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Watkins LV, Dunstall H, Musicha C, Lawthom C, John K, Bright C, Richings C, Harding K, Moon S, Pape SE, Winterhalder R, Allgar V, Thomas RH, McLean B, Laugharne R, Shankar R. Rapid switching from levetiracetam to brivaracetam in pharmaco-resistant epilepsy in people with and without intellectual disabilities: a naturalistic case control study. J Neurol 2023; 270:5889-5902. [PMID: 37610448 DOI: 10.1007/s00415-023-11959-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Approximately one quarter of people with an intellectual disability (PwID) have epilepsy of whom nearly three-quarters are pharmaco-resistant. There are higher reported neuropsychiatric side-effects to anti-seizure medication (ASM) in this group. Levetiracetam (LEV) is a first-line ASM with a stronger association with neuropsychiatric symptoms for PwID than other ASMs. Brivaracetam (BRV) is a newer ASM. Recent studies suggest a beneficial effect of swapping people who experience neuropsychiatric events with LEV to BRV. However, there is limited evidence of this for PwID. This evaluation analyses real world outcomes of LEV to BRV swap for PwID compared to those without ID. METHODS We performed a multicentre, retrospective review of clinical records. Demographic, clinical characteristics and reported adverse events of patients switched from LEV to BRV (2016-2020) were recorded at 3 months pre and 6- and 12-month post-BRV initiation. Outcomes were compared between PwID and those without and summarised using cross-tabulations and logistic regression models. A Bonferroni correction was applied. RESULTS Of 77 participants, 46 had ID and 52% had a past psychiatric illness. 71% participants switched overnight from LEV to BRV. Seizure reduction of > 50% was seen in 40% patients. Psychiatric illness history was predictive of having neuropsychiatric side-effects with LEV but not BRV (p = 0.001). There was no significant difference for any primary outcomes between PwID versus without ID. CONCLUSIONS Switching from LEV to BRV appears as well tolerated and efficacious in PwID as those without ID with over 90% still on BRV after 12 months.
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Affiliation(s)
- L V Watkins
- Swansea Bay University Health Board, Port Talbot, UK
- University of South Wales, Aberdare, UK
- University of Plymouth, Plymouth, UK
| | - H Dunstall
- Swansea Bay University Health Board, Port Talbot, UK
| | - C Musicha
- University of Plymouth, Plymouth, UK
| | - C Lawthom
- Aneurin Bevan University Health Board, Newport, UK
- Swansea University, Swansea, UK
| | - K John
- Aneurin Bevan University Health Board, Newport, UK
| | - C Bright
- University of South Wales, Aberdare, UK
- Aneurin Bevan University Health Board, Newport, UK
| | - C Richings
- Aneurin Bevan University Health Board, Newport, UK
| | - K Harding
- Aneurin Bevan University Health Board, Newport, UK
| | - S Moon
- Swansea Bay University Health Board, Port Talbot, UK
| | - S E Pape
- Oxleas NHS Foundation Trust, Kent, UK
| | | | - V Allgar
- University of Plymouth, Plymouth, UK
| | - R H Thomas
- Newcastle University, Newcastle upon Tyne, UK
- The Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - B McLean
- University of Plymouth, Plymouth, UK
| | | | - Rohit Shankar
- University of Plymouth, Plymouth, UK.
- Cornwall Partnership NHS Foundation Trust, Threemilestone Industrial Estate, Truro, TR4 9LD, UK.
