Anticonvulsant therapy in aged patients. Clinical pharmacokinetic considerations

The implications of frailty in older adults with epilepsy

Older adults constitute a large proportion of people with epilepsy (PWE) due to the changing demographics worldwide and epilepsy's natural history. Aging-related pathophysiological changes lower the tolerance and increase our vulnerability to stressors, which manifests as frailty. Frailty is closely associated with adverse health outcomes. This narrative review examines the interplay between frailty and epilepsy, especially in older adults, emphasizing its clinical implications, including its role in managing PWE. Mechanistically, frailty develops through complex interactions among molecular and cellular damage, including genomic instability, mitochondrial dysfunction, and hormonal changes. These contribute to systemic muscle mass, bone density, and organ function decline. The concept of frailty has evolved from a primarily physical syndrome to include social, psychological, and cognitive dimensions. The "phenotypic frailty" model, which focuses on physical performance, and the "deficit accumulation" model, which quantifies health deficits, provide frameworks for understanding and assessing frailty. PWE are potentially more prone to developing frailty due to a higher prevalence of risk factors predisposing to frailty. These include, but are not limited to, polypharmacy, higher comorbidity, low exercise level, social isolation, low vitamin D, and osteoporosis. We lack commercial biomarkers to measure frailty but can diagnose it using self- or healthcare provider-administered frailty scales. Recent attempts to develop a PWE-specific frailty scale are promising. Unlike chronological age, frailty is reversible, so its management using multidisciplinary care teams should be strongly considered. Frailty can affect antiseizure medication (ASM) tolerance secondary to its impact on pharmacokinetics and pharmacodynamics. While frailty's effect on seizure control efficacy of ASM is poorly understood, its undoubted association with overall poor outcomes, including epilepsy surgery, behooves us to consider its presence and implication while treating older PWE. Incorporation of frailty measures in future research is essential to improve our understanding of frailty's role in PWE health. PLAIN LANGUAGE SUMMARY: Frailty is the declining state of the human body. People with epilepsy are more prone to it. It should be factored into their management.

Central Nervous System Medications: Pharmacokinetic and Pharmacodynamic Considerations for Older Adults

Most drugs have not been evaluated in the older population. Recognizing physiological alterations associated with changes in drug disposition and with the ultimate effect, especially in central nervous system-acting drugs, is fundamental. While considering pharmacokinetics, it should be noted that the absorption of most drugs from the gastrointestinal tract does not change in advanced age. There are only few data about the effect of age on the transdermal absorption of medications such as fentanyl. Absorption from an intramuscular injection may be similar in older adults as in younger patients. The distribution of lipophilic drugs (such as diazepam) is increased owing to a relative increase in the percentage of body fat, causing drug accumulation and prolonged drug elimination following cessation. Phase I drug biotransformation is variably decreased in aging, impacting elimination, and hepatic drug clearance has been shown to decrease in older individuals by 10-40% for most drugs studied. Lower doses of phenothiazines, butyrophenones, atypical antipsychotics, antidepressants (citalopram, mirtazapine, and tricyclic antidepressants), and benzodiazepines (such as diazepam) achieve the same extent of exposure. For renally cleared drugs with no prior metabolism (such as gabapentin), the glomerular filtration rate appropriately estimates drug clearance. Important pharmacodynamic changes in older adults include an increased sedative effect of benzodiazepines at a given drug exposure, and a higher sensitivity to mu opiate receptor agonists and to opioid adverse effects. Artificial intelligence, physiologically based pharmacokinetic modeling and simulation, and concentration-effect modeling enabling a differentiation between the pharmacokinetic and the pharmacodynamic effects of aging might help to close some of the gaps in knowledge.

Effectiveness and Safety/Tolerability of Eslicarbazepine Acetate in Epilepsy Patients Aged ≥ 60 Versus < 60 Years: A Subanalysis from the Euro-Esli Study

Introduction

Clinical practice studies help guide antiepileptic drug (AED) therapy in patient groups routinely excluded from clinical trials, such as the elderly. The Euro-Esli study investigated the effectiveness and safety/tolerability of eslicarbazepine acetate (ESL) when used in everyday clinical practice in Europe. A subanalysis of data from elderly patients (≥ 60 years) included in the Euro-Esli study was conducted to assess these aspects of ESL use in this population.

Methods

Euro-Esli was a pooled analysis of 14 European clinical practice studies. Effectiveness parameters included responder (≥ 50% seizure frequency reduction) and seizure freedom rates after 3, 6 and 12 months of treatment and at last visit. Safety and tolerability were assessed throughout the follow-up by evaluating adverse events (AEs) and ESL discontinuation due to AEs, respectively. Data were compared for patients aged ≥ 60 versus those aged < 60 years at study entry.

