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Almohaish S, Cook AM, Brophy GM, Rhoney DH. Personalized antiseizure medication therapy in critically ill adult patients. Pharmacotherapy 2023; 43:1166-1181. [PMID: 36999346 DOI: 10.1002/phar.2797] [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: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/01/2023]
Abstract
Precision medicine has the potential to have a significant impact on both drug development and patient care. It is crucial to not only provide prompt effective antiseizure treatment for critically ill patients after seizures start but also have a proactive mindset and concentrate on epileptogenesis and the underlying cause of the seizures or seizure disorders. Critical illness presents different treatment issues compared with the ambulatory population, which makes it challenging to choose the best antiseizure medications and to administer them at the right time and at the right dose. Since there is a paucity of information available on antiseizure medication dosing in critically ill patients, therapeutic drug monitoring is a useful tool for defining each patient's personal therapeutic range and assisting clinicians in decision-making. Use of pharmacogenomic information relating to pharmacokinetics, hepatic metabolism, and seizure etiology may improve safety and efficacy by individualizing therapy. Studies evaluating the clinical implementation of pharmacogenomic information at the point-of-care and identification of biomarkers are also needed. These studies may make it possible to avoid adverse drug reactions, maximize drug efficacy, reduce drug-drug interactions, and optimize medications for each individual patient. This review will discuss the available literature and provide future insights on precision medicine use with antiseizure therapy in critically ill adult patients.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Aaron M Cook
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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2
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Chen CY, Zhou Y, Cui YM, Yang T, Zhao X, Wu Y. Population pharmacokinetics and dose simulation of oxcarbazepine in Chinese paediatric patients with epilepsy. J Clin Pharm Ther 2019; 44:300-311. [PMID: 30636182 DOI: 10.1111/jcpt.12792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/17/2018] [Accepted: 10/26/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Chao-Yang Chen
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Ying Zhou
- Department of Pharmacy; Peking University First Hospital; Beijing China
- School of Pharmaceutical Sciences; Peking University Health Science Center; Beijing China
| | - Yi-Min Cui
- Department of Pharmacy; Peking University First Hospital; Beijing China
- School of Pharmaceutical Sciences; Peking University Health Science Center; Beijing China
| | - Ting Yang
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Xia Zhao
- Department of Pharmacy; Peking University First Hospital; Beijing China
- School of Pharmaceutical Sciences; Peking University Health Science Center; Beijing China
| | - Ye Wu
- Department of Pediatrics; Peking University First Hospital; Beijing China
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3
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Knezevic CE, Marzinke MA. Clinical Use and Monitoring of Antiepileptic Drugs. J Appl Lab Med 2018; 3:115-127. [DOI: 10.1373/jalm.2017.023689] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/19/2018] [Indexed: 01/17/2023]
Abstract
Abstract
Background
Antiepileptic drugs (AEDs) have been used for the treatment of epilepsy and other neurological disorders since the late 19th century. There are currently several classes of AEDs available for epilepsy management, many of which are also used to treat migraines, bipolar disorder, schizophrenia, depression, and neuropathic pain. Because of their molecular and mechanistic diversity, as well as the potential for drug–drug interactions, AEDs are prescribed and monitored in a highly personalized manner.
Content
This review provides a general overview of the use of AEDs with a focus on the role of therapeutic drug monitoring. Discussed topics include mechanisms of action, guidelines on the clinical applications of AEDs, clinical tests available for AED monitoring, and genetic factors known to affect AED efficacy.
Summary
Implementation of AED therapies is highly individualized, with many patient-specific factors considered for drug and dosage selection. Both therapeutic efficacy and target blood concentrations must be established for each patient to achieve seizure mitigation or cessation. The use of an AED with any additional drug, including other AEDs, requires an evaluation of potential drug–drug interactions. Furthermore, AEDs are commonly used for nonepilepsy indications, often in off-label administration to treat neurological or psychiatric disorders.
