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Milosavljević F, Manojlović M, Matković L, Molden E, Ingelman-Sundberg M, Leucht S, Jukić MM. Pharmacogenetic Variants and Plasma Concentrations of Antiseizure Drugs: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2425593. [PMID: 39115847 PMCID: PMC11310823 DOI: 10.1001/jamanetworkopen.2024.25593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/04/2024] [Indexed: 08/11/2024] Open
Abstract
Importance Precise estimation of a patient's drug metabolism capacity is important for antiseizure dose personalization. Objective To quantify the differences in plasma concentrations for antiseizure drugs associated with variants of genes encoding drug metabolizing enzymes. Data Sources PubMed, Clinicaltrialsregister.eu, ClinicalTrials.gov, International Clinical Trials Registry Platform, and CENTRAL databases were screened for studies from January 1, 1990, to September 30, 2023, without language restrictions. Study Selection Two reviewers performed independent study screening and assessed the following inclusion criteria: appropriate genotyping was performed, genotype-based categorization into subgroups was possible, and each subgroup contained at least 3 participants. Data Extraction and Synthesis The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed for data extraction and subsequent quality, validity, and risk-of-bias assessments. The results from the included studies were pooled with random-effect meta-analysis. Main Outcomes and Measures Plasma concentrations of antiseizure drugs were quantified with the dose-normalized area under the concentration-time curve, the dose-normalized steady state concentration, or the concentrations after a single dose at standardized dose and sampling time. The ratio of the means was calculated by dividing the mean drug plasma concentrations of carriers and noncarriers of the pharmacogenetic variant. Results Data from 98 studies involving 12 543 adult participants treated with phenytoin, valproate, lamotrigine, or carbamazepine were analyzed. Studies were mainly conducted within East Asian (69 studies) or White or European (15 studies) cohorts. Significant increases of plasma concentrations compared with the reference subgroup were observed for phenytoin, by 46% (95% CI, 33%-61%) in CYP2C9 intermediate metabolizers, 20% (95% CI, 17%-30%) in CYP2C19 intermediate metabolizers, and 39% (95% CI, 24%-56%) in CYP2C19 poor metabolizers; for valproate, by 12% (95% CI, 4%-20%) in CYP2C9 intermediate metabolizers, 12% (95% CI, 2%-24%) in CYP2C19 intermediate metabolizers, and 20% (95% CI, 2%-41%) in CYP2C19 poor metabolizers; and for carbamazepine, by 12% (95% CI, 3%-22%) in CYP3A5 poor metabolizers. Conclusions and Relevance This systematic review and meta-analysis found that CYP2C9 and CYP2C19 genotypes encoding low enzymatic capacity were associated with a clinically relevant increase in phenytoin plasma concentrations, several pharmacogenetic variants were associated with statistically significant but only marginally clinically relevant changes in valproate and carbamazepine plasma concentrations, and numerous pharmacogenetic variants were not associated with statistically significant differences in plasma concentrations of antiseizure drugs.
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Affiliation(s)
- Filip Milosavljević
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
- Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, München, Germany
| | - Marina Manojlović
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Lena Matković
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
- Institute for Mental Health, Belgrade, Serbia
| | - Espen Molden
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Magnus Ingelman-Sundberg
- Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, München, Germany
| | - Marin M. Jukić
- Department of Physiology, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
- Pharmacogenetics Section, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Ramakrishnan K, Kesavan R, Venkatraman S, Narayan SK, Kumar RR, Shewade D. Impact of CYP2C9*2 and *3 polymorphisms on valproate-associated adverse drug reactions in individuals living with epilepsy: a case-control study. Per Med 2023; 20:417-424. [PMID: 37811569 DOI: 10.2217/pme-2023-0033] [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] [Indexed: 10/10/2023]
Abstract
Epilepsy is characterized by repeated seizure activity. Valproate, a commonly used antiepileptic drug, shows large inter-individual variation in plasma valproic levels and causes many adverse drug reactions. Aim: To find the influence of CYP2C9*2 and *3 polymorphisms on valproate-associated adverse drug reactions and plasma valproic acid levels in people with epilepsy. Methods: We recruited 158 people with epilepsy (79 cases and 79 controls) from an epilepsy clinic. Steady-state plasma valproic acid levels were measured using liquid chromatography-mass spectrometry and genotyping of CYP2C9 variants was carried out with helps of RT-PCR. Results: The presence of a mutant heterozygous genotype showed an odds ratio (OR) of 2.82 (95% CI: 1.10-7.24) and the adjusted OR was 5.39 (95% CI: 1.69-17.16). There was no significant difference in steady-state plasma valproate concentration between genotypes. Conclusion: The presence of a mutant heterozygous CYP2C9 genotype possesses five-times the risk of developing adverse drug reactions to valproate in people with epilepsy.