Results

Euro-Esli included 2058 patients (mean age 44.0 years). Age at study entry was known for 2057 patients, of whom 358 (17.4%) and 1699 (82.6%) were aged ≥ 60 and < 60 years, respectively. Mean maximum ESL dose was   882.0 and 1008.2 mg/day in patients aged ≥ 60 and < 60 years, respectively  (p < 0.001). At all timepoints, responder and seizure freedom rates were significantly higher in patients aged ≥ 60 versus < 60 years; for example, at 12 months, responder rates were 83.9 and 73.7%, respectively (p = 0.002), and seizure freedom rates were 58.5 and 37.1%, respectively (p < 0.001). The incidence of AEs was significantly higher in patients aged ≥ 60 versus < 60 years (41.4 vs. 32.5%; p = 0.001), but the rate of discontinuation due to AEs was comparable between age groups (16.2 vs 13.1%; p = not significant). The safety/tolerability of ESL in patients aged ≥ 60 years was consistent with its known    profile.

Conclusion

Eslicarbazepine acetate was efficacious and generally well tolerated when used to treat elderly patients with focal epilepsy in clinical practice, with no new or unexpected safety signals emerging in this setting.

Funding

Eisai Ltd.

Antiepileptic drugs--best practice guidelines for therapeutic drug monitoring: a position paper by the subcommission on therapeutic drug monitoring, ILAE Commission on Therapeutic Strategies

Although no randomized studies have demonstrated a positive impact of therapeutic drug monitoring (TDM) on clinical outcome in epilepsy, evidence from nonrandomized studies and everyday clinical experience does indicate that measuring serum concentrations of old and new generation antiepileptic drugs (AEDs) can have a valuable role in guiding patient management provided that concentrations are measured with a clear indication and are interpreted critically, taking into account the whole clinical context. Situations in which AED measurements are most likely to be of benefit include (1) when a person has attained the desired clinical outcome, to establish an individual therapeutic concentration which can be used at subsequent times to assess potential causes for a change in drug response; (2) as an aid in the diagnosis of clinical toxicity; (3) to assess compliance, particularly in patients with uncontrolled seizures or breakthrough seizures; (4) to guide dosage adjustment in situations associated with increased pharmacokinetic variability (e.g., children, the elderly, patients with associated diseases, drug formulation changes); (5) when a potentially important pharmacokinetic change is anticipated (e.g., in pregnancy, or when an interacting drug is added or removed); (6) to guide dose adjustments for AEDs with dose-dependent pharmacokinetics, particularly phenytoin.

Epilepsy in the older patient

The world population is aging rapidly. The post World War II ‘baby boomers’ have benefited from improved medical science, sanitation, political freedom, and social and economic development, resulting in the knock-on demographic trend of an aging population. From a health-economic perspective, this places increasing demands on society and on health services to meet evolving medical and social needs. By 2025, over 30% of the populations of developed countries will be aged over 60 years (US Bureau of Census 2004).

Age‐Related Changes in Pharmacokinetics: Predictability and Assessment Methods

Although there have been relatively few studies of the pharmacokinetics of antiepileptic drugs (AEDs) in old age, available evidence indicates that the clearance of most old and new generation AEDs is reduced on average by about 20-40% in elderly patients compared with nonelderly adults. Depending on the pharmacokinetic characteristics of the drug, the reduction in clearance can be ascribed to a physiological reduction in rate of drug metabolism, to a decrease in renal excretion rate, or to both. Studies have consistently demonstrated that interindividual pharmacokinetic variability in old age is particularly prominent, due not only to the influence of aging-related physiological changes, but also to the impact of comorbidities and drug-drug interactions. For extensively metabolized drugs, there are no reliable tools to predict with a high degree of accuracy the pharmacokinetic behavior of an AED in an individual patient. With renally eliminated drugs, determination of creatinine clearance may provide a useful clue in predicting individual changes in drug clearance and the consequent need for dosage adjustment. In the therapeutic setting, measurement of serum AED concentrations can be valuable in individualizing dosage in an elderly person, even though it should be remembered that in the case of drugs that are highly bound to plasma proteins the total serum concentration may underestimate the level of unbound, pharmacologically active drug. Because aging is also associated with important pharmacodynamic changes that may alter the relationship between serum drug concentration and pharmacological effects, pharmacokinetic measurements alone are not a substitute for the need to monitor clinical response carefully and to adjust dosage accordingly.

Population pharmacokinetic modelling of carbamazepine in epileptic elderly patients: implications for dosage

BACKGROUND

Proper use of antiepileptic drugs in the elderly involves knowledge of their pharmacokinetics to ensure a patient-specific balance between efficacy and toxicity. However, populations of epileptic patients on chronic carbamazepine (CBZ) therapy which have been studied have included data of relatively few elderly patients.

AIMS

The aim of the present study was to evaluate the population pharmacokinetics of CBZ in elderly patients on chronic monotherapy.

