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Abstract
Introduction: Brivaracetam (BRV) is an analog of levetiracetam (LEV) with 15-30 times greater affinity to SV2A and greater brain permeability than LEV. These properties have stimulated interest in its clinical trial data and post-marketing experience. Areas covered: The authors provide a background on epilepsy and its treatment, discuss the racetam family of antiepileptic drugs to which BRV belongs, and then discuss BRV properties and its efficacy and tolerability in the treatment of epilepsy. Expert opinion: While preclinical data suggest a broad spectrum of efficacy, BRV is only approved for focal epilepsy. The recommended starting dose is 100 mg per day, but in the absence of urgency, it may be prudent to start at 50 mg per day, considered the lowest effective dose. There was no added benefit when BRV was used adjunctively with LEV in clinical trials. However, post-marketing data suggest that some patients may experience improved seizure control when switching from LEV. Behavioral adverse effects seemed less common than with LEV, and most patients switched to BRV after experiencing behavioral adverse effects on LEV reported improvement. Prior or anticipated intolerability to LEV is the strongest indication for BRV in clinical practice.
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Affiliation(s)
- Yamane Makke
- Department of Neurology, Vanderbilt University Medical Center , Nashville , TN , USA
| | - Bassel Abou-Khalil
- Department of Neurology, Vanderbilt University Medical Center , Nashville , TN , USA
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Engineering brain activity patterns by neuromodulator polytherapy for treatment of disorders. Nat Commun 2019; 10:2620. [PMID: 31197165 PMCID: PMC6565674 DOI: 10.1038/s41467-019-10541-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 05/15/2019] [Indexed: 11/08/2022] Open
Abstract
Conventional drug screens and treatments often ignore the underlying complexity of brain network dysfunctions, resulting in suboptimal outcomes. Here we ask whether we can correct abnormal functional connectivity of the entire brain by identifying and combining multiple neuromodulators that perturb connectivity in complementary ways. Our approach avoids the combinatorial complexity of screening all drug combinations. We develop a high-speed platform capable of imaging more than 15000 neurons in 50ms to map the entire brain functional connectivity in large numbers of vertebrates under many conditions. Screening a panel of drugs in a zebrafish model of human Dravet syndrome, we show that even drugs with related mechanisms of action can modulate functional connectivity in significantly different ways. By clustering connectivity fingerprints, we algorithmically select small subsets of complementary drugs and rapidly identify combinations that are significantly more effective at correcting abnormal networks and reducing spontaneous seizures than monotherapies, while minimizing behavioral side effects. Even at low concentrations, our polytherapy performs superior to individual drugs even at highest tolerated concentrations. Brain disorders are associated with network dysfunctions that are not addressed by conventional drug screens. Here, the authors use high-throughput functional imaging of brain activity in zebrafish larvae to study the effects of individual drugs on network connectivity and demonstrate an algorithm that predicts the most effective drug combinations to normalize both the activity patterns and the animal behavior.
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Villanueva V, López-González FJ, Mauri JA, Rodriguez-Uranga J, Olivé-Gadea M, Montoya J, Ruiz-Giménez J, Zurita J. BRIVA-LIFE-A multicenter retrospective study of the long-term use of brivaracetam in clinical practice. Acta Neurol Scand 2019; 139:360-368. [PMID: 30506559 DOI: 10.1111/ane.13059] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Evaluate long-term effectiveness and tolerability of brivaracetam in clinical practice in patients with focal epilepsy. MATERIALS AND METHODS This was a multicenter retrospective study. Patients aged ≥16 years were started on brivaracetam from November 2016 to June 2017 and followed over 1 year. Data were obtained from medical records at 3, 6 and 12 months after treatment initiation for evaluation of safety- and seizure-related outcomes. RESULTS A total of 575 patients were included in analyses; most had been treated with ≥4 lifetime antiepileptic drugs. Target dosage was achieved by 30.6% of patients on the first day. Analysis of primary variables at 12 months revealed that mean reduction in seizure frequency was 36.0%, 39.7% of patients were ≥50% responders and 17.5% were seizure-free. Seizure-freedom was achieved by 37.5% of patients aged ≥65 years. Incidence of adverse events (AEs) and psychiatric AEs (PAEs) was 39.8% and 14.3%, respectively, and discontinuation due to these was 8.9% and 3.7%, respectively. Somnolence, irritability, and dizziness were the most frequently reported AEs. At baseline, 228 (39.7%) patients were being treated with levetiracetam; most switched to brivaracetam (dose ratio 1:10-15). Among those who switched because of PAEs (n = 53), 9 (17%) reported PAEs on brivaracetam, and 3 (5.7%) discontinued because of PAEs. Tolerability was not highly affected among patients with learning disability or psychiatric comorbidity. CONCLUSIONS In a large population of patients with predominantly drug-resistant epilepsy, brivaracetam was effective and well-tolerated; no unexpected AEs occurred over 1 year, and the incidence of PAEs was lower compared with levetiracetam.
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Tyrlikova I, Brazdil M, Rektor I, Tyrlik M. Perampanel as monotherapy and adjunctive therapy for focal onset seizures, focal to bilateral tonic-clonic seizures and as adjunctive therapy of generalized onset tonic-clonic seizures. Expert Rev Neurother 2018; 19:5-16. [DOI: 10.1080/14737175.2019.1555474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Ivana Tyrlikova
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
- Brno Epilepsy Center, 1st Department of Neurology, St. Anne’s Univ. Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Milan Brazdil
- Brno Epilepsy Center, 1st Department of Neurology, St. Anne’s Univ. Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Ivan Rektor
- Brno Epilepsy Center, 1st Department of Neurology, St. Anne’s Univ. Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Michal Tyrlik
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
- University of Maryland, College Park, USA
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Abou-Khalil B, Klein P, Shah A, Ryvlin P, Specchio LM, Gama H, Rocha F, Blum D, Grinnell T, Cheng H, Jung J. Tolerability of adjunctive eslicarbazepine acetate according to concomitant lamotrigine or carbamazepine use: A subgroup analysis of three phase III trials in adults with focal (partial-onset) seizures. Epilepsy Res 2018; 147:80-86. [DOI: 10.1016/j.eplepsyres.2018.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/27/2018] [Accepted: 08/27/2018] [Indexed: 11/17/2022]
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Gupte-Singh K, Wilson JP, Barner JC, Richards KM, Rascati KL, Hovinga C. Patterns of antiepileptic drug use in patients with potential refractory epilepsy in Texas Medicaid. Epilepsy Behav 2018; 87:108-116. [PMID: 30120071 DOI: 10.1016/j.yebeh.2018.07.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/25/2018] [Accepted: 07/25/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Antiepileptic drug (AED) monotherapy is usually effective in 60% of the patients with epilepsy while the remaining patients have refractory epilepsy. This study compared treatment patterns (adherence, persistence, addition, and switching) associated with refractory and nonrefractory epilepsy. METHODS Texas Medicaid claims from 09/01/07-12/31/13 were analyzed, and patients eligible for the study 1) were between 18 and 62 years of age, 2) had a prescription claim for an AED during the identification period (03/01/08-12/31/11) with no prior baseline AED use (6-month), and 3) had evidence of epilepsy diagnosis within 6 months of AED use. Based on AED use in the identification period, patients were categorized into "refractory" (≥3AEDs) and "nonrefractory" (<3AEDs) cohorts. The index date was the date of the first AED claim. Patients in both cohorts were matched 1:1 using propensity scoring and compared for adherence (proportion of days covered (PDC) ≥80% vs. <80%), persistence, addition (yes/no), and switching (yes/no) using multivariate conditional regression models. Conditional logistic regression and Cox proportional hazard models were used to address the study objectives. RESULTS Of the 10,599 eligible patients, 2798 (26.5%) patients in the refractory cohort were matched to patients in the nonrefractory cohort. Patients in the refractory cohort had significantly higher (p < 0.005) mean (±Standard deviation (SD)) adherence (88.6% (±19.1%) vs. 77.0% ± (25.8%)) and persistence (328.0 (±87.3) days vs. 294.9 ± (113.4) days) as compared with patients in the nonrefractory cohort. Compared with patients with nonrefractory epilepsy, patients with refractory epilepsy were 3.6 times (odds ratio (OR) = 3.553; 95% confidence interval (CI) = 3.060-4.125; p < 0.0001) more likely to adhere to AEDs and had a 34.7% (hazard ratio (HR) = 0.653; 95% CI = 0.608-0.702; p < 0.0001) lower hazard rate of discontinuation of AEDs. Also, patients with refractory epilepsy were 3.7 times (OR = 3.723; 95% CI = 2.902-4.776; p < 0.0001) more likely to add an alternative AED and 3.6 times (OR = 3.591; 95% CI = 3.010-4.284; p < 0.0001) more likely to switch to an alternative AED. CONCLUSION Patients with refractory epilepsy were significantly more likely to adhere and persist to AED regimen and were significantly more likely to add and switch to an alternative AED than patients with nonrefractory epilepsy.
