study was to assess patient reported adverse events and associated factors among epileptic patients taking antiepileptic drugs on follow-up at University of Gondar Referral Hospital.

Methods:

Cross-sectional study was done on 354 adult epileptic patients. Patients who were on antiepileptic drugs for epilepsy treatment for less than a year, those who were below 18 years old, patients with incomplete information on the chart and those who were involuntary or uncooperative were excluded from the study. Data were entered in to SPSS version 20.0 for analysis. Bivariate and multivariate binary logistic regression analysis was done to see factors associated with antiepileptic drugs adverse effect. Level of statistical significance was declared at p ≤ 0.05.

Result:

Generalized tonic clonic seizure was the most common (86.2%) type of epilepsy. A total of 79 adverse events were reported. The most frequently encountered adverse events were fatigue (5.08%), gastrointestinal disturbance (4.24%) and sedation/depression (4.24%). Adverse drug effect of antiepileptic drugs was significantly associated with illiterate educational status, increased number of antiepileptic drugs, no seizure during last follow-up and last year, and 1–5 seizures for the last year.

Conclusion:

About one-sixth of epileptic patients reported adverse drug effects. Adverse drug effects were more commonly seen in patients with low educational status, increased number of antiepileptic drugs, absence of seizure during last follow-up and last year, and 1–5 seizures for the last year. So clinicians should give emphasis for patients with these characteristics to counsel on how to minimize or prevent adverse drug events from antiepileptic drugs or giving reassurance about it if it is minor.

Correlation between prescribed daily dose, seizure freedom and defined daily dose in antiepileptic drug treatment

Background Although defined daily doses (DDD) for antiepileptic drugs (AED) have been assigned only in combination therapy, based on the literature, most patients take them in monotherapy. Furthermore, discrepancies between DDD and prescribed daily dose (PDD) were observed. Objective First, to determine PDDs of AEDs and to reveal PDD/DDD ratio among seizure free versus not seizure free patients in everyday clinical practice. Second, to test the applicability of 75% cut-off of DDD to achieve seizure freedom. Furthermore, to find out what factors might influence PDD. Setting Outpatient data files at a Hungarian university hospital were studied. Methods A retrospective, 20-year cross-sectional database was compiled from 1282 epileptic outpatients' files. Main outcome measure Seizure freedom and PDD were used as outcome measures. Results The mean DDD% of all prescribed AEDs increased steadily from monotherapy, through bitherapy towards polytherapy (p < 0.0001). Most seizure free patients took AEDs in doses in the range of ≤75% of DDDs in monotherapy and bitherapy. Older AEDs (carbamazepine and valproate) were given in a significantly higher mean dose in bitherapy in the seizure free group. Among the newer types, only levetiracetam and lamotrigine had a significantly higher DDD% in mono-, bi-, and polytherapy. Confirmed by logistic regression analysis, gender, age, type of epilepsy, and number of AEDs had a significant impact on the value of 75% DDD. Conclusion No significant unfavourable impact of the lower ratio of PDD/DDD on the outcome of achieving seizure freedom has been confirmed. As a measure of seizure freedom, 75% of DDD may be used, although individual therapy must be emphasised. Precisely quantified DDD would provide a more accurate calculation of other derived values.

An Emergency Medicine-Focused Review of Seizure Mimics

BACKGROUND

Seizures result in a change in motor, sensory, and behavioral symptoms caused by abnormal neurologic electrical activity. The symptoms share similar presentations of several other conditions, leading to difficulties in diagnosis and frequent improper management.

OBJECTIVE

This review evaluates adult patients with suspected seizure, signs and symptoms of seizure, mimics of seizure, and an approach to management of seizure mimics.

