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Zeng Q, Xia X, Jiang L, Chen J, Liu Y, Hu Y. Efficacy and safety of adjunctive perampanel treatment in pediatric patients with epilepsy aged 4-12 years: a real-world study. J Neurol 2024; 271:4566-4576. [PMID: 38717610 DOI: 10.1007/s00415-024-12416-y] [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: 03/25/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVE To determine the efficacy and safety of perampanel (PER) as an adjunctive therapy in children aged 4-12 years with epilepsy. METHODS We performed a non-randomized, open-label, placebo-uncontrolled, real-world self-controlled study that included 216 young children (aged 4-12 years) with epilepsy who received PER as adjunctive therapy at the children's hospital affiliated with Chongqing Medical University from July 4, 2020, to September 20, 2023. RESULTS (1) The efficacy rates of adjunctive PER therapy at 3, 6, 9, and 12 months were 62.8%, 67.8%, 65.3%, and 61.2%, respectively. PER showed efficacy in alleviating focal seizures, generalized tonic-clonic seizures, myoclonic seizures, and absence seizures. The efficacy rates for variants of self-limited epilepsy with centrotemporal spikes (SeLECTS) and Lennox-Gastaut syndrome (LGS) were 89.5% and 66.7%, respectively. (2) Focal non-motor onset seizures with or without impaired awareness, focal to bilateral tonic-clonic seizures (FBTCS), LGS, variants of SeLECTS, the number of concomitant antiseizure medications (ASMs), a family history of epilepsy, and focal lesions on cranial magnetic resonance imaging were independent factors affecting efficacy. The order of PER addition did not affect efficacy. The retention rates at 3, 6, 9, and 12 months were 90.7%, 84.7%, 74.7%, 64.9%, respectively. (3) Adverse reactions occurred in 45 patients (45/216, 20.8%), with irritability/aggressive behavior (18/216, 8.3%) and somnolence (14/216, 6.5%) being the most common. Twelve patients (12/216, 5.6%) withdrew from the study because of adverse reactions. CONCLUSION In young Chinese children with epilepsy, PER is effective, safe, and well-tolerated as an adjunctive therapy, making it a viable option for use with broad-spectrum ASMs.
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Affiliation(s)
- Qiao Zeng
- Department of Neurology, Children's Hospital of Chongqing Medical University, No. 136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
- Big Data Engineering Center, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xueqian Xia
- Department of Neurology, Children's Hospital of Chongqing Medical University, No. 136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, No. 136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Jin Chen
- Department of Neurology, Children's Hospital of Chongqing Medical University, No. 136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Yuhang Liu
- Department of Neurology, Children's Hospital of Chongqing Medical University, No. 136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China
| | - Yue Hu
- Department of Neurology, Children's Hospital of Chongqing Medical University, No. 136 Zhongshan 2nd Road, Yu Zhong District, Chongqing, 400014, China.
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.
- National Clinical Research Center for Child Health and Disorders (Chongqing), Chongqing, China.
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.
- Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, Chongqing, China.
- Big Data Engineering Center, Children's Hospital of Chongqing Medical University, Chongqing, China.
