Perfil de pacientes em idade reprodutiva tratadas por epilepsia / Profile of patients in reproductive age treated by epilepsy

Objetivo: Descrever o perfil de pacientes em idade reprodutiva internadas por epilepsia nas regiões brasileiras em 5 anos, elucidando os riscos promovidos por ela durante a gravidez e abordando o gerenciamento do quadro. Métodos: Pesquisa e análise de dados disponibilizados pelo Departamento de Informática do Sistema Único de Saúde (DATASUS), acerca das internações em mulheres em idade reprodutiva (10 a 49 anos) por epilepsia, avaliando a ocorrência, de acordo com faixa etária, etnia e região do Brasil, no período de janeiro de 2012 a dezembro de 2016. Resultados: No total, foram notificadas 42.204 internações de mulheres em idade reprodutiva associadas à epilepsia, estando a maior parte delas (22,66%) na faixa de 20 a 29 anos e na de 40 a 49 anos (22,59%). O Sudeste correspondeu a 43,01% do total de casos (18.152), seguido pela Região Sul, com 9.456 registros (22,4%), e pelo Nordeste (8.245; 19,53%). A etnia mais atingida foi a de brancas (15.804; 37,44% dos atendimentos) e pardas (12.200; 28,9%). Conclusão: O planejamento da gravidez em mulheres epilépticas contribui para redução dos riscos tanto maternos quanto fetais, pois permite ao prescritor e à gestante pesar quais os benefícios e os malefícios de cada terapia anticonvulsivante disponível. Vale lembrar que uma abordagem individualizada da paciente epiléptica grávida por equipe multidisciplinar se faz necessária para melhorar os desfechos e prevenir internações por crises convulsivas. (AU)

Objective: To describe the profile of female patients in childbearing age hospitalized due to epilepsy in the Brazilian regions in 5 years, elucidating the risks it causes during pregnancy, and addressing the management of the condition. Methods: Research and analysis of data provided by the Informatics Department of the Unified Health System (DATASUS), concerning hospitalizations of women of childbearing age (10-49 years) due to epilepsy, evaluating the occurrence according to age, ethnicity and the region in Brazil, from January 2012 to December 2016. Results: A total of 42,204 admissions of women of childbearing age due to epilepsy were reported, with most of them in the age group from 20 to 29 years old (22,66%), and in the 40-49 age group (22.59%). The Southeast Region accounted for 43.01% of the total number of cases (18,152), followed by the South Region, with 9,456 records (22.4%), and the Northeast (8,245 - 19.53%). The most affected ethnic group was the white one (15,804; 37,44% of the admissions) and brown one (12,200; 28,9%). Conclusion: Pregnancy planning in epileptic women contributes to both maternal and fetal risk reduction, since it allows the prescriber and the pregnant woman to weigh the benefits and harms of each available anticonvulsant therapy. It is worth remembering that an individualized, multidisciplinary approach of the epileptic pregnant patient is necessary to improve the outcomes, and to prevent hospitalizations due to seizures. (AU)

Phenytoin-Induced Gingival Overgrowth Management with Periodontal Treatment

Phenytoin-induced gingival overgrowth (PIGO) is a common complication of the continuous use of medications. This paper presents a case of PIGO hindering oral function and compromising oral hygiene and aesthetics, which was treated with a combination of nonsurgical and surgical periodontal therapies. A 39-year-old male patient was referred for dental treatment with several complaints, especially upper and lower gingival overgrowth that hindered speech and swallowing. Generalized deep probing pockets and bone loss were detected. Diagnosis of gingival overgrowth associated with phenytoin and chronic periodontitis was established. The treatment plan consisted of conservative therapy with education on oral health, motivation and meticulous oral hygiene instruction in combination with scaling and root planing. During the revaluation period, a marked reduction in the clinical parameters was noted, particularly probing pocket depth reduction. Surgical therapy for removal of gingival overgrowth was also performed to achieve pocket reduction. Supportive periodontal therapy was proposed and the patient is currently under follow-up for 4 years. Management of PIGO may be obtained by the use of periodontal procedures combined with good oral hygiene and periodontal supportive care.

