Herbal medicine and epilepsy: proconvulsive effects and interactions with antiepileptic drugs

Diet-derived circulating antioxidants and risk of epilepsy: a Mendelian randomization study

Background

Previous studies suggest a link between diet-derived circulating antioxidants and epilepsy, but the causal relationship is unclear. This study aims to investigate the causal effect of these antioxidants on epilepsy.

Methods

To assess the causal link between dietary antioxidants and epilepsy risk, we conducted a two-sample Mendelian randomization (MR) analysis. This involved examining antioxidants such as zinc, selenium, α- and γ-tocopherol, vitamin A (retinol), vitamin C (ascorbate), and vitamin E (α-tocopherol). We utilized instrumental variables (IVs) which were genetic variations highly associated with these commonly used antioxidants. Exposure data were sourced from a comprehensive genome-wide association study (GWAS). We aggregated data from the International League Against Epilepsy (ILAE) Consortium sample, which included various types of epilepsy, as an outcome variable. Finally, we applied the inverse variance weighting method and conducted sensitivity analyses for further validation.

Results

Based on the primary MR estimates and subsequent sensitivity analyses, the inverse variance weighting (IVW) method revealed that a genetically predicted increase in zinc per standard deviation was positively associated with three types of epilepsy. This includes all types of epilepsy (OR = 1.06, 95% CI: 1.02-1.11, p = 0.008), generalized epilepsy (OR = 1.13, 95% CI: 1.01-1.25, p = 0.030), and focal epilepsy (documented hippocampal sclerosis) (OR = 1.01, 95% CI: 1.00-1.02, p = 0.025). However, there is no evidence indicating that other antioxidants obtained from the diet affect the increase of epilepsy either positively or negatively.

Conclusion

Our research indicates that the risk of developing epilepsy may be directly linked to the genetic prediction of zinc, whereas no such association was found for other antioxidants.

Herb-drug interactions: A short review on central and peripheral nervous system drugs

Herbal medicines are widely perceived as natural and safe remedies. However, their concomitant use with prescribed drugs is a common practice, often undertaken without full awareness of the potential risks and frequently without medical supervision. This practice introduces a tangible risk of herb-drug interactions, which can manifest as a spectrum of consequences, ranging from acute, self-limited reactions to unpredictable and potentially lethal scenarios. This review offers a comprehensive overview of herb-drug interactions, with a specific focus on medications targeting the Central and Peripheral Nervous Systems. Our work draws upon a broad range of evidence, encompassing preclinical data, animal studies, and clinical case reports. We delve into the intricate pharmacodynamics and pharmacokinetics underpinning each interaction, elucidating the mechanisms through which these interactions occur. One pressing issue that emerges from this analysis is the need for updated guidelines and sustained pharmacovigilance efforts. The topic of herb-drug interactions often escapes the attention of both consumers and healthcare professionals. To ensure patient safety and informed decision-making, it is imperative that we address this knowledge gap and establish a framework for continued monitoring and education. In conclusion, the use of herbal remedies alongside conventional medications is a practice replete with potential hazards. This review not only underscores the real and significant risks associated with herb-drug interactions but also underscores the necessity for greater awareness, research, and vigilant oversight in this often-overlooked domain of healthcare.

Use of complementary and alternative medicine in children affected by oncologic, neurologic and liver diseases: a narrative review

Complementary and alternative medicine (CAM) consist of a broad group of restorative resources often linked to existing local cultures and established health care systems and are also increasingly used in children with some serious illnesses. In this narrative review, we examine the epidemiology of the use, efficacy, and safety of complementary and alternative medicine in pediatric oncology, neurology, and hepatology. We searched for relevant articles published in Pubmed evaluating CAM use and its efficacy in safety in children affected by oncologic, neurologic and liver diseases. CAM is used to improve the success of conventional therapies, but also to alleviate the pain, discomfort, and suffering resulting from the diseases and their treatment, which are often associated with a significant burden of adverse effects. CAM use must be evaluated in children with neurological, oncological and liver diseases.

Parent-reported complementary and alternative medicine use among pediatric patients with epilepsy at two tertiary centers in Turkey - Prevalence and predictors

BACKGROUND

Complementary and alternative medicine (CAM) consists of various medical practices and products not recognized as a part of conventional medicine. There are few studies on CAMs used for childhood epilepsy. We aimed to determine the prevalence and socio-demographic factors affecting CAM use in children with epilepsy.

METHODS

This is a cross-sectional prospective descriptive study. The study included all parents who agreed to participate and had children with epilepsy. The data was collected using a questionnaire developed from a literature review of CAM use in pediatric epilepsy patients.

RESULTS

A total of 219 parent-child pairs were included in the study. Seventy-five participants had one or more comorbid disorders. 55.3% of participating children with epilepsy were taking more than one antiseizure medication (ASM). 30.1% of parents reported using some form of CAM for their children in the previous year. Only 60.6% of parents discussed their CAM decision with their child's doctor before using it. Univariate analysis showed that the patient's age, presence of comorbid disorders, duration of ASM, and family history of epilepsy were statistically significant predictors for CAM use. However, the presence of comorbidities was the only significant predictor of CAM use in logistic regression.

CONCLUSION

Even though most parents believe CAMs have no effect on their children with epilepsy, they frequently use them. We propose that the predictors identified in this study can help to identify potential CAM users. Since most parents do not report the use of CAM, physicians should routinely inquire about CAM use.

Use of Integrative, Complementary, and Alternative Medicine in Children with Epilepsy: A Global Scoping Review

(1) Background: Epilepsy is one of the most common chronic neurological disorders in childhood. Complementary and alternative medicine (CAM) use is highly prevalent in patients with epilepsy. Despite CAM's widespread and increasing popularity, its prevalence, forms, perceived benefits, and potential risks in pediatric epilepsy are rarely explored. (2) Methods: We performed a scoping review of the available literature on the use of CAM in pediatric epilepsy. (3) Results: Overall, global cross-sectional studies showed a variable degree of CAM usage among children with epilepsy, ranging from 13 to 44% in prevalence. Popular types of CAMs reported were supplements, cannabis products, aromatherapy, herbal remedies, dietary therapy, massage therapy, and prayer. Families often report that CAM is effective, although there are limited objective measures of this. Potential risks lie in the use of CAM, such as herbal remedies, and/or unregulated, contaminated, or unpurified products. Studies also underscored inadequate patient-physician discussions regarding CAM. (4) Conclusions: A better understanding of this topic would aid clinicians in guiding patients/families on the use of CAM. Further studies on the efficacy of the different types of CAM used, as well as potential side effects and drug interactions are needed.

Efficacy and safety of traditional Chinese medicine for the treatment of epilepsy: A updated meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy and safety of Traditional Chinese Medicine (TCM) in the treatment of epilepsy.

METHODS

A comprehensive search of the database in both Chinese and English was performed. Data from the selected studies were extracted and analyzed independently by two authors.

RESULTS

30 randomized controlled trials (RCTs) were included in the meta-analysis with a total of 2471 patients. Among them, 4 trials (n = 235) focused on TCM monotherapy, while the other 26 trials (n = 2236) assessed the benefit of TCM as an add-on therapy to antiseizure medications (ASMs). For the efficacy, the meta-analysis found (1) The effective rate in TCM monotherapy group was higher than that in control group (OR = 4.92, 95 % CI: 2.29-10.57, Z = 4.08, P 0.0001); (2) The add-on of TCM also increased the effective rate (OR = 3.37, 95 % CI: 2.65-4.30, Z = 9.85, P 0.00001) and seizure freedom rate (OR = 1.93, 95 % CI: 1.53-2.44, Z = 5.58, P 0.00001). In terms of safety, the add-on of TCM reduced the rate of total adverse events (OR = 0.46, 95 % CI: 0.31-0.67, Z = 3.96, P 0.0001) as well as adverse events of the gastrointestinal and nervous system. 26 different TCM prescriptions were used in these included RCTs. Among them, the 5 most frequently used herbs were Acorus tatarinowii (19 out of 26), Glycyrrhiza uralensis (13 out of 26), Gastrodia elata (12 out of 26), Pinellia ternata (11 out of 26) and Poria cocos (11 out of 26).

