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Klein P, Kaminski RM, Koepp M, Löscher W. New epilepsy therapies in development. Nat Rev Drug Discov 2024; 23:682-708. [PMID: 39039153 DOI: 10.1038/s41573-024-00981-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/24/2024]
Abstract
Epilepsy is a common brain disorder, characterized by spontaneous recurrent seizures, with associated neuropsychiatric and cognitive comorbidities and increased mortality. Although people at risk can often be identified, interventions to prevent the development of the disorder are not available. Moreover, in at least 30% of patients, epilepsy cannot be controlled by current antiseizure medications (ASMs). As a result of considerable progress in epilepsy genetics and the development of novel disease models, drug screening technologies and innovative therapeutic modalities over the past 10 years, more than 200 novel epilepsy therapies are currently in the preclinical or clinical pipeline, including many treatments that act by new mechanisms. Assisted by diagnostic and predictive biomarkers, the treatment of epilepsy is undergoing paradigm shifts from symptom-only ASMs to disease prevention, and from broad trial-and-error treatments for seizures in general to mechanism-based treatments for specific epilepsy syndromes. In this Review, we assess recent progress in ASM development and outline future directions for the development of new therapies for the treatment and prevention of epilepsy.
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Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA.
| | | | - Matthias Koepp
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Wolfgang Löscher
- Translational Neuropharmacology Lab., NIFE, Department of Experimental Otology of the ENT Clinics, Hannover Medical School, Hannover, Germany.
- Center for Systems Neuroscience, Hannover, Germany.
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2
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Manners J, Jusuf E, Parikh GY, Gasior M, Vaitkevicius H, Morris NA. Super Refractory Status Epilepticus Improved After Emergency Use of Ganaxolone: Case Report. Neurohospitalist 2024; 14:327-331. [PMID: 38895012 PMCID: PMC11181981 DOI: 10.1177/19418744241232181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
We present a case of a 34-year-old man with epilepsy who developed super refractory status epilepticus in the setting of COVID-19 pneumonia in whom aggressive therapy with multiple parenteral, enteral, and non-pharmacologic interventions were utilized without lasting improvement in clinical examination or electroencephalogram (EEG). The patient presented with multiple recurrences of electrographic status epilepticus throughout a prolonged hospital stay. Emergency use authorization was obtained for intravenous ganaxolone, a neuroactive steroid that is a potent modulator of both synaptic and extrasynaptic GABAA receptors. Following administration of intravenous ganaxolone according to a novel dosing paradigm, the patient showed sustained clinical and electrographic improvement.
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Affiliation(s)
- Jody Manners
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
- Naval Medical Leader and Professional Development Command, Bethesda, MD, USA
| | - Emily Jusuf
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gunjan Y. Parikh
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Nicholas A. Morris
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
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3
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Almohaish S, Tesoro EP, Brophy GM. Status Epilepticus: An Update on Pharmacological Management. Semin Neurol 2024; 44:324-332. [PMID: 38580318 DOI: 10.1055/s-0044-1785503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Status epilepticus (SE) is a neurological emergency that requires timely pharmacological therapy to cease seizure activity. The treatment approach varies based on the time and the treatment stage of SE. Benzodiazepines are considered the first-line therapy during the emergent treatment phase of SE. Antiseizure medicines such as phenytoin, valproic acid, and levetiracetam are recommended during the urgent treatment phase. These drugs appear to have a similar safety and efficacy profile, and individualized therapy should be chosen based on patient characteristics. Midazolam, propofol, pentobarbital, and ketamine are continuous intravenous infusions of anesthetic medications utilized in the refractory SE (RSE) period. The most efficacious pharmacotherapeutic treatments for RSE and superrefractory status epilepticus are not clearly defined.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Eljim P Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
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4
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Durai Samy NK, Taksande K. Exploring Ciprofol Alternatives: A Comprehensive Review of Intravenous Anesthesia Options. Cureus 2024; 16:e57581. [PMID: 38707079 PMCID: PMC11069617 DOI: 10.7759/cureus.57581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
Ciprofol is a recently developed, short-acting γ-aminobutyric acid receptor agonist sedative that is more potent than propofol. Still, there have been few clinical studies of this agent to date. This review explores alternative intravenous anesthesia options to ciprofol, considering their pharmacology, clinical efficacy, safety profile, and practical considerations. While ciprofol offers advantages such as rapid onset and predictable offset, concerns regarding its safety profile and individual variability in response have prompted the search for alternatives. Propofol, etomidate, ketamine, and dexmedetomidine are discussed as established options, each with unique characteristics and potential benefits. Emerging agents, including remimazolam, sufentanil, alfaxalone, and brexanolone, are examined for their potential role in anesthesia management. Recommendations for future research include large-scale comparative studies, optimization of dosing strategies, and personalized approaches guided by pharmacogenomic insights. Ultimately, the future of intravenous anesthesia lies in a multifaceted approach that integrates evidence-based practices, technological innovations, and individualized patient care to enhance safety, efficacy, and patient satisfaction across the perioperative continuum. Collaboration among stakeholders will be crucial in advancing the field and shaping the future landscape of intravenous anesthesia options.
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Affiliation(s)
- Nandha Kumar Durai Samy
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Karuna Taksande
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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5
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Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, Bartos JA, Rodriguez AJ, Kurz MC, Panchal AR, Rittenberger JC. 2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2024; 149:e254-e273. [PMID: 38108133 DOI: 10.1161/cir.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.
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Reddy DS. Neurosteroids as Novel Anticonvulsants for Refractory Status Epilepticus and Medical Countermeasures for Nerve Agents: A 15-Year Journey to Bring Ganaxolone from Bench to Clinic. J Pharmacol Exp Ther 2024; 388:273-300. [PMID: 37977814 PMCID: PMC10801762 DOI: 10.1124/jpet.123.001816] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/05/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023] Open
Abstract
This article describes recent advances in the use of neurosteroids as novel anticonvulsants for refractory status epilepticus (RSE) and as medical countermeasures (MCs) for organophosphates and chemical nerve agents (OPNAs). We highlight a comprehensive 15-year journey to bring the synthetic neurosteroid ganaxolone (GX) from bench to clinic. RSE, including when caused by nerve agents, is associated with devastating morbidity and permanent long-term neurologic dysfunction. Although recent approval of benzodiazepines such as intranasal midazolam and intranasal midazolam offers improved control of acute seizures, novel anticonvulsants are needed to suppress RSE and improve neurologic function outcomes. Currently, few anticonvulsant MCs exist for victims of OPNA exposure and RSE. Standard-of-care MCs for postexposure treatment include benzodiazepines, which do not effectively prevent or mitigate seizures resulting from nerve agent intoxication, leaving an urgent unmet medical need for new anticonvulsants for RSE. Recently, we pioneered neurosteroids as next-generation anticonvulsants that are superior to benzodiazepines for treatment of OPNA intoxication and RSE. Because GX and related neurosteroids that activate extrasynaptic GABA-A receptors rapidly control seizures and offer robust neuroprotection by reducing neuronal damage and neuroinflammation, they effectively improve neurologic outcomes after acute OPNA exposure and RSE. GX has been selected for advanced, Biomedical Advanced Research and Development Authority-supported phase 3 trials of RSE and nerve agent seizures. In addition, in mechanistic studies of neurosteroids at extrasynaptic receptors, we identified novel synthetic analogs with features that are superior to GX for current medical needs. Development of new MCs for RSE is complex, tedious, and uncertain due to scientific and regulatory challenges. Thus, further research will be critical to fill key gaps in evaluating RSE and anticonvulsants in vulnerable (pediatric and geriatric) populations and military persons. SIGNIFICANCE STATEMENT: Following organophosphate and nerve agent intoxication, refractory status epilepticus (RSE) occurs despite benzodiazepine treatment. RSE occurs in 40% of status epilepticus patients, with a 35% mortality rate and significant neurological morbidity in survivors. To treat RSE, neurosteroids are better anticonvulsants than benzodiazepines. Our pioneering use of neurosteroids for RSE and nerve agents led us to develop ganaxolone as a novel anticonvulsant and neuroprotectant with significantly improved neurological outcomes. This article describes the bench-to-bedside journey of bringing neurosteroid therapy to patients, with ganaxolone leading the way.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, Texas and Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, Bryan, Texas
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7
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Meshkat S, Teopiz KM, Di Vincenzo JD, Bailey JB, Rosenblat JD, Ho RC, Rhee TG, Ceban F, Kwan ATH, Cao B, McIntyre RS. Clinical efficacy and safety of Zuranolone (SAGE-217) in individuals with major depressive disorder. J Affect Disord 2023; 340:893-898. [PMID: 37557991 DOI: 10.1016/j.jad.2023.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/16/2023] [Accepted: 08/03/2023] [Indexed: 08/11/2023]
Abstract
Major depressive disorder (MDD) is a common mental disorder with a high rate of morbidity and mortality. Dysfunctional signaling of gamma-aminobutyric acid (GABA) has been implicated in some studies in the etiology of MDD. Zuranolone (SAGE-217) is a novel, oral neuroactive steroid and an investigational positive allosteric modulator of synaptic and extrasynaptic GABAA receptors. Herein, we aimed to evaluate the efficacy and safety of Zuranolone in individuals with MDD. We reviewed seven studies including 1662 participants with MDD. Zuranolone was investigated as an oral, once-daily, 14-day treatment course. The results of our synthesis indicate that the antidepressant effects of Zuranolone are rapid, clinically meaningful, and replicated across multiple randomized clinical trials. In addition to replicated efficacy, Zuranolone is associated with an acceptable level of treatment-emergent adverse events and discontinuation without serious adverse events. It is believed that Zuranolone's antidepressant effects arise from its ability to enhance inhibitory GABAergic signaling by increasing synaptic and extrasynaptic GABAA activity and regulation of GABAA receptor expression. Taken together, preliminary evidence suggests the potential for antidepressant effects of Zuranolone. Zuranolone has been approved by FDA for postpartum depression, and is showing efficacy in major depressive disorder. Future research vistas should seek to determine the durability of this treatment approach as well as its effects on domain-specific outcomes (e.g., anhedonia, circadian rhythm, arousal systems) along with application in other diagnostic entities (e.g., bipolar depression).
