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Cuellar-Valencia L, Claros-Hulbert A, Ortegon A, Pino J, Velandia L, Correa-Morales JE. Subcutaneous Levetiracetam Administration in Latino Patients on Home Care. Am J Hosp Palliat Care 2024; 41:1029-1036. [PMID: 37907203 DOI: 10.1177/10499091231212450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
Background: Levetiracetam has a favorable pharmacology profile to be used subcutaneously. However, its subcutaneous use is still considered off-label as this is beyond its license. The evidence base for its safety, tolerability, and efficacy is limited to observational studies. Objectives: To report the safety and efficacy of subcutaneous levetiracetam in Latino patients on home care. Design: Observational retrospective case series study. Subjects: Consecutive sample of Latino adults with life-limiting illnesses. Methods: A case series framework with 4 domains (selection, ascertainment, causality, and reporting) to ensure reporting quality was used. Additionally, 8 relevant outcomes established in a previous comprehensive review, were collected and reported. Adverse reactions were documented using the Common Terminology Criteria for Adverse Events. Results: Fifteen Latino patients with oncological and non-oncological diagnoses received subcutaneous levetiracetam for a mean of 21 days on home care. Levetiracetam was most frequently initiated subcutaneously due to loss of the oral route. The average dosage of subcutaneous levetiracetam was 1200 mg. Only 1 patient required a dose adjustment, and only 2 patients experienced a total of 5 seizures during the therapy trial. No adverse reactions were reported. Conclusions: Subcutaneous levetiracetam appears to be effective and safe. This case series of Latino patients in home care expands the evidence of its use in the home care setting. The preliminary data reported by now on multiple case series warrants robust trials.
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Affiliation(s)
- Laura Cuellar-Valencia
- Faculty of Medicine, Universidad de La Sabana, Bogotá DC, Colombia
- Colombian National Cancer Institute, Bogotá DC, Colombia
| | - Angelica Claros-Hulbert
- Faculty of Medicine, Universidad de La Sabana, Bogotá DC, Colombia
- Colombian National Cancer Institute, Bogotá DC, Colombia
| | - Adriana Ortegon
- Forja home care IPS, Bogotá DC, Colombia
- Faculty of Medicine, Universidad del Bosque, Bogotá DC, Colombia
| | - Juliana Pino
- Faculty of Medicine, Universidad de La Sabana, Bogotá DC, Colombia
- Forja home care IPS, Bogotá DC, Colombia
| | | | - Juan Esteban Correa-Morales
- Faculty of Medicine, Universidad de La Sabana, Bogotá DC, Colombia
- Colombian National Cancer Institute, Bogotá DC, Colombia
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Maglalang PD, Sinha J, Zimmerman K, McCann S, Edginton A, Hornik CP, Hornik CD, Muller WJ, Al-Uzri A, Meyer M, Chen JY, Anand R, Perrin EM, Gonzalez D. Application of Physiologically Based Pharmacokinetic Modeling to Characterize the Effects of Age and Obesity on the Disposition of Levetiracetam in the Pediatric Population. Clin Pharmacokinet 2024; 63:885-899. [PMID: 38814425 PMCID: PMC11225543 DOI: 10.1007/s40262-024-01367-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Levetiracetam is an antiseizure medication used for several seizure types in adults and children aged 1 month and older; however, due to a lack of data, pharmacokinetic (PK) variability of levetiracetam is not adequately characterized in certain populations, particularly neonates, children younger than 2 years of age, and children older than 2 years of age with obesity. OBJECTIVE This study aimed to address the gap by leveraging PK data from two prospective standard-of-care pediatric trials (n = 88) covering an age range from 1 month to 19 years, including those with obesity (64%), and applying a physiologically based PK (PBPK) modeling framework. METHODS A published PBPK model of levetiracetam for children aged 2 years and older was extended to pediatric patients younger than 2 years of age and patients older than 2 years of age with obesity by accounting for the obesity and age-related changes in PK using PK-Sim® software. The prospective pediatric data, along with the literature data for neonates and children younger than 2 years of age, were used to evaluate the extended PBPK models. RESULTS Overall, 82.4% of data fell within the 90% interval of model-predicted concentrations, with an average fold error within twofold of the accepted criteria. PBPK modeling revealed that children with obesity had lower weight-normalized clearances (0.053 L/h/kg) on average than children without obesity (0.063 L/h/kg). The effect of maturation was well-characterized, resulting in comparable PBPK-simulated, weight-normalized clearances for neonates and children younger than 2 years of age reported from the literature. CONCLUSIONS PBPK modeling simulations revealed that the current US FDA-labeled pediatric dosing regimen listed in the prescribing information can produce the required exposure of levetiracetam in these target populations with dose adjustments for children with obesity aged 4 years to younger than 16 years.
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Affiliation(s)
- Patricia D Maglalang
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kanecia Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA
| | - Sean McCann
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA
| | - William J Muller
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Amira Al-Uzri
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | | | | | | | - Eliana M Perrin
- Department of Pediatrics, School of Medicine and School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Gonzalez
- Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA.
- Division of Clinical Pharmacology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
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Wang R, Wang T, Han X, Chen M, Li S. Development of a physiologically based pharmacokinetic model for levetiracetam in patients with renal impairment to guide dose adjustment based on steady-state peak/trough concentrations. Xenobiotica 2024; 54:116-123. [PMID: 38344757 DOI: 10.1080/00498254.2024.2317888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/08/2024] [Indexed: 02/22/2024]
Abstract
Levetiracetam may cause acute renal failure and myoclonic encephalopathy at high plasma levels, particularly in patients with renal impairment. The aim of this study was to develop a physiologically based pharmacokinetic (PBPK) model to predict levetiracetam pharmacokinetics in Chinese adults with epilepsy and renal impairment and define appropriate levetiracetam dosing regimen.PBPK models for healthy subjects and epilepsy patients with renal impairment were developed, validated, and adapted. Furthermore, we predicted the steady-state trough and peak concentrations of levetiracetam in patients with renal impairment using the final PBPK model, thereby recommending appropriate levetiracetam dosing regimens for different renal function stages. The predicted maximum plasma concentration (Cmax), time to maximum concentration (Tmax), area under the plasma concentration-time curve (AUC) were in agreement (0.8 ≤ fold error ≤ 1.2) with the observed, and the fold error of the trough concentrations in end-stage renal disease (ESRD) was 0.77 - 1.22. The prediction simulations indicated that the recommended doses of 1000, 750, 500, and 500 mg twice daily for epilepsy patients with mild, moderate, severe renal impairment, and ESRD, respectively, were sufficient to achieve the target plasma concentration of levetiracetam.
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Affiliation(s)
- Rongrong Wang
- Department of Pharmacy, Medical Security Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Tianlin Wang
- Department of Pharmacy, Medical Security Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xueliang Han
- Chinese PAP qinghai Hospital, Xining, People's Republic of China
| | - Mengli Chen
- Department of Pharmacy, Medical Security Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Shu Li
- Department of Pharmacy, Medical Security Center, Chinese PLA General Hospital, Beijing, People's Republic of China
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Cook AM, Hall K, Kolpek JH, Morbitzer KA, Jordan JD, Rhoney DH. Enhanced renal clearance impacts levetiracetam concentrations in patients with traumatic brain injury with and without augmented renal clearance. BMC Neurol 2024; 24:12. [PMID: 38166710 PMCID: PMC10759330 DOI: 10.1186/s12883-023-03515-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The purpose of this study was to examine the impact of ARC on levetiracetam concentrations during the first week following acute TBI. The hypothesis was levetiracetam concentrations are significantly lower in TBI patients with augmented renal clearance (ARC) compared to those with normal renal clearance. METHODS This is a prospective cohort pharmacokinetic study of adults with moderate to severe TBI treated with levetiracetam during the first week after injury. Serial blood collections were performed daily for analysis of levetiracetam, cystatin C, and 12-hr creatinine clearance (CrCl) determinations. Patients were divided into two cohorts: with (CrCl ≥130 ml/min/1.73 m2) and without ARC. RESULTS Twenty-two patients with moderate to severe TBI were included. The population consisted primarily of young male patients with severe TBI (mean age 40 years old, 68% male, median admission GCS 4). Each received levetiracetam 1000 mg IV every 12 h for the study period. ARC was present in 77.3% of patients, with significantly lower levetiracetam concentrations in ARC patients and below the conservative therapeutic range (< 6mcg/mL) for all study days. In patients without ARC, the serum concentrations were also below the expected range on all but two study days (Days 4 and 5). Four of the 22 (18.2%) patients exhibited seizure activity during the study period (two of these patients exhibited ARC). Cystatin C concentrations were significantly lower in patients with ARC, though the mean for all patients was within the typical normal range. CONCLUSIONS ARC has a high prevalence in patients with moderate to severe TBI. Levetiracetam concentrations after standard dosing were low in all TBI patients, but significantly lower in patients with ARC. This study highlights the need to consider personalized drug dosing in TBI patients irrespective of the presence of ARC. CLINICAL TRIAL REGISTRATION This study was registered at cliicaltrials.gov (NCT02437838) Registered on 08/05/2015, https://clinicaltrials.gov/ct2/show/NCT02437838 .
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Affiliation(s)
- Aaron M Cook
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
- Pharmacy Services UKHealthCare, Lexington, KY, USA
| | - Kaylee Hall
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Jimmi Hatton Kolpek
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Kathryn A Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Campus Box 7574, Chapel Hill, NC, 27599, USA
| | - J Dedrick Jordan
- Departments of Neurology and Neurosurgery, Duke University, Durham, NC, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Campus Box 7574, Chapel Hill, NC, 27599, USA.
