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Furcich J, Boucher AA, Grace J. Onset of Acute Intermittent Porphyria After Etonogestrel Implant Insertion: A Case Report. J Pediatr Hematol Oncol 2024; 46:319-321. [PMID: 38968544 DOI: 10.1097/mph.0000000000002920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/11/2024] [Indexed: 07/07/2024]
Abstract
A 17-year-old previously healthy female developed posterior reversible encephalopathy syndrome 1 week after etonogestrel implantation. She had a previous etonogestrel implant removed 4 months prior after unrelenting abdominal pain and hyponatremia with a negative workup for other etiologies, including hypercoagulable disorders and malignancy. This second insertion and resulting hospitalization allowed for the diagnosis of acute intermittent porphyria (AIP) to be confirmed. Progesterone can induce enzymatic activity upstream of porphobilinogen deaminase, the enzyme implicated in AIP, resulting in build-up of toxic metabolites. AIP requires high clinical suspicion for diagnosis but should be considered when hormonal triggers lead to unexplained neurovisceral symptoms.
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Affiliation(s)
| | - Alexander A Boucher
- Department of Pediatrics, Division of Pediatric Hematology/Oncology
- Department of Medicine, Division of Hematology, Oncology, and Transplantation
| | - James Grace
- Department of Medicine, Division of Hospital Medicine, University of Minnesota, Minneapolis, MN
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Mahon E, Marsh O, Uriarte A, Stabile F. The effect of oral zonisamide treatment on serum phenobarbital concentrations in epileptic dogs. Front Vet Sci 2024; 11:1389615. [PMID: 38868500 PMCID: PMC11168201 DOI: 10.3389/fvets.2024.1389615] [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: 02/21/2024] [Accepted: 04/26/2024] [Indexed: 06/14/2024] Open
Abstract
Zonisamide is used in dogs for the treatment of epileptic seizures. It is predominantly metabolised by CYP450 hepatic enzymes. When used concurrently with phenobarbital (PB), zonisamide clearance is increased and its elimination half-life decreases. However, the effect that zonisamide may have on serum PB concentrations in dogs has not been previously described. Eight dogs diagnosed with idiopathic epilepsy and two dogs with structural epilepsy commenced zonisamide at 8.0 mg/kg/12 h [7.4-10 mg/kg/12 h] following an increase in the frequency of epileptic seizures. Nine dogs were receiving PB every 12 h (4.2 mg/kg/12 h [3.8-6 mg/kg/12 h]), and one dog was receiving PB every 8 h (6 mg/kg/8 h). Following the addition of zonisamide and despite no increase in PB dosage, an increase in phenobarbital serum PB concentration was observed in 9 out of 10 dogs in subsequent measurements. In five dogs, phenobarbital serum concentrations were raised to concentrations higher than the reported hepatotoxic concentrations (trough>35 mg/L). This required a reduction in daily doses of PB. This case series suggests that zonisamide affects the metabolism of PB and causes an increase in PB serum concentrations over time.
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Affiliation(s)
- Elizabeth Mahon
- Department of Neurology and Neurosurgery, Southfields Veterinary Specialists, Part of Linnaeus Ltd, Essex, United Kingdom
| | - Oliver Marsh
- Department of Neurology and Neurosurgery, Dick White Referrals, Part of Linnaeus Ltd, Newmarket, United Kingdom
| | - Ane Uriarte
- Department of Neurology and Neurosurgery, Southfields Veterinary Specialists, Part of Linnaeus Ltd, Essex, United Kingdom
| | - Fabio Stabile
- Department of Neurology and Neurosurgery, Wear Referrals, Part of Linnaeus Ltd, Bradbury, United Kingdom
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Stöllberger C, Finsterer J, Schneider B. Interactions between antiepileptic drugs and direct oral anticoagulants for primary and secondary stroke prevention. Expert Opin Drug Metab Toxicol 2024; 20:359-376. [PMID: 38712571 DOI: 10.1080/17425255.2024.2352466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Direct oral anticoagulants (DOAC) are the guideline-recommended therapy for prevention of stroke in atrial fibrillation (AF) and venous thromboembolism. Since approximately 10% of patients using antiepileptic drugs (AED) also receive DOAC, aim of this review is to summarize data about drug-drug interactions (DDI) of DOAC with AED by using data from PubMed until December 2023. AREAS COVERED Of 49 AED, only 16 have been investigated regarding DDI with DOAC by case reports or observational studies. No increased risk for stroke was reported only for topiramate, zonisamide, pregabalin, and gabapentin, whereas for the remaining 12 AED conflicting results regarding the risk for stroke and bleeding were found. Further 16 AED have the potential for pharmacodynamic or pharmacokinetic DDI, but no data regarding DOAC are available. For the remaining 17 AED it is unknown if they have DDI with DOAC. EXPERT OPINION Knowledge about pharmacokinetic and pharmacodynamic DDI of AED and DOAC is limited and frequently restricted to in vitro and in vivo findings. Since no data about DDI with DOAC are available for 67% of AED and an increasing number of patients have a combined medication of DOAC and AED, there is an urgent need for research on this topic.
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Bartoszek A, Trzpil A, Kozub A, Fornal E. Optimization of the Zebrafish Larvae Pentylenetetrazol-Induced Seizure Model for the Study of Caffeine and Topiramate Interactions. Int J Mol Sci 2023; 24:12723. [PMID: 37628904 PMCID: PMC10454524 DOI: 10.3390/ijms241612723] [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: 07/27/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Epilepsy is a common neurological disorder characterized by seizures that cause neurobiological and behavioral impairment. Caffeine (CAF), which is the most widely consumed stimulant in the world, is reported to influence epileptic seizures and antiepileptic drugs, especially topiramate (TPM). The aim of the study was to optimize the zebrafish larvae pentylenetetrazol-induced seizure model for the study of CAF and TPM interactions, which include the determination of dose space, and the delivery of an analytical method for monitoring CAF, TPM, and CAF metabolite paraxanthine (PAR) in Zebrafish larvae. Methods: The zebrafish larvae, 4 days post-fertilization, were incubated for 18 h with CAF, TPM, or CAF + TPM, with subsequent locomotor activity assessment. Seizures were evoked by adding PTZ solution to obtain a final concentration of 20 mM. Subsequently, the liquid chromatography-mass spectrometry (LC-MS/MS) analytical method was used to simultaneously assess the levels of both CAF and TPM in the larvae. CAF (50 mg/L) and TPM (75 μM) given separately decreased the average larvae locomotor activity compared to the PTZ group but, however, were not able to lower it to the control level. Co-administration of 25 mg/L CAF and 50 μM TPM suppressed the activity to the same level. Adding 25 μM TPM to 50 mg/L CAF decrease the measured CAF level in the larvae. Until proven otherwise, CAF consumption should be regarded as a potential determinant in the modulation of TPM's efficacy in the management of epileptic seizures. The optimized model will contribute to the standardization of studying CAF and TPM interactions and building the understanding of the molecular bases of the interaction.
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Affiliation(s)
- Adrian Bartoszek
- Department of Bioanalytics, Medical University of Lublin, ul. Jaczewskiego 8b, 20-090 Lublin, Poland (E.F.)
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Besag FMC, Berry D, Vasey MJ, Patsalos PN. Drug-drug interactions between antiseizure medications and antipsychotic medications: a narrative review and expert opinion. Expert Opin Drug Metab Toxicol 2023; 19:829-847. [PMID: 37925741 DOI: 10.1080/17425255.2023.2278676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Antiseizure medications (ASMs) and antipsychotic drugs are frequently coadministered with the potential for drug-drug interactions. Interactions may either be pharmacokinetic or pharmacodynamic, resulting in a decrease or increase in efficacy and/or an increase or decrease in adverse effects. AREAS COVERED The clinical evidence for pharmacokinetic and pharmacodynamic interactions between ASMs and antipsychotics is reviewed based on the results of a literature search in MEDLINE conducted in April 2023. EXPERT OPINION There is now extensive published evidence for the clinical importance of interactions between ASMs and antipsychotics. Enzyme-inducing ASMs can decrease blood concentrations of many of the antipsychotics. There is also evidence that enzyme-inhibiting ASMs can increase antipsychotic blood concentrations. Similarly, there is limited evidence showing that antipsychotic drugs may affect the blood concentrations of ASMs through pharmacokinetic interactions. There is less available evidence for pharmacodynamic interactions, but these can also be important, as can displacement from protein binding. The lack of published evidence for an interaction should not be interpreted as meaning that the given interaction does not occur; the evidence is building continually. There is no substitute for careful patient monitoring and sound clinical judgment.
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Affiliation(s)
- Frank M C Besag
- Child and Adolescent Mental Health Services (CAMHS), East London NHS Foundation Trust, Bedford, UK
- School of Pharmacy, University College London, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dave Berry
- Toxicology Unit, Kings College Hospital, London, UK
| | - Michael J Vasey
- Child and Adolescent Mental Health Services (CAMHS), East London NHS Foundation Trust, Bedford, UK
| | - Philip N Patsalos
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
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MacMahon T, Kelly YP. Zonisamide-induced distal renal tubular acidosis and critical hypokalaemia. BMJ Case Rep 2023; 16:e254615. [PMID: 37041041 PMCID: PMC10105998 DOI: 10.1136/bcr-2023-254615] [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: 04/13/2023] Open
Abstract
A woman in her 20s presented with rapidly progressive muscle weakness and a 1-month preceding history of fatigability, nausea and vomiting. She was found to have critical hypokalaemia (K+ 1.8 mmol/L), a prolonged corrected QT interval (581 ms) and a normal anion gap metabolic acidosis (pH 7.15) due to zonisamide-induced distal (type 1) renal tubular acidosis. She was admitted to the intensive care unit for potassium replacement and alkali therapy. Clinical and biochemical improvement ensued, and she was discharged after a 27-day inpatient stay.
