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Wang J, Wu W, Wan J, Zhan L, Chen Y, Yun F, Ji Y, Suo G, Zheng Y, Shen D, Zhang Q. Preliminary study on the mechanism of SAHA in the treatment of refractory epilepsy induced by GABRG2(F343L) mutation. Biochem Pharmacol 2024; 227:116449. [PMID: 39053637 DOI: 10.1016/j.bcp.2024.116449] [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: 04/18/2024] [Revised: 07/02/2024] [Accepted: 07/22/2024] [Indexed: 07/27/2024]
Abstract
Mutations in the γ-amino butyric acid type A (GABAA) receptor γ2 subunit gene, GABRG2, have been associated with refractory epilepsy. Increasing evidence indicates that suberoylanilide hydroxamic acid (SAHA), a broad-spectrum histone acetyltransferases (HDACs) inhibitor, can inhibit seizure onset. However, the mechanisms involved remains unknown. The present study aimed to explore the anti-epileptic effect and underlying mechanisms of SAHA in the treatment of refractory epilepsy induced by GABRG2 mutation. In the zebrafish line expressing human mutant GABRG2(F343L), Tg(hGABRG2F343L), SAHA was found to reduce seizure onset, swimming activity, and neuronal activity. In both Tg(hGABRG2F343L) zebrafish and HEK293T cells transfected with GABAA receptor subunits, SAHA could improve the pan-acetylation level and reduce the expression of HDAC1/10. The decreased expressions of GABAA receptor subunits could be rescued by SAHA treatment both in vivo and in vitro, which might be the result of increased gene transcription and protein trafficking. The up-regulated acetylation of histone H3 and H4 as well as Bip expression might be involved in the process. Taken together, our data proved that both histone and non-histone acetylation might contribute to the anti-epileptic effect of SAHA in refractory epilepsy caused by GABRG2(F343L) mutation, demonstrating SAHA as a promising therapeutic agent for refractory epilepsy.
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Affiliation(s)
- Jie Wang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, NMPA Key Laboratory for Research and Evaluation of Tissue Engineering Technology Products, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, Nantong University, Nantong, China
| | - Wenwen Wu
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, NMPA Key Laboratory for Research and Evaluation of Tissue Engineering Technology Products, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, Nantong University, Nantong, China
| | - Jiali Wan
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, NMPA Key Laboratory for Research and Evaluation of Tissue Engineering Technology Products, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, Nantong University, Nantong, China
| | - Longwu Zhan
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, NMPA Key Laboratory for Research and Evaluation of Tissue Engineering Technology Products, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, Nantong University, Nantong, China
| | - Yuhan Chen
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, NMPA Key Laboratory for Research and Evaluation of Tissue Engineering Technology Products, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, Nantong University, Nantong, China
| | - Feng Yun
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, NMPA Key Laboratory for Research and Evaluation of Tissue Engineering Technology Products, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, Nantong University, Nantong, China
| | - Yuhua Ji
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, NMPA Key Laboratory for Research and Evaluation of Tissue Engineering Technology Products, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, Nantong University, Nantong, China
| | - Guihai Suo
- Department of Pediatrics, Affiliated Hospital of Nantong University, Medical School, Nantong University, Nantong, China
| | - Yuqin Zheng
- Department of Pediatrics, Affiliated Hospital of Nantong University, Medical School, Nantong University, Nantong, China
| | - Dingding Shen
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School, Nantong University, Nantong, China.
| | - Qi Zhang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-innovation Center of Neuroregeneration, NMPA Key Laboratory for Research and Evaluation of Tissue Engineering Technology Products, Jiangsu Clinical Medicine Center of Tissue Engineering and Nerve Injury Repair, Nantong University, Nantong, China.
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Ratcliffe C, Pradeep V, Marson A, Keller SS, Bonnett LJ. Clinical prediction models for treatment outcomes in newly diagnosed epilepsy: A systematic review. Epilepsia 2024; 65:1811-1846. [PMID: 38687193 DOI: 10.1111/epi.17994] [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: 01/30/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024]
Abstract
Up to 35% of individuals diagnosed with epilepsy continue to have seizures despite treatment, commonly referred to as drug-resistant epilepsy. Uncontrolled seizures can directly, or indirectly, negatively impact an individual's quality of life. To inform clinical management and life decisions, it is important to be able to predict the likelihood of seizure control. Those likely to achieve seizure control will be able to return sooner to their usual work and leisure activities and require less follow-up, whereas those with a poor prognosis will need more frequent clinical attendance and earlier consideration of epilepsy surgery. This is a systematic review aimed at identifying demographic, clinical, physiological (e.g., electroencephalographic), and imaging (e.g., magnetic resonance imaging) factors that may be predictive of treatment outcomes in patients with newly diagnosed epilepsy (NDE). MEDLINE and Embase were searched for prediction models of treatment outcomes in patients with NDE. Study characteristics were extracted and subjected to assessment of risk of bias (and applicability concerns) using the PROBAST (Prediction Model Risk of Bias Assessment Tool) tool. Baseline variables associated with treatment outcomes are reported as prognostic factors. After screening, 48 models were identified in 32 studies, which generally scored low for concerns of applicability, but universally scored high for susceptibility to bias. Outcomes reported fit broadly into four categories: drug resistance, short-term treatment response, seizure remission, and mortality. Prognostic factors were also heterogenous, but the predictors that were commonly significantly associated with outcomes were those related to seizure characteristics/types, epilepsy history, and age at onset. Antiseizure medication response was often included as a baseline variable, potentially obscuring other factor relationships at baseline. Currently, outcome prediction models for NDE demonstrate a high risk of bias. Model development could be improved with a stronger adherence to recommended TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) practices. Furthermore, we outline actionable changes to common practices that are intended to improve the overall quality of prediction model development in NDE.
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Affiliation(s)
- Corey Ratcliffe
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Vishnav Pradeep
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Simon S Keller
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Laura J Bonnett
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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Alturaifi A, Alshaikh H, Khojah O, Alqarni A, Albedaiwi T, Albluwi A, Alqurashi E, Kecheck H, Fallatah H, Almakati R, Gahtani R, Aljohani R, Alhubayshi M, Makkawi S. Drug-Resistant Epilepsy: Experience From a Tertiary Care Center in Saudi Arabia. Cureus 2024; 16:e61913. [PMID: 38975393 PMCID: PMC11227904 DOI: 10.7759/cureus.61913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/09/2024] Open
Abstract
Objectives This study aimed to describe the clinical characteristics, investigational results, and management strategies in patients with drug-resistant epilepsy (DRE). Methods This retrospective cohort study included all adult and adolescent patients (aged 14 years or older) diagnosed with DRE who visited the adult neurology clinic at King Abdulaziz Medical City, Jeddah, Saudi Arabia from January 2019 to December 2021. DRE was defined as failure to achieve seizure freedom despite undergoing adequate trials of two well-tolerated and appropriately selected antiseizure medications. Results This study included 299 patients with DRE. Most patients were in their second to fourth decade, with a mean age of 37 ± 17 years. Focal onset epilepsy was diagnosed in 52.5% of the patients, and an etiology for epilepsy was determined in 44.1% of the patients. Findings in brain magnetic resonance imaging were abnormal in 49% of the patients, whereas abnormal findings in electroencephalograms were found in 27.5%. The most common antiseizure medication was levetiracetam (67.6% of cases). Conclusion The findings of this study confirm the challenges in diagnosing and managing patients with DRE and emphasize the necessity for careful and comprehensive patient evaluation. Further research is needed to investigate the effectiveness, safety, and accessibility of diagnostic and therapeutic resources for patients with DRE.
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Affiliation(s)
- Adilah Alturaifi
- Department of Neuroscience, Ministry of National Guard Health Affairs, Jeddah, SAU
- Department of Research and Development, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Hatoon Alshaikh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Osama Khojah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Research and Development, King Abdullah International Medical Research Center, Jeddah, SAU
- Department of Neuroscience, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Abdulaziz Alqarni
- Department of Neuroscience, Ministry of National Guard Health Affairs, Jeddah, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Tarfah Albedaiwi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Amira Albluwi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Elaf Alqurashi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Husun Kecheck
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Halah Fallatah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Reuof Almakati
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Raghad Gahtani
- Department of Neuroscience, Ministry of National Guard Health Affairs, Jeddah, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Rahaf Aljohani
- Department of Neuroscience, Ministry of National Guard Health Affairs, Jeddah, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Madihah Alhubayshi
- Department of Neuroscience, Ministry of National Guard Health Affairs, Jeddah, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Research and Development, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Seraj Makkawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Research and Development, King Abdullah International Medical Research Center, Jeddah, SAU
- Department of Neuroscience, Ministry of National Guard Health Affairs, Jeddah, SAU
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Wang H, Wang J, Lin B, Zhang H, Sun Y, Wu Y, Ye W, Miao J. Effect of Age, Comedications, and CYP3A4/5 Polymorphisms on Perampanel Exposure in Chinese Pediatric Patients With Epilepsy. J Clin Pharmacol 2024; 64:737-743. [PMID: 38381330 DOI: 10.1002/jcph.2415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/22/2024] [Indexed: 02/22/2024]
Abstract
Perampanel (PER) is a new type of antiseizure medication used for partial or generalized seizures. However, the plasma concentration shows obvious individual variability in children. The present study aims to ascertain the effect of age, comedications, and cytochrome P450 (CYP) 3A4/5 polymorphisms on PER exposure in Chinese pediatric patients with epilepsy. Clinical data were retrospectively collected in a tertiary children's hospital medical records system from January 2021 to December 2022. The influence factors on the daily dose, plasma concentration, and concentration-to-dose ratio (CDR) of PER were investigated. A total of 135 pediatric patients with 178 blood samples were involved. With a median daily dose of 4.0 mg (interquartile range, 3.0-5.0 mg), the median plasma concentration was 409.4 ng/mL (interquartile range, 251.7-639.4 ng/mL). The CDR in patients aged less than 4 years was significantly decreased by 48.0% and 39.1% compared with those aged 4-11 years and 12 years or older, respectively. Enzyme inducers significantly decreased the CDR of PER by 34.5%, while valproic acid showed an increase of 71.7%. In addition, genotype CYP3A5*3/*3 carriers presented a significant increase of 21.5% compared to the CYP3A5*1/*3 expresser. No correlations were observed between the CDR and CYP3A4∗1G polymorphism. PER showed high variations in individual plasma concentrations. Age younger than 4 years, comedication with enzyme inducers or valproic acid, and possession of the CYP3A5*3 genotype potentially predicted PER exposure in pediatric patients with epilepsy.
