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Malmberg C, Värendh M, Berling P, Charokopou M, Eklund E. Cost Effectiveness of Adding Fenfluramine to Standard of Care for Patients with Dravet Syndrome in Sweden. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:543-554. [PMID: 38758509 DOI: 10.1007/s40258-024-00886-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE This study evaluated, in a Swedish setting, the cost effectiveness of fenfluramine (FFA) as an add-on to standard of care (SoC) for reducing seizure frequency in Dravet syndrome, a severe developmental epileptic encephalopathy. METHODS Cost effectiveness of FFA+SoC compared with SoC only was evaluated using a patient-level simulation model with a lifetime horizon. Patient characteristics and treatment effects, including convulsive seizures, seizure-free days and mortality, were derived from FFA clinical trials. Resource use and costs included cost of drug acquisition, routine care and monitoring, as well as ongoing and emergency resources. Quality of life (QoL) estimates for patients and their caregivers were derived from clinical trial data. Robustness was evaluated by one-way sensitivity analysis, probabilistic sensitivity analysis and scenario analyses. RESULTS Lifetime cost of FFA+SoC was ~3 million SEK per patient compared with ~1.5 million SEK for SoC only. FFA+SoC generated 15% more QALYs than SoC only (21.2 vs 18.5 over a lifetime), resulting in an incremental cost-effectiveness ratio (ICER) of ~540,000 SEK. Moreover, FFA+SoC had a higher probability of being cost effective than SoC only from a willingness-to-pay threshold of 710,000 SEK. Results remained generally consistent across scenario analyses, with only few exceptions (exclusions of carer utility or FFA effect on sudden unexpected death in epilepsy). CONCLUSION Due to better seizure control, FFA is a clinically meaningful add-on therapy and was estimated to be a cost-effective addition to current SoC for patients with this rare disease in Sweden at a willingness-to-pay threshold of 1,000,000 SEK.
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Affiliation(s)
- Chiara Malmberg
- The Swedish Institute for Health Economics (IHE), Lund, Sweden.
| | - Magnus Värendh
- The Swedish Institute for Health Economics (IHE), Lund, Sweden
| | | | | | - Erik Eklund
- Clinical Sciences, Pediatric Neurology, Lund University, Lund, Sweden
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Guo J, Min D, Farrell EK, Zhou Y, Faingold CL, Cotten JF, Feng HJ. Enhancing the action of serotonin by three different mechanisms prevents spontaneous seizure-induced mortality in Dravet mice. Epilepsia 2024; 65:1791-1800. [PMID: 38593237 PMCID: PMC11166528 DOI: 10.1111/epi.17966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is an underestimated complication of epilepsy. Previous studies have demonstrated that enhancement of serotonergic neurotransmission suppresses seizure-induced sudden death in evoked seizure models. However, it is unclear whether elevated serotonin (5-HT) function will prevent spontaneous seizure-induced mortality (SSIM), which is characteristic of human SUDEP. We examined the effects of 5-HT-enhancing agents that act by three different pharmacological mechanisms on SSIM in Dravet mice, which exhibit a high incidence of SUDEP, modeling human Dravet syndrome. METHODS Dravet mice of both sexes were evaluated for spontaneous seizure characterization and changes in SSIM incidence induced by agents that enhance 5-HT-mediated neurotransmission. Fluoxetine (a selective 5-HT reuptake inhibitor), fenfluramine (a 5-HT releaser and agonist), SR 57227 (a specific 5-HT3 receptor agonist), or saline (vehicle) was intraperitoneally administered over an 8-day period in Dravet mice, and the effect of these treatments on SSIM was examined. RESULTS Spontaneous seizures in Dravet mice generally progressed from wild running to tonic seizures with or without SSIM. Fluoxetine at 30 mg/kg, but not at 20 or 5 mg/kg, significantly reduced SSIM compared with the vehicle control. Fenfluramine at 1-10 mg/kg, but not .2 mg/kg, fully protected Dravet mice from SSIM, with all mice surviving. Compared with the vehicle control, SR 57227 at 20 mg/kg, but not at 10 or 5 mg/kg, significantly lowered SSIM. The effect of these drugs on SSIM was independent of sex. SIGNIFICANCE Our data demonstrate that elevating serotonergic function by fluoxetine, fenfluramine, or SR 57227 significantly reduces or eliminates SSIM in Dravet mice in a sex-independent manner. These findings suggest that deficits in serotonergic neurotransmission likely play an important role in the pathogenesis of SSIM, and fluoxetine and fenfluramine, which are US Food and Drug Administration-approved medications, may potentially prevent SUDEP in at-risk patients.
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Affiliation(s)
- Jialing Guo
- National Health Commission Key Laboratory of Birth Defect Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Daniel Min
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Emory K. Farrell
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Yupeng Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Carl L. Faingold
- Department of Pharmacology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Joseph F. Cotten
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Hua-Jun Feng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
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Del Pozo A, Knox KM, Lehmann LM, Davidson S, Rho SL, Jayadev S, Barker-Haliski M. Chronic evoked seizures in young pre-symptomatic APP/PS1 mice induce serotonin changes and accelerate onset of Alzheimer's disease-related neuropathology. Prog Neurobiol 2024; 235:102591. [PMID: 38484965 PMCID: PMC11015961 DOI: 10.1016/j.pneurobio.2024.102591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE Hyperexcitability is intimately linked to Alzheimer's disease (AD) pathology, but the precise timing and contributions of neuronal hyperexcitability to disease progression is unclear. Seizure induction in rodent AD models can uncover new therapeutic targets. Further, investigator-evoked seizures can directly establish how hyperexcitability and AD-associated risk factors influence neuropathological hallmarks and disease course at presymptomatic stages. METHODS Corneal kindling is a well-characterized preclinical epilepsy model that allows for precise control of seizure history to pair to subsequent behavioral assessments. 2-3-month-old APP/PS1, PSEN2-N141I, and transgenic control male and female mice were thus sham or corneal kindled for 2 weeks. Seizure-induced changes in glia, serotonin pathway proteins, and amyloid β levels in hippocampus and prefrontal cortex were quantified. RESULTS APP/PS1 females were more susceptible to corneal kindling. However, regardless of sex, APP/PS1 mice experienced extensive seizure-induced mortality versus kindled Tg- controls. PSEN2-N141I mice were not negatively affected by corneal kindling. Mortality correlated with a marked downregulation of hippocampal tryptophan hydroxylase 2 and monoamine oxidase A protein expression versus controls; these changes were not detected in PSEN2-N141I mice. Kindled APP/PS1 mice also exhibited soluble amyloid β upregulation and glial reactivity without plaque deposition. SIGNIFICANCE Evoked convulsive seizures and neuronal hyperexcitability in pre-symptomatic APP/PS1 mice promoted premature mortality without pathological Aβ plaque deposition, whereas PSEN2-N141I mice were unaffected. Disruptions in serotonin pathway metabolism in APP/PS1 mice was associated with increased glial reactivity without Aβ plaque deposition, demonstrating that neuronal hyperexcitability in early AD causes pathological Aβ overexpression and worsens long-term outcomes through a serotonin-related mechanism.
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Affiliation(s)
- Aaron Del Pozo
- Center for Epilepsy Drug Discovery (CEDD), Department of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Kevin M Knox
- Center for Epilepsy Drug Discovery (CEDD), Department of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Leanne M Lehmann
- Center for Epilepsy Drug Discovery (CEDD), Department of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Stephanie Davidson
- Center for Epilepsy Drug Discovery (CEDD), Department of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Seongheon Leo Rho
- Center for Epilepsy Drug Discovery (CEDD), Department of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Suman Jayadev
- Department of Neurology, University of Washington, Seattle, WA 98195, USA
| | - Melissa Barker-Haliski
- Center for Epilepsy Drug Discovery (CEDD), Department of Pharmacy, University of Washington, Seattle, WA 98195, USA.
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Besag FMC, Vasey MJ, Chin RFM. Evaluating fenfluramine hydrochloride as an oral solution for the treatment of seizures associated with Lennox-Gastaut syndrome. Expert Rev Neurother 2024; 24:235-249. [PMID: 38315124 DOI: 10.1080/14737175.2024.2313548] [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: 12/01/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Lennox-Gastaut syndrome (LGS) is a severe childhood-onset developmental and epileptic encephalopathy characterized by treatment-refractory seizures, including tonic/atonic 'drop' seizures, and intellectual impairment and slow spike-wave discharges on the electroencephalogram. Fenfluramine, previously prescribed as a weight-loss drug but then withdrawn, has recently been approved in the US, EU, and UK for the adjunct treatment of seizures associated with LGS. AREAS COVERED The authors review the efficacy and safety findings from clinical trials of fenfluramine in LGS. The authors then discuss the evidence for adverse effects that may be of particular concern to fenfluramine, namely cardiac abnormalities, and weight loss, in the context of the use of fenfluramine for the treatment of the refractory seizures in LGS. EXPERT OPINION Fenfluramine has demonstrated efficacy in reducing the frequency of seizures in LGS, notably drop seizures, in short-term and long-term clinical trials. Valvular heart disease and pulmonary hypertension have not been reported at the low doses (≤26 mg/day) used in these studies, however, data are limited. Due to its novel mechanism of action, fenfluramine may be of benefit in LGS which has not responded adequately to other antiseizure medications. However, none of these medications, including fenfluramine, achieves the ultimate goal of seizure freedom in most cases.
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Affiliation(s)
- Frank M C Besag
- Child and Adolescent Mental Health Services (CAMHS), East London NHS Foundation Trust, Bedford, UK
- School of Pharmacy, University College London, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michael J Vasey
- Child and Adolescent Mental Health Services (CAMHS), East London NHS Foundation Trust, Bedford, UK
| | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, The University of Edinburgh, Edinburgh, UK
- Department of Paediatric Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
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Strzelczyk A, Becker H, Tako L, Hock S, Hattingen E, Rosenow F, Mann C. Fenfluramine for the treatment of status epilepticus: use in an adult with Lennox-Gastaut syndrome and literature review. Neurol Res Pract 2024; 6:10. [PMID: 38383582 PMCID: PMC10882814 DOI: 10.1186/s42466-023-00306-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Novel treatments are needed to control refractory status epilepticus (SE). This study aimed to assess the potential effectiveness of fenfluramine (FFA) as an acute treatment option for SE. We present a summary of clinical cases where oral FFA was used in SE. METHODS A case of an adult patient with Lennox-Gastaut syndrome (LGS) who was treated with FFA due to refractory SE is presented in detail. To identify studies that evaluated the use of FFA in SE, we performed a systematic literature search. RESULTS Four case reports on the acute treatment with FFA of SE in children and adults with Dravet syndrome (DS) and LGS were available. We report in detail a 30-year-old woman with LGS of structural etiology, who presented with generalized tonic and dialeptic seizures manifesting at high frequencies without a return to clinical baseline constituting the diagnosis of SE. Treatment with anti-seizure medications up to lacosamide 600 mg/d, brivaracetam 300 mg/d, valproate 1,600 mg/d, and various benzodiazepines did not resolve the SE. Due to ongoing refractory SE and following an unremarkable echocardiography, treatment was initiated with FFA, with an initial dose of 10 mg/d (0.22 mg/kg body weight [bw]) and fast up-titration to 26 mg/d (0.58 mg/kg bw) within 10 days. Subsequently, the patient experienced a resolution of SE within 4 days, accompanied by a notable improvement in clinical presentation and regaining her mobility, walking with the assistance of physiotherapists. In the three cases reported in the literature, DS patients with SE were treated with FFA, and a cessation of SE was observed within a few days. No treatment-emergent adverse events were observed during FFA treatment in any of the four cases. CONCLUSIONS Based on the reported cases, FFA might be a promising option for the acute treatment of SE in patients with DS and LGS. Observational data show a decreased SE frequency while on FFA, suggesting a potentially preventive role of FFA in these populations. KEY POINTS We summarize four cases of refractory status epilepticus (SE) successfully treated with fenfluramine. Refractory SE resolved after 4-7 days on fenfluramine. Swift fenfluramine up-titration was well-tolerated during SE treatment. Treatment-emergent adverse events on fenfluramine were not observed. Fenfluramine might be a valuable acute treatment option for SE in Dravet and Lennox-Gastaut syndromes.