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Affiliation(s)
- Shakila Meshkat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Julia B Bailey
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Roger C Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Felicia Ceban
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Angela T H Kwan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Faculty of Medicine, Ottawa University, Ottawa, Ontario, Canada
| | - Bing Cao
- School of Psychology and Key Laboratory of Cognition and Personality, Ministry of Education, Southwest University, Chongqing 400715, PR China
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada.
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8
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Perucca E, Bialer M, White HS. New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: I. Role of GABA as a Modulator of Seizure Activity and Recently Approved Medications Acting on the GABA System. CNS Drugs 2023; 37:755-779. [PMID: 37603262 PMCID: PMC10501955 DOI: 10.1007/s40263-023-01027-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/22/2023]
Abstract
γ-Aminobutyric acid (GABA) is the most prevalent inhibitory neurotransmitter in the mammalian brain and has been found to play an important role in the pathogenesis or the expression of many neurological diseases, including epilepsy. Although GABA can act on different receptor subtypes, the component of the GABA system that is most critical to modulation of seizure activity is the GABAA-receptor-chloride (Cl-) channel complex, which controls the movement of Cl- ions across the neuronal membrane. In the mature brain, binding of GABA to GABAA receptors evokes a hyperpolarising (anticonvulsant) response, which is mediated by influx of Cl- into the cell driven by its concentration gradient between extracellular and intracellular fluid. However, in the immature brain and under certain pathological conditions, GABA can exert a paradoxical depolarising (proconvulsant) effect as a result of an efflux of chloride from high intracellular to lower extracellular Cl- levels. Extensive preclinical and clinical evidence indicates that alterations in GABAergic inhibition caused by drugs, toxins, gene defects or other disease states (including seizures themselves) play a causative or contributing role in facilitating or maintaning seizure activity. Conversely, enhancement of GABAergic transmission through pharmacological modulation of the GABA system is a major mechanism by which different antiseizure medications exert their therapeutic effect. In this article, we review the pharmacology and function of the GABA system and its perturbation in seizure disorders, and highlight how improved understanding of this system offers opportunities to develop more efficacious and better tolerated antiseizure medications. We also review the available data for the two most recently approved antiseizure medications that act, at least in part, through GABAergic mechanisms, namely cenobamate and ganaxolone. Differences in the mode of drug discovery, pharmacological profile, pharmacokinetic properties, drug-drug interaction potential, and clinical efficacy and tolerability of these agents are discussed.
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Affiliation(s)
- Emilio Perucca
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia.
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.
- Melbourne Brain Centre, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia.
| | - Meir Bialer
- Institute of Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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9
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Becker LL, Gratopp A, Prager C, Elger CE, Kaindl AM. Treatment of pediatric convulsive status epilepticus. Front Neurol 2023; 14:1175370. [PMID: 37456627 PMCID: PMC10343462 DOI: 10.3389/fneur.2023.1175370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Status epilepticus is one of the most common life-threatening neurological emergencies in childhood with the highest incidence in the first 5 years of life and high mortality and morbidity rates. Although it is known that a delayed treatment and a prolonged seizure can cause permanent brain damage, there is evidence that current treatments may be delayed and the medication doses administered are insufficient. Here, we summarize current knowledge on treatment of convulsive status epilepticus in childhood and propose a treatment algorithm. We performed a structured literature search via PubMed and ClinicalTrails.org and identified 35 prospective and retrospective studies on children <18 years comparing two and more treatment options for status epilepticus. The studies were divided into the commonly used treatment phases. As a first-line treatment, benzodiazepines buccal/rectal/intramuscular/intravenous are recommended. For status epilepticus treated with benzodiazepine refractory, no superiority of fosphenytoin, levetirazetam, or phenobarbital was identified. There is limited data on third-line treatments for refractory status epilepticus lasting >30 min. Our proposed treatment algorithm, especially for children with SE, is for in and out-of-hospital onset aids to promote the establishment and distribution of guidelines to address the treatment delay aggressively and to reduce putative permanent neuronal damage. Further studies are needed to evaluate if these algorithms decrease long-term damage and how to treat refractory status epilepticus lasting >30 min.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Gratopp
- Department of Pediatric Pneumonology, Immunology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Prager
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian E. Elger
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Beta Clinic, Bonn, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Becker LL, Kaindl AM. Corticosteroids in childhood epilepsies: A systematic review. Front Neurol 2023; 14:1142253. [PMID: 36970534 PMCID: PMC10036579 DOI: 10.3389/fneur.2023.1142253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/12/2023] Open
Abstract
Corticosteroids have been used for the treatment of patients with epilepsy for more than 6 decades, based on the hypothesis of inflammation in the genesis and/or promotion of epilepsy. We, therefore, aimed to provide a systematic overview of the use of corticosteroid regimes in childhood epilepsies in line with the PRISMA guidelines. We performed a structured literature search via PubMed and identified 160 papers with only three randomized controlled trials excluding the substantial trials on epileptic spasms. Corticosteroid regimes, duration of treatment (days to several months), and dosage protocols were highly variable in these studies. Evidence supports the use of steroids in epileptic spasms; however, there is only limited evidence for a positive effect for other epilepsy syndromes, e.g., epileptic encephalopathy with spike-and-wave activity in sleep [(D)EE-SWAS] or drug-resistant epilepsies (DREs). In (D)EE-SWAS (nine studies, 126 patients), 64% of patients showed an improvement either in the EEG or in their language/cognition following various steroid treatment regimes. In DRE (15 studies, 436 patients), a positive effect with a seizure reduction in 50% of pediatric and adult patients and seizure freedom in 15% was identified; however, no recommendation can be drawn due to the heterozygous cohort. This review highlights the immense need for controlled studies using steroids, especially in DRE, to offer patients new treatment options.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Angela M. Kaindl
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Swarnalingam E, Woodward K, Esser M, Jacobs J. Management and prognosis of pediatric status epilepticus. ZEITSCHRIFT FÜR EPILEPTOLOGIE 2022. [DOI: 10.1007/s10309-022-00538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Pediatric status epilepticus is a neurological emergency with the potential for severe developmental and neurological consequences. Prompt diagnosis and management are necessary.
Objectives
To outline the existing best available evidence for managing pediatric and neonatal status epilepticus, in the light of emerging randomized controlled studies. We also focus on short and long-term prognoses.
Materials and methods
This is a systematic overview of the existing literature.
Results
Status epilepticus, its treatment, and prognosis are usually based on the continuation of seizure activity at 5 and 30 min. Refractory and super-refractory status epilepticus further complicates management and requires continuous EEG monitoring with regular reassessment and adjustment of therapy. Benzodiazepines have been accepted as the first line of treatment on the basis of reasonable evidence. Emerging randomized controlled trials demonstrate equal efficacy for parenterally administered phenytoin, levetiracetam, and valproic acid as second-line agents. Beyond this, the evidence for third-line options is sparse. However, encouraging evidence for midazolam and ketamine exists with further data required for immunological, dietary, and surgical interventions.
Conclusion
Our overview of the management of pediatric and neonatal status epilepticus based on available evidence emphasizes the need for evidence-based guidelines to manage status epilepticus that fails to respond to second-line treatment.
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Intravenous ganaxolone in pediatric super-refractory status epilepticus: A single hospital experience. Epilepsy Behav Rep 2022; 20:100567. [PMID: 36325100 PMCID: PMC9619166 DOI: 10.1016/j.ebr.2022.100567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/29/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Synaptic GABAA receptor (GABAAR) internalization contributes to the drug resistant nature of super-refractory status epilepticus (SRSE). Ganaxolone is a 3β-methylated synthetic analog of the endogenous neuroactive steroid, allopregnanolone, that has positive allosteric modulatory activity on synaptic and extrasynaptic GABAA receptors. Ganaxolone is currently in clinical trials to treat rare pediatric seizure disorders and established and refractory SE. Two pediatric patients with SRSE (age 17 and age 7) were treated under emergency investigational new drug (E-IND) applications with intravenous (IV) ganaxolone administered as an initial bolus and a maintenance infusion for up to 4.5 days with intermittent IV boluses as-needed followed by taper on day 5 and transitioned to chronic treatment using ganaxolone suspension. Adjunctive ganaxolone was effective in terminating SRSE in both patients, safely permitting IV anesthetics to be weaned. Seizure control has been maintained after transitioning to enteric ganaxolone. Further investigation of ganaxolone as a safe and effective treatment for SRSE is warranted.
