1
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Jalilian Khave L, Noori M, Rahimi-Movaghar A, Noroozi A. Management of gabapentin misuse in a patient with previous history of opioid use disorder: Case report. Asian J Psychiatr 2023; 80:103322. [PMID: 36423434 DOI: 10.1016/j.ajp.2022.103322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/10/2022] [Indexed: 11/13/2022]
Abstract
We present a 37-year-old male who misuses 12 g of gabapentin per day associated with dependence and withdrawal. He had a previous history of opioid use disorder (OUD) which has been in remission. An outpatient gradual dose reduction regimen was tried and failed and the patient decided to discontinue gabapentin abruptly. Symptomatic medication to relieve gabapentin withdrawal was also unsuccessful and resulted in the reinstatement of OUD. Finally, the patient was stabilized using buprenorphine maintenance treatment and discontinued opioids and gabapentin misuse. The clinical implications and significance of taking regulatory actions to control gabapentin misuse have been discussed.
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Affiliation(s)
- Laya Jalilian Khave
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.; Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehri Noori
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Noroozi
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran.
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2
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Evoy KE, Peckham AM, Covvey JR, Tidgewell KJ. Gabapentinoid Pharmacology in the Context of Emerging Misuse Liability. J Clin Pharmacol 2021; 61 Suppl 2:S89-S99. [PMID: 34396549 DOI: 10.1002/jcph.1833] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/13/2021] [Indexed: 12/15/2022]
Abstract
This article will review the epidemiology and pharmacology of gabapentinoids (gabapentin and pregabalin) relevant to their emerging misuse potential and provide guidance for clinical and regulatory management. Gabapentinoids are γ-aminobutyric acid analogues that produce their therapeutic effects by inhibiting voltage-gated calcium channels and decreasing neurotransmitter release. Recently gabapentinoid prescribing and use have increased tremendously. Although traditionally thought to possess a favorable safety profile, gabapentinoid misuse has also risen significantly. Gabapentinoid misuse generally occurs in combination with other substances, most notably opioids, and may be for purposes of eliciting euphoric effects, enhancing the effects of other substances, or self-treating conditions such as withdrawal, pain, anxiety, or insomnia. Given its faster onset, increased bioavailability and potency, and nonsaturable absorption, pregabalin's pharmacokinetics theoretically enhance its misuse liability versus gabapentin. However, gabapentin can produce similar euphoric effects, and epidemiologic studies have identified higher rates of gabapentin misuse in the United States, likely because of greater availability and less regulated prescribing. Although adverse events of gabapentinoid-only ingestion are relatively benign, a growing body of evidence indicates that gabapentinoids significantly increase opioid-related morbidity and mortality when used concomitantly. In addition, significant withdrawal effects may occur on abrupt discontinuation. As a result of these trends, several US states have begun to further regulate gabapentinoid prescribing, reclassifying it as a controlled substance or mandating reporting to local prescription drug-monitoring programs. Although increased regulation of gabapentin prescribing may be warranted, harm reduction efforts and increased patient and provider education are necessary to mitigate this concerning gabapentinoid misuse trend.
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Affiliation(s)
- Kirk E Evoy
- The University of Texas at Austin College of Pharmacy, Austin, Texas, USA.,University Health System, San Antonio, Texas, USA
| | - Alyssa M Peckham
- School of Pharmacy, Northeastern University, Boston, Massachusetts, USA.,Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jordan R Covvey
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kevin J Tidgewell
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
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3
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Wang Z, Zhao M, Gao S. Epileptic Seizures After Allogeneic Hematopoietic Stem Cell Transplantation. Front Neurol 2021; 12:675756. [PMID: 34335446 PMCID: PMC8322618 DOI: 10.3389/fneur.2021.675756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
Technique in allogeneic hematopoietic stem cell transplantation has greatly advanced over the past decades, which has led to an increase in the number of patients receiving transplantation, but the complex procedure places these transplant recipients at high risk of a large spectrum of complications including neurologic involvement. As a common manifestation of neurological disorders, epileptic seizures after transplantation have been of great concern to clinicians because it seriously affects the survival rate and living quality of those recipients. The aim of this review is to elucidate the incidence of seizures after allogeneic hematopoietic stem cell transplantation, and to further summarize in detail its etiologies, possible mechanisms, clinical manifestations, therapeutic schedule, and prognosis, hoping to improve doctors' understandings of concurrent seizures following transplantation, so they can prevent, process, and eventually improve the survival and outlook for patients in a timely manner and correctly.