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Affiliation(s)
- Huijuan Wang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Research Center for Clinical Pharmacy, Zhejiang University, Hangzhou, China
| | - Junyan Wang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Bin Lin
- Department of Pharmacy, Changxing People's Hospital; Changxing Branch, Second Affiliated Hospital of Zhejiang University School of Medicine, Huzhou, China
- Key Laboratory of Intelligent Pharmacy and Individualized Therapy of Huzhou, Huzhou, China
| | - Huifen Zhang
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yangyang Sun
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yuanyuan Wu
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Weifeng Ye
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jing Miao
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Research Center for Clinical Pharmacy, Zhejiang University, Hangzhou, China
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Matricardi S, Scorrano G, Prezioso G, Burchiani B, Di Cara G, Striano P, Chiarelli F, Verrotti A. The latest advances in the pharmacological management of focal epilepsies in children: a narrative review. Expert Rev Neurother 2024; 24:371-381. [PMID: 38433525 DOI: 10.1080/14737175.2024.2326606] [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: 01/22/2024] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Focal epilepsy constitutes the most common epilepsy in children, and medical treatment represents the first-line therapy in this condition. The main goal of medical treatment for children and adolescents with epilepsy is the achievement of seizure freedom or, in drug-resistant epilepsies, a significant seizure reduction, both minimizing antiseizure medications (ASM)-related adverse events, thus improving the patient's quality of life. However, up to 20-40% of pediatric epilepsies are refractory to drug treatments. New ASMs came to light in the pediatric landscape, improving the drug profile compared to that of the preexisting ones. Clinicians should consider several factors during the drug choice process, including patient and medication-specific characteristics. AREAS COVERED This narrative review aims to summarize the latest evidence on the effectiveness and tolerability of the newest ASMs administered as monotherapy or adjunctive therapy in pediatric epilepsies with focal onset seizures, providing a practical appraisal based on the existing evidence. EXPERT OPINION The latest ASMs have the potential to be effective in the pharmacological management of focal onset seizures in children, and treatment choice should consider several drug- and epilepsy-related factors. Future treatments should be increasingly personalized and targeted on patient-specific pathways. Future research should focus on discovering new chemical compounds and repurposing medications used for other indications.
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Affiliation(s)
- Sara Matricardi
- Department of Paediatrics, University of Chieti, Chieti, Italy
| | | | | | | | - Giuseppe Di Cara
- Department of Paediatrics, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Paediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Alberto Verrotti
- Department of Paediatrics, University of Perugia, Perugia, Italy
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Wu C, Wu H, Zhou Y, Liu X, Huang S, Zhu S. Effectiveness analysis of three-drug combination therapies for refractory focal epilepsy. Neurotherapeutics 2024; 21:e00345. [PMID: 38490875 PMCID: PMC11070276 DOI: 10.1016/j.neurot.2024.e00345] [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: 09/09/2023] [Revised: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
Selecting appropriate antiseizure medications (ASMs) for combination therapy in patients with drug-resistant epilepsy (DRE) is a complex task that requires an empirical approach, especially in patients receiving polytherapy. We aimed to analyze the effectiveness of various three-drug combinations in a group of patients with DRE under real-world conditions. This single-center, longitudinal observational study investigated patients with drug-resistant focal epilepsy who received three-drug regimens in the outpatient clinic of Tongji Hospital from September 2019 to December 2022. The effectiveness of each triple regimen was evaluated by the seizure-free rate and within-patient ratio of the seizure frequency (a seizure frequency ratio [SFR]<1 indicated superior efficacy). The independent t-test or Mann-Whitney U test was used for effectiveness analysis, and P values were adjusted by the Benjamini-Hochberg method for multiple comparisons. A total of 511 triple trials comprising 76 different regimens were conducted among 323 enrolled patients. Among these triple regimens, lamotrigine (LTG)/valproic acid (VPA)/topiramate (TPM) was the most frequently prescribed (29.4%, n = 95). At the last clinical visit, 14.9% (n = 48) of patients achieved seizure freedom after receiving triple therapy. LTG/VPA/TPM and LTG/VPA/levetiracetam (LEV) exhibited the highest seizure-free rates at 17.9% and 12.8%, respectively. These two regimens also had significantly lower median SFRs of 0.48 (interquartile range [IQR], 0.17-0.85; adjusted P < 0.001) and 0.63 (IQR, 0.21-1.04; adjusted P < 0.01), respectively. LTG/VPA/perampanel (PER) was another promising regimen that showed marginal effectiveness (median SFR = 0.67; adjusted P = 0.053). LTG/VPA/phenobarbital had the highest incidence of regimen-specific side effects (40.0%, 4/10), while the incidence of side effects from LTG/VPA/LEV was minimal (5.1%, 2/39). In conclusion, LTG/VPA/TPM and LTG/VPA/LEV exhibited superior efficacy and good tolerability in treating patients with DRE. Our results provide preliminary insights into the selection of ASMs for three-drug combination therapies in this clinically challenging population.
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Affiliation(s)
- Chunmei Wu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Huiting Wu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Yingying Zhou
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Xiaoyan Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Shanshan Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China.
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China.
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Yin W, Dong C, Stevenson A, Lloyd V, Petrillo M, Baratta M, Hui T, Han S. Effects of Strong Inhibition of Cytochrome P450 3A and UDP glucuronosyltransferase 1A9 and Strong Induction of Cytochrome P450 3A on the Pharmacokinetics, Safety, and Tolerability of Soticlestat: Two Drug-Drug Interaction Studies in Healthy Volunteers. Drug Metab Dispos 2024; 52:180-187. [PMID: 38123352 DOI: 10.1124/dmd.123.001444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/07/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
Two open-label, phase 1 studies (NCT05064449, NCT05098041) investigated the effects of cytochrome P450 (CYP) 3A inhibition (via itraconazole), UDP glucuronosyltransferase (UGT) 1A9 inhibition (via mefenamic acid), and CYP3A induction (via rifampin) on the pharmacokinetics of soticlestat and its metabolites M-I and M3. In period 1 of both studies, participants received a single dose of soticlestat 300 mg. In period 2, participants received itraconazole on days 1-11 and soticlestat 300 mg on day 5 (itraconazole/mefenamic acid study; part 1); mefenamic acid on days 1-7 and soticlestat 300 mg on day 2 (itraconazole/mefenamic acid study; part 2); or rifampin on days 1-13 and soticlestat 300 mg on day 11 (rifampin study). Twenty-eight healthy adults participated in the itraconazole/mefenamic acid study (14 per part) and 15 participated in the rifampin study (mean age, 38.1-40.7 years; male, 79-93%). For maximum observed concentration, the geometric mean ratios (GMRs) of soticlestat + itraconazole, mefenamic acid, or rifampin to soticlestat alone were 116.6%, 107.3%, and 13.2%, respectively, for soticlestat; 10.7%, 118.0%, and 266.1%, respectively, for M-I, and 104.6%, 88.2%, and 66.6%, respectively, for M3. For area under the curve from time 0 to infinity, the corresponding GMRs were 124.0%, 100.6%, and 16.4% for soticlestat; 13.3%, 117.0%, and 180.8% for M-I; and 120.3%, 92.6%, and 58.4% for M3. Soticlestat can be administered with strong CYP3A and UGT1A9 inhibitors, but not strong CYP3A inducers (except for antiseizure medications, which will be further evaluated in ongoing phase 3 studies). In both studies, all treatment-emergent adverse events were mild or moderate. SIGNIFICANCE STATEMENT: These drug-drug interaction studies improve our understanding of the potential changes that may arise in soticlestat exposure in patients being treated with CYP3A inhibitors, UGT1A9 inhibitors, or CYP3A inducers. The results build on findings from previously published soticlestat studies and provide important information to help guide clinical practice. Soticlestat has shown positive phase 2 results and is currently in phase 3 development for the treatment of seizures in patients with Dravet syndrome and Lennox-Gastaut syndrome.
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Affiliation(s)
- Wei Yin
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Cheng Dong
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | | | - Valerie Lloyd
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Marco Petrillo
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Mike Baratta
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Tom Hui
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Steve Han
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts
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Cohen JM, Alvestad S, Suarez EA, Schaffer A, Selmer RM, Havard A, Bateman BT, Cesta CE, Zoega H, Odsbu I, Huybrechts KF, Kjerpeseth LJ, Straub L, Leinonen MK, Bjørk MH, Nørgaard M, Gissler M, Ulrichsen SP, Hernandez-Diaz S, Tomson T, Furu K. Comparative Risk of Major Congenital Malformations With Antiseizure Medication Combinations vs Valproate Monotherapy in Pregnancy. Neurology 2024; 102:e207996. [PMID: 38165339 PMCID: PMC10870741 DOI: 10.1212/wnl.0000000000207996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Valproate should be avoided in pregnancy, but it is the most effective drug for generalized epilepsies. Alternative treatment may require combinations of other drugs. Our objectives were to describe first trimester use of antiseizure medication (ASM) combinations that are relevant alternatives to valproate and determine whether specific combinations were associated with a lower risk of major congenital malformations (MCM) compared with valproate monotherapy. METHODS We conducted a population-based cohort study using linked national registers from Denmark, Finland, Iceland, Norway, and Sweden and administrative health care data from the United States and New South Wales, Australia. We described first trimester use of ASM combinations among pregnant people with epilepsy from 2000 to 2020. We compared the risk of MCM after first trimester exposure to ASM combinations vs valproate monotherapy and low-dose valproate plus lamotrigine or levetiracetam vs high-dose valproate (≥1,000 mg/d). We used log-binomial regression with propensity score weights to calculate adjusted risk ratios (aRRs) and 95% CIs for each dataset. Results were pooled using fixed-effects meta-analysis. RESULTS Among 50,905 pregnancies in people with epilepsy identified from 7.8 million total pregnancies, 788 used lamotrigine and levetiracetam, 291 used lamotrigine and topiramate, 208 used levetiracetam and topiramate, 80 used lamotrigine and zonisamide, and 91 used levetiracetam and zonisamide. After excluding pregnancies with use of other ASMs, known teratogens, or a child diagnosed with MCM of infectious or genetic cause, we compared 587 exposed to lamotrigine-levetiracetam duotherapy and 186 exposed to lamotrigine-topiramate duotherapy with 1959 exposed to valproate monotherapy. Pooled aRRs were 0.41 (95% CI 0.24-0.69) and 1.26 (0.71-2.23), respectively. Duotherapy combinations containing low-dose valproate were infrequent, and comparisons with high-dose valproate monotherapy were inconclusive but suggested a lower risk for combination therapy. Other combinations were too rare for comparative safety analyses. DISCUSSION Lamotrigine-levetiracetam duotherapy in first trimester was associated with a 60% lower risk of MCM than valproate monotherapy, while lamotrigine-topiramate was not associated with a reduced risk. Duotherapy with lamotrigine and levetiracetam may be favored to treat epilepsy in people with childbearing potential compared with valproate regarding MCM, but whether this combination is as effective as valproate remains to be determined. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in people with epilepsy treated in the first trimester of pregnancy, the risk of major congenital malformations is lower with lamotrigine-levetiracetam duotherapy than with valproate alone, but similar with lamotrigine-topiramate.
