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Kerr WT, Ngo LY, Zhu L, Patten A, Cheng JY, Reddy AS, French JA. Time to prerandomization seizure count design sufficiently assessed the safety and tolerability of perampanel for the treatment of primary generalized tonic-clonic seizures. Epilepsia 2024. [PMID: 38864472 DOI: 10.1111/epi.18023] [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: 02/22/2024] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVE Static assignment of participants in randomized clinical trials to placebo or ineffective treatment confers risk from continued seizures. An alternative trial design of time to exceed prerandomization monthly seizure count (T-PSC) has replicated the efficacy conclusions of traditionally designed trials, with shorter exposure to placebo and ineffective treatment. Trials aim to evaluate efficacy as well as safety and tolerability; therefore, we evaluated whether this T-PSC design also could replicate the trial's safety and tolerability conclusions. METHODS We retrospectively applied the T-PSC design to analyze treatment-emergent adverse events (TEAEs) from a blinded, placebo-controlled trial of perampanel for primary generalized tonic-clonic seizures (NCT01393743). The safety analysis set consisted of 81 and 82 participants randomized to perampanel and placebo arms, respectively. We evaluated the incidences of TEAEs, treatment-related TEAEs, serious TEAEs, and TEAEs of special interest that occurred before T-PSC relative to those observed during the full-length trial. RESULTS Of the 67 and 59 participants who experienced TEAEs in the perampanel and placebo arms during full-length trial, 66 (99%) and 54 (92%) participants experienced TEAEs with onset occurring before T-PSC, respectively. When limited to treatment-related TEAEs, 55 of 56 (98%) and 32 of 37 (86%) participants reported treatment-related TEAEs that occurred before T-PSC in the perampanel and placebo arms, respectively. There were more TEAEs after T-PSC with placebo as compared to perampanel (Fisher exact odds ratio = 8.6, p = .035), which resulted in overestimation of the difference in TEAE rate. There was a numerical reduction in serious TEAEs (3/13 occurred after T-PSC, one in placebo and two in perampanel). SIGNIFICANCE Almost all TEAEs occurred before T-PSC. More treatment-related TEAEs occurred after T-PSC for participants randomized to placebo than perampanel, which may be due to either a shorter T-PSC or delayed time to TEAE for placebo.
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Affiliation(s)
- Wesley T Kerr
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Advith S Reddy
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jacqueline A French
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA
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2
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Kerr WT, Reddy AS, Seo SH, Kok N, Stacey WC, Stern JM, Pennell PB, French JA. Increasing challenges to trial recruitment and conduct over time. Epilepsia 2023; 64:2625-2634. [PMID: 37440282 PMCID: PMC10592378 DOI: 10.1111/epi.17716] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE This study was undertaken to evaluate how the challenges in the recruitment and retention of participants in clinical trials for focal onset epilepsy have changed over time. METHODS In this systematic analysis of randomized clinical trials of adjunct antiseizure medications for medication-resistant focal onset epilepsy, we evaluated how the numbers of participants, sites, and countries have changed since the first such trial in 1990. We also evaluated the proportion of participants who completed each trial phase and their reasons for early trial exit. We analyzed these trends using mixed effects generalized linear models accounting for the influence of the number of trial sites and trial-specific variability. RESULTS The number of participants per site has steadily decreased over decades, with recent trials recruiting fewer than five participants per site (reduction by .16 participants/site/year, p < .0001). Fewer participants also progressed from recruitment to randomization over time (odds ratio = .94/year, p = .014). Concurrently, there has been an increase in the placebo response over time (increase in median percent reduction of .4%/year, p = .02; odds ratio of increase in 50% responder rate of 1.03/year, p = .02), which was not directly associated with the number of sites per trial (p > .20). SIGNIFICANCE This historical analysis highlights the increasing challenges with participant recruitment and retention, as well as increasing placebo response. It serves as a call to action to change clinical trial design to address these challenges.
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Affiliation(s)
- Wesley T. Kerr
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Advith S. Reddy
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sung Hyun Seo
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neo Kok
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - William C. Stacey
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - John M. Stern
- Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Page B. Pennell
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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3
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Miller MI, Shih LC, Kolachalama VB. Machine Learning in Clinical Trials: A Primer with Applications to Neurology. Neurotherapeutics 2023; 20:1066-1080. [PMID: 37249836 PMCID: PMC10228463 DOI: 10.1007/s13311-023-01384-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
We reviewed foundational concepts in artificial intelligence (AI) and machine learning (ML) and discussed ways in which these methodologies may be employed to enhance progress in clinical trials and research, with particular attention to applications in the design, conduct, and interpretation of clinical trials for neurologic diseases. We discussed ways in which ML may help to accelerate the pace of subject recruitment, provide realistic simulation of medical interventions, and enhance remote trial administration via novel digital biomarkers and therapeutics. Lastly, we provide a brief overview of the technical, administrative, and regulatory challenges that must be addressed as ML achieves greater integration into clinical trial workflows.
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Affiliation(s)
- Matthew I Miller
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord Street, Evans 636, Boston, MA, 02118, USA
| | - Ludy C Shih
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, 02118, USA
| | - Vijaya B Kolachalama
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord Street, Evans 636, Boston, MA, 02118, USA.
- Department of Computer Science and Faculty of Computing & Data Sciences, Boston University, Boston, MA, 02115, USA.
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4
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Klein A, Berger TC, Hapfelmeier A, Schaffert M, Matuja W, Schmutzhard E, Winkler AS. Does the presence of a specialist doctor reduce the burden of disease in people with epilepsy in low-resource settings? A comparison of two epilepsy clinics in rural Tanzania. Epilepsy Behav 2023; 139:109030. [PMID: 36577550 DOI: 10.1016/j.yebeh.2022.109030] [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: 08/26/2022] [Revised: 11/05/2022] [Accepted: 11/28/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND With an estimated lifetime prevalence of epilepsy of 7.6 per 1,000 people, epilepsy represents one of the most common neurological disorders worldwide, with the majority of people with epilepsy (PWE) living in low-income and middle-income countries (LMICs). Adequately treated, up to 70 % of PWE will become seizure-free, however, as many as 85% of PWE worldwide, mostly from LMICs, do not receive adequate treatment. OBJECTIVE To assess the impact of the presence of a neurologist on the management of PWE in Tanzania. METHODS Two epilepsy clinics in rural Tanzania, one continuously attended by a neurologist, and one mainly attended by nurses with training in epilepsy and supervised intermittently by specialist doctors (neurologists/psychiatrists) were comparatively analyzed by multivariable linear and logistic regression models with regard to the outcome parameters seizure frequency, the occurrence of side effects of antiepileptic medication and days lost after a seizure. RESULTS The presence of a neurologist significantly reduced the mean number of seizures patients experienced per month by 4.49 seizures (p < 0.01) while leading to an increase in the occurrence of reported side effects (OR: 2.15, p = 0.02). CONCLUSION The presence of a neurologist may play a substantial role in reducing the burden of the disease of PWE in LMICs. Hence, specialist training should be encouraged, and relevant context-specific infrastructure established.
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Affiliation(s)
- Ana Klein
- Center for Global Health, Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Germany.
| | - Toni Christoph Berger
- Center for Global Health, Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Germany; Department of Neurology, Oslo University Hospital, Oslo, Norway.
| | - Alexander Hapfelmeier
- Institute of General Practice and Health Services Research, School of Medicine, Technical University of Munich, Germany; Institute of AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Germany.
| | - Matthias Schaffert
- Paracelsus Medical University, Department for Paediatric and Adolescent Surgery, Salzburg, Austria.
| | - William Matuja
- Department of Neurology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | | | - Andrea S Winkler
- Center for Global Health, Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Germany; Centre for Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway.
