Comparison of cardiovascular risk calculation tools in pharmacy practice.

OBJECTIVE: To examine the use of various cardiovascular disease (CVD) risk estimation calculators in pharmacy practice. DESIGN: Longitudinal cohort study. SETTING: Midwestern university worksite from August 2008 through May 2012. PARTICIPANTS: University employees with hypertension, dyslipidemia, and diabetes. INTERVENTION: Risk estimation calculators were applied to data from a pharmacist-run chronic disease management program. MAIN OUTCOME MEASURE: Difference in estimated CVD risk from multiple estimation calculators. RESULTS: At baseline and 12 months, non-lab-based tools reported significantly higher 10-year CVD risk percentages compared with lab-based tools among the same cohort of patients (10.63% vs. 8.71% at baseline, P < 0.001; 9.34% vs. 7.31% at 12 months, P < 0.001). In addition, the electronic version of 10-year CVD risk reported significantly higher values than the paper version when applied to the same patient cohort (7.31% vs. 6.60% at 12 months, P = 0.018). CONCLUSION: CVD risk estimation tools report significantly different values and are not interchangeable. Pharmacists using non-lab-based tools should expect significantly higher risk estimates than estimates derived from lab-based tools and therefore should use the same version of the estimation tool over the long term.

Using employee experts to offer an interprofessional diabetes risk reduction program to fellow employees.

A recent increase in the incidence of diabetes and pre-diabetes is causing many employers to spend more of their healthcare benefit budgets to manage the conditions. A self-insured university in the USA has implemented an interprofessional diabetes mellitus risk reduction program using its own employee faculty and staff experts to help fellow employees manage their diabetes and pre-diabetes. The interprofessional team consists of five pharmacists, a dietitian, an exercise physiologist, a health educator and a licensed mental health practitioner. In addition, the participant's physician serves as a consultant to the program, as does a human resources healthcare benefits specialist and a wellness coordinator. The volunteer program takes place at the worksite during regular business hours and is free of charge to the employees. The faculty and staff delivering the program justify the cost of their time through an interprofessional educational model that the program will soon provide to university students.

Implementation of the Pharmacists' Patient Care Process in a Medicinal Chemistry Course.

Objective. To implement the Pharmacists' Patient Care Process (PPCP) in a medicinal chemistry course. Methods. Doctor of Pharmacy students in a medicinal chemistry course were challenged to apply the PPCP in a lesson on cholinesterase inhibitors and NMDA receptor antagonist in the treatment of Alzheimer's disease. A clinical faculty member with expertise in the topic reviewed the clinical information provided to ensure applicability to patient care. A pre- and post-course survey was administered to assess students' understanding of the PPCP and the effectiveness of the strategies used. Students' pre- and post-course responses were analyzed, and qualitative themes were identified. Results. Of the 141 students enrolled in the course, 96% and 97% completed the pre- and post-course surveys, respectively. Students' post-course responses were higher than pre-course answers to the question that they knew all the steps of the PPCP (96% vs 66%, respectively). Ninety one percent in the post-course survey compared to 62% in the pre-course survey listed the PPCP steps correctly. In addition, more than 90% of the students indicated that the strategies used in the class helped them understand and relate to the PPCP. Qualitative responses revealed themes with positive responses related to the course, course activities, PPCP goals and curriculum design based on the implementation of the PPCP. Conclusion. The introduction of the PPCP as a framework for all pharmacy practitioners is a worthy endeavor. Purposeful strategies to introduce the PPCP in a medicinal course were positively received by students. Formalized efforts to implement the PPCP in clinical, social and administrative, and science courses are critical to introduce the PPCP as a framework for all future pharmacy practitioners.

Prevalence, treatment, and control of hypertension in residents of skilled nursing facilities.

