1
|
Pharmacological Strategies for Stroke Intervention: Assessment of Pathophysiological Relevance and Clinical Trials. Clin Neuropharmacol 2023; 46:17-30. [PMID: 36515293 DOI: 10.1097/wnf.0000000000000534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The present review describes stroke pathophysiology in brief and discusses the spectrum of available treatments with different promising interventions that are in clinical settings or are in clinical trials. METHODS Relevant articles were searched using Google Scholar, Cochrane Library, and PubMed. Keywords for the search included ischemic stroke, mechanisms, stroke interventions, clinical trials, and stem cell therapy. RESULTS AND CONCLUSION Stroke accounts to a high burden of mortality and morbidity around the globe. Time is an important factor in treating stroke. Treatment options are limited; however, agents with considerable efficacy and tolerability are being continuously explored. With the advances in stroke interventions, new therapies are being formulated with a hope that these may aid the ongoing protective and reparative processes. Such therapies may have an extended therapeutic time window in hours, days, weeks, or longer and may have the advantage to be accessible by a majority of the patients.
Collapse
|
2
|
Wen Y, Wang X, Li D, Zhang Q, Deng B, Chen Y. Rapid detection of phenytoin sodium by partial-least squares and linear regression models combined with surface-enhanced Raman spectroscopy. J Pharm Biomed Anal 2022; 223:115160. [DOI: 10.1016/j.jpba.2022.115160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 11/01/2022] [Accepted: 11/09/2022] [Indexed: 11/13/2022]
|
3
|
Jain P, Aneja S, Cunningham J, Arya R, Sharma S. Treatment of benzodiazepine-resistant status epilepticus: Systematic review and network meta-analyses. Seizure 2022; 102:74-82. [DOI: 10.1016/j.seizure.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/06/2022] [Accepted: 09/25/2022] [Indexed: 10/31/2022] Open
|
4
|
Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
Collapse
Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
| |
Collapse
|
5
|
Pires PC, Santos LT, Rodrigues M, Alves G, Santos AO. Intranasal fosphenytoin: The promise of phosphate esters in nose-to-brain delivery of poorly soluble drugs. Int J Pharm 2020; 592:120040. [PMID: 33157214 DOI: 10.1016/j.ijpharm.2020.120040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
Intranasal administration could increase both safety and efficacy of drugs acting on the central nervous system, but low solubility severely limits administration through this route. Phenytoin's prodrug, fosphenytoin, is hydrophilic and freely soluble in water, but less permeable since it is dianionic. We aimed to assess whether this phosphoester prodrug could be a suitable alternative to phenytoin in intranasal delivery. Secondly, we aimed to compare simple formulation strategies in fosphenytoin delivery. Fosphenytoin formulations containing thermosensitive and/or mucoadhesive (hydroxypropyl methylcellulose, HPMC) polymers were developed, guided by viscosity, gelling temperatures, osmolality, and in vitro drug release tests. Then, a pharmacokinetic study was performed, comparing an intravenous fosphenytoin solution, an intranasal fosphenytoin solution, and intranasal fosphenytoin mucoadhesive formulations with or without albumin. Formulations containing HPMC allowed high drug strengths, and had a relatively fast release profile, which was not changed by albumin. Intranasal administration of a formulation with HPMC and albumin prolonged drug concentration over time and led to complete or even increased absolute bioavailability. Moreover, phenytoin's blood levels did not reach the high peak obtained with intravenous administration. In conclusion, the use of phosphate ester prodrugs could be an efficient and safe strategy to increase the intranasal bioavailability of poorly soluble drugs.
