Lamotrigine-induced severe cutaneous adverse reactions

Effects of dosage in new users of lamotrigine inducing epidermal necrolysis: Results of the German Registry of Severe Skin Reactions

OBJECTIVE

This study was undertaken to determine the impact of dosage in new users of lamotrigine (LTG) and the concomitant intake of valproic acid (VPA) on epidermal necrolysis (EN).

METHODS

A total of 102 EN cases with exposure to LTG were identified (1992-2018) in the German Registry of Severe Skin Reactions. All cases are validated by an independent expert committee. Six cases were excluded due to lack of exposure in the relevant time frame. Causality assessment was performed with ALDEN (Algorithm for Assessment of Drug Causality in EN) on definite/probable cases (≥12 years; n = 84). Evaluation of dosing regimen was restricted to cases with complete LTG dosing history (n = 74).

RESULTS

Demography showed a mean age of 42.4 years, female predominance (69%), and low mortality (7.3%). Epilepsy was the indication for use in 87.5%. LTG was the very probable cause in 71.4% and probable cause in 28.6%. On average, one additional antiseizure medication was taken, most frequently VPA (43/84). Combined LTG/VPA treatment showed no statistically significant difference in morbidity or mortality. Mean time latency from initiation of LTG to reaction onset was 24.2 days, varying between 21 days with high initial dose and 29.2 days with low initial dose. Low initial LTG dose (n = 9) revealed higher mortality (22.2%) and higher severity (5/9) than high initial dose (n = 35, mortality = 14.3%, 14/35 higher severity). No patient died when the starting dose was as recommended. The highest mortality (25%) was found in patients with no dose increase (n = 8), which correlated with higher age. Despite the recommended or low initial dose, 52.7% of patients developed EN, in contrast to 39.2% with a slow, recommended, or no dose escalation.

SIGNIFICANCE

Neither the initial dose, dose escalation, nor the combination with VPA seems to influence the general occurrence of EN. However, EN patients with the recommended starting dose and the recommended dose escalation had the best outcome in terms of clinical severity and mortality.

Lamotrigine-induced neutropenia after high-dose concomitant initiation with phenytoin

Lamotrigine has been repeatedly reported to cause hematologic toxicities, which may be associated with high initial doses or excessive escalation. A 29-year-old lady experienced profound neutropenia after two weeks of lamotrigine high initial dose, started within two days of phenytoin. The too-early dose intensification may have produced lamotrigine-induced blood dyscrasia.

The use of biostatic human amnion and platelet-rich plasma in topical treatment of toxic epidermal necrolysis-A case report

BACKGROUND

Toxic epidermal necrolysis (TEN) (also known as Lyell syndrome) and Stevens-Johnson syndrome (SJS) are life-threatening mucocutaneous blistering diseases. They are characterized by generalized blisters and epidermal inflammation, most likely resulting from the administration or interaction of medicines.

AIMS

To report potential new method in the treatment of TEN.

PATIENTS/METHODS

This article presents a case report of a 35-year-old man suffering from TEN covering about 95% of his body surface. Lesions occurred in the patient during antiepileptic therapy, after taking simultaneously amoxicillin (with clavulanic acid) and naproxen followed by lamotrigine treatment. Standard general treatment was performed. Intravenous feeding was necessary. Due to acute respiratory failure, the patient required mechanical ventilation. Two methods were combined in topical treatment: application of platelet-rich plasma (PRP) and a simultaneous biostatic human amnion transplant.

RESULTS

In the presented case, the combination of both methods contributed to a significant acceleration of wound healing. After the application of PRP and biostatic amnion transplantation, the healing of wounds on the back and posterior surfaces of the legs was completed after six days. The surgical treatment most probably contributed to a significant acceleration of wound healing.

CONCLUSION

The case report shows that topical TEN/SJS treatment with biostatic human amnion and PRP has a positive clinical effect and may be a new method of treatment of TEN.

Drug-drug interactions and clinical considerations with co-administration of antiretrovirals and psychotropic drugs

Psychotropic medications are frequently co-prescribed with antiretroviral therapy (ART), owing to a high prevalence of psychiatric illness within the population living with HIV, as well as a 7-fold increased risk of HIV infection among patients with psychiatric illness. While ART has been notoriously associated with a multitude of pharmacokinetic drug interactions involving the cytochrome P450 enzyme system, the magnitude and clinical impact of these interactions with psychotropics may range from negligible effects on plasma concentrations to life-threatening torsades de pointes or respiratory depression. This comprehensive review summarizes the currently available information regarding drug-drug interactions between antiretrovirals and pharmacologic agents utilized in the treatment of psychiatric disorders-antidepressants, stimulants, antipsychotics, anxiolytics, mood stabilizers, and treatments for opioid use disorder and alcohol use disorder-and provides recommendations for their management. Additionally, overlapping toxicities between antiretrovirals and the psychotropic classes are highlighted. Knowledge of the interaction and adverse effect potential of specific antiretrovirals and psychotropics will allow clinicians to make informed prescribing decisions to better promote the health and wellness of this high-risk population.