METHODS

We have used the non-parametric expectation maximization (NPEM) program in the USC*PACK collection of PC programs to estimate individual and population post-induction pharmacokinetics of CBZ in epileptic elderly patients who received chronic CBZ monotherapy. Age-related changes of CBZ population pharmacokinetics were evaluated from routine therapeutic drug monitoring (TDM) data of 37 elderly and 35 younger patients with epilepsy. As a 'historical control' we used previously published population modelling results from 99 young epileptic patients on chronic CBZ monotherapy. In that control group, TDM was performed in the same pharmacokinetic (PK) laboratory, using the same sampling strategy as in the present study, and the same PK population modelling software was used for data analysis.

RESULTS AND CONCLUSIONS

A poor correlation was found between daily CBZ dose and serum concentrations in the elderly patients (r=0.2, P=0.25). Probably statistically significant difference in the median values of the CBZ metabolic rate constant (P<0.001) between elderly and relatively young epileptic patients was found. Our results showed that age-related influences in CBZ pharmacokinetics in elderly patients should be considered in the optimal planning of CBZ dosage regimens. Most elderly patients with epilepsy will usually need CBZ dosages lower than those based on the median population PK parameter values obtained from younger patients. The present population model is also uniquely well suited for the new 'multiple model' design of dosage regimens to hit target therapeutic goals with maximum precision.

The influence of old age and enzyme inducing comedication on the pharmacokinetics of valproic acid at steady-state: A case-matched evaluation based on therapeutic drug monitoring data

PURPOSE

To evaluate the influence of aging on the pharmacokinetics of valproic acid (VPA) at steady-state and on the susceptibility of VPA metabolism to enzyme induction by antiepileptic comedication.

METHODS

The database of the therapeutic drug monitoring service of a large neurological hospital was searched to identify patients aged > or = 65 years stabilized on VPA therapy. Apparent VPA oral clearance (CL/F) calculated for each elderly patient was compared with that determined in an equal number of VPA-treated controls aged 20-50 years and matched for gender, body weight and antiepileptic drug (AED) comedication.

RESULTS

A total of 71 elderly patients aged 70.0+/-4.4 years, including 20 receiving enzyme inducing AEDs, was included in the main evaluation. In the absence of enzyme inducing comedication, VPA CL/F in the elderly was similar to that found in non-elderly controls (9.7+/-4.6 versus 10.2+/-4.6mlh(-1)kg(-1)). Elderly patients on enzyme inducing comedication, on the other hand, had lower CL/F values than enzyme induced younger controls (11.7+/-5.4 versus 16.0+/-6.3mlh(-1)kg(-1), p<0.05). Since VPA CL/F is known to increase with increasing dosage, a lower VPA dosage in elderly patients comedicated with enzyme inducers compared with controls may have contributed to differences in CL/F between the two groups.

CONCLUSIONS

In the absence of enzyme inducing comedication, VPA clearance in the elderly was comparable to that observed in controls. VPA clearance in elderly patients receiving enzyme inducing AEDs was lower than in controls, the difference being probably due to an influence of age as well as to the fact that mean VPA dosage was lower in these patients than in controls. Since our measurements of clearance were based on total serum VPA concentrations and VPA binding to plasma proteins is known to be reduced in old age, it is likely that the clearance of unbound, pharmacologically active, VPA was decreased to an important extent in the elderly, presumably as a result of a decline in drug metabolizing capacity.

Pharmacokinetic variability of new antiepileptic drugs at different ages

Newer generation antiepileptic drugs (AEDs) are increasingly used to treat epilepsies in infants, children, and the elderly. For rational prescribing in these populations, it is essential to understand the pharmacokinetic changes that occur during development and aging. Data obtained in recent years indicate that the apparent oral clearance (CL/F) of lamotrigine, topiramate, levetiracetam, oxcarbazepine, gabapentin, tiagabine, zonisamide, vigabatrin, and felbamate is considerably higher in children than in adults,the magnitude of the difference being on average in the order of 20%to 120%, depending on the drug and the age distribution of the assessed population. Information on the pharmacokinetics of these drugs in newborns is completely lacking or very sparse. Studies in the elderly have demonstrated that significant pharmacokinetic changes also occur at the other extreme of age. On average, CL/F values of newer generation AEDs have been found to be reduced by 10% to 50% compared with those found in young or middle-aged adults. These pharmacokinetic changes are clinically important and con-tribute to age-related differences in dosage requirements.