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Affiliation(s)
- Thomas MacMahon
- Intensive Care Unit, Tallaght University Hospital, Dublin, Ireland
| | - Yvelynne P Kelly
- Intensive Care Unit, Tallaght University Hospital, Dublin, Ireland
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Mouterde M, Daali Y, Rollason V, Čížková M, Mulugeta A, Al Balushi KA, Fakis G, Constantinidis TC, Al-Thihli K, Černá M, Makonnen E, Boukouvala S, Al-Yahyaee S, Yimer G, Černý V, Desmeules J, Poloni ES. Joint Analysis of Phenotypic and Genomic Diversity Sheds Light on the Evolution of Xenobiotic Metabolism in Humans. Genome Biol Evol 2022; 14:6852765. [PMID: 36445690 PMCID: PMC9750130 DOI: 10.1093/gbe/evac167] [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: 02/21/2022] [Revised: 11/03/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022] Open
Abstract
Variation in genes involved in the absorption, distribution, metabolism, and excretion of drugs (ADME) can influence individual response to a therapeutic treatment. The study of ADME genetic diversity in human populations has led to evolutionary hypotheses of adaptation to distinct chemical environments. Population differentiation in measured drug metabolism phenotypes is, however, scarcely documented, often indirectly estimated via genotype-predicted phenotypes. We administered seven probe compounds devised to target six cytochrome P450 enzymes and the P-glycoprotein (P-gp) activity to assess phenotypic variation in four populations along a latitudinal transect spanning over Africa, the Middle East, and Europe (349 healthy Ethiopian, Omani, Greek, and Czech volunteers). We demonstrate significant population differentiation for all phenotypes except the one measuring CYP2D6 activity. Genome-wide association studies (GWAS) evidenced that the variability of phenotypes measuring CYP2B6, CYP2C9, CYP2C19, and CYP2D6 activity was associated with genetic variants linked to the corresponding encoding genes, and additional genes for the latter three. Instead, GWAS did not indicate any association between genetic diversity and the phenotypes measuring CYP1A2, CYP3A4, and P-gp activity. Genome scans of selection highlighted multiple candidate regions, a few of which included ADME genes, but none overlapped with the GWAS candidates. Our results suggest that different mechanisms have been shaping the evolution of these phenotypes, including phenotypic plasticity, and possibly some form of balancing selection. We discuss how these contrasting results highlight the diverse evolutionary trajectories of ADME genes and proteins, consistent with the wide spectrum of both endogenous and exogenous molecules that are their substrates.
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Affiliation(s)
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Martina Čížková
- Institute of Archaeology of the Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Anwar Mulugeta
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Khalid A Al Balushi
- College of Pharmacy, National University of Science and Technology, Muscat, Sultanate of Oman
| | - Giannoulis Fakis
- Department of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Khalid Al-Thihli
- Department of Genetics, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Marie Černá
- Department of Medical Genetics, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Eyasu Makonnen
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia,Center for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sotiria Boukouvala
- Department of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupolis, Greece
| | - Said Al-Yahyaee
- Department of Genetics, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Getnet Yimer
- Center for Global Genomics & Health Equity, Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Viktor Černý
- Department of Anthropology and Human Genetics, Faculty of Science, Charles University, Prague, Czech Republic
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Clinically Relevant Interactions Between Ritonavir-Boosted Nirmatrelvir and Concomitant Antiseizure Medications: Implications for the Management of COVID-19 in Patients with Epilepsy. Clin Pharmacokinet 2022; 61:1219-1236. [PMID: 35895276 PMCID: PMC9325946 DOI: 10.1007/s40262-022-01152-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 01/06/2023]
Abstract
Ritonavir-boosted nirmatrelvir (RBN) has been authorized recently in several countries as an orally active anti-SARS-CoV-2 treatment for patients at high risk of progressing to severe COVID-19 disease. Nirmatrelvir is the active component against the SARS-CoV-2 virus, whereas ritonavir, a potent CYP3A inhibitor, is intended to boost the activity of nirmatrelvir by increasing its concentration in plasma to ensure persistence of antiviral concentrations during the 12-hour dosing interval. RBN is involved in many clinically important drug–drug interactions both as perpetrator and as victim, which can complicate its use in patients treated with antiseizure medications (ASMs). Interactions between RBN and ASMs are bidirectional. As perpetrator, RBN may increase the plasma concentration of a number of ASMs that are CYP3A4 substrates, possibly leading to toxicity. As victims, both nirmatrelvir and ritonavir are subject to metabolic induction by concomitant treatment with potent enzyme-inducing ASMs (carbamazepine, phenytoin, phenobarbital and primidone). According to US and European prescribing information, treatment with these ASMs is a contraindication to the use of RBN. Although remdesivir is a valuable alternative to RBN, it may not be readily accessible in some settings due to cost and/or need for intravenous administration. If remdesivir is not an appropriate option, either bebtelovimab or molnupiravir may be considered. However, evidence about the clinical efficacy of bebtelovimab is still limited, and molnupiravir, the only orally active alternative, is deemed to have appreciably lower efficacy than RBN and remdesivir.
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Pozzi M, Zanotta N, Epifanio R, Baldelli S, Cattaneo D, Clementi E, Zucca C. Lacosamide effectiveness and tolerability in patients with drug-resistant epilepsy and severe disability under polytherapy: Therapy optimization as emerging from an observational study. Epilepsy Behav 2022; 128:108598. [PMID: 35151192 DOI: 10.1016/j.yebeh.2022.108598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We explored the efficacy and safety of lacosamide combined with inhibitors of fast-inactivated sodium channels or with other antiepileptic drugs, in patients with drug refractory focal epilepsy associated with intellectual or psychiatric disability. METHODS Observational study of lacosamide including the monitoring of lacosamide trough plasma levels and of electroencephalograms. RESULTS We followed up 44 patients from the start of lacosamide therapy for up to 3 years, with a clinical, electroencephalogram (EEG), and pharmacological follow-up. Median patients' age was 32.7 years, median age at epilepsy onset was 3.5 years. Intellectual disability was severe in 55.4% of the cohort and drug refractoriness was diagnosed in 88.6% of patients, who had predominantly focal seizures (80%). The severity of their epilepsy was suggested by the use of combined therapies with non-sodium blockers and sodium blockers in 75% of patients. Lacosamide was added to previous therapies and up-titrated to a median of 300 mg/d. Lacosamide add-on led to simplification of the previous drug regimen with a dose reduction in 87.9% of users of sodium blockers and in 66.7% of users of non-sodium blockers, and to withdrawal of previously administered sodium blockers in 48.5% users and non-sodium blockers in 47.6% users. Lacosamide was prescribed at lower doses in the presence of oxcarbazepine (p = 0.029), lamotrigine (p = 0.015), and topiramate (p < 0.001). Mean lacosamide plasma levels were 6.0 ± 2.4 mg/L; they were in linear correlation with the administered dose (R2 = 0.38, p < 0.001) and were influenced by the association with lamotrigine (p = 0.008), zonisamide (p = 0.012), and clobazam (p = 0.028). Lacosamide combination regimens led to an average reduction of 42% in baseline seizure frequency, with 50% patients reporting ≥50% seizure frequency reduction. Efficacy was directly correlated with lacosamide dose (R2 = 0.47, p < 0.001, B = 0.53) and trough plasma levels (R2 = 0.31, p < 0.001, B = 0.16). Electroencephalogram profiles were improved in 40.9% of patients and EEG improvement was not significantly correlated with seizure frequency reduction. Lacosamide safety was good, with 37 adverse reactions in 30 patients, of which 50% were attributed to lacosamide and led to lacosamide withdrawal in 18% of cases. The retention rate of lacosamide was of 88.6% at 1 year, 86.4% at 2 years, and 72.7% after three years. The severity of intellectual disability was directly correlated with increased possibility of lacosamide retention (OR = 0.46 per severity tier, p = 0.016). CONCLUSION Lacosamide add-on allowed dose reduction of previous therapies and reduced the frequency of seizures, showing good tolerability even at high doses, without exceeding reference plasma levels.
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Affiliation(s)
- Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Nicoletta Zanotta
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Roberta Epifanio
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Sara Baldelli
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, 20157 Milan, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, 20157 Milan, Italy
| | - Emilio Clementi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy; Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, Luigi Sacco University Hospital, University of Milan, 20157 Milan, Italy.
