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Lau A, Haag H, Maharaj A. A Simulation-Based Assessment of Levetiracetam Concentrations Following Fixed and Weight-Based Loading Doses: A Meta-Regression and Pharmacokinetic Modeling Analysis. J Clin Pharmacol 2024; 64:1173-1180. [PMID: 38708556 DOI: 10.1002/jcph.2449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/08/2024] [Indexed: 05/07/2024]
Abstract
Current recommendations for refractory status epilepticus (SE) unresponsive to benzodiazepines suggest a loading dose of levetiracetam (LEV) of 60 mg/kg to a maximum of 4500 mg. LEV therapeutic drug monitoring can help guide therapy and is garnering increasing attention. The objective of this study is to simulate the probability of target attainment (PTA) of fixed dose and weight-based loading doses of LEV with respect to established therapeutic target concentrations. Meta-regression of the current literature was performed to evaluate the relationship between intravenous LEV loading dose and seizure cessation in refractory SE patients. A previously published pharmacokinetic model was used to simulate the PTA capacity of competing single intravenous dosing schemes (fixed vs weight-based dosing) to achieve maximum (Cpeak) and 12-h (C12h) plasma concentrations that exceed 12 mg/L. The meta-regression indicated that dosage was not a statistically significant modulator of seizure control at dosages between 20 and 60 mg/kg. Stochastic simulations showed all dosing schemes achieved plasma Cpeak >12 mg/L, but C12h levels were <12 mg/L in subjects over 60 kg with a fixed dose ≤2000 mg or in subjects <60 kg with a weight-based dose <30 mg/kg. Dosages of 40 and 60 mg/kg provided ≥90% PTAs across all weights. Using a weight-based loading dose of 40 mg/kg, up to a suggested maximum of 4500 mg, improves the likelihood of achieving a sustained therapeutic drug concentration after the initial LEV dose, whereas fixed <3000 mg may not achieve the desired concentration before maintenance dosing.
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Affiliation(s)
- Anthony Lau
- Emergency Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hans Haag
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- Infectious Disease, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Anil Maharaj
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Yin H, Lv X, Wang Z, Xiao S, Liang J, Sun J, Jiang L, Liu Y. In vitro inhibitory effects of selumetinib on activity of human UDP-glucuronosyltransferases and prediction of in vivo drug-drug interactions. Toxicol In Vitro 2024; 99:105863. [PMID: 38823552 DOI: 10.1016/j.tiv.2024.105863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 06/03/2024]
Abstract
Selumetinib is an oral, effective, and selective tyrosine kinase inhibitor targeting mitogen-activated protein kinase 1 and 2 (MEK1/2), which is clinically active in multiple tumor types, such as neurofibromatosis type 1 (NF1), melanoma, gliomas and non-small cell lung cancer (NSCLC). The purpose of this article was to assess the effects of selumetinib on the activities of twelve human UDP-glucosyltransferases (UGTs) including UGT1A1, 1A3, 1A4, 1A6, 1A7, 1A8, 1A9, 1A10, 2B4, 2B7, 2B15, and 2B17, and its potential for inducing clinical drug-drug interactions (DDIs). The results demonstrated that selumetinib potently inhibited the activity of UGT2B7 through the mechanism of mixed inhibition with the inhibition constant value of 5.79 ± 0.65 μM. Furthermore, the plasma concentration of UGT2B7 substrate as the co-administered drug was predicted to be increased by at least 84 % when patients took selumetinib 75 mg twice daily, suggesting a high potential to induce clinical DDIs. Selumetinib exhibited weak inhibitory effects on other human UGTs and was unlikely to trigger off UGTs-mediated DDIs except for UGT2B7. Therefore, the combination of selumetinib with the substrate drug of UGT2B7 requires additional attention to avoid adverse events in clinical treatment.
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Affiliation(s)
- Hang Yin
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin 124221, China
| | - Xin Lv
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin 124221, China
| | - Zhen Wang
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin 124221, China
| | - Shichao Xiao
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin 124221, China
| | - Jiaqi Liang
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin 124221, China
| | - Jie Sun
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin 124221, China
| | - Lili Jiang
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin 124221, China.
| | - Yong Liu
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin 124221, China.
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3
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Tantillo GB, Sullivan-Baca E, Rehman R, López MR, Haneef Z. Health care utilization of Hispanic/Latino veterans with epilepsy: A national population-based study. Epilepsia 2024; 65:1668-1678. [PMID: 38557951 DOI: 10.1111/epi.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Hispanic/Latino people with epilepsy are a growing population that has been understudied in clinical epilepsy research. U.S. veterans are at a higher risk of epilepsy due to greater exposures including traumatic brain injury. Hispanic/Latino Veterans with Epilepsy (HL-VWEs) represent a growing population; however the treatment utilization patterns of this population have been vastly understudied. METHODS HL-VWE were identified from administrative databases during fiscal year 2019. Variables compared between Hispanic and non-Hispanic VWEs included demographics, rurality, service era, utilization of clinical services/investigations, and service-connected injury. Chi-square and Student's t tests were used for comparisons. RESULTS Among 56 556 VWEs, 3247 (5.7%) were HL. HL-VWEs were younger (59.2 vs 63.2 years; p < .01) and more commonly urban-dwelling (81.6% vs 63.2%, p < .01) compared to non-HL-VWEs. They were also more likely to have served in recent missions such as the Persian Gulf War and post- 9/11 wars (p < .01). HL-VWEs had a higher utilization of all neurology services examined including neurology clinic visits, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, electroencephalography (EEG), epilepsy monitoring, and comprehensive epilepsy care (p < .01 for all). HL-VWEs were more likely to visit an emergency room or have seizure-related hospitalizations (p < .01). HL-VWEs were more likely to have a service-connected disability greater or equal to 50% (p < .01). SIGNIFICANCE This study is one of the largest cohorts examining HL-VWEs. We found higher utilization of services in neurology, epilepsy, and neuroimaging by HL-VWEs. HL-VWE are younger, more commonly urban-dwelling, and more likely to have served during recent combat periods and have higher amounts of service-connected disability. Given that the proportion of Hispanic veterans is projected to rise over time, more research is needed to provide the best interventions and mitigate the long-term impact of epilepsy on this diverse patient group.
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Affiliation(s)
| | - Erin Sullivan-Baca
- Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Houston VA Medical Center, Houston, Texas, USA
| | - Rizwana Rehman
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
- Durham VA Medical Center, Durham, North Carolina, USA
| | - María Raquel López
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
- University of Miami Medical Center, Miami, Florida, USA
| | - Zulfi Haneef
- Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Houston VA Medical Center, Houston, Texas, USA
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
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Milosheska D, Roškar R, Vovk T, Lorber B, Grabnar I, Trontelj J. An LC-MS/MS Method for Quantification of Lamotrigine and Its Main Metabolite in Dried Blood Spots. Pharmaceuticals (Basel) 2024; 17:449. [PMID: 38675410 PMCID: PMC11053667 DOI: 10.3390/ph17040449] [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] [Received: 02/21/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The antiepileptic drug lamotrigine (LTG) shows high pharmacokinetic variability due to genotype influence and concomitant use of glucuronidation inducers and inhibitors, both of which may be frequently taken by elderly patients. Our goal was to develop a reliable quantification method for lamotrigine and its main glucuronide metabolite lamotrigine-N2-glucuronide (LTG-N2-GLU) in dried blood spots (DBS) to enable routine therapeutic drug monitoring and to identify altered metabolic activity for early detection of drug interactions possibly leading to suboptimal drug response. RESULTS The analytical method was validated in terms of selectivity, accuracy, precision, matrix effects, haematocrit, blood spot volume influence, and stability. It was applied to a clinical study, and the DBS results were compared to the concentrations determined in plasma samples. A good correlation was established for both analytes in DBS and plasma samples, taking into account the haematocrit and blood cell-to-plasma partition coefficients. It was demonstrated that the method is suitable for the determination of the metabolite-to-parent ratio to reveal the metabolic status of individual patients. CONCLUSIONS The clinical validation performed confirmed that the DBS technique is a reliable alternative for plasma lamotrigine and its glucuronide determination.
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Affiliation(s)
- Daniela Milosheska
- Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia (T.V.)
| | - Robert Roškar
- Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia (T.V.)
| | - Tomaž Vovk
- Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia (T.V.)
| | - Bogdan Lorber
- Department of Neurology, University Medical Centre Ljubljana, Zaloška cesta 2, 1000 Ljubljana, Slovenia
| | - Iztok Grabnar
- Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia (T.V.)
| | - Jurij Trontelj
- Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia (T.V.)
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Wei S, Li X, Wu H, Zhang Q, Wu Y, Zhao Z, Mei S, Feng W. UGT1A polymorphism rs4148324 associated with topiramate plasma concentration to dose ratio in children with epilepsy. Seizure 2024; 116:107-112. [PMID: 37858371 DOI: 10.1016/j.seizure.2023.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/23/2023] [Accepted: 10/06/2023] [Indexed: 10/21/2023] Open
Abstract
PURPOSE The objective of this study is to evaluate the association between genetic polymorphisms and the concentration to dose ratio of topiramate in children with epilepsy. METHODS A cohort of 163 pediatric patients with epilepsy receiving topiramate therapy were enrolled. The ultra-performance liquid chromatography-tandem mass spectrometry method was employed to measure the trough plasma concentration of topiramate at steady-state. These concentrations were normalized by dividing them by the ratio of total daily dose to body weight, yielding the concentration to dose ratio (CDR) of topiramate. MassArray system identified 30 single nucleotide polymorphisms associated with the pharmacokinetics and pharmacodynamics of topiramate. The CDR values were logarithmic transformed (lnCDR) for normal distribution. The association between the identified genetic polymorphisms and lnCDR was assessed using the PLINK software, employing linear regression analysis with adjustments by epilepsy types, estimated glomerular filtration rate, alanine aminotransferase, valproic acid, phenobarbital, and oxcarbazepine. RESULTS Variant rs4148324 (UGT1A1/3/4/5/6/7/8/9/10, BETA = 0.182, P = 0.010) was significantly associated with lnCDR of topiramate. Patients carrying the G allele exhibited higher normalized topiramate plasma concentrations. No other significant associations were found. CONCLUSIONS In pediatric patients receiving topiramate therapy, rs4148324 was associated with normalized topiramate plasma concentration. Further studies are warranted to validate and confirm the findings.
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Affiliation(s)
- Shifeng Wei
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing 100070, China; Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China
| | - Xingmeng Li
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Han Wu
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing 100070, China; Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China
| | - Qiang Zhang
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing 100070, China; Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China
| | - Yun Wu
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing 100070, China; Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China.
| | - Shenghui Mei
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing 100070, China; Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China.
| | - Weixing Feng
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China.
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Lin CY, Chang CW, Tseng WEJ, Wu T, Cheng MY, Lee CH, Chiang HI, Lin WR, Lin CN, Liu CJ, Chen PR, Cheng HF, Lim SN. Therapeutic drug monitoring of perampanel: Clinical utility and impact of co-medication on pharmacokinetic variability. Heliyon 2024; 10:e23962. [PMID: 38226257 PMCID: PMC10788532 DOI: 10.1016/j.heliyon.2023.e23962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/19/2023] [Indexed: 01/17/2024] Open
Abstract
Background Perampanel (PER) is a newly developed antiseizure medication (ASM). This study aimed to determine the utilization of therapeutic drug monitoring (TDM) for PER in a real-world clinical setting and investigate the influence of concomitant use of ASMs on the plasma concentration profile of PER. Method We analyzed data from the Chang Gung Research Database, which is the largest multi-institutional electronic medical records database in Taiwan. The main outcomes were the comparisons of PER plasma concentration and the ratio of concentration to the weight-adjusted dose (C/D; [ng/mL]/[mg/kg/d]) among patients received TDM of different clinical indication and among different ASM co-medication subgroups. Results Overall, 88 plasma samples were collected from 66 epilepsy patients treated with PER. The majority of patients (77.3 %) underwent PER TDM owing to poorly controlled seizures. There was a trend toward a higher plasma concentration and C/D ratio in those suspected of having PER toxicity owing to adverse events than of other indications. The PER concentration exhibited dose linearity. The mean PER plasma concentrations in patients co-medicated with enzyme-inducing ASMs were significantly lower than those in the patients who were not prescribed enzyme-inducing or enzyme-inhibiting ASMs, and co-medication with carbamazepine (CBZ) resulted in a significant reduction in the PER concentration. Conclusion PER concentration exhibited a linear regression relationship with PER dose, and the plasma concentration of the drug was highly susceptible to the drug's interactions with enzyme-inducing ASMs. TDM with clear indication could help determine the influence of ASMs used concomitantly on PER concentrations and guide clinical adjustments.
