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Cross JH, Benítez A, Roth J, Andrews JS, Shah D, Butcher E, Jones A, Sullivan J. A comprehensive systematic literature review of the burden of illness of Lennox-Gastaut syndrome on patients, caregivers, and society. Epilepsia 2024; 65:1224-1239. [PMID: 38456647 DOI: 10.1111/epi.17932] [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: 09/29/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024]
Abstract
Fully elucidating the burden that Lennox-Gastaut syndrome (LGS) places on individuals with the disease and their caregivers is critical to improving outcomes and quality of life (QoL). This systematic literature review evaluated the global burden of illness of LGS, including clinical symptom burden, care requirements, QoL, comorbidities, caregiver burden, economic burden, and treatment burden (PROSPERO ID: CRD42022317413). MEDLINE, Embase, and the Cochrane Library were searched for articles that met predetermined criteria. After screening 1442 deduplicated articles and supplementary manual searches, 113 articles were included for review. A high clinical symptom burden of LGS was identified, with high seizure frequency and nonseizure symptoms (including developmental delay and intellectual disability) leading to low QoL and substantial care requirements for individuals with LGS, with the latter including daily function assistance for mobility, eating, and toileting. Multiple comorbidities were identified, with intellectual disorders having the highest prevalence. Although based on few studies, a high caregiver burden was also identified, which was associated with physical problems (including fatigue and sleep disturbances), social isolation, poor mental health, and financial difficulties. Most economic analyses focused on the high direct costs of LGS, which arose predominantly from medically treated seizure events, inpatient costs, and medication requirements. Pharmacoresistance was common, and many individuals required polytherapy and treatment changes over time. Few studies focused on the humanistic burden. Quality concerns were noted for sample representativeness, disease and outcome measures, and reporting clarity. In summary, a high burden of LGS on individuals, caregivers, and health care systems was identified, which may be alleviated by reducing the clinical symptom burden. These findings highlight the need for a greater understanding of and better definitions for the broad spectrum of LGS symptoms and development of treatments to alleviate nonseizure symptoms.
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Affiliation(s)
- J Helen Cross
- University College London National Institute for Health and Care Research Biomedical Research Centre Great Ormond Street Institute of Child Health, London, UK
| | - Arturo Benítez
- Takeda Pharmaceutical Company, Cambridge, Massachusetts, USA
| | - Jeannine Roth
- Takeda Pharmaceuticals International, Zurich, Switzerland
| | - J Scott Andrews
- Takeda Pharmaceutical Company, Cambridge, Massachusetts, USA
| | - Drishti Shah
- Takeda Pharmaceutical Company, Cambridge, Massachusetts, USA
| | | | | | - Joseph Sullivan
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
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Gidal BE, Resnick T, Smith MC, Wheless JW. Zonisamide: A Comprehensive, Updated Review for the Clinician. Neurol Clin Pract 2024; 14:e200210. [PMID: 38170117 PMCID: PMC10759004 DOI: 10.1212/cpj.0000000000200210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/15/2023] [Indexed: 01/05/2024]
Abstract
Purpose of Review Zonisamide (ZNS) was first approved in the United States in 2000 for the adjunctive treatment of patients aged 16 years or older with partial (focal) seizures. Although ZNS has been proven to treat multiple seizure types, it has been largely underutilized in US clinical practice. Recent Findings Published literature demonstrated that antiseizure medications (ASMs) acting on Na+ and Ca2+ channels may add beneficial effects in many seizure types by reducing seizure frequency and leading to overall improvements. In addition, effects of ZNS may lead to clinical improvements in Parkinson disease, alcohol and sleep disorders, pain, and migraine. ZNS is available in multiple formulations and is a safe and effective, broad spectrum ASM. Summary The purpose of this review was to provide an update to what is known about the efficacy of ZNS and where it shows benefits in the treatment of patients with epilepsy and other CNS disorders through its many unique mechanisms of action.
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Affiliation(s)
- Barry E Gidal
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - Trevor Resnick
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - Michael C Smith
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - James W Wheless
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
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Besag FMC, Vasey MJ, Chin RFM. Current and emerging pharmacotherapy for the treatment of Lennox-Gastaut syndrome. Expert Opin Pharmacother 2023; 24:1249-1268. [PMID: 37212330 DOI: 10.1080/14656566.2023.2215924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Lennox-Gastaut syndrome (LGS) is a severe childhood-onset epileptic encephalopathy, characterized by multiple seizure types, generalized slow spike-and-wave complexes in the EEG, and cognitive impairment. Seizures in LGS are typically resistant to treatment with antiseizure medications (ASMs). Tonic/atonic ('drop') seizures are of particular concern, due to their liability to cause physical injury. AREAS COVERED We summarize evidence for current and emerging ASMs for the treatment of seizures in LGS. The review focuses on findings from randomized, double-blind, placebo-controlled trials (RDBCTs). For ASMs for which no double-blind trials were identified, lower quality evidence was considered. Novel pharmacological agents currently undergoing investigation for the treatment of LGS are also briefly discussed. EXPERT OPINION Evidence from RDBCTs supports the use of cannabidiol, clobazam, felbamate, fenfluramine, lamotrigine, rufinamide, and topiramate as adjunct treatments for drop seizures. Percentage decreases in drop seizure frequency ranged from 68.3% with high-dose clobazam to 14.8% with topiramate. Valproate continues to be considered the first-line treatment, despite the absence of RDBCTs specifically in LGS. Most individuals with LGS will require treatment with multiple ASMs. Treatment decisions should be individualized and take into account adverse effects, comorbidities, general quality of life, and drug interactions, as well as individual efficacy.
