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Wu R, Li K, Zhao Z, Mei S. Fixed parameters in the population pharmacokinetic modeling of valproic acid might not be suitable: external validation in Chinese adults with epilepsy or after neurosurgery. Eur J Clin Pharmacol 2024; 80:1819-1828. [PMID: 39210212 DOI: 10.1007/s00228-024-03746-x] [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: 05/09/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE This study aims to assess the predictive performance of published valproic acid (VPA) population pharmacokinetic (PPK) models using an external data set in Chinese adults with epilepsy or after neurosurgery. METHODS A total of 384 concentrations from 290 Chinese adults with epilepsy or after neurosurgery were used for external validation. Data on published VPA PPK models were extracted from the literature. Prediction-based diagnostics (such as F20 and F30), simulation-based diagnostics, and Bayesian forecasting were used to evaluate the predictability of models. RESULTS The results of prediction-based diagnostics of all models were unsatisfactory. Models B, F, and H showed the best prediction performance in simulation-based diagnostics and Bayesian forecasting, demonstrating superior precision and accuracy. Bayesian forecasting demonstrated significant improvements in the model predictability. CONCLUSION The published PPK models showed extensive variation in predictive performance for extrapolation among Chinese adults with epilepsy or after neurosurgery patients. Fixed parameters of Vd and Ka in the PPK modeling of VPA might be the reason for the unsatisfied predictive performance. Bayesian forecasting significantly improved model predictability and may help to individualize VPA dosing.
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Affiliation(s)
- Ruoyun Wu
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Kai Li
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, China.
| | - Shenghui Mei
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People's Republic of China.
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, China.
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Romero Carratala M, Pérez de Amezaga Tomás L, Sala Carazo M, Rialp Cervera G. Meropenem for the management of valproic acid intoxication: a case report and a review of the literature. Med Intensiva 2024; 48:620-622. [PMID: 38997905 DOI: 10.1016/j.medine.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 07/14/2024]
Affiliation(s)
| | | | - María Sala Carazo
- Intensive Care Unit Deparment, Son Llàtzer Hospital, Palma de Mallorca, Spain
| | - Gemma Rialp Cervera
- Intensive Care Unit Deparment, Son Llàtzer Hospital, Palma de Mallorca, Spain
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Qiming Q, Ping Z, Huiqi L, Leyu X, LIren L, Ming L. Retrospective Analysis of Steady-State Sodium Valproate Plasma Concentrations in Chinese Patients With Bipolar Disorder: Impact of Demographic and Clinical Characteristics. Ther Drug Monit 2024; 46:658-663. [PMID: 38648661 PMCID: PMC11389878 DOI: 10.1097/ftd.0000000000001199] [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: 10/09/2023] [Accepted: 12/26/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND This study comprehensively examined the demographic and clinical characteristics of patients undergoing valproic acid therapy and explored their potential impact on plasma valproic acid concentrations. All enrolled patients were administered the extended-release formulation. An in-depth investigation of factors, including dose, age, sex, body mass index, co-administered medications, and laboratory test findings, was conducted to evaluate their potential influence on study outcomes. METHODS In total, 164 patients met the inclusion criteria and were included in the analysis. The patient age ranged from 13 to 60 years, with a median age of 25.71 years. Most patients (89%) received a daily dose of 1 g valproic acid. Co-administered psychiatric medications included aripiprazole, quetiapine, and lorazepam. Laboratory test results, such as hemoglobin and transaminase levels, were also collected as part of the study. RESULTS The average plasma valproic acid plasma concentration was 79.8 mg/L. The dose significantly affected valproic acid concentrations, as a higher percentage of measurements exceeded the therapeutic range at a daily dose of 1 g. Furthermore, females exhibited significantly higher valproic acid concentrations compared with males at the same dose ( P < 0.05). However, different age groups showed no statistically significant differences in valproic acid concentrations ( P > 0.05). The co-administered antipsychotic and antidepressant medications significantly affected valproate concentrations, as reflected in the multiple regression model ( P < 0.01). CONCLUSIONS This study offers valuable insights into the demographic and clinical characteristics of patients undergoing valproic acid therapy. It highlights the influence of dose, sex, and concomitant medications on plasma valproic acid concentrations. Overall, these findings can help guide dose adjustments and implement personalized treatment strategies in valproic acid therapy.
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Affiliation(s)
- Qian Qiming
- Clinical Pharmacy Center, Naufans Hospital, Southern Medical University, Guangzhou, China; and
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zheng Ping
- Clinical Pharmacy Center, Naufans Hospital, Southern Medical University, Guangzhou, China; and
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Huiqi
- Clinical Pharmacy Center, Naufans Hospital, Southern Medical University, Guangzhou, China; and
| | - Xu Leyu
- Clinical Pharmacy Center, Naufans Hospital, Southern Medical University, Guangzhou, China; and
| | - Li LIren
- Clinical Pharmacy Center, Naufans Hospital, Southern Medical University, Guangzhou, China; and
| | - Lei Ming
- Clinical Pharmacy Center, Naufans Hospital, Southern Medical University, Guangzhou, China; and
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Gu C, Zhang Y, Yuan F, Huang K, Lin Z, Chen Q, Chen Y, Wu Y, Wang D, Wang S. Effect of a Declined Plasma Concentration of Valproic Acid Induced by Meropenem on the Antiepileptic Efficacy of Valproic Acid. J Clin Lab Anal 2024; 38:e25025. [PMID: 38563451 PMCID: PMC11073810 DOI: 10.1002/jcla.25025] [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: 11/10/2023] [Revised: 01/23/2024] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE This study aimed to indicate whether a declined plasma concentration of valproic acid (VPA) induced by co-administration of meropenem (MEPM) could affect the antiepileptic efficacy of VPA. METHODS We retrospectively reviewed data of hospitalized patients who were diagnosed with status epilepticus or epilepsy between 2010 and 2019. Patients co-administered VPA and MEPM during hospitalization were screened and assigned to the exposure group, while those co-administerd VPA and other broad-spectrum antibiotics were allocated to the control group. RESULTS The exposure group and control group included 50 and 11 patients, respectively. With a similar dosage of VPA, the plasma concentration of VPA significantly decreased during co-administration (24.6 ± 4.3 μg/mL) compared with that before co-administration (88.8 ± 13.6 μg/mL, p < 0.0001), and it was partly recovered with the termination of co-administration (39.8 ± 13.2 μg/mL, p = 0.163) in the exposure group. The inverse probability of treatment weighting estimated the treatment efficacy via changes in seizure frequency, seizure duration, and concomitant use of antiepileptic drugs, which were not significantly different between the exposure and control groups. In the exposure group, there was no significant differences in seizure frequency between the periods of before-during and before-after (p = 0.074 and 0.153, respectively). Seizure duration during VPA-MEPM co-administration was not significantly different from that before co-administration (p = 0.291). CONCLUSIONS In this study, the reduced plasma concentration of VPA induced by the co-administration of MEPM did not affect the antiepileptic efficacy of VPA. This conclusion should be interpreted with caution, and more research is warranted. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR2000034567. Registered on 10 July 2020.
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Affiliation(s)
- Chunping Gu
- Department of Pharmacy, Nanfang Hospital, Southern Medical UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of New Drug Design and EvaluationGuangzhouChina
| | - Yongfang Zhang
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Fumiao Yuan
- Department of Pharmacy, Nanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Kaibin Huang
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Zhenzhou Lin
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Qiong Chen
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Yan Chen
- Department of Pharmacy, Nanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Yongming Wu
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Dongmei Wang
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Shengnan Wang
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
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Petrucelli N, Hayes BD, Shelat N, Elshaboury RH, Pearson JC, Koehl JL. Evaluating Clinical Sequelae of the Carbapenem-Valproate Interaction: A Retrospective Analysis. Open Forum Infect Dis 2024; 11:ofae130. [PMID: 38524229 PMCID: PMC10960597 DOI: 10.1093/ofid/ofae130] [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] [Received: 12/14/2023] [Accepted: 03/05/2024] [Indexed: 03/26/2024] Open
Abstract
Background Previous studies identified a rapid decrease in valproate serum concentrations when coadministered with a carbapenem; however, the specific consequences and subsequent therapy adjustments are not well described. We aimed to investigate the clinical and therapeutic implications of the carbapenem-valproate drug-drug interaction. Methods This retrospective analysis included data from 2 large academic medical centers during January 2017 to June 2022. The primary outcome was incidence of seizures or behavioral events stratified by valproate indication. All adult patient encounters with concomitant administration of any carbapenem antimicrobial and valproate were included. Patients without prolonged exposure to valproate prior to hospitalization, without valproate levels pre- and post-carbapenem administration, with an admitting diagnosis of seizure, with exposure to other agents that decrease valproate concentrations, or who had a seizure during the hospitalization prior to carbapenem exposure were excluded. Results Two hundred fifty-eight episodes of concomitant use among 78 unique adult patients were included. Valproate was used for seizure control in 41 patients (52.6%) and for mood-related disorders in 37 (47.4%). In those prescribed valproate for its antiepileptic properties, seizures occurred following carbapenem administration in 46.3% of encounters. In those taking valproate for mood-related disorders, 50.8% met the primary endpoint of behavioral disturbance. Conclusions Our study demonstrates significant clinical implications of the carbapenem-valproate interaction. Clinicians should be aware of this interaction and consider alternative antimicrobial and/or antiepileptic agents whenever possible. Adding or increasing doses of antiepileptic agents and/or consultation with a neurologist prior to concomitant use should be considered when this combination cannot be avoided.