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Zheng XX, You YX, Zhao LL, Du Y, Xu SQ, Tang DQ. Effects of UGT1A, CYP2C9/19 and ABAT polymorphisms on plasma concentration of valproic acid in Chinese epilepsy patients. Pharmacogenomics 2023; 24:153-162. [PMID: 36718958 DOI: 10.2217/pgs-2022-0156] [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: 02/01/2023] Open
Abstract
Aim: To evaluate the association between genetic polymorphisms and plasma concentration-to-dose ratio of valproic acid (CDRV) in Chinese epileptic patients. Methods: A total of 46 epileptic patients treated with valproic acid therapy were enrolled. 18 SNPs in nine genes related to valproic acid were directly sequenced with Sanger methods. Results: Patients carrying UGT1A6 heterozygous genotypes had significantly lower CDRV than those carrying the wild-type genotypes. In contrast, patients with the homozygote genotypes of CYP2C9 and ABAT had higher CDRV than those with the wild-type genotypes and patients with the heterozygous genotypes of CYP2C19 had higher CDRV. Conclusion: Detection of genetic polymorphism in these genes might facilitate an appropriate dose of valproic acid for epileptic patients. Further studies with larger cohorts are necessary to underpin these observations.
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Affiliation(s)
- Xiao-Xiao Zheng
- Department of Clinical Pharmacy, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, 269 University Road, Xuzhou City, Jiangsu Province, P.R. China
| | - Yu-Xin You
- Jiangsu Key Laboratory of New Drug Research & Clinical Pharmacy, Xuzhou Medical University, Xuzhou, 221004, China
| | - Lin-Lin Zhao
- Jiangsu Key Laboratory of New Drug Research & Clinical Pharmacy, Xuzhou Medical University, Xuzhou, 221004, China
| | - Yan Du
- Jiangsu Key Laboratory of New Drug Research & Clinical Pharmacy, Xuzhou Medical University, Xuzhou, 221004, China.,Department of Pharmaceutical Analysis, Xuzhou Medical University, Xuzhou, 221004, China
| | - Sheng-Qiu Xu
- Department of Clinical Pharmacy, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, 269 University Road, Xuzhou City, Jiangsu Province, P.R. China
| | - Dao-Quan Tang
- Jiangsu Key Laboratory of New Drug Research & Clinical Pharmacy, Xuzhou Medical University, Xuzhou, 221004, China.,Department of Pharmaceutical Analysis, Xuzhou Medical University, Xuzhou, 221004, China
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Significance of UGT1A6, UGT1A9, and UGT2B7 genetic variants and their mRNA expression in the clinical outcome of renal cell carcinoma. Mol Cell Biochem 2022:10.1007/s11010-022-04637-4. [PMID: 36571650 DOI: 10.1007/s11010-022-04637-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 12/07/2022] [Indexed: 12/27/2022]
Abstract
UDP-glucuronosyltransferase (UGT) metabolizes a number of endogenous and exogenous substrates. Renal cells express high amounts of UGT; however, the significance of UGT in patients with renal cell carcinoma (RCC) remains unknown. In this study, we profile the mRNA expression of UGT subtypes (UGT1A6, UGT1A9, and UGT2B7) and their genetic variants in the kidney tissue of 125 Japanese patients with RCC (Okayama University Hospital, Japan). In addition, we elucidate the association between the UGT variants and UGT mRNA expression levels and clinical outcomes in these patients. The three representative genetic variants, namely, UGT1A6 541A > G, UGT1A9 i399C > T, and UGT2B7-161C > T, were genotyped, and their mRNA expression levels in each tissue were determined. We found that the mRNA expression of the three UGTs (UGT1A6, UGT1A9, and UGT2B7) are significantly downregulated in RCC tissues. Moreover, in patients with RCC, the UGT2B7-161C > T variant and high UGT2B7 mRNA expression are significantly correlated with preferable cancer-specific survival (CSS) and overall survival (OS), respectively. As such, the UGT2B7-161C > T variant and UGT2B7 mRNA expression level were identified as significant independent prognostic factors of CSS and CSS/OS, respectively. Taken together, these findings indicate that UGT2B7 has a role in RCC progression and may, therefore, represent a potential prognostic biomarker for patients with RCC.
