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Reed L, Ciliberto M, Fong SL, Nickels K, Kossoff E, Wirrell E, Joshi C. Efficacy of felbamate in a cohort of patients with epilepsy with myoclonic atonic seizures (EMAtS). Epilepsy Res 2024; 201:107314. [PMID: 38354549 DOI: 10.1016/j.eplepsyres.2024.107314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/16/2024]
Abstract
Epilepsy with myoclonic atonic seizures (EMAtS) is a rare childhood onset developmental and epileptic encephalopathy which is frequently refractory to medical therapy. The optimal antiseizure medication remains unknown. This study reports the efficacy of felbamate in children with EMAtS. Six large pediatric epilepsy centers performed a retrospective chart review on patients diagnosed with EMAtS at their institutions and collected data on felbamate usage and efficacy. Responders were classified as patients who had a 50% or greater reduction in seizures with a given therapy. Out of 259 patients, 37 (14%) were treated with felbamate. The efficacy of felbamate was 62%, which was greater than that of either levetiracetam or valproic acid (15%, p < 0.001% and 32%, p = 0.001 respectively) and similar to that of the ketogenic diet (69%, p = 0.8). Felbamate appears to be an effective treatment for EMAtS and should be strongly considered in the treatment course of this disease.
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Affiliation(s)
- Laurel Reed
- University of Michigan, C.S. Mott Children's Hospital, 1500 E. Hospital Dr., SPC 4279, Ann Arbor, MI 48109-4279, USA.
| | | | - Susan L Fong
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2015, Cincinnati, OH 45529-3026, USA
| | | | - Eric Kossoff
- Johns Hopkins Hospital, Suite 2158 - 200 North Wolfe Street, Baltimore, MD 21287, USA
| | | | - Charuta Joshi
- University of Texas, Southwestern, 1935 Medical District Dr, Dallas, TX 75235, USA
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Rissardo JP, Fornari Caprara AL. Cenobamate (YKP3089) and Drug-Resistant Epilepsy: A Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1389. [PMID: 37629678 PMCID: PMC10456719 DOI: 10.3390/medicina59081389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/08/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023]
Abstract
Cenobamate (CNB), ([(R)-1-(2-chlorophenyl)-2-(2H-tetrazol-2-yl)ethyl], is a novel tetrazole alkyl carbamate derivative. In November 2019, the Food and Drug Administration approved Xcopri®, marketed by SK Life Science Inc., (Paramus, NJ, USA) for adult focal seizures. The European Medicines Agency approved Ontozry® by Arvelle Therapeutics Netherlands B.V.(Amsterdam, The Neatherlands) in March 2021. Cenobamate is a medication that could potentially change the perspectives regarding the management and prognosis of refractory epilepsy. In this way, this study aims to review the literature on CNB's pharmacological properties, pharmacokinetics, efficacy, and safety. CNB is a highly effective drug in managing focal onset seizures, with more than twenty percent of individuals with drug-resistant epilepsy achieving seizure freedom. This finding is remarkable in the antiseizure medication literature. The mechanism of action of CNB is still poorly understood, but it is associated with transient and persistent sodium currents and GABAergic neurotransmission. In animal studies, CNB showed sustained efficacy and potency in the 6 Hz test regardless of the stimulus intensity. CNB was revealed to be the most cost-effective drug among different third-generation antiseizure medications. Also, CNB could have neuroprotective effects. However, there are still concerns regarding its potential for abuse and suicidality risk, which future studies should clearly assess, after which protocols should be changed. The major drawback of CNB therapy is the slow and complex titration and maintenance phases preventing the wide use of this new agent in clinical practice.
