The manifestations of metabolic acidosis during acetazolamide treatment in a cohort of pediatric idiopathic intracranial hypertension

BACKGROUND

Idiopathic intracranial hypertension is characterized by increased intracranial pressure with unidentified pathology. Despite its use as the first-line treatment, data on acetazolamide's effectiveness and safety in pediatric idiopathic intracranial hypertension is sparse. This study's objective was to assess those issues and the need for routine blood gas monitoring during treatment.

METHODS

Retrospective observational cohort study, based on multicenter computerized medical charts of pediatric patients with idiopathic intracranial hypertension diagnosed between 2007-2018 in three medical centers serving one metropolitan area (an estimated population of 400,000 children). Clinical and laboratory data of children up to 18 years old, fulfilling the Friedman criteria and taking acetazolamide, were collected and analyzed.

RESULTS

Sixty-eight patients were included with a mean acetazolamide treatment duration of 8.5 months and a median maximal dose 18 mg/kg/d. Sixty-two children had mild (76%), moderate (13%), or severe (1.5%) metabolic acidosis. At least one adverse effect (neurologic, gastrointestinal, renal) was recorded among 27% of patients. No significant difference was found between the mean pH of children with or without clinical adverse effects (p = 0.35). No correlation was found between laboratory acidosis and adverse effect severity (p = 0.3), or between median acetazolamide dose and acidosis level (p = 0.57).

CONCLUSIONS

Although laboratory finding of metabolic acidosis is common among patients with idiopathic intracranial hypertension treated with acetazolamide, it is not correlated with clinics. Therefore, we recommend sending blood tests during acetazolamide treatment based on clinical judgment. A higher resolution version of the Graphical abstract is available as Supplementary information.

Effects of acetazolamide on linear growth in children with pseudotumor cerebri syndrome

Background/introduction

While oral acetazolamide is a cornerstone of management of adult and pediatric PTCS, previous studies have suggested that acetazolamide used in children with other conditions may influence growth.

Aims and methods

Retrospective chart review involving a single tertiary medical center. Thirty-four children with definite or probable PTCS were identified. Analysis was restricted to individuals from whom anthropometric data were available before and during acetazolamide treatment (n=22).

Results

Half of individuals (n=11/22) showed a decline in BMI Z-scores. Sixty-three percent (n=14/22) showed a decrease in height Z-scores during treatment with acetazolamide; in 6 of these 14 children who had complete data, 3 showed at least a partial recovery of height Z-scores after discontinuation of acetazolamide.

Conclusion

Acetazolamide may be associated with growth suppression in some children treated for pediatric PTCS. In some cases, the growth suppression appears to reverse once the acetazolamide is stopped.

Osmoprotectants in Hybrid Liposome/HPMC Systems as Potential Glaucoma Treatment

The combination of acetazolamide-loaded nano-liposomes and Hydroxypropyl methylcellulose (HPMC) with similar components to the preocular tear film in an osmoprotectant media (trehalose and erythritol) is proposed as a novel strategy to increase the ocular bioavailability of poorly soluble drugs. Ophthalmic formulations based on acetazolamide-loaded liposomes, dispersed in the osmoprotectant solution (ACZ-LP) or in combination with HPMC (ACZ-LP-P) were characterized and in vivo evaluated. The pH and tonicity of both formulations resulted in physiological ranges. The inclusion of HPMC produced an increment in viscosity (from 0.9 to 4.7 mPa·s. 64.9 ± 2.6% of acetazolamide initially included in the formulation was retained in vesicles. In both formulations, a similar onset time (1 h) and effective time periods were observed (7 h) after a single instillation (25 μL) in normotensive rabbits' eyes. The AUC_0-8h of the ACZ-LP-P was 1.5-fold higher than of ACZ-LP (p < 0.001) and the maximum hypotensive effect resulted in 1.4-fold higher (p < 0.001). In addition, the formulation of ACZ in the hybrid liposome/HPMC system produced a 30.25-folds total increment in ocular bioavailability, compared with the drug solution. Excellent tolerance in rabbits' eyes was confirmed during the study.