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Zhao W, Meng H. Effects of genetic polymorphism of drug-metabolizing enzymes on the plasma concentrations of antiepileptic drugs in Chinese population. Bioengineered 2022; 13:7709-7745. [PMID: 35290166 PMCID: PMC9278974 DOI: 10.1080/21655979.2022.2036916] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/02/2022] Open
Abstract
As a chronic brain disease, epilepsy affects ~50 million people worldwide. The traditional antiepileptic drugs (AEDs) are widely applied but showing various problems. Although the new AEDs have partially solved the problems of traditional AEDs, the current clinical application of traditional AEDs are not completely replaced by new drugs, particularly due to the large individual differences in drug plasma concentrations and narrow therapeutic windows among patients. Therefore, it is still clinically important to continue to treat patients using traditional AEDs with individualized therapeutic plans. To date, our understanding of the molecular and genetic mechanisms regulating plasma concentrations of AEDs has advanced rapidly, expanding the knowledge on the effects of genetic polymorphisms of genes encoding drug-metabolizing enzymes on the plasma concentrations of AEDs. It is increasingly imperative to summarize and conceptualize the clinical significance of recent studies on individualized therapeutic regimens. In this review, we extensively summarize the critical effects of genetic polymorphisms of genes encoding drug-metabolizing enzymes on the plasma concentrations of several commonly used AEDs as well as the clinical significance of testing genotypes related to drug metabolism on individualized drug dosage. Our review provides solid experimental evidence and clinical guidance for the therapeutic applications of these AEDs.
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Affiliation(s)
- Weixuan Zhao
- Department of Neurology, the First Hospital of Jilin University, Jilin University, Changchun, China
| | - Hongmei Meng
- Department of Neurology, the First Hospital of Jilin University, Jilin University, Changchun, China
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Iannaccone T, Sellitto C, Manzo V, Colucci F, Giudice V, Stefanelli B, Iuliano A, Corrivetti G, Filippelli A. Pharmacogenetics of Carbamazepine and Valproate: Focus on Polymorphisms of Drug Metabolizing Enzymes and Transporters. Pharmaceuticals (Basel) 2021; 14:204. [PMID: 33804537 PMCID: PMC8001195 DOI: 10.3390/ph14030204] [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: 01/11/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 12/18/2022] Open
Abstract
Pharmacogenomics can identify polymorphisms in genes involved in drug pharmacokinetics and pharmacodynamics determining differences in efficacy and safety and causing inter-individual variability in drug response. Therefore, pharmacogenomics can help clinicians in optimizing therapy based on patient's genotype, also in psychiatric and neurological settings. However, pharmacogenetic screenings for psychotropic drugs are not routinely employed in diagnosis and monitoring of patients treated with mood stabilizers, such as carbamazepine and valproate, because their benefit in clinical practice is still controversial. In this review, we summarize the current knowledge on pharmacogenetic biomarkers of these anticonvulsant drugs.