[Severe skin reactions due to new medications]

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and a specific form of hypersensitivity syndrome which is nowadays called "drug reaction with eosinophilia and systemic symptoms" (DRESS) are severe, mainly drug-induced skin reactions. Whereas SJS/TEN is considered one reaction entity of different severity, DRESS has to be distinguished from SJS/TEN but also from other severe exanthems due to multiorgan involvement. Although SJS/TEN is generally referred to as drug reaction, in total only about three quarters of the cases are actually caused by drugs. After the clinical diagnosis is made, identification of the potential inducing factor is most important. In case medications are considered as causal, their withdrawal plays a key role in management. In order to identify and withdraw the inducing agent, a detailed and thorough medication history must be obtained. Agents identified or confirmed as inducers of SJS/TEN by pharmacoepidemiological studies are allopurinol, antibacterial sulfonamides, various antiepileptics, nevirapine and nonsteroidal anti-inflammatory drugs of the oxicam-type. Among drugs inducing DRESS are also various antiepileptics, but in addition allopurinol, sulfonamides and minocycline. Some cases of SJS/TEN and DRESS associated with the use of new medication, including targeted therapies and biologicals, have been observed.

Retrospective review of paediatric case reports of Stevens-Johnson syndrome and toxic epidermal necrolysis with lamotrigine from an international pharmacovigilance database

OBJECTIVES

This study aims to characterise paediatric reports with lamotrigine (LTG) and Stevens-Johnson syndrome or toxic epidermal necrolysis (SJS/TEN), and to explore whether potential risk factors can be identified.

DESIGN

This is a retrospective review of suspected adverse drug reaction (ADR) reports. Reported time from LTG start to SJS/TEN onset, indication for use and dose was explored. To identify potential risk groups, report features (eg, ages, patient sex, co-reported drugs) for LTG and SJS/TEN were contrasted with two reference groups in the same database, using shrinkage logOR.

SETTING

Reports were retrieved from VigiBase, the WHO global database of individual case safety reports, in January 2015.

PATIENTS

Data for patients aged ≤17 years old were extracted.

RESULTS

There were 486 reports of SJS/TEN in LTG-treated paediatric patients. Ninety-seven per cent of the cases with complete information on time to onset of SJS/TEN occurred within 8 weeks of initiation of LTG therapy. The median time to onset was 15 days (IQR: 10-22 days). The proportion of SJS/TEN with LTG and valproic acid (VPA) co-reporting was significantly more than non-cutaneous ADRs (43% vs 19%, (logOR: 1.60 (99% CI: 1.33 to 1.84)).

CONCLUSIONS

The results suggest that VPA co-medication with LTG therapy is a risk factor for SJS/TEN in the paediatric population. Although this relationship has been identified from individual case reports, this is the first supportive study from a large compilation of cases. SJS/TEN risk is highest in first 8 weeks of treatment with LTG in children and clinicians should be aware of this risk during this period.

Stevens-Johnson syndrome and toxic epidermal necrolysis: an update on pharmacogenetics studies in drug-induced severe skin reaction

Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening drug reactions involving skin and membranes mucous, which are associated with significant morbidity and mortality and triggered, especially by drug exposure. Different studies have demonstrated that drug response is a multifactorial character and that the interindividual variability in this response depends on both environmental and genetic factors. The last ones have a relevant significance. In fact, the identification of new specific genetic markers involved in the response to drugs, will be of great utility to establish a more personalized therapeutic approach and to prevent the appearance of these adverse reactions. In this review, we summarize recent progresses in the Pharmacogenetics studies related to Stevens-Johnson syndrome/toxic epidermal necrolysis reporting the major genetic factors identified in the last years as associated with the disease and highlighting the use of some of these genomic variants in the clinical practice.