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Affiliation(s)
- Nick Petrucelli
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bryan D Hayes
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Division of Medical Toxicology, Harvard Medical School, Boston, Massachusetts, USA
| | - Nidhi Shelat
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ramy H Elshaboury
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey C Pearson
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jennifer L Koehl
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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Perković Vukčević N, Mijatović Jovin V, Vuković Ercegović G, Antunović M, Kelečević I, Živanović D, Vučinić S. Carbapenems as Antidotes for the Management of Acute Valproic Acid Poisoning. Pharmaceuticals (Basel) 2024; 17:257. [PMID: 38399472 PMCID: PMC10893297 DOI: 10.3390/ph17020257] [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: 12/04/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Valproic acid (VPA) is a broad-spectrum drug primarily used in the treatment of epilepsy and bipolar disorder. It is not an uncommon occurrence for VPA to cause intoxication. The established treatment of VPA poisoning includes supportive care, multiple doses of activated charcoal, levocarnitine and hemodialysis/hemoperfusion. There is a clinically significant interaction between carbapenem antibiotics and VPA. By affecting enterohepatic recirculation, carbapenems can increase the overall VPA clearance from the blood of intoxicated patients. It is suggested that carbapenems could successfully be used as antidotes in the treatment of acute VPA poisonings. THE AIM To evaluate the effectiveness of carbapenems in the treatment of patients acutely poisoned by VPA. PATIENTS AND METHODS This retrospective study included patients acutely poisoned by VPA and treated with carbapenems at the Department of Clinical Toxicology at the Military Medicinal Academy in Serbia for a two-year period. RESULTS After the admission, blood concentrations of VPA kept increasing, reaching their peak at 114-724 mg/L, while the mental state of the patients continued to decline, prompting a decision to introduce carbapenems. After the introduction of carbapenems, the concentrations of the drug dropped by 46-93.59% (average 72%) followed by rapid recovery of consciousness. Ten out of eleven patients had positive outcomes, while one patient died. The most commonly observed complication in our group of patients was bronchopneumonia. CONCLUSIONS The application of carbapenems for the management of acute VPA poisoning might be a useful and effective treatment option.
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Affiliation(s)
- Nataša Perković Vukčević
- National Poison Control Centre, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty Military Medical Academy, University of Defense, 11042 Belgrade, Serbia
| | - Vesna Mijatović Jovin
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
| | - Gordana Vuković Ercegović
- National Poison Control Centre, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty Military Medical Academy, University of Defense, 11042 Belgrade, Serbia
| | - Marko Antunović
- National Poison Control Centre, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty Military Medical Academy, University of Defense, 11042 Belgrade, Serbia
| | - Igor Kelečević
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
| | - Dejan Živanović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Department of Psychology, College of Social Work, 11000 Belgrade, Serbia
| | - Slavica Vučinić
- National Poison Control Centre, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty Military Medical Academy, University of Defense, 11042 Belgrade, Serbia
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Zou D, Zhang R, Yu L, Hu T, Wu B. Seizures associated with antibiotics: a real-world disproportionality analysis of FAERS database. Expert Opin Drug Saf 2023; 22:1143-1148. [PMID: 37417744 DOI: 10.1080/14740338.2023.2234825] [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: 03/16/2023] [Accepted: 06/05/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Drug-induced seizures are a common occurrence in clinical practice, with research indicating that around 6% of initial seizures are due to drug toxicity. The use of antibiotics is one such cause of drug-related seizures. Previous systematic review has identified specific antibiotics that pose a risk of seizures, but a comprehensive analysis of a large patient sample is needed to determine the risk associated with various drugs. OBJECTIVE This study aimed to evaluate the association between seizures and various antibiotics that are presently accessible. METHODS To identify potential risk signals from the US Food and Drug Administration adverse event reporting system (FAERS) database, a disproportionality analysis was conducted. The reporting odds ratio (ROR) using the frequency approach and the information component (IC) using the Bayesian approach were used to detect signals. The median time-to-onset of seizure, as well as the Weibull distribution parameters were calculated to analyze the onset time. RESULTS A total of 14,407,157 FAERS reports were analyzed.10 antibiotics were associated with seizures that were defined by 41 preferred terms. Onset time were aligned with the wear out failure type profile. CONCLUSION This study identified 10 antibiotics that showed significant associations with seizures. Imipenem-cilastatin had the highest seizure ROR.
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Affiliation(s)
- Dan Zou
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- West China School of Pharmacy, Sichuan University, Chengdu, Sichuan, China
| | - Rui Zhang
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lei Yu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tingting Hu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bin Wu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Huang Z, Yao G, Zhang C, Zhou X, Zou G, Zhuo C. Evaluation and Analysis of the Rationality of Clinical Use of Carbapenems in Surgical Departments of a Tertiary Hospital in Southwest China. Infect Drug Resist 2023; 16:2259-2269. [PMID: 37090035 PMCID: PMC10120811 DOI: 10.2147/idr.s403787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Purpose With the increasing frequency and intensity of carbapenem consumption, carbapenem-resistant organisms (CRO) have become a focus of anti-infection research. This study aimed to evaluate the rationality of the clinical use of carbapenems among inpatients in the surgical departments of a tertiary hospital in southwest China. Patients and methods A point-score system was established for evaluation based on the clinical practices in surgical departments and selected carbapenem prescriptions from June 2020 to June 2021 for hepatobiliary surgery, gastrointestinal surgery, and neurosurgery in the study hospital. Prescriptions with a total score ≥ 270 were defined as rational. Descriptive statistics were used to describe the characteristics and rationality of the prescriptions. The chi-square test, Mann-Whitney U-test, and Kruskal-Wallis H-test were used to compare characteristics between rational and irrational prescriptions. Linear regression analysis was used to determine the factors affecting the rationality of carbapenem prescriptions. Results According to 192 carbapenem prescription records, the median age of patients was 62 years [IQR, 48.0-73.0], and 20% of patients had abdominal infections, 10% had lung infections, 14% had intracranial infections, and 3% had urinary tract infections. 56% of carbapenem prescriptions were irrational. Compared with rational carbapenem prescriptions, irrational prescriptions had a higher proportion of those with inappropriate indications (49% vs 0%, p < 0.05), incorrect variety selection (15% vs 0%, p<0.05), and unreasonable assessment of etiology and efficacy (46% vs 8%, p < 0.05). Linear regression analysis suggested that the diagnosis of cholecystitis (standardized regression coefficient=0.183, p<0.05) and replaced medication (standardized regression coefficient = 0.154, p<0.05) influenced the rationality of carbapenem prescriptions. Conclusion Our study shows that the irrational use of carbapenems deserves attention, especially in surgical departments. Interventions for carbapenem use that are based on evaluation criteria should be developed to reduce the emergence and spread of carbapenem-resistant bacteria.
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Affiliation(s)
- Zhongyue Huang
- Institute of Medical Information/Medical Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Gaoqiong Yao
- Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Chengzhi Zhang
- Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xin Zhou
- Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Guanyang Zou
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, People’s Republic of China
- Correspondence: Guanyang Zou, No. 232, Waihuan East Road, Panyu District, Guangzhou, Guangdong Province, 510006, People’s Republic of China, Email
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of China
- Chao Zhuo, 195 Dongfeng West Road, Yuexiu District, Guangzhou, Guangdong Province, 510030, People’s Republic of China, Email
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Patel J, Berezowski I, Mazer-Amirshahi M, Frasure SE, Tran QK, Pourmand A. Valproic Acid Overdose: Case Report and Literature Review. J Emerg Med 2022; 63:651-655. [PMID: 36229318 DOI: 10.1016/j.jemermed.2022.07.009] [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] [Received: 03/08/2022] [Revised: 05/24/2022] [Accepted: 07/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Valproic acid (VPA) is a common antiepileptic drug that is also used routinely for various psychiatric disorders. VPA toxicity typically manifests as central nervous system depression, while hyperammonemic encephalopathy and hepatotoxicity are potentially life-threatening complications. CASE REPORT We describe the case of a 56-year-old man who presented to the emergency department after an intentional VPA overdose, was found to have hyperammonemia, and was treated with L-carnitine exclusively. He was subsequently admitted to the hospital for monitoring and serial laboratory testing. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although VPA toxicity has conventionally been managed by gastric decontamination, L-carnitine, and, in severe and refractory cases, extracorporeal removal, recent literature supports the use of carbapenem antibiotics, particularly meropenem. Thus, we report the details of current treatment modalities for VPA toxicity by reviewing current literature.
