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Sankar R, Chez M, Pina-Garza JE, Dixon-Salazar T, Flamini JR, Hyslop A, McGoldrick P, Millichap JJ, Resnick T, Rho JM, Wolf S. Proposed anti-seizure medication combinations with rufinamide in the treatment of Lennox-Gastaut syndrome: Narrative review and expert opinion. Seizure 2023; 110:42-57. [PMID: 37321047 DOI: 10.1016/j.seizure.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023] Open
Abstract
Lennox-Gastaut syndrome (LGS) is a severe, chronic, complex form of early childhood-onset epilepsy characterized by multiple seizure types, generalized slow (≤2.5 Hz) spike-and-wave activity and other electroencephalography abnormalities, and cognitive impairment. A key treatment goal is early seizure control, and several anti-seizure medications (ASMs) are available. Due to the low success rate in achieving seizure control with monotherapy and an absence of efficacy data supporting any particular combination of ASMs for treating LGS, a rational approach to selection of appropriate polytherapy should be applied to maximize benefit to patients. Such "rational polytherapy" involves consideration of factors including safety (including boxed warnings), potential drug-drug interactions, and complementary mechanisms of action. Based on the authors' clinical experience, rufinamide offers a well-considered first adjunctive therapy for LGS, particularly in combination with clobazam and other newer agents for LGS, and may be particularly useful for reducing the frequency of tonic-atonic seizures associated with LGS.
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Affiliation(s)
- Raman Sankar
- Departments of Neurology and Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA; UCLA Mattel Children's Hospital, Los Angeles, CA, USA.
| | - Michael Chez
- Sutter Health, Roseville, CA, USA; California Northstate University School of Medicine, Elk Grove, CA, USA
| | | | | | | | - Ann Hyslop
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Patricia McGoldrick
- Boston Children's Health Physicians, Valhalla, NY, USA; Maria Fareri Children's Hospital, Valhalla, NY, USA; New York Medical College, Valhalla, NY, USA
| | - John J Millichap
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Jong M Rho
- Departments of Neurosciences, Pediatrics & Pharmacology, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Steven Wolf
- Boston Children's Health Physicians, Valhalla, NY, USA; Maria Fareri Children's Hospital, Valhalla, NY, USA; New York Medical College, Valhalla, NY, USA
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Abstract
There are numerous potential factors that may affect growth in children with epilepsy, and these must be evaluated in any child with appetite and weight concerns. Antiseizure medications (ASMs) have potential adverse effects, and many may affect appetite, thus impacting normal growth and weight gain. The aim of this review is to focus on the impact of both epilepsy and ASMs on appetite and weight in children. We systematically reviewed studies using Medline assessing the impact of ASMs on appetite and weight in children. Eligible studies included randomized controlled trials and open-label studies (open-label extension and interventional) that targeted or included the pediatric population (0-18 years of age). Each study was classified using the American Academy of Neurology (AAN) Classification of Evidence for Therapeutic Studies, and the level of evidence for impact on appetite and weight in children was graded. ASMs associated with decreased appetite and/or weight loss include fenfluramine, topiramate, zonisamide, felbamate, rufinamide, stiripentol, cannabidiol, brivaracetam and ethosuximide; ASMs with minimal impact on weight and appetite in children include oxcarbazepine, eslicarbazepine, lamotrigine, levetiracetam, lacosamide, carbamazepine, vigabatrin and clobazam. The ASM most robustly associated with increased appetite and/or weight gain is valproic acid; however, both pregabalin and perampanel may also lead to modest weight gain or increased appetite in children. Certain ASMs may impact both appetite and weight, which may lead to increased morbidity of the underlying disease and impaired adherence to the treatment regimen.
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Zhang L, Wang J, Wang C. Efficacy and safety of antiseizure medication for Lennox-Gastaut syndrome: a systematic review and network meta-analysis. Dev Med Child Neurol 2022; 64:305-313. [PMID: 34590711 DOI: 10.1111/dmcn.15072] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 07/27/2021] [Accepted: 09/01/2021] [Indexed: 12/27/2022]
Abstract
AIM To compare and rank the efficacy and safety of antiseizure medication (ASM) in patients with Lennox-Gastaut syndrome (LGS). METHOD We included randomized controlled trials (RCTs) assessing the efficacy of ASM for LGS compared with placebo or with each other. The efficacy and safety were reported in terms of an at least 50% monthly seizure frequency reduction in drop seizures, dropout, and serious adverse events. Outcomes were ranked according to the surface under the cumulative ranking curve (SUCRA). RESULTS A total of eight RCTs with 1171 patients were included, involving six ASMs: lamotrigine, rufinamide, cannabidiol, topiramate, clobazam, and felbamate. The calculated SUCRA showed that rufinamide, cannabidiol, and topiramate had the highest probability of achieving a response; however, no significant differences were found among these treatments. Cannabidiol, topiramate, and rufinamide were more likely to result in dropouts; moreover, a significantly greater percentage of patients receiving cannabidiol experienced premature discontinuation as compared to placebo, clobazam, and lamotrigine. INTERPRETATION All ASMs showed a significantly higher response rate than placebo. SUCRA ranking demonstrated that rufinamide and cannabidiol are more efficacious than other treatments in reducing drop seizures. However, there was no significant difference between these treatments.
