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Sanchez G, Byl M, Pham QG, Eapen BC. Neuropharmacology in Traumatic Brain Injury. Phys Med Rehabil Clin N Am 2024; 35:619-636. [PMID: 38945655 DOI: 10.1016/j.pmr.2024.02.001] [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] [Indexed: 07/02/2024]
Abstract
One of the primary goals in traumatic brain injury (TBI) treatment is to minimize secondary brain damage and promote neuroprotection. In TBI rehabilitation, we seek to facilitate neurologic recovery and restore what independence is possible given a patient's physical and cognitive impairments. These goals must be balanced with treatment of the various symptoms that may occur following TBI. This is challenging given the fact that many of the typical treatments for certain symptoms also come with side effects which could be problematic in the TBI population.
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Affiliation(s)
- Gabriel Sanchez
- Physical Medicine & Rehabilitation Residency Program, Greater Los Angeles VA Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
| | - Merideth Byl
- Physical Medicine & Rehabilitation Residency Program, Greater Los Angeles VA Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
| | - Quynh Giao Pham
- Division of Physical Medicine and Rehabilitation, Department of Medicine, David Geffen School of Medicine at UCLA; Physical Medicine & Rehabilitation Residency Program, Greater Los Angeles VA Healthcare System, David Geffen School of Medicine at UCLA
| | - Blessen C Eapen
- Division of Physical Medicine and Rehabilitation, University of California, Los Angeles (UCLA); Physical Medicine and Rehabilitation Service, VA Greater Los Angeles Healthcare System; David Geffen School of Medicine at UCLA.
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Beneficial cognitive effect of lamotrigine in severe acquired brain injury: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
BACKGROUND Lamotrigine (LAM), an antiepileptic, with panoply of indications and uses in neurology, is FDA approved, in psychiatry, for bipolar prophylaxis. Apart from this indication, trend of its use in psychiatry is on the rise addressing a multitude of disorders. STUDY QUESTION LAM remains one of only few psychotropic drugs with antiglutamate activity. This might render LAM a potential therapeutic option in treatment-resistant major psychiatric disorders. We reviewed LAM pharmacology and its diverse indications while examining the extant evidence. METHODS EMBASE, Ovid MEDLINE, PubMed, Scopus, Web of Science, and Cochrane Database of Systemic Reviews were searched for all relevant studies up to date of June 2016. RESULTS Sound evidence supports use of LAM for acute bipolar depression and prophylaxis, treatment-resistant schizophrenia, treatment-resistant obsessive-compulsive disorder, posttraumatic stress disorder, depersonalization disorder, and affective dysregulation and behavioral dyscontrol domains of borderline personality disorder. Less compelling evidence is present for use in behavioral and psychological symptoms of dementia and neuropsychiatric sequelae of traumatic brain injury. No evidence supports use in autism spectrum disorder or acute unipolar depression. CONCLUSIONS LAM is an important addition to the psychopharmacological armamentarium. Level of evidence supporting the use of LAM in off-label indications is highly variable, and hence, sound clinical judgment is necessary for its proper use and placement in real-life psychiatric practice and psychopharmacotherapy algorithms.
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Hanaya R, Arita K. The New Antiepileptic Drugs: Their Neuropharmacology and Clinical Indications. Neurol Med Chir (Tokyo) 2016; 56:205-20. [PMID: 26935782 PMCID: PMC4870175 DOI: 10.2176/nmc.ra.2015-0344] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The administration of antiepileptic drugs (AEDs) is the first treatment of epilepsy, one of the most common neurological diseases. Therapeutic guidelines include newer AEDs as front-line drugs; monotherapy with new AEDs is delivered in Japan. While about 70% of patients obtain good seizure control by taking one to three AEDs, about 60% experience adverse effects and 33% have to change drugs. Compared to traditional AEDs, the prolonged administration of new AEDs elicits fewer adverse effects and fewer drug interactions and their teratogenicity may be lower. These characteristics increase drug compliance and allow combination therapy for drug-resistant epilepsy, although the antiepileptic effects of the new AEDs are not greater than of traditional AEDs. Comorbidities are not rare in epileptics; many adult patients present with stroke and brain tumors. In stroke patients requiring risk control and in chemotherapy-treated brain tumor patients, their fewer drug interactions render the new AEDs advantageous. Also, new AEDs offer favorable side benefits for concurrent diseases and conditions. Patients with stroke and traumatic brain injury often present with psychiatric/behavioral symptoms and cognitive impairment and some new AEDs alleviate such symptoms. This review presents an outline of the new AEDs used to treat adult patients based on the pharmacological activity of the drugs and discusses possible clinical indications from the perspective of underlying causative diseases and comorbidities.