Lamotrigine-induced severe cutaneous adverse reaction: Update data from 1999-2014

We systematically reviewed and analyzed published patients with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) associated with lamotrigine therapy to identify characteristics of these reactions. We identified a total of 70 patients (42 SJS, five SJS/TEN, 23 TEN). The female to male ratio was 2.83:1 in the TEN group and 1.47:1 in the SJS group. Patients in the TEN group were younger than in the SJS group but this difference was not significant (28.35 versus 32.71 years, respectively; p=0.27). The median time to onset was 25.33 versus 18.42 days for SJS and TEN, respectively. The median dosage at onset was 36.46 versus 57.29mg, and final dosage 111.25 versus 97.92mg/day for SJS and TEN, respectively. The median final dosages did not significantly differ. Concomitant use of valproate acid was reported in 54.55% of the SJS patients and 50.00% of the TEN patients. Three fatal reactions were reported, of which two patients deteriorated rapidly and died within 12h of admission, indicating that this disease can develop rapidly before effective treatment. There was no significant difference between the SJS and TEN groups in any of the clinical factors examined which confirmed the opinion that SJS and TEN are part of a single disease spectrum.

Comorbidity of Stevens-Johnson syndrome and neutropenia associated with lamotrigine: a case report

A 19-year-old woman with a medical history of depressive mood arrived and was treated with lamotrigine at 25 mg/day. On day 10, a high fever of 39.3 °C and a diffuse, erythematous, pruritic full-body rash involving the palms of her hands and the soles of her feet developed, and she was diagnosed with Stevens-Johnson syndrome (SJS). On day 17, white blood cell count (WBC) result was 1,240/μl with 54.1% neutrophils (670/μl), and the WBC decreased to 840/μl with 60.7% neutrophils (510/μl) on day 18. The trend toward improvement included skin symptoms after steroid pulse therapy using 1000 mg/day. Based on the clinical course, we concluded that the SJS and leukopenia and/or neutropenia are associated with lamotrigine. Monitoring of WBC should be kept in mind when administering lamotrigine.

Toxic epidermal necrolysis induced by lamotrigine treatment in a child

Toxic epidermal necrolysis is an unpredictable and severe adverse drug reaction. In toxic epidermal necrolysis, epidermal damage appears to result from keratinocyte apoptosis. This condition is triggered by many factors, principally drugs such as antiepileptic medications, antibiotics (particularly sulfonamide), nonsteroidal anti-inflammatory drugs, allopurinol, and nevirapine. Lamotrigine has been reported potentially cause serious cutaneous reactions, and concomitant use of valproic acid with lamotrigine significantly increases this risk. We describe a case of an 11-year-old girl with tic and major depressive disorders who developed toxic epidermal necrolysis after treatment with lamotrigine, and who was diagnosed both clinically and pathologically. Children are more susceptible to lamotrigine-induced rash than adults, and risk of serious rash can be lessened by strict adherence to dosing guidelines. Unfortunately, in our case, the patient was administered a higher dose than the required regimen. Therefore, clinicians should strictly adhere to the dose regimen when using lamotrigine, especially in children.

Single centre 20 year survey of antiepileptic drug-induced hypersensitivity reactions

BACKGROUND

Epilepsy is a chronic neurological disease which affects about 1% of the human population. There are 50 million patients in the world suffering from this disease and 2 million new cases per year are observed. The necessary treatment with antiepileptic drugs (AEDs) increases the risk of adverse reactions. In case of 15% of people receiving AEDs, cutaneous reactions, like maculopapular or erythematous pruritic rash, may appear within four weeks of initiating therapy with AEDs.

METHODS

This study involved 300 epileptic patients in the period between September 1989 and September 2009. A cutaneous adverse reaction was defined as a diffuse rash, which had no other obvious reason than a drug effect, and resulted in contacting a physician.

RESULTS

Among 300 epileptic patients of Neurological Practice in Kielce (132 males and 168 females), a skin reaction to at least one AED was found in 30 patients. As much as 95% of the reactions occurred during therapies with carbamazepine, phenytoin, lamotrigine or oxcarbazepine. One of the patients developed Stevens-Johnson syndrome.

CONCLUSION

Some hypersensitivity problems of epileptic patients were obviously related to antiepileptic treatment. Among AEDs, gabapentin, topiramate, levetiracetam, vigabatrin, and phenobarbital were not associated with skin lesions, although the number of patients in the case of the latter was small.

Toxic epidermal necrolysis due to concomitant use of lamotrigine and valproic Acid

Anti-epileptic drugs can be associated with a wide spectrum of cutaneous adverse reactions ranging from simple maculopapular rashes to more severe and life threatening reactions like Stevens-Johnson syndrome and toxic epidermal necrolysis. These rashes are well documented with older antiepileptic drugs like phenytoin, phenobarbitone and carbamazapine. Lamotrigine is a newer, unrelated antiepileptic drug that causes skin rashes in 3-10% of new users. Higher starting dose or rapid escalation, concurrent treatment with valproic acid, and a previous history of a rash with other antiepileptic drugs are well recognized risk factors for lamotrigine related serious rashes. We report two patients with toxic epidermal necrolysis, resulting from concomitant use of lamotrigine and valproic acid. It is emphasized that clinicians adhere to the recommended dosage guidelines and adopt a slow dose titration when initiating treatment with lamotrigine.