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Affiliation(s)
- Zhuo Wang
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Munan Zhao
- Department of Oncology, The First Hospital of Jilin University, Changchun, China
| | - Sujun Gao
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
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4
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Rogala BG, Charpentier MM, Nguyen MK, Landolf KM, Hamad L, Gaertner KM. Oral Anticancer Therapy: Management of Drug Interactions. J Oncol Pract 2020; 15:81-90. [PMID: 30763198 DOI: 10.1200/jop.18.00483] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Oral anticancer therapy is increasingly integrated into the care of patients with cancer. Recognition and management of drug-drug interactions (DDIs) is critical to providing efficacious and safe anticancer treatment. DDIs with QTc-prolonging agents, anticoagulants, enzyme inducers and inhibitors, antidepressants, and acid suppressants are commonly encountered with anticancer therapies. Here, we review frequently observed DDIs and outline literature-supported suggestions for their management.
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Affiliation(s)
| | | | | | | | - Lamya Hamad
- 4 Roswell Park Cancer Institute, Buffalo, NY
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5
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Grossi E, Tavano Blessi G, Sacco PL. Magic Moments: Determinants of Stress Relief and Subjective Wellbeing from Visiting a Cultural Heritage Site. Cult Med Psychiatry 2019; 43:4-24. [PMID: 29998384 DOI: 10.1007/s11013-018-9593-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We provide an experimental evaluation of the impact of aesthetic experiences in terms of stress reduction (cortisol levels) and wellbeing increase. The test experience is a visit to the vault of the Sanctuary of Vicoforte, Italy. Data have been collected using a double step method. A structured interview in relation to the individual subjective well-being has been administered to a sample of 100 subjects. In addition, a sample of their saliva has been taken, and its cortisol level measured, before and after the experience, and likewise for momentary wellbeing measured on a Visual Analogous Scale. Subjects reported an average increase of 40% in wellbeing and a decrease of the 60% in the cortisol level. The recorded cortisol level values dropped on average well beyond the decrease normally associated to its circadian cycle. The modulating role of various variables has been appreciated, and profiling of the typical subjects who are wellbeing respondents/non-respondents and cortisol respondents/non-respondents has been carried out. We conclude that aesthetic experience seems to have a noticeable impact on individual physical and mental health. In both dominions, cultural participation intensity is significantly correlated to the response. The study underlines the potential of the arts and culture as a new platform for public health practices and new approaches to welfare policy design.
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Affiliation(s)
- Enzo Grossi
- Villa Santa Maria Institute, Tavernerio, Italy
| | | | - Pier Luigi Sacco
- IULM University, Milan, Italy.
- FBK-IRVAPP, Trento, Italy.
- Harvard University and MetaLAB (at) Harvard, Cambridge, MA, USA.
