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Pigliasco F, Cafaro A, Barco S, Stella M, Mattioli F, Riva A, Mancardi MM, Lattanzi S, Bandettini R, Striano P, Cangemi G. Innovative LC-MS/MS method for therapeutic drug monitoring of fenfluramine and cannabidiol in the plasma of pediatric patients with epilepsy. J Pharm Biomed Anal 2024; 245:116174. [PMID: 38703746 DOI: 10.1016/j.jpba.2024.116174] [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: 02/12/2024] [Revised: 03/25/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
We present a novel liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for quantifying fenfluramine (FFA), its active metabolite norfenfluramine (norFFA), and Epidyolex®, a pure cannabidiol (CBD) oral solution in plasma. Recently approved by the EMA for the adjunctive treatment of refractory seizures in patients with Dravet and Lennox-Gastaut syndromes aged above 2 years, FFA and CBD still do not have established therapeutic blood ranges, and thus need careful drug monitoring to manage potential pharmacokinetic and pharmacodynamic interactions. Our method, validated by ICH guidelines M10, utilizes a rapid extraction protocol from 100 µL of human plasma and a reversed-phase C-18 HPLC column, with deuterated internal standards. The Thermofisher Quantiva triple-quadrupole MS coupled with an Ultimate 3000 UHPLC allowed multiple reaction monitoring detection, ensuring precise analyte quantification. The assay exhibited linear responses across a broad spectrum of concentrations: ranging from 1.64 to 1000 ng/mL for both FFA and CBD, and from 0.82 to 500 ng/mL for norFFA. The method proves accurate and reproducible, free from matrix effect. Additionally, FFA stability in plasma at 4 °C and -20 °C for up to 7 days bolsters its clinical applicability. Plasma concentrations detected in patients samples, expressed as mean ± standard deviation, were 0.36 ± 0.09 ng/mL for FFA, 19.67 ± 1.22 ng/mL for norFFA. This method stands as a robust tool for therapeutic drug monitoring (TDM) of FFA and CBD, offering significant utility in assessing drug-drug interactions in co-treated patients, thus contributing to optimized patient care in complex therapeutic scenarios.
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Affiliation(s)
- Federica Pigliasco
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alessia Cafaro
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sebastiano Barco
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Manuela Stella
- Gaslini Trial Centre, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Francesca Mattioli
- Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy; Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Roberto Bandettini
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy; Paediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Horonyova P, Durisova I, Cermakova P, Babelova L, Buckova B, Sofrankova L, Valachovic M, Hsu YHH, Balazova M. The subtherapeutic dose of valproic acid induces the activity of cardiolipin-dependent proteins. BIOCHIMICA ET BIOPHYSICA ACTA. BIOENERGETICS 2024; 1865:149501. [PMID: 39079622 DOI: 10.1016/j.bbabio.2024.149501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/29/2024] [Accepted: 07/26/2024] [Indexed: 08/04/2024]
Abstract
A mood-stabilizing anticonvulsant valproic acid (VPA) is a drug with a pleiotropic effect on cells. Here, we describe the impact of VPA on the metabolic function of human HAP1 cells. We show that VPA altered the biosynthetic pathway of cardiolipin (CL) and affected the activities of mitochondrial enzymes such as pyruvate dehydrogenase, α-ketoglutarate dehydrogenase and NADH dehydrogenase. We demonstrate that a therapeutic dose of VPA (0.6 mM) has a harmful effect on cell growth and increases the production of reactive oxygen species and superoxides. On the contrary, less concentrated VPA (0.06 mM) increased the activities of CL-dependent enzymes leading to an increased level of oxidative phosphorylation and ATP production. The effect of VPA was also tested on the Barth syndrome model, which is characterized by a reduced amount of CL and an increased level of monolyso-CL. In this model, VPA treatment slightly attenuated the mitochondrial defects by altering the activities of CL-dependent enzymes. However, the presence of CL was essential for the increase in ATP production by VPA. Our findings highlight the potential therapeutic role of VPA in normalizing mitochondrial function in BTHS and shed light on the intricate interplay between lipid metabolism and mitochondrial physiology in health and disease. SUMMARY: This study investigates the dose-dependent effect of valproate, a mood-stabilizing drug, on mitochondrial function. The therapeutic concentration reduced overall cellular metabolic activity, while a subtherapeutic concentration notably improved the function of cardiolipin-dependent proteins within mitochondria. These findings shed light on novel aspects of valproate's effect and suggest potential practical applications for its use. By elucidating the differential effects of valproate doses on mitochondrial activity, this research underscores the drug's multifaceted role in cellular metabolism and highlights avenues for further exploration in therapeutic interventions.
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Affiliation(s)
- Paulina Horonyova
- Department of Membrane Biochemistry, Institute of Animal Biochemistry and Genetics, Centre of Biosciences, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Ivana Durisova
- Department of Membrane Biochemistry, Institute of Animal Biochemistry and Genetics, Centre of Biosciences, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Petra Cermakova
- Department of Biochemistry, Faculty of Natural Sciences, Comenius University, Bratislava, Slovakia
| | - Lenka Babelova
- Department of Membrane Biochemistry, Institute of Animal Biochemistry and Genetics, Centre of Biosciences, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Barbora Buckova
- Department of Biochemistry, Faculty of Natural Sciences, Comenius University, Bratislava, Slovakia
| | - Lucia Sofrankova
- Institute of Biochemistry and Microbiology, Faculty of Chemical and Food Technology, Slovak University of Technology in Bratislava, Slovakia
| | - Martin Valachovic
- Department of Membrane Biochemistry, Institute of Animal Biochemistry and Genetics, Centre of Biosciences, Slovak Academy of Sciences, Bratislava, Slovakia
| | | | - Maria Balazova
- Department of Membrane Biochemistry, Institute of Animal Biochemistry and Genetics, Centre of Biosciences, Slovak Academy of Sciences, Bratislava, Slovakia.
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Saito M, Nomura A, Hasegawa D, Watanabe N, Uchida K, Okuno S, Nakai M, Orito K. Clinical efficacy and tolerability of zonisamide monotherapy in dogs with newly diagnosed idiopathic epilepsy: Prospective open-label uncontrolled multicenter trial. J Vet Intern Med 2024; 38:2228-2236. [PMID: 38780448 PMCID: PMC11256125 DOI: 10.1111/jvim.17108] [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: 12/31/2023] [Accepted: 05/02/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Zonisamide (ZNS) is a newer generation antiseizure medication (ASM) used to treat epilepsy in dogs and cats. However, scientific and clinical information, particularly regarding monotherapy, is limited. OBJECTIVES To evaluate the antiseizure efficacy and tolerability of ZNS monotherapy in dogs with newly diagnosed idiopathic epilepsy (IE). ANIMALS Study included 56 client-owned dogs newly diagnosed with IE. METHODS This was a prospective multicenter, open-label, uncontrolled study. All dogs were ASM-naïve and had ≥2 seizures within 12 weeks. Dogs were administered 2.7-14.4 mg/kg ZNS PO q12h and followed up for ≥12 weeks. Data from the 12-week maintenance treatment period were compared with those from the 4- to 12-week pretreatment period for efficacy evaluation. Data from the entire ZNS administration period were used to assess tolerability. RESULTS Fifty-six dogs were included in our study. Of the dogs, 53 were assessed for efficacy; 40 (76%) had a ≥ 50% reduction in seizure frequency, and 29 (55%) achieved seizure freedom. For 90% of the dogs with ≥50% reduction in seizure frequency, the mean ZNS dose was 4.8 (range, 2.7-8.6) mg/kg q12h and the mean trough plasma ZNS concentration was 18.9 (range, 8.0-48.0) μg/mL. In 7 of the 56 dogs (13%), reduced activity, decreased appetite, vomiting, hindlimb weakness, soft stools, or constipation was observed, albeit mild and temporary. Laboratory tests revealed no relevant changes. CONCLUSIONS AND CLINICAL IMPORTANCE Our study suggests that ZNS monotherapy is effective and well-tolerated in dogs with newly diagnosed IE.
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Affiliation(s)
- Miyoko Saito
- Laboratory of Small Animal Surgery (Neurology), School of Veterinary MedicineAzabu UniversitySagamiharaJapan
| | - Akinori Nomura
- Department of Product DevelopmentBussan Animal Health Co, LtdOsakaJapan
| | - Daisuke Hasegawa
- Laboratory of Veterinary Clinical Neurology, Graduate School of Veterinary MedicineNippon Veterinary and Life Science UniversityTokyoJapan
| | | | | | | | - Masahiro Nakai
- Department of Product DevelopmentBussan Animal Health Co, LtdOsakaJapan
| | - Kensuke Orito
- Laboratory of Physiology II, School of Veterinary MedicineAzabu UniversitySagamiharaJapan
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Li W, Yang X, Chen Q, Wang Z, Duan Y, Chen L. Monitoring levetiracetam concentration in saliva during pregnancy is stable and feasible. CNS Neurosci Ther 2024; 30:e14827. [PMID: 38992878 PMCID: PMC11239326 DOI: 10.1111/cns.14827] [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: 10/07/2023] [Revised: 05/07/2024] [Accepted: 06/20/2024] [Indexed: 07/13/2024] Open
Abstract
AIMS This multicenter prospective cohort study (registration no. ChiCTR2000032089) aimed to investigate the relationship between saliva and plasma levetiracetam concentrations to determine whether saliva could be used for routine monitoring of levetiracetam during pregnancy. METHODS The slot concentrations of levetiracetam in simultaneously obtained saliva and plasma samples were measured using UPLC-MS/MS. The correlations between saliva and plasma levetiracetam concentrations and the dose-normalized concentrations were compared among pregnant women in different stages and nonpregnant control participants with epilepsy. RESULTS In total, 231 patients with 407 plasma and saliva sample pairs were enrolled from 39 centers. Linear relationships between salivary and plasma levetiracetam concentrations were reported in the enrolled population (r = 0.898, p < 0.001), including pregnant (r = 0.935, p < 0.001) and nonpregnant participants (r = 0.882, p < 0.001). Plasma concentrations were moderately higher than saliva concentrations, with ratios of saliva to plasma concentrations of 0.98 for nonpregnant women, 0.98, 1, and 1.12 for pregnant women during the first trimester, the second trimester, the and third trimester, respectively. The effective range of saliva levetiracetam concentration was found to be 9.98 μg/mL (lower limit) with an area under the curve (AUC) of 0.937 (95% confidence intervals, 0.915-0.959), sensitivity of 88.9%, specificity of 86.8%, and p < 0.001, to 24.05 μg/mL (upper limit) with an AUC of 0.952 (0.914-0.99), sensitivity of 100%, specificity of 92.3%, and p = 0.007. CONCLUSION The saliva/plasma concentration ratio of levetiracetam remains constant during pregnancy and is similar to that in non-pregnant individuals. Monitoring levetiracetam concentration in saliva during pregnancy should be widely promoted.
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Affiliation(s)
- Wanling Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ximeng Yang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qian Chen
- Center of Biostatistics, Design, Measurement and Evaluation, Department of Clinical Research Management, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Zhenlei Wang
- NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, Clinical Trial Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yifei Duan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Yang J, Wang J, Ning L, Wu C, Liu Y, Xia J, Guan Y, Liu Q, Zheng J. Influence of UGT2B7, UGT1A4 and ABCG2 Polymorphisms on the Pharmacokinetics and Therapeutic Efficacy of Lamotrigine in Patients with Epilepsy. Eur J Drug Metab Pharmacokinet 2024; 49:437-447. [PMID: 38709450 DOI: 10.1007/s13318-024-00894-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND AND OBJECTIVES A substantial inter-individual variability has been observed in the pharmacokinetics of lamotrigine. The aim of the study was to investigate the impact of genetic polymorphism of the metabolizing enzymes (UGT2B7, UGT1A4) and transporter (ABCG2) on the pharmacokinetics and therapeutic efficacy of lamotrigine in patients with epilepsy. METHODS The genetic analysis of single-nucleotide polymorphisms was conducted using polymerase chain reaction sequence. High-performance liquid chromatography/tandem mass spectrometry was employed to measure the plasma concentrations of lamotrigine. The efficacy of lamotrigine was assessed by evaluating the reduction rate of epileptic seizure frequency. RESULTS This study included a cohort of 331 patients who were treated with lamotrigine as monotherapy. A linear correlation was observed between the lamotrigine concentration and daily dose taken (r = 0.58, p < 2.2e-16). Statistically significant differences were found in both the median plasma concentration and dose-adjusted concentration (C/D ratio) when comparing the ineffective to the effective group (p < 0.05). Multivariate analysis showed that UGT1A4 rs2011425, ABCG2 rs2231142 polymorphisms and age had a significant relationship with the lamotrigine concentrations (p < 0.05). Age was a predictive factor for C/D ratio (p < 0.001). Lamotrigine concentration and weight were good predictive factors for effective seizure outcomes (odds ratio [OR] = 0.715, 95% CI 0.658-0.776, p < 0.001; OR = 0.926, 95% CI 0.901-0.951, p < 0.001, respectively). The cut-off values of lamotrigine trough concentrations for clinical outcomes in the age-related groups were determined as 2.49 μg/ml (area under the receiver-operating characteristic curve [AUC]: 0.828, 95% CI 0.690-0.966), 2.70 μg/ml (AUC: 0.805, 95% CI 0.745-0.866) and 3.25 μg/ml (AUC: 0.807, 95% CI 0.686-0.928) for the adult group, adolescent group, and toddler and school-age group, respectively. CONCLUSIONS UGT1A4 rs2011425 and ABCG2 rs2231142 were correlated with lamotrigine concentrations. Lower lamotrigine trough concentration was found in the ineffective group and the troughs were associated with seizure outcomes.
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Affiliation(s)
- Jing Yang
- Department of Neurology, The Second Affiliated Hospital of Guizhou Medical University, Kaili, 556000, Guizhou, China
| | - Jinxingyi Wang
- Department of Pharmacy, The Second Affiliated Hospital of Guizhou Medical University, Kaili, 556000, Guizhou, China
| | - Lijie Ning
- Department of Neurology, The Second Affiliated Hospital of Guizhou Medical University, Kaili, 556000, Guizhou, China
| | - Changsong Wu
- Department of Neurology, The Second Affiliated Hospital of Guizhou Medical University, Kaili, 556000, Guizhou, China
| | - Yang Liu
- Department of Pharmacy, The Second Affiliated Hospital of Guizhou Medical University, Kaili, 556000, Guizhou, China
| | - Jie Xia
- Department of Pharmacy, The Second Affiliated Hospital of Guizhou Medical University, Kaili, 556000, Guizhou, China
| | - Yanping Guan
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, 510006, China.
| | - Qian Liu
- Department of Pharmacy, The Second Affiliated Hospital of Guizhou Medical University, Kaili, 556000, Guizhou, China.
| | - Jianghuan Zheng
- Department of Neurology, The Second Affiliated Hospital of Guizhou Medical University, Kaili, 556000, Guizhou, China.