DISCUSSION

A seizure is caused by abnormal neurologic electrical activity resulting in altered motor, sensory, and behavioral symptoms. Other conditions may present similarly, causing a challenge in diagnosis. These conditions include syncope, psychogenic nonepileptic seizures, stroke or transient ischemic attack, sleep disorders, movement disorders, and migraines. Diagnosis of seizures in the emergency department (ED) is often clinical. Differentiation between seizures and other conditions can be difficult. Laboratories and imaging provide little benefit in definitive diagnosis in the emergency setting. For patients that have an apparent seizure, resuscitation and management is precedent while identifying any provoking factors and treatment of those factors. For adults recovering from suspected seizure, the combination of a focused history, physical examination, and additional studies can provide assistance in diagnosis.

CONCLUSIONS

Patients with an apparent seizure should be resuscitated with identification of provoking factors. Many conditions can mimic seizures. A focused history, physical examination, and additional studies will assist in differentiating seizures from mimics.

Do oral contraceptives increase epileptic seizures?

INTRODUCTION

Hormonal contraceptives are used by over 100 million people worldwide. Recently, there has been an emerging interest in studying the potential impact of oral contraceptives (OCs) on certain neurological conditions. It has been suspected for some time that hormonal birth control increases seizure activity in women with epilepsy, but there is little supportive data. Areas covered: Literature from PubMed and online sources was analyzed with respect to hormonal contraception and epilepsy or seizures. New evidence indicates that OCs can cause an increase in seizures in women with epilepsy. The epilepsy birth control registry, which surveyed women with epilepsy, found that those using hormonal contraceptives self-reported 4.5 times more seizures than those that did not use such contraceptives. A preclinical study confirmed these outcomes wherein epileptic animals given ethinyl estradiol, the primary component of OCs, had more frequent seizures that are more likely to be resistant. Expert commentary: OC pills may increase seizures in women with epilepsy and such refractory seizures are more likely to cause neuronal damage in the brain. Thus, women of child bearing age with epilepsy should consider using non-hormonal forms of birth control to avoid risks from OC pills. Additional research into the mechanisms and prospective clinical investigation are needed.

Levetiracetam-induced cutaneous adverse drug reactions were not associated with HLA genes in a small sample of Chinese patients with epilepsy

PURPOSE

This study aimed to evaluate the clinical characteristics of levetiracetam (LEV)-induced cutaneous adverse drug reactions (cADRs) and to explore its possible genetic association with the human leukocyte antigen (HLA) genes.

METHODS

Nine cases with LEV-induced cADRs were recruited. Demographic and clinical information of these cases was summarized. Additionally, cases were matched with LEV-tolerant controls (1:4). High-resolution HLA class I and class II genotyping was performed for each participant. The allele frequencies between the cases and controls were compared.

RESULTS

All LEV-induced cADRs were mild skin rashes which occurred within 28 days of LEV exposure. The mean latency from LEV exposure to skin rash was (15.67±5.41) days (ranging 6-27). The carrier rates of the two alleles, HLA-DRB1*0405 and HLA-DQB1*0401, were higher in cases compared with controls (the same P=0.036, OR=13.875, 95% CI: 1.273-151.230). The association between the HLA-C*0304 allele and LEV-induced cADRs was boundary (P=0.05, OR=5.2, 95% CI: 1.086-24.897). However, the above-mentioned HLA alleles didn't reach statistical significance after multiple comparisons.

CONCLUSIONS

Safety monitoring was necessary within four weeks after the initiation of LEV treatment, although it has been regarded as a safe antiepileptic drug. Our study failed to show any potential link between HLA alleles and LEV-induced cADRs in Han Chinese. Further studies are needed to clarify the genetic and immunological mechanisms of LEV-induced cADRs.

