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Karamian A, Farzaneh H, Taheri M, Seifi A. Effectiveness of Levetiracetam versus phenytoin in preventing seizure in traumatic brain injury patients: A systematic review and meta-analysis. Clin Neurol Neurosurg 2024; 240:108251. [PMID: 38569246 DOI: 10.1016/j.clineuro.2024.108251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/06/2024] [Accepted: 03/18/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Traumatic brain injury (TBI) and the subsequent Post-traumatic seizure (PTS) is a growing public health concern. Generally, anti-seizure drugs (ASDs) are recommended for PTS prophylaxis and treatment. This meta-analysis aimed to review the current state of knowledge and the evidence for the efficacy and safety of Levetiracetam (LEV) on the incidence of seizure in TBI patients compared to Phenytoin (PHT). METHODS A search was carried out based on PubMed, MEDLINE, Europe PMC database, and Cochrane Library up to November 2023. A total of 16 studies (3 randomized clinical trials, 10 retrospective cohort studies, and 3 prospective cohort studies) including 5821 TBI patients included in our meta-analysis. We included studies comparing LEV and PHT after brain injury in both adults and children. Risk of bias assessment was done for randomized controlled trials (RCTs) with a risk-of-bias tool (RoB-2) and the Newcastle-Ottawa Scale (NOS) was used to assess the quality of cohort studies. Two RCTs in our meta-analysis had a high risk of bias, therefore we applied sensitivity analysis to evaluate the robustness of our results. RESULTS The most commonly reported dosage for LEV was 500 mg twice daily and for PHT it was 5 mg/kg. There was no significant difference between LEV and PHT groups in reducing the early seizure incidence (OR = 0.85; 95% CI = [0.60, 1.21]; p = 0.375, fixed-effect, I2 = 21.75%). The result of sensitivity analysis for late seizure showed no significant difference between LEV and PHT in reducing the late seizure occurrence after TBI (OR = 0.87; 95% CI = [0.21, 3.67]; p = 0.853, fixed-effect, I2 = 0%). The mortality in TBI patients treated with LEV was not statistically significant compared to the PHT group (OR = 1.11; 95% CI = [0.92, 1.34], p = 0.266). The length of stay in the hospital was not significantly different between the LEV and PHT groups (MD = -1.33; 95% CI = [-4.55, 1.90]; p = 0.421). However, in comparison to PHT, LEV shortened the length of ICU stay (MD = -2.25; 95% CI = [-3.58, -0.91]; p =0.001). In terms of adverse effects, more patients in the PHT group have experienced adverse events compared to LEV but the difference was not significant (OR = 0.69; 95% CI = [0.44, 1.08]; p = 0. 11). CONCLUSION The results of our meta-analysis showed LEV and PHT have similar effects on the occurrence of early and late seizures in TBI patients. Therefore, none of the drugs is superior to the other in reducing PTS. However, treating TBI patients with LEV did not shorten the length of hospital stay in comparison to PHT but reduced the length of ICU stay significantly. The analysis showed that patients in the LEV experienced fewer side effects than in the PHT group, while it was not sufficiently clear whether all reported side effects were related to the drug alone or other factors. The mortality was similar between the LEV and PHT groups. Finally, we recommend more high-quality randomized controlled trials to confirm the current findings before making any recommendations in practice.
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Affiliation(s)
- Armin Karamian
- School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Hana Farzaneh
- Department of Radiology (Neuroradiology) at Massachusetts General Hospital, United States
| | - Mojtaba Taheri
- Department of Surgery, University of Baltimore, MD, United States
| | - Ali Seifi
- Department of Neurosurgery, Division of Neurocritical Care, University of Texas Health at San Antonio, San Antonio, TX 78229, United States.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lee PY, Wei YT, Chao KSC, Chu CN, Chung WH, Wang TH. Anti-epileptic drug use during adjuvant chemo-radiotherapy is associated with poorer survival in patients with glioblastoma: A nationwide population-based cohort study. J Cancer Res Ther 2024; 20:555-562. [PMID: 38687925 DOI: 10.4103/jcrt.jcrt_750_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 10/31/2022] [Indexed: 05/02/2024]
Abstract
INTRODUCTION There are emerging but inconsistent evidences about anti-epileptic drugs (AEDs) as radio- or chemo-sensitizers to improve survival in glioblastoma patients. We conducted a nationwide population-based study to evaluate the impact of concurrent AED during post-operative chemo-radiotherapy on outcome. MATERIAL AND METHODS A total of 1057 glioblastoma patients were identified by National Health Insurance Research Database and Cancer Registry in 2008-2015. Eligible criteria included those receiving surgery, adjuvant radiotherapy and temozolomide, and without other cancer diagnoses. Survival between patients taking concurrent AED for 14 days or more during chemo-radiotherapy (AED group) and those who did not (non-AED group) were compared, and subgroup analyses for those with valproic acid (VPA), levetiracetam (LEV), or phenytoin were performed. Multivariate analyses were used to adjust for confounding factors. RESULTS There were 642 patients in the AED group, whereas 415 in the non-AED group. The demographic data was balanced except trend of more patients in the AED group had previous drug history of AEDs (22.6% vs. 18%, P 0.078). Overall, the AED group had significantly increased risk of mortality (HR = 1.18, P 0.016) compared to the non-AED group. Besides, an adverse dose-dependent relationship on survival was also demonstrated in the AED group (HR = 1.118, P 0.0003). In subgroup analyses, the significant detrimental effect was demonstrated in VPA group (HR = 1.29,P 0.0002), but not in LEV (HR = 1.18, P 0.079) and phenytoin (HR = 0.98, P 0.862). CONCLUSIONS Improved survival was not observed in patients with concurrent AEDs during chemo-radiotherapy. Our real-world data did not support prophylactic use of AEDs for glioblastoma patients.
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Affiliation(s)
- Peng-Yi Lee
- Department of Radiation Oncology, Show-Chwan Memorial Hospital, No. 542, Section 1 CHUNG-SHAN Road, Changhua, Taiwan
- Department of Radiation Oncology, Lin Shin Hospital, No. 36, Section 3 Huizhong Road, Taichung, Taiwan
- Department of Radiation Oncology, China Medical University Beigang Hospital, Yunlin, Taiwan
- Department of Radiation Oncology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Yu-Ting Wei
- Division of Family Medicine, Department of Community Medicine, China Medical University Hospital, Taichung, Taiwan
- Division of Occupational Medicine, Department of Community Medicine, China Medical University Hospital, Taichung, Taiwan
| | | | - Chin-Nan Chu
- Department of Radiation Oncology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Graduate Institute of Medical Science, China Medical University, Taichung, Taiwan
| | - Wen-Hui Chung
- Department of Radiation Oncology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Ti-Hao Wang
- Department of Radiation Oncology, China Medical University Hospital, China Medical University, Taichung, Taiwan
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Tyagi S, Mishra R, Mazumder A, Mazumder R, Singh G, Pandey P. Synthesis, in silico screening, and biological evaluation of novel pyridine congeners as anti-epileptic agents targeting AMPA (α-amino-3-hydroxy-5-methylisoxazole) receptors. Chem Biol Drug Des 2024; 103:e14498. [PMID: 38453241 DOI: 10.1111/cbdd.14498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 12/23/2023] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
The research involves the synthesis of a series of new pyridine analogs 5(i-x) and their evaluation for anti-epileptic potential using in silico and in vivo models. Synthesis of the compounds was accomplished by using the Vilsmeier-Haack reaction principle. AutoDock 4.2 was used for their in silico screening against AMPA (-amino-3-hydroxy-5-methylisoxazole) receptor (PDB ID:3m3f). For in vivo testing, the maximal electroshock seizure (MES) model was used. The physicochemical, pharmacokinetic, drug-like, and drug-score features of all synthesized compounds were assessed using the online Swiss ADME and Protein Plus software. The in silico results showed that all the synthesized compounds 5(i-x) had 1-3 interactions and affinities ranging from -6.5 to -8.0 kJ/mol with the targeted receptor compared to the binding affinities of the standard drug phenytoin and the original ligand of the target (P99), which were -7.6 and -6.8 kJ/mol, respectively. In vivo study results showed that the compound 5-Carbamoyl-2-formyl-1-[2-(4-nitrophenyl)-2-oxo-ethyl]-pyridinium gave 60% protection against epileptic seizures compared to 59% protection afforded by regular phenytoin. All of them met Lipinski's rule of five and had drug-likeness and drug score values of 0.55 and 0.8, respectively, making them chemically and functionally like phenytoin. According to the findings of the studies, the synthesized derivatives have the potential to be employed as a stepping stone in the development of novel anti-epileptic drugs.
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Affiliation(s)
- Shivani Tyagi
- Noida Institute of Engineering and Technology (Pharmacy Institute), Greater Noida, Uttar Pradesh, India
| | - Rakhi Mishra
- Noida Institute of Engineering and Technology (Pharmacy Institute), Greater Noida, Uttar Pradesh, India
| | - Avijit Mazumder
- Noida Institute of Engineering and Technology (Pharmacy Institute), Greater Noida, Uttar Pradesh, India
| | - Rupa Mazumder
- Noida Institute of Engineering and Technology (Pharmacy Institute), Greater Noida, Uttar Pradesh, India
| | - Gurvinder Singh
- School of Pharmaceutical Science, Lovely Professional University, Phagwara, Punjab, India
| | - Pratibha Pandey
- Noida Institute of Engineering and Technology (Pharmacy Institute), Greater Noida, Uttar Pradesh, India
- Noida Institute of Engineering and Technology, Biotechnology Department, Greater Noida, Uttar Pradesh, India
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Kan-Tor Y, Ness L, Szlak L, Benninger F, Ravid S, Chorev M, Rosen-Zvi M, Shimoni Y, Fisher RS. Comparing the efficacy of anti-seizure medications using matched cohorts on a large insurance claims database. Epilepsy Res 2024; 201:107313. [PMID: 38417192 DOI: 10.1016/j.eplepsyres.2024.107313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 03/01/2024]
Abstract
Epilepsy is a severe chronic neurological disease affecting 60 million people worldwide. Primary treatment is with anti-seizure medicines (ASMs), but many patients continue to experience seizures. We used retrospective insurance claims data on 280,587 patients with uncontrolled epilepsy (UE), defined as status epilepticus, need for a rescue medicine, or admission or emergency visit for an epilepsy code. We conducted a computational risk ratio analysis between pairs of ASMs using a causal inference method, in order to match 1034 clinical factors and simulate randomization. Data was extracted from the MarketScan insurance claims Research Database records from 2011 to 2015. The cohort consisted of individuals over 18 years old with a diagnosis of epilepsy who took one of eight ASMs and had more than a year of history prior to the filling of the drug prescription. Seven ASM exposures were analyzed: topiramate, phenytoin, levetiracetam, gabapentin, lamotrigine, valproate, and carbamazepine or oxcarbazepine (treated as the same exposure). We calculated the risk ratio of UE between pairs of ASM after controlling for bias with inverse propensity weighting applied to 1034 factors, such as demographics, confounding illnesses, non-epileptic conditions treated by ASMs, etc. All ASMs exhibited a significant reduction in the prevalence of UE, but three drugs showed pair-wise differences compared to other ASMs. Topiramate consistently was associated with a lower risk of UE, with a mean risk ratio range of 0.68-0.93 (average 0.82, CI: 0.56-1.08). Phenytoin and levetiracetam were consistently associated with a higher risk of UE with mean risk ratio ranges of 1.11 to 1.47 (average 1.13, CI 0.98-1.65) and 1.15 to 1.43 (average 1.2, CI 0.72-1.69), respectively. Large-scale retrospective insurance claims data - combined with causal inference analysis - provides an opportunity to compare the effect of treatments in real-world data in populations 1,000-fold larger than those in typical randomized trials. Our causal analysis identified the clinically unexpected finding of topiramate as being associated with a lower risk of UE; and phenytoin and levetiracetam as associated with a higher risk of UE (compared to other studied drugs, not to baseline). However, we note that our data set for this study only used insurance claims events, which does not comprise actual seizure frequencies, nor a clear picture of side effects. Our results do not advocate for any change in practice but demonstrate that conclusions from large databases may differ from and supplement those of randomized trials and clinical practice and therefore may guide further investigation.
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Affiliation(s)
- Yoav Kan-Tor
- AI for Healthcare and Life Sciences Department, IBM Research, Haifa, Israel
| | - Lior Ness
- AI for Healthcare and Life Sciences Department, IBM Research, Haifa, Israel
| | - Liran Szlak
- AI for Healthcare and Life Sciences Department, IBM Research, Haifa, Israel
| | - Felix Benninger
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sivan Ravid
- AI for Healthcare and Life Sciences Department, IBM Research, Haifa, Israel
| | - Michal Chorev
- AI for Healthcare and Life Sciences Department, IBM Research, Haifa, Israel; Centre for Applied Research, IBM Australia, Melbourne, Australia
| | - Michal Rosen-Zvi
- AI for Healthcare and Life Sciences Department, IBM Research, Haifa, Israel; Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Yishai Shimoni
- AI for Healthcare and Life Sciences Department, IBM Research, Haifa, Israel
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Kermanshahi N, Hamidi N, Weisberg J, Beg U, Dabrowski M, Padmanaban V, Betz J, Mansouri A. The Prevalence of Seizures in Brain Metastasis Patients on Anticonvulsant Prophylaxis: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 183:e613-e624. [PMID: 38199459 DOI: 10.1016/j.wneu.2023.12.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Brain metastasis (BM) prognosis is incredibly poor and is often associated with considerable morbidity. Seizures are commonly present in these patients, and their biopsychosocial impact can be dangerous. The use of antiepileptic drugs (AEDs) as primary prophylaxis remains controversial. This systematic review and meta-analysis aim to evaluate the efficacy of AED prophylaxis in patients with BM. METHODS MEDLINE via PubMed, Web of Science, EMBASE, and Cochrane were searched for articles pertinent to AED prophylaxis use in patients with BM. Patients with BM previously treated for cancer who were seizure naive at the time of inclusion were included. Data regarding patient characteristics, type of AED, prior treatments, and groups at a high risk of seizure were extracted. Seizure prevalence was obtained. RESULTS Eight studies were included in this systematic review and meta-analysis; 1902 total patients with BM were included, with 381 receiving antiepileptic prophylaxis, and 1521 receiving no prophylaxis. Although the odds of a seizure in the treatment group was found to be 1.158 times the odds of a seizure in the control group, the odds ratio was not statistically significant (t-statistic = 0.62, P value = 0.5543). CONCLUSIONS There was no significant difference in the odds of seizure development in control groups compared to patients receiving prophylactic antiepileptic therapy. As patients with BM present with heterogeneity in tumor characteristics and receive various treatment modalities, future research is needed to identify groups that may benefit more significantly from AED prophylaxis.
