Predictors for and use of rescue medication in adults with epilepsy: A multicentre cross-sectional study from Germany

BACKGROUND

Seizure clusters, prolonged seizures, and status epilepticus are life-threatening neurological emergencies leading to irreversible neuronal damage. Benzodiazepines are current evidence-based rescue therapy options; however, recent investigations indicated the prescription of mainly unsuitable benzodiazepines and inappropriate use of rescue medication.

OBJECTIVE

To examine current use, satisfaction, and adverse events concerning rescue medication in patients with epilepsy in Germany.

PATIENTS AND METHODS

The study was conducted at epilepsy centres in Frankfurt am Main, Greifswald, Marburg, and Münster between 10/2020 and 12/2020. Patients with an epilepsy diagnosis were assessed based on a questionnaire examining a 12-month period.

RESULTS

In total, 486 patients (mean age: 40.5, range 18-83, 58.2 % female) participated in this study, of which 125 (25.7 %) reported the use of rescue medication. The most frequently prescribed rescue medications were lorazepam tablets (56.8 %, n = 71 out of 125), buccal midazolam (19.2 %, n = 24), and rectal diazepam (10.4 %, n = 13). Seizures continuing for over several minutes (43.2 %, n = 54), seizure clusters (28.0 %, n = 35), and epileptic auras (28.0 %, n = 35) were named as indications, while 28.0 % (n = 35) stated they administered the rescue medication for every seizure. Of those continuing to have seizures, 46.0 % did not receive rescue medication. On average, rescue medication prescription occurred 7.1 years (SD 12.7, range 0-66) after an epilepsy diagnosis.

CONCLUSIONS

Unsuitable oral benzodiazepines remain widely prescribed for epilepsy patients as rescue medication. Patients also reported inappropriate use of medication. A substantial proportion of patients who were not seizure-free did not receive rescue medication prescriptions. Offering each patient at risk for prolonged seizures or clusters of seizures an individual rescue treatment with instructions on using it may decrease mortality and morbidity and increase quality of life. .

Prevalence of and factors associated with the early prescription of antiseizure medications in adults newly diagnosed with epilepsy in Germany

BACKGROUND

There is little information on prescription patterns of antiseizure medications (ASMs) during the early management of patients with epilepsy in Germany. Therefore, this study investigated the prevalence of and the factors associated with ASM prescription in patients newly diagnosed with epilepsy in this country.

METHODS

Adults diagnosed for the first time with epilepsy in one of 128 neurology practices in Germany between 2005 and 2021 were included (Disease Analyzer database, IQVIA). The prescription of ASMs was assessed within 30 days, six months, and 12 months of the diagnosis. Covariates were demographic factors, epilepsy sub-diagnoses, and co-diagnoses frequently associated with epilepsy.

RESULTS

This study included 55,962 participants (mean [SD] age 52.5 [20.0] years; 50.5 % men). The prevalence of ASM prescription ranged from 45.0 % within 30 days to 66.0 % within 12 months of the diagnosis. Men were less likely to receive ASMs within six and 12 months of epilepsy diagnosis than women. In addition, epilepsy sub-diagnoses of symptomatic, complex, or generalized nature were associated with increased odds of ASM prescription compared with epilepsy of unspecified nature. Finally, there was an inverse and significant association between multiple co-diagnoses (e.g., diabetes, mental and behavioral disorders due to use of alcohol, and traumatic brain injury) and ASM prescribing.

CONCLUSIONS

A substantial proportion of participants were prescribed ASMs in the year following epilepsy diagnosis, highlighting that the early prescription of ASMs was necessary for these patients. Further research is warranted to corroborate the present findings in other countries and settings.

Differential effects of antiseizure medications on neurogenesis: Evidence from cells to animals

Neurogenesis, the process of generating functionally integrated neurons from neural stem and progenitor cells, is involved in brain development during embryonic stages but continues throughout life. Adult neurogenesis plays essential roles in many brain functions such as cognition, brain plasticity, and repair. Abnormalities in neurogenesis have been described in many neuropsychiatric and neurological disorders, including epilepsy. While sharing a common property of suppressing seizures, accumulating evidence has shown that some antiseizure medications (ASM) exhibit neuroprotective potential in the non-epileptic models including Parkinson's disease, Alzheimer's disease, cerebral ischemia, or traumatic brain injury. ASM are a heterogeneous group of medications with different mechanisms of actions. Therefore, it remains to be revealed whether neurogenesis is a class effect or related to them all. In this comprehensive literature study, we reviewed the literature data on the influence of ASM on the neurogenesis process during brain development and also in the adult brain under physiological or pathological conditions. Meanwhile, we discussed the underlying mechanisms associated with the neurogenic effects of ASM by linking the reported in vivo and in vitro studies. PubMed, Web of Science, and Google Scholar databases were searched until the end of February 2023. A total of 83 studies were used finally. ASM can modulate neurogenesis through the increase or decrease of proliferation, survival, and differentiation of the quiescent NSC pool. The present article indicated that the neurogenic potential of ASM depends on the administered dose, treatment period, temporal administration of the drug, and normal or disease context.

Fenfluramine for the treatment of status epilepticus: use in an adult with Lennox-Gastaut syndrome and literature review

BACKGROUND

Novel treatments are needed to control refractory status epilepticus (SE). This study aimed to assess the potential effectiveness of fenfluramine (FFA) as an acute treatment option for SE. We present a summary of clinical cases where oral FFA was used in SE.

METHODS

A case of an adult patient with Lennox-Gastaut syndrome (LGS) who was treated with FFA due to refractory SE is presented in detail. To identify studies that evaluated the use of FFA in SE, we performed a systematic literature search.

RESULTS

Four case reports on the acute treatment with FFA of SE in children and adults with Dravet syndrome (DS) and LGS were available. We report in detail a 30-year-old woman with LGS of structural etiology, who presented with generalized tonic and dialeptic seizures manifesting at high frequencies without a return to clinical baseline constituting the diagnosis of SE. Treatment with anti-seizure medications up to lacosamide 600 mg/d, brivaracetam 300 mg/d, valproate 1,600 mg/d, and various benzodiazepines did not resolve the SE. Due to ongoing refractory SE and following an unremarkable echocardiography, treatment was initiated with FFA, with an initial dose of 10 mg/d (0.22 mg/kg body weight [bw]) and fast up-titration to 26 mg/d (0.58 mg/kg bw) within 10 days. Subsequently, the patient experienced a resolution of SE within 4 days, accompanied by a notable improvement in clinical presentation and regaining her mobility, walking with the assistance of physiotherapists. In the three cases reported in the literature, DS patients with SE were treated with FFA, and a cessation of SE was observed within a few days. No treatment-emergent adverse events were observed during FFA treatment in any of the four cases.

CONCLUSIONS

Based on the reported cases, FFA might be a promising option for the acute treatment of SE in patients with DS and LGS. Observational data show a decreased SE frequency while on FFA, suggesting a potentially preventive role of FFA in these populations.

KEY POINTS

We summarize four cases of refractory status epilepticus (SE) successfully treated with fenfluramine. Refractory SE resolved after 4-7 days on fenfluramine. Swift fenfluramine up-titration was well-tolerated during SE treatment. Treatment-emergent adverse events on fenfluramine were not observed. Fenfluramine might be a valuable acute treatment option for SE in Dravet and Lennox-Gastaut syndromes.

A Comprehensive Review of Essential Oils and Their Pharmacological Activities in Neurological Disorders: Exploring Neuroprotective Potential

Numerous studies have demonstrated essential oils' diverse chemical compositions and pharmacological properties encompassing antinociceptive, anxiolytic-like, and anticonvulsant activities, among other notable effects. The utilization of essential oils, whether inhaled, orally ingested, or applied topically, has commonly been employed as adjunctive therapy for individuals experiencing anxiety, insomnia, convulsions, pain, and cognitive impairment. The utilization of synthetic medications in the treatment of various disorders and symptoms is associated with a wide array of negative consequences. Consequently, numerous research groups across the globe have been prompted to explore the efficacy of natural alternatives such as essential oils. This review provides a comprehensive overview of the existing literature on the pharmacological properties of essential oils and their derived compounds and the underlying mechanisms responsible for these observed effects. The primary emphasis is on essential oils and their constituents, specifically targeting the nervous system and exhibiting significant potential in treating neurodegenerative disorders. The current state of research in this field is characterized by its preliminary nature, highlighting the necessity for a more comprehensive overlook of the therapeutic advantages of essential oils and their components. Integrating essential oils into conventional therapies can enhance the effectiveness of comprehensive treatment regimens for neurodegenerative diseases, offering a more holistic approach to addressing the multifaceted nature of these conditions.

Psychotropic Drug-Related Weight Gain and Its Treatment

Psychotropic drug-related weight gain (PDWG) is a common occurrence and is highly associated with non-initiation, discontinuation, and dissatisfaction with psychiatric drugs. Moreover, PDWG intersects with the elevated risk for obesity and associated morbidity that has been amply reported in the psychiatric population. Evidence indicates that differential liability for PDWG exists for antipsychotics, antidepressants, and anticonvulsants. During the past two decades, agents within these classes have become available with significantly lower or no liability for PDWG and as such should be prioritized. Although lithium is associated with weight gain, the overall extent of weight gain is significantly lower than previously estimated. The benefit of lifestyle and behavioral modification for obesity and/or PDWG in psychiatric populations is established, with effectiveness similar to that in the general population. Metformin is the most studied pharmacological treatment in the prevention and treatment of PDWG, and promising data are emerging for glucagon-like peptide-1 (GLP-1) receptor agonists (e.g., liraglutide, exenatide, semaglutide). Most pharmacologic antidotes for PDWG are supported with low-confidence data (e.g., topiramate, histamine-2 receptor antagonists). Future vistas for pharmacologic treatment for PDWG include large, adequately controlled studies with GLP-1 receptor agonists and possibly GLP-1/glucose-dependent insulinotropic polypeptide co-agonists (e.g., tirzepatide) as well as specific dietary modifications.

