New Antiepileptic Drugs: Lacosamide, Rufinamide, and Vigabatrin

Efficacy, tolerability and safety of add-on third-generation antiseizure medications in treating focal seizures worldwide: a network meta-analysis of randomised, placebo-controlled trials

Background

Adjunctive newer antiseizure medications (ASMs) are being used in patients with treatment-resistant focal-onset seizures (FOS). An updated network meta-analysis (NMA) was necessary to compile evidence in this critical area.

Methods

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Scopus from their inception until 17 January 2024, evaluating the efficacy, tolerability, and safety of rufinamide (RUF), brivaracetam (BRV), cenobamate (CNB), eslicarbazepine (ESL), lacosamide (LCM), retigabine (RTG), and perampanel (PER) as adjunctive treatments for FOS. Efficacy outcomes included seizure response and seizure freedom. Tolerability was assessed by discontinuation due to adverse events (AEs). Safety outcomes were evaluated based on the number of patients experiencing at least one AE and serious adverse events (SAEs). This review is registered with PROSPERO (CRD42023485130).

Findings

A total of 29 studies involving 11,750 participants were included. For seizure response, all ASMs were significantly superior to placebo, with RTG ranking highest, followed by CNB. Considering dosage, CNB 400 mg/d was top-ranked, followed by RTG 1200 mg/d. For seizure freedom, BRV was highest-ranked, followed by CNB, with BRV 100 mg/d leading, followed by CNB 400 mg/d. Regarding tolerability, LCM 600 mg/d had the lowest ranking, followed by CNB 400 mg/d. For the safety outcome of AEs, ESL 1200 mg/d was ranked lowest, followed by CNB 400 mg/d. Regarding SAEs, LCM 400 mg/d was ranked lowest, followed by RTG 1200 mg/d.

Interpretation

ASMs at different dosages have varying efficacy and tolerability profiles. We have provided hierarchical rankings of ASMs for efficacy and safety outcomes. Our findings offer the most comprehensive evidence available to inform patients, families, physicians, guideline developers, and policymakers about the choice of ASMs in patients with treatment-resistant FOS.

Funding

None.

The efficacy and safety of rufinamide in drug-resistant epilepsy: A meta-analysis of double-blind, randomized, placebo controlled trials

OBJECTIVE

To evaluate the clinical efficacy and safety of rufinamide in drug-resistant epilepsy.

METHODS

We searched PubMed, Web of Science and Clinical trial.org up to August 6, 2015. Study selection, extraction and risk of bias assessment were performed independently by two authors. A random or fixed-effect model was used to derive pooled effects risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

Five randomized controlled trials were included in the final analysis with a total of 1512 patients. Rufinamide increased the 50% (RR 1.852, 95%CI 1.446-2.372, P<0.001) and 75% (RR 8.547, 95%CI 2.534-28.832, P<0.001) responder rates but not the seizure-free rate (RR 1.740, 95%CI 0.511-5.924, P=0.376) compared to placebo. Subgroup analysis demonstrated that the effect of rufinamide may be dose-dependent and related to seizure type. Regarding safety, rufinamide increased the rate of at least one adverse event (RR 1.103, 95%CI 1.047-1.161, P<0.001) and the withdrawal rate due to adverse events (RR 2.341, 95%CI 1.556-3.522, P<0.001), but it did not increase the rate of severe adverse events (RR 1.454, 95%CI 0.945-2.241, P=0.090). Individual adverse events (headache, dizziness, fatigue, somnolence, nausea, diplopia and vomiting) were significantly higher in the rufinamide group.

CONCLUSIONS

This study confirmed significant effects of rufinamide as adjunctive treatment for drug-resistant seizures, both partial and tonic-atonic. However, rufinamide may induce more tolerable (but not severe) adverse events. Further large clinical trials to investigate the long-term efficacy and safety of rufinamide are warranted.