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Affiliation(s)
- Ryosuke Hanaya
- Department of Neurosurgery, Kagoshima University Graduate School of Medical and Dental Sciences
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Ciurleo R, Bramanti P, Calabrò RS. Pharmacotherapy for disorders of consciousness: are 'awakening' drugs really a possibility? Drugs 2014; 73:1849-62. [PMID: 24170667 DOI: 10.1007/s40265-013-0138-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Disorders of consciousness, including the coma state, vegetative state and minimally conscious state, are among the least understood and least curable conditions in modern neurology. Structural or functional injuries may produce impairments in the neuronal circuits (the ascending reticular activating system and thalamocortical loops) responsible for maintaining the wakefulness state and awareness, associated with a change in neurotransmitter concentrations. Pharmacological agents that are able to restore the levels of neurotransmitters and, consequently, neural synaptic plasticity and functional connectivity of consciousness networks, may play an important role as drugs useful in improving the consciousness state. Currently, there is growing interest in the scientific community with regard to pharmacological agents that act on the gamma amino-butyric acid (GABA) system, such as zolpidem and baclofen, and monoamine systems, such as dopaminergic agents and some antidepressants. The purpose of this article is to provide a comprehensive overview of these potential 'awakening' drugs in patients with disorders of consciousness. The possible mechanisms by which these drugs may exert their effects in promoting recovery of consciousness are discussed, highlighting how many findings are often the result of sporadic events rather than prospective controlled trials or implementation of standard treatment guidelines.
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Affiliation(s)
- Rosella Ciurleo
- IRCCS Centro Neurolesi "Bonino-Pulejo", Via Palermo S.S. 113, C.da Casazza, 98124, Messina, Italy,
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Pistoia F, Mura E, Govoni S, Fini M, Sarà M. Awakenings and awareness recovery in disorders of consciousness: is there a role for drugs? CNS Drugs 2010; 24:625-38. [PMID: 20658796 DOI: 10.2165/11535940-000000000-00000] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Disorders of consciousness (DOC) include coma, vegetative state (VS) and minimally conscious state (MCS). Coma is a condition of unarousability with a complete absence of wakefulness and awareness, whereas VS is characterized by a lack of awareness despite a preserved wakefulness. Patients in coma are unconscious because they lack both wakefulness and awareness. Patients in a VS are unconscious because, although they are wakeful, they lack awareness. Patients in a MCS show minimal but definite behavioural evidence of self and environmental awareness. Coma results from diffuse bilateral hemispheric lesions or selective damage to the ascending reticular system (which is functionally connected to the cerebral cortex by intralaminar thalamic nuclei). VS is a syndrome that is considered to be the result of a disconnection of different cortical networks rather than a dysfunction of a single area or a global reduction in cortical metabolism. As revealed by functional imaging studies, clinical recovery is often associated with a functional restoration of cortico-thalamo-cortical connections. Depending on the amount of network restored, patients may regain full consciousness or remain in a MCS. Molecular and neural mediators may indirectly contribute to the above restoration processes owing to their role in the phenomenon of neural synaptic plasticity. Therefore, there is growing interest in the possible effects of drugs that act at the level of the CNS in promoting emergence from DOC. Sporadic cases of dramatic recovery from DOC after the administration of various pharmacological agents, such as baclofen, zolpidem and amantadine, have been recently supported by intriguing scientific observations. Analysis of the reported cases of recovery, with particular attention paid to the condition of the patients and to the association of their improvement with the start of drug administration, suggests that these treatments might have promoted the clinical improvement of some patients. These drugs are from various and diverging classes, but can be grouped into two main categories, CNS stimulants and CNS depressants. Some of these treatments seem to directly encourage a consciousness restoration, while others play a more determinant role in improving cognitive domains, especially in patients with residual cognitive impairment, than in the field of consciousness. Given the great interest recently generated in the scientific community by the increasing number of papers addressing this issue, further investigation of the above treatments, with particular attention paid to their mechanisms of action, the neurotransmitters involved and their effects on cortico-thalamo-cortical circuitry, is needed.