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Affiliation(s)
- Adam Strzelczyk
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.
| | - Hendrik Becker
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
| | - Lisa Tako
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
| | - Susanna Hock
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
| | - Elke Hattingen
- Goethe-University Frankfurt, Department of Neuroradiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
| | - Catrin Mann
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
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Pietrafusa N, Trivisano M, Casellato S, Correale C, Cappelletti S, De Liso P, Onida I, Sotgiu S, Butera A, Specchio N, Vigevano F. Fenfluramine below the age of 2 years in Dravet syndrome: What about safety and efficacy? Epilepsia 2024; 65:e7-e13. [PMID: 38065833 DOI: 10.1111/epi.17854] [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: 11/03/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/22/2023]
Abstract
Dravet syndrome (DS) is a rare developmental and epileptic encephalopathy. Infants with DS are especially vulnerable to the detrimental effects of prolonged and frequent seizures on development. Fenfluramine (FFA) is approved for the treatment of DS in patients aged 2 years and older. This study aims to evaluate the safety and efficacy of FFA in patients with DS younger than 2 years. We analyzed safety, tolerability, seizure, and neuropsychological outcome in a real-world setting. Developmental profile was investigated using Griffiths Mental Development Scales (GMDS). Five patients received FFA at a mean age of 14.9 months (9.6-18.6). Median follow-up was 13 months (interquartile range [IQR] = 12.9-24.4). All patients showed good tolerance to FFA. No significant variation of body mass index or echocardiographic issue was observed. Monthly median convulsive seizure frequency (MCSF) was 1.71 (IQR = 1.56-3.27) at the 6-month baseline period and .92 (IQR = .43-1.28) at last follow-up, with a median 54.43 (IQR = 40.91-60.83) percentage reduction in MCSF. Two of five patients had a performance improvement on GMDS subscales. Overall, the use of FFA below the age of 2 years in our small sample of patients was safe and represents a promising opportunity for seizure control and for protection of the neurodevelopmental outcome.
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Affiliation(s)
- Nicola Pietrafusa
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marina Trivisano
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Susanna Casellato
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Cinzia Correale
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Cappelletti
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola De Liso
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ilaria Onida
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Stefano Sotgiu
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Ambra Butera
- Neurology and Child Psychiatry Unit, Gaetano Barresi Department of Human Pathology of Adulthood and Development, University of Messina, Messina, Italy
| | - Nicola Specchio
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federico Vigevano
- Neurological Sciences and Rehabilitation Medicine Scientific Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Cha J, Filatov G, Smith SJ, Gammaitoni AR, Lothe A, Reeder T. Fenfluramine increases survival and reduces markers of neurodegeneration in a mouse model of Dravet syndrome. Epilepsia Open 2024; 9:300-313. [PMID: 38018342 PMCID: PMC10839300 DOI: 10.1002/epi4.12873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVE In patients with Dravet syndrome (DS), fenfluramine reduced convulsive seizure frequency and provided clinical benefit in nonseizure endpoints (e.g., executive function, survival). In zebrafish mutant scn1 DS models, chronic fenfluramine treatment preserved neuronal cytoarchitecture prior to seizure onset and prevented gliosis; here, we extend these findings to a mammalian model of DS (Scn1a+/- mice) by evaluating the effects of fenfluramine on neuroinflammation (degenerated myelin, activated microglia) and survival. METHODS Scn1a+/- DS mice were treated subcutaneously once daily with fenfluramine (15 mg/kg) or vehicle from postnatal day (PND) 7 until 35-37. Sagittal brain sections were processed for immunohistochemistry using antibodies to degraded myelin basic protein (D-MBP) for degenerated myelin, or CD11b for activated (inflammatory) microglia; sections were scored semi-quantitatively. Apoptotic nuclei were quantified by TUNEL assay. Statistical significance was evaluated by 1-way ANOVA with post-hoc Dunnett's test (D-MBP, CD11b, and TUNEL) or Logrank Mantel-Cox (survival). RESULTS Quantitation of D-MBP immunostaining per 0.1 mm2 unit area of the parietal cortex and hippocampus CA3 yielded significantly higher spheroidal and punctate myelin debris counts in vehicle-treated DS mice than in wild-type mice. Fenfluramine treatment in DS mice significantly reduced these counts. Activated CD11b + microglia were more abundant in DS mouse corpus callosum and hippocampus than in wild-type controls. Fenfluramine treatment of DS mice resulted in significantly fewer activated CD11b + microglia than vehicle-treated DS mice in these brain regions. TUNEL staining in corpus callosum was increased in DS mice relative to wild-type controls. Fenfluramine treatment in DS mice lowered TUNEL staining relative to vehicle-treated DS mice. By PND 35-37, 55% of control DS mice had died, compared with 24% of DS mice receiving fenfluramine treatment (P = 0.0291). SIGNIFICANCE This is the first report of anti-neuroinflammation and pro-survival after fenfluramine treatment in a mammalian DS model. These results corroborate prior data in humans and animal models and suggest important pharmacological activities for fenfluramine beyond seizure reduction. PLAIN LANGUAGE SUMMARY Dravet syndrome is a severe epilepsy disorder that impairs learning and causes premature death. Clinical studies in patients with Dravet syndrome show that fenfluramine reduces convulsive seizures. Additional studies suggest that fenfluramine may have benefits beyond seizures, including promoting survival and improving control over emotions and behavior. Our study is the first to use a Dravet mouse model to investigate nonseizure outcomes of fenfluramine. Results showed that fenfluramine treatment of Dravet mice reduced neuroinflammation significantly more than saline treatment. Fenfluramine-treated Dravet mice also lived longer than saline-treated mice. These results support clinical observations that fenfluramine may have benefits beyond seizures.
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Affiliation(s)
- John Cha
- University of California San FranciscoSan FranciscoCaliforniaUSA
- Zogenix, Inc. (now a part of UCB)EmeryvilleCaliforniaUSA
| | - Gregory Filatov
- Zogenix, Inc. (now a part of UCB)EmeryvilleCaliforniaUSA
- Crosshair Therapeutics, Inc.SunnyvaleCaliforniaUSA
| | - Steven J. Smith
- Zogenix, Inc. (now a part of UCB)EmeryvilleCaliforniaUSA
- WuXi AppTec, Inc.San FranciscoCaliforniaUSA
| | | | | | - Thadd Reeder
- Zogenix, Inc. (now a part of UCB)EmeryvilleCaliforniaUSA
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Simeone KA, Martenz DM, Iyer SH, Booth CP, Herr SE, Matthews SA, Draves SB, Heinemann LL, Greenberg PL, Lhatoo SD, Donner E, Simeone TA. Personalization of SUDEP risk: A survey of transient subclinical comorbid changes. Epilepsy Res 2024; 199:107259. [PMID: 38086218 DOI: 10.1016/j.eplepsyres.2023.107259] [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: 05/07/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE Preclinical data report within subject modifiable ailments emerge weeks prior to SUDEP, including sleep disorders and cardiorespiratory changes; findings which support anecdotal clinical data. Here, we bridge preclinical findings with future clinical/preclinical studies, and survey whether caretakers or family members of victims noticed transient changes prior to SUDEP. The aim of this pilot study is to identify potential modifiable changes that may synergistically increase SUDEP risk for future research. METHODS A mobile electronic survey was posted on SUDEP community websites. The survey queried whether changes in seizures, sleep, physical well-being, emotional well-being, cognition, breathing, or heart rate were noticed before SUDEP. RESULTS The most profound finding was that 85% of victims had multiple transient ailments prior to SUDEP. Changes in seizures (28/54), and sleep (30/58) occurred in more than 50% of the victims and represent the most influential changes identified. The second and third most influential changes were a reduction in physical well-being (25/57) and emotional well-being (26/56). Changes were observed within the last two months of life in approximately one third of the cases, and more than four months prior to SUDEP in approximately one third of cases, indicating a potential time frame for proactive preventative strategies. Respondents also noted changes in cognition (16/55), breathing (9/54) or heart rate (8/55). Data indicate these changes may be associated with increased SUDEP risk within subject. Study limitations include the responses were based on memory, there was a potential for data to be over reported, and caretakers were not prompted to observe changes a priori, thus some existing changes may have gone unnoticed. SIGNIFICANCE Data support the preclinical findings that transient, subclinical (i.e., not severe enough to require medical intervention), modifiable ailments may increase risk of SUDEP. This suggests that just as an epilepsy type can change over a lifetime and epilepsy type-specific treatments can reduce SUDEP risk, further personalization of SUDEP risk will improve our understanding as to whether variables contribute to risk differently across lifespan. Thus, with a dynamic capacity to change, differing factors may contribute to the distribution of risk probability within an individual at any given time. Understanding whether different combinations of transient changes are specific to epilepsy type, age, or sex needs to be determined to move the field forward in hopes of developing a personalized approach to preventative strategies.
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Affiliation(s)
- Kristina A Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States.
| | | | - Shruthi H Iyer
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Cameron P Booth
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Shelby E Herr
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Stephanie A Matthews
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Samantha B Draves
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Laura L Heinemann
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Pierce L Greenberg
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Samden D Lhatoo
- Department of Neurology, University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, United States
| | - Elizabeth Donner
- Department of Paediatrics, Division of Neurology, Hospital for Sick Children, Canada
| | - Timothy A Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
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Fan HC, Yang MT, Lin LC, Chiang KL, Chen CM. Clinical and Genetic Features of Dravet Syndrome: A Prime Example of the Role of Precision Medicine in Genetic Epilepsy. Int J Mol Sci 2023; 25:31. [PMID: 38203200 PMCID: PMC10779156 DOI: 10.3390/ijms25010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024] Open
Abstract
Dravet syndrome (DS), also known as severe myoclonic epilepsy of infancy, is a rare and drug-resistant form of developmental and epileptic encephalopathies, which is both debilitating and challenging to manage, typically arising during the first year of life, with seizures often triggered by fever, infections, or vaccinations. It is characterized by frequent and prolonged seizures, developmental delays, and various other neurological and behavioral impairments. Most cases result from pathogenic mutations in the sodium voltage-gated channel alpha subunit 1 (SCN1A) gene, which encodes a critical voltage-gated sodium channel subunit involved in neuronal excitability. Precision medicine offers significant potential for improving DS diagnosis and treatment. Early genetic testing enables timely and accurate diagnosis. Advances in our understanding of DS's underlying genetic mechanisms and neurobiology have enabled the development of targeted therapies, such as gene therapy, offering more effective and less invasive treatment options for patients with DS. Targeted and gene therapies provide hope for more effective and personalized treatments. However, research into novel approaches remains in its early stages, and their clinical application remains to be seen. This review addresses the current understanding of clinical DS features, genetic involvement in DS development, and outcomes of novel DS therapies.