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Jin W, Wang J, Chen S, Chen Q, Li D, Zhu M, Fu X, Huang Y, Lin P. UPLC-MS/MS determination of 71 neuropsychotropic drugs in human serum. Heliyon 2024; 10:e32274. [PMID: 38975205 PMCID: PMC11226775 DOI: 10.1016/j.heliyon.2024.e32274] [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: 10/24/2023] [Revised: 05/23/2024] [Accepted: 05/30/2024] [Indexed: 07/09/2024] Open
Abstract
In this study, a UPLC-MS/MS method was developed for the rapid detection of 71 neuropsychotropic drugs in human serum for drug concentration monitoring and toxicity screening. The analytes were separated from the biological matrix by protein precipitation using a methanol-acetonitrile solvent mixture. The chromatographic separation was performed on a Kromasil ClassicShell C18 column (2.1*50 mm, 2.5 μ m) with gradient elution using acetonitrile-0.2 % acetic acid and 10 mM ammonium acetate as the mobile phases (flow rate 0.4 mL/min, column temperature 40 °C, injection volume 5 μL). An electrospray ion source in both positive and negative ion modes with multiple ion monitoring was used. The total run time was 6 min. All compounds were quantified using the isotope internal standard method. Totally, 71 drugs were detected within their linear ranges with correlation coefficients greater than 0.990. The intra- and inter-batch precision relative standard deviations (RSDs) for the low, medium, and high concentration points were less than 15 %, with an accuracy of 90%-110 %. All compounds except Moclobemide N-oxindole are stabilised within 7 days. The relative matrix effect results for each analyte were within ±20 % of the requirements. The method is validated according to Clinical and Laboratory Standards Institute guidelines, easy to use, and has a low cost.
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Affiliation(s)
- Weifeng Jin
- Department of Medical Laboratory, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China
| | - Jianhua Wang
- Shanghai Biotree Biomedical Technology Co, China
| | - Shuzi Chen
- Department of Medical Laboratory, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China
| | - Qing Chen
- Department of Medical Laboratory, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China
| | - Dan Li
- Department of Medical Laboratory, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China
| | - Mengyuan Zhu
- Department of Medical Laboratory, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China
| | - Xiaomei Fu
- Department of Medical Laboratory, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China
| | - Yingyu Huang
- Shanghai Biotree Biomedical Technology Co, China
| | - Ping Lin
- Department of Medical Laboratory, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China
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Lee ZN, van Nuland M, Bognàr T, Leijten FSS, van der Elst KCM. Association of Lamotrigine Plasma Concentrations with Efficacy and Toxicity in Patients with Epilepsy: A Retrospective Study. Ther Drug Monit 2024:00007691-990000000-00211. [PMID: 38648664 DOI: 10.1097/ftd.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/29/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND There is limited evidence to support the currently suggested lamotrigine (LTG) therapeutic reference range of 2.5-15 mg/L for the treatment of seizures. The objective of this study was to evaluate the association of LTG plasma concentrations with the efficacy and toxicity of the treatment in patients with epilepsy. METHODS Patients whose LTG plasma concentration was measured between January 2013 and February 2022 were included. Efficacy was defined as seizure freedom for at least 6 months around the time of measured LTG concentration. Toxicity was defined as any LTG-related adverse drug effect documented in each patient's health record or when the reason for measuring the LTG concentration was toxicity. In addition, the dose-concentration relationship of LTG was assessed. RESULTS In total, 549 concentrations from 259 patients with epilepsy were included. The most common reasons for therapeutic drug monitoring were suspected inefficacy (39%) and pregnancy (21%). The LTG plasma concentration was not associated with efficacy (adjusted odds ratio = 0.94; 95% confidence interval, 0.85-1.04). The LTG plasma concentration was positively associated with the incidence of toxicity after adjusting for age, sex, and number of antiepileptic drugs (odds ratio = 1.11; 95% confidence interval, 1.04-1.19). The daily dose had a significant linear correlation with the LTG plasma concentration ( P < 0.001). CONCLUSIONS The LTG plasma concentration was associated with toxicity, whereas no association with efficacy was found. A reference range of 2.5-10 mg/L may be considered to decrease the risk of toxicity while maintaining similar efficacy. Therapeutic drug monitoring may be useful when LTG-related toxicity is suspected and in cases of pharmacokinetic changes (eg, pregnancy and concomitant use of interacting drugs) that can influence the LTG plasma concentration.
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Affiliation(s)
- Ze-Ning Lee
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; and
| | - Merel van Nuland
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; and
| | - Tim Bognàr
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; and
| | - Frans S S Leijten
- Department of Clinical Neurophysiology, Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kim C M van der Elst
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; and
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Schierscher T, Salzmann L, Singh N, Fischer V, Kobel A, Bauland F, Geistanger A, Risch L, Geletneky C, Seger C, Taibon J. An isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS)-based candidate reference measurement procedure (RMP) for the quantification of primidone in human serum and plasma. Clin Chem Lab Med 2024; 62:1327-1338. [PMID: 38549258 DOI: 10.1515/cclm-2023-1032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/12/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVES Primidone is an anticonvulsive drug used in the treatment of epilepsy and essential tremor. It offers beneficial effects in controlling seizures, but its usage is also associated with possible side effects. To ensure optimal therapy, it is crucial to measure its concentration through accurate quantification methods. Therefore, our main goal was to develop and validate a new reference measurement procedure (RMP) for accurately measuring primidone levels in human serum and plasma. METHODS In our study, we focused on the separation of primidone from both known and unknown interferences using a C18 column. To achieve accurate sample preparation, we developed a protocol involving protein precipitation followed by a high dilution step. The validation of the assay and determination of measurement uncertainty were carried out following guidelines from organizations such as the Clinical and Laboratory Standards Institute, the International Conference on Harmonization, and the Guide to the Expression of Uncertainty in Measurement. These rigorous validation processes ensure the reliability and accuracy of our method for quantifying primidone levels in human serum and plasma samples. RESULTS The RMP was shown to be highly selective and specific, with no evidence of matrix interference. It can be used to quantify primidone in the range of 0.150-30.0 μg/mL. Intermediate precision was less than 4.0 %, and repeatability CV ranged from 1.0 to 3.3 % across all concentration levels. The relative mean bias ranged from 0.1 to 3.9 % for native serum levels, and from -2.6 to 2.8 % for lithium-heparin plasma levels. The measurement uncertainties for single measurements and target value assignment were 1.5-4.1 % and 0.9-1.0 %, respectively. CONCLUSIONS In this study, we introduce an innovative LC-MS/MS-based candidate RMP specifically designed for primidone in human serum and plasma. Our RMP offers a traceable platform, facilitating the standardization of routine assays and enabling the evaluation of clinically relevant samples. With this novel approach, we aim to enhance the accuracy and reliability of primidone measurements, ultimately benefiting the field of clinical research and patient care.
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Affiliation(s)
| | | | | | | | - Anja Kobel
- Dr. Risch Ostschweiz AG, Buchs, Switzerland
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9
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Maglalang PD, Sinha J, Zimmerman K, McCann S, Edginton A, Hornik CP, Hornik CD, Muller WJ, Al-Uzri A, Meyer M, Chen JY, Anand R, Perrin EM, Gonzalez D. Application of Physiologically Based Pharmacokinetic Modeling to Characterize the Effects of Age and Obesity on the Disposition of Levetiracetam in the Pediatric Population. Clin Pharmacokinet 2024; 63:885-899. [PMID: 38814425 PMCID: PMC11225543 DOI: 10.1007/s40262-024-01367-2] [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] [Accepted: 03/10/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Levetiracetam is an antiseizure medication used for several seizure types in adults and children aged 1 month and older; however, due to a lack of data, pharmacokinetic (PK) variability of levetiracetam is not adequately characterized in certain populations, particularly neonates, children younger than 2 years of age, and children older than 2 years of age with obesity. OBJECTIVE This study aimed to address the gap by leveraging PK data from two prospective standard-of-care pediatric trials (n = 88) covering an age range from 1 month to 19 years, including those with obesity (64%), and applying a physiologically based PK (PBPK) modeling framework. METHODS A published PBPK model of levetiracetam for children aged 2 years and older was extended to pediatric patients younger than 2 years of age and patients older than 2 years of age with obesity by accounting for the obesity and age-related changes in PK using PK-Sim® software. The prospective pediatric data, along with the literature data for neonates and children younger than 2 years of age, were used to evaluate the extended PBPK models. RESULTS Overall, 82.4% of data fell within the 90% interval of model-predicted concentrations, with an average fold error within twofold of the accepted criteria. PBPK modeling revealed that children with obesity had lower weight-normalized clearances (0.053 L/h/kg) on average than children without obesity (0.063 L/h/kg). The effect of maturation was well-characterized, resulting in comparable PBPK-simulated, weight-normalized clearances for neonates and children younger than 2 years of age reported from the literature. CONCLUSIONS PBPK modeling simulations revealed that the current US FDA-labeled pediatric dosing regimen listed in the prescribing information can produce the required exposure of levetiracetam in these target populations with dose adjustments for children with obesity aged 4 years to younger than 16 years.
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Affiliation(s)
- Patricia D Maglalang
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kanecia Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA
| | - Sean McCann
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA
| | - William J Muller
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Amira Al-Uzri
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | | | | | | | - Eliana M Perrin
- Department of Pediatrics, School of Medicine and School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Gonzalez
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA.
- Division of Clinical Pharmacology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
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10
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McGinnis CB, Wang F, Chiappelli AL, Okonkwo DO, Darby JM. Phenobarbital as Anticonvulsant Prophylaxis in Patients With Traumatic Brain Injury at Risk for Alcohol Withdrawal Syndrome. J Pharm Pract 2024; 37:665-670. [PMID: 36961745 DOI: 10.1177/08971900231167932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
Background: Anticonvulsant prophylaxis (ACP) for early post-traumatic seizures (PTS) is recommended in patients with traumatic brain injury (TBI). Phenobarbital (PB) may be used to prevent alcohol withdrawal syndrome (AWS) in at-risk patients. The dual-purpose use of PB in the TBI population would allow for consolidation of pharmacotherapy. Objective: The primary objective of this study was to determine the frequency of early PTS in TBI patients at risk of AWS treated with PB as ACP. Secondary objectives included determining rates of over sedation and endotracheal intubation. Methods: Patients received an intravenous (IV) loading dose of PB at 15-20 mg/kg followed by 1 mg/kg every 12 hours for 7 days with a goal level of 15-20 mcg/mL. Medication data, seizure frequency, and episodes of over sedation and endotracheal intubation were collected. Results: Eighty patients were treated with PB over a 1-year period. Thirty-nine patients were analyzed. Median loading dose was 19.9 (Interquartile Range 19.1-20.0) mg/kg with a median post load level of 21.7 mcg/mL (IQR 18.3-25.8) mcg/mL. One patient (2.6%) had electrographic evidence for early PTS. PB was discontinued in 4 (10.3%) patients out of concern for over sedation. One patient required endotracheal intubation after rapid PB loading. Conclusion: The frequency of early PTS was low when PB was used as primary ACP in patients with TBI at risk for AWS. Over sedation is a potential adverse effect that should be considered in the choice of ACP. No conclusions can be drawn as to the effectiveness of PB in preventing AWS.
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Affiliation(s)
- Cory B McGinnis
- Department of Pharmacy, UPMC Presbyterian, Pittsburgh, PA, USA
| | - Fajun Wang
- Department of Critical Care Medicine, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - David O Okonkwo
- Department of Neurological Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph M Darby
- Department of Critical Care Medicine, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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11
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Abady MM, Jeong JS, Kwon HJ. Simultaneous quantification of 11 antiepileptic drugs using limited isotope-labeled internal standards in LC-MS/MS: An accuracy assessment. J Chromatogr B Analyt Technol Biomed Life Sci 2024; 1240:124143. [PMID: 38761469 DOI: 10.1016/j.jchromb.2024.124143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/28/2024] [Accepted: 04/28/2024] [Indexed: 05/20/2024]
Abstract
This study aims to establish an LC-MS/MS method to simultaneously analyze 11 antiepileptic drugs with a particular focus on maintaining accuracy while reducing the number of isotope-labeled internal standards employed for cost-effectiveness. By applying a water/acetonitrile gradient elution containing 0.1 % formic acid and 2 mM ammonium formate as the mobile phase, optimal sensitivity for the target drugs could be obtained in positive ESI mode in LC-MS/MS. After optimizing various extraction techniques, extraction with 70 % acetonitrile was selected as it provided good recoveries (>93 %) for all targets without matrix effects. Accuracies within 3 % were achieved from the combination of six internal standards, while accuracies of 5 % and 10 % were obtained by reducing the number of internal standards to four and two, respectively, for more economical analysis. The accuracy of the established method was maintained in hyperglycemia, hyperlipidemia, and hyperalbuminemia sera, suggesting that it can be successfully applied to individual serum samples with various properties.
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Affiliation(s)
- Mariam M Abady
- Organic Metrology Group, Korea Research Institute of Standards and Science, Yuseong-gu, Daejeon 34113, Republic of Korea; Department of Bio-Analytical Science, University of Science and Technology, 217 Gajeong-ro, Yuseong-gu, Daejeon 34113, Republic of Korea; Department of Nutrition and Food Science, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Ji-Seon Jeong
- Organic Metrology Group, Korea Research Institute of Standards and Science, Yuseong-gu, Daejeon 34113, Republic of Korea; Department of Bio-Analytical Science, University of Science and Technology, 217 Gajeong-ro, Yuseong-gu, Daejeon 34113, Republic of Korea
| | - Ha-Jeong Kwon
- Organic Metrology Group, Korea Research Institute of Standards and Science, Yuseong-gu, Daejeon 34113, Republic of Korea.
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12
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Ghane N, Khalili S, Khorasani SN, Das O, Ramakrishna S, Neisiany RE. Antiepileptic drug-loaded and multifunctional iron oxide@silica@gelatin nanoparticles for acid-triggered drug delivery. Sci Rep 2024; 14:11400. [PMID: 38762571 PMCID: PMC11102556 DOI: 10.1038/s41598-024-62248-z] [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: 11/16/2023] [Accepted: 05/15/2024] [Indexed: 05/20/2024] Open
Abstract
The current study developed an innovative design for the production of smart multifunctional core-double shell superparamagnetic nanoparticles (NPs) with a focus on the development of a pH-responsive drug delivery system tailored for the controlled release of Phenytoin, accompanied by real-time monitoring capabilities. In this regard, the ultra-small superparamagnetic iron oxide@silica NPs (IO@Si MNPs) were synthesized and then coated with a layer of gelatin containing Phenytoin as an antiepileptic drug. The precise saturation magnetization value for the resultant NPs was established at 26 emu g-1. The polymeric shell showed a pH-sensitive behavior with the capacity to regulate the release of encapsulated drug under neutral pH conditions, simultaneously, releasing more amount of the drug in a simulated tumorous-epileptic acidic condition. The NPs showed an average size of 41.04 nm, which is in the desired size range facilitating entry through the blood-brain barrier. The values of drug loading and encapsulation efficiency were determined to be 2.01 and 10.05%, respectively. Moreover, kinetic studies revealed a Fickian diffusion process of Phenytoin release, and diffusional exponent values based on the Korsmeyer-Peppas equation were achieved at pH 7.4 and pH 6.3. The synthesized NPs did not show any cytotoxicity. Consequently, this new design offers a faster release of PHT at the site of a tumor in response to a change in pH, which is essential to prevent epileptic attacks.