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Delanty N, Mohanraj R, Shankar R, Wehner T, Stephen LJ, D'Souza W, Cappucci S, McMurray R, Sainz-Fuertes R, Villanueva V. Perampanel for the treatment of epilepsy with genetic aetiology: Real-world evidence from the PERMIT Extension study. Epilepsy Res 2024; 202:107339. [PMID: 38492461 DOI: 10.1016/j.eplepsyres.2024.107339] [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: 12/08/2023] [Revised: 02/14/2024] [Accepted: 02/29/2024] [Indexed: 03/18/2024]
Abstract
Genetic factors contribute to the aetiology of epilepsy in >50% of cases, and information on the use of antiseizure medications in people with specific aetiologies will help guide treatment decisions. The PERMIT Extension study pooled data from two real-world studies (PERMIT and PROVE) to investigate the effectiveness and safety/tolerability of perampanel (PER) when used to treat people with focal and generalised epilepsy in everyday clinical practice. This post-hoc analysis of PERMIT Extension explored the use of PER when used to treat individuals presumed to have epilepsy with a genetic aetiology. Assessments included retention rate (evaluated at 3, 6 and 12 months), effectiveness (responder and seizure freedom rates; evaluated at 3, 6, 12 months and the last visit [last observation carried forward) and tolerability (adverse events [AEs]). Of the 6822 people with epilepsy included in PERMIT Extension, 1012 were presumed to have a genetic aetiology. The most common genetic aetiologies were idiopathic generalised epilepsy (IGE; 58.2%), tuberous sclerosis (1.1%), Dravet syndrome (0.8%) and genetic epilepsy with febrile seizures plus (GEFS+; 0.5%). Retention rates at 3, 6 and 12 months in the total genetic aetiology population were 89.3%, 79.7% and 65.9%, respectively. In the total genetic aetiology population, responder rates at 12 months and the last visit were 74.8% and 68.3%, respectively, and corresponding seizure freedom rates were 48.9% and 46.5%, respectively. For the specific aetiology subgroups, responder rates at 12 months and the last visit were, respectively: 90.4% and 84.4% (IGE), 100% and 57.1% (tuberous sclerosis), 100% and 71.4% (Dravet syndrome), and 33.3% and 20.0% (GEFS+). Corresponding seizure freedom rates were, respectively: 73.1% and 64.6% (IGE), 33.3% and 22.2% (tuberous sclerosis), 20.0% and 28.6% (Dravet syndrome), and 0% and 0% (GEFS+). The incidence of AEs was 46.5% for the total genetic aetiology population, 48.8% for IGE, 27.3% for tuberous sclerosis, 62.5% for Dravet syndrome, and 20% for GEFS+. Tolerability findings were consistent with PER's known safety profile. PER was effective and generally well tolerated when used in individuals with a presumed genetic epilepsy aetiology in clinical practice. PER was effective across a wide range of genetic aetiologies.
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Affiliation(s)
- Norman Delanty
- Department of Neurology, Beaumont Hospital, Dublin, Ireland.
| | - Rajiv Mohanraj
- Greater Manchester Neurosciences Centre, Salford Royal Hospital, UK
| | | | - Tim Wehner
- National Hospital for Neurology and Neurosurgery, UCLH Foundation Trust, and Department of Clinical and Experimental Epilepsy, UCL, London, UK
| | - Linda J Stephen
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, UK
| | - Wendyl D'Souza
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Victoria, Australia
| | | | | | | | - Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Perversi F, Costa C, Labate A, Lattanzi S, Liguori C, Maschio M, Meletti S, Nobili L, Operto FF, Romigi A, Russo E, Di Bonaventura C. The broad-spectrum activity of perampanel: state of the art and future perspective of AMPA antagonism beyond epilepsy. Front Neurol 2023; 14:1182304. [PMID: 37483446 PMCID: PMC10359664 DOI: 10.3389/fneur.2023.1182304] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/07/2023] [Indexed: 07/25/2023] Open
Abstract
Glutamate is the brain's main excitatory neurotransmitter. Glutamatergic neurons primarily compose basic neuronal networks, especially in the cortex. An imbalance of excitatory and inhibitory activities may result in epilepsy or other neurological and psychiatric conditions. Among glutamate receptors, AMPA receptors are the predominant mediator of glutamate-induced excitatory neurotransmission and dictate synaptic efficiency and plasticity by their numbers and/or properties. Therefore, they appear to be a major drug target for modulating several brain functions. Perampanel (PER) is a highly selective, noncompetitive AMPA antagonist approved in several countries worldwide for treating different types of seizures in various epileptic conditions. However, recent data show that PER can potentially address many other conditions within epilepsy and beyond. From this perspective, this review aims to examine the new preclinical and clinical studies-especially those produced from 2017 onwards-on AMPA antagonism and PER in conditions such as mesial temporal lobe epilepsy, idiopathic and genetic generalized epilepsy, brain tumor-related epilepsy, status epilepticus, rare epileptic syndromes, stroke, sleep, epilepsy-related migraine, cognitive impairment, autism, dementia, and other neurodegenerative diseases, as well as provide suggestions on future research agenda aimed at probing the possibility of treating these conditions with PER and/or other AMPA receptor antagonists.