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Affiliation(s)
- Frank M C Besag
- East London NHS Foundation Trust, Bedford, UK
- School of Pharmacy, University College London, London, UK
- Department of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, The University of Edinburgh, Edinburgh, UK
- Department of Paediatric Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
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Strzelczyk A, Schubert-Bast S. Psychobehavioural and Cognitive Adverse Events of Anti-Seizure Medications for the Treatment of Developmental and Epileptic Encephalopathies. CNS Drugs 2022; 36:1079-1111. [PMID: 36194365 PMCID: PMC9531646 DOI: 10.1007/s40263-022-00955-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 02/06/2023]
Abstract
The developmental and epileptic encephalopathies encompass a group of rare syndromes characterised by severe drug-resistant epilepsy with onset in childhood and significant neurodevelopmental comorbidities. The latter include intellectual disability, developmental delay, behavioural problems including attention-deficit hyperactivity disorder and autism spectrum disorder, psychiatric problems including anxiety and depression, speech impairment and sleep problems. Classical examples of developmental and epileptic encephalopathies include Dravet syndrome, Lennox-Gastaut syndrome and tuberous sclerosis complex. The mainstay of treatment is with multiple anti-seizure medications (ASMs); however, the ASMs themselves can be associated with psychobehavioural adverse events, and effects (negative or positive) on cognition and sleep. We have performed a targeted literature review of ASMs commonly used in the treatment of developmental and epileptic encephalopathies to discuss the latest evidence on their effects on behaviour, mood, cognition, sedation and sleep. The ASMs include valproate (VPA), clobazam, topiramate (TPM), cannabidiol (CBD), fenfluramine (FFA), levetiracetam (LEV), brivaracetam (BRV), zonisamide (ZNS), perampanel (PER), ethosuximide, stiripentol, lamotrigine (LTG), rufinamide, vigabatrin, lacosamide (LCM) and everolimus. Bromide, felbamate and other sodium channel ASMs are discussed briefly. Overall, the current evidence suggest that LEV, PER and to a lesser extent BRV are associated with psychobehavioural adverse events including aggressiveness and irritability; TPM and to a lesser extent ZNS are associated with language impairment and cognitive dulling/memory problems. Patients with a history of behavioural and psychiatric comorbidities may be more at risk of developing psychobehavioural adverse events. Topiramate and ZNS may be associated with negative effects in some aspects of cognition; CBD, FFA, LEV, BRV and LTG may have some positive effects, while the remaining ASMs do not appear to have a detrimental effect. All the ASMs are associated with sedation to a certain extent, which is pronounced during uptitration. Cannabidiol, PER and pregabalin may be associated with improvements in sleep, LTG is associated with insomnia, while VPA, TPM, LEV, ZNS and LCM do not appear to have detrimental effects. There was variability in the extent of evidence for each ASM: for many first-generation and some second-generation ASMs, there is scant documented evidence; however, their extensive use suggests favourable tolerability and safety (e.g. VPA); second-generation and some third-generation ASMs tend to have the most robust evidence documented over several years of use (TPM, LEV, PER, ZNS, BRV), while evidence is still being generated for newer ASMs such as CBD and FFA. Finally, we discuss how a variety of factors can affect mood, behaviour and cognition, and untangling the associations between the effects of the underlying syndrome and those of the ASMs can be challenging. In particular, there is enormous heterogeneity in cognitive, behavioural and developmental impairments that is complex and can change naturally over time; there is a lack of standardised instruments for evaluating these outcomes in developmental and epileptic encephalopathies, with a reliance on subjective evaluations by proxy (caregivers); and treatment regimes are complex involving multiple ASMs as well as other drugs.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany. .,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
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Alonso-Singer P, Aguilar-Amat Prior MJ, Oliva-Navarro J, Massot-Tarrús A, Giráldez BG, Bermejo P, DeToledo-Heras M, Aledo-Serrano Á, Martínez-Cayuelas E, Tirado-Requero P, Velázquez-Fragua R, López-Sobrino G, Ojeda J. Perampanel as adjuvant treatment in epileptic encephalopathies: A multicenter study in routine clinical practice. Epilepsy Behav 2022; 134:108836. [PMID: 35870432 DOI: 10.1016/j.yebeh.2022.108836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/13/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Developmental and epileptic encephalopathies (DEEs) are a heterogeneous group of syndromes, including Lennox-Gastaut syndrome (LGS), which are refractory to multiple therapies. Perampanel efficacy has been reported in LGS but further real-world evidence is needed in DEEs. METHODS A multicenter, retrospective, 1-year observational study in patients with DEEs on adjuvant perampanel treatment was conducted to assess perampanel safety and effectiveness in this type of patients in a real-world setting. Seizure types [focal onset seizures (FOS), generalized tonic-clonic seizures (GTCS), tonic seizures (TS), atonic seizures (AtS), atypical absences (AA), and myoclonic seizures (MS)] and seizure clusters were divided in different frequency groups: daily, weekly, and monthly seizures, and absent or seizure freedom. Patients could have more than one seizure type. For each frequency group, group change and seizure freedom were analyzed. RESULTS Eighty-seven patients diagnosed with DEEs (45 males) of median age 22 [1-70] years were included. The most frequent DEEs were LGS (35.6%) and Lennox-like syndrome (37.9%). At baseline 20 patients had three to five types of seizures, 36 patients had two types of seizures and 31 patients had one predominant type of seizure. The mean number of seizure types per patient at baseline was 2.12 ± 0.97 which was reduced to 1.62 ± 0.91 at 12 months (p < 0.001). Overall, 51.7% of patients had a significant improvement in at least one seizure type. At baseline, 45 patients had GTCS, 42 FOS, 41 TS, 18 AA, 16 AtS, 11 MS, and 30 seizures clusters. Seizure freedom for each specific type at 12 months was significantly achieved by 35% of patients with GTCS (p < 0.001), 17% (p = 0.016) with TS and 37% with seizure clusters (p < 0.001). Patients achieved seizure freedom from other seizure types but with no statistical significance: 7% FOS-free, 28% AA-free, 6% Ats-free, and 18% MS-free. Regarding changes of group at 12 months, 22% of TS and 19% of FOS improved significantly to a group with lower seizure frequency (p = 0.004 and p = 0.02, respectively). In remaining groups (4% of GTCS, 11% of AA, 18% of Ats, 18% of MS, and 13% of seizure clusters), the improvement was not statistically significant. Twenty-nine patients discontinued perampanel: 18 (21%) due to AEs, 8 (9%) due to lack of efficacy, and 3 (3%) due to seizure worsening. Adverse events, mostly mild or moderate, were reported in 53% of patients, and irritability/mood changes (22%) and somnolence (17%) were the most frequent. CONCLUSION This is the first large-scale real-world study with perampanel across different seizure types in patients with DEEs. Perampanel was effective, especially in GTCS, TS, and FOS, as well as in seizure clusters. Perampanel was generally well-tolerated without unexpected AEs.
