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Mula M, Borghs S, Ferro B, Zaccara G, Dainese F, Ferlazzo E, Romigi A, Gambardella A, Perucca E. Effect of drug treatment changes and seizure outcomes on depression and suicidality in adults with drug-resistant focal epilepsy. Epilepsia 2024; 65:473-482. [PMID: 38073337 DOI: 10.1111/epi.17856] [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: 06/23/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVE To investigate changes in depressive and suicidality status and their relationship with seizure outcomes after the addition or substitution of another antiseizure medication (ASM) in adults with drug-resistant focal epilepsy. METHODS Seven hundred seventy consecutively enrolled patients were assessed and followed prospectively for seizure outcome and depressive status over a 6-month period after starting treatment with a newly introduced ASM. The Neurological Disorders Depression Inventory for Epilepsy (NDDIE) was used to screen for depression and suicidality. Correlations of NDDIE results with clinical and treatment-related variables were assessed by using a stepwise logistic regression model. RESULTS At baseline, 50% of patients had a positive screening test result for depression and 13% had a positive screening test result for suicidal ideation. A psychiatric comorbidity at baseline was associated with a 2.3 times increased risk of an initially negative NDDIE screening result becoming positive at re-assessment after 6 months. In addition, the number of ASMs taken at baseline correlated with an increased risk of a change in depression screening test results from negative to positive during follow-up, whereas no association was identified with sociodemographic and epilepsy-related variables, including seizure outcomes. Approximately 6% of patients who were initially negative at screening for suicidal ideation became positive at the 6-month re-assessment. The risk of switch from a negative to a positive screening test result for suicidal ideation was increased more than two-fold in individuals who screened positive for depression at baseline, and was unrelated to the type of ASM introduced, sociodemographic variables, or seizure outcomes. SIGNIFICANCE Almost 1 in 5 adults with drug-resistant focal epilepsy who screen negative for depression become positive when re-assessed 6 months after a treatment change. At re-assessment 6 months later, 6.1% who screen initially negative for passive suicidal ideation become positive. These changes in screening status are independent of type of ASM introduced or seizure outcomes but correlate with psychiatric status at baseline.
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Affiliation(s)
- Marco Mula
- Institute of Medical and Biomedical Education, St George's University of London and the Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | | | | | - Filippo Dainese
- Department of Neuroscience, Unit of Neurology and Neurophysiology, University Hospital of Padova, Padova, Italy
| | - Edoardo Ferlazzo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
- Regional Epilepsy Centre, Great Metropolitan Hospital BMM, Reggio Calabria, Italy
| | - Andrea Romigi
- Sleep Medicine Center, IRCCS Neuromed Istituto Neurologico Mediterraneo, Pozzilli, Italy
- Psychology Faculty, International Telematic University Uninettuno, Rome, Italy
| | | | - Emilio Perucca
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
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Krauss GL, Chung SS, Ferrari L, Stern S, Rosenfeld WE. Cognitive and psychiatric adverse events during adjunctive cenobamate treatment in phase 2 and phase 3 clinical studies. Epilepsy Behav 2024; 151:109605. [PMID: 38184949 DOI: 10.1016/j.yebeh.2023.109605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Cognitive and psychiatric adverse events in patients with epilepsy are important determinants of therapeutic outcomes and patient quality of life. We assessed the relationship between adjunctive cenobamate treatment and selected cognitive and psychiatric treatment-emergent adverse events (TEAEs) in adults with uncontrolled focal epilepsy. METHODS This was a retrospective analysis of pooled populations of patients with focal epilepsy from two phase 2, randomized, double-blind clinical trials; two open-label extensions (OLEs) of those trials; and a long-term, open-label, phase 3 safety study. Occurrence of cognitive and psychiatric TEAEs in patients treated with adjunctive cenobamate or placebo during double-blind treatment were evaluated. Exposure-adjusted incidence rates of the cognitive and psychiatric TEAEs, defined as the number of TEAEs per patient-year of treatment, during up to 7 years of long-term adjunctive cenobamate treatment, were determined in the pooled OLE and phase 3 patient populations. RESULTS The pooled randomized trials resulted in a population of 442 patients treated with cenobamate (100 mg/day: n = 108; 200 mg/day: n = 223; 400 mg/day: n = 111) and 216 placebo-treated patients. The combined open-label studies resulted in pooled populations of cenobamate-treated patients ranging from n = 1690 during Year 1 to n = 103 during Year 7. Among cenobamate-treated (all doses) and placebo-treated patients during double-blind treatment, cognitive TEAEs were reported by ≤ 1.9 % (range, 0 %-1.9 %) and ≤ 0.5 % (range, 0 %-0.5 %), respectively, and psychiatric TEAEs by ≤ 3.6 % (range, 0 %-3.6 %) and ≤ 3.2 % (range, 0 %-3.2 %), respectively. During up to 7 years of open-label adjunctive cenobamate treatment, exposure-adjusted incidence rates of cognitive and psychiatric TEAEs were < 0.018 and < 0.038 events per patient-year, respectively. Discontinuation of adjunctive cenobamate due to cognitive or psychiatric TEAEs assessed in this study during double-blind or open-label treatment occurred in ≤ 0.3 % and ≤ 1.7 % of patients, respectively. CONCLUSIONS Cognitive and psychiatric TEAEs were reported by similar numbers of cenobamate- and placebo-treated patients during double-blind adjunctive cenobamate treatment (< 4 % of patients), and exposure-adjusted incidence rates of these TEAEs remained low during open-label cenobamate treatment for up to 7 years. Treatment discontinuations due to these TEAEs were rare. The results of this post-hoc analysis indicate that adjunctive cenobamate treatment exhibits a low incidence of cognitive or psychiatric TEAEs in patients with uncontrolled focal seizures.
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Affiliation(s)
- Gregory L Krauss
- Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
| | - Steve S Chung
- Neuroscience Institute, Banner-University Medical Center, 755 East McDowell Road, Phoenix, AZ 85006.
| | - Louis Ferrari
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, USA.
| | - Sean Stern
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, USA.
| | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, 11134 Conway Road, St. Louis, MO 63131, USA.