Preventive treatment of migraine: Non-specific oral agents

Migraine headache is highly prevalent and the most common neurologic disorder, affecting one billion people worldwide. It is also the most disabling condition in people under 50, with a huge impact on working ability, family, and social life. Access to effective preventive medication is important and may be considered if the patient has 6 or more migraine days per month, ineffective abortive agents, or disability on 2 or more days per month. Propranolol, metoprolol, candesartan, topiramate, divalproex, lisinopril, amitriptyline, and venlafaxine have the strongest evidence to support for use. Flunarizine and pizotifen may also be effective. Selection of preventive treatments is based on individual characteristics, comorbid conditions, efficacy, contraindications, side effects, cost, compliance, and drug. An adequate trial of migraine prophylaxis is usually 2 months at the target dose, and it is always important to re-evaluate indication for prophylactic use after a period of time.

Lamotrigine efficacy, safety, and tolerability for women of childbearing age with bipolar I disorder: Meta-analysis from four randomized, placebo-controlled maintenance studies

This meta-analysis investigated the efficacy, safety, and tolerability of lamotrigine versus placebo in preventing relapse and recurrence of mood episodes in women of childbearing age with bipolar I disorder. Following up to 16 weeks' open-label lamotrigine treatment, responders were randomized to double-blind treatment, including lamotrigine 100-400 mg/day or placebo, in four trials of up to 76 weeks. Women aged 18-45 years who received ≥ 1 dose of study treatment and had ≥ 1 efficacy assessment in the double-blind phase were pooled for efficacy analysis. The primary outcome was median time to intervention for any mood episode (TIME). Of 717 eligible women in the open-label phase, 287 responded and were randomized to lamotrigine (n = 153) or placebo (n = 134). The randomized group had a mean (SD) of 2.0(2.02) manic and 2.5(2.02) depressive episodes in the 3 years before screening. Median TIME was 323 days with lamotrigine and 127 days with placebo (HR 0.69; 95% CI 0.49, 0.96; p = 0.030). Lamotrigine delayed time to intervention for any depressive episode (HR 0.59; 95% CI 0.39, 0.90; p = 0.014) with no treatment difference for manic episodes (HR 0.91; 95% CI 0.52, 1.58; p = 0.732). 2/717 (< 1%) participants experienced serious rash-related adverse events (AEs) during the open-label phase, and 52/717 (7%) had non-serious rash-related events leading to study withdrawal. Incidence of AEs and AEs leading to withdrawal were similar between lamotrigine and placebo groups. Lamotrigine delayed relapse and recurrence of mood episodes, largely by preventing depressive episodes, and was well tolerated in women of childbearing age.

Blocking channels to metastasis: targeting sodium transport in breast cancer

The development of therapies that can suppress invasion and prevent metastasis, 'anti-metastatic drugs', is an important area of unmet therapeutic need. The new results of a recent open-label, multicentre randomised trial published in J Clin Oncol showed a significant disease-free survival (DFS) benefit for breast cancer patients receiving presurgical, peritumoral injection of lidocaine, an amide local anaesthetic, which blocks voltage-gated sodium channels (VGSCs). VGSCs are expressed on electrically excitable cells, including neurons and cardiomyocytes, where they sustain rapid membrane depolarisation during action potential firing. As a result of this key biophysical function, VGSCs are important drug targets for excitability-related disorders, including epilepsy, neuropathic pain, affective disorders and cardiac arrhythmia. A growing body of preclinical evidence highlights VGSCs as key protagonists in regulating altered sodium influx in breast cancer cells, thus driving invasion and metastasis. Furthermore, prescription of certain VGSC-inhibiting medications has been associated with reduced cancer incidence and improved survival in several observational studies. Thus, VGSC-inhibiting drugs already in clinical use may be ideal candidates for repurposing as possible anti-metastatic therapies. While these results are promising, further work is required to establish whether other VGSC inhibitors may afford superior metastasis suppression. Finally, increasing preclinical evidence suggests that several other ion channels are also key drivers of cancer hallmarks; thus, there are undoubtedly further opportunities to harness ion transport inhibition that should also be explored.

Alterations in salivary biochemical composition and redox state disruption induced by the anticonvulsant valproic acid in male rat salivary glands

OBJECTIVE

To investigate the effects of the anticonvulsant valproic acid (VPA) on salivary glands in male rat using biochemical, functional, histomorphometric, and redox state parameters.

MATERIALS AND METHODS

Twenty-four male Wistar rats were randomly distributed into three groups (n = 8 per group): Control (0.9% saline solution), VPA100 (100 mg/kg), and VPA400 (400 mg/kg). After 21 consecutive days of treatment with by intragastric gavage. Pilocarpine-induced saliva was collected to determine salivary flow rate, pH, buffering capacity, and biochemical composition. Analyses of histomorphometric parameters and redox balance markers were performed on the parotid and submandibular glands.

RESULTS

Salivary flow rate, pH, buffering capacity, total protein, potassium, sodium, and chloride were similar between groups. However, phosphate and calcium were reduced in VPA400, while amylase was increased in both VPA100 and VPA400. We did not detect significant differences in the areas of acini, ducts, and connective tissue in the salivary glands between the groups. There were no significant changes in the redox status of the submandibular glands. In turn, in the parotid glands we detected reduced total oxidizing capacity and lipid peroxidation, measured as thiobarbituric acid reactive substances (TBARs) and higher uric acid concentration in both the VPA100 and VPA400 groups, and increased superoxide dismutase (SOD) in the VPA400 group.

CONCLUSION

Chronic treatment with VPA modified the salivary biochemical composition and caused disruption in the redox state of the parotid gland in rats.

Neuropathic pain: From actual pharmacological treatments to new therapeutic horizons

Neuropathic pain, caused by a lesion or disease affecting the somatosensory system, affects between 3 and 17% of the general population. The treatment of neuropathic pain is challenging due to its heterogeneous etiologies, lack of objective diagnostic tools and resistance to classical analgesic drugs. First-line treatments recommended by the Special Interest Group on Neuropathic Pain (NeuPSIG) and European Federation of Neurological Societies (EFNS) include gabapentinoids, tricyclic antidepressants (TCAs) and selective serotonin noradrenaline reuptake inhibitors (SNRIs). Nevertheless these treatments have modest efficacy or dose limiting side effects. There is therefore a growing number of preclinical and clinical studies aim at developing new treatment strategies to treat neuropathic pain with better efficacy, selectivity, and less side effects. In this review, after a brief description of the mechanisms of action, efficacy, and limitations of current therapeutic drugs, we reviewed new preclinical and clinical targets currently under investigation, as well as promising non-pharmacological alternatives and their potential co-use with pharmacological treatments.

Neuroimaging alterations associated with medication use in early-onset bipolar disorder: An updated review

BACKGROUND

Pediatric bipolar disorder (PBD) is a severe disorder characterized by mood fluctuations starting at a young age. Several neuroimaging studies revealed a specific biological signature of PBD involving alterations in the amygdala and prefrontal regions. Considering the growing concerns regarding the effects of PBD treatments on developing brains, this review aims to provide an overview of the studies investigating the effect of mood stabilizers, antipsychotics, and anticonvulsants on neuroimaging findings in PBD.

METHODS

We searched PubMed, Scopus, and Web of Science to identify all structural magnetic resonance imaging (sMRI), functional magnetic resonance imaging (fMRI), and diffusion tensor imaging (DTI) studies exploring the effects of medications on neuroimaging findings in PBD. A total of 18 studies met our inclusion criteria (fMRI n = 11, sMRI n = 6, DTI n = 1).

RESULTS

Although the findings varied highly across the studies, some investigations consistently indicated that medications primarily affect the prefrontal cortex and the amygdala. Moreover, despite some exceptions, the reported medication effects predominantly lean towards structural and functional normalization.

LIMITATIONS

The reviewed studies differ in methods, medications, and fMRI paradigms. Furthermore, most studies used observational approaches with small sample sizes, minimizing the statistical power.

CONCLUSIONS

Evidence suggests the potential of antipsychotics and mood stabilizers to modulate the neuroimaging findings in PBD patients, mostly normalizing brain structure and function in key mood-regulating regions.

Evaluation of common prescription analgesics and adjuvant analgesics as markers of suicide risk: a longitudinal population-based study in England

Background

Analgesics prescriptions may provide a marker for identifying individuals at higher risk of suicide. In particular, awareness of which analgesics are implicated may help clinicians assess and modify risk.

Method

A case-control study in England using the Clinical Practice Research Datalink (for primary care records) linked with hospital and national mortality electronic registries. We included patients aged ≥15 who died by suicide between 2001 and 2019 (N = 14,515), to whom we individually matched 580,159 controls by suicide date and general practice (N = 594,674). Odds ratios (ORs) for suicide, controlled for age and sex, were assessed using conditional logistic regression.