Examining the relationship between fatigue and cognition after stroke: A systematic review

Many stroke survivors experience fatigue, which is associated with a variety of factors including cognitive impairment. A few studies have examined the relationship between fatigue and cognition and have obtained conflicting results. The aim of the current study was to review the literature on the relationship between fatigue and cognition post-stroke. The following databases were searched: EMBASE (1980-February, 2014), PsycInfo (1806-February, 2014), CINAHL (1937-February, 2014), MEDLINE (1946-February, 2014), Ethos (1600-February, 2014) and DART (1999-February, 2014). Reference lists of relevant papers were screened and the citation indices of the included papers were searched using Web of Science. Studies were considered if they were on adult stroke patients and assessed the following: fatigue with quantitative measurements (≥ 3 response categories), cognition using objective measurements, and the relationship between fatigue and cognition. Overall, 413 papers were identified, of which 11 were included. Four studies found significant correlations between fatigue and memory, attention, speed of information processing and reading speed (r = -.36 to .46) whereas seven studies did not. Most studies had limitations; quality scores ranged from 9 to 14 on the Critical Appraisal Skills Programme Checklists. There was insufficient evidence to support or refute a relationship between fatigue and cognition post-stroke. More robust studies are needed.

M-current preservation contributes to anticonvulsant effects of valproic acid

Valproic acid (VPA) has been widely used for decades to treat epilepsy; however, its mechanism of action remains poorly understood. Here, we report that the anticonvulsant effects of nonacute VPA treatment involve preservation of the M-current, a low-threshold noninactivating potassium current, during seizures. In a wide variety of neurons, activation of Gq-coupled receptors, such as the m1 muscarinic acetylcholine receptor, suppresses the M-current and induces hyperexcitability. We demonstrated that VPA treatment disrupts muscarinic suppression of the M-current and prevents resultant agonist-induced neuronal hyperexcitability. We also determined that VPA treatment interferes with M-channel signaling by inhibiting palmitoylation of a signaling scaffold protein, AKAP79/150, in cultured neurons. In a kainate-induced murine seizure model, administration of a dose of an M-channel inhibitor that did not affect kainate-induced seizure transiently eliminated the anticonvulsant effects of VPA. Retigabine, an M-channel opener that does not open receptor-suppressed M-channels, provided anticonvulsant effects only when administered prior to seizure induction in control animals. In contrast, treatment of VPA-treated mice with retigabine induced anticonvulsant effects even when administered after seizure induction. Together, these results suggest that receptor-induced M-current suppression plays a role in the pathophysiology of seizures and that preservation of the M-current during seizures has potential as an effective therapeutic strategy.

Therapeutic drug monitoring in epilepsy clinic: a multi-disciplinary approach

Epilepsy is a common public health problem and needs multi-disciplinary treatment. Therapeutic drug monitoring (TDM) is one of step of the multi-disciplinary treatment in epilepsy at Epilepsy clinic, Khon Kaen University (Thailand). The TDM service has been established since 2008. Here, we aimed to study the roles of TDM order and epilepsy control. This is a prospective descriptive study in which data collection was done from January 1 to December 31, 2010, the period when pharmacists took part in assessing the appropriateness in measurement and interpretation of TDM in order to provide suggestions for physicians. The 112 patients under study had an average age of 38.21±15.36 years; 254 samples were collected for therapeutic drug monitoring; phenytoin was submitted mostly for drug monitoring at 46.46%; 44.49% of submissions for drug level monitoring were made owing to a suspected sub-therapeutic level. Associations were found between reasons of sending samples for drug level monitoring and the measured drug levels, i.e., 66.67% of drug levels found was so low that they were undetectable in sample for patients' compliance investigation and 38.94% of the drug levels were found to be sub-therapeutic as for the case where submission of samples was done because of suspected sub-therapeutic level, 40% of the cases were found to be in toxicity range in the cases with suspected over-therapeutic levels and monitoring levels, 58.25% were found to be within the therapeutic range. Pharmacists used the interpreted results in patients' care by recommending physicians to monitor therapeutic drug closely, to adjust the dosage of drugs, and to recommend checking patients' compliance in their use of drugs at 56.5, 38.9, and 4.3%, respectively. Physicians' responses were found to be absolute follow, partial follow and not follow at 77.95, 11.03, and 7.48%, respectively. In conclusion, associations were found between reasons of TDM order and measured drug level. Therapeutic drug monitoring services at the Epilepsy Clinic was useful in supporting clinical information queries. Pharmacists could make use of interpreted drug level information by recommending physicians to monitor drug levels and adjust individual dosage regimen accordingly. It should be noted that physicians accepted pharmacists' recommendation, denoting multi-disciplinary care team that would lead to greater efficiency.