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6
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Vu LC, Piccenna L, Kwan P, O'Brien TJ. New-onset epilepsy in the elderly. Br J Clin Pharmacol 2018; 84:2208-2217. [PMID: 29856080 PMCID: PMC6138506 DOI: 10.1111/bcp.13653] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/02/2018] [Accepted: 05/02/2018] [Indexed: 12/30/2022] Open
Abstract
People who are 60 years old and older have the highest incidence of developing new-onset epilepsy. The increase of the ageing population has resulted in a greater number of patients with new-onset epilepsy or at risk of developing the condition. Previously published review articles regarding epilepsy in older patients have had a broad focus, including people who were diagnosed with epilepsy in their childhood or middle age. The present review focuses on the causes, treatment, prognosis and psychosocial impact of new-onset epilepsy in people aged ≥60 years. Following a search of the medical electronic databases and relevant references, we identified 22 studies overall that met the inclusion criteria. Only four randomized clinical trials (RCTs) were identified that compared different antiepileptic drug treatments in this population, demonstrating that newer-generation antiepileptic drugs (e.g. lamotrigine and levetiracetam) were generally better tolerated. One uncontrolled study provided promising evidence of good outcomes and safety for surgical resection as a treatment for people with uncontrolled seizures. Five studies reported that people ≥60 years with new-onset epilepsy have significant cognitive impairments (e.g. memory loss) and psychological issues including depression, anxiety and fatigue. We found that there is limited evidence to guide treatment in people with Alzheimer's disease and epilepsy. The specific features of new-onset epilepsy in this target population significantly influences the choice of treatment. Cognitive and psychiatric screening before treatment may be useful for management. Two studies with proposed guidelines were identified but no formal clinical practice guidelines exist for this special population to assist with appropriate management. There is a need for more RCTs that investigate effective treatments with limited side effects. More research studies on the psychosocial effects of new-onset epilepsy, and long-term outcomes, for people aged ≥60 years are also required.
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Affiliation(s)
- Lily Chi Vu
- Melbourne Brain Centre at the Royal Melbourne Hospital; Departments of Medicine and Neurology, Royal Melbourne HospitalUniversity of MelbourneMelbourneVictoria3050Australia
| | - Loretta Piccenna
- Departments of Neuroscience and Neurology, Central Clinical SchoolMonash University, The Alfred HospitalMelbourneVictoria3004Australia
| | - Patrick Kwan
- Melbourne Brain Centre at the Royal Melbourne Hospital; Departments of Medicine and Neurology, Royal Melbourne HospitalUniversity of MelbourneMelbourneVictoria3050Australia
- Departments of Neuroscience and Neurology, Central Clinical SchoolMonash University, The Alfred HospitalMelbourneVictoria3004Australia
| | - Terence J. O'Brien
- Melbourne Brain Centre at the Royal Melbourne Hospital; Departments of Medicine and Neurology, Royal Melbourne HospitalUniversity of MelbourneMelbourneVictoria3050Australia
- Departments of Neuroscience and Neurology, Central Clinical SchoolMonash University, The Alfred HospitalMelbourneVictoria3004Australia
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7
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EPICON consensus: Recommendations for proper management of switching to eslicarbazepine acetate in epilepsy. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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8
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Röth A, Maciejewski J, Nishimura JI, Jain D, Weitz JI. Screening and diagnostic clinical algorithm for paroxysmal nocturnal hemoglobinuria: Expert consensus. Eur J Haematol 2018. [DOI: 10.1111/ejh.13059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Deepak Jain
- Alexion Pharmaceuticals, Inc.; New Haven CT USA
| | - Jeffrey I. Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute; Hamilton ON Canada
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9
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Kılıç B, Güngör S, Arslan M, Selimoğlu MA, Yılmaz S. Seizures in Pediatric Patients With Liver Transplant and Efficacy of Levetiracetam. J Child Neurol 2017; 32:740-745. [PMID: 28420301 DOI: 10.1177/0883073817703502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to evaluate the risk factors, clinical implications, and prognosis of new-onset seizures that occurred after pediatric liver transplantation, and to assess the efficacy of levetiracetam treatment. The clinical and laboratory data of liver transplanted 28 children who had seizures after liver transplantation and specifically of 18 children who received levetiracetam were analyzed retrospectively. Sixteen patients (88.9%) remained seizure-free and in 2 (11.1%), more than 50% reduction in seizures were detected with levetiracetam treatment. In conclusion, seizures are generally the most common complication by a spectrum of seizure types, and sometimes cause symptomatic epilepsy. The most common risk factors for seizures in transplant recipients is immunosuppressant toxicity. Currently, there isn't a specific treatment involving the transplant patient population. Levetiracetam may be preferable in pediatric patients as it's reliable for liver disease and has advantages in the treatment of postoperative seizures due to its intravenous usage.