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Li KY, Hsu CY, Yang YH. A review of cognitive and behavioral outcomes of Brivaracetam. Kaohsiung J Med Sci 2023; 39:104-114. [PMID: 36661137 DOI: 10.1002/kjm2.12648] [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: 07/15/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 01/21/2023] Open
Abstract
Anti-seizure medications (ASMs) can cause cognitive or behavioral adverse drug reactions, which is an important consideration when selecting an appropriate ASM. Brivaracetam (BRV) is a newer synaptic vesicle protein 2A ligand, which is expected to result in fewer neuropsychiatric adverse effects due to its mechanism of action. To understand the impact of BRV on cognition and behavior compared with other ASMs, we conducted a review of the literature using the Cochrane Library, PubMed/MEDLINE, and Embase. After the screening process, a total of two animal studies, one randomized controlled trial, one pooled analysis of clinical trials, one controlled study, and nine observational studies were included. The animal studies showed that BRV did not worsen cognitive or behavioral performance in rodents. The human studies showed that BRV was associated with fewer cognitive adverse events compared with other second- or third-generation ASMs. In addition, BRV was less associated with behavioral disturbance than levetiracetam. In summary, this review revealed that BRV has a limited impact on cognition and behavior. For patients who are intolerant to levetiracetam and have levetiracetam-related behavioral side effects, switching to BRV could be beneficial. However, heterogeneity between studies resulted in low-quality of evidence, and further trials are needed to confirm the findings.
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Affiliation(s)
- Kuan-Ying Li
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chung-Yao Hsu
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yuan-Han Yang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Neuroscience Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of and Master's Program in Neurology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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3
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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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Fukuyama K, Okada M. Brivaracetam and Levetiracetam Suppress Astroglial L-Glutamate Release through Hemichannel via Inhibition of Synaptic Vesicle Protein. Int J Mol Sci 2022; 23:ijms23094473. [PMID: 35562864 PMCID: PMC9101419 DOI: 10.3390/ijms23094473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 02/07/2023] Open
Abstract
To explore the pathophysiological mechanisms of antiseizure and adverse behavioural/psychiatric effects of brivaracetam and levetiracetam, in the present study, we determined the effects of brivaracetam and levetiracetam on astroglial L-glutamate release induced by artificial high-frequency oscillation (HFO) bursts using ultra-high-performance liquid chromatography. Additionally, the effects of brivaracetam and levetiracetam on protein expressions of connexin43 (Cx43) and synaptic vesicle protein 2A (SV2A) in the plasma membrane of primary cultured rat astrocytes were determined using a capillary immunoblotting system. Acutely artificial fast-ripple HFO (500 Hz) burst stimulation use-dependently increased L-glutamate release through Cx43-containing hemichannels without affecting the expression of Cx43 or SV2A in the plasma membrane, whereas acute physiological ripple HFO (200 Hz) stimulation did not affect astroglial L-glutamate release or expression of Cx43 or SV2A. Contrarily, subchronic ripple HFO and acute pathological fast-ripple HFO (500 Hz) stimulations use-dependently increased L-glutamate release through Cx43-containing hemichannels and Cx43 expression in the plasma membrane. Subchronic fast-ripple HFO-evoked stimulation produced ectopic expression of SV2A in the plasma membrane, but subchronic ripple HFO stimulation did not generate ectopic SV2A. Subchronic administration of brivaracetam and levetiracetam concentration-dependently suppressed fast-ripple HFO-induced astroglial L-glutamate release and expression of Cx43 and SV2A in the plasma membrane. In contrast, subchronic ripple HFO-evoked stimulation induced astroglial L-glutamate release, and Cx43 expression in the plasma membrane was inhibited by subchronic levetiracetam administration, but was not affected by brivaracetam. These results suggest that brivaracetam and levetiracetam inhibit epileptogenic fast-ripple HFO-induced activated astroglial transmission associated with hemichannels. In contrast, the inhibitory effect of therapeutic-relevant concentrations of levetiracetam on physiological ripple HFO-induced astroglial responses probably contributes to the adverse behavioural/psychiatric effects of levetiracetam.
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Alan T. Antiseizure medication discovery: Recent and future paradigm shifts. Epilepsia Open 2022; 7 Suppl 1:S133-S141. [PMID: 35090197 PMCID: PMC9340309 DOI: 10.1002/epi4.12581] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 11/06/2022] Open
Abstract
Despite the ever-increasing number of available options for the treatment of epilepsies and the remarkable advances on the understanding of their pathophysiology, the proportion of refractory patients has remained approximately unmodified during the last 100 years. How efficient are we translating positive outcomes from basic research to clinical trials and/or the clinical scenario? It is possible that fresh thinking and exploration of new paradigms is required to arrive at truly novel therapeutic solutions, as seemingly proven by recently approved first-in-class antiseizure medications and drug candidates undergoing late clinical trials. Here, the author discusses some approximations in line with the network pharmacology philosophy, which may result in highly innovative (and, hopefully, safer and/or more efficacious) medications for the control of seizures, as embodied with some recent examples in the field, namely tailored multi-target agents and low-affinity ligands.