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5
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Das S, Jiang X, Jiang W, Tung R, Ting TY, Polli JE. Lack of association between generic brittleness and neuropsychiatric measures in patients with epilepsy. Epilepsy Behav 2022; 128:108587. [PMID: 35151189 DOI: 10.1016/j.yebeh.2022.108587] [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: 10/31/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE In a prior bioequivalence study, generic brittle (GB) patients with epilepsy who were considered at risk of worsened seizures or drug side effects from switching antiepileptic drug (AED) formulations demonstrated no significant difference in their drug levels when switched between a brand and generic AED. An alternative basis for being GB may relate to having a personality or mindset that predisposes to poor outcomes from a formulation switch. The objective of this study was to explore whether GB patients with epilepsy could be differentiated from not GB patients based on standardized measures of personality, mood, outlook, and beliefs. METHODS This was an exploratory, observational, case-control, non-therapeutic study in patients with epilepsy. Patient interviews were conducted, and histories were collected, yielding each patient (n = 148) to be determined as GB or not GB. Eight neuropsychiatry tests were administered to n = 127 of these patients. Tests included Neuroticism Extraversion Openness Personality Inventory 3 (NEO-PI 3), Life Orientation Test-Revised (LOT-R), Quality of Life in Epilepsy Inventory-89 (QOLIE-89), Adverse Childhood Experiences Score (ACE), Physical Symptoms Questionnaire or Patient Health Questionnaire-15 (PHQ-15), Beck Depression Inventory II (BDI-II), Beck Anxiety Inventory (BAI), and the Beliefs About Medicines Questionnaire Epilepsy (BMQ-Epilepsy). A total of 23 Chi squared analyses, along with logistical regression, were performed to assess which tests and sub-elements associated with GB status. RESULTS None of the neuropsychiatry tests or their sub-elements differentiated GB patients from not GB patients. Results implicate that standardized measures of personality, mood, outlook, and beliefs about their healthcare do not differ between GB and not GB patients with epilepsy, possibly because generic brittleness is caused by factors that neuropsychiatry tests do not measure. CONCLUSIONS We hypothesized that being GB may relate to having a personality or mindset that predisposes patients to attributing poor outcomes to a formulation switch. However, findings here in patients with epilepsy did not uncover neuropsychiatric factors that predict which patients were GB and which were not GB.
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Affiliation(s)
- Sharmila Das
- University of Maryland, Department of Pharmaceutical Sciences, 20 Penn Street, Baltimore, MD 21201, USA
| | - Xiaohui Jiang
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Office of Generic Drugs, Office of Research and Standards, 10903 New Hampshire Avenue, White Oak, MD 20993, USA
| | - Wenlei Jiang
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Office of Generic Drugs, Office of Research and Standards, 10903 New Hampshire Avenue, White Oak, MD 20993, USA
| | - Renee Tung
- University of Maryland, Department of Pharmaceutical Sciences, 20 Penn Street, Baltimore, MD 21201, USA; University of Maryland, Department of Neurology, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Tricia Y Ting
- University of Maryland, Department of Neurology, 22 South Greene Street, Baltimore, MD 21201, USA; Georgetown University, 3900 Reservoir Road NW, Washington, D.C. 20007, United States
| | - James E Polli
- University of Maryland, Department of Pharmaceutical Sciences, 20 Penn Street, Baltimore, MD 21201, USA.
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Steriade C, Sperling MR, DiVentura B, Lozano M, Shellhaas RA, Kessler SK, Dlugos D, French J. Proposal for an updated seizure classification framework in clinical trials. Epilepsia 2022; 63:565-572. [PMID: 34997581 PMCID: PMC9302660 DOI: 10.1111/epi.17120] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/13/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022]
Abstract
The International League Against Epilepsy (ILAE) seizure classification scheme has been periodically updated to improve its reliability and applicability to clinicians and researchers alike. Here, members of the Epilepsy Study Consortium propose a pragmatic seizure classification, based on the ILAE scheme, designed for use in clinical trials with a focus on outcome measures that have high reliability, broad interpretability across stakeholders, and clinical relevance in the context of the development of novel antiseizure medications. Controversies around the current ILAE classification scheme are discussed in the context of clinical trials, and pragmatic simplifications to the existing scheme are proposed, for intended use by investigators, industry sponsors, and regulatory agencies.
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Affiliation(s)
- Claude Steriade
- New York University Comprehensive Epilepsy Center, New York, New York, USA.,Epilepsy Study Consortium, Reston, Virginia, USA
| | - Michael R Sperling
- Epilepsy Study Consortium, Reston, Virginia, USA.,Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Meryl Lozano
- Epilepsy Study Consortium, Reston, Virginia, USA
| | - Renée A Shellhaas
- Epilepsy Study Consortium, Reston, Virginia, USA.,Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sudha Kilaru Kessler
- Epilepsy Study Consortium, Reston, Virginia, USA.,Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dennis Dlugos
- Epilepsy Study Consortium, Reston, Virginia, USA.,Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacqueline French
- New York University Comprehensive Epilepsy Center, New York, New York, USA.,Epilepsy Study Consortium, Reston, Virginia, USA
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7
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Network Theory and Switching Behaviors: A User Guide for Analyzing Electronic Records Databases. FUTURE INTERNET 2021. [DOI: 10.3390/fi13090228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As part of studies that employ health electronic records databases, this paper advocates the employment of graph theory for investigating drug-switching behaviors. Unlike the shared approach in this field (comparing groups that have switched with control groups), network theory can provide information about actual switching behavior patterns. After a brief and simple introduction to fundamental concepts of network theory, here we present (i) a Python script to obtain an adjacency matrix from a records database and (ii) an illustrative example of the application of network theory basic concepts to investigate drug-switching behaviors. Further potentialities of network theory (weighted matrices and the use of clustering algorithms), along with the generalization of these methods to other kinds of switching behaviors beyond drug switching, are discussed.
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8
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Asadi-Pooya AA, Brigo F, Lattanzi S, Karakis I, Asadollahi M, Trinka E, Talaat El Ghoneimy L, Pretorius C, Contreras G, Daza-Restrepo A, Valente K, D'Alessio L, Turuspekova ST, Aljandeel G, Khachatryan S, Ashkanani A, Tomson T, Kutlubaev M, Guekht A, Alsaadi T, Calle-Lopez Y, Mesraoua B, Ríos-Pohl L, Al-Asmi A, Villanueva V, Igwe SC, Kissani N, Jusupova A. Complementary and alternative medicine in epilepsy: A global survey of physicians' opinions. Epilepsy Behav 2021; 117:107835. [PMID: 33611098 DOI: 10.1016/j.yebeh.2021.107835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/25/2020] [Accepted: 01/30/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate the opinions of physicians on the use of complementary and alternative medicine (CAM) in patients with epilepsy (PWE) worldwide. METHODS Online survey addressed to neurologists and psychiatrists from different countries. RESULTS Totally, 1112 physicians from 25 countries (different world region: Europe, North America, South America, Middle-East, Africa, Former Soviet Union Republics) participated; 804 (72.3%) believed that CAM might be helpful in PWE. The most commonly endorsed CAM included meditation (41%) and yoga (39%). Female sex, psychiatry specialization, and working in North and South America were associated with the belief that CAM is helpful in PWE. Two-hundred and forty five out of 1098 participants (22.3%) used/prescribed CAM to PWE; among them, 174 (71%) people perceived CAM to be less effective and 114 (46.5%) people found CAM to be safer than conventional antiseizure medications (ASMs). The most common reasons to prescribe CAM for PWE were: to satisfy the patient (49.9%), dissatisfaction with the efficacy (35.6%), and dissatisfaction with the adverse effects (31.2%) of conventional therapies. CONCLUSION Although the evidence supporting the use of CAM for the treatment of epilepsy is extremely sparse, most physicians worldwide believe that it could be integrated with the use of conventional ASMs, at least in some patients. High-quality controlled trials are warranted to provide robust evidence on the usefulness of CAM options in PWE.