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Affiliation(s)
- Betül Kılıç
- 1 Inönü University, Faculty of Medicine, Department of Pediatric Neurology, Malatya, Turkey
| | - Serdal Güngör
- 1 Inönü University, Faculty of Medicine, Department of Pediatric Neurology, Malatya, Turkey
| | - Müjgan Arslan
- 1 Inönü University, Faculty of Medicine, Department of Pediatric Neurology, Malatya, Turkey
| | - Mukadder Ayşe Selimoğlu
- 2 Inönü University, Faculty of Medicine, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Malatya, Turkey
| | - Sezai Yılmaz
- 3 Inönü University, Faculty of Medicine, Department of Surgery, Malatya, Turkey
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10
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EPICON consensus: recommendations for proper management of switching to eslicarbazepine acetate in epilepsy. Neurologia 2016; 33:290-300. [PMID: 27349151 DOI: 10.1016/j.nrl.2016.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/05/2016] [Accepted: 04/10/2016] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The objective of the EPICON Project is to develop a set of recommendations on how to adequately switch from carbamazepine (CBZ) and oxcarbazepine (OXC) to eslicarbazepine acetate (ESL) in some patients with epilepsy. METHODS A steering committee drafted a questionnaire of 56 questions regarding the transition from CBZ or OXC to ESL in clinical practice (methodology and change situation). The questionnaire was then distributed to 54 epilepsy experts in 2 rounds using the Delphi method. An agreement/disagreement consensus was defined when a median ≥ 7 points or ≤ 3 was achieved, respectively, and a relative interquartile range ≤ 0.40. We analysed the results obtained to reach our conclusions. RESULTS Our main recommendations were the following: switching from CBZ to ESL must be carried out over a period of 1 to 3 weeks with a CBZ:ESL dose ratio of 1:1.3 and is recommended for patients who frequently forget to take their medication, those who work rotating shifts, polymedicated patients, subjects with cognitive problems, severe osteoporosis-osteopaenia, dyslipidaemia, or liver disease other than acute liver failure, as well as for men with erectile dysfunction caused by CBZ. The transition from OXC to ESL can take place overnight with an OXC:ESL dose ratio of 1:1 and it is recommended for patients who frequently forget to take their medication, those who work rotating shifts, polymedicated patients, or those with cognitive problems. The transition was not recommended for patients with prior rash due to CBZ or OXC use. CONCLUSION The EPICON Project offers a set of recommendations about the clinical management of switching from CBZ or OXC to ESL, using the Delphi method.
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11
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Karlov VA, Guekht AB, Guzeva VI, Lipatova LV, Bazilevich SN, Mkrtchyan VR, Vlasov PN, Zhidkova IA, Mukhin KY, Petrukhin AS, Lebedeva AV. [Algorithms of mono- and polytherapy in clinical epileptology]. Zh Nevrol Psikhiatr Im S S Korsakova 2016. [PMID: 28635941 DOI: 10.17116/jnevro201611671120-129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The large number of antiepileptic drugs (AEDs) at the physician's disposal provides not only a broad therapeutic potential in the treatment of epilepsy (EP), but creates difficulties in the adequate choice of AED. The sufficient experience in the management of patients with epilepsy has been gained so far in the world, based on which the International League Against Epilepsy (ILAE), updated classification, adopted the basic definition of efficiency, remission, resistance, evidence of research on the effectiveness of AED therapy, and introduced the concept of "resolved" epilepsy. In this article, a group of Russian experts suggest recommendations on the main steps in the choice of therapy in epilepsy. Possible drug interactions between different AEDs and other drugs as well as main characteristics of mono- and polytherapy of epilepsy are described. Some features of the use of AEDs in the elderly, characteristics of the "female" epilepsy related to the reproductive function and basic requirements for the therapy of epilepsy in children are presented.
