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Bouchard J, Yates C, Calello DP, Gosselin S, Roberts DM, Lavergne V, Hoffman RS, Ostermann M, Peng A, Ghannoum M. Extracorporeal Treatment for Gabapentin and Pregabalin Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Am J Kidney Dis 2021; 79:88-104. [PMID: 34799138 DOI: 10.1053/j.ajkd.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/11/2021] [Indexed: 11/11/2022]
Abstract
Toxicity from gabapentin and pregabalin overdose is commonly encountered. Treatment is supportive, and the use of extracorporeal treatments (ECTRs) is controversial. The EXTRIP workgroup conducted systematic reviews of the literature and summarized findings following published methods. Thirty-three articles (30 patient reports and 3 pharmacokinetic studies) met the inclusion criteria. High gabapentinoid extracorporeal clearance (>150mL/min) and short elimination half-life (<5 hours) were reported with hemodialysis. The workgroup assessed gabapentin and pregabalin as "dialyzable" for patients with decreased kidney function (quality of the evidence grade as A and B, respectively). Limited clinical data were available (24 patients with gabapentin toxicity and 7 with pregabalin toxicity received ECTR). Severe toxicity, mortality, and sequelae were rare in cases receiving ECTR and in historical controls receiving standard care alone. No clear clinical benefit from ECTR could be identified although major knowledge gaps were acknowledged, as well as costs and harms of ECTR. The EXTRIP workgroup suggests against performing ECTR in addition to standard care rather than standard care alone (weak recommendation, very low quality of evidence) for gabapentinoid poisoning in patients with normal kidney function. If decreased kidney function and coma requiring mechanical ventilation are present, the workgroup suggests performing ECTR in addition to standard care (weak recommendation, very low quality of evidence).
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Affiliation(s)
- Josée Bouchard
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, SAMU 061, Balears, Spain; IdISBa Clinical Toxicology Workgroup, Palma de Mallorca, Spain
| | - Diane P Calello
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey; New Jersey Poison Information and Education System, Newark, New Jersey
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux, Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, Quebec, Canada; Department of Emergency Medicine, McGill University, Montreal, Quebec, Canada; Centre Antipoison du Québec, Quebec City, Quebec, Canada
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, Australia; Drug Health Services, Royal Prince Alfred Hospital, Sydney, Australia
| | - Valéry Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, Grossman School of Medicine, New York University, New York, New York
| | - Marlies Ostermann
- Department of Critical Care & Nephrology, King's College, London, United Kingdom; Guy's & St Thomas Hospital, London, United Kingdom
| | - Ai Peng
- Department of Nephrology and Rheumatology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China
| | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada.
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Giri TK, Chakrabarty S, Ghosh B. Non-Invasive Extraction of Gabapentin for Therapeutic Drug Monitoring by Reverse Iontophoresis: Effect of pH, Ionic Strength, and Polyethylene Glycol 400 in the Receiving Medium. CURR PHARM ANAL 2019. [DOI: 10.2174/1573412914666180910115059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Monitoring of plasma concentrations is a necessity for narrow therapeutic index
potent drugs. Development of non-invasive methods can save the patients from the trauma of needles
and hence is considered as a research priority.
Introduction:
Gabapentin, an anti-epileptic drug requires therapeutic monitoring because of its narrow
therapeutic index. The objective of the study was to develop a suitable method for the non-invasive
extraction of gabapentin for the same.
Methods:
Transdermal reverse iontophoresis was performed using pig ear skin as a barrier membrane.
Three compartment iontophoretic cells were used for the extraction study. Extractions were carried out
under low intensity electric field (current intensity- 0.5 mA/cm2, electrical field approximately 5 V).
The donor compartment was charged with aqueous gabapentin (10 µg/ml in phosphate buffer of pH
7.4). For studying the effect of receiving vehicle (pH, ionic strength, and enhancer) on the extraction
efficiency of gabapentin, the two receiver chambers were charged with media having varying concentration
of these factors. Drug content was determined by HPLC.
Results:
Compared to other pHs, cumulative extraction of gabapentin at pH 5 was significantly higher
at both anode and cathode (p<0.001). At low ionic strength, extraction of gabapentin increased linearly
with the increase in concentration of ions up to a certain value but at very high ionic strength the pattern
reversed. Similar results were obtained with enhancer (polyethylene glycol 400). Extraction increased
with increase in polyethylene glycol 400 up to 3% and then decreased.
