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Anastasaki C, Chatterjee J, Koleske JP, Gao Y, Bozeman SL, Kernan CM, Marco Y Marquez LI, Chen JK, Kelly CE, Blair CJ, Dietzen DJ, Kesterson RA, Gutmann DH. NF1 mutation-driven neuronal hyperexcitability sets a threshold for tumorigenesis and therapeutic targeting of murine optic glioma. Neuro Oncol 2024:noae054. [PMID: 38607967 DOI: 10.1093/neuonc/noae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND With the recognition that noncancerous cells function as critical regulators of brain tumor growth, we recently demonstrated that neurons drive low-grade glioma initiation and progression. Using mouse models of neurofibromatosis type 1 (NF1)-associated optic pathway glioma (OPG), we showed that Nf1 mutation induces neuronal hyperexcitability and midkine expression, which activates an immune axis to support tumor growth, such that high-dose lamotrigine treatment reduces Nf1-OPG proliferation. Herein, we execute a series of complementary experiments to address several key knowledge gaps relevant to future clinical translation. METHODS We leverage a collection of Nf1-mutant mice that spontaneously develop OPGs to alter both germline and retinal neuron-specific midkine expression. Nf1-mutant mice harboring several different NF1 patient-derived germline mutations were employed to evaluate neuronal excitability and midkine expression. Two distinct Nf1-OPG preclinical mouse models were used to assess lamotrigine effects on tumor progression and growth in vivo. RESULTS We establish that neuronal midkine is both necessary and sufficient for Nf1-OPG growth, demonstrating an obligate relationship between germline Nf1 mutation, neuronal excitability, midkine production, and Nf1-OPG proliferation. We show anti-epileptic drug (lamotrigine) specificity in suppressing neuronal midkine production. Relevant to clinical translation, lamotrigine prevents Nf1-OPG progression and suppresses the growth of existing tumors for months following drug cessation. Importantly, lamotrigine abrogates tumor growth in two Nf1-OPG strains using pediatric epilepsy clinical dosing. CONCLUSIONS Together, these findings establish midkine and neuronal hyperexcitability as targetable drivers of Nf1-OPG growth and support the use of lamotrigine as a potential chemoprevention or chemotherapy agent for children with NF1-OPG.
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Affiliation(s)
- Corina Anastasaki
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jit Chatterjee
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua P Koleske
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yunqing Gao
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephanie L Bozeman
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Chloe M Kernan
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lara I Marco Y Marquez
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ji-Kang Chen
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Caitlin E Kelly
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Connor J Blair
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dennis J Dietzen
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert A Kesterson
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana, USA
| | - David H Gutmann
- Departments of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
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Almuhana G, Alsalhi A, Alsalhi H, Al-Hoqail IA. New insight into the management of toxic epidermal necrolysis following the coadministration of lamotrigine and valproic acid. Int J Dermatol 2023; 62:e231-e233. [PMID: 36637061 DOI: 10.1111/ijd.16584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/27/2022] [Accepted: 01/02/2023] [Indexed: 01/14/2023]
Affiliation(s)
- Ghadah Almuhana
- Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alsalhi
- Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hisham Alsalhi
- Department of Psychiatry, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Ibrahim A Al-Hoqail
- Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Ayele BA, Ali K, Mulatu E. Toxic epidermal necrosis associated with phenobarbitone: a case report and brief review of the literatures. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2021; 17:88. [PMID: 34496964 PMCID: PMC8425050 DOI: 10.1186/s13223-021-00589-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/23/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN)/Stevens-Johnson syndrome (SJS) is the spectrum of severe, acute, mucocutaneous, T-cell mediated delayed type IV hypersensitivity reaction and universally related to different drugs. Phenobarbitone is known to cause hypersensitivity reactions with benign pattern; ranging from a mild to moderate rashes but not life-threatening reactions such as TEN/SJS. CASE REPORT We report a 14-year-old asthmatic male patient admitted to a local hospital for an acute exacerbation of asthma, after he presented with shortness of breath, cough, and fever. He was treated with bronchodilator and antibiotics. On subsequent days, the patient developed new onset generalized tonic clonic seizure in the hospital for which he was started on phenobarbitone of 100 mg twice daily. Two weeks after initiation of phenobarbitone, the patient developed extensive blistering skin eruptions; which subsequently exfoliated unevenly. Associated with the hypersensitivity skin reaction, the patient reported low grade fever, sore throat, and dysphagia. The exfoliation also involved oral and conjunctival mucosa; with estimated 65% body surface area involvement. The laboratory investigations were relevant for mild leucocytosis, prolonged prothrombin time, and reduced albumin. Phenobarbitone was discontinued and replaced with clonazepam; and the patient was managed with fluids replacement, IV antibiotics, twice daily wound care, analgesics, and naso gastric tube feeding. On subsequent days the patients' clinical condition started improving; the skin lesion also started to heal and exfoliate in most of the affected skin surface areas, and the patient was discharged improved after ten days of intensive care unit. CONCLUSION In summary, the present case describes, a 14-years-old young child with history of asthma and seizure disorder; and developed toxic epidermal necrosis following exposure to Phenobarbitone. This case also highlighted the better prognosis observed in pediatric population with TEN.
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Affiliation(s)
- Biniyam A. Ayele
- Department of Neurology, School of Medicine, College of Health Sciences Addis Ababa University, Liberia Street, PO Box 6396, Addis Ababa, Ethiopia
| | - Kemal Ali
- Department of Neurology, School of Medicine, College of Health Sciences Addis Ababa University, Liberia Street, PO Box 6396, Addis Ababa, Ethiopia
| | - Eliyas Mulatu
- Department of Dermatovenereology, Addis Ababa University, Addis Ababa, Ethiopia
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Abstract
BACKGROUND Lamotrigine is an anticonvulsant as well as a mood stabilizer. Apart from its established use in the treatment of epilepsy, there has been an expansion of its use in the treatment of mental disorders. Patients with epilepsy as well as those with mental disorders are at increased risk of deliberate drug overdoses. An evidence base for the safety profile of lamotrigine in overdose is an essential tool for prescribers. The objective of this study was to carry out a narrative synthesis of the existing evidence for the safety profile of lamotrigine in overdose. METHODS A systematic search was conducted of EMBASE (1974 to December 2015), MEDLINE (1946 to December 2015), PsycINFO (1806 to December 2015) and CINAHL (1981 to December 2015) databases. Studies were included in which there was a deliberate or accidental single drug overdose of lamotrigine, with its toxic effects described. Studies that did not involve an overdose were excluded. A narrative synthesis of the described toxic effects was carried out. RESULTS Out of 562 articles identified, 26 studies were included, mainly in the form of case reports and series. The most commonly described toxic effects of lamotrigine were on the central nervous system, specifically seizures, movement disorders and reduced consciousness. Other toxic effects included QTc interval and QRS complex prolongations, hypersensitivity reactions, serotonin syndrome as well as rhabdomyolysis possibly due to seizures and/or agitation. Deaths were recorded in two studies, with cardiovascular and neurological toxic effects described. CONCLUSIONS Even though lamotrigine has been reported to be well tolerated, there is a risk of toxic effects which can be life threatening in overdose. This needs to be borne in mind when prescribing to patients at an increased risk of deliberate drug overdose.