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Affiliation(s)
- Jacqueline M Cohen
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Silje Alvestad
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth A Suarez
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Andrea Schaffer
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Randi M Selmer
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Alys Havard
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Brian T Bateman
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Carolyn E Cesta
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Helga Zoega
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Ingvild Odsbu
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Krista F Huybrechts
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Lars J Kjerpeseth
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Loreen Straub
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Maarit K Leinonen
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Marte-Helene Bjørk
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Mette Nørgaard
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Mika Gissler
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Sinna P Ulrichsen
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Sonia Hernandez-Diaz
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Torbjörn Tomson
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Kari Furu
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
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9
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Mammadova D, Vecko J, Hofmann M, Schüssler SC, Deiters L, Canda A, Wieland AK, Gollwitzer S, Hamer H, Trollmann R. A single-center observational study on long-term neurodevelopmental outcomes in children with tuberous sclerosis complex. Orphanet J Rare Dis 2023; 18:349. [PMID: 37946245 PMCID: PMC10637019 DOI: 10.1186/s13023-023-02959-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare multisystem disorder caused by mutations in the TSC1 or TSC2 gene. More than 90% of patients with TSC develop neurological and/or neuropsychiatric manifestations. The aim of the present study was to determine the developmental and cognitive long-term outcomes of pediatric TSC patients. METHODS This cross-sectional, monocenter study included pediatric TSC patients who received multidisciplinary long-term care with a last visit between 2005 and 2019. Neurological manifestations and cognitive development (BSID, K-ABC) were analyzed in relation to age and type of mutation. RESULTS Thirty-five patients aged 13.5 ± 7.8 years were included in the study. Diagnosis was confirmed genetically in 65.7% of patients (TSC1, 26.1%; TSC2, 65.2%; NMI, 8.7%). Mean age at diagnosis was 1.3 ± 3.5 years; 74.3% of the patients had been diagnosed within the first year of life due to seizures (62.9%) or/and cardiac rhabdomyomas (28.6%). The most common TSC manifestations included structural brain lesions (cortical tubers, 91.4%; subependymal nodules, 82.9%), epilepsy (85.7%), and cardiac rhabdomyomas (62.9%). Mean age at seizure onset was 1.5 ± 2.3 years, with onset in 80.0% of patients within the first two years of life. Infantile spasms, which were the first seizure type in 23.3% of the patients, developed earlier (0.6 ± 0.4 years) than focal seizures (1.8 ± 2.5 years). Refractory epilepsy was present in 21 (70.0%) patients, mild or severe intellectual impairment in 66.6%, and autism spectrum disorders in 11.4%. Severe cognitive impairment (33.3%) was significantly associated with epilepsy type and age at seizure onset (p < 0.05). CONCLUSIONS The results emphasized the phenotypic variability of pediatric-onset TSC and the high rate of neurological and neuropsychiatric morbidity. Early-onset refractory epilepsy was associated with impaired cognitive development. Children of all ages with TSC require multidisciplinary long-term care and individual early-intervention programs.
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Affiliation(s)
- D Mammadova
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - J Vecko
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - M Hofmann
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - S C Schüssler
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - L Deiters
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - A Canda
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - A K Wieland
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - S Gollwitzer
- Department of Neurology, Epilepsy Center, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - H Hamer
- Department of Neurology, Epilepsy Center, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Regina Trollmann
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany.
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
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10
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Perkins JD, Abdelmoneim MS, Wilkins SS, Kamran S, Mesraoua B, Melikyan G, Alrabi A, El-Bardissy A, Elalamy O, Al Hail HJ. Dosage, time, and polytherapy dependent effects of different levetiracetam regimens on cognitive function. Epilepsy Behav 2023; 148:109453. [PMID: 37783028 DOI: 10.1016/j.yebeh.2023.109453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/20/2023] [Accepted: 09/16/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVE Cognitive impairment is a potential drawback of antiseizure medications. This study aimed to evaluate the impact of different levetiracetam drug regimens on cognitive function. METHODS A retrospective analysis identified 221 patients diagnosed with seizures who underwent cognitive screening. Patients were categorized into four groups: no medications, non-levetiracetam medications, high and low dose levetiracetam. Composite scores determined low and high levetiracetam groups whereby one point was added for each increment in dosage, duration since uptake, and concurrent anti-seizure medication. Variables known to affect cognition were recorded and classified as demographic, seizure-related, diagnosis-related, and psychopathology. Logistic regression was used to identify variables associated with cognitive scores below cut-off. RESULTS Multivariable analysis found being male, non-active in the community, less than 12 years of education, left temporal lobe epilepsy, high seizure frequency, and depression were associated with poor cognitive performance. In a final regression analysis, the high levetiracetam group exhibited a 4.5-fold higher likelihood of scoring below cut-off than the medication-free group (OR 4.5, CI 1.5-13.6, p<.08). Depression (OR 2.1, CI 1.1-3.9, p<.03), being male (OR 2.2, CI 1.1-4.3, p<.02), and not being active in the community (OR 3.8, 1.6-8.7, p <.003) remained significant contributors to the model. Language (p<.05), attention (p<.05), and delayed recall (p<.001) were the most affected cognitive domains. SIGNIFICANCE When taken in small doses, for brief periods as monotherapy, levetiracetam minimally influences cognition. At higher doses, as part of long-term seizure management, in conjunction with multiple ASMs, LEV is associated with cognitive impairment.
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Affiliation(s)
- Jon Davis Perkins
- Hamad Medical Corporation, Doha, Qatar; PMARC, University of Edinburgh, Edinburgh. UK.
| | | | - Stacy Schantz Wilkins
- Greater Los Angeles VA Medical Center, Los Angeles, CA, USA; David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Saadat Kamran
- Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine, Qatar, Education City, Doha, Qatar
| | - Boulenouar Mesraoua
- Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine, Qatar, Education City, Doha, Qatar
| | - Gayane Melikyan
- Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine, Qatar, Education City, Doha, Qatar
| | | | | | - Osama Elalamy
- Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine, Qatar, Education City, Doha, Qatar
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11
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Winter Y, Sandner K, Glaser M, Ciolac D, Sauer V, Ziebart A, Karakoyun A, Chiosa V, Saryyeva A, Krauss J, Ringel F, Groppa S. Synergistic effects of vagus nerve stimulation and antiseizure medication. J Neurol 2023; 270:4978-4984. [PMID: 37368131 PMCID: PMC10511567 DOI: 10.1007/s00415-023-11825-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Vagus nerve stimulation (VNS) is an effective, non-pharmacological therapy for epileptic seizures. Until now, favorable combinations of different groups of antiseizure medication (ASM) and VNS have not been sufficiently addressed. The aim of this study was to identify the synergistic effects between VNS and different ASMs. METHODS We performed an observational study of patients with epilepsy who were implanted with VNS and had a stable ASM therapy during the first 2 years after the VNS implantation. Data were collected from the Mainz Epilepsy Registry. The efficacy of VNS depending on the concomitantly used ASM group/individual ASMs was assessed by quantifying the responder rate (≥ 50% seizure reduction compared to the time of VNS implantation) and seizure freedom (absence of seizures during the last 6 months of the observation period). RESULTS One hundred fifty one patients (mean age 45.2 ± 17.0 years, 78 females) were included in the study. Regardless of the used ASM, the responder rate in the whole cohort was 50.3% and the seizure freedom was 13.9%. Multiple regression analysis showed that combination of VNS with synaptic vesicle glycoprotein (SV2A) modulators (responder rate 64.0%, seizure freedom 19.8%) or slow sodium channel inhibitors (responder rate 61.8%, seizure freedom 19.7%) was associated with a statistically significant better responder rate and seizure freedom than combinations of VNS and ASM with other mechanism of action. Within these ASM groups, brivaracetam showed a more favorable effect than levetiracetam, whereas lacosamide and eslicarbazepine were comparable in their effects. CONCLUSION Our data suggest that the combination of VNS with ASMs belonging to either SV2A modulators or slow sodium channel inhibitors could be optimal to achieve a better seizure control following VNS. However, these preliminary data require further validation under controlled conditions.
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Affiliation(s)
- Yaroslav Winter
- Department of Neurology, Mainz Comprehensive Epilepsy and Sleep Medicine Center, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr 1, 55131, Mainz, Germany.
- Department of Neurology, Philipps-University, Marburg, Germany.
| | - Katharina Sandner
- Department of Neurology, Mainz Comprehensive Epilepsy and Sleep Medicine Center, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr 1, 55131, Mainz, Germany
| | - Martin Glaser
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Dumitru Ciolac
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Viktoria Sauer
- Department of Neurology, Philipps-University, Marburg, Germany
| | - Andreas Ziebart
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ali Karakoyun
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Vitalie Chiosa
- Laboratory of Neurobiology and Medical Genetics, Department of Neurology, Nicolae Testemitąnu State University of Medicine and Pharmacy, Chisinau, Moldova
| | - Assel Saryyeva
- Department of Neurosurgery, Medical School Hannover, MHH, Hannover, Germany
| | - Joachim Krauss
- Department of Neurosurgery, Medical School Hannover, MHH, Hannover, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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12
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Damnjanović I, Tsyplakova N, Stefanović N, Tošić T, Catić-Đorđević A, Karalis V. Joint use of population pharmacokinetics and machine learning for optimizing antiepileptic treatment in pediatric population. Ther Adv Drug Saf 2023; 14:20420986231181337. [PMID: 37359445 PMCID: PMC10288421 DOI: 10.1177/20420986231181337] [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: 01/30/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Purpose Unpredictable drug efficacy and safety of combined antiepileptic therapy is a major challenge during pharmacotherapy decisions in everyday clinical practice. The aim of this study was to describe the pharmacokinetics of valproic acid (VA), lamotrigine (LTG), and levetiracetam (LEV) in a pediatric population using nonlinear mixed-effect modeling, while machine learning (ML) algorithms were applied to identify any relationships among the plasma levels of the three medications and patients' characteristics, as well as to develop a predictive model for epileptic seizures. Methods The study included 71 pediatric patients of both genders, aged 2-18 years, on combined antiepileptic therapy. Population pharmacokinetic (PopPK) models were developed separately for VA, LTG, and LEV. Based on the estimated pharmacokinetic parameters and the patients' characteristics, three ML approaches were applied (principal component analysis, factor analysis of mixed data, and random forest). PopPK models and ML models were developed, allowing for greater insight into the treatment of children on antiepileptic treatment. Results Results from the PopPK model showed that the kinetics of LEV, LTG, and VA were best described by a one compartment model with first-order absorption and elimination kinetics. Reliance on random forest model is a compelling vision that shows high prediction ability for all cases. The main factor that can affect antiepileptic activity is antiepileptic drug levels, followed by body weight, while gender is irrelevant. According to our study, children's age is positively associated with LTG levels, negatively with LEV and without the influence of VA. Conclusion The application of PopPK and ML models may be useful to improve epilepsy management in vulnerable pediatric population during the period of growth and development.
