51
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Römer M, Dörfler J, Huebner J. The use of ketogenic diets in cancer patients: a systematic review. Clin Exp Med 2021; 21:501-536. [PMID: 33813635 PMCID: PMC8505380 DOI: 10.1007/s10238-021-00710-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/26/2021] [Indexed: 12/29/2022]
Abstract
Ketogenic diets are a widely known, yet controversial treatment for cancer patients. In this review, we summarize the clinical evidence for anti-tumor effects, as well as the effects on anthropometry, quality of life, adverse events and adherence in cancer patients. In April 2019, a systematic search was conducted searching five electronic databases (EMBASE, Cochrane, PsychInfo, CINAHL and Medline) to find studies analyzing the use, effectiveness and potential harm of a ketogenic diet in cancer patients of any age as sole or complementary therapy. From all 19.211 search results, 46 publications concerning 39 studies with 770 patients were included in this systematic review. The therapy concepts included all forms of diets with reduced carbohydrate intake, that aimed to achieve ketosis for patients with different types of cancer. Most studies had a low quality, high risk of bias and were highly heterogeneous. There was no conclusive evidence for anti-tumor effects or improved OS. The majority of patients had significant weight loss and mild to moderate side effects. Adherence to the diet was rather low in most studies. Due to the very heterogeneous results and methodological limitations of the included studies, clinical evidence for the effectiveness of ketogenic diets in cancer patients is still lacking.
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Affiliation(s)
- Maximilian Römer
- Klinik Für Innere Medizin II, Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
| | - Jennifer Dörfler
- Klinik Für Innere Medizin II, Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Jutta Huebner
- Klinik Für Innere Medizin II, Hämatologie Und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
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The Effects of a Ketogenic Diet on Patients with Dihydrolipoamide Dehydrogenase Deficiency. Nutrients 2021; 13:nu13103523. [PMID: 34684524 PMCID: PMC8540285 DOI: 10.3390/nu13103523] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Dihydrolipoamide dehydrogenase (DLD lipoamide dehydrogenase, the E3 subunit of the pyruvate dehydrogenase complex (PDHC)) is the third catalytic enzyme of the PDHC, which converts pyruvate to acetyl-CoA catalyzed with the introduction of acetyl-CoA to the tricyclic acid (TCA) cycle. In humans, PDHC plays an important role in maintaining glycose homeostasis in an aerobic, energy-generating process. Inherited DLD-E3 deficiency, caused by the pathogenic variants in DLD, leads to variable presentations and courses of illness, ranging from myopathy, recurrent episodes of liver disease and vomiting, to Leigh disease and early death. Currently, there is no consensus on treatment guidelines, although one suggested solution is a ketogenic diet (KD). Objective: To describe the use and effects of KD in patients with DLD-E3 deficiency, compared to the standard treatment. Results: Sixteen patients were included. Of these, eight were from a historical cohort, and of the other eight, four were on a partial KD. All patients were homozygous for the D479V (or D444V, which corresponds to the mutated mature protein without the mitochondrial targeting sequence) pathogenic variant in DLD. The treatment with partial KD was found to improve patient survival. However, compared to a historical cohort, the patients’ quality of life (QOL) was not significantly improved. Conclusions: The use of KD offers an advantage regarding survival; however, there is no significant improvement in QOL.