O crescimento gengival induzido pela fenitoína é uma complicação comum do uso contínuo da medicacão. Este artigo apresenta um caso de crescimento gengival excessivo que dificultava a função oral e comprometia a higiene oral e a estética, o qual foi tratado com uma combinação de terapias periodontais não-cirúrgicas e cirúrgicas. Paciente masculino de 39 anos de idade foi encaminhado para tratamento odontológico com várias queixas, especialmente do crescimento gengival superior e inferior que prejudicava a fala e deglutição. Profundidades de sondagens severas generalizadas e perda óssea foram detectadas. Diagnóstico de crescimento gengival induzido pela fenitoína e periodontite crônica foi estabelecido. O plano de tratamento consistiu de terapia conservadora com educação, motivação e meticulosa instrução de higiene oral em associação com raspagem e alisamento corono-radicular. Durante o período de reavaliação, uma acentuada redução nos parâmentros clínicos foi observada, principalmente uma redução das profundidades de sondagem. Terapia cirúrgica para remoção do excesso de tecido gengival também foi realizada para conseguir redução das bolsas. Terapia periodontal de suporte foi proposta e o paciente está atualmente sob acompanhamento por um período de 4 anos. O manejo do crescimento gengival induzido pela fenitoína pode ser obtido pelo uso de procedimentos periodontais combinados com uma boa higiene oral e cuidados periodontais de suporte.

Hipovitaminose D em idosos institucionalizados tratados com anticonvulsivantes, uma associação frequente / Hypovitaminosis D in institutionalized elders treated with anticonvulsants, a common association

CONTEXTO: A população idosa apresenta alta prevalência de hipovitaminose D, sendo provável que, exposta ao uso de anticonvulsivantes, ocorra agravamento dessa condição.OBJETIVO: Avaliar a interferência do uso crônico de fármacos anticonvulsivantes nos níveis séricos de vitamina D em idosos institucionalizados com idade acima de 65 anos.MÉTODOS: Foram estudados 18 idosos institucionalizados tratados com anticonvulsivantes, por no mínimo 12 meses, comparados a 16 idosos não tratados.RESULTADOS: O estudo demonstrou que os dois grupos cursaram com deficiência de vitamina D, sendo mais pronunciada no grupo tratado com anticonvulsivantes. Embora não houvesse diferença estatisticamente significativa nos valores de paratormônio, nos idosos tratados foi observada uma tendência de níveis mais elevados, 53,44 ± 28,92 pg/ml em comparação aos idosos não tratados, 38,5 ± 10,08 pg/ml (P = 0,42). Foi observada diferença estatisticamente significativa entre os níveis séricos de 25-hidroxivitamina D nas pacientes do sexo feminino tratadas de 9,22 ± 3,80 ng/ml versus não tratadas, 18,78 ± 7,62 ng/ml (P = 0,03).CONCLUSÃO: Nossos achados sugerem que idosos institucionalizados apresentam menores níveis séricos de 25-hidroxivitamina D, configurando um estado de deficiência, e diferença significativa foi detectada nas mulheres tratadas com fármacos anticonvulsivantes.