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Affiliation(s)
- Komal Gupte-Singh
- Health Outcomes and Pharmacy Practice Division, The University of Texas College of Pharmacy, 2409 University Avenue, Stop A1930, Austin, TX 78712, United States of America.
| | - James P Wilson
- Health Outcomes and Pharmacy Practice Division, The University of Texas College of Pharmacy, 2409 University Avenue, Stop A1930, Austin, TX 78712, United States of America.
| | - Jamie C Barner
- Health Outcomes and Pharmacy Practice Division, The University of Texas College of Pharmacy, 2409 University Avenue, Stop A1930, Austin, TX 78712, United States of America.
| | - Kristin M Richards
- Health Outcomes and Pharmacy Practice Division, The University of Texas College of Pharmacy, 2409 University Avenue, Stop A1930, Austin, TX 78712, United States of America.
| | - Karen L Rascati
- Health Outcomes and Pharmacy Practice Division, The University of Texas College of Pharmacy, 2409 University Avenue, Stop A1930, Austin, TX 78712, United States of America.
| | - Collin Hovinga
- Health Outcomes and Pharmacy Practice Division, The University of Texas College of Pharmacy, 2409 University Avenue, Stop A1930, Austin, TX 78712, United States of America; Institute for Advanced Clinical Trials for Children (I-ACT), United States of America.
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Chi X, Li R, Hao X, Chen J, Xiong W, Xu H, He Y, Liu W, Tong X, Zhang L, Jiang X, Gao H, Zhou D. Response to treatment schedules after the first antiepileptic drug failed. Epilepsia 2018; 59:2118-2124. [PMID: 30246334 DOI: 10.1111/epi.14565] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Xiaosa Chi
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
- Department of Geriatrics; Affiliated Hospital of Qingdao University; Qingdao Shandong China
| | - Rui Li
- Regenerative Medical Research Center; West China Hospital; Sichuan University; Chengdu China
| | - Xiaoting Hao
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
| | - Jiani Chen
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
| | - Weixi Xiong
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
| | - Hao Xu
- Department of Biostatistics; School of Public Health; Yale University; New Haven Connecticut
| | - Yazhou He
- Usher Institute of Population Health Sciences and Informatics; University of Edinburgh; Edinburgh UK
| | - Wenyu Liu
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
| | - Xin Tong
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
| | - Le Zhang
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
| | - Xinyue Jiang
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
| | - Hui Gao
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
| | - Dong Zhou
- Department of Neurology; West China Hospital; Sichuan University; Chengdu China
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Chi NF, Kuan YC, Huang YH, Chan L, Hu CJ, Liu HY, Chiou HY, Chien LN. Development and validation of risk score to estimate 1-year late poststroke epilepsy risk in ischemic stroke patients. Clin Epidemiol 2018; 10:1001-1011. [PMID: 30174459 PMCID: PMC6110266 DOI: 10.2147/clep.s168169] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objective This study aimed to develop and validate a prognostic model for the 1-year risk of late poststroke epilepsy (PSE). Materials and methods We included patients initially diagnosed with ischemic stroke between 2003 and 2014 in a National Health Insurance claims-based cohort in Taiwan. Patients were further divided into development and validation cohorts based on their year of stroke diagnosis. Multivariable Cox regression with backward elimination was used to analyze the association between 1-year PSE and risk factors before and on stroke admission. Results In total, 1,684 (1.93%) and 725 (1.87%) ischemic stroke patients comprising the development and validation cohorts, respectively, experienced late PSE within 1 year after stroke. Seven clinical variables were examined to be independently associated with 1-year risk of PSE. We developed a risk score called "PSEiCARe" ranging from 0 to 16 points, comprising the following factors: prolonged hospital stay (>2 weeks, 1 point), seizure on admission (6 points), elderly patients (age ≥80 years, 1 point), intensive care unit stay on admission (3 points), cognitive impairment (dementia, 2 points), atrial fibrillation (2 points), and respiratory tract infection (pneumonia) on admission (1 point). Patients were further classified into low-, medium-, high-, and very-high-risk groups. The incidence (per 100 person-years) was 0.64 (95% CI: 0.56-0.71) for the low-risk, 2.62 (95% CI: 2.43-2.82) for the medium-risk, 10.3 (95% CI: 9.48-11.3) for the high-risk, and 28.2 (95% CI: 24.0-33.0) for the very-high-risk groups. Discrimination and calibration were satisfactory, with a Harrell's C of 0.762 in the development model and 0.792 in the validation model. Conclusion PSEiCARe is an easy-to-use prognostic score that integrates patient characteristics and clinical factors on stroke admission to predict 1-year PSE risk; it has the potential to assist individualized patient management and improve clinical practice, thereby preventing the occurrence of late PSE.
