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Park Y, Kim S, Koo DL, Nam H. A Case of Perampanel Overdose Presenting with Respiratory Failure. J Epilepsy Res 2022; 12:68-70. [PMID: 36685743 PMCID: PMC9830032 DOI: 10.14581/jer.22012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/30/2022] [Accepted: 07/22/2022] [Indexed: 01/09/2023] Open
Abstract
Perampanel is a novel antiepileptic drug that has been used as an adjunctive treatment for focal-onset seizures. No reports to date have documented respiratory suppression as a side effect of perampanel in adults. Herein, we report a 51-year-old man with focal epilepsy presented with type 2 respiratory failure after accidently consuming of 66 mg of perampanel. Clinicians should consider the possibility of respiratory compromise whenever a high dose of perampanel needs to be administered to patients.
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Affiliation(s)
- Yangmi Park
- Department of Neurology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Seondeuk Kim
- Department of Neurology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Dae Lim Koo
- Department of Neurology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyunwoo Nam
- Department of Neurology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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2
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Ding Z, Wang X, Zhang N, Sun C, Zhao G, Peng Y, Zheng J. Metabolic Activation of Perampanel Mediated by CYP1A2. Chem Res Toxicol 2022; 35:490-498. [PMID: 35200000 DOI: 10.1021/acs.chemrestox.1c00396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Perampanel (PRP), a noncompetitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropanoic acid (AMPA) receptor antagonist with high selectivity, has been used as a new adjuvant for the treatment of fractional seizures with or without primary generalized tonic-clonic seizures and secondary generalized seizures in epilepsy patients over the age of 12. Adverse events such as liver injury have been reported during the clinical application of PRP. The purpose of the study is to explore the in vitro and in vivo metabolic activation of PRP. Two GSH conjugates were detected in rat liver microsomal incubations containing PRP, GSH, and NADPH. The two GSH conjugates were both obtained from the bile of rats and rat primary hepatocytes after exposure to PRP. Similar microsomal incubations complemented with N-acetylcysteine (NAC) in place of GSH offered two NAC conjugates. As expected, the NAC conjugates were detected in the urine of PRP-treated rats. One of the two NAC conjugates was identified as NAC conjugate 12 verified by chemical synthesis. The individual human recombinant P450 enzyme incubation assay demonstrated that CYP1A2 dominated the catalysis for the metabolic activation of PRP. Pretreatment with α-naphthoflavone (NTF) decreased the formation of PRP-derived GSH conjugates in both livers of rats and cultured primary hepatocytes after being treated with PRP. Additionally, NTF was found to decrease the susceptibility of primary hepatocytes to the cytotoxicity of PRP. The findings indicate that PRP was metabolized to the corresponding epoxide, which could participate in PRP-induced cytotoxicity.
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Affiliation(s)
- Zifang Ding
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P.R. China
| | - Xu Wang
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P.R. China
| | - Ning Zhang
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P.R. China
| | - Chen Sun
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P.R. China
| | - Guode Zhao
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P.R. China
| | - Ying Peng
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P.R. China
| | - Jiang Zheng
- Wuya College of Innovation, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, P.R. China.,State Key Laboratory of Functions and Applications of Medicinal Plants, Key Laboratory of Pharmaceutics of Guizhou Province, Guizhou Medical University, Guiyang, Guizhou 550025, P.R. China.,Key Laboratory of Environmental Pollution, Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, Guizhou 550025, P.R. China
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Takahashi H, Muroya T, Okamoto Y, Tamagaki K, Maeshima K, Onoe A, Nakamura F, Nakajima M, Sakuramoto K, Kajino K, Ikegawa H, Kuwagata Y. Lacosamide poisoning improved by hemodialysis. Acute Med Surg 2022; 9:e775. [PMID: 35924090 PMCID: PMC9340780 DOI: 10.1002/ams2.775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/18/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hiroki Takahashi
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Takashi Muroya
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Yasutaka Okamoto
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Keisuke Tamagaki
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Kenji Maeshima
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Atsunori Onoe
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Mari Nakajima
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Kazuhito Sakuramoto
