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Deng DZ, Husari KS. Approach to Patients with Seizures and Epilepsy: A Guide for Primary Care Physicians. Prim Care 2024; 51:211-232. [PMID: 38692771 DOI: 10.1016/j.pop.2024.02.008] [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: 05/03/2024]
Abstract
Seizures and epilepsy are common neurologic conditions that are frequently encountered in the outpatient primary care setting. An accurate diagnosis relies on a thorough clinical history and evaluation. Understanding seizure semiology and classification is crucial in conducting the initial assessment. Knowledge of common seizure triggers and provoking factors can further guide diagnostic testing and initial management. The pharmacodynamic characteristics and side effect profiles of anti-seizure medications are important considerations when deciding treatment and counseling patients, particularly those with comorbidities and in special populations such as patient of childbearing potential.
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Affiliation(s)
- Doris Z Deng
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, 600 N. Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA
| | - Khalil S Husari
- Department of Neurology, Comprehensive Epilepsy Center, Johns Hopkins University, 600 N. Wolfe Street, Meyer 2-147, Baltimore, MD 21287, USA.
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Abady MM, Jeong JS, Kwon HJ. Simultaneous quantification of 11 antiepileptic drugs using limited isotope-labeled internal standards in LC-MS/MS: An accuracy assessment. J Chromatogr B Analyt Technol Biomed Life Sci 2024; 1240:124143. [PMID: 38761469 DOI: 10.1016/j.jchromb.2024.124143] [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: 01/31/2024] [Revised: 03/28/2024] [Accepted: 04/28/2024] [Indexed: 05/20/2024]
Abstract
This study aims to establish an LC-MS/MS method to simultaneously analyze 11 antiepileptic drugs with a particular focus on maintaining accuracy while reducing the number of isotope-labeled internal standards employed for cost-effectiveness. By applying a water/acetonitrile gradient elution containing 0.1 % formic acid and 2 mM ammonium formate as the mobile phase, optimal sensitivity for the target drugs could be obtained in positive ESI mode in LC-MS/MS. After optimizing various extraction techniques, extraction with 70 % acetonitrile was selected as it provided good recoveries (>93 %) for all targets without matrix effects. Accuracies within 3 % were achieved from the combination of six internal standards, while accuracies of 5 % and 10 % were obtained by reducing the number of internal standards to four and two, respectively, for more economical analysis. The accuracy of the established method was maintained in hyperglycemia, hyperlipidemia, and hyperalbuminemia sera, suggesting that it can be successfully applied to individual serum samples with various properties.
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Affiliation(s)
- Mariam M Abady
- Organic Metrology Group, Korea Research Institute of Standards and Science, Yuseong-gu, Daejeon 34113, Republic of Korea; Department of Bio-Analytical Science, University of Science and Technology, 217 Gajeong-ro, Yuseong-gu, Daejeon 34113, Republic of Korea; Department of Nutrition and Food Science, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Ji-Seon Jeong
- Organic Metrology Group, Korea Research Institute of Standards and Science, Yuseong-gu, Daejeon 34113, Republic of Korea; Department of Bio-Analytical Science, University of Science and Technology, 217 Gajeong-ro, Yuseong-gu, Daejeon 34113, Republic of Korea
| | - Ha-Jeong Kwon
- Organic Metrology Group, Korea Research Institute of Standards and Science, Yuseong-gu, Daejeon 34113, Republic of Korea.
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Panda PK, Bhardwaj S, Murugan VK, Elwadhi A, Dhamija P, Tiwari L, Sharawat IK. Early versus late switch over of antiseizure medications from intravenous to the oral route in children with seizures: Single-blinded, randomized controlled trial (ELAIO trial). Epilepsy Res 2024; 202:107360. [PMID: 38652997 DOI: 10.1016/j.eplepsyres.2024.107360] [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: 01/16/2024] [Revised: 03/18/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Early switch-over of anti-seizure medications (ASMs) from intravenous to oral route may reduce the duration of hospitalization, drug acquisition costs, and behavioral upset in hospitalized children with seizures. OBJECTIVE The primary objective was to compare short-term seizure recurrence within 1 week in hospitalized children aged 1 month to 18 years with new-onset/breakthrough seizures after an early versus late switch-over from intravenous to the oral route of ASMs. Secondary objectives were to compare the incidence of status epilepticus, duration of hospital stay, drug acquisition costs, and caregiver-reported satisfaction scores in both groups. METHODS In this single-blind randomized controlled trial, patients with seizures were categorized based on the number of ASMs required and the history of status epilepticus. Patients in each category were randomized in a 1:1 ratio into either early or late switch-over (ES or LS) groups. In the ES groups, ASMs were tapered one-by-one between 0 and 24 hours of seizure freedom, while in the LS groups, they were tapered one-by-one between 24 and 48 hours of seizure freedom. RESULTS A total of 112 children were enrolled in the study, with 56 in each arm. Seizure recurrence at 1 week and 12 weeks was comparable in ES and LS groups (3/55 vs. 1/54 at 1 week, p=0.61; 7/49 vs. 6/49 at 12 weeks, p=0.98). Drug acquisition costs were significantly lower in the ES group (393±274 vs. 658±568 INR, p=0.002). Thrombophlebitis and dysphoria were significantly more common in the LS group (p=0.008 and 0.03, respectively). CONCLUSION The early switch-over of ASMs from intravenous to oral route is safe without any significant increased risk of short-term seizure recurrence and also associated with a reduction in the incidence of thrombophlebitis and ASM acquisition costs. TRIAL REGISTRATION NO CTRI/2021/03/032145.
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Affiliation(s)
- Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Sanjot Bhardwaj
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Vignesh Kaniyappan Murugan
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Aman Elwadhi
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Puneet Dhamija
- Department of Pharmacology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Lokesh Tiwari
- Pediatric Intensive Care Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
| | - Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India.
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Marinescu SC(N, Apetroaei MM, Nedea MI(I, Arsene AL, Velescu BȘ, Hîncu S, Stancu E, Pop AL, Drăgănescu D, Udeanu DI. Dietary Influence on Drug Efficacy: A Comprehensive Review of Ketogenic Diet-Pharmacotherapy Interactions. Nutrients 2024; 16:1213. [PMID: 38674903 PMCID: PMC11054576 DOI: 10.3390/nu16081213] [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: 03/28/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
It is widely acknowledged that the ketogenic diet (KD) has positive physiological effects as well as therapeutic benefits, particularly in the treatment of chronic diseases. Maintaining nutritional ketosis is of utmost importance in the KD, as it provides numerous health advantages such as an enhanced lipid profile, heightened insulin sensitivity, decreased blood glucose levels, and the modulation of diverse neurotransmitters. Nevertheless, the integration of the KD with pharmacotherapeutic regimens necessitates careful consideration. Due to changes in their absorption, distribution, metabolism, or elimination, the KD can impact the pharmacokinetics of various medications, including anti-diabetic, anti-epileptic, and cardiovascular drugs. Furthermore, the KD, which is characterised by the intake of meals rich in fats, has the potential to impact the pharmacokinetics of specific medications with high lipophilicity, hence enhancing their absorption and bioavailability. However, the pharmacodynamic aspects of the KD, in conjunction with various pharmaceutical interventions, can provide either advantageous or detrimental synergistic outcomes. Therefore, it is important to consider the pharmacokinetic and pharmacodynamic interactions that may arise between the KD and various drugs. This assessment is essential not only for ensuring patients' compliance with treatment but also for optimising the overall therapeutic outcome, particularly by mitigating adverse reactions. This highlights the significance and necessity of tailoring pharmacological and dietetic therapies in order to enhance the effectiveness and safety of this comprehensive approach to managing chronic diseases.
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Affiliation(s)
- Simona Cristina (Nicolescu) Marinescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Amethyst Radiotherapy Center, 42, Drumul Odăi, 075100 Otopeni, Romania
| | - Miruna-Maria Apetroaei
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Marina Ionela (Ilie) Nedea
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Andreea Letiția Arsene
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Marius Nasta Institute of Pneumophthiology, 90, Viilor Street, 050159 Bucharest, Romania
| | - Bruno Ștefan Velescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Sorina Hîncu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Fundeni Clinical Institute, 258, Fundeni Street, 022328 Bucharest, Romania
| | - Emilia Stancu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Anca Lucia Pop
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Doina Drăgănescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
| | - Denisa Ioana Udeanu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania (A.L.A.); (B.Ș.V.); (S.H.); (E.S.); (A.L.P.); (D.D.); (D.I.U.)