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Affiliation(s)
- Talevi Alan
- Laboratory of Bioactive Research and Development (LIDeB), Faculty of exact Sciences, University of La Plata (UNLP), 47 & 15, La Plata (B1900AJK), Buenos Aires, Argentina
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Okada M, Fukuyama K, Shiroyama T, Ueda Y. Brivaracetam prevents astroglial l-glutamate release associated with hemichannel through modulation of synaptic vesicle protein. Biomed Pharmacother 2021; 138:111462. [PMID: 33706129 DOI: 10.1016/j.biopha.2021.111462] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/11/2022] Open
Abstract
The antiepileptic/anticonvulsive action of brivaracetam is considered to occur via modulation of synaptic vesicle protein 2A (SV2A); however, the pharmacological mechanisms of action have not been fully characterised. To explore the antiepileptic/anticonvulsive mechanism of brivaracetam associated with SV2A modulation, this study determined concentration-dependent effects of brivaracetam on astroglial L-glutamate release associated with connexin43 (Cx43), tumour-necrosis factor-α (TNFα) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)/glutamate receptor of rat primary cultured astrocytes using ultra-high-performance liquid chromatography. Furthermore, interaction among TNFα, elevated extracellular K+ and brivaracetam on expression of SV2A and Cx43 was determined using capillary immunoblotting. TNFα and elevated extracellular K+ predominantly enhanced astroglial L-glutamate release associated with respective AMPA/glutamate receptor and hemichannel. These effects were enhanced by a synergistic effect of TNFα and elevated extracellular K+ in combination. The activation of astroglial L-glutamate release, and expression of SV2A and Cx43 in the plasma membrane was suppressed by subchronic brivaracetam administration but were unaffected by acute administration. These results suggest that migration of SV2A to the astroglial plasma membrane by hyperexcitability activates astroglial glutamatergic transmission, perhaps via hemichannel activation. Subchronic brivaracetam administration suppressed TNFα-induced activation of AMPA/glutamate receptor and hemichannel via inhibition of ectopic SV2A. These findings suggest that combined inhibition of vesicular and ectopic SV2A functions contribute to the antiepileptic/anticonvulsive mechanism of brivaracetam action.
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Affiliation(s)
- Motohiro Okada
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu, Mie 514-8507, Japan.
| | - Kouji Fukuyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu, Mie 514-8507, Japan.
| | - Takashi Shiroyama
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu, Mie 514-8507, Japan.
| | - Yuto Ueda
- Department of Neuropsychiatry, Division of Neuroscience, Graduate School of Medicine, Mie University, Tsu, Mie 514-8507, Japan.
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Lamouret V, Kurth C, Intravooth T, Steinhoff BJ. Is the anticonvulsant activity of levetiracetam dose-dependent? Seizure 2020; 83:197-202. [PMID: 33197757 DOI: 10.1016/j.seizure.2020.10.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Although levetiracetam (LEV) is globally established as a leading antiseizure medication (ASM) it is still a controversial matter whether dose increases correspond with an increased efficacy if LEV in the recommended dose range did not show satisfying efficacy. In our clinical perception we questioned the value of dose increases in such non-responders. METHODS In this retrospective monocenter study we analyzed the data of adult people with epilepsies (PWE) with focal-onset seizures who had been treated at the department of adults of the Kork Epilepsy Center between 2009 and 2019, who had been on a stable daily LEV dose and in whom LEV was further increased due to further seizures in spite of baseline LEV in a recommended daily dose range. For reasons of data homogeneity, we included only PWE with at least two definite seizures during the hospital stay under the baseline LEV dose who were treated and observed as in-patients after the increase of LEV for a period at least three-fold longer than the baseline interval before. Additional data acquisition comprised clinical data including adverse events, serum concentrations of LEV and other ASMs, and additional laboratory findings. The primary outcome variable was the change of seizure frequency prior to and after the increase of LEV. RESULTS Out of 518 PWE who had been on LEV during their hospital stay, a total of 61 PWE fulfilled the inclusion criteria. After a gradual dose increment, 91,8 % of PWE showed a reduced seizure frequency, 73,8 % had a reduction of seizures of 50 % or more, and 21,3 % were seizure-free during the observation period. A significant seizure reduction could be shown with a seizure count of 2,5/week prior to the increment and 0,7/week after dose increment (p < 0,00001). Seven PWE reported minor adverse events and ten PWE showed slight laboratory changes (within normal levels). CONCLUSION Contrary to our long-term clinical impression, LEV dose increments were reasonable and improved the seizure situation in PWE, usually without additional safety hazards.