Treatment and management of neuromuscular channelopathies

OPINION STATEMENT

Neuromuscular channelopathies are heterogeneous disorders with marked phenotypic and genotypic variability. These include non-dystrophic myotonia (NDM), periodic paralysis (PP), and congenital myasthenic syndrome (CMS). Their diverse clinical manifestations remain a challenge in diagnosis and management to this date. These disorders impact quality of life and cause lifelong disabling symptoms. Treatment options are few and not FDA-approved. This is largely due to a paucity of large, randomized clinical trials in these rare diseases. Challenges of conducting such trials include the rarity of these disorders and the genetic heterogeneity. Physicians rely on off-label use of drugs to treat muscle channelopathies to reduce morbidity and improve quality of life. Besides pharmacological treatment, dietary modifications, lifestyle changes, awareness of triggers, and genetic counseling also play an important role in long-term disease management. This article reviews the current management strategies for neuromuscular channelopathies.

Reduction in mortality and teratogenicity following simultaneous administration of folic acid and vitamin E with antiepileptic, antihypertensive and anti-allergic drugs

Aim:

The present study was designed to evaluate the teratogenic effects on breeding pattern in mice following administration of lamotrigine (LT) and levetiracetam (LV) and its combination with anti-hypertensive and anti-allergic drugs. Moreover, possibility of decrease in teratogenic effect was also evaluated upon simultaneous administration of these combinations with folic acid or vitamin E.

Materials and Methods:

The study was carried out on mature female mice housed in polycarbonate breeding cages. Drugs were administered continuously till the birth of neonates and pups were examined for any teratogenic potential of drugs.

Results:

The results of the study reveals that teratogenic effects of lamotrigine, methyldopa and loratadine (LTMLO) combination were seems to be reduced upon simultaneous administration with folic acid, while addition of vitamin E was found to be more effective in reducing the mortality rate of levetiracetam, methyldopa and loratadine combination.

Conclusion:

Teratogenic effects of LTMLO combination were better prevented by folic acid. However, further studies on large number of animals and humans are required before reaching to definite conclusion.

Clinical pharmacokinetic interactions between antiepileptic drugs and hormonal contraceptives

Contraceptive management in women with epilepsy is critical owing to the potential maternal and fetal risks if contraception or seizure management fails. This article briefly describes the pharmacokinetic interactions between antiepileptic drugs (AEDs) and hormonal contraceptives and the rational strategies that may overcome these risks. Hormonal contraception, including the use of oral contraceptives (OCs), is widely used in many women with epilepsy - there is no strong evidence of seizures worsening with their use. AEDs are the mainstay for seizure control in women with epilepsy. However, there are many factors to consider in the choice of AED therapy and hormonal contraception, since some AEDs can reduce the efficacy of OCs owing to pharmacokinetic interactions. Estrogens and progestogens are metabolized by cytochrome P450 3A4. AEDs, such as phenytoin, phenobarbital, carbamazepine, felbamate, topiramate, oxcarbazepine and primidone, induce cytochrome P450 3A4, leading to enhanced metabolism of either or both the estrogenic and progestogenic component of OCs, thereby reducing their efficacy in preventing pregnancy. OCs can also decrease the concentrations of AEDs such as lamotrigine and, thereby, increase the risk of seizures. Increased awareness of AED interactions may help optimize seizure therapy in women with epilepsy.

