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Wahab A, Iqbal A. Black-Box Warnings of Antiseizure Medications: What is Inside the Box? Pharmaceut Med 2023; 37:233-250. [PMID: 37119452 DOI: 10.1007/s40290-023-00475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/01/2023]
Abstract
Antiseizure medications can cause serious adverse reactions and have deleterious drug interactions that often complicate the clinical management of patients. When the US Food and Drug Administration (FDA) wants to alert healthcare providers and patients about the risk of potentially serious or fatal drug reactions, the FDA requires the manufacturers of these medications to format these warnings within a "black-box" border, and prominently display this box on the first section of the package insert; such warnings are called "black-box warnings (BBWs)". The BBW is a way for the FDA to urge physicians to evaluate patients more rigorously and carefully weigh the risks and benefits, before prescribing medication that has the potential to cause serious adverse reactions, and to formulate a plan for close monitoring during therapy. The FDA BBW provides the extra layer of safety but many healthcare providers fail to comply with these warnings. Currently, there are 26 FDA-approved antiseizure medications in the US market, 38% of which have received BBWs, and most of the antiseizure medications with BBWs are older-generation drugs. Some antiseizure medications have multiple BBWs; for example, valproic acid has three BBWs including hepatotoxicity, fetal risk, and pancreatitis, carbamazepine has BBWs of serious skin and hematological reactions, and felbamate also has two BBWs including hepatic failure and aplastic anemia. The purpose of this review is to provide insight into each BBW received by antiseizure medications and discuss the FDA recommendations for evaluating the drug benefit/risk, and for monitoring parameters before the initiation of and during treatment.
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Affiliation(s)
- Abdul Wahab
- Department of Pharmacy, Emory Healthcare, Emory Decatur Hospital, Decatur, GA, 30033, USA.
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Sayin S, Bagci M. Acute lymphocytic leukemia in a patient with long-term carbamazepine exposure: Acute lymphoblastic leukemia that develops in a patient who has been using carbamazepine for a long time. J Oncol Pharm Pract 2023; 29:477-478. [PMID: 35656781 DOI: 10.1177/10781552221105856] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Carbamazepine is an antiepileptic drug used in the treatment of epilepsy, trigeminal neuralgia, and bipolar disorder. Hematological effects that may develop with this anticonvulsant; agranulocytosis, thrombocytopenia, leukopenia, aplastic anemia, eosinophilia, or pancytopenia. CASE REPORT In this article, we wanted to present a case diagnosed with acute lymphoblastic leukemia after long-term use of carbamazepine because of epilepsy. MANAGEMENT AND OUTCOME Bone marrow smear was evaluated and blastic cell infiltration was observed. The carbamazepine treatment was discontinued and standard chemotherapy was started for acute lymphoblastic leukemia (CALGB protocol). Levetiracetam was started for epilepsy. DISCUSSION Carbamazepine is an iminostilbene derivative. Carbamazepine is an antiepileptic drug that exhibits a number of side effects such as headache, abdominal pain, high blood pressure, as well as hematological disorders. In addition to causing thrombocytopenia, hypogammaglobulinemia, leukopenia, and neutropenia, it can have serious effects such as agranulocytosis, aplastic anemia, pure red cell aplasia, leukemia, or DRESS syndrome. The incidence of serious side effects from carbamazepine pharmacotherapy is low, and their exact mechanism of action is still unknown.