Adverse drug reactions induced by valproic acid

Valproic acid is a widely-used first-generation antiepileptic drug, prescribed predominantly in epilepsy and psychiatric disorders. VPA has good efficacy and pharmacoeconomic profiles, as well as a relatively favorable safety profile. However, adverse drug reactions have been reported in relation with valproic acid use, either as monotherapy or polytherapy with other antiepileptic drugs or antipsychotic drugs. This systematic review discusses valproic acid adverse drug reactions, in terms of hepatotoxicity, mitochondrial toxicity, hyperammonemic encephalopathy, hypersensitivity syndrome reactions, neurological toxicity, metabolic and endocrine adverse events, and teratogenicity.

Psychiatric medications: adverse cutaneous drug reactions

Psychiatric medications are among the most widely prescribed medications in the United States. Adverse cutaneous drug reactions are associated with psychiatric medications in approximately 2% to 5% of the individuals for whom they are prescribed. Although most adverse cutaneous drug reactions associated with psychotropic medications are benign and easily treated, some can be disfiguring or life-threatening, particularly those associated with the mood stabilizers. Adverse cutaneous drug reactions associated with antidepressants, antipsychotics, and mood stabilizers are reviewed, and important issues that are of concern for the dermatologist who must consider when and how to safely discontinue a psychotropic medication in their patients are presented.

Photochemical reactions involved in the phototoxicity of the anticonvulsant and antidepressant drug lamotrigine (Lamictal)

Lamotrigine (LTG) [3,5-diamino-6-(2,3-dichlorophenyl)-1,2,4-triazine], an anticonvulsant and antidepressant drug Lamictal, produces a (photo)toxic response in some patients. LTG absorbs UV light, generating singlet oxygen (1O2) with a quantum yield of 0.22 in CH2Cl2, 0.11 in MeCN and 0.01 in D2O. A small production of superoxide radical anion was also detected in acetonitrile. Thus, LTG is a moderate photosensitizer producing phototoxicity and oxidizing linoleic acid. LTG is a weak 1O2 quencher (k(q) = 3.2 x 10(5) M(-1) s(-1) in MeCN), but its photodecomposition products in dimethyl sulfoxide (DMSO) quenched 1O2 very efficiently. Upon intense UV irradiation from a xenon lamp, LTG was photobleached rapidly in DMSO and slowly in acetonitrile, alcohol and water. The rate increased significantly when laser pulses at 266 nm were employed. The photobleaching products generated 1O2 twice as strongly as LTG. Photobleaching was usually accompanied by the release of chloride anions, which increased in the presence of ascorbic acid. This suggests the formation of aryl radicals via dechlorination, a process which may be responsible for the photoallergic response observed in some patients. Our results demonstrate that LTG is a moderate generator of 1O2 prone to photodechlorination, especially in a reducing environment, which can contribute to the reported phototoxicity of LTG.

Toxic epidermal necrolysis (TEN) Lyell's syndrome

Toxic epidermal necrolysis, a unique rapidly developing mucocutaneous reaction pattern, characterized by sheets of erythema, necrosis and bullous detachment of the epidermis, closely resembling that of scalding of the skin and rapidly fatal, was described by Lyell, and is now recognized as toxic epidermal necrolysis (TEN) Lyell's syndrome. The condition is indistinguishable from staphylococcal scalded skin syndrome (SSSS), and generalized fixed drug eruption. Hence, there has always been controversy as regards terminology. It is well conceived that TEN is equivalent to Stevens-Johnson syndrome (SJS), at its greatest severity. TEN, therefore, is a great challenge and warrants instant attention based on a thorough knowledgeable background covering several related facets including the recent advances in pathogenesis and management strategies. The details contained in the following text should prove very useful in the comprehension of a largely intractable entity.

A non-randomized study to investigate the effects of the atypical antipsychotic aripiprazole on the steady-state pharmacokinetics of lamotrigine in patients with bipolar I disorder

OBJECTIVE

To determine the effect of aripiprazole on steady-state pharmacokinetics of lamotrigine in patients with bipolar I disorder who were clinically stable on lamotrigine (100-400 mg/day) for >or=4 weeks.

METHODS

In this open-label study, aripiprazole was administered at 10 mg/day for 3 days, 20 mg/day for 3 days, then 30 mg/day for 8 days. Blood samples were collected on Days -1 and 14 for determination of lamotrigine steady-state pharmacokinetic parameters. Safety and tolerability were assessed.