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Affiliation(s)
- Jigar Patel
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ivan Berezowski
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, District of Columbia
| | - Sarah E Frasure
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland; Program in Trauma, The R. Adam Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ali Pourmand
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Smolders EJ, Ter Heine R, Natsch S, Kramers K. Meropenem to Treat Valproic Acid Intoxication. Ther Drug Monit 2022; 44:359-362. [PMID: 35170557 DOI: 10.1097/ftd.0000000000000973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/21/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT This therapeutic drug monitoring (TDM) grand round describes a patient with serious valproic acid intoxication. A total valproic acid level of 844 mg/L and an unbound valproic acid level of 604 mg/L were observed. Meropenem was administered to enhance the clearance of valproic acid. This off-label usage of meropenem is based on the drug-drug interaction between carbapenems and valproic acid, which reduced the level of valproic acid within 24 hours after administration.
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Affiliation(s)
- Elise J Smolders
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center ; and
| | - Rob Ter Heine
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center ; and
| | - Stephanie Natsch
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center ; and
| | - Kees Kramers
- Department of Pharmacology-Toxicology and Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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11
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Hosseinpoor Z, Farzanegan B, Baniasadi S. Comparing Important and Well-documented Potential Drug–Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center. Indian J Crit Care Med 2022; 26:574-578. [PMID: 35719432 PMCID: PMC9160617 DOI: 10.5005/jp-journals-10071-23902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Drug–drug interaction (DDI) is one of the major healthcare challenges in intensive care units (ICUs). The prevalence of DDIs and interacting drug pairs may vary between different types of ICUs. This study aimed to compare the frequency and nature of important and well-documented potential DDIs (pDDIs) in three types of ICUs. Materials and methods A prospective study was conducted in medical (M), surgical (S), and emergency (E) ICUs of a tertiary referral center for respiratory diseases. A pharmacist checked the patients’ files three days in a week for 6 months. The pDDIs were identified using the Lexi-Interact database. Interactions with a severity rating of D (modify regimen) and X (avoid combination) and with a reliability rating of good and excellent were considered important and well-documented. These pDDIs were evaluated in terms of drug combinations, mechanisms of interaction, and clinical management. Results One hundred eighty-nine patients admitted to MICU, SICU, and EICU were included in the study. The percentage of patients who experienced at least one important and well-documented pDDI was 18.8% in MICU, 11.1% in SICU, and 11.8% in EICU. The most common drug pairs causing important and well-documented interactions were atracurium + hydrocortisone in MICU, meropenem + valproic acid in MICU and EICU, and aspirin + warfarin in SICU. Conclusion The current study shows different frequency and nature of pDDIs between three types of ICUs. We recommend conducting similar studies in other settings to develop evidence-based guidance on clinically relevant pDDIs in different types of ICUs. How to cite this article Hosseinpoor Z, Farzanegan B, Baniasadi S. Comparing Important and Well-documented Potential Drug–Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center. Indian J Crit Care Med 2022;26(5):574–578.
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Affiliation(s)
- Zeinab Hosseinpoor
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
- Shadi Baniasadi, Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Phone: +98-21-26105387, e-mail: ,
| | - Behrooz Farzanegan
- Critical Care Quality Improvement Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shadi Baniasadi
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Zhanel GG, Pozdirca M, Golden AR, Lawrence CK, Zelenitsky S, Berry L, Schweizer F, Bay D, Adam H, Zhanel MA, Lagacé-Wiens P, Walkty A, Irfan N, Naber K, Lynch JP, Karlowsky JA. Sulopenem: An Intravenous and Oral Penem for the Treatment of Urinary Tract Infections Due to Multidrug-Resistant Bacteria. Drugs 2022; 82:533-557. [PMID: 35294769 DOI: 10.1007/s40265-022-01688-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 12/29/2022]
Abstract
Sulopenem (formerly known as CP-70,429, and CP-65,207 when a component of a racemic mixture with its R isomer) is an intravenous and oral penem that possesses in vitro activity against fluoroquinolone-resistant, extended spectrum β-lactamases (ESBL)-producing, multidrug-resistant (MDR) Enterobacterales. Sulopenem is being developed to treat patients with uncomplicated and complicated urinary tract infections (UTIs) as well as intra-abdominal infections. This review will focus mainly on its use in UTIs. The chemical structure of sulopenem shares properties of penicillins, cephalosporins, and carbapenems. Sulopenem is available as an oral prodrug formulation, sulopenem etzadroxil, which is hydrolyzed by intestinal esterases, resulting in active sulopenem. In early studies, the S isomer of CP-65,207, later developed as sulopenem, demonstrated greater absorption, higher drug concentrations in the urine, and increased stability against the renal enzyme dehydropeptidase-1 compared with the R isomer, which set the stage for its further development as a UTI antimicrobial. Sulopenem is active against both Gram-negative and Gram-positive microorganisms. Sulopenem's β-lactam ring alkylates the serine residues of penicillin-binding protein (PBP), which inhibits peptidoglycan cross-linking. Due to its ionization and low molecular weight, sulopenem passes through outer membrane proteins to reach PBPs of Gram-negative bacteria. While sulopenem activity is unaffected by many β-lactamases, resistance arises from alterations in PBPs (e.g., methicillin-resistant Staphylococcus aureus [MRSA]), expression of carbapenemases (e.g., carbapenemase-producing Enterobacterales and in Stenotrophomonas maltophilia), reduction in the expression of outer membrane proteins (e.g., some Klebsiella spp.), and the presence of efflux pumps (e.g., MexAB-OprM in Pseudomonas aeruginosa), or a combination of these mechanisms. In vitro studies have reported that sulopenem demonstrates greater activity than meropenem and ertapenem against Enterococcus faecalis, Listeria monocytogenes, methicillin-susceptible S. aureus (MSSA), and Staphylococcus epidermidis, as well as similar activity to carbapenems against Streptococcus agalactiae, Streptococcus pneumoniae, and Streptococcus pyogenes. With some exceptions, sulopenem activity against Gram-negative aerobes was less than ertapenem and meropenem but greater than imipenem. Sulopenem activity against Escherichia coli carrying ESBL, CTX-M, or Amp-C enzymes, or demonstrating MDR phenotypes, as well as against ESBL-producing Klebsiella pneumoniae, was nearly identical to ertapenem and meropenem and greater than imipenem. Sulopenem exhibited identical or slightly greater activity than imipenem against many Gram-positive and Gram-negative anaerobes, including Bacteroides fragilis. The pharmacokinetics of intravenous sulopenem appear similar to carbapenems such as imipenem-cilastatin, meropenem, and doripenem. In healthy subjects, reported volumes of distribution (Vd) ranged from 15.8 to 27.6 L, total drug clearances (CLT) of 18.9-24.9 L/h, protein binding of approximately 10%, and elimination half-lives (t½) of 0.88-1.03 h. The estimated renal clearance (CLR) of sulopenem is 8.0-10.6 L/h, with 35.5% ± 6.7% of a 1000 mg dose recovered unchanged in the urine. An ester prodrug, sulopenem etzadroxil, has been developed for oral administration. Initial investigations reported a variable oral bioavailability of 20-34% under fasted conditions, however subsequent work showed that bioavailability is significantly improved by administering sulopenem with food to increase its oral absorption or with probenecid to reduce its renal tubular secretion. Food consumption increases the area under the curve (AUC) of oral sulopenem (500 mg twice daily) by 23.6% when administered alone and 62% when administered with 500 mg of probenecid. Like carbapenems, sulopenem demonstrates bactericidal activity that is associated with the percentage of time that free concentrations exceed the MIC (%f T > MIC). In animal models, bacteriostasis was associated with %f T > MICs ranging from 8.6 to 17%, whereas 2-log10 kill was seen at values ranging from 12 to 28%. No pharmacodynamic targets have been documented for suppression of resistance. Sulopenem concentrations in urine are variable, ranging from 21.8 to 420.0 mg/L (median 84.4 mg/L) in fasted subjects and 28.8 to 609.0 mg/L (median 87.3 mg/L) in those who were fed. Sulopenem has been compared with carbapenems and cephalosporins in guinea pig and murine systemic and lung infection animal models. Studied pathogens included Acinetobacter calcoaceticus, B. fragilis, Citrobacter freundii, Enterobacter cloacae, E. coli, K. pneumoniae, Proteus vulgaris, and Serratia marcescens. These studies reported that overall, sulopenem was non-inferior to carbapenems but