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Affiliation(s)
- Jamir Pitton Rissardo
- Medicine Department, Federal University of Santa Maria, Santa Maria 97105-900, Brazil;
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Wahab A, Iqbal A. Black-Box Warnings of Antiseizure Medications: What is Inside the Box? Pharmaceut Med 2023; 37:233-250. [PMID: 37119452 DOI: 10.1007/s40290-023-00475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/01/2023]
Abstract
Antiseizure medications can cause serious adverse reactions and have deleterious drug interactions that often complicate the clinical management of patients. When the US Food and Drug Administration (FDA) wants to alert healthcare providers and patients about the risk of potentially serious or fatal drug reactions, the FDA requires the manufacturers of these medications to format these warnings within a "black-box" border, and prominently display this box on the first section of the package insert; such warnings are called "black-box warnings (BBWs)". The BBW is a way for the FDA to urge physicians to evaluate patients more rigorously and carefully weigh the risks and benefits, before prescribing medication that has the potential to cause serious adverse reactions, and to formulate a plan for close monitoring during therapy. The FDA BBW provides the extra layer of safety but many healthcare providers fail to comply with these warnings. Currently, there are 26 FDA-approved antiseizure medications in the US market, 38% of which have received BBWs, and most of the antiseizure medications with BBWs are older-generation drugs. Some antiseizure medications have multiple BBWs; for example, valproic acid has three BBWs including hepatotoxicity, fetal risk, and pancreatitis, carbamazepine has BBWs of serious skin and hematological reactions, and felbamate also has two BBWs including hepatic failure and aplastic anemia. The purpose of this review is to provide insight into each BBW received by antiseizure medications and discuss the FDA recommendations for evaluating the drug benefit/risk, and for monitoring parameters before the initiation of and during treatment.
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Affiliation(s)
- Abdul Wahab
- Department of Pharmacy, Emory Healthcare, Emory Decatur Hospital, Decatur, GA, 30033, USA.
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Rabinowicz S, Schreiber T, Heimer G, Bar-Yosef O, Nissenkorn A, E ZD, Arkush L, Hamed N, Ben-Zeev B, Tzadok M. Felbamate for pediatric epilepsy—should we keep on using it as the last resort? Front Neurol 2022; 13:979725. [PMID: 36203978 PMCID: PMC9530252 DOI: 10.3389/fneur.2022.979725] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionConcerns regarding felbamate adverse effects restrict its widespread use in children with drug-resistant epilepsy. We aimed to examine the efficacy and safety of felbamate in those children and identify the ones who may benefit most from its use.MethodsWe retrospectively reviewed the medical files of all patients who were treated with felbamate in a tertiary pediatric epilepsy clinic between 2009–2021. Drug efficacy was determined at the first 3 months of treatment and thereafter. Therapeutic response and adverse reactions were monitored throughout the course of treatment.ResultsOur study included 75 children (age 8.9 ± 3.7 years), of whom 53 were treated with felbamate for seizures, 16 for electrical status epilepticus during sleep and 6 for both. The median follow-up time was 16 months (range 1–129 months). The most common cause for epilepsy was genetic (29%). The median number of previous anti-seizure medications was six [4–8]. A therapeutic response ≥50% was documented in 37 (51%) patients, and a complete response in 9 (12%). Nineteen patients (25%) sustained adverse reactions, including three cases of elevated liver enzymes and one case of neutropenia with normal bone marrow aspiration. In all cases, treatment could be continued. All children with intractable epilepsy following herpes encephalitis showed a response to felbamate.ConclusionFelbamate is an efficacious and safe anti-seizure medication in the pediatric population.
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Affiliation(s)
- Shira Rabinowicz
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- *Correspondence: Shira Rabinowicz
| | - Tal Schreiber
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gali Heimer
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer Bar-Yosef
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Andreea Nissenkorn
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar-Dayan E
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Leo Arkush
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nasrin Hamed
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Bruria Ben-Zeev
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Tzadok