BACKGROUND: Elderly people have a high prevalence of hypovitaminosis D, especially when they are exposed to anticonvulsants.OBJECTIVE: The present study evaluated the influence of chronic use of anticonvulsants on serum levels of vitamin D in institutionalized elders aged above 65 years.METHODS: Eighteen elderly subjects treated with anticonvulsants were studied for at least 12 months and compared to 16 untreated elders.RESULTS: Vitamin D deficiency was observed in both groups, but the group treated with anticonvulsants showed a more remarkable deficiency. Although there was no statistically significant difference in serum parathyroid hormone levels, elderly patients in treatment had a higher value (53.44 ± 28.92 pg/ml) compared to untreated elders (38.5 ± 10.8 pg/ml: p = 0.42). Statistically significant difference was observed between serum 25-hydroxyvitamin D in treated female patients (9.22 ± 3.80 ng/ml) compared to untreated female patients (18.78 ± 7.62 ng/ml: p = 0.03).DISCUSSION: The observed deficiency in both groups suggests that elderly subjects have lower serum 25-hydroxyvitamin D. Compared to untreated elderly women, elderly women treated with anticonvulsants showed a significantly lower serum level of vitamin D.

Lesão hepática grave induzida por fármacos anticonvulsivantes: relato de casos / Serious liver injury induced by anticonvulsants drugs: case reports

JUSTIFICATIVA E OBJETIVOS: Inúmeros medicamentos empregados rotineiramente na prática médica podem apresentar como efeito adverso significativo a agressão hepática, manifestando-se, por vezes, com lesões graves irreversíveis, sendo possível causa de óbito em determinadas situações. O objetivo deste estudo foi relatar dois casos de pacientes que apresentaram hepatotoxicidade por fármacos anticonvulsivantes, suas consequências e possível prevenção. RELATO DOS CASOS: Caso 1: Paciente do sexo feminino, 12 anos, com história de epilepsia, em uso de carbamazepina (CBZ), haloperidol, clorpromazina e clobazan. Ao exame clínico apresentava-se sonolenta e confusa, com exames laboratoriais contendo dosagem de CBZ elevada e enzimas hepáticas alteradas. Apresentou piora progressiva com surgimento de icterícia, elevação de enzimas hepáticas e diminuição do nível de consciência. A paciente evoluiu com broncopneumonia, hemorragia pulmonar, insuficiência respiratória e óbito. Caso 2: Paciente do sexo masculino, 4 anos, em uso contínuo de depakene, foi encaminhado com quadro de sonolência, icterícia, diminuição do nível de consciência, náuseas e dor abdominal. Houve agravamento do quadro hemodinâmico, com abalos mioclônicos, choque hipovolêmico e óbito. Durante a internação apresentou elevação de enzimas hepáticas e, assim como no primeiro caso, as sorologias virais eram negativas e a tomografia de crânio não apresentava anormalidades. CONCLUSÃO: Nos últimos anos, lesões hepáticas induzidas por diferentes agentes têm sido cada vez mais observadas. E, progressivamente, a importância dada a esse fenômeno tem aumentado de maneira significativa. Sendo o fígado o principal órgão metabolizador corporal, é esperado um comprometimento proporcionalmente extenso à medida que um número crescente de substâncias farmacológicas é utilizado. Diante do exposto, destaca-se a importância do uso racional de interações medicamentosas, na tentativa de prevenir lesões possivelmente evitáveis.

BACKGROUND AND OBJECTIVES: Countless medicines employees routinely in medical practice can present as significant adverse effect the hepatic aggression, manifesting, sometimes, with serious irreversible injuries, being a possible cause of death in determined situations. The objective of this study was reported two cases of patients who presented hepatotoxicity by anticonvulsants, its consequences and possible prevention. CASE REPORTS: Case 1: Female patient, 12 years, with a history of epilepsy, in use of carbamazepine (CBZ), haloperidol, chlorpromazine and clobazam. On clinical examination the patient was drowsy and confused, with laboratory containing elevation of CBZ dosage and liver enzymes changed. There was progressive worsening, with appearance of jaundice, elevation of liver enzymes and decreased level of consciousness. The patient evolved with bronchopneumonia, pulmonary hemorrhage, respiratory failure and death.Case 2: Male patient, 4 years, in continuous use of depakene, was directed with drowsiness, jaundice, decreased level of consciousness, nausea and abdominal pain. There was aggravation of hemodynamic status, with myoclonic tremors, hypovolemic shock and death. During hospitalization in our department, presented liver enzymes elevated and, as in the first case, viral serology was negative and tomography of skull showed no abnormalities. CONCLUSION: In recent years, liver injury induced by different agents has been increasingly observed. And gradually, the importance given to this phenomenon has increased significantly. Being the liver the main metabolizing organ body is expected a proportionally extensive involvement as a growing number of pharmacological substances is used. Given the above, highlights the importance of rational use of drug interactions in an attempt to prevent possibly avoidable injuries.

