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1.
Semin Pediatr Neurol ; 49: 101119, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38677803

RESUMO

Clinical pharmacists are a part of the integrated health care team and provide valuable input on medication management for patients with acute and chronic disease states. Using epilepsy as a model, pharmacist involvement in patient care has been associated with significant reductions in monthly seizure frequency. Given differences in etiology, pediatric patients with epilepsy are likely to have higher number of treatments, with additional pharmacodynamic and pharmacokinetic differences, adding to the importance of utilizing a pediatric clinical pharmacist practitioner with neuropharmacology expertise. There is an increasing exposure to critically ill patients with epilepsy and other neurological disorders in the pediatric intensive care unit (PICU). These patients are more medically complex, increasing the risk for medication errors and increased health care costs. Emphasis on neurocritical care education is a vital component to improving patient outcomes. Inclusion of a clinical pharmacist practitioner in these settings yields a positive impact on major health outcomes. In 2018, the Neurocritical Care Society developed consensus recommendations on the standards for the development of adult neurocritical care units. A pharmacist-delivered pediatric critical care neuropharmacology rotation represents a novel approach to expanding physician education to improve patient outcomes. While there are sparse publications highlighting the importance of adult critical care and NCC pharmacists, no such literature exists describing the benefits of pediatric neurocritical care (PNCC) pharmacists. To the best of our knowledge, this is the first manuscript describing the role of clinical pharmacist practitioners in the development of PNCC program and the benefits they provide to patient care and education.


Assuntos
Cuidados Críticos , Currículo , Neurofarmacologia , Pediatria , Farmacêuticos , Humanos , Cuidados Críticos/métodos , Pediatria/educação , Neurofarmacologia/educação , Neurologia/educação , Criança , Papel Profissional
2.
Am J Health Syst Pharm ; 80(19): 1357-1363, 2023 09 22.
Artigo em Inglês | MEDLINE | ID: mdl-37257050

RESUMO

PURPOSE: This initiative conducted a needs assessment regarding the extent of potential risk for accidental carbohydrate exposure in patients on the ketogenic diet in acute care settings at 2 academic medical centers. SUMMARY: Medications used in the emergency department, intensive care unit, or operating room can contain carbohydrates or be diluted in carbohydrate-containing fluids. Use of these medications can shift patients on the ketogenic diet out of ketosis, causing breakthrough seizures. Despite standard clinical practices, there are no consensus guidelines to date for the logistical management of these patients during hospital admissions. This lack of standardized management increases the risk for parenteral medication errors during transitions within the healthcare system. A review of the literature demonstrates increased medication safety errors compounded by this lack of systemwide endeavors. Initiatives enhancing provider education and quality improvement safety measures have been reported; however, the extent of the potential risk with regard to medication formulation has not been assessed. Fifty medications were evaluated for their potential risk for carbohydrate exposure in a real-world quality improvement needs assessment conducted at 2 academic medical centers. CONCLUSION: Because of increased exposure to carbohydrate-containing medications and medication safety errors, the authors recommend developing institutional protocols, an order set in the electronic medical record, and a multidisciplinary approach for patients on the ketogenic diet. Further research is warranted to assess the impact of these quality improvement measures on safety and clinical outcomes and to justify the development and implementation of consensus guidelines in centers of excellence that serve these patients.


Assuntos
Dieta Cetogênica , Cetose , Humanos , Dieta Cetogênica/efeitos adversos , Dieta Cetogênica/métodos , Convulsões , Carboidratos/uso terapêutico , Erros de Medicação/prevenção & controle , Cetose/tratamento farmacológico
3.
Ann Clin Transl Neurol ; 10(4): 656-663, 2023 04.
Artigo em Inglês | MEDLINE | ID: mdl-36793218

RESUMO

Precision medicine for Mendelian epilepsy is rapidly developing. We describe an early infant with severely pharmacoresistant multifocal epilepsy. Exome sequencing revealed the de novo variant p.(Leu296Phe) in the gene KCNA1, encoding the voltage-gated K+ channel subunit KV 1.1. So far, loss-of-function variants in KCNA1 have been associated with episodic ataxia type 1 or epilepsy. Functional studies of the mutated subunit in oocytes revealed a gain-of-function caused by a hyperpolarizing shift of voltage dependence. Leu296Phe channels are sensitive to block by 4-aminopyridine. Clinical use of 4-aminopyridine was associated with reduced seizure burden, enabled simplification of co-medication and prevented rehospitalization.