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Affiliation(s)
- Lanlan Zhang
- Department of Pediatrics, Yancheng Maternal and Children's Health Hospital, Yancheng City, Jiangsu Province, China
| | - Juan Wang
- Department of Pediatrics, Yancheng Maternal and Children's Health Hospital, Yancheng City, Jiangsu Province, China
| | - Chengzhong Wang
- Department of Pediatrics, Yancheng Maternal and Children's Health Hospital, Yancheng City, Jiangsu Province, China
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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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Abstract
BACKGROUND Epilepsy is a central nervous system disorder (neurological disorder). Epileptic seizures are the result of excessive and abnormal cortical nerve cell electrical activity in the brain. Despite the development of more than 10 new antiepileptic drugs (AEDs) since the early 2000s, approximately a third of people with epilepsy remain resistant to pharmacotherapy, often requiring treatment with a combination of AEDs. In this review, we summarised the current evidence regarding rufinamide, a novel anticonvulsant medication, which, as a triazole derivative, is structurally unrelated to any other currently used anticonvulsant medication when used as an add-on treatment for drug-resistant epilepsy. In January 2009, rufinamide was approved by the US Food and Drug Administration for the treatment of children four years of age and older with Lennox-Gastaut syndrome. It is also approved as an add-on treatment for adults and adolescents with focal seizures. This is an updated version of the original Cochrane Review published in 2018. OBJECTIVES To evaluate the efficacy and tolerability of rufinamide when used as an add-on treatment for people with drug-resistant epilepsy. SEARCH METHODS We imposed no language restrictions. We contacted the manufacturers of rufinamide and authors in the field to identify any relevant unpublished studies. SELECTION CRITERIA Randomised, double-blind, placebo-controlled, add-on trials of rufinamide, recruiting people (of any age or gender) with drug-resistant epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and extracted the relevant data. We assessed the following outcomes: 50% or greater reduction in seizure frequency (primary outcome); seizure freedom; treatment withdrawal; and adverse effects (secondary outcomes). Primary analyses were intention-to-treat (ITT) and we presented summary risk ratios (RRs) with 95% confidence intervals (CIs). We evaluated dose response in regression models. We carried out a risk of bias assessment for each included study using the Cochrane 'Risk of bias' tool and assessed the overall certainty of evidence using the GRADE approach. MAIN RESULTS The review included six trials, representing 1759 participants. Four trials (1563 participants) included people with uncontrolled focal seizures. Two trials (196 participants) included individuals with established Lennox-Gastaut syndrome. Overall, the age of adults ranged from 18 to 80 years and the age of children ranged from 4 to 16 years. Baseline phases ranged from 28 to 56 days and double-blind phases from 84 to 96 days. Five of the six included trials described adequate methods of concealment of randomisation, and only three described adequate blinding. All analyses were by ITT. Overall, five studies were at low risk of bias and one had unclear risk of bias due to lack of reported information around study design. All trials were sponsored by the manufacturer of rufinamide and therefore were at high risk of funding bias. The overall RR for 50% or greater reduction in seizure frequency was 1.79 (95% CI 1.44 to 2.22; 6 randomised controlled trials (RCTs), 1759 participants; moderate-certainty evidence), indicating that rufinamide (plus conventional AED) was significantly more effective than placebo (plus conventional AED) in reducing seizure frequency by at least 50% when added to conventionally used AEDs in people with drug-resistant focal epilepsy. Data from only one study (73 participants) reported seizure freedom: RR 1.32 (95% CI 0.36 to 4.86; 1 RCT, 73 participants; moderate-certainty evidence). The overall RR for treatment withdrawal (for any reason and due to AED) was 1.83 (95% CI 1.45 to 2.31; 6 RCTs, 1759 participants; moderate-certainty evidence), showing that rufinamide was significantly more likely to be withdrawn than placebo. Most adverse effects were significantly more likely to occur in the rufinamide-treated group. Adverse events significantly associated with rufinamide were headache, dizziness, somnolence, vomiting, nausea, fatigue, and diplopia. The RRs for these adverse effects were as follows: headache 1.36 (95% Cl 1.08 to 1.69; 3 RCTs, 1228 participants; high-certainty evidence); dizziness 2.52 (95% Cl 1.90 to 3.34; 3 RCTs, 1295 participants; moderate-certainty evidence); somnolence 1.94 (95% Cl 1.44 to 2.61; 6 RCTs, 1759 participants; moderate-certainty evidence); vomiting 2.95 (95% Cl 1.80 to 4.82; 4 RCTs, 777 participants; low-certainty evidence); nausea 1.87 (95% Cl 1.33 to 2.64; 3 RCTs, 1295 participants; moderate-certainty evidence); fatigue 1.46 (95% Cl 1.08 to 1.97; 3 RCTs, 1295 participants; moderate-certainty evidence); and diplopia 4.60 (95% Cl 2.53 to 8.38; 3 RCTs, 1295 participants; low-certainty evidence). There was no important heterogeneity between studies for any outcomes. Overall, we assessed the evidence as moderate to low certainty due to wide CIs and potential risk of bias from some studies contributing to the analysis. AUTHORS' CONCLUSIONS For people with drug-resistant focal epilepsy, rufinamide when used as an add-on treatment was effective in reducing seizure frequency. However, the trials reviewed were of relatively short duration and provided no evidence for long-term use of rufinamide. In the short term, rufinamide as an add-on was associated with several adverse events. This review focused on the use of rufinamide in drug-resistant focal epilepsy, and the results cannot be generalised to add-on treatment for generalised epilepsies. Likewise, no inference can be made about the effects of rufinamide when used as monotherapy.
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Affiliation(s)
- Mariangela Panebianco
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anthony G Marson
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Liverpool Health Partners, Liverpool, UK
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Caraballo RH, Pociecha J, Reyes G, Espeche A, Galichio S, Fasulo L, Semprino M. Rufinamide as add-on therapy in children with epileptic encephalopathies other than Lennox-Gastaut syndrome: A study of 34 patients. Epilepsy Behav 2020; 108:107074. [PMID: 32334364 DOI: 10.1016/j.yebeh.2020.107074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/15/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Here, we present a multicenter series of patients with developmental and epileptic encephalopathies (DEE) and related electroclinical patterns (REP) other than Lennox-Gastaut syndrome (LGS) who were treated with rufinamide as add-on therapy. METHODS Medical records of 34 patients with DEE and REP other than LGS treated with add-on rufinamide seen at four pediatric neurology centers in Argentina between May 2014 and March 2019 were retrospectively analyzed. RESULTS We evaluated 34 patients (18 males, 16 females), aged between 2 and 15 years with a mean and median age of 6 and 8 years, respectively. The children had different types of childhood-onset refractory DEE and REP other than LGS and were treated with rufinamide for a mean period of 20 months (range, 12-60 months). Twenty-two of 34 patients (64.5%) who received rufinamide as add-on therapy had a greater than 50% decrease in seizures, and two patients (5.8%) became seizure-free. Four patients (11.7%) had a 25-50% seizure reduction, while seizure frequency remained unchanged in four others (11.7%) and increased in two patients (5.8%). The final mean dosage of rufinamide was 31.5 ± 15.5 mg/kg per day (range, 19-75.4 mg/kg) if combined with valproic acid and of 35.4 ± 11.5 mg/kg per day (range, 8-60.5 mg/kg) without valproic acid. Adverse effects were recorded in nine patients (26.4%). A seizure increase was reported in two of 24 patients (7.3%). CONCLUSION Rufinamide may be used as a treatment option in DEE and REP other than LGS.
