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Recent advancements to enhance the therapeutic efficacy of antiepileptic drugs. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2021; 71:527-544. [PMID: 36651558 DOI: 10.2478/acph-2021-0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/19/2023]
Abstract
Epilepsy is a multifactorial neurological disorder characterized by recurrent or unprovoked seizures. Over the past two decades, many new antiepileptic drugs (AEDs) were developed and are in use for the treatment of epilepsy. However, drug resistance, drug-drug interaction and adverse events are common problems associated with AEDs. Antiepileptic drugs must be used only if the ratio of efficacy, safety, and tolerability of treatment are favorable and outweigh the disadvantages including treatment costs. The application of novel drug delivery techniques could enhance the efficacy and reduce the toxicity of AEDs. These novel techniques aim to deliver an optimal concentration of the drug more specifically to the seizure focus or foci in the CNS without numerous side-effects. The purpose of this article is to review the recent advancements in antiepileptic treatment and summarize the novel modalities in the route of administration and drug delivery, including gene therapy, for effective treatment of epilepsy.
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Panraksa P, Tipduangta P, Jantanasakulwong K, Jantrawut P. Formulation of Orally Disintegrating Films as an Amorphous Solid Solution of a Poorly Water-Soluble Drug. MEMBRANES 2020; 10:membranes10120376. [PMID: 33261025 PMCID: PMC7759778 DOI: 10.3390/membranes10120376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 12/28/2022]
Abstract
The objective of the present study was to develop an orally disintegrating film (ODF) for a poorly water-soluble drug, phenytoin (PHT), using the cosolvent solubilization technique to achieve the amorphization of the drug, followed by the preparation of ODFs. Eleven formulations were prepared with different polymers, such as polyvinyl alcohol (PVA) and high methoxyl pectin (HMP) by the solvent casting method. The prepared films were subjected to characterization for weight variations, thickness, surface pH, disintegration time and mechanical strength properties. Then, differential scanning calorimetry, X-ray diffraction analysis and the drug release patterns of the selected films were evaluated. Among the prepared formulations, the formulation composed of 1% w/w of PVA, 0.04% w/w of sodium starch glycolate with polyethylene glycol 400, glycerin and water as cosolvents (PVA-S4) showed promising results. The physical appearance and mechanical strength properties were found to be good. The PVA-S4 film was clear and colorless with a smooth surface. The surface pH was found to be around 7.47 and the in vitro disintegration time was around 1.44 min. The drug content of the PVA-S4 film was 100.27%. X-ray diffractometry and thermal analysis confirmed the transition of phenytoin in the PVA-S4 film into a partially amorphous state during film preparation using the cosolvent solubilization approach. The resulting PVA-S4 film showed a higher dissolution rate in comparison to the film without a cosolvent. Overall, this study indicated the influence of cosolvents on enhancing the solubility of a poorly water-soluble drug and its film dissolution.
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Affiliation(s)
- Pattaraporn Panraksa
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand; (P.P.); (P.T.)
| | - Pratchaya Tipduangta
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand; (P.P.); (P.T.)
| | - Kittisak Jantanasakulwong
- Division of Packaging Technology, School of Agro-Industry, Faculty of Agro-Industry, Chiang Mai University, Chiang Mai 50100, Thailand;
- Cluster of Agro Bio-Circular-Green Industry (Agro BCG), Chiang Mai University, Chiang Mai 50100, Thailand
| | - Pensak Jantrawut
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand; (P.P.); (P.T.)