Pediatric Glaucoma: Pharmacotherapeutic Options

Childhood glaucoma is a major therapeutic challenge for pediatric ophthalmologists and glaucoma specialists worldwide. Management depends on the etiology and age at presentation. A variety of drugs are available for the control of intraocular pressure in children; however, none of these drugs have been licensed by the regulatory agencies for use in children. Furthermore, evidence gained from randomized controlled trials in the pediatric population is sparse, and little is known regarding the use of newer anti-glaucoma preparations. This evidence-based review aims to discuss the available pharmacotherapeutic options for glaucoma in children. Topical adrenoceptor blockers, topical and systemic carbonic anhydrase inhibitors, prostaglandin (PG) analogs, adrenoceptor agonists, parasympathomimetics, and combined preparations are available for use in children, but usually as an off-label indication. Therefore, it is important to recognize that serious side effects have been reported, even with topical drops, and measures to reduce systemic absorption should be taken. Most drugs have been shown to have comparable ocular hypotensive effects, with the lowest occurrence of systemic side effects with PG analogs. Whereas a newly introduced prostaglandin analog, tafluprost, and some other preservative-free preparations have shown promising results in adult glaucoma patients, no pediatric reports are available as yet. Future studies may describe their role in treating pediatric glaucoma. This review also shares some suggested treatment pathways for primary congenital glaucoma (PCG), juvenile open angle glaucoma (JOAG), developmental glaucoma, aphakic/pseudophakic glaucoma, and uveitic glaucoma.

Clinical experience with long-term acetazolamide treatment in children with nondystrophic myotonias: a three-case report

BACKGROUND

Today, treatment of the nondystrophic myotonias consists of mexiletine, although care has to be taken because of the proarrhythmogenic potential of this drug. In this article, we report years of experience with the carbonic anhydrase inhibitor acetazolamide.

PATIENTS

We present three children with nondystrophic myotonias.

RESULTS

During acetazolamide treatment, symptoms and signs of myotonia decreased in our children.

CONCLUSIONS

Based on this clinical experience and the favorable pharmacologic profile of acetazolamide, it may be a good treatment option for children with nondystrophic myotonias.

The activity of lowering intraocular pressure of cassiae seed extract in a DBA/2J mouse glaucoma model

PURPOSE

To evaluate the activity of lowering intraocular pressure (IOP) by Cassiae seed in the DBA/2J mouse glaucoma model.

METHODS

Young male (mean age: 3 months) inherited glaucoma mice (BDA/2J) were enrolled in this study. To evaluate the potential of Cassiae seed in the treatment of glaucoma, all subjects were divided into 6 groups. There were 1 sham group, positive control identified as group 2 topical brimonidine and group 3 oral acetazolamide, and groups 4-6 Cassiae seed extract (CSE) groups. The lactate dehydrogenase (LDH) level in the anterior aqueous humor and the changes of IOP were investigated. Contents of total polyphenol glycosides in the CSE were measured using a high-performance liquid chromatography (HPLC) method. Chromatographic separation was performed on a Cosmosil 5C(18)-MS reverse-phase HPLC column (4.6×250-mm i.d., 5 μm) with methanol/0.1% H(3)PO(4) as the mobile phases in a gradient elution mode at a flow rate of 1.0 mL/min and an injection volume of 10 μL. The wavelength of UV detector was set at 254 nm.

RESULTS

The LDH level in the anterior aqueous humor and IOP significantly decreased after treatment with CSE. The IOP-lowering effect of CSE was comparable to those of oral acetazolamide and brimonidine instillation. There were no abnormal findings in the external appearance, and body weight change after treatment with CSE for 5 weeks. Chrysophanol and physcion were measured by an HPLC method to obtain total polyphenol glycosides of the CSE, and were involved in the IOP-lowering function.

CONCLUSION

Cassiae seed may be safe and beneficial for treating glaucoma due to its significant IOP- and LDH-lowering activities.