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Shao W, Shen C, Wang W, Sun H, Wang X, Geng K, Wang X, Xie H. Development and Validation of Physiologically Based Pharmacokinetic Model of Levetiracetam to Predict Exposure and Dose Optimization in Pediatrics. J Pharm Sci 2023; 112:2667-2675. [PMID: 37023853 DOI: 10.1016/j.xphs.2023.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 03/29/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023]
Abstract
Levetiracetam (Lev) is an antiepileptic drug that has been increasingly used in the epilepsy pediatric population in recent years, but its pharmacokinetic behavior in pediatric population needs to be characterized clearly. Clinical trials for the pediatric drug remain difficult to conduct due to ethical and practical factors. The purpose of this study was to use the physiologically based pharmacokinetic (PBPK) model to predict changes in plasma exposure of Lev in pediatric patients and to provide recommendations for dose adjustment. A PBPK model of Lev in adults was developed using PK-Sim® software and extrapolated to the entire age range of the pediatric population. The model was evaluated using clinical pharmacokinetic data. The results showed the good fit between predictions and observations of the adult and pediatric models. The recommended doses for neonates, infants and children are 0.78, 1.67 and 1.22 times that of adults, respectively. Moreover, at the same dose, plasma exposure in adolescents was similar to that of adults. The PBPK models of Lev for adults and pediatrics were successfully developed and validated to provide a reference for the rational administration of drugs in the pediatric population.
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Affiliation(s)
- Wenxin Shao
- Anhui Provincial Center for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, Anhui, China
| | - Chaozhuang Shen
- Anhui Provincial Center for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, Anhui, China
| | - Wenhui Wang
- Anhui Provincial Center for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, Anhui, China
| | - Hua Sun
- Anhui Provincial Center for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, Anhui, China
| | - Xiaohu Wang
- Anhui Provincial Center for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, Anhui, China
| | - Kuo Geng
- Anhui Provincial Center for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, Anhui, China
| | - Xingwen Wang
- Anhui Provincial Center for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, Anhui, China
| | - Haitang Xie
- Anhui Provincial Center for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu 241001, Anhui, China.
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Shen C, Shao W, Wang W, Sun H, Wang X, Geng K, Wang X, Xie H. Physiologically based pharmacokinetic modeling of levetiracetam to predict the exposure in hepatic and renal impairment and elderly populations. CPT Pharmacometrics Syst Pharmacol 2023; 12:1001-1015. [PMID: 37170680 PMCID: PMC10349187 DOI: 10.1002/psp4.12971] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 05/13/2023] Open
Abstract
Levetiracetam (LEV) is an anti-epileptic drug approved for use in various populations. The pharmacokinetic (PK) behavior of LEV may be altered in the elderly and patients with renal and hepatic impairment. Thus, dosage adjustment is required. This study was conducted to investigate how the physiologically-based PK (PBPK) model describes the PKs of LEV in adult and elderly populations, as well as to predict the PKs of LEV in patients with renal and hepatic impairment in both populations. The whole-body PBPK models were developed using the reported physicochemical properties of LEV and clinical data. The models were validated using data from clinical studies with different dose ranges and different routes and intervals of administration. The fit performance of the models was assessed by comparing predicted and observed blood concentration data and PK parameters. It is recommended that the doses be reduced to ~70%, 60%, and 45% of the adult dose for the mild, moderate, and severe renal impairment populations and ~95%, 80%, and 57% of the adult dose for the Child Pugh-A (CP-A), Child Pugh-B (CP-B), and Child Pugh-C (CP-C) hepatic impairment populations, respectively. No dose adjustment is required for the healthy elderly population, but dose reduction is required for the elderly with organ dysfunction accordingly, on a scale similar to that of adults. A PBPK model of LEV was successfully developed to optimize dosing regimens for special populations.
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Affiliation(s)
- Chaozhuang Shen
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
| | - Wenxin Shao
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
| | - Wenhui Wang
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
| | - Hua Sun
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
| | - Xiaohu Wang
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
| | - Kuo Geng
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
| | - Xingwen Wang
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
| | - Haitang Xie
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
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Klanovicz N, Camargo AF, Ramos B, Michelon W, Treichel H, Teixeira ACSC. A review of hybrid enzymatic-chemical treatment for wastewater containing antiepileptic drugs. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023:10.1007/s11356-023-27487-z. [PMID: 37184794 DOI: 10.1007/s11356-023-27487-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/03/2023] [Indexed: 05/16/2023]
Abstract
Epilepsy is one of the most common neurological diseases worldwide and requires treatment with antiepileptic drugs for many years or for life. This fact leads to the need for constant production and use of these compounds, placing them among the four pharmaceutical classes most found in wastewater. Even at low concentrations, antiepileptics pose risks to human and environmental health and are considered organic contaminants of emerging concern. Conventional treatments have shown low removal of these drugs, requiring advanced and innovative approaches. In this context, this review covers the results and perspectives on (1) consumption and occurrence of antiepileptics in water, (2) toxicological effects in aquatic ecosystems, (3) enzymatic and advanced oxidation processes for degrading antiepileptics drugs from a molecular point of view (biochemical and chemical phenomena), (4) improvements in treatment efficiency by hybridization, and (5) technical aspects of the enzymatic-AOP reactors.
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Affiliation(s)
- Natalia Klanovicz
- Research Group in Advanced Oxidation Processes (AdOx), Department of Chemical Engineering, Escola Politécnica, University of São Paulo, São Paulo, 05508080, Brazil.
- Laboratory of Microbiology and Bioprocesses (LAMIBI), Federal University of Fronteira Sul, Erechim, Brazil.
| | - Aline Frumi Camargo
- Laboratory of Microbiology and Bioprocesses (LAMIBI), Federal University of Fronteira Sul, Erechim, Brazil
- Graduate Program in Biotechnology and Bioscience, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Bruno Ramos
- Research Group in Advanced Oxidation Processes (AdOx), Department of Chemical Engineering, Escola Politécnica, University of São Paulo, São Paulo, 05508080, Brazil
| | | | - Helen Treichel
- Laboratory of Microbiology and Bioprocesses (LAMIBI), Federal University of Fronteira Sul, Erechim, Brazil
| | - Antonio Carlos Silva Costa Teixeira
- Research Group in Advanced Oxidation Processes (AdOx), Department of Chemical Engineering, Escola Politécnica, University of São Paulo, São Paulo, 05508080, Brazil
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Quantification of levetiracetam in plasma and urine and its application to a pharmacokinetic study of traumatic brain injury patients. Bioanalysis 2023; 15:31-42. [PMID: 36927087 DOI: 10.4155/bio-2022-0230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Background: Levetiracetam is an antiepileptic drug used to prevent or treat seizure in patients with severe traumatic brain injury. This study aimed to develop and validate methodology suitable for measuring levetiracetam concentrations in human plasma and urine. Methods: Plasma or urine (10 μl) samples were spiked with [2H6]-levetiracetam and processed using an acetonitrile precipitation. ESI-LC-MS/MS was employed for analyte detection. Results: The levetiracetam calibration was linear from 0.1 to 50 mg/l in a combined matrix of plasma and urine. Intra- and inter-assay imprecision and accuracy in plasma were <7.7 and 109%, and in urine were <7.9 and 108%, respectively. Conclusion: The validated method was applied to a pharmacokinetic study of levetiracetam in critically ill patients with severe traumatic brain injury.
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Chen J, You X, Wu W, Guo G, Lin R, Ke M, Huang P, Lin C. Application of PBPK modeling in predicting maternal and fetal pharmacokinetics of levetiracetam during pregnancy. Eur J Pharm Sci 2023; 181:106349. [PMID: 36496167 DOI: 10.1016/j.ejps.2022.106349] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/13/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022]
Abstract
Levetiracetam is currently being used to treat epilepsy in pregnant women. The plasma concentration of levetiracetam drops sharply during pregnancy, and the inability of pregnant women to maintain therapeutic concentrations can lead to seizures. This study aimed to predict the changes in fetal and maternal plasma exposure to levetiracetam during pregnancy and provide advice on dose adjustment. The physiology-based pharmacokinetics (PBPK) model was developed using PK-Sim and Mobi software, and validated following comparison of the observed plasma concentration and pharmacokinetic parameters. The levetiracetam PBPK model for mother and the fetus at various stages of pregnancy was successfully established and verified. Predictions indicated that the area under the steady-state concentration-time curve for levetiracetam decreased to 83, 62, and 67% of baseline values in the first, second, and third trimesters, respectively. Based on PBPK predictions, the recommended dose of levetiracetam is 1.2, 1.6, and 1.5 times the baseline dose in the first, second, and third trimesters, respectively, not exceeding 4000 mg/day in the third trimester due to fetal safety. The levetiracetam PBPK model for pregnancy was successfully developed and validated, and could provide alternative levetiracetam dosing regimens across the stages of pregnancy.
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Affiliation(s)
- Jiarui Chen
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Xiang You
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Wanhong Wu
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Guimu Guo
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Rongfang Lin
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Meng Ke
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Pinfang Huang
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Cuihong Lin
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China.
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D'Onofrio G, Riva A, Amadori E, Lattanzi S, Rose K, Verrotti A, Striano P. Pharmacokinetic considerations surrounding the use of levetiracetam for seizure prophylaxis in neurocritical care - an overview. Expert Opin Drug Metab Toxicol 2022; 18:575-585. [PMID: 36006892 DOI: 10.1080/17425255.2022.2117606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Levetiracetam (LEV) is one of the most widely used anti-seizure medications (ASMs) in clinical practice. This is due both to a different mechanism of action when compared to other ASMs and its easy handling. Indeed, because of its interesting pharmacokinetic properties, it is often used outside of the labelled indications, notably in the neurocritical setting as prophylaxis of epileptic seizures. AREAS COVERED A literature search was conducted and the most relevant studies on the pharmacokinetic properties of LEV were selected by two independent investigators. Current evidence on the use of ASM prophylaxis in the neurocritical setting was also reviewed, highlighting and discussing the strengths and limits of LEV as drug of choice for anti-epileptic prophylaxis in this scenario. EXPERT OPINION LEV has a "near-ideal" pharmacokinetic profile, which makes it an attractive drug for ASM prophylaxis in neurocritical care. However, current recommendations restrict ASMs prophylaxis to very selected circumstances and the role of LEV is marginal. Moreover, studies are generally designed to compare LEV versus phenytoin, whereas studies comparing LEV versus placebo are lacking. Further randomized trials will be needed to better elucidate LEV utility and its neuroprotective role in the neurocritical setting.