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Mula M. Impact of psychiatric comorbidities on the treatment of epilepsies in adults. Expert Rev Neurother 2023; 23:895-904. [PMID: 37671683 DOI: 10.1080/14737175.2023.2250558] [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: 06/24/2023] [Accepted: 08/17/2023] [Indexed: 09/07/2023]
Abstract
INTRODUCTION Epilepsy is often accompanied by psychiatric comorbidities and the management of epilepsy in these patients presents unique challenges due to the interplay between the underlying neurological condition and the psychiatric symptoms and the combined use of multiple medications. AREAS COVERED This paper aims to explore the complexities associated with managing epilepsy in the presence of psychiatric comorbidities, focusing on the impact of psychiatric disorders on epilepsy treatment strategies and the challenges posed by the simultaneous administration of multiple medications. EXPERT OPINION Patients with epilepsy and psychiatric comorbidities seem to present with a more severe form of epilepsy that is resistant to drug treatments and burdened by an increased morbidity and mortality. Whether prompt treatment of psychiatric disorders can influence the long-term prognosis of the epilepsy is still unclear as well as the role of specific treatment strategies, such as neuromodulation, in this group of patients. Clinical practice recommendations and guidelines will prompt the development of new models of integrated care to be implemented.
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Affiliation(s)
- Marco Mula
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospital, London, UK of Great Britain and Northern Ireland
- Institute of Medical and Biomedical Education, St George's University of London, London, UK
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Lee HC, Kim BK, Kang K, Lee WW, Yoo I, Kim YS, Lee JJ. Patient with Epilepsy Showing Psychiatric Symptoms after Remission of Seizures and Normalization of Electroencephalography: The Phenomenon of Forced Normalization? J Epilepsy Res 2023; 13:19-21. [PMID: 37720682 PMCID: PMC10501814 DOI: 10.14581/jer.23004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 09/19/2023] Open
Abstract
Psychiatric disorders are commonly observed in patients with epilepsy. Among them, the phenomenon known as forced normalization is scarce. Herein, we report the case of a 41-year-old patient who showed long-term first-onset psychiatric symptoms after seizure remission and normalization of electroencephalography. After changing the antiepileptic drug regimen and psychiatric treatment, the patient's symptoms regressed. However, the exact pathological mechanisms remain to be elucidated. Changing the regimen of antiepileptic drugs and long-term psychiatric treatment may help control this phenomenon.
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Affiliation(s)
- Hyoung Cheol Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Woong-Woo Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Ilhan Yoo
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Yong Soo Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Jung-Ju Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
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Smith ML. "Is this normal after such a major surgery?" Memory complaint after right temporal lobe excision in an adolescent. Epilepsy Behav Rep 2021; 18:100515. [PMID: 35243287 PMCID: PMC8857461 DOI: 10.1016/j.ebr.2021.100515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/17/2021] [Accepted: 12/02/2021] [Indexed: 12/01/2022] Open
Abstract
Memory deficits are commonly associated with temporal-lobe epilepsy. Memory may worsen after surgical resection of the temporal lobe. Risk factors for decline are structural integrity of the mesial temporal lobe structures and intact pre-operative memory. Subjective memory complaints are influenced by depression or other psychological disorders. A 16-year-old girl underwent resection from the right lateral and medial temporal lobe and after surgery she complained of a significant memory impairment, which was unexpected given her baseline assessment. Before undertaking a neuropsychological assessment, she was referred for a psychiatric consultation which revealed depression, leading to treatment with anditdepressant medication. Over time she also admitted to severe headaches and inadequate sleep. With these issues addressed, assessment indicated memory performance had not changed relative to her preoperative baseline with stability or improvement in memory across longitudinal assessments. This case illustrates the contribution of mood state and other potential factors in contributing to subjective memory complaints.
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Affiliation(s)
- Mary Lou Smith
- Address: Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Toronto ON M5G 1X8, Canada.
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Lattanzi S, Cagnetti C, Foschi N, Ciuffini R, Osanni E, Chiesa V, Dainese F, Dono F, Canevini MP, Evangelista G, Paladin F, Bartolini E, Ranzato F, Nilo A, Pauletto G, Marino D, Rosati E, Bonanni P, Marrelli A. Adjunctive Perampanel in Older Patients With Epilepsy: A Multicenter Study of Clinical Practice. Drugs Aging 2021; 38:603-610. [PMID: 34075567 PMCID: PMC8266697 DOI: 10.1007/s40266-021-00865-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
Background Clinical data regarding use of newer antiseizure medications (ASMs) in an older population are limited. In randomized-controlled, placebo-controlled trials, older patients are under-represented, and protocols deviate markedly from routine clinical practice, limiting the external validity of results. Studies performed in a naturalistic setting are a useful complement to characterize the drug profile. Perampanel is a third-generation ASM and the first and only non-competitive alfa-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptor antagonist. Objective The aim of this study was to assess the effectiveness and tolerability of adjunctive perampanel over a 1‐year period in a population of older patients with epilepsy treated in a real-world setting. Methods Older (≥ 65 years of age) patients prescribed add-on perampanel at 12 Italian epilepsy centers were retrospectively identified. Seizure occurrence, adverse events (AEs), and drug withdrawal were analyzed. Effectiveness outcomes included the rates of seizure response (≥ 50% reduction in baseline monthly seizure frequency), seizure freedom, and treatment discontinuation. Safety and tolerability outcomes were the rate of treatment discontinuation due to AEs and the incidence of AEs. Results A total of 92 patients with a median age of 69 (range 65–88) years were included. The median daily dose of perampanel at 12 months was 6 mg (interquartile range 4–6 mg). At 12 months, 53 (57.6%) patients were seizure responders, and 22 (23.9%) patients were seizure free. Twenty (21.7%) patients discontinued perampanel; the reasons for treatment withdrawal were insufficient efficacy (n = 6/20; 30.0%), AEs (n = 12/20; 60.0%), and a combination of both (n = 2/20; 10%). The most common AEs included irritability (8.7%), somnolence (4.3%), and dizziness/vertigo (4.3%). The rate of behavioral and psychiatric AEs was higher in patients with history of psychiatric comorbidities (p = 0.044). There were no differences in the occurrence of behavioral and psychiatric AEs according to the concomitant use of levetiracetam (p = 0.776) and history of cognitive decline (p = 0.332). Conclusions Adjunctive perampanel was associated with improvement in seizure control and good tolerability in a real-life setting and can represent a viable therapeutic option in older patients with epilepsy.