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Affiliation(s)
| | - Adam Todd
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, UK
| | - Andrew Husband
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, UK
| | - Joe Reilly
- Professor of Mental Health, School of Medicine, Pharmacy and Health, Wolfson Research Institute, Queen's Campus University Boulevard, Thornaby, Stockton-On-Tees TS17 6BH, UK
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Wang XQ, Lv B, Wang HF, Zhang X, Yu SY, Huang XS, Zhang JT, Tian CL, Lang SY. Lamotrigine-induced severe cutaneous adverse reaction: Update data from 1999-2014. J Clin Neurosci 2015; 22:1005-11. [PMID: 25913750 DOI: 10.1016/j.jocn.2015.01.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/29/2014] [Accepted: 01/04/2015] [Indexed: 11/29/2022]
Abstract
We systematically reviewed and analyzed published patients with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) associated with lamotrigine therapy to identify characteristics of these reactions. We identified a total of 70 patients (42 SJS, five SJS/TEN, 23 TEN). The female to male ratio was 2.83:1 in the TEN group and 1.47:1 in the SJS group. Patients in the TEN group were younger than in the SJS group but this difference was not significant (28.35 versus 32.71 years, respectively; p=0.27). The median time to onset was 25.33 versus 18.42 days for SJS and TEN, respectively. The median dosage at onset was 36.46 versus 57.29mg, and final dosage 111.25 versus 97.92mg/day for SJS and TEN, respectively. The median final dosages did not significantly differ. Concomitant use of valproate acid was reported in 54.55% of the SJS patients and 50.00% of the TEN patients. Three fatal reactions were reported, of which two patients deteriorated rapidly and died within 12h of admission, indicating that this disease can develop rapidly before effective treatment. There was no significant difference between the SJS and TEN groups in any of the clinical factors examined which confirmed the opinion that SJS and TEN are part of a single disease spectrum.
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Affiliation(s)
- Xiang-qing Wang
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China.
| | - Bin Lv
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China
| | - Hong-fen Wang
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China
| | - Xu Zhang
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China
| | - Sheng-yuan Yu
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China
| | - Xu-sheng Huang
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China
| | - Jia-tang Zhang
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China
| | - Cheng-lin Tian
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China
| | - Sen-yang Lang
- Department of Neurology, The Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China
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Barvaliya MJ, Patel MK, Patel TK, Tripathi CB. Toxic epidermal necrolysis due to lamotrigine in a pediatric patient. J Pharmacol Pharmacother 2013; 3:336-8. [PMID: 23326109 PMCID: PMC3543558 DOI: 10.4103/0976-500x.103695] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
A 12-year-male child developed toxic epidermal necrolysis (TEN) probably due to lamotrigine. The patient was on antiepileptic therapy (sodium valproate and clonazepam) since 6–7 months, and lamotrigine was added in the regimen 1–2 months back. A serious cutaneous reaction is more likely to occur during the first 2 months of starting lamotrigine. The use of lamotrigine as an add-on to valproate may have precipitated the reaction. Other drugs were ruled out based on the incubation period of TEN. Drug interactions should be kept in mind with multiple antiepileptic therapies. The patient died because of the severity of reactions and delay in starting the treatment with steroids. One must be vigilant in early detection of the reaction.
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Affiliation(s)
- Manish J Barvaliya
- Department of Pharmacology, Government Medical College, Bhavnagar, India
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Huang HT, Chang CL, Tzeng DS. Toxic epidermal necrolysis after sun-exposure probably due to lamotrigine and chlorpromazine. Asian J Psychiatr 2010; 3:240-2. [PMID: 23050897 DOI: 10.1016/j.ajp.2010.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 08/25/2010] [Accepted: 09/08/2010] [Indexed: 11/17/2022]
Abstract
Toxic epidermal necrolysis is a life-threatening disease. It may be induced by many kinds of drugs especially anti-epileptics such as lamotrigine, but less sun-exposure related. Lamotrigine has been effective for partial complex seizure and bipolar disorder and caused serious side effects such as Stevens-Johnson syndrome or toxic epidermal necrolysis. We reported a case of the patient who developed the manic episode and received lamotrigine and chlorpromazine drugs. After combination of lamotrigine and chlorpromazine, the patient developed skin rash to toxic epidermal necrolysis after sun-exposure. We had discontinued both drugs, given supportive treatment, and let him prevent sun-exposure greatly. The disease process got subsided nearly 4 weeks later. Clinicians should carefully prescribe mood stabilizer and photo-toxic or photosensitivity medications with higher drug-eruption rate.
