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Riva A, Coppola A, Bisulli F, Verrotti A, Bagnasco I, Elia M, Darra F, Lattanzi S, Meletti S, La Neve A, Di Gennaro G, Brambilla I, Santoro K, Prisco T, Macari F, Gambardella A, di Bonaventura C, Balestrini S, Marini C, Pruna D, Capovilla G, Specchio N, Gobbi G, Striano P. Italian report on RARE epilepsies (i-RARE): A consensus on multidisciplinarity. Epilepsia Open 2024. [PMID: 39176980 DOI: 10.1002/epi4.13020] [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: 05/12/2024] [Revised: 07/07/2024] [Accepted: 07/24/2024] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVE Rare and complex epilepsies encompass a diverse range of disorders characterized by seizures. We aimed to establish a consensus on key issues related to these conditions through collaboration among experienced neurologists, neuropediatricians, and patient advocacy representatives. METHODS Employing a modified Delphi method, a scientific board comprising 20 physicians and 4 patient advocacy representatives synthesized existing literature with their expertise to formulate statements on contentious topics. A final 32-member expert panel, representing diverse regions of Italy, validated these statements through a two-round voting process, with consensus defined as an average score ≥7. RESULTS Sixteen statements reached a consensus, emphasizing the necessity for epidemiological studies to ascertain the true prevalence of rare epilepsies. Etiology emerged as a crucial factor influencing therapeutic strategies and outcome prediction, with particular concern regarding prolonged and tonic-clonic seizures. The importance of early implementation of specific drugs and non-pharmacological interventions in the treatment algorithm for developmental and epileptic encephalopathies (DEEs) was underscored. Multidisciplinary care involving experts with diverse skills was deemed essential, emphasizing non-seizure outcomes in adolescence and adulthood. SIGNIFICANCE This national consensus underscores the imperative for personalized, comprehensive, and multidisciplinary management of rare epilepsies/DEEs. It advocates for increased research, particularly in epidemiology and therapeutic approaches, to inform clinical decision-making and healthcare policies, ultimately enhancing patients' outcomes. PLAIN LANGUAGE SUMMARY The modified Delphi method is broadly used to evaluate debated topics. In this work, we sought the consensus on integrated and social care in epilepsy management. Both representatives of high-level epilepsy centers and patients' caregivers were directly involved.
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Affiliation(s)
- Antonella Riva
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Antonietta Coppola
- Epilepsy Center, Department of Neuroscience, Odontostomatology and Reproductive Sciences, Federico II University of Naples, Naples, Italy
| | - Francesca Bisulli
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | | | - Irene Bagnasco
- Division of Neuropsychiatry, Epilepsy Center for Children, Martini Hospital, Turin, Italy
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute-IRCCS, Troina, Italy
| | - Francesca Darra
- Unit of Child Neuropsychiatry, Department of Engineering for Innovation Medicine, University of Verona, Full Member of the ERN EpiCARE Verona, Verona, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Stefano Meletti
- Neurophysiology Unit and Epilepsy Centre, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | | | - Isabella Brambilla
- Dravet Italia Onlus, Verona, Italy
- Epag ERN EpiCare, Verona, Italy
- Research Center For Pediatric Epilepsies (CREP), Department of Surgery, Dentistry, Paediatrics and Gynecology, University of Verona, Verona, Italy
- Alleanza Epilessie Rare e Complesse, Italy
| | | | | | | | - Antonio Gambardella
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carlo di Bonaventura
- Department of Human Neurosciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Simona Balestrini
- Neuroscience Department, Meyer Children's Hospital, Florence, Italy
- University of Florence, Florence, Italy
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Carla Marini
- Child Neurology and Psychiatry Unit Children's Hospital "G. Salesi" Azienda Ospedaliero-Universitaria Delle Marche Ancona, Ancona, Italy
| | - Dario Pruna
- Pediatric Neurology and Epileptology Unit, Pediatric Department, ARNAS G. Brotzu/ASL, Cagliari, Italy
| | - Giuseppe Capovilla
- Child Neuropsychiatry Department, Epilepsy Center, "C. Poma Hospital", Mantova, Italy
- Fondazione Poliambulanza, Brescia, Italy
| | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Rome, Italy
| | - Giuseppe Gobbi
- Associazione Famiglie LGS Italia, Correggio, Italy
- Or.S.A, Treviso, Italy
- Associazione Sclerosi Tuberosa, Rome, Italy
| | - Pasquale Striano
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
- IRCCS Istituto "Giannina Gaslini," Full Member of the ERN EpiCARE, Genoa, Italy