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Affiliation(s)
- Serhat Sayin
- Department of Hematology, Faculty of Medicine in 52993Selcuk University, Konya, Turkey
| | - Metin Bagci
- Department of Hematology, Faculty of Medicine in 52993Selcuk University, Konya, Turkey
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Batool S, Voloshyna D, Usama M, Suleman M, Sandhu QI, Nepal L, Ghobriel NG, Mengar J, Mohammed Rasmy AS. The Co-Existence of Agranulocytosis and Stevens-Johnson Syndrome (SJS) in Carbamazepine Therapy: A Case Report. Cureus 2022; 14:e28917. [PMID: 36237740 PMCID: PMC9547122 DOI: 10.7759/cureus.28917] [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] [Accepted: 09/07/2022] [Indexed: 11/30/2022] Open
Abstract
The therapeutic significance of carbamazepine in individuals with trigeminal neuralgia, epilepsy, and bipolar disorder is well recognized. Although it has high effectiveness, it raises the patient's risk for some adverse effects. The relationship between carbamazepine usage and agranulocytosis is well-established. Agranulocytosis is characterized by an unusually low number of neutrophils. This disorder poses a grave hazard to the patient since they are more likely to get potentially lethal bacterial or fungal infections. Moreover, carbamazepine is one of the most common causes of Stevens-Johnson syndrome (SJS), a severe skin condition with a high mortality rate. In cases where agranulocytosis and Stevens-Johnson syndrome coexist, the prognosis is relatively poor. We report a rare case of a patient who developed agranulocytosis and Stevens-Johnson syndrome after taking carbamazepine. Neutrophils accounted for 2.1% of the patient's differential leukocyte count. Furthermore, Naranjo's scale found a score of 8 for Stevens-Johnson syndrome, placing it in the "probable" category, while a score of 9 for agranulocytosis indicated that it was a confirmed adverse reaction to carbamazepine.
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Ghusn W, Bouchard C, Frye MA, Acosta A. Weight-centric treatment of depression and chronic pain. OBESITY PILLARS (ONLINE) 2022; 3:100025. [PMID: 37990725 PMCID: PMC10661995 DOI: 10.1016/j.obpill.2022.100025] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2023]
Abstract
Background Depression and chronic pain are two major chronic non-communicable diseases (CNCD). Considering the bidirectional relationship between obesity and CNCD, it is of the utmost importance to understand the effect of medications utilized to treat these diseases on body weight. Methods This is a clinical review on the effect of medications for depression and chronic pain on body weight. We searched PubMed, Scopus, MEDLINE, and Google Scholar databases for studies on the topic from January 1, 1950 to April 1, 2022 in English language. Additionally, we present expert opinions in the fields of obesity, depression and chronic pain, providing a weight-centric approach to treat depression and chronic pain. Results Several antidepressant and chronic pain medications are associated with weight gain. Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidases, mirtazapine and trazodone are common antidepressants that can increase body weight while bupropion is significantly associated with weight loss. Gabapentin and pregabalin are common chronic pain medications that are linked to weight gain. On the other hand, topiramate is associated with significant weight loss. Obesity, depression and chronic pain experts recommend avoiding medications that can increase body weight if another effective alternative is available. Conclusion By shifting prescribing practices toward a weight-conscious approach (i.e., switching from weight gain medications to weight loss/neutral), it is possible to mitigate the incidence of drug-induced weight gain.
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Affiliation(s)
- Wissam Ghusn
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Mark A. Frye
- Department of Psychiatry, Mayo Clinic, Rochester, MN, USA
| | - Andres Acosta
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Sangüesa E, Cirujeda C, Concha J, Padilla PP, García CB, Ribate MP. Exploring the usefulness of plasma level determination and pharmacogenetics for patients treated with clozapine. Per Med 2022; 19:181-192. [PMID: 35259926 DOI: 10.2217/pme-2021-0029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Aims: The aims of the present study were to assess the variance of plasma clozapine (CLZ) levels and to identify the influence of sociodemographic and pharmacogenetic factors on it and to introduce these tools in a clinical setting. Patients & methods: CLZ concentration was measured and genetic variants of CLZ pharmacokinetic and pharmacodynamic factors were assessed in 23 patients with psychotic disorders. Results: A significant association between mean concentration/dose ratio (C/D) and smoking status, age and weight were found. There was a significant difference in mean plasma CLZ levels and gender. The rs762551 AA genotype in smokers had a significantly lower C/D. Conclusion: In addition to classical factors, monitoring of plasma concentrations together with pharmacogenetics led to greater individualization of treatment.