CONCLUSION

This study suggested that TCM may be a relatively efficacious and safe clinical strategy for the treatment of epilepsy. Several limitations still exist, such as the risk of bias in the included studies, the diversified composition of TCM prescriptions, and the relatively low quality of study design.

On epilepsy perception: Unravelling gaps and issues

Epilepsy is one of the most common neurological diseases, but it can sometimes be under-reported or have a time delay in diagnosis. This data is not surprising if we consider that a person often seeks medical attention only after presenting a generalized tonic-clonic seizure. Epilepsy diagnostic delay is caused by several factors: under-reporting by patients, under-diagnosed epileptic manifestations by inexperienced clinicians, and lack of time in the emergency setting. The consequences of this delay are increased accidents, a high rate of premature mortality, and economic expanses for the healthcare system. Moreover, people with epilepsy have a higher probability of comorbidities than the general population, such as mood disorders or cognitive problems. Along with recurrent seizures, these comorbid diseases promote isolation and stigmatization of people with epilepsy, who suffer from discrimination at school, in the workplace, and even in social relationships. Public awareness of epilepsy and its comorbidities is necessary to prevent diagnostic delays and overcome social and professional iniquities for people with epilepsy.

Complementary and alternative medicine for treating epilepsy in China: A systematic review

There are about 10 million people with epilepsy (PWE) in China. In addition to therapies approved by the National Medical Products Administration, the use of complementary and alternative medicine (CAM) is prevalent in Chines PWE. These CAM therapies mainly comprise traditional Chinese medicine herbs (TCMHs), acupuncture, and music. A retrospective literature search was performed to summarize the updates of CAM in China in the past ten years, and sixty-two papers were finally included. In this following review, we listed the animal and clinical studies to summarize the antiepileptic mechanisms and clinical efficacy of CAM in Chines PWE. The main mechanisms of TCMHs and acupuncture included regulation of neurotransmitters and receptors, voltage-gated ion channels modulation, expression of apoptosis-related genes, antioxidant response, and anti-inflammation. Although there were enormous clinical studies on them, the current available clinical trials were small, short-term, heterogeneous, and had a high risk of bias. With regard to music, a few studies conducted by Chinese scholars suggested that it was beneficial for PWE as an add-on therapy, which was consistent with the results of foreign studies. Further randomized clinical trials in large populations are required to prove the effectiveness and safety of CAM.

Use of Complementary and Alternative Medicine Among Patients With Epilepsy and Diabetes Mellitus, Focusing on the Outcome of Treatment

Introduction: Millions all over the world live with epilepsy, and they may require long-term drug treatment. The use and interest in complementary and alternative medicine (CAM) have grown over the previous years. Coadministration of herbal products with medicines may result in adverse drug reactions (ADRs) and/or unfavorable interactions. The aims of this study were to determine the prevalence of CAM use among patients with epilepsy, to compare the results to those of the patients with diabetes mellitus (DM), to reveal factors that may drive the use of CAM, and to measure outcomes and adherence. It was also our intent to have state-of-the-art information on CAM use in our region among patients with the two diseases above.

Materials and Methods: We conducted a non-interventional study using a self-developed questionnaire. It was distributed among adult patients with either epilepsy or DM who also suffered from cardiovascular consequences. A database was compiled from the anonymous questionnaires filled in voluntarily by the patients. Basic statistics were used to analyze this database.

Results: A total of 227 questionnaires were filled in by 127 patients (55.9%) with epilepsy and 100 patients (44.1%) with DM. Mean age was 54.54 ± 17.33 years. Of the patients, 50.2% were male. Average body weight was 80.3 ± 17.3 kg. Of the patients, 22 (9.7%) used CAM because they believed in CAM. Two of them reported ADRs. Among the patients with epilepsy, the ratio was only 7.9% compared to 12% among those with DM. While the number of CAM users was higher among younger patients with epilepsy, it was the elderly patients with DM who tended to use CAM.

Conclusion: Attention should be paid to reliance on CAM during the follow-up. Our finding that health-conscious patients tend to use CAM more often (than the general population) may indicate it is necessary to discuss CAM usage sincerely. CAMs modulating cytochrome P450 (CYP) enzymes were the most common, leading to interactions with medication used and resulting in ADRs. This shows the importance of educating patients and treating team including clinical pharmacists in this field.

Evaluation of Factors Impacting the Efficacy of Single or Combination Therapies of Valproic Acid, Carbamazepine, and Oxcarbazepine: A Longitudinal Observation Study

Objective: This study aimed to determine the efficacy and clinical factors related to the pharmacodynamics of single or combination therapies of valproic acid (VPA), carbamazepine (CBZ), and oxcarbazepine (OXC), three commonly used anti-epileptic drugs (AEDs) in China.

Methods: The study evaluated the records of 2027 outpatients in a Changsha hospital, located in China, from December 23, 2015 to October 28, 2019. The baseline seizure frequency was assessed during the first visit. AED efficacy was determined based on the reduction in seizures from baseline at the subsequent visits. Multivariable ordinal regression analysis was used to determine the association between the clinical factors (demographic characteristics, clinical features, and medication situation) and AED efficacy. For validation, the clinical efficacies of AEDs were compared as both single agents and in combinations. Differences in adverse effect (AEs) categories were analyzed by Chi-square between AED groups.

Results: Records of patients receiving VPA, CBZ, and OXC were evaluated. Serum concentrations of VPA and CBZ is significantly correlated with efficacy (OR 1.030 [1.024–1.037], p < 0 0.0001; OR 1.250 [1.146–1.63], p < 0.0001, respectively) and OXC efficacy correlated to the serum concentration of the metabolite 10,11-dihydro-10-hydroxy-carbazepine (monohydroxy derivative, MHD) serum concentrations (OR 1.060 [1.031–1.089], p < 0.0001). Significant differences existed between females and males in VPA efficacy (OR 1.318 [1.033–1.682], p = 0.027). After validation, VPA, in combination with OXC (OR 1.93 [1.38–2.70], p<0.001), or with VGB (Vigabatrin) (OR 2.36 [1.38–2.70], p = 0.002), showed significantly better efficacy than as a single agent. OXC efficacy was also affected by the duration of epilepsy (OR 0.965 [0.946–0.984], p < 0.001). Additionally, the efficacies of OXC and VPA were also affected by the seizure type. Seizure reduction improved significantly with an increasing number of pharmacists’ educations in the first three visits period. There were no differences in AEs incidence among these 3 AEDs except for Psychiatric (0.02) and nervous system disorders (0.0001).

Conclusion: Serum concentrations of VPA and CBZ may positively affect their efficacies, while OXC efficacies are correlated to MHD serum concentrations. The efficacy of VPA was higher in females compared to males. VPA-OXC and VPA-VGB combinations had higher efficacies compared to monotherapy. Besides, OXC efficacy is probably reducing by the duration of epilepsy. Additionally, VPA efficacy for focal or generalized seizures is superior to mixed-type seizures. OXC was more effective for focal seizures compared to mixed-type ones. Education provided by pharmacists improved the seizures to some extent, and there were no significant differences between most categories of adverse effects for the investigated AEDs.

Complementary and alternative medicine in epilepsy: A global survey of physicians' opinions

PURPOSE

To investigate the opinions of physicians on the use of complementary and alternative medicine (CAM) in patients with epilepsy (PWE) worldwide.

METHODS

Online survey addressed to neurologists and psychiatrists from different countries.