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Affiliation(s)
- Hueng-Chuen Fan
- Department of Pediatrics, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan;
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli 356, Taiwan
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan
| | - Ming-Tao Yang
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan;
- Department of Chemical Engineering and Materials Science, Yuan Ze University, Taoyuan 320, Taiwan
| | - Lung-Chang Lin
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Kuo-Liang Chiang
- Department of Pediatric Neurology, Kuang-Tien General Hospital, Taichung 433, Taiwan;
- Department of Nutrition, Hungkuang University, Taichung 433, Taiwan
| | - Chuan-Mu Chen
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan
- The iEGG and Animal Biotechnology Center, and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
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10
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Strzelczyk A, Lagae L, Wilmshurst JM, Brunklaus A, Striano P, Rosenow F, Schubert‐Bast S. Dravet syndrome: A systematic literature review of the illness burden. Epilepsia Open 2023; 8:1256-1270. [PMID: 37750463 PMCID: PMC10690674 DOI: 10.1002/epi4.12832] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023] Open
Abstract
We performed a systematic literature review and narrative synthesis according to a pre-registered protocol (Prospero: CRD42022376561) to identify the evidence associated with the burden of illness in Dravet syndrome (DS), a developmental and epileptic encephalopathy characterized by drug-resistant epilepsy with neurocognitive and neurobehavioral impairment. We searched MEDLINE, Embase, and APA PsychInfo, Cochrane's database of systematic reviews, and Epistemonikos from inception to June 2022. Non-interventional studies reporting on epidemiology (incidence, prevalence, and mortality), patient and caregiver health-related quality of life (HRQoL), direct and indirect costs and healthcare resource utilization were eligible. Two reviewers independently carried out the screening. Pre-specified data were extracted and a narrative synthesis was conducted. Overall, 49 studies met the inclusion criteria. The incidence varied from 1:15 400-1:40 900, and the prevalence varied from 1.5 per 100 000 to 6.5 per 100 000. Mortality was reported in 3.7%-20.8% of DS patients, most commonly due to sudden unexpected death in epilepsy and status epilepticus. Patient HRQoL, assessed by caregivers, was lower than in non-DS epilepsy patients; mean scores (0 [worst] to 100/1 [best]) were 62.1 for the Kiddy KINDL/Kid-KINDL, 46.5-54.7 for the PedsQL and 0.42 for the EQ-5D-5L. Caregivers, especially mothers, were severely affected, with impacts on their time, energy, sleep, career, and finances, while siblings were also affected. Symptoms of depression were reported in 47%-70% of caregivers. Mean total direct costs were high across all studies, ranging from $11 048 to $77 914 per patient per year (PPPY), with inpatient admissions being a key cost driver across most studies. Mean costs related to lost productivity were only reported in three publications, ranging from approximately $19 000 to $20 000 PPPY ($17 596 for mothers vs $1564 for fathers). High seizure burden was associated with higher resource utilization, costs and poorer HRQoL. The burden of DS on patients, caregivers, the healthcare system, and society is profound, reflecting the severe nature of the syndrome. Future studies will be able to assess the impact that newly approved therapies have on reducing the burden of DS.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
| | - Lieven Lagae
- Department of Development and RegenerationUniversity Hospitals KU LeuvenLeuvenBelgium
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience InstituteUniversity of Cape TownCape TownSouth Africa
| | - Andreas Brunklaus
- Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgowUK
- School of Health and WellbeingUniversity of GlasgowGlasgowUK
| | - Pasquale Striano
- IRCCS ‘G. Gaslini’ InstituteGenovaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenoaGenovaItaly
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
| | - Susanne Schubert‐Bast
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
- Department of NeuropediatricsGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
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11
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Sullivan J, Lagae L, Cross JH, Devinsky O, Guerrini R, Knupp KG, Laux L, Nikanorova M, Polster T, Talwar D, Ceulemans B, Nabbout R, Farfel GM, Galer BS, Gammaitoni AR, Lock M, Agarwal A, Scheffer IE. Fenfluramine in the treatment of Dravet syndrome: Results of a third randomized, placebo-controlled clinical trial. Epilepsia 2023; 64:2653-2666. [PMID: 37543865 DOI: 10.1111/epi.17737] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE This study was undertaken to assess the safety and efficacy of fenfluramine in the treatment of convulsive seizures in patients with Dravet syndrome. METHODS This multicenter, randomized, double-blind, placebo-controlled, parallel-group, phase 3 clinical trial enrolled patients with Dravet syndrome, aged 2-18 years with poorly controlled convulsive seizures, provided they were not also receiving stiripentol. Eligible patients who had ≥6 convulsive seizures during the 6-week baseline period were randomized to placebo, fenfluramine .2 mg/kg/day, or fenfluramine .7 mg/kg/day (1:1:1 ratio) administered orally (maximum dose = 26 mg/day). Doses were titrated over 2 weeks and maintained for an additional 12 weeks. The primary endpoint was a comparison of the monthly convulsive seizure frequency (MCSF) during baseline and during the combined titration-maintenance period in patients given fenfluramine .7 mg/kg/day versus patients given placebo. RESULTS A total of 169 patients were screened, and 143 were randomized to treatment. Mean age was 9.3 ± 4.7 years (±SD), 51% were male, and median baseline MCSF in the three groups ranged 12.7-18.0 per 28 days. Patients treated with fenfluramine .7 mg/kg/day demonstrated a 64.8% (95% confidence interval = 51.8%-74.2%) greater reduction in MCSF compared with placebo (p < .0001). Following fenfluramine .7 mg/kg/day, 72.9% of patients had a ≥50% reduction in MCSF compared with 6.3% in the placebo group (p < .0001). The median longest seizure-free interval was 30 days in the fenfluramine .7 mg/kg/day group compared with 10 days in the placebo group (p < .0001). The most common adverse events (>15% in any group) were decreased appetite, somnolence, pyrexia, and decreased blood glucose. All occurred in higher frequency in fenfluramine groups than placebo. No evidence of valvular heart disease or pulmonary artery hypertension was detected. SIGNIFICANCE The results of this third phase 3 clinical trial provide further evidence of the magnitude and durability of the antiseizure response of fenfluramine in children with Dravet syndrome.
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Affiliation(s)
- Joseph Sullivan
- University of California, San Francisco, San Francisco, California, USA
| | - Lieven Lagae
- Department of Pediatric Neurology, University of Leuven, Leuven, Belgium
| | - J Helen Cross
- University College London, National Institute for Health and Care Research Biomedical Research Centre, Great Ormond Street Institute of Child Health, London, UK
| | - Orrin Devinsky
- New York University Langone Medical Center, New York, New York, USA
| | - Renzo Guerrini
- Meyer Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Florence, Italy
| | - Kelly G Knupp
- University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Linda Laux
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Tilman Polster
- Department of Epileptology (Krankenhaus Mara, Bethel Epilepsy Center), Bielefeld University Medical School, Bielefeld, Germany
| | - Dinesh Talwar
- University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Berten Ceulemans
- Department of Pediatric Neurology, University of Antwerp, Edegem, Belgium
| | - Rima Nabbout
- Hôpital Universitaire Necker-Enfants Malades, Service de Neurologie Pédiatrique, Centre de Référence Épilepsies Rares, Imagine Institute, Institut National de la Santé et de la Recherche Médicale, Unite Mixté de Recherche 1163, Paris Descartes University, Paris, France
| | | | | | | | - Michael Lock
- Consultant biostatistician based in Haiku, Haiku, Hawaii, USA
| | | | - Ingrid E Scheffer
- University of Melbourne, Austin Health and Royal Children's Hospital, Melbourne, Victoria, Australia
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12
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Dini G, Di Cara G, Ferrara P, Striano P, Verrotti A. Reintroducing Fenfluramine as a Treatment for Seizures: Current Knowledge, Recommendations and Gaps in Understanding. Neuropsychiatr Dis Treat 2023; 19:2013-2025. [PMID: 37790801 PMCID: PMC10543412 DOI: 10.2147/ndt.s417676] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023] Open
Abstract
Despite the introduction of new anti-seizure medications in recent years, approximately one-third of the epileptic population continues to experience seizures. Recently, the anti-obesity medication fenfluramine (FFA) has been successfully repurposed, and it has received approval from various regulatory agencies for the treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome. The potential antiseizure effects of FFA were initially observed in patients with photosensitive epilepsy in the 1980s but it was not rigorously explored as a treatment option until 30 years later. This narrative review aims to provide an overview of the historical progression of FFA's use, starting from initial clinical observations to preclinical studies and, ultimately, successful clinical trials in the field of epilepsy.
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Affiliation(s)
- Gianluca Dini
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | | | - Pietro Ferrara
- Department of Pediatrics, Campus Bio-Medico University, Rome, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto “G. Gaslini”, Genoa, Italy
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13
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Perulli M, Scala I, Venditti R, Amadio A, Luigia Gambardella M, Quintiliani M, Contaldo I, Veredice C, Della Marca G, Brunetti V, Battaglia DI. Short- vs long-term assessment of heart rate variability: Clinical significance in Dravet Syndrome. Epilepsy Behav 2023; 146:109357. [PMID: 37499580 DOI: 10.1016/j.yebeh.2023.109357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Heart rate variability (HRV) is a promising prognostic biomarker in Dravet Syndrome (DS), but different studies are not always comparable, limiting its clinical application. In fact, multiple HRV parameters, analyzed over different timescales and in different states are reported. The aim of this study was to assess which HRV parameter is more reproducible and clinically significant, analyzing differences between wake and sleep. METHOD Patients with DS, with available 24 h-ECG Holter-derived HRV, were screened to evaluate if they had EEG-derived ECG traces available within one month before/after the Holter. A 5-minute period in the awake and sleep state were analyzed and correlated with the 24 h-HRV. Several relevant clinical features such as age, a recent history of status epilepticus (SE), and frequent generalized tonic-clonic seizures (GTCS) were correlated to HRV parameters with multiple linear regression models. RESULTS Thirty-oneawake recordings and 22 sleep recordings were included. HF was the parameter with the highest correlation in awake (Rho 0.745, p < 0.001) and in sleep (Rho 0.727, p < 0.001). Age was a significant factor in simple models for most of the parameters except RMSSD. A recent history of SE was associated with a significant reduction of HRV, both in simple and multiple regressions for all parameters except for awake LF and for sleep RMSSD and PNN50. Frequent GTCS were associated with a significant decrease in sleep RMSSD, HF, and LF, also when correcting for the effect of age and history of SE. When compared pairwise, a significant increase in sleep was seen for HF (median + 24.45 ms2, IQR -7.51/+172.18 ms2, p = 0.036; increase in 15/22 patients). CONCLUSION A moderate degree of correlation between long- and short-term HRV was seen both in sleep and in awake, and a strong correlation for awake HF. HF, both in awake and sleep, was significantly associated with high seizure burden, including SE and frequent GTCS.