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Wirrell EC, Lagae L, Scheffer IE, Cross JH, Specchio N, Strzelczyk A. Practical considerations for the use of fenfluramine to manage patients with Dravet syndrome or Lennox-Gastaut syndrome in clinical practice. Epilepsia Open 2024. [PMID: 38962968 DOI: 10.1002/epi4.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/20/2024] [Accepted: 06/04/2024] [Indexed: 07/05/2024] Open
Abstract
Fenfluramine (FFA), an antiseizure medication (ASM) with serotonergic and sigma-1 receptor activity, is used to manage patients with developmental and epileptic encephalopathies (DEEs). It is approved in the US for treating seizures associated with Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) in patients ≥2 years old and as add-on therapy for seizures associated with DS and LGS in the EU, UK, and Japan in similarly aged patients. Consensus guidelines for treatment of DS have recommended FFA to be an early-line ASM, and it has also shown efficacy in managing seizures associated with LGS. DS and LGS are DEEs associated with a range of seizure types, developmental impairments, and multiple comorbidities. Here we provide case vignettes describing 4 patients (3 DS and 1 LGS) aged 4-29 years old in whom up to 14 ASMs had previously failed, to illustrate real-world practice issues encountered by neurologists. This review provides guidance on the use of FFA in the context of ASM polytherapy and drug-drug interactions (DDIs), behavioral issues, dose titration, and adverse events. Along with data from the clinical trial program, these case vignettes emphasize the low risk of DDIs, a generally well-tolerated safety profile, and other seizure and nonseizure benefits (eg, improved cognition and sleep) associated with the use of FFA in DS or LGS. PLAIN LANGUAGE SUMMARY: Fenfluramine is used to treat seizures in individuals with Dravet syndrome and Lennox-Gastaut syndrome, but there are a range of issues that clinicians may face when treating patients. This review highlights four patients from the authors' everyday clinical work and offers guidance and practical considerations by neurologists with expertise in managing these complex conditions related to drug interactions, dosing, and side effects associated with fenfluramine.
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Affiliation(s)
- Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lieven Lagae
- Member of the European Reference Network EpiCARE, Department of Pediatric Neurology, University of Leuven, Leuven, Belgium
| | - Ingrid E Scheffer
- Austin Hospital and Royal Children''s Hospital, Florey and Murdoch Children's Research Institutes, University of Melbourne, Melbourne, Victoria, Australia
| | - J Helen Cross
- Developmental Neurosciences Research & Teaching Department, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Rome, Italy
| | - Adam Strzelczyk
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
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Matricardi S, Scorrano G, Prezioso G, Burchiani B, Di Cara G, Striano P, Chiarelli F, Verrotti A. The latest advances in the pharmacological management of focal epilepsies in children: a narrative review. Expert Rev Neurother 2024; 24:371-381. [PMID: 38433525 DOI: 10.1080/14737175.2024.2326606] [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: 01/22/2024] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Focal epilepsy constitutes the most common epilepsy in children, and medical treatment represents the first-line therapy in this condition. The main goal of medical treatment for children and adolescents with epilepsy is the achievement of seizure freedom or, in drug-resistant epilepsies, a significant seizure reduction, both minimizing antiseizure medications (ASM)-related adverse events, thus improving the patient's quality of life. However, up to 20-40% of pediatric epilepsies are refractory to drug treatments. New ASMs came to light in the pediatric landscape, improving the drug profile compared to that of the preexisting ones. Clinicians should consider several factors during the drug choice process, including patient and medication-specific characteristics. AREAS COVERED This narrative review aims to summarize the latest evidence on the effectiveness and tolerability of the newest ASMs administered as monotherapy or adjunctive therapy in pediatric epilepsies with focal onset seizures, providing a practical appraisal based on the existing evidence. EXPERT OPINION The latest ASMs have the potential to be effective in the pharmacological management of focal onset seizures in children, and treatment choice should consider several drug- and epilepsy-related factors. Future treatments should be increasingly personalized and targeted on patient-specific pathways. Future research should focus on discovering new chemical compounds and repurposing medications used for other indications.