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Affiliation(s)
| | - Nastia Tsyplakova
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikola Stefanović
- Department of Pharmacy, Faculty of Medicine, University of Nis, Nis, Serbia
| | - Tatjana Tošić
- Clinic of Pediatric Internal Medicine, Department of Pediatric Neurology, University Clinical Center of Nis, Nis, Serbia
| | | | - Vangelis Karalis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
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13
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Stöber TM, Batulin D, Triesch J, Narayanan R, Jedlicka P. Degeneracy in epilepsy: multiple routes to hyperexcitable brain circuits and their repair. Commun Biol 2023; 6:479. [PMID: 37137938 PMCID: PMC10156698 DOI: 10.1038/s42003-023-04823-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 04/06/2023] [Indexed: 05/05/2023] Open
Abstract
Due to its complex and multifaceted nature, developing effective treatments for epilepsy is still a major challenge. To deal with this complexity we introduce the concept of degeneracy to the field of epilepsy research: the ability of disparate elements to cause an analogous function or malfunction. Here, we review examples of epilepsy-related degeneracy at multiple levels of brain organisation, ranging from the cellular to the network and systems level. Based on these insights, we outline new multiscale and population modelling approaches to disentangle the complex web of interactions underlying epilepsy and to design personalised multitarget therapies.
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Affiliation(s)
- Tristan Manfred Stöber
- Frankfurt Institute for Advanced Studies, 60438, Frankfurt am Main, Germany
- Institute for Neural Computation, Faculty of Computer Science, Ruhr University Bochum, 44801, Bochum, Germany
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University, 60590, Frankfurt, Germany
| | - Danylo Batulin
- Frankfurt Institute for Advanced Studies, 60438, Frankfurt am Main, Germany
- CePTER - Center for Personalized Translational Epilepsy Research, Goethe University, 60590, Frankfurt, Germany
- Faculty of Computer Science and Mathematics, Goethe University, 60486, Frankfurt, Germany
| | - Jochen Triesch
- Frankfurt Institute for Advanced Studies, 60438, Frankfurt am Main, Germany
| | - Rishikesh Narayanan
- Cellular Neurophysiology Laboratory, Molecular Biophysics Unit, Indian Institute of Science, Bangalore, 560012, India
| | - Peter Jedlicka
- ICAR3R - Interdisciplinary Centre for 3Rs in Animal Research, Faculty of Medicine, Justus Liebig University Giessen, 35390, Giessen, Germany.
- Institute of Clinical Neuroanatomy, Neuroscience Center, Goethe University, 60590, Frankfurt am Main, Germany.
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14
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Gordon LG, Elliott TM, Bennett C, Hollway G, Waddell N, Vadlamudi L. Early cost-utility analysis of genetically guided therapy for patients with drug-resistant epilepsy. Epilepsia 2022; 63:3111-3121. [PMID: 36082520 DOI: 10.1111/epi.17408] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Existing gene panels were developed to understand the etiology of epilepsy, and further benefits will arise from an effective pharmacogenomics panel for personalizing therapy and achieving seizure control. Our study assessed the cost-effectiveness of a pharmacogenomics panel for patients with drug-resistant epilepsy, compared with usual care. METHODS A cost-utility analysis was employed using a discrete event simulation model. The microsimulation model aggregated the costs and benefits of genetically guided treatment versus usual care for 5000 simulated patients. The 10-year model combined data from various sources including genomic databases on prevalence of variants, population-level pharmaceutical claims on antiseizure medications, published long-term therapy retention rates, patient-level cost data, and systematic reviews. Incremental cost per quality-adjusted life-year (QALY) gained was computed. Deterministic and probabilistic sensitivity analyses were undertaken to address uncertainty in model parameters. RESULTS The mean cost of the genetically guided treatment option was AU$98 199 compared with AU$95 386 for usual care. Corresponding mean QALYs were 4.67 compared with 4.28 for genetically guided and usual care strategies, respectively. The incremental cost per QALY gained was AU$7381. In probabilistic sensitivity analyses, the incremental cost per QALY gained was AU$6321 (95% uncertainty interval = AU$3604-AU$9621), with a 100% likelihood of being cost-effective in the Australian health care system. The most influential drivers of the findings were the monthly health care costs associated with reduced seizures, costs when seizures continued, and the quality-of-life estimates under genetically guided and usual care strategies. SIGNIFICANCE This early economic evaluation of a pharmacogenomics panel to guide treatment for drug-resistant epilepsy could potentially be cost-effective in the Australian health care system. Clinical trial evidence is necessary to confirm these findings.
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Affiliation(s)
- Louisa G Gordon
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,School of Nursing and Cancer and Palliative Care Outcomes Centre, Queensland University of Technology, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Thomas M Elliott
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Carmen Bennett
- University of Queensland Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - Georgina Hollway
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,genomiQa, Brisbane, Queensland, Australia
| | - Nicola Waddell
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,genomiQa, Brisbane, Queensland, Australia
| | - Lata Vadlamudi
- University of Queensland Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia.,Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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15
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Metcalf CS, Gagangras S, Bulaj G, White HS. Synergistic effects of the galanin analog 810-2 with the antiseizure medication levetiracetam in rodent seizure models. Epilepsia 2022; 63:3090-3099. [PMID: 36177529 DOI: 10.1111/epi.17420] [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: 07/27/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The use of many antiseizure medications (ASMs) is limited due to pharmacoresistance and dose-limiting side effects, suggesting an unmet need for novel therapeutic approaches. The neuropeptide galanin reduces seizures in several preclinical seizure and epilepsy models, but its clinical utility is limited due to rapid metabolism and poor blood-brain barrier penetration. The lead galanin analog 810-2 is systemically bioavailable and reduces seizures when administered alone. Further development of this analog, with the potential for use as an add-on therapy in patients with epilepsy, requires a better understanding of the use of this analog in combination with approved ASMs. We sought to evaluate 810-2 in combination with commonly used ASMs in rodent models of seizures. METHODS The mouse 6-Hz seizure assay was used to test efficacy of 810-2 in combination with levetiracetam (LEV), valproic acid (VPA), or lacosamide (LCM) using a 1:1 dose ratio in isobolographic studies. Further characterization was performed for the combination of 810-2 and LEV in the mouse corneal kindling and rat 6-Hz assays. RESULTS Whereas the combination of 810-2 with VPA and LCM yielded additive interactions, the combination of 810-2 with LEV demonstrated a synergistic interaction in the mouse 6-Hz assay. Supra-additive effects were also observed in the mouse corneal kindling and rat 6-Hz assays for this combination. SIGNIFICANCE The combination of 810-2 with LEV suggests the potential for this galanin analog to be further developed as an add-on therapy for patients with epilepsy, particularly when coadministered with LEV.
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Affiliation(s)
- Cameron S Metcalf
- Epilepsy Therapy Screening Program Contract Site, Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Saurabh Gagangras
- Epilepsy Therapy Screening Program Contract Site, Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Grzegorz Bulaj
- Department of Medicinal Chemistry, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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16
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Stödberg T, Tomson T, Anderlid BM, Andersson T, Henry O, Åmark P, Wedell A. Outcome at age 7 of epilepsy presenting in the first 2 years of life. A population-based study. Epilepsia 2022; 63:2096-2107. [PMID: 35652437 PMCID: PMC9544859 DOI: 10.1111/epi.17314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/23/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
Objective Existing data suggest that epilepsy presenting in the first few years of life carries a worse prognosis than later onset. However, studies are few and methods differ, making interpretations of data uncertain. This study analyzes outcome at age 7 and potential prognostic factors in a well‐characterized population‐based cohort with epilepsy onset during the first 2 years of life. Methods An incidence cohort of 116 prospectively identified cases of epilepsy with seizure onset before age 2 years was described in Stödberg et al. (2020). Cases were originally retrieved from the Stockholm Incidence Registry of Epilepsy (SIRE), which registered all cases with a first unprovoked epileptic seizure from September 1, 2001, in Northern Stockholm. Data on treatment and outcome at age 7 years were collected from electronic medical records and through interviews with parents. Outcome and potential prognostic factors were analyzed with descriptive statistics and multivariable log binomial regression analysis. Results Eleven children (9.5%) died before age 7. Polytherapy was common. Epilepsy surgery was performed in two children. At age 7 years, 61 of 116 children (53%) had been seizure‐free for the last 2 years or longer. Intellectual disability was diagnosed in 57 of 116 children (49%), autism spectrum disorder in 13 (11%), and cerebral palsy in 28 (24%). West syndrome had a similar seizure remission rate but a worse cognitive outcome. There was no difference in outcome between first and second year onset. Six predictors, including etiology, remained associated with two or more outcome variables after regression analysis. Significance About half of children with infantile‐onset epilepsy will become seizure‐free and half of them will have intellectual disability. Etiology was confirmed as a major independent predictor of outcome. Our study contributes to a more firm knowledge base when counseling parents of infants diagnosed with epilepsy.
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Affiliation(s)
- Tommy Stödberg
- Department of Women's and Children`s Health, Karolinska Institute, Stockholm, Sweden.,Department of Pediatric Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Britt-Marie Anderlid
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Andersson
- Institute of Environmental Medicine, Stockholm, Sweden.,Centre for Occupational and Environmental Medicine, Stockholm Regional Council
| | - Olivia Henry
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Per Åmark
- Department of Women's and Children`s Health, Karolinska Institute, Stockholm, Sweden
| | - Anna Wedell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Centre for Inherited Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden
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17
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Dini G, Tulli E, Dell’Isola GB, Mencaroni E, Di Cara G, Striano P, Verrotti A. Improving Therapy of Pharmacoresistant Epilepsies: The Role of Fenfluramine. Front Pharmacol 2022; 13:832929. [PMID: 35668937 PMCID: PMC9164301 DOI: 10.3389/fphar.2022.832929] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/29/2022] [Indexed: 01/24/2023] Open
Abstract
Epilepsy is among the most common neurological chronic disorders, with a prevalence of 0.5-1%. Despite the introduction of new antiepileptic drugs during recent years, about one third of the epileptic population remain drug-resistant. Hence, especially in the pediatric population limited by different pharmacokinetics and pharmacodynamics and by ethical and regulatory issues it is needed to identify new therapeutic resources. New molecules initially used with other therapeutic indications, such as fenfluramine, are being considered for the treatment of pharmacoresistant epilepsies, including Dravet Syndrome (DS) and Lennox-Gastaut Syndrome (LGS). Drug-refractory seizures are a hallmark of both these conditions and their treatment remains a major challenge. Fenfluramine is an amphetamine derivative that was previously approved as a weight loss drug and later withdrawn when major cardiac adverse events were reported. However, a new role of fenfluramine has emerged in recent years. Indeed, fenfluramine has proved to be a promising antiepileptic drug with a favorable risk-benefit profile for the treatment of DS, LGS and possibly other drug-resistant epileptic syndromes. The mechanism by which fenfluramine provide an antiepileptic action is not fully understood but it seems to go beyond its pro-serotoninergic activity. This review aims to provide a comprehensive analysis of the literature, including ongoing trials, regarding the efficacy and safety of fenfluramine as adjunctive treatment of pharmacoresistant epilepsies.