RESULTS

Totally, 1112 physicians from 25 countries (different world region: Europe, North America, South America, Middle-East, Africa, Former Soviet Union Republics) participated; 804 (72.3%) believed that CAM might be helpful in PWE. The most commonly endorsed CAM included meditation (41%) and yoga (39%). Female sex, psychiatry specialization, and working in North and South America were associated with the belief that CAM is helpful in PWE. Two-hundred and forty five out of 1098 participants (22.3%) used/prescribed CAM to PWE; among them, 174 (71%) people perceived CAM to be less effective and 114 (46.5%) people found CAM to be safer than conventional antiseizure medications (ASMs). The most common reasons to prescribe CAM for PWE were: to satisfy the patient (49.9%), dissatisfaction with the efficacy (35.6%), and dissatisfaction with the adverse effects (31.2%) of conventional therapies.

CONCLUSION

Although the evidence supporting the use of CAM for the treatment of epilepsy is extremely sparse, most physicians worldwide believe that it could be integrated with the use of conventional ASMs, at least in some patients. High-quality controlled trials are warranted to provide robust evidence on the usefulness of CAM options in PWE.

Essential oil related seizures (EORS): A multi-center prospective study on essential oils and seizures in adults

OBJECTIVE

Essential oils (EOs) like eucalyptus and camphor have pro-convulsant properties. These EOs are present in many over- the- counter balms and oils. The effect of exposure to these EOs and occurrence of seizure is not systematically studied. The aim of this study was to evaluate the relationship between essential oils and the first episode of seizure and breakthrough seizures in known epileptic patients.

METHODS

This was a multi-center prospective study, conducted in four hospitals over four years. Every person presenting with the first episode of seizure or breakthrough seizure was asked about exposure to EOs, mode of exposure, time to onset of a seizure in relationship to exposure, duration of seizure, type of seizure, and antiepileptic drug therapy.

RESULTS

During the four-year period there were 55 patients with essential oil-related seizure (EORS). 22(40 %) had essential oil-induced seizures (EOIS) and 33(60 %) had essential oil-provoked seizures (EOPS). The female: male ratio was 1:1.1, the age of the patients ranged from 8 months to 77 years. In the EOIS group, 95 % had generalized tonic-clonic seizures and 5% had focal impaired awareness seizures. In the EOPS group, 42.4 % had focal impaired awareness seizures, 27.3 % generalized tonic-clonic seizures, 15 % focal to bilateral tonic-clonic seizures, and 15 % focal aware motor seizures. EOs implicated were preparations containing eucalyptus and camphor.

CONCLUSION

Exposure to essential oils of eucalyptus and camphor is an under-recognized cause of the first and breakthrough seizure. Identifying the true causative factor will prevent unnecessary antiepileptic drug therapy and future recurrence.

Eucalyptus Oil-Induced Seizures in Children: A Single-Center Prospective Study

Objective

Eucalyptus oil (EO) is known to have proconvulsant properties. EO is present in many over-the-counter preparations and used orally or topically to treat many ailments. In this study, we seek to describe clinical features, neuroimaging, and electroencephalographic findings and follow up outcome in children with eucalyptus oil-induced seizures (EOIS).

Materials and methods

This was a single-center prospective observational study, conducted at a tertiary care hospital from South India over a period of two years. Children (up to 18 years of age) with a first afebrile seizure or breakthrough seizures with preexisting epilepsy and with a recent exposure to EO were included. Data from all the children including demographic data, exposure to EO, mode of exposure, time to onset of seizures in relation to exposure, duration of seizure, type of seizure, investigations, and antiepileptic drug therapy were noted. All the patients were followed up for recurrence of seizures for six to nine months. 

Results

During the study period of two years, a total of 17 children met the inclusion criteria, with a median (range) age of 3.75 years (23 - 150 months) and 10 (59%) were male. Only one patient had breakthrough seizures and all other 16 children had a first episode of seizure. All the children had generalized tonic-clonic seizures with median duration of three minutes (30 sec - 30 minutes). The median (range) interval between EO exposure and the onset of seizures was 20 minutes (10 - 120 minutes). All the children had taken EO drops orally mixed in either water or milk in different amounts. All the patients' brain neuroimaging was normal. All the patients had normal electroencephalography except for four children. Only five patients were treated with antiepileptic drugs for two weeks and one patient with preexisting epilepsy was continued on the same antiepileptic drug. None of the patients had a recurrence of seizures during the follow-up period of six to nine months.

Conclusion 

EOIS is an underrecognized and rare entity of seizures in children. EOIS can occur as first seizures or as breakthrough seizures in preexisting epilepsy patients. Despite the previous case reports in the literature quoting the seizurogenic potential of EO, this awareness is lacking in both clinicians and parents. We also recommend clinicians inquire about exposure to EO while approaching a child with first afebrile seizures or breakthrough seizures, which can prevent unnecessary investigations and long-term antiepileptic drug therapy.

Status analysis of herbal drug therapies in epilepsy: advancements in the use of medicinal plants with anti-inflammatory properties

BACKGROUND

Use of plants and plant products in health care has shown exponential increase in past two decades.

INTRODUCTION

In-spite of the availability of well-established pharmacotherapy for epilepsy, a large no of population still explores alternative treatments due to refractory seizures, adverse effects of drugs, chronic treatment, inaccessibility of standard therapies in rural areas and the social stigma attached to the disease. Various studies on medicinal plants showed the protective effect of herbals in animal models of epilepsy.

METHOD

In the present review, a status analysis of the traditional use of various medicinal plants in epilepsy with a special focus on plats having anti-inflammatory potential is recorded.

RESULT AND CONCLUSION

The shortcomings of research on medicinal plants which needs to be explored further in order to tackle the growing need of safer and effective drugs for epilepsy are discussed. Overall, there is a huge scope of herbal drugs in CNS disorders especially epilepsy, either as an adjunct by reducing the dose and thus side effects of standard anti-epileptic drugs or as standalone agent . Although, there is still an urgent need of well planned randomized controlled clinical trials to validate their efficacy and safety.

Complementary and alternative medicine (CAM) for epilepsy treatment in the Middle East and North Africa (MENA) region

INTRODUCTION

The aim of this study is to provide the reader with a review on Complementary and Alternative Medicine (CAM) treatment in epilepsy in the Middle East and North Africa (MENA) region, to describe the extent and factors associated with its use among patients with epilepsy (PWE), and to recommend how effectively we will be able to reduce this alarming use.

MATERIAL AND METHODS

Retrospective literature search from 1945 to December 2019, regarding CAM use in the MENA region, using electronic databases (PubMed, Scopus, Google Scholar, Web of Science).

CONCLUSION

The use of CAM and consultation of traditional healers for the treatment of epilepsy has so far been widespread practice for centuries in the MENA region. Lack of health professionals and non-adherence to conventional epilepsy treatment are strongly associated with the use of CAM. Improvement in the level of knowledge of epilepsy among PWE, healthcare professionals, including traditional healers, will educate PWE and their caregivers on potentially unsafe practices and promote adherence to Antiseizure Drugs (ASDs). Additionally, randomized controlled trials are needed to study the role and value of various CAM treatment options in PWEs.

Proconvulsant effects of Nepeta menthoides hydro alcoholic extract in different seizure tests: behavioral and biochemical studies

In Iran, both Nepeta menthoides - the endemic species of Nepeta genus - and Lavandula officinalis are known as Ustukhuddoos and used widely as medicinal herbs. In Iranian traditional medicine, Ustukhuddoos has been recommended for several neuronal diseases including depression and epilepsy. While the antiepileptic effects of Lavandula officinalis have been investigated in a number of studies, no reports are available taking into account the effect of Nepeta menthoides on epilepsy. Since convulsion is an important side effect of some medicinal plants, a thorough study of the effects of Nepeta menthoides on epilepsy seems necessary.