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Affiliation(s)
- Chih-Yin Lin
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Wei Chang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Tony Wu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Neurology, Xiamen Chang Gung Hospital, Xiamen, Fujian, China
| | - Mei-Yun Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Medical Science, National Tsing Hua University, Hsinchu, Taiwan
| | - Chih-Hong Lee
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsing-I Chiang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chia-Ni Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Jing Liu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Ru Chen
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hui-Fen Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Siew-Na Lim
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Bodor GS, Rands AJ. Quantitative LC-MS/MS Method for the Simultaneous Measurement of Six Antiepileptics and Pentobarbital in Human Serum. Methods Mol Biol 2024; 2737:43-54. [PMID: 38036809 DOI: 10.1007/978-1-0716-3541-4_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Antiepileptic drugs (AEDs) are a chemically diverse group of medications that are used to control seizures and different clinical forms of epilepsy. AEDs can be used as single agents but are commonly administered in combination, as a multi-drug regimen. AEDs have narrow therapeutic windows. Therapeutic ranges may not be properly defined, and symptoms of toxic serum concentrations may include increased frequency of seizures, as seen when AED concentrations are subtherapeutic. Pentobarbital, a barbiturate, is a potent anti-seizure medication, but it is also used in the treatment of head injury. Therapeutic drug monitoring (TDM) is required for optimal treatment of epilepsy. The method presented here is designed to measure serum concentrations of six commonly administered antiepileptic drugs (levetiracetam (Keppra), lamotrigine, lacosamide, 10-hydroxycarbazepine (oxcarbazepine metabolite), topiramate, zonisamide) and that of pentobarbital by LC-MS/MS. Liquid-liquid sample extraction is followed by reversed-phase chromatography using biphenyl HPLC column and gradient elution. Two MRM transitions are monitored for each drug, and their heavy isotope labeled internal standards. Six-point calibration curve is generated with each batch of analysis for quantitation of AEDs. The method's AMR covers the clinically relevant concentration range for each AED. The method has <10% CV throughout the AMR, is free of matrix effect commonly found in clinical samples, and is free from cross reactivity by other AEDs.
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Affiliation(s)
- Geza S Bodor
- Department of Pathology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
- UCHealth University of Colorado Hospital Clinical Laboratory, Aurora, CO, USA.
| | - Amanda J Rands
- UCHealth University of Colorado Hospital Clinical Laboratory, Aurora, CO, USA
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Lim SN, Wu T, Chang CW, Johnny Tseng WE, Cheng MY, Hsieh HY, Lee CH, Lin WR, Liu CJ, Chen PR, Lin CN. Clinical impact of therapeutic drug monitoring for newer anti-seizure medications in patients with epilepsy: A real-world observation study. Biomed J 2023; 47:100680. [PMID: 38036171 DOI: 10.1016/j.bj.2023.100680] [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: 08/21/2023] [Revised: 10/18/2023] [Accepted: 11/24/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND The clinical value of therapeutic drug monitoring (TDM) for newer anti-seizure medications (ASMs) remains uncertain. This study aimed to assess the impact of newer ASM TDM on clinical decision making in patients with epilepsy. METHODS We retrospectively identified all plasma requests for newer ASM level measurement as part of routine clinical management in the outpatient departments of seven medical institutes across Taiwan between September 2016 and May 2019. Data collected from reviewed medical records included clinical and medication details, indications for TDM requests, test results, interpretation, and impact on patient management. RESULTS A total of 682 visits with 1051 plasma samples were included. The most frequently analyzed ASMs were levetiracetam (36.1%), oxcarbazepine (18.4%), and lamotrigine (12.0%). Reasons for TDM included poorly controlled seizures (55.3%), concerns about drug-drug interactions (12.3%), and suspicion of drug overdose (10.6%). 68.8% of samples were within the orienting therapeutic range, even for patients with poorly controlled seizures. TDM for non-adherence concerns showed 54.3% below the orienting therapeutic range, while ASM-related adverse events assessment only 8.9% showed levels exceeding the orienting therapeutic range. Following TDM results, 64.2% of cases had medication adjustments, mainly dosage increases. Overall, 55.9% of newer ASM TDM visits showed improved outcomes, including reduced seizures (47.5%) and fewer ASM-related side effects (8.4%). CONCLUSIONS These findings suggest that appropriate utilization of TDM for newer ASMs provides clinical benefits in adjunct to complement clinical decision making in the management of epilepsy patients in a real-world clinical setting.
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Affiliation(s)
- Siew-Na Lim
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Tony Wu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Wei Chang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; PhD Program in Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yun Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiang-Yao Hsieh
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hong Lee
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wey-Ran Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan
| | - Chun-Jing Liu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan
| | - Po-Ru Chen
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan
| | - Chia-Ni Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
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9
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Milosheska D, Roškar R. Simple HPLC-UV Method for Therapeutic Drug Monitoring of 12 Antiepileptic Drugs and Their Main Metabolites in Human Plasma. Molecules 2023; 28:7830. [PMID: 38067559 PMCID: PMC10708341 DOI: 10.3390/molecules28237830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/21/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
The objective of the present report was to develop and validate a simple, selective, and reproducible high-performance liquid chromatography method with UV detection suitable for routine therapeutic drug monitoring of the most commonly used antiepileptic drugs and some of their metabolites. Simple precipitation of plasma proteins with acetonitrile was used for sample preparation. 10,11-dihydrocarbamazepine was used as an internal standard. Chromatographic separation of the analytes was achieved by gradient elution on a Phenyl-Hexyl column at 40 °C, using methanol and potassium phosphate buffer (25 mM; pH 5.1) as a mobile phase. The method was validated according to the FDA guidelines for bioanalytical method validation. It showed to be selective, accurate, precise, and linear over the concentration ranges of 1-50 mg/L for phenobarbital, phenytoin, levetiracetam, rufinamide, zonisamide, and lacosamide; 0.5-50 mg/L for lamotrigine, primidone, carbamazepine and 10-monohydroxycarbazepine; 0.2-10 mg/L for carbamazepine metabolites: 10,11-trans-dihydroxy-10,11-dihydrocarbamazepine and carbamazepine-10,11-epoxide; 0.1-10 mg/L for oxcarbazepine; 2-100 mg/L for felbamate and 3-150 mg/L for ethosuximide. The suitability of the validated method for routine therapeutic drug monitoring was confirmed by quantification of the analytes in plasma samples from patients with epilepsy on combination antiepileptic therapy.
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Affiliation(s)
| | - Robert Roškar
- University of Ljubljana, Faculty of Pharmacy, Aškerčeva Cesta 7, 1000 Ljubljana, Slovenia
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Salzmann L, Wild J, Singh N, Schierscher T, Liesch F, Bauland F, Geistanger A, Risch L, Geletneky C, Seger C, Taibon J. An isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS)-based candidate reference measurement procedure (RMP) for the quantification of gabapentin in human serum and plasma. Clin Chem Lab Med 2023; 61:1955-1966. [PMID: 36689915 DOI: 10.1515/cclm-2022-0998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/23/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To describe and validate a reference measurement procedure (RMP) for gabapentin, employing quantitative nuclear magnetic resonance (qNMR) spectroscopy to determine the absolute content of the standard materials in combination with isotope dilution-liquid chromatograph-tandem mass spectrometry (ID-LC-MS/MS) to accurately measure serum and plasma concentrations. METHODS A sample preparation protocol based on protein precipitation in combination with LC-MS/MS analysis using a C8 column for chromatographic separation was established for the quantification of gabapentin. Assay validation and determination of measurement uncertainty were performed according to guidance from the Clinical and Laboratory Standards Institute, the International Conference on Harmonization, and the Guide to the expression of uncertainty in measurement. ID-LC-MS/MS parameters evaluated included selectivity, specificity, matrix effects, precision and accuracy, inter-laboratory equivalence, and uncertainty of measurement. RESULTS The use of qNMR provided traceability to International System (SI) units. The chromatographic assay was highly selective, allowing baseline separation of gabapentin and the gabapentin-lactam impurity, without observable matrix effects. Variability between injections, preparations, calibrations, and days (intermediate precision) was <2.3%, independent of the matrix, while the coefficient of variation for repeatability was 0.9-2.0% across all concentration levels. The relative mean bias ranged from -0.8-1.0% for serum and plasma samples. Passing-Bablok regression analysis indicated very good inter-laboratory agreement; the slope was 1.00 (95% confidence interval [CI] 0.98 to 1.03) and the intercept was -0.05 (95% CI -0.14 to 0.03). Pearson's correlation coefficient was ≥0.996. Expanded measurement uncertainties for single measurements were found to be ≤5.0% (k=2). CONCLUSIONS This analytical protocol for gabapentin, utilizing traceable and selective qNMR and ID-LC-MS/MS techniques, allows for the standardization of routine tests and the reliable evaluation of clinical samples.
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Affiliation(s)
| | - Janik Wild
- Dr. Risch Ostschweiz AG, Buchs, Switzerland
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11
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Wei S, Li X, Zhang Q, Wu H, Wu Y, Zhao Z, Mei S, Feng W. Population pharmacokinetics of topiramate in Chinese children with epilepsy. Eur J Clin Pharmacol 2023; 79:1401-1415. [PMID: 37597080 DOI: 10.1007/s00228-023-03549-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/05/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE Topiramate, a broad-spectrum antiepileptic drug, exhibits substantial inter-individual variability in both its pharmacokinetics and therapeutic response. The aim of this study was to investigate the influence of patient characteristics and genetic variants on topiramate clearance using population pharmacokinetic (PPK) models in a cohort of Chinese pediatric patients with epilepsy. METHOD The PPK model was constructed using a nonlinear mixed-effects modeling approach, utilizing a dataset comprising 236 plasma concentrations of topiramate obtained from 181 pediatric patients with epilepsy. A one-compartment model combined with a proportional residual model was employed to characterize the pharmacokinetics of topiramate. Covariate analysis was performed using forward addition and backward elimination to assess the influence of covariates on the model parameters. The model was thoroughly evaluated through goodness-of-fit analysis, bootstrap, visual predictive checks, and normalized prediction distribution errors. Monte Carlo simulations were utilized to devise topiramate dosing strategies. RESULT In the final PPK models of topiramate, body weight, co-administration with oxcarbazepine, and a combined genotype of GKIR1-UGT (GRIK1 rs2832407, UGT2B7 rs7439366, and UGT1A1 rs4148324) were identified as significant covariates affecting the clearance (CL). The clearance was estimated using the formulas CL (L/h) = 0.44 × (BW⁄11.7)0.82 × eOXC for the model without genetic variants and CL (L/h) = 0.49 × (BW⁄11.7)0.81 × eOXC × eGRIK1-UGT for the model incorporating genetic variants. The volume of distribution (Vd) was estimated using the formulas Vd (L) = 6.6 × (BW⁄11.7). The precision of all estimated parameters was acceptable. Furthermore, the model demonstrated good predictability, exhibiting stability and effectiveness in describing the pharmacokinetics of topiramate. CONCLUSION The clearance of topiramate in pediatric patients with epilepsy may be subject to the influence of factors such as body weight, co-administration with oxcarbazepine, and genetic polymorphism. In this study, PPK models were developed to better understand and account for these factors, thereby improving the precision and individualization of topiramate therapy in children with epilepsy.
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Affiliation(s)
- Shifeng Wei
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Xingmeng Li
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, People's Republic of China
| | - Qiang Zhang
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Han Wu
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Yun Wu
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, People's Republic of China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China.
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China.
| | - Shenghui Mei
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan West Road, Fengtai District, Beijing, 100070, People's Republic of China.
- Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, 100069, People's Republic of China.
| | - Weixing Feng
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Xicheng District, Beijing, 100045, People's Republic of China.
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12
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Ghosn NJ, Xie K, Pattnaik AR, Gugger JJ, Ellis CA, Sweeney E, Fox E, Bernabei JM, Johnson J, Boccanfuso J, Litt B, Conrad EC. A pharmacokinetic model of antiseizure medication load to guide care in the epilepsy monitoring unit. Epilepsia 2023; 64:1236-1247. [PMID: 36815252 PMCID: PMC10424095 DOI: 10.1111/epi.17558] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Evaluating patients with drug-resistant epilepsy often requires inducing seizures by tapering antiseizure medications (ASMs) in the epilepsy monitoring unit (EMU). The relationship between ASM taper strategy, seizure timing, and severity remains unclear. In this study, we developed and validated a pharmacokinetic model of total ASM load and tested its association with seizure occurrence and severity in the EMU. METHODS We studied 80 patients who underwent intracranial electroencephalographic recording for epilepsy surgery planning. We developed a first order pharmacokinetic model of the ASMs administered in the EMU to generate a continuous metric of overall ASM load. We then related modeled ASM load to seizure likelihood and severity. We determined the association between the rate of ASM load reduction, the length of hospital stay, and the probability of having a severe seizure. Finally, we used modeled ASM load to predict oncoming seizures. RESULTS Seizures occurred in the bottom 50th percentile of sampled ASM loads across the cohort (p < .0001, Wilcoxon signed-rank test), and seizures requiring rescue therapy occurred at lower ASM loads than seizures that did not require rescue therapy (logistic regression mixed effects model, odds ratio = .27, p = .01). Greater ASM decrease early in the EMU was not associated with an increased likelihood of having a severe seizure, nor with a shorter length of stay. SIGNIFICANCE A pharmacokinetic model can accurately estimate ASM levels for patients in the EMU. Lower modeled ASM levels are associated with increased seizure likelihood and seizure severity. We show that ASM load, rather than ASM taper speed, is associated with severe seizures. ASM modeling has the potential to help optimize taper strategy to minimize severe seizures while maximizing diagnostic yield.
