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Several medications are approved to treat coronavirus disease 2019 (COVID-19) in Korea including nirmatrelvir/ritonavir, remdesivir, and regdanvimab. There is potential drug-drug interaction between antiepileptic drugs (AEDs) and the medications used to treat COVID-19. Several AEDs such as phenytoin, carbamazepine, phenobarbital, and primidone are strong cytochrome P450 inducers and can inhibit the drugs used for COVID-19. Particularly, these drugs are contraindicated with nirmatrelvir/ritonavir (Paxlovid®). There is a weaker drug-drug interaction between the AEDs and remdesivir. No significant interaction has been reported between the AEDs and molnupiravir. Pharmacokinetic interactions of the AEDs are important in effective management of COVID-19 in patients with epilepsy.
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Background@#Obesity, obstructive sleep apnea (OSA), and excessive daytime sleepiness (EDS) are common conditions and are interrelated. Obesity is a risk factor for OSA and independently associated with EDS. We aimed to evaluate frequency of EDS in morbid obese patients with OSA and to identify contribution factor for EDS. @*Methods@#This was a retrospective cross-sectional study in single sleep center. Consecutive patients with OSA (with apnea-hypopnea index 5/h or more) with morbid obesity (body mass index over 35 kg/m2) was enrolled. EDS were defined as Epworth Sleepiness Scale of 10 points or more. Clinical and polysomnographic variables were compared between those with and without EDS. @*Results@#Total 110 morbid obese patients with OSA were enrolled, and 34 (31%) of them had EDS. Those with EDS had higher subjective symptom of insomnia and depression. Rapid eye movement sleep latency was shorter and minimum saturation was lower for those with EDS. Multivariate logistic regression analysis identified insomnia severity (odds ratio, 1.117) and minimum saturation (odds ratio, 0.952) as independent contribution factor for EDS. @*Conclusions@#Result of this study suggest that 31.4% of morbid obese patients with OSA have EDS, and it can be affected by insomnia severity and desaturation during sleep.
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Rapid eye movement sleep behavior disorder (RBD) is a parasomnia that is characterized by dream-enactment behavior, which can often result in sleep related injury. RBD is strongly associated with neurodegenerative disease especially with alpha-synucleinopathy. More than 70% of the patients convert to neurodegenerative disease including Parkinson’s disease or diffuse Lewy body dementia with a median period of 7.5 years. Treatment for RBD is currently focused on symptomatic treatment to prevent the injury. First step is establishing safe sleep environment to avoid injury. Clonazepam and melatonin are most commonly used medication for symptomatic treatment for RBD, however, well-designed randomized clinical trials are lacking. Prognostic counselling with longitudinal follow-up is also crucial in managing patients with RBD, which should be individualized for each patient with regular systematic follow-up evaluation.
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Rapid eye movement sleep behavior disorder (RBD) is a parasomnia that is characterized by dream-enactment behavior, which can often result in sleep related injury. RBD is strongly associated with neurodegenerative disease especially with alpha-synucleinopathy. More than 70% of the patients convert to neurodegenerative disease including Parkinson’s disease or diffuse Lewy body dementia with a median period of 7.5 years. Treatment for RBD is currently focused on symptomatic treatment to prevent the injury. First step is establishing safe sleep environment to avoid injury. Clonazepam and melatonin are most commonly used medication for symptomatic treatment for RBD, however, well-designed randomized clinical trials are lacking. Prognostic counselling with longitudinal follow-up is also crucial in managing patients with RBD, which should be individualized for each patient with regular systematic follow-up evaluation.
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Status epilepticus (SE) is one of the most serious neurologic emergencies. SE is a condition that encompasses a broad range of semiologic subtypes and heterogeneous etiologies. The treatment of SE primarily involves the management of the underlying etiology and the use of antiepileptic drug therapy to rapidly terminate seizure activities. The Drug Committee of the Korean Epilepsy Society performed a review of existing guidelines and literature with the aim of providing practical recommendations for antiepileptic drug therapy. This article is one of a series of review articles by the Drug Committee and it summarizes staged antiepileptic drug therapy for SE. While evidence of good quality supports the use of benzodiazepines as the first-line treatment of SE, such evidence informing the administration of second- or third-line treatments is lacking; hence, the recommendations presented herein concerning the treatment of established and refractory SE are based on case series and expert opinions. The choice of antiepileptic drugs in each stage should consider the characteristics and circumstances of each patient, as well as their estimated benefit and risk to them. In tandem with the antiepileptic drug therapy, careful searching for and treatment of the underlying etiology are required.