Reacciones adversas cutáneas a medicamentos: Vigilancia durante un año en un Hospital Universitario. Uruguay 2008-2009 / Adverse cutaneous reactions to Drugs among hospitalized patients: A one year surveillance

Background: Adverse cutaneous reactions to Drugs (CDRs) are of particular interest among all adverse Drug reactions (ADR) due to their frequency, potential severity and because of the importance of an early diagnosis. Antimicrobial agents, anticonvulsants and non-steroidal anti-inflammatory Drugs are the Drugs associated to the highest risk of CDRs. Aim: To assess CDRs in hospitalized patients and identify the Drugs involved. Material and Methods: All patients hospitalized in the Hospital de Clínicas in Montevideo, Uruguay, with suspected CDRs, detected during one year, were included in this prospective study. The imputability was established using the Karch and Lasagna algorithm modified by Naranjo. We analyzed age, gender, Drugs involved, causal disease, severity, latency and evolution. Results: Seventeen patients, aged 17 to 85 years (15 females) with CDRs were identifed. Twelve had morbilliform exanthemas, four had reactions with eosinophilia and systemic symptoms and one had a Stevens Johnson syndrome. The Drugs involved were antimicrobials in nine cases, hypouricemic agents in four cases, anticonvulsants in three cases and aspartic insulin in one. Twelve patients had a life threatening reaction and one required admission to the intensive care unit. No deaths occurred. Conclusions: CDRs were more common in women and most of them were caused by antimicrobial agents.

Cutaneous drug reactions in patients admitted to the dermatology unit at the University Hospital of the West Indies, Kingston, Jamaica / Reacciones cutáneas medicamentosas en pacientes ingresados en la Unidad de Dermatología del Hospital Universitario de West Indies, Kingston, Jamaica

OBJECTIVE: Cutaneous reactions are among the most common adverse reactions to drugs. The purpose of this study is to examine the aetiology and outcome of cutaneous drug reactions among patients admitted to the Dermatology Ward at the University Hospital of the West Indies. SUBJECTS AND METHODS: This was a retrospective study looking at all patients who were admitted with a diagnosis of a cutaneous drug eruption from January 1, 1997 to December 31, 2005. Data included patient demographics, date of admission to hospital, duration of hospitalization and a detailed drug history including any previous episodes of drug sensitivity. All drugs reportedly ingested by the patients up to three months prior to their cutaneous reaction were documented and the period of time between drug ingestion and the appearance of skin lesions was also noted. Clinical diagnosis, co-morbidities, histopathological diagnosis, final outcome and all ensuing disabilities were noted. The data retrieved were collated and analyzed using SPSS 12.0. RESULTS: The results showed a female to male ratio of 2.2:1. The categories of drugs most commonly implicated were antimicrobials followed by anti-epileptic drugs and nonsteroidal anti-inflammatory drugs. The most common form of drug eruption requiring admission was the exanthematous drug eruption followed by erythema multiforme, toxic epidermal necrolysis and Stevens-Johnson syndrome. CONCLUSION: In general, the causative agents identified and the types of drug eruptions were similar to those found in previous studies. However, the anti-epileptic drugs, phenytoin and carbamazepine, ranked among the most commonly implicated drugs which differ significantly from other studies.