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Affiliation(s)
- Estela Sangüesa
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - Christine Cirujeda
- Centro Neuropsiquiátrico Nuestra Señora del Carmen. Hermanas Hospitalarias, Zaragoza, Spain
| | - Julia Concha
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - Pedro Pablo Padilla
- Centro Neuropsiquiátrico Nuestra Señora del Carmen. Hermanas Hospitalarias, Zaragoza, Spain
| | - Cristina Belén García
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
| | - María Pilar Ribate
- Pharmacy degree, Faculty of Health Sciences, Universidad San Jorge, Villanueva de Gállego, Zaragoza, Spain
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Chen L, Chia C, Saha A. Drug Reaction with Eosinophilia and Systemic Symptoms and Agranulocytosis Presenting as Cervical Lymphadenopathy. Hosp Pharm 2022; 57:130-134. [PMID: 35521028 PMCID: PMC9065511 DOI: 10.1177/0018578721990899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare cause of cervical lymphadenopathy. It is a potentially life-threatening hypersensitivity reaction, commonly characterized by fever, rash, hematological abnormalities, and multi-organ involvement. Its association with agranulocytosis is even rarer, with fewer than 10 cases describing the coexistence of DRESS with agranulocytosis reported in the English literature. Case Summary: An otherwise well 40-year-old female presented with a sore throat and cervical lymphadenopathy, with investigations revealing DRESS and agranulocytosis secondary to carbamazepine. Conclusion: DRESS and agranulocytosis are serious, potentially life-threatening adverse drug reactions which can initially present as cervical lymphadenopathy. As carbamazepine is considered first-line therapy for certain chronic neuropathic conditions such as trigeminal neuralgia, clinicians should be aware of the varying clinical presentations of both conditions.
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Affiliation(s)
- Laura Chen
- Monash Health, Clayton, VIC, Australia,Laura Chen, Department of Dentistry, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia.
| | | | - Anik Saha
- Monash Health, Clayton, VIC, Australia
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El-Shimi OS, Farag AA, El-Rebigi AM, Kharboush TG, Bayomy HES, Khashaba RA. Carbamazepine-Induced Hematological and Immunological Alterations in Egyptian Children with Idiopathic Generalized Seizures. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1736156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractCarbamazepine (CBZ) is one of the oldest antiepileptic drugs (AEDs) that is still used for the treatment of tonic-clonic seizures in children. Long-term use of AEDs induces potential toxic effects that may remain undetermined for a long time. Earlier studies have revealed a wide spectrum of hematological toxicities associated with CBZ. This study was conducted to unveil the toxic effects of carbamazepine as an antiepileptic monotherapy on hematological and immunological parameters in a group of Egyptian pediatric patients using it for different durations. Fifty pediatric epileptics of either sex were enrolled; 38 were taking CBZ as antiepileptic monotherapy for ≥ 6 months and 12 were newly diagnosed untreated patients. Hematological and immunological parameters studied were compared with their age and sex-matched 15 controls and among groups. CBZ was found more toxic for total leukocyte count, lymphocyte count, serum IgA and IgM levels (p < 0.001, 0.001, < 0.001, < 0.001, respectively). Hemoglobin level, platelets count, serum C4 level and IgA were negatively correlated with serum CBZ level (Spearman's rho = – 0.62, – 0.42, – 0.34, – 0.13; p < 0.001, 0.008, 0.04, 0.44, respectively). CBZ treatment duration associated inversely with platelets, lymphocyte, and eosinophil counts (p < 0.001, 0.03, 0.01, respectively). Epileptic children on CBZ monotherapy had their hematologic and immunologic systems affected, which mandates routine monitoring of these children.