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Affiliation(s)
- Claire E Knezevic
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mark A Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
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Antunes NDJ, van Dijkman SC, Lanchote VL, Wichert-Ana L, Coelho EB, Alexandre Junior V, Takayanagui OM, Tozatto E, van Hasselt JGC, Della Pasqua O. Population pharmacokinetics of oxcarbazepine and its metabolite 10-hydroxycarbazepine in healthy subjects. Eur J Pharm Sci 2017; 109S:S116-S123. [PMID: 28528287 DOI: 10.1016/j.ejps.2017.05.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 05/15/2017] [Indexed: 01/11/2023]
Abstract
Oxcarbazepine is indicated for the treatment of partial or generalised tonic-clonic seizures. Most of the absorbed oxcarbazepine is converted into its active metabolite, 10-hydroxycarbazepine (MHD), which can exist as R-(-)- and S-(+)-MHD enantiomers. Here we describe the influence of the P-glycoprotein (P-gp) inhibitor verapamil, on the disposition of oxcarbazepine and MHD enantiomers, both of which are P-gp substrates. Healthy subjects (n=12) were randomised to oxcarbazepine or oxcarbazepine combined with verapamil at doses of 300mg b.i.d. and 80mg t.i.d., respectively. Blood samples (n=185) were collected over a period of 12h post oxcarbazepine dose. An integrated PK model was developed using nonlinear mixed effects modelling using a meta-analytical approach. The pharmacokinetics of oxcarbazepine was described by a two-compartment model with absorption transit compartments and first-order elimination. The concentration-time profiles of both MHD enantiomers were characterised by a one-compartment distribution model. Clearance estimates (95% CI) were 84.9L/h (69.5-100.3) for oxcarbazepine and 2.0L/h (1.9-2.1) for both MHD enantiomers. The volume of distribution was much larger for oxcarbazepine (131L (97-165)) as compared to R-(-)- and S-(+)-MHD (23.6L (14.4-32.8) vs. 31.7L (22.5-40.9), respectively). Co-administration of verapamil resulted in a modest increase of the apparent bioavailability of oxcarbazepine by 12% (10-28), but did not affect parent or metabolite clearances. Despite the evidence of comparable systemic levels of OXC and MHD following administration of verapamil, differences in brain exposure to both moieties cannot be excluded after P-glycoprotein inhibition.
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Affiliation(s)
- Natalicia de Jesus Antunes
- Department of Clinical Chemistry and Toxicology, Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Brazil
| | - Sven C van Dijkman
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Vera Lucia Lanchote
- Department of Clinical Chemistry and Toxicology, Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Brazil
| | - Lauro Wichert-Ana
- Department of Internal Medicine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil
| | - Eduardo Barbosa Coelho
- Department of Internal Medicine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil
| | - Veriano Alexandre Junior
- Department of Neurobehavioural Sciences, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil
| | | | - Eduardo Tozatto
- Department of Clinical Chemistry and Toxicology, Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Brazil
| | - J G Coen van Hasselt
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Oscar Della Pasqua
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands; Clinical Pharmacology & Therapeutic Group, School of Life and Medical Sciences, University College London, London, UK.
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van Dijkman SC, Rauwé WM, Danhof M, Della Pasqua O. Pharmacokinetic interactions and dosing rationale for antiepileptic drugs in adults and children. Br J Clin Pharmacol 2017; 84:97-111. [PMID: 28815754 DOI: 10.1111/bcp.13400] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/19/2017] [Accepted: 07/30/2017] [Indexed: 01/31/2023] Open
Abstract
AIMS Population pharmacokinetic modelling has been widely used across many therapeutic areas to identify sources of variability, which are incorporated into models as covariate factors. Despite numerous publications on pharmacokinetic drug-drug interactions (DDIs) between antiepileptic drugs (AEDs), such data are not used to support the dose rationale for polytherapy in the treatment of epileptic seizures. Here we assess the impact of DDIs on plasma concentrations and evaluate the need for AED dose adjustment. METHODS Models describing the pharmacokinetics of carbamazepine, clobazam, clonazepam, lamotrigine, levetiracetam, oxcarbazepine, phenobarbital, phenytoin, topiramate, valproic acid and zonisamide in adult and paediatric patients were collected from the published literature and implemented in NONMEM v7.2. Taking current clinical practice into account, we explore simulation scenarios to characterize AED exposure in virtual patients receiving mono- and polytherapy. Steady-state, maximum and minimum concentrations were selected as parameters of interest for this analysis. RESULTS Our simulations show that DDIs can cause major changes in AED concentrations both in adults and children. When more than one AED is used, even larger changes are observed in the concentrations of the primary drug, leading to significant differences in steady-state concentration between mono- and polytherapy for most AEDs. These results suggest that currently recommended dosing algorithms and titration procedures do not ensure attainment of appropriate therapeutic concentrations. CONCLUSIONS The effect of DDIs on AED exposure cannot be overlooked. Clinical guidelines must consider such covariate effects and ensure appropriate dosing recommendations for adult and paediatric patients who require combination therapy.