RESULTS

Eighteen patients were administered aripiprazole in combination with lamotrigine. Geometric mean (GM) values for lamotrigine maximum plasma concentration were similar for lamotrigine alone (26 ng/mL) and with co-administered aripiprazole (23 ng/mL). GM values for plasma lamotrigine area under the concentration-time curve (AUCtau) were comparable for lamotrigine alone (434 ng/h/mL) and with co-administered aripiprazole (394 ng/h/mL). Median T(max) of lamotrigine alone and combined with aripiprazole was 1.98 and 0.77 h, respectively. No changes to lamotrigine dose-normalized plasma trough concentrations were observed with co-administered aripiprazole. Sixteen patients (88.9%) experienced >or=1 adverse event (AE), the most common of which was insomnia (n = 6).

CONCLUSIONS

Aripiprazole had no meaningful effect on lamotrigine steady-state pharmacokinetics in patients with bipolar I disorder. No dosage adjustment of lamotrigine is required and the combination was generally safe and well tolerated.

The adverse effects of antiepileptic drugs in children

Efficacy of antiepileptic drugs (AEDs) are often equivalent, hence selection of an AED is often determined by the adverse effects (AEs). The development of neurocognitive AEs is almost inevitable with use of AEDs, especially in high-risk groups. Teratogenesis with major or minor malformations is of great concern during the first trimester of pregnancy, but an increasing body of information suggests that potential neurocognitive developmental delay may also occur with use of AEDs in the latter part of pregnancy. Decreased bone mineral density has been found in adults and children receiving both enzyme-inducing AEDs and valproate, an enzyme-inhibiting drug. AEDs may influence the lipid profile, body weight, reproductive, hormonal and other endocrine functions, and sleep architecture. There are age-specific AEs related to pharmacokinetic differences that have been highlighted in this review with emphasis on the pediatric population. A classification of AEs using different parameters is also included.

Toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is an unpredictable, life-threatening drug reaction associated with a 30% mortality. Massive keratinocyte apoptosis is the hallmark of TEN. Cytotoxic T lymphocytes appear to be the main effector cells and there is experimental evidence for involvement of both the Fas-Fas ligand and perforin/granzyme pathways. Optimal treatment for these patients remains to be clarified. Discontinuation of the offending drug and prompt referral to a burn unit are generally agreed upon steps. Beyond that, however, considerable controversy exists. Evidence both pro and con exists for the use of IVIG, systemic corticosteroid, and other measures. There is also evidence suggesting that combination therapies may be of value. All the clinical data, however, is anecdotal or based on observational or retrospective studies. Definitive answers are not yet available. Given the rarity of TEN and the large number of patients required for a study to be statistically meaningful, placebo controlled trials are logistically difficult to accomplish. The absence of an animal model further hampers research into this condition. This article reviews recent data concerning clinical presentation, pathogenesis and treatment of TEN.

LEARNING OBJECTIVES

At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, prognosis, and treatment of TEN.

Lamotrigine-induced Stevens-Johnson syndrome

PURPOSE

A case of lamotrigine-induced Stevens-Johnson syndrome (SJS) is reported.

SUMMARY

A 29-year-old woman with a medical history of schizoaffective disorder arrived at the emergency department with a severe generalized skin reaction. Three to four days prior she had noticed bumps on her lips that had spread to her oral mucosa. She had also developed a diffuse, erythematous, pruritic full-body rash involving the palms of her hands and the soles of her feet and began to feel feverish. Her medications at admission included aripiprazole 30 mg p.o. daily, escitalopram 10 mg p.o. daily, and lamotrigine 75 mg p.o. daily. Lamotrigine was the only new medication, initiated four weeks before this admission. The dermatology service confirmed the diagnosis of SJS using punch biopsy. Lamotrigine was suspected to be the culprit and was discontinued immediately. The patient was given oral prednisone 40 mg and intravenous fluids. Hydroxyzine was given for pruritus, and petroleum jelly and viscous lidocaine were applied to her lips. On hospital day 2, her symptoms and dermatological manifestations improved, but she continued to complain about irritation and slight pain of the mouth. She then received a mouthwash consisting of diphenhydramine, viscous lidocaine, and sodium bicarbonate. On hospital day 3, the patient had improved substantially and was discharged home. Reports of these dermatological reactions in patients receiving lamotrigine for the treatment of bipolar disorder are limited. Dosing, prompt recognition, and patient education are crucial for preventing morbidity and mortality associated with the development of serious cutaneous reactions.

CONCLUSION

SJS was associated with lamotrigine use, despite appropriate dosing and dosage adjustment.