Association of oestrogen-containing contraceptives with pulmonary lymphangioleiomyomatosis in women with tuberous sclerosis complex--findings from a survey

OBJECTIVES About 30-40% of women with tuberous sclerosis complex (TSC) develop pulmonary lymphangioleiomyomatosis (LAM). Oestrogen seems to be involved in LAM pathogenesis and oestrogen-containing contraception should be avoided in women with known LAM. However, there is very little data on the use of contraceptives in TSC patients. METHODS We conducted a survey on the use of contraception and disease characteristics. The questionnaire was forwarded to all adult female TSC patients listed in the database of a German patient organisation. RESULTS Data from 39 such patients could be analysed. Of these, 15 were diagnosed with LAM. Twenty-five patients (65%) confirmed current or past use of oestrogen-containing contraceptives. We found a suggestive correlation between the history of oestrogen-containing contraception, and LAM (Odds ratio: 6.500; 95% confidence interval: 1.199-35.230). However, oestrogen use was not associated with LAM complications. CONCLUSIONS Based on our findings, oestrogen-containing contraceptives should be resorted to by these patients only with great caution, and avoided whenever possible.

Development, maintenance and disruption of the blood-brain barrier

The interface between the blood circulation and the neural tissue features unique characteristics that are encompassed by the term 'blood-brain barrier' (BBB). The main functions of this barrier, namely maintenance of brain homeostasis, regulation of influx and efflux transport, and protection from harm, are determined by its specialized multicellular structure. Every constituent cell type makes an indispensable contribution to the BBB's integrity. But if one member of the BBB fails, and as a result the barrier breaks down, there can be dramatic consequences and neuroinflammation and neurodegeneration can occur. In this Review, we highlight recently gained mechanistic insights into the development and maintenance of the BBB. We then discuss how BBB disruption can cause or contribute to neurological disease. Finally, we examine how this knowledge can be used to explore new possibilities for BBB repair.

Microperfusion of 3-MPA into the brain augments GABA

In vivo effects of microperfusion of a GABA synthesis inhibitor (3-MPA) into the striatum and hippocampus on amino acid concentrations and electrical neuronal activity were investigated. Paradoxical elevations in GABA in the striatum (5-fold in anesthetized and 50-fold in awake rats) and hippocampus (2-fold in anesthetized and 15-fold in awake rats) were documented under steady-state concentrations of 3-MPA along with expected increases in glutamate (a 15-fold increase and a 250-fold increase in the striatum of anesthetized and awake rats, respectively; a 7-fold increase and a 25-fold increase in the hippocampus of anesthetized and awake rats, respectively). There was no clear epileptiform or seizure activity. Explanations for the paradoxical increase in GABA are offered, and emphasis is placed on the dependency of disinhibition on the model in which its effects are studied as well as on the prevailing level of activation of the probed network.

Bioequivalent antiepileptic drug switching and the risk of seizure-related events

BACKGROUND

Older antiepileptic drugs (AEDs) are known to have a narrow therapeutic index. As a consequence, switching between bioequivalent AEDs remains controversial in the management of epilepsy. We investigated the association between A-rated switching of each class of currently available AED and emergent treatment for a seizure-related event.

METHODS

We used a case-control method and claims data from the 2010 to 2011 Truven Health MarketScan(®) Commercial Claims Database to estimate the risk of seizure following a medication switch. Cases and controls with an epilepsy diagnosis were identified by emergency/inpatient or outpatient visit claims, respectively. Cases and controls (N=9110) were matched 1:1 by age, epilepsy diagnosis category and seizure medication. The exposure was defined as a switch between A-rated AEDs during the 90 days prior to index date. Conditional logistic regression was used to estimate the association, adjusting for gender, baseline Deyo-Charlson Comorbidity Index (0, 1, 2, or 3+), region (Northeast, Central, South, and West), and total AED medications.

RESULTS

A switch between A-rated AEDs occurred in 1053 (23.2%) cases and 827 (18.1%) matched controls. The unadjusted and adjusted odds ratios of a seizure-related event for switching were 1.38 (95% CI: 1.25-1.52) and 1.27 (95% CI: 1.14-1.41), respectively. The independent risk of an event also increased with each category increase in the Charlson score (CCI=1: 1.17, 95% CI: 1.02-1.33; CCI=2: 1.33, 95% CI: 1.09-1.62; CCI=3+: 1.99, 95% CI: 1.64-2.41). Older AEDs had infrequent switches compared to newer agents and were not associated with events.