appeared to be superior to cephalosporins. A phase III clinical trial (SURE-1) reported that sulopenem was not non-inferior to ciprofloxacin in women infected with fluoroquinolone-susceptible pathogens, due to a higher rate of asymptomatic bacteriuria in sulopenem-treated patients at the test-of-cure visit. However, the researchers reported superiority of sulopenem etzadroxil/probenecid over ciprofloxacin for the treatment of uncomplicated UTIs in women infected with fluoroquinolone/non-susceptible pathogens, and non-inferiority in all patients with a positive urine culture. A phase III clinical trial (SURE-2) compared intravenous sulopenem followed by oral sulopenem etzadroxil/probenecid with ertapenem in the treatment of complicated UTIs. No difference in overall success was noted at the end of therapy. However, intravenous sulopenem followed by oral sulopenem etzadroxil was not non-inferior to ertapenem followed by oral stepdown therapy in overall success at test-of-cure due to a higher rate of asymptomatic bacteriuria in the sulopenem arm. After a meeting with the US FDA, Iterum stated that they are currently evaluating the optimal design for an additional phase III uncomplicated UTI study to be conducted prior to the potential resubmission of the New Drug Application (NDA). It is unclear at this time whether Iterum intends to apply for EMA or Japanese regulatory approval. The safety and tolerability of sulopenem has been reported in various phase I pharmacokinetic studies and phase III clinical trials. Sulopenem (intravenous and oral) appears to be well tolerated in healthy subjects, with and without the coadministration of probenecid, with few serious drug-related treatment-emergent adverse events (TEAEs) reported to date. Reported TEAEs affecting ≥1% of patients were (from most to least common) diarrhea, nausea, headache, vomiting and dizziness. Discontinuation rates were low and were not different than comparator agents. Sulopenem administered orally and/or intravenously represents a potentially well tolerated and effective option for treating uncomplicated and complicated UTIs, especially in patients with documented or highly suspected antimicrobial pathogens to commonly used agents (e.g. fluoroquinolone-resistant E. coli), and in patients with documented microbiological or clinical failure or patients who demonstrate intolerance/adverse effects to first-line agents. This agent will likely be used orally in the outpatient setting, and intravenously followed by oral stepdown in the hospital setting. Sulopenem also allows for oral stepdown therapy in the hospital setting from intravenous non-sulopenem therapy. More clinical data are required to fully assess the clinical efficacy and safety of sulopenem, especially in patients with complicated UTIs caused by resistant pathogens such as ESBL-producing, Amp-C, MDR E. coli. Antimicrobial stewardship programs will need to create guidelines for when this oral and intravenous penem should be used.
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Affiliation(s)
- George G Zhanel
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada.
| | - Marianna Pozdirca
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alyssa R Golden
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada
| | - Courtney K Lawrence
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Sheryl Zelenitsky
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Liam Berry
- Department of Chemistry, Faculty of Science, University of Manitoba, Winnipeg, MB, Canada
| | - Frank Schweizer
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada.,Department of Chemistry, Faculty of Science, University of Manitoba, Winnipeg, MB, Canada
| | - Denice Bay
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada
| | - Heather Adam
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada.,Clinical Microbiology, Diagnostic Services, Shared Health, Winnipeg, MB, Canada
| | - Michael A Zhanel
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada
| | - Philippe Lagacé-Wiens
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada.,Clinical Microbiology, Diagnostic Services, Shared Health, Winnipeg, MB, Canada
| | - Andrew Walkty
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada.,Clinical Microbiology, Diagnostic Services, Shared Health, Winnipeg, MB, Canada
| | - Neal Irfan
- Department of Medicine, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Kurt Naber
- Department of Urology, Technical University of Munich, Munich, Germany
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care, Allergy and Clinical Immunology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - James A Karlowsky
- Clinical Microbiology, Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, MS673-820 Sherbrook Street, Winnipeg, Manitoba, MB, R3A 1R9, Canada.,Clinical Microbiology, Diagnostic Services, Shared Health, Winnipeg, MB, Canada
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13
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Wu X, Li H, Dong W, Yang X, Jin Y, Gong Y, Zhang Z, Liu X. Determination of Free Valproic Acid Concentration in 569 Clinical Samples by LC-MS/MS After Hollow Fiber Centrifugal Ultrafiltration Treatment. Ther Drug Monit 2021; 43:789-796. [PMID: 33990504 DOI: 10.1097/ftd.0000000000000903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To perform therapeutic drug monitoring of total and free plasma valproic acid (VPA) concentrations in clinical samples and to analyze the related factors. METHODS The total VPA concentration in plasma was determined by ultrahigh-performance liquid chromatography with precolumn derivatization with α-bromoacetophenone, and the free VPA concentration was determined by liquid chromatography-tandem mass spectrometry after the plasma was treated by hollow fiber centrifugal ultrafiltration. Regression analysis was performed to examine the associations between free plasma VPA, total plasma VPA, and the plasma protein binding rate. The impact of individual situations, outpatient or inpatient factors, and drug combinations on VPA concentrations were examined. RESULTS Of the 569 clinical samples, 268 were inpatients and 301 were outpatients, and the total VPA concentration in 138 cases (24.2%) was lower than the effective treatment concentration range; the total and free VPA concentrations in outpatient samples were 11.0% and 26.1% higher than those of inpatients, respectively. There was no linear relationship between the free and total VPA concentrations. The relationship equation between the plasma protein binding rate and free VPA concentrations was as follows: Y = 0.0255X2 - 1.1357X + 97.429 (r = 0.8011). The total and free VPA concentrations were significantly decreased after the coadministration of phenobarbital (83.7% and 64.3% of the control group, P < 0.05) or carbapenem antibiotics (32.0% and 32.7% of the control group, P < 0.05). CONCLUSIONS The total VPA concentrations in patients with epilepsy at our hospital was lower than the effective treatment concentration range, which was inadequate for epilepsy control; the total VPA concentrations of outpatients were higher than those of inpatients; as phenobarbital affects VPA metabolism, therapeutic drug monitoring is recommended. Carbapenem antibiotic coadministration with VPA should be avoided because carbapenem antibiotics can lead to the failure of VPA antiepileptic treatment.
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Affiliation(s)
- Xikun Wu
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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14
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Lan X, Mo K, Nong L, He Y, Sun Y. Factors Influencing Sodium Valproate Serum Concentrations in Patients with Epilepsy Based on Logistic Regression Analysis. Med Sci Monit 2021; 27:e934275. [PMID: 34776507 PMCID: PMC8603630 DOI: 10.12659/msm.934275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background We aimed to explore the risk factors that affect the serum concentration of sodium valproate (VPA-Na) in patients with epilepsy and to provide references for the rationale of the use of VPA-Na. Material/Methods The enzyme-multiplied immunoassay technique was used to determine the serum VPA-NA concentrations of 109 patients, and the results were retrospectively analyzed and summarized. A multivariate logistic regression model was used to analyze substandard serum VPA-Na concentrations. Results Fifty-six patients (51.38%) treated with VPA-Na tablets were within the effective treatment range of 50–100 μg/mL, while 53 patients (48.62%) were out of the treatment range. The results indicated that the standard-reaching rate of serum drug concentration in the juvenile group was higher than that in the adult and elderly groups; the standard-reaching rates of serum drug concentrations in the low-dose group and the intermediate-dose group were lower than that in the high-dose group; and the standard-reaching rate of serum drug concentration in the group receiving carbapenems in combination was lower than that in the non-combination group; all differences were statistically significant. The combination with carbapenems and enzyme inducers was an independent risk factor for VPA-Na serum concentration below the target level in hospitalized patients. Conclusions To improve clinical efficacy and reduce the occurrence of adverse reactions, there is a need for therapeutic drug monitoring of VPA-Na. Moreover, individual administration should be implemented when VPA-Na tablets are used in the treatment of epilepsy because of the significant fluctuation in VPA-Na blood concentration.