Findings

Suicide risks were highest in those prescribed adjuvant analgesics (pregabalin, gabapentin and carbamazepine) (adjusted OR 4.07; 95% confidence intervals CI: 3.62-4.57), followed by those prescribed opioids (adjusted OR 2.01; 95% CI: 1.88-2.15) and those prescribed non-opioid analgesics (adjusted OR 1.48; 95% CI: 1.39-1.58) compared to those not prescribed these medications. By individual analgesic, the highest suicide risks were seen in patients prescribed oxycodone (adjusted OR 6.70; 95% CI: 4.49-9.37); pregabalin (adjusted OR 6.50; 95% CI: 5.41-7.81); morphine (adjusted OR 4.54; 95% CI: 3.73-5.52); and gabapentin (adjusted OR 3.12; 95% CI: 2.59-3.75). Suicide risk increased linearly with the number of analgesic prescriptions in the final year (p < 0.01 based on the likelihood ratio test), and the more different analgesics categories were prescribed in the final year (p < 0.01 based on the likelihood ratio test).

Interpretation

Analgesic prescribing was associated with higher suicide risk. This is a particular issue with regard to adjuvant non-opiate analgesics.

Funding

There was no funding for this study.

Design, synthesis, and pharmacological evaluation of [1, 3] dioxolo-chromeno[2,3-b]pyridines as anti-seizure agents

An efficient one-pot three-component reaction for the synthesis of [1,3]dioxolo[4',5':6,7]chromeno[2,3-b]pyridines 4(a-i) has been developed. Synthesis was achieved by reacting sesamol (1), aromatic aldehydes 2(a-i), and 2-aminopropene-1,1,3-tricarbonitrile (3) in the presence of triethylamine at 100 °C under neat reaction condition. Simple operational procedure, broad substrate scope, column chromatography free separations, and high yield of products make it an efficient and largely acceptable synthetic strategy. Synthesized compounds 4(a-i) were further screened for preliminary anticonvulsant activity using MES and scPTZ tests. These analogs were also checked for neurotoxicity and hepatotoxicity. Selected active compounds have been then screened quantitatively to determine ED50 and TD50 values. Analog 4h was found effective in both preclinical seizure models with significant therapeutic/toxicity profile (4h: ED50 = 34.7 mg/kg, MES test; ED50 = 37.9 mg/kg, scPTZ test; TD50 = 308.7 mg/kg). Molecular dynamic simulation for 100 ns of compound 4h-complexed with GABAA receptor revealed good thermodynamic behavior and fairly stable interactions (4h, Docking score =  - 10.94). In conclusion, effective synthetic strategy, significant anticonvulsant activity with good toxicity profile and detailed molecular modeling studies led us to anticipate the emergence of these analogs as valid leads for the development of future effective neurotherapeutic agents.

Transfer of anticonvulsants and lithium into amniotic fluid, umbilical cord blood & breast milk: A systematic review & combined analysis

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.

Exploring new cyclohexane carboxamides based GABA agonist: Design, synthesis, biological evaluation, in silico ADME and docking studies

The new series of 5a-e, 6a-e and 7a-e derivatives were designed, synthesized and tested for their anticonvulsant activity using "gold standard methods" ScPTZ and MES model, neurotoxicity, liver enzymes and neurochemical assay. Screening of the synthesized analogues exhibited variable anticonvulsant potential especially in chemically induced seizures. Quantification study showed that compounds 6d and 6e were the most potent analogues with ED₅₀ 44.77 and 11.31 mg/kg, respectively in ScPTZ test. Compound 6e (0.031 mmol/kg) was about 2 fold more potent than phenobarbital (0.056 mmol/kg) and was 30 folds more potent than Ethosuximide (0.92 mmol/kg) as reference standard drug. Moreover, all the synthesized compounds were screened for acute neurotoxicity using the rotarod method to recognize motor impairment, whereas all compounds devoid from neurotoxicity except compound 5a, 5b, 7a and 7e. The most active compounds were examined for acute toxicity and the estimates for LD₅₀ were stated. Further neurochemical study was performed to investigate the effect of the most active compounds in ScPTZ test on GABA level in brain of the mice; a significant elevation in GABA level was obvious for compound 6d compared to control group confirming GABAergic modulating activity. Docking study was accomplished to examine the binding interaction of the newly synthesized analogues with GABA-AT enzyme. Additionally, physicochemical and pharmacokinetic parameters were predicted. The attained results indicate that the newly target compounds are considered a promising scaffolds for further development of newly anticonvulsants.

[Evaluation of the Knowledge of Women of Childbearing Age with Epilepsy about the Impact of Their Disease in Contraception, Pregnancy and Breastfeeding: A Multicenter Cross-Sectional Study]

INTRODUCTION

The interaction of antiseizure medication with contraceptives, its potential teratogenicity and implications in pregnancy and breastfeeding are aspects to consider in the neurological care of women with epilepsy of childbearing age. To ensure the commitment in therapeutic decisions and the appropriate planning of maternity, it is essential that women are informed about the implications of their disease in these domains. The main aim of this study was to assess the knowledge of women of childbearing age with epilepsy concerning the impact of epilepsy in contraception, pregnancy and breastfeeding. As secondary aims we defined (1) the demographic, clinical and therapeutic characterization of this group of patients, (2) the identification of variables that correlated with the level of knowledge of women with epilepsy, and (3) the identification of preferential methods to acquire new knowledge about epilepsy.

MATERIAL AND METHODS

The study was observational, cross-sectional and multicentric, and was carried out in five hospitals of the Lisbon metropolitan area. After identifying all women of childbearing age with epilepsy followed in the epilepsy clinic of each center, we applied an electronic questionnaire based on a non-systematic review of the literature.

RESULTS

One hundred and fourteen participants were validated, with a median age of 33 years. Half of the participants were on monotherapy, and the majority had no seizures in the last six months. We identified important gaps in the participants' knowledge. Sections about complications and administration of antiseizure medication during pregnancy were the ones with the worst results. None of the clinical and demographic variables correlated with the final questionnaire score. Having had a previous pregnancy and the desire to breastfeed in a future pregnancy were positively correlated with the performance in breastfeeding section. Face-to-face discussion during medical outpatient visits was selected as the preferential method to learn about epilepsy, and the internet and social media were the least preferred ones.

CONCLUSION

The knowledge of women of childbearing age with epilepsy in the Lisbon metropolitan area concerning the impact of epilepsy in contraception, pregnancy and breastfeeding seems to have significant gaps. Medical teams should consider engaging in patient education particularly during outpatient clinics.

Challenges in epilepsy diagnosis and management in a low-resource setting: An experience from Bhutan

Epilepsy is an important cause of morbidity and mortality especially in low- and middle-income countries. People with epilepsy (PWE) face difficulties in access to healthcare, appropriate diagnostic tests and anti-seizure medications (ASM). Bhutan is one such country in the Himalayas that has reported doubling of the prevalence of epilepsy from 155.7 per 100,000 population in 2017 to 312.4 in 2021. The country has one centre for electroencephalography and magnetic resonance imaging for a population of 0.7 million and does not have any neurologists as of 2023. There are 16 ASMs registered in the country but only selected medications are available at the primary level hospitals (phenobarbital, phenytoin and diazepam). There are challenges in the availability of these medicines all time round the year in all levels of hospitals. Neurosurgical treatment options are limited by the lack of adequate pre-surgical evaluation facilities and lack of trained human resources. The majority of PWE have reported facing societal stigma with significant impact on the overall quality of life. It is important to screen for psychiatric comorbidities and provide psychological support wherever possible. There is a need for a comprehensive national guideline that will cater to the needs of PWE and their caregivers within the resources available in the country. A special focus on the institutional and human resource capacity development for the study and care of epilepsy is recommended.

Pharmacological and toxicity effects of Zhumeria majdae and its bioactive constituents: A review

Zhumeria majdae Rech. F. & Wendelbo. traditionally has been used in several remedies, as a carminative agent especially for children, as an antiseptic agent, and it is used in treating diarrhea, stomach irritations, headaches, colds, convulsions, spasms, dysmenorrhea, and healing wounds. According to clinical studies, it is highly effective for reducing inflammation and pain, treating bacterial and fungal infections, morphine tolerance, morphine dependence, withdrawal syndrome symptoms, convulsions, and diabetes. The goal of this review is to find therapeutic opportunities by analyzing the traditional uses and pharmacological effects of the chemical constituents of Z. majdae. The information on Z. majdae in this review was gathered from scientific databases or search engines (PubMed, Wiley Online Library, Scopus, SID, Google Scholar, and Microsoft Academic). The literature cited in this review dates from 1992 to 2021. Several bioactive components including linalool, camphor, manool, and bioactive diterpenoids are presen in different parts of Z. majdae. Various properties were observed such as antioxidant, antinociceptive, anti-inflammatory, antimicrobial, antiviral, larvicidal, anticonvulsant, antidiabetic, and anticancer properties. Also, the effect of Z. majdae on morphine tolerance, morphine dependence, and withdrawal syndrome as well as its toxicology has been established. Although there are in vitro and animal studies on several pharmacological effects of Z. majdae, the lack of clinical studies is significant. Therefore, further clinical trials should be performed to confirm the in vitro and animal findings.

Supply problems of antiseizure medication are common among epilepsy patients in Germany

OBJECTIVE

To evaluate the frequency of reported antiseizure medication (ASM) supply problems among patients with epilepsy (PWE) in Germany.

METHODS

The Epi2020 study was a multicenter study focusing on different healthcare aspects of adult PWE in Germany. In addition to basic clinical and demographic characteristics, PWE were asked to answer a questionnaire regarding supply difficulties regarding their ASM, and if they had to discontinue ASM treatment due to supply problems. Generic switch of medication was recorded, and adverse effects were measured using the Liverpool Adverse Events Profile (LAEP) scale. Data were analyzed to detect predictors of supply problems.