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Affiliation(s)
- Gianluca Dini
- Department of Pediatrics, University of Perugia, Genoa, Italy,*Correspondence: Gianluca Dini,
| | - Eleonora Tulli
- Department of Pediatrics, University of Perugia, Genoa, Italy
| | | | | | | | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS “G. Gaslini” Institute, Genoa, Italy,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
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18
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Liparoti G, Burchiani B, Mencaroni E, Tripodi D, Di Cara G, Verrotti A. Individualizing doses of antiepileptic drugs. Expert Opin Drug Metab Toxicol 2022; 18:219-233. [PMID: 35523739 DOI: 10.1080/17425255.2022.2075342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This review aims to identify the optimal therapeutic dosage of anti-epileptic drugs in terms of efficacy and safety in patients with multiple comorbidities. AREAS COVERED We have analyzed changes in terms of pharmacokinetics and pharmacodynamics of Brivaracetam, Carbamazepine, Lacosamide, Lamotrigine, Levetiracetam, Topiramate, Valproate, and Zonisamide in liver disease, chronic kidney disease, and in patients admitted to intensive care unit. Our literature search covers the past 5 years. We used PubMed, Google Scholar, and EMBASE database's to support our article. EXPERT OPINION To ensure that the patient with seizure receives the best treatment in relation to their comorbidities, careful clinical-laboratory monitoring is necessary to maximize effectiveness while maintaining safety, especially in the case of polytherapy.
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Affiliation(s)
- Giulia Liparoti
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | | | | | - Domenico Tripodi
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio"of Chieti-Pescara, Chieti, Italy
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19
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Ahmed H, Khan MA, Ali Zaidi SA, Muhammad S. In Silico and In Vivo: Evaluating the Therapeutic Potential of Kaempferol, Quercetin, and Catechin to Treat Chronic Epilepsy in a Rat Model. Front Bioeng Biotechnol 2021; 9:754952. [PMID: 34805114 PMCID: PMC8599161 DOI: 10.3389/fbioe.2021.754952] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022] Open
Abstract
Recently, alternative therapies are gaining popularity in the treatment of epilepsy. The present study aimed to find out the antiepileptic potential of quercetin, catechin, and kaempferol. In vivo and in silico experiments were conducted to investigate their therapeutic potential. 25 mg/kg/day of pentylenetetrazole was administered for 4 weeks after epilepsy was induced in the rats; this was followed by the behavioral studies and histological analysis of rat brain slices. Binding affinities of kaempferol, quercetin, and catechin were assessed by performing in silico studies. Kaempferol, quercetin, and catechin were found to have the highest binding affinity with the synaptic vesicle 2A (SV2A) protein, comparable to standard levetiracetam (LEV). The mRNA levels of SV2A, as well as the expression of TNF, IL 6, IL 1 beta, NFkB, IL 1Ra, IL 4, and IL 10, were investigated using qPCR. Our results indicate for the first time that SV2A is also a transporter of understudied phytoflavonoids, due to which a significant improvement was observed in epileptic parameters. The mRNA levels of SV2A were found to be significantly elevated in the PF-treated rats when compared with those of the control rats with epilepsy. Additionally, downregulation of the pro-inflammatory cytokines and upregulation of the anti-inflammatory cytokines were also noted in the PF-treated groups. It is concluded that kaempferol, quercetin, and catechin can effectively decrease the epileptic seizures in our chronic epilepsy rat model to a level that is comparable to the antiepileptic effects induced by levetiracetam drug.
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Affiliation(s)
- Hammad Ahmed
- Faculty of Pharmacy, The University of Lahore, Defence Road Campus, Lahore, Pakistan.,Imran Idrees College of Pharmacy, Sialkot, Pakistan
| | | | | | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany.,Department of Neurosurgery, University of Helsinki and University Hospital, Helsinki, Finland
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20
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Pottoo FH, Salahuddin M, Khan FA, AL Dhamen MA, Alsaeed WJ, Gomaa MS, Vatte C, Alomary MN. Combinatorial Regimen of Carbamazepine and Imipramine Exhibits Synergism against Grandmal Epilepsy in Rats: Inhibition of Pro-Inflammatory Cytokines and PI3K/Akt/mTOR Signaling Pathway. Pharmaceuticals (Basel) 2021; 14:1204. [PMID: 34832986 PMCID: PMC8624327 DOI: 10.3390/ph14111204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 02/06/2023] Open
Abstract
Epilepsy is a neurodegenerative disorder that causes recurring seizures. Thirty-five percent of patients remain refractory, with a higher prevalence of depression. We investigated the anticonvulsant efficacy of carbamazepine (CBZ; 20 and 50 mg/kg), imipramine (IMI; 10 and 20 mg/kg) alone, and as a low dose combination. This preclinical investigation included dosing of rats for 14 days followed by elicitation of electroshock on the last day of treatment. Along with behavioral monitoring, the rat hippocampus was processed for quantification of mTOR, IL-1β, IL-6 and TNF-α levels. The histopathological analysis of rat hippocampus was performed to ascertain neuroprotection. In vitro studies and in silico studies were also conducted. We found that the low dose combinatorial therapy of CBZ (20 mg/kg) + IMI (10 mg/kg) exhibits synergism (p < 0.001) in abrogation of maximal electroshock (MES) induced convulsions/tonic hind limb extension (THLE), by reducing levels of pro-inflammatory cytokines, and weakening of the PI3K/Akt/mTOR signal. The combination also exhibits cooperative binding at the Akt. As far as neuroprotection is concerned, the said combination increased cell viability by 166.37% compared to Pentylenetetrazol (PTZ) treated HEK-293 cells. Thus, the combination of CBZ (20 mg/kg) + IMI (10 mg/kg) is a fruitful combination therapy to elevate seizure threshold and provide neuroprotection.
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Affiliation(s)
- Faheem Hyder Pottoo
- Department of Pharmacology, College of Clinical Pharmacy, Imam Abdul Rahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia; (M.A.A.D.); (W.J.A.)
| | - Mohammed Salahuddin
- Department of Clinical Pharmacy Research, Institute for Research and Medical Consultation, Imam Abdul Rahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia;
| | - Firdos Alam Khan
- Department of Stem cell Research, Institute for Research and Medical Consultation, Imam Abdul Rahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia;
| | - Marwa Abdullah AL Dhamen
- Department of Pharmacology, College of Clinical Pharmacy, Imam Abdul Rahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia; (M.A.A.D.); (W.J.A.)
| | - Walaa Jafar Alsaeed
- Department of Pharmacology, College of Clinical Pharmacy, Imam Abdul Rahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia; (M.A.A.D.); (W.J.A.)
| | - Mohamed S. Gomaa
- Department of Pharmaceutical Chemistry, College of Clinical Pharmacy, Imam Abdul Rahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia;
| | - Chittibabu Vatte
- Department of Biochemistry, College of Medicine, Imam Abdul Rahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia;
| | - Mohammad N. Alomary
- National Centre for Biotechnology, Kind Abdulaziz City for Science and Technology (KACST), P.O. Box 1982, Riyadh 11442, Saudi Arabia
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21
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Löscher W. Single-Target Versus Multi-Target Drugs Versus Combinations of Drugs With Multiple Targets: Preclinical and Clinical Evidence for the Treatment or Prevention of Epilepsy. Front Pharmacol 2021; 12:730257. [PMID: 34776956 PMCID: PMC8580162 DOI: 10.3389/fphar.2021.730257] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/04/2021] [Indexed: 01/09/2023] Open
Abstract
Rationally designed multi-target drugs (also termed multimodal drugs, network therapeutics, or designed multiple ligands) have emerged as an attractive drug discovery paradigm in the last 10-20 years, as potential therapeutic solutions for diseases of complex etiology and diseases with significant drug-resistance problems. Such agents that modulate multiple targets simultaneously are developed with the aim of enhancing efficacy or improving safety relative to drugs that address only a single target or to combinations of single-target drugs. Although this strategy has been proposed for epilepsy therapy >25 years ago, to my knowledge, only one antiseizure medication (ASM), padsevonil, has been intentionally developed as a single molecular entity that could target two different mechanisms. This novel drug exhibited promising effects in numerous preclinical models of difficult-to-treat seizures. However, in a recent randomized placebo-controlled phase IIb add-on trial in treatment-resistant focal epilepsy patients, padsevonil did not separate from placebo in its primary endpoints. At about the same time, a novel ASM, cenobamate, exhibited efficacy in several randomized controlled trials in such patients that far surpassed the efficacy of any other of the newer ASMs. Yet, cenobamate was discovered purely by phenotype-based screening and its presumed dual mechanism of action was only described recently. In this review, I will survey the efficacy of single-target vs. multi-target drugs vs. combinations of drugs with multiple targets in the treatment and prevention of epilepsy. Most clinically approved ASMs already act at multiple targets, but it will be important to identify and validate new target combinations that are more effective in drug-resistant epilepsy and eventually may prevent the development or progression of epilepsy.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany, and Center for Systems Neuroscience Hannover, Hannover, Germany
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22
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Malformations of Cortical Development, Cognitive Involvementand Epilepsy: A Single Institution Experience in 19 Young Patients. CHILDREN-BASEL 2021; 8:children8080637. [PMID: 34438528 PMCID: PMC8392186 DOI: 10.3390/children8080637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/07/2021] [Accepted: 07/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Malformations of cortical development (MCD) include a wide range of congenital disorders mostly causing severe cognitive dysfunction and epilepsy. OBJECTIVE to report on clinical features including cognitive involvement, epileptic seizures with response to antiseizure medications, comorbidities in young patients affected by MCD and followed in a single tertiary hospital. PATIENTS AND METHODS A retrospective review of the medical records and magnetic resonance images (MRI) of 19 young patients with an age ranging between eight days and fifteen years affected by MCD and admitted to Pediatrics Department University of Catania, Italy from October 2009 and October 2020 were selected. Patients were distinguished in three groups following the Barcovich et al. 2012 classification for MCD: 4 (21%) in Group I; 8 (42%) in Group II; and, and 7 (37%) in Group III. Clinical features and MRI of the patients including cognitive involvement, epilepsy type and response to drugs treatment were analyzed. RESULTS In Group I, two patients showed cortical dysplasia and two dysembryoplastic neuroepithelial tumors plus focal cortical dysplasia; developmental delay/intellectual disability (DD/ID) was severe in one, moderate in one and absent in two; the type of seizures was in all the cases focal to bilateral tonic-clonic (FBTCs), and drug resistant was found in one case. In Group II, three patients showed neuronal hetero-topias and five had pachygyria-lissencephaly: DD/ID was severe in four, moderate in two, and absent in two; the type of seizure was focal (FS) in five, focal to bilateral tonic-clonic (FBTCs) in two, infantile spasms (IS) in one, and drug resistant was found in three. In Group III, six showed polymicrogyria and one schizencephaly: DD/ID was found severe in five, moderate in two, and the type of seizure was focal (FS) in five, FBTCS in two, and drug resistance was found in three.