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Affiliation(s)
- V A Karlov
- Evdokimov Moscow State Medical and Dentistry University, Moscow, Russia
| | - A B Guekht
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V I Guzeva
- Saint-Petersburg State Medical Academy, St. Petersburg, Russia
| | - L V Lipatova
- Bekhterev Saint-Petersburg Research Psychoneurological Institute, St. Petersburg, Russia
| | | | - V R Mkrtchyan
- Soloviev Scientific-Practical Psycho-Neurological Сenter, Moscow, Russia
| | - P N Vlasov
- Evdokimov Moscow State Medical and Dentistry University, Moscow, Russia
| | - I A Zhidkova
- Evdokimov Moscow State Medical and Dentistry University, Moscow, Russia
| | - K Yu Mukhin
- Svt. Luka's Institute of Child Neurology and Epilepsy, Moscow, Russia
| | - A S Petrukhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Lebedeva
- Pirogov Russian National Research Medical University, Moscow, Russia
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Abstract
Characteristics of using valproic acid drugs in women, from puberty to menopause period, are reviewed. Based on initial treatment efficacy, type of epileptic seizures and a form of epilepsy, the author emphasizes the practical use of valproates during pregnancy in dependence on the situation. Several scenarios of pregnancy course and possible treatment tactics are presented.
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Affiliation(s)
- P N Vlasov
- Evdokimov Moscow State University of Medical Dentistry, Moscow
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13
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Ben-Menachem E. Medical management of refractory epilepsy-Practical treatment with novel antiepileptic drugs. Epilepsia 2014; 55 Suppl 1:3-8. [DOI: 10.1111/epi.12494] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2013] [Indexed: 01/21/2023]
Affiliation(s)
- Elinor Ben-Menachem
- Institute of Clinical Neuroscience and Physiology; Sahlgrenska University Hospital; Goteborg Sweden
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14
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Abstract
The objective of this modeling study was to assess different dosage regimens that might be used to guide clinicians in transitioning patients from gabapentin to pregabalin therapy when such a transition is clinically warranted. Two different gabapentin to pregabalin transition designs were simulated based on their respective population pharmacokinetic profiles. The first design involved immediate discontinuation of gabapentin therapy with initiation of pregabalin therapy at the next scheduled dose period. The second design featured a gradual transition involving coadministration of 50% of the gabapentin dosage and 50% of the desired pregabalin dosage for 4 days, followed by discontinuation of gabapentin and fully targeted dosages of pregabalin. Both transition designs were studied at 3 dosage levels: gabapentin 900 mg/d to pregabalin 150 mg/d, gabapentin 1800 mg/d to pregabalin 300 mg/d, and gabapentin 3600 mg/d to pregabalin 600 mg/d. Overall drug exposure achieved during the 2 transition designs was the sum of the gabapentin and pregabalin concentrations, expressed as pregabalin-equivalent concentrations. The pharmacokinetic simulations show that during the transition period in both designs, predicted pregabalin-equivalent concentrations did not depart from those calculated during periods of steady-state gabapentin or pregabalin monotherapy. Transition from gabapentin to pregabalin was seamless and rapid, with predicted pregabalin-equivalent concentrations highly comparable with plasma pregabalin concentrations within 1 day of pregabalin initiation in the immediate discontinuation model and within 1 day of gabapentin cessation in the gradual discontinuation model. These data suggest that transitioning patients from gabapentin to pregabalin could theoretically be achieved by either of the 2 approaches assessed.