| | - Claudio Zucca
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
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Chiew AL, Buckley NA. The serotonin toxidrome: shortfalls of current diagnostic criteria for related syndromes. Clin Toxicol (Phila) 2021; 60:143-158. [PMID: 34806513 DOI: 10.1080/15563650.2021.1993242] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Serotonin syndrome (toxicity) describes adverse drug effects from toxic amounts of intra-synaptic central nervous system serotonin. A wide range of drugs have been implicated to cause serotonin toxicity, not all justifiably. The plausible agents all have a final common pathway resulting in a substantial increase in central nervous system serotonergic neurotransmission. Serotonin toxicity is characterized by neuromuscular excitation, mental status changes, and autonomic dysregulation. Signs and symptoms represent a spectrum of toxicity (mild to life-threatening) related to increasing serotonin concentrations. As there is no consensus on the threshold for "toxicity" or diagnostic criteria, the true incidence of serotonin toxicity is unknown. The incidence in overdose is easier to quantify and is reasonably common in serotonergic antidepressant overdoses. In a large case series of overdoses, moderate serotonin toxicity occurred in 14% of poisonings with a selective serotonin reuptake inhibitor. While half those ingesting a monoamine oxidase inhibitor in combination with a serotonergic agent in overdose exhibit at least moderately severe serotonin toxicity. In contrast, the incidence of serotonin toxicity in those on therapeutic serotonergic agents appears to be very low. OBJECTIVES To provide a narrative review of the current diagnostic criteria, utilizing case reports of fatalities to evaluate how many meet the various diagnostic criteria and propose practical solutions to resolve controversies in diagnosis. METHODS A review of serotonin toxicity diagnostic criteria in the English literature was completed by searching Embase and PubMed from January 1990 to July 2021 for the keywords "serotonin syndrome/toxicity" paired with "diagnostic criteria" or "diagnosis." Also, fatal cases of serotonin toxicity identified from a recent systematic review were independently examined to determine what diagnostic criteria were met and whether serotonin toxicity or another cause was most likely. REVIEW OF DIAGNOSIS CRITERIA Serotonin toxicity is a clinical diagnosis, four diagnostic criteria (Sternbach, Serotonin Syndrome Scale, Radomski, and Hunter) have been proposed. However, the Serotonin Syndrome Scale has not been validated in patients with serotonin toxicity and only utilized in those on a serotonergic agent. The remaining three criteria are utilized more widely but have undergone little refinement or validation. REVIEW OF FATAL CASES Shortfalls with diagnostic criteria can be illustrated by examining case fatalities. Of 55 fatal cases reviewed, 12 (22%) were unlikely to be serotonin toxicity. Sternbach and Radomski criteria were met by 25 (45%), 20 (36%) had insufficient data reported and 10 (18%) met an exclusion criterion. Few had sufficient information reported to determine whether Hunter Criteria were met, with only 13 (24%) documented as meeting the criteria, the remaining 42 (76%) had insufficient data. RESOLVING SHORTFALLS IN CURRENT DIAGNOSTIC CRITERIA As serotonin toxicity is a clinical diagnosis, issues arise when basing the diagnosis on symptom criteria alone, without considering whether the drug/s ingested increase central nervous system serotonin or whether there is an alternative diagnosis. This has resulted in case reports and government warnings for drugs that cannot plausibly cause significant serotonin toxicity (e.g., ondansetron and antipsychotics). We propose when assessing for a serotonin toxidrome, both the causative agent(s) and clinical scenario is considered to determine the likelihood of serotonin toxicity. Then the clinical features assessed, those with a moderate to high prior probability (e.g., serotonergic drug-drug interaction, overdose, recent initiation or increase in dose of serotonergic agent/s) could be diagnosed based on the Hunter criteria. However, those with a low probability (e.g., stable therapeutic doses of a serotonergic agent) require more specific and stringent criteria. Finally, we propose a minimum dataset for case reports/series of serotonin toxicity. CONCLUSIONS More complete and accurate reporting of serotonin toxicity cases is required in the future, to avoid further misleading associations that are physiologically implausible.
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Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Randwick, Australia.,NSW Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia.,Clinical Pharmacology and Toxicology Research Group, Biomedical Informatics and Digital Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Pahwa P, Singh T, Goel RK. Anticonvulsant Effect of Asparagus racemosus Willd. in a Mouse Model of Catamenial Epilepsy. Neurochem Res 2021; 47:422-433. [PMID: 34623565 DOI: 10.1007/s11064-021-03455-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/05/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
Asparagus racemosus Willd. (Family Liliaceae), also known as female reproductive tonic, is traditionally used across the Sub-Himalayan region in Uttarakhand, India for treatment of epilepsy and disorders of female reproductive system. Therefore, in this study, we investigated the anticonvulsant effect of A. racemosus in a mouse model of catamenial epilepsy. We artificially increased progesterone and neurosteroid levels (a state of pseudo-pregnancy) in adult Swiss albino female mice by injecting pregnant mares' serum gonadotropin (PMSG) (5 IU s.c.), followed by human chorionic gonadotropin (HCG) (5 IU s.c.) after 46 h. In the following 10 days, A. racemosus treatment was given along with measurement of progesterone, estradiol, and corticosterone levels in the blood. Neurosteroid withdrawal was induced by finasteride (50 mg/kg, i.p.) on treatment day 9. Twenty-four hours after finasteride administration (day 10 of treatment), seizure susceptibility was evaluated with the sub-convulsant pentylenetetrazole (PTZ) dose (40 mg/kg i.p.). Four hours after PTZ, animals were assessed for depression like phenotypes followed by euthanasia and separation of brain parts (cortex and hippocampus). The results showed that PMSG and HCG treatment elevated progesterone and estradiol levels. Treatment with finasteride increased seizure susceptibility and depression due to decreased progesterone and elevated estrogen levels coupled with decreased monoamine and elevated corticosterone levels. A. racemosus treatment, on the other hand, significantly decreased seizure susceptibility and depression like behaviors, possibly because of increased progesterone, restored estradiol, corticosterone, and monoamine levels. We concluded that herbal formulations using A. racemosus root extracts may be used as monotherapy or adjuvant therapy along with available AEDs for the better and safe management of catamenial epilepsy as well as comorbid depression.
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Affiliation(s)
- Priyanka Pahwa
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, 147002, India
| | - Tanveer Singh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, 147002, India.,Department of Neuroscience and Experimental Therapeutics, Health Science Center, College of Medicine, Texas A&M University, Bryan, TX, 77807, USA
| | - Rajesh Kumar Goel
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, 147002, India.
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Likasitthananon N, Nabangchang C, Simasathien T, Vichutavate S, Phatarakijnirund V, Suwanpakdee P. Hypovitaminosis D and risk factors in pediatric epilepsy children. BMC Pediatr 2021; 21:432. [PMID: 34600517 PMCID: PMC8487104 DOI: 10.1186/s12887-021-02906-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
Background Anti-seizure medication (ASM) treatment is one of the significant risk factors associated with abnormal vitamin D status in epilepsy patients. Multiple studies have shown that adult epilepsy patients can exhibit vitamin D deficiency. However, there are few reports investigating pediatric epilepsy patients. In this study, we aimed to identify risk factors related to hypovitaminosis D in pediatric epilepsy patients in Thailand. Methods A cross-sectional retrospective cohort study was conducted in 138 pediatric epilepsy patients who received anticonvulsants from April 2018 to January 2019. Demographic data, seizure types, puberty status, physical activity, duration, and types of anti-seizure medications were analyzed. Patients with abnormal liver function, abnormal renal function, and who received vitamin D supplements or ketogenic diet containing vitamin D were excluded. Levels of serum vitamin D (25(OH)D) were measured. Results All 138 subjects were enrolled, the age ranged from 1.04 – 19.96 years; (mean = 9.65 ± 5.09), the mean serum 25(OH) D level was 26.56 ± 9.67 ng/ml. The prevalence of vitamin D deficiency was 23.2% and insufficiency was 47.8% respectively. Two risk factors—puberty status (OR 5.43, 95% CI 1.879-15.67) and non-enzyme-inhibiting ASMs therapy (OR 3.58, 95% CI 1.117-11.46)—were significantly associated with hypovitaminosis D, as shown by multivariate analyses. Conclusions Our study reports the high prevalence of hypovitaminosis D in pediatric epilepsy patients in Thailand despite being located in the tropical zone. These findings can guide clinicians to measure vitamin D status in pediatric epilepsy patients particularly when they reach puberty and/or are using non-enzyme-inhibiting ASMs therapy. Early detection of vitamin D status and prompt vitamin D supplementation can prevent fractures and osteoporosis later in life. Trial registration TCTR20210215005 (http://www.clinicaltrials.in.th/).
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Affiliation(s)
| | - Charcrin Nabangchang
- Neurology Division, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - Thitiwan Simasathien
- Neurology Division, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - Suchavadee Vichutavate
- Endocrine Division, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | | | - Piradee Suwanpakdee
- Neurology Division, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand.
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Gautam M, Thapa G. Cytochrome P450-mediated estrogen catabolism therapeutic avenues in epilepsy. Acta Neurol Belg 2021; 121:603-612. [PMID: 32743748 DOI: 10.1007/s13760-020-01454-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/23/2020] [Indexed: 01/11/2023]
Abstract
Epilepsy is a neuropsychiatric disorder, which does not have any identifiable cause. However, experimental and clinical results have asserted that the sex hormone estrogen level and endocrine system function influence the seizure and epileptic episodes. There are available drugs to control epilepsy, which passes through the metabolism process. Cytochrome P-450 family 1 (CYP1A1) is a heme-containing mono-oxygenase that are induced several folds in most of the tissues and cells contributing to their differential expression, which regulates various metabolic processes upon administration of therapeutics. CYP1A1 gene family has been found to metabolize estrogen, a female sex hormone, which plays a central role in maintaining the health of brain altering the level of estrogen active neuropsychiatric disorder like epilepsy. Hence, in this article, we endeavor to provide an opinion of estrogen, its effects on epilepsy and catamenial epilepsy, their metabolism by CYP1A1 and new way forward to differential diagnosis and clinical management of epilepsy in future.
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Affiliation(s)
- Megha Gautam
- Department of Biological Science, Faculty of Science and Engineering, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Ganesh Thapa
- Department of Biological Science, Faculty of Science and Engineering, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland.
- Biohazards and Biosafety, Estates and Facilities, Trinity College of Dublin, The University of Dublin, College Green, Dublin 2, D02 PN40, Ireland.
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Hellfritzsch M, Christensen J, Nielsen LP. Rivaroxaban Plasma Levels and Levetiracetam. Ann Intern Med 2020; 173:771. [PMID: 33137273 DOI: 10.7326/l20-1064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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15
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Jha M, Alam O, Naim MJ, Sharma V, Bhatia P, Sheikh AA, Nawaz F, Alam P, Manaithiya A, Kumar V, Nazar S, Siddiqui N. Recent advancement in the discovery and development of anti-epileptic biomolecules: An insight into structure activity relationship and Docking. Eur J Pharm Sci 2020; 153:105494. [PMID: 32730845 DOI: 10.1016/j.ejps.2020.105494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 12/22/2022]
Abstract
Although there have been many advancements in scientific research and development, the cause of epilepsy still remains an open challenge. In spite of high throughput research in the field of anti-epileptic drugs, efficacy void is still prevalent before the researchers. Researchers have persistently been exploring all the possibilities to curb undesirable side effects of the anti-epileptic drugs or looking for a more substantial approach to diminish or cure epilepsy. The drug development has shown a hope to medicinal chemists and researchers to carry further research by going through a substantial literature survey. This review article attempts to describe the recent developments in the anti-epileptic agents, pertaining to different molecular scaffolds considering their structure-activity relationship, docking studies and their mechanism of actions.