- Marius Nasta Institute of Pneumophthiology, 90, Viilor Street, 050159 Bucharest, Romania
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Zhang J, Zuo H, Fu Y, Cao Y, Li Q, Zhang Q, Zheng Y, Wang Y, Wu D, Chen W, Fang J. Intranasal delivery of phenytoin loaded layered double hydroxide nanoparticles improves therapeutic effect on epileptic seizures. J Nanobiotechnology 2024; 22:144. [PMID: 38566094 PMCID: PMC10985904 DOI: 10.1186/s12951-024-02405-8] [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: 11/06/2023] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
Improving the efficiency of antiseizure medication entering the brain is the key to reducing its peripheral toxicity. A combination of intranasal administration and nanomedicine presents a practical approach for treating epileptic seizures via bypassing the blood-brain barrier. In this study, phenytoin (PHT) loaded layered double hydroxide nanoparticles (BSA-LDHs-PHT) were fabricated via a coprecipitation - hydrothermal method for epileptic seizure control. In this study, we expound on the preparation method and characterization of BSA-LDHs-PHT. In-vitro drug release experiment shows both rapid and continuous drug release from BSA-LDHs-PHT, which is crucial for acute seizure control and chronic epilepsy therapy. In-vivo biodistribution assays after intranasal administration indicate excellent brain targeting ability of BSA-LDHs. Compared to BSA-Cyanine5.5, BSA-LDHs-Cyanine5.5 were associated with a higher brain/peripheral ratio across all tested time points. Following intranasal delivery with small doses of BSA-LDHs-PHT, the latency of seizures in the pentylenetetrazole-induced mouse models was effectively improved. Collectively, the present study successfully designed and applied BSA-LDHs-PHT as a promising strategy for treating epileptic seizures with an enhanced therapeutic effect.
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Affiliation(s)
- Jingxin Zhang
- Department of Neurology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China
| | - Huali Zuo
- The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China
| | - Yanlu Fu
- Department of Neurology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China
| | - Yina Cao
- Department of Neurology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China
| | - Qiwei Li
- Department of Neurology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China
| | - Qi Zhang
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Yuyi Zheng
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Yi Wang
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Di Wu
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Weiyu Chen
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China.
| | - Jiajia Fang
- Department of Neurology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, China.
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Costa B, Vale N. Virus-Induced Epilepsy vs. Epilepsy Patients Acquiring Viral Infection: Unravelling the Complex Relationship for Precision Treatment. Int J Mol Sci 2024; 25:3730. [PMID: 38612542 PMCID: PMC11011490 DOI: 10.3390/ijms25073730] [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: 12/07/2023] [Revised: 01/04/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
The intricate relationship between viruses and epilepsy involves a bidirectional interaction. Certain viruses can induce epilepsy by infecting the brain, leading to inflammation, damage, or abnormal electrical activity. Conversely, epilepsy patients may be more susceptible to viral infections due to factors, such as compromised immune systems, anticonvulsant drugs, or surgical interventions. Neuroinflammation, a common factor in both scenarios, exhibits onset, duration, intensity, and consequence variations. It can modulate epileptogenesis, increase seizure susceptibility, and impact anticonvulsant drug pharmacokinetics, immune system function, and brain physiology. Viral infections significantly impact the clinical management of epilepsy patients, necessitating a multidisciplinary approach encompassing diagnosis, prevention, and treatment of both conditions. We delved into the dual dynamics of viruses inducing epilepsy and epilepsy patients acquiring viruses, examining the unique features of each case. For virus-induced epilepsy, we specify virus types, elucidate mechanisms of epilepsy induction, emphasize neuroinflammation's impact, and analyze its effects on anticonvulsant drug pharmacokinetics. Conversely, in epilepsy patients acquiring viruses, we detail the acquired virus, its interaction with existing epilepsy, neuroinflammation effects, and changes in anticonvulsant drug pharmacokinetics. Understanding this interplay advances precision therapies for epilepsy during viral infections, providing mechanistic insights, identifying biomarkers and therapeutic targets, and supporting optimized dosing regimens. However, further studies are crucial to validate tools, discover new biomarkers and therapeutic targets, and evaluate targeted therapy safety and efficacy in diverse epilepsy and viral infection scenarios.
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Affiliation(s)
- Bárbara Costa
- PerMed Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal;
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
| | - Nuno Vale
- PerMed Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal;
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, s/n, 4200-450 Porto, Portugal
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Gidal BE, Resnick T, Smith MC, Wheless JW. Zonisamide: A Comprehensive, Updated Review for the Clinician. Neurol Clin Pract 2024; 14:e200210. [PMID: 38170117 PMCID: PMC10759004 DOI: 10.1212/cpj.0000000000200210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/15/2023] [Indexed: 01/05/2024]
Abstract
Purpose of Review Zonisamide (ZNS) was first approved in the United States in 2000 for the adjunctive treatment of patients aged 16 years or older with partial (focal) seizures. Although ZNS has been proven to treat multiple seizure types, it has been largely underutilized in US clinical practice. Recent Findings Published literature demonstrated that antiseizure medications (ASMs) acting on Na+ and Ca2+ channels may add beneficial effects in many seizure types by reducing seizure frequency and leading to overall improvements. In addition, effects of ZNS may lead to clinical improvements in Parkinson disease, alcohol and sleep disorders, pain, and migraine. ZNS is available in multiple formulations and is a safe and effective, broad spectrum ASM. Summary The purpose of this review was to provide an update to what is known about the efficacy of ZNS and where it shows benefits in the treatment of patients with epilepsy and other CNS disorders through its many unique mechanisms of action.
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Affiliation(s)
- Barry E Gidal
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - Trevor Resnick
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - Michael C Smith
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - James W Wheless
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
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Dhoisne M, Delval A, Mathieu D, Mazeraud A, Bournisien L, Derambure P, Tortuyaux R. Seizure recurrences in generalized convulsive status epilepticus under sedation: What are its predictors and its impact on outcome? Rev Neurol (Paris) 2023:S0035-3787(23)01112-8. [PMID: 38052663 DOI: 10.1016/j.neurol.2023.09.006] [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: 08/17/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Management of status epilepticus (SE) is focused on the early seizure termination. Refractory SE is an indication for sedation in patients with SE, but up to 75% of patients may be ventilated due to a neurological or respiratory failure. In patients requiring sedation, the clinical assessment is not sufficient to assess seizure control. Identifying those at risk of recurrent seizures could be useful to adapt their management. On the other hand, patients with low risk could benefit from an early withdrawal of sedation to avoid the impact of inappropriate sedation on outcome. OBJECTIVE To determine the prevalence and the predictors of uncontrolled SE and its impact on outcome in patients with generalized convulsive SE (GCSE) requiring mechanical ventilation (MV). METHODS We retrospectively included patients admitted to the intensive care unit with GCSE requiring MV. Uncontrolled SE was defined as persistent or recurrent seizures during sedation or within 24hours following withdrawal. A multivariable logistic regression model was used to assess the associated factors. RESULTS Uncontrolled SE occurred in 37 out of 220 patients (17%). Persistent seizures at admission, higher SAPS II and central nervous system infection were associated with a higher risk of uncontrolled SE. Acute toxic or metabolic etiologies were associated with a decreased risk of uncontrolled SE. In a supplementary analysis, decrease of albumin blood levels was associated with uncontrolled SE. Uncontrolled SE was associated with a poor functional outcome and mortality at 90 days. CONCLUSIONS Seventeen percent of patients with a GCSE requiring MV suffered from uncontrolled SE. Etiology and persistent seizures at admission were the main predictors of uncontrolled SE. Patients with uncontrolled SE had a longer duration of sedation and MV, a poor functional outcome and a higher mortality. Further studies are required to determine the impact of continuous electroencephalogram monitoring on the clinical course.
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Affiliation(s)
- M Dhoisne
- Department of Clinical Neurophysiology, hôpital Roger-Salengro, CHU de Lille, avenue du Professeur-Emile-Laine, 59000 Lille, France
| | - A Delval
- Department of Clinical Neurophysiology, hôpital Roger-Salengro, CHU de Lille, avenue du Professeur-Emile-Laine, 59000 Lille, France; Inserm, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - D Mathieu
- Intensive Care Unit, CHU de Lille, Lille, France
| | - A Mazeraud
- Service d'anesthésie-réanimation, GHU de Paris psychiatrie et neurosciences, Paris, France; Département neurosciences, unité perception et mémoire, Institut Pasteur, Paris, France
| | - L Bournisien
- Intensive Care Unit, CHU de Lille, Lille, France
| | - P Derambure
- Department of Clinical Neurophysiology, hôpital Roger-Salengro, CHU de Lille, avenue du Professeur-Emile-Laine, 59000 Lille, France; Inserm, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - R Tortuyaux
- Department of Clinical Neurophysiology, hôpital Roger-Salengro, CHU de Lille, avenue du Professeur-Emile-Laine, 59000 Lille, France; Intensive Care Unit, CHU de Lille, Lille, France.