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Affiliation(s)
- Marco Perulli
- Neuropsichiatria Infantile, Dipartimento di Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Irene Scala
- Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Scienze Dell'invecchiamento, Neurologiche, Ortopediche e Della Testa-collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Romina Venditti
- Neuropsichiatria Infantile, Dipartimento di Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Amadio
- Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Scienze Dell'invecchiamento, Neurologiche, Ortopediche e Della Testa-collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Luigia Gambardella
- Neuropsichiatria Infantile, Dipartimento di Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michela Quintiliani
- Neuropsichiatria Infantile, Dipartimento di Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ilaria Contaldo
- Neuropsichiatria Infantile, Dipartimento di Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Chiara Veredice
- Neuropsichiatria Infantile, Dipartimento di Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giacomo Della Marca
- Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Scienze Dell'invecchiamento, Neurologiche, Ortopediche e Della Testa-collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Brunetti
- Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Scienze Dell'invecchiamento, Neurologiche, Ortopediche e Della Testa-collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenica Immacolata Battaglia
- Neuropsichiatria Infantile, Dipartimento di Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
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14
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Sills GJ. Pharmacological diversity amongst approved and emerging antiseizure medications for the treatment of developmental and epileptic encephalopathies. Ther Adv Neurol Disord 2023; 16:17562864231191000. [PMID: 37655228 PMCID: PMC10467199 DOI: 10.1177/17562864231191000] [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: 02/20/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
Developmental and epileptic encephalopathies (DEEs) are rare neurodevelopmental disorders characterised by early-onset and often intractable seizures and developmental delay/regression, and include Dravet syndrome and Lennox-Gastaut syndrome (LGS). Rufinamide, fenfluramine, stiripentol, cannabidiol and ganaxolone are antiseizure medications (ASMs) with diverse mechanisms of action that have been approved for treating specific DEEs. Rufinamide is thought to suppress neuronal hyperexcitability by preventing the functional recycling of voltage-gated sodium channels from the inactivated to resting state. It is licensed for adjunctive treatment of seizures associated with LGS. Fenfluramine increases extracellular serotonin levels and may reduce seizures via activation of specific serotonin receptors and positive modulation of the sigma-1 receptor. Fenfluramine is licensed for adjunctive treatment of seizures associated with Dravet syndrome and LGS. Stiripentol is a positive allosteric modulator of type-A gamma-aminobutyric acid (GABAA) receptors. As a broad-spectrum inhibitor of cytochrome P450 enzymes, its antiseizure effects may additionally arise through pharmacokinetic interactions with co-administered ASMs. Stiripentol is licensed for treating seizures associated with Dravet syndrome in patients taking clobazam and/or valproate. The mechanism(s) of action of cannabidiol remains largely unclear although multiple targets have been proposed, including transient receptor potential vanilloid 1, G protein-coupled receptor 55 and equilibrative nucleoside transporter 1. Cannabidiol is licensed as adjunctive treatment in conjunction with clobazam for seizures associated with Dravet syndrome and LGS, and as adjunctive treatment of seizures associated with tuberous sclerosis complex. Like stiripentol, ganaxolone is a positive allosteric modulator at GABAA receptors. It has recently been licensed in the USA for the treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder. Greater understanding of the causes of DEEs has driven research into the potential use of other novel and repurposed agents. Putative ASMs currently in clinical development for use in DEEs include soticlestat, carisbamate, verapamil, radiprodil, clemizole and lorcaserin.
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Affiliation(s)
- Graeme J. Sills
- School of Life Sciences, University of Glasgow, Room 341, Sir James Black Building, Glasgow G12 8QQ, UK
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15
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Del Pozo A, Knox KM, Lehmann L, Davidson S, Rho S, Jayadev S, Barker-Haliski M. Chronic evoked seizures in young pre-symptomatic APP/PS1 mice induce serotonin changes and accelerate onset on Alzheimer's disease-related neurpathology. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.05.522897. [PMID: 36711965 PMCID: PMC9881977 DOI: 10.1101/2023.01.05.522897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE People with early-onset Alzheimer's disease (AD) are at elevated seizure risk. Further, chronic seizures in pre-symptomatic stages may disrupt serotonin pathway-related protein expression, precipitating the onset of AD-related pathology and burden of neuropsychiatric comorbidities. METHODS 2-3-month-old APP/PS1, PSEN2-N141I, and transgenic control mice were sham or corneal kindled for 2 weeks to model chronic seizures. Seizure-induced changes in glia, serotonin pathway proteins, and amyloid beta; levels in hippocampus and prefrontal cortex were quantified. RESULTS APP/PS1 mice experienced worsened mortality versus kindled Tg- controls. APP/PS1 females were also more susceptible to chronic kindled seizures. These changes correlated with a marked downregulation of hippocampal tryptophan hydroxylase 2 and monoamine oxidase A protein expression compared to controls; these changes were not detected in PSEN2-N141I mice. Kindled APP/PS1 mice exhibited amyloid beta; overexpression and glial overactivity without plaque deposition. PSEN2 protein expression was AD model-dependent. SIGNIFICANCE Seizures evoked in pre-symptomatic APP/PS1 mice promotes premature mortality in the absence of pathological amyloid deposition. Disruptions in serotonin pathway metabolism are associated with increased glial reactivity and PSEN2 downregulation without amyloid beta; deposition. This study provides the first direct evidence that seizures occurring prior to amyloid beta, plaque accumulation worsen disease burden in an AD genotype-specific manner.
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16
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Teran FA, Sainju RK, Bravo E, Wagnon J, Kim Y, Granner A, Gehlbach BK, Richerson GB. Seizures Cause Prolonged Impairment of Ventilation, CO 2 Chemoreception and Thermoregulation. J Neurosci 2023; 43:4959-4971. [PMID: 37160367 PMCID: PMC10324997 DOI: 10.1523/jneurosci.0450-23.2023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/24/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) has been linked to respiratory dysfunction, but the mechanisms underlying this association remain unclear. Here we found that both focal and generalized convulsive seizures (GCSs) in epilepsy patients caused a prolonged decrease in the hypercapnic ventilatory response (HCVR; a measure of respiratory CO2 chemoreception). We then studied Scn1a R1407X/+ (Dravet syndrome; DS) and Scn8a N1768D/+ (D/+) mice of both sexes, two models of SUDEP, and found that convulsive seizures caused a postictal decrease in ventilation and severely depressed the HCVR in a subset of animals. Those mice with severe postictal depression of the HCVR also exhibited transient postictal hypothermia. A combination of blunted HCVR and abnormal thermoregulation is known to occur with dysfunction of the serotonin (5-hydroxytryptamine; 5-HT) system in mice. Depleting 5-HT with para-chlorophenylalanine (PCPA) mimicked seizure-induced hypoventilation, partially occluded the postictal decrease in the HCVR, exacerbated hypothermia, and increased postictal mortality in DS mice. Conversely, pretreatment with the 5-HT agonist fenfluramine reduced postictal inhibition of the HCVR and hypothermia. These results are consistent with the previous observation that seizures cause transient impairment of serotonergic neuron function, which would be expected to inhibit the many aspects of respiratory control dependent on 5-HT, including baseline ventilation and the HCVR. These results provide a scientific rationale to investigate the interictal and/or postictal HCVR as noninvasive biomarkers for those at high risk of seizure-induced death, and to prevent SUDEP by enhancing postictal 5-HT tone.SIGNIFICANCE STATEMENT There is increasing evidence that seizure-induced respiratory dysfunction contributes to the pathophysiology of sudden unexpected death in epilepsy (SUDEP). However, the cellular basis of this dysfunction has not been defined. Here, we show that seizures impair CO2 chemoreception in some epilepsy patients. In two mouse models of SUDEP we found that generalized convulsive seizures impaired CO2 chemoreception, and induced hypothermia, two effects reported with serotonergic neuron dysfunction. The defects in chemoreception and thermoregulation were exacerbated by chemical depletion of serotonin and reduced with fenfluramine, suggesting that seizure-induced respiratory dysfunction may be due to impairment of serotonin neuron function. These findings suggest that impaired chemoreception because of transient inhibition of serotonergic neurons may contribute to the pathophysiology of SUDEP.
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Affiliation(s)
- Frida A Teran
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
- Medical Scientist Training Program, University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa 52242
| | - Rup K Sainju
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
| | - Eduardo Bravo
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa 52242
| | - Jacy Wagnon
- Department of Neuroscience, The Ohio State University, Columbus, Ohio 43210
| | - YuJaung Kim
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
| | - Alex Granner
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
| | - Brian K Gehlbach
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa 52242
| | - George B Richerson
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa 52242
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, Iowa 52242
- Neurology, Veterans Affairs Medical Center, Iowa City, Iowa 52242
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17
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Abstract
Fenfluramine (Fintepla®) is an oral anti-seizure medication (ASM) with a novel mechanism of action consisting of activity in the serotonergic system coupled with positive allosteric modulation effects at sigma-1 receptors. Originally approved for use at high doses as an appetite suppressant, it was subsequently withdrawn after being linked to valvular heart disease (VHD) and pulmonary arterial hypertension (PAH), before being investigated for use at low doses as an adjunctive ASM in patients with developmental epileptic encephalopathies, including Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) who have pharmacoresistant seizures. In clinical trials, treatment with adjunctive fenfluramine markedly reduced convulsive seizure frequency in patients with DS that were sustained for up to 3 years, and reduced drop seizure frequency in patients with LGS that were sustained for up to 1 year. Notably, fenfluramine was also associated with clinically meaningful improvements in aspects of everyday executive functioning (EF) not entirely explainable by seizure reduction alone. Furthermore, it was generally well tolerated with, importantly, no reports of VHD or PAH. Thus, adjunctive fenfluramine is a novel and effective treatment for pharmacoresistant seizures associated with DS and LGS that may also improve aspects of everyday EF in some patients.
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Affiliation(s)
- James E Frampton
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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18
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Li M, Yang L, Qian W, Ray S, Lu Z, Liu T, Zou YY, Naumann RK, Wang H. A novel rat model of Dravet syndrome recapitulates clinical hallmarks. Neurobiol Dis 2023:106193. [PMID: 37295561 DOI: 10.1016/j.nbd.2023.106193] [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: 03/24/2023] [Revised: 05/14/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Dravet syndrome (DS) is a debilitating infantile epileptic encephalopathy characterized by seizures induced by high body temperature (hyperthermia), sudden unexpected death in epilepsy (SUDEP), cognitive impairment, and behavioral disturbances. The most common cause of DS is haploinsufficiency of the SCN1A gene, which encodes the voltage-gated sodium channel Nav1.1. In current mouse models of DS, the epileptic phenotype is strictly dependent on the genetic background and most mouse models exhibit drastically higher SUDEP rates than patients. Therefore, we sought to develop an alternative animal model for DS. Here, we report the generation and characterization of a Scn1a halploinsufficiency rat model of DS by disrupting the Scn1a allele. Scn1a+/- rats show reduced Scn1a expression in the cerebral cortex, hippocampus and thalamus. Homozygous null rats die prematurely. Heterozygous animals are highly susceptible to heat-induced seizures, the clinical hallmark of DS, but are otherwise normal in survival, growth, and behavior without seizure induction. Hyperthermia-induced seizures activate distinct sets of neurons in the hippocampus and hypothalamus in Scn1a+/- rats. Electroencephalogram (EEG) recordings in Scn1a+/- rats reveal characteristic ictal EEG with high amplitude bursts with significantly increased delta and theta power. After the initial hyperthermia-induced seizures, non-convulsive, and convulsive seizures occur spontaneously in Scn1a+/- rats. In conclusion, we generate a Scn1a haploinsufficiency rat model with phenotypes closely resembling DS, providing a unique platform for establishing therapies for DS.