Adjunctive pharmacological management of persistent, nonmalignant pain in older individuals

Chronic or persistent pain is a common comorbidity of aging, primarily due to the relatively high frequency of pain-associated disorders in this population (e.g., inflammatory and noninflammatory musculoskeletal disease, zoster infection, diabetes, stroke, and peripheral and central neurological diseases). Acetaminophen, nonsteroidal anti-inflammatory drugs and opioids are important long-term analgesics in this age group. However, adjunctive agents are also important in the management of persistent pain in the elderly, especially neuropathic pain. Oral antiepileptic drugs, mexiletine, baclofen, tricyclic antidepressants, selective serotonin–norepinephrine dual reuptake inhibitors and intranasal/injectable calcitonin are the subjects of this review of the management of persistent, nonmalignant pain in the elderly. While some of these agents are considered narrow-spectrum analgesics (e.g., baclofen in trigeminal neuralgia and calcitonin in bone pain), most are broad-spectrum analgesics, useful in neuropathic pain syndromes of multiple etiologies. Within the antiepileptic drug class, gabapentin and carbamazepine can be considered first-line agents, followed by lamotrigine and pregabalin as second-line agents, and the other most recently approved drugs as third-line or ‘salvage’ agents. The tricyclic antidepressants have numerous precautions/contraindications and tolerability issues in this population, thus reducing their utility. Duloxetine and venlafaxine are the only useful analgesics among the modern antidepressants. Challenges for the future include not only the search for more effective and less toxic adjunctive analgesics for the elderly, but also translating our knowledge of current and future analgesics into effective therapies in the ‘real world’ community and institutional settings where elderly people live. There is no justification in our society today for anyone to live with untreated or undertreated persistent pain.

Clinical Pharmacokinetics of New-Generation Antiepileptic Drugs at the Extremes of Age

In recent years, several new-generation antiepileptic drugs (AEDs) have been introduced in clinical practice. These agents, which include felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, tiagabine, topiramate, vigabatrin and zonisamide, are being increasingly used in the treatment of epilepsy at the extremes of age. For a rational prescribing of these drugs in specific age groups, major pharmacokinetic changes that occur during development and aging need to be taken into consideration. A review of available evidence indicates that the apparent oral clearance (CL/F) of new-generation AEDs in children is increased by 20-170% (depending on the type of drug and characteristics of the patients studied) compared with adults, with the highest CL/F values usually being observed in the youngest age groups. These findings do not necessarily apply to the first weeks of life, when drug eliminating capacity is still undergoing maturation, as in the case of lamotrigine for which preliminary data suggest that CL/F in neonates aged <2 months can be much lower than in infants aged 2-12 months. At the other extreme of age, in the elderly, CL/F is almost invariably reduced (on average by 10-50%) compared with values found in non-elderly adults. Age-related CL/F changes, together with the large interindividual pharmacokinetic variability, contribute to the need for individualised dosage requirements in these patients. Measurement of serum drug concentrations can be useful as an aid to dosage individualization in these age groups but interpretation of therapeutic drug monitoring data should also take into account the possibility of age-related changes in pharmacodynamic sensitivity and, for neonates and the elderly, alterations in drug binding to serum proteins.

In the End, New Antiepileptics May be Less Expensive than Older Antiepileptics for Geriatric Patients

New Onset Geriatric Epilepsy: A Randomized Study of Gabapentine, Lamotrigine, and Carbamazepine

Rowan AJ, Ramsay RE, Collins JF, Pryor F, Boardman KD, Uthman BM, Spitz M, Frederick T, Towne A, Carter GS, Marks W, Felicetta J, Tomyanovich ML; VA Cooperative Study 428 Group

Neurology 2005;64:1868–1873

Objective

To determine the relative tolerability and efficacy of two newer antiepileptic drugs, lamotrigine (LTG) and gabapentin (GBP), as compared with carbamazepine (CBZ) in older patients with epilepsy.

Methods

This was an 18-center, randomized, double-blind, double dummy, parallel study of 593 elderly subjects with newly diagnosed seizures. Patients were randomly assigned to one of three treatment groups: GBP 1,500 mg/day, LTG 150 mg/day, CBZ 600 mg/day. The primary outcome measure was retention in trial for 12 months.

Results

Mean age was 72 years. The most common etiology was cerebral infarction. Patients had multiple medical conditions and took an average of seven comedications. Mean plasma levels at 6 weeks were as follows: GBP 8.67 ± 4.83 μg/mL, LTG 2.87 ± 1.60 μg/mL, CBZ 6.79 ± 2.92 μg/mL. They remained stable throughout the trial. Early terminations: LTG 44.2%, GBP 51%, CBZ 64.5% ( p = 0.0002). Significant paired comparisons: LTG vs CBZ: p < 0.0001; GBP vs CBZ: p = 0.008. Terminations for adverse events: LTG 12.1%, GBP 21.6%, CBZ 31% ( p = 0.001). Significant paired comparisons: LTG vs CBZ: p < 0.0001; LTG vs GBP: p = 0.015. There were no significant differences in seizure-free rate at 12 months.

Conclusions

The main limiting factor in patient retention was adverse drug reactions. Patients taking LTG or GBP did better than those taking CBZ. Seizure control was similar among groups. LTG and GBP should be considered as initial therapy for older patients with newly diagnosed seizures.