Collapse
Affiliation(s)
- Patrícia C Pires
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Liliana T Santos
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Márcio Rodrigues
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Research Unit for Inland Development (UDI-IPG), Polytechnic Institute of Guarda, 6300-559 Guarda, Portugal.
| | - Gilberto Alves
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Adriana O Santos
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| |
Collapse
|
6
|
Cardiovascular complications of epileptic seizures. Epilepsy Behav 2020; 111:107185. [PMID: 32554232 DOI: 10.1016/j.yebeh.2020.107185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/14/2022]
Abstract
Seizure disorders are associated with multisystem complications. Cardiovascular complications account for a significant proportion of morbidity and mortality in these patients. As such, particular attention must be paid to the incidence of cardiovascular complications especially in populations at increased risk. The background for cardiac dysfunction lies in the interplay of genetic/molecular, autonomic, and iatrogenic factors that contribute to its onset. The purpose of this review was to summarize the state of literature in the last decade with regard to cardiac complications of epileptic seizures in order to increase awareness of short- and long-term debilitating cardiac complications as well as facilitate informed clinical decision-making. Taken together, the evidence provided in this review suggests that cardiac dysfunction following seizures should not be viewed as a separate entity but as an important complication of epileptic seizures. Appropriate cardiac therapy should be instituted in the postictal medical management of epileptic seizures. In acute states, postictal cardiac troponinemia (elevated cTn) should be worked up. Longer-term, monitoring for the development of cardiac structural and functional abnormalities is prudent.
Collapse
|
7
|
Nakamura K, Ohbe H, Matsui H, Naraba H, Nakano H, Takahashi Y, Fushimi K, Yasunaga H. Phenytoin versus fosphenytoin for second-line treatment of status epilepticus: propensity score matching analysis using a nationwide inpatient database. Seizure 2020; 80:124-130. [PMID: 32563922 DOI: 10.1016/j.seizure.2020.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 05/11/2020] [Accepted: 05/21/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE For status epilepticus, the choice of antiepileptic drugs for second-line treatment after benzodiazepine remains controversial: phenytoin or fosphenytoin are recommended, however, it has been unknown which is better. Using a nationwide database, we compared the efficacy and safety of them. METHOD An observational study conducted with the Japanese Diagnosis Procedure Combination inpatient database identified adult patients who had been admitted for status epilepticus and who had received intravenous diazepam on the day of admission from January 1, 2011 through December 31, 2015. Propensity score matching was applied to compare outcomes of the phenytoin and fosphenytoin groups. RESULTS The analysis examined data of 5265 patients: 2969 patients received phenytoin; 2296 received fosphenytoin, on the day of admission. One-to-one propensity score matching created 1871 matched pairs. No significant difference was found for vasopressor use on the day of admission (4.2 % vs. 4.4 %; odds ratio 1.07; 95 % confidence intervals 0.77-1.48; p = 0.69), or for mechanical ventilation on the day of admission, in-hospital mortality, length of hospital stay, or total hospitalization cost. Higher age, comorbidity of cardiac diseases and lower body mass index were associated significantly with increased vasopressor use, whereas the dose of phenytoin equivalents and the choice of fosphenytoin were not. CONCLUSIONS This nationwide observational study found no evidence that fosphenytoin provides higher efficacy or safety than phenytoin for treatment of status epilepticus in adults after diazepam. Age, cardiac disease and low body mass index were identified as independent risk factors for vasopressor use in both phenytoin and fosphenytoin.
Collapse
Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonancho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonancho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonancho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonancho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| |
Collapse
|
8
|
Fosphenytoin in Status Epilepticus: The Ice Needs to be Broken. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1751-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
9
|
Efficacy, Tolerability and Serum Phenytoin Levels after Intravenous Fosphenytoin Loading Dose in Children with Status Epilepticus. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1754-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
10
|
Pires PC, Peixoto D, Teixeira I, Rodrigues M, Alves G, Santos AO. Nanoemulsions and thermosensitive nanoemulgels of phenytoin and fosphenytoin for intranasal administration: Formulation development and in vitro characterization. Eur J Pharm Sci 2019; 141:105099. [PMID: 31672614 DOI: 10.1016/j.ejps.2019.105099] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/10/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
Abstract
Phenytoin is a low solubility anticonvulsant drug. It has, nonetheless, other possible therapeutic indications, such as neuropathic pain, including trigeminal neuralgia, or wound healing. Its use has decreased due to side effects, but nasal/intranasal administration could significantly increase drug safety and efficacy. The aim of this work was to develop and study nanoemulsions and thermosensitive nanoemulgels of phenytoin and fosphenytoin, in combination, for intranasal administration, with immediate and sustained release profiles. Nanoemulsions were prepared by adding the aqueous phase, containing gelling polymers in the case of nanoemulgels, to emulsion preconcentrates, followed, in the optimized procedure, by premix membrane emulsification. Formulation design and optimization was guided by drug strength, rheological behavior, osmolality, mean droplet size and polydispersity. Fosphenytoin interfered significantly with Carbopol but not with Pluronic's gelation, and allowed to achieve drug strengths equivalent to 22 or 27 mg/g of phenytoin in lead nanoemulsions, and 16.7 mg/g of phenytoin in the lead nanoemulgel. The final selected low viscosity nanoemulsions had an immediate or prolonged fosphenytoin release profile, depending of anhydrous phase proportion (10% or 40%, respectively). The thermosensitive nanoemulgel, with 10% anhydrous phase, showed prolonged drug release. Future studies will establish whether they are more suited for topical effects or therapeutic brain delivery.