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Impact of early pharmacological treatment on cognitive and behavioral outcome after traumatic brain injury in adults: a meta-analysis. J Clin Psychopharmacol 2009; 29:468-77. [PMID: 19745647 DOI: 10.1097/jcp.0b013e3181b66f04] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early pharmacological treatment has the potential to reduce some of the disabling cognitive and behavioral problems that result from traumatic brain injury (TBI). Although a large number of treatments have been developed, clinical research has yielded inconsistent findings with respect to the effectiveness of these pharmacological treatments on cognitive and behavioral outcomes. Furthermore, their relative efficacy has not been evaluated, thereby hindering advances in the treatment of TBI. A meta-analysis of research that examined the impact of pharmacological treatments on cognitive and behavioral outcomes in the early stages after TBI between January 1980 and May 2008 was therefore undertaken. The PubMed and PsycINFO databases were searched using 35 terms. All articles were screened using detailed inclusion criteria. Weighted Cohen's d effect sizes, percent overlap statistics, and fail-safe N statistics were calculated for each pharmacological agent. Studies that used different experimental designs were examined separately. Eleven pharmacological treatments were investigated by 22 clinical studies, comprising 6472 TBI patients in the treatment groups and 6460 TBI controls. One dopamine agonist (amantadine) and 1 bradykinin antagonist (CP-0127 [Bradycor]) produced marked treatment benefits (d > or = 0.8) for a single measure of arousal (Glasgow Coma Scale). Notably, drug dosage and the measure chosen to assess outcome influenced the probability of finding a treatment benefit.
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Clemens B, Piros P, Bessenyei M, Hollódy K. Lamotrigine decreases EEG synchronization in a use-dependent manner in patients with idiopathic generalized epilepsy. Clin Neurophysiol 2007; 118:910-7. [PMID: 17258504 DOI: 10.1016/j.clinph.2006.11.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2006] [Revised: 11/19/2006] [Accepted: 11/23/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the quantitative EEG effects of lamotrigine (LTG) monotherapy. HYPOTHESIS LTG was predicted to decrease thalamo-cortical neuronal synchronization in idiopathic generalized epilepsy (IGE). METHODS Waking EEG background activity of 19 IGE patients was investigated before treatment and in the course of LTG monotherapy. Raw absolute power (RAP), raw percent power (RRP), and raw mean frequency (RMF) were computed for 19 electrodes and four frequency bands (delta=1.5-3.5Hz, theta=3.5-7.5Hz, alpha=7.5-12.5Hz, and beta=12.5-25.0Hz). Inter- and intrahemispheric coherence was computed for eight electrode pairs and the four frequency bands. In addition, scalp-averages were calculated for each variable. Group differences were computed by means of nonparametric statistics including correction for multiple comparisons. RESULTS Main results were decreased delta and theta RAP (p<0.05 for scalp-averages). LTG compressed the delta, theta, and alpha RAP datasets, reducing the upper limit of the scatter in particular. Spearman r-values indicated marked correlation between the starting values (RAPuntreated) and the LTG-related decrease (RAPtreated-RAPuntreated) in three bands: delta (r=-0.72; p=0.0005), theta (r=-0.59; p=0.007), and alpha (r=-0.61; p=0.006). Thus, the greater the baseline neuronal synchronization, the marked the dampening effect of LTG on it. The remaining findings were decreased theta RRP, theta RMF, and increased alpha RMF (p<0.05 for scalp-averages). The electrode-related changes were small but topographically consistent across the 19 electrode sites. LTG did not affect coherence. CONCLUSIONS 1. LTG partially normalized the spectral composition of EEG background activity. LTG decreased pathological thalamo-cortical synchronization in use-dependent manner. 2. LTG did not cause quantitative EEG alterations suggesting worsening of the physiological brain functions. Instead, its profile suggested a mild psychostimulant effect. SIGNIFICANCE The results contribute to the understanding of the effect of LTG at the network level.