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Affiliation(s)
| | - Nima Hamidi
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Jake Weisberg
- Arizona College of Osteopathic Medicine, Arizona, USA
| | - Usman Beg
- Loma Linda University, Loma Linda, California, USA
| | | | - Varun Padmanaban
- Penn State Department of Neurosurgery, Hershey, Pennsylvania, USA
| | | | - Alireza Mansouri
- Penn State Department of Neurosurgery, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Hershey, Pennsylvania, USA
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Kegele J, Wagner T, Kowenski T, Wiesmayr M, Gatterer C, Alber M, Matuja W, Schmutzhard E, Lerche H, Winkler AS. Long-term clinical course and treatment outcomes of individuals with Nodding Syndrome. J Neurol Sci 2024; 457:122893. [PMID: 38278097 DOI: 10.1016/j.jns.2024.122893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 12/28/2023] [Accepted: 01/13/2024] [Indexed: 01/28/2024]
Abstract
Nodding Syndrome is a poorly understood epilepsy disorder in sub-Saharan Africa. The cause(s) of the disease, risk factors and long-term outcomes are unknown or controversial. The objectives of this study were to describe the long-term clinical course and treatment outcomes of individuals suffering from Nodding Syndrome. In addition, we aimed to provide a comprehensive characterization of the epileptological and social features of patients with Nodding Syndrome. From 11/2014 to 4/2015, we conducted a hospital-based, cross-sectional and observational study in Mahenge, Tanzania. Seventy-eight individuals (female:male ratio: 40:38, age at examination: 21.1 ± 6.39 (SD) years) have been enrolled, of whom 38 (49%) had also been examined in 2005 and in 2009. The 10-year clinical course analysis of this revisited subgroup revealed a calculated case fatality of 0.8-2.3%. Progressive physical or cognitive deterioration has not been observed in any of the 78 individuals and more than half of the people studied (38/69; 55%) managed to live and work independently. 14/78 individuals (18%) were seizure-free, (no head nodding, no other seizure types), 13 of whom were taking antiseizure medication. Phenytoin was more effective against head nodding seizures (14/19 (74%)) than monotherapy with other available antiseizure medication (phenobarbitone 12/25 (48%) and carbamazepine 7/22 (32%), p = 0.02, chi-square test). Our ten-year clinical outcome data show that Nodding Syndrome is not a fatal disease, however, the response to treatment is worse than in epilepsy patients in general. Phenytoin may be more effective than carbamazepine and phenobarbitone, but further studies are needed to confirm this observation.
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Affiliation(s)
- Josua Kegele
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Hoppe-Seyler Straße 3, 72076 Tuebingen, Germany.
| | - Thomas Wagner
- Centre for Pediatric and Adolescent Medicine, University Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Teresa Kowenski
- Medical University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria
| | - Matthias Wiesmayr
- Medical University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria
| | | | - Michael Alber
- Pediatric Neurology and Developmental Medicine, University of Tübingen, Hoppe-Seyler Straße 3, 72076 Tuebingen, Germany.
| | - Wiliam Matuja
- Department of Neurology, Muhimbili University of Health and Allied Sciences, United Nations Rd, Dar es Salaam, Tanzania
| | - Erich Schmutzhard
- Department of Neurology, Medical University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria.
| | - Holger Lerche
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Hoppe-Seyler Straße 3, 72076 Tuebingen, Germany.
| | - Andrea S Winkler
- Department of Neurology, Center for Global Health, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675 Munich, Germany; Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Forskningsveien 3A, 0373 Oslo, Norway; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
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Cohen H, Mahajna G, Ben-Shushan T, Matok I, Eyal S. The extent of cytochrome P450 3A induction by antiseizure medications: A systematic review and network meta-analysis. Epilepsia 2024; 65:445-455. [PMID: 38010146 DOI: 10.1111/epi.17822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/24/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE Antiseizure medications (ASMs) are commonly categorized as enzyme-inducers and non-enzyme-inducers based on their propensity to enhance the metabolism of concomitantly administered drugs. This systematic review and network meta-analysis aimed to rank ASMs as cytochrome P450 3A (CYP3A)-inducers based on a comparative assessment of ASM-induced reduction in the concentrations of sensitive substrate drugs. METHODS The protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews; CRD42022335846), and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) standards were followed. We searched MEDLINE, Embase, and Cochrane until March 14, 2023 without an initial date restriction. Data were additionally obtained via the US Food and Drug Administration database. Studies had to be prospective, with ASM monotherapy for ≥5 days. The primary parameter was the magnitude of change in the area under the concentration-time curve of CYP3A substrates following treatment with the ASM. The standardized mean difference (SMD) was used as the point estimate for the indirect comparisons between ASMs using the pairwise method. Bias risk was assessed using the PKclin tool. RESULTS We identified 14 open-label, fixed-sequence studies with 370 participants. The effect size of 600 mg/day carbamazepine did not differ from those of 300 mg/day phenytoin (SMD = -.06, 95% confidence interval [CI] = -.18 to .07) and 200 mg/day cenobamate (SMD = -.11, 95% CI = -.26 to .04). Carbamazepine at 600 mg/day was the strongest CYP3A-inducer (P-score = .88), followed by carbamazepine 400 mg/day (.83), phenytoin 300 mg/day (.79), and cenobamate 200 mg/day (.73). Eslicarbazepine (800 mg/day) ranked higher than cenobamate 100 mg/day and oxcarbazepine 900 mg/day (.60, .39, and .37, respectively). SIGNIFICANCE Despite the limited number of studies, our network meta-analysis emphasizes that the magnitude of ASM effects on CYP3A substrate metabolism is a dose-dependent continuum. When possible, ASM classification as inducers should apply cutoff values tailored to the outcome. Prescribers should monitor plasma concentrations or clinical effects of CYP3A substrates and consider selecting concomitant medications accordingly.
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Affiliation(s)
- Hagar Cohen
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ghadeer Mahajna
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tomer Ben-Shushan
- Medical Library Authority, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Matok
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sara Eyal
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
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Rafiei P, Raeeszadeh M, Mohammadzadeh P. Comparative efficacy of Salix aegyptiaca's active compound versus phenytoin in healing full-thickness rat skin wounds: An animal model study. J Tissue Viability 2024; 33:135-143. [PMID: 38290935 DOI: 10.1016/j.jtv.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/12/2023] [Accepted: 01/24/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Wound healing poses a challenging therapeutic scenario, requiring diverse clinical approaches. OBJECTIVES This study aims to assess the wound-healing potential of Salix aegyptiaca's flower ointment compared to phenytoin, considering the active constituents of S. aegyptiaca and its traditional usage. METHODS Initially, the active components of S. aegyptiaca were isolated and identified through the GC-MS technique. Subsequently, for the experimental intervention, thirty-five rats were divided into five distinct groups: control (C), phenytoin (F), and three S. aegyptiaca ointment groups at different concentrations (5 % - S5, 25 % - S25, and 50 % - S50). Anesthesia was administered, and wounds were induced on the animals' necks following a standard procedure. These wounds were then treated for a duration of 21 days. Wound healing progress was quantified, and histopathological assessments were conducted using hematoxylin and eosin staining and Mason's trichrome staining. RESULTS The main active compounds of S. aegyptiaca, namely n-hexadecanoic acid and oleic acid, were identified via GC-MS analysis. Although the initial group weights did not show a significant difference (P = 0.271), a significant variation was observed in the final weights (P = 0.003). The S50 group exhibited a lower wound healing rate than the S25 group on the 7th and 14th days but surpassed it on the 21st day (C < F < S5≈S25 CONCLUSION The findings highlight the superior wound-healing efficacy of 50 % S. aegyptiaca ointment over phenytoin ointment.
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Affiliation(s)
- Pouria Rafiei
- Graduate of Faculty of Veterinary Sciences, Sanandaj Branch, Islamic Azad University, Sanandaj, Iran
| | - Mahdieh Raeeszadeh
- Department of Basic Sciences, Sanandaj Branch, Islamic Azad University, Sanandaj, Iran.
| | - Peyman Mohammadzadeh
- Department of Pathobiology Sciences, Sanandaj Branch, Islamic Azad University, Sanandaj, Iran
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Manjunathan S, Agarwal S, Saini L, Tiwari S, Bains A, Shakrawal J, Aggarwal D, Dixit PK. Phenytoin-induced Purple Glove Syndrome Unraveling the Puzzle of Friable Hair and Seizures in an Infant. Indian J Pediatr 2023; 90:1257-1258. [PMID: 37505410 DOI: 10.1007/s12098-023-04781-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Sujatha Manjunathan
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Saurabh Agarwal
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Lokesh Saini
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India.
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Anupama Bains
- Department of Dermatology, Venereology, and Leprology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Jyoti Shakrawal
- Department of Ophthalmology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Divya Aggarwal
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Pawan Kumar Dixit
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
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Webb AJ, Avramovska S, Qualls S, Lo CK, Roberts RJ, Barra ME. Impact of an enteral nutrition holding guideline on daily nutrition goals in patients taking phenytoin. Nutr Clin Pract 2023; 38:1334-1342. [PMID: 37537901 DOI: 10.1002/ncp.11051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/26/2023] [Accepted: 07/09/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Concomitant administration of enteral nutrition (EN) and phenytoin decreases phenytoin absorption. Concerns over impaired nutrition, however, may prevent EN from being held surrounding phenytoin administration. This study aimed to evaluate whether EN holding guidelines impacted nutrition goal achievement in patients taking phenytoin. METHODS Adult patients administered enteral phenytoin for acute or chronic seizures while receiving EN during a neurocritical care admission 6 months before and after EN holding guideline implementation were eligible. Patients without phenytoin concentrations or a clinical registered dietitian assessment were excluded. The primary outcome was the percentage of nutrition daily goals attained before and after implementation. Secondary end points included the incidence of hypoglycemia, differences in measured phenytoin concentrations, and rates of therapeutic (10-20 mcg/ml) and high-therapeutic (15-20 mcg/ml) concentration attainment. Concentrations were adjusted for hypoalbuminemia using the Winter-Tozer equation. RESULTS Fifty-five patients representing 412 patient days and 1110 phenytoin administrations were included with 29 preimplementation and 26 postimplementation patients. Median percent attainment of daily EN goals was consistent preimplementation and postimplementation (86% vs 83%, P = 0.48). No significant change in rates of days with hypoglycemia was observed. Adjusted phenytoin concentrations were similar before and after implementation (14.1 vs 15.2 mcg/ml, P = 0.45), but the preimplementation cohort had a lower proportion of high-therapeutic concentrations (23% vs 36%, P = 0.018). CONCLUSION Holding EN for phenytoin did not impact attainment of daily nutrition goals and was not associated with increased rates of hypoglycemia. This is the first study to evaluate the effect of EN holding on nutrition goals in patients receiving phenytoin.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Simona Avramovska
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pharmacy, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Stephanie Qualls
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carmen Kaman Lo
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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12
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Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. Anti-seizure medications for neonates with seizures. Cochrane Database Syst Rev 2023; 10:CD014967. [PMID: 37873971 PMCID: PMC10594593 DOI: 10.1002/14651858.cd014967.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Newborn infants are more prone to seizures than older children and adults. The neuronal injury caused by seizures in neonates often results in long-term neurodevelopmental sequelae. There are several options for anti-seizure medications (ASMs) in neonates. However, the ideal choice of first-, second- and third-line ASM is still unclear. Further, many other aspects of seizure management such as whether ASMs should be initiated for only-electrographic seizures and how long to continue the ASM once seizure control is achieved are elusive. OBJECTIVES 1. To assess whether any ASM is more or less effective than an alternative ASM (both ASMs used as first-, second- or third-line treatment) in achieving seizure control and improving neurodevelopmental outcomes in neonates with seizures. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 2. To assess maintenance therapy with ASM versus no maintenance therapy after achieving seizure control. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 3. To assess treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, Epistemonikos and three databases in May 2022 and June 2023. These searches were not limited other than by study design to trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that included neonates with EEG-confirmed or clinically diagnosed seizures and compared (1) any ASM versus an alternative ASM, (2) maintenance therapy with ASM versus no maintenance therapy, and (3) treatment of clinical or EEG seizures versus treatment of clinical seizures alone. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility, risk of bias and independently extracted data. We analysed treatment effects in individual trials and reported risk ratio (RR) for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence interval (CI). We used GRADE to assess the certainty of evidence. MAIN RESULTS We included 18 trials (1342 infants) in this review. Phenobarbital versus levetiracetam as first-line ASM in EEG-confirmed neonatal seizures (one trial) Phenobarbital is probably more effective than levetiracetam in achieving seizure control after first loading dose (RR 2.32, 95% CI 1.63 to 3.30; 106 participants; moderate-certainty evidence), and after maximal loading dose (RR 2.83, 95% CI 1.78 to 4.50; 106 participants; moderate-certainty evidence). However, we are uncertain about the effect of phenobarbital when compared to levetiracetam on mortality before discharge (RR 0.30, 95% CI 0.04 to 2.52; 106 participants; very low-certainty evidence), requirement of mechanical ventilation (RR 1.21, 95% CI 0.76 to 1.91; 106 participants; very low-certainty evidence), sedation/drowsiness (RR 1.74, 95% CI 0.68 to 4.44; 106 participants; very low-certainty evidence) and epilepsy post-discharge (RR 0.92, 95% CI 0.48 to 1.76; 106 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Phenobarbital versus phenytoin as first-line ASM in EEG-confirmed neonatal seizures (one trial) We are uncertain about the effect of phenobarbital versus phenytoin on achieving seizure control after maximal loading dose of ASM (RR 0.97, 95% CI 0.54 to 1.72; 59 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Maintenance therapy with ASM versus no maintenance therapy in clinically diagnosed neonatal seizures (two trials) We are uncertain about the effect of short-term maintenance therapy with ASM versus no maintenance therapy during the hospital stay (but discontinued before discharge) on the risk of repeat seizures before hospital discharge (RR 0.76, 95% CI 0.56 to 1.01; 373 participants; very low-certainty evidence). Maintenance therapy with ASM compared to no maintenance therapy may have little or no effect on mortality before discharge (RR 0.69, 95% CI 0.39 to 1.22; 373 participants; low-certainty evidence), mortality at 18 to 24 months (RR 0.94, 95% CI 0.34 to 2.61; 111 participants; low-certainty evidence), neurodevelopmental disability at 18 to 24 months (RR 0.89, 95% CI 0.13 to 6.12; 108 participants; low-certainty evidence) and epilepsy post-discharge (RR 3.18, 95% CI 0.69 to 14.72; 126 participants; low-certainty evidence). Treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates (two trials) Treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation (MD -1871.16, 95% CI -4525.05 to 782.73; 68 participants; low-certainty evidence), mortality before discharge (RR 0.59, 95% CI 0.28 to 1.27; 68 participants; low-certainty evidence) and epilepsy post-discharge (RR 0.75, 95% CI 0.12 to 4.73; 35 participants; low-certainty evidence). The trials did not report on mortality or neurodevelopmental disability at 18 to 24 months. We report data from the most important comparisons here; readers are directed to Results and Summary of Findings tables for all comparisons. AUTHORS' CONCLUSIONS Phenobarbital as a first-line ASM is probably more effective than levetiracetam in achieving seizure control after the first loading dose and after the maximal loading dose of ASM (moderate-certainty evidence). Phenobarbital + bumetanide may have little or no difference in achieving seizure control when compared to phenobarbital alone (low-certainty evidence). Limited data and very low-certainty evidence preclude us from drawing any reasonable conclusion on the effect of using one ASM versus another on other short- and long-term outcomes. In neonates who achieve seizure control after the first loading dose of phenobarbital, maintenance therapy compared to no maintenance ASM may have little or no effect on all-cause mortality before discharge, mortality by 18 to 24 months, neurodevelopmental disability by 18 to 24 months and epilepsy post-discharge (low-certainty evidence). In neonates with hypoxic-ischaemic encephalopathy, treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation, all-cause mortality before discharge and epilepsy post-discharge (low-certainty evidence). All findings of this review apply only to term and late preterm neonates. We need well-designed RCTs for each of the three objectives of this review to improve the precision of the results. These RCTs should use EEG to diagnose seizures and should be adequately powered to assess long-term neurodevelopmental outcomes. We need separate RCTs evaluating the choice of ASM in preterm infants.