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Affiliation(s)
| | - Juan Pociecha
- Department of Neurology, Juan P Garrahan Hospital, Buenos Aires, Argentina
| | - Gabriela Reyes
- Department of Neurology, Juan P Garrahan Hospital, Buenos Aires, Argentina
| | - Alberto Espeche
- Department of Neurology, Hospital Materno-infantil, Salta, Argentina
| | - Santiago Galichio
- Department of Neurology, Hospital de Niños Victor J. Vilela, Rosario, Argentina
| | - Lorena Fasulo
- Department of Neurology, Clínica San Lucas, Neuquen, Argentina
| | - Marcos Semprino
- Department of Neurology, Clínica San Lucas, Neuquen, Argentina
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Balagura G, Riva A, Marchese F, Verrotti A, Striano P. Adjunctive Rufinamide in Children with Lennox-Gastaut Syndrome: A Literature Review. Neuropsychiatr Dis Treat 2020; 16:369-379. [PMID: 32103957 PMCID: PMC7008198 DOI: 10.2147/ndt.s185774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/14/2020] [Indexed: 01/23/2023] Open
Abstract
Lennox-Gastaut syndrome (LGS) is a severe, childhood-onset, developmental epileptic encephalopathy, with different etiologies and co-morbidities. Seizure treatment in LGS represents a major challenge; new antiepileptic drugs (AEDs) are developed to especially address seizures resulting in high morbidity and mortality, such as drop seizures. Rufinamide (RFN) is one of the latest AEDs licensed for patients with LGS. Its mechanism of action involves sodium channels in a way that is unrelated to other AEDs. Here we discuss the use of adjunctive RFN in children and adolescents with LGS and its efficacy and safety profile, based on a systematic literature review. RFN shows a very favorable profile in terms of adverse events and drug-interactions in children. It is particularly effective on tonic-atonic seizures and spasms, impacting on the quality of life of the patients. Further studies are needed to clarify the interaction profile with the newest AEDs for LGS and to assess correlations between the etiology of LGS and drug response to individualize treatment and maximize efficacy.
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Affiliation(s)
- Ganna Balagura
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health, University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, Genoa, Italy
| | - Antonella Riva
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, Genoa, Italy
| | - Francesca Marchese
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, Genoa, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health, University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, Genoa, Italy
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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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Kim SH, Kang HC, Lee JS, Kim HD. Rufinamide efficacy and safety in children aged 1-4 years with Lennox-Gastaut syndrome. Brain Dev 2018; 40:897-903. [PMID: 30166208 DOI: 10.1016/j.braindev.2018.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE The treatment options for Lennox-Gastaut syndrome (LGS), a pediatric epileptic syndrome, are limited, especially in younger children. Rufinamide tablets were safe and effective as an add-on treatment in Korean children and adolescents <20 years of age with LGS. This subgroup analysis aimed to evaluate the efficacy and safety of rufinamide tablets in LGS pediatric patients aged 1-4 years. METHODS This was a retrospective, observational study in LGS patients aged 1-4 years who received 12 weeks of treatment with rufinamide orally as an adjuvant treatment between April and June 2010. The proportion of responders (patients with a ≥50% reduction in seizure frequency after rufinamide treatment) was evaluated according to the type of seizure. The proportion of patients who were seizure-free was also evaluated. Adverse events (AEs) were evaluated after 12 weeks of treatment. RESULTS Among the 15 patients evaluated, one discontinued treatment because of worsening seizures 4 weeks after administration of rufinamide. Seven (46.67%) patients were responders and four patients were seizure-free. There were four responders with convulsive seizures, one each for myoclonic seizures and drop attacks, and spasms. The responder rate was increased to 69.23% by long-term treatment of rufinamide. AEs were experienced by three patients. One patient each experienced somnolence, fatigue, and rash. CONCLUSION Rufinamide tablets were efficacious and well tolerated in LGS patients aged 1-4 years, at doses up to 1000 mg per day, when given as add-on therapy to other antiepileptic drugs.