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Affiliation(s)
- Nina J. Ghosn
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Xie
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Akash R. Pattnaik
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James J. Gugger
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colin A. Ellis
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth Sweeney
- Penn Statistics in Imaging and Visualization Endeavor Center, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Fox
- Department of Statistics, Stanford University, Stanford, California, USA
- Department of Computer Science, Stanford University, Stanford, California, USA
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - John M. Bernabei
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jenaye Johnson
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacqueline Boccanfuso
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian Litt
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erin C. Conrad
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Sullivan-Baca E, Lorkiewicz SA, Rehman R, Van Cott AC, Towne AR, Haneef Z. Utilization of epilepsy care among Women Veterans: A population-based study. Epilepsy Res 2023; 192:107130. [PMID: 37004372 DOI: 10.1016/j.eplepsyres.2023.107130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/01/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Higher healthcare utilization in epilepsy correlates with better clinical and quality of life outcomes. Women Veterans with epilepsy (WVE) have unique characteristics that may affect access and utilization of care. This study investigates epilepsy care in WVE, with respect to utilization of outpatient, inpatient, and emergency room care. METHODS Data were collected from 58,525 Veterans with epilepsy using the Veterans Health Administration (VHA) Corporate Data Warehouse administrative data. Overall, 8.5% of the sample were women (n = 4983). Neurology visits, comprehensive epilepsy care, neuroimaging, ASM prescription and hospital and emergency care were analyzed, and comparisons were made with men Veterans with epilepsy to identify gender differences. RESULTS Compared to men, a greater proportion of WVE utilized services including neurology (73.8% vs. 62.0%), comprehensive epilepsy care (16.1% vs. 11.7%), epilepsy monitoring unit evaluation (EMU; 6.1% vs. 2.9%), neuroimaging (CT: 39.1% vs. 36.6%; MRI: 43.7% vs. 32.5%), and electroencephalograms: (EEG: 36.5% vs. 29.1%). WVE also evidenced higher percentages of seizure-related emergency room care usage vs. men (15.2 vs. 12.6) and hospitalizations (12.3 vs. 10.0) and were prescribed a greater number of ASMs (average:2.3 vs. 1.9). Valproate was prescribed to 17.6% of WVE, despite potential teratogenic concerns. SIGNIFICANCE WVE have greater utilization of epilepsy care within the VHA system compared to men, which could lead to better epilepsy management and quality of life. However, higher rates of emergency care, hospitalizations, and concurrent ASMs among WVE highlight the clinical complexity and raise concern for potentially comorbid conditions including psychogenic non-epileptic seizures.
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Affiliation(s)
- Erin Sullivan-Baca
- Department of Neurology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Sara A Lorkiewicz
- Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA
| | - Rizwana Rehman
- Epilepsy Centers of Excellence, Veteran's Health Administration, USA; Durham VA Medical Center, 508 Fulton St., Durham, NC 27705, USA
| | - Anne C Van Cott
- Neurology Division, VA Pittsburgh Healthcare System, 4100 Allequippa St., Pittsburgh, PA 15240, USA; Department of Neurology, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Alan R Towne
- Epilepsy Centers of Excellence, Veteran's Health Administration, USA; Epilepsy Centers of Excellence, Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd., Richmond, VA 23249, USA; Department of Neurology, Virginia Commonwealth University School of Medicine, 1201 East Marshall Street, Richmond, VA 23298, USA
| | - Zulfi Haneef
- Department of Neurology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA; Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA; Epilepsy Centers of Excellence, Veteran's Health Administration, USA.
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14
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Dao Trong P, Jungwirth G, Unterberg A, Herold-Mende C, Warta R. The Antiepileptic Drug Oxcarbazepine Inhibits the Growth of Patient-Derived Isocitrate Dehydrogenase Mutant Glioma Stem-like Cells. Cells 2023; 12:cells12081200. [PMID: 37190109 DOI: 10.3390/cells12081200] [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] [Received: 03/01/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
Patients diagnosed with isocitrate dehydrogenase mutant (IDHmut) gliomas suffer frequently from seizures. Although the clinical course is less aggressive than that of its IDH wildtype counterpart, recent discoveries have shown that epileptic activity can promote tumor proliferation. However, it is not known if antiepileptic drugs confer additional value by inhibiting tumor growth. In this study, the antineoplastic properties of 20 FDA-approved antiepileptic drugs (AEDs) were tested in six patient-derived IDHmut glioma stem-like cells (GSCs). Cell proliferation was assessed using the CellTiterGlo-3D assay. Two of the screened drugs (oxcarbazepine and perampanel) demonstrated an antiproliferative effect. A subsequent eight-point dose-response curve proved the dose-dependent growth inhibition for both drugs, but only oxcarbazepine reached an IC50 value below 100 µM in 5/6 GSCs (mean 44.7 µM; range 17.4-98.0 µM), approximating the possible cmax for oxcarbazepine in patient serums. Furthermore, the treated GSC spheroids were 82% smaller (mean volume 1.6 nL vs. 8.7 nL; p = 0.01 (live/deadTM fluorescence staining)), and the apoptotic events increased by more than 50% (caspase-3/7 activity; p = 0.006). Taken together, this drug screen of a large series of antiepileptic drugs identified oxcarbazepine as a potent proapoptotic drug in IDHmut GSCs, which combines antiepileptic and antineoplastic properties to treat this seizure-prone patient population.
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Affiliation(s)
- Philip Dao Trong
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, INF400, 69120 Heidelberg, Germany
| | - Gerhard Jungwirth
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, INF400, 69120 Heidelberg, Germany
| | - Andreas Unterberg
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, INF400, 69120 Heidelberg, Germany
| | - Christel Herold-Mende
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, INF400, 69120 Heidelberg, Germany
| | - Rolf Warta
- Division of Experimental Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, INF400, 69120 Heidelberg, Germany
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15
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MacMahon T, Kelly YP. Zonisamide-induced distal renal tubular acidosis and critical hypokalaemia. BMJ Case Rep 2023; 16:e254615. [PMID: 37041041 PMCID: PMC10105998 DOI: 10.1136/bcr-2023-254615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
A woman in her 20s presented with rapidly progressive muscle weakness and a 1-month preceding history of fatigability, nausea and vomiting. She was found to have critical hypokalaemia (K+ 1.8 mmol/L), a prolonged corrected QT interval (581 ms) and a normal anion gap metabolic acidosis (pH 7.15) due to zonisamide-induced distal (type 1) renal tubular acidosis. She was admitted to the intensive care unit for potassium replacement and alkali therapy. Clinical and biochemical improvement ensued, and she was discharged after a 27-day inpatient stay.
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Affiliation(s)
- Thomas MacMahon
- Intensive Care Unit, Tallaght University Hospital, Dublin, Ireland
| | - Yvelynne P Kelly
- Intensive Care Unit, Tallaght University Hospital, Dublin, Ireland
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16
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Polymorphisms Affecting the Response to Novel Antiepileptic Drugs. Int J Mol Sci 2023; 24:ijms24032535. [PMID: 36768858 PMCID: PMC9917302 DOI: 10.3390/ijms24032535] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
Epilepsy is one of the most frequent chronic neurologic disorders that affects nearly 1% of the population worldwide, especially in developing countries. Currently, several antiepileptic drugs (AEDs) are available for its therapy, and although the prognosis is good for most patients, 20%-30% amongst them do not reach seizure freedom. Numerous factors may explain AED-resistance such as sex, age, ethnicity, type of seizure, early epilepsy onset, suboptimal dosing, poor drug compliance, alcohol abuse, and in particular, genetic factors. Specifically, the interindividual differences in drug response can be caused by single nucleotide polymorphisms (SNPs) in genes encoding for drug efflux transporters, for the brain targets of AEDs, and for enzymes involved in drug metabolism. In this review, we used the PubMed database to retrieve studies that assessed the influence of SNPs on the pharmacokinetic (PK), pharmacodynamic (PD), and efficacy of new antiepileptic drugs. Our results showed that polymorphisms in the ABCB1, ABCC2, UGT1A4, UGT2B7, UGT2B15, CYP2C9, and CYP2C19 genes have an influence on the PK and efficacy of AEDs, suggesting that a genetic pre-evaluation of epileptic patients could help clinicians in prescribing a personalized treatment to improve the efficacy and the safety of the therapy.
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17
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Methamphetamine detection using nanoparticle-based biosensors: A comprehensive review. SENSING AND BIO-SENSING RESEARCH 2022. [DOI: 10.1016/j.sbsr.2022.100538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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18
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Mansour NM, El-Sherbiny D, Ibrahim FA, El Subbagh HI. Validation of a specific Reversed-Phase HPLC method for the quantification of three racetams; Piracetam, Levetiracetam, and brivaracetam in the presence of Co-administered drugs in their pharmaceuticals; greenness assessment and application to biological fluid and in-vitro dissolution testing. Microchem J 2022. [DOI: 10.1016/j.microc.2022.107703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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Nucera B, Brigo F, Trinka E, Kalss G. Treatment and care of women with epilepsy before, during, and after pregnancy: a practical guide. Ther Adv Neurol Disord 2022; 15:17562864221101687. [PMID: 35706844 PMCID: PMC9189531 DOI: 10.1177/17562864221101687] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/03/2022] [Indexed: 01/16/2023] Open
Abstract
Women with epilepsy (WWE) wishing for a child represent a highly relevant subgroup of epilepsy patients. The treating epileptologist needs to delineate the epilepsy syndrome and choose the appropriate anti-seizure medication (ASM) considering the main goal of seizure freedom, teratogenic risks, changes in drug metabolism during pregnancy and postpartum, demanding for up-titration during and down-titration after pregnancy. Folic acid or vitamin K supplements and breastfeeding are also discussed in this review. Lamotrigine and levetiracetam have the lowest teratogenic potential. Data on teratogenic risks are also favorable for oxcarbazepine, whereas topiramate tends to have an unfavorable profile. Valproate needs special emphasis. It is most effective in generalized seizures but should be avoided whenever possible due to its teratogenic effects and the negative impact on neuropsychological development of in utero-exposed children. Valproate still has its justification in patients not achieving seizure freedom with other ASMs or if a woman decides to or cannot become pregnant for any reason. When valproate is the most appropriate treatment option, the patient and caregiver must be fully informed of the risks associated with its use during pregnancies. Folate supplementation is recommended to reduce the risk of major congenital malformations. However, there is insufficient information to address the optimal dose and it is unclear whether higher doses offer greater protection. There is currently no general recommendation for a peripartum vitamin K prophylaxis. During pregnancy most ASMs (e.g. lamotrigine, oxcarbazepine, and levetiracetam) need to be increased to compensate for the decline in serum levels; exceptions are valproate and carbamazepine. Postpartum, baseline levels are reached relatively fast, and down-titration is performed empirically. Many ASMs in monotherapy are (moderately) safe for breastfeeding and women should be encouraged to do so. This review provides a practically oriented overview of the complex management of WWE before, during, and after pregnancy.
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Affiliation(s)
- Bruna Nucera
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria
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20
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Craig JJ, Scott S, Leach JP. Epilepsy and pregnancy: identifying risks. Pract Neurol 2021; 22:98-106. [PMID: 34887343 DOI: 10.1136/practneurol-2019-002304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 11/04/2022]
Abstract
Pregnancy is a time of physical, physiological and psychological challenge. For women with epilepsy, as well as its potential for joy and fulfilment, pregnancy may bring additional risks and difficulties. Clinicians must anticipate and prevent these complications, ensuring that pregnancy, delivery and motherhood proceed without obstetric or medical complications, using available evidence to balance individual risks of undertreatment and overtreatment. Here we review epilepsy management in pregnancy, identifying some of the known effects of epilepsy and its treatment on gestation, fetal malformation, delivery, and neurocognitive and behavioural development. We outline strategies to reduce obstetric and fetal complications in women with epilepsy, while recognising the sometimes competing need to maintain or improve seizure control. We reinforce the importance of identifying those at highest risk, who may require additional measures or safeguards.