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Affiliation(s)
- Mukund Jha
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Ozair Alam
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India.
| | - Mohd Javed Naim
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Vrinda Sharma
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Parth Bhatia
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Aadil Ahmad Sheikh
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Farah Nawaz
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Perwaiz Alam
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Ajay Manaithiya
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Vivek Kumar
- Department of Cardiology, Fortis Heart Institute, New Delhi, 110025, India
| | - Shagufi Nazar
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
| | - Nadeem Siddiqui
- Medicinal Chemistry and Molecular Modelling Lab, Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110062, India
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Hézode C, Kwo P, Sperl J, Hwang P, Long J, Talwani R, Robertson MN, Haber BA. Elbasvir/grazoprevir in women with hepatitis C virus infection taking oral contraceptives or hormone replacement therapy. Int J Womens Health 2019; 11:617-628. [PMID: 31819666 PMCID: PMC6875497 DOI: 10.2147/ijwh.s203022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 08/01/2019] [Indexed: 01/03/2023] Open
Abstract
Introduction Some direct-acting antiviral regimens for hepatitis C virus (HCV) infection pose safety or efficacy concerns if coadministered with drugs containing ethinyl estradiol. The present analysis was conducted to examine the impact of concomitant oral contraceptive pills (OCP) or hormone replacement therapy (HRT) during treatment with elbasvir (EBR)/grazoprevir (GZR) in women with HCV genotype (GT)1 or GT4 infection. Methods This is a post hoc, integrated retrospective analysis of female participants with HCV GT1 or GT4 infection who received EBR 50 mg/GZR 100 mg once daily for 12 weeks in phase 2/3 clinical trials. The primary end point was sustained virologic response at 12 weeks after therapy completion (SVR12). For this analysis, participants were stratified according to whether they received OCP or HRT during the original treatment study. Results A total of 1,022 women with HCV GT1 or GT4 infection were included (receiving OCP/HRT, n=81; not receiving OCP/HRT, n=941). Most participants receiving OCP/HRT were treatment-naive (79%), noncirrhotic (91.4%), and aged >35 years (71.6%). SVR12 rates were similar in women receiving OCP/HRT and those not receiving OCP/HRT (95.1% vs 96.3%). SVR12 rates remained high across all subgroups within the population receiving OCP/HRT: SVR12 rates were 94.6%, 100%, and 100% in participants with GT1a, GT1b, and GT4 infection, and all women aged 18-35 years achieved SVR (21/21). Treatment-related adverse events occurred in 40.7% (33/81) and 30.1% (283/941) of women receiving and those not receiving OCP/HRT, respectively. Conclusion The efficacy and safety of EBR/GZR administered for 12 weeks was similar in women receiving OCP/HRT and those not on OCP/HRT. These data indicate that EBR/GZR can be safely used for the treatment of HCV GT1 or GT4 infection in women receiving concomitant OCP/HRT.
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Affiliation(s)
- Christophe Hézode
- Service d'Hépatologie, Hôpital Henri-Mondor, AP-HP, Université Paris-Est, INSERM U955, Créteil, France
| | - Paul Kwo
- Division of Gastroenterology/Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jan Sperl
- Department of Hepatogastroenterology, Institut Klinické a Experimentální Medicíny (IKEM), Prague, Czech Republic
| | - Peggy Hwang
- Department of Infectious Disease, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Jianmin Long
- Department of Infectious Disease, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Rohit Talwani
- Department of Infectious Disease, Merck & Co., Inc., Kenilworth, NJ, USA
| | | | - Barbara A Haber
- Department of Infectious Disease, Merck & Co., Inc., Kenilworth, NJ, USA
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Acute effect of cannabidiol on the activity of various novel antiepileptic drugs in the maximal electroshock- and 6 Hz-induced seizures in mice: Pharmacodynamic and pharmacokinetic studies. Neuropharmacology 2019; 158:107733. [DOI: 10.1016/j.neuropharm.2019.107733] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/26/2019] [Accepted: 07/31/2019] [Indexed: 12/23/2022]
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18
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Kondo E, Ikeda T, Goto H, Nishikori M, Maeda N, Matsumoto K, Kitagawa H, Noda N, Sugimoto S, Hara J. Pharmacokinetics of thiotepa in high-dose regimens for autologous hematopoietic stem cell transplant in Japanese patients with pediatric tumors or adult lymphoma. Cancer Chemother Pharmacol 2019; 84:849-860. [PMID: 31428821 PMCID: PMC6768914 DOI: 10.1007/s00280-019-03914-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 07/25/2019] [Indexed: 12/17/2022]
Abstract
Purpose Thiotepa is used in high-dose chemotherapy (HDT) before autologous hematopoietic stem cell transplantation (HSCT) to treat solid tumors and hematological malignancies. This Phase 1 study was conducted to establish the pharmacokinetics (PK) of thiotepa in a Japanese population. Methods HDT/HSCT was performed in pediatric patients (≥ 2 years) with solid tumors or brain tumors (thiotepa 200 mg/m2/day IV-infused over 24 h on HSCT Days − 12, − 11, − 5, and − 4 and melphalan 70 mg/m2/day IV-infused over 1 h on Days − 11, − 5, and − 4) and adult patients (≥ 16 years) with malignant lymphoma (thiotepa 200 mg/m2/day 2-h IV-infusion on HSCT Days − 4 and − 3 plus busulfan 0.8 mg/kg 2-h IV-infusion every 6 h from HSCT Days − 8 to − 5). Pharmacokinetics of thiotepa were assessed following initial dose. Safety and efficacy were also evaluated. Results Nine pediatric and 10 adult patients were enrolled. Mean volume of distribution (Vz) of thiotepa normalized with body surface area (BSA) was lower for pediatric patients (16.4 L/m2) compared with adult patients (26.4 L/m2) as expected due to the higher specific surface area of children. Clearance and biological half-life were similar between pediatric and adult patients. Two serious adverse events (cardiac arrest and pulmonary edema) were observed. Survival rate (Day 100 post-HSCT) was 77.8% (95% CI 36.5–93.9%) for pediatric patients and 100% for adult patients. Conclusion Thiotepa elimination was comparable in pediatric and adult patients with cancer. Lower Vz in pediatric compared with adult patients was expected. HDT with thiotepa prior to autologous HSCT was well tolerated. Study registration Japic CTI-163433. Electronic supplementary material The online version of this article (10.1007/s00280-019-03914-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eisei Kondo
- Department of Hematology and Oncology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
- Department of Hematology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan.
| | - Takashi Ikeda
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroaki Goto
- Hematology/Oncology and Regenerative Medicine, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Momoko Nishikori
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoko Maeda
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Kimikazu Matsumoto
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hideo Kitagawa
- Sumitomo Dainippon Pharma Co., Ltd., 6-8, Doshomachi 2-chome, Chuo-ku, Osaka, Japan
| | - Naoto Noda
- Sumitomo Dainippon Pharma Co., Ltd., 6-8, Doshomachi 2-chome, Chuo-ku, Osaka, Japan
| | - Saori Sugimoto
- Sumitomo Dainippon Pharma Co., Ltd., 6-8, Doshomachi 2-chome, Chuo-ku, Osaka, Japan
| | - Junichi Hara
- Department of Pediatric Hematology/Oncology, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
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Sekimoto H, Rikitake Y. Efficacy and safety of levetiracetam in Japanese epilepsy patients: A retrospective cohort study. J Clin Pharm Ther 2019; 44:912-923. [DOI: 10.1111/jcpt.13015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/04/2019] [Accepted: 07/14/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Hiromi Sekimoto
- Department of Pharmacy National Hospital Organization Kobe Medical Center Kobe Japan
- Laboratory of Medical Pharmaceutics Kobe Pharmaceutical University Kobe Japan
| | - Yoshiyuki Rikitake
- Laboratory of Medical Pharmaceutics Kobe Pharmaceutical University Kobe Japan
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Development of Caco-2 cells-based gene reporter assays and evaluation of herb-drug interactions involving CYP3A4 and CYP2D6 gene expression. Chem Biol Interact 2019; 303:79-89. [PMID: 30772286 DOI: 10.1016/j.cbi.2019.01.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/03/2019] [Accepted: 01/25/2019] [Indexed: 01/03/2023]
Abstract
The indiscriminate use of medicinal plants and herbal medicinal products concomitantly with conventional drugs may result in herb-drug interactions that may lead to fluctuations in drug bioavailability, therapeutic failure, and/or toxic effects. CYP450 enzymes play an important role in drug biotransformation and herb-drug interactions. Thus, the aim of this study was to develop and apply Caco-2 cells-based gene reporter assays to study in vitro the potential occurrence of CYP3A4 and CYP2D6 gene expression modulation by standardized extracts of selected medicinal plants. Reporter cell lines developed showed a significant increase in CYP3A4 and CYP2D6 reporter fluorescent emission, 4 and 16-fold respectively, when compared to the controls. The standardized extracts of Cecropia glaziovii, Bauhinia forficata and Echinacea sp. significantly increased CYP3A4 reporter fluorescence, and those of Ilex paraguariensis, Bauhinia forficata and Echinacea sp. significantly decreased CYP2D6 reporter fluorescence in Caco-2 cells-based gene reporter assays. The data obtained suggest that CYP3A4 and CYP2D6 gene expression seem to be modulated by the extracts tested. In addition, the reporter cell lines developed are functional assays that could be used to study drug-drug and herb-drug interactions during the research and development of new drugs.