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Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology, KMCH Institute of Health Sciences and Research (KMCHIHSR), Coimbatore, Tamil Nadu, India
- KMCH Research Foundation, Coimbatore, Tamil Nadu, India
| | | | | | - Ronit Pressler
- Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
- Clinical Neurophysiology and Neonatology, Cambridge University Hospital, Cambridge, UK
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK
| | - Francesco Brigo
- Neurology, Hospital of Merano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, Merano-Meran, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano-Bozen, Italy
| | - Hans Hartmann
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Pressler RM, Abend NS, Auvin S, Boylan G, Brigo F, Cilio MR, De Vries LS, Elia M, Espeche A, Hahn CD, Inder T, Jette N, Kakooza-Mwesige A, Mader S, Mizrahi EM, Moshé SL, Nagarajan L, Noyman I, Nunes ML, Samia P, Shany E, Shellhaas RA, Subota A, Triki CC, Tsuchida T, Vinayan KP, Wilmshurst JM, Yozawitz EG, Hartmann H. Treatment of seizures in the neonate: Guidelines and consensus-based recommendations-Special report from the ILAE Task Force on Neonatal Seizures. Epilepsia 2023; 64:2550-2570. [PMID: 37655702 DOI: 10.1111/epi.17745] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
Seizures are common in neonates, but there is substantial management variability. The Neonatal Task Force of the International League Against Epilepsy (ILAE) developed evidence-based recommendations about antiseizure medication (ASM) management in neonates in accordance with ILAE standards. Six priority questions were formulated, a systematic literature review and meta-analysis were performed, and results were reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 standards. Bias was evaluated using the Cochrane tool and risk of Bias in non-randomised studies - of interventions (ROBINS-I), and quality of evidence was evaluated using grading of recommendations, assessment, development and evaluation (GRADE). If insufficient evidence was available, then expert opinion was sought using Delphi consensus methodology. The strength of recommendations was defined according to the ILAE Clinical Practice Guidelines development tool. There were six main recommendations. First, phenobarbital should be the first-line ASM (evidence-based recommendation) regardless of etiology (expert agreement), unless channelopathy is likely the cause for seizures (e.g., due to family history), in which case phenytoin or carbamazepine should be used. Second, among neonates with seizures not responding to first-line ASM, phenytoin, levetiracetam, midazolam, or lidocaine may be used as a second-line ASM (expert agreement). In neonates with cardiac disorders, levetiracetam may be the preferred second-line ASM (expert agreement). Third, following cessation of acute provoked seizures without evidence for neonatal-onset epilepsy, ASMs should be discontinued before discharge home, regardless of magnetic resonance imaging or electroencephalographic findings (expert agreement). Fourth, therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy (evidence-based recommendation). Fifth, treating neonatal seizures (including electrographic-only seizures) to achieve a lower seizure burden may be associated with improved outcome (expert agreement). Sixth, a trial of pyridoxine may be attempted in neonates presenting with clinical features of vitamin B6-dependent epilepsy and seizures unresponsive to second-line ASM (expert agreement). Additional considerations include a standardized pathway for the management of neonatal seizures in each neonatal unit and informing parents/guardians about the diagnosis of seizures and initial treatment options.
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Affiliation(s)
- Ronit M Pressler
- Clinical Neuroscience, UCL-Great Ormond Street Institute of Child Health, London, UK
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stéphan Auvin
- Department Medico-Universitaire Innovation Robert-Debré, Robert Debré Hospital, Public Hospital Network of Paris, Pediatric Neurology, University of Paris, Paris, France
| | - Geraldine Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of Paracelsus Medical Private University, Bolzano-Bozen, Italy
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Saint-Luc University Hospital, and Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Linda S De Vries
- Department of Neonatology, University Medical Center, Utrecht, the Netherlands
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute-IRCCS, Troina, Italy
| | - Alberto Espeche
- Department of Neurology, Hospital Materno Infantil, Salta, Argentina
| | - Cecil D Hahn
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Terrie Inder
- Department of Pediatrics, Newborn Medicine, Children's Hospital of Orange County, University of California, Irvine, Irvine, California, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Angelina Kakooza-Mwesige
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Silke Mader
- Scientific Affairs, European Foundation for the Care of Newborn Infants, Munich, Germany
| | - Eli M Mizrahi
- Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
- Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, and Montefiore Medical Center, Bronx, New York, USA
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital and University of Western Australia, Nedlands, Western Australia, Australia
| | - Iris Noyman
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Pediatric Neurology Unit, Pediatric Division, Soroka Medical Center, Beer-Sheva, Israel
| | - Magda L Nunes
- Pontifícia Universidade Católica do Rio Grande do Sul-PUCRS School of Medicine and the Brain Institute, Porto Alegre, Brazil
| | - Pauline Samia
- Departments of Pediatrics and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Eilon Shany
- Department of Neonatology, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Renée A Shellhaas
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Ann Subota
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chahnez Charfi Triki
- Child Neurology Department, Hedi Chaker Hospital, Sfax Medical School, University of Sfax, Sfax, Tunisia
| | - Tammy Tsuchida
- Departments of Neurology and Pediatrics, Children's National Health System, George Washington University School of Medicine, Washington, District of Columbia, USA
| | | | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elissa G Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Hans Hartmann
- Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Hedges A, Findlay MC, Davis GE, Wolfe BM, Hawryluk GWJ, Menacho ST, Ansari S. Levetiracetam dosing for seizure prophylaxis in neurocritical care patients. Brain Inj 2023; 37:1167-1172. [PMID: 36856437 DOI: 10.1080/02699052.2023.2184495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/21/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND/OBJECTIVE Levetiracetam is used for seizure prophylaxis in patients presenting with subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI). We aim to characterize the optimal levetiracetam dosage for seizure prophylaxis. METHODS This retrospective cohort study included adult patients at an academic tertiary hospital presenting with SAH or TBI who received levetiracetam at a total daily dose (TDD) equivalent to or greater than 1000 mg. The primary outcome was combined seizure incidence, including clinical and subclinical seizures. RESULTS We identified 139 patients (49.6% male, mean age 53 years) for inclusion. For patients receiving a 1000-mg TDD, the administration was 500 mg twice daily. For patients receiving >1000-mg TDD, 77/78 patients received 1000 mg twice daily and one patient received 750 mg twice daily. Patients receiving 1000-mg TDD had a higher seizure incidence than those receiving >1000-mg TDD (p = 0.01), despite no difference in examined confounders, including history of alcoholism (p = 0.49), benzodiazepine use (p = 0.28), or propofol use (p = 0.17). No difference in adverse effects was observed (anemia, p = 0.44; leukopenia, p = 0.60; thrombocytopenia, p = 0.86). CONCLUSIONS Patients may experience a reduced incidence of clinical and electroencephalographic seizures with levetiracetam dosing >1000-mg TDD.
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Affiliation(s)
- Ashley Hedges
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah, USA
| | | | - Gary E Davis
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah, USA
| | - Brianne M Wolfe
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah, USA
| | | | - Sarah T Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Safdar Ansari
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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15
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Iyer AS. Is Levetiracetam a Superior Anti-Seizure Medication in Pediatric Status Epilepticus? Indian Pediatr 2023; 60:517-518. [PMID: 37209049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- Anand S Iyer
- Pediatric Neurologist, Apollo Hospitals International Ltd, Ahmedabad, Gujarat.
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16
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Naeem B, Ashfaq M, Qureshi MA. Efficacy Of Levetiracetam Versus Phenytoin As A Second-Line Antiepileptic Drug In The Management Of Benzodiazepine-Refractory Status Epilepticus Among Children. J Ayub Med Coll Abbottabad 2023; 35:410-414. [PMID: 38404082 DOI: 10.55519/jamc-03-11897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Status Epilepticus (SE) is a life-threatening neurological emergency requiring appropriate therapy to terminate seizure activity. SE is managed with supportive measures and ultra-short-acting benzodiazepines. However, limited data is available in the paediatric population regarding the next best option when this fails. This study aimed at finding new data to recommend levetiracetam or phenytoin as the second-line option. METHODS One hundred and thirty-seven patients with status epilepticus were randomized into two groups; group-I was given IV Levetiracetam (LEV) at 20 mg/kg/dose over 5 minutes followed by a maintenance dose of 20mg/kg/dose BID, whereas Group II received phenytoin at 20mg/kg IV loading dose followed by a maintenance dose of 5-8 mg/kg/day divided BID. The primary outcome was seizure cessation, defined as the termination of the apparent convulsion 30 min after the administration of phenytoin or levetiracetam. Secondary outcomes were the use of different anti-convulsants for continued management, admittance to critical treatment, and severe adverse events (including mortality, Stevens-Johnson syndrome, rash, airway problems, cardiovascular instability, extravasation, and severe agitation). Data was recorded via a clinical proforma and was analyzed by SPSS software version 25. All numerical data were expressed in mean±SD forms, and frequency was determined for qualitative baseline data. Secondary outcomes were tested through the χ2 test, A p-value of ≤0.05 was considered statistical significance. RESULTS Levetiracetam terminated seizures in 94% of children compared to 77% in those treated with phenytoin. The mean time to seizure termination was 19.94±3.76 minutes for the LEV Group as compared to 23.791±9.1 min for the PHT group. (p=0.046). Regarding safety, a profile study shows LEV has fewer and less severe side effects compared to Phenytoin. CONCLUSIONS Levetiracetam is a safe, well-tolerated, and effective treatment as a second-line antiepileptic drug in the management of status epilepticus.
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Affiliation(s)
- Babar Naeem
- Paediatrics Department, Jinnah Hospital Lahore, Pakistan
| | - Mommna Ashfaq
- Paediatrics Department, Jinnah Hospital Lahore, Pakistan
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Tyson M, Trenear R, Skellett S, Maconochie I, Mullen N. Survey About Second-Line Agents for Pediatric Convulsive Status Epilepticus. Pediatr Emerg Care 2023; 39:247-252. [PMID: 35510724 DOI: 10.1097/pec.0000000000002745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Convulsive status epilepticus (CSE) is the most common neurological emergency in children. It is a frequent cause of admission to pediatric intensive care units and is associated with significant short- and long-term morbidity. Management of CSE is a step-wise approach: first-line antiseizure agents (typically benzodiazepines) followed by a second-line agent before deeper anesthesia usually accompanied by intubation and ventilation. Current guidelines in the United Kingdom specify phenytoin as the second-line agent of choice for CSE. Two recent large international randomized controlled trials compared the efficacy of phenytoin with that of another second-line agent levetiracetam. Both studies found levetiracetam to be noninferior to phenytoin. METHODS We conducted an online survey of clinicians across 67 emergency departments that treat children and 29 pediatric intensive care units in the United Kingdom and Ireland to assess their current and preferred second-line agents for treating pediatric CSE in light of recently published evidence. The survey was distributed via the Pediatric Emergency Research in United Kingdom and Ireland network and the Pediatric Critical Care Society. RESULTS We found that although most clinicians use phenytoin, as per current guidelines, they seek greater flexibility in choice of second-line agent, with levetiracetam being the preferred alternative to phenytoin. CONCLUSIONS To facilitate use of levetiracetam for treatment of CSE in pediatrics, it should be included as a second-line agent in addition to phenytoin in the next update of the National Institute for Health and Care Excellence and other United Kingdom clinical guidelines.
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Affiliation(s)
- Marguerite Tyson
- From the Paediatric Intensive Care Unit, Great Ormond Street Hospital
| | | | - Sophie Skellett
- Paediatric Intensive Care Unit, Great Ormond Street Hospital
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London
| | - Niall Mullen
- Department of Paediatric Emergency Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, United Kingdom
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Yin T, Liang H, Huang Q, Zhou B, Tang M, Lou J, Xiang D. A Survey of Therapeutic Drug Monitoring Status in China. Ther Drug Monit 2023; 45:151-158. [PMID: 36920501 PMCID: PMC10013164 DOI: 10.1097/ftd.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 11/21/2021] [Indexed: 03/16/2023]
Abstract
OBJECTIVE To understand the status of therapeutic drug monitoring (TDM) in China Mainland, and thus lay down the foundation for further improvement in TDM. METHODS In the present study, a nationwide questionnaire survey was conducted, which was distributed and collected using a mobile-based application. Clinicians, pharmacists, and clinical laboratory physicians belonging to different levels of public hospitals were involved as subjects/objects. The contents of the survey included TDM implementation in their hospital and information regarding their opinions and suggestions on TDM work. Mann-Whitney test was used to compare the difference between top tertiary hospitals and non-top tertiary hospitals. RESULTS A total of 475 questionnaires were collected, 383 from top tertiary hospitals (3A hospitals) and 92 from non-top tertiary hospitals (other than 3A hospitals). A total of 240 clinicians, TDM pharmacists, and clinical laboratory physicians were involved, with an effective rate of 50.5%. Top tertiary hospitals were associated with certain advantages, such as the number of TDM testing facilities, annual sample size, number of monitoring varieties, and interpretation rate of monitoring reports, compared with non-top tertiary hospitals. In particular, β-lactamase inhibitor, olanzapine, carbamazepine, and glucocorticoids seemed to be the main projects that clinicians wanted to assess. The drugs for which TDM was commonly performed included vancomycin, valproic acid, carbamazepine, phenytoin sodium, and methotrexate. The most commonly used detection methods include high-performance liquid chromatography, immunization, 2D-LC, and LC-MS. The monitoring concentration range was found to be inconsistent for most of the drugs. Currently, no unified regulation exists for TDM charges in China, which is no more than ¥200 in general. Clinicians rely on pharmacists for professional guidance. Importantly, improvement in the interpretation of monitoring reports, proficiency testing, and cooperation with clinical departments may aid in improving the level of TDM service. CONCLUSIONS This survey objectively reflected the current status of TDM work in hospitals in China, and provided a strong reference base for devising strategies for improvement and effective execution of TDM work.
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Affiliation(s)
- Tao Yin
- Department of Pharmacy,Xiangya Hospital,Central South University,Changsha,China
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19
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Kim E, Kim HC, Van Reet J, Böhlke M, Yoo SS, Lee W. Transcranial focused ultrasound-mediated unbinding of phenytoin from plasma proteins for suppression of chronic temporal lobe epilepsy in a rodent model. Sci Rep 2023; 13:4128. [PMID: 36914775 PMCID: PMC10011522 DOI: 10.1038/s41598-023-31383-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/10/2023] [Indexed: 03/16/2023] Open
Abstract
The efficacy of many anti-epileptic drugs, including phenytoin (PHT), is reduced by plasma protein binding (PPB) that sequesters therapeutically active drug molecules within the bloodstream. An increase in systemic dose elevates the risk of drug side effects, which demands an alternative technique to increase the unbound concentration of PHT in a region-specific manner. We present a low-intensity focused ultrasound (FUS) technique that locally enhances the efficacy of PHT by transiently disrupting its binding to albumin. We first identified the acoustic parameters that yielded the highest PHT unbinding from albumin among evaluated parameter sets using equilibrium dialysis. Then, rats with chronic mesial temporal lobe epilepsy (mTLE) received four sessions of PHT injection, each followed by 30 min of FUS delivered to the ictal region, across 2 weeks. Two additional groups of mTLE rats underwent the same procedure, but without receiving PHT or FUS. Assessment of electrographic seizure activities revealed that FUS accompanying administration of PHT effectively reduced the number and mean duration of ictal events compared to other conditions, without damaging brain tissue or the blood-brain barrier. Our results demonstrated that the FUS technique enhanced the anti-epileptic efficacy of PHT in a chronic mTLE rodent model by region-specific PPB disruption.