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Affiliation(s)
- Teresa Iannaccone
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (T.I.); (V.M.); (F.C.); (V.G.); (B.S.); (A.I.); (A.F.)
| | - Carmine Sellitto
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (T.I.); (V.M.); (F.C.); (V.G.); (B.S.); (A.I.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Valentina Manzo
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (T.I.); (V.M.); (F.C.); (V.G.); (B.S.); (A.I.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Francesca Colucci
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (T.I.); (V.M.); (F.C.); (V.G.); (B.S.); (A.I.); (A.F.)
| | - Valentina Giudice
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (T.I.); (V.M.); (F.C.); (V.G.); (B.S.); (A.I.); (A.F.)
| | - Berenice Stefanelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (T.I.); (V.M.); (F.C.); (V.G.); (B.S.); (A.I.); (A.F.)
| | - Antonio Iuliano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (T.I.); (V.M.); (F.C.); (V.G.); (B.S.); (A.I.); (A.F.)
| | - Giulio Corrivetti
- European Biomedical Research Institute of Salerno (EBRIS), 84125 Salerno, Italy;
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (T.I.); (V.M.); (F.C.); (V.G.); (B.S.); (A.I.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
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Impact of Age and Genotype on Serum Concentrations of Valproic Acid and Its Hepatotoxic Metabolites in Chinese Pediatric Patients With Epilepsy. Ther Drug Monit 2020; 42:760-765. [DOI: 10.1097/ftd.0000000000000751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Xu ZY, Guo HL, Li L, Zhang M, Jing X, Xu ZJ, Qiu JC, Lu XP, Ding XS, Chen F, Xu J. Genetic and Non-genetic Factors Contributing to the Significant Variation in the Plasma Trough Concentration-to-Dose Ratio of Valproic Acid in Children With Epilepsy. Front Pediatr 2020; 8:599044. [PMID: 33553069 PMCID: PMC7855978 DOI: 10.3389/fped.2020.599044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
Objective: This study was conducted to evaluate the potential genetic and non-genetic factors contributing to plasma trough concentration-to-dose (C 0/D) ratio of valproic acid (VPA) in pediatric patients with epilepsy. Study Design: A single-center, retrospective cohort study was performed by collecting data from 194 children aged 1-14 years between May 2018 and November 2018. The oral solution (n = 135) group and the sustained-release (SR) tablet group (n = 59) were defined, and the plasma VPA C 0 was measured. Twenty-six single-nucleotide polymorphisms (SNPs) were chosen for genotyping with the MassARRAY system. A multiple logistic regression model was used for data analysis. Results: Body weight (BW) and age were positively correlated with the C 0/D ratio in 194 patients, but the positive correlation disappeared after the patients were divided into oral solution and SR tablet subgroups. The average C 0/D ratio was significantly increased by 2.11-fold (P = 0.000) in children who took VPA SR tablets compared with children who were administered VPA oral solutions. No significant association between genetic variants and the C 0/D ratio was found, even for the five well-studied SNPs, namely UGT2B7 G211T, C802T, C161T, T125C, and CYP2C9 * 3 A1075C. However, a significant association between the C 0/D ratio and UGT1A6/9 Del>A (rs144486213) was observed in the VPA oral solution group, but not in the VPA SR tablet group. Conclusions: The dosage forms of sodium valproate, rather than BW, age, or genetic polymorphisms, significantly affected the VPA C 0/D ratios in pediatric patients with epilepsy. Based on our findings, switching the dosage form between solution and SR tablet should be performed cautiously. Total daily dose adjustment should be considered, and the plasma concentration, seizure-control effect, and adverse drug reaction should also be monitored very closely.