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53
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Dietary-Induced Ketogenesis: Adults Are Not Children. Nutrients 2021; 13:nu13093093. [PMID: 34578970 PMCID: PMC8467931 DOI: 10.3390/nu13093093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 08/28/2021] [Accepted: 08/30/2021] [Indexed: 01/01/2023] Open
Abstract
There is increasing interest in the use of a ketogenic diet for various adult disorders; however, the ability of adults to generate ketones is unknown. Our goal was to challenge the hypothesis that there would be no difference between adults and children regarding their ability to enter ketosis. Methods: Two populations were studied, both treated with identical very low-carbohydrate high-fat diets: a retrospective series of children with epilepsy or/and metabolic disorders (2009–2016) and a prospective clinical trial of adults with glioblastoma. Dietary intake was assessed based upon written food diaries and 24-h dietary recall. Ketogenic ratio was calculated according to [grams of fat consumed]/[grams of carbohydrate and protein consumed]. Ketone levels (β-hydroxybutyrate) were measured in blood and/or urine. Results: A total of 168 encounters amongst 28 individuals were analyzed. Amongst both children and adults, ketone levels correlated with nutritional ketogenic ratio; however, the absolute ketone levels in adults were approximately one quarter of those seen in children. This difference was highly significant in a multivariate linear regression model, p < 0.0001. Conclusions: For diets with comparable ketogenic ratios, adults have lower blood ketone levels than children; consequently, high levels of nutritional ketosis are unobtainable in adults.
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Cervenka M, Pascual JM, Rho JM, Thiele E, Yellen G, Whittemore V, Hartman AL. Metabolism-based therapies for epilepsy: new directions for future cures. Ann Clin Transl Neurol 2021; 8:1730-1737. [PMID: 34247456 PMCID: PMC8351378 DOI: 10.1002/acn3.51423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/28/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Thousands of years after dietary therapy was proposed to treat seizures, how alterations in metabolism relates to epilepsy remains unclear, and metabolism-based therapies are not always effective. METHODS We consider the state of the science in metabolism-based therapies for epilepsy across the research lifecycle from basic to translational to clinical studies. RESULTS This analysis creates a conceptual framework for creative, rigorous, and transparent research to benefit people with epilepsy through the understanding and modification of metabolism. INTERPRETATION Despite intensive past efforts to evaluate metabolism-based therapies for epilepsy, distinct ways of framing a problem offer the chance to engage different mindsets and new (or newly applied) technologies. A comprehensive, creative, and inclusive problem-directed research agenda is needed, with a renewed and stringent adherence to rigor and transparency across all levels of investigation.
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Affiliation(s)
- Mackenzie Cervenka
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Juan M. Pascual
- Department of NeurologyUniversity of Texas SouthwesternDallasTexasUSA
| | - Jong M. Rho
- Departments of Neurosciences and PediatricsUniversity of CaliforniaSan DiegoCaliforniaUSA
| | - Elizabeth Thiele
- Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Gary Yellen
- Department of NeurobiologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Vicky Whittemore
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthRockvilleMarylandUSA
| | - Adam L. Hartman
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthRockvilleMarylandUSA
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55
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Kaul N, Nicolo JP, O’Brien TJ, Kwan P. Practical considerations of dietary therapies for epilepsy in adults. ACTA EPILEPTOLOGICA 2021. [DOI: 10.1186/s42494-021-00051-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractDespite the increasing number of anti-seizure medications becoming available, the proportion of patients with drug-resistant epilepsy remains unchanged. Dietary therapy for epilepsy is well-established practice in paediatric care, but relatively underutilised in adults. Recently, international recommendations have been published to guide the treatment of adults receiving dietary therapy for epilepsy.This review focuses on the specific aspects of care unique to the management of adults receiving dietary therapy for epilepsy, including patient selection, diet composition, initiation, monitoring and cessation of dietary treatment. We emphasise the need for a multidisciplinary team approach with appropriately trained neurologists and dietitians to provide holistic care while the patients are receiving dietary therapy. Future research should focus on the optimal diet composition and meeting the psychosocial needs of adults with epilepsy to maximise efficacy and adherence to dietary treatment.