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9
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Prugue C, Tjiattas-Saleski L, Enkemann S. Isochromosome Mosaic Turner Syndrome With Epilepsy and Developmental Abnormalities: A Case Report. Cureus 2023; 15:e50961. [PMID: 38249224 PMCID: PMC10800156 DOI: 10.7759/cureus.50961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
Turner syndrome (TS) is a genetic disorder resulting from the partial or complete absence of one X chromosome in females. This condition gives rise to a spectrum of physical and developmental characteristics. Isochromosome mosaic Turner syndrome (IMTS) is a distinct form of this disorder, characterized by genetically different cell lineages, where one or more of the lineages contain an isochromosome X consisting of either p or q arms. While IMTS is relatively common, the relationship between IMTS and epilepsy along with developmental abnormalities remains an area of further investigation. An eight-year-old female presented with a seizure lasting more than 10 minutes, subsequent bilateral hand weakness, and an abnormal gait. Neurologic evaluation revealed a 24-hour amplitude-integrated electroencephalogram (EEG) demonstrating generalized sharp and slow waves increased with hyperventilation and left-sided delta activity. Both the brain magnetic resonance imaging (MRI) and repeated EEG, conducted while the patient was sedated, showed normal results. The patient was diagnosed with generalized epilepsy with underlying left hemispheric dysfunction. Early medical history revealed acid reflux, heightened sensitivity or aversion to certain textures, swallowing difficulties, attention-deficit/hyperactivity disorder, extremity clumsiness, and a focal seizure one year prior. In the following months, the patient continued having generalized tonic-clonic seizures and developed bilateral muscle weakness in her arms and legs. This prompted genetic testing, which revealed a karyotype of 45,X,t(17;20)(q23;p13)/46,X,I(X)(q10),t(17;20)(q23;p13) consistent with IMTS and an additional chromosomal translocation. This rare case highlights the potential association between IMTS and the development of epilepsy, emphasizing the importance of a multidisciplinary approach in evaluating TS patients. There is a need for further research that explores the genetic link between TS variants and epilepsy, as well as other intellectual disorders.
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Affiliation(s)
- Cesar Prugue
- Medical School, Edward Via College of Osteopathic Medicine-Carolinas, Spartanburg, USA
| | | | - Steven Enkemann
- Genetics, Edward Via College of Osteopathic Medicine-Carolinas, Spartanburg, 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 2023:100680. [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 request, 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 visit 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, 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, 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, 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, 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, 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, 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, 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 and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Jing Liu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, Taiwan
| | - Po-Ru Chen
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center, 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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Abo Al-Azayem S, Kishk NA, Shamloul R, Attia A, Elsayed RM, Magdy R. Patterns and predictors of sexual dysfunction in women with epilepsy. Epilepsy Behav 2023; 147:109421. [PMID: 37677900 DOI: 10.1016/j.yebeh.2023.109421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/07/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Available data about sexual-related problems among Egyptian women with epilepsy (WWE) are scarce. Hence, this work aimed to study the pattern and predictors of sexual dysfunction in a sample of Egyptian WWE. METHODS In this cross-sectional study, sexually active WWE and age and years of marriage-matched healthy controls were included. The Female Sexual Function Index questionnaire (FSFI) was used to assess sexual function in both groups. RESULTS In the patient group (n = 142), the median age was 33 (28-39), whereas the median age of the control group (n = 142) was 33.5 (28-36). Women with epilepsy had significantly lower desire, arousal, pain, and FSFI-total scores than the control group (P = 0.001, 0.001, 0.023, 0.008, respectively). There was a significant difference between the FSFI-total score of women on polytherapy and those on monotherapy (P = 0.042), as well as between those on enzyme-inducing ASMs and those on ASMs that did not affect P450 (P = 0.032). Seizure frequency in the last three months was negatively correlated with scores of desire, arousal, lubrication, orgasm, and satisfaction (P 0.047, 0.02, 0.009, 0.013, 0.046, respectively). By multiple backward linear regression models, age, and seizure frequency were the significant predictors of the FSFI-total score (B -0.219, -0.33, respectively). CONCLUSION The pattern of sexual dysfunction among Egyptian WWE is characterized by reduced sexual desire, arousal deficits, and sexual-related pain. Seizure frequency, epilepsy duration, enzyme-inducing medications, and multiple anti-seizure medications (ASMs) may adversely affect WWE's sexual health. The only factor that could predict higher sexual dysfunction in WWE was higher seizure frequency.
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Affiliation(s)
| | - Nirmeen A Kishk
- Department of Neurology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Reham Shamloul
- Department of Neurology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Abeer Attia
- Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Radwa M Elsayed
- Department of Family Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rehab Magdy
- Department of Neurology, Faculty of Medicine, Cairo University, Cairo, Egypt.
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12
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Prasertsup W, Chomchai S, Mekavuthikul P, Phuditshinnapatra J. Phenytoin Intoxication in a Patient Receiving a Therapeutic Dose for Postoperative Seizure Prophylaxis: A Case Study. Ther Drug Monit 2023; 45:573-575. [PMID: 37705408 DOI: 10.1097/ftd.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/10/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE Phenytoin is commonly prescribed to prevent postoperative seizures. Despite the rarity of the CYP2C9 genetic polymorphism, which may result in poor phenytoin metabolism, in the Thai population, the authors report a case of phenytoin toxicity in a patient with poor metabolism administered with a standard dose of phenytoin. CASE REPORT A 58-year-old Thai woman presented to the outpatient clinic with a 2-day history of nausea, vomiting, and dizziness. She underwent craniotomy for tumor removal 2 weeks after being diagnosed with tuberculum sellae meningioma. After the surgery, she was prescribed 300 mg of phenytoin daily to prevent seizures. During the physical examination, ataxia, horizontal nystagmus, and cerebellar abnormalities were observed, with an initial serum phenytoin concentration of 58.85 mg/L. The brain imaging results were unremarkable. Omeprazole was the only recognized drug interaction; however, it is highly unlikely to account for this condition. Pharmacogenetic investigation of CYP2C9 revealed a homozygous CYP2C9*3/*3 mutation, which is indicative of suboptimal drug metabolism and can reduce phenytoin metabolism by 50%. This patient was administered repeated dosages of activated charcoal over the course of 2 days. Her symptoms eventually subsided, with the phenytoin levels dropping to 29.51 mg/L. CONCLUSIONS In the absence of an overdose history or drug-drug interaction, CYP2C9 polymorphism should be suspected in patients with phenytoin toxicity. In such situations, the phenytoin dosage must be decreased and monitored closely.
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Affiliation(s)
- Warisa Prasertsup
- Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj Poison Control Center, Bangkok, Thailand
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13
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Schmidt CT, Deligiannidis KM, Kittel-Schneider S, Frodl T, Spigset O, Paulzen M, Schoretsanitis G. Transfer of anticonvulsants and lithium into amniotic fluid, umbilical cord blood & breast milk: A systematic review & combined analysis. Prog Neuropsychopharmacol Biol Psychiatry 2023; 124:110733. [PMID: 36805301 DOI: 10.1016/j.pnpbp.2023.110733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/21/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Data on the ability of anticonvulsants and lithium to enter fetal and newborn circulation has become increasingly available; here we estimated penetration ratios in a series of matrices from combined samples of pregnant/breastfeeding women treated with anticonvulsants or lithium. METHODS We conducted a systematic literature search in PubMed/EMBASE for studies with concentrations of anticonvulsants/lithium from maternal blood, amniotic fluid, umbilical cord blood and/or breast milk. Penetration ratios were calculated by dividing the concentrations in amniotic fluid, umbilical cord plasma or breast milk by the maternal concentrations. When data from multiple studies were available, we calculated combined penetration ratios, weighting studies' mean by study size. RESULTS Ninety-one eligible studies for brivaracetam, carbamazepine, clonazepam, ethosuximide, gabapentin, lacosamide, lamotrigine, levetiracetam, lithium, oxcarbazepine, perampanel, phenobarbital, phenytoin, pregabalin, primidone, topiramate, valproate, vigabatrin and zonisamide were identified. For amniotic fluid, the highest penetration ratios were estimated for levetiracetam (mean 3.56, range 1.27-5.85, n = 2) and lowest for valproate (mean 0.11, range 0.02-1.02, n = 57). For umbilical cord plasma, oxcarbazepine had the highest ratio (mean 1.59, range 0.11-4.33, n = 12) with clonazepam having the lowest (mean 0.55, range 0.52-0.59, n = 2). For breast milk, the highest ratios were observed for oxcarbazepine (mean 3.75, range 0.5-7.0, n = 2), whereas the lowest were observed for valproate (mean 0.04, range 0.01-0.22, n = 121). DISCUSSION We observed substantial variability between anticonvulsants and lithium regarding their ability to enter fetal/newborn circulation. Assessing concentrations of anticonvulsants and lithium in maternal samples can provide a surrogate of fetal/infant exposure, although patterns of concentration-dependent effects for maternal/neonatal safety are lacking.
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Affiliation(s)
- Chiara Theresa Schmidt
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, JARA - Translational Brain Medicine, Aachen, Germany
| | - Kristina M Deligiannidis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry at the Donald and Barbara Zucker, School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; The Departments of Obstetrics & Gynecology and Molecular Medicine at the Zucker, School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sarah Kittel-Schneider
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Thomas Frodl
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, JARA - Translational Brain Medicine, Aachen, Germany
| | - Olav 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
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, JARA - Translational Brain Medicine, Aachen, Germany; Alexianer Hospital Aachen, Aachen, Germany
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry at the Donald and Barbara Zucker, School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland.