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Affiliation(s)
- Sven C van Dijkman
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden, The Netherlands
| | - Willem M Rauwé
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden, The Netherlands
| | - Meindert Danhof
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden, The Netherlands
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline, Stockley Park, UK.,Clinical Pharmacology & Therapeutics Group, University College London, London, UK
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6
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Dijkman SC, Wicha SG, Danhof M, Della Pasqua OE. Individualized Dosing Algorithms and Therapeutic Monitoring for Antiepileptic Drugs. Clin Pharmacol Ther 2017; 103:663-673. [DOI: 10.1002/cpt.777] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 05/24/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Sven C. Dijkman
- Division of PharmacologyLeiden Academic Centre for Drug ResearchLeiden The Netherlands
| | - Sebastian G. Wicha
- Department of Pharmaceutical BiosciencesUppsala UniversityUppsala Sweden
| | - Meindert Danhof
- Division of PharmacologyLeiden Academic Centre for Drug ResearchLeiden The Netherlands
| | - Oscar E. Della Pasqua
- Clinical Pharmacology Modelling & SimulationGlaxoSmithKlineUxbridge UK
- Clinical Pharmacology and TherapeuticsUniversity College LondonLondon UK
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Chouchi M, Kaabachi W, Klaa H, Tizaoui K, Turki IBY, Hila L. Relationship between ABCB1 3435TT genotype and antiepileptic drugs resistance in Epilepsy: updated systematic review and meta-analysis. BMC Neurol 2017; 17:32. [PMID: 28202008 PMCID: PMC5311838 DOI: 10.1186/s12883-017-0801-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/19/2017] [Indexed: 12/28/2022] Open
Abstract
Background Antiepileptic drugs (AEDs) are effective medications available for epilepsy. However, many patients do not respond to this treatment and become resistant. Genetic polymorphisms may be involved in the variation of AEDs response. Therefore, we conducted an updated systematic review and a meta-analysis to investigate the contribution of the genetic profile on epilepsy drug resistance. Methods We proceeded to the selection of eligible studies related to the associations of polymorphisms with resistance to AEDs therapy in epilepsy, published from January 1980 until November 2016, using Pubmed and Cochrane Library databases. The association analysis was based on pooled odds ratios (ORs) and 95% confidence intervals (CIs). Results From 640 articles, we retained 13 articles to evaluate the relationship between ATP-binding cassette sub-family C member 1 (ABCB1) C3435T polymorphism and AEDs responsiveness in a total of 454 epileptic AEDs-resistant cases and 282 AEDs-responsive cases. We found a significant association with an OR of 1.877, 95% CI 1.213–2.905. Subanalysis by genotype model showed a more significant association between the recessive model of ABCB1 C3435T polymorphism (TT vs. CC) and the risk of AEDs resistance with an OR of 2.375, 95% CI 1.775–3.178 than in the dominant one (CC vs. TT) with an OR of 1.686, 95% CI 0.877–3.242. Conclusion Our results indicate that ABCB1 C3435T polymorphism, especially TT genotype, plays an important role in refractory epilepsy. As genetic screening of this genotype may be useful to predict AEDs response before starting the treatment, further investigations should validate the association.
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Affiliation(s)
- Malek Chouchi
- Department of Genetic, Tunis El Manar University, Faculty of Medicine of Tunis, 15 Jebel Lakhdhar street, La Rabta, 1007, Tunis, Tunisia. .,Department of Child Neurology, National Institute Mongi Ben Hmida of Neurology, UR12SP24 Abnormal Movements of Neurologic Diseases, Jebel Lakhdhar street, La Rabta, 1007, Tunis, Tunisia.