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Affiliation(s)
- Gianluca D'Onofrio
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Antonella Riva
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Elisabetta Amadori
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Klaus Rose
- klausrose Consulting, Riehen, Switzerland
| | - Alberto Verrotti
- Pediatric Unit, Department of Medicine and Surgery, University of Perugia, 06156 Perugia, Italy
| | - Pasquale Striano
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
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11
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Tilen R, Paioni P, Goetschi AN, Goers R, Seibert I, Müller D, Bielicki JA, Berger C, Krämer SD, Meyer zu Schwabedissen HE. Pharmacogenetic Analysis of Voriconazole Treatment in Children. Pharmaceutics 2022; 14:pharmaceutics14061289. [PMID: 35745860 PMCID: PMC9227859 DOI: 10.3390/pharmaceutics14061289] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Abstract
Voriconazole is among the first-line antifungal drugs to treat invasive fungal infections in children and known for its pronounced inter- and intraindividual pharmacokinetic variability. Polymorphisms in genes involved in the metabolism and transport of voriconazole are thought to influence serum concentrations and eventually the therapeutic outcome. To investigate the impact of these genetic variants and other covariates on voriconazole trough concentrations, we performed a retrospective data analysis, where we used medication data from 36 children suffering from invasive fungal infections treated with voriconazole. Data were extracted from clinical information systems with the new infrastructure SwissPKcdw, and linear mixed effects modelling was performed using R. Samples from 23 children were available for DNA extraction, from which 12 selected polymorphism were genotyped by real-time PCR. 192 (49.1%) of 391 trough serum concentrations measured were outside the recommended range. Voriconazole trough concentrations were influenced by polymorphisms within the metabolizing enzymes CYP2C19 and CYP3A4, and within the drug transporters ABCC2 and ABCG2, as well as by the co-medications ciprofloxacin, levetiracetam, and propranolol. In order to prescribe an optimal drug dosage, pre-emptive pharmacogenetic testing and careful consideration of co-medications in addition to therapeutic drug monitoring might improve voriconazole treatment outcome of children with invasive fungal infections.
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Affiliation(s)
- Romy Tilen
- Division of Infectious Diseases and Hospital Epidemiology, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland; (P.P.); (C.B.)
- Biopharmacy, Department of Pharmaceutical Sciences, University Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland; (R.G.); (I.S.)
- Correspondence: (R.T.); (H.E.M.z.S.)
| | - Paolo Paioni
- Division of Infectious Diseases and Hospital Epidemiology, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland; (P.P.); (C.B.)
| | - Aljoscha N. Goetschi
- Biopharmacy, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 4, 8093 Zurich, Switzerland; (A.N.G.); (S.D.K.)
| | - Roland Goers
- Biopharmacy, Department of Pharmaceutical Sciences, University Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland; (R.G.); (I.S.)
| | - Isabell Seibert
- Biopharmacy, Department of Pharmaceutical Sciences, University Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland; (R.G.); (I.S.)
| | - Daniel Müller
- Institute of Clinical Chemistry, University Hospital Zurich, Rämistr. 100, 8091 Zurich, Switzerland;
| | - Julia A. Bielicki
- Paediatric Research Centre, University Children’s Hospital Basel, Basel, Spitalstrasse 33, 4056 Basel, Switzerland;
| | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland; (P.P.); (C.B.)
| | - Stefanie D. Krämer
- Biopharmacy, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 4, 8093 Zurich, Switzerland; (A.N.G.); (S.D.K.)
| | - Henriette E. Meyer zu Schwabedissen
- Biopharmacy, Department of Pharmaceutical Sciences, University Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland; (R.G.); (I.S.)
- Correspondence: (R.T.); (H.E.M.z.S.)
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12
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Sinha J, Karatza E, Gonzalez D. Physiologically-based pharmacokinetic modeling of oxcarbazepine and levetiracetam during adjunctive antiepileptic therapy in children and adolescents. CPT Pharmacometrics Syst Pharmacol 2022; 11:225-239. [PMID: 34816634 PMCID: PMC8846633 DOI: 10.1002/psp4.12750] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/09/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022] Open
Abstract
Oxcarbazepine (OXZ) and levetiracetam (LEV) are two new generation anti‐epileptic drugs, often co‐administered in children with enzyme‐inducing antiepileptic drugs (EIAEDs). The anti‐epileptic effect of OXZ and LEV are linked to the exposure of OXZ’s active metabolite 10‐monohydroxy derivative (MHD) and (the parent) LEV, respectively. However, little is known about the confounding effect of age and EIAEDs on the pharmacokinetics (PKs) of MHD and LEV. To address this knowledge gap, physiologically‐based pharmacokinetic (PBPK) modeling was performed in the PK‐Sim software using literature data from children greater than or equal to 2 years of age. Age‐related changes in clearance (CL) of MHD and LEV were characterized, both in the presence (group 1) and absence (group 2) of concomitant EIAEDs. The drug‐drug interaction effect of EIAEDs was estimated as the difference in CL estimates between groups 1 and 2. PBPK modeling suggests that bodyweight normalized CL (ml/min/kg) is higher in younger children than their older counterparts (i.e., due to an influence of age). Concomitant EIAEDs further increase MHD’s CL to a fixed extent of 25% at any age, but EIAEDs’ effect on LEV’s CL increases with age from 20% (at 2 years) to 30% (at adolescence). Simulations with the maximum recommended doses (MRDs) revealed that children between 2 and 4 years and greater than 4 years, who are not on EIAEDs, are at risk of exceeding the reference exposure range for OXZ and LEV, respectively. This analysis demonstrates the use of PBPK modeling in understanding the confounding effect of age and comedications on PKs in children and adolescents.
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Affiliation(s)
- Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Pediatrics, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eleni Karatza
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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13
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Pal R, Singh K, Khan SA, Chawla P, Kumar B, Akhtar MJ. Reactive metabolites of the anticonvulsant drugs and approaches to minimize the adverse drug reaction. Eur J Med Chem 2021; 226:113890. [PMID: 34628237 DOI: 10.1016/j.ejmech.2021.113890] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 09/01/2021] [Accepted: 09/29/2021] [Indexed: 12/22/2022]
Abstract
Several generations of antiepileptic drugs (AEDs) are available in the market for the treatment of seizures, but these are amalgamated with acute to chronic side effects. The most common side effects of AEDs are dose-related, but some are idiosyncratic adverse drug reactions (ADRs) that transpire due to the formation of reactive metabolite (RM) after the bioactivation process. Because of the adverse reactions patients usually discontinue the medication in between the treatment. The AEDs such as valproic acid, lamotrigine, phenytoin etc., can be categorized under such types because they form the RM which may prevail with life-threatening adverse effects or immune-mediated reactions. Hepatotoxicity, teratogenicity, cutaneous hypersensitivity, dizziness, addiction, serum sickness reaction, renal calculi, metabolic acidosis are associated with the metabolites of drugs such as arene oxide, N-desmethyldiazepam, 2-(1-hydroxyethyl)-2-methylsuccinimide, 2-(sulphamoy1acetyl)-phenol, E-2-en-VPA and 4-en-VPA and carbamazepine-10,11-epoxide, etc. The major toxicities are associated with the moieties that are either capable of forming RM or the functional groups may itself be too reactive prior to the metabolism. These functional groups or fragment structures are typically known as structural alerts or toxicophores. Therefore, minimizing the bioactivation potential of lead structures in the early phases of drug discovery by a modification to low-risk drug molecules is a priority for the pharmaceutical companies. Additionally, excellent potency and pharmacokinetic (PK) behaviour help in ensuring that appropriate (low dose) candidate drugs progress into the development phase. The current review discusses about RMs in the anticonvulsant drugs along with their mechanism vis-a-vis research efforts that have been taken to minimize the toxic effects of AEDs therapy.
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Affiliation(s)
- Rohit Pal
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, Ghal Kalan, Ferozpur, G.T. Road, Moga, 142001, Punjab, India
| | - Karanvir Singh
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, Ghal Kalan, Ferozpur, G.T. Road, Moga, 142001, Punjab, India
| | - Shah Alam Khan
- Department of Pharmaceutical Chemistry, College of Pharmacy, National University of Science and Technology, PO 620, PC 130, Azaiba, Bousher, Muscat, Oman
| | - Pooja Chawla
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, Ghal Kalan, Ferozpur, G.T. Road, Moga, 142001, Punjab, India
| | - Bhupinder Kumar
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, Ghal Kalan, Ferozpur, G.T. Road, Moga, 142001, Punjab, India.
| | - Md Jawaid Akhtar
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, Ghal Kalan, Ferozpur, G.T. Road, Moga, 142001, Punjab, India; Department of Pharmaceutical Chemistry, College of Pharmacy, National University of Science and Technology, PO 620, PC 130, Azaiba, Bousher, Muscat, Oman.