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Affiliation(s)
- Ola Samir El-Shimi
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Amina Ali Farag
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Benha University, Benha, Egypt
| | | | | | - Hanaa El-Sayed Bayomy
- Department Public Health and Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt
| | - Rana Atef Khashaba
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Benha University, Benha, Egypt
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Eshiet UI, Ubaka CM, Ukwe CV. Infrequent Monitoring of the Effects of Valproate and Carbamazepine Therapy in Patients With Epilepsy in Nigeria. J Cent Nerv Syst Dis 2020; 12:1179573520925934. [PMID: 32536783 PMCID: PMC7268118 DOI: 10.1177/1179573520925934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/17/2020] [Indexed: 11/17/2022] Open
Abstract
Background Carbamazepine and valproate are widely used in the treatment of epileptic seizures. However, these agents exhibit certain adverse effects including hematopoietic disorders (carbamazepine) and severe hepatotoxicity (valproate). Purpose To determine the extent of monitoring of the hematologic effects of carbamazepine as well as the extent of monitoring of the hepatic effects of valproate in patients with epilepsy receiving treatment with these agents. Method A cross-sectional antiepileptic drug use study using case notes of patients with epilepsy managed at the neurologic clinics of 2 tertiary medical facilities in Nigeria between January and December 2017. Results Carbamazepine was the most frequently prescribed antiepileptic drug (48.24%), followed by valproate (29.34%) and levetiracetam (9.24%). Pretreatment monitoring of hematologic effect was carried out in only 61.11% of patients placed on carbamazepine therapy while follow-up monitoring was done in 3.7% of these patients. Also, in patients placed on valproate therapy, pretreatment and follow-up monitoring of the hepatic effect was done in only 33.71% and 19.0% of the patients, respectively. Conclusions The extent of monitoring of the hematologic effects of carbamazepine, as well as the hepatic effects of valproate in the cohort studied, is poor.
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Affiliation(s)
- Unyime Israel Eshiet
- Department of Clinical Pharmacy and Biopharmacy, University of Uyo, Uyo, Nigeria
| | | | - Chinwe Victoria Ukwe
- Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria, Nsukka, Nigeria
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Mupparapu M, Ko E, Omolehinwa TT, Chhabra A. Neurologic Disorders of the Maxillofacial Region. Dent Clin North Am 2019; 64:255-278. [PMID: 31735232 DOI: 10.1016/j.cden.2019.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The maxillofacial region is complex in its anatomy and in its variation in the presentation of neurologic disorders. The diagnosis and management of neurologic disorders in clinical practice remains a challenge. A good understanding of the neurologic disorder in its entirety helps dentists in the diagnosis and appropriate referral to a specialist for further investigations and management of the condition. Neurologic disorders described in this article are under broad categories of sensory and motor disturbances as well as movement disorders and infections. This article summarizes the most common maxillofacial neurologic disorders that dentists might encounter in clinical practice.
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Affiliation(s)
- Mel Mupparapu
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA.
| | - Eugene Ko
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA
| | - Temitope T Omolehinwa
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA
| | - Avneesh Chhabra
- UT Southwestern Medical Center, Harry Hines Boulevard, Dallas, TX 75390, USA
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Membrane Stabilizer Medications in the Treatment of Chronic Neuropathic Pain: a Comprehensive Review. Curr Pain Headache Rep 2019; 23:37. [DOI: 10.1007/s11916-019-0774-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Avinash A, Amberkar VM, Kunder SK, Madhyastha S, Meenakumari K. Carbamazepine-induced Life-threatening Stevens-Johnson Syndrome and Agranulocytosis: The Maiden Case. J Clin Diagn Res 2017; 10:FD01-FD03. [PMID: 28208879 DOI: 10.7860/jcdr/2016/23748.9065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 09/26/2016] [Indexed: 11/24/2022]
Abstract
Stevens-Johnson syndrome is one of the few dermatological emergencies in clinical practice. The syndrome is often secondary to the usage of drugs, of which allopurinol, penicillins, sulfa drugs, ibuprofen, sodium valproate, phenytoin, lamotrigine and carbamazepine are commonly implicated. Agranulocytosis is the existence of a clinically significant reduction in neutrophil count. This condition is a serious threat to the patient, as he/she is at a greater risk of contracting bacterial or fungal infections, which may prove to be fatal. The co-existence of Stevens-Johnson syndrome and agranulocytosis in the same patient further increases the risk of morbidity and mortality. To the best of our knowledge, there are no reports available in the existing literature, of cases that were reported with both these life-threatening conditions in a single patient, at the same point of time. This is a case narrative of a patient who presented with both Stevens-Johnson syndrome and agranulocytosis, following the administration of carbamazepine The patient's differential leucocyte count revealed a neutrophil proportion of 2.33%. A causality assessment done using Naranjo's algorithm showed that carbamazepine "definitely" caused Agranulocytosis and "probably" caused Stevens-Johnson syndrome.