Conclusion:
Extraction flux can be optimized by manipulation of the receiver media.
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Affiliation(s)
- Tapan Kumar Giri
- NSHM College of Pharmaceutical Technology, NSHM Knowledge Campus, Kolkata Group of Institutions, 124 BL Saha Road, Kolkata-700053, West Bengal, India
| | - Subhasis Chakrabarty
- NSHM College of Pharmaceutical Technology, NSHM Knowledge Campus, Kolkata Group of Institutions, 124 BL Saha Road, Kolkata-700053, West Bengal, India
| | - Bijaya Ghosh
- NSHM College of Pharmaceutical Technology, NSHM Knowledge Campus, Kolkata Group of Institutions, 124 BL Saha Road, Kolkata-700053, West Bengal, India
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Trzcinski S, Rosenberg RE, Vasquez Montes D, Sure A, Zhou P, Tishelman J, Mansky R, McLeod L, Tracy J, Buckland AJ, Errico TJ. Use of Gabapentin in Posterior Spinal Fusion is Associated With Decreased Postoperative Pain and Opioid Use in Children and Adolescents. Clin Spine Surg 2019; 32:210-4. [PMID: 30688677 DOI: 10.1097/BSD.0000000000000783] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of this study was to examine associations of gabapentin use with inpatient postoperative daily pain scores and opioid use in children undergoing PSF for AIS. SUMMARY OF BACKGROUND DATA Gabapentin use in posterior spinal fusion (PSF) postoperative pain management for adolescent idiopathic scoliosis (AIS) is increasingly common in order to decrease opioid use and improve pain control, though there is conflicting data on dosing and effectiveness to support this practice in real world settings. METHODS Retrospective cohort study of children aged 10 to 21 years undergoing PSF for AIS between January 2013 and June 2016 at an urban academic tertiary care center. Adjuvant gabapentin exposure was defined as at least 15 mg/kg/d by postoperative day (POD) 1 with an initial loading dose of 10 mg/kg on day of surgery. Primary outcomes were daily postoperative mean pain score and opioid use [morphine milligram equivalents/kg/day(mme/kg/d)]. Secondary outcomes were short and long-term complications. RESULTS Among 129 subjects (mean age, 14.6 y, 74% female, mean coronal cobb, 55.2 degrees), 24 (19%) received gabapentin. Unadjusted GABA exposure was associated with significantly lower opioid use on POD1 and 2 (49% and 31%mme/kg/d, respectively) and lower pain scores (14%) on POD2. Adjusting for preexisting back pain, preoperative coronal Cobb angle, and site, GABA use was associated with significantly lower mean pain scores on POD1 through POD3 (-0.68, P=0.01; -0.86, P=0.002; -0.63, P=0.04). Gabapentin use was also associated with decreased opioid use on POD1 and POD2 (-0.39mme/kg/d, P<0.001; -0.27, P=0.02). There was no difference in complications by gabapentin exposure. CONCLUSIONS Addition of gabapentin as adjuvant therapy for adolescent PSF, beginning on day of surgery, is associated with improved pain scores and decreased opioid use in the first 48 to 72 hours postoperatively. LEVEL OF EVIDENCE This is a retrospective cohort study, classified as Level III under "Therapeutic Studies Investigating the Results of a Treatment."