Collapse
Affiliation(s)
- Patrícia C Pires
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Diana Peixoto
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Isaura Teixeira
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Márcio Rodrigues
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Research Unit for Inland Development (UDI-IPG), Polytechnic Institute of Guarda, 6300-749 Guarda, Portugal.
| | - Gilberto Alves
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Adriana O Santos
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| |
Collapse
|
11
|
Abstract
Background Continuous electroencephalogram (CEEG) monitoring is increasingly being used for brain monitoring in neurocritical care setting. This is because of the proven effectiveness of CEEG in diagnosing nonconvulsive status epilepticus (NCSE) as a cause of unexplained consciousness disorder. CEEG has been demonstrated to be effective in determining the response to, and outcome of, NCSE treatment. Main body In this review article, the authors described the indication and methods of CEEG and diagnosis based on EEG pattern. As a condition characterized by unexplained consciousness disorder, NCSE is frequently encountered in the neurocritical care setting and is only accompanied by an altered EEG change without any clinically apparent manifestation, such as convulsion. Thus, it is considered a form of status epilepticus manifesting mainly with consciousness disorder. This is a diagnostic challenge but should not be overlooked as NCSE is a curable condition. However, CEEG is required for the correct diagnosis of NCSE, which is difficult to perform in daily clinical practice. There also are several challenges regarding urgent EEG monitoring in the intensive care unit setting, including system-related problems, such as the preparation of mobile EEG devices and collodion-applied electrodes; human resource-related problems, such as staffing of EEG technicians and physicians who can respond flexibly to unscheduled needs; and EEG-specific difficulties in interpretation/diagnosis. These issues preclude the wide spread of CEEG in daily practice. Conclusion Recently, importance of CEEG was well accepted; however, no definitive diagnostic criteria exist for identifying EEG patterns suggestive of NCSE, especially the ambiguous significance of periodic discharges (PDs) further complicates the diagnosis of NCSE. Thus, analyzing the change in EEG patterns over time is important for the correct diagnosis of NCSE. Further studies are needed to collect sufficient CEEG data and assess the outcome of patients who have undergone therapeutic interventions.