This study was designed to investigate the potential anti- or pro-convulsant activity of Nepeta menthoides and its effects on oxidative stress markers. Since an herbal medicine showed opposite effects in two animal models of epilepsy in our laboratory, authers decided to study Nepeta effects through several seizure tests including the intravenous pentylenetetrazol (i.v. PTZ) infusion, the maximal electroshock (MES), acute PTZ and PTZ-kindling tests. These seizure models are generally used for screening pro- or anti-epileptic drugs. Nepeta menthoides (400 mg/kg) significantly reduced the dose of PTZ necessary for clonus seizure induction. Combining either phenytoin (Phen) or Valproate (Val) with Nepeta decreased their antiepileptic effects. Therefore, Nepeta menthoides not only failed to prevent the seizures but also increased sensitivity to them. Nepeta raised brain NO levels in different seizure tests. It seems there is a relation between NO elevation by Nepeta and increased sensitivity to seizures that should be investigated later.

Epilepsy: Workup and Management in Adults

When managing epilepsy, there is a temptation to focus care with respect to the last and the next seizure. However, epilepsy is a multifaceted chronic condition and should be treated as such. Epilepsy comes with many physical risks, psychological effects, and socioeconomic ramifications, demanding a long-term commitment from the treating physician. Patients with epilepsy, compared to other chronically ill patient populations, have a worse quality of life, family function, and less social support. The majority of patients are well controlled on antiseizure drugs. However, approximately one-third will continue to have seizures despite optimized medical management. The primary aim of this article is to explore the long-term management of chronic epilepsy, and to address some of the particular needs of patients with chronic epilepsy.

Proconvulsant effect of trans-cinnamaldehyde in pentylenetetrazole-induced kindling model of epilepsy: The role of TRPA1 channels

The transient receptor potential ankyrin 1 (TRPA1), a member of the TRP superfamily, is widely distributed in the central nervous system (CNS) and plays an important role in pain and inflammation. However, no data has been reported regarding the effects of TRPA1 on epileptic seizures. Thus, this study was designed to investigate the sub-chronic effect of trans-cinnamaldehyde (TCA), an agonist of TRPA1, in pentylenetetrazole (PTZ) induced kindling model via electrocorticography (ECoG). Furthermore, the expressions of cAMP response element binding protein (CREB), brain-derived neurotrophic factor (BDNF), and NMDA receptor subunit NR2B were measured using Western blotting. Rats were kindled by intraperitoneal (i.p.) PTZ (35 mg/kg) injections. After electrode implantation and healing period, 10 and 30 mg/kg TCA was given i.p. for 14 consecutive days. On the next day, ECoG recordings were obtained after the injection of PTZ (35 mg/kg, i.p.), and twenty-four hours later, rats were decapitated for molecular analyses. TCA, at a dose of 30 mg/kg, decreased the first myoclonic jerk latency and increased seizure duration and total spike activity. Additionally, both doses of TCA enhanced CREB, BDNF, and NR2B expressions, which were increased by the kindling. The evidence from this study suggests that long term activation of TRPA1 channels causes an exacerbated seizure activity. Moreover, PTZ-induced increases in CREB, BDNF, and NR2B levels were enhanced by the repeated administrations of TCA.

Optimizing Management of Medically Responsive Epilepsy

PURPOSE OF REVIEW

This article reviews the management of patients with medically responsive epilepsy, including discussion of factors that may lead to transient breakthrough seizures and patient and physician strategies to maintain freedom from seizures.

RECENT FINDINGS

Imperfect adherence, unanticipated changes in ongoing medical therapy, inadvertent use of proconvulsants or concurrent medications that alter epilepsy medication kinetics, and a variety of seizure precipitants such as stress or sleep deprivation may alter long-term seizure control.

SUMMARY

The majority of patients with epilepsy are medically responsive. Many potential factors may lead to breakthrough seizures in these patients. Identification of these factors, patient education, and use of self-management techniques including mindfulness therapy and cognitive-behavioral therapy may play a role in protecting patients with epilepsy against breakthrough seizures.

Complementary and integrative medicine in epilepsy: What patients and physicians perceive

PURPOSE

The purpose of the current study was to investigate the extent to which people with epilepsy (PWE) use complementary and integrative medicine (CIM) to treat their illness and to assess their perceptions. We also investigated the perceptions of their treating physicians.

METHODS

In this cross-sectional study, all adult patients with epilepsy, who had the illness for at least one year, were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, from January 2019 until March 2019. A questionnaire was designed for this survey. We also designed a similar questionnaire to investigate perceptions of the physicians in the same region.

RESULTS

One hundred and one patients participated. Seventy-one patients (70%) believed that CIM would be helpful in treating seizures; the most commonly reported CIM therapies were prayers, exercise, and herbs. Sixteen patients (16%) had actually used CIM to treat their seizures, but only one patient perceived that CIM was more effective than antiepileptic drugs to bring her seizures under control. Thirty-one neurologists participated in the study. Seventeen neurologists (55%) believed that CIM would be helpful in treating epileptic seizures. The most commonly reported CIM therapies were meditation, yoga, and exercise.

CONCLUSION

Complementary and integrative medicine is considered and used by many PWE to treat epileptic seizures. Cultural issues probably play an important role in having faith in CIM. Physicians involved in the care of PWE should provide appropriate information regarding the safety and efficacy of various CIM treatments for PWE.

Use of complementary and alternative medicine among adults with epilepsy in a university epilepsy clinic in Poland

INTRODUCTION

The use of complementary and alternative medicine (CAM) is becoming increasingly prevalent both in general population and patients with chronic diseases. The aim of the study was to determine the prevalence, reasons, and factors influencing the use of CAM in Polish patients with epilepsy (PWE).

MATERIAL AND METHODS

This prospective study involved PWE treated in a university epilepsy clinic. Data on epilepsy, antiepileptic drugs, level of education, vocational activity, and patterns of CAM were collected from a structured interview and from medical records.

RESULTS

The sample population consisted of 473 PWE (mean age: 35.3 years); 220 (46.5%) were females, and 228 (46.5%) were in remission. Overall 26.8% (127) of the cohort used at least one type of CAM. The CAM modalities most frequently used were herbal and dietary supplements (32.3%), energy healing (31.5%), and marijuana (27.6%). The internet was the most common source of information on CAM (45.7%). In one-third of subjects, CAM usage affected negatively compliance to standard treatment. Logistic regression analysis revealed several independent risk factors for CAM use in PWE: younger age, longer duration of epilepsy, lack of remission, and lower level of education.

CONCLUSION

A significant proportion of PWE uses CAM, and its usage may affect negatively compliance to standard treatment. Our findings highlight poor communication between patients and physicians with regard to CAM use. Healthcare professionalists should routinely check for CAM utilization in PWE to prevent potential harm related to its use.

Use of dietary and herbal supplements in adult patients with epilepsy

PURPOSE

To study the extent and characteristics of dietary and herbal supplements use in a large cohort of adult patients with epilepsy.

METHODS

This prospective study included 490 patients receiving care at a university epilepsy clinic. A number of variables, including demographics, characteristics of epilepsy and its treatment, comedication as well as data related to supplements intake were collected from medical records and a dedicated questionnaire.

RESULTS

Overall 247 patients (50.4%) took at least one dietary supplement; nearly half (111, 44.9%) of this group took >1 products. Multivitamins and magnesium were the most prevalent supplements. Most of the patients used supplements for general health rather than their epilepsy condition. The average number of supplements and prescription medications used per person was 5.4. Ten percent (25 of 247) of subjects used dietary supplements which could have proconvulsive effect or potential for interaction with prescription medications. Multivariate analysis revealed two independent variables associated with supplements intake, younger age and female sex.

CONCLUSION

Dietary and herbal supplements use is common in patients with epilepsy, adding to the burden of overmedication. Concurrent use of supplements may potentially lead to interactions with prescription medications or loss of seizure control. Health care providers should routinely check for dietary supplements use to limit potential harm related to their intake.