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Key Words
- AMPA, alpha-amino-3-hydroxy-5-methyl-4-isoxazoleproprionic acid
- ASMs, anti-seizure medications
- E-IND, emergency investigational new drug
- FIRES, fever-induced refractory epilepsy syndrome
- GABAAR, GABAA receptors
- GNX, ganaxolone
- KA, kainate
- NMDA, N-methyl-d-aspartate
- NORSE, new onset refractory status epilepticus
- Neurosteroids
- Pediatric
- SE, status epilepticus
- SRSE, super-refractory status epilepticus
- Status epilepticus
- Super-refractory status epilepticus
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Levien TL, Baker DE. Formulary Drug Reviews: Brexanolone Injection. Hosp Pharm 2022; 57:615-621. [PMID: 36081541 PMCID: PMC9445546 DOI: 10.1177/0018578719867685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.
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Vaitkevicius H, Ramsay RE, Swisher CB, Husain AM, Aimetti A, Gasior M. Intravenous ganaxolone for the treatment of refractory status epilepticus: Results from an open-label, dose-finding, phase 2 trial. Epilepsia 2022; 63:2381-2391. [PMID: 35748707 PMCID: PMC9796093 DOI: 10.1111/epi.17343] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Patients with refractory status epilepticus (RSE) have failed treatment with benzodiazepines and ≥1 second-line intravenous (IV) antiseizure medication (ASM). Guidelines recommend IV anesthesia when second-line ASMs have failed, but potential harms can outweigh the benefits. Novel treatments are needed to stop and durably control RSE without escalation to IV anesthetics. Ganaxolone is an investigational neuroactive steroid in development for RSE treatment. This study's objective was to determine the appropriate dosing for IV ganaxolone in RSE and obtain a preliminary assessment of efficacy and safety. METHODS This was an open-label, phase 2 trial conducted from February 19, 2018 to September 18, 2019, at three sites in the United States. Patients were aged ≥12 years, had convulsive or nonconvulsive SE, and failed to respond to ≥1 second-line IV ASM. Twenty-one patients were screened; 17 were enrolled. Patients received IV ganaxolone added to standard-of-care ASMs. Ganaxolone infusion was initiated as an IV bolus (over 3 min) with continuous infusion of decreasing infusion rates for 48-96 h followed by an 18-h taper. There were three ganaxolone dosing cohorts: low, 500 mg/day; medium, 650 mg/day; and high, 713 mg/day. The primary end point was the number of patients not requiring escalation to IV anesthetic treatment within 24 h of ganaxolone initiation. RESULTS Most of the 17 enrolled patients (65%) had nonconvulsive SE, and had failed a median of three prior ASMs, including first-line benzodiazepine and second-line IV ASM therapy. Median time to SE cessation following ganaxolone initiation was 5 min. No patient required escalation to third-line IV anesthetics during the 24-h period following ganaxolone initiation. Two treatment-related serious adverse events (sedation) were reported. Of the three deaths, none was considered related to ganaxolone; all occurred 9-22 days after completing ganaxolone. SIGNIFICANCE IV ganaxolone achieved rapid and durable seizure control in patients with RSE, and showed acceptable safety and tolerability.
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Affiliation(s)
- Henrikas Vaitkevicius
- Department of NeurologyBrigham and Women's HospitalBostonMassachusettsUSA,Marinus PharmaceuticalsRadnorPennsylvaniaUSA
| | - R. Eugene Ramsay
- International Center for EpilepsySt. Bernard HospitalNew OrleansLouisianaUSA
| | | | - Aatif M. Husain
- Department of NeurologyDuke UniversityDurhamNorth CarolinaUSA,Neurodiagnostic CenterVeterans Affairs Medical CenterDurhamNorth CarolinaUSA
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Wald J, Henningsson A, Hanze E, Hoffmann E, Li H, Colquhoun H, Deligiannidis KM. Allopregnanolone Concentrations in Breast Milk and Plasma from Healthy Volunteers Receiving Brexanolone Injection, With Population Pharmacokinetic Modeling of Potential Relative Infant Dose. Clin Pharmacokinet 2022; 61:1307-1319. [PMID: 35869362 PMCID: PMC9439988 DOI: 10.1007/s40262-022-01155-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/25/2022]
Abstract
Background and Objective Women with postpartum depression (PPD) may expose their infants to antidepressants via breast milk. Brexanolone is the only FDA-approved antidepressant specifically indicated for the treatment of PPD. This open-label, phase Ib study of healthy lactating volunteers assessed pharmacokinetic (PK) properties of brexanolone and a population PK (PopPK) model determined the relative infant dose (RID) in breastfeeding mothers. Methods Twelve participants received a 60-h infusion of brexanolone (titration up to 90 µg/kg/h). Allopregnanolone concentration was measured in breast milk and plasma. The RID was computed using a nonlinear mixed-effects PopPK model of patients with PPD and healthy women (N = 156). Model results were extended across an integrated dataset of participants through day 7. Results Allopregnanolone concentration–time profiles were similar between breast milk and plasma (partition coefficient for concentration gradient [milk : plasma] 1.36). Mean (95% CI) Cmax was 89.7 ng/mL (74.19–108.39), and median (95% CI) tmax was 47.8 h (47.8–55.8) in plasma. The overall PK profile was best described by a two-compartment model with linear elimination and distribution. Body weight was the only significant covariate identified. There were no apparent differences in PopPK AUC and Cmax between participants with or without concomitant antidepressant treatment. Maximum RID was 1.3%. Conclusion The PopPK model successfully described the variability and concentration–time profiles of allopregnanolone in breast milk and plasma in healthy participants and in the plasma of brexanolone-treated patients with PPD. The rapid elimination of allopregnanolone from plasma and breast milk, and low RID, suggests the appropriateness of brexanolone weight-based dosing and supports other PK-related labeling recommendations. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-022-01155-w.
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Affiliation(s)
- Jeffrey Wald
- Sage Therapeutics, Inc., 215 First Street, Cambridge, MA, 02142, USA.
| | | | | | - Ethan Hoffmann
- Sage Therapeutics, Inc., 215 First Street, Cambridge, MA, 02142, USA
| | - Haihong Li
- Sage Therapeutics, Inc., 215 First Street, Cambridge, MA, 02142, USA
| | - Helen Colquhoun
- Sage Therapeutics, Inc., 215 First Street, Cambridge, MA, 02142, USA
| | - Kristina M Deligiannidis
- Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
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16
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Cerne R, Lippa A, Poe MM, Smith JL, Jin X, Ping X, Golani LK, Cook JM, Witkin JM. GABAkines - Advances in the discovery, development, and commercialization of positive allosteric modulators of GABA A receptors. Pharmacol Ther 2022; 234:108035. [PMID: 34793859 PMCID: PMC9787737 DOI: 10.1016/j.pharmthera.2021.108035] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 11/08/2021] [Indexed: 12/25/2022]
Abstract
Positive allosteric modulators of γ-aminobutyric acid-A (GABAA) receptors or GABAkines have been widely used medicines for over 70 years for anxiety, epilepsy, sleep, and other disorders. Traditional GABAkines like diazepam have safety and tolerability concerns that include sedation, motor-impairment, respiratory depression, tolerance and dependence. Multiple GABAkines have entered clinical development but the issue of side-effects has not been fully solved. The compounds that are presently being developed and commercialized include several neuroactive steroids (an allopregnanolone formulation (brexanolone), an allopregnanolone prodrug (LYT-300), Sage-324, zuranolone, and ganaxolone), the α2/3-preferring GABAkine, KRM-II-81, and the α2/3/5-preferring GABAkine PF-06372865 (darigabat). The neuroactive steroids are in clinical development for post-partum depression, intractable epilepsy, tremor, status epilepticus, and genetic epilepsy disorders. Darigabat is in development for epilepsy and anxiety. The imidazodiazepine, KRM-II-81 is efficacious in animal models for the treatment of epilepsy and post-traumatic epilepsy, acute and chronic pain, as well as anxiety and depression. The efficacy of KRM-II-81 in models of pharmacoresistant epilepsy, preventing the development of seizure sensitization, and in brain tissue of intractable epileptic patients bodes well for improved therapeutics. Medicinal chemistry efforts are also ongoing to identify novel and improved GABAkines. The data document gaps in our understanding of the molecular pharmacology of GABAkines that drive differential pharmacological profiles, but emphasize advancements in the ability to successfully utilize GABAA receptor potentiation for therapeutic gain in neurology and psychiatry.
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Affiliation(s)
- Rok Cerne
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA,Faculty of Medicine, University of Ljubljana, Zaloška cesta 4, Ljubljana, Slovenia.,RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Arnold Lippa
- RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA
| | | | - Jodi L. Smith
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA
| | - Xiaoming Jin
- Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Xingjie Ping
- Department of Anatomy and Cell Biology, Indiana University/Purdue University, Indianapolis, IN, USA
| | - Lalit K. Golani
- Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - James M. Cook
- RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Jeffrey M. Witkin
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent, Indianapolis, IN USA,RespireRx Pharmaceuticals Inc, Glen Rock, NJ, USA,Department of Chemistry and Biochemistry, Milwaukee Institute of Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
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Why won't it stop? The dynamics of benzodiazepine resistance in status epilepticus. Nat Rev Neurol 2022; 18:428-441. [PMID: 35538233 DOI: 10.1038/s41582-022-00664-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/08/2022]
Abstract
Status epilepticus is a life-threatening neurological emergency that affects both adults and children. Approximately 36% of episodes of status epilepticus do not respond to the current preferred first-line treatment, benzodiazepines. The proportion of episodes that are refractory to benzodiazepines is higher in low-income and middle-income countries (LMICs) than in high-income countries (HICs). Evidence suggests that longer episodes of status epilepticus alter brain physiology, thereby contributing to the emergence of benzodiazepine resistance. Such changes include alterations in GABAA receptor function and in the transmembrane gradient for chloride, both of which erode the ability of benzodiazepines to enhance inhibitory synaptic signalling. Often, current management guidelines for status epilepticus do not account for these duration-related changes in pathophysiology, which might differentially impact individuals in LMICs, where the average time taken to reach medical attention is longer than in HICs. In this Perspective article, we aim to combine clinical insights and the latest evidence from basic science to inspire a new, context-specific approach to efficiently managing status epilepticus.