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Masumshah R, Aghdam R, Eslahchi C. A neural network-based method for polypharmacy side effects prediction. BMC Bioinformatics 2021; 22:385. [PMID: 34303360 PMCID: PMC8305591 DOI: 10.1186/s12859-021-04298-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Polypharmacy is a type of treatment that involves the concurrent use of multiple medications. Drugs may interact when they are used simultaneously. So, understanding and mitigating polypharmacy side effects are critical for patient safety and health. Since the known polypharmacy side effects are rare and they are not detected in clinical trials, computational methods are developed to model polypharmacy side effects. RESULTS We propose a neural network-based method for polypharmacy side effects prediction (NNPS) by using novel feature vectors based on mono side effects, and drug-protein interaction information. The proposed method is fast and efficient which allows the investigation of large numbers of polypharmacy side effects. Our novelty is defining new feature vectors for drugs and combining them with a neural network architecture to apply for the context of polypharmacy side effects prediction. We compare NNPS on a benchmark dataset to predict 964 polypharmacy side effects against 5 well-established methods and show that NNPS achieves better results than the results of all 5 methods in terms of accuracy, complexity, and running time speed. NNPS outperforms about 9.2% in Area Under the Receiver-Operating Characteristic, 12.8% in Area Under the Precision-Recall Curve, 8.6% in F-score, 10.3% in Accuracy, and 18.7% in Matthews Correlation Coefficient with 5-fold cross-validation against the best algorithm among other well-established methods (Decagon method). Also, the running time of the Decagon method which is 15 days for one fold of cross-validation is reduced to 8 h by the NNPS method. CONCLUSIONS The performance of NNPS is benchmarked against 5 well-known methods, Decagon, Concatenated drug features, Deep Walk, DEDICOM, and RESCAL, for 964 polypharmacy side effects. We adopt the 5-fold cross-validation for 50 iterations and use the average of the results to assess the performance of the NNPS method. The evaluation of the NNPS against five well-known methods, in terms of accuracy, complexity, and running time speed shows the performance of the presented method for an essential and challenging problem in pharmacology. Datasets and code for NNPS algorithm are freely accessible at https://github.com/raziyehmasumshah/NNPS .
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Affiliation(s)
- Raziyeh Masumshah
- Department of Computer and Data Sciences, Faculty of Mathematical Sciences, Shahid Beheshti University, Tehran, Iran
| | - Rosa Aghdam
- School of Biological Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran.
| | - Changiz Eslahchi
- Department of Computer and Data Sciences, Faculty of Mathematical Sciences, Shahid Beheshti University, Tehran, Iran.
- School of Biological Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran.
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Sunwoo JS, Jo H, Kang KW, Kim KT, Kim D, Kim DW, Kim MJ, Kim S, Kim W, Moon HJ, Park HR, Byun JI, Seo JG, Lim SC, Chu MK, Han SH, Hwang KJ, Seo DW. Survey on Antiepileptic Drug Therapy in Patients with Drug Resistant Epilepsy. J Epilepsy Res 2021; 11:72-82. [PMID: 34395226 PMCID: PMC8357558 DOI: 10.14581/jer.21010] [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: 05/24/2021] [Revised: 06/15/2021] [Accepted: 06/18/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose Individualized anti-epileptic drug (AED) selection in patient with epilepsy is crucial. However, there is no unified opinion in treating patients with drug resistant epilepsy (DRE). This survey aimed to make a consolidate consensus with epileptologists’ perspectives of the treatment for Korean DRE patients by survey responses. Methods The survey was conducted with Korean epilepsy experts who have experience prescribing AEDs via e-mail. Survey questionnaires consisted of six items regarding prescription patterns and practical questions in treating patients with DRE in Korea. The research period was from February 2021 to March 2021. Results The survey response rate was 83.3% (90/108). Most (77.8%) of the responders are neurologists. The proportion of patients whose seizures were not controlled by the second AED was 26.9%. The proportion of patients who had taken five or more AEDs is 13.9%, and those who are currently taking five or more AEDs are 7.3%, of which 54.5% and 37.9% reported positive effects on additional AED, respectively. The majority (91.1%) of respondents answered that the mechanism of action was the top priority factor when adding AED. Regarding data priority, responders considered that expert opinion should have the top priority, followed by clinical experiences, reimbursement guidelines and clinical evidence. Responders gave 64.9 points (range from 0 to 100) about overall satisfaction on reimbursement system of Health Insurance Review and Assessment Service for AED. Conclusions This study on AED therapy for DRE patients is the first nationwide trial in Korean epilepsy experts. In five drug failure, the top priorities on AED selection are mechanism of action and expert opinion. These findings might help to achieve consensus and recognize the insight on optimal therapy of AED in DRE.
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Affiliation(s)
- Jun-Sang Sunwoo
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Hyunjin Jo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Keun Tae Kim
- , KoreaDepartment of Neurology, Keimyung University School of Medicine, Daegu
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Min-Jee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Saeyoon Kim
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Woojun Kim
- Department of Neurology, The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, Korea
| | - Hye-Jin Moon
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Ha Ree Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jung-Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jong-Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung Chul Lim
- Department of Neurology, The Catholic University of Korea St. Vincent's Hospital, Suwon, Korea
| | - Min Kyung Chu
- Department of Neurology, Severance Hospital, Seoul, Korea
| | - Su-Hyun Han
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kyoung Jin Hwang
- Department of Neurology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Dae-Won Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Samson Osuntokun O, Grace Akingboye B, Olayiwola G, Adekemi Abayomi T, Oladele Ayoka A. The impairment of motor coordination following chronic carbamazepine-levetiracetam combination treatment with evidence of corticocerebellar toxicity in male Wistar rats. Brain Res 2021; 1767:147565. [PMID: 34175264 DOI: 10.1016/j.brainres.2021.147565] [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: 09/16/2020] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022]
Abstract
This study examined the effects of carbamazepine (CBZ) or levetiracetam (LEV) and sub-therapeutic doses of the combination of the two conventional antiepileptics on some of the markers of motor coordination. Twenty-four male Wistar rats (140 ± 5 g) were randomized into 4 groups (n = 6). Group I rats received physiological saline (0.2 ml), group II were administered CBZ (25.0 mg/kg), group III received LEV (50 mg/kg), while group IV rats were given sub-therapeutic doses of CBZ (12.5 mg/kg) and LEV (25 mg/kg) intraperitoneally for 28 days. Thereafter the animals were subjected to behavioral and biochemical investigations, while the frontal lobe and cerebellar tissue were preserved for histological investigation. Data were subjected to descriptive and inferential statistics, and the results presented as mean ± SEM, analyzed using one-way Analysis of variance (ANOVA) and Student- Newman Keuls post hoc analysis where appropriate. p < 0.05 was considered statistically significant. There was significant alteration in fine and skilled movement after the CBZ, and CBZ + LEV chronic treatment compared with the control. The CBZ, and CBZ + LEV combination treatment increased the frontal lobe and cerebellar activities of acetylcholinesterase, malondialdehyde concentration, tissue necrotic factor alpha and decreased the activities of super oxide dismutase relative to the control. Disorganization of the histoarchitecture of the frontal lobe and cerebellum was characterized by cellular atrophy, chromatolysis and hyalinization. Chronic CBZ, and CBZ + LEV combination treatment produced psychomotor dysfunction and neurotoxicity in this order CBZ + LEV > CBZ > LEV in the rats.
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Affiliation(s)
- Opeyemi Samson Osuntokun
- Department of Physiology, Faculty of Basic Medical Sciences, College of Health Sciences, Osun State University, Osogbo, Nigeria; Department of Physiology, Faculty of Basic Medical Sciences, Federal University, Oye Ekiti, Ekiti State.
| | - Busayo Grace Akingboye
- Department of Physiology, Faculty of Basic Medical Sciences, College of Health Sciences, Osun State University, Osogbo, Nigeria
| | - Gbola Olayiwola
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Taiwo Adekemi Abayomi
- Department of Anatomy, Faculty of Basic Medical Sciences, College of Health Sciences, Osun State University, Osogbo, Nigeria
| | - Abiodun Oladele Ayoka
- Department of Physiological Sciences, Faculty of Basic Medical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
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26
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Fattorusso A, Matricardi S, Mencaroni E, Dell'Isola GB, Di Cara G, Striano P, Verrotti A. The Pharmacoresistant Epilepsy: An Overview on Existent and New Emerging Therapies. Front Neurol 2021; 12:674483. [PMID: 34239494 PMCID: PMC8258148 DOI: 10.3389/fneur.2021.674483] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/27/2021] [Indexed: 12/21/2022] Open
Abstract
Epilepsy is one of the most common neurological chronic disorders, with an estimated prevalence of 0. 5 - 1%. Currently, treatment options for epilepsy are predominantly based on the administration of symptomatic therapy. Most patients are able to achieve seizure freedom by the first two appropriate drug trials. Thus, patients who cannot reach a satisfactory response after that are defined as pharmacoresistant. However, despite the availability of more than 20 antiseizure medications (ASMs), about one-third of epilepsies remain drug-resistant. The heterogeneity of seizures and epilepsies, the coexistence of comorbidities, and the broad spectrum of efficacy, safety, and tolerability related to the ASMs, make the management of these patients actually challenging. In this review, we analyze the most relevant clinical and pathogenetic issues related to drug-resistant epilepsy, and then we discuss the current evidence about the use of available ASMs and the alternative non-pharmacological approaches.
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Affiliation(s)
- Antonella Fattorusso
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | - Sara Matricardi
- Child Neurology and Psychiatry Unit, Children's Hospital “G. Salesi”, Ospedali Riuniti Ancona, Ancona, Italy
| | - Elisabetta Mencaroni
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | | | - Giuseppe Di Cara
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS “G. Gaslini” Institute, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Alberto Verrotti
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
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Tulli E, Di Cara G, Iapadre G, Striano P, Verrotti A. An update on brivaracetam for the treatment of pediatric partial epilepsy. Expert Opin Pharmacother 2021; 22:1387-1395. [PMID: 33896317 DOI: 10.1080/14656566.2021.1921151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Brivaracetam (BRV) is an antiseizure medication (ASM), which has been approved as an adjunctive treatment in adults and pediatric patients aged four years and older with focal onset seizures. It is a second-generation levetiracetam (LEV) derivative, sharing the same mechanism of action, binding synaptic vesicles 2A (SV2A). BRV shows higher binding affinity and selectivity and higher brain permeability than LEV.Areas covered: This article reviews randomized controlled trials, retrospective and prospective studies published up to December 2020, searched in electronic databases MEDLINE, EMBASE and the Clinical Trial Database and provide an overview of efficacy, safety and tolerability of BRV in pediatric patients with partial epilepsy. Furthermore, the authors provide their expert opinion on the drug and give their future perspectives.Expert opinion: The analysis of the literature data has demonstrated the safety and efficacy of BRV in pediatric patients, with more evidence in children aged 4 to 16 years with an onset of focal seizures. However, a positive response was also achieved in patients affected by some encephalopathic epilepsies. Comparative efficacy studies between BRV and other ASMs, in addition to well-designed RCTs that include larger pediatric populations are needed to better define the role and potentiality of this ASM.