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Affiliation(s)
| | - Cinzia Costa
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Neurological Clinic, S. Maria Della Misericordia Hospital, Perugia, Italy
| | - Angelo Labate
- Neurophysiopatology and Movement Disorders Clinic, University of Messina, Messina, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Claudio Liguori
- Department of Systems Medicine, University of Rome ‘Tor Vergata”, Rome, Italy
- Epilepsy Center, Neurology Unit, University Hospital “Tor Vergata”, Rome, Italy
| | - Marta Maschio
- Center for Tumor-Related Epilepsy, UOSD Neuro-Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Stefano Meletti
- Neurology Department, University Hospital of Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Lino Nobili
- Child Neuropsychiatry Unit, IRCCS Istituto G. Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Child and Maternal Health (DINOGMI), University of Genova, Genova, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
- Department of Science of Health, School of Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Andrea Romigi
- Sleep Medicine Center, Neurological Mediterranean Institute IRCCS Neuromed, Pozzilli, Italy
- Psychology Faculty, International Telematic University Uninettuno, Rome, Italy
| | - Emilio Russo
- Department of Science of Health, School of Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Carlo Di Bonaventura
- Epilepsy Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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Maeda A, Neshige S, Katsumata R, Nonaka M, Ishibashi H, Maruyama H. Exacerbation of Repetitive Falls Due to Atonic Seizures Following Perampanel Administration. Cureus 2023; 15:e40818. [PMID: 37485229 PMCID: PMC10362973 DOI: 10.7759/cureus.40818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
A 47-year-old man presented with tonic-clonic seizures characterized by convulsions. He repeatedly exhibited seizures despite treatment with four anti-seizure medications. During the titration process of perampanel (PER), the seizures paradoxically increased in intensity and frequency, resulting in trauma. Video electroencephalogram monitoring revealed interictal rapid rhythms and generalized spikes and documented atonic seizures. Thus, the patient was diagnosed with Lennox-Gastaut syndrome. Upon discontinuation of PER, the patient's atonic seizures with falls improved, probably suggesting a paradoxical effect of PER. A non-competitive antagonist selective for AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptors may have caused the weakness and delayed recovery from prolonged atonia that caused injuries.
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Affiliation(s)
- Akiko Maeda
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, JPN
| | - Shuichiro Neshige
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, JPN
| | - Riho Katsumata
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, JPN
| | - Megumi Nonaka
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Hiroshima, JPN
| | - Haruka Ishibashi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, JPN
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, JPN
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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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Besag FMC, Vasey MJ, Chin RFM. Current and emerging pharmacotherapy for the treatment of Lennox-Gastaut syndrome. Expert Opin Pharmacother 2023; 24:1249-1268. [PMID: 37212330 DOI: 10.1080/14656566.2023.2215924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Lennox-Gastaut syndrome (LGS) is a severe childhood-onset epileptic encephalopathy, characterized by multiple seizure types, generalized slow spike-and-wave complexes in the EEG, and cognitive impairment. Seizures in LGS are typically resistant to treatment with antiseizure medications (ASMs). Tonic/atonic ('drop') seizures are of particular concern, due to their liability to cause physical injury. AREAS COVERED We summarize evidence for current and emerging ASMs for the treatment of seizures in LGS. The review focuses on findings from randomized, double-blind, placebo-controlled trials (RDBCTs). For ASMs for which no double-blind trials were identified, lower quality evidence was considered. Novel pharmacological agents currently undergoing investigation for the treatment of LGS are also briefly discussed. EXPERT OPINION Evidence from RDBCTs supports the use of cannabidiol, clobazam, felbamate, fenfluramine, lamotrigine, rufinamide, and topiramate as adjunct treatments for drop seizures. Percentage decreases in drop seizure frequency ranged from 68.3% with high-dose clobazam to 14.8% with topiramate. Valproate continues to be considered the first-line treatment, despite the absence of RDBCTs specifically in LGS. Most individuals with LGS will require treatment with multiple ASMs. Treatment decisions should be individualized and take into account adverse effects, comorbidities, general quality of life, and drug interactions, as well as individual efficacy.