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Affiliation(s)
- Evgenii Kim
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Hyun-Chul Kim
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
- Department of Artificial Intelligence, Kyungpook National University, Daegu, South Korea
| | - Jared Van Reet
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Mark Böhlke
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - Seung-Schik Yoo
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Wonhye Lee
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Rollo E, Romozzi M, Dono F, Bernardo D, Consoli S, Anzellotti F, Ricciardi L, Paci L, Sensi SL, Della Marca G, Servidei S, Calabresi P, Vollono C. Treatment of benzodiazepine-refractory status epilepticus: A retrospective, cohort study. Epilepsy Behav 2023; 140:109093. [PMID: 36739634 DOI: 10.1016/j.yebeh.2023.109093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Status epilepticus (SE) is a frequent neurological emergency, derived from the failure of mechanisms responsible for seizure termination. The present study aims to compare the efficacy of the most common antiseizure medications (ASMs) employed for the treatment of benzodiazepine-refractory SE. METHODS We performed a retrospective cohort study of all SE episodes treated in our hospital between January 2016 and December 2020. Inclusion criteria were: age ≥ 18 years; a diagnosis of status epilepticus. Exclusion criteria were: status epilepticus resolved by initial therapy with benzodiazepines; impossibility to retrieve medical records. We considered as effective the ASM that was the last drug introduced or increased in dose before termination of SE and without changes in the co-medication. RESULTS A total of 244 episodes in 219 patients were included in the study. The mean age of the final study cohort was 63.6 ± 19.2, with 108 (49%) men. In the total cohort, phenytoin (PHT) showed the highest response rate (57.6%), followed by lacosamide (LCM) (40.7%) and valproate (VPA) (39.8%). The comparative efficacy among the different drugs was significantly different (p < 0.001). In the pairwise comparisons, VPA was superior to levetiracetam (LEV) (response rate: 39.75% vs 24.71%; p = 0.004), but not to LCM. Phenytoin had a significantly higher resolution rate compared to VPA (response rate: 57.63% vs 39.75%; p = 0.02) and LEV (response rate: 57.63% vs 24.71; p < 0.001). The clinical predictors of anaesthetics administration were a disorder of consciousness upon clinical presentation, previous diagnosis of epilepsy, and younger age. CONCLUSION In our cohort of SE, PHT showed higher effectiveness in terminating established SE, as well as refractory SE in the subgroup of patients treated with anaesthetics.
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Affiliation(s)
- Eleonora Rollo
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marina Romozzi
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fedele Dono
- Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, "G. D'Annunzio" Università di Chieti-Pescara, Chieti, Italy; Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST-, University G. D'Annunzio of Chieti-Pescara, Italy.
| | - Daniela Bernardo
- Centro Clinico NEMO, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Consoli
- Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, "G. D'Annunzio" Università di Chieti-Pescara, Chieti, Italy
| | - Francesca Anzellotti
- Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, "G. D'Annunzio" Università di Chieti-Pescara, Chieti, Italy
| | | | | | - Stefano L Sensi
- Dipartimento di Neuroscienze, Imaging e Scienze Cliniche, "G. D'Annunzio" Università di Chieti-Pescara, Chieti, Italy; Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST-, University G. D'Annunzio of Chieti-Pescara, Italy
| | - Giacomo Della Marca
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Serenella Servidei
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy; Neurofisiopatologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Calabresi
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Catello Vollono
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy; Neurofisiopatologia, Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Samara QA, Ifraitekh AS, Al Jayyousi O, Sawan S, Hazaimeh E, Jbarah OF. Use of antiepileptic drugs as prophylaxis against posttraumatic seizures in the pediatric population: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:49. [PMID: 36746821 DOI: 10.1007/s10143-023-01963-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
We aim to assess the effect of anti-epileptic drug (AED) prophylaxis for early or late posttraumatic seizures, targeting the pediatric population with traumatic brain injury (TBI). We systematically searched for studies reporting the incidence of posttraumatic seizures in pediatric patients who suffered from TBI and received AEDs prophylactically following their TBI incident. Studies that included adult patients, adult and pediatric patients but did not report results for the pediatric population separately, and patients who did not suffer from a TBI were excluded. Studies that did not indicate the use of antiepileptic drugs prophylactically following TBI were excluded. A total of 10 studies were included involving 4621 posttraumatic brain injury patients of the pediatric age population (<18). Five studies assessed the effect of prophylaxis on early seizures, four on late seizures and one on any seizure. The mean incidence of posttraumatic seizures with AED prophylaxis was 8% for early seizures and 7.1% for late seizures. Moreover, one study revealed no benefit of AED prophylaxis for early posttraumatic seizures. Meta-analysis revealed a significant difference in the incidence of early posttraumatic seizures with antiepileptic prophylaxis. However, no significant difference for late posttraumatic seizures has been shown. In conclusion, AED prophylaxis seems to be effective against early posttraumatic seizures for the pediatric population, with levetiracetam possibly being more effective. Also, there is no observed benefit for late posttraumatic seizures.
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Affiliation(s)
- Qais A Samara
- Department of Neurosurgery, Faculty of Medicine, Al-Balqa Applied University, PO Box 206, Al Salt, 19117, Jordan.
| | - Ali S Ifraitekh
- Faculty of Medicine, Hashemite University, PO Box 330127, Zarqa, Jordan
| | - Obada Al Jayyousi
- Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
| | - Siya Sawan
- Faculty of Medicine, University of Jordan, PO Box 11942, Amman, Jordan
| | - Ethar Hazaimeh
- Neurology Department, Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
| | - Omar F Jbarah
- Neurosurgery Department, Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
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Noel MS, Kim S, Hartley ML, Wong S, Picozzi V, Staszewski H, Kim DW, Van Tornout JM, Philip PA, Chung V, Ocean AJ, Wang‐Gillam A. A randomized phase II study of SM-88 plus methoxsalen, phenytoin, and sirolimus in patients with metastatic pancreatic cancer treated in the second line and beyond. Cancer Med 2022; 11:4169-4181. [PMID: 35499204 PMCID: PMC9678093 DOI: 10.1002/cam4.4768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/11/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This trial explores SM-88 used with methoxsalen, phenytoin, and sirolimus (MPS) in pretreated metastatic pancreatic ductal adenocarcinoma (mPDAC) METHODS: Forty-nine patients were randomized to daily 460 or 920 mg oral SM-88 with MPS (SM-88 Regimen). The primary endpoint was objective response rate (RECIST 1.1). RESULTS Thirty-seven patients completed ≥ one cycle of SM-88 Regimen (response evaluable population). Disease control rate (DCR), overall survival (OS), and progression-free survival (PFS) did not differ significantly between dose levels. Stable disease was achieved in 9/37 patients (DCR, 24.3%); there were no complete or partial responses. Quality-of-life (QOL) was maintained and trended in favor of 920 mg. SM-88 Regimen was well tolerated; a single patient (1/49) had related grade 3 and 4 adverse events, which later resolved. In the intention-to-treat population of 49 patients, the median overall survival (mOS) was 3.4 months (95% CI: 2.7-4.9 months). Those treated in the second line had an mOS of 8.1 months and a median PFS of 3.8 months. Survival was higher for patients with stable versus progressive disease (any line; mOS: 10.6 months vs. 3.9 months; p = 0.01). CONCLUSIONS SM-88 Regimen has a favorable safety profile with encouraging QOL effects, disease control, and survival trends. This regimen should be explored in the second-line treatment of patients with mPDAC. CLINICALTRIALS gov Identifier: NCT03512756.
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Affiliation(s)
- Marcus S. Noel
- Georgetown Lombardi Comprehensive Cancer CenterWashingtonDistrict of ColumbiaUSA
| | - Semmie Kim
- TYME Technologies Inc.BedminsterNew JerseyUSA
| | - Marion L. Hartley
- The Ruesch Center for the Cure of Gastrointestinal CancersWashingtonDistrict of ColumbiaUSA
| | - Steve Wong
- Sarcoma Oncology Research CenterSanta MonicaCaliforniaUSA
| | | | | | - Dae Won Kim
- The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | | | - Philip Agop Philip
- Karmanos Cancer CenterWayne State UniversityMichiganDetroitUSA
- SWOGFarmington HillsMichiganUSA
| | | | - Allyson J. Ocean
- Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNew YorkUSA
| | - Andrea Wang‐Gillam
- Washington University School of Medicine in St. LouisSt. LouisMissouriUSA
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Okamoto G, Furuya E, Terada K, Yasukawa K, Takanashi JI, Kobayashi E. Fosphenytoin dosing regimen including optimal timing for the measurement of serum phenytoin concentration in pediatric patients. Brain Dev 2022; 44:725-731. [PMID: 35879140 DOI: 10.1016/j.braindev.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/02/2022] [Accepted: 06/30/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to evaluate the pediatric fosphenytoin dosing regimen, including optimal timing for the measurement of total serum phenytoin concentration (CPHT). METHODS We retrospectively investigated pediatric patients with status epilepticus or seizure clusters treated with fosphenytoin between April 2013 and March 2018. Two CPHT measurements were analyzed, one 2-4 h after the loading dose and another before the second dose. Individual pharmacokinetic parameters were estimated using the Bayesian method and were used to simulate CPHT. RESULTS The present study involved 12 pediatric patients; the loading dose of fosphenytoin was 22.1 (17.2-27.2) mg/kg. The CPHT was 13.4 (8.6-18.9) μg/mL 2-4 h after the loading dose. The CPHT estimated from individual pharmacokinetic parameters 12 and 24 h after the loading dose was 9.5 (6.7-14.2) and 5.8 (3.7-10.0) μg/mL, respectively. If fosphenytoin was administered at a loading dose of 22.5 mg/kg and a maintenance dose of 5 or 7.5 mg/kg (administered every 12 h, starting 12 h after the loading dose), then the CPHT on day 8 was estimated to be 5.74 (2.6-15.4) μg/mL at 5 mg/kg and 13.9 (5.7-31.0) μg/mL at 7.5 mg/kg. CONCLUSIONS In pediatric patients, a maintenance dose of fosphenytoin should be started 12 h after the loading dose, and a maintenance dose of 5-7.5 mg/kg/dose every 12 h may be better than every 24 h. We recommend measuring CPHT at 2 and 12 h after the loading dose to simplify and safely adjust the dosage in clinical practice.
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Affiliation(s)
- Go Okamoto
- Department of Pharmacy, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan.
| | - Emari Furuya
- Department of Pharmacy, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Kanae Terada
- Department of Pharmacy, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Kumi Yasukawa
- Pediatric Intensive Care Unit, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Jun-Ichi Takanashi
- Department of Pediatrics, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Emiko Kobayashi
- Department of Pharmacy, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
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Soto-Insuga V, González-Alguacil E, García-Peñas JJ. [Paediatric status epilepticus]. Rev Neurol 2022; 75:225-238. [PMID: 36218253 DOI: 10.33588/rn.7508.2022196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Status epilepticus is defined as the situation resulting from the failure of the mechanisms responsible for terminating an epileptic seizure. In 2015, an operational concept was adopted internationally in which two times are identified: a first time, at which treatment must begin (five minutes for convulsive status, 10-15 minutes for focal and non-convulsive status); and a second time, after which there is considered to be a high risk of subsequent sequelae (30 minutes in the case of the convulsive). It occurs in 3-42/100,000 children per year, who are refractory or super-refractory in 10-40% of cases. DEVELOPMENT This article will review the different therapeutic options for status, from early treatment at home to the different first-line (benzodiazepines), second-line (phenobarbital, valproic acid, phenytoin, levetiracetam and lacosamide) or third-line treatments, which include both pharmacological (anaesthetics, propofol, ketamine, lidocaine, topiramate, brivaracetam or perampanel) and non-pharmacological (ketogenic diet, immunomodulatory treatments or epilepsy surgery) therapies. CONCLUSIONS Early identification and treatment of a prolonged crisis are essential to prevent progression to status. Although with fewer sequelae than in adults, status epilepticus in children represents a cause of mortality of up to 3-5%, while 25% of them will develop subsequent epilepsy, as well as a considerable percentage of neurological sequelae.
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Affiliation(s)
- V Soto-Insuga
- Hospital Infantil Universitario Niño Jesús, 28009 Madrid, España
| | | | - J J García-Peñas
- Hospital Infantil Universitario Niño Jesús, 28009 Madrid, España
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Liu Q, Wang Y, Tan D, Liu Y, Zhang P, Ma L, Liang M, Chen Y. The Prevention and Reversal of a Phenytoin-Resistant Model by N-acetylcysteine Therapy Involves the Nrf2/P-Glycoprotein Pathway at the Blood-Brain Barrier. J Mol Neurosci 2022; 72:2125-2135. [PMID: 36028602 DOI: 10.1007/s12031-022-02056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022]
Abstract
The transporter hypothesis is one of the most popular hypotheses of drug-resistant epilepsy (DRE). P-glycoprotein (P-gp), a channel protein at the blood-brain barrier (BBB), plays an important role in the transport of some anti-seizure drugs from brain tissue into vessels, which reduces drug concentrations and diminishes the effects of drug treatment. We performed this study to test whether P-gp is overexpressed in DRE and identify ways to prevent and reverse DRE. In this study, we established a phenytoin (PHT)-resistant mouse model and revealed that P-gp was overexpressed at the BBB in PHT-resistant mice. The P-gp inhibitor nimodipine decreased the resistance of phenytoin. Antioxidative preventive treatment with N-acetylcysteine (NAC) prevented the mice from entering a PHT-resistant state, and NAC therapy tended to reverse PHT resistance into sensitivity. We were also able to induce PHT resistance by activating the Nrf2/P-gp pathway, which indicates that oxidative stress plays an important role in drug resistance. Taken together, these findings suggest that antioxidative therapy may be a promising strategy for overcoming DRE.
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Affiliation(s)
- Qiankun Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, China
| | - You Wang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, China
| | - Dandan Tan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, China
| | - Yong Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, China
| | - Peng Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, China
| | - Limin Ma
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, China
| | - Minxue Liang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, China
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, China.
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Terman SW, Lin CC, Kerr WT, DeLott LB, Callaghan BC, Burke JF. Changes in the Use of Brand Name and Generic Medications and Total Prescription Cost Among Medicare Beneficiaries With Epilepsy. Neurology 2022; 99:e751-e761. [PMID: 35705496 PMCID: PMC9484734 DOI: 10.1212/wnl.0000000000200779] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To characterize trends in antiseizure medication (ASM) fills and total prescription costs in people with epilepsy. METHODS This was a retrospective cohort study of beneficiaries with epilepsy (ASM, plus ICD codes) in a 20% random Medicare sample, with continuous Fee-For-Service coverage (Parts A, B, and D) in 2008-2018. We summed the number of pill days and costs (adjusted to 2018 dollars) per person-year for each ASM. ASMs were categorized into brand vs generic, first vs newer generation, and enzyme inducers vs noninducers. RESULTS There were 77,000-133,000 beneficiaries with epilepsy per year. The most common ASM was phenytoin in 2008, which shifted to levetiracetam in 2018 (2008: phenytoin 25%, levetiracetam 14%; 2018: phenytoin 9%, levetiracetam 27%). Brand name (2008: 56%; 2018: 14%), first-generation (2008: 55%; 2018: 32%), and enzyme-inducing ASMs (2008: 44%; 2018: 24%) each decreased over time as a proportion of pill days. The number of brand pill days per person-year initially decreased (e.g., 2008: 250; 2009: 121; 2010: 96) but then plateaued (2013-2018: between 66 and 69) given a notable increase in lacosamide pill days per person (2008: 0; 2018: 20). Total brand name costs per year initially decreased 2008-2010 (2008: $150 million; 2010: $72 million) but then increased after 2010 (2018: $256 million). In 2018, brand name ASMs represented 79% of costs despite representing only 14% of pill days, a 1-year pill supply became 277% more expensive for brand name medications but 42% less expensive for generic medications over time (2008: brand ∼$2,800 vs generic ∼$800; 2018: brand ∼$10,700 vs generic ∼$460), and many common brand name ASMs cost approximately 10-fold more per pill day than their generic equivalents. DISCUSSION First-generation and enzyme-inducing ASMs waned from 2008 to 2018. Although brand name ASMs initially waned translating into lower costs and potentially higher value care, after 2010, brand name costs markedly increased because of increasing use of lacosamide plus a 277% increase in per-pill cost of brand name ASMs. Brand name ASMs represented a minority of prescriptions, but the majority of costs.