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Affiliation(s)
- Xiaobu Lan
- Department of Pharmacy, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland).,Department of Pharmacy, The First People's Hospital of Nanning, Nanning, Guangxi, China (mainland)
| | - Kai Mo
- Department of Pharmacy, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland).,Department of Pharmacy, The First People's Hospital of Nanning, Nanning, Guangxi, China (mainland)
| | - Li Nong
- Department of Pharmacy, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland).,Department of Pharmacy, The First People's Hospital of Nanning, Nanning, Guangxi, China (mainland)
| | - Yi He
- Department of Pharmacy, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland).,Department of Pharmacy, The First People's Hospital of Nanning, Nanning, Guangxi, China (mainland)
| | - Yuhong Sun
- Department of Pharmacy, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland).,Department of Pharmacy, The First People's Hospital of Nanning, Nanning, Guangxi, China (mainland)
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Clinically Relevant Interactions with Anti-Infectives on Intensive Care Units-A Multicenter Delphi Study. Antibiotics (Basel) 2021; 10:antibiotics10111330. [PMID: 34827267 PMCID: PMC8614667 DOI: 10.3390/antibiotics10111330] [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: 09/30/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022] Open
Abstract
Patients in intensive care units (ICUs) are at high risk of drug–drug interactions (DDIs) due to polypharmacy. Little is known about type and frequency of DDIs within German ICUs. Clinical pharmacists’ interventions (PI) recorded in a national database (ADKA-DokuPIK) were filtered for ICU patients. Binary DDIs involving ≥1 anti-infective agent with >1 database entry were selected. A modified two-step Delphi process with a group of senior hospital pharmacists was employed to evaluate selected DDIs for clinical relevance by using a five-point scale and to develop guidance for clinical practice. In total, 16,173 PI were recorded, including 1836 (11%) DDIs in the ICU setting. Of the latter, 41% (756/1836) included ≥1 anti-infective agent, 32% (590/1836) were binary DDIs, and 25% (455/1836) were listed at least twice. This translates into 88 different DDIs, 74% (65/88) of which were rated as being clinically relevant by our expert panel. The majority of DDIs (76% [67/88]) included macrolides, antifungals, or fluoroquinolones. This percentage was even higher in DDIs being rated as clinically relevant by the experts (85% [55/65]). It is noted that an inter-professional discussion and approach is needed in the individual patient management of DDIs. The guidance developed might be a tool for decision support.
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Saitov G, Müller A, Bastian B, Michalski D. [Pharmacotherapy and intensive care aspects of status epilepticus: update 2020/2021]. Anaesthesist 2021; 70:874-887. [PMID: 34212230 PMCID: PMC8492596 DOI: 10.1007/s00101-021-01000-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
Die gezielte Therapie epileptischer Ereignisse und im Speziellen des Status epilepticus (SE) setzt das sichere Erkennen der Krankheitsbilder voraus, wofür gerade bei Formen mit vorwiegend nichtmotorischen Symptomen klinische und elektroenzephalographische Expertise notwendig ist. Die im Jahr 2020 erfolgte Fortschreibung der deutschen Leitlinie zur Behandlung des SE hält an der streng stufengerechten Therapie fest, die eskalierend die Anwendung von Benzodiazepinen, spezifischen Antiepileptika und Anästhetika vorsieht. Bisher ist die Eingrenzung eines in den allermeisten Fällen wirksamen sowie zugleich sicheren und interaktionsfreien Antiepileptikums nicht gelungen. Individuelle Vorerkrankungen und aktuelle Begleitumstände gehen daher genauso wie Erfahrungen des Behandlerteams in die differenzierte Behandlung des SE ein. Insbesondere bei therapierefraktären Formen des SE erweist sich die Therapie als durchaus kompliziert und hat regelhaft intensivmedizinische Implikationen. Mithin ergeben sich im Zuge der modernen SE-Behandlung zahlreiche interdisziplinäre Schnittstellen. Zukünftige wissenschaftliche Fragstellungen werden sich u. a. mit der optimalen Therapie des nonkonvulsiven SE und hier v. a. dem Ausmaß und dem Zeitpunkt von adäquaten Therapieschritten sowie mit assoziierten ethischen Fragen einer Therapieeskalation beschäftigen.
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Affiliation(s)
- Gabrielė Saitov
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - Annekatrin Müller
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Börge Bastian
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
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Wu X, Dong W, Li H, Yang X, Jin Y, Zhang Z, Jiang Y. CYP2C9*3/*3 Gene Expression Affects the Total and Free Concentrations of Valproic Acid in Pediatric Patients with Epilepsy. Pharmgenomics Pers Med 2021; 14:417-430. [PMID: 33859491 PMCID: PMC8043849 DOI: 10.2147/pgpm.s301893] [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: 01/14/2021] [Accepted: 03/16/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To perform therapeutic drug monitoring (TDM) of total and free plasma valproic acid (VPA) concentrations in pediatric patients with epilepsy and to analyze related factors. Patients and Methods Pediatric epileptic patients treated in 2015-2019 in our hospital were assessed. Total and free plasma VPA concentrations were obtained by UPLC and LC-MS/MS, respectively. Regression analysis was performed to examine the associations of free plasma VPA with total plasma VPA and plasma protein binding rate. The impacts of individual situation, CYP2C9 genotype, and drug combination on VPA concentration were examined. Results Of the 251 patients, 81 had lower total concentrations than effective therapeutic levels; 86 and 31 patients had infections and central nervous system dysplasia, respectively. VPA's daily doses and free drug concentrations were significantly lower in the CYP2C9 *3/*3 genotype group versus the CYP2C9 *1/*3 and CYP2C9 *1/*1 groups (P<0.05). Free and total VPA concentrations were linked by Y = 0.0004 X2 + 0.042 X + 0.3035 (r=0.6981); VPA plasma protein binding rate and free VPA concentration were related by Y = 0.0003 X2 - 0.0127 X + 0.9777 (r=0.8136). Both total and free VPA concentrations were significantly decreased in patients simultaneously administered phenobarbital, meropenem and biapenem (P<0.05), with therapeutic failure after meropenem/biapenem co-administration. Conclusion Free VPA amounts have nonlinear relationships with total VPA amounts and plasma protein binding rate in epileptic children. Additionally, CYP2C9 *3/*3 expression affects VPA metabolism. Since phenobarbital affects VPA metabolism, TDM is recommended. Meanwhile, carbapenem-co-administration with VPA should be prohibited.
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Affiliation(s)
- Xikun Wu
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Weichong Dong
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Haoran Li
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Xiuling Yang
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Yiran Jin
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Zhiqing Zhang
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Ye Jiang
- Pharmacy College, Hebei Medical University, Shijiazhuang City, People's Republic of China
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Yu X, Chu Z, Li J, He R, Wang Y, Cheng C. Pharmacokinetic Drug-drug Interaction of Antibiotics Used in Sepsis Care in China. Curr Drug Metab 2021; 22:5-23. [PMID: 32990533 DOI: 10.2174/1389200221666200929115117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Many antibiotics have a high potential for interactions with drugs, as a perpetrator and/or victim, in critically ill patients, and particularly in sepsis patients. METHODS The aim of this review is to summarize the pharmacokinetic drug-drug interaction (DDI) of 45 antibiotics commonly used in sepsis care in China. Literature search was conducted to obtain human pharmacokinetics/ dispositions of the antibiotics, their interactions with drug-metabolizing enzymes or transporters, and their associated clinical drug interactions. Potential DDI is indicated by a DDI index ≥ 0.1 for inhibition or a treatedcell/ untreated-cell ratio of enzyme activity being ≥ 2 for induction. RESULTS The literature-mined information on human pharmacokinetics of the identified antibiotics and their potential drug interactions is summarized. CONCLUSION Antibiotic-perpetrated drug interactions, involving P450 enzyme inhibition, have been reported for four lipophilic antibacterials (ciprofloxacin, erythromycin, trimethoprim, and trimethoprim-sulfamethoxazole) and three antifungals (fluconazole, itraconazole, and voriconazole). In addition, seven hydrophilic antibacterials (ceftriaxone, cefamandole, piperacillin, penicillin G, amikacin, metronidazole, and linezolid) inhibit drug transporters in vitro. Despite no clinical PK drug interactions with the transporters, caution is advised in the use of these antibacterials. Eight hydrophilic antibiotics (all β-lactams; meropenem, cefotaxime, cefazolin, piperacillin, ticarcillin, penicillin G, ampicillin, and flucloxacillin), are potential victims of drug interactions due to transporter inhibition. Rifampin is reported to perpetrate drug interactions by inducing CYP3A or inhibiting OATP1B; it is also reported to be a victim of drug interactions, due to the dual inhibition of CYP3A4 and OATP1B by indinavir. In addition, three antifungals (caspofungin, itraconazole, and voriconazole) are reported to be victims of drug interactions because of P450 enzyme induction. Reports for other antibiotics acting as victims in drug interactions are scarce.