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Affiliation(s)
- Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | - Claudia Cagnetti
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Nicoletta Foschi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Roberta Ciuffini
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Elisa Osanni
- Epilepsy and Psychopathology Unit, IRCCS Medea, Conegliano, Treviso, Italy
| | | | | | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Maria Paola Canevini
- Epilepsy Center, San Paolo Hospital, Milan, Italy
- Department of Health Sciences, Università degli Studi, Milan, Italy
| | - Giacomo Evangelista
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | | | | | | | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, ASUFC, Udine, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, ASUFC, Udine, Italy
| | - Daniela Marino
- Neurology Unit, Department of Cardiac, Thoracic, Neurological and Vascular Sciences, San Donato Hospital, Arezzo, Italy
| | - Eleonora Rosati
- Neurology Unit 2, Neuromuscular and Sense Organs Department, Careggi University Hospital, Florence, Italy
| | - Paolo Bonanni
- Epilepsy and Psychopathology Unit, IRCCS Medea, Conegliano, Treviso, Italy
| | - Alfonso Marrelli
- Neurophysiopathology Unit, Epilepsy Center, San Salvatore Hospital, L'Aquila, Italy
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7
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Akanuma N, Adachi N, Fenwick P, Ito M, Okazaki M, Hara K, Ishii R, Sekimoto M, Kato M, Onuma T. Individual vulnerabilities to psychosis after antiepileptic drug administration. BMJ Neurol Open 2021; 2:e000036. [PMID: 33681791 PMCID: PMC7903174 DOI: 10.1136/bmjno-2019-000036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 07/19/2020] [Accepted: 07/28/2020] [Indexed: 11/06/2022] Open
Abstract
Background Psychosis often develops after the administration of antiepileptic drugs (AEDs) in patients with epilepsy. However, the individual vulnerability and clinical condition of such patients have been rarely scrutinised. We investigated the effect of individually consistent (trait-dependent) and inconsistent (state-dependent) characteristics. Methods The individual characteristics, clinical states and psychotic outcome of patients from eight adult epilepsy clinics were retrospectively reviewed over 6-month periods after a new drug (AED or non-AED) administration between 1981 and 2015. Results A total of 5018 new drugs (4402 AEDs and 616 non-AEDs) were used in 2015 patients with focal epilepsy. Subsequently, 105 psychotic episodes (81 interictal and 24 postictal) occurred in 89 patients. Twelve patients exhibited multiple episodes after different AED administrations. Trait-dependent characteristics (early onset of epilepsy, known presumed causes of epilepsy, lower intellectual function and a family history of psychosis) were significantly associated with the patients who exhibited psychosis. Absence of family history of epilepsy was also associated with psychosis but not significantly. Subsequent logistic regression analysis with a model incorporating family history of psychosis and epilepsy, and intellectual function was the most appropriate (p=0.000). State-dependent characteristics, including previous psychotic history and epilepsy-related variables (longer duration of epilepsy, AED administration, higher seizure frequency and concomitant use of AEDs) were significantly associated with psychotic episodes. Subsequent analysis found that a model including AED administration and previous psychotic history was the most appropriate (p=0.000). Conclusion Psychosis occurring after new AED administration was related to the individual vulnerability to psychosis and intractability of epilepsy.
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Affiliation(s)
- Nozomi Akanuma
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Peter Fenwick
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Mitsutoshi Okazaki
- Department of Psychiatry, National Centre Hospital for Mental, Nervous and Muscular Disorders, NCNP, Kodaira, Japan
| | | | - Ryouhei Ishii
- Department of Psychiaty, University of Osaka Graduate School of Medicine, Osaka, Japan
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Integration of postmortem amygdala expression profiling, GWAS, and functional cell culture assays: neuroticism-associated synaptic vesicle glycoprotein 2A (SV2A) gene is regulated by miR-133a and miR-218. Transl Psychiatry 2020; 10:297. [PMID: 32839459 PMCID: PMC7445165 DOI: 10.1038/s41398-020-00966-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/15/2020] [Accepted: 07/28/2020] [Indexed: 12/27/2022] Open
Abstract
Recent genome-wide studies have begun to identify gene variants, expression profiles, and regulators associated with neuroticism, anxiety disorders, and depression. We conducted a set of experimental cell culture studies of gene regulation by micro RNAs (miRNAs), based on genome-wide transcriptome, proteome, and miRNA expression data from twenty postmortem samples of lateral amygdala from donors with known neuroticism scores. Using Ingenuity Pathway Analysis and TargetScan, we identified a list of mRNA-protein-miRNA sets whose expression patterns were consistent with miRNA-based translational repression, as a function of trait anxiety. Here, we focused on one gene from that list, which is of particular translational significance in Psychiatry: synaptic vesicle glycoprotein 2A (SV2A) is the binding site of the anticonvulsant drug levetiracetam ((S)-α-Ethyl-2-oxo-1-pyrrolidineacetamide), which has shown promise in anxiety disorder treatments. We confirmed that SV2A is associated with neuroticism or anxiety using an original GWAS of a community cohort (N = 1,706), and cross-referencing a published GWAS of multiple cohorts (Ns ranging from 340,569 to 390,278). Postmortem amygdala expression profiling implicated three putative regulatory miRNAs to target SV2A: miR-133a, miR-138, and miR-218. Moving from association to experimental causal testing in cell culture, we used a luciferase assay to demonstrate that miR-133a and miR-218, but not miR-138, significantly decreased relative luciferase activity from the SV2A dual-luciferase construct. In human neuroblastoma cells, transfection with miR-133a and miR-218 reduced both endogenous SV2A mRNA and protein levels, confirming miRNA targeting of the SV2A gene. This study illustrates the utility of combining postmortem gene expression data with GWAS to guide experimental cell culture assays examining gene regulatory mechanisms that may contribute to complex human traits. Identifying specific molecular mechanisms of gene regulation may be useful for future clinical applications in anxiety disorders or other forms of psychopathology.