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Affiliation(s)
- Samuel W Terman
- From the Department of Neurology, University of Michigan, Ann Arbor, MI.
| | - Chun C Lin
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Wesley T Kerr
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Lindsey B DeLott
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Brian C Callaghan
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| | - James F Burke
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
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Panda SP, Dhurandhar Y, Agrawal M. The interplay of epilepsy with impaired mitophagy and autophagy linked dementia (MAD): A review of therapeutic approaches. Mitochondrion 2022; 66:27-37. [PMID: 35842181 DOI: 10.1016/j.mito.2022.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/21/2022] [Accepted: 07/10/2022] [Indexed: 12/28/2022]
Abstract
The duration and, age of dementia have been linked to a higher risk of seizures. The exact mechanism that drives epileptogenesis in impaired mitophagy and autophagy linked dementia (MAD) is fully defined after reviewing the Scopus, Publon, and Pubmed databases. The epileptogenesis in patients with Alzheimer's disease dementia (ADD) and Parkinson's disease dementia (PDD) is due to involvement of amyloid plaques (Aβ), phosphorylated tau (pTau), Parkin, NF-kB and NLRP3 inflammasome. Microglia, the prime protective and inflammatory cells in the brain exert crosstalk between mitophagy and inflammation. Several researchers believed that the inflammatory brain cells microglia could be a therapeutic target for the treatment of a MAD associated epilepsy. There are conventional antiepileptic drugs such as gabapentin, lamotrigine, phenytoin sodium, carbamazepine, oxcarbazepine, felbamate, lamotrigine, valproate sodium, and topiramate are prescribed by a psychiatrist to suppress seizure frequency. Also, the conventional drugs generate serious adverse effects and synergises dementia characteristics. The adverse effect of carbamazepine is neurotoxic and also, damages haemopoietic system and respiratory tract. The phenytoin treatment causes cerebellar defect and anemia. Dementia and epilepsy have a complicated relationship, thus targeting mitophagy for cure of epileptic dementia makes sense. Complementary and alternative medicine (CAM) is one of the rising strategies by many patients of the world, not only to suppress seizure frequency but also to mitigate dementia characteristics of patients. Therefore our present review focus on the interplay between epilepsy and MAD and their treatment with CAM approaches.
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Affiliation(s)
- Siva Prasad Panda
- Institute of Pharmaceutical Research, GLA University, Mathura, Uttar Pradesh, India.
| | - Yogita Dhurandhar
- Institute of Pharmaceutical Research, GLA University, Mathura, Uttar Pradesh, India.
| | - Mehak Agrawal
- Institute of Pharmaceutical Research, GLA University, Mathura, Uttar Pradesh, India.
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Nevitt SJ, Sudell M, Cividini S, Marson AG, Tudur Smith C. Antiepileptic drug monotherapy for epilepsy: a network meta-analysis of individual participant data. Cochrane Database Syst Rev 2022; 4:CD011412. [PMID: 35363878 PMCID: PMC8974892 DOI: 10.1002/14651858.cd011412.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in 2017. Epilepsy is a common neurological condition with a worldwide prevalence of around 1%. Approximately 60% to 70% of people with epilepsy will achieve a longer-term remission from seizures, and most achieve that remission shortly after starting antiepileptic drug treatment. Most people with epilepsy are treated with a single antiepileptic drug (monotherapy) and current guidelines from the National Institute for Health and Care Excellence (NICE) in the United Kingdom for adults and children recommend carbamazepine or lamotrigine as first-line treatment for focal onset seizures and sodium valproate for generalised onset seizures; however, a range of other antiepileptic drug (AED) treatments are available, and evidence is needed regarding their comparative effectiveness in order to inform treatment choices. OBJECTIVES To compare the time to treatment failure, remission and first seizure of 12 AEDs (carbamazepine, phenytoin, sodium valproate, phenobarbitone, oxcarbazepine, lamotrigine, gabapentin, topiramate, eventrate, zonisamide, eslicarbazepine acetate, lacosamide) currently used as monotherapy in children and adults with focal onset seizures (simple focal, complex focal or secondary generalised) or generalised tonic-clonic seizures with or without other generalised seizure types (absence, myoclonus). SEARCH METHODS For the latest update, we searched the following databases on 12 April 2021: the Cochrane Register of Studies (CRS Web), which includes PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Epilepsy Group Specialised Register and MEDLINE (Ovid, 1946 to April 09, 2021). We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators and experts in the field. SELECTION CRITERIA We included randomised controlled trials of a monotherapy design in adults or children with focal onset seizures or generalised onset tonic-clonic seizures (with or without other generalised seizure types). DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD) and network meta-analysis (NMA) review. Our primary outcome was 'time to treatment failure', and our secondary outcomes were 'time to achieve 12-month remission', 'time to achieve six-month remission', and 'time to first seizure post-randomisation'. We performed frequentist NMA to combine direct evidence with indirect evidence across the treatment network of 12 drugs. We investigated inconsistency between direct 'pairwise' estimates and NMA results via node splitting. Results are presented as hazard ratios (HRs) with 95% confidence intervals (CIs) and we assessed the certainty of the evidence using the CiNeMA approach, based on the GRADE framework. We have also provided a narrative summary of the most commonly reported adverse events. MAIN RESULTS IPD were provided for at least one outcome of this review for 14,789 out of a total of 22,049 eligible participants (67% of total data) from 39 out of the 89 eligible trials (43% of total trials). We could not include IPD from the remaining 50 trials in analysis for a variety of reasons, such as being unable to contact an author or sponsor to request data, data being lost or no longer available, cost and resources required to prepare data being prohibitive, or local authority or country-specific restrictions. No IPD were available from a single trial of eslicarbazepine acetate, so this AED could not be included in the NMA. Network meta-analysis showed high-certainty evidence that for our primary outcome, 'time to treatment failure', for individuals with focal seizures; lamotrigine performs better than most other treatments in terms of treatment failure for any reason and due to adverse events, including the other first-line treatment carbamazepine; HRs (95% CIs) for treatment failure for any reason for lamotrigine versus: eventrate 1.01 (0.88 to 1.20), zonisamide 1.18 (0.96 to 1.44), lacosamide 1.19 (0.90 to 1.58), carbamazepine 1.26 (1.10 to 1.44), oxcarbazepine 1.30 (1.02 to 1.66), sodium valproate 1.35 (1.09 to 1.69), phenytoin 1.44 (1.11 to 1.85), topiramate 1.50 (1.23 to 1.81), gabapentin 1.53 (1.26 to 1.85), phenobarbitone 1.97 (1.45 to 2.67). No significant difference between lamotrigine and eventrate was shown for any treatment failure outcome, and both AEDs seemed to perform better than all other AEDs. For people with generalised onset seizures, evidence was more limited and of moderate certainty; no other treatment performed better than first-line treatment sodium valproate, but there were no differences between sodium valproate, lamotrigine or eventrate in terms of treatment failure; HRs (95% CIs) for treatment failure for any reason for sodium valproate versus: lamotrigine 1.06 (0.81 to 1.37), eventrate 1.13 (0.89 to 1.42), gabapentin 1.13 (0.61 to 2.11), phenytoin 1.17 (0.80 to 1.73), oxcarbazepine 1.24 (0.72 to 2.14), topiramate 1.37 (1.06 to 1.77), carbamazepine 1.52 (1.18 to 1.96), phenobarbitone 2.13 (1.20 to 3.79), lacosamide 2.64 (1.14 to 6.09). Network meta-analysis also showed high-certainty evidence that for secondary remission outcomes, few notable differences were shown for either seizure type; for individuals with focal seizures, carbamazepine performed better than gabapentin (12-month remission) and sodium valproate (six-month remission). No differences between lamotrigine and any AED were shown for individuals with focal seizures, or between sodium valproate and other AEDs for individuals with generalised onset seizures. Network meta-analysis also showed high- to moderate-certainty evidence that, for 'time to first seizure,' in general, the earliest licensed treatments (phenytoin and phenobarbitone) performed better than the other treatments for individuals with focal seizures; phenobarbitone performed better than both first-line treatments carbamazepine and lamotrigine. There were no notable differences between the newer drugs (oxcarbazepine, topiramate, gabapentin, eventrate, zonisamide and lacosamide) for either seizure type. Generally, direct evidence (where available) and network meta-analysis estimates were numerically similar and consistent with confidence intervals of effect sizes overlapping. There was no important indication of inconsistency between direct and network meta-analysis results. The most commonly reported adverse events across all drugs were drowsiness/fatigue, headache or migraine, gastrointestinal disturbances, dizziness/faintness and rash or skin disorders; however, reporting of adverse events was highly variable across AEDs and across studies. AUTHORS' CONCLUSIONS High-certainty evidence demonstrates that for people with focal onset seizures, current first-line treatment options carbamazepine and lamotrigine, as well as newer drug eventrate, show the best profile in terms of treatment failure and seizure control as first-line treatments. For people with generalised tonic-clonic seizures (with or without other seizure types), current first-line treatment sodium valproate has the best profile compared to all other treatments, but lamotrigine and eventrate would be the most suitable alternative first-line treatments, particularly for those for whom sodium valproate may not be an appropriate treatment option. Further evidence from randomised controlled trials recruiting individuals with generalised tonic-clonic seizures (with or without other seizure types) is needed.
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Affiliation(s)
- Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Maria Sudell
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Sofia Cividini
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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Wang BC, Chiu HY, Luh HT, Lin CJ, Hsieh SH, Chen TJ, Wu CR, Chen PY. Comparative efficacy of prophylactic anticonvulsant drugs following traumatic brain injury: A systematic review and network meta-analysis of randomized controlled trials. PLoS One 2022; 17:e0265932. [PMID: 35358219 PMCID: PMC8970384 DOI: 10.1371/journal.pone.0265932] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 03/11/2022] [Indexed: 11/19/2022] Open
Abstract
We systematically compared the effects of prophylactic anticonvulsant drug use in patients with traumatic brain injury. We searched four electronic databases from their inception until July 13, 2021. Two researchers independently screened, appraised, and extracted the included studies. Network meta-analysis using multivariate random effects and a frequentist framework was adopted for data analysis. The risk of bias of each study was assessed using the Cochrane risk of bias tool, and confidence in evidence was assessed through confidence in network meta-analysis (CINeMA). A total of 11 randomized controlled trials involving 2,450 participants and six different treatments (i.e., placebo, carbamazepine, phenytoin, levetiracetam, valproate, and magnesium sulfate) were included. We found that anticonvulsant drugs as a whole significantly reduced early posttraumatic seizures (PTS) but not late PTS compared with placebo (odd ratios [ORs] = 0.42 and 0.82, 95% confidence intervals [CIs] = 0.21–0.82 and 0.47–1.43). For the findings of network meta-analysis, we observed that phenytoin (ORs = 0.43 and 0.71; 95% CIs = 0.18–1.01 and 0.23–2.20), levetiracetam (ORs = 0.56 and 1.58; 95% CIs = 0.12–2.55 and 0.03–84.42), and carbamazepine (ORs = 0.29 and 0.64; 95% CIs = 0.07–1.18 and 0.08–5.28) were more likely to reduce early and late PTS compared with placebo; however, the treatment effects were not significant. Sensitivity analysis, after excluding a study enrolling only children, revealed that phenytoin had a significant effect in preventing early PTS (OR = 0.33; 95% CI = 0.14–0.78). Our findings indicate that no antiepileptic drug had an effect on early or late PTS superior to that of another; however, the sensitivity analysis revealed that phenytoin might prevent early PTS. Additional studies with large sample sizes and a rigorous design are required to obtain high-quality evidence on prophylactic anticonvulsant drug use in patients with traumatic brain injury.
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Affiliation(s)
- Bo-Cyuan Wang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, New Taipei City Municipal Tucheng Hospital (Built and Operated by Chang Gung Medical Foundation), Taipei, Taiwan
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Hui-Tzung Luh
- Department of Neurosurgery, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
| | - Chia-Jou Lin
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Shu-Hua Hsieh
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Ting-Jhen Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Chia-Rung Wu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Pin-Yuan Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Medicine, College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- * E-mail:
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Thomas RB, Muttavarapu SS, Shetty PK, Lewis LE. Efficacy and Utilization Patterns of Anti-Epileptic Drugs in the Management of Neonatal Seizures: A Comparative Exploration. Neurol India 2022; 70:574-578. [PMID: 35532621 DOI: 10.4103/0028-3886.344647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Management of neonatal seizures with available limited guidelines across different gestation can cause long-term neurological and cognitive impairment. OBJECTIVES To compare utilization and observe the efficacy of anti-epileptic drugs in the treatment of neonatal seizures. The association of hypoxic-ischemic encephalopathy with NS and the etiology of HIE were also determined. SUBJECTS AND METHODS A retrospective cohort study was conducted at a tertiary care hospital for a period of one year. It was approved by IEC prior to initiation. PARTICIPANTS Neonates admitted for seizure management and perinatal asphyxia with hypoxic-ischemic encephalopathy were included in the study. Both term and preterm 267 neonates from January 2014 to July 2018 were retrospectively analyzed. The drugs with the fastest seizure resolution, least recurrence, and readmission rates were considered efficient. Phenobarbitone, levetiracetam, and phenytoin were compared as they were commonly prescribed. Inpatient medical records and hospital databases served as sources of information. RESULTS Phenobarbitone was commonly utilized, followed by phenytoin and levetiracetam. The commonly prescribed combination was phenobarbitone (first-line agent) and phenytoin (second-line agent). Phenobarbitone immediately resolved seizures (97, 75.1%) and had the least cases of seizure recurrences (53, 41.1%) and readmissions (20, 15.5%), making it most efficient. The best second-line agent was phenytoin, with the least seizure recurrence (4, 8.51%), least readmissions (7, 14.8%), and fastest resolution (25, 53.1%). Levetiracetam was an efficient third-line agent. Hypoxic-ischemic encephalopathy was the most observed cause of neonatal seizures. CONCLUSION Phenobarbitone was observed as the most utilized and efficient anti-epileptic drug, followed by phenytoin and levetiracetam. Owing to limitations in this study, there is an alarming need for standardized clinical trials to establish thorough guidelines.