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Affiliation(s)
- Nai-Fang Chi
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, Republic of China.,Department of Neurology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Yi-Chun Kuan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, Republic of China.,Department of Neurology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, Republic of China.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, Republic of China
| | - Yao-Hsien Huang
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, Republic of China.,Department of Neurology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Lung Chan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, Republic of China.,Department of Neurology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Chaur-Jong Hu
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, Republic of China.,Department of Neurology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, Republic of China.,PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Hung-Yi Liu
- Health and Clinical Research Data Center, College of Public Health, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Li-Nien Chien
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan, Republic of China,
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Consider potential drug interactions when starting combination therapy with antiepileptic drugs. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0525-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shorvon SD, Bermejo PE, Gibbs AA, Huberfeld G, Kälviäinen R. Antiepileptic drug treatment of generalized tonic-clonic seizures: An evaluation of regulatory data and five criteria for drug selection. Epilepsy Behav 2018; 82:91-103. [PMID: 29602083 DOI: 10.1016/j.yebeh.2018.01.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 01/28/2018] [Accepted: 01/29/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND A generalized tonic-clonic seizure (GTCS) is the most severe form of common epileptic seizure and carries the greatest risk of harm. The aim of this review is to provide an evidence-based guide for the selection of antiepileptic drugs (AEDs) for patients with GTCSs. Eight AEDs are approved in Europe and the USA for the treatment of both primarily GTCSs (PGTCSs) and secondarily GTCSs (SGTCSs) and are considered in this paper. METHODS Each AED is evaluated using five criteria: (1) efficacy, by seizure type (a: PGTCSs and b: SGTCSs); (2) adverse effects; (3) interactions; (4) adherence and dosing; and (5) mechanism of action (MOA). To ensure the inclusions of robust data, only efficacy data accepted by regulatory authorities were considered, and data related to adverse effects, interactions, adherence, and MOA were all extracted from UK Summaries of Product Characteristics (SPCs). RESULTS (1a) There is class 1 evidence of the efficacy of only four AEDs in controlling PGTCSs (lamotrigine, levetiracetam, perampanel, and topiramate). (1b) There is no class 1 evidence of the efficacy of any AED in SGTCSs although some evidence from pooled/subgroup analyses or meta-analyses supports the use of the four AEDs (levetiracetam, perampanel, topiramate, and with less robust data for lamotrigine). (2) AEDs are associated with different, but to some extent overlapping, common adverse effect profiles but have differing idiosyncratic adverse effects. (3) Pharmacokinetic interactions are seen with most, but not all, AEDs and are most common with carbamazepine and phenytoin. (4) Good adherence is important for seizure control and is influenced by frequency of dosing, among other factors. (5) Mechanism of action is also a consideration in rationalising AED selection when switching or combining AEDs. CONCLUSION Ultimately, the choice of AED depends on all these factors but particularly on efficacy and adverse effects. Different patients will weigh the various factors differently, and the role of the treating physician is to provide accurate information to allow patients to make informed choices.
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Affiliation(s)
- Simon D Shorvon
- UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, WC1N 3BG, UK.
| | - Pedro E Bermejo
- Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | | | - Gilles Huberfeld
- Sorbonne Université, Pitié-Salpêtrière Hospital, Neurophysiology Department, Paris, France; INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France
| | - Reetta Kälviäinen
- Epilepsy Center/Neurocenter, Kuopio University Hospital, Kuopio, Finland; Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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A novel action of lacosamide on GABA A currents sets the ground for a synergic interaction with levetiracetam in treatment of epilepsy. Neurobiol Dis 2018; 115:59-68. [PMID: 29621596 DOI: 10.1016/j.nbd.2018.03.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/03/2018] [Accepted: 03/30/2018] [Indexed: 01/01/2023] Open
Abstract
Epilepsy is one of the most common chronic neurological diseases, and its pharmacological treatment holds great importance for both physicians and national authorities, especially considering the high proportion of drug-resistant patients (about 30%). Lacosamide (LCM) is an effective and well-tolerated new-generation antiepileptic drug (AED), currently licensed as add-on therapy for partial-onset seizures. However, LCM mechanism of action is still a matter of debate, although its effect on the voltage sensitive sodium channels is by far the most recognized. This study aimed to retrospectively analyze a cohort of 157 drug-resistant patients treated with LCM to describe the most common and effective therapeutic combinations and to investigate if the LCM can affect also GABAA-mediated neurotransmission as previously shown for levetiracetam (LEV). In our cohort, LEV resulted the compound most frequently associated with LCM in the responder subgroup. We therefore translated this clinical observation into the laboratory bench by taking advantage of the technique of "membrane micro-transplantation" in Xenopus oocytes and electrophysiological approaches to study human GABAA-evoked currents. In cortical brain tissues from refractory epileptic patients, we found that LCM reduces the use-dependent GABA impairment (i.e., "rundown") that it is considered one of the specific hallmarks of drug-resistant epilepsies. Notably, in line with our clinical observations, we found that the co-treatment with subthreshold concentrations of LCM and LEV, which had no effect on GABAA currents on their own, reduced GABA impairment in drug-resistant epileptic patients, and this effect was blocked by PKC inhibitors. Our findings demonstrate, for the first time, that LCM targets GABAA receptors and that it can act synergistically with LEV, improving the GABAergic function. This novel mechanism might contribute to explain the clinical efficacy of LCM-LEV combination in several refractory epileptic patients.
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Tsai JJ, Wu T, Leung H, Desudchit T, Tiamkao S, Lim KS, Dash A. Perampanel, an AMPA receptor antagonist: From clinical research to practice in clinical settings. Acta Neurol Scand 2018; 137:378-391. [PMID: 29214650 DOI: 10.1111/ane.12879] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 12/21/2022]
Abstract
Epileptic seizures are refractory to treatment in approximately one-third of patients despite the recent introduction of many newer antiepileptic drugs (AEDs). Development of novel AEDs therefore remains a high priority. Perampanel is a first-in-class non-competitive selective AMPA receptor antagonist with a unique mechanism of action. Clinical efficacy and safety of perampanel as adjunctive treatment for focal seizures with/without secondary generalization (±SG) and primary generalized tonic-clonic (PGTC) seizures have been established in five phase 3 randomized controlled trials (RCTs), and a long-term extension study, and perampanel is approved as monotherapy for focal seizures ±SG in the USA. In patients with focal seizures ±SG, add-on perampanel resulted in median percent reduction in seizure frequency 23.3%-34.5% and ≥50% responder rate 28.5%-37.6%; in PGTC seizures, these results were 76.5% and 64.2%, respectively. Efficacy among adolescents (reduction in seizure frequency 34.8%-35.6%; ≥50% responder rate 40.9%-45.0%) and elderly people (reduction in seizure frequency 12.5%-16.9%; ≥50% responder rate 22.2%-42.9%) is similar to those in adults, and results remain comparable between Asian (reduction in seizure frequency 17.3%-38.0%) and global populations. Perampanel has been extensively studied in real-world clinical practice, with similar efficacy and safety results to the RCTs (≥50% responder rate 12.8%-75.0%; adverse events of somnolence/sedation, dizziness, ataxia, and behavioral changes). Real-world observational studies suggest that perampanel tolerability can be improved by slow titration (2 mg every 2-4 weeks), and bedtime administration can mitigate somnolence and dizziness. Counseling about the potential for behavioral changes and close monitoring are recommended.