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Affiliation(s)
- Pablo Alonso-Singer
- Epilepsy Unit, Neurology Service, University Hospital La Paz, Madrid, Spain.
| | | | | | - Andreu Massot-Tarrús
- Epilepsy Unit, Department of Neurology, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Beatriz G Giráldez
- Epilepsy Unit, Neurology Service, University Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Pedro Bermejo
- Epilepsy Unit, University Hospital Puerta de Hierro, Majadahonda, Spain
| | | | - Ángel Aledo-Serrano
- Epilepsy Program, Department of Neurology, Ruber Internacional Hospital, Madrid, Spain
| | | | | | | | | | - Joaquín Ojeda
- Neurology Unit, University Hospital Infanta Sofía, Madrid, Spain
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Aslan M, Gungor S. Effectiveness of zonisamide in childhood refractory epilepsy. Childs Nerv Syst 2022; 38:971-976. [PMID: 35083515 DOI: 10.1007/s00381-022-05458-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Zonisamide (ZNS) is a new generation antiepileptic drug (AED) used in refractory epilepsy. This study assessed the effectiveness and reliability of ZNS in childhood refractory epilepsy. METHOD Sixty-eight epilepsy patients who were followed up in the paediatric neurology clinic, between 2013 and 2019, and in whom add-on therapy ZNS had been added as their seizures had continued despite multiple drugs being used, were included in this retrospective study. Their demographic findings, seizure aetiology, pre-treatment and post-treatment electroencephalography findings, treatment responses and any side effects of the drugs given were assessed in these patients. RESULTS There were 46 (67.6%) patients in the refractory generalized epilepsy (RGE) group using multiple AEDs and 22 (32.35%) patients in the refractory focal epilepsy (RFE) group. Of these patients, 12 (17.65%) were being followed up for idiopathic epilepsy and 8 (11.76%) were being followed up for epilepsy of unknown aetiology. Twenty-two (32.36%) patients were followed up for structural abnormality, 8 patients (11.77%) were followed up for genetic disease, 4 patients (5.88%) were followed up for infectious sequel, 14 patients (20.59%) were followed up for metabolic reasons. In the RGE group, a more than 50% reduction was found in the seizures of 26 (56.5%) patients, while the seizures of 7 (15.2%) patients were found to have terminated completely. In the RFE group, a more than 50% reduction was found in the seizures of 19 (86.4%) patients, while the seizures of 2 (9.1%) patients were found to have terminated completely. The termination or a more than 50% reduction in seizures in 4 of the 6 patients followed up for a diagnosis of tuberous sclerosis complex (TSC) was significant. CONCLUSION ZNS is an effective and reliable option as an add-on therapy in paediatric refractory epilepsy, especially in focal epilepsy. It can also be considered for treatment in TSC patients.
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Affiliation(s)
- Mahmut Aslan
- Department of Paediatrics, Mersin City Training and Research Hospital, Mersin, 33100, Turkey.
| | - Serdal Gungor
- Department of Paediatric Neurology, Faculty of Medicine, Inonu University, Malatya, Turkey
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Management of Lennox-Gastaut syndrome beyond childhood: A comprehensive review. Epilepsy Behav 2021; 114:107612. [PMID: 33243685 DOI: 10.1016/j.yebeh.2020.107612] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 11/21/2022]
Abstract
Lennox-Gastaut syndrome (LGS) is a childhood-onset epileptic encephalopathy characterized by multiple types of medically intractable seizures, cognitive impairment, and generalized slow spike-wave discharges in electroencephalography (EEG). Although the onset of this epileptic syndrome occurs typically before eight years of age with a peak age between 3 and 5 years, lifelong persistence of the syndrome is usual. The evolution of clinical features, EEG findings, and paucity of knowledge about LGS among adult health care providers can make LGS significantly underdiagnosed in the adult population. Management of LGS remains problematic beyond childhood due to intractable seizures, the difficult transition from pediatric to adult neurologists, challenging behaviors, impaired cognition, poor quality of life, and disabled social life. In focusing on the management of LGS beyond childhood, this narrative review describes medical and surgical management of epilepsy, the transition from pediatric to adult care, and management of other common comorbidities associated with LGS. Several antiepileptic drugs (AEDs) such as lamotrigine, topiramate, felbamate, rufinamide, clobazam, and Epidiolex (pure pharmaceutical grade cannabidiol (CBD) oil) have been noted to be effective in well-designed, randomized controlled trials. Other non-pharmacological therapies, such as vagus nerve stimulation, ketogenic diet, and epilepsy surgery, have been frequently utilized in the management of intractable seizures associated with LGS. However, effective management of LGS requires a broader perspective to not only control seizures but improve the quality of life by addressing cognitive and behavioral problems, sleep disturbances, physical disability, social disability, and educational and employment challenges.