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Affiliation(s)
- B Clemens
- Kenézy Gyula Memorial Hospital, Department of Neurology, Epilepsy Center, Debrecen, Hungary.
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Giacino J, Whyte J. The vegetative and minimally conscious states: current knowledge and remaining questions. J Head Trauma Rehabil 2005; 20:30-50. [PMID: 15668569 DOI: 10.1097/00001199-200501000-00005] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In the last 2 decades, the minimally conscious state has been distinguished conceptually from the vegetative state and operational criteria for these diagnoses have been published. Standardized and individualized assessment tools have been developed to assist with the diagnosis of severe disorders of consciousness and the measurement of clinical improvement. The natural course of recovery and the importance of key prognostic predictors have been elucidated. Important advances have also been made in defining the similarities and differences in the pathophysiology of these two states, and functional imaging modalities have begun to explicate the neural substrate underlying the behavioral features of these disorders. Research on the efficacy of treatments for severe disorders of consciousness lags behind, due to the practical and ethical difficulties in executing large rigorously controlled clinical trials. The past and future scientific developments in this area provide an important background for continuing discussions of the ethical controversies surrounding end-of-life decision making and resource allocation.
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Affiliation(s)
- Joseph Giacino
- JFK Johnson Rehabilitation Institute, 65 James St, Edison, NJ, USA.
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Whyte J, Katz D, Long D, DiPasquale MC, Polansky M, Kalmar K, Giacino J, Childs N, Mercer W, Novak P, Maurer P, Eifert B. Predictors of outcome in prolonged posttraumatic disorders of consciousness and assessment of medication effects: A multicenter study. Arch Phys Med Rehabil 2005; 86:453-62. [PMID: 15759228 DOI: 10.1016/j.apmr.2004.05.016] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To develop predictive models of recovery from the vegetative state (VS) and minimally conscious state (MCS) after traumatic brain injury (TBI) and to gather preliminary evidence on the impact of various psychotropic medications on the recovery process to support future randomized controlled trials. Design Longitudinal observational cohort design, in which demographic information, injury and acute care history, neuroimaging data, and an initial Disability Rating Scale (DRS) score were collected at the time of study enrollment. Weekly follow-up data, consisting of DRS score, current psychoactive medications, and medical complications, were gathered until discharge from inpatient rehabilitation. SETTING Seven acute inpatient rehabilitation facilities in the United States and Europe with specialized programs for treating patients in the VS and MCS. PARTICIPANTS People with TBI (N=124) who were in the VS or MCS 4 to 16 weeks after injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES DRS score at 16 weeks after injury and time until commands were first followed (among those participants demonstrating no command following at study enrollment). Results DRS score at enrollment, time between injury and enrollment, and rate of DRS change during the first 2 weeks of poststudy observation were all highly predictive of both outcomes. No variables related to injury characteristics or lesions on neuroimaging were significant predictors. Of the psychoactive medications, amantadine hydrochloride was associated with greater recovery and dantrolene sodium was associated with less recovery, in terms of the DRS score at 16 weeks but not the time until commands were followed. More detailed analysis of the timing of functional improvement, with respect to the initiation of amantadine provided suggestive, but not definitive, evidence of the drug's causal role. CONCLUSIONS These findings show the feasibility of improving outcome prediction from the VS and MCS using readily available clinical variables and provide suggestive evidence for the effects of amantadine and dantrolene, but these results require confirmation through randomized controlled trials.