OBJECTIVE: To determine the prevalence, treatment, and control of hypertension (HTN) in elderly residents of skilled nursing facilities (SNFs). To determine variables that may influence the treatment and control of HTN in residents of SNFs. DESIGN: Concurrent medical record review of SNF residents who had resided at a facility for a minimum of 30 days. SETTING: Twelve SNFs in western Iowa and eastern Nebraska. PARTICIPANTS: All residents studied were living in one of the 12 SNFs, N=966. MAIN OUTCOME MEASURE(S): Data collected from each medical record included: demographic characteristics, past medical history, blood pressure (BP) taken over the preceding 30 days, and antihypertensive medications and their doses. The BP reading used to define BP control, or lack thereof, was based on the last recorded BP measurement in the medical record. RESULTS: The total percentage of patients with HTN was 77%. Of those with HTN, 71% had controlled BP and 29% had uncontrolled BP. The average number of antihypertensive drugs used was not significantly different between patients with controlled and uncontrolled BP. Multivariate analysis failed to identify any patient demographic characteristic or comorbidity that correlated with a higher rate of BP control. The number of antihypertensive drugs administered correlated significantly with BP control. The specific type of antihypertensive drug or drug combination did not correlate with BP control. Patients with controlled BP were significantly more likely to be receiving antihypertensive therapy at higher doses than patients with uncontrolled BP.

Use of α2δ Ligands for Restless Legs Syndrome/Willis Ekbom Disease.

Restless legs syndrome is a common neurological condition affecting a substantial portion of the population. It can be an idiopathic disorder, or one that is secondary to another cause. Given that the underlying pathophysiology of restless legs syndrome is not well understood, several drug classes have been studied for symptom control. While dopamine agonists have long been the mainstay of first-line treatment for restless legs syndrome, recently, the α2δ ligands have been increasingly used. These agents have proven both efficacious and safe in a number of clinical trials. Additionally, compared with the dopamine agonists, they have been associated with less augmentation, a phenomenon whereby symptoms emerge earlier in the day, become more severe, and may spread to areas of the body previously unaffected. Newer clinical guidelines for restless legs syndrome are increasingly recommending the α2δ ligands as a logical first-choice medication for patients needing drug therapy for symptom control.

Spotlight on perampanel in the management of seizures: design, development and an update on place in therapy.

PURPOSE: Perampanel is a first-in-class antiepileptic medication approved for the treatment of partial (focal) seizures, and as adjunctive treatment for primarily generalized tonic-clonic seizures. The pharmacology, efficacy data, adverse-effect profile, pharmacokinetics and place in therapy are reviewed. SUMMARY: Perampanel is indicated for use in patients with epilepsy who are 12 years of age or older. It is the first medication designed specifically to be a non-competitive antagonist at post-synaptic α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptors. Efficacy in refractory seizures has been established, and ongoing efficacy demonstrated by post-marketing data. The drug is completely absorbed, and exhibits a half-life that allows for once-daily administration in doses up to 12 mg/day. Drug interactions are minimal, but increased doses may be necessary when given with strong inducers of cytochrome P450 enzymes, including when perampanel is co-administered with other antiepileptics that exhibit this property. The most common adverse effects noted in both clinical trials and post-marketing are dizziness and somnolence. Psychiatric and behavioral adverse events have been documented in both adult and pediatric patients, including those with no corresponding diagnostic history. CONCLUSION: Perampanel is a novel adjunctive antiepileptic medication that is an effective option for adolescents and adults with partial seizures, and primarily generalized tonic-clonic seizures uncontrolled with other medications.

Effects of prednisone on the International Normalized Ratio.

PURPOSE: The effects of prednisone on the International Normalized Ratio (INR) values of a patient were examined. SUMMARY: A 66-year-old white man with a history of multiple myeloma was treated in an ambulatory care anticoagulation clinic for deep vein thrombosis. His INR values were normal during therapy with warfarin 14 mg weekly and thalidomide 300 mg daily. His INR values began to increase after three months of starting prednisone 10 mg daily. His weekly dose of warfarin was changed over the next two years, and his dietary intake of vitamin K was increased. For every INR value that was below the therapeutic goal, the patient was not taking prednisone; every time the INR value was above the therapeutic goal, he was taking prednisone. In November 2004, the prednisone and thalidomide were stopped and only the warfarin was continued. After a few dosage increases, ending with a weekly warfarin dose of 21 mg, the patient's INR values remained in the therapeutic range. Multiple variables must be examined when assessing INR values, as many things interact with warfarin. For example, tobacco use, alcohol consumption, and changes in vitamin K intake can affect the INR. Since this patient did not use tobacco or consume alcohol and had a fairly consistent dietary intake of vitamin K, these variables were ruled out as influencing the INR. In this case, the changes in his INR values corresponded to the addition or deletion of prednisone. CONCLUSION: A patient's INR values increased after the addition of prednisone to his warfarin regimen.