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14
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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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15
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Celdran de Castro A, Nascimento FA, Beltran-Corbellini Á, Toledano R, Garcia-Morales I, Gil-Nagel A, Aledo-Serrano Á. Levetiracetam, from broad-spectrum use to precision prescription: A narrative review and expert opinion. Seizure 2023; 107:121-131. [PMID: 37023625 DOI: 10.1016/j.seizure.2023.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
Levetiracetam (LEV) is an antiseizure medication (ASM) whose mechanism of action involves the modulation of neurotransmitters release through binding to the synaptic vesicle glycoprotein 2A. It is a broad-spectrum ASM displaying favorable pharmacokinetic and tolerability profiles. Since its introduction in 1999, it has been widely prescribed, becoming the first-line treatment for numerous epilepsy syndromes and clinical scenarios. However, this might have resulted in overuse. Increasing evidence, including the recently published SANAD II trials, suggests that other ASMs are reasonable therapeutic options for generalized and focal epilepsies. Not infrequently, these ASMs show better safety and effectiveness profiles compared to LEV (partially due to the latter's well-known cognitive and behavioral adverse effects, present in up to 20% of patients). Moreover, it has been shown that the underlying etiology of epilepsy is significantly linked to ASMs response in particular scenarios, highlighting the importance of an etiology-based ASM choice. In the case of LEV, it has demonstrated an optimal effectiveness in Alzheimer's disease, Down syndrome, and PCDH19-related epilepsies whereas, in other etiologies such as malformations of cortical development, it may show negligible effects. This narrative review analyzes the current evidence related to the use of LEV for the treatment of seizures. Illustrative clinical scenarios and practical decision-making approaches are also addressed, therefore aiming to define a rational use of this ASM.
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Jawaid W. For the love of all that is holy, stop prescribing sodium valproate and carbamazepine together. Pak J Med Sci 2023; 39:314. [PMID: 36694773 PMCID: PMC9842997 DOI: 10.12669/pjms.39.1.7281] [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: 10/25/2022] [Revised: 11/05/2022] [Accepted: 11/12/2022] [Indexed: 11/20/2022] Open
Abstract
Sodium valproate and carbamazepine are two time-tested drugs for treatment of epilepsy. Individually, they are usually excellent choices in treating a broad spectrum of epileptic seizures. They are, however, not friendly with each other. Their co-administration affects the drug levels of each other by influencing the action of hepatic enzymes. This write up attempts to give an overview of the mechanism of this drug interaction, and informs readers why this combination is a bad choice. The author hopes that this will help in raising awareness among the physicians regarding the dangers of this prescription, and in putting a full stop to this practice.
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Affiliation(s)
- Wajid Jawaid
- Correspondence: Wajid Jawaid Department of Neurology, Dow University of Health Sciences & Dr. Ruth K.M Pfau Civil Hospital, Karachi, Pakistan.
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17
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Mhaimeed N, Mhaimeed N, Shad MU. Pharmacokinetic mechanisms underlying clinical cases of valproic acid autoinduction: A review. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2022. [DOI: 10.1016/j.jadr.2022.100426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Yan R, Tuo J, Tai Z, Zhang H, Yang J, Yu C, Xu Z. Management of anti-seizure medications in lactating women with epilepsy. Front Neurol 2022; 13:1005890. [DOI: 10.3389/fneur.2022.1005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/28/2022] [Indexed: 11/18/2022] Open
Abstract
Epilepsy is a common neurological disease. At present, there are about 70 million epilepsy patients in the world, half of them are women, and 30–40% of women with epilepsy are of childbearing potential. Patients with epilepsy who are of childbearing potential face more challenges, such as seizures caused by hormonal fluctuations and the risk of adverse effects on the mother and baby from taking anti-seizure medications (ASMs). Breast milk is one of the best gifts that a mother can give her baby, and breastfeeding can bring more benefits to the baby. Compared with healthy people, people with epilepsy have more concerns about breastfeeding because they are worried that ASMs in their milk will affect the growth and development of the baby, and they are always faced with the dilemma of whether to breastfeed after childbirth. Regarding, whether women with epilepsy can breastfeed while taking ASMs, and whether breastfeeding will adversely affect the baby is still an important topic of concern for patients and doctors. This article reviews the existing research on breastfeeding-related issues in women with epilepsy to guide clinical practice, and improve the breastfeeding compliance of women with epilepsy.
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Cucchiara F, Luci G, Giannini N, Giorgi FS, Orlandi P, Banchi M, Di Paolo A, Pasqualetti F, Danesi R, Bocci G. Association of plasma levetiracetam concentration, MGMT methylation and sex with survival of chemoradiotherapy-treated glioblastoma patients. Pharmacol Res 2022; 181:106290. [DOI: 10.1016/j.phrs.2022.106290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/18/2022] [Accepted: 06/02/2022] [Indexed: 12/27/2022]
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Infection-Induced Elevated Plasma Perampanel in a Patient with Hemimegalencephaly. Case Rep Pediatr 2022; 2022:9844820. [PMID: 35529828 PMCID: PMC9076349 DOI: 10.1155/2022/9844820] [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] [Received: 10/23/2021] [Revised: 02/27/2022] [Accepted: 04/13/2022] [Indexed: 11/17/2022] Open
Abstract
Perampanel is a noncompetitive, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid glutamate receptor antagonist. Herein, we report a case of increased perampanel plasma concentration and impaired consciousness triggered by an infection. The patient had refractory epilepsy associated with hemimegalencephaly. During adolescence, perampanel (maximum dose, 10 mg, oral), valproic acid, clobazam, and lacosamide were administered for seizure control. He was admitted to our hospital with high fever, impaired consciousness, and elevated perampanel plasma level (from 1,300 to 1,790 ng/mL), but with no increase in the concentration of other antiseizure medications. Further examinations (blood, cerebrospinal fluid, brain magnetic resonance images, and electroencephalogram) revealed no physical cause for impaired consciousness. After discontinuation of perampanel, his level of consciousness gradually improved. The pharmacokinetics of perampanel may be modified by both hemimegalencephaly and infection, resulting in an elevated plasma concentration of perampanel. This case underlines the importance of monitoring perampanel plasma concentration in patients with underlying brain disease who develop an infection.
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Halimeh M, Yang Y, Sheehan T, Vieluf S, Jackson M, Loddenkemper T, Meisel C. Wearable device assessments of antiseizure medication effects on diurnal patterns of electrodermal activity, heart rate, and heart rate variability. Epilepsy Behav 2022; 129:108635. [PMID: 35278938 DOI: 10.1016/j.yebeh.2022.108635] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/04/2022] [Accepted: 02/19/2022] [Indexed: 11/03/2022]
Abstract
Patient-generated health data provide a great opportunity for more detailed ambulatory monitoring and more personalized treatments in many diseases. In epilepsy, robust diagnostics applicable to the ambulatory setting are needed as diagnosis and treatment decisions in current clinical practice are primarily reliant on patient self-reports, which are often inaccurate. Recent work using wearable devices has focused on methods to detect and forecast epileptic seizures. Whether wearable device signals may also contain information about the effect of antiseizure medications (ASMs), which may ultimately help to better monitor their efficacy, has not been evaluated yet. Here we systematically investigated the effect of ASMs on different data modalities (electrodermal activity, EDA, heart rate, HR, and heart rate variability, HRV) simultaneously recorded by a wearable device in 48 patients with epilepsy over several days in the epilepsy long-term monitoring unit at a tertiary hospital. All signals exhibited characteristic diurnal variations. HRV, but not HR or EDA-based metrics, were reduced by ASMs. By assessing multiple signals related to the autonomic nervous system simultaneously, our results provide novel insights into the effects of ASMs on the sympathetic and parasympathetic interplay in the setting of epilepsy and indicate the potential of easy-to-wear wearable devices for monitoring ASM action. Future work using longer data may investigate these metrics on multidien cycles and their utility for detecting seizures, assessing seizure risk, or informing treatment interventions.
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Affiliation(s)
- Mustafa Halimeh
- Computational Neurology, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany
| | - Yonghua Yang
- Hospital of Xi'an Jiaotong University, Pediatric Department, Shaanxi, China
| | | | | | | | | | - Christian Meisel
- Computational Neurology, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany.
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22
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Liparoti G, Burchiani B, Mencaroni E, Tripodi D, Di Cara G, Verrotti A. Individualizing doses of antiepileptic drugs. Expert Opin Drug Metab Toxicol 2022; 18:219-233. [PMID: 35523739 DOI: 10.1080/17425255.2022.2075342] [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: 12/25/2022]
Abstract
INTRODUCTION This review aims to identify the optimal therapeutic dosage of anti-epileptic drugs in terms of efficacy and safety in patients with multiple comorbidities. AREAS COVERED We have analyzed changes in terms of pharmacokinetics and pharmacodynamics of Brivaracetam, Carbamazepine, Lacosamide, Lamotrigine, Levetiracetam, Topiramate, Valproate, and Zonisamide in liver disease, chronic kidney disease, and in patients admitted to intensive care unit. Our literature search covers the past 5 years. We used PubMed, Google Scholar, and EMBASE database's to support our article. EXPERT OPINION To ensure that the patient with seizure receives the best treatment in relation to their comorbidities, careful clinical-laboratory monitoring is necessary to maximize effectiveness while maintaining safety, especially in the case of polytherapy.