| | - Wajih Kaabachi
- Division of Histology and Immunology Division, Department of Basic Sciences, Faculty of Medicine of Tunis, 15 Jebel Lakhdhar street, La Rabta, 1007, Tunis, Tunisia
| | - Hedia Klaa
- Department of Child Neurology, National Institute Mongi Ben Hmida of Neurology, UR12SP24 Abnormal Movements of Neurologic Diseases, Jebel Lakhdhar street, La Rabta, 1007, Tunis, Tunisia
| | - Kalthoum Tizaoui
- Division of Histology and Immunology Division, Department of Basic Sciences, Faculty of Medicine of Tunis, 15 Jebel Lakhdhar street, La Rabta, 1007, Tunis, Tunisia
| | - Ilhem Ben-Youssef Turki
- Department of Child Neurology, National Institute Mongi Ben Hmida of Neurology, UR12SP24 Abnormal Movements of Neurologic Diseases, Jebel Lakhdhar street, La Rabta, 1007, Tunis, Tunisia
| | - Lamia Hila
- Department of Genetic, Faculty of Medicine of Tunis, 15 Jebel Lakhdhar street, La Rabta, 1007, Tunis, Tunisia
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Balestrini S, Sisodiya SM. Pharmacogenomics in epilepsy. Neurosci Lett 2017; 667:27-39. [PMID: 28082152 PMCID: PMC5846849 DOI: 10.1016/j.neulet.2017.01.014] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/05/2017] [Accepted: 01/06/2017] [Indexed: 12/12/2022]
Abstract
Genetic variation can influence response to antiepileptic drug (AED) treatment through various effector processes. Metabolism of many AEDs is mediated by the cytochrome P450 (CYP) family; some of the CYPs have allelic variants that may affect serum AED concentrations. ‘Precision medicine’ focuses on the identification of an underlying genetic aetiology allowing personalised therapeutic choices. Certain human leukocyte antigen, HLA, alleles are associated with an increased risk of idiosyncratic adverse drug reactions. New results are emerging from large-scale multinational efforts, likely imminently to add knowledge of value from a pharmacogenetic perspective.
There is high variability in the response to antiepileptic treatment across people with epilepsy. Genetic factors significantly contribute to such variability. Recent advances in the genetics and neurobiology of the epilepsies are establishing the basis for a new era in the treatment of epilepsy, focused on each individual and their specific epilepsy. Variation in response to antiepileptic drug treatment may arise from genetic variation in a range of gene categories, including genes affecting drug pharmacokinetics, and drug pharmacodynamics, but also genes held to actually cause the epilepsy itself. From a purely pharmacogenetic perspective, there are few robust genetic findings with established evidence in epilepsy. Many findings are still controversial with anecdotal or less secure evidence and need further validation, e.g. variation in genes for transporter systems and antiepileptic drug targets. The increasing use of genetic sequencing and the results of large-scale collaborative projects may soon expand the established evidence. Precision medicine treatments represent a growing area of interest, focussing on reversing or circumventing the pathophysiological effects of specific gene mutations. This could lead to a dramatic improvement of the effectiveness and safety of epilepsy treatments, by targeting the biological mechanisms responsible for epilepsy in each specific individual. Whilst much has been written about epilepsy pharmacogenetics, there does now seem to be building momentum that promises to deliver results of use in clinic.
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Affiliation(s)
- Simona Balestrini
- NIHR University College London Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, and Epilepsy Society, Chalfont-St-Peter, Bucks, United Kingdom; Neuroscience Department, Polytechnic University of Marche, Ancona, Italy
| | - Sanjay M Sisodiya
- NIHR University College London Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, and Epilepsy Society, Chalfont-St-Peter, Bucks, United Kingdom.
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Li X, Zhang J, Wu X, Yan H, Zhang Y, He RH, Tang YJ, He YJ, Tan D, Mao XY, Yin JY, Liu ZQ, Zhou HH, Liu J. Polymorphisms of ABAT, SCN2A and ALDH5A1 may affect valproic acid responses in the treatment of epilepsy in Chinese. Pharmacogenomics 2016; 17:2007-2014. [PMID: 27918244 DOI: 10.2217/pgs-2016-0093] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The clinical efficacy of valproic acid (VPA) varies greatly among epileptic patients. To find the potential genetic factors related to VPA responses, the pharmacogenetics study was conducted. Methods: Two hundred and one Chinese Han epileptic patients who were treated by VPA for at least 1 year were recruited. Up to 24 SNPs in 11 candidate genes that correlate with the metabolism, transport or target of VPA were genotyped. Results: Three SNPs, rs1731017 (ABAT), rs2304016 (SCN2A) and rs1054899 (ALDH5A1) were found associated with VPA responses with the p-values of 0.003, 0.007 and 0.048, respectively. Further interaction analysis showed that the interaction between rs17183814 (ABAT) and rs1641022 (SCN2A) was also correlated with the response of VPA (p = 0.006). Conclusion: This study found three SNPs and one interaction among ABAT, SCN2A and ALDH5A1 were significantly associated with VPA response, which indicated that these genes may play important roles in the pharmacological mechanism of VPA.
