1
|
Cuellar-Valencia L, Claros-Hulbert A, Ortegon A, Pino J, Velandia L, Correa-Morales JE. Subcutaneous Levetiracetam Administration in Latino Patients on Home Care. Am J Hosp Palliat Care 2024; 41:1029-1036. [PMID: 37907203 DOI: 10.1177/10499091231212450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
Background: Levetiracetam has a favorable pharmacology profile to be used subcutaneously. However, its subcutaneous use is still considered off-label as this is beyond its license. The evidence base for its safety, tolerability, and efficacy is limited to observational studies. Objectives: To report the safety and efficacy of subcutaneous levetiracetam in Latino patients on home care. Design: Observational retrospective case series study. Subjects: Consecutive sample of Latino adults with life-limiting illnesses. Methods: A case series framework with 4 domains (selection, ascertainment, causality, and reporting) to ensure reporting quality was used. Additionally, 8 relevant outcomes established in a previous comprehensive review, were collected and reported. Adverse reactions were documented using the Common Terminology Criteria for Adverse Events. Results: Fifteen Latino patients with oncological and non-oncological diagnoses received subcutaneous levetiracetam for a mean of 21 days on home care. Levetiracetam was most frequently initiated subcutaneously due to loss of the oral route. The average dosage of subcutaneous levetiracetam was 1200 mg. Only 1 patient required a dose adjustment, and only 2 patients experienced a total of 5 seizures during the therapy trial. No adverse reactions were reported. Conclusions: Subcutaneous levetiracetam appears to be effective and safe. This case series of Latino patients in home care expands the evidence of its use in the home care setting. The preliminary data reported by now on multiple case series warrants robust trials.
Collapse
Affiliation(s)
- Laura Cuellar-Valencia
- Faculty of Medicine, Universidad de La Sabana, Bogotá DC, Colombia
- Colombian National Cancer Institute, Bogotá DC, Colombia
| | - Angelica Claros-Hulbert
- Faculty of Medicine, Universidad de La Sabana, Bogotá DC, Colombia
- Colombian National Cancer Institute, Bogotá DC, Colombia
| | - Adriana Ortegon
- Forja home care IPS, Bogotá DC, Colombia
- Faculty of Medicine, Universidad del Bosque, Bogotá DC, Colombia
| | - Juliana Pino
- Faculty of Medicine, Universidad de La Sabana, Bogotá DC, Colombia
- Forja home care IPS, Bogotá DC, Colombia
| | | | - Juan Esteban Correa-Morales
- Faculty of Medicine, Universidad de La Sabana, Bogotá DC, Colombia
- Colombian National Cancer Institute, Bogotá DC, Colombia
| |
Collapse
|
2
|
Tan S, Ng JS, Tang C, Stretton B, Kovoor J, Gupta A, Delloso T, Zhang T, Goh R, El-Masri S, Kiley M, Maddocks I, Harroud A, Stacpoole S, Crawford G, Bacchi S. Subcutaneous sodium valproate in palliative care: A systematic review. Palliat Med 2024; 38:492-497. [PMID: 38444061 PMCID: PMC11025302 DOI: 10.1177/02692163241234597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND Seizures are an important palliative symptom, the management of which can be complicated by patients' capacity to swallow oral medications. In this setting, and the wish to avoid intravenous access, subcutaneous infusions may be employed. Options for antiseizure medications that can be provided subcutaneously may be limited. Subcutaneous sodium valproate may be an additional management strategy. AIM To evaluate the published experience of subcutaneous valproate use in palliative care, namely with respect to effectiveness and tolerability. DESIGN A systematic review was registered (PROSPERO CRD42023453427), conducted and reported according to PRISMA reporting guidelines. DATA SOURCES The databases PubMed, EMBASE and Scopus were searched for publications until August 11, 2023. RESULTS The searches returned 429 results, of which six fulfilled inclusion criteria. Case series were the most common study design, and most studies included <10 individuals who received subcutaneous sodium valproate. There were three studies that presented results on the utility of subcutaneous sodium valproate for seizure control, which described it to be an effective strategy. One study also described it as an effective treatment for neuropathic pain. The doses were often based on presumed 1:1 oral to subcutaneous conversion ratios. Only one study described a local site adverse reaction, which resolved with a change of administration site. CONCLUSIONS There are limited data on the use of subcutaneous sodium valproate in palliative care. However, palliative symptoms for which subcutaneous sodium valproate have been used successfully are seizures and neuropathic pain. The available data have described few adverse effects, supporting its use with an appropriate degree of caution.