RESULTS

In total, 434 PWE with a mean age of 40 years (median 37 years, SD = 15.5, range: 18-83 years, 254 female) participated in this study. 53.7% of PWE (n = 233) reported that at least once in the past 12 months their ASM was not available at the pharmacy, and 24.9% (n = 108) reported having experienced ASM supply problems three times or more during the past 12 months. Patients with epilepsy treated with carbamazepine and zonisamide reported frequent problems with availability in 45.8% and 44.8% respectively, whereas those treated with lacosamide and valproate reported supply problems less frequently (17.0% and 16.4%, respectively). Nine patients (2.1%) were unable to take their ASM as prescribed at least once in the past 12 months due to supply problems. Forty-nine patients (11.3%) reported having to switch ASM due to supply difficulties with generic replacement occurring in 39.4% (n = 171) of patients. Those with supply problems were more likely to be treated with more ASMs and scored higher on the LAEP.

CONCLUSION

Supply problems with ASM are frequent among PWE in Germany and are reported for older and newer ASMs. Supply problems contribute to ASM nonadherence and are positively correlated with the number of ASM taken and adverse events.

[Severe cutaneous drug reactions in children]

Severe cutaneous drug reactions also occur in children and range from reactions with blister forming of skin and mucosa to extensive exanthems with altered differential blood count and involvement of internal organs. The first group includes Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), which are considered as one disease entity with different degrees of severity and are also referred to as "epidermal" or "epithelial necrolysis" (EN). The group of drug reactions with primarily systemic alterations is represented by a condition known as drug reaction with eosinophilia and systemic symptoms (DRESS).Although EN is generally considered as a drug reaction, a causative agent can only be identified in about 50% of all pediatric cases. Once a clear diagnosis is established, specific treatment measures should be carried out, whereby discontinuation of the causative agent plays a decisive role in drug-induced cases. In order to be able to identify and discontinue the drug responsible, a detailed medication history must be obtained. Certain antiepileptic drugs, sulfonamides and sulfasalazine are among the most frequent triggers of EN and DRESS in children. Supportive therapy including appropriate topical treatment, pain management and ophthalmological consultations are of utmost importance in EN but a short-term immunomodulating treatment with cyclosporine A has been shown to be helpful. In contrast, in DRESS middle to long-term systemic treatment with glucocorticosteroids is recommended.

A Case of Perampanel Overdose Presenting with Respiratory Failure

Perampanel is a novel antiepileptic drug that has been used as an adjunctive treatment for focal-onset seizures. No reports to date have documented respiratory suppression as a side effect of perampanel in adults. Herein, we report a 51-year-old man with focal epilepsy presented with type 2 respiratory failure after accidently consuming of 66 mg of perampanel. Clinicians should consider the possibility of respiratory compromise whenever a high dose of perampanel needs to be administered to patients.

The effect of anticonvulsants on survival among patients with GBM brain tumors undergoing radiation: A SEER-Medicare analysis

BACKGROUND

Patients with glioblastoma multiforme (GBM) who undergo radiation often require anticonvulsants during treatment. The aim of this study was to determine the effects of anticonvulsants on GBM clinical outcomes.

METHODS

A retrospective analysis was performed using the SEER-Medicare database. All patients with GBM who were treated with radiation and concurrently taking an anticonvulsant were included in final analysis. Each class of medication was further subdivided by mechanism of action. Descriptive statistics were performed for all variables. Kaplan Meier survival curves were generated for each class of medication and Cox regression analysis was performed to assess the effect of each individual variable on survival.

RESULTS

There were 1561 patients available for final analysis. On multivariate Cox regression analysis, GBM patients taking sodium/calcium (Na/Ca) channel blocker anticonvulsants during radiation therapy demonstrated both improved overall survival (OS) (HR, 0.799; 95% CI [0.716, 0.891]; P < 0.001) and cancer specific survival (CSS) (HR, 0.814; 95% CI [0.727, 0.911]; P < 0.001).

CONCLUSION

OS was significantly better in patients taking NA/Ca channel blockers among patients with GBM who were concurrently undergoing radiation therapy.

Variability and efficacy in treatment effects on manic symptoms with lithium, anticonvulsants, and antipsychotics in acute bipolar mania: A systematic review and meta-analysis

BACKGROUND

Acute mania is a psychiatric emergency requiring rapid management. However, randomised controlled trials (RCTs) have shown considerable individual differences in treatment effects on manic symptoms with antimanic drugs.

METHODS

We searched the MEDLINE, CENTRAL, EMBASE, PsycINFO, and ClinicalTrials.gov to identify RCTs without language restrictions from inception to April 19, 2022. We included double-blind RCTs of oral antimanic monotherapy versus placebo in adult patients. The primary outcome was variability in improvement of manic symptoms (assessed using the coefficient of variation ratio [CVR]). The secondary outcomes were overall improvement of manic symptoms and acceptability (i.e., discontinuation for any reason). The pooled effects of outcomes were calculated by random-effects meta-analyses using restricted maximum likelihood methods. The quality of the included studies was assessed using the Cochrane Risk of Bias (ROB) Assessment Tool. This study was registered with OSF (DOI:10.17605/OSF.IO/G4JNY).

FINDINGS

We included 39 RCTs (N=12150; mean age=39·9 years, interquartile range [IQR]=38·7-41·1; mean proportion of female=48·6%, IQR=42·3%-52·3%) and investigated 14 antimanic drugs. We found that eight antimanic drugs compared to placebo were associated with lower CVRs (95% confidence interval [CI]; I²), including risperidone (0·51; 0·37-0·70; 0%), haloperidol (0·54; 0·44-0·67; 4%), olanzapine (0·59; 0·44-0·79; 47%), ziprasidone (0·61; 0·53-0·71; 0%), lithium (0·63; 0·52-0·76; 0%), quetiapine (0·65; 0·48-0·87; 2%), aripiprazole (0·68; 0·56-0·84; 25%), and cariprazine (0·70; 0·49-0·99; 28%). There were nine antimanic drugs associated with greater efficacy than placebo, including risperidone (reported as standardised mean difference; 95% CI; I²: 0·64; 0·31-0·97; 15%), haloperidol (0·57; 0·29-0·85; 64%), cariprazine (0·51; 0·24-0·78; 0%), olanzapine (0·44; 0·30-0·58; 0%), lithium (0·42; 0·29-0·55; 0%), ziprasidone (0·42; 0·26-0·58; 0%), quetiapine (0·40; 0·13-0·67; 0%), asenapine (0·40; 0·13-0·67; 0%), and aripiprazole (0·32; 0·14-0·49; 53%). Ziprasidone (reported as risk ratio; 95% CI; I²: 0·83; 0·79-0·89; 0%) and olanzapine (0·63; 0·49-0·80; 35%) were associated with better acceptability relative to placebo. Among the 39 RCTs, none had a high ROB.

INTERPRETATION

We demonstrated that eight antimanic drugs were associated with lower variability and better efficacy than placebo, suggesting that these antimanic drugs were associated with more homogenous and predictable improvements of manic symptoms in patients with acute mania.

FUNDING

The study was supported by from the Ministry of Science and Technology (MOST-110-2314-B-016-035, MOST-111-2314-B-016-054), Medical Affairs Bureau (MND-MAB-D-111102), and Tri-service General Hospital (TSGH-E-111229).

Pharmacological evidence for the possible involvement of the NMDA receptor pathway in the anticonvulsant effect of tramadol in mice

Background

Previous studies have shown controversial results regarding the pro- or anticonvulsant effects of tramadol. Additionally, the underlying mechanism of seizure induction or alleviation by tramadol has not been fully understood. In the current study, the effects of tramadol on pentylenetetrazole (PTZ)-induced seizure and the possible involvement of the N-methyl-D-aspartate (NMDA) pathway were assessed in mice.

Methods

Male Naval Medical Research Institute (NMRI) mice were treated with intravenous infusion of PTZ in order to induce clonic seizures and determine seizure threshold. Tramadol was injected intraperitoneally (0.1-150 mg/kg) 30 minutes prior to elicitation of seizures. The possible effects of intraperitoneal injections of NMDA receptor antagonists, ketamine (0.5 mg/kg) and MK-801 (0.5 mg/kg) on the anticonvulsant property of tramadol were investigated subsequently.

Results

Tramadol (1-100 mg/kg) increased PTZ-induced seizure threshold in a dose-dependent, time-independent manner, with optimal anticonvulsant effect at a dose of 100 mg/kg. Acute administration of either ketamine (0.5 mg/kg) or MK-801 (0.5 mg/kg) potentiated the anticonvulsant effect of a subeffective dose of tramadol (0.3 mg/kg).

Conclusion

These results suggest a possible role of the NMDA pathway in the anticonvulsant effect of tramadol.

Effects of Maternal Use of Antiseizure Medications on Child Development

Most children born to women with epilepsy (WWE) are normal, but have increased risks for malformations and poor neuropsychological outcomes. Antiseizure medications (ASMs) are among the most commonly prescribed teratogenic medications in women of childbearing age. However, WWE typically cannot avoid using ASMs during pregnancy. Teratogenic risks vary across ASMs. Valproate poses a special risk for anatomic and behavioral teratogenic risks compared with other ASMs. The risks for many ASMs remain uncertain. Women of childbearing potential taking ASMs should be taking folic acid. Breastfeeding while taking ASMs seems safe. WWE should receive informed consent outlining risks before conception.