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21
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Bovet L, Samer C, Daali Y. Preclinical Evaluation of Safety of Fucoidan Extracts From Undaria pinnatifida and Fucus vesiculosus for Use in Cancer Treatment. Integr Cancer Ther 2019; 18:1534735419876325. [PMID: 31522564 PMCID: PMC7242795 DOI: 10.1177/1534735419876325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Luc Bovet
- Geneva University Hospitals, Geneva, Switzerland
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Impact of Drug Interactions on Clobazam and N-Desmethylclobazam Concentrations in Pediatric Patients With Epilepsy. Ther Drug Monit 2018; 40:452-462. [PMID: 29746397 DOI: 10.1097/ftd.0000000000000530] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clobazam (CLB) is approved as adjunctive treatment for seizures associated with Lennox-Gastaut syndrome in patients aged 2 years and older. It is converted to an active metabolite N-desmethylclobazam (NCLB) by CYP3A4, which is then broken down to an inactive metabolite by CYP2C19. This study characterizes the impact of CYP3A4 and CYP2C19 drug interactions on CLB and NCLB serum concentrations (Cp) and concentration/dose (Cp/D) ratios in pediatric patients with epilepsy. METHODS This was a retrospective chart review including patients older than 1 month, who received CLB between April 2012 and March 2017. Extracted data included patient demographics, CLB daily dose, CLB and NCLB Cp, calculated CLB and NCLB Cp/Cp and Cp/D ratios, and all concomitant drugs. RESULTS The study included 995 CLB concentration sets from 302 patients (median age 7.6 years and range 0.2-40.1 years). Pharmacokinetic variability was extensive, as seen by widespread ranges of CLB and NCLB Cp, NCLB/CLB Cp ratio, and 3 Cp/D ratios (CLB, NCLB, and CLB + NCLB). Comedications, described as CYP3A4 inducers and/or CYP2C19 inhibitors (carbamazepine, eslicarbazepine, felbamate, (fos)phenytoin, oxcarbazepine, pentobarbital, phenobarbital, rufinamide, and topiramate), generally increased NCLB/CLB Cp ratio (267%-400%), NCLB Cp/D ratio (167%-202%), and CLB + NCLB Cp/D ratio (142%-185%) and decreased CLB Cp/D ratio (47%-76%) compared with a group of concentration sets in patients receiving only neutral comedications (P < 0.025 for all comparisons). Older age was associated with higher Cp/D ratios (mg/kg), indicative of decreased clearance. CONCLUSIONS Pharmacokinetic variability of CLB in pediatric patients is extensive, and it is influenced by drug-drug interactions and age. Therapeutic drug monitoring of CLB and active metabolite NCLB with calculation of various Cp/Cp and Cp/D ratios can provide useful insight into CLB pharmacokinetics and help differentiate between causes of variability.
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Fritz A, Busch D, Lapczuk J, Ostrowski M, Drozdzik M, Oswald S. Expression of clinically relevant drug-metabolizing enzymes along the human intestine and their correlation to drug transporters and nuclear receptors: An intra-subject analysis. Basic Clin Pharmacol Toxicol 2018; 124:245-255. [PMID: 30253071 DOI: 10.1111/bcpt.13137] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/18/2018] [Indexed: 12/23/2022]
Abstract
The oral bioavailability of many drugs is highly influenced not only by hepatic but also by intestinal biotransformation. To estimate the impact of intestinal phase I and II metabolism on oral drug absorption, knowledge on the expression levels of the respective enzymes is an essential prerequisite. In addition, the potential interplay of metabolism and transport contributes to drug disposition. Both mechanisms may be subjected to coordinative regulation by nuclear receptors, leading to unwanted drug-drug interactions due to induction of intestinal metabolism and transport. Thus, it was the aim of this study to comprehensively analyse the regional expression of clinically relevant phase I and II enzymes along the entire human intestine and to correlate these data to expression data of drug transporters and nuclear receptors of pharmacokinetic relevance. Gene expression of 11 drug-metabolizing enzymes (CYP2B6, 2C8, 2C9, 2C19, 2D6, 3A4, 3A5, SULT1A, UGT1A, UGT2B7, UGT2B15) was studied in duodenum, jejunum, ileum and colon from six organ donors by real-time RT-PCR. Enzyme expression was correlated with expression data of the nuclear receptors PXR, CAR and FXR as well as drug transporters observed in the same cohort. Intestinal expression of all studied metabolizing enzymes was significantly higher in the small intestine compared to colonic tissue. CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A4/5, SULT1A, UGT1A and UGT2B7 expression increased from the duodenum to jejunum but was markedly lower in the ileum. In the small intestine, that is, the predominant site of drug absorption, the highest expression has been observed for CYP3A4, CYP2C9, SULT1A and UGT1A. In addition, significant correlations were found between several enzymes and PXR as well as ABC transporters in the small intestine. In conclusion, the observed substantial site-dependent intestinal expression of several enzymes may explain regional differences in intestinal drug absorption. The detected correlations between intestinal enzymes, transporters and nuclear receptors provide indirect evidence for their coordinative expression, regulation and function in the human small intestine.
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Affiliation(s)
- Anja Fritz
- Department of Clinical Pharmacology, Center of Drug Absorption and Transport, University Medicine Greifswald, Greifswald, Germany
| | - Diana Busch
- Department of Clinical Pharmacology, Center of Drug Absorption and Transport, University Medicine Greifswald, Greifswald, Germany
| | - Joanna Lapczuk
- Department of Experimental and Clinical Pharmacology, Pomeranian Medical University, Szczecin, Poland
| | - Marek Ostrowski
- Department of General and Transplantation Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Marek Drozdzik
- Department of Experimental and Clinical Pharmacology, Pomeranian Medical University, Szczecin, Poland
| | - Stefan Oswald
- Department of Clinical Pharmacology, Center of Drug Absorption and Transport, University Medicine Greifswald, Greifswald, Germany
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An analysis of allele, genotype and phenotype frequencies, actionable pharmacogenomic (PGx) variants and phenoconversion in 5408 Australian patients genotyped for CYP2D6, CYP2C19, CYP2C9 and VKORC1 genes. J Neural Transm (Vienna) 2018; 126:5-18. [DOI: 10.1007/s00702-018-1922-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022]
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Perez Jimenez TE, Mealey KL, Schnider D, Grubb TL, Greene SA, Court MH. Identification of canine cytochrome P-450s (CYPs) metabolizing the tramadol (+)-M1 and (+)-M2 metabolites to the tramadol (+)-M5 metabolite in dog liver microsomes. J Vet Pharmacol Ther 2018; 41:815-824. [PMID: 30113702 DOI: 10.1111/jvp.12706] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/12/2022]
Abstract
We previously showed that (+)-tramadol is metabolized in dog liver to (+)-M1 exclusively by CYP2D15 and to (+)-M2 by multiple CYPs, but primarily CYP2B11. However, (+)-M1 and (+)-M2 are further metabolized in dogs to (+)-M5, which is the major metabolite found in dog plasma and urine. In this study, we identified canine CYPs involved in metabolizing (+)-M1 and (+)-M2 using recombinant enzymes, untreated dog liver microsomes (DLMs), inhibitor-treated DLMs, and DLMs from CYP inducer-treated dogs. A canine P-glycoprotein expressing cell line was also used to evaluate whether (+)-tramadol, (+)-M1, (+)-M2, or (+)-M5 are substrates of canine P-glycoprotein, thereby limiting their distribution into the central nervous system. (+)-M5 was largely formed from (+)-M1 by recombinant CYP2C21 with minor contributions from CYP2C41 and CYP2B11. (+)-M5 formation in DLMs from (+)-M1 was potently inhibited by sulfaphenazole (CYP2C inhibitor) and chloramphenicol (CYP2B11 inhibitor) and was greatly increased in DLMs from phenobarbital-treated dogs. (+)-M5 was formed from (+)-M2 predominantly by CYP2D15. (+)-M5 formation from (+)-M1 in DLMs was potently inhibited by quinidine (CYP2D inhibitor) but had only a minor impact from all CYP inducers tested. Intrinsic clearance estimates showed over 50 times higher values for (+)-M5 formation from (+)-M2 compared with (+)-M1 in DLMs. This was largely attributed to the higher enzyme affinity (lower Km) for (+)-M2 compared with (+)-M1 as substrate. (+)-tramadol, (+)-M1, (+)-M2, or (+)-M5 were not p-glycoprotein substrates. This study provides a clearer picture of the role of individual CYPs in the complex metabolism of tramadol in dogs.
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Affiliation(s)
- Tania E Perez Jimenez
- Program in Individualized Medicine (PrIMe), Department of Veterinary Clinical Sciences, Pharmacogenomics Laboratory, Washington State University College of Veterinary Medicine, Pullman, Washington
| | - Katrina L Mealey
- Program in Individualized Medicine (PrIMe), Department of Veterinary Clinical Sciences, Pharmacogenomics Laboratory, Washington State University College of Veterinary Medicine, Pullman, Washington
| | - Darren Schnider
- Program in Individualized Medicine (PrIMe), Department of Veterinary Clinical Sciences, Pharmacogenomics Laboratory, Washington State University College of Veterinary Medicine, Pullman, Washington
| | - Tamara L Grubb
- Program in Individualized Medicine (PrIMe), Department of Veterinary Clinical Sciences, Pharmacogenomics Laboratory, Washington State University College of Veterinary Medicine, Pullman, Washington
| | - Stephen A Greene
- Program in Individualized Medicine (PrIMe), Department of Veterinary Clinical Sciences, Pharmacogenomics Laboratory, Washington State University College of Veterinary Medicine, Pullman, Washington
| | - Michael H Court
- Program in Individualized Medicine (PrIMe), Department of Veterinary Clinical Sciences, Pharmacogenomics Laboratory, Washington State University College of Veterinary Medicine, Pullman, Washington
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Rodieux F, Vutskits L, Posfay-Barbe KM, Habre W, Piguet V, Desmeules JA, Samer CF. When the Safe Alternative Is Not That Safe: Tramadol Prescribing in Children. Front Pharmacol 2018; 9:148. [PMID: 29556194 PMCID: PMC5844975 DOI: 10.3389/fphar.2018.00148] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 02/13/2018] [Indexed: 01/10/2023] Open
Abstract
Children represent a vulnerable population in which management of nociceptive pain is complex. Drug responses in children differ from adults due to age-related differences. Moreover, therapeutic choices are limited by the lack of indication for a number of analgesic drugs due to the challenge of conducting clinical trials in children. Furthermore the assessment of efficacy as well as tolerance may be complicated by children's inability to communicate properly. According to the World Health Organization, weak opioids such as tramadol and codeine, may be used in addition to paracetamol and ibuprofen for moderate nociceptive pain in both children and adults. However, codeine prescription has been restricted for the last 5 years in children because of the risk of fatal overdoses linked to the variable activity of cytochrome P450 (CYP) 2D6 which bioactivates codeine. Even though tramadol has been considered a safe alternative to codeine, it is well established that tramadol pharmacodynamic opioid effects, efficacy and safety, are also largely influenced by CYP2D6 activity. For this reason, the US Food and Drug Administration recently released a boxed warning regarding the use of tramadol in children. To provide safe and effective tramadol prescription in children, a personalized approach, with dose adaptation according to CYP2D6 activity, would certainly be the safest method. We therefore recommend this approach in children requiring chronic or recurrent nociceptive pain treatment with tramadol. In case of acute inpatients nociceptive pain management, prescribing tramadol at the minimal effective dose, in a child appropriate dosage form and after clear instructions are given to the parents, remains reasonable based on current data. In all other situations, morphine should be preferred for moderate to severe nociceptive pain conditions.
