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Lin YS, Thummel KE, Thompson BD, Totah RA, Cho CW. Sources of Interindividual Variability. Methods Mol Biol 2021; 2342:481-550. [PMID: 34272705 DOI: 10.1007/978-1-0716-1554-6_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The efficacy, safety, and tolerability of drugs are dependent on numerous factors that influence their disposition. A dose that is efficacious and safe for one individual may result in sub-therapeutic or toxic blood concentrations in others. A significant source of this variability in drug response is drug metabolism, where differences in presystemic and systemic biotransformation efficiency result in variable degrees of systemic exposure (e.g., AUC, Cmax, and/or Cmin) following administration of a fixed dose.Interindividual differences in drug biotransformation have been studied extensively. It is recognized that both intrinsic factors (e.g., genetics, age, sex, and disease states) and extrinsic factors (e.g., diet , chemical exposures from the environment, and the microbiome) play a significant role. For drug-metabolizing enzymes, genetic variation can result in the complete absence or enhanced expression of a functional enzyme. In addition, upregulation and downregulation of gene expression, in response to an altered cellular environment, can achieve the same range of metabolic function (phenotype), but often in a less predictable and time-dependent manner. Understanding the mechanistic basis for variability in drug disposition and response is essential if we are to move beyond the era of empirical, trial-and-error dose selection and into an age of personalized medicine that will improve outcomes in maintaining health and treating disease.
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Affiliation(s)
- Yvonne S Lin
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA.
| | - Kenneth E Thummel
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Brice D Thompson
- Department of Pharmaceutics, University of Washington, Seattle, WA, USA
| | - Rheem A Totah
- Department of Medicinal Chemistry, University of Washington, Seattle, WA, USA
| | - Christi W Cho
- Department of Medicinal Chemistry, University of Washington, Seattle, WA, USA
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Pennell PB, French JA, May RC, Gerard E, Kalayjian L, Penovich P, Gedzelman E, Cavitt J, Hwang S, Pack AM, Sam M, Miller JW, Wilson SH, Brown C, Birnbaum AK, Meador KJ. Changes in Seizure Frequency and Antiepileptic Therapy during Pregnancy. N Engl J Med 2020; 383:2547-2556. [PMID: 33369356 PMCID: PMC7919187 DOI: 10.1056/nejmoa2008663] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Among women with epilepsy, studies regarding changes in seizure frequency during pregnancy have been limited by the lack of an appropriate nonpregnant comparator group to provide data on the natural course of seizure frequency in both groups. METHODS In this prospective, observational, multicenter cohort study, we compared the frequency of seizures during pregnancy through the peripartum period (the first 6 weeks after birth) (epoch 1) with the frequency during the postpartum period (the following 7.5 months after pregnancy) (epoch 2). Nonpregnant women with epilepsy were enrolled as controls and had similar follow-up during an 18-month period. The primary outcome was the percentage of women who had a higher frequency of seizures that impaired awareness during epoch 1 than during epoch 2. We also compared changes in the doses of antiepileptic drugs that were administered in the two groups during the first 9 months of epoch 1. RESULTS We enrolled 351 pregnant women and 109 controls with epilepsy. Among the 299 pregnant women and 93 controls who had a history of seizures that impaired awareness and who had available data for the two epochs, seizure frequency was higher during epoch 1 than during epoch 2 in 70 pregnant women (23%) and in 23 controls (25%) (odds ratio, 0.93; 95% confidence interval [CI], 0.54 to 1.60). During pregnancy, the dose of an antiepileptic drug was changed at least once in 74% of pregnant women and in 31% of controls (odds ratio, 6.36; 95% CI, 3.82 to 10.59). CONCLUSIONS Among women with epilepsy, the percentage who had a higher incidence of seizures during pregnancy than during the postpartum period was similar to that in women who were not pregnant during the corresponding epochs. Changes in doses of antiepileptic drugs occurred more frequently in pregnant women than in nonpregnant women during similar time periods. (Funded by the National Institutes of Health; MONEAD ClinicalTrials.gov number, NCT01730170.).