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Affiliation(s)
- Valerija Lamouret
- Kork Epilepsy Center, Kehl-Kork, Germany; Department of Pediatrics, St-Elisabethen-Krankenhaus, Lörrach, Germany
| | | | | | - Bernhard J Steinhoff
- Kork Epilepsy Center, Kehl-Kork, Germany; University Hospital of Neurology, Freiburg, Germany.
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Moseley BD, Chanteux H, Nicolas JM, Laloyaux C, Gidal B, Stockis A. A review of the drug−drug interactions of the antiepileptic drug brivaracetam. Epilepsy Res 2020; 163:106327. [DOI: 10.1016/j.eplepsyres.2020.106327] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/11/2020] [Accepted: 03/30/2020] [Indexed: 01/16/2023]
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Steinhoff BJ, Staack AM. Levetiracetam and brivaracetam: a review of evidence from clinical trials and clinical experience. Ther Adv Neurol Disord 2019; 12:1756286419873518. [PMID: 31523280 PMCID: PMC6734620 DOI: 10.1177/1756286419873518] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/12/2019] [Indexed: 01/15/2023] Open
Abstract
Until the early 1990s, a limited number of antiepileptic drugs (AEDs) were available. Since then, a large variety of new AEDs have been developed and introduced, several of them offering new modes of action. One of these new AED families is described and reviewed in this article. Levetiracetam (LEV) and brivaracetam (BRV) are pyrrolidone derivate compounds binding at the presynaptic SV2A receptor site and are thus representative of AEDs with a unique mode of action. LEV was extensively investigated in randomized controlled trials and has a very promising efficacy both in focal and generalized epilepsies. Its pharmacokinetic profile is favorable and LEV does not undergo clinically relevant interactions. Adverse reactions comprise mainly asthenia, somnolence, and behavioral symptoms. It has now been established as a first-line antiepileptic drug. BRV has been recently introduced as an adjunct antiepileptic drug in focal epilepsy with a similarly promising pharmacokinetic profile and possibly increased tolerability concerning psychiatric adverse events. This review summarizes the essential preclinical and clinical data of LEV and BRV that is currently available and includes the experiences at a large tertiary referral epilepsy center.