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Affiliation(s)
- John J Craig
- Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Shona Scott
- Department of Clinical Neurosciences, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, UK
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21
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Ion-Channel Antiepileptic Drugs: An Analytical Perspective on the Therapeutic Drug Monitoring (TDM) of Ezogabine, Lacosamide, and Zonisamide. ANALYTICA 2021. [DOI: 10.3390/analytica2040016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The term seizures includes a wide array of different disorders with variable etiology, which currently represent one of the most important classes of neurological illnesses. As a consequence, many different antiepileptic drugs (AEDs) are currently available, exploiting different activity mechanisms and providing different levels of performance in terms of selectivity, safety, and efficacy. AEDs are currently among the psychoactive drugs most frequently involved in therapeutic drug monitoring (TDM) practices. Thus, the plasma levels of AEDs and their metabolites are monitored and correlated to administered doses, therapeutic efficacy, side effects, and toxic effects. As for any analytical endeavour, the quality of plasma concentration data is only as good as the analytical method allows. In this review, the main techniques and methods are described, suitable for the TDM of three AEDs belonging to the class of ion channel agents: ezogabine (or retigabine), lacosamide, and zonisamide. In addition to this analytical overview, data are provided, pertaining to two of the most important use cases for the TDM of antiepileptics: drug–drug interactions and neuroprotection activity studies. This review contains 146 references.
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22
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Eap CB, Gründer G, Baumann P, Ansermot N, Conca A, Corruble E, Crettol S, Dahl ML, de Leon J, Greiner C, Howes O, Kim E, Lanzenberger R, Meyer JH, Moessner R, Mulder H, Müller DJ, Reis M, Riederer P, Ruhe HG, Spigset O, Spina E, Stegman B, Steimer W, Stingl J, Suzen S, Uchida H, Unterecker S, Vandenberghe F, Hiemke C. Tools for optimising pharmacotherapy in psychiatry (therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests): focus on antidepressants. World J Biol Psychiatry 2021; 22:561-628. [PMID: 33977870 DOI: 10.1080/15622975.2021.1878427] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives: More than 40 drugs are available to treat affective disorders. Individual selection of the optimal drug and dose is required to attain the highest possible efficacy and acceptable tolerability for every patient.Methods: This review, which includes more than 500 articles selected by 30 experts, combines relevant knowledge on studies investigating the pharmacokinetics, pharmacodynamics and pharmacogenetics of 33 antidepressant drugs and of 4 drugs approved for augmentation in cases of insufficient response to antidepressant monotherapy. Such studies typically measure drug concentrations in blood (i.e. therapeutic drug monitoring) and genotype relevant genetic polymorphisms of enzymes, transporters or receptors involved in drug metabolism or mechanism of action. Imaging studies, primarily positron emission tomography that relates drug concentrations in blood and radioligand binding, are considered to quantify target structure occupancy by the antidepressant drugs in vivo. Results: Evidence is given that in vivo imaging, therapeutic drug monitoring and genotyping and/or phenotyping of drug metabolising enzymes should be an integral part in the development of any new antidepressant drug.Conclusions: To guide antidepressant drug therapy in everyday practice, there are multiple indications such as uncertain adherence, polypharmacy, nonresponse and/or adverse reactions under therapeutically recommended doses, where therapeutic drug monitoring and cytochrome P450 genotyping and/or phenotyping should be applied as valid tools of precision medicine.
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Affiliation(s)
- C B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, Switzerland, Geneva, Switzerland
| | - G Gründer
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - P Baumann
- Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - N Ansermot
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - A Conca
- Department of Psychiatry, Health Service District Bolzano, Bolzano, Italy.,Department of Child and Adolescent Psychiatry, South Tyrolean Regional Health Service, Bolzano, Italy
| | - E Corruble
- INSERM CESP, Team ≪MOODS≫, Service Hospitalo-Universitaire de Psychiatrie, Universite Paris Saclay, Le Kremlin Bicetre, France.,Service Hospitalo-Universitaire de Psychiatrie, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - S Crettol
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - M L Dahl
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J de Leon
- Eastern State Hospital, University of Kentucky Mental Health Research Center, Lexington, KY, USA
| | - C Greiner
- Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Germany
| | - O Howes
- King's College London and MRC London Institute of Medical Sciences (LMS)-Imperial College, London, UK
| | - E Kim
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, South Korea.,Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea
| | - R Lanzenberger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - J H Meyer
- Campbell Family Mental Health Research Institute, CAMH and Department of Psychiatry, University of Toronto, Toronto, Canada
| | - R Moessner
- Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - H Mulder
- Department of Clinical Pharmacy, Wilhelmina Hospital Assen, Assen, The Netherlands.,GGZ Drenthe Mental Health Services Drenthe, Assen, The Netherlands.,Department of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy and Pharmaceutical Sciences, University of Groningen, Groningen, The Netherlands.,Department of Psychiatry, Interdisciplinary Centre for Psychopathology and Emotion Regulation, University of Groningen, Groningen, The Netherlands
| | - D J Müller
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - M Reis
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Clinical Chemistry and Pharmacology, Skåne University Hospital, Lund, Sweden
| | - P Riederer
- Center of Mental Health, Clinic and Policlinic for Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg, Würzburg, Germany.,Department of Psychiatry, University of Southern Denmark Odense, Odense, Denmark
| | - H G Ruhe
- Department of Psychiatry, Radboudumc, Nijmegen, the Netherlands.,Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, Netherlands
| | - O Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - E Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - B Stegman
- Institut für Pharmazie der Universität Regensburg, Regensburg, Germany
| | - W Steimer
- Institute for Clinical Chemistry and Pathobiochemistry, Technical University of Munich, Munich, Germany
| | - J Stingl
- Institute for Clinical Pharmacology, University Hospital of RWTH Aachen, Germany
| | - S Suzen
- Department of Toxicology, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - H Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - S Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - F Vandenberghe
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Center for Psychiatric Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - C Hiemke
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
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23
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Hashimoto Y, Kotake K, Watanabe N, Fujiwara T, Sakamoto S. Lamotrigine in the maintenance treatment of bipolar disorder. Cochrane Database Syst Rev 2021; 9:CD013575. [PMID: 34523118 PMCID: PMC8440301 DOI: 10.1002/14651858.cd013575.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bipolar disorder is a chronic mental disorder with repetitive mania/hypomania as well as depressive episodes, which eventually results in marked impairment in overall functioning and health-related quality of life. A worldwide prevalence rate of 2.4% has been reported. The risk of suicide is higher in people with bipolar disorder than those with other mental disorders. Therefore, effective management of bipolar disorder in the maintenance period is warranted to minimize the risk of relapse or recurrence. Although lithium has been the standard treatment of bipolar disorder for many years, it is associated with adverse effects and teratogenicity. Lamotrigine is approved to be expected for prevention of recurrence for the maintenance treatment of bipolar disorder. In addition, lamotrigine is as effective as lithium. Therefore, we performed a systematic review to confirm the efficacy and safety of lamotrigine in the maintenance treatment of bipolar disorder. OBJECTIVES To assess the efficacy and tolerability of lamotrigine in the maintenance treatment of bipolar disorder. SEARCH METHODS We searched Ovid MEDLINE, Embase, PsycINFO, the Cochrane Common Mental Disorders Group's Specialized Register (CCMDCTR) and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 21 May 2021. We also searched international trial registries and contacted experts in the field. SELECTION CRITERIA We included randomized controlled trials enrolling adults with bipolar disorder who were treated with lamotrigine, placebo or lithium. DATA COLLECTION AND ANALYSIS Two reviews authors independently checked the eligibility of studies and extracted data using a standardized form. Data extracted included study characteristics, participant characteristics, intervention details, settings, and outcome measures in the term of efficacy and tolerability. Study information were then entered into RevMan web. MAIN RESULTS We included 11 studies with a total of 2314 participants in this review; 1146 were randomized to lamotrigine, 869 were randomized to placebo and, 299 to lithium. We rated all studies as having an unclear risk of bias in at least one domain of Cochrane's tool for assessing risk of bias, with the most commonly observed weakness being selection bias (random sequence generation and allocation concealment). We judged five studies to be at a high risk of detection bias (blinding of outcome assessment). These potential biases pose as major threat to the validity of the included studies in this review. Outcomes of efficacy showed a possible advantage of lamotrigine over placebo. The estimated risk ratio (RR) for recurrence of manic symptom at one year as measured by the Young Mania Rating Scale (YMRS) was 0.67, (95% confidence interval (CI) 0.51 to 0.87; 3 studies, 663 participants; low-certainty evidence) in favor of lamotrigine. The RR of clinical worsening with the need for additional psychotropic treatment (RR 0.82, 95% CI 0.70 to 0.98; 4 studies, 756 participants) based on moderate-certainty evidence. The possible benefits of lamotrigine were also seen for the outcome of treatment withdrawal due to any reason at 6-12 months after treatment (RR 0.88, 95% CI 0.78 to 0.99; 4 studies, 700 participants; moderate-certainty evidence). Regarding tolerability, our analyses showed that the incidence rates of adverse effects were similar between the lamotrigine group and the placebo group (short-term effect: RR 1.07, 95% CI 0.81 to 1.42; 5 studies, 1138 participants; very low-certainty evidence; long-term effect: RR 0.97, 95% CI 0.77 to 1.23; 4 studies, 756 participants; moderate-certainty evidence). In the comparison between lamotrigine and lithium, efficacy was similar between groups except for recurrence of mania episode at one year. Recurrence of manic symptoms was higher in the lamotrigine group than that of the lithium group (RR 2.13, 95% CI 1.32 to 3.44; 3 studies, 602 participants; moderate-certainty evidence). Analysis of adverse effects at 6-12 months showed that a lower proportion of participants experienced at least one adverse effect when treated with lamotrigine compared to lithium (RR 0.70, 95% CI 0.51 to 0.96; 4 studies, 691 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Low- to moderate-certainty evidence collectively suggests that lamotrigine may be superior to placebo as a treatment modality for bipolar disorder. In comparison to lithium, people with bipolar disorder seem to tolerate lamotrigine better in the long run; however, the demonstrated efficacy in the maintenance of bipolar disorder was similar between the two groups.
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Affiliation(s)
| | - Kazumasa Kotake
- Department of Pharmacy, Okayama Saiseikai General Hospital, Kita-Ku, Japan
| | - Norio Watanabe
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
| | - Takashi Fujiwara
- Department of Otolaryngology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shinji Sakamoto
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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24
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Ha C, Lee HS, Joo EY, Shon YM, Hong SB, Seo DW, Lee SY. Levetiracetam Therapeutic Drug Monitoring in a Large Cohort of Korean Epileptic Patients. Pharmaceuticals (Basel) 2021; 14:ph14080826. [PMID: 34451923 PMCID: PMC8401685 DOI: 10.3390/ph14080826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/12/2021] [Accepted: 08/19/2021] [Indexed: 12/04/2022] Open
Abstract
Levetiracetam is a new antiepileptic drug (AED) used for treating and preventing partial or generalized seizures. The usefulness of levetiracetam therapeutic drug monitoring (TDM) is related to inter- or intra-individual pharmacokinetic variability, drug interactions, and patient noncompliance. We aimed to investigate the levetiracetam TDM status in Korean epilepsy patients. Serum trough levetiracetam concentrations were measured using liquid chromatography–tandem mass spectrometry in 710 samples from 550 patients. The median (range) daily and weight-adjusted levetiracetam doses were 1500 (20–5000) mg and 25.5 (3.03–133.0) mg/kg, respectively. Patients on levetiracetam monotherapy constituted only 19.5% of the population, while 30.1% were on co-medication with valproate and 56.0% with enzyme-inducing AEDs (EIAEDs). Observed levetiracetam concentrations were widely distributed, ranging 0.8–95 mg/L, with a median of 17.3 mg/L. Levetiracetam concentrations were therapeutic, supra-therapeutic, and sub-therapeutic in 58.5% (n = 393), 11.6% (n = 78), and 29.9% (n = 201) of samples, respectively. There was a strong correlation between weight-adjusted levetiracetam dosage and concentrations (ρ = 0.6896, p < 0.0001). In this large-scale clinical study, a large inter-individual difference in levetiracetam pharmacokinetics was observed, and levetiracetam concentrations were influenced by EIAEDs. For individual dose adjustments and monitoring compliance, routine levetiracetam TDM is needed in epilepsy patients.
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Affiliation(s)
- Changhee Ha
- Samsung Medical Center, Department of Laboratory Medicine and Genetics, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (C.H.); (H.-S.L.)
| | - Hyun-Seung Lee
- Samsung Medical Center, Department of Laboratory Medicine and Genetics, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (C.H.); (H.-S.L.)
| | - Eun Yeon Joo
- Neuroscience Center, Samsung Medical Center, Department of Neurology, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (E.Y.J.); (Y.-M.S.); (S.B.H.)
| | - Young-Min Shon
- Neuroscience Center, Samsung Medical Center, Department of Neurology, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (E.Y.J.); (Y.-M.S.); (S.B.H.)
| | - Seung Bong Hong
- Neuroscience Center, Samsung Medical Center, Department of Neurology, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (E.Y.J.); (Y.-M.S.); (S.B.H.)
| | - Dae-Won Seo
- Neuroscience Center, Samsung Medical Center, Department of Neurology, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (E.Y.J.); (Y.-M.S.); (S.B.H.)