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Affiliation(s)
- Xuan Yu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Zixuan Chu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Jian Li
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Rongrong He
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Yaya Wang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Chen Cheng
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
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19
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Chai PYC, Chang CT, Chen YH, Chen HY, Tam KW. Effect of drug interactions between carbapenems and valproate on serum valproate concentration: a systematic review and meta-analysis. Expert Opin Drug Saf 2020; 20:215-223. [PMID: 33322967 DOI: 10.1080/14740338.2021.1865307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Concurrent use of valproate and carbapenem antibiotics may decrease serum valproate concentration (SVC). This study evaluated the effects of carbapenem-valproate drug interactions. Research design and methods: We screened PubMed, EMBASE, and Cochrane databases for eligible prospective or retrospective studies that evaluated the effect of concurrent use of carbapenem and valproate compared with valproate alone on SVC. Primary outcomes were the change in SVC from before the addition of the carbapenem to the SVC during the use of carbapenems and after carbapenem discontinuation, and seizure-related outcomes. Secondary outcomes were the influence of valproate or carbapenem dose on SVC and Drug Interaction Probability Scale scores. Results: Twelve studies (633 patients) were included. Compared with valproate alone, combination treatment with carbapenem substantially decreased mean SVC (mean difference, -43.98 mg/L; 95% confidence interval, -48.18 to -39.78). The onset of SVC decreases was within 1-3 days following carbapenem initiation. Seizure frequency increased by 26.3% during combination treatment. No difference was found in mean SVC between the different doses of valproate or carbapenem during combination treatment. Mean SVC increased to similar pre-carbapenem level within 1 to 2 weeks after carbapenem discontinuation. Conclusions: The drug interaction between valproate and carbapenem causes substantial SVC decreases, even to subtherapeutic levels, which may increase the risk of seizures.
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Affiliation(s)
| | - Chian-Ting Chang
- Department of Pharmacy, Chang Gung Memorial Hospital , Keelung, Taiwan
| | - Yi-Hua Chen
- Department of Pharmacy, Chang Gung Memorial Hospital , Keelung, Taiwan
| | - Hui-Yu Chen
- Department of Pharmacy, Chang Gung Memorial Hospital , Linkou, Taiwan
| | - Ka-Wai Tam
- Center for Evidence-Based Health Care, Department of Medical Research, Shuang Ho Hospital, Taipei Medical University , New Taipei City, Taiwan.,Division of General Surgery, Department of Surgery Shuang Ho Hospital, Taipei Medical University , New Taipei City, Taiwan.,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University , Taipei, Taiwan.,Cochrane Taiwan, Taipei Medical University , Taipei, Taiwan
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Chen IL, Lee CH, Hsiao SC, Shih FY. Interactions between carbapenems and valproic acid among the patients in the intensive care units. J Crit Care 2020; 62:151-156. [PMID: 33383308 DOI: 10.1016/j.jcrc.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate risk factors for epileptic seizures or status epilepticus (SE) in patients concomitantly receiving valproic acid (VPA) and carbapenems. MATERIALS AND METHODS Adult patients in the intensive care units (ICUs) who concomitantly received VPA and carbapenems from 2007 to 2017 were included. The impacts of different carbapenems on serum concentration of VPA were compared. RESULTS Among 162 patients included, 104 (64.2%) and 45 (27.8%) developed epileptic seizures and SE, respectively. The risk factors for epileptic seizures were age (per year increase, adjusted odds ratio [aOR], 1.03), initial antiepileptic regimen (monotherapy and polytherapy, aOR, 0.43 and 0.18, respectively), and VPA serum concentration after concomitant carbapenem administration (per 1 μg/mL increase, aOR, 0.96). VPA serum concentration after concomitant carbapenem administration was an independent risk factor for SE (per μg/mL increase, aOR, 0.98). Concomitant imipenem/cilastatin administration did not significantly decrease VPA serum concentration compared to that by meropenem or ertapenem. The length of stay and number of days on ventilation after concomitant carbapenem administration in the ICUs were significantly more in those with epileptic seizures or SE. CONCLUSIONS Carbapenems decreased VPA serum concentration and increased the risk of epileptic seizures and SE, which led to increased length of ICU stay.
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Affiliation(s)
- I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Chen-Hsiang Lee
- Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Shu-Chen Hsiao
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Fu-Yuan Shih
- Department of Neurosurgery, Chang Gung University College of Medicine and Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
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21
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Factors to influence the accuracy of albumin adjusted free valproic acid concentration. J Formos Med Assoc 2020; 120:1114-1120. [PMID: 32978045 DOI: 10.1016/j.jfma.2020.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is recommended during treatment with valproic acid (VPA), as is the measurement of free VPA concentration (MfVPA). However, MfVPA is unavailable in many institutions. Based on the highly protein-bound characteristics of VPA, an albumin-adjusted formula has been proposed to predict free VPA concentration (PfVPA). Nevertheless, the factors affecting the accuracy of this formula remain unknown, as does the concordance between MfVPA and PfVPA. METHODS Adult patients receiving VPA and undergoing TDM were enrolled. Free and total serum concentration (TVPA) were categorized as subtherapeutic, therapeutic, or supratherapeutic based on the reference range of 5-15 and 50-100 μg/mL, respectively. Concordance was defined as MfVPA and PfVPA, or MfVPA and TVPA, falling within the same category. Multivariate logistic regression with generalized estimating equation was adopted to identify factors affecting concordance, and the receiver operating characteristic curve was applied to determine the cutoff values of predictors. RESULTS A total of 98 data points from 51 participants were included for analysis. The concordance of MfVPA and PfVPA, and MfVPA and TVPA, was 72% and 44%, respectively. Blood urea nitrogen (BUN) (0.97 [0.95-0.99], P = 0.01) and TVPA (0.97 [0.95-0.99], P = 0.02) had a significant influence on the concordance of MfVPA and PfVPA. The cutoff values of TVPA and BUN for the accuracy of the albumin-adjusted formula were 56.4 μg/mL and 51.05 mg/dL, respectively. CONCLUSION If MfVPA is not available, the albumin-adjusted formula should be applied before VPA dosage adjustment when TVPA is < 56.4 μg/mL and BUN is < 51.05 mg/dL.
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Roberti R, Palleria C, Nesci V, Tallarico M, Di Bonaventura C, Cerulli Irelli E, Morano A, De Sarro G, Russo E, Citraro R. Pharmacokinetic considerations about antiseizure medications in the elderly. Expert Opin Drug Metab Toxicol 2020; 16:983-995. [DOI: 10.1080/17425255.2020.1806236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Roberta Roberti
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Caterina Palleria
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Valentina Nesci
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Martina Tallarico
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Carlo Di Bonaventura
- Neurology Unit, Department of Human Neurosciences, “Sapienza” University, Rome, Italy
| | | | - Alessandra Morano
- Neurology Unit, Department of Human Neurosciences, “Sapienza” University, Rome, Italy
| | | | - Emilio Russo
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
| | - Rita Citraro
- Science of Health Department, School of Medicine, University of Catanzaro, Italy
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Wu C, Lin F, Lin S, Ho Y, Huang C, Shen L, Wu FL. Clinical pharmacy service and international collaboration: Model and experience from a medical center in Taiwan. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Chien‐Chih Wu
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Fang‐Ju Lin
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Shu‐Wen Lin
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Yunn‐Fang Ho
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Chih‐Fen Huang
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Li‐Jiuan Shen
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Fe‐Lin Lin Wu
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- Department of Pharmacy Cancer Center, College of Medicine, National Taiwan University Taipei Taiwan
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Muñoz-Pichuante D, Villa-Zapata L, Lolas R. Meropenem for management of valproic acid overdose: a case report. Drug Metab Pers Ther 2020; 35:/j/dmdi.ahead-of-print/dmdi-2019-0028/dmdi-2019-0028.xml. [PMID: 32609645 DOI: 10.1515/dmpt-2019-0028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 03/20/2020] [Indexed: 11/15/2022]
Abstract
Objectives Valproic acid (VPA) is an anticonvulsant used in several clinical scenarios. VPA has been increasingly associated with intentional or unintentional overdose. In patients presenting with severe VPA overdose, supportive care and airway protection are cornerstones of treatment, while levocarnitine is suggested in patients with hyperammonemia and hemodialysis is recommended in patients with VPA serum concentrations (SC) >1,300 mg/L and presence of cerebral edema or shock. Meropenem is a carbapenem antibiotic with a broad spectrum of activity. The pharmacological interaction between VPA and meropenem is characterized by a rapid decrease in VPA concentrations, which contraindicates concurrent use. Case presentation The following case report describes the use of meropenem to enhance the clearance of VPA in the case of severe VPA overdose. A patient with altered mental status was transported to the emergency department (ED) after VPA overdose. Meropenem was prescribed for significant elevated VPA SC. An important decline in SC was observed with short-term meropenem dosing, and an improvement in mental status occurred shortly after administration. Conclusions Carbapenem therapy has the potential to be used as last line strategy in the management of severe VPA overdose in patients where SC represent a significant risk of toxicity and clinical symptoms suggest difficulty managing the patient.