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Affiliation(s)
- Shin Hye Kim
- Department of Pediatrics, Myongji Hospital, Goyang, Republic of Korea
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Pediatric Epilepsy Clinics, Severance Children's Hospital, Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Soo Lee
- Division of Pediatric Neurology, Pediatric Epilepsy Clinics, Severance Children's Hospital, Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Pediatric Epilepsy Clinics, Severance Children's Hospital, Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Abstract
BACKGROUND Epilepsy is a central nervous system disorder (neurological disorder). Epileptic seizures are the result of excessive and abnormal cortical nerve cell electrical activity in the brain. Despite the development of more than 10 new antiepileptic drugs (AEDs) since the early 2000s, approximately a third of people with epilepsy remain resistant to pharmacotherapy, often requiring treatment with a combination of AEDs. In this review, we summarised the current evidence regarding rufinamide, a novel anticonvulsant medication, which, as a triazole derivative, is structurally unrelated to any other currently used anticonvulsant medication, when used as an add-on treatment for refractory epilepsy. In January 2009, rufinamide was approved by the US Food and Drug Administration for treatment of children four years of age and older with Lennox-Gastaut syndrome. It is also approved as an add-on treatment for adults and adolescents with focal seizures. OBJECTIVES To evaluate the efficacy and tolerability of rufinamide when used as an add-on treatment in people with refractory epilepsy. SEARCH METHODS On 2 October 2017, we searched the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO), MEDLINE (Ovid, 1946), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language restrictions. We also contacted the manufacturers of rufinamide and authors in the field to identify any relevant unpublished studies. SELECTION CRITERIA Randomised, double-blind, placebo-controlled, add-on trials of rufinamide, recruiting people (of any age or gender) with refractory epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and extracted the relevant data. We assessed the following outcomes: 50% or greater reduction in seizure frequency (primary outcomes); seizure freedom; treatment withdrawal; and adverse effects (secondary outcomes). Primary analyses were intention-to-treat (ITT) and we presented summary risk ratios (RR) with 95% confidence intervals (CI). We evaluated dose response in regression models. We carried out a risk of bias assessment for each included study using the Cochrane 'Risk of bias' tool and assessed the overall quality of evidence using the GRADE approach, which we presented in a 'Summary of findings' table. MAIN RESULTS The review included six trials, representing 1759 participants. Four trials (1563 participants) included people with uncontrolled focal seizures. Two trials (196 participants) included established Lennox-Gastaut syndrome. Overall, the age of the adults ranged from 18 to 80 years and the age of the infants ranged from four to 16 years. Baseline phase ranged from 28 to 56 days and double-blind phases from 84 to 96 days. Five of the six included trials described adequate methods of concealment of randomisation and only three described adequate blinding. All analyses were by ITT. Overall, five studies were at low risk of bias, and one had unclear risk of bias due to lack of reported information around study design. All trials were sponsored by the manufacturer of rufinamide, and therefore, were at high risk of funding bias.The overall RR for 50% or greater reduction in seizure frequency was 1.79 (95% CI 1.44 to 2.22; 6 RCTs; moderate-quality evidence) indicating that rufinamide (plus conventional AED) was significantly more effective than placebo (plus conventional AED) in reducing seizure frequency by at least 50%, when added to conventionally used AEDs in people with refractory focal epilepsy. The overall RR for treatment withdrawal (for any reason and due to AED) was 1.83 (95% CI 1.45 to 2.31; 6 RCTs; moderate-quality evidence) showing that rufinamide was significantly more likely to be withdrawn than placebo. In respect of adverse effects, most were significantly more likely to occur in the rufinamide-treated group. The adverse events significantly associated with rufinamide were: headache, dizziness, somnolence, vomiting, nausea, fatigue and diplopia. The RRs of these adverse effects were: headache 1.36 (95% Cl 1.08 to 1.69; 3 RCTs; high-quality evidence); dizziness 2.52 (95% Cl 1.90 to 3.34; 3 RCTs; moderate-quality evidence); somnolence 1.94 (95% Cl 1.44 to 2.61; 6 RCTs; moderate-quality evidence); vomiting 2.95 (95% Cl 1.80 to 4.82; 4 RCTs; low-quality evidence); nausea 1.87 (95% Cl 1.33 to 2.64; 3 RCTs; moderate-quality evidence); fatigue 1.46 (95% Cl 1.08 to 1.97; 3 RCTs; moderate-quality evidence); and diplopia 4.60 (95% Cl 2.53 to 8.38; 3 RCTs; low-quality evidence). There was no important heterogeneity between studies for any of the outcomes. Overall, we assessed the evidence as moderate to low quality, due to potential risk of bias from some studies contributing to the analysis and wide CIs. AUTHORS' CONCLUSIONS In people with drug-resistant focal epilepsy, rufinamide when used as an add-on treatment was effective in reducing seizure frequency. However, the trials reviewed were of relatively short duration and provided no evidence for the long-term use of rufinamide. In the short term, rufinamide as an add-on was associated with several adverse events. This review focused on the use of rufinamide in drug-resistant focal epilepsy and the results cannot be generalised to add-on treatment for generalised epilepsies. Likewise, no inference can be made about the effects of rufinamide when used as monotherapy.
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Affiliation(s)
- Mariangela Panebianco
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneLiverpoolUKL9 7LJ
| | - Hemanshu Prabhakar
- All India Institute of Medical SciencesDepartment of Neuroanaesthesiology and Critical CareAnsari NagarNew DelhiIndia110029
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneLiverpoolUKL9 7LJ
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Kothare S, Kluger G, Sachdeo R, Williams B, Olhaye O, Perdomo C, Bibbiani F. Dosing considerations for rufinamide in patients with Lennox–Gastaut syndrome: Phase III trial results and real-world clinical data. Seizure 2017; 47:25-33. [DOI: 10.1016/j.seizure.2017.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/13/2017] [Accepted: 02/16/2017] [Indexed: 11/25/2022] Open
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Skov M, de Paoli FV, Nielsen OB, Pedersen TH. The anti-convulsants lacosamide, lamotrigine, and rufinamide reduce myotonia in isolated human and rat skeletal muscle. Muscle Nerve 2017; 56:136-142. [PMID: 27783415 DOI: 10.1002/mus.25452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 10/14/2016] [Accepted: 10/19/2016] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In myotonia congenita, loss of ClC-1 Cl- channel function results in skeletal muscle hyperexcitability and myotonia. Anti-myotonic treatment has typically targeted the voltage-gated sodium channel in skeletal muscle (Nav1.4). In this study we explored whether 3 sodium channel-modulating anti-epileptics can reduce myotonia in isolated rat and human muscle. METHODS Dissected muscles were rendered myotonic by ClC-1 channel inhibition. The ability of the drugs to suppress myotonia was then assessed from subclinical to maximal clinical concentrations. Drug synergy was determined using isobole plots. RESULTS All drugs were capable of abolishing myotonia in both rat and human muscles. Lamotrigine and rufinamide completely suppressed myotonia at submaximal clinical concentrations, whereas lacosamide had to be raised above the maximal clinical concentration to suppress myotonia completely. A synergistic effect of lamotrigine and rufinamide was observed. CONCLUSION These findings suggest that lamotrigine and rufinamide could be considered for anti-myotonic treatment in myotonia congenita. Muscle Nerve 56: 136-142, 2017.