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Affiliation(s)
- Xi Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Jun Zhang
- Department of nephrology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, P. R. China
| | - Xi Wu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Han Yan
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Yin Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Ruo-Hui He
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Yong-Jun Tang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Yi-Jing He
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Dan Tan
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Xiao-Yuan Mao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Ji-Ye Yin
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Zhao-Qian Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Hong-Hao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
| | - Jie Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People’s Republic of China
- Institute of Clinical Pharmacology, Hunan Key Laboratory of Pharmacogenetics, Central South University, Changsha 410078, Hunan, People’s Republic of China
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Shorvon S, Schmidt D. The right and the wrong with epilepsy and her science. Epilepsia Open 2016; 1:76-85. [PMID: 29588932 PMCID: PMC5719833 DOI: 10.1002/epi4.12011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2016] [Indexed: 12/26/2022] Open
Abstract
This is a commentary and an opinion paper attempting a critical reassessment of the methods and practices of epilepsy research as we see it. The enormous progress in the field of epilepsy in recent years is a cause of celebration. Advances have been made on most fronts, and the position of patients with epilepsy in society has greatly improved. However, there have also been culs‐de‐sac and dead ends of modern science and clinical practice which are also intriguing. It may be true that we can learn more from our mistakes than from our successes. In this opinion paper, we have listed some of the successes and some of the failures of past epilepsy practice, and also areas of current practice and theory which we feel are likely to prove mistaken. The underlying reasons for misdirected practices and theories include, in our view, the influence of fashion, bad science, and the bureaucracies of practice and academic medicine. As a result, some findings are far from objective. Recognition is the first step to remediation, and hopefully future research will minimize some of the pitfalls mentioned in this article and bring the “End of Epilepsy,” as defined and predicted by Oswei Temkin, closer than it is today.
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Affiliation(s)
- Simon Shorvon
- UCL Institute of Neurology National Hospital for Neurology and Neurosurgery London United Kingdom
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11
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van Dijkman SC, Alvarez-Jimenez R, Danhof M, Della Pasqua O. Pharmacotherapy in pediatric epilepsy: from trial and error to rational drug and dose selection - a long way to go. Expert Opin Drug Metab Toxicol 2016; 12:1143-56. [PMID: 27434782 DOI: 10.1080/17425255.2016.1203900] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Whereas ongoing efforts in epilepsy research focus on the underlying disease processes, the lack of a physiologically based rationale for drug and dose selection contributes to inadequate treatment response in children. In fact, limited information on the interindividual variation in pharmacokinetics and pharmacodynamics of anti-epileptic drugs (AEDs) in children drive prescription practice, which relies primarily on dose regimens according to a mg/kg basis. Such practice has evolved despite advancements in pediatric pharmacology showing that growth and maturation processes do not correlate linearly with changes in body size. AREAS COVERED In this review we aim to provide 1) a comprehensive overview of the sources of variability in the response to AEDs, 2) insight into novel methodologies to characterise such variation and 3) recommendations for treatment personalisation. EXPERT OPINION The use of pharmacokinetic-pharmacodynamic principles in clinical practice is hindered by the lack of biomarkers and by practical constraints in the evaluation of polytherapy. The identification of biomarkers and their validation as tools for drug development and therapeutics will require some time. Meanwhile, one should not miss the opportunity to integrate the available pharmacokinetic data with modeling and simulation concepts to prevent further delays in the development of personalised treatments for pediatric patients.