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de Biase S, Nilo A, Bernardini A, Gigli GL, Valente M, Merlino G. Timing use of novel anti-epileptic drugs: is earlier better? Expert Rev Neurother 2019; 19:945-954. [DOI: 10.1080/14737175.2019.1636649] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Stefano de Biase
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
| | - Annacarmen Nilo
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
| | - Andrea Bernardini
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
| | - Gian Luigi Gigli
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
- DMIF, University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine Medical School, Udine, Italy
| | - Giovanni Merlino
- Stroke Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
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11
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Yi ZM, -, Wen C, Cai T, Xu L, Zhong XL, Zhan SY, Zhai SD. Levetiracetam for epilepsy: an evidence map of efficacy, safety and economic profiles. Neuropsychiatr Dis Treat 2018; 15:1-19. [PMID: 30587993 PMCID: PMC6301299 DOI: 10.2147/ndt.s181886] [Citation(s) in RCA: 12] [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] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy, safety and economics of levetiracetam (LEV) for epilepsy. MATERIALS AND METHODS PubMed, Scopus, the Cochrane Library, OpenGrey.eu and ClinicalTrials.gov were searched for systematic reviews (SRs), meta-analyses, randomized controlled trials (RCTs), observational studies, case reports and economic studies published from January 2007 to April 2018. We used a bubble plot to graphically display information of included studies and conducted meta-analyses to quantitatively synthesize the evidence. RESULTS A total of 14,803 records were obtained. We included 30 SRs/meta-analyses, 34 RCTs, 18 observational studies, 58 case reports and 2 economic studies after the screening process. The included SRs enrolled patients with pediatric epilepsy, epilepsy in pregnancy, focal epilepsy, generalized epilepsy and refractory focal epilepsy. Meta-analysis of the included RCTs indicated that LEV was as effective as carbamazepine (CBZ; treatment for 6 months: 58.9% vs 64.8%, OR=0.76, 95% CI: 0.50-1.16; 12 months: 54.9% vs 55.5%, OR=1.24, 95% CI: 0.79-1.93), oxcarbazepine (57.7% vs 59.8%, OR=1.34, 95% CI: 0.34-5.23), phenobarbital (50.0% vs 50.9%, OR=1.20, 95% CI: 0.51-2.82) and lamotrigine (LTG; 61.5% vs 57.7%, OR=1.22, 95% CI: 0.90-1.66). SRs and observational studies indicated a low malformation rate and intrauterine death rate for pregnant women, as well as low risk of cognitive side effects. But psychiatric and behavioral side effects could not be ruled out. LEV decreased discontinuation due to adverse events compared with CBZ (OR=0.52, 95% CI: 0.41-0.65), while no difference was found when LEV was compared with placebo and LTG. Two cost-effectiveness evaluations for refractory epilepsy with decision-tree model showed US$ 76.18 per seizure-free day gained in Canada and US$ 44 per seizure-free day gained in Korea. CONCLUSION LEV is as effective as CBZ, oxcarbazepine, phenobarbital and LTG and has an advantage for pregnant women and in cognitive functions. Limited evidence supports its cost-effectiveness. REGISTERED NUMBER PROSPERO (No CRD 42017069367).
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Affiliation(s)
- Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
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- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
| | - Cheng Wen
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University Health Science Center, Beijing, China
| | - Ting Cai
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Lu Xu
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Xu-Li Zhong
- Department of Pharmacy, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Si-Yan Zhan
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Center for Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China,
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Zahnert F, Krause K, Immisch I, Habermehl L, Gorny I, Chmielewska I, Möller L, Weyand AM, Mross PM, Wagner J, Menzler K, Knake S. Brivaracetam in the Treatment of Patients with Epilepsy-First Clinical Experiences. Front Neurol 2018; 9:38. [PMID: 29467714 PMCID: PMC5808159 DOI: 10.3389/fneur.2018.00038] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/16/2018] [Indexed: 01/15/2023] Open
Abstract
Objectives To assess first clinical experiences with brivaracetam (BRV) in the treatment of epilepsies. Methods Data on patients treated with BRV from February to December 2016 and with at least one clinical follow-up were collected from electronic patient records. Data on safety and efficacy were evaluated retrospectively. Results In total, 93 patients were analyzed; 12 (12.9%) received BRV in monotherapy. The mean duration to follow-up was 4.85 months (MD = 4 months; SD = 3.63). Fifty-seven patients had more than one seizure per month at baseline and had a follow-up of more than 4 weeks; the rate of ≥50% responders was 35.1% (n = 20) in this group, of which five (8.8%) patients were newly seizure-free. In 50.5% (47/93), patients were switched from levetiracetam (LEV) to BRV, of which 43 (46.2%) were switched immediately. Adverse events (AE) occurred in 39.8%, with 22.6% experiencing behavioral and 25.8% experiencing non-behavioral AE. LEV-related AE (LEV-AE) were significantly reduced by switching to BRV. The discontinuation of BRV was reported in 26/93 patients (28%); 10 of those were switched back to LEV with an observed reduction of AE in 70%. For clinical reasons, 12 patients received BRV in monotherapy, 75% were seizure–free, and previous LEV-AE improved in 6/9 patients. BRV-related AE occurred in 5/12 cases, and five patients discontinued BRV. Conclusion BRV seems to be a safe, easy, and effective option in the treatment of patients with epilepsy, especially in the treatment of patients who have psychiatric comorbidities and might not be good candidates for LEV treatment. BRV broadens the therapeutic spectrum and facilitates personalized treatment.
