Practices in the prescription of antiseizure medications: is it time to change?

The treatment of epilepsy has advanced over the past 30 years through the development of new antiseizure medications (ASMs). Unfortunately, not all of them have been approved yet in Brazil, and many are still underused. When comparing new ASMs to older ones, they are generally not more effective in treating epilepsy. However, they offer better tolerability, with fewer interactions and long-term side effects, especially for patients with comorbidities or those requiring polytherapy. Enzyme induction caused by older ASMs is associated with increased cholesterol levels, drug interactions with decreased effects of statins and other cardiovascular medications, anticoagulants, chemotherapy, immunosuppressors, anti-infective agents (including HIV treatment), antidepressants, and contraceptives. Additionally, they can reduce levels of vitamin D and sex hormones, as well as decrease bone density. The increasing concern about these effects during life, especially after prolonged exposure, has led most developed countries to change prescription patterns in favor of new ASMs, particularly levetiracetam and lamotrigine. Both are also considered the safest options for women of childbearing age. Regrettably, the prescription trends in Brazil have remained largely unchanged over time. This can be partially attributed to the slower approval process of ASM and the reluctance of general physicians and neurologists to embrace these new concepts. In this concise review, we highlight the various advantages linked to the new ASM, aiming to promote a shift in the prescription pattern for ASM. The selection of ASM should be customized according to individual characteristics, and practical suggestions for choosing ASMs are provided in this paper.

O tratamento da epilepsia avançou nos últimos 30 anos com o desenvolvimento de novos medicamentos anticrise (MAC). Infelizmente, nem todos estão aprovados no Brasil e muitos ainda são subutilizados. Os novos MAC não são mais eficazes que os antigos, mas apresentam melhor tolerabilidade, menos interações e efeitos colaterais a longo prazo, especialmente para pacientes com comorbidades ou que necessitam de politerapia. A indução enzimática causada pelos MAC antigos está associada ao aumento dos níveis de colesterol, interações medicamentosas com redução do efeito das estatinas e outros medicamentos cardiovasculares, anticoagulantes, quimioterapia, imunossupressores, agentes anti-infecciosos (incluindo tratamento do HIV), antidepressivos e contraceptivos. Além disso, podem reduzir os níveis de vitamina D e hormônios sexuais, podendo afetar a massa óssea. A crescente preocupação sobre estes efeitos ao longo da vida, com a exposição prolongada, levou a maioria dos países desenvolvidos a modificar o padrão de prescrição com maior uso dos novos MAC, especialmente levetiracetam e lamotrigina. Ambos são considerados as opções mais seguras para mulheres em idade fértil. Infelizmente, as tendências de prescrição no Brasil permaneceram praticamente inalteradas ao longo do tempo. Isto pode ser parcialmente explicado pela lentidão no processo de aprovação dos MAC e à resistência dos médicos generalistas e neurologistas em adotar estes novos conceitos. Nesta revisão, destacamos as vantagens dos novos MAC e a necessidade da mudança no padrão de prescrição também no Brasil. A escolha do MAC deve ser feita de acordo com as características individuais dos pacientes e sugestões práticas são apresentadas.

The Relationship Between Depression and Anxiety Symptoms of Adult PWE and Caregivers in a Tertiary Center.

Background: Although several studies have emphasized the association between epilepsy and psychiatric disorders, fewer have investigated the impact of epilepsy on caregivers' emotional status, mainly in adult people with epilepsy (PWE). Here we investigated depressive symptoms, suicidal ideation, and anxiety symptoms in a large group of adult PWE and their caregivers. Methods: We analyzed symptoms of depression [with the Beck Depression Inventory-II (BDI-II)], suicidal ideation (with BDI-II item 9), and anxiety symptoms (with the Beck Anxiety Inventory) in a large group of adult PWE [N = 548 (60% women; median age 41)] and caregivers [N = 191 (72% women; median age 47)] from a Brazilian tertiary center, considering sociodemographic and clinical aspects. We also applied the Liverpool Adverse Events Profile to assess anti-seizure drugs adverse events. Results: While the presence (p = 0.026) (and intensity, p = 0.007) of depressive symptoms and suicidal ideation (p = 0.02) were higher in PWE compared to caregivers, the proportion of clinical anxiety symptoms (p = 0.32) (and the intensity, p = 0.13) was similar in both groups. Although the rates of suicidal ideation were higher in focal epilepsy (20%), both generalized genetic epilepsy and caregivers also presented elevated frequencies (11%) of suicidal ideation. The analyses of 120 patient-caregiver dyads revealed that the intensity of depressive symptoms in PWE (but not anxiety) correlated with the intensity of depressive (r = 0.35; p < 0.001) and anxiety (r = 0.25; p = 0.01) symptoms in their caregivers. In the multivariate analyses of PWE, focal epilepsy (compared to GGE) was associated with clinical depressive symptoms (odds ratio, OR 2.1) and suicidal ideation (OR 3.2), while recurrent seizures (compared to the seizure-free group) were associated with suicidal ideation (OR 2.6) and anxiety symptoms (OR 2.1). Also, caregivers with anxiety symptoms were 8 times more likely to exhibit depressive symptoms, and those with depressive symptoms were 8 times more likely to present anxiety symptoms. Conclusion: Our study suggests that specific attention for the caregivers' mental health is as essential as PWE. There is an urgent need for more studies involving caregivers to identify their emotional distress and provide adequate treatment.