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Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Eugen Trinka
- Department of Neurology, Christian-Doppler Medical Centre, Paracelsus Medical University, 5020 Salzburg, Austria; Institute of Nursing Science and Practice, Paracelsus Medical University, 5020 Salzburg, Austria; Centre for Cognitive Neuroscience, 5020 Salzburg, Austria, Associated Member of the European Reference Network EpiCARE
| | | | - Chrisma Pretorius
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Guilca Contreras
- Department of Pediatric Neurology, Hospital Metropolitano, Quito, Ecuador
| | | | - Kette Valente
- Laboratory of Clinical Neurophysiology, Deparment of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil
| | - Luciana D'Alessio
- Buenos Aires University, Epilepsy Center, Ramos Mejía and El Cruce Hospitals, IBCN-CONICET, Buenos Aires, Argentina
| | - Saule T Turuspekova
- Department of Nervous Diseases with a Course of Neurosurgery, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | - Ghaieb Aljandeel
- Iraqi Council for Medical Specializations, Faculty of Epileptology, Medical City, Baghdad, Iraq
| | - Samson Khachatryan
- Department of Neurology and Neurosurgery, National Institute of Health, Yerevan, Armenia
| | | | - Torbjörn Tomson
- Department of Clinical Nueroscience, Karolinska institutet, Stockholm, Sweden
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Alla Guekht
- Moscow Research and Clinical Center for Neurospychiatry; Department of Neurology, Nerosurgery and Medical Genetics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Taoufik Alsaadi
- Deptartment of Neurology, American Center for Psychiatry and Neurology, Dubai, United Arab Emirates
| | - Yamile Calle-Lopez
- Neurology Section, University of Antioquia, Fundación Clínica del Norte-Neuroclínica, Medellín, Colombia
| | - Boulenouar Mesraoua
- Neurosciences Department, Hamad Medical Corporation and Weill Cornell Medical College, Doha, Qatar
| | | | - Abdullah Al-Asmi
- Neurology Unit, Department of Medicine, College of Medicine and Health Sceinces, Sultan Qaboos University, Oman
| | - Vicente Villanueva
- Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Stanley C Igwe
- Department of NeuroPsychiatry, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Najib Kissani
- Laboratory of Clinical and Experimental Neuroscience, Faculty of Medicine, Cadi Ayyad University, Marrakech, Morocco; Department of Neurology, Teaching Hospital Mohammed VI, Marrakesh, Morocco
| | - Asel Jusupova
- Kyrgyz State Medical Academy, Neurology and Clinical Genetics Department, Bishkek, Kyrgyzstan
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Lattanzi S, Trinka E, Striano P, Rocchi C, Salvemini S, Silvestrini M, Brigo F. Highly Purified Cannabidiol for Epilepsy Treatment: A Systematic Review of Epileptic Conditions Beyond Dravet Syndrome and Lennox-Gastaut Syndrome. CNS Drugs 2021; 35:265-281. [PMID: 33754312 PMCID: PMC8005394 DOI: 10.1007/s40263-021-00807-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cannabidiol (CBD), which is one major constituent of the Cannabis sativa plant, has anti-seizure properties and does not produce euphoric or intrusive side effects. A plant-derived, highly purified CBD formulation with a known and constant composition has been approved by the US Food and Drug Administration for the treatment of seizures associated with Dravet syndrome, Lennox-Gastaut syndrome, and tuberous sclerosis complex. In the European Union, the drug has been authorized by the European Medicines Agency for the treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome, in conjunction with clobazam, and is under regulatory review for the treatment of seizures in patients with tuberous sclerosis complex. OBJECTIVES This systematic review aimed to summarize the currently available body of knowledge about the use of this US Food and Drug Administration/European Medicines Agency-approved oral formulation of pharmaceutical-grade CBD in patients with epileptic conditions, especially developmental and epileptic encephalopathies other than Dravet syndrome and Lennox-Gastaut syndrome. METHODS The relevant studies were identified through MEDLINE and the US National Institutes of Health Clinical Trials Registry in October 2020. There were no date limitations or language restrictions. The following types of studies were included: clinical trials, cohorts, case-control, cross-sectional, clinical series, and case reports. Participants had to meet the following criteria: any sex, any ethnicity, any age, diagnosis of epilepsy, receiving plant-derived, highly purified (> 98% w/w) CBD in a sesame oil-based oral solution for the treatment of seizures. Data extracted from selected records included efficacy, tolerability, and safety outcomes. RESULTS Five hundred and seventy records were identified by database and trial register searching. Fifty-seven studies were retrieved for detailed assessment, of which 42 were eventually included for the review. The participants of the studies included patients of both pediatric and adult age. Across the trials, purified CBD was administered at dosages up to 50 mg/kg/day. In a randomized double-blind controlled trial in patients with tuberous sclerosis complex, CBD was associated with a significantly greater percent reduction in seizure frequency than placebo over the treatment period. Open-label studies suggested the effectiveness of CBD in the treatment of children and adults presenting with other epilepsy syndromes than those addressed by regulatory trials, including CDKL5 deficiency disorder and Aicardi, Dup15q, and Doose syndromes, SYNGAP1 encephalopathy, and epilepsy with myoclonic absences. The most common adverse events observed during treatment with CBD included somnolence, decreased appetite, diarrhea, and increased serum aminotransferases. CONCLUSIONS The currently available data suggest that response to treatment with a highly purified, plant-derived CBD oil-based solution can be seen in patients across a broad range of epilepsy disorders and etiologies. The existing evidence can provide preliminary support for additional research.
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Affiliation(s)
- Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Center for Cognitive Neuroscience, Salzburg, Austria.,Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genoa, Italy
| | - Chiara Rocchi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Sergio Salvemini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy.,Division of Neurology, "Franz Tappeiner" Hospital, Merano, BZ, Italy
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10
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Rodrigues FB, Ferreira JJ. Strategies to minimize placebo effects in research investigations. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2020; 153:49-70. [PMID: 32563293 DOI: 10.1016/bs.irn.2020.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Placebo-controlled trials are the research standard to evaluate new interventions for which there is no standard of care. While lessening performance and detection bias, such design provides a direct mode of comparison against the probed intervention. Still, using placebo arms may pose new challenges to the design, conduct and analysis of clinical trials. This is particularly relevant in circumstances of non-additivity between the therapeutic and the placebo effects, if the outcome of interest has floor or ceiling effects, or when the predicted effect size of the intervention is large and leads to small sample sizes. There are several possible strategies to mitigate the confounding effects of the placebo, each relevant to specific clinical trial designs. This chapter puts into context the new challenges created by the placebo effect, discusses possible ways around them, and explores the future of the field.
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Affiliation(s)
- Filipe B Rodrigues
- UCL Huntington's Disease Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom; Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Instituto de Medicina Molecular, Lisbon, Portugal
| | - Joaquim J Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Instituto de Medicina Molecular, Lisbon, Portugal; CNS-Campus Neurológico Sénior, Torres Vedras, Portugal.
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11
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Abstract
Placebos impact epilepsy in a number of ways. Through randomized clinical trials, explicit clinical use, and also through implicit clinical use, placebos play a role in epilepsy. This chapter will discuss the reasons placebo is used, the determinants of placebo response in epilepsy, observations about placebo specific to epilepsy, and ways in which clinical trial design is impacted by placebo.
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12
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Romero J, Larimer P, Chang B, Goldenholz SR, Goldenholz DM. Natural variability in seizure frequency: Implications for trials and placebo. Epilepsy Res 2020; 162:106306. [PMID: 32172145 PMCID: PMC7194486 DOI: 10.1016/j.eplepsyres.2020.106306] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 12/27/2019] [Accepted: 02/28/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Changes in patient-reported seizure frequencies are the gold standard used to test efficacy of new treatments in randomized controlled trials (RCTs). Recent analyses of patient seizure diary data suggest that the placebo response may be attributable to natural fluctuations in seizure frequency, though the evidence is incomplete. Here we develop a data-driven statistical model and assess the impact of the model on interpretation of placebo response. METHODS A synthetic seizure diary generator matching statistical properties seen across multiple epilepsy diary datasets was constructed. The model was used to simulate the placebo arm of 5000 RCTs. A meta-analysis of 23 historical RCTs was compared to the simulations. RESULTS The placebo 50 %-responder rate (RR50) was 27.3 ± 3.6 % (simulated) and 21.1 ± 10.0 % (historical). The placebo median percent change (MPC) was 22.0 ± 6.0 % (simulated) and 16.7 ± 10.3 % (historical). CONCLUSIONS A statistical model of daily seizure count generation which incorporates quantities related to the natural fluctuations of seizure count data produces a placebo response comparable to those seen in historical RCTs. This model may be useful in better understanding the seizure count fluctuations seen in patients in other clinical settings.