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Reddy DS. Neurosteroid replacement therapy for catamenial epilepsy, postpartum depression and neuroendocrine disorders in women. J Neuroendocrinol 2022; 34:e13028. [PMID: 34506047 PMCID: PMC9247111 DOI: 10.1111/jne.13028] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 12/11/2022]
Abstract
Neurosteroids are involved in the pathophysiology of many neuroendocrine disorders in women. This review describes recent advancements in pharmacology of neurosteroids and emphasizes the benefits of neurosteroid replacement therapy for the management of neuroendocrine disorders such as catamenial epilepsy (CE), postpartum depression (PPD) and premenstrual brain conditions. Neurosteroids are endogenous modulators of neuronal excitability. A variety of neurosteroids are present in the brain including allopregnanolone (AP), allotetrahydro-deoxycorticosterone and androstanediol. Neurosteroids interact with synaptic and extrasynaptic GABAA receptors in the brain. AP and related neurosteroids, which are positive allosteric modulators of GABAA receptors, are powerful anticonvulsants, anxiolytic, antistress and neuroprotectant agents. In CE, seizures are most often clustered around a specific menstrual period in women. Neurosteroid withdrawal-linked plasticity in extrasynaptic receptors has been shown to play a key role in catamenial seizures, anxiety and other mood disorders. Based on our extensive research spanning two decades, we have proposed and championed neurosteroid replacement therapy as a rational strategy for treating disorders marked by neurosteroid-deficiency, such as CE and other related ovarian or menstrual disorders. In 2019, AP (renamed as brexanolone) was approved for treating PPD. A variety of synthetic neurosteroids are in clinical trials for epilepsy, depression and other brain disorders. Recent advancements in our understanding of neurosteroids have entered a new era of drug discovery and one that offers a high therapeutic potential for treating complex brain disorders.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University College of Medicine, Bryan, TX, USA
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19
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The imidazodiazepine, KRM-II-81: An example of a newly emerging generation of GABAkines for neurological and psychiatric disorders. Pharmacol Biochem Behav 2022; 213:173321. [PMID: 35041859 DOI: 10.1016/j.pbb.2021.173321] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023]
Abstract
GABAkines, or positive allosteric modulators of γ-aminobutyric acid-A (GABAA) receptors, are used for the treatment of anxiety, epilepsy, sleep, and other disorders. The search for improved GABAkines, with reduced safety liabilities (e.g., dependence) or side-effect profiles (e.g., sedation) constituted multiple discovery and development campaigns that involved a multitude of strategies over the past century. Due to the general lack of success in the development of new GABAkines, there had been a decades-long draught in bringing new GABAkines to market. Recently, however, there has been a resurgence of efforts to bring GABAkines to patients, the FDA approval of the neuroactive steroid brexanolone for post-partum depression in 2019 being the first. Other neuroactive steroids are in various stages of clinical development (ganaxolone, zuranolone, LYT-300, Sage-324, PRAX 114, and ETX-155). These GABAkines and non-steroid compounds (GRX-917, a TSPO binding site ligand), darigabat (CVL-865), an α2/3/5-preferring GABAkine, SAN711, an α3-preferring GABAkine, and the α2/3-preferring GABAkine, KRM-II-81, bring new therapeutic promise to this highly utilized medicinal target in neurology and psychiatry. Herein, we also discuss possible conditions that have enabled the transition to a new age of GABAkines. We highlight the pharmacology of KRM-II-81 that has the most preclinical data reported. KRM-II-81 is the lead compound in a new series of orally bioavailable imidazodiazepines entering IND-enabling safety studies. KRM-II-81 has a preclinical profile predicting efficacy against pharmacoresistant epilepsies, traumatic brain injury, and neuropathic pain. KRM-II-81 also produces anxiolytic- and antidepressant-like effects in rodent models. Other key features of the pharmacology of this compound are its low sedation rate, lack of tolerance development, and the ability to prevent the development of seizure sensitization.
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20
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The Neuroactive Steroid Pregnanolone Glutamate: Anticonvulsant Effect, Metabolites and Its Effect on Neurosteroid Levels in Developing Rat Brains. Pharmaceuticals (Basel) 2021; 15:ph15010049. [PMID: 35056106 PMCID: PMC8780580 DOI: 10.3390/ph15010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/02/2022] Open
Abstract
Pregnanolone glutamate (PA-G) is a neuroactive steroid that has been previously demonstrated to be a potent neuroprotective compound in several biological models in vivo. Our in vitro experiments identified PA-G as an inhibitor of N-methyl-D-aspartate receptors and a potentiator of γ-aminobutyric acid receptors (GABAARs). In this study, we addressed the hypothesis that combined GABAAR potentiation and NMDAR antagonism could afford a potent anticonvulsant effect. Our results demonstrated the strong age-related anticonvulsive effect of PA-G in a model of pentylenetetrazol-induced seizures. PA-G significantly decreased seizure severity in 12-day-old animals, but only after the highest dose in 25-day-old animals. Interestingly, the anticonvulsant effect of PA-G differed both qualitatively and quantitatively from that of zuranolone, an investigational neurosteroid acting as a potent positive allosteric modulator of GABAARs. Next, we identified 17-hydroxy-pregnanolone (17-OH-PA) as a major metabolite of PA-G in 12-day-old animals. Finally, the administration of PA-G demonstrated direct modulation of unexpected neurosteroid levels, namely pregnenolone and dehydroepiandrosterone sulfate. These results suggest that compound PA-G might be a pro-drug of 17-OH-PA, a neurosteroid with a promising neuroprotective effect with an unknown mechanism of action that may represent an attractive target for studying perinatal neural diseases.
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21
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Voinescu PE, Pennell KD, Bay CP, Stowe ZN, Peng L, Frye CA, Tang KY, Pennell PB. Pregnant women with more seizures have lower allopregnanolone concentrations. Epilepsy Res 2021; 177:106778. [PMID: 34597960 DOI: 10.1016/j.eplepsyres.2021.106778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/11/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022]
Abstract
Neuroactive steroids have rapid, nongenomic effects on neuronal excitability. The effects in humans are less clear. We compared seizure control and concentrations of neuroactive steroids, known to influence neuroexcitability in animal studies, in pregnant women. Participants were prospectively followed throughout pregnancy with seizure-medication diaries and blood samples, assayed for steroid concentrations with gas chromatography-mass spectrometry. Baseline seizure frequency was calculated for the preconception year, and it was determined if seizure frequency was increased in each trimester. The Wilcoxon rank-sum test was used to compare neuroactive steroid concentrations in between the group with increased frequency to the group without, as calculated for the respective trimester, with the Holm-Bonferroni method to correct for multiple comparisons. Among eighty-three pregnancies included, twenty-eight had increased seizure frequency during at least one trimester (15, 18 and 10, respectively) compared to preconception seizure frequency. Allopregnanolone concentrations were lower in the 3rd trimester (p < 0.001), with a similar trend in the 1st (p = 0.08), for pregnancies with increased compared to those with stable seizure frequency. Other neuroactive steroid concentrations were similar. Our findings suggest that lower allopregnanolone concentrations are associated with increased seizure frequency during pregnancy. Validation of these finding in a larger cohort has potential important clinical applications.
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Affiliation(s)
- P Emanuela Voinescu
- Department of Neurology, Division of Epilepsy, Brigham and Women's Hospital, United States; Department of Medicine, Division of Women's Health, Brigham and Women's Hospital, United States; Harvard Medical School, United States.