Las reacciones cutáneas se hallan entre las reacciones adversas más comunes frente a los medicamentos. El propósito de este estudio fue examinar la etiología y la evolución clínica de las reacciones cutáneas medicamentosas entre pacientes ingresados a la sala de dermatología en el Hospital Universitario de West Indies. MÉTODOS: Este es un estudio retrospectivo que pasa revista a todos los pacientes que fueron ingresados con diagnóstico de erupción cutánea desde el 1ero. de enero de 1997 al 31 de diciembre de 2005. RESULTADOS: Los resultados mostraron una proporción hembra-varón de 2.2:1. Las categorías de los medicamentos más frecuentemente implicados fueron los antimicrobianos, seguidos por los medicamentos antiepilépticos y los antiinflamatorios no esteroideos. La forma más común de erupción que requirió ingreso a causa de medicamentos, fue la erupción exantemática medicamentosa seguida por el eritema multiforme, la necrólisis epidérmica tóxica, y el síndrome de Stevens-Johnson. CONCLUSIÓN: En general, los agentes causativos identificados y los tipos de erupciones medicamentosas, fueron similares a los hallados en estudios previos. Sin embargo, los antiepilépticos conocidos como fenitoína y carbamazepina, estuvieron entre los medicamentos más comúnmente implicados, presentándose en tal sentido una diferencia significativa con los otros estudios.

Pharmacovigilance in epileptic patients using antiepileptic drugs

OBJECTIVE: To investigate the occurrence of adverse effects of antiepileptic drugs (AED) in chronic epileptic patients in mono or polytherapy. METHOD: We evaluated consecutive patients that met the following inclusion criteria: age of 18 years or older, diagnosis of epilepsy for at least one year, stable dose of AED for at least three months. Patients were asked if they had any adverse event related to the AED. After that, they were interviewed according to a detailed semi-structure questionnaire. We also assessed specifically the adverse events in the last four weeks. The data were analyzed regarding the use of monotherapy x polytherapy, and the presence of probable depression (score >15) according to the Center for Epidemiologic Studies Depression Scale. RESULTS: Sixty-five patients were evaluated, 35 women, mean age 38.3 years; 35 patients were in use of monotherapy and 35 in polytherapy. Only 45 (69.2 percent) patients spontaneously reported adverse effects. After the formal questionnaire, 63 (97 percent) patients referred experiencing an adverse event (p<0.001). Seventeen men had adverse events, as opposed to 28 women (p=0.042). When the last four weeks were evaluated, patients with probable depression presented adverse events more frequently (p<0.0001). CONCLUSION: Our data suggest that adverse events are highly prevalent when a detailed questionnaire is applied and that depression may aggravate the number and intensity of side effects in patients using AEDs.

Significación clínico-epidemiológica de la hepatotoxicidad por fármacos en la consulta hepatológica / Clinic-epidemiological significance of the hepatotoxicity by pharmaceutical preparations in the liver consultation

Se analizaron los datos epidemiológicos y clínico-evolutivos de la hepatotoxicidad por fármacos en una experiencia de 10 años (1988-1998) de nuestra Unidad de Hígado, que incluye 10342 historias clínicas de registro prospectivo. La prevalencia en este material fué de 5,6 por ciento, con ligero predominio femenino (1.4:1) y en mayores de 40 años; más del 50 por ciento ingirieron 2 o más fármacos. Predominaron las formas agudas (91.4 por ciento) e ictéricas (60.4 por ciento) con manifestaciones sistémicas de hipersensibilidad en 29.3 por ciento, el 4.5 por ciento de las formas agudas se presentaron como fallo hepático agudo severo, con necesidad de transplante hepático en un caso. los 4 casos de hepatitis crónica presentaron evolución a la cirrosis en un caso, y un caso de colestasis con ductopenia (CBP-simil) evolucionó favorablemente en 19 semanas, recibiendo ácido ursode-soxicólico 10 mg/k/día. Seis fármacos representaron el 53.4 por ciento de los casos: anticonceptivos orales, isoniacida, sulfamidas, clorpropamida, carbamacepina y amiodarona.