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14
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Wood KE, Palmer KL, Krasowski MD. Correlation of elevated lamotrigine and levetiracetam serum/plasma levels with toxicity: A long-term retrospective review at an academic medical center. Toxicol Rep 2021; 8:1592-1598. [PMID: 34522622 PMCID: PMC8424104 DOI: 10.1016/j.toxrep.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/05/2021] [Accepted: 08/28/2021] [Indexed: 11/15/2022] Open
Abstract
Lamotrigine and levetiracetam are widely used second-generation anti-epileptic drugs. Existing literature indicates that overdose of either drug is typically benign, but neurologic and cardiac toxicity can occur in some cases. In this retrospective study, we analyzed a large dataset of serum/plasma drug levels for lamotrigine and levetiracetam. The data covered 1,930 unique patients (5,046 levels) for lamotrigine and 2,451 patients (4,359 levels) for levetiracetam. We performed detailed chart review on all patients with one or more lamotrigine levels greater than 14.0 mg/L (293 unique patients) and all patients with one or more levetiracetam levels of 80 mg/L or higher (106 unique patients). No deaths directly attributable to lamotrigine or levetiracetam toxicity were reported. For cases with lamotrigine levels greater than 14.0 mg/L, the majority of patients were asymptomatic (55.3 %, n = 162). The most common presenting symptoms were ataxia (14.3 %, n = 42), seizures (14.0 %, n = 41), dizziness (11.9 %, n = 35), and altered mental status (11.6 %, n = 34). There were 12 overdoses (11 intentional) involving lamotrigine, all of which presented with either altered mental status (n = 8) or seizures (n = 4). The highest estimated dose reportedly ingested was 20 g. Cardiac toxicity was observed in two cases involving intentional overdose of lamotrigine. For patients with levetiracetam serum/plasma levels of 80 mg/L or higher, 48 patients (45.3 %) were asymptomatic. Symptomatic patients most commonly presented with seizures (31.1 %, n = 33) and altered mental status (15.1 %, n = 16), and none showed cardiac symptoms. There were only two cases involving intentional levetiracetam overdose, one of which presented with altered mental status after ingestion of 45 g and the other asymptomatic after ingestion of 6 g. Overall, our data is consistent with previous investigations that lamotrigine and levetiracetam toxicity most typically presents with neurologic symptoms and rarely cardiac arrhythmias. Approximately half of the patients with elevated lamotrigine or levetiracetam drug levels are asymptomatic.
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Affiliation(s)
- Kelly E. Wood
- Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, 52242, USA
| | - Kendra L. Palmer
- Department of Pathology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Matthew D. Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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15
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Urata S, Yoshikawa N, Saito K, Tazaki T, Ohno R, Takeshima H, Ikeda R. Delayed methotrexate elimination in a patient with primary central nervous system lymphoma: A case report. J Clin Pharm Ther 2021; 46:1796-1799. [PMID: 34008211 DOI: 10.1111/jcpt.13425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Methotrexate (MTX) is an important agent for the treatment of primary central nervous system lymphomas (PCNSL) but needs to be given in big doses by intravenous infusions to achieve therapeutic concentrations in the cerebrospinal fluid. However, co-administration with many drugs may delay the excretion of MTX which may cause serious adverse effects if the serum concentration exceeds 0.1 µmol/L 72 h after an intravenous infusion. CASE SUMMARY A 67-year-old Japanese female with PCNSL was treated with high-dose MTX-based chemotherapy. The serum MTX concentration 72 h post-infusion was 0.153 µmol/L when she was taking levofloxacin (LVFX) but <0.1 µmol/L 72 h after 4 subsequent infusions when she was not taking LVFX. She was given many other drugs but the timing of the short course of LVFX and the fact that ciprofloxacin also delays MTX excretion suggests that LVFX was the cause. WHAT IS NEW AND CONCLUSION Co-administration of LVFX may delay the excretion of MTX. Therefore, serum concentrations of MTX should be monitored to help prevent and improve the management of potentially serious MTX drug-drug interaction.
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Affiliation(s)
- Shuhei Urata
- Department of Pharmacy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Naoki Yoshikawa
- Department of Pharmacy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Kiyotaka Saito
- Department of Neurosurgery, Division of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tomoya Tazaki
- Department of Pharmacy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Rie Ohno
- Department of Pharmacy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Hideo Takeshima
- Department of Neurosurgery, Division of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Ryuji Ikeda
- Department of Pharmacy, University of Miyazaki Hospital, Miyazaki, Japan
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16
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Naji-Talakar S, Sharma S, Martin LA, Barnhart D, Prasad B. Potential implications of DMET ontogeny on the disposition of commonly prescribed drugs in neonatal and pediatric intensive care units. Expert Opin Drug Metab Toxicol 2021; 17:273-289. [PMID: 33256492 PMCID: PMC8346204 DOI: 10.1080/17425255.2021.1858051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Introduction: Pediatric patients, especially neonates and infants, are more susceptible to adverse drug events as compared to adults. In particular, immature small molecule drug metabolism and excretion can result in higher incidences of pediatric toxicity than adults if the pediatric dose is not adjusted.Area covered: We reviewed the top 29 small molecule drugs prescribed in neonatal and pediatric intensive care units and compiled the mechanisms of their metabolism and excretion. The ontogeny of Phase I and II drug metabolizing enzymes and transporters (DMETs), particularly relevant to these drugs, are summarized. The potential effects of DMET ontogeny on the metabolism and excretion of the top pediatric drugs were predicted. The current regulatory requirements and recommendations regarding safe and effective use of drugs in children are discussed. A few representative examples of the use of ontogeny-informed physiologically based pharmacokinetic (PBPK) models are highlighted.Expert opinion: Empirical prediction of pediatric drug dosing based on body weight or body-surface area from the adult parameters can be inaccurate because DMETs are not mature in children and the age-dependent maturation of these proteins is different. Ontogeny-informed-PBPK modeling provides a better alternative to predict the pharmacokinetics of drugs in children.
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Affiliation(s)
- Siavosh Naji-Talakar
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Sheena Sharma
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Leslie A. Martin
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Derek Barnhart
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Bhagwat Prasad
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
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17
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Methaneethorn J, Leelakanok N. Population Pharmacokinetics of Levetiracetam: a Systematic Review. ACTA ACUST UNITED AC 2021; 17:122-134. [PMID: 33622228 DOI: 10.2174/1574884716666210223110658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/30/2020] [Accepted: 01/05/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The use of levetiracetam (LEV) has been increasing given its favorable pharmacokinetic profile. Numerous population pharmacokinetic studies for LEV have been conducted. However, there are some discrepancies regarding factors affecting its pharmacokinetic variability. Therefore, this systematic review aimed to summarize significant predictors for LEV pharmacokinetics as well as the need for dosage adjustments. METHODS We performed a systematic search for population pharmacokinetic studies of LEV conducted using a nonlinear-mixed effect approach from PubMed, Scopus, CINAHL Complete, and Science Direct databases from their inception to March 2020. Information on study design, model methodologies, significant covariate-parameter relationships, and model evaluation was extracted. The quality of the reported studies was also assessed. RESULTS A total of 16 studies were included in this review. Only two studies were conducted with a two-compartment model, while the rest were performed with a one-compartment structure. Bodyweight and creatinine clearance were the two most frequently identified covariates on LEV clearance (CLLEV). Additionally, postmenstrual age (PMA) or postnatal age (PNA) were significant predictors for CLLEV in neonates. Only three studies externally validated the models. Two studies conducted pharmacodynamic models for LEV with relatively small sample size. CONCLUSION Significant predictors for LEV pharmacokinetics are highlighted in this review. For future research, a population pharmacokinetic-pharmacodynamic model using a larger sample size should be conducted. From a clinical perspective, the published models should be externally evaluated before clinical implementation.
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Affiliation(s)
- Janthima Methaneethorn
- Pharmacokinetic Research Unit, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok. Thailand
| | - Nattawut Leelakanok
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi. Thailand
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18
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Li ZR, Wang CY, Zhu X, Jiao Z. Population Pharmacokinetics of Levetiracetam: A Systematic Review. Clin Pharmacokinet 2021; 60:305-318. [PMID: 33447943 DOI: 10.1007/s40262-020-00963-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Levetiracetam has been widely used as a treatment option for different types of epilepsy in both adults and children. Because of its large between-subject variability, several population pharmacokinetic studies have been performed to identify its pharmacokinetic covariates, and thus facilitate individualised therapy. OBJECTIVE The aim of this review was to provide a synopsis for population pharmacokinetic studies of levetiracetam and explore the identified influencing covariates. METHODS We systematically searched the PubMed and Embase databases from inception to 30 June 2020. The information on study designs, target population, model characteristics, and identified covariates was summarised. Moreover, the pharmacokinetic profiles were compared among neonates, children, and adults. RESULTS Fourteen studies were included, among which two involved neonates, four involved children, two involved both children and adults, and six involved adults only. The median value of apparent clearance for children (0.074 L/h/kg [range 0.038-0.079]) was higher than that for adults (0.054 L/h/kg [range 0.039-0.061]). Body weight was found to significantly influence the apparent clearance and volume of distribution, whereas renal function influenced the clearance. Likewise, coadministration with enzyme-inducing antiepileptic drugs (such as carbamazepine and phenytoin) increased the drug clearance by 9-22%, whereas coadministration with valproate acid decreased it by 18.8%. CONCLUSION Levetiracetam dose regimen is dependent on the body size and renal function of patients. Further studies are needed to evaluate levetiracetam pharmacokinetics in neonates and pregnant women.
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Affiliation(s)
- Zi-Ran Li
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 Huaihai West Road, Shanghai, 200030, People's Republic of China.,Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Chen-Yu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 Huaihai West Road, Shanghai, 200030, People's Republic of China
| | - Xiao Zhu
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 Huaihai West Road, Shanghai, 200030, People's Republic of China.