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Kentarou Kajino
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Hitoshi Ikegawa
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Japan
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Winkler GA, Minns AB, Kreshak AA. Severe Perampanel Toxicity in a Pediatric Patient With Prolonged Symptoms. J Emerg Med 2021; 61:e99-e102. [PMID: 34479751 DOI: 10.1016/j.jemermed.2021.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/01/2021] [Accepted: 07/03/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Perampanel is a new antiepileptic used to treat partial-onset seizures and generalized tonic-clonic seizures in people older than 12 years old. Perampanel is a selective, non-competitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist, with a prolonged half-life of approximately 105 hours. Few cases of significant toxicity have been reported, and effects in overdose are poorly understood. CASE REPORT This case describes a 20-month-old healthy female who ingested 8 mg of perampanel. She presented to a pediatric emergency department 1 hour after ingestion with ataxia, irritability, and somnolence. Vital signs were: heart rate 130 beats per minute, blood pressure 112/97 mmHg, temperature 99°F, respiratory rate 30 breaths per minute. She was admitted to the pediatric intensive care unit. During the hospitalization, she developed hypotension and bradycardia which improved with stimulation and fluid resuscitation. Intermittent bradycardia persisted for 32 hours after ingestion. Physical examination was notable for somnolence and truncal ataxia with irritability when aroused, all of which improved throughout the hospitalization. A quantitative level obtained on hospital day 3 (HD) was 750ng/ml. On HD 3 the patient was noted to be ataxic but otherwise had an age-appropriate neurologic examination. She was discharged on HD 4 with normal vital signs, return to baseline mental status, and baseline gait. The patient's cardiovascular, neurologic, and behavioral symptoms were attributed to perampanel toxicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS ?: Toxicity from a perampanel overdose is poorly understood both in adults and pediatric patients with significant cardiovascular, behavioral, and central nervous system abnormalities.
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Affiliation(s)
- Garret A Winkler
- Division of Medical Toxicology, Department of Emergency Medicine, University of California at San Diego Medical Center, VA San Diego Healthcare System, an Diego, CA.
| | - Alicia B Minns
- Division of Medical Toxicology, Department of Emergency Medicine, University of California at San Diego Medical Center, VA San Diego Healthcare System, an Diego, CA
| | - Allyson A Kreshak
- Division of Medical Toxicology, Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, CA
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Minhaj FS, Leonard JB, Klein-Schwartz W. Clinical effects and outcomes of perampanel overdoses reported to U.S. poison centers. Clin Toxicol (Phila) 2021; 60:239-242. [PMID: 34275405 DOI: 10.1080/15563650.2021.1945083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Perampanel is indicated for partial onset seizures in children and adults. The mechanism is unique among antiepileptic agents as it inhibits glutamate activity on AMPA receptors. Currently, there are few published case reports describing overdose. METHODS This is a retrospective observational study of all single substance perampanel ingestions from January 2014 to December 2019 reported to the national poison data system (NPDS). The primary outcome is to describe the clinical effects of perampanel exposures. Secondary outcomes include evaluation of management and investigation of a dose-effect relationship for the purpose of triaging acute unintentional exposures. RESULTS A total of 138 exposures were reported to NPDS since the release of the agent. Median age was 20 years (IQR 10-38) with 68 (49.3%) males. The reason for exposure was most commonly therapeutic error (80, 58.0%), followed by exploratory ingestion (24, 17.4%), and suicidal ingestion (14, 10.1%). A total of six (4.3%) patients developed major effects, 20 (14.5%) moderate, 32 (23.2%) minor effects and 22 (15.9%) no effect. An additional 54 (39.1%) cases were not followed. Almost half of cases were managed at home. Of those that were in a healthcare facility (HCF) (n = 72), most were treated/evaluated and released (31, 43.1%), followed by admission to a non-critical care unit (20, 27.8%), and critical care unit (13, 18.1%). Most frequently reported symptoms were drowsiness (27, 19.6%), agitation (20, 14.5%), ataxia (13, 9.4%), and confusion (12, 8.7%). The most common therapies provided in a HCF were intravenous fluids (22,30.6%), followed by benzodiazepines (14, 19.4%), then other types of sedation (9, 12.5%). There were too few cases to determine a dose cut off for triaging. CONCLUSIONS While drowsiness, agitation, ataxia, and confusion were the most often reported symptoms, close to 19% developed moderate/major effects and almost 4% of patients received potentially life-saving interventions.