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Tran P, Yoo HD, Ngo L, Cho HY, Lee YB. Population pharmacokinetics of gabapentin in healthy Korean subjects with influence of genetic polymorphisms of ABCB1. J Pharmacokinet Pharmacodyn 2017; 44:567-579. [PMID: 29018999 DOI: 10.1007/s10928-017-9549-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
Abstract
The objective of this study was to perform population pharmacokinetic (PK) analysis of gabapentin in healthy Korean subjects and to investigate the possible effect of genetic polymorphisms (1236C > T, 2677G > T/A, and 3435C > T) of ABCB1 gene on PK parameters of gabapentin. Data were collected from bioequivalence studies, in which 173 subjects orally received three different doses of gabapentin (300, 400, and 800 mg). Only data from reference formulation were used. Population pharmacokinetics (PKs) of gabapentin was estimated using a nonlinear mixed-effects model (NONMEM). Gabapentin showed considerable inter-individual variability (from 5.2- to 8.7-fold) in PK parameters. Serum concentration of gabapentin was well fitted by a one-compartment model with first-order absorption and lag time. An inhibitory Emax model was applied to describe the effect of dose on bioavailability. The oral clearance was estimated to be 11.1 L/h. The volume of distribution was characterized as 81.0 L. The absorption rate constant was estimated at 0.860 h-1, and the lag time was predicted at 0.311 h. Oral bioavailability was estimated to be 68.8% at dose of 300 mg, 62.7% at dose of 400 mg, and 47.1% at dose of 800 mg. The creatinine clearance significantly influenced on the oral clearance (P < 0.005) and ABCB1 2677G > T/A genotypes significantly influenced on the absorption rate constant (P < 0.05) of gabapentin. However, ABCB1 1236C > T and 3435C > T genotypes showed no significant effect on gabapentin PK parameters. The results of the present study indicate that the oral bioavailability of gabapentin is decreased when its dosage is increased. In addition, ABCB1 2677G > T/A polymorphism can explain the substantial inter-individual variability in the absorption of gabapentin.
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Affiliation(s)
- Phuong Tran
- College of Pharmacy, Institute of Bioequivalence and Bridging Study, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju, 61186, Republic of Korea
| | - Hee-Doo Yoo
- College of Pharmacy, Institute of Bioequivalence and Bridging Study, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju, 61186, Republic of Korea
| | - Lien Ngo
- College of Pharmacy, Institute of Bioequivalence and Bridging Study, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju, 61186, Republic of Korea
| | - Hea-Young Cho
- College of Pharmacy, CHA University, 335, Pangyo-ro, Bungdang-gu, Seongnam-si, Gyeonggi-do, 13488, Republic of Korea
| | - Yong-Bok Lee
- College of Pharmacy, Institute of Bioequivalence and Bridging Study, Chonnam National University, 77 Yongbong-ro, Buk-gu, Gwangju, 61186, Republic of Korea.
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Nonoda Y, Iwasaki T, Ishii M. The efficacy of gabapentin in children of partial seizures and the blood levels. Brain Dev 2014; 36:194-202. [PMID: 23647918 DOI: 10.1016/j.braindev.2013.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 03/26/2013] [Accepted: 04/06/2013] [Indexed: 01/27/2023]
Abstract
AIM To evaluate the long-term efficacy of gabapentin (GBP) and usefulness of measurement of the blood level for the observation of patients that have partial seizures. METHODS Thirty patients (20 effective cases and 10 ineffective cases) treated with GBP for the localization related epilepsy had their peak blood levels of GBP. The levels were measured seven time points, one, 6, 12, 18, 24, 30, and 36month after the start of medication. The efficacy of GBP was evaluated at one month after the initiation of medication and every year for 3years, based on the R Ratio and the degree of improvement for the paroxysmal strength and length. RESULTS GBP levels were higher in the effective cases than the levels in the ineffective cases 6months after and 1year after the initiation of medication (p<0.05). The level 6months after the start in the effective cases was 5.429±2.384μg/ml (mean±SD), and 5.837±3.217μg/ml after 1year. The cases that were effective for 1year maintained approximately the same efficacy for 3years after the initiation of medication, but there was no correlation between the level and the R Ratio, paroxysmal strength and length. CONCLUSIONS No precise definition of the therapeutic range was recognized because of no correlation between GBP level and the improvement of clinical manifestations. We recommend the GBP optimal range that is established the range within 3-8μg/ml (mean; 5μg/ml) as therapeutic target without the side effect.
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Affiliation(s)
- Yutaka Nonoda
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Toshiyuki Iwasaki
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan.