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Mechanisms Underlying Aggressive Behavior Induced by Antiepileptic Drugs: Focus on Topiramate, Levetiracetam, and Perampanel. Behav Neurol 2018; 2018:2064027. [PMID: 30581496 PMCID: PMC6276511 DOI: 10.1155/2018/2064027] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/30/2018] [Indexed: 12/28/2022] Open
Abstract
Antiepileptic drugs (AEDs) are effective against seizures, but their use is often limited by adverse effects, among them psychiatric and behavioral ones including aggressive behavior (AB). Knowledge of the incidence, risk factors, and the underlying mechanisms of AB induced by AEDs may help to facilitate management and reduce the risk of such side effects. The exact incidence of AB as an adverse effect of AEDs is difficult to estimate, but frequencies up to 16% have been reported. Primarily, levetiracetam (LEV), perampanel (PER), and topiramate (TPM), which have diverse mechanisms of action, have been associated with AB. Currently, there is no evidence for a specific pharmacological mechanism solely explaining the increased incidence of AB with LEV, PER, and TPM. Serotonin (5-HT) and GABA, and particularly glutamate (via the AMPA receptor), seem to play key roles. Other mechanisms involve hormones, epigenetics, and “alternative psychosis” and related phenomena. Increased individual susceptibility due to an underlying neurological and/or a mental health disorder may further explain why people with epilepsy are at an increased risk of AB when using AEDs. Remarkably, AB may occur with a delay of weeks or months after start of treatment. Information to patients, relatives, and caregivers, as well as sufficient clinical follow-up, is crucial, and there is a need for further research to understand the complex relationship between AED mechanisms of action and the induction/worsening of AB.
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Yang TW, Moon J, Kim TJ, Jun JS, Lim JA, Lee ST, Jung KH, Park KI, Jung KY, Chu K, Lee SK. HLA-A*11:01 is associated with levetiracetam-induced psychiatric adverse events. PLoS One 2018; 13:e0200812. [PMID: 30020991 PMCID: PMC6051654 DOI: 10.1371/journal.pone.0200812] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 07/03/2018] [Indexed: 11/19/2022] Open
Abstract
Levetiracetam (LEV) is effective for focal and generalized epilepsy and is used worldwide because of its relatively few drug interactions and favorable tolerability. However, some psychiatric adverse events (PAEs) have been reported, resulting in drug withdrawal. The pathophysiology of LEV-induced PAE has not yet been elucidated. In this study, we investigated the relationship between PAEs and human leukocyte antigen (HLA) genes. Eleven epilepsy patients, who developed PAEs after the administration of LEV and spontaneously improved after drug withdrawal, were enrolled retrospectively. Genomic DNA from the peripheral blood was extracted, and four-digit allele genotyping of HLA genes was performed. The genotype frequencies of HLA genes were compared to those of 80 patients in which LEV was well tolerated, as well as to 485 individuals from the general Korean population. The frequency of the HLA-A*1101 allele was significantly higher in the LEV-induced PAEs group compared to both the LEV-tolerant group (p = 0.021, OR 4.80, 95% CI 1.30-17.74) and the general Korean population (p = 0.015, OR 4.62, 95% CI 1.38-15.45). This study is the first attempt at investigating the relationship between the HLA system and LEV-induced PAE. The results of this study suggest that the HLA-A*1101 allele could be a risk factor for the development of PAEs.
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Affiliation(s)
- Tae-Won Yang
- Department of Neurology, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - Jangsup Moon
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tae-Joon Kim
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Sun Jun
- Department of Neurology, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Jung-Ah Lim
- Department of Neurology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Soon-Tae Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Keun-Hwa Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - Ki-Young Jung
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kon Chu
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Kun Lee
- Department of Neurology, Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
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Abstract
Purpose of review The pharmacological treatment of patients with epilepsy and psychiatric comorbidities may sometimes represent a therapeutic challenge. This review is focused on the pharmacological management of patients with epilepsy and psychiatric problems in terms of rationalization of the antiepileptic drug (AED) treatment and the pharmacological management of the most clinically relevant psychiatric comorbidities, namely mood and anxiety disorders, psychoses, and attention deficit hyperactivity disorder (ADHD). Recent findings Up to 8% of patients with drug-resistant epilepsy develop treatment-emergent psychiatric adverse events of AED regardless of the mechanism of action of the drug and this is usually related to an underlying predisposition given by the previous psychiatric history and the involvement of mesolimbic structures. Careful history taking, periodic screening for mood and anxiety disorders, low starting doses, and slow titration schedules can reduce the possibility of AED-related problems. A pragmatic checklist for the pharmacological management of patients with epilepsy and psychiatric disorders is presented. Summary patients should be informed of potential behavioral effects of AEDs but no drugs should be excluded a priori. Any psychiatric comorbidity should be addressed in the appropriate setting and full remission and recovery should always represent the first goal of any therapeutic intervention. Neurologists should be aware of the side effects of major psychotropic drug classes in order to fully counsel their patients and other health professionals involved.
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Hallucination: A rare complication of levetiracetam theraphy. North Clin Istanb 2017; 4:267-269. [PMID: 29270577 PMCID: PMC5724923 DOI: 10.14744/nci.2017.44366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 11/03/2016] [Indexed: 11/20/2022] Open
Abstract
Levetiracetam is a new antiepileptic drug. In addition to epilepsy, it is also used for treating anxiety disorders and dystonia as well as tardive dyskinesia associated with the use of levodopa and neuroleptic drugs. Phenytoin therapy in a 10-year-old boy with convulsions was discontinued following cardiac rhythm impairment. The patient was then started on levetiracetam. However, visual and auditory hallucinations were observed on the 1st day of levetiracetam therapy. Levetiracetam was discontinued and replaced with sodium valproate, and the hallucinations resolved. The purpose of this report was to remind physicians that hallucinations are one of the rare complications of levetiracetam.