Collapse
|
12
|
Jędrzejczak J, Mazurkiewicz-Bełdzińska M, Szmuda M, Majkowska-Zwolińska B, Steinborn B, Ryglewicz D, Owczuk R, Bartkowska-Śniatkowska A, Widera E, Rejdak K, Siemiński M, Nagańska E. Convulsive status epilepticus management in adults and children: Report of the Working Group of the Polish Society of Epileptology. Neurol Neurochir Pol 2018; 52:419-426. [PMID: 29937151 DOI: 10.1016/j.pjnns.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/11/2018] [Indexed: 10/14/2022]
Abstract
INTRODUCTION The Working Group was established at the initiative of the General Board of the Polish Society of Epileptology (PSE) to develop an expert position on the treatment of convulsive status epilepticus (SE) in adults and children in Poland. Generalized convulsive SE is the most common form and also represents the greatest threat to life, highlighting the importance of the choice of appropriate therapeutic treatment. AIM OF GUIDELINE We present the therapeutic options separately for treatment during the early preclinical (>5-30min), established (30-60min), and refractory (>60min) SE phases. This division is based on time and response to AEDs, and indicates a practical approach based on pathophysiological data. RESULTS Benzodiazepines (BZD) are the first-line drugs. In cases of ineffective first-line treatment and persistence of the seizure, the use of second-line treatment: phenytoin, valproic acid or phenobarbital is required. SE that persists after the administration of benzodiazepines and phenytoin or another second-line AED at appropriate doses is defined as refractory and drug resistant and requires treatment in the intensive care unit (ICU). EEG monitoring is essential during therapy at this stage. Anesthesia is typically continued for an initial period of 24h followed by a slow reversal and is re-established if seizures recur. Anesthesia is usually administered either to the level of the "burst suppression pattern" or to obtain the "EEG suppression" pattern. CONCLUSIONS Experts agree that close and early cooperation with a neurologist and anesthetist aiming to reduce the risk of pharmacoresistant cases is an extremely important factor in the treatment of patients with SE. This report has educational, practical and organizational aspects, outlining a standard plan for SE management in Poland that will improve therapeutic efficacy.
Collapse
Affiliation(s)
- J Jędrzejczak
- Department of Neurology and Epileptology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | - M Szmuda
- Department of Developmental Neurology, Chair of Neurology, Medical University of Gdańsk, Poland
| | - B Majkowska-Zwolińska
- Centre for Epilepsy Diagnosis and Treatment, Foundation of Epileptology, Warsaw, Poland
| | - B Steinborn
- Department of Developmental Neurology, Poznan Univerity of Medical Sciences, Poznań, Poland
| | - D Ryglewicz
- 1st Neurological Department, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - R Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Poland
| | - A Bartkowska-Śniatkowska
- Department of Paediatric Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznań, Poland
| | - E Widera
- Clinic of Pediatrics and Neurology of Developmental Age, Medical University of Silesia, Katowice, Poland
| | - K Rejdak
- Department of Neurology, Medical University of Lublin, Poland
| | - M Siemiński
- Department of Emeregency Medicine, Medical University of Gdansk, Poland
| | - E Nagańska
- Department of Experimental and Clinical Neuropathology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland.
| |
Collapse
|
13
|
Clark SL, Leloux MR, Dierkhising RA, Cascino GD, Hocker SE. IV fosphenytoin in obese patients: Dosing strategies, safety, and efficacy. Neurol Clin Pract 2016; 7:45-52. [PMID: 29849211 DOI: 10.1212/cpj.0000000000000322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Previous studies evaluated the disposition of IV phenytoin loading doses and found that obese patients had increased drug distribution into excess body weight, larger volumes of distribution, and longer half-lives when compared to their nonobese counterparts. We assess the safety and efficacy of fosphenytoin loading doses in patients with different body mass indices (BMIs). Methods A retrospective chart review was conducted in 410 patients who received fosphenytoin. Patients were divided into 2 groups: BMI <30 (nonobese) and BMI ≥30 (obese). Patient demographics, fosphenytoin dose administered in mg/kg body weight, renal and liver function tests, fosphenytoin drug levels, and pre- and post-fosphenytoin administration vital signs were collected to assess for adverse events. Necessity of additional antiepileptic loading doses was used as a surrogate for clinical efficacy. Results The median dose of fosphenytoin administered was 19 mg/kg (interquartile range 15-20). The most frequently encountered adverse event was hypotension, which occurred in 39% of the cohort. Using a Bonferroni adjustment for multiple comparisons, there were no differences in adverse events between the 2 groups. The need for additional antiepileptic loading doses was not different between the 2 groups (p = 0.07). Conclusions The incidence of adverse events and the need for repeat loading antiepileptic medications was similar between the 2 groups. From our findings, the patients in our study did not receive empiric loading dose adjustments and the current method of loading fosphenytoin achieves similar outcomes, regardless of the patient's BMI.
Collapse
|