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Abstract
OPINION STATEMENT Solid organ transplantation is frequently complicated by a spectrum of seizure types, including single partial-onset or generalized tonic-clonic seizures, acute repetitive seizures or status epilepticus, and sometimes the evolution of symptomatic epilepsy. There is currently no specific evidence involving the transplant patient population to guide the selection, administration, or duration of antiepileptic drug (AED) therapy, so familiarity with clinical AED pharmacology and application of sound judgment are necessary for successful patient outcomes. An initial detailed search for symptomatic seizure etiologies, including metabolic, infectious, cerebrovascular, and calcineurin inhibitor treatment-related neurotoxic complications such as posterior reversible encephalopathy syndrome (PRES), is imperative, as underlying central nervous system disorders may impose additional serious risks to cerebral or general health if not promptly detected and appropriately treated. The mainstay for post-transplant seizure management is AED therapy directed toward the suspected seizure type. Unfavorable drug interactions could place the transplanted organ at risk, so choosing an AED with limited interaction potential is also crucial. When the transplanted organ is dysfunctional or vulnerable to rejection, AEDs without substantial hepatic metabolism are favored in post-liver transplant patients, whereas after renal transplantation, AEDs with predominantly renal elimination may require dosage adjustment to prevent adverse effects. Levetiracetam, gabapentin, pregabalin, and lacosamide are drugs of choice for treatment of partial-onset seizures in post-transplant patients given their efficacy spectrum, generally excellent tolerability, and lack of drug interaction potential. Levetiracetam is the drug of choice for primary generalized seizures in post-transplant patients. When intravenous drugs are necessary for acute seizure management, benzodiazepines and fosphenytoin are the traditional and best evidence-based options, although intravenous levetiracetam, valproate, and lacosamide are emerging options. Availability of several newer AEDs has greatly expanded the therapeutic armamentarium for safe and efficacious treatment of post-transplant seizures, but future prospective clinical trials and pharmacokinetic studies within this specific patient population are needed.
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16
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Sánchez-Álvarez J, Mauri-Llerda J, Gil-Nagel A, Casas-Fernández C, Salas-Puig J, Lahuerta J, Sancho-Rieger J. Consensus-recommended diagnostic and therapeutic guidelines for drug-resistant epilepsy in Spain (Consenso RATE-España). NEUROLOGÍA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.nrleng.2011.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Sánchez-Álvarez JC, Mauri-Llerda JA, Gil-Nagel A, Casas-Fernández C, Salas-Puig J, Lahuerta J, Sancho-Rieger J. Consensus-recommended diagnostic and therapeutic guidelines for drug-resistant epilepsy in Spain (Consenso RATE-España). Neurologia 2011; 27:481-90. [PMID: 22078652 DOI: 10.1016/j.nrl.2011.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 09/06/2011] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVE To ascertain the opinions of an Epilepsy Expert Group and prepare a consensus document on the definition of drug-resistant epilepsy (DRE) according to the International League Against Epilepsy (ILAE) and the different healthcare levels for the patient with epilepsy in Spain. MATERIAL AND METHODS The study was conducted using the Delphi method, by means of successive rounds of questionnaires. A scientific committee prepared a preliminary document and fourteen associated questions, which were sent by e-mail to the panel of experts. They included items related to the concept of DRE, health care levels and the route between these levels for patients with DRE. RESULTS A total of 41 experts answered the questionnaire. They agreed regarding the necessity and applicability of the DRE definition according to the ILAE, the need for an expert panel on epilepsy, specialist epilepsy clinics, and clinical epilepsy units stratified depending on the level of activities they carried out. There was moderate consensus on the resources and activity of the clinical units of reference and there was no consensus on the referral of patients who have suffered an epileptic seizure to an epilepsy clinic. CONCLUSIONS The expert panel agreed with the definition of DRE according to the ILAE and on referring patients with DRE for a detailed study in an epilepsy clinic or epilepsy clinical unit. They highlighted the need for video-EEG monitoring in the study of patients with DRE and the need to propose other forms of treatment in selected patients.
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Affiliation(s)
- J C Sánchez-Álvarez
- Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico Universitario San Cecilio, Granada, España.