Assuntos
Epilepsia Generalizada , Epilepsia , Humanos , 4-Aminopiridina/farmacologia , 4-Aminopiridina/uso terapêutico , Mutação com Ganho de Função , Mutação , Epilepsia/tratamento farmacológico , Epilepsia/genética , Canal de Potássio Kv1.1/genética
4.
Epilepsy Curr ; 22(3): 201-204, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-36451851

RESUMO

This American Epilepsy Society (AES) official statement provides information and preliminary guidance to Society members related to the U.S. Food & Drug Administration (FDA) December 22, 2021 Emergency Use Authorization for Paxlovid™ for the oral treatment of mild to moderate COVID-19 in adults and children (≥12 years and weighing ≥40 kg). Paxlovid is likely to be widely prescribed, and important considerations for patients on antiseizure medications (ASMs) include key contraindications and potential toxicity or dose adjustments while taking Paxlovid. This statement highlights concerns and provides information about their pharmacologic basis. Of particular concern, concomitant use of Paxlovid with the ASMs carbamazepine, phenobarbital, phenytoin, and primidone is contraindicated, because they are strong inducers of the CYP3A4 isozyme that metabolizes Paxlovid and thereby could cause loss of virologic response and development of resistance. Alternate oral or intravenous COVID-19 treatments should be considered. A second concern is that Paxlovid may increase the plasma concentrations of many ASMs, because it inhibits the CYP3A4 isozyme. ASMs that are metabolized, at least in part, by CYP3A4 include cannabidiol, carbamazepine, clobazam, clonazepam, diazepam, ethosuximide, everolimus, felbamate, lacosamide, midazolam, oxcarbazepine, perampanel, stiripentol, tiagabine, and zonisamide. Patients receiving these medications may warrant closer monitoring while being treated with Paxlovid.

5.
J Pharm Pract ; : 8971900221126570, 2022 Oct 04.
Artigo em Inglês | MEDLINE | ID: mdl-36193947

RESUMO

Some patients with epilepsy experience seizure clusters, which may be defined as 2 or more seizures occurring within 24 hours. Left untreated, seizure clusters increase the risk for physical injury and may progress to status epilepticus, irreversible neurologic injury, and death. Rescue therapy is based on benzodiazepine treatment. Prompt, appropriate use should be specified in patients' individualized seizure action plans. Most seizure clusters occur outside the hospital setting. The ideal rescue therapy allows for easy and quick administration by a nonmedical person, which may minimize the need for intervention by emergency medical personnel or transportation to the hospital. In the 2 decades before the approval of 2 intranasal benzodiazepines in 2019 and 2020, rectal diazepam was the only route of administration approved by the US Food and Drug Administration specifically for seizure clusters. Each of the approved intranasal formulations has a unique profile. Both offer a convenient and socially acceptable route of administration. Recognition of seizure clusters and timing of proper administration are key to successful use of rescue therapy. Pharmacists' counseling plays an important role in reinforcing when and how to appropriately administer rescue therapies and the importance of consistently using rescue treatment when indicated to promote effective management. This review includes resources for pharmacists, patients, and caregivers; reviews currently available treatments; and discusses seizure action plans that support effective treatment of seizure clusters.

6.
Curr Treat Options Neurol ; 24(7): 285-304, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35702419

RESUMO

Purpose of Review: This review provides guidance for acute spinal cord injury (SCI) management through an analytical assessment of the most recent evidence on therapies available for treating SCI, including newer therapies under investigation. We present an approach to the SCI patient starting at presentation to acute rehabilitation and prognostication, with additional emphasis on the pediatric population when evidence is available. Recent Findings: Further studies since the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated a potential functional outcome benefit with ultra-early surgical intervention ≤ 8 h post-SCI. Subsequent analysis of the National Acute Spinal Cord Injury Study (NASCIS) II and NASCIS III trials have demonstrated potentially serious complications from intravenous methylprednisolone with limited benefit. Newer therapies actively being studied have demonstrated limited or no benefit in preclinical and clinical trials with insufficient evidence to support use in acute SCI treatment. Summary: Care for SCI patients requires a multi-disciplinary team. Immediate evaluation and management are focused on preventing additional injury and restoring perfusion to the affected cord. Rapid assessment and intervention involve focused neurological examination, targeted imaging, and surgical intervention when indicated. There are currently no evidence-based recommendations for pathomechanistically targeted therapies.

7.
J Pediatr Pharmacol Ther ; 27(1): 29-37, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35002556

RESUMO

OBJECTIVE: Early treatment of infantile spasms (IS) may be imperative for improvement of neurodevelopmental outcomes. Existing studies have led to inconclusive recommendations with variation in treatment. Our objective was to determine the national average cost, initial diagnostic workup, treatments, and hospital length of stay for patients with IS. METHODS: This retrospective cohort study was designed to review data of patients < 2 years from 43 non-profit institutions. Data obtained included patient demographics, length of stay, admission cost, and treatments used from 2004 to 2014. Cost data were collected and adjusted to 2014 dollars, the year data were analyzed. RESULTS: A total of 6183 patients met study criteria (n = 3382, 55% male). Three-quarters of patients (n = 4684, 76%) had an electroencephalogram, 56.4% had brain imaging (n = 3487), and 17% (n = 1050) underwent a lumbar puncture. Medication for IS was initiated during inpatient hospital stay in two-thirds of all patients (n = 4139, 67%). Most patients were initiated on corticotropin (n = 2066, 33%) or topiramate (n = 1804, 29%). Average length of stay was 5.8 days with an average adjusted cost of $18,348. Over time there was an 86.6% increase in cost from an average $12,534.54 (2004) to $23,391.20 (2014), a significant change (p < 0.01). This correlated with an increase in average length of stay. CONCLUSIONS: Variability exists in diagnostic workup and pharmacotherapy initiated for IS, which may lead to differences in the cost of hospital stay. Further studies may help determine contributing factors to increased cost and improve health care utilization for IS patients.

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