Pharmacological and clinical aspects of antiepileptic drug use in the elderly

In this article, epidemiological and clinical aspects related to the use of antiepileptic drugs (AEDs) in the elderly are highlighted. Studies have shown that people with epilepsy receiving AED treatment show important deficits in physical and social functioning compared with age-matched people without epilepsy. To what extent these deficits can be ascribed to epilepsy per se or to the consequences of AED treatment remains to be clarified. The importance of characterizing the effects of AEDs in an elderly population is highlighted by epidemiological surveys indicating that the prevalence of AED use is increased in elderly people, particularly in those living in nursing homes. Both the pharmacokinetics and the pharmacodynamics of AEDs may be altered in old age, which may contribute to the observation that AEDs are among the drug classes most commonly implicated as causing adverse drug reactions in an aged population. Age alone is one of several contributors to alterations in AED response in the elderly; other factors include physical frailty, co-morbidities, dietary influences, and drug interactions. Individualization of dosage, avoidance of unnecessary polypharmacy, and careful observation of clinical response are essential for an effective and safe utilization of AEDs in an elderly population.

Pharmacokinetic dosage guidelines for elderly subjects

Ageing is associated with a decline in drug elimination; hence, using the same doses as in younger adults may result in higher plasma drug concentrations and toxicity. Two approaches are available for dose correction to account for decreased drug elimination. One procedure is based on the extrarenal elimination fraction (Q(0)) and the age-dependent changes in creatinine clearance; the other uses the decline in total drug clearance (CL). Mean values of Q(0) and CL in young and old people are reported for many drugs in the literature and are summarised in this article. Although the pharmacokinetic techniques for dose adjustment in the elderly are useful, they provide only an average dose correction and neglect age-dependent changes in drug bio-availability, plasma protein binding, the fate of active metabolites, and altered sensitivity to drugs. To account for pharmacodynamic changes in old age, clinical and/or biochemical targets should be defined as therapeutic goals. Drugs whose effects cannot be monitored in these terms should be avoided in elderly individuals.

Phenobarbital Pharmacokinetics in Old Age: A Case-matched Evaluation Based on Therapeutic Drug Monitoring Data

PURPOSE

To assess the influence of aging on the pharmacokinetics of phenobarbital (PB) at steady state in patients receiving long-term therapy.

METHODS

Serum PB concentrations from the database of the therapeutic drug monitoring service of a large neurological hospital were used to calculate apparent clearance values (CL/F) in 224 patients aged 65 years and older (mean, 73 +/- 6.1 years). CL/F values in these patients were compared with those determined in an equal number of controls aged 20 to 50 years (mean, 35.7 +/- 7.9 years) and matched for gender, body weight, and type of anticonvulsant comedication. Correlations of CL/F with age, body weight, gender, and comedication also were explored within each age group.

RESULTS

PB CL/F values were significantly lower in elderly patients than in controls (3.2 +/- 0.8 vs. 4.1 +/- 1.2 ml/h/kg; p < 0.0001). Age was identified as a statistically significant predictor of CL/F at multiple regression analysis, but it accounted for only a modest component of the interindividual pharmacokinetic variation. Comedication with carbamazepine (CBZ) and phenytoin (PHT) was associated with a moderate decrease in PB CL/F, which reached statistical significance in the elderly group (p < 0.01 for CBZ comedication; p < 0.001 for PHT comedication).

CONCLUSIONS

Aging is associated with a significant decrease in PB clearance, which might be related to a reduction in glomerular filtration rate or diminished drug-metabolizing capacity in the liver or both. Because of this, older patients will require lower dosages to achieve serum PB concentrations comparable with those found in nonelderly adults.

Managing Bipolar Disorder in the Elderly

Clinical research in geriatric psychopharmacology has been a relatively neglected focus compared with the wealth of information on younger populations, and there is a dearth of published, controlled trials. Similarly, these are limited data in the area of geriatric bipolar disorder. Although there is an absence of rigorous, evidence-based information, preliminary data on older adults with bipolar disorder suggest some promising treatment options and important differences in older versus younger patients with bipolar illness. Lithium, while widely utilised in younger populations, is often poorly tolerated in the elderly. Clinical evidence regarding use of antiepileptic compounds in late-life bipolar disorder is generally compiled from bipolar disorder studies in mixed populations, studies in older adults with seizure disorders, and studies on dementia and psychotic conditions other than bipolar disorder. Valproate semisodium and carbamazepine are widely prescribed compounds in older adults with bipolar disorder. However, the popularity of these compounds has occurred in context of an absence of evidence-based data. The atypical antipsychotics have expanded the treatment armamentarium for bipolar disorder in mixed populations and may offer particular promise in management of bipolar illness in older populations as well. Olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole are atypical antipsychotics that have been approved by the US FDA for the treatment of bipolar disorder; however, there are no published, controlled trials with atypical antipsychotics specific to mania in geriatric patients. Preliminary reports on the use of clozapine, risperidone, olanzapine and quetiapine suggest a role for the use of these agents in late-life bipolar disorder. Information with ziprasidone and aripiprazole specific to geriatric bipolar disorder is still lacking.