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Brodie MJ, Besag F, Ettinger AB, Mula M, Gobbi G, Comai S, Aldenkamp AP, Steinhoff BJ. Epilepsy, Antiepileptic Drugs, and Aggression: An Evidence-Based Review. Pharmacol Rev 2017; 68:563-602. [PMID: 27255267 PMCID: PMC4931873 DOI: 10.1124/pr.115.012021] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antiepileptic drugs (AEDs) have many benefits but also many side effects, including aggression, agitation, and irritability, in some patients with epilepsy. This article offers a comprehensive summary of current understanding of aggressive behaviors in patients with epilepsy, including an evidence-based review of aggression during AED treatment. Aggression is seen in a minority of people with epilepsy. It is rarely seizure related but is interictal, sometimes occurring as part of complex psychiatric and behavioral comorbidities, and it is sometimes associated with AED treatment. We review the common neurotransmitter systems and brain regions implicated in both epilepsy and aggression, including the GABA, glutamate, serotonin, dopamine, and noradrenaline systems and the hippocampus, amygdala, prefrontal cortex, anterior cingulate cortex, and temporal lobes. Few controlled clinical studies have used behavioral measures to specifically examine aggression with AEDs, and most evidence comes from adverse event reporting from clinical and observational studies. A systematic approach was used to identify relevant publications, and we present a comprehensive, evidence-based summary of available data surrounding aggression-related behaviors with each of the currently available AEDs in both adults and in children/adolescents with epilepsy. A psychiatric history and history of a propensity toward aggression/anger should routinely be sought from patients, family members, and carers; its presence does not preclude the use of any specific AEDs, but those most likely to be implicated in these behaviors should be used with caution in such cases.
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Affiliation(s)
- Martin J Brodie
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Frank Besag
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Alan B Ettinger
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Marco Mula
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Gabriella Gobbi
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Stefano Comai
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Albert P Aldenkamp
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Bernhard J Steinhoff
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
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Belcastro V, Pisani LR, Bellocchi S, Casiraghi P, Gorgone G, Mula M, Pisani F. Brain tumor location influences the onset of acute psychiatric adverse events of levetiracetam therapy: an observational study. J Neurol 2017; 264:921-927. [PMID: 28315958 DOI: 10.1007/s00415-017-8463-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
To explore possible correlations among brain lesion location, development of psychiatric symptoms and the use of antiepileptic drugs (AEDs) in a population of patients with brain tumor and epilepsy. The medical records of 283 patients with various types of brain tumor (161 M/122 F, mean age 64.9 years) were analysed retrospectively. Patients with grade III and IV glioma, previous history of epileptic seizures and/or psychiatric disorders were excluded. Psychiatric symptoms occurring after initiation of AED therapy were considered as treatment emergent psychiatric adverse events (TE-PAEs) if they fulfilled the following conditions: (1) onset within 4 weeks after the beginning of AED therapy; (2) disappearance on drug discontinuation; (3) absence of any other identified possible concurrent cause. The possible influence of the following variables were analysed: (a) AED drug and dose; (b) location and neuroradiologic features of the tumor, (c) location and type of EEG epileptic abnormalities, (d) tumor excision already or not yet performed; (e) initiation or not of radiotherapy. TE-PAEs occurred in 27 of the 175 AED-treated patients (15.4%). Multivariate analysis showed a significant association of TE-PAEs occurrence with location of the tumor in the frontal lobe (Odds ratio: 5.56; 95% confidence interval 1.95-15.82; p value: 0.005) and treatment with levetiracetam (Odds ratio: 3.61; 95% confidence interval 1.48-8.2; p value: 0.001). Drug-unrelated acute psychiatric symptoms were observed in 4 of the 108 AED-untreated patients (3.7%) and in 7 of the 175 AED-treated patients (4%). The results of the present study suggest that an AED alternative to levetiracetam should be chosen to treat epileptic seizures in patients with a brain tumor located in the frontal lobe to minimize the possible onset of TE-PAEs.
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Affiliation(s)
| | - Laura Rosa Pisani
- Neurology Unit, "Cutrona Zodda" Hospital, Barcellona Pozzo di Gotto, ME, Italy
| | | | | | | | - Marco Mula
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals, NHS Foundation Trust and Institute of Medical and Biomedical Sciences, St George's University of London, London, UK
| | - Francesco Pisani
- Department of Experimental and Clinical Medicine, University of Messina, Messina, Italy
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Anzellotti F, Franciotti R, Zhuzhuni H, D’Amico A, Thomas A, Onofrj M. Nonepileptic seizures under levetiracetam therapy: a case report of forced normalization process. Neuropsychiatr Dis Treat 2014; 10:959-64. [PMID: 24926197 PMCID: PMC4049430 DOI: 10.2147/ndt.s60089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Nonepileptic seizures (NES) apparently look like epileptic seizures, but are not associated with ictal electrical discharges in the brain. NES constitute one of the most important differential diagnoses of epilepsy. They have been recognized as a distinctive clinical phenomenon for centuries, and video/electroencephalogram monitoring has allowed clinicians to make near-certain diagnoses. NES are supposedly unrelated to organic brain lesions, and despite the preponderance of a psychiatric/psychological context, they may have an iatrogenic origin. We report a patient with NES precipitated by levetiracetam therapy; in this case, NES was observed during the disappearance of epileptiform discharges from the routine video/electroencephalogram. We discuss the possible mechanisms underlying NES with regard to alternative psychoses associated with the phenomenon of the forced normalization process.