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Affiliation(s)
- Giulia Liparoti
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | | | | | - Domenico Tripodi
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio"of Chieti-Pescara, Chieti, Italy
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Sinha J, Karatza E, Gonzalez D. Physiologically-based pharmacokinetic modeling of oxcarbazepine and levetiracetam during adjunctive antiepileptic therapy in children and adolescents. CPT Pharmacometrics Syst Pharmacol 2022; 11:225-239. [PMID: 34816634 PMCID: PMC8846633 DOI: 10.1002/psp4.12750] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/09/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022] Open
Abstract
Oxcarbazepine (OXZ) and levetiracetam (LEV) are two new generation anti‐epileptic drugs, often co‐administered in children with enzyme‐inducing antiepileptic drugs (EIAEDs). The anti‐epileptic effect of OXZ and LEV are linked to the exposure of OXZ’s active metabolite 10‐monohydroxy derivative (MHD) and (the parent) LEV, respectively. However, little is known about the confounding effect of age and EIAEDs on the pharmacokinetics (PKs) of MHD and LEV. To address this knowledge gap, physiologically‐based pharmacokinetic (PBPK) modeling was performed in the PK‐Sim software using literature data from children greater than or equal to 2 years of age. Age‐related changes in clearance (CL) of MHD and LEV were characterized, both in the presence (group 1) and absence (group 2) of concomitant EIAEDs. The drug‐drug interaction effect of EIAEDs was estimated as the difference in CL estimates between groups 1 and 2. PBPK modeling suggests that bodyweight normalized CL (ml/min/kg) is higher in younger children than their older counterparts (i.e., due to an influence of age). Concomitant EIAEDs further increase MHD’s CL to a fixed extent of 25% at any age, but EIAEDs’ effect on LEV’s CL increases with age from 20% (at 2 years) to 30% (at adolescence). Simulations with the maximum recommended doses (MRDs) revealed that children between 2 and 4 years and greater than 4 years, who are not on EIAEDs, are at risk of exceeding the reference exposure range for OXZ and LEV, respectively. This analysis demonstrates the use of PBPK modeling in understanding the confounding effect of age and comedications on PKs in children and adolescents.
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Affiliation(s)
- Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eleni Karatza
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Greene SA, Kwak C, Kamin M, Vernillet L, Glenn KJ, Gabriel L, Kim HW. Effect of cenobamate on the single-dose pharmacokinetics of multiple cytochrome P450 probes using a cocktail approach in healthy subjects. Clin Transl Sci 2021; 15:899-911. [PMID: 34877801 PMCID: PMC9010261 DOI: 10.1111/cts.13204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 11/30/2022] Open
Abstract
This study was designed to evaluate the effects of cenobamate, an antiseizure medication for focal seizures, on the pharmacokinetics of cytochrome P450 probes (bupropion, CYP2B6; midazolam, CYP3A4/5; warfarin, CYP2C9; and omeprazole, CYP2C19) in healthy subjects. Probes were administered alone on days 1 (bupropion) and 7 (midazolam/warfarin/omeprazole), and with cenobamate 100 mg/day on day 69 (midazolam) and cenobamate 200 mg/day on days 99 (bupropion) and 105 (midazolam/warfarin/omeprazole). No significant interaction was concluded if 90% confidence intervals (CIs) for geometric mean ratios (GMRs) for area under the curve (AUC) and maximum concentration of CYP substrates and/or their metabolites were within the no‐effect interval (0.80–1.25). When co‐administered with cenobamate 100 mg/day, AUC from time of administration up to the time of the last quantifiable concentration (AUC0–last) GMR (90% CIs) for midazolam was 0.734 (0.647–0.832). When co‐administered with cenobamate 200 mg/day, AUC0–last GMRs (90% CI) for midazolam, bupropion, S‐warfarin, and omeprazole were 0.277 (0.238–0.323), 0.615 (0.522–0.724), 1.14 (1.10–1.18), and 2.07 (1.44–2.98), respectively. Co‐administration of cenobamate with midazolam and bupropion probes led to values that were outside and below the no effect boundary, indicating that cenobamate induces the CYP3A4/5 and CYP2B6 enzymes. Co‐administration of cenobamate led to omeprazole values which were outside and above the no‐effect boundary, but with high variability, suggesting that cenobamate may moderately inhibit CYP2C19 activity. No effect on CYP2C9 was observed with the cenobamate and warfarin combination. Co‐administration of cenobamate with these probes drugs was well‐tolerated. In this study, 200 mg/day cenobamate moderately induced CYP3A4/5 (dose‐dependently; 100 mg/day was a weak inducer), was a weak inducer of CYP2B6, moderately inhibited CYP2C19, and had a negligible effect on CYP2C9.
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Affiliation(s)
| | | | - Marc Kamin
- SK Life Science, Inc., Paramus, New Jersey, USA
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Cucchiara F, Ferraro S, Luci G, Bocci G. Relevant pharmacological interactions between alkylating agents and antiepileptic drugs: Preclinical and clinical data. Pharmacol Res 2021; 175:105976. [PMID: 34785318 DOI: 10.1016/j.phrs.2021.105976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/07/2021] [Accepted: 11/07/2021] [Indexed: 01/01/2023]
Abstract
Seizures are relatively common in cancer patients, and co-administration of chemotherapeutic and antiepileptic drugs (AEDs) is highly probable and necessary in many cases. Nonetheless, clinically relevant interactions between chemotherapeutic drugs and AEDs are rarely summarized and pharmacologically described. These interactions can cause insufficient tumor and seizure control or lead to unforeseen toxicity. This review focused on pharmacokinetic and pharmacodynamic interactions between alkylating agents and AEDs, helping readers to make a rational choice of treatment optimization, and thus improving patients' quality of life. As an example, phenobarbital, phenytoin, and carbamazepine, by increasing the hepatic metabolism of cyclophosphamide, ifosfamide and busulfan, yield smaller peak concentrations and a reduced area under the plasma concentration-time curve (AUC) of the prodrugs; alongside, the maximum concentration and AUC of their active products were increased with the possible onset of severe adverse drug reactions. On the other side, valproic acid, acting as histone deacetylase inhibitor, showed synergistic effects with temozolomide when tested in glioblastoma. The present review is aimed at providing evidence that may offer useful suggestions for rational pharmacological strategies in patients with seizures symptoms undertaking alkylating agents. Firstly, clinicians should avoid the use of enzyme-inducing AEDs in combination with alkylating agents and prefer the use of AEDs, such as levetiracetam, that have a low or no impact on hepatic metabolism. Secondly, a careful therapeutic drug monitoring of both alkylating agents and AEDs (and their active metabolites) is necessary to maintain therapeutic ranges and to avoid serious adverse reactions.
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Affiliation(s)
- Federico Cucchiara
- Unit of Pharmacology, Department of Clinical and Experimental, University of Pisa, Pisa, Italy
| | - Sara Ferraro
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giacomo Luci
- Unit of Pharmacology, Department of Clinical and Experimental, University of Pisa, Pisa, Italy
| | - Guido Bocci
- Unit of Pharmacology, Department of Clinical and Experimental, University of Pisa, Pisa, Italy.
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Yousfan A, Rubio N, Al-Ali M, Nattouf AH, Kafa H. Intranasal delivery of phenytoin-loaded nanoparticles to the brain suppresses pentylenetetrazol-induced generalized tonic clonic seizures in an epilepsy mouse model. Biomater Sci 2021; 9:7547-7564. [PMID: 34652351 DOI: 10.1039/d1bm01251g] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this work we describe the preparation and characterization of lecithin-chitosan nanoparticles (L10Ci+), and investigate their ability to deliver the anti-epileptic drug phenytoin (PHT) to mouse brain following intranasal (IN) administration. L10Ci+ were retained in the nasal cavity compared to PHT in PEG200 solution (PHT/PEG), which suffered immediate nasal drainage. PHT was detected in the brain after 5 min of IN administration reaching a maximum of 11.84 ± 2.31 %ID g-1 after 48 hours. L10Ci+ were associated with a higher brain/plasma ratio (Cb/p) compared to the experimental control comprising free PHT injected via the intraperitoneal route (PHT-IP) across all tested time points. Additionally, L10Ci+ led to lower PHT accumulation in the liver and spleen compared to PHT-IP, which is vital for lowering the systemic side effects of PHT. The relatively high drug targeting efficiency (DTE%) of 315.46% and the drug targeting percentage (DTP%) of 68.29%, combined with the increasing anterior-to-posterior gradient of PHT in the brain confirmed the direct nose-to-brain transport of PHT from L10Ci+. Electroencephalogram (EEG) analysis was used to monitor seizure progression. L10Ci+ resulted in a complete seizure suppression after 4 hours of administration, and this inhibition persisted even with an 8-fold reduction of the encapsulated dose compared to the required PHT-IP dose to achieve a similar inhibitory effect due to systemic loss. The presented findings confirm the possibility of using L10Ci+ as a non-invasive delivery system of PHT for the management of epilepsy using reduced doses of PHT.