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Abstract
Lennox-Gastaut syndrome (LGS), a childhood-onset severe developmental and epileptic encephalopathy (DEE), is an entity that encompasses a heterogenous group of aetiologies, with no single genetic cause. It is characterised by multiple seizure types, an abnormal EEG with generalised slow spike and wave discharges and cognitive impairment, associated with high morbidity and profound effects on the quality of life of patients and their families. Drug-refractory seizures are a hallmark and treatment is further complicated by its multiple morbidities, which evolve over the patient's lifetime. This review provides a comprehensive overview of the current and future options for the treatment of seizures associated with LGS. Six treatments are specifically indicated as adjunct therapies for the treatment of seizures associated with LGS in the US: lamotrigine, clobazam, rufinamide, topiramate, felbamate and most recently cannabidiol. These therapies have demonstrated reductions in drop seizures in 15%-68% of patients across trials, with responder rates (≥ 50% reduction in drop seizures) of 37%-78%. Valproate is still the preferred first-line treatment, generally in combination with lamotrigine or clobazam. Other treatments frequently used off-label include the broad spectrum anti-epileptic drugs (AED) levetiracetam, zonisamide and perampanel, while recent evidence from observational studies has indicated that a newer AED, the levetiracetam analogue brivaracetam, may be effective and well tolerated in LGS patients. Other treatments in clinical development include fenfluramine in late phase III, perampanel, soticlestat-OV953/TAK-953, carisbamate and ganaxolone. Non-pharmacologic interventions include the ketogenic diet, vagus nerve stimulation and surgical interventions; these are also expanding, with the potential for less invasive techniques for corpus callosotomy that have promise for reducing complications. However, despite these advancements, patients continue to experience a significant burden. Because LGS is not a single entity, tailoring of treatment is needed as opposed to a 'one size fits all' approach. Further research is needed into the underlying aetiologies and pathophysiology of LGS, together with advancements in treatments that encompass the spectrum of seizures associated with this complex syndrome.
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Visa-Reñé N, Raspall-Chaure M, Paredes-Carmona F, Coromina JS, Macaya-Ruiz A. Clinical experience with brivaracetam in a series of 46 children. Epilepsy Behav 2020; 107:107067. [PMID: 32302941 DOI: 10.1016/j.yebeh.2020.107067] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/16/2020] [Accepted: 03/22/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The primary objective of the study was to analyze the efficacy of brivaracetam (BRV) in pediatric patients 12 months after starting treatment. The secondary objective was to establish safety 3, 6, and 12 months after starting treatment. MATERIALS AND METHOD This was an observational and retrospective study. Data were collected from the electronic medical record. Inclusion criteria were as follows: patients under 18 years of age, diagnosis of focal or generalized epilepsy, treatment as an added therapy, initiation of treatment with BRV between June and September 2017, and at least one unprovoked seizure in the year prior to the start of treatment. RESULTS Forty-six patients were included. The response rate was 65%, including 30% seizure-free patients. The rate of adverse effects was 43.5%, resulting in withdrawal in 16 patients (34.7%). The most common adverse effects were drowsiness (17.3%) and irritability (17.3%). CONCLUSIONS Brivaracetam is effective in very diverse childhood epilepsies, including some that present with primarily generalized seizures. Given the characteristics of the population studied, we have not been able to confirm a better tolerability of BRV compared with levetiracetam (LEV).
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Affiliation(s)
- Núria Visa-Reñé
- Paediatric Department, Hospital Universitari Arnau de Vilanova [Arnau de Vilanova University Hospital], Lleida, Spain.
| | - Miquel Raspall-Chaure
- Paediatric Neurology Department, Hospital Materno-Infantil Vall d'Hebron [Vall d'Hebron Maternity-Neonatal Hospital], Barcelona, Spain
| | - Fernando Paredes-Carmona
- Paediatric Department, Hospital Universitari Arnau de Vilanova [Arnau de Vilanova University Hospital], Lleida, Spain
| | - Júlia Sala Coromina
- Paediatric Neurology Department, Hospital Materno-Infantil Vall d'Hebron [Vall d'Hebron Maternity-Neonatal Hospital], Barcelona, Spain
| | - Alfons Macaya-Ruiz
- Paediatric Neurology Department, Hospital Materno-Infantil Vall d'Hebron [Vall d'Hebron Maternity-Neonatal Hospital], Barcelona, Spain
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Borrelli S, El Tahry R. Therapeutic approach to Lennox-Gastaut syndrome: a systematic review. Acta Neurol Belg 2019; 119:315-324. [PMID: 31286465 DOI: 10.1007/s13760-019-01185-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/02/2019] [Indexed: 01/18/2023]
Abstract
Lennox-Gastaut syndrome (LGS) is a rare, age-related syndrome, characterized by multiple seizure types, mental regression, and specific EEG abnormalities. It is one of the most challenging epilepsy: treatment is rarely effective and the final prognosis remains poor, despite the availability of several antiepileptic drugs, validated through well-designed, randomized, controlled trials. However, it is reasonable to consider non-medical treatments, such as surgery, after failure of two-to-three drugs. This review has as goal to describe systematically the different therapeutic options for LGS, including, not only recognized antiepileptic drugs, but also new oral drugs, immune therapy, diet, surgery, and neurostimulation techniques.
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Affiliation(s)
- Serena Borrelli
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium.
| | - Riem El Tahry
- Department of Neurology, Center for Refractory Epilepsy, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
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Besag FMC, Vasey MJ. An evaluation of clobazam tablets and film (AQST-120) for the treatment of Lennox-Gastaut syndrome. Expert Opin Pharmacother 2019; 20:1563-1574. [PMID: 31373526 DOI: 10.1080/14656566.2019.1642872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Lennox-Gastaut syndrome (LGS) is a chronic, epileptic encephalopathy, characterized by multiple seizure types, distinctive slow spike-wave patterns in the electroencephalogram (EEG), and severe cognitive and behavioral comorbidities. Seizures are typically refractory and long-term prognosis is poor. No antiseizure drug (ASD) is fully effective as a monotherapy. Clobazam (CLB) was licensed in the United States in 2011 as an adjunctive therapy for seizures in LGS. In 2018, a new formulation, CLB oral soluble film (COSF) (AQST-120), was approved by the Federal Drug Administration (FDA) for the same indication. Areas covered: The authors summarize current pharmacological options and guidelines for the management of seizures in LGS and efficacy and safety findings from phase II and III randomized controlled trials of adjunctive CLB in patients with LGS. An open-label extension trial is also considered. A pharmacokinetic comparison of COSF and CLB tablets is also undertaken. Expert opinion: CLB is partly effective as an add-on therapy in treating seizures in LGS. Adverse effects, pharmacokinetic interactions and the potential for tolerance with long-term treatment should be weighed against the clinical benefit when considering the introduction of CLB in this population. COSF has a similar pharmacokinetic profile to CLB tablets and may help to improve adherence to treatment.