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Affiliation(s)
- Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,Department of Basic Neuroscience, Faculty of Medicine, University of GenevaGeneva, Switzerland.,Division of Anesthesiology, Unit for Pediatric Anesthesia, Children's Hospitals of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Klara M Posfay-Barbe
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Children's Hospital of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Walid Habre
- Division of Anesthesiology, Unit for Pediatric Anesthesia, Children's Hospitals of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,Anesthesiological Investigations Unit, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Valérie Piguet
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of LausanneGeneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
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Effects of UGT2B7 Genetic Polymorphisms on Serum Concentrations of Valproic Acid in Chinese Children With Epilepsy Comedicated With Lamotrigine. Ther Drug Monit 2017; 38:343-9. [PMID: 26717295 DOI: 10.1097/ftd.0000000000000271] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Valproic acid (VPA) is widely used in the treatment of children with epilepsy. Genetic polymorphisms in genes encoding drug-metabolizing enzymes may be an important source of interindividual variability in VPA metabolism. VPA is a substrate of uridine diphosphate glucuronosyltransferase 2B7 (UGT2B7). In this study, we seek to evaluate the effects of genetic polymorphisms of the UGT2B7 gene on serum VPA concentrations in epileptic children comedicated with lamotrigine (LTG). METHODS We recruited 166 Chinese children with epilepsy who were treated with VPA in combination with LTG. Serum VPA and LTG concentrations were measured by fluorescence polarization immunoassay and high performance liquid chromatography, respectively. The UGT2B7 -161C > T in the 5'-upstream regions and 211 G > T, 372A > G, 735A > G, and 802C > T in the coding regions were genotyped using polymerase chain reaction amplification followed by direct automated DNA sequencing. RESULTS Our data show that patients carrying the variant UGT2B7 -161C > T or 802C > T genotypes had significantly higher adjusted VPA concentrations than those carrying the wild-type genotypes. The significant associations were potentiated after adjusted by age and adjusted LTG concentration. However, no associations were detected between the other studied UGT2B7 genotypes and adjusted VPA concentrations, even after adjusting by age and comedication. CONCLUSIONS These results suggest that the UGT2B7 -161C > T or 802C > T mutations affect VPA pharmacokinetics, which are potentially enhanced by age and concomitant LTG administration. These findings provide a potential mechanism underlying interindividual variation in the disposition of VPA in combination with LTG.
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No clinically meaningful pharmacokinetic interaction between the hepatitis C virus inhibitors elbasvir and grazoprevir and the oral contraceptives ethinyl estradiol and levonorgestrel. Eur J Clin Pharmacol 2017; 73:593-600. [DOI: 10.1007/s00228-017-2216-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/06/2017] [Indexed: 01/07/2023]
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Abstract
BACKGROUND Lamotrigine is an anticonvulsant as well as a mood stabilizer. Apart from its established use in the treatment of epilepsy, there has been an expansion of its use in the treatment of mental disorders. Patients with epilepsy as well as those with mental disorders are at increased risk of deliberate drug overdoses. An evidence base for the safety profile of lamotrigine in overdose is an essential tool for prescribers. The objective of this study was to carry out a narrative synthesis of the existing evidence for the safety profile of lamotrigine in overdose. METHODS A systematic search was conducted of EMBASE (1974 to December 2015), MEDLINE (1946 to December 2015), PsycINFO (1806 to December 2015) and CINAHL (1981 to December 2015) databases. Studies were included in which there was a deliberate or accidental single drug overdose of lamotrigine, with its toxic effects described. Studies that did not involve an overdose were excluded. A narrative synthesis of the described toxic effects was carried out. RESULTS Out of 562 articles identified, 26 studies were included, mainly in the form of case reports and series. The most commonly described toxic effects of lamotrigine were on the central nervous system, specifically seizures, movement disorders and reduced consciousness. Other toxic effects included QTc interval and QRS complex prolongations, hypersensitivity reactions, serotonin syndrome as well as rhabdomyolysis possibly due to seizures and/or agitation. Deaths were recorded in two studies, with cardiovascular and neurological toxic effects described. CONCLUSIONS Even though lamotrigine has been reported to be well tolerated, there is a risk of toxic effects which can be life threatening in overdose. This needs to be borne in mind when prescribing to patients at an increased risk of deliberate drug overdose.
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Affiliation(s)
| | - Adam Todd
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, UK
| | - Andrew Husband
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, UK
| | - Joe Reilly
- Professor of Mental Health, School of Medicine, Pharmacy and Health, Wolfson Research Institute, Queen's Campus University Boulevard, Thornaby, Stockton-On-Tees TS17 6BH, UK
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Fan HC, Lee HS, Chang KP, Lee YY, Lai HC, Hung PL, Lee HF, Chi CS. The Impact of Anti-Epileptic Drugs on Growth and Bone Metabolism. Int J Mol Sci 2016; 17:E1242. [PMID: 27490534 PMCID: PMC5000640 DOI: 10.3390/ijms17081242] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/20/2016] [Accepted: 07/28/2016] [Indexed: 12/13/2022] Open
Abstract
Epilepsy is a common neurological disorder worldwide and anti-epileptic drugs (AEDs) are always the first choice for treatment. However, more than 50% of patients with epilepsy who take AEDs have reported bone abnormalities. Cytochrome P450 (CYP450) isoenzymes are induced by AEDs, especially the classical AEDs, such as benzodiazepines (BZDs), carbamazepine (CBZ), phenytoin (PT), phenobarbital (PB), and valproic acid (VPA). The induction of CYP450 isoenzymes may cause vitamin D deficiency, hypocalcemia, increased fracture risks, and altered bone turnover, leading to impaired bone mineral density (BMD). Newer AEDs, such as levetiracetam (LEV), oxcarbazepine (OXC), lamotrigine (LTG), topiramate (TPM), gabapentin (GP), and vigabatrin (VB) have broader spectra, and are safer and better tolerated than the classical AEDs. The effects of AEDs on bone health are controversial. This review focuses on the impact of AEDs on growth and bone metabolism and emphasizes the need for caution and timely withdrawal of these medications to avoid serious disabilities.
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Affiliation(s)
- Hueng-Chuen Fan
- Department of Pediatrics, Tungs' Taichung Metroharbor Hospital, Wuchi, 435 Taichung, Taiwan.
- Department of Nursing, Jen-Teh Junior College of Medicine, Nursing and Management, 356 Miaoli, Taiwan.
| | - Herng-Shen Lee
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, 813 Kaohsiung, Taiwan.
| | - Kai-Ping Chang
- Department of Pediatrics, Taipei Veterans General Hospital, 112 Taipei, Taiwan.
| | - Yi-Yen Lee
- Division of Pediatric Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 112 Taipei, Taiwan.
- Faculty of Medicine, National Yang-Ming University, 112 Taipei, Taiwan.
| | - Hsin-Chuan Lai
- Department of Pediatrics, Tungs' Taichung Metroharbor Hospital, Wuchi, 435 Taichung, Taiwan.
- Department of Nursing, Jen-Teh Junior College of Medicine, Nursing and Management, 356 Miaoli, Taiwan.
| | - Pi-Lien Hung
- Department of Pediatrics, Kaohsiung Chang Gung Medical Center, 833 Kaohsiung, Taiwan.
| | - Hsiu-Fen Lee
- Department of Pediatrics, Taichung Veterans General Hospital, 407 Taichung, Taiwan.
| | - Ching-Shiang Chi
- Department of Pediatrics, Tungs' Taichung Metroharbor Hospital, Wuchi, 435 Taichung, Taiwan.
- Department of Nursing, Jen-Teh Junior College of Medicine, Nursing and Management, 356 Miaoli, Taiwan.