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Affiliation(s)
- Juan Romero
- Harvard Medical School Beth Israel Deaconess Medical Center, Department of Neurology, United States
| | - Phil Larimer
- Harvard Medical School Beth Israel Deaconess Medical Center, Department of Neurology, United States
| | - Bernard Chang
- Harvard Medical School Beth Israel Deaconess Medical Center, Department of Neurology, United States
| | - Shira R Goldenholz
- Harvard Medical School Beth Israel Deaconess Medical Center, Department of Neurology, United States
| | - Daniel M Goldenholz
- Harvard Medical School Beth Israel Deaconess Medical Center, Department of Neurology, United States.
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13
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Anderson BJ, Morse JD, Hannam JA, Cortinez LI. Pharmacokinetic and pharmacodynamic considerations of general anesthesia in pediatric subjects. Expert Opin Drug Metab Toxicol 2020; 16:279-295. [PMID: 32148110 DOI: 10.1080/17425255.2020.1739648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Introduction: The target concentration strategy uses PKPD information for dose determination. Models have also quantified exposure-response relationships, improved understanding of developmental pharmacokinetics, rationalized dose prescription, provided insight into the importance of covariate information, explained drug interactions and driven decision-making and learning during drug development.Areas covered: The prime PKPD consideration is parameter estimation and quantification of variability. The main sources of variability in children are age (maturation) and weight (size). Model use is mostly confined to pharmacokinetics, partly because anesthesia effect models in the young are imprecise. Exploration of PK and PD covariates and their variability hold potential to better individualize treatment.Expert opinion: The ability to model drugs using computer-based technology is hindered because covariate data required to individualize treatment using these programs remain lacking. Target concentration intervention strategies remain incomplete because covariate information that might better predict individualization of dose is absent. Pharmacogenomics appear a valuable area for investigation for pharmacodynamics and pharmacodynamics. Effect measures in the very young are imprecise. Assessment of the analgesic component of anesthesia is crude. While neuromuscular monitoring is satisfactory, depth of anaesthesia EEG interpretation is inadequate. Closed loop anesthesia is possible with better understanding of EEG changes.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - James D Morse
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - L Ignacio Cortinez
- División Anestesiología, Pontificia Universidad Católica De Chile, Santiago De Chile, Chile
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Morales-Quezada L, Martinez D, El-Hagrassy MM, Kaptchuk TJ, Sterman MB, Yeh GY. Neurofeedback impacts cognition and quality of life in pediatric focal epilepsy: An exploratory randomized double-blinded sham-controlled trial. Epilepsy Behav 2019; 101:106570. [PMID: 31707107 PMCID: PMC7203763 DOI: 10.1016/j.yebeh.2019.106570] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/28/2019] [Accepted: 09/13/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Children with epilepsy experience cognitive deficits and well-being issues that have detrimental effects on their development. Pharmacotherapy is the standard of care in epilepsy; however, few interventions exist to promote cognitive development and to mitigate disease burden. We aimed to examine the impact of two different modalities of neurofeedback (NFB) on cognitive functioning and quality-of-life (QOL) measurements in children and adolescents with controlled focal epilepsy. The study also explored the effects of NFB on clinical outcomes and electroencephalography (EEG) quantitative analysis. METHODS Participants (n = 44) with controlled focal epilepsy were randomized to one of three arms: sensorimotor rhythm (SMR) NFB (n = 15), slow cortical potentials (SCP) NFB (n = 16), or sham NFB (n = 13). All participants received 25 sessions of intervention. The attention switching task (AST), Liverpool Seizure Severity Scale (LSSS), seizure frequency (SF), EEG power spectrum, and coherence were measured at baseline, postintervention, and at 3-month follow-up. RESULTS In children and adolescents with controlled focal epilepsy, SMR training significantly reduced reaction time in the AST (p = 0.006), and this was correlated with the difference of change for theta power on EEG (p = 0.03); only the SMR group showed a significant decrease in beta coherence (p = 0.03). All groups exhibited improvement in QOL (p = <0.05). CONCLUSIONS This study provides the first data on two NFB modalities (SMR and SCP) including cognitive, neurophysiological, and clinical outcomes in pediatric epilepsy. Sensorimotor rhythm NFB improved cognitive functioning, while all the interventions showed improvements in QOL, demonstrating a powerful placebo effect in the sham group.
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Affiliation(s)
- Leon Morales-Quezada
- Neuromodulation Center, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA, USA.
| | - Diana Martinez
- Boston Neurodynamics, Brookline, Massachussetss, USA.,Neocemod, Centro de Neuromodulacion, Aguascalientes, Mexico
| | - Mirret M. El-Hagrassy
- Neuromodulation Center, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Ted J. Kaptchuk
- Program in Placebo Studies and Therapeutic Encounter, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - M. Barry Sterman
- Department of Neurobiology, UCLA School of Medicine, USA; Department of Biobehavioral Psychiatry, UCLA School of Medicine, USA
| | - Gloria Y. Yeh
- Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Osher Center for Integrative Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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15
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Cross JH, Cock H. A perspective on cannabinoids for treating epilepsy: Do they really change the landscape? Neuropharmacology 2019; 170:107861. [PMID: 31770546 DOI: 10.1016/j.neuropharm.2019.107861] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 12/22/2022]
Abstract
With the licensing of cannabidiol for drug resistant seizures in Dravet and Lennox Gastaut syndromes in the United states in 2018, interest in the potential for cannabis-based-medicinal products to meet currently unmet needs for people with epilepsy continues to grow. This review summarizes current knowledge and discusses the implications for future research and practice. Both cannabidiol and tetrahydrocannabinol, the main components, have been extensively studied in animal models, with multimodal mechanisms of action proposed. Only pure cannabidiol formulations have been rigorously evaluated in controlled trials thus far, with modest but significant improvements in motor seizures. Adverse effects include diarrhoea, somnolence and reduced appetite, with mostly acceptable tolerability, but a not insignificant (up to 1 in 23) risk of serious adverse events. Recognized drug interactions include with valproate (increased risk of hepatotoxicity) and clobazam (contributing to somnolence, increased secretions, probably chest infections, and potentially efficacy). Whilst there is public (and producer) interest in products also containing tetrahydrocannabinol, clinicians have justifiable concerns about exposing a group already vulnerable to mental health and neurobehavioural comorbidities to the associated additional risks in these domains. Artisanal preparations, with often inconsistent/unknown constituents are frequently used but not recommended. A gulf exists between the actual evidence, including a lack of comparative studies and public beliefs, fuelled by media and anecdote. Continued education of the public, policymakers, researchers and healthcare providers about what is and isn't yet known, together with on-going good quality research is essential to mitigate against future potential risks, particularly in relation to vulnerable populations. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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Affiliation(s)
- J Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child Health, Guilford St, London, WC1N 1EH, UK; Great Ormond Street for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK; Young Epilepsy, Lingfield, Surrey, UK
| | - Hannah Cock
- Institute of Molecular and Clinical Sciences, St George's University of London, SW17 0RE, UK; Atkinson Morley Regional Epilepsy Network, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
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16
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Leal Rato M, Duarte GS, Ferreira AN, Alves M, Mainoli B, Teodoro T, Mestre TA, Costa J, Ferreira JJ. Nocebo response in Parkinson's disease: A systematic review and meta-analysis. Parkinsonism Relat Disord 2019; 65:13-19. [DOI: 10.1016/j.parkreldis.2019.04.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/23/2019] [Accepted: 04/19/2019] [Indexed: 12/19/2022]
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17
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Joseph PD, Caldwell PH, Barnes EH, Hynes K, Choong CS, Turner S, Vosk C, White J, Richichi K, Craig JC. Completeness of protocols for clinical trials in children submitted to ethics committees. J Paediatr Child Health 2019; 55:291-298. [PMID: 30161286 DOI: 10.1111/jpc.14189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/20/2018] [Accepted: 07/23/2018] [Indexed: 12/11/2022]
Abstract
AIM Studies of published clinical trials involving children have shown frequent omissions in key aspects of design and conduct, but these problems may be artefactual and due to editorial processes and space limitations. To determine actual design and conduct, we analysed the completeness of key domains in trial protocols involving children submitted to Human Research Ethics Committees. METHODS The ethics committees of all eight children's hospitals in Australia were invited to participate. De-identified trial protocols submitted for review in 2012 were evaluated using a checklist derived from Consolidated Standards of Reporting Trials, the Cochrane Risk of Bias Tool and Good Clinical Practice guidelines. RESULTS Four ethics committees agreed to participate, and 69 protocols were analysed. The domains almost always reported were clustered around the background and trial plan (planned interventions for each group (99%), specific objectives (97%) and scientific background (96%)). Risk-of-bias domains such as random sequence generation and blinding of participants were often reported (75-90%). Domains least reported were clustered around the statistical analysis plan (66%), specified intention-to-treat analysis (54%), the justification for the proposed trial based upon a systematic review (48%) and age-specific outcomes (48%). CONCLUSIONS Protocols of trials involving children assessed by ethics committees generally include details on background and basic design, but many key domains in trial design and conduct are not covered. Despite widespread recognition of how problems in the design and conduct of trials may lead to unreliable results, investigators still appear to be omitting key elements in trial protocols.