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Affiliation(s)
- Ze-Yue Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hong-Li Guo
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ling Li
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Min Zhang
- Department of Pharmacy, Boston Medical Center, Boston, MA, United States
| | - Xia Jing
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ze-Jun Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jin-Chun Qiu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiao-Peng Lu
- Department of Neurology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xuan-Sheng Ding
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Feng Chen
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
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Zhang H, Zhang W, Li Y, Yan J, Zhang J, Wang B. Correlations between UGT2B7∗2 gene polymorphisms and plasma concentrations of carbamazepine and valproic acid in epilepsy patients. Brain Dev 2018; 40:100-106. [PMID: 28958730 DOI: 10.1016/j.braindev.2017.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 08/19/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The study aims to detect the polymorphisms in uridine diphosphate glucuronyl transferase (UGT) 2B7∗2 and investigate the corresponding effects on the blood concentrations of valproic acid (VPA) and carbamazepine (CBZ). METHODS A chemiluminescence immunoassay analyzer was used to detect the plasma concentrations of VPA or CBZ in patients. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was used to analyze UGT2B7∗2 gene polymorphisms. RESULTS A total of 117 patients were enrolled under the VPA group, out of which 84 patients were aged 6years or older. Comparison of the blood concentrations of VPA showed significant differences among patients with the three standard genotypes (mutant, heterozygous, and wild-type) based on one-way ANOVA (F=4.386, p=0.016). In addition, comparison of the blood concentrations among the three genotypes in the CBZ group (78 patients) showed no significant differences based on analysis using ANOVA (F=0.897, p=0.412). CONCLUSION The UGT2B7∗2 gene polymorphisms significantly affect the standard blood concentrations of VPA, but not CBZ.
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Affiliation(s)
- Hui Zhang
- Department of Neurology, Baotou Central Hospital, Baotou 014040, China
| | - Wenfang Zhang
- Department of Neurology, The Fourth Affiliated Hospital of Baotou Medical College, Baotou 014032, China.
| | - Yuechun Li
- Department of Neurology, Baotou Central Hospital, Baotou 014040, China
| | - Jie Yan
- Department of Neurology, Baotou Central Hospital, Baotou 014040, China
| | - Jinfeng Zhang
- Department of Neurology, Baotou Central Hospital, Baotou 014040, China
| | - Baojun Wang
- Department of Neurology, Baotou Central Hospital, Baotou 014040, China
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Wang P, Lin XQ, Cai WK, Xu GL, Zhou MD, Yang M, He GH. Effect of UGT2B7 genotypes on plasma concentration of valproic acid: a meta-analysis. Eur J Clin Pharmacol 2017; 74:433-442. [DOI: 10.1007/s00228-017-2395-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/04/2017] [Indexed: 01/11/2023]
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Sun Y, Yu J, Yuan Q, Wu X, Wu X, Hu J. Early post-traumatic seizures are associated with valproic acid plasma concentrations and UGT1A6/CYP2C9 genetic polymorphisms in patients with severe traumatic brain injury. Scand J Trauma Resusc Emerg Med 2017; 25:85. [PMID: 28841884 PMCID: PMC5574127 DOI: 10.1186/s13049-017-0382-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/30/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Seizure is a common complication for severe traumatic brain injury (TBI). Valproic acid (VPA) is a first-line antiepileptic drug, though its metabolism is affected by genetic polymorphisms and varies between individuals. The aim of this study was to investigate such association and to explore its influence on the occurrence of early post-traumatic seizure. METHODS A prospective case control study was conducted from 2012 to 2016 recruiting adult patients with severe TBI. Electroencephalograph (EEG) monitoring was performed approximately 4 h for each patient from day 1 to day 7 after injury. If seizures were detected, EEG monitoring was extended until 12 h after seizures being controlled. Genetic polymorphisms in UGT1A6, UGT2B7, CYP2C9, and CYP2C19 were analyzed in association with daily VPA plasma concentrations, adjusted dosages, and occurrence of seizures. RESULTS Among the 395 recruited patients, eighty-three (21%) had early post-traumatic seizure, of which 30 (36.14%) were non-convulsive. Most seizures were first detected on day 1 (34.94%) and day 2 (46.99%) after injury. Patients with seizure had longer ICU length of stay and relatively lower VPA plasma concentrations. Patients with UGT1A6_19T > G/541A > G/552A > C double heterozygosities or CYP2C9 extensive metabolizers (EMs) initially had lower adjusted VPA plasma concentrations (power >0.99) and accordingly require higher VPA dosages during later time of treatment (power >0.99). The odds ratio indicated a higher risk of early post-traumatic seizure occurrence in male patients (OR 1.96, 95% CI 1.01-3.81, p = 0.043), age over 65 (OR 2.13, 95% CI 1.01-4.48), and with UGT1A6_19T > G/541A > G/552A > C double heterozygosities (OR 2.38, 95% CI 1.11-5.10, p = 0.02), though the power of the difference was between 0.54 to 0.61. DISCUSSION Due to limited facility, the actual frequency of non-convulsive seizures is suspected to be higher than identified. There has been discrepancy regarding to genetic polymorphisms and VPA metab olism between this study and some previous reports. This could be related to confounders such as sample size, race, and patient age. Another limitation is that the case numbers of certain genotypes are limited in this study. CONCLUSIONS Continuous EEG monitoring is necessary to detect both convulsive and non-convulsive early post-traumatic seizures in severe TBI patients. UGT1A6/CYP2C9 polymorphisms have influence on VPA metabolism. UGT1A6_19T > G/541A > G/552A > C double heterozygositie is associated with occurrence of early post-traumatic seizures in addition to patients' age and gender. Further investigations with larger sample size are required to confirm the difference. TRIAL REGISTRATION Retrospectively registered with Chinese Clinical Trail Registry on 1st Jan 2016 ( ChiCTR-OPC-16007687 ).