Collapse
Affiliation(s)
- Sheryn Tan
- University of Adelaide, Adelaide, SA, Australia
| | | | - Charis Tang
- University of Adelaide, Adelaide, SA, Australia
| | - Brandon Stretton
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Joshua Kovoor
- University of Adelaide, Adelaide, SA, Australia
- Ballarat Base Hospital, Ballarat Central, VIC, Australia
| | | | | | | | - Rudy Goh
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | | | - Ian Maddocks
- Flinders University, Bedford Park, SA, Australia
| | | | - Sybil Stacpoole
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Gregory Crawford
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Stephen Bacchi
- Flinders University, Bedford Park, SA, Australia
- Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| |
Collapse
|
3
|
Kondasinghe JS, Look ML, Moffat P, Bradley K. Subcutaneous Levetiracetam and Sodium Valproate Use in Palliative Care Patients. J Pain Palliat Care Pharmacother 2022; 36:228-232. [PMID: 35930500 DOI: 10.1080/15360288.2022.2107145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Palliative care patients experience seizures in different stages of their disease and may not tolerate oral medications toward the end of life. Subcutaneous infusions of levetiracetam and sodium valproate are increasingly used off-label. This retrospective analysis (conducted from January 2019 to July 2020 in Australia) reports the effectiveness and adverse effects of levetiracetam and sodium valproate delivered via subcutaneous infusion. The doses ranged from 500 to 3000 mg/d of levetiracetam and 500 to 2500 mg/d of sodium valproate. The concentrations ranged from 20 to 83 mg/mL of levetiracetam and 20 to 50 mg/mL of sodium valproate. Subcutaneous levetiracetam was given for a median duration of 6.5 days, with no seizure recurrences in 75% of patients and no reported adverse effects in any patients. Subcutaneous sodium valproate was given for a median duration of 3.5 days, with no reported seizure recurrences in 83% of patients and one report of a localized skin reaction. This analysis suggests that subcutaneous levetiracetam and sodium valproate can effectively control seizures in palliative care populations, with minimal localized reactions.
Collapse
|
4
|
Wernli U, Dürr F, Jean-Petit-Matile S, Kobleder A, Meyer-Massetti C. Subcutaneous Drugs and Off-label Use in Hospice and Palliative Care: A Scoping Review. J Pain Symptom Manage 2022; 64:e250-e259. [PMID: 35870656 DOI: 10.1016/j.jpainsymman.2022.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Subcutaneous drug administration is an interesting approach for symptom control in hospice and palliative care. However, most drugs have no marketing authorization for subcutaneous administration and are therefore used off-label. In order to meet the requirements of a safe and effective drug therapy, especially in highly vulnerable patients, it is essential to investigate the scope of evidence of these common practices. OBJECTIVES The purpose of this scoping review was to provide an overview of available data on the tolerability and/or effectiveness of subcutaneously administered and off-label used drugs. METHOD We performed a scoping review according to the PRISMA extension to identify data available on the tolerability and/or effectiveness of 17 predefined drugs that are commonly administered subcutaneously in Swiss hospices and hospice-like institutions and that have no marketing authorization (off-label use). RESULTS The scoping review identified 57 studies with most data available on their tolerability (68% local, 54% systemic), clinical effects (82%), details on dosage (96%) and routes of application (100%). Information on pharmacokinetic properties was mostly missing and only available for fentanyl, levetiracetam, midazolam, and ondansetron. For seven drugs, less than five articles were identified and no studies on codeine or clonazepam were available. CONCLUSION This work provides an overview of current evidence on subcutaneous and off-label used drugs in hospice and palliative care. Although both are common practices, evidence on tolerability and effectiveness, particularly pharmacokinetic data, is limited and the identified information gaps need to be closed. This work establishes a basis for further research in this area.