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Affiliation(s)
- A Avinash
- Postgraduate, Department of Pharmacology, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
| | - V Mohanbabu Amberkar
- Associate Professor, Department of Pharmacology, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
| | - Sushil Kiran Kunder
- Postgraduate, Department of Pharmacology, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
| | - Sharath Madhyastha
- Assistant Professor, Department of Medicine, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
| | - K Meenakumari
- Associate Professor, Department of Pharmacology, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
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Jha A, Abhilash KPP, Bandhyopadhyay R, Victor PJ. Hypoglycemia - a rare complication of carbamazepine overdose. Indian J Pharmacol 2015; 46:651-2. [PMID: 25538340 PMCID: PMC4264084 DOI: 10.4103/0253-7613.144941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/24/2014] [Accepted: 07/28/2014] [Indexed: 11/23/2022] Open
Abstract
Carbamazepine overdose usually presents with neurological manifestations such as ataxia, seizures and altered sensorium or cardiac manifestations that include tachycardia, hypotension and ventricular extra-systoles. We report a patient with carbamazepine overdose who manifested recurrent hypoglycemia on the third and fourth day following ingestion that resolved with supportive therapy.
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Affiliation(s)
- Avanish Jha
- Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Rini Bandhyopadhyay
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Peter John Victor
- Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
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Demler TL, Trigoboff E. Are clozapine blood dyscrasias associated with concomitant medications? INNOVATIONS IN CLINICAL NEUROSCIENCE 2011; 8:35-41. [PMID: 21637633 PMCID: PMC3105838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Clozapine is an atypical antipsychotic agent used for refractory schizophrenia. It has a relatively low affinity for D2 receptors and thus is associated with a lower incidence of extrapyramidal side effects when compared with typical antipsychotics. Clozapine as monotherapy can induce a rare, but serious, blood dyscrasia called agranulocytosis; however, some concomitant medications may contribute to the risk. Examples of these medications are mood-stabilizing antiepileptic drugs, such as carbamazepine, and sulfonamide antibiotics, such as sulfamethoxazole. There were no studies at the writing of this article examining the effect of concomitant medications on clozapine blood dyscrasias, and few published reports describing enhanced bone marrow suppression in those taking clozapine. The primary objective of this study was to evaluate the effect of concomitant medications used in a state psychiatric hospital on clozapine-induced blood dyscrasias. This was a retrospective record review of adverse drug reactions reported at an adult inpatient state psychiatric center. The records for a pilot sample of 26 patients with reported clozapine-related adverse drug reactions between January 1, 2007, and June 30, 2009, were reviewed. Fundamental to this study were reported adverse drug reactions defined as 1) substantial drops in white blood cell or absolute neutrophil count (a substantial drop in white blood cell is >3,000 or absolute neutrophil count is >1,500 over a 3-week period); 2) mild leukopenia/granulocytopenia; and 3) moderate-severe leukopenia/granulocytopenia. Concomitant medications were examined for contributions to an increased potential for clozapine-induced blood dyscrasias. Other data collected included demographic information (age, gender, ethnicity), medical and psychiatric diagnoses, dose and duration of medications, and changes in medications. Medications that had a statistically significant impact on the incidence of clozapine-induced blood dyscrasias are reported in this article, as well as the possible duration of medication use prior to induction of an adverse drug reaction.
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