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Affiliation(s)
- Eleonora Tulli
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | | | - Giulia Iapadre
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscolar Diseases Unit, IRRCS Istituto Giannina Gaslini, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
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Brandt C, McGuire L, Uetrecht J. Severe cutaneous adverse reaction associated with antiseizure medications: Diagnosis, management, and prevention. Epilepsy Behav 2021; 117:107844. [PMID: 33639435 DOI: 10.1016/j.yebeh.2021.107844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/06/2023]
Abstract
Severe cutaneous adverse reactions (SCARs) are potentially life-threatening, with considerable morbidity and mortality. They are nonimmediate hypersensitivity reactions that occur in specifically predisposed patients with delayed T-cell-mediated hypersensitivity reaction. Antiseizure medications (ASMs) are among the drugs that can induce SCAR. Increased awareness of SCAR among clinicians treating patients with ASMs is critically important for early recognition of symptoms, prompt identification and removal of the causal drug, and early intervention to reduce SCAR-related acute and long-term morbidity and mortality. The diagnosis, management, and prevention of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) are reviewed, along with the current understanding of the pathomechanisms and role of genetics in SCAR development. Supportive care and immunomodulating treatments for SCAR are discussed.
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Affiliation(s)
- Christian Brandt
- Department of General Epileptology, Bethel Epilepsy Centre, Mara Hospital, Bielefeld, Germany.
| | - Lynanne McGuire
- MedVal Scientific Information Services, LLC, Princeton, NJ, USA
| | - Jack Uetrecht
- Department of Pharmacology & Toxicology, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
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29
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Rosenfeld WE, Nisman A, Ferrari L. Efficacy of adjunctive cenobamate based on number of concomitant antiseizure medications, seizure frequency, and epilepsy duration at baseline: A post-hoc analysis of a randomized clinical study. Epilepsy Res 2021; 172:106592. [PMID: 33662894 DOI: 10.1016/j.eplepsyres.2021.106592] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/28/2021] [Accepted: 02/16/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In an 18-week, double-blind, placebo-controlled study (YKP3089C017; NCT01866111), cenobamate was effective for the treatment of focal-onset seizures. This post-hoc analysis examined the effects of baseline clinical features on the efficacy of adjunctive cenobamate during the study. METHODS Adults with uncontrolled focal seizures despite treatment with 1-3 antiepileptic drugs/antiseizure medications (AEDs/ASMs) were randomized 1:1:1:1 to placebo or cenobamate 100, 200, or 400 mg once daily. Median percent seizure frequency reduction/28 days and ≥50% responder rates were assessed during the 12-week maintenance phase (n = 397) by number of baseline (concomitant) ASMs (1, 2, >2), median baseline seizure frequency/28 days (≤9.5 vs >9.5), and median baseline duration of epilepsy (≤23 vs >23 years). RESULTS For patients taking 1 concomitant ASM, median percent seizure frequency reductions ranged from 44.7% to 86.0% for cenobamate-treated patients vs 24.1% for placebo; for 2 concomitant ASMs, reductions were 41.4-57.9% with cenobamate vs 33.3% for placebo; and for >2 concomitant ASMs, reductions were 41.5-67.4% with cenobamate vs 26.4% for placebo. The highest reductions occurred in the 200- and 400-mg/day cenobamate groups. For patients with baseline seizure frequency ≤9.5, the greatest reduction in median percent seizure frequency occurred in the 200-mg/day cenobamate group (66.5%); for patients with baseline seizure frequency >9.5 the greatest reduction occurred in the 400-mg/day cenobamate group (70.7%). Similar improvements were observed when assessed by median duration of epilepsy at baseline. For cenobamate-treated patients taking 1, 2, or >2 ASMs respectively, ≥50% responder rates of up to 66.7% (400 mg), 62.2% (200 mg), and 66.0% (400 mg) were observed, vs 20.0%, 29.3%, and 23.9% for placebo, respectively; 100% seizure reductions were observed in up to 25.0% (400 mg/day), 22.2% (400 mg/day), and 19.1% (400 mg/day) of cenobamate-treated patients, vs 0%, 0%, and 2.2% for placebo, respectively. Incidence of common (≥10%) central nervous system adverse events (dizziness, somnolence, fatigue, and diplopia) were highest in the >2 ASM group, but the rates were within the range reported in the primary study. CONCLUSIONS Clinically relevant reductions in seizure frequency including 100% seizure reductions occurred with adjunctive cenobamate regardless of number of concomitant ASMs, baseline seizure frequency, or disease duration. The greatest reductions occurred in the 200- and 400-mg/day groups.
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Affiliation(s)
- William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, 11134 Conway Road, 63131 St. Louis, MO, USA.
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30
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Guery D, Rheims S. Clinical Management of Drug Resistant Epilepsy: A Review on Current Strategies. Neuropsychiatr Dis Treat 2021; 17:2229-2242. [PMID: 34285484 PMCID: PMC8286073 DOI: 10.2147/ndt.s256699] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022] Open
Abstract
Drug resistant epilepsy (DRE) is defined as the persistence of seizures despite at least two syndrome-adapted antiseizure drugs (ASD) used at efficacious daily dose. Despite the increasing number of available ASD, about a third of patients with epilepsy still suffer from drug resistance. Several factors are associated with the risk of evolution to DRE in patients with newly diagnosed epilepsy, including epilepsy onset in the infancy, intellectual disability, symptomatic epilepsy and abnormal neurological exam. Pharmacological management often consists in ASD polytherapy. However, because quality of life is driven by several factors in patients with DRE, including the tolerability of the treatment, ASD management should try to optimize efficacy while anticipating the risks of drug-related adverse events. All patients with DRE should be evaluated at least once in a tertiary epilepsy center, especially to discuss eligibility for non-pharmacological therapies. This is of paramount importance in patients with drug resistant focal epilepsy in whom epilepsy surgery can result in long-term seizure freedom. Vagus nerve stimulation, deep brain stimulation or cortical stimulation can also improve seizure control. Lastly, considering the effect of DRE on psychologic status and social integration, comprehensive care adaptations are always needed in order to improve patients' quality of life.
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Affiliation(s)
- Deborah Guery
- Department of Functional Neurology and Epileptology, Hospices Civils De Lyon and University of Lyon, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils De Lyon and University of Lyon, Lyon, France.,Lyon's Neuroscience Research Center, INSERM U1028/CNRS UMR 5292, Lyon, France.,Epilepsy Institute, Lyon, France
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31
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Oliva CF, Gangi G, Marino S, Marino L, Messina G, Sciuto S, Cacciaguerra G, Comella M, Falsaperla R, Pavone P. Single and in combination antiepileptic drug therapy in children with epilepsy: how to use it. AIMS MEDICAL SCIENCE 2021. [DOI: 10.3934/medsci.2021013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Albsoul-Younes AM, Masri AT, Gharaibeh LF, Murtaja AA, Al-Qudah AA. Frequency of antiepileptic drugs and response change in pediatric patients receiving 2 or more antiepileptic drugs. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2020; 25:269-275. [PMID: 33130807 PMCID: PMC8015607 DOI: 10.17712/nsj.2020.4.20190113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the frequency of changes in antiepileptic drugs (AEDs) use, as well as concomitant changes in the degree of seizure control in pediatric patients, who are receiving 2 or more AEDs. METHODS A prospective follow-up study at Jordan University Hospital`s pediatric neurology clinics was conducted on epileptic pediatric patients receiving at least 2 AEDs between December 2013 and April 2014. Patients were followed for 12 months. RESULTS A total of 82 patients were included, with a mean age of 7.2+/- 4.7 years. The mean number of AEDs received by patients at enrollment was 2.4+/-0.6, and 2.5+/-0.7 after follow-up. Most patients (63.4%) experienced no change in seizure control, and the majority reported at least one adverse drug reaction. Most patients received lower doses than recommended, both at the beginning and end of the study. During the year, only 3 patients (4%) were eligible for dose tapering, which would then be converted to monotherapy. Follow-up appointments average was 4.2+/-2.9 visits/patients in one year. The frequency of medication changes and dose adjustment was very low, about one-third (29.3%) of patients requiring no change in AEDs during any follow-up visits. CONCLUSION During the one year follow-up study, most patients on polytherapy maintained their level of response to the AEDs, with minimal changes in their regimen despite frequent follow-up visits. Only a small percent could be converted to AEDs monotherapy.
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Affiliation(s)
- Abla M Albsoul-Younes
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, Jordan. E-mail:
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Guery D, Rheims S. Is the mechanism of action of antiseizure drugs a key element in the choice of treatment? Fundam Clin Pharmacol 2020; 35:552-563. [PMID: 33090514 DOI: 10.1111/fcp.12614] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/02/2020] [Accepted: 10/02/2020] [Indexed: 12/20/2022]
Abstract
About 25 antiseizure drugs are available for the treatment of patients with epilepsy. The choice of the most suited drug for a specific patient is primarily based on the results of the pivotal randomized clinical trials and on the patient's characteristics and comorbidities. Whether or not the mechanism of action of the antiseizure drugs should be also taken into account to better predict the patient's response to the treatment remains a matter of debate. Despite the apparent complexity and diversity of antiseizure drug mechanisms of action, the reality unfortunately remains that they are very close, in particular with regard to their relationship with the pathophysiology of epilepsy. With the only exception of the association between lamotrigine and sodium valproate, there are no clinical data that formally support a synergistic association between certain antiseizure drugs in terms of efficacy. However, anticipating risk of adverse events by limiting as far as possible the combination of drugs, which share the same mechanisms of action, is undoubtedly an important driver of daily therapeutic decisions.
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Affiliation(s)
- Deborah Guery
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and University of Lyon, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and University of Lyon, Lyon, France.,Lyon's Neuroscience Research Center, INSERM U1028 / CNRS UMR 5292, Lyon, France.,Epilepsy Institute, Lyon, France
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Łuszczki JJ, Podgórska D, Kozińska J, Jankiewicz M, Plewa Z, Kominek M, Żółkowska D, Florek-Łuszczki M. Polygonogram with isobolographic synergy for three-drug combinations of phenobarbital with second-generation antiepileptic drugs in the tonic-clonic seizure model in mice. Pharmacol Rep 2020; 73:111-121. [PMID: 33025394 PMCID: PMC7862539 DOI: 10.1007/s43440-020-00164-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/05/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
Background Combination therapy consisting of two or more antiepileptic drugs (AEDs) is usually prescribed for patients with refractory epilepsy. The drug–drug interactions, which may occur among currently available AEDs, are the principal criterion taken by physicians when prescribing the AED combination to the patients. Unfortunately, the number of possible three-drug combinations tremendously increases along with the clinical approval of novel AEDs. Aim To isobolographically characterize three-drug interactions of phenobarbital (PB) with lamotrigine (LTG), oxcarbazepine (OXC), pregabalin (PGB) and topiramate (TPM), the maximal electroshock-induced (MES) seizure model was used in male albino Swiss mice. Materials and method The MES-induced seizures in mice were generated by alternating current delivered via auricular electrodes. To classify interactions for 6 various three-drug combinations of AEDs (i.e., PB + TPM + PGB, PB + OXC + TPM, PB + LTG + TPM, PB + OXC + PGB, PB + LTG + PGB and PB + LTG + OXC), the type I isobolographic analysis was used. Total brain concentrations of PB were measured by fluorescent polarization immunoassay technique. Results The three-drug mixtures of PB + TPM + PGB, PB + OXC + TPM, PB + LTG + TPM, PB + OXC + PGB, PB + LTG + PGB and PB + LTG + OXC protected the male albino Swiss mice from MES-induced seizures. All the observed interactions in this seizure model were supra-additive (synergistic) (p < 0.001), except for the combination of PB + LTG + OXC, which was additive. It was unable to show the impact of the studied second-generation AEDs on total brain content of PB in mice. Conclusions The synergistic interactions among PB and LTG, OXC, PGB and TPM in the mouse MES model are worthy of being transferred to clinical trials, especially for the patients with drug resistant epilepsy, who would benefit these treatment options.