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Affiliation(s)
- Daniel Muñoz-Pichuante
- Universidad Austral de Chile, Facultad de Ciencias, Instituto de Farmacia, Valdivia, Chile
- Hospital Base de Valdivia, Valdivia, Chile
| | - Lorenzo Villa-Zapata
- University of Colorado, Skaggs School Pharmacy and Pharmaceutical Sciences, Center for Pharmaceutical Outcomes Research, Denver, USA
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Thomas C, Priano J, Smith TL. Meropenem as an antidote for intentional valproic acid overdose. Am J Emerg Med 2020; 38:690.e1-690.e2. [PMID: 31980292 DOI: 10.1016/j.ajem.2019.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/24/2019] [Indexed: 11/17/2022] Open
Abstract
Valproic acid (VPA) is a broad-spectrum antiepileptic drug indicated for monotherapy and adjunctive therapy of seizures, and complex manic episodes associated with bipolar disorder [1]. While uncommon due to monitoring, VPA can cause toxicity at supratherapeutic levels [1, 2]. Traditional treatment for VPA toxicity is primarily supportive care, however activated charcoal, l-carnitine, and hemodialysis have been successful in removing free VPA [2]. An interaction between carbapenem antibiotics and VPA is well-established and listed in respective package inserts as a combination to be avoided due to decreased VPA efficacy [1, 3]. Recent literature suggests co-administration of meropenem with VPA reduces mean plasma VPA levels by 50-80% [4, 6]. This case report describes the successful use of carbapenems to intentionally lower toxic VPA levels in a 42 year old female that presented to the emergency department with VPA toxicity from an overdose with divalproex sodium.
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Affiliation(s)
- Caitlin Thomas
- Pharmacy Department, AdventHealth Orlando, 601 E Rollins St, Orlando, 32803, FL, USA
| | - James Priano
- Pharmacy Department, AdventHealth Orlando, 601 E Rollins St, Orlando, 32803, FL, USA
| | - Tracey L Smith
- Pharmacy Department, AdventHealth Orlando, 601 E Rollins St, Orlando, 32803, FL, USA.
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Dreucean D, Beres K, McNierney-Moore A, Gravino D. Use of meropenem to treat valproic acid overdose. Am J Emerg Med 2019; 37:2120.e5-2120.e7. [DOI: 10.1016/j.ajem.2019.158426] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022] Open
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Abstract
Introduction: Valproic acid is a commonly used antiepileptic drug. Combining valproate derivatives with carbapenem antibiotics is associated with a potential drug interaction that decreases serum concentration of valproate and may expose the patient to uncontrolled seizure risk from valproate subtherapeutic concentration. Raising awareness of this drug interaction among health care providers including emergency department physicians, neurologists, and pharmacists is highly needed. The aim of this article was to review the current literature about the potential drug interaction resulting from combining valproate derivatives with carbapenem antibiotics and to establish therapeutic recommendations regarding their use together. Methods: A review of the literature was conducted using Medline (through PubMed), Ovid, Embase, Cochrane library using the following keywords: valproate, valproic acid, carbapenem, ertapenem, doripenem, meropenem, imipenem, and valproate drug interaction. In addition, a manual search through major journals for articles referenced in PubMed was performed. Related publications from January 1998 till November 2018 were included in the initial search. Relevant publications were reviewed, and data regarding patients, type of carbapenem used, valproic acid dosing and level, interaction severity, and clinical outcome were summarized. Results and Discussion: Few clinical trials and multiple case reports have shown that carbapenem antibiotics including meropenem, ertapenem, imipenem, and doripenem can decrease the serum concentration of valproate derivatives leading to a subtherapeutic serum concentration and seizures in some patients. Valproic acid serum concentration may be significantly decreased with addition of a carbapenem antibiotic but generally return toward normal shortly after discontinuation of the carbapenem antibiotic. Conclusions: Generally, the concurrent use of carbapenem antibiotics with valproate derivatives should be avoided due to the potential of drug-drug interaction that results in subtherapeutic valproate serum concentration. Other antimicrobial agents should be considered as alternatives to carbapenems but if a concurrent carbapenem is necessary, using an additional antiepileptic agent is recommended. Therapeutic drug monitoring of valproate serum concentrations is warranted when a carbapenem-valproic acid combination therapy is unavoidable.
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Affiliation(s)
| | - Alla Laila
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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28
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Carnovale C, Pozzi M, Mazhar F, Mosini G, Gentili M, Peeters GGAM, Clementi E, Radice S. Interactions Between Antiepileptic and Antibiotic Drugs: A Systematic Review and Meta-Analysis with Dosing Implications. Clin Pharmacokinet 2018; 58:875-886. [DOI: 10.1007/s40262-018-0720-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Drug-drug interactions (DDIs) are common and avoidable complications that are associated with poor patient outcomes. Neurocritical care patients may be at particular risk for DDIs due to alterations in pharmacokinetic profiles and exposure to medications with a high DDI risk. This review describes the principles of DDI pharmacology, common and severe DDIs in Neurocritical care, and recommendations to minimize adverse outcomes. A review of published literature was performed using PubMed by searching for 'Drug Interaction' and several high DDI risk and common neurocritical care medications. Key medication classes included anticoagulants, antimicrobials, antiepileptics, antihypertensives, sedatives, and selective serotonin reuptake inhibitors. Additional literature was also reviewed to determine the risk in neurocritical care and potential therapeutic alternatives. Clinicians should be aware of interactions in this setting, the long-term complications, and therapeutic alternatives.
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Affiliation(s)
- Brian Spoelhof
- Department of Pharmacy, Lahey Hospital and Medical Center, Burlington, MA, USA.
| | - Salia Farrokh
- Neurocritical Care, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lucia Rivera-Lara
- Department of Anesthesiology and Critical Care Medicine, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Khobrani MA, Dudley SW, Huckleberry YC, Kopp BJ, Biggs AD, French RNE, Shirazi FM, Erstad BL. Intentional use of carbapenem antibiotics for valproic acid toxicity: A case report. J Clin Pharm Ther 2018; 43:723-725. [DOI: 10.1111/jcpt.12705] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/10/2018] [Indexed: 11/30/2022]
Affiliation(s)
- M. A. Khobrani
- Department of Pharmacy Practice & ScienceCollege of PharmacyThe University of Arizona Tucson AZ USA
- Department of Pharmacy Practice & ScienceCollege of PharmacyKing Khalid University Abha Saudi Arabia
| | - S. W. Dudley
- Arizona Poison & Drug Information CenterCollege of PharmacyThe University of Arizona Tucson AZ USA
| | - Y. C. Huckleberry
- Department of Pharmacy ServicesBanner University Medical Center ‐ Tucson Tucson AZ USA
| | - B. J. Kopp
- Department of Pharmacy ServicesBanner University Medical Center ‐ Tucson Tucson AZ USA
| | - A. D. Biggs
- Department of Pharmacy ServicesFroedtert Hospital Milwaukee WI USA
| | - R. N. E. French
- Arizona Poison & Drug Information CenterCollege of PharmacyThe University of Arizona Tucson AZ USA
- Department of Emergency MedicineBanner University Medical Center ‐ Tucson Tucson AZ USA
| | - F. M. Shirazi
- Arizona Poison & Drug Information CenterCollege of PharmacyThe University of Arizona Tucson AZ USA
- Department of Emergency MedicineBanner University Medical Center ‐ Tucson Tucson AZ USA
| | - B. L. Erstad
- Department of Pharmacy Practice & ScienceCollege of PharmacyThe University of Arizona Tucson AZ USA
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31
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Analysis of the Variables Influencing Valproic Acid Concentration in the Serum and Cerebrospinal Fluid of Chinese Patients After Craniotomy. Ther Drug Monit 2017; 39:450-456. [PMID: 28604475 DOI: 10.1097/ftd.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Valproic acid (VPA) has been widely used in Chinese patients after craniotomy. Many studies have focused on the influencing factors of VPA serum concentration, but conclusions are sometimes paradoxical. Furthermore, the concentration of VPA in the cerebrospinal fluid (CSF) has been rarely reported. In the present study, VPA CSF concentrations were measured, and the potential factors influencing serum concentration and CSF distribution of VPA were investigated. In addition, the functional relationship between serum and CSF concentration was explored. METHODS Subjects were patients who underwent craniotomy and were administrated with VPA and had a lumbar puncture. Serum and CSF VPA concentrations were measured by use of the Abbott i1000 system. CYP2C9 (430 C>T, 1075 A>C, 1076 T>C, 1080 C>G), UGT1A6 (541 A>G, 552 A>C), UGT2B7 (211 G>T, 802 C>T), and ABCB1 (1236 C>T, 2677 G>T/A, 3435 C>T) genotypes were determined by direct sequencing. Information, such as age, gender, and height, was collected, and their effect on serum and CSF VPA concentrations was investigated by univariate analysis and multiple linear regression analysis. RESULTS First, the concomitant use of carbapenems (β' = -0.422) and UGT1A6 (552 AA → AC) (β' = -0.249) had a significant negative correlation with the weight-adjusted VPA serum concentration (C:W ratio), whereas CYP2C9 (1075 AA → AC) (β' = 0.186) and gender (female compared with male) (β' = 0.322) showed a positive correlation with VPA serum C:W ratio. The coefficient of determination (R) was only 0.348. Second, the relationship between the serum concentration and the CSF square root of the concentration (R = 0.705) had a better linear fit. Third, serum VPA concentration (β' = 0.810), concomitant use of glycerol fructose (β' = 0.160), and age (≥65 compared with <65) (β' = 0.118) showed a positive correlation (R = 0.748) with the variability of square root of the concentration of the CSF. CONCLUSIONS In Chinese patients, after craniotomy, female patients with 1 or more of CYP2C9 (1075 AC) and UGT1A6 (552 AA) genotypes required a lower VPA dosage compared with male patient. There was a better-fitted linear relationship between VPA serum and the square root of CSF concentrations. CSF VPA concentrations were relatively stable, with only age and the use of glycerol fructose having a small influence.