Osteoporosis in long-term care residents with multiple sclerosis.

OBJECTIVE: To assess the fracture risk of long-term care residents with multiple sclerosis (MS) using ultrasound heel-scan technology and identification of risk factors and areas where intervention by a pharmacist might affect patient outcomes. DESIGN: Bilateral-heel scans were performed on all patients who consented to take part in the study. A retrospective review of each subject's medical records was performed to identify known risk factors for osteoporosis. SETTING: A long-term care facility in Omaha, Nebraska. PARTICIPANTS: All patients with a primary diagnosis of MS residing at the facility were eligible for participation. Of 11 patients identified, 10 consented to participate. MAIN OUTCOME MEASURES: T-scores of the right and left heel as determined by ultrasound-heel scan were used to determine if study participants met criteria for osteopenia or osteoporosis as set forth by the World Health Organization. CONCLUSION: Patients in our population who have MS are at high risk for fracture. There are several areas in which pharmacists can intervene to prevent fracture and improve patient outcomes, including administration of heel scans for persons believed to be at risk, recommendation of over-the-counter supplements, and education of both patients and health care practitioners.

Comprehensive overview: efficacy, tolerability, and cost-effectiveness of clobazam in Lennox-Gastaut syndrome.

Clobazam is the newest medication approved by the US Food and Drug Administration (FDA) for the treatment of Lennox-Gastaut syndrome (LGS) in patients at least 2 years of age, although the medication has been available in countries around the world to treat epilepsy and anxiety disorders for many years. Though classified as a benzodiazepine, the drug differs structurally from other drugs in the class as it possesses nitrogen atoms at the 1 and 5 positions within the heterocyclic ring rather than at the 1 and 4 positions. This difference and the classification of clobazam as a partial agonist are believed to be responsible for the decreased incidence of sedative effects compared to other benzodiazepines. Adverse events associated with clobazam use in clinical trials have generally been mild to moderate in nature. Data from an open-label extension trial have confirmed that clobazam is efficacious for the treatment of seizures associated with LGS, particularly atonic seizures (drop seizures), over the long term. Tolerance to the drug's antiepileptic effects does not seem to be a common occurrence. The drug has proven to be a cost-effective option for therapy, particularly due to its ability to decrease the number of seizures that require medical treatment. Clobazam represents a welcome addition to the treatment options for LGS.

Pharmacologic treatment of chronic obstructive pulmonary disease: past, present, and future.

Pharmacologic treatment of chronic obstructive pulmonary disease (COPD) has evolved considerably during the past several decades. Initial treatment of the disease was accomplished primarily through antibiotics, mucolytic agents, and nonselective sympathomimetic agents. Up-to-date treatment guidelines stratified according to strength of evidence are published in the National Heart, Lung, and Blood Institute-World Health Organization workshop report on the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Current drug therapy for stable COPD focuses primarily on bronchodilation through inhaled beta2-agonists and anticholinergic agents, immunization, and elimination of smoking as a risk factor. Although many pharmacologic agents are available to treat COPD, no drug has demonstrated effectiveness in halting progression of the disease. Rather, the goal of drug therapy at this time is to maintain control of symptoms and prevent COPD exacerbations. Compared with asthma, research into treatment for COPD has been minimal. However, a long-acting anticholinergic agent, tiotropium, has received approval status by the United States Food and Drug Administration. The drug has been shown to improve spirometric parameters, quality of life, and utilization of health care resources. In addition, several new targets for the treatment of COPD are being studied, and a few agents, including some that theoretically may slow functional decline in patients with COPD, are in development.

Cost of a pharmacist-directed intervention to increase treatment of hypercholesterolemia.