Severity features of suicide attempters with epilepsy

BACKGROUND

After the Food and Drug Administration alert about antiepileptic medication and suicide, incident epilepsy has been associated with first or recurrent suicide attempts independently of psychiatric comorbidities and antiepileptic treatment. Following this thread, the aim of this study was to analyze if epilepsy was associated with a higher severity of lifetime suicide attempts (SAs).

METHODS

Analyses were carried out on 1677 adults hospitalized between 1999 and 2012 after a SA in a specialized ward for affective episodes. Five severity features were studied: frequent SAs (&gt;2), early onset of first SA (≤26 years), history of violent SA, high suicide intent and high lethality of the SA. Adjusted logistic regression models were used to estimate the association between the lifetime diagnosis of epilepsy and the severity features.

RESULTS

Among suicide attempters, ninety-three patients reported a lifetime diagnosis of epilepsy (5.5%). Epileptic patients diagnosed after the first SA were more likely to be frequent suicide attempters than non-epileptic ones. They showed also higher SA planification scores.

LIMITATIONS

Diagnosis accuracy is limited by the use of self-reports for epilepsy. The lack of precise information about the disease course and treatment have not allowed for further statistical analysis. With regard to psychiatric comorbidities, personality disorders could not be taken into account.

CONCLUSIONS

Suicide attempters with epilepsy present an increased severity in some aspects of their suicidal behavior regardless of demographic and clinical variables. Our results give support to the existence of a bidirectional association between epilepsy and suicidal behavior.

Off-label use of antidepressants, antipsychotics, and mood-stabilizers in psychiatry

Off-label drug prescribing in psychiatry is increasing. Many psychotropic drugs are approved for psychopathologic syndromes rather than based on international standard diagnostic classification systems which might facilitate the clinical decision for off-label prescriptions. The objective of this study was to analyze the prevalence and category of off-label use of psychotropic drugs. The study was conducted in 10 psychiatric hospitals in Germany over a period of 2 years. Prescription data of all patients were retrospectively analyzed after identification of antidepressants, antipsychotics, and mood-stabilizers, which were classified as off-label according to the German prescribing information and diagnostic classification according to ICD-10. In total, 53,909 patient cases (46% female) with a mean age of 46.8 (SD: 18) years were included in the study. 30.2% of the cases received at least one off-label prescription of a psychotropic drug during hospital stay. Off-label prevalence rates differed markedly between different diagnostic groups (ICD-10 F0/G3: 47%, F1: 33%, F2: 25%, F3: 21%, F4: 27%, F6: 46%, F7: 84%). The most often off-label prescribed drugs were quetiapine and mirtazapine for organic mental disorders (F0/G3), valproate and quetiapine in patients with disorders due to psychoactive substance use (F1), valproate in patients with psychotic disorders (F2), and risperidone and olanzapine in patients with affective disorders (F3). The prevalence rate of psychotropic off-label prescriptions is high if restricted to product description and ICD-10 diagnosis. Therefore, current psychiatric guidelines should drug-specifically issue this problem by defining psychiatric off-label indications based on a clear benefit-risk assessment.

Evaluation of factors associated with medication adherence in patients with bipolar disorder using a medication event monitoring system: a 6-month follow-up prospective study

BACKGROUND

Non-adherence in patients with bipolar disorder (BD) results in symptoms, such as aggravation, BD recurrence, emergency room visits, re-hospitalization, and poor psychosocial outcomes. Though non-adherence rates have been reported to range between 30-50% in patients with BD, the problem of adherence is often either overlooked by the physician or denied by the patient. An essential first step to enhancing medication adherence is to objectively estimate adherence. The Medication Event Monitoring System (MEMS), which is a pill bottle cap with a microprocessor, is an accurate device for assessing medication adherence. Using the MEMS, we aimed to measure medication adherence in patients with BD and evaluate the factors associated with and 6-month changes in medication adherence.

METHODS

Participants with BD were recruited from the psychiatric outpatient clinic of the Korea University Guro Hospital. The medication adherence of each participant was assessed using the MEMS, a self-report, pill count, and clinician rating. MEMS-measured adherence was reassessed after 6 months. Patient demographics were recorded and clinical assessments were conducted. Data were analyzed using Kappa statistics and Pearson's correlation analysis.

RESULTS

Of the 59 participants, 50 records were included in the analysis. Patient adherence and adherence rate assessed by the MEMS were lower than those assessed by the other measures. MEMS-measured adherence was correlated more closely with pill counts than with self-reports or clinician ratings. MEMS-measured adherence was negatively associated with prescription duration and the Brief Psychiatric Rating Scale-Affect Subscale Score. Six-month changes in MEMS-measured adherence were positively associated with attitude toward drugs and negatively associated with weight gain assessed by the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale.

CONCLUSIONS

Clinicians may have to consider the limited accuracy of self-reporting and clinician rating methods and exercise caution when assessing the medication adherence of patients with BD using these methods. Our findings may assist clinicians in the assessment and improvement of medication adherence in patients with BD and, consequently, may be useful for the treatment and prevention of BD recurrence.

COVID-19 and antiepileptic drugs: an approach to guide practices when nirmatrelvir/ritonavir is co-prescribed

Management and dose adjustment are a major concern for clinicians in the absence of specific clinical outcome data for patients on antiepileptic drugs (AEDs), in the event of short-term (5 days) nirmatrelvir/ritonavir co-exposure. Therefore, in this report, we identified drugs that require dose adjustment because of drug-drug interactions (DDIs) between nirmatrelvir/ritonavir and AEDs. We hereby used four databases (Micromedex Drug Interaction, Liverpool Drug Interaction Group for COVID-19 Therapies, Medscape Drug Interaction Checker, and Lexicomp Drug Interactions) and DDI-Predictor.In the light of applying the DDI-Predictor, for carbamazepine, clobazam, oxcarbazepine, eslicarbazepine, phenytoin, phenobarbital, pentobarbital, rufinamide, and valproate as CYP3A4 inducers, we recommend that a dose adjustment of short-term nirmatrelvir/ritonavir as a substrate (victim) drug would be more appropriate instead of these AEDs to avoid impending DDI-related threats in patients with epilepsy.

Risk factors for acute encephalitis and early seizure recurrence in complex febrile seizures

The purpose of this study is to elucidate risk factors for central nervous system infection and early seizure recurrence in children with febrile seizures (FSs) and thus facilitate outpatient management of complex FS. This single-center, retrospective cohort study investigated 688 children (6-60 months old) with FSs in Japan during 2011-2021. We investigated the incidence and clinical manifestations of children with acute encephalitis or bacterial meningitis. Logistic regression modeling was used to examine risk factors for seizure recurrence within 24 h. Among children with recurrent FSs, the distribution of intervals between first and second FS was assessed. Among 145 children with complex FSs, 2 patients (1.4%) had acute viral encephalitis and none had bacterial meningitis. Acute encephalitis was found in 2 of 8 patients (25%) with FSs prolonged ≥30 min and 2 of 3 patients (67%) requiring ≥2 intravenous anticonvulsants to stop seizures. Seizure recurrence within 24 h was observed in 16% of participants and was independently associated with preceding use of diazepam and family history of FS. In 82% of patients with FS recurrence within 24 h, early recurrences occurred within 8 h of the first seizure.      Conclusion: Patients with prolonged or refractory FSs are still indicated for hospital admission due to the risk of acute encephalitis. FS patients with a family history of FS may be managed safely by 8-h observation or single-dose rectal diazepam as prophylaxis against early recurrent seizure. What is Known: • Hospitalization has been recommended for children with complex febrile seizures due to the increased risk of central nervous infections. • Recent studies showed low incidences of bacterial meningitis (<1%) in children with complex febrile seizures in the presence of routine immunization. What is New: • Acute encephalitis was identified in 1.4% of children with complex febrile seizures, characterized by prolonged seizures ≥30 min and refractory seizures. • Early recurrent seizures may be safely managed by prophylactic diazepam or 8-h expectant observation.

Comparative effectiveness of mood stabilizers and antipsychotics in the prevention of hospitalization after lithium discontinuation in bipolar disorder

The aim of the study was to compare the real-world effectiveness of mood stabilizers and antipsychotics in the prevention of psychiatric hospitalizations and treatment failure after lithium discontinuation in a nationwide bipolar cohort. Using health-care registers, we identified everyone in Finland diagnosed with bipolar disorder during 1987-2018 who discontinued lithium after using it for at least one year (n = 4 052, median period of lithium use before discontinuation 2.7 years). The risk of psychiatric hospitalization and treatment failure (psychiatric hospitalization, death or change in medication) were investigated with within-individual Cox regression. Of mood stabilizer monotherapies, the periods of valproate use (HR = 0.83, 95% CI = 0.71 - 0.97) had lower risk of hospitalization than nonuse of mood stabilizers. Of antipsychotic monotherapies, the use of long-acting injectable (LAI) antipsychotics (HR = 0.48, 95% CI = 0.26 - 0.88) and chlorprothixene (HR = 0.62, 95% CI = 0.44 - 0.88) were associated with lower risk and the use of quetiapine (HR = 1.26, 95% CI = 1.07 - 1.48) and oral olanzapine (HR = 1.23, 95% CI = 1.01 - 1.49) with higher risk of psychiatric hospitalizations than nonuse of antipsychotics. Of mood stabilizer monotherapies, lithium use was associated with lower risk of treatment failure (HR = 0.82, 95% CI = 0.76 - 0.88) than valproate use. The results suggest that antipsychotic LAIs are especially effective in the prevention of psychiatric hospitalizations after lithium discontinuation. The need to alter used medications may be the lowest when lithium is restarted.