Aging biology and geriatric clinical pharmacology

Population aging evokes doomsday economic and sociological prognostication, despite a minority of older people suffering significant dependency and the potential for advances in therapeutics of age-related disease and primary aging. Biological aging processes are linked mechanistically to altered drug handling, altered physiological reserve, and pharmacodynamic responses. Parenteral loading doses need only be adjusted for body weight as volumes of distribution are little changed, whereas oral loading doses in some cases may require reduction to account for age-related increases in bioavailability. Age-related reduction of hepatic blood flow and hepatocyte mass and primary aging changes in hepatic sinusoidal endothelium with effects on drug transfer and oxygen delivery reduce hepatic drug clearance. Primary renal aging is evident, although renal clearance reduction in older people is predominantly disease-related and is poorly estimated by standard methods. The geriatric dosing axiom, "start low and go slow" is based on pharmacokinetic considerations and concern for adverse drug reactions, not from clinical trial data. In the absence of generalizable dosage guidelines, individualization via effect titration is required. Altered pharmacodynamics are well documented in the cardiovascular system, with changes in the autonomic system, autacoid receptors, drug receptors, and endothelial function to modify baseline cardiovascular tone and responses to stimuli such as postural change and feeding. Adverse drug reactions and polypharmacy represent major linkages to avoidable morbidity and mortality. This, combined with a deficient therapeutic evidence base, suggests that extrapolation of risk-benefit ratios from younger adults to geriatric populations is not necessarily valid. Even so, therapeutic advances generally may convert healthy longevity from an asset of fortunate individuals into a general social benefit.

Aging May Be Associated with Concentrations of Tamoxifen and Its Metabolites in Breast Cancer Patients

BACKGROUND

Although tamoxifen (TAM) is the predominant adjuvant therapy for estrogen receptor positive (ER(+)) breast tumors, 50% of breast cancer patients do not respond positively to this therapy, or they experience adverse side effects. This variability in TAM responsiveness may be due to differences in TAM metabolism that stem from differences in race, age, and body mass index (BMI). Thus, the purpose of this study was to test the hypothesis that race, age, and BMI are associated with the metabolism of TAM to two primary metabolites, N-desmethyltamoxifen (N-DMT) and 4-hydroxytamoxifen (4-OHT).

METHODS

The study design was cross-sectional, and data were analyzed using independent sample t tests and multiple linear regression models. Breast cancer patients (n = 99) taking TAM for at least 30 days were recruited from a local hospital clinic. Each participant provided informed consent, completed a questionnaire, and donated a blood sample. The questionnaire was used to ascertain race, age, and BMI. The blood samples were used to measure plasma concentrations of TAM, N-DMT, and 4-OHT.

RESULTS

Plasma concentrations of TAM, N-DMT, and 4-OHT differed among individual patients. Age, but not race and BMI, was positively associated with plasma concentrations of TAM and N-DMT, even after adjustment for potential confounders (p = 0.02 for TAM and p = 0.03 for N-DMT).

CONCLUSIONS

This study suggests that aging may alter the metabolism of TAM. As increased levels of TAM and TAM metabolites may provide a possible explanation for why older women taking TAM are at increased risk for adverse side effects, future studies should determine whether age-related differences in the concentrations of TAM and TAM metabolites are associated with differences in TAM toxicity or responsiveness.

Serum carbamazepine concentrations in elderly patients: a case-matched pharmacokinetic evaluation based on therapeutic drug monitoring data

PURPOSE

To assess the influence of aging on the steady-state pharmacokinetics of carbamazepine (CBZ) in a large population of patients evaluated in a therapeutic drug monitoring (TDM) setting.

METHODS

The database of a large TDM service was used to identify retrospectively steady-state serum CBZ concentrations in 157 elderly patients with epilepsy (65 years and older) treated with CBZ alone or in combination with phenobarbital (PB). CBZ apparent oral clearance (CL/F) values were calculated and compared with those determined in an equal number of controls aged 20 to 50 years, and matched for gender, body weight, and comedication.

RESULTS

Compared with corresponding controls, mean CBZ CL/F values were 23% and 24% lower, respectively, in the groups of elderly patients receiving monotherapy (57.1 +/- 20.6 vs. 74.6 +/- 28.3 ml/h/kg; p < 0.0001) and PB comedication (74.7 +/- 25.5 vs. 98.7 +/- 34.9 ml/h/kg; p < 0.01). Within each age group, patients comedicated with PB showed significantly higher CBZ CL/F values than those on monotherapy. A negative correlation between CL/F and age was found both within the monotherapy and the PB comedicated groups. In addition, CL/F values showed a positive relation with the administered daily dosage, which persisted within subgroups homogeneous for age and comedication. The independent influence of age, CBZ dosage, and comedication on CBZ CL/F was confirmed by multiple regression analysis.