- Correspondence: (D.-W.S.); (S.-Y.L.); Tel.: +82-2-3410-3595 (D.-W.S.); +82-2-3410-1834 (S.-Y.L.); Fax: +82-2-3410-0052 (D.-W.S.); +82-2-3410-2719 (S.-Y.L.)
| | - Soo-Youn Lee
- Samsung Medical Center, Department of Laboratory Medicine and Genetics, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (C.H.); (H.-S.L.)
- Samsung Medical Center, Department of Clinical Pharmacology and Therapeutics, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
- Correspondence: (D.-W.S.); (S.-Y.L.); Tel.: +82-2-3410-3595 (D.-W.S.); +82-2-3410-1834 (S.-Y.L.); Fax: +82-2-3410-0052 (D.-W.S.); +82-2-3410-2719 (S.-Y.L.)
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25
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Meirinho S, Rodrigues M, Fortuna A, Falcão A, Alves G. Liquid chromatographic methods for determination of the new antiepileptic drugs stiripentol, retigabine, rufinamide and perampanel: A comprehensive and critical review. J Pharm Anal 2021; 11:405-421. [PMID: 34513117 PMCID: PMC8424363 DOI: 10.1016/j.jpha.2020.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 10/26/2020] [Accepted: 11/17/2020] [Indexed: 01/28/2023] Open
Abstract
The new antiepileptic drugs perampanel, retigabine, rufinamide and stiripentol have been recently approved for different epilepsy types. Being them an innovation in the antiepileptics armamentarium, a lot of investigations regarding their pharmacological properties are yet to be performed. Besides, considering their broad anticonvulsant activities, an extension of their therapeutic indications may be worthy of investigation, especially regarding other seizure types as well as other central nervous system disorders. Although different liquid chromatographic (LC) methods coupled with ultraviolet, fluorescence, mass or tandem-mass spectrometry detection have already been developed for the determination of perampanel, retigabine, rufinamide and stiripentol, new and more cost-effective methods are yet required. Therefore, this review summarizes the main analytical aspects regarding the liquid chromatographic methods developed for the analysis of perampanel, retigabine (and its main active metabolite), rufinamide and stiripentol in biological samples and pharmaceutical dosage forms. Furthermore, the physicochemical and stability properties of the target compounds will also be addressed. Thus, this review gathers, for the first time, important background information on LC methods that have been developed and applied for the determination of perampanel, retigabine, rufinamide and stiripentol, which should be considered as a starting point if new (bio)analytical techniques are aimed to be implemented for these drugs.
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Affiliation(s)
- Sara Meirinho
- Faculty of Health Sciences, Health Sciences Research Center, University of Beira Interior (CICS UBI), 6200-506, Covilhã, Portugal
| | - Márcio Rodrigues
- Faculty of Health Sciences, Health Sciences Research Center, University of Beira Interior (CICS UBI), 6200-506, Covilhã, Portugal
- Research Unit for Inland Development, Polytechnic Institute of Guarda (UDI-IPG), 6300-654, Guarda, Portugal
| | - Ana Fortuna
- Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, 3000-548, Coimbra, Portugal
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548, Coimbra, Portugal
| | - Amílcar Falcão
- Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, 3000-548, Coimbra, Portugal
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548, Coimbra, Portugal
| | - Gilberto Alves
- Faculty of Health Sciences, Health Sciences Research Center, University of Beira Interior (CICS UBI), 6200-506, Covilhã, Portugal
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26
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Zhu X, Xiao T, Huang S, Liu S, Li X, Shang D, Wen Y. Case Report: Predicting the Range of Lamotrigine Concentration Using Pharmacokinetic Models Based on Monte Carlo Simulation: A Case Study of Antiepileptic Drug-Related Leukopenia. Front Pharmacol 2021; 12:706329. [PMID: 34354594 PMCID: PMC8329375 DOI: 10.3389/fphar.2021.706329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022] Open
Abstract
Lamotrigine (LTG), a wide-spectrum antiepileptic drug, is frequently associated with cutaneous side-effects, whereas hematological side-effects such as leukopenia have rarely been reported for it. We report the case of a 15-year-old Chinese female epileptic patient weighing 60 kg who developed combined asymptomatic leukopenia after receiving concomitant therapy with LTG and valproate acid (VPA). In this case report, antiepileptic drug-related leukopenia may have occurred in definite relation to an increase in LTG concentration and reversed with the discontinuation of VPA. Monte Carlo (MC) simulations were performed to estimate the steady-state serum concentrations (Css) of LTG for different dosing regimens in adolescent Chinese epileptic patients weighing the same as the patient considered in the case study, based on pharmacokinetic (PK) models published in past research. Adjustments to the dosage of LTG for the patient were analyzed to illustrate the application of MC simulations and verify the results. The predicted LTG concentrations within a prediction interval between the 10th and 90th percentiles that represented 80% of the simulated populations, could adequately capture the measured LTG concentrations of the patient, indicating that MC simulations are a useful tool for estimating drug concentrations. Clinicians may benefit from the timely probabilistic predictions of the range of drug concentration based on an MC simulation that considers a large sample of virtual patients. The case considered here highlights the importance of therapeutic drug monitoring (TDM) and implementing model-informed precision dosing in the course of a patient’s individualized treatment to minimize adverse reactions.
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Affiliation(s)
- Xiuqing Zhu
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Tao Xiao
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Shanqing Huang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Shujing Liu
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xiaolin Li
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Dewei Shang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Yuguan Wen
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
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27
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Gronich N, Stein N, Muszkat M. Association Between Use of Pharmacokinetic-Interacting Drugs and Effectiveness and Safety of Direct Acting Oral Anticoagulants: Nested Case-Control Study. Clin Pharmacol Ther 2021; 110:1526-1536. [PMID: 34287842 PMCID: PMC9290518 DOI: 10.1002/cpt.2369] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/29/2021] [Indexed: 12/29/2022]
Abstract
Concomitant use of direct oral anticoagulants (DOACs) and medications with inhibition/induction effect on P-gp/CYP3A might increase risk of bleeding/treatment failure, respectively. We designed a nested case-control study within a Clalit cohort of patients with atrial fibrillation (AF) and a cohort of patients with venous thromboembolism, new users of a DOAC (January 1, 2010 to August 24, 2020). Propensity scores were constructed from demographic/clinical characteristics, and medications at cohort entry. Each case of: (i) serious bleeding event; (ii) stroke/systemic emboli (SE) in patients with AF; (iii) recurrent thromboembolism in patients with thromboembolism, was matched by age, sex, length of follow-up, year of cohort entry, DOAC type, and DOAC indication, to up to 20 controls. Within 89,284 patients with AF and venous thromboembolism and 126,302 patient-years of follow-up, there were 1,587 serious bleeding events. Risk of serious bleeding increased in association with concurrent prescription of P-gp/CYP3A4 inhibitors. Specifically, higher bleeding risk was associated with dabigatran-verapamil, rivaroxaban-verapamil, and rivaroxaban-amiodarone concurrent prescriptions: adjusted odds ratios (ORs) 2.29 (1.13-4.60), 2.18 (1.07-4.40), and 1.68 (1.14-2.49), respectively. There were 1,116 events of stroke/SE, in 79,302 DOAC-treated patients with AF and 118,124 patient-years of follow-up. Concomitant use of phenytoin, carbamazepine, valproic acid, or levetiracetam was associated with risk for stroke/SE: adjusted OR 2.18 (1.55-3.10). Risk of recurrent venous thromboembolism could not be assessed due to the low number of cases. Concurrent prescriptions of dabigatran or rivaroxaban with verapamil, and of rivaroxaban with amiodarone, are associated with increased risk for serious bleeding. Higher risk for stroke/SE in patients with AF is associated with concurrent prescriptions of DOACs with phenytoin, carbamazepine, valproic acid, or levetiracetam.
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Affiliation(s)
- Naomi Gronich
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nili Stein
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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28
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Demir M, Akarsu EO, Dede HO, Bebek N, Yıldız SO, Baykan B, Akkan AG. Investigation of the Roles of New Antiepileptic Drugs and Serum BDNF Levels in Efficacy and Safety Monitoring and Quality of Life: A Clinical Research. ACTA ACUST UNITED AC 2021; 15:49-63. [PMID: 30864528 PMCID: PMC7497568 DOI: 10.2174/1574884714666190312145409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 12/11/2022]
Abstract
Objective: We aimed to determine the therapeutic drug monitoring (TDM) features and the relation to Brain-Derived Neurotrophic Factor (BDNF) of frequently used new antiepileptic drugs (NADs) including lamotrigine (LTG), oxcarbazepine (OXC), zonisamide (ZNS) and lacosamide (LCM). Moreover, we investigated their effect on the quality of life (QoL). Methods: Eighty epileptic patients who had been using the NADs, and thirteen healthy participants were included in this cross-sectional study. The participants were randomized into groups. The QOLIE-31 test was used for the assessment of QoL. We also prepared and applied “Safety Test”. HPLC method for TDM, and ELISA method for BDNF measurements were used consecutively. Results: In comparison to healthy participants, epileptic participants had lower marriage rate (p=0.049), education level (p˂0.001), alcohol use (p=0.002). BDNF levels were higher in patients with focal epilepsy (p=0.013) and in those with higher education level (p=0.016). There were negative correlations between serum BDNF levels and serum ZNS levels (p=0.042) with LTG-polytherapy, serum MHD levels (a 10-monohydroxy derivative of OXC, p=0.041) with OXC-monotherapy. There was no difference in BDNF according to monotherapy-polytherapy, drug-resistant groups, regarding seizure frequency. There was a positive correlation between total health status and QoL (p˂0.001). QOLIE-31 overall score (OS) was higher in those with OXC-monotherapy (76.5±14.5). OS (p˂0.001), seizure worry (SW, p=0.004), cognition (C, p˂0.001), social function (SF, p˂0.001) were different in the main groups. Forgetfulness was the most common unwanted effect. Conclusion: While TDM helps the clinician to use more effective and safe NADs, BDNF may assist in TDM for reaching the therapeutic target in epilepsy.
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Affiliation(s)
- Meral Demir
- Department of Medical and Clinical Pharmacology, Istanbul Faculty of Medicine, Istanbul University, Fatih / Capa 34093, Istanbul, Turkey.,Department of Medical and Clinical Pharmacology, Cerrahpasa Faculty of Medicine, Istanbul University, Cerrahpasa Street / Fatih 34093, Istanbul, Turkey
| | - Emel O Akarsu
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Fatih / Capa 34093, Istanbul, Turkey
| | - Hava O Dede
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Fatih / Capa 34093, Istanbul, Turkey
| | - Nerses Bebek
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Fatih / Capa 34093, Istanbul, Turkey
| | - Sevda O Yıldız
- Department of Biostatistics, Istanbul Faculty of Medicine, Istanbul University, Fatih / Capa 34093, Istanbul, Turkey
| | - Betül Baykan
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Fatih / Capa 34093, Istanbul, Turkey
| | - Ahmet G Akkan
- Department of Medical and Clinical Pharmacology, Cerrahpasa Faculty of Medicine, Istanbul University, Cerrahpasa Street / Fatih 34093, Istanbul, Turkey
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29
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Tauzin M, Tréluyer JM, Nabbout R, Chemaly N, Billette de Villemeur T, Desguerre I, Lui G, Gana I, Boujaafar S, Zheng Y, Benaboud S, Bouazza N, Chenevier-Gobeaux C, Freihuber C, Hirt D. Predictive Performance of Population Pharmacokinetic Models of Levetiracetam in Children and Evaluation of Dosing Regimen. J Clin Pharmacol 2021; 61:1366-1375. [PMID: 33997989 DOI: 10.1002/jcph.1910] [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: 11/15/2020] [Accepted: 05/11/2021] [Indexed: 11/08/2022]
Abstract
Levetiracetam is a broad-spectrum antiepileptic drug that exhibits high interindividual variability in serum concentrations in children. A population pharmacokinetic approach can be used to explain this variability and optimize dosing schemes. The objectives are to identify the best predictive population pharmacokinetic model for children and to evaluate recommended doses using simulations and Bayesian forecasting. A validation cohort included children treated with levetiracetam who had a serum drug concentration assayed during therapeutic drug monitoring. We assessed the predictive performance of all the population pharmacokinetic models published in the literature using mean prediction errors, root mean squared errors, and visual predictive checks. A population model was finally constructed on the data, and dose simulations were performed to evaluate doses. We included 267 levetiracetam concentrations ranging from 2 to 69 mg/L from 194 children in the validation cohort. Six published models were externally evaluated. Most of the models underestimated the variability of our population. A 1-compartment model with first-order absorption and elimination with allometric scaling was finally fitted on our data. In our cohort, 57% of patients had a trough concentration <12 mg/L and 12% <5 mg/L. To reach a trough concentration >5 mg/L, doses ≥30 mg/kg/d for patients ≤50 kg and ≥2000 mg/d for patients >50 kg are required. In our population, a high percentage of children had low trough concentrations. Our population pharmacokinetic model could be used for therapeutic drug monitoring of levetiracetam in children.