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Affiliation(s)
- Jarogniew J Łuszczki
- Department of Pathophysiology, Medical University, Jaczewskiego 8b, 20-090, Lublin, PL, Poland. .,Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland.
| | - Dominika Podgórska
- Department of Pathophysiology, Medical University, Jaczewskiego 8b, 20-090, Lublin, PL, Poland
| | - Justyna Kozińska
- Chair and Clinic of Hematooncology and Bone Marrow Transplantation, Medical University, Lublin, Poland
| | - Marek Jankiewicz
- Chair and Clinic of Cardiology, Medical University, Lublin, Poland
| | - Zbigniew Plewa
- Department of General, Oncological and Minimally Invasive Surgery, 1st Military Clinical Hospital, Lublin, Poland
| | - Mateusz Kominek
- Clinic of Orthopedics and Traumatology, Medical University, Lublin, Poland
| | - Dorota Żółkowska
- Department of Neurology, School of Medicine, University of California-Davis, Sacramento, CA, USA
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Diet in the Treatment of Epilepsy: What We Know So Far. Nutrients 2020; 12:nu12092645. [PMID: 32872661 PMCID: PMC7551815 DOI: 10.3390/nu12092645] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 02/07/2023] Open
Abstract
Epilepsy is a chronic and debilitating neurological disorder, with a worldwide prevalence of 0.5–1% and a lifetime incidence of 1–3%. An estimated 30% of epileptic patients continue to experience seizures throughout life, despite adequate drug therapy or surgery, with a major impact on society and global health. In recent decades, dietary regimens have been used effectively in the treatment of drug-resistant epilepsy, following the path of a non-pharmacological approach. The ketogenic diet and its variants (e.g., the modified Atkins diet) have an established role in contrasting epileptogenesis through the production of a series of cascading events induced by physiological ketosis. Other dietary regimens, such as caloric restriction and a gluten free diet, can also exert beneficial effects on neuroprotection and, therefore, on refractory epilepsy. The purpose of this review was to analyze the evidence from the literature about the possible efficacy of different dietary regimens on epilepsy, focusing on the underlying pathophysiological mechanisms, safety, and tolerability both in pediatric and adult population. We believe that a better knowledge of the cellular and molecular biochemical processes behind the anticonvulsant effects of alimentary therapies may lead to the development of personalized dietary intervention protocols.
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Yu L, Feng J, Yu Z, Dai H. Trends of anti-seizure medication use in pediatric patients in six cities in China from 2013 to 2018. Epilepsy Res 2020; 167:106448. [PMID: 32916644 DOI: 10.1016/j.eplepsyres.2020.106448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/17/2020] [Accepted: 08/18/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The aim of this study was to describe the prevalence of the use and prescribing patterns of anti-seizure medications (ASMs) over a six-year period, and to provide real-world evidence on medicine utilization of pediatric patients with epilepsy in China. METHODS ASM prescriptions for pediatric patients written from 2013 to 2018 were extracted from the database of the Hospital Prescription Analysis Cooperative Project. Trends of ASM use were analyzed by total prescriptions, cost, age, sex, ASM class and specific ASM. Prescribing patterns of ASMs were also analyzed. RESULTS A total of 44,675 ASM prescriptions were extracted for analysis in this study. Throughout the study period, a slight increase of ASM prescriptions was observed from 6170 in 2013 to 8211 in 2018. Children aged between 6 and 18 years, accounted for 78 % of total prescriptions every year. ASM use in boys was about 1.5 times higher than that in girls. Newer ASMs were prescribed more than older ASMs during this period. Sodium valproate was the most frequently prescribed ASM in 2013, and its use decreased in girls in 2016. Levetiracetam increased from 19.10 % in 2013 to 28.09 % in 2018 and became the most common ASM at the end of this study. Meanwhile, the use of oxcarbazepine increased from 19.31 % to 22.04 %, whereas the use of lamotrigine had declined from 18.43 % to 10.72 %. Monotherapy (66.24 %) was more frequently used than combined therapy, which included dual combination (25.80 %) and triple or more combinations (7.96 %). CONCLUSION There is an increased ASM prescription trend in childhood usage. Levetiracetam has replaced sodium valproate as the most frequently prescribed ASM in pediatric patients. Newer ASMs with fewer side effects and drug interactions are increasingly utilized, which is consistent with evolving recommendations by the medical community.
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Affiliation(s)
- Lingyan Yu
- Department of Pharmacy, Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Jianhua Feng
- Department of Pediatrics, Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Zhenwei Yu
- Department of Pharmacy, Sir Run Run Shaw Hospital of Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China.
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Mochol M, Taubøll E, Aukrust P, Ueland T, Andreassen OA, Svalheim S. Interleukin 18 (IL-18) and its binding protein (IL-18BP) are increased in patients with epilepsy suggesting low-grade systemic inflammation. Seizure 2020; 80:221-225. [DOI: 10.1016/j.seizure.2020.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/09/2020] [Accepted: 05/21/2020] [Indexed: 12/15/2022] Open
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Halford JJ, Edwards JC. Seizure freedom as an outcome in epilepsy treatment clinical trials. Acta Neurol Scand 2020; 142:91-107. [PMID: 32353166 DOI: 10.1111/ane.13257] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/16/2020] [Accepted: 04/26/2020] [Indexed: 12/29/2022]
Abstract
Seizure freedom is recognized as the goal of epilepsy treatment by patients, families, and in treatment guidelines and is associated with notably improved quality of life. However, many studies of epilepsy treatments (including antiseizure medications/antiepileptic drugs, neurostimulation, and dietary therapies) fail to report data on seizure freedom. Even among studies that include this outcome, methods for defining and analyzing seizure freedom vary considerably. Thus, the available data are often difficult to interpret and comparisons between studies are particularly challenging. Although these issues had been identified over a decade ago, there remains a lack of clarity and standardized methods used in analyzing and reporting seizure freedom outcomes in studies of epilepsy treatments. In addition, it remains unclear whether short-term seizure freedom outcomes from pivotal clinical trials are predictive of longer-term seizure freedom outcomes for patients with treatment-refractory epilepsy. Ultimately, the limitations of the available data lead to the potential for misinterpretation and misunderstanding of seizure freedom outcomes associated with the spectrum of available treatments when examining treatment options for patients. Clearly defined outcome analyses of seizure freedom attainment and duration are essential in future clinical studies of treatment for seizures to guide treatment selection and modification for patients.
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Affiliation(s)
- Jonathan J. Halford
- Department of Neurology Medical University of South Carolina Charleston SC USA
| | - Jonathan C. Edwards
- Department of Neurology Medical University of South Carolina Charleston SC USA
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Matricardi S, Operto FF, Farello G, Coppola G, Verrotti A. Withdrawal seizures: possible risk factors. Expert Rev Neurother 2020; 20:667-672. [DOI: 10.1080/14737175.2020.1780917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Sara Matricardi
- Department of Child Neuropsychiatry, Children’s Hospital “G. Salesi”, Ospedali Riuniti Ancona, Ancona, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry, Department of Medicine, Surgery, and Odontoiatry, University of Salerno, Salerno, Italy
| | - Giovanni Farello
- Pediatric Clinic, Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Giangennaro Coppola
- Pediatric Clinic, Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L’Aquila, L’Aquila, Italy
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Luszczki JJ, Panasiuk A, Zagaja M, Karwan S, Bojar H, Plewa Z, Florek-Łuszczki M. Polygonogram and isobolographic analysis of interactions between various novel antiepileptic drugs in the 6-Hz corneal stimulation-induced seizure model in mice. PLoS One 2020; 15:e0234070. [PMID: 32479532 PMCID: PMC7263629 DOI: 10.1371/journal.pone.0234070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/17/2020] [Indexed: 12/11/2022] Open
Abstract
Pharmacotherapy with two antiepileptic drugs in combination is usually prescribed to epilepsy patients with refractory seizures. The choice of antiepileptic drugs in combination should be based on synergistic cooperation of the drugs with respect to suppression of seizures. The selection of synergistic interactions between antiepileptic drugs is challenging issue for physicians, especially, if 25 antiepileptic drugs are currently available and approved to treat epilepsy patients. The aim of this study was to determine all possible interactions among 5 second-generation antiepileptic drugs (gabapentin (GBP), lacosamide (LCM), levetiracetam (LEV), pregabalin (PGB) and retigabine (RTG)) in the 6-Hz corneal stimulation-induced seizure model in adult male albino Swiss mice. The anticonvulsant effects of 10 various two-drug combinations of antiepileptic drugs were evaluated with type I isobolographic analysis associated with graphical presentation of polygonogram to visualize the types of interactions. Isobolographic analysis revealed that 7 two-drug combinations of LEV+RTG, LEV+LCM, GBP+RTG, PGB+LEV, GBP+LEV, PGB+RTG, PGB+LCM were synergistic in the 6-Hz corneal stimulation-induced seizure model in mice. The additive interaction was observed for the combinations of GBP+LCM, GBP+PGB, and RTG+LCM in this seizure model in mice. The most beneficial combination, offering the highest level of synergistic suppression of seizures in mice was that of LEV+RTG, whereas the most additive combination that protected the animals from seizures was that reporting additivity for RTG+LCM. The strength of interaction for two-drug combinations can be arranged from the synergistic to the additive, as follows: LEV+RTG > LEV+LCM > GBP+RTG > PGB+LEV > GBP+LEV > PGB+RTG > PGB+LCM > GBP+LCM > GBP+PGB > RTG+LCM.
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Affiliation(s)
- Jarogniew J. Luszczki
- Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland
- * E-mail: ,
| | - Anna Panasiuk
- Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
- Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Mirosław Zagaja
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland
| | | | - Hubert Bojar
- Department of Toxicology and Food Safety, Institute of Rural Health, Lublin, Poland
| | - Zbigniew Plewa
- Department of General, Oncological and Minimally Invasive Surgery, 1st Military Clinical Hospital, Lublin, Poland
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