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Affiliation(s)
- Sven C van Dijkman
- a Division of Pharmacology , Leiden Academic Centre for Drug Research , Leiden , The Netherlands
| | - Ricardo Alvarez-Jimenez
- a Division of Pharmacology , Leiden Academic Centre for Drug Research , Leiden , The Netherlands
| | - Meindert Danhof
- a Division of Pharmacology , Leiden Academic Centre for Drug Research , Leiden , The Netherlands
| | - Oscar Della Pasqua
- b Clinical Pharmacology and Discovery Medicine , GlaxoSmithKline , Stockley Park , UK.,c Clinical Pharmacology and Therapeutics , University College London , London , UK
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Baghel R, Grover S, Kaur H, Jajodia A, Rawat C, Srivastava A, Kushwaha S, Agarwal R, Sharma S, Kukreti R. Evaluating the Role of Genetic Variants on first-line antiepileptic drug response in North India: Significance of SCN1A and GABRA1 Gene Variants in Phenytoin Monotherapy and its Serum Drug Levels. CNS Neurosci Ther 2016; 22:740-57. [PMID: 27245092 DOI: 10.1111/cns.12570] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 12/18/2022] Open
Abstract
AIM The present study aimed to evaluate association of genetic variants on drug response and therapy optimization parameters in patients treated with first-line antiepileptic drugs (AEDs). Genetic variants from ion channels, their functionally related genes, and synaptic vesicle cycle (SVC) genes with a potential role in epilepsy pathophysiology were thus prioritized. METHODS A total of 12 genes from ion channels and related gene set and seven genes from SVC comprising 155 SNPs were genotyped and evaluated with drug response, dose levels, and drug levels in 408 patients with epilepsy. RESULTS Both GABRA1 and SCN1A variants showed haplotypic and diplotypic associations in response to phenytoin (PHT). Diplotype analysis of GABRA1 variants revealed association of rs12658835|rs7735530 (AG/AG) (P-valuecorrected = 0.034, OR = 3.75, 95% CI = 1.36-11.05) and rs12658835|rs7735530|rs7732641|rs2279020 (AGCA/AGCA) (P-valuecorrected = 0.035, OR = 2.48, 95% CI = 0.96-6.41) with recurrent seizures. SCN1A haplotype rs6432860|rs3812718 (AC: P-valuecorrected = 0.022, OR = 2.72, 95% CI = 1.39-5.35) and diplotype (AC/AC: P-valuecorrected = 0.034, OR = 6.42, 95% CI = 1.10-65.76) were further observed to be associated with recurrent seizures. With respect to therapy optimization parameters, we observed significantly lower dose-adjusted drug levels at maximum dose of PHT in patients carrying AC/AC diplotype (P-value = 0.021). CONCLUSION The results further substantiate the role of GABRA1 in PHT mode of action and contribution of SCN1A in response and therapy optimization with PHT monotherapy.
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Affiliation(s)
- Ruchi Baghel
- Institute of Genomics and Integrative Biology (IGIB), Council of Scientific and Industrial Research (CSIR), Delhi, India
| | - Sandeep Grover
- Institute of Genomics and Integrative Biology (IGIB), Council of Scientific and Industrial Research (CSIR), Delhi, India.,Department of Paediatrics, Division of Pneumonology-Immunology, Charité University Medical Centre, Berlin, Germany
| | - Harpreet Kaur
- Institute of Genomics and Integrative Biology (IGIB), Council of Scientific and Industrial Research (CSIR), Delhi, India
| | - Ajay Jajodia
- Institute of Genomics and Integrative Biology (IGIB), Council of Scientific and Industrial Research (CSIR), Delhi, India
| | - Chitra Rawat
- Institute of Genomics and Integrative Biology (IGIB), Council of Scientific and Industrial Research (CSIR), Delhi, India
| | - Ankit Srivastava
- Institute of Genomics and Integrative Biology (IGIB), Council of Scientific and Industrial Research (CSIR), Delhi, India
| | - Suman Kushwaha
- Institute of Human Behavior & Allied Sciences (IHBAS), Delhi, India
| | - Rachna Agarwal
- Institute of Human Behavior & Allied Sciences (IHBAS), Delhi, India
| | - Sangeeta Sharma
- Institute of Human Behavior & Allied Sciences (IHBAS), Delhi, India
| | - Ritushree Kukreti
- Institute of Genomics and Integrative Biology (IGIB), Council of Scientific and Industrial Research (CSIR), Delhi, India
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Abstract
Genetic factors contribute to the high interindividual variability in response to antiepileptic drugs. However, most genetic markers identified to date have limited sensitivity and specificity, and the value of genetic testing in guiding antiepileptic drug (AED) therapy is limited. The best defined indication for testing relates to HLA-B*15:02 genotyping to identify those individuals of South Asian ethnicity who are at high risk for developing serious adverse cutaneous reactions to carbamazepine. The indication for HLA-A*31:01 testing to identify individuals at risk for skin reactions from carbamazepine, or for CYP2C9 genotyping to identify individuals at risk for serious skin reactions from phenytoin is less compelling. The use of genetic testing to guide epilepsy treatment is likely to increase in the future, as better understanding of the function of epilepsy genes will permit the application of precision medicine targeting the biological mechanisms responsible for epilepsy in the specific individual.
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Affiliation(s)
| | - Emilio Perucca
- a 1 C. Mondino National Neurological Institute, Pavia, Italy.,b 2 Department of Internal Medicine and Therapeutics, Division of Clinical and Experimental Pharmacology, University of Pavia, Pavia, Italy
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