The use of prophylactic antiepileptic medication and driving restrictions for craniotomies among Australian and New Zealand neurosurgeons

Prophylactic antiepileptic drug (pAED) use for craniotomy surgery is currently not supported in literature [1-5] except possibly in traumatic brain injury (TBI) [6]. Post craniotomy driving restrictions using the Austroad guidelines are based upon literature on TBI and not specifically craniotomy [16-18]. This study was to review Australian and New Zealand neurosurgeons on their use of pAED and advice on driving restrictions post craniotomy surgery. A voluntary and anonymous survey link was distributed to the members of the Neurosurgical Society of Australasia (NSA) through the NSA newsletter. The survey was available on the SurveyMonkey platform in the year 2021 August to December. Questions regarding the use of pAED and duration of driving restrictions were presented to survey participants. Sixty-one (26 %) out of 231 neurosurgeons responded to the survey. Thirty-six percent of respondents stated that they prescribed pAEDs regularly whilst thirty-two percent of respondents did not routinely prescribe pAEDs for craniotomy surgery. Driving restrictions varied but the most common driving restriction post craniotomy surgery was 6 months. There were divided opinions among NSA members in regards to pAED use and driving restrictions. The rationale for pAED use and prolonged driving restrictions for craniotomy surgery needs to be re-evaluated with current literature. The significant effect this may have on the well-being and quality life of patients need to be considered before prescribing pAEDs or long driving restrictions.

Antiseizure Medication Treatment and Outcomes in Patients with Subarachnoid Hemorrhage Undergoing Continuous EEG Monitoring

BACKGROUND

Patients with aneurysmal subarachnoid hemorrhage (aSAH) with electroencephalographic epileptiform activity (seizures, periodic and rhythmic patterns, and sporadic discharges) are frequently treated with antiseizure medications (ASMs). However, the safety and effectiveness of ASM treatment for epileptiform activity has not been established. We used observational data to investigate the effectiveness of ASM treatment in patients with aSAH undergoing continuous electroencephalography (cEEG) to develop a causal hypothesis for testing in prospective trials.

METHODS

This was a retrospective single-center cohort study of patients with aSAH admitted between 2011 and 2016. Patients underwent ≥ 24 h of cEEG within 4 days of admission. All patients received primary ASM prophylaxis until aneurysm treatment (typically within 24 h of admission). Treatment exposure was defined as reinitiation of ASMs after aneurysm treatment and cEEG initiation. We excluded patients with non-cEEG indications for ASMs (e.g., epilepsy, acute symptomatic seizures). Outcomes measures were 90-day mortality and good functional outcome (modified Rankin Scale scores 0-3). Propensity scores were used to adjust for baseline covariates and disease severity.

RESULTS

Ninety-four patients were eligible (40 continued ASM treatment; 54 received prophylaxis only). ASM continuation was not significantly associated with higher 90-day mortality (propensity-adjusted hazard ratio [HR] = 2.01 [95% confidence interval (CI) 0.57-7.02]). ASM continuation was associated with lower likelihood for 90-day good functional outcome (propensity-adjusted HR = 0.39 [95% CI 0.18-0.81]). In a secondary analysis, low-intensity treatment (low-dose single ASM) was not significantly associated with mortality (propensity-adjusted HR = 0.60 [95% CI 0.10-3.59]), although it was associated with a lower likelihood of good outcome (propensity-adjusted HR = 0.37 [95% CI 0.15-0.91]), compared with prophylaxis. High-intensity treatment (high-dose single ASM, multiple ASMs, or anesthetics) was associated with higher mortality (propensity-adjusted HR = 6.80 [95% CI 1.67-27.65]) and lower likelihood for good outcomes (propensity-adjusted HR = 0.30 [95% CI 0.10-0.94]) compared with prophylaxis only.

CONCLUSIONS

Our findings suggest the testable hypothesis that continuing ASMs in patients with aSAH with cEEG abnormalities does not improve functional outcomes. This hypothesis should be tested in prospective randomized studies.

Drug Safety in Episodic Migraine Management in Adults. Part 2: Preventive Treatments

PURPOSE OF REVIEW

The aim of this review is to aid in decision-making when choosing safe and effective options for preventive migraine medications.

RECENT FINDINGS

In Part 2, we have compiled clinically relevant safety considerations for commonly used migraine prophylactic treatments. Preventive treatment of episodic migraine includes nonspecific and migraine-specific drugs. While medications from several pharmacological classes-such as anticonvulsants, beta-blockers, and antidepressants-have an established efficacy in migraine prevention, they are associated with a number of side effects. The safety of migraine-specific treatments such as anti-CGRP monoclonal antibodies and gepants are also discussed. This review highlights safety concerns of commonly used migraine prophylactic agents and offers suggestions on how to mitigate those risks.

Adverse Fetal and Neonatal Outcomes following in-utero exposure to Oxcarbazepine: A Systematic Review and Meta-Analysis

AIM

This systematic review aims to assess the safety profile of oxcarbazepine during pregnancy.

METHODS

Observational studies that included women who took oxcarbazepine anytime during pregnancy were included in our systematic review. The review did not include non-English articles, reviews, meta-analyses, case reports, and animal studies. Different online sources such as MEDLINE, Cochrane library, Virtual Health Library, etc. were searched for published and unpublished literature. Assessment of the risk of bias in observational studies was done using the Newcastle-Ottawa Scale. The meta-analyses were performed using a random-effect model. GRADE was used for the evaluation of the quality of evidence for the primary outcomes.

RESULTS

We included 19 cohort studies with a total number of 5,071,137 patients, of which 2,450 were exposed to oxcarbazepine either as monotherapy or polytherapy. The summary odds ratio (OR) was 1.69 (95% CI, 0.95-2.98) for congenital malformations following in-utero exposure to oxcarbazepine as compared to the control group of unexposed patients [seven studies (n=625)], and was 1.19 (95% CI, 0.67-2.12) when compared to those following lamotrigine (LTG) exposure during pregnancy [3 studies (n=591)]. In total, three studies (n=770) reported the association between in-utero oxcarbazepine exposure and fetal/perinatal deaths. The meta-analysis yielded a summary OR of 3.33 (95% CI, 1.70-6.51).

SIGNIFICANCE

Our systematic review will help healthcare providers and guideline developers regarding the treatment of epilepsy and other neurological disorders during pregnancy. More cohort studies with a higher sample size concerning oxcarbazepine use in pregnant patients are required to truly assess the in-utero safety profile of the drug.

Worth the paper they're printed on? Findings from an independent evaluation of how understandable patient information leaflets for antiseizure medications are

OBJECTIVE

The Patient Information Leaflet (PIL) is an authoritative document that all people with epilepsy (PWE) in the European Union receive when prescribed anti-seizure medication (ASM). We undertook the first independent, comprehensive assessment to determine how understandable they are. Regulators state that when patients are asked comprehension questions about them, ≥80% should answer correctly. Also recommended PILs have a maximum reading requirement of US Grade 8.

METHODS

Study 1: Obtained 140 current ASM PILs written in English. 'Readability' assessed using 4 tests, with and without adjustment for influence of familiar, polysyllabic words. 179 online materials on epilepsy also assessed. Study 2: Two PILs from Study 1 randomly selected (Pregabalin Focus; Inovelon) and shown to 35 people from UK epilepsy population. Their comprehension was assessed. Study 3: To understand whether student population provides accessible alternative population for future examination of ASM PILs, Study 3 was completed. Used same methods as Study 2 but participants were 262 UK university students.

RESULTS

Study 1: No PIL had a reading level of Grade 8. Median was 11. Adjusting for context, the PILs were still at Grade 10.5. PILs for branded ASMs were most readable. PILs were no more readable than (unregulated) online materials. Study 2: Users struggled to comprehend the PILs key messages. The 8 questions asked about pregabalin were typically answered correctly by 54%. For Inovelon it was 62%. Study 3: Most student participants comprehend the PILs key messages. The questions about Inovelon were answered correctly by 90%; for pregabalin it was 86%.

SIGNIFICANCE

This is the first independent and comprehensive examination of ASM PILs. Found PILs being used fail to meet recommendations and regulatory requirements and risk not being understandable to substantial proportion of users. In finding that people from epilepsy population differ markedly in comprehension of PILs compared to students, study highlights importance of completing user testing with the target population.

Trends in antiseizure medication prescription patterns among all adults, women, and older adults with epilepsy: A German longitudinal analysis from 2008 to 2020

INTRODUCTION

The prescription patterns of antiseizure medication (ASM) are subject to new scientific evidence and sociodemographic and practical aspects. This study analyzed trends in ASM prescription patterns among all adults with epilepsy, with special consideration for women of childbearing potential (WOCBP) and older adult (≥65 years old) patients.

METHODS

Data from four questionnaire-based cohort studies, conducted in 2008, 2013, 2016, and 2020, were analyzed for ASM prescription frequencies and common mono- and dual therapy regimens. Statistical comparisons were performed with the Chi-square test and one-way analysis of variance.