| | - Kurt D Pennell
- School of Engineering at Brown University, United States
| | - Camden P Bay
- Department of Radiology and the Center for Clinical Investigation at Brigham and Women's Hospital, Boston, MA, United States
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, United States
| | - Limin Peng
- Rollins School of Public Health, Emory University, United States
| | - Cheryl A Frye
- Department of Psychology, Center for Neuroscience, University at Albany, United States
| | - Kathleen Y Tang
- Harvard School of Public Health, Harvard Pilgrim Health Care Institute, United States
| | - Page B Pennell
- Department of Neurology, Division of Epilepsy, Brigham and Women's Hospital, United States; Department of Medicine, Division of Women's Health, Brigham and Women's Hospital, United States; Harvard Medical School, United States; Department of Neurology, University of Pittsburgh, United States
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22
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Rosenthal ES. Seizures, Status Epilepticus, and Continuous EEG in the Intensive Care Unit. Continuum (Minneap Minn) 2021; 27:1321-1343. [PMID: 34618762 DOI: 10.1212/con.0000000000001012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW This article discusses the evolving definitions of seizures and status epilepticus in the critical care environment and the role of critical care EEG in both diagnosing seizure activity and serving as a predictive biomarker of clinical trajectory. RECENT FINDINGS Initial screening EEG has been validated as a tool to predict which patients are at risk of future seizures. However, accepted definitions of seizures and nonconvulsive status epilepticus encourage a treatment trial when the diagnosis on EEG is indeterminate because of periodic or rhythmic patterns or uncertain clinical correlation. Similarly, recent data have demonstrated the diagnostic utility of intracranial EEG in increasing the yield of seizure detection. EEG has additionally been validated as a diagnostic biomarker of covert consciousness, a predictive biomarker of cerebral ischemia and impending neurologic deterioration, and a prognostic biomarker of coma recovery and status epilepticus resolution. A recent randomized trial concluded that patients allocated to continuous EEG had no difference in mortality than those undergoing intermittent EEG but could not demonstrate whether this lack of difference was because of studying heterogeneous conditions, examining a monitoring tool rather than a therapeutic approach, or examining an outcome measure (mortality) perhaps more strongly associated with early withdrawal of life-sustaining therapy than to a sustained response to pharmacotherapy. SUMMARY Seizures and status epilepticus are events of synchronous hypermetabolic activity that are either discrete and intermittent or, alternatively, continuous. Seizures and status epilepticus represent the far end of a continuum of ictal-interictal patterns that include lateralized rhythmic delta activity and periodic discharges, which not only predict future seizures but may be further classified as status epilepticus on the basis of intracranial EEG monitoring or a diagnostic trial of antiseizure medication therapy. In particularly challenging cases, neuroimaging or multimodality neuromonitoring may be a useful adjunct documenting metabolic crisis. Specialized uses of EEG as a prognostic biomarker have emerged in traumatic brain injury for predicting language function and covert consciousness, cardiac arrest for predicting coma recovery, and subarachnoid hemorrhage for predicting neurologic deterioration due to delayed cerebral ischemia.
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Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
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Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
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Abstract
Context Refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE) are neurological emergencies with considerable mortality and morbidity. In this paper, we provide an overview of causes, evaluation, treatment, and consequences of RSE and SRSE, reflecting the lack of high-quality evidence to inform therapeutic approach. Sources This is a narrative review based on personal practice and experience. Nevertheless, we searched MEDLINE (using PubMed and OvidSP vendors) and Cochrane central register of controlled trials, using appropriate keywords to incorporate recent evidence. Results Refractory status epilepticus is commonly defined as an acute convulsive seizure that fails to respond to two or more anti-seizure medications including at least one nonbenzodiazepine drug. Super-refractory status epilepticus is a status epilepticus that continues for ≥24 hours despite anesthetic treatment, or recurs on an attempted wean of the anesthetic regimen. Both can occur in patients known to have epilepsy or de novo, with increasing recognition of autoimmune and genetic causes. Electroencephalography monitoring is essential to monitor treatment response in refractory/super-refractory status epilepticus, and to diagnose non-convulsive status epilepticus. The mainstay of treatment for these disorders includes anesthetic infusions, primarily midazolam, ketamine, and pentobarbital. Dietary, immunological, and surgical treatments are viable in selected patients. Management is challenging due to multiple acute complications and long-term adverse consequences. Conclusions We have provided a synopsis of best practices for diagnosis and management of refractory/superrefractory status epilepticus and highlighted the lack of sufficient high-quality evidence to drive decision making, ending with a brief foray into avenues for future research.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Lisa Garrity
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; USA. Correspondence to: Dr Ravindra Arya, Division of Neurology, Cincinnati Children's Hospital Medical Center, MLC 2015, 3333 Burnet Avenue, Cincinnati, Ohio, 45229 USA.
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25
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[S2k guidelines: status epilepticus in adulthood : Guidelines of the German Society for Neurology]. DER NERVENARZT 2021; 92:1002-1030. [PMID: 33751150 PMCID: PMC8484257 DOI: 10.1007/s00115-020-01036-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/16/2023]
Abstract
This S2k guideline on diagnosis and treatment of status epilepticus (SE) in adults is based on the last published version from 2021. New definitions and evidence were included in the guideline and the clinical pathway. A seizures lasting longer than 5 minutes (or ≥ 2 seizures over more than 5 mins without intermittend recovery to the preictal neurological state. Initial diagnosis should include a cCT or, if possible, an MRI. The EEG is highly relevant for diagnosis and treatment-monitoring of non-convulsive SE and for the exclusion or diagnosis of psychogenic non-epileptic seizures. As the increasing evidence supports the relevance of inflammatory comorbidities (e.g. pneumonia) related clinical chemistry should be obtained and repeated over the course of a SE treatment, and antibiotic therapy initiated if indicated.Treatment is applied on four levels: 1. Initial SE: An adequate dose of benzodiazepine is given i.v., i.m., or i.n.; 2. Benzodiazepine-refractory SE: I.v. drugs of 1st choice are levetiracetam or valproate; 3. Refractory SE (RSE) or 4. Super-refractory SE (SRSE): I.v. propofol or midazolam alone or in combination or thiopental in anaesthetic doses are given. In focal non-convulsive RSE the induction of a therapeutic coma depends on the circumstances and is not mandatory. In SRSE the ketogenic diet should be given. I.v. ketamine or inhalative isoflorane can be considered. In selected cased electroconvulsive therapy or, if a resectable epileptogenic zone can be defined epilepsy surgery can be applied. I.v. allopregnanolone or systemic hypothermia should not be used.
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Abstract
INTRODUCTION Postpartum depression (PPD) is a serious and common complication of childbirth that can have deleterious effects not only on the mother but on the cognitive and behavioral development of exposed children. Brexanolone is a novel, soluble synthetic formulation of the natural hormone allopregnanolone and acts as a positive allosteric modulator of the gamma-aminobutyric acid A receptor (GABAA). Allopregnanolone levels dramatically decrease during the postpartum time-period and some studies indicate lower serum levels of allopregnanolone during pregnancy in women that go on to develop PPD.Areas covered: The author provides an overview of brexanolone as a treatment option for PPD including coverage of its pharmacokinetics, efficacy, safety, and tolerability. Furthermore, the author gives her expert perspectives on its use and its standing in the treatment armamentarium moving forward.Expert opinion: Brexanolone represents a breakthrough for psychiatry due to its novel mechanism of action, its rapid onset of action, and its sustained effects without continued administration. It is appropriate for use in women with moderate to severe PPD. Experience with the medication and further research is needed to clarify whether the current recommended dosing regimen is required for efficacy.
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Affiliation(s)
- Jennifer L Payne
- Associate Professor of Psychiatry and Behavioral Sciences, Women's Mood Disorders Center, Johns Hopkins School of Medicine, Baltimore, United States
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Rapid effects of neurosteroids on neuronal plasticity and their physiological and pathological implications. Neurosci Lett 2021; 750:135771. [PMID: 33636284 DOI: 10.1016/j.neulet.2021.135771] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 11/22/2022]
Abstract
Current neuroscience research on neurosteroids and their synthetic analogues - neuroactive steroids - clearly demonstrate their drug likeness in a variety of neurological and psychiatric conditions. Moreover, research on neurosteroids continues to provide novel mechanistic insights into receptor activation or inhibition of various receptors. This mini-review will provide a high-level overview of the research area and discuss the various classes of potential physiological and pathological implications discovered so far.
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Kapur J, Joshi S. Progesterone modulates neuronal excitability bidirectionally. Neurosci Lett 2021; 744:135619. [PMID: 33421486 PMCID: PMC7821816 DOI: 10.1016/j.neulet.2020.135619] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/24/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022]
Abstract
Progesterone acts on neurons directly by activating its receptor and through metabolic conversion to neurosteroids. There is emerging evidence that progesterone exerts excitatory effects by activating its cognate receptors (progesterone receptors, PRs) through enhanced expression of α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptors (AMPARs). Progesterone metabolite 5α,3α-tetrahydro-progesterone (allopregnanolone, THP) mediates its anxiolytic and sedative actions through the potentiation of synaptic and extrasynaptic γ-aminobutyric acid type-A receptors (GABAARs). Here, we review progesterone's neuromodulatory actions exerted through PRs and THP and their opposing role in regulating seizures, catamenial epilepsy, and seizure exacerbation associated with progesterone withdrawal.
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Affiliation(s)
- Jaideep Kapur
- Department of Neurology, University of Virginia-HSC, Charlottesville, VA, 22908, United States; Department of Neuroscience, University of Virginia-HSC, Charlottesville, VA, 22908, United States; UVA Brain Institute, University of Virginia-HSC, Charlottesville, VA, 22908, United States
| | - Suchitra Joshi
- Department of Neurology, University of Virginia-HSC, Charlottesville, VA, 22908, United States.