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Affiliation(s)
- Sara Matricardi
- Department of Paediatrics, University of Chieti, Chieti, Italy
| | | | | | | | - Giuseppe Di Cara
- Department of Paediatrics, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Paediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Alberto Verrotti
- Department of Paediatrics, University of Perugia, Perugia, Italy
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Xu Y, Chen D, Liu L. Optimal dose of fenfluramine in adjuvant treatment of drug-resistant epilepsy: evidence from randomized controlled trials. Front Neurol 2024; 15:1371704. [PMID: 38590719 PMCID: PMC10999678 DOI: 10.3389/fneur.2024.1371704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/08/2024] [Indexed: 04/10/2024] Open
Abstract
Objective Several clinical trials have suggested that fenfluramine (FFA) is effective for the treatment of epilepsy in Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS). However, the exploration of its optimal target dose is ongoing. This study aimed to summarize the best evidence to inform this clinical issue. Materials and methods We searched PubMed, Embase (via Ovid), and Web of Science for relevant literature published before December 1st, 2023. Randomized, double-blind, placebo-controlled studies that evaluated the efficacy, safety, and tolerability of FFA in DS and LGS were identified and meta-analysis was performed according to doses. The study was registered with PROSPERO (CRD42023392454). Results Six hundred and twelve patients from four randomized controlled trials were enrolled. The results demonstrated that FFA at 0.2, 0.4, or 0.7 mg/kg/d showed significantly greater efficacy compared to placebo in terms of at least 50% reduction (p < 0.001, p < 0.001, p < 0.001) and at least 75% reduction (p < 0.001, p = 0.007, p < 0.001) in monthly seizure frequency from baseline. Moreover, significantly more patients receiving FFA than placebo were rated as much improved or very much improved in CGI-I by both caregivers/parents and investigators (p < 0.001). The most common treatment-emergent adverse events were decreased appetite, diarrhea, fatigue, and weight loss, with no valvular heart disease or pulmonary hypertension observed in any participant. For dose comparison, 0.7 mg/kg/d group presented higher efficacy on at least 75% reduction in seizure (p = 0.006) but not on at least 50% reduction. Weight loss (p = 0.002), decreased appetite (p = 0.04), and all-cause withdrawal (p = 0.036) were more common in 0.7 mg/kg/d group than 0.2 mg/kg/d. There was no statistical difference in other safety parameters between these two groups. Conclusion The higher range of the licensed dose achieves the optimal balance between efficacy, safety, and tolerability in patients with DS and LGS. Clinical trial registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023392454.
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Affiliation(s)
| | | | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Sankar R, Chez M, Pina-Garza JE, Dixon-Salazar T, Flamini JR, Hyslop A, McGoldrick P, Millichap JJ, Resnick T, Rho JM, Wolf S. Proposed anti-seizure medication combinations with rufinamide in the treatment of Lennox-Gastaut syndrome: Narrative review and expert opinion. Seizure 2023; 110:42-57. [PMID: 37321047 DOI: 10.1016/j.seizure.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023] Open
Abstract
Lennox-Gastaut syndrome (LGS) is a severe, chronic, complex form of early childhood-onset epilepsy characterized by multiple seizure types, generalized slow (≤2.5 Hz) spike-and-wave activity and other electroencephalography abnormalities, and cognitive impairment. A key treatment goal is early seizure control, and several anti-seizure medications (ASMs) are available. Due to the low success rate in achieving seizure control with monotherapy and an absence of efficacy data supporting any particular combination of ASMs for treating LGS, a rational approach to selection of appropriate polytherapy should be applied to maximize benefit to patients. Such "rational polytherapy" involves consideration of factors including safety (including boxed warnings), potential drug-drug interactions, and complementary mechanisms of action. Based on the authors' clinical experience, rufinamide offers a well-considered first adjunctive therapy for LGS, particularly in combination with clobazam and other newer agents for LGS, and may be particularly useful for reducing the frequency of tonic-atonic seizures associated with LGS.