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19
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Sime FB, Roberts JA, Jeffree RL, Pandey S, Adiraju S, Livermore A, Butler J, Parker SL, Wallis SC, Lipman J, Cotta MO. Population Pharmacokinetics of Levetiracetam in Patients with Traumatic Brain Injury and Subarachnoid Hemorrhage Exhibiting Augmented Renal Clearance. Clin Pharmacokinet 2021; 60:655-664. [PMID: 33428169 DOI: 10.1007/s40262-020-00979-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with severe trauma exhibit augmented renal clearance, which can alter the dosing requirement of renally eliminated drugs. This study aimed to develop a population pharmacokinetic model for levetiracetam in patients with severe traumatic brain injury and aneurysmal subarachnoid hemorrhage, and use it to describe optimal dosing regimens. METHODS This was a prospective open-label observational study. Critically ill adult patients with severe traumatic brain injury or aneurysmal subarachnoid hemorrhage without renal dysfunction and receiving levetiracetam were eligible. Serial levetiracetam plasma concentrations were analyzed to develop a population pharmacokinetic model and perform dosing simulations. RESULTS A two-compartment model best described the concentration-time data from 30 patients. The mean ± standard deviation parameter estimates were bioavailability (F) of 0.8 ± 0.2, absorption rate constant of 2.4 ± 2 h-1, clearance 2.5 ± 1.1 L/h, central volume of distribution 8.9 ± 3.0 L/h, and transfer rate constraints of 1.8 ± 1.1 h-1 from central to peripheral compartments and 0.7 ± 0.3 h-1 from peripheral to central compartments. For the simulated intermittent dosing regimens, on average, the median trough concentration reduced by 50% for every 40-mL/min/1.73 m2 increase in urinary creatinine clearance. Simulated doses of at least 6 g/day were required for some levels of augmented renal clearance. CONCLUSIONS Patients with severe traumatic brain injury and aneurysmal subarachnoid hemorrhage with augmented renal clearance are at risk of not achieving target levetiracetam plasma concentrations. We suggest dose titration guided by measured creatinine clearance, and/or, therapeutic drug monitoring if available, to minimize the risk of seizures.
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Affiliation(s)
- Fekade Bruck Sime
- University of Queensland Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, QLD, 4029, Australia. .,Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, QLD, 4029, Australia.,Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Division of Anesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Rosalind L Jeffree
- Kenneth G. Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Saurabh Pandey
- University of Queensland Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, QLD, 4029, Australia
| | - Santosh Adiraju
- University of Queensland Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, QLD, 4029, Australia
| | - Amelia Livermore
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jenie Butler
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Suzanne L Parker
- University of Queensland Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, QLD, 4029, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, QLD, 4029, Australia
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, QLD, 4029, Australia.,Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Division of Anesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane & Women's Hospital Campus, Herston, QLD, 4029, Australia. .,Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.
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21
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Karatza E, Markantonis SL, Savvidou A, Verentzioti A, Siatouni A, Alexoudi A, Gatzonis S, Mavrokefalou E, Karalis V. Pharmacokinetic and pharmacodynamic modeling of levetiracetam: investigation of factors affecting the clinical outcome. Xenobiotica 2020; 50:1090-1100. [PMID: 32208795 DOI: 10.1080/00498254.2020.1746981] [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: 02/06/2023]
Abstract
This study aimed to evaluate the pharmacokinetics and pharmacodynamics of oral levetiracetam therapy in drug refractory adult epileptic outpatients, as well as factors affecting them. Concentration-time data were collected at steady state, while seizure recurrence was monitored for 13 months. Non-linear mixed effects modeling was applied, and covariates assessed included weight, height, age, daily dose and creatinine clearance.Plasma concentrations of levetiracetam were best described by a one-compartment pharmacokinetic model (V/F = 34.7 L) with first-order absorption (ka = 0.616 h-1) and clearance (CL/F = 3.26 L/h). Patient's CrCL was found to significantly affect levetiracetam clearance (beta = 0.795). Time to seizure occurrence followed an exponential distribution and the mean time to seizure occurrence was estimated Te = 22.08 days. Seizure rate per month followed a Poisson distribution, while mean seizure rate per month was estimated λ = 1.33. Daily dose significantly affected the mean estimated time to seizure (beta = -2.2) and the mean monthly seizure rate (beta = 2.27) in a reverse way. Using discrete time Markov chains, it was shown that the transition probability from focal seizures to focal to bilateral tonic-clonic is significantly altered in relation to patient's CrCL.Simulations showed that dose should be adjusted in relation to CrCL, while low doses of levetiracetam are more effective for seizure control. Modeling and simulation in every-day clinical practice may provide significant information for the optimization of seizure control using well-known agents.
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Affiliation(s)
- Eleni Karatza
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Sophia L Markantonis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Andria Savvidou
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Verentzioti
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Siatouni
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasia Alexoudi
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stylianos Gatzonis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Vangelis Karalis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
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Wang K, Zhu H, Zhao H, Zhang K, Tian Y. Application of carbamyl in structural optimization. Bioorg Chem 2020; 98:103757. [PMID: 32217370 DOI: 10.1016/j.bioorg.2020.103757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/07/2020] [Accepted: 03/12/2020] [Indexed: 12/11/2022]
Abstract
Carbamyl is considered a privileged structure in medicinal chemistry. It has a wide range of biological activities such as antimicrobial, anticancer, anti-epilepsy, for which the best evidence is a number of marketed carbamyl-containing drugs. Carbamyl is formed of primary amine and carbonyl moieties that act as hydrogen bond donors and hydrogen acceptors with residues of targets respectively, which are benefit for improving pharmacological activities. In other cases, the introduced carbamyl improves drug-like properties including oral bioavailability. In this review, we introduce the carbamyl-containing drugs and the application of carbamyl in structural optimization as a result of enhancing activities or/and drug-like properties.
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Affiliation(s)
- Kuanglei Wang
- School of Biotechnology and Health Sciences, Wuyi University, Jiangmen 529020, PR China; International Healthcare Innovation Institute (Jiangmen), Jiangmen 529040, PR China; School of Chemical Engineering and Light Industry, Guangdong University of Technology, Guangzhou 510006, PR China
| | - Hongxi Zhu
- School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Hongqian Zhao
- School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, PR China
| | - Kun Zhang
- School of Biotechnology and Health Sciences, Wuyi University, Jiangmen 529020, PR China; International Healthcare Innovation Institute (Jiangmen), Jiangmen 529040, PR China; School of Chemical Engineering and Light Industry, Guangdong University of Technology, Guangzhou 510006, PR China.
| | - Yongshou Tian
- School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, PR China.
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Volumetric Absorptive Microsampling: A New Sampling Tool for Therapeutic Drug Monitoring of Antiepileptic Drugs. Ther Drug Monit 2020; 41:681-692. [PMID: 31095069 DOI: 10.1097/ftd.0000000000000652] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Volumetric absorptive microsampling (VAMS) is a novel sampling technique for the collection of fixed-volume capillary blood. In this study, a new analytical method was developed and used to quantify 14 different antiepileptic drugs (AEDs) and 2 active metabolites in samples collected by VAMS. These data were compared with concentration measurements in plasma. METHODS The authors developed a selective and sensitive liquid chromatography-mass spectrometry (LC-MS/MS) assay to measure the concentrations of several AEDs in whole blood collected by VAMS, which were compared with a commercially available LC-MS/MS kit for AED monitoring in plasma. Drugs and internal standards were extracted from whole blood/plasma samples by a simple protein precipitation. RESULTS An LC-MS/MS method analyzing VAMS samples was successfully developed and validated for the determination of various AED concentrations in whole blood according to EMA guidelines for bioanalytical method validation. Extraction recovery was between 91% and 110%. No matrix effect was found. The method was linear for all drugs with R ≥0.989 in all cases. Intra-assay and inter-assay reproducibility analyses demonstrated accuracy and precision within acceptance criteria. Carry over and interferences were negligible. No volumetric HCT% bias was found at 3 different HCT values (35%-55%) with recovery being consistently above 87%. Samples are very stable at temperatures ranging from -20°C to 37°C and for a 4-month period. Leftover EDTA samples from 133 patients were tested to determine concentration differences between plasma and whole blood sampled by VAMS. The resulting difference varied less than 15% apart from those drugs with a blood/plasma ratio (R) different from 1. CONCLUSIONS The assay allows for highly sensitive and selective quantification of several AEDs in whole blood samples collected by VAMS. The developed method is accurate and precise and free from matrix effects and volumetric HCT% bias.
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Zhang Y, Jiang Y, Yuan F, Song C, Zhao Z, Jiang W. An Epileptic Patient with Recurrent Hyperbilirubinemia Caused by Gilbert Syndrome. Case Rep Gastroenterol 2020; 14:39-47. [PMID: 32095123 PMCID: PMC7011721 DOI: 10.1159/000504645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/06/2019] [Indexed: 02/02/2023] Open
Abstract
Gilbert syndrome (GS) is characterized by intermittent indirect bilirubin elevation. Several antiepileptic drugs (AEDs) impair the liver function to different degrees, such as valproic acid, lamotrigine, phenobarbital, phenytoin, and carbamazepine. Herein, we present the case of a 26-year-old epileptic patient with frequently recurring mild hyperbilirubinemia during taking AEDs. After repeated adjustment of the doses and types of AEDs, the bilirubin level still remained elevated. He was then referred to the Gastroenterology Department. The results of diagnostic tests, clinical manifestation, imaging studies, liver biopsy and whole-exome sequencing all made contributions to our conclusion that GS played an important role in the elevation of bilirubin. Ultimately, his seizure was controlled by levetiracetam (500 mg per day) and he was advised to periodically undergo the liver function tests.
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Affiliation(s)
- Yaoyao Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yongli Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhihan Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Peters BJ, Hofer M, Daniels CE, Winters JL. Effect of plasma exchange on antifactor Xa activity of enoxaparin and serum levetiracetam levels. Am J Health Syst Pharm 2019; 75:1883-1888. [PMID: 30463865 DOI: 10.2146/ajhp170885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE The effect of therapeutic plasma exchange (TPE) on antifactor Xa activity in a patient treated with enoxaparin and levetiracetam is reported. SUMMARY A 52-year-old woman was treated with levetiracetam and prophylactic enoxaparin while receiving TPE to manage respiratory failure due to anti-MDA5 antibody-associated interstitial lung disease (ILD) with dermatomyositis. Due to a scant amount of evidence regarding the management of these medications in TPE, therapeutic monitoring principles were used to assess the effect TPE had on these medications. A pre-TPE antifactor Xa activity level and levetiracetam serum assay, a post-TPE antifactor Xa activity level and levetiracetam serum assay, levetiracetam serum assays at 1 and 6 hours after the patient received her next dose, and a levetiracetam assay of the waste plasma from the TPE were collected for therapeutic drug monitoring and pharmacokinetic calculations. Utilizing standard population pharmacokinetic data, the expected antifactor Xa activity without TPE was 0.14 IU/mL. This concentration was significantly higher than the undetectable concentration (<0.1 IU/mL) that was drawn immediately after TPE, suggesting significant removal of antifactor Xa activity. The measured levetiracetam level did not significantly differ from the expected post-TPE levetiracetam level that was calculated using patient-specific pharmacokinetic data. CONCLUSION In a patient receiving TPE to manage anti-MDA5 antibody ILD associated with dermatomyositis and a prior seizure, TPE significantly altered enoxaparin antifactor Xa activity as evidenced by the undetectable antifactor Xa activity level drawn after TPE. Alternatively, TPE had a minimal effect on the clearance of levetiracetam as evidenced by the post-TPE level and fraction elimination of only 5% of total body stores.