RESULTS

Overall, the individual prescription patterns among 1,642 adult patients with epilepsy were analyzed. A significant increase in the prescription frequency of third-generation ASMs, from 59.3% to 84.2% (p = 0.004), was accompanied by a decrease in the frequency of first- and second-generation ASMs (5.4% to 2.1% and 34.9% to 12.6%, respectively). This trend was accompanied by a significant decrease in the use of enzyme-inducing ASMs, from 23.9% to 4.6% (p = 0.004). Among frequently prescribed ASMs, prescriptions of carbamazepine (18.6% to 3.1%, p = 0.004) and valproate (15.4% to 8.7%, p = 0.004) decreased, whereas prescriptions of levetiracetam (18.0% up to 32.4%, p = 0.004) increased significantly. The prescription frequency of lamotrigine remained largely constant at approximately 20% (p = 0.859). Among WOCBP, the prescription frequencies of carbamazepine (11.4% to 2.0%, p = 0.004) and valproate (16.1% to 6.1%, p = 0.004) decreased significantly. Levetiracetam monotherapy prescriptions increased significantly (6.6% to 30.4%, p = 0.004) for WOCBP, whereas lamotrigine prescriptions remained consistent (37.7% to 44.9%, p = 0.911). Among older adult patients, a significant decrease in carbamazepine prescriptions (30.1% to 7.8%, p = 0.025) was the only relevant change in ASM regimens between 2008 and 2020. In patients with genetic generalized epilepsies, levetiracetam was frequently used as an off-label monotherapy (25.0% to 35.3%).

CONCLUSION

These results show a clear trend toward the use of newer and less interacting third-generation ASMs, with lamotrigine, levetiracetam, and lacosamide representing the current ASMs of choice, displacing valproate and carbamazepine over the last decade. In WOCBP, prescription patterns shifted to minimize teratogenic effects, whereas, among older adults, the decrease in carbamazepine use may reflect the avoidance of hyponatremia risks and attempts to reduce the interaction potential with other drugs and ASMs. Levetiracetam is frequently used off-label as a monotherapy in patients with genetic generalized epilepsy.

The prevalence and major determinants of non-compliance with anti-seizure medication among children

Background: A wide range of adherence to the use of anti-seizure medications has been reported among children with the disease, and accordingly, various factors on the degree of adherence to the drug have been reported. But in our society, there is no clear picture of drug adherence and related factors among children with seizures. We evaluated the frequency of adherence to anti-seizure medication as well as related factors. Methods: This cross-sectional study was conducted on 120 children with epilepsy who referred to Ali Asghar Hospital in Tehran, Iran, during 2019 and 2020. Along with demographic characteristics, adherence to antiepileptic medications was assessed by the Modified Morisky Scale (MMS). Results: The overall frequency of adherence to anti-seizure medications among children was reported to be about 41.7%. Among all baseline characteristics, much higher adherence was revealed in patients with educated parents. The rate of drug adherence in children with a history of perinatal morbidities was much lower than in other patients. The type of seizure could also affect the rate of drug adherence as the highest and the lowest adherence was found concerning focal impaired awareness seizure (57.1%) and atonic seizures (11.1%) indicating a significant difference (P = 0.022). The most common causes of non-adherence to treatment were expressing inability to treat the patient (23.0%), parents' forgetfulness to give medicine to the child (18.3%), and not taking medication when traveling or leaving home (16.7%). Conclusion: The lower level of education of the parents, type of seizure, as well as the presence ofunderlying perinatal morbidity in the child can predict non-compliance with anticonvulsant medication regimens among affected children.

Levetiracetam-induced gingival hyperplasia

Levetiracetam is a new generation antiseizure medication which binds to synaptic vesicle protein SV2A and inhibits the release of neurotransmitters. Gingival hyperplasia is a common side effect of conventional antiseizure medications like phenytoin, but very rare with the newer ones. A 14-year-old boy was started on levetiracetam 250 mg twice daily after a generalized seizure. Five days later he presented with gingival swelling and painful oral aphthae, without lymphadenopathy or systemic symptoms. Blood investigations were normal. After one-month of stopping the drug, the lesions cleared. This case highlights the importance of maintaining good oral hygiene and periodic dental review in patients on antiseizure medications.

Patterns of Antiepileptic Drug Reactions in Children: A Multicenter Study

Objectives

Antiepileptic drugs are among the most common triggers of cutaneous adverse reactions. About 5-17% of epileptic patients develop idiosyncratic skin reactions at some point during their treatment course, most of which occur within the first two months of drug initiation. This study aimed to investigate the pattern of cutaneous drug reactions associated with anticonvulsant use among the pediatric population in Iran to identify high-risk individuals.

Materials & Methods

In this retrospective descriptive study, medical records of children aged two months to 14 years, who were diagnosed with drug reactions due to anticonvulsant drugs between April 2007 and March 2018, were reviewed, and relevant information were extracted. This multicenter study was conducted in several provinces of Iran.

Results

A total of 186 cases with a final diagnosis of the antiepileptic drug-induced eruption were evaluated. The median age of participants was 36 months (range: 2-168), and 56% were male. In approximately 70% of the children, the phenobarbital was the culprit. The median time interval between initiation of the causative drug and development of rash and fever was 10 and 7 days, respectively. The most common rash type was maculopapular rashes (69%). Overall, 33% of the patients only received antihistamines after discontinuation of the causative drug.

Conclusion

Similar to previously published studies in Iran, phenobarbital was the main cause of cutaneous drug reactions to antiepileptic drugs, indicating the necessity of paying more attention when prescribing phenobarbital for Iranian pediatrics.

Seizures and epilepsy in patients with ischaemic stroke

BACKGROUND

With the increased efficacy of stroke treatments, diagnosis and specific treatment needs of patients with post-stroke seizures (PSS) and post-stroke epilepsy have become increasingly important. PSS can complicate the diagnosis of a stroke and the treatment of stroke patients, and can worsen post-stroke morbidity. This narrative review considers current treatment guidelines, the specifics of antiseizure treatment in stroke patients as well as the state-of-the-art in clinical and imaging research of post-stroke epilepsy. Treatment of PSS needs to consider indications for antiseizure medication treatment as well as individual clinical and social factors. Furthermore, potential interactions between stroke and antiseizure treatments must be carefully considered. The relationship between acute recanalizing stroke therapy (intravenous thrombolysis and mechanical thrombectomy) and the emergence of PSS is currently the subject of an intensive discussion. In the subacute and chronic post-stroke phases, important specific interactions between necessary antiseizure and stroke treatments (anticoagulation, cardiac medication) need to be considered. Among all forms of prevention, primary prevention is currently the most intensively researched. This includes specifically the repurposing of drugs that were not originally developed for antiseizure properties, such as statins. PSS are presently the subject of extensive basic clinical research. Of specific interest are the role of post-stroke excitotoxicity and blood-brain barrier disruption for the emergence of PSS in the acute symptomatic as well as late (> 1 week after the stroke) periods. Current magnetic resonance imaging research focussing on glutamate excitotoxicity as well as diffusion-based estimation of blood-brain barrier integrity aim to elucidate the pathophysiology of seizures after stroke and the principles of epileptogenesis in structural epilepsy in general. These approaches may also reveal new imaging-based biomarkers for prediction of PSS and post-stroke epilepsy.

CONCLUSION

PSS require the performance of individual risk assessments, accounting for the potential effectiveness and side effects of antiseizure therapy. The use of intravenous thrombolysis and mechanical thrombectomy is not associated with an increased risk of PSS. Advances in stroke imaging may reveal biomarkers for PSS.

Effects of anti-seizure medications on sleep architecture and daytime sleepiness in patients with epilepsy: A literature review

Anti-seizure medications (ASMs) may improve or be detrimental to sleep. A literature review (as an update to the 2014 review by Jain and Glauser [https://doi.org/10.1111/epi.12478]) of 25 ASMs of interest (articles from 12 ASMs included) on the effect of ASMs/non-drug treatments on sleep in patients with epilepsy was conducted. The most common objective instrument was polysomnography, and the most common subjective measures were the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index. Eslicarbazepine acetate, lacosamide, and perampanel improved or had no effect on sleep. Perampanel was associated with low incidence of insomnia, and lacosamide with low incidence of daytime sleepiness adverse events. Clonazepam, felbamate, lamotrigine, oxcarbazepine, and phenobarbital worsened or had no effect on sleep. Lamotrigine may be associated with insomnia risk and phenobarbital with daytime sleepiness. Data for valproic acid were mixed. Overall, cannabidiol, carbamazepine, and levetiracetam had no effect on sleep. Epilepsy surgery may benefit sleep in patients with a good surgical outcome. Some ASMs, and, possibly, epilepsy surgery, may have positive effects on sleep, possibly linked to achieving seizure control. Nonetheless, other ASMs may worsen sleep in some settings. Clinicians should consider such observations when making treatment decisions, particularly for patients with comorbid sleep disorders.

Pharmacological and non-pharmacological strategies for preventing postherpetic neuralgia: a systematic review and network meta-analysis

Background

Postherpetic neuralgia (PHN) is a refractory complication of herpes zoster (HZ). To prevent PHN, various strategies have been aggressively adopted. However, the efficacy of these strategies remains controversial. Therefore, we aimed to estimate the relative efficacy of various strategies used in clinical practice for preventing PHN using a network meta-analysis (NMA).

Methods

We performed a systematic and comprehensive search to identify all randomized controlled trials. The primary outcome was the incidence of PHN at 3 months after acute HZ. We performed both frequentist and Bayesian NMA and used the surface under the cumulative ranking curve (SUCRA) values to rank the interventions evaluated.

Results

In total, 39 studies were included in the systematic review and NMA. According to the SUCRA value, the incidence of PHN was lower in the order of continuous epidural block with local anesthetics and steroids (EPI-LSE), antiviral agents with subcutaneous injection of local anesthetics and steroids (AV + sLS), antiviral agents with intracutaenous injection of local anesthetics and steroids (AV + iLS) at 3 months after acute HZ. EPI-LSE, AV + sLS and AV + iLS were also effective in preventing PHN at 1 month after acute HZ. And paravertebral block combined with antiviral and antiepileptic agents was effective in preventing PHN at 1, 3, and 6 months.