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Affiliation(s)
- Nazanin Ghane
- Department of Chemical Engineering, Isfahan University of Technology, Isfahan, 84156-83111, Iran
| | - Shahla Khalili
- Department of Chemical Engineering, Isfahan University of Technology, Isfahan, 84156-83111, Iran
| | - Saied Nouri Khorasani
- Department of Chemical Engineering, Isfahan University of Technology, Isfahan, 84156-83111, Iran.
| | - Oisik Das
- Department of Civil, Environmental and Natural Resources Engineering, Luleå University of Technology, 97187, Luleå, Sweden.
| | - Seeram Ramakrishna
- Center for Nanotechnology & Sustainability, National University of Singapore, Singapore, 117574, Singapore
| | - Rasoul Esmaeely Neisiany
- Department of Polymer Engineering, Hakim Sabzevari University, Sabzevar, 9617976487, Iran.
- Biotechnology Centre, Silesian University of Technology, Krzywoustego 8, 44-100, Gliwice, Poland.
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13
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Biso L, Aringhieri S, Carli M, Scarselli M, Longoni B. Therapeutic Drug Monitoring in Psychiatry: Enhancing Treatment Precision and Patient Outcomes. Pharmaceuticals (Basel) 2024; 17:642. [PMID: 38794212 PMCID: PMC11124530 DOI: 10.3390/ph17050642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/09/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
Psychiatric disorders often require pharmacological interventions to alleviate symptoms and improve quality of life. However, achieving an optimal therapeutic outcome is challenging due to several factors, including variability in the individual response, inter-individual differences in drug metabolism, and drug interactions in polytherapy. Therapeutic drug monitoring (TDM), by measuring drug concentrations in biological samples, represents a valuable tool to address these challenges, by tailoring medication regimens to each individual. This review analyzes the current landscape of TDM in psychiatric practice, highlighting its significance in optimizing drug dosages, minimizing adverse effects, and improving therapeutic efficacy. The metabolism of psychiatric medications (i.e., mood stabilizers, antipsychotics, antidepressants) often exhibits significant inter-patient variability. TDM can help address this variability by enhancing treatment personalization, facilitating early suboptimal- or toxic-level detection, and allowing for timely interventions to prevent treatment failure or adverse effects. Furthermore, this review briefly discusses technological advancements and analytical methods supporting the implementation of TDM in psychiatric settings. These innovations enable quick and cost-effective drug concentration measurements, fostering the widespread adoption of TDM as a routine practice in psychiatric care. In conclusion, the integration of TDM in psychiatry can improve treatment outcomes by individualizing medication regimens within the so-called precision medicine.
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Affiliation(s)
- Letizia Biso
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Stefano Aringhieri
- Mental Health and Pathological Addiction Department, AUSL Romagna Forlì-Cesena, 47121 Forlì, Italy;
| | - Marco Carli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Marco Scarselli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
| | - Biancamaria Longoni
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (L.B.); (M.C.); (M.S.)
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14
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Heger K, Burns ML, Nikanorova M, Johannessen SI, Johannessen Landmark C. Pharmacokinetic Variability of Rufinamide and Stiripentol in Children with Refractory Epilepsy: A Retrospective Study of Therapeutic Drug Monitoring from the National Epilepsy Centers in Denmark and Norway. Ther Drug Monit 2024:00007691-990000000-00228. [PMID: 38758628 DOI: 10.1097/ftd.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/03/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Rufinamide and stiripentol, orphan drugs used in Lennox-Gastaut and Dravet syndromes, respectively, are antiseizure medications (ASMs), often administered to children; however, pharmacokinetic studies are lacking. The authors compared the pharmacokinetic variability of these drugs with respect to the dose, serum concentrations, comedication, age, and duration of treatment. METHODS Children and adolescents (<18 years) whose serum concentrations were measured were retrospectively identified from the therapeutic drug monitoring (TDM) databases at 2 national epilepsy centers in Norway and Denmark (2012-2021). RESULTS Data from 165 patients (56% boys/44% girls) treated with rufinamide and 52 patients (50% boys/50% girls) treated with stiripentol were included. For rufinamide, the median age was 10 (range 2-17) years, dose 23 (3-73) mg/d, and serum concentration 34 (3-227) µmol/L [8.1 mg/L (0.71-54.0 mg/L)]. For stiripentol, the median age was 8.5 (range 1-17) years, dose 37 (18-76) mg/d, and serum concentration 33 (4-113) µmol/L [7.7 mg/L (0.93-26.3 mg/L)]. The concomitant use of 1-9 other ASMs during the data collection was noted. Pharmacokinetic variability, calculated as the concentration/(dose/kg) ratio, ranged from 0.26 to 11.31 (µmol/L)/(mg/kg) for rufinamide and 0.17-1.52 (µmol/L)/(mg/kg) for stiripentol. The intraindividual coefficients of variation ranged widely, from 5% to 110% for rufinamide and 11%-117% for stiripentol. The treatment period was at least 5 years in 50% of patients. No statistically significant effects of age, sex, or ASM comedication were observed, possibly due to the small sample size and heterogeneous groups with variable seizure situations, comorbidities, and changes in comedication and physiology. CONCLUSIONS This study demonstrates considerable pharmacokinetic variability in and between patients for both drugs and similar use in terms of age, burden of comedication and retention rates. TDM may be useful in the clinical setting to monitor and optimize treatment in this vulnerable patient group.
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Affiliation(s)
- Katrine Heger
- Department of Pharmacy, Oslo Metropolitan University, Oslo, Norway
| | | | - Marina Nikanorova
- The National Center for Epilepsy, Member of the ERN EpiCARE, Oslo University Hospital, Oslo, Norway; and
| | - Svein I Johannessen
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
- The Danish Epilepsy Center Filadelfia, Dianalund, Denmark
| | - Cecilie Johannessen Landmark
- Department of Pharmacy, Oslo Metropolitan University, Oslo, Norway
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
- The Danish Epilepsy Center Filadelfia, Dianalund, Denmark
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15
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Cancellerini C, Belotti LMB, Mohamed S, Solda' M, Esposito E, Bisulli F, Mostacci B, Vignatelli L, Tinuper P, Contin M, Licchetta L. Fingerprick volumetric absorptive microsampling for therapeutic drug monitoring of antiseizure medications: Reliability and real-life feasibility in epilepsy patients. J Pharm Biomed Anal 2024; 242:116065. [PMID: 38401349 DOI: 10.1016/j.jpba.2024.116065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 02/26/2024]
Abstract
Volumetric absorptive microsampling (VAMS) is increasingly proposed as a clinically reliable therapeutic drug monitoring (TDM) sampling methodology. The study aimed to establish the reliability and real-life feasibility of patient self-collected capillary VAMS for TDM of antiseizure medication (ASMs), using plasma ASMs concentrations from venous blood as a reference standard. Nurses collected venous and capillary blood samples using VAMS. Afterward, persons with epilepsy (PWE) performed VAMS sampling by themselves. All samples were analyzed by UHPLC-MS/MS. We performed a cross-validation study, comparing ASMs concentrations obtained by VAMS nurses and patients' self-collected versus plasma through Bland-Altman analysis and Passing-Bablok regression. We enrolled 301 PWE (M: F 42.5%:57.5%; mean age 44±16 years), treated with 13 ASMs, providing a total of 464 measurements. Statistical analysis comparing VAMS self-collected versus plasma ASMs concentrations showed a bias close to zero and slope and intercept values indicating a good agreement for CBZ, LCS, LEV, LTG, OXC, PB, and PHT, while a systematic difference between the two methods was found for VPA, PMP, TPM and ZNS. This is the first study showing the reliability and feasibility of the real-world application of PWE self-collected VAMS for most of the ASMs considered, giving a promising basis for at-home VAMS applications.
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Affiliation(s)
- Chiara Cancellerini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy
| | - Laura Maria Beatrice Belotti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy
| | - Susan Mohamed
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy
| | - Martina Solda'
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy
| | - Erika Esposito
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy
| | - Francesca Bisulli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy
| | - Luca Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Manuela Contin
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Laura Licchetta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full member of the European Reference Network EpiCARE, Bologna, Italy
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16
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Steinhoff BJ, Georgiou D, Dietmann D, Intravooth T. Cenobamate Plasma Levels in Patients with Epilepsy: Correlation with Efficacy and Tolerability? J Clin Med 2024; 13:2757. [PMID: 38792299 PMCID: PMC11122064 DOI: 10.3390/jcm13102757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Objective: Cenobamate is approved by the European Medicine Agency for the treatment of adult patients with epilepsy (PWEs) with ongoing focal-onset seizures despite appropriate treatment with at least two established antiseizure medications. Pivotal trials and post-marketing real-world observational studies suggest high efficacy with unusually high seizure-free rates. The authors sought to investigate the plasma levels of cenobamate under steady-state conditions in seizure-free versus non-responding PWEs, and in PWEs who experienced adverse events versus those who did not. Methods: Blood samples were collected from adult PWEs who were treated with adjunct cenobamate under steady-state conditions. Daily doses, concomitant medications, efficacy, and tolerability were assessed. The plasma cenobamate levels of seizure-free versus non-responding PWEs and between PWEs with and those without clinical adverse events were compared. Results: Samples from 101 PWEs were included. Thirty-six PWEs were seizure-free and 65 were non-responders. In 31 PWEs, adverse events were apparent, whereas in the remaining 70, no tolerability issues were reported. A linear correlation was found between the daily doses (range: 100 mg-400 mg) and the plasma levels (3.8 mg/L-54.6 mg/L). Neither the daily doses nor the plasma levels differed significantly between the investigated subgroups. The main reason for this result was that the individual therapeutic ranges varied widely: seizure freedom and adverse effects were observed alongside low doses and plasma levels in some PWEs. Conversely, there were examples of PWEs who did not respond or who reported no tolerability issues at high doses or plasma levels. Conclusions: To evaluate the individual therapeutic range and to better understand the influence of other drugs in cases where concomitant medications are used, the therapeutic drug monitoring of cenobamate may be useful. A general therapeutic range cannot be defined.
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Affiliation(s)
- Bernhard J. Steinhoff
- Kork Epilepsy Center, Kehl-Kork, 77694 Kehl, Germany; (D.G.); (D.D.); (T.I.)
- Medical Faculty, University of Freiburg, 79104 Freiburg im Breisgau, Germany
| | - Dimitra Georgiou
- Kork Epilepsy Center, Kehl-Kork, 77694 Kehl, Germany; (D.G.); (D.D.); (T.I.)
| | - Daniel Dietmann
- Kork Epilepsy Center, Kehl-Kork, 77694 Kehl, Germany; (D.G.); (D.D.); (T.I.)
| | - Tassanai Intravooth
- Kork Epilepsy Center, Kehl-Kork, 77694 Kehl, Germany; (D.G.); (D.D.); (T.I.)
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17
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Kenger İH, Yıldız H, Hüsunet MT, DÖNbak L, Kayraldız A. Elucidation of the cytogenotoxic potential of vigabatrin and its in silico computer-assisted DNA interaction. Drug Chem Toxicol 2024; 47:314-321. [PMID: 36752088 DOI: 10.1080/01480545.2023.2174988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/17/2023] [Accepted: 01/24/2023] [Indexed: 02/09/2023]
Abstract
Vigabatrin (VGB) is a gammaaminobutyric acid-ergic (GABA-ergic) antiepileptic drug (AED) and is one of 2 approved drugs available to treat infantile spasms (IS). The aim of this study is to elucidate conflicting data on the toxic effects of VGB and to obtain detailed information about its possible cytogenotoxic effects in human lymphocytes. For this purpose, in vitro Chromosomal Aberration (CA), Sister Chromatid Exchange (SCE), Micronucleus (MN) tests, and Comet Assay were performed to determine possible genotoxic and cytotoxic effects of VGB. In addition, the binding energy level of VGB to DNA was determined in silico by molecular docking. The highest concentration (80 μg/ml) of VGB increased the SCE, CA, MN and micronucleated binuclear cell (BNMN) frequency significantly compared to the control after 24 and 48 hours of treatment. In the tail density and tail length parameters, the dose-dependent increase was found to be statistically significant compared to the control. At the 40 and 80 μg/ml concentrations of VGB for 48 hours caused a statistically significant increase in both CA/Cell and AC percentages, while MI and NDI decreased only significantly at the highest concentration (80 µg/ml) causing. In the Comet Assay head density, tail density and tail length parameters, the dose-dependent increase was found to be statistically significant compared to the control. Also, the in silico molecular docking analysis showed that VGB interacts with B-DNA close to the threshold binding energy. The lowest negative free binding energy (ΔG binding) was found as -5.13 kcal/mol. In conclusion, all results are evaluated together, it has been determined that VGB has cytogenotoxic effects in vitro and binds to DNA in silico with significant free binding energy.