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de Andrés F, Lionetto L, Curto M, Capi M, Cipolla F, Negro A, Martelletti P. Acute, transitional and long-term cluster headache treatment: pharmacokinetic issues. Expert Opin Drug Metab Toxicol 2016; 12:1011-20. [DOI: 10.1080/17425255.2016.1201067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Fernando de Andrés
- CICAB Clinical Research Centre, Extremadura University Hospital and Medical School, Badajoz, Spain
| | - Luana Lionetto
- Advanced Molecular Diagnostics Unit, IDI-IRCCS, Rome, Italy
| | - Martina Curto
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Matilde Capi
- NESMOS Department, Sapienza University of Rome, Rome, Italy
| | | | - Andrea Negro
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
| | - Paolo Martelletti
- Department of Molecular Medicine, Sant’Andrea Medical Center, Sapienza University of Rome, Rome, Italy
- Regional Referral Headache Center, Sant’Andrea Hospital, Rome, Italy
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Starting, Choosing, Changing, and Discontinuing Drug Treatment for Epilepsy Patients. Neurol Clin 2016; 34:363-81, viii. [DOI: 10.1016/j.ncl.2015.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Farooq M, Kelly EJ, Unadkat JD. CYP2D6 Is Inducible by Endogenous and Exogenous Corticosteroids. Drug Metab Dispos 2016; 44:750-7. [PMID: 26965986 PMCID: PMC4851303 DOI: 10.1124/dmd.115.069229] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/09/2016] [Indexed: 12/21/2022] Open
Abstract
Although cytochrome P450 (CYP) 2D6 has been widely considered to be noninducible on the basis of human hepatocyte studies, in vivo data suggests that it is inducible by endo- and xenobiotics. Therefore, we investigated if the experimental conditions routinely used in human hepatocyte studies may be a confounding factor in the lack of in vitro induction of CYP2D6. Sandwich cultured human hepatocytes (SCHH) were preincubated with or without dexamethasone (100 nM) for 72 hours before incubation with 1μM endogenous (cortisol or corticosterone) or exogenous (dexamethasone or prednisolone) corticosteroids. At 72 hours, CYP2D6 mRNA, protein, and activity were quantified by real-time quantitative polymerase chain reaction, quantitative proteomics, and formation of dextrorphan from dextromethorphan, respectively. In the absence of supplemental dexamethasone, CYP2D6 activity, mRNA, and protein were significantly and robustly (>10-fold) induced by all four corticosteroids. However, this CYP2D6 induction was abolished in cells preincubated with supplemental dexamethasone. These data show, for the first time, that CYP2D6 is inducible in vitro but the routine presence of 100 nM dexamethasone in the culture medium masks this induction. Our cortisol data are in agreement with the clinical observation that CYP2D6 is inducible during the third trimester of pregnancy when the plasma concentrations of cortisol increase to ∼1μM. These findings, if confirmed in vivo, have implications for predicting CYP2D6-mediated drug-drug interactions and call for re-evaluation of regulatory guidelines on screening for CYP2D6 induction by xenobiotics. Our findings also suggest that cortisol may be a causative factor in the in vivo induction of CYP2D6 during pregnancy.
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Affiliation(s)
- Muhammad Farooq
- Department of Pharmaceutics, University of Washington, Seattle, Washington
| | - Edward J Kelly
- Department of Pharmaceutics, University of Washington, Seattle, Washington
| | - Jashvant D Unadkat
- Department of Pharmaceutics, University of Washington, Seattle, Washington
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Lionetto L, Borro M, Curto M, Capi M, Negro A, Cipolla F, Gentile G, Martelletti P. Choosing the safest acute therapy during chronic migraine prophylactic treatment: pharmacokinetic and pharmacodynamic considerations. Expert Opin Drug Metab Toxicol 2016; 12:399-406. [DOI: 10.1517/17425255.2016.1154042] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Antiepileptic drugs (AEDs) are routinely prescribed for the management of a variety of neurologic and psychiatric conditions, including epilepsy and epilepsy syndromes. Physiologic changes due to aging, pregnancy, nutritional status, drug interactions, and diseases (ie, those involving liver and kidney function) can affect pharmacokinetics of AEDs. This review discusses foundational pharmacokinetic characteristics of AEDs currently available in the United States, including clobazam but excluding the other benzodiazepines. Commonalities of pharmacokinetic properties of AEDs are discussed in detail. Important differences among AEDs and clinically relevant pharmacokinetic interactions in absorption, distribution, metabolism, and/or elimination associated with AEDs are highlighted. In general, newer AEDs have more predictable kinetics and lower risks for drug interactions. This is because many are minimally or not bound to serum proteins, are primarily renally cleared or metabolized by non–cytochrome P450 isoenzymes, and/or have lower potential to induce/inhibit various hepatic enzyme systems. A clear understanding of the pharmacokinetic properties of individual AEDs is essential in creating a safe and effective treatment plan for a patient.
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Affiliation(s)
- Marketa Marvanova
- Chair and Associate Professor, College of Health Professions, School of Pharmacy, North Dakota State University, Fargo, North Dakota,
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Hanaya R, Arita K. The New Antiepileptic Drugs: Their Neuropharmacology and Clinical Indications. Neurol Med Chir (Tokyo) 2016; 56:205-20. [PMID: 26935782 PMCID: PMC4870175 DOI: 10.2176/nmc.ra.2015-0344] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The administration of antiepileptic drugs (AEDs) is the first treatment of epilepsy, one of the most common neurological diseases. Therapeutic guidelines include newer AEDs as front-line drugs; monotherapy with new AEDs is delivered in Japan. While about 70% of patients obtain good seizure control by taking one to three AEDs, about 60% experience adverse effects and 33% have to change drugs. Compared to traditional AEDs, the prolonged administration of new AEDs elicits fewer adverse effects and fewer drug interactions and their teratogenicity may be lower. These characteristics increase drug compliance and allow combination therapy for drug-resistant epilepsy, although the antiepileptic effects of the new AEDs are not greater than of traditional AEDs. Comorbidities are not rare in epileptics; many adult patients present with stroke and brain tumors. In stroke patients requiring risk control and in chemotherapy-treated brain tumor patients, their fewer drug interactions render the new AEDs advantageous. Also, new AEDs offer favorable side benefits for concurrent diseases and conditions. Patients with stroke and traumatic brain injury often present with psychiatric/behavioral symptoms and cognitive impairment and some new AEDs alleviate such symptoms. This review presents an outline of the new AEDs used to treat adult patients based on the pharmacological activity of the drugs and discusses possible clinical indications from the perspective of underlying causative diseases and comorbidities.
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Affiliation(s)
- Ryosuke Hanaya
- Department of Neurosurgery, Kagoshima University Graduate School of Medical and Dental Sciences
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Jacobson L. Hypothalamic-pituitary-adrenocortical axis: neuropsychiatric aspects. Compr Physiol 2014; 4:715-38. [PMID: 24715565 DOI: 10.1002/cphy.c130036] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Evidence of aberrant hypothalamic-pituitary-adrenocortical (HPA) activity in many psychiatric disorders, although not universal, has sparked long-standing interest in HPA hormones as biomarkers of disease or treatment response. HPA activity may be chronically elevated in melancholic depression, panic disorder, obsessive-compulsive disorder, and schizophrenia. The HPA axis may be more reactive to stress in social anxiety disorder and autism spectrum disorders. In contrast, HPA activity is more likely to be low in PTSD and atypical depression. Antidepressants are widely considered to inhibit HPA activity, although inhibition is not unanimously reported in the literature. There is evidence, also uneven, that the mood stabilizers lithium and carbamazepine have the potential to augment HPA measures, while benzodiazepines, atypical antipsychotics, and to some extent, typical antipsychotics have the potential to inhibit HPA activity. Currently, the most reliable use of HPA measures in most disorders is to predict the likelihood of relapse, although changes in HPA activity have also been proposed to play a role in the clinical benefits of psychiatric treatments. Greater attention to patient heterogeneity and more consistent approaches to assessing treatment effects on HPA function may solidify the value of HPA measures in predicting treatment response or developing novel strategies to manage psychiatric disease.
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Hashi S, Yano I, Shibata M, Masuda S, Kinoshita M, Matsumoto R, Ikeda A, Takahashi R, Matsubara K. Effect of CYP2C19 polymorphisms on the clinical outcome of low-dose clobazam therapy in Japanese patients with epilepsy. Eur J Clin Pharmacol 2014; 71:51-8. [DOI: 10.1007/s00228-014-1773-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 10/09/2014] [Indexed: 10/24/2022]
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Pharmakokinetische Wechselwirkungen illegaler Drogen mit Arzneimitteln. Rechtsmedizin (Berl) 2014. [DOI: 10.1007/s00194-013-0935-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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MacLaughlan David S, Salzillo S, Bowe P, Scuncio S, Malit B, Raker C, Gass JS, Granai CO, Dizon DS. Randomised controlled trial comparing hypnotherapy versus gabapentin for the treatment of hot flashes in breast cancer survivors: a pilot study. BMJ Open 2013; 3:e003138. [PMID: 24022390 PMCID: PMC3773636 DOI: 10.1136/bmjopen-2013-003138] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To compare the efficacy of hypnotherapy versus gabapentin for the treatment of hot flashes in breast cancer survivors, and to evaluate the feasibility of conducting a clinical trial comparing a drug with a complementary or alternative method (CAM). DESIGN Prospective randomised trial. SETTING Breast health centre of a tertiary care centre. PARTICIPANTS 15 women with a personal history of breast cancer or an increased risk of breast cancer who reported at least one daily hot flash. INTERVENTIONS Gabapentin 900 mg daily in three divided doses (control) compared with standardised hypnotherapy. Participation lasted 8 weeks. OUTCOME MEASURES The primary endpoints were the number of daily hot flashes and hot flash severity score (HFSS). The secondary endpoint was the Hot Flash Related Daily Interference Scale (HFRDIS). RESULTS 27 women were randomised and 15 (56%) were considered evaluable for the primary endpoint (n=8 gabapentin, n=7 hypnotherapy). The median number of daily hot flashes at enrolment was 4.5 in the gabapentin arm and 5 in the hypnotherapy arm. HFSS scores were 7.5 in the gabapentin arm and 10 in the hypnotherapy arm. After 8 weeks, the median number of daily hot flashes was reduced by 33.3% in the gabapentin arm and by 80% in the hypnotherapy arm. The median HFSS was reduced by 33.3% in the gabapentin arm and by 85% in the hypnotherapy arm. HFRDIS scores improved by 51.6% in the gabapentin group and by 55.2% in the hypnotherapy group. There were no statistically significant differences between groups. CONCLUSIONS Hypnotherapy and gabapentin demonstrate efficacy in improving hot flashes. A definitive trial evaluating traditional interventions against CAM methods is feasible, but not without challenges. Further studies aimed at defining evidence-based recommendations for CAM are necessary. TRIAL REGISTRATION clinicaltrials.gov (NCT00711529).