DISCUSSION

We found a modest association between AED switching and seizure-related events. Our analysis suggests that the behavior of switching alone may lead to seizure-related events regardless of the medication or type of switch. Other disease or environmental characteristics may contribute to this association. Based on these and other findings, health care professionals and patients should be cautious about switching bioequivalent AEDs.

Randomized controlled trial of trigeminal nerve stimulation for drug-resistant epilepsy

OBJECTIVE

To explore the safety and efficacy of external trigeminal nerve stimulation (eTNS) in patients with drug-resistant epilepsy (DRE) using a double-blind randomized controlled trial design, and to test the suitability of treatment and control parameters in preparation for a phase III multicenter clinical trial.

METHODS

This is a double-blind randomized active-control trial in DRE. Fifty subjects with 2 or more partial onset seizures per month (complex partial or tonic-clonic) entered a 6-week baseline period, and then were evaluated at 6, 12, and 18 weeks during the acute treatment period. Subjects were randomized to treatment (eTNS 120 Hz) or control (eTNS 2 Hz) parameters.

RESULTS

At entry, subjects were highly drug-resistant, averaging 8.7 seizures per month (treatment group) and 4.8 seizures per month (active controls). On average, subjects failed 3.35 antiepileptic drugs prior to enrollment, with an average duration of epilepsy of 21.5 years (treatment group) and 23.7 years (active control group), respectively. eTNS was well-tolerated. Side effects included anxiety (4%), headache (4%), and skin irritation (14%). The responder rate, defined as >50% reduction in seizure frequency, was 30.2% for the treatment group vs 21.1% for the active control group for the 18-week treatment period (not significant, p = 0.31, generalized estimating equation [GEE] model). The treatment group experienced a significant within-group improvement in responder rate over the 18-week treatment period (from 17.8% at 6 weeks to 40.5% at 18 weeks, p = 0.01, GEE). Subjects in the treatment group were more likely to respond than patients randomized to control (odds ratio 1.73, confidence interval 0.59-0.51). eTNS was associated with reductions in seizure frequency as measured by the response ratio (p = 0.04, analysis of variance [ANOVA]), and improvements in mood on the Beck Depression Inventory (p = 0.02, ANOVA).

CONCLUSIONS

This study provides preliminary evidence that eTNS is safe and may be effective in subjects with DRE. Side effects were primarily limited to anxiety, headache, and skin irritation. These results will serve as a basis to inform and power a larger multicenter phase III clinical trial.

CLASSIFICATION OF EVIDENCE

This phase II study provides Class II evidence that trigeminal nerve stimulation may be safe and effective in reducing seizures in people with DRE.

Antiepileptic drugs: adverse effects and drug interactions

The goal of epilepsy treatment is no seizures and no side effects. Antiepileptic drugs (AEDs) are the mainstay of treatment. Chronic use, however, often leads to serial drug changes over time, exposing patients with epilepsy (PWE) to recurrent risks due to adverse effects (AEs) and drug interactions. Both unwanted acute and chronic AEs may occur that are usually dose-related, suggested by AED pharmacology, and addressed with appropriate use of serum drug concentrations. Idiosyncratic AEs can pose significant health issues for PWE and be lifesaving with early identification. AED pharmacokinetics and pharmacodynamic properties serve as the foundation for anumber of drug interactions. Hepatic enzyme systems may facilitate AED interaction with other coadministered medication through induction or inhibition of drug metabolism and result in AEs or seizures from drug interactions. A working knowledge of AED pharmacology is an essential component of good clinical practice to help clinicians predict potential AEs and DIs in the treatments of PWE.