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Affiliation(s)
- Page B Pennell
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Jacqueline A French
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Ryan C May
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Elizabeth Gerard
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Laura Kalayjian
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Patricia Penovich
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Evan Gedzelman
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Jennifer Cavitt
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Sean Hwang
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Alison M Pack
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Maria Sam
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - John W Miller
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Steffanie H Wilson
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Carrie Brown
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Angela K Birnbaum
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Kimford J Meador
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
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Beydoun A, DuPont S, Zhou D, Matta M, Nagire V, Lagae L. Current role of carbamazepine and oxcarbazepine in the management of epilepsy. Seizure 2020; 83:251-263. [PMID: 33334546 DOI: 10.1016/j.seizure.2020.10.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/30/2020] [Accepted: 10/22/2020] [Indexed: 02/08/2023] Open
Abstract
Epilepsy is one of the most common neurological disorders, affecting approximately 50 million people worldwide. Despite a dramatic increase in treatment options over the past 30 years, it still ranks fourth in the world's disease burden. There are now close to 30 antiepileptic drugs (AEDs), with more than two thirds introduced to the market after carbamazepine (CBZ) and one third after its derivative, oxcarbazepine (OXC). Following the introduction of these newer AEDs, the role of CBZ and OXC in the therapeutic armamentarium for seizure control and effective epilepsy management needs to be reviewed. The main guidelines list both CBZ and OXC as first-line options or second-line alternatives for the treatment of focal-onset epilepsy and primary generalized tonic-clonic seizures. While evidence suggests that overall AEDs have similar efficacy, some newer AEDs may be better tolerated than CBZ. In line with this, there have been changes in treatment patterns, with many variations across different countries. However, CBZ remains among the two or three most prescribed drugs for focal epilepsy in many countries, and is widely used across Europe, Africa, South America, and Asia, where it represents a good compromise between cost, availability, and effectiveness. OXC is among the first-choice options for the initial treatment of focal-onset seizures in several countries, including the US and China, where the oral suspension is commonly prescribed. This review provides guidance on the optimal use of these two drugs in clinical practice, including in children, the elderly, and in pregnancy.
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Affiliation(s)
- Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sophie DuPont
- Epilepsy Unit and Rehabilitation Unit, Hôpital de la Pitié-Salpêtrière, AP-HP, Centre de recherche de l'Institut du cerveau et de la moelle épinière (ICM), UMPC-UMR 7225 CNRS-UMRS 975 Inserm, Paris, France; Université Paris Sorbonne, Paris, France
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Maha Matta
- Novartis Pharma Services, Dubaï, United Arab Emirates
| | | | - Lieven Lagae
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium.
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O'Dwyer R. Epilepsy: Workup and Management in Adults. Semin Neurol 2020; 40:624-637. [PMID: 33176373 DOI: 10.1055/s-0040-1719069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
When managing epilepsy, there is a temptation to focus care with respect to the last and the next seizure. However, epilepsy is a multifaceted chronic condition and should be treated as such. Epilepsy comes with many physical risks, psychological effects, and socioeconomic ramifications, demanding a long-term commitment from the treating physician. Patients with epilepsy, compared to other chronically ill patient populations, have a worse quality of life, family function, and less social support. The majority of patients are well controlled on antiseizure drugs. However, approximately one-third will continue to have seizures despite optimized medical management. The primary aim of this article is to explore the long-term management of chronic epilepsy, and to address some of the particular needs of patients with chronic epilepsy.