- Cluster of Agro Bio-Circular-Green Industry (Agro BCG), Chiang Mai University, Chiang Mai 50100, Thailand
- Correspondence: or ; Tel.: +66-5394-4309
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Ratri DMN, Rahmadi M, Islamiyah WR, Harum NF. Overview of therapeutic changes in antiepileptic drugs in adult patients. J Basic Clin Physiol Pharmacol 2020; 30:/j/jbcpp.ahead-of-print/jbcpp-2019-0346/jbcpp-2019-0346.xml. [PMID: 31926092 DOI: 10.1515/jbcpp-2019-0346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/22/2019] [Indexed: 06/10/2023]
Abstract
Background Previous studies suggest a highly variable response of antiepileptic drugs (AEDs). This may be because the response to AEDs has been changed to sustained period of freedom from seizures. This study was conducted to determine whether therapeutic changes of AEDs in the treatment of seizure would be observable in an Indonesian population. Methods The study was conducted at the outpatient neurology polyclinic at the Universitas Airlangga Hospital, Surabaya, Indonesia. This was an observational retrospective cohort study, examining the outcomes of 41 cases of switching AEDs (increase or decrease of the dose, switch to branded or generic, or added or reduced type of AEDs). Results After treatment with the switched AED, seizure did not show any significant improvement. However, the incidence of seizure during and after the therapeutic change showed a downward trend (from 44% to 32%). Conclusions According to the present study, mere optimization of antiepileptic therapy may not result in a steep decrease in seizure events, particularly in polytherapy with AEDs. On the other hand, monotherapy with AEDs evidences to decreasing tendency of seizures.
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Affiliation(s)
- Dinda M N Ratri
- Universitas Airlangga, Clinical Pharmacy Department, Faculty of Pharmacy, Surabaya, East Java, Indonesia
| | - Mahardian Rahmadi
- Universitas Airlangga, Clinical Pharmacy Department, Faculty of Pharmacy, Surabaya, East Java, Indonesia
- Universitas Airlangga, Clinical Pharmacy Department, Surabaya, East Java, Indonesia
| | - Wardah R Islamiyah
- Universitas Airlangga, Neurology Department, Faculty of Medicine, Surabaya, East Java, Indonesia
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Nene D, Mundlamuri RC, Satishchandra P, Prathyusha PV, Nagappa M, Bindu PS, Raghavendra K, Saini J, Bharath RD, Thennarasu K, Taly AB, Sinha S. Comparing the efficacy of sodium valproate and levetiracetam following initial lorazepam in elderly patients with generalized convulsive status epilepticus (GCSE): A prospective randomized controlled pilot study. Seizure 2019; 65:111-117. [PMID: 30682680 DOI: 10.1016/j.seizure.2019.01.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This randomized control study was conducted to compare the efficacy of sodium valproate (SVP) and levetiracetam (LEV) following initial intravenous lorazepam in elderly patients (age: >60years) with generalized convulsive status epilepticus (GCSE) and to identify predictors of poor seizure control. METHODS A total of 118 patients (mean age: 67.5 ± 7.5 years, M:F = 1.6:1), who had presented with GCSE were randomized into the SVP or LEV treatment arms. All patients received initial intravenous lorazepam (0.1 mg/kg) followed by one of the two antiepileptic drugs (AEDs), parenteral SVP (20-25 mg/kg) or LEV (20-25 mg/kg). Those who failed to achieve control with the initial AED, were crossed over to receive the other AED. One-hundred patients (SVP = 50; LEV = 50) completed the study. RESULTS SE could be controlled with lorazepam and one of the AEDs (SVP or LEV) in 71.18% (84/118). Intention-to-treat analysis showed that the two groups did not differ significantly in terms of seizure control [SVP: 41/60 (68.3%); LEV: 43/58 (74.1%), p = 0.486]. Of 100 patients who completed the study, seizure control was achieved in 38/50(76%) in the SVP and 43/50(86%) in the LEV group (p = 0.202). After crossing over to the second AED, SE could be controlled in an additional in 50% (6/12) in SVP (+LEV) group and in 14.3% (1/7) in LEV (+SVP) group. Overall, after the second AED, seizure control was achieved in 77.1% (91/118). Higher STESS was associated with poor therapeutic response (p = 0.049). CONCLUSIONS The efficacy of SVP and LEV following initial lorazepam in controlling GCSE in elderly population was comparable, hence the choice of AED could be individualized.