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Affiliation(s)
- Felix Zahnert
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Kristina Krause
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Ilka Immisch
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Lena Habermehl
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Iris Gorny
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Izabella Chmielewska
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Leona Möller
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Anna M Weyand
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Peter M Mross
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Jan Wagner
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Katja Menzler
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
| | - Susanne Knake
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Philipps University of Marburg, Marburg, Germany
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Kappes JA, Hayes WJ, Strain JD, Farver DK. Brivaracetam: An Adjunctive Treatment for Partial-Onset Seizures. J Clin Pharmacol 2017; 57:811-817. [PMID: 28394442 DOI: 10.1002/jcph.900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/28/2017] [Indexed: 11/07/2022]
Abstract
Brivaracetam is an analogue of levetiracetam that is Food and Drug Administration-approved for adjunctive treatment of partial-onset seizures in patients 16 years and older. In placebo-controlled trials adjunct brivaracetam demonstrated efficacy in reducing the frequency of seizures. The most commonly reported adverse effects are somnolence, dizziness, and fatigue. Clinical trials have evaluated brivaracetam for safety and efficacy in adjunctive treatment of partial-onset seizures in patients 16 years and older for up to 16 weeks. Brivaracetam's mechanism is similar to that of levetiracetam but with greater receptor binding affinity on synaptic vesicle protein 2A and inhibitory effects on sodium channels. Clinically significant differences between these agents are undetermined. Brivaracetam is available as oral tablets, oral solution, and intravenous solution. The Food and Drug Administration-approved dose is 50 mg twice daily, and titration is not required. Brivaracetam does not need dose adjustment for renal impairment and has minimal drug-drug interactions. Current limitations of brivaracetam include lack of head-to-head trials, limited long-term safety and efficacy data, and cost. Overall, brivaracetam is a viable adjunct therapeutic option for refractory partial-onset seizures in those who have failed conventional therapies.
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Affiliation(s)
- John A Kappes
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy, Rapid City Regional Hospital, Rapid City, SD, USA
| | - William J Hayes
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy, VA Black Hills Health Care System, Fort Meade, SD, USA
| | - Joe D Strain
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy, Rapid City Regional Hospital, Rapid City, SD, USA
| | - Debra K Farver
- Department of Pharmacy Practice, South Dakota State University, College of Pharmacy, SD Human Services Center, Yankton, SD, USA
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Can Matching-Adjusted Indirect Comparison Methods Mitigate Placebo Response Differences Among Patient Populations in Adjunctive Trials of Brivaracetam and Levetiracetam? CNS Drugs 2017; 31:899-910. [PMID: 28856580 PMCID: PMC5658476 DOI: 10.1007/s40263-017-0462-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with focal seizures recruited into adjunctive antiepileptic drug (AED) trials have become more refractory and severe over time; concurrently, placebo responses have increased. To attempt to account for heterogeneity among trials, propensity-score weighted patient-level data were used to indirectly compare placebo responses reported in brivaracetam and levetiracetam trials. METHODS Patient-level data from randomised, placebo-controlled brivaracetam (recruited 2007-2014) and levetiracetam (1993-1998) trials were pooled. Consistent inclusion/exclusion criteria were applied and outcomes were defined consistently. Potentially confounding baseline characteristics were adjusted for using propensity score weighting. Weighting success was assessed using placebo response. RESULTS In total, 707 and 473 active drug and 399 and 253 placebo patients comprised the brivaracetam and levetiracetam groups, respectively. Before weighting, several baseline variables were significantly different between groups; after weighting, prior vagal nerve stimulation, co-morbid depression and co-morbid anxiety remained different. Before weighting, median seizure frequency reduction was 21.7 and 3.9% in the brivaracetam and levetiracetam placebo arms, respectively; after weighting, median reduction was 15.0 and 6.0%. The comparison of non-randomised groups could be biased by unobserved confounding factors and region of residence. Lifetime AED history was unavailable in the brivaracetam trials and excluded from analysis. CONCLUSIONS Placebo responses remained different between brivaracetam and levetiracetam trials after propensity score weighting, indicating the presence of residual confounding factors associated with placebo response in these trials. It therefore remains problematic to conduct reliable indirect comparisons of brivaracetam and levetiracetam given the current evidence base, which may apply to comparisons between other AED trials.