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Affiliation(s)
- Miao Li
- The Brain Cognition and Brain Disease Institute, Shenzhen-Hong Kong Institute of Brain Science, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; CAS Key Laboratory of Brain Connectome and Manipulation, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lixin Yang
- The Brain Cognition and Brain Disease Institute, Shenzhen-Hong Kong Institute of Brain Science, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; CAS Key Laboratory of Brain Connectome and Manipulation, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Weixin Qian
- CAS Key Laboratory of Brain Connectome and Manipulation, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Saikat Ray
- Department of Brain Sciences, Weizmann Institute of Science, Rehovot, Israel
| | - Zhonghua Lu
- The Brain Cognition and Brain Disease Institute, Shenzhen-Hong Kong Institute of Brain Science, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; CAS Key Laboratory of Brain Connectome and Manipulation, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Tao Liu
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Ying-Ying Zou
- Department of Pathology and Pathophysiology, Faculty of Basic Medical Sciences, Kunming Medical University, Kunming, China
| | - Robert K Naumann
- The Brain Cognition and Brain Disease Institute, Shenzhen-Hong Kong Institute of Brain Science, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; CAS Key Laboratory of Brain Connectome and Manipulation, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hong Wang
- The Brain Cognition and Brain Disease Institute, Shenzhen-Hong Kong Institute of Brain Science, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; CAS Key Laboratory of Brain Connectome and Manipulation, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; Shenzhen Key Laboratory of Drug Addiction, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.
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Klein P, Krauss GL, Steinhoff BJ, Devinsky O, Sperling MR. Failure to use new breakthrough treatments for epilepsy. Epilepsia 2023; 64:1458-1465. [PMID: 36855241 DOI: 10.1111/epi.17564] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/29/2023] [Accepted: 02/27/2023] [Indexed: 03/02/2023]
Abstract
Despite the approval of ~20 additional antiseizure medications (ASMs) since the 1980s, one-third of epilepsy patients experience seizures despite therapy. Drug-resistant epilepsy (DRE) is associated with cognitive and psychiatric comorbidities, socioeconomic impairment, injuries, and a 9.3-13.4 times higher mortality rate than in seizure-free patients. Improved seizure control can reduce morbidity and mortality. Two new ASMs were launched in the United States in 2020: cenobamate for focal epilepsy in adults and fenfluramine for Dravet syndrome (DS). They offer markedly improved efficacy. Cenobamate achieved 21% seizure freedom with the highest dose and decreased tonic-clonic seizures by 93% during maintenance treatment in a randomized clinical trial (RCT). In long-term, open-label studies, 10%-36% of patients were seizure-free for a median duration of ~30-45 months. Fenfluramine treatment in DS reduced convulsive seizure frequency by 56% over placebo at the highest dose, with 8% of patients free of convulsive seizures, and 25% with only one convulsive seizure over 14 weeks. These results were sustained for up to 3 years in open-label extension studies. Mortality was reduced 5-fold. These results are superior to all other approved ASMs, placing these two drugs among the most effective antiseizure therapies. The adverse event profiles resemble those of other ASMs. Despite greater efficacy and similar toxicity, these medications are infrequently used. Two years after US market entry, < 5% of either adults with focal DRE or patients with DS were treated with either cenobamate or fenfluramine. We believe this is a failure of our medical system, resulting from limited knowledge about these drugs stemming partly from the separation of academia from industry; restrictions to access created by health care payors, hospitals, and regulatory agencies; and insufficient post-launch information about the efficacy and safety of these ASMs.
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Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland, USA
| | - Gregory L Krauss
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, Maryland, USA
| | - Bernhard J Steinhoff
- Epilepsiezentrum Kork, Kehl-Kork, Germany and Medical Faculty, Albert-Ludwigs University, Freiburg, Germany
| | - Orrin Devinsky
- NYU Langone School of Medicine, Department of Neurology, New York, New York, USA
| | - Michael R Sperling
- Thomas Jefferson University, Department of Neurology, Philadelphia, Pennsylvania, USA
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20
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Sourbron J, Lagae L. Fenfluramine: a plethora of mechanisms? Front Pharmacol 2023; 14:1192022. [PMID: 37251322 PMCID: PMC10213522 DOI: 10.3389/fphar.2023.1192022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/10/2023] [Indexed: 05/31/2023] Open
Abstract
Developmental and epileptic encephalopathies are rare, treatment-resistant epilepsies with high seizure burden and non-seizure comorbidities. The antiseizure medication (ASM) fenfluramine is an effective treatment for reducing seizure frequency, ameliorating comorbidities, and potentially reducing risk of sudden unexpected death in epilepsy (SUDEP) in patients with Dravet syndrome and Lennox-Gastaut syndrome, among other rare epilepsies. Fenfluramine has a unique mechanism of action (MOA) among ASMs. Its primary MOA is currently described as dual-action sigma-1 receptor and serotonergic activity; however, other mechanisms may be involved. Here, we conduct an extensive review of the literature to identify all previously described mechanisms for fenfluramine. We also consider how these mechanisms may play a role in the reports of clinical benefit in non-seizure outcomes, including SUDEP and everyday executive function. Our review highlights the importance of serotonin and sigma-1 receptor mechanisms in maintaining a balance between excitatory (glutamatergic) and inhibitory (γ-aminobutyric acid [GABA]-ergic) neural networks, and suggests that these mechanisms may represent primary pharmacological MOAs in seizures, non-seizure comorbidities, and SUDEP. We also describe ancillary roles for GABA neurotransmission, noradrenergic neurotransmission, and the endocrine system (especially such progesterone derivatives as neuroactive steroids). Dopaminergic activity underlies appetite reduction, a common side effect with fenfluramine treatment, but any involvement in seizure reduction remains speculative. Further research is underway to evaluate promising new biological pathways for fenfluramine. A better understanding of the pharmacological mechanisms for fenfluramine in reducing seizure burden and non-seizure comorbidities may allow for rational drug design and/or improved clinical decision-making when prescribing multi-ASM regimens.
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Abstract
PURPOSE OF REVIEW Epilepsy affects 70 million people worldwide and is a significant cause of morbidity and early mortality. The mainstay of therapy is oral medications. Epilepsy drug development is escalating, driven by continued drug resistance in up to a third of epilepsy patients. Treatment development now focuses on discovery of novel mechanisms of action and syndrome-specific therapies. RECENT FINDINGS Difficult-to-treat epilepsy related to conditions including tuberous sclerosis complex (TSC), Lennox Gastaut syndrome (LGS) and Dravet syndrome (DS) have been the target of recent developments. Disease-modifying therapy for epilepsy related to TSC with vigabatrin at onset of first electroencephalographic epileptiform changes, rather than after first clinical seizure, has demonstrated strongly positive seizure and developmental outcomes. Fenfluramine, approved for DS and, more recently, LGS, has robust data supporting efficacy, safety/tolerability, as well as mortality, quality of life and cognitive function. Rescue therapy has expanded to include better tolerated benzodiazepines in the form of nasal midazolam and valium. Cenobamate, a first-in-class inactivator of the persistent voltage-gated sodium channel and approved for adult partial onset epilepsy, has exceptional efficacy and tolerability and will be expanded to children and to generalized onset epilepsy in adults. SUMMARY The repertoire of available and developmental therapies for epilepsy is rapidly expanding, and now includes disease-modifying vigabatrin in TSC and agents with extraordinary efficacy, fenfluramine and cenobamate.
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Affiliation(s)
- Amanda W Pong
- Mid-Atlantic Epilepsy and Sleep Center, Mid-Atlantic Neurological Institute, Bethesda, Maryland, USA
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22
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Efficacy and Safety of Fenfluramine in Epilepsy: A Systematic Review and Meta-analysis. Neurol Ther 2023; 12:669-686. [PMID: 36853503 PMCID: PMC10043095 DOI: 10.1007/s40120-023-00452-1] [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: 01/07/2023] [Accepted: 02/07/2023] [Indexed: 03/01/2023] Open
Abstract
INTRODUCTION Fenfluramine (FFA) is an amphetamine derivative that promotes the release and blocks the neuronal reuptake of serotonin. Initially introduced as an appetite suppressant, FFA also showed antiseizure properties. This systematic review aimed to assess the efficacy and safety of FFA for the treatment of seizures in patients with epilepsy. METHODS We systematically searched (in week 3 of June 2022) MEDLINE, the Cochrane Central Register of Controlled Trials, and the US National Institutes of Health Clinical Trials Registry. Randomized, double- or single-blinded, placebo-controlled studies of FFA in patients with epilepsy and uncontrolled seizures were identified. Efficacy outcomes included the proportions of patients with ≥ 50% and 100% reductions in baseline seizure frequency during the treatment period. Tolerability outcomes included the proportions of patients who withdrew from treatment for any reason and suffered adverse events (AEs). The risk of bias in the included studies was assessed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. The risk ratio (RR) along with the 95% confidence interval (CI) were estimated for each outcome. RESULTS Three trials were identified and a total of 469 Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) subjects were randomized. All three trials were judged to be at low risk of biases. In patients with DS, the RRs for ≥ 50% and 100% reductions in convulsive seizure frequency for the FFA group compared to placebo were 5.61 (95% CI 2.73-11.54) and 4.71 (95% CI 0.57-39.30), respectively. In patients with LGS, the corresponding RRs for ≥ 50% and 100% reductions in drop seizure frequency were 2.58 (95% CI 1.33-5.02) and 0.50 (95% CI 0.031-7.81), respectively. The drug was withdrawn for any reason in 10.1% and 5.8% of patients receiving FFA and placebo, respectively (RR 1.79, 95% CI 0.89-3.59). Treatment discontinuation due to AEs occurred in 5.4% and 1.2% of FFA- and placebo-treated patients, respectively (RR 3.63, 95% CI 0.93-14.16). Decreased appetite, diarrhoea, fatigue, and weight loss were AEs associated with FFA treatment. CONCLUSION Fenfluramine reduces the frequency of seizures in patients with DS and LGS. Decreased appetite, diarrhoea, fatigue, and weight loss are non-cardiovascular AEs associated with FFA.