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Affiliation(s)
- Pathma D Joseph
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.,Pharmacy Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Patrina Hy Caldwell
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Elizabeth H Barnes
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kay Hynes
- Pharmacy Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Catherine S Choong
- Department of Diabetes and Endocrinology, Princess Margaret Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Sean Turner
- Pharmacy Department, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Claire Vosk
- Pharmacy Department, Monash Health, Melbourne, Victoria, Australia
| | - Jessie White
- Clinical Research and Education, Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Kate Richichi
- Flinders Medical Centre and Repatriation General Hospital, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Jonathan C Craig
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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18
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Hausman-Kedem M, Menascu S, Kramer U. Efficacy of CBD-enriched medical cannabis for treatment of refractory epilepsy in children and adolescents - An observational, longitudinal study. Brain Dev 2018; 40:544-551. [PMID: 29674131 DOI: 10.1016/j.braindev.2018.03.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 03/15/2018] [Accepted: 03/28/2018] [Indexed: 01/08/2023]
Abstract
The objective of this observational study was to evaluate the efficacy of medical cannabis for the treatment of refractory epilepsy. Fifty-seven patients (age 1-20 years) with epilepsy of various etiologies were treated with Cannabis oil extract (CBD/THC ratio of 20:1) for at least 3 months (Median follow up time-18 months). Forty-Six Patients were included in the efficacy analysis. Average CBD dose was11.4 mg/kg/d. Twenty-six patients (56%) had ≤50% reduction in mean monthly seizure frequency. There was no statistically significant difference in response rate among various epilepsy etiologies, and cannabis strain used. Younger age at treatment onset (<10 years) and higher CBD dose (>11 mg/kg/d) were associated with better response to treatment. Adverse reactions were reported in 46% of patients and were the main reason for treatment cessation. Our results suggest that adding CBD-enriched cannabis extract to the treatment regimen of patients with refractory epilepsy may result in a significant reduction in seizure frequency according to parental reports. Randomized controlled trials are necessary to assess its true efficacy.
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Affiliation(s)
- Moran Hausman-Kedem
- Pediatric Neurology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.
| | - Shay Menascu
- Pediatric Neurology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kramer
- Pediatric Neurology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
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19
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Suraev A, Lintzeris N, Stuart J, Kevin RC, Blackburn R, Richards E, Arnold JC, Ireland C, Todd L, Allsop DJ, McGregor IS. Composition and Use of Cannabis Extracts for Childhood Epilepsy in the Australian Community. Sci Rep 2018; 8:10154. [PMID: 29977078 PMCID: PMC6033872 DOI: 10.1038/s41598-018-28127-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 06/04/2018] [Indexed: 12/20/2022] Open
Abstract
Recent surveys suggest that many parents are using illicit cannabis extracts in the hope of managing seizures in their children with epilepsy. In the current Australian study we conducted semi-structured interviews with families of children with diverse forms of epilepsy to explore their attitudes towards and experiences with using cannabis extracts. This included current or previous users of cannabis extracts to treat their child's seizures (n = 41 families), and families who had never used (n = 24 families). For those using cannabis, extracts were analysed for cannabinoid content, with specific comparison of samples rated by families as "effective" versus those rated "ineffective". Results showed that children given cannabis extracts tended to have more severe epilepsy historically and had trialled more anticonvulsants than those who had never received cannabis extracts. There was high variability in the cannabinoid content and profile of cannabis extracts rated as "effective", with no clear differences between extracts perceived as "effective" and "ineffective". Contrary to family's expectations, most samples contained low concentrations of cannabidiol, while Δ9-tetrahydrocannabinol was present in nearly every sample. These findings highlight profound variation in the illicit cannabis extracts being currently used in Australia and warrant further investigations into the therapeutic value of cannabinoids in epilepsy.
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Affiliation(s)
- A Suraev
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - N Lintzeris
- Addiction Medicine, Central Clinical School, Faculty of Medicine, The University of Sydney, Sydney, 2006, Australia
- The Langton Centre, Drug and Alcohol Services, South East Sydney Local Health District, NSW Health, Surry Hills, 2010, Australia
| | - J Stuart
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R C Kevin
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R Blackburn
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - E Richards
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - J C Arnold
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
- Department of Pharmacology, Faculty of Medicine, University of Sydney, Sydney, NSW, 2006, Australia
| | - C Ireland
- Epilepsy Action Australia, Sydney, Australia
| | - L Todd
- Epilepsy Action Australia, Sydney, Australia
| | - D J Allsop
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - I S McGregor
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia.
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20
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Haut SR, Lipton RB, Cornes S, Dwivedi AK, Wasson R, Cotton S, Strawn JR, Privitera M. Behavioral interventions as a treatment for epilepsy: A multicenter randomized controlled trial. Neurology 2018; 90:e963-e970. [PMID: 29444968 DOI: 10.1212/wnl.0000000000005109] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 12/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the effect of a stress-reduction intervention in participants with medication-resistant epilepsy. METHODS Adults with medication-resistant focal epilepsy (n = 66) were recruited from 3 centers and randomized to 1 of 2 interventions: (1) progressive muscle relaxation (PMR) with diaphragmatic breathing, or (2) control focused-attention activity with extremity movements. Following an 8-week baseline period, participants began 12 weeks of double-blind treatment. Daily self-reported mood and stress ratings plus seizure counts were completed by participants using an electronic diary, and no medication adjustments were permitted. The primary outcome was percent reduction in seizure frequency per 28 days comparing baseline and treatment; secondary outcomes included stress reduction and stress-seizure interaction. RESULTS In the 66 participants in the intention-to-treat analysis, seizure frequency was reduced from baseline in both treatment groups (PMR: 29%, p < 0.05; focused attention: 25%, p < 0.05). PMR and focused attention did not differ in seizure reduction (p = 0.38), although PMR was associated with stress reduction relative to focused attention (p < 0.05). Daily stress was not a predictor of seizures. CONCLUSIONS Both PMR and the focused-attention groups showed reduced seizure frequency compared to baseline in participants with medication-resistant focal seizures, although the 2 treatments did not differ. PMR was more effective than focused attention in reducing self-reported stress. CLINICALTRIALSGOV IDENTIFIER NCT01444183.