CONCLUSIONS

CBZ CL/F is decreased in an age-dependent manner in elderly patients compared with younger subjects, presumably because a reduction in the rate of CYP3A4-mediated drug metabolism. Elderly patients retain their sensitivity to dose-dependent autoinduction and to heteroinduction by enzyme-inducing AEDs, but their metabolic rates remain considerably below those observed in matched controls. As a result of this, patients in old age will require lower CBZ dosages to achieve serum concentrations comparable with those found in nonelderly adults.

Treating epilepsy in the elderly: safety considerations

The incidence of epilepsy increases with advancing age. Epilepsy in the elderly has different aetiologies from that in younger populations, cerebrovascular disease being the most common condition associated with seizures. Partial seizures are the predominant seizure type in older patients. A diagnosis of epilepsy in the elderly is based mainly on the history and is frequently delayed. In addition, seizure imitators are especially frequent. In many cases ancillary tests for diagnosis may show normal age-related variants, sometimes making results difficult to interpret. Treating epilepsy in the elderly is problematic due to a number of issues that relate to age and comorbidity. The physical changes associated with increasing age frequently lead to changes in the pharmacokinetics of many anticonvulsants. The treatment of epilepsy in the elderly is also complicated by the existence of other diseases that might affect the metabolism or excretion of anticonvulsants and the presence of concomitant medications that might interact with them. Moreover, specific trials of anticonvulsants in the aged population are scarce. General guidelines for treatment include starting at lower doses, slowing the titration schedule, individualising the choice of anticonvulsant to the characteristics of the patient, avoiding anticonvulsants with important cognitive or sedative adverse effects, and where possible, treating with monotherapy.

Assessing risk to benefit ratio in antiepileptic drug therapy

Assessment of risk to benefit ratio in patients with epilepsy is crucial in determining the need for treatment, the choice of drugs and the use of monitoring tools such as laboratory tests and other investigations. Active epilepsy per se carries significant risks in terms of increased mortality, susceptibility to psychopathology and physical injury, and reduced quality of life as a result of restricted lifestyle, stigma and prejudice. By preventing the occurrence of seizures, antiepileptic drugs (AEDs) attenuate or eliminate altogether seizure-related risks, but other risks may arise due to the side effects of the drugs, all of which have a relatively narrow therapeutic index. While there are no major differences in the degree of efficacy between AEDs which are effective in any given seizure type, side effect profiles differ considerably from one agent to another and represent a major factor in determining choice of treatment. Assessment of risk to benefit ratio should also take into consideration patient-specific factors such as type and severity of the epilepsy, age, sex, childbearing potential, medical and drug history, associated disease, use of concomitant medication (including the contraceptive pill) and the prospected patient's compliance. In some benign epilepsy syndromes, such as idiopathic partial epilepsy with centro-temporal spikes, the risk of side effects from AEDs may outweigh potential benefits in terms of seizure control, and treatment is generally not indicated. At the opposite end of the spectrum, the serious morbidity and mortality associated with severe epileptic encephalopathies, such as the Lennox-Gastaut syndrome, justifies aggressive treatment even with drugs associated with a relatively high risk of life threatening side effects such as felbamate. The present article will provide an overview of specific risks associated with epilepsy and with the various drugs used for its treatment, and will attempt to evaluate the complex balance between these risks and therapeutic benefits in different categories of patients.

Predictive capacity of carbamazepine pharmacokinetic parameters in a Portuguese outpatient population

The individualization of anticonvulsant therapy regimens can contribute to the implementation of appropriate carbamazepine (CBZ) maintenance doses in epileptic patients. An accurate method for the prediction of concentrations based on a determination of parameters and serum concentrations could be of clinical relevance in the management of epilepsy. In this study, we retrospectively evaluated the predictive performance in an adult outpatient population of six different methods, representing six sets of CBZ pharmacokinetic parameters selected according to the literature using a Bayesian computer program (PKS System; Abbott Laboratories, Abbott Park, IL, USA). The study involved 50 patients with two or more available concentrations selected under several inclusion criteria. The patients were taking CBZ (between 200 and 1600 mg/d) in monotherapy or polytherapy regimens and had no hepatic or renal disease. Steady state concentrations were predicted according to the use of prior information and using one and two feedback patient concentrations. Accuracy and precision were assessed by mean prediction error (ME), mean squared prediction error (MSE) and root mean squared prediction error (RMSE). The analysis showed CL = 0.067 L/hour/kg and Vd = 1.19 L/kg as the most accurate and precise set of pharmacokinetic parameters, presenting the highest percentage of clinically acceptable estimates (error < 2 microg/mL). Additionally, predictions based on one measured feedback concentration were found to be more accurate and precise than prior population-based predictions; the use of two previous patient concentrations further improved predictive capacity but failed to show a significant difference when compared with predictions based on one measured feedback concentration. In conclusion, the adoption of the previously mentioned set of parameters as population estimates and the use of at least one feedback concentration through the Bayesian approach seems to be essential for a better CBZ use in clinical practice. Finally, despite the obtained results, we believe that the Portuguese pharmacokinetic parameter determination of antiepileptics should be carried out to improve the rationale and cost-effectiveness of anticonvulsant therapy.