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Affiliation(s)
- Frank M C Besag
- East London Foundation NHS Trust , Bedford , UK.,University College London , London , UK.,King's College London , London , UK
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Verrotti A, Striano P, Iapadre G, Zagaroli L, Bonanni P, Coppola G, Elia M, Mecarelli O, Franzoni E, Liso PD, Vigevano F, Curatolo P. The pharmacological management of Lennox-Gastaut syndrome and critical literature review. Seizure 2018; 63:17-25. [DOI: 10.1016/j.seizure.2018.10.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/11/2018] [Accepted: 10/25/2018] [Indexed: 12/29/2022] Open
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13
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Willems LM, Bertsche A, Bösebeck F, Hornemann F, Immisch I, Klein KM, Knake S, Kunz R, Kurlemann G, Langenbruch L, Möddel G, Müller-Schlüter K, von Podewils F, Reif PS, Steinhoff BJ, Steinig I, Rosenow F, Schubert-Bast S, Strzelczyk A. Efficacy, Retention, and Tolerability of Brivaracetam in Patients With Epileptic Encephalopathies: A Multicenter Cohort Study From Germany. Front Neurol 2018; 9:569. [PMID: 30083127 PMCID: PMC6064736 DOI: 10.3389/fneur.2018.00569] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/25/2018] [Indexed: 01/10/2023] Open
Abstract
Objective: To evaluate the efficacy and tolerability of brivaracetam (BRV) in a severely drug refractory cohort of patients with epileptic encephalopathies (EE). Method: A multicenter, retrospective cohort study recruiting all patients treated with EE who began treatment with BRV in an enrolling epilepsy center between 2016 and 2017. Results: Forty-four patients (27 male [61%], mean age 29 years, range 6 to 62) were treated with BRV. The retention rate was 65% at 3 months, 52% at 6 months and 41% at 12 months. A mean retention time of 5 months resulted in a cumulative exposure to BRV of 310 months. Three patients were seizure free during the baseline. At 3 months, 20 (45%, 20/44 as per intention-to-treat analysis considering all patients that started BRV including three who were seizure free during baseline) were either seizure free (n = 4; 9%, three of them already seizure-free at baseline) or reported at least 25% (n = 4; 9%) or 50% (n = 12; 27%) reduction in seizures. An increase in seizure frequency was reported in two (5%) patients, while there was no change in the seizure frequency of the other patients. A 50% long-term responder rate was apparent in 19 patients (43%), with two (5%) free from seizures for more than six months and in nine patients (20%, with one [2 %] free from seizures) for more than 12 months. Treatment-emergent adverse events were predominantly of psychobehavioural nature and were observed in 16%. Significance: In this retrospective analysis the rate of patients with a 50% seizure reduction under BRV proofed to be similar to those seen in regulatory trials for focal epilepsies. BRV appears to be safe and relatively well tolerated in EE and might be considered in patients with psychobehavioral adverse events while on levetiracetam.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Astrid Bertsche
- Department of Neuropediatrics, University of Rostock, Rostock, Germany.,Centre of Pediatric Research, Hospital for Children and Adolescents, Leipzig, Germany
| | - Frank Bösebeck
- Epilepsy Center Rotenburg, Agaplesion Diakonieklinikum Rotenburg, Rotenburg, Germany
| | - Frauke Hornemann
- Centre of Pediatric Research, Hospital for Children and Adolescents, Leipzig, Germany
| | - Ilka Immisch
- Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Karl M Klein
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Rhina Kunz
- Epilepsy Center Greifswald and Department of Neurology, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - Gerhard Kurlemann
- Department of Neuropediatrics, Westfälische Wilhelms-University, Münster, Germany
| | - Lisa Langenbruch
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology - Epileptology, Westfälische Wilhelms-University, Münster, Germany
| | - Gabriel Möddel
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology - Epileptology, Westfälische Wilhelms-University, Münster, Germany
| | - Karen Müller-Schlüter
- Epilepsy Center for Children, University Hospital Neuruppin, Brandenburg Medical School, Neuruppin, Germany
| | - Felix von Podewils
- Epilepsy Center Greifswald and Department of Neurology, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - Philipp S Reif
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | | | - Isabel Steinig
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany.,Department of Neuropediatrics, Goethe University Frankfurt, Frankfurt, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
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Cross JH, Auvin S, Falip M, Striano P, Arzimanoglou A. Expert Opinion on the Management of Lennox-Gastaut Syndrome: Treatment Algorithms and Practical Considerations. Front Neurol 2017; 8:505. [PMID: 29085326 PMCID: PMC5649136 DOI: 10.3389/fneur.2017.00505] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/08/2017] [Indexed: 12/12/2022] Open
Abstract
Lennox–Gastaut syndrome (LGS) is a severe epileptic and developmental encephalopathy that is associated with a high rate of morbidity and mortality. It is characterized by multiple seizure types, abnormal electroencephalographic features, and intellectual disability. Although intellectual disability and associated behavioral problems are characteristic of LGS, they are not necessarily present at its outset and are therefore not part of its diagnostic criteria. LGS is typically treated with a variety of pharmacological and non-pharmacological therapies, often in combination. Management and treatment decisions can be challenging, due to the multiple seizure types and comorbidities associated with the condition. A panel of five epileptologists met to discuss consensus recommendations for LGS management, based on the latest available evidence from literature review and clinical experience. Treatment algorithms were formulated. Current evidence favors the continued use of sodium valproate (VPA) as the first-line treatment for patients with newly diagnosed de novo LGS. If VPA is ineffective alone, evidence supports lamotrigine, or subsequently rufinamide, as adjunctive therapy. If seizure control remains inadequate, the choice of next adjunctive antiepileptic drug (AED) should be discussed with the patient/parent/caregiver/clinical team, as current evidence is limited. Non-pharmacological therapies, including resective surgery, the ketogenic diet, vagus nerve stimulation, and callosotomy, should be considered for use alongside AED therapy from the outset of treatment. For patients with LGS that has evolved from another type of epilepsy who are already being treated with an AED other than VPA, VPA therapy should be considered if not trialed previously. Thereafter, the approach for a de novo patient should be followed. Where possible, no more than two AEDs should be used concomitantly. Patients with established LGS should undergo review by a neurologist specialized in epilepsy on at least an annual basis, including a thorough reassessment of their diagnosis and treatment plan. Clinicians should always be vigilant to the possibility of treatable etiologies and alert to the possibility that a patient’s diagnosis may change, since the seizure types and electroencephalographic features that characterize LGS evolve over time. To date, available treatments are unlikely to lead to seizure remission in the majority of patients and therefore the primary focus of treatment should always be optimization of learning, behavioral management, and overall quality of life.