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Affiliation(s)
- Devavrat Nene
- Department of Neurology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
| | | | | | | | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
| | - Parayil Sankaran Bindu
- Department of Neurology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
| | - Kenchaiah Raghavendra
- Department of Neurology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
| | - Jitender Saini
- Department of Neuroimaging and Interventions Radiology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
| | - Rose Dawn Bharath
- Department of Neuroimaging and Interventions Radiology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
| | - Kandavel Thennarasu
- Department of Biostatistics, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
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Kong Q, Min X, Sun R, Gao J, Liang R, Li L, Chu X. Effects of pharmacological treatments on hippocampal NCAM1 and ERK2 expression in epileptic rats with cognitive dysfunction. Oncol Lett 2016; 12:1783-1791. [PMID: 27588125 PMCID: PMC4997984 DOI: 10.3892/ol.2016.4882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 11/03/2016] [Indexed: 11/15/2022] Open
Abstract
The present study aimed to investigate the effects of various pharmacological agents on the hippocampal expression of neural cell adhesion molecule 1 (NCAM1) and extracellular signal-regulated kinase 2 (ERK2) in epileptic rats with cognitive dysfunction. The experiments were conducted using 120 Wistar rats: 20 controls and 100 with pilocarpine-induced status epilepticus (SE). The SE rats were randomly assigned to 5 groups (n=20/group) that received daily treatments for 1 month with one of the following: (i) saline (no effect on epilepsy); (ii) carbamazepine (an anticonvulsant); (iii) oxcarbazepine (an anticonvulsant); (iv) aniracetam (a nootropic); or (v) donepezil (an acetylcholinesterase inhibitor). Spatial learning and memory were assessed using a Morris Water Maze (MWM). Hippocampal tissue was assessed for NCAM1 and ERK2 messenger RNA (mRNA) expression by reverse transcription polymerase chain reaction, and protein expression by immunochemistry. The results revealed that SE rats had significantly poorer MWM performances compared with controls (P<0.01). Performance in SE rats was improved with donepezil treatment (P<0.01), but declined with carbamazepine (P<0.01). Compared with controls, saline-treated SE rats exhibited increased hippocampal NCAM1 mRNA expression (P<0.01). Among SE rats, NCAM1 mRNA expression was highest in those treated with donepezil, followed by aniracetam-, saline-, oxcarbazepine- and carbamazepine-treated rats. Compared to controls, saline-treated SE rats exhibited decreased hippocampal ERK2 mRNA expression (P<0.01). Among SE rats, ERK2 mRNA expression was highest in those treated with donepezil, followed by aniracetam, saline, oxcarbazepine and carbamazepine. NCAM1 and ERK2 protein expression levels were parallel to those of the mRNA. In saline-treated SE rats, hippocampal ERK2 expression was decreased and NCAM1 expression was increased; thus, these two molecules may be involved in the impairment of spatial memory. Carbamazepine augmented this impairment, whereas donepezil was found to ameliorate the dysfunction associated with epilepsy. In conclusion, ERK2 and NCAM1 have significant roles in impairment of spatial memory in SE rats. Carbamazepine may increase this impairment, while donepezil may decrease this impairment.