Antiepileptic drug use in nursing home residents: effect of age, gender, and comedication on patterns of use

PURPOSE

Examine antiepileptic drug (AED) use in nursing homes by age, gender, and use of comedication that can interact with AEDs.

METHODS

Two point-prevalence evaluations of AED use from computerized medical records of nursing home residents throughout the United States (set 1, 43,757; set 2, 41,386) 65 years and older serviced by PHARMERICA.

RESULTS

10.5% of residents received an AED. Of the age group 65-84 years, 15 % received an AED compared with 6.1% of those 85 years or older (p < 0.001). Gender differences were present; 13.4% of the male residents and 9.4% of the female residents were treated with an AED (p < 0.001). The most frequently prescribed AEDs were phenytoin, carbamazepine, clonazepam, or phenobarbital. The average number of routine medications taken by AED recipients was 5.6, greater than the average of 4.6 for other residents.

CONCLUSIONS

AEDs are extensively prescribed for elderly nursing home residents. Men and persons aged 65-85 years were more likely to receive AEDs than were women or those older than 85 years. AED recipients receive more routine medications than do other residents, including co-medications that alter hepatic metabolism and clinical response. The reasons for age and gender differences are unclear and require further study.

Kinetic profile of carbamazepine in an adult Portuguese outpatient population

OBJECTIVE

The aim of our work was to define the kinetic profile of carbamazepine (CBZ), in order to improve on dosing schedules through a Bayesian approach.

METHOD

Carbamazepine dose/steady-state trough concentrations data pairs and associated information were collected retrospectively on a population of adult epileptic patients.

RESULTS

Fifty patients (index population) with two or more available concentrations (total of 174 determinations) met our inclusion criteria. Patients were taking CBZ (200-1800 mg/day) in mono- or polytherapy regimens. The analysis assumed a one-compartmental model with first-order absorption and elimination. Due to the data source (only trough concentrations were measured as part of hospital routine), the volume of distribution was fixed at 1.19 l/kg. The final estimates for CL were: 0.075 +/- 0.027 (mono- and polytherapy), 0.069 +/- 0.020 (monotherapy), and 0.106 +/- 0.037 l/h/kg (polytherapy). In order to validate these results, we assessed their predictive capacity using 18 new patients (validation population), submitted to the same inclusion criteria and using Prediction-Error analysis. The results suggested a different CL value for our population compared to earlier published clearance values. The results also pointed to an increased metabolic rate associated with polytherapy. The prediction capacity of the optimization method derived from a Portuguese population made in an a priori evaluation indicated a low error (-0.04 microg/ml), close to the theoretical zero value.

CONCLUSION

Our results provide specific data on CBZ disposition in a Portuguese population and given the wide variability in the literature values, our data may help improve dosing of CBZ in Portuguese patients.

Neuropharmacology in the elderly

Psychotropic medications present special problems in the elderly because of altered pharmacokinetics and pharmacodynamics. Aging is associated with changes in absorption, distribution, and elimination of medications. Pharmacodynamic changes refer to alterations in end-organ responsiveness occurring with aging. Common problems that further complicate psychotropic drug use in the elderly include polypharmacy, compliance, lack of specific diagnosis, and concomitant physical illness. The treating physician must be aware of these issues when prescribing psychotropic medications for the elderly.

The aging liver. Drug clearance and an oxygen diffusion barrier hypothesis

A change in drug clearance with age is considered an important factor in determining the high prevalence of adverse drug reactions associated with prescribing medications for the elderly. Despite this, no general principles have been available to guide drug administration in the elderly, although a substantial body of clearance and metabolism data has been generated in humans and experimental animals. A review of age-related change in drug clearances established that patterns of change are not simply explained in terms of hepatic blood flow, hepatic mass and protein binding changes. In particular, the maintained clearance of drugs subject to conjugation processes while oxygen-dependent metabolism declines, and all in vitro tests of enzyme function have been normal, requires new explanations. Reduction in hepatic oxygen diffusion as part of a general change in hepatocyte surface membrane permeability and conformation does provide one explanation for the paradoxical patterns of drug metabolism, and increased hepatocyte volume would also modify oxygen diffusion path lengths (the 'oxygen diffusion barrier' hypothesis). The reduction in clearances of high extraction drugs does correlate with observed reduction in hepatic perfusion. Dosage guidelines emerge from these considerations. The dosage of high clearance drugs should be reduced by approximately 40% in the elderly while the dosage of low clearance drugs should be reduced by approximately 30%, unless the compound is principally subject to conjugation mechanisms. If the hepatocyte diffusion barrier hypothesis is substantiated, this concept may lead to therapeutic (preventative and/or restorative) approaches to increased hepatocyte oxygenation in the elderly. This may lead to approaches for modification of the aging process in the liver.