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Basu T, Maguire J, Salpekar JA. Hypothalamic-pituitary-adrenal axis targets for the treatment of epilepsy. Neurosci Lett 2021; 746:135618. [PMID: 33429002 DOI: 10.1016/j.neulet.2020.135618] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/25/2020] [Accepted: 12/29/2020] [Indexed: 12/20/2022]
Abstract
Stress is a common seizure trigger in persons with epilepsy. The body's physiological response to stress is mediated by the hypothalamic-pituitary-adrenal (HPA) axis and involves a hormonal cascade that includes corticotropin releasing hormone (CRH), adrenocorticotropin releasing hormone (ACTH) and the release of cortisol (in humans and primates) or corticosterone (in rodents). The prolonged exposure to stress hormones may not only exacerbate pre-existing medical conditions including epilepsy, but may also increase the predisposition to psychiatric comorbidities. Hyperactivity of the HPA axis negatively impacts the structure and function of the temporal lobe of the brain, a region that is heavily involved in epilepsy and mood disorders like anxiety and depression. Seizures themselves damage temporal lobe structures, further disinhibiting the HPA axis, setting off a vicious cycle of neuronal damage and increasing susceptibility for subsequent seizures and psychiatric comorbidity. Treatments targeting the HPA axis may be beneficial both for epilepsy and for associated stress-related comorbidities such as anxiety or depression. This paper will highlight the evidence demonstrating dysfunction in the HPA axis associated with epilepsy which may contribute to the comorbidity of psychiatric disorders and epilepsy, and propose treatment strategies that may dually improve seizure control as well as alleviate stress related psychiatric comorbidities.
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Affiliation(s)
- Trina Basu
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA 02111, United States
| | - Jamie Maguire
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA 02111, United States
| | - Jay A Salpekar
- Kennedy Krieger Institute, Johns Hopkins University Medical School, Baltimore, MD 21205, United States.
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Numoto S, Kurahashi H, Sato A, Kubota M, Shiihara T, Okanishi T, Tanaka R, Kuki I, Fukuyama T, Kashiwagi M, Ikeno M, Kubota K, Akasaka M, Mimaki M, Okumura A. Acute encephalopathy in children with tuberous sclerosis complex. Orphanet J Rare Dis 2021; 16:5. [PMID: 33407677 PMCID: PMC7789140 DOI: 10.1186/s13023-020-01646-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
Objective We examined the clinical manifestations of acute encephalopathy (AE) and identify risk factors for AE in children with tuberous sclerosis complex (TSC). Methods The clinical data of 11 children with clinically diagnosed TSC associated with AE and 109 children with clinically diagnosed TSC alone aged 4 years or older were collected from 13 hospitals. Results Of the 11 children with AE, 5 had histories of febrile seizures (FS), and all had histories of febrile status epilepticus (FSE). AE developed within 24 h after fever onset in all children with seizures lasting 30 min or longer. All children developed coma after seizure cessation. Head magnetic resonance imaging (MRI) revealed widespread abnormalities in the cerebral cortex, subcortical white matter, corpus callosum, basal ganglia, and thalamus. One child died; seven had severe neurological sequelae; and the other three, mild sequelae. Logistic regression analysis revealed that a history of FSE was correlated with the development of AE. Significance AE in children with TSC was characterized by sudden onset after fever, followed by coma, widespread brain edema evident on MRI, and poor outcomes. A history of FSE was a risk factor for the development of AE.
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Affiliation(s)
- Shingo Numoto
- Department of Pediatrics, Aichi Medical University, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan.
| | - Hirokazu Kurahashi
- Department of Pediatrics, Aichi Medical University, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Atsushi Sato
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaya Kubota
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Shiihara
- Department of Neurology, Gunma Children's Medical Center, Shibukawa, Gunma, Japan
| | - Tohru Okanishi
- Department of Child Neurology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Ryuta Tanaka
- Department of Child Health, Ibaraki Pediatric Education and Training Station, University of Tsukuba, Mito, Japan
| | - Ichiro Kuki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | | | | | - Mitsuru Ikeno
- Department of Pediatrics, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuo Kubota
- Department of Pediatrics, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Manami Akasaka
- Department of Pediatrics, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Masakazu Mimaki
- Department of Pediatrics, Teikyo University School of Medicine, Tokyo, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
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Lévesque M, Biagini G, Avoli M. Neurosteroids and Focal Epileptic Disorders. Int J Mol Sci 2020; 21:ijms21249391. [PMID: 33321734 PMCID: PMC7763947 DOI: 10.3390/ijms21249391] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/27/2020] [Accepted: 12/08/2020] [Indexed: 11/18/2022] Open
Abstract
Neurosteroids are a family of compounds that are synthesized in principal excitatory neurons and glial cells, and derive from the transformation of cholesterol into pregnenolone. The most studied neurosteroids—allopregnanolone and allotetrahydrodeoxycorticosterone (THDOC)—are known to modulate GABAA receptor-mediated transmission, thus playing a role in controlling neuronal network excitability. Given the role of GABAA signaling in epileptic disorders, neurosteroids have profound effects on seizure generation and play a role in the development of chronic epileptic conditions (i.e., epileptogenesis). We review here studies showing the effects induced by neurosteroids on epileptiform synchronization in in vitro brain slices, on epileptic activity in in vivo models, i.e., in animals that were made epileptic with chemoconvulsant treatment, and in epileptic patients. These studies reveal that neurosteroids can modulate ictogenesis and the occurrence of pathological network activity such as interictal spikes and high-frequency oscillations (80–500 Hz). Moreover, they can delay the onset of spontaneous seizures in animal models of mesial temporal lobe epilepsy. Overall, this evidence suggests that neurosteroids represent a new target for the treatment of focal epileptic disorders.
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Affiliation(s)
- Maxime Lévesque
- Montreal Neurological Institute-Hospital & Department of Neurology and Neurosurgery, 3801 University Street, Montreal, QC H3A 2B4, Canada;
- Correspondence: ; Tel.: +1-514-398-8909
| | - Giuseppe Biagini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Università 4, 41121 Modena, Italy;
| | - Massimo Avoli
- Montreal Neurological Institute-Hospital & Department of Neurology and Neurosurgery, 3801 University Street, Montreal, QC H3A 2B4, Canada;
- Department of Physiology, McGill University, Montreal, QC H3A 2B4, Canada
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32
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Amorim E, McGraw CM, Westover MB. A Theoretical Paradigm for Evaluating Risk-Benefit of Status Epilepticus Treatment. J Clin Neurophysiol 2020; 37:385-392. [PMID: 32890059 DOI: 10.1097/wnp.0000000000000753] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aggressive treatment of status epilepticus with anesthetic drugs can provide rapid seizure control, but it might lead to serious medical complications and worse outcomes. Using a decision analysis approach, this concise review provides a framework for individualized decision making about aggressive and nonaggressive treatment in status epilepticus. The authors propose and review the most relevant parameters guiding the risk-benefit analysis of treatment aggressiveness in status epilepticus and present real-world-based case examples to illustrate how these tools could be used at the bedside and serve to guide future research in refractory status epilepticus treatment.
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Affiliation(s)
- Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, California, U.S.A.,Neurology Service, Zuckerberg San Francisco General Hospital, San Francisco, California, U.S.A.,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Massachusetts, U.S.A
| | - Chris M McGraw
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.; and
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33
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Maciel CB, Legriel S. Considering postanoxic status epilepticus as a potential modifiable factor and treatment target: A step forward. Resuscitation 2020; 158:279-281. [PMID: 33253765 DOI: 10.1016/j.resuscitation.2020.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/20/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Carolina B Maciel
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL 32611, USA; Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Neurology, University of Utah, Salt Lake City, UT 84132, USA
| | - Stephane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay 78150, France; IctalGroup, Le Chesnay 78150, France; AfterROSC, Paris 75014, France; University Paris-Saclay, UVSQ, INSERM, CESP, Villejuif 94800, France.
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Lucchi C, Costa AM, Senn L, Messina S, Rustichelli C, Biagini G. Augmentation of endogenous neurosteroid synthesis alters experimental status epilepticus dynamics. Epilepsia 2020; 61:e129-e134. [DOI: 10.1111/epi.16654] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Chiara Lucchi
- Department of Biomedical, Metabolic, and Neural Sciences University of Modena and Reggio Emilia Modena Italy
| | - Anna Maria Costa
- Department of Biomedical, Metabolic, and Neural Sciences University of Modena and Reggio Emilia Modena Italy
| | - Lara Senn
- Department of Biomedical, Metabolic, and Neural Sciences University of Modena and Reggio Emilia Modena Italy
| | - Simone Messina
- Department of Biomedical, Metabolic, and Neural Sciences University of Modena and Reggio Emilia Modena Italy
| | - Cecilia Rustichelli
- Department of Life Sciences University of Modena and Reggio Emilia Modena Italy
| | - Giuseppe Biagini
- Department of Biomedical, Metabolic, and Neural Sciences University of Modena and Reggio Emilia Modena Italy
- Center for Neuroscience and Neurotechnology University of Modena and Reggio Emilia Modena Italy
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Willems LM, Bauer S, Jahnke K, Voss M, Rosenow F, Strzelczyk A. Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review. CNS Drugs 2020; 34:801-826. [PMID: 32705422 PMCID: PMC8316215 DOI: 10.1007/s40263-020-00747-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. OBJECTIVES This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. METHODS A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. RESULTS There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. CONCLUSIONS RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-Oncology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg (Lahn), Germany
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Gofton TE, Hirsch LJ. Author response: New onset refractory status epilepticus research: What is on the horizon? Neurology 2020; 94:596. [PMID: 32229639 DOI: 10.1212/wnl.0000000000009187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Convulsive status epilepticus (CSE) is one of the most common pediatric neurological emergencies. Ongoing seizure activity is a dynamic process and may be associated with progressive impairment of gamma-aminobutyric acid (GABA)-mediated inhibition due to rapid internalization of GABAA receptors. Further hyperexcitability may be caused by AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) and NMDA (N-methyl-D-aspartic acid) receptors moving from subsynaptic sites to the synaptic membrane. Receptor trafficking during prolonged seizures may contribute to difficulties treating seizures of longer duration and may provide some of the pathophysiological underpinnings of established and refractory SE (RSE). Simultaneously, a practice change toward more rapid initiation of first-line benzodiazepine (BZD) treatment and faster escalation to second-line non-BZD treatment for established SE is in progress. Early administration of the recommended BZD dose is suggested. For second-line treatment, non-BZD anti-seizure medications (ASMs) include valproate, fosphenytoin, or levetiracetam, among others, and at this point there is no clear evidence that any one of these options is better than the others. If seizures continue after second-line ASMs, RSE is manifested. RSE treatment consists of bolus doses and titration of continuous infusions under continuous electro-encephalography (EEG) guidance until electrographic seizure cessation or burst-suppression. Ultimately, etiological workup and related treatment of CSE, including broad spectrum immunotherapies as clinically indicated, is crucial. A potential therapeutic approach for future studies may entail consideration of interventions that may accelerate diagnosis and treatment of SE, as well as rational and early polytherapy based on synergism between ASMs by utilizing medications targeting different mechanisms of epileptogenesis and epileptogenicity.
