Special populations: The management of seizures in HIV-positive patients

Abstract

An increasing percentage of patients with new-onset seizures are HIV positive. The evaluation and management is distinctly different from managing the non-HIV-infected patient. Clinicians must be familiar with comorbid infectious etiologies and the relative value of electroencephalogram, imaging, and serum and cerebrospinal fluid laboratory tests. Traditional antiepileptic drug (AED) therapies are contraindicated and may lead to increased HIV viral replication through either directed cellular mechanisms or interference with antiretroviral therapies. Newer AEDs have pharmacokinetic properties that make them reasonable choices, although none have been specifically studied for efficacy or safety in HIV. Lastly, optimal choice of an AED should reflect commonly encountered neurologic and psychiatric comorbidities.

Seizures in HIV/AIDS: a southern African perspective

“…Gabapentin, topiramate, and levetiracetam are minimally protein‐bound. Gabapentin is not metabolized at all, whilst the metabolism of levetiracetam is independent of the cytochrome p450 (CYP 450) system (19). However, all the newer AEDs are expensive, an important consideration in developing countries.…”

The Effect of Raltegravir on the Glucuronidation of Lamotrigine

“…Moreover, there are several examples of drug‐drug interactions between drugs that are both metabolized via glucuronidation, potentially based on hepatic competition for glucuronidation 20 , 21 . Therefore, and because of the importance of drug‐drug interactions in the management of seizures in HIV‐infected patients, 10 we felt it was appropriate to investigate raltegravir's influence on the glucuronidation of the UGT substrate lamotrigine in a clinical study.…”

“…An example of a UGT‐substrate that may be prescribed to HIV‐infected patients is the antiepileptic agent lamotrigine, which is hepatically metabolized to lamotrigine‐2N‐glucuronide 9 . Lamotrigine is one of the recommended antiepileptic agents for the management of seizures in HIV‐infected patients 10 . Seizures are not rare in HIV‐infected patients: retrospective studies indicate that 2% to 20% of the HIV‐infected patients will have seizures at some time during their illness 11 .…”

“…9 Lamotrigine is one of the recommended antiepileptic agents for the management of seizures in HIV-infected patients. 10 Seizures are not rare in HIV-infected patients: retrospective studies indicate that 2% to 20% of the HIVinfected patients will have seizures at some time during their illness. 11 In addition, lamotrigine is one of the few drugs with proven efficacy in the treatment of HIV-associated neuropathic pain.…”

Clinical Relevance of Drug Interactions in HIV-Infected Patients Receiving Antiretroviral Therapy

“…With rifampicin it may be necessary to increase the dose from 200 mg/12 hours to 300 mg/12 hours, and to monitor liver function Efavirenz (Brennan et al, 2005;DeJong et al 2004Manosuthi et al, 2005Manosuthi et al, , 2006Matteelli et al, 2007aMatteelli et al, , 2007bWeiner et al, 2005) 2: high risk 2: high risk It is recommended to increase rifabutin dose to 450-600 mg/day and to use the usual dose of efavirenz (600 mg/day) (Matteelli et al, 2007b) Etravirine (Abel et al, 2008) 2: high risk 3: medium risk (Lim et al, 2004;Mullin et al, 2004;Romanelli & Pomeroy, 2003 (Mullin et al, 2004;Romanelli & Pomeroy, 2003;Tran et al, 2001;Tseng & Foisy, 1999 Table 8. Clinical relevant drug interactions mediated by traditional anticonvulsants (DHHS, 2011;Tran et al, 2001)  Etravirine-Ranitidine.…”