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Affiliation(s)
- Rebecca O'Dwyer
- Department of Neurological Science, Rush University Medical Center, Chicago, Illinois
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Pharmacokinetic Monitoring of Levetiracetam in Portuguese Refractory Epileptic Patients: Effect of Gender, Weight and Concomitant Therapy. Pharmaceutics 2020; 12:pharmaceutics12100943. [PMID: 33019727 PMCID: PMC7601255 DOI: 10.3390/pharmaceutics12100943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/26/2020] [Accepted: 09/29/2020] [Indexed: 11/24/2022] Open
Abstract
Levetiracetam is a second-generation antiepileptic drug, widely used in the treatment of focal and generalized epilepsy due to its pharmacokinetic and safety profiles. Its pharmacokinetic monitoring is ascribed as useful to personalize its dosing regimen. The aim of the present study was to describe, for the first time, the pharmacokinetics of levetiracetam in Portuguese refractory epileptic patients. Therefore, a retrospective study was carried out on 65 Portuguese refractory epileptic patients (pharmacokinetic study: 48; validation study: 17) admitted to the Refractory Epilepsy Centre of the Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal. The pharmacokinetic parameters of levetiracetam were estimated by applying a one-compartment model with first-order absorption and elimination analysis. Male patients showed higher distribution volume (Vd/F) and oral clearance (CL/F) than female patients (median Vd/F: 52.40 L in males and 38.60 L in females, p = 0.011; median CL/F: 4.71 L/h in males and 3.91 L/h in females, p = 0.028). Higher values of Vd/F (p = 0.026) and CL/F (p = 0.003) were also found in overweight patients relative to normal weight and obese patients. Carbamazepine was the co-administered antiepileptic drug that mostly affected the pharmacokinetics of levetiracetam, increasing both Vd/F (61.30 L with carbamazepine and 39.10 L without carbamazepine, p = 0.007) and CL/F (6.71 L/h with carbamazepine and 3.91 L/h without carbamazepine, p < 0.001). The pharmacokinetics of levetiracetam was affected by gender, body mass index, and co-administration of carbamazepine. This study highlights the impact of several factors on the CL/ and Vd/F of levetiracetam when administered to refractory epileptic patients. The importance of its pharmacokinetic monitoring in clinical pharmacy stands out, thereby enabling the optimization of antiepileptic drug therapy.
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Powell JR, Cook J, Wang Y, Peck R, Weiner D. Drug Dosing Recommendations for All Patients: A Roadmap for Change. Clin Pharmacol Ther 2020; 109:65-72. [PMID: 32453862 PMCID: PMC7818440 DOI: 10.1002/cpt.1923] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/15/2020] [Indexed: 12/16/2022]
Abstract
Most drug labels do not contain dosing recommendations for a significant portion of real‐world patients for whom the drug is prescribed. Current label recommendations predominately reflect the population studied in pivotal trials that typically exclude patients who are very young or old, emaciated or morbidly obese, pregnant, or have multiple characteristics likely to influence dosing. As a result, physicians may need to guess the correct dose and regimen for these patients. It is now feasible to provide dose and regimen recommendations for these patients by integrating available scientific knowledge and by utilizing or modifying current regulatory agency‐industry practices. The purpose of this commentary is to explore several factors that should be considered in creating a process that will provide more effective, safe, and timely drug dosing recommendations for most, if not all, patients. These factors include the availability of real‐world data, development of predictive models, experience with the US Food and Drug Administration (FDA)’s pediatric exclusivity program, development of clinical decision software, funding mechanisms like the Prescription Drug Users Fee Act (PDUFA), and harmonization of global regulatory policies. From an examination of these factors, we recommend a relatively simple, efficient expansion of current practices designed to predict, confirm, and continuously improve drug dosing for more patients. We believe implementing these recommendations will benefit patients, payers, industry, and regulatory agencies.
