PracticeUpdate Neurology February 2019

EDITOR’S PICKS 15

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis AssociatedWith Antiepileptic Drugs Epilepsia

Management of Antiplatelet Therapy in Patients Undergoing Neuroendovascular Procedures Take-home message • Endovascular therapies are indicated in several cerebrovascular conditions, and their applica- tion is expanding. Management of antiplatelet agents in patients undergoing these therapies poses a challenge, and guidance for clinicians on the topic is scarce. This reviewdiscusses the literature on antiplatelet use in endovascular therapies and provides some useful guidance. The article discusses the basic mechanisms of platelet function and the various antiplatelet therapies, and goes on to provide guidance on therapy decisions. A decision flow chart starts with a recommendation for dual antiplatelet therapy 5 to 10 days before the procedure, and further management is guided by P2Y12 reaction unit values. • The article can be a useful reference for patient management in the context of neuro- logical endovascular therapies. Codrin Lungu MD Journal of Neurosurgery Abstract Neuroendovascular techniques for treating cerebral aneu- rysms and other cerebrovascular pathology are increasingly becoming the standard of care. Intraluminal stents, aneu- rysm coils, and other flow diversion devices typically require concomitant antiplatelet therapy to reduce thromboembolic complications. The variability inherent with the pharmaco- dynamic response to common antiplatelet agents such as aspirin and clopidogrel complicates optimal selection of anti- platelet agents by clinicians. This review serves to discuss the literature related to antiplatelet use in neuroendovascu- lar procedures and provides recommendations for clinicians on how to approach patients with variable response to anti- platelet agents, particularly clopidogrel. Management of Antiplatelet Therapy in Patients Under- going Neuroendovascular Procedures. J Neurosurg 2018 Oct 01;129(4)890-905, KS Kim, JF Fraser, S Grupke, AM Cook. www.practiceupdate.com/c/75016 dual antiplatelet therapy 5 to 10 days before the procedure, and further management is guided by P2Y12 reaction unit values. " " A decision flow chart starts with a recommendation for

Take-home message • Using the FDA Adverse Event Reporting System, the authors attempted to quantify the risk of Stevens-Johnson syndrome (SJS) and toxic epi- dermal necrolysis (TEN) associated with antiepileptic medications as a class. Based on 198 cases reported between 2014 and 2017, the reporting odds ratio (ROR) for SJS/TEN was 8.7 compared with non-AEDs, and one-third of the AEDs assessed (11/34) were associated with a significantly increased risk of SJS/TEN. • While this may be seem like a well-established fact, this report is quite significant in quantifying the high risk of SJS, a potentially fatal and preventable condition, for AEDs as a class and individually, especially since these drugs are used across multiple specialties, and many practitioners may not be familiar with the associated risks. Omar Khan MD Abstract TEN associated with AEDs as a class, as well as individual AEDs, in the United States. METHODS An analysis was performed of the US Food and Drug Administration Adverse Event Reporting System (FAERS) from July 2014 through December 2017. Rates of SJS/ TEN were calculated for each AED compared with all other non-AEDs. Reporting odds ratios (RORs), proportional reporting ratios (PRRs), and 95% confidence intervals (CIs) were calculated using OpenEpi. RESULTS With 198 reports, AEDs had more reports of SJS/TEN than any other medica- tion class. AEDs as a class had an ROR of 8.7 (95% CI 7.5-10.2) and a PRR of 8.7 (95% CI 7.5-10.2) compared with all other non-AEDs. The AEDs with the highest risk estimates were zonisamide (ROR 70.2, 95% CI 33.1-148.7; PRR 68.7, 95% CI 32.9-143.5), rufinamide (ROR 60.0, 95% CI 8.3-433.5; PRR 58.9, 95% CI 8.4-411.5), clorazepate (ROR 56.0, 95% CI 7.8-404.1; PRR 55.1, 95% CI 7.8-385.0), lamotrigine (ROR 53.0, 95% CI 43.2-64.9; PRR 52.2, 95% CI 42.7-63.7), phenytoin (ROR 26.3, 95% CI 15.5-44.7; PRR 26.1, 95% CI 15.4- 44.2), and carbamazepine (ROR 24.5, 95% CI 16.0-37.5; PRR 24.3, 95% CI 16.0-37.1). SIGNIFICANCE Although AEDs as a class were associated with 9 times the risk of SJS/ TEN compared with non-AEDs, there were 6 AEDs with risk estimates greater than 20. Increased awareness of this risk among both prescribers and patients, particularly varia- tions in risk among different AEDs, along with education on early recognition of SJS/TEN signs/symptoms, may help mitigate the number and severity of these adverse events. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis With Antiepileptic Drugs: An Analysis of the US Food and Drug Administration Adverse Event Reporting Sys- tem. Epilepsia 2018 Nov 05;[EPub Ahead of Print], EP Borrelli, EY Lee, AM Descoteaux, et al. www.practiceupdate.com/c/76191 " While this may be seem like a well-established fact, this report is quite significant in quantifying the high risk of SJS… for AEDs as a class and individually… " OBJECTIVE Stevens-Johnson syndrome (SJS) and toxic epidermal necroly- sis (TEN) are rare and potentially fatal adverse skin reactions that are most commonly triggered by certain medica- tions. One class of medications that has been highly associated with SJS/TEN reactions is antiepileptic drugs (AEDs). We sought to quantify the risk of SJS/

VOL. 4 • NO. 1 • 2019