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Affiliation(s)
- Francesca Anzellotti
- Department of Neuroscience and Imaging, Aging Research Centre, Gabriele d’Annunzio University Foundation, Gabriele d’Annunzio University, Chieti, Italy
| | - Raffaella Franciotti
- Department of Neuroscience and Imaging, Aging Research Centre, Gabriele d’Annunzio University Foundation, Gabriele d’Annunzio University, Chieti, Italy
| | - Holta Zhuzhuni
- Department of Neuroscience and Imaging, Aging Research Centre, Gabriele d’Annunzio University Foundation, Gabriele d’Annunzio University, Chieti, Italy
| | - Aurelio D’Amico
- Department of Neuroscience and Imaging, Aging Research Centre, Gabriele d’Annunzio University Foundation, Gabriele d’Annunzio University, Chieti, Italy
| | - Astrid Thomas
- Department of Neuroscience and Imaging, Aging Research Centre, Gabriele d’Annunzio University Foundation, Gabriele d’Annunzio University, Chieti, Italy
| | - Marco Onofrj
- Department of Neuroscience and Imaging, Aging Research Centre, Gabriele d’Annunzio University Foundation, Gabriele d’Annunzio University, Chieti, Italy
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16
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Korczyn AD, Schachter SC, Brodie MJ, Dalal SS, Engel J, Guekht A, Hecimovic H, Jerbi K, Kanner AM, Landmark CJ, Mares P, Marusic P, Meletti S, Mula M, Patsalos PN, Reuber M, Ryvlin P, Štillová K, Tuchman R, Rektor I. Epilepsy, cognition, and neuropsychiatry (Epilepsy, Brain, and Mind, part 2). Epilepsy Behav 2013; 28:283-302. [PMID: 23764496 PMCID: PMC5016028 DOI: 10.1016/j.yebeh.2013.03.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2013] [Indexed: 12/13/2022]
Abstract
Epilepsy is, of course, not one disease but rather a huge number of disorders that can present with seizures. In common, they all reflect brain dysfunction. Moreover, they can affect the mind and, of course, behavior. While animals too may suffer from epilepsy, as far as we know, the electrical discharges are less likely to affect the mind and behavior, which is not surprising. While the epileptic seizures themselves are episodic, the mental and behavioral changes continue, in many cases, interictally. The episodic mental and behavioral manifestations are more dramatic, while the interictal ones are easier to study with anatomical and functional studies. The following extended summaries complement those presented in Part 1.
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Affiliation(s)
- Amos D. Korczyn
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv 69978, Israel
| | - Steven C. Schachter
- Center for Integration of Medicine and Innovative Technology, Harvard Medical School, Boston, MA, USA
| | | | - Sarang S. Dalal
- Zukunftskolleg & Department of Psychology, University of Konstanz, Germany
- Lyon Neuroscience Research Center (CRNL), INSERM U1028, CNRS UMR5292, University Lyon I, Brain Dynamics and Cognition Team, Lyon, France
| | | | - Alla Guekht
- Russian National Research Medical University, Moscow City Hospital No. 8 for Neuropsychiatry, Moscow, Russia
| | - Hrvoje Hecimovic
- Zagreb Epilepsy Center, Department of Neurology, University Hospital, Zagreb, Croatia
| | - Karim Jerbi
- Lyon Neuroscience Research Center (CRNL), INSERM U1028, CNRS UMR5292, University Lyon I, Brain Dynamics and Cognition Team, Lyon, France
| | - Andres M. Kanner
- Department of Neurology, University of Miami, Miller School of Medicine, Miami FL, USA
| | - Cecilie Johannessen Landmark
- Department of Pharmacy and Biomedical Science, Oslo, Norway
- Akershus University College of Applied Sciences, Oslo, Norway
| | - Pavel Mares
- Institute of Physiology, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Petr Marusic
- Department of Neurology, Charles University in Prague, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| | - Stefano Meletti
- Department of Biomedical Sciences, Metabolism, and Neuroscience, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Mula
- Amedeo Avogadro University, Novara, Italy
| | - Philip N. Patsalos
- Department of Clinical and Experimental Epilepsy, UCL-Institute of Neurology, London and Epilepsy Society, Chalfont St Peter, UK
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - Philippe Ryvlin
- Service de neurologie fonctionnelle et d’épileptologie, Hôpital Neurologique, HCL TIGER, CRNL, INSERM U1028, UMR-CNRS 5292, Université Lyon-1, Lyon, France
| | - Klára Štillová
- Masaryk University, Brno Epilepsy Center, St. Anne’s Hospital and School of Medicine, and Central European Institute of Technology (CEITEC), Brno, Czech Republic
| | - Roberto Tuchman
- Autism and Neurodevelopment Program, Miami Children’s Hospital Dan Marino Center, Departments of Neurology and Psychiatry, Herbert Wertheim College of Medicine, Florida International University, FL, USA
| | - Ivan Rektor
- Masaryk University, Brno Epilepsy Center, St. Anne’s Hospital and School of Medicine, and Central European Institute of Technology (CEITEC), Brno, Czech Republic
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Alsaadi T, Zamel K, Sameer A, Fathalla W, Koudier I. Depressive disorders in patients with epilepsy: Why should neurologists care? Health (London) 2013. [DOI: 10.4236/health.2013.56a1003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hallucination in a seizure patient using levetiracetam: a case report. Case Rep Med 2012; 2012:706243. [PMID: 22851978 PMCID: PMC3407664 DOI: 10.1155/2012/706243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 06/13/2012] [Accepted: 06/27/2012] [Indexed: 11/17/2022] Open
Abstract
Levetiracetam, a relatively new antiepileptic drug (AED), is used mainly as adjuvant and less as monotherapy of seizure. Though rare, Levetiracetam is reported to induce hallucination. To highlight the potential of this adverse drug event, we report a seizure-case that had auditory hallucination with Levetiracetam. A 32-year lady had 7-year history of unresponsive spells which increased in the last year, also occurred while asleep and were diagnosed as “generalized seizure” with video-EEG. With gradual optimization of Levetiracetam to 2250 mg, she continuously heard distressing sound of saw cutting wooden blocks. After 3-day continuous auditory hallucination, Levetiracetam had to be changed to sodium valproate.