Pediatric epilepsy surgery: anesthetic considerations

Despite advances in antiepileptic medication therapy, a significant number of pediatric patients with epilepsy have seizures that are not well controlled. This article provides anesthesiologists with an overview of seizures in the pediatric population, including evaluation, medical treatment, surgical options, and the anesthetic implications of caring for this special population.

Characterizing and understanding body weight patterns in patients treated with pregabalin

OBJECTIVE

We examined patterns of weight change among patients treated with pregabalin for up to 1 year.

METHODS

Patients with ≥1 pre-treatment weight measurement, ≥2 measurements in Period 1 (day 2-56), and ≥2 during Period 2 (day 57-356) were identified from pooled data of 106 studies including 43,525 patients. Seven patterns were developed and used for exploratory 'change point' analyses (day on-treatment when weight-change trend changed from initial trajectory) and to assess patterns of weight change by baseline weight/body mass index (BMI).

RESULTS

A total of 3187 patients (from 41 studies) were eligible. 98.9% of patients were described by three of the seven patterns. The majority of patients (2607/3187 [81.8%]) remained within ±7% of baseline weight ('Pattern 4'). Fewer patients (463/3187 [14.5%]) were 'delayed weight gainers' (exceeded 7% weight gain in Period 2 but not Period 1 ['Pattern 6']), fewer still (82/3187 [2.6%]) were 'early weight gainers' (exceeded ≥7% baseline weight in Period 1 and remained above 7% or continued to gain weight in Period 2 ['Pattern 7']). Overall weight gainers (Patterns 6, 7) experienced 1-year weight gain (median [% change]) of +6.20 kg [+9.12%] and 5.46 kg [+13.9%] vs. 2.22 kg [+2.10%] for non-weight gainers (Pattern 4). Average baseline weight/BMI was lower for weight gainers (Patterns 6, 7) versus other patterns. Early weight gainers (Pattern 7) had change point day at day 40 versus day 54 for Pattern 4 and day 69 for Pattern 6. Use of concomitant medications and influence of comorbid conditions on weight should be considered as inherent variables when interpreting the study.

CONCLUSIONS

The majority of patients treated with pregabalin (150-600 mg/day) for 1 year maintained weight within ±7% baseline weight. One in six patients gained ≥7% weight from baseline, and generally exceeded 7%, 2-12 months after treatment onset.

Patterns of treatment response in newly diagnosed epilepsy

OBJECTIVE

To delineate the temporal patterns of outcome and to determine the probability of seizure freedom with successive antiepileptic drug regimens in newly diagnosed epilepsy.

METHODS

Patients in whom epilepsy was diagnosed and the first antiepileptic drug prescribed between July 1, 1982, and April 1, 2006, were followed up until March 31, 2008. Outcomes were categorized into 4 patterns: (A) early and sustained seizure freedom; (B) delayed but sustained seizure freedom; (C) fluctuation between periods of seizure freedom and relapse; and (D) seizure freedom never attained. Probability of seizure freedom with successive drug regimens was compared. Seizure freedom was defined as no seizures for ≥1 year.

RESULTS

A total of 1,098 patients were included (median age 32 years, range 9-93). At the last clinic visit, 749 (68%) patients were seizure-free, 678 (62%) on monotherapy. Outcome pattern A was observed in 408 (37%), pattern B in 246 (22%), pattern C in 172 (16%), and pattern D in 272 (25%) patients. There was a higher probability of seizure freedom in patients receiving 1 compared to 2 drug regimens, and 2 compared to 3 regimens (p < 0.001). The difference was greater among patients with symptomatic or cryptogenic than with idiopathic epilepsy. Less than 2% of patients became seizure-free on subsequent regimens but a few did so on their sixth or seventh regimen.

CONCLUSIONS

Most patients with newly diagnosed epilepsy had a constant course which could usually be predicted early. The chance of seizure freedom declined with successive drug regimens, most markedly from the first to the third and among patients with localization-related epilepsies.