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Affiliation(s)
- İbrahim Halil Kenger
- Faculty of Medicine, Department of Medical Genetics, Gaziantep Islam, Science, and Technology University, Gaziantep, Turkey
| | - Hamit Yıldız
- Faculty of Medicine, Department of Internal Medicine, Gaziantep University, Gaziantep, Turkey
| | - Mehmet Tahir Hüsunet
- Faculty of Medicine, Department of Medical Genetics, Gaziantep Islam, Science, and Technology University, Gaziantep, Turkey
| | - Lale DÖNbak
- Faculty of Science, Department of Biology, Kahramanmaras Sutcu Imam University, Onikişubat, Türkiye
| | - Ahmet Kayraldız
- Faculty of Science, Department of Biology, Kahramanmaras Sutcu Imam University, Onikişubat, Türkiye
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18
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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 2024:00007691-990000000-00212. [PMID: 38648661 DOI: 10.1097/ftd.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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19
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Alshaya AI, Alhammad AM. How Reliable Are Serum Levetiracetam Levels to Be Used as a Primary Endpoint? Crit Care Med 2024; 52:e203-e204. [PMID: 38483228 DOI: 10.1097/ccm.0000000000006145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Affiliation(s)
- Abdulrahman I Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah M Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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20
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Goo Y, der Nederlanden AM, Bleasel A, Alffenaar JW, Kim HY. Dose Monitoring of Lamotrigine Monotherapy in Pregnancy: Are Pregnant Women with Epilepsy Currently Optimally Managed? A Systematic Review. Ther Drug Monit 2024; 46:181-194. [PMID: 38366344 DOI: 10.1097/ftd.0000000000001186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Lamotrigine monotherapy is the first-line treatment for epilepsy in pregnant women. However, altered pharmacokinetics during pregnancy can lead to suboptimal drug levels and increased seizure risk. This systematic review aimed to evaluate current therapeutic drug monitoring (TDM) strategies for lamotrigine monotherapy in pregnant women with epilepsy and provide guidance for monitoring and dose adjustments. METHODS A systematic search was performed using the Ovid-MEDLINE, Ovid-EMBASE, and Ovid-Cochrane Central Register of Controlled Trials databases. Studies were included if data on lamotrigine dosing, concentration, TDM strategies, efficacy, or safety were available. RESULTS Eleven studies were analyzed, revealing heterogeneity in outcomes with selective reporting of TDM strategies; however, clear similarities were observed. Blood samples were collected every 1-3 months during pregnancy to maintain prepregnancy baseline drug levels. Lamotrigine's apparent and relative clearance increased across trimesters, particularly in the second and third trimesters, coinciding with a period of increased seizure frequency and required dose adjustments. Details on dose adjustments were limited. Some studies have proposed using the threshold of the ratio to the target concentration to predict increased seizure risk. No distinct association was observed between adverse newborn outcomes and lamotrigine dose or serum concentration. Few maternal adverse effects have been reported after delivery, confirming the necessity of empirical postpartum tapering. CONCLUSIONS Further studies are required to establish evidence-based standardized protocols encompassing all aspects of TDM. Early interventions, such as empirical dose increases during pregnancy and postpartum tapering, and routine monitoring from preconception to the postpartum period may enhance seizure control, reducing the risk of breakthrough seizures for the mother and unborn child.
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Affiliation(s)
- Yeonkyung Goo
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Andrew Bleasel
- Neurology Department, Westmead Hospital, Westmead, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia ; and
| | - Jan-Willem Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Hannah Yejin Kim
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
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Heger K, Kjeldstadli K, Ring N, Aaberg KM, Kjeldsen SF, Burns ML, Johannessen SI, Johannessen Landmark C. Pharmacokinetic Variability of Sulthiame: The Impact of Age, Drug-Drug Interactions, and Biochemical Markers of Toxicity in Patients with Epilepsy. Ther Drug Monit 2024; 46:237-245. [PMID: 38158595 DOI: 10.1097/ftd.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/25/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Sulthiame is an antiseizure medication increasingly used for epilepsy. The aim of this study was to investigate the pharmacokinetic variability of sulthiame in children and adults with epilepsy with respect to age, comedication, dose, serum concentration, and biochemical markers of toxicity in a clinical setting. METHOD Retrospective quantitative data from the therapeutic drug monitoring (TDM) database at the Section for Clinical Pharmacology, the National Center for Epilepsy, Norway (2015-2021), were used. RESULTS TDM data from 326 patients (127 female/199 male) were included [mean age, 11.4 (range 2-44) years; mean weight, 41 (range 14-109) kg]. Interindividual pharmacokinetic variability in the concentration/(dose/body weight) (C/(D/kg)) ratio was 16-fold; intraindividual variability was up to 8-fold (coefficient of variation = 10%-78%). Young children (younger than 6 years) had a significantly lower C/(D/kg) ratio than older age groups ( P < 0.05). Various comedications did not significantly affect the C/(D/kg) ratio, possibly owing to the small sample size. However, CYP2C19-mediated inhibition by sulthiame was indicated because patients using clobazam and sulthiame (n = 28) had a 3.5-fold higher N-desmethylclobazam C/(D/kg) ratio than those using neutral comedication (n = 45; P < 0.001). Patients with pH values below the adjusted normal range (7.32-7.42; n = 15) had a 33% higher sulthiame concentration than those with normal pH values (n = 22; P < 0.05). Blood gas measurements, especially pH, may serve as markers of toxicity and can be used in combination with clinical data when toxicity is suspected. CONCLUSIONS This study revealed the extensive intraindividual and interindividual pharmacokinetic variability of sulthiame, with age as a contributing factor. Sulthiame has clinically relevant interactions with clobazam. The use of TDM and pH as a biochemical marker may contribute to individualized and safe sulthiame treatment.
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Affiliation(s)
- Katrine Heger
- Department of Pharmacy, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Kari Kjeldstadli
- Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Nelly Ring
- Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Kari Modalsli Aaberg
- The National Center for Epilepsy, Sandvika, Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway; and
| | - Signe Flood Kjeldsen
- Section for Clinical Pharmacology, The National Center for Epilepsy, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Margrete Larsen Burns
- Section for Clinical Pharmacology, The National Center for Epilepsy, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Svein I Johannessen
- The National Center for Epilepsy, Sandvika, Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway; and
- Section for Clinical Pharmacology, The National Center for Epilepsy, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Cecilie Johannessen Landmark
- Department of Pharmacy, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- The National Center for Epilepsy, Sandvika, Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway; and
- Section for Clinical Pharmacology, The National Center for Epilepsy, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
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Scherf-Clavel M, Baumann P, Hart XM, Schneider H, Schoretsanitis G, Steimer W, Zernig G, Zurek G. Behind the Curtain: Therapeutic Drug Monitoring of Psychotropic Drugs from a Laboratory Analytical Perspective. Ther Drug Monit 2024; 46:143-154. [PMID: 36941240 DOI: 10.1097/ftd.0000000000001092] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE Therapeutic drug monitoring (TDM) is a well-established tool for guiding psychopharmacotherapy and improving patient care. Despite their established roles in the prescription of psychotropic drugs, the "behind the curtain" processes of TDM requests are invariably obscure to clinicians, and literature addressing this topic is scarce. METHODS In the present narrative review, we provide a comprehensive overview of the various steps, starting from requesting TDM to interpreting TDM findings, in routine clinical practice. Our goal was to improve clinicians' insights into the numerous factors that may explain the variations in TDM findings due to methodological issues. RESULTS We discussed challenges throughout the TDM process, starting from the analyte and its major variation forms, through sampling procedures and pre-analytical conditions, time of blood sampling, sample matrices, and collection tubes, to analytical methods, their advantages and shortcomings, and the applied quality procedures. Additionally, we critically reviewed the current and future advances in the TDM of psychotropic drugs. CONCLUSIONS The "behind the curtain" processes enabling TDM involve a multidisciplinary team, which faces numerous challenges in clinical routine. A better understanding of these processes will allow clinicians to join the efforts for achieving higher-quality TDM findings, which will in turn improve treatment effectiveness and safety outcomes of psychotropic agents.
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Affiliation(s)
- Maike Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) Work Group on "Therapeutic Drug Monitoring" (Chair: Prof. Dr Med. Dipl.-Psych. Stefan Unterecker, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany)
| | - Pierre Baumann
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) Work Group on "Therapeutic Drug Monitoring" (Chair: Prof. Dr Med. Dipl.-Psych. Stefan Unterecker, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany)
- German Society for Clinical Chemistry and Laboratory Medicine e. V. (DGKL), Section Therapeutic Drug Monitoring and Clinical Toxicology, Berlin/Bonn, Germany
| | - Xenia M Hart
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) Work Group on "Therapeutic Drug Monitoring" (Chair: Prof. Dr Med. Dipl.-Psych. Stefan Unterecker, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany)
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Heike Schneider
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) Work Group on "Therapeutic Drug Monitoring" (Chair: Prof. Dr Med. Dipl.-Psych. Stefan Unterecker, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany)
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
- German Society for Clinical Chemistry and Laboratory Medicine e. V. (DGKL), Section Therapeutic Drug Monitoring and Clinical Toxicology, Berlin/Bonn
- INSTAND e.V. Society for Promoting Quality Assurance in Medical Laboratories, Duesseldorf, Germany
- German Society for Clinical Chemistry and Laboratory Medicine e. V. (DGKL), Section Therapeutic Drug Monitoring and Clinical Toxicology, Berlin/Bonn, Germany
| | - Georgios Schoretsanitis
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) Work Group on "Therapeutic Drug Monitoring" (Chair: Prof. Dr Med. Dipl.-Psych. Stefan Unterecker, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany)
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Werner Steimer
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) Work Group on "Therapeutic Drug Monitoring" (Chair: Prof. Dr Med. Dipl.-Psych. Stefan Unterecker, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany)
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich, Munich, Germany
- German Society for Clinical Chemistry and Laboratory Medicine e. V. (DGKL), Section Therapeutic Drug Monitoring and Clinical Toxicology, Berlin/Bonn
| | - Gerald Zernig
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) Work Group on "Therapeutic Drug Monitoring" (Chair: Prof. Dr Med. Dipl.-Psych. Stefan Unterecker, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany)
- Department of Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
- Private Practice for Psychotherapy and Court-certified Expert Witness, Hall in Tirol, Austria; and
| | - Gabriela Zurek
- Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) Work Group on "Therapeutic Drug Monitoring" (Chair: Prof. Dr Med. Dipl.-Psych. Stefan Unterecker, Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Germany)
- Medical Laboratory Bremen, Bremen, Germany
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Müller IR, Grandi VT, Santos Paulino SG, Villa BD, Zembruski BM, Forcelini CM, Hahn SR, Antunes MV, Linden R. Determination of carbamazepine in fingerprints: a feasibility study to evaluate adherence in epilepsy patients. Bioanalysis 2024; 16:415-427. [PMID: 38497729 PMCID: PMC11216515 DOI: 10.4155/bio-2023-0265] [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: 12/20/2023] [Accepted: 02/23/2024] [Indexed: 03/19/2024] Open
Abstract
Background: Fingerprint drug concentrations can be used as a noninvasive and convenient alternative to evaluate adherence to pharmacotherapy. Methods: Fingerprints were applied over glass slides, extracted and analyzed by ultra-high performance LC-MS/MS. The assay and drug adherence questionnaires were applied to 30 epilepsy patients. Results: The assay had linearity in the range 0.05-10 ng fingerprint-1, with precision of 2.16-7.9% and accuracy of 95.0-102.8%. Carbamazepine (CBZ) levels in fingerprints were stable at 45°C for 15 days. Concentrations in patient samples were 0.06-9.28 ng fingerprint-1. A significant difference (p = 0.003) was found between CBZ concentrations in fingerprints between patient groups divided as low and medium/high adherence. Conclusion: This method can potentially be applied to the identification of epilepsy patients with low adherence to CBZ pharmacotherapy.
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Affiliation(s)
- Isadora Ritter Müller
- Analytical Toxicology Laboratory, Universidade Feevale, Rua Rubem Berta, 200, Novo Hamburgo, RS, CEP, 93525-080, Brazil
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Rua Rubem Berta, 200, Novo Hamburgo, RS, CEP, 93525-080, Brazil
| | - Valéria Tessaro Grandi
- College of Medicine, Universidade de Passo Fundo, Rua Teixeira Soares, 817, Passo Fundo, RS, CEP, 99010-080, Brazil
| | - Sarah Gondim Santos Paulino
- College of Medicine, Universidade de Passo Fundo, Rua Teixeira Soares, 817, Passo Fundo, RS, CEP, 99010-080, Brazil
| | - Bárbara De Villa
- College of Pharmacy, Universidade de Passo Fundo, Rodovia BR 285, Km 293, Passo Fundo, RS, CEP, 99052-900, Brazil
| | - Bianca Modena Zembruski
- College of Pharmacy, Universidade de Passo Fundo, Rodovia BR 285, Km 293, Passo Fundo, RS, CEP, 99052-900, Brazil
| | | | - Siomara Regina Hahn
- College of Pharmacy, Universidade de Passo Fundo, Rodovia BR 285, Km 293, Passo Fundo, RS, CEP, 99052-900, Brazil
| | - Marina Venzon Antunes
- Analytical Toxicology Laboratory, Universidade Feevale, Rua Rubem Berta, 200, Novo Hamburgo, RS, CEP, 93525-080, Brazil
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Rua Rubem Berta, 200, Novo Hamburgo, RS, CEP, 93525-080, Brazil
| | - Rafael Linden
- Analytical Toxicology Laboratory, Universidade Feevale, Rua Rubem Berta, 200, Novo Hamburgo, RS, CEP, 93525-080, Brazil
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Rua Rubem Berta, 200, Novo Hamburgo, RS, CEP, 93525-080, Brazil
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Guo X, Qiu W, Li B, Qi Y, Wang S, Zhao R, Cheng B, Han X, Du H, Pan Z, Zhao S, Qiu J, Li G, Xue H. Hypoxia-Induced Neuronal Activity in Glioma Patients Polarizes Microglia by Potentiating RNA m6A Demethylation. Clin Cancer Res 2024; 30:1160-1174. [PMID: 37855702 DOI: 10.1158/1078-0432.ccr-23-0430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 08/22/2023] [Accepted: 10/17/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE Neuronal activity in the brain has been reported to promote the malignant progression of glioma cells via nonsynaptic paracrine and electrical synaptic integration mechanisms. However, the interaction between neuronal activity and the immune microenvironment in glioblastoma (GBM) remains largely unclear. EXPERIMENTAL DESIGN By applying chemogenetic techniques, we enhanced and inhibited neuronal activity in vitro and in a mouse model to study how neuronal activity regulates microglial polarization and affects GBM progression. RESULTS We demonstrate that hypoxia drove glioma stem cells (GSC) to produce higher levels of glutamate, which activated local neurons. Neuronal activity promoted GBM progression by facilitating microglial M2 polarization through enriching miR-200c-3p in neuron-derived exosomes, which decreased the expression of the m6A writer zinc finger CCCH-type containing 13 (ZC3H13) in microglia, impairing methylation of dual specificity phosphatase 9 (DUSP9) mRNA. Downregulation of DUSP9 promoted ERK pathway activation, which subsequently induced microglial M2 polarization. In the mouse model, cortical neuronal activation promoted microglial M2 polarization whereas cortical neuronal inhibition decreased microglial M2 polarization in GBM xenografts. miR-200c-3p knockdown in cortical neurons impaired microglial M2 polarization and GBM xenograft growth, even when cortical neurons were activated. Treatment with the anti-seizure medication levetiracetam impaired neuronal activation and subsequently reduced neuron-mediated microglial M2 polarization. CONCLUSIONS These findings indicated that hypoxic GSC-induced neuron activation promotes GBM progression by polarizing microglia via the exosomal miR-200c-3p/ZC3H13/DUSP9/p-ERK pathway. Levetiracetam, an antiepileptic drug, blocks the abnormal activation of neurons in GBM and impairs activity-dependent GBM progression. See related commentary by Cui et al., p. 1073.