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Whitney R, Sharma S, Ramachandrannair R. Sudden unexpected death in epilepsy in children. Dev Med Child Neurol 2023. [PMID: 36802063 DOI: 10.1111/dmcn.15553] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/20/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related mortality in children and adults living with epilepsy. The incidence of SUDEP is comparable in both children and adults; it is approximately 1.2 per 1000 person years. The pathophysiology of SUDEP is not well understood but may involve mechanisms such as cerebral shutdown, autonomic dysfunction, altered brainstem function, and cardiorespiratory demise. Risk factors for SUDEP include the presence of generalized tonic-clonic seizures, nocturnal seizures, possible genetic predisposition, and non-adherence to antiseizure medications. Pediatric-specific risk factors are not fully elucidated. Despite recommendations from consensus guidelines, many clinicians still do not follow the practice of counseling their patients about SUDEP. SUDEP prevention has been an area of important research focus and includes several strategies, such as obtaining seizure control, optimizing treatment regimens, nocturnal supervision, and seizure detection devices. This review discusses what is currently known about SUDEP risk factors and reviews current and future preventive strategies for SUDEP.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Suvasini Sharma
- Neurology Division, Department of Pediatrics, Lady Harding Medical College and Kalawati Saran Children Hospital, New Delhi, India
| | - Rajesh Ramachandrannair
- Division of Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Knupp KG, Scheffer IE, Ceulemans B, Sullivan J, Nickels KC, Lagae L, Guerrini R, Zuberi SM, Nabbout R, Riney K, Agarwal A, Lock M, Dai D, Farfel GM, Galer BS, Gammaitoni AR, Polega S, Davis R, Gil‐Nagel A. Fenfluramine provides clinically meaningful reduction in frequency of drop seizures in patients with Lennox-Gastaut syndrome: Interim analysis of an open-label extension study. Epilepsia 2023; 64:139-151. [PMID: 36196777 PMCID: PMC10099582 DOI: 10.1111/epi.17431] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE This study was undertaken to evaluate the long-term safety and effectiveness of fenfluramine in patients with Lennox-Gastaut syndrome (LGS). METHODS Eligible patients with LGS who completed a 14-week phase 3 randomized clinical trial enrolled in an open-label extension (OLE; NCT03355209). All patients were initially started on .2 mg/kg/day fenfluramine and after 1 month were titrated by effectiveness and tolerability, which were assessed at 3-month intervals. The protocol-specified treatment duration was 12 months, but COVID-19-related delays resulted in 142 patients completing their final visit after 12 months. RESULTS As of October 19, 2020, 247 patients were enrolled in the OLE. Mean age was 14.3 ± 7.6 years (79 [32%] adults) and median fenfluramine treatment duration was 364 days; 88.3% of patients received 2-4 concomitant antiseizure medications. Median percentage change in monthly drop seizure frequency was -28.6% over the entire OLE (n = 241) and -50.5% at Month 15 (n = 142, p < .0001); 75 of 241 patients (31.1%) experienced ≥50% reduction in drop seizure frequency. Median percentage change in nondrop seizure frequency was -45.9% (n = 192, p = .0038). Generalized tonic-clonic seizures (GTCS) and tonic seizures were most responsive to treatment, with median reductions over the entire OLE of 48.8% (p < .0001, n = 106) and 35.8% (p < .0001, n = 186), respectively. A total of 37.6% (95% confidence interval [CI] = 31.4%-44.1%, n = 237) of investigators and 35.2% of caregivers (95% CI = 29.1%-41.8%, n = 230) rated patients as Much Improved/Very Much Improved on the Clinical Global Impression of Improvement scale. The most frequent treatment-emergent adverse events were decreased appetite (16.2%) and fatigue (13.4%). No cases of valvular heart disease (VHD) or pulmonary arterial hypertension (PAH) were observed. SIGNIFICANCE Patients with LGS experienced sustained reductions in drop seizure frequency on fenfluramine treatment, with a particularly robust reduction in frequency of GTCS, the key risk factor for sudden unexpected death in epilepsy. Fenfluramine was generally well tolerated; VHD or PAH was not observed long-term. Fenfluramine may provide an important long-term treatment option for LGS.
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Affiliation(s)
- Kelly G. Knupp
- University of Colorado, Children's Hospital ColoradoAuroraColoradoUSA
| | - Ingrid E. Scheffer
- University of Melbourne, Austin Hospital and Royal Children's HospitalMelbourneVictoriaAustralia
| | - Berten Ceulemans
- Department of Pediatric NeurologyAntwerp University HospitalAntwerpBelgium
| | - Joseph Sullivan
- University of California, San Francisco Weill Institute for Neurosciences, Benioff Children's HospitalSan FranciscoCaliforniaUSA
| | | | - Lieven Lagae
- Member of the European Reference Network EpiCARE, Department of Pediatric NeurologyUniversity of LeuvenLeuvenBelgium
| | - Renzo Guerrini
- Pediatric Neurology and Neurogenetics UnitAnna Meyer Children's Hospital, University of FlorenceFlorenceItaly
- Stella Maris Foundation, Scientific Institute for Research and Health CarePisaItaly
| | - Sameer M. Zuberi
- Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgowUK
| | - Rima Nabbout
- Reference Center for Rare EpilepsiesNecker–Sick Children University Hospital, Public Hospital Network of Paris, member of EpiCARE, Imagine Institute, Paris Cité UniversityParisFrance
| | - Kate Riney
- Neuroscience UnitQueensland Children's HospitalSouth BrisbaneQueenslandAustralia
- School of Clinical MedicineUniversity of QueenslandSt LuciaQueenslandAustralia
| | | | - Michael Lock
- Independent Consultant, Zogenix (now a part of UCB)HaikuHawaiiUSA
| | - David Dai
- Syneos HealthMorrisvilleNorth CarolinaUSA
| | | | | | | | | | - Ronald Davis
- Neurology and Epilepsy Research CenterOrlandoFloridaUSA
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25
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Meskis MA. Improving the quality of life for adults with Dravet syndrome. Dev Med Child Neurol 2022; 65:732-733. [PMID: 36426907 DOI: 10.1111/dmcn.15469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022]
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26
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He Z, Li Y, Zhao X, Li B. Dravet Syndrome: Advances in Etiology, Clinical Presentation, and Treatment. Epilepsy Res 2022; 188:107041. [DOI: 10.1016/j.eplepsyres.2022.107041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/08/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
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27
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Fenfluramine for the Treatment of Dravet Syndrome and Lennox Gastaut Syndrome: A Review. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00741-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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28
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Kløvgaard M, Sabers A, Ryvlin P. Update on Sudden Unexpected Death in Epilepsy. Neurol Clin 2022; 40:741-754. [DOI: 10.1016/j.ncl.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Guerrini R, Specchio N, Aledo‐Serrano Á, Pringsheim M, Darra F, Mayer T, Gil‐Nagel A, Polster T, Zuberi SM, Lothe A, Gammaitoni A, Strzelczyk A. An examination of the efficacy and safety of fenfluramine in adults, children, and adolescents with Dravet syndrome in a real-world practice setting: A report from the Fenfluramine European Early Access Program. Epilepsia Open 2022; 7:578-587. [PMID: 35801621 PMCID: PMC9712464 DOI: 10.1002/epi4.12624] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/03/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To examine the efficacy and safety of fenfluramine in patients with Dravet syndrome (DS) in three age groups: <6, 6-17, and ≥18 years old, treated in a real-world setting. METHODS Patients with DS were treated with fenfluramine in the European Union Early Access Program (EAP). Following a 28-day baseline period to establish the pretreatment monthly convulsive seizure frequency (MCSF), fenfluramine was started at a dose chosen by the treating physician and gradually titrated based on efficacy and tolerability up to a maximum of 0.7 mg/kg/day. Seizure incidence was recorded in a written diary, and adverse events (AEs) were reported at each patient visit. Cardiovascular safety was assessed by transthoracic echocardiography before treatment started and at least every 6 months thereafter. RESULTS A total of 149 patients have enrolled in the EAP and 63 were <6 years old, 62 were 6-17 years old, and 24 were ≥18 years old. After 3 months of treatment 62%, 53%, and 50% of patients demonstrated ≥75% reduction in MCSF in the <6, 6-17, and ≥18-year-old groups, respectively. This pattern of response was sustained through 12 months of treatment with 55%, 46%, and 80% of the <6, 6-17, and ≥18-year-old groups, respectively, experiencing a ≥75% reduction in MCSF. Most common AEs were loss of appetite (21%) and somnolence (16%). No valvular heart disease or pulmonary artery hypertension was observed. SIGNIFICANCE The magnitude, consistency, and durability of the response to add-on fenfluramine is consistent across age groups in patients with Dravet syndrome.
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Affiliation(s)
- Renzo Guerrini
- Children's Hospital A MeyerUniversity of Florence, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCAREFlorenceItaly
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeuroscienceBambino Gesù Children's Hospital IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCARERomeItaly
| | - Ángel Aledo‐Serrano
- Epilepsy Program, Department of NeurologyHospital Ruber InternacionalMadridSpain
| | - Milka Pringsheim
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and AdolescentsSchön KlinikVogtareuthGermany,Department for Congenital Heart Disease and Pediatric CardiologyGerman Heart CenterMunichGermany,Research Institute for Rehabilitation, Transition and PalliationParacelsus Medical UniversitySalzburgAustria
| | - Francesca Darra
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and PediatricsUniversity of Verona, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCAREVeronaItaly
| | - Thomas Mayer
- Epilepsy Center KleinwachauDresden‐RadebergGermany
| | - Antonio Gil‐Nagel
- Epilepsy Program, Department of NeurologyHospital Ruber InternacionalMadridSpain
| | - Tilman Polster
- Krankenhaus Mara – Bethel Epilepsy Centre, Department of Epileptology, Medical SchoolBielefeld UniversityBielefeldGermany
| | - Sameer M. Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & Institute of Health & WellbeingUniversity of GlasgowGlasgowUK
| | | | | | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine‐Main and Department of NeurologyGoethe‐University FrankfurtFrankfurt am MainGermany
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30
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Samanta D. Fenfluramine: A Review of Pharmacology, Clinical Efficacy, and Safety in Epilepsy. CHILDREN 2022; 9:children9081159. [PMID: 36010049 PMCID: PMC9406381 DOI: 10.3390/children9081159] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022]
Abstract
Despite the availability of more than 30 antiseizure medications (ASMs), the proportion of patients who remain refractory to ASMs remains static. Refractory seizures are almost universal in patients with epileptic encephalopathies. Since many of these patients are not candidates for curative surgery, there is always a need for newer ASMs with better efficacy and safety profile. Recently, the anti-obesity medication fenfluramine (FFA) has been successfully repurposed, and various regulatory agencies approved it for seizures associated with Dravet and Lennox–Gastaut syndromes. However, there is a limited in-depth critical review of FFA to facilitate its optimal use in a clinical context. This narrative review discusses and summarizes the antiseizure mechanism of action of FFA, clinical pharmacology, and clinical studies related to epilepsy, focusing on efficacy and adverse effects.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR 72202, USA
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31
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Sudden Unexpected Death in Epilepsy. Neurol Int 2022; 14:600-613. [PMID: 35893283 PMCID: PMC9326725 DOI: 10.3390/neurolint14030048] [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: 05/12/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
Epilepsy is a complex neurological condition with numerous etiologies and treatment options. In a subset of these patients, sudden unexpected death can occur, and to date, there are numerous explanations as to the pathophysiological mechanisms and how to mitigate these catastrophic outcomes. Approximately 2.3 million Americans have epilepsy, and nearly 150,000 people develop the condition each year. Sudden unexpected death in epilepsy (SUDEP) accounts for 2–18% of all epilepsy-related deaths and this is equivalent to one death in 1000 person-years of diagnosed epilepsy. It is more common in young adults aged 20–45. Seizures in the past year; the absence of terminal remission in the last five years; increased seizure frequency, particularly GTCS; and nocturnal seizures are the most potent modifiable risk factors for SUDEP. Patients not receiving any antiepileptic drug therapy are at higher risk of SUDEP. Patient education on medication compliance; care plans for seizure clusters (rescue medicines); epilepsy self-management programs; and lifestyle changes to avoid seizure-triggering factors, including avoiding excessive alcohol use and sleep deprivation, should be provided by health care providers. Continued research into SUDEP will hopefully lead to effective interventions to minimize occurrences. At present, aggressive control of epilepsy and enhanced education for individuals and the public are the most effective weapons for combating SUDEP. This narrative review focuses on updated information related to SUDEP epidemiology; pathophysiology; risk factor treatment options; and finally, a discussion of important clinical studies. We seek to encourage clinicians who care for patients with epilepsy to be aggressive in controlling seizure activity and diligent in their review of risk factors and education of patients and their families about SUDEP.