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Lambert B, Lightfoot K, Meskell R, Whiteley VJ, Martin-McGill KJ, Schoeler NE. Keto-on-the-Clock: A Survey of Dietetic Care Contact Time Taken to Provide Ketogenic Diets for Drug-Resistant Epilepsy in the UK. Nutrients 2021; 13:nu13082484. [PMID: 34444643 PMCID: PMC8400576 DOI: 10.3390/nu13082484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
Medical ketogenic diets (KDs) are effective yet resource-intensive treatment options for drug-resistant epilepsy (DRE). We investigated dietetic care contact time, as no recent data exist. An online survey was circulated to ketogenic dietitians in the UK and Ireland. Data were collected considering feeding route, KD variant and type of ketogenic enteral feed (KEF), and the estimated number of hours spent on patient-related activities during the patient journey. Fifteen dietitians representing nine KD centres responded. Of 335 patients, 267 (80%) were 18 years old or under. Dietitians spent a median of 162 h (IQR 54) of care contact time per patient of which a median of 48% (IQR 6) was direct contact. Most time was required for the classical KD taken orally (median 193 h; IQR 213) as a combined tube and oral intake (median 211 h; IQR 172) or a blended food KEF (median 189 h; IQR 148). Care contact time per month was higher for all KDs during the three-month initial trial compared to the two-year follow-up stage. Patients and caregivers with characteristics such as learning or language difficulties were identified as taking longer. Twelve out of fifteen (80%) respondents managed patients following the KD for more than two years, requiring an estimated median contact care time of 2 h (IQR 2) per patient per month. Ten out of fifteen (67%) reported insufficient official hours for dietetic activities. Our small survey gives insight into estimated dietetic care contact time, with potential application for KD provision and service delivery
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Affiliation(s)
- Bridget Lambert
- Vitaflo (International) Ltd., 182 Sefton Street, Liverpool L3 4BQ, UK;
| | - Kathryn Lightfoot
- Leeds Children’s Hospital, 2nd Floor, 2 Park Lane, Leeds LS3 1ES, UK; (K.L.); (R.M.)
| | - Rachel Meskell
- Leeds Children’s Hospital, 2nd Floor, 2 Park Lane, Leeds LS3 1ES, UK; (K.L.); (R.M.)
| | - Victoria J. Whiteley
- Royal Manchester Children’s Hospital, Oxford Road, Manchester M13 9WL, UK;
- School of Health and Society, University of Salford, 43 The Crescent, Manchester M5 4WT, UK
| | - Kirsty J. Martin-McGill
- Department of Clinical Sciences and Nutrition, University of Chester, Parkgate Road, Chester CH1 4BJ, UK;
| | - Natasha E. Schoeler
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK
- Correspondence: ; Tel.: +44-(0)-20-7242-9789
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57
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Zweers H, van Wegberg AMJ, Janssen MCH, Wortmann SB. Ketogenic diet for mitochondrial disease: a systematic review on efficacy and safety. Orphanet J Rare Dis 2021; 16:295. [PMID: 34217336 PMCID: PMC8254320 DOI: 10.1186/s13023-021-01927-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/13/2021] [Indexed: 12/01/2022] Open
Abstract
Background No curative therapy for mitochondrial disease (MD) exists, prioritizing supportive treatment for symptom relief. In animal and cell models ketones decrease oxidative stress, increase antioxidants and scavenge free radicals, putting ketogenic diets (KDs) on the list of management options for MD. Furthermore, KDs are well-known, safe and effective treatments for epilepsy, a frequent symptom of MD. This systematic review evaluates efficacy and safety of KD for MD. Methods We searched Pubmed, Cochrane, Embase and Cinahl (November 2020) with search terms linked to MD and KD. From the identified records, we excluded studies on Pyruvate Dehydrogenase Complex deficiency. From these eligible reports, cases without a genetically confirmed diagnosis and cases without sufficient data on KD and clinical course were excluded. The remaining studies were included in the qualitative analysis. Results Only 20 cases (14 pediatric) from the 694 papers identified met the inclusion criteria (one controlled trial (n = 5), 15 case reports). KD led to seizure control in 7 out of 8 cases and improved muscular symptoms in 3 of 10 individuals. In 4 of 20 cases KD reversed the clinical phenotype (e.g. cardiomyopathy, movement disorder). In 5 adults with mitochondrial DNA deletion(s) related myopathy rhabdomyolysis led to cessation of KD. Three individuals with POLG mutations died while being on KD, however, their survival was not different compared to individuals with POLG mutations without KD. Conclusion Data on efficacy and safety of KD for MD is too scarce for general recommendations. KD should be considered in individuals with MD and therapy refractory epilepsy, while KD is contraindicated in mitochondrial DNA deletion(s) related myopathy. When considering KD for MD the high rate of adverse effects should be taken into account, but also spectacular improvements in individual cases. KD is a highly individual management option in this fragile patient group and requires an experienced team. To increase knowledge on this—individually—promising management option more (prospective) studies using adequate outcome measures are crucial. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01927-w.
