Levetiracetam-induced pancytopenia

A retrospective evaluation of phenobarbital-induced hematologic changes in 69 cats

BACKGROUND

Phenobarbital (PB) is used as a first-line treatment for recurrent epileptic seizures in cats. While hematologic abnormalities are well-known side effects of antiepileptic therapy with PB in humans and dogs, little is known about such alterations in cats.

OBJECTIVES

The aim of this retrospective study was to investigate the prevalence and clinical relevance of cytopenia during PB treatment in cats.

METHODS

In this single-center, retrospective clinical study, 69 cats-with suspected idiopathic epilepsy admitted to the Small Animal Clinic of the University of Veterinary Medicine in Vienna (VMU)-were included. A complete blood count for each patient was performed, and changes in hematocrit, leukocytes, neutrophils, and thrombocytes were documented and graded.

RESULTS

Fifty-three out of 69 cats (76.8%) showed cytopenias with a reduction of at least one cell fraction during PB treatment. The most frequent change was neutropenia (60%), followed by leukopenia (49.3%), thrombocytopenia (24.1%), and anemia (20.3%). Most of the changes were mild or moderate; only one patient (1.5%) showed severe leukopenia and neutropenia, and one was a life-threatening neutropenia (1.5%) with a serum PB concentration within or even below the therapeutic range. These patients did not present with clinical symptoms other than those related to epileptic episodes. Cats who received combination therapy showed lower hematocrits than those who received monotherapy. A tendency for leukocytes and neutrophils to decrease during PB treatment was also seen.

CONCLUSIONS

Blood cytopenias may frequently occur in cats on chronic PB therapy, even when serum drug levels are within the therapeutic range. However, clinical signs are typically mild to moderate and rarely severe.

Perampanel-Induced, New-Onset Thrombocytopenia in a Patient With Refractory Seizures: A Case Report

Perampanel (Fycompa) is a glutamate receptor antagonist known to be a safe, effective, and well-tolerated medication; nevertheless, adverse effects are possible. This case report aims to raise the suspicion of perampanel-induced thrombocytopenia and discuss its possible pathways implicated. Here, we present the case of a 66-year-old female patient with a generalized tonic-clonic seizure initially managed with levetiracetam, valproic acid, and lacosamide; however, the patient continued to have seizures clinically as well as on the electroencephalogram. The patient was initiated on 2 mg of perampanel and reached up to 12 mg within a week, after which the seizure was controlled. Nevertheless, after perampanel initiation, a gradual platelet count reduction was observed. Upon withdrawal of perampanel, the platelet count dramatically improved reaching up to her baseline. Although perampanel is known to be a safe medication, a hematological complication such as thrombocytopenia is possible. The exact mechanism remains unclear. Further studies are required to understand the association between thrombocytopenia and perampanel to identify high-risk populations and prevent this condition sequentially.

Severe pancytopenia and coagulopathy discovered during anesthesia after pre-anesthetic evaluation - A report of two cases

BACKGROUND

Pre-anesthetic evaluation is an important aspect of perioperative patient management. However, anesthesiologists often encounter challenges during anesthesia due toconditions that are not detected during pre-anesthetic evaluations.

CASE

Case 1 involved a 74-year-old female patient scheduled for cranioplasty and meningioma excision. Severe pancytopenia was detected during anesthesia. Cranioplasty was onlyperformed, the surgery was terminated, and drug-induced pancytopenia was diagnosed andtreated. The pre-anesthetic test results were normal, except for anemia. Case 2 involved a71-year-old male patient who discovered large ecchymosis during general anesthesia preparation in the operating room for choledochal cyst surgery. Surgery was canceled to evaluatethe bleeding tendency, and acquired coagulation factor VIII deficiency was diagnosed andtreated. The pre-anesthetic tests were normal, except for prolongation of the activated partial thromboplastin time.

CONCLUSIONS

Abrupt hematologic and hemostatic changes may occur during anesthesiaeven though pre-anesthetic evaluation findings are normal.

Associations of levetiracetam use with the safety and tolerability profile of chemoradiotherapy for patients with newly diagnosed glioblastoma

Background

Levetiracetam (LEV) is one of the most frequently used antiepileptic drugs (AED) for brain tumor patients with seizures. We hypothesized that toxicity of LEV and temozolomide-based chemoradiotherapy may overlap.