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Wong BJ, Agarwal R, Chen MI. Anesthesia for the Pediatric Patient With Epilepsy and Minimally Invasive Surgery for Epilepsy. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00457-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Löscher W, Sills GJ, White HS. The ups and downs of alkyl-carbamates in epilepsy therapy: How does cenobamate differ? Epilepsia 2021; 62:596-614. [PMID: 33580520 DOI: 10.1111/epi.16832] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/13/2022]
Abstract
Since 1955, several alkyl-carbamates have been developed for the treatment of anxiety and epilepsy, including meprobamate, flupirtine, felbamate, retigabine, carisbamate, and cenobamate. They have each enjoyed varying levels of success as antiseizure drugs; however, they have all been plagued by the emergence of serious and sometimes life-threatening adverse events. In this review, we compare and contrast their predominant molecular mechanisms of action, their antiseizure profile, and where possible, their clinical efficacy. The preclinical, clinical, and mechanistic profile of the prototypical γ-aminobutyric acidergic (GABAergic) modulator phenobarbital is included for comparison. Like phenobarbital, all of the clinically approved alkyl-carbamates share an ability to enhance inhibitory neurotransmission through modulation of the GABAA receptor, although the specific mechanism of interaction differs among the different drugs discussed. In addition, several alkyl-carbamates have been shown to interact with voltage-gated ion channels. Flupirtine and retigabine share an ability to activate K+ currents mediated by KCNQ (Kv7) K+ channels, and felbamate, carisbamate, and cenobamate have been shown to block Na+ channels. In contrast to other alkyl-carbamates, cenobamate seems to be unique in its ability to preferentially attenuate the persistent rather than transient Na+ current. Results from recent randomized controlled clinical trials with cenobamate suggest that this newest antiseizure alkyl-carbamate possesses a degree of efficacy not witnessed since felbamate was approved in 1993. Given that ceno-bamate's mechanistic profile is unique among the alkyl-carbamates, it is not clear whether this impressive efficacy reflects an as yet undescribed mechanism of action or whether it possesses a unique synergy between its actions at the GABAA receptor and on persistent Na+ currents. The high efficacy of cenobamate is, however, tempered by the risk of serious rash and low tolerability at higher doses, meaning that further safety studies and clinical experience are needed to determine the true clinical value of cenobamate.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience Hannover, Hannover, Germany
| | - Graeme J Sills
- School of Life Sciences, University of Glasgow, Glasgow, UK
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
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Abstract
Lennox-Gastaut syndrome (LGS), a childhood-onset severe developmental and epileptic encephalopathy (DEE), is an entity that encompasses a heterogenous group of aetiologies, with no single genetic cause. It is characterised by multiple seizure types, an abnormal EEG with generalised slow spike and wave discharges and cognitive impairment, associated with high morbidity and profound effects on the quality of life of patients and their families. Drug-refractory seizures are a hallmark and treatment is further complicated by its multiple morbidities, which evolve over the patient's lifetime. This review provides a comprehensive overview of the current and future options for the treatment of seizures associated with LGS. Six treatments are specifically indicated as adjunct therapies for the treatment of seizures associated with LGS in the US: lamotrigine, clobazam, rufinamide, topiramate, felbamate and most recently cannabidiol. These therapies have demonstrated reductions in drop seizures in 15%-68% of patients across trials, with responder rates (≥ 50% reduction in drop seizures) of 37%-78%. Valproate is still the preferred first-line treatment, generally in combination with lamotrigine or clobazam. Other treatments frequently used off-label include the broad spectrum anti-epileptic drugs (AED) levetiracetam, zonisamide and perampanel, while recent evidence from observational studies has indicated that a newer AED, the levetiracetam analogue brivaracetam, may be effective and well tolerated in LGS patients. Other treatments in clinical development include fenfluramine in late phase III, perampanel, soticlestat-OV953/TAK-953, carisbamate and ganaxolone. Non-pharmacologic interventions include the ketogenic diet, vagus nerve stimulation and surgical interventions; these are also expanding, with the potential for less invasive techniques for corpus callosotomy that have promise for reducing complications. However, despite these advancements, patients continue to experience a significant burden. Because LGS is not a single entity, tailoring of treatment is needed as opposed to a 'one size fits all' approach. Further research is needed into the underlying aetiologies and pathophysiology of LGS, together with advancements in treatments that encompass the spectrum of seizures associated with this complex syndrome.