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Affiliation(s)
- J Robert Powell
- Clinical Pharmacology Consultant, Chapel Hill, North Carolina, USA
| | - Jack Cook
- Clinical Pharmacology, Pfizer Inc, Groton, Connecticut, USA
| | - Yaning Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard Peck
- Roche Innovation Center Basel, Pharma Research & Early Development (pRED), Basel, Switzerland
| | - Dan Weiner
- Pharmacometrics Consultant, Chapel Hill, North Carolina, USA
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Birnbaum AK, Meador KJ, Karanam A, Brown C, May RC, Gerard EE, Gedzelman ER, Penovich PE, Kalayjian LA, Cavitt J, Pack AM, Miller JW, Stowe ZN, Pennell PB. Antiepileptic Drug Exposure in Infants of Breastfeeding Mothers With Epilepsy. JAMA Neurol 2020; 77:441-450. [PMID: 31886825 DOI: 10.1001/jamaneurol.2019.4443] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance There is limited information on infant drug exposure via breastfeeding by mothers who are receiving antiepileptic drug therapy. Objective To provide direct, objective information on antiepileptic drug exposure through breast milk. Design, Setting, and Participants This prospective cohort study was conducted between December 2012 to October 2016, with follow-up in children until 6 years of age at 20 sites across the United States. Data were collected via an observational multicenter investigation (Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs [MONEAD]) of outcomes in pregnant mothers with epilepsy and their children. Pregnant women with epilepsy who were aged 14 to 45 years, had pregnancies that had progressed to less than 20 weeks' gestational age, and had measured IQ scores of more than 70 points were enrolled and followed up through pregnancy and 9 postpartum months. Their infants were enrolled at birth. Data were analyzed from May 2014 to August 2019. Exposures Antiepileptic drug exposure in infants who were breastfed. Main Outcomes and Measures The percentage of infant-to-mother concentration of antiepileptic drugs. Antiepileptic drug concentrations were quantified from blood samples collected from infants and mothers at the same visit, 5 to 20 weeks after birth. Concentrations of antiepileptic drugs in infants at less than the lower limit of quantification were assessed as half of the lower limit. Additional measures collected were the total duration of all daily breastfeeding sessions and/or the volume of pumped breast milk ingested from a bottle. Results A total of 351 women (of 865 screened and 503 eligible individuals) were enrolled, along with their 345 infants (179 female children [51.9%]; median [range] age, 13 [5-20] weeks). Of the 345 infants, 222 (64.3%) were breastfed; the data collection yielded 164 matching infant-mother concentration pairs from 138 infants. Approximately 49% of all antiepileptic drug concentrations in nursing infants were less than the lower limit of quantification. The median percentage of infant-to-mother concentration for all 7 antiepileptic drugs and 1 metabolite (carbamazepine, carbamazepine-10,11-epoxide, levetiracetam, lamotrigine, oxcarbazepine, topiramate, valproate, and zonisamide) ranged from 0.3% (range, 0.2%-0.9%) to 44.2% (range, 35.2%-125.3%). In multiple linear regression models, maternal concentration was a significant factor associated with lamotrigine concentration in infants (Pearson correlation coefficient, 0.58; P < .001) but not levetiracetam concentration in infants. Conclusions and Relevance Overall, antiepileptic drug concentrations in blood samples of infants who were breastfed were substantially lower than maternal blood concentrations. Given the well-known benefits of breastfeeding and the prior studies demonstrating no ill effects when the mother was receiving antiepileptic drugs, these findings support the breastfeeding of infants by mothers with epilepsy who are taking antiepileptic drug therapy.