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Affiliation(s)
- J.-J. Tsai
- Department of Neurology; National Cheng Kung University Hospital and School of Medicine; National Cheng Kung University; Tainan Taiwan
| | - T. Wu
- Department of Neurology; Chang Gung Memorial Hospital; Chang Gung University; Taoyuan City Taiwan
| | - H. Leung
- Department of Medicine and Therapeutics; Faculty of Medicine; Prince of Wales Hospital; Hong Kong Hong Kong
| | - T. Desudchit
- Department of Paediatrics; King Chulalongkorn Memorial Hospital; Bangkok Thailand
| | - S. Tiamkao
- Integrated Epilepsy Research Group; Department of Medicine; Faculty of Medicine; Khon Kaen University; Khon Kaen Thailand
| | - K.-S. Lim
- Division of Neurology; Department of Medicine; Faculty of Medicine; University of Malaya; Kuala Lumpur Malaysia
| | - A. Dash
- Eisai Singapore Pte. Ltd.; Singapore
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Neal A, D'Souza W, Hepworth G, Lawn N, Cook M, Nikpour A. Efficacy and tolerability of adjuvant lacosamide: The role of clinical characteristics and mechanisms of action of concomitant AEDs. Epilepsy Behav 2018; 80:25-32. [PMID: 29396359 DOI: 10.1016/j.yebeh.2017.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/21/2017] [Accepted: 11/22/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The objective of this study was to analyze the effectiveness and long-term tolerability of adjuvant lacosamide (LCM) in a multicenter cohort. We aim to assess outcomes of LCM-containing antiepileptic drug (AED) combinations based upon 'mechanism of action' (MoA) and patient's clinical features. METHODS Consecutive patients commenced on LCM, with focal epilepsy were identified from three Australian hospitals. The 12-month efficacy endpoints were greater than 50% reduction in seizure frequency (responders) and seizure freedom. Tolerability endpoints were cessation of LCM for any reason, cessation due to side-effects and censoring due to inefficacy. Outcomes were assessed according to concomitant AEDs according to their MoA and the clinical risk factor profile. RESULTS Three hundred ten patients were analyzed and followed for median 17.3months. Two hundred ninety-nine (97%) had drug-resistant epilepsy, and 155 (50%) had tried more than 7 AEDs at LCM commencement. Adjuvant LCM was associated with responder and seizure freedom rate of 29% and 9% respectively at 12months. Lower baseline seizure frequency, a prior 6-month period of seizure freedom at any time since epilepsy diagnosis and being on fewer concomitant AEDs were predictive of 12-month seizure freedom. Previous focal to bilateral tonic-clonic seizures (FBTCS), lower baseline seizure frequency, and concomitant AED reduction after LCM commencement were associated with improved LCM tolerability. No specific MoA AED combinations offered any efficacy or tolerability advantage. SIGNIFICANCE Adjuvant LCM is associated with seizure freedom rates of 9% at 12months after commencement and is predicted by lower prior seizure frequency, a period of 6months or longer of seizure freedom since diagnosis and fewer concomitant AEDs. While the broad MoA of concomitant AEDs did not influence efficacy or tolerability outcomes, we have provided a framework that may be utilized in future studies to help identify optimal synergistic AED combinations.
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Affiliation(s)
- Andrew Neal
- Department of Medicine, The University of Melbourne, Australia; Department of Neurology, St Vincent's Hospital Melbourne, Australia.
| | - Wendyl D'Souza
- Department of Medicine, The University of Melbourne, Australia; Department of Neurology, St Vincent's Hospital Melbourne, Australia
| | - Graham Hepworth
- Statistical Consulting Centre, The University of Melbourne, Australia
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Mark Cook
- Department of Medicine, The University of Melbourne, Australia; Department of Neurology, St Vincent's Hospital Melbourne, Australia
| | - Armin Nikpour
- Department of Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
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Benbadis S, Klein P, Schiemann J, Diaz A, Elmoufti S, Whitesides J. Efficacy, safety, and tolerability of brivaracetam with concomitant lamotrigine or concomitant topiramate in pooled Phase III randomized, double-blind trials: A post-hoc analysis. Epilepsy Behav 2018; 80:129-134. [PMID: 29414542 DOI: 10.1016/j.yebeh.2017.12.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to assess the efficacy and safety of adjunctive brivaracetam (BRV) with concomitant use of lamotrigine (LTG) or topiramate (TPM) in patients with uncontrolled focal seizures. METHODS Data were pooled from three randomized, placebo-controlled Phase III studies (NCT00490035/N01252, NCT00464269/N01253, NCT01261325/N01358) of adults with focal (partial-onset) seizures. Patients taking concomitant levetiracetam were excluded from the efficacy populations, but included in the safety populations. This post-hoc analysis reports data from patients taking BRV in the approved therapeutic range (50-200mg/day) concomitantly with LTG or TPM. RESULTS The number of patients in each of the three BRV dosage groups was small, particularly for the TPM subgroup. Mean percent reduction over placebo in baseline-adjusted focal seizure frequency/28days for BRV 50, 100, and 200mg/day was 8.7, 5.3, and 8.9 in the LTG subgroup (n=220), and 8.4, 21.3, and -4.2 in the TPM subgroup (n=122). The ≥50% responder rate with concomitant LTG or TPM with BRV 50, 100, and 200mg/day or placebo was LTG: 28.1%, 36.1%, 34.1%, and 29.1%; and TPM: 14.3%, 44.4%, 25.0%, and 17.5%. There were numerically ≥50%, ≥75%, ≥90%, and 100% responder rates for patients taking BRV ≥50mg/day compared with placebo in both subgroups. In the LTG and TPM safety populations (n=245 versus n=125), treatment-emergent adverse events (TEAEs) were reported with LTG 68.7% versus 68.4%, and TPM 65.6% versus 57.8% (BRV ≥50mg/day versus placebo). Discontinuations due to TEAEs versus placebo were LTG 7.3% versus 6.3% and TPM 8.2% versus 4.7%. The three most frequently reported TEAEs for both subgroups were somnolence, dizziness, and fatigue. Of these, the incidence of fatigue in the LTG population appeared to increase with dose. SIGNIFICANCE In this post-hoc pooled analysis, BRV administered with concomitant LTG or TPM reduced seizure frequency and was generally well tolerated for BRV doses of 50-200mg/day.
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Affiliation(s)
- Selim Benbadis
- Comprehensive Epilepsy Program, University of South Florida, Tampa, FL, USA.
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
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Liguori C, Izzi F, Manfredi N, D'Elia A, Mari L, Mercuri NB, Fabio P. Efficacy and tolerability of perampanel and levetiracetam as first add-on therapy in patients with epilepsy: A retrospective single center study. Epilepsy Behav 2018; 80:173-176. [PMID: 29414548 DOI: 10.1016/j.yebeh.2018.01.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/04/2018] [Accepted: 01/04/2018] [Indexed: 11/29/2022]
Abstract
Perampanel (PER) is a third generation antiepileptic drug (AED), recently approved as add-on therapy in both focal and generalized seizures. Levetiracetam (LEV) is a second generation AED, widely used in patients with epilepsy because of its favorable safety and efficacy profiles. Perampanel and LEV treatments have been associated with the occurrence of similar adverse events (AEs) (sleepiness, irritability, depression, anxiety, aggressiveness). The aim of the present retrospective single center study was to verify the efficacy and tolerability of PER and LEV used as first add-on therapy in patients with epilepsy affected by secondarily generalized seizures. We collected data from 15 patients treated with PER and 26 patients treated with LEV and followed at our site with follow-up visits at 3, 6, and 12months. This retrospective study documented the comparable efficacy of PER and LEV as first add-on treatments in patients affected by uncontrolled secondarily generalized seizures. However, more patients withdrawn LEV because of AEs compared with PER at the 3- and 12-month follow-up visits. The better tolerability of PER observed in this study could be related to the low therapeutic dose of PER prescribed when it is used as first adjunctive treatment for better controlling secondarily generalized seizures.