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Affiliation(s)
- Faisal Syed Minhaj
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Dean D, Passalacqua KD, Dolcourt B. Truncal Ataxia and Prolonged Coma in an Exploratory Pediatric Perampanel Ingestion. J Med Toxicol 2021; 17:309-311. [PMID: 34075549 DOI: 10.1007/s13181-021-00847-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Several overdoses of the antiepileptic drug perampanel have been reported in adults, but very few have been reported in children. We report the case of an observed exploratory ingestion of perampanel in a 2-year-old child that resulted in ataxia and prolonged coma. CASE REPORT A previously healthy 2-year-old female patient presented to the emergency department (ED) 30 minutes after the witnessed ingestion of 30 mg of perampanel (2 mg/kg). Within minutes of ingestion, she displayed ataxia and inability to walk. Upon ED presentation, she had normal vital signs but was minimally responsive with physical stimulation. Naloxone was given without response. She was intubated because of profound central nervous system depression and transferred to a pediatric tertiary care facility. She remained intubated with no pharmacological sedation. Physical exam showed a horizontal nystagmus. Detailed neurologic examination of ataxia and coordination was not possible, and she did not demonstrate hyperreflexia, clonus, or rigidity. Her mental status gradually improved, and she was extubated approximately 72 hours after exposure. After extubation, the patient still exhibited truncal ataxia and did not return to baseline until 96 hours post ingestion. Serum drawn approximately 16 hours after exposure showed 870 ng/mL perampanel (ref < 20 ng/mL). She remained hemodynamically stable throughout her hospital course, despite protracted depressed mental status. DISCUSSION Given the severity of our patient's presentation, pediatric patients showing symptoms of perampanel overdose should be triaged to the ED for evaluation in anticipation of a prolonged clinical course with decreased consciousness and hypoventilation.
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Affiliation(s)
- Diana Dean
- Florida Poison Information Center - Tampa, 1 Davis Blvd, Suite 203, Tampa, FL, 33606, USA.
| | - Karla D Passalacqua
- Henry Ford Hospital, Department of Graduate Medical Education, Detroit, MI, USA
| | - Bram Dolcourt
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.,Michigan Poison Center at Wayne State University School of Medicine, Detroit, MI, USA
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Morsi RZ, Katz JA. "Zombielike" Aggression in Perampanel Overdose. Cureus 2021; 13:e14971. [PMID: 34123667 PMCID: PMC8191684 DOI: 10.7759/cureus.14971] [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] [Indexed: 11/16/2022] Open
Abstract
Perampanel is an antiepileptic drug that blocks amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid-type glutamate receptors. To date, little is known about the management of perampanel intoxication. We report a case of “zombielike” behavior secondary to intentional perampanel overdose. An 18-year-old male with idiopathic generalized epilepsy and focal features presented with aggressive and “zombielike” behavior after suicide attempt via intentional perampanel overdose, amounting to approximately 128 mg. Clinical symptoms gradually improved with continuous dexmedetomidine infusion and intravenous lorazepam boluses five days after being admitted to the intensive care unit. While perampanel intoxication has been reported to be associated with central nervous system-related adverse effects, awareness of this association is necessary to prompt more appropriate management tailored to perampanel toxicity.
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Affiliation(s)
| | - Jeffrey A Katz
- Anesthesia, NorthShore University HealthSystem, Evanston, USA
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Pediatric perampanel poisoning. Am J Emerg Med 2020; 38:1545.e1-1545.e2. [DOI: 10.1016/j.ajem.2020.04.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/08/2020] [Accepted: 04/11/2020] [Indexed: 11/21/2022] Open
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