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Affiliation(s)
- Angela K Birnbaum
- Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis
| | - Kimford J Meador
- Department of Neurology & Neurological Sciences, Stanford University, Stanford, California
| | - Ashwin Karanam
- Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis
| | | | - Ryan C May
- The Emmes Corporation, Rockville, Maryland
| | | | | | | | - Laura A Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | - John W Miller
- Department of Neurology, University of Washington, Seattle.,Department of Neurological Surgery, University of Washington, Seattle
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin at Madison, Madison
| | - Page B Pennell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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30 years of second-generation antiseizure medications: impact and future perspectives. Lancet Neurol 2020; 19:544-556. [DOI: 10.1016/s1474-4422(20)30035-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/30/2019] [Accepted: 11/28/2019] [Indexed: 01/31/2023]
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Abstract
Common genetic generalised epilepsy syndromes encountered by clinicians include childhood and juvenile absence epilepsies, juvenile myoclonic epilepsy and generalised tonic-clonic seizures on awakening. Treatment of these syndromes involves largely the use of broad-spectrum antiseizure drugs. Those effective for the generalised epilepsies include sodium valproate, phenobarbital, ethosuximide, clobazam, clonazepam, lamotrigine, levetiracetam, topiramate, zonisamide and, more recently, perampanel and brivaracetam. Results from the few rigorous studies comparing outcomes with drugs for genetic generalised epilepsies show valproate to be the most effective. The majority of patients with genetic generalised epilepsy syndromes will become seizure free on antiseizure monotherapy; those for whom control proves elusive may benefit from combination regimens. Early counselling regarding management may assist the patient to come to terms with their diagnosis and improve long-term outcomes. Treatment can be lifelong in some individuals, although others may remain seizure free without medication. Choice of antiseizure medication depends on the efficacy for specific seizure types, as well as tolerability. For patients prescribed comedication, drug interactions should be considered. In particular, for young women taking oral hormonal contraceptives, ≥ 200 mg/day of topiramate can decrease the circulating concentration of ethinylestradiol and ≥ 12 mg/day of perampanel can induce levonorgestrel metabolism. The use of valproate in women of childbearing potential is limited by associated teratogenic and neurodevelopmental effects in offspring. Given that valproate is often the antiseizure drug of choice for genetic generalised epilepsies, this creates a dilemma for patients and clinicians. Decision making can be aided by comprehensive assessment and discussion of treatment options. Psychiatric comorbidities are common in adolescents and adults with genetic generalised epilepsies. These worsen the prognosis, both in terms of seizure control and quality of life. Attendant lifestyle issues can impact significantly on the individual and society. Frontal lobe dysfunction, which can present in patients with juvenile myoclonic epilepsy, can adversely affect the long-term outlook, regardless of the nature of seizure control. Ongoing management requires consideration of psychosocial and behavioural factors that can complicate diagnosis and treatment. An assured supportive attitude by the neurologist can be an important contributor to a positive outcome. The mechanisms underlying genetic generalised epilepsies, including genetic abnormalities, are unclear at present. As the pathophysiology is unravelled, this may lead to the development of novel therapies and improved outcomes for patients with these syndromes.
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Affiliation(s)
- Linda J Stephen
- West Glasgow Ambulatory Care Hospital, Dalnair St, Glasgow, G3 8SJ, UK.
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60
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Abstract
The management of epilepsy during pregnancy involves optimizing seizure control for the mother, while ensuring the best outcome for the developing fetus. Preconception counseling regarding contraception, folic acid, and antiseizure medications (ASMs) will maximize positive outcomes. Folic acid supplementation is recommended to decrease risk of neural tube defects, similar to the general population, and has been associated with improved cognitive outcomes and decreased risk of autistic traits in offspring. Efforts should be made to optimize the ASM regimen before pregnancy to the fewest number of ASMs, lowest effective doses, with avoidance of more teratogenic agents such as valproic acid. Valproic acid is associated with the highest increased risk of major congenital malformations, as well as reduced cognitive outcomes and neurodevelopmental disorders. Decreasing or changing ASMs during pregnancy should be done with caution, as convulsive seizures have been associated with adverse fetal outcomes including cognitive impairment. Physiologic changes during pregnancy affect ASM levels and in turn, risk for seizures, necessitating frequent monitoring of ASM serum concentrations. Mothers should also be counseled postpartum about how the benefits of breastfeeding outweigh the transmission of medication into breast milk. Communication between providers (obstetrics and neurology) and pregnant women with epilepsy is essential.