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Affiliation(s)
- Sheryl R Haut
- From Montefiore-Einstein Epilepsy Center (S.R.H.) and Departments of Neurology (S.R.H., R.B.L.) and Epidemiology and Population Health (R.B.L.), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY; University of California (S. Cornes), San Francisco, CA; Division of Biostatistics & Epidemiology (A.K.D.), Department of Biomedical Sciences, Paul L. Foster School of Medicine and Biostatistics & Epidemiology Consulting Lab, Office of Research Resources, Texas Tech University Health Sciences Center, El Paso, TX; and Departments of Family and Community Medicine (R.W.), Integrative Medicine UC Cancer Institute (S. Cotton), Psychiatry and Behavioral Neuroscience (J.R.S.), and Neurology (M.P.), University of Cincinnati College of Medicine, OH.
| | - Richard B Lipton
- From Montefiore-Einstein Epilepsy Center (S.R.H.) and Departments of Neurology (S.R.H., R.B.L.) and Epidemiology and Population Health (R.B.L.), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY; University of California (S. Cornes), San Francisco, CA; Division of Biostatistics & Epidemiology (A.K.D.), Department of Biomedical Sciences, Paul L. Foster School of Medicine and Biostatistics & Epidemiology Consulting Lab, Office of Research Resources, Texas Tech University Health Sciences Center, El Paso, TX; and Departments of Family and Community Medicine (R.W.), Integrative Medicine UC Cancer Institute (S. Cotton), Psychiatry and Behavioral Neuroscience (J.R.S.), and Neurology (M.P.), University of Cincinnati College of Medicine, OH
| | - Susannah Cornes
- From Montefiore-Einstein Epilepsy Center (S.R.H.) and Departments of Neurology (S.R.H., R.B.L.) and Epidemiology and Population Health (R.B.L.), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY; University of California (S. Cornes), San Francisco, CA; Division of Biostatistics & Epidemiology (A.K.D.), Department of Biomedical Sciences, Paul L. Foster School of Medicine and Biostatistics & Epidemiology Consulting Lab, Office of Research Resources, Texas Tech University Health Sciences Center, El Paso, TX; and Departments of Family and Community Medicine (R.W.), Integrative Medicine UC Cancer Institute (S. Cotton), Psychiatry and Behavioral Neuroscience (J.R.S.), and Neurology (M.P.), University of Cincinnati College of Medicine, OH
| | - Alok K Dwivedi
- From Montefiore-Einstein Epilepsy Center (S.R.H.) and Departments of Neurology (S.R.H., R.B.L.) and Epidemiology and Population Health (R.B.L.), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY; University of California (S. Cornes), San Francisco, CA; Division of Biostatistics & Epidemiology (A.K.D.), Department of Biomedical Sciences, Paul L. Foster School of Medicine and Biostatistics & Epidemiology Consulting Lab, Office of Research Resources, Texas Tech University Health Sciences Center, El Paso, TX; and Departments of Family and Community Medicine (R.W.), Integrative Medicine UC Cancer Institute (S. Cotton), Psychiatry and Behavioral Neuroscience (J.R.S.), and Neurology (M.P.), University of Cincinnati College of Medicine, OH
| | - Rachel Wasson
- From Montefiore-Einstein Epilepsy Center (S.R.H.) and Departments of Neurology (S.R.H., R.B.L.) and Epidemiology and Population Health (R.B.L.), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY; University of California (S. Cornes), San Francisco, CA; Division of Biostatistics & Epidemiology (A.K.D.), Department of Biomedical Sciences, Paul L. Foster School of Medicine and Biostatistics & Epidemiology Consulting Lab, Office of Research Resources, Texas Tech University Health Sciences Center, El Paso, TX; and Departments of Family and Community Medicine (R.W.), Integrative Medicine UC Cancer Institute (S. Cotton), Psychiatry and Behavioral Neuroscience (J.R.S.), and Neurology (M.P.), University of Cincinnati College of Medicine, OH
| | - Sian Cotton
- From Montefiore-Einstein Epilepsy Center (S.R.H.) and Departments of Neurology (S.R.H., R.B.L.) and Epidemiology and Population Health (R.B.L.), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY; University of California (S. Cornes), San Francisco, CA; Division of Biostatistics & Epidemiology (A.K.D.), Department of Biomedical Sciences, Paul L. Foster School of Medicine and Biostatistics & Epidemiology Consulting Lab, Office of Research Resources, Texas Tech University Health Sciences Center, El Paso, TX; and Departments of Family and Community Medicine (R.W.), Integrative Medicine UC Cancer Institute (S. Cotton), Psychiatry and Behavioral Neuroscience (J.R.S.), and Neurology (M.P.), University of Cincinnati College of Medicine, OH
| | - Jeffrey R Strawn
- From Montefiore-Einstein Epilepsy Center (S.R.H.) and Departments of Neurology (S.R.H., R.B.L.) and Epidemiology and Population Health (R.B.L.), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY; University of California (S. Cornes), San Francisco, CA; Division of Biostatistics & Epidemiology (A.K.D.), Department of Biomedical Sciences, Paul L. Foster School of Medicine and Biostatistics & Epidemiology Consulting Lab, Office of Research Resources, Texas Tech University Health Sciences Center, El Paso, TX; and Departments of Family and Community Medicine (R.W.), Integrative Medicine UC Cancer Institute (S. Cotton), Psychiatry and Behavioral Neuroscience (J.R.S.), and Neurology (M.P.), University of Cincinnati College of Medicine, OH
| | - Michael Privitera
- From Montefiore-Einstein Epilepsy Center (S.R.H.) and Departments of Neurology (S.R.H., R.B.L.) and Epidemiology and Population Health (R.B.L.), Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY; University of California (S. Cornes), San Francisco, CA; Division of Biostatistics & Epidemiology (A.K.D.), Department of Biomedical Sciences, Paul L. Foster School of Medicine and Biostatistics & Epidemiology Consulting Lab, Office of Research Resources, Texas Tech University Health Sciences Center, El Paso, TX; and Departments of Family and Community Medicine (R.W.), Integrative Medicine UC Cancer Institute (S. Cotton), Psychiatry and Behavioral Neuroscience (J.R.S.), and Neurology (M.P.), University of Cincinnati College of Medicine, OH
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Khan A, Fahl Mar K, Schilling J, Brown WA. Magnitude and pattern of placebo response in clinical trials of antiepileptic medications: Data from the Food and Drug Administration 1996-2016. Contemp Clin Trials 2017; 64:95-100. [PMID: 29101042 DOI: 10.1016/j.cct.2017.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/26/2017] [Accepted: 10/29/2017] [Indexed: 01/11/2023]
Abstract
This study aimed to replicate and extend the findings of previous investigations looking at treatment responses in antiepileptic clinical trials over time and to examine the effects of subject age and duration of treatment. To address the potential biases of published literature, we examined the reported data from 14 investigational antiepileptic drugs (AEDs) (34 trials, 59 treatment arms, 10,783 patients) reviewed and approved by the US FDA (1996-2016). For each treatment arm, we recorded drug and placebo response (percent reduction in seizure frequency), calculated effect sizes, and examined these measures over time. Regression analysis showed that placebo response has increased significantly over time (R2=0.292, p=0.001) from 5% to 20% reduction in seizure frequency in 20years. Response to drug treatment appears to have increased in parallel but the trend was not statistically significant (p=0.143). Effect sizes have remained stable over time (p=0.084). Treatment duration was not related to treatment response or outcomes. Including younger patients in trials appeared to predict lower drug response (β=1.44, p=0.012) and effect size (β=0.014, p=0.047) but not placebo response (p=0.141). These FDA-reviewed and source-verified data support and extend prior findings from published literature that response to placebo treatment is noticeably increasing over time, nearly quadrupling in magnitude, while AED efficacy remains the same due to a parallel increase in drug response. The rise in placebo response appears to be an ongoing phenomenon rather than a mere historical artifact. Future design and interpretation of data from clinical trials of investigational antiepileptic drugs can be informed by these observations.