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Affiliation(s)
- Heidi Zweers
- Department of Gastroenterology and Hepatology - Dietetics, Radboudumc, Postbus 9101, 6500 HB, Nijmegen, The Netherlands. .,Radboud Center for Mitochondrial Medicine (RCMM), Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands.
| | - Annemiek M J van Wegberg
- Department of Gastroenterology and Hepatology - Dietetics, Radboudumc, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Mitochondrial Medicine (RCMM), Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands
| | - Mirian C H Janssen
- Radboud Center for Mitochondrial Medicine (RCMM), Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands.,Department of Internal Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Saskia B Wortmann
- Radboud Center for Mitochondrial Medicine (RCMM), Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands.,University Children's Hospital, Paracelsus Medical University, Salzburg, Austria
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58
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Epilepsy in Mitochondrial Diseases-Current State of Knowledge on Aetiology and Treatment. CHILDREN-BASEL 2021; 8:children8070532. [PMID: 34206602 PMCID: PMC8303198 DOI: 10.3390/children8070532] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/02/2021] [Accepted: 06/18/2021] [Indexed: 12/22/2022]
Abstract
Mitochondrial diseases are a heterogeneous group of diseases resulting from energy deficit and reduced adenosine triphosphate (ATP) production due to impaired oxidative phosphorylation. The manifestation of mitochondrial disease is usually multi-organ. Epilepsy is one of the most common manifestations of diseases resulting from mitochondrial dysfunction, especially in children. The onset of epilepsy is associated with poor prognosis, while its treatment is very challenging, which further adversely affects the course of these disorders. Fortunately, our knowledge of mitochondrial diseases is still growing, which gives hope for patients to improve their condition in the future. The paper presents the pathophysiology, clinical picture and treatment options for epilepsy in patients with mitochondrial disease.
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59
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Fattorusso A, Matricardi S, Mencaroni E, Dell'Isola GB, Di Cara G, Striano P, Verrotti A. The Pharmacoresistant Epilepsy: An Overview on Existent and New Emerging Therapies. Front Neurol 2021; 12:674483. [PMID: 34239494 PMCID: PMC8258148 DOI: 10.3389/fneur.2021.674483] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/27/2021] [Indexed: 12/21/2022] Open
Abstract
Epilepsy is one of the most common neurological chronic disorders, with an estimated prevalence of 0. 5 - 1%. Currently, treatment options for epilepsy are predominantly based on the administration of symptomatic therapy. Most patients are able to achieve seizure freedom by the first two appropriate drug trials. Thus, patients who cannot reach a satisfactory response after that are defined as pharmacoresistant. However, despite the availability of more than 20 antiseizure medications (ASMs), about one-third of epilepsies remain drug-resistant. The heterogeneity of seizures and epilepsies, the coexistence of comorbidities, and the broad spectrum of efficacy, safety, and tolerability related to the ASMs, make the management of these patients actually challenging. In this review, we analyze the most relevant clinical and pathogenetic issues related to drug-resistant epilepsy, and then we discuss the current evidence about the use of available ASMs and the alternative non-pharmacological approaches.