Localized purpura associated with lamotrigine

Antiepileptic drug hypersensitivity syndrome consists of fever, rash, and internal organ involvement and usually occurs within the first 2 months of initiation of therapy. This report describes a 13-year-old female with a right frontal high-grade glioma and complex partial seizures who developed localized purpura after 23 months of lamotrigine monotherapy. This case study is the second report of localized purpura after prolonged lamotrigine treatment suggesting this may be an atypical lamotrigine-induced drug reaction.

Toxic epidermal necrolysis with combination lamotrigine and valproate in bipolar disorder

Toxic epidermal necrolysis (TEN) is the most severe and potentially life-threatening cutaneous reaction associated with lamotrigine. The risk of developing TEN during lamotrigine therapy is low and previously reported cases most involved epileptic patients. However, the risk of TEN with combination lamotrigine and valproate is greater than with monotherapy. We present here the emergence of TEN in a 32-year-old bipolar woman who was concomitantly treated with lamotrigine and valproate. The patient developed high fever, pharyngitis, cervical lymphadenopathy, mucosal sloughing, generalized erythematous eruptions and more than 40% epidermal detachment of the total body surface area (TBSA) after we added lamotrigine to her medications of valproate and trazodone. The patient's illness course was protracted and accompanied with hepatitis, pneumonitis and hematologic abnormalities. In the beginning of her illness course, our patient did not respond to antihistamine treatment. However, she made a full recovery without any sequela after she had received systemic corticosteroid and intensive resuscitation. Our case suggests that early use of systemic corticosteroid might be beneficial in treating TEN patients, if there is not any clinical contraindication.

Lamotrigine in psychiatry: pharmacology and therapeutics

Following the introduction of lamotrigine in 1994 as a treatment for epilepsy in the United States, the drug has seen progressively greater application in psychiatry, particularly as a treatment for bipolar disorder. This review critically evaluates the support for lamotrigine use across a broad range of psychiatric disorders as well as discuss its pharmacology, side-effect profile, and interactions with other medications.

Necrolisis epidérmica tóxica por lamotrigina

Toxic epidermal necrolysis (TEN) is a serious entity consisting of a generalized eruption with the formation of flaccid blisters. It affects at least 30 % of the cutaneous surface and is usually related to the prior ingestion of medications. We describe TEN symptoms related to the introduction of lamotrigine, an anti-epileptic drug prescribed in this case for the prevention of migrainous episodes.

Treatment of acute mania--from clinical trials to recommendations for clinical practice

No consensus has been reached with regard to the treatment of bouts of acute mania in various parts of the world. Controlled clinical trials have, at last, provided irrefutable evidence of the activity of lithium, which has long been used alone, as well as that of divalproate or its derivatives and, to a lesser extent, carbamazepine. The new antipsychotic agents have more recently established their efficacy, especially olanzapine, risperidone and aripiprazole. It is paradoxical to note that, in Europe, haloperidol is still the reference substance used in clinical trials despite the fact that it is not officially indicated in the treatment of mania. In the USA, lithium, divalproate or antipsychotics can be prescribed as first-line treatment. In Europe, lithium remains the first-line medication, whereas divalproate and atypical antipsychotic agents are used only as second-line therapy. The conventional antipsychotic agents (such as haloperidol, loxapine or zuclopenthixol) which should no longer be prescribed during manic episodes given the potential risks and side effects associated with these substances (extrapyramidal side effects, depressogenic effect, malignant syndrome) are still prescribed extensively in Europe. Although both types of medication (antipsychotics, normothymic agents and/or anticonvulsants) have proved to be clinically effective in the management of mania by reducing the mania scores overall, the same does not apply, however, to all symptoms of mania. Factorial approaches to mania have all shown that since there are several clinical forms of mania, several lines of manic symptoms can be identified. Antipsychotic and normothymic agents and/or anticonvulsants do not appear to have the same effects on each of these identifiable clusters of symptoms, mainly psychotic features. We believe that it is vitally important for future clinical trials of mania treatment to focus on the treatment effect by adopting a factorial approach to the episode with an appropriate methodological structure provided to this end. These questions highlight the uncertainty shrouding the very structure of manic episodes, namely that these are predominantly of a thymic or psychotic nature. The Europeans undoubtedly consider mania to be more of a thymic episode and prefer lithium as the first-line treatment, whereas the Americans believe that psychotic symptoms dominate and widely prescribe antipsychotic agents. However, from the standpoint of clinical trials currently available, even though antipsychotic agents are certainly effective in reducing the scores on the mania scales, can they be considered purely as antimania treatments?

Anticonvulsant Hypersensitivity Syndrome: Lymphocyte Toxicity Assay for the Confirmation of Diagnosis and Risk Assessment

OBJECTIVE

To report a case of anticonvulsant hypersensitivity syndrome (AHS) precipitated by exposure to phenobarbital.