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Affiliation(s)
- Qingxia Kong
- Department of Neurology, Affiliated Hospital of Jining Medical College, Jining, Shandong 272129, P.R. China
| | - Xia Min
- Department of Neurology, Affiliated Hospital of Jining Medical College, Jining, Shandong 272129, P.R. China
| | - Ran Sun
- Department of Neurology, Affiliated Hospital of Jining Medical College, Jining, Shandong 272129, P.R. China
| | - Jianying Gao
- Department of Nuclear Medicine, Affiliated Hospital of Jining Medical College, Jining, Shandong 272129, P.R. China
| | - Ruqing Liang
- Department of Neurology, Affiliated Hospital of Jining Medical College, Jining, Shandong 272129, P.R. China
| | - Lei Li
- Department of Neurology, Affiliated Hospital of Jining Medical College, Jining, Shandong 272129, P.R. China
| | - Xu Chu
- Department of Neurology, Affiliated Hospital of Jining Medical College, Jining, Shandong 272129, P.R. China
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Yuce-Dursun B, Danis O, Demir S, Ogan A, Onat F. Proteomic changes in the cortex membrane fraction of genetic absence epilepsy rats from Strasbourg. J Integr Neurosci 2015; 13:633-44. [PMID: 25352154 DOI: 10.1142/s021963521450023x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Epilepsy is a serious neurodegenerative disorder with a high incidence and a variety of presentations and causes. Studies on brain from various animal models including chronic models: Genetic Absence Epilepsy Rats from Strasbourg (GAERS) are very useful for understanding the fundamental mechanisms associated with human epilepsy. Individual regions of the brain have different protein composition in different conditions. Therefore, proteomic analyses of the brain compartments are preferred for the development of new therapeutic targets in different pathophysiological conditions like neurodegenerative disorders. In this study, we describe a proteomic profiling of membrane fraction of cortex tissue from epileptic GAERS and non-epileptic Wistar rat brain by two-dimensional gel electrophoresis coupled with matrix-assisted laser desorption/ionization mass spectroscopy. Comparing the optical density of spots between groups, we found that one protein expression was significantly down-regulated (guanine nucleotide-binding protein G(I)/G(S)/G(T) subunit beta-1) and one protein expression was significantly up-regulated (14-3-3 protein epsilon isoform) in GAERS group. Our results indicate that these proteins might have played a significant role in epilepsy and may be considered as valuable therapeutic targets in the absence of epilepsy.
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Affiliation(s)
- Basak Yuce-Dursun
- Marmara University, Faculty of Arts and Sciences, Department of Chemistry, 34722, Istanbul, Turkey
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Asadi-Pooya AA, Razavizadegan SMA, Abdi-Ardekani A, Sperling MR. Adjunctive use of verapamil in patients with refractory temporal lobe epilepsy: a pilot study. Epilepsy Behav 2013; 29:150-4. [PMID: 23973639 DOI: 10.1016/j.yebeh.2013.07.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 06/17/2013] [Accepted: 07/08/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The present study aimed to determine if adjunctive use of verapamil, as a P-glycoprotein (P-gp) inhibitor, is efficacious in decreasing seizure frequency in patients with refractory temporal lobe epilepsy. MATERIALS AND METHODS This was an open-label pilot study. Adult patients with refractory temporal lobe epilepsy were studied. Baseline seizure type and seizure count were determined. Patients were divided randomly into two groups. Group A received verapamil 120 mg/day (n=13), and group B received 240 mg/day (n=6). All patients were followed for eight weeks. The proportion of responders, which consist of patients with more than 50% reduction in seizure frequency from baseline, was tabulated. RESULTS Nineteen patients were studied. Seven patients (36.84%) reached the responder rate. Three patients (50%) in group B were among the responders; two of these patients achieved seizure freedom. Four patients (30.7%) in group A responded favorably to verapamil. CONCLUSION Developing new means of improving the effectiveness of existing antiepileptic drugs is a desirable way of tackling the dilemma of medically refractory epilepsy. Hypothetically, P-gp inhibitors (e.g., verapamil) might be used to counteract the removal of AEDs from the epileptogenic tissue. Such a strategy was adopted in this non-placebo-controlled, open-label, pilot study. We observed a significant achievement in seizure control associated with adjunctive use of verapamil in patients with refractory temporal lobe epilepsy.
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Affiliation(s)
- Ali A Asadi-Pooya
- Department of Neurology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, USA.