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Affiliation(s)
- Antonella Fattorusso
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | - Sara Matricardi
- Child Neurology and Psychiatry Unit, Children's Hospital “G. Salesi”, Ospedali Riuniti Ancona, Ancona, Italy
| | - Elisabetta Mencaroni
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | | | - Giuseppe Di Cara
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS “G. Gaslini” Institute, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Alberto Verrotti
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
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60
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Zhang Y, Zhang T, Yang W, Chen H, Geng X, Li G, Chen H, Wang Y, Li L, Sun B. Beneficial Diets and Pancreatic Cancer: Molecular Mechanisms and Clinical Practice. Front Oncol 2021; 11:630972. [PMID: 34123787 PMCID: PMC8193730 DOI: 10.3389/fonc.2021.630972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/19/2021] [Indexed: 01/02/2023] Open
Abstract
Pancreatic cancer (PC) is a malignant tumor with high invasiveness, easy metastatic ability, and chemoresistance. Patients with PC have an extremely low survival rate due to the difficulty in early diagnosis. It is estimated that nearly 90% of PC cases are caused by environmental risk factors. Approximately 50% of PC cases are induced by an unhealthy diet, which can be avoided. Given this large attribution to diet, numerous studies have assessed the relationship between various dietary factors and PC. This article reviews three beneficial diets: a ketogenic diet (KD), a Mediterranean diet (MD), and a low-sugar diet. Their composition and impact mechanism are summarized and discussed. The associations between these three diets and PC were analyzed, and we aimed to provide more help and new insights for the prevention and treatment of PC.
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Affiliation(s)
- Yang Zhang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Tao Zhang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wenbo Yang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongze Chen
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xinglong Geng
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guanqun Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hua Chen
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yongwei Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Le Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, China
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61
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Platten M, Friedrich M, Wainwright DA, Panitz V, Opitz CA. Tryptophan metabolism in brain tumors - IDO and beyond. Curr Opin Immunol 2021; 70:57-66. [PMID: 33813026 DOI: 10.1016/j.coi.2021.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/27/2021] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
Metabolism of the essential amino acid tryptophan is a key metabolic pathway that restricts antitumor immunity and is a drug development target for cancer immunotherapy. Tryptophan metabolism is active in brain tumors including gliomas and promotes a malignant phenotype and contributes to the immunosuppressive tumor microenvironment. In recent years, improved understanding of the regulation and downstream function of tryptophan metabolism has been significantly expanded beyond the initial in vitro observation that the enzyme indoleamine-2,3-dioxygenase 1 (IDO1) promotes the depletion of intracellular tryptophan. Here, we revisit the specific roles of tryptophan metabolites in regulating brain functioning and neuronal integrity as well as in the context of brain tumors. This review summarizes recent developments in identifying key regulators, as well as the cellular and molecular effects of tryptophan metabolism with a particular focus on potential therapeutic targets in glioma.
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Affiliation(s)
- Michael Platten
- Department of Neurology, Medical Faculty Mannheim, MCTN, Heidelberg University, Heidelberg, Germany; DKTK CCU Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Mirco Friedrich
- Department of Neurology, Medical Faculty Mannheim, MCTN, Heidelberg University, Heidelberg, Germany; DKTK CCU Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Derek A Wainwright
- Departments of Neurological Surgery, Medicine - Division of Hematology/Oncology, and Microbiology-Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Verena Panitz
- DKTK Brain Cancer Metabolism Group, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Neurology and National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Christiane A Opitz
- DKTK Brain Cancer Metabolism Group, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Neurology and National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany.