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Background@#and Purpose The aim of this study was to survey the expert opinions on treatments for convulsive status epilepticus (CSE) and nonconvulsive status epilepticus (NCSE) in adults. @*Methods@#Forty-two South Korean epileptologists participated in this survey. They completed an online questionnaire regarding various patient scenarios and evaluated the appropriateness of medications used to treat CSE and NCSE. @*Results@#Initial treatment with a benzodiazepine (BZD) followed by either a second BZD or an antiepileptic drug (AED) monotherapy was the preferred treatment strategy. More than two-thirds of the experts used a second BZD when the first one failed, and consensus was reached for 84.8% of the survey items. The preferred BZD was intravenous (IV) lorazepam for the initial treatment of status epilepticus. IV fosphenytoin and IV levetiracetam were chosen for AED monotherapy after the failure of BZD. The treatments for NCSE were similar to those for CSE. Continuous IV midazolam infusion was the treatment of choice for iatrogenic coma in refractory CSE, but other AEDs were preferred over iatrogenic coma in refractory NCSE. @*Conclusions@#The results of this survey are consistent with previous guidelines, and can be cautiously applied in clinical practice when treating patients with CSE or NCSE.
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Autoimmune epilepsy is a newly emerging area of epilepsy. The concept of “autoimmune” as an etiology has recently been revisited thanks to advances in autoimmune encephalitis and precision medicine with immunotherapies. Autoimmune epilepsy presents with specific clinical manifestations, and various diagnostic approaches including cerebrospinal fluid analysis, neuroimaging, and autoantibody tests are essential for its differential diagnosis. The diagnosis is often indeterminate despite performing a thorough evaluation, and therefore empirical immunotherapy may be applied according to the judgment of the clinician. Autoimmune epilepsy often manifests as new-onset refractory status epilepticus (NORSE). A patient classified as NORSE should receive empirical immunotherapy as soon as possible. On the other hand, a morecautious, stepwise approach is recommended for autoimmune epilepsy that presents with episodic events. The type of autoimmune epilepsy is also an important factor to consider when choosing from among various immunotherapy options. Clinicians should additionally take the characteristics of antiepileptic drugs into account when using them as an adjuvant therapy. This expert opinion discusses the diagnostic and treatment approaches for autoimmune epilepsy from a practical point of view.
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Epilepsy is a common neurological disorder that is mainly treated using antiepileptic drugs.Several antiepileptic drugs such as phenobarbital, phenytoin, primidone, and ethosuximide were developed in the early 20th century. More than 10 types of antiepileptic drugs have been developed since the 1990s, and there are now more than 20 antiepileptic drugs in active clinical use. The choice of antiepileptic drugs is based on the clinical features of the seizure types, electroencephalogram findings, epileptic syndrome, and drug stability. Currently there are 19 antiepileptic drugs approved by the Korean Food and Drug Administration, 18 of which (with the exclusion of brivaracetam) are covered by the National Health Insurance Service in Korea. We reviewed the selection of antiepileptic drugs according to the classification of epileptic seizures.
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The incidence and prevalence of epilepsy are highest in elderly people, and the etiologies of epilepsy in the elderly differ from those in other age groups. Moreover, diagnosing and treating epilepsy in elderly people may be challenging due to differences in clinical characteristics and physiological changes associated with aging. This review focuses on the pharmacological treatment of epilepsy in elderly patients.
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Antiepileptic drugs (AEDs) are the primary treatment strategy for epilepsy. As the use of AEDs has become more widespread and diverse over the past century, it has become necessary to refine the associated prescription strategies. This prompted the Drug Committee of the Korean Epilepsy Society to perform a systemic review of both international and domestic guidelines as well as literature related to medical treatment of epilepsy, and prepared a series of reviews to provide practical guidelines for clinicians to follow. This article is the first in a series on AED treatments for epilepsy in South Korea.