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Affiliation(s)
- Rachael Benson
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States
| | - Alison Pack
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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61
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Al-Roubaie Z, Guadagno E, Ramanakumar AV, Khan AQ, Myers KA. Clinical utility of therapeutic drug monitoring of antiepileptic drugs: Systematic review. Neurol Clin Pract 2019; 10:344-355. [PMID: 32983615 DOI: 10.1212/cpj.0000000000000722] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/19/2019] [Indexed: 11/15/2022]
Abstract
Objective To systematically review and evaluate the available evidence supporting or refuting clinical use of therapeutic drug monitoring (TDM) of antiepileptic drugs (AEDs) in patients with epilepsy. Methods We searched MEDLINE, Embase, BIOSIS, Cochrane, PubMed, Africa-Wide Information, Web of Science, and grey literature. Randomized controlled studies and observational studies that compared the clinical outcomes of TDM vs non-TDM were included. Two reviewers independently extracted the data. The primary outcome was seizure control; adverse effects were considered as secondary outcomes. The PROSPERO ID of this systematic review's protocol is CRD42018089925. Results Sixteen studies were identified meeting eligibility requirements. Four randomized controlled trials (RCTs), 1 meta-analysis, and 11 quasiexperimental (QE) studies were included in the systematic review. Results from the analysis of RCTs showed no significant positive effect of TDM on seizure outcome (only 25% positive effect of phenytoin). However, some of the QE studies found that TDM was associated with better seizure control or lower rates of adverse effects. The existing evidence from various designs has shown various methodological implications, which warrants inconclusive results and highlights the requirement of more number of studies in this line. Conclusions If optimally implemented, TDM may enhance clinical care, particularly for phenytoin and other AEDs with complex pharmacokinetics. However, the ideal method for implementation is unclear, and serum drug levels should be considered in context with patient-reported clinical data regarding seizure control and adverse events.
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Affiliation(s)
- Zanab Al-Roubaie
- Department of Pharmacology (ZA-R), Faculty of Medicine, Université de Montréal; Research Institute of the McGill University Health Centre (ZA-R, AVR, AQK, KAM), Montréal; Medical Library (EG), McConnell Resource Centre, McGill University Health Centre, Montreal; and Departments of Pediatrics and Neurology & Neurosurgery (KAM), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Elena Guadagno
- Department of Pharmacology (ZA-R), Faculty of Medicine, Université de Montréal; Research Institute of the McGill University Health Centre (ZA-R, AVR, AQK, KAM), Montréal; Medical Library (EG), McConnell Resource Centre, McGill University Health Centre, Montreal; and Departments of Pediatrics and Neurology & Neurosurgery (KAM), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Agnihotram V Ramanakumar
- Department of Pharmacology (ZA-R), Faculty of Medicine, Université de Montréal; Research Institute of the McGill University Health Centre (ZA-R, AVR, AQK, KAM), Montréal; Medical Library (EG), McConnell Resource Centre, McGill University Health Centre, Montreal; and Departments of Pediatrics and Neurology & Neurosurgery (KAM), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Afsheen Q Khan
- Department of Pharmacology (ZA-R), Faculty of Medicine, Université de Montréal; Research Institute of the McGill University Health Centre (ZA-R, AVR, AQK, KAM), Montréal; Medical Library (EG), McConnell Resource Centre, McGill University Health Centre, Montreal; and Departments of Pediatrics and Neurology & Neurosurgery (KAM), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kenneth A Myers
- Department of Pharmacology (ZA-R), Faculty of Medicine, Université de Montréal; Research Institute of the McGill University Health Centre (ZA-R, AVR, AQK, KAM), Montréal; Medical Library (EG), McConnell Resource Centre, McGill University Health Centre, Montreal; and Departments of Pediatrics and Neurology & Neurosurgery (KAM), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Menon S, Siewe Fodjo JN, Weckhuysen S, Bhwana D, Njamnshi AK, Dekker M, Colebunders R. Women with epilepsy in sub-Saharan Africa: A review of the reproductive health challenges and perspectives for management. Seizure 2019; 71:312-317. [PMID: 31521949 DOI: 10.1016/j.seizure.2019.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Epilepsy is one of the commonest neurological conditions affecting women of reproductive age. Epilepsy management during pregnancy is a clinical conundrum, requiring a balance between seizure control and risk minimization for the women with epilepsy (WWE) as well as for their fetuses. The objective of this comprehensive review is to explore the reproductive health challenges of WWE in sub-Saharan Africa (SSA) and ways to address them. METHOD Relevant documentation published until June 2019 were retrieved via literature searches performed in PubMed and Google Scholar, as well as a manual search to identify grey literature. RESULTS WWE in SSA are generally more stigmatized and sexually exploited than women without epilepsy. Contraception use among WWE was reported only in Senegal (51%) and Kenya (14.7%). Only two prospective studies (one in Senegal and one in Nigeria) investigated pregnancy outcomes for a total of 97 WWE. The prevalence of convulsive epilepsy in pregnancy was estimated at 3.33 per 1000. Among pregnant WWE treated with first line anti-epileptic drugs, 16.2% had miscarriages, 41.9% premature births, and 4.1% had babies with malformations. Carbamazepine, which is frequently prescribed to pregnant WWE in SSA, still entails a 2.1-fold increased risk of congenital malformation. No reports were found concerning pre-conceptual counseling and post-natal outcomes in WWE in SSA. CONCLUSION Our review underscores the need for contextualized evidence-based clinical guidelines and a collaborative approach to treat WWE in SSA. High risks of congenital malformations and drug interactions with first line AED warrant the provision of safer second line alternatives.