STUDY OBJECTIVE: To evaluate the cost of a pharmacist-directed intervention that prompts physicians to treat hypercholesterolemia more aggressively in patients with coronary heart disease (CHD). METHODS: Health care resource use and CHD outcomes were evaluated for 612 patients with CHD followed for 2 years after an index hospitalization for an ischemic event. After discharge, the physicians of 309 patients who had been admitted from January 1--March 31, 1999, were contacted by telephone and mail concerning lipid profiles and statin therapy. These patients were the intervention group. Controls were 303 patients admitted from October 1--December 31, 1998; their physicians were not contacted. Costs of the physician-prompting intervention, clinic visits, laboratory tests, statin drugs, and CHD outcomes were compared between these two patient groups. RESULTS: The number of clinic visits, laboratory tests, and statins prescribed was significantly greater for the intervention group versus the controls. A significantly higher percentage of patients in the intervention group (55%) than in the control group (18%) achieved their National Cholesterol Education Program target low-density lipoprotein cholesterol level and had significantly better CHD outcomes. The cost of the physician-prompting intervention (pharmacist salaries, postage, telephone calls) was $102,941. For patients in the intervention and control groups, respectively, the cost of statin therapy was $352,365 and $200,087, the cost of clinic visits and laboratory tests $48,097 and $27,367, and the cost of coronary heart disease outcomes, such as myocardial infarction, coronary artery bypass graft, percutaneous transluminal and coronary angioplasty, $1,073,495 and $1,741,220. The total cost was $1,576,898 and $1,968,674, respectively, for patients in the intervention and control groups. Net savings was $1394/patient over the 2-year period. CONCLUSION: A relatively simple physician-prompting intervention involving patients with CHD significantly improved the use of lipid testing and statin therapy. Improved use of statins was associated with better CHD outcomes. As a result, the physician-prompting intervention was associated with cost savings. This intervention should be implemented for patients with CHD discharged after hospitalization for an ischemic event.

Potential interactions between exercise and drug therapy.

Certain physiological changes caused by aerobic exercise can alter the pharmacokinetics of some drugs. A systematic review of the pharmacokinetic changes that can affect drugs as a result of aerobic exercise is provided. Eleven commonly used drugs are reviewed for their potential interaction with exercising patients. Serum concentrations of two beta-blocking agents, atenolol and propranolol, and one antibiotic, doxycycline, have shown to increase as a result of exercise. No pharmacokinetic changes have been found in exercising patients taking carvedilol or verapamil. Patients who exercise after taking digoxin experience a decreased digoxin serum concentration with an increased skeletal muscle concentration. The clearance of theophylline has been shown to decrease resulting in an increase in plasma half-life during exercise. The risk of hypoglycaemia may increase when patients with diabetes mellitus inject insulin into a muscle just prior to exercising that muscle. Increasing physical activity in patients taking warfarin has been shown to decrease the international normalised ratio. Much is still unknown regarding the interactions that exist between exercise and drug therapy. More studies need to be completed in this area before definite conclusions are made and clinical relevance can be established. Clinicians should be aware that the potential for such interactions exists, especially for drugs with a narrow therapeutic range and in patients who participate in extreme sporting activities.

The economic impact of chronic obstructive pulmonary disease.

The cost burden associated with chronic bronchitis and emphysema, collectively known as chronic obstructive pulmonary disease (COPD), is large. The disease impacts not only on patients but caregivers and society as well. An estimated 16 million people in the US are currently diagnosed with COPD, the majority having chronic bronchitis. Mortality associated with this disease is on the upswing, as is its prevalence in the female population and the elderly. It is currently the fourth most common cause of death both in the US and worldwide. To date, the only proven cost-effective therapies for the disease are the cessation or prevention of smoking, which is the single most common cause of COPD, and vaccination to prevent influenza and pneumococcal infection. Hospitalisation and associated costs represent the greatest healthcare expenditures for people with the disease. Long-term oxygen therapy is also among the most costly interventions in terms of total money spent on direct medical costs for COPD treatment, although it is probably cost-effective because of its positive impact on rates of mortality. In fact, oxygen therapy is the only intervention to date that has been shown to decrease death rates due to COPD. Appropriate treatment with medication has the potential to decrease resource utilisation but does not appear to affect death rates. Similarly, pulmonary rehabilitation programs appear to benefit patients in terms of quality of life; however, long-term cost-effectiveness and effects on mortality have yet to be elucidated. Indirect costs also contribute a substantial part of the economic burden of the disease but are significantly harder to quantify.

Perampanel: a new agent for adjunctive treatment of partial seizures.