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Affiliation(s)
- Amal Yousfan
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Syria
| | - Noelia Rubio
- Department of Chemistry and Materials, Imperial College London, SW7 2AZ, UK
| | - Mohammad Al-Ali
- Department of Molecular Biology and Biotechnology, Atomic Energy Commission of Syria, Damascus, Syria.
| | - Abdul Hakim Nattouf
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Syria
| | - Houmam Kafa
- Department of Molecular Biology and Biotechnology, Atomic Energy Commission of Syria, Damascus, Syria.
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Karaźniewicz-Łada M, Główka AK, Mikulska AA, Główka FK. Pharmacokinetic Drug-Drug Interactions among Antiepileptic Drugs, Including CBD, Drugs Used to Treat COVID-19 and Nutrients. Int J Mol Sci 2021; 22:ijms22179582. [PMID: 34502487 PMCID: PMC8431452 DOI: 10.3390/ijms22179582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 12/22/2022] Open
Abstract
Anti-epileptic drugs (AEDs) are an important group of drugs of several generations, ranging from the oldest phenobarbital (1912) to the most recent cenobamate (2019). Cannabidiol (CBD) is increasingly used to treat epilepsy. The outbreak of the SARS-CoV-2 pandemic in 2019 created new challenges in the effective treatment of epilepsy in COVID-19 patients. The purpose of this review is to present data from the last few years on drug–drug interactions among of AEDs, as well as AEDs with other drugs, nutrients and food. Literature data was collected mainly in PubMed, as well as google base. The most important pharmacokinetic parameters of the chosen 29 AEDs, mechanism of action and clinical application, as well as their biotransformation, are presented. We pay a special attention to the new potential interactions of the applied first-generation AEDs (carbamazepine, oxcarbazepine, phenytoin, phenobarbital and primidone), on decreased concentration of some medications (atazanavir and remdesivir), or their compositions (darunavir/cobicistat and lopinavir/ritonavir) used in the treatment of COVID-19 patients. CBD interactions with AEDs are clearly defined. In addition, nutrients, as well as diet, cause changes in pharmacokinetics of some AEDs. The understanding of the pharmacokinetic interactions of the AEDs seems to be important in effective management of epilepsy.
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Affiliation(s)
- Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 60-781 Poznań, Poland; (M.K.-Ł.); (A.A.M.)
| | - Anna K. Główka
- Department of Bromatology, Poznan University of Medical Sciences, 60-354 Poznań, Poland;
| | - Aniceta A. Mikulska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 60-781 Poznań, Poland; (M.K.-Ł.); (A.A.M.)
| | - Franciszek K. Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 60-781 Poznań, Poland; (M.K.-Ł.); (A.A.M.)
- Correspondence: ; Tel.: +48-(0)61-854-64-37
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The Effect of Plasma Protein Binding on the Therapeutic Monitoring of Antiseizure Medications. Pharmaceutics 2021; 13:pharmaceutics13081208. [PMID: 34452168 PMCID: PMC8401952 DOI: 10.3390/pharmaceutics13081208] [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: 06/10/2021] [Revised: 07/27/2021] [Accepted: 07/27/2021] [Indexed: 12/17/2022] Open
Abstract
Epilepsy is a widely diffused neurological disorder including a heterogeneous range of syndromes with different aetiology, severity and prognosis. Pharmacological treatments are based on the use, either in mono- or in polytherapy, of antiseizure medications (ASMs), which act at different synaptic levels, generally modifying the excitatory and/or inhibitory response through different action mechanisms. To reduce the risk of adverse effects and drug interactions, ASMs levels should be closely evaluated in biological fluids performing an appropriate Therapeutic Drug Monitoring (TDM). However, many decisions in TDM are based on the determination of the total drug concentration although measurement of the free fraction, which is not bound to plasma proteins, is becoming of ever-increasing importance since it correlates better with pharmacological and toxicological effects. Aim of this work has been to review methodological aspects concerning the evaluation of the free plasmatic fraction of some ASMs, focusing on the effect and the clinical significance that drug-protein binding has in the case of widely used drugs such as valproic acid, phenytoin, perampanel and carbamazepine. Although several validated methodologies are currently available which are effective in separating and quantifying the different forms of a drug, prospective validation studies are undoubtedly needed to better correlate, in real-world clinical contexts, pharmacokinetic monitoring to clinical outcomes.
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Gaies E, Zgolli F, Charfi R, Ben Sassi M, EL Jebari H, Salouage I, Daghfous R, Trabelsi S. Drug interaction between carbamazepine and other antiepileptic drugs in Tunisian epileptic patients. LA TUNISIE MEDICALE 2021; 99:877-880. [PMID: 35261014 PMCID: PMC9003587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Carbamazepine could be used on monotherapy or associated to other antiepileptic drugs (AED). In these cases, drug interactions should be taken into account. AIM To assess the influence of the coadministration of CBZ with other AED on the trough plasmatic concentration (C0) of CBZ in epileptic adults. METHODS We performed a retrospective study over a period of 9 years in the Department of Clinical Pharmacology in the Tunisian National Centre "Chalbi Belkahia" of Pharmacovigilance. Our study included samples from adult patients receiving CBZ alone or associated to other AED for epilepsy. Trough plasma CBZ plasma concentrations were measured by an immunological method. Included samples were divided in four groups: i/ group 1 (G1) receiving CBZ as monotherapy, ii/ group 2 (G2) treated by CBZ with an enzyme inducer (phenobarbital or phenytoin), iii/ group 3 (G3) taking CBZ associated to an enzyme inhibitor (valproic acid (VPA)), iv/ group 4 (G4), treated by CBZ associated to enzyme inducer (phenobarbital or phenytoin) and enzyme inhibitor (valproic acid) at the same time. RESULTS There were no significant differences between different groups in age, weight and sex ratio. However statistical analysis showed a significant decrease in C0/D CBZ ratio between G1 and G2 and between G1 and G4 (p<0.001). However, the difference was not significant between G1 and G3 (p=1.2044). CONCLUSION It is important to check and to prevent the consequences of the interaction between CBZ and other AED in order to avoid inefficiency and toxicity.
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Affiliation(s)
- Emna Gaies
- 1. Service de Pharmacologie Clinique-Centre National de Pharmacovigilance / Faculté de Médecine de Tunis
| | - Fatma Zgolli
- 1. Service de Pharmacologie Clinique-Centre National de Pharmacovigilance / Faculté de Médecine de Tunis
| | - Rim Charfi
- 1. Service de Pharmacologie Clinique-Centre National de Pharmacovigilance / Faculté de Médecine de Tunis
| | - Mouna Ben Sassi
- 1. Service de Pharmacologie Clinique-Centre National de Pharmacovigilance / Faculté de Médecine de Tunis
| | - Hanene EL Jebari
- 1. Service de Pharmacologie Clinique-Centre National de Pharmacovigilance / Faculté de Médecine de Tunis
| | - Issam Salouage
- 1. Service de Pharmacologie Clinique-Centre National de Pharmacovigilance / Faculté de Médecine de Tunis
| | - Riadh Daghfous
- 1. Service de Pharmacologie Clinique-Centre National de Pharmacovigilance / Faculté de Médecine de Tunis
| | - Sameh Trabelsi
- 1. Service de Pharmacologie Clinique-Centre National de Pharmacovigilance / Faculté de Médecine de Tunis
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Gidal BE, Ferry J, Reyderman L, Piña-Garza JE. Use of extended-release and immediate-release anti-seizure medications with a long half-life to improve adherence in epilepsy: A guide for clinicians. Epilepsy Behav 2021; 120:107993. [PMID: 33971390 DOI: 10.1016/j.yebeh.2021.107993] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 11/18/2022]
Abstract
Poor adherence to anti-seizure medications (ASMs) is associated with breakthrough seizures and potentially increased toxicity in patients with epilepsy. Extended-release (ER) drugs and immediate-release (IR) drugs with a long half-life (t1/2) that permit once-daily dosing (such as, perampanel, zonisamide, lamotrigine [IR, ER] and topiramate [ER]) have a number of advantages over short t1/2 ASMs that require multiple daily dosing. These advantages include simplification of dosing regimens, reduction in pill burden, and a decrease in the peak-to-trough fluctuations in serum drug concentration that may be associated with a decreased risk of adverse effects and seizures. Such properties have wider implications in improving patient adherence to treatment. This article is intended as a practical guide for clinicians that provides an overview of the features of ER ASMs and long t1/2 IR ASMs that are advantageous in the context of patient adherence and pharmacokinetic "forgiveness" (after missing a dose). In addition, we note that efforts to improve adherence should not depend solely on drug dosing regimens and drug pharmacokinetics, but should be part of a wider strategy that includes therapeutic drug monitoring, improved healthcare provider-patient dialogue, patient education, and the use of "reminder" technology.