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Affiliation(s)
- Rose B Thomas
- Department of Pharmacy Practice, Manipal College of Pharmceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Spandana Siri Muttavarapu
- Department of Pharmacy Practice, Manipal College of Pharmceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Prasanna K Shetty
- Department of Pharmacy Practice, Manipal College of Pharmceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Leslie E Lewis
- Department of Neonatology, Kasturba Medical College, Manipal, Karnataka, India
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Garg R, Aggarwal A, Sharma S, Narang M, Malhotra R. Antiseizure Drug Levels in Children Aged 2-12 Years Presenting With Breakthrough Seizures: A Single Center Cross-sectional Study. Indian Pediatr 2021; 58:850-852. [PMID: 34183465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To study the antiseizure drug levels and associated factors in children with breakthrough seizures. METHODS This cross-sectional study conducted at a public hospital from November, 2017 to April, 2019, included 145 children with epilepsy aged 2 to 12 years presenting with breakthrough seizure. Antiseizure drug levels were measured, and the levels were categorized as within, below, and above the reference range. RESULTS Children with epilepsy receiving sodium valproate, phenytoin and carbamazepine were 111 (73%), 31 (20.4%) and 10 (6.6%), respectively, of which 7 were receiving multiple antiseizure drugs. Drug levels below the reference range were found in 64 (44.1%), within the reference range in 70 (48.3%), and the above reference range in 11 (7.6%) children. CONCLUSIONS Nearly half the children with breakthrough seizures had sub-therapeutic levels, especially those on phenytoin therapy. Drug levels in below therapeutic range were not associated with occurrence of breakthrough seizures.
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Affiliation(s)
- Rajan Garg
- Department of Pediatrics, UCMS and GTB Hospital, Delhi. Correspondence to: Dr. Rajan Garg, Department of Pediatrics, University College of Medical Science and GTB Hospital, Delhi110095.
| | - Anju Aggarwal
- Department of Pediatrics, UCMS and GTB Hospital, Delhi
| | - Sangeeta Sharma
- Department of Neuropsychopharmacology, Institute of Human Behaviour and Allied Sciences, Delhi
| | - Manish Narang
- Department of Pediatrics, UCMS and GTB Hospital, Delhi
| | - Rajeev Malhotra
- Department of Statistics, Delhi Cancer Registry, Dr. BRAIRCH, AIIMS, New Delhi
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Abstract
Genetic testing has yielded major advances in our understanding of the causes of epilepsy. Seizures remain resistant to treatment in a significant proportion of cases, particularly in severe, childhood-onset epilepsy, the patient population in which an underlying causative genetic variant is most likely to be identified. A genetic diagnosis can be explanatory as to etiology, and, in some cases, might suggest a therapeutic approach; yet, a clear path from genetic diagnosis to treatment remains unclear in most cases. Here, we discuss theoretical considerations behind the attempted use of small molecules for the treatment of genetic epilepsies, which is but one among various approaches currently under development. We explore a few salient examples and consider the future of the small molecule approach for genetic epilepsies. We conclude that significant additional work is required to understand how genetic variation leads to dysfunction of epilepsy-associated protein targets, and how this impacts the function of diverse subtypes of neurons embedded within distributed brain circuits to yield epilepsy and epilepsy-associated comorbidities. A syndrome- or even variant-specific approach may be required to achieve progress. Advances in the field will require improved methods for large-scale target validation, compound identification and optimization, and the development of accurate model systems that reflect the core features of human epilepsy syndromes, as well as novel approaches towards clinical trials of such compounds in small rare disease cohorts.
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Affiliation(s)
- Ethan M Goldberg
- Department of Pediatrics, Division of Neurology, Abramson Research Center, The Epilepsy Neurogenetics Initiative, The Children's Hospital of Philadelphia, Abramson Research Center Room 502A, 19104, Philadelphia, PA, USA.
- Departments of Neurology and Neuroscience, The University of Pennsylvania Perelman School of Medicine, 19104, Philadelphia, PA, USA.
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Asadi-Pooya AA, Rostaminejad M, Zeraatpisheh Z, Mirzaei Damabi N. Cosmetic adverse effects of antiseizure medications; A systematic review. Seizure 2021; 91:9-21. [PMID: 34052629 DOI: 10.1016/j.seizure.2021.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/28/2021] [Accepted: 05/06/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We systematically reviewed the existing literature on the cosmetic adverse effects of antiseizure medications (ASMs) in order to depict a clear picture of these unwanted side effects of ASMs with a particular attention to hair loss, hirsutism, acne, and gingival hyperplasia. METHODS This systematic review was prepared according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Scopus, MEDLINE, and Google Scholar from the inception to 25 March, 2021 were systematically searched. These key words (title/abstract) were used: "hair loss" OR "hirsutism" OR "acne" OR "gingival hyperplasia" AND "seizure" OR "epilepsy" OR "anriseizure" OR "antiepileptic". The exclusion criteria included: non-original studies, articles not in English, and animal studies. RESULTS The primary search yielded 3938 studies; 127 studies were related to the topic and were included in the current systematic review. The most robust evidence on cosmetic adverse effects of ASMs were related to phenytoin (causing gingival hyperplasia, hirsutism, and acne) and valproate (causing hair loss and hirsutism); however, many other ASMs were also implicated in causing these cosmetic adverse effects. CONCLUSION Antiseizure medications may be associated with various cosmetic adverse effects. Phenytoin and valproate are the most notorious ASMs in this regard; but, other ASMs have also been implicated in causing hair loss, hirsutism, acne, and gingival hyperplasia. Physicians should pay more attention to these significant adverse effects that may affect a patient's facial attractiveness, quality of life, and emotional state.
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Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
| | | | - Zahra Zeraatpisheh
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Roper L, Lyttle MD, Gamble C, Humphreys A, Messahel S, Lee ED, Noblet J, Hickey H, Rainford N, Iyer A, Appleton R, Woolfall K. Planning for success: overcoming challenges to recruitment and conduct of an open-label emergency department-led paediatric trial. Emerg Med J 2021; 38:191-197. [PMID: 33051276 PMCID: PMC7907583 DOI: 10.1136/emermed-2020-209487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/03/2020] [Accepted: 09/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Key challenges to the successful conduct of The Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children (EcLiPSE) trial were identified at the pre-trial stage. These included practitioner anxieties about conducting research without prior consent (RWPC), inexperience in conducting an ED-led trial and use of a medication that was not usual ED practice. As part of an embedded study, we explored parent and practitioner experiences of recruitment, RWPC and conduct of the trial to inform the design and conduct of future ED-led trials. METHODS A mixed-methods study within a trial involving (1) questionnaires and interviews with parents of randomised children, (2) interviews and focus groups with EcLiPSE practitioners and (3) audio-recorded trial discussions. We analysed data using thematic analysis and descriptive statistics as appropriate. RESULTS A total of 143 parents (93 mothers, 39 fathers, 11 missing information) of randomised children completed a questionnaire and 30 (25 mothers, 5 fathers) were interviewed. We analysed 76 recorded trial recruitment discussions. Ten practitioners (4 medical, 6 nursing) were interviewed, 36 (16 medical, 20 nursing) participated in one of six focus groups. Challenges to the success of the trial were addressed by having a clinically relevant research question, pragmatic trial design, parent and practitioner support for EcLiPSE recruitment and research without prior consent processes, and practitioner motivation and strong leadership. Lack of leadership negatively affected practitioner engagement and recruitment. EcLiPSE completed on time, achieving its required sample size target. CONCLUSIONS Successful trial recruitment and conduct in a challenging ED-led trial was driven by trial design, recruitment experience, teamwork and leadership. Our study provides valuable insight from parents and practitioners to inform the design and conduct of future trials in this setting.
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Affiliation(s)
- Louise Roper
- Institute of Population Health & Society, University of Liverpool, Liverpool, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Amy Humphreys
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Shrouk Messahel
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Elizabeth D Lee
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Joanne Noblet
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Naomi Rainford
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Anand Iyer
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Richard Appleton
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Kerry Woolfall
- Institute of Population Health & Society, University of Liverpool, Liverpool, UK
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Lv Y, Liang H, Li J, Li X, Tang X, Gao S, Zou H, Zhang J, Wang M, Xiao L. Central inhibition prevents the in vivo acute toxicity of harmine in mice. J Toxicol Sci 2021; 46:289-301. [PMID: 34078836 DOI: 10.2131/jts.46.289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Harmine is a β-carboline alkaloid that displays antidepressant, antitumor and other pharmacological effects. However, the strong toxic effects limit its clinical application, and should be first considered. PURPOSE To evaluate the in vivo toxicity of harmine and explore intervention strategies against its toxicity. METHODS The in vivo toxicity of harmine was assessed from the symptoms, biochemical indices, and cardiovascular effects in mice. The intervention experiments were performed by using anesthetics, central drugs, and peripheral anticholinergics. RESULTS The acute toxicity of harmine is significantly dose-dependent and the median lethal dose is 26.9 mg/kg in vivo. The typical symptoms include convulsion, tremor, jumping, restlessness, ataxia, opisthotonos, and death; it also changes cardiovascular function. The anesthetics improved the survival rate and abolished the symptoms after harmine poisoning. Two central inhibitors, benzhexol and phenytoin sodium, uniformly improved the survival rates of mice poisoned with harmine. The peripheral anticholinergics didn't show any effects. CONCLUSION Harmine exposure leads to central neurological symptoms, cardiovascular effects and even death through direct inhibition of the central AChE activity, where the death primarily comes from central neurological symptoms and is cooperated by the secondary cardiovascular collapse. Central inhibition prevents the acute toxicity of harmine, and especially rapid gaseous anesthetics such as isoflurane, might have potential application in the treatment of harmine poisoning.
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Affiliation(s)
- Yang Lv
- College of Pharmacy, Xinjiang Medical University, China
- Faculty of Naval Medicine, Second Military Medical University (Naval Medical University), China
| | - Hongyu Liang
- Faculty of Naval Medicine, Second Military Medical University (Naval Medical University), China
- College of Traditional Chinese Medicine, Jilin Agricultural University, China
| | - Jun Li
- College of Pharmacy, Xinjiang Medical University, China
- Faculty of Naval Medicine, Second Military Medical University (Naval Medical University), China
| | - Xiuxiu Li
- Faculty of Naval Medicine, Second Military Medical University (Naval Medical University), China
| | - Xiaohui Tang
- College of Pharmacy, Xinjiang Medical University, China
| | - Songyu Gao
- Faculty of Naval Medicine, Second Military Medical University (Naval Medical University), China
| | - Hao Zou
- Department of Pharmaceutical Sciences, School of Pharmacy, Second Military Medical University, China
| | - Jing Zhang
- College of Traditional Chinese Medicine, Jilin Agricultural University, China
| | - Mei Wang
- College of Pharmacy, Xinjiang Medical University, China
| | - Liang Xiao
- Faculty of Naval Medicine, Second Military Medical University (Naval Medical University), China
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Abstract
Currently used treatment protocols for neonatal seizures vary among centers with limited evidence to support the choice of a given antiseizure medication. Because of concerns about the potential negative impact of phenobarbital on long-term neurodevelopment outcomes, our unit transitioned to fosphenytoin as the first-line antiseizure medication. A retrospective observational cohort study was conducted to compare the acute and long-term outcomes of fosphenytoin and phenobarbital as first-line antiseizure medication for neonatal seizure treatment. The 2 study groups had similar baseline characteristics for neonatal variables as well as maternal antenatal complications. We did not find any differences in the acute outcomes between the 2 groups. However, significantly fewer infants in the fosphenytoin group had moderate-to-severe neurodevelopmental delay at the 18- and 24-month assessments. In conclusion, although both medications were equally efficacious for acute neonatal seizure control, fosphenytoin had the potential for significantly better neurodevelopmental outcomes at 18-24 months of age.
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Affiliation(s)
- Veronica Alix
- Department of Pediatrics, Baystate Children's Hospital, UMMS-Baystate, Springfield, MA, USA
| | - Mansi James
- Department of Pediatrics, Baystate Children's Hospital, UMMS-Baystate, Springfield, MA, USA
| | - Anthony H Jackson
- Department of Pediatrics, Baystate Children's Hospital, UMMS-Baystate, Springfield, MA, USA
- Department of Neurology, UMMS-Baystate, Springfield, MA, USA
| | - Paul F Visintainer
- Epidemiology & Biostatistics, Office of Research, UMMS-Baystate, Springfield, MA, USA
| | - Rachana Singh
- Department of Pediatrics, Baystate Children's Hospital, UMMS-Baystate, Springfield, MA, USA
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Yamamoto Y, Terada K, Araki Y, Fukushima Y, Imai K, Kagawa Y, Takahashi Y. Therapeutic Monitoring of Lacosamide in Japanese Patients With Epilepsy: Clinical Response, Tolerability, and Optimal Therapeutic Range. Ther Drug Monit 2020; 42:754-759. [PMID: 32941398 DOI: 10.1097/ftd.0000000000000764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lacosamide is a novel anticonvulsant that acts by enhancing sodium channel slow inactivation. The aims of this study were to evaluate the influence of concomitant antiepileptic drugs (AEDs) on serum lacosamide concentration and explore the relationship between lacosamide serum concentration and both clinical response and adverse effects. METHODS The authors analyzed 649 serum samples from 426 Japanese patients with epilepsy. The concentration-to-dose (CD) ratio of lacosamide was compared among patients on various AED regimens. Clinical information about seizure frequency and adverse events was obtained from clinical records. RESULTS In patients who did not receive enzyme-inducing AEDs, the CD ratio (mean ± SD) of lacosamide was 1.84 ± 0.68. By contrast, the CD ratio in patients who received phenytoin, carbamazepine, and phenobarbital was 1.42 ± 0.66 (22.8% lower), 1.46 ± 0.40 (20.7% lower), and 1.36 ± 0.38 (26.1% lower), respectively. Seventy-four patients (17.3%) achieved >50% seizure reduction. The median lacosamide concentration in patients who received and did not receive a sodium channel blocker was 6.6 mcg/mL (26.4 μmol/L) and 8.4 mcg/mL (33.6 μmol/L), respectively. Adverse events, including dizziness, somnolence, diplopia, and anorexia, were reported by 70 patients (16.4%). The incidence rate in patients treated with sodium channel blockers was significantly higher than that in patients not treated with these drugs (21.1% vs. 10.3%; P < 0.005), and the median lacosamide concentration in these patient groups was 5.1 (20.4 μmol/L) and 7.5 mcg/mL (30 μmol/L), respectively. CONCLUSIONS Therapeutic drug monitoring of lacosamide is clinically useful because it allows physicians to estimate the extent of drug interactions and adjust the dose in individual AED regimens.