Collapse
Affiliation(s)
- Ursina Wernli
- Clinical Pharmacology and Toxicology (U.W., C.M.M.), Inselspital Bern, Switzerland; Graduate School for Health Sciences (U.W.), University of Bern, Switzerland.
| | - Fabienne Dürr
- Institute of Primary Health Care BIHAM (F.D., C.M.M.), University of Bern, Switzerland
| | | | - Andrea Kobleder
- Institute of Applied Nursing Science (A.K.), Eastern Switzerland University of Applied Sciences OST, St Gallen, Switzerland
| | - Carla Meyer-Massetti
- Clinical Pharmacology and Toxicology (U.W., C.M.M.), Inselspital Bern, Switzerland; Institute of Primary Health Care BIHAM (F.D., C.M.M.), University of Bern, Switzerland
| |
Collapse
|
5
|
Arce Gálvez L, Baena Álvarez C. Experiencia de uso de levetiracetam subcutáneo en pacientes paliativos: consideración pronóstica y farmacológica. Neurologia 2022. [DOI: 10.1016/j.nrl.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
6
|
Arce Gálvez L, Baena Álvarez C. Experience with subcutaneous levetiracetam in palliative care patients: prognostic and pharmacological considerations. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:501-502. [PMID: 35527111 DOI: 10.1016/j.nrleng.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/13/2021] [Indexed: 10/18/2022] Open
Affiliation(s)
- L Arce Gálvez
- Departamento de Medicina Física y Rehabilitación, Universidad del Valle, Cali, Colombia; Unidad de Medicina del Dolor y Cuidado Paliativo, Hospital Universitario del Valle, Evaristo García E.S.E., Cali, Colombia.
| | - C Baena Álvarez
- Departamento de Medicina Física y Rehabilitación, Universidad del Valle, Cali, Colombia; Unidad de Medicina del Dolor y Cuidado Paliativo, Hospital Universitario del Valle, Evaristo García E.S.E., Cali, Colombia
| |
Collapse
|
7
|
Bilbao-Meseguer I, Barrasa H, Rodríguez-Gascón A, Asín-Prieto E, Maynar J, Sánchez-Izquierdo JÁ, Solinís MÁ, Isla A. Optimization of levetiracetam dosing regimen in critically ill patients with augmented renal clearance: a Monte Carlo simulation study. J Intensive Care 2022; 10:21. [PMID: 35449037 PMCID: PMC9022299 DOI: 10.1186/s40560-022-00611-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022] Open
Abstract
Background Levetiracetam pharmacokinetics is extensively altered in critically ill patients with augmented renal clearance (ARC). Consequently, the dosage regimens commonly used in clinical practice may not be sufficient to achieve target plasma concentrations. The aim of this study is to propose alternative dosage regimens able to achieve target concentrations in this population. Furthermore, the feasibility of the proposed dosing regimens will be discussed from a clinical point of view. Methods Different dosage regimens for levetiracetam were evaluated in critically ill patients with ARC. Monte Carlo simulations were conducted with extended or continuous infusions and/or high drug doses using a previously developed population pharmacokinetic model. To assess the clinical feasibility of the proposed dosages, we carried out a literature search to evaluate the information on toxicity and efficacy of continuous administration or high doses, as well as the post-dilution stability of levetiracetam. Results According to the simulations, target concentrations in patients with CrCl of 160 or 200 mL/min can be achieved with the 3000 mg daily dose by prolonging the infusion time of levetiracetam. For patients with CrCl of 240 mL/min, it would be necessary to administer doses higher than the maximum recommended. Available evidence suggests that levetiracetam administration in continuous infusion or at higher doses than those approved seems to be safe. It would be desirable to re-examinate the current recommendations about drug stability and to achieve a consensus in this issue. Conclusions Conventional dosage regimens of levetiracetam (500–1500 mg twice daily in a short infusion) do not allow obtaining drug plasma concentrations among the defined target in critically ill patients with ARC. Therefore, new dosing guidelines with specific recommendations for patients in this subpopulation are needed. This study proposes new dosages for levetiracetam, including extended (4 or 6 h) infusions, continuous infusions or the administration of doses higher than the recommended in the summary of product characteristics (> 3000 mg). These new dosage recommendations take into account biopharmaceutical and pharmacokinetic aspects and meet feasibility criteria, which allow them to be transferred to the clinical environment with safety and efficacy. Nevertheless, further clinical studies are needed to confirm these results.