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Affiliation(s)
- Claudio Liguori
- Epilepsy Centre, Neurophysiopathology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | - Francesca Izzi
- Epilepsy Centre, Neurophysiopathology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Natalia Manfredi
- Epilepsy Centre, Neurophysiopathology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Alessio D'Elia
- Epilepsy Centre, Neurophysiopathology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luisa Mari
- Epilepsy Centre, Neurophysiopathology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Nicola Biagio Mercuri
- Epilepsy Centre, Neurophysiopathology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy; IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Placidi Fabio
- Epilepsy Centre, Neurophysiopathology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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New differentially expressed genes and differential DNA methylation underlying refractory epilepsy. Oncotarget 2018; 7:87402-87416. [PMID: 27903967 PMCID: PMC5349997 DOI: 10.18632/oncotarget.13642] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/08/2016] [Indexed: 02/06/2023] Open
Abstract
Epigenetics underlying refractory epilepsy is poorly understood, especially in patients without distinctive genetic alterations. DNA methylation may affect gene expression in epilepsy without affecting DNA sequences. Herein, we analyzed genome-wide DNA methylation and gene expression in brain tissues of 10 patients with refractory epilepsy using methylated DNA immunoprecipitation linked with sequencing and mRNA Sequencing. Diverse distribution of differentially methylated genes was found in X chromosome, while differentially methylated genes appeared rarely in Y chromosome. 62 differentially expressed genes, such as MMP19, AZGP1, DES, and LGR6 were correlated with refractory epilepsy for the first time. Although general trends of differentially enriched gene ontology terms and Kyoto Encyclopedia of Genes and Genome pathways in this study are consistent with previous researches, differences also exist in many specific gene ontology terms and Kyoto Encyclopedia of Genes and Genome pathways. These findings provide a new genome-wide profiling of DNA methylation and gene expression in brain tissues of patients with refractory epilepsy, which may provide a basis for further study on the etiology and mechanisms of refractory epilepsy.
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Abstract
Monotherapy remains the standard initial therapy of epilepsy, but when the first antiepileptic drug (AED) fails, combination therapy may be considered. The choice of combination therapy should take into consideration pharmacokinetic interactions, as well as pharmacodynamic interactions related to mechanism of action. There is evidence that an AED combination with different mechanisms of action is more likely to be successful than a combination with the same mechanisms. The combination of lamotrigine and valproate has been demonstrated to be synergistic in its efficacy. However, there are limited data to support other synergistic AED combinations.
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Brodie MJ. Pharmacological Treatment of Drug-Resistant Epilepsy in Adults: a Practical Guide. Curr Neurol Neurosci Rep 2017; 16:82. [PMID: 27443649 DOI: 10.1007/s11910-016-0678-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
More than 30 % of adults with epilepsy do not fully control on the currently available antiepileptic drugs (AEDs). For these and many other patients, combinations of agents, often possessing different mechanisms of actions, are employed with the aim of achieving seizure freedom or the best available prognosis in terms of reduced seizure numbers and severity. This review discusses my own approach to optimising outcomes in as many of these patients as possible by adjusting the drug burden using a combination of two, three or sometimes four or more AEDs. Modes of drug action are reviewed and practical strategies for treating different patients with drug-resistant epilepsy have been explored. Only for sodium valproate with lamotrigine is there good evidence of synergism. The final part of this practical paper consists of six individual illustrative cases with appropriate comments.
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Affiliation(s)
- Martin J Brodie
- Epilepsy Unit, West Glasgow ACH-Yorkhill, Dalnair Street, Glasgow, G3 8SJ, Scotland, UK.
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Anti-Epileptic Drug Combination Efficacy in an In Vitro Seizure Model - Phenytoin and Valproate, Lamotrigine and Valproate. PLoS One 2017; 12:e0169974. [PMID: 28076384 PMCID: PMC5226812 DOI: 10.1371/journal.pone.0169974] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 12/24/2016] [Indexed: 11/30/2022] Open
Abstract
In this study, we investigated the relative efficacy of different classes of commonly used anti-epileptic drugs (AEDs) with different mechanisms of action, individually and in combination, to suppress epileptiform discharges in an in vitro model. Extracellular field potential were recorded in 450 μm thick transverse hippocampal slices prepared from juvenile Wistar rats, in which “epileptiform discharges” (ED’s) were produced with a high-K+ (8.5 mM) bicarbonate-buffered saline solution. Single and dual recordings in stratum pyramidale of CA1 and CA3 regions were performed with 3–5 MΩ glass microelectrodes. All drugs—lamotrigine (LTG), phenytoin (PHT) and valproate (VPA)—were applied to the slice by superfusion at a rate of 2 ml/min at 32°C. Effects upon frequency of ED’s were assessed for LTG, PHT and VPA applied at different concentrations, in isolation and in combination. We demonstrated that high-K+ induced ED frequency was reversibly reduced by LTG, PHT and VPA, at concentrations corresponding to human therapeutic blood plasma concentrations. With a protocol using several applications of drugs to the same slice, PHT and VPA in combination displayed additivity of effect with 50μM PHT and 350μM VPA reducing SLD frequency by 44% and 24% individually (n = 19), and together reducing SLD frequency by 66% (n = 19). 20μM LTG reduced SLD frequency by 32% and 350μM VPA by 16% (n = 18). However, in combination there was a supra-linear suppression of ED’s of 64% (n = 18). In another independent set of experiments, similar results of drug combination responses were also found. In conclusion, a combination of conventional AEDs with different mechanisms of action, PHT and VPA, displayed linear additivity of effect on epileptiform activity. More intriguingly, a combination of LTG and VPA considered particularly efficacious clinically showed a supra-additive suppression of ED’s. This approach may be useful as an in vitro platform for assessing drug combination efficacy.
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Moura LMVR, Westover MB, Kwasnik D, Cole AJ, Hsu J. Causal inference as an emerging statistical approach in neurology: an example for epilepsy in the elderly. Clin Epidemiol 2016; 9:9-18. [PMID: 28115873 PMCID: PMC5221551 DOI: 10.2147/clep.s121023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The elderly population faces an increasing number of cases of chronic neurological conditions, such as epilepsy and Alzheimer's disease. Because the elderly with epilepsy are commonly excluded from randomized controlled clinical trials, there are few rigorous studies to guide clinical practice. When the elderly are eligible for trials, they either rarely participate or frequently have poor adherence to therapy, thus limiting both generalizability and validity. In contrast, large observational data sets are increasingly available, but are susceptible to bias when using common analytic approaches. Recent developments in causal inference-analytic approaches also introduce the possibility of emulating randomized controlled trials to yield valid estimates. We provide a practical example of the application of the principles of causal inference to a large observational data set of patients with epilepsy. This review also provides a framework for comparative-effectiveness research in chronic neurological conditions.