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Background@#and PurposeThe first-line medications for the symptomatic treatment of rapid eye movement sleep behavior disorder (RBD) are clonazepam and melatonin taken at bedtime. We aimed to identify the association between depression and treatment response in patients with idiopathic RBD (iRBD). @*Methods@#We reviewed the medical records of 123 consecutive patients (76 males; age, 66.0±7.7 years; and symptom duration, 4.1±4.0 years) with iRBD who were treated with clonazepam and/or melatonin. Clonazepam and melatonin were initially administered at 0.25–0.50 and 2 mg/day, respectively, at bedtime, and the doses were subsequently titrated according to the response of individual patients. Treatment response was defined according to the presence or absence of any improvement in dream-enacting behaviors or unpleasant dreams after treatment. @*Results@#Forty (32.5%) patients were treated with clonazepam, 56 (45.5%) with melatonin, and 27 (22.0%) with combination therapy. The doses of clonazepam and melatonin at followup were 0.5±0.3 and 2.3±0.7 mg, respectively. Ninety-six (78.0%) patients reported improvement in their RBD symptoms during a mean follow-up period of 17.7 months. After adjusting for potential confounders, depression was significantly associated with a negative treatment response (odds ratio=3.76, 95% confidence interval=1.15–12.32, p=0.029). @*Conclusions@#We found that comorbid depression is significantly associated with a negative response to clonazepam and/or melatonin in patients with iRBD. Further research with larger numbers of patients is needed to verify our observations and to determine the clinical implications of comorbid depression in the pathophysiology of iRBD.
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Background@#and PurposeResponses to oral appliances (OAs) in obstructive sleep apnea (OSA) vary, and have not been fully evaluated in Korean patients. In this study we aimed to determine the efficacy of OAs for the first-line treatment of Korean patients with moderate or severe OSA. @*Methods@#This multicenter prospective observational study included 45 patients with moderate or severe OSA that had been newly diagnosed between March 2017 and May 2018 and who underwent OA treatment for 1 month. Questionnaires were completed and polysomnography (PSG) was performed before and after OA treatment. The primary outcome measures were improvement in the absolute apnea-hypopnea index (AHI) and the percentage reduction in the AHI. The secondary outcomes were improvements in the questionnaire scores related to sleep-associated symptoms and PSG parameters. @*Results@#The patients were aged 47.4±12.1 years (mean±SD), only two of them were female, and their AHI at baseline was 29.7±10.9/h. After OA treatment the AHI had reduced by 63.9±25.8%, with the reduction was similar between the patients with moderate OSA and those with severe OSA. Overall 31.1% of the patients achieved a normal AHI (<5/h), and 64.4% had an AHI of ≤10/h after the treatment. The body mass index (BMI) was the most reliable factor for predicting the percentage reduction in the AHI. The OAs also improved the sleep architecture and subjective sleep-related symptoms. @*Conclusions@#The OAs were effective in patients with moderate or severe OSA. The OAs reduced the mean AHI to 63.9% of the baseline value, and this reduction was influenced by the BMI.
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A 77-year-old female with a history of osteoarthritis visited our clinic complaining of lower back pain, paresthesia in both legs, and voiding difficulty. Her pain and temperature sensations were diminished below the L1 dermatome, and proprioception was decreased in both feet. The findings of a routine laboratory workup, echocardiogram, and cerebrospinal fluid studies were normal. Spine magnetic resonance imaging revealed high T2-weighted signal intensities and diffusion restriction in the posterior conus medullaris. The patient was diagnosed and treated for posterior spinal artery infarction.
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Idoso , Feminino , Humanos , Artérias , Líquido Cefalorraquidiano , Caramujo Conus , Difusão , Pé , Infarto , Perna (Membro) , Dor Lombar , Imageamento por Ressonância Magnética , Osteoartrite , Parestesia , Propriocepção , Sensação , Compressão da Medula Espinal , Isquemia do Cordão Espinal , Doenças Vasculares da Medula Espinal , Medula Espinal , Coluna VertebralRESUMO
OBJECTIVES: To assess the effect and safety of transcranial direct-current stimulation (tDCS) in primary chronic insomnia. METHODS: A one-month, double-blind, randomized, sham-controlled trial was performed. A total of 7 patients with primary chronic insomnia received tDCS using anodal (n=3), cathodal (n=2), or sham stimulation (n=2). They were followed up at 1 week and 1 month after treatment. The primary outcome measures included improvement in total sleep time (TST), sleep latency (SL), and sleep efficiency (SE) at 1 month follow-up. RESULTS: TST and SE were improved with tDCS at 1 month follow-up in all patients (100%) of the anodal group, one (50%) of the cathodal group, and one (50%) of the sham group. tDCS improved SL at 1 month follow-up in two patients (67%) of the anodal group, one (50%) of the cathodal group, and none (0%) of the sham group. With respect to adverse events, transient itching sensation occurred in one patient of the anodal group. None of the other groups reported adverse events. CONCLUSIONS: Our results suggest that tDCS may be effective and safe for treatment of primary chronic insomnia. A larger controlled study needs to be further investigated.