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Affiliation(s)
| | - Mikaela Hofer
- previously Pharm.D. student, University of Minnesota, College of Pharmacy, Minneapolis, MN
| | - Craig E Daniels
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Jeffrey L Winters
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine, Mayo Clinic Rochester, Rochester, MN
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Ali HM, Gamal M, Abdelwahab NS, Farid NF. Simple GC–MS method for analysis of Levetiracetam and process-related toxic impurity. Microchem J 2019. [DOI: 10.1016/j.microc.2019.02.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kim MJ, Yum MS, Yeh HR, Ko TS, Lim HS. Pharmacokinetic and Pharmacodynamic Evaluation of Intravenous Levetiracetam in Children With Epilepsy. J Clin Pharmacol 2018; 58:1586-1596. [PMID: 30052270 DOI: 10.1002/jcph.1282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/18/2018] [Indexed: 11/08/2022]
Abstract
This study aimed to evaluate the safety and tolerability of intravenous (IV) levetiracetam (LEV) as a monotherapy in children aged 1 month-16 years and to explore the pharmacokinetics (PK) of IV LEV and the time to seizure after IV then oral administration of LEV in pediatric children with epilepsy. Children diagnosed with acute unprovoked seizures requiring in-hospital IV LEV administration were included. After administration, the clinical seizure outcomes, side effects, and the Korean-Child Behavior Checklist were monitored and the PK and repeated time to seizure were analyzed via modeling using NONMEM software. Overall, 37 children with epilepsy were enrolled and underwent a PK analysis (median age, 4.6 years; median weight, 18.0 kg). Nine children (24.3%) had seizure recurrence during the follow-up period (median, 3.8 months) and 5 children (13.5%) experienced LEV-associated adverse events such as irritability (n = 2; 5.4%) and somnolence (n = 3; 8.1%). The plasma LEV concentrations after IV LEV were best described by a one-compartment linear PK model. Only body weight was associated with both the clearance and volume of distribution of LEV. The Weibull distribution model described the time to seizure recurrence well; no statistically significant predictor for the time to seizure was identified. Therefore, IV LEV was a well-tolerated and effective alternative in children with acute unprovoked seizures, and models for the PK and time to repeated seizure recurrence after LEV were successfully developed. In particular, the current use of a weight-based IV LEV dosing regimen in pediatric children is practical.
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Affiliation(s)
- Min-Jee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Ryun Yeh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong-Seok Lim
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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30
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Population Pharmacokinetic Modeling of Levetiracetam in Pediatric and Adult Patients With Epilepsy by Using Routinely Monitored Data. Ther Drug Monit 2017; 38:371-8. [PMID: 26913593 DOI: 10.1097/ftd.0000000000000291] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Levetiracetam, a second-generation antiepileptic drug, is frequently used for managing partial-onset seizures. About 70% of the administered dose is excreted in urine unchanged, and dosage adjustment is recommended based on the individual's renal function. In this study, a population pharmacokinetic model of levetiracetam was developed using routinely monitored serum concentration data for individualized levetiracetam therapy. METHODS Patients whose serum concentrations of levetiracetam at steady-state were routinely monitored at Kyoto University Hospital from April 2012 to March 2013 were enrolled. The influence of patient characteristics on levetiracetam pharmacokinetics was evaluated using the nonlinear mixed-effects modeling (NONMEM) program. RESULTS A total of 583 steady-state concentrations from 225 patients were used for the analysis. The median patient age and estimated glomerular filtration rate (eGFR) were 38 (range: 1-89) years and 98 (15-189) mL·min·1.73 m, respectively. Serum concentration-time data of levetiracetam were well described by a 1-compartment model with first-order absorption. Oral clearance was allometrically related to the individual body weight and eGFR. An increase in the dose significantly increased oral clearance. No improvement in model fit was observed by including the covariate of any concomitant antiepileptic drugs. The population mean clearance for an adult weighing 70 kg and with a normal renal function was 4.8 and 5.9 L/h for 500 mg bis in die (bid) and 1500 mg bid, respectively. CONCLUSIONS Oral clearance allometrically related with body weight and eGFR can well predict the routine therapeutic drug monitoring data from pediatric to aged patients with varying renal function. Dosage adjustments based on renal function are effective in controlling the trough and peak concentrations in similar ranges.
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Patsalos PN, Zugman M, Lake C, James A, Ratnaraj N, Sander JW. Serum protein binding of 25 antiepileptic drugs in a routine clinical setting: A comparison of free non-protein-bound concentrations. Epilepsia 2017; 58:1234-1243. [DOI: 10.1111/epi.13802] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Philip N. Patsalos
- Department of Clinical & Experimental Epilepsy; NIHR University College London Hospitals Biomedical Research Centre; UCL Institute of Neurology; London United Kingdom
- Chalfont Centre for Epilepsy; Chalfont St. Peter United Kingdom
| | - Miguel Zugman
- Department of Clinical & Experimental Epilepsy; NIHR University College London Hospitals Biomedical Research Centre; UCL Institute of Neurology; London United Kingdom
- Chalfont Centre for Epilepsy; Chalfont St. Peter United Kingdom
| | - Charlotte Lake
- Department of Clinical & Experimental Epilepsy; NIHR University College London Hospitals Biomedical Research Centre; UCL Institute of Neurology; London United Kingdom
- Chalfont Centre for Epilepsy; Chalfont St. Peter United Kingdom
| | - Anthony James
- Department of Clinical & Experimental Epilepsy; NIHR University College London Hospitals Biomedical Research Centre; UCL Institute of Neurology; London United Kingdom
- Chalfont Centre for Epilepsy; Chalfont St. Peter United Kingdom
| | - Neville Ratnaraj
- Department of Clinical & Experimental Epilepsy; NIHR University College London Hospitals Biomedical Research Centre; UCL Institute of Neurology; London United Kingdom
- Chalfont Centre for Epilepsy; Chalfont St. Peter United Kingdom
| | - Josemir W. Sander
- Department of Clinical & Experimental Epilepsy; NIHR University College London Hospitals Biomedical Research Centre; UCL Institute of Neurology; London United Kingdom
- Chalfont Centre for Epilepsy; Chalfont St. Peter United Kingdom
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Population pharmacokinetics and dose-response relationship of levetiracetam in adult patients with epilepsy. Epilepsy Res 2017; 132:8-14. [DOI: 10.1016/j.eplepsyres.2017.02.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/15/2017] [Accepted: 02/23/2017] [Indexed: 10/20/2022]
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Van Matre ET, Mueller SW, Fish DN, MacLaren R, Cava LF, Neumann RT, Kiser TH. Levetiracetam Pharmacokinetics in a Patient with Intracranial Hemorrhage Undergoing Continuous Veno-Venous Hemofiltration. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:458-462. [PMID: 28446744 PMCID: PMC5414484 DOI: 10.12659/ajcr.902709] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patient: Male, 78 Final Diagnosis: Right thalamic intraparenchymal hemorrhage with intraventricular extension Symptoms: Altered mental status • left sided weakness Medication: Levetiracetam Clinical Procedure: Continuous renal replacement therapy Specialty: Critical Care Medicine
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Affiliation(s)
- Edward T Van Matre
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Scott W Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Douglas N Fish
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Luis F Cava
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert T Neumann
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Smetana KS, Cook AM, Bastin MLT, Oyler DR. Antiepileptic dosing for critically ill adult patients receiving renal replacement therapy. J Crit Care 2016; 36:116-124. [PMID: 27546759 DOI: 10.1016/j.jcrc.2016.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/06/2016] [Accepted: 06/28/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this review was to evaluate current literature for dosing recommendations for the use of antiepileptic medications in patients receiving renal replacement therapy (RRT). DATA SOURCES With the assistance of an experienced medical librarian specialized in pharmacy and toxicology, we searched MEDLINE, EMBASE, CINAHL, Web of Science, WorldCat, and Scopus through May 2016. STUDY SELECTION AND DATA EXTRACTION Four hundred three articles were screened for inclusion, of which 130 were identified as potentially relevant. Micromedex® DRUGDEX as well as package inserts were used to obtain known pharmacokinetic properties and dosage adjustment recommendations in RRT if known. DATA SYNTHESIS Data regarding antiepileptic drug use in RRT are limited and mostly consist of case reports limiting our proposed dosing recommendations. Known pharmacokinetic parameters should guide dosing, and recommendations are provided where possible. CONCLUSION Additional studies are necessary before specific dosing recommendations can be made for most antiepileptic drugs in critically ill patients receiving RRT, specifically with newer agents.