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Ng BG, Eklund EA, Shiryaev SA, Dong YY, Abbott MA, Asteggiano C, Bamshad MJ, Barr E, Bernstein JA, Chelakkadan S, Christodoulou J, Chung WK, Ciliberto MA, Cousin J, Gardiner F, Ghosh S, Graf WD, Grunewald S, Hammond K, Hauser NS, Hoganson GE, Houck KM, Kohler JN, Morava E, Larson AA, Liu P, Madathil S, McCormack C, Meeks NJ, Miller R, Monaghan KG, Nickerson DA, Palculict TB, Papazoglu GM, Pletcher BA, Scheffer IE, Schenone AB, Schnur RE, Si Y, Rowe LJ, Serrano Russi AH, Russo RS, Thabet F, Tuite A, Mercedes Villanueva M, Wang RY, Webster RI, Wilson D, Zalan A, Wolfe LA, Rosenfeld JA, Rhodes L, Freeze HH. Predominant and novel de novo variants in 29 individuals with ALG13 deficiency: Clinical description, biomarker status, biochemical analysis, and treatment suggestions. J Inherit Metab Dis 2020; 43:1333-1348. [PMID: 32681751 PMCID: PMC7722193 DOI: 10.1002/jimd.12290] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022]
Abstract
Asparagine-linked glycosylation 13 homolog (ALG13) encodes a nonredundant, highly conserved, X-linked uridine diphosphate (UDP)-N-acetylglucosaminyltransferase required for the synthesis of lipid linked oligosaccharide precursor and proper N-linked glycosylation. De novo variants in ALG13 underlie a form of early infantile epileptic encephalopathy known as EIEE36, but given its essential role in glycosylation, it is also considered a congenital disorder of glycosylation (CDG), ALG13-CDG. Twenty-four previously reported ALG13-CDG cases had de novo variants, but surprisingly, unlike most forms of CDG, ALG13-CDG did not show the anticipated glycosylation defects, typically detected by altered transferrin glycosylation. Structural homology modeling of two recurrent de novo variants, p.A81T and p.N107S, suggests both are likely to impact the function of ALG13. Using a corresponding ALG13-deficient yeast strain, we show that expressing yeast ALG13 with either of the highly conserved hotspot variants rescues the observed growth defect, but not its glycosylation abnormality. We present molecular and clinical data on 29 previously unreported individuals with de novo variants in ALG13. This more than doubles the number of known cases. A key finding is that a vast majority of the individuals presents with West syndrome, a feature shared with other CDG types. Among these, the initial epileptic spasms best responded to adrenocorticotropic hormone or prednisolone, while clobazam and felbamate showed promise for continued epilepsy treatment. A ketogenic diet seems to play an important role in the treatment of these individuals.
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Affiliation(s)
- Bobby G. Ng
- Human Genetics Program, Sanford Children’s Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Erik A. Eklund
- Human Genetics Program, Sanford Children’s Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
- Department of Clinical Sciences, Lund, Pediatrics, Lund University, Lund, Sweden
| | - Sergey A. Shiryaev
- Human Genetics Program, Sanford Children’s Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
| | - Yin Y. Dong
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Mary-Alice Abbott
- Department of Pediatrics, Baystate Children’s Hospital, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts
| | - Carla Asteggiano
- CEMECO—CONICET, Children Hospital, School of Medicine, National University of Cordoba, Cordoba, Argentina
- Chair of Pharmacology, Catholic University of Cordoba, Cordoba, Argentina
| | - Michael J. Bamshad
- Department of Pediatrics, University of Washington, Seattle, Washington
- Department of Genome Sciences, University of Washington, Seattle, Washington
| | - Eileen Barr
- Department of Human Genetics, Emory University, Atlanta, Georgia
| | - Jonathan A. Bernstein
- Stanford University School of Medicine, Stanford, California
- Stanford Center for Undiagnosed Diseases, Stanford University, Stanford, California
| | | | - John Christodoulou
- Brain and Mitochondrial Research Group, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Wendy K. Chung
- Department of Pediatrics, Columbia University, New York, New York
- Department of Medicine, Columbia University, New York, New York
| | - Michael A. Ciliberto
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Janice Cousin
- Section of Human Biochemical Genetics, National Human Genome Research Institute, Bethesda, Maryland
| | - Fiona Gardiner
- University of Melbourne, Austin Health, Melbourne, Australia
| | - Suman Ghosh
- Department of Pediatrics Division of Pediatric Neurology, University of Florida College of Medicine, Gainesville, Florida
| | - William D. Graf
- Division of Pediatric Neurology, Department of Pediatrics, Connecticut Children’s; University of Connecticut, Farmington, Connecticut
| | - Stephanie Grunewald
- Metabolic Medicine Department, Great Ormond Street Hospital, Institute of Child Health University College London, NIHR Biomedical Research Center, London, UK
| | - Katherine Hammond
- Division of Pediatric Neurology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Natalie S. Hauser
- Inova Translational Medicine Institute Division of Medical Genomics Inova Fairfax Hospital Falls Church, Virginia
| | - George E. Hoganson
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
| | - Kimberly M. Houck
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, Texas
| | - Jennefer N. Kohler
- Stanford University School of Medicine, Stanford, California
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Eva Morava
- Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota
| | - Austin A. Larson
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Pengfei Liu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Baylor Genetics Laboratories, Houston, Texas