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62
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Schoeler NE, Simpson Z, Zhou R, Pujar S, Eltze C, Cross JH. Dietary Management of Children With Super-Refractory Status Epilepticus: A Systematic Review and Experience in a Single UK Tertiary Centre. Front Neurol 2021; 12:643105. [PMID: 33776895 PMCID: PMC7994594 DOI: 10.3389/fneur.2021.643105] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/17/2021] [Indexed: 12/16/2022] Open
Abstract
Ketogenic diet therapies (KDT) are high-fat, low carbohydrate diets used as an effective treatment option for drug-resistant epilepsy. There is limited research on the efficacy of KDT for super-refractory status epilepticus (SRSE). We systematically review evidence for use of KDT in children with SRSE and present a single UK tertiary centre's experience. Thirty one articles were included, of which 24 were “medium” or “low” quality. One hundred and forty seven children with SRSE started KDT, of which 141 (96%) achieved ketosis. KDT was started mean 5.3 days (range 1–420) after status epilepticus (SE) started. SRSE resolved in 85/141 (60%) children after mean 6.3 days (range 0–19) post SE onset, but it is unclear whether further treatments were initiated post-KDT. 13/141 (9%) children died. Response to KDT was more likely when initiated earlier (p = 0.03) and in females (p = 0.01). Adverse side effects were reported in 48/141 (34%), mostly gastrointestinal; potentially serious adverse effects occurred in ≤4%. Eight children with SRSE, all diagnosed with febrile infection-related epilepsy syndrome, were treated with KDT at Great Ormond Street Hospital for Children. KDT was initiated enterally at mean day 13.6+/− 5.1 of admission. Seven of 8 (88%) children reported adverse side effects, which were potentially serious in 4/8 (50%), including metabolic acidosis, hypoglycaemia and raised amylase. SE ceased in 6/8 (75%) children after mean 25+/− 9.4 days post onset, but other treatments were often started concomitantly and all children started other treatments post-KDT. Two of 8 (25%) children died during admission and another died post-admission. Four of the remaining 5 children continue to have drug-resistant seizures, one of whom remains on KDT; seizure burden was unknown for one child. Our findings indicate that KDT is possible and safe in children with SRSE. Cessation of SRSE may occur in almost two-thirds of children initiated with KDT, but a causal effect is difficult to determine due to concomitant treatments, treatments started post-KDT and the variable length of time post-KDT onset when SRSE cessation occurs. Given that serious adverse side effects seem rare and response rates are (cautiously) favorable, KDT should be considered as an early treatment option in this group.
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Affiliation(s)
- Natasha E Schoeler
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Zoe Simpson
- Department of Dietetics, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Runming Zhou
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Suresh Pujar
- Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Christin Eltze
- Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - J H Cross
- Developmental Neurosciences Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Paediatric and Neurology, Great Ormond Street Hospital for Children, London, United Kingdom.,Young Epilepsy, Lingfield, United Kingdom
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63
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Enhancement of Ketone Supplements-Evoked Effect on Absence Epileptic Activity by Co-Administration of Uridine in Wistar Albino Glaxo Rijswijk Rats. Nutrients 2021; 13:nu13010234. [PMID: 33467454 PMCID: PMC7830695 DOI: 10.3390/nu13010234] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/05/2021] [Accepted: 01/12/2021] [Indexed: 12/11/2022] Open
Abstract
Both uridine and exogenous ketone supplements decreased the number of spike-wave discharges (SWDs) in a rat model of human absence epilepsy Wistar Albino Glaxo/Rijswijk (WAG/Rij) rats. It has been suggested that alleviating influence of both uridine and ketone supplements on absence epileptic activity may be modulated by A1 type adenosine receptors (A1Rs). The first aim was to determine whether intraperitoneal (i.p.) administration of a specific A1R antagonist 1,3-dipropyl-8-cyclopentylxanthine (DPCPX; 0.2 mg/kg) and a selective adenosine A2A receptor antagonist (7-(2-phenylethyl)-5-amino-2-(2-furyl)-pyrazolo-[4,3-e]-1,2,4-triazolo [1,5-c]pyrimidine) (SCH 58261; 0.5 mg/kg) have a modulatory influence on i.p. 1000 mg/kg uridine-evoked effects on SWD number in WAG/Rij rats. The second aim was to assess efficacy of a sub-effective dose of uridine (i.p. 250 mg/kg) combined with beta-hydroxybutyrate salt + medium chain triglyceride (KSMCT; 2.5 g/kg, gavage) on absence epilepsy. DPCPX completely abolished the i.p. 1000 mg/kg uridine-evoked alleviating effect on SWD number whereas SCH 58261 was ineffective, confirming the A1R mechanism. Moreover, the sub-effective dose of uridine markedly enhanced the effect of KSMCT (2.5 g/kg, gavage) on absence epileptic activity. These results demonstrate the anti-epilepsy benefits of co-administrating uridine and exogenous ketone supplements as a means to treat absence epilepsy.