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Affiliation(s)
- Martin Skov
- Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000, Aarhus C, Denmark
| | - Frank V de Paoli
- Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000, Aarhus C, Denmark.,Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Ole B Nielsen
- Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000, Aarhus C, Denmark
| | - Thomas H Pedersen
- Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000, Aarhus C, Denmark
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13
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Jaraba S, Santamarina E, Miró J, Toledo M, Molins A, Burcet J, Becerra JL, Raspall M, Pico G, Miravet E, Cano A, Fossas P, Fernández S, Falip M. Rufinamide in children and adults in routine clinical practice. Acta Neurol Scand 2017; 135:122-128. [PMID: 26923380 DOI: 10.1111/ane.12572] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To explore the long-term effectiveness of rufinamide in managing Lennox-Gastaut Syndrome (LGS), other epileptic encephalopathies, and intractable focal epilepsies in adults and children in routine clinical practice. METHODS A multicentre, retrospective chart review of patients prescribed adjunctive rufinamide at seven Spanish epilepsy centres, with assessments at six and 12 months. RESULTS We evaluated data from 58 patients (40 male, age range 7-57 years), 25 of whom were diagnosed with LGS, 12 with other epileptic encephalopathies and 21 of whom were diagnosed with focal epilepsies, mainly frontal lobe. The mean daily rufinamide dose was 32.0 mg/kg (range 12.5-66.7 mg/kg) in children and 24.7 mg/kg (range 5.0-47.0 mg/kg) in adults, and the most commonly used concomitant antiepileptic drugs were levetiracetam and valproate. Rufinamide was discontinued in 25 patients (43.1%) during the 1-year follow-up, and the most common reason was lack of effectiveness (n = 12, 20.7% of total). The frequency of generalized tonic-clonic seizures was significantly reduced from baseline at 6 and 12 months (P = 0.001), both in patients with generalized epilepsies and in patients with focal epilepsies. Significant seizure frequency reduction from baseline was observed at 12 months (P = 0.01) for tonic/atonic seizures and at 6 months (P = 0.001) for focal seizures. Side effects were reported in 21 patients (36.2%): nausea, vomiting and weight loss were most frequent. CONCLUSIONS Rufinamide was well tolerated and was effective in reducing frequency of generalized tonic-clonic, tonic/atonic and focal seizures in both children and adults with severe refractory epilepsies, primarily LGS.
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Affiliation(s)
- S. Jaraba
- Epilepsy Unit; Neurology Department; Hospital Universitari de Bellvitge; L'Hospitalet de Llobregat; Barcelona Spain
- Neurology Department; Hospital de Viladecans; Viladecans Barcelona Spain
| | - E. Santamarina
- Epilepsy Unit; Neurology Department; Hospital Universitari Vall d′Hebron; Barcelona Spain
| | - J. Miró
- Epilepsy Unit; Neurology Department; Hospital Universitari de Bellvitge; L'Hospitalet de Llobregat; Barcelona Spain
| | - M. Toledo
- Epilepsy Unit; Neurology Department; Hospital Universitari Vall d′Hebron; Barcelona Spain
| | - A. Molins
- Neurology Department; Hospital Josep Trueta; Girona Spain
| | - J. Burcet
- Neurology Department; Hospital del Vendrell; Tarragona Spain
| | - J. L. Becerra
- Epilepsy Unit; Hospital Universitari Germans Trias i Pujol; Badalona Barcelona Spain
| | - M. Raspall
- Epilepsy Unit; Paediatric Neurology Deparment; Hospital Universitari Vall d′Hebron; Barcelona Spain
| | - G. Pico
- Paediatric Neurology Department; Hospital Son Dureta; Palma de Mallorca Spain
| | - E. Miravet
- Paediatric Neurology Department; Hospital Son Dureta; Palma de Mallorca Spain
| | - A. Cano
- Neurology Department; Hospital de Mataró; Barcelona Spain
| | - P. Fossas
- Neurology Department; Hospital de Mataró; Barcelona Spain
| | - S. Fernández
- Epilepsy Unit; Neurology Department; Hospital Universitari de Bellvitge; L'Hospitalet de Llobregat; Barcelona Spain
- Neurology Department; Hospital Plató; Barcelona Spain
| | - M. Falip
- Epilepsy Unit; Neurology Department; Hospital Universitari de Bellvitge; L'Hospitalet de Llobregat; Barcelona Spain
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Bektaş G, Çalışkan M, Aydın A, Pembegül Yıldız E, Tatlı B, Aydınlı N, Özmen M. Aggravation of atonic seizures by rufinamide: A case report. Brain Dev 2016; 38:654-7. [PMID: 26906013 DOI: 10.1016/j.braindev.2016.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/03/2016] [Accepted: 02/08/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rufinamide is a novel antiepileptic drug used as adjunctive therapy in patients with Lennox-Gastaut syndrome and provides seizure control especially in tonic and atonic seizures. Rufinamide is expected to be effective in intractable epilepsy when atonic and tonic seizures exist. However, rufinamide induced seizure aggravation has been reported in a few patients, which was not associated with a specific type of seizure. CASE A 12-year-old boy with intractable epilepsy had tonic and atonic seizures despite treatment with valproic acid (3000mg/day), levetiracetam (3000mg/day) and clobazam (40mg/day). Rufinamide was administered as adjuvant therapy. After 2weeks on rufinamide, he experienced atonic seizure worsening, and the frequency of epileptic discharges increased. The deterioration in seizure frequency and epileptiform discharges resolved when rufinamide was discontinued. CONCLUSION Rufinamide may aggravate atonic seizures in patients with intractable epilepsy.
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Affiliation(s)
- Gonca Bektaş
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Turkey.