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Affiliation(s)
- Frank M C Besag
- East London NHS Foundation Trust, Bedford, UK
- School of Pharmacy, University College London, London, UK
- Department of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, The University of Edinburgh, Edinburgh, UK
- Department of Paediatric Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
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Effectiveness and tolerability of adjunctive perampanel in the treatment of pediatric patients with uncontrolled epilepsy: A retrospective, single-center, real-world study. Epilepsy Behav 2022; 137:108961. [PMID: 36327645 DOI: 10.1016/j.yebeh.2022.108961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/06/2022] [Accepted: 10/15/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The main aim of this study was to assess the efficacy, safety, and tolerability of adjunctive perampanel (PER) in the treatment of children and adolescents with epilepsy. METHODS Pediatric patients who visited the pediatric epilepsy clinic of Henan Provincial People's Hospital between May 2020 and December 2021 were recruited. All participants were treated with PER as adjunctive therapy and were seen routinely (minimum: a baseline and 12-week visit). The efficacy and tolerability of adjunctive PER for the treatment of epilepsy were investigated. RESULTS One hundred and fourteen patients were enrolled, among whom 7 (6.1%) were lost to follow-up. At 12 weeks, the responder rate and the seizure-free rate were 56.1% (60/107) and 32.7% (35/107), respectively. The responder rate increased with the duration of PER administration and was significantly higher when PER was used as an early add-on (after ≤2 prior antiseizure medications (ASMs)) than a late add-on (after >2 prior ASMs). However, there was no significant difference in the treatment efficacy of adjunctive PER in patients with different epilepsy etiologies or types. Adverse events, including irritability, dizziness, somnolence, ataxic gait, weight gain, and tinnitus, were reported in thirty-two patients (29.9%). CONCLUSIONS In a routine clinical setting of pediatric patients with epilepsy, good effectiveness and tolerability of adjunctive PER were demonstrated. Notably, patients initiating PER as an early add-on showed a better seizure outcome than those initiating PER as a late add-on.
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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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Rabinowicz S, Schreiber T, Heimer G, Bar-Yosef O, Nissenkorn A, E ZD, Arkush L, Hamed N, Ben-Zeev B, Tzadok M. Felbamate for pediatric epilepsy—should we keep on using it as the last resort? Front Neurol 2022; 13:979725. [PMID: 36203978 PMCID: PMC9530252 DOI: 10.3389/fneur.2022.979725] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionConcerns regarding felbamate adverse effects restrict its widespread use in children with drug-resistant epilepsy. We aimed to examine the efficacy and safety of felbamate in those children and identify the ones who may benefit most from its use.MethodsWe retrospectively reviewed the medical files of all patients who were treated with felbamate in a tertiary pediatric epilepsy clinic between 2009–2021. Drug efficacy was determined at the first 3 months of treatment and thereafter. Therapeutic response and adverse reactions were monitored throughout the course of treatment.ResultsOur study included 75 children (age 8.9 ± 3.7 years), of whom 53 were treated with felbamate for seizures, 16 for electrical status epilepticus during sleep and 6 for both. The median follow-up time was 16 months (range 1–129 months). The most common cause for epilepsy was genetic (29%). The median number of previous anti-seizure medications was six [4–8]. A therapeutic response ≥50% was documented in 37 (51%) patients, and a complete response in 9 (12%). Nineteen patients (25%) sustained adverse reactions, including three cases of elevated liver enzymes and one case of neutropenia with normal bone marrow aspiration. In all cases, treatment could be continued. All children with intractable epilepsy following herpes encephalitis showed a response to felbamate.ConclusionFelbamate is an efficacious and safe anti-seizure medication in the pediatric population.