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Affiliation(s)
- John Whyte
- Moss Rehabilitation Research Institute/Albert Einstein Healthcare Network, Philadelphia, PA, USA.
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Giacino JT, Trott CT. Rehabilitative management of patients with disorders of consciousness: grand rounds. J Head Trauma Rehabil 2004; 19:254-65. [PMID: 15247847 DOI: 10.1097/00001199-200405000-00006] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are no standards of care to guide the selection of rehabilitation assessment and treatment procedures for patients with disorders of consciousness. Recently, consensus-based recommendations for management of patients in the vegetative and minimally conscious states have been developed and disseminated in neurology and neurorehabilitation. This is an important first step toward achieving evidence-based guidelines of care. OBJECTIVE Using a "Grand Rounds" format, we illustrate the application of consensus-based diagnostic, prognostic, and treatment recommendations in a patient who sustained severe traumatic brain injury with prolonged alteration in consciousness. After discussing the salient features of the case, we summarize the basic tenets of clinical care for this population.
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Affiliation(s)
- Joseph T Giacino
- The Center for Head Injuries, JFK Johnson Rehabilitation Institute, and New Jersey Neuroscience Institute at JFK Medical Center, 65 James Street, Edison, NJ 08818, USA.
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Pachet A, Friesen S, Winkelaar D, Gray S. Beneficial behavioural effects of lamotrigine in traumatic brain injury. Brain Inj 2003; 17:715-22. [PMID: 12850956 DOI: 10.1080/0269905031000110445] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Anti-convulsant medications have been employed to treat behavioural disorders resulting from traumatic brain injury (TBI). However, there is a paucity of literature investigating the use of lamotrigine to treat aggression and agitation in patients with TBI. In a single case study design, the present study examined the effectiveness of lamotrigine to treat aggressive and agitated behaviour in a 40-year-old male who sustained a severe TBI. A substantial decrease in problematic behaviours and a significant improvement in neurobehavioural functioning were observed after lamotrigine treatment. This case study provides some support for the use of lamotrigine to treat aggression and agitation in patients with a TBI. Further research is needed to examine the relationship between lamotrigine and functional outcome after TBI.
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Affiliation(s)
- Arlin Pachet
- Brain Injury Rehabilitation Provincial Program, Alberta Hospital Ponoka, Alberta Mental Health Board, Alberta, Canada.
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Brown ES, Frol A, Bobadilla L, Nejtek VA, Perantie DC, Dhillon H. Effect of lamotrigine on mood and cognition in patients receiving chronic exogenous corticosteroids. PSYCHOSOMATICS 2003; 44:204-8. [PMID: 12724501 DOI: 10.1176/appi.psy.44.3.204] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mood changes, cognitive deficits, and psychosis have been reported during corticosteroid therapy. However, minimal data are available on the treatment of these side effects. This pilot study examined the effect of 12 weeks of open-label lamotrigine treatment (dose: mean=340 mg/day, SD=65) on mood and cognition in five patients receiving prescription corticosteroids continuously for at least 6 months before study entry. The participants showed significant improvement in cognition with lamotrigine. Two subjects who met criteria for a current major depressive episode at baseline had baseline-to-exit reductions in scores on the Hamilton Depression Rating Scale of more than 20 points. These pilot data suggest that lamotrigine may be associated with improved mood and performance on cognitive tasks in steroid-treated patients. Larger controlled trials are needed to confirm these preliminary findings.
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Affiliation(s)
- E Sherwood Brown
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75390-8849, USA.
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Abstract
Lamotrigine is an anticonvulsant drug with good efficacy and safety in the treatment of epilepsy. There is now substantial evidence that lamotrigine is also useful in treating resistant depression, rapid cycling bipolar affective disorder, depressive episodes in bipolar affective disorder and in the maintenance phase or prophylaxis of bipolar affective disorder. There are possible roles in managing mood changes in borderline personality disorder, reducing chronic pain and treating schizoaffective disorder. The general range of doses found effective in affective disorders is from 50 to 300 mg daily. Clinical use seems to involve a titration of dose upwards over several weeks until the desired effect is obtained. However, further definitive double-blind, randomised controlled trials against gold standard treatments are required. Lamotrigine has a preferable side-effect profile compared to standard agents for bipolar affective disorder such as lithium or carbamazepine. Further research is certainly warranted and, given its tolerability, could point to lamotrigine as the treatment of choice for some affective disorders.