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Affiliation(s)
- Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | | | - Sarah Weckhuysen
- Department of Neurology, University of Antwerp, Antwerp, Belgium; Neurogenetics group, University of Antwerp, Antwerp, Belgium
| | - Dan Bhwana
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
| | - Alfred K Njamnshi
- Neurology Department, Yaoundé Central Hospital, Yaoundé, Cameroon; Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon; Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon; Brain Research Africa Initiative (BRAIN), Geneva, Switzerland
| | - Marieke Dekker
- Department of Internal Medicine and Pediatrics, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
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Pennell PB, Meador KJ. Reducing birth defects in women with epilepsy: Research leading to results. Neurology 2019; 93:375-376. [PMID: 31391246 DOI: 10.1212/wnl.0000000000007999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Page B Pennell
- From Brigham and Women's Hospital and Harvard Medical School (P.B.P.), Boston, MA; and Stanford University (K.J.M.), CA.
| | - Kimford J Meador
- From Brigham and Women's Hospital and Harvard Medical School (P.B.P.), Boston, MA; and Stanford University (K.J.M.), CA
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64
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Kusznir Vitturi B, Barreto Cabral F, Mella Cukiert C. Outcomes of pregnant women with refractory epilepsy. Seizure 2019; 69:251-257. [DOI: 10.1016/j.seizure.2019.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/05/2019] [Accepted: 05/11/2019] [Indexed: 10/26/2022] Open
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65
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Management of epilepsy in women. Lancet Neurol 2019; 18:481-491. [DOI: 10.1016/s1474-4422(18)30495-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 11/19/2018] [Accepted: 12/10/2018] [Indexed: 01/01/2023]
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66
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Barnard S, French J. Collaboration of Care for Women with Epilepsy in their Reproductive Years. J Womens Health (Larchmt) 2019; 28:339-345. [PMID: 30767686 DOI: 10.1089/jwh.2018.7506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Over half a million women of childbearing age have epilepsy, many of which will require family planning care at some point in their reproductive years. Matters relating to contraception, pregnancy, fertility, and sexual functioning are all impacted to varying degrees by the use of antiepileptic drugs (AEDs) to treat epilepsy and require active management by a woman's neurologist. It is important that a woman's obstetrician/gynecologist (OBGYN) and internist are aware of the way in which their care may be related to her epilepsy care and how this can be successfully comanaged with her neurologist. This includes the impact AED therapies have on pregnancy, such as risk of teratogenicity, changes to AED clearance rates during pregnancy and postpartum, and risk of seizure worsening while pregnant; interactions of hormonal contraceptives and AEDs; side effects of AED treatment on hormonal systems and sexual functioning; and matters of fertility and infertility treatments. The current editorial discusses these relationships between AED choice, dose, and family planning matters for women with epilepsy in their childbearing years to support the collaboration of care between her neurologist, OBGYN, and internist.
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Karceski S. Pregnancy, anti-seizure medications, and seizures. Neurology 2018; 91:e1271-e1274. [PMID: 30249683 DOI: 10.1212/wnl.0000000000006231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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