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Endres D, Perlov E, Feige B, Altenmüller DM, Venhoff N, Tebartz van Elst L. Schizophrenia Associated with Epileptiform Discharges without Seizures Successfully Treated with Levetiracetam. Front Psychiatry 2017; 8:12. [PMID: 28228737 PMCID: PMC5296318 DOI: 10.3389/fpsyt.2017.00012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/17/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Schizophrenia-like disorders can be divided into endogenic or primary, idiopathic, polygenetic forms, and different secondary, organic subgroups [e.g., (para)epileptic, immunological, degenerative]. Epileptic and paraepileptic explanatory approaches have a long tradition due to the high rate of electroencephalography (EEG) alterations in patients with schizophrenia. CASE PRESENTATION We present the case of a 23-year-old female patient suffering, since the age of 14 years, from a fluctuating paranoid-hallucinatory syndrome with formal thought disorder, fear, delusions of persecution, auditory, visual, and tactile hallucinations, as well as negative and cognitive symptoms. Laboratory measurements showed increased titers of antinuclear antibodies (ANAs) in the context of ulcerative colitis. While there was no clear history or evidence of epileptic seizures, the EEG showed generalized 3 Hz polyspike wave complexes. Under treatment with levetiracetam, the symptoms disappeared and the patient was able to complete vocational training. CONCLUSION The schizophrenia-like symptoms associated with epileptiform discharges but not overt seizures and the good response to antiepileptic treatment could be interpreted in the context of a (para)epileptic pathomechanism. The EEG alterations might be due to a polygenetic effect due to different genes. Mild immunological mechanisms in the framework of ulcerative colitis and increased ANA titers might have supported the network instability. This case report illustrates (1) the importance of EEG screenings in schizophrenia, (2) a potential pathogenetic role of epileptiform discharges in a subgroup of patients with schizophrenia-like symptoms, and (3) that antiepileptic medication with levetiracetam could be a successful treatment alternative in schizophrenia-like disorders with EEG alterations.
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Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry, Faculty of Medicine, University of Freiburg , Freiburg , Germany
| | - Evgeniy Perlov
- Section for Experimental Neuropsychiatry, Department of Psychiatry, Faculty of Medicine, University of Freiburg , Freiburg , Germany
| | - Bernd Feige
- Section for Experimental Neuropsychiatry, Department of Psychiatry, Faculty of Medicine, University of Freiburg , Freiburg , Germany
| | - Dirk-Matthias Altenmüller
- Freiburg Epilepsy Center, Department of Neurosurgery, Faculty of Medicine, University of Freiburg , Freiburg , Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, University of Freiburg , Freiburg , Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry, Faculty of Medicine, University of Freiburg , Freiburg , Germany
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Response to “Response to Zhang et al.: Levetiracetam vs. brivaracetam for adults with refractory focal seizures: A meta-analysis and indirect comparison”. Seizure 2016; 41:184-6. [DOI: 10.1016/j.seizure.2016.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/01/2016] [Indexed: 11/24/2022] Open
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Response to Zhang et al.: Levetiracetam vs. brivaracetam for adults with refractory focal seizures: A meta-analysis and indirect comparison. Seizure 2016; 41:182-3. [DOI: 10.1016/j.seizure.2016.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 07/17/2016] [Indexed: 11/21/2022] Open
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