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Affiliation(s)
- Arif Khan
- Northwest Clinical Research Center, Bellevue, WA, USA; Department of Psychiatry, Duke University School of Medicine, Durham, NC, USA.
| | | | - Joshua Schilling
- Department of Cardiology, Baystate Medical Center, University of Massachusetts, Springfield, MA, USA
| | - Walter A Brown
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA
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Koo CM, Kang HC. Could Cannabidiol be a Treatment Option for Intractable Childhood and Adolescent Epilepsy? J Epilepsy Res 2017; 7:16-20. [PMID: 28775950 PMCID: PMC5540685 DOI: 10.14581/jer.17003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/17/2017] [Indexed: 01/13/2023] Open
Abstract
Epilepsy is an important disease that affects brain function, particularly in those under 3 years old. Uncontrolled seizures can affect cognitive function and quality of life. For these reasons, many trials have been conducted to investigate treatments for pediatric epilepsy. Currently, many antiepileptic drugs are available for the treatment of epilepsy, but cases of intractable epilepsy continue to exist. In the past, cannabis has been tested as a potential treatment of intractable epilepsy. Since 2013, 10 epilepsy centers in America have conducted research regarding the efficacy of cannabis to treat epilepsy. Cannabis has many components, including cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC). THC has psychoactive properties exerted through its binding of the cannabinoid receptor (CBR) whereas CBD is a CBR antagonist. The inhibition of epilepsy by CBD may therefore be caused by various mechanisms, although the detailed mechanisms of CBD actions have not yet been well defined. In most studies, trial doses of CBD were 2-5 mg/kg/day. Several such studies have shown that CBD does have efficacy for treatment of epilepsy. Reported adverse effects of CBD were mostly mild, including drowsiness, diarrhea, and decreased appetite. Severe adverse reactions requiring treatment, such as status epilepticus, have also been reported but it is not clear that this is related to CBD. Furthermore, many previous studies have been limited by an open-label or survey design. In future, double-blind, controlled trials are required and the use of CBD to treat other neurological problems should also be investigated.
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Affiliation(s)
- Chung Mo Koo
- Department of Pediatrics, Changwon Gyeongsang National University Hospital, Changwon, Korea
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Department of Pediatrics, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
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Can Matching-Adjusted Indirect Comparison Methods Mitigate Placebo Response Differences Among Patient Populations in Adjunctive Trials of Brivaracetam and Levetiracetam? CNS Drugs 2017; 31:899-910. [PMID: 28856580 PMCID: PMC5658476 DOI: 10.1007/s40263-017-0462-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with focal seizures recruited into adjunctive antiepileptic drug (AED) trials have become more refractory and severe over time; concurrently, placebo responses have increased. To attempt to account for heterogeneity among trials, propensity-score weighted patient-level data were used to indirectly compare placebo responses reported in brivaracetam and levetiracetam trials. METHODS Patient-level data from randomised, placebo-controlled brivaracetam (recruited 2007-2014) and levetiracetam (1993-1998) trials were pooled. Consistent inclusion/exclusion criteria were applied and outcomes were defined consistently. Potentially confounding baseline characteristics were adjusted for using propensity score weighting. Weighting success was assessed using placebo response. RESULTS In total, 707 and 473 active drug and 399 and 253 placebo patients comprised the brivaracetam and levetiracetam groups, respectively. Before weighting, several baseline variables were significantly different between groups; after weighting, prior vagal nerve stimulation, co-morbid depression and co-morbid anxiety remained different. Before weighting, median seizure frequency reduction was 21.7 and 3.9% in the brivaracetam and levetiracetam placebo arms, respectively; after weighting, median reduction was 15.0 and 6.0%. The comparison of non-randomised groups could be biased by unobserved confounding factors and region of residence. Lifetime AED history was unavailable in the brivaracetam trials and excluded from analysis. CONCLUSIONS Placebo responses remained different between brivaracetam and levetiracetam trials after propensity score weighting, indicating the presence of residual confounding factors associated with placebo response in these trials. It therefore remains problematic to conduct reliable indirect comparisons of brivaracetam and levetiracetam given the current evidence base, which may apply to comparisons between other AED trials.
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Shorvon S, Schmidt D. The right and the wrong with epilepsy and her science. Epilepsia Open 2016; 1:76-85. [PMID: 29588932 PMCID: PMC5719833 DOI: 10.1002/epi4.12011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2016] [Indexed: 12/26/2022] Open
Abstract
This is a commentary and an opinion paper attempting a critical reassessment of the methods and practices of epilepsy research as we see it. The enormous progress in the field of epilepsy in recent years is a cause of celebration. Advances have been made on most fronts, and the position of patients with epilepsy in society has greatly improved. However, there have also been culs‐de‐sac and dead ends of modern science and clinical practice which are also intriguing. It may be true that we can learn more from our mistakes than from our successes. In this opinion paper, we have listed some of the successes and some of the failures of past epilepsy practice, and also areas of current practice and theory which we feel are likely to prove mistaken. The underlying reasons for misdirected practices and theories include, in our view, the influence of fashion, bad science, and the bureaucracies of practice and academic medicine. As a result, some findings are far from objective. Recognition is the first step to remediation, and hopefully future research will minimize some of the pitfalls mentioned in this article and bring the “End of Epilepsy,” as defined and predicted by Oswei Temkin, closer than it is today.
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Affiliation(s)
- Simon Shorvon
- UCL Institute of Neurology National Hospital for Neurology and Neurosurgery London United Kingdom
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Perucca E, Wiebe S. Not all that glitters is gold: A guide to the critical interpretation of drug trials in epilepsy. Epilepsia Open 2016; 1:9-21. [PMID: 29588925 PMCID: PMC5867835 DOI: 10.1002/epi4.3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 01/10/2023] Open
Abstract
Clinical trials represent the best source of evidence on which to base treatment decisions. For such evidence to be utilized meaningfully, however, it is essential that results are interpreted correctly. This requires a good understanding of strengths and weaknesses of the adopted design, the clinical relevance of the outcome measures, and the many factors that could affect such outcomes. As a general rule, uncontrolled studies tend to provide misleading evidence as a result of the impact of confounders such as regression to the mean, patient‐related bias, and observer bias. On the other hand, although randomized controlled trials (RCTs) are qualitatively superior, aspects of their execution may still decrease their validity. Bias and decreased validity in RCTs may occur by chance alone (for example, treatment groups may not necessarily be balanced for important variables despite randomization) or because of specific features of the trial design. In the case of industry‐driven studies, bias often influences the outcome in favor of the sponsor's product. Factors that need to be carefully scrutinized include (1) the purpose for which the trial is conducted; (2) potential bias due to unblinding or lack of blinding; (3) the appropriateness of the control group; (4) the power of the study in detecting clinically relevant differences; (5) the extent to which eligibility criteria could affect outcomes and be representative of routine clinical practice; (6) whether the treatments being compared are used optimally in terms of dosing, duration of treatment, and other variables; (7) the appropriateness of the statistical comparisons; (8) the clinical relevance of the outcome measures and whether all key outcome information is reported (for example, responder rates in completers); and (9) potential bias in the way results are presented and discussed. This article discusses each of these aspects and illustrates the discussion with examples taken from published antiepileptic drug trials.