Case Summary

An 11-year-old girl receiving phenobarbital developed fever, exfoliative skin rash, mucous membrane lesions, alopecia, and hepatic inflammation. Investigations ruled out an infectious etiology; an adverse event following phenobarbital administration was considered. Applying the Naranjo probability scale for objective causality assessment showed the adverse reaction was probably due to phenobarbital. The diagnosis was confirmed by in vitro lymphocyte toxicity assay, which demonstrated increased cell death following exposure to phenobarbital, as well as other aromatic anticonvulsants and lamotrigine.

DISCUSSION

AHS is a rare, potentially fatal event with multisystem manifestations. It is reported following exposure to aromatic antiepileptics. The mechanism proposed for AHS is accumulation of toxic arene oxide metabolites due to a defect in epoxide hydrolase—mediated detoxification. Despite the difference in chemical structure of lamotrigine, in vitro susceptibility to AHS was demonstrated in our patient.

CONCLUSIONS

Although AHS is a rare event, it should be suspected in patients who develop unexplained systemic manifestations following exposure to aromatic antiepileptics. The potential of lamotrigine to cause AHS should be remembered when this drug is used in subjects who have developed AHS on exposure to phenobarbital and other first-line antiepileptic agents.

Treatment of bipolar depression: current status, continued challenges, and the STEP-BD approach

Even though at least 10% (if not 20%) of those who experience a first lifetime episode of depression will subsequently develop bipolar disorder, the alliance of academic and industry research agendas that leads to developing and testing new antidepressants has failed to produce a sufficient knowledge base. It is therefore impossible to apply a truly empirical approach to guide the treatment of people with bipolar depression. Consequently, there are holes in contemporary evidenced-based practice guidelines large enough to drive a truck through; furthermore, there are some recommendations that have no factual basis other than expert opinion. However, with new research emerging on lamotrigine and olanzapine, in addition to the pending results of larger studies supported by the National Institute of Mental Health and the Stanley Foundation, there is evidence that some progress is being made.

Adverse cutaneous reactions to mood stabilizers

Of all the psychotropic medications currently available, the mood-stabilizing agents have the highest incidence of severe and life-threatening adverse cutaneous drug reactions (ACDRs). An exanthematous eruption in a patient treated with a mood-stabilizing agent should be viewed as possibly being the initial symptom of a severe and life-threatening ACDR, such as a hypersensitivity reaction, Stevens-Johnson syndrome, or toxic epidermal necrolysis. The combination of mood-stabilizing agents may increase the risk of such reactions. The mood-stabilizing agents addressed in this article are carbamazepine, lithium carbonate, valproic acid, topiramate, lamotrigine, gabapentin, and oxcarbazepine. Prior to the initiation of a mood stabilizer, the potential benefits, risks, and adverse effects should be communicated to the patient. If possible, slow dose escalation should be attempted by the physician. Patients should also be advised to seek medical attention if they suspect a drug-induced skin reaction. If the physician suspects a severe ACDR, the offending agent should be removed immediately.

Management of toxic epidermal necrolysis in a 15-year-old girl

Toxic epidermal necrolysis, a life-threatening reaction to certain types of drugs, is characterised by epidermal sloughing of more than 30% of the total body surface area. Patient survival depends on prompt referral to a specialist burns unit.

New and emerging prophylactic agents for migraine

Frequent, severe and long-lasting migraine attacks require prophylaxis. Established drugs used for the prevention of migraine such as beta-adrenoceptor antagonists (beta-blockers), calcium channel antagonists, antidepressants and others have an unknown mode of action in migraine. Their prophylactic effect in migraine was discovered by chance in clinical practice when these drugs were used for other purposes. Recently, research into the mechanisms of migraine and the progressive recognition that cortical hyperexcitability and an imbalance between neuronal inhibition [mediated by gamma-aminobutyric acid (GABA)] and excitation (mediated by excitatory amino acids) may play an important role in migraine pathophysiology have lead to the identification of potential new agents for the prevention of migraine attacks. This paper reviews the recent literature on these new agents. A search was conducted using MEDLINE from 1998 to November 2001 with the following search terms: migraine, preventive, prophylactic and treatment. Headache textbooks edited in 2000 and 2001 were also used. After analysing the available controlled and uncontrolled clinical studies as well as abstracts, divalproex sodium (valproate semisodium) can be recommended for the prevention of migraine. Lamotrigine may be useful for preventing aura associated with migraine, and topiramate seems a promising option pending trials with more patients, which are currently underway. Riboflavin (which is possibly involved in improving neuronal energy production) appears to be a promising agent, although comparisons with established prophylactic medications are needed. Gabapentin, magnesium, lisinopril and botulinum toxin A have recently been suggested to be effective; however, at present, there are insufficient rigorous and reliable controlled data on these drugs for them to be indicated for such use. Emerging options such as tiagabine, levetiracetam, zonisamide and petasites may all be useful, but controlled data are required to confirm their efficacy. The anti-asthma medication montelukast was found to be effective in an open trial, but ineffective in a recently completed controlled trial. There is an expectation that modern neuroscience will soon provide more efficacious and better tolerated prophylactic medications for migraine.