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32
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Aledo-Serrano Á, Cabal-Paz B, Gardella E, Gómez-Porro P, Martínez-Múgica O, Beltrán-Corbellini A, Toledano R, García-Morales I, Gil-Nagel A. Effect of Fenfluramine on Seizures and Comorbidities in SCN8A-Developmental and Epileptic Encephalopathy: A Case Series. Epilepsia Open 2022; 7:525-531. [PMID: 35802036 PMCID: PMC9436303 DOI: 10.1002/epi4.12623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/02/2022] [Indexed: 11/06/2022] Open
Abstract
SCN8A-developmental and epileptic encephalopathy is caused by mutations in the SCN8A gene encoding the Nav 1.6 sodium channel, and is characterized by intractable multivariate seizures and developmental regression. Fenfluramine is a repurposed drug with proven antiseizure efficacy in Dravet syndrome and Lennox-Gastaut syndrome. The effect of fenfluramine treatment was assessed in a retrospective series of three patients with intractable SCN8A epilepsy and severe neurodevelopmental comorbidity (n=2 females; age 2.8-13 years; 8-16 prior failed antiseizure medications (ASM); treatment duration: 0.75-4.2 years). In the 6 months prior to receiving fenfluramine, patients experienced multiple seizure types, including generalized tonic-clonic, focal and myoclonic seizures, and status epilepticus. Overall seizure reduction was 60%-90% in the last 3, 6, and 12 months of fenfluramine treatment. Clinically meaningful improvement was noted in ≥1 non-seizure comorbidity per patient after fenfluramine, as assessed by physician-ratings of ≥"Much Improved" on the Clinical Global Impression of Improvement scale. Improvements included ambulation in a previously non-ambulant patient and better attention, sleep, and language. One patient showed mild irritability which resolved; no other treatment-related adverse events were reported. There were no reports of valvular heart disease or pulmonary arterial hypertension. Fenfluramine may be a promising ASM for randomized clinical trials in SCN8A-related disorders.
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Affiliation(s)
- Ángel Aledo-Serrano
- Epilepsy Program, Neurology Department, Ruber Internacional Hospital, Madrid, Spain
| | - Borja Cabal-Paz
- Epilepsy Program, Neurology Department, Ruber Internacional Hospital, Madrid, Spain.,Neurology Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Elena Gardella
- Department of Epilepsy Genetics and Personalized Treatment, Danish Epilepsy Center, Dianalund, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Pablo Gómez-Porro
- Epilepsy Program, Neurology Department, Ruber Internacional Hospital, Madrid, Spain.,Neurology Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Otilia Martínez-Múgica
- Pediatric Neurology Section, Pediatrics Department, Donostia University Hospital, San Sebastian, Spain
| | | | - Rafael Toledano
- Epilepsy Program, Neurology Department, Ruber Internacional Hospital, Madrid, Spain.,Epilepsy Unit, Neurology Department, Ramon y Cajal University Hospital, Madrid, Spain
| | - Irene García-Morales
- Epilepsy Program, Neurology Department, Ruber Internacional Hospital, Madrid, Spain.,Epilepsy Unit, Neurology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Antonio Gil-Nagel
- Epilepsy Program, Neurology Department, Ruber Internacional Hospital, Madrid, Spain
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PAEDIATRIC SUDDEN UNEXPECTED DEATH IN EPILEPSY: FROM PATHOPHYSIOLOGY TO PREVENTION. Seizure 2022; 101:83-95. [DOI: 10.1016/j.seizure.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 11/22/2022] Open
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Knupp KG, Scheffer IE, Ceulemans B, Sullivan JE, Nickels KC, Lagae L, Guerrini R, Zuberi SM, Nabbout R, Riney K, Shore S, Agarwal A, Lock M, Farfel GM, Galer BS, Gammaitoni AR, Davis R, Gil-Nagel A. Efficacy and Safety of Fenfluramine for the Treatment of Seizures Associated With Lennox-Gastaut Syndrome: A Randomized Clinical Trial. JAMA Neurol 2022; 79:554-564. [PMID: 35499850 PMCID: PMC9062770 DOI: 10.1001/jamaneurol.2022.0829] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Question Is adjunctive fenfluramine effective in patients with Lennox-Gastaut syndrome (LGS)? Findings In this randomized clinical trial of 263 patients with LGS, use of 0.7-mg/kg/d fenfluramine resulted in a greater reduction in drop seizures than with placebo, more patients achieving a 50% or greater reduction in drop seizure frequency, and greater reduction in generalized tonic-clonic seizure frequency. Treatment-emergent adverse events included decreased appetite, but no patient developed valvular heart disease or pulmonary hypertension. Meaning Findings from this trial suggest that fenfluramine may be a safe and effective treatment option for patients with LGS. Importance New treatment options are needed for patients with Lennox-Gastaut syndrome (LGS), a profoundly impairing, treatment-resistant, developmental and epileptic encephalopathy. Objective To evaluate the efficacy and safety of fenfluramine in patients with LGS. Design, Setting, and Participants This multicenter, double-blind, placebo-controlled, parallel-group randomized clinical trial was conducted from November 27, 2017, to October 25, 2019, and had a 20-week trial duration. Patients were enrolled at 65 study sites in North America, Europe, and Australia. Included patients were aged 2 to 35 years with confirmed diagnosis of LGS and experienced 2 or more drop seizures per week during the 4-week baseline. Using a modified intent-to-treat method, data analysis was performed from November 27, 2017, to October 25, 2019. The database lock date was January 30, 2020, and the date of final report was September 11, 2021. Interventions Patients were randomized to receive either a 0.7-mg/kg/d or 0.2-mg/kg/d (maximum 26 mg/d) dose of fenfluramine or placebo. After titration (2-week period), patients were taking their randomized dose for 12 additional weeks. Main Outcomes and Measures Primary efficacy end point was percentage change from baseline in drop seizure frequency in patients who received 0.7 mg/kg/d of fenfluramine vs placebo. Results A total of 263 patients (median [range] age, 13 [2-35] years; 146 male patients [56%]) were randomized to the 0.7-mg/kg/d fenfluramine group (n = 87), 0.2-mg/kg/d fenfluramine group (n = 89), or placebo group (n = 87). The median percentage reduction in frequency of drop seizures was 26.5 percentage points in the 0.7-mg/kg/d fenfluramine group, 14.2 percentage points in the 0.2-mg/kg/d fenfluramine group, and 7.6 percentage points in the placebo group. The trial met its primary efficacy end point: patients in the 0.7-mg/kg/d fenfluramine group achieved a −19.9 percentage points (95% CI, −31.0 to −8.7 percentage points; P = .001) estimated median difference in drop seizures from baseline vs placebo. More patients in the 0.7-mg/kg/d fenfluramine group achieved a 50% or greater response (22 of 87 [25%]; P = .02) vs placebo (9 of 87 [10%]). Site investigators and caregivers gave a much improved or very much improved rating on the Clinical Global Impression of Improvement scale to more patients in the 0.7-mg/kg/d fenfluramine group than patients in the placebo group (21 [26%] vs 5 [6%]; P = .001). The seizure subtype that appeared most responsive to fenfluramine was generalized tonic-clonic seizure (120 of 263 [46%]), with a decrease in frequency of 45.7% in the 0.7-mg/kg/d fenfluramine group and 58.2% in the 0.2-mg/kg/d fenfluramine group compared with an increase of 3.7% in the placebo group. Most common treatment-emergent adverse events included decreased appetite (59 [22%]), somnolence (33 [13%]), and fatigue (33 [13%]). No cases of valvular heart disease or pulmonary arterial hypertension were observed. Conclusions and Relevance Results of this trial showed that, in patients with LGS, fenfluramine compared with placebo provided a significantly greater reduction in drop seizures and may be a particularly advantageous choice in patients who experience generalized tonic-clonic seizures. Trial Registration ClinicalTrials.gov Identifier: NCT03355209
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Affiliation(s)
- Kelly G Knupp
- Department of Neurology, Children's Hospital Colorado, Aurora
| | - Ingrid E Scheffer
- Austin Hospital and Royal Children's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Berten Ceulemans
- Department of Paediatric Neurology, Antwerp University Hospital, Antwerp, Belgium
| | - Joseph E Sullivan
- Weill Institute for Neurosciences, Benioff Children's Hospital, University of California San Francisco, San Francisco
| | | | - Lieven Lagae
- Steering Committee, European Reference Network EpiCARE, Lyon, France.,Department of Paediatric Neurology, KU Leuven, Leuven, Belgium
| | - Renzo Guerrini
- Pediatric Neurology and Neurogenetics Unit, Anna Meyer Children's Hospital, University of Florence, Florence, Italy.,Neurobiologia e Neurogenetica dei Disturbi del Neurosviluppo, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Fondazione Stella Maris, Pisa, Italy
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, United Kingdom
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies, Necker-Enfants Malades Hospital, Imagine Institute, University Paris Descartes, Paris, France
| | - Kate Riney
- Neuroscience Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Svetlana Shore
- Zogenix Inc, Emeryville, California.,Now with Neurocrine Biosciences, San Diego, California
| | | | - Michael Lock
- Zogenix Inc, Emeryville, California.,Now with Zogenix Inc, Haiku, Hawaii
| | | | | | | | - Ronald Davis
- Neurology and Epilepsy Research Center, Orlando, Florida
| | - Antonio Gil-Nagel
- Department of Neurology, Epilepsy Program, Hospital Ruber Internacional, Madrid, Spain
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Wirrell EC, Hood V, Knupp KG, Meskis MA, Nabbout R, Scheffer I, Wilmshurst J, Sullivan J. The International Consensus on Diagnosis and Management of Dravet Syndrome. Epilepsia 2022; 63:1761-1777. [PMID: 35490361 PMCID: PMC9543220 DOI: 10.1111/epi.17274] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 11/29/2022]
Abstract
Objective This study was undertaken to gain consensus from experienced physicians and caregivers regarding optimal diagnosis and management of Dravet syndrome (DS), in the context of recently approved, DS‐specific therapies and emerging disease‐modifying treatments. Methods A core working group was convened consisting of six physicians with recognized expertise in DS and two representatives of the Dravet Syndrome Foundation. This core group summarized the current literature (focused on clinical presentation, comorbidities, maintenance and rescue therapies, and evolving disease‐modifying therapies) and nominated the 31‐member expert panel (ensuring international representation), which participated in two rounds of a Delphi process to gain consensus on diagnosis and management of DS. Results There was strong consensus that infants 2–15 months old, presenting with either a first prolonged hemiclonic seizure or first convulsive status epilepticus with fever or following vaccination, in the absence of another cause, should undergo genetic testing for DS. Panelists agreed on evolution of specific comorbidities with time, but less agreement was achieved on optimal management. There was also agreement on appropriate first‐ to third‐line maintenance therapies, which included the newly approved agents. Whereas there was agreement for recommendation of disease‐modifying therapies, if they are proven safe and efficacious for seizures and/or reduction of comorbidities, there was less consensus for when these should be started, with caregivers being more conservative than physicians. Significance This International DS Consensus, informed by both experienced global caregiver and physician voices, provides a strong overview of the impact of DS, therapeutic goals and optimal management strategies incorporating the recent therapeutic advances in DS, and evolving disease‐modifying therapies.