Medication adherence and adverse effect profile of antiepileptic drugs in Nigerian patients with epilepsy

Aim: Medication adherence remains a major challenge among patients with epilepsy (PWE) with the adverse effect profile of antiepileptic drugs (AEDs) as one of its main drivers. Methods: This was a cross-sectional questionnaire-based study among PWE in selected Nigerian tertiary healthcare facilities using the Morisky Medication Adherence Scale and the Liverpool Adverse Effect Profile (LAEP). Results: 126 PWE from four tertiary healthcare facilities were included in this study comprising of 59 (46.8%) males and 67 (53.2%) females. Carbamazepine (104/70.7%), sodium valproate (23/15.6%) and phenytoin (11/7.5%) were the most commonly prescribed AEDs. Using the Morisky Medication Adherence Scale, 17.2, 38.3 and 44.5% of patients were classified as having high, medium and low adherence, respectively. The mean LAEP score was 23.69 ± 6.07. The most common reported adverse effects among respondents were tiredness (30.4%) and headache (22.5%). Conclusion: Medication adherence to AED was poor among patients in this study.

Recent Advances in Antiepileptic Herbal Medicine

BACKGROUND

Epilepsy is one of the most common neurological disorders worldwide, with about 80 percent of cases thought to be in developing nations where it is mostly linked to superstition. The limited supply, high cost as well as low efficacy and adverse side effects of antiepileptic drugs (AEDs) is a matter of major concern. Herbal medicine has always been traditionally part of treatment of epilepsy. Herbal medicines are generally well tolerated, with fewer side effects.

METHOD

To highlight some herbal extracts that have been studied for their anticonvulsant activity in animal models, literature search from PubMed and Science Direct, was performed. The keywords for the search consisted of combinations of the following terms: Herbal antiepileptic and/or anticonvulsant, botanicals + epilepsy. Literature published in the last five years was considered.

RESULTS

Eighteen (18) anticonvulsant herbal agents are reported and discussed. Experiments mostly consisted of phenotypic screens in rodents, with little diversity in screening methods. In most experiments, the tested extracts prolonged the time to onset of seizures and decreased their duration. Most experimenters implicate potentiation of GABAergic activity as the mode of action of the extracts, even though some experimenters did not fully characterise the bioactive chemical composition of their extracts.

CONCLUSION

Potential herbal remedies have shown positive results in animal models. It remains unclear how many make it into clinical trials and eventually making part of the AED list. More rigorous research, applying strict research methodology with uniform herbal combinations, as well as clinical studies are urgently needed.

Increased seizure susceptibility and other toxicity symptoms following acute sulforaphane treatment in mice

Activation of Nrf2 with sulforaphane has recently gained attention as a new therapeutic approach in the treatment of many diseases, including epilepsy. As a plant-derived compound, sulforaphane is considered to be safe and well-tolerated. It is widely consumed, also by patients suffering from seizure and taking antiepileptic drugs, but no toxicity profile of sulforaphane exists. Since many natural remedies and dietary supplements may increase seizure risk and potentially interact with antiepileptic drugs, the aim of our study was to investigate the acute effects of sulforaphane on seizure thresholds and activity of some first- and second-generation antiepileptic drugs in mice. In addition, some preliminary toxicity profile of sulforaphane in mice after intraperitoneal injection was evaluated. The LD₅₀ value of sulforaphane in mice was estimated at 212.67mg/kg, while the TD₅₀ value - at 191.58mg/kg. In seizure tests, sulforaphane at the highest dose tested (200mg/kg) significantly decreased the thresholds for the onset of the first myoclonic twitch and generalized clonic seizure in the iv PTZ test as well as the threshold for the 6Hz-induced psychomotor seizure. At doses of 10-200mg/kg, sulforaphane did not affect the threshold for the iv PTZ-induced forelimb tonus or the threshold for maximal electroshock-induced hindlimb tonus. Interestingly, sulforaphane (at 100mg/kg) potentiated the anticonvulsant efficacy of carbamazepine in the maximal electroshock seizure test. This interaction could have been pharmacokinetic in nature, as sulforaphane increased concentrations of carbamazepine in both serum and brain tissue. The toxicity study showed that high doses of sulforaphane produced marked sedation (at 150-300mg/kg), hypothermia (at 150-300mg/kg), impairment of motor coordination (at 200-300mg/kg), decrease in skeletal muscle strength (at 250-300mg/kg), and deaths (at 200-300mg/kg). Moreover, blood analysis showed leucopenia in mice injected with sulforaphane at 200mg/kg. In conclusion, since sulforaphane was proconvulsant at a toxic dose, the safety profile and the risk-to-benefit ratio of sulforaphane usage in epileptic patients should be further evaluated.

Caregiver-reported religious beliefs and complementary and alternative medicine use among children admitted to an epilepsy monitoring unit

Complementary and alternative medicine (CAM) includes a wide range of practices and products that are generally outside the use of conventional medicine as practiced in Western cultures. Use of CAM in persons with epilepsy is high, even compared to individuals with other chronic health conditions. In this study, we surveyed caregivers of children admitted to a regional epilepsy monitoring unit (EMU) in the southeast United States to assess CAM use among patients (N=225). Thirteen percent of respondents indicated current use of CAM by their child, 16% reported past use, and 43% reported interest in future use, most commonly in marijuana as a potential treatment (23%). Over 25% of respondents expressed interest in CAM use related to side effects of anti-epileptic medications. Regarding prayer as a form of CAM, a large majority of respondents in this sample identified as Christian and actively prayed for their child's illness, revealing a high prevalence of spiritual practices in this population. Eighty-one percent of respondents reported that they had not discussed CAM use with their doctor. Discussing CAM use with a health care provider was significantly related to past CAM use (p<.02), but not current use or willingness to try CAM in the future (p>.05). These results have important implications for future practice and support increased communication and patient education, as many anti-epileptic medications interact with certain herbs and supplements, posing a potential health risk and treatment barrier in this population.

Review of Ginkgo biloba-induced toxicity, from experimental studies to human case reports

Ginkgo biloba seeds and leaves have been used as a traditional herbal remedy for thousands of years, and its leaf extract has been consumed as a botanical dietary supplement for decades. Ginkgo biloba extract is a complex mixture with numerous components, including flavonol glycosides and terpene lactones, and is one of the most widely sold botanical dietary supplements worldwide. Concerns about potential health risks for the general population have been raised because of the widespread human exposure to Ginkgo biloba and its potential toxic and carcinogenic activities in rodents. The National Toxicology Program conducted 2-year gavage studies on one Ginkgo biloba leaf extract and concluded that there was clear evidence of carcinogenic activity of this extract in mice based on an increased incidence of hepatocellular carcinoma and hepatoblastoma. Recently, Ginkgo biloba leaf extract has been classified as a possible human carcinogen (Group 2B) by the International Agency for Research on Cancer. This review presents updated information on the toxicological effects from experimental studies both in vitro and in vivo to human case reports (caused by ginkgo seeds or leaves), and also summarizes the negative results from relatively large clinical trials.

Complementary and alternative medicines use among pediatric patients with epilepsy in a multiethnic community

OBJECTIVE

Prior studies highlighted that patients on chronic medications who used complementary and alternative medicines (CAMs) did not share this information with their healthcare providers. Furthermore, there might be potential adverse interactions between CAMs and antiepileptic drug (AED) therapy. However, there are no studies that investigate the effect of religion or race on CAM use in a multiethnic community. Therefore, we aimed to investigate CAM usage among pediatric patients with epilepsy (PPE) and identify predictors of CAM usage in our multiethnic setting.

METHODS

This was a cross-sectional study where caregivers of recruited at an outpatient epilepsy clinic between September 2013 and July 2014 completed a self-administered survey. Those who declined participation, lacked understanding of English or Mandarin, or missed the clinic appointments were excluded. Those caring for more than one patient participated only once.