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Affiliation(s)
- J Helen Cross
- Clinical Neurosciences Section, UCL Institute of Child Health, ERN EpiCARE, London, United Kingdom
| | | | - Mercè Falip
- Epilepsy Unit, Neurology Service, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, G. Gaslini Institute, Genoa, Italy
| | - Alexis Arzimanoglou
- Epilepsy Unit, Child Neurology Department, Hospital San Juan de Déu, ERN EpiCARE, Barcelona, Spain.,Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon, France
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15
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Ostendorf AP, Ng YT. Treatment-resistant Lennox-Gastaut syndrome: therapeutic trends, challenges and future directions. Neuropsychiatr Dis Treat 2017; 13:1131-1140. [PMID: 28461749 PMCID: PMC5404809 DOI: 10.2147/ndt.s115996] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Lennox-Gastaut syndrome is a severe, childhood-onset electroclinical syndrome comprised of multiple seizure types, intellectual and behavioral disturbances and characteristic findings on electroencephalogram of slow spike and wave complexes and paroxysmal fast frequency activity. Profound morbidity often accompanies a common and severe seizure type, the drop attack. Seizures often remain refractory, or initial treatment efficacy fades. Few individuals are seizure free despite the development of multiple generations of antiseizure medications over decades and high-level evidence on several choices. Approved medications such as lamotrigine, topiramate, rufinamide, felbamate and clobazam have demonstrated efficacy in reducing seizure burden. Cannabidiol has emerged as a promising investigational therapy with vast social interest yet lacks a standard, approved formulation. Palliative surgical procedures, such as vagal nerve stimulation and corpus callosotomy may provide reduction in total seizures and drop attacks. Emerging evidence suggests that complete callosotomy provides greater improvement in seizures without additional side effects. Etiologies such as dysplasia or hypothalamic hamartoma may be amenable for focal resection and thus offer potential to reverse this devastating epileptic encephalopathy.
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Affiliation(s)
- Adam P Ostendorf
- Department of Pediatrics, Neurology Section, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | - Yu-Tze Ng
- Department of Pediatrics, Baylor College of Medicine, The Children’s Hospital of San Antonio, San Antonio, TX, USA
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Thampratankul L, Khongkhatithum C, Visudtibhan A. Efficacy and safety of zonisamide in Thai children and adolescents with intractable seizures. J Child Neurol 2015; 30:527-31. [PMID: 25246299 DOI: 10.1177/0883073814549246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This retrospective study examined the efficacy and safety of zonisamide for Thai children and adolescents with intractable seizures. The medical records of 24 patients (13 male, 11 female), aged 2 to 18 years (median 11.5, mean 10.4) who received zonisamide were reviewed. The underlying illness, etiology of epilepsy, seizure types, previous and concomitant antiepileptic drugs, dosage, and adverse effects of the drug were collected. Zonisamide's efficacy was evaluated on the basis of seizure reduction rates. At final evaluation, 7 patients were still taking zonisamide from 4.7 to 10.3 mg/kg/d (median 8). One patient became seizure-free and the other 6 experienced favorable seizure control. The median duration of zonisamide therapy was 23.75 months (range 20.5-25 months). Minor adverse effects were reported in 41.6% of patients during the first 3 months of therapy. Zonisamide is an option for the treatment of intractable seizures with favorable seizure control in children and adolescents.