| | - Sujana Madathil
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colleen McCormack
- Stanford University School of Medicine, Stanford, California
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Naomi J.L. Meeks
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Rebecca Miller
- Inova Translational Medicine Institute Division of Medical Genomics Inova Fairfax Hospital Falls Church, Virginia
| | | | | | | | - Gabriela Magali Papazoglu
- CEMECO—CONICET, Children Hospital, School of Medicine, National University of Cordoba, Cordoba, Argentina
| | - Beth A. Pletcher
- Department of Pediatrics, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ingrid E. Scheffer
- University of Melbourne, Austin Health, Melbourne, Australia
- University of Melbourne, Royal Children’s Hospital, Florey and Murdoch Institutes, Melbourne, Australia
| | | | | | - Yue Si
- GeneDx, Inc. Laboratory, Gaithersburg, Maryland
| | - Leah J. Rowe
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Alvaro H. Serrano Russi
- Division of Medical Genetics Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | - Allysa Tuite
- Department of Pediatrics, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Raymond Y. Wang
- Division of Metabolic Disorders, Children’s Hospital of Orange County, Orange, California
- Department of Pediatrics, University of California-Irvine, Orange, California
| | - Richard I. Webster
- T.Y. Nelson Department of Neurology and Neurosurgery, The Children’s Hospital, Westmead, Australia
- Kids Neuroscience Centre, The Children’s Hospital, Westmead, Australia
| | - Dorcas Wilson
- Netcare Sunninghill Hospital, Sandton, South Africa
- Nelson Mandela Children’s Hospital, Johannesburg, South Africa
| | - Alice Zalan
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
| | | | - Lynne A. Wolfe
- Undiagnosed Diseases Program, Common Fund, National Institutes of Health, Bethesda, Maryland
| | - Jill A. Rosenfeld
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Baylor Genetics Laboratories, Houston, Texas
| | | | - Hudson H. Freeze
- Human Genetics Program, Sanford Children’s Health Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California
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Felbamate in the treatment of refractory epileptic spasms. Epilepsy Res 2020; 161:106284. [PMID: 32058261 DOI: 10.1016/j.eplepsyres.2020.106284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/29/2020] [Accepted: 02/01/2020] [Indexed: 11/24/2022]
Abstract
Several small case series provide conflicting impressions of the efficacy of felbamate for treatment of epileptic spasms. Using a large single-center cohort of children with epileptic spasms, we retrospectively evaluated the efficacy and safety of felbamate. We identified all patients with video-EEG confirmed epileptic spasms who were treated with felbamate at our center. We quantified felbamate exposure by calculating peak and weighted-average weight-based dose. Clinical response was defined as resolution of epileptic spasms for at least 28 days, beginning not more than 3 months after felbamate initiation. Electroclinical response was defined as clinical response accompanied by overnight video-EEG demonstrating freedom from epileptic spasms and hypsarrhythmia. Among a cohort of 476 infants, we identified 62 children who were treated with felbamate, of whom 58 had previously failed treatment with hormonal therapy or vigabatrin. Median peak and weighted-average felbamate dosages were 47 and 40 mg/kg/day, respectively. Five (8%) children were classified as clinical responders and two (3%) children were classified as electroclinical responders. Among 17 patients with latency from epileptic spasms onset to felbamate initiation of less than 12 months, we observed 4 (24%) clinical responders. This study suggests that felbamate may be efficacious for treatment of epileptic spasms and that further rigorous study is warranted.
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Moavero R, Pisani LR, Pisani F, Curatolo P. Safety and tolerability profile of new antiepileptic drug treatment in children with epilepsy. Expert Opin Drug Saf 2018; 17:1015-1028. [PMID: 30169997 DOI: 10.1080/14740338.2018.1518427] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Treatment of pediatric epilepsy requires a careful evaluation of the safety and tolerability profile of antiepileptic drugs (AEDs) to avoid or minimize as much as possible adverse events (AEs) on various organs, hematological parameters, and growth, pubertal, motor, cognitive and behavioral development. AREAS COVERED Treatment-emergent AEs (TEAEs) reported in the literature 2000-2018 regarding second- and third-generation AEDs used in the pediatric age, with exclusion of the neonatal period that exhibits specific peculiarities, have been described on the basis of their frequency, severity/tolerability, and particular association with a given AED. EXPERT OPINION Somnolence/sedation and behavioral changes, like irritability and nervousness, are among the most commonly observed TEAEs associated with almost all AEDs. Lamotrigine, Gabapentin, Oxcarbazepine, and Levetiracetam appear to be the best-tolerated AEDs with a ≤2% withdrawal rate, while Tiagabine and Everolimus are discontinued in up to >20% of the patients because of intolerable TEAEs. For some AEDs, literature data are scanty to draw a high-level evidence on their safety and tolerability profile. The reasons are: insufficient population size, short duration of treatments, or lack of controlled trials. A future goal is that of identifying clearer, easier, and more homogeneous methodological strategies to facilitate AED testing in pediatric populations.