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18
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St. Louis EK. The Art of Managing Conversions between Antiepileptic Drugs: Maximizing Patient Tolerability and Quality of Life. Pharmaceuticals (Basel) 2010; 3:2956-2969. [PMID: 27713385 PMCID: PMC2946260 DOI: 10.3390/ph3092956] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 08/12/2010] [Accepted: 09/02/2010] [Indexed: 11/16/2022] Open
Abstract
Conversion between anti-epilectic drugs (AEDs) is frequently necessary in epilepsy care, exposing patients to a risk of incurring adverse effects and reduced quality of life. Little practical guidance is available to practitioners to guide conversions between AED monotherapies, or in adding a new adjunctive AED into a polytherapy regimen. This article reviews the impact of adverse effects of AEDs on quality of life in epilepsy patients, then reviews several important patient-related factors such as age, gender, medical and psychiatric co-morbidities, and co-medications that must be considered when selecting AEDs and ensuring tolerable and safe AED conversions. Practical strategies for transitional polytherapy AED conversion are then considered in different commonly encountered clinical scenarios in newly diagnosed and refractory epilepsy care, including inadequate seizure control, intolerable adverse effects, or idiosyncratic safety hazards. Successful conversion between AEDs requires regular monitoring for patient-reported adverse effects and appropriately reactive adjustment of AED therapy to maximize patient quality of life.
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Affiliation(s)
- Erik K. St. Louis
- Department of Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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19
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St Louis EK, Rosenfeld WE, Bramley T. Antiepileptic drug monotherapy: the initial approach in epilepsy management. Curr Neuropharmacol 2010; 7:77-82. [PMID: 19949565 PMCID: PMC2730009 DOI: 10.2174/157015909788848866] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2008] [Revised: 04/23/2009] [Accepted: 05/19/2009] [Indexed: 11/22/2022] Open
Abstract
Antiepileptic drug (AED) monotherapy is the preferred initial management approach in epilepsy care, since most patients may be successfully managed with the first or second monotherapy utilized. This article reviews the rationale and evidence supporting preferential use of monotherapy when possible and guidelines for initiating and successfully employing AED monotherapy. Suggested approaches to consider when patients fail monotherapy include substituting a new AED monotherapy, initiating chronic maintenance AED polytherapy, or pursuit of non-pharmacologic treatments such as epilepsy surgery or vagus nerve stimulation. Reducing AED polytherapy to monotherapy frequently reduces the burden of adverse effects and may also improve seizure control. AED monotherapy remains the optimal approach for managing most patients with epilepsy.
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St Louis EK. Monotherapy to polytherapy: antiepileptic drug conversions through the spectrum of epilepsy care. Curr Neuropharmacol 2010; 7:75-6. [PMID: 19949564 PMCID: PMC2730008 DOI: 10.2174/157015909788848910] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The process of conversion between AED monotherapies is frequently necessary in epilepsy care, yet little practical guidance is available to practitioners. This article introduces an issue of Current Neuropharmacology devoted to the theme of AED conversions and related issues. In this series of articles, we reviewed the role of AED monotherapy in newly diagnosed epilepsy, the practice of transitional polytherapy during AED monotherapy conversions in patients experiencing breakthrough seizures or adverse effects, chronic maintenance polytherapy for refractory epilepsy, and the related topics of strategies for minimizing adverse effects, appropriate blood level monitoring, and patient-related factors in AED conversions. Successful conversion between AED monotherapies and polytherapy drug sequencing requires that practitioners possess and apply a thorough knowledge of epilepsy, AED pharmacology, and clinical reasoning, while being sensitive and reactive to patient reported adverse effects of treatment.
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St Louis EK. Truly "rational" polytherapy: maximizing efficacy and minimizing drug interactions, drug load, and adverse effects. Curr Neuropharmacol 2009; 7:96-105. [PMID: 19949567 PMCID: PMC2730011 DOI: 10.2174/157015909788848929] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Revised: 04/23/2009] [Accepted: 05/19/2009] [Indexed: 11/22/2022] Open
Abstract
While several newer AEDs have study data that support monotherapy usage, most possess FDA indications for adjunctive treatment of partial onset seizures, leading to their initial (and often persistent) clinical use as adjunctive polytherapy for patients with refractory epilepsy. This review considers a practical approach to the appropriate role for polytherapy in epilepsy, presents the evidence for AED polytherapy, reviews the mythic but practically reasonable concept of "rational polytherapy," and concludes with practical strategies for avoiding and employing polytherapy in clinical practice. The appropriate indications for AED polytherapy include transitional polytherapy during titration of a new adjunctive AED toward monotherapy or long-term maintenance AED polytherapy in medically refractory epilepsy.