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Affiliation(s)
- Lunliya Thampratankul
- Division of Neurology, Department of Pediatrics, Faculty of Medicine-Ramathibodi Hospital, Mahidol University, Ratchathewee, Bangkok, Thailand
| | - Chaiyos Khongkhatithum
- Division of Neurology, Department of Pediatrics, Faculty of Medicine-Ramathibodi Hospital, Mahidol University, Ratchathewee, Bangkok, Thailand
| | - Anannit Visudtibhan
- Division of Neurology, Department of Pediatrics, Faculty of Medicine-Ramathibodi Hospital, Mahidol University, Ratchathewee, Bangkok, Thailand
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17
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Rudakova IG, Belova YA. New possibilities of monotherapy of symptomatic and cryptogenic partial epilepsy. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:115-119. [DOI: 10.17116/jnevro2015115511115-119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Montouris GD, Wheless JW, Glauser TA. The efficacy and tolerability of pharmacologic treatment options for Lennox-Gastaut syndrome. Epilepsia 2014; 55 Suppl 4:10-20. [PMID: 25284033 DOI: 10.1111/epi.12732] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2014] [Indexed: 11/27/2022]
Affiliation(s)
| | - James W. Wheless
- Neurology; University of Tennessee Health Science Center; LeBonheur Children's Hospital; Memphis Tennessee U.S.A
| | - Tracy A. Glauser
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio U.S.A
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20
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Eun SH, Kim HD, Eun BL, Lee IK, Chung HJ, Kim JS, Kang HC, Lee YM, Suh ES, Kim DW, Eom S, Lee JS, Moon HK. Comparative trial of low- and high-dose zonisamide as monotherapy for childhood epilepsy. Seizure 2011; 20:558-63. [DOI: 10.1016/j.seizure.2011.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/29/2011] [Accepted: 04/01/2011] [Indexed: 10/18/2022] Open
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22
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Abstract
Lennox-Gastaut syndrome is an epilepsy syndrome that begins in childhood (between 1 and 8 years of age), worsens during latency and persists frequently into adulthood, is refractory to antiepileptic medications, and results in cognitive decline and behavioral problems in affected individuals. Seizure types consist primarily of axial tonic, atonic, and atypical absence; nocturnal tonic seizures are the most common seizure pattern in this population, but often are not one of the initial seizure patterns. Some patients also have myoclonic seizures; this seizure pattern is less frequent than the three preceding types. Although there are some cases that are cryptogenic, most are symptomatic, arising during prenatal and perinatal periods from intrauterine infections, and vascular insults to the brain. Examples of causes of Lennox-Gastaut syndrome include migrational abnormalities of the brain, late effects of CNS infections, certain genetic disorders such as tuberous sclerosis, and inherited metabolic disorders. The difficulty early in the course of Lennox-Gastaut syndrome is distinguishing this diagnosis from severe myoclonic epilepsy of infancy (Dravet syndrome) or from myoclonic-astatic epilepsy (Doose syndrome), as the seizure patterns in these three syndromes may overlap at the onset. EEG is a helpful diagnostic tool in the diagnosis of Lennox-Gastaut syndrome, usually demonstrating high voltage, bifrontal 1.5-2.5 Hz spike and wave complexes interictally, and attenuation with paroxysmal fast activity (10-13 Hz) during the ictal phase. Treatment options for Lennox-Gastaut syndrome have been less than optimal. In recent years, several drugs have been tested and approved for the treatment of this syndrome; these include felbamate, lamotrigine, topiramate, and rufinamide. The long-term outcome does not appear to be any better with the newer antiepileptic drugs than when using earlier prescribed antiepileptic drugs or polytherapy. Treatment options other than antiepileptic drugs include a ketogenic diet, vagus nerve stimulation, and corpus callosotomy. Long-term outcome of these patients relative to seizure control and cognition is poor. Most develop moderate intellectual disability within a few years of onset of the syndrome. Many develop behavioral problems with inattention, hyperactivity, and aggression.
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Affiliation(s)
- Patricia K Crumrine
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 45th Street & Penn Ave., Pittsburgh, PA 15201, USA.
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Zaccara G, Tramacere L, Cincotta M. Drug safety evaluation of zonisamide for the treatment of epilepsy. Expert Opin Drug Saf 2011; 10:623-31. [PMID: 21663459 DOI: 10.1517/14740338.2011.571201] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Verrotti A, Loiacono G, Coppola G, Spalice A, Mohn A, Chiarelli F. Pharmacotherapy for children and adolescents with epilepsy. Expert Opin Pharmacother 2011; 12:175-94. [PMID: 21208135 DOI: 10.1517/14656566.2010.517194] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Childhood epilepsies are the most frequent neurological problems that occur in children. Despite the introduction of new antiepileptic drugs (AEDs) 25-30% of children with epilepsy remain refractory to medical therapy. AREAS COVERED This review aims to highlight the main published data on the treatment of childhood epilepsy. The electronic database, PubMed, and abstract proceedings were used to identify studies. The aim of antiepileptic therapy should be to provide complete seizure control, if possible without the burden of any side effect. Since 1993, new agents have been approved for use as an antiepileptic. Although there are few published data (especially in pediatric populations) to establish that the second-generation AEDs are more efficacious than the older AEDs, they appear to have better tolerability. EXPERT OPINION Old AEDs are efficacious agents that continue to play a major role in the current treatment of epilepsy. These agents actually remain the first-line treatment for many specific seizure types or epileptic syndromes. The new AEDs were initially approved as adjunct agents and--subsequently--as monotherapy for various seizure types in the adult and children. Despite these improvements, few AEDs are now considered to be a first-choice for the treatment of epilepsy in children.
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Affiliation(s)
- Alberto Verrotti
- University of Chieti, Department of Pediatrics, Ospedale Policlinico, Via dei Vestini 5, Chieti, Italy.
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Abstract
Lennox-Gastaut syndrome occurs in 3% of children with epilepsy and is characterized by multiple seizure types, slow spike-and-wave discharges and a poor prognosis for seizure control and cognitive development. Although randomized controlled trials of adjunctive felbamate, lamotrigine, topiramate and rufinamide have demonstrated a > or =50% reduction in seizure frequency, very few children achieve complete seizure control and a Cochrane review of the treatment of Lennox-Gastaut syndrome concluded that the optimum treatment was uncertain and that no drug has been shown to be highly efficacious. Valproate, lamotrigine and topiramate were considered recently by expert panels in the US and Europe to be the first-line drugs. The ketogenic diet may be more effective than antiepileptic drugs and should be considered early in treatment. An improvement in the management of Lennox-Gastaut syndrome requires a better understanding of the pathophysiology of this disorder and the development of animal models in which to test new compounds.
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Affiliation(s)
- Aspasia Michoulas
- Division of Neurology, Department of Pediatrics, University of British Columbia and British Columbia's Children's Hospital, Vancouver, British Columbia, Canada
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Stephen LJ, Kelly K, Wilson EA, Parker P, Brodie MJ. A prospective audit of adjunctive zonisamide in an everyday clinical setting. Epilepsy Behav 2010; 17:455-60. [PMID: 20207201 DOI: 10.1016/j.yebeh.2010.01.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 01/13/2010] [Accepted: 01/15/2010] [Indexed: 10/19/2022]
Abstract
This audit examined outcomes for 203 patients prescribed zonisamide (ZNS) for various uncontrolled seizure types at a specialist outpatient service. Forty-two (20.7%) patients achieved 6 months of seizure freedom, and an additional 37 (18.2%) had a 50% seizure reduction for 6 months on a stable ZNS dose. Seizure freedom was more likely in patients with primary generalized (24/61, 39%) than in those with partial-onset (18/141, 12.7%) seizures (P<0.001). Eight patients (5 seizure free) were maintained on ZNS monotherapy. More patients became seizure free with ZNS as monotherapy or first add-on, compared with those in whom ZNS was the second, third, or fourth adjunctive drug (P=0.001). Seizure freedom was less likely in patients treated with hepatic enzyme-inducing agents (13/113, 11.5%) than in those receiving noninducing AEDs (24/82, 29.3%) (P=0.002). ZNS was discontinued in 72 (35.5%) patients largely because of side effects (n=58, 28.6%). Commonest complaints leading to withdrawal were sedation (n=14), nausea and vomiting (n=13), neuropsychiatric symptoms (n=12), rash (n=6), and weight loss (n=6). Around 80% of patients who became seizure free on ZNS or had the drug withdrawn did so on a dose 200mg. ZNS is an effective broad-spectrum AED that can also produce a range of dose-dependent and idiosyncratic side effects.