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Affiliation(s)
- Lidia MVR Moura
- Massachusetts General Hospital, Department of Neurology, Epilepsy Service, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - M Brandon Westover
- Massachusetts General Hospital, Department of Neurology, Epilepsy Service, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David Kwasnik
- Massachusetts General Hospital, Department of Neurology, Epilepsy Service, Boston, MA, USA
| | - Andrew J Cole
- Massachusetts General Hospital, Department of Neurology, Epilepsy Service, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - John Hsu
- Massachusetts General Hospital, Mongan Institute, Boston, MA, USA
- Harvard Medical School, Department of Medicine, Boston, MA, USA
- Harvard Medical School, Department of Health Care Policy, Boston, MA, USA
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Impact of remote monitoring on clinical events and associated health care utilization: A nationwide assessment. Heart Rhythm 2016; 13:2279-2286. [DOI: 10.1016/j.hrthm.2016.08.024] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Indexed: 11/20/2022]
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Knupp KG, Leister E, Coryell J, Nickels KC, Ryan N, Juarez-Colunga E, Gaillard WD, Mytinger JR, Berg AT, Millichap J, Nordli DR, Joshi S, Shellhaas RA, Loddenkemper T, Dlugos D, Wirrell E, Sullivan J, Hartman AL, Kossoff EH, Grinspan ZM, Hamikawa L. Response to second treatment after initial failed treatment in a multicenter prospective infantile spasms cohort. Epilepsia 2016; 57:1834-1842. [PMID: 27615012 DOI: 10.1111/epi.13557] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Infantile spasms (IS) represent a severe epileptic encephalopathy presenting in the first 2 years of life. Recommended first-line therapies (hormonal therapy or vigabatrin) often fail. We evaluated response to second treatment for IS in children in whom the initial therapy failed to produce both clinical remission and electrographic resolution of hypsarhythmia and whether time to treatment was related to outcome. METHODS The National Infantile Spasms Consortium established a multicenter, prospective database enrolling infants with new diagnosis of IS. Children were considered nonresponders to first treatment if there was no clinical remission or persistence of hypsarhythmia. Treatment was evaluated as hormonal therapy (adrenocorticotropic hormone [ACTH] or oral corticosteroids), vigabatrin, or "other." Standard treatments (hormonal and vigabatrin) were compared to all other nonstandard treatments. We compared response rates using chi-square tests and multivariable logistic regression models. RESULTS One hundred eighteen infants were included from 19 centers. Overall response rate to a second treatment was 37% (n = 44). Children who received standard medications with differing mechanisms for first and second treatment had higher response rates than other sequences (27/49 [55%] vs. 17/69 [25%], p < 0.001). Children receiving first treatment within 4 weeks of IS onset had a higher response rate to second treatment than those initially treated later (36/82 [44%] vs. 8/34 [24%], p = 0.040). SIGNIFICANCE Greater than one third of children with IS will respond to a second medication. Choosing a standard medication (ACTH, oral corticosteroids, or vigabatrin) that has a different mechanism of action appears to be more effective. Rapid initial treatment increases the likelihood of response to the second treatment.
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Affiliation(s)
- Kelly G Knupp
- Department of Pediatrics and Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Erin Leister
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Jason Coryell
- Departments of Pediatrics and Neurology, School of Medicine, Oregon Health & Sciences University, Portland, Oregon, U.S.A
| | - Katherine C Nickels
- Departments of Neurology and Pediatrics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Nicole Ryan
- Division of Neurology, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Elizabeth Juarez-Colunga
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - William D Gaillard
- Center For Neuroscience, Children's National Health System, Washington, District of Columbia, U.S.A
| | - John R Mytinger
- Division of Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, U.S.A
| | - Anne T Berg
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - John Millichap
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Douglas R Nordli
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Sucheta Joshi
- Department of Pediatrics & Communicable Diseases (Division of Pediatric Neurology), University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Renée A Shellhaas
- Department of Pediatrics & Communicable Diseases (Division of Pediatric Neurology), University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Dennis Dlugos
- Division of Neurology, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Elaine Wirrell
- Departments of Neurology and Pediatrics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Joseph Sullivan
- Departments of Pediatrics and Neurology, University of California San Francisco, San Francisco, California, U.S.A
| | - Adam L Hartman
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Eric H Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Zachary M Grinspan
- Departments of Pediatrics and Healthcare Policy & Research, Weill Cornell Medical Center, New York, New York, U.S.A
| | - Lorie Hamikawa
- Department of Neurology, University of Washington, Seattle, Washington, U.S.A
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Lai ECC, Hsieh CY, Su CC, Yang YHK, Huang CW, Lin SJ, Setoguchi S. Comparative persistence of antiepileptic drugs in patients with epilepsy: A STROBE-compliant retrospective cohort study. Medicine (Baltimore) 2016; 95:e4481. [PMID: 27583857 PMCID: PMC5008541 DOI: 10.1097/md.0000000000004481] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 06/24/2016] [Accepted: 07/11/2016] [Indexed: 11/30/2022] Open
Abstract
We compared persistence of antiepileptic drugs (AEDs) including carbamazepine, oxcarbazepine, gabapentin, lamotrigine, topiramate, valproic acid, and phenytoin in an Asian population with epilepsy.A retrospective cohort study was conducted by analyzing Taiwan's National Health Insurance Research Database (NHIRD). Adult epilepsy patients newly prescribed with AEDs between 2005 and 2009 were included. The primary outcome was persistence, defined as the treatment duration from the date of AED initiation to the date of AED discontinuation, switching, hospitalization due to seizure or disenrollment from databases, whichever came first. Cox proportional hazard models were used to estimate the risk of non-persistence with AEDs.Among the 13,061 new users of AED monotherapy (mean age: 58 years; 60% men), the persistence ranged from 218.8 (gabapentin) to 275.9 (oxcarbazepine) days in the first treatment year. The risks of non-persistence in patients receiving oxcarbazepine (adjusted hazard ratio [HR], 0.78; 95% CI, 0.74-0.83), valproic acid (0.88; 0.85-0.92), lamotrigine (0.72; 0.65-0.81), and topiramate (0.90; 0.82-0.98) were significantly lower than in the carbamazepine group. Compared with carbamazepine users, the non-persistence risk was higher in phenytoin users (1.10; 1.06-1.13), while gabapentin users (1.03; 0.98-1.09) had similar risk. For risk of hospitalization due to seizure and in comparison with carbamazepine users, oxcarbazepine (0.66; 0.58-0.74) and lamotrigine (0.46; 0.35-0.62) users had lower risk, while phenytoin (1.35; 1.26-1.44) users had higher risk. The results remained consistent throughout series of sensitivity and stratification analyses.The persistence varied among AEDs and was better for oxcarbazepine, valproic acid, lamotrigine, and topiramate, but worse for phenytoin when compared with carbamazepine.
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Affiliation(s)
- Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Cheng-Yang Hsieh
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine
- Department of Neurology, Tainan Sin Lau Hospital
| | - Chien-Chou Su
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine
| | - Yea-Huei Kao Yang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine
- Health Outcome Research Center
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Swu-Jane Lin
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Soko Setoguchi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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McGinnis E, Kessler SK. Lacosamide use in children with epilepsy: Retention rate and effect of concomitant sodium channel blockers in a large cohort. Epilepsia 2016; 57:1416-25. [DOI: 10.1111/epi.13466] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 01/07/2023]
Affiliation(s)
- Emily McGinnis
- Departments of Neurology and Pediatrics; Perelman School of Medicine at the University of Pennsylvania; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania U.S.A
| | - Sudha Kilaru Kessler
- Departments of Neurology and Pediatrics; Perelman School of Medicine at the University of Pennsylvania; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania U.S.A
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Rogawski MA, Löscher W, Rho JM. Mechanisms of Action of Antiseizure Drugs and the Ketogenic Diet. Cold Spring Harb Perspect Med 2016; 6:a022780. [PMID: 26801895 PMCID: PMC4852797 DOI: 10.1101/cshperspect.a022780] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Antiseizure drugs (ASDs), also termed antiepileptic drugs, are the main form of symptomatic treatment for people with epilepsy, but not all patients become free of seizures. The ketogenic diet is one treatment option for drug-resistant patients. Both types of therapy exert their clinical effects through interactions with one or more of a diverse set of molecular targets in the brain. ASDs act by modulation of voltage-gated ion channels, including sodium, calcium, and potassium channels; by enhancement of γ-aminobutyric acid (GABA)-mediated inhibition through effects on GABAA receptors, the GABA transporter 1 (GAT1) GABA uptake transporter, or GABA transaminase; through interactions with elements of the synaptic release machinery, including synaptic vesicle 2A (SV2A) and α2δ; or by blockade of ionotropic glutamate receptors, including α-amino-3-hydroxy-5-methyl-4-isoxazole-propionate (AMPA) receptors. The ketogenic diet leads to increases in circulating ketones, which may contribute to the efficacy in treating pharmacoresistant seizures. Production in the brain of inhibitory mediators, such as adenosine, or ion channel modulators, such as polyunsaturated fatty acids, may also play a role. Metabolic effects, including diversion from glycolysis, are a further postulated mechanism. For some ASDs and the ketogenic diet, effects on multiple targets may contribute to activity. Better understanding of the ketogenic diet will inform the development of improved drug therapies to treat refractory seizures.