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Affiliation(s)
- Barry E Gidal
- School of Pharmacy, University of Wisconsin, Madison, WI, USA.
| | - Jim Ferry
- Formerly: Eisai Inc., Woodcliff Lake, NJ, USA
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Prakash S, Rathore C, Rana K, Patel H. Antiepileptic drugs and serotonin syndrome- A systematic review of case series and case reports. Seizure 2021; 91:117-131. [PMID: 34153897 DOI: 10.1016/j.seizure.2021.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 12/12/2022] Open
Abstract
Serotonin syndrome (SS) is a drug‑induced, potentially fatal, clinical syndrome resulting from drugs that have serotonergic properties. Several antiepileptic drugs (AEDs) are known to have serotonergic properties and it can be hypothesized that such AEDs can cause SS. This study aims to review the literature on SS in patients receiving AEDs. We performed a systematic review of Scopus and MEDLINE/PUBMED for case reports and case series of SS where patients had received at least one AED at the onset of symptoms. The cases published in the English literature between 1 January 1991 and 1 April 2021 were included. Initial search identified 1263 articles of which 63 (76 patients) were included in the final analysis. Most of the included cases (53 cases, 70%) have been published in the last 10 years. The mean age of the 76 patients was 40.6 ± 17.8 years, and 51% of cases were females. These patients had been exposed to a total of 8 different types of AEDs. Valproic acid was the most common drug (29, 38%), followed by lamotrigine (22, 29%), gabapentin (16, 21%), pregabalin (seven, 9%), topiramate (five, 7%) and carbamazepine (two, 3%). There has been one case each with phenytoin and oxcarbazepine. Seven (9%) patients received more than one AEDs. Most patients (67, 88%) also received other serotoninergic agents. Only nine (12%) patients were on AEDs alone. The most common clinical condition for using AEDs was psychiatric disorders (36 patients, 47.3%), followed by migraine (17, 22.4%), other painful conditions (15, 19.7%), epilepsy (7, 9.2%), and perioperative conditions (8, 10.5%). Death was reported in two patients. We suggest that AEDs, because of their serotonergic properties, may induce SS, especially in patients who are on another serotonergic agent.
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Affiliation(s)
- Sanjay Prakash
- Professor and Head, Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, 391760, India.
| | - Chaturbhuj Rathore
- Professor, Department of Neurology, Smt. B. K. Shah Medical institute and research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, 391760, India.
| | - Kaushik Rana
- Assistant Professor, Department of Neurology, Smt. B. K. Shah Medical institute and research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, 391760, India
| | - Harsh Patel
- Senior Resident, Department of Neurology, Smt. B. K. Shah Medical institute and research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara Gujarat, 391760, India.
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Boon P, Ferrao Santos S, Jansen AC, Lagae L, Legros B, Weckhuysen S. Recommendations for the treatment of epilepsy in adult and pediatric patients in Belgium: 2020 update. Acta Neurol Belg 2021; 121:241-257. [PMID: 33048338 PMCID: PMC7937601 DOI: 10.1007/s13760-020-01488-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 08/26/2020] [Indexed: 12/31/2022]
Abstract
To guide health care professionals in Belgium in selecting the appropriate antiepileptic drugs (AEDs) for their epilepsy patients, a group of Belgian epilepsy experts developed recommendations for AED treatment in adults and children (initial recommendations in 2008, updated in 2012). As new drugs have become available, others have been withdrawn, new indications have been approved and recommendations for pregnant women have changed, a new update was pertinent. A group of Belgian epilepsy experts (partly overlapping with the group in charge of the 2008/2012 recommendations) evaluated the most recent international guidelines and relevant literature for their applicability to the Belgian situation (registration status, reimbursement, clinical practice) and updated the recommendations for initial monotherapy in adults and children and add-on treatment in adults. Recommendations for add-on treatment in children were also included (not covered in the 2008/2012 publications). Like the 2008/2012 publications, the current update also covers other important aspects related to the management of epilepsy, including the importance of early referral in drug-resistant epilepsy, pharmacokinetic properties and tolerability of AEDs, comorbidities, specific considerations in elderly and pregnant patients, generic substitution and the rapidly evolving field of precision medicine.
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Affiliation(s)
- Paul Boon
- Reference Center for Refractory Epilepsy, Department of Neurology, Ghent University Hospital, Ghent, Belgium.
| | | | - Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieven Lagae
- Reference Center for Refractory Epilepsy, Pediatric Neurology, Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
| | - Benjamin Legros
- Department of Neurology, Reference Center for the Treatment of Refractory Epilepsy, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sarah Weckhuysen
- Department of Neurology, Antwerp University Hospital, Antwerp, Belgium
- VIB-Center for Molecular Neurology, University of Antwerp, Antwerp, Belgium
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Almeida Â, Calisto V, Esteves VI, Schneider RJ, Figueira E, Soares AMVM, Freitas R. Can ocean warming alter sub-lethal effects of antiepileptic and antihistaminic pharmaceuticals in marine bivalves? AQUATIC TOXICOLOGY (AMSTERDAM, NETHERLANDS) 2021; 230:105673. [PMID: 33221665 DOI: 10.1016/j.aquatox.2020.105673] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 06/11/2023]
Abstract
The negative effects induced in marine organisms by Climate Change related abiotic factors consequences, namely ocean warming, are well-known. However, few works studied the combined impacts of ocean warming and contaminants, as pharmaceutical drugs. Carbamazepine (CBZ) and cetirizine (CTZ) occur in the marine environment, showing negative effects in marine organisms. This study aimed to evaluate the impacts of ocean warming on the effects of CBZ and CTZ, when acting individually and combined (drug vs drug), in the edible clam Ruditapes philippinarum. For that, drugs concentration, bioconcentration factors and biochemical parameters, related with clam's metabolic capacity and oxidative stress, were evaluated after 28 days exposure to environmentally relevant scenarios of these stressors. The results showed limited impacts of the drugs (single and combined) at control and warming condition. Indeed, it appeared that warming improved the oxidative status of contaminated clams (higher reduced to oxidized glutathione ratio, lower lipid peroxidation and protein carbonylation levels), especially when both drugs were combined. This may result from clam's defence mechanisms activation and reduced metabolic capacity that, respectively, increased elimination and limited production of reactive oxygen species. At low stress levels, defence mechanisms were not activated which resulted into oxidative stress. The present findings highlighted that under higher stress levels clams may be able to activate defence strategies that were sufficient to avoid cellular damages and loss of redox homeostasis. Nevertheless, low concentrations were tested in the present study and the observed responses may greatly change under increased pollution levels or temperatures. Further research on this topic is needed since marine heat waves are increasing in frequency and intensity and pollution levels of some pharmaceuticals are also increasing in coastal systems.
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Affiliation(s)
- Ângela Almeida
- Biology Department & CESAM, University of Aveiro, 3810-193, Aveiro, Portugal
| | - Vânia Calisto
- Chemistry Department & CESAM, University of Aveiro, 3810-193, Aveiro, Portugal
| | - Valdemar I Esteves
- Chemistry Department & CESAM, University of Aveiro, 3810-193, Aveiro, Portugal
| | - Rudolf J Schneider
- BAM Federal Institute for Materials Research and Testing, Richard-Willstaetter -Str. 11, D-12489, Berlin, Germany
| | - Etelvina Figueira
- Biology Department & CESAM, University of Aveiro, 3810-193, Aveiro, Portugal
| | - Amadeu M V M Soares
- Biology Department & CESAM, University of Aveiro, 3810-193, Aveiro, Portugal
| | - Rosa Freitas
- Biology Department & CESAM, University of Aveiro, 3810-193, Aveiro, Portugal.
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Sommerfeld-Klatta K, Zielińska-Psuja B, Karaźniewcz-Łada M, Główka FK. New Methods Used in Pharmacokinetics and Therapeutic Monitoring of the First and Newer Generations of Antiepileptic Drugs (AEDs). Molecules 2020; 25:E5083. [PMID: 33147810 PMCID: PMC7663638 DOI: 10.3390/molecules25215083] [Citation(s) in RCA: 18] [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: 09/24/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 12/30/2022] Open
Abstract
The review presents data from the last few years on bioanalytical methods used in therapeutic drug monitoring (TDM) of the 1st-3rd generation and the newest antiepileptic drug (AEDs) cenobamate in patients with various forms of seizures. Chemical classification, structure, mechanism of action, pharmacokinetic data and therapeutic ranges for total and free fractions and interactions were collected. The primary data on bioanalytical methods for AEDs determination included biological matrices, sample preparation, dried blood spot (DBS) analysis, column resolution, detection method, validation parameters, and clinical utility. In conclusion, the most frequently described method used in AED analysis is the LC-based technique (HPLC, UHPLC, USLC) combined with highly sensitive mass detection or fluorescence detection. However, less sensitive UV is also used. Capillary electrophoresis and gas chromatography have been rarely applied. Besides the precipitation of proteins or LLE, an automatic SPE is often a sample preparation method. Derivatization was also indicated to improve sensitivity and automate the analysis. The usefulness of the methods for TDM was also highlighted.