| | - Mine Çalışkan
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Turkey
| | - Ali Aydın
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Turkey
| | - Edibe Pembegül Yıldız
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Turkey
| | - Burak Tatlı
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Turkey
| | - Nur Aydınlı
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Turkey
| | - Meral Özmen
- Department of Pediatric Neurology, Istanbul Medical Faculty, Istanbul University, Turkey
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15
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McMurray R, Striano P. Treatment of Adults with Lennox-Gastaut Syndrome: Further Analysis of Efficacy and Safety/Tolerability of Rufinamide. Neurol Ther 2016; 5:35-43. [PMID: 26861566 PMCID: PMC4919131 DOI: 10.1007/s40120-016-0041-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Management of Lennox-Gastaut syndrome (LGS) in adulthood can be particularly challenging. Published reports describing the use of rufinamide specifically in adult patients with LGS are scarce. A post hoc subgroup analysis of data from a phase III trial was conducted to investigate the efficacy and safety/tolerability of rufinamide in adults with LGS. METHODS A randomized, double-blind, placebo-controlled trial was conducted in patients with LGS, aged 4 years and above. During an 84-day, double-blind treatment period, patients received either adjunctive rufinamide therapy or placebo. Efficacy and safety/tolerability were assessed in a post hoc subgroup analysis of adult patients (≥18 years). Efficacy was assessed as change from baseline in 28-day seizure frequency, 50% responder rate, and seizure freedom rate; each calculated for total seizures and drop attacks. Safety/tolerability assessments included the evaluation of adverse events (AEs). RESULTS Thirty-one adults aged 18-37 years with LGS received treatment with either rufinamide (n = 21) or placebo (n = 10). Three patients in the rufinamide group did not complete the trial. The median change from baseline in seizure frequency was -31.5% for rufinamide versus +22.1% for placebo (P = 0.008) for all seizures and -54.9% versus +21.7% (P = 0.002) for drop attacks. Responder rates were 33.3% for rufinamide versus 0% for placebo (P = 0.066) for all seizures and 57.1% versus 10.0% (P = 0.020) for drop attacks. No patient achieved freedom from all seizures but two rufinamide-treated patients (9.5%) became free of drop attacks. Overall, 71.4% of patients treated with rufinamide and 60.0% of patients treated with placebo experienced AEs; most commonly, somnolence (33.3% vs. 20.0%) and vomiting (19.0% vs. 0%). Most AEs were of mild or moderate intensity. CONCLUSION Rufinamide demonstrated favorable efficacy and was generally well tolerated when used as adjunctive treatment for adults with LGS. FUNDING Eisai.
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Affiliation(s)
- Rob McMurray
- European Knowledge Centre, Eisai Europe Ltd, Mosquito Way, Hatfield, Hertfordshire, AL10 9SN, UK.
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, G. Gaslini Institute, University of Genoa, Genoa, Italy
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16
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Xu Z, Zhao H, Chen Z. The efficacy and safety of rufinamide in drug-resistant epilepsy: A meta-analysis of double-blind, randomized, placebo controlled trials. Epilepsy Res 2016; 120:104-10. [PMID: 26811934 DOI: 10.1016/j.eplepsyres.2016.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 10/08/2015] [Accepted: 01/06/2016] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Zhenghao Xu
- Laboratory of Brain Function and Disease in Chinese Medicine, College of Basic Medical Science, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Huawei Zhao
- The Affiliated Children's Hospital, College of Medical Sciences, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zhong Chen
- Laboratory of Brain Function and Disease in Chinese Medicine, College of Basic Medical Science, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China; Department of Pharmacology, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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Verrotti A, Loiacono G, Rossi A, Tartaro A, Delli Pizzi A, Coppola G. Successful Treatment of Refractory Seizures With Rufinamide in Children With Schizencephaly: Report of 3 Cases. J Child Neurol 2015; 30:1079-83. [PMID: 25051969 DOI: 10.1177/0883073814542951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 06/06/2014] [Indexed: 11/16/2022]
Abstract
Schizencephaly is an uncommon malformation of cortical development. Patients with schizencephaly present with a broad range of severe neurologic symptoms including pharmacoresistant epilepsy. Rufinamide is a new antiepileptic drug approved for use as adjunctive therapy of seizures associated with Lennox-Gastaut syndrome and it is also effective for refractory partial seizures. We report 3 cases of pediatric patients aged 7.2, 8.1, and 10.1 years, respectively, with intractable epilepsy associated with bilateral open-lip schizencephaly and septo-optic dysplasia. The follow-up ranged from 3.8 to 4.1 years. In our patients, the introduction of rufinamide as adjunctive drug led to a dramatic decline in the number of seizures and an improvement in EEG epileptic activity without side effects. Rufinamide seems to be efficacious and safe in patients with epileptic encephalopathies associated with pharmacoresistant epilepsy; further and larger clinical reports and controlled studies could confirm the usefulness of this anticonvulsant drug.
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Affiliation(s)
| | - Giulia Loiacono
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Armando Tartaro
- Department of Neuroscience and Imaging, Institute of Advanced Technology, G. d'Annunzio University, Chieti, Italy
| | - Andrea Delli Pizzi
- Department of Neuroscience and Imaging, Institute of Advanced Technology, G. d'Annunzio University, Chieti, Italy
| | - Giangennaro Coppola
- Child Neuropsychiatry Clinic, Medical School, University of Salerno, Salerno, Italy
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18
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Kessler SK, McCarthy A, Cnaan A, Dlugos DJ. Retention rates of rufinamide in pediatric epilepsy patients with and without Lennox-Gastaut Syndrome. Epilepsy Res 2015; 112:18-26. [PMID: 25847334 PMCID: PMC4805421 DOI: 10.1016/j.eplepsyres.2015.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/26/2015] [Accepted: 02/06/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of rufinamide (RFM) in patients with Lennox-Gastaut Syndrome (LGS) compared to those with other epilepsy syndromes using time to treatment failure (retention rate) as the outcome measure. METHODS In this retrospective cohort study, characteristics and outcomes of all patients receiving RFM in 2009 and 2010 were recorded. The primary outcome measure was RFM failure, defined as discontinuation of RFM or initiation of an additional antiepileptic therapy. The secondary outcome measure was discontinuation of RFM. Kaplan-Meier method survival curves were generated for time to RFM failure, for all patients and by the presence or absence of Lennox Gastaut Syndrome (LGS). The impact of age, seizure type, fast or slow drug titration, and concomitant therapy with valproate on retention rate were evaluated using Cox regression models. RESULTS One hundred thirty-three patients were included, 39 (30%) of whom had LGS. For all patients, the probability of remaining on RFM without additional therapy was 45% at 12 months and 30% at 24 months. LGS diagnosis was an independent predictor of time to RFM failure (HR 0.51, 95% CI 0.31-0.83), with a median time to failure of 18 months in LGS compared to 6 months in all others (p=0.006). CONCLUSIONS In a broad population of children with refractory epilepsy, around half will continue taking the medication for at least a year without additional therapy. Patients with LGS are two times more likely to continue RFM without additional therapy compared to those without LGS.