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Affiliation(s)
- Michael A Rogawski
- Department of Neurology, University of California, Davis, Sacramento, California 95817
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany
| | - Jong M Rho
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Department of Physiology and Pharmacology, University of Calgary, Alberta, Canada
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Devinsky O, Dilley C, Ozery-Flato M, Aharonov R, Goldschmidt Y, Rosen-Zvi M, Clark C, Fritz P. Changing the approach to treatment choice in epilepsy using big data. Epilepsy Behav 2016; 56:32-7. [PMID: 26827299 DOI: 10.1016/j.yebeh.2015.12.039] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 12/22/2015] [Accepted: 12/24/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE A UCB-IBM collaboration explored the application of machine learning to large claims databases to construct an algorithm for antiepileptic drug (AED) choice for individual patients. METHODS Claims data were collected between January 2006 and September 2011 for patients with epilepsy > 16 years of age. A subset of patient claims with a valid index date of AED treatment change (new, add, or switch) were used to train the AED prediction model by retrospectively evaluating an index date treatment for subsequent treatment change. Based on the trained model, a model-predicted AED regimen with the lowest likelihood of treatment change was assigned to each patient in the group of test claims, and outcomes were evaluated to test model validity. RESULTS The model had 72% area under receiver operator characteristic curve, indicating good predictive power. Patients who were given the model-predicted AED regimen had significantly longer survival rates (time until a treatment change event) and lower expected health resource utilization on average than those who received another treatment. The actual prescribed AED regimen at the index date matched the model-predicted AED regimen in only 13% of cases; there were large discrepancies in the frequency of use of certain AEDs/combinations between model-predicted AED regimens and those actually prescribed. CONCLUSIONS Chances of treatment success were improved if patients received the model-predicted treatment. Using the model's prediction system may enable personalized, evidence-based epilepsy care, accelerating the match between patients and their ideal therapy, thereby delivering significantly better health outcomes for patients and providing health-care savings by applying resources more efficiently. Our goal will be to strengthen the predictive power of the model by integrating diverse data sets and potentially moving to prospective data collection.
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Affiliation(s)
- Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Medical Center, 223 E. 34th Street, New York, NY 10016, USA.
| | | | - Michal Ozery-Flato
- IBM Research, University of Haifa Campus, Mount Carmel, Haifa 3498825, Israel.
| | - Ranit Aharonov
- IBM Research, University of Haifa Campus, Mount Carmel, Haifa 3498825, Israel.
| | - Ya'ara Goldschmidt
- IBM Research, University of Haifa Campus, Mount Carmel, Haifa 3498825, Israel.
| | - Michal Rosen-Zvi
- IBM Research, University of Haifa Campus, Mount Carmel, Haifa 3498825, Israel.
| | - Chris Clark
- UCB Pharma, 1950 Lake Park Dr., Smyrna, GA 30080, USA.
| | - Patty Fritz
- UCB Pharma, 1950 Lake Park Dr., Smyrna, GA 30080, USA.
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Moura LMVR, Carneiro TS, Cole AJ, Hsu J, Vickrey BG, Hoch DB. Association between addressing antiseizure drug side effects and patient-reported medication adherence in epilepsy. Patient Prefer Adherence 2016; 10:2197-2207. [PMID: 27826186 PMCID: PMC5096772 DOI: 10.2147/ppa.s119973] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIM Adherence to treatment is a critical component of epilepsy management. This study examines whether addressing antiepileptic drug (AED) side effects at every visit is associated with increased patient-reported medication adherence. PATIENTS AND METHODS This study identified 243 adults with epilepsy who were seen at two academic outpatient neurology settings and had at least two visits over a 3-year period. Demographic and clinical characteristics were abstracted. Evidence that AED side effects were addressed was measured through 1) phone interview (patient-reported) and 2) medical records abstraction (physician-documented). Medication adherence was assessed using the validated Morisky Medication Adherence Scale-4. Complete adherence was determined as answering "no" to all questions. RESULTS Sixty-two (25%) patients completed the interviews. Participants and nonparticipants were comparable with respect to demographic and clinical characteristics; however, a smaller proportion of participants had a history of drug-resistant epilepsy than nonparticipants (17.7% vs 30.9%, P=0.04). Among the participants, evidence that AED side effects were addressed was present in 48 (77%) medical records and reported by 51 (82%) patients. Twenty-eight (45%) patients reported complete medication adherence. The most common reason for incomplete adherence was missed medication due to forgetfulness (n=31, 91%). There was no association between addressing AED side effects (neither physician-documented nor patient-reported) and complete medication adherence (P=0.22 and 0.20). DISCUSSION AND CONCLUSION Among patients with epilepsy, addressing medication side effects at every visit does not appear to increase patient-reported medication adherence.
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Affiliation(s)
- Lidia M V R Moura
- Department of Neurology
- Correspondence: Lidia M V R Moura, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Wang 739D, Boston, MA 02114, USA, Tel +1 617 726 3311, Fax +1 617 726 9250, Email
| | | | | | - John Hsu
- Mongan Institute for Health Policy, Department of Medicine, Massachusetts General Hospital
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Barbara G Vickrey
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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CRISPR/Cas9 facilitates investigation of neural circuit disease using human iPSCs: mechanism of epilepsy caused by an SCN1A loss-of-function mutation. Transl Psychiatry 2016; 6:e703. [PMID: 26731440 PMCID: PMC5068877 DOI: 10.1038/tp.2015.203] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/10/2015] [Indexed: 11/10/2022] Open
Abstract
Mutations in SCN1A, the gene encoding the α subunit of Nav1.1 channel, can cause epilepsies with wide ranges of clinical phenotypes, which are associated with the contrasting effects of channel loss-of-function or gain-of-function. In this project, CRISPR/Cas9- and TALEN-mediated genome-editing techniques were applied to induced pluripotent stem cell (iPSC)-based-disease model to explore the mechanism of epilepsy caused by SCN1A loss-of-function mutation. By fluorescently labeling GABAergic subtype in iPSC-derived neurons using CRISPR/Cas9, we for the first time performed electrophysiological studies on SCN1A-expressing neural subtype and monitored the postsynaptic activity of both inhibitory and excitatory types. We found that the mutation c.A5768G, which led to no current of Nav1.1 in exogenously transfected system, influenced the properties of not only Nav current amount, but also Nav activation in Nav1.1-expressing GABAergic neurons. The two alterations in Nav further reduced the amplitudes and enhanced the thresholds of action potential in patient-derived GABAergic neurons, and led to weakened spontaneous inhibitory postsynaptic currents (sIPSCs) in the patient-derived neuronal network. Although the spontaneous excitatory postsynaptic currents (sEPSCs) did not change significantly, when the frequencies of both sIPSCs and sEPSCs were further analyzed, we found the whole postsynaptic activity transferred from the inhibition-dominated state to excitation in patient-derived neuronal networks, suggesting that changes in sIPSCs alone were sufficient to significantly reverse the excitatory level of spontaneous postsynaptic activity. In summary, our findings fill the gap of our knowledge regarding the relationship between SCN1A mutation effect recorded on exogenously transfected cells and on Nav1.1-expressing neurons, and reveal the physiological basis underlying epileptogenesis caused by SCN1A loss-of-function mutation.