| | - Masahiro Ishii
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
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Cao L, Liang S, Tan X, Meng J. Determination of gabapentin in human plasma by capillary electrophoresis-laser induced fluorescence detection with and without solid-phase extraction. Mikrochim Acta 2012. [DOI: 10.1007/s00604-012-0835-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Jia S, Park JH, Lee J, Kwon SW. Comparison of two aerosol-based detectors for the analysis of gabapentin in pharmaceutical formulations by hydrophilic interaction chromatography. Talanta 2011; 85:2301-6. [DOI: 10.1016/j.talanta.2011.04.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 04/03/2011] [Accepted: 04/05/2011] [Indexed: 11/30/2022]
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Abstract
Epilepsy is a relatively common maternal complication affecting 0.3-0.5% of pregnant women. For most mothers with epilepsy, the use of antiepileptic drugs (AED) is unavoidable, even during pregnancy and lactation. Therefore, the fetus is indirectly exposed to AED via the placenta and breast milk. AED are also prescribed for female patients with other diseases, such as bipolar disorders. In clinical settings, physicians are frequently questioned whether or not women patients taking AED should breast-feed their offspring. Thus, it is necessary to establish an optimum AED regimen for women taking AED, in particular for those with epilepsy during pregnancy and lactation. In this article, we critically review the effects of AED on infants via breast milk and attempt to provide suggestions for clinicians regarding these effects during breast-feeding, based on the data of transplacental passage of AED, breast milk concentration/maternal serum concentration ratios, AED metabolism in infants and the effects of AED in breast milk on infants.
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Affiliation(s)
- Lei Chen
- Department of Neuropsychiatry, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Rusy LM, Hainsworth KR, Nelson TJ, Czarnecki ML, Tassone JC, Thometz JG, Lyon RM, Berens RJ, Weisman SJ. Gabapentin Use in Pediatric Spinal Fusion Patients. Anesth Analg 2010; 110:1393-8. [DOI: 10.1213/ane.0b013e3181d41dc2] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
The newer antiepileptic drugs (AEDs) provide more therapeutic options and overall improved safety and tolerability for patients. To provide the best care, physicians must be familiar with the latest tolerability and safety data. This is particularly true in children, given there are relatively fewer studies examining the effects of AEDs in children compared with adults. Since we now have significant paediatric literature on each of these agents, we provide a comprehensive and current literature review of the newer AEDs, focusing on safety and tolerability data in children and adolescents. Because the safety profiles in children differ from those in adults, familiarity with this literature is important for child neurologists and other paediatric caregivers. We have organized the data by organ system for each AED for easier reference.
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Affiliation(s)
- Dean P Sarco
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Children's Hospital Boston, Boston, Massachusetts, USA.
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Abstract
Gabapentin is a structural analogue of GABA used in the treatment of the partial epilepsies of adult and child of more than 12 years, in monotherapy or in association with other anticonvulsant drugs. In association, gabapentin presents the advantage of not interfering with the other anticonvulsant drugs. The interindividual pharmacokinetic variability and the saturable absorption are, with the adaptation in case of renal insufficiency, the only arguments in favor of TDM. During clinical studies, the plasma concentrations of gabapentin were generally included between 2 and 20 mg/L. For this molecule, the level of proof of the interest of therapeutic drug monitoring was estimated in: possibly useful.
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Affiliation(s)
- Olivier Tribut
- Laboratoire de Pharmacologie Biologique, CHU Pontchaillou, Rennes, France.
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Pichini S, Papaseit E, Joya X, Vall O, Farré M, Garcia-algar O, de laTorre R. Pharmacokinetics and Therapeutic Drug Monitoring of Psychotropic Drugs in Pediatrics. Ther Drug Monit 2009; 31:283-318. [DOI: 10.1097/ftd.0b013e31819f3328] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The issue of how much an antiepileptic drug (AED) crosses the placenta and relative safety of lactation in mothers receiving AEDs are common clinical questions. Educating potential mothers with epilepsy regarding available information is warranted so that informed decisions and any needed neonatal monitoring is performed. Unfortunately, there is still limited data regarding the degree in which anticonvulsants cross the placenta and penetrate into breast milk. There is a greater appreciation of the factors that influence AED passive transfer across the placenta and into breast milk, as well as factors that ultimately influence neonatal AED distribution. In general, women with epilepsy can have healthy babies even with significant placental exposure and can breast-feed their babies safely with some cautions. Phenobarbital and primidone should be avoided in parents wishing to breast-feed. For the AEDs ethosuximide, levetiracetam, lamotrigine, topiramate, and zonisamide, there is a potential for significant breast milk concentrations; however, there are no firm guidelines on whether lactation is safe. In all cases, parents should be counseled to monitor their child for side effects and the need for routine monitoring.