Collapse
Affiliation(s)
- Idoia Bilbao-Meseguer
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, 01006, Vitoria-Gasteiz, Spain.,Department of Pharmacy, Cruces University Hospital, Plaza de Cruces 12, Barakaldo, 48903, Bizkaia, Spain
| | - Helena Barrasa
- Bioaraba, Intensive Care Unit, Vitoria-Gasteiz, Spain.,Osakidetza Basque Health Service, Araba University Hospital, Intensive Care Unit, c/ Olaguibel no. 29, Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, 01006, Vitoria-Gasteiz, Spain.,Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, Spain
| | - Eduardo Asín-Prieto
- Inserm U1070: Pharmacologie des anti-infectieux, Pôle Biologie Santé-Bâtiment B36, Université de Poitiers, 1 rue Georges Bonnet, 86022, Poitiers, France.,PharmaMar, Avda. De los Reyes, 1, Pol. Ind. La Mina-Norte, Colmenar Viejo, 28770, Madrid, Spain
| | - Javier Maynar
- Bioaraba, Intensive Care Unit, Vitoria-Gasteiz, Spain.,Osakidetza Basque Health Service, Araba University Hospital, Intensive Care Unit, c/ Olaguibel no. 29, Vitoria-Gasteiz, Spain
| | | | - María Ángeles Solinís
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, 01006, Vitoria-Gasteiz, Spain. .,Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, Spain.
| | - Arantxazu Isla
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, 01006, Vitoria-Gasteiz, Spain. .,Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, Spain.
| |
Collapse
|
8
|
Westphal S, Hertler C, Blum D, Schettle M. Subcutaneous Levetiracetam Application Sustains Therapeutic Drug Levels. Palliat Med Rep 2021; 2:157-159. [PMID: 34223515 PMCID: PMC8241392 DOI: 10.1089/pmr.2020.0119] [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] [Accepted: 04/29/2021] [Indexed: 11/12/2022] Open
Abstract
We report on a patient suffering from seizures caused by cerebral metastases of adenocarcinoma of the lung. Initially, the patient was treated effectively with oral levetiracetam. As the disease progressed, oral intake was no longer possible. Since levetiracetam had controlled the patient's seizures well, the medication delivery mode was switched first to intravenous application, followed by a return to oral administration. After further deterioration, subcutaneous levetiracetam application was used to control epileptic symptoms while avoiding the sedating effects of subcutaneous midazolam. Subcutaneous levetiracetam allowed for stable seizure control in the end-of-life situation. Serum levels of levetiracetam were assessed for all application conditions and demonstrate that therapeutic drug levels can be reached by subcutaneous application. This report from a tertiary care center in Switzerland adds to the sparse but growing evidence base for the use of subcutaneous levetiracetam to manage seizures in palliative and end-of-life care.