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Affiliation(s)
- Karina Sommerfeld-Klatta
- Department of Toxicology, Poznan University of Medical Sciences, 60-631 Poznań, Poland; (K.S.-K.); (B.Z.-P.)
| | - Barbara Zielińska-Psuja
- Department of Toxicology, Poznan University of Medical Sciences, 60-631 Poznań, Poland; (K.S.-K.); (B.Z.-P.)
| | - Marta Karaźniewcz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 60-781 Poznań, Poland;
| | - Franciszek K. Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 60-781 Poznań, Poland;
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Shakkour Z, Habashy KJ, Berro M, Takkoush S, Abdelhady S, Koleilat N, Eid AH, Zibara K, Obeid M, Shear D, Mondello S, Wang KK, Kobeissy F. Drug Repurposing in Neurological Disorders: Implications for Neurotherapy in Traumatic Brain Injury. Neuroscientist 2020; 27:620-649. [PMID: 33089741 DOI: 10.1177/1073858420961078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) remains a significant leading cause of death and disability among adults and children globally. To date, there are no Food and Drug Administration-approved drugs that can substantially attenuate the sequelae of TBI. The innumerable challenges faced by the conventional de novo discovery of new pharmacological agents led to the emergence of alternative paradigm, which is drug repurposing. Repurposing of existing drugs with well-characterized mechanisms of action and human safety profiles is believed to be a promising strategy for novel drug use. Compared to the conventional discovery pathways, drug repurposing is less costly, relatively rapid, and poses minimal risk of the adverse outcomes to study on participants. In recent years, drug repurposing has covered a wide range of neurodegenerative diseases and neurological disorders including brain injury. This review highlights the advances in drug repurposing and presents some of the promising candidate drugs for potential TBI treatment along with their possible mechanisms of neuroprotection. Edaravone, glyburide, ceftriaxone, levetiracetam, and progesterone have been selected due to their potential role as putative TBI neurotherapeutic agents. These drugs are Food and Drug Administration-approved for purposes other than brain injuries; however, preclinical and clinical studies have shown their efficacy in ameliorating the various detrimental outcomes of TBI.
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Affiliation(s)
- Zaynab Shakkour
- Department of Biochemistry & Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Moussa Berro
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Samira Takkoush
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Samar Abdelhady
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Nadia Koleilat
- Division of Child Neurology, Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali H Eid
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Kazem Zibara
- PRASE and Biology Department, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Makram Obeid
- Division of Child Neurology, Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Deborah Shear
- Brain Trauma Neuroprotection/Neurorestoration, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Sicilia, Italy
| | - Kevin K Wang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Departments of Emergency Medicine, Psychiatry, Neuroscience and Chemistry, University of Florida, Gainesville, FL, USA
| | - Firas Kobeissy
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Departments of Emergency Medicine, Psychiatry, Neuroscience and Chemistry, University of Florida, Gainesville, FL, USA
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Jun H, Rong Y, Yih C, Ho J, Cheng W, Kiang TKL. Comparisons of Four Protein-Binding Models Characterizing the Pharmacokinetics of Unbound Phenytoin in Adult Patients Using Non-Linear Mixed-Effects Modeling. Drugs R D 2020; 20:343-358. [PMID: 33026608 PMCID: PMC7691416 DOI: 10.1007/s40268-020-00323-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2020] [Indexed: 12/01/2022] Open
Abstract
Background and objective Phenytoin is extensively protein bound with a narrow therapeutic range. The unbound phenytoin is pharmacologically active, but total concentrations are routinely measured in clinical practice. The relationship between free and total phenytoin has been described by various binding models with inconsistent findings. Systematic comparison of these binding models in a single experimental setting is warranted to determine the optimal binding behaviors. Methods Non-linear mixed-effects modeling was conducted on retrospectively collected data (n = 37 adults receiving oral or intravenous phenytoin) using a stochastic approximation expectation–maximization algorithm in MonolixSuite-2019R2. The optimal base structural model was initially developed and utilized to compare four binding models: Winter–Tozer, linear binding, non-linear single-binding site, and non-linear multiple-binding site. Each binding model was subjected to error and covariate modeling. The final model was evaluated using relative standard errors (RSEs), goodness-of-fit plots, visual predictive check, and bootstrapping. Results A one-compartment, first-order absorption, Michaelis–Menten elimination, and linear protein-binding model best described the population pharmacokinetics of free phenytoin at typical clinical concentrations. The non-linear single-binding-site model also adequately described phenytoin binding but generated larger RSEs. The non-linear multiple-binding-site model performed the worst, with no identified covariates. The optimal linear binding model suggested a relatively high binding capacity using a single albumin site. Covariate modeling indicated a positive relationship between albumin concentration and the binding proportionality constant. Conclusions The linear binding model best described the population pharmacokinetics of unbound phenytoin in adult subjects and may be used to improve the prediction of free phenytoin concentrations. Electronic supplementary material The online version of this article (10.1007/s40268-020-00323-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Heajin Jun
- College of Pharmacy, Seoul National University, Seoul, Republic of Korea.,Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Katz Group Centre for Pharmacy and Health Research, Room 3-142D, 11361-87 Avenue, Edmonton, AB, T6G 2E1, Canada
| | - Yan Rong
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Katz Group Centre for Pharmacy and Health Research, Room 3-142D, 11361-87 Avenue, Edmonton, AB, T6G 2E1, Canada
| | - Catharina Yih
- Department of Pharmacy, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jordan Ho
- Department of Pharmacy, Vancouver General Hospital, Vancouver, BC, Canada
| | - Wendy Cheng
- Department of Pharmacy, Vancouver General Hospital, Vancouver, BC, Canada
| | - Tony K L Kiang
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Katz Group Centre for Pharmacy and Health Research, Room 3-142D, 11361-87 Avenue, Edmonton, AB, T6G 2E1, Canada.
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Prediction of Serum-Free and Cerebrospinal Fluid Valproic Acid Levels in Patients With Hypoalbuminemia After Craniotomy. Ther Drug Monit 2020; 42:610-616. [DOI: 10.1097/ftd.0000000000000749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Conceição J, Adeoye O, Cabral-Marques H, Concheiro A, Alvarez-Lorenzo C, Sousa Lobo JM. Carbamazepine bilayer tablets combining hydrophilic and hydrophobic cyclodextrins as a quick/slow biphasic release system. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101611] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Zhao D, Shridharmurthy D, Alcusky MJ, Yuan Y, Nunes AP, Hume AL, Baek J, Lapane KL. The Prevalence and Factors Associated with Antiepileptic Drug Use in US Nursing Home Residents. Drugs Aging 2020; 37:137-145. [PMID: 31845208 DOI: 10.1007/s40266-019-00732-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Antiepileptic drugs (AEDs) are commonly used by nursing home residents, both on- and off-label. The landscape of AED use has changed over the past two decades; however, despite this, contemporaneous research on AED use in US nursing home residents is scant. OBJECTIVE The aim of this study was to estimate the prevalence of AED use, describe prescribing patterns, identify factors associated with AED use, and assess whether these factors differ among AEDs with expanded indications in older adults (i.e. gabapentin, pregabalin, topiramate, and lamotrigine). METHODS We conducted a cross-sectional study among 549,240 long-stay older residents who enrolled in fee-for-service Medicare and lived in 15,111 US nursing homes on 1 September 2016. Demographics and conditions associated with AED indications, epilepsy comorbidities, and safety data came from the Minimum Data Set Version 3.0 (MDS 3.0). Medicare Part D claims were used to identify AED use. Robust Poisson models and multinomial logistic models for clustered data estimated adjusted prevalence ratios (aPR), adjusted odds ratios (aOR), and 95% confidence intervals (CIs). RESULTS Overall, 24.0% used AEDs (gabapentin [13.3%], levetiracetam [4.7%], phenytoin [1.9%], pregabalin [1.8%], and lamotrigine [1.2%]). AED use was associated with epilepsy (aPR 3.73, 95% CI 3.69-3.77), bipolar disorder (aPR 1.20, 95% CI 1.18-1.22), pain (aPRmoderate/severe vs. no pain 1.42, 95% CI 1.40-1.44), diabetes (aPR 1.27, 95% CI 1.26-1.28), anxiety (aPR 1.12, 95% CI 1.11-1.13), depression (aPR 1.17, 95% CI 1.15-1.18), or stroke (aPR 1.08, 95% CI 1.06-1.09). Residents with advancing age (aPR85+ vs. 65-74 years 0.73, 95% CI 0.73-0.74), Alzheimer's disease/dementia (aPR 0.87, 95% CI 0.86-0.88), or cognitive impairment (aPRsevere vs. no impairment 0.62, 95% CI 0.61-0.63) had decreased AED use. Gabapentinoid use was highly associated with pain (aORmoderate/severe vs. no pain 2.07, 95% CI 2.01-2.12) and diabetes (aOR 1.79, 95% CI 1.76-1.82), but not with an epilepsy indication. CONCLUSIONS AED use was common in nursing homes, with gabapentin most commonly used (presumably for pain). That multiple comorbidities were associated with AED use underscores the need for future studies to investigate the safety and effectiveness of AED use in nursing home residents.
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Affiliation(s)
- Danni Zhao
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Divya Shridharmurthy
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Matthew J Alcusky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Yiyang Yuan
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Anthony P Nunes
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Anne L Hume
- Department of Family Medicine, Alpert Medical School, Brown University, Memorial Hospital of Rhode Island, Providence, RI, 02903, USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
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Dahdaleh S, Malhotra P. Treatment of Central Nervous System Complications of Renal Dialysis and Transplantation. Curr Treat Options Neurol 2019; 21:13. [DOI: 10.1007/s11940-019-0553-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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