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Kwan P, Brodie MJ, Laurenza A, FitzGibbon H, Gidal BE. Analysis of pooled phase III trials of adjunctive perampanel for epilepsy: Impact of mechanism of action and pharmacokinetics on clinical outcomes. Epilepsy Res 2015; 117:117-24. [PMID: 26448264 DOI: 10.1016/j.eplepsyres.2015.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 08/07/2015] [Accepted: 09/07/2015] [Indexed: 11/27/2022]
Abstract
AIM To further explore the impact of concomitant antiepileptic drugs (AEDs) on the efficacy and tolerability of adjunctive perampanel for focal epilepsy. METHODS Data were pooled from three phase III trials of adjunctive perampanel in patients (≥12 years of age) with refractory partial-onset seizures. Concomitant AEDs were categorized according to whether or not they were enzyme-inducing AEDs (EIAEDs; known to reduce perampanel plasma concentrations) or sodium channel blockers (SCBs). Post hoc analyses assessed the impact of co-administration of non-EIAED SCBs and the overall number of concomitant AEDs on changes in seizure frequency, 50% responder rates, rates of treatment-emergent adverse events (TEAEs), and rates of discontinuation due to TEAEs, in patients randomized to receive daily placebo or perampanel 2, 4, 8, or 12mg. RESULTS Amongst 1480 randomized and treated patients, most were receiving two or more concomitant AEDs (n=1273, 86.0%), one or more EIAEDs (n=1083, 73.2%), and/or one or more SCBs (n=1203, 81.3%) at Baseline. The magnitude of seizure reduction appeared unaffected by the presence of non-EIAED SCBs, but lower in the presence of multiple AEDs. Frequency of TEAEs did not appear to be affected by the presence of non-EIAED SCBs or multiple AEDs. CONCLUSION Beyond the known interactions between perampanel and EIAEDs, perampanel efficacy appears to be unaffected by the use of concomitant non-EIAED SCBs, but may be reduced in the presence of multiple concomitant AEDs (possibly indicative of the presence of more refractory epilepsy). Nonetheless, with careful titration to balance efficacy and tolerability, perampanel may be combined with a range of AEDs, facilitating integration into treatment plans.
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Affiliation(s)
- Patrick Kwan
- Department of Medicine, The University of Melbourne, Melbourne, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia; The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | | | - Antonio Laurenza
- Eisai Neuroscience Product Creation Unit, Woodcliff Lake, NJ, USA.
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Faught E, Helmers SL, Begley CE, Thurman DJ, Dilley C, Clark C, Fritz P. Newer antiepileptic drug use and other factors decreasing hospital encounters. Epilepsy Behav 2015; 45:169-75. [PMID: 25819943 DOI: 10.1016/j.yebeh.2015.01.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/16/2015] [Accepted: 01/28/2015] [Indexed: 11/15/2022]
Abstract
A retrospective analysis was conducted in one claims database and was confirmed in a second independent database (covering both commercial and government insurance plans between 11/2009 and 9/2011) for the understanding of factors influencing antiepileptic drug (AED) use and the role of AEDs and other health-care factors in hospital encounters. In both datasets, epilepsy cases were identified by AED use and epilepsy diagnosis coding. Variables analyzed for effect on hospitalization rates were as follows: (1) use of first-generation AEDs or second-generation AEDs, (2) treatment changes, and (3) factors that may affect AED choice. Lower rates of epilepsy-related hospital encounters (encounters with an epilepsy diagnosis code) were associated with use of second-generation AEDs, deliberate treatment changes, and treatment by a neurologist. Epilepsy-related hospital encounters were more frequent for patients not receiving an AED and for those with greater comorbidities. On average, patients taking ≥1 first-generation AED experienced epilepsy-related hospitalizations every 684days, while those taking ≥1second-generation AED were hospitalized every 1001days (relative risk reduction of 31%, p<0.01). Prescriptions for second-generation AEDs were more common among neurologists and among physicians near an epilepsy center. Use of second-generation AEDs, access to specialty care, and deliberate efforts to change medications following epilepsy-related hospital encounters improved outcomes of epilepsy treatment based on average time between epilepsy-related hospital encounters. These factors may be enhanced by public health policies, private insurance reimbursement policies, and education of patients and physicians.
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Affiliation(s)
- Edward Faught
- Department of Neurology, Emory University School of Medicine, 101 Woodruff Circle NE, Atlanta, GA 30322, USA.
| | - Sandra L Helmers
- Department of Neurology, Emory University School of Medicine, 101 Woodruff Circle NE, Atlanta, GA 30322, USA.
| | - Charles E Begley
- Division of Management, Policy, and Community Health, The University of Texas - Houston School of Public Health, 1200 Hermann Pressler Street, E317, Houston, TX 77030, USA.
| | - David J Thurman
- Department of Neurology, Emory University School of Medicine, 101 Woodruff Circle NE, Atlanta, GA 30322, USA.
| | - Cynthia Dilley
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
| | - Chris Clark
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
| | - Patty Fritz
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
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Wang Z, Li X, Powers A, Cavazos JE. Outcomes associated with switching from monotherapy to adjunctive therapy for patients with partial onset seizures. Expert Rev Pharmacoecon Outcomes Res 2014; 15:349-55. [DOI: 10.1586/14737167.2015.989217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
USL255 is a once-daily, extended-release formulation of the well-established antiepileptic drug topiramate that was recently approved by the US FDA. As a capsule formulation, USL255 can be swallowed intact or opened and sprinkled onto soft food for patients with swallowing difficulties, including children (≥2 years old) and older patients. USL255 has been evaluated in seven key Phase I and III studies. Compared with immediate-release topiramate taken twice daily, once-daily USL255 provides equivalent topiramate exposure with a 26% reduction in plasma fluctuations. A multinational, Phase III, randomized, double-blind, placebo-controlled clinical trial in patients with refractory partial-onset seizures (PREVAIL) demonstrated that USL255 (200 mg/day) significantly improved seizure control and clinical outcomes versus placebo. USL255 is generally safe and well-tolerated, with a low incidence of neuropsychiatric and neurocognitive adverse events. These data suggest that USL255 may provide a useful treatment option for seizure control with convenient once-daily dosing.
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Affiliation(s)
- Steve Chung
- Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Suite 300, Phoenix, AZ 85013, USA
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