Collapse
Affiliation(s)
- Sophia Westphal
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Caroline Hertler
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - David Blum
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Markus Schettle
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
9
|
Más-Sesé G, Martín-Bautista D, Navarro-Catalá A. Experience of using subcutaneous levetiracetam in palliative patients. NEUROLOGÍA (ENGLISH EDITION) 2021; 36:474-475. [DOI: 10.1016/j.nrleng.2020.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022] Open
|
10
|
Sutherland A, Meldon C, Harrison T, Miller M. Subcutaneous Levetiracetam for the Management of Seizures at the End of Life: An Audit and Updated Literature Review. J Palliat Med 2020; 24:976-981. [PMID: 33296254 DOI: 10.1089/jpm.2020.0414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: The aim of this study is to report the results of a second cycle audit of the use of subcutaneous levetiracetam (Keppra®) and an updated literature review of management of seizures in palliative care patients. Methods: A comprehensive literature review on the use of subcutaneous levetiracetam performed in 2016 was updated. A retrospective audit of the use of subcutaneous levetiracetam for inpatients at Sir Michael Sobell House Hospice during the period of 2019-2020 was performed. Ethical approval was not required and was therefore not sought. Results: We report an additional 66 cases identified through an updated literature review and our audit. Fourteen articles were identified from the literature review, reporting a total of 120 cases where subcutaneous levetiracetam was administered. We report 19 further cases of subcutaneous levetiracetam administration between April 2019 and April 2020. Doses ranged from 500 mg to 4000 mg daily. Doses above 2000 mg were administered using a T60 syringe driver. The oral-to-subcutaneous conversion ratio was 1:1 in all but one case where the dose had to be reduced to fit a T34 syringe driver, after which the T60s were purchased. Levetiracetam was not mixed with other medications, but administered alone using water as the diluent for injection. Where necessary, the dose was appropriately adjusted for renal function. No site reactions were reported. Conclusions: Combined analysis of the 139 cases of subcutaneous levetiracetam administration suggests that this treatment continues to have a role in management of seizures at the end of life. Clinical outcomes suggest that therapeutic levels may be achieved, although there are only very limited data available with a few cases worldwide to support this. Randomized controlled trials are urgently needed to establish the efficacy and tolerability of subcutaneous levetiracetam administration.
Collapse
Affiliation(s)
- Anna Sutherland
- Department of Palliative Medicine, Michael Sobell House Hospice, Churchill Hospital, Oxford, United Kingdom
| | - Charlotte Meldon
- Department of Palliative Medicine, Michael Sobell House Hospice, Churchill Hospital, Oxford, United Kingdom
| | - Timothy Harrison
- Department of Palliative Medicine, Michael Sobell House Hospice, Churchill Hospital, Oxford, United Kingdom
| | - Mary Miller
- Department of Palliative Medicine, Michael Sobell House Hospice, Churchill Hospital, Oxford, United Kingdom
| |
Collapse
|
11
|
Filling Gaps on Stability Data: Development, Validation and Application of a Multianalyte UHPLC-DAD Method to Determine the Stability of Commonly Administered Drugs in Different Carrier Solutions Used in Palliative Care. ANALYTICA 2020. [DOI: 10.3390/analytica1010005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In palliative care, continuous subcutaneous infusion (CSCI) is common practice for drug administration when oral application of drugs is not feasible or not reliable anymore. However, use of CSCI is limited to chemical stability of drugs and their combination in carrier solution. To determine the stability of different mixtures of commonly used drugs in palliative care, a multi-analyte UHPLC-DAD method controlled by an internal standard was successfully developed. The method was validated in terms of specificity, accuracy, precision, and linearity across the calibration range. Seven analytes could be separated within 10 min by C18-reversed phase chromatography. The method was successfully applied to close gaps in stability data and complete missing data for decision makers in health care units. Our results indicated the stability of binary mixtures and one ternary mixture in 0.9% saline and 5% glucose as carrier solutions. The obtained data will support pharmacists in palliative care for the preparation of parenteral drug solutions in the future.
Collapse
|
12
|
Más-Sesé G, Martín-Bautista D, Navarro-Catalá A. [Experience of using subcutaneous levetiracetam in palliative patients]. Neurologia 2020. [PMID: 32900522 DOI: 10.1016/j.nrl.2020.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- G Más-Sesé
- Unidad de Neurología, Hospital la Pedrera, Denia, Alicante, España.