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Humanos , Seguimentos , Avaliação de Resultados em Cuidados de Saúde , Prurido , Sensação , Distúrbios do Início e da Manutenção do Sono , Estimulação Transcraniana por Corrente ContínuaRESUMO
OBJECTIVES: Restless leg syndrome (RLS) is a common sensorimotor disorder and is frequently associated with periodic limb movement in sleep (PLMS). Also about one third of patient with RLS have periodic limb movement during wakefulness (PLMW). However there is little research on the correlation between PLMW and RLS. We aimed to evaluate difference in sleep characteristics between patients with RLS with PLMW and those without PLMW. METHODS: Our study included twenty eight RLS patients. Subjects underwent suggested immobilization test (SIT) prior to one full-night polysomnography study. Patients were classified into two groups according to the presence of PLMW based on SIT-PLMW index. Polysomnographic findings, subjective sleep quality, and hematologic results were analyzed and compared between the two groups. RESULTS: Mean age of patient with frequent PLMW (SIT-PLMW ≥40/hr) was significantly higher. RLS patients with frequent PLMW were also significantly related to insomnia severity. The PLMS index was higher in patients with PLMW and showed a significant correlation with the PLMW index. CONCLUSIONS: PLMW influence sleep quality such as insomnia and is correlated with movement during sleep.
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Humanos , Extremidades , Imobilização , Polissonografia , Síndrome das Pernas Inquietas , Distúrbios do Início e da Manutenção do Sono , VigíliaRESUMO
BACKGROUND AND PURPOSE: This study aimed to determine the subjective and objective improvements in sleep quality after treatment with gamma-aminobutyric acid (GABA; 300 mg daily) extracted from unpolished rice germ. METHODS: This study was a prospective, randomized, double-blind, and placebo-controlled trial. In total, 40 patients who complained of insomnia symptoms were enrolled and randomly assigned to the GABA treatment group (n=30) or the placebo group (n=10). Polysomnography was performed, and sleep questionnaires were administered before treatment and after 4 weeks of treatment. RESULTS: After 4 weeks of treatment the sleep latency had decreased [13.4±15.7 min at pretreatment vs. 5.7±6.2 min at posttreatment (mean±SD), p=0.001] and the sleep efficacy had increased (79.4±12.9% vs. 86.1±10.5%, p=0.018) only in the GABA treatment group. Adverse events occurred in four subjects (10%). CONCLUSIONS: This study shows that treatment with unpolished-rice-germ-derived GABA improved not only the subjective sleep quality but also the objective sleep efficacy without severe adverse events.
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Humanos , Ácido gama-Aminobutírico , Polissonografia , Estudos Prospectivos , Distúrbios do Início e da Manutenção do SonoRESUMO
OBJECTIVES: To investigate brain oscillatory characteristics according to brightness and color temperature of light emitting diode (LED) light in young and elderly subjects. METHODS: We analyzed 22 young (age, 29.0±5.2 years) and 23 elderly (age, 64.8±4.5 years) healthy subjects. A LED light source was used with a combination of two color temperature (6,500 K vs. 3,000 K) and two brightness (700 lx vs. 300 lx) conditions. Participants were exposed to each light condition in relaxed wakefulness. Then, we analyzed power spectral density and functional connectivity from eye-open electroencephalography. RESULTS: A main effect of brightness on delta (p=0.044) and theta (p=0.038) power was significant in the elderly subjects. Bright light enhanced delta and theta power in the frontal region. By contrast, power spectral density of young subjects was affected by color temperature; high color temperature significantly increased beta-band power of the central region (p=0.034). Regarding functional connectivity, a significant effect of color temperature was observed in delta (p=0.006) and beta (p=0.046) frequencies. High color temperature light enhanced beta connectivity of young subjects (p=0.007), while not affecting that of elderly subjects (p=0.979). CONCLUSIONS: The present study demonstrated that spectral power and functional connectivity as well as subjective feelings are affected by the brightness and color temperature of LED light. These results might help us to understand the neurophysiological effects of light and identify the optimal indoor lighting conditions for an individual's environment.
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Idoso , Humanos , Encéfalo , Eletroencefalografia , Voluntários Saudáveis , VigíliaRESUMO
Orthostatic hypotension (OH) is a common feature of sympathetic autonomic dysfunction and can lead to lightheadedness, weakness, dizziness, and syncope. It is defined as decrease in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing. OH is associated with an increased incidence of cerebrovascular disease, myocardial infarction, and mortality. Non-pharmacological treatments may alleviate OH-related symptoms; however, are not sufficient when used alone. Pharmacological treatment is essential in managing OH. In this review, we aimed to discuss non-pharmacological and pharmacological treatment options for OH.