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Miziak B, Chrościńska-Krawczyk M, Błaszczyk B, Radzik I, Czuczwar SJ. Novel approaches to anticonvulsant drug discovery. Expert Opin Drug Discov 2013; 8:1415-27. [DOI: 10.1517/17460441.2013.837047] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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de Assis TMR, Costa G, Bacellar A, Orsini M, Nascimento OJM. Status epilepticus in the elderly: epidemiology, clinical aspects and treatment. Neurol Int 2012; 4:e17. [PMID: 23355930 PMCID: PMC3555219 DOI: 10.4081/ni.2012.e17] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 07/23/2012] [Accepted: 07/30/2012] [Indexed: 11/25/2022] Open
Abstract
The aim of the study was to review the epidemiology, clinical profile and discuss the etiology, prognosis and treatment options in patients aged 60 years or older presenting with status epilepticus. We performed a systematic review involving studies published from 1996 to 2010, in Medline/PubMed, Scientific Electronic Library on line (Scielo), Latin-American and Caribbean Center of Health Sciences Information (Lilacs) databases and textbooks. Related articles published before 1996, when relevant for discussing epilepsy in older people, were also included. Several population studies had shown an increased incidence of status epilepticus after the age of 60 years. Status epilepticus is a medical and neurological emergency that is associated with high morbidity and mortality, and is a major concern in the elderly compared to the general population. Prompt diagnosis and effective treatment of convulsive status epilepticus are crucial to avoid brain injury and reduce the fatality rate in this age group.
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Affiliation(s)
- Telma M R de Assis
- Department of Neurology, São Rafael Hospital, Salvador, BA; ; Federal Fluminense University Pos-Graduating Program on Neurology\Neuroscience, Rio de Janeiro, Brazil
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Alternative therapeutic options for medical management of epilepsy in apes. J Zoo Wildl Med 2012; 42:291-4. [PMID: 22946407 DOI: 10.1638/2010-0184.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Phenobarbital has been the primary antiepileptic drug used in primates, but the dosage required for seizure control is frequently associated with significant side effects. Newer antiepileptic drugs and adjunctive therapies currently being used in human medicine provide additional options for treatment of nonhuman primates. This report describes different drug regimes used for control of epileptic seizures in apes at the Milwaukee County Zoo (Milwaukee, Wisconsin, U.S.A.), including the addition of acetazolamide to phenobarbital, levetiracetam, carbamazepine, and the use of extended cycle oral contraceptives to assist seizure control in female apes with catamenial epilepsy.
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Salat R, Salat K. New approach to predicting proconvulsant activity with the use of Support Vector Regression. Comput Biol Med 2012; 42:575-81. [PMID: 22348824 DOI: 10.1016/j.compbiomed.2012.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 10/31/2011] [Accepted: 02/01/2012] [Indexed: 12/31/2022]
Abstract
Antiepileptic drugs are commonly used for many therapeutic indications, including epilepsy, neuropathic pain, bipolar disorder and anxiety. Accumulating data suggests that many of them may lower the seizure threshold in men. In the present paper we deal with the possibility of using Support Vector Regression (SVR) to forecast the proconvulsant activity of compounds exerting anticonvulsant activity in the electroconvulsive threshold test in mice. A new approach to forecast this drug-related toxic effect by means of the support vector machine (SVM) in the regression mode is discussed below. The efficacy of this mathematical method is compared to the results obtained in vivo. Since SVR investigates the anticonvulsant activity of the compounds more thoroughly than it is possible using animal models, this method seems to be a very helpful tool for predicting additional dose ranges at which maximum anticonvulsant activity without toxic effects is observed. Good generalizing properties of SVR allow to assess the therapeutic dose range and toxicity threshold. Noteworthy, this method is very interesting for ethical reasons as this mathematical model enables to limit the use of living animals during the anticonvulsant screening process.
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Affiliation(s)
- Robert Salat
- Warsaw University of Life Sciences, Warsaw, Poland.
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Affiliation(s)
- Sajun Chung
- Department of Pediatrics, Kyunghee University College of Medicine, Korea.