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Belelli D, Hogenkamp D, Gee KW, Lambert JJ. Realising the therapeutic potential of neuroactive steroid modulators of the GABA A receptor. Neurobiol Stress 2019; 12:100207. [PMID: 32435660 PMCID: PMC7231973 DOI: 10.1016/j.ynstr.2019.100207] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/19/2019] [Indexed: 01/27/2023] Open
Abstract
In the 1980s particular endogenous metabolites of progesterone and of deoxycorticosterone were revealed to be potent, efficacious, positive allosteric modulators (PAMs) of the GABAA receptor (GABAAR). These reports were followed by the discovery that such steroids may be synthesised not only in peripheral endocrine glands, but locally in the central nervous system (CNS), to potentially act as paracrine, or autocrine "neurosteroid" messengers, thereby fine tuning neuronal inhibition. These discoveries triggered enthusiasm to elucidate the physiological role of such neurosteroids and explore whether their levels may be perturbed in particular psychiatric and neurological disorders. In preclinical studies the GABAAR-active steroids were shown to exhibit anxiolytic, anticonvulsant, analgesic and sedative properties and at relatively high doses to induce a state of general anaesthesia. Collectively, these findings encouraged efforts to investigate the therapeutic potential of neurosteroids and related synthetic analogues. However, following over 30 years of investigation, realising their possible medical potential has proved challenging. The recent FDA approval for the natural neurosteroid allopregnanolone (brexanolone) to treat postpartum depression (PPD) should trigger renewed enthusiasm for neurosteroid research. Here we focus on the influence of neuroactive steroids on GABA-ergic signalling and on the challenges faced in developing such steroids as anaesthetics, sedatives, analgesics, anticonvulsants, antidepressants and as treatments for neurodegenerative disorders.
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Affiliation(s)
- Delia Belelli
- Systems Medicine, Neuroscience, Mail Box 6, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, United Kingdom
| | - Derk Hogenkamp
- Department of Pharmacology, 110C Med Surge1, Mail Code 4625, University of California, Irvine, School of Medicine, Irvine, CA, 92697, USA
| | - Kelvin W Gee
- Department of Pharmacology, 110C Med Surge1, Mail Code 4625, University of California, Irvine, School of Medicine, Irvine, CA, 92697, USA
| | - Jeremy J Lambert
- Systems Medicine, Neuroscience, Mail Box 6, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, United Kingdom
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Hanin A, Lambrecq V, Denis JA, Imbert-Bismut F, Rucheton B, Lamari F, Bonnefont-Rousselot D, Demeret S, Navarro V. Cerebrospinal fluid and blood biomarkers of status epilepticus. Epilepsia 2019; 61:6-18. [PMID: 31828792 DOI: 10.1111/epi.16405] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 12/28/2022]
Abstract
Status epilepticus is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms that lead to abnormally prolonged seizures and require urgent administration of antiepileptic drugs. Refractory status epilepticus requires anesthetics drugs and may lead to brain injury with molecular and cellular alterations (eg, inflammation, and neuronal and astroglial injury) that could induce neurologic sequels and further development of epilepsy. Outcome scores based on demographic, clinical, and electroencephalography (EEG) condition are available, allowing prediction of the risk of mortality, but the severity of brain injury in survivors is poorly evaluated. New biomarkers are needed to predict with higher accuracy the outcome of patients admitted with status in an intensive care unit. Here, we summarize the findings of studies from patients and animal models of status epilepticus. Specific protein markers can be detected in the cerebrospinal fluid and the blood. One of the first described markers of neuronal death is the neuron-specific enolase. Gliosis resulting from inflammatory responses after status can be detected through the increase of S100-beta, or some cytokines, like the High Mobility Group Box 1. Other proteins, like progranulin may reflect the neuroprotective mechanisms resulting from the brain adaptation to excitotoxicity. These new biomarkers aim to prospectively identify the severity and development of disability, and subsequent epilepsy of patients with status. We discuss the advantages and disadvantages of each biomarker, by evaluating their brain specificity, stability in the fluids, and sensitivity to external interferences, such as hemolysis. Finally, we emphasize the need for further development and validation of such biomarkers in order to better assess patients with severe status epilepticus.
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Affiliation(s)
- Aurélie Hanin
- Brain and Spine Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
| | - Virginie Lambrecq
- Brain and Spine Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France.,Epilepsy Unit (VL, VN) and Neuro-Intensive care Unit (SD), Neurology Department, AP-HP, GH Pitié-Salpêtrière-Charles Foix, Paris, France.,Sorbonne Université, Paris, France
| | - Jérôme Alexandre Denis
- Sorbonne Université, Paris, France.,Department of Endocrine and Oncological Biochemistry (J.AD), Metabolic Biochemistry (BR, DBR, FI, FL), AP-HP, GH Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Françoise Imbert-Bismut
- Department of Endocrine and Oncological Biochemistry (J.AD), Metabolic Biochemistry (BR, DBR, FI, FL), AP-HP, GH Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Benoît Rucheton
- Department of Endocrine and Oncological Biochemistry (J.AD), Metabolic Biochemistry (BR, DBR, FI, FL), AP-HP, GH Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Foudil Lamari
- Department of Endocrine and Oncological Biochemistry (J.AD), Metabolic Biochemistry (BR, DBR, FI, FL), AP-HP, GH Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Dominique Bonnefont-Rousselot
- Department of Endocrine and Oncological Biochemistry (J.AD), Metabolic Biochemistry (BR, DBR, FI, FL), AP-HP, GH Pitié-Salpêtrière-Charles Foix, Paris, France.,UTCBS, U 1022 Inserm, UMR 8258 CNRS, Paris University, Paris, France
| | - Sophie Demeret
- Epilepsy Unit (VL, VN) and Neuro-Intensive care Unit (SD), Neurology Department, AP-HP, GH Pitié-Salpêtrière-Charles Foix, Paris, France
| | - Vincent Navarro
- Brain and Spine Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France.,Epilepsy Unit (VL, VN) and Neuro-Intensive care Unit (SD), Neurology Department, AP-HP, GH Pitié-Salpêtrière-Charles Foix, Paris, France.,Sorbonne Université, Paris, France
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Billakota S, Devinsky O, Kim KW. Why we urgently need improved epilepsy therapies for adult patients. Neuropharmacology 2019; 170:107855. [PMID: 31751547 DOI: 10.1016/j.neuropharm.2019.107855] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 11/12/2019] [Accepted: 11/15/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Up to a third of patients with epilepsy suffer from recurrent seizures despite therapeutic advances. RESULTS Current epilepsy treatments are limited by experiential data from treating different types of epilepsy. For example, we lack evidence-based approaches to efficacious multi-drug therapies or identifying potentially serious or disabling adverse events before medications are initiated. Despite advances in neuroscience and genetics, our understanding of epilepsy pathogenesis and mechanisms of treatment-resistance remains limited. For most patients with epilepsy, precision medicine for improved seizure control and reduced toxicity remains a future goal. CONCLUSION A third of epilepsy patients suffer from ongoing seizures and even more suffer from adverse effects of treatment. There is a critical need for more effective and safer therapies for epilepsy patients with frequent comorbitidies, including depression, anxiety, migraine, and cognitive impairments, as well as special populations (e.g., women, elderly). Advances from genomic sequencing techniques may identify new genes and regulatory elements that influence both the depth of the epilepsies' roots within brain circuitry as well as ASD resistance. Improved understanding of epilepsy mechanisms, identification of potential new therapeutic targets, and their assessment in randomized controlled trials are needed to reduce the burden of refractory epilepsy. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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Affiliation(s)
- Santoshi Billakota
- NYU Langone Comprehensive Epilepsy Center and NYU Langone School of Medicine, New York, NY, USA.