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Affiliation(s)
- Sudha Kilaru Kessler
- Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, United States.
| | - Ann McCarthy
- Temple University School of Medicine, United States
| | - Avital Cnaan
- Departments of Pediatrics and Epidemiology and Biostatistics, George Washington University and Children's National Medical Center, United States
| | - Dennis J Dlugos
- Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, United States
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Sharma S, Jain P, Gulati S, Sankhyan N, Agarwala A. Use of the modified Atkins diet in Lennox Gastaut syndrome. J Child Neurol 2015; 30:576-9. [PMID: 24659735 DOI: 10.1177/0883073814527162] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is scanty data regarding the efficacy and tolerability of the modified Atkins diet in children with Lennox-Gastaut syndrome. This study was a retrospective review of children with Lennox-Gastaut syndrome treated with the modified Atkins diet from May 2009 and March 2011. The diet was initiated in those children who persisted to have daily seizures despite the use of at least 3 appropriate antiepileptic drugs. Twenty-five children were started on a modified Atkins diet, restricting carbohydrate intake to 10 g/d. After 3 months, 2 patients were seizure-free, and 10/25 children had >50% reduction in seizure frequency. At 6 months, of 11 patients on the diet, 3 were seizure free and 8 had >50% reduction in seizure frequency. At 1 year, all 9 children on diet had >50% reduction in seizure frequency. The side effects of the diet were mild. The modified Atkins diet was found to be effective and well tolerated in children with Lennox-Gastaut syndrome.
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Affiliation(s)
- Suvasini Sharma
- Division of Pediatric Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India Division of Pediatric Neurology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Puneet Jain
- Division of Pediatric Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India Division of Pediatric Neurology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Sheffali Gulati
- Division of Pediatric Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Naveen Sankhyan
- Division of Pediatric Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anuja Agarwala
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Coppola G, Besag F, Cusmai R, Dulac O, Kluger G, Moavero R, Nabbout R, Nikanorova M, Pisani F, Verrotti A, von Stülpnagel C, Curatolo P. Current role of rufinamide in the treatment of childhood epilepsy: literature review and treatment guidelines. Eur J Paediatr Neurol 2014; 18:685-90. [PMID: 24929673 DOI: 10.1016/j.ejpn.2014.05.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/14/2014] [Accepted: 05/18/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The literature on the efficacy and safety of rufinamide in childhood-onset epilepsy syndromes currently includes approximately 600 paediatric patients. This paper summarizes the views of a panel of experienced European epileptologists with regard to the current role of rufinamide in the treatment of childhood epilepsies. RESULTS Rufinamide is effective in decreasing the seizure frequency in the Lennox-Gastaut syndrome (LGS), especially tonic and atonic seizures. It might consequently be preferred to other drugs as a second-line treatment for LGS when drop-attacks are frequent. The mean responder rate in the published studies is 38% with seizure freedom achieved in 2.4% of patients. Rufinamide has shown some efficacy in epileptic encephalopathies other than LGS. It can be also effective as adjunctive therapy in children and adolescents with drug-resistant partial seizures. The available data suggest that rufinamide has an acceptable risk/benefit ratio with quite a low risk of aggravating seizures. Common adverse effects (somnolence, nausea and vomiting) are usually mild and self-limiting; they are more frequently observed during titration than in the maintenance phase, suggesting that low escalation rates might be associated with fewer adverse effects. Rufinamide appears to have a favourable cognitive profile compared with other antiepileptic drugs. CONCLUSION Rufinamide is only approved for adjunctive treatment of seizures associated with LGS in children 4 years of age and older. There are very few data on rufinamide treatment at the onset of LGS or early in the course of the disorder; whether early treatment will improve outcome has yet to be determined.
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Affiliation(s)
- Giangennaro Coppola
- Child and Adolescent Neuropsychiatry, Medical School, University of Salerno, Italy
| | - Frank Besag
- South Essex Partnership University NHS Foundation Trust, Bedfordshire, United Kingdom
| | - Raffaella Cusmai
- Neurology Unit, "Bambino Gesù" Children's Hospital, IRCCS, Rome, Italy
| | - Olivier Dulac
- Inserm U1129, Neuropediatrics Department, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, CEA, Orsay, France
| | - Gerhard Kluger
- Clinic for Neuropediatrics and Neurological Rehabilitation, Epilepsy-Center for Children and Adolescents, Vogtareuth, Germany; Paracelsus Medical University, Salzburg, Austria
| | - Romina Moavero
- Department of Systems Medicine, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Italy
| | - Rima Nabbout
- Centre de Reference Epilepsies Rares, Inserm U1129, Neuropediatrics Department, Necker-Enfants Malades Hospital, APHP, Paris Descartes University, CEA, Orsay, France
| | | | | | | | - Celina von Stülpnagel
- Clinic for Neuropediatrics and Neurological Rehabilitation, Epilepsy-Center for Children and Adolescents, Vogtareuth, Germany
| | - Paolo Curatolo
- Department of Systems Medicine, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Italy.
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21
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Ohtsuka Y, Yoshinaga H, Shirasaka Y, Takayama R, Takano H, Iyoda K. Rufinamide as an adjunctive therapy for Lennox–Gastaut syndrome: A randomized double-blind placebo-controlled trial in Japan. Epilepsy Res 2014; 108:1627-36. [DOI: 10.1016/j.eplepsyres.2014.08.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/25/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
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Efficacy and safety of rufinamide in children under four years of age with drug-resistant epilepsies. Eur J Paediatr Neurol 2014; 18:641-5. [PMID: 24912730 DOI: 10.1016/j.ejpn.2014.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 05/01/2014] [Accepted: 05/06/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Studies on the efficacy and tolerability of rufinamide in infants and young children are scarce. Here we report on an open, retrospective, and pragmatic study about safety and efficacy of rufinamide in children aged less than four years, in terms of seizures types and epilepsy syndromes. METHODS Forty children (mean age 39.5 months; range 22-48) were enrolled in the study. The mean follow-up period was 12.2 months (range 5-21). Rufinamide was initiated at a mean age of 26.7 months (range 12-42). Final rufinamide mean dosage was 31.5 mg/kg/day if associated with valproic acid and 44.2 mg/kg/day if not. RESULTS The highest seizure reduction rate was observed in the epileptic spasms (46%) and drop attacks (42%) groups. Seizure reduction was also observed in tonic seizures (35%) and in the focal seizure (30%) groups. In terms of epilepsy syndrome, rufinamide was effective in Lennox-Gastaut syndrome. Results were very poor for those affected by Dravet's syndrome. Globally, responder rate was 27.5%, including two (5%) patients seizure-free. Adverse reactions occurred in 37.5% of children and were mainly represented by vomiting, drowsiness, irritability, and anorexia. Discontinuation rate due to treatment-emergent adverse events was 15%. CONCLUSION The present study concludes that rufinamide may be a safe and effective drug for a broad range of seizures and epilepsy syndromes in infants and young children and represents a valid therapeutic option in this population.