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Affiliation(s)
- Manon Tauzin
- Service de Pharmacologie Clinique, Hôpital Cochin, APHP, Paris, France.,Réanimation néonatale et néonatologie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Jean-Marc Tréluyer
- Service de Pharmacologie Clinique, Hôpital Cochin, APHP, Paris, France.,EA 7323, Université Paris Descartes Sorbonne Paris Cité, Paris, France.,Unité de recherche Clinique, Hôpital Universitaire Necker-Enfants Malades, APHP, Université Paris Descartes, Paris, France
| | - Rima Nabbout
- Centre de référence épilepsies rares, Service de Neurologie pédiatrique, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - Nicole Chemaly
- Centre de référence épilepsies rares, Service de Neurologie pédiatrique, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - Thierry Billette de Villemeur
- Sorbonne Université, UPMC, GRC ConCer-LD and AP-HP, Hôpital Trousseau, Service de Neuropédiatrie-Pathologie du développement, Centre de référence des déficits intellectuels de causes rares, Paris, France
| | - Isabelle Desguerre
- Centre de référence épilepsies rares, Service de Neurologie pédiatrique, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - Gabrielle Lui
- Service de Pharmacologie Clinique, Hôpital Cochin, APHP, Paris, France.,EA 7323, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Ines Gana
- Service de Pharmacologie Clinique, Hôpital Cochin, APHP, Paris, France
| | - Sana Boujaafar
- Service de Pharmacologie Clinique, Hôpital Cochin, APHP, Paris, France.,Unité de recherche Clinique, Hôpital Universitaire Necker-Enfants Malades, APHP, Université Paris Descartes, Paris, France
| | - Yi Zheng
- Service de Pharmacologie Clinique, Hôpital Cochin, APHP, Paris, France
| | - Sihem Benaboud
- Service de Pharmacologie Clinique, Hôpital Cochin, APHP, Paris, France.,EA 7323, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Naim Bouazza
- EA 7323, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Camille Chenevier-Gobeaux
- Service de Diagnostic Biologique Automatisé, Hôpital Cochin, Hôpitaux Universitaires Paris Centre (HUPC), Assistance Publique des Hôpitaux de Paris (APHP), Paris, France
| | - Cécile Freihuber
- Sorbonne Université, UPMC, GRC ConCer-LD and AP-HP, Hôpital Trousseau, Service de Neuropédiatrie-Pathologie du développement, Centre de référence des déficits intellectuels de causes rares, Paris, France
| | - Déborah Hirt
- Service de Pharmacologie Clinique, Hôpital Cochin, APHP, Paris, France.,EA 7323, Université Paris Descartes Sorbonne Paris Cité, Paris, France.,Inserm 1018 CESP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
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Zhu X, Huang W, Lu H, Wang Z, Ni X, Hu J, Deng S, Tan Y, Li L, Zhang M, Qiu C, Luo Y, Chen H, Huang S, Xiao T, Shang D, Wen Y. A machine learning approach to personalized dose adjustment of lamotrigine using noninvasive clinical parameters. Sci Rep 2021; 11:5568. [PMID: 33692435 PMCID: PMC7946912 DOI: 10.1038/s41598-021-85157-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 02/23/2021] [Indexed: 12/11/2022] Open
Abstract
The pharmacokinetic variability of lamotrigine (LTG) plays a significant role in its dosing requirements. Our goal here was to use noninvasive clinical parameters to predict the dose-adjusted concentrations (C/D ratio) of LTG based on machine learning (ML) algorithms. A total of 1141 therapeutic drug-monitoring measurements were used, 80% of which were randomly selected as the "derivation cohort" to develop the prediction algorithm, and the remaining 20% constituted the "validation cohort" to test the finally selected model. Fifteen ML models were optimized and evaluated by tenfold cross-validation on the "derivation cohort,” and were filtered by the mean absolute error (MAE). On the whole, the nonlinear models outperformed the linear models. The extra-trees’ regression algorithm delivered good performance, and was chosen to establish the predictive model. The important features were then analyzed and parameters of the model adjusted to develop the best prediction model, which accurately described the C/D ratio of LTG, especially in the intermediate-to-high range (≥ 22.1 μg mL−1 g−1 day), as illustrated by a minimal bias (mean relative error (%) = + 3%), good precision (MAE = 8.7 μg mL−1 g−1 day), and a high percentage of predictions within ± 20% of the empirical values (60.47%). This is the first study, to the best of our knowledge, to use ML algorithms to predict the C/D ratio of LTG. The results here can help clinicians adjust doses of LTG administered to patients to minimize adverse reactions.
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Affiliation(s)
- Xiuqing Zhu
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Wencan Huang
- Department of Pharmacy, Guangzhou Bureau of Civil Affairs Psychiatric Hospital, Guangzhou, 510430, China
| | - Haoyang Lu
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Zhanzhang Wang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Xiaojia Ni
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Jinqing Hu
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Shuhua Deng
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Yaqian Tan
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Lu Li
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Ming Zhang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Chang Qiu
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China
| | - Yayan Luo
- Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China.,Institute of Neuropsychiatry, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China
| | - Hongzhen Chen
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China
| | - Shanqing Huang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China
| | - Tao Xiao
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China
| | - Dewei Shang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China. .,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China.
| | - Yuguan Wen
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China. .,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, 510370, China.
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Hotta K, Ishida T, Noritake KI, Kita K, Mano Y. Quantitative and qualitative application of a novel capillary microsampling device, Microsampling Wing™ (MSW), using antiepileptic drugs in rats. J Pharm Biomed Anal 2020; 194:113788. [PMID: 33281005 DOI: 10.1016/j.jpba.2020.113788] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/04/2020] [Accepted: 11/20/2020] [Indexed: 01/11/2023]
Abstract
A novel microsampling device, namely, the Microsampling Wing™ (MSW), was evaluated using three anti-epileptic drugs (AEDs): carbamazepine, lamotrigine, and phenytoin. A simultaneous assay method of the three AEDs was developed and qualified via liquid chromatography with tandem mass spectrometry. Using 2.8 μL plasma, the three AEDs were quantifiable from 1 or 2 ng/mL. According to the intra-assay reproducibility assessment and additional validation parameters, the established method is reproducible. To apply the device to a pharmacokinetic (PK) study in rats, a cocktail of the three AEDs was orally administered to rats. Whole blood samples were serially collected using the MSW device and a glass capillary from the tail vein, and plasma samples (each 2.8 μL) from each device were assayed to compare PK parameters. The PK parameters of the three AEDs were similar between the two devices. A metabolite identification study was also conducted after oral administration of carbamazepine to rats. At least seven metabolites were detected in plasma, and the major metabolite was carbamazepine 10,11-epoxide, which is in accordance with the reported results. These findings suggest that the MSW device is a useful microsampling device for PK and metabolite identification studies.
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Affiliation(s)
- Koichiro Hotta
- Drug Metabolism and Pharmacokinetics, Eisai Co., Ltd., Tokodai 5-1-3, Tsukuba-shi, Ibaraki, 300-2635, Japan
| | - Tomomi Ishida
- Drug Metabolism and Pharmacokinetics, Eisai Co., Ltd., Tokodai 5-1-3, Tsukuba-shi, Ibaraki, 300-2635, Japan
| | - Ken-Ichi Noritake
- Preclinical Safety Research Unit, Tsukuba R&D Supporting Division, Sunplanet Co., Ltd., Japan
| | - Kenji Kita
- Bioanalysis Unit, Tsukuba R&D Supporting Division, Sunplanet Co., Ltd., Tokodai 5-1-3, Tsukuba-shi, Ibaraki, 300-2635, Japan
| | - Yuji Mano
- Drug Metabolism and Pharmacokinetics, Eisai Co., Ltd., Tokodai 5-1-3, Tsukuba-shi, Ibaraki, 300-2635, Japan.
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US FDA-validated green GC-MS method for analysis of gabapentin, tramadol and/or amitriptyline mixtures in biological fluids. Bioanalysis 2020; 12:1521-1533. [PMID: 33118848 DOI: 10.4155/bio-2020-0217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Mixtures of gabapentin, tramadol and/or amitriptyline are usually recommended for treatment of neuropathic pain. Materials & methods/results: A novel GC-MS/MS method was developed to assess the studied mixture whether in pure forms or human biological fluids (plasma/urine). The chromatographic detection was performed using MS detector applying the selected ion-monitoring mode. An (Agilent, CA, USA) GC-MS with triple axis single quadrupole detector unit was used for the analysis equipped with HP-5MS (5% phenyl methyl siloxane) column. Helium was the carrier gas and positive electron impact ionization mode was applied. Conclusion: The developed method was able to assess the mixture components simultaneously within six minutes. Validation of the method was assured according to US FDA guidelines and Eco-Scale assessment.
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Faught E. Measure for Measure: Measuring the Usefulness of Measuring Antiseizure Medication Levels. Epilepsy Curr 2020; 20:132-133. [PMID: 32550829 PMCID: PMC7281894 DOI: 10.1177/1535759720915845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Therapeutic Drug Monitoring of Newer Antiepileptic Drugs: A Randomized Trial for
Dosage Adjustment Aícua-Rapún I, André P, Rossetti AO, et al. Ann Neurol.
2020;87(1):22-29. doi:10.1002/ana.25641. Objective: Therapeutic drug monitoring (TDM) of antiepileptic drugs (AEDs) is widely
established for older generation AEDs, whereas there is limited evidence about newer
AEDs. Our aim is to assess the benefit of TDM of newer generation AEDs in epilepsy.
Methods: We performed a randomized, controlled trial comparing systematic with
rescue TDM of lamotrigine, levetiracetam, oxcarbazepine, topiramate, brivaracetam,
zonisamide, or pregabalin. Participants were adults with epilepsy, in whom treatment
with newer generation AEDs was initiated or needed adjustment. In the systematic TDM
arm, AED plasma levels were available at each appointment, whereas in the rescue TDM
arm, levels were known only if a study end point was reached (inefficacy or adverse
events). The primary outcome was the proportion of participants who followed 1 year
without reaching one of the predefined end points. Results: A total of 151
participants were enrolled; global retention in the study was similar in both arms
(56% overall, 58% in the systematic, and 53% in the rescue TDM arm,
P = .6, Cox regression). There was no difference in terms of
outcome regarding treatment efficacy or tolerability. Partial adherence of
clinicians to TDM (adjusting or not AED dosage based on blood levels) did not
explain this lack of benefit. Interpretation: This study provides class A evidence
that systematic drug-level monitoring of newer generation AEDs does not bring
tangible benefits in the management of patients with epilepsy. Poor correlation
between clinical effects and drug levels likely accounts for this finding. However,
TDM is useful in several situations, such as pregnancy, as well as when there are
compliance issues.
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Hashimoto Y, Kotake K, Watanabe N, Fujiwara T, Sakamoto S. Lamotrigine in the maintenance treatment of bipolar disorder. Hippokratia 2020. [DOI: 10.1002/14651858.cd013575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Kazumasa Kotake
- Okayama Saiseikai General Hospital; Department of Pharmacy; Kita-Ku Okayama Japan
| | - Norio Watanabe
- Kyoto University Graduate School of Medicine/School of Public Health; Department of Health Promotion and Human Behavior; Yoshida Konoe-cho, Sakyo-ku Kyoto Kyoto Japan 606-8501
| | - Takashi Fujiwara
- Kurashiki Central Hospital; Department of Otolaryngology; 1-1-1 Miwa Kurashiki Okayama Japan 710-8602
| | - Shinji Sakamoto
- Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Department of Neuropsychiatry; Okayama Okayama Japan
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Kim H, Kim DW, Lee ST, Byun JI, Seo JG, No YJ, Kang KW, Kim D, Kim KT, Cho YW, Yang KI. Antiepileptic Drug Selection According to Seizure Type in Adult Patients with Epilepsy. J Clin Neurol 2020; 16:547-555. [PMID: 33029959 PMCID: PMC7541973 DOI: 10.3988/jcn.2020.16.4.547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022] Open
Abstract
Epilepsy is a common neurological disorder that is mainly treated using antiepileptic drugs. Several antiepileptic drugs such as phenobarbital, phenytoin, primidone, and ethosuximide were developed in the early 20th century. More than 10 types of antiepileptic drugs have been developed since the 1990s, and there are now more than 20 antiepileptic drugs in active clinical use. The choice of antiepileptic drugs is based on the clinical features of the seizure types, electroencephalogram findings, epileptic syndrome, and drug stability. Currently there are 19 antiepileptic drugs approved by the Korean Food and Drug Administration, 18 of which (with the exclusion of brivaracetam) are covered by the National Health Insurance Service in Korea. We reviewed the selection of antiepileptic drugs according to the classification of epileptic seizures.
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Affiliation(s)
- Hyeyun Kim
- Department of Neurology, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Jung Ick Byun
- Department of Neurology, Kyunghee University Hospital at Gangdong, Seoul, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University, School of Medicine, Daegu, Korea
| | - Yong Won Cho
- Department of Neurology, Keimyung University, School of Medicine, Daegu, Korea.
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea.