| | - Orrin Devinsky
- NYU Langone Comprehensive Epilepsy Center and Professor of Neurology, Neurosurgery, and Psychiatry at NYU Langone School of Medicine, New York, NY, USA; Saint Barnabas Institute of Neurology and Neurosurgery, Livingston, NJ, USA
| | - Kyung-Wha Kim
- NYU Langone Comprehensive Epilepsy Center and NYU Langone School of Medicine, New York, NY, USA
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Fechner A, Hubert K, Jahnke K, Knake S, Konczalla J, Menzler K, Ronellenfitsch MW, Rosenow F, Strzelczyk A. Treatment of refractory and superrefractory status epilepticus with topiramate: A cohort study of 106 patients and a review of the literature. Epilepsia 2019; 60:2448-2458. [DOI: 10.1111/epi.16382] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Anne Fechner
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
| | - Kristina Hubert
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
| | - Kolja Jahnke
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
| | - Susanne Knake
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
- Department of Neurology Epilepsy Center Hessen Philipps University Marburg Marburg (Lahn) Germany
| | - Jürgen Konczalla
- Department of Neurosurgery Goethe University Frankfurt Frankfurt am Main Germany
| | - Katja Menzler
- Department of Neurology Epilepsy Center Hessen Philipps University Marburg Marburg (Lahn) Germany
| | - Michael W. Ronellenfitsch
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
- Dr Senckenberg Institute of Neurooncology Goethe University Frankfurt Frankfurt am Main Germany
- Frankfurt Cancer Institute Goethe University Frankfurt Frankfurt am Main Germany
| | - Felix Rosenow
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
| | - Adam Strzelczyk
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
- Department of Neurology Epilepsy Center Hessen Philipps University Marburg Marburg (Lahn) Germany
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Mouro FM, Miranda-Lourenço C, Sebastião AM, Diógenes MJ. From Cannabinoids and Neurosteroids to Statins and the Ketogenic Diet: New Therapeutic Avenues in Rett Syndrome? Front Neurosci 2019; 13:680. [PMID: 31333401 PMCID: PMC6614559 DOI: 10.3389/fnins.2019.00680] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/13/2019] [Indexed: 12/21/2022] Open
Abstract
Rett syndrome (RTT) is an X-linked neurodevelopmental disorder caused mainly by mutations in the MECP2 gene, being one of the leading causes of mental disability in females. Mutations in the MECP2 gene are responsible for 95% of the diagnosed RTT cases and the mechanisms through which these mutations relate with symptomatology are still elusive. Children with RTT present a period of apparent normal development followed by a rapid regression in speech and behavior and a progressive deterioration of motor abilities. Epilepsy is one of the most common symptoms in RTT, occurring in 60 to 80% of RTT cases, being associated with worsening of other symptoms. At this point, no cure for RTT is available and there is a pressing need for the discovery of new drug candidates to treat its severe symptoms. However, despite being a rare disease, in the last decade research in RTT has grown exponentially. New and exciting evidence has been gathered and the etiopathogenesis of this complex, severe and untreatable disease is slowly being unfolded. Advances in gene editing techniques have prompted cure-oriented research in RTT. Nonetheless, at this point, finding a cure is a distant reality, highlighting the importance of further investigating the basic pathological mechanisms of this disease. In this review, we focus our attention in some of the newest evidence on RTT clinical and preclinical research, evaluating their impact in RTT symptomatology control, and pinpointing possible directions for future research.
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Affiliation(s)
- Francisco Melo Mouro
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Catarina Miranda-Lourenço
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Maria Sebastião
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Maria José Diógenes
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Willems LM, Bauer S, Rosenow F, Strzelczyk A. Recent advances in the pharmacotherapy of epilepsy: brivaracetam and perampanel as broad-spectrum antiseizure drugs for the treatment of epilepsies and status epilepticus. Expert Opin Pharmacother 2019; 20:1755-1765. [DOI: 10.1080/14656566.2019.1637420] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Laurent Maximilian Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
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Arya R, Rotenberg A. Dietary, immunological, surgical, and other emerging treatments for pediatric refractory status epilepticus. Seizure 2019; 68:89-96. [DOI: 10.1016/j.seizure.2018.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023] Open
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Gaínza-Lein M, Fernández IS, Ulate-Campos A, Loddenkemper T, Ostendorf AP. Timing in the treatment of status epilepticus: From basics to the clinic. Seizure 2019; 68:22-30. [DOI: 10.1016/j.seizure.2018.05.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/18/2018] [Accepted: 05/29/2018] [Indexed: 02/07/2023] Open
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Abstract
Patients with prolonged seizures that do not respond to intravenous benzodiazepines and a second-line anticonvulsant suffer from refractory status epilepticus and those with seizures that do not respond to continuous intravenous anesthetic anticonvulsants suffer from super-refractory status epilepticus. Both conditions are associated with significant morbidity and mortality. A strict pharmacological treatment regimen is urgently required, but the level of evidence for the available drugs is very low. Refractory complex focal status epilepticus generally does not require anesthetics, but all intravenous non-anesthetizing anticonvulsants may be used. Most descriptive data are available for levetiracetam, phenytoin and valproate. Refractory generalized convulsive status epilepticus is a life-threatening emergency, and long-term clinical consequences are eminent. Administration of intravenous anesthetics is mandatory, and drugs acting at the inhibitory gamma-aminobutyric acid (GABA)A receptor such as midazolam, propofol and thiopental/pentobarbital are recommended without preference for one of those. One in five patients with anesthetic treatment does not respond and has super-refractory status epilepticus. With sustained seizure activity, excitatory N-methyl-d-aspartate (NMDA) receptors are increasingly expressed post-synaptically. Ketamine is an antagonist at this receptor and may prove efficient in some patients at later stages. Neurosteroids such as allopregnanolone increase sensitivity at GABAA receptors; a Phase 1/2 trial demonstrated safety and tolerability, but randomized controlled data failed to demonstrate efficacy. Adjunct ketogenic diet may contribute to termination of difficult-to-treat status epilepticus. Randomized controlled trials are needed to increase evidence for treatment of refractory and super-refractory status epilepticus, but there are multiple obstacles for realization. Hitherto, prospective multicenter registries for pharmacological treatment may help to improve our knowledge.
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Affiliation(s)
- Martin Holtkamp
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
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Abstract
PURPOSE OF REVIEW Seizures and status epilepticus are very common diagnoses in the critically ill patient and are associated with significant morbidity and mortality. There is an abundance of research on the utility of antiseizure medications in this setting, but limited randomized-controlled trials to guide the selection of medications in these patients. This review examines the current guidelines and treatment strategies for status epilepticus and provides an update on newer antiseizure medications in the critical care settings. RECENT FINDINGS Time is brain applies to status epilepticus, with delays in treatment corresponding with worsened outcomes. Establishing standardized treatment protocols within a health system, including prehospital treatment, may lead to improved outcomes. Once refractory status epilepticus is established, continuous deep sedation with intravenous anesthetic agents should be effective. In cases, which prove highly refractory, novel approaches should be considered, with recent data suggesting multiple recently approved antiseizure medications, appropriate therapeutic options, as well as novel approaches to upregulate extrasynaptic γ-aminobutyric acid channels with brexanolone. SUMMARY Although there are many new treatments to consider for seizures and status epilepticus in the critically ill patient, the most important predictor of outcome may be rapid diagnosis and treatment. There are multiple new and established medications that can be considered in the treatment of these patients once status epilepticus has become refractory, and a multidrug regimen will often be necessary.
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Affiliation(s)
- Baxter Allen
- Division of Neurocritical Care, Department of Neurology, University of California, Los Angeles, California, USA
- Division of Neurocritical Care, Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Paul M. Vespa
- Division of Neurocritical Care, Department of Neurology, University of California, Los Angeles, California, USA
- Division of Neurocritical Care, Department of Neurosurgery, University of California, Los Angeles, California, USA
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Santamarina E, Abraira L, Toledo M. Update in status epilepticus. Med Clin (Barc) 2019; 153:70-77. [PMID: 30803796 DOI: 10.1016/j.medcli.2019.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 11/25/2022]
Abstract
Status epilepticus (SE) is a neurological emergency that requires urgent antiepileptic therapies, and a rapid treatment of its cause. In recent years, its definition has been updated to adapt it to all types of SE; this update helps to standardise the treatment. The new definition is based on two times: point t1, after which the event will not spontaneously cease, and period t2, after which neuronal damage may appear. There are three lines of treatment: first, benzodiazepines; second, antiepileptic drugs; and third, intravenous anaesthetics. The application of the different lines of treatment raises still unanswered questions, since the prognosis also depends on the aetiology, age and duration. For this reason, different prognostic scales are being developed to help us to assess its evolution and in turn, adapt the aggressiveness of the treatment to each patient.
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Affiliation(s)
- Estevo Santamarina
- Unidad de Epilepsia, Servicio de Neurología, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - Laura Abraira
- Unidad de Epilepsia, Servicio de Neurología, Hospital Universitario Vall d'Hebron, Barcelona, España; Universitat Autònoma de Barcelona, Barcelona, España
| | - Manuel Toledo
- Unidad de Epilepsia, Servicio de Neurología, Hospital Universitario Vall d'Hebron, Barcelona, España
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Saporito MS, Gruner JA, DiCamillo A, Hinchliffe R, Barker-Haliski M, White HS. Intravenously Administered Ganaxolone Blocks Diazepam-Resistant Lithium-Pilocarpine–Induced Status Epilepticus in Rats: Comparison with Allopregnanolone. J Pharmacol Exp Ther 2018; 368:326-337. [DOI: 10.1124/jpet.118.252155] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/12/2018] [Indexed: 11/22/2022] Open
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Progesterone, 5a-dihydropogesterone and allopregnanolone's effects on seizures: A review of animal and clinical studies. Seizure 2018; 63:26-36. [DOI: 10.1016/j.seizure.2018.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/16/2018] [Accepted: 10/20/2018] [Indexed: 02/07/2023] Open
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