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Affiliation(s)
- Ben Green
- Department of Psychiatry, University of Liverpool, UK.
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Abstract
Anticonvulsants are becoming increasingly popular for the management of psychiatric and neuropsychiatric syndromes. This may be related to antikindling properties of these agents in addition to modulation of gamma-aminobutyric acid, serotonin, and other neurotransmitters. Treatment selection is complicated by the inconsistent availability of randomized controlled data among the growing range of choices. Moreover, generalization of psychiatric to neuropsychiatric applications of anticonvulsant treatments is not universally applicable. This paper reviews the use of newer anticonvulsants in the management of neuropsychiatric disorders, particularly aggression and agitation. The largest body of treatment data is available for valproic acid, which appears to be efficacious and well-tolerated in a wide range of neuropsychiatric disorders. Less consistent data are available for other medications. Further prospective studies are warranted to examine the use of these medications in neuropsychiatric populations.
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Affiliation(s)
- Edward Kim
- Robert Wood Johnson Medical School, The University of Medicine and Dentistry of New Jersey, Piscataway 08854, USA.
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Abstract
OBJECTIVE To provide a qualitative, systematic update and review of the pharmacology, pharmacokinetics, efficacy in mood disorders, adverse effects, and costs of lamotrigine. DATA SOURCES Citations obtained from MEDLINE searches (1985-September 2001) using lamotrigine as a text word, articles identified in reference lists of pertinent articles, abstracts presented at conferences, and research data from GlaxoSmithKline. DATA EXTRACTION English-language articles were considered for possible inclusion. Each title and abstract was examined to determine whether the publication contained up-to-date information relevant to the objective. Twenty clinical trials that provided data on response rates in mood disorders were tabulated. DATA SYNTHESIS Lamotrigine's primary action is to modulate voltage-gated sodium channels. Evidence suggests that it decreases glutamate transmission, directly reduces calcium influx, mildly blocks transmitter reuptake, and alters intracellular mechanisms of resting transmitter release. The average half-life of lamotrigine is approximately 24 hours, but decreases to approximately 7.4 hours when used concurrently with phenytoin, and increases to approximately 59 hours with valproic acid. Seven of the 20 clinical trials were randomized, double-blind, and controlled. Existing data are inadequate to evaluate lamotrigine use in major depression. The pooled response rates for patients with depressed, manic, mixed, and rapid cycling bipolar disorder were similar, ranging from 52% to 63%. Adverse effects are infrequent when the drug is used alone, but become more frequent when lamotrigine is combined with other anticonvulsants. While most rashes are mild, approximately 1 in 500 patients develops exfoliative dermatitis. A slow upward dose titration is recommended to reduce the incidence of serious rash, but this may delay the attainment of adequate dosage for 6 weeks. Lamotrigine has positive effects on cognitive function, but occasionally produces insomnia. Lamotrigine costs 2-4 times more than lithium, carbamazepine, and generic valproic acid. CONCLUSIONS When efficacy, adverse effects, and cost are considered, lamotrigine should probably be reserved as a second-line agent for bipolar depression.
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Affiliation(s)
- Stephen C Hurley
- College of Pharmacy, Idaho State University, Pocatello, ID, USA.
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Abstract
Lamotrigine is a newly available antiepileptic drug with a broad spectrum of efficacy and a tolerability profile that is favorable for use in many patients. Problems with rash are related to rate of dose ascension and drug interactions with valproate. Efficacy in treatment of mood disorder and some pain syndromes will broaden the use of this unique compound.
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Affiliation(s)
- L J Willmore
- Saint Louis University School of Medicine, 1402 South Grand Boulevard (M226), St. Louis, MO 63104, USA.
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