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An alternative perspective on the management of status epilepticus. Epilepsy Behav 2008; 12:349-53. [PMID: 18262847 DOI: 10.1016/j.yebeh.2007.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 12/25/2007] [Indexed: 02/08/2023]
Abstract
The definition of status epilepticus (SE) has been reduced from 30 minutes to 5 minutes and this article questions if treatment should not be offered before reaching that window. After provision of first aid, benzodiazepines (BDZ) are the initial form of intervention, with either nasal or buccal midazolam being favored for nonprofessionals. Proper patient supervision, including admission to an intensive care unit for more difficult patients, is endorsed, and the need to warn nonprofessionals of the potential risk of respiratory depression is imperative. The article criticizes the use of phenytoin as the antiepileptic medication (AEM) with which to load patients, as it is no longer a first-line AEM, and argues in favor of using a first-line AEM such as valproate or carbamazepine, or preferably the AEM that previously proved efficacious in a patient with known epilepsy who was noncompliant. Alternative routes of administration of AEMs are discussed, and the use of blood level monitoring, as an adjunct to management, to protect against further episodes of SE, is supported. Touched on in this article are the use of some of the newer AEMs in the management of SE and exploration of treatment strategies that acknowledge that treatment must also include patient education that incorporates techniques to enhance compliance.
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Beyenburg S, Elger CE, Reuber M. Acute confusion or altered mental state: consider nonconvulsive status epilepticus. Gerontology 2007; 53:388-96. [PMID: 17684419 DOI: 10.1159/000106829] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Accepted: 06/05/2007] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The diagnosis of nonconvulsive status epilepticus (NCSE) is particularly challenging in elderly patients. Confusion, personality change, dysphasia, subtle motor activity and nystagmus may be the only presenting signs. OBJECTIVE To review current knowledge about NCSE with special focus on older people. METHODS Systematic review of the current literature via Medline search. CONCLUSION Although prospective studies are still lacking, NCSE may be one of the most frequently missed diagnoses in patients presenting with altered mental status. Elderly patients are at particular risk of diagnostic errors because of the broad range of presentations of NCSE, significant comorbidities (especially cerebrovascular disease), limited awareness of this particular seizure emergency or difficulties with access to electroencephalography. Although diagnostic criteria and treatment remain controversial, the diagnosis of NCSE is important because it is potentially reversible.
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Affiliation(s)
- Stefan Beyenburg
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg, USA.
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Steinhoff BJ, Somerville ER, Van Paesschen W, Ryvlin P, Schelstraete I. The SKATE™ study: An open-label community-based study of levetiracetam as add-on therapy for adults with uncontrolled partial epilepsy. Epilepsy Res 2007; 76:6-14. [PMID: 17681453 DOI: 10.1016/j.eplepsyres.2007.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 05/25/2007] [Accepted: 06/02/2007] [Indexed: 10/23/2022]
Abstract
The Safety of Keppra as Adjunctive Therapy in Epilepsy (SKATE) study aimed to evaluate the safety and efficacy of levetiracetam (Keppra, LEV) as add-on therapy for refractory partial seizures in clinical practice. This Phase IV, 16-week, open-label study recruited patients > or =16-year old with treatment-resistant partial seizures. LEV (1000 mg/day) was added to a stable concomitant antiepileptic drug regimen. LEV dosage was adjusted based on seizure control and tolerability to a maximum of 3000 mg/day. 1541 patients (intent-to-treat population) were recruited including 1346 (87.3%) who completed the study and 77.0% who declared further continuing on LEV after the trial. Overall, 50.5% of patients reported at least one adverse event that was considered related to LEV treatment. The most frequently reported drug-related adverse events were mild-to-moderate somnolence, fatigue, dizziness and headache. Serious adverse events considered related to LEV occurred in 1.0% of patients. 7.5% of patients reported adverse events as the most important reason for study drug discontinuation. The median reduction from baseline in the frequency of all seizures was 50.2%; 15.8% of patients were seizure free; 50.1% had seizure frequency reduction of > or =50%. At the end of the study, 60.4% of patients were considered by the investigator to show marked or moderate improvement. There was a significant improvement in health-related quality of life as assessed with the QOLIE-10-P (total score increasing from 55.6 to 61.6; p<0.001). This community-based study suggests that LEV is well tolerated and effective as add-on therapy for refractory partial seizures in adults. These data provide supportive evidence for the safety and efficacy of LEV demonstrated in the pivotal Phase III placebo-controlled studies.