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Affiliation(s)
- Raman Sankar
- Departments of Neurology and Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA; UCLA Mattel Children's Hospital, Los Angeles, CA, USA.
| | - Michael Chez
- Sutter Health, Roseville, CA, USA; California Northstate University School of Medicine, Elk Grove, CA, USA
| | | | | | | | - Ann Hyslop
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Patricia McGoldrick
- Boston Children's Health Physicians, Valhalla, NY, USA; Maria Fareri Children's Hospital, Valhalla, NY, USA; New York Medical College, Valhalla, NY, USA
| | - John J Millichap
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Jong M Rho
- Departments of Neurosciences, Pediatrics & Pharmacology, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Steven Wolf
- Boston Children's Health Physicians, Valhalla, NY, USA; Maria Fareri Children's Hospital, Valhalla, NY, USA; New York Medical College, Valhalla, NY, USA
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Strzelczyk A, Schubert-Bast S. Psychobehavioural and Cognitive Adverse Events of Anti-Seizure Medications for the Treatment of Developmental and Epileptic Encephalopathies. CNS Drugs 2022; 36:1079-1111. [PMID: 36194365 PMCID: PMC9531646 DOI: 10.1007/s40263-022-00955-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 02/06/2023]
Abstract
The developmental and epileptic encephalopathies encompass a group of rare syndromes characterised by severe drug-resistant epilepsy with onset in childhood and significant neurodevelopmental comorbidities. The latter include intellectual disability, developmental delay, behavioural problems including attention-deficit hyperactivity disorder and autism spectrum disorder, psychiatric problems including anxiety and depression, speech impairment and sleep problems. Classical examples of developmental and epileptic encephalopathies include Dravet syndrome, Lennox-Gastaut syndrome and tuberous sclerosis complex. The mainstay of treatment is with multiple anti-seizure medications (ASMs); however, the ASMs themselves can be associated with psychobehavioural adverse events, and effects (negative or positive) on cognition and sleep. We have performed a targeted literature review of ASMs commonly used in the treatment of developmental and epileptic encephalopathies to discuss the latest evidence on their effects on behaviour, mood, cognition, sedation and sleep. The ASMs include valproate (VPA), clobazam, topiramate (TPM), cannabidiol (CBD), fenfluramine (FFA), levetiracetam (LEV), brivaracetam (BRV), zonisamide (ZNS), perampanel (PER), ethosuximide, stiripentol, lamotrigine (LTG), rufinamide, vigabatrin, lacosamide (LCM) and everolimus. Bromide, felbamate and other sodium channel ASMs are discussed briefly. Overall, the current evidence suggest that LEV, PER and to a lesser extent BRV are associated with psychobehavioural adverse events including aggressiveness and irritability; TPM and to a lesser extent ZNS are associated with language impairment and cognitive dulling/memory problems. Patients with a history of behavioural and psychiatric comorbidities may be more at risk of developing psychobehavioural adverse events. Topiramate and ZNS may be associated with negative effects in some aspects of cognition; CBD, FFA, LEV, BRV and LTG may have some positive effects, while the remaining ASMs do not appear to have a detrimental effect. All the ASMs are associated with sedation to a certain extent, which is pronounced during uptitration. Cannabidiol, PER and pregabalin may be associated with improvements in sleep, LTG is associated with insomnia, while VPA, TPM, LEV, ZNS and LCM do not appear to have detrimental effects. There was variability in the extent of evidence for each ASM: for many first-generation and some second-generation ASMs, there is scant documented evidence; however, their extensive use suggests favourable tolerability and safety (e.g. VPA); second-generation and some third-generation ASMs tend to have the most robust evidence documented over several years of use (TPM, LEV, PER, ZNS, BRV), while evidence is still being generated for newer ASMs such as CBD and FFA. Finally, we discuss how a variety of factors can affect mood, behaviour and cognition, and untangling the associations between the effects of the underlying syndrome and those of the ASMs can be challenging. In particular, there is enormous heterogeneity in cognitive, behavioural and developmental impairments that is complex and can change naturally over time; there is a lack of standardised instruments for evaluating these outcomes in developmental and epileptic encephalopathies, with a reliance on subjective evaluations by proxy (caregivers); and treatment regimes are complex involving multiple ASMs as well as other drugs.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany. .,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
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