RESULTS

Of the 195 surveys collected, 178 were used for analysis. The PPE used an average of 1.50 AEDs (range: 0-4). Forty-nine (27.5%) caregivers reported giving CAMs to their PPE. Commonly used CAMs were multivitamins (44.4%), traditional herbs (42.2%), and acupuncture (17.4%). Multivitamins were mostly given by Christian/Catholic caregivers while Buddhist caregivers mostly gave traditional herbs or acupuncture. The majority of the CAM users were Chinese. Univariate analysis showed that caregivers with secondary school (high school) education were 3.52 times more likely to use CAMs compared to those with primary school (elementary school) education.

CONCLUSIONS

While some caregivers gave CAMs to their PPE, they had various misconceptions and did not discuss the usage with their healthcare providers. We propose that the predictors identified in this study can help to identify potential CAM users. Healthcare providers should routinely probe about the usage of CAMs by PPE, and thereafter, the suitability of CAM use could be evaluated. The caregivers will benefit from open discussion with healthcare professionals on the safe use of AEDs with or without CAMs.

Use of complementary and alternative medicine (CAM) by parents in their children and adolescents with epilepsy - Prevelance, predictors and parents' assessment

BACKGROUND

The use of complementary and alternative medicine (CAM) is popular. Parents of children suffering from epilepsy may also consider administering CAM to their children. Systematic data about frequency of and motivations for CAM use, however, are scarce.

METHODS

In a university hospital's neuropaediatric department parents of patients aged 0-18 years suffering from epilepsy were consecutively invited to take part in a structured interview during 4 months in 2014.

RESULTS

Of the invited parents, 164/165 (99%) agreed to participate. From those, 21/164 (13%) stated that they used CAM in their child. The highest independent predictive value of CAM use was the occurrence of adverse drug events (ADE) of anticonvulsants as judged by parents. Patients affected by ADE had a 5.6 higher chance of receiving CAM compared to patients without ADE. Most commonly used were homeopathy (14/21, 67%) and osteopathy (12/21, 57%). The internet was the most frequently used source of information (14/21, 67%). Of the parents, 10/21 (48%) described positive effects of CAM on seizure frequency, 12/21 (57%) on general condition of their child, and 20/21 (95%) wished to continue CAM for epilepsy therapy. From the non-users of CAM, 91/143 (66%) expressed the desire to learn more about CAM for epilepsy therapy.

LIMITATIONS

Our study was performed in a university hospital in a large urban city in Eastern Germany. CAM user rates can differ in other parts of Germany and Europe, in other institutions and for chronic diseases other than epilepsy.

CONCLUSION

The main reason for CAM use was the occurrence of ADE of anticonvulsants. More than half of the parents saw a benefit of CAM for their children. Almost all parents wished to continue CAM use, even those who did not see concrete positive effects.

Pharmacokinetic interaction of Acacia catechu with CYP1A substrate theophylline in rabbits

OBJECTIVE

To investigate the effect of black catechu (BC) on the pharmacokinetics of theophylline (CYP1A2 substrate, with narrow therapeutic index) in rabbits.

METHODS

In the present investigation the effect of BC on the pharmacokinetics of theophylline, a CYP1A2 substrate was determined. In the study, BC (264 mg/kg, p. o.) or saline (control group) was given to rabbits for 7 consecutive days and on the 8th day theophylline (16 mg/kg) was administered orally one hour after BC or saline treatment. Blood samples were withdrawn at different time intervals (0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 24 and 36 h) from the marginal ear vein.

RESULTS

The pretreatment of rabbits with BC resulted in a significant increase in maximum blood concentration, time of peak concentration and area under the concentration time profile curve until last observation which was about 41.32%, 35.71% and 15.03%, respectively. While decreases in clearance, volume of distribution, and half-life were observed. It is suggested that BC pretreatment decreases the CYP1A metabolic activity leading to increase in bioavailability and decrease in oral clearance of theophylline, which may be due to inhibition of CYP1A.

CONCLUSION

BC can significantly alter theophylline pharmacokinetics in vivo possibly due to inhibition of CYP1A and P-glycoprotein activity. Based on these results, precaution should be exercised when administering BC with CYP1A substrate.

An ethnopharmacological and historical analysis of "Dictamnus", a European traditional herbal medicine

ETHNOPHARMACOLOGICAL RELEVANCE AND BACKGROUND

"Dictamnus" was a popular name for a group of medicinal herbaceous plant species of the Rutaceae and Lamiaceae, which since the 4th century have been used for gynaecological problems and other illnesses BCE and still appear in numerous ethnobotanical records.

AIMS

This research has as four overarching aims: Determining the historical evolution of medical preparations labelled "Dictamnus" and the different factors affecting this long-standing herbal tradition. Deciphering and differentiating those medicinal uses of "Dictamnus" which strictly correspond to Dictamnus (Rutaceae), from those of Origanum dictamnus and other Lamiaceae species. Quantitatively assessing the dependence from herbal books, and pharmaceutical tradition, of modern Dictamnus ethnobotanical records. Determining whether differences between Western and Eastern Europe exist with regards to the Dictamnus albus uses in ethnopharmacology and ethnomedicine.

METHODS

An exhaustive review of herbals, classical pharmacopoeias, ethnobotanical and ethnopharmacological literature was conducted. Systematic analysis of uses reported which were standardized according to International Classification of Diseases - 10 and multivariate analysis using factorial, hierarchical and neighbour joining methods was undertaken.

RESULTS AND DISCUSSION

The popular concept "Dictamnus" includes Origanum dictamnus L., Ballota pseudodictamnus (L.) Benth. and B. acetabulosa (L.) Benth. (Lamiaceae), as well as Dictamnus albus L. and D. hispanicus Webb ex Willk. (Rutaceae), with 86 different types of uses. Between 1000 and 1700 CE numerous complex preparations with "Dictamnus" were used in the treatment of 35 different pathologies. On biogeographical grounds the widespread D. albus is a far more likely prototypical "Dictamnus" than the Cretan endemic Origanum dictamnus. However both form integral parts of the "Dictamnus" complex. Evidence exists for a sufficiently long and coherent tradition for D. albus and D. hispanicus, use to treat 47 different categories of diseases.

CONCLUSIONS

This approach is a model for understanding the cultural history of plants and their role as resources for health care. "Dictamnus" shows how transmission of traditional knowledge about materia medica, over 26 centuries, represents remarkable levels of development and innovation. All this lead us to call attention to D. albus and D. hispanicus which are highly promising as potential herbal drug leads. The next steps of research should be to systematically analyse phytochemical, pharmacological and clinical evidence and to develop safety, pharmacology and toxicology profiles of the traditional preparations.

The importance of botanical treatments in traditional societies and challenges in developing countries

Epilepsy is one of the most common neurological conditions worldwide, with many affected persons found in Asia, Latin America, and sub-Saharan Africa. Relatedly, the large majority found in these regions does not receive the appropriate therapy with antiepileptic drugs (AEDs), stemming from various reasons among which are lack of access to AEDs, social stigma, and negative cultural attitudes. The presence of epilepsy resistant to the available AEDs coupled with the frequent AED side effects has further fueled the widespread and growing use of botanicals as alternative therapy in several traditional societies in these developing countries since people with epilepsy (PWE) consider them as safe and effective. There have, however, been few botanicals that have been examined for their pharmacological activities related to traditional uses, and there is hardly any conclusive evidence regarding their efficacy in humans or knowledge about the exact mechanism(s) of action. This review discusses some botanical treatments that have been used for epilepsy in developing countries and the challenges faced. This article is part of a Special Issue entitled "Botanicals for Epilepsy".