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Asadi-Pooya AA, Sperling MR. Potentiation of anti-epileptic drugs effectiveness by pyronaridine in refractory epilepsy. Med Hypotheses 2007; 69:560-3. [PMID: 17368747 DOI: 10.1016/j.mehy.2006.12.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 12/14/2006] [Indexed: 11/17/2022]
Abstract
One of the major neurobiological mechanisms proposed in drug resistant epilepsy is removal of anti-epileptic drugs (AEDs) from the epileptogenic tissue through excessive expression of multi-drug efflux transporters such as P-glycoprotein (P-gp). P-gp, the encoded product of the human multi-drug resistance-1 (MDR-1; ABCB1) gene, is of particular clinical relevance in the emergence of multi-drug resistance (MDR), which may play an important role in preventing treatment response of some tumors and infectious diseases to chemotherapeutic agents and antibiotics. It has been shown that MDR-1 is over-expressed in brain tissue (hippocampal neurons) in patients with refractory temporal lobe epilepsy. For direct evidence that drug transporters such as P-gp are responsible for drug resistance, an experiment can be conducted to determine whether seizure control is improved when P-gp inhibitors are administered in addition to existing AEDs in patients with medically refractory epilepsy. In comparison with first and second-generation of P-gp inhibitors, third-generation inhibitors such as pyronaridine (PND) have advantages, such as higher potency and specificity for P-gp, lack of non-specific cytotoxicity, relatively long duration of action with reversibility, and good oral bioavailability. We suggest that a pilot study be conducted to determine whether adding of PND to existing AEDs decreases seizure frequency in patients with drug resistant epilepsy, and should this show promise, that a double-blind randomized controlled trial be designed to test the efficacy of PND.
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Affiliation(s)
- Ali Akbar Asadi-Pooya
- Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, PA, USA.
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17
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Abstract
The development of novel chemotherapeutic agents and advances in treatment technique have improved survival for patients diagnosed with some forms of cancer, but treatments are not always site specific and may place normal tissues at risk. The central nervous system (CNS) is susceptible to treatment effects and complaints of memory loss and generalized cognitive decline are common among cancer patients. Despite the frequency of subjective patient complaints, studies evaluating the cognitive abilities of patients have inconsistently reported chemotherapy-related declines. On careful review of the literature, discrepant findings across studies (some documenting chemotherapy-related cognitive declines and others failing to detect such changes) may be attributed to differences in methodology. Most studies have been retrospective in design, omit pretreatment assessment of function, use small or heterogeneous samples, use inappropriate measures to assess cognition, and fail to incorporate control subjects. Though rare to date, prospective, randomized, longitudinal studies that incorporate pretreatment comprehensive neuropsychological assessment are necessary to define the severity and pattern of treatment-related change. Building on a foundation of solid science, future studies may identify subgroups of patients susceptible to significant chemotherapy-related cognitive decline. Once these groups are identified and the mechanisms underlying the decline are elucidated, attention may be turned to the development of treatments that may optimize cognitive function and improve patient quality of life.
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Affiliation(s)
- Anne E Kayl
- The University of Texas, M.D. Anderson Cancer Center, Houston, Texas 77030-1402, USA.