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Guery D, Rheims S. Clinical Management of Drug Resistant Epilepsy: A Review on Current Strategies. Neuropsychiatr Dis Treat 2021; 17:2229-2242. [PMID: 34285484 PMCID: PMC8286073 DOI: 10.2147/ndt.s256699] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022] Open
Abstract
Drug resistant epilepsy (DRE) is defined as the persistence of seizures despite at least two syndrome-adapted antiseizure drugs (ASD) used at efficacious daily dose. Despite the increasing number of available ASD, about a third of patients with epilepsy still suffer from drug resistance. Several factors are associated with the risk of evolution to DRE in patients with newly diagnosed epilepsy, including epilepsy onset in the infancy, intellectual disability, symptomatic epilepsy and abnormal neurological exam. Pharmacological management often consists in ASD polytherapy. However, because quality of life is driven by several factors in patients with DRE, including the tolerability of the treatment, ASD management should try to optimize efficacy while anticipating the risks of drug-related adverse events. All patients with DRE should be evaluated at least once in a tertiary epilepsy center, especially to discuss eligibility for non-pharmacological therapies. This is of paramount importance in patients with drug resistant focal epilepsy in whom epilepsy surgery can result in long-term seizure freedom. Vagus nerve stimulation, deep brain stimulation or cortical stimulation can also improve seizure control. Lastly, considering the effect of DRE on psychologic status and social integration, comprehensive care adaptations are always needed in order to improve patients' quality of life.
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Affiliation(s)
- Deborah Guery
- Department of Functional Neurology and Epileptology, Hospices Civils De Lyon and University of Lyon, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils De Lyon and University of Lyon, Lyon, France.,Lyon's Neuroscience Research Center, INSERM U1028/CNRS UMR 5292, Lyon, France.,Epilepsy Institute, Lyon, France
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Fei Y, Shi R, Song Z, Wu J. Metabolic Control of Epilepsy: A Promising Therapeutic Target for Epilepsy. Front Neurol 2020; 11:592514. [PMID: 33363507 PMCID: PMC7753014 DOI: 10.3389/fneur.2020.592514] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/20/2020] [Indexed: 12/16/2022] Open
Abstract
Epilepsy is a common neurological disease that is not always controlled, and the ketogenic diet shows good antiepileptic effects drug-resistant epilepsy or seizures caused by specific metabolic defects via regulating the metabolism. The brain is a vital organ with high metabolic demands, and epileptic foci tend to exhibit high metabolic characteristics. Accordingly, there has been growing interest in the relationship between brain metabolism and epilepsy in recent years. To date, several new antiepileptic therapies targeting metabolic pathways have been proposed (i.e., inhibiting glycolysis, targeting lactate dehydrogenase, and dietary therapy). Promising strategies to treat epilepsy via modulating the brain's metabolism could be expected, while a lack of thorough understanding of the role of brain metabolism in the control of epilepsy remains. Herein, this review aims to provide insight into the state of the art concerning the brain's metabolic patterns and their association with epilepsy. Regulation of neuronal excitation via metabolic pathways and antiepileptic therapies targeting metabolic pathways are emphasized, which could provide a better understanding of the role of metabolism in epilepsy and could reveal potential therapeutic targets.
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Affiliation(s)
- Yanqing Fei
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ruting Shi
- Department of Rehabilitation, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhi Song
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jinze Wu
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, China
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