Phenobarbital use in pediatric perampanel overdose with coma, respiratory compromise

Abstract

Perampanel (Fycompa®) is a non-competitive alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) glutamate receptor antagonistic antiepileptic medication used to treat generalized seizure disorders. Very little is known about the management of patients following perampanel overdose, particularly in the pediatric population. We report a case of a pediatric patient, initially presenting with increased aggression and erratic behavior, who quickly developed severe respiratory failure and prolonged coma following an intentional ingestion of between 80 and 216 mg of perampanel (1.64-4.43 mg/kg of body weight). Phenobarbital was initiated to increase the metabolism of perampanel and for seizure prophylaxis. Perampanel toxicity has been associated with a range of symptoms including bradycardia, hypotension, hyponatremia, central nervous system depression, prolonged coma, hypercoagulable state, and erratic, aggressive "zombie-like" behavior. With a reported half-life of 105 hours, no known reversal agent, and limited evidence-based management, clinicians should be prepared for prompt resuscitation and prolonged management of patients with suspected perampanel intoxication.

Educational objectives: 1.Identify symptoms of perampanel overdose and consider early intubation and resuscitation for prolonged coma and respiratory failure.2.Describe alternative methods to increase metabolization of medications with prolonged half-life.

Keywords: Coma; Fycompa; Ingestion; Overdose; Pediatric; Perampanel; Phenobarbital; Toxicology.