Conclusions

The continuous epidural block with local anesthetics and steroid, antiviral agents with intracutaneous or subcutaneous injection of local anesthetics and a steroid, and paravertebral block combined with antiviral and antiepileptic agents are effective in preventing PHN.

Continuous Electroencephalogram and Antiseizure Medication Use in an International Pediatric Traumatic Brain Injury Population

BACKGROUND

Electrographic seizures are frequent and associated with worse outcomes following traumatic brain injury (TBI). Despite this, the use of continuous electroencephalogram (cEEG) remains low. Our study describes cEEG usage and treatment dosing antiseizure medications (ASMs) in an international pediatric TBI population, hypothesizing that children monitored with cEEG have an increased rate of treatment ASMs because of electrographic seizure detection, compared with children who are not monitored with cEEG.

METHODS

This subanalysis of the TBI cohort of the international PANGEA study included children, 7 days to 17 years of age, with acute neurological insults admitted to pediatric intensive care units. We analyzed demographics, injury severity, and therapies including prophylactic or treatment ASMs. We evaluated the relationships between cEEG use, seizure frequency, and receipt of treatment ASMs. [Formula: see text] or Fisher's exact test was used to analyze categorical variables, and the Kruskal-Wallis or Mann-Whitney U-test was used for continuous variables. Multivariable analysis for treatment ASM use was performed using logistic regression.

RESULTS

One hundred-twenty-three of 174 patients with TBI were included. Twenty-seven patients (21.9%) underwent cEEG at any point during pediatric intensive care unit admission. Preexisting seizure disorder (18.2% vs. 2.3%, p = 0.014) and neuromuscular blockade use (52.4% vs. 24.1%, p = 0.011) were more frequently observed in the group monitored on cEEG when compared with those that were not. Presenting median Glasgow Coma Scale score was worse in the cEEG group (7 vs. 9, p = 0.044). There was no significant difference in age, use of intracranial pressure monitoring, or hyperosmolar therapy between the cEEG monitored and nonmonitored groups. Patients who were monitored on cEEG were more likely to receive a treatment dose ASM than those without cEEG monitoring (66.7% vs. 28.1%, p = 0.0002). When compared with those without treatment ASM, the treatment ASM group had more electrographic seizures on their first electroencephalogram following injury (51.6% vs. 4%, p = 0.0001) and more clinical seizures (55.8% vs. 0%, p < 0.0001).

CONCLUSIONS

Children monitored with cEEG after TBI have an increased prescription of treatment ASMs and clinical and electrographic seizures. The increased rate of treatment ASMs in the cEEG group may indicate increased recognition of electrographic seizures.

Treatment of bipolar disorders in older adults: a review

BACKGROUND

Old age bipolar disorder has been an orphan of psychiatric research for a long time despite the fact that bipolar disorder (BD)-I and II together may affect 0.5-1.0% of the elderly. It is also unclear whether aetiology, course of illness and treatment should differ in patients with a first manifestation in older age and patients suffering from a recurrence of a BD known for decades. This narrative review will summarize the current state of knowledge about the epidemiology, clinical features, and treatment of BD in the elderly.

METHODS

We conducted a Medline literature search from 1970 to 2021 using MeSH terms "Bipolar Disorder" × "Aged" or "Geriatric" or "Elderly". Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Varying cut-off ages have been applied to differentiate old age from adult age BD. Within old age BD, there is a reasonable agreement of distinct entities, early and late-onset BD. They differ to some extent in clinical symptoms, course of illness, and some co-morbidities. Point prevalence of BD in older adults appears slightly lower than in working-age adults, with polarity of episodes shifting towards depression. Psychopharmacological treatment needs to take into account the special aspects of somatic gerontology and the age-related change of pharmacokinetic and pharmacodynamic characteristics. The evidence for commonly used treatments such as lithium, mood-stabilizing antiepileptics, antipsychotics, and antidepressants remains sparse. Preliminary results support a role of ECT as well as psychotherapy and psychosocial interventions in old age BD.

CONCLUSIONS

There is an obvious need of further research for all treatment modalities of BD in old age. The focus should be pharmacological and psychosocial approaches, as well as their combination, and the role of physical treatment modalities such as ECT.

Effects of Gabapentin on Dorsal Anterior Cingulate Cortex GABA and Glutamate Levels and Their Associations With Abstinence in Alcohol Use Disorder: A Randomized Clinical Trial

OBJECTIVE

Although gabapentin has demonstrated efficacy in mitigating alcohol withdrawal symptoms and preventing relapse drinking in individuals with alcohol use disorder (AUD), the neurobiological mechanisms of action underlying these therapeutic effects remain unknown. The present study evaluated changes in GABA and glutamate levels in the dorsal anterior cingulate cortex (dACC) as candidate mechanisms of action.

METHODS

In a 16-week randomized clinical trial, 68 adults with AUD, including a history of alcohol withdrawal syndrome, received 1,200 mg/day of gabapentin (N=37) or placebo (N=31) and nine medical management visits after ≥72 hours of abstinence. Proton MR spectroscopy (¹H-MRS) estimates of dACC levels of GABA (N=67) and glutamate (N=64) were acquired before start of treatment and again approximately 14 days after randomization. Percent days abstinent was reported via timeline followback interview.

RESULTS

The effects of gabapentin on GABA and glutamate levels were significantly associated with participants' percent days abstinent during early treatment. Specifically, gabapentin was associated with greater increases in glutamate and greater decreases in GABA levels in participants who remained mostly or entirely abstinent, and yet the opposite in participants who drank on more than half of the days preceding the second scan. Furthermore, gabapentin-treated participants with greater increases in glutamate levels during early treatment had significantly more percent days abstinent across the remainder of the study, relative to placebo-treated participants.

CONCLUSIONS

In addition to providing insight into the mechanisms through which gabapentin may promote abstinence in individuals with AUD, this study also provides evidence for a biomarker of efficacious treatment that may be used to evaluate other glutamatergic or GABAergic medications for AUD and related conditions.

Anticonvulsant and neuroprotective effects of carbamazepine-levetiracetam adjunctive treatment in convulsive status epilepticus rat model: Inhibition of cholinergic transmission

This study evaluated the anticonvulsant and neuroprotective effects of carbamazepine (CBZ), levetiracetam (LEV), and CBZ + LEV adjunctive treatment in convulsive status epilepticus (CSE) rat model. Twenty-five male Wistar rats were randomized into five groups (n = 5). Groups I and II received 0.2 ml of normal saline intraperitoneally (i.p), while groups III-V received CBZ (25 mg/kg i.p), LEV (50 mg/kg i.p) or combination of sub-therapeutic doses of CBZ (12.5 mg/kg i.p) and LEV (25 mg/kg i.p). Thirty minutes later, seizure was kindled with pilocarpine hydrochloride (350 mg/kg) in group II-V rats. Seizure indices, markers of excitotoxicity, and astroglioses were determined, while the hippocampal morphometry was also evaluated. The data was analysed using descriptive and inferential statistics, while the results were presented as mean ± SEM in graphs or tables, and the level of significance was taken at p < 0.05. The anticonvulsant treatments delayed the inception of seizure indices (p = 0.0006), while the percentage mortality decreased significantly (p = 0.0001) in all the treatment groups. The hippocampal concentrations of acetylcholine, malondialdehyde, and tissue necrotic factor-alpha decreased significantly (p = 0.0077) in all the treated group relative to the positive control. The reactive astrogliosis in the hippocampus (CA 1) increased significantly (p = 0.0001) compared with the control but abrogated in all the treatment groups relative to the positive control. The anticonvulsant and neuroprotective effects are in this order: LEV < CBZ + CBZ < CBZ. The drug efficacy is attributable to the inhibition of cholinergic transmission.

Risk of Stevens-Johnson syndrome and toxic epidermal necrolysis associated with anticonvulsants in a Japanese population: Matched case-control and cohort studies

BACKGROUND

Evidence for the risk and incidence of anticonvulsant-induced Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in Japan is scarce.

METHODS

We conducted a matched case-control study using a large-scale Japanese claims database. SJS/TEN cases were identified using a claims-based algorithm developed in a previous study (sensitivity 76.9%, specificity 99.0%). Conditional logistic regression with Firth's bias correction to address an issue of rare events was used to estimate odds ratios (ORs) for SJS/TEN for each anticonvulsant use (90 days before the index date) versus non-use. 90-day cumulative incidence of SJS/TEN per 100,000 new users was calculated for 33 anticonvulsants. Causality between anticonvulsant use and SJS/TEN in each exposed case was assessed using the algorithm of drug causality for epidermal necrolysis (ALDEN) score.

RESULTS

From 5,114,492 subjects, we selected 71 SJS/TEN cases and 284 controls. We observed significantly increased ORs for SJS/TEN among new users of carbamazepine (OR 68.00) and lamotrigine (OR 36.00) with ALDEN scores of "probable" or higher. Cumulative incidence of SJS/TEN was 93.83 for carbamazepine and 84.33 for lamotrigine. One case newly exposed to phenytoin which developed SJS/TEN was rated "unlikely" in ALDEN causality, resulting in cumulative incidence of 66.27. Cumulative incidence of SJS/TEN was 25.23 for levetiracetam, 7.52 for clonazepam, and 1.23 for diazepam, but their ALDEN scores were "very unlikely".

CONCLUSIONS

This study is the first to document the differential risk of SJS/TEN for anticonvulsants in a real-world setting in Japan. Exposure to carbamazepine and lamotrigine was associated with an increased risk of SJS/TEN.