Botanicals as "new" drugs: US development

Botanicals are ingredients that can be marketed as foods, drugs, cosmetics, and medical devices in the United States. When a botanical is intended to diagnose, treat, prevent, mitigate, or cure a disease, it is considered to be a "drug". This article reviews the US regulatory requirements for botanicals as "new" drugs. An overview of the regulatory principles used to determine product category and the basic elements of an Investigational New Drug application and New Drug Application with the US Food and Drug Administration are presented. This article is part of a Special Issue entitled "Botanicals for Epilepsy".

Issues and promise in clinical studies of botanicals with anticonvulsant potential

Botanicals are increasingly used by people with epilepsy worldwide. However, despite abundant preclinical data on the anticonvulsant properties of many herbal remedies, there are very few human studies assessing safety and efficacy of these products in epilepsy. Additionally, the methodology of most of these studies only marginally meets the requirements of evidence-based medicine. Although the currently available evidence for the use of cannabinoids in epilepsy is similarly lacking, several carefully designed and well controlled industry-sponsored clinical trials of cannabis derivatives are planned to be completed in the next couple of years, providing the needed reliable data for the use of these products. The choice of the best botanical candidates with anticonvulsant properties and their assessment in well-designed clinical trials may significantly improve our ability to effectively and safely treat patients with epilepsy. This article is part of a Special Issue entitled "Botanicals for Epilepsy".

The relevance of pharmacognosy in pharmacological research on herbal medicinal products

As all medicines, herbal medicinal products are expected to be safe, effective, and of appropriate quality. However, regulations on herbal medicinal products vary from country to country, and herbal preparations do occur not only in the form of medicinal products but also as less strictly regulated product groups like dietary supplements. Therefore, it is not always easy for the consumers to discriminate high-quality products from low-quality products. On the other hand, herbal medicines have many special features that distinguish them from conventional medicinal products. Plants are complex multicomponent mixtures; in addition, their phytochemical composition is not constant because of inherent variability and a plethora of external influences. Therefore, the production process of an herbal medicinal product needs to be strictly monitored. First of all, the starting materials need to be correctly authenticated and free of adulterants and contaminants. During plant growth, many factors like harvest season and time, developmental stage, temperature, and humidity have a strong impact on plant metabolite production. Also, postharvest processing steps like drying and storage can significantly alter the phytochemical composition of herbal material. As the production of many phytopharmaceuticals includes an extraction step, the extraction solvent and conditions need to be optimized in order to enrich the bioactive constituents in the extract. The quality of finished preparations needs to be determined either on the basis of marker constituents or on the basis of analytical fingerprints. Thus, all production stages should be accompanied by appropriate quality assessment measures. Depending on the particular task, different methods need to be applied, ranging from macroscopic, microscopic, and DNA-based authentication methods to spectroscopic methods like vibrational spectroscopy and chromatographic and hyphenated methods like HPLC, GC-MS and LC-MS. Also, when performing pharmacological and toxicological studies, many features inherent in herbal medicinal products need to be considered in order to guarantee valid results: concerning in vitro studies, difficulties are often related to lacking knowledge of ADME characteristics of the bioactive constituents, nuisance compounds producing false positive and false negative results, and solubility problems. In in vivo animal studies, the route of administration is a very important issue. Clinical trials on herbal medicinal products in humans very often suffer from a poor reporting quality. This often hampers or precludes the pooling of clinical data for systematic reviews. In order to overcome this problem, appropriate documentation standards for clinical trials on herbal medicinal products have been defined in an extension of the CONSORT checklist. This article is part of a Special Issue entitled "Botanicals for Epilepsy".

Therapeutic drug monitoring of antiepileptic drugs in a tertiary care hospital in India

INTRODUCTION

Therapeutic drug monitoring (TDM) helps to optimize the dose of antiepileptic drugs. Only limited information is available about the clinical utility of TDM of antiepileptic drugs in India. Hence, we aimed to study the clinical utility of antiepileptic TDM in a tertiary care hospital in India and to explore the association between the plasma drug levels and the occurrence of breakthrough seizures and drug toxicity.

METHODS

All patients taking antiepileptic drugs for whom TDM was done from January 2008 to December 2010 were included in the study. All relevant information was obtained from patient medical records. Trough levels were measured for all drugs using chemiluminescence assay. Drug levels were interpreted as within, below, and above the reference range, as recommended by the International League Against Epilepsy guidelines.

RESULTS

Of the 420 samples analyzed during this period, 396 samples were included in this study for analysis. The maximum number of requests was for phenytoin (50%) followed by valproic acid (26%). The most common indication for TDM was dosage adjustment (38%) followed by breakthrough seizures (34%). Among the 135 samples received with breakthrough seizures as indication, more than 50% had drug levels either within or above the reference range. Among the 62 samples referred with clinical symptoms of suspected toxicity, drug levels were above the reference range in only 52% of the samples.

CONCLUSIONS

Therapeutic drug monitoring was found to be useful in practice, in tailoring drug dosage in accordance with the needs of individual patient, in distinguishing nonresponders from noncompliants, and in aiding in making critical decisions. However, the "reference range" of these antiepileptic drugs was not reliable in predicting the occurrence of breakthrough seizures and clinical symptoms of suspected drug toxicity.

Camphor: an herbal medicine causing grand mal seizures

Camphor is usually used in the USA to repel insects, but it is widely used in other countries as an herb. We report the case of a 52-year-old previously healthy Nepali man who ingested approximately 10 g of pure camphor with therapeutic intention. He developed grand mal seizures, and was evaluated in an emergency room. He failed to recall the camphor ingestion initially, and was treated with phenytoin for new-onset idiopathic seizures. Examining physicians only later found out about his camphor ingestion. Finding the cause of new-onset seizures is often challenging for emergency room physicians, internists and neurologists. In addition to other well-reported causes of secondary seizures, herbal medications and supplements must also be explored.

Antioxidants as a preventive treatment for epileptic process: a review of the current status

Epilepsy is known as one of the most frequent neurological diseases, characterized by an enduring predisposition to generate epileptic seizures. Oxidative stress is believed to directly participate in pathways leading to neurodegeneration, which serves as the most important propagating factor, leading to the epileptic condition and cognitive decline. Moreover, there is also a growing body of evidence showing the disturbance of antioxidant system balance and consequently increased production of reactive species in patients with epilepsy. A meta-analysis, conducted in the present review confirms an association between epilepsy and increased lipid peroxidation. Furthermore, it was also shown that some of the antiepileptic drugs could potentially be responsible for additionally increased lipid peroxidation. Therefore, it is reasonable to propose that during the epileptic process neuroprotective treatment with antioxidants could lead to less sever structural damages, reduced epileptogenesis and milder cognitive deterioration. To evaluate this hypothesis studies investigating the neuroprotective therapeutic potential of various antioxidants in cells, animal seizure models and patients with epilepsy have been reviewed. Numerous beneficial effects of antioxidants on oxidative stress markers and in some cases also neuroprotective effects were observed in animal seizure models. However, despite these encouraging results, till now only a few antioxidants have been further applied to patients with epilepsy as an add-on therapy. Based on the several positive findings in animal models, a strong need for more carefully planned, randomized, double-blind, cross-over, placebo-controlled clinical trials for the evaluation of antioxidants efficacy in patients with epilepsy is warranted.

CAM use in pediatric neurology: an exploration of concurrent use with conventional medicine

BACKGROUND

Previous studies have found that up to 60% of children with neurologic conditions have tried complementary and alternative medicine (CAM).

OBJECTIVE

To assess the use of CAM among patients presenting to neurology clinics at two academic centers in Canada.

METHODS

A survey instrument was developed to inquire about use of CAM products and therapies, including reasons for use, perceived helpfulness, and concurrent use with conventional medicine, and administered to patients or their parents/guardians at the Stollery Children's Hospital in Edmonton and the Children's Hospital of Eastern Ontario (CHEO) in Ottawa.