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Affiliation(s)
- Linda J Stephen
- Epilepsy Unit, Division of Cardiovascular & Medical Sciences, Western Infirmary, Glasgow, Scotland, UK.
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Efficacy and tolerability of adjunctive therapy with zonisamide in childhood intractable epilepsy. Brain Dev 2010; 32:208-12. [PMID: 19304420 DOI: 10.1016/j.braindev.2009.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Revised: 02/12/2009] [Accepted: 02/16/2009] [Indexed: 11/20/2022]
Abstract
PURPOSE This study investigated the efficacy and safety of zonisamide (ZNS) adjunctive therapy in children with intractable epilepsy to existing antiepileptic drugs (AEDs). METHODS A clinical retrospective study was performed from 2003 to 2005 at two tertiary epilepsy centers. We reviewed the data from 163 children (107 boys and 56 girls) who experienced more than four seizures per month, whose seizures were intractable to an initial 2 or more AEDs, and could be followed up for at least 6months after ZNS adjunctive therapy initiation. Efficacy was estimated by seizure reduction rate according to seizure types including infantile spasms, and adverse events were also measured. RESULTS Seventy-nine patients (48.5%) out of 163 patients experienced a reduction in seizure frequency of more than 50%, and 25 patients (15.3%) became seizure-free. The rate of seizure reduction greater than 50% in children with partial seizures was 40.5% (17/42) and in children with generalized seizures was 51.2% (62/121). Of 36 patients who manifested mainly myoclonic seizures, 20 patients (55.6%) showed a seizure reduction of more than 50% and 9 patients (25.0%) were seizure-free. Mean maintenance dosage of drug was 8.2mg/kg/day (range 5.0-16.0mg/kg/day). Adverse events were documented in 15 children (9.2%), including somnolence (8 patients), fatigue, and anorexia, but all were transient and successfully managed. One patient discontinued ZNS therapy due to acute pancreatitis. CONCLUSION ZNS adjunctive therapy is an effective and safe treatment in various childhood intractable epilepsy.
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Verrotti A, Coppola G, Parisi P, Mohn A, Chiarelli F. Bone and calcium metabolism and antiepileptic drugs. Clin Neurol Neurosurg 2010; 112:1-10. [DOI: 10.1016/j.clineuro.2009.10.011] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 08/21/2009] [Accepted: 10/10/2009] [Indexed: 12/20/2022]
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Effectiveness and tolerability of zonisamide in children with epilepsy: A retrospective review. Seizure 2010; 19:31-5. [DOI: 10.1016/j.seizure.2009.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 10/27/2009] [Accepted: 10/29/2009] [Indexed: 11/17/2022] Open
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Andrade DM, Hamani C, Minassian BA. Treatment options for epileptic myoclonus and epilepsy syndromes associated with myoclonus. Expert Opin Pharmacother 2009; 10:1549-60. [PMID: 19527185 DOI: 10.1517/14656560903025189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Myoclonus is a brief shock-like movement that has many different etiologies. The degree to which it disturbs quality of life is extremely variable, as is its response to treatment. OBJECTIVE In this review, we focus on the treatment strategies for epileptic myoclonus in some common disorders, and in others that are not so common but where myoclonus is a prominent feature and has been studied more. METHODS An extended literature review in the English language was conducted through PubMed and text books. CONCLUSION Epileptic myoclonus is a manifestation of cortical irritability. The precise etiology is important when determining the best course of treatment. Response to treatment is variable and usually depends on the epileptic syndrome. Some antiepileptic drugs may worsen myoclonus even in patients with syndromes where most patients have a good response to that same drug. Therefore, clinicians must always have in mind that worsening in myoclonus may be ameliorated by decrease or withdrawal rather than increase of medication.
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Affiliation(s)
- Danielle M Andrade
- Division of Neurology, Krembil Neuroscience Centre, University of Toronto, Toronto Western Hospital, Toronto, Canada
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Abstract
Lennox-Gastaut syndrome (LGS) is a rare, age-related syndrome, characterized by multiple seizure types, a specific electro-encephalographic pattern, and mental regression. However, published data on the etiology, evolution, and therapeutic approach of LGS are contradictory, partly because the precise definition of LGS used in the literature varies. In the most recent classification, LGS belongs to the epileptic encephalopathies and is highly refractory to all antiepileptic drugs. Numerous treatments, medical and non-medical, have been proposed and results mostly from open studies or case series have been published. Sometimes, patients with LGS are included in a more global group of patients with refractory epilepsy. Only 6 randomized double-blind controlled trials of medical treatments, which included patients with LGS, have been published. Overall, treatment is rarely effective and the final prognosis remains poor in spite of new therapeutic strategies. Co-morbidities need specific treatment. This paper summarizes the definition, diagnosis and therapeutic approach to LGS, including not only recognized antiepileptic drugs, but also "off label" medications, immune therapy, diet, surgery and some perspectives for the future.
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Affiliation(s)
- Kenou van Rijckevorsel
- Reference Centre of Refractory Epilepsy, Cliniques Universitaires St Luc, Université Catholique de Louvain, Avenue Hippocrate, 10, B-1200 Brussels, Belgium.
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