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Affiliation(s)
- Xiaofan Guo
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
- Department of Neurology, Loma Linda University Health, Loma Linda, California
| | - Wei Qiu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Boyan Li
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Yanhua Qi
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Shaobo Wang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Rongrong Zhao
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Bo Cheng
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xiao Han
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
- Department of Neurosurgery, Jinan Children's Hospital, Jinan, Shandong, China
| | - Hao Du
- Department of Cell Biology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Ziwen Pan
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Shulin Zhao
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Jiawei Qiu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Gang Li
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Hao Xue
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
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Buhl Rasmussen AS, Andersen CL, Weimann A, Yang T, Tron C, Gandemer V, Dalhoff K, Rank CU, Schmiegelow K. Therapeutic drug monitoring of imatinib - how far are we in the leukemia setting? Expert Rev Clin Pharmacol 2024; 17:225-234. [PMID: 38345044 DOI: 10.1080/17512433.2024.2312256] [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: 12/01/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION Tyrosine kinase inhibitors (TKIs) have revolutionized survival rates of chronic myeloid leukemia (CML) and Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL) and replaced hematopoietic stem cell transplantation (hSCT) as the key treatment option for these patients. More recently, the so-called Philadelphia chromosome-like (Ph-like) ALL has similarly benefitted from TKIs. However, many patients shift from the first generation TKI, imatinib, due to treatment-related toxicities or lack of treatment efficacy. A more personalized approach to TKI treatment could counteract these challenges and potentially be more cost-effective. Therapeutic drug monitoring (TDM) has led to higher response rates and less treatment-related toxicity in adult CML but is rarely used in ALL or in childhood CML. AREAS COVERED This review summarizes different antileukemic treatment indications for TKIs with focus on imatinib and its pharmacokinetic/-dynamic properties as well as opportunities and pitfalls of TDM for imatinib treatment in relation to pharmacogenetics and co-medication for pediatric and adult Ph+/Ph-like leukemias. EXPERT OPINION TDM of imatinib adds value to standard monitoring of ABL-class leukemia by uncovering non-adherence and potentially mitigating adverse effects. Clinically implementable pharmacokinetic/-dynamic models adjusted for relevant pharmacogenetics could improve individual dosing. Prospective trials of TDM-based treatments, including both children and adults, are needed.
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Affiliation(s)
- Anna Sofie Buhl Rasmussen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Allan Weimann
- Pediatric Oncology Research Laboratory, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Tianwu Yang
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Camille Tron
- Department of Biological Pharmacology, Rennes University Hospital, Rennes, France
| | - Virginie Gandemer
- Department of Pediatric Hematology and Oncology, Rennes University Hospital, Rennes, France
| | - Kim Dalhoff
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie Utke Rank
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
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Hentschel M, Stoffel-Wagner B, Surges R, von Wrede R, Dolscheid-Pommerich RC. Value of drug level concentrations of brivaracetam, lacosamide, and perampanel in care of people with epilepsy. Epilepsia 2024; 65:620-629. [PMID: 38158709 DOI: 10.1111/epi.17873] [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: 08/25/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE The aim of this study was to determine whether clinical efficacy and reported adverse effects (AEs) of the newer antiseizure medications (ASMs) brivaracetam (BRV), lacosamide (LCM), and perampanel (PER) have been associated with plasma levels of these ASMs. We also investigated whether plasma levels outside the reference range has led to dose adjustments. METHODS Plasma levels of 300 people with epilepsy (PWE) seen at our tertiary epilepsy center were determined by liquid chromatography-tandem mass spectrometry. PWE received BRV (n = 100), LCM (n = 100), or PER (n = 100), in most cases in polytherapy. Demographic and clinical data were retrospectively analyzed and related to plasma levels. Clinical efficacy of BRV, LCM, or PER was assessed retrospectively by comparing seizure frequency at the time of current blood draw with seizure frequency at the time of first administration. AEs were also recorded and, if reported, compared retrospectively with the time of first administration. RESULTS No significant associations were found between plasma levels of BRV, LCM, or PER and seizure freedom (BRV, p = 1.000; LCM, p = .243; PER, p = .113) or responder status (BRV, p = .118; LCM, p = .478; PER, p = .069) at presentation. There was also no pattern between plasma levels and the occurrence of AEs. In the majority of cases, drug levels outside the reference ranges have not led to adjustments in the daily doses of BRV (93.5%), LCM (93.9%), or PER (89.1%). SIGNIFICANCE Plasma levels at a given time point did not allow conclusions to be drawn about seizure control or the occurrence of AEs. Our findings indicate that efficacy and tolerability cannot be predicted based on averaged data from a single plasma measurement due to high interindividual variability. Instead, individual reference values should be established when sufficient clinical data are available, in line with the 2008 International League Against Epilepsy position paper on therapeutic drug monitoring.
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Affiliation(s)
- Matthias Hentschel
- Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | - Birgit Stoffel-Wagner
- Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Randi von Wrede
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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Jarernsiripornkul N, Tiamkao S, Wongtaweepkij K, Jorns TP, Junsuaydee K, Nontasen N, Gayrash S, Kampichit S. Comparing patient reported and medical record data of adverse drug reactions to anti-seizure drugs. Int J Clin Pharm 2024; 46:101-110. [PMID: 37843693 DOI: 10.1007/s11096-023-01653-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Anti-seizure drugs (ASDs) can potentially cause serious adverse drug reactions (ADRs). Patient self-reporting can increase the rate of ADR detection, but studies examining patient self-reporting of ADRs caused by ASDs are lacking. AIM To determine the characteristics of ADRs reported by patients receiving ASDs, assess laboratory data and medical record confirmation of patient-reported ADRs, and explore factors associated with laboratory data and medical record confirmation. METHOD A self-reporting questionnaire was distributed to patients prescribed ASDs at outpatient clinics. Patients assessed the causality of suspected ADRs using Causality Assessment Tool. Naranjo's algorithm was used by researchers for causality assessment. Medical records were used to gather information on ADR symptoms, ASD medication, and abnormal laboratory data. RESULTS From 478 distributed questionnaires, 93.1% completed the questionnaire and 67.4% of respondents reported at least one ADR. The most common ADRs were drowsiness (50.7%), dizziness (9.7%), and ataxia (4.3%). For causality, suspected ADRs were classified as possible in 52.3% of cases and probable in 46.3% of cases by patients, and possible in 64.7% of cases and probable in 25.7% of cases by researchers. Only 12.7% of patients had laboratory data and/or medical record confirmation of suspected ADRs. The psychiatry clinic was less likely to confirm suspected ADRs compared to the epilepsy clinic (OR = 0.412, p = 0.022). CONCLUSION Confirmation of patient-reported ADRs with either laboratory data or medical records was uncommon. Recording patient-reported ADRs in patients' medical history and monitoring laboratory tests related to patient-reported symptoms should be promoted to increase the safety of ASD treatment.
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Affiliation(s)
- Narumol Jarernsiripornkul
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand.
| | - Somsak Tiamkao
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kamonphat Wongtaweepkij
- Division of Clinical Pharmacy, Faculty of Pharmacy, Srinakharinwirot University, Nakhon Nayok, Thailand
| | | | - Kanjana Junsuaydee
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Nattakan Nontasen
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Sasina Gayrash
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
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Zhang M, Jin Y, Li W, He C, Di X, Duan Y, Chen L, Wang Z. Quantitation of levetiracetam concentrations in plasma and saliva samples by ultra-performance liquid chromatography-tandem mass spectrometry: Application to therapeutic drug monitoring for pregnant women with epilepsy. Biomed Chromatogr 2024; 38:e5777. [PMID: 37990827 DOI: 10.1002/bmc.5777] [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: 09/05/2023] [Revised: 10/11/2023] [Accepted: 10/25/2023] [Indexed: 11/23/2023]
Abstract
Although levetiracetam (LEV) has favorable linear pharmacokinetic properties, therapeutic drug monitoring (TDM) is necessary for pregnant women with epilepsy. This study aims to build a simple, reliable, and sensitive ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for determining LEV concentrations in plasma and saliva samples, to support the routine TDM of LEV in Chinese pregnant women with epilepsy. The stable isotope-labeled LEV-d6 was used as the internal standard. The extracted samples were analyzed using a UPLC-MS/MS system with positive electrospray ionization. Mobile phase A was water containing 5 mM ammonium acetate and 0.1% formic acid, and phase B was 1:1 methanol-acetonitrile with 0.1% formic acid. The method was validated and utilized to determine LEV concentrations in non-pregnant and pregnant patients with epilepsy. The developed method was validated in both plasma and saliva samples over a concentration range of 0.1-50 μg/mL. The intra- and inter-batch accuracy for LEV ranged from -7.0% to 2.9%, with precisions between 2.7% and 9.3%. In pregnant patients, the mean dose-standardized LEV trough plasma concentrations were significantly lower than those in non-pregnant patients (4.73 ± 2.99 vs. 7.74 ± 3.59 ng/mL per mg/day; P < 0.0001). It is recommended that the TDM of LEV should be routinely performed during the different stages of pregnancy.
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Affiliation(s)
- Mengyu Zhang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Clinical Trial Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Ying Jin
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Clinical Trial Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Wanling Li
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Chaoqun He
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Clinical Trial Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xiangjie Di
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Clinical Trial Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yifei Duan
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Lei Chen
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Zhenlei Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
- Clinical Trial Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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Li Y, Guo H, Hu Y, Wang J, Zhang Y, Huang J, Xu J, Chen J, Lu X, Chen F. Effectiveness and safety of mono- and add-on perampanel in pediatric patients with epilepsy: Experience from a single-center retrospective study. Epilepsia Open 2024; 9:268-277. [PMID: 37943144 PMCID: PMC10839354 DOI: 10.1002/epi4.12865] [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: 06/14/2023] [Accepted: 11/06/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVE To evaluate the effectiveness and safety of perampanel (PER) monotherapy (MT) or add-on therapy (AT) in Chinese children with epilepsy, as well as to evaluate the data from routine therapeutic drug monitoring (TDM) of PER for these pediatric patients. METHODS This retrospective and observational study was carried out on children with epilepsy (n = 340) from 2020 to 2022 at the Children's Hospital of Nanjing Medical University. Outcome measures were the responder rate (50% or greater seizure reduction), long-term efficacy, and tolerability (number and types of adverse events) in MT and AT groups. Concentrations of plasma PER obtained from these patients, if available, were analyzed too. RESULTS A total of 279 patients achieved at least 3 months of therapy, and 58.1% responded to PER therapy. 53 of the responders were seizure-free (32.7%). The retention rate dropped from 88.0% at 3 months to 40.6% at 12 months after treatment. Patients with MT achieved better seizure control than those with AT (P < 0.001). Intriguingly, PER exerted a very weak effect on patients who took more than 2 ASMs or were diagnosed with drug-resistant epilepsy. There were no significant differences in tolerability between the two groups. In addition, 179 patients were routinely monitored for PER, and the trough concentrations (C0 ) for these patients ranged from 30.0 to 992.0 ng/mL. However, no significant difference in C0 was observed between responders and nonresponders (333 ng/mL vs 325.5 ng/mL, P = 0.264). SIGNIFICANCE This study provides effectiveness and safety data on Chinese children with epilepsy treated with PER either as MT or as AT. The efficacy of patients receiving MT was much better than cases administered with more than 2 ASMs or diagnosed with drug-resistant epilepsy. In addition, no association was found between the plasma PER concentration and efficacy or safety. PLAIN LANGUAGE SUMMARY The study reports the effects of perampanel on seizures and adverse effects in Chinese patients with epilepsy younger than 18 years. Seizures decreased in 58.1% of patients (responders); in a third of these responders, seizures stopped. After treatment was started, 88% of patients were still on perampanel at 3 months and 40.6% at 12 months. People who were treated with perampanel only were more likely to respond than those who received perampanel and other antiseizure treatments, although perampanel was tolerated equally well in these groups. Plasma perampanel concentration did not predict seizure response or adverse effects.
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Affiliation(s)
- Yue Li
- Pharmaceutical Sciences Research CenterDepartment of PharmacyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Hong‐Li Guo
- Pharmaceutical Sciences Research CenterDepartment of PharmacyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Ya‐Hui Hu
- Pharmaceutical Sciences Research CenterDepartment of PharmacyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Jie Wang
- Pharmaceutical Sciences Research CenterDepartment of PharmacyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Yuan‐Yuan Zhang
- Pharmaceutical Sciences Research CenterDepartment of PharmacyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Jian Huang
- Pharmaceutical Sciences Research CenterDepartment of PharmacyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Jing Xu
- Pharmaceutical Sciences Research CenterDepartment of PharmacyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Jing Chen
- Department of NeurologyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Xiao‐Peng Lu
- Department of NeurologyChildren's Hospital of Nanjing Medical UniversityNanjingChina
| | - Feng Chen
- Pharmaceutical Sciences Research CenterDepartment of PharmacyChildren's Hospital of Nanjing Medical UniversityNanjingChina
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Lee S, Kim HC, Jang Y, Lee HS, Ahn S, Lee S, Jung K, Park K, Jung K, Oh J, Lee S, Yu K, Jang I, Lee S, Chu K, Lee SK. Topiramate dosage optimization for effective antiseizure management via population pharmacokinetic modeling. Ann Clin Transl Neurol 2024; 11:424-435. [PMID: 38062636 PMCID: PMC10863906 DOI: 10.1002/acn3.51962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/07/2023] [Accepted: 11/18/2023] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE Despite the suggested topiramate serum level of 5-20 mg/L, numerous institutions have observed substantial drug response at lower levels. We aim to investigate the correlation between topiramate serum levels, drug responsiveness, and adverse events to establish a more accurate and tailored therapeutic range. METHODS We retrospectively analyzed clinical data collected between January 2017 and January 2022 at Seoul National University Hospital. Drug responses to topiramate were categorized as "insufficient" or "sufficient" by reduction in seizure frequency ≥ 50%. A population pharmacokinetic model estimated serum levels from spot measurements. ROC curve analysis determined the optimal cutoff values. RESULTS A total of 389 epilepsy patients were reviewed having a mean dose of 178.4 ± 117.9 mg/day and the serum level, 3.9 ± 2.8 mg/L. Only 5.6% samples exhibited insufficient response, with a mean serum level of 3.6 ± 2.5 mg/L while 94.4% demonstrated sufficient response, with a mean 4.0 ± 2.8 mg/L, having no statistical significance. Among the 69 reported adverse events, logistic regression analysis identified a significant association between ataxia and serum concentration (p = 0.04), with an optimal cutoff value of 6.5 mg/L. INTERPRETATION This study proposed an optimal therapeutic concentration for topiramate based on patients' responsiveness to the drug and the incidence of adverse effects. We recommended serum levels below 6.5 mg/L to mitigate the risk of ataxia-related side effects while dose elevation was found unnecessary for suboptimal responders, as the drug's effectiveness plateaus at minimal doses.