PURPOSE: The pharmacology, pharmacokinetics, efficacy, safety, and place in therapy of perampanel are reviewed. SUMMARY: Perampanel, a first-in-class antiepileptic agent, was recently approved for use as adjunctive therapy for the treatment of resistant partial seizures in patients 12 years of age and older. It acts as a selective, noncompetitive antagonist at postsynaptic α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate (AMPA) receptors. Perampanel exhibits linear pharmacokinetics and has a half-life of approximately 105 hours. The drug is rapidly and nearly completely absorbed after oral administration, achieving its maximum serum concentration in approximately 1 hour. Its bioavailability is nearly complete. Several efficacy studies have consistently demonstrated the utility of perampanel as adjunctive therapy for the treatment of refractory partial seizures with or without secondary generalization. Drug interactions have been noted with agents that induce cytochrome P-450 hepatic enzymes, including other antiepileptics, and alterations in perampanel dosing may be necessary when these medications are used concurrently. Adverse effects associated with perampanel use are primarily related to the central nervous system, and slow dosage adjustment and bedtime administration are recommended to maximize patient tolerance. The drug's labeling includes a boxed warning about the possible induction of serious adverse psychiatric and behavioral reactions that necessitate close monitoring. Perampanel is not recommended for individuals with severe liver disease or severely compromised kidney function, including those undergoing hemodialysis. CONCLUSION: Perampanel is a novel antiepileptic agent specifically designed to exhibit selective noncompetitive antagonist activity at AMPA receptors. Perampanel has consistently demonstrated the ability to control treatment-refractory partial seizures in many patients.

Safety overview of FDA-approved medications for the treatment of the motor symptoms of Parkinson's disease.

INTRODUCTION: Parkinson's disease (PD) is among the most common of the neurodegenerative disorders. Treatment is primarily focused on correcting neurotransmitter imbalances. Several classes of medication are available for this purpose. AREAS COVERED: A Medline search was performed to gather information about the safety of the medications approved for the treatment of the motor symptoms of PD. This was supplemented with additional articles obtained from online sources and information provided by the FDA and the manufacturers. The focus of this review is the side-effect and safety profiles of carbidopa/levodopa, dopamine agonists, selective monoamine oxidase inhibitors, catechol-o-methyltransferase inhibitors, anticholinergics and amantadine. EXPERT OPINION: Though serious side-effects may occur, as a group, the medications used for the treatment of PD motor symptoms tend to produce side-effects that are mild to moderate in nature, and that primarily reflect the focus on dopaminergic therapies. Care plans for Parkinson's patients should be approached based on the needs of the individual as disease presentation, lifestyle, level of disability, concurrent disease states and the presence of non-motor symptoms make each case unique. Patients and caregivers must have realistic expectations about the use of PD medications.

Safety profile of two novel antiepileptic agents approved for the treatment of refractory partial seizures: ezogabine (retigabine) and perampanel.

INTRODUCTION: Complex-partial seizures are frequently resistant to antiepileptic therapy. Two new medications with mechanisms of action novel within the antiepileptic class have recently received approval for the adjunctive treatment of partial (focal) seizures. AREAS COVERED: A Medline search was conducted to identify preclinical and clinical studies of ezogabine and perampanel. This was supplemented with additional articles obtained from online sources and information provided by the FDA and the manufacturers. The focus of this review is on the safety profiles of ezogabine (retigabine), a novel antiepileptic that targets voltage-gated potassium channels, and perampanel, a noncompetitive α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate glutamate receptor antagonist. EXPERT OPINION: Central nervous system effects are predominant within the adverse event profiles of both ezogabine and perampanel. In addition, ezogabine exerts its inhibitory effects on potassium channels in the urogenital tract potentially resulting in urinary retention and related outcomes. Recent reports of blue discoloration of the skin and in the retinas of long-term ezogabine users have surfaced. Both drugs have demonstrated the ability to induce neuropsychiatric symptoms. Though both are welcome additions to the antiepileptic drug class, additional monitoring, appropriate counseling, and careful selection of patients are warranted to minimize adverse events.

Neurogenetic disorders and treatment of associated seizures.