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Ruiz-Garzon JA, Rojas-Velandia CA, Calderon-Ospina CA. Drug Therapeutic Failures as a Cause of Admission to an Intensive Care Unit at a University Hospital. J Res Pharm Pract 2019; 8:168-172. [PMID: 31728349 PMCID: PMC6830022 DOI: 10.4103/jrpp.jrpp_18_69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/20/2019] [Indexed: 11/04/2022] Open
Abstract
Objective Drug therapeutic failures (TFs) are included in pharmacovigilance reporting, as some authors consider them a type of adverse drug reaction. Given their high frequency in Colombia, we studied their importance as a cause of admission to an intensive care unit (ICU). Methods This was a cross-sectional observational study. Clinical records of patients who arrived at the emergency service of a third-care level university hospital were reviewed. Information was collected by a resident in clinical toxicology, and each case was validated and analyzed by a research team using the algorithm proposed by Vaca González and Schumock and Thornton criteria for preventability to evaluate the existence of possible medication errors. Findings In total, 697 clinical records were evaluated and 18 patients presented TFs (2.6%, 95% confidence interval 1.5%-4.1%) as the cause of admission to the ICU. The most frequent TFs were seizures (56%) and hypertension (28%). The most commonly associated medications were valproic acid (28%) and losartan (28%). Ten cases (56%) were associated with drug misuse and the same number of cases was preventable, according to Schumock and Thornton criteria. Conclusion This is the first study assessing TFs as a cause of admission to the ICU in the Colombian population. The frequency of TFs in our study was similar to that described in the literature; being the most common cause the inappropriate drug use, particularly for drugs with complex kinetics, such as antiepileptic drugs.
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Affiliation(s)
| | | | - Carlos-Alberto Calderon-Ospina
- Department of Biomedical Sciences, Pharmacology Unit, Universidad del Rosario, Bogotá, Colombia.,Center for Research in Genetics and Genomics, GENIUROS Research Group, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
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Kuczynska J, Karas-Ruszczyk K, Zakrzewska A, Dermanowski M, Sienkiewicz-Jarosz H, Kurkowska-Jastrzebska I, Bienkowski P, Konopko M, Dominiak M, Mierzejewski P. Comparison of plasma, saliva, and hair lamotrigine concentrations. Clin Biochem 2019; 74:24-30. [PMID: 31672648 DOI: 10.1016/j.clinbiochem.2019.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/08/2019] [Accepted: 09/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND In some clinical situations (pregnancy, aging, drug resistance, toxicity), measurements of lamotrigine plasma levels may be reliable. Limited studies indicate that saliva and hair could be alternative sources for monitoring lamotrigine therapy. The drug content in hair can also be used to assess the history of drug therapy and to ascertain long-term patient compliance. The aims of this study were to 1) determine the correlations among plasma, saliva, and hair lamotrigine concentrations, 2) evaluate saliva as an alternative matrix for monitoring drug levels and 3) evaluate hair as a source of information on adherence to antiepileptic treatment and on the correlation of hair concentrations with clinical outcomes in patients with epilepsy. METHODS Plasma, saliva, and hair lamotrigine concentrations were measured by liquid chromatography-tandem mass spectrometry in positive ionization mode. The study group (n = 85) was recruited among the epileptic patients at the Institute of Psychiatry and Neurology, Warsaw, Poland. RESULTS Plasma concentrations were not influenced by sex, age, or the concomitant use of other antiepileptic drugs. Lamotrigine saliva and plasma concentrations were strongly correlated (r = 0.82, p < 0.001). Lamotrigine hair concentrations were correlated with the plasma concentrations (r = 0.53, p < 0.001) and daily dose in mg/kg (r = 0.23, p = 0.024). The analysis revealed no significant correlation between lamotrigine hair levels and the number of seizures in the previous 3 months (r = -0.1, p > 0.05). CONCLUSIONS The lamotrigine saliva concentration is strongly correlated with its plasma level, and saliva can be used as an alternative matrix to plasma for monitoring. Lamotrigine can also be successfully measured in hair, and the drug levels in hair tend to be correlated with the levels in plasma. However, lamotrigine levels in hair may not correspond to clinical outcomes (i.e., seizure episodes).
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Affiliation(s)
- Julita Kuczynska
- Department of Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland.
| | | | - Alicja Zakrzewska
- Department of Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Michał Dermanowski
- Department of Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | | | | | | | - Magdalena Konopko
- 1st Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Monika Dominiak
- Department of Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Paweł Mierzejewski
- Department of Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland
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Giri TK, Chakrabarty S, Ghosh B. Non-Invasive Extraction of Gabapentin for Therapeutic Drug Monitoring by Reverse Iontophoresis: Effect of pH, Ionic Strength, and Polyethylene Glycol 400 in the Receiving Medium. CURR PHARM ANAL 2019. [DOI: 10.2174/1573412914666180910115059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Monitoring of plasma concentrations is a necessity for narrow therapeutic index
potent drugs. Development of non-invasive methods can save the patients from the trauma of needles
and hence is considered as a research priority.
Introduction:
Gabapentin, an anti-epileptic drug requires therapeutic monitoring because of its narrow
therapeutic index. The objective of the study was to develop a suitable method for the non-invasive
extraction of gabapentin for the same.
Methods:
Transdermal reverse iontophoresis was performed using pig ear skin as a barrier membrane.
Three compartment iontophoretic cells were used for the extraction study. Extractions were carried out
under low intensity electric field (current intensity- 0.5 mA/cm2, electrical field approximately 5 V).
The donor compartment was charged with aqueous gabapentin (10 µg/ml in phosphate buffer of pH
7.4). For studying the effect of receiving vehicle (pH, ionic strength, and enhancer) on the extraction
efficiency of gabapentin, the two receiver chambers were charged with media having varying concentration
of these factors. Drug content was determined by HPLC.
Results:
Compared to other pHs, cumulative extraction of gabapentin at pH 5 was significantly higher
at both anode and cathode (p<0.001). At low ionic strength, extraction of gabapentin increased linearly
with the increase in concentration of ions up to a certain value but at very high ionic strength the pattern
reversed. Similar results were obtained with enhancer (polyethylene glycol 400). Extraction increased
with increase in polyethylene glycol 400 up to 3% and then decreased.
Conclusion:
Extraction flux can be optimized by manipulation of the receiver media.
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Affiliation(s)
- Tapan Kumar Giri
- NSHM College of Pharmaceutical Technology, NSHM Knowledge Campus, Kolkata Group of Institutions, 124 BL Saha Road, Kolkata-700053, West Bengal, India
| | - Subhasis Chakrabarty
- NSHM College of Pharmaceutical Technology, NSHM Knowledge Campus, Kolkata Group of Institutions, 124 BL Saha Road, Kolkata-700053, West Bengal, India
| | - Bijaya Ghosh
- NSHM College of Pharmaceutical Technology, NSHM Knowledge Campus, Kolkata Group of Institutions, 124 BL Saha Road, Kolkata-700053, West Bengal, India
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A repository of protein abundance data of drug metabolizing enzymes and transporters for applications in physiologically based pharmacokinetic (PBPK) modelling and simulation. Sci Rep 2019; 9:9709. [PMID: 31273226 PMCID: PMC6609630 DOI: 10.1038/s41598-019-45778-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/04/2019] [Indexed: 01/09/2023] Open
Abstract
Population factors such as age, gender, ethnicity, genotype and disease state can cause inter-individual variability in pharmacokinetic (PK) profile of drugs. Primarily, this variability arises from differences in abundance of drug metabolizing enzymes and transporters (DMET) among individuals and/or groups. Hence, availability of compiled data on abundance of DMET proteins in different populations can be useful for developing physiologically based pharmacokinetic (PBPK) models. The latter are routinely employed for prediction of PK profiles and drug interactions during drug development and in case of special populations, where clinical studies either are not feasible or have ethical concerns. Therefore, the main aim of this work was to develop a repository of literature-reported DMET abundance data in various human tissues, which included compilation of information on sample size, technique(s) involved, and the demographic factors. The collation of literature reported data revealed high inter-laboratory variability in abundance of DMET proteins. We carried out unbiased meta-analysis to obtain weighted mean and percent coefficient of variation (%CV) values. The obtained %CV values were then integrated into a PBPK model to highlight the variability in drug PK in healthy adults, taking lamotrigine as a model drug. The validated PBPK model was extrapolated to predict PK of lamotrigine in paediatric and hepatic impaired populations. This study thus exemplifies importance of the DMET protein abundance database, and use of determined values of weighted mean and %CV after meta-analysis in PBPK modelling for the prediction of PK of drugs in healthy and special populations.
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Eto D, Tanaka R, Suzuki Y, Sato Y, Itoh H. Comparison of performance characteristics between high-performance liquid chromatography and latex agglutination turbidimetric immunoassay for therapeutic drug monitoring of zonisamide. J Clin Lab Anal 2019; 33:e22940. [PMID: 31218755 PMCID: PMC6757127 DOI: 10.1002/jcla.22940] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/22/2019] [Accepted: 05/15/2019] [Indexed: 12/02/2022] Open
Abstract
Background Recently, the Nanopia® TDM Zonisamide reagent using the latex particle‐enhanced turbidimetric immunoassay (LTIA) method was developed. The aim of this study was to compare the differences in serum zonisamide (ZNS) concentrations quantified by the high‐performance liquid chromatography (HPLC) method and the LTIA method using a TBA‐25FR analyzer. Methods A total of 78 samples from 33 patients were quantified by both HPLC and LTIA methods. Deproteinization was used as pretreatment for the HPLC method. The ZNS concentrations quantified by two methods were compared. Results The HPLC method had intra‐ and inter‐day precision lower than 1.86% and 9.00%, and accuracy better than 2.44% and 6.33%, respectively. The LTIA method showed intra‐ and inter‐day precision lower than 2.50% and 5.20%, and accuracy better than 15.80% and 10.60%, respectively. The lower limits of quantification for the HPLC and LTIA methods were 1.0 and 5.0 µg/mL, respectively. The ZNS concentration quantified by the HPLC method correlated strongly with that by the LTIA method (r = 0.953, P < 0.001). A Bland‐Altman plot suggested no systematic error between ZNS concentrations quantified by HPLC and LTIA methods. Conclusion This study confirmed no differences between the concentrations quantified by the HPLC and LTIA methods at both high and low concentrations, demonstrating the confidence of measurement by the LTIA method.
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Affiliation(s)
- Daiki Eto
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
| | - Yosuke Suzuki
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
| | - Yuhki Sato
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, Yufu-shi, Oita, Japan
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Clinically Relevant Effect of UGT1A4*3 on Lamotrigine Serum Concentration Is Restricted to Postmenopausal Women-A Study Matching Therapeutic Drug Monitoring and Genotype Data From 534 Patients. Ther Drug Monit 2019; 40:567-571. [PMID: 30086088 DOI: 10.1097/ftd.0000000000000540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have reported inconsistent findings regarding the impact of the UGT1A4*3 variant allele on lamotrigine (LTG) exposure. As no studies have controlled for nongenetic factors, the aim of this study was to compare serum concentrations of LTG in carriers versus noncarriers of UGT1A4*3 adjusting for differences in age, sex, and valproic acid (VPA) comedication. METHODS Matched data on serum concentration of LTG and UGT1A4 genotype patients with known information about VPA comedication were included retrospectively from a therapeutic drug monitoring service. Linear mixed-model analysis was used to evaluate the impact of the UGT1A4*3 variant on dose-adjusted serum concentrations (C/D ratio) of LTG. Subanalyses were performed to assess the impact of UGT1A4*3 in relation to age, sex, and VPA comedication. RESULTS In total, 534 patients (1735 LTG serum concentrations) were included. In the study population, UGT1A4*3 carriers (n = 87; 16.3%) were estimated to have a 13% lower LTG C/D ratio compared with noncarriers (P = 0.01). Subanalyses showed that the quantitative impact of UGT1A4*3 was greatest in postmenopausal women (>50 years) without VPA comedication. In these patients (n = 99), UGT1A4*3 carriers displayed a 40% lower LTG C/D ratio than noncarriers (P = 0.001). The UGT1A4*3 variant had no significant effect on LTG C/D ratio in the other subpopulations (P > 0.1). Regardless of patient subgroup, the concomitant use of VPA was the strongest determinant of LTG exposure by increasing the C/D ratio 2.5-fold (P < 0.001). CONCLUSIONS This study shows that UGT1A4*3 generally has a modest impact on LTG exposure, but it could lead to clinically relevant lowering in LTG serum concentration among postmenopausal women. The clinical impact of UGT1A4*3 in these patients needs to be assessed in relation to comedication with VPA, which is associated with a substantial increase in serum concentration of LTG.