| | | | - A Navarro-Catalá
- Farmacia Hospitalaria, Hospital la Pedrera, Denia, Alicante, España
| |
Collapse
|
13
|
Papa P, Oricchio F, Ginés M, Maldonado C, Tashjian A, Ibarra M, Percovich M, Fagiolino P, Pedragosa B, Vázquez M. Pharmacokinetics of Subcutaneous Levetiracetam in Palliative Care Patients. J Palliat Med 2020; 24:248-251. [PMID: 32267792 DOI: 10.1089/jpm.2019.0525] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Seizure control is challenging in the palliative care setting. Subcutaneous (SC) levetiracetam (LEV) is currently an off-label route of administration and effectiveness, tolerability, and pharmacokinetics studies for this route are scarce. Objectives: This prospective study aimed at evaluating effectiveness and tolerability of SC LEV as well as characterizing its pharmacokinetics. Subjects: Patients (n = 7) who attended the palliative care clinic between September 2018 and January 2019 with diagnosis of seizures, ≥18 years, and in need of SC route of administration were included in the study. Measurements: LEV plasma levels were determined using high-performance liquid chromatography and pharmacokinetic analysis were performed using Monolix 2018R2 (France). pH and osmolality of the three SC infusion solutions were also determined. Results: Seven patients took part in the study. Seizures were controlled in six out of seven patients with doses of 1000 and 3000 mg/day. Adverse effects were mild. pH and osmolality of the SC infusion solutions were within the accepted values reported in the literature. Mean plasma LEV concentrations were 14.4 mg/L (1000 mg/day) and 27.7 mg/L (2000 mg/day). The population clearance (2.5 L/h) and the elimination half-life (10.4 hours) were successfully estimated. Conclusions: Based on this data, SC LEV was effective and well tolerated. Pharmacokinetic parameters for the SC route were successfully determined.
Collapse
Affiliation(s)
- Patricia Papa
- Palliative Care Clinic, Sanatorio Médica Uruguaya, Montevideo, Uruguay
| | - Florencia Oricchio
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Therapeutic Drug Monitoring Service, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Mariana Ginés
- Palliative Care Clinic, Sanatorio Médica Uruguaya, Montevideo, Uruguay
| | - Cecilia Maldonado
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Therapeutic Drug Monitoring Service, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Araceli Tashjian
- Palliative Care Clinic, Sanatorio Médica Uruguaya, Montevideo, Uruguay
| | - Manuel Ibarra
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Therapeutic Drug Monitoring Service, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Mariana Percovich
- Palliative Care Clinic, Sanatorio Médica Uruguaya, Montevideo, Uruguay
| | - Pietro Fagiolino
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Therapeutic Drug Monitoring Service, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Berta Pedragosa
- Palliative Care Clinic, Sanatorio Médica Uruguaya, Montevideo, Uruguay
| | - Marta Vázquez
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Therapeutic Drug Monitoring Service, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| |
Collapse
|
14
|
Kälviäinen R, Reinikainen M. Management of prolonged epileptic seizures and status epilepticus in palliative care patients. Epilepsy Behav 2019; 101:106288. [PMID: 31133511 DOI: 10.1016/j.yebeh.2019.04.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/24/2019] [Indexed: 12/17/2022]
Abstract
Prolonged seizures and status epilepticus (SE) are relevant problems in palliative care. Timely recognition and effective early treatment with first- and second-line antiepileptic drugs (AEDs) may prevent unnecessary hospitalizations. Seizures should be recognized and addressed like any other symptom that causes discomfort or reduces quality of life. Use of alternative AED administration routes (buccal, intranasal, or subcutaneous) may offer possibilities for effective and individualized AED therapy, even during the last days of life. In hospice or home care, however, also intravenous treatment is possible via vascular access devices for long-term use. Aggressive unlimited intensive care unit (ICU) treatment of refractory SE in palliative patients is mostly not indicated. At worst, intensive care can be futile and possibly harmful: death in the ICU is often preceded by long and aggressive treatments. Metastatic cancer, old age, high severity of acute illness, overall frailty, poor functional status before hospital admission, and the presence of severe comorbidities all increase the probability of poor outcome of intensive care. When several of these factors are present, consideration of withholding intensive care may be in the patient's best interests. Anticipated outcomes influence patients' preferences. A majority of patients with a limited life expectancy because of an incurable disease would not want aggressive treatment, if the anticipated outcome was survival but with severe functional impairment. Doctors' perceptions about their patients' wishes are often incorrect, and therefore, advance care planning including seizure management should be done early in the course of the disease. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
Collapse
Affiliation(s)
- Reetta Kälviäinen
- Epilepsy Center, Neurocenter, Kuopio University Hospital, Kuopio, Finland; Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
| | - Matti Reinikainen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland; Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
| |
Collapse
|
15
|
Abstract
Palliative sedation (PS) is performed in the terminally ill patient to manage one or more refractory symptoms. Proportional PS, which means that drugs can be titrated to the minimum effective dose, is the form most widely used. From a quarter to a third of all terminally ill patients undergo PS, with a quarter of these requiring continuous deep sedation. The prevalence of PS varies according to the care setting and case mix. The most frequent refractory physical symptoms are delirium and dyspnea, but PS is also considered for existential suffering or psychological distress, which is an extremely difficult and delicate issue to deal with. Active consensus from the patient and advanced care planning is recommended for PS. The decision-making process concerning the continuation or withdrawal of other treatments is not the same as that used for PS. The practice differs totally from euthanasia in its intentions, procedures, and results. The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering. It does not have a detrimental effect on survival.