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Affiliation(s)
- Yoshiaki Yamamoto
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama
- Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, Yada; and
| | - Kiyohito Terada
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama
| | - Yasukiyo Araki
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama
| | - Yutaro Fukushima
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama
| | - Katsumi Imai
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama
| | - Yoshiyuki Kagawa
- Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, Yada; and
- Laboratory of Clinical Pharmacokinetics and Drug Safety, Shizuoka General Hospital, Kita Ando, Shizuoka, Japan
| | - Yukitoshi Takahashi
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Urushiyama
- Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, Yada; and
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Abstract
BACKGROUND Antisocial personality disorder (AsPD) is associated with rule-breaking, criminality, substance use, unemployment, relationship difficulties, and premature death. Certain types of medication (drugs) may help people with AsPD. This review updates a previous Cochrane review, published in 2010. OBJECTIVES To assess the benefits and adverse effects of pharmacological interventions for adults with AsPD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also checked reference lists and contacted study authors to identify studies. SELECTION CRITERIA Randomised controlled trials in which adults (age 18 years and over) with a diagnosis of AsPD or dissocial personality disorder were allocated to a pharmacological intervention or placebo control condition. DATA COLLECTION AND ANALYSIS Four authors independently selected studies and extracted data. We assessed risk of bias and created 'Summary of findings tables' and assessed the certainty of the evidence using the GRADE framework. The primary outcomes were: aggression; reconviction; global state/global functioning; social functioning; and adverse events. MAIN RESULTS We included 11 studies (three new to this update), involving 416 participants with AsPD. Most studies (10/11) were conducted in North America. Seven studies were conducted exclusively in an outpatient setting, one in an inpatient setting, and one in prison; two studies used multiple settings. The average age of participants ranged from 28.6 years to 45.1 years (overall mean age 39.6 years). Participants were predominantly (90%) male. Study duration ranged from 6 to 24 weeks, with no follow-up period. Data were available from only four studies involving 274 participants with AsPD. All the available data came from unreplicated, single reports, and did not allow independent statistical analysis to be conducted. Many review findings were limited to descriptive summaries based on analyses carried out and reported by the trial investigators. No study set out to recruit participants on the basis of having AsPD; many participants presented primarily with substance abuse problems. The studies reported on four primary outcomes and six secondary outcomes. Primary outcomes were aggression (six studies) global/state functioning (three studies), social functioning (one study), and adverse events (seven studies). Secondary outcomes were leaving the study early (eight studies), substance misuse (five studies), employment status (one study), impulsivity (one study), anger (three studies), and mental state (three studies). No study reported data on the primary outcome of reconviction or the secondary outcomes of quality of life, engagement with services, satisfaction with treatment, housing/accommodation status, economic outcomes or prison/service outcomes. Eleven different drugs were compared with placebo, but data for AsPD participants were only available for five comparisons. Three classes of drug were represented: antiepileptic; antidepressant; and dopamine agonist (anti-Parkinsonian) drugs. We considered selection bias to be unclear in 8/11 studies, attrition bias to be high in 7/11 studies, and performance bias to be low in 7/11 studies. Using GRADE, we rated the certainty of evidence for each outcome in this review as very low, meaning that we have very little confidence in the effect estimates reported. Phenytoin (antiepileptic) versus placebo One study (60 participants) reported very low-certainty evidence that phenytoin (300 mg/day), compared to placebo, may reduce the mean frequency of aggressive acts per week (phenytoin mean = 0.33, no standard deviation (SD) reported; placebo mean = 0.51, no SD reported) in male prisoners with aggression (skewed data) at endpoint (six weeks). The same study (60 participants) reported no evidence of difference between phenytoin and placebo in the number of participants reporting the adverse event of nausea during week one (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.06 to 16.76; very low-certainty evidence). The study authors also reported that no important side effects were detectable via blood cell counts or liver enzyme tests (very low-certainty evidence). The study did not measure reconviction, global/state functioning or social functioning. Desipramine (antidepressant) versus placebo One study (29 participants) reported no evidence of a difference between desipramine (250 to 300 mg/day) and placebo on mean social functioning scores (desipramine = 0.19; placebo = 0.21), assessed with the family-social domain of the Addiction Severity Index (scores range from zero to one, with higher values indicating worse social functioning), at endpoint (12 weeks) (very low-certainty evidence). Neither of the studies included in this comparison measured the other primary outcomes: aggression; reconviction; global/state functioning; or adverse events. Nortriptyline (antidepressant) versus placebo One study (20 participants) reported no evidence of a difference between nortriptyline (25 to 75 mg/day) and placebo on mean global state/functioning scores (nortriptyline = 0.3; placebo = 0.7), assessed with the Symptom Check List-90 (SCL-90) Global Severity Index (GSI; mean of subscale scores, ranging from zero to four, with higher scores indicating greater severity of symptoms), at endpoint (six months) in men with alcohol dependency (very low-certainty evidence). The study measured side effects but did not report data on adverse events for the AsPD subgroup. The study did not measure aggression, reconviction or social functioning. Bromocriptine (dopamine agonist) versus placebo One study (18 participants) reported no evidence of difference between bromocriptine (15 mg/day) and placebo on mean global state/functioning scores (bromocriptine = 0.4; placebo = 0.7), measured with the GSI of the SCL-90 at endpoint (six months) (very low-certainty evidence). The study did not provide data on adverse effects, but reported that 12 patients randomised to the bromocriptine group experienced severe side effects, five of whom dropped out of the study in the first two days due to nausea and severe flu-like symptoms (very low-certainty evidence). The study did not measure aggression, reconviction and social functioning. Amantadine (dopamine agonist) versus placebo The study in this comparison did not measure any of the primary outcomes. AUTHORS' CONCLUSIONS The evidence summarised in this review is insufficient to draw any conclusion about the use of pharmacological interventions in the treatment of antisocial personality disorder. The evidence comes from single, unreplicated studies of mostly older medications. The studies also have methodological issues that severely limit the confidence we can draw from their results. Future studies should recruit participants on the basis of having AsPD, and use relevant outcome measures, including reconviction.
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Affiliation(s)
- Najat R Khalifa
- Department of Psychiatry, Queen's University, Kingston, Canada
| | - Simon Gibbon
- Arnold Lodge, Nottinghamshire Healthcare NHS Foundation Trust, Leicester, UK
| | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Natalie H-Y Cheung
- Forensic Research, Nottinghamshire Healthcare NHS Foundation Trust, Leicester, UK
| | - Lucy McCarthy
- Arnold Lodge, Nottinghamshire Healthcare NHS Foundation Trust, Leicester, UK
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Abstract
BACKGROUND This is an updated version of the Cochrane Review previously published in 2018. The incidence of seizures following supratentorial craniotomy for non-traumatic pathology has been estimated to be between 15% to 20%; however, the risk of experiencing a seizure appears to vary from 3% to 92% over a five-year period. Postoperative seizures can precipitate the development of epilepsy; seizures are most likely to occur within the first month of cranial surgery. The use of antiepileptic drugs (AEDs) administered pre- or postoperatively to prevent seizures following cranial surgery has been investigated in a number of randomised controlled trials (RCTs). OBJECTIVES To determine the efficacy and safety of AEDs when used prophylactically in people undergoing craniotomy and to examine which AEDs are most effective. SEARCH METHODS For the latest update we searched the following databases on 29 September 2019: Cochrane Epilepsy Group Specialized Register, CENTRAL, MEDLINE, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP). We did not apply any language restrictions. SELECTION CRITERIA We included RCTs of people with no history of epilepsy who were undergoing craniotomy for either therapeutic or diagnostic reasons. We included trials with adequate randomisation methods and concealment; these could either be blinded or unblinded parallel trials. We did not stipulate a minimum treatment period, and we included trials using active drugs or placebo as a control group. DATA COLLECTION AND ANALYSIS Three review authors (JW, JG, YD) independently selected trials for inclusion, extracted data and assessed risk of bias. We resolved any disagreements through discussion. Outcomes investigated included the number of participants experiencing seizures (early (occurring within first week following craniotomy), and late (occurring after first week following craniotomy)), the number of deaths and the number of people experiencing disability and adverse effects. Due to the heterogeneous nature of the trials, we did not combine data from the included trials in a meta-analysis; we presented the findings of the review in narrative format. Visual comparisons of outcomes are presented in forest plots. MAIN RESULTS We included 10 RCTs (N = 1815), which were published between 1983 and 2015. Three trials compared a single AED (phenytoin) with placebo or no treatment. One, three-armed trial compared two AEDs (phenytoin, carbamazepine) with no treatment. A second three-armed trial compared phenytoin, phenobarbital with no treatment. Of these five trials comparing AEDs with placebo or no treatment, two trials reported a statistically significant advantage for AED treatment compared to controls for early seizure occurrence; all other comparisons showed no clear or statistically significant differences between AEDs and control treatment. None of the trials that were head-to-head comparisons of AEDs (phenytoin versus sodium valproate, phenytoin versus phenobarbital, levetiracetam versus phenytoin, zonisamide versus phenobarbital) reported any statistically significant differences between treatments for either early or late seizure occurrence. Only five trials reported incidences of death. One trial reported statistically significantly fewer deaths in the carbamazepine and no-treatment groups compared with the phenytoin group after 24 months of treatment, but not after six months of treatment. Incidences of adverse effects of treatment were poorly reported; however, three trials did show that significantly more adverse events occurred on phenytoin compared to valproate, placebo, or no treatment. No trials reported any results relating to functional outcomes such as disability. We considered the evidence to be of low certainty for all reported outcomes due to methodological issues and variability of comparisons made in the trials. AUTHORS' CONCLUSIONS There is limited, low-certainly evidence to suggest that AED treatment administered prophylactically is either effective or not effective in the prevention of postcraniotomy (early or late) seizures. The current evidence base is limited due to the different methodologies employed in the trials and inconsistencies in the reporting of outcomes including deaths and adverse events. Further evidence from good-quality, contemporary trials is required in order to assess the clinical effectiveness of prophylactic AED treatment compared to placebo or no treatment, or other AEDs in preventing postcraniotomy seizures in this select group of patients.
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Affiliation(s)
- Janette Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Jennifer Weston
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Yenal Dundar
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
- Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Sarah J Nevitt
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Liverpool Health Partners, Liverpool, UK
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Yokoyama R, Hayashi R, Umemori Y, Arimatsu A, Yuki A, Abe R. Refractory Bullous Pemphigoid Improved by Discontinuation of Phenytoin as an CYP3A4 Inducer. Acta Derm Venereol 2020; 100:adv00108. [PMID: 32215663 PMCID: PMC9128886 DOI: 10.2340/00015555-3472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Rei Yokoyama
- Division of Dermatology, Nagaoka Red Cross Hospital, Niigata, Japan
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Srivastava K, Bhartiya S, Gavli V, Patil R, Rajadhyaksha S. Efficacy, Tolerability and Serum Phenytoin Levels after Intravenous Fosphenytoin Loading Dose in Children with Status Epilepticus. Indian Pediatr 2020; 57:218-221. [PMID: 32198860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate the efficacy and tolerability of intravenous fosphenytoin in children with status epilepticus, and resulting serum total phenytoin levels. METHODS In this prospective study, 51 children aged less than 18 years received intravenous loading dose of fosphenytoin (18-20 mg/kg). Serum total phenytoin levels were estimated at 90 -100 minutes. Outcomes studied were (i) seizure control and local and/or systemic adverse effects in next 24 hours and (ii) phenytoin levels and its correlation with dose received, seizure control and adverse effects. RESULTS The actual dose of fosphenytoin received varied from 15.1 to 25 mg/kg. Seizures were controlled in 45 (88%) children and, two required additional dose of 10 mg/kg. None of the children showed any local or systemic adverse effects. Serum total phenytoin levels were in the therapeutic range (10-20 µg/mL) in 12 (23.5%), sub-therapeutic in 16 (31.3%) and supra-therapeutic in 25 (49%) children. There was weak correlation of the phenytoin levels with dose of fosphenytoin received, seizure control, or adverse effects. CONCLUSIONS Intravenous fosphenytoin loading dose of 20 mg/kg is effective in controlling seizures in 88% of children with status epilepticus, with a good safety profile. Seizure control and adverse effects appear to be independent of serum total phenytoin levels achieved.
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Affiliation(s)
- Kavita Srivastava
- Pediatric Neurology Unit, Department of Pediatrics, Bharati Vidyapeeth Deemed University Medical College, Pune, India. Correspondence to: Dr Kavita Srivastava, Professor in Pediatrics, 3rd floor, Bharati Hospital, Katraj, Pune 411 043, India.
| | - Shirish Bhartiya
- Pediatric Neurology Unit, Department of Pediatrics, Bharati Vidyapeeth Deemed University Medical College, Pune, India
| | - Vrushabh Gavli
- Pediatric Neurology Unit, Department of Pediatrics, Bharati Vidyapeeth Deemed University Medical College, Pune, India
| | - Rahul Patil
- Pediatric Neurology Unit, Department of Pediatrics, Bharati Vidyapeeth Deemed University Medical College, Pune, India
| | - Surekha Rajadhyaksha
- Pediatric Neurology Unit, Department of Pediatrics, Bharati Vidyapeeth Deemed University Medical College, Pune, India
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Vignesh V, Rameshkumar R, Mahadevan S. Comparison of Phenytoin, Valproate and Levetiracetam in Pediatric Convulsive Status Epilepticus: A Randomized Double-blind Controlled Clinical Trial. Indian Pediatr 2020; 57:222-227. [PMID: 32198861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To compare the efficacy of phenytoin, valproate, and levetiracetam in the management of pediatric convulsive status epilepticus. DESIGN Randomized double-blind controlled clinical trial. SETTING Pediatric critical care division in a tertiary care institute from June, 2016 to December, 2018. PARTICIPANTS 110 children aged three month to 12 year with convulsive status epilepticus. INTERVENTION Patients not responding to 0.1 mg/kg intravenous lorazepam were randomly assigned (1:1:1) to receive 20 mg/kg of phenytoin (n=35) or valproate (n=35) or levetiracetam (n=32) over 20 minutes. Patients with nonconvulsive status epilepticus, recent hemorrhage, platelet count less than 50,000 or International normalized ratio (INR) more than 2, head injury or neurosurgery in the past one-month, liver or kidney disease, suspected or known neurometabolic or mitochondrial disorders or structural malformations, and allergy to study drugs; and those who were already on any one of the study drugs for more than one month or had received one of the study drugs for current episode, were excluded. OUTCOME MEASURE The primary outcome was the proportion of patients that achieved control of convulsive status epilepticus at the end of 15 minutes after completion of the study drug infusion. Secondary outcomes were time to control of seizure, rate of adverse events, and the requirement of additional drugs to control seizure, length of ventilation, hospital stay, and functional status after three months (Glasgow Outcome Scale). RESULTS The study was stopped after the planned mid-interim analysis for futility. Intention to treat analysis was done. There was no difference in primary outcome in phenytoin (31/35, 89%), valproate (29/35, 83%), and levetiracetam (30/32, 94%) (P=0.38) groups. There were no differences between the groups for secondary outcomes. One patient in the phenytoin group had a fluid-responsive shock, and one patient in the valproate group died due to encephalopathy and refractory shock. CONCLUSIONS Phenytoin, valproate, and levetiracetam were equally effective in controlling pediatric convulsive status epilepticus.
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Affiliation(s)
- Vinayagamoorthy Vignesh
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. Correspondence to: Dr Rameshkumar Ramachandran, Associate Professor, Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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de Oliveira EG, de Oliveira RS, Zatta KC, Furian AF, Oliveira MS, Pohlmann AR, Guterres SS, Beck RCR. Phenytoin-loaded lipid-core nanocapsules improve the technological properties and in vivo performance of fluidised bed granules. Mater Sci Eng C Mater Biol Appl 2020; 111:110753. [PMID: 32279762 DOI: 10.1016/j.msec.2020.110753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/20/2019] [Accepted: 02/15/2020] [Indexed: 11/20/2022]
Abstract
Lipid-core nanocapsules (LNCs) were recently reported by our group as a suitable binder system to produce fluidised bed granules. However, there is still a lack of knowledge about the influence of using these nanocarriers loaded with a drug on the properties of the granules and their in vivo performance. Therefore, this study was designed to produce innovative fluidised bed granules containing phenytoin-loaded LNCs (LNCPHT) as a strategy to evaluate the influence of the presence of the drug-loaded nanocarriers on their in vitro and in vivo properties. Granules were produced using a mixture of maltodextrin and phenytoin (1:0.004 w/w) as substrate. They were prepared by fluid bed granulation using water or LNCPHT as the liquid binder, affording good yields (73-82%) of granules with low moisture content (<5%). Granules prepared with LNCPHT had larger mean size (122 μm) compared to maltodextrin primary particles (50 μm) due to the formation of solid bridges. Moreover, the use of LNCPHT as the liquid binder improved their powder flow properties. The nanocarriers were recovered after aqueous dispersion (3.00 mg.mL-1 of PHT) with a redispersibility close to 90%. After reconstitution in water, granules containing LNCPHT showed an improved dissolution behaviour compared to those prepared without them. In addition, they showed a higher mucoadhesive effect due to a combined effect of the LNCPHT and maltodextrin in the interactions with porcine intestinal mucosa. Regarding the in vivo studies, granules containing the combination of non-encapsulated PHT and PHT-loaded lipid-core nanocapsules increased the latency to seizures compared to placebo granules, showing effective anticonvulsant effect in mice. In conclusion, the use of drug-loaded nanocapsules as binder is an encouraging approach to produce fluidised bed mucoadhesive granules with improved technological properties and in vivo performance.