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Okumura LM, Andreolio C, Di Giorgio C, Carvalho PRA, Piva JP. Meropenem-induced low valproate levels in a cerebral palsy child. Braz J Infect Dis 2017; 21:491. [PMID: 28343819 PMCID: PMC9427987 DOI: 10.1016/j.bjid.2017.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 01/05/2017] [Accepted: 01/06/2017] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lucas Miyake Okumura
- Hospital de Clínicas de Porto Alegre, Divisão de Farmácia Clínica, Porto Alegre, RS, Brazil.
| | - Cinara Andreolio
- Hospital de Clínicas de Porto Alegre, Unidade de Terapia Intensiva Pediátrica, Porto Alegre, RS, Brazil
| | - Carla Di Giorgio
- Hospital de Clínicas de Porto Alegre, Unidade de Terapia Intensiva Pediátrica, Porto Alegre, RS, Brazil
| | | | - Jefferson Pedro Piva
- Hospital de Clínicas de Porto Alegre, Unidade de Terapia Intensiva Pediátrica, Porto Alegre, RS, Brazil
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Flügel D. [Not Available]. PRAXIS 2017; 106:143-150. [PMID: 28169598 DOI: 10.1024/1661-8157/a002596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Zusammenfassung. Der Status epilepticus, vor allem der konvulsive tonisch-klonische (Grand mal) Status epilepticus, ist ein Notfall, der zu einer sofortigen Behandlung führen muss. Die frühe Behandlung ist effektiver als der spätere Beginn, ebenso wie der Einsatz standardisierter Therapieprotokolle. Nach der Gabe von Benzodiazepinen muss die Aufdosierung eines Antikonvulsivums (Levetiracetam, Valproat oder Phenytoin) erfolgen, um das Wiederauftreten von Anfällen zu verhindern. Beim refraktären Status epilepticus werden die Anästhetika Propofol oder Midazolam (oder Thiopental) vorzugsweise unter EEG-Ableitung mit einem Burst-Suppressions-Muster eingesetzt. Neben der raschen Therapie sollte die Diagnostik nach der Ursache des Status epilepticus nicht vergessen werden. Insbesondere bei Persistenz sollte immer auch die Überprüfung der Diagnose erfolgen, um das Vorliegen eines Pseudostatus nicht-epileptischer Anfälle nicht zu übersehen.
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Wen ZP, Fan SS, Du C, Yin T, Zhou BT, Peng ZF, Xie YY, Zhang W, Chen Y, Xiao J, Chen XP. Drug-drug interaction between valproic acid and meropenem: a retrospective analysis of electronic medical records from neurosurgery inpatients. J Clin Pharm Ther 2017; 42:221-227. [PMID: 28145574 DOI: 10.1111/jcpt.12501] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 12/09/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Z.-P. Wen
- Department of Clinical Pharmacology; Xiangya Hospital; Central South University; Changsha Hunan China
- Hunan Key Laboratory of Pharmacogenetics; Institute of Clinical Pharmacology; Central South University; Changsha Hunan China
- Cooperative Innovation Center for Molecular Target New Drug Study; University of South China; Hengyang Hunan China
| | - S.-S. Fan
- Department of Neurosurgery; Xiangya Hospital; Central South University; Changsha Hunan China
| | - C. Du
- Department of Neurosurgery; Xiangya Hospital; Central South University; Changsha Hunan China
| | - T. Yin
- Department of Pharmacy; Xiangya Hospital; Central South University; Changsha Hunan China
| | - B.-T. Zhou
- Department of Pharmacy; Xiangya Hospital; Central South University; Changsha Hunan China
| | - Z.-F. Peng
- Department of Neurosurgery; Xiangya Hospital; Central South University; Changsha Hunan China
| | - Y.-Y. Xie
- Department of Neurosurgery; Xiangya Hospital; Central South University; Changsha Hunan China
| | - W. Zhang
- Department of Clinical Pharmacology; Xiangya Hospital; Central South University; Changsha Hunan China
- Hunan Key Laboratory of Pharmacogenetics; Institute of Clinical Pharmacology; Central South University; Changsha Hunan China
- Cooperative Innovation Center for Molecular Target New Drug Study; University of South China; Hengyang Hunan China
| | - Y. Chen
- Department of Clinical Pharmacology; Xiangya Hospital; Central South University; Changsha Hunan China
- Hunan Key Laboratory of Pharmacogenetics; Institute of Clinical Pharmacology; Central South University; Changsha Hunan China
| | - J. Xiao
- Department of Pharmacy; Xiangya Hospital; Central South University; Changsha Hunan China
| | - X.-P. Chen
- Department of Clinical Pharmacology; Xiangya Hospital; Central South University; Changsha Hunan China
- Hunan Key Laboratory of Pharmacogenetics; Institute of Clinical Pharmacology; Central South University; Changsha Hunan China
- Cooperative Innovation Center for Molecular Target New Drug Study; University of South China; Hengyang Hunan China
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Bede P, Lawlor D, Solanki D, Delanty N. Carbapenems and valproate: A consumptive relationship. Epilepsia Open 2016; 2:107-111. [PMID: 29750220 PMCID: PMC5939412 DOI: 10.1002/epi4.12030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 11/16/2022] Open
Abstract
A clinical case series is presented to characterize the interaction between carbapenem antibiotics and sodium valproate. Six illustrative cases are presented in which carbapenem therapy led to the rapid depletion of serum valproate levels, and one case is presented to demonstrate the difficulty of initiating valproate therapy in patients already on meropenem. The speed of valproate depletion after the initiation of carbapenem therapy, the effect of treatment duration, clinical manifestations, delay in valproate level normalization after carbapenem therapy, the efficacy of supplemental valproate doses, and the usefulness of valproate dose escalation are evaluated. Five out of the 7 patients became acutely symptomatic owing to their subtherapeutic valproate levels. The presented cases also highlight the relatively slow normalization of valproate levels after discontinuation of the antibiotic therapy. Our cases suggest that the interaction is not absorption‐mediated because all of our patients received intravenous valproate. We observed that the introduction of alternative antiepileptic drugs (AEDs) may be preferable to valproate dose escalation, which is ineffective in the presence of concomitant meropenem therapy. The characterization and recognition of this interaction have implications for the management of a particularly vulnerable patient cohort.
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Affiliation(s)
- Peter Bede
- Department of Neurology Beaumont Hospital Dublin Dublin Ireland.,Academic Unit of Neurology Trinity College Dublin Dublin Ireland
| | - Diane Lawlor
- Department of Pharmacy Beaumont Hospital Dublin Dublin Ireland
| | - Damodar Solanki
- Department of Pharmacy Beaumont Hospital Dublin Dublin Ireland
| | - Norman Delanty
- Department of Neurology Beaumont Hospital Dublin Dublin Ireland.,Royal College of Surgeons of Ireland Dublin Ireland
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