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Affiliation(s)
- Hsien-Te Huang
- Department of Psychiatry, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
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Pfeifer JC, Kowatch RA, DelBello MP. Pharmacotherapy of bipolar disorder in children and adolescents: recent progress. CNS Drugs 2010; 24:575-93. [PMID: 20441242 DOI: 10.2165/11533110-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Child and adolescent bipolar disorder (BPD) is a serious psychiatric disorder that often causes significant impairment in functioning. Pharmacological intervention is the cornerstone of treatment for bipolar youth, although psychotherapeutic interventions may be beneficial as adjunctive treatment. Medications used for the treatment of BPD in adults are still commonly used for bipolar children and adolescents. With the recent US FDA indication of risperidone, aripiprazole, quetiapine and olanzapine for the treatment of bipolar youth, the atypical antipsychotics are rapidly becoming a first-line treatment option. However, these agents are associated with adverse effects such as increased appetite, weight gain and type II diabetes mellitus. Although several evidence-based medications are now available for the treatment of BPD in younger populations, additional studies to evaluate the short- and long-term efficacy and potential for adverse events of these and other medications are needed.
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Affiliation(s)
- Jonathan C Pfeifer
- Division of Child Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Abstract
PURPOSE A case of lamotrigine-induced Stevens-Johnson syndrome (SJS) is reported. SUMMARY A 29-year-old woman with a medical history of schizoaffective disorder arrived at the emergency department with a severe generalized skin reaction. Three to four days prior she had noticed bumps on her lips that had spread to her oral mucosa. She had also developed a diffuse, erythematous, pruritic full-body rash involving the palms of her hands and the soles of her feet and began to feel feverish. Her medications at admission included aripiprazole 30 mg p.o. daily, escitalopram 10 mg p.o. daily, and lamotrigine 75 mg p.o. daily. Lamotrigine was the only new medication, initiated four weeks before this admission. The dermatology service confirmed the diagnosis of SJS using punch biopsy. Lamotrigine was suspected to be the culprit and was discontinued immediately. The patient was given oral prednisone 40 mg and intravenous fluids. Hydroxyzine was given for pruritus, and petroleum jelly and viscous lidocaine were applied to her lips. On hospital day 2, her symptoms and dermatological manifestations improved, but she continued to complain about irritation and slight pain of the mouth. She then received a mouthwash consisting of diphenhydramine, viscous lidocaine, and sodium bicarbonate. On hospital day 3, the patient had improved substantially and was discharged home. Reports of these dermatological reactions in patients receiving lamotrigine for the treatment of bipolar disorder are limited. Dosing, prompt recognition, and patient education are crucial for preventing morbidity and mortality associated with the development of serious cutaneous reactions. CONCLUSION SJS was associated with lamotrigine use, despite appropriate dosing and dosage adjustment.
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Affiliation(s)
- Olga Hilas
- Clinical Pharmacy Practice, St. John's University, 8000 Utopia Parkway, Queens, NY 11439, USA
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Heymann WR. Toxic epidermal necrolysis 2006. J Am Acad Dermatol 2006; 55:867-9. [PMID: 17052494 DOI: 10.1016/j.jaad.2006.06.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2006] [Revised: 06/26/2006] [Accepted: 06/28/2006] [Indexed: 10/24/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Shuster J. Hypothyroidism Associated with Quetiapine Therapy; Paradoxical Bronchospasm Associated with Albuterol; Alcohol Cravings with Paroxetine Therapy?; Lamotrigine-Induced Toxic Epidermal Necrolysis – Three Cases; Acute Lung Injury with Vinorelbine; Adverse Events Related to Epinephrine Use in Asthma Patients Seen in the Emergency Department; Collecting Information from Patients Having Adverse Events; New Anticonvulsants – New Adverse Effects. Hosp Pharm 2006. [DOI: 10.1310/hpj4107-632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of prevention, and promote reporting of ADRs to the FDA's medWatch program (800-FDA-1088). If you have reported an interesting preventable ADR to medWatch, please consider sharing the account with our readers.
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Affiliation(s)
- Joel Shuster
- ISMP, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006
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