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Affiliation(s)
- Collin A Hovinga
- Departments of Clinical Pharmacy and Pediatrics, University of Tennessee Health Science Center, LeBonheur Children's Medical Center, Memphis, Tennessee 38105, USA
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Jalalizadeh H, Souri E, Tehrani MB, Jahangiri A. Validated HPLC method for the determination of gabapentin in human plasma using pre-column derivatization with 1-fluoro-2,4-dinitrobenzene and its application to a pharmacokinetic study. J Chromatogr B Analyt Technol Biomed Life Sci 2007; 854:43-7. [PMID: 17517538 DOI: 10.1016/j.jchromb.2007.03.039] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2006] [Revised: 03/06/2007] [Accepted: 03/26/2007] [Indexed: 11/20/2022]
Abstract
A rapid, sensitive and accurate high-performance liquid chromatographic method with UV detection was developed and validated for the quantification of gabapentin in human plasma. Gabapentin was quantified using pre-column derivatization with 1-fluoro-2,4-dinitrobenzene following protein precipitation of plasma with acetonitrile. Amlodipine was used as internal standard. The chromatographic separation was carried out on a Nova-Pak C(18) column using a mixture of 50 mM NaH(2)PO(4) (pH=2.5)-acetonitrile (30:70, v/v) as mobile phase with UV detection at 360 nm. The flow rate was set at 1.5 ml/min. The method was linear over the range of 0.05-5 microg/ml of gabapentin in plasma (r(2)>0.999). The within-day and between-day precision values were in the range of 2-5%. The limit of quantification of the method was 0.05 microg/ml. The method was successfully used to study the pharmacokinetics of gabapentin in healthy volunteers.
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Affiliation(s)
- Hassan Jalalizadeh
- Department of Medicinal Chemistry, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran 14155-6451, Iran
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Souri E, Jalalizadeh H, Shafiee A. Optimization of an HPLC Method for Determination of Gabapentin in Dosage Forms through Derivatization with 1-Fluoro-2,4-dinitrobenzene. Chem Pharm Bull (Tokyo) 2007; 55:1427-30. [DOI: 10.1248/cpb.55.1427] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Effat Souri
- Department of Medicinal Chemistry, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Medical Sciences/University of Tehran
| | - Hassan Jalalizadeh
- Department of Medicinal Chemistry, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Medical Sciences/University of Tehran
| | - Abbas Shafiee
- Department of Medicinal Chemistry, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Medical Sciences/University of Tehran
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Abstract
Psychopharmacologic treatment in pediatric critical care requires a careful child or adolescent psychiatric evaluation, including a thorough review of the history of present illness or injury, any current or pre-existing psychiatric disorder, past history, and laboratory studies. Although there is limited evidence to guide psychopharmacologic practice in this setting, psychopharmacologic treatment is increasing in critical care, with known indications for treatment, benefits, and risks; initial dosing guidelines; and best practices. Treatment is guided by the knowledge bases in pediatric physiology, psycho-pharmacology, and treatment of critically ill adults. Pharmacologic considerations include pharmacokinetic and pharmcodynamic aspects of specific drugs and drug classes, in particular elimination half-life, developmental considerations, drug interactions, and adverse effects. Evaluation and management of pain is a key initial step, as pain may mimic psychiatric symptoms and its effective treatment can ameliorate them. Patient comfort and safety are primary objectives for children who are acutely ill and who will survive and for those who will not. Judicious use of psychopharmacolgic agents in pediatric critical care using the limited but growing evidence base and a clinical best practices collaborative approach can reduce anxiety,sadness, disorientation, and agitation; improve analgesia; and save lives of children who are suicidal or delirious. In addition to pain, other disorders or indications for psychopharmacologic treatment are affective disorders;PTSD; post-suicide attempt patients; disruptive behavior disorders (especially ADHD); and adjustment, developmental, and substance use disorders. Treating children who are critically ill with psychotropic drugs is an integral component of comprehensive pediatric critical care in relieving pain and delirium; reducing inattention or agitation or aggressive behavior;relieving acute stress, anxiety, or depression; and improving sleep and nutrition. In palliative care, psychopharmacology is integrated with psychologicapproaches to enhance children's comfort at the end of life. Defining how best to prevent the adverse consequences of suffering and stress in pediatric critical care is a goal for protocols and for new psychopharmacologic research [23,153].
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