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Lee JJ, Song HS, Hwang YH, Lee HW, Suh CK, Park SP. Psychiatric symptoms and quality of life in patients with drug-refractory epilepsy receiving adjunctive levetiracetam therapy. J Clin Neurol 2011; 7:128-36. [PMID: 22087206 PMCID: PMC3212598 DOI: 10.3988/jcn.2011.7.3.128] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 03/09/2011] [Accepted: 03/09/2011] [Indexed: 01/31/2023] Open
Abstract
Background and Purpose Levetiracetam (LEV) is a new antiepileptic drug that has been found to be effective as an adjunctive therapy for uncontrolled partial seizures. However, the results of several studies suggested that LEV has negative psychotropic effects, including irritability, aggressiveness, suicidality, and mood disorders. We investigated the impact of adjunctive LEV on psychiatric symptoms and quality of life (QOL) in patients with drug-refractory epilepsy (DRE) and determined the risk factors provoking psychiatric adverse events. Methods A 24-week, prospective, open-label study was conducted. At enrollment, we interviewed patients and reviewed their medical charts to collect demographic and clinical information. They were asked to complete self-report health questionnaires designed to measure various psychiatric symptoms and QOL at enrollment and 24 weeks later. Results Seventy-one patients were included in the study, 12 patients (16.9%) of whom discontinued LEV therapy due to serious adverse events including suicidality. The risk factor for premature withdrawal was a previous history of psychiatric diseases (odds ratio 4.59; 95% confidence interval, 1.22-17.32). LEV intake resulted in significant improvements in Beck Anxiety Inventory score (p<0.01) and some domains of the Symptom Checklist-90-Revised, such as somatization (p<0.05), obsessive-compulsiveness (p<0.05), depression (p<0.05), and anxiety (p<0.05). These improvements were not related to the occurrence of seizure freedom. The Quality of Life in Epilepsy Inventory-31 overall score and subscale scores, such as seizure worry (p<0.01), overall QOL (p<0.05), emotional well-being (p<0.05), energy-fatigue (p<0.05), and social function (p<0.05), also improved. Conclusions Adjunctive LEV in patients with DRE is likely to improve psychiatric symptoms and QOL. Clinicians should be well aware of the psychiatric histories of patients to prevent them from developing serious adverse events related to LEV.
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Affiliation(s)
- Jang-Joon Lee
- Department of Neurology, Daegu Fatima Hospital, Daegu, Korea
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Abstract
Levetiracetam (Keppra®, E Keppra®) is an established second-generation antiepileptic drug (AED). Worldwide, levetiracetam is most commonly approved as adjunctive treatment of partial onset seizures with or without secondary generalization; other approved indications include monotherapy treatment of partial onset seizures with or without secondary generalization, and adjunctive treatment of myoclonic seizures associated with juvenile myoclonic epilepsy and primary generalized tonic-clonic (GTC) seizures associated with idiopathic generalized epilepsy. Levetiracetam has a novel structure and unique mechanisms of action. Unlike other AEDs, the mechanisms of action of levetiracetam appear to involve neuronal binding to synaptic vesicle protein 2A, inhibiting calcium release from intraneuronal stores, opposing the activity of negative modulators of GABA- and glycin-gated currents and inhibiting excessive synchronized activity between neurons. In addition, levetiracetam inhibits N-type calcium channels. Levetiracetam is associated with rapid and complete absorption, high oral bioavailability, minimal metabolism that consists of hydrolysis of the acetamide group, and primarily renal elimination. It lacks cytochrome P450 isoenzyme-inducing potential and is not associated with clinically significant pharmacokinetic interactions with other drugs, including other AEDs. The efficacy of oral immediate-release levetiracetam in controlling seizures has been established in numerous randomized, double-blind, controlled, multicentre trials in patients with epilepsy. Adjunctive levetiracetam reduced the frequency of seizures in paediatric and adult patients with refractory partial onset seizures to a significantly greater extent than placebo. Monotherapy with levetiracetam was noninferior to that with carbamazepine controlled release in controlling seizures in patients with newly diagnosed partial onset seizures. Levetiracetam also provided seizure control relative to placebo as adjunctive therapy in patients with idiopathic generalized epilepsy with myoclonic seizures or GTC seizures. In addition, patients receiving oral levetiracetam showed improvements in measures of health-related quality of life relative to those receiving placebo. Although treatment-emergent adverse events were commonly reported in the clinical trials of levetiracetam, the overall proportion of patients who experienced at least one treatment-emergent adverse event was broadly similar in the levetiracetam and placebo treatment groups, with most events being mild to moderate in severity. Levetiracetam is not associated with cognitive impairment or drug-induced weight gain, but has been associated with behavioural adverse effects in some patients.
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Mula M, Hesdorffer DC. Suicidal behavior and antiepileptic drugs in epilepsy: analysis of the emerging evidence. DRUG HEALTHCARE AND PATIENT SAFETY 2011; 3:15-20. [PMID: 21753899 PMCID: PMC3132858 DOI: 10.2147/dhps.s13070] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Indexed: 11/23/2022]
Abstract
Two years after the warning issued by the Food and Drug Administration on an increased risk of suicide for people taking antiepileptic drugs (AEDs), a number of pharmacoepidemiologic studies have been published but the scientific community is far from definitive answers. The present paper is aimed at reviewing available evidence on the association between AEDs and suicidal behavior, discussing major variables involved such as the relationship between epilepsy, depression, and suicide and the psychotropic potential of AEDs. All studies published so far show a lack of concordance and are constrained by various methodological limitations. What seems to be established is that mood disorders represent a frequent comorbidity in epilepsy and suicide is a serious complication more frequently encountered in epilepsy rather than in the general population. Moreover, a subgroup of patients appears to be at risk of developing treatment-emergent psychiatric adverse effects of AEDs independently of the specific mechanism of action of the drug. The prior history of suicide attempt, especially preceding the onset of the epilepsy, may represent a key element explaining why what is observed is independent of the specific mechanism of the drug. In general terms, risks associated with stopping, or not even starting, AEDs in epilepsy might well be in excess of the risk of suicide in epilepsy, as deaths due to accident and epilepsy itself may predominate. Clinicians need to pay attention not only to seizure patterns when choosing the appropriate AED but also to a number of different parameters (eg, age, gender, working needs, medical comorbidities, history of psychiatric disorders, and suicidality before epilepsy onset) and not the least the mental state of the patient. Missing severe complications such as suicidal behavior or delaying its treatment may worsen the prognosis of epilepsy.