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Affiliation(s)
- Romina Moavero
- a Child Neurology and Psychiatry Unit, Systems Medicine Department , Tor Vergata University of Rome , Rome , Italy.,b Child Neurology Unit, Neuroscience and Neurorehabilitation Department , "Bambino Gesù", Children's Hospital, IRCCS , Rome , Italy
| | | | - Francesco Pisani
- d Department of Clinical and Experimental Medicine , University of Messina , Messina , Italy
| | - Paolo Curatolo
- a Child Neurology and Psychiatry Unit, Systems Medicine Department , Tor Vergata University of Rome , Rome , Italy
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Abstract
The mainstay of treatment of childhood epilepsy is to administer antiepileptic drugs (AEDs). This article provides an overview of the clinical approach to drug treatment of childhood epilepsy, focusing on general principles of therapy and properties of recently introduced medications. Initiation and cessation of therapy, adverse medication effects, drug interactions, indications for the various AEDs, and off-label use of AEDs are reviewed. The distinct challenges in treatment of epileptic spasms and neonatal seizures are addressed. Finally, ideas for the future of drug treatment of childhood epilepsy are presented, with particular attention to precision medicine.
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Affiliation(s)
- Louis T Dang
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Room 12-733, 1540 East Hospital Drive, Ann Arbor, MI 48109-4279, USA.
| | - Faye S Silverstein
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, 8301 MSRB3, 1150 West Medical Center Drive, Ann Arbor, MI 48109-5646, USA
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Onakpoya IJ, Heneghan CJ, Aronson JK. Post-Marketing Regulation of Medicines Withdrawn from the Market Because of Drug-Attributed Deaths: An Analysis of Justification. Drug Saf 2017; 40:431-441. [PMID: 28238125 DOI: 10.1007/s40264-017-0515-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Several medicinal products have been withdrawn from the market because of drug-attributed deaths. However, there has been no investigation of whether such withdrawals were justified, and the extent to which confirmatory studies are used to investigate drug-adverse event relationships when deaths are reported is uncertain. We documented medicinal products withdrawn from the market because of drug-attributed deaths, identified confirmatory studies investigating the drug-adverse event relationships, examined whether withdrawals of medicinal products because of drug-attributed deaths after marketing were justified based on a mechanistic analysis, and examined the trends over time. METHODS We searched electronic and non-electronic sources to identify medicinal products that were withdrawn because of drug-attributed deaths. We used a previously published algorithm to examine whether the withdrawals of products were justified. We then searched PubMed and Google Scholar to identify studies investigating the drug-adverse event relationships, used the Oxford Centre for Evidence-Based Medicine criteria to document the levels of evidence, and assessed whether the evidence of an association was confirmed. RESULTS We included 83 medicinal products. The reasons for withdrawal appeared to have been justified in 80 cases (96%). The median interval between the first reported adverse reaction that was related to the cause of death and the first reported death was 1 year (interquartile range = 1-3); products were withdrawn sooner when the interval between the first reported relevant adverse reaction and the first death was shorter. Confirmatory studies were conducted in 57 instances (69%), and there was evidence of an association in 52 cases (63%). Four products (5%) were re-introduced after initial withdrawal. CONCLUSION Regulatory authorities have been justified in making withdrawal decisions when deaths have been attributed to medicinal products, using the precautionary principle when alternative decisions could have been made. Medicinal products are likely to be quickly withdrawn from the market when there is a short interval to the first reported deaths. The use of an algorithm such as we have used in this study could help to expedite the process of decision making.
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Affiliation(s)
- Igho J Onakpoya
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Gibson Building, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.
| | - Carl J Heneghan
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Gibson Building, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - Jeffrey K Aronson
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Gibson Building, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
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