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Affiliation(s)
- Yirui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road, Shanghai, 200040 People’s Republic of China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road, Shanghai, 200040 People’s Republic of China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road, Shanghai, 200040 People’s Republic of China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road, Shanghai, 200040 People’s Republic of China
| | - Xuehai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road, Shanghai, 200040 People’s Republic of China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road, Shanghai, 200040 People’s Republic of China
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13
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Analysis of the Variables Influencing Valproic Acid Concentration in the Serum and Cerebrospinal Fluid of Chinese Patients After Craniotomy. Ther Drug Monit 2017; 39:450-456. [PMID: 28604475 DOI: 10.1097/ftd.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Valproic acid (VPA) has been widely used in Chinese patients after craniotomy. Many studies have focused on the influencing factors of VPA serum concentration, but conclusions are sometimes paradoxical. Furthermore, the concentration of VPA in the cerebrospinal fluid (CSF) has been rarely reported. In the present study, VPA CSF concentrations were measured, and the potential factors influencing serum concentration and CSF distribution of VPA were investigated. In addition, the functional relationship between serum and CSF concentration was explored. METHODS Subjects were patients who underwent craniotomy and were administrated with VPA and had a lumbar puncture. Serum and CSF VPA concentrations were measured by use of the Abbott i1000 system. CYP2C9 (430 C>T, 1075 A>C, 1076 T>C, 1080 C>G), UGT1A6 (541 A>G, 552 A>C), UGT2B7 (211 G>T, 802 C>T), and ABCB1 (1236 C>T, 2677 G>T/A, 3435 C>T) genotypes were determined by direct sequencing. Information, such as age, gender, and height, was collected, and their effect on serum and CSF VPA concentrations was investigated by univariate analysis and multiple linear regression analysis. RESULTS First, the concomitant use of carbapenems (β' = -0.422) and UGT1A6 (552 AA → AC) (β' = -0.249) had a significant negative correlation with the weight-adjusted VPA serum concentration (C:W ratio), whereas CYP2C9 (1075 AA → AC) (β' = 0.186) and gender (female compared with male) (β' = 0.322) showed a positive correlation with VPA serum C:W ratio. The coefficient of determination (R) was only 0.348. Second, the relationship between the serum concentration and the CSF square root of the concentration (R = 0.705) had a better linear fit. Third, serum VPA concentration (β' = 0.810), concomitant use of glycerol fructose (β' = 0.160), and age (≥65 compared with <65) (β' = 0.118) showed a positive correlation (R = 0.748) with the variability of square root of the concentration of the CSF. CONCLUSIONS In Chinese patients, after craniotomy, female patients with 1 or more of CYP2C9 (1075 AC) and UGT1A6 (552 AA) genotypes required a lower VPA dosage compared with male patient. There was a better-fitted linear relationship between VPA serum and the square root of CSF concentrations. CSF VPA concentrations were relatively stable, with only age and the use of glycerol fructose having a small influence.
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