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Affiliation(s)
- Keaton S Smetana
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY.
| | - Aaron M Cook
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Douglas R Oyler
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
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Yamamoto J, Toublanc N, Kumagai Y, Stockis A. Levetiracetam pharmacokinetics in Japanese subjects with renal impairment. Clin Drug Investig 2015; 34:819-28. [PMID: 25312351 DOI: 10.1007/s40261-014-0237-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVE The anti-epileptic drug levetiracetam is excreted renally. The objective of this trial was to evaluate the pharmacokinetics of levetiracetam in Japanese patients with renal impairment including end-stage renal disease (ESRD) to confirm that existing dosing instructions-based on data from European patients-are appropriate in a Japanese population. METHODS This was a nonrandomised, open-label trial. Six participants were allocated to each of five groups (normal renal function, mild, moderate and severe renal impairment and ESRD); 30 participants in total. Participants received a single dose of levetiracetam 500 mg (normal or mild), 250 mg (moderate or severe), or 500 mg followed by 250 mg post-haemodialysis (ESRD). Blood and urine samples were obtained serially for levetiracetam and metabolite determinations. Noncompartmental pharmacokinetic parameters were calculated and steady-state profiles were simulated using the superposition method. RESULTS In this trial, levetiracetam total clearance decreased proportionally with creatinine clearance: 52, 31, 25, 20 and 11 mL/min/1.73 m(2) in healthy controls and in patients with mild, moderate, severe renal impairment, and ESRD, respectively. Simulated levetiracetam plasma profiles using the recommended dose adjustments were within the range for normal renal function. Overall, results from this trial were consistent with historical European data. CONCLUSION These findings confirm that the dosing instructions are appropriate for Japanese patients with renal impairment including ESRD.
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Affiliation(s)
- Junichi Yamamoto
- UCB Pharma, Shinjuku Grand Tower, 8-17-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan,
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Lin CH, Chen CL, Lin TK, Chen NC, Tsai MH, Chuang YC. Levetiracetam in the Treatment of Epileptic Seizures After Liver Transplantation. Medicine (Baltimore) 2015; 94:e1350. [PMID: 26402799 PMCID: PMC4635739 DOI: 10.1097/md.0000000000001350] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
After liver transplantation, patients may develop seizures or epilepsy due to a variety of etiologies. The ideal antiepileptic drugs for these patients are those with fewer drug interactions and less hepatic toxicity. In this study, we present patients using levetiracetam to control seizures after liver transplantation. We retrospectively enrolled patients who received levetiracetam for seizure control after liver transplantation. We analyzed the etiology of liver failure that required liver transplantation, etiology of the seizures, outcomes of seizure control, and the condition of the patient after follow-up at the outpatient department. Hematological and biochemical data before and after the use of levetiracetam were also collected. Fifteen patients who received intravenous or oral levetiracetam monotherapy for seizure control after liver transplantation were enrolled into this study. All of the patients remained seizure-free during levetiracetam treatment. Two patients died during the follow-up, and the other 13 patients were alive at the end of the study period and all were seizure-free without neurological sequelae that interfered with their daily activities. No patients experienced liver failure or rejection of the donor liver due to ineffective immunosuppressant medications. The dosage of immunosuppressants did not change before and after levetiracetam treatment, and there were no changes in hematological and biochemical data before and after treatment. Levetiracetam may be a suitable antiepileptic drug for patients who undergo liver transplantation due to fewer drug interactions and a favorable safety profile.
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Affiliation(s)
- Chih-Hsiang Lin
- From the Department of Neurology (C-HL, T-KL, N-CC, M-HT, Y-CC); Liver Transplantation Program and Department of Surgery (C-LC); Center for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine (C-LC, Y-CC); Department of Biological Science, National Sun Yet-sen University (Y-CC); and Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (Y-CC)
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Anderson GD, Saneto RP. Modified-Release Formulations of Second-Generation Antiepileptic Drugs: Pharmacokinetic and Clinical Aspects. CNS Drugs 2015; 29:669-81. [PMID: 26369919 DOI: 10.1007/s40263-015-0268-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Modified-release or extended-release (XR) formulations are used to decrease the frequency of dosing for drugs with rapid elimination, to improve convenience and adherence. Use of a modified-release formulation can decrease the peak to trough fluctuations in serum concentrations and theoretically improve the therapeutic benefit of the drug, by decreasing adverse events associated with the higher peak concentrations. Once-daily formulations of lamotrigine (Lamictal XR(®)), levetiracetam (Keppra XR(®)), oxcarbazepine (Oxtellar XR(®), Apydan(®) extent) and topiramate (Qudexy XR™, Trokendi XR™) are approved for the treatment of focal and/or generalized onset seizures. Other seizure medications have been approved for non-epileptic symptoms. Gabapentin XR (Gralise(®)) is approved for the treatment of post-herpetic neuralgias. Gabapentin enacarbil XR (Horizant(®)) is a prodrug of gabapentin and is indicated for treatment of post-herpetic neuralgia and restless leg syndrome, a novel indication. For all but Qudexy XR™, the tablets/capsules must be swallowed whole, without cutting, crushing or chewing, in order to maintain the XR properties of the formulation. Qudexy XR™ can be swallowed intact or the capsules can be opened and sprinkled onto soft food for those with swallowing difficulties, for example, children and the elderly. The bioavailability of Gralise(®) and Horizant(®) is significantly affected by food, specifically fat content, and should be taken with a meal to maximize absorption. Overall, the primary advantage of the newly released XR formulations is the once-daily dosing to improve convenience and adherence, with very limited data suggesting improved tolerability.
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Affiliation(s)
- Gail D Anderson
- Department of Pharmacy, University of Washington, Box 357630, Seattle, WA, 98195, USA.
| | - Russell P Saneto
- Division of Pediatric Neurology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
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Freitas-Lima P, Ferreira FIS, Bertucci C, Alexandre Júnior V, Dreossi SAC, Pereira LRL, Sakamoto AC, Queiroz RHC. Stir bar-sorptive extraction, solid phase extraction and liquid-liquid extraction for levetiracetam determination in human plasma: comparing recovery rates. BRAZ J PHARM SCI 2015. [DOI: 10.1590/s1984-82502015000200017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
<p>Levetiracetam (LEV), an antiepileptic drug (AED) with favorable pharmacokinetic profile, is increasingly being used in clinical practice, although information on its metabolism and disposition are still being generated. Therefore a simple, robust and fast liquid-liquid extraction (LLE) followed by high-performance liquid chromatography method is described that could be used for both pharmacokinetic and therapeutic drug monitoring (TDM) purposes. Moreover, recovery rates of LEV in plasma were compared among LLE, stir bar-sorptive extraction (SBSE), and solid-phase extraction (SPE). Solvent extraction with dichloromethane yielded a plasma residue free from usual interferences such as commonly co-prescribed AEDs, and recoveries around 90% (LLE), 60% (SPE) and 10% (SBSE). Separation was obtained using reverse phase Select B column with ultraviolet detection (235 nm). Mobile phase consisted of methanol:sodium acetate buffer 0.125 M pH 4.4 (20:80, v/v). The method was linear over a range of 2.8-220.0 µg mL<sup>-1</sup>. The intra- and inter-assay precision and accuracy were studied at three concentrations; relative standard deviation was less than 10%. The limit of quantification was 2.8 µg mL<sup>-1</sup>. This robust method was successfully applied to analyze plasma samples from patients with epilepsy and therefore might be used for pharmacokinetic and TDM purposes.</p>
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Anderson GD, Hakimian S. Pharmacokinetic of antiepileptic drugs in patients with hepatic or renal impairment. Clin Pharmacokinet 2014; 53:29-49. [PMID: 24122696 DOI: 10.1007/s40262-013-0107-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Many factors influence choice of antiepileptic drugs (AEDs), including efficacy of the drug for the indication (epilepsy, neuropathic pain, affective disorder, migraine), tolerability, and toxicity. The first-generation AEDs and some newer AEDs are predominately eliminated by hepatic metabolism. Other recent AEDs are eliminated by renal excretion of unchanged drug or a combination of hepatic metabolism and renal excretion. The effect of renal and hepatic disease on the dosing will depend on the fraction of the AED eliminated by hepatic and/or renal excretion, the metabolic isozymes involved, as well as the extent of protein binding, if therapeutic drug monitoring is used. For drugs that are eliminated by renal excretion, methods of estimating creatinine clearance can be used to determine dose adjustments. For drugs eliminated by hepatic metabolism, there are no specific markers of liver function that can be used to provide guidance in dosage adjustments. Based on studies with probe drugs, the hepatic metabolic enzymes are differentially affected depending on the cause and severity of hepatic disease, which can aid in predicting dose adjustment when clinical data are not available. Several AEDs are also associated with laboratory markers of mild hepatic dysfunction and, rarely, more severe hepatic injury. In contrast, the risk of renal injury from AEDs is generally low. In general, co-morbid hepatic or renal diseases influence the decision for the selection of an AED. For some patients dosing changes to their existing AEDs may be appropriate. For others, a change to another AED may be a better option.