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Affiliation(s)
- Seolah Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
| | - Hyun Chul Kim
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulSouth Korea
- Integrated Major in Innovative Medical ScienceSeoul National University Graduate SchoolSeoulSouth Korea
| | - Yoonhyuk Jang
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
| | - Han Sang Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
- Center for Hospital MedicineSeoul National University HospitalSeoulSouth Korea
| | - Seon‐Jae Ahn
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
- Center for Hospital MedicineSeoul National University HospitalSeoulSouth Korea
| | - Soon‐Tae Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
| | - Keun‐Hwa Jung
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
| | - Kyung‐Il Park
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
- Division of NeurologySeoul National University Hospital Healthcare System Gangnam CenterSeoulSouth Korea
| | - Ki‐Young Jung
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulSouth Korea
- Department of PharmacologyJeju National University College of MedicineJeju Special Self‐Governing ProvinceRepublic of Korea
| | - SeungHwan Lee
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulSouth Korea
| | - Kyung‐Sang Yu
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulSouth Korea
| | - In‐Jin Jang
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulSouth Korea
| | - Soyoung Lee
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of Medicine and HospitalSeoulSouth Korea
- Integrated Major in Innovative Medical ScienceSeoul National University Graduate SchoolSeoulSouth Korea
| | - Kon Chu
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
| | - Sang Kun Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical InnovationBiomedical Research Institute, Seoul National University College of Medicine and HospitalSeoulSouth Korea
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Guo X, Qiu W, Wang C, Qi Y, Li B, Wang S, Zhao R, Cheng B, Han X, Du H, Gao Z, Pan Z, Zhao S, Li G, Xue H. Neuronal Activity Promotes Glioma Progression by Inducing Proneural-to-Mesenchymal Transition in Glioma Stem Cells. Cancer Res 2024; 84:372-387. [PMID: 37963207 DOI: 10.1158/0008-5472.can-23-0609] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 08/28/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023]
Abstract
Neuronal activity can drive progression of high-grade glioma by mediating mitogen production and neuron-glioma synaptic communications. Glioma stem cells (GSC) also play a significant role in progression, therapy resistance, and recurrence in glioma, which implicates potential cross-talk between neuronal activity and GSC biology. Here, we manipulated neuronal activity using chemogenetics in vitro and in vivo to study how it influences GSCs. Neuronal activity supported glioblastoma (GBM) progression and radioresistance through exosome-induced proneural-to-mesenchymal transition (PMT) of GSCs. Molecularly, neuronal activation led to elevated miR-184-3p in neuron-derived exosomes that were taken up by GSCs and reduced the mRNA N6-methyladenosine (m6A) levels by inhibiting RBM15 expression. RBM15 deficiency decreased m6A modification of DLG3 mRNA and subsequently induced GSC PMT by activating the STAT3 pathway. Loss of miR-184-3p in cortical neurons reduced GSC xenograft growth, even when neurons were activated. Levetiracetam, an antiepileptic drug, reduced the neuronal production of miR-184-3p-enriched exosomes, inhibited GSC PMT, and increased radiosensitivity of tumors to prolong survival in xenograft mouse models. Together, these findings indicate that exosomes derived from active neurons promote GBM progression and radioresistance by inducing PMT of GSCs. SIGNIFICANCE Active neurons secrete exosomes enriched with miR-184-3p that promote glioblastoma progression and radioresistance by driving the proneural-to-mesenchymal transition in glioma stem cells, which can be reversed by antiseizure medication levetiracetam.
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Affiliation(s)
- Xiaofan Guo
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
- Department of Neurology, Loma Linda University Health, Loma Linda, California
| | - Wei Qiu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Chaochao Wang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
- Department of Neurosurgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong, China
| | - Yanhua Qi
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Boyan Li
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Shaobo Wang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Rongrong Zhao
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Bo Cheng
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xiao Han
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
- Department of Neurosurgery, Jinan Children's Hospital, Jinan, Shandong, China
| | - Hao Du
- Department of Cell Biology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Zijie Gao
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Ziwen Pan
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Shulin Zhao
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Gang Li
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
| | - Hao Xue
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong, China
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Shi X, Zhang D, Zhao Z, Mei S. UHPLC-MS/MS for plasma lamotrigine analysis and comparison with a homogenous enzyme immunoassay. Bioanalysis 2024; 16:233-243. [PMID: 38334119 DOI: 10.4155/bio-2023-0183] [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] [Indexed: 02/10/2024] Open
Abstract
Aims: To develop and validate a UHPLC-MS/MS method for lamotrigine (LTG) analysis in human plasma and evaluate its agreement with a homogenous enzyme immunoassay (HEIA). Materials & methods: The UHPLC-MS/MS method was developed and validated according to the USFDA/EMA guidelines. A Bland-Altman plot was used to evaluate the agreement between UHPLC-MS/MS and HEIA. Results: Samples were pretreated with one-step protein precipitation and separated in 2.6 min. The intra- and inter-day bias and imprecisions were -15.8 to 15.0% and less than 11.17%, respectively. The recovery and matrix factor were 98.30 to 111.97%. The mean overestimation of UHPLC-MS/MS compared with HEIA was 21.57%. Conclusion: A rapid, sensitive and robust UHPLC-MS/MS method for plasma LTG analysis was developed and validated and was a 21.57% overestimation compared with HEIA.
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Affiliation(s)
- Xiaoxu Shi
- Children's Hospital, Capital Institute Of Paediatrics, 2 Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Dongjie Zhang
- Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, China
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100045, China
| | - Zhigang Zhao
- Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, China
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100045, China
| | - Shenghui Mei
- Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, China
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100045, China
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Lin CY, Chang CW, Tseng WEJ, Wu T, Cheng MY, Lee CH, Chiang HI, Lin WR, Lin CN, Liu CJ, Chen PR, Cheng HF, Lim SN. Therapeutic drug monitoring of perampanel: Clinical utility and impact of co-medication on pharmacokinetic variability. Heliyon 2024; 10:e23962. [PMID: 38226257 PMCID: PMC10788532 DOI: 10.1016/j.heliyon.2023.e23962] [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: 10/15/2023] [Accepted: 12/19/2023] [Indexed: 01/17/2024] Open
Abstract
Background Perampanel (PER) is a newly developed antiseizure medication (ASM). This study aimed to determine the utilization of therapeutic drug monitoring (TDM) for PER in a real-world clinical setting and investigate the influence of concomitant use of ASMs on the plasma concentration profile of PER. Method We analyzed data from the Chang Gung Research Database, which is the largest multi-institutional electronic medical records database in Taiwan. The main outcomes were the comparisons of PER plasma concentration and the ratio of concentration to the weight-adjusted dose (C/D; [ng/mL]/[mg/kg/d]) among patients received TDM of different clinical indication and among different ASM co-medication subgroups. Results Overall, 88 plasma samples were collected from 66 epilepsy patients treated with PER. The majority of patients (77.3 %) underwent PER TDM owing to poorly controlled seizures. There was a trend toward a higher plasma concentration and C/D ratio in those suspected of having PER toxicity owing to adverse events than of other indications. The PER concentration exhibited dose linearity. The mean PER plasma concentrations in patients co-medicated with enzyme-inducing ASMs were significantly lower than those in the patients who were not prescribed enzyme-inducing or enzyme-inhibiting ASMs, and co-medication with carbamazepine (CBZ) resulted in a significant reduction in the PER concentration. Conclusion PER concentration exhibited a linear regression relationship with PER dose, and the plasma concentration of the drug was highly susceptible to the drug's interactions with enzyme-inducing ASMs. TDM with clear indication could help determine the influence of ASMs used concomitantly on PER concentrations and guide clinical adjustments.
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Affiliation(s)
- Chih-Yin Lin
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Wei Chang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Tony Wu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Neurology, Xiamen Chang Gung Hospital, Xiamen, Fujian, China
| | - Mei-Yun Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Medical Science, National Tsing Hua University, Hsinchu, Taiwan
| | - Chih-Hong Lee
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsing-I Chiang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chia-Ni Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Jing Liu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Ru Chen
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hui-Fen Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Siew-Na Lim
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Dervis E, Karatay KB, Durkan K, Kilcar AY. Radiolabeling of Zonisamide for a Diagnostic Perspective. Curr Radiopharm 2024; 17:91-98. [PMID: 37818565 DOI: 10.2174/0118744710249156231002115024] [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: 02/15/2023] [Revised: 07/04/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023]
Abstract
OBJECTIVE Epilepsy is one of the oldest and the most common chronic neurological diseases. Antiepileptic drugs (AEDs) are the backbone of epilepsy treatment. However, epileptogenesis has not been fully elucidated. One of the critical reasons for this is the lack of reliable biomarkers. Neuroimaging suggests a non-invasive examination and investigation tool that can detect critical pathophysiological changes involved in epileptogenesis and monitor disease progression. In the current study, the radiolabeling potential of Zonisamide (ZNS) (the secondgeneration AED) with Technetium-99m (99mTc) is examined to neuroimage the epileptogenic processes by contributing to the development of potential radiotracers. METHODS ZNS was labeled with 99mTc and the radiochemical yield of [99mTc]Tc-ZNS was determined with TLRC (Thin Layer Liquid Radio Chromatography and HPLRC (High Performance Liquid Radio Chromatography) radiochromatographic methods. In vitro behavior of [99mTc]Tc-ZNS was determined with time-dependent uptake of [99mTc]Tc-ZNS on the SHSY5Y human neuroblastoma cells. RESULTS The radiochemical yield of [99mTc]Tc-ZNS was determined as 98.03 ± 1.24% (n = 6) according to radiochromatographic studies results. [99mTc]Tc-ZNS demonstrated 5.38 and 6.18 times higher uptake values than the control group on the human neuroblastoma SH-SY5Y cell line at 120 and 240 minutes, respectively. CONCLUSION This study showed that the current radiolabeled antiepileptic drug has a diagnostic potential to be used in imaging neurological processes.
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Affiliation(s)
- Emine Dervis
- Department of Nuclear Applications, Institute of Nuclear Sciences, Ege University, Izmir, Turkey
| | - Kadriye Busra Karatay
- Department of Nuclear Applications, Institute of Nuclear Sciences, Ege University, Izmir, Turkey
| | - Kubra Durkan
- Department of Nuclear Applications, Institute of Nuclear Sciences, Ege University, Izmir, Turkey
| | - Ayfer Yurt Kilcar
- Department of Nuclear Applications, Institute of Nuclear Sciences, Ege University, Izmir, Turkey
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Liu R, Xiao L, Hu Y, Yan Q, Liu X. Rescue strategies for valproic acid overdose poisoning: Case series and literature review. Clin Case Rep 2024; 12:e8367. [PMID: 38161627 PMCID: PMC10753133 DOI: 10.1002/ccr3.8367] [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: 07/07/2023] [Revised: 11/25/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Valproic acid (VPA) is a wide-ranging anti-epileptic medication that primarily affects bipolar disorder, mania, and migraine. The leading causes of mortality associated with acute poisoning from VPA are nervous system toxicity, drug-induced shock due to encephalopathy from hyperammonemia, as well as acute liver and kidney failure, and respiratory depression that contribute to hemodynamic instability. Treatment of acute VPA poisoning primarily involves in vitro elimination methods, including hemoperfusion (HP), hemodialysis, and hemofiltration, as well as drug remedies such as L-carnitine and meropenem. Nonetheless, there are conflicting opinions regarding drug usage. This article details the three cases of acute poisoning from VPA. The fundamental approach to treatment employs HP assisted by blood concentration monitoring to alleviate shock and stabilize hemodynamics. This investigation presents guidance for the treatment and management of acute poisoning with VPA in clinical settings.
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Affiliation(s)
- Renzhu Liu
- Department of Clinical PharmacyXiangtan Central HospitalXiangtanChina
- Zhou Honghao Research Institute XiangtanXiangtan Central HospitalXiangtanChina
| | - Lu Xiao
- Department of Children Health CareXiangtan Maternal and Child Care Service CentreXiangtanChina
| | - Yixiang Hu
- Department of Clinical PharmacyXiangtan Central HospitalXiangtanChina
- Zhou Honghao Research Institute XiangtanXiangtan Central HospitalXiangtanChina
| | - Qingzi Yan
- Department of Clinical PharmacyXiangtan Central HospitalXiangtanChina
- Zhou Honghao Research Institute XiangtanXiangtan Central HospitalXiangtanChina
| | - Xiang Liu
- Department of Clinical PharmacyXiangtan Central HospitalXiangtanChina
- Zhou Honghao Research Institute XiangtanXiangtan Central HospitalXiangtanChina
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Kacirova I, Urinovska R, Grundmann M. Therapeutic monitoring of lacosamide, perampanel, and zonisamide during breastfeeding. Epilepsy Res 2024; 199:107264. [PMID: 38041996 DOI: 10.1016/j.eplepsyres.2023.107264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 11/20/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE To provide additional information on the transport of the new anti-seizure medications lacosamide, perampanel, and zonisamide in breast milk and breastfed infants. METHODS Between 2013 and 2022, concentrations of anti-seizure medications were measured in six women with epilepsy (each drug in two patients) using high-performance liquid chromatography. Additionally, concentrations were determined after two consecutive pregnancies in women receiving lacosamide and one woman receiving zonisamide. In all cases, anti-seizure medication concentrations were measured in the maternal serum and breast milk, and five cases, in the infant serum. RESULTS For lacosamide, the ratios of breast milk/maternal serum concentration varied between 0.77 and 0.93, the ratios of infant/maternal serum concentrations were 0.16 and 0.35, and the ratios of infant serum/milk concentrations were 0.21 and 0.38. For perampanel, the ratios of breast milk/maternal serum concentration were 0.01 and 0.10 and the ratio of infant/maternal serum concentration was 0.36. For zonisamide, the ratios of breast milk/maternal serum concentration varied between 0.76 and 1.26, the ratios of infant/maternal serum concentrations between 0.44 and 0.85, and the ratios of infant serum/milk concentrations between 0.55 and 1.05. CONCLUSIONS Breastfeeding is recommended for women using lacosamide, perampanel, and zonisamide. However, the actual exposure can only be accurately evaluated by determining the serum concentration of anti-seizure medication in breastfed infants.
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Affiliation(s)
- Ivana Kacirova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
| | - Romana Urinovska
- Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic.
