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

Lécio Figueira Pinto; Lucas Scárdua Silva; Rafael Batista João; Vinícius Boldrini; Fernando Cendes; Clarissa Lin Yasuda

doi:10.1055/s-0043-1777806

Arquivos de Neuro-Psiquiatria, Inhaltsverzeichnis

CC BY 4.0 · Arq Neuropsiquiatr 2024; 82(06): s00431777806
DOI: 10.1055/s-0043-1777806

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

Práticas na prescrição de medicamentos anticrise: está na hora de mudar?

Authors

Lécio Figueira Pinto

¹Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto Central, Divisão de Clínica Neurológica, São Paulo SP, Brazil.

²Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Psiquiatria, Programa de Neuropsiquiatria (PROJEPSI) São Paulo SP, Brazil.
Lucas Scárdua Silva

³Universidade Estadual de Campinas, Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas SP, Brazil.

⁴Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil.
Rafael Batista João

³Universidade Estadual de Campinas, Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas SP, Brazil.

⁴Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil.
Vinícius Boldrini

³Universidade Estadual de Campinas, Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas SP, Brazil.

⁴Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil.
Fernando Cendes

³Universidade Estadual de Campinas, Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas SP, Brazil.

⁴Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil.
Clarissa Lin Yasuda

³Universidade Estadual de Campinas, Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), Campinas SP, Brazil.

⁴Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil.

Abstract

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.

Resumo

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.

Keywords

Epilepsy - Therapeutics - Anticonvulsants

Palavras-chave

Epilepsia - Terapêutica - Anticonvulsivantes

Bibliographical Record
Lécio Figueira Pinto, Lucas Scárdua Silva, Rafael Batista João, Vinícius Boldrini, Fernando Cendes, Clarissa Lin Yasuda. Practices in the prescription of antiseizure medications: is it time to change?. Arq Neuropsiquiatr 2024; 82: s00431777806.
DOI: 10.1055/s-0043-1777806

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Referenzen

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