Methods

Using a pooled cohort of patients with newly diagnosed glioblastoma included in clinical trials prior to chemoradiotherapy (CENTRIC, CORE, AVAglio) or prior to maintenance therapy (ACT-IV), we tested associations of hematologic toxicity, nausea or emesis, fatigue, and psychiatric adverse events during concomitant and maintenance treatment with the use of LEV alone or with other AED versus other AED alone or in combination versus no AED use at the start of chemoradiotherapy and of maintenance treatment.

Results

Of 1681 and 2020 patients who started concomitant chemoradiotherapy and maintenance temozolomide, respectively, 473 and 714 patients (28.1% and 35.3%) were treated with a LEV-containing regimen, 538 and 475 patients (32.0% and 23.5%) with other AED, and 670 and 831 patients (39.9% and 41.1%) had no AED. LEV was associated with higher risk of psychiatric adverse events during concomitant treatment in univariable and multivariable analyses (RR 1.86 and 1.88, P < .001) while there were no associations with hematologic toxicity, nausea or emesis, or fatigue. LEV was associated with reduced risk of nausea or emesis during maintenance treatment in multivariable analysis (HR = 0.80, P = .017) while there were no associations with hematologic toxicity, fatigue, or psychiatric adverse events.

Conclusions

LEV is not associated with reduced tolerability of chemoradiotherapy in patients with glioblastoma regarding hematologic toxicity and fatigue. Antiemetic properties of LEV may be beneficial during maintenance temozolomide.

Delayed Recognition of Levetiracetam-induced Pancytopenia

Blood dyscrasias associated with levetiracetam use can be difficult to identify, especially when other potential differential diagnoses are concurrently present. Here we present a 57-year-old man with metastatic adenocarcinoma of unknown primary origin on levetiracetam who initially presented with an in-stent thrombosis of the right external iliac vein and then developed worsening thrombocytopenia followed by pancytopenia. Levetiracetam was not identified as the culprit until other causes like platelet consumption, heparin-induced thrombocytopenia, idiopathic immune thrombocytopenic purpura, and bone marrow involvement by metastatic disease were ruled out.

LEARNING POINTS

Levetiracetam can cause both acute and delayed-onset pancytopenia through bone marrow suppression.The phenomenon is normally reversible and blood counts improve with drug cessation.Clinicians should consider checking a complete blood profile within a month of drug initiation, particularly in high-risk patients.

Prophylactic levetiracetam-induced pancytopenia with traumatic extra-dural hematoma: Case report

BACKGROUND

Pancytopenia has only rarely been reported with Levetiracetam use. It is a potentially life threatening adverse effect that requires cessation of therapy.

CASE DESCRIPTION

We describe a case of an otherwise well thirty-two-year-old man who underwent an emergent craniotomy for evacuation of a traumatic extra-dural haematoma. Post-operatively, he developed pancytopenia which corrected with cessation of levetiracetam.

CONCLUSION

This report aims to increase awareness of this rare side effect and reiterates the judicious use of prophylactic levetiracetam in brain trauma.

Temozolomide-induced aplastic anaemia and incidental low-grade B-cell non-Hodgkin lymphoma in a geriatric patient with glioblastoma multiforme

Glioblastoma multiforme is an astrocyte-derived tumour representing the most aggressive primary brain malignancy. The median overall survival is 10-12 months, but it drops to 3-8.5 months for the cohort with more than 65 years old, which account to half of all patients. Initial management in this patient population aims to balance overall patient survival and quality of life with the inherent risks of treatment intervention, which include maximal safe tumour resection, radiation and temozolomide (TMZ) chemotherapy. This is accomplished through risk stratification as a function of patient age, functional status, comorbidities, tumour location and methylguanine methyltransferase promoter methylation status. We describe the care of a patient with prolonged febrile neutropaenia, with a rare but fatal complication from TMZ-induced idiosyncratic reaction, leading to aplastic anaemia and a provoking diagnosis of low-grade B-cell non-Hodgkin's lymphoma.

Levetiracetam and lamotrigine effects as mono- and polytherapy on bone mineral density in epileptic patients

OBJECTIVE

The purpose of this study was to determine the effect of lamotrigine (LTG) and levetiracetam (LEV) as mono- and polytherapy on biochemical markers of bone turnover and bone mineral density in Egyptian adult patients with epilepsy.

METHODS

Forty-eight patients were divided into four groups: two received monotherapy of either LTG or LEV, and the other two groups received polytherapy comprising (valproate [VPA] + LTG or VPA + LEV). Thirty matched healthy participants were included in the study. Participants completed a nutritional and physical activity questionnaire. Biochemical markers of bone and mineral metabolism and bone mineral density of the lumbar spine were measured at baseline and at six months.