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Affiliation(s)
- Emilio Perucca
- C. Mondino National Neurological Institute Pavia Italy.,Division of Clinical and Experimental Pharmacology Department of Internal Medicine and Therapeutics University of Pavia Pavia Italy
| | - Samuel Wiebe
- Department of Clinical Neurosciences and Hotchkiss Brain Institute Cumming School of Medicine University of Calgary Calgary Alberta Canada.,Department of Community Health Sciences and O'Brien Institute for Public Health Cumming School of Medicine University of Calgary Calgary Alberta Canada
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Analysis of nocebo effects of antiepileptic drugs across different conditions. J Neurol 2016; 263:1274-9. [DOI: 10.1007/s00415-015-8018-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 12/29/2015] [Accepted: 12/30/2015] [Indexed: 10/22/2022]
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Franco V, French JA, Perucca E. Challenges in the clinical development of new antiepileptic drugs. Pharmacol Res 2016; 103:95-104. [DOI: 10.1016/j.phrs.2015.11.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/13/2015] [Accepted: 11/18/2015] [Indexed: 12/26/2022]
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Devinsky O, Marsh E, Friedman D, Thiele E, Laux L, Sullivan J, Miller I, Flamini R, Wilfong A, Filloux F, Wong M, Tilton N, Bruno P, Bluvstein J, Hedlund J, Kamens R, Maclean J, Nangia S, Singhal NS, Wilson CA, Patel A, Cilio MR. Cannabidiol in patients with treatment-resistant epilepsy: an open-label interventional trial. Lancet Neurol 2015; 15:270-8. [PMID: 26724101 DOI: 10.1016/s1474-4422(15)00379-8] [Citation(s) in RCA: 593] [Impact Index Per Article: 65.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/09/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Almost a third of patients with epilepsy have a treatment-resistant form, which is associated with severe morbidity and increased mortality. Cannabis-based treatments for epilepsy have generated much interest, but scientific data are scarce. We aimed to establish whether addition of cannabidiol to existing anti-epileptic regimens would be safe, tolerated, and efficacious in children and young adults with treatment-resistant epilepsy. METHODS In this open-label trial, patients (aged 1-30 years) with severe, intractable, childhood-onset, treatment-resistant epilepsy, who were receiving stable doses of antiepileptic drugs before study entry, were enrolled in an expanded-access programme at 11 epilepsy centres across the USA. Patients were given oral cannabidiol at 2-5 mg/kg per day, up-titrated until intolerance or to a maximum dose of 25 mg/kg or 50 mg/kg per day (dependent on study site). The primary objective was to establish the safety and tolerability of cannabidiol and the primary efficacy endpoint was median percentage change in the mean monthly frequency of motor seizures at 12 weeks. The efficacy analysis was by modified intention to treat. Comparisons of the percentage change in frequency of motor seizures were done with a Mann-Whitney U test. RESULTS Between Jan 15, 2014, and Jan 15, 2015, 214 patients were enrolled; 162 (76%) patients who had at least 12 weeks of follow-up after the first dose of cannabidiol were included in the safety and tolerability analysis, and 137 (64%) patients were included in the efficacy analysis. In the safety group, 33 (20%) patients had Dravet syndrome and 31 (19%) patients had Lennox-Gastaut syndrome. The remaining patients had intractable epilepsies of different causes and type. Adverse events were reported in 128 (79%) of the 162 patients within the safety group. Adverse events reported in more than 10% of patients were somnolence (n=41 [25%]), decreased appetite (n=31 [19%]), diarrhoea (n=31 [19%]), fatigue (n=21 [13%]), and convulsion (n=18 [11%]). Five (3%) patients discontinued treatment because of an adverse event. Serious adverse events were reported in 48 (30%) patients, including one death-a sudden unexpected death in epilepsy regarded as unrelated to study drug. 20 (12%) patients had severe adverse events possibly related to cannabidiol use, the most common of which was status epilepticus (n=9 [6%]). The median monthly frequency of motor seizures was 30.0 (IQR 11.0-96.0) at baseline and 15.8 (5.6-57.6) over the 12 week treatment period. The median reduction in monthly motor seizures was 36.5% (IQR 0-64.7). INTERPRETATION Our findings suggest that cannabidiol might reduce seizure frequency and might have an adequate safety profile in children and young adults with highly treatment-resistant epilepsy. Randomised controlled trials are warranted to characterise the safety profile and true efficacy of this compound. FUNDING GW Pharmaceuticals, Epilepsy Therapy Project of the Epilepsy Foundation, Finding A Cure for Epilepsy and Seizures.
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Affiliation(s)
- Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Langone Medical Center, New York, NY, USA.
| | - Eric Marsh
- Departments of Neurology and Pediatrics, Division of Child Neurology, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, New York University Langone Medical Center, New York, NY, USA
| | | | - Linda Laux
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Joseph Sullivan
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Ian Miller
- Miami Children's Hospital, Miami, FL, USA
| | - Robert Flamini
- Pediatric and Adolescent Neurodevelopmental Associates, Atlanta, GA, USA
| | | | - Francis Filloux
- University of Utah Medical Center and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Matthew Wong
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicole Tilton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Patricia Bruno
- Massachusettes General Hospital for Children, Boston, MA, USA
| | - Judith Bluvstein
- Comprehensive Epilepsy Center, New York University Langone Medical Center, New York, NY, USA
| | - Julie Hedlund
- Comprehensive Epilepsy Center, New York University Langone Medical Center, New York, NY, USA
| | - Rebecca Kamens
- Departments of Neurology and Pediatrics, Division of Child Neurology, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jane Maclean
- Departments of Neurology and Pediatrics, Division of Child Neurology, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Srishti Nangia
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nilika Shah Singhal
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Carey A Wilson
- University of Utah Medical Center and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Anup Patel
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Maria Roberta Cilio
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
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Goldenholz DM, Moss R, Scott J, Auh S, Theodore WH. Confusing placebo effect with natural history in epilepsy: A big data approach. Ann Neurol 2015; 78:329-36. [PMID: 26150090 DOI: 10.1002/ana.24470] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 06/29/2015] [Indexed: 11/12/2022]
Abstract
For unknown reasons, placebos reduce seizures in clinical trials in many patients. It is also unclear why some drugs showing statistical superiority to placebo in one trial may fail to do so in another. Using Seizuretracker.com, a patient-centered database of 684,825 seizures, we simulated "placebo" and "drug" trials. These simulations were employed to clarify the sources of placebo effects in epilepsy, and to identify methods of diminishing placebo effects. Simulation 1 included 9 trials with a 6-week baseline and 6-week test period, starting at time 0, 3, 6…24 months. Here, "placebo" reduced seizures regardless of study start time. Regression-to-the-mean persisted only for 3 to 6 months. Simulation 2 comprised a 6-week baseline and then 2 years of follow-up. Seizure frequencies continued to improve throughout follow-up. Although the group improved, individuals switched from improvement to worsening and back. Simulation 3 involved a placebo-controlled "drug" trial, to explore methods of placebo response reduction. An efficacious "drug" failed to demonstrate a significant effect compared with "placebo" (p = 0.12), although modifications either in study start time (p = 0.025) or baseline population reduction (p = 0.0028) allowed the drug to achieve a statistically significant effect compared with placebo. In epilepsy clinical trials, some seizure reduction traditionally attributed to placebo effect may reflect the natural course of the disease itself. Understanding these dynamics will allow future investigations into optimal clinical trial design and may lead to identification of more effective therapies. Ann Neurol 2015;78:329-336.
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Affiliation(s)
- Daniel M Goldenholz
- Clinical Epilepsy Section and EEG Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | | | - Jonathan Scott
- EEG Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Sungyoung Auh
- Clinical Neurosciences Program, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - William H Theodore
- Clinical Epilepsy Section and EEG Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
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Anderson BJ, Hannam JA. Considerations when using pharmacokinetic/pharmacodynamic modeling to determine the effectiveness of simple analgesics in children. Expert Opin Drug Metab Toxicol 2015; 11:1393-408. [PMID: 26155821 DOI: 10.1517/17425255.2015.1061505] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Assessment of analgesic drugs includes comparative studies to other analgesics and local anesthesia blockade, number needed to treat estimates and opioid sparing descriptions. An additional methodology is to define the concentration-response relationship using pharmacokinetic/pharmacodynamic (PK/PD) modeling. AREAS COVERED A concentration-response relationship allows analgesic effect comparison between drugs for different acute pain types. Covariates such as size, age and organ function impact greatly on PK in children. The cumulative effect of confounding factors (e.g., pharmacogenetics, placebo and changes in baseline pain over time) complicates PD. Other factors (outcome measures, method of measurement, failure to account for study attrition) impact on outcome. Population PK/PD modeling approaches allow us to account for these various factors to some extent. EXPERT OPINION Nonlinear mixed effects models help interpret analgesic data and their use is increasing. The PK is relatively well understood. The next investigative step will involve investigation into covariate effects for PD. Mathematical functions for both placebo models and dropout models are well described and should be incorporated into analgesic effectiveness studies that investigate a range of doses. Improvements in pain assessment tools and a greater understanding of pharmacogenomics factors will help individualize analgesic therapy.
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Affiliation(s)
- Brian J Anderson
- a University of Auckland School of Medicine, Department of Anaesthesiology , Auckland, New Zealand +64 9 3074903 ; +64 9 3098989 ;
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