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A Population Pharmacokinetic–Pharmacogenetic Model of Lamotrigine in Chinese Children With Epilepsy. Ther Drug Monit 2018; 40:730-737. [DOI: 10.1097/ftd.0000000000000563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Kim MJ, Yum MS, Yeh HR, Ko TS, Lim HS. Pharmacokinetic and Pharmacodynamic Evaluation of Intravenous Levetiracetam in Children With Epilepsy. J Clin Pharmacol 2018; 58:1586-1596. [PMID: 30052270 DOI: 10.1002/jcph.1282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/18/2018] [Indexed: 11/08/2022]
Abstract
This study aimed to evaluate the safety and tolerability of intravenous (IV) levetiracetam (LEV) as a monotherapy in children aged 1 month-16 years and to explore the pharmacokinetics (PK) of IV LEV and the time to seizure after IV then oral administration of LEV in pediatric children with epilepsy. Children diagnosed with acute unprovoked seizures requiring in-hospital IV LEV administration were included. After administration, the clinical seizure outcomes, side effects, and the Korean-Child Behavior Checklist were monitored and the PK and repeated time to seizure were analyzed via modeling using NONMEM software. Overall, 37 children with epilepsy were enrolled and underwent a PK analysis (median age, 4.6 years; median weight, 18.0 kg). Nine children (24.3%) had seizure recurrence during the follow-up period (median, 3.8 months) and 5 children (13.5%) experienced LEV-associated adverse events such as irritability (n = 2; 5.4%) and somnolence (n = 3; 8.1%). The plasma LEV concentrations after IV LEV were best described by a one-compartment linear PK model. Only body weight was associated with both the clearance and volume of distribution of LEV. The Weibull distribution model described the time to seizure recurrence well; no statistically significant predictor for the time to seizure was identified. Therefore, IV LEV was a well-tolerated and effective alternative in children with acute unprovoked seizures, and models for the PK and time to repeated seizure recurrence after LEV were successfully developed. In particular, the current use of a weight-based IV LEV dosing regimen in pediatric children is practical.
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Affiliation(s)
- Min-Jee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Ryun Yeh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong-Seok Lim
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Noskova TY, Abaimov DA, Sariev AK, Fedin PA, Krasnikov AV, Shvedkov VV, Sejfulla RD. [The clinical significance of the lamotrigine pharmacokinetic variability]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:23-29. [PMID: 29460901 DOI: 10.17116/jnevro20181181123-29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To estimate pharmacokinetic variability of lamotrigine (LTG) and its clinical significance. MATERIAL AND METHODS One hundred patients, including 74 women, aged from 18 to 77 years (38.23±14.37 years), with focal epilepsy were examined. Monotherapy with LTG was administered to 54 patients, duotherapy to 46 patients (LTG and valproic acid combination to 27 patients, LTG and liver enzymes inducers to 19 patients). Patients underwent procedures of therapeutic drug monitoring (TDM). Minimal (Cssmin) and maximal (Cssmax) steady-state LTG plasma concentrations, and concentration-to-weight ratio (CDR) were calculated. RESULTS AND CONCLUSION In patients who used LTG in monotherapy, LTG Cssmin was 5.6±4.65 mg/l, Cssmax 7.59±5.54 mg/l. In the group that received LTG in combination with valproate, LTG Сssmin was 7.8 [5.4; 11.8] mg / l and Cssmax 11.4 [7.3; 15.3] mg/l. In the group that received LTG in combination with drug-inducers of glucuronidation, Cssmin was 2.5 [1.99; 4.32] mg/l, Cssmax 4.73 [2.91; 6.70] mg/l. Statistically significant differences in CDR parameter between groups with LTG monotherapy and duotherapy, both with inducer and with inhibitors, as well as between groups of duotherapy with inductors and with inhibitors were obtained. The results of the study indicate a pronounced pharmacokinetic variability of the LTG. Conducting TDM allows the establishment of individual therapeutic concentrations of LTG in blood plasma and setting a correction vector for antiepileptic therapy.
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Affiliation(s)
| | - D A Abaimov
- Research Center of Neurology, Moscow, Russia
| | - A K Sariev
- Research Center of Neurology, Moscow, Russia
| | - P A Fedin
- Research Center of Neurology, Moscow, Russia
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Abstract
Given the distinctive characteristics of both epilepsy and antiepileptic drugs (AEDs), therapeutic drug monitoring (TDM) can make a significant contribution to the field of epilepsy. The measurement and interpretation of serum drug concentrations can be of benefit in the treatment of uncontrollable seizures and in cases of clinical toxicity; it can aid in the individualization of therapy and in adjusting for variable or nonlinear pharmacokinetics; and can be useful in special populations such as pregnancy. This review examines the potential for TDM of newer AEDs such as eslicarbazepine acetate, felbamate, gabapentin, lacosamide, lamotrigine, levetiracetam, perampanel, pregabalin, rufinamide, retigabine, stiripentol, tiagabine, topiramate, vigabatrin, and zonisamide. We describe the relationships between serum drug concentration, clinical effect, and adverse drug reactions for each AED as well as the different analytical methods used for serum drug quantification. We discuss retrospective studies and prospective data on the serum drug concentration-efficacy of these drugs and present the pharmacokinetic parameters, oral bioavailability, reference concentration range, and active metabolites of newer AEDs. Limited data are available for recent AEDs, and we discuss the connection between drug concentrations in terms of clinical efficacy and nonresponse. Although we do not propose routine TDM, serum drug measurement can play a beneficial role in patient management and treatment individualization. Standardized studies designed to assess, in particular, concentration-efficacy-toxicity relationships for recent AEDs are urgently required.
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Affiliation(s)
- Shery Jacob
- Department of Pharmaceutics, College of Pharmacy, Gulf Medical University, University Street, P.O.Box No.4184, Ajman, UAE.
| | - Anroop B Nair
- Department of Pharmaceutics, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
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Xu S, Liu L, Chen Y, Liu M, Lu T, Wang H, Liu S, Zhao M, Zhao L. Population pharmacokinetics of lamotrigine co-administered with valproic acid in Chinese epileptic children using nonlinear mixed effects modeling. Eur J Clin Pharmacol 2018; 74:583-591. [DOI: 10.1007/s00228-018-2414-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 01/04/2018] [Indexed: 11/28/2022]
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Population Pharmacokinetics of Topiramate in Japanese Pediatric and Adult Patients With Epilepsy Using Routinely Monitored Data. Ther Drug Monit 2017; 39:124-131. [PMID: 28230619 DOI: 10.1097/ftd.0000000000000383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Topiramate is a second-generation antiepileptic drug used as monotherapy and adjunctive therapy in adults and children with partial seizures. A population pharmacokinetic (PPK) analysis was performed to improve the topiramate dosage adjustment for individualized treatment. METHODS Patients whose steady-state serum concentration of topiramate was routinely monitored at Kyoto University Hospital from April 2012 to March 2013 were included in the model-building data. A nonlinear mixed effects modeling program was used to evaluate the influence of covariates on topiramate pharmacokinetics. The obtained PPK model was evaluated by internal model validations, including goodness-of-fit plots and prediction-corrected visual predictive checks, and was externally confirmed using the validation data from January 2015 to December 2015. RESULTS A total of 177 steady-state serum concentrations from 93 patients were used for the model-building analysis. The patients' age ranged from 2 to 68 years, and body weight ranged from 8.6 to 105 kg. The median serum concentration of topiramate was 1.7 mcg/mL, and half of the patients received carbamazepine coadministration. Based on a one-compartment model with first order absorption and elimination, the apparent volume of distribution was 105 L/70 kg, and the apparent clearance was allometrically related to the body weight as 2.25 L·h·70 kg without carbamazepine or phenytoin. Combination treatment with carbamazepine or phenytoin increased the apparent clearance to 3.51 L·h·70 kg. Goodness-of-fit plots, prediction-corrected visual predictive check, and external validation using the validation data from 43 patients confirmed an appropriateness of the final model. Simulations based on the final model showed that dosage adjustments allometrically scaling to body weight can equalize the serum concentrations in children of various ages and adults. CONCLUSIONS The PPK model, using the power scaling of body weight, effectively elucidated the topiramate serum concentration profile ranging from pediatric to adult patients. Dosage adjustments based on body weight and concomitant antiepileptic drug help obtain the dosage of topiramate necessary to reach an effective concentration in each individual.
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Rodrigues C, Chiron C, Rey E, Dulac O, Comets E, Pons G, Jullien V. Population pharmacokinetics of oxcarbazepine and its monohydroxy derivative in epileptic children. Br J Clin Pharmacol 2017; 83:2695-2708. [PMID: 28771787 DOI: 10.1111/bcp.13392] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 06/27/2017] [Accepted: 07/30/2017] [Indexed: 12/31/2022] Open
Abstract
AIMS Oxcarbazepine is an antiepileptic drug with an activity mostly due to its monohydroxy derivative metabolite (MHD). A parent-metabolite population pharmacokinetic model in children was developed to evaluate the consistency between the recommended paediatric doses and the reference range for trough concentration (Ctrough ) of MHD (3-35 mg l-1 ). METHODS A total of 279 plasma samples were obtained from 31 epileptic children (age 2-12 years) after a single dose of oxcarbazepine. Concentration-time data were analysed with Monolix 4.3.2. The probability to obtain Ctrough between 3-35 mg l-1 was determined by Monte Carlo simulations for doses ranging from 10 to 90 mg kg-1 day-1 . RESULTS A parent-metabolite model with two compartments for oxcarbazepine and one compartment for MHD best described the data. Typical values for oxcarbazepine clearance, central and peripheral distribution volume and distribution clearance were 140 l h-1 70 kg-1 , 337 l 70 kg-1 , 60.7 l and 62.5 l h-1 , respectively. Typical values for MHD clearance and distribution volume were 4.11 l h-1 70 kg-1 and 54.8 l 70 kg-1 respectively. Clearances and distribution volumes of oxcarbazepine and MHD were related to body weight via empirical allometric models. Enzyme-inducing antiepileptic drugs (EIAEDs) increased MHD clearance by 29.3%. Fifty-kg children without EIAEDs may need 20-30 mg kg-1 day-1 instead of the recommended target maintenance dose (30-45 mg kg-1 day-1 ) to obtain Ctrough within the reference range. By contrast, 10-kg children with EIAEDs would need 90 mg kg-1 day-1 instead of the maximum recommended dose of 60 mg kg-1 day-1 . CONCLUSION This population pharmacokinetic model of oxcarbazepine supports current dose recommendations, except for 10-kg children with concomitant EIAEDs and 50-kg children without EIAEDs.
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Affiliation(s)
- Christelle Rodrigues
- INSERM U1129, Paris, France.,Paris Descartes University, CEA, Gif-sur-Yvette, France
| | - Catherine Chiron
- INSERM U1129, Paris, France.,Paris Descartes University, CEA, Gif-sur-Yvette, France
| | - Elisabeth Rey
- INSERM U1129, Paris, France.,Paris Descartes University, CEA, Gif-sur-Yvette, France
| | - Olivier Dulac
- INSERM U1129, Paris, France.,Paris Descartes University, CEA, Gif-sur-Yvette, France
| | - Emmanuelle Comets
- INSERM, IAME, UMR1137, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,INSERM, CIC 1414, Université Rennes 1, Rennes, France
| | - Gérard Pons
- INSERM U1129, Paris, France.,Paris Descartes University, CEA, Gif-sur-Yvette, France
| | - Vincent Jullien
- INSERM U1129, Paris, France.,Paris Descartes University, CEA, Gif-sur-Yvette, France.,Service de Pharmacologie, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015, Paris, France
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D'Anto J, Wnuk W, Rossetti AO, Decosterd LA, Buclin T, Novy J. Lamotrigine serum levels: Ceiling effect in people with epilepsy in remission? Epilepsy Behav 2017; 74:41-44. [PMID: 28686906 DOI: 10.1016/j.yebeh.2017.03.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiepileptic drug titration in epilepsy remains mostly empirical. Since in practice seizure remission may be obtained with low doses, we aimed to determine whether patients in remission have lower lamotrigine levels than those with ongoing seizures. METHODS Retrospective comparison of the distribution of lamotrigine levels among unselected patients in remission and with ongoing seizures. Remission was defined as 3 times the longuest interseizure interval and at least one year. Only trough levels were analyzed. RESULTS Between 2009 and 2014, we identified 93 adults, among whom 10 were in remission. Patients in remission had significantly (p=0.008) lower serum levels (median 2.3mg/L, range: 0.7-8.2) than those with ongoing seizures (median 5.4mg/L, range: 1.1-18.2). We did not find any patient in remission with levels higher than 8.2mg/L. Distribution of dosages also differed among the groups, but less significantly (median: 175 vs 300mg, p=0.03). CONCLUSION An association between lamotrigine serum levels and seizure response can be observed. This suggests the existence of a ceiling level, above which remission is unlikely and should prompt antiepileptic medication switch rather than further up-titration of lamotrigine in drug-naïve patients with epilepsy.
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Affiliation(s)
| | | | - Andrea O Rossetti
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Laurent A Decosterd
- Laboratory and Division of Clinical Pharmacology, Service of Biomedicine, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Thierry Buclin
- Laboratory and Division of Clinical Pharmacology, Service of Biomedicine, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Jan Novy
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland.
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