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Affiliation(s)
- Shannon MacLaughlan David
- Department of Obstetrics and Gynecology, Stanford Women's Cancer Center, Stanford University, Stanford, California, USA
| | - Sandra Salzillo
- Program in Women's Oncology, Women & Infants Hospital, Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Patrick Bowe
- Providence Hypnosis Center, Providence, Rhode Island, USA
| | - Sandra Scuncio
- Program in Women's Oncology, Women & Infants Hospital, Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Bridget Malit
- Department of Pediatrics, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Christina Raker
- Program in Women's Oncology, Women & Infants Hospital, Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Jennifer S Gass
- Program in Women's Oncology, Women & Infants Hospital, Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - C O Granai
- Program in Women's Oncology, Women & Infants Hospital, Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Don S Dizon
- Department of Internal Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
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Kirby BJ, Collier AC, Kharasch ED, Dixit V, Desai P, Whittington D, Thummel KE, Unadkat JD. Complex drug interactions of HIV protease inhibitors 2: in vivo induction and in vitro to in vivo correlation of induction of cytochrome P450 1A2, 2B6, and 2C9 by ritonavir or nelfinavir. Drug Metab Dispos 2011; 39:2329-37. [PMID: 21930825 DOI: 10.1124/dmd.111.038646] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Drug-drug interactions (DDIs) with the HIV protease inhibitors (PIs) are complex, paradoxical (e.g., ritonavir/alprazolam), and involve multiple mechanisms. As part of a larger study to better understand these DDIs and to devise a framework for in vitro to in vivo prediction of these DDIs, we determined the inductive effect of ∼2 weeks of administration of two prototypic PIs, nelfinavir (NFV), ritonavir (RTV), and rifampin (RIF; induction positive control) on the cytochrome P450 enzymes CYP1A2, CYP2B6, CYP2C9, and CYP2D6 and the inductive or inductive plus inhibitory effect of NFV, RTV, or RIF on CYP3A and P-glycoprotein in healthy human volunteers. Statistically significant induction of CYP1A2 (2.1-, 2.9-, and 2.2-fold), CYP2B6 (1.8-, 2.4-, and 4-fold), and CYP2C9 (1.3-, 1.8-, and 2.6-fold) was observed after NFV, RTV, or RIF treatment, respectively (as expected, CYP2D6 was not induced). Moreover, we accurately predicted the in vivo induction of these enzymes by quantifying their induction by the PIs in human hepatocytes and by using RIF as an in vitro to in vivo scalar. On the basis of the modest in vivo induction of CYP1A2, CYP2B6, or CYP2C9, the in vivo paradoxical DDIs with the PIs are likely explained by mechanisms other than induction of these enzymes such as induction of other metabolic enzymes, transporters, or both.
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Affiliation(s)
- Brian J Kirby
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
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Ferrari A, Tiraferri I, Neri L, Sternieri E. Clinical pharmacology of topiramate in migraine prevention. Expert Opin Drug Metab Toxicol 2011; 7:1169-81. [PMID: 21756204 DOI: 10.1517/17425255.2011.602067] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Migraine is a widespread disorder. Migraine patients experience worse health-related quality of life than the general population. The availability of effective and tolerable treatments for this disorder is an important medical need. This narrative review focuses on the clinical pharmacology of topiramate, an antiepileptic drug that was approved for the prophylaxis of migraine where it should act as a neuromodulator. AREAS COVERED A PubMed database search (from 2000 to 24 January 2011) and a review of the human studies published on topiramate and migraine was conducted. EXPERT OPINION Topiramate is an important option for the prophylaxis of migraine and is of proven efficacy and tolerability. It has also been studied in chronic migraine with encouraging results, even in patients with medication overuse. However, in migraine prevention its efficacy is comparable to the other first-line drugs and there are no published trials with a superiority design which can establish topiramate's role in the available therapeutic armamentarium.
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Affiliation(s)
- Anna Ferrari
- University of Modena and Reggio Emilia, Headache and Drug Abuse Inter-Dep. Research Centre, Division of Toxicology and Clinical Pharmacology, Modena, Italy.
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Affiliation(s)
- Julien Dubois
- Université de Toulouse, Centre de Recherche Cerveau et Cognition, Université Paul Sabatier, Toulouse, France.
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Abstract
Interindividual differences in drug transporter expression can result in variability in drug response. This variation in gene expression is determined, in part, by the actions of nuclear hormone receptors that act as xenobiotic- and endobiotic-sensing transcription factors. Among the ligand-activated nuclear receptors, signaling through the pregnane X receptor (PXR), constitutive androstane receptor (CAR), farnesoid X receptor (FXR), and vitamin D receptor (VDR) constitute major pathways regulating drug transporter expression in tissues. Hence, these endobiotic- and xenobiotic-sensing nuclear receptors are intrinsically involved in environmental influences of drug response. Moreover, because nuclear receptor genes are polymorphic, these transcription factors are also thought to contribute to heritability of variable drug action. In this chapter, the molecular aspects of drug transporter gene regulation by ligand-activated nuclear receptors will be reviewed including their clinical relevance.
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Pharmaco-EEG-based assessment of the interaction between ethanol and oxcarbazepine. Pharmacol Rep 2010; 62:278-86. [DOI: 10.1016/s1734-1140(10)70267-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 10/19/2009] [Indexed: 11/17/2022]
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Jaeckle KA, Ballman K, Furth A, Buckner JC. Correlation of enzyme-inducing anticonvulsant use with outcome of patients with glioblastoma. Neurology 2009; 73:1207-13. [PMID: 19822870 DOI: 10.1212/wnl.0b013e3181bbfeca] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Clinical trials involving patients with glioblastoma (GBM) distinguish cohorts who are treated with enzyme-inducing anticonvulsants (EIAC). Such anticonvulsants induce hepatic P450 microsomal enzymes, which accelerate the metabolism of certain chemotherapy and molecular targeted agents. However, the resultant effect of such induction on patient outcome has received limited study. METHODS We performed a correlative analysis of baseline EIAC use with outcome, using a cross-sectional database of 620 patients with newly diagnosed GBM treated prospectively on North Central Cancer Treatment Group trials. RESULTS At registration, 72% were receiving treatment with EIAC; 2% were receiving non-EIACs, and the 26% were not receiving anticonvulsants (26%). Surprisingly, in the multivariable Cox model, overall survival (OS) and progression-free survival (PFS) showed a positive correlation with EIAC use (hazard ratio [HR] = 0.75, p = 0.0028 and HR = 0.80, p = 0.022), even after adjustment for the known prognostic factors of age, performance status, extent of resection, steroid use, and baseline neurocognitive function. Specifically, the median OS was longer in EIAC compared with non-EIAC patients (12.3 vs 10.7 months, p = 0.0002). Similarly, PFS was longer in EIAC patients (5.6 vs 4.8 months, p = 0.003). No differences in median OS or PFS were observed when comparing patients with or without a history of seizures at baseline. CONCLUSIONS Paradoxically, enzyme-inducing anticonvulsant (EIAC) use correlated with superior outcome of patients with glioblastoma. These results suggest that in comparative clinical trials testing agents metabolized by P450 microsomal enzymes, treatment arms may need stratification for the proportion of patients receiving EIAC.
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Zuin M, Giorgini A, Selmi C, Battezzati PM, Cocchi CA, Crosignani A, Benetti A, Invernizzi P, Podda M. Acute liver and renal failure during treatment with buprenorphine at therapeutic dose. Dig Liver Dis 2009; 41:e8-e10. [PMID: 18294936 DOI: 10.1016/j.dld.2007.12.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Revised: 12/14/2007] [Accepted: 12/17/2007] [Indexed: 12/11/2022]
Abstract
Buprenorphine is a semi-synthetic opioid derivative commonly used in the treatment of heroin addiction. Life-threatening complications have been described following overdoses while few cases of hepatotoxicity due to drug use at therapeutic doses have been recently described in hepatitis C virus carriers. In these cases, however, histological assessment was not exhaustive and no extra-hepatic organ failure was observed. We describe herein a case of acute liver and kidney failure in a patient with previously latent hepatitis C virus chronic infection following recommended doses of buprenorphine. Histology did not demonstrate any feature compatible with hepatitis C virus reactivation or liver cirrhosis and suspension of the treatment led to the resolution of both liver and kidney failure. Causality criteria fulfillment indicates a high probability of buprenorphine-induced liver toxicity. No signs of pre-existant kidney impairment or of pre- or post-renal causes were observed. Since buprenorphine is metabolized through cytochrome P450 3A4, we genotyped six genetic polymorphisms previously described in poor metabolizers but could not confirm these pharmacogenetic bases in this case. In conclusion, we surmise that buprenorphine at suggested doses can induce liver and kidney failure in susceptible individuals, possibly through direct mitochondrial toxicity.
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Affiliation(s)
- M Zuin
- Department of Medicine, Division of Internal Medicine, San Paolo School of Medicine, University of Milan, Milan, Italy.
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Abstract
The modern antiepileptic drug (AED) era--spanning a period of more than 150 years from the first use of bromide in 1857 to 2008--has seen the introduction into clinical practice of a diverse group of effective and safe drugs. These AEDs have provided considerable benefits for those afflicted with epilepsy of all kinds. In as many as 60-70% of newly treated patients, current AEDs lead to satisfactory control of seizures and a favorable risk-benefit balance for the great majority of patients, albeit with considerable differences in response depending on the type of seizure and epilepsy syndrome and rare serious adverse events. Unfortunately, in 20-30% of patients, epilepsy cannot be controlled. Patients with drug-resistant epilepsy often have serious comorbidity, including injury, depression, anxiety, and increased mortality. The aim of antiepileptic treatment should be to control seizures as quickly as possible with no or minimal side effects and with no negative impact on the quality of life. Improved seizure control is likely to reduce the morbidity and increased mortality associated with uncontrolled epilepsy. In this short overview, the options and the limitations of treating patients with epilepsy are briefly summarized.
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