Transient Gerstmann syndrome as manifestation of stroke: Case report and brief literature review.

Gerstmann Syndrome (GS) is a rare neurological condition described as a group of cognitive changes corresponding to a tetrad of symptoms comprising agraphia, acalculia, right-left disorientation and finger agnosia. It is known that some specific brain lesions may lead to such findings, particularly when there is impairment of the angular gyrus and adjacent structures. In addition, the possibility of disconnection syndrome should be considered in some cases. The purpose of this article is to report a case of a young, cardiac patient, non-adherent to treatment, who presented with a stroke in which transient clinical symptoms were compatible with the tetrad of GS. The case report is followed by a discussion and brief review of the relevant literature.

A síndrome de Gerstmann (SG) é uma condição neurológica rara, caracterizada por um grupo de alterações cognitivas que correspondem a uma tétrade composta por agrafia, acalculia, desorientação direita-esquerda e agnosia para dedos. Sabe-se que certas lesões encefálicas específicas podem levar a tais achados, particularmente quando ocorre acometimento do giro angular e estruturas adjacentes. Além disso, a possibilidade de síndrome de desconexão deve ser considerada em alguns casos. O propósito deste artigo é relatar o caso de um paciente jovem cardiopata e não aderente ao tratamento que se apresentou com uma síndrome encéfalo-vascular associada a alterações clínicas transitórias compatíveis com a tétrade da SG. Este relato de caso é acompanhado de discussão e breve revisão de dados pertinentes da literatura.

Sensory multiple mononeuropathy induced by pravastatin use: from a case report to literature's review / Mononeuropatia múltipla sensitiva induzida pelo uso de pravastatina: de um relato de caso à revisão de literatura

Statins are frequently prescribed in clinical practice for their proven efficacy in prevention of cardiovascular and cerebrovascular diseases. Despite the recognized beneficial effects of this class of drugs, in recent years, many studies published in medical literature have shown a wide range of adverse effects as a consequence of this therapy, including the risk of peripheral neuropathy. The purpose of this article is to report a case in which clinical features consistent with multiple mononeuropathy probably secondary to use of pravastatin were observed. The case report is followed by a review of the relevant literature.

As estatinas são frequentemente prescritas na prática clínica por sua comprovada eficácia na prevenção de doenças cardiovasculares e cérebrovasculares. Apesar dos reconhecidos efeitos benéficos dessa classe medicamentosa, nos últimos anos, diversos estudos publicados na literatura médica vem evidenciando uma ampla variedade de efeitos colaterais como consequência desta terapia, incluindo o risco de neuropatias periféricas. O objetivo deste artigo é relatar um caso no qual foram observadas manifestações clínicas compatíveis com o diagnóstico de mononeuropatia múltipla sensitiva, provavelmente secundária ao uso de pravastatina. O relato de caso é acompanhando de uma revisão de dados pertinentes da literatura.

Transient Gerstmann syndrome as manifestation of stroke: Case report and brief literature review / Síndrome de Gerstmann transitória como manifestação de acidente vascular encefálico: relato de caso e breve revisão de literatura

ABSTRACT Gerstmann Syndrome (GS) is a rare neurological condition described as a group of cognitive changes corresponding to a tetrad of symptoms comprising agraphia, acalculia, right-left disorientation and finger agnosia. It is known that some specific brain lesions may lead to such findings, particularly when there is impairment of the angular gyrus and adjacent structures. In addition, the possibility of disconnection syndrome should be considered in some cases. The purpose of this article is to report a case of a young, cardiac patient, non-adherent to treatment, who presented with a stroke in which transient clinical symptoms were compatible with the tetrad of GS. The case report is followed by a discussion and brief review of the relevant literature.

RESUMO A síndrome de Gerstmann (SG) é uma condição neurológica rara, caracterizada por um grupo de alterações cognitivas que correspondem a uma tétrade composta por agrafia, acalculia, desorientação direita-esquerda e agnosia para dedos. Sabe-se que certas lesões encefálicas específicas podem levar a tais achados, particularmente quando ocorre acometimento do giro angular e estruturas adjacentes. Além disso, a possibilidade de síndrome de desconexão deve ser considerada em alguns casos. O propósito deste artigo é relatar o caso de um paciente jovem cardiopata e não aderente ao tratamento que se apresentou com uma síndrome encéfalo-vascular associada a alterações clínicas transitórias compatíveis com a tétrade da SG. Este relato de caso é acompanhado de discussão e breve revisão de dados pertinentes da literatura.