Collapse
Affiliation(s)
| | | | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy.
| |
Collapse
|
16
|
Howard P, Remi J, Remi C, Charlesworth S, Whalley H, Bhatia R, Hitchens M, Mihalyo M, Wilcock A. Levetiracetam. J Pain Symptom Manage 2018; 56:645-649. [PMID: 30036676 DOI: 10.1016/j.jpainsymman.2018.07.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/13/2018] [Indexed: 11/20/2022]
Abstract
Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).
Collapse
Affiliation(s)
- Paul Howard
- Mountbatten Hospice, Isle of Wight, United Kingdom
| | - Jan Remi
- University Hospital of Munich, Germany
| | | | | | - Helen Whalley
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, United Kingdom
| | | | | | - Mary Mihalyo
- Mylan School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
17
|
Grönheit W, Popkirov S, Wehner T, Schlegel U, Wellmer J. Practical Management of Epileptic Seizures and Status Epilepticus in Adult Palliative Care Patients. Front Neurol 2018; 9:595. [PMID: 30116217 PMCID: PMC6082965 DOI: 10.3389/fneur.2018.00595] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 07/04/2018] [Indexed: 11/13/2022] Open
Abstract
In terminally ill patients, paroxysmal or episodic changes of consciousness, movements and behavior are frequent. Due to ambiguous appearance, the correct diagnosis of epileptic seizures (ES) and non-epileptic events (NEE) is often difficult. Treatment is frequently complicated by the underlying condition, and an approach indicated in healthier patients may not always be appropriate in the palliative care setting. This article provides recommendations for diagnosis of ES and NEE and treatment options for ES in adult palliative care patients, including aspects of alternative administration routes for antiepileptic drugs such as intranasal, subcutaneous, or rectal application.
Collapse
Affiliation(s)
- Wenke Grönheit
- Ruhr-Epileptology, Department of Neurology, University Hospital Bochum, Bochum, Germany.,Department of Neurology, University Hospital Bochum, Bochum, Germany
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Bochum, Bochum, Germany
| | - Tim Wehner
- Ruhr-Epileptology, Department of Neurology, University Hospital Bochum, Bochum, Germany.,Department of Neurology, University Hospital Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Bochum, Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Bochum, Bochum, Germany.,Department of Neurology, University Hospital Bochum, Bochum, Germany
| |
Collapse
|
18
|
|
19
|
Furtado I, Gonçalves F, Gonçalves J, Neves J. Continuous subcutaneous levetiracetam in end-of-life care. BMJ Case Rep 2018; 2018:bcr-2017-222340. [PMID: 29351934 DOI: 10.1136/bcr-2017-222340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Seizures constitute a determining aspect in quality of life and are frequently challenging in palliative care-a field where treatment has yet to be standardised. Levetiracetam-a new generation anticonvulsant-has proved efficacy both through oral, as well as intravenous administration in the general population. This case reports on the use of continuous subcutaneous levetiracetam to effectively control seizures in a terminally ill patient without patent oral route.
Collapse
Affiliation(s)
- Inês Furtado
- Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| | | | - João Gonçalves
- Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| | - João Neves
- Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| |
Collapse
|