RESULTS

Overall CAM use at the Stollery was 78%, compared to 48% at CHEO. The most common CAM products used were multi-vitamins (84%), vitamin C (37%), homeopathic remedies (24%), and fish oil/omega 3 s (22%). The most common CAM practices used were massage (47%), chiropractic (37%), faith healing (18%), aromatherapy (16%), homeopathy (16%), and relaxation (16%). Many patients used CAM products at the same time as conventional medicine but just over half (57%) discussed this concurrent use with their physician.

CONCLUSION

CAM use is common in pediatric neurology patients and most respondents felt that it was helpful, with few or no harms associated. However, this use is often undisclosed, increasing possibility of interactions with conventional drugs. We urge clinicians to inquire about CAM use during routine history taking at every patient visit. Parents would clearly like more information about CAM from their specialty clinics; such information would be easier to share if more primary data were available about the safety and effectiveness of commonly used therapies.

Types and sociodemographic correlates of complementary and alternative medicine (CAM) use among people with epilepsy in Oman

Nonpharmacological treatment strategies that originate from sociocultural teachings and are beyond the scope of allopathic medicine are commonly used among people with epilepsy (PWE) in many parts of the world. The present study explored the types and sociodemographic correlates of complementary and alternative medicine (CAM) use among PWE in Oman among attendees of a neurological unit at a tertiary care center. Data on the types of CAM were gathered from telephone interviews. The relevant demographic and clinical characteristics of the participants were obtained from electronic medical records. Of the total of 101 participants, 73.3% were CAM users. The majority of these participants have not disclosed their CAM use to their allopathic health-care providers. The most common types of CAM reported were those falling under the 'mind-body' type (incantations and fumigation) and biologically based (herbal concoctions) or a combination of them. Compared to non-CAM users, a significant and greater proportion of CAM users attributed the etiology of their illness to nonbiomedical factors such as 'evil eyes' (P=0.04). The multivariate logistic regression model indicated that the use of CAM was highly associated with age of <30years (OR=3.09; 95% CI: 1.10, 5.46), unemployment (OR=2.04; 95% CI: 1.15, 6.39), having basic school education (OR=2.21; 95% CI: 0.83, 5.18), low family income (OR=1.52; 95% CI: 0.91, 2.11), and the presence of hypersalivation (OR=2.20; 95% CI: 1.01, 4.39). Further studies are needed to harmonize these two healing practices. On the whole, this study indicates that among attendees of tertiary care utilization, CAM is common among PWE in Oman. The most utilized type of CAM falls under the umbrella of mind-body practice.

Pattern and predictors of complementary and alternative medicine (CAM) use among pediatric patients with epilepsy

Parents of pediatric patients with chronic conditions such as epilepsy increasingly opt for complementary and alternative medicine (CAM). However, data on the pattern and reasons of CAM use in childhood epilepsy are scarce. The objectives of this study were as follows: first, to characterize CAM use among pediatric patients with epilepsy by assessing its spectrum, prevalence, costs, and frequency of use; second, to evaluate the influence of CAM use on compliance and satisfaction with conventional care as well as to explore parent-child neurologist communication concerning CAM; and third, to investigate predictors of CAM use. A postal survey was administered to all parents of pediatric outpatients with epilepsy aged 6 to 12, who have received treatment at the neuropediatric outpatient clinic of the University Children's Hospital Heidelberg between 2007 and 2009. One hundred thirty-two of the 297 distributed questionnaires were suitable for inclusion in statistical analysis (44.7%). Forty-nine participants indicated that their children used CAM during the previous year (37.1%). Thirty different types of CAM were used, with homeopathy (55.1%), osteopathy (24.5%), and kinesiology (16.3%) being the most commonly named. A mean of 86€ (0€-500€) and 3h (1 h-30 h) per month was committed to CAM treatment. Only 53% of the users informed their child neurologist of the additional CAM treatment, while 85.6% of all parents wished to discuss CAM options with their child neurologist. Seventy-five percent of users considered the CAM treatment effective. Among the participants most likely to seek CAM treatment are parents whose children show a long duration of epileptic symptoms, parents who make use of CAM treatment themselves, and parents who value a holistic and natural treatment approach. A substantial portion of pediatric patients with epilepsy receive CAM treatment. The high prevalence of use and significant level of financial and time resources spent on CAM indicate the high importance of these treatment options for parents. On the other hand, communication concerning CAM with the child neurologist is largely insufficient despite the wish to speak about CAM. Complementary and alternative medicine users' high compliance with conventional treatment and high perceived effectiveness of CAM support an integrative approach to CAM for pediatric patients with epilepsy. Our study implies that in addition to open parent-child neurologist communication, active inquiry on CAM treatments is necessary to enable informed decision making by parents and to establish the suitability of CAM treatment for the patient. Reliable predictors for CAM use, which allow for improved identification of patients with a high likelihood to receive CAM treatment, are the duration of the illness, use of CAM by the parents themselves, and the desire of the parents to receive a holistic and natural treatment for their child.

Interaction of carbamazepine with herbs, dietary supplements, and food: a systematic review

Background. Carbamazepine (CBZ) is a first-line antiepileptic drug which may be prone to drug interactions. Systematic review of herb- and food-drug interactions on CBZ is warranted to provide guidance for medical professionals when prescribing CBZ. Method. A systematic review was conducted on six English databases and four Chinese databases. Results. 196 out of 3179 articles fulfilled inclusion criteria, of which 74 articles were reviewed and 33 herbal products/dietary supplement/food interacting with CBZ were identified. No fatal or severe interactions were documented. The majority of the interactions were pharmacokinetic-based (80%). Traditional Chinese medicine accounted for most of the interactions (n = 17), followed by food (n = 10), dietary supplements (n = 3), and other herbs/botanicals (n = 3). Coadministration of 11 and 12 of the studied herbal products/dietary supplement/food significantly decreased or increased the plasma concentrations of CBZ. Regarding pharmacodynamic interaction, Xiao-yao-san, melatonin, and alcohol increased the side effects of CBZ while caffeine lowered the antiepileptic efficacy of CBZ. Conclusion. This review provides a comprehensive summary of the documented interactions between CBZ and herbal products/food/dietary supplements which assists healthcare professionals to identify potential herb-drug and food-drug interactions, thereby preventing potential adverse events and improving patients' therapeutic outcomes when prescribing CBZ.

Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: a systematic literature review

BACKGROUND AND AIMS

The use of herbs and dietary supplements (HDS) alone or concomitantly with medications can potentially increase the risk of adverse events experienced by the patients. This review aims to evaluate the documented HDS-drug interactions and contraindications.

METHODS

A structured literature review was conducted on PubMed, EMBASE, Cochrane Library, tertiary literature and Internet.

RESULTS

While 85 primary literatures, six books and two web sites were reviewed for a total of 1,491 unique pairs of HDS-drug interactions, 213 HDS entities and 509 medications were involved. HDS products containing St. John's Wort, magnesium, calcium, iron, ginkgo had the greatest number of documented interactions with medications. Warfarin, insulin, aspirin, digoxin, and ticlopidine had the greatest number of reported interactions with HDS. Medications affecting the central nervous system or cardiovascular system had more documented interactions with HDS. Of the 882 HDS-drug interactions being described its mechanism and severity, 42.3% were due to altered pharmacokinetics and 240 were described as major interactions. Of the 152 identified HDS contraindications, the most frequent involved gastrointestinal (16.4%), neurological (14.5%), and renal/genitourinary diseases (12.5%). Flaxseed, echinacea, and yohimbe had the largest number of documented contraindications.

CONCLUSIONS

Although HDS-drug interactions and contraindications primarily concerned a relatively small subset of commonly used medications and HDS entities, this review provides the summary to identify patients, HDS products, and medications that are more susceptible to HDS-drug interactions and contraindications. The findings would facilitate the health-care professionals to communicate these documented interactions and contraindications to their patients and/or caregivers thereby preventing serious adverse events and improving desired therapeutic outcomes.