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Affiliation(s)
- Shira Rabinowicz
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- *Correspondence: Shira Rabinowicz
| | - Tal Schreiber
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gali Heimer
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer Bar-Yosef
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Andreea Nissenkorn
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar-Dayan E
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Leo Arkush
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nasrin Hamed
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Bruria Ben-Zeev
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Tzadok
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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10
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Alonso-Singer P, Aguilar-Amat Prior MJ, Oliva-Navarro J, Massot-Tarrús A, Giráldez BG, Bermejo P, DeToledo-Heras M, Aledo-Serrano Á, Martínez-Cayuelas E, Tirado-Requero P, Velázquez-Fragua R, López-Sobrino G, Ojeda J. Perampanel as adjuvant treatment in epileptic encephalopathies: A multicenter study in routine clinical practice. Epilepsy Behav 2022; 134:108836. [PMID: 35870432 DOI: 10.1016/j.yebeh.2022.108836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/13/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Developmental and epileptic encephalopathies (DEEs) are a heterogeneous group of syndromes, including Lennox-Gastaut syndrome (LGS), which are refractory to multiple therapies. Perampanel efficacy has been reported in LGS but further real-world evidence is needed in DEEs. METHODS A multicenter, retrospective, 1-year observational study in patients with DEEs on adjuvant perampanel treatment was conducted to assess perampanel safety and effectiveness in this type of patients in a real-world setting. Seizure types [focal onset seizures (FOS), generalized tonic-clonic seizures (GTCS), tonic seizures (TS), atonic seizures (AtS), atypical absences (AA), and myoclonic seizures (MS)] and seizure clusters were divided in different frequency groups: daily, weekly, and monthly seizures, and absent or seizure freedom. Patients could have more than one seizure type. For each frequency group, group change and seizure freedom were analyzed. RESULTS Eighty-seven patients diagnosed with DEEs (45 males) of median age 22 [1-70] years were included. The most frequent DEEs were LGS (35.6%) and Lennox-like syndrome (37.9%). At baseline 20 patients had three to five types of seizures, 36 patients had two types of seizures and 31 patients had one predominant type of seizure. The mean number of seizure types per patient at baseline was 2.12 ± 0.97 which was reduced to 1.62 ± 0.91 at 12 months (p < 0.001). Overall, 51.7% of patients had a significant improvement in at least one seizure type. At baseline, 45 patients had GTCS, 42 FOS, 41 TS, 18 AA, 16 AtS, 11 MS, and 30 seizures clusters. Seizure freedom for each specific type at 12 months was significantly achieved by 35% of patients with GTCS (p < 0.001), 17% (p = 0.016) with TS and 37% with seizure clusters (p < 0.001). Patients achieved seizure freedom from other seizure types but with no statistical significance: 7% FOS-free, 28% AA-free, 6% Ats-free, and 18% MS-free. Regarding changes of group at 12 months, 22% of TS and 19% of FOS improved significantly to a group with lower seizure frequency (p = 0.004 and p = 0.02, respectively). In remaining groups (4% of GTCS, 11% of AA, 18% of Ats, 18% of MS, and 13% of seizure clusters), the improvement was not statistically significant. Twenty-nine patients discontinued perampanel: 18 (21%) due to AEs, 8 (9%) due to lack of efficacy, and 3 (3%) due to seizure worsening. Adverse events, mostly mild or moderate, were reported in 53% of patients, and irritability/mood changes (22%) and somnolence (17%) were the most frequent. CONCLUSION This is the first large-scale real-world study with perampanel across different seizure types in patients with DEEs. Perampanel was effective, especially in GTCS, TS, and FOS, as well as in seizure clusters. Perampanel was generally well-tolerated without unexpected AEs.