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23
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Grosso S, Balestri P. Efficacy and tolerability of add-on Lacosamide in children with Lennox-Gastaut syndrome. Acta Neurol Scand 2014; 130:e39-40. [PMID: 25052288 DOI: 10.1111/ane.12254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S. Grosso
- Pediatric Neurology-Immunology and Endocrinology Unit; University of Siena; Siena Italy
- Department of Pediatrics; University of Siena; Siena Italy
| | - P. Balestri
- Department of Pediatrics; University of Siena; Siena Italy
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24
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Thome-Souza S, Kadish NE, Ramgopal S, Sánchez Fernández I, Bergin AM, Bolton J, Harini C, Libenson M, Olson H, Peters J, Poduri A, Rotenberg A, Takeoka M, Kothare SV, Kapur K, Bourgeois BFD, Loddenkemper T. Safety and retention rate of rufinamide in 300 patients: A single pediatric epilepsy center experience. Epilepsia 2014; 55:1235-44. [DOI: 10.1111/epi.12689] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Sigride Thome-Souza
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department and Institute of Psychiatry; Faculty of Medicine; University of São Paulo; São Paulo Brazil
| | - Navah E. Kadish
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Sriram Ramgopal
- Department of Pediatrics; The Children's Hospital of Pittsburgh; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania U.S.A
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Child Neurology; Hospital Sant Joan de Déu; University of Barcelona; Barcelona Spain
| | - Ann M. Bergin
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Jeffrey Bolton
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Chellamani Harini
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Mark Libenson
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Heather Olson
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Jurriaan Peters
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Annapurna Poduri
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Alexander Rotenberg
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Masanori Takeoka
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Sanjeev V. Kothare
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
- Langone School of Medicine; New York University Medical Center; New York New York U.S.A
| | - Kush Kapur
- Department of Neurology; Clinical Research Center; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Blaise F. D. Bourgeois
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Boston Massachusetts U.S.A
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25
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Grosso S, Coppola G, Cusmai R, Parisi P, Spalice A, Foligno S, Verrotti A, Balestri P. Efficacy and tolerability of add-on lacosamide in children with Lennox-Gastaut syndrome. Acta Neurol Scand 2014; 129:420-4. [PMID: 24479878 DOI: 10.1111/ane.12221] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Available data on the efficacy of lacosamide in children with Lennox-Gastaut syndrome (LGS) are scarce and controversial. We present our experience with lacosamide therapy in children affected by LGS. MATERIAL AND METHODS Medical charts of all children affected by LGS receiving oral lacosamide adjunctive therapy in six paediatric neurology centres were retrospectively evaluated. Efficacy was determined according to the frequency of countable seizures during the 4 weeks prior to treatment and the frequency in the last 4 weeks of observation. Patients whose seizure frequency was reduced by at least 50% were defined as responders. RESULTS Eighteen children (mean age 12.3 years) were identified. After a mean follow-up period of 9 months, 33% of patients were responders. None of them was seizure-free during the study period. The overall seizure reduction rate was 29%. The percentage reductions from baseline in tonic seizures and drop-attacks rates were 31% and 20%, respectively. Adverse reactions occurred in 44% of patients. The drug was discontinued in four (22%) patients because of increased seizure frequency (three cases) and walking instability (another patient). CONCLUSIONS A third of children with LGS were responders after lacosamide adjunctive therapy. Although caution is still necessary when the drug is used in children with LGS, our preliminary observations suggest that lacosamide might be effective and represent a possible therapeutic option in children affected by LGS.
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Affiliation(s)
- S. Grosso
- Pediatric Neurology-Immunology and Endocrinology Unit; University of Siena; Siena Italy
- Department of Pediatrics; University of Siena; Siena Italy
| | - G. Coppola
- Institute of Child and Adolescence Neuropsychiatry; University of Salerno; Salerno Italy
| | - R. Cusmai
- Neurology Unit; Bambino Gesù Children's Hospital; Rome Italy
| | - P. Parisi
- Child Neurology; NESMOS Department; Faculty of Medicine and Psychology; Sapienza University of Rome; Italy
| | - A. Spalice
- Department of Pediatrics; Child Neurology Division; Sapienza University of Rome; Rome Italy
| | - S. Foligno
- Child Neurology; NESMOS Department; Faculty of Medicine and Psychology; Sapienza University of Rome; Italy
| | - A. Verrotti
- Clinical Pediatrics; University of Perugia; Perugia Italy
| | - P. Balestri
- Department of Pediatrics; University of Siena; Siena Italy
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26
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Abstract
Rufinamide is a novel anticonvulsant medication approved by the US Food and Drug Administration (FDA) in 2008 for the treatment of seizures associated with Lennox-Gastaut syndrome in patients 4 years of age and older, based upon clinical trials demonstrating clinical efficacy and tolerability. Rufinamide is especially effective for tonic-atonic seizures in Lennox-Gastaut syndrome, but is subsequently proving to be safe and effective in clinical practice for a broad patient population with refractory epilepsy. Although further research and clinical experience is needed, rufinamide holds the promise to positively impact the care of children with epilepsy. In this review, we review the use of rufinamide in pediatric epilepsy, with a focus on efficacy and safety.
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Affiliation(s)
- David T Hsieh
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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