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Chong E, Oh H, Kim DJ, Kim SM, Lee SY. Quantification of Gabapentin, Lacosamide, Perampanel, Pregabalin, Rufinamide, and Vigabatrin in Serum Using Liquid Chromatography-Tandem Mass Spectrometry. Methods Mol Biol 2024; 2737:25-32. [PMID: 38036807 DOI: 10.1007/978-1-0716-3541-4_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Antiepileptic drugs (AEDs) have been used to control epilepsy. More than 17 new AEDs, including gabapentin (GPN), lacosamide (LCM), perampanel (PER), pregabalin (PRG), rufinamide (RFM), and vigabatrin (VGB) have been approved and marketed since 1989. Accurate measurement of serum concentration of the antiepileptic drugs is crucial to achieve optimal efficacy and avoid adverse events. We describe an accurate and precise liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the simultaneous quantification of GPN, LCM, PER, PRG, RFM, and VGB in serum. The method requires a small volume of sample (10 μL) and has a total chromatographic run time of 4 min for simultaneous measurement of these drugs. The method showed good accuracy with a bias of -0.2-5%. The intra- and inter-day imprecision were less than 5.0% for all the analytes. The linear assay ranges were 0.3-26 μg/mL for GPN, 0.15-24 μg/mL for LCM, 7.4-1881 ng/mL for PER, 0.03-13 μg/mL for PRG, 0.78-90 μg/mL for RFM, and 0.3-43 μg/mL for VGB.
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Affiliation(s)
- Eunbin Chong
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Seoul, South Korea
| | - Hyeonju Oh
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Seoul, South Korea
| | - Dong Ju Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Seoul, South Korea
| | - Sang-Mi Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Seoul, South Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Seoul, South Korea.
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Yamamoto Y, Usui N, Kagawa Y, Imai K. Time-Course Changes in Lamotrigine Concentration after Addition of Valproate and the Safety and Long-Term Tolerability of Lamotrigine-Valproate Combination Therapy. Biol Pharm Bull 2024; 47:43-48. [PMID: 37952977 DOI: 10.1248/bpb.b23-00608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
The aim of this study was to evaluate the time-course changes in lamotrigine (LTG) concentration after addition of valproate (VPA) and the safety and tolerability of the combination therapy. We reviewed our therapeutic drug monitoring (TDM) database and found 345 patients on LTG who received add-on therapy with VPA. VPA had been added at least 12 weeks after patients finished stepwise LTG titration. Also, we retrospectively evaluated the LTG concentration after addition of VPA and the safety and long-term tolerability of LTG-VPA combination therapy. Plasma LTG concentration increased more than 1.5-fold within 15 d of addition of VPA and reached a peak at 30 d. The rate of increase in LTG concentration occurred in a VPA concentration-dependent manner. During the first 120 d after addition of VPA, adverse events were reported by 58 patients (16.8%), but no patient developed cutaneous reactions. Kaplan-Meier analysis showed estimated retention rates for LTG-VPA combination therapy of 74.5% at 5 years. At 5 years, the mean concentration of LTG was 11.1 µg/mL (43.3 µmol/L). Because addition of VPA leads to a marked increase in LTG concentration over a short period, TDM for LTG should be performed at the earliest from 14 d after starting VPA. At 120 d after starting VPA therapy, the higher LTG concentration due to addition of VPA is not associated with an increased risk of cutaneous reactions. Although LTG-VPA combination therapy increases LTG concentration, it is well tolerated and has a high long-term retention rate.
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Affiliation(s)
- Yoshiaki Yamamoto
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders
- Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka
| | - Naotaka Usui
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders
| | - Yoshiyuki Kagawa
- Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka
- Laboratory of Clinical Pharmacokinetics and Drug Safety, Shizuoka General Hospital
| | - Katsumi Imai
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders
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Peters BJ, Brown AE, Thornton NM, Winters JL, Chalmers SJ. The effect of plasma exchange on serum levels of lacosamide: A case report. Am J Health Syst Pharm 2023; 80:1781-1786. [PMID: 37712141 DOI: 10.1093/ajhp/zxad224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Indexed: 09/16/2023] Open
Abstract
PURPOSE We describe the case of a 22-year-old male who developed thyroid storm necessitating therapeutic plasma exchange (TPE). The patient's past medical history was complicated by epilepsy, for which he took lacosamide. Little evidence was available to guide lacosamide dosing during TPE. Because of an exacerbation of the patient's underlying epilepsy in the context of the thyroid storm, we conducted therapeutic medication monitoring of lacosamide concentrations to guide management. SUMMARY We arranged for measurement of the lacosamide concentration immediately before TPE (5.1 μg/mL) and 2.5 hours after the initial measurement (3.4 μg/mL) to determine the amount of lacosamide removed by TPE. Utilizing population pharmacokinetic parameters, we calculated the expected concentration and compared this to the measured concentration. The difference between these values was used to determine the percentage removed via TPE compared to the expected post-TPE concentration. We found that one TPE session removed an additional 20% of serum lacosamide. CONCLUSION TPE appeared to remove an additional 20% of lacosamide when compared to the expected post-TPE concentration.
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Affiliation(s)
- Bradley J Peters
- Department of Pharmacy, Mayo Clinic Rochester, Rochester, MN, USA
| | - Andrew E Brown
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Nathaniel M Thornton
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Jeffrey L Winters
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Sarah J Chalmers
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
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Chouchana M, Smati J, Bloch V, Fontan JE, Etain B, Delage C. Lamotrigine in mood disorders: Flash survey on prescribing habits and blood tests practices. L'ENCEPHALE 2023; 49:640-644. [PMID: 37246103 DOI: 10.1016/j.encep.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Therapeutic drug monitoring for lamotrigine is poorly documented in bipolar and depressive disorders. In order to evaluate its use among French psychiatrists, we explored prescribing habits, therapeutic monitoring and dosage adjustment of lamotrigine through a flash survey. METHODS A survey was broadcasted by the network of Expert Centers for Bipolar Disorder and Resistant Depression and by the Collegial of Psychiatry of the Assistance publique des Hôpitaux de Paris. Questions concerned the frequency of prescribing depending on the mood disorder, the frequency of plasma levels, therapeutic monitoring, dosage adjustment and the limitation represented by dermatological risk. RESULTS Of the 99 hospital psychiatrists who responded, 66 practiced in a university hospital and 62 for more than 5years. Overall, lamotrigine was more frequently prescribed for type 2 bipolar disorder (often: 51%) than for type 1 bipolar disorder (often: 22%). Dermatotoxicity was a major barrier to prescribing for 15% (n=13) of respondents. Nearly two-thirds of prescribers (61%, n=59) measured lamotrigine, of which 50% (n=29) systematically. However, 40% of them did not have an opinion on the optimal plasma concentration. In total, 22% (n=13) always adjusted the dosage according to the result. The first argument for dosage adjustment was clinical response for 80% (n=47) of prescribers, adverse effects for 17% (n=10) and plasma levels for only 4% (n=2). CONCLUSION While many psychiatrists report using plasma dosage of lamotrigine, few use the plasma level result to adapt dosage and many have no opinion of the target values for plasma concentrations. This illustrates the lack of data and recommendations regarding the use of therapeutic pharmacological monitoring of lamotrigine in bipolar and depressive disorders.
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Affiliation(s)
- Margot Chouchana
- Service de pharmacie, Assistance publique des Hôpitaux de Paris, hôpital Lariboisière-Fernand-Widal, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France; Inserm UMRS-1144, optimisation thérapeutique en neuropsychopharmacologie, université Paris Cité, 75006 Paris, France.
| | - Julie Smati
- Service de pharmacie, Assistance publique des Hôpitaux de Paris, hôpital Lariboisière-Fernand-Widal, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France
| | - Vanessa Bloch
- Service de pharmacie, Assistance publique des Hôpitaux de Paris, hôpital Lariboisière-Fernand-Widal, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France; Inserm UMRS-1144, optimisation thérapeutique en neuropsychopharmacologie, université Paris Cité, 75006 Paris, France; Faculté de pharmacie de Paris, université Paris Cité, 75006 Paris, France
| | - Jean-Eudes Fontan
- Service de pharmacie, Assistance publique des Hôpitaux de Paris, hôpital Lariboisière-Fernand-Widal, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France
| | - Bruno Etain
- Inserm UMRS-1144, optimisation thérapeutique en neuropsychopharmacologie, université Paris Cité, 75006 Paris, France; Centres experts trouble bipolaire et dépression résistante, Assistance publique des Hôpitaux de Paris, Hôpital Lariboisière-Fernand-Widal, 75010 Paris, France
| | - Clément Delage
- Service de pharmacie, Assistance publique des Hôpitaux de Paris, hôpital Lariboisière-Fernand-Widal, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France; Inserm UMRS-1144, optimisation thérapeutique en neuropsychopharmacologie, université Paris Cité, 75006 Paris, France; Faculté de pharmacie de Paris, université Paris Cité, 75006 Paris, France
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Lim SN, Wu T, Chang CW, Johnny Tseng WE, Cheng MY, Hsieh HY, Lee CH, Lin WR, Liu CJ, Chen PR, Lin CN. Clinical impact of therapeutic drug monitoring for newer anti-seizure medications in patients with epilepsy: A real-world observation study. Biomed J 2023:100680. [PMID: 38036171 DOI: 10.1016/j.bj.2023.100680] [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: 08/21/2023] [Revised: 10/18/2023] [Accepted: 11/24/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND The clinical value of therapeutic drug monitoring (TDM) for newer anti-seizure medications (ASMs) remains uncertain. This study aimed to assess the impact of newer ASM TDM on clinical decision making in patients with epilepsy. METHODS We retrospectively identified all plasma requests for newer ASM level measurement as part of routine clinical management in the outpatient departments of seven medical institutes across Taiwan between September 2016 and May 2019. Data collected from reviewed medical records included clinical and medication details, indications for TDM request, test results, interpretation, and impact on patient management. RESULTS A total of 682 visits with 1051 plasma samples were included. The most frequently analyzed ASMs were levetiracetam (36.1%), oxcarbazepine (18.4%), and lamotrigine (12.0%). Reasons for TDM included poorly controlled seizures (55.3%), concerns about drug-drug interactions (12.3%), and suspicion of drug overdose (10.6%). 68.8% of samples were within the orienting therapeutic range, even for patients with poorly controlled seizures. TDM for non-adherence concerns showed 54.3% below the orienting therapeutic range, while ASM-related adverse events assessment only 8.9% showed levels exceeding the orienting therapeutic range. Following TDM results, 64.2% of cases had medication adjustments, mainly dosage increases. Overall, 55.9% of newer ASM TDM visit showed improved outcomes, including reduced seizures (47.5%) and fewer ASM-related side effects (8.4%). CONCLUSIONS These findings suggest that appropriate utilization of TDM for newer ASMs provides clinical benefits in adjunct to complement clinical decision making in the management of epilepsy patients in a real-world clinical setting.
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Affiliation(s)
- Siew-Na Lim
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Tony Wu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Wei Chang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; PhD Program in Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yun Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiang-Yao Hsieh
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hong Lee
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wey-Ran Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Jing Liu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan
| | - Po-Ru Chen
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan
| | - Chia-Ni Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
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Milosheska D, Roškar R. Simple HPLC-UV Method for Therapeutic Drug Monitoring of 12 Antiepileptic Drugs and Their Main Metabolites in Human Plasma. Molecules 2023; 28:7830. [PMID: 38067559 PMCID: PMC10708341 DOI: 10.3390/molecules28237830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/21/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
The objective of the present report was to develop and validate a simple, selective, and reproducible high-performance liquid chromatography method with UV detection suitable for routine therapeutic drug monitoring of the most commonly used antiepileptic drugs and some of their metabolites. Simple precipitation of plasma proteins with acetonitrile was used for sample preparation. 10,11-dihydrocarbamazepine was used as an internal standard. Chromatographic separation of the analytes was achieved by gradient elution on a Phenyl-Hexyl column at 40 °C, using methanol and potassium phosphate buffer (25 mM; pH 5.1) as a mobile phase. The method was validated according to the FDA guidelines for bioanalytical method validation. It showed to be selective, accurate, precise, and linear over the concentration ranges of 1-50 mg/L for phenobarbital, phenytoin, levetiracetam, rufinamide, zonisamide, and lacosamide; 0.5-50 mg/L for lamotrigine, primidone, carbamazepine and 10-monohydroxycarbazepine; 0.2-10 mg/L for carbamazepine metabolites: 10,11-trans-dihydroxy-10,11-dihydrocarbamazepine and carbamazepine-10,11-epoxide; 0.1-10 mg/L for oxcarbazepine; 2-100 mg/L for felbamate and 3-150 mg/L for ethosuximide. The suitability of the validated method for routine therapeutic drug monitoring was confirmed by quantification of the analytes in plasma samples from patients with epilepsy on combination antiepileptic therapy.
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Affiliation(s)
| | - Robert Roškar
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva Cesta 7, 1000 Ljubljana, Slovenia
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Yu L, Chen M, Liu J, Yu Z, Feng J, Dai H. Initial therapeutic target attainment of perampanel in pediatric patients with epilepsy. Front Pharmacol 2023; 14:1209815. [PMID: 38035012 PMCID: PMC10684762 DOI: 10.3389/fphar.2023.1209815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Perampanel is a promising option for the treatment of pediatric epilepsy, but its plasma concentration varies among patients. This retrospective study aimed to investigate the initial target attainment of perampanel plasma concentration in pediatric patients with epilepsy in China. Inpatients admitted from January 2020 to December 2021 in a tertiary hospital were retrospectively included according to pre-set criteria. Demographic characteristics of patients and dosing strategies and therapeutic drug monitoring results were collected. A total of 137 pediatric patients (84 females and 53 males, aged from 0.6 to 16.4 years) were include for analysis. The perampanel concentrations varied greatly from 60 to 1,560 mg/L among patients, but 89.8% had suitable perampanel concentrations (100-1,000 ng/mL). The concomitant use of enzyme-inductive antiepileptic drugs (AEDs) was the only identified risk factor associated with target nonattainment (OR = 5.92, 95% confidence interval 1.68-20.9). Initial perampanel target attainment in pediatric patients is satisfactory. Routine therapeutic drug monitoring to achieved the suggested concentration range for these patients may be unnecessary, except for those receiving combined enzyme inductive AEDs.
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Affiliation(s)
- Lingyan Yu
- Department of Pharmacy, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Meng Chen
- Department of Pharmacy, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jieqiong Liu
- Department of Pharmacy, 903 Hospital of the Joint Logistic Support Force of the PLA, Hangzhou, Zhejiang, China
| | - Zhenwei Yu
- Department of Pharmacy, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianhua Feng
- Department of Pediatrics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Chaijamorn W, Phunpon S, Sathienluckana T, Charoensareerat T, Pattharachayakul S, Rungkitwattanakul D, Srisawat N. Lacosamide dosing in patients receiving continuous renal replacement therapy. J Intensive Care 2023; 11:50. [PMID: 37946296 PMCID: PMC10633951 DOI: 10.1186/s40560-023-00700-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/05/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Lacosamide is one of the anticonvulsants used in critically ill patients. This study aimed to suggest appropriate lacosamide dosing regimens in critically ill patients receiving continuous renal replacement therapy (CRRT) via Monte Carlo simulations. METHODS Mathematical models were created using published demographic and pharmacokinetics in adult critically ill patients. CRRT modalities with different effluent rates were added into the models. Lacosamide regimens were evaluated on the probability of target attainment (PTA) using pharmacodynamic targets of trough concentrations and area under the curve within a range of 5-10 mg/L and 80.25-143 and 143-231 mg*h/L for the initial 72 h-therapy, respectively. Optimal regimens were defined from regimens that yielded the highest PTA. Each dosing regimen was tested in a group of different 10,000 virtual patients. RESULTS Our results revealed the optimal lacosamide dosing regimen of 300-450 mg/day is recommended for adult patients receiving both CRRT modalities with 20-25 effluent rates. The dose of 600 mg/day was suggested in higher effluent rate of 35 mL/kg/h. Moreover, a patient with body weight > 100 kg was less likely to attain the targets. CONCLUSIONS Volume of distribution, total clearance, CRRT clearance and body weight were significantly contributed to lacosamide dosing. Clinical validation of the finding is strongly indicated.