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18
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Abstract
PURPOSE OF REVIEW Few drugs are licensed in pregnancy, and data on drug use in pregnancy are mainly retrospective and uncontrolled. Pregnancy exposure has increased recently to new classes of drugs, as they have been shown to be effective and well tolerated outside of pregnancy. RECENT FINDINGS Anti-nausea therapies, H2-receptor and proton pump inhibitors appear to be safe. Metformin is being trialed for treatment in gestational diabetes and initial reports appear encouraging. Concern has been raised about statins in early pregnancy and should be avoided. New antiepileptic medication appears effective with low risk of abnormality. However, when combined with valproate, risks are still high. Selective serotonin reuptake inhibitors for depression appear to be effective, with likely low risk for teratogenesis, although neonatal behavioural syndrome following their use in the third trimester is a concern. Angiotensin II inhibitors should be avoided in the second and third trimesters of pregnancy. Smoking cessation programmes need to be reevaluated. SUMMARY Information about safety of drugs and caution about prescribing in pregnancy should continue. Until large clinical trials are performed, the risk/benefit ratio of drugs during pregnancy will remain uncertain.
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Affiliation(s)
- Phillipa M Kyle
- Obstetrics and Gynaecology, Christchurch School of Medicine and Health Sciences, University of Otago, New Zealand.
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Affiliation(s)
- Elizabeth J Donner
- Division of Neurology and Program in Brain and Behavior, Hospital for Sick Children, Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Beyenburg S, Mitchell AJ, Schmidt D, Elger CE, Reuber M. Anxiety in patients with epilepsy: systematic review and suggestions for clinical management. Epilepsy Behav 2005; 7:161-71. [PMID: 16054870 DOI: 10.1016/j.yebeh.2005.05.014] [Citation(s) in RCA: 236] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Accepted: 05/24/2005] [Indexed: 11/18/2022]
Abstract
Up to 50 or 60% of patients with chronic epilepsy have various mood disorders including depression and anxiety. Whereas the relationship between epilepsy and depression has received much attention, less is known about anxiety disorders. It is now recognized that anxiety can have a profound influence on the quality of life of patients with epilepsy. The relationship between anxiety disorders and epilepsy is complex. It is necessary to distinguish between different manifestations of anxiety disorder: ictal, postictal, and interictal anxiety. Preexisting vulnerability factors, neurobiological factors, iatrogenic influences (antiepileptic drugs, epilepsy surgery), and psychosocial factors are all likely to play a role, but with considerable individual differences. Despite the high prevalence of anxiety disorders in patients with epilepsy, there are no systematic treatment studies or evidence-based guidelines for best treatment practice. Nevertheless, a practical approach based on the temporal relationship between anxiety and epileptic seizures allows clinicians to consider appropriate treatment strategies to reduce the psychiatric comorbidity in patients with epilepsy.
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Affiliation(s)
- Stefan Beyenburg
- Department of Neurology, Centre Hospitalier de Luxembourg, Rue Barblé 4, L-1210 Luxembourg, Luxembourg.
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21
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Beyenburg S, Schmidt D. [Patients with epilepsy and anxiety disorders. Diagnosis and treatment]. DER NERVENARZT 2005; 76:1077-8, 1081-2, 1084-6 passim. [PMID: 15717111 DOI: 10.1007/s00115-004-1867-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Up to 50-60% of patients with epilepsy may develop psychiatric complications, in particular depression, anxiety, and psychotic disorders. Although this comorbidity has received a great deal of attention in recent years, the anxiety spectrum of psychiatric disturbances in epilepsy patients has not been extensively studied, although this comorbidity has a significant effect on the medical management and quality of life. The etiology is multifactorial, including neurobiological and shared pathophysiological mechanisms as well as psychosocial and iatrogenic factors (e.g., influence of antiepileptic drugs, epilepsy surgery). Despite the high prevalence of comorbid anxiety in epilepsy, very little is known about optimal treatment strategies. This article reviews the complex interrelationships between anxiety disorders and epilepsy from a clinical point of view. The evaluation of anxiety relative to ictal, peri-ictal, and postictal states is described, and medical treatment options for anxiety disorders in patients with epilepsy are discussed, illustrating that their treatment extends far beyond seizure control.
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Affiliation(s)
- S Beyenburg
- Département des Neurosciences, Centre Hospitalier de Luxembourg.
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