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Affiliation(s)
- Edilene Gadelha de Oliveira
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Rafaela Santos de Oliveira
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Kelly Cristine Zatta
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ana Flávia Furian
- Departamento de Ciência e Tecnologia de Alimentos (UFSM), Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Mauro Schneider Oliveira
- Programa de Pós-Graduação em Farmacologia, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Adriana Raffin Pohlmann
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Sílvia Stanisçuaski Guterres
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ruy Carlos Ruver Beck
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Kapur J, Elm J, Chamberlain JM, Barsan W, Cloyd J, Lowenstein D, Shinnar S, Conwit R, Meinzer C, Cock H, Fountain N, Connor JT, Silbergleit R. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med 2019; 381:2103-2113. [PMID: 31774955 PMCID: PMC7098487 DOI: 10.1056/nejmoa1905795] [Citation(s) in RCA: 271] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The choice of drugs for patients with status epilepticus that is refractory to treatment with benzodiazepines has not been thoroughly studied. METHODS In a randomized, blinded, adaptive trial, we compared the efficacy and safety of three intravenous anticonvulsive agents - levetiracetam, fosphenytoin, and valproate - in children and adults with convulsive status epilepticus that was unresponsive to treatment with benzodiazepines. The primary outcome was absence of clinically evident seizures and improvement in the level of consciousness by 60 minutes after the start of drug infusion, without additional anticonvulsant medication. The posterior probabilities that each drug was the most or least effective were calculated. Safety outcomes included life-threatening hypotension or cardiac arrhythmia, endotracheal intubation, seizure recurrence, and death. RESULTS A total of 384 patients were enrolled and randomly assigned to receive levetiracetam (145 patients), fosphenytoin (118), or valproate (121). Reenrollment of patients with a second episode of status epilepticus accounted for 16 additional instances of randomization. In accordance with a prespecified stopping rule for futility of finding one drug to be superior or inferior, a planned interim analysis led to the trial being stopped. Of the enrolled patients, 10% were determined to have had psychogenic seizures. The primary outcome of cessation of status epilepticus and improvement in the level of consciousness at 60 minutes occurred in 68 patients assigned to levetiracetam (47%; 95% credible interval, 39 to 55), 53 patients assigned to fosphenytoin (45%; 95% credible interval, 36 to 54), and 56 patients assigned to valproate (46%; 95% credible interval, 38 to 55). The posterior probability that each drug was the most effective was 0.41, 0.24, and 0.35, respectively. Numerically more episodes of hypotension and intubation occurred in the fosphenytoin group and more deaths occurred in the levetiracetam group than in the other groups, but these differences were not significant. CONCLUSIONS In the context of benzodiazepine-refractory convulsive status epilepticus, the anticonvulsant drugs levetiracetam, fosphenytoin, and valproate each led to seizure cessation and improved alertness by 60 minutes in approximately half the patients, and the three drugs were associated with similar incidences of adverse events. (Funded by the National Institute of Neurological Disorders and Stroke; ESETT ClinicalTrials.gov number, NCT01960075.).
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Affiliation(s)
- Jaideep Kapur
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Jordan Elm
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - James M Chamberlain
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - William Barsan
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - James Cloyd
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Daniel Lowenstein
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Shlomo Shinnar
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Robin Conwit
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Caitlyn Meinzer
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Hannah Cock
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Nathan Fountain
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Jason T Connor
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Robert Silbergleit
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
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Hong WP, Chen TS, Huang CW. Stimulus-induced rhythmic, periodic ictal discharges during funduscopic examination in a patient with status epilepticus. Epileptic Disord 2019; 21:475-478. [PMID: 31649004 DOI: 10.1684/epd.2019.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs), an unusual pattern in electroencephalography, have been described in critically-ill encephalopathic patients in response to alerting stimuli. The phenomenon may be seen in patients with a broad range of aetiologies, including cerebral infarct, haemorrhage, anoxia, and degenerative diseases. Here, we report a unique case of status epilepticus presenting with SIRPIDs during funduscopic examination-induced focal to bilateral tonic-clonic seizures.
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Affiliation(s)
- Wei-Pin Hong
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Department of Neurology, Tainan Hospital, Ministry of Health and Welfare, Tainan
| | - Tsang-Shan Chen
- Department of Neurology, Tainan Sin-Lau Hospital, Tainan, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
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Moerke C, Jaco I, Dewitz C, Müller T, Jacobsen AV, Gautheron J, Fritsch J, Schmitz J, Bräsen JH, Günther C, Murphy JM, Kunzendorf U, Meier P, Krautwald S. The anticonvulsive Phenhydan ® suppresses extrinsic cell death. Cell Death Differ 2019; 26:1631-1645. [PMID: 30442947 PMCID: PMC6748113 DOI: 10.1038/s41418-018-0232-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/30/2018] [Accepted: 10/30/2018] [Indexed: 12/27/2022] Open
Abstract
Different forms of regulated cell death-like apoptosis and necroptosis contribute to the pathophysiology of clinical conditions including ischemia-reperfusion injury, myocardial infarction, sepsis, and multiple sclerosis. In particular, the kinase activity of the receptor-interacting serine/threonine protein kinase 1 (RIPK1) is crucial for cell fate in inflammation and cell death. However, despite its involvement in pathological conditions, no pharmacologic inhibitor of RIPK1-mediated cell death is currently in clinical use. Herein, we screened a collection of clinical compounds to assess their ability to modulate RIPK1-mediated cell death. Our small-scale screen identified the anti-epilepsy drug Phenhydan® as a potent inhibitor of death receptor-induced necroptosis and apoptosis. Accordingly, Phenhydan® blocked activation of necrosome formation/activation as well as death receptor-induced NF-κB signaling by influencing the membrane function of cells, such as lipid raft formation, thus exerting an inhibitory effect on pathophysiologic cell death processes. By targeting death receptor signaling, the already FDA-approved Phenhydan® may provide new therapeutic strategies for inflammation-driven diseases caused by aberrant cell death.
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Affiliation(s)
- Caroline Moerke
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Isabel Jaco
- Toby Robins Research Centre, Institute of Cancer Research, London, SW3 6JB, UK
| | - Christin Dewitz
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Tammo Müller
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Annette V Jacobsen
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Jérémie Gautheron
- Université Pierre et Marie Curie, UMR_S 938, Inserm, 75012, Paris, France
| | - Jürgen Fritsch
- Institute for Clinical Microbiology and Hygiene, University of Regensburg, 93053, Regensburg, Germany
| | - Jessica Schmitz
- Department of Pathology, University of Hannover, 30625, Hannover, Germany
| | - Jan Hinrich Bräsen
- Department of Pathology, University of Hannover, 30625, Hannover, Germany
| | - Claudia Günther
- Department of Medicine 1, Friedrich-Alexander-University, 91052, Erlangen, Germany
| | - James M Murphy
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Pascal Meier
- Toby Robins Research Centre, Institute of Cancer Research, London, SW3 6JB, UK
| | - Stefan Krautwald
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany.
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Liao YF, Liao CH, Chu YJ, Fan PC. Pharmacotherapy and electroencephalographic evolution in SCN8A encephalopathy: A case report. J Formos Med Assoc 2019; 118:1266-1267. [PMID: 31010614 DOI: 10.1016/j.jfma.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/29/2019] [Accepted: 04/08/2019] [Indexed: 06/09/2023] Open
Affiliation(s)
- Ying-Feng Liao
- Department of Pediatrics, National Taiwan University Children Hospital, National Taiwan University, Taipei, Taiwan
| | - Chun-Hua Liao
- Department of Pediatrics, National Taiwan University Children Hospital, National Taiwan University, Taipei, Taiwan
| | - Yen-Ju Chu
- Department of Pediatric Neurology, National Taiwan University Children Hospital, National Taiwan University, Taipei, Taiwan
| | - Pi-Chuan Fan
- Department of Pediatrics, National Taiwan University Children Hospital, National Taiwan University, Taipei, Taiwan; Department of Pediatric Neurology, National Taiwan University Children Hospital, National Taiwan University, Taipei, Taiwan.
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Sharobeam A, Mamun A, Kwok A, Zandiehvakili M, Beran RG. Management and attitudes toward patients with epilepsy in general practice: How far have we come in three decades? Epilepsy Behav 2019; 97:92-95. [PMID: 31203105 DOI: 10.1016/j.yebeh.2019.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Previous surveys of Australian primary care physicians' attitudes regarding epilepsy and persons with epilepsy (PWE), conducted 20-30 years ago, identified the need for further education in epilepsy care for frontline clinicians. This follow-up study of general practitioners (GPs) in Sydney was conducted to determine the degree of changes in knowledge, attitudes, and management of PWE, with the purpose of evaluating if there had been significant improvement during this period. METHODS A questionnaire, evaluating various aspects of epilepsy care, including investigations, preferred healthcare provider (HCP), and attitudes toward epilepsy was developed, largely based on the previous work, piloted, and completed by a representative sample of Sydney GPs. RESULTS A total of 52 completed responses were received. Thirty-six out of 47 GPs (77%) chose neurologists as the most important HCP followed by the GP (9/47; 18.7%). Almost half of the GPs (25/51; 49%) mentioned that they never initiated antiepileptic medication (AEM) therapy by themselves yet half of these GPs would alter the neurologist's regimen, without necessitating referral back to that neurologist. Another 27% (14/51 GPs) rarely commenced AEM therapy. Six out of 50 GPs did not mention an electroencephalogram (EEG) as a routine investigation, and 21/50 did not mention magnetic resonance imaging (MRI) as routine for PWE. The five most commonly used AEMs, identified by at least 10% of respondents, were sodium valproate (42), carbamazepine (37), levetiracetam (31), lamotrigine (16), and phenytoin (15). Emotional, behavioral, and psychosocial issues were perceived to be more common among PWE; however, they could contribute equally well to society as people without epilepsy. CONCLUSION The results of the study indicate a perceptual shift regarding GP's attitudes to epilepsy; however, there remain deficiencies in knowledge, particularly with regard to investigations and management. The study highlights the need for more formal training of GPs in caring for PWE.
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Affiliation(s)
| | - Abul Mamun
- Campbelltown Hospital, Sydney, Australia
| | | | | | - Roy G Beran
- Liverpool Hospital, Sydney, Australia; University of NSW, Sydney, Australia; Griffith University, Gold Coast, Australia; Strategic Health Evaluators, Sydney, Australia; Sechenov University, Moscow, Russia.
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Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2002 and last updated in 2017. This review is one in a series of Cochrane Reviews investigating pair-wise monotherapy comparisons.Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment, up to 70% of individuals with active epilepsy have the potential to become seizure-free and go into long-term remission shortly after starting drug therapy with a single antiepileptic drug in monotherapy.Worldwide, carbamazepine and phenytoin are commonly-used broad spectrum antiepileptic drugs, suitable for most epileptic seizure types. Carbamazepine is a current first-line treatment for focal onset seizures in the USA and Europe. Phenytoin is no longer considered a first-line treatment, due to concerns over adverse events associated with its use, but the drug is still commonly used in low- to middle-income countries because of its low cost. No consistent differences in efficacy have been found between carbamazepine and phenytoin in individual trials; however, the confidence intervals generated by these trials are wide, and therefore, synthesising the data of the individual trials may show differences in efficacy. OBJECTIVES To review the time to treatment failure, remission and first seizure with carbamazepine compared with phenytoin when used as monotherapy in people with focal onset seizures (simple or complex focal and secondarily generalised), or generalised onset tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS For the latest update, we searched the following databases on 13 August 2018: the Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy's Specialised Register and CENTRAL; MEDLINE; the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov); and the World Health Organization International Clinical Trials Registry Platform (ICTRP). We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators, and experts in the field. SELECTION CRITERIA Randomised controlled trials comparing monotherapy with either carbamazepine or phenytoin in children or adults with focal onset seizures or generalised onset (tonic-clonic) seizures. DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD) review. Our primary outcome was time to treatment failure. Our secondary outcomes were time to first seizure post-randomisation, time to six-month remission, time to 12-month remission, and incidence of adverse events. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs), with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS IPD were available for 595 participants out of 1102 eligible individuals, from four out of 11 trials (i.e. 54% of the potential data). For remission outcomes, a HR greater than 1 indicates an advantage for phenytoin; and for first seizure and withdrawal outcomes, a HR greater than 1 indicates an advantage for carbamazepine. Most participants included in analysis (78%) were classified as experiencing focal onset seizures at baseline and only 22% were classified as experiencing generalised onset seizures; the results of this review are therefore mainly applicable to individuals with focal onset seizures.Results for the primary outcome of the review were: time to treatment failure for any reason related to treatment (pooled HR adjusted for seizure type for 546 participants: 0.94, 95% CI 0.70 to 1.26, moderate-certainty evidence); time to treatment failure due to lack of efficacy (pooled HR adjusted for seizure type for 546 participants: 0.99, 95% CI 0.69 to 1.41, moderate-certainty evidence); both showing no clear difference between the drugs and time to treatment failure due to adverse events (pooled HR adjusted for seizure type for 546 participants: 1.27, 95% CI 0.87 to 1.86, moderate-certainty evidence), showing that treatment failure due to adverse events may occur earlier on carbamazepine than phenytoin, but we cannot rule out a slight advantage to carbamazepine or no difference between the drugs.For our secondary outcomes (pooled HRs adjusted for seizure type), we did not find any clear differences between carbamazepine and phenytoin: time to first seizure post-randomisation (582 participants): 1.15, 95% CI 0.94 to 1.40, moderate-certainty evidence); time to 12-month remission (551 participants): 1.00, 95% CI 0.79 to 1.26, moderate-certainty evidence); and time to six-month remission (551 participants): 0.90, 95% CI 0.73 to 1.12, moderate-certainty evidence).For all outcomes, results for individuals with focal onset seizures were similar to overall results (moderate-certainty evidence), and results for the small subgroup of individuals with generalised onset seizures were imprecise, so we cannot rule out an advantage to either drug, or no difference between drugs (low-certainty evidence). There was also evidence that misclassification of seizure type may have confounded the results of this review, particularly for the outcome 'time to treatment failure'. Heterogeneity was present in analysis of 'time to first seizure' for individuals with generalised onset seizures, which could not be explained by subgroup analysis or sensitivity analyses.Limited information was available about adverse events in the trials and we could not compare the rates of adverse events between carbamazepine and phenytoin. Some adverse events reported on both drugs were abdominal pain, nausea, and vomiting, drowsiness, motor and cognitive disturbances, dysmorphic side effects (such as rash). AUTHORS' CONCLUSIONS Moderate-certainty evidence provided by this systematic review does not show any differences between carbamazepine and phenytoin in terms of effectiveness (retention) or efficacy (seizure recurrence and seizure remission) for individuals with focal onset or generalised onset seizures.However, some of the trials contributing to the analyses had methodological inadequacies and inconsistencies, which may have had an impact on the results of this review. We therefore do not suggest that results of this review alone should form the basis of a treatment choice for a person with newly-onset seizures. We did not find any evidence to support or refute current treatment policies. We implore that future trials be designed to the highest quality possible, with consideration of masking, choice of population, classification of seizure type, duration of follow-up, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
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