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Affiliation(s)
- Weerachai Chaijamorn
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Pathum Wan, Bangkok, 10330, Thailand.
| | | | | | | | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Dhakrit Rungkitwattanakul
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Academic of Science, Royal Society of Thailand, Bangkok, Thailand
- Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand
- Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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45
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Salzmann L, Spescha T, Singh N, Kobel A, Fischer V, Schierscher T, Bauland F, Geistanger A, Risch L, Geletneky C, Seger C, Taibon J. An isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS)-based candidate reference measurement procedure for the quantification of topiramate in human serum and plasma. Clin Chem Lab Med 2023; 61:1942-1954. [PMID: 37466369 DOI: 10.1515/cclm-2022-1273] [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: 12/16/2022] [Accepted: 07/05/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Topiramate is an antiepileptic drug (AED) used for the monotherapy or adjunctive treatment of epilepsy and for the prophylaxis of migraine. It has several pharmacodynamic properties that contribute to both its clinically useful properties and observed adverse effects. Accurate measurement of its concentration is therefore essential for dose adjustment/optimisation of AED therapy. Our aim was to develop and validate a novel reference measurement procedure (RMP) for the quantification of topiramate in human serum and plasma. METHODS An isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS) method in combination with a protein-precipitation-based sample preparation allows for quantification of topiramate in human serum and plasma. To assure traceability to SI units, quantitative nuclear magnetic resonance (qNMR) was applied to characterize the reference material used as primary calibrator for this RMP. Matrix effects were determined by performing a post-column infusion experiment and comparing standard line slopes. Accuracy and precision was evaluated performing an extensive five day precision experiment and measurement uncertainty was evaluated according Guide to the Expression of Uncertainty in Measurement (GUM). RESULTS The method enabled topiramate quantification within the range of 1.20-36.0 μg/mL without interference from structurally related compounds and no evidence of a matrix effect. Intermediate precision was ≤3.2 % and repeatability was 1.4-2.5 % across all concentration levels. The relative mean bias was -0.3 to 3.5 %. Expanded measurement uncertainties for target value assignment (n=6) were found to be ≤2.9 % (k=2) independent of the concentration level and the nature of the sample. CONCLUSIONS In human serum and plasma, the RMP demonstrated high analytical performance for topiramate quantification and fulfilled the requirements on measurement uncertainty. Traceability to SI units was established by qNMR content determination of the topiramate, which was used for direct calibration of the RMP. This RMP is, therefore, fit for purpose for routine assay standardization and clinical sample evaluation.
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Affiliation(s)
| | | | | | - Anja Kobel
- Dr. Risch Ostschweiz AG, Buchs, Switzerland
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46
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Salzmann L, Wild J, Singh N, Schierscher T, Liesch F, Bauland F, Geistanger A, Risch L, Geletneky C, Seger C, Taibon J. An isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS)-based candidate reference measurement procedure (RMP) for the quantification of gabapentin in human serum and plasma. Clin Chem Lab Med 2023; 61:1955-1966. [PMID: 36689915 DOI: 10.1515/cclm-2022-0998] [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: 10/05/2022] [Accepted: 12/23/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To describe and validate a reference measurement procedure (RMP) for gabapentin, employing quantitative nuclear magnetic resonance (qNMR) spectroscopy to determine the absolute content of the standard materials in combination with isotope dilution-liquid chromatograph-tandem mass spectrometry (ID-LC-MS/MS) to accurately measure serum and plasma concentrations. METHODS A sample preparation protocol based on protein precipitation in combination with LC-MS/MS analysis using a C8 column for chromatographic separation was established for the quantification of gabapentin. Assay validation and determination of measurement uncertainty were performed according to guidance from the Clinical and Laboratory Standards Institute, the International Conference on Harmonization, and the Guide to the expression of uncertainty in measurement. ID-LC-MS/MS parameters evaluated included selectivity, specificity, matrix effects, precision and accuracy, inter-laboratory equivalence, and uncertainty of measurement. RESULTS The use of qNMR provided traceability to International System (SI) units. The chromatographic assay was highly selective, allowing baseline separation of gabapentin and the gabapentin-lactam impurity, without observable matrix effects. Variability between injections, preparations, calibrations, and days (intermediate precision) was <2.3%, independent of the matrix, while the coefficient of variation for repeatability was 0.9-2.0% across all concentration levels. The relative mean bias ranged from -0.8-1.0% for serum and plasma samples. Passing-Bablok regression analysis indicated very good inter-laboratory agreement; the slope was 1.00 (95% confidence interval [CI] 0.98 to 1.03) and the intercept was -0.05 (95% CI -0.14 to 0.03). Pearson's correlation coefficient was ≥0.996. Expanded measurement uncertainties for single measurements were found to be ≤5.0% (k=2). CONCLUSIONS This analytical protocol for gabapentin, utilizing traceable and selective qNMR and ID-LC-MS/MS techniques, allows for the standardization of routine tests and the reliable evaluation of clinical samples.
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Affiliation(s)
| | - Janik Wild
- Dr. Risch Ostschweiz AG, Buchs, Switzerland
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47
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Salzmann L, Spescha T, Singh N, Schierscher T, Bachmann M, Bauland F, Geistanger A, Risch L, Geletneky C, Seger C, Taibon J. An isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS)-based candidate reference measurement procedure (RMP) for the quantification of lamotrigine in human serum and plasma. Clin Chem Lab Med 2023; 61:1930-1941. [PMID: 36785916 DOI: 10.1515/cclm-2022-0997] [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: 10/05/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVES We developed an isotope dilution (ID)-liquid chromatography-tandem mass spectrometry (LC-MS/MS)-based candidate reference measurement procedure (RMP) for lamotrigine in human serum and plasma, using quantitative nuclear magnetic resonance-characterized reference standards to ensure traceability to the International System of Units. METHODS A sample preparation protocol based on protein precipitation combined with LC-MS/MS analysis using a C18 column for chromatographic separation was established for the quantification of lamotrigine in human serum and plasma. Assay validation was performed according to current guidelines. Spiked serum and plasma samples were used to assess selectivity and specificity; a post-column infusion experiment and comparison of standard line slopes were performed to ascertain possible matrix effects. Precision and accuracy were determined in a 5 days validation experiment. Measurement uncertainty was determined per the Guide to the Expression of Uncertainty in Measurement. RESULTS The method allowed the quantification of lamotrigine in serum and plasma in a range of 0.600-24.0 μg/mL without any observable matrix effects. The relative mean bias (n=6) ranged from 1.7 to 3.7%; intermediate precision, including variances in between-day, -calibration, and -injection, was ≤2.4%, independent of the level and matrix. Total measurement uncertainty for a single measurement was ≤2.6%; expanded uncertainty was ≤5.2% (coverage factor k=2). CONCLUSIONS This candidate RMP based on ID-LC-MS/MS provides a traceable and reliable platform for the standardization of routine assays and the evaluation of clinical samples.
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48
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Zhang L, Liu M, Qin W, Shi D, Mao J, Li Z. Modeling the protein binding non-linearity in population pharmacokinetic model of valproic acid in children with epilepsy: a systematic evaluation study. Front Pharmacol 2023; 14:1228641. [PMID: 37869748 PMCID: PMC10587682 DOI: 10.3389/fphar.2023.1228641] [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: 05/25/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Background: Several studies have investigated the population pharmacokinetics (popPK) of valproic acid (VPA) in children with epilepsy. However, the predictive performance of these models in the extrapolation to other clinical environments has not been studied. Hence, this study evaluated the predictive abilities of pediatric popPK models of VPA and identified the potential effects of protein binding modeling strategies. Methods: A dataset of 255 trough concentrations in 202 children with epilepsy was analyzed to assess the predictive performance of qualified models, following literature review. The evaluation of external predictive ability was conducted by prediction- and simulation-based diagnostics as well as Bayesian forecasting. Furthermore, five popPK models with different protein binding modeling strategies were developed to investigate the discrepancy among the one-binding site model, Langmuir equation, dose-dependent maximum effect model, linear non-saturable binding equation and the simple exponent model on model predictive ability. Results: Ten popPK models were identified in the literature. Co-medication, body weight, daily dose, and age were the four most commonly involved covariates influencing VPA clearance. The model proposed by Serrano et al. showed the best performance with a median prediction error (MDPE) of 1.40%, median absolute prediction error (MAPE) of 17.38%, and percentages of PE within 20% (F20, 55.69%) and 30% (F30, 76.47%). However, all models performed inadequately in terms of the simulation-based normalized prediction distribution error, indicating unsatisfactory normality. Bayesian forecasting enhanced predictive performance, as prior observations were available. More prior observations are needed for model predictability to reach a stable state. The linear non-saturable binding equation had a higher predictive value than other protein binding models. Conclusion: The predictive abilities of most popPK models of VPA in children with epilepsy were unsatisfactory. The linear non-saturable binding equation is more suitable for modeling non-linearity. Moreover, Bayesian forecasting with prior observations improved model fitness.
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Affiliation(s)
- Lina Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Maochang Liu
- Department of Pharmacy, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Weiwei Qin
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Dandan Shi
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junjun Mao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Zeyun Li
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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49
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Fujita Y, Murai M, Muraki S, Suetsugu K, Tsuchiya Y, Hirota T, Matsunaga N, Ieiri I. Population Pharmacokinetic Analysis of Drug-Drug Interactions Between Perampanel and Carbamazepine Using Enzyme Induction Model in Epileptic Patients. Ther Drug Monit 2023; 45:653-659. [PMID: 36645709 DOI: 10.1097/ftd.0000000000001055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/02/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Perampanel (PER) is an oral antiepileptic drug and its concomitant use with carbamazepine (CBZ) leads to decreased PER concentrations. However, the magnitude of its influence may vary, depending on the dynamics of the enzyme induction properties of CBZ. This study aimed to develop a population pharmacokinetic (PPK) model considering the dynamics of enzyme induction and evaluate the effect of CBZ on PER pharmacokinetics. METHODS We retrospectively collected data on patient background, laboratory tests, and prescribed drugs from electronic medical records. We developed 2 PPK models incorporating the effect of CBZ-mediated enzyme induction to describe time-concentration profiles of PER using the following different approaches: (1) treating the concomitant use of CBZ as a categorical covariate (empirical PPK model) and (2) incorporating the time-course of changes in the amount of enzyme by CBZ-mediated induction (semimechanistic PPK model). The bias and precision of the predictions were investigated by calculating the mean error, mean absolute error, and root mean squared error. RESULTS A total of 133 PER concentrations from 64 patients were available for PPK modelling. PPK analyses showed that the co-administration of CBZ increased the clearance of PER. Goodness-of-fit plots indicated a favorable description of the observed data and low bias. The mean error, mean absolute error, and root mean square error values based on the semimechanistic model were smaller than those obtained using the empirical PPK model for predicting PER concentrations in patients with CBZ. CONCLUSIONS We developed 2 PPK models to describe PER pharmacokinetics based on different approaches, using electronic medical record data. Our PPK models support the use of PER in clinical practice.
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Affiliation(s)
- Yuito Fujita
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, Fukuoka, Japan; and
| | - Mariko Murai
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, Fukuoka, Japan; and
| | - Shota Muraki
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, Fukuoka, Japan; and
| | | | - Yuichi Tsuchiya
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
| | - Naoya Matsunaga
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Science, Kyushu University, Fukuoka, Japan; and
| | - Ichiro Ieiri
- Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan
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50
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Liu JT, Brown CS, Mara KC, Riker RR, Rabinstein AA, Fraser GL, May TL, Armstrong KJ, Seder DB, Gagnon DJ. Derivation and Validation of a New Equation for Estimating Free Valproate Concentration in Critically Ill Adult Patients. Crit Care Explor 2023; 5:e0987. [PMID: 37868026 PMCID: PMC10586844 DOI: 10.1097/cce.0000000000000987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Abstract
IMPORTANCE Protein binding of valproate varies among ICU patients, altering the biologically active free valproate concentration (VPAC). Free VPAC is measured at few laboratories and is often discordant with total VPAC. Existing equations to predict free VPAC are either not validated or are inaccurate in ICU patients. OBJECTIVES We designed this study to derive and validate a novel equation to predict free VPAC using data from ICU patients and to compare its performance to published equations. DESIGN Retrospective cohort study. SETTING Two academic medical centers. PARTICIPANTS Patients older than 18 years old with concomitant free and total VPACs measured in the ICU were included in the derivation cohort if admitted from 2014 to 2018, and the validation cohort if admitted from 2019 to 2022. MAIN OUTCOMES AND MEASURES Multivariable linear regression was used to derive an equation to predict free VPAC. Modified Bland-Altman plots and the rate of therapeutic concordance between the measured and predicted free VPAC were compared. RESULTS Demographics, median free and total VPACs, and valproate free fractions were similar among 115 patients in the derivation cohort and 147 patients in the validation cohort. The Bland-Altman plots showed the new equation performed better (bias, 0.3 [95% limits of agreement, -13.6 to 14.2]) than the Nasreddine (-9.2 [-26.5 to 8.2]), Kodama (-9.7 [-30.0 to 10.7]), Conde Giner (-7.9 [-24.9 to 9.1]), and Parent (-9.9 [-30.7 to 11.0]) equations, and similar to Doré (-2.0 [-16.0 to 11.9]). The Doré and new equations had the highest therapeutic concordance rate (73%). CONCLUSIONS AND RELEVANCE For patients at risk of altered protein binding such as ICU patients, existing equations to predict free VPAC are discordant with measured free VPAC. A new equation had low bias but was imprecise. External validation should be performed to improve its precision and generalizability. Until then, monitoring free valproate is recommended during critical illness.
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Affiliation(s)
- Ji Tong Liu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
| | | | | | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
- Maine Medical Center Research Institute, Portland, ME
| | - Kaitlin J Armstrong
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Department of Pharmacy, Maine Medical Center, Portland, ME
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
- Maine Medical Center Research Institute, Portland, ME
| | - David J Gagnon
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Maine Medical Center Research Institute, Portland, ME
- Department of Pharmacy, Maine Medical Center, Portland, ME
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