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Affiliation(s)
- Pablo Alonso-Singer
- Epilepsy Unit, Neurology Service, University Hospital La Paz, Madrid, Spain.
| | | | | | - Andreu Massot-Tarrús
- Epilepsy Unit, Department of Neurology, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Beatriz G Giráldez
- Epilepsy Unit, Neurology Service, University Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Pedro Bermejo
- Epilepsy Unit, University Hospital Puerta de Hierro, Majadahonda, Spain
| | | | - Ángel Aledo-Serrano
- Epilepsy Program, Department of Neurology, Ruber Internacional Hospital, Madrid, Spain
| | | | | | | | | | - Joaquín Ojeda
- Neurology Unit, University Hospital Infanta Sofía, Madrid, Spain
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11
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Yoshida S, Amamoto M, Takahashi T, Tomita I, Yuge K, Hara M, Iwama K, Matsumoto N, Matsuishi T. Perampanel markedly improved clinical seizures in a patient with a Rett‐like phenotype and 960‐kb deletion on chromosome 9q34.11 including the
STXBP1. Clin Case Rep 2022; 10:e05811. [PMID: 35600024 PMCID: PMC9107918 DOI: 10.1002/ccr3.5811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
Intractable epilepsy was successfully controlled using perampanel, an α‐amino‐3‐hydroxy‐5‐methyl‐4‐isoxazole propionic acid‐type glutamate receptor antagonist, in a 27‐year‐old woman who presented with a Rett syndrome‐like phenotype and novel 960‐kb deletion involving syntaxin‐binding protein 1 on chromosome 9q34.11. Perampanel may be an effective antiepileptic drug for intractable epilepsy associated with STXBP1 mutations.
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Affiliation(s)
- Syun Yoshida
- Children’s Medical Center Kitakyushu City Yahata Hospital Kitakyushu Japan
| | - Masano Amamoto
- Children’s Medical Center Kitakyushu City Yahata Hospital Kitakyushu Japan
| | - Tomoyuki Takahashi
- Division of Gene Therapy and Regenerative Medicine Cognitive and Molecular Research Institute of Brain Diseases Kurume University School of Medicine Kurume Japan
| | - Ichiro Tomita
- Children’s Medical Center Kitakyushu City Yahata Hospital Kitakyushu Japan
| | - Kotaro Yuge
- Department of Pediatrics and Child Health Kurume University School of Medicine Fukuoka Japan
| | - Munetsugu Hara
- Department of Pediatrics and Child Health Kurume University School of Medicine Fukuoka Japan
| | - Kazuhiro Iwama
- Department of Human Genetics Graduate School of Medicine Yokohama City University Kanagawa Japan
| | - Naomichi Matsumoto
- Department of Human Genetics Graduate School of Medicine Yokohama City University Kanagawa Japan
| | - Toyojiro Matsuishi
- Division of Gene Therapy and Regenerative Medicine Cognitive and Molecular Research Institute of Brain Diseases Kurume University School of Medicine Kurume Japan
- Research Center for Children and Research Center for Rett Syndrome St. Mary’s Hospital Fukuoka Japan
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12
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Devi N, Madaan P, Ameen R, Sahu JK, Bansal D. Short-term and long-term efficacy and safety of antiseizure medications in Lennox Gastaut syndrome: a network meta-analysis. Seizure 2022; 99:164-175. [DOI: 10.1016/j.seizure.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/17/2022] Open
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13
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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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