RESULTS

In the LEV monotherapy group, the bone formation markers showed a significant decrease in serum alkaline phosphatase and serum osteocalcin levels while the bone resorption marker showed a significant increase in urinary deoxypyridinoline levels. After six months of treatment, bone mineral density showed a significant decrease in all treated groups, while among monotherapy groups, this significant decrease was more prevalent in the LEV monotherapy group compared with the LTG monotherapy group. Furthermore, there was significant negative correlation between urinary deoxypyridinoline levels and bone mineral density in the LEV monotherapy group.

CONCLUSION

Using new generation antiepileptics, LEV monotherapies and polytherapy showed harmful effects on bone but LTG did not.

Levetiracetam Adverse Drug Reaction: Pancytopenia

Pancytopenia secondary to levetiracetam administration is infrequent but possible. Here, we report a case of pancytopenia associated with levetiracetam in a 4-month-old infant. However, increased incidence of upper respiratory tract infections (URTIs) has been reported frequently. It appears that URTI is a heralding side effect of pancytopenia and tip of the iceberg.

Herbal approach in the treatment of pancytopenia

Pancytopenia is a health condition in which there is a reduction in the amount of leucocytes, erythrocytes and thrombocytes. If more than one of the blood cells is low then the condition is called as bicytopenia. The pancytopenic condition is observed in treatment of diseased conditions like thalassemia and hepatitis C. Iatrogenically pancytopenia is caused by some antibiotics and anti-HCV drugs. Medical conditions like aplastic anaemia, lymphoma, copper deficiency, and so forth can also cause pancytopenia. Pancytopenia can in turn decrease the immunity of the person and thereby can be fatal. Current therapies for pancytopenia include bone marrow stimulant drugs, blood transfusion and bone marrow transplant. The current therapies are very excruciating and have long-term side-effects. Therefore, treating these condition using herbal drugs is very important. Herbs like wheatgrass, papaya leaves and garlic are effective in treating single lineage cytopenias. The present review is focused on the potential effects of natural herbs for the treatment of pancytopenia.

Antiepilepsy drugs and the immune system

OBJECTIVE

To alert physicians about the peculiar adverse effects of antiepilepsy drugs (AEDs) on the immune system.

DATA SOURCES

PubMed literature during the past 25 years.

STUDY SELECTIONS

Reports and review articles on the hypersensitivities of AEDs and their effect on immunity.

RESULTS

AEDs have significant effects on the immune system in the form of hypersensitivity or immune suppression. IgE-mediated reactions can be urticaria, angioedema, bronchospasm, or anaphylaxis. Non-IgE-mediated reactions, more commonly associated with aromatic AEDs, can be in the form of nonspecific rashes or serious reactions, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptom syndrome, and acute generalized exanthematous pustulosis. Because of strong genetic predispositions for certain AEDs in causing severe reactions, HLA analysis before initiation of the drug is advised in certain populations. Immunoglobulin levels can be reduced to various degrees, particularly by carbamazepine, valproate, phenytoin, levetiracetam, zonisamide, and lamotrigine. Spontaneous return to normal levels can be rapid or take months to a few years, and intravenous immunoglobulin supplementation may be needed. Cellular effects can be in the form of cytopenias, inhibition of lymphocyte function, or cytokine dysregulation.

CONCLUSION

When prescribing AEDs, physicians should pay special attention to their potential adverse effects on immunity or hypersensitivity, which can be severe and even fatal. For early recognition and intervention, monitoring such patients is necessary. The cornerstone of management is discontinued use of the suspected medication and avoidance of drugs of similar structure, particularly among members of the aromatic group.

Pancytopenia associated with levetiracetam in an epileptic woman

Haematological toxicity due to antiepileptic drugs is uncommon, but the increased risk of aplastic anaemia has been reported. Few case reports have been published regarding pancytopenia associated with levetiracetam treatment, and its intrinsic pathogenesis is still unknown. We describe the case of a woman aged 77 years who presented with abdominal pain and loss of appetite. She had been taking valproic acid, due to a previous episode of epileptic seizures, and presented with drowsiness and dizziness. Valproate was discontinued and therapy with levetiracetam was initiated. 2 days later, we observed severe anaemia, leucopenia and thrombocytopenia, which were attributed to levetiracetam. Although she recovered soon after the treatment was discontinued, it took 2 weeks for cell counts to return to normal.