Valproate-associated stomatitis

The purpose of this article is to report a case of severe stomatitis in a patient with pediatric epilepsy taking divalproex sodium. The case was reviewed with detailed oral examinations. This 5-year-old child developed severe stomatitis 18 months after institution of divalproex sodium. Cessation of the medication was associated with resolution of the stomatitis. A review of the pertinent literature is also provided. Stomatitis is a rare but potentially serious adverse effect of divalproex sodium administration.

New antiepileptic drugs

BACKGROUND

Eight novel anticonvulsant drugs have been introduced in the United States in the past 10 years, as well as two new intravenous preparations of anticonvulsant drugs. The role of each in the treatment of patients with epilepsy is being refined as experience and research data accumulate.

REVIEW SUMMARY

Gabapentin, tiagabine, and oxcarbazepine are effective for partial seizures, whereas felbamate, lamotrigine, topiramate, levetiracetam, and zonisamide treat both partial and generalized seizure types. In general, these newer agents differ from older agents by relative lack of drug-drug interactions, and many show improved tolerability compared with phenytoin and carbamazepine. Each has distinguishing features that can prove useful in specific clinical situations. Despite limited Food and Drug Administration indications, all are useful in monotherapy under certain circumstances. Fosphenytoin avoids the adverse effects of intravenous phenytoin vehicle, and intravenous valproate represents a much needed option in patients who require rapid loading of this medication.

CONCLUSIONS

The greater number of antiseizure drugs available today makes it possible to tailor treatment to individual patient needs, allowing more patients to be free of debilitating adverse effects. Additionally, some patients can achieve complete seizure freedom even after failing one or more other antiepileptic drugs.

Life-threatening adverse events of antiepileptic drugs

Treating a patient with antiepileptic drugs (AEDs) may give rise to unexpected life-threatening adverse events. Despite extensive experimental and clinical testing to ensure safety, most AEDs on the market have been associated with cases of severe cutaneous reactions, serious hematological disorders, or hepatic failure. Most of these disorders emerge as idiosyncratic immune-mediated disease or are related to toxic metabolic products of the AEDs. Early diagnosis is the only means of reducing the harmful, potentially fatal effects of these reactions. A high degree of suspicion, knowledge of risk factors, and close physician-patient contact increases the likelihood of early diagnosis and treatment. When diagnosed, severe reactions must be fully documented and reported to health authorities. The very rare occurrence of life threatening events should not, in general, limit treatment decision-making. Future epidemiological, chemical, and genetic research might provide methods for ascertaining which patients are at risk, so undue exposure can be avoided.

Antiepileptic drugs in the 21st century

During the past 10 years, there has been a welcome influx of novel agents for the treatment of epilepsy. Many show advantages compared to older agents, including better adverse effect profiles and lack of drug-drug interactions. The sheer number of agents now available makes distinction among them confusing at times. Agents differ in spectrum of action, pharmacokinetic profile (affecting dosing schedule and drug interactions), and titration time. This review highlights the differences between the various new agents and the more traditional antiseizure drugs. Evidence for the widespread use of these compounds outside their indication, particularly for diseases other than epilepsy, is reviewed as well.

Newer antiepileptic drugs: advantages and disadvantages

The choice of an antiepileptic drug depends firstly on its efficacy in specific seizure types and epilepsies. However, it is imperative to consider whether possible adverse events will outweigh any benefits. The advantages and disadvantages of vigabatrin, lamotrigine, gabapentin, topiramate, tiagabine and felbamate are considered in some detail, and oxcarbazepine, stiripentol, remacemide, zonisamide and levetiracetam more briefly. Vigabatrin is effective for partial seizures and infantile spasms, but visual field defects are limiting its use. Lamotrigine has a wide spectrum, needs to be prescribed with care. Gabapentin is unlikely to cause adverse effects, but has relatively poor efficacy. Topiramate is widely effective, but can be poorly tolerated. Tiagabine is relatively untried in childhood epilepsies. The use of felbamate is restricted to severe refractory epilepsies. Stiripentol can be effective in severe myoclonic epilepsy in infancy. Zonisamide has a special place in the progressive myoclonus epilepsies. Levetiracetam, remacemide and oxcarbazepine have been used mainly for partial seizures: further studies of their roles in other circumstances are required.