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Affiliation(s)
- Marco Mula
- Department of Clinical and Experimental Medicine, Amedeo Avogadro University and Division of Neurology, University Hospital Maggiore della Carità, Novara, Italy
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White JR, Walczak TS, Marino SE, Beniak TE, Leppik IE, Birnbaum AK. Zonisamide discontinuation due to psychiatric and cognitive adverse events: a case-control study. Neurology 2010; 75:513-8. [PMID: 20697103 DOI: 10.1212/wnl.0b013e3181eccfb5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Zonisamide (ZNS) is an antiepileptic drug (AED) that has been associated with psychiatric adverse events (PAE) and cognitive adverse events (CAE); controlled studies evaluating these adverse events are limited. Our objectives were to 1) determine the incidence of PAE and CAE leading to the discontinuation of ZNS and 2) identify risk factors for PAE and CAE associated with the discontinuation of ZNS. METHODS All patients exposed to ZNS at MINCEP Epilepsy Care between March 2000 and September 2008 were identified. Reasons for discontinuing ZNS were documented. Separate case-control studies were performed to identify risk factors associated with the discontinuation of ZNS due to PAE or CAE via multivariate binary logistic regression. RESULTS A total of 544 patients were exposed to ZNS during the study period. PAE and CAE were the most frequently identified reasons for terminating ZNS therapy. The incidence of PAE severe enough to be associated with the discontinuation of ZNS was 6.9%; the incidence of CAE was 5.8%. Factors associated with termination of ZNS therapy due to PAE were past psychiatric history (p = 0.005), symptomatic generalized epilepsy (p = 0.027), and lower maximum ZNS serum concentration (mean = 17.9 mg/L vs 34.7 mg/L, p < 0.001). Independent variables associated with discontinuing ZNS due to CAE were greater number of concomitant AEDs (p = 0.011) and lower maximum ZNS serum concentration (mean = 16.6 mg/L vs 30.6 mg/L, p = 0.002). CONCLUSIONS We have identified clinically relevant risk factors associated with the discontinuation of ZNS. Our findings support the concept that selected patients are relatively more vulnerable to CNS adverse events when exposed to ZNS.
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Affiliation(s)
- J R White
- MINCEP Epilepsy Care, Minneapolis, MN 55416, USA.
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Karouni M, Arulthas S, Larsson PG, Rytter E, Johannessen SI, Landmark CJ. Psychiatric comorbidity in patients with epilepsy: a population-based study. Eur J Clin Pharmacol 2010; 66:1151-60. [PMID: 20669014 DOI: 10.1007/s00228-010-0861-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 06/22/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE Patients with epilepsy often suffer from concomitant psychiatric disorders. Treatment patterns and the extent of comorbidity are insufficiently investigated and appropriate methods are scarce. The purpose of the study was to estimate the prevalence of psychiatric comorbidity in patients with epilepsy and to investigate prescription patterns of drugs prescribed for psychiatric disorders in epilepsy. METHODS Prescription data from the Norwegian Prescription Database (NorPD) regarding the use of CNS-active drugs included anonymous data from almost 190,000 patients and 1.1-1.3 million prescriptions per year (2004-2007). Searches were based upon use of specific drugs, defined daily doses, number of patients, prescriptions, gender, and age. Reimbursement codes related to psychiatric diagnosis were used as indicators for clinical use. RESULTS The prevalence of psychiatric comorbidity in patients with epilepsy was estimated to be 32%. There were 56% women and 44% men participating in the study. Among patients using antidepressants two thirds were women, but no gender differences were seen with antipsychotic medication. Antidepressants and antipsychotics were used 3.4 (20.9%) and 5.8 (13.4%) times more frequently than in the general population, accounting for 7.88 and 1.99 defined daily doses (DDDs)/1,000 inhabitants/day/year respectively. Lamotrigine was the most commonly used antiepileptic drug (AED) in epilepsy, accounting for 33% of the use of AEDs (in total 5.65 DDDs/1,000 inhabitants/day/year). The use of benzodiazepines was 9.55 DDDs/1,000 inhabitants/day/year. The patients had complex pharmacotherapy with two to eight concomitant drugs. CONCLUSION The present study gives an estimate of psychiatric comorbidity of 32% in patients with epilepsy in a nation-wide population. The pharmacotherapy in this patient population is complex. The results provide valuable data on prescription patterns that contribute to pharmacovigilance on a national scale.
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Affiliation(s)
- Mohamad Karouni
- Department of Pharmacy, Faculty of Health Sciences, Oslo University College, Pilestredet 50, 0167, Oslo, Norway
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Abstract
Anti-epileptic drugs (AEDs) continue to be the mainstay of epilepsy treatment, but the benefits of seizure control need to be weighed carefully against possible adverse effects, which can include behavioral problems and psychiatric disorders. In this paper, the associations between AEDs and psychosis, depression and behavioral changes are reviewed. The concept of forced normalization and its clinical counterpart, alternative psychosis, are also discussed. Depression seems to be linked with AEDs potentiating GABAergic neurotransmission in patients with limbic system abnormalities such as hippocampal sclerosis. Psychoses have been described as associated with several of the new AEDs, and they are often seen in a setting in which previously refractory patients suddenly become seizure-free. In general terms, the use of AEDs in monotherapy, adopting slow titration schedules and low doses when possible, can significantly reduce the occurrence of behavioral adverse effects. A previous history of psychiatric disorder or a familial predisposition are important risk factors and should be always considered when choosing the appropriate AED.
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Affiliation(s)
- Marco Mula
- Department of Neurology, Amedeo Avogadro University, Novara, Italy.
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Abstract
Epilepsy is a common chronic disorder that requires long-term antiepileptic drug therapy. Approximately one half of patients fail the initial antiepileptic drug and about 35% are refractory to medical therapy, highlighting the continued need for more effective and better tolerated drugs. Levetiracetam is an antiepileptic drug marketed since 2000. Its novel mechanism of action is modulation of synaptic neurotransmitter release through binding to the synaptic vesicle protein SV2A in the brain. Its pharmacokinetic advantages include rapid and almost complete absorption, minimal insignificant binding to plasma protein, absence of enzyme induction, absence of interactions with other drugs, and partial metabolism outside the liver. The availability of an intravenous preparation is yet another advantage. It has been demonstrated effective as adjunctive therapy for refractory partial-onset seizures, primary generalized tonic-clonic seizures, and myoclonic seizures of juvenile myoclonic epilepsy. In addition, it was found equivalent to controlled release carbamazepine as first-line therapy for partial-onset seizures, both in efficacy and tolerability. Its main adverse effects in randomized adjunctive trials in adults have been somnolence, asthenia, infection, and dizziness. In children, the behavioral adverse effects of hostility and nervousness were also noted. Levetiracetam is an important addition to the treatment of epilepsy.
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Affiliation(s)
- Bassel Abou-Khalil
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, Tennessee, USA.
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