Selection of antiepileptic drugs in older people

Perceived quality of life (QOLIE-31-P), depression (NDDI-E), anxiety (GAD-7), and insomnia in patients with epilepsy attended at a refractory epilepsy unit in real-life clinical practice

Objectives

This study aims to evaluate the relationship between psychiatric comorbidity (anxiety and depression), somnolence, and quality of life, using validated scales in patients with epilepsy in real-life clinical practice and clinical and demographic variables.

Methods

A cross-sectional observational study was conducted. Self-administered scales of anxiety disorders (GAD-7), depression (NDDI-E), somnolence (Epworth Sleepiness Scale (ESS)), and quality of life (QOLIE-31-P) in patients with epilepsy treated in the refractory epilepsy unit of a tertiary hospital were employed.

Results

Eighty-four patients, 44.3 ± 17.4 years, 48.2% women, epilepsy duration 21.5 ± 15.9 years, and number of antiepileptic drugs 1.9 ± 1.2 were included. Severe anxiety was present in 14.3%, depression in 20.2%, and somnolence in 14.3% of patients. QOLIE-31-P score was 62.0 ± 19.2. Depression and focal epilepsy (OR = 4.5[1.3, 20.7], p = 0.029), as well as anxiety and temporal lobe epilepsy (OR = 4.3 [1.0, 18.1], p = 0.044), were associated. Moreover, relationships between worse quality of life and higher scores from NDDI-E (β =  − 1.42, adjusted p = 0.006) and GAD-7 (β =  − 1.21, adjusted p = 0.006), especially in drug-resistant epilepsy (β =  − 8.08, adjusted p = 0.045) and female sex (β =  − 7.83, adjusted p = 0.034), were identified. Statistically significant negative associations were observed between problems to fall asleep and overall quality of life score (β =  − 11.64, adjusted p = 0.022), sleep disturbance and energy (β =  − 14.78, adjusted p = 0.027), and mood (β = 12.40, adjusted p = 0.027) scores.

Conclusions

The multidimensional evaluation revealed that higher levels of anxiety and depression are associated with worse quality of life in real clinical practice in patients with epilepsy, especially in females and drug-resistant epilepsy. In addition, sleep disturbances are associated with particular aspects of the quality of life. Further studies with longitudinal follow-up would be useful to adequately manage these comorbidities in patients with epilepsy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-021-05595-3.

The Relationship Between Valproate and Lamotrigine/Levetiracetam Use and Prognosis in Patients With Epilepsy and Heart Failure: A Danish Register-Based Study

OBJECTIVE

To compare the hazard for all-cause mortality and mortality due to heart failure (HF) between valproate (VPA) and levetiracetam (LEV)/lamotrigine (LTG) users in patients aged ≥ 65 with comorbidities of epilepsy and HF.

METHODS

This was a cohort study using Danish registers during the period from January 1996 to July 2018. The study population included new users of LTG, LEV or VPA. A Cox regression model was used to compute crude and adjusted hazard ratios for the outcome, using an intention-to-treat approach. Average treatment effects (eg, 1-year absolute risks), risk differences and the ratio of risks were computed using the G-formula based on a Cox regression model for the outcomes at the end of the follow-up period.

RESULTS

We included 1345 subjects in the study population. VPA users (n = 696), when compared to LTG/LEV users (n = 649), had an increased hazard of mortality due to HF (hazard ratio [HR] 2.39; 95% CI 1.02-5.60) and to all-cause mortality (HR 1.37; 95% CI 1.01-1.85) in both crude and adjusted analyses. The 1-year absolute risks for all-cause mortality were 29% (95% CI 25%-33%) and 22% (95% CI 18%-26%) for VPA and LTG/LEV users. For mortality due to HF, 1-year absolute risks were 5% (95% CI 3%-7%) and 2% (95% CI 1%-4%) for VPA and LTG/LEV users. The average risk ratio, with LTG/LEV as the reference group, was 1.31 (95% CI 1.02-1.71) for all-cause mortality and 2.35 (95% CI 1.11-5.76) for HF mortality.

CONCLUSION

In older people with HF and epilepsy, treatment with VPA was associated with a higher risk of all-cause and HF mortality compared to treatment with LTG and LEV.