Seizures are a frequent complication associated with several neurogenetic disorders. Antiepileptic medications remain the mainstay of treatment in these patients. We summarized the available data associated with various antiepileptic therapies used to treat patients with neurogenetic disorders who experienced recurrent seizures. A MEDLINE search was conducted to identify articles and abstracts describing the use of antiepileptic therapy for the treatment of various neurogenetic syndromes. Of all the neurogenetic syndromes, only autism spectrum disorders, Angelman syndrome, Rett syndrome, Dravet syndrome, and tuberous sclerosis complex were identified as having sufficient published information to evaluate therapy. Some efficacy trends were identified, including frequent successes with valproic acid with clonazepam for epilepsy with Angelman syndrome; valproic acid, stiripentol, and clobazam (triple combination therapy) for epilepsy with Dravet syndrome; and vigabatrin for infantile spasms associated with tuberous sclerosis complex. Due to a paucity of information regarding the mechanisms by which seizures are generated in the various disorders, approach to seizure control is primarily based on clinical experience and a limited amount of study data exploring patient outcomes. Although exposure of the developing brain to antiepileptic medications is of some concern, the control of epileptic activity is an important undertaking in these individuals, as the severity of eventual developmental delay often appears to correlate with the severity of seizures. As such, early aggressive therapy is warranted.

Review of the treatment of restless legs syndrome: focus on gabapentin enacarbil.

The FDA approved gabapentin enacarbil in 2011 as the first non-dopaminergic agent for the treatment of restless legs syndrome (RLS) symptoms. Although gabapentin enacarbil is a pro-drug of gabapentin, its pharmacokinetics differ. Absorption of gabapentin enacarbil is more predictable, and inter-patient variability in bioavailability is lower than that of gabapentin. Studies have demonstrated superiority of gabapentin enacarbil compared to placebo. Comparisons to currently available RLS treatments are lacking, but clinical trials demonstrate comparable improvement in RLS symptoms to the dopamine agonists ropinirole and pramipexole, which are usually considered first-line therapy for daily RLS symptoms. Gabapentin enacarbil was well tolerated in clinical trials. The role of the drug in RLS treatment remains undefined, although it will likely be used as an alternative for refractory RLS when other treatments have failed. Additionally, gabapentin enacarbil may be recommended for patients with daily RLS symptoms that are less intense or are associated with pain as an alternative to dopamine agonists.

Gabapentin enacarbil for the treatment of restless legs syndrome (RLS).

INTRODUCTION: Gabapentin enacarbil is a new treatment for restless legs syndrome (RLS). It is a prodrug of the anticonvulsant gabapentin. However, unlike gabapentin, gabapentin enacarbil does not demonstrate saturable absorption. This allows for once-daily dosing and less variability in serum levels. AREAS COVERED: This review focuses on therapies used to treat RLS, both historical and recent. Data from available trials are summarized, with a particular focus on the efficacy and safety of gabapentin enacarbil. Potential advantages and disadvantages of this therapy in comparison with other RLS treatment modalities are discussed. EXPERT OPINION: Placebo-controlled trials of gabapentin enacarbil demonstrate considerable efficacy in the treatment of RLS. However, head-to-head trials comparing gabapentin enacarbil with other medications used in the treatment of RLS, including gabapentin, are lacking. Potential advantages with gabapentin enacarbil related to its pharmacokinetic profile are thus difficult to ascertain. Efficacy of gabapentin enacarbil appears comparable with that of the dopamine agonists, long considered the therapy of choice in patients with RLS. Given the lack of direct-comparison trials, and the significant cost differential of gabapentin enacarbil versus established therapies, the drug is likely to be used for patients who have failed other medication trials, or those who experience prolonged symptoms and prefer once-daily dosing.

Safety and efficacy of vigabatrin for the treatment of infantile spasms.

In 2009, vigabatrin became the first FDA approved medication for the treatment of infantile spasms in the United States. There are few well-designed prospective studies comparing the drug to placebo or other modalities used in the treatment of infantile spasms. The available data have demonstrated that vigabatrin is efficacious in the treatment of infantile spasms regardless of underlying etiology, but that it is particularly beneficial in patients with a diagnosis of tuberous sclerosis. Adrenocorticotropic hormone (ACTH), the only other medication with robust efficacy data, has been used as first line therapy for infantile spasms associated with other etiologies, and in general controls spasms sooner than vigabatrin, though relapse is common with both therapies. Vigabatrin is generally well tolerated. However, use has been associated with permanent loss of peripheral vision in some patients. In children with tuberous sclerosis, vigabatrin should be considered as initial therapy for infantile spasms. It is a viable alternative for patients with suboptimal response, contraindications or intolerance to ACTH.