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Affiliation(s)
- Elaine C Wirrell
- Divisions of Child and Adolescent Medicine and Epilepsy Department of Neurology Mayo Clinic Rochester MN USA
| | | | - Kelly G Knupp
- Departments of Pediatrics and Neurology University of Colorado Anschutz Campus Aurora CO USA
| | | | - Rima Nabbout
- Reference Centre for Rare Epilepsies Department of Pediatric Neurology Necker–Enfants Malades Hospital, APHP, Member of European Reference Network EpiCARE, Institut Imagine, INSERM, UMR 1163 Université de Paris Paris France
| | - Ingrid Scheffer
- University of Melbourne Austin Health and Royal Children’s Hospital Florey Institute of Neuroscience and Mental Health Murdoch Children’s Research Institute Melbourne Australia
| | - Jo Wilmshurst
- Department of Paediatric Neurology Red Cross War Memorial Children’s Hospital Neuroscience Institute University of Cape Town South Africa
| | - Joseph Sullivan
- Departments of Neurology and Pediatrics Benioff Children’s Hospital University of California San Francisco CA USA
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Patodia S, Somani A, Liu J, Cattaneo A, Paradiso B, Garcia M, Othman M, Diehl B, Devinsky O, Mills JD, Foong J, Thom M. Serotonin transporter in the temporal lobe, hippocampus and amygdala in SUDEP. Brain Pathol 2022; 32:e13074. [PMID: 35478467 PMCID: PMC9425018 DOI: 10.1111/bpa.13074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/17/2022] [Accepted: 03/31/2022] [Indexed: 11/30/2022] Open
Abstract
Several lines of evidence link deficient serotonin function and SUDEP. Chronic treatment with serotonin reuptake inhibitors (SRIs) reduces ictal central apnoea, a risk factor for SUDEP. Reduced medullary serotonergic neurones, modulators of respiration in response to hypercapnia, were reported in a SUDEP post‐mortem series. The amygdala and hippocampus have high serotonergic innervation and are functionally implicated in seizure‐related respiratory dysregulation. We explored serotonergic networks in mesial temporal lobe structures in a surgical and post‐mortem epilepsy series in relation to SUDEP risk. We stratified 75 temporal lobe epilepsy patients with hippocampal sclerosis (TLE/HS) into high (N = 16), medium (N = 11) and low risk (N = 48) groups for SUDEP based on generalised seizure frequency. We also included the amygdala in 35 post‐mortem cases, including SUDEP (N = 17), epilepsy controls (N = 10) and non‐epilepsy controls (N = 8). The immunohistochemistry labelling index (LI) and axonal length (AL) of serotonin transporter (SERT)‐positive axons were quantified in 13 regions of interest with image analysis. SERT LI was highest in amygdala and subiculum regions. In the surgical series, higher SERT LI was observed in high risk than low risk cases in the dentate gyrus, CA1 and subiculum (p < 0.05). In the post‐mortem cases higher SERT LI and AL was observed in the basal and accessory basal nuclei of the amygdala and peri‐amygdala cortex in SUDEP compared to epilepsy controls (p < 0.05). Patients on SRI showed higher SERT in the dentate gyrus (p < 0.005) and CA4 (p < 0.05) but there was no difference in patients with or without a psychiatric history. Higher SERT in hippocampal subfields in TLE/HS cases with SUDEP risk factors and higher amygdala SERT in post‐mortem SUDEP cases than epilepsy controls supports a role for altered serotonergic networks involving limbic regions in SUDEP. This may be of functional relevance through reduced 5‐HT availability.
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Affiliation(s)
- Smriti Patodia
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Alyma Somani
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Joan Liu
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Alice Cattaneo
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Beatrice Paradiso
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Maria Garcia
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Muhammad Othman
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Beate Diehl
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK.,Departments of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Orrin Devinsky
- NYU Langone Comprehensive Epilepsy Center, New York University, New York City, New York, USA
| | - James D Mills
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK.,Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jackie Foong
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK.,Departments of Psychiatry, National Hospital for Neurology and Neurosurgery, London, UK
| | - Maria Thom
- Department of clinical and experimental epilepsy, UCL Queen Square Institute of Neurology, London, UK.,Departments of Neuropathology, National Hospital for Neurology and Neurosurgery, London, UK
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Abstract
PURPOSE OF REVIEW Sudden unexpected death in epilepsy (SUDEP) is a major contributor to premature mortality in people with epilepsy. This review provides an update on recent findings on the epidemiology of SUDEP, clinical risk factors and potential mechanisms. RECENT FINDINGS The overall risk rate of SUDEP is approximately 1 per 1000 patients per year in the general epilepsy population and that children and older adults have a similar incidence. Generalized convulsive seizures (GCS), perhaps through their effects on brainstem cardiopulmonary networks, can cause significant postictal respiratory and autonomic dysfunction though other mechanisms likely exist as well. Work in animal models of SUDEP has identified multiple neurotransmitter systems, which may be future targets for pharmacological intervention. There are also chronic functional and structural changes in autonomic function in patients who subsequently die from SUDEP suggesting that some SUDEP risk is dynamic. Modifiable risks for SUDEP include GCS seizure frequency, medication adherence and nighttime supervision. SUMMARY Current knowledge of SUDEP risk factors has identified multiple targets for SUDEP prevention today as we await more specific therapeutic targets that are emerging from translational research studies.
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Affiliation(s)
- Daniel Friedman
- NYU Grossman School of Medicine, Department of Neurology, 223 East 34th Street, New York, New York, USA
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Sourbron J, Lagae L. Serotonin receptors in epilepsy: novel treatment targets? Epilepsia Open 2022; 7:231-246. [PMID: 35075810 PMCID: PMC9159250 DOI: 10.1002/epi4.12580] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/08/2022] [Accepted: 01/20/2022] [Indexed: 11/24/2022] Open
Abstract
Despite the availability of over 30 antiseizure medications (ASMs), there is no “one size fits it all,” so there is a continuing search for novel ASMs. There are divergent data demonstrating that modulation of distinct serotonin (5‐hydroxytryptamine, 5‐HT) receptors subtypes could be beneficial in the treatment of epilepsy and its comorbidities, whereas only a few ASM, such as fenfluramine (FA), act via 5‐HT. There are 14 different 5‐HT receptor subtypes, and most epilepsy studies focus on one or a few of these subtypes, using different animal models and different ligands. We reviewed the available evidence of each 5‐HT receptor subtype using MEDLINE up to July 2021. Our search included medical subject heading (MeSH) and free terms of each “5‐HT subtype” separately and its relation to “epilepsy or seizures.” Most research underlines the antiseizure activity of 5‐HT1A,1D,2A,2C,3 agonism and 5‐HT6 antagonism. Consistently, FA, which has recently been approved for the treatment of seizures in Dravet syndrome, is an agonist of 5‐HT1D,2A,2C receptors. Even though each study focused on a distinct seizure/epilepsy type and generalization of different findings could lead to false interpretations, we believe that the available preclinical and clinical studies emphasize the role of serotonergic modulation, especially stimulation, as a promising avenue in epilepsy treatment.
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Affiliation(s)
- Jo Sourbron
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital KU Leuven, Leuven, Belgium.,Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Lieven Lagae
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital KU Leuven, Leuven, Belgium
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Strzelczyk A, Schubert-Bast S. A Practical Guide to the Treatment of Dravet Syndrome with Anti-Seizure Medication. CNS Drugs 2022; 36:217-237. [PMID: 35156171 PMCID: PMC8927048 DOI: 10.1007/s40263-022-00898-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 01/14/2023]
Abstract
Dravet syndrome is a severe developmental and epileptic encephalopathy characterised by refractory seizures and cognitive dysfunction. The treatment is challenging, not least because the seizures are highly drug resistant, requiring multiple anti-seizure medications (ASMs), while some ASMs can exacerbate seizures. Initial treatments include the broad-spectrum ASMs valproate (VPA), and clobazam (CLB) in some regions; however, they are generally insufficient to control seizures. With this in mind, three adjunct ASMs have been approved specifically for the treatment of seizures in patients with Dravet syndrome: stiripentol (STP) in 2007 in the European Union and 2018 in the USA, cannabidiol (CBD) in 2018/2019 (in combination with CLB in the European Union) and fenfluramine (FFA) in 2020. These "add-on" therapies (mostly to VPA/CLB) are used as escalation therapies, with the choice dependent on availability in different countries, patient characteristics and caregiver preferences. Topiramate is also frequently used, with evidence of efficacy in Dravet syndrome, and there is anecdotal evidence of efficacy with bromide, which is frequently used in Germany and Japan. With a growing treatment landscape for Dravet syndrome, there can be practical challenges for clinicians, particularly with issues associated with polypharmacy. This practical guide provides an overview of these main ASMs including their indications/contraindications, mechanism of action, efficacy, safety and tolerability profile, dosage requirements, and laboratory and clinical parameters to be evaluated. Standard laboratory and clinical parameters include blood counts, liver function tests, serum concentrations of ASMs, monitoring the growth of children, as well as weight loss and acceleration of behavioural problems. Regular cardiac monitoring is also important with FFA as it has previously been associated with cases of cardiac valve disease when used in adults at high doses (up to 120 mg/day) in combination with phentermine as a therapy for obesity. Importantly, no signs of heart valve disease have been documented to date at the low doses used in patients with developmental and epileptic encephalopathies. In addition, potential drug-drug interactions and their consequences are a key consideration in everyday practice. Interactions that potentially require dosage adjustments to alleviate adverse events include the following: STP + CLB resulting in increased plasma concentrations of CLB and its active metabolite norclobazam may increase somnolence, and an interaction with STP and VPA may increase gastrointestinal adverse events. Cannabidiol has a bi-directional interaction with CLB producing an increase in plasma concentrations of 7-OH-CBD and norclobazam resulting in the potential for increased somnolence and sedation. In addition, CBD is associated with elevations of liver transaminases particularly in patients taking concomitant VPA. The interaction between FFA and STP requires a dose reduction of FFA. Furthermore, concomitant administration of VPA with topiramate has been associated with encephalopathy and/or hyperammonaemia. Finally, we briefly describe other ASMs used in Dravet syndrome, and current key clinical trials.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany. .,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Susanne Schubert-Bast
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528 Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
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