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The integration of allometry and virtual populations to predict clearance and clearance variability in pediatric populations over the age of 6 years. Clin Pharmacokinet 2014; 52:693-703. [PMID: 23588537 DOI: 10.1007/s40262-013-0065-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Pharmacokinetics play an integral role in the pediatric drug development process. The determination of pharmacokinetic parameters, particularly clearance, in different age groups directly informs dosing strategies for subsequent efficacy trials. Allometric scaling for prediction of pediatric clearance from the observed clearance in adults has been used in this effort. Clinical trial simulation, a powerful tool used to inform clinical trial design, requires both an estimate of clearance along with an estimate of the expected pharmacokinetic variability. The standard deviations (SD) of individual clearance values for adults are typically used and may lead to inaccurate predictions by not taking into account the more widespread distribution of factors such as body weight in the pediatric population. The objective of this study was to assess the accuracy of allometric prediction of drug clearance as well as methods for predicting clearance variability in children 6 years of age and older. METHODS US Food and Drug Administration (FDA) clinical pharmacology reviews of pediatric studies conducted from 2002 onwards were reviewed to collate adult and pediatric clearance and clearance variability for studies including children 6 years of age and older. A set of 1,000 virtual adults {A} and a set of 5,000 virtual children (aged 2-17) {P} were generated on the basis of the White American NHANES database. Pediatric clearances were predicted in method 1 by using the geometric mean adult clearance from the in vivo study and calculating pediatric clearance for each virtual child within a subset {P'} of {P} that contained only those children that were within the age range of the in vivo pediatric study. In method 2, adult clearance values were randomly generated from the geometric mean adult clearance and standard deviation and assigned to each virtual adult in {A}. For each adult, allometric clearance scaling was completed with each virtual child within {P'}. The prediction error for the predicted and observed clearance and the clearance variability metric, coefficient of variation (CV), was calculated. The prediction accuracy as a function of the lowest age range (2 years and older) included in the study was also assessed. RESULTS Thirty-nine unique drugs were included in the study. For both method 1 and method 2, 100 % of predicted pediatric mean clearances were within 2-fold of the observed values and approximately 82 % were within a 30 % prediction error. There was a significant increase in the prediction accuracy of CV using method 2 vs. method 1. There was a major bias towards underprediction of pediatric CV in method 1 whereas method 2 was precise and not biased. Clearance and CV prediction accuracy were not a function of the age range included in the in vivo studies. The observed CV between the adult and pediatric study groups was not significantly different although, on average, the observed pediatric CV was 32 % greater than that from adult studies. CONCLUSIONS Allometric scaling may be a useful tool during pediatric drug development to predict drug clearance and dosing requirements in children 6 years of age and older. A novel methodology is reported that employs virtual adult and pediatric populations and adult pharmacokinetic data to accurately predict clearance variability in specific pediatric subpopulations. This approach has important implications for both clinical trial simulations and sample size determination for pediatric pharmacokinetic studies.
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Stockis A, Lu S, Tonner F, Otoul C. Clinical pharmacology of levetiracetam for the treatment of epilepsy. Expert Rev Clin Pharmacol 2014; 2:339-50. [DOI: 10.1586/ecp.09.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Toublanc N, Lacroix BD, Yamamoto J. Development of an Integrated Population Pharmacokinetic Model for Oral Levetiracetam in Populations of Various Ages and Ethnicities. Drug Metab Pharmacokinet 2014; 29:61-8. [DOI: 10.2133/dmpk.dmpk-13-rg-045] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cook AM, Arora S, Davis J, Pittman T. Augmented Renal Clearance of Vancomycin and Levetiracetam in a Traumatic Brain Injury Patient. Neurocrit Care 2013; 19:210-4. [DOI: 10.1007/s12028-013-9837-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Stockis A, Sargentini-Maier ML, Horsmans Y. Brivaracetam disposition in mild to severe hepatic impairment. J Clin Pharmacol 2013; 53:633-41. [PMID: 23649964 DOI: 10.1002/jcph.82] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 03/12/2013] [Indexed: 12/31/2022]
Abstract
Brivaracetam is a high-affinity synaptic vesicle protein 2A (SV2A) ligand in clinical development for epilepsy. This open-label, single-dose study evaluated brivaracetam disposition in participants with different degrees of hepatic impairment versus matched healthy controls. Twenty-six participants (38-72 years; 19 males and 7 females) with hepatic impairment classified by Child-Pugh score (mild, n = 6; moderate, n = 7; severe, n = 7) or normal hepatic function (n = 6) received a single oral dose of 100 mg brivaracetam. The pharmacokinetics of brivaracetam and its three main metabolites (acid, hydroxy, hydroxyacid) were determined and correlated with impairment severity. Dynamic liver function tests correlated with hepatic impairment severity. The plasma half-life of brivaracetam was 9.8, 14.2, 16.4, and 17.4 hours and the area under the plasma concentration-time curve was 29.7, 44.6, 46.7, and 47.1 µg h/mL in healthy controls and participants with mild, moderate, and severe liver impairment, respectively. Production of the acid metabolite was increased and the hydroxylated metabolites were decreased in participants with hepatic impairment versus healthy controls. Exposure to brivaracetam increased by 50-60% in patients with hepatic impairment, irrespective of severity. The relative importance of biotransformation pathways was altered; cytochrome P450 (CYP)-dependent hydroxylation decreased; CYP-independent acid metabolite formation increased concomitantly.
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Affiliation(s)
- Armel Stockis
- UCB Pharma, Clinical Pharmacology, Braine-l'Alleud, Belgium.
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Peternel L, Kristan K, Petruševska M, Rižner TL, Legen I. Suitability of Isolated Rat Jejunum Model for Demonstration of Complete Absorption in Humans for BCS-Based Biowaiver Request. J Pharm Sci 2012; 101:1436-49. [DOI: 10.1002/jps.23027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 11/22/2011] [Accepted: 12/02/2011] [Indexed: 12/18/2022]
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Komotar RJ, Raper DMS, Starke RM, Iorgulescu JB, Gutin PH. Prophylactic antiepileptic drug therapy in patients undergoing supratentorial meningioma resection: a systematic analysis of efficacy. J Neurosurg 2011; 115:483-90. [DOI: 10.3171/2011.4.jns101585] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Meningiomas are one of the more common intracranial neoplasms. The risk of seizures and secondary aspiration, brain edema, and brain injury often leads practitioners to administer prophylactic antiepileptic drugs (AEDs) perioperatively. The efficacy of this practice remains controversial, however, with prior investigations reaching conflicting results and recent studies focusing on AED side effects. The authors performed a systematic analysis of outcomes following supratentorial meningioma resection with and without prophylactic AED administration in the hope of clarifying the role of AEDs in the perioperative care of patients with these lesions.
Methods
A MEDLINE search of the literature (1979–2010) was performed. Comparisons were made for patient and tumor characteristics as well as success of repair, morbidity, and seizure outcome. Statistical analyses of categorical variables were undertaken using chi-square and Fisher exact tests.
Results
Nineteen studies, involving 698 patients, were included. There were no significant differences in the extent of resection, perioperative mortality, or recurrence between the AED and no-AED cohorts. Likewise, there were no significant differences in the incidence of early or late seizures between the cohorts.
Conclusions
The results of this systematic analysis supports the conclusion that the prophylactic administration of anticonvulsants during resection of supratentorial meningiomas provides no benefit in the prevention of either early or late postoperative seizures. Despite their traditional role in this patient population, the routine use of AEDs should be carefully reconsidered.
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Affiliation(s)
- Ricardo J. Komotar
- 1Department of Neurological Surgery, Memorial Sloan–Kettering Cancer Center, New York, New York
| | | | - Robert M. Starke
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - J. Bryan Iorgulescu
- 1Department of Neurological Surgery, Memorial Sloan–Kettering Cancer Center, New York, New York
| | - Philip H. Gutin
- 1Department of Neurological Surgery, Memorial Sloan–Kettering Cancer Center, New York, New York
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Abstract
Levetiracetam (Keppra®, E Keppra®) is an established second-generation antiepileptic drug (AED). Worldwide, levetiracetam is most commonly approved as adjunctive treatment of partial onset seizures with or without secondary generalization; other approved indications include monotherapy treatment of partial onset seizures with or without secondary generalization, and adjunctive treatment of myoclonic seizures associated with juvenile myoclonic epilepsy and primary generalized tonic-clonic (GTC) seizures associated with idiopathic generalized epilepsy. Levetiracetam has a novel structure and unique mechanisms of action. Unlike other AEDs, the mechanisms of action of levetiracetam appear to involve neuronal binding to synaptic vesicle protein 2A, inhibiting calcium release from intraneuronal stores, opposing the activity of negative modulators of GABA- and glycin-gated currents and inhibiting excessive synchronized activity between neurons. In addition, levetiracetam inhibits N-type calcium channels. Levetiracetam is associated with rapid and complete absorption, high oral bioavailability, minimal metabolism that consists of hydrolysis of the acetamide group, and primarily renal elimination. It lacks cytochrome P450 isoenzyme-inducing potential and is not associated with clinically significant pharmacokinetic interactions with other drugs, including other AEDs. The efficacy of oral immediate-release levetiracetam in controlling seizures has been established in numerous randomized, double-blind, controlled, multicentre trials in patients with epilepsy. Adjunctive levetiracetam reduced the frequency of seizures in paediatric and adult patients with refractory partial onset seizures to a significantly greater extent than placebo. Monotherapy with levetiracetam was noninferior to that with carbamazepine controlled release in controlling seizures in patients with newly diagnosed partial onset seizures. Levetiracetam also provided seizure control relative to placebo as adjunctive therapy in patients with idiopathic generalized epilepsy with myoclonic seizures or GTC seizures. In addition, patients receiving oral levetiracetam showed improvements in measures of health-related quality of life relative to those receiving placebo. Although treatment-emergent adverse events were commonly reported in the clinical trials of levetiracetam, the overall proportion of patients who experienced at least one treatment-emergent adverse event was broadly similar in the levetiracetam and placebo treatment groups, with most events being mild to moderate in severity. Levetiracetam is not associated with cognitive impairment or drug-induced weight gain, but has been associated with behavioural adverse effects in some patients.
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Freitas-Lima P, Alexandre V, Pereira LRL, Feletti F, Perucca E, Sakamoto AC. Influence of enzyme inducing antiepileptic drugs on the pharmacokinetics of levetiracetam in patients with epilepsy. Epilepsy Res 2011; 94:117-20. [DOI: 10.1016/j.eplepsyres.2011.01.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 01/03/2011] [Accepted: 01/08/2011] [Indexed: 11/25/2022]
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Ishii Y, Tanaka T. [Pharmacology and clinical results of levetiracetam (E Keppra(®) Tablets), a new antiepileptic drug]. Nihon Yakurigaku Zasshi 2011; 137:95-102. [PMID: 21321459 DOI: 10.1254/fpj.137.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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LC method for therapeutic drug monitoring of levetiracetam: Evaluation of the assay performance and validation of its application in the routine area. Clin Biochem 2010; 43:473-82. [DOI: 10.1016/j.clinbiochem.2009.10.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 10/22/2009] [Accepted: 10/22/2009] [Indexed: 11/21/2022]
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