The relationship between epilepsy and sexual dysfunction: a review of the literature

Background and objectives

Regardless of the disease states that people suffer from, maintaining sexual function is an important indicator of quality of life. The objective of this review was to figure out the relationship between epilepsy, antiepileptic drugs (AEDs) and sexual dysfunction.

Results

In various epidemiological and clinical studies, epilepsy has been correlated with a reduction in sexual function. This sexual dysfunction is not always detected in epileptic patients until systematic efforts are put in place, as part of the assessment and treatment process. Therefore, precise evaluations of the incidence of treatment related sexual dysfunction in epileptic patients is still lacking.

Conclusions

This literature review concluded that sexual function is influenced by the pathophysiology of epilepsy, as well as through the use of AEDs. To maximize quality of care in patients with epilepsy and those patients with other disease states who receive AEDs, it is important to address the status of the patient’s sexual function as part of the initial routine assessment and with any treatment related follow-up. Minimizing the effects of AED related sexual dysfunction can be achieved by raising awareness among patients, providing education and training for physicians regarding sexual dysfunction and obtaining a baseline sexual history from the patient so are important recommendations. In addition, systematic studies are needed to explore the risk and mechanism of such treatment related side effects on sexual function.

Caracterização da epilepsia com início após os 60 anos de idade

Resumo Introdução: Apesar da elevada incidência, a epilepsia no idoso ainda exibe peculiaridades pouco estudadas. A apresentação clínica na maioria das vezes é atípica e os achados nos exames complementares pouco ajudam no diagnóstico. Existem poucas publicações caracterizando esse grupo de indivíduos. Objetivo: Descrever as características de pacientes com epilepsia iniciada após os 60 anos de idade. Método: Foi desenvolvido estudo descritivo de série de casos, onde foram avaliados, consecutivamente, 50 pacientes com diagnóstico de epilepsia iniciada após os 60 anos de idade, atendidos no ambulatório de epilepsia do Hospital da Restauração (Recife-PE). Resultados: Dos 50 pacientes incluídos no estudo, a idade média foi de 75,3 (±13) anos, sendo que 30 (60,0%) eram do sexo feminino e 20 (40,0%) do sexo masculino. A idade média da primeira crise foi de 72,5 (±11,5) anos. Predominaram as crises epilépticas focais (83,8%). A ocorrência de estado de mal epiléptico foi baixa nesse grupo (4,0%). A epilepsia sintomática foi a mais frequente, tendo como etiologia vascular a causa mais encontrada (43,0%). A medicação mais utilizada foi a carbamazepina, e as crises apresentaram uma boa resposta terapêutica com monoterapia em dose baixa. O eletroencefalograma apresentou resultado normal em número elevado de casos (50,0%) e a neuroimagem na maioria das vezes (83,0%) apresentou achados inespecíficos. Conclusão: A epilepsia no idoso é predominantemente focal e sintomática, apresenta baixa ocorrência de estado de mal epiléptico e boa resposta terapêutica. O eletroencefalograma e a neuroimagem, na maioria das vezes, são inespecíficos.

The New Antiepileptic Drugs: Their Neuropharmacology and Clinical Indications

The administration of antiepileptic drugs (AEDs) is the first treatment of epilepsy, one of the most common neurological diseases. Therapeutic guidelines include newer AEDs as front-line drugs; monotherapy with new AEDs is delivered in Japan. While about 70% of patients obtain good seizure control by taking one to three AEDs, about 60% experience adverse effects and 33% have to change drugs. Compared to traditional AEDs, the prolonged administration of new AEDs elicits fewer adverse effects and fewer drug interactions and their teratogenicity may be lower. These characteristics increase drug compliance and allow combination therapy for drug-resistant epilepsy, although the antiepileptic effects of the new AEDs are not greater than of traditional AEDs. Comorbidities are not rare in epileptics; many adult patients present with stroke and brain tumors. In stroke patients requiring risk control and in chemotherapy-treated brain tumor patients, their fewer drug interactions render the new AEDs advantageous. Also, new AEDs offer favorable side benefits for concurrent diseases and conditions. Patients with stroke and traumatic brain injury often present with psychiatric/behavioral symptoms and cognitive impairment and some new AEDs alleviate such symptoms. This review presents an outline of the new AEDs used to treat adult patients based on the pharmacological activity of the drugs and discusses possible clinical indications from the perspective of underlying causative diseases and comorbidities.