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Garnett WR, St Louis EK, Henry TR, Bramley T. Transitional polytherapy: tricks of the trade for monotherapy to monotherapy AED conversions. Curr Neuropharmacol 2009; 7:83-95. [PMID: 19949566 PMCID: PMC2730010 DOI: 10.2174/157015909788848884] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Revised: 04/23/2009] [Accepted: 05/19/2009] [Indexed: 01/31/2023] Open
Abstract
The goal of epilepsy therapy is to help patients achieve seizure freedom without adverse effects. While monotherapy is preferable in epilepsy treatment, many patients fail a first drug due to lack of efficacy or failure to tolerate an initial medication, necessitating an alteration in therapy. Sudden changes between monotherapies are rarely feasible and sometimes deleterious given potential hazards of acute seizure exacerbation or intolerable adverse effects. The preferred method for converting between monotherapies is transitional polytherapy, a process involving initiation of a new antiepileptic drug (AED) and adjusting it toward a target dose while maintaining or reducing the dose of the baseline medication. A fixed-dose titration strategy of maintaining the baseline drug dose while titrating the new medication is preferable when breakthrough seizures are occurring and no adverse effects are present. However, a flexible titration strategy involving reduction of the baseline drug dose to ensure adequate tolerability of the new adjunctive medication is preferred when patients are already experiencing adverse effects. This article reviews pharmacokinetic considerations pertinent for ensuring successful transitional polytherapy with the standard and newer antiepileptic drugs. Practical consensus recommendations "from an expect panel (SPECTRA, Study by a Panel of Experts Considerations for Therapy Replacement and Antiepileptics) for a successful monotherapy" AED conversions are then summarized. Transitional polytherapy is most successful when clinicians appropriately manage the titration strategy and consider pharmacokinetic factors germane to the baseline and new adjunctive medication.
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St Louis EK, Louis EK. Minimizing AED adverse effects: improving quality of life in the interictal state in epilepsy care. Curr Neuropharmacol 2009; 7:106-14. [PMID: 19949568 PMCID: PMC2730001 DOI: 10.2174/157015909788848857] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Revised: 04/23/2009] [Accepted: 05/19/2009] [Indexed: 11/22/2022] Open
Abstract
The goals of epilepsy therapy are to achieve seizure freedom while minimizing adverse effects of treatment. However, producing seizure-freedom is often overemphasized, at the expense of inducing adverse effects of treatment. All antiepileptic drugs (AEDs) have the potential to cause dose-related, "neurotoxic" adverse effects (i.e., drowsiness, fatigue, dizziness, blurry vision, and incoordination). Such adverse effects are common, especially when initiating AED therapy and with polytherapy. Dose-related adverse effects may be obviated in most patients by dose reduction of monotherapy, reduction or elimination of polytherapy, or substituting for a better tolerated AED. Additionally, all older and several newer AEDs have idiosyncratic adverse effects which usually require withdrawal in an affected patient, including serious rash (i.e., Stevens-Johnson Syndrome, toxic epidermal necrolysis), hematologic dyscrasias, hepatotoxicity, teratogenesis in women of child bearing potential, bone density loss, neuropathy, and severe gingival hyperplasia. Unfortunately, occurrence of idiosyncratic AED adverse effects cannot be predicted or, in most cases, prevented in susceptible patients. This article reviews a practical approach for the definition and identification of adverse effects of epilepsy therapies, and reviews the literature demonstrating that adverse effects result in detrimental quality of life in epilepsy patients. Strategies for minimizing AED adverse effects by reduction or elimination of AED polytherapy, appropriately employing drug-sparing therapies, and optimally administering AEDs are outlined, including tenets of AED selection, titration, therapeutic AED laboratory monitoring, and avoidance of chronic idiosyncratic adverse effects.
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Raspall-Chaure M, Neville BG, Scott RC. The medical management of the epilepsies in children: conceptual and practical